Every finding on record at Brookhaven Nursing & Rehab

Based on interview and record review, the facility failed to provide care per standarda of practice when staff failed to correctly enter and follow the wound care specialist recommendations for the wound care treatment of one resident (Resident #1). The census was 64.Review of the facility's policy, Wound Care and Treatment, undated, showed the following:-It is the purpose of the facility is to prevent and treat all wounds;-There must be a specific order for the treatment;-The care plan should reflect the current status of the wound and appropriate goals and approaches.1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 09/26/25;-Diagnoses included cellulitis (a common, potentially serious bacterial skin infection affecting the dermis and subcutaneous tissues, typically causing red, hot, swollen, and tender skin) and gangrene.Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 10/01/25, showed the following:-The resident was cognitively intact;-The resident requires moderate assistance for transfers.Review of the resident's care plan, updated 10/31/25, showed the following: -Resident had impaired skin integrity with risk for poor skin healing, additional breakdown due to bilateral lower leg cellulitis-Treatments will be in place to improve/heal existing skin issues and prevent further skin breakdown to the extent possible secondary to medical complexities through review;-Treatments per physician orders, assess/document/review with physician for wounds without improvement for treatments order changes;-Observe, document and report any indications of dehydration to the physician;-Encourage hydration by offering fluids, ensure fresh water is at bedside, offer and assist with drinks of water as needed;-Nutritional consultation as needed for wound healing nutritional approaches;-Wound dressing changes twice daily. Cleanse all areas and apply Dakins(a widely used, hospital-grade antiseptic used to cleanse skin and soft tissue wounds, prevent infections, and treat burns or chronic ulcers) to the left foot and cover with dry gauze and rolled gauze;-Treatments were changed when the Family Nurse Practitioner (FNP) rounded. Betadine (a trusted, broad-spectrum antiseptic used to treat minor cuts, scrapes, and burns by killing bacteria, fungi, and viruses to prevent infection) for the left toe treatment and cover loosely with gauze, start date 10/31/25;Review of the resident's December 2025 Physician Order Sheet (POS) showed an order, dated 11/14/25, for left big toe. Staff to cleanse wound with hypochlorous acid (wound cleanser), do not rinse from wounds or skin, and paint with Betadine two times a day. Review of the resident's Wound Care Specialist progress note, dated 12/12/26, showed the following:-The treatment will remain the same for the left big toe wound;-The wound care FNP completed wound care and debridement of the resident's wounds;-The resident's wound measured 7.2 cm length, 3.5 cm width, eschar (dead, devitalized tissue that is hard pr soft in texture, usually black, brown, or tan in color ) 90%, slough(non-viable yellow, tan, gray, green, or brown tissue usually moist) 10%;-Wound Recommendations/orders and certified plan of care: Cleanse wound with hypochlorous acid, do not rinse, use to irrigate and scrub the wound bed, paint with betadine, and apply calcium alginate (a highly absorptive, biodegradable, and biocompatible material derived from brown seaweed, commonly used as a medical dressing for moderate to heavily exuding wounds) dressing to the wound base. Cut to fit inside of wound edges and do not place on the skin. Change dressing daily and as needed for soiling, saturation or unscheduled removal;-All orders will remain in effect until discontinued, revised, or replaced with additional orders. It is okay to continue current treatment orders until able to obtain supplies/medications for updated orders.-Signed by the wound care FNP.Review of the resident's December 2025 POS showed an order change, dated 12/15/25, for the left big toe. Staff to cleanse wound with hypochlorous acid (product is non-cytoxic. Do not use with silver), do not rinse from wounds or skin, paint with Betadine two times a daily. Treatment once every other day. (Order was updated three days after the FNP visit and did not include orders for use of the calcium alginate dressing.)Review of the resident's Wound Care Specialist progress note, dated 12/19/25, showed the following:-The treatment will remain the same for the left big toe wound;-The wound care FNP completed wound care and debridement of the resident's wounds;-The resident's wound measured 7.2 cm length, 1.2 cm width, eschar 90% and slough 10%;-Wound Recommendations/orders and certified plan of care: Cleanse wound with hypochlorous acid, do not rinse, use to irrigate and scrub the wound bed, paint with betadine, and apply calcium alginate dressing to the wound base. Cut to fit inside of wound edges and do not place on the skin. Change dressing daily and as needed for soiling, saturation or unscheduled removal;-All orders will remain in effect until discontinued, revised, or replaced with additional orders. It is okay to continue current treatment orders until able to obtain supplies/medications for updated orders.-Signed by the wound care FNP.Review of the resident's nursing note dated 12/19/25, at 1:35 PM, showed the wound care FNP rounded and clarified orders for undressing cleansing, debriding, and taking manual measurements. Staff should paint the big toe in betadine and calcium alginate placed around the toe in the crevice between the toe and the healthy foot tissue. The resident is considering getting the great toe removed surgically but is unsure if insurance will cover it. Review of the resident's December 2025 POS showed an order change, dated 12/19/25, for the left big toe. Staff to cleanse wound with hypochlorous acid, do not rinse from wounds or skin, paint with Betadine two times a day, and apply calcium alginate to crevice between the toe and foot once every other day. (The FNP ordered the dressing change daily and calcium alginate to be cut to fit in wound.)Review of the resident's care plan, updated 12/19/25, showed the following added:-Wound care FNP rounded and clarified orders for undressing cleansing, debriding, and taking manual measurements;-Wound care throughout left leg should be done every other day and as needed when soiled/dislodged;-The big toe should be painted in Betadine and calcium alginate placed around the toe in the crevice between the toe and the healthy foot tissue;-Resident is considering getting the great toe removed surgically but being unsure if insurance will cover it.Review of the resident's care plan, updated 12/29/25, showed the following added: -When seen by the wound care FNP, he/she asked if the facility could get an order for podiatry consult for the resident's left foot great toe due to dry gangrene.Review of the resident's Wound Care Specialist Progress Note, dated 01/02/26, showed the following:-The wound care FNP completed wound care and debridement of the resident's wounds;-The resident's wound measured 7cm length, 3.2cm width, granulation 10%, eschar)70%, slough 20%;-Wound recommendations/orders and certified plan of cares for left big toe: Cleanse wound with hypochlorous acid, do not rinse, use to irrigate and scrub the wound bed, paint with betadine and apply Calcium alginate dressing to the wound base. Cut to fit inside of wound edges and do not place on the skin. Change dressing daily and as needed for soiling, saturation or unscheduled removal;-All orders will remain in effect until discontinued, revised, or replaced with additional orders. It is okay to continue current treatment orders until able to obtain supplies/medications for updated orders.-Signed by the wound care FNP.Review of the resident's January 2026 POS showed staff did not update the order to reflect the correct frequency (daily) and direction to cut calcium alginate to fit in the wound. Review of the resident's Wound Care Specialist Progress Note, dated 01/09/26 showed the following:-The wound care FNP completed assessment of the resident's wounds;-All orders will remain in effect until discontinued, revised, or replaced with additional orders. It is okay to continue current treatment orders until able to obtain supplies/medications for updated orders.-Signed by the wound care FNP.Review of the resident's January 2026 POS showed staff did not update the order to reflect the correct frequency (daily) and direction to cut calcium alginate to fit in the wound. During an interview on 04/24/26, at 11:21 A.M., Licensed Practical Nurse (LPN) A said the following:-He/she completed wound care on the resident. He/she remembered doing wound care every day for a while, but then thought the order changed to every other day;-The wound care FNP visited the facility once a week. The FNP assessed the resident's wounds and made recommendations for wound care. The facility nurse entered the order into the computer, and the physician signed off on it;-The facility staff follow the recommendations of the wound care FNP if they assess the resident's wounds;-He/she did not know why the orders would not match the recommendations of the wound care FNP.During an interview on 04/24/26, at 1:28 P.M., LPN C said the following:-The resident's left big toe was being treated by staff to prevent infection;-He/she performed wound care on the resident the day before he/she left the facility;-The nurses follow the wound care recommendations made by the wound care FNP. If the wound care FNP updated wound care recommendations or orders the facility nurse wrote an order and the physician signed it;-He/she did not know the order for the big toe treatment frequency changed. He/she did not know decreasing treatment to every other day had not been recommended by the FNP. He/she does not know why the order was changed;-The orders in the computer should match the recommendations made by the wound care FNP.During an interview on 04/24/26, at 1:54 P.M., Registered Nurse (RN) D said the following:-He/she believed the nurses were supposed to follow the wound care recommendations from the wound care FNP unless the physician gives different orders;-He/she would contact the physician if the wound care orders did not match the recommendations made by the wound care FNP.During an interview on 04/24/26, at 12:33 P.M., the Wound Care FNP said the following:-The resident's left big toe had dry gangrene and was necrotic. He/she was trying to get the left big toe to dry up to facilitate self-amputation;-He/she came to the facility once a week and assessed the resident's wounds. He/she made recommendations for wound care, and the facility nurse would enter those recommendations into the computer as an order for the physician to sign;-He/she believed that the recommendations were being followed by the facility nurses;-He/she did not know the nurses had decreased the frequency of the left big toe treatment order for every other day. He/she did not regularly look at the orders in the computer after he/she relayed those orders to the nurse;-He/she did not decrease the frequency for the left big toe due to the increased drainage. The residents' increased activity caused the left big toe to have more drainage;-He/she expected the staff at the facility to follow his/her and the physician's recommendations/orders for wound treatment;-The facility staff should contact him/her if they need an order changed or if they have any concerns;-If the facility staff had questions regarding the wound care orders/recommendations, they can check his/her wound care progress notes.During an interview on 05/05/26, at 9:11 A.M., the resident's physician said the following: -The wound care FNP assessed and treated the resident's wounds;-He/she expected the facility staff to follow the wound care FNP's recommendations for wound care;-The staff generally rounded with the wound care FNP and would update or add any orders based on the wound care FNP's recommendations;-He/she did not know the wound order placed by the nurse for the resident's big toe did not match the recommendations from the wound care FNP;-He/she assumed that the order the nurse put in the computer matched the recommendations from the wound care FNP. During an interview on 04/24/26, at 4:32 P.M., the Director of Nursing (DON) said the following:-The wound care FNP came in once a week to assess and provide recommendations for the resident's wounds;-A facility nurse rounded with the wound care FNP while they completed their assessments of the wounds;-The wound care FNP communicates with the nurse recommendations for wound care treatments, and the nurse entered them into the computer for the physician to sign;-The nurse was expected to put the recommendations into the computer as a physician's order, they should match what is written in the wound care progress note;-He/she did not know that the order frequency for the left big toe did not match the recommendations in the wound care FNP note. He/she thinks it may have been a miscommunication with the nurse that put in the orders.During an interview on 04/24/26, at 5:15 P.M, the Administrator said the following:-He/she expected the nurses to enter orders per the recommendations from the wound care FNP. If the staff has concerns, they should contact the physician;-He/she expected staff to follow physician orders for wound care treatments.Complaint #2992931

Based on interview and record review, the facility failed to protect each resident's right to be treated with dignity and respect when one staff (Certified Medication Tech (CMT) F) spoke to one resident (Resident #1) disrespectfully in a raised voice and threatening manner. The facility census was 70.Review of the facility policy titled, Your Rights, As a Resident in a Long-Term Care Facility, undated, showed the following:-Residents will always be provided with the highest level of care and service, and if for any reason a resident feels that such needs are not being met by their facility staff, they are entitled to a variety of avenues in which to resolve their concerns;-Residents shall be treated with consideration, respect, and full recognition of dignity and individuality.1. Review of Resident #1's face sheet (admission data) showed the following:-admission date of 06/28/23;-Diagnoses included unspecified dementia (loss of memory) and schizophrenia (impairment in a person's daily functioning).Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/05/25, showed the following information:-Memory problems with moderately impaired cognitive skills;-No behaviors noted.Review of the resident's care plan, revised on 07/01/25, showed the following:-Has history of suicidal ideation;-There are times when the resident may act and say things that are not real or true. Staff to provide frequent monitoring and support;-Received antipsychotic medications related to schizoaffective disorder;-Risk for pain related to my medical complexities;-Receiving anti-anxiety medications.Review of the resident's progress notes dated 08/30/25, at 1:50 P.M., showed the Director of Nursing (DON) documented the resident and Certified Medication Tech (CMT) F noted to have had a verbal disagreement in hallway during medication pass. The resident became agitated, smacked the medication cart with his/her hand, and called the staff member a bitch. Staff members intervened separating the resident and the CMT. Situation was deescalated and resident was redirected to his/her room without further incidence.Review of the resident's written statement, undated, showed the resident said he/she rolled his/her wheelchair to the medication cart and asked for his/her medications from CMT F. He/she was told he/she would have to wait. The resident said he/she did not want to wait until noon to get his/her meds. At this time the resident smacked the cart with his/her hand and called the staff member a bitch because he/she was upset, due to the fact the CMT F's response was if the resident kept asking , the resident would be the last person to receive his/her meds.During interviews on 09/03/25, at 10:19 A.M. and 10:35 A.M., the resident said the following:-He/she had some issues with getting his/her medications late;-CMT F didn't want anyone near his/her cart, but wanted to go room-to-room to pass the resident's medications;-On 08/30/25, around 10:00 A.M., he/she needed his/her pain meds as he/she had pain. On a scale of 1 to 10, 10 being the highest, she rated his/her pain that morning at 8. He/she asked CMT F for his/her pain meds. CMT F told him/her the meds would get passed out when they get passed out. The resident said he/she did hit the medication cart, as he/she was upset by what CMT F had said. After the resident hit CMT F's med cart, the CMT said if you hit my cart again that will be the last time you hit it;-He/she didn't know if CMT F was threatening him/her, as they had been arguing. He/she didn't want to be around CMT F because he/she was not friendly.Review of Certified Nurse Aide (CNA) H's written statement, undated, showed CNA H noted he/she was coming out of another resident's room, into the hallway. He/she overheard CMT F say if you bump into my cart one more time it will be the last time you ever bump into the cart.During an interview on 09/04/25, at 8:55 A.M., CNA H said if he/she was working on 08/30/25 during the day. He/she could hear CMT F as he/she was talking with a raised voice. CMT F said to the resident, if he/she hit the cart one more time, that would be the last thing the resident hit. He/she said that it wasn't something to say to a resident and it was disrespectful and threatening.Review of the Housekeeper Supervisor's (HS) written statement, undated, showed he/she was in the hallway and overheard a verbal altercation between the resident and CMT F. He/she said the resident approached the medication cart asking for his/her morning medication. CMT F responded with you will have to wait, I will get to you and to stop speaking to CMT F that way. He/she states the resident was not rude when asking for his/her medication and replied, I'm just asking for my morning meds.Review of CMT F's written statement, undated, showed CMT F noted he/she was in the hallway passing meds to another resident. The resident rolled up to his/her cart asking for his/her morning medication and CMT F told the resident he/she would have to wait since there were three more residents ahead of him/her. At that time the resident hit the med cart and called CMT F a bitch. CMT F said the resident said he/she was going to kick his/her ass and CMT F's response back to the resident was if you hit me, it will be the last time you hit anyone.During an interview on 09/03/25, at 2:36 P.M., CMT F said the following:-On 08/30/25, he/she started down 100 hall, straight from the dining room;-The resident was about second or third from the end of the hall. He/she was a few rooms up from the resident, getting another resident's medications ready. The resident came out of his/her room and was speaking to another resident;-CMT F was popping the medication for the resident that Resident #1 was speaking too. Resident #1 said to the other resident, he/she was not doing this shit today, this bitch was not giving me my meds at 12;-Resident #1 asked CMT F when he/she was going to get his/her medications. CMT F told the resident there were three people in front of him/her and it was only 8:00 A.M.;-The resident was going past him/her, when the resident turned his/herself around and said to the CMT that he/she still wanted his/her meds and it wouldn't take long;-CMT F said he/she was doing someone else's and the resident said bitch this, bitch that and hit the medication cart. CMT F said don't hit the cart and the resident said bitch, he/she would do what he/she wants;-CMT F screamed for RN C and told RN C the resident was calling him/her bitch. RN C came around the corner and he/she told RN C the resident kept hitting and kicking the cart;-RN C took the resident somewhere;-The resident came back and he/she was still passing medications. The resident said something about CMT F dying and the resident was going to whoop my ass. CMT F said to the resident if you touch CMT F, it will be the last person the resident hit. He/she went to find RN C and called the DON;-He/she has been told in the past that he/she can't demand someone to give him/her the respect he/she thinks he/she should receive;-CMT F said what he/she meant by the statement to the resident was that he/she would call the police.Review of the DON's written statement, undated, showed the DON was notified by the charge nurse that it had been reported to him/her, that CMT F had stated to the resident, if you hit my cart again it will be the last time you hit anything. The resident and CMT F were immediately separated and situation de-escalated.During an interview on 09/03/25, at 1:24 P.M., CMT A said it would not be appropriate to threaten a resident as that was against their rights as a resident.During an interview on 09/03/25, at 1:32 P.M., RN B said the following:-On 08/30/25, he/she could hear CMT F in the hall, and he/she was going to the nurses' station, from another resident's room. He/she heard CMT F say this lady is kicking my med cart, I need you to come up here;- He/she went to the cart and CMT F was near the cart, but the resident was not close to the cart. He/she asked the resident to go to his/her room and he/she told CMT F he/she needed to be professional and could not fight with residents;-CMT F got louder and said you don't understand, he/she's kicking my med cart. RN B said we have to watch our presentation. We can all get overwhelmed;-As he/she walked away, CMT F kept saying if he/she kicks my med cart one time, and I didn't hear exactly what CMT F said, but CNA H was there and heard it. He/she thought CMT F said something like, that would be the last time he/she kicked my cart. He/she was not sure of exact words, but felt it was a threat. RN C was the charge nurse and he/she reported it to the DON;-Threats are disrespectful.During an interview on 09/03/25, at 1:50 P.M., RN C said the following:-CMT F began his/her medication pass, going down 300 hall. He/she came out of a resident's room and a nurse aide was standing in the center at the ends of all the halls. The CNA H said hey, we need you something going on.;-CMT F was at his/her cart and the resident was close to the cart. By the time he/she had gotten close, it had settled down. After the disagreement at med cart, he/she asked the resident to go back to his/her room, they would get his/her meds, but it would be just a bit. The resident went outside to have a cigarette. The resident said to RN C, that CMT F said he/she was going to make the resident his/her last one to received medications. RN C told the resident not to worry about it as he/she wouldn't allow that to happen as that wouldn't be appropriate. He/she thought that was the end and CNA A came to him/her and said that CMT F told the resident if you bump into my cart that will be the last time you bump my cart;-He/she messaged the DON;-RN C got the resident's meds and administered them.During an interview on 09/03/25, at 2:12 P.M., CNA D said threats would be disrespectful.During an interview on 09/03/25, at 2:27 P.M., CNA E said he/she has seen CMT F be hateful to residents. If staff threaten a resident, it's disrespectful.During an interview on 09/04/25, at 8:45 A.M., Licensed Practical Nurse (LPN) G said the following:-He/she has witnessed CMT F be disrespectful to residents;-Saying to a resident if they do something that will be the last time they do it would be disrespectful.During an interview on 09/03/25, at 3: 24 P.M., the DON said the following:-If staff suspect something against a resident's rights, they need to report that to the charge nurse and the DON;-Some residents have behaviors, but staff have received training on interventions;-If a resident is having a bad day, staff need to help them to feel better;-The resident does have triggers;-He/she was notified by CMT F about the incident with the resident and when on the phone with the CMT, the charge nurse also called;-RN C reported to the DON that CMT F said to the resident if you hit the med cart again it would be the last time you do that. When the DON questioned CMT F what was meant by the statement, the CMT said he/she meant things could be done like notifying the nurse, calling the police or medication changes;-The statement like that should never be made to a resident and it is disrespectful.During an interview on 09/04/25, at 10:05 A.M., the Administrator said the following:-He/she expected staff to intervene if they see staff treating residents disrespectfully;-He/she expected staff to report any concerns related resident rights to the nurse and administration;-It is not acceptable to say to a resident if you touch me or my med cart, or hit me or my med cart, I'll be the last person you hit.Complaint #2604357

Based on observation, interview, and record review, the facility failed to provide care per policy and standards of practice and failed have a system in place for timely administration of medications to residents when staff administered one resident's (Resident #2) medication late. The facility census was 70.Review of the facility's policy titled, Medication, Administration Guidelines, undated, showed the following:-It was the purpose of this facility that residents receive their medications on a timely basis and in accordance with established policies.1. Review of Resident #2's face sheet (brief resident profile) showed the following information:-admission date of 08/21/25;-Diagnoses included bipolar disorder (mental health condition with extreme mood swings between periods of mania), anxiety disorder, heart failure, hypertension (high blood pressure), and heart failure.Review of the resident's September 2025 Physician Order Sheet (POS) showed the following: -An order, dated 08/21/25, for alprazolam (used to treat anxiety) 1 milligrams (mg), three times daily as needed for anxiety;-An order, dated 08/21/25, for carvedilol (used to treat circulation issues in the heart) 25 mg, two times daily, for heart issues;-An order dated 08/21/25, for clonidine HCI (high blood pressure) 0.1 mg, two times daily, for high blood pressure;-An order, dated 08/21/25, for lamotrigine (used to treat epilepsy and bipolar disorder) 150 mg, one tablet by mouth two times per day, for bipolar disorder;-An order, dated 08/21/25, for loperamide (used to control diarrhea) 2mg capsule every six hours as need for diarrhea;- An order, dated 08/21/25, for magnesium oxide 400 mg tablet, one tablet by mouth two times a day for chronic diastolic heart failure; -An order, dated 08/21/25, for oxycodone (used to treat pain) 10 mg tablet, one tablet every six hours as needed for pain;- An order, dated 08/21/25, for pantoprazole (used to treat heart burn) 40mg tablet, one table two times per day, for gastro-esophageal reflux disease, one scoop by mouth one time a day related to constipation;-An order, dated 08/21/25, for promethazine (used to treat nausea) 25 mg tablet , one tablet every eight hours as needed for nausea;-An order, dated 08/21/25, for Ventolin HFA inhaler (used to treat asthma) 90 micrograms, (breathing problems) two puffs every four hours as needed for asthma;- An order, dated 08/22/25, for aspirin 81 mg by mouth one time per day for long term use of aspirin;- An order, dated 08/22/25, for lisinopril 40 mg (used treat high blood pressure) tablet, one tablet by mouth one time a day for high blood pressure;-An order, dated 08/22/25, for lurasidone 80 mg (used to treat bipolar disorder) two tablets by mouth one time daily for bipolar disorder;-An order, dated 08/22/25, for sertraline 100 mg (used to treat bipolar disorder) two tablets one time daily for bipolar disorder;-An order, dated 08/27/25, for trazadone 100 mg (used to treat sleep problems), give with 150 mg to equal 250 mg at bedtime for insomnia (sleep disorder);- An order dated 08/27/25, for trazadone 150 mg, give with 100 mg to equal 250 mg at bedtime for insomnia.Review of the resident's September 2025 Medication Administration Record (MAR) showed the following medications were scheduled for administration at 8:00 A.M. -Aspirin 81 mg;-Carvedilol 25 mg;-Clonidine 0.1 mg;-Lamotrigine 150 mg;-Lisinopril 40 mg;-Lurasidone 80 mg;-Magnesium 400 mg;-Pantoprazole 40 mg-Meclizine HCI 12.5 mg;-Sertraline 200 mg.Observation on 09/03/25, at 10:09 A.M., showed Certified Medication Technician (CMT) A prepared medications for administration to the resident including the following medications:-Aspirin 81 mg;-Carvedilol 25 mg;-Clonidine 0.1 mg;-Lamotrigine 150 mg;-Lisinopril 40 mg;-Lurasidone 80 mg;-Magnesium 400 mg;-Pantoprazole 40 mg-Meclizine HCI 12.5 mg;-Sertraline 200 mg.-CMT A administered all medications as at 10:15 A.M., two hours and 15 minutes after the scheduled administration time. During an interview on 09/03/25, at 9:45 A.M., the resident said he/she doesn't always get his/her meds at the scheduled time. He/she got his/her 8:00 P.M., meds around 9:00 P.M. or 9:30 P.M. yesterday.During an interview on 09/03/25, at 1:24 P.M., Certified Medication Technician (CMT) A said the following:-The MARs tell staff which medications and times the medications are to be administered;-Staff clicks each medication in the electronic record and that indicated staff administered the medication;-Medications can be administered one hour before or after the time they're due, if it's given after that time frame it's late;-There is one CMT for halls 100, 200, and 300, which is around 50 residents. He/she has the heaviest medication load in the morning and some medications are always late.During interviews on 09/03/25, at 1:32 P.M., Registered Nurse (RN) B said the following:-The MARS shows staff what medications to administer and the time to administer:-The facility has one CMT for halls 100 through 300, and one CMT on 400 and 500 halls;-Medications may be administered one hour before and one hour after the prescribed time. If staff administer an 8:00 A.M., after 9:00 A.M., it would be given late;-Staff should be administering medications as ordered by the physician.During interviews on 09/03/25 at 1:50 P.M., RN C said the following:-The facility has one CMT to administer medications on 100 through 300 halls and one back in the academy;-Medications can be administered one hour prior and one hour after the ordered time;-He/she knows there are timeliness issues;-Staff should be passing them within the time frames.During an interview on 09/03/25, at 2:12 P.M., Certified Nurse Aide (CNA) D said he/she has received complaints from residents about medications not being passed timely, mainly in the afternoon.During an interview on 09/03/25, at 2:27 P.M., CNA E said he/she has received complaints about residents not getting their medications timely.During an interview on 09/03/25, at 2:36 P.M., CMT F said the following:-He/she knows which meds to pass by looking at the MAR;-He/she knows the staff have one hour before and one hour after the time to pass a medication;-He/she passed medications as ordered, except it's impossible to pass them on time as he/she was responsible for 58 residents.During an interview on 09/03/25, at 3:24 P.M., the Director of Nursing (DON) said the following:-He/she has two CMTs that work the floor. One is on the 400 and 500 halls and the other covers 100 through 300 halls. The 100 to 300 halls have around 49 residents. It's the responsibility of the CMT to pass all the meds on their halls;-Medications can be passed one hour before and one hour after the ordered time;-If the medication is ordered at 8 A.M., and it's administered after 10:00 A.M., that would be considered late;-He/she expects staff to pass medications as ordered by the physician.During an interview on 09/04/25, at 8:45 A.M., Licensed Practical Nurse (LPN) G said the following:-Staff know what medications and times to pass meds by looking at the MAR. Medications may be passed one hour before and one hour after the ordered time;-If a medication is ordered at 8:00 A.M., it would need to be passed no later than 9:00 A.M. Passing an 8:00 A.M., med after 10:00 A.M., would mean it's late and it would be a medication error;-Staff should be following the physician's orders.During an interview on 09/04/25, at 10:05 A.M., the Administrator said the following:-He/she wasn't aware medications were being administered late, until yesterday;-If the medication is not administered timely, an hour before or an hour after the med time, by policy it could be a medication error;-He/she expected staff to pass medications as ordered.Complaint 2604358

Based on record review and interview, the facility failed to provide pharmacy services to meet the needs of each resident when the facility failed to properly transcribe ordered medications, failed to clarify medication orders timely, and failed to administer medications as ordered for one resident (Resident #4) went he/she discharged from the hospital. The facility census was 70.Review of the facility's policy titled, Physician's Orders, undated, showed the following:-Physician's orders must be signed by the physician and dated when such order was signed;-Current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors;-Physician's orders must be reviewed and renewed;-Medication orders specify the type, route, dosage, frequency, and strength of the medication orders.Review of the facility's policy titled, Medication, Administration Guidelines, undated, showed the following:-It is the purpose of this facility that residents receive their medications on a timely basis and in accordance with established policies;-If there is doubt concerning the administering of medications, the physician's order must be verified before the medication is administered.1. Review of Resident # 4's face sheet (brief resident profiled) showed the following information:-admission date of 07/05/25 with latest return of 08/08/25;-Diagnosis included schizoaffective disorder, bipolar type (mental health condition that combines symptoms such as hallucinations, delusions with bipolar symptoms such as high or low episodes), anxiety disorder (excessive worry), insomnia (sleep disorder causing difficulty with falling or staying asleep), unspecified psychosis (experiences symptoms such as delusions), depression (persistent feelings of sadness), post-traumatic stress disorder (PTSD (condition that develops after experiencing or witnessing a traumatic event), and pain disorder exclusively related to psychological factors.Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by staff), dated 07/10/25, showed the following:-Cognitively intact;-Independent with all daily living skills;-No behaviors noted.Review of the resident's care plan, last revised on 07/08/25, showed the following:-Resident has history of/at risk for suicidal ideation. Resident had documented events, associated with suicidal and hospitalizations. Staff to assess for suicidal thoughts. Staff to place resident 1:1 observations. Staff to observe for signs/symptoms of depression;-Resident has PTSD, has developed fear, terror, dread, or helplessness following exposure to a traumatic event. Maintain safety and integrity during post traumatic episode, using appropriate therapeutic interventions;-At times resident may act or say things that are not real or true;-Resident at risk for mood changes, adjustment issues, side effects of medications due to chronic schizoaffective disorder, bipolar type. Staff will administer anti-depressants as directed. Assess/document/review with physician any side effects. Staff will administer anti-psychotic as directed and assess for any side effects. Assess/document/report to physician any changes in mood/behaviors;-Resident is unable to make decisions on his/her own due to schizoaffective disorder, bipolar type. Therefore, resident has a guardian who makes decisions for him/her.Review of the resident's August 2025 progress notes showed the following:-On 08/02/25, at 7:02 P.M., Licensed Practical Nurse (LPN) G documented the resident presented to the nurses' station and said he/she wasn't feeling well. Certified nurse aide (CNA) obtained vitals which were stable. The resident went to the dining area and told another resident that he/she was dizzy and didn't feel well. This nurse directed a CNA to get a wheelchair and take the resident to his/her room to lie down. The resident cursed at the nurse and proceeded to his/her room. After several minutes this nurse went to the resident's room and talked with the resident. The resident said his/her significant other just broke up with him/her and he/she wanted to self-harm. The nurse contacted the guardian and received permission to send resident to the hospital for evaluation and treatment. Resident exited building approximately 6:00 P.M.;-On 08/04/25, at 1:07 P.M., the resident returned to the facility with new orders entered. Physician communication sent for provider to advise on changes per hospital discharge and red alerts triggered for clozapine (antipsychotic medication primarily used to treat severe, treatment-resistant schizophrenia) and changes made to oxybutynin (used to treat symptoms of an overactive bladder) per hospital discharge with physician communication to advise.Review of the physician communication form, dated 08/04/25, showed form sent to the medical director, stating new order for fluphenazine (antipsychotic medicine that is used to treat psychotic disorders such as schizophrenia) 5 milligram (mg) two tablets three times daily, triggers a red alert with clozapine, and Seroquel (used to treat the symptoms of schizophrenia, bipolar disorder and major depressive disorder) 300 mg at bedtime for insomnia triggers red alert for clozapine. Please advise on adding new orders. Review of the resident's discharge papers, dated 08/04/25, showed the following medications:-Propranolol (used to treat blood pressure) 20 mg, one tablet by mouth three times daily;-Fluphenazine 5 mg, two tablets by mouth three times daily for psychosis;-Divalproex sodium (anticonvulsant) 500 mg, one tablet by mouth, twice daily for mood stabllizer;-Benztropine (used to treat involuntary movements) 1mg, one tablet by mouth twice daily for extrapyramidal symptoms (a group of side effects that can occur with certain medications, particularly antipsychotic drugs. They affect the motor system, causing involuntary movements, muscle stiffness, and other symptoms);-Gabapentin (used to treat nerve pain) 300mg, one tablet by mouth three times daily for mood stabilizer;-Seroquel 300 mg, two capsules by mouth at bedtime for insomnia;-Pantoprazole (used to treat damage from gastroesophageal reflux disease (GERD - a condition in which backward flow of acid from the stomach causes heartburn)) 40 mg, one table by mouth daily for heartburn;-Nicotine patch, 14 mg/24 hour transdermal film, extended for nicotine cravings;-Ketoconazole (used treat fungal infections) topical 2% cream, apply daily for skin protection;-Lasix (increase the flow of urine to remove excess fluid) 20 mg one tablet by mouth daily for fluid retention;-Clotrimazole (treats fungal and yeast infections) topical, 1 % cream, apply twice daily;-Miralax (stool softener), one packet by mouth daily;-Oxybutynin 5 mg, two tablets by mouth daily for urinary discomfort;-Magnesium oxide (used for laxative) 400 mg, one tablet daily by mouth.Review of the August 2025 Physician's Order Sheet (POS) showed the following:-An order, dated 02/01/24, metformin (works by decreasing the amount of sugar the liver produces) 500 mg, one tablet by mouth twice daily for obesity;-An order, dated 06/10/24, levetiracetam (medication to prevent seizures) 500 mg, one tablet by mouth twice daily for epilepsy;-An order, dated 10/30/24, for magnesium oxide 400 mg, one tablet by mouth for hypomagnesemia;-An order, dated 11/13/24, Lasix 20 mg, one tablet daily for chest pain;-An order, dated 02/25/25, Depakote (divalproex sodium) extended release XR 500mg, tablet by mouth, twice daily for schizoaffective disorder, bipolar type;-An order dated 02/25/25, pantroprazole 40 mg, one tablet by mouth for esophageal reflux disease;-An order dated 02/25/25, for propranolol 20 mg, tablet by mouth, three times daily for high blood pressure;-An order dated 02/26/25, for gabapentin 300 mgs, two capsules by mouth for persistent mood disorders (discharge orders were for gabapentin 300mg one tablet by mouth three times daily);-An order dated 04/08/25, for Prazosin (used for nightmares) 1 mg, tablet by mouth at bedtime for PTSD;-An order dated 04/09/25, for Prazosin, 1 mg tablet by mouth as needed for PTSD;-An order, dated 04/20/25, clozapine 50 mg, tablet by mouth twice daily for schizoaffective disorder, bipolar type;-An order, dated 08/04/25, benztropine 1 mg tablet, twice daily for extrapyramidal and movement disorder;-An order dated 08/04/25 nicotine patch, apply 24 hours for nicotine cravings;-An order dated 08/04/25, oxybutynin chloride (used to treat overactive bladder) 15 mg, tablet by mouth daily for dysuria (discharge orders were for 5 mg, two tablets by mouth daily).(Staff did not add the hospital discharge orders for fluphenazine, Seroquel, ketoconazole, clotrimazole, or Miralax.)Review of the provider transition of care visit with the nurse practitioner (NP), dated 08/05/25, showed the following:-Resident seen in the dining hall;-Resident sent to the hospital for suicidal ideation after break-up with significant other who was also a resident. He/she was deemed able to return to the facility on [DATE]. Medication changes, added Seroquel 100 mg at bedtime;-Chart review, medications reconciled with facility management and administrative reporting;-Medications reviewed, recommended Seroquel not in place, added;-Current medications reviewed.Review of a provider order form, dated 08/05/25, showed an order for 300 mg of Seroquel at bedtime approved by provider.Review of the August 2025 POS showed staff did not add the order for Seroquel to the POS.Review of the resident's August 2025 Medication Administration Record (MAR) showed the following:-On 08/04/25, benztropine 1mg tablet, at 5:00 P.M., no staff signed off as administering the medication or documented a reason for not administering the medication; -On 08/04/25, clozapine 50 mg tablet, at 5:00 P.M., no staff signed off as administering the medication documented a reason for not administering the medication; -On 08/04/25, gabapentin 300 mg, two capsules at 5:00 P.M., no staff signed off as administering the medication documented a reason for not administering the medication;-On 08/04/25, levetiracetam 500 mg tablet at 5:00 P.M., no staff signed off as administering the medication documented a reason for not administering the medication; -On 08/04/25, Metformin 500 mg tablet at 5:00 P.M., no staff signed off as administering the medication documented a reason for not administering the medication; -On 08/04/25, Metformin 500 mg tablet at 5:00 P.M., no staff signed off as administering the medication documented a reason for not administering the medication;-On 08/04/25, propranolol 20 mg tablet, ordered at 7:00 P.M., no staff signed off as administering the medication documented a reason for not administering the medication; -On 08/04/25, Depakote ER 500 mg tablet, ordered at 8:00 P.M., no staff signed off as administering the medication documented a reason for not administering the medication; -On 08/04/25, Prazosin 1 mg tablet, ordered 8:00 P.M., no staff signed off as administering the medication documented a reason for not administering the medication. Review of the resident's August 2025 progress notes showed the following:-On 08/07/25, at 5:00 P.M., resident observed standing at receptionist desk at approximately 12:10 P.M., and turned to this nurse passing by to ask what would happen if he/she cut his/herself so deep he/she bled to death. Nurse spoke briefly to the resident who said he/she was suicidal, before the nurse reported information to the Assistant Director of Nursing (ADON)/Director of Nursing (DON) and the NP. NP ordered 15-minute checks and noted resident was not currently receiving Seroquel. The nurse noted Seroquel was not on the current medication list in the electronic health record, called pharmacy to request Seroquel, and entered order in electronic health record (HER) for Seroquel to match dose given at the hospital during hospitalization. NP informed of the discrepancy between the 100 mg of Seroquel the NP originally ordered, and what the resident reportedly received in the hospital. The written order was updated to reflect the 300 mg dose given at the hospital. When entering medication changes from the hospital into EHR, other discrepancies were noted. Communicated with NP and DON, discrepancies, and per NP, all medications changed back to those the resident was on prior to hospitalization. Resident discussed how he/she was feeling with DON and then with the nurse up until approximately 1:25 P.M. This nurse employed therapeutic communication, and suggested resident may benefit from counseling to assist the resident in working through his/her concerns and toward achieving his/her goals, but the resident did not seem interested. Resident was ultimately hospitalized .During an interview on 09/03/25, at 1:24 P.M., Certified Medication Technician (CMT) A said the following:-Medication changes are added to the EHR by the nurse on duty. If a resident is returning from the hospital, the nurse looks at the discharge from the hospital to see which medications a resident is supposed to take;-He/she doesn't know if anyone monitors the medications to see if they're added to the EHR accurately;-He/she did know the resident went to the hospital, but he/she didn't know if there were any medication changes;-The MARs tell staff which medications and times the medications are to be administered;-He/she follows the MAR.During interviews on 09/03/25, at 1:32 P.M., Registered Nurse (RN) B said the following:-The nurse is the one that adds any new orders for residents;-He/she didn't know the full process of who does what;-When a resident returns from the hospital the admitting nurse would add the new medication orders;-The MARS shows staff what medications to administer and the time to administer:-Staff should be administering medications as ordered by the physician.During interviews on 09/03/25, at 1:50 P.M., RN C said the following:-The nurse working the floor usually adds any new medication orders to the EHR for residents. If it's during the week, there may be others that could add them;-He/she puts in the exact orders on a discharge sheet from the hospital;-Some medications may not be covered by insurance, and they reach out to the pharmacy to see if there is a formulary, then staff get a new order from the doctor;-The MAR shows what medications should be administered and the time;-He/she wasn't working when the resident returned from the hospital the first time, so he/she doesn't know if the residents' medications were put in accurately;-If it's a new medication and they can't get the medication, they should document but sometimes he/she doesn't when he/she has more important things to do;-Staff should follow physician's orders, the ones in the EHR;-If staff have questions, they message the providers.During an interview on 09/03/25, at 2:36 P.M., CMT F said the following:-He/she knows which meds to pass by looking at the MAR;-He/she passed medications as ordered.During an interview on 09/04/25, at 8:45 A.M., Licensed Practical Nurse (LPN) G said the following:-Depending on how busy things are when a resident returns from the hospital, would indicate who puts in the medication orders;-If it's during the evening or weekend, the charge nurse is responsible for putting the discharge orders into the computer;-The medications listed on the discharge paperwork would be the medications that need to be put into the EHR;-If he/she had questions, and depending on what they're in regards too, he/she would either call the pharmacy or provider for clarification or new orders;-If a medication is not administered it would be a medication error;-Medications should be administered as ordered;-If they have questions about medications, they reach out to the provider and document that in the progress notes;-Staff should be following the physician's orders. During an interview on 09/03/25, at 3: 24 P.M., the DON said the following:-When a resident is discharged from the hospital, they will have discharge orders and the nurse admitting the resident is responsible for making changes in the computer for any medications. Sometimes there are others to help during the week;-The admitting nurse should put the medications into the system as they are listed on the hospital discharge. The provider does sign off on the medication changes from the hospital;-He/she didn't believe there were any changes for the resident after his/her hospital stay on 08/02/25, he/she would need to look;-Staff would have put the orders in as they were received from the hospital;-He/she remembered there being an issue with the fluphenazine, but he/she doesn't remember anything about the resident missing any medications, such as Seroquel;-He/she expected the medications to be administered as ordered.During an interview on 09/04/25, at 9:20 A.M., the NP said the following:-Staff are supposed to consult with the provider or him/her after a resident is discharged from the hospital;-In the situation with this resident, he/she was told the resident did not get back with discharge papers, so he/she is not sure how they put in different medications;-The nurse that admitted the resident added medications the resident had not been on since the resident was admitted in February or March;-He/she was able to access the hospital records and it the facility nurse did not put in the correct medications, the nurse put in several medications the resident isn't taking;-He/she told the nurse to put the resident back on the medications the resident was taking when he/she went to the hospital;-He/she didn't get the paperwork from the hospital until 08/07/25;-He/she knew the hospital had the resident taking the fluphenazine, but the resident hadn't been on this medication since February;-He/she didn't know if the facility sent the resident with any paperwork showing the medications the resident has been taking at the facility, but he/she should have been sent with current orders;-The resident was discharged from the hospital on [DATE]. He/she saw the resident at the facility on 08/05/25. The facility had no documentation from the hospital on which meds the resident was to be taking;-The medication list in the EHR on 08/05/25 did not match anything;-He/she expected staff to give medications as ordered and if they have questions, they need to reach out to the providers;-The nurse that admitted the resident placed orders for medications that should not have been done;-It took until 08/07/25 to get the medications straightened out, and the resident had already gone back to the hospital;-He/she doesn't change psychiatric meds because he/she is not a psychiatrist and expects an MD or psych doctor to make the necessary changes;-If staff don't pass medication as prescribed it's a medication error;-A similar incident happened back in February or March when the staff doubled all the resident's medications and he/she almost overdosed.During an interview on 09/04/25, at 10:05 A.M., the Administrator said the following:-The charge nurse that's admitting a resident from the hospital is in charge of verifying the medication orders with the attending physician. Typically, there would be a system to double, or triple check the system to ensure medications are entered and administered as ordered;-He/she would expect staff to add medications as ordered from the hospital. If there are questions, he/she would expect staff to reach out to the provider, and document the information;-He/she expected staff to pass medications as ordered.Complaint 2584214

