Every finding on record at Cleburne County Nursing Home

Based on observations, interviews, resident record review, and review of a facility policy titled Hand Hygiene the facility failed to ensure Employee Identifier (EI) #3, Certified Nursing Assistant (CNA), did not create the potential for cross-contamination during meal delivery on 9/25/2023 when she was observed not washing or sanitizing her hands between residents. after touching a dirty bedside table, dirty window blinds, and a resident chair before touching the clean tray cart, donning gloves and setting up a resident tray. This had the potential to affect 21 residents who received meal trays on unit two. Findings include: A facility policy titled Hand Hygiene with an implemented date of 6/1/2022 documented the following: . All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand Hygiene Table . Between resident contacts . After handling contaminated objects . Before applying and after removing personal protective equipment (PPE), including gloves . On 9/25/2023 at 5:14 PM, EI #2 CNA was observed delivering meal trays to residents in their rooms. EI #2 delivered a tray with bare hands, for RI #5, placing the tray on RI #5's bedside table. EI #2 then pulled the window blinds down and left the room without washing or sanitizing her hands. EI #2 then delivered a meal tray for RI #1, placing the tray on the bedside table, moving the bedside table in front of RI #1, and exiting the room without washing or sanitizing her hands. RI #4 was in the hallway in a chair. EI #2 pushed RI #4 in the chair, holding the handles of the chair, to a common area without washing or sanitizing her hands. EI #2 continued to pass out meal trays without washing or sanitizing her hands, touching the food cart down the hall, and delivering a meal tray for RI #3. EI #2 set the tray down and moved the bedside table in front of the resident. EI #2 continued out of the room without washing or sanitizing her hands, and delivered a tray for RI #2. EI #2 placed the tray on the bedside table, turned the resident around in the wheelchair by the handles of the wheelchair, and then pushed the bedside table up to the resident. EI #2 then, without washing or sanitizing her hands, donned gloves and began setting up the meal tray for RI #2, opening containers of food, drinks, silverware, and condiments. EI #2 then removed her gloves and went to the common area down the hall and pushed RI #4 in a chair from the common area to RI #4's room. EI #2 then delivered RI #4's meal tray, all without washing her hands. On 9/25/2023 at 5:30 PM EI #2 CNA was asked, when was she supposed to wash or sanitize her hands. EI #2 responded, before entering and after leaving every room. EI #2 stated, that the facility policy was to wash or sanitize hands before entering and after leaving every room. EI #2 stated, she did not sanitize or wash her hands before touching the clean trays after handling the dirty bedside tables, window shades, resident's chairs, donning or doffing gloves. EI #2 stated, the risk of not washing or sanitizing her hands after touching a dirty tray was the spread of germs, infections. EI #2 stated, she should have washed or sanitized her hands after leaving each room before picking up each clean tray. On 9/26/2023 at 11:00 AM EI #1 Infection Preventionist was asked, according to policy when should staff wash or sanitize their hands. EI #1 responded, before entering a room, when visibly dirty, when in contact with a resident, when leaving the room, and when delivering or picking up the trays. EI #1 stated, the risk for what EI #2 had done, was contamination of everything she touched. EI #1 stated, she should have washed or sanitized her hands before entering every room and leaving every room.

Based on observation, interviews, an unlabeled facility document, and the facility's IN-SERVICE TRAINING REPORT, the facility failed to ensure Employee Identifier (EI) #3, a Certified Nursing Assistant (CNA) changed her personal protective equipment (PPE) between caring for persons (residents) under investigation (PUIs) for COVID-19. This deficient practice affected Resident Identifier (RI) #3, RI #4, and RI #6, three of four sampled residents cohorted on the PUI unit. Findings include: An unlabeled typed document by the facility read, . Tuesday, 1/12/2021 . * COVID unit is relocated to Unit 1. Rationale: We have exhausted our current COVID unit capacity. Cases are located on Unit 1 near the rear exit of Unit 1. Anticipating additional cases to arise as there are exposed roommate . Wednesday, 1/13/2021 * . (RI #5) . become PUIs (person under investigation) d/t (due to) positive roommate exposure and are isolated in place. Saturday, 1/16/2021 . (RI #6) become PUI d/t positive roommate exposure. (RI #6) is relocated to (Room Location #1) (alone). Tuesday, 1/19/2021 * Entire building tested . * COVID unit is extended again. * 4 negative residents from Unit 1 remain: (RI #3) & (RI #4) - both roommate. They are placed together on PUI unit and have no roommate exposure at this time. * (RI #6) & (RI #5) - cohorted due to roommate exposure. * We cohorted these residents in a small area outside fire doors to provide a safe barrier . On 1/21/2021 beginning at 9:28 AM, the PUI unit was observed. RI #3 and RI #4 were in their room lying in bed. At 9:29 AM, EI #3, a CNA exited the room of RI #5 and RI #6, dressed in a gown, face mask and gloves. The CNA exited the room and place the trash in a red bin, gelled (sanitized) her hands and returned to RI #5's and RI #6's room, wearing the same personal protective equipment (PPE). EI #3 then was observed to exit the room, sanitize her hands and enter the room of RI #3 and RI #4. At 9:38 AM, EI #3 exited the room of RI #3 and RI #4, sanitized her hands before and after she placed a trash bag in the bin. On 1/21/2021 at 9:40 AM, an interview was conducted with EI #3, the CNA assigned to care for RI #3, RI #4, RI #5 and RI #6. EI #3 stated she initially provided care to RI #6, then she exited the room, gelled her hands, took the trash to the bin and then took a new trash bag into the resident's room. EI #3 stated she then entered the room of RI #3 and RI #4 to provide care to those residents. EI #3 stated after she provided care to RI #3, she gelled her hands and provided care to RI #4. After providing care to RI #3 and RI #4, EI #3 gelled her hands, took the trash to the bin, gelled her hands again and placed a new trash bag in the resident's room. EI #3 acknowledged all four residents were under investigation. When asked if she discarded her PPE prior to entering the room of RI #3 and RI #4, EI #3 said no, she just sanitized her hands. When asked if changed PPE after care for RI #3 prior to caring for RI #4, EI #3 said no. When asked if she should have changed her PPE prior to entering RI #3 and RI #4's room, EI #3 said yes, she should have. When asked what the potential harm could have been, EI #3 stated one of the residents could get sick because of not changing the PPE. During an interview on 1/21/2021 at 1:00 PM, EI #2, the Infection Control Preventionist stated the CNA (EI #3) should have changed her PPE before going into the room of RI #3 and RI #4. According to a facility document titled IN-SERVICE TRAINING REPORT, attended by EI #3 (CNA), on 9/28/2020, EI #2, the Infection Control Preventionist presented training to the CNAs, NAs (Nurse Aides) and nurses titled COVID+ vs (versus) PUI and proper donning (putting on)/doffing (taking off) of PPE. The content of the training was As we care for residents who are COVID positive, as well as residents who are under investigation for COVID infection, we must take care to properly don/doff PPE to prevent the spread of COVID-19. Current CDC (Centers for Disease Control and Prevention) guidelines state that all PPE must be doffed after caring for each PUI resident . This deficiency was cited as a result of complaint/report number AL 977.

Based on record review, interviews and a facility document titled Resident Rights the facility failed to ensure Resident Identifier (RI) #1 was informed prior to a scheduled medical appointment that he/she would be quarantined for 14 days upon return due to the facility. This affected RI #1, one of six sampled residents. Findings include: A facility document titled Residents Rights, revised 8/2018, documented . (c) Planning and Implementing Care. The resident has the right to be informed of, and participate in, his or her treatment, including: . (2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: . (iii) The right to be informed, in advance, of changes to the plan of care . RI #1 was admitted to the facility on [DATE]. RI #1's Significant Change in Status Assessment with an assessment reference date of 12/31/2020 indicated the resident was cognitively intact with a Brief Interview of Mental Status (BIMS) of 15. According to RI #1's medical record, the resident went out of the facility on 1/4/2021 for a follow-up medical appointment. In a telephone interview on 1/20/2021 at 12:12 PM, RI #1's family member stated she was not aware prior to RI #1 going out to the medical appointment that the resident would have to be quarantined when he/she returned to the facility. RI #1's family member stated had she known this, the follow-up medical appointment could have been rescheduled. In an interview on 1/21/2021 at 9:50 AM, Employee Identifier (EI) #2, the Infection Control Preventionist, was asked what happens when a resident goes out for a doctor's appointment. EI #2 responded, before the resident goes, the facility talks to the resident and family to be sure they know they will be on isolation for 14 days when they come back to the facility. EI #2 was asked if residents were routinely placed on isolation after leaving the facility for a doctor's appointment. EI #2 responded yes and explained it was recommended due to their county positivity rate for COVID being so high. When asked about RI #1, EI #2 stated RI #1's family was not notified before RI #1 left for his/her follow-up medical appointment that RI #1 would be on isolation when the resident returned. In an interview on 1/24/2021 at 11:57 AM, RI #1 was asked if he/she was informed prior to going to the medical appointment on 1/4/2021 that he/she would be required to be on isolation upon return to the facility. RI #1 stated no, he/she was not informed. RI #1 was asked if he/she would have liked to have been informed that he/she would be required to go on isolation after the appointment. RI #1 stated yes, because had he/she known, he/she would not have gone to the appointment since it was just a routine check. This deficiency was cited as a result of complaint/report number AL 977.

Based on interview, record review and a facility policy tilted Abuse, Neglect and Exploitation the facility failed to report two allegation of physical abuse involving Resident Identifier (RI) # 50 and RI # 44 within two hours of staff being made aware of the incident. This affected 2 of 3 abuse files reviewed during the survey. Findings Include: A review of a policy titled Abuse, Neglect and Exploitation dated (MONTH) 2019 documented the following: . VII Reporting/Response . Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . On 6/1/2019 at 11:49 AM, the State Agency received a report by the facility regarding physical abuse by RI #50 toward another resident. The report indicated the incident occurred on 5/31/19 at 5:06 PM. On 6/17/19 at 1:12 PM, the State Agency received a report by the facility regarding physical abuse by a staff toward RI #44. The report indicated the incident occurred on 6/17/19 at 7:00 AM. On 07/09/19 2:36 PM, Employee Identifier (EI) #1, Administrator was interviewed. He was asked when did the allegation of physical abuse occur concerning RI #50. EI #1 replied on 5/31/19. He was asked when was it reported to the State Agency. EI #1 replied on 6/1/19, after he became aware, that was a Saturday morning. EI #1 was asked when should it have been reported to the State Agency. He replied it should have been reported by 7:06 PM on 5/31/19. EI #1 was asked when did the incident of physical abuse involving RI #44 occur. He replied on 6/17/18 at 7:00 AM. EI #1 was asked when was it reported to the State Agency. He replied at 12:02 PM on 6/17/18. When asked when should it have been reported to the State Agency, EI #1 replied by 9:00 AM on 6/17/18. EI #1 was asked why should allegations of abuse be reported to the State Agency within 2 hours. He replied to protect the resident or others involved.

Based on observation, record review, the facility's policy titled, Incontinence - Perineal Care, and interviews, the facility failed to ensure Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA) changed gloves and washed her hands after removing a soiled brief from Resident Identifier (RI) #5. EI #1 placed a clean brief on the resident and adjusted the resident's clothing and bed linens without washing her hands or changing gloves. This deficient practice affected RI #5, one of one residents observed for incontinent care. Findings include: The facility's policy titled Incontinence - Perineal Care dated January 2016, revealed Objective: To prevent infection . Procedure . 15. Partner must then remove gloves, wash hands and put on new gloves before placing clean pad under resident. RI #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set with an assessment resident date of 03/30/2017 Section H - Bladder and Bowel assessed RI #5 as frequently incontinent of urine and bowel. On 04/20/2017 at 1:45 p. m., Employee Identifier (EI) #1, a CNA, was observed providing incontinent care for RI #5. EI #1 washed her hands, put on gloves and provided care. EI #1 placed a clean brief on the resident, changed the pad underneath the resident before washing her hands and changed gloves. On 4/20/2017 at 2:30 p.m., an interview was conducted with EI #1. EI #1 was asked what is the importance of washing hands before applying a clean brief to the resident after incontinent care? EI #1 replied, to ensure we don't spread germs from one area to another or one resident to another. EI #1 was ask what the potential problem if you do not wash your hands before applying a clean brief? They could get an infection or C Dif (Clostridium Difficile infection). If I spread the germs from one resident to another, it makes the resident sicker when they get C Dif. On 4/20/2017 at 2:45 p.m. EI #2, the Director of Nursing was interviewed. EI #2 was asked if the staff should wash their hands after cleaning the perineal area. EI #2 replied staff should clean resident's perineal area, wash their hands and apply clean gloves, then apply the clean brief. EI #2 was ask what would happen if a CNA did not wash hands. EI #2 replied contamination and infection could occur.

Based on interview and record review, the facility failed to ensure that Resident Identifier (RI) #10, a resident who receives [MEDICAL TREATMENT] three times a week, had admission physician orders [REDACTED]. This affected RI #10, one of one sampled residents reviewed for [MEDICAL TREATMENT]. Findings include: RI #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a facility document titled, Physician order [REDACTED].#10 with a Start Date From 5/1/2016 Thru 12/22/2016 revealed no orders to check shunt for thrill or bruit until 12/22/16 after it was brought to the facility's attention by the surveyor. The list further revealed no orders to monitor access site for bleeding or how to provide emergency treatment in the event of hemorrhage/prolonged bleeding. On 12/22/2016 at 9:52 a.m., the surveyor conducted an interview with EI #1, Registered Nurse, MDS Coordinator. The surveyor asked EI #1, what orders should be obtained when a resident is admitted with [MEDICAL TREATMENT]. EI #1 replied, Where they should go, the days and chair time, maintenance care of shunt and site, checking for thrill and bruit and what to do in the event of an emergency, such as prolonged bleeding. When asked if RI #10 had admission orders [REDACTED]. They've written them today to check every shift that (she/he) is here in the facility.

