Every finding on record at Hammond Health Services

Based on observation, interview and record review, the facility did not ensure prescription medications were administered by qualified staff to resident's (R) skin for 2 of 5 observations. (R24 and R26) Findings include: Surveyor reviewed facility policy titled, Medication Administration, stated in part: .-1. Medications are prepared only by licensed nursing, medical, pharmacy or other personnel authorized by state regulations to prepare medications . Surveyor reviewed R24's physician orders on 02/04/25 which state in part: -Ammonium Lactate External Lotion 12 % (Lactic acid), apply to both legs topically in the morning for dry skin. -Nystatin External Powder 100000 unit/GM, apply to skin infection area topically three times a day for Candida yeast infection. Surveyor reviewed R26's physician orders on 02/04/25 which state in part: -Lac-Hydrin External Cream 12 % (Lactic Acid (Ammonium Lactate), apply to Bilateral Legs topically one time a day for dry skin. On 02/04/25 at 8:13 AM, Surveyor observed Licensed Practical Nurse (LPN) D administer R24's medications. Surveyor observed R24's prescription cream and Nystatin powder sitting on R24's bedside dresser. LPN D indicated that R24 has prescription cream for R24's legs, but LPN D will need to check with Certified Nurse Assistant (CNA)s to see if CNAs applied prescription cream to R24's legs. LPN D took prescription medication bottles that were lying on bedside dresser and brought the prescriptions back to medication cart. LPN D stated, Prescription creams should be in medication cart locked. LPN D stated she has been off for a week and unsure why the creams are in R24's room. Surveyor asked LPN D what is the normal process for applying prescription creams to R24's legs. LPN D indicated that only nurses are supposed to apply prescription creams to R24's legs. On 02/04/25 at 8:15 AM, Surveyor observed LPN D approach CNA E and asked CNA E if CNA E applied prescription medication to R24's legs this morning. CNA E indicated that CNA E applied R24's special creams after R24 received a bath this morning. On 02/04/25 at 8:16 AM, Surveyor observed LPN D approach Registered Nurse (RN) C and informed RN C that CNA E had applied prescription creams to R24 and R26. Surveyor asked RN C if CNAs are allowed to apply prescription creams. RN C indicated that CNAs are not allowed to apply prescription creams ever. RN C indicated that sometimes prescription medications will be left in resident rooms if there is a self-administer order put in the chart that they can self-administer the medication. On 02/04/25 at 11:18 AM, Surveyor interviewed Director of Nursing (DON) B and asked expectation for who administers and applies prescription topical medications for R24 and R26. DON B indicated that DON B already went into R26's room and took topical medications out of room. DON B indicated that CNAs are not to administer any medications under any circumstances and that education is already in effect.

Based on observation, interview and record review, the facility staff did not ensure proper hand hygiene when distributing food. The facility did not have a freezer internal temperature monitoring system for stored foods. Staff did not check the dishwasher internal temperature for proper dish sanitization. This has the potential for foodborne illness to all 28 residents (R) reviewed in the facility. Findings include: Facility policy entitled Hand Washing-Food and Nutrition Services, stated in part, . Hands and exposed portions of arms should be washed immediately before engaging in food preparation. 1. b. After touching bare human body parts other than clean hands and clean, exposed portions of arms, i. Before donning disposable gloves for working with food and after gloves are removed, j. After engaging in other activities that contaminate the hands . Example 1 On 01/30/24 at 7:46 AM, Surveyor observed Cook D serve breakfast in the main dining room. Surveyor observed Cook D take his right gloved hand and scratch under his left gloved wrist below the band-aid located on his forearm/wrist. Cook D then reached for toast with the contaminated right gloved hand and buttered the toast. Then Cook D took a pair of tongs, picked the bread up, placed the piece of toast onto the plate, and readjusted the toast with the contaminated gloved right hand. Surveyor did not observe hand hygiene performed before, during, or after serving breakfast to all residents. On 01/30/24 at 11:44 AM, Surveyor observed Cook D prepping/serving room trays and the main dining room. Cook D applied a pair of gloves and picked up Cook D's eyeglasses off the kitchen counter and applied them on his face. Then Cook started serving lunch. Surveyor witnessed 4 cold chicken sandwiches on a plate off to the side of the steam table. Cook D picked up a cold chicken sandwich with contaminated gloved hands and placed the sandwich on R15's plate. Cook D picked up another cold chicken sandwich with contaminated gloved hands and placed the sandwich on R13's plate. Surveyor observed Cook D readjust eyeglasses with gloved fingertips and palms and then touch Cook D's face with gloved hands and scratched cheek. Cook D continued with contaminated gloved hands to pick up cold chicken sandwiches and serve them to residents. Surveyor did not observe any hand hygiene before, during, or after prepping/serving food to residents. On 01/30/24 at 12:00 PM, Surveyor interviewed Dietary Manager (DM) C and asked about hand hygiene in the kitchen when prepping/serving food. DM C indicated that the expectation for all staff in the kitchen is to wash their hands before and after prepping/serving meals. DM C indicated that Cook D should have taken gloves off and washed his hands after scratching his arm with gloved hands. DM C indicated that Cook D should have taken his gloves off and washed his hands after touching eyeglasses and placing them on his face. Example 2 On 01/29/24 at 12:20 PM, Surveyor observed freezer #3 to not have an internal thermostat. On 01/29/24 at 12:25 PM, Surveyor interviewed DM C and asked how the staff keeps food stored properly in the freezer if there is no internal temperature gauge in case the outside gauge thermometer breaks. DM C indicated that staff read the thermometer off the outside and there is no internal thermometer. DM C then indicated that she ran out of an internal thermometer and is ordering one for freezer #3. Example 3 On 01/29/24 at 12:30 PM, Surveyor observed Dietary Aide (DA) E washing dishes in the kitchen. Surveyor did not observe DA E check the internal temperature when washing dishes. On 01/29/24 at 12:35 PM, Surveyor interviewed DA E and asked if internal dishwasher temperatures are checked. DA E indicated that staff check the temperature gauges on the bottom gauge and the top gauge. DA E indicated they do not check an internal temperature. On 01/31/24 at 7:32 AM, Surveyor interviewed DM C and asked about checking dishwasher temperatures when washing dishes. DM C indicated that the kitchen uses a hot wash cycle and checks temperature gauges on the bottom and top gauge for correct temperature. Surveyor asked DM C if the staff checks internal temperature to make sure the correct sanitizing system is in place. DM C indicated that the kitchen does not check internal temperatures. DM C can order some internal temperature stickers to place for the first cycle of dishes being washed going forward.

Based on observation, interview and record review, the facility did not ensure a resident with an enteral tube receives the appropriate treatment and services to prevent complications. Registered Nurse (RN) administered a medication through Resident (R) 12's enteral tube without completing a water flush prior to the medication. This occurred for 1 of 2 enteral medication observations. Findings include: According to the National Library of Medicine, when administering medications via enteral tube, .After tube placement is checked, a clean 60-mL [milliliters] syringe is used to flush the tube with a minimum of 15 mL of water before administering the medication. Follow agency policy regarding flushing amount . https://www.ncbi.nlm.nih.gov/ According to facility policy and procedure, entitled, Medication Administration Enteral Tubes, last reviewed/revised 01/23 .Enteral tubes are flushed with at least 15 ml of water before administering any medications and after all medications have been administered . R12 was admitted to the facility on [DATE], with the following diagnosis, in part: dysphagia (difficulty swallowing) following nontraumatic intracerebral hemorrhage. R12 had the following physician order on the medical record: May crush and cocktail all medications and administer via G-tube every shift. Flush with 30cc [ml] of water before and after administration of medication . On 01/30/24 at 11:11 AM, Surveyor observed RN F administer a medication through R12's enteral tube. After preparing and dissolving the medication, RN F carried the medication to the bedside table and explained to R12 what they were going to do. RN F obtained a graduate and syringe from the over bed table and filled the graduate with warm water. RN F exposed the enteral tube, assessed the site, and gave the tube a gentle tug to verify placement, per facility policy. RN F drew the dissolved medication into a syringe, opened the port on the tube and instilled the medication into the tube. RN F followed the medication with 200 milliliters of water for the ordered water flush. RN F did not flush the enteral tube with water before administering the medication. On 01/31/24 at 7:32 AM, Surveyor interviewed RN F about the procedure for administering medications through an enteral tube. RN F stated once they have the medications prepared, they go in and explain to the resident what they are going to do. Then they expose the tube, observe the insertion site, and gives it a gentle tug to verify placement. Then if placement is good and no concerns observed at the site, they administer the medication with a syringe and follow it with a water flush. Surveyor asked if they do a water flush before administering medications. RN F stated they did not usually do a water flush prior to administering the medication. On 01/31/24 at 9:15 AM, Surveyor interviewed Director of Nursing (DON) B about the observation of RN F administering a medication through R12's enteral tube without doing a water flush prior to the medication. DON B stated their policy stated a water flush should be completed prior to administering the medication. DON B stated RN F was not following facility policy.

Based on record review and interview, the facility failed to notify ombudsman of emergency transfers to hospital for 12 of 12 residents reviewed for notification of transfers (R9, R17, R32, R184, R22, R15, R2, R23, R185, R186, R187 and R188). Example 1: R9 was admitted to facility 08/30/22. Resident discharged with return anticipated on 09/07/22 to emergency room and R9 admitted to hospital on 09/08/22. Facility completed bed hold. MD/Resident representative notified. R9's medical record had no documentation of Ombudsman notification of hospital transfer. On 01/04/22 at 2:30 p.m., Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A asked about notification of Ombudsman for transfers/discharges. NHA A stated she was notifying the Ombudman monthly of the involuntary transfers, but she did not know she had to notify Ombudsman regarding the hospital transfers. NHA A gave Surveyor a list of residents who were transferred to the hospital during the timeframe of January through December of 2022. The Ombudsman was not notified of these transfers: R17 was hospitalized [DATE]. Ombudsman was not notified. R32 was hospitalized [DATE] and 10/24/22. Ombudsman was not notified. R184 was hospitalized [DATE], 07/31/22, and 10/18/22. Ombudsman not notified. R22 was hospitalized [DATE]. Ombudsman not notified. R15 was hospitalized [DATE], 06/24/22, 11/01/22, and 12/21/22. Ombudsman not notified. R2 was hospitalized [DATE]. Ombudsman not notified. R23 was hospitalized [DATE]. Ombudsman not notified. R185 was hospitalized [DATE]. Ombudsman not notified. R186 was hospitalized [DATE]. Ombudsman not notified. R187 was hospitalized [DATE] and 10/27/22. Ombudsman not notified. R188 was hospitalized [DATE]. Ombudsman not notified. NHA A did not notify ombudsman of hospital transfers. 40590 Example 2 R17 was admitted to the facility on [DATE] and has diagnoses that include nontraumatic intracerebral hemorrhage, hemiplegia and hemiparesis of left side. Hospital Discharge Summary dated 12/19/22 indicates that R17 was treated for new onset diabetes mellitus with diabetic ketoacidosis, acute hypoxic respiratory failure secondary to COVID-pneumonia, and sepsis. R17 was transferred to the hospital on12/13/22 and returned to the facility on [DATE]. On 01/04/23 at 3:34 PM, Surveyor reviewed the bed hold policy and ombudsman notification for R17's 12/13/22 hospitalization . The facility did not notify the State Ombudsman of this transfer to the hospital. 46694 Example 3 Review of R32's medical record documented on 10/24/2022 at 8:18 a.m., with orders to send to the emergency room for evaluation. MDS dated [DATE] indicated Discharge Return not anticipated. On 01/05/23 at 8:55 a.m., Surveyor was unable to find ombudsman notification. Surveyor asked Nursing Home Administrator (NHA) A for this notification. NHA A replied that with this emergent transfer to the hospital the ombudsman was not notified until yesterday when a different surveyor asked for this paperwork. NHA A provided surveyors with a list of the residents that she sent notification to ombudsman this morning, after Surveyors had asked questions about the facility process for notifying the ombudsman.

Based on observation, interview and record review, the facility did not ensure each resident receives food prepared by methods that conserve nutritive value for 3 of 12 originally sampled residents (R16, R12, and R7) and 1 supplemental sampled resident (R8). When altering food texture, facility staff added water to food, which dilutes the nutritional value of food, instead of using something which preserves the nutritional value for R16, R12, R7 and R8. This is evidenced by; Observations of meal preparation on 09/28/21 beginning at 3:59 PM. Cook D was observed to puree baked zucchini. Cook D placed the zucchini into the Robot Coupe (food processor) and turned the machine on by pulsing it. Cook D was observed to add approximately 1/4 cup of water to the Robot Coupe and pulsed the machine some more. Cook D then placed the pureed zucchini into a metal container and placed it in the steam table for service. Cook D was observed to puree cheese pizza. Cook D placed four slices of pizza into the Robot Coupe. Cook D added approximately 1/4 cup water and then pulsed the machine. Cook D then got more water to thin the consistency further, again adding approximately 1/4 cup of water. Cook D then repeated this process again adding an additional approximately 1/4 cup of water. During an Interview with Cook D when she finished pureeing the pizza, Surveyor asked how much liquid was added to the four servings of pizza. Cook D stated, Approximately 3/4 cup. On 09/28/21 at 5:21 PM, Surveyor requested further information from District Manager E including a list of which residents receive altered diets, policy and procedures for pureeing foods and recipes used for pureeing foods. On 09/29/21 at 9:00 AM, during an interview with Dietary Manager C and District Manager E, Surveyor explained concerns about adding water when pureeing foods and thereby diluting the nutritional value of the pureed foods. Dietary Manager C and District Manager E provided recipes for baked zucchini and pizza. Surveyor reviewed the recipes with them, and asked what should be added to the pizza in order to get the correct consistency. District Manager E stated that for pureeing pizza they should have used marinara or tomato sauce. District Manager E added when adjusting consistency they should be using something that is already used in the recipe. District Manager E and Dietary Manager C identified the following residents and their altered diets which were impacted by the practice of pureeing foods with water. The residents identified are Resident (R)8, who has a Dysphasia Puree diet, R16 who has a Dysphasia Puree, R12 who has a Dysphasia Puree and R7 who has a Dysphasia Mechanical soft diet. On 09/29/21 at 9:26 AM, an interview with Dietary Manager C identified that for adjusting the texture of the baked zucchini, staff should have used [MEDICATION(S)] which is the liquid used in the recipe. Record reviews were completed for R8, R16, and R12; each of these residents has gained weight within the past month. Review of R7's medical record indicated they experienced a 1.8% weight loss within the past month, which could not be attributed to the observed dietary practices.