Based on observation, interview, and record review, the facility failed to ensure an environment as free of accident hazards as possible when the facility failed to complete a smoking assessment per policy and failed to care plan smoking for one resident (Resident #268) and when staff allowed three residents (Resident #27, #48, and #67), who were care planned to store smoking supplies at the nurses' station, to maintain smoking supplies on their person and in their room. The facility census was 75. Review of the facility's Smoking and Marijuana Use Policy, undated, showed the following: -All residents are advised that the facility is a supervised smoking facility; -There is a designated smoking area outside; -All smoking materials will be kept at the nurses' stations in an approved smoking container when not in use; -Residents are not to keep smoking materials, electronic or vapor smoking replacement devices (including juice), or smokeless tobacco in their rooms. -At no time are residents permitted to store tobacco, tobacco paraphernalia, or lighters in their rooms. -Residents will be accompanied by a staff member during all smoke breaks where cigarettes will be provided and the staff member will have the lighter, unless a residents has been assessed to smoke on their own. At that time a resident will be able to ask a staff member to provide them with a cigarette and lighter and smoke on their own; -After the resident has finished smoking all remaining materials will be turned back into the nurses' station; -All smoking will be supervised to ensure the safety of the residents, staff, and the facility, unless a smoking assessment has determined that the resident is safe to smoke on their own. 1. Review of Resident #27's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnosis included chronic obstructive pulmonary disease (COPD - a chronic lung disease causing restricted airflow and breathing problems), diabetes, atrial fibrillation (irregular rapid heart rate that causes poor blood flow), infection of the kidneys, and acute upper respiratory infections. Review of the resident's admission packet showed the following: -Resident rules and regulations related to smoking signed on 01/24/22 by the resident the Social Service Director (SSD) and a staff representative as the witness; -For safety reasons, the resident and any visitors to this facility are hereby advised not to smoke except under supervision and/or in designated smoking areas; -Residents may not retain matches or lighters. Review of the resident's Smoking Risk assessment dated , 11/01/24, showed the resident was a safe smoker and should follow facility policy. Review of the resident's Care Plan, dated 01/03/23 and last reviewed on 12/03/24, showed following: -The resident was at risk for potential complications related to smoking cigarettes; -The resident will continue to be safe and follow instructions with smoking; -The resident will maintain cigarettes and lighter at the nurses' station; -The resident will not smoke in his/her room or bathroom or other portions of the facility Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 11/01/24, showed the resident was cognitively intact. During an interview on 12/09/24, at 2:30 P.M., the resident said he/she can smoke when he/she wants to and he/she carries cigarettes and a lighter on his/her person. He/she keeps his/her cigarettes and lighter in his/her room. The staff do not keep his/her cigarettes or lighter locked up. An interview and observation on 12/10/24, at 12:20 P.M., showed the following: -The resident's pack of cigarettes with two cigarettes and one black lighter was in his/her black/red checkered jacket in his/her room; -The resident had a brand new pack of cigarettes in his/her jacket pocket; -The resident said he/she orders cigarettes and lighters from another state; -The resident showed a package of what would have been four to five lighters with one blue lighter left in pack kept in his/her nightstand cabinet near bed. During observations throughout the survey process, 12/08/24 through 12/13/24, showed the resident independently propelled self to the end of the 200 hall and exited through the door to a patio area, retrieved cigarettes and a lighter from his/her jacket pocket, and smoked several times through the day. 2. Review of Resident #268's face sheet showed the following: -admitted [DATE]; -Diagnoses included COPD, stroke, nicotine dependence, high blood pressure, and heart disease. Review of the resident's Admission Packet showed the following: -Resident rules and regulations related to smoking signed on 12/02/24 by the resident, the SSD, and a staff representative as the witness. -For safety reasons, the resident and any visitors to this facility are hereby advised not to smoke except under supervision and/or in designated smoking areas. -Residents may not retain matches or lighters. Review of the resident's care plan, dated 12/03/24, showed staff did not care plan related to the resident smoking or possession of smoking supplies. Review of the resident's admission MDS, dated [DATE], showed the resident was cognitively intact. Review of the residents medical record showed staff did not document completion of a smoking assessment. During an interview on 12/10/24, at approximately 1:00 P.M., the following the resident said he/she smokes unsupervised and keeps his/her cigarettes on his/her person and in his/her room. 3. Review of Resident #49's face sheet showed the following: -admitted [DATE]; -Diagnoses included polyosteoarthritis (degeneration of joint cartilage and the underlying bone affecting five or more joints at the same time) and tobacco use. Review of the resident's Smoking risk Assessment, dated 11/17/24, showed the reside was a safe smoker and should follow facility policy. Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's care plan, last reviewed on 11/26/24, showed the following: -The resident was at risk for potential complications related to smoking cigarettes; -The resident will continue to be safe and follow instructions with smoking; -The resident will maintain cigarettes and lighter at the nurses' station; -The resident will not smoke in his/her room or bathroom or other portions of the facility. Interviews and observations showed the following: -On 12/08/24, at 4:30 P.M., the resident was on the edge of his/her bed eating soup and sandwich. There were four individual cigarettes and one lighter on the resident's bedside table. The resident was planning to go outside to smoke after the meal; -On 12/09/24, at 2:25 P.M., the resident said he/she had to go to the nurses' station to get smoking supplies. The resident was leaving his/her room with a cigarette in his/her hand; -On 12/11/24, at 10:45 A.M., two cigarettes were on the resident's bedside table. The resident was not in the room; -On 12/11/24, at 11:16 A.M., after the nurse completed wound care the resident reached inside the bedside table and picked up a cigarette and left the room with the cigarette in his/her hand. 4. Review of Resident #67's face sheet showed the following: -admitted [DATE]; -Diagnoses included acute gastric ulcer (open sore that develops in the stomach lining) with hemorrhage (loss of blood from damaged blood vessel) and myocardial infarction (heart attack). Review of the resident's Admission Packet showed the following: -Resident rules and regulations related to smoking signed on 08/26/24 by the resident, the SSD, and an registered nurse (RN) witness; -For safety reasons, the resident and any visitors to this facility are hereby advised not to smoke except under supervision and/or in designated smoking areas. Residents may not retain matches or lighters. Review of the resident's care plan, last reviewed on 12/01/24, showed the following: -Resident chooses to smoke, at risk of injury or fire; -The resident usually smoked a pipe; -The resident will have supervised smoking in designated area and will smoke safety; -There will be a designated smoking area, designated time, and staff assigned will assist with residents that smoke; -Pipe and lighters are kept at the nursing station. Review of the resident's Smoking Risk Assessment, dated 12/01/24, showed the reside was a safe smoker and should follow facility policy. Review of the resident's quarterly MDS, dated [DATE], showed the the resident was cognitively intact. During interview and observation on 12/08/24, at 3:55 P.M., the resident was seated in a wheelchair in his/her room. The resident had a tobacco pipe, bag of tobacco grounds, and two lighters on the bedside table. The resident said he/she could come and go to smoke as wanted. 5. During an interview on 12/13/24, at 10:20 A.M., Certified Nurse Aide (CNA) H said that residents carry their own smoking supplies and extras supplies are kept in the medication room. The residents are able to visit each in others room. During an interview on 12/12/24, at 3:00 A.M., RN I said most of the residents who smoke keep their cigarettes and lighters on their person and in their rooms. The residents go outside unsupervised anytime of day or night. The smoking areas are the front entrance area or the patio off of 200 hall. During an interview on 12/13/24, at 12:48 P.M., the Director of Nursing (DON) said that smokers should be assessed for safe smoking and should have the information in the care plan. Some residents carry cigarettes on them daily, their lighter and cigarettes, and some are kept in the medication room. During an interview on 12/13/24, at 11:30 A.M., the Administrator said all residents should turn in their cigarettes and lighters after the smoke breaks. All Cigarettes and lighters should be kept locked up. Cigarettes and lighters cannot be kept on the resident's person or in the residents' rooms. Residents and staff should follow the policy for safety. The Administrator was not aware that residents were allowed to keep their cigarettes and lighters. 37358 41787

Based on observation, interview, and record review, the facility failed to ensure food prepared by the facility was palatable to the residents. The facility census was 75. Review of the facility policy, Food Temperatures, Nutrition and Dining Services Manual, dated May 2015, showed hot foods should be at least 120 degrees Fahrenheit (F) when served to the resident. 1. During an interview on 12/09/24, at 11:14 A.M., Resident #40 said the following: -He/she preferred to eat his/her meals in his/her room; -The food was cold probably at least half the time -He/she would like to have food that is warm, most of the time; -He/she said the eggs are always cold in the morning; -Eggs are his/her biggest complaint about the food, but it would be nice if it could all be warm. During interviews in the resident council meeting on 12/10/24, at 1:00 P.M., residents said the following: -Resident #36 said he/she believed the meat was of low quality and the food is not hot; -Resident #55 said he/she received at least half of his/her food barely warm or cold. -Resident #17 said that day's meal was cold. Observation of a sample hall meal tray on 12/11/24, at approximately 11:55 A.M., showed the following: -The meal consisted of apple glazed chicken, rice, lima beans, a slice of bread, and pears; -The food was not hot and tasted bland with no seasoning present; -The chicken temperature measured 127 degrees F, rice 129.7 degrees F, lima beans 123.2 degrees F, pears at 58 degrees F and two cups of tea read at 75 degrees F each. During an interview on 12/11/24, at approximately 12:25 P.M., Resident #33, said the following: -This was one of the worst meals that he/she has had since being at the facility; -A lot of the food here is not great, but this was very bad; -He/she said it was dry, cold, bland and gross to look at. Observation on 12/12/24, at 8:05 A.M., of a sampled meal tray showed the following: -The sausage patty was greasy and shriveled up as if cooked too long. -Temperature for the scrambled eggs read at 97.1 degrees F; -Temperature for the sausage patty read at 85.9 degrees F; -Temperature for the orange juice read at 54.2 degrees F; During an interview on 12/13/24, at 12:51 P.M., [NAME] T said the following: -Staff do audit trays to check temps if anyone complains about temps; -Drinks should be 32 degrees F or under; -The apple chicken meal is not the normal meal, with all the same colors, as earlier today; During an interview on 12/13/24, at 1:13 P.M., the Dietary Manager said the residents were not too crazy about the chicken meal just served yesterday; During an interview on 12/13/24, at 2:08 P.M., the Administrator said he expected staff to follow the policy regarding food service.

Based on observation, interview, and record review, the facility failed to keep food safe from potential contamination or bacterial growth when staff placed clean dishes upside down on a tray, while still wet, which could potentially contaminate any food, served from those items. The facility census was 75. 1. Review of the facility's policy, Dish Machine, Nutrition and Dining Services Manual, dated May 2015, showed the following: -Pull the rack out of the machine to air dry; -Allow to air dry and stack in proper area. Record review of the 1999 Food Code, issued by the Food and Drug Administration, showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food; -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Observation on 12/08/24, at 2:10 P.M., showed the following: -110 plastic bowls were stacked, upside down, with visible water droplets trapped, preventing air flow; -78 dessert cups were stacked, upside down, with visible water droplets trapped, preventing air flow; -74 ceramic plates were stacked, upside down, with visible water droplets trapped, preventing air flow; -73 serving trays were stacked, upside down, with visible water droplets trapped, preventing air flow. Observation on 12/10/24, at 10:00 A.M., showed the following: -114 plastic bowls were stacked, upside down, with visible water droplets trapped, preventing air flow; -76 dessert cups were stacked, upside down, with visible water droplets trapped, preventing air flow; -86 ceramic plates were stacked, upside down, with visible water droplets trapped, preventing air flow; -73 serving trays were stacked, upside down, with visible water droplets trapped, preventing air flow; -72 plate covers were stacked, upside down, with visible water droplets trapped, preventing air flow; -6 metal steam table pans were stacked, upside down, with visible water droplets trapped, preventing air flow. Observation on 12/12/24, at approximately 11:50 A.M., showed the following: -58 Dessert cups were stacked, upside down, with visible water droplets trapped, preventing air flow; -29 plastic trays were stacked, upside down, with visible water droplets trapped, preventing air flow; -13 plate covers were stacked, upside down, with visible water droplets trapped, preventing air flow. During an interview on 12/13/24, at 12:35 P.M., Dietary Aide S said the following: -The dishes have to air dry before being putting away; -Dishes should be dry before being stacked. During an interview on 12/13/24, at 12:51 P.M., [NAME] T said all dishes should be dried and then put the dishes away. During an interview on 12/13/24, at 1:13 P.M., the Dietary Manager said the following: -Dishes should be air dried when pulled from the dishwasher, then stacked and put away. -Dishes should not be put away or stacked wet due to bacteria During an interview on 12/13/24, at 2:08 P.M., the Administrator said he expected staff to following food service policy.

Based on observation, record review, and interviews, the facility failed establish and maintain an effect infection control program when the facility failed to screen all staff for tuberculosis (a contagious infection that usually attacks the lungs) at hire when the facility failed to complete the two-step tuberculin (TB) skin test for three staff member (Certified Nurse Aide (CNA) N, Licensed Practical Nurse (LPN) D, Dietary Aide (DA) M), out of 10 sampled staff members, per facility policy and standards of practice. Staff also failed maintain catheters (a tube that is inserted into the bladder to drain urine) in a manner to prevent the possible introduction bacteria in the system when the catheter bag and tubing for one resident (Resident #14) was on the ground. Staff also failed to administer medication in manner to prevent possible contamination when staff touched medications and the inside of medication cups with bare hands to administer medications to five residents (Resident #47, #24, #24, #51, and #227). Staff also failed to conduct hand hygiene in a manner to prevent possible cross-contamination when staff failed to conduct hand hygiene during incontinent cares for one resident (Resident #38). Staff also failed to prevent possible cross-contamination when staff failed to sanitize items used in a resident room after providing wound care to two resident (Resident #49 and #60) prior to returning the items to the treatment cart. Staff also failed to complete hand hygiene to prevent possible cross-contamination when staff did not complete hand hygiene per standards of practice during wound care for one resident (Resident #60). Staff also failed to sanitize a multi-resident use glucometer (used to check blood glucose levels) per standards of practice and manufacture recommendations for two residents (Resident #42 and #3). The facility census was 75. 1. Review of the facility's policy, Tuberculosis Control, undated, showed the following information: -Provide a tuberculin skin test (Mantoux - five tuberculin units of purified protein derivative (PPD)) to all employees during the pre-employment procedures, unless a previous reaction greater than 10 mm (millimeters) is documented. If the initial skin test result is 0 to 9 mm, a second test should be given at least one week later and no more than three weeks after the first test; -All employees will be screened for TB; -Once the decision has been made to employ an individual, the individual will be asked for documentation of a prior PPD skin test that determines if an individual has TB; -If the employee does not have documentation of a prior PPD, the first step PPD will be administered by the nursing department, documented on the Employee Immunization Record, and must be read prior to or no later than the start date; -All PPDs will be documented on Employee Immunization Record including new hires and annual administration. After the PPD has been administered, the results will be documented in mm. Review of the Centers for Disease Control and Prevention website, updated 03/08/21, showed the following: -The TB skin test is performed by injecting a small amount of fluid (called tuberculin) into the skin on the lower part of the arm; -A person given the tuberculin skin test must return within 48 to 72 hours to have a trained health care worker look for a reaction on the arm; -Results should be documented in mm; -A second skin test should be administered one to three weeks later; -The test should be read 48 to 72 hours after administration; -The results should be documented in mm. 2. Review of CNA N's personnel record showed the following: -Date of hire as 07/31/23; -The first step TB was placed on 08/04/23 (five days after the CNA's hire date) and read on 08/06/23; -The second step was placed on 08/20/23, and read on 08/22/23. 3. Review of LPN D's personnel record showed the following: -Date of hire as 02/13/24; -The first step TB was placed on 02/15/24 and read on 02/19/24 (after the 48 to 72 hours window); -The second step TB was placed on 02/19/24 (the same day the first step was read). The second step was read on 02/22/24. 4. Review of DA M's personnel record showed the following: -Date of hire as 10/14/24; -The first step TB was placed on 10/25/24 (nine days after the DA's hire date) and read on 10/27/24; -The second step TB was placed on 11/01/24 (five days after the first step was read). The second step was read on 11/03/24. 5. During interview on 12/13/24, at 1:00 P.M., the Administrator said that newly hired staff should have the initial TB test done at orientation and the second step should not be started on the same day the first step was read. Staff should follow policy and procedure. 41787 6. Review of the Centers for Disease Control and Prevention (CDC) Clinical Safety: Preventing Catheter-Associated Urinary Tract Infections (CAUTI) web-site showed a CAUTI occurs when germs (usually bacteria) enter the urinary tract through the urinary catheter and cause infection. Maintain the catheter's closed sterile drainage system Review of the Guidelines for Prevention of Catheter-Associated Urinary Tract Infections 2009, updated 06/06/19, showed a catheter collection bag should not rest on the floor. Observation on 12/10/24, at 9:39 A.M., showed Resident #14 sat in his/her wheelchair in the dining room looking out the window. The resident's catheter (a tube that is inserted into the bladder to drain urine) bag was setting on the floor and the catheter tube was coming out of the resident's pant leg and was on the ground and under the resident's socked foot. Approximately one foot of tubing was touching the ground (potentially contaminating the tubing). Observation on 12/10/24, at 1:24 P.M., showed Resident #14 sat in his/her wheelchair in the hall near the nursing station. The resident's catheter bag was covered by a dignity bag with the bag dragging on the floor. The catheter tubing was coming out of the resident's pant leg and approximately one foot of tubing was dragging on the ground (potentially contaminate the tubing). Observation on 12/10/24, at 1:53 P.M., showed the Activity Director pushed Resident #14 in his/her wheelchair from the hallway to the dining room for a music program. The resident's catheter tubing and dignity bag were dragging on the floor through the hall to the dining room (potentially contaminate the tubing). During an interview on 12/13/24, at 10:20 A.M., CNA H said catheters should be in a dignity bag and the tubing should not be dragging on the floor. During an interview on 12/13/24, at 11:02 A.M., LPN D said catheters are typically under the a resident in a dignity bag. The tubing should be coiled in the bag and should not be dragging on the floor. During an interview on 12/13/24, at 11:16 A.M., LPN E said resident catheters should be in a dignity bag and tubing should be in the bag as much as possible. Tubing and bag should not be dragging on the ground. During an interview on 12/13/24, at 12:48 P.M., the Director of Nursing (DON) said resident catheter tubing and bag should not be on the floor. During an interview on 12/13/24, at 1:00 P.M., the Administrator said resident catheter bags and tubing should not be dragging on the floor. 7. Review of the facility's policy titled Medication Administration, undated, showed the following: -Medications are given to benefit a resident's health as ordered by the physician; -Staff should wash hands; -Administer medications; -Discard disposable items and clean reusable items. Review of the facility's policy titled Handwashing, undated, showed staff to use brush to clean under nails as necessary. Observation on 12/11/24, at 4:00 P.M., showed the following: -Certified Medication Tech (CMT) B was passing medications. The CMT's fingernails were approximately 1/4 inch in length and had black dirt appearance underneath the nails of both hands. -As the CMT prepared medication for Resident #47, he/she put his/her finger into the medication cup (potentially contaminate the medication cup) to remove from the pile of cups. He she prepared three medications and provided to the resident. -The CMT then prepared medications for Resident #24. The CMT put his/her finger into the medication cup (potentially contaminate the medication cup) to remove from the pile of cups. He/she prepared and provided three medications to the resident. -The CMT then prepared medications for Resident #34. The CMT put his/her finger into the medication cup (potentially contaminate the medication cup) to remove from the pile of cups and prepared and administered one medication to the resident. Observation on 12/11/24, at 4:15 P.M., showed the following: -CMT W was preparing medications for Resident #51. The CMT removed a medication card of the medication cart drawer and pushed a tablet out of the card. The tablet landed on the top of the medication cart (potentially contaminating the tablet). The CMT picked up the tablet with his/her bare hands (potentially contaminating the tablet) and put into the medication cup. The CMT then picked up a second medication card and popped out a pill into his/her fingers (potentially contaminating the pill)and put into the medication cup. He/she then entered the resident room and provided the medications. -The CMT returned to the medication cart and prepared the next resident's medication without completing hand hygiene. The CMT removed medication cards for Resident #227. The CMT took the first medication card and pushed one tablet into his/her hand (potentially contaminating the tablet. and put into the medication cup. He/she then took the second medication card and pushed one tablet into his/her fingers (potentially contaminating the tablet) and put the tablet into the medication cup. He/she then entered the resident room and provided the medication. During an interview on 12/13/24, at 10:05 A.M., CMT B said staff should use hand sanitizer between each resident and before each medication pass. Staff should handle medication cups from the outside of the medication cup only. Staff should not put fingers inside the medication cup. If a pill dropped on the medication cart, staff should not touch the pill with their bare finger and put the medication back in the cup. Staff should not administer the dropped pill. Staff should not pop pills from the medication card into their fingers and then put into the cup. Staff should pop the pill directly from the card into the cup. During an interview on 12/13/24, at 10:12 A.M., CMT C said staff should clean hands before the start of the medication pass and should clean hands between each resident. The medication cups should be handled from the bottom or sides and should not be pick up by putting a finger into the cup. Staff should keep their fingernails clean when working. During an interview on 12/13/24, at 11:02 A.M., LPN D said the following: -Staff should not put their finger in the medication cup when picking up medication cups, the cups should be stacked upside down so they can be picked up by the outside of the cups; -Staff should not pop out pills into their fingers or drop a pill on the cart and then pick up with their hand and put into the medication cup; -Staff should keep their fingernails clean. During an interview on 12/13/24, at 11:16 A.M., LPN E said staff should clean hands between each resident and staff should not have dirty fingernails. He/she was aware of staff with dirty fingernails, but had not personally talked to the staff about their fingernails. Staff should pick up medication cups from the sides of the cups and should not put their finger in the cup to pick up. Staff should pop out pills into the cup, not into their hands, and should not pick up a pill that dropped on to the cart and put into the medication cup and give to the resident. During an interview on 12/13/24, at 12:19 P.M., the Assistant Director of Nursing (ADON) said staff should complete hand hygiene between residents before and after medication pass. Staff should take medication card to medication cup and pop the pill directly into cup. Staff should not pop pills into their hand and should not pick up a pill from cart and put into the cup and give to the resident. Staff should dispose of the pill dropped on cart. Staff should have clean fingernails while working. During an interview on 12/13/24, at 1:00 P.M., the Administrator said staff should follow policy and procedure for hand hygiene with medication pass. Staff fingernails should be per policy. 8. Observation on 12/11/24 showed the following: -At 11:18 A.M., CNA J was in Resident #38's room preparing to change resident's incontinent brief; -The CNA applied gloves and prepared the needed supplies; -The aide opened the front of the incontinent brief and provided incontinent care; -Without removing or changing gloves (potentially contaminated gloves) the aide assisted the resident to roll to his/her right side by holding edge of bed pad; -The aide then wiped the resident's buttock with a wet wipe and removed the brief. The brief was saturated with urine and small amount of bowel movement. The aide placed the brief into the trash; -Without changing gloves or completing hand hygiene the aide applied a clean brief; -The aide assisted the resident to roll to back to his/her back side by touching the resident's hip and leg with the same gloved hands; -The aide then pulled the clean brief through to the resident's right side; -The aide then wiped the residents front private area again with one wipe; -He/she pulled the brief up and taped in place with the same gloved hands; -With the same gloved hands, the aide put both of his/her hands on resident's foot to hold the foot down for resident to reposition self; -The aide then pulled down resident's shirt with same gloved hands and put a pillow under the resident's left arm and another pillow under the resident's right arm; -The aide pulled up top sheet to cover resident, with the same gloves; -The aide gave the call light and bed controls to the resident and moved the side table closer to the bed; -The aide then sealed the clean wipes and removed the trash bag from the can; -At 11:29 A.M., the aide left the resident room and walked down the hall with the same gloves on and trash bag in hand; -He/she entered the soiled utility room and disposed of trash bags and removed his/her gloves; -Without using hand sanitizer or washing hands the aide took a drink from his/her pants pockets, opened and took a drink. Then put the drink back in their pocket; -The Aide walked down the hall to talk with other staff and then entered the clean utility to gather additional supplies, then returned to and entered the soiled utility and got trash bins; -The aide then stopped at the nurses' station and used hand sanitizer. During an interview on 12/13/24, at 10:20 A.M., CNA H said during incontinent care staff should clean hands before resident contact and apply gloves. Gloves should be changed at least once during cares, between dirty and clean. Staff should not put on gloves and never take off and not clean hands until they enter the soiled utility room. During an interview on 12/13/24, at 10:12 A.M., CMT C said staff should clean hands before starting any personal cares and should clean their hands between each resident. During an interview on 12/13/24, at 11:02 A.M., LPN D said CNAs should be cleaning their hands before and after every resident care. They should be changing their gloves between dirty and clean tasks. Staff should not put on gloves and use from dirty to clean and leave the room with the same gloves on. During an interview on 12/13/24, at 12:19 P.M., the ADON said staff should wash hands with soap and water before entering resident rooms and should use hand sanitizer or wash hands between dirty and clean personal cares. Staff should change gloves and complete hand hygiene. Staff should not complete incontinent care with the same gloved hands through the entire procedure and then exit the room with same gloved hands to soiled utility room. During an interview on 12/13/24, at 12:48 P.M., DON said hand hygiene should be completed before and after every resident contact. Staff can use an alcohol-based cleanser or soap and water. Staff should clean their hands between every dirty and clean process and use clean gloves. Staff should not use the same gloved hands from beginning to end of cares. During an interview on 12/13/24, at 1:00 P.M., Administrator said staff should follow policy and procedure for hand hygiene with incontinent care. 9. Review of the facility's policy titled Wound Care and Treatment, undated, showed the following: -The treatment cart should be left in the hall and locked; -Move the cart to the resident's room and park it outside the room; -Remove the supplies needed and re-lock the cart; -Set up the supplies on a clean surface at the bedside; -Supplies are never placed on the bed, but the soiled trash bag may be; -Hand washing must be done as outlined in the guidelines; -Remove the soiled dressing and place in the trash bag; -Place the soiled scissors on one corner of the setup, not touching any of the other supplies; -Removed the gloves and discard the bag; -Clean scissors with 60 seconds of contact with alcohol and place on a clean corner of setup; -Wash hands and put on clean gloves; -Clean the wound according to the order. Clean from the center outward; -Place soiled gauze in the trash bag; -Remove gloves, place in trash bag, and put on clean pair of gloves; -Apply clean dressing as ordered; -Wash hands; -Trash is bagged in the room and again in the bag on the cart, then disposed of in the soiled utility room in the infectious waste container. Observations on 12/12/24 showed the following: -At 9:40 A.M., LPN D prepared wound care supplies for Resident #49 in the hallway outside the resident room; -The LPN put the full size wound cleanser bottle (medical product that removes debris, bacteria, and other contaminants from a wound to promote healing and reduce the risk of infection), an unopened package of 200 count gauze pads, an unopened package of 10 count 2 by 2 inch alginate wound dressing (type of absorbent wound dressing) on the table, two tubi-grips (tubular bandage that provides support and compression for a variety of injuries and conditions), 4 unopened packages of ABD pads (highly absorbent dressings that provide padding and protection for large wounds), an open package of sterile cotton tip applicators, a tube of gentamicin ointment (topical antibiotic used to treat infection of the skin), and an open box of exam gloves on the table; -The LPN applied a gown and entered the resident's room. The LPN washed his/her hands at the sink and then applied gloves. The LPN brought the bedside table with supplies into the resident's room; -At 10:19 A.M., after completing wound care the LPN removed the bedside table from the room with the remaining supplies, which included the wound cleanser bottle, an opened package of alginate wound dressing, 2 unopened packages of ABD pads, an open package of sterile cotton tip applicators, the tube of gentamicin ointment, the open box of exam gloves, and moved the table to the nursing station; -The LPN moved the treatment cart to the nursing station; -Without disinfecting any of the supplies the LPN put the wound cleanser bottle, gauze and wound dressing supplies, and the gentamicin ointment tube into the nurse cart. During an interview on 12/13/24, at 11:02 A.M., LPN D said wound care supplies should be sanitized if they are shared supplies. Staff should not take in a whole bottle of wound cleanser and would generally just spray the clean gauze with wound cleanser before entering resident room. Any shared supply or equipment should be cleaned with bleach wipes before putting back into the treatment cart. During an interview on 12/13/24, at 11:16 A.M., LPN E said staff should sanitize wound care equipment between each resident. During an interview on 12/13/24, at 12:19 P.M., ADON said staff should not take wound cleanser bottle into the room. If needed, the bottle should be wiped down with the disinfecting wipes before using again. During an interview on 12/13/24, at 12:48 P.M., DON said staff should only take in the supplies needed and what they will use for wound care. They should not take an entire unopened package of gauze pads and the wound cleanser bottle into the resident room, only dedicated supplies. During an interview on 12/13/24, at 1:00 P.M., Administrator said staff should follow policy and procedure for infection control with wound care. 50185 10. Review of the facility's undated policy titled Handwashing, showed the purpose was to reduce transmission of organisms from resident to resident, nursing staff to resident, and resident to nursing staff. Review of the facility's policy titled Wound Care and Treatment, undated, showed the following information: -Clean technique is used. Care must be taken to prevent contamination of the supplies and surfaces used in wound care; -Set up supplies on a clean surface at the bedside. Cover the surface with a clean barrier before putting the supplies down; -Handwashing must be done as outlined; -Explain the procedure to the patient, cut the tape with clean scissors, and don gloves; -Remove the soiled dressing and place in a trash bag, place soiled scissors on one corner of setup, not touching any of the other supplies; remove gloves and discard, Clean scissors with 60 seconds of contact with alcohol and place on a clean corner of setup; -Wash hands and don new gloves; -Clean the wound according to the order, clean from the center outward; -Place soiled gauze in the trash; -Remove gloves, place in the trash, and don clean gloves; -Apply clean dressing and wash your hands. Review of Resident #60's face sheet (brief look at resident information), showed the following information: -admitted [DATE]; -Diagnoses include unspecified open wound to right hip, chronic viral hepatitis C (a lifelong liver infection caused by the hepatitis C virus), and herpes viral vesicular dermatitis (a skin infection caused by the herpes simplex virus. Review of the resident's care plan, revised on 12/09/24, showed staff to clean hands before and when leaving the room. Staff to wear gloves and a gown for high contact resident care. Observation on 12/10/24, at 10:34 A.M., showed the following: -LPN F and LPN G were outside of the resident's room with gloves on. LPN F sanitized scissors and a bedside table that was being used as a clean barrier with bleach sani-wipes; -LPN F and LPN G entered the resident's isolation room with the supplies and bedside table, donned gowns and gloves, and placed scissors, wound cleanser, a large pack of gauze, calcium alginate, and foam pads on the bedside table; -Both LPN's entered the resident's bathroom, removed gloves, washed hands, and donned clean gloves; -LPN F obtained the scissors from the bedside table and cut off the dressing to the residents left elbow. He/she placed the scissors back down onto a corner of the clean bedside table; -LPN F cleansed the wound and attempted to manage an extensive amount of drainage from the resident's wound. LPN G handed LPN F clean supplies as needed. -LPN F removed gloves, did not complete hand hygiene, and donned clean gloves (potentially contaminating the gloves). The LPN applied the clean dressing to the wound; -LPN F removed gloves, washed hands, donned clean gloves, and moved onto the resident's right hip wound; -LPN F removed the soiled dressing to the right hip, removed gloves, washed hands, and donned clean gloves; -LPN F obtained the wound cleanser bottle and sprayed the wound directly, cleansed wound with gauze, discarded gauze, used hand sanitizer on gloved hands with no glove change, obtained the soiled scissors from the bedside table, laid them back down on the bedside table. The LPN did not perform hand hygiene or change gloves. -LPN F obtained a clean pair of scissors LPN G had laid down onto the bedside table and LPN F cut a small square out of the calcium alginate which was placed onto the right hip's wound bed; -Without performing hand hygiene or a glove change, LPN F moved onto a scabbed area on the residents hip and cleansed the area with wound cleanser and gauze. -LPN F removed gloves, did not perform hand hygiene, donned clean gloves, and collected trash, soiled supplies such as wound cleanser, scissors, gauze pack, and left over supplies left on bedside table; -LPN F and LPN G entered the resident's bathroom, removed gowns and gloves, and washed hands; -Both LPN's exited the room with the bedside table of soiled supplies and sanitized the scissors. Staff did not sanitize the the wound cleanser bottle that had entered the residents isolation room. During an interview on 12/13/24, at 11:02 A.M., LPN D said hand hygiene should be performed before care, when going from dirty to clean, and after care. Supplies brought into resident rooms for wound care, such as wound cleanser and scissors should be sanitized before and after use. During an interview on 12/13/24, at 11:18 A.M., LPN E said all supplies that go into multiple areas should be sanitized before and after use. During an interview on 12/13/24, at 12:19 A.M., the ADON said staff are expected to wash their hands with soap and water when they enter a resident's room, when going from a dirty to clean surface, and before leaving the room. All supplies brought in and out of resident rooms should be sanitized with a sani-wipe and should be allowed to air dry prior to using them again. During an interview on 12/13/24, at 12:47 P.M., the DON said staff are expected to perform hand hygiene in between residents, when going from a dirty to clean surface, and after care. The DON expected staff to be performing glove changes along with the hand hygiene. All supplies brought in and out of resident rooms should be sanitized before and after going into resident rooms. During an interview on 12/13/24, at 1:00 P.M., the Administrator he expected staff to follow policy regarding hand hygiene and infection control. 11. Review of the facility's policy titled Cleaning and Disinfecting, undated, showed the following: -The glucometer should be cleaned and disinfected between each patient; -The following products have been approved for cleaning and disinfecting of the meter: Medline Micro-Kill Bleach germicidal bleach wipes and Clorox Healthcare Bleach germicidal and disinfectant wipes; -Staff should wash hands with soap and water; -Put on single-use medical protective gloves; -Inspect for blood, debris, or lint anywhere on the meter; -Blood and bodily fluids must be thoroughly cleaned from the surface of the meter. Review of the facility's policy titled Diabetic Infection Control, undated, showed the following information: -Enviromental surfaces such as glucometer will be decontaminated anytime contamination with blood or body fluids occurs or is suspected using an Environmental Protection Agency (EPA) registered disinfectant; -Multiple resident use glucometers will be cleaned and disinfected after each use using an EPA registered disinfectant wipe according to container label; -Annual training on diabetic infection control and glucometer use procedure will be completed. Review of the glucometer's manufactures instructions, undated, showed the following information: -The meter should be cleaned and disinfected between each patient; -Wash hands with soap and water, put on single use medical protective gloves, inspect or blood, debris, dust, or lint anywhere on the meter. Blood and bodily fluids must be thoroughly cleaned from the surface of the meter; -Approved disinfection products included Dispatch Hospital Cleaner Disinfectant Towels with Bleach, Clorox Healthcare Bleach Germicidal and Disinfectant Wipes, and Midline Micro-Kill Bleach Germicidal Wipes; -To clean the meter, use a moist, lint free cloth dampened with a mild detergent. Wipe all external areas of the meter including both back and the front until visibly clean; -To disinfect the meter, clean the meter surface with one of the approved disinfecting wipes. Wipe all external areas of the meter including both front and back surfaces until visibly wet; -Wipe meter dry, or allow to air dry, remove gloves, dispose of infectious material. Observation on 12/11/24, at 11:21 A.M., showed LPN D sanitized his/her hands, donned gloves, obtained a glucometer from inside of the medication cart. After LPN D obtained the glucometer, he/she laid the glucometer down on top of the medication cart. LPN D did not disinfect the glucometer again. He/she obtained a glucose test strip, obtained the glucometer, and entered Resident #42's room. LPN D obtained the resident;s blood sugar reading, exited the room, obtained a sani-wipe and placed the glucometer inside of it and placed it on the med cart. The LPN did not wipe/clean the glucometer. Observation on 12/11/24, at 11:30 A.M., showed LPN D sanitized his/her hands, donned gloves, and obtained a glucometer from inside of a sani-wipe on top of the medication cart. The LPN D entered Resident #3's room and attempted to collect glucose level. The glucometer read error. LPN D exited the resident's room and did not disinfect the glucometer. He/she laid the glucometer down onto the medication cart. LPN removed his/her gloves, sanitized hands, and donned clean gloves. The LPN obtained the glucometer and test strip and entered the resident's room for a second attempt, the glucometer read error. LPN D exited the resident's room, did not disinfect the glucometer, and laid the glucometer down onto the medication cart. The LPN removed his/her gloves, sanitized hands, and donned clean gloves. He/she obtained glucometer and test strip and entered the resident's room for a third attempt and was successful. LPN D exited the resident's room and laid the glucometer inside of a sani-wipe on top of the medication cart. The LPN did not wipe/clean the glucometer. During an interview on 12/13/24, at 11:02 A.M., LPN D said glucometers should be wiped clean and kept covered with a sani-wipe. There is a required dry time of two to three minutes. During an interview on 12/13/24, at 11:18 A.M., LPN E said glucometers should be sanitized with a sani-wipe and then kept covered with a sani-wipe and let sit. During an interview on 12/13/24, at 12:19 A.M., the ADON said glucometers should be cleansed with a sani-wipe and then be allowed to air dry. During an interview on 12/13/24, at 1:00 P.M., the Administrator said staff should follow infection control policies.