Based on interview and record review, the facility failed to ensure Resident Identifier (RI) #10, a resident receiving [MEDICAL TREATMENT] three times a week, had admission physician orders [REDACTED]. This affected RI #10, one of one sampled residents receiving [MEDICAL TREATMENT]. Findings include: RI #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a facility document titled, Physician order [REDACTED].#10 with a Start Date From 5/1/2016 Thru 12/22/2016 revealed no orders to check shunt for thrill or bruit until 12/22/16 after it was brought to the facility's attention by surveyor. The list further revealed no orders to monitor access site for bleeding or what emergency care to provide in the event of hemorrhage/prolonged bleeding. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/26/2016, assessed RI #10 as requiring physical assistance with most activities of daily living (ADLs). On 12/22/2016 at 9:52 a.m., the surveyor conducted an interview with EI #1, Registered Nurse, MDS Coordinator. The surveyor asked EI #1 what orders should be obtained regarding a resident admitted with [MEDICAL TREATMENT]. EI #1 replied, Where they should go, the days and chair time, maintenance care of shunt and site, checking for thrill and bruit and what to do in the event of an emergency, such as prolonged bleeding. When asked if RI #10 had admission orders [REDACTED]. They've written them today to check every shift that (she/he) is here in the facility. EI #1 answered, . complications signs and symptoms and interventions, post [MEDICAL TREATMENT] to monitor for any signs and symptoms of adverse reactions .

Based on record review and interview, the facility failed to ensure a comprehensive care plan regarding [MEDICAL TREATMENT] was developed for Resident Identifier (RI) #10, a resident receiving [MEDICAL TREATMENT] three times a week. The facility further failed to ensure RI #8's care plan was revised with an appropriate intervention following a fall. This affected RI #8 and RI #10, two of 15 sampled residents. Findings include: 1) RI #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #10's care plans revealed RI #10 did not have a [MEDICAL TREATMENT] care plan. On 12/22/2016 at 9:52 a.m., the surveyor conducted an interview with Employee Identifier (EI) #1, Registered Nurse, MDS Coordinator. EI #1 was asked what should be put on a [MEDICAL TREATMENT] care plan. EI #1 answered, Their time and where they go, meal preparations before and after, facilitate transport, complications signs and symptoms and interventions, frequent communication with the [MEDICAL TREATMENT] center for continuity of care . notification of physician with any abnormalities and post [MEDICAL TREATMENT] to monitor for any signs and symptoms of adverse reactions and they're listed on the care plan. When EI #1 was asked if RI #10 had a [MEDICAL TREATMENT] care plan, EI #1 replied, (Her/His) [MEDICAL TREATMENT] was mentioned on (her/his) pain care plan . When asked if the pain care plan addressed where and when RI #10 went to [MEDICAL TREATMENT], checking the thrill or bruit, or what to do regarding prolonged bleeding or adverse reactions, EI #1 said, no ma'am. 2) RI #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #8's fall care plan revealed an intervention on 12/02/16 to Remind resident to lock wc (wheelchair) before rising. RI #8 had an assisted fall on 12/01/16 while using the bedside commode and the fall did not result from use of a wheelchair. On 12/22/2016 at 10:08 a.m., the surveyor conducted an interview with EI #2, RN, Quality Assurance Coordinator. When asked what intervention(s) were put in place for RI #8 following a fall on 12/01/2016, EI #2 replied, . I added the wrong intervention on (her/his) care plan for falls. When you brought it to my attention, I pulled the minutes from my meeting and noticed my error . and corrected it on 12/20/16 .

Based on record review, observation and interviews, the facility failed to ensure a dietary staff member washed their hands in a manner to prevent cross contamination. This had the potential to affect 72 of 73 residents that receive meals from the kitchen. The facility also failed to ensure a CNA (Certified Nursing Assistant) washed/sanitized her hands after cleaning urine from RI (Resident Identifier) #6 and before touching and applying a clean brief during incontinent care on 3/09/2016. The facility further failed to ensure a CNA washed/sanitized her hands after cleaning bm (bowel movement) from RI #3 and before touching and pulling up a clean brief during incontinent care on 3/09/2016. These failures affected two of three sampled residents who were observed during incontinent care. Findings Include: A review of a policy titled, HANDWASHING TECHNIQUE, with a revised date of 02/10/15 revealed the following: OBJECTIVE: TO PREVENT THE SPREAD OF INFECTION PROCEDURE: .7. WITH A NEW PAPER TOWEL, TURN OFF FAUCET AND DISCARD PAPER TOWEL. 1) On 03/09/2016 at 11:52 AM, an observation was made during trayline of Employee Identifier (EI)#6, a Dietary Staff/Cook. EI #6 readjusted her hair net, walked to the sink, turned the faucet knobs on and washed her hands, dried her hands with paper towel, discarded the paper towel and turned the faucet knobs off with her bare hands and placed on clean gloves. EI #6 went to the trayline and placed plate lids on top of plated plates and placed juices on residents' trays. On 03/09/2016 at 3:05 PM, an interview was conducted with EI #6. EI #6 was asked, what was the facility's policy and procedure for washing hands. EI #6 explained when staff come back into the kitchen from being outside they were to wash their hands and if they shake a resident's hand they were to wash their hands. EI #6 was asked how was she to wash her hands. EI #6 explained get the soap, turn water on, count to 20, get paper towel. EI #6 further explained she usually turned the water off with the back of her hand and dried her hands with a paper towel and pressed the foot stool to the garbage can and threw the paper towel away. EI #6 was asked why did she turn the water off with the back of her hands. EI #6 explained she was used to doing it and she saw no point of turning the water off with a paper towel. EI #6 was asked why should she wash her hands per the facility's policy and procedure. EI #6 explained they should wash their hands because of germs or touching something dirty. EI #6 was asked what was the potential harm in not washing her hands per the facility policy. EI #6 stated residents could become sick. On 03/10/2016 at 1:10 PM, an interview was conducted with EI #5, Dietary Manager. EI #5 was asked, what was the process when washing hands per the facility's policy and procedure. EI #5 explained staff was to go to the sink, turn on water, get soap, wash hands for 15 to 20 seconds under water of 100 degrees and lather up, get paper towel, dry hands and use the paper towel and turn the water faucet off and place in the trash. EI #5 was asked why should staff follow the facility's policy and procedure on hand washing. EI #5 stated to control germs. EI #5 was asked, what was the potential harm in staff not following the facility's policy and procedure for handwashing. EI #5 replied foodborne illness and germs could make someone sick and it could contaminate all the food. A review of a facility policy titled, Perineal Care with a date of January 2016 revealed: .Procedure: . 2. If resident has fecal material or other matter, apply gloves, remove with tissue .Dispose of soiled gloves .wash hands . 2) RI #6 was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's most recent Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/05/2016 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 9, which indicated the resident was moderately cognitively impaired for daily decision making. The MDS also revealed the resident was frequently incontinent of urine. On 3/09/2016 at 9:38 AM, EI #3, CNA, was observed performing incontinent care for RI #6. RI #6 was incontinent of urine. EI #3 donned gloves. EI #3 performed perineal care and then rolled the urine soiled brief from underneath the resident. EI #3 changed gloves and placed clean brief underneath the resident. EI #3 then removed gloves and washed her hands. On 3/9/2016 at 5:25 PM, an interview was conducted with EI #3. EI #3 was asked when she was supposed to wash/sanitize her hands during incontinent care. EI #3 said before and after incontinent care. EI #3 was asked when did she washed/sanitized her hands during RI #6's incontinent care. EI #3 said after she got done. EI #3 was asked what she should have done after she cleaned urine from RI #6 and before she touched and put the clean brief on the resident. EI #3 said she should have changed her gloves, washed her hands and donned new gloves. EI #3 was asked if she washed/sanitized her hands after cleaning urine from RI #6 and before she touched and placed the clean brief on the resident. EI #3 said no. EI #3 was asked what the potential harm was if she did not wash/sanitize her hands after she cleaned urine from RI #6 and before she touched and placed the clean brief on the resident. EI #3 said it could have given the resident a bacterial infection. 3) RI #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's most recent Significant Change MDS with an ARD of 2/18/2016 revealed the resident had a BIMS of 0, which indicated the resident was severely impaired for daily decision making. The MDS also revealed the resident required extensive assistance for toilet use and personal hygiene. The MDS further revealed the resident was frequently incontinent of bladder and always continent of bowel. A review of RI #3's Care Plan revealed: Problem/Need . Problem Onset: 10/01/2015 Resident has incontinence of bowel and bladder at times . On 3/09/2016 at 9:54 AM, EI #4, CNA, was observed performing incontinent care for RI #3. RI #3 had a small incontinent bm. EI #4 donned clean gloves and removed the resident's brief. EI #4 changed gloves and cleaned RI #3's buttocks with wipes. Another CNA placed a clean brief on the resident. EI #4 pulled the clean brief up on the resident without washing or sanitizing her hands. On 3/09/2016 at 5:20 PM, an interview was conducted with EI #4. EI #4 was asked when hands were supposed to be washed/sanitized during incontinent care. EI #4 said before, during and after incontinent care. EI #4 was asked when she washed/sanitized her hands during the incontinent care of RI #3. EI #4 said after incontinent care was finished. EI #4 was asked what she should have done after she cleaned bm from RI #3 and before she pulled up the clean brief. EI #4 said she should have changed gloves and washed her hands. EI #4 was asked if she washed/sanitized her hands after she cleaned bm from the resident and before she touched the clean brief. EI #4 said, No, I did not. EI #4 was asked what was the potential harm in not washing/sanitizing her hands after cleaning bm from the resident and before she pulled up the clean brief. EI #4 said it could contaminate their clothes, it could get on their clothes and harm them and it could cause infection. On 3/10/2016 at 10:52 AM, an interview was conducted with EI #1, RN (Registered Nurse) Supervisor. EI #1 was asked at what point during incontinent care CNAs should wash/sanitize their hands. EI #1 said before and after incontinent care. EI #1 was asked if it was an acceptable practice of that facility for a CNA to clean bm and urine from a resident and then touch a clean brief without washing or sanitizing their hands. EI #1 said they should wash their hands. EI #1 was asked what a CNA should do after cleaning urine and bm from a resident and before she touched a clean brief. EI #1 said they should take the soiled gloves off, wash their hands and don clean gloves. EI #1 was asked what the potential harm was if a CNA cleaned urine and bm from a resident and touched a clean brief without washing their hands. EI #1 said infection control. On 3/10/2016 at 10:55 AM, an interview was conducted with EI #7, LPN (Licensed Practical Nurse)/Infection Control Nurse. EI #7 was asked if the facility had an infection control committee. EI #7 said yes. EI #7 was asked how often the committee met. EI #7 said quarterly. EI #7 was asked what measures the facility had in place to monitor/investigate causes of infection and the manner of how the infection was spread. EI #7 said tracking and trending, monthly and quarterly and lab reports. EI #7 was asked what system the facility had in place to determine what procedures such as isolation should be applied to an individual resident. EI #7 said policy and procedure along with meeting a certain criteria. EI #7 also said it depended on which organism it was that determined which isolation was needed. EI #7 was asked what system the facility had in place to maintain records of incidents and corrective actions regarding infections. EI #7 said infection log. EI #7 was asked what types of infections were currently being monitored. EI #7 said there were none trending at that time. EI #7 was asked if staff were washing their hands according to facility policy. EI #7 said the staff was checking off on hand washing that week. EI #7 was asked how staff was monitored to ensure they were washing their hands according to facility policy. EI #7 said by doing spot checks.

Based on record review, observation and interviews, the facility failed to ensure a CNA (Certified Nursing Assistant) was seated while feeding RI (Resident Identifier) #6 the dinner meal on 3/09/2016. This affected one of four sampled residents observed being assisted with meals. Findings Include: A review of a facility policy titled, Quality of Life - Dignity with a revised date of October 2009 revealed: Policy Interpretation and Implementation .1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. RI #6 was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's most recent Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/05/2016 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 9, which indicated the resident was moderately cognitively impaired for daily decision making. The MDS also revealed the resident required extensive assistance of one person for eating. On 3/09/2016 at 5:55 PM, EI (Employee Identifier) #2, CNA was observed standing at the bedside while feeding RI #6 the evening meal. On 3/09/2016 at 6:11 PM, EI #2 was observed to continue to stand at the bedside while feeding RI #6 the evening meal. On 3/10/2016 at 8:41 AM, RI #6 was asked by the surveyor how it made him/her feel when the CNA stood over him/her and fed him/her. RI #6 said, I didn't like it. On 3/10/2016 at 10:26 AM, a telephone interview was conducted with EI #2. EI #2 was asked what position she was in when she assisted RI #6 to eat dinner on 3/09/2016. EI #2 said, I was standing beside RI #6's bed. EI #2 was asked what position she should be in when assisting a resident to eat. EI #2 said, Sitting. EI #2 was asked why she was standing above the resident when assisting the resident with eating. EI #2 said because there was nowhere to sit. EI #2 was asked if RI #6 had chairs in the room. EI #2 said yes, but she went backward when she sat in the chair. EI #2 was asked if she could have gotten another chair. EI #2 said yes. EI #2 was asked what the potential harm was in standing over a resident while assisting them to eat. EI #2 said they might feel scared. On 3/10/2016 at 10:55 AM, an interview was conducted with EI #1, RN (Registered Nurse) Supervisor. EI #1 was asked what position a CNA should be in when assisting a resident with eating in their room. EI #1 said the CNA should pull the chair beside the resident and feed them like they would feed themselves. EI #1 was asked if it was an acceptable practice of that facility for a CNA to stand over a resident and feed them. EI #1 said no. EI #1 was asked what the potential harm was in a CNA standing and feeding residents. EI #1 said, It's a dignity issue.

