Every finding on record at Fairview at Redstone Village

Based on observations, interviews, and a review of facility policies titled MEAL SERVICE and Cleaning and Disinfection of Resident-Care Equipment, the facility failed to ensure staff changed gloves and performed hand hygiene during meal delivery and pick up. On 2/14/22 during the supper meal delivery in the downstairs dining room, Employee Identifier (EI) #5 Certified Nursing Assistant (CNA) was observed to deliver a supper tray to Resident Identifier (RI) #2 and RI #11 without changing gloves or performing hand hygiene before each resident's tray delivery and set up. On 2/15/22 during the breakfast meal tray pick up, EI #6, Staffing Coordinator, picked up breakfast trays from RI #251 and RI #31 without performing hand hygiene after each resident's tray was removed from their rooms. Further the facility failed to ensure EI #4, Licensed Practical Nurse (LPN), did not place used resident care equipment in her pocket. This had the potential to affect RI #11, RI #31, and the other 21 residents who resided on level one of the facility. Findings Include: A review of a facility policy titled MEAL SERVICE with an effective date of January 2010 revealed . GENERAL INFECTION CONTROL GUIDELINES . 3. Observe (standard) universal precautions or other infection control standards as approved by appropriate facility committee. 4. Perform hand hygiene between resident meal preparation . RI #2 was readmitted to the facility on [DATE]. RI #11 was readmitted to the facility on [DATE]. On 2/14/22 at 5:09 PM, EI #5, CNA, was observed to set a plate from a tray in front of RI #2, cut the meat with gloves on and take the empty tray to the counter with the same gloves on. EI #5 then picked up another tray while wearing the same gloves and delivered the tray to RI #11. EI #5 opened the yogurt, put the plate on the table for RI #11, and took the tray to the counter. EI #5 then removed the gloves and put on a clean pair of gloves. On 2/14/22 at 5:19 PM, an interview was conducted with EI #5. EI #5 was asked, when did she change her gloves between RI #2 and RI #11. EI #5 replied, she did not change gloves. EI #5 was asked, what was the risk of not changing gloves between residents. EI #5 replied, sanitation and contamination. EI #5 was asked, if she should have changed her gloves between residents. EI #5 replied, yes. RI #251 was admitted to the facility on [DATE]. RI #31 was readmitted to the facility on [DATE]. On 2/15/22 at 8:34 AM, EI #6, Staffing Coordinator, was observed to exit RI #251's room with a dirty tray. EI #6 walked down the hallway, placed the dirty tray on the food cart, and then positioned the food cart in front of RI #31's room without washing her hands. EI #6 then went into RI #31's room, without sanitizing or washing her hands, and asked the resident about lunch preferences. EI #6 then picked up RI #31's breakfast tray off the bedside table, exited RI #31's room and placed the tray on the food cart. On 2/15/22 at 8:39 AM, EI #6 was asked, how long had she worked at the facility. EI #6 replied, five years. EI #6 was asked, what room did she get the dirty tray out of before going into RI #31's room. EI #6 replied, RI #251's room. EI #6 was asked, when did she sanitize or wash her hands before going into RI #31's room. EI #6 replied, she thought she hit the sanitizer in the room, but she forgot. EI #6 was asked, what was the risk of not washing or sanitizing her hands before going into RI #31's room. EI #6 replied, germs. EI #6 was asked, should she have sanitized or washed her hands before going into RI #31's room. EI #6 replied, yes, always. EI #6 was asked, what was the policy on washing hands before going into a resident room. EI #6 replied, to sanitize or wash your hands before going into a room. On 2/17/22 at 8:13 AM, an interview was conducted with EI #2 RN, Infection Preventionist. EI #2 was asked, how long had she worked there. EI #2 replied, about a year and a half. EI #2 was asked, how often was staff trained on washing or sanitizing their hands. EI #2 replied, on hire, annually and as needed, group or individual, verbal or one on one. EI #2 was asked, what was the policy on washing hands when picking up a dirty tray from a resident's room and then putting it on the cart and entering another resident's room. EI #2 replied, they should sanitize before entering another residents room. EI #2 was asked, when should staff pick up a dirty tray and put it on the food cart and enter another resident's room without sanitizing their hands. EI #2 replied, never. EI #2 was asked, what was the risk of not washing their hands after picking up a dirty tray and entering another resident's room. EI #2 replied, cross contamination. EI #2 was asked, when should staff serving trays in the dining room with gloves on change them. EI #2 replied, between each resident. EI #2 was asked, what was the risk of not changing gloves in between residents when in the dining room serving trays. EI #2 replied, cross contamination. A review of the policy titled Cleaning and Disinfection of Resident-Care Equipment with an effective date of March 2020 revealed: Policy: Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection. RI #250 was admitted to the facility on [DATE]. 02/15/22 06:50 PM EI #4 was observed to assess vital signs for RI #250 and then place the used pulse oximeter and the thermometer in her pocket. On 2/15/22 at 7:18 PM, an Interview was conducted with EI #4, LPN. EI #4 was asked, how long had she worked there. EI #4 replied, two going on three years. EI #4 was asked, where had she placed the pulse oximeter and the thermometer. EI #4 replied, in her pocket. EI #4 was asked, was the thermometer and the pulse oximeter dirty. EI #4 replied, yes. EI #4 was asked, should she put the dirty thermometer and the pulse oximeter in her pocket. EI #4 replied, no. EI #4 was asked, what was the risk of putting a dirty pulse oximeter and thermometer in her pocket. EI #4 replied, bacteria or infection. On 2/17/22 at 10:47 AM, an interview was conducted with EI #1 RN. Director of Nursing (DON). EI #1 was asked, when should equipment be placed in nurse's pocket. EI #1 replied, equipment should not be in the pocket. EI #1 was asked, why not. EI #1 replied, infection control. EI #1 was asked, when should staff change gloves while serving meals in the dining room. EI #1 replied, after each resident. EI #1 was asked, when should staff sanitize hands while picking up dirty trays from resident rooms. EI #1 replied, in between each resident before going to the next room. EI #1 was asked, what harm was there in not sanitizing between residents while picking up trays on units. EI #1 replied, possibly infection control.

Based on observations, interviews, and a review of the facility policy Medication Administration, the facility failed to ensure Employee Identifier (EI) #4, Licensed Practical Nurse (LPN), one of three licensed staff observed with a medication cart, did not leave a medication cart unlocked and unattended on 2/15/22, one of four days of the survey. This affected one of two medication carts in the facility and had the potential to affect all 23 residents on level one whose medications were in the medication cart left unlocked and unattended. Findings Include: A review of a facility policy titled Medication Administration with an effective date of February 2021 revealed, . Policy Explanation and Compliance Guidelines: . 4. Medication cart will be locked or under direct observation of authorized associates. RI #11 was readmitted to the facility on [DATE]. On 2/15/22 at 6:43 PM, EI #4, LPN, was observed to position the medication cart in front of Resident Identifier (RI) #11's room to obtain RI #11's blood pressure, oxygen saturation and temperature, while leaving the medication cart unlocked. EI #4 entered RI #11's bathroom, out of site of the medication cart, and washed her hands while leaving the medication cart unlocked and unattended. On 2/15/22 at 7:18 PM EI #4 was asked how long she had worked at the facility. She replied, two going on three years. EI #4 was asked, when should she lock the medication cart. EI #4 replied, every time she was leaving the medication cart if it was not within view. EI #4 was asked, what was the risk of not locking the medication cart. EI #4 replied, somebody touching the cart, getting medications, and looking at what the residents' medications were. EI #4 was asked if she locked the medication cart when she was in RI #11's room. She replied, no. EI #4 was asked if she should have locked the medication cart, to which she replied, she should have. On 2/17/22 at 10:47 AM, an interview was conducted with EI #1, Registered Nurse/Director of Nursing. EI #1 was asked, what was the process for locking the medication cart. EI #1 replied, it should be locked when not in sight of the medication cart nurse. EI #1 was asked, when should the medication cart be left unlocked while the nurse was in a resident room giving medications. EI #1 replied, only if the cart could remain in sight of the nurse. EI #1 was asked what was the risk of leaving a medication cart unlocked while not is the sight of the nurse. EI #1 replied, the risk of someone getting in the cart.

Based on record reviews, interviews, review of the facility's investigation file and a review of the facility's policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure a staff member, Employee Identifier (EI) #7, did not verbally abuse Resident Identifier (RI) #1 on 8/29/21. This affected RI #1 one of three residents sampled for abuse. Findings Include: A facility policy titled Abuse, Neglect and Exploitation dated 11/28/16 documented: . Each resident has the right to be free from abuse . Residents must not be subject to abuse by anyone, including, but not limited to; facility staff . RI #1 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #1's most recent quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/25/21 documented a brief interview of mental status score (BIMS) of 3/15 which indicated RI #1 was cognitively impaired. The facility investigation summary and conclusion documented the following: . On August 30, 2021 (EI #8), dining room server, reported to EI #9, director of dining, that EI #7, CNA, was interacting inappropriately with (RI #1) in the dining room on August 29 2021 at approx. 5:15 p.m. At approximately 3:15 p.m. on August 30, 2021, EI #9 brought EI #8 to be interviewed by (EI #1), . (Administrator) and (EI #2), Director of Nursing. After interviewing (EI #8), (EI #7) was put on administrative leave and an immediate investigation was initiated. An initial report of the incident was filed through the ADPH (Alabama Department of Public Health) Online Incident Reporting System . on August 30, 2021. After more detailed review of the facts and evidence, including an audio recording made by EI #8, four additional employees, . (EI #6 CNA, EI #4 CNA, EI #10 CNA, and EI #5 Sous Chef) . were also placed on administrative leave . Conclusion: . Based on the interviews conducted and information provided it was the opinion of this investigator that the allegation of mental abuse by (EI #7) is substantiated . (EI #7) has been terminated due to her role in the incident. (EI #5, EI #10, EI #4 and EI #6) . were also terminated . A witness statement handwritten by EI #6 CNA documented . On Sunday evening 8-29-21 during dinner time (EI #4 CNA, EI #10 CNA), and (EI #5 Sous Chef) was at the counter talking with our back turned (EI #7 CNA) was sitting at the table with (RI #1) telling (him/her) to touch me inappropriate I turned around and told (RI #1) no don't touch me . (EI #7) continued to provoke (RI #1) I told her not to do this. A witness statement handwritten by EI #4 CNA documented . On 8/29/21 during dinner, (EI #7 CNA) was talking reckless and sexsual towards resident. (RI #1) Me myself and (EI #6 CNA) was talking to (EI #5 Sous Chef) when (EI #7) kept telling/provoking resident to touch (EI #6) . (EI #7) continue to tell resident come on (RI #1) touch her. A witness statement handwritten by EI #8 Dining Room Server documented . Last night, August 29th I worked . CNA's were all sitting in the corner talking extremely loud. (EI #7 CNA) was the main CNA being loud kept . (RI #1) to play in another CNA's pussy. (EI #7) told (RI #1) to grab another CNA's Butt . (EI #7) grabbed (his/her) arm and lead it to another CNA's butt. Then proceeded to do it again to show (RI #1) how to do it right while saying That's not how you treat a woman let me show you. A witness statement handwritten by EI #3 Dining Room Manager documented . On August 29, 2021 . (EI #8 Dining Room Server) found me . and she told me she had a recording for me to hear. It was a recording of a CNA . and another CNA talking to (RI #1). They were telling (him/her) to slap her on her Ass . An interview was conducted with EI #2, Abuse Coordinator on 9/15/21 at 1:15 PM. EI #2 was asked when she became aware of an incident involving RI #1 on 8/29/21. EI #2 stated on 8/30/21 when EI #8 and EI #9 came and reported the incident. EI #2 was asked what was done after it was reported. EI #2 stated EI #7 was suspended and an investigation was initiated. EI #2 was asked if EI #7 worked on 8/30/21. EI #2 stated no her last day to work was 8/29/21. EI #2 further stated EI #7 was terminated on 9/2/21. EI #2 was asked what type of abuse RI #1 experienced and who was responsible. EI #2 stated mental abuse and that EI #7 was the main person involved but the other employees heard the abuse and did not report it. An interview was conducted with EI #1, Administrator on 9/15/21 at 2:00 PM. EI #1 was asked when she became aware of an incident involving RI #1. EI #1 stated on Monday 8/30/21 when EI #8 and EI #9 reported the incident and stated there was an audio recording. EI #1 was asked what was done after the report was made. EI #1 stated that she determined who was working by talking to human resources, called EI #7 and told her she was suspended. EI #1 stated after listening to the recording the rest of the employees involved were suspended on 8/31/21. All the employees involved were terminated on 9/2/21. EI #1 was asked what type of abuse did RI #1 experience. EI #1 stated mental due to how he was talked to by the employee. ************************* Once the facility became aware of the incident on 8/30/2021, the following corrective actions were taken: On 8/30/2021 after the incident the physician and RI #1's sponsor were notified. On 8/31/21 RI #1 was assessed by the Director of Nursing Services to verify extent of injury. Resident had no recollection of events or any change from normal mental status. RI #1 was assessed by the Medical Director on 9/1/21 who reported resident did not appear to have any recollection of the incident or any negative mental or emotional effects. On 8/30/21 EI #7 was placed on suspension and terminated on 9/2/21. EI #'s 4, 5, 6 and 10 were placed on suspension on 8/31/21 and terminated on 9/2/21. EI #3 was placed on suspension on 9/8/21 and terminated on 9/13/21. On 9/2/21 EI #8 was given one on one abuse training (Abuse, Neglect and Exploitation). On 9/3/21 EI #3 was given one on one abuse training (Abuse, Neglect and Exploitation) with focus on reporting guidelines. Beginning 8/30/21-9/2/21 an inservice education program was conducted with direct and non-direct care staff addressing circumstances that require reporting including appropriate time frames. Inservice education program addressing circumstances that require reporting including appropriate time frames will be provided quarterly. Beginning on 8/30/21 management staff will conduct random audit five days weekly for four weeks, then weekly for one month and then monthly for three months to monitor dining room during meal times to ensure appropriate conversation and behavior. The Quality Assurance performance improvement committee will review audit results monthly for 3 months. ************************* After review of the facility's investigation file, in-service/education records, staff and resident interviews, the facility implemented corrective actions from 8/30/21 -9/13/21; thus past noncompliance was cited. This deficiency was cited as a result of the investigation of complaint/report number AL 530.