Based on interview and record review, the facility failed to complete the required Preadmission Screening and Resident Review (PASARR - a two-level tool used to screen each resident in a nursing facility for a mental disorder or intellectual disability prior to admission) for one resident (Resident #5), prior to or upon admission to the facility, to ensure the resident received appropriate care and services, out of a selected sample of three residents. The facility census was 75. Review showed the facility did not provide a policy or procedure addressing completion of PASARR forms. 1. Review of Resident #5's face sheet showed the following information: -admitted [DATE]; -Diagnoses included paranoid schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly) and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 11/18/24, showed the following: -Cognitively intact; -Resident was taking antipsychotic medication on a routine basis. Review of the resident's care plan, last reviewed 11/18/24, showed the following: -Resident had delusions (fixed, false beliefs that persist despite clear evidence to the contrary); -Staff should redirect resident; -Staff should administer medication per physician orders; -Staff will be aware that a delusion is an actual reality to the resident; -Staff will not argue with the resident about the delusion; -Staff will attempt to distract resident from the delusion, Review of the resident's medical record showed no documentation of a PASARR available. During an interview on 12/10/24, at 3:05 P.M., the Business Office Manager (BOM) said he/she was unable to locate a documention of the level one PASARR for the resident. During an interview on 12/13/24, at 9:10 A.M., the Social Services Director (SSD) said that he/she and the BOM were involved in completion of the forms for the level one and level two PASARR. They try to complete them within 48 hours of a resident admission. During an interview on 12/13/24, at 1:00 P.M., Administrator said that the resident's PASARR was done in 2007 before electronic records. Staff should check that residents have a DA 124 on admission if needed according to their diagnosis.

Based on observation, interview, and record review, the facility failed to ensure a resident's choice of code status (resident's wish to receive cardiopulmonary resuscitation (CPR - an emergency procedure for a person whose heart has stopped or who is no longer breathing) or do not resuscitate (DNR - does not wish to receive CPR)) was consistent throughout one resident's (Resident #55) medical records. The facility census was 75. Review showed no facility policy provided. 1. Review of Resident #55's face sheet showed the following: -admitted [DATE]; -Code status of DNR; -Diagnoses included cerebral infarction (stroke - medical emergency that occurs when blood flow to the brain is interrupted), Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) without dyskinesia (uncontrolled, involuntary muscle movement), cognitive communication deficit, and Type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)) . Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated [DATE], showed moderate cognitive impairment. Review of the resident's care plan, last reviewed [DATE], showed the following: -Resident had chosen to be DNR; -Staff should follow the resident's wishes; -No CPR and do not call 911 call for cardiac arrest; -Review quarterly and as needed to ensure residents wishes are as he/she chooses. Review of the resident's Outside the Hospital Do Not Resuscitate (OHDNR - written order that authorizes emergency medical services to withhold (CPR) from a person in a non-hospital setting if they experience cardiac or respiratory arrest showed the resident signed the form on on [DATE] and the physician signed the order on [DATE]. Review of the resident's progress notes, showed the Social Service Director documented the following: -On [DATE], at 2:36 P.M., the resident changed his/her code status from a full code (whish to received CPR) to a DNR status. The resident verbalized understanding of the difference between full code and DNR, including that resuscitation efforts will not be initiated in the event of cardiac arrest. This order has been updated in resident files and documented. Review of the resident's current physician's order sheet showed an order, dated [DATE], for resident to be a full code. During an interview on [DATE], at 12:00 P.M., Certified Nurse Aide (CNA) A said resident code status was located on each resident's door, either a red or green dot, and in the care plan. He/she said staff could also ask the nurse for code status. The code status should be the same in each area. Observation on [DATE], at 1:00 P.M., showed the resident's the name tag on his/her door had a red dot. During an interview on [DATE], at 9:10 A.M., MDS Coordinator & Social Service Director (SSD) said resident code status was located in the care plan and should be consistent throughout the chart. The SSD ensured that code status was consistent in chart and on the resident door. They would not expect the code status to be DNR on the door and in the care plan, but have an physician order noting full code. During an interview on [DATE], on 10:05 A.M., Certified Medication Tech (CMT) B said code status was on the resident door and on the face sheet. It should be the same status in each area. During an interview on [DATE], on 10:12 A.M., CMT C said code status was located on resident doors with colored dots. He/she did not know if there was a second location, but would expect the information to be the same if it was in nursing notes. During an interview on [DATE], on 11:02 A.M., Licensed Practical Nurse (LPN) D said code status was located in the computer system and a colored dot system on resident doors. There was also an advance directive form in the chart. He/she expected the status would be consistent throughout chart. During an interview on [DATE], at 11:16 A.M., LPN E said code status was located in the electronic medical record and on the resident door. He/she said it should be the same throughout the chart. During an interview on [DATE], at 12:19 P.M., the Assistant Director of Nursing (ADON) said resident code status should be consistent throughout the chart. During an interview on [DATE], at 12:48 P.M., the Director of Nursing (DON) said code status was in the medical record on the face sheet and under advance directives tab. The physician orders should not say full code if the face sheet and advance directives show DNR. The information should be the same throughout chart. During an interview on [DATE], at 1:00 P.M., the Administrator said staff should follow policy and ensure accurate code status.

Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice when the facility failed to follow consistently document and physician orders and failed to routinely document of notification of the physician and assessments in an elbow wound for one resident (Resident #60), out of 17 sampled residents. The facility census was 75. Review of the facility's policy titled Physician Orders, undated, showed the following information: -Current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors; -Orders must be reviewed and renewed; -Treatment orders must specify what is to be done, location, and frequency and duration of the treatment. Review of the facility's policy titled Resident Examination and Assessment, undated, showed the following information: -Examine and note the intactness, moisture, color, texture, and presence of bruises, pressure sores, redness, edema, and rashes of the resident's skin; -Document the following in the resident's chart date and time the assessment was performed; name and title of individuals who performed the assessment; assessment data obtained during the assessment; how the resident tolerated the assessment; if the resident refused and why; the signature and title of the person recording the data; and notify the supervisor if the resident were to refuse; -Notify the physician of any abnormalities such as wounds or rashes on the resident's skin, worsening pain as reported by the resident. 1. Review of the Resident #60's face sheet (brief look at resident information), showed the following information: -admitted [DATE]; -Diagnoses included fusion of the spine, dislocation of other internal joint prosthesis, and anxiety. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 10/16/24, showed the following information: -Cognitively intact; -No skin conditions documented. Review of the resident's care plan, last revised on 01/11/24, showed staff to observe for changes in skin condition during daily care and bath days and report. Review of the resident's Comprehensive Shower Sheet, dated 11/05/24, showed the resident did not have any skin abnormality to the left elbow. Review of the resident's Comprehensive Shower Sheet, dated 11/12/24, showed the resident had his/her elbow circled with the indication as other. Review of the resident's physician visit note, dated 11/12/24, showed the following: -Resident had a history of osteomyelitis (inflammation of bone caused by infection) and methicillin-resistant staphylococcus aureus (MRSA - a type of staph bacteria that is resistant to many antibiotics). -Olecranon bursitis (a condition characterized by swelling, redness, and pain) of the left elbow. The resident had an aspiration last week and swelling had returned. Physician reviewed labs from the week prior on the resident's phone. Culture and sensitivity was normal with no need for antibiotics at this time; -Reported increased anxiety. Staff will get psych to visit the resident for adjustments. Review of the resident's nurse's note dated 11/14/24, at 8:47 A.M., showed the resident complained of pain in his/her right elbow. There was a small area that was leaking serosanguineous (a type of wound drainage that contains both blood and serum) fluid. Staff applied bandage and called on-call physician. Staff was waiting for a return phone call. Review of the resident's nurse's note dated 11/14/24, at 1:40 P.M., showed the nurse spoke with the physician's nurse practitioner, who said due to the resident's elbow increasing in blood loss, saturating two rolls of kerlix (a type of bandage), the resident was to be sent to the hospital. The resident left the building at 1:40 P.M. Review of the resident's medical record showed staff did not document when the resident returned to the facility nor any discharge instructions from his/her hospital visit. Review of the resident's comprehensive shower sheet, dated 11/15/24, showed the resident had his/her elbow circled with a note stating pin-hole and the indication as other. Review of the resident's nurse's note dated 11/18/24, at 9:33 P.M., showed the resident had his/her left arm wrapped at around 5:30 P.M The resident asked the nurse to loosen the dressing. While loosing the dressing, the nurse observed red moisture on the kerlix under the ace wrap. Staff changed the kerlix. There was no bleeding observed at the time of the dressing change. Staff reapplied the ace wrap. Resident continued to complain of pain. (Staff did not document notifying the resident's physician of the resident's complaints of pain or of the wound change.) Review of the resident's medical record from 11/19/24 through 11/23/24, showed staff did not document regarding the resident's left elbow wound. Review of the visiting wound clinic visit notes, dated 11/23/24, showed the following information: -The resident had a history of hardware in his/her left elbow following a severe fracture. To date he/she was unable to use the left arm. In the left joint was a large effusion (escape of fluid into the body cavity) and it was apparent that it had been a problem for a while; -The resident has seen his/her specialist for the elbow a few weeks ago and some fluid was aspirated. There was no evidence at that time of infection. Bleeding had since started after the aspiration; -The resident had been to two hospital emergency room s and the suggestion was for the staff to hold pressure. On today's visit, it took 40 minutes of holding pressure to the area and expressing as much of the serosanguinous fluid as possible; -Measurements included 0.2 centimeters (cm) in length, and 0.3 cm in width; -New orders for treatment included cleanse with hypochlorous (a weak unstable acid that is a powerful disinfectant and antimicrobial agent) acid, apply calcium alginate ( a wound dressing material that absorbs excess moisture and promotes healing) to the wound bed, cover with abdominal pad, cover with conforming gauze roll, and change dressing as needed for soiling. Review of the resident's physician order sheet, dated 11/01/24 through 11/26/24, showed staff did not document any order for treatment of the resident's left elbow wound. Review of the resident's physician visit notes, dated 11/26/24, showed the following information: -Left wound had dehisced (gape or burst open) and was then lanced by the visiting wound clinic. The resident sent to the hospital due to the bleeding (which continued after pressure was applied), reinforcement of the wound was given, and warm compress. Anxiety present. -Resident previously positive for MRSA of another wound. Left arm continues with abscess and is still having some slight bleeding, would like to obtain a culture again if possible; -Obtain culture if possible and keep pressure dressing in place if drainage/bleeding continues. Review of the resident's nurses' notes, dated 11/26/24, showed the following information: -New orders received to increase Buspar (an anxiolytic drug used to treat anxiety) to 20 milligram (mg) three times a day, obtain culture of elbow if possible, and utilize pressure dressing to left elbow if bleeding continues. Review of the resident's physician order sheet, dated 11/01/24 through 12/13/24, showed staff did not document regarding the new wound treatment obtained during November. Review of the resident's medical record from 11/25/24 through 11/30/24, showed staff did not document assessment or treatment of the resident's left elbow wound. Review of the visiting wound clinic's visit notes showed the following information: -The resident's left elbow wound drained just as much as it ever has. The opening has gotten larger and there is now more than just serosanguinous drainage coming out. It is difficult to describe the tissue other than the elbow joint debris. There is one free floating bone portion that expressed out of the wound as well, which measured 1.2 cm by 3 cm. -After expressing as much of the contents of the joint effusion, the wound was covered with dressing. Recommend changing daily for this week. -The resident requested another wound culture, this time of his/her elbow drainage. Given the presence of bone shard, he/she did prepare a portion of the bone to send off to the lab for bacterial identification and sensitivity. Review of the resident's medical record, dated 11/30/24 through 12/02/24, showed staff did not document assessment or treatment regarding the resident's left elbow wound. Review of the resident's physician visit notes, dated 12/03/24, showed the following information: -The resident and staff were concerned regarding the swelling and drainage on the left elbow, now followed by swelling of the resident's wrist and hand; -The resident reports feelings of weakness, increased pain, and a decreased appetite; -Will get a wound culture. The resident reports his/her surgeon said he/she needs to be on antibiotics. Review of the resident's physician order sheet showed staff did not document new orders were entered after the physician's visit on 12/03/24. Review of visiting wound clinic's visit notes, dated 12/06/24, showed the following information: -Wound culture results were back showing staphylococcus epidermis (common blood infection that can cause virulence (damage) once it invades the human body via prosthetic devices). The Assistant Director of Nursing (ADON) sending report to primary care provider; -The entrance of the left elbow wound continued to grow. The resident reported he/she had a similar issue in the past with osteomyelitis and his/her elbow and a replacement of the hardware; -This could best be described as a rejection or infection of the hardware in the elbow; -Measurements included 1.5 cm in length and 1.6 cm in width. Review of the residents' nurses notes, dated 12/06/24, showed the nurse practitioner from the visiting wound clinic was in the facility and new orders received. Review of the resident's physician order sheet showed staff did not enter no new orders until 12/09/24. The new order was to cleanse left elbow with pure and clean, pat dry, place calcium alginate to the wound bed, cut to fit, cover with dry dressing, and change dressing daily and as needed. Review of the resident's medical record on 12/09/24, at 12:07 P.M., showed no weekly skin assessments entered by the nursing staff and showed no weekly wound monitoring of the resident's left elbow wound. Observation on 12/09/24, at 10:38 A.M., showed Licensed Practical Nurse (LPN) F removed the resident's dressing to the left elbow. As soon as LPN F removed the dressing, red and yellow drainage came pouring out of the wound. LPN attempted to stop the drainage with pressure and several pieces of gauze. The resident began weeping and questioning the state of his/her wound. At 11:02 A.M., the drainage continued, and LPN F went ahead and applied the ordered treatment. LPN F told the resident he/she would be getting into contact with the resident's physician regarding the amount of drainage. During an interview on 12/09/24, at 1:44 P.M., the resident said the following: -He/she had concerns regarding a wound to his/her left elbow. Staff have been notified of this wound, but he/she does not believe them when they say they will do something about it. The wound has been there a few weeks now and was supposed to be cultured; -He/she continued to want a culture done. He/she has reported this to the staff. The ADON told him/her no, that she had one recently and the physician will just use those results. -He/she had a history of abscess' busting and then testing positive for MRSA; -His/her surgeon did collect a culture of the left elbow wound on 11/06/24, but the results did not indicate an infection at that time. However, the wound and his/her physical condition has worsened since that time; -He/she most recently had tested positive for MRSA in his/her right hip wound. Review of the resident's physician visit notes, dated 12/10/24, showed the resident was having an increase in drainage and pain. Will do x-ray to rule out any osteomyelitis due to his/her pain. Will use most recent culture and initiate Clindamycin (an antibiotic that fights bacteria in the body) 300 milligram (mg) capsule by mouth four times a day for 7 days, and Flagyl (antibiotic that is used to treat bacterial infections) 500 mg by mouth two times a day for 7 days. Review of the resident's physician order sheet, showed the following orders entered for 12/10/24: -Obtain wound culture of left elbow wound; -Obtain x-ray of left arm to rule out osteomyelitis; -Clindamycin 300 mg capsule, give one capsule by mouth four times a day; -Flagyl 500 mg tablet, give one tablet by mouth two times a day; -STAT (immediately) x-ray 2 view of left forearm and humerus related to severe pain and history of osteomyelitis. During an interview on 12/10/24, at 11:44 A.M., Licensed Practical Nurse (LPN) F said he/she did not know of any orders for a culture to the resident's left elbow wound on 11/26/24. However, he/she did obtain new orders on this date for a wound culture and an x-ray. Review of the resident's nurses' notes, dated 12/10/24, showed per the Director of Nursing (DON) the visiting wound clinic provider reviewed the culture that was completed on 11/13/24 and discontinued the order that was given on 11/26/24 due to at that time there was no evidence of increase in drainage. During an interview on 12/10/24, at 12:15 P.M., the ADON said the following: -She believed the DON said the visiting wound clinic's provider discontinued the 11/26/24 order for the wound culture from the resident's primary physician due to the visiting wound clinic's provider saying there was no drainage to the wound at that time; -She called the primary care physician's nurse practitioner today and told him that the drainage is worse. That nurse practitioner said they can just base treatment off the wound culture that was obtained on 11/13/24 by the visiting wound clinic's provider -The visiting wound clinic started seeing the resident on 11/13/24. Review of the resident's medical record showed staff did not document staff collected a culture collected of the resident's left elbow wound on 11/13/24. The only culture obtained was of the resident's right hip wound, which tested positive for MRSA. During an interview on 12/10/24, at 12:51 P.M., the ADON said the following: -She clarified with the DON regarding the wound culture and he told her that the culture obtained on 11/13/24 was actually on the right hip wound; -No culture has been obtained of the left elbow; -She contacted the primary care physician's nurse practitioner again and he said to go ahead and get a new culture, which is what is reflected in the physician's order sheet. Review of the resident's medical record on 12/11/24 showed results from the x-ray showed no acute forearm or humerus fractures and did not given mention of osteomyelitis. Review of the resident's nurses' notes, dated 12/11/24, showed the wound culture that was obtained per the visiting wound clinic's provider resulted. Staff spoke with primary care physician's nurse practitioner who said to continue with current antibiotic protocol and obtain a new culture. Review of the resident's medical record, as of 12/12/24, showed staff did not document a wound culture had been collected. During an interview on 12/12/24, at 10:29 A.M., the ADON said the following: -She monitors wounds by performing treatments; -Wounds that are not caused by pressure are not measured by her, only by the visiting wound clinic's provider she believes; -She showed the surveyor the resident's wound management log inside the medical record, which did not list or provide any information regarding the resident's left elbow wound. During an interview on 12/13/24, at 10:27 A.M., the visiting wound care provider said the following: -They began treating the resident's left elbow wound on 11/23/24; -He/she had never obtained any tissue cultures on the resident's left elbow wound, nor has he/she seen any results from a tissue culture; -This resident was followed by several physicians which seemed to complicate treatment; -He/she would not and has not discontinued any other physician's orders; -He/she did obtain a bone culture from a bone that was expressed out of the wound. That culture showed staphylococcus epidermidis. The resident started the antibiotics due to these results; -He/she would expect to be contacted regarding any worsening of the wound. During an interview on 12/13/24, at 11:02 A.M., LPN D said the nurses do not measure any type of wounds. The visiting wound clinic does all the measurements. nurses just go and assess the area and report any findings. During an interview on 12/13/24, at 11:18 A.M., LPN E said if a skin issue was brought to his/her attention, he/she would go and assess the area, measure, document, perform a treatment, and contact the physician. During an interview on 12/13/24, at 12:19 P.M., the ADON said the following: -There should be documentation as to when, and why a resident is sent out, as well as documentation as to when the resident returns. If there is no documentation, it's still known due to it being talked about in morning meetings; -Skin assessments are completed weekly during showers. Any issues are reported to the nurses and they assess the issue and are supposed to document and/or tell her and she will measure the area; -Wounds are tracked by visualizing the wound during treatments being completed on them; she realizes documentation is lacking; -The resident's left elbow wound is tracked by completing treatments on the wound, the visiting wound clinic's provider measures every Friday; -The resident has never had a culture on the left elbow wound tissue, he/she has only had the expelled bone cultured, which resulted on 12/05/24; -Once those results were obtained, she called the primary care physician and obtained antibiotic orders; -On 11/26/24, there was an order for a wound culture, but the primary care physician's nurse practitioner discontinued that; -The primary care physician came in and found no reason to do the wound culture at that time; -The resident has so many physicians involved in his/her care, it can make it difficult; -Physician orders should be followed, and residents have a little bit of say in their care but often times that doesn't change it much; -She expects staff to refer to social services if a resident has a mental decline; -The resident's mental status has not been brought to her attention; -Everything should be documented in the resident's chart, but she realized documentation is an issue. During an interview on 12/13/24, at 12:47 P.M., the DON said the following: -If a skin concern is brought to staff's attention, it should be reported to the charge nurse; the charge nurse will consult the primary care provider and put in any new orders; -Wounds should be monitored weekly and the nurses' notes should reflect that. During an interview on 12/13/24, at 1:00 P.M., the Administrator said wounds should be documented somewhere and care planned. 41787

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received services consistent with professional standards of practice when the facility failed to document regular full wound assessments for one resident (Resident #60) out of 17 sampled residents, who had a pressure ulcer to the right hip. The facility census was 75. Review of the facility's policy titled Resident Examination and Assessment, undated, showed the following information: -Examine and note the intactness, moisture, color, texture, and presence of bruises, pressure sores, redness, edema (swelling), and rashes of the resident's skin; -Document the following in the resident's chart the date and time the assessment was performed; name and title of individuals who performed the assessment; assessment data obtained during the assessment; how the resident tolerated the assessment; if the resident refused and why; the signature and title of the person recording the data; and notify the supervisor if the resident were to refuse; -Notify the physician of any abnormalities such as wounds or rashes on the resident's skin, and worsening pain as reported by the resident. 1. Review of the resident's face sheet (brief look at resident information) showed the following information: -admitted [DATE]; -Diagnoses included unspecified open wound of right hip. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument, completed by facility staff), dated 10/16/24, showed the following information: -Cognitively intact; -Not at risk for pressure ulcers; -No skin conditions or pressure ulcers documented; -Diagnoses included anemia, anxiety, and depression. Review of the resident's Physician Order Sheet, dated 10/21/24, showed resident visited wound clinic for evaluation and treatment of wound to right hip. Review of the resident's care plan, dated 10/22/24, showed the following information: -The resident had skin breakdown noted to the right hip measuring 3 centimeters (cm) by 2 cm. The wound bed had eschar (a collection of dry dead tissue within a wound which presents itself as tan, brown, or black) present with wound edges undefined and no drainage or odor noted. Resident visiting wound clinic to treat. Review of the resident's wound management log, dated 11/01/24, showed the right hip wound measured 3.5 cm by 2.5 cm. Review of the resident's medical record, dated 11/02/24 to 11/10/24, showed staff did not document an assessment or measurements of the resident's right hip wound. Review of the resident's progress note, dated 11/11/24, showed resident had a history of poor mobility, was up to the wheelchair most of the day and when was in bed, laid on his/her left side. The resident had a cushion in place on his/her wheelchair. Staff to continue with current orders. Staff educated the resident on offloading to reduce pressure to the hip. (Staff did not document an assessment of the wound.) Review of the resident's wound management log, dated 11/12/24, showed the right hip wound measured 2.3 cm by 3.1 cm (11 days after the prior log entry). Review of the resident's wound manage log, dated 11/13/24 to 12/13/24, showed staff did not document regarding the resident's right hip wound. Review of the resident's medical record, dated 11/13/24 to 11/28/24, showed staff did not document an assessment or measurements of the resident's right hip wound. Review of the resident's Physician Order Sheet, dated 11/29/24, showed the following: -Current treatment for right hip wound included cleanse right hip wound with pure and clean (wound cleaner), pat dry, place calcium alginate ( (a wound dressing made from calcium or sodium alginate, a natural polymer derived from cell walls of brown seaweed, which creates a moist healing environment for wounds and treats moderately heavy draining wounds) inside of the wound bed, and cover with foam border gauze, and change every other day and as needed. Review of the resident's progress note, dated 12/09/24, showed the following: -Resident had a history of poor mobility, was up to the wheelchair most of the day and when in bed, laid on his/her left side. The resident had a cushion in place on his/her wheelchair. Staff to continue with current orders. Staff educated resident on offloading to reduce pressure to the hip. The wound orders for right hip updated. (Staff did not document an assessment of the wound.) Review of the resident's care plan, dated 12/09/24, showed the following information: -A new order to cleanse right hip with pure and clean, pat dry, place calcium alginate inside of the wound bed and cover with foam border gauze every other day and as needed. Review of the resident's medical record, dated 11/13/24 through 12/13/24, showed staff did not document an assessment or measurements of the resident's right hip wound. Review of the resident's medical record showed no visiting wound clinic notes had been scanned into the system. During an interview on 12/09/24, at 12:07 P.M., the resident said staff do not come in and assess his/her wound on a weekly basis. During an interview on 12/12/24, at 10:29 A.M., the Assistant Director of Nursing (ADON) said the following: -She assesses and measured the resident's wounds and puts those measurements in the resident's medical record under the wound management log; -She used the visiting wound clinic's providers measurements and that's what she enters into the chart. The visiting clinic came in weekly. During an interview on 12/13/24, at 11:02 A.M., Licensed Practical Nurse (LPN) D said the following: -When an open area was brought to his/her attention, he/she assessed the wound, called the physician, and documented in the progress notes; -Measurements were not completed unless the resident was seen by the visiting wound clinic, then the clinic obtained measurements. During an interview on 12/13/24, at 11:18 A.M., LPN E said if a new skin issue was brought to his/her attention, he/she would assess, measure, document, perform a treatment, and contact the resident's physician. During an interview on 12/13/24, at 12:19 P.M., the ADON said the following: -The nurses are expected to assess and document any new open areas. They should report to her the area, and she will go and measure it; -Wounds are tracked and or monitored by visual assessments during wound care; -Everything is expected to be documented, but she realized that documentation has been an issue. During an interview on 12/13/24, at 12:47 P.M., the Director of Nursing (DON) said wound monitoring should be completed weekly and documented in the nurses' notes. During an interview on 12/13/24, at 1:00 P.M., the Administrator said wound documentation should be somewhere in the residents medical record.

Based on record review and interview, the facility failed to provide pharmacy services to meet the needs of each resident when staff failed to have ordered medications on hand for administration for two residents (Resident #49 and #13). The facility census was 75. Review of the facility policy titled Medication Administration, undated, showed medications are given to benefit a resident's health as ordered by the physician. 1. Review of Resident #49's face sheet (brief information sheet about the resident) showed the following: -admitted [DATE]; -Diagnoses included vitamin B12 deficiency (condition that develops when the body cannot make enough healthy red blood cells because it doesn't have enough vitamin B12). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/17/24, showed the resident was cognitively intact. Review of the resident's care plan, last reviewed 11/26/24, showed the following: -Resident had the potential for cardiac (heart) complications secondary to hypertension (high blood pressure), hyperlipidemia (high cholesterol), and vitamin deficiency (occurs when the body doesn't have enough of a vitamin over a long period of time); -Staff should administer cardiac medications as ordered. Review of the resident's Physician Order Sheet, current as of 12/13/24, showed an order, dated 06/05/23, for B Complex-Vitamin B12 tablet (group of B vitamins that play a role in your body's function), one tablet once per day. Review of the resident's November 2024 Medication Administration Record (MAR) showed the following: -On 11/01/24 through 11/08/24, staff documented B Complex-Vitamin B12 as administered; -On 11/09/24 and 11/10/24, staff documented B Complex-Vitamin B12 as not administered due to drug/item unavailable; -On 11/11/24 through 11/13/24, staff documented B Complex-Vitamin B12 as administered; -On 11/14/24 through 11/30/24 staff documented B Complex-Vitamin B12 as not administered due to the drug/item unavailable. (Staff documented 18 doses out of 30 doses for the month of November as not available.) Review of the resident's MAR, dated 12/01/24 through 12/13/24, showed the following: -On 12/01/24 through 12/13/24, staff documented the B Complex-Vitamin B12 as not administered due to the drug/item unavailable. (Staff documented 13 doses out of 13 doses for the month of December as not available.) During an interview on 12/09/24, at 2:25 P.M., the resident said there were times that he/she was told that there medications not available. During an interview on 12/13/24, at 12:19 P.M., the Assistant Director of Nursing (ADON) said she was not aware the resident had not received the Vitamin B12 since November. 2. Review of Resident #13's face sheet showed the following: -admitted [DATE]; -Diagnoses included constipation and pain. Review of the resident's care plan, last reviewed 11/07/24, showed the following: -Resident had idiopathic progressive neuropathy (a nerve condition that can cause a range of symptoms, including pain, numbness, tingling, swelling, or muscle weakness) which caused his/her pain and resident was not always able to tell staff he/she was in pain; -Staff should ask resident was having pain; -Resident was at risk for pain issues related to muscle spasms and arthritis; -Staff should administer pain medications as directed; -Assess/document/review with physician indications of side effects, ineffectiveness. -Resident was at risk for complications due to constipation to include hemorrhoids and bowel; -Staff interventions will be in place to prevent complications related to constipation to the extent possible related to medical complexities through review; -Staff should administer stool softeners, laxative and/or other interventions as ordered/needed with follow up. Review of the resident's quarterly MDS, dated [DATE], showed the resident had severe cognitive impairment. Review of the resident's POS, current as of 12/13/24, showed the following: -An order, dated 12/31/21, for acetaminophen (used to treat mild to moderate pain) 325 milligrams (mg), administer two tablets twice daily; -An order, dated 05/09/23, for Senna Plus (two different types of laxatives combined in one formula) 8.6-50 mg capsule, administer one capsule twice daily. Review of the resident's MAR, dated 12/01/24 through 12/13/24, showed the following: -On 12/01/24 through 12/06/24, morning dose staff documented the Senna Plus as not administered, drug/item unavailable; -On 12/07/24, staff documented the acetaminophen 325 mg morning dose as not administered; drug/item unavailable. -On 12/08/24 through 12/11/24, staff documented the acetaminophen 325 mg morning and evening dose, as not administered, drug/item unavailable. -On 12/07/24 evening dose through 12/11/24, staff documented the Senna Plus as not administered, drug/item unavailable; (Staff documented nine doses of Tylenol 325 mg out of 25 doses as not available for December and 21 doses of Senna Plus out of 25 doses as not available for December.) 3. During an interview on 12/13/24, at 10:05 A.M., Certified Medication Technician (CMT) B said that staff should follow physician orders when administering medications. If a medication was not available, staff should look in the emergency kit and notify the nurse of medication not available. He/she did not know if the nurse notified the doctor of the unavailable dose. During an interview on 12/13/24, at 10:12 A.M., CMT C said that staff should follow physician orders for medication administration. If a medication was not available, he/she would notify the ADON and make a list of medications needed. He/she would not expect a resident to miss a medication for multiple days to weeks. During an interview on 12/13/24, at 11:02 A.M., Licensed Practical Nurse (LPN) D said staff should notify the ADON if a medication was not available for a resident. Ideally medications should be refilled before running out of medications or over-the-counter vitamins. He/she would not expect a resident to go multiple days without ordered medications without the nurse discussing with a physician. During an interview on 12/13/24, at 11:16 A.M., LPN E said that nurses and CMTs should provide medications as ordered by the physician. If a medication was not available in the medication cart, staff should check the medication room and the emergency kit. If not available, staff should notify the charge nurse for instructions. During an interview on 12/13/24, at 12:19 P.M., the ADON said staff should provide medications according to the physician orders. If a medication was not available, staff should check the medication room and should notify the ADON to have the medication ordered. During an interview on 12/13/24, at 12:48 P.M., the Director of Nursing (DON) said staff should follow the physician orders for medication administration. If a medication was not available, staff should check the medication room for extra supplies or notify the ADON for ordering. Residents should not go multiple days without ordered medications. During an interview on 12/13/24, at 1:00 P.M., the Administrator said the staff should follow policy and procedure for medication administration. The staff should notify the charge nurse, ADON, or DON if a medication was not available.