Based on observation and staff interview, the facility did not maintain an infection control program designed to prevent the development and transmission of disease and infection during care and medication pass observations involving 2 Residents (R) (R2 and R3) of 4 sampled residents. Staff did not appropriately cleanse hands per standards of practice during cares for R2. R3 was on droplet precautions due to a recent ER (emergency room ) visit. Staff did not offer hand hygiene to R3 prior to placing a total of eight oral medications in R3's bare left hand. Findings include: The Morbidity and Mortality Weekly Report dated 10/25/02 and published by the CDC (Centers for Disease Control and Prevention) entitled Guideline for Hand Hygiene in Health Care Settings indicated recommendations to wash hands after removing gloves and to decontaminate hands after contact with body fluids or excretions and when moving from a contaminated body site to a clean body site during patient care. The above information can also be found at: https://www.cdc.gov/handhygiene/providers/index.html with the page last reviewed on March 15, 2016 and the page last updated on March 24, 2017. 1. On 7/29/2020 at 4:30 PM, the Surveyor observed CNA (Certified Nursing Assistant)-C assist R2 with incontinence cares in the bathroom. CNA-C sanitized hands and put gloves on. CNA-C cleansed soft stool from R2's anal area with disposable wipes. Without removing gloves, and without washing or sanitizing hands, CNA-C pulled up R2's brief and pants. CNA-C then removed gloves, and without washing or sanitizing hands, CNA-C pulled R2's fabric face mask over R2's nose, assisted with transferring R2 to the wheelchair by holding R2's hands, clothing and gait belt. CNA-C removed the gait belt from around R2's waist, turned the wheelchair around and pushed the wheelchair to the sink for R2 to wash hands. CNA-C then placed soap in hand, placed the soap from hand to R2's hand for R2 to wash hands with, and handed R2 two disposable towels to dry hands on. CNA-C washed hands in the bathroom sink. CNA-C picked up the gait belt, opened the bottom drawer of the night stand and placed the gait belt in the drawer. CNA-C then sanitized hands. On 7/29/2020 at 4:50 PM, the Surveyor interviewed CNA-C regarding hand hygiene observations when providing incontinence cares for R2. CNA-C verified cleansing of soft stool was completed for R2 with disposable wipes, gloves were not removed and hands were not washed or sanitized prior to pulling up R2's brief and pants, and hands were not washed or sanitized after glove removal prior to touching clean items. CNA-C then stated CNA-C did not wash or sanitize hands after glove removal and/or prior to touching clean items because there was not sanitizer in the bathroom to use. 2. On 7/29/20 at 4:48 PM, the Surveyor observed RN (Registered Nurse)-D prepare and administer R3's medication. R3 was on droplet precautions due to a recent ER visit. After preparing R3's medication, RN-D donned PPE (personal protective equipment) and entered R3's room. The Surveyor noted R3 was sitting in a chair with a bedside table in close proximity. Without offering hand hygiene or cleansing R3's hands, the Surveyor observed RN-D place two pills in R3's bare left hand. The Surveyor then observed R3 place the medication in R3's mouth. The Surveyor observed RN-D and R3 repeat the process three times as R3 consumed a total of eight oral medications. Following the observation, RN-D exited R3's room without providing hand hygiene. In addition, the Surveyor did not observe hand sanitizer on R3's bedside table or within R3's reach. On 7/29/20 at 5:40 PM, the Surveyor interviewed RN-D regarding the observation. RN-D verified RN-D placed a total of eight medications in R3's bare uncleansed left hand. RN-D verified R3 wasn't offered hand hygiene prior to or following the administration of medication. RN-D stated R3 did not leave R3's room due to droplet precautions; however, RN-D confirmed staff entered R3's room with meal trays, newspapers and supplies. RN-D verified potentially contaminated items brought into R3's room warranted the necessity of of hand hygiene prior to hand-to-mouth contact.

Based on observation, interview and record review, the facility did not develop a comprehensive person-centered care plan that specified the use and care of hand splints for a resident with hand contractures. This occurred for 1 of 17 residents reviewed for care plans, Resident (R) 14. This is evidenced by: R14 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. On R14's Minimum Data Set (MDS) assessment, dated 09/06/19, R14's Brief Interview for Mental Status score was 0, indicating severe cognitive impairment. That same MDS assessment indicated R14 required extensive assistance or was totally dependent for all activities of daily living. The MDS also indicated R14 had impaired range of motion of both upper extremities. On 10/28/19 at 9:15 AM, Surveyor observed R14 resting in a Broda chair (type of wheel chair.) Both of R14's hands had severe contratures of the fingers (rigid joints.) R14 had white pads in both hands under the contracted fingers. The pads attached around the back of the hand with a Velcro strap. R14's daughter explained R14 came to this facility from an out of state facility with R14's hands in that condition. R14 developed a sore on the palm of one hand from the fingernails digging into the palm. The facility provided the pads to protect the skin on R14's hands. Review of R14's medical record identified no orders for use of the pads in R14's hands. Review of R14's plan of care identified no direction for use and care of the pads in R14's hands. Review of R14's Treatment Administration Record (TAR) identified the following treatment, dated 12/11/18: Soak hands in warm Epsom salt and gently take dressing off dry as able, replace dressing daily. Further review of R14's (MONTH) TAR, identified R14 refused that treatment 25 out of 29 days so far in October. On 10/29/19 at 2:35 PM, Surveyor interviewed Licensed Practical Nurse (LPN) C who reported the care of the pads in R14's hands was done daily, if R14 will allow it. LPN C stated R14 no longer had any open sores on the hands, so R14's hands were not being soaked with Epsom salts and no dressings were being used. LPN C stated the current treatment to R14's hands was the pads in R14's hands. LPN C stated the nurse was supposed to remove the pads daily and wash R14's hands. LPN C stated they put clean pads back in R14's hands after washing and inspecting the skin. LPN C stated R14 often does not allow staff to do anything with the pads. LPN C stated R14 yelled and said leave me alone, so that was why the treatment was documented as refused on the TAR. On 10/29/19 at 2:58 PM, Surveyor interviewed Certified Nursing Assistant (CNA) D and CNA E. When asked if they removed the hand pads from R14's hands when they did bedtime cares, both CNAs were uncertain. LPN C was present and stated only the nurses care for R14's hands. Then both CNA D and CNA [NAME] stated they do not do anything with R14's hands during bedtime cares. On 10/29/19 at 3:15 PM, Surveyor interviewed Director of Nursing (DON) B about the treatment for [REDACTED]. DON B stated that treatment should have been discontinued, since it was not being done, and R14 no longer had any open sores in R14's hands. When asked if there was an order for [REDACTED]. or plan of care, DON B confirmed that treatment was not on either R14's TAR or plan of care. When asked who was responsible to change the pads, clean the hands, and assess R14's skin, DON B stated the CNAs did that daily during morning and bedtime cares, and weekly during R14's bath. On 10/30/19 at 6:59 AM, Surveyor interviewed CNA F, who was assigned as bath aide. CNA F stated once per week on bath days, CNA F took the pads out of R14's hands and washed R14's hands. CNA F reported the skin in R14's hands was currently intact. Surveyor reviewed the bath schedule. R14 was scheduled for a bath on Monday evenings by a Hospice CN[NAME] Reviewed Hospice aide documentation for 10/28/19 which stated, in part, .bed bath given, peri care and oral cares done .no issues or concerns. No documentation about the condition of R14's hands or changing of pads in hands noted. On 10/30/19 at 7:20 AM, Surveyor observed CNA G and CNA H provide morning cares for R14. After providing incontinence care for R14, CNA H removed dirty gloves, performed hand hygiene with alcohol based hand sanitizer, obtained a basin with warm, soapy water and applied clean gloves. CNA H explained to R14 what was being done, and then attempted to remove the pad from one of R14's hands. R14 began to yell and resist the cares. CNA H stopped the procedure and spoke to R14 to calm R14. Several attempts were made by both CNA H and CNA G to remove the pads from R14's hands. Each time R14 yelled and resisted the cares. Surveyor asked if this happened frequently, CNA H stated it depended on the day and R14's mood, but R14 did often resist the removal of the pads from R14's hands. When asked what was done when R14 resisted this care, CNA H stated the care is stopped and attempted later. CNA H confirmed they do attempt to provide this care every morning when doing morning cares for R14. On 10/30/19 at 9:22 AM, Surveyor interviewed DON B about the documentation for use and care of the pads in R14's hands. DON B confirmed the directions for use and care of the hand pads should be on R14's care plan to ensure someone was removing them, washing the hands and assessing the skin daily. DON B stated this direction was not on R14's plan of care, but would be added.

Based on observation, interview and record review, three of five residents reviewed for range of motion were not provided with range of motion services to improve or maintain their range of motion. Residents R4, R5 and R18 have no program to maintain and/or prevent further decline in range of motion (ROM). The facility did not complete assessments of restorative needs for the residents. This is evidenced by 1. R4 has [DIAGNOSES REDACTED]. R4 is unable to ambulate. R4 was observed to have left sided weakness and moved his upper left extremity with his right hand as needed. Review of R4's Minimum Data Set (MDS) dated (MONTH) 3, (YEAR) states that R4 has a functional limitation in range of motion in his upper and lower extremity on one side of his body. Review of R4's care plan on 11/05/18 at 11:44 AM indicates the care plan does not mention limited range of motion or any programs to maintain the range of motion R4 currently has. Review of R4's care guides sheets reveals he has no program for ROM. Review of R4's progress notes back to 5/2018 reveals no doccumentation related to range of motion. Interview with the Director of Nursing (DON) on 11/06/18 at 12:46 PM. The DON was asked if R4 has a range of motion program. The DON replied that he does not have any restorative program. Interview with Certified Nursing Assistant (CNA) A on 11/06/18 at 1:58 PM revealed the following information. R4's left hand is tight in the morning - like a fist, you have to stretch it out just to get in there and wash it good, if not done it stays like a fist. R4 also needs to have on a left leg brace during transfers. CNA A reported R4 is sore in the morning sometimes but is cooperative, and rarely refuses anything. CNA A reviewed the care guide cards and reported R4 has nothing under restorative program on them. Interview with R4 on 11/07/18 at 8:57 AM. When asked if staff do exercises, or stretches with him to keep his hand, arm and/or leg limber and to keep them from getting stiff or contracted, R4 stated they do not. R4 confirmed he wears a brace on his left leg for transfers and during the day. When asked if R4 would be willing to participate in range of motion exercises so that his extremities stay limber and don't get contracted, he stated he would if they were one on one as he does not like to participate in the big group exercises. Interview with the DON on 11/07/18 at 9:35 AM revealed R4 does not have a range of motion program. The DON stated they stretch the arm and leg to get him dressed in the morning but R4 does not have anything besides the routine care assistance. The DON did provide a rehabilitation screen which was completed on 10/09/18 which merely states No functional decline noted from staff. 2. R5 has [DIAGNOSES REDACTED]. Surveyor observed R5 during two meals and noted R5 does not try to use the left hand or arm. The medical record documents the resident is dependent on staff for dressing, eating, bathing, toileting and personal hygiene. The CNA care guide was reviewed and under the heading of Restorative, it is blank. Surveyor interviewed CNA B on 11/06/18 at 3:00 p.m., asking about R5's ability to move her arms and what programs were in place. CNA B indicated R5 uses her left hand and arm very little and can lift her right arm about half way. Surveyor asked about a restorative program for R5. CNA B checked the CNA care guide and stated R5 does not have a restorative program or any range of motion exercises. On 11/06/18 at 12:50 PM, Surveyor interviewed the DON who stated R5 does not have an ROM program because R5 can at times feed herself so is able to use her hands fine. There is no documentation in the record as to what range of motion exercises have been done within the last year. An evaluation done by the Occupational Therapy Assistant on 10/10/18 stated, Staff reporting resident has been showing more movement in upper extremities and has been occasionally self feeding. Resident has severe dementia and would not benefit from therapy and carry over training. On 11/06/18 at 1:24 p.m., Surveyor interviewed CNA C about R5's limited range of motion. CNA C indicated R5 had a broken arm at one time and that is why she has some limits. CNA C stated that at times R5 can lift it up, starting to feed herself with her right hand occasionally. Surveyor asked if R5 is on restorative exercises or a program. CNA C checked the care plan and stated, I think I chart on her for restorative.CNA C went to the DON to ask, the DON stated, No she is not on a program. Surveyor asked for clarification on which arm was limited. CNA C indicated R5 has used her left arm very little since she was admitted . 3. R18 has an admitting [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documents the same information. The medical record has no documentation on restorative programs or assessment of R18's restorative needs. On 11/05/18 at 12:05 p.m., Surveyor observed cares for R18, noting R18 is dependent for transfers and transferred with a sit to stand lift. Range of motion exercises were not provided. On 11/07/18 at 07:16 AM, Surveyor observed CNA C and CNA A provide morning care. The CNAs offered a teddy bear for R18 to hold for reassurance. The CNAs dressed R18's upper body. ROM was not provided with cares. CNA A says he can only lift his arm half way, with the left arm more restricted in movement. R18 is unable to turn himself side to side. The CNAs turned him onto his side to position R18 for incontinent cares. Surveyor asked if R18 is on a restorative program. The CNAs reviewed the CNA care guide and stated that R18 is not on any program. On 11/07/18 at 10:50 a.m., Surveyor interviewed the DON about the restorative program process for dependent residents. The DON indicated they have no program set up since the residents can move their arms and legs. Surveyor asked how the facility would ensure that the range of motion the residents currently have will not decline if some type of maintenance program is not offered or assessed, including dementia residents. The DON acknowledged there has been no assessment or plan set up to maintain the residents' range of motion.

Based on observation, interview and medical record review, the facility did not provide care and services to prevent the development of a pressure injury, for 1 of 2 residents observed for pressure injuries (R1). R1 was observed to have a pressure injury to the bottom of her right heel. R1's right heel was observed not being floated off her mattress or off the foot pedal of her wheelchair. This is evidenced by: R1's [DIAGNOSES REDACTED]. R1 has a history of a deep tissue injury (DTI), (pressure injury) on the bottom of her right heel, discovered 01/18/17, after readmission from the hospital. Surveyor was provided with a copy of a Pressure Ulcer Healing Chart (PUSH) form that identified R1's right heel ulcer was healed on 02/22/17. R1's Minimum Data Set (MDS) assessments of 01/23/17 and 07/24/17, identify R1 requires extensive assistance of two staff for bed mobility and transfers. R1 has functional limitations in range of motion on both sides of her upper and lower extremities. This MDS identified R1 is at risk for pressure injuries. R1's Braden Scale for Predicting Pressure Sore Risk, completed 07/21/17, scored R1 at a 17, which the facility identified as R1 being at Low Risk on this Braden Scale. On 07/31/17 beginning at 1:07 p.m., Surveyor observed Certified Nursing Assistant (CNA) A and CNA B assist R1 with personal cares. R1 way lying on her back with her heels on the air mattress and a pillow under her knees. R1's knees are bent when she is on her back. Surveyor observed R1's right heel and noted an approximate 1 centimeter (cm) circular area of dark brownish tissue on the bottom of R1's right heel surrounded by redness in a circular area extending out approximately two centimeters from the dark area. The CNAs repositioned a pillow under R1's knees but R1's heels were on the mattress. CNA B said she was going to get one of those heels up cushions. When CNA B returned to R1's room with a heels up cushion, the CNAs positioned it and a pillow under R1's lower legs. Surveyor observed R1 bend her knees more and this movement caused her right heel to be resting against the heels up cushion, not being floated. CNA B told Surveyor (the Director of Nurse's name) said it's a callous and it has been there a long time. At 1:22 p.m. on 07/31/17, Licensed Practical Nurse (LPN) C came to R1's room and checked R1's right heel and said it is red around it, that is new to me. LPN C said the Director of Nursing (DON) told her to use skin prep on it and will have the Nurse Practitioner look at it tomorrow. LPN C wiped R1's right heel area with a skin prep pad. On 07/31/17 at 1:45 p.m., Surveyor spoke with the DON and told her about R1's right heel and Surveyors' concern of it looking like a pressure injury. The DON said it is a callous that has been there for a long time. Surveyor told the DON the area was red and looked like more than just a callous. The DON said we healed it a while ago. Surveyor told the DON that LPN C said the redness was new to her. The DON said she would go check R1's right heel. On 07/31/17 at 2:07 p.m., the DON told Surveyor she had looked at R1's right heel and cleaned it and half of the brown part came off and it has a pink base under it. The DON said awhile ago R1 had a pressure area in the same place. The DON said she called R1's doctor and the area was very light pink and blanchable when she looked at it. She (R1) is using tennis shoes. The DON said it is a brown colored callous in the middle, not eschar, a little pink tissue around that. The DON told Surveyor the Nurse Practitioner (NP) will look at it tomorrow. On 08/01/17 at 7:25 a.m., Surveyor observed R1's right heel with the DON and Registered Nurse (RN) E. R1's right heel looked the same to Surveyor as it did on 07/31/17. The DON said it was a scab and peeling back yesterday. The DON said it is not blanchable, it is definitely pressure, it's been fine for months. On 08/01/17 at 7:42 a.m., the DON showed Surveyor Prevalon heel float boots and said they would use those for R1 when she is in bed. Surveyor reviewed R1's July 2017 treatment administration record (TAR) and noted an entry was initialed for the night shift of 07/30/17. This entry reads: DIABETIC FOOT CHECK EVERY SHIFT. R1's July, 2017 TAR also contained entries that read FLOAT HEELS IN BED and CHECK FOOT WEAR FOR PRESSURE RISK. There were no inititals signed on this TAR for these two items. Surveyor discussed R1's 07/21/17, Braden Scale and what a 17 indicated. The DON pointed out the comment written at the top of R1's Braden Scale that read R1 was low risk based on that assessment. Surveyor questioned R1 being at low risk for pressure injuries given R1's issues with immobility, needing extensive assistance with cares and having a history of a pressure injury. The DON said she (R1) would be a high risk for pressure injury. Surveyor asked the DON if that calloused area on the bottom of R1's right heel was caused from a pressure injury. The DON said yes. Surveyor asked the DON if they were measuring the callous area on R1's right heel. The DON said they were not measuring it. Surveyor asked the DON if they consider a callous/scab in an area that had been a deep tissue injury healed. The DON said what she (R1) had there Monday was not what we were calling a callous. The callous was off to the side. The new area is next to the prior area and is pressure. Surveyor asked the DON for a copy of the NP's progress note from 08/01/17, for the NP's assessment of R1's right heel. The DON said they didn't have it yet. R1 was readmitted from the hospital on [DATE]. Surveyor read a Skin Assessment sheet for R1 dated 07/17/17. There was no documentation of a callous being present on R1's right heel or a callous identified on the body diagram on R1's right heel. R1's care plan in place on 07/31/17 read in part: Potential for pressure of bony prominences r/t (related to) HX (history) of pressure injuries. Interventions included: Keep heels off of bed, raise legs in bed as resident allows. Date Initiated: 11/05/2015. And .protect elbows and heels from being exposed to friction. Date Initiated: 05/05/2017. Surveyor did not locate information on R1's care plan of a callous on her right heel that they were monitoring. R1's CNA care plan section for Skin Intervention read: . float heel, reposition q (every) 2 hours, shoes on when up in w/c. On 08/01/17, Surveyor read the documentation by the DON completed 07/31/17 on a SKIN GRID - PRESSURE.[MEDICAL CONDITION] ULCER/OTHER form. This identified R1 had a scab measuring 0.9 cm long and 0.8 cm wide on the bottom of her right heel that was unable to be staged. This was identified being from pressure. The surrounding tissue was identified as non-blanchable intact skin, stage 1, measuring 1.6 cm in length by 1.4 cm in width. An Occurrence Report for R1 for 07/31/17, contained an entry dated 08/01/17, that read in part: Resident pulls knees up and heels rub against pillow and or heels up cushion, hx (history) of PI (pressure injury) in same area. Under description of wound was written callous on right heel has opened, hx PI, pink area exposed at base of area after cleaning . And Conclusion callous on right heel has opened, hx PI. pink area exposed at base of area after cleansing on 7/31/17, area has red/brown scab in place 8/1/17. resident denies pain during examine on 7/31/17. was guarding right foot today during tx (treatment), did c/o (complain) of pain in that area during tx. tx per order. NP here and updated. NP examined, does not see eschar, callous is off and scab in place. updated on c/o pain during tx and current meds, noew (sic) order received for [MEDICATION NAME] gel prior to tx. heel protection boots on while in bed, will wear stocking or slipper on right foot while up in w/c (wheelchair) until healed. will keep feet elevated while in bed. On 08/02/17 at 12:45 p.m., Surveyor observed R1 in her wheelchair in the dining room. R1 had a sock on and her right heel was resting on the foot pedal of her wheelchair. Surveyor could see there was no pillow under R1's right leg to float her right heel off the foot pedal. At 1:05 p.m. on 08/02/17, Surveyor entered R1's room, R1's right heel was resting against the front wheel of her wheelchair. There was no heel boot on R1's right foot. Surveyor asked LPN D what R1 had on her right foot/heel. LPN D said Allevyn and her sock. Surveyor asked if R1 had a heel protector on her right foot. LPN D said no, those are just on in bed. The foot pedal of R1's wheelchair is a hard material. The foot pedal was not padded. There was not a pillow under R1's leg to prop her right heel pressure injury off the foot pedal. On 08/02/17 at 1:08 p.m., Surveyor shared the above observation with the DON and the concern of R1's right heel being on the hard foot pedal.