Based on interviews, record review, review of the facility investigative file and review of a facility policy titled, Abuse, Neglect and Exploitation, the facility failed to report an abuse allegation involving Resident Identifier (RI) #1 to the State Agency when the allegation was reported to the facility on [DATE]. The facility did not report to the State Agency until 8/30/21. This affected RI #1 one of three residents sampled for abuse. Findings Include: The facility policy titled Abuse, Neglect and Exploitation dated 11/28/16 documented: . 13. In response to allegations of abuse . the facility must: a. Ensure that all alleged violations involving abuse . are reported immediately, but not later than 2 hours after the allegation is made . RI #1 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #1's most recent quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/25/21 documented a brief interview of mental status score (BIMS) of 3/15 which indicated RI #1 was cognitively impaired. Review of the Alabama Department of Public Health Online Incident Reporting System revealed the incident of mental abuse as follows: . associate reported that (EI #7) was interacted with (RI #1) in a demeaning and inappropriate manner., with a date and time of occurrence reported as 8/29/21 at 5:30 PM, was not reported to the State Agency until 8/30/21 at 3:15 pm. A witness statement handwritten by EI #3 Dining Room Manager documented . On August 29, 2021 . (EI #8 Dining Room Server) found me . and she told me she had a recording for me to hear. It was a recording of a CNA . and another CNA talking to (RI #1). They were telling (him/her) to slap her on her Ass . The facility investigation summary and conclusion documented on 8/29/21 EI #8 Dining Room Server reported to EI #3 Dining Room Manager, that EI #7 was interacting inappropriately with RI #1 in the dining room. The investigation revealed that EI #8 reported the incident to her supervisor EI #3 immediately after the incident happened on 8/29/21 and advised her that she had made an audio recording of it. EI #3 listened to at least some of the recording but instead of reporting it to any supervisor at that time, she advised EI #8 to report it to another supervisor EI #9 the following day, 8/30/21. When the incident was reported on 8/30/21, EI #9 brought EI #8 to the abuse coordinator, EI #2 and the administrator EI #1 and an investigation was initiated. An interview was conducted with EI #8, Dining Room Server, on 9/14/21 at 4:45 PM. EI #8 was asked what lead to her recording the incident on 8/29/21 involving RI #1. EI #8 stated she saw it happening and wanted evidence that it happened in case no one believed her. EI #8 was asked what she observed on 8/29/21. EI #1 stated RI #1 rolled his/her wheelchair over to where several other employees were by the kitchen. The employees were talking amongst and started to bring RI #1 into it. EI #8 stated that was when she started to record the incident. EI #8 stated EI #7 started talking to RI #1 in sexual manner and telling him/her to touch another employee on the butt. EI #8 was asked what she did after this. EI #8 stated she went downstairs and told her supervisor EI #3 and gave her the recording. EI #8 further stated EI #3 told her that no one was there to report the incident to so she should report it on 8/30/21 to EI #9. EI #8 was asked if she reported the incident the next day. EI #8 stated yes it was reported to EI #9. EI #8 stated after it was reported she went with EI #9 to report to the EI #2, Abuse Coordinator. An interview was conducted with EI # 2, Abuse Coordinator on 9/15/21 at 1:15 PM. EI #2 was asked when she became aware of the incident on 8/29/21 involving RI #1. EI #2 stated on 8/30/21 at 3:15 PM when EI #8 and EI #9 came to her office and reported the incident. When asked when the incident happened, EI #2 replied, on 8/29/21 in the second floor dining room around 5:00 PM. EI #2 was asked if the incident was reported timely. EI #2 stated no it should have been reported immediately to the supervisor and within two hours to the State Agency. EI #2 was asked what EI #3 should have done when it was reported to her on 8/29/21 by EI #8. She stated EI #3 should have called her or the administrator to report the incident. EI #2 further stated it could have been reported to any nursing supervisor who was working that day or she could have called her supervisor EI #9. EI #2 was asked if the abuse policy was followed concerning reporting abuse. EI #2 stated no. EI #2 was asked why EI #3 thought she had 72 hours to report the abuse. EI #2 stated she did not know, she was trained and should have know. An interview was conducted with EI #1, Administrator on 9/15/21 at 2:00 PM. EI #1 was asked when she became aware of an incident involving RI #1. EI #1 stated on Monday 8/30/21 when EI #8 and EI #9 reported the incident and stated there was an audio recording. EI #1 was asked what type of abuse did RI #1 experience. EI #1 stated mental due to how he/she was talked to by the employee. EI #1 was asked if this incident was reported timely. EI #1 stated no, not on Sunday when it happened, it was reported on Monday when they became aware of it. EI #1 was asked why the incident was not reported timely. EI #1 stated none of the people involved reported the abuse, they should have, they were trained to report all abuse immediately. EI #1 was asked why it was important to report abuse timely. EI #1 stated to take care of it and remove the resident from harms way. ************************* Once the facility became aware of the incident on 8/30/2021, the following corrective actions were taken: On 8/30/2021 after the incident the physician and RI #1's sponsor were notified. On 8/31/21 RI #1 was assessed by the Director of Nursing Services to verify extent of injury. Resident had no recollection of events or any change from normal mental status. RI #1 was assessed by the Medical Director on 9/1/21 who reported resident did not appear to have any recollection of the incident or any negative mental or emotional effects. On 8/30/21 EI #7 was placed on suspension and terminated on 9/2/21. EI #'s 4, 5, 6 and 10 were placed on suspension on 8/31/21 and terminated on 9/2/21. EI #3 was placed on suspension on 9/8/21 and terminated on 9/13/21. On 9/2/21 EI #8 was given one on one abuse training (Abuse, Neglect and Exploitation). On 9/3/21 EI #3 was given one on one abuse training (Abuse, Neglect and Exploitation) with focus on reporting guidelines. Beginning on 8/30/21-9/2/21 an inservice education program on Abuse, Neglect and Exploitation was conducted with direct and non-direct care staff addressing circumstances that require reporting including appropriate time frames. Inservice education program addressing circumstances that require reporting including appropriate time frames will be provided quarterly. Beginning on 8/30/21 management staff will conduct random audit five days weekly for four weeks, then weekly for one month and then monthly for three months to monitor dining room during meal times to ensure appropriate conversation and behavior. The Quality Assurance performance improvement committee will review audit results monthly for 3 months. ************************* After review of the facility's investigation file, in-service/education records, staff and resident interviews, the facility implemented corrective actions from 8/30/21 -9/13/21; thus past noncompliance was cited. This deficiency was cited as a result of the investigation of complaint/report number AL 530.

Based on interviews, record review and review of a facility policy titled, NOTIFICATION OF CHANGE, the facility failed to ensure Resident Identifier (RI) #1's family was notified when RI #1 received a new order for [MEDICATION NAME] on 07/19/19. This deficient practice affected RI #1, one of three residents sampled for notification. Findings Include: On 08/21/19, the State Agency received a complaint allegation regarding RI #1's family/responsible party not being notified of him/her receiving new medications. A review of a facility policy titled, NOTIFICATION OF CHANGE, with an effective date of 11/28/16, revealed: .Notification of Change. a. A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is: .iii. A need to alter treatment significantly ( .or to commence a new form or treatment) . RI #1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #1's Physician's Telephone Order form, dated 07/19/19, revealed: .[MEDICATION NAME] 15 MG (MILLIGRAM) TABLET GIVE ONE TABLET BY MOUTH AT NIGHT FOR DEPRESSION . A review of RI #1's medical record revealed there was no evidence of notification of RI #1's family/responsible when RI #1 received a new order for [MEDICATION NAME] on 07/19/19. On 08/31/19 at 3:50 p.m., a follow-up interview was conducted with Employee Identifier (EI) #2, Registered Nurse (RN). EI #2 was asked did she contact RI #1's family/responsible party when she received an order for [REDACTED].#2 said no, she did not. On 08/31/19 at 4:42 p.m., a follow-up interview was conducted with EI #1, RN/Director of Nursing. EI #1 was asked when a resident received an order for [REDACTED].#1 said yes. EI #1 was asked if there was any evidence in the medical record that RI #1's family/responsible party was notified when he/she received the new order for [MEDICATION NAME] on 07/19/19. EI #1 answered no. This deficiency was written as a result of the investigation of complaint/report #AL 450.

Based on interviews, medical record review and review of facility policy titled, Fall Management Systems, the facility failed to consider all causal factors, including a new order for [MEDICATION NAME] on 07/19/19, when determining the root cause of Resident Identifier (RI) #1's fall on 07/22/19. This deficient practice affected RI #1, one of three residents sampled for falls. Findings Include: On 08/21/19, the State Agency received a complaint alleging the facility failed to monitor side effects of a new psychiatric medication that RI #1 was placed on and the failure to monitor resulted in falls. A review of a facility policy titled, Fall Management Systems, with an effective date of (MONTH) 6, (YEAR), documented: .f. When a resident sustains a fall, assessment will include investigation using the Incident/Accident Report to determine probably (probable) causal factors .that may be implicated in the fall. RI #1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 08/30/19 at 9:18 a.m., a telephone interview was conducted with Employee Identifier (EI) #4, Medical Director. EI #4 was asked, should RI #1 have been monitored for side effects of [MEDICATION NAME]. EI #4 said yes. EI #4 was asked why was it important to monitor side effects. EI #4 stated side effects can cause confusion, risk of falls and less effectiveness for some of the medication if there was an interaction. EI #4 was asked what could not monitoring side effects lead to. EI #4 answered, unidentified side effects and risk for the residents. On 08/31/19 at 9:45 a.m., an interview was conducted with Employee Identifier (EI) #1, Registered Nurse (RN)/Director of Nursing. EI #1 was asked what was the process nurses should follow when a resident falls. EI #1 said it should be reported when giving report to the next shift and put on the Medical Director's list for follow-up. EI #1 was asked was RI #1's name placed on the doctor's list after a fall on 07/22/19. EI #1 replied no. EI #1 was asked should RI #1's medications have been reviewed after the fall on 07/22/19. EI #1 said yes, if he/she had been placed on the Medical Director's list his/her medications would have been reviewed as part of follow-up. EI #1 was asked what was the concern with RI #1 not being placed on the doctor's log. EI #1 answered, he/she was not evaluated post fall by the doctor.