Based on record review and interview, the facility failed an medication error of less than 5 percent when staff made four medication errors out of 32 opportunities, affecting two residents (Resident #13 and #42) resulting in a 12.5 percent medication error rate The facility census was 75. Review of the facility policy, Medication Administration,' undated, showed the following: -Medications are given to benefit a resident's health as ordered by the physician; -Read the label three times before administering the medication. First when comparing the label with the medication sheet. Second when setting up the medication. Third when preparing to administer the medication to the resident; -Administer the medication; -Record the medication given on the medication sheet. 1. Review of Resident # 13's face sheet showed the following: -admitted [DATE]; -Diagnoses included Vitamin D deficiency, constipation, and pain. Review of the resident's physician orders, dated 12/01/24 through 12/13/24, showed the following: -An order, dated 12/31/21, for acetaminophen (generic for Tylenol) 325 milligrams (mg), administer two tablets twice daily; -An order, dated 11/27/22, for Vitamin D3 2,000 unit, 1 capsule once daily. The order was on hold from 10/16/24 at 12:01 A.M. to 12/11/24 12:59 A.M.; -An order, dated 10/17/24 to 12/12/24, vitamin D3 3,000iu, administer 2 capsules once daily for eight weeks. -An order, dated 05/09/23, for Senna Plus 8.6-50 mg, administer 1 capsule twice daily; During an interview and observation on 12/12/24, at 7:46 A.M., Certified Medication Tech (CMT) B prepared medications for the resident near the nursing station. The CMT administered the following medications: -Vitamin D3 5,000 units, one tablet, and Vitamin D3 1,000 units, one tablet, for a total of 6000 units; -Vitamin D3 1,000 units, one tablet (ordered amount of two tablets); -The CMT did not administer and stated there was no Tylenol 325 mg available. The CMT said the Tylenol had not been available for a couple of days, they were waiting on the supply to arrive; -The CMT did not administer Senna Plus. During an interview on 12/12/24, at 9:30 A.M., CMT B said that he/she realized that he/she did not have the Senna-plus available at the time of administration and had notified the Assistant Director of Nursing (ADON) for supplies of both Tylenol 325 mg and Senna-Plus and they should be available later this day. During an interview on 12/13/24, at 10:05 A.M., CMT B said that if medications were not available, staff should look in the emergency kit and notify the nurse of any medication not available. He/she did not know if the nurses notified the doctor. The order for Vitamin D3 of 2,000 units should have been given as two tablets of the 1,000 units available. During an interview on 12/13/24, at 10:12 A.M., CMT C said that staff should follow physician orders and provide all medications as ordered. If a medication was not available, he/she would tell the ADON and make a list of medications needed. During an interview on 12/13/24, at 11:02 A.M., Licensed Practical Nurse (LPN) D said that if a medication was not available, the staff should notify ADON and put in an order, Ideally it should be refilled before running out of medications or over-the-counter medications. The nurse may need to notify the physician if a medication was unavailable to see if an alternative was recommended instead of the resident being without the medication. During an interview on 12/13/24, at 11:16 A.M., LPN E said that staff should follow physician orders for medication administration and notify the physician if a medication was not available for recommendations to hold or change to an alternative option. During an interview on 12/13/24, at 12:19 P.M., the ADON said staff should notify the ADON when medications were not available for medication administration. During an interview on 12/13/24, at 12:48 P.M., the Director of Nursing (DON) said when medications were not available, staff should check medication room for extra supplies or notify ADON for ordering. Staff should follow physician orders when administering medications. Residents should not have to go without medications. During an interview on 12/13/24, at 1:00 P.M., Administrator said that staff should follow policy and procedure for medication pass. 2. Review of the facility's policy titled Medication Administration, undated, did not show any direction regarding insulin administration and/or fast acting insulin requirements. Review of the publication of the National Library of Medicine, titled Optimal Prandial Timing of Bolus Insulin in Diabetes Management, dated 11/2016, taking rapid acting insulin 15 to 20 minutes before a meal provides significant improvements in post-meal control and is recommended whenever possible. Review of the Mayo Clinic's Insulin aspart,recombiant (intravenous route,subcutaneous (below the skin), updated 10/01/24, showed when used as a mealtime insulin, Novolog(R) and Insulin Aspart FlexPen(R) (a fast acting injectable insulin) should be taken within 5 to 10 minutes before a meal or immediately before a meal. Review of Resident #42's face sheet (brief look at resident information) showed the following information: -admitted [DATE]; -Diagnoses included chronic kidney disease, high blood pressure, diabetes, and weakness. Review of the resident's care plan, last revised on 03/15/22, showed the following information: -Administer and assess side effects and effectiveness of medications as ordered to include both scheduled and sliding scale insulin; -Accu-Check's (meter quantitatively measures glucose (sugar) in the blood) per physicians orders; -Assess/document/review signs and symptoms of low blood sugar. If symptoms are present, provide a high protein snack and follow physician orders. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 11/12/24, showed the following information: -Received insulin injections six days out of the week; -Received hypoglycemic (low blood sugar) medications. Review of the resident's physician order sheet, dated 12/13/24, showed the following: - A current order for insulin aspart 100 units/milliliter (ml), administer six units subcutaneously with meals at 7:00 A.M., 12:00 P.M., and 5:00 P.M. Observation on 12/11/24, at 11:21 A.M., showed LPN D obtain the resident's blood sugar reading. LPN D administered six units of insulin aspart subcutaneously (beneath the skin) in the resident's right lower quadrant of the abdomen. The LPN did not offer a snack to the resident room. There were no snacks visiable in the resident's room. Observation on 12/11/24, at 12:15 P.M., showed the resident had not been served a lunch tray (54 minutes after the administration of the fast-acting insulin). During an interview on 12/11/24, at 12:15 P.M., the resident said he/she usually eats or should eat something within 30 minutes of staff administering insulin. The resident said if he/she had to wait an hour or more, it wouldn't be a good thing. During an interview on 12/13/24, at 10:12 A.M., CMT C said insulin should be given as close to meals as possible. During an interview on 12/13/24, at 11:02 A.M., LPN D said insulin administration times depends on the individual resident, some residents are fragile and some are not. The appropriate timing for a resident to have a snack or meal within insulin administration is 30 minutes. During an interview on 12/13/24, at 11:18 A.M., LPN E said a meal or snack should be provided within 30 minutes of insulin administration. During an interview on 12/13/24, at 12:19 P.M., the ADON said the appropriate timing for a resident to have a snack or meal within insulin administration is 30 minutes. It would be acceptable if a resident had to wait up to an hour for a snack or meal after insulin administration, that is just not best practice. During an interview on 12/13/24, at 12:47 P.M., the Director of Nursing (DON) said anytime fast acting insulin is administered, an immediate snack or meal should be provided. During an interview on 12/13/24, at 1:00 P.M., the Administrator said He expects staff to follow policy and procedure related to insulin administration.

Based on observation, interview, and record review, the facility failed to ensure the residents were free of significant mediation errors when the facility failed to provide a meal service and/or a snack for one resident (Resident #42) after administering rapid acting insulin. The facility census was 75. Review of the facility's policy titled Medication Administration, undated, did not show any direction regarding insulin administration and/or fast acting insulin requirements. Review of the publication of the National Library of Medicine, titled Optimal Prandial Timing of Bolus Insulin in Diabetes Management, dated 11/2016, taking rapid acting insulin 15 to 20 minutes before a meal provides significant improvements in post-meal control and is recommended whenever possible. Review of the Mayo Clinic's Insulin aspart,recombiant (intravenous route,subcutaneous (below the skin), updated 10/01/24, showed when used as a mealtime insulin, Novolog(R) and Insulin Aspart FlexPen(R) (a fast acting injectable insulin) should be taken within 5 to 10 minutes before a meal or immediately before a meal. 1. Review of Resident #42's face sheet (brief look at resident information) showed the following information: -admitted [DATE]; -Diagnoses included chronic kidney disease, high blood pressure, diabetes, and weakness. Review of the resident's care plan, last revised on 03/15/22, showed the following information: -Administer and assess side effects and effectiveness of medications as ordered to include both scheduled and sliding scale insulin; -Accu-Check's (meter quantitatively measures glucose (sugar) in the blood) per physicians orders; -Assess/document/review signs and symptoms of low blood sugar. If symptoms are present, provide a high protein snack and follow physician orders. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool filled out by facility staff), dated 11/12/24, showed the following information: -Received insulin injections six days out of the week; -Received hypoglycemic (low blood sugar) medications. Review of the resident's physician order sheet, dated 12/13/24, showed the following: - A current order for insulin aspart 100 units/milliliter (ml), administer six units subcutaneously with meals at 7:00 A.M., 12:00 P.M., and 5:00 P.M. Observation on 12/11/24, at 11:21 A.M., showed Licensed Practical Nurse (LPN) D obtain the resident's blood sugar reading. LPN D administered six units of insulin aspart subcutaneously (beneath the skin) in the resident's right lower quadrant of the abdomen. The LPN did not offer a snack to the resident room. There were no snacks visible in the resident's room. Observation on 12/11/24, at 12:15 P.M., showed the resident had not been served a lunch tray (54 minutes after the administration of the fast-acting insulin). During an interview on 12/11/24, at 12:15 P.M., the resident said he/she usually eats or should eat something within 30 minutes of staff administering insulin. The resident said if he/she had to wait an hour or more, it wouldn't be a good thing. During an interview on 12/13/24, at 10:12 A.M., Certified Medication Tech (CMT) C said insulin should be given as close to meals as possible. During an interview on 12/13/24, at 11:02 A.M., LPN D said insulin administration times depends on the individual resident, some residents are fragile and some are not. The appropriate timing for a resident to have a snack or meal within insulin administration is 30 minutes. During an interview on 12/13/24, at 11:18 A.M., LPN E said a meal or snack should be provided within 30 minutes of insulin administration. During an interview on 12/13/24, at 12:19 P.M., the Assistant Director of Nursing (ADON) said the appropriate timing for a resident to have a snack or meal within insulin administration is 30 minutes. It would be acceptable if a resident had to wait up to an hour for a snack or meal after insulin administration, that is just not best practice. During an interview on 12/13/24, at 12:47 P.M., the Director of Nursing (DON) said anytime fast acting insulin is administered, an immediate snack or meal should be provided. During an interview on 12/13/24, at 1:00 P.M., the Administrator said He expects staff to follow policy and procedure related to insulin administration.

Based on interview and record review, the facility failed to protect the resident's (Resident #1) right to be free from verbal and emotional abuse, by a staff member (Certified Nurse Aide (CNA) B) when staff yelled at and belittled the resident. The facility census was 70. Review of the facility's policy titled Handle with Care, Behavior Management System, Verbal Intervention Manual for Participants, latest publication 2012, showed the following: -Creating a universal perception of physical and psychological safety; -In order to act in the resident's best interest, staff need to be in control of their feelings and behavior; -Staff should interact with the resident during a crisis by allowing ventilation without becoming judgmental; considering the validity of the feeling if not the behavior, as it is impossible to tell another person how to feel; focus on one issue at a time; offer alternate choices the resident can make, contrasted by the inappropriate choices and the attached consequences; and persuade the individual to agree on the course of action to be taken. 1. Review of Resident #1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), depression (medical illness that negatively affects how you feel, the way you think and how you act), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome, and asthma (a respiratory condition marked by spasms in the lungs, causing difficulty in breathing). Review of the resident's current care plan showed the following: -The resident has a history of suicidal ideation, psychotropic drug use, and elopements and/or attempts to elope; -The resident has a guardian. Review of the resident's quarterly, Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 9/24/23, showed the resident was cognitively intact. During interviews on 10/12/23, at 2:06 P.M., and 10/13/23, at 3:30 P.M., Licensed Practical Nurse (LPN) A said the following: -The resident started cursing and was opening the door to the unit, wanting to get out; -He/she and Certified Nurse Aide (CNA) B ran up to try to stop the resident and stepped in between the resident and the doors; -The resident reached around CNA B and grabbed his/her arm and he/she yelled loudly because it hurt; -He/she did hear CNA B saying rude and mean comments to the resident and mocking him/her. CNA B was acting like he/she were crying. Review of the CNA Fs written statement, dated 10/8/23, showed the following: -He/she was called to the unit to help with a resident showing behaviors; -He/she witnessed Certified Medication Tech (CMT) H, LPN A, and CNA B trying to provoke the resident with some song as a joke, laughing, and and laughing about not fist-bumping the resident any longer; -They also cursed towards the resident; -He/she said that was enough and this is not how you redirect. During an interview on 10/12/23, at 10:00 P.M., CNA F said the following: -When CNA F and the resident were outside, CNA B came outside and was yelling at the resident and saying things to hurt the resident's feelings; -CNA was telling the resident that even though the resident wants CNA B to come to the resident's graduation, they (CNA B) would never want to come to see the resident graduate because they don't care; -CNA B would pretend to cry and say Boo-Hoo does that hurt your feelings?; -CNA B also told the resident that since he/she loves to fist-bump, he/she will make sure to never fist bump the resident ever again, but the resident can watch CNA B fist bump everyone else. Review of CNA G's written statement, dated 10/8/23, showed the following: -The resident got very inappropriately verbal and was calling staff names; -CNA B was egging the resident on; -After the resident finally began to calm down, the resident asked CNA B for a fist bump and CNA B replied that I will fist pound or hug any mother fucker in here before I hug or fist pound you! Review of LPN E's written statement, dated 10/8/23, showed the following: -He/she was informed that the resident had gone outside and he/she sent CNA F out to talk to resident and talk into coming back inside; -Upon returning, CNA F reported that CNA B had also come outside to make comments to provoke the resident. During an interview on 10/12/23, at 4:50 P.M., LPN E said the following: -Staff that works the skilled side usually know the residents in the unit because there are times one of them may have to go over there and work a shift; -Staff have to be professional; -The resident did go outside with CNA F; -After some time, CNA F came back in and said CNA B is taunting and making fun of the resident; -CNA F told him/her that CNA B came outside, and probably not realizing CNA F was also outside, and start singing, Boo-Hoo cry baby, and saying, where the resident could hear, that the resident really wants CNA B to be at his/her graduation, but now he/she wouldn't be caught at his/her graduation and carrying on to antagonize the resident; -At this time, CNA F went and got the resident to join them on the SNF side for a little while to let everything cool down; -He/she texted the on-call nurse and requested the Administrator come up. Review of the resident's and facility's records showed no documentation of an investigation into the allegations of verbal abuse. During an interview on 10/12/23, at 11:20 A.M., CMT C said the staff are able to usually deescalate the resident pretty easily. During an interview on 10/13/23, at 12:55 P.M., the MDS Coordinator, said the following: -He/she did hear about the incident involving staff and the resident; -They are supposed to deescalate verbally. During an interview on 10/13/23, at 10:15 A.M., the Assistant Director of Nursing (ADON) said the following: -He/she was not told that there was any yelling or about any staff going out after the resident and taunting/degrading the resident in any way. During an interview on 10/12/23, at 11:00 A.M., at 1:25 P.M., and on 10/13/23, at 9:00 A.M., the Administrator said the comments of possible verbal abuse were no told to him by staff or the resident. MO00225606

Based on interviews and record review, the facility failed to ensure all allegations of possible abuse were reported within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff witnessed and provided written statements regarding allegations verbal abuse of one resident (Resident #1) by a facility staff member. The facility census was 70. Review of the facility's policy abuse policy, undated, showed the following: -All allegations of abuse, neglect, exploitation, and mistreatment, injuries of unknown sources and misappropriation of resident property will be reported immediately, but no later than the following timeframes; -If abuse is alleged or there is serious bodily injury, the allegation must be reported within two hours after the allegation was made; -If the allegation does not allege abuse or result in serious bodily injury, the report must be made within 24-hours after the allegation was made; -All employees of the facility are mandated reporters; -The facility will ensure all reports are made within two hours (abuse or serious bodily injury) or within 24-hours (non-abuse); -The two hour timeframe must be met even during the night shift or during the weekend. 1. Review of Resident #1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), depression (medical illness that negatively affects how you feel, the way you think and how you act), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome, and asthma (a respiratory condition marked by spasms in the lungs, causing difficulty in breathing). Review of the resident's current care plan showed the following: -The resident has a history of suicidal ideation, psychotropic drug use, and elopements and/or attempts to elope; -The resident has a guardian. Review of the resident's quarterly, Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 9/24/23, showed the resident was cognitively intact. During interviews on 10/12/23, at 2:06 P.M., and 10/13/23, at 3:30 P.M., Licensed Practical Nurse (LPN) A said the following: -The resident started cursing and was opening the door to the unit, wanting to get out; -He/she and Certified Nurse Aide (CNA) B ran up to try to stop the resident and stepped in between the resident and the doors; -The resident reached around CNA B and grabbed his/her arm and he/she yelled loudly because it hurt; -He/she did hear CNA B saying rude and mean comments to the resident and mocking him/her. CNA B was acting like he/she were crying. Review of the CNA Fs written statement, dated 10/8/23, showed the following: -He/she was called to the unit to help with a resident showing behaviors; -He/she witnessed Certified Medication Tech (CMT) H, LPN A, and CNA B trying to provoke the resident with some song as a joke, laughing, and and laughing about not fist-bumping the resident any longer; -They also cursed towards the resident; -He/she said that was enough and this is not how you redirect. During an interview on 10/12/23, at 10:00 P.M., CNA F said the following: -When CNA F and the resident were outside, CNA B came outside and was yelling at the resident and saying things to hurt the resident's feelings; -CNA was telling the resident that even though the resident wants CNA B to come to the resident's graduation, they (CNA B) would never want to come to see the resident graduate because they don't care; -CNA B would pretend to cry and say Boo-Hoo does that hurt your feelings?; -CNA B also told the resident that since he/she loves to fist-bump, he/she will make sure to never fist bump the resident ever again, but the resident can watch CNA B fist bump everyone else. Review of CNA G's written statement, dated 10/8/23, showed the following: -The resident got very inappropriately verbal and was calling staff names; -CNA B was egging the resident on; -After the resident finally began to calm down, the resident asked CNA B for a fist bump and CNA B replied that I will fist pound or hug any mother fucker in here before I hug or fist pound you! Review of LPN E's written statement, dated 10/8/23, showed the following: -He/she was informed that the resident had gone outside and he/she sent CNA F out to talk to resident and talk into coming back inside; -Upon returning, CNA F reported that CNA B had also come outside to make comments to provoke the resident. During an interview on 10/12/23, at 4:50 P.M., LPN E said the following: -Staff that works the skilled side usually know the residents in the unit because there are times one of them may have to go over there and work a shift; -Staff have to be professional; -The resident did go outside with CNA F; -After some time, CNA F came back in and said CNA B is taunting and making fun of the resident; -CNA F told him/her that CNA B came outside, and probably not realizing CNA F was also outside, and start singing, Boo-Hoo cry baby, and saying, where the resident could hear, that the resident really wants CNA B to be at his/her graduation, but now he/she wouldn't be caught at his/her graduation and carrying on to antagonize the resident; -At this time, CNA F went and got the resident to join them on the SNF side for a little while to let everything cool down; -He/she texted the on-call nurse and requested the Administrator come up. Review of the resident's and facility's records showed staff did not document reporting the allegation so abuse to the DHSS. Review of DHSS records showed the home did not receive a self-report regarding the allegations of abuse. During an interview on 10/12/23, at 11:20 A.M., CMT C said the following: -He/she would report any complaint of abuse to the charge nurse, right away; -The nurse should then report it to state, immediately, but could not was not sure of the exact timeframe to report. During an interview on 10/12/23, at 11:50 A.M., LPN D said the following: -Staff have two hours to report any abuse allegation to state; -If a staff thinks there is potentially abuse, staff should report to state right away or contacted the Director of Nursing (DON) so they could report it. During an interview on 10/13/23, at 10:15 A.M., the Assistant Director of Nursing (ADON) said the following: -He/she was not told that there was any yelling or about any staff going out after the resident and taunting/degrading the resident in any way. During an interview on 10/12/23, at 11:00 A.M., at 1:25 P.M., and on 10/13/23, at 9:00 A.M., the Administrator said the comments of possible verbal abuse were not told to him by staff or the resident. He expected staff to understand to report up to supervisors and then one of them (supervisors) would report to state within 2 hours if there were allegations of abuse. MO00225606

Based on interview and record review, the facility failed to document completion of a full investigation of an allegation of employee to resident abuse towards one resident (Resident #1). The facility census was 70. Record review of the facility's Abuse Policy under the section, Investigation, undated, showed the following: -Designated facility personnel will begin the investigation immediately; -A root cause investigation and analysis will be completed; -The information gathered is given to administration; -The Administrator or designee will investigate the incident with the assistance of appropriate personnel; -The investigation will include who was involved; resident's involved statements; resident's roommate's statement; interviews with 3 to 4 residents receiving care from the alleged staff; interviews from 3 to 4 department staff (if possible); involved staff and witness statements of events; a description of the resident's behavior and environment at the time of the incident; injuries present including a resident assessment; observation of resident and staff behaviors; and environmental considerations; -All staff must cooperate during the investigation to assure the resident if fully protected. 1. Review of Resident #1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), depression (medical illness that negatively affects how you feel, the way you think and how you act), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome, and asthma (a respiratory condition marked by spasms in the lungs, causing difficulty in breathing). Review of the resident's current care plan showed the following: -The resident has a history of suicidal ideation, psychotropic drug use, and elopements and/or attempts to elope; -The resident has a guardian. Review of the resident's quarterly, Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 9/24/23, showed the resident was cognitively intact. During interviews on 10/12/23, at 2:06 P.M., and 10/13/23, at 3:30 P.M., Licensed Practical Nurse (LPN) A said the following: -The resident started cursing and was opening the door to the unit, wanting to get out; -He/she and Certified Nurse Aide (CNA) B ran up to try to stop the resident and stepped in between the resident and the doors; -The resident reached around CNA B and grabbed his/her arm and he/she yelled loudly because it hurt; -He/she did hear CNA B saying rude and mean comments to the resident and mocking him/her. CNA B was acting like he/she were crying. Review of the CNA Fs written statement, dated 10/8/23, showed the following: -He/she was called to the unit to help with a resident showing behaviors; -He/she witnessed Certified Medication Tech (CMT) H, LPN A, and CNA B trying to provoke the resident with some song as a joke, laughing, and and laughing about not fist-bumping the resident any longer; -They also cursed towards the resident; -He/she said that was enough and this is not how you redirect. During an interview on 10/12/23, at 10:00 P.M., CNA F said the following: -When CNA F and the resident were outside, CNA B came outside and was yelling at the resident and saying things to hurt the resident's feelings; -CNA was telling the resident that even though the resident wants CNA B to come to the resident's graduation, they (CNA B) would never want to come to see the resident graduate because they don't care; -CNA B would pretend to cry and say Boo-Hoo does that hurt your feelings?; -CNA B also told the resident that since he/she loves to fist-bump, he/she will make sure to never fist bump the resident ever again, but the resident can watch CNA B fist bump everyone else. Review of CNA G's written statement, dated 10/8/23, showed the following: -The resident got very inappropriately verbal and was calling staff names; -CNA B was egging the resident on; -After the resident finally began to calm down, the resident asked CNA B for a fist bump and CNA B replied that I will fist pound or hug any mother fucker in here before I hug or fist pound you! Review of LPN E's written statement, dated 10/8/23, showed the following: -He/she was informed that the resident had gone outside and he/she sent CNA F out to talk to resident and talk into coming back inside; -Upon returning, CNA F reported that CNA B had also come outside to make comments to provoke the resident. During an interview on 10/12/23, at 4:50 P.M., LPN E said the following: -Staff that works the skilled side usually know the residents in the unit because there are times one of them may have to go over there and work a shift; -Staff have to be professional; -The resident did go outside with CNA F; -After some time, CNA F came back in and said CNA B is taunting and making fun of the resident; -CNA F told him/her that CNA B came outside, and probably not realizing CNA F was also outside, and start singing, Boo-Hoo cry baby, and saying, where the resident could hear, that the resident really wants CNA B to be at his/her graduation, but now he/she wouldn't be caught at his/her graduation and carrying on to antagonize the resident; -At this time, CNA F went and got the resident to join them on the SNF side for a little while to let everything cool down; -He/she texted the on-call nurse and requested the Administrator come up. Review of the resident's and facility's records showed staff did not document an investigation into the allegations of physical, verbal, and emotional abuse. During an interview on 10/13/23, at 10:15 A.M., the Assistant Director of Nursing (ADON) said the following: -He/she was not told that there was any yelling or about any staff going out after the resident and taunting/degrading the resident in any way. During an interview on 10/12/23, at 11:00 A.M., at 1:25 P.M., and on 10/13/23, at 9:00 A.M., the Administrator said the comments of possible verbal abuse were not told to him by staff or the resident. MO00225606

Based on interview and record review, the facility staff failed to notify one resident's (Resident #1) representative in a timely manner when the resident had a change in condition, including falls. The facility census was 69. Review of the facility's policy titled, Event Investigation, undated, showed the following: -Notify the resident's representative of a change of condition or any concerns that have been identified; -Detailed procedure for completing the Report of Event Form, Responsible Party: Document who and how related and date and time of notification. This must be documented in the medical record. 1. Review of Resident #1's face sheet (resident's information at a quick glance) showed the following: -admitted [DATE]; -On hospice services; -Diagnoses included Alzheimer's disease and primary insomnia (decreased ability to fall asleep and/or stay asleep). Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 05/09/23, showed the following information: -Severe impaired cognition; -Required extensive assistance with bed mobility, transfers, and toilet use; -Balance when moving from seated to standing position: not steady, only able to stabilize with human assistance; -Balance moving on and off toilet: not steady, only able to stabilize with human assistance; -Balance moving from surface to surface transfer (transfer between bed and chair or wheelchair): not steady, only able to stabilize with human assistance; -Used wheelchair for mobility; Review of the resident's care plan, updated 08/07/23, showed the following: -When the resident sustains a fall, staff to complete an assessment prior to moving the resident, to include vital signs. Staff to notify the resident's physician and responsible party. Review of the resident's Event Report showed a nurse documented the following: -On 07/28/23, at 2:54 A.M., the nurse heard a loud scream. A certified nurse assistant (CNA) went to check the resident and found the resident on the floor by his/her bed. Upon evaluation by the nurse, the resident had a raised area to his/her forehead, and to his/her forearm. The resident complained of pain to his/her right shoulder. Neurological checks and vital signs initiated. Staff placed a call to the physician on call and who gave an order for x-ray to right shoulder and right forearm; -Notifications: Resident representative notified: No. Review of the resident's physician orders, dated 07/28/23, showed a radiology order for an x-ray of the resident's right shoulder and right forearm. Review of the X-Ray results, dated 07/28/23, showed no evidence of acute fractures. Review of the resident's progress notes showed staff did not document on 07/28/23. Staff did not document notifying the resident's family/representative of the fall with injury, the order for x-rays, or the x-ray results. 34906 During an interview on 08/19/23, at 6:10 P.M., Registered Nurse (RN) A said after a resident fall, the nurse should assess the resident and notify the physician and the resident's responsible party. During an interview on 08/24/23, at 10:54 A.M., Licensed Practical Nurse (LPN) B said after a resident fall, the nurse should address any immediate injuries, send the resident to the hospital (if needed), and contact the resident's physician and the resident's responsible party. During an interview on 08/24/23, a 2:48 P.M., the Assistant Director of Nursing (ADON) said the following: -After a resident fall, the nurse should notify the resident's responsible party within 20 to 30 minutes, after contacting the resident's physician and assessing the resident for injuries; -If a nurse was unable to reach a resident's responsible party by phone, that nurse should pass on in report for the next shift to contact the resident's responsible party; -The nurse should document the notification of the resident's responsible party on the event report or the resident's progress note; -The nurse should notify the resident's responsible party of x-ray results and document the notification in the resident's progress notes. During an interview on 08/24/23, at 3:00 P.M., the Administrator said the following: -After a resident fall, the nurse should first assess and stabilize the resident, and call the physician; -The nurses should then notify the resident's responsible party within 30 minutes of the fall; -The nurse should notify the resident's responsible party of new physician orders and of any x-ray results; -The nurse should document the resident's fall and notification of the responsible party on the resident's progress note and on the event report. MO00223152

Based on observation, interview, and record review the facility failed to ensure food was stored, prepared, and distributed in a manner to prevent possibly contamination when staff failed to keep ice machine free of white substances, failed to dispose of outdated refrigerated foods, and when stored clean, wet dishes on a tray. This had the potential to affect all residents who consumed food from the facility kitchen. The facility census was 68. 1. Review of the 2013 Missouri Food Code showed food-contact surfaces of equipment and utensils shall be clean to sight and touch. Review of the facility's policy titled, Nutrition and Dining Services Manual, [DATE], showed wash the inside of the machine thoroughly with warm detergent solution, rinse with baking soda water, and dry monthly. Inside of the machine will be de-limed per facility guidelines monthly. Observations of the kitchen on [DATE], beginning at 9:01 A.M., and on [DATE], at 3:00 P.M., showed the inside of the ice machine, above the ice and around the hinges, had a white substance present. During an interview on [DATE], at 3:10 P.M., Dietary Aide A said the following: -Kitchen staff have a cleaning list, weekly deep clean and daily cleaning for A.M., and P.M., staff; -Dietary staff clean the outside of the ice machine and maintenance cleans the inside of the machine; -Dietary staff let maintenance know when something needs to be cleaned by maintenance. During an interview on [DATE], at 3:16 P.M., Dietary Aide B, said the following: -Kitchen staff have a daily and weekly cleaning schedule; -Maintenance cleans the inside of the ice machine. He/she empties the ice machine; -He/she lets the Dietary Manager know when something needs to be cleaned by maintenance. During an interview on [DATE], at 3:20 P.M., Dietary Manager said the following: -Maintenance is responsible for cleaning the inside of the ice machine. He/she done that a couple weeks ago; -Maintenance cleans the ice machine quarterly; -When something needs to be cleaned by maintenance, he/she speaks to maintenance verbally or there is a binder they write requests in. During an interview on [DATE], at 3:27 P.M., the Administrator said maintenance is responsible for cleaning the inside of the ice machine and dietary staff should be letting maintenance know when the machine needs to be cleaned. 2. Review of the US Food and Drug Administration policy, under the section of Food Labeling and Handling, currently updated [DATE], showed the following: -Facility staff must ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated; -Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable) or discarded. Review of the facility's policy titled Nutrition and Dining Services Manual, [DATE], said the Dining Services Manager is responsible for receiving and storing food and nonfood items. Observations of the kitchen on [DATE], beginning at 9:01 A.M., [DATE], at 10:33 A.M., showed the following: -One full gallon of coleslaw dressing and one partial gallon of coleslaw dressing with the manufacturer expiration date of [DATE]; -One partial gallon of mustard with manufacturer expiration date of [DATE]. During an interview on [DATE], at 3:10 P.M., Dietary Aide A said it's not acceptable to use expired foods. If it's past the manufacture's expiration date, the food should be sent back or thrown out. During an interview on [DATE], at 3:16 P.M., Dietary Aide B said it's not acceptable to use expired foods. He/she would let the DM know and it would be thrown out. During an interview on [DATE], at 3:20 P.M., Dietary Manager said it's not acceptable to use expired foods. During an interview on [DATE], at 3:27 P.M., the Administrator, said it's not acceptable to use foods past the expired date, they should be thrown out. 3. Record review of the 2017 Food Code, issued by the Food and Drug Administration, showed the following: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food; -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Review of the facility's policy titled Nutrition and Dining Services Manual, [DATE], showed the following: -Items are to be air dried; -No moisture can be found on stacked item. Observations of the kitchen on [DATE], beginning at 9:1 A.M., showed two separate trays of small clear cups, placed on the trays, upside down with trapped water inside with no air movement for drying. During an interview on [DATE], at 3:10 P.M., Dietary Aide A said all dishes should be air dried and never put away wet. During an interview on [DATE], at 3:16 P.M., Dietary Aide B said dishes should be put upside down in the drain to air dry. They should not be put away wet. During an interview on [DATE], at 3:20 P.M., Dietary Manager said dishes should be air dried. Staff should never put dishes away wet. During an interview on [DATE], at 3:27 P.M., the Administrator, said dishes and cups should be put away dry, not wet.