Based on observation, interview, medical record review and facility policy review, facility staff did not provide care in a manner to prevent infection for 1 of 1 resident observed for wound cares (R1). R1 was observed during a dressing change where the Licensed Practical Nurse (LPN) did not perform hand hygiene at the correct times or by the correct technique. LPN placed treatment supplies on R1's tray table without first putting down a barrier or disinfecting the tray table. This is evidenced by: The facility's Hand Hygiene policy and procedure revised 01/2017, identified hand hygiene should be performed: Before having direct contact with residents. After contact with a resident's intact skin. After contact with . wound dressings. After removing gloves. Procedure 6. Rub hands together vigorously for 20 seconds generating friction on all surfaces of the hands and fingers. 8. Dry hands with paper towel. 9. Turn faucets off with the paper towel. On 07/31/17 at 1:22 p.m., LPN C entered R1's room. LPN C sanitized her hands and applied gloves. LPN C uncovered R1 and Surveyor observed a dressing on R1's right knee. This dressing was dated 07/17/17. LPN C then checked R1's right heel, handling R1's leg and foot. LPN C said she was going to get a new dressing for R1's right knee. LPN C removed her gloves and washed her hands, turned off the water faucet with her bare hand and then obtained paper towels and dried her hands. LPN C left R1's room at 1:28 p.m. LPN C returned to R1's room at 1:37 p.m. LPN C placed the treatment supplies she brought with her, a bottle of Dermal Wound Cleanser, a package with an Allevyn dressing in it, on R1's tray table without first disinfecting the tray table or placing a barrier on the tray table. Other treatment items were placed on top of the Allevyn package. LPN C then applied gloves, without washing or sanitizing her hands. LPN C removed the dressing. With the same gloves on, LPN C then used the dermal wound cleanser and a gauze to clean R1's right knee wound. LPN C then wiped the edges of R1's right knee wound with the skin prep pad. At this time, LPN C removed her gloves and washed her hands for five seconds and turned off the faucet with her hand and then obtained paper towels and dried her hands. On 08/01/17 at 10:45 a.m., Surveyor spoke with LPN C about the observations on 07/31/17, with R1. Surveyor asked LPN C how long she should wash her hands for. LPN C did not give Surveyor a time. LPN C said we sing something. Surveyor shared her observation of LPN C washing her hands for eight seconds and turning off the faucet with her hands instead of a paper towel. LPN C said, I realized that. Surveyor told LPN C, the next time you washed your hands it was for five seconds and you turned the faucet off with your hand and then used paper towels to dry your hands. LPN C said she knew she should use a paper towel to turn off the faucet. Surveyor discussed setting the treatment supplies on R1's tray table without a barrier or disinfecting the tray table. Surveyor asked if the bottle of dermal cleanser was used just for R1. LPN C said yes. LPN C was asked where she took the bottle of cleanser. LPN C said to the treatment room but it will be used just for R1.