Based on interviews, medical record review and review of a facility policy titled, [MEDICAL CONDITION] MEDICATION POLICY, the facility failed to ensure Resident Identifier (RI) #1 was not prescribed a new psychoactive medication, [MEDICATION NAME], without monitoring the resident for any side effects of the medication. This deficient practice affected RI #1, one of three residents sampled for [MEDICAL CONDITION] drug use. Finding Included: A review of a facility policy titled, [MEDICAL CONDITION] MEDICATION POLICY, with an Effective Date: APRIL, (YEAR), documented: PURPOSE: The facility will ensure appropriate use oft [MEDICAL CONDITION] medications, evaluation and monitoring. Standards: 1. The facility will make every effort to comply with state and federal regulations to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits. 4. [MEDICAL CONDITION] medications include . and antidepressant classes of drugs. Actions: . 2. Effects and efficacy will be monitored on each specific resident. RI #1 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of RI #1's medical record revealed no monitor was added to RI #1's Medication Administration Record [REDACTED]. On 08/29/19 at 2:44 p.m., a telephone interview was conducted with Employee Identifier (EI) #2, Registered Nurse (RN). EI #2 was asked did [MEDICAL CONDITION] medications require any special considerations when entering them. EI #2 said she had to enter the classification and put down the drug's side effects so the nurse can put down if they are lethargic or effective. EI #2 was asked did she recall receiving an order for [REDACTED].#2 stated she did. EI #2 was asked what else should have been entered in the computer for the MAR for [MEDICATION NAME] since it was a [MEDICAL CONDITION]. EI #2 replied she did not realize antidepressants were [MEDICAL CONDITION]. On 08/30/19 at 9:18 a.m., a telephone interview was conducted with EI #4, Medical Director. EI #4 was asked what was her role in monitoring of side effects for [MEDICAL CONDITION] medications. EI #4 said she always checked if she started someone on a new medication and the pharmacy reviewed each resident's medications each month and provided her with a list of any resident who could have potential interactions, side effects and needing reductions and she answered each one. She further stated in addition, nurses reported side effects to her and put residents on her list to see when she visited twice a week. EI #4 was asked was she notified by any nurse that RI #1 was experiencing dizzy spells after starting [MEDICATION NAME] on 07/19/19 and requesting her to see RI #1 on her 07/31/19 visit to the facility. EI #4 replied the only time she knew RI #1 was when she had an assisted fall on 08/01/19. EI #4 was asked why would RI #1 have been given a new order for [MEDICATION NAME]. EI #4 stated, that was a good question because he/she was already well-controlled on [MEDICATION NAME] and she did not know why RI #1 was ordered the [MEDICATION NAME]. EI #4 was asked since the order was written, should RI #1 have had a side effects monitor for the [MEDICATION NAME]. EI #4 said yes. EI #4 was asked to explain the process the facility had in place to monitor the side effects of the residents' medications. EI #4 answered, the pharmacist reported to them monthly and they should be monitoring them on the MAR. EI #4 was asked why was it important to monitor side effects. EI #4 stated, 1. they can cause confusion, 2. risk of falls and 3. less effectiveness for some of the medication if there was an interaction. She further stated it can also cause serotoni[DIAGNOSES REDACTED] and there could be cardiac and renal effects of the medication. EI #4 was asked if the facility was not monitoring for side effects and documenting them for RI #1, how would they have known she was experiencing side effects. EI #4 stated she did not know how they would be doing it if they were not documenting it. She further stated they would not know what to look for. EI #4 was asked what could that lead to. EI #4 answered, unidentified side effects and risk for the residents. EI #4 was asked what would she have done if she had reviewed the medications and saw RI #1 had been started on [MEDICATION NAME] on 07/19/19 and then fallen on 07/22/19. EI #4 said she would have discontinued it because RI #1 was already on [MEDICATION NAME] for depression. On 08/31/19 at 9:45 a.m., an interview was conducted with EI #1, RN/Director of Nursing (DON). EI #1 was asked should [MEDICATION NAME] have special requirements/monitors. EI #1 said yes, it should have a pre-psychoactive side effect and post-psychoactive side effect monitor and also a behavior monitoring with a behavior type and behavior count. EI #1 was asked did RI #1 have a monitor for side effects for [MEDICATION NAME]. EI #1 replied no. EI #1 was asked should the side effects monitor have been entered. EI #1 stated yes. When asked how did she ensure that the special requirement/monitors were entered for the medications that were supposed to have them, EI #1 explained that the Unit Managers (UM) review new orders daily and the special requirements are underlined and listed on the orders. EI #1 was asked if a medication should have a monitor and did not have one, should they be able to identify it at that time. EI #1 said yes. EI #1 was asked what should be done when the UM identified that the monitors were not on the MAR. EI #1 answered they should correct it. On 08/31/19 at 3:50 p.m., a follow-up interview was conducted with EI #2, RN. EI #2 was asked did she know what side effects to monitor for a resident on [MEDICAL CONDITION] medications. EI #2 answered no, she did not. On 09/01/19 at 9:52 a.m., a telephone interview was conducted with EI #3, RN/UM. EI #3 was asked what all she did after receiving an order. EI #3 said make sure it was sent to pharmacy, let the DON and family know, let the Medical Director know. EI #3 further stated that she went through all their other orders to make sure they are not already on that kind of medication or if it was an increase or decrease and if they had any allergy to the medication since they go to different doctors. EI #3 was asked was she responsible for checking orders. EI #3 stated yes. EI #3 was asked what was she checking them for. EI #3 replied to make sure the medication got started and if there were any standing orders that needed to go with them like the side effects monitoring or anything like that. EI #3 was asked did she know why RI #1 did not have a side effects monitor in place after starting [MEDICATION NAME] on 07/19/19. EI #3 said, no and they tried to make sure the monitors were in place for any side effects so they could monitor any changes. When asked should the daily or 72 hour medication checks have identified that RI #1 did not have a side effects monitor, EI #3 answered, there was not any flag to alert them that the special requirements and side effects monitors were not there, but they should have seen that they were not there and entered them in the computer. EI #3 further stated it only printed off medication orders but she still should have looked to make sure the monitors were there. On 09/01/19 at 11:28 a.m., a follow-up interview was conducted with EI #1, RN/DON. EI #1 was asked when the UM were checking medications how would they know that the side effects monitoring was not entered. EI #1 said they would print out their orders and look for the side effects monitor that prints separately but still under the resident's name for the time period they were checking. EI #1 was asked should the UM have identified that RI #1 did not have a side effects monitor for [MEDICATION NAME] when checking the orders. EI #1 replied yes. EI #1 was asked should it have been identified prior to this survey that RI #1 did not have those monitors. EI #1 said yes. EI #1 was asked why were the monitors not entered. EI #1 answered, it was missed by the nurse entering the order, the UM and herself.

Based on interviews, medical record review and review of a facility policy titled, Quality Assessment and Assurance, the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee identified that RI #1 did not have a side effects monitor placed on the Medication Administration Record [REDACTED]. During the QAA Committee Meeting on 08/23/19 the committee reviewed RI #1's 07/22/19 fall for quality deficiencies. This affected RI #1, one of one residents reviewed for QAA Review. Findings Included: A review of a facility policy titled, Quality Assessment and Assurance, with a Date Implemented: 11/28/16, revealed: .This facility will operate a Quality Assessment and Assurance Committee to identify quality issues and develop and implement appropriate plans of action to correct identified quality deficiencies within the facility through an interdisciplinary approach. RI #1 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of RI #1's medical record revealed no side effects monitor was put in place to document side effects on the Medication Administration Record [REDACTED]. On 09/01/19 at 11:28 a.m., an interview was conducted with Employee Identifier (E) #1, Registered Nurse (RN)/Director of Nursing (DON). EI #1 was asked should it have been identified prior to this survey that RI #1 did not have a side effects monitor in place for the [MEDICATION NAME]. EI #1 said yes. EI #1 was asked why was it not identified. EI #1 replied, it was missed by the nurse entering the order, the Unit Manager (UM) and herself. At 12:55 p.m., a follow-up interview was conducted with EI #1, also the QAA Committee Leader. EI #1 was asked did the QAA Committee identify the lack of side effects monitoring during the 08/23/19 meeting when RI #1's 07/22/19 fall was reviewed. EI #1 said no. EI #1 was asked why not. EI #1 replied, with their initial review of RI #1's fall, they did not suspect any side effects from [MEDICATION NAME] had caused the fall. She further stated there were no reports of dizziness or other side effects. EI #1 was asked how did she review the side effects if RI #1 did not have a side effects monitor. EI #1 replied it was common practice for nurses to monitor for side effects of all medications. EI #1 was asked what was the purpose of the QAA review. EI #1 stated to identify quality deficiencies. EI #1 was asked during the pre-QAA review and/or during the formal QAA review, should the fact that RI #1 did not have a side effects monitor have been identified. EI #1 said they did not check at that time for the monitoring because they did not see it as an issue. EI #1 was asked what would she have done if it had been identified. EI #1 answered, they would have put RI #1's monitoring in place and reviewed everyone else on any [MEDICAL CONDITION] to make sure theirs was in place as well.

Based on observation, medical record review, interview and review of a facility policy titled, Clean Dressing Change, the facility failed to ensure a Licensed Practical Nurse (LPN)/Wound Nurse, Employee Identifier (EI) #2, washed her hands and put on clean gloves after cleaning the sacral wound and prior to applying Silvermed Hydrogel (wound treatment gel) to the wound bed during the provision of wound care for Resident Identifier (RI) #43 on 06/05/2019. This affected RI #43, one of two sampled residents observed during the provision of wound care. Findings include: A review of a facility policy titled, Clean Dressing Change with an implementation date of (MONTH) 2019, revealed: .Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross contamination .12. Cleanse the wound as ordered .13. Wash hands and put on clean gloves. 14 .topical ointments or creams . RI #43 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #43's Physician order [REDACTED].CLEAN SACRAL WOUND EVERY 3 DAYS WITH NORMAL SALINE PAT DRY WITH GAUZE. APPLY SILVER HYDROGEL TO WOUND AND COVER WITH SILICONE FOAM DRESSING . On 06/05/2019 at 3:22 PM, the surveyor observed EI #2 perform RI #43's wound care. EI #2 washed her hands and put on clean gloves. EI #2 cleaned RI #43's sacral wound with normal saline and gauze. Without removing her gloves, washing her hands or applying new gloves, EI #2 applied the Silvermed Hydrogel to the wound with a cotton tipped applicator. On 06/05/2019 at 3:50 PM, an interview was conducted with EI #2. The surveyor asked EI #2, after she cleaned the wound, were her gloves clean or dirty. EI #2 replied dirty. The surveyor asked EI #2 did she wash her hands and change her gloves after she cleaned the wound and prior to applying the Silvermed Hydrogel. EI #2 replied no. On 06/06/19 at 2:35 PM, a follow up interview was conducted with EI#2. The surveyor asked EI #2 why should she wash her hands after cleaning a wound. EI#2 replied because the wound was dirty and that was the standard of practice. The surveyor asked EI #2 what problems could it cause the resident by not washing her hands and changing her gloves. EI #2 replied it could cause infection.

Based on observations, interviews, and review of the facility policies, Leftover Food Storage and Use and Use of Gloves and Hairnets, the facility failed to ensure: 1. a dietary staff member changed her gloves or washed hands before going to another task and 2. a food product in the freezer was labeled with an open and use by date. This had the potential to affect 47 of 48 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Use of Gloves and Hairnets with an effective date of February 1, 2002, revealed: PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses.PROCESS: .c. Wash hands before and after wearing or changing gloves . e. Change gloves when activities are changed . On 3/15/2017 at 8:55 a.m., the surveyor observed EI (Employee Indentifer) #6, the Dishwasher, washing dishes. EI #6 was on the dirty side scraping food from pans. EI #6 left the dirty side of the room and went to the clean side of the room to pick up clean utensils out of a crate. EI #6 did not wash her hands or change her gloves before returning to the clean side. EI #6 went back to the dirty side and picked up two cake pans out of the sink and scraped them. EI #6 went back to the clean side to pick up more clean utensils. EI #6 did not change her gloves or wash her hands. On 3/16/2017 at 9:05 a.m., the surveyor conducted an interview with EI #6. EI #6 was asked who was responsible for washing dishes. EI #6 replied she was and another worker. EI #6 was asked what should she do when leaving the dirty side of the dish room and going to the clean side. EI #6 replied take her gloves off, wash her hands, and put on new gloves. EI #6 was asked when should she wash her hands in the dish room. EI #6 replied every time she took off her gloves. EI #6 was asked why should she wash her hands in the kitchen. EI #6 replied to prevent the spread of germs. EI #6 was asked what was the facility policy on washing hands when leaving the dirty side of the dish room and going to the clean side. EI #6 replied change gloves, wash hands and put on new gloves. EI #6 was asked if she scraped pans on the dirty side of the dish room and went to the clean side of the dish room. EI #6 replied yes. EI #6 was asked if she took two pans out of the sink and put them in the wash area and went back to the clean side. EI #6 replied yes. EI #6 was asked if she washed her hands after both tasks. EI #6 replied no. EI #6 was asked what was the potential harm when she was working on the dirty side and going back to the clean side to work. EI #6 replied cross contamination. On 3/16/2017 at 11:00 a.m., the surveyor conducted an interview with EI #1, Dietary Service Director. EI #1 was asked what should be done when leaving the dirty side of the dish room and going to the clean side. EI #1 replied anytime you leave the dirty side, wash hands before touching clean dishes. EI #1 was asked, when should you wash your hands in the dish room. EI #1 replied, anytime you change position or leave your area. EI #1 was asked what was the facility policy on washing hands when leaving the dirty side and going to the clean side. EI #1 replied, wash your hands. EI #1 was asked what was the potential harm when working on the dirty side and start working on the clean side without changing gloves or washing your hands. EI #1 replied cross contamination. 2) A review of a policy titled, Leftover Food Storage and Use with an effective date February 1, 2002, revealed PURPOSE: To assure that food borne illnesses are avoided. PROCESS: .b. Leftover foods should be covered, labeled and dated . On 3/14/2017 at 2:05 p.m., the surveyor observed apple fritters in the freezer in a clear bag with no open or use by date. On 3/16/2017 at 10:20 a.m., the surveyor conducted a telephone interview with EI #7, Executive Chef. EI #7 was asked what food product in the freezer was open with no open or use by date. EI #7 replied apple fritters. EI #7 was asked why there were no dates on it. EI #7 replied the employee who used it did not write it down. EI #7 was asked what the facility policy said regarding dates on food items. EI #7 replied once opened, put an open and use by date on it. EI #7 was asked when should food items be labeled. EI #7 replied as soon as they were opened, put a use by date on them. EI #7 was asked what was the potential harm when there was no label on food items. EI #7 replied it could be harm to the resident, you do not know how long it has been there.