Based on observations, record review and interview the nursing staff failed to consistently provide weekly skin assessments, failed to monitor pressure ulcers, and failed to provide the physician ordered treatments to promote healing and prevent new pressure ulcers from developing for three residents (Residents #1, #5, and #10), identified by staff as having facility-acquired pressure ulcers. Ten residents were selected for review, five with pressure ulcers, in the facility with a census of 76. 1. Record review of the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel's Prevention and treatment of [REDACTED]. Washington DC: National Pressure Ulcer Advisory Panel; 2009 showed the following pressure ulcer classification system: -Stage I-intact skin with non-blanchable redness of a localized area usually over a bony prominence; -Stage II-partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Bruising indicates suspected deep tissue injury; -Stage III-full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling; -Stage IV-full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. Often include undermining and tunneling; -Unstageable-full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the "the body's natural cover" and should not be removed; -Suspected deep tissue injury- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. 2. Record review of the undated facility policies regarding pressure ulcer risk assessment, pressure ulcer treatment, and prevention of pressure ulcers showed the following information: -A pressure ulcer risk assessment will be completed upon admission, weekly for a total of four weeks, quarterly, with any decline or change of status, and annually; -Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated; -Nursing staff will assess and document a resident's significant risk factors for developing pressure ulcers; -Nurses are to be notified to inspect the skin if skin changes are identified and monitored by nurses conducting skin assessments at least weekly to identify changes; -Nurse shall assess and document a full assessment of a pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue, pain assessment and current treatment, including support surfaces; -A resident at risk can develop a pressure ulcer within two to six hours of the onset of pressure, this resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers; -Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue; -The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes; -Pressure can also come from splints, casts, bandages, and wrinkles in the bed linen. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected; -Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e., perspiration, feces, urine, wound discharge, soap residue, etc.), decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition; -Once a pressure ulcer develops, it can be extremely difficult to heal; -Pressure ulcer treatment program should focus on the following strategies: assessing the resident and the pressure ulcers, managing tissue loads, pressure ulcer care, managing bacterial colonization and infection, and education and quality improvement; -When eschar (dead tissue, usually dark in color, can be hard and dry or moist and sometimes foul smelling) is present, a pressure ulcer cannot be accurately staged until the eschar is removed; -Suspected deep tissue injury is also considered unstageable; -Pressure ulcer treatment requires a comprehensive approach, including debridement (removal of dead or damaged tissue by means of surgical intervention, mechanical through friction, and chemical through enzyme medication), managing infections, managing systemic issues ([MEDICAL CONDITIONS], etc) maximizing the potential for healing and pain control; -Documentation in the resident's medical record should include the date and the time the wound care was given, any problems or complaints made by the resident related to the procedure, resident refusal of the treatment and the reason why, and the signature and title of the person recording the data. 3. Record review of Resident #1's OBRA admission Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 9/27/13, showed the following information: -Admission to the facility on [DATE], from an acute care hospital; -[DIAGNOSES REDACTED]. -Assessed by staff being alert and oriented; -Assessed by staff as requiring extensive assistance with bed mobility, transfers and personal hygiene; -On admission staff assessed the resident with one Stage II pressure ulcer and one Stage IV pressure ulcer. The Stage IV pressure ulcer measured 1.0 centimeter (cm) by 1.0 cm; -No unstageable pressure areas were identified. Record review of the facility's weekly nurse skin condition report dated 9/20/13, showed the following information: -Pressure reduction devices identified were pressure reduction mattress on bed and Podus boots (boots that suspend the heels to provide pressure relief); -The resident had pain related to wound and wound treatment and received medication prior to wound treatment that was effective; -Staff documented the resident had one Stage II pressure ulcer on his/her left heel measuring 1.0 cm by 0.5 cm with a pink wound bed, serous (serum) drainage, and surrounding skin pink with slight [MEDICAL CONDITION] (swelling); -Staff documented the resident had one Stage IV pressure ulcer on his/her left ischial area (hip) that measured 1 inch by 1 inch with a pink wound bed, and serosanguinous (bloody) drainage; -Staff did not identify any other pressure ulcer. Record review of the resident's physician care note dated 9/26/13, showed the following information -Admission for therapy including wound VAC (a vacuum assisted closure device used to facilitate wound healing by converting an open wound to a closed wound). The resident had osteo[DIAGNOSES REDACTED] (infection of the bones) that involved the coccyx and sacrum (lower back area) which contained [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA- a resistant bacterial infection that is difficult to treat); -The resident had a history of [REDACTED]. -The resident was alert and oriented times four, had [MEDICAL CONDITION] of the lower extremities with no upper extremity symptoms; -The resident had thin atrophic (wasting) musculature and flexion contractures of lower extremities. -The resident had an ulcer on the left heel which was present earlier in the year and showed improvement. -The resident had an ulcer over the left ischial tuberosity (area that supports weight when sitting) that measured approximately 3.5 cm in diameter. No surrounding hyperemia (redness). -The resident had a wound VAC over his/her sacrum. The physician documented he/she did not see the wound, but noted the absence of redness of the skin surrounding the dressing; -The resident may require a referral to the wound clinic. Record review of the care plan for the resident dated 10/1/13, showed the following information: -Resident with chronic pressure ulcer with risk for complications related to infection, additional skin breakdown, infection, dehydration due to chronic infection with recent surgical interventions, significant limitations in mobility with compromised circulatory system due to paraplegic condition, fall history, and weight loss. Staff to encourage and assist the resident with turning and positioning. Staff to monitor for changes in skin status that may indicate worsening of the pressure ulcer and notify the physician. Staff to use supportive/protective devices to assist with positioning, has leg brace and needs pillow between legs for support or abduction pillow. Resident to have an air mattress. -Staff added an undated entry to apply heel/feet protectors as allowed for pressure reduction. Treatments as ordered for wounds to include wound VAC-followed by wound clinic with order changes as directed. Record review of the facility's weekly wound nurse's wound and skin status reports through 10/4/13, showed the following information: -On admission (9/19/13), the staff identified the resident had three pressure ulcers; -Staff did not document a wound assessment at that time; -On 10/2/13 staff documented the following: -The left buttock/left ischial area pressure ulcer was unstagable with slough/eschar measuring 3.9 cm by 3.2 cm with no depth. Wound status shown as deteriorated. Treatment shown to cleanse ischial wound on bilateral (both) buttocks with antibacterial soap and water. Staff notified the resident's physician; -The pressure ulcer to the resident's left heel was Stage II measuring 1.8 cm by 0.8 cm with no depth. Treatment included to cleanse wound with normal saline, pat dry and apply a [MEDICATION NAME] foam dressing to the left heel every three days; -The pressure ulcer to the resident's sacrum was Stage III measuring 9.6 cm by 8.4 cm with depth of 0.3 cm. Wound bed with 90% granulation (healthy tissue) and 10% slough with serosanguineous drainage. Wound status shown as improved. Treatment included to change the wound VAC twice weekly, and wound VAC dressing as needed for loose or soiled dressing, cleanse wound with antibacterial soap and water, irrigate with normal saline, gently pat peri-wound (area around wound) skin dry and apply -(documentation ended); -The resident had a new pressure ulcer on his/her right buttock/right ischial area identified as a Stage II that measured 3.6 cm by 3.2 cm with no depth. Treatment included cleansing ischial wounds on bilateral buttocks with antibacterial soap and water. Staff notified the resident's physician; -The resident had a new unstagable/suspected deep tissue injury pressure ulcer on his/her left buttock that measured 2.6 cm by 0.6 cm with no depth. Treatment was the same as the ischial wounds. During an interview on 11/5/13, at 2:50 P.M., the Assistant Director of Nurses (ADON) said the left buttock wound was put in the computer in error and they have not been able to delete it from their reports. During an interview on 11/20/13, at 11:03 A.M., the administrator said the weekly wound nurse's wound and skin status report ending 10/4/13, was the beginning of this report. The administrator said prior reports were completed by the charge nurses and were incomplete. Record review of the resident's physician care note dated 10/3/13, showed the following information: -Vital signs temperature 99.7, pulse 78 (50-100), respirations 16 (14-20), blood pressure (BP) 146/80 (100-150/60-90) oxygen saturation 98% and weight at 95 pounds; -Lungs clear, and heart regular; -Wound VAC over sacrum area. The wound was doing OK. The left ischial tuberosity showed some slough and redness surrounding it, the one on the right (ischial tuberosity) was cleaner; -The resident had a history of [REDACTED]. -Plan: place the resident on [MEDICATION NAME] (antibiotic) 100 mg twice a day for a full six weeks and refer the resident to the wound clinic and get their recommendations. Record review of the October 2013 physician's orders [REDACTED]. Clean sacrum with normal saline and apply black foam negative pressure dressing every three days and as needed; -Order date 10/3/13, for a wound clinic consult as soon as possible. Staff to change wound VAC every three days; -Order date 10/23/13, staff to discontinue previous ischial wound orders and do ischial wound treatments twice a day. Wash wounds with antibacterial soap and water, apply santyl (enzymatic [MEDICATION NAME] ointment used to remove dead skin from wounds) to wound bed only and cover with dry gauze and secure. Record review of the October 2013 treatment administration record (TAR) for the resident showed the following information:-Staff did not start the twice a day treatments to the resident's ischial wounds until 10/26/13 (three days after the new order); -Order dated 10/14/13, for left heel wound was written as an "as needed" treatment rather than as routine every three days. Staff failed to perform any heel treatments. Record review of the facility's skin inspection report dated 10/24/13, by registered nurse (RN) A showed the resident's skin status as intact. During an interview on 10/31/13, at 9:45 A.M., the resident said he/she has wounds on both ischial areas and also a wound VAC on his/her sacral area. The resident said he/she had not had the wound treatments yet that day and the dressings on the wounds were wet with urine. Some of his/her treatments are for twice a day. During an interview on 10/31/13, at 10:30 A.M., registered nurse (RN) A said he/she was doing the treatments today and he/she had never worked those halls before. RN A said he/she would do the scheduled 6:00 A.M. to 2:00 P.M. treatments starting at 12:30 P.M. During an interview on 10/31/13 at 11:10 A.M., a family member of the resident said the resident was at the facility for rehabilitation and to heal the pressure ulcers so he/she can return home. The family member said the ulcers will not heal when they are wet with urine. RN A had been in the room and knew the resident's dressings were soiled. During an interview on 10/31/13 at 1:45 P.M., certified nurse aide (CNA) E said he/she worked the day shift today and will be leaving at 2:00 P.M., CNA E said the resident has had to be changed three times this shift due to his/her catheter leaking and being wet. During an observation and interviews on 10/31/13, at 2:00 P.M., RN A said he/she was staying overtime to help do the resident's treatments and then leaving and the evening shift would complete the day treatments he/she had not completed. The resident was positioned on an air mattress. Licensed practical nurse (LPN) B said all the resident's dressings were last changed on Monday (10/28/13) and all were due to be changed today. LPN B said some of the dressings are to be changed twice a day routinely for the day and night shifts. LPN B said if the day shift does not complete the ordered treatments he/she did them on the evening shift. LPN B said it had happened before. LPN B said the wound VAC treatment is usually done on the day shift but he/she has done it on the evening shift before. LPN B said he/she changed the two ischial dressings last evening shift about 7:00-7:30 P.M. and they have not been changed again until now (ordered treatment is for twice a day). LPN B said the dressings were saturated with urine. The instructions for the treatments are on the wall by the resident's bed from the wound clinic. RN A proceeded with the treatment for [REDACTED]. RN A said he/she had never done a treatment with a wound VAC and asked LPN B to take over and he/she said would assist him/her. LPN B completed the treatments on the resident's sacral area with the wound VAC, and also did the ordered treatments for the resident's acquired pressure ulcer on right ischial and both heels pressure areas. The resident said he/she is worried that he/she is not getting better. Record review of the wound and skin status report dated through 10/31/13, showed the resident's pressure ulcers were last monitored by the wound nurse on the prior week 10/23/13 for the 10/25/13 weekly report. During an interview on 10/31/13, at 3:55 P.M., the ADON said this is his/her ninth day in the facility. The ADON said he/she started on 10/10/13 and had been in orientation. The ADON said he/she would be doing the weekly nurse wound and skin status reports. During an observation on 11/5/13 at 1:00 P.M., LPN D completed the day shift ordered treatments to the resident's ischial pressure ulcers. The new facility-acquired pressure ulcer on the resident's right ischial area was deep (Stage III) and measured approximately 4.0 cm by 3.0 cm. The left ischial pressure ulcer had eschar and measured approximately 2.5 cm by 1.0 cm. Record review of the last nurse wound and skin status report dated 10/31/13, showed the right buttock/ischial wound a Stage II measuring 3.9 cm by 3.0 cm with no depth, completed by the ADON. During an interview on 11/5/13, at 2:00 P.M., LPN B said the resident's right ischial pressure ulcer should be staged at Stage III now. During an interview on 11/5/13 at 2:50 P.M., the ADON said he/she assessed the resident's right ischial area wound on 10/30/13. The ADON said the pressure ulcer was a Stage III. The ADON was unaware the Stage II wound could be staged up. Record review of the outpatient wound clinic progress note dated 11/6/13, showed the following information: -The resident denied fevers and chills; -Wound care orders included to apply Santyl (an agent that removes dead skin) wet to dry twice a day for the ischial pressure ulcers; -The resident tolerated the procedures well but the wounds continued to increase in size and were not clean; -The right ischial pressure ulcer measured at 6.0 cm by 3.8 cm with a depth of 1.8 cm; -The resident's sacral wound was very clean, but the ischial wounds both displayed some necrotic tissue and required further debridement; -Wound VAC discontinued to sacral area; -Treatments for the right ischial area, left ischial area and sacral pressure ulcers was changed to every other day and as needed if the dressing became soiled. -Treatment orders included [MEDICATION NAME] paste (an agent that helps promote an optimal healing environment and assists with autolytic debridement) in wound bed only, with separated (fluffed up) gauze on top of the [MEDICATION NAME] to help hold the honey in place and to aid in debridement of wounds, then cover with [MEDICATION NAME] foam adhesive and secure; -Follow-up in two weeks. Record review of the resident's nurses' notes showed the following information:-11/11/13 at 6:12 P.M., staff documented the resident's suprapubic catheter was leaking. Staff removed 24 French catheter with 10 cc bulb and inserted 24 French with 30 cc bulb; -11/12/13 at 3:28 A.M., staff documented no leaking observed from suprapubic catheter; -11/16/13 at 3:33 A.M., staff documented the resident's temperature at 101.1 Fahrenheit and the dressings were soiled and detached. Wound care done as ordered. The left ischial pressure ulcer was worsening and deepening. Medication administered before dressing changes for pain; -11/17/13 at 12:46 A.M., late entry for 11/16/13, at 9:30 P.M., staff documented the resident had a temperature at 103.0 Fahrenheit. Tylenol and cold cloths administered. Re-check of temperature in 40 minutes showed temperature at 104.2. Staff called the resident's physician and received new orders to send the resident to the emergency room . Staff documented the resident was on a new antibiotic for a urinary tract infection [MEDICAL CONDITION]. Record review of the hospital records regarding the resident's admission on 11/16/13, at 10:55 P.M., showed the following information: -The resident presented to the emergency room with a fever [MEDICAL CONDITION]; -The resident was oriented to person, place, and time; -The resident had three sacral pressure ulcers of Stage III or greater. The two lower ulcers had necrotic-looking tissue in them. Significant redness of the wound; -Life threatening symptoms treated noted as urosepsis; -Further evaluation was needed regarding osteo[DIAGNOSES REDACTED]. Wound consultation for the sacral pressure ulcers was needed. During an interview on 11/22/13, at 10:05 A.M., the resident said he/she had both ischial pressure ulcers debrided. The ischial wounds were down to the bone (Stage IV) and he/she [MEDICAL CONDITION]. The resident said the sacral wound was healing. The resident was unsure when he/she would get out of the hospital and said that he/she is on steroids and antibiotics now. During an interview on 12/3/13, at 1:41 P.M., the resident's physician said the resident had wounds when he/she entered the facility. The physician said the new facility-acquired right ischial pressure ulcer was large when staff identified it but he suspected the resident had underlying tissue damage. The resident had many health concerns. The physician said the leaking catheter would be sterile urine and would not have interfered with the wound care. MO 310 4. Record review of Healthpoint Biotherapeutics information regarding Collangenase Santyl showed the following information: -Santyl ointment is a sterile enzymatic [MEDICATION NAME] ointment. It possesses the unique ability to digest collagen in necrotic tissue; -It is indicated for [MEDICATION NAME] chronic dermal ulcers and severely burned areas; -Santyl ointment should be applied once daily (or more frequently if the dressing becomes soiled, as from incontinence); -Use of Santyl ointment should be terminated when debridement of necrotic tissue is complete and granulation tissue is well established. 5. Record review of Resident #5's nurses' notes showed the following information: -On 12/10/13, at 6:22 A.M., staff documented the resident had an open area on his/her coccyx measuring 2.5 cm by 1.0 cm. Staff documented the resident needed a treatment order. (Staff did not document notifying the resident's physician to get a treatment order); -Staff did not document on the pressure ulcer again until 12/19/13; -On 12/19/13, at 6:27 P.M., staff documented the resident had open area on his/her bottom and that staff applied barrier cream per orders. -On 10/20/13, at 3:33 P.M., the staff documented the resident had an open area on his/her bottom and care was provided to the resident as ordered; -On 11/5/13, at 1:49 P.M., staff documented to discontinue treatments and start [MEDICATION NAME] (treatment used for ulcers) to coccyx wound twice a day until healed and then discontinue the treatment. Record review of the resident's care plan dated 10/1/13, showed the following information: -Due to incontinence, the resident is at risk for skin breakdown; -Staff were directed to clean and dry skin after each incontinent episode and apply topical barrier cream/lotion as needed; -Staff were directed to do weekly and as needed skin checks and report any concerns to the Director of Nurses (DON) and physician for treatment orders; -On 10/24/13, staff documented treatment orders included to cleanse the wound to the resident's coccyx with wound cleanser and 4 by 4's (gauze pads), apply Santyl to wound bed, cover with 4 by 4's and secure with tape as needed. Record review of the October 2013 physician orders [REDACTED]. Santyl to the wound bed, cover with 4 by 4's and secure with tape daily and as needed. Record review of the treatment administration record (TAR) for October 2013 for the resident showed the following information: -On 10/24/13, staff were directed to cleanse the resident's coccyx wound with wound cleanser and 4 by 4's, apply Santyl to wound bed, and cover with 4 by 4's and secure with tape daily; -Staff documented doing the treatments from 10/25/13 to 10/31/13. Record review of the wound nurses' weekly wound and skin status report through 10/4/13 showed the following information: -On the report dated through 10/10/13, the resident was not identified with a pressure ulcer; -The report dated through 10/17/13, showed on 10/16/13, the staff identified the resident had an unstagable-slough/eschar pressure ulcer on his/her sacrum that measured 1.7 cm by 0.7 cm with no depth. The wound bed showed 100% granulation (formation of new tissue, usually pink or red in color) and no drainage. Treatment included Zinc 220, multivitamin with minerals tablet, and Vitamin C 500 mg. and for the staff to cleanse the wound to the resident's coccyx with wound cleanser and 4 by 4's, apply Santyl to the wound bed, cover with 4 by 4's and secure with tape daily and as needed; -On the report dated through 10/25/13, staff documented the resident had a Stage II pressure ulcer on his/her sacrum and on 10/24/13 it measured 3.0 cm by 1.6 cm with a depth of 0.4 cm. The wound bed exhibited 100% slough with no drainage. Treatment was the same as on the report 10/17/13; -On the report through 10/31/13, staff documented the last assessment was completed on 10/24/13; -On the report through 11/5/13, completed by the ADON, the ADON documented the resident had a Stage II pressure ulcer on his/her sacrum, that was facility-acquired and identified on 10/16/13. On 10/30/13, it measured 2.8 cm by 1.6 cm with a depth of 0.4 cm. The wound bed showed 90% [MEDICATION NAME] tissue (layer of cells forming the epidermis of the skin and surface layer of mucous and serous membranes) and 10% granulation with sanguineous (bloody) drainage. Staff were to cleanse the wound to the coccyx/sacrum with wound cleanser and 4 by 4's, apply Santyl to the wound bed, cover with 4 by 4's and secure with tape daily and as needed. During an interview on 10/31/13, at 12:20 P.M., the resident was up in his/her wheelchair in room. The resident said he/she has a sore on his/her bottom and it hurt to sit. The resident said he/she wanted to lie down. The resident said he/she did not know how he/she got the sore bottom. During an observation and interview on 10/31/13, at 1:50 P.M., RN A prepared to perform the resident's treatment. The resident did not have a dressing on his/her coccyx/sacrum wound. The wound was an open Stage II pressure ulcer. RN A said the pressure ulcer had no eschar present and did not need the Santyl. RN A did the treatment without using the Santyl. During an observation and interview on 11/5/13, at 12:30 P.M LPN F prepared to do the treatment for [REDACTED]. LPN F said the dressing came off two to three times a day. LPN F said the eschar is gone. Although contraindicated by the manufacturer's recommendations LPN F did the treatment as ordered by the physician using the Santyl on the pressure ulcer. LPN F said he/she would contact the resident's physician for another treatment instead of using the Santyl treatment. During an interview on 12/3/13, at 1:41 P.M., the resident's physician said he/she gave a verbal treatment order for the resident's wound and he/she goes by what the staff tells him/her the wound looks like when he/she is called for notification and for a treatment order. During an interview on 12/3/13, at 1:41 P.M., the medical director of the facility said Santyl should not be used on a wound with granulation tissue (formation of new tissue, usually pink or red in color) present. Santyl should only be used for debridement because you do not want to damage good tissue using Santyl. 6. Record review of Resident #10's admission data, dated 3/21/13, showed the following information: -Arrived by ambulance 3/21/13, at 3:00 P.M.; -Staff documented two skin tears to the resident's left elbow and left wrist with bruising, three skin tears with an abrasion to the resident's face, head and left cheek, and bruises to right and left lower legs; -Staff did not identify any pressure ulcers; -The resident required the assistance of two persons and was on bed rest; -The resident was incontinent of bowel and bladder. Record review of the resident's care plan, dated 4/3/13, showed the following information: -Resident identified at risk for skin breakdown due to generalized weakness and increased need for assistance with toileting and hygiene; -Staff to assist with toileting both to request as well as prompted toileting, resident will need assistance with toilet hygiene, incontinent care if needed and assistance with positioning to avoid pressure areas; -During staff assisted showers, the staff was to note and report any areas of redness/breakdown to the charge nurse; -Staff to encourage adequate hydration to promote skin integrity; -Staff to apply ointment to heel and pressure relieving device; -Staff to notify physician of any changes to include additional skin breakdown and poor healing. Record review of the resident's wound nurses' weekly wound and skin status reports showed the following information: -The resident was not identified with any pressure ulcers on the report on the week dated through 10/4/13; -The resident not identified with any pressure ulcers on the report on the week dated through 10/10/13; -The resident not identified with any pressure ulcers on the report on the week dated through 10/17/13; -On the report dated through 10/25/13, staff documented the resident had an unstageable pressure ulcer with slough and eschar to his/her left heel identified on 10/24/13 that measured 4.0 cm by 6.0 cm with a depth of 0.5 cm. The wound bed was 100% eschar and had serous (serum) drainage. Treatment orders included Santyl to the wound bed of the left heel, apply gauze moistened with normal saline, cover with dry 4 by 4 and secure with conform gauze and tape; -The resident not listed on the wound nurses' weekly wound and skin status report for the week through 10/31/13; -On the report dated through 11/5/13, completed by the ADON, the ADON documented the resident had an unstageable pressure ulcer with slough and eschar to his/her left heel. On 10/30/13 the pressure ulcer measured 4.0 cm by 5.7 cm with a depth of 0.5 cm. Documentation showed the wound was 10% slough and 90% eschar and had sanguineous (bloody) drainage. The treatment documented was the same as on the report dated through 10/25/13; -On the report dated through 11/8/13, staff documented the resident had an unstageable pressure ulcer with slough/eschar to his/her left heel that measured 3.8 cm by 5.6 cm with a depth of 0.6 cm on 11/6/13. The wound bed was 25% slough and 75% eschar and had purulent (product of inflammation that contains pus) drainage. Treatment orders were changed to [MEDICATION NAME] blue moistened with normal saline, wrung out of excess moisture and secured with [MEDICATION NAME] foam for protection; -On the report dated through 11/22/13, staff documented the following information: -The resident's left heel pressure ulcer was unstageable and measured 1.0 cm by 1.2 cm with depth of 0.4 cm on 11/20/13. The treatment documented was the same as on the report through 11/8/13. -On 11/22/13, staff

Based on observation, interview and record review, the facility failed to consistently assess, monitor, treat, follow physician's orders, and notify the physician regarding hyperglycemic (high blood sugar) /hypoglycemic (low blood sugar) episodes for two residents (Resident #15 and Resident #1). The facility failed to develop an appropriate policy and procedure to direct staff when residents show signs and symptoms of [DIAGNOSES REDACTED]/[MEDICAL CONDITION]. This failure resulted in Resident #15's admission to the hospital with apparent [MEDICAL CONDITION] activity related to [DIAGNOSES REDACTED]. The facility failed to consistently assess, monitor, treat, and notify the physician regarding changes for one resident's (Resident #5) skin tear and burn and one resident's (Resident #4) wound on the ear or ears and toe wound. The facility failed to adequately and appropriately treat one resident's pain (Resident #1). This deficient practice represents five facility failures that affected four residents in a sample selection of 12 residents and one additionally selected resident in a facility with a census of 51. 1. Review of Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 10th edition, 2004, showed the following information regarding diabetes mellitus and insulin: -Diabetes mellitus is a group of metabolic diseases characterized by elevated levels of glucose (sugar) in the blood resulting from defects in insulin secretion, insulin action, or both; -The usual reference range for normal serum sugar is 70 to 105 milligrams per deciliter (mg/dL); -Insulin (is) a hormone produced by the pancreas (that) controls the level of sugar in the blood by regulating the production and storage of sugar ....For patients who require insulin to help control blood sugar levels, maintaining as much consistency as possible in the amount of calories and carbohydrates ingested at different meal times is essential. In addition, consistency in the approximate time intervals between meals, with the addition of snacks if necessary, helps in preventing hypoglycemic reactions and in maintaining overall blood sugar control; -[DIAGNOSES REDACTED] occurs when the blood sugar falls to less than 50 to 60 mg/dL. It can be caused by too much insulin or oral hypoglycemic agents, too little food, or excessive physical exercise ....In severe [DIAGNOSES REDACTED], central nervous system function is so impaired that the patient needs the assistance of another person for treatment of [REDACTED].[DIAGNOSES REDACTED] can occur at any time of the day or night (and) often occurs before meals, especially if meals are delayed or snacks are omitted. Record review of the undated policy the facility provided for hyper/[DIAGNOSES REDACTED] was titled, "Glucose Testing". The policy showed the following information:-It is the practice of this facility to follow OSHA guidelines when performing any invasive procedure involving contact with blood or body fluids; -Blood sugar testing shall be performed according to physician order and per manufacturer guidelines for the specific equipment being utilized; -Blood sugar parameters shall be obtained by physician order upon admission; -Only safety lancets shall be utilized when performing sugar testing. Lancets are to be disposed of immediately following one time use in an approved sharps disposal container. (The policy did not include the signs and symptoms of/or the risk factors related to [MEDICAL CONDITION] or [DIAGNOSES REDACTED] and procedures staff should follow to stabilize the residents' blood sugar levels in either case, high or low.) 2. Record review of Resident #15's admission orders [REDACTED]'s placed in the chest to help control abnormal heart rhythms), [MEDICAL CONDITION] (an irregular and often rapid heart rhythm), [MEDICAL CONDITION] (lung disease), diabetes, gastro-[MEDICAL CONDITION] reflux disease (acid reflux), [MEDICAL CONDITION], history of stroke. -A physician's order for [MEDICATION NAME] HCL (an oral anti-diabetic medication) 500 milligram (mg) twice a day; -A physician's order for sliding scale insulin before meals and at bedtime of [MEDICATION NAME] regular fast acting insulin, administer if the resident's blood sugar levels were above normal at the following values: 101-150 mg/dL = two units, 151-200 mg/dL = four units, 201-250 mg/dL = eight units, 251-300 mg/dL = 12 units, above 300 = 16 units mg/dL and staff to call the physician; -A physician's order for [MEDICATION NAME] 50% solution (50% sugar water), 50 milliliter (ml), as needed for [DIAGNOSES REDACTED]. Record review of the admission nursing assessment, dated 12/20/10, showed staff documented the resident was alert, friendly, and cooperative. Record review of the care plan, dated 12/31/10, showed the following information:-The resident required extensive assistance for dressing, bathing, toileting, hygiene, transfers, and mobility due to weakness, shortness of breath and multiple surgical abdominal wounds; (Staff did not identify any problems regarding the resident's [DIAGNOSES REDACTED]. Staff did not establish any routine procedures to stabilize the resident's blood sugar levels in either case, high or low.) Record review of the blood sugar/sliding scale flow sheet starting on the resident's admitted d 12/20/10 at 4:30 P.M. and continuing daily showed the following information:-From admission to 1/18/11, the resident's blood sugar levels were not above a level that required staff to administer insulin above two to four units, with the exception of 12/24/10 at noon the resident had a 203 mg/dL blood sugar and staff administered eight units of regular insulin; -On 1/19/11, staff documented the resident's blood sugar at 6:00 A.M. at 90 mg/dL and no insulin given, at 11:30 A.M. blood sugar at 109 mg/dL and staff gave the resident two units of [MEDICATION NAME] regular insulin, at 4:30 P.M. blood sugar at 69 mg/dL and no insulin given and at 9:00 P.M. blood sugar at 96 mg/dL and no insulin given; -On 1/20/11, staff did not document checking the resident's blood sugar before breakfast or lunch. At 4:30 P.M., staff documented the resident's blood sugar at 226 mg/dL then marked over the 226 and wrote 266 mg/dL and that staff administered 12 units of regular [MEDICATION NAME] insulin. (The physician's order for administration of sliding scale [MEDICATION NAME]was, if 226 mg/dL then eight units administered, if 266 mg/dL then 12 units administered). During an interview on 1/28/11 at 3:10 P.M., Licensed Practical Nurse (LPN) B said he/she remembered the evening of 1/20/11. He/she checked the resident's blood sugar between 4:00 and 5:00 P.M., it was low and he/she did not give the resident insulin. He/she said if the reading is below 120 mg/dL no insulin is given. (LPN B documented giving the resident 12 units of [MEDICATION NAME] regular insulin at 4:30 P.M. on 1/20/11). During an interview on 2/15/11, at 1:19 P.M., Certified Medication Technician (CMT) E said on 1/20/11, about 7:30 to 8:00 P.M., he/she went to give the resident his/her night medications. The resident was in bed, holding onto the bed rails, jerking and looking around. The resident's eyes were wide and not focused. CMT E said he/she stuck his/her head out the door for help. LPN B came and took over the care of the resident. During an interview on 1/28/11 at 4:00 P.M., Certified Nurse Aide (CNA) D said CMT E found the resident shaking when he/she went in to give the resident his/her night medications. CMT E stayed with him/her while CNA D went for the nurse. He/she said the resident's eyes were real big and he/she was shaking. LPN B and LPN C went to check the resident and said the resident had a low blood sugar. During an interview on 1/28/11 at 3:10 P.M., LPN B said on 01/20/11, about 8:00 P.M., he/she checked the resident's blood sugar and it was low at 47 mg/dL and he/she administered oral [MEDICATION NAME] to the resident. The resident was not alert to his/her name and it looked like he/she had a [MEDICAL CONDITION]. On recheck, the blood sugar was down to 40 mg/dL. The resident was sent to the emergency room . Record review of the blood sugar/sliding scale flow sheet showed on 1/20/11, at 8:30 P.M., showed staff documented the resident's blood sugar at 47 mg/dL (low) and staff gave the resident an Ensure (a liquid nutritional supplement) to drink. There was no documentation in the record whether or not the resident was able to consume the supplement. Record review of the nurses' notes, dated 01/20/11, showed the following information: -At 8:35 P.M., staff documented the resident experienced observed [MEDICAL CONDITION] activity for at least five minutes. The resident had no memory of the [MEDICAL CONDITION]. The resident's blood sugar was 47 mg/dL and staff gave the resident Ensure. The resident's blood sugar went down to 40 mg/dL and the resident had slurred speech, was disorientated, and his/her skin was pale and cool. Staff paged the on-call physician at 8:15 P.M. and 8:25 P.M. At 8:35 P.M., the physician returned the call and told staff to send the resident to the emergency room . At 8:45 P.M., staff notified the resident's family. At 8:55 P.M., staff called the ambulance. At 9:10 P.M., the ambulance left the facility with the resident. During an interview on 1/28/11 at 9:45 A.M., the resident and family member said prior to admission to the facility the resident never had a blood sugar over 110 mg/dL and never had a [MEDICAL CONDITION]. The staff called the family member on 1/20/11, and said the resident had a [MEDICAL CONDITION] and the resident was going to the emergency room . Later, the hospital staff told the family member that the resident had a low blood sugar. Record review of the January 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., (25 minutes after staff documented giving the resident the supplement.) staff rechecked the resident's blood sugar and found it had dropped to 40 mg/dL. Staff administered oral [MEDICATION NAME] 50% solution 50 ml. During an interview on 1/28/11, at 3:45 P.M., LPN C said he/she did some of the paper work on the resident the evening of 1/20/11, when the resident had a [MEDICAL CONDITION] and was sent to the emergency room . He/she said the resident did not have a history of [MEDICAL CONDITION]. LPN C said the treatment nurse (LPN B) did the blood sugar checks and gave the insulin. (LPN B documented giving the resident 12 units of [MEDICATION NAME] regular insulin at 4:30 P.M. on 1/20/11). LPN C said the resident's blood sugar went down to 47 mg/dL and LPN B gave the resident oral [MEDICATION NAME] and a power shake. The blood sugar went down to 40 mg/dL and the resident was sent to the emergency room . Record review of the hospital medical records regarding the resident's admission on 1/20/11, showed the following information: -Ambulance arrived at the facility at 9:05 P.M.; -Facility staff reported the resident had a five minute long [MEDICAL CONDITION], followed by slurred speech and confusion. Resident had no history of a previous [MEDICAL CONDITION]; -Resident presented to ambulance staff with confusion, slurred speech and initial blood sugar was at 34 mg/dL. Ambulance staff administered 25 grams of [MEDICATION NAME] 50% intravenously. Resident quickly became more oriented and his/her speech improved; -Ambulance arrived at the hospital at 9:32 P.M. resident was alert and had clear and fluent speech. Hospital staff documented the resident's blood sugar at 9:48 P.M. at 122 mg/dL; -Resident admitted to the hospital with [REDACTED]. During an interview on 3/3/11 at 3:00 P.M., the resident's physician said with a physician order for [REDACTED]. Complaint #MO 987 3. Record review of the manufacturer's instructions for [MEDICATION NAME] showed: Test blood sugar levels while using insulin, such as [MEDICATION NAME]. Do not make any changes to your dose or type of insulin without talking to your healthcare provider. Any change of insulin should be made cautiously and only under medical supervision. Record review of the manufacturer's instruction booklet for owners of the [MEDICATION NAME] glucometer (the machine used by the facility to measure the resident's blood sugar levels) showed: The glucometer measured blood sugar results from 20 to 600 mg/dL. If the blood sugar result is less than 20, LO appears on the readout and if the blood sugar result is greater than 600, HI appears on the readout. Always repeat the test to confirm LO and HI results. If results still display LO or HI, call your Doctor or Diabetes Healthcare Professional immediately. Record review of Resident #1's quarterly Minimum Data Set (MDS) a federally mandated comprehensive assessment tool, completed by facility staff, dated 2/2/11, showed the following information: -Independent cognitive skills for decision making; -Limited assistance of one for turning, transfers, dressing, and toileting; -Impaired range of motion of both legs; -Continent of bowel and bladder; -[DIAGNOSES REDACTED]. Record review of a progress note dated 2/10/11, showed the resident presented for a follow up visit accompanied by a family member. The family member stated the resident's blood sugars have been consistently low in the mornings around 35. The resident had not been eating 100% of his/her meals and the facility still continued to administer insulin to the resident. When the family member realized the resident's blood sugars had been consistently low during a visit at the facility the family member notified the physician. The resident's insulin orders had been changed at that point and since then the resident's blood sugars have been regularized. It seems the facility try to send the resident to the ER when he/she is unresponsive, give him/her glucose, and then cancel the ambulance trip when the resident woke up, however facility staff continued to give the resident insulin. Record review of the resident's care plan, last updated 3/25/11, showed the following information: -Poorly controlled insulin dependent diabetes; -Check blood sugar per the physician's orders; -Document results of blood sugar testing and notify the physician if indicated, then document the follow-up actions performed; -Administer and monitor side effects and effectiveness of medications as ordered to include both scheduled and sliding scale insulin; -Assess, document, and report signs and symptoms of [MEDICAL CONDITION] (high BS) including appetite loss, nausea, vomiting, warm and diaphoretic (sweating) skin, urinary frequency, and weight loss; -Assess, document, report signs and symptoms of [DIAGNOSES REDACTED] (low BS) including lightheadedness, cool and diaphoretic skin, decreased level of consciousness, dizziness, increased thirst, increased hunger, urinary frequency, and nausea; -Provide high protein snacks immediately for [DIAGNOSES REDACTED]; -Document refusal of resident and/or family to follow dietary restrictions, and educate them on the adverse consequences of failure to follow the ordered plan of care; -Offer high protein between-meal snacks. Record review of the Physician's Order Sheet (POS), dated 3/2011, showed the following information: -[DIAGNOSES REDACTED]. -An order, dated 3/10/11, to check the resident's blood sugar before meals, at bedtime, and at 2:00 A.M.; -An order, dated 3/10/11, for sliding scale [MEDICATION NAME](a fast-acting insulin). Administer subcutaneously (injected under the skin) if the resident's blood sugar is above normal at the following values: 120-160 mg/dl = three units, 161 to 200 mg/dl = five units, 201-240mg/dl = eight units, 241-280 mg/dl = twelve units, 281-320mg/dl = sixteen units, notify the physician for blood sugar levels over 200 or below 80; -An order, dated 3/10/11, to administer [MEDICATION NAME] (long [MEDICATION NAME]that gives a steady release of insulin to help control blood sugar for 24 hours) 15 units at bedtime. -An order, dated 3/29/11, may use [MEDICATION NAME] (raises blood sugar levels) per package directions for low blood sugar as needed; -An order, dated 4/2/11, to notify the physician for blood sugar levels of 500 or greater and only during regular business hours unless there is a problem; During interview on 3/24/11, at 2:04 P.M., a family member of Resident #1 said the resident had been at the facility since June 2010. The family members called the resident and frequently realized over the phone the resident's voice was slurred and needed his/her blood sugar checked. The family called the facility about the concern and multiple times, the resident's blood sugar was low. The facility blames the physician. Last week, at 9:30 P.M., the family member said the facility called him/her and said they had given the resident [MEDICATION NAME] and [MEDICATION NAME] when the resident felt clammy. They checked the resident's blood sugar after the insulin and it was 64. The facility called the paramedics. In the care plan meeting the facility staff said they do not check the resident's blood sugar when they give the [MEDICATION NAME], because it is a long-acting insulin. The resident is a very brittle diabetic. Record review of the blood sugar/sliding scale flow sheet and nurses' notes showed on 3/17/11, at 9:00 P.M., the resident's blood sugar was 64. At 9:15 P.M., the nurse assessed the resident as unresponsive, cold and clammy (cool, moist, and usually pale) with blood sugar of 64. He/she administered [MEDICATION NAME] to the resident as ordered. The nurse documented staff were unable to awaken the resident. At 9:20 P.M., a CNA attempted to awaken the resident while the nurse phoned an ambulance and the resident's family. At 9:25 P.M., a CNA stated the resident had awakened, ate yogurt, and drank a health shake. An ambulance arrived at the facility. At an unknown time the resident refused to go to the emergency room . The nurse assessed the resident as being fully awake and rechecked the resident's blood sugar at 87. The nurse provided a peanut butter sandwich to the resident. At 11:00 P.M., the resident had eaten 100 % of the sandwich. The resident's blood sugar was 229; During an interview on 3/28/11, at 2:15 P.M., Registered Nurse (RN) Q said on 3/17/11, the resident's 8:00 P.M. blood sugar was okay. RN Q said at 9:00 P.M., he/she administered the ordered bedtime dose of 15 units [MEDICATION NAME] and realized the resident was not responding to him/her. RN Q touched the resident and the resident was cold and clammy, so he/she checked the resident's blood sugar and it was low. RN Q said staff had administered a pain medication to the resident an hour earlier. RN Q said the resident woke up for him/her "after not very long" and ate half a container of yogurt. Then the resident slipped "back into it" and became unresponsive. RN Q said he/she notified the resident's physician and obtained an order to send the resident to the ER. RN Q said by the time the ambulance and the resident's family member arrived, the resident's blood sugar was 87 and he/she refused to go to the hospital. RN Q was unsure whether the resident had been unresponsive from the low blood sugar or the pain medication. Record review of the blood sugar/sliding scale flow sheet and nurses' notes showed the following information: -On 3/19/11, at 8:40 P.M., the flow sheet showed the resident's blood sugar as 485. At 8:45 A.M., the nurses' notes showed the resident returned from a leave of absence and refused supper. The resident's blood sugar was 485. Staff called the physician on-call for the resident's physician who ordered staff to administer [MEDICATION NAME] 15 units and 20 units of the sliding scale insulin. Staff administered the insulin and provided a bedtime snack for the resident. (Staff did not recheck the resident's blood sugar for approximately five and a half hours at 2:10 A.M.); -On 3/20/11, at 2:10 A.M. The resident's blood sugar was 41. The nurse rechecked the blood sugar and it had dropped to 30. The resident was slow to respond and only grimaced to painful stimuli. The nurse paged the resident's physician. At 2:20 A.M., the resident responded verbally and had been able to follow commands to swallow. The nurse administered glucose (sugar) gel by mouth to the resident. At 2:30 A.M., the resident only responded to pain. The resident's blood sugar was 44. (Staff did not recheck the resident's blood sugar until an hour later). At 3:35 A.M., the resident's blood sugar was 83. The resident had awakened, was alert, oriented, and followed commands. Staff did not document showing the resident's physician answered the facility's page; - On 3/20/11, at 8:45 P.M., the resident returned from a leave of absence and had a blood sugar that was HI. The nurse administered 15 units of [MEDICATION NAME], and phoned the on-call physician. The physician ordered staff to administer 20 units of sliding scale insulin one time immediately and to set up an appointment for the resident with his/her physician. At 8:51 P.M., the flow sheet showed the resident's blood sugar was HI. (Staff did not recheck the resident's blood sugar for over five hours). At 2:00 A.M., staff documented the resident's blood sugar as 146; -On 3/22/11, at 6:45 A.M., the flow sheet showed the resident's blood sugar was 496. A nurse administered 16 units of sliding scale insulin. The staff did not document in the nurse's notes regarding the resident's elevated blood sugar. (Staff did not recheck the resident's blood sugar for four and a half hours). At 11:20 A.M. the resident's blood sugar was 252. Over four hours later at 4:50 P.M., the flow sheet showed the resident's blood sugar was 501. Almost an hour later at 5:45 P.M., the nurse notified the resident's physician the resident's blood sugar was 501. The physician ordered staff to revise the current sliding scale insulin order to include administering 18 units of sliding scale insulin for blood sugar 320 to 400 and 20 units of sliding scale insulin for blood sugar over 400. (Staff did not recheck the resident's blood sugar until two hours later). At 7:45 P.M., the resident's blood sugar was 179; -On 3/24/11, at 8:05 P.M., the flow sheet showed the resident's blood sugar was HI and almost an hour and a half later at 9:30 P.M., it was HI again. The nurse notified the on-call physician. The on-call physician advised the nurse to administer the sliding scale insulin as previously ordered and stated he did not want to be called again about this resident because the resident's blood sugar was so out of control. The physician advised the nurse to notify all facility staff not to phone him again about this resident, and he would advise the resident's physician of the same. Staff did not recheck the resident's blood sugar for four and a half hours; (Staff did not document making additional calls to notify the DON, the administrator or the medical director that they had no physician to contact regarding the resident's out of control blood sugar levels.) - On 3/25/11, at 2:00 A.M., the resident's blood sugar was 385 and staff administered 18 units of sliding scale insulin. The nurse assessed the resident as pale, clammy, drowsy, and hard to awaken. There were no signs or symptoms of the resident being in distress. (Staff did not recheck the resident's blood sugar for four and a half hours). At 6:30 A.M., the flow sheet showed the resident's blood sugar was 136, and staff administered three units of sliding scale insulin. Staff documented the resident went to [MEDICAL TREATMENT] that day. Staff did not document times when the resident left the facility or when he/she returned to the facility. (Staff did not recheck the resident's blood sugar for thirteen and a half hours). At 8:00 P.M., staff documented the resident's blood sugar was 551. The staff administered 20 units of sliding scale insulin. At 8:10 P.M., a nurse reported laboratory results and the resident's abnormal elevated blood sugar to the physician on call for the resident's physician. The staff had administered the resident 15 units of [MEDICATION NAME] per schedule and 20 units of sliding scale insulin. (Staff did not recheck the resident's blood sugar for over five hours); -On 3/26/11, at 7:00 A.M., the flow sheet showed the resident's blood sugar was 332, and staff administered 18 units of sliding scale insulin. At 6:10 P.M., the resident returned to the facility after a leave of absence with a family member. Staff did not recheck the resident's blood sugar until 8:05 P.M., almost two hours after the resident returned to the facility. Staff had not checked the resident's blood sugar for thirteen hours. The flow sheet showed the resident's blood sugar was HI, and staff administered 20 units of sliding scale insulin. At 9:30 P.M., the flow sheet showed the resident's blood sugar was HI and staff administered 15 units of [MEDICATION NAME]. Staff did not document in the nurses' notes regarding the resident's elevated abnormal blood sugar. (Staff did not recheck the resident's blood sugar for three hours and forty-five minutes). At 1:15 A.M., the flow sheet showed the resident's blood sugar was 143, and staff administered three units of sliding scale insulin; -On 3/27/11, at 8:10 P.M., the resident returned to the facility with a family member at approximately 7:45 P.M. The flow sheet showed at 8:10 P.M., the resident's blood sugar was HI. Staff administered the resident 20 units of sliding scale insulin at 8:10 P.M. and 15 units of [MEDICATION NAME] at 8:30 P.M. (Staff did not recheck the resident's blood sugar for five and a half hours). At 2:00 A.M., the flow sheet showed the resident's blood sugar was 234, and staff administered eight units of sliding scale insulin; -On 3/29/11, at 5:00 P.M., the flow sheet showed the resident's blood sugar was 531 and staff administered 20 units of sliding scale insulin . At 5:30 P.M., nurse documented in the nurses' notes he/she administered 20 units of sliding scale insulin for a blood sugar of 531. (Staff did not recheck the resident's blood sugar for over three hours). At 8:30 P.M., the resident's blood sugar was 262 and the nurse administered 12 units of sliding scale insulin; -On 4/1/11, at 6:30 A.M., the flow sheet showed the resident's blood sugar was 442 and staff administered 15 units of sliding scale insulin. The flow sheet showed the resident on a leave of absence at 11:30 A.M. Staff did not document when the resident left or the returned to the facility. At 4:30 P.M. the flow sheet showed the residents blood sugar as 524, and the resident received 16 units of sliding scale insulin. (Staff did not recheck the resident's blood sugar until three hours later). At 8:00 P.M., the resident's blood sugar was 497; staff administered 16 units of sliding scale insulin and 15 units of [MEDICATION NAME]. At 10:00 P.M., the resident returned from [MEDICAL TREATMENT]. (Staff did not recheck the resident's blood sugar for ten and a half hours); -On 4/2/11, at 6:30 A.M., the resident's blood sugar was 411 on the flow sheet, and administered 16 units of sliding scale insulin. At 6:45 A.M., staff notified the resident's physician of the resident's blood sugar levels. The resident's physician stated she did not want staff to call her for high blood sugar levels. The nurse told the physician the resident had a physician's order to notify her if the resident's blood sugar was below 80 or above 200. The physician said she did not want to be called unless the resident's blood sugar was greater than 500, and only during business hours unless there was a problem. At 6:55 A.M., the nurse notified the Director of Nursing (DON) of the physician's order. The DON instructed the nurse to notify the facility's medical director of Resident #1's physician's orders. The medical director said he is not responsible for other physicians' residents. The medical director said in his opinion staff should go by the blood sugar parameters ordered, and not follow the order to report just during business hours. The medical director placed an order for [REDACTED]. -On 4/3/11, at 8:00 P.M., the flow sheet showed the resident's blood sugar as HI, and the nurse administered sliding scale insulin per the physician's order, but did not notify the resident's physician per the physician's order received on 4/2/11. An hour and fifteen minutes later at 9:15 P.M., the resident's blood sugar was 503. There was no documentation the staff administered insulin to the resident. Staff did not recheck the resident's blood sugar for over five and a half hours. During interview on 3/25/11, at 1:10 P.M., the DON said Resident #1's family did not want the medical director involved with the resident's care because of prior history with that physician. During an interview on 3/29/11, at 10:25 A.M., the DON said she expected staff to follow the physician's orders for a resident's abnormal blood sugar. She said staff should not attempt to give anything by mouth to a resident who is unresponsive. She expected staff to recheck a resident's blood sugar 15 minutes after contacting the resident's physician. She saw no reason for staff to not take a follow up blood sugar. The DON expected staff to document the interventions administered and any follow up or outcome in the nurses' notes. She expected staff to recheck any resident's blood sugar a half hour after staff administered [MEDICATION NAME] or insulin. If the resident was unresponsive staff should recheck the blood sugar. If the resident was unresponsive staff should recheck the resident's blood sugar in 15 minutes. If the resident's physician did not return staffs phone calls, she expected staff to contact the facility's medical director for further guidance. She expected any new orders to be documented in the nurses' notes. During an interview on 3/28/11, at 9:30 A.M., Licensed Practical Nurse (LPN) J said if a resident's blood sugar is HI he/she notifies the resident's physician and gives the highest dose of sliding scale insulin. LPN J said he/she rarely got a call back from Resident #1's physician. LPN J rechecks the resident's blood sugar after half an hour, and if it was still high would again phone the resident's physician. If the resident's blood sugar remained high and the resident was unresponsive, he/she would call 911 for an ambulance. LPN J said if a resident's blood sugar was LO he/she would administer [MEDICATION NAME] and notify the resident's physician. He/she would check the resident's blood sugar five minutes after the administration of [MEDICATION NAME] and if the resident was unresponsive would call 911 and the resident's physician. He/she would recheck a HI blood sugar after 15 minutes and a LO blood sugar after 5 minutes. During an interview on 4/5/11, at 1:20 P.M., the facility's medical director said the facility staff phoned him 4/2/11, with concerns regarding a resident (Resident # 1) under another physician's care. The medical director said it was the first time staff had notified him of any abnormal blood sugar levels regarding another physician's resident. Record review of an undated services and compensation contract for medical director services provided by facility staff showed the medical director shall be responsible for the implementation of resident care policies and providing reasonable medical supervision as necessary. The medical director shall share responsibility for assuring facility is providing appropriate care as required, which involves monitoring and ensuring imple