Based on medical record reviews, policy review, observation, and interview, the facility did not ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers, and a resident who has had a history of [REDACTED].#1, #5). 1. Resident #1 has resided in the facility since 2011. Resident # #1 developed a pressure ulcer in the facility on his left heel. The ulcer is first identified as a stage III pressure ulcer at the wound clinic on 09/02/15. The care plan did not include updated interventions until after the heel ulcer was identified at the wound clinic. Interventions on the care plan were not followed: the podus boot that was to be on the left foot at all times was observed not on, in addition the heels were not floated on three observations during survey. Resident #1 developed signs and symptoms of infection, and experienced pain in the left heel. On 10/01/15, the physician could visualize bone in the heel ulcer (identifying as a stage IV pressure ulcer), and the resident was hospitalized . 2. Resident #5 developed multiple avoidable pressure ulcers while in the facility and the facility did not ensure appropriate interventions were put into place to prevent pressure ulcers from occurring and did not ensure that Resident #5 received the appropriate care to prevent pressure ulcers from worsening. The failure to promptly identify pressure ulcers and implement interventions (for Residents #1 and #5) to prevent the pressure ulcers from deteriorating created a finding of immediate jeopardy. The immediate jeopardy began on 07/29/15. The Nursing Home Administrator (NHA), Director of Nursing (DON) and Corporate Consultant were notified of the immediate jeopardy on 10/01/15 at 11:30 a.m. The jeopardy was removed on 10/01/15; however, the deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) while the facility fully trains and implements its wound care protocol. This is evidenced by: The facility policy titled, Pressure Ulcer Prevention/Treatment .all residents will be assessed on admission and weekly for four weeks, quarterly, and with a significant change of condition using the Braden Risk Assessment, and Skin Integrity Assessment: Prevention and Treatment Care plan The Following interventions are efforts to stabilize, reduce or remove underlying risk factors. At risk (15-18) Frequent turning, maximal remobilization, reduce pressure to heels, manage moisture, nutrition, and friction and shear, pressure reduction support surface if bed or chair-bound. Moderate risk (13-14) Turning schedule use foam wedge for 30 degree lateral positioning, pressure reduction support surface, maximal remobilization, reduce pressure to heels, manage moisture, nutritional and friction and shear . Procedure: 10. Review and revise skin integrity assessment: Prevention and treatment care plan to reflect interventions to heal pressure ulcers and stabilize, reduce or remove underlying risk factors. Resident #1 has resided in the facility for approximately five years. Resident #1 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], identifies no pressure ulcers, but that Resident #1 is receiving other wound care. Resident #1's Braden score on 06/02/15 was 15; on 09/03/15 the score is 13, meaning the resident is at moderate risk for predicting a pressure sore. The MDS, dated [DATE], identifies Resident #1 has severe cognitive impairment, and needs extensive assistance of two for transfers. The MDS identifies one stage III ulcer, that is not healed. The care plan titled, Has pressure ulcer related to disease process [MEDICAL CONDITIONS], history of ulcers- left heel ulcer, revised 09/10/15. Goal: Pressure ulcer will show signs of healing and remain free from infection, target dated 12/16/15. Interventions: Assess/record/monitor wound healing weekly and PRN (as needed) .report improvements and declines to MD, Keep heels off of bed float heels in bed, dated 05/21/14 needs bed cradle to keep bedding off of feet to protect the skin while in bed, 09/10/15. Podus boot on left foot at all times, keep loose, 09/11/15. The care plan titled, Actual chronic pain related to wounds: stasis ulcers of left leg .interventions in part: Podus boot to left foot as ordered, date initiated 09/03/15, revision on 09/17/15. The care plan, Therapeutic nutritional risk r/t (related to) .stasis ulcers, slightly low [MEDICATION NAME], weight loss and decreased intake, 04/15/15. Interventions in part: Provide supplements per wife's request .Mighty shake with breakfast, magic cup at noon, 04/14/15. (This is the most recent nutritional intervention). Surveyor reviewed the medical record on 09/29/15, starting with 06/29/15. There is no mention of a pressure ulcer in the notes until the following: 09/01/15 Resident unna boot changed this am to left leg, no change noted to ongoing open areas. heel is deeper than the rest. Resident goes to wound clinic tomorrow, 9/2 will alert MD via consult report paper. 09/02/15 The report of consultation sent by the facility to the wound clinic in part: Reason for consultation: Please provide us with wound measurements - please check left heel. The left heel ulcer was not assessed by the facility. The wound clinic consult reports: 09/02/15 Report of findings: Decubitus ulcers .new Diagnosis: [REDACTED]. 1. please order flex boot 2. Continue every other day [MEDICATION NAME] and unna boot 3. Keep CAM walker boot on 24/7 until flex boot arrives but send it with him . Nurse's note: 09/02/15 Resident returned from wound appointment Decubitus ulcers, venous stasis [MEDICAL CONDITION] ulcers. Next visit 09/09/15 .new stage heel decubitus ulcer. Orders for flex boot .keep CAM walker boot on 24/7 until flex boot arrives . Physical therapist note: 09/02/15 Date of injury/onset: 2014 for venous ulcers, 9/2/15 for heel ulcer Assessment: He presents today with new open area on left posterior heel . Subjective: Wife reports 'they said to tell you that he has a new sore on his heel' Pain level: patient denies pain when asked, however winces at times especially with debridement of heel wound. Wounds: #4 Left posterior heel: length 2.4 cm x width 2.2 cm, depth 0.2 cm Wound bed: 75% slough, 25% granulation Objective: A large, open area noted to posterior left heel that was not present last visit.Patients left shoe .is completely broken down and soiled with both residue from unna boot and urine. On 09/29/15, Surveyor asked for all documentation on how the heel ulcer was unavoidable. On 09/30/15, Surveyor reviewed the skin grid documentation: 09/02/15 Site left heel, stage III, length 2 cm x width 2 cm, no depth. 09/09/15 Stage III, length 2.6 cm x width 1.8 cm x depth 0.2 cm, no drainage or odor. 09/17/15 Stage III length 3.0 cm X width X 1.5 cm x depth 0.4 cm Color of drainage: yellow, Odor? Yes before and after. Cleansed with wound cleanser, packed with [MEDICATION NAME] and covered with abd and kling. Heel free boot on. Wound Clinic consult report 09/09/15 Recommendations: Dressing changes every other day. Keep podus boot relatively loose to avoid increased pressure/swelling at foot. return 09/16/15. Heel measurement at clinic: L 2.6 cm x W 1.8 cm x 0.2 cm The nurses' notes document a foul odor to drainage on 09/14/15; it does not specify if the drainage is from the heel or stasis ulcers. On 09/15/15, Keflex 500 four times a day was ordered by the wound clinic physician. Physical therapist note: 09/16/15 Assessment: .he will benefit from alternative/foot/heel protection to prevent further breakdown and promote healing. Wounds at heel, .remain large and with excessive drainage. Pain level, unable to tolerate any pressure on the left heel, but denies pain when asked .Wound type: 2 pressure ulcers Left heel. #4 Location left posterior heel: 3.5 cm x 1.7 cm, depth variable #5 Location L lower leg lateral ankle 2.0 cm Width 2.3 cm depth: unable to measure . #4 90 % slough 10 % granulation #5 90% slough 10 % granulation Exudate #4 moderate serosanguineous drainage (left heel ulcer), #5 moderate serosanguineous drainage Nurses' notes in part: 09/18/15 13:45 (1:45 p.m.), L (left) leg dressing was wet with yellow drainage. Changes (sic) and additional abd (abdominal) added in the heel area. Has been having copious amounts of yellow drainage .temp 99.0 this a.m resident has been dozing pretty much all day . Wound clinic consult reports 09/23/15 Bactrim DS i po BID x 7 days, d/c keflex, follow up here in 2 days. Heel measurement: length 2.5 cm length X 2.2 cm width, depth unable to measure. 09/28/15 Recommendations Return 10/1, please note MD does not see patent each visit. Please contact directly for concerns other than direct wound care. Heel measurements: Length 3.5 cm x width 1.5 cm x depth unable to measure. Nurse's note: 09/30/15 .left heel stage III, 3- 10% slough .3.5 length X 1.5 width X unable (This is identical to wound clinic documentation on 09/28/15.) On 09/30/15, Surveyor reviewed the documentation provided about the heel ulcer. The skin grid sheets had an area on the heel last documented in February 2013. The August 13, 2015 skin assessment sheet did not identify any open areas or callouses of the heel. The old and new care plan was reviewed. There had been no interventions other than float heels, which the Care Area Assessment identified as an intervention 10/23/14, Has lower leg stasis (sic) ulcers. floats heels in bed and has a foot cradle on bed . The flex boot (described as podus boot was the only intervention identified; this occurred after the stage III was identified.) The medical record review shows a 6% weight loss the past month. The dietary assessment includes in part: New stage III decub on left heel .summary: Resident continues to select his own meals and to eat independently with set up. His intakes vary, but are usually 75-100 % .he continues to receive a mighty shake with breakfast and a magic cup with lunch .braden score records adequate nutrition. There are no current labs to review .Care plan reviewed and is current. Nutritional interventions to promote healing were not added. On 10/01/15 at 9:08 a.m., Surveyor interviewed the DON to ask if the heel area was being debrided. The DON stated, No the heel is not debrided, only the stasis ulcers have had some debridement. The wound clinic documents the heel was debrided on 09/02/15. The DON went on to say the heel ulcer was there for a long time. Again Surveyor asked for any documentation or weekly assessments showing the status of the heel prior to 09/02/15. Information was not provided. Observations On 09/30/15 at 7:05 a.m., Surveyor observed Resident #1 without the podus boot on, lying in bed. The heels were not floated, but in direct contact with the mattress. The observation continued until 7:40 a.m. On 09/30/15 at 1:22 p.m., Surveyor observed personal cares provided by Certified Nursing Assistant (CNA) J, the podus boot was not put on when Resident #1 was put to bed. The heels were not offloaded. On 09/30/15 at 2:25 p.m., Surveyor went into the resident's room to speak to a family member, who pulled up the blankets to show Surveyor the dressing that Resident #1 had in place. The podus boot was not on and the heels were not floated. On 09/30/15 at 3:20 p.m., Surveyor had CNA K go into Resident #1's room to check his heels. There was a pillow between the legs of Resident #1, not floating the heels. The podus boot was not on. On 10/01/15 at 6:50 a.m., Surveyor observed Resident #1 in bed lying on his right side, and had CNA B come in the room to check his feet. Resident #1 did not have heels floated. Wound care On 09/30/15 at 7:45 a.m., Surveyor observed wound care being performed by the DON. When the left heel was cleansed, Resident #1 yelled out, What the h-- are you doing? The DON applied the [MEDICATION NAME] to the heel, the resident yelled out, I cannot live like this. Resident #1 was moaning when the unna boot was wrapped over the heel area. Interviews On 09/29/15 at 1:30 p.m., Surveyor was going to observe personal cares for Resident #1. Resident #1 was agitated and yelling at the CNAs, and talking about the past in fragmented sentences. When they would approach him he would yell out. CNA I stated to Resident #1, I know you are in pain, we will take it easy. CNA I took Surveyor aside and stated, He has changed so much the past few weeks. I think it is the pain in his leg, he used to be so happy. After two approaches, the attempt for personal cares was stopped, due to Resident #1's agitation. On 09/30/15 at 1:22 p.m., Surveyor observed CNA J assist Resident #1 with personal cares, CNA J commented on being concerned with how Resident #1 had changed recently with being more uncooperative with cares, and not eating well. CNA J stated, I wonder if it is his leg, or if he has pain and that is why he has been acting so differently. On 09/30/15 at 1:50 p.m., Surveyor interviewed Resident #1's Family Member (FM) N, who visits daily with him. FM N had concerns about Resident #1 not wanting to eat the past week or so and talking out of his mind. FM N stated, I wonder if it really is his dementia or all this other stuff going on with the new medicines and the wound. Surveyor asked if FM N was aware of the heel ulcer. FM N stated, Yes, the wound clinic had told me to throw out his old shoe about a month ago, then it was the walking boot a few days, and now the boot he has in the room. Last week I came and he did not have the boot on. Surveyor asked if FM N knew why. FM N stated it was because the whole boot was soaked from drainage so it was washed and drying. Now she sees they have another boot for him to use. He should have had the boot on. Surveyor asked if his heels were on pillows at other times. FM N stated, That pillow thing has not been happening when I am here. Surveyor asked if Resident #1 has experienced increased pain. FM N stated, He has never complained of any pain, the past few weeks he says it hurts down into his heel. He even hit the wound care nurse when she dressed his heel because it hurt. He is not one to complain. On 09/30/15 at 4:00 p.m., Surveyor interviewed the DON to ask if the pressure ulcer had been seen by the staff prior to 09/02/15. The DON stated, No. Surveyor asked if they were doing daily inspection of his feet with his high risk for pressure ulcers. The DON stated, No, we could not because he had the unna boot on and went to the wound clinic to have it changed. Surveyor reviewed the treatment records for August. The staff had performed the wound care removing the unna boot and redressing the wound seven times in August (2nd, 3rd, 8th, 15th, 23rd, 28th, and 30th). There is no documented assessment of the skin integrity of the heel on these dates. On 10/01/15 at 9:30 a.m., Surveyor completed a telephone interview with the primary physician, MD G, who stated he is not managing the wounds for Resident #1, and was not aware of a stage III heel ulcer, that the wound clinic manages the wounds on the lower extremities. On 10/01/15 at 5:15 p.m., Surveyor interviewed the wound clinic physician, MD F, on the telephone. Surveyor reviewed the wound consult reports and noted the stage III pressure ulcer being identified on 09/02/15. MD F acknowledged that he saw it and it was a stage III. Surveyor asked if it was avoidable. MD F stated if pressure relief had been provided to the heel, it did not have to happen. Surveyor asked if the podus boot (flex boot) was to be on at all times. MD F stated, Yes, he cannot have any pressure on the heel. I write the orders and it is frustrating because you cannot follow it through. Surveyor asked if MD F saw Resident #1 today. MD F said, Yes and the heel has deteriorated. I could see exposed bone. The resident experienced increased pain with the heel dressing change, so have had him admitted to the hospital to rule out osteo[DIAGNOSES REDACTED]. On 10/05/15 at 8:10 a.m., Surveyor interviewed the DON and asked if she had staged the heel ulcer on 09/30/15. The DON stated, No, why would I do that when it is already staged. Resident #1 was admitted to the hospital on [DATE]. On 10/05/15, Surveyor reviewed the hospital paperwork. The Vascular Surgery consult note, dated 10/01/15, in part: Musculoskeletal: .full thickness ulceration on calcaneous (heel) . A full thickness wound is a stage IV wound, the national pressure ulcer advisory panel (NPUP) definition: A wound that has full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. The hospital 10/03/15 summary states in part: Non- healing foot ulcers- .cultures grew multiple organisms .including staph aureus and morganella. On 09/29/15 at 12:25 p.m., Surveyor reviewed the medical record for Resident #5 and noted the following: - Resident #5 was admitted to the facility on [DATE], is his own person and is able to make his own decisions. Resident #5 has a [DIAGNOSES REDACTED]. - MDS, dated [DATE], stated Resident #5 had one unstageable pressure ulcer upon admission, was continent of bowel function and was at risk for pressure ulcers. - MDS, dated [DATE], stated Resident #5 was frequently incontinent of bowel and was alert and oriented. MDS states Resident #5 was at risk for pressure ulcers and now has a Stage II and Stage III pressure. - CNA care plan, received 09/29/15, states Resident #5 is to be offered toileting before and after meals, at night and as needed and requires the assistance of two staff members due to needing to be transferred by a mechanical lift and having a right above the knee amputation. Care plan also states Resident #5 is to be repositioned every two hours, keep heels off the bed, has an air mattress and is to wear a Prafo boot. - A Braden assessment, dated 07/16/15, had a score of 13, which states Resident #5 is at moderate risk for pressure ulcer development. - Upon entrance to facility, on 09/29/15, Surveyor was told the facility did not have a wound certified nurse employed. PRESSURE ULCER TIMELINE On 09/29/15 at 12:25 p.m., Surveyor reviewed the medical record for Resident #5 and noted the following timeline of events in regard to Resident #5 acquiring pressure ulcers while in the facility; - 07/15/15: Resident #5 was admitted to facility with an unstageable pressure ulcer to the left heel, which is considered chronic and scabbed areas to his toes. - 07/15/15: Facility nursing admission skin assessment stated Resident #5 to have a 1 cm dry spot to the left heel and no areas noted to the coccyx or to the right stump area. - 07/16/15: Resident #5's care plan stated Resident #5 was to be turned and repositioned every two hours with assist of two. Care plan provided to Surveyor on 10/01/15 states to keep heel off of bed (date initiated 07/16/15). Pressure ulcer to the coccyx care plan states: . 3. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Manage friction and shear: elevate HOB no more than 30 degrees unless clinical condition precluded, use lift sheet to move resident, protect elbows and left heel from being exposed to friction (date initiated 07/16/15). - 07/17/15: NN: Has left lateral foot heel with moist open area from chronic callous. - 07/19/15: NN: (Resident #5) has right AKA (amputation) which is old. no prosthetic. no shoes .he has left lateral foot heel with moist 0.5 cm open area and chronic callous. Surveyor was not provided a comprehensive nursing assessment on this open area and was unable to identify physician notification of open area. - 07/21/15: Wound Clinic note: Patient came wearing only hospital sock; Prafo boot had been given to patient at last visit, by prosthetics. Patient appeared unsure if he has this boot or not, but after further discussion, stated that he has it at home and that he can pick it up on his way back home. Called American Heritage Home and spoke with RN (Registered Nurse) to update her on wound on right AKA (above knee amputation) and need for heel protection. RN will initiate calcium alginate packing to right AKA wound and have patient wear his Prafo boot; if unable to get boot from home, then she will have patient wear a Rooke boot. Wound note stated wound to heel was an unstageable declared as a Stage II Pressure Ulcer and ulcer is currently closed. Wound to right AKA stump has exposed bone at the tip and in the undermining and measures 0.2 cm x 0.2 cm x 0.1 cm. Scant serosang drainage noted. Current treatment: in order to protect heel, care for left leg and keep wound open on right AKA until heals from inside out, recommend: cleanse wound, pack with calcium alginate and cover with [MEDICATION NAME] or other dressing. Daily Care of left lower extremity and heel: ammonium [MEDICATION NAME] 12% lotion to leg BID and protect heel with either Prafo boot or Rooke boot. Patient is not to transfer independently when wearing Rooke Boot. Patient education on treatment plan and appears to agree to use lotion, dress right stump and to wear Prafo boot. - 07/21/15: Nursing Notes (NN) stated Resident #5 was to have a Prafo boot to left heel (or Rooke boot if unable to get Prafo boot from home) for heel protection. Cleanse wound to right AKA: Pack wound with calcium alginate; cover with [MEDICATION NAME] dressing - change dressing daily. - 07/23/15: Nutritional Assessment: Wound to R(right) stump and heel .recommend double meat portions. - 07/24/15: NN: Resident #5 often refuses to lay down to elevate left lower extremity. - 07/26/15: NN: Tiny O/A (open area) on R stump. Cleansed, alginate applied and covered with [MEDICATION NAME] dressing. No drainage, redness, pain or swelling. There was no documented assessment of this open area and were no changes to the care plan. - 07/28/15: Braden score of 16 states Resident #5 is at low risk for pressure ulcers. - 07/28/15: NN: Tiny pinpoint open area on end of right stump. Cleansed, alginate applied with [MEDICATION NAME] dressing. No redness. Scant serou-sang drainage. - 07/29/15: NN: Resident #5 has been refusing to wear Rooke boot on LLE. Nursing note does not identify refusal to wear Prafo boot or if resident has the Prafo boot in the facility. There is no documentation to indicate that staff educated the resident about wearing the boot or explored alternatives that might be acceptable to the resident for keeping pressure off the heel. - 08/03/15: Facility nursing skin assessment states Resident #5 has a pinpoint size open area to the right AKA stump. Surveyor was unable to identify physician notification on open area. - 08/04/15: Facility nursing skin assessment states Resident #5 has an unstageable left heel pressure ulcer which measures 2 cm x 2 cm. - 08/06/15: NN states the area to the left heel is now open and that rounding physician noted the open area while on rounds. Open area measures 2 cm x 2 cm. - 08/12/15: Facility nursing skin assessment states Resident #5 has a Stage III pressure ulcer to his left heel which measures 2 cm x 1 cm x 0.2, has a pinpoint open area to the right stump. Slough present. The pressure ulcer has now progressed to a stage III. The facility revised the care plan to have a Prafo boot on at all times (even though he has been resistant to wearing it at times when up), keep heels off of bed float heel (date initiated 08/12/15), reposition every two hours when in bed/chair (date initiated 08/12/15). - 08/19/15: Facility nursing skin assessment states Resident #5 has a stage III pressure ulcer to his left heel which measures 2 cm x 2 cm x 0.2 cm, and has a pinpoint open area to the right stump which now has redness surrounding the wound. Even though the pressure ulcer now has depth and has redness surrounding the wound, there is no documentation to indicate that staff consulted with the physician or revised the care plan. - 08/26/15: Facility nursing skin assessment states Resident #5 has a stage III pressure ulcer to his left heel which measures 2 cm x 2 cm x 0.2 cm, and has a pinpoint open area to the right stump. - 09/01/15: Wound Clinic report states Resident #5 has a stage III pressure ulcer to the left heel which measured at 1.2 cm x 1.8 cm x 0.1 cm. Wound clinic report also stated Resident #5 has a wound to the right AKA stump which measures 0.1 cm x 0.1 cm with pink tissue present and has a small amount of serous exudate expressed with [DIAGNOSES REDACTED] spreading outward 0.5 cm. - 09/01/15: Veteran's Affairs Medical Center (VAMC) communication form states facility to cleanse wound to right stump and to use [MEDICATION NAME] and cover. Heel is to be cleansed, skin prep to be applied around wound, apply calcium alginate to wound bed and cover. Sensifoot stocking is to be worn 24/7 and a Prafo boot is to be worn. Surveyor was unable to identify the Sensifoot stocking intervention on the CNA care plan and comprehensive care plans received 09/29/15, 10/01/15 or 10/07/15. - 09/02/15: Facility Infection Control Report states Resident #5 has an onset date of 09/02/15 for an infection to the right AKA stump and an ATB (antibiotic) was started on 09/05/15. The resident's temperature on 09/04/15 and 09/05/15 was 99.1 - 09/05/15: Physician order [REDACTED]. - 09/07/15: Physician order [REDACTED]. May go per ambulance, for infection to right AKA stump. - 09/09/15: Facility nursing skin assessment states Resident #5 has an open area to right stump which measures 0.25 cm x 0.25 cm x <1.0 cm and has increased drainage and increased redness and swelling to area. - 09/09/15: Physician order [REDACTED]. Hospital blood culture report states Resident #5 tested positive for Gram Positive Cocci. Resident #5 received an order for [REDACTED]. - 09/10/15: Wound Clinic report states Resident #5 has a stage III pressure ulcer to the left heel which measures 1 cm x 1 cm x shallow, and has a stage III pressure ulcer to the right AKA stump which measures 0.3 cm x 0.5 cm x shallow. Report states pressure ulcer to right stump has moderate yellow cloudy serous drainage with no odor and has bright red [DIAGNOSES REDACTED] marked with permanent marker, which was dated 09/07/15. - 09/10/15: VAMC communication form given to facility states: Resident #5 started on [MEDICATION NAME] 500 mg daily for 10 days for right stump infection on 09/05/15. Then sent to urgent care on 09/07/15 due to increased pain, redness and swelling. On 09/09/15, wound more swollen, red and painful (was to continue on [MEDICATION NAME]). Was sent toER on [DATE] in which [MEDICATION NAME] was started for ten days and also had x-ray of femur x 2 views and an ultra sound also completed. Follow up is needed. - 09/14/15: Facility nursing skin assessment states Resident #5 has a stage II pressure ulcer to the coccyx which measures 0.8 cm x 0.8 cm x <0.1 cm. - 09/14/15: Facility documented temperature: 99.4 - 09/14/15: Fax sent to physician stating resident has a stage II pressure ulcer to coccyx which measures 0.8 cm round. Area cleansed with normal saline, skin prep applied and covered with allevyn. Dressing to be changed every two to three days until healed; AHCC protocol. Response from physician on 09/15/15 states, Agree. - 09/15/15: Comprehensive Nursing Care plan updated to keep Resident #5's heels off the bed, air mattress to be implemented and resident is to lie down between meals (date initiated on CP 09/15/15). - 09/15/15: NN: Resident aware of coccyx pressure ulcer and encouraged to lay side to side. -09/15/15: Care plan updated to include: Encourage to lay down between meals when in the bldg. for skin integrity. If preferring recliner place w/c cushion in recliner for skin integrity. - 09/16/15: NN states the [MEDICAL TREATMENT] clinic was notified to reposition Resident #5 due to pressure ulcer to the coccyx. - 09/16/15: Facility nursing skin assessment states Resident #5 has a stage II pressure ulcer to the coccyx which measures 0.8 cm x 0.8 cm. - 09/16/15: MDS states Resident #5 has a stage II pressure ulcer to coccyx which was acquired in-house and a stage III pressure ulcer which was acquired prior to admission. - 09/16/15: Nutritional Assessment states the wound to the coccyx is worse, Braden scale indicates inadequate nutrition but eats well, labs are monitored by [MEDICAL TREATMENT] and the care plan was reviewed and updated. Surveyor was unable to identify any new nutritional interventions. - 09/16/15: Interdisciplinary Team note states, IDT reviewed reports on new pressure area on coccyx. area examined, 1 cm @ irregular edges, slough present on base of wound, two <0.5 scabbed areas noted on right buttocks. Resident had recliner brought in from home this weekend, historically does not stay in bed more than a couple hours at night. Sits up in w/c and plays on computer per night shift. Staff encourages him to lie down but often declines. was sitting in recliner for short time yesterday afternoon. resident demands staff place regular pillow and throw pillow under buttocks in wc he does have pressure relieving cushion in wc. has been educated on importance of just using appropriate cushion. he declines. roho cushion placed in recliner for pressure relief. air mattress placed last evening. resident only stayed in bed from 2-4 am. he had been up playing on computer. call placed to Davita to alert them of pressure area and asked that they reposition resident while in [MEDICAL TREATMENT] chair. will attempt to talk to resident when he returns, will ask about possible options at night while using computer, possibly using it while in bed. Dietician here today and will update. Surveyor requested all IDT notes on all three pressure ulcers and was only provided with this note. Surveyor , on 10/01/15, asked the DON why the facility only had one interdisciplinary note for Resident #5 in regard to having three pressure ulcers and the DON did not reply. - 09/16/15: Care plan states Roho cushion was to be placed in the lounge chair. - 09/17/15: Wound Clinic report states Resident #5 has a stage III pressure ulcer to the right AKA stump which measures 0.3 cm x 0.5 cm x shallow, has moderate pink tinged serous and raw egg-white consistency, has pink hue 2 cm out from wound bed at 12:00 and 6:00 and currently has an infection containing staph aureus organisms which is resolving. Report also states Resident #5 has a stage III pressure ulcer to the right sacrum area which is mixed with red and yellow nonviable tissue and measures 1 cm x 0.8 cm x 0 cm. The report did not indicate a size of the wound to the left heel. The wound clinic report states wound to right AKA stump was cultured and showed a resistance to [MEDICATION NAME] ATB which the resident was currently taking. Report stated right AKA stump wound continues to have a clear pink tinged drainage oozing from opening. Opening of wound is still very small. [DIAGNOSES REDACTED] is mostly resolved, slight pink hue remains just over. He has been taking ATB as prescribed. He has not had his supplies delivered yet for his wound care. Call American Heritage Center to inquire. It seems and only two supplies just recently arrived at the facility sent