Based on observation, interview, medical record review and a review of a facility policy titled, Enteral Tube Medication Administration the facility failed to ensure licensed staff checked the gastrostomy tube placement for Resident Identifier (RI) #9 prior to giving 9 a.m. medications on 3/15/17. This affected one of three nurses observed giving medications to one of one residents receiving medications by tube. Findings Include: A review of the Alabama Board of Nursing, Alabama Administrative Code, Chapter 610-X-6 Standards of Nursing Practice revealed: .610-X-6-.05 Practice of Practical Nursing (Licensed Practical Nurse Practice) . (2) Competence in the practice of practical nursing by a licensed practical nurse shall include, but is not limited to: . (ii) Standards for nursing practice. (iii) Standardized procedures for nursing practice including but not limited to facilities policies and procedures. A review of facility policy with a revised date of 2/13 revealed .POLICY: The facility assures the safe and effective administration of enteral .medications.Enteral tube placement must be checked via auscultation and/or aspiration before any fluids or medications are administered. RI #9 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 3/15/17 at 9:35 a.m. Employee Identifier (EI) #3, Licensed Practical Nurse (LPN), was observed giving medications to RI #9 per gastrostomy tube. EI #3 prepared six medications, each in a separate medication cup. EI #3 carried the medications in RI #9's room on a tray and got tap water. EI #3 placed the barrel of the syringe into the port end of the gastrostomy tube and gave 30 milliliters (ml) of water. EI #3 gave the medications, gave water between each medication and followed with 30 ml water once the medications were completed. EI #3 did not check the tube placement prior to giving the water or medications. On 3/15/17 at 4:14 p.m. a phone interview was conducted with EI #3, LPN. EI #3 was asked what was the policy for giving medications by tube. EI #3 replied set up the medications, take them into the resident's room, wash hands and put on gloves. EI #3 said check the placement of the tube and give the water flush, then the medications and follow with water flush when complete. EI #3 was asked if she was supposed to check the tube placement before giving fluids or medications. EI #3 replied yes. EI #3 was asked if she checked the placement of the tube before giving fluids or medications. EI #3 replied no. EI #3 was asked what was the harm in not checking the tube placement before giving fluids or medications. EI #3 replied the tube could not be in place and the medications may not go to the stomach. On 3/15/17 at 5:38 p.m., an interview was conducted with EI #2, Director of Nursing. EI #2 was asked what was the policy for giving medications by tube. EI #2 replied, they are to set up the medications, take them into the room on a tray, get the water, then check the placement of the tube and give the medications and the water. EI #2 was asked if staff should check the tube placement before giving medications or fluids and she replied yes. EI #2 was asked what was the harm if the placement of the tube was not checked. EI #2 replied the tube could not be in place and contents would not go into the stomach.

Based on observations, interviews and a review of a facility policy titled, Laundry Services, the facility failed to ensure a laundry aide washed her hands and wore Personal Protective Equipment (PPE) when removing clean clothing from the dryer. This had the potential to affect all 48 residents residing in the facility. Findings Include: A review of a policy titled, Laundry Services with an effective date of February 2016, revealed: .Purpose: To assure a clean supply of liens (linens) and to protect employees who handle and process laundry .D. Protecting Personnel Who Sort Laundry . 2. Laundry personnel should wash their hands . before going into the clean linen areas . On 3/15/2017 at 9:20 a.m., the surveyor observed a Laundry Aide, (Employee Identifier) EI #4, taking residents' clothes out of the dryer. The clothes were touching EI #4's clothes in the chest area. EI #4 did not have on PPE. At 10:55 a.m., the surveyor observed EI #4 sweeping the floor. EI #4 went into another room to put the dust pan and the broom away. The surveyor observed that EI #4 did not wash her hands in the room. EI #4 returned to the clean side of the laundry room and began to take the residents' clothes from the dryer. The residents' clean clothes touched EI #4's clothes. On 3/16/2017 at 11:45 a.m., the surveyor conducted an interview with EI #4. EI #4 was asked who was responsible for taking clothes out of the washer/dryer. EI #4 replied, she was. EI #4 was asked when should she wash her hands in the laundry. EI #4 replied when she came into the laundry and when putting dirty clothes into the machine. EI #4 was asked if she was wearing PPE on 3/15/2017. EI #4 replied no. EI #4 was asked when putting clothes in the dryer, did the clothes touch her chest. EI #4 replied yes. EI #4 was asked when using the broom and dust pan to sweep the floor around the dryer if she washed her hands before taking the clothes out of the dryer. EI #4 replied she should have washed her hands. EI #4 was asked what was the potential harm when clean clothes touched her clothes. EI #4 replied, contamination. On 3/16/2017 at 11:50 a.m., the surveyor conducted an interview with EI #5, Housekeeping Supervisor. EI #5 was asked if she observed EI #4 sweeping and putting the broom away. EI #5 replied yes. EI #5 was asked if EI #4 washed her hands after putting the broom away. EI #5 said she did not believe so. EI #5 was asked what was the potential harm when her clothes touched clean resident clothing. EI #5 replied cross contamination.

Based on observation, interview and record review the facility to ensure the following: 1. An open bottle of Italian dressing had an open and use by date. 2. 8 eggs were not stored in water and had an open and use by date. 3. Tea spigots were free of a unknown black substance. This was observed on 2-10-16 and had the potential to affect 44 residents receiving meals from the kitchen. Findings Include: A review of a policy titled Sanitation, Safety and Infection Control with an effective date of May 1, 2003 documented the following: .27 Tea URN Remove nozzle and soak in a sanitizing solution for a at least two minutes; or, by soaking in hot water .for at least 30 seconds the dispensing system or nozzle needs to be air dried completely before use . A review of a policy titled Leftover Food Storage and Use with and effective date of February 1, 2002 documented the following: .Procedure: Commercially prepared Potentially Hazardous foods will be dated when opened with the date that the product is opened and a use by date that will be 7 days from the date opened .If the product is made in the facility the use by date should be 3 days from the date the item was prepared. On 2/10/16 at 10:20AM the Surveyor observed the tea spigot in the kitchen with EI (Employee Identifier) # 1, Dietary Manager. The Tea spigot was dirty. Four paper towels were used to get rid of the rust. EI # 1 stated they give the whole urn to the dishwasher at the end of the night and they are supposed to wash them. EI # 1 stated this had not been done in a couple of days or more. The Surveyor asked EI # 1 to check another tea spigot and it was observed to be black with more than a weeks build up. EI # 1 stated she generally tried to check them once a week. On 2/10/16 at 3:15PM the Surveyor and EI # 1, Dietary Manger observed the following items in the walk in refrigerator. Italian Dressing with a manufacturer date of 1/12/16. The Italian dressing had no open or use by date. The Dressing was observed to be opened. Eight pasteurized eggs were observed in a pan of water. The eggs were uncovered and had no open or use by date. On 2/10/16 at 3:30PM an interview was conducted with EI # 1. EI # 1 was asked if the Italian Dressing should have an open and use by date. EI # 1 replied yes, so you can make sure you use prior to it expiring. EI # 1 was asked what is the potential harm in not having and open and use by date. EI # 1 replied if its expired and you give it to someone it could make them sick. EI # 2 was asked why the 8 eggs were observed stored in a pan with water. EI # 1 replied she did not know and they may have been going to use them for something. EI # 1 was asked how the eggs should be stored. EI # 1 replied you should take them out of the water and put a use by date on them. EI # 1 replied you should have a use by date on the eggs because if its expired, it could make someone sick. EI # 1 was asked if the tea spigots were dirty when observed earlier by the Surveyor. EI # 2 replied yes. EI # 1 replied the tea spigot should be cleaned daily. EI # 1 was asked what is the potential harm of having a dirty tea spigot. EI # 1 replied it could potentially make someone sick.