At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". A monitoring visit was completed on 4/20/11. Based on interviews, observations and record review completed during the onsite revisit, it was determined the facility had implemented corrective action to address and lower the violation at this time. The facility had provided in-service training on " insulin reaction information " to all nursing staff that monitor residents ' blood sugar levels and administer insulin. They have reevaluated the insulin administration process for each resident at risk and have in some cases revised the protocols for that individual. The facility developed individualized plans and parameters for each resident with each resident ' s individual physician. The facility has nursing staff monitor and check each other by requiring two nurses initial with each insulin administration. The facility increased the administrative audits of the staff monitoring of blood sugars and have identified some failures. They have dealt with each one by training and or reprimanding the individual involved. The DON and ADON (RN) do the audits and they increased them from the time of exit (one time daily) to two times daily. They also changed the way they are doing the audits based on problems that they found. Record review of the resident charts showed staff notified the physicians each time the protocols required notification and the facility has dealt appropriate for each individual resident dependent on insulin. The facility was still in the process of developing additional policy and protocols. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a "G" level. This statement does not denote that the facility has complied with State Law (Section 198.026.1 RSMo) requiring that prompt remedial action to be taken to address Class I violation.

Based on facility medical records, hospital medical records, observations, and interviews with residents, staff, family and physician the facility failed to provide the assessments, monitoring, and services necessary to prevent the development of pressure ulcers for three randomly selected residents (Resident #16, Resident #15 and Resident #17) with facility acquired pressure sores. The facility failed to consistently assess, monitor, treat, and notify the physician regarding development and changes in two residents' (Resident #4 and Resident #5) pressure ulcers in a sample selection of 12 residents in a facility with a census of 51. 1. Pressure ulcer staging according to State and Federal guidelines: - Stage I pressure ulcer (a persistent area of skin redness without a break in the skin, that is nonblanchable) -Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister. -Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. -Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. According to terminology defining unstageable pressure ulcers in the Long-Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0: -Unstageable-Non-removable dressing - Known but not stageable due to non-removable dressing/device. -Unstageable-Slough and/or Eschar - Known but not stageable due to coverage of wound bed by slough and/or eschar. -Unstageable-Deep Tissue - Suspected deep tissue injury in evolution. Record review of the U.S. Department of Health and Senior Services, Agency for Health Care Policy and Research revealed "a bed-bound individual may form pressure ulcers in as little as one to two hours, whereas those who are confined to chairs may form pressure ulcers in even less time because of the greater relative force on their skin. When a resident is identified as being at risk for pressure ulcer development or presents with a pressure ulcer, then preventative interventions should be instituted that address pressure reduction (or management of tissue loads) and repositioning needs. Reducing or eliminating the risk factors can prevent pressure ulcer formation or deterioration of existing ulcers". According to The Merck Manual of Geriatrics (third edition) Risk Factors for the development of pressure ulcers include the following: -Moisture (as it occurs with urinary and fecal incontinence) -Unrelieved pressure for more than two hours; -Immobility; -Inactivity; -[MEDICAL CONDITION]; -Infection; -[MEDICAL CONDITION]; -Declined ability to respond to pressure related discomfort; -History of pressure ulcers. According to Medical Surgical Nursing, Critical Thinking for Collaborative Care 4th edition, many residents require turning and repositioning every two hours. However, pressure ulcers can occur in less time, and the actual turning/repositioning schedule for each resident should be individualized based upon the resident's risk factors such as immobility and disease processes. Pillows and other positioning devices are to be used at all times to keep heels pressure free for high risk residents. Frequent assessment of heel positioning is needed to ensure that pressure is not redistributed to another high risk area, such as the sides of the feet. Assessment is needed even more frequently when devices that hide the feet, such as boots, are used, especially if the resident has a peripheral vascular problem. Individuals who are in bed should not be positioned on the pressure ulcer. If the ulcer is on a circumscribed area such as the heel, positioning devices should be used to raise the ulcer off the support surface Record review of the facility "Wound Care Protocol" provided 2/7/11, showed the following information:-Objective identified to establish a systematic approach to the treatment of [REDACTED]. -All licensed nurses are responsible for assessment and evaluation; -Interdisciplinary team (director of nurses, assistant director of nurses, dietician, dietary manager, physical therapist, occupational therapist, and physician) will meet on a weekly basis to evaluate the wound-healing process; -A wound is defined as any interruption in the continuity of the integumentary (skin) system; -Pressure ulcers are defined as localized area of tissue necrosis that lend to develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time; -Wounds must have physician orders [REDACTED]. 2. Record review of the Physician orders [REDACTED]. -[DIAGNOSES REDACTED]. -Resident received nothing by mouth, had a G tube (surgically placed tube through the abdominal wall) for nutrition and hydration; -Resident had a urinary catheter; -Staff to use EPC (preventative cream) to his/her buttocks to prevent skin breakdown; -Staff to clean the resident's left elbow daily until healed; -Physician ordered on [DATE], [MEDICATION NAME] (antibiotic) one gram intramuscular injection; -Physician ordered on [DATE], staff to suction the resident as needed, oxygen at two liters as needed to keep oxygen level above 90%, tube feeding lowered, water flush increased, lab work, and [MEDICATION NAME] (antibiotic) 500 mg by the [DEVICE] every day for seven days; -Physician ordered on [DATE], resident's head of bed elevated 45 degrees at all times; Record review of the admission nursing assessments for the resident dated 1/19/11, showed the following information:-Staff identified the resident had a G tube, two skin tears, and both heels pink; -Staff did not identify the resident with any pressure ulcers or stasis ulcers; -Staff identified the resident with a urinary catheter. Record review of the director of nursing (DON)'s weekly review of skin problems for 1/13/11 to 1/19/11 showed the resident had no identified skin problems. Record review of the nurses' notes regarding the resident showed on 1/24/11, no time identified, pressure ulcers noted on the resident's right buttock and coccyx area, no measurements documented. Staff documented the physician was notified. Record review of the Physician orders [REDACTED]. -On 1/25/11, the physician ordered staff to turn the resident every two hours, obtain an air mattress, [MEDICATION NAME] (ointment for the treatment of [REDACTED]. with dry dressing and tape twice daily until healed, and staff to float the resident's heels off of the bed when resident is in bed. During an interview on 1/26/11 at 10:40 A.M., the new DON said the resident had "boggy" (spongy) heels on admission to the facility. The resident had new spots on his/her coccyx and bottom identified by staff yesterday. The DON said she will complete the first weekly skin problem log tomorrow for this week. The last report, done by the former DON, did not identify all the skin problems in the facility. The resident receives tube feedings, is total care, and will respond to stimuli. The DON said the resident should have had the air mattress when he/she admitted to the facility. Staff are using heel protectors on the resident and floating the resident's heels off the bed. During an observation and interview on 1/26/11 at 12:45 P.M., the new DON did the treatment to the resident's buttocks. The resident had acquired two Stage III pressure ulcers on his/her right buttock. The DON said an air mattress had been ordered for the resident. Observation and review of the new DON's first weekly report of skin problems dated 1/23/11 to 1/29/11, showed the following information regarding the resident: -Stage III pressure ulcer on resident's right lateral buttock measuring 5.5 centimeter (cm) by 1.0 cm (depth of the ulcer not measured); -Stage III pressure ulcer on resident's right medial buttock measuring 6.0 cm by 2.0 cm (depth of the ulcer not measured); -Fluid filled blister on the resident's left outer foot measuring 4.0 cm by 2.0 cm; -Right heel blister with necrotic center measuring 6.5 cm by 6.0 cm; -Left heel thickened dermis with blister measuring 7 cm by 6.0 cm; -Left elbow with scab measuring 1.0 cm by 0.5 cm. During an interview on 1/28/11 at 9:30 A.M., the DON said he/she was still doing skin checks on all the residents in the facility but was near completion. Record review of the new DON's weekly report of skin problems dated 1/30/11 to 2/5/11, showed the following information regarding the resident: -Stage III pressure ulcer on resident's right lateral buttock measuring 5.0 cm by 3.0 cm (depth of ulcer not measured) with scant amount of drainage; -Stage III pressure ulcer on resident's right medial buttock measuring 4.5 cm by 2.8 cm (depth of ulcer not measured) with scant amount of drainage; -Stage I left lateral foot documented as blister measuring 3.0 cm by 4.5 cm; -Stage I right heel blister measuring 3.0 cm by 2.5 cm; -Stage I left heel blister measuring 6.5 cm by 9.5 cm. Record review of the nurses' notes regarding the resident on 2/10/11 at 7:30 P.M., showed staff notified the physician of the resident's respiratory and cardiac changes and the physician ordered staff to send the resident immediately to the hospital. Record review of the hospital medical record regarding the resident's admission on 2/10/11, showed the following information: -Resident arrived in the emergency department in respiratory distress; -Resident with severe debility after a stroke requiring tube feedings and with resultant paralysis; -Findings were consistent with pneumonia; -Resident had multiple pressure ulcers on admission to the hospital. Stage III pressure ulcer right inner buttock, Stage III pressure ulcer right outer buttock, Stage II pressure ulcer left buttock, suspected deep tissue injury left outer foot, suspected deep tissue injury to left heel, suspected deep tissue injury right heel; -Resident was discharged from the hospital to another facility on 2/23/11. Complaint #MO 424 3. Record review of the facility admission order dated 12/20/10, regarding Resident #15 showed the following information:-[DIAGNOSES REDACTED]. -On 12/21/10, treatment ordered to change dressings to abdominal wounds twice a day using packing strip to fill the wound bed, cover with an abdominal pad and secure with tape; -On 12/21/10, treatment ordered to change the resident's [MEDICAL CONDITION] wafer and pouch as needed. Record review of the facility admission nursing assessment regarding the resident dated 12/20/10, showed the following information: -[DIAGNOSES REDACTED]. -The resident had a urinary catheter; -Staff described the resident as alert, friendly, and cooperative. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff dated 12/27/10, showed staff identified the resident was not at risk for pressure ulcers and he/she did not have any pressure ulcers. Record review of the physician orders [REDACTED]. Record review of the resident's care plan dated 12/31/10, showed the following information:-The resident required extensive assistance for dressing, bathing, toileting, hygiene, transfers, and mobility due to weakness, shortness of breath, and his/her multiple surgical abdominal wounds; -Staff were to observe the resident for changes in skin condition during daily care and on bath days; -Staff were to assist the resident with repositioning every two hours and as needed; -The resident had potential for skin breakdown/impairment related to his/her [MEDICAL CONDITION]; -Nursing staff to do weekly and as needed skin checks and report any concerns to the DON and physician for treatment orders; -Staff to use pressure relieving devices to bed/chair to minimize pressure points and promote skin integrity; -Resident to have weekly skin checks by the licensed staff and quarterly pressure ulcer risk assessment to ensure the appropriate plan of care is provided. Record review of the nurses' notes regarding the resident dated 1/3/11 at 3:20 A.M., showed the resident had a large open area on his/her right buttock near the coccyx measuring approximately 10.0 cm by 5.0 cm, the wound bed was pink with a small amount of bleeding. Staff documented cream applied, and awaiting treatment orders. Record review of the resident's weekly skin report dated 1/12/11, showed the resident with two new Stage II pressure ulcers on his/her right buttock. One measured 3.6 cm by 2.0 cm and the other measured 0.8 cm by 0.4 cm. Record review of the physician's telephone orders for the resident showed an order on 1/17/11, for the staff to cleanse the resident's buttock wound with gauze and wound cleanser and apply hydrofirm blue, cover with gauze, secure with tape and change every three days. (Staff first identified the wound on 1/3/11, 14 days prior) Record review of the DON's weekly report of skin problems for the week 1/13/11 to 1/19/11, did not identify the resident with the new Stage II pressure ulcers on his/her buttock. Record review of the resident's care plan showed staff did not update the care plan until 1/27/11, when staff documented they identified the resident had buttock wounds established and documented interventions for staff to monitor closely for signs and symptoms of infection, turn the resident every two hours, and encourage the resident on proper nutritional intake to promote healing. Record review of the DON's weekly report of skin problems for the week 1/23/11 to 1/29/11, identified the resident with the two Stage II pressure ulcers on his/her right medial buttock and right medial upper buttock. During observation and interview on 1/26/11 at 9:40 A.M., the resident was in his/her wheelchair in room. The resident's call light was not within reach and both of his/her legs were wrapped. The resident did not have a urinary catheter. The resident said when he/she had to urinate, he/she has to go right away, sometimes he/she wets on his/herself if he/she has to wait too long for assistance. The resident said his/her bottom was raw. The resident said sometimes he/she gets soiled because his/her [MEDICAL CONDITION] bag is not changed timely. The resident wants to go home. During observation and interview on 1/30/11 at 12:05 P.M., the resident's family said the resident gets upset with the night shift and calls him/her at home during the night. The staff always give excuses not to take the resident to the bathroom or to use the bedside commode, and staff tell the resident to wet on him/herself. Record review of the DON's weekly report of skin problems for the week 2/13/11 to 2/19/11, staff identified on 2/15/11, the resident had a third Stage II pressure ulcer on the resident's left buttock measuring 3.1 cm by 2.2 cm. During an interview on 3/3/11 at 3:00 P.M., the resident's physician said he/she was not aware the resident had pressure ulcers. He/she said the staff should be getting the resident up, and turning the resident. The physician said the resident should not get any pressure ulcers. Complaint #MO 987 4. Record review of the facility admission nursing assessment and nurses' notes regarding Resident #17's admission to the facility on [DATE], showed the following information: -Resident arrived at the facility at 12:45 P.M., in a wheelchair; -Staff transferred resident to bed with the use of a Hoyer mechanical lift; -Resident on oxygen at 2 liters via nasal cannula; -Resident alert and wearing a brace on his/her right leg; -Staff identified an old scab on the resident's right upper forearm; -Staff documented the resident had a scar on his/her left anterior chest where the pacemaker placed; -Staff documented the resident had a healing incision on his/her right lower leg from the surgical repair of a [MEDICAL CONDITION] with steri strips above and below the knee where the staples had been removed; -Staff documented the resident did not have reddened areas or broken skin to his/her coccyx and no other areas of broken skin on his/her body; -Resident goes out for [MEDICAL TREATMENT] treatments. Record review of the physician orders [REDACTED]. -[DIAGNOSES REDACTED]. -Resident goes out for [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. Record review of the resident's admission MDS, dated [DATE], showed the following information: -Staff identified resident at risk to develop pressure ulcer; -Staff identified resident with a surgical wound; -Staff assessed resident without a pressure ulcer or stasis ulcer; -Resident was not identified on the turning-repositioning program. Record review of the DON weekly report of skin problems showed he/she identified on 2/17/11, the following on the resident: -Stage II pressure ulcer on his/her right medical buttock measuring 4.0 cm by 3.5 cm; -Stage I pressure ulcer on coccyx measuring 2.0 by 1.0; -Both heels with deep tissue injury; -Treatment plan [MEDICATION NAME] with gauze to pressure ulcers, staff to float resident's heels, and get an air mattress. During an interview on 2/18/11 at 3:20 P.M., the resident said the staff check his/her bottom every night. He/she got an air mattress today. He/she had to go to [MEDICAL TREATMENT] four times a week for a few weeks now due to holding fluids. The resident said he/she had been lying down in the afternoons now and not staying up too long in the chairs. Record review of the resident's care plan on 2/18/11, showed staff had not addressed the resident's pressure ulcers. During an interview on 3/3/11 at 3:00 P.M., the resident's physician said he was not aware the resident had pressure ulcers. The resident was there for short term rehabilitation and should be getting care to prevent pressure ulcers. Record review of the DON weekly report of skin problems ending 3/5/11, showed the following information regarding the resident: -Both heels with deep tissue injury and the treatment plan identified podus boots (suspends the heel to provide pressure relief) and repositioning; -Stage II on right medial buttock measuring 4.3 cm by 3.0 cm and the treatment plan identified staff to use [MEDICATION NAME] every shift. 5. Record review of Resident #4's admission nursing assessment flowsheet, dated 2/4/11, at 6:00 P.M., showed the time of admission as 2:50 P.M. The nurse did not indicate any body marks or concerns, abrasions, bruises, skin tears, stasis ulcers, or pressure ulcers on the form. Record review of a status upon admission, admission nursing assessment, dated 2/4/11, at 2:50 P.M., showed the following information regarding skin condition: -Dark intact areas on buttocks; -Sore from oxygen tubing, covered with bandaid; -[MEDICATION NAME] ([MEDICATION NAME] dressing that provides a moist environment to promote healing to the wound) on the second toe of the right foot; -[MEDICATION NAME] on left heel. Record review of the activities of daily living (ADL) function assessment, dated 2/4/11, at 6:00 P.M., showed the following information: -Short and long term memory okay; -Highest pressure ulcer present, staff marked none (0). Record review of the admission narrative nursing note, dated 2/4/11, at 6:00 P.M., showed the resident arrived at the facility at 2:50 P.M., the resident was incontinent of bowel and bladder. The nurse documented the resident had "two dark intact areas on the coccyx, [MEDICATION NAME] on the second toe of the right foot, and heel of left foot". The resident had "a bandaid on the right ear". The resident "states it is for oxygen tubing". The nurse did not document any further assessment of the pressure ulcers. Record review of a temporary problem list, showed the following information: -On 2/4/11, staff documented the resident had potential for altered skin integrity; -Interventions included air mattress, turn every two hours, and proper nutrition and fluids; Record review of the resident's admission physician order [REDACTED]. -[DIAGNOSES REDACTED]. and ulcer of heel; -Air mattress to bed; -Cleanse left upper buttock with safeclenz, then apply [MEDICATION NAME], change every three days and as needed until healed; -Podus boot as needed; -Staff did not document any treatment orders for the two pressure ulcers on the coccyx, the right heel and the left foot that were documented in the admission nursing note, dated 2/4/11. Record review of the resident's admission MDS, dated [DATE], showed the following information: -Entry date into the facility on [DATE]; -Required extensive assistance for bed mobility, transfers, dressing, personal hygiene, and toilet use; -Frequently incontinent of bowel and bladder; -One stage II pressure ulcer present on admission; -One stage III pressure ulcer, present on admission, measuring 2.3 cm x 1.8 cm, with 0 depth. Record review of the February 2011 treatment administration record (TAR), showed the following information: -Staff dated the order to cleanse the left upper buttock pressure ulcer with safeclenz, cover with [MEDICATION NAME], change every three days and as needed as 2/8/11. Staff did not document the treatment until 2/16/11 (12 days after admission to facility); -Staff did not document any treatment or monitoring for the two intact pressure ulcers on the coccyx, the left foot and the right heel pressure ulcers that were noted on the admission nursing note. Record review of the flow sheet nurses' note, dated 2/14/11, showed staff documented the resident had skin conditions on the left heel. The nurse documented [MEDICATION NAME] for protection. The nurse did not document size, stage, or condition of the pressure ulcers. Record review of the weekly skin report (decubitus report, man picture), dated 2/17/11, showed the following information: -Left upper buttock, measured 2.2 cm x 2.1 cm, with 0 depth, stage III. The pressure ulcer had scant purulent (contains pus) drainage. The treatment consisted of safeclenz and [MEDICATION NAME]. The resident's progress is "static". The resident had an air mattress. Record review of the weekly skin report (computer form), dated 2/23/11, showed the following information: -The resident admitted to the facility with a stage III pressure ulcer on the left upper buttock, measuring approximately 2.2 cm x 2.3 cm, no depth listed, with scant bloody discharge present. "Bellding" is apparently resulting from the removal of the [MEDICATION NAME] dressing. The nurse documented he/she would contact the physician to suggest changing to an alternate dressing to prevent skin tearing. The resident developed an pressure ulcer on his/her posterior ears, bilaterally, due to the oxygen tubing. The pressure ulcers are currently stage I, closed. The facility instituted ear protectors to address the pressure ulcer. The note did not include measurements for the pressure ulcers on the bilateral ears. Record review of the resident's care plan, showed the following information: -Problem onset date of 2/26/11, showed the resident had skin breakdown with pressure ulcers to the heel and buttocks. The resident is at risk for poor healing, infection, as well as additional skin breakdown with history of wound infection, multiple surgeries, and lack of mobility; -Assess and monitor the size and stage of pressure ulcer and condition of the surrounding skin once a week; -Cleanse upper buttock with safeclenz, apply [MEDICATION NAME], change every three days and as needed until healed; -The care plan did not address interventions for the pressure ulcers to the heel. Record review of a temporary problem list, showed the following information: -On 3/1/11, staff documented to discontinue the safeclenz and [MEDICATION NAME] to the upper buttock every three days and as needed. Begin [MEDICATION NAME] and leave open to air every shift for skin breakdown. Begin [MEDICATION NAME] to right ear for protection from oxygen tubing, change every three days and as needed. Record review of the resident's care plan, showed the following information: -Problem onset date of 3/8/11 showed the resident had a stage II pressure ulcer anterior to the right ear, secondary to pressure from oxygen tubing; -Interventions included: -Encircle the oxygen tubing with tape to relieve pressure near the ear; -Wound care as ordered by the physician; -Weekly evaluation of wound healing; -Daily observation of skin with routine care. -Adjust the treatment plan if no healing within 2-4 weeks; -Monitor for changes in skin status that may indicate worsening of the pressure ulcer and notify the physician; -On unknown date, staff documented to continue ear protectors bilaterally to prevent irritation or skin breakdown; -On 3/10/11, staff documented culture and sensitivity (laboratory test used to determine the type of bacteria and which antibiotics are appropriate for treatment), right anterior ear, stage II; -On 3/12/11, staff documented [MEDICATION NAME] (antibiotic), one tablet twice a day for seven days, [DIAGNOSES REDACTED]. -On 3/15/11, staff documented [MEDICATION NAME] (antibacterial) ointment to anterior area on right ear until healed. Record review of the March 2011 POS, showed the following information: -Continuing physician order [REDACTED]. -Continuing physician order [REDACTED]. -On 3/9/11, staff documented an order for [REDACTED]. -On 3/11/11, staff documented an order for [REDACTED]. -On 3/13/11, staff documented an order to cleanse the wound to the right ear with normal saline, pat dry, and apply [MEDICATION NAME]. Cover with [MEDICATION NAME](non-adherent absorbent dressing that acts as a barrier between the wound and the excretions) or gauze twice a day until healed. Discontinue previous treatments to the ear. Continue [MEDICATION NAME] as previously ordered; -Staff did not obtain a physician's orders [REDACTED]. Record review of the March 2011 TAR, showed the following information: -Staff documented the left upper buttock pressure ulcer as healed. Discontinue the order on 3/1/11. -Staff documented completing the treatment of [REDACTED]. Staff documented to discontinue the order on 3/13/11. -On 3/13/11, staff documented starting treatment of [REDACTED]. Apply [MEDICATION NAME] and cover with [MEDICATION NAME] or gauze twice a day until healed; -Staff did not document any monitoring or treatment of [REDACTED]. Record review of the final wound culture report for the ear, dated 3/12/11, showed the ear wound had moderate Proteus mirabilis (bacteria found in fecal material), moderate [MEDICAL CONDITION] (MRSA is a resistant bacterial infection difficult to treat). [MEDICAL CONDITION] has developed a resistance to the [MEDICAL CONDITION] anti-infective, [MEDICATION NAME] broad-spectrum) and scant alpha streptococcus (bacteria that in many species cause disease in humans). Record review of the weekly skin report (decubitus report, man picture), dated 3/16/11 (first pressure ulcer assessment since 2/23/11) showed the following information: -Left upper buttocks, measuring 2.1 cm x 1.7 cm, with no depth. The nurse documented it as a stage III, but noted "may be staged down next review". The wound color was pink, pale color. The pressure ulcer had scant purulent drainage. The treatment consisted of [MEDICATION NAME], open to air, related to history of skin tear with tape. -Anterior to the right ear, measuring 0.1 cm 0.1 cm, with no depth, stage II. The wound bed was pink with scant, purulent drainage. The treatment consists of [MEDICATION NAME]. The progress is "static". Observation on 3/22/11, showed licensed practical nurse (LPN) A entered the room and observed the resident's buttocks. The resident did not have a pressure ulcer to the buttocks at that time. The nurse asked the resident about the [MEDICATION NAME] ointment and the resident said he/she wanted to keep the ointment order as needed, even though the buttocks pressure ulcer had healed. LPN A said the resident had a pressure ulcer to the buttocks when he/she first came in, but not a bad area. Certified nursing assistant (CNA) G applied [MEDICATION NAME] to the resident's buttocks. During interview on 3/23/11, at 8:40 A.M., LPN F said he/she would be doing the resident's treatment. The resident has a little place on the ear, that he/she thought was healing. Observation on 3/23/11, at 1:44 P.M., LPN F entered the resident's room and washed his/her hands. The nurse laid the treatment supplies on a non-slip mat on the bedside table. The nurse did not cleanse the table or place a towel to provide a clean surface for the treatment supplies. The nurse applied gloves and removed a band aid from an anterior pressure ulcer on the right ear (The March 2011 POS showed an order, dated 3/13/11, to cover the pressure ulcer with [MEDICATION NAME] or gauze). The band aid had bloody drainage on it. The nurse threw the band aid into the regular trash bag in the trashcan. The nurse removed his/her gloves and applied new gloves. The nurse did not wash his/her hands. The pressure ulcer on the anterior portion of the ear was a small scabbed area with purple color to it. Blood continued to ooze from the ear pressure ulcer. The nurse cleansed the right ear with normal saline and gauze. The nurse applied [MEDICATION NAME] to the pressure ulcer. The nurse removed his/her gloves and applied new gloves. The nurse did not wash his/her hands. The nurse obtained scissors from his/her pocket and cut the [MEDICATION NAME] pad to a smaller size. The nurse laid the scissors on the bedside table. The nurse dated the dressing and secured it with paper tape. The nurse removed his/her gloves and raised the level of the bed, using the bed controls. The nurse washed his/her hands. During an interview on 3/24/11, at 2:50 P.M., the DON said the resident had skin irritation to the posterior portion of both ears. They wrap tape around the oxygen tubing to reduce the irritation. The area on the front of the resident's right ear is not a pressure area. The DON thinks it was caused by the resident scratching it. The facility cultured the area and it had bacteria in it and they started [MEDICATION NAME] ointment to it. The pressure ulcer tracking is on the "man report". Some of the pressure ulcer assessments were on the computer form for one week. The 2/23/11 assessment is the computer week. The facility went back to the "man" picture because the staff who was going to train the nurses is sick. During an interview on 3/29/11, at 10:28 A.M., the DON said the skin assessments for residents who are high-risk for skin breakdown, but do not have current breakdown will be done by another RN. The assess