Based on interview and record review, the facility did not promptly consult with a physician when a need to alter treatment should have been identified resulting in an immediate jeopardy situation for 1 of 6 sampled residents (Resident #1). Resident #1 has a history of [MEDICAL CONDITIONS], and had been receiving treatment for [REDACTED]. Resident #1 had an unna boot on his left lower leg. On 09/14/15, the wound developed a foul odor, a fax was sent to the physician, and resent on 09/15/15, at which time Keflex (an antibiotic was ordered). The wound continued to drain large amounts of drainage, had a foul odor, and Resident #1 had a low grade fever on 09/18/15. The facility did not consult with a physician until his next scheduled appointment on 09/23/15. An additional antibiotic was ordered this date. Resident #1 had a fever of 101 degrees on 09/25/15, with continued foul drainage. Resident #1 was hosptalized on [DATE] with [MEDICAL CONDITION], abscesses of the stasis ulcers. The wound culture showed multiple organisms and intravenous medications of [MEDICATION NAME] was initiated in the hospital. The failure to immediately consult with a physician relating to signs and symtoms of an infection so that treatment orders could be obtained resulted in an immediate jeopardy. The immediate jeopardy began on 09/18/15. The Nursing Home Administrator (NHA), Director of Nursing (DON) and corporate consultant were notified of the immediate jeopardy on October 1, 2015 at 11:30 a.m. The immediate jeopardy was removed on 10/01/15. The deficient practice continues at a scope and severity of level D (potential for harm that is not immediate jeopardy/isolated) as the facility fully reviews and implements its policies. This is evidenced by: Resident #1 has resided in the facility for approximately five years and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], identifies no pressure ulcers, but that Resident #1 is receiving application of non-surgical dressings. The MDS, dated [DATE], identifies Resident #1 has severe cognitive impairment, and needs extensive assistance of two for transfers. The MDS identifies one stage III ulcer that is not healed. Resident #1 goes to the wound clinic on a regular basis for treatment of [REDACTED]. The care plan titled, Has chronic stasis ulcers, related to [MEDICAL CONDITIONS], last revised 12/05/13. Goal: Will have no signs or symptoms of infection through review date, target date 12/16/15. Interventions in part: Compression stocking on right leg as ordered, document/measure wound weekly, evaluate wound for size, depth, margins; peri-wound skin, sinuses, undermining, exudates, [MEDICAL CONDITION], granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated, 12/05/13 minimize skin exposure to moisture due to incontinence, wound drainage ., Monitor/document/report to MD PRN (as needed) for signs and symptoms of infection; green drainage, foul odor, redness and swelling .excessive pain, fever. The current physician orders [REDACTED]. 07/08/15 Gelcast unna boot, apply topically as directed, change every other day, [MEDICATION NAME] to wound/unna boot/coban. On 09/16/15, the unna boot was discontinued at the wound clinic and the new order is: Apply [MEDICATION NAME] to Left leg to fill/cover medial ankle wounds followed by cover, 2 x week dressing change. On 09/23/15, the wound clinic restarts the unna boot that is to be changed. The primary physician note, dated 07/23/15, in part: As of now plan is for routine hospitalization when indicated . WOUND Clinic report of consultation: 07/22/15 Worsening venous stasis ulcers. Unna boot is being wrapped too tight. Please wrap gently from toes to knee. Please continue unna boot change 2 x a week, [MEDICATION NAME] to wounds. 07/30/15 Continue [MEDICATION NAME] to wound beds, unna boot foot to knee (above widest part of calf), change dressing 2 x week. 08/05/15 Improved, venous stasis wounds. Follow up here weekly, PT (physical therapy) department, continue current dressings. 08/19/15 Continue current dressing. 08/26/15 Continue dressing changes every other day, return to PT 09/02/15. 09/02/15 Continue every other day [MEDICATION NAME] and unna boot. 09/09/15 Dressing changes every other day. Keep podus boot relatively loose to avoid increased pressure/swelling at foot. Return 09/16/15. Nurses' notes: 09/14/15 Describe focus area: infection left foot and leg. Current status: Dressing changed at change of shift. Has redness and foul yellow drainage .Left has numerous areas of maceration. Sheep skin in boot is saturated with drainage .09/15/15 .Resident unna boot intact, [MEDICAL CONDITION] to toes area continues, remains reddened and macerated. Still awaiting fax sent yesterday to Dr. 09/15/15 .MD started him on Keflex qid (four times a day) wife aware. Will see MD F at wound clinic tomorrow. Wound Clinic consult report 09/16/16 Reason for consultation: Started on Keflex .wound infection .Please provide us with measurements .Physician recommendations. D/C unna boot. Plan: every other day dressing changes: [MEDICATION NAME] to all open areas, cover with kerlix wrap and 4 x 4 to absorb drainage. Next appointment 09/23/15, Follow up one week . Nurses' notes in part: 09/17/15 14:06 (2:06 p.m.), Copious amounts, yellow sero sanguineous drainage. Has a puddle on the floor after breakfast .wrapped in Abdominal pads to help contain the drainage. Resident had minimal pain . 09/17/15 22:06 (10:06 p.m.), Dressing change to be done every other day, but resident has copious amounts of yellow sero sanguineous drainage .wrapped in abds .this is not urine. Drainage is very smelly. 09/18/15 Has been having copious amounts of yellow drainage. No contact with urine. T 99 this a.m. Resident dozing pretty much all day. Ate 1/2 of his meals. 09/19/15 10:46 a.m., Dressing changed weeping with lots of yellowish odorous drainage. More padding done to absorb .resident had some facial grimacing with dressing . 09/19/15 13:58 (1:58 p.m.), Dressing change this a.m., weeping and macerated with foul odor . 09/19/15 19:50 (7:50 p.m.), Very irritable with other residents. Refused to eat supper . 09/20/15 10:59 a.m.,. Dressing saturated yellow odorous drainage soiled flex boot, even boot has been soiled with drainage prior to today. More padding applied once more to absorb drainage . 09/20/15 21:31 (9:31 p.m.), Did not eat, too agitated in dining room once everyone in ding room .Was irritable to other residents. 09/21/15 Leg is raw, copious amounts of serous drainage pouring out of it. Improvement noted, no foul odor. Redressed soaking through, abdominal pads used. 09/22/15 Completed antibiotic at noon (Keflex) Continues to drain yellowish odorous drainage. 09/23/15 To wound clinic, start Bactrim DS (double strength) bid (twice a day) x 7 days. Spit out meds, tried to strike CNA (Certified Nursing Assistant) in face. Wound clinic consult report: 09/23/15 Report of findings: Unna boot placed today, next appointment 09/24 and 09/25/15 There is no documentation on dressing change, appearance of wound, wound drainage, odor or pain. 09/25/15 5:24 a.m. T-101 degrees at 1:10 a.m., gave Tylenol. T 100.8 degrees at 5:00 a.m., given 2nd dose of Tylenol. 09/25/15 8:21 a.m., Wound has had gross amounts of serous drainage Wound clinic consult report 09/25/15 Reason for consultation: Reported temp of 101 at 1:30 a.m., with prn Tylenol decreased to 99.5 this a.m. at 7:30 a.m. Recommendations: Continue as per appointments scheduled last week, Monday 09/28/15. 09/25/15 Recommendations: 1. Bactrim DS i po bid x 7 days 2. D/C keflex 3. Follow up here in 2 days with (PT name). 4. Place foley catheter. Nurses' notes continue in part: 09/25/15 12:00 p.m., Orders sent via fax at this time related to fever last night and today .sent to MD. G and call placed on his line and also his cell phone .he has some [MEDICAL CONDITION] in left foot underneath the unna boot. no cough but runny nose, no green secretions .lungs sounds are diminished as usual. 09/25/15 13:41 (1:41 p.m.), MD G ordered chest x-ray, and cath ua/uc (urinalysis and culture), to go to emergency room if fever persists. 09/25/15 14:03 (2:03 p.m.), At 1330 (1:30 p.m.), MD F called with order to start [MEDICATION NAME] 500 mg daily, continue with [MEDICATION NAME] DS .if temp goes above 100.5 degrees sent to ER. At the time resident returned at 1130 a.m., Temp 99.5. 09/25/15 18:30 (6:30 p.m.), no audible wheezing, congestion or cough, lung sounds slightly diminished bilaterally. (This is previously documented as his usual.) 09/25/15 19:32 (7:32 p.m.), Chest X-ray results received; slight right lower lobe infiltrate . 09/26/15 00:18 (12:18 a.m.), MD. H (the on call physician) returned call continue [MEDICATION NAME] as previous for 7 days. 09/26/15 .changed dressing to LLE and noted large amount of serous, foul smelling drainage. No cough noted .no signs or symptoms resp distress noted or reported. 09/27/15 5:22 a.m., T- 100.0 at 0400, given Tylenol 650 mg . 09/27/15 13:56 (1:56 p.m.), Resident agitated during shift evidenced by refusal to let RN take vital signs x 2 .no cough noted or esp distress . 09/27/15 22:41 (9:41p.m.), O2 sats within normal limits, no cough noted or resp distress . 09/28/15 10:25 a.m., Resident continues on [MEDICATION NAME] and [MEDICATION NAME] DS, .leg still had large amount of drainage, goes to wound clinic 3 days a week .T- 98.7 09/28/15 10:48 a.m., .ua/uc no growth . 09/28/15 13:39 (1:39 p.m.), .11:00 a.m. wound clinic appointment .resident returned at 1315 (1:15 p.m.) with next appointment order on 10/1 at 10 a.m. Wound Clinic Consult Report 09/28/15 Reason for consultation: LLE foot draining copious- foul odor- yellow open areas, low grade fever T. 100.0, had to change unna boot dressing here, 09/26/15, now on Bactrim DS and [MEDICATION NAME] - worsening. Recommendations from PT: Return 10/01/15. Please note MD does not (the word not is underlined) see patient each visit. Contact directly for concerns other than direct wound care. Nurses' notes continue: 09/28/15 21:30 (9:30 p.m.), Has low grade temp, (vital sign record documents T-99.8 degrees at 18:26 (6:26 p.m.)) 09/29/15 T. 98.9, refused supper, drank 360 plus his fiber drink. weight down to 202#. Dietary aware and will notify dietician in a.m. (Resident #1 has lost seven pounds, 3.3 % of his body weight, since the facility first identified the foul odor to the wound on 09/14/15.) 09/30/15 15:47 (3:47 p.m.), Faxing MD to request diet texture change to regular with ground meat, nectar liquids, and [MEDICATION NAME] silver daily. Resident has had 8 # weight loss in 5 days, and has order for video swallow study. Dietary will also change the health shake daily to magic cup each meal, and add extra margarine and gravy. 09/30/15 17:18 (5:18 p.m.), Resident is showing a possible change in condition in the following areas:Eating/swallowing, weight status . On 10/01/15, Resident #1 returned to the wound clinic; he was sent directly to the hospital from the appointment. Interviews On 09/29/15 at 1:30 p.m., Surveyor was going to observe personal cares for Resident #1. Resident #1 was agitated and yelling at the CNAs, and talking about the past in fragmented sentences. When they would approach him he would yell out. CNA I stated to Resident #1, I know you are in pain, we will take it easy. CNA I took Surveyor aside and stated, He has changed so much the past few weeks. I think it is the pain in his leg, he used to be so happy. After two approaches, the attempt for personal cares was stopped, due to resident's agitation. On 09/30/15 at 1:22 p.m., Surveyor observed CNA J assist Resident #1 with personal cares, CNA J commented on being concerned with how Resident #1 had changed recently with being more uncooperative with cares, and not eating well. CNA J stated, I wonder if it is his leg, or if he has pain and that is why he has been acting so differently. On 09/30/15 at 1:50 p.m., Surveyor interviewed Resident #1's Family Member (FM) N, who visits daily with him. FM N had concerns about Resident #1 not wanting to eat the past week or so and talking out of his mind. FM N stated, I wonder if it really is his dementia or all this other stuff going on with the new medicines and the wound. I think all of his medicine should be reviewed. Surveyor asked if FM N was referring to the antibiotics. FM N stated, Yes, he is on two new ones. FM N went on to talk about how the drainage has been so bad it has soaked through his clothes and onto his protective boots. On 09/30/15 at 3:30 p.m., Surveyor interviewed the DON, who oversees all wound care for the facility, doing weekly rounds on Wednesdays. The DON is not wound care certified. Surveyor asked for any physician contact from 09/17/15 until the return to the wound clinic on 09/23/15. The DON said she would find more information. On 10/01/15 at 8:00 a.m., the NHA brought in the facility timeline. The timeline documented the facility had done all staff education on 09/16/15, after the nurse had faxed the physician about the foul odor, and waited until 09/15/15 to re-fax the information. On 10/01/15 at 9:30 a.m., Surveyor did a telephone interview with the primary physician, MD G, who stated he is not managing the wounds for Resident #1, and was not aware of a Keflex order for an infection. MD G indicated he would not order Keflex unless he had actually seen the wound. Surveyor asked if MD G would expect to be notified about the signs and symptoms of the wound infection. MD G stated, I was called about a fever. I do not manage the wounds. I know this resident has a lot of wound issues and goes to the wound clinic; they manage the wounds on his lower extremities. Surveyor asked if MD G was aware that a physician does not see the resident on each wound clinic visit. MD G stated, I really do not know how that works. On 10/01/15 at 2:00 p.m., Surveyor and Surveyor interviewed the DON. The DON stated that Resident #1 had been seen by a physician at the wound clinic on 09/16/15, so did not understand why there was a concern. The DON expected drainage from the wounds, since the unna boot had been removed, and did not understand what the nurses should have identified sooner. Surveyor shared that the documentation showed: increased (copious amounts) of drainage, foul odor, a fever, decreased appetite, increased irritability 09/17/15 until the return appointment. On 10/01/15 at 5:15 p.m., Surveyor interviewed the wound clinic physician, MD F, on the telephone. Surveyor reviewed the nurses' notes 09/17 - 09/23/15 and asked MD F if he would have expected to be notified before 09/23/15 at the return appointment about the signs of infection. MD F stated, Right, I would want to be contacted, this resident is fragile and has to be watched very closely. MD F clarified that he only saw the resident about every other week at the wound clinic; the other visits were conducted by physical therapy, and if there was a concern the therapist would call him. Surveyor asked if the increased drainage was expected after the unna boot was removed. MD F stated, Venous stasis ulcers do have a lot of drainage, but to be yellow and have an odor is not normal, and I was not aware of a low grade fever on 09/18/15. MD F went on to say that he examined the wound today and could see exposed bone on the medial leg and heel with increased redness. He is concerned with osteo[DIAGNOSES REDACTED] so has had the resident hospitalized . On 10/05/15, Surveyor reviewed the hospital admission papers. The admitting [DIAGNOSES REDACTED]. Summary in part: Cultures grew multiple organisms- antibiotics changed. Vascular surgery progress note 10/03/15: If wounds do not heal or they deteriorate, we will need to make a decision of proceeding with an AKA (above-the-knee amputation) or Hospice care. The facility removed the immediate jeopardy on 10/01/15 by reviewing all residents with pressure ulcers and assessing the wounds to identify changes in condition. The facility also educated nursing staff on physician notification, change of condition, signs of infection, measuring wounds, wound prevention and treatment and treatment completion and documentation.