Based on observations, interviews and record review, the facility failed to follow their policy and procedure related to the assessment, management and monitoring of pressure sores. The facility failed to ensure wounds were identified and assessed, treatments were correctly transcribed and implemented, and care plans were developed to meet individualized needs. These failures resulted in the decline of wounds that residents were admitted with and contributed to the development of new in-house wounds. A. Facility staff failed to ensure acceptable terminology was used and thorough descriptions, size and stage were documented on the initial (11/03/14) "Body Assessment Tool" for Resident Identifier (RI) #15. Two areas on admission were described as "predecubs." Between 11/03/14 and 11/26/14, weekly documentation of the wound condition was not provided as mandated in the policy and procedure. On 11/26/14 a new unstageable pressure ulcer, with eschar was identified on the top of the resident's right foot. A second new Stage II ulcer was identified on 12/16/14 to the resident's coccyx. The initial, generic care plan for RI #15 was not individualized for this resident's specific skin needs, including the presence of orthotic boots with a need for routine skin inspection. The initial care plan was not individualized until 12/23/14 (49 days after admission) and included no mention of the resident's use of orthotic boot(s). The Treatment Administration Record (TAR) did not include each pressure sore treatment ordered by the Physician, and lacked consistent documentation to ensure the treatments were given. admission orders [REDACTED]. B. The facility failed to ensure RI #22's admission skin assessment dated [DATE], documented measurements/stages for an area identified on the left heel. On 1/7/2015 the Nurse's Notes identified the left heel wound as a DTI (Deep Tissue Injury). The left heel wound was not documented, per policy and procedure, on the weekly "Pressure Ulcer Report" until 1/22/2015. On 1/28/2015 documentation of RI #22's wounds, an unstageable left heel and a Stage III sacrum, did not contain any description other than size and stage. On 1/29/2015, the Treatment Nurse was observed measuring RI #22's wounds using inches and calling them centimeters. Facility staff also failed to ensure [MEDICATION NAME] was documented as provided on the treatment record as ordered on [DATE] and 1/18/2015. The facility further failed to develop an individualized care plan to address RI #22's wounds on the sacrum, right hip, and left heel. C. Facility staff failed to ensure RI #13's admission skin assessment dated [DATE], documented measurements/stages for pressure ulcers on RI #13's right and left heels. There was no complete assessment of the wounds, to include color, tissue type or other descriptions, on admission or thereafter. The treatment to the left heel was transcribed from the physician's orders [REDACTED]. The facility failed to develop an individualized care plan to address RI #13's wounds on the left and right heels. On 1/28/2015 the Wound Nurse documented an inaccurate measurement of the left heel ulcer, as 1 cm X 1 cm (centimeter) after using a measuring device marked with inches. Measurements documented on the resident's 1/6/2015 Body Assessment Tool differed significantly from the measurements documented of the same area on the 1/7/2015 Pressure Ulcer Report. D. The facility failed to ensure RI #25's admission skin assessment dated [DATE], documented measurements for the Stage II coccyx pressure ulcer. The coccyx wound was not documented, per policy and procedure, on the weekly "Pressure Ulcer Report." There was no other assessment of the coccyx wound documented. The facility licensed staff failed to ensure moisture barrier with bordered foam was documented as provided on the treatment record for 1/14/2015 and 1/15/2015 as ordered. The facility failed to develop an individualized care plan to address RI #25's Stage II coccyx wound. E. The facility failed to ensure the left ankle wounds of RI #12 were completely assessed and described on admission 12/04/2014, and routine documentation was provided of the wound deterioration to Stage III on 1/14/2015. Five new areas to the buttock were identified on 12/20/2014 without documentation of a complete assessment and follow-up of the condition of these wounds. There was no treatment ordered for the buttocks until 1/17/2015. Facility staff further failed to document the presence of the pressure sores, stage, and size on the 12/11/2014 Minimum Data Set (MDS) assessment. F. The facility failed to ensure RI #6 received a complete pressure ulcer assessment, including location, description, and measurements when a discolored area was found on the resident's bottom on 12/22/2014 and 1/7/2015. The facility failed to provide weekly skin assessments for RI #6 to monitor the progress of the sacral discoloration. This affected Resident Identifier (RI) #s: 15, 22, 12, 13, 25, and 6, six of seven sampled residents identified as having pressure sores. On 01/31/15 at 3:10 PM, the Administrator, Director of Nursing and the Assistant Executive Director/Marketing Director were notified the findings of substandard quality of care at the Immediate Jeopardy level of "K" in the area of Quality of Care, F314. The Immediate Jeopardy began on 11/3/14 and was relieved on 1/31/15 at 7:30 PM. Findings include: The facility's policy titled "Pressure Ulcers" with an effective date of 11/1/2011 revealed: "...PROCESS: V. Assessment of Risk All residents are considered at risk for the development of pressure ulcers. During the admission nursing assessment process, the condition of the resident's skin should be noted. The Ulcer Record... should be completed when pressure ulcers are found on admission... III. Documentation... c) The status of ulcers should be recorded on the Ulcer Record weekly... e) Observations pertinent to the resident's skin status should be recorded in the nurses' notes, as appropriate f) The interdisciplinary plan of care communicates care instructions to staff..." The facility's policy titled "Pressure Ulcers" with an effective date of 2/1/2012 revealed: "...Pressure Ulcer Stages/Categories... Stage I: Non-blanchable [DIAGNOSES REDACTED]... Stage II: Partial thickness... red, pink wound bed without slough. May also present as an intact or open... blister... Stage III: Full thickness skin loss... Slough may be present... Stage IV: Full thickness tissue loss... Additional Categories... Unstageable... Suspected Deep Tissue Injury... discolored intact skin or blood-filled blister..." The facility "Staff Education Acknowledgement" signed by attendees on 11/19 (11/19/2014) with "Education Provided by" Employee Identifier (EI) #9 revealed 16 staff signatures including 10 CNAs (Certified Nursing Assistants), 4 LPNs (Licensed Practical Nurses), and 2 RNs (Registered Nurses). The (undated) "Education Provided" titled "Pressure Ulcer Prevention & Management" revealed: "...The facility shall establish and utilize a systematic approach for pressure ulcer prevention and promotion of pressure ulcer healing that includes efforts to identify risk, stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate..." The (undated) "Education Provided" titled "Documentation of Wound Treatments" revealed the following: "...Policy: The purpose of this guideline is to provide a consistent process for accurate and complete wound treatment documentation... Policy Explanation... The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are ... 1. complete 2. accurately documented ... Treatment Documentation Guidelines: 1. Type of wound... 2. Ulcer stage... 3. Measurements ... 4. Description of wound characteristics ... 5. Current treatment 6. Weekly progress ... 8. Modification of interventions 9. Notifications to physician... responsible party regarding wound or treatment changes... Frequency of Wound Documentation: 1. Weekly 2. After each dressing change 3. PRN (as needed) with any change in condition or change in wound status." 1) RI #15 was admitted to the facility 11/03/14 with [DIAGNOSES REDACTED]. According to the 11/03/14 admission "Nursing Assessment", RI #15 was totally dependent on staff for transfers, toilet use, and was incontinent of bowel and bladder. RI #15 scored an "18" on the initial Braden Scale -For Predicting Pressure Sore Risk dated 11/3/2014. A score of "18" indicated the resident was mild risk for pressure ulcer development. An admission "Body Assessment Tool" dated 11/03/14 documented five areas to the resident's skin: 1) "red, dry spot L (left) foot" (on the left lateral ankle); 2) "red spot" (on inner aspect of left foot); 3) "predecub(decubitus)" (on right buttock); 4) "predecub(decubitus) (on left buttock); and 5) "unstageable eschar" (on the right heel). The assessment did not identify any other wounds. The admitting physician's orders [REDACTED]. Cover L (left) heel /c (with) dry dressing, Keep multipodus (orthotic) boots on both feet @ (at) all times, Apply Zinc Oxide to sacral area after bath, pericare & PRN (and as needed)..." A review RI #15's medical record revealed these orders were not transferred to the November or December Treatment Administration Records nor was there documentation that these orders were discontinued. A Nurse's Note dated 11/03/14 identified the measurements of the wounds as follows: " ... unstageable eschar noted to right foot heel, 3 1/2 cm (centimeters) long by 2 cm wide, dark colored hard layer over complete area of wound, predecubitus without depth noted to top inner portion of bilateral buttock, on Right buttock wound is 1 1/2 cm tall by 1/2 cm wide, Left buttock wound is 1 cm by 1 cm..." There was no documentation/measurements in this note about the red areas identified on the resident's left lateral ankle and left inner foot. RI #15's initial care plan, dated 11/03/14, identified the resident as "admitted with skin breakdown " with the goal to maintain intact healthy skin. Interventions included to: "Encourage to consume all foods & Fluids offered, Preventative treatment as needed & Ordered, Vitamins & Minerals as ordered, Provide tx (treatment) as ordered." The plan did not address the use of the resident's multipodus (orthotic) boots, ordered to be worn to both feet at both all times. An 11/06/14 physician's orders [REDACTED]. A review of the November 2014 Treatment Administration Record (TAR) indicated treatment was not signed as provided on 11/15, 11/20, 11/22, and 11/26. On 11/26/14, the facility's "Pressure Ulcer Report" documented measurements of RI #15's right heel wound as unstageable, 3 cm X 4 cm. This report also documented a new pressure ulcer located on top of RI #15's right foot as unstageable, 2.6 cm X 1.3 cm. On 11/28/14, new physician's orders [REDACTED]." The TAR documented these orders were not implemented until 12/02/14, four days later. No treatment was documented on 12/25/14. Although the top right foot wound was identified on 11/26/14, a treatment order was not obtained until 11/28/14, to "Clean top of R foot /c normal saline, pat dry, apply xeroform, cover /c gauze, wrap /c roll gauze QD." These orders were not documented as provided on the TAR until 12/02/14, four days after they were ordered. During a review of the medical record on 11/10/2014, the "Daily Skilled Nursing Notes" included documentation of a "Blister area observed to upper left buttocks. Duoderm applied. Will observe for changes." No description, size or stage was written. A corresponding Physician orders [REDACTED]. duoderm to left buttocks changed every three days 2. Check /q (every) shift." This treatment was signed off as done every three days through 11/28/2014. After the 11/28/14 treatment, treatments were not documented on the 12/2014 TAR until 12/04/2014, six days later. On 11/28/14 an order was also written to "Apply [MEDICATION NAME] spray to L heel BID (twice daily)." The treatment was not initiated until 12/02/14 (four days after ordered), and was signed off as given only once a day throughout December. On 12/16/14, a new area was identified on the "Pressure Ulcer Report." A Stage II wound to RI # 15's coccyx was documented as 2 cm x 2 cm. A Physician order [REDACTED]. Change daily & PRN. Re-eval (evaluate) in 7 days." According to the December TAR, the treatment began on 12/20/14, four days after the coccyx wound was identified. Also, according to this treatment record, there was no treatment provided on 12/22/14 and 12/23/14 to RI #15's coccyx wound. The 12/16/14 "Pressure Ulcer Report" documented RI #15's wound to the top of the right foot as a Stage III measuring 1.5 cm X 3.8 cm and the right heel as a Stage III measuring 4.0 cm X 3.6 cm. The Wound Note also dated 12/16/14 contained different measurements of the same wounds; the wound to the top of the right foot was documented as a Stage III measuring 2 cm X 2.28 cm and the right heel was documented measuring 3.0 cm X 3.5 cm with slough. Both entries were signed by EI # 9, the Treatment Nurse on 12/16/2014. On 12/23/14, RI #15's family took the resident to a wound clinic for consultation and evaluation. The consultant Wound Physician recommended orders for daily dressing changes to the right heel and right dorsal foot with 4 x 4's, Kerlix, and [MEDICATION NAME] AG (silver). An additional order was listed to "Discontinue use of boot to right foot." These consultant's Wound Care Orders were not transcribed to the facility's physician's orders [REDACTED]. RI #15 was seen again at the Wound Clinic 12/30/14. The consultant's report documented orders to: "Discontinue boot to right leg; No ambulation/PT (Physical Therapy) until further notice; Full body lift; Elevate legs at all times." Orders continued for the daily dressing change with [MEDICATION NAME] AG to the right heel and right dorsal foot. The consultant's orders were not transferred to the facility's Physician order [REDACTED]. On 01/15/15 at 5:00 PM, the surveyor asked Employee Identifier (EI) #4, the Licensed Practical Nurse Wound Consultant, why there were no assessments of RI #15's wounds before 11/26/14. EI #4 explained she was called in around the end of November 2014, to help the assigned Treatment Nurse (EI #9). EI #4 did not know why there was not documentation of resident's wounds before she was asked to consult. On 01/15/15 at 6:25 PM, the Director of Nursing, EI #2 was asked why no wound measurements were documented for RI #15 between 11/03/14 and 11/26/14. EI #2 stated she did not know. When asked who was assigned to the care of RI #15's wounds, EI #2 explained there was no treatment nurse, and residents were entering the facility with more wounds than the floor nurses could handle. When asked if a regular (wound) assessment was completed, EI #2 stated she had assumed a size and description was documented. On 01/27/15 at 4:45 PM, EI #9, Treatment Nurse, was interviewed. She confirmed that before she began documenting wounds, she did not have much training. On 01/27/15 at 5:10 PM, the Consultant Wound Nurse, EI #4 reviewed RI #15's medical record and confirmed the lack of wound documentation in RI #15's medical record. On 01/31/15 at 8:20 AM, the Director of Nursing (EI #2) was asked if anyone had monitored the nursing staff to ensure they were documenting (wounds) accurately. EI #2 stated she knew this was a need, it was a work in progress. EI #2 was unable to explain the lack of consistent documentation by nursing staff on the treatment records, and transcription errors. 2.) RI #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #22's admission "BODY ASSESSMENT TOOL" completed by EI #10, LPN (Licensed Practical Nurse) on 1/6/2015 revealed the following: "...HIP: Stage 3 area R (right)...quarter size...COCCYX: Stage 3 area half dollar size...HEELS: L (left) dark purple unblanchable..." On 1/28/2015 at 4:45 PM, the day Charge Nurse (EI #10) was asked who was responsible for completing "Body Assessment Tools" when residents were admitted . EI #10 said it was the charge nurse on duty when the resident arrived. She stated she was trained to complete them when she was hired, by going with the charge nurse who explained the paperwork. EI #10 was asked what type of measuring device she routinely used. She replied, clear or paper measuring devices with centimeters and inches. EI #10 was asked if the device included use of quarter and half dollar measurements. EI #10 said no, that she used the terms quarter and half dollar to give a visual idea of the size to the person who would be reading the assessment after her. EI #10 was asked how she could be sure what a quarter or half dollar size was, every time, without an exact measurement. She said she would not be able to tell, and neither would the next nurse, without an exact measurement. RI #22's "INITIAL CARE PLAN" dated 1/6/2015 revealed Xs in the boxes next to the following items on the pre-printed care plan: "Risk for Skin Breakdown (Actual Skin breakdown)...Encourage to consume all foods & (and) Fluids...Preventative treatment as needed & Ordered...Vitamins & minerals as ordered..." RI #22's physician order [REDACTED]. RI #22's treatment record dated 1/7/2015 through 1/31/2015, revealed no documentation of the provision of the [MEDICATION NAME] spray to bilateral heels on the 17th and 18th on the 6:00 PM to 6:00 AM shift, as ordered 1/7/2015. RI #22's admission MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 1/11/2015, revealed two Stage II and two Stage III pressure ulcers were present with the most severe tissue type being slough. There was no documentation of Deep Tissue Injury. RI #22's wound measurements in the "NURSE'S NOTES" revealed the following: "...1/7/15...L heel DTI (deep tissue injury) measuring 4 X 5 cm (centimeters)... 1/14/15...L heel DTI ...4 X 5 cm... 1/22/15...L heel DTI...5 X 5 cm...Stage III to lower sacral area also resolved..." There was no further description of the left heel wound in RI #22's Nurse's Notes. The facility's "PRESSURE ULCER REPORT" was not completed to include RI #22's L heel wound until 1/22/2015, 16 days after the wound was identified on 1/6/2015 on the resident's Body Assessment Tool. The facility's "PRESSURE ULCER REPORT'' dated 1/29/2015 was given to the surveyor on 1/28/2015. Measurements for a Stage III wound to the mid-sacrum and an unstageable left heel wound were included on the report. There was no further assessment (description/color/type of tissue in wound bed/drainage/odor) of these wounds for 1/28/2015. On 1/29/2015 at 10:40 AM, an observation was made of EI #9, RN (Registered Nurse) Treatment Nurse, measuring wounds for RI #22. EI #9 measured the first wound (mid-sacrum), described it as a Stage III that measured 0.8 cm by one inch. The surveyor asked EI #9 if she was measuring in inches or centimeters. EI #9 replied, both. EI #9 stated she was confused and not sure. EI #9 then described a new Stage III that she had not seen before, on the lower sacral area with yellow slough in the wound bed. EI #9 used inches as her unit of measure on the measuring device, but stated the measurement was "0.2 by 0.3 cm." The surveyor asked EI #9 what were the small increments on the other side of the measuring device. EI #9 said she did not know; that she had always used the other side, which indicated inches. As EI #9 prepared to measure RI #22's left heel wound, she said there was serosanguineous drainage on the resident's sock. She also said she did not know if it was drainage or [MEDICATION NAME] that was sprayed on the heel. EI #9 described the heel as unstageable with black eschar. EI #9 was confused and tried to measure the heel wound with the measuring device using inches. EI #9 left the room for a few minutes accompanied by the DON, and returned with a different measuring device (in centimeters). EI #9 then measured the left heel wound, as 4 cm X 4 cm. The surveyor asked EI #2 RN, DON (Director of Nursing, to re-measure RI #22's wounds. She described a 4.3 cm by 4.2 cm unstageable black left heel wound with moderate serosanguineous drainage on the sock. EI #2 said she would want to keep the heel covered and dressed, and that she did not recall the sock being wet before. EI #2 described a 1.7 cm X 1.8 by 0.4 cm Stage III mid-sacral wound with yellow slough and red granulation, and a 0.7 cm X 0.4 cm Stage II lower sacral wound with a pink wound bed and no depth. On 1/29/15 at 2:40 PM, the Treatment Nurse (EI #9) was asked why RI #22 had no description of a left heel wound. EI #9 said she was learning and she left that part out of the note. EI #9 was asked why RI #22's left heel wound was not documented on the Ulcer Report prior to 1/22/2015. She responded, because it was not open. On 1/30/2015 at 2:00 PM, the EI #2, DON was asked why RI #22's left heel wound was not documented on the ulcer report until 1/22/2015 (16 days after the wound was identified on 1/6/2015 on the resident's Body Assessment Tool). EI #2 said she could not think of any reason for the omission. When asked why EI #9 only documented open areas on the ulcer report, EI #2 did not know. EI #2 did not know why EI #9 was not following policy for pressure ulcer documentation. EI #2 was asked why EI #9's wound assessments were inadequate. She said she did not know why EI #9 was struggling, and that EI #9 had consultants and support at the facility. 3.) RI #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #13 scored a "13" on the initial Braden Scale -For Predicting Pressure Sore Risk dated 12/30/2014. A score of "13" indicated the resident was at moderate risk for pressure ulcer development. RI #13's admission "BODY ASSESSMENT TOOL" completed on 12/30/2014, by an unidentified nurse, revealed the following: "...COCCYX: redness... HEELS: (B) (bilateral); Tx (treatment) in place...(R) (right) knee stage II..." The body diagram contained Xs on the right and left heels and the center of the buttocks. There was no documented assessment or description of wounds, to identify size, stage, color, wound bed, drainage, or odor. RI #13's "INITIAL CARE PLAN" dated 12/30/2014, revealed Xs in the boxes next to the following items on the pre-printed care plan: "Risk for Skin Breakdown (admitted with areas)...Encourage to consume all foods & (and) Fluids...Preventative treatment as needed & Ordered...Vitamins & minerals as ordered, Tx (Treatment ) as ordered." RI #13's admission MDS with an ARD (Assessment Reference Date) of 1/6/2015, revealed two Stage II Pressure ulcers with the most severe tissue type being granulation. RI #13's weekly "BODY ASSESSMENT TOOL" completed 1/6/2015 by EI #9, RN (Registered Nurse), Treatment Nurse, revealed the following: "...(R) (right) heel us (unstageable) 1.8 X 0.6... (L) (left) heel 1 X 1 Stage I..." There was no unit of measure or description of wounds documented. These measurements differed from the measurements recorded on the next day, 1/7/2015 on the "PRESSURE ULCER REPORT". RI #13's "PRESSURE ULCER REPORT" completed 1/7/2015 by EI #9 revealed the following measurements to the left and right heel: "...(L) heel (stage) I 2 X 3 cm (centimeter)... (R) heel unstageable 3.2 X 2.8 cm..." RI #13's physician order [REDACTED]...1030 (10:30 AM) (1) Cleanse (L) heel (with) NS (normal saline), cover (with) duoderm (change) q (every) 72 hrs (hours)... (2) Cleanse (R) heel (with) NS, apply Santyl cover (with) 4 X 4 (gauze)... wrap (with) kling qd (every day)..." RI #13's treatment record (TAR) dated 1/20/2015 revealed the following: "...Cleanse (L) heel (with) NS, cover (with) duoderm and change Q72 hrs (every 72 hours)...6p-6a..." The treatment was transcribed onto the treatment record on the 6:00 PM to 6:00 AM shift to be completed on 1/20, 1/24, and 1/28/2015, which was every four days contrary to the physician's orders [REDACTED]. On 1/29/2015 at 2:40 PM, EI #9, Treatment Nurse, was asked who was responsible for measurements of wounds on admission. EI #9 said she was, and she tried to see wounds as soon as she could. When asked about the purpose of the "Body Assessment Tool," EI #9 said it was to prompt you to any skin issues of concern. EI #9 was asked what the wound documentation should include. She said, measurements, color, tissue type, changes, odor, tunneling, undermining, and the peri-wound. EI #9 was asked why her measurements and descriptions were not accurate and consistent. She said she was still learning. EI #9 was asked why it was important to measure and document wound progression. EI #9 said, "To determine if your treatment is correct and if wounds are healing." EI #9 was asked what increments she routinely used to measure wounds. She replied, centimeters. When asked why she attempted to measure in inches, EI #9 replied, she was anxious and nervous. EI #9 was asked how she had addressed the staff during the education she provided them on 11/19/2014. She said it was a verbal overview of the content of the policy. EI #9 was asked how she expected the staff to completely and accurately document wound assessments when she did not. EI #9 said, "I can't." On 1/29/2015 at 3:30 PM, EI #9 was interviewed again. EI #9 was asked who guided care planning interventions for wound care and prevention. The Treatment Nurse said she gives her reports to MDS and Dietary, and they all work together. EI #9 was asked why were wound and pressure ulcer care plans not individualized for residents. She said she could not answer that question. EI #9 was asked what the importance of individualized care plans for residents with wounds was. EI #9 said, "To ensure (residents are) getting the best care and treatment to get skin problems healed." On 1/30/2015 at 2:40 PM, EI #2, DON, was asked why it was important for nurses and the facility to follow policy and procedure, and to accurately and completely document pressure ulcers and the treatments provided. EI #2 responded, so that they could understand the residents' needs, treat them, track wounds for progress, and adjust treatments as needed. EI #2 was asked what harm would result if that was not done. She said it could affect the overall well-being of the residents. EI #2 was asked why there were blanks on the Treatment Record. She said the nurses were not documenting treatments. EI #2 was asked what the harm was, in failing to document treatments as ordered. She answered, noncompliance and failure to deliver patient care. EI #2 was asked who monitored that the orders on the MAR (Medication Administration Record) and TAR (Treatment Administration Record) were followed. EI #2 said that was part of EI #9's daily rounds. She also said that every Charge Nurse who picks up a chart or writes an order should look to see that it is done. When asked what problem was caused by not monitoring that orders were followed, EI #2 said, confusion. On 1/28/2015 at 6:10 PM, EI #13, (RN, MDS/Care Plan Coordinator) was asked what care plans were in place for RI #13's pressure ulcers. She read the pre-printed items on RI #13's "INITIAL CARE PLAN" dated 12/30/2014. EI #13 was asked were those individualized interventions for pressure ulcers. EI #13 said they were generalized for pressure ulcers. EI #13 was asked how would that care plan let staff know what areas to protect and treat. She replied, "It doesn't." EI #13 was asked how this care plan was individualized for the resident with pressure ulcer concerns. She said, "It's not." EI #13 was asked when should comprehensive care plans be complete after admission. EI #13 said 21 days. EI #13 was asked how long RI #13 had been in the facility. She responded, 29 or 30 days. 4.) RI #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #25's admission "BODY ASSESSMENT TOOL" dated 1/3/2015 revealed the following: "...COCCYX: Stage II Pressure Ulcer... HEELS: redness noted... educated about floating heels..." RI #25's "INITIAL CARE PLAN" dated 1/3/2015 revealed Xs in the boxes next to the following items on the pre-printed care plan: "Risk for Skin Breakdown (admitted with Stage II)...Encourage to consume all foods & (and) Fluids...Preventative treatment as needed & Ordered...Vitamins & minerals as ordered..." RI #25's admission MDS, with and ARD (Assessment Reference Date) of 1/8/2015, revealed one Stage II pressure ulcer, with the worst tissue type being slough. RI #25's physician order [REDACTED]. RI #25's Treatment Record for January 2015 revealed no documentation on 1/14 and 1/15 for the provision of wound care to the coccyx as ordered on [DATE]. RI #25's "BODY ASSESSMENT TOOL" dated 1/13/2015, revealed the following: "...#1 dark red... (#1 was drawn on the lower right side of the back on the diagram)... COCCYX: see below...#2 dark red (#2 drawn on two areas on the buttocks on the diagram)... HEELS: see below...#3 red (#3 was drawn on the right heel on the diagram)..." There was no other assessment or measurement of the red areas. On 1/31/2015 at 12:30 PM, EI #1,the facility administrator, stated that wounds for RI #25 were not documented on the Ulcer Report. On 1/31/2015 at 2:55 PM, EI #2, DON (Director of Nursing) was asked why was there no individualized care plan for pressure ulcers for EI #25. She said she did not know why. EI #2 was asked why it was important for care plans to be individualized. She said so that therapy that is put into place can be evaluated. EI #2 was asked about the reason for blanks on the treatment record. She said the nurse did not document the treatment as ordered. EI #2 was asked why was it important to document treatments as ordered. She said to show compliance for the physician orders. When asked the reason the resident's wounds were not on Ulcer Report, EI #2 said she did not know the reason. EI #2 was asked what harm there was in not following facility policy and procedure. She said it was non-compliance and possibly harmful to the resident. 5.) RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #12's admission "BODY ASSESSMENT TOOL" dated 12/4/2014, revealed: "...COMMENTS: 1 ? inch open area..." There was no wound location, stage or description documented on the "BODY ASSESSMENT TOOL." RI #12's Physician order [REDACTED]. RI #12's care plan for the problem "...Risk for skin breakdow