Based on facility medical records, hospital medical records, observations, and interviews with residents, staff, family and physician the facility failed to provide the assessments, monitoring, and services necessary to prevent the development of pressure ulcers for three randomly selected residents (Resident #16, Resident #15 and Resident #17) with facility acquired pressure sores. The facility failed to consistently assess, monitor, treat, and notify the physician regarding development and changes in two residents' (Resident #4 and Resident #5) pressure ulcers in a sample selection of 12 residents in a facility with a census of 51. 1. Pressure ulcer staging according to State and Federal guidelines: - Stage I pressure ulcer (a persistent area of skin redness without a break in the skin, that is nonblanchable) -Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister. -Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. -Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. According to terminology defining unstageable pressure ulcers in the Long-Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0: -Unstageable-Non-removable dressing - Known but not stageable due to non-removable dressing/device. -Unstageable-Slough and/or Eschar - Known but not stageable due to coverage of wound bed by slough and/or eschar. -Unstageable-Deep Tissue - Suspected deep tissue injury in evolution. Record review of the U.S. Department of Health and Senior Services, Agency for Health Care Policy and Research revealed "a bed-bound individual may form pressure ulcers in as little as one to two hours, whereas those who are confined to chairs may form pressure ulcers in even less time because of the greater relative force on their skin. When a resident is identified as being at risk for pressure ulcer development or presents with a pressure ulcer, then preventative interventions should be instituted that address pressure reduction (or management of tissue loads) and repositioning needs. Reducing or eliminating the risk factors can prevent pressure ulcer formation or deterioration of existing ulcers". According to The Merck Manual of Geriatrics (third edition) Risk Factors for the development of pressure ulcers include the following: -Moisture (as it occurs with urinary and fecal incontinence) -Unrelieved pressure for more than two hours; -Immobility; -Inactivity; -[MEDICAL CONDITION]; -Infection; -[MEDICAL CONDITION]; -Declined ability to respond to pressure related discomfort; -History of pressure ulcers. According to Medical Surgical Nursing, Critical Thinking for Collaborative Care 4th edition, many residents require turning and repositioning every two hours. However, pressure ulcers can occur in less time, and the actual turning/repositioning schedule for each resident should be individualized based upon the resident's risk factors such as immobility and disease processes. Pillows and other positioning devices are to be used at all times to keep heels pressure free for high risk residents. Frequent assessment of heel positioning is needed to ensure that pressure is not redistributed to another high risk area, such as the sides of the feet. Assessment is needed even more frequently when devices that hide the feet, such as boots, are used, especially if the resident has a peripheral vascular problem. Individuals who are in bed should not be positioned on the pressure ulcer. If the ulcer is on a circumscribed area such as the heel, positioning devices should be used to raise the ulcer off the support surface Record review of the facility "Wound Care Protocol" provided 2/7/11, showed the following information:-Objective identified to establish a systematic approach to the treatment of [REDACTED]. -All licensed nurses are responsible for assessment and evaluation; -Interdisciplinary team (director of nurses, assistant director of nurses, dietician, dietary manager, physical therapist, occupational therapist, and physician) will meet on a weekly basis to evaluate the wound-healing process; -A wound is defined as any interruption in the continuity of the integumentary (skin) system; -Pressure ulcers are defined as localized area of tissue necrosis that lend to develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time; -Wounds must have physician orders [REDACTED]. 2. Record review of the Physician orders [REDACTED]. -[DIAGNOSES REDACTED]. -Resident received nothing by mouth, had a G tube (surgically placed tube through the abdominal wall) for nutrition and hydration; -Resident had a urinary catheter; -Staff to use EPC (preventative cream) to his/her buttocks to prevent skin breakdown; -Staff to clean the resident's left elbow daily until healed; -Physician ordered on [DATE], [MEDICATION NAME] (antibiotic) one gram intramuscular injection; -Physician ordered on [DATE], staff to suction the resident as needed, oxygen at two liters as needed to keep oxygen level above 90%, tube feeding lowered, water flush increased, lab work, and [MEDICATION NAME] (antibiotic) 500 mg by the [DEVICE] every day for seven days; -Physician ordered on [DATE], resident's head of bed elevated 45 degrees at all times; Record review of the admission nursing assessments for the resident dated 1/19/11, showed the following information:-Staff identified the resident had a G tube, two skin tears, and both heels pink; -Staff did not identify the resident with any pressure ulcers or stasis ulcers; -Staff identified the resident with a urinary catheter. Record review of the director of nursing (DON)'s weekly review of skin problems for 1/13/11 to 1/19/11 showed the resident had no identified skin problems. Record review of the nurses' notes regarding the resident showed on 1/24/11, no time identified, pressure ulcers noted on the resident's right buttock and coccyx area, no measurements documented. Staff documented the physician was notified. Record review of the Physician orders [REDACTED]. -On 1/25/11, the physician ordered staff to turn the resident every two hours, obtain an air mattress, [MEDICATION NAME] (ointment for the treatment of [REDACTED]. with dry dressing and tape twice daily until healed, and staff to float the resident's heels off of the bed when resident is in bed. During an interview on 1/26/11 at 10:40 A.M., the new DON said the resident had "boggy" (spongy) heels on admission to the facility. The resident had new spots on his/her coccyx and bottom identified by staff yesterday. The DON said she will complete the first weekly skin problem log tomorrow for this week. The last report, done by the former DON, did not identify all the skin problems in the facility. The resident receives tube feedings, is total care, and will respond to stimuli. The DON said the resident should have had the air mattress when he/she admitted to the facility. Staff are using heel protectors on the resident and floating the resident's heels off the bed. During an observation and interview on 1/26/11 at 12:45 P.M., the new DON did the treatment to the resident's buttocks. The resident had acquired two Stage III pressure ulcers on his/her right buttock. The DON said an air mattress had been ordered for the resident. Observation and review of the new DON's first weekly report of skin problems dated 1/23/11 to 1/29/11, showed the following information regarding the resident: -Stage III pressure ulcer on resident's right lateral buttock measuring 5.5 centimeter (cm) by 1.0 cm (depth of the ulcer not measured); -Stage III pressure ulcer on resident's right medial buttock measuring 6.0 cm by 2.0 cm (depth of the ulcer not measured); -Fluid filled blister on the resident's left outer foot measuring 4.0 cm by 2.0 cm; -Right heel blister with necrotic center measuring 6.5 cm by 6.0 cm; -Left heel thickened dermis with blister measuring 7 cm by 6.0 cm; -Left elbow with scab measuring 1.0 cm by 0.5 cm. During an interview on 1/28/11 at 9:30 A.M., the DON said he/she was still doing skin checks on all the residents in the facility but was near completion. Record review of the new DON's weekly report of skin problems dated 1/30/11 to 2/5/11, showed the following information regarding the resident: -Stage III pressure ulcer on resident's right lateral buttock measuring 5.0 cm by 3.0 cm (depth of ulcer not measured) with scant amount of drainage; -Stage III pressure ulcer on resident's right medial buttock measuring 4.5 cm by 2.8 cm (depth of ulcer not measured) with scant amount of drainage; -Stage I left lateral foot documented as blister measuring 3.0 cm by 4.5 cm; -Stage I right heel blister measuring 3.0 cm by 2.5 cm; -Stage I left heel blister measuring 6.5 cm by 9.5 cm. Record review of the nurses' notes regarding the resident on 2/10/11 at 7:30 P.M., showed staff notified the physician of the resident's respiratory and cardiac changes and the physician ordered staff to send the resident immediately to the hospital. Record review of the hospital medical record regarding the resident's admission on 2/10/11, showed the following information: -Resident arrived in the emergency department in respiratory distress; -Resident with severe debility after a stroke requiring tube feedings and with resultant paralysis; -Findings were consistent with pneumonia; -Resident had multiple pressure ulcers on admission to the hospital. Stage III pressure ulcer right inner buttock, Stage III pressure ulcer right outer buttock, Stage II pressure ulcer left buttock, suspected deep tissue injury left outer foot, suspected deep tissue injury to left heel, suspected deep tissue injury right heel; -Resident was discharged from the hospital to another facility on 2/23/11. Complaint #MO 424 3. Record review of the facility admission order dated 12/20/10, regarding Resident #15 showed the following information:-[DIAGNOSES REDACTED]. -On 12/21/10, treatment ordered to change dressings to abdominal wounds twice a day using packing strip to fill the wound bed, cover with an abdominal pad and secure with tape; -On 12/21/10, treatment ordered to change the resident's [MEDICAL CONDITION] wafer and pouch as needed. Record review of the facility admission nursing assessment regarding the resident dated 12/20/10, showed the following information: -[DIAGNOSES REDACTED]. -The resident had a urinary catheter; -Staff described the resident as alert, friendly, and cooperative. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff dated 12/27/10, showed staff identified the resident was not at risk for pressure ulcers and he/she did not have any pressure ulcers. Record review of the physician orders [REDACTED]. Record review of the resident's care plan dated 12/31/10, showed the following information:-The resident required extensive assistance for dressing, bathing, toileting, hygiene, transfers, and mobility due to weakness, shortness of breath, and his/her multiple surgical abdominal wounds; -Staff were to observe the resident for changes in skin condition during daily care and on bath days; -Staff were to assist the resident with repositioning every two hours and as needed; -The resident had potential for skin breakdown/impairment related to his/her [MEDICAL CONDITION]; -Nursing staff to do weekly and as needed skin checks and report any concerns to the DON and physician for treatment orders; -Staff to use pressure relieving devices to bed/chair to minimize pressure points and promote skin integrity; -Resident to have weekly skin checks by the licensed staff and quarterly pressure ulcer risk assessment to ensure the appropriate plan of care is provided. Record review of the nurses' notes regarding the resident dated 1/3/11 at 3:20 A.M., showed the resident had a large open area on his/her right buttock near the coccyx measuring approximately 10.0 cm by 5.0 cm, the wound bed was pink with a small amount of bleeding. Staff documented cream applied, and awaiting treatment orders. Record review of the resident's weekly skin report dated 1/12/11, showed the resident with two new Stage II pressure ulcers on his/her right buttock. One measured 3.6 cm by 2.0 cm and the other measured 0.8 cm by 0.4 cm. Record review of the physician's telephone orders for the resident showed an order on 1/17/11, for the staff to cleanse the resident's buttock wound with gauze and wound cleanser and apply hydrofirm blue, cover with gauze, secure with tape and change every three days. (Staff first identified the wound on 1/3/11, 14 days prior) Record review of the DON's weekly report of skin problems for the week 1/13/11 to 1/19/11, did not identify the resident with the new Stage II pressure ulcers on his/her buttock. Record review of the resident's care plan showed staff did not update the care plan until 1/27/11, when staff documented they identified the resident had buttock wounds established and documented interventions for staff to monitor closely for signs and symptoms of infection, turn the resident every two hours, and encourage the resident on proper nutritional intake to promote healing. Record review of the DON's weekly report of skin problems for the week 1/23/11 to 1/29/11, identified the resident with the two Stage II pressure ulcers on his/her right medial buttock and right medial upper buttock. During observation and interview on 1/26/11 at 9:40 A.M., the resident was in his/her wheelchair in room. The resident's call light was not within reach and both of his/her legs were wrapped. The resident did not have a urinary catheter. The resident said when he/she had to urinate, he/she has to go right away, sometimes he/she wets on his/herself if he/she has to wait too long for assistance. The resident said his/her bottom was raw. The resident said sometimes he/she gets soiled because his/her [MEDICAL CONDITION] bag is not changed timely. The resident wants to go home. During observation and interview on 1/30/11 at 12:05 P.M., the resident's family said the resident gets upset with the night shift and calls him/her at home during the night. The staff always give excuses not to take the resident to the bathroom or to use the bedside commode, and staff tell the resident to wet on him/herself. Record review of the DON's weekly report of skin problems for the week 2/13/11 to 2/19/11, staff identified on 2/15/11, the resident had a third Stage II pressure ulcer on the resident's left buttock measuring 3.1 cm by 2.2 cm. During an interview on 3/3/11 at 3:00 P.M., the resident's physician said he/she was not aware the resident had pressure ulcers. He/she said the staff should be getting the resident up, and turning the resident. The physician said the resident should not get any pressure ulcers. Complaint #MO 987 4. Record review of the facility admission nursing assessment and nurses' notes regarding Resident #17's admission to the facility on [DATE], showed the following information: -Resident arrived at the facility at 12:45 P.M., in a wheelchair; -Staff transferred resident to bed with the use of a Hoyer mechanical lift; -Resident on oxygen at 2 liters via nasal cannula; -Resident alert and wearing a brace on his/her right leg; -Staff identified an old scab on the resident's right upper forearm; -Staff documented the resident had a scar on his/her left anterior chest where the pacemaker placed; -Staff documented the resident had a healing incision on his/her right lower leg from the surgical repair of a [MEDICAL CONDITION] with steri strips above and below the knee where the staples had been removed; -Staff documented the resident did not have reddened areas or broken skin to his/her coccyx and no other areas of broken skin on his/her body; -Resident goes out for [MEDICAL TREATMENT] treatments. Record review of the physician orders [REDACTED]. -[DIAGNOSES REDACTED]. -Resident goes out for [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. Record review of the resident's admission MDS, dated [DATE], showed the following information: -Staff identified resident at risk to develop pressure ulcer; -Staff identified resident with a surgical wound; -Staff assessed resident without a pressure ulcer or stasis ulcer; -Resident was not identified on the turning-repositioning program. Record review of the DON weekly report of skin problems showed he/she identified on 2/17/11, the following on the resident: -Stage II pressure ulcer on his/her right medical buttock measuring 4.0 cm by 3.5 cm; -Stage I pressure ulcer on coccyx measuring 2.0 by 1.0; -Both heels with deep tissue injury; -Treatment plan [MEDICATION NAME] with gauze to pressure ulcers, staff to float resident's heels, and get an air mattress. During an interview on 2/18/11 at 3:20 P.M., the resident said the staff check his/her bottom every night. He/she got an air mattress today. He/she had to go to [MEDICAL TREATMENT] four times a week for a few weeks now due to holding fluids. The resident said he/she had been lying down in the afternoons now and not staying up too long in the chairs. Record review of the resident's care plan on 2/18/11, showed staff had not addressed the resident's pressure ulcers. During an interview on 3/3/11 at 3:00 P.M., the resident's physician said he was not aware the resident had pressure ulcers. The resident was there for short term rehabilitation and should be getting care to prevent pressure ulcers. Record review of the DON weekly report of skin problems ending 3/5/11, showed the following information regarding the resident: -Both heels with deep tissue injury and the treatment plan identified podus boots (suspends the heel to provide pressure relief) and repositioning; -Stage II on right medial buttock measuring 4.3 cm by 3.0 cm and the treatment plan identified staff to use [MEDICATION NAME] every shift. 5. Record review of Resident #4's admission nursing assessment flowsheet, dated 2/4/11, at 6:00 P.M., showed the time of admission as 2:50 P.M. The nurse did not indicate any body marks or concerns, abrasions, bruises, skin tears, stasis ulcers, or pressure ulcers on the form. Record review of a status upon admission, admission nursing assessment, dated 2/4/11, at 2:50 P.M., showed the following information regarding skin condition: -Dark intact areas on buttocks; -Sore from oxygen tubing, covered with bandaid; -Duoderm ([MEDICATION NAME] dressing that provides a moist environment to promote healing to the wound) on the second toe of the right foot; -Duoderm on left heel. Record review of the activities of daily living (ADL) function assessment, dated 2/4/11, at 6:00 P.M., showed the following information: -Short and long term memory okay; -Highest pressure ulcer present, staff marked none (0). Record review of the admission narrative nursing note, dated 2/4/11, at 6:00 P.M., showed the resident arrived at the facility at 2:50 P.M., the resident was incontinent of bowel and bladder. The nurse documented the resident had "two dark intact areas on the coccyx, duoderm on the second toe of the right foot, and heel of left foot". The resident had "a bandaid on the right ear". The resident "states it is for oxygen tubing". The nurse did not document any further assessment of the pressure ulcers. Record review of a temporary problem list, showed the following information: -On 2/4/11, staff documented the resident had potential for altered skin integrity; -Interventions included air mattress, turn every two hours, and proper nutrition and fluids; Record review of the resident's admission physician order [REDACTED]. -[DIAGNOSES REDACTED]. and ulcer of heel; -Air mattress to bed; -Cleanse left upper buttock with safeclenz, then apply duoderm, change every three days and as needed until healed; -Podus boot as needed; -Staff did not document any treatment orders for the two pressure ulcers on the coccyx, the right heel and the left foot that were documented in the admission nursing note, dated 2/4/11. Record review of the resident's admission MDS, dated [DATE], showed the following information: -Entry date into the facility on [DATE]; -Required extensive assistance for bed mobility, transfers, dressing, personal hygiene, and toilet use; -Frequently incontinent of bowel and bladder; -One stage II pressure ulcer present on admission; -One stage III pressure ulcer, present on admission, measuring 2.3 cm x 1.8 cm, with 0 depth. Record review of the February 2011 treatment administration record (TAR), showed the following information: -Staff dated the order to cleanse the left upper buttock pressure ulcer with safeclenz, cover with duoderm, change every three days and as needed as 2/8/11. Staff did not document the treatment until 2/16/11 (12 days after admission to facility); -Staff did not document any treatment or monitoring for the two intact pressure ulcers on the coccyx, the left foot and the right heel pressure ulcers that were noted on the admission nursing note. Record review of the flow sheet nurses' note, dated 2/14/11, showed staff documented the resident had skin conditions on the left heel. The nurse documented duoderm for protection. The nurse did not document size, stage, or condition of the pressure ulcers. Record review of the weekly skin report (decubitus report, man picture), dated 2/17/11, showed the following information: -Left upper buttock, measured 2.2 cm x 2.1 cm, with 0 depth, stage III. The pressure ulcer had scant purulent (contains pus) drainage. The treatment consisted of safeclenz and duoderm. The resident's progress is "static". The resident had an air mattress. Record review of the weekly skin report (computer form), dated 2/23/11, showed the following information: -The resident admitted to the facility with a stage III pressure ulcer on the left upper buttock, measuring approximately 2.2 cm x 2.3 cm, no depth listed, with scant bloody discharge present. "Bellding" is apparently resulting from the removal of the duoderm dressing. The nurse documented he/she would contact the physician to suggest changing to an alternate dressing to prevent skin tearing. The resident developed an pressure ulcer on his/her posterior ears, bilaterally, due to the oxygen tubing. The pressure ulcers are currently stage I, closed. The facility instituted ear protectors to address the pressure ulcer. The note did not include measurements for the pressure ulcers on the bilateral ears. Record review of the resident's care plan, showed the following information: -Problem onset date of 2/26/11, showed the resident had skin breakdown with pressure ulcers to the heel and buttocks. The resident is at risk for poor healing, infection, as well as additional skin breakdown with history of wound infection, multiple surgeries, and lack of mobility; -Assess and monitor the size and stage of pressure ulcer and condition of the surrounding skin once a week; -Cleanse upper buttock with safeclenz, apply duoderm, change every three days and as needed until healed; -The care plan did not address interventions for the pressure ulcers to the heel. Record review of a temporary problem list, showed the following information: -On 3/1/11, staff documented to discontinue the safeclenz and duoderm to the upper buttock every three days and as needed. Begin [MEDICATION NAME] and leave open to air every shift for skin breakdown. Begin duoderm to right ear for protection from oxygen tubing, change every three days and as needed. Record review of the resident's care plan, showed the following information: -Problem onset date of 3/8/11 showed the resident had a stage II pressure ulcer anterior to the right ear, secondary to pressure from oxygen tubing; -Interventions included: -Encircle the oxygen tubing with tape to relieve pressure near the ear; -Wound care as ordered by the physician; -Weekly evaluation of wound healing; -Daily observation of skin with routine care. -Adjust the treatment plan if no healing within 2-4 weeks; -Monitor for changes in skin status that may indicate worsening of the pressure ulcer and notify the physician; -On unknown date, staff documented to continue ear protectors bilaterally to prevent irritation or skin breakdown; -On 3/10/11, staff documented culture and sensitivity (laboratory test used to determine the type of bacteria and which antibiotics are appropriate for treatment), right anterior ear, stage II; -On 3/12/11, staff documented [MEDICATION NAME] (antibiotic), one tablet twice a day for seven days, [DIAGNOSES REDACTED]. -On 3/15/11, staff documented [MEDICATION NAME] (antibacterial) ointment to anterior area on right ear until healed. Record review of the March 2011 POS, showed the following information: -Continuing physician order [REDACTED]. -Continuing physician order [REDACTED]. -On 3/9/11, staff documented an order for [REDACTED]. -On 3/11/11, staff documented an order for [REDACTED]. -On 3/13/11, staff documented an order to cleanse the wound to the right ear with normal saline, pat dry, and apply [MEDICATION NAME]. Cover with [MEDICATION NAME](non-adherent absorbent dressing that acts as a barrier between the wound and the excretions) or gauze twice a day until healed. Discontinue previous treatments to the ear. Continue [MEDICATION NAME] as previously ordered; -Staff did not obtain a physician's orders [REDACTED]. Record review of the March 2011 TAR, showed the following information: -Staff documented the left upper buttock pressure ulcer as healed. Discontinue the order on 3/1/11. -Staff documented completing the treatment of [REDACTED]. Staff documented to discontinue the order on 3/13/11. -On 3/13/11, staff documented starting treatment of [REDACTED]. Apply [MEDICATION NAME] and cover with [MEDICATION NAME] or gauze twice a day until healed; -Staff did not document any monitoring or treatment of [REDACTED]. Record review of the final wound culture report for the ear, dated 3/12/11, showed the ear wound had moderate Proteus mirabilis (bacteria found in fecal material), moderate [MEDICAL CONDITION] (MRSA is a resistant bacterial infection difficult to treat). [MEDICAL CONDITION] has developed a resistance to the [MEDICAL CONDITION] anti-infective, [MEDICATION NAME] broad-spectrum) and scant alpha streptococcus (bacteria that in many species cause disease in humans). Record review of the weekly skin report (decubitus report, man picture), dated 3/16/11 (first pressure ulcer assessment since 2/23/11) showed the following information: -Left upper buttocks, measuring 2.1 cm x 1.7 cm, with no depth. The nurse documented it as a stage III, but noted "may be staged down next review". The wound color was pink, pale color. The pressure ulcer had scant purulent drainage. The treatment consisted of [MEDICATION NAME], open to air, related to history of skin tear with tape. -Anterior to the right ear, measuring 0.1 cm 0.1 cm, with no depth, stage II. The wound bed was pink with scant, purulent drainage. The treatment consists of duoderm. The progress is "static". Observation on 3/22/11, showed licensed practical nurse (LPN) A entered the room and observed the resident's buttocks. The resident did not have a pressure ulcer to the buttocks at that time. The nurse asked the resident about the [MEDICATION NAME] ointment and the resident said he/she wanted to keep the ointment order as needed, even though the buttocks pressure ulcer had healed. LPN A said the resident had a pressure ulcer to the buttocks when he/she first came in, but not a bad area. Certified nursing assistant (CNA) G applied [MEDICATION NAME] to the resident's buttocks. During interview on 3/23/11, at 8:40 A.M., LPN F said he/she would be doing the resident's treatment. The resident has a little place on the ear, that he/she thought was healing. Observation on 3/23/11, at 1:44 P.M., LPN F entered the resident's room and washed his/her hands. The nurse laid the treatment supplies on a non-slip mat on the bedside table. The nurse did not cleanse the table or place a towel to provide a clean surface for the treatment supplies. The nurse applied gloves and removed a band aid from an anterior pressure ulcer on the right ear (The March 2011 POS showed an order, dated 3/13/11, to cover the pressure ulcer with [MEDICATION NAME] or gauze). The band aid had bloody drainage on it. The nurse threw the band aid into the regular trash bag in the trashcan. The nurse removed his/her gloves and applied new gloves. The nurse did not wash his/her hands. The pressure ulcer on the anterior portion of the ear was a small scabbed area with purple color to it. Blood continued to ooze from the ear pressure ulcer. The nurse cleansed the right ear with normal saline and gauze. The nurse applied [MEDICATION NAME] to the pressure ulcer. The nurse removed his/her gloves and applied new gloves. The nurse did not wash his/her hands. The nurse obtained scissors from his/her pocket and cut the [MEDICATION NAME] pad to a smaller size. The nurse laid the scissors on the bedside table. The nurse dated the dressing and secured it with paper tape. The nurse removed his/her gloves and raised the level of the bed, using the bed controls. The nurse washed his/her hands. During an interview on 3/24/11, at 2:50 P.M., the DON said the resident had skin irritation to the posterior portion of both ears. They wrap tape around the oxygen tubing to reduce the irritation. The area on the front of the resident's right ear is not a pressure area. The DON thinks it was caused by the resident scratching it. The facility cultured the area and it had bacteria in it and they started [MEDICATION NAME] ointment to it. The pressure ulcer tracking is on the "man report". Some of the pressure ulcer assessments were on the computer form for one week. The 2/23/11 assessment is the computer week. The facility went back to the "man" picture because the staff who was going to train the nurses is sick. During an interview on 3/29/11, at 10:28 A.M., the DON said the skin assessments for residents who are high-risk for skin breakdown, but do not have current breakdown will be done by another RN. The assessments wil

Based on observation, interview, and record review, the facility failed to follow infection control guidelines for dressing changes for three residents (Resident #1, #2, and #4). Resident #1 had orders for contact isolation precautions related to Methicillin Resistant Staphylococcus Aureus (MRSA) (a bacterial infection that have developed a resistance to the Methicillin- a [MEDICATION NAME] broad-spectrum anti-infective) in his/her nasal passages; [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE) (a type of bacteria resistant to many antibiotics, especially [MEDICATION NAME]) in his/her urinary tract; and E. coli (an infectious organism found in the intestine) on the surgical incision of his/her above the knee amputation (AKA). Resident #4's wound was infected with MRSA and the facility failed to initiate any isolation precautions. The facility failed to initiate contact isolation precautions for one resident (Resident #9) who currently had Clostridium difficile (c-diff) (a bacteria that causes diarrhea) infection. The facility failed to prevent the spread of possible infection during personal care for Resident #1 who had VRE in the urine. This deficient practice affected four residents in a sample selection of 12 residents in a facility with a census of 51 with potential to affect others. 1. According to the Centers for Disease Control's (CDC) guidelines for isolation precautions and prevention of infectious agents in health care setting showed: Contact Precautions are intended to prevent transmission of infectious agents, which are spread by direct or indirect contact with the patient or the patient's environment. Contact precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission. A single-patient room is preferred for patients who require Contact Precautions. Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning personal protective equipment upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE, [DIAGNOSES REDACTED]icile, and other intestinal tract pathogens). Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 2/2/11, showed the following information: -Independent cognitive skills for decision making; -Limited assistance of one for turning, transfers, dressing, and toileting; -Impaired range of motion of both legs; -Continent of bowel and bladder; -[DIAGNOSES REDACTED]. Record review of the care plan, last updated 3/25/11, showed: -Wound care as ordered by the physician; -Post and follow appropriate isolation precautions per company policy; -Inform resident, responsible party, visitors, and staff of isolation requirements and monitor for compliance; -Laboratory tests per physician's orders and notify the physician of abnormal results per policy; -Monitor surgical incision for signs of infection; -Maintain the wrapping of the amputation to enhance healing; -Provide pain medication; -Weekly evaluation of wound healing. Record review of the physician's order sheet (POS), dated 3/2011, showed: -[DIAGNOSES REDACTED]. -An order, dated 3/10/11, for contact isolation; -An order, dated 3/10/11, to perform daily dressing changes to the right AKA with four by four inch gauze, roll of gauze and stump sock. Record review of nurses' notes showed: -On 2/25/11, at unknown time, a nurse documented the resident's stump incision dressing had a moderate amount of yellow brown drainage and the resident's temperature was 99.2 degrees Fahrenheit (F). Staff notified the physician. At 1:40 P.M., staff received orders to obtain a wound culture of the right stump incision, follow up with the cardiovascular surgeon and obtain a urine specimen (UA) for testing; -On 2/26/11, at 1:45 A.M., staff contacted the physician who instructed staff to administer [MEDICATION NAME] (antibiotic) 500 mg, daily, for five days; -On 2/28/11, at 4:30 P.M., staff faxed the laboratory culture reports to the physician; -On 2/28/11, at 4:55 P.M., staff notified the physician that the resident's right surgical BKA was dehiscing (surgical incision coming open). The physician instructed staff to send the resident to the ER; -On 2/28/11, at 8:15 P.M., the resident was admitted to the hospital with [REDACTED]. Record review of laboratory results showed: -On 2/28/11, the resident's urine tested positive for VRE. The organism showed resistant to [MEDICATION NAME]; -On 2/29/11, wound drainage from the resident's AKA tested positive for E. coli Record review of hospital discharge orders, dated 3/9/11, showed: -[DIAGNOSES REDACTED]. -Instructions for contact isolation procedures due to VRE in the urine. Observation and interview on 3/22/11, at 9:15 A.M., showed Licensed Practical Nurse (LPN) J removed the resident's pants and old dressing. The nurse changed gloves, but did not wash his/her hands and poured wound cleanser onto a two inch by two inch square of gauze. LPN J wiped the incision of the AKA, several times, using back and forth motions, with the same two inch gauze square. The incision was approximately seven inches long. The nurse continued to wear the same gloves to place two four by four inch gauze squares over the incision, and wrapped the site with a roll of gauze. LPN J put the same stump sock back onto the amputation site. The nurse removed his/her gloves and put them in a trash bag that contained the soiled dressing and placed the trash bag in the trash container on the treatment cart. The nurse placed the wound cleaner back into the treatment cart without wiping off the bottle, possibly introducing bacteria into the treatment cart. LPN J said he/she administered wound care the way he/she normally administered wound care on the resident's amputation. The nurse said he/she did not normally clean the wound cleaner bottle prior to putting it back in the treatment cart. Observation on 3/22/11, at 9:55 A.M., LPN J removed the trash, containing the contaminated dressing and guaze, from the treatment cart and placed it in the regular trash in the dirty utility room. LPN J said the soiled dressing were "not bloody or anything". LPN J did not wash his/her hands or use alcohol gel before or after he/she left the dirty utility room. Observation and interview on 3/24/11, showed Certified Nurse Assistant (CNA) V removed the resident's pants, opened the incontinent brief and cleaned his/her frontal perineal area, inner upper legs, and between the legs, using only one disposable washcloth. The resident urinated on the CNA's gloved hand as he/she provided care. CNA V removed the incontinent brief and obtained a second wipe. CNA V wiped both gloved hands several times with the same wipe. The CNA picked up the soiled incontinent brief and the wipes and on the way to the bathroom; and ran his/her contaminated gloved hand along the footboard of the resident's bed. The CNA reached around the half opened bathroom door and grasped the door handle to open the door, still wearing the same contaminated gloves. CNA V placed his/her left hand on the door jamb as he/she entered the bathroom wearing the contaminated gloves. The CNA placed the soiled brief, wipes and gloves in the trash. CNA V placed his/her hands under running water, for approximately five seconds, turned off the water with his/her right hand and then used his/her right hand to push a bar on the paper towel dispenser. The CNA did not use any soap to wash his/her hands. The CNA contaminated the resident's bed, bathroom door handle, doorjamb, sink, and paper towel dispenser. CNA V donned new gloves and put an incontinent brief on the resident. After LPN A performed a dressing change on the resident's AKA, the nurse placed a stump sock onto the resident's AKA stump. The nurse said he/she did not cleanse the incision because there was no order to cleanse the site, just to change the dressing. LPN A said staff used the same stump sock on the resident's infected amputation site since the resident returned from the hospital on [DATE]. CNA V continued to wear the same gloves to put the pants, sock, and shoe on the resident. After LPN A and CNA V transferred the resident into his/her wheelchair, they removed their gloves and washed their hands. LPN A picked up an unopened four by four inch gauze packet from the resident's over bed table and placed it in a box of four by four inch gauze packets in the treatment cart. The nurse said he/she puts unused treatment supplies back into the treatment cart if they are unopened. During an interview on 3/29/11, at 10:25 A.M., the DON was unaware staff had used the same shrink sock since the resident's readmission. She said staff should put a clean stump sock on the resident after all dressing changes. During interview on 3/24/11, at 2:04 P.M., a family member of Resident #1 said the resident had been there since June 2010. No one told the family anything about laundry. They never told us what was going on, just said the resident had an infection. The family had been doing the resident's laundry at home. The facility posted the second sign yesterday regarding the specific precautions for the infection. The family member said they asked about the infection more than once and they were told the only concern was if you touched body fluids. During an interview on 3/28/11, at 9:30 A.M., LPN J said when he/she performed dressing changes on the resident he/she put the same stump sock back onto the resident. The nurse said he/she had not seen another stump sock for the resident. 2. Record review of Resident #2's quarterly MDS dated [DATE], showed the following information: -Staff performed a brief interview of the resident for mental status; -Staff assessed the resident as rarely/never understood; -Extensive assistance of one for bed mobility, transfers, walking, dressing, toilet use, personal hygiene and bathing; -Limited assistance of one for eating; -Occasionally incontinent of bowel and bladder; -At risk for developing pressure sores; -One stage II pressure sore (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater). Record review of the POS, dated 3/11, showed the following information: -[DIAGNOSES REDACTED]. -An order, dated 2/26/11, for staff to cleanse the resident's right leg with soap and water, apply extra protective cream (EPC) on the right leg and around the right heel pressure sore, apply Santyl (an enzymatic [MEDICATION NAME] ointment used to remove dead skin from wounds) to necrotic (dead) tissue (on the pressure sore) then cover with Xeroform (fine mesh external gauze dressing impregnated with an antiseptic petroleum blend) overlay, for moisture, and four by four inch gauze squares and secure them with gauze wrap and netting daily. Record review of the care plan, last updated 1/28/11, showed: -Pressure relieving boot for right foot; -Place pressure reducing boot on right foot and release as ordered; -Unable to turn/reposition self; -Turn and reposition every two hours and PRN; -Weekly skin assessment with bath/shower; -Pressure relieving devices to bed/chair to promote skin integrity. Observation and interview on 3/23/11, at 1:30 P.M., showed LPN A assembled treatment supplies and lay the supplies on a towel on the resident's over bed table. The nurse removed a pressure reducing boot from the resident's right leg, the dressing from the resident's right heel and positioned the resident's foot onto a towel on the bed. LPN A changed his/her gloves, but did not wash his/her hands. The nurse moistened two washcloths with water and applied soap to one of the washcloths. The nurse cleansed the resident's right leg from the knee down to the foot including around the pressure sore, possibly introducing bacteria into the pressure sore. The nurse then rinsed the resident's right leg, from the knee down to the foot, including around the pressure sore, possibly introducing bacteria into the pressure sore. LPN A changed his/her gloves, but did not wash his/her hands then applied EPC on the resident's right leg from the knee down it the foot including around the pressure sore, again, possibly introducing bacteria into the pressure sore. The nurse removed his/her gloves, but did not wash his/her hands. LPN A put Santyl on the inside of an opened wrapper of a four by four inch gauze square. The nurse gloved, did not wash his/her hands or cleanse the pressure sore. The nurse put Santyl into the pressure sore with his/her gloved finger, applied Xeroform, and covered it with four by four gauze squares. The nurse put the same netting over the dressing that had covered the previous dressing. The nurse removed his/her gloves and washed his/her hands. The nurse picked up an unopened four by four inch gauze packet from the resident's over bed table and placed it in a box of four by four inch gauze packets in the treatment cart. The nurse said he/she puts unused treatment supplies back into the treatment cart if they are unopened. The nurse said he/she administered wound care to the resident the way he/she normally administered wound care. LPN A said I always wash my hands when I go from dirty to clean during a dressing change. The nurse said staff normally put the same netting back on the resident after a dressing change. 3. Record review of Resident #4's admission MDS, dated [DATE], showed the following information: -Entry date into the facility on [DATE]; -Required extensive assistance for bed mobility, transfers, dressing, personal hygiene and toilet use; -Frequently incontinent of bowel and bladder; -One stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) pressure ulcer present on admission; -One stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer, present on admission, measuring 2.3 centimeters (cm) x 1.8 cm, with 0 depth. Record review of the resident's care plan, showed the following information: -Problem onset date of 3/8/11 showed the resident had a stage II pressure ulcer anterior (front) to the right ear, secondary to pressure from oxygen tubing; -Wound care as ordered by the physician; -On 3/10/11, staff documented culture and sensitivity, right anterior ear, stage II; -On 3/12/11, staff documented [MEDICATION NAME] (antibiotic), one tablet, twice a day for seven days, [DIAGNOSES REDACTED]. -On 3/15/11, staff documented [MEDICATION NAME] ointment (a broad-spectrum topical antibiotic), to the anterior area, on the right ear, until healed. Record review of the March 2011 POS, showed the following information: -An order, dated 2/9/11, for staff to cleanse the left upper buttock with safeclenz, then apply [MEDICATION NAME], change every three days and as needed until healed; -An order, dated 2/9/11, for staff to cleanse right foot, second toe with safeclenz wound cleanser), apply [MEDICATION NAME] and change every three days and as needed; -On 3/9/11, staff documented an order for [REDACTED]. -On 3/11/11, staff documented an order for [REDACTED]. [MEDICATION NAME] 250 milligram (mg), twice a day, for seven days; -On 3/13/11, staff documented an order to cleanse the right ear wound with normal saline, pat dry, apply [MEDICATION NAME] then cover with [MEDICATION NAME] or gauze twice a day until healed. Discontinue previous treatments to the ear. Continue [MEDICATION NAME] as previously ordered. Record review of the final wound culture report for the ear, dated 3/12/11, showed the ear wound had moderate Proteus mirabilis (bacteria found in fecal material), moderate MRSA and scant alpha streptococcus (bacteria that in many species cause disease in humans). Observation on 3/21/11, at 3:24 P.M., showed the resident lay in bed. The resident's room did not have a red barrel or red trash bags in the room or an isolation sign on the door. Observation on 3/23/11, at 1:44 P.M., LPN F entered the resident's room and washed his/her hands. The nurse laid the treatment supplies on a non-slip mat on the bedside table. The nurse did not cleanse the table or place a towel to provide a clean surface for the treatment supplies. The nurse applied gloves and removed a band aid from an anterior pressure ulcer on the resident's right ear. The band aid had bloody drainage on it. The nurse threw the band aid into the regular trash bag in the trashcan. The nurse removed his/her gloves and applied new gloves. The nurse did not wash his/her hands. The pressure ulcer on the anterior portion of the ear was a small scabbed area with purple color to it. Blood continued to ooze from the pressure ulcer. The nurse cleansed the right ear with normal saline and gauze and applied [MEDICATION NAME] to the pressure ulcer. The nurse removed his/her gloves and applied new gloves; hd/she did not wash his/her hands. The nurse obtained scissors from his/her pocket, cut the [MEDICATION NAME] pad to a smaller size then laid the scissors on the bedside table. The nurse dated the dressing and secured it with paper tape. LPN F removed his/her gloves and raised the level of the bed, using the bed controls. The nurse applied new gloves and removed the [MEDICATION NAME] from the resident's right foot, second toe pressure ulcer. The nurse washed his/her hands and applied new gloves. The nurse cleansed the pressure ulcer with normal saline and gauze and threw the gloves into the regular trashbag in the trashcan. The resident said his/her toe became injured during a helicopter ride to the hospital and that started the pressure ulcer. At 1:57 P.M., LPN F said he/she was waiting for the [MEDICATION NAME] to be brought from the sister facility next door. The person who normally orders supplies had a family emergency and had not been there to order supplies. At 2:00 P.M., LPN F said he/she received a new report regarding the [MEDICATION NAME]. The sister facility did not have any [MEDICATION NAME] in their building either. Another staff person left to go purchase [MEDICATION NAME]. At 2:00 P.M., LPN F carried the bottle of normal saline and the scissors to the bathroom. The nurse washed his/her hands in the bathroom. The room did not have red biohazard buckets in the room. Observation on 3/23/11, at 2:48 P.M., showed LPN C sanitized his/her hands, opened the treatment cart, obtained a medication cup, sat it on the treatment cart and put gloves in his/her pocket. The nurse put gauze in the medication cup and sprayed the gauze with Carraklenz (wound cleanser). The nurse took the gloves out of his/her pocket and laid the unopened [MEDICATION NAME] packet on the television stand in the resident's room. The nurse did not cleanse the television stand or place a towel for a clean surface for the supplies. The nurse did not wash his/her hands prior to starting the treatment. The nurse cleansed the toe pressure ulcer with the gauze, patted dry the pressure ulcer with a dry gauze. He/she opened the [MEDICATION NAME] package, took scissors out of his/her pocket, cut the [MEDICATION NAME] to size, laid the scissors on the television stand and placed the [MEDICATION NAME] on the resident's right foot, second toe pressure ulcer. The nurse dated the [MEDICATION NAME], with a pen he/she took out of his/her pocket, put the pen back into his/her pocket, removed his/her gloves and placed them in the same trashcan. At 3:00 P.M., the nurse washed his/her hands. The room did not have red biohazard buckets. During an interview on 3/24/11, at 2:50 P.M., the DON said the area on the front of the resident's right ear was not a pressure area. The DON thought it was caused by the resident scratching it. The culture showed the ulcer had bacteria in it and they started [MEDICATION NAME] ointment. During an interview on 3/29/11, at 10:28 A.M., the DON said staff should check the treatment order and wash their hands before gathering supplies. They should bring the equipment to the room and clean the bedside table or place a towel on the table to provide a clean surface. They should provide hand hygiene and remove the dressing. Staff should change their gloves and wash their hands or sanitize with alcohol-based sanitizer. Staff should clean the wound and apply the dressing. Before the staff leaves the room, they should wash their hands or use alcohol-based hand sanitizer. Staff should remove the soiled dressing from the room in a closed trash bag. If a resident is in isolation, staff should put the soiled dressing in a biohazard bucket and it should not leave the room. Staff should not go from dirty to clean. They should not cross-contaminate. Staff should wash their hands before they provide the dressing change whether they are in isolation or not. When the nurse receives a culture report, they are the one responsible to get the set-up to place the resident in isolation. Record review of the facility's Methicillin-resistant staph aureus infections policy (undated) showed the following information: -Staphylococcus aureus is a gram-positive coccus. It thrives on human skin and mucous membranes, grows rapidly, and can be carried by its host for long periods of time without causing clinical consequences. However, if given the opportunity, it can be responsible for a variety of serious diseases, such as pneumonia, cellulitis, and suppurative wound infections, abscesses, and sepsis; -The bacteria is transmitted by direct (usually skin to skin) contact; -Guide to prevent the transfer of MRSA includes cohort residents in a designated area of the facility; -Keep cohorted residents in the designated area until two cultures, one week apart are MRSA negative; -Handwashing must be stressed for visitors before leaving the room. Instructions on proper hand washing can be posted on the door of the patient's room; -Equipment should be left in the room; -Cover draining areas with dressings; -Use gloves with contact with any secretions/excretions whether or not MRSA colonized; -Use of gloves and masks for all MRSA wound manipulations (cleaning, dressing changes, whirlpool baths); close contact (bathing and bed making) with patients; -Gloves and masks are unnecessary if just entering the room for brief visits or to give medications. However, hand washing must follow any contact with the environment; -Strict hand washing with [MEDICATION NAME] soap for a minimum of 10 seconds friction, turn faucet off with a paper towel after the removal of all gloves, after contact with an MRSA colonized or infected patient, bedclothes, lines, or environment; between touching different anatomical sites on the same patient-one site infected, the other not; -An alcohol rinse, gel, or foam can be used on the hands as an adjunct to handwashing, but not as a replacement for hand washing; -Dressings and other contaminated disposable items should be placed in trash bags and tied inside the patient's room. Dressing should not be placed in uncovered trash containers. 4. During interview on 3/25/11, at 1:10 P.M., the DON said she is in charge of infection control in the facility. They look at all orders related to antibiotics. The DON receives the pink slips from the orders to review. The facility receives a report from the lab regarding cultures from the previous month. The facility determines what bacteria or viruses occurred on each hall. The facility determines if cross-contamination occurred within a hall. The facility discusses it in the monthly quality assurance meetings. The facility has four residents currently with [DIAGNOSES REDACTED]. The facility is looking at those residents to make certain they have isolation precautions. The facility pays close attention to perineal care and looks for a breakdown in the system. They note if a resident came from the hospital with an infection. The facility frequently does in-service training on hand-washing. The facility will start making sure bacteria do not appear in wounds where it should not be. During an interview on 3/25/11, at 1:20 P.M., the administrator said the facility had not noticed any trends in infections. The facility has residents with infections, but had not identified a system problem for a cause of the infections. During an interview on 3/29/11, at 10:25 A.M., the DON said she expected staff to perform hand hygiene prior to assembling treatment supplies. She expected staff to check the physician's orders prior to administering treatments. She expected staff to clean the bedside table, lay a towel on the table, and place the treatment supplies on the towel. She said staff should wash their hands, remove the old dressing, and then wash their hands or use alcohol gel. The DON expected staff to administer treatments per the physician's orders. She expected staff to leave sealed supplies in the resident's room. She said if a resident is in isolation she expected staff to dispose of soiled supplies and dressings in the isolation trash can in the residents' room. The DON said she expected staff to cleanse inside a wound, then cleanse around the wound. She expected staff to use as much gauze as needed to not contaminate the wound. 5. Record review of Resident #9's quarterly MDS, dated [DATE], showed the following information: -Short and long term memory problem; -Severely impaired decision making skills; -Required extensive assistance for bed mobility, transfers, dressing, personal hygiene, and toilet use; -Always incontinent of bowel; -Indwelling urinary catheter. Record review of the resident's care plan showed the following information: -Bowel incontinence, provide care to maintain hygiene and comfort, to include clothing management; -Urinary catheter, provide care every shift and as needed; -The resident's care plan did not address his/her C.diff diagnosis, interventions or precautions for staff related to the diagnosis. Record review of the nurses' notes showed the following information: -On 3/18/11, at 5:00 P.M., the nurse documented the resident had diarrhea that evening and the resident reported he/she did not feel good; -On 3/19/11, at 5:00 P.M., the nurse documented the resident had been incontinent of large, loose, watery, mucousy and slimy stool. The nurse notified hospice. The physician ordered a stool to check for [DIAGNOSES REDACTED] and started the resident on [MEDICATION NAME] 500 mg, every eight hours for ten days; -On 3/19/11 at 9:30 P.M., the nurse documented collection of the stool specimen; -On 3/22/11, at 5:30 P.M., the nurse documented receipt of the laboratory report showing the resident was positive for [DIAGNOSES REDACTED]. The nurse notified the physician and the hospice nurse. The physician ordered to increase the [MEDICATION NAME] to 500 mg every eight hours for 14 days for the treatment of [REDACTED]. Staff did not document placement of the resident in contact isolation. Record review of the March 2011 POS, showed the following information: -On 3/19/11, the physician ordered stool for [DIAGNOSES REDACTED], ASAP; [MEDICATION NAME] 500 mg, every eight hours for 10 days; discontinue the [MEDICATION NAME] if stool test results come back negative; -On 3/22/11, the physician ordered to increase the [MEDICATION NAME] 500 mg, every eight hours, to continue for total of 14 days for [DIAGNOSES REDACTED]. Record review of the laboratory report, collected on 3/19/11, received on 3/21/11, and reported on 3/22/11, showed the resident positive for [DIAGNOSES REDACTED]. Observation on 3/23/11, at 1:19 P.M., showed the resident sat in a wheelchair in the dining room. CNA R wheeled the resident to his/her and shut the door. At 1:25 P.M., 2:44 P.M., and 3:14 P.M., the resident sat in the recliner in the room. The room did not have red isolation barrels or a contact isolation sign on the door. At 5:35 P.M., the resident ate in the dining room. Observation on 3/24/11, at 8:16 A.M., showed the resident sat in the wheelchair in the dining room. At 8:19 A.M., CNA G and CNA R wheeled the resident to his/her room. Both aides applied gloves. The aides removed the wheelchair pedals and applied a gait belt around the resident's waist. CNA R attached the resident's catheter bag to his/her side pant pocket. The two aides transferred the resident to the recliner. The aides put the call light in reach and put on the resident's oxygen. Both aides removed their gloves, threw them in the trash, and washed their hands. The resident's room did not have any red isolation barrels or contact isolation sign on the door. During an interview on 3/24/11, at 3:20 P.M., the DON said when a resident receives a [DIAGNOSES REDACTED] diagnosis, if the resident is symptomatic and the stool is not contained in a the brief, the facility puts the resident in isolation in a private room. As long as the resident is not symptomatic and the stool is contained in a brief, the resident can come out of the room for meals and activities. The room should have biohazard (red barrels) buckets for linens. A sign should be posted at the door to see the nurse and with the special precautions for the infection. The resident is asymptomatic. The family is doing the resident's laundry again. Directly after the [DIAGNOSES REDACTED] diagnosis, the facility did the resident's laundry. The resident should have red barrels in the room and a sign on the door. During an interview on 3/25/11, at 1:10 P.M., the DON said Resident #9 has a full set-up for contact isolation now. The facility took immediate action. During an interview on 3/29/11, at 11:00 A.M., the DON said if a resident had a positive [DIAGNOSES REDACTED] laboratory test or signs and symptoms, such as mucous or odor, the charge nurse who received the positive culture should post the precaution notice and start the isolation. The charge nurse should place the personal protective equipment outside the door to the room and follow the contact isolation policy. Biohazard (red buckets) should be placed in the room for soiled items and trash. Record review of the facility policy titled "Guidelines for the prevention and control of Clostridium difficile" showed the following information: -Transmission of [DIAGNOSES REDACTED]icile occurs when the organism or its spores are ingested orally. This may occur because of direct contact, person to person spread on hands or from the environment; -Private room is recommended, especially for residents who are fecally incontinent or who cannot practice good handwashing; -Contact precautions should be used for [DIAGNOSES REDACTED]icile-associated diarrhea (CDAD) with diarrhea; -Hands should be washed frequently with soap and water; -Gloves should be worn when entering the room; -Gowns should be worn if physical contact with the resident or the resident's environment is anticipated; -Common use equipment such as stethoscopes should be dedicated to the infected patient and not shared between residents; -Precautions should continue until diarrhea ceases, less than three stools per day; -Should have some system in place for alerting healthcare workers and visitors that a resident is on contact precautions, such as labeling the chart or door of the room, without compromising that resident's privacy; -The environment of a resident with CDAD should be cleaned thoroughly at least twice per day, with special attention to those items likely to be contaminated with feces, such as bedrails and bedside commodes.