Based on observation, interview and record review, the facility did not provide necessary care and services in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This occurred for 1 of 1 residents (Resident #1) who was receiving care for venous stasis ulcers. Resident #1 is receiving care for stasis ulcers and a facility acquired stage III pressure ulcer (identified as a stage IV from wound clinic on last day of survey). Resident #1 experienced infection in the wounds and significant pain. Resident #1 also experienced declines in bowel and bladder and weight that the facility failed to address. The wound clinic expressed concerns that the unna boot was not applied correctly and the leg and dressing were soaked with urine upon arrival to appointments. This is evidenced by Resident #1 has resided in the facility for approximately five years and has [DIAGNOSES REDACTED]. Resident #1 has chronic venous stasis ulcers that have been treated at a wound clinic for over two years. Resident #1's treatment has been an unna boot since October 2014. The quarterly Minimum Data Set (MDS), dated [DATE], identifies no pressure ulcers, but that Resident #1 is receiving other wound care. This MDS identifies a brief interview for mental statas (BIMS) score of 2 (severe cognitive impairement). The Minimum Data Set, dated dated [DATE], identifies Resident #1 has severe cognitive impairment, and needs extensive assistance of two for transfers. The MDS identifies one stage III ulcer, that is not healed. Resident #1 is frequently incontinent of urine. Pain: The care plan titled, Actual Chronic pain r/t (related to) wound: stasis ulcer of left leg, last revised 12/05/13. Goal in part: Will be free from non-verbal indicators of pain Interventions in part: Podus boot left foot as ordered, 09/03/15, complete pain assessment .with new complaints of pain .encourage to try different pain relieving methods, positioning, relaxation therapy .evaluate effectiveness of pain interventions prn .is able to call for assistance when in pain, ask for medication tell you how much pain is experienced, 12/05/13. (The MDS, dated [DATE], documents severe cognitive impairment, assessed by the staff. The resident was unable to do the brief interview for mental status questions.) Report to nurse any change in usual activity, attendance patterns or refusal to attend activities related to s/s (signs/symptoms) or c/o of pain or discomfort, 12/05/13. The pressure ulcer care plan does not address pain. Nurses' notes on 09/15-09/18, 09/22, 09/24, and 09/26-09/28 state no complaint of pain. The notes do not indicate when the pain was assessed or what the resident was doing at the time. Nurses' notes on 09/17 and 09/19 indicate pain with the dressing changes. On 09/29/15 at 1:30 p.m., Surveyor was going to observe personal cares for Resident #1. Resident #1 was agitated and yelling at the Certified Nursing Assistants (CNAs), and talking about the past in fragmented sentences. When they would approach Resident #1, he would yell out. CNA I stated to Resident #1, I know you are in pain, we will take it easy. CNA I took Surveyor aside and stated, He has changed so much the past few weeks. I think it is the pain in his leg, he used to be so happy. After two approaches, the attempt for personal cares was stopped, due to Resident #1's agitation. On 09/30/15 at 7:45 a.m. Surveyor observed wound care being performed by the Director of Nursing (DON). When the left heel was cleansed, Resident #1 yelled out, What the h-- are you doing? The DON applied the [MEDICATION NAME] to the heel, the resident yelled out, I cannot live like this. Resident #1 was moaning when the unna boot was wrapped over the heel area; after the heel area was wrapped no further complaints of pain were observed. The DON wrapped the unna boot, so that it ended, approximately 3-4 inches below the knee. On 09/30/15 at 1:22 p.m Surveyor observed CNA J assist Resident #1 with personal cares. CNA J commented on being concerned with how Resident #1 had changed recently with being more uncooperative with cares, and not eating well. CNA J stated, I wonder if it is his leg, or if he has pain and that is why he has been acting so differently. CNA J went to remove the pants and noted they were wet, and had to be changed. Surveyor asked when was the last time Resident #1 had been toileted or changed. CNA J stated, About 10:45 a.m. Licensed Practical Nurse (LPN) S came in the room as cares were being performed. Resident #1's left leg was very swollen above the top of where the unna boot ended. LPN S came back to the room at 1:47 p.m., with a [MEDICATION NAME] sock and applied it to the left leg, and said, This will help even out the fluid and help the blood flow. On 09/30/15 at 1:40 p.m., Surveyor interviewed Resident #1's Family Member (FM) N, who visits daily with him. FM N had concerns about Resident #1 not wanting to eat the past week or so and talking out of his mind. FM N stated, I wonder if it really is his dementia or all this other stuff going on with the new medicines and the wound. I think all of his medicine should be reviewed. Surveyor asked if FM N was referring to the antibiotics. FM N stated, Yes he is on two new ones. FM N went on to talk about how the drainage and urine has been so bad it has soaked through his clothes and onto his protective boots. Surveyor asked if FM N had been present at the wound clinic and observed his clothes wet. FM N said, Yes, his pants are all wet down onto his legs. It is so long by the time he leaves and gets back from the appointment he cannot help it. Surveyor asked if Resident #1 has experienced increased pain. FM N stated, He has never complained of any pain until about two months ago. The past few weeks he says it hurts down into his heel; he even hit the wound care nurse when she dressed his heel because it hurt. He is not one to complain. Surveyor reviewed the medication administration records. Resident #1 was given Tylenol for fever; there were no [MEDICATION NAME] given for pain for the month of September. The pain assessment completed on 06/03/15 documents no signs or symptoms of pain. The non-interviewable residents section has no areas of concern checked. The pain assessment on 09/03/15 for non-interviewable residents: Has there been a change in habit such as: the following are marked, change in level of physical activity, withdrawing from relationships, a change in mood or emotions. Current plan is effective. No change necessary to care plan. The pain assessment on 09/05/15: history of pain medicine use: generally refuses pain meds, current prn use tylenol and hydro-[MEDICATION NAME], does not appear to be in pain, and will deny pain. Non-interviewable residents, change in habit: the following are marked, constipation, decreased appetite, change in level of physical activity, withdrawing from relationships, difficulty or not wanting to participate in therapy, withdrawn from activities. Evaluation of pain management: Current plan is effective, no change necessary to care plan. Weight loss Surveyor observed Resident #1 at his noon meal on 09/29/15. His wife sat next to him and encouraged him to eat. He was served mashed potatoes, meat and gravy, wax beans and dessert. Resident #1 ate a only a few bites of the dessert. On 09/30/15, Surveyor observed Resident #1 served his breakfast consisting of a banana, scrambled eggs, toast, bacon, yogurt, coffle apple juice, and a pink drink. Resident #1 drank the apple juice and the pink drink, not eating any of the meal. The medical record review shows a 6% weight loss the past month. The dietary assessment, dated 09/08/15, includes in part: New stage III decub on left heel .summary: Resident continues to select his own meals and to eat independently with set up. His intakes vary, but are usually 75-100 % .he continues to receive a mighty shake with breakfast and a magic cup with lunch .braden score records adequate nutrition. There are no current labs to review .Care plan reviewed and is current. Nutritional interventions to promote healing were not added. Stassis Ulcer Care The care plan titled, Has chronic stasis ulcers, related to [MEDICAL CONDITIONS], last revised 12/05/13. Goal: Will have no signs or symptoms of infection through review date, target date 12/16/15. Interventions in part: Compression stocking on right leg as ordered, document/measure wound weekly, evaluate wound for size, depth, margins; peri-wound skin, sinuses, undermining, exudates, [MEDICAL CONDITION], granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated , 12/05/13 minimize skin exposure to moisture due to incontinence, wound drainage ., Monitor/document/report to MD PRN (as needed) for signs and symptoms of infection; green drainage, foul odor, redness and swelling .excessive pain, fever. The current physician orders [REDACTED]. 07/08/15 Gelcast unna boot , apply topically as directed, change every other day, [MEDICATION NAME] to wound/unna boot/coban. On 09/16/15, the unna boot is discontinued at the wound clinic and the new order is: Apply [MEDICATION NAME] to Left leg to fill/cover medial ankle wounds followed by cover, 2 x week dressing change. On 09/23/15, the wound clinic restarts the unna boot that is to be changed. Wound Clinic report of consultation: 07/22/15 Worsening venous stasis ulcers. Unna boot is being wrapped too tight. Please wrap gently from toes to knee. Please continue unna boot change 2 x a week, [MEDICATION NAME] to wounds. 07/30/15 Continue [MEDICATION NAME] to wound beds, unna boot foot to knee (above widest part of calf), change dressing 2 x week. 08/05/15 Improved, venous stasis wounds. Follow up here weekly, PT (physical therapy) department, continue current dressings 08/19/15 Continue current dressing 08/26/15 Continue dressing changes every other day, return to PT 09/02/15 09/02/15 Report of findings: .Venous stasis [MEDICAL CONDITION], ulcers .Continue every other day [MEDICATION NAME] and unna boot Wound progress note by the physical therapist 09/02/15 .there have been challenges with appropriate wrapping of (Resident #1's name) leg . 09/09/15 Dressing changes every other day. Keep podus boot relatively loose to avoid increased pressure/swelling at foot. Return 09/16/15. Nurses' notes: 09/14/15 Describe focus area: infection left foot and leg. Current status: Dressing changed at change of shift. Has redness and foul yellow drainage .Left has numerous areas of maceration. Sheep skin in boot is saturated with drainage .09/15/15 .Resident unna boot intact, [MEDICAL CONDITION] to toes area continues, remains reddened and macerated. Still awaiting fax sent yesterday to Dr. 09/15/15 .MD started him on Keflex qid (four times a day) wife aware. Will see MD F at wound clinic tomorrow. Wound Clinic Note 09/16/15 Assessment: .there have been challenges with appropriate wrapping of (Resident #1's name) leg . Subjective: Wife reports the flexboot from last week 'got wet' and she found him in the new one he is currently wearing. She is worried about his incontinence and how this may be contributing to the wound/skin issues . Objective: .Lateral ankle now has large open ulceration significantly increased in size from previous encounter .patient smells strongly of urine, and the flex/podus boot is saturated. Wound (s) #1 Location: L lower leg medial ankle (previously three separate wounds), length 5.8 cm X Width 5.2 cm Wound Clinic consultation report 09/16/15 Recommendations .D/C unna boot .Call MD G to consider a Foley . Wound clinic progress note 09/16/15 by physical therapist: Assessment: .he is followed here in the clinic and additional dressing changes performed by nursing home staff. There have been challenges with appropriate wrapping of (Resident name), leg and increasing LE (lower extremity) [MEDICAL CONDITION] . Nurses' notes in part: 09/16/15 MD called regarding foley consideration. MD ordered monitor of wound site for urine exposure during dressing changes. Report findings in 3 days. 09/17/15 14:06 (2:06 p.m.), Copious amounts, yellow sero sanguineous drainage. Has a puddle on the floor after breakfast .wrapped in Abdominal pads to help contain the drainage. Resident had minimal pain . 09/17/15 22:06 (10:06 p.m.), Dressing change to be done every other day, but resident has copious amounts of yellow sero sanguineous drainage .wrapped in abds .this is not urine. Drainage is very smelly. 09/18/15 Has been having copious amounts of yellow drainage. No contact with urine. T 99 this a.m. Resident dozing pretty much all day. Ate 1/2 of his meals. 09/19/15 10:46 a.m., Dressing changed weeping with lots of yellowish odorous drainage. More padding done to absorb .resident had some facial grimacing with dressing . 09/19/15 13:58 (1:58 p.m.), Dressing change this a.m., weeping and macerated with foul odor . 09/19/15 19:50 (7:50 p.m.), Very irritable with other residents. Refused to eat supper . 09/20/15 10:59 a.m.,. Dressing saturated yellow odorous drainage soiled flex boot, even boot has been soiled with drainage prior to today. More padding applied once more to absorb drainage . 09/20/15 21:31 (9:31 p.m.), Did not eat, too agitated in dining room once everyone in ding room .Was irritable to other residents. 09/21/15 Leg is raw, copious amounts of serous drainage pouring out of it. Improvement noted, no foul odor. Redressed soaking through, abdominal pads used. 09/22/15 Completed antibiotic at noon (Keflex) Continues to drain yellowish odorous drainage. Wound clinic consult report 09/23/15 Report of findings: Unna boot placed today, next appointment 09/25/15 .Recommendations: 1. Bactrim DS i po bid x 7 days 2. D/C keflex 3. Follow up here in 2 days with (PT name). 4. Place foley catheter. 09/23/15 To wound clinic, start Bactrim DS (double strength) bid (twice a day) x 7 days. Wound clinic measurements: New area Left foot plantar surface 5.5 cm Length X 3.5 cm Width, depth <0.1 cm. Left medial ankle: 3.5 cm x 3.5 cm. On 09/23 and 09/24/15, there are no documented temperatures for Resident #1; he has had signs and symptoms of infection and is on antibiotics. On 09/24 and 09/25/15, there is no documentation on dressing change, appearance of wound, wound drainage, odor or pain. Nurses' notes continued: 09/24/15 .did d/c (discontinue) his toileting program as he is always incontinent will change to a check and change by staff . The MDS 09/08/15, documents Resident #1 is frequently incontinent of urine, and always continent of bowel, and was on a toileting program. This is a decline in bowel/bladder function in the past two weeks. 09/25/15 5:24 a.m. T-101 degrees at 1:10 a.m., gave Tylenol. T 100.8 degrees at 5:00 a.m., given 2nd dose of Tylenol. 09/25/15 8:21 a.m., Spoke with Dr. F's nurse on 09/24/15 voiced concerns with new order to place foley cath without appropriate diagnosis, nursing staff has charted no urine exposure to wound .Wound has had gross amounts of serous drainage .also documented even when leg dressing is saturated, pants in peri area remain dry .writer did ask why a condom cath was not mention in order. waiting for doctor response. foley has not been placed. (There is no further documentation on the catheter, or interventions to avoid possible urine getting on the dressing.) Wound clinic consult report 09/25/15 Reason for consultation: Reported temp of 101 at 1:30 a.m., with prn Tylenol decreased to 99.5 this a.m. at 7:30 a.m. Recommendations: Continue as per appointments scheduled last week, Monday 09/28/15. Nurses' notes continue in part: 09/25/15 12:00 p.m., Orders sent via fax at this time related to fever last night and today .sent to Dr. G and call placed on his line and also his cell phone .he has some [MEDICAL CONDITION] in left foot underneath the unna boot. no cough but runny nose, no green secretions .lungs sounds are diminished as usual. 09/25/15 18:30 (6:30 p.m.), No audible wheezing, congestion or cough, lung sounds slightly diminished bilaterally. (This is previously documented as his usual.) 09/26/15 .changed dressing to LLE and noted large amount of serous, foul smelling drainage. No cough noted .no signs or symptoms resp distress noted or reported. 09/27/15 5:22 a.m., T- 100.0 at 0400, given Tylenol 650 mg . 09/28/15 10:25 a.m., Resident continues on [MEDICATION NAME] and [MEDICATION NAME] DS, .leg still had large amount of drainage, goes to wound clinic 3 days a week .T- 98.7. 09/28/15 13:39 (1:39 p.m.), .11:00 a.m. wound clinic appointment .resident returned at 1315 (1:15 p.m.) with next appointment order on 10/1 at 10 a.m. Wound Clinic Consult Report 09/28/15 Reason for consultation: LLE foot draining copious- foul odor- yellow open areas, low grade fever T. 100.0, had to change unna boot dressing here, 09/26/15, now on Bactrim DS and [MEDICATION NAME] - worsening. Recommendations from PT: Return 10/01/15. Please note MD does not (the word not is underlined) see patient each visit. Contact directly for concerns other than direct wound care. Measurements Left plantar surface: Length 6.5 cm x W 5.5 cm, Depth <0.1 cm, Left medial ankle: 7.5 cm X 5.8 cm unable to measure depth. (larger in size) Nurses' notes continue: 09/28/15 21:30 (9:30 p.m.), Has low grade temp, (vital sign record documents T-99.8 degrees at 18:26 (6:26 p.m.)) On 10/01/15, Resident #1 returned to the wound clinic; he was sent directly to the hospital from the appointment. On 10/05/15 at 8:00 a.m., Surveyor interviewed the DON, about the concerns the physician had about the unna boot being applied correctly and asked if they had done all staff education on the procedure. The DON stated, No, I make sure it is not too tight. We all know what we are doing. He has had this dressing way before I ever started here. Surveyor asked about the urine concerns. The DON stated, We montiored for three days, and I do not think it was urine. On 10/01/15 at 5:15 p.m., Surveyor interviewed the wound clinic physician, MD F, on the telephone. Surveyor reviewed some of the concerns the physician had made on the consult reports. Surveyor asked if the unna boot had been on too tightly. MD F stated, Yes, that has happened a few times. I think they get new staff in and they are not trained on how to apply the unna boot correctly. It has been only wrapped part way up the leg, allowing [MEDICAL CONDITION] to be above the unna boot. The facility has not been consistent with the unna boot. Surveyor asked if the resident had been wet with urine. MD F said, Yes we have had problems with that on some of our visits. I have suggested a foley catheter to manage this concern, and they were to contact his primary physician to get things started. I do not know what happened with that. Surveyor reviewed the signs and symptoms of infection Resident #1 was having. MD F stated, Venous stasis ulcers do have a lot of drainage, but to be yellow and have an odor is not normal and I was not aware of a low grade fever on 09/18/15. MD F went on to say that he examined the wound today and could see exposed bone on the medial leg, and the heel (stage IV pressure ulcer). MD F also stated the resident experienced increased pain with the heel dressing change and was concerned with osteo[DIAGNOSES REDACTED] so has had the resident hospitalized . On 10/05/15, Surveyor reviewed the hospital admission papers. The admitting [DIAGNOSES REDACTED]. Summary in part: Cultures grew multiple organisms- antibiotics changed. Vascular surgery progress note 10/03/15: If wounds do not heal or they deteriorate, we will need to make a decision of proceeding with an AKA (amputation) or Hospice care.