Based on interview and record review, the facility failed to ensure Resident Identifier (RI) #2's care plan was followed in order to perform an Abnormal Involuntary Movement Scale (AIMS) test every three months. This affected one of five residents whose care plans were reviewed for psychoactive medications. Findings Include: A review of a facility policy titled, AIMS Test dated January 2016 revealed the following: .Policy: To provide both a guideline and ongoing monitoring of resident for possible side effects of anti-psychotic medication. Procedure: .AIMS Test is done quarterly and as needed . Further review of a facility policy titled, USING THE CARE PLAN dated January 2016 revealed the following: .Policy: A care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. RI #2's Anti-Psychotic Medication Care Plan with a Problem Onset date of 04/17/2015 documented RI #2's AIMS tests were to be performed every three months and with any significant change or dosage change. A review of RI #2's AIMS conducted were dated as follows: 04/18/2015, 11/25/2015 and 03/09/2016. AIMS test were not conducted every three months. RI#2 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/05/2016 revealed RI #2's Brief Interview for Mental Status score of 15, indicating resident was cognitively intact. An interview was conducted on 03/10/2016 at 10:27 AM with Employee Identifier (EI) #1, RN (Registered Nurse) Supervisor. EI #1 was asked what was the facility's policy and procedure for completing AIMS on residents that used [MEDICAL CONDITION] medications. EI #1 explained they are to be completed quarterly. EI #1 was asked when was RI #2's admission AIMS test performed. EI #1 stated 04/18/2015. EI #1 was asked when was RI #2's next quarterly AIMS test completed. EI #1 stated on 11/25/2015. EI #1 was asked after RI #2's AIMS test was completed on 11/25/2015, when was the next AIMS test completed. EI #1 explained it was due on February 25, 2016 but she completed one on 03/09/2016. EI #1 was asked why quarterly AIMS test should be completed on a consistent basis for RI #2. EI #1 explained to assess and make sure that the [MEDICAL CONDITION] medication was effective and to ensure it did not have any side effects. EI #1 was asked were quarterly AIMS completed in a timely manner for RI #2. EI #1 stated no. EI #1 was asked why were the AIMS test not completed quarterly. EI #1 stated there was no system in place or carried over for new staff. EI #1 was asked when was RI #2's care plan for use of [MEDICAL CONDITION] medications developed. EI #1 stated 04/17/2015. EI #1 was asked what approach did RI #2's Care Plan mention regarding AIMS. EI #1 stated to perform AIMS test every three months. EI #1 was asked was this done. EI #1 stated no. EI #1 was asked what was the potential harm in not following the care plan for quarterly AIMS test for RI #2's use of a [MEDICAL CONDITION] medication. EI #1 replied, adverse side effects.

Based on observations, interview, and review of facility policy, the facility failed to ensure: 1) items were not stored in the cooler past the use-by-date on the label; 2) cold foods were not served from the trayline at a temperature greater than 41 degrees Fahrenheit during the 02/04/2015 lunch meal; 3) staff verified the temperature of liver and onions was greater than or equal to 135 degrees Fahrenheit; and 4) staff did not store open employee beverages in the walk-in cooler, creating the potential for cross-contamination. These failures had the potential to affect all 78 residents receiving meals from the kitchen. Findings Include: 1) Review of the Food and Drug Administration Food Code 2013, Chapter 3 Food, pages 92 and 94, revealed the following: "...3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) ... refrigerated, READY-TO -EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded... 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD... shall be discarded if it: (1) Exceeds the temperature and time combination specified..." During the initial tour of the kitchen on 02/03/2015 beginning at 10:20 AM, the surveyor noted an open bag of shredded carrots labeled "Prepared 1-10-15 Use By 1-13-15." The surveyor also noted the following items exceeding their use-by-dates in the left side of the double reach-in cooler: 1) A plastic pitcher of "Super cereal" labeled with a use by date of 01/30/2015; 2) A foil covered stainless steel container of "Biscuit Gravy" labeled with a use-by-date of 01/04/2015; 3) A foil covered stainless steel container of "Gravy" labeled with a use-by-date of 01/04/2015; 4) A foil covered stainless steel container of "Puree Eggs" labeled with a use-by-date of 01/04/2015; and 5) A foil covered stainless steel container of "Puree Meat" labeled with a use-by-date of 01/04/2015. Employee Identifier (EI) #18, the Dietary Manager, was interviewed on 02/04/2015 at 4:00 PM. When asked what procedures were in place to ensure items were discarded if the use-by-date was exceeded, EI #18 stated all dietary staff are responsible for checking as they put items in the refrigerator. When asked what potential harm could occur if if items were not discarded once the use-by-date had been exceeded, EI #18 stated it could potentially make residents sick. 2) Review of the facility's policy titled "Monitoring Food Temperatures for Meal Service", dated 1998, revealed the following: "... PROCEDURE: ...2. The Cook will record the temperature for each food item on the Food Temperature Log. 3. ... Cold foods and beverages which do not record as 41 (degrees) F (Fahrenheit) or below will be chilled on ice and in the freezer..." During trayline observations on 02/04/2015 beginning at 11:40 AM, the surveyor observed EI #19, a cook, obtain and record the following temperatures: potato salad-44 degrees F macaroni salad-42 degrees F Neither item was placed back in the cooler or freezer to bring below 41 degrees F. The first and second carts left the kitchen with potato salad and macaroni salad exceeding 41 degrees at 12:41 PM. Review of the facility's recipes for "Potato Salad" and "Macaroni Salad" revealed both items contained eggs. 3) Review of the facility's policy titled "Monitoring Food Temperatures for Meal Service", dated 1998, revealed the following: "... PROCEDURE: 1. Food temperatures will be taken and recorded for all hot and cold foods prior to placement on the serving line..." During trayline observations on 02/04/2015 beginning at 11:40 AM, the surveyor observed EI #19, a cook, obtain and record temperatures of items on the steam table. EI #19 was not observed to check the temperature of the liver and onions prior to the start of plating at 12:14 PM. After the first and second cart left the kitchen at 12:41 PM, the surveyor asked EI #19 if she had checked the temperature of the liver and onions. EI #19 stated, "I'll be honest. I don't think I did." Employee Identifier (EI) #18, the Dietary Manager, was interviewed on 02/04/2015 at 4:00 PM. When asked what items should be checked for proper temperature prior to serving, EI #18 stated all of them before serving. When asked what potential harm could occur if liver and onions were served without verifying they were at the proper temperature, EI #18 stated she did not know. 4) During the initial tour of the kitchen on 02/03/2015 beginning at 10:20 AM, the surveyor noted a partially consumed bottle of soda, labeled with the Dietary Manager's name and dated 02/02/2015, located in the walk-in cooler where food for residents was stored. During trayline observations on 02/04/2015 beginning at 11:40 AM, the surveyor noted a partially consumed bottle of orange soda, labeled with an employee's name stored in the walk-in cooler with resident food. Employee Identifier (EI) #18, the Dietary Manager, was interviewed on 02/04/2015 at 4:00 PM. When asked what the facility policy was regarding employees' drinks, EI #18 stated there was no policy addressing it, but staff do not eat or drink in food storage or preparation areas..

Based on observations, interviews and record reviews, the facility failed to ensure: 1) During medication pass observations, staff members washed their hands after removing gloves and did not place bare fingers into pill pouches with crushed medications. 2) During incontinence care observations: a. Employee Identifier (EI) #6, a CNA (Certified Nursing Assistant) washed her hands and changed her gloves between clean and dirty. b. EI #3, an LPN (Licensed Practical Nurse) assisting with incontinence care, did not remove his gloves and leave the room without washing his hands. EI #3 further failed to wash his hands upon re-entering the room and donning gloves. 3) During wound care observations, EI #2, RN/Unit Mg. (Registered Nurse/Unit Manager) did not touch 4x4 gauze with ungloved hands and further did not touch 4x4 gauze against the privacy curtain prior to using the gauze for RI (Resident Identifier) #1's wound care. This affected three of six LPN's observed during medication pass on two of two units, one of two incontinence care observations, and one of two wound care observations. 1) A review of the facility policy titled "Administering Medications" with a revision date of April 2007 revealed: "Policy Interpretation and Implementation...14. Staff shall follow established facility infection control procedures (...handwashing...) when these apply to the administration of medications...." A review of the facility policy titled "Subcutaneous Injections" with a revision date of April 2007 revealed: "... Steps in the Procedure ...2. Put on gloves. ...17. Remove gloves and discard in designated container. Perform hand antisepsis. ..." A review of the facility policy titled "Handwashing/Hand Hygiene" with a revision date of October 2009 revealed: "...When to Wash Hands ...d. after removing gloves; ... Removing PPE (Personal Protective Equipment) 7. Hand hygiene is always the final step after removing and disposing of personal protective equipment. 8. The use of gloves does not replace handwashing/hand hygiene. ..." Resident Identifier (RI) #8 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#8's Physician orders revealed an order dated 2/2/15 for Contact Isolation due to MRSA (Methicillin Resistant Staphylococcus Aureus) in the urine. On 2/3/15 at 3:00 PM, the surveyor observed medication administration with Employee Identifier (EI) # 4, LPN (Licensed Practical Nurse). EI #4 went to RI #8's room to administer medications, obtain accucheck and administer insulin. EI #4 performed the accucheck, administered the pills and gave the subcutaneous injection. EI #4 removed her gloves and went to the medication cart. At the medication cart, EI #4 washed the accucheck machine, then went to the nurses station to wash her hands. On 2/3/15 at 3:15 PM, the surveyor interviewed EI #4 about the medication pass observation for RI #8. EI #4 was asked when should hands be washed. She replied before administering and after administering medications. When asked what should be done after gloves are removed, EI #4 stated wash your hands. EI #4 was asked what should she have done after administering the subcutaneous injection and before leaving RI #8's room. She replied that she should have washed her hands before leaving. EI #4 was asked what the potential for harm was in not washing her hands after medication administration. EI #4 replied spreading the infection. RI #12 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's Physician orders for February 2015 revealed RI #12 had orders for [MEDICATION NAME] eye drops three times a day and [MEDICATION NAME] eye drops three times a day. On 2/3/15 at 3:52 PM, the surveyor observed EI #5 administer eye drops to RI #12. EI #5 administered [MEDICATION NAME] eye drops to RI #12, removed her gloves, moved the privacy curtain, opened the medication cart, placed the eye drop bottles into containers, locked the medication cart and then washed her hands. On 2/3/15 at 4:04 PM, the surveyor interviewed EI #5 about the medication pass observation on RI #12. EI #5 was asked when should hands be washed. She replied after removing gloves. When EI #5 was asked if she had washed her hands after removing her gloves, she replied no. EI #5 was asked what should be done after administering RI #12's eye drops and before leaving the resident's room. She replied hands should be washed and she had not. EI #5 was asked what was the potential for harm in not washing her hands after removing her gloves. She replied infection. RI #7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #7's Physician Orders for February 2015 revealed orders for [MEDICATION NAME] for pain, [MEDICATION NAME] and [MEDICATION NAME] for Epilepsy. On 2/4/15 at 3:15 PM, the surveyor observed EI #3, LPN, administer [MEDICATION NAME] and [MEDICATION NAME] to RI #7. EI #3 was observed to place his finger into the pill pouches after he had crushed each of the three medications individually. On 2/4/15 at 3:40 PM, the surveyor interviewed EI #3 about his medication administration to RI #7. EI #3 was asked how should pill pouches be opened. He replied pinch the sides and slide open. When asked how pill pouches should be opened after the pills were crushed, EI #3 stated the same way. EI #3 was asked if fingers should be placed into the pill pouches. He replied no. When EI #3 was asked what the potential for harm was in putting fingers into pill pouches, he stated cross contamination. On 2/4/15 at 4:12 PM, EI #3 approached the surveyor and stated he had later caught himself about to put his fingers into a pill pouch. EI #3 then stated, "I think it has become a habit." On 2/5/15 at 3:12 PM, EI #2 RN/Infection Control Nurse was interviewed. EI #2 was asked when should hands be washed during medication pass. She replied at the beginning and at the end. EI #2 was asked what PPE (Personal Protective Equipment) should be worn during a subcutaneous injection. She replied gloves. When EI #2 was asked what should be done after removing gloves. She stated wash your hands. EI #2 was asked if fingers should be placed inside pill pouches. She replied no. EI #2 was asked what the potential for harm was in not washing hands after removing gloves and placing fingers into pill pouches. She replied cross contamination. 2) a. A review of Potter and Perry's "Fundamentals of Nursing", Eighth Edition, copyright 2013, Chapter 39 "Hygiene", pages 797 to 805 revealed the following: "SKILL 39-1 BATHING AND PERINEAL CARE ...a. Provide perineal hygiene... (2) ... (a) Apply pair of clean gloves. ...(c) Wash labia majora...p. Remove soiled gloves and discard in trash; ...q.... (1) perform hand hygiene and apply clean pair of gloves... (5) Clean buttocks and anus, washing front to back... Remove contaminated gloves... perform hand hygiene...." RI #7 was readmitted tot he facility on 12/3/2014 with [DIAGNOSES REDACTED]. On 2/4/15 at 7:37 AM, the surveyor observed Employee Identifier (EI) #6, a CNA (Certified Nursing Assistant) perform incontinence care on RI #7. EI #3, a Licensed Practical Nurse (LPN) assisted her. EI #6 entered RI #7's room and put on her gloves and began incontinence care. EI #6 completed incontinence care to include perineal care with small bowel movement noted,washed mattress, placed draw sheet to bed, positioned RI #7, and covered RI #7 with sheet and blanket. EI #6 discarded supplies in plastic bag. Then EI #6 removed her gloves and washed her hands. EI #6 had not washed her hands or changed her gloves throughout the entire process. On 2/4/15 at 8:14 AM, The surveyor interviewed EI #6, the CNA who performed incontinent care on RI #7. EI #6 was asked when should hands be washed. She replied after every step on incontinence care. When asked if hands should be washed upon entering a residents room and before putting on gloves, she replied yes and stated she had not done this. When EI #6 was asked when should gloves be changed during incontinence care, she replied after handling dirty things and further stated she had not washed her hands or changed gloves until she was completely finished. EI #6 was asked what the potential for harm was in not changing her gloves or washing her hands during incontinence care. She replied infection control. b. During this same incontinence care observation on 2/4/15 at 7:37 AM, EI #3, LPN who assisted with incontinence care on RI #7, entered RI #7's room and washed his hands. EI #6, the CNA, needed more towels. EI #3 left RI #7's room. When EI #3 returned, he handed the towels to EI #6, washed his hands and put on gloves. EI #6 needed more cloths to clean RI #7. EI #3 removed his gloves and left the room. EI #3 returned with cloths, washed his hands and put on gloves. During the change of linens, EI #3 removed his gloves and left the room again. When EI #3 returned to the room, he put on gloves. EI #3 did not wash his hands after removing his gloves each time or prior to putting on clean gloves. On 2/4/15 at 8:22 AM, the surveyor interviewed EI #3, LPN about the incontinence care on RI #7. When EI #3 was asked when should hands be washed, he stated before, during and after care. EI #3 was asked what should be done after removing gloves. He replied wash your hands. EI # 3 was asked what should be done prior to leaving the resident's room. EI #3 stated wash your hands and further stated that he had not done this every time. EI #3 was asked what the potential for harm was in not washing hands. He stated cross contamination. On 2/5/15 at 3:12 PM, the surveyor interviewed EI #2, RN/Infection Control Nurse. EI #2 was asked when should gloves be changed and hands washed during incontinence care. She replied wash your hands before putting on gloves, after removing gloves and after you are finished. When EI #2 was asked if gloves should be changed when going from clean to dirty or front to back, she replied definitely. EI #2 was asked what should be done when gloves are removed. She replied wash your hands. EI #2 was asked what the potential for harm was in not changing gloves or washing hands during incontinence care. She replied infection. 3) Review of a facility policy titled "Wound Care" with a revision date of October 2010 revealed the following: "... Steps in the Procedure 1. Use disposable cloth ...to establish clean field on resident's overbed table. Place all items to be used during the procedure on the clean field. Arrange the supplies so they can be easily reached. ...14. Be certain all clean items are on clean field. ..." Review of a facility policy titled "Dressings, Dry/Clean" with a revision date of February 2014 revealed the following: "...Steps in the Procedure ...15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. ..." RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Significant Change Minimum Data Set ((MDS) dated [DATE] documented RI #1 was severely impaired in cognition, and required total dependence on staff for bed mobility and toileting. This MDS also revealed that RI #1 had an unstageable pressure ulcer. A review of RI #1's Physician Orders for January 2015 revealed an order dated 1/22/15 for wound care to RI #1's coccyx daily and as needed. On 2/5/15 at 11:07 AM, the surveyor observed EI #1, LPN (Licensed Practical Nurse) and EI #2, RN/Unit Mgr. (Registered Nurse/Unit Manager) perform wound care to RI #1's unstageable coccyx wound. EI #s 1 and 2 assisted with the set up of supplies for RI #1's wound care. EI #2 entered the room with 4x4 gauze in her bare hands and as she was placing the 4x4 gauze on the overbed table, EI #2 bumped the gauze against the privacy/dividing curtain. EI #1 then moved the overbed table from the right side of the room to the left side of the room. During this process, the 4x4 gauze was touching the privacy/dividing curtain and remained touching the curtain throughout the wound care. EI #1 began performing the wound care. EI #1 sprayed saline wash into cups and then saturated the 4x4 gauze. EI #1 cleansed the wound with one 4x4 gauze and then unfolded it and reused the same gauze to continue cleaning. EI #1 got a second 4x4 gauze and again unfolded it and reused the same gauze to clean RI #'s wound. On 2/5/15 at 2:53 PM, the surveyor interviewed EI #1, the LPN performing wound care to RI #1. EI #1 was asked if clean 4x4 gauze should be touched with bare hands. She replied that gloves should be worn to touch 4x4 gauze. The surveyor explained wound care observation regarding the 4x4 gauze touching the privacy/dividing curtain. EI #1 stated she did not realize the gauze was touching the curtain. EI #1 was asked what was the potential for harm in the 4x4 gauze being touched with ungloved hands and touching the privacy curtain. EI #1 replied it messed up the clean field. EI #1 was asked how often should a 4x4 gauze be used during wound care. She replied once. EI #1 further stated that she thought she could fold the 4x4 and use it again like in perineal care. On 2/5/15 at 3:12 PM, the surveyor interviewed EI #2, RN/Unit Mgr and Infection Control Nurse. EI #2 was asked how should 4x4 gauze be handled. She replied with gloves. EI #2 was asked if she had worn gloves while handling the 4x4 gauze for RI #1's wound care. She replied no. EI #2 was asked if the gauze should touch the privacy curtain. She replied no due to germs and infection control. EI #2 further stated that the privacy curtain was considered dirty. EI #2 was asked if 4x4 gauze should be reused during wound care. She replied no due to infection control.