Based on observation, interview, and record review, the facility failed to follow infection control guidelines for dressing changes for three residents (Resident #1, #2, and #4). Resident #1 had orders for contact isolation precautions related to Methicillin Resistant Staphylococcus Aureus (MRSA) (a bacterial infection that have developed a resistance to the Methicillin- a [MEDICATION NAME] broad-spectrum anti-infective) in his/her nasal passages; [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE) (a type of bacteria resistant to many antibiotics, especially [MEDICATION NAME]) in his/her urinary tract; and E. coli (an infectious organism found in the intestine) on the surgical incision of his/her above the knee amputation (AKA). Resident #4's wound was infected with MRSA and the facility failed to initiate any isolation precautions. The facility failed to initiate contact isolation precautions for one resident (Resident #9) who currently had Clostridium difficile (c-diff) (a bacteria that causes diarrhea) infection. The facility failed to prevent the spread of possible infection during personal care for Resident #1 who had VRE in the urine. This deficient practice affected four residents in a sample selection of 12 residents in a facility with a census of 51 with potential to affect others. 1. According to the Centers for Disease Control's (CDC) guidelines for isolation precautions and prevention of infectious agents in health care setting showed: Contact Precautions are intended to prevent transmission of infectious agents, which are spread by direct or indirect contact with the patient or the patient's environment. Contact precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission. A single-patient room is preferred for patients who require Contact Precautions. Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning personal protective equipment upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE, [DIAGNOSES REDACTED]icile, and other intestinal tract pathogens). Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 2/2/11, showed the following information: -Independent cognitive skills for decision making; -Limited assistance of one for turning, transfers, dressing, and toileting; -Impaired range of motion of both legs; -Continent of bowel and bladder; -[DIAGNOSES REDACTED]. Record review of the care plan, last updated 3/25/11, showed: -Wound care as ordered by the physician; -Post and follow appropriate isolation precautions per company policy; -Inform resident, responsible party, visitors, and staff of isolation requirements and monitor for compliance; -Laboratory tests per physician's orders and notify the physician of abnormal results per policy; -Monitor surgical incision for signs of infection; -Maintain the wrapping of the amputation to enhance healing; -Provide pain medication; -Weekly evaluation of wound healing. Record review of the physician's order sheet (POS), dated 3/2011, showed: -[DIAGNOSES REDACTED]. -An order, dated 3/10/11, for contact isolation; -An order, dated 3/10/11, to perform daily dressing changes to the right AKA with four by four inch gauze, roll of gauze and stump sock. Record review of nurses' notes showed: -On 2/25/11, at unknown time, a nurse documented the resident's stump incision dressing had a moderate amount of yellow brown drainage and the resident's temperature was 99.2 degrees Fahrenheit (F). Staff notified the physician. At 1:40 P.M., staff received orders to obtain a wound culture of the right stump incision, follow up with the cardiovascular surgeon and obtain a urine specimen (UA) for testing; -On 2/26/11, at 1:45 A.M., staff contacted the physician who instructed staff to administer [MEDICATION NAME] (antibiotic) 500 mg, daily, for five days; -On 2/28/11, at 4:30 P.M., staff faxed the laboratory culture reports to the physician; -On 2/28/11, at 4:55 P.M., staff notified the physician that the resident's right surgical BKA was dehiscing (surgical incision coming open). The physician instructed staff to send the resident to the ER; -On 2/28/11, at 8:15 P.M., the resident was admitted to the hospital with [REDACTED]. Record review of laboratory results showed: -On 2/28/11, the resident's urine tested positive for VRE. The organism showed resistant to [MEDICATION NAME]; -On 2/29/11, wound drainage from the resident's AKA tested positive for E. coli Record review of hospital discharge orders, dated 3/9/11, showed: -[DIAGNOSES REDACTED]. -Instructions for contact isolation procedures due to VRE in the urine. Observation and interview on 3/22/11, at 9:15 A.M., showed Licensed Practical Nurse (LPN) J removed the resident's pants and old dressing. The nurse changed gloves, but did not wash his/her hands and poured wound cleanser onto a two inch by two inch square of gauze. LPN J wiped the incision of the AKA, several times, using back and forth motions, with the same two inch gauze square. The incision was approximately seven inches long. The nurse continued to wear the same gloves to place two four by four inch gauze squares over the incision, and wrapped the site with a roll of gauze. LPN J put the same stump sock back onto the amputation site. The nurse removed his/her gloves and put them in a trash bag that contained the soiled dressing and placed the trash bag in the trash container on the treatment cart. The nurse placed the wound cleaner back into the treatment cart without wiping off the bottle, possibly introducing bacteria into the treatment cart. LPN J said he/she administered wound care the way he/she normally administered wound care on the resident's amputation. The nurse said he/she did not normally clean the wound cleaner bottle prior to putting it back in the treatment cart. Observation on 3/22/11, at 9:55 A.M., LPN J removed the trash, containing the contaminated dressing and guaze, from the treatment cart and placed it in the regular trash in the dirty utility room. LPN J said the soiled dressing were "not bloody or anything". LPN J did not wash his/her hands or use alcohol gel before or after he/she left the dirty utility room. Observation and interview on 3/24/11, showed Certified Nurse Assistant (CNA) V removed the resident's pants, opened the incontinent brief and cleaned his/her frontal perineal area, inner upper legs, and between the legs, using only one disposable washcloth. The resident urinated on the CNA's gloved hand as he/she provided care. CNA V removed the incontinent brief and obtained a second wipe. CNA V wiped both gloved hands several times with the same wipe. The CNA picked up the soiled incontinent brief and the wipes and on the way to the bathroom; and ran his/her contaminated gloved hand along the footboard of the resident's bed. The CNA reached around the half opened bathroom door and grasped the door handle to open the door, still wearing the same contaminated gloves. CNA V placed his/her left hand on the door jamb as he/she entered the bathroom wearing the contaminated gloves. The CNA placed the soiled brief, wipes and gloves in the trash. CNA V placed his/her hands under running water, for approximately five seconds, turned off the water with his/her right hand and then used his/her right hand to push a bar on the paper towel dispenser. The CNA did not use any soap to wash his/her hands. The CNA contaminated the resident's bed, bathroom door handle, doorjamb, sink, and paper towel dispenser. CNA V donned new gloves and put an incontinent brief on the resident. After LPN A performed a dressing change on the resident's AKA, the nurse placed a stump sock onto the resident's AKA stump. The nurse said he/she did not cleanse the incision because there was no order to cleanse the site, just to change the dressing. LPN A said staff used the same stump sock on the resident's infected amputation site since the resident returned from the hospital on [DATE]. CNA V continued to wear the same gloves to put the pants, sock, and shoe on the resident. After LPN A and CNA V transferred the resident into his/her wheelchair, they removed their gloves and washed their hands. LPN A picked up an unopened four by four inch gauze packet from the resident's over bed table and placed it in a box of four by four inch gauze packets in the treatment cart. The nurse said he/she puts unused treatment supplies back into the treatment cart if they are unopened. During an interview on 3/29/11, at 10:25 A.M., the DON was unaware staff had used the same shrink sock since the resident's readmission. She said staff should put a clean stump sock on the resident after all dressing changes. During interview on 3/24/11, at 2:04 P.M., a family member of Resident #1 said the resident had been there since June 2010. No one told the family anything about laundry. They never told us what was going on, just said the resident had an infection. The family had been doing the resident's laundry at home. The facility posted the second sign yesterday regarding the specific precautions for the infection. The family member said they asked about the infection more than once and they were told the only concern was if you touched body fluids. During an interview on 3/28/11, at 9:30 A.M., LPN J said when he/she performed dressing changes on the resident he/she put the same stump sock back onto the resident. The nurse said he/she had not seen another stump sock for the resident. 2. Record review of Resident #2's quarterly MDS dated [DATE], showed the following information: -Staff performed a brief interview of the resident for mental status; -Staff assessed the resident as rarely/never understood; -Extensive assistance of one for bed mobility, transfers, walking, dressing, toilet use, personal hygiene and bathing; -Limited assistance of one for eating; -Occasionally incontinent of bowel and bladder; -At risk for developing pressure sores; -One stage II pressure sore (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater). Record review of the POS, dated 3/11, showed the following information: -[DIAGNOSES REDACTED]. -An order, dated 2/26/11, for staff to cleanse the resident's right leg with soap and water, apply extra protective cream (EPC) on the right leg and around the right heel pressure sore, apply Santyl (an enzymatic [MEDICATION NAME] ointment used to remove dead skin from wounds) to necrotic (dead) tissue (on the pressure sore) then cover with Xeroform (fine mesh external gauze dressing impregnated with an antiseptic petroleum blend) overlay, for moisture, and four by four inch gauze squares and secure them with gauze wrap and netting daily. Record review of the care plan, last updated 1/28/11, showed: -Pressure relieving boot for right foot; -Place pressure reducing boot on right foot and release as ordered; -Unable to turn/reposition self; -Turn and reposition every two hours and PRN; -Weekly skin assessment with bath/shower; -Pressure relieving devices to bed/chair to promote skin integrity. Observation and interview on 3/23/11, at 1:30 P.M., showed LPN A assembled treatment supplies and lay the supplies on a towel on the resident's over bed table. The nurse removed a pressure reducing boot from the resident's right leg, the dressing from the resident's right heel and positioned the resident's foot onto a towel on the bed. LPN A changed his/her gloves, but did not wash his/her hands. The nurse moistened two washcloths with water and applied soap to one of the washcloths. The nurse cleansed the resident's right leg from the knee down to the foot including around the pressure sore, possibly introducing bacteria into the pressure sore. The nurse then rinsed the resident's right leg, from the knee down to the foot, including around the pressure sore, possibly introducing bacteria into the pressure sore. LPN A changed his/her gloves, but did not wash his/her hands then applied EPC on the resident's right leg from the knee down it the foot including around the pressure sore, again, possibly introducing bacteria into the pressure sore. The nurse removed his/her gloves, but did not wash his/her hands. LPN A put Santyl on the inside of an opened wrapper of a four by four inch gauze square. The nurse gloved, did not wash his/her hands or cleanse the pressure sore. The nurse put Santyl into the pressure sore with his/her gloved finger, applied Xeroform, and covered it with four by four gauze squares. The nurse put the same netting over the dressing that had covered the previous dressing. The nurse removed his/her gloves and washed his/her hands. The nurse picked up an unopened four by four inch gauze packet from the resident's over bed table and placed it in a box of four by four inch gauze packets in the treatment cart. The nurse said he/she puts unused treatment supplies back into the treatment cart if they are unopened. The nurse said he/she administered wound care to the resident the way he/she normally administered wound care. LPN A said I always wash my hands when I go from dirty to clean during a dressing change. The nurse said staff normally put the same netting back on the resident after a dressing change. 3. Record review of Resident #4's admission MDS, dated [DATE], showed the following information: -Entry date into the facility on [DATE]; -Required extensive assistance for bed mobility, transfers, dressing, personal hygiene and toilet use; -Frequently incontinent of bowel and bladder; -One stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) pressure ulcer present on admission; -One stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer, present on admission, measuring 2.3 centimeters (cm) x 1.8 cm, with 0 depth. Record review of the resident's care plan, showed the following information: -Problem onset date of 3/8/11 showed the resident had a stage II pressure ulcer anterior (front) to the right ear, secondary to pressure from oxygen tubing; -Wound care as ordered by the physician; -On 3/10/11, staff documented culture and sensitivity, right anterior ear, stage II; -On 3/12/11, staff documented [MEDICATION NAME] (antibiotic), one tablet, twice a day for seven days, [DIAGNOSES REDACTED]. -On 3/15/11, staff documented [MEDICATION NAME] ointment (a broad-spectrum topical antibiotic), to the anterior area, on the right ear, until healed. Record review of the March 2011 POS, showed the following information: -An order, dated 2/9/11, for staff to cleanse the left upper buttock with safeclenz, then apply duoderm, change every three days and as needed until healed; -An order, dated 2/9/11, for staff to cleanse right foot, second toe with safeclenz wound cleanser), apply duoderm and change every three days and as needed; -On 3/9/11, staff documented an order for [REDACTED]. -On 3/11/11, staff documented an order for [REDACTED]. [MEDICATION NAME] 250 milligram (mg), twice a day, for seven days; -On 3/13/11, staff documented an order to cleanse the right ear wound with normal saline, pat dry, apply [MEDICATION NAME] then cover with [MEDICATION NAME] or gauze twice a day until healed. Discontinue previous treatments to the ear. Continue [MEDICATION NAME] as previously ordered. Record review of the final wound culture report for the ear, dated 3/12/11, showed the ear wound had moderate Proteus mirabilis (bacteria found in fecal material), moderate MRSA and scant alpha streptococcus (bacteria that in many species cause disease in humans). Observation on 3/21/11, at 3:24 P.M., showed the resident lay in bed. The resident's room did not have a red barrel or red trash bags in the room or an isolation sign on the door. Observation on 3/23/11, at 1:44 P.M., LPN F entered the resident's room and washed his/her hands. The nurse laid the treatment supplies on a non-slip mat on the bedside table. The nurse did not cleanse the table or place a towel to provide a clean surface for the treatment supplies. The nurse applied gloves and removed a band aid from an anterior pressure ulcer on the resident's right ear. The band aid had bloody drainage on it. The nurse threw the band aid into the regular trash bag in the trashcan. The nurse removed his/her gloves and applied new gloves. The nurse did not wash his/her hands. The pressure ulcer on the anterior portion of the ear was a small scabbed area with purple color to it. Blood continued to ooze from the pressure ulcer. The nurse cleansed the right ear with normal saline and gauze and applied [MEDICATION NAME] to the pressure ulcer. The nurse removed his/her gloves and applied new gloves; hd/she did not wash his/her hands. The nurse obtained scissors from his/her pocket, cut the [MEDICATION NAME] pad to a smaller size then laid the scissors on the bedside table. The nurse dated the dressing and secured it with paper tape. LPN F removed his/her gloves and raised the level of the bed, using the bed controls. The nurse applied new gloves and removed the duoderm from the resident's right foot, second toe pressure ulcer. The nurse washed his/her hands and applied new gloves. The nurse cleansed the pressure ulcer with normal saline and gauze and threw the gloves into the regular trashbag in the trashcan. The resident said his/her toe became injured during a helicopter ride to the hospital and that started the pressure ulcer. At 1:57 P.M., LPN F said he/she was waiting for the duoderm to be brought from the sister facility next door. The person who normally orders supplies had a family emergency and had not been there to order supplies. At 2:00 P.M., LPN F said he/she received a new report regarding the duoderm. The sister facility did not have any duoderm in their building either. Another staff person left to go purchase duoderm. At 2:00 P.M., LPN F carried the bottle of normal saline and the scissors to the bathroom. The nurse washed his/her hands in the bathroom. The room did not have red biohazard buckets in the room. Observation on 3/23/11, at 2:48 P.M., showed LPN C sanitized his/her hands, opened the treatment cart, obtained a medication cup, sat it on the treatment cart and put gloves in his/her pocket. The nurse put gauze in the medication cup and sprayed the gauze with Carraklenz (wound cleanser). The nurse took the gloves out of his/her pocket and laid the unopened duoderm packet on the television stand in the resident's room. The nurse did not cleanse the television stand or place a towel for a clean surface for the supplies. The nurse did not wash his/her hands prior to starting the treatment. The nurse cleansed the toe pressure ulcer with the gauze, patted dry the pressure ulcer with a dry gauze. He/she opened the duoderm package, took scissors out of his/her pocket, cut the duoderm to size, laid the scissors on the television stand and placed the duoderm on the resident's right foot, second toe pressure ulcer. The nurse dated the duoderm, with a pen he/she took out of his/her pocket, put the pen back into his/her pocket, removed his/her gloves and placed them in the same trashcan. At 3:00 P.M., the nurse washed his/her hands. The room did not have red biohazard buckets. During an interview on 3/24/11, at 2:50 P.M., the DON said the area on the front of the resident's right ear was not a pressure area. The DON thought it was caused by the resident scratching it. The culture showed the ulcer had bacteria in it and they started [MEDICATION NAME] ointment. During an interview on 3/29/11, at 10:28 A.M., the DON said staff should check the treatment order and wash their hands before gathering supplies. They should bring the equipment to the room and clean the bedside table or place a towel on the table to provide a clean surface. They should provide hand hygiene and remove the dressing. Staff should change their gloves and wash their hands or sanitize with alcohol-based sanitizer. Staff should clean the wound and apply the dressing. Before the staff leaves the room, they should wash their hands or use alcohol-based hand sanitizer. Staff should remove the soiled dressing from the room in a closed trash bag. If a resident is in isolation, staff should put the soiled dressing in a biohazard bucket and it should not leave the room. Staff should not go from dirty to clean. They should not cross-contaminate. Staff should wash their hands before they provide the dressing change whether they are in isolation or not. When the nurse receives a culture report, they are the one responsible to get the set-up to place the resident in isolation. Record review of the facility's Methicillin-resistant staph aureus infections policy (undated) showed the following information: -Staphylococcus aureus is a gram-positive coccus. It thrives on human skin and mucous membranes, grows rapidly, and can be carried by its host for long periods of time without causing clinical consequences. However, if given the opportunity, it can be responsible for a variety of serious diseases, such as pneumonia, cellulitis, and suppurative wound infections, abscesses, and sepsis; -The bacteria is transmitted by direct (usually skin to skin) contact; -Guide to prevent the transfer of MRSA includes cohort residents in a designated area of the facility; -Keep cohorted residents in the designated area until two cultures, one week apart are MRSA negative; -Handwashing must be stressed for visitors before leaving the room. Instructions on proper hand washing can be posted on the door of the patient's room; -Equipment should be left in the room; -Cover draining areas with dressings; -Use gloves with contact with any secretions/excretions whether or not MRSA colonized; -Use of gloves and masks for all MRSA wound manipulations (cleaning, dressing changes, whirlpool baths); close contact (bathing and bed making) with patients; -Gloves and masks are unnecessary if just entering the room for brief visits or to give medications. However, hand washing must follow any contact with the environment; -Strict hand washing with [MEDICATION NAME] soap for a minimum of 10 seconds friction, turn faucet off with a paper towel after the removal of all gloves, after contact with an MRSA colonized or infected patient, bedclothes, lines, or environment; between touching different anatomical sites on the same patient-one site infected, the other not; -An alcohol rinse, gel, or foam can be used on the hands as an adjunct to handwashing, but not as a replacement for hand washing; -Dressings and other contaminated disposable items should be placed in trash bags and tied inside the patient's room. Dressing should not be placed in uncovered trash containers. 4. During interview on 3/25/11, at 1:10 P.M., the DON said she is in charge of infection control in the facility. They look at all orders related to antibiotics. The DON receives the pink slips from the orders to review. The facility receives a report from the lab regarding cultures from the previous month. The facility determines what bacteria or viruses occurred on each hall. The facility determines if cross-contamination occurred within a hall. The facility discusses it in the monthly quality assurance meetings. The facility has four residents currently with [DIAGNOSES REDACTED]. The facility is looking at those residents to make certain they have isolation precautions. The facility pays close attention to perineal care and looks for a breakdown in the system. They note if a resident came from the hospital with an infection. The facility frequently does in-service training on hand-washing. The facility will start making sure bacteria do not appear in wounds where it should not be. During an interview on 3/25/11, at 1:20 P.M., the administrator said the facility had not noticed any trends in infections. The facility has residents with infections, but had not identified a system problem for a cause of the infections. During an interview on 3/29/11, at 10:25 A.M., the DON said she expected staff to perform hand hygiene prior to assembling treatment supplies. She expected staff to check the physician's orders prior to administering treatments. She expected staff to clean the bedside table, lay a towel on the table, and place the treatment supplies on the towel. She said staff should wash their hands, remove the old dressing, and then wash their hands or use alcohol gel. The DON expected staff to administer treatments per the physician's orders. She expected staff to leave sealed supplies in the resident's room. She said if a resident is in isolation she expected staff to dispose of soiled supplies and dressings in the isolation trash can in the residents' room. The DON said she expected staff to cleanse inside a wound, then cleanse around the wound. She expected staff to use as much gauze as needed to not contaminate the wound. 5. Record review of Resident #9's quarterly MDS, dated [DATE], showed the following information: -Short and long term memory problem; -Severely impaired decision making skills; -Required extensive assistance for bed mobility, transfers, dressing, personal hygiene, and toilet use; -Always incontinent of bowel; -Indwelling urinary catheter. Record review of the resident's care plan showed the following information: -Bowel incontinence, provide care to maintain hygiene and comfort, to include clothing management; -Urinary catheter, provide care every shift and as needed; -The resident's care plan did not address his/her C.diff diagnosis, interventions or precautions for staff related to the diagnosis. Record review of the nurses' notes showed the following information: -On 3/18/11, at 5:00 P.M., the nurse documented the resident had diarrhea that evening and the resident reported he/she did not feel good; -On 3/19/11, at 5:00 P.M., the nurse documented the resident had been incontinent of large, loose, watery, mucousy and slimy stool. The nurse notified hospice. The physician ordered a stool to check for [DIAGNOSES REDACTED] and started the resident on [MEDICATION NAME] 500 mg, every eight hours for ten days; -On 3/19/11 at 9:30 P.M., the nurse documented collection of the stool specimen; -On 3/22/11, at 5:30 P.M., the nurse documented receipt of the laboratory report showing the resident was positive for [DIAGNOSES REDACTED]. The nurse notified the physician and the hospice nurse. The physician ordered to increase the [MEDICATION NAME] to 500 mg every eight hours for 14 days for the treatment of [REDACTED]. Staff did not document placement of the resident in contact isolation. Record review of the March 2011 POS, showed the following information: -On 3/19/11, the physician ordered stool for [DIAGNOSES REDACTED], ASAP; [MEDICATION NAME] 500 mg, every eight hours for 10 days; discontinue the [MEDICATION NAME] if stool test results come back negative; -On 3/22/11, the physician ordered to increase the [MEDICATION NAME] 500 mg, every eight hours, to continue for total of 14 days for [DIAGNOSES REDACTED]. Record review of the laboratory report, collected on 3/19/11, received on 3/21/11, and reported on 3/22/11, showed the resident positive for [DIAGNOSES REDACTED]. Observation on 3/23/11, at 1:19 P.M., showed the resident sat in a wheelchair in the dining room. CNA R wheeled the resident to his/her and shut the door. At 1:25 P.M., 2:44 P.M., and 3:14 P.M., the resident sat in the recliner in the room. The room did not have red isolation barrels or a contact isolation sign on the door. At 5:35 P.M., the resident ate in the dining room. Observation on 3/24/11, at 8:16 A.M., showed the resident sat in the wheelchair in the dining room. At 8:19 A.M., CNA G and CNA R wheeled the resident to his/her room. Both aides applied gloves. The aides removed the wheelchair pedals and applied a gait belt around the resident's waist. CNA R attached the resident's catheter bag to his/her side pant pocket. The two aides transferred the resident to the recliner. The aides put the call light in reach and put on the resident's oxygen. Both aides removed their gloves, threw them in the trash, and washed their hands. The resident's room did not have any red isolation barrels or contact isolation sign on the door. During an interview on 3/24/11, at 3:20 P.M., the DON said when a resident receives a [DIAGNOSES REDACTED] diagnosis, if the resident is symptomatic and the stool is not contained in a the brief, the facility puts the resident in isolation in a private room. As long as the resident is not symptomatic and the stool is contained in a brief, the resident can come out of the room for meals and activities. The room should have biohazard (red barrels) buckets for linens. A sign should be posted at the door to see the nurse and with the special precautions for the infection. The resident is asymptomatic. The family is doing the resident's laundry again. Directly after the [DIAGNOSES REDACTED] diagnosis, the facility did the resident's laundry. The resident should have red barrels in the room and a sign on the door. During an interview on 3/25/11, at 1:10 P.M., the DON said Resident #9 has a full set-up for contact isolation now. The facility took immediate action. During an interview on 3/29/11, at 11:00 A.M., the DON said if a resident had a positive [DIAGNOSES REDACTED] laboratory test or signs and symptoms, such as mucous or odor, the charge nurse who received the positive culture should post the precaution notice and start the isolation. The charge nurse should place the personal protective equipment outside the door to the room and follow the contact isolation policy. Biohazard (red buckets) should be placed in the room for soiled items and trash. Record review of the facility policy titled "Guidelines for the prevention and control of Clostridium difficile" showed the following information: -Transmission of [DIAGNOSES REDACTED]icile occurs when the organism or its spores are ingested orally. This may occur because of direct contact, person to person spread on hands or from the environment; -Private room is recommended, especially for residents who are fecally incontinent or who cannot practice good handwashing; -Contact precautions should be used for [DIAGNOSES REDACTED]icile-associated diarrhea (CDAD) with diarrhea; -Hands should be washed frequently with soap and water; -Gloves should be worn when entering the room; -Gowns should be worn if physical contact with the resident or the resident's environment is anticipated; -Common use equipment such as stethoscopes should be dedicated to the infected patient and not shared between residents; -Precautions should continue until diarrhea ceases, less than three stools per day; -Should have some system in place for alerting healthcare workers and visitors that a resident is on contact precautions, such as labeling the chart or door of the room, without compromising that resident's privacy; -The environment of a resident with CDAD should be cleaned thoroughly at least twice per day, with special attention to those items likely to be contaminated with feces, such as bedrails and bedside commodes.