Based on record review and interview, the facility did not complete a performance review of each nurse aide, once every 12 months, for 2 of 5 Certified Nursing Assistants. This has the potential to affect all 35 residents, who live in the facility. This is evidenced by: On 10/05/15, Surveyor reviewed Certified Nursing Assistant (CNA) performance reviews. The following information was identified: -CNA A's most recent performance evaluation has a completion date of 10/31/13. -CNA B's most recent performance evaluation has a completion date of 01/22/14. Evaluations should identify areas of growth for training purposes. The facility was cited for care tags at F325 (assistance with eating), 312 (ADL assistance) and 282 (following the care plan). CNAs A and B work with all residents in the facility. On 10/05/15 at 10:20 a.m., Surveyor interviewed the Nursing Home Administrator (NHA). The NHA indicated she provided the Surveyor with CNA A and B's most recent evaluations. The NHA explained the business office staff keeps track of when CNA performance evaluations are due and the forms are then provided to the Director of Nursing. The NHA indicated she is not sure why CNA A's evaluation was missed. The NHA went on to say that CNA B's evaluation should been completed in January. This is around the time the DON started at the facility.

Based on policy reviews, facility records, and staff interviews, the facility did not involve the medical director in: -Assisting the facility to identify, evaluate, and address/resolve medical and clinical concerns and issues that affected resident care, medical care, and quality of life. This contributed to numerous citations such as: notifying a physician with a change in condition, resident assessment, quality of care citations regarding such things as care and services provided to residents, assistance and supervision to prevent accidents, maintaining nutritional status, pressure ulcers, a drug regimen free of unnecessary drugs, pharmacy services such as proper storage of medications and accurate dispensing of medications, and infection control. These issues have the potential to affect all 35 residents currently residing in the facility. This is evidenced by: According to American Medical Directors Association, The Medical Director has an important role in helping the facility deal with regulatory and survey issues.the medical director can help ensure appropriate systems exist to facilitate good medical care, establish and apply good monitoring systems and effective documentation and follow up of findings and help improve physician compliance with regulations. During and after the survey process, the medical director can clarify for the surveyors clinical questions or information about the care of specific residents, request surveyor clarification of citations on clinical care, attend the exit conference to demonstrate physician interest and help in understanding the nature and scope of the facility's deficiencies and help the facility draft corrective actions. Surveyor reviewed the facility's Medical Director Agreement signed on 03/31/14. The agreement states, III. Responsibilities and Functions of Medical Director. The Medical Director agrees to the following responsibilities and to perform the following functions: 1. Be responsible for the medical direction and overall coordination or medical care in the Facility . 3. Be responsible for evaluation and taking appropriate steps to correct situations of possible inadequate medical care that the Medical Director identifies or receives a report . 5. Develop a liaison with, and monitor the activities of, attending physicians in efforts to ensure effective and appropriate medical care and provide oversight and supervision of physician services and the medical care of residents. At the Facility's request, the Medical Director shall assist in developing, in conjunction with the Facility and its corporate office staff, the rules, regulations, and policies that attending physicians are expected to observe in admitting and caring for their residents in the Facility . 7. Assure the support of essential medical consultants as needed . 8. Assist the Facility in its review and response to any surveys, complaints, or inspections or any medical care or treatment issues or concerns . 14. Advise the Facility's Administrator as to the adequacy of the Facility's resident care services and medical equipment, and participate in any review of care by the Facility. 15. Conduct bi-weekly rounds of the facility with the Director of Nursing or his or her designee at a mutually convenient day and time. Be available for consultation at all other times with the Facility's Administrator and Director of Nursing, or their designee(s), in evaluating the adequacy of the Facility and its staff to meet the psychosocial as well as the medical and physical needs of specific residents and of residents in general, and be available as a resource on resident care issues and developments . 17. Be available for consultation on, development of, and participation in in-service training programs and staff development plans and programs . The facility had not expanded the role of the medical director On 10/05/15 at 7:00 a.m., Surveyor interviewed the Nursing Home Administrator (NHA) who stated Medical Director (MD) E has not identified any issues that needed to be evaluated. The NHA stated the role of the Medical Director is to look at the overall operation of the facility, talk about trends and would step in if sees a problem like issues with other physicians. The NHA stated MD E wouldn't hesitate to contact other providers if needed. The NHA further stated MD E had been the medical director for eight years. Surveyor questioned the NHA if she had reviewed the federal tag F501 and its guidance related to the role of the medical director with MD E. The NHA stated, The expectations are laid out in the contract. The facility had not involved the medical director in providing staff education The NHA stated MD E has not been involved with facility education. Immediate jeopardy citations were issued at F157 (consultation with physician) and F314 (wound care). Actual harm citation at F309 (pain) and other citations in relation to inappropriate antibiotics (F329). During the survey, it was communicated by staff that they have a hard time getting hold of the wound clinic doctor and the primary physician does not deal with the wounds. Physicians are ordering antibiotics before cultures are completed and needing to change the antibiotic several times. These are ongoing issues for the facility. On 10/05/15 at 1:45 p.m., Surveyor and Surveyor met with the Director of Nursing (DON). Surveyor asked if the facility has utilized the medical director to assist with encouraging communication from the wound clinic and between doctors or to educate and encourage doctors to complete cultures prior to prescribing an antibiotic. The DON stated they have not utilized the medical director or discussed challenges with him. The DON felt the medical director would be open and willing to help out if asked. On 10/05/15 at 7:30 a.m., Surveyor interviewed MD E. Surveyor questioned MD E if the facility had informed him of the immediate jeopardy citations. MD S stated, No. MD E stated the facility had called him and informed him the facility was receiving citations and the state surveyors would like to speak to him on Monday. When asked by the surveyor if the facility had shared the federal regulation F501 related to role of the Medical Director with him, MD E stated, No. MD E stated he was not asked for his input into the removal plans for the citations. MD E stated he had not identified any areas that needed improvement. MD E further stated he sees his role as the medical director as looking at quality of care. If he sees issues he would bring them up. For example, if a physician was not making timely visits he would call them.

Based on observation, interview, record review and policy/procedure review, the facility did not establish an Infection Control Program under which it investigates, controls and prevents infections in the facility. The facility line list identified residents with infections (#1, #3) that were not put on precautions per the facility policy; this had the potential to spread infection to all 35 residents in the facility. Glucometers were not cleaned and disinfected per the standard of practice; that had the potential to affect 2 of 4 (#9, #4) residents that use the same glucometer. Resident #1 was on the line list identified as having an upper respiratory tract infection 09/03/15, a wound infection 09/14/15, and pneumonia 09/25/15. Resident #1 was not put on droplet precautions for respiratory symptoms, or put on contact precautions for a wound infection. Resident #3 was on the line list in June for pneumonia; she was not put on droplet precautions, or isolated to her room. Facility nursing staff did not follow facility policy and procedure with appropriate use of the glucometers while taking blood sugars. This is evidenced by: Surveyor reviewed the nurses' notes of Resident #1 and noted the following: 09/03/15 14:21 (2:21 p.m.) Sneezing, sniffling, and this am, large copious amounts of yellow secretions from nose, and mouth .he did later go to church . 09/03/15 21:56 (9:56 p.m.), T-98.1, out to meals and activities per normal. 09/04/15 Fax orders received from MD G for persisting/increasing/resp symptoms. 09/05/15 12:55 p.m., Continues with congested cough . 09/05/15 22:32 (10:32 p.m.), .ate fair, does not stay in dining room long. The line list list identifies Resident #1 onset of an upper respiratory infection (URI) on 09/03/15; contact or droplet precautions are not identified. Resident #1 was not isolated to his room. The line list has Resident #1 on for a LLE (left lower leg) wound infection, onset date of 09/14/15. Contact precautions are not identified. On 09/23/15, Resident #1 is on the line list again with a cutaneous infection, with an onset of 09/23/15; contact precautions are not identified. The nurses' notes document the wound has foul smelling, excessive drainage during this time. 09/25/15 5:24 a.m., Fever 101 degrees 09/25/15 10:50 a.m. Resident left facility at 0910 after breakfast via handi-lift . 09/25/15 13:41 (1:41 p.m.) Order for chest xray . 09/25/15 19:32 (7:32 p.m.), Chest X-ray results, slight right lower lobe infiltrate The line list has Resident #1 on with a URI, with right lower lobe infiltrate, with onset of 09/25/15. Resident #1 has no droplet or contact precautions identified. Resident #1 left the facility and went to the wound clinic with a fever. On 09/27/15 and 09/28/15, the nurses' notes document that Resident #1 has a fever. Surveyor entered the facility on 09/29/15 and observed the resident out in the dining room for meals. Example 2 Resident #3 is on the line list with a respiratory infection of pneumonia, with an onset date of 06/29/15, getting intramuscular and oral antibiotics. There are no identified droplet precautions for Resident #3. The infection control surveillance worksheet completed by Registered Nurse (RN) M, has droplet with a question mark on the antibiotic use section. The nurses' notes were reviewed and do not have any documentation on precautions that were put in place. On 10/05/15 at 10:30 a.m., Surveyor interviewed the infection control nurse, RN M, about the line list. Surveyor asked if the resident has signs and symptoms of upper respiratory infection if precautions should be in place. RN M agreed that droplet precautions should have been in place, but they were not really sure if either above examples were really pneumonia when she looked at her criteria. Surveyor stated if it had been contagious all of the residents living here could have been sick. Surveyor asked why Resident #1 was not on contact precautions, with an infected, draining wound. RN M stated, He should be on contact precautions. Surveyor asked what the facility policy is for keeping residents isolated if they have a fever. RN M stated, They should be in their room until 24 hours fever free. Surveyor shared the concern with Resident #1 going out to appointments and being with other residents when he had not been fever free for 24 hours. 3. GLUCOMETERS Facility policy titled, Glucose Monitoring Equipment: Disinfect/Decontaminate, dated July 2015, states: 2. Place the glucometer on the over-bed table on a clean surface, e.g , paper towel, wax paper Cleaning the Glucometer: 1. Use the disinfectant wipe to clean all external parts of the glucometer with gloves on .2. Remove gloves. 3. Perform hand hygiene. 4. Don clean gloves. 5. Obtain a second wipe with fresh paper towel. 6. Use the wipe to clean all external parts of the glucometer for the second cleaning, 7. Place the glucometer on the fresh paper towel .8. Remove gloves. 9. Perform hand hygiene. 10. Place glucometer in appropriate storage until next blood glucose test. On 09/30/15 at 7:25 a.m., Surveyor observed RN O during routine medication administration task, perform routine blood sugar test on Resident #9. RN O cleaned the glucometer with an appropriate cleansing wipe and then entered Resident #9's room. Resident #9 was lying in his bed. RN O placed the glucometer on the uncleaned bedside table and did not use a barrier. After completing the blood sugar test, RN O returned to the hallway to the medication cart where she used one cleansing wipe to clean the glucometer. She then placed the glucometer on top of the medication cart and did not use a barrier and did not clean the glucometer a second time per facility policy. Surveyor did not observe RN O place the glucometer in an appropriate storage place until the next blood sugar test was completed. Surveyor noted RN O to just leave the glucometer on top of the medication cart. On 09/30/15 at 7:25 a.m., Surveyor observed RN O, during routine medication administration task, perform routine blood sugar tests on residents residing on the A wing. Surveyor observed a glucometer sitting on top of the medication cart. RN O cleaned the glucometer with an appropriate cleansing wipe and then entered Resident #14's room. Resident #14 was noted to be sitting on the edge of the bed. RN O placed the glucometer on the uncleaned bedside table and did not use a barrier. After completing the blood sugar test, RN O returned to the hallway to the medication cart where she used one cleansing wipe to clean the glucometer. She then placed the glucometer on top of the medication cart and did not not use a barrier and did not clean the glucometer a second time per facility policy. Surveyor did not observe RN O place the glucometer in an appropriate storage place until the next blood sugar test was completed. Surveyor noted RN O to just leave the glucometer on top of the medication cart. On 09/30/15 at 7:15 a.m., Surveyor interviewed RN O in regard to the glucometer. RN O stated each medication cart has a glucometer and they have to share with all residents who receive blood sugar tests each day. RN O stated the glucometers are cleaned with a cleansing wipe and then left on the medication cart until the next resident test is completed. On 09/30/15 at 8:25 a.m., Surveyor discussed concerns with glucometer cleaning with the Director of Nursing (DON). The DON agreed that RN O was not following the facility's policy and procedure for appropriate cleaning and storage of the glucometer.