Based on record review, interviews, and review of facility policy, the facility failed to ensure Resident Identifier (RI) #4's physician and sponsor were notified of RI #4's repeated refusals of sliding scale insulin. This affected RI #4, a diabetic resident, 1 of 11 residents for whom Medication Administration Records (MARs) were reviewed. Findings Include: Review of the facility's policy titled "Refusal of Medications and Treatments, Documentation of", revised December 2006, revealed the following: "... Policy Interpretation and Implementation... 2. Documentation related to resident's refusal of treatment shall include at least the following: ... g. If and when the physician was notified as well as the physician's response;... 3. Repeated refusals shall be reported to the Director of Nursing Services and Attending Physician." Review of the facility's policy titled "Change in Resident's Condition or Status", revised April 2007, revealed the following: "... Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status... Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: ... f. Refusal of treatment or medications (i.e. (that is), two (2) or more consecutive times)..." RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #4's current "Physician Orders" revealed an order dated 04/02/2014 for the following: Finger Stick Blood Sugars at 6 AM, 4 PM, and 9 PM with [MEDICATION NAME] Insulin sliding scale subcutaneously (SQ): 201-250= 2 units SQ 251-300= 4 units SQ 301-350= 6 units SQ 351-400= 8 units SQ Review of RI #4's MARs from 12/01/2014 through 02/04/2015 revealed RI #4 had refused sliding scale insulin on the following dates and times when indicated based on the Finger Stick Blood Sugar result: December: 1 Refusal 12th at 6:00 AM (Glucose=207) January: 17 Refusals 4th at 6:00 AM (Glucose= 207) 7th at 9:00 PM (Glucose= 227) 16th at 9:00 PM (Glucose= 308) 17th at 9:00 PM (Glucose= 235) 18th at 9:00 PM (Glucose= 281) 19th at 6:00 AM (Glucose= 230) 19th at 9:00 PM (Glucose= 213) 20th at 9:00 PM (Glucose= 261) 21st at 4:00 PM (Glucose= 239) 21st at 9:00 PM (Glucose= 254) 23rd at 4:00 PM (Glucose= 238) 26th at 9:00 PM (Glucose= 299) 28th at 9:00 PM (Glucose= 283) 29th at 9:00 PM (Glucose= 307) 30th at 6:00 AM (Glucose= 214) 30th at 9:00 PM (Glucose= 321) 31st at 9:00 PM (Glucose= 318) February: 2 Refusals 3rd at 9:00 PM (Glucose= 201) 4th at 6:00 AM (Glucose= 228) While the MAR documented RI #4's refusals, there was no documentation regarding notification of the physician or sponsor. EI #8, the Director of Nursing was interviewed on 02/05/2015 at 9:14 AM. When asked how medication refusals should be addressed, EI #8 explained if the resident continually refused the physician would need to be notified so he could review. When asked at what point the physician should be notified, EI #8 stated after two or three refusals. When asked when the sponsor should be made aware, EI #8 stated the same, after two or three refusals, because the sponsor could talk to the resident as well. After reviewing RI #4's MARs and refusals, EI #8 was asked how the refusals should have been handled. EI #8 stated the physician and sponsor should have been notified. When asked why it was important to notify the physician of insulin refusals, EI #8 explained that if the physician was not notified he would be unaware. EI #8 further explained that if unaware, when the physician comes and sees higher glucose values he could increase RI #4's insulin, causing a yo-yo effect in the blood sugars. EI #8 stated it could also lead to the possibility of unnecessary testing if the physician was unaware of the resident refusing insulin. EI #8 then stated she would review RI #4's medical record to see if she could find any evidence the physician or sponsor had been notified regarding the insulin refusals. At 9:51 AM, after reviewing the chart, EI #8 stated she saw no documentation of physician or sponsor notifications, only the refusals documented on the MARs. EI #9, the Medical Director, as well as RI #4's physician, was interviewed on 2/05/2015 at 10:36 AM. When asked if he recalled the facility notifying him of RI #4's insulin refusals, EI #9 stated he did not recall that and explained the facility would normally send a fax. When asked if he had been notified if his treatment approach would have changed, EI #9 stated he would have talked to RI #4 about other options. RI #4's sponsor was interviewed on 02/05/2015 at 10:45 AM. When asked if the facility had notified her of RI #4 refusing insulin, the sponsor stated, "No, ma'am." The sponsor further stated she was also here to back up the facility because she could talk to RI #4 and RI #4 listens to her.

Based on interview and record review, the facility failed to notify the State Agency within twenty-four hours of RI (Resident Identifier) #14 alleging an incident of physical abuse on 07/05/2014. The facility further failed to suspend EI (Employee Identifier) #11 , the CNA (Certified Nursing Assistant) involved in RI #14's 07/05/2014 allegation of abuse. This affected 1 of 2 abuse investigation files reviewed. Findings Include: The facility's Operational Policy and Procedure Manual for Long-Term Care included Abuse Policies and Procedures (Revised 8/14/07) and had a section on: "Reporting Abuse to State Agencies and Other Entities/Individuals... Policy Statement All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law..." There was also a section on: "Protection of Residents During Abuse Investigations... Policy Interpretation and Implementation 1. During abuse investigations, residents will be protected from harm by the following measures: a. Employees accused of participating in the alleged abuse will be immediately suspended . . . " RI #14 was readmitted to the facility on [DATE]. RI #14's most recent Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 11/24/2014 documented a BIMS (Brief Interview for Mental Status) score of 14 out of possible 15, indicating RI #14 was cognitively intact. A Resident Incident Report on RI #14 dated 07/05/2014 at 04:41 AM described a large bruise on RI #14's left arm between the elbow and shoulder. During the investigation of RI #14's bruise, RI #14 alleged a CNA caused the bruise. A typed "Record of Events" dated July 5, 2014 was written by EI #13, the Administrator, and then signed by EI #13 and the committee who was called by EI #13 to help investigate the alleged physical abuse. The "Record of Events" documented the following: EI #13, the Administrator, was called at home on July 5, 2014 and told that RI #14 had a huge bruise on the left arm and that RI #14 had accused EI #11, a CNA, of hurting her arm on July 3, 2014 after the fireworks. The "Alabama Department of Public Health (ADPH) Online Incident Reporting System" form documented that ADPH was not notified until Friday July 18, 2014 at 5:17:20 PM, 13 days after becoming aware of RI #14's allegation of abuse. The Archived Time Card Report on EI #11 showed that EI #11 worked on July 3rd as well as July 5th and 6th, 2014. On 02/05/2014 at 11:00 AM an interview was conducted with EI #12, the Abuse Coordinator, Social Services Director. EI #12 was asked what the facility's policy stated about reporting allegations of abuse to the State Agency. EI #12 replied that any allegation of abuse is to be reported to the State Agency within 24 hours. EI #12 was asked if this was done on July 5, 2014 when RI #14 said EI #11 caused a bruise on her left arm and EI #12 said "no ma'am, I do not think so." EI #12 was asked why it was not reported and her response was "we should have". EI #12 was asked if the alleged CNA was put on suspension on July 5, 2014 when the investigation started. EI #12 stated that she was off during this time and learned about it when coming back to work. EI #12 looked at the abuse investigation for July 5, 2014 and EI #12 was asked again if the alleged CNA was put on suspension on July 5, 2014 and this time, EI #12 said no, EI #11 was not suspended on July 5, 2014 during the investigation.