Based on interviews, record review, and the identified concern areas with the care of pressure sores, the facility Administrator failed to ensure nursing staff were trained in the identification, assessment, care planning, treatment and monitoring of pressure sores. The Administrator failed to manage the resources of the facility in such a way as to ensure the staff were utilizing the training provided and followed the facility policies for the provision of care and services to residents identified at risk for and or with pressure ulcers. This deficient practice affected 6 of 7 sampled residents with pressure ulcers. Resident Identifier (RI) Numbers: 15, 22, 12, 13, 25 and 6. On 01/31/15 at 3:10 PM, the Administrator, the Director of Nursing (DON) and the Assistant Executive Director/Marketing Director were notified of the findings of substandard quality of care at the Immediate Jeopardy level of "K" in the area of Administration, F 490. The Immediate Jeopardy began on 11/3/14 and was relieved on 1/31/15 at 7:30 PM. The findings include: Cross reference F 314 A review of facility staff education documentation revealed the current wound/treatment nurse, EI # 9, had also provided staff education to licensed nursing staff and certified nursing assistants on the facility policy and procedure on the topics of Pressure Ulcer Prevention and Management and Documentation of Wound Treatment on November 19, 2014. The Director of Nursing, EI #2 stated, during an interview on 1/30/15 at 2:20 PM, she did not know why the wound/treatment nurse, EI #9 was still not following the facility Policy and Procedure for pressure ulcer documentation and completing inadequate assessments. When asked what was done about it, EI #2 said that she, EI #9, had other consultants and EI #4. On 01/30/15 at 3:45 PM, EI #1, the Administrator, was asked what support she had provided the staff regarding pressure sores, care planning, assessments and Medication/Treatment Administration Records. EI #1 explained consultants from their pharmaceutical company had inserviced and audited the facility (including Medication Administration Records) on a monthly basis; the regional nurse from their management firm assisted with care plans and Minimum Data Set assessments. When asked if anyone had been monitoring these concerns, EI #1 stated their pharmaceutical company was responsible for the medications, the Director of Nursing (DON) was responsible for care planning, and the Regional Nurse from their management company provided quarterly visits, completing an audit sheet of concerns and a mock audit. EI #1 stated she would have to look back at the documentation to determine if the Regional Manager had found any concerns with any of the above areas. EI #1 stated the DON and Nursing Administrative staff have monitored pressure sores on a daily basis, as well as the consultants, but she would have to check her documentation. EI #1 was not sure whether the pharmaceutical company monitored transcriptions or medication administration (delivery) errors. When asked if the former Treatment Nurse (prior to the current treatment/wound nurse, EI # 9) had provided any training to EI #9, EI #1 said she had not. A Licensed Practical nurse experienced in pressure sores had been called in to train EI #9. EI #1 stated it was the responsibility of the DON and RN (Registered Nurse) Supervisor, or the Wound Care Nurse to monitor the documentation and assessment of pressure sores. The surveyor asked EI #1 how she had assessed or addressed these concerns, and if these concerns were new. EI #1 stated some concerns were new; she monitors, and addresses the concerns through the QA process. EI #1 acknowledged they needed additional training or monitoring tools. ****************************** Allegation of Compliance (AoC) for F 490: 1. Immediate action(s) taken: On January 30, 2015 the wound care consultant conducted a body audit on all current residents with pressure ulcers, no additional wounds found secondary to the body audit process. Appropriate measures were put in place by 1/31/15 to confirm treatments with MAR's and TAR's. Contracted wound care nurse consultant has been hired by facility on 1/30/15 to assess, measure, document and treat all pressure ulcers in house and/or admitted with pressure ulcer(s). Contracted wound care nurse consultant will be in the facility 7 days a week to complete wound care documentation and treatment. This is effective 1/30/15 and will continue until further notice or until a qualified wound care nurse can be hired and trained. Once a qualified wound care nurse is hired he/she will receive support and training. 2. Identification of other residents having the potential to be affected was accomplished by: Body Audits were completed for all residents in-house on 1/30/2015 by the nursing management team and/or designee's. Any issues noted will be assessed and addressed timely. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: Licensed Nursing Personnel beginning 1/30/15 were educated on various topics related to pressure ulcers. Licensed Personnel will be required to complete training before returning to work. Training will be provided for all licensed staff to understand the importance of documentation and assessment of pressure ulcers. Body audits were completed on all new admissions on 1/30/2015 by wound care consultant. Corrective action date: 1/31/15. On 1/31/15 at 7:30 PM, after a review of facility documentation of staff inservices, wound consultant documentation, and interviews with staff of inservice and education related to wound care, it was determined the facility had implemented corrective actions. The Administrator, Director of Nursing and the Assistant Executive Director/Marketing Director were informed Immediate Jeopardy for F490, Administration, was relieved onsite. The scope and severity of F 490 was lowered to a "H" level to allow the facility time to monitor and revise their corrective actions as needed to achieve substantial compliance.