Based on interviews and record review, the facility failed to ensure Resident Identifier (RI) #7's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/2014 was coded to reflect an in-house acquired Stage Two Pressure Ulcer with an onset date of 12/19/2014. This affected one of 14 sampled residents for whom MDSs were reviewed. Findings Include: When asked for a policy on coding MDS Assessments for pressure ulcers, the facility provided a typed letter stating they used the RAI (Resident Assessment Instrument) Manual Section M as their guide. Review of the RAI Manual, Chapter 3, Section M: Skin Conditions (October 2011) provided by the facility revealed the following: "SECTION M: SKIN CONDITIONS Intent: The items in this section document the risk, presence, appearance, and change of pressure ulcers... M0210: Unhealed Pressure Ulcer(s)... Steps for Assessment 1. Review the medical record, including skin care flow sheets or other skin tracking forms. 2. Speak with direct care staff and the treatment nurse to confirm conclusions from the medical record review. 3. Examine the resident and determine whether any skin ulcers are present... Coding Instructions... Code 1, yes: if the resident had any pressure ulcer... in the 7-day look-back period..." RI #7 was readmitted to the facility on [DATE]. Review of RI #7's Nurses Notes from 12/19/2014 revealed staff had noted an open area measuring 2 cm (centimeters) by 2.5 cm to RI #7's left buttock with a purple non-blanchable area at the base of the wound. RI #7's wound notes indicated the left buttocks wound originated on 12/19/2014. The nurse doing the assessment on 12/19/2014 documented the wound as a Stage Two Pressure Ulcer. RI #7's Quarterly MDS Assessment with an ARD of 12/23/2014 did not reflect RI #7's Stage Two Pressure Ulcer. Employee Identifier (EI) #7, the MDS Coordinator, was interviewed on 02/05/2015 at 8:15 AM. The surveyor asked when RI #7 had developed a pressure ulcer, and EI #7 stated 12/19/2014. When asked why it was not reflected on the 12/23/2014 Quarterly MDS Assessment, EI #7 stated it had not been staged at that point and the Nurses' Notes called it an "open area." EI #7 further stated she was not sure the wound notes had been available to her at that time.

Based on record review and interviews, the facility failed to ensure a care plan was developed to address Resident Identifier (RI) #4's repeated refusals of sliding scale insulin. This affected one of 14 residents for whom care plans were reviewed. Findings Include: RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #4's current "Physician Orders" revealed an order dated 04/02/2014 for the following: Finger Stick Blood Sugars at 6 AM, 4 PM, and 9 PM with [MEDICATION NAME] Insulin sliding scale subcutaneously (SQ): 201-250= 2 units SQ 251-300= 4 units SQ 301-350= 6 units SQ 351-400= 8 units SQ Review of RI #4's MARs from 12/01/2014 through 02/04/2015 revealed RI #4 had refused sliding scale insulins once in December, 17 times in January, and twice in February. Review of all current care plans for RI #4, last reviewed 12/4/2014, revealed no care plan addressing insulin refusals. None of the current care plans listed approaches instructing staff on appropriate actions to be taken if RI #4 refused insulin. During an interview on 02/05/2015 at 8:20 AM, Employee Identifier (EI) #7, the Care Plan Coordinator, was asked how refusals of medications such as insulins should be addressed in the way of a care plan. EI #7 stated she would not be aware until the next assessment, but staff should let her know prior to then. When asked how she would be made aware of the need to create a careplan, EI #7 explained she normally care planned for refusals if staff let her know. EI #7 stated, "It's (it is) all about communication with staff."After reviewing RI #4's MARs and refusals, EI #7 stated "We may need to pull (RI#4's) MARs so the doctor can review it." EI #8, the Director of Nursing, was interviewed on 02/05/2015 at 9:14 AM. After reviewing RI #4's MARs and refusals, EI #8 was asked how it should have been handled. EI #8 stated the care plans should address it. When asked what potential harm could occur if RI #4's refusals were not addressed, EI #8 stated that if RI #4's blood sugars stayed elevated, it could affect vision, kidneys, and extremities. When asked how staff would know how to respond to RI #4's refusals if not care planned, EI #8 explained nursing judgement, but further explained the care plan is the driving force to make sure everyone is on the same page.

Based on observations, record review, and interview, the facility failed to ensure Resident Identifier (RI) #7's care plans were updated to reflect the resident's preference to have the bed adjusted so that the television was at eye level. This affected one of 14 sampled residents for whom care plans were reviewed. Findings Include: Review of the facility's policy titled "Care Plans- Comprehensive", revised October 2009, revealed the following: "...Policy Interpretation and Implementation... 3. Each resident's comprehensive care plan is designed to: ...d. Reflect the resident's expressed wishes regarding care and treatment goals..." RI #7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #7's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 12/23/2014 revealed RI #7 suffered no short or long term memory impairment and had modified independence for cognitive skills for daily decision making in new situations only. Review of RI #7's current care plans, revised 10/09/2014, revealed a fall intervention of "Keep my bed in lowest position..." On 02/03/2015 and 02/04/2015 RI #7 was observed in bed with the bed raised and not in the lowest position. On 02/05/2015 at 7:40 AM, RI #7 was observed in bed with the bed in the lowest position. Employee Identifier (EI) #7, the Care Plan Coordinator, was interviewed on 02/05/2015 at 8:15 AM. When asked about the intervention of bed in lowest position, EI #7 stated she should have updated RI #7's care plan to reflect the preference to have the bed at eye level with the television because RI #7 will get upset if it is not.

Based on observations, interviews, and record review, the facility failed to ensure licensed staff performing wound care to RI (Resident Identifier) #1 did not allow 4X4 gauze to be handled with ungloved hands and touch the privacy/dividing curtain prior to using the 4x4 gauze for RI #1's wound care. The facility further failed to ensure that Employee Identifier (EI) #1 did not use the 4x4 gauze more than once during RI #1's wound care. This affected one of two wound care observations. Findings include: Review of a facility policy titled "Wound Care" with a revision date of October 2010 revealed the following: "... Steps in the Procedure 1. Use disposable cloth ...to establish clean field on resident's overbed table. Place all items to be used during the procedure on the clean field. Arrange the supplies so they can be easily reached. ...14. Be certain all clean items are on clean field. ..." Review of a facility policy titled "Dressings, Dry/Clean" with a revision date of February 2014 revealed the following: "...Steps in the Procedure... 15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. ..." RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Significant Change Minimum Data Set ((MDS) dated [DATE] documented RI #1 was severely impaired in cognition, and required total dependence on staff for bed mobility and toileting. This MDS also revealed that RI #1 had an unstageable pressure ulcer. A review of RI #1's Physician order [REDACTED].#1's coccyx daily and as needed. On 2/5/15 at 11:07 AM, the surveyor observed EI #1, LPN (Licensed Practical Nurse) and EI #2, RN/Unit Mgr. (Registered Nurse/Unit Manager) perform wound care to RI #1's unstageable coccyx wound. EI #s 1 and 2 assisted with the set up of supplies for RI #1's wound care. EI #2 entered the room with 4x4 gauze in her bare hands and as she was placing the 4x4 gauze on the overbed table, EI #2 bumped the gauze against the privacy/dividing curtain. EI #1 then moved the overbed table from the right side of the room to the left side of the room. During this process, the 4x4 gauze was touching the privacy/dividing curtain and remained touching the curtain throughout the wound care. EI #2 measured the wound and EI #1 began performing the wound care. EI #1 sprayed saline wash into cups and then saturated the 4x4 gauze. EI #1 cleansed the wound with one 4x4 gauze and then unfolded it and reused the same 4x4 gauze to continue cleaning the wound. EI #1 got a second 4x4 gauze and again unfolded it and reused the same 4x4 gauze to clean the wound. On 2/5/15 at 2:53 PM, the surveyor interviewed EI #1, the LPN performing wound care to RI #1. EI #1 was asked if clean 4x4 gauze should be touched with bare hands. She replied that gloves should be worn to touch the gauze. The surveyor explained wound care observation regarding the 4x4 gauze touching the privacy/dividing curtain. EI #1 stated she did not realize the 4x4 gauze was touching the curtain. EI #1 was asked what was the potential for harm in the gauze being touched with ungloved hands and touching the privacy curtain. EI #1 replied it messed up the clean field. EI #1 was asked how often should a 4x4 gauze be used during wound care. She replied once. EI #1 further stated that she thought she could fold the 4x4 and use it again like in perineal care. On 2/5/15 at 3:12 PM, the surveyor interviewed EI #2, RN/Unit Mgr and Infection Control Nurse. EI #2 was asked how should 4x4 gauze be handled. She replied with gloves. EI #2 was asked if she had worn gloves while handling the 4x4 gauze for RI #1's wound care. She replied no. EI #2 was asked if 4x4 gauze should touch the privacy curtain. She replied no due to germs and infection control. EI #2 further stated that the privacy curtain was considered dirty. EI #2 was asked if 4x4 gauze should be reused during wound care. She replied no due to infection control.

Based on record review and interview, the facility failed to ensure a Significant Change Minimum Data Set (MDS) was completed for Resident Identifier (RI) #9 in December 2014 when the resident experienced a significant improvement in Activities of Daily Living (ADLs) as well as bowel and bladder status. This affected 1 of 14 sampled residents for whom MDSs were reviewed. Findings Include: Review of the facility's policy titled "Change in a Resident's Condition or Status", revised April 2007, revealed the following: "... Policy Interpretation and Implementation... 2. A "significant change" of condition is a decline or improvement in the resident's status that: ... b. Impacts more than one area of the resident's health status; and c. Requires interdisciplinary review and/or revision to the care plan... 7. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA (Omnibus Budget Reconciliation Act) regulations governing resident assessments..." RI #9 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with a [DIAGNOSES REDACTED]. Review of RI #9's Quarterly MDS with an Assessment Reference Date (ARD) of 10/08/2014 in comparison with the Quarterly MDS with an ARD of 12/18/2014 revealed RI #9 had made the following improvements in ADLs as well as bowel and bladder status: RI #9 went from requiring extensive assistance of one person to requiring limited assistance of one person for bed mobility, transfers, locomotion on the unit, dressing, toilet use, and personal hygiene. For locomotion off the unit, RI #9 improved from being totally dependent on one staff to only requiring limited assistance. RI #9 also improved from requiring set up and supervision for eating, to independent with set up help. In October, RI #9 had a catheter and was occasionally incontinent of bowel. By December, RI #9 had improved to always continent of both bowel and bladder. During an interview on 02/05/2015 at 8:40 AM, Employee Identifier (EI) #7, the MDS Coordinator, and the surveyor reviewed RI #9's Quarterly MDS Assessments from both October and December 2014. When asked if RI #9 would require a Significant Change Assessment, EI #7 explained RI #9 could have had a Significant Change Assessment in December but it had been an oversight. EI #7 further explained the facility had been undergoing many changes during that time and communication was not at its greatest. EI #7 stated the Restorative Nurse was responsible for doing the ADL and Bowel and Bladder Assessments, and she (EI #7) was responsible for opening the assessments. When asked if, as the MDS Coordinator, she reviewed the MDSs prior to finalizing, EI #7 stated she was responsible for several sections and trusted that others did theirs correctly.

This citation was written as a result of the investigation of complaint/report AL 125. Based on record reviews and interviews the facility failed to follow professional standards of practice, the facility's policy and procedures and Resident Identifier (RI) #1's physician orders [REDACTED]. 1) Licensed staff failed to provide treatment to RI #1's surgical wound as ordered by the physician to change the bandage to the left hip every other day and to cleanse the left hip with wound cleanser then cover with an abdominal pad. 2) Licensed staff stopped RI #1's surgical wound treatment order on 4/29/2014 without obtaining a physician's orders [REDACTED]. 3) Licensed staff provided treatment to RI #1's surgical wound without a physician's orders [REDACTED].#1. RI #1 was subsequently hospitalized with the wound infected [MEDICAL CONDITIONS] and Proteus Mirabilis that required further surgical intervention, hospitalization and a six week course of intravenous (IV) antibiotics via a Peripherally Inserted Central Catheter (PICC) line. These deficient practices affected RI #1, one of two sampled residents, and posed an immediate threat to the health and safety of RI #1, as it is likely to cause serious harm, injury, impairment, or death. On 6/7/2014 at 6:55 PM, the Administrator and Director of Nursing (DON) were made aware that the surveyors identified an Immediate Jeopardy level "J" at F 281. The Immediate Jeopardy began on 4/23/2014 and was relieved on 6/7/2014 at 11:05 PM, when it was verified the facility implemented immediate corrective actions to remove the immediacy. The scope and severity level of F 281 was lowered to a "D" level to allow the facility time to monitor and if necessary, revise their corrective actions to achieve substantial compliance with F 281. Findings include: A review of the Alabama Board on Nursing Chapter 610-X-6 Standards of Nursing Practice, documented: "... 610-X-6-.04 Practice of Professional Nursing (Registered Nurse Practice) (1) The practice of professional nursing includes, but is not limited to: ... (f) Documentation of nursing interventions and responses to care in an accurate, timely, thorough and clear manner. (g) Executing medical regimens including administering medications and treatments prescribed by a licensed or otherwise legally authorized prescriber. ... 610-X-6-.05 Practice of Practical Nursing (Licensed Practical Nurse Practice) (1) The practice of practical nursing includes ... (f) Administering medications and treatments when ordered by a legally authorized prescriber. ... 610-X-6-.06 Documentation Standards ... (2) Documentation of nursing care shall be: (b) Accurate. (c) Complete. Complete documentation includes reporting and documenting on appropriate records a patient's ... treatments, medications, other nursing care rendered ... A signature of the writer, whether electronic or written, is required in order for the documentation to be considered complete ... (d) Timely. (i) Charted at the time or after the care, including medications, is provided ... ." A review of the facility's policy, with a revised date of 2/17/2009, documented: "Charting and Documentation ... Policy Statement, All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. ..." RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's admission MDS (Minimum Data Set) with an Assessment Reference Date (ARD) date of 4/28/2014 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact for daily decision making skills. Section M1040. Other Ulcers, Wounds and Skin Problems revealed RI #1 had a surgical wound. Section M1200. Skin and Ulcer Treatments indicated RI #1 required surgical wound care. RI #1's April 2014 admission physician's orders [REDACTED]. CLEAN LEFT HIP WITH WOUND CLEANSER, AND APPLY ABD (abdominal) PAD. SECURE WITH TAPE EVERY OTHER DAY. ..." The April physician's orders [REDACTED]. RI #4's April 2014 electronic Treatment Administration Record (eTAR) included the treatment order to the left hip to be completed on the following scheduled days: 4/23/2014 (Wednesday), 4/25/2014 (Friday) and 4/27/2014 (Sunday). In the space on the eTAR to document whether the treatment had been given was an "N" entered for each day -- 4/23/2014, 4/25/2014 and 4/27/2014. According to the legend at the top of the eTAR an "N" indicated the treatment was "Not Administered." The eTAR also included a discontinue date to stop RI #1's treatment on 4/29/2014. No other wound treatment documentation was entered on the April 2014 eTAR. RI #1's May 2014 eTAR had an order to treat RI#1's left hip wound dated 5/4/2014. On 5/4/2014 order was received to "CLEANSE LEFT HIP WITH WOUND CLEANSER, PAT DRY. APPLY CALCIUM ALGINATE DRESSING APPLY SKIN PREP AROUND WOUND AND COVER WITH ABD PAD EVERYDAY UNTIL HEALED." On 5/5/2014 RI #1 was discharged to the hospital. A nurses note dated 4/27/2014 at 10:49 PM and signed by EI (Employee Identifier) #5, LPN (Licensed Practical Nurse) charge nurse, documented, "...Site open to air no bandage on it at this time. site pinkish around staples ..." During an interview on 6/6/2014 at 2:00 PM, EI #5 was asked about RI #1's wound and dressing. EI #5 explained that at times the incision had been left open to air (without a dressing covering the wound as ordered). Review of EI #3's Employee Disciplinary Report (EDR) dated 6/7/2014 revealed, "... Nature of Offense ... Substandard Work ... Dressing not completed by LPN charge nurse on 4/23, 4/25, 4/27. RN Supervisor dc'd (discontinued) dressing order on 4/29/2014, but there is no written/signed order on chart, nor no explanation in nurses notes explaining why order was dc'd..." This form was signed by for EI #3, RN (Registered Nurse) Unit Manager, EI #2, DON (Director of Nursing) and EI #1, the Administrator. EI #3 was interviewed on 6/7/2014 at 8:35 AM. EI #3 was asked who made the decision to leave RI #1's dressing off and to leave the resident's incision open to air. EI #3 admitted she made the decision to leave RI #1's wound open to air without a dressing. EI #3 further explained that when the incision site was left open to air, the charge nurse was responsible for documenting in the resident's record. EI #3 was unable to recall who the charge nurse was when the dressing was left open and uncovered. When asked if there was an order or a standing order to leave the resident's wound uncovered, EI #3 stated, no. EI #3 was asked if she had followed the physician's orders [REDACTED]. EI #3 was asked who was responsible for ensuring treatment orders were followed. EI #3 confirmed that it was her job to make sure they (the charge nurses) did their jobs to ensure treatment orders were followed. When asked what was the harm in not following doctors orders, EI #3 stated there was potential for infection or complications and that proper care would not be given. EI #3 was asked why the treatment for [REDACTED]. A review of a facility EDR (Employee Disciplinary Report) dated 6/4/2014, with an incident date of 5/1/2014 for EI #4, LPN Treatment Nurse revealed "...Nature of Offense ... Substandard Work ... Family upset over wound ... Dressing change was completed by this employee but no written order for dressing change and no documentation completed regarding wound care. ..." On 6/7/2014 at 2:45 PM an interview was conducted with EI #4, LPN Treatment Nurse. When asked about the reason for her Employee Disciplinary Report, EI #4 stated she received the disciplinary action for not documenting the appearance of RI #1's wound and for not writing an order for [REDACTED].#1's wound. EI #4 was asked when did she provide treatment to RI #1's wound, but admitted she did not know when the treatment was done because she did not chart it. On 6/7/2014 at 1:05 PM an interview was conducted with EI #2, RN, DON (Director of Nursing). EI #2 was asked why EI #3's (Unit Manager) Employee Disciplinary Report documented RI #1's dressing was not completed by the LPN charge nurse on 4/23, 4/25, and 4/27. EI #2 stated that it was EI #3's responsibility as unit manager to over see care given by nurses on her unit. EI #2 was asked who entered the 4/29/2014 stop date for RI #1's treatment to be discontinued. EI #2 explained that, according to the facility's computer system, EI #3 (the Unit Manager) modified the order. In a subsequent interview on 6/7/2014 at 1:50 PM, EI #2 explained that she could not answer why RI #1's 4/21/2014 treatment order was discontinued on 4/29/2014 because there was no documentation in RI #1's medical record to explain why. EI #2 was asked why EI #4's (LPN/Treatment Nurse) Employee Disciplinary Report documented EI #4 completed a dressing change and did not write an order or document that she performed a treatment to RI #1's wound. EI #2 confirmed that EI #4 was written up because she did not document the treatment and did not write an order for [REDACTED].#1. EI #2 was asked what the facility's policy was for following doctor's orders. EI #2 stated the facility's policy was to follow doctor's orders as written. When asked why RI #1's incision had been left open to air (uncovered), EI #2 stated she did not know because their was no documentation to explain why. EI #2 was asked what was the harm in not following physicians orders. EI #2 stated that it violated the facility's policy and it is the basis of everything they do to provide the care the doctor has ordered for the residents. ******************************************************** On 6/7/2014 at 10:45 PM, the Administrator provided the surveyors with an acceptable AoC which documented the following: "F 281 - This is an Allegation of Compliance (AoC) The resident's chart has been reviewed to verify that all current orders are being carried out as ordered by the attending Physician. This will be checked daily by the RN Supervisor until the resident is discharged home. If an error is found, it will be corrected immediately. The resident's June 2014 paper MAR (Medication Administration Record)and TAR have been printed from the computer and nurses will be responsible to fill in the blanks on the paper MARs and TARs along with charting the eMAR (electronic) in the computer until the resident is discharged home. The RN Supervisor will check the paper MAR and TAR daily to ensure that this resident's records reflect all treatments for her has been properly documented. This will also prevent a nurse from canceling an order without proper reason. If problems are found, disciplinary actions will be taken up to termination. All licensed personnel will be inserviced starting immediately on the severity of this deficiency and others will be inserviced before being allowed to return to work. IN-SERVICE EFFECTIVE IMMEDIATELY 6/7/2014 NO STAFF MAY RETURN TO WORK UNTIL INSERVICED ON: 1. Must verify that all current orders are being carried out as ordered. 2. The order will be checked daily per RN supervisor until discharge with disciplinary action up to termination. 3. If errors found, it will be corrected immediately by charge nurse. 4. MAR and TAR will be implemented from computer a. Charge nurse will be responsible for filling in blanks b. Charting will continue on eMAR in computer until discharge ALL MARs AND TARs must be completed on ALL residents There will not be a blank left on either form from this day forward" ******************************************************* After receiving an acceptable AoC on 6/7/2014 at 10:45 PM, RI #1's June MAR and TAR were reviewed and various nursing staff interviewed regarding the in-service on providing treatment as ordered by physician and recording all treatments provided.

This citation was written as a result of the investigation of complaint/report AL 125. Based on record review, interview and review of facility policies, the facility failed to ensure: 1) Licensed staff provided wound treatments as ordered to RI (Resident Identifier) #1. RI #1 was admitted to the facility on [DATE] following a left hip replacement with orders for wound care. There was no documentation in RI #1's medical record that the licensed staff completed the wound treatments as ordered. 2) Licensed staff did not change RI #1's wound treatment without the physician's approval. Licensed staff entered a discontinue date of 4/29/2014 on RI #1's treatment record to stop the treatment to her left hip wound. 3) A licensed staff member, who stated she provided wound care to RI #1 during her stay failed to obtain a physician's orders [REDACTED]. RI #1 was subsequently hospitalized with a wound infected [MEDICAL CONDITIONS] and Proteus mirabilis that required excision, debridement and a six week course of antibiotic therapy via PICC (Peripherally Inserted Central Catheter) line. This affected one of two residents sampled with orderd for wound care. These deficient practices posed an immediate threat to the health and safety of residents, as it is likely to cause serious harm, injury, impairment, or death. On 6/7/2014 at 6:55 PM, the Administrator and DON (Director of Nursing) were made aware that the surveyors identified an Immediate Jeopardy level "J" at F 309. The Immediate Jeopardy began 4/23/2014 and was relieved 6/7/2014 at 11:05 PM, when it was verified the facility implemented immediate corrective actions to remove the immediacy. The scope and severity level of F 309 was lowered to an "D" level to allow the facility time to monitor and if necessary, revise their corrective actions to achieve substantial compliance with F 309. Findings include: Refer to F 281 and F 490 The facility policy and procedure titled "Charting and Documentation," with a revised date of 2/17/2009, documented "... Policy Interpretation and Implementation 1. All observations ... services performed ... must be documented in the resident's clinical records ... 6. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused ... ." The facility policy and procedure titled "Medication Orders," with a revised date of December 2008, revealed "... Recording Orders ... 6. Treatment Orders: a. When recording treatment orders, specify: b. The specific treatment, frequency and duration of the treatment ..." RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's admission MDS (Minimum Data Set) with an Assessment Reference Date (ARD) date of 4/28/2014 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact for daily decision making skills. Section M1040. Other Ulcers, Wounds and Skin Problems revealed RI #1 had a surgical wound. Section M1200. Skin and Ulcer Treatments indicated RI #1 required surgical wound care. RI #1's April 2014 admission physician's orders [REDACTED]. CLEAN LEFT HIP WITH WOUND CLEANSER, AND APPLY ABD (abdominal) PAD. SECURE WITH TAPE EVERY OTHER DAY. ..." The April physician's orders [REDACTED]. RI #4's April 2014 electronic Treatment Administration Record (eTAR) included the treatment order to the left hip to be completed on the following scheduled days: 4/23/2014 (Wednesday), 4/25/2014 (Friday) and 4/27/2014 (Sunday). In the space on the eTAR to document whether the treatment had been given was an "N" entered for each day -- 4/23/2014, 4/25/2014 and 4/27/2014. According to the legend at the top of the eTAR an "N" indicated the treatment was "Not Administered." The eTAR also included a discontinue date to stop RI #1's treatment on 4/29/2014. No other wound treatment documentation was entered on the April 2014 eTAR. A review of RI #1's Nurses Notes revealed there was no documention of any dressing changes completed by facility staff. A Nurses Note dated 4/27/2014 at 10:49 PM, documented "...Site open to air no bandage on it at this time. site pinkish around staples ... ." This entry was signed by EI (Employee Identifier) #5, LPN (Licensed Practical Nurse) Charge Nurse. During an interview on 6/6/2014 at 2:00 PM, EI #5 was asked about RI #1's wound and dressing. EI #5 explained that at times the incision had been left open to air (without a dressing covering the wound as ordered). Review of EI #3's Employee Disciplinary Report (EDR) dated 6/7/2014 revealed, "... Nature of Offense ... Substandard Work ... Dressing not completed by LPN charge nurse on 4/23, 4/25, 4/27. RN Supervisor dc'd (discontinued) dressing order on 4/29/2014, but there is no written/signed order on chart, nor no explanation in nurses notes explaining why order was dc'd..." This form was signed by for EI #3, RN (Registered Nurse) Unit Manager, EI #2, DON and EI #1, the Administrator. EI #3 was interviewed on 6/7/2014 at 8:35 AM. EI #3 was asked who made the decision to leave RI #1's dressing off and to leave the resident's incision open to air. EI #3 admitted she made the decision to leave RI #1's wound open to air without a dressing. EI #3 further explained that when the incision site was left open to air, the charge nurse was responsible for documenting in the resident's record. EI #3 was unable to recall who the charge nurse was when the dressing was left open and uncovered. When asked if there was an order or a standing order to leave the resident's wound uncovered, EI #3 stated, "No." EI #3 was asked if she had followed the physician's orders [REDACTED]. EI #3 was asked who was responsible for ensuring treatment orders were followed. EI #3 confirmed that it was her job to make sure they (the charge nurses) did their jobs to ensure treatment orders were followed. When asked what was the harm in not following doctors orders, EI #3 stated there was potential for infection or complications and that proper care would not be given. EI #3 was asked why the treatment for [REDACTED]. A facility Employee Disciplinary Report (EDR) with an incident date of 4/23/14 for EI # 7, an LPN, documented "...Facts of the Incident: Dressing ordered on...(RI #1) was not completed by this employee. Resident has developed a wound infection and family concerned that care not consistently given. ... ." RI #1's eTAR documented her wound treatment was not administered on 4/23/2014. A facility Employee Disciplinary Report with an incident date of 4/25/14, for EI #8, an LPN, documented "...Facts of the Incident: Dressing ordered on ...(RI #1) was not completed by this employee... . This item was left red in computer charting until cleared..." 4/25/2014 was the date RI #1's eTAR documented her wound treatment was not administered. A review of a facility Employee Disciplinary Report dated 6/4/2014, with an incident date of 5/1/2014 for EI #4, LPN Treatment Nurse revealed "... Nature of Offense ... Substandard Work ... Family upset over wound ... Dressing change was completed by this employee but no written order for dressing change and no documentation completed regarding wound care ..." On 6/7/2014 at 2:45 PM an interview was conducted with EI #4, LPN Treatment Nurse. When asked about the reason for her Employee Disciplinary Report, EI #4 stated she received the disciplinary action for not documenting the appearance of RI #1's wound and for not writing an order for [REDACTED].#1's wound. EI #4 was asked when did she provide treatment to RI #1's wound, but admitted she did not know when the treatment was done because she did not chart it. On 5/5/2014 the resident was admitted to the hospital for wound debridement and closure of her infected surgical wound. The hospital Infectious Disease Consultation dated 5/6/2014 documented: "...Left hip wound infection. ... History of Present Illness: ... permanent hip endoprosthesis on April 16, 2014 for femoral neck left [MEDICAL CONDITION] after a fall. ... She was discharged to a nursing home rehab ... where she was noted to have redness around the incisions 1 week postoperative with progressive more swelling. ... a wound culture [MEDICAL CONDITION] and Proteus mirabilis. ... RI #1 was placed on IV antibiotics via PICC line." During an interview on 6/7/2014 at 10:10 AM, RI #1's family members stated they visited everyday and noticed RI #1 did not have a bandage on her wound. The family members also stated they did not see anyone treat RI #1's wound during their daily visits and remembered that the wound never had a dressing on it until around 4/30/2014 when it began to drain. On 6/7/2014 at 1:05 PM an interview was conducted with EI #2, RN, DON (Director of Nursing). EI #2 was asked why EI #3's (Unit Manager) Employee Disciplinary Report documented RI #1's dressing was not completed by the LPN charge nurse on 4/23, 4/25, and 4/27. EI #2 stated that it was EI #3's responsibility as unit manager to over see care given by nurses on her unit. EI #2 was asked who entered the 4/29/2014 stop date for RI #1's treatment to be discontinued. EI #2 explained that, according to the facility's computer system, EI #3 (the Unit Manager) modified the order. In a subsequent interview on 6/7/2014 at 1:50 PM, EI #2 explained that she could not answer why RI #1's 4/21/2014 treatment order was discontinued on 4/29/2014 because there was no documentation in RI #1's medical record to explain why. EI #2 was asked why EI #4's (LPN/Treatment Nurse) Employee Disciplinary Report documented EI #4 completed a dressing change and did not write an order or document that she performed a treatment to RI #1's wound. EI #2 confirmed that EI #4 was written up because she did not document the treatment and did not write an order for [REDACTED].#1. EI #2 was asked what the facility's policy was for following doctor's orders. EI #2 stated the facility's policy was to follow doctor's orders as written. When asked why RI #1's incision had been left open to air (uncovered), EI #2 stated she did not know because their was no documentation to explain why. EI #2 was asked what was the harm in not following physicians orders. EI #2 stated that it violated the facility's policy and it is the basis of everything they do to provide the care the doctor has ordered for the residents. She further stated if it is not documented, there is no proof to show what care you provided for your resident. ************************************************************** On 6/7/2014 at 10:45 PM , the Administrator provided the surveyors with an acceptable AoC which documented the following: " F # 309 - This is an allegation of Compliance The resident's TAR for June 2014 has been printed from the computer and it will be the charge nurse's immediate responsibility to chart both paper TAR and chart on the E-TAR (electronic TAR) until the resident is discharged . It will be the RN Supervisor's responsibility to check daily to assure all areas of treatments have been rendered and signed off by the responsible charge nurse. The RN supervisor will be responsible to also check daily the resident's last skin assessment for any changes in condition and verify an order has been received if applicable. The RN supervisor will be responsible to complete a weekly skin assessment of this resident and compare it to the most recent skin assessment completed by the charge nurse to assure there are no new areas of concerns that need addressing. All licensed personnel will be inserviced starting immediately on the severity of this deficiency and others will be inserviced before being allowed to return to work. All licensed personnel will be inserviced starting immediately on the severity of this deficiency and others will be in serviced before allowing returning to work. Inservice Effective Immediately 6/7/2014 NO STAFF MAY RETURN TO WORK UNTIL INSERVICED ON: 1. Must verify that all current orders are being carried out as ordered 2. The order will be checked daily per RN supervisor until discharge with disciplinary action up to termination 3. If errors found, it will be corrected immediately by charge nurse 4. MAR and TAR will be implemented from computer a. Charge nurse will be responsible for filling in blanks b. Charting will continue on eMAR in computer until discharge All MARs and TARs must be completed on ALL residents There will not be a blank left on either form from this day forward" ************************************************************** After receiving an acceptable AoC on 6/7/2014 at 10:45 PM, the in-service sign in sheet was reviewed and various nursing staff were identified and interviewed regarding orders being carried out as ordered.