Based on the multiple serious concerns identified through record review, observation and interviews, the management company failed to ensure the facility identified, monitored and resolved concerns with the care and treatment of [REDACTED]. The management company failed to provide the over-sight needed to ensure quality care was provided. On 01/31/15 at 3:10 PM, the Administrator, the Director of Nursing (DON) and the Assistant Executive Director/Marketing Director were notified of the findings of substandard quality of care at the Immediate Jeopardy level of "K" in the area of Administration, F 493. The Immediate Jeopardy began on 11/3/14 and was relieved on 1/31/15 at 7:30 PM. Findings included: Cross reference F 314 and F 490 A review of the "Site Visits" provided by the facility's management company revealed five visits had been made throughout the previous year, each of a four-day duration with recommendations for training. a) 1/27/14 through 1/31/14: purpose was to provide "healthcare support and training to get ready for survey and meet new administrator." Recommended training included: oxygen therapy and safety; pericare with CNA (Certified Nursing Assistant); and medication pass with nurses. b) 5/27/14 through 5/30/14: On this quarterly site visit, recommended training included: "MDS (Minimum Data Set) training with administration and MDS coordinator and back up person; AOD (computer) basic training with Administrator...; Medicare documentation (scheduled for 7/16/14). c) 8/4/14 through 8/7/14: MDS training with MDS Coordinator; AOD basic training with DON. d) 10/6/14 through 10/9/14: a quarterly site visit; MDS and care plan training with MDS Coordinator; MDS and care plan training with social services. e) 11/23/14 through 11/26/14: follow up on mock survey. Recommendations were made for Medicare documentation, and nursing assessment tools and completion (to be done 12/16/14). On 01/31/15 at 9:15 AM, the surveyor contacted the Regional Health Services Director (EI #14) of the facility's management company by telephone. The surveyor confirmed with EI #14, her goal of providing guidance in health care management. EI #14 stated she completed mock surveys to determine problems and develop corrective action plans. The surveyor asked what guidance she had provided regarding pressure sores, wound assessments and follow-up. EI #14 explained the facility had experienced a significant amount of turn-over with wound nurses, along with DONs. EI #14 further explained she had seen wound care but no documentation regarding size, healing, progression. EI #14 again stated there had been changes in wound care staff and she had seen wound care not being done properly, but had to turn over that responsibility to the Director of Nursing (DON). The surveyor asked the cause of the system breakdown in wound care. EI #14 stated it was due to the large turn-over of DONs, as well as staff. The surveyor asked EI #14 if she had done any one-on-one monitoring with staff about measuring wounds. EI #14 had not, because she was told a wound care consultant had been brought in to do training (EI #4), who was also working with staff in their documentation of care. EI #14 affirmed the facility did not have the right documentation and support to show care has been provided. ************************ Allegation of Compliance (AoC) for F 493: 1. Immediate action(s) taken: On January 30, 2015 the wound care consultant conducted a body audit on all current residents with pressure ulcers, no additional wounds found secondary to the body audit process. Appropriate measures were put in place by 1/31/15 to confirm treatments with MAR's and TAR's. Contracted wound care nurse consultant has been hired by facility on 1/30/15 to assess, measure, document and treat all pressure ulcers in house and/or admitted with pressure ulcer(s). Contracted wound care nurse consultant will be in the facility 7 days a week to complete wound care documentation and treatment. This is effective 1/30/15 and will continue until further notice or until a qualified wound care nurse can be hired and trained. Management nurse consultant will assist with this process as necessary. 2. Identification of other residents having the potential to be affected was accomplished by: Body Audits were completed for all residents in-house on 1/30/2015 by the nursing management team and/or designee's. Any issues noted will be assessed and addressed timely. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: Licensed Nursing Personnel beginning 1/30/15 were educated and will be re-educated on the facility policy for Pressure Ulcers. Licensed Personnel will be required to complete training before returning to work. Education and training to include in-services will be conducted at a minimum of once a quarter. Management consultant nurse will be in the facility Tuesday, February 2, 2015 to continue training/education with current Director of Nursing for wound care. Monthly on-site visits by management nurse consultant will continue to ensure additional ongoing training of licensed personnel. Management nurse consultant will provide support as needed in regards to nursing personnel and retention. Corrective action completion date: 1/31/2015. ************************ On 1/31/15 at 7:30 PM after a review of facility documentation of staff inservices, wound consultant documentation, and interviews with staff of inservice and education related to wound care, it was determined the facility had implemented the corrective actions to remove the immediacy. The Administrator, Director of Nursing and Assistant Executive Director/Marketing Director were informed the Immediate Jeopardy for F 493, Administration, was relieved onsite. The scope and severity of F 493 was lowered to a "H" level to allow the facility time to monitor and revise their corrective actions as needed to achieve substantial compliance.

Based on observation, interviews and record review, the facility failed to individualize care plans to meet the needs of RI #15, 22, 13 and 25. This affected four of 24 sampled residents for whom care plans were reviewed. Findings included: 1) RI #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Initial "Body Assessment Tool" completed on 11/03/14, identified the presence of unstageable eschar to the resident's right heel, as well as several "predecubitus" to the right and left buttocks. The admission physician's orders [REDACTED]." The "Initial Care Plan" dated 11/03/14, addressed "Risk for Skin Breakdown" but did not include measures to address the multipodus boot. An additional generic care plan dated 12/05/14, was added to address a problem of "Resists Care", but was not individualized to assist caregivers with interventions for RI #15's specific behaviors. Additional (more individualized) care plans were not added until 12/23/14, seven weeks (49 days) after admission. The resident's need related to the use of one (rather than two) multipodus boot was still not addressed. On 01/27/15 at 6:00 PM, the licensed nurse who assisted with the care plan revision of RI #15 was interviewed, Employee Identifier (EI) #3. The surveyor asked why the initial generic care plan dated 11/03/14, had not been individualized until 12/23/14. EI #3 explained the initial care plan was typically used until the comprehensive assessment had been completed (and an individualized plan was developed.) A total of 21 days after admission is needed for the completion of the care plan. EI #3 explained she had written in additional interventions to the 12/23/14 care plan, dating them as 11/28/14--the date of implementation. EI #3 stated 11/28/14 was the first date she got involved with RI #15's care plan. EI #3 was not aware of the reason why the resident's boot had not been addressed. 2) RI #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #22's admission "BODY ASSESSMENT TOOL" completed by EI #11, LPN on 1/6/2015 revealed the following: "...HIP: Stage 3 area R (right)...quarter size...COCCYX: Stage 3 area half dollar size...HEELS: L (left) dark purple unblanchable..." RI #22's "INITIAL CARE PLAN" dated 1/6/2015 revealed Xs in the boxes next to the following items on the pre-printed care plan: "Risk for Skin Breakdown (Actual Skin breakdown)...Encourage to consume all foods & (and) Fluids...Preventative treatment as needed & Ordered...Vitamins & minerals as ordered..." Although the resident's wounds had been identified on admission (the same day care planned), this initial plan did not address risk factors identified or more specific instructions for care of the wounds to the right hip, coccyx, or left heel. RI #22's admission MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 1/11/2015, revealed a BIMS (Brief Interview for Mental Status) score of 9, which indicated moderately impaired cognition. The MDS also revealed that two Stage II and two Stage III pressure ulcers were present with the most severe tissue type being slough. On 1/29/2015 at 3:30 PM, EI #9 was asked who guided care planning for interventions for wound care. The treatment nurse said she gives her reports to MDS and dietary and they all work together. EI #9 was asked why wound and pressure ulcer care plans were not individualized for residents. She said she could not answer that question. EI #9 was asked what the importance of individualized care plans for residents with wounds was. EI #9 said, "To ensure getting the best care and treatment to get skin problems healed." 3) RI #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #13's admission "BODY ASSESSMENT TOOL" completed on 12/30/2014, by an unidentified nurse, revealed the following: "...COCCYX: redness...HEELS: (B) (bilateral); Tx (treatment) in place...(R) (right) knee stage II..." . RI #13's "INITIAL CARE PLAN" dated 12/30/2014 revealed Xs in the boxes next to the following items on the generic pre-printed care plan: "Risk for Skin Breakdown (admitted with areas)...Encourage to consume all foods & (and) Fluids...Preventative treatment as needed & Ordered...Vitamins & minerals as ordered..." This plan did not address RI #13's bilateral heel wounds and specific interventions for care. RI #13's admission MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 1/6/2015, revealed a BIMS (Brief Interview for Mental Status) score of 10, which indicated moderately impaired cognitive impairment. The MDS also revealed two Stage II Pressure ulcers with the most severe tissue type being granulation. On 1/28/2015 at 9:25 AM, RI #13 was observed sitting in a wheelchair wearing soft boot style house shoes. RI #13 propped the right boot heel on the edge of the wheelchair foot rest causing pressure on the heel. On 1/28/2015 at 6:10 PM EI #13, RN, MDS/Care Plan coordinator, was asked what care plans were in place for RI #13's pressure ulcers. She read the pre-printed items on RI #13's "INITIAL CARE PLAN" dated 12/30/2014. EI #13 was asked were those individualized interventions for pressure ulcers. EI #13 they were generalized for pressure ulcers. EI #13 was asked how that care plan let staff know what areas to protect and treat. She replied, "It doesn't." EI #13 was asked how that care plan was individualized for the resident for pressure ulcer concerns. She said, "It's not." EI #13 was asked when should comprehensive care plans be completed after admission. EI #13 said 21 days. EI #13 was asked how long RI #13 had been in the facility. She said, 29 or 30 days. 4) RI #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #25's admission "BODY ASSESSMENT TOOL" dated 1/3/2015 revealed the following: "...COCCYX: Stage II Pressure Ulcer...HEELS: redness noted...educated about floating heels..." RI #25's "INITIAL CARE PLAN" dated 1/3/2015 revealed Xs in the boxes next to the following items on the pre-printed care plan: "Risk for Skin Breakdown (admitted with Stage II)...Encourage to consume all foods & (and) Fluids...Preventative treatment as needed & Ordered...Vitamins & minerals as ordered..." This plan did not address RI #25's risk factors identified or specific instructions for care of the coccyx wound or red heels. RI #25's admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/8/2015 revealed a BIMS (Brief Interview for Mental Status) score of 11 which indicated moderate cognitive impairment. The MDS also revealed one Stage II with the worst tissue type being slough. RI #25's "BODY ASSESSMENT TOOL" dated 1/13/2015 revealed the following: "...#1 dark red...(#1 points to the lower right side of the back on the diagram)...COCCYX: see below...#2 dark red (#2 points to areas on the buttocks on the diagram)...HEELS: see below...#3 red (#3 points to the right heel on the diagram)..." On 1/31/2015 at 2:55 PM, EI #2, the DON (Director of Nursing) was asked why was there no individualized care plan for pressure ulcers for EI #25. She said she did not know why. EI #2 was asked why it was important for care plans to be individualized. She said so that therapy that is put into place can be evaluated.

Based on observation, interview, and record review, the facility failed to ensure medications were administered as ordered by the Physician for RI (Resident Identifier) #6, #18, #19, #20, and #21. Of 31 opportunities, 6 medications were given in error on 2 of 2 halls by 3 of 3 nurses on 1 of 2 shifts, resulting in a medication pass error rate of 19%. This affected 5 of 7 residents observed during medication pass. Findings Included: The facility policy "...Medication Administration ...General Guidelines ..." with a review date of 6/12, revealed: "...POLICY: Medications are administered as prescribed, in accordance with good nursing principles and practices ...PROCEDURE: ...Medications are administered in accordance with written orders of the attending physician ..." The facility policy "...Nebulizer Therapy..." with a review date of 6/12, revealed: "...POLICY: Medications are administered as prescribed, in accordance with good nursing principles and practices ...PROCEDURE: 5. Instruct patient to breathe slowly and deeply throughout the treatment ..." 1) RI #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #6's Physician order [REDACTED]. On 1/13/2015 at 3:50 PM while observing medication administration, EI #7, RN (Registered Nurse), set up a Nebulizer treatment for [REDACTED]. The resident's sitter was present in the room. EI #7 was observed by the surveyor during medication pass until 4:38 PM, when the surveyor returned to RI #6's room. The Nebulizer mask was lying on the resident's bedside table. The sitter stated that the steam ran out, so she took the mask off of the resident; it had been finished about 10 minutes. 2) RI #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #18's Physician order [REDACTED]...1 CAPSULE BY MOUTH THREE TIMES DAILY ...9 AM 1PM 5PM ..." On 1/13/2015 at 4:25 PM while observing medication administration, EI #7 stated RI #18's [MEDICATION NAME] 300 mg 1:00 PM dose had not been given. RI #18's pharmacy strip pack, containing a 300 mg [MEDICATION NAME] capsule for the 1:00 PM dose, was observed in the medication cart. On 1/14/2015 at 2:50 PM, EI #7 was asked who was responsible for administering the 1:00 PM dose of [MEDICATION NAME] to RI #18 on 1/13/2015. EI #7 said she would have to accept responsibility. EI #7 was asked why the medication was not administered at 1:00 PM. EI #7 stated the shift was split with another nurse, and she did not realize it had not been given. EI #7 was asked what the potential harm was in RI #18 not receiving the medication as ordered. EI #7 stated the resident took [MEDICATION NAME] for jaw pain; if a dose was missed it would affect the pain level of RI #18. EI #7 was asked about the facility policy regarding administration of medication by nurses. EI #7 said there were five rights: the right route, medication, time, resident, and dose. EI #7 was asked if residents are to complete medication administration in the presence of licensed staff. EI #7 said yes, the nurses check to make sure residents have swallowed all PO (by mouth) medications. EI #7 was asked what licensed staff remained with RI #6 during the Nebulizer administration. EI #7 stated, "We do not have to remain with the resident during Nebulizer administration for the whole time." EI #7 was asked if RI #6 completed the Nebulizer administration. EI #7 said, "I believe (the resident) did." EI #7 was asked how she knew. EI #7 said she went back and looked at the Nebulizer. EI #7 was asked when she went back to look; EI #7 said she was not sure. EI #7 was asked what is the facility policy regarding the duties of sitters. EI #7 said they are just to sit. 3) RI #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/14/2015 at 8:25 AM, a Licensed Practical Nurse, EI #6, was observed administering medication to RI #19. A total of five oral (PO)medications were administered. While verifying medications administered, physician's orders [REDACTED]...8AM ..." EI #6 did not administer the Vitamin B-12 to RI #19 during this medication pass. On 1/14/2015 at 12:05 PM, an interview was conducted with EI #6. EI #6 was asked if RI #19 was supposed to receive B-12 and he said yes. EI #6 was asked why the resident did not get the B-12 during the medication pass. EI #6 said he did not think he missed it. EI #6 was asked what the B-12 was being given for; he said, for energy. EI #6 was asked what the harm was in not administering medication as ordered. EI #6 stated the resident could be lacking energy. 4) RI #20 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED]...3 units ..." On 1/14/2015 at 11:00 AM, the surveyor observed as the LPN, EI #8, checked RI #20's physician's orders [REDACTED]. On 1/14/2015 at 11:40 AM, the surveyor asked EI #8 why she had administered 5 units of insulin to RI #20. EI #8 stated the sliding scale order was for 5 units, and the order date was 1/14/2015. EI #8 was asked to look at the new order a third time. After she did, EI #8 clarified the new order was for 3 units; the 5 units had been discontinued. EI #8 was asked why she administered the 5 units instead of 3 units. She said she misread the order; the potential harm for RI #20 could be a drop in blood sugar. 5) RI #21 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #21's admission Physician's orders dated 1/14/2015, revealed: "...EC ASA ([MEDICATION NAME] coated aspirin) ...325mg BID (twice a day) ...Vit (Vitamin) B12 100mcg... QD (daily)..." On 1/15/2015 at 8:30 AM, during the medication pass, EI #6 administered a 325 mg [MEDICATION NAME] tablet, a 1000 mcg B-12 tablet, and two other tablets to RI #21. EI #6 then initialed EC ASA on the MAR (medication administration record). The surveyor then asked him to look at the bottle the pill came from. EI #6 pulled out the [MEDICATION NAME] bottle. On 1/15/2015 at 8:40 AM, an interview was conducted with EI #6. He was asked why he gave RI #21 [MEDICATION NAME]. EI #6 said the bottles were right next to each other; he needed to read carefully and be careful. EI #6 was asked why the resident was taking EC ASA. EI #6 responded to prevent blood clots after surgery. The MAR (where EI #6 initialed the Vitamin B-12) revealed an extra 0 had been added to the 100 mcg dose order (causing it to appear to be a 1000 mcg dose, as contained in the bottle). On 1/15/15 at 12:30 PM, the RN/DON, (Registered Nurse/Director of Nursing was asked why 1000 mcg B-12 was given to RI #21, when only 100 mcg had been ordered. The DON said the nurses that transcribed it were probably in a hurry.