This citation was written as a result of the investigation of complaint/report AL 125. Based on interview and record review, the administration failed to provide oversight to ensure licensed staff were knowledgeable and able to correctly utilize the electronic health record system to document physician orders [REDACTED].#1 as evidenced by: 1) The eTAR (electronic Treatment Administration Record) component of the Electronic Health Record failed to reflect the accuracy of and the completion of physician ordered treatments for RI #1's surgical wound; 2) The eMAR (electronic Medication Administration Record) component failed to reflect RI #1's physician's orders [REDACTED]. Staff further failed to document the medication as administered as ordered. RI #1 was admitted to the facility with an order for [REDACTED]. This affected RI (Resident Identifier) #1, one of two sampled residents identified with wounds. These deficient practices posed an immediate threat to the health and safety of residents, as it is likely to cause serious harm, injury impairment, or death. On 6/7/2014 at 6:55 PM, the Administrator and DON ( Director of Nursing) were made aware that the surveyors identified an Immediate Jeopardy level "J" at F 490. The Immediate Jeopardy began on 4/23/2014 and was relieved on 6/7/2014 at 11:05 PM, when it was verified the facility implemented immediate corrective actions to remove the immediacy. The scope and severity level of F 490 was lowered to an "D" level to allow the facility time to monitor and if necessary, revise their corrective actions to achieve substantial compliance with F 490. Findings include: Refer to F 309, F 281 and F 514 The facility job description titled "Administrator" with a date of hire 3/22/04, revealed the following: "...Delegation of Authority As the Administrator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties...Administrative Functions...Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities...Interpret the facility's policy and procedures to employees...as necessary...Ensure that all employees...follow established policies and procedures...Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed... Miscellaneous...ensure each resident receives the necessary nursing, medical, ...services..." A policy titled "Resident Care Charting in the EHR... Mandatory--Must be implemented as written" with an effective date 11/01/2013, revealed the following "...It is the policy of this facility that resident care documentation occurs 24/7 within the...(EHR). Documentation is designed to occur at the point of service by those direct care givers responsible for the resident's care delivery... . 6. Licensed nurse charting occurs in several places in ...b. Narrative notes are required when further explanation of events, physician's actions or interactions...occur and need documentation. ...e. eMAR and eTAR for the recording of delivery of medication and/or treatments prescribed by the physician... ." A facility memo addressed to "CHARGE NURSES" dated 04/08/2014 revealed the following: "Everyone needs to check the RED in the eMARS (electronic Medication Administration Record) and eTARS (electronic Treatment Administration Record) and IF YOU ADMINISTERED the medications or PERFORMED the TREATMENTS, you need to sign off that you have done so...THIS RED MUST BE CLEARED UP! IF THE MEDS (medications) WERE NOT ADMINISTERED OR THE TREATMENTS WERE NOT PERFORMED, DO NOT SIGN THAT THEY WERE!..." Another facility memo addressed to "CHARGE NURSES" dated 05/02/14 revealed the following: "We have QA'd (Quality Assurance) the Administration Records and have cleared them up through 04/30/14...Please make sure at the end of your shift nothing is in the red and that all charts that need charting on have been completed..." During an interview on 6/5/14 at 4:00 PM, the QA (Quality Assurance)/ IT (Information Technology) Registered Nurse EI (Employee Identifier) #6 explained that the facility went [MEDICATION NAME] on 3/4/2014 and had used both paper and computer records for a couple of weeks. EI #6 explained an in-service was done and they talked to staff and trained them on the computer system to correct and ensure documentation was accurate. EI #6 explained that nursing staff were leaving a lot of blanks because they did not understand how to use the system. EI # 6 stated that she was cleaning up the MARs and TARs. On 6/7/2014 at 1:50 PM an interview was conducted with EI #2, RN, DON (Director of Nursing). EI #2 was asked why was the treatment for [REDACTED]. EI #2 stated facility staff were still in the learning process, but that was no excuse. Staff know if they are not able to document in the computer or eMAR or eTAR, they can document on a paper MAR or TAR. An interview with the facility's Administrator, EI #1 was conducted on 6/7/14 at 2:15 PM. EI #1 was asked how she ensured that the nurses were able to appropriately use the computer system to document treatments and medications. EI #1 explained that the administrative staff was assigned to stay, even on second and third shifts, to assist nurses if needed on implementation. EI #1 stated the QA/IT (EI #6) nurse would periodically go in and check the entries on the eMARs and eTARs. EI #1 stated that EI #6 (QA/IT) and EI #2 (DON) were responsible for ensuring nurses were adequately trained in the computer system. EI #1 was asked why was there no documentation for RI #1's treatments and antibiotic. EI #1 stated she did not know why and was not made aware until they met with RI #1's family on 5/1/2014 and not aware of the antibiotic issue until 6/6/2014. EI #1 was asked what was the harm in not documenting antibiotics and wound treatments. EI #1 explained that if you do not document it, it was not done. ************************************************************* On 6/7/2014 at 10:45 PM, the Administrator provided the surveyors with an acceptable Allegation of Compliance which documented the following: "F 490 - This is an allegation of Compliance The resident MARs and TARs for June 2014 have been printed off the computer and the charge nurse will sign both paper MAR and TAR in addition to the computerized eTAR and eMAR. The RN supervisor will be responsible to check the paper MAR and TAR to ensure all licensed staff have enter information into the computer system accurately. The facility will print all residents paper MARs and TARs on 6/9/2014. The licensed personnel will be responsible for charting on both paper eMAR and eTAR while going back through a retraining period on the proper procedures of how to use American Health Tech's modules on eMARs and eTARs. Director of Nursing will assign all administrative staff resident's they will be responsible for checking paper trail eMAR and eTAR to assure the nurse or nurses are knowledgeable and proficient in their documentation of these two forms. The retraining session will be for two weeks only and then disciplinary action will be taken for those nurses who do not comply with accurate documentation requirements in the computer system. All licensed personnel will be inserviced starting immediately on the severity of this deficiency and others will be inserviced before being allowed to return to work. IN-SERVICE EFFECTIVE IMMEDIATELY 6/7/2014 NO STAFF MAY RETURN TO WORK UNTIL INSERVICED ON: 1. Must verify that all current orders are being carried out as ordered. 2. The order will be checked daily per RN supervisor until discharge with disciplinary action up to termination. 3. If errors found, it will be corrected immediately by charge nurse 4. MAR and TAR will be implemented from computer a. Charge nurse will be responsible for filling in blanks b. Charting will continue on eMAR in computer until discharge. ALL MARs and TARs must be completed on ALL residents. There will not be a blank left on either form from this day forward" ******************************************************** After receiving an acceptable Allegation of Compliance on 6/7/2014 at 10:45 PM, various nursing staff including LPN's were interviewed regarding their inservice on entering documentation accurately into the electronic record system.

Based on observation, interviews and record review, the facility failed to conduct weekly skin assessments on Resident Identifier (RI) #7, a resident at risk for further skin breakdown, as care planned. Since the implementation of the care plan to perform weekly skin assessments dated 02/20/14, there were no skin condition reports for 02/22/14 and for the entire months of March and April 2014. On 04/14/14, RI #7 was identified as having an open area to his right thumb that measured 2cm (centimeter) x (by) 1cm x 0.2cm. On 05/15/14, RI #7 had a Stage III pressure ulcer on his right thumb, that measured 3.8 cm x 1.5 cm with 0.1 cm depth. The wound bed was red and granulated with serosanguineous (bloody) drainage and a pink spot was noted in the middle of the wound bed. This affected RI #7, one of four residents identified by the facility as having a pressure ulcer. Findings include: RI #7 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #7's Quarterly Minimum Data Set (MDS) with an assessment reference date of 02/25/14, identified RI #7 as being totally dependent on staff for all Activities of Daily Living (ADLs). RI #7 was assessed as being at risk of developing pressure ulcers. During this assessment period, RI #7 had one Stage II pressure ulcer that was identified by the facility on 02/19/14. RI #7's care plan with a problem onset date of 02/20/14 and last reviewed 04/30/14 documented "I have pressure ulcers and am at risk for further skin breakdown R/T (related to) inability to control body movements & contractures D/T (due to) [MEDICAL CONDITION] requiring staff assistance to reposition and under ideal body weight ... ." The approaches listed were: " ... Weekly skin assessment per my charge nurse and document ... ." A facility form titled "Skin Assessment, Nail Care & Weekly Blood Pressure" revealed RI #7 was to have weekly skin assessments done on Saturdays on the 3-11 shift. Since the implementation of the care plan to perform weekly skin assessments dated 02/20/14, there were no skin condition reports for 02/22/14 and for the entire months of March and April 2014. The only skin condition reports in RI #7's medical record were dated 05/03/14 and 05/10/14. RI #7's "Departmental Notes" written by EI #8, the wound care LPN, documented " ... 4/14/2014 1:42 PM ... Open are (area) to right thumb ... Entire area is 2cm (centimeter) x (by) 1cm x 0.2cm red around edge ... ." On 05/15/14 at 12:55 PM, the surveyor observed EI #8, the wound care LPN and EI #9, a LPN, perform wound care on RI #7's right thumb. EI #8 measured the area to RI #7's right thumb. RI #7 had a Stage III pressure ulcer on his right thumb, that measured 3.8 cm by 1.5 cm with 0.1 cm depth. The wound bed was red and granulated with serosanguineous (bloody) drainage and a pink spot was noted in the middle of the wound bed. In an interview on 05/16/14 at 3:15 PM, EI #8, the wound care LPN stated the pressure ulcer to RI #7's right thumb was first identified on 04/14/14. When asked how often the nurse perform body audits, EI #8 said once a week. The surveyor asked EI #8 should someone have identified the area to RI #7's right thumb. EI #8 replied yes. The surveyor asked EI #8 who should that have been. EI #8 said, "The nurses who do the skin assessments. It should be done on a certain day of each week." The surveyor asked EI #8 did she have any body audit sheets from the month of April (2014). EI #8 replied no. During an interview on 05/16/14 at 4:55 PM, EI #21, a LPN was identified as working with RI #7 and asked if she recalled performing a body audit on RI #7 on 04/12/14 and 04/20/14. EI #21 replied, "If the audit is in the chart I did. If its not I don't recall whether I did or not ... ." In a telephone interview on 05/16/14 at 6:55 PM, EI #22, the LPN assigned to care for RI #7 on 04/05/14, was asked if he performed the scheduled body audit on RI #7 on 04/05/14. EI #22 replied, he didn't know if he had or not. During an interview on 05/16/14 at 7:05 PM, EI #1, the Director of Nursing (DON) was asked what evidence the facility had to prove body audits were being performed. EI #1 said, "The skin audit in the chart."

Based on observation, interviews and record review, the facility failed to ensure pain medication was administered to Resident Identifier (RI) #7, an alert and oriented resident who communicated he was in pain during a dressing change to his right thumb on 05/15/14. Although, RI #7 exhibited facial grimaces and requested pain medication during the treatment, Employee Identifier (EI) #9, a Licensed Practical Nurse (LPN) failed to stop the treatment, assess the resident's pain level and medicate RI #7 for his pain. This affected RI #7, one of four residents observed for wound care. Findings include: The facility's policy titled "PAIN MANAGEMENT", dated 03/29/04, documented: "Purpose: To ensure each resident who experiences pain will have a comprehensive assessment of that pain and have a treatment plan established to treat his or her pain ... Procedure: 1. Considerations ... * Unrelieved pain has a negative physical and psychological consequence including the potential for threatening functional ability ... ." RI #7 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #7's care plan with a problem onset date of 09/30/11 documented "I am at risk for pain ... ." RI #7's Quarterly Minimum Data Set with an assessment reference date of 02/25/14, indicated RI #7 was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15. RI #7's "Physician Orders" for May 2014 documented " ... [MEDICATION NAME] 650 MG (milligram) SUPPOSITORY INSERT ONE RECTALLY EVERY 4 HOURS AS NEEDED FOR PAIN ... [MEDICATION NAME] 5-325 MG GIVE BY MOUTH EVERY 6 HOURS AS NEEDED FOR BREAKTHROUGH PAIN ... ." On 05/15/14 at 12:55 p.m., the surveyor observed EI #8, the wound care LPN and EI #9, a LPN, perform wound care on RI #7's right thumb. RI #7 was observed lying in bed on his right side with a wedge device to his back. EI #9 removed the dressing from RI #7's right thumb with a pair of scissors. There was brownish-like drainage on the old dressing. RI #7 exhibited facial grimaces as EI #9 cut the dressing from the resident's thumb. RI #7 was asked by the staff if he wanted something for pain. RI #7 nodded his head up and down to indicate yes. EI #9 informed RI #7 that he would give him something for pain as soon as the treatment was completed. EI #8 measured the area to RI #7's right thumb. RI #7 had a Stage III pressure ulcer on his right thumb, that measured 3.8 cm by 1.5 cm with 0.1 cm depth. The wound bed was red and granulated with serosanguineous (bloody) drainage and a pink spot was noted in the middle of the wound bed. EI #8 asked RI #7 if he was hurting after observing RI #7's facial grimaces. RI #7 nodded his head up and down to indicate yes. EI #8 responded to RI #7 that the dressing change would soon be over. At that time, EI #8 pulled RI #7's right thumb back so EI #9 could place a clean dressing on RI #7's thumb. RI #7 continued to exhibit facial grimaces during the treatment. EI #8 explained to RI #7 that after one more dressing was placed on his thumb, he would be given something for pain. During an interview on 05/15/14 at 5:15 p.m., RI #7 was asked, when the nurses did the treatment to his right thumb what would he say his pain level was, on a scale of 0 to 10. RI #7 replied, "9." The facility's "PAIN EVALUATION" documented " ... Ask resident: "Please rate the intensity of your worst pain ... with 0 being no pain and 10 as the worst pain you can imagine ... ." In an interview on 05/16/14 at 1:55 p.m., EI #9 acknowledged that he administered [MEDICATION NAME] 7.5/325 mg to RI #7 after the dressing was changed on RI #7's right thumb. EI #9 stated it was RI #7's scheduled dose of pain medication for 1:00 PM. In a follow-up interview on 05/16/14 at 2:55 PM, EI #9 was asked did RI #7 have any orders to be medicated before his dressing change. EI #9 replied no. EI #9 said RI #7 had around the clock scheduled and PRN (as needed) pain medication. EI #9 said if he created a lot of pain for RI #7, he tried to give him the PRN as soon as he could. The surveyor asked EI #9 did RI #7 usually complain of pain during the dressing change. EI #9 said on yesterday (05/15/14) there were two of them (EI #8 and EI #9) performing the dressing change on RI #7's right thumb. EI #9 said EI #8 was holding the thumb out more than he normally did when he changed the dressing. EI #9 replied that's where he thought the pain came from. The surveyor asked EI #9, what did he think should have done when RI #7 nodded his head to indicate he was in pain. EI #9 stated he tried to give RI #7 reassurance that he would give him pain medication as soon as they were finished with the dressing change. EI #9 said to him (EI #9), it would be more painful on RI #7 to go and get the resident's pain medication and then start all over again. The surveyor asked EI #9 did the facility have a policy on what the nurse should do if a resident complains of pain during a dressing change. EI #9 replied he didn't think so. On 05/16/14 at 3:15 p.m., the surveyor conducted an interview with EI #8. The surveyor asked EI #8 did the facility have a policy that dictated what a nurse should do when a resident complains of pain during a dressing change. EI #8 replied she didn't think so. The surveyor asked EI #8, what should the nurse do when a resident complains of pain during a dressing change. EI #8 said, "Stop and give them something." The surveyor shared with EI #8 that RI #7 shared with the surveyor that on yesterday, his pain level was a 9 during the dressing change. The surveyor asked EI #8, what would she consider a 9 to be on the pain level of 0 to 10. EI #8 replied, "Very close to the worst you could be. I would say horrific. I would want something." In an interview on 05/16/14 at 7:05 p.m., EI #1, the Director of Nursing (DON) was asked, what should the nurse do when a resident complains of pain during a dressing change. EI #1 replied the pain needed to be addressed. EI #1 said the source of the pain needed to be found. When asked what she considered a pain score of 9 to be on a scale of 0 to 10, EI #1 said, "I would consider that pretty severe pain."

Based on observations, interviews and record review, the facility failed to implement Resident Identifier (RI) #7's pressure ulcer care plan by not performing weekly skin assessments. Since the implementation of the care plan to perform weekly skin assessments dated 02/20/14, there were no skin condition reports for 02/22/14 and for the entire months of March and April 2014. On 04/14/14, RI #7 was identified as having an open area to his right thumb that measured 2 cm (centimeter) x (by) 1 cm x 0.2 cm. On 05/15/14, RI #7 had a Stage III pressure ulcer on his right thumb, that measured 3.8 cm x 1.5 cm with 0.1 cm depth. The wound bed was red and granulated with serosanguineous (bloody) drainage and a pink spot was noted in the middle of the wound bed. The facility further failed to ensure the correct treatment was being used on RI #8's Stage IV pressure ulcer to the coccyx. This affected RI #7 and #8, two of four residents observed for wound care. Findings include: 1) RI #7 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #7's Quarterly Minimum Data Set (MDS) with an assessment reference date of 02/25/14, identified RI #7 as being totally dependent on staff for all Activities of Daily Living (ADLs). RI #7 was assessed as being at risk of developing pressure ulcers. During this assessment period, RI #7 had one Stage II pressure ulcer that was identified by the facility on 02/19/14. RI #7's care plan with a problem onset date of 02/20/14 and last reviewed 04/30/14 documented "I have pressure ulcers and am at risk for further skin breakdown R/T (related to) inability to control body movements & contractures D/T (due to) [MEDICAL CONDITION] requiring staff assistance to reposition and under ideal body weight ... ." The approaches listed were: " ... Weekly skin assessment per my charge nurse and document ... ." A facility form titled "Skin Assessment, Nail Care & Weekly Blood Pressure" revealed RI #7 was to have weekly skin assessments done on Saturdays on the 3-11 shift. Since the implementation of the care plan to perform weekly skin assessments dated 02/20/14, there were no skin condition reports for 02/22/14 and for the entire months of March and April 2014. The only skin condition reports in RI #7's medical record were dated 05/03/14 and 05/10/14. RI #7's "Departmental Notes" written by EI #8, the wound care LPN, documented: " ... 4/14/2014 1:42 PM ... Open are (area) to right thumb ... Entire area is 2cm (centimeter) x (by) 1cm x 0.2cm red around edge ... 4/16/2014 1:18 PM ... Right inner thumb, unstagable (unstageable) 2cm x 1cm x0.2cm, red wound bed with yellowish white tendon measuring 0.5cm in center. Minimal serosanguineous drainage, odor free. Light pink, blanchable per wound skin. [MEDICATION NAME] tx (treatment) continues as ordered ... 4/24/2014 12:47 PM ... Unstageable wound inplace (in place) to area. 3cm x 1.4cm x 0.1cm, red wound bed with minimal serosanguineous drainage with slight green odor free drainage to center of dressing. Blanchable, red peri wound skin, [MEDICATION NAME] ongoing to wound, cover with dry gauze and secure with paper tape ... 4/30/2014 12:56 PM ... Right inner thumb unstageable has increased in size to 4cm x 1cm x 0.1cm with red wound bed, [MEDICATION NAME] tx ongoing ... 5/8/2014 4:18 PM ... Right inner thumb unstagable (unstageable) 3cm x 1cm x 0.1cm, red non blanchable wound, minimal sanguineous drainage, [MEDICATION NAME] tx ongoing ... ." On 05/15/14 at 12:55 PM, the surveyor observed EI #8, the wound care LPN and EI #9, a LPN, perform wound care on RI #7's right thumb. EI #8 measured the area to RI #7's right thumb. RI #7 had a Stage III pressure ulcer on his right thumb, that measured 3.8 cm by 1.5 cm with 0.1 cm depth. The wound bed was red and granulated with serosanguineous (bloody) drainage and a pink spot was noted in the middle of the wound bed. In an interview on 05/16/14 at 3:15 PM, EI #8, the wound care LPN stated the pressure ulcer to RI #7's right thumb was first identified on 04/14/14. When asked how often the nurse perform body audits, EI #8 said once a week. The surveyor asked EI #8 should someone have identified the area to RI #7's right thumb. EI #8 replied yes. The surveyor asked EI #8 who should that have been. EI #8 said, "The nurses who do the skin assessments. It should be done on a certain day of each week." The surveyor asked EI #8 did she have any body audit sheets from the month of April (2014). EI #8 replied no. During an interview on 05/16/14 at 4:55 PM, EI #21, a LPN was identified as working with RI #7 and asked if she recalled performing a body audit on RI #7 on 04/12/14 and 04/20/14. EI #21 replied, "If the audit is in the chart I did. If its not I don't recall whether I did or not ... ." In a telephone interview on 05/16/14 at 6:55 PM, EI #22, the LPN assigned to care for RI #7 on 04/05/14, was asked if he performed the scheduled body audit on RI #7 on 04/05/14. EI #22 replied, he didn't know if he had or not. During an interview on 05/16/14 at 7:05 PM, EI #1, the Director of Nursing (DON) stated when she first saw the area to RI #7's right thumb it was beefy red. EI #1 stated to her, it was just an open area. When asked how often the nurses should perform skin audits, EI #1 said weekly. EI #1 was asked what evidence the facility had to prove body audits were being performed. EI #1 said, "The skin audit in the chart." 2) RI #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #8's Quarterly MDS with an assessment reference date of 02/12/14, identified RI #8 as being at risk for developing pressure ulcers. During this assessment period, RI #8 was identified as having one Stage IV pressure ulcer that measured 3.0cm (centimeter) in length by 0.2cm in width with 0.4cm depth. RI #8's physician order [REDACTED]." During RI #8's wound care observation on 05/13/14 at 8:11 p.m., performed by EI #7, a Registered Nurse (RN) and EI #8, the wound care LPN. EI #8 flushed the coccyx wound with Saline and patted the wound dry with two 4x4 gauze. EI #8 then used [MEDICATION NAME] to pack the wound bed, then covered the wound with a [MEDICATION NAME] dressing. The surveyor asked EI #8 the name of the dressing she used to pack RI #8's wound bed. EI #8 spelled out "[MEDICATION NAME]" to the surveyor. In an interview on 05/16/14 at 8:25 a.m., EI #8 was asked if she used the correct dressing ordered to pack RI #8's pressure sore on 5/13/14, when she changed his dressing. EI #8 stated, "No, I guess not if I used [MEDICATION NAME] instead of Silver Calcium Alginate." The surveyor asked EI #8 how long had she been using the [MEDICATION NAME] versus the Silver Calcium Alginate. EI #8 stated she did not know.