Based on record review and interview, the facility failed to: 1.) Routinely document the provision of medication ordered for RI #2. 2.) Ensure Wound Clinic Physician orders [REDACTED]. The facility further failed to ensure RI #15's treatment orders were transcribed accurately, timely, and documented on the treatment record as provided during November and December 2014. 3.) Ensure [MEDICATION NAME] was documented on the treatment record on 1/17/2015 and 1/18/15 as ordered for RI #22's left heel. 4.) Ensure the treatment to RI #13's left heel was transcribed from the physician's orders [REDACTED]. The facility also failed to clarifiy, correctly transcribe, and document two different right heel treatment orders on 1/20/15. 5.) Ensure the dressing to RI #25's coccyx was documented on the treatment record on 1/11, 1/14, and 1/15 as ordered on [DATE]. This affected 5 of 12 residents for whom MARs (Medication Administration Record) and TARs (Treatment Administration Record) were reviewed. Findings included: 1.) RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's Physician orders [REDACTED]. RI #2's May 2014 Medication Administration Record [REDACTED]. On 1/15/15 at 8:10 PM, an interview was conducted with Employee Identifier (EI) #2, RN/DON (Registered Nurse/Director of Nursing). She was asked why Pyridostigmine was not administered routinely as ordered for RI #2 until 5/13/2014. EI #2 stated that she did not know why; any missed medication could be harmful to the resident's condition, and could cause an increase in pain or irreversible effects. 2.) RI #15 was admitted to the facility 11/03/14 with [DIAGNOSES REDACTED]. The admitting physician's orders [REDACTED].@ (at) all times, Apply Zinc Oxide to sacral area after bath, pericare & PRN (and as needed)..." A review RI #15's medical record revealed these orders were not transferred to the November or December Treatment Administration Records nor was there documentation that these orders were discontinued. An 11/06/14 physician's orders [REDACTED]. A review of the November 2014 Treatment Administration Record (TAR) indicated treatment was not signed as provided on 11/15, 11/20, 11/22, and 11/26. On 11/26/14, the facility's "Pressure Ulcer Report" documented measurements of RI #15's right heel wound as unstageable, 3 cm X 4 cm. This report also documented a new pressure ulcer located on top of RI #15's right foot as unstageable, 2.6 cm X 1.3 cm. On 11/28/14, new physician's orders [REDACTED]." The TAR documented these orders were not implemented until 12/02/14, four days later. No treatment was documented on 12/25/14. Although the top right foot wound was identified on 11/26/14, a treatment order was not obtained until 11/28/14, to "Clean top of R foot /c normal saline, pat dry, apply xeroform, cover /c gauze, wrap /c roll gauze QD." These orders were not documented as provided on the TAR until 12/02/14, four days after they were ordered. During a review of the medical record on 11/10/2014, the "Daily Skilled Nursing Notes" included documentation of a "Blister area observed to upper left buttocks. Duoderm applied. Will observe for changes." No description, size or stage was written. A corresponding Physician orders [REDACTED]. duoderm to left buttocks changed every three days 2. Check /q (every) shift." This treatment was signed off as done every three days through 11/28/2014. After the 11/28/14 treatment, treatments were not documented on the 12/2014 TAR until 12/04/2014, six days later. On 11/28/14 an order was also written to "Apply [MEDICATION NAME] spray to L heel BID (twice daily)." The treatment was not initiated until 12/02/14 (four days after ordered), and was signed off as given only once a day throughout December. A Physician order [REDACTED]. Change daily & PRN. Re-eval (evaluate) in 7 days." According to the December TAR, the treatment began on 12/20/14, four days after the coccyx wound was identified. Also, according to this treatment record, there was no treatment provided on 12/22/14 and 12/23/14 to RI #15's coccyx wound. On 12/23/14, RI #15's family took the resident to a wound clinic for consultation and evaluation. The consultant Wound Physician recommended orders for daily dressing changes to the right heel and right dorsal foot with 4 x 4's, Kerlix, and [MEDICATION NAME] AG (silver). An additional order was listed to "Discontinue use of boot to right foot." These consultant's Wound Care Orders were not transcribed to the facility's physician's orders [REDACTED]. RI #15 was seen again at the Wound Clinic 12/30/14. The consultant's report documented orders to: "Discontinue boot to right leg; No ambulation/PT (Physical Therapy) until further notice; Full body lift; Elevate legs at all times." Orders continued for the daily dressing change with [MEDICATION NAME] AG to the right heel and right dorsal foot. The consultant's orders were not transferred to the facility's Physician order [REDACTED]. On 01/31/15 at 8:20 AM, the Director of Nursing (EI #2) was asked if anyone had monitored the nursing staff to ensure they were documenting (wounds) accurately. EI #2 stated she knew this was a need, it was a work in progress. EI #2 was unable to explain the lack of consistent documentation by nursing staff on the treatment records, and transcription errors. 3.) RI #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #22's physician order [REDACTED]. RI #22's admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/11/2015 revealed a BIMS (Brief Interview for Mental Status) score of 9, which indicated moderately impaired cognition. The MDS also revealed that two Stage II and two Stage III pressure ulcers were present with the most severe tissue type being slough. There was no documentation of Deep Tissue Injury. RI #22's wound measurements in the "NURSE'S NOTES" revealed the following: "...1/14/15...L heel DTI (Deep Tissue Injury)...4 X 5 cm... 1/22/15...L heel DTI...5 X 5 cm..." There was no further description of the left heel wound. RI #22's treatment record dated 1/7/2015 through 1/31/2015, revealed no documentation of the provision of the [MEDICATION NAME] spray to bilateral heels for the 17th and 18th on the 6:00 PM to 6:00 AM shift, as ordered 1/7/2015. 4.) RI #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #13's admission MDS with an ARD (Assessment Reference Date) of 1/6/2015, revealed a BIMS (Brief Interview for Mental Status) score of 10, which indicated moderately impaired cognitive impairment. The MDS also revealed two Stage II Pressure ulcers with the most severe tissue type being granulation. RI #13's physician order [REDACTED]...1030 (10:30 AM) (1) Cleanse (L) heel (with) NS (normal saline), cover (with) duoderm (change) q (every) 72 hrs (hours)... (2) Cleanse (R) heel (with) NS, apply Santyl cover (with) 4 X 4 (gauze)... wrap (with) kling qd (every day)... ...1700 (5:00 PM) (1) Paint (with) [MEDICATION NAME] or liquid barrier film wrap (with) dry gauze...float (R) heel..." RI #13's treatment record dated 1/20/2015 revealed the following: "...Cleanse (L) heel (with) NS, cover (with) duoderm and change Q72 hrs (every 72 hours)...6p-6a..." Provision of treatment was documented on the treatment record on the 6:00 PM to 6:00 AM shift for 1/20, 1/24, and 1/28/2015, which was every four days (instead of every 72 hours as ordered). RI #13's treatment record dated 1/20/2015 also revealed: "...Cleanse (R) heel (with) NS, apply santyl cover (with) 4 X 4 (gauze)...wrap (with) kling qd (every day)...6p-6a..." Provision of treatment was documented on the treatment record for 1/20, 1/21, and 1/22. A slash (\) was marked across the treatment record for the 23rd and "order changed 1/20..." was hand written in the space. RI #13's treatment record dated 1/20/2015 further revealed: "...Paint (with) [MEDICATION NAME] or liquid barrier film wrap (with) dry gauze (and) float (R) heel...6P-6a..." Provision of treatment was documented on the record beginning 1/23. "Refused" was written on the record for 1/25; initials with an "R" inside a circle were written on 1/26. The facility received two different treatment orders for the right heel, without clarification for which order to follow. On 1/30/2015 at 2:40 PM, EI #2 was asked why it was important for nurses and the facility to follow policy and procedure, and to accurately and completely document pressure ulcers and the treatments provided. EI #2 responded, so that they could understand the residents' needs, treat them, track wounds for progress, and adjust treatments as needed. EI #2 was asked what harm would result if that was not done. She said it could affect the overall well-being of the residents. EI #2 was asked why there were blanks on the Treatment Record. She said the nurses were not documenting treatments. EI #2 was asked what the harm was, in failing to document treatments as ordered. She answered, noncompliance and failure to deliver patient care. EI #2 was asked who monitored that the orders on the MAR (Medication Administration Record) and TAR (Treatment Administration Record) were followed. EI #2 said that was part of EI #9's daily rounds. She also said that every Charge Nurse who picks up a chart or writes an order should look to see that it is done. When asked what problem was caused by not monitoring that orders were followed, EI #2 said, confusion. 5.) RI #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #25's admission MDS with and ARD (Assessment Reference Date) of 1/8/2015 revealed a BIMS (Brief Interview for Mental Status) score of 11, which indicated moderate cognitive impairment. The MDS also revealed one Stage II pressure ulcer, with the worst tissue type being slough. RI #25's physician order [REDACTED]. RI #25's Treatment Record for January 2015 revealed, a circle around the initials on 1/11 and no documentation on 1/14 and 1/15 for the provision of wound care to the coccyx as ordered on [DATE]. On 1/31/2015 at 2:55 PM, EI #2, DON (Director of Nursing) was asked about the reason for blanks on the treatment record. She said the nurse did not document the treatment as ordered. EI #2 was asked why was it important to document treatments as ordered. She said to show compliance for the physician orders. F514 was cited as a result of the investigation of complaint/report #AL 159.

Based on observation, interviews and record review, the facility failed to ensure the Quality Assessment and Assurance (QA & A) Committee identified and corrected concerns with: a) the provision of pressure sore assessment and monitoring; b) the documentation and administration of medications; and c) the development of individualized care plans based on each resident's assessment tool, in a timely manner. This directly affected 11 of 24 sampled residents, including Resident Identifier (RI) #s: 2, 6, 12, 13, 15, 18, 19, 20, 21, 22 and 25. Findings included: On 01/31/15 at 8:55 AM, the Administrator, Employee Identifier (EI) #1 confirmed she served as the facility's QA & A Coordinator. EI #1 provided documentation (on 01/15/15) of the committee's active functioning, which included representation from the Medical Director, Director of Nursing, Nursing and Non-Nursing personnel. EI #1 also confirmed the committee met on at least a quarterly basis to track and trend concerns raised by family members, the State survey agency, the Grievance system, and outside Consultants. On 01/30/15 at 2:35 PM, the concerns with resident assessments and individualized care plans were discussed with both the Director of Nursing (DON) and the Administrator. The DON stated there had been at least three previous MDS assessment/care plan coordinators over the past year, prior to those in place at this time. The surveyor asked the Administrator if the QA Committee had monitored the care plan process. The Administrator said she would have to review the QA notes. Additional concerns regarding the assessment and monitoring of pressure sores were also discussed at this time. The surveyor asked why the Wound Nurse had not been following the policy and procedure. Neither the DON nor the Administrator knew. The surveyor asked if QA monitoring had been done to address the concern with pressure sores. EI #1 stated she would have to review the QA notes. On 01/30/15 at 3:45 PM, the surveyor asked the Administrator what support had been provided to staff related to pressure sores, accurate medication administration and transcriptions, care planning and assessments. EI #1 explained their pharmaceutical company assisted with the medication administration education, the management consultant assisted with training related to care planning and assessments (in addition to their in-house training). EI #1 stated she would have to review the management consultant's documentation to determine whether any concerns were found with the above. When asked how she had addressed the concerns encountered by the surveyors, EI #1 stated some of the concerns were new and added, "I monitor. I address concerns to QA process. I realize we need additional training or monitoring tools." On 01/31/15 at 8:30 AM, the surveyor asked the Administrator again, if she had found anything to address the above concerns in their QA documentation. EI #1 affirmed there was nothing in the QA.