Based on observation, record review and interview, the facility did not provide services according to each resident's written plan of care for 5 of 9 residents (Resident #13, #5, #1, #3 and #9) reviewed. 1. Resident #13 was not provided a gait belt with ambulation when the care plan stated he was to be transferred with an assistance of one facility staff member. 2. Resident #5 was transferred with a mechanical lift by one staff member when the care plan states he was to be transferred by two staff members. 3. Resident #1's heels were not floated as the care plan instructs. 4. Resident #3's toileting care plan and meal interventions were not followed by the Certified Nursing Assistants. 5. Resident #9 did not recieve assistance with meals as directed by the care plan. As evidenced by: 1. On 10/01/15, Surveyor reviewed the medical record for Resident #13 and noted the following; - Minimum Data Set (MDS), dated [DATE] and 07/27/15, states Resident #13 is at high risk for falls and has a history of a fracture from a fall prior to admission. - Certified Nursing Assistant (CNA) care plan, received 10/01/15, states Resident #13 is to be transferred by the assistance of one staff member and is at high risk for falls. On 10/01/15 at 9:30 a.m., Surveyor observed Business Office (BO) R assist Resident #13 into a standing position from a chair in the day room by holding onto his hands. BO R then walked backwards, holding onto Resident #13's hands, assisting him to ambulate out of the day room, past the nurses' station and down a hallway where she then assisted him into a chair next to a phone. Survyeor interviewed BO R in regard to the transfer status of Resident #13. BO R stated, I don't know what his transfer status is .I just work in the business office. On 10/01/15 at approximately 9:35 a.m., Surveyor interviewed Licensed Practical Nurse (LPN) Q in regard to the transfer status of Resident #13. LPN Q stated Resident #13 was to be transferred by one assist from a qualified nursing staff member and a gait belt was to be used. LPN Q stated, (BO R) shouldn't be transferring him. On 10/01/15, Surveyor interviewed the Director of Nursing (DON) in regard to the above noted observation and concerns in regard to Resident #13's care plan not being followed. The DON confirmed that Resident #13 was to be transferred with an assist of one facility staff member who was qualified to transfer residents and a gait belt should have been used. 2. On 09/29/15 at 12:25 p.m., Surveyor reviewed the medical record for Resident #5 and noted the following: - MDS, dated [DATE] and 09/16/15, stated Resident #5 was at high risk for falls. - Comprehensive nursing care plan, received 09/29/15, stated Resident #5 was at high risk for falls, had an above the knee amputation to the right leg and required the use of a mechanical lift for transfer with the assistance of two facility nursing staff members. - CNA care plan, received 09/29/15, stated Resident #5 was to be transferred by two facility staff members with the use of a mechanical lift machine. On 10/01/15 at 9:10 a.m., Surveyor observed CNA J and CNA P transfer Resident #5 into the bathroom using a mechanical sit to stand. After Resident #5 was done using the toilet, CNA P assisted Resident #5 into a standing position with the sit to stand and then took him over to his bed where she then lowered him onto the bed. CNA J stayed in the bathroom to wash her hands. Surveyor asked the CNAs how Resident #5 was to be transferred and both responded the resident was a two assist and felt that both of them should have stayed with the resident while removing him from the bathroom and placing him down on the bed. On 10/01/15, Surveyor interviewed the DON in regard to the above noted observation and discussed concerns with both staff members not transferring Resident #5 safely to his bed and not following the current plan of care. The DON agreed with this surveyor's concern. 3. Resident #1 has [DIAGNOSES REDACTED]. The MDS, dated [DATE], identifies Resident #1 has severe cognitive impairment, and needs extensive assistance of two for transfers. The MDS identifies one stage III ulcer, that is not healed. The care plan titled, Has pressure ulcer related to disease process [MEDICAL CONDITIONS], history of ulcers- left heel ulcer, revised 09/10/15. Goal: Pressure ulcer will show signs of healing and remain free from infection, target dated 12/16/15. Interventions: Assess/record/monitor wound healing weekly and PRN (as needed) .report improvements and declines to MD, Keep heels off of bed float heels in bed, dated 05/21/14 needs bed cradle to keep bedding off of feet to protect the skin while in bed, 09/10/15. Podus boot on left foot at all times, keep loose, 09/11/15. On 09/30/15 at 7:05 a.m., Surveyor observed Resident #1 without the podus boot on, lying in bed. The heels were not floated, but in direct contact with the mattress. The observation ended at 7:40 a.m. On 09/30/15 at 1:22 p.m., Surveyor observed personal cares provided to Resident #1 by CNA J. The podus boot was not put on when Resident #1 was put to bed. The heels were not offloaded. On 09/30/15 at 2:25 p.m., Surveyor went into Resident #1's room to speak to a family member, who pulled up the blankets to show Surveyor the boot was not on and the heels were not floated on pillows. On 09/30/15 at 3:20 p.m., Surveyor had CNA K go into Resident #1's room to check his heels. There was a pillow between the legs of Resident #1, not floating the heels. The podus boot was not on. On 10/01/15 at 6:50 a.m., Surveyor observed Resident #1 in bed lying on his right side, and had CNA B come in the room to check his feet. Resident #1 did not have his right heel floated 4. Resident #3 MDS, dated [DATE], documents the resident is frequently incontinent. The Brief Interview for Mental Status (BIMS) score is 12, meaning cognitive impairment. Resident #3 needs assist of two for pivot transfers. The care plan titled, Potential for bladder incontinence r/t change (decline) in mobility, need for assist .last revised 10/27/14 .Interventions in part: Scheduled toiletiing A 2 on rising, before and after meals . On 09/29/15 at 12:55 p.m., after lunch, CNA J and CNA U assisted Resident #3 to lie down. Resident #3 was not toileted as directed by the care plan, but was put into bed and then provided peri-care. Resident #3's care plan titled, Nutritional risk r/t DM (Diabetes), recent hospitalization , confusion, abnormal labs, weight loss .needs assist with eating, revised 09/21/15. The self care deficit care plan, has the interventions: Eating: assistive device-requires plastic, light weight glass. Use straw cut in half to drink liquids. Eating is able to eat independently. On 09/29/15 at 12:10 p.m., Surveyor observed Resident #3 eating lunch; Resident #3 had orange juice and water with regular straws. On 09/30/15 at 8:10 a.m., Surveyor observed Resident #3 eating breakfast. The cup of orange juice and milk had a full straw. CNA B was assisting Resident #3 at 8:15 a.m.; CNA B left Resident #3 at 8:25 a.m. Resident #3 continued to try to drink from her cups, that had only a third of liquid in the bottom, Resident #3 picked up the cup and tried to maneuver the straw, as it kept moving around. Resident #3 was not able to get the liquids out of the bottom of the cup. The observation continued until 8:35 a.m., with no assistance for Resident #3. On 10/05/15 at 10:05 a.m., Surveyor interviewed Dietary Manager (DM) C about the care plan interventions. DM C indicated the care plan should be followed. 5. On 10/01/15 at 8:00 a.m., Surveyor reviewed Resident #9's medical record and comprehensive care plan. The MDS, dated [DATE], documents a score of 4 on the BIMS, indicating Resident #9 has severe cognitive impairment. The MDS documents the resident needs supervision and one person physical assist with eating. The comprehensive care plan for ADL (activities of daily living) self-care performance deficit for eating interventions states, A1 (assist of one) staff participation to eat as he'll allow - reapproach as indicated. On 09/30/15 at approximately 8:15 a.m., Surveyor observed Resident #9 eating alone at the dining table. There was no staff assisting the resident. Resident #9 spilled the food that was on his plate onto the table. Resident #9 ate his food off the tablecloth, scraping it up with his fork. Staff did not intervene or assist the resident. The observation continued until 8:40 a.m. On 10/05/15 at 10:00 a.m., Surveyor interviewed the DON and asked where on the CNA care plan it indicates to assist Resident #9 with eating. DON said that Resident #9 sits at an assist table; the CNAs know to assist those residents. Surveyor discussed the above observation of Resident #9 eating food off the table and no assistance was offered. DON told Surveyor that she would expect the CNAs to assist if resident allowed.

Based on observation, record review and interview, the facility did not provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for: - 11 of 11 residents who are diabetic and did not have their insulin stored at the appropriate temperature - 3 of 4 residents (Resident #14, #15 and #1) reviewed for self-administration of medications - 1 of 12 residents (Resident #5) reviewed for accurate and complete medication administration record (MAR) 1. The facility has 11 diabetics within the facility who require insulin to be stored in the medication refrigerator where temperatures are not being recorded appropriately according to facility policy and the medication refrigerator was unclean. 2. Resident #14 and #15 were observed to take their own medication with no self-administration assessment and were deemed unsafe to take medications by themselves by the facility. 3. Resident #1's fiberlax was left at his table, after the Registered Nurse gave the medication. Resident #1 did not finish the medication. 4. Resident #5's MAR was not accurate due to staff not signing off when medications and treatments were to be given. As evidenced by: MEDICATION REFRIGERATOR TEMPERATURES Facility policy titled, Storage and Expiration of Medications, Biological, Syringes and Needles, dated 01/01/13, states, 11. Facility should ensure that medications and biological's are stored at their appropriate temperatures according to the United States Pharmacopoeia guidelines for temperature ranges. Facility staff should monitor the temperature .twice a day. 11.2 Refrigeration: 36 degrees - 46 degrees F. On 10/05/15 at 10:25 a.m., Surveyor entered the facility's medication room with Licensed Practical Nurse (LPN) S. Surveyor noted a sign on the medication refrigerator which stated, Fridge temps are to be monitored and documented every AM and NOC shift. Surveyor opened the medication refrigeration and noted several insulin pens to be stored in it. Surveyor asked LPN S if she would show her the temperature log for the medication refrigeration. LPN S provided temperature logs for September 2015 and October 2015. Surveyor noted that out of 30 days in September, the facility did not record refrigerator temperatures for two morning shifts. Surveyor also noted that two days out of September were recorded at 47 degrees, which is above the required temperature. Surveyor noted that out of five days recorded in October, the facility did not record temperatures for three afternoon shifts. Surveyor asked LPN S why there were holes in the medication refrigerator logs and LPN S stated there should not be any holes and it appears that some shifts are not checking the temperature of the refrigeration. On 10/05/15, Surveyor received a list of all residents within the facility who are diabetic and receive insulin which is stored the medication refrigerator. Surveyor noted 11 residents had insulin which is stored in the medication refrigerator. On 10/05/15 at 10:50 a.m., Surveyor interviewed the Nursing Home Administrator (NHA) in regard to the above noted observation. The NHA stated the nursing staff were to follow facility policy and would check into the situation. UNCLEAN MEDICATION REFRIGERATOR/OPEN AND UNDATED FOOD ITEMS On 10/05/15 at 10:25 a.m., Surveyor entered the facility's medication room with LPN S. Surveyor opened the medication refrigerator and noted several insulin pens to be stored in it, along with opened and unopened liquid supplements. Surveyor noted the bottom of the refrigerator to have a sticky orange layer on the bottom. Surveyor asked LPN S if the refrigerator needed to be cleaned and LPN S said yes. Surveyor noted two opened 16 fluid ounce containers of Chocolate Protein Energy Shakes, which did not contain an opened date. One container had approximately a fourth liquid in the container and the other was approximately half full. Surveyor asked LPN S if an open date should be on the container and LPN S stated yes and agreed with Surveyor that no date had been entered onto the open containers. On 10/05/15 at approximately 10:30 a.m., Surveyor interviewed LPN B in regard to the opened and undated chocolate protein energy shakes. LPN B stated nursing staff should have dated them when they opened them and that was the facility's policy. LPN B then took both above noted opened and undated containers and wrote down today's date on them. Surveyor asked LPN B what she was doing and LPN B stated, I'm putting today's date on them .they must have come from the kitchen today. LPN B had no way to verify when the containers were opened. On 10/05/15 at 10:50 a.m., Surveyor discussed concerns with the unclean refrigerator and the opened and undated food items with the NHA. SELF-ADMINISTRATION On 09/30/15 at 7:15 a.m., Surveyor observed Registered Nurse (RN) O administer medication during the routine medication administration task. At 7:35 a.m., Surveyor observed RN O administer the following medications at the nurses' cart in the hallway for Resident #14: - Aspirin 81 mg tablet - Calcium with vitamin D tablet - Citalopram 40 mg tablet - Colace stool softner two tabs - Metoprolol 50 mg tablet - One multivitamin tablet - Prilosec 20 mg tablet - Klor-Con 10 meq tablet - B-6 100 mg tablet - Valsartan-HCTZ 320/25 mg tablet - Meclizine 25 mg tablet - Lasix 20 mg tablet - Lyrica 50 mg capsule Surveyor noted RN O to enter Resident #14's room with a cup full of the above noted medications and place them on the bedside table next to the bed. Resident #14 was sitting on the edge of the bed. RN O then left the room and signed off in the MAR that all medications had been taken by Resident #14. RN O then proceeded to pass medications to other residents. Surveyor stayed with RN O until 8:05 at which time Surveyor returned to Resident #14's room. No cup of pills was seen at this time. Surveyor was unable to see an empty pill cup in the garbage can, which was located next to the bed. Surveyor was unable to identify if Resident #14 took her medications. At 7:50 a.m., Surveyor observed RN O prepare medications for Resident #15 while she was in the hallway and noted Resident #15 to be sitting in her wheelchair. Surveyor observed RN O prepare Miralax 17 grams into a clear plastic cup and then mix it with water. RN O then handed the Miralax liquid to Resident #15. Resident #15 took a small drink and then a facility staff member pushed Resident #15 in her wheelchair to the dining room which was located outside of the view of RN O. Surveyor noted RN O to sign off in the MAR that Resident #15 had taken the miralax. Surveyor stayed with RN O until 8:05 a.m. At approximately 8:08 a.m., Surveyor went into the dining room and was unable to find a clear plastic cup in front of Resident #14 who was now sitting at a table along with three other residents. Surveyor was unable to determine if Resident #14 had taken her medication. On 09/30/15 at 8:25 a.m., Surveyor interviewed the Director of Nursing (DON) in regard to the above noted observations. Surveyor asked the DON if Resident #14 and #15 had a self-administration assessment and were safe to take medication on their own. The DON stated that both Resident #14 and #15 were not safe to take medications on their own and did not have a self-administration of medication assessment. On 09/30/15, the DON approached Surveyor and stated she had educated RN O in regard to ensuring that medication is given by the nurse, she is to observe the residents take the entire medication and should not walk away when the resident is unsafe to take their own medication. Resident #3's MDS, dated [DATE], documents he has severe cognitive impairment. The physician orders [REDACTED].>Fiberlax powder 1 tablespoon in liquid and give by mouth twice daily for constipation, 09/22/14 On 09/30/15 at 8:37 a.m., Surveyor observed RN O give Resident #1 a plastic cup with orange liquid and walked away. Surveyor observed the cup sitting on the table. Resident #3 had about two inches of liquid remaining in the cup. At 8:43 a.m., the cup was still on the table with the same amount, Surveyor moved closer to see that the substance had thickened and was solid in the bottom of the cup. The observation continued until 8:55 a.m. At this time, Dietary Aide (DA) V cleared the table and threw the cup containing the medication into the garbage. On 10/01/15 at 2:00 p.m., Surveyor shared the observation with the DON, who acknowledged that Resident #1 cannot self administer medications. On 10/05/15 at 8:10 a.m., Surveyor interviewed RN O about the contents of the cup that was left with the resident. RN O stated, It was his fiberlax, that turns orange. I thought it was an over the counter medication so I could leave it. Missing documentation: On 09/30/15, Surveyor reviewed the September 2015 MAR and Treatment Administration Record (TAR) for Resident #5 and noted the following: SEPTEMBER: - Staff to monitor for s/s of dehydration twice daily was not signed off as completed for five times out of 30 days. - Lactulose 10 gm/15 ml solution to be given for liver disease was not signed off as given four times out of 30 days. - Omeprazole 20 mg was not signed off as given two times out of 30 days. - Bactrim DS antibiotic, which was to be given for ten days, starting 09/18/15 and ending 09/28/15, was not signed off as given for two times out of ten days. - Lantus Insulin six units to be injected subcutaneous at bedtimes was not signed off as given for two times out of 30 days. - Staff to provide pain rating was not signed off as completed for three times out of 30 days. - Wear sensifoot stocking 24/7 and Praffo boot 24/7 was not signed off as completed for five times out of 14 days. - V-shaped skin tear R (right) dorsal hand (1.0x1.0) approximated and covered with opsite. Will change as needed and monitor for infection daily until healed was not signed off as completed for one time out of 15 days. - Skin tear Right posterior forearm close to wrist .Monitor for infection daily until healed, was not signed off as completed for one time out of six days required. - Posterior L (left) heel and R (right) stump; cleanse wounds with cleaner and cover sponge. Apply skin prep to surrounding skin, was not signed off as completed four out of eight times. - M(Monday)-W(Wednesday)-F(Friday) wound care: toes and right AKA stump. 1. Cleanse, 2. Aloe vesta to toes, knees stump and cover mepiliex, was not completed four out of eight times. On 09/30/15 at approximately 4:00 p.m., Surveyor interviewed the NHA and the DON in regard to Resident #5's MARs and TARs not being signed off as completed, which indicated the medication or treatment was not provided to the resident. The DON agreed with Surveyor by stating the nursing staff should be signing off on all medication and treatments provided to the resident and if not signed off, then it wasn't given. No medication or treatment error reports were provided to Surveyor .

Based on interview and record review, the facility did not ensure the care plans were reviewed and revised for two of ten residents' care plans, which were reviewed. 1. Resident #2's care plan was not updated to identify the current location of a wander alert device on the resident's wheelchair. The care plan was not updated to identify the resident's spouse gives the resident food, not consistent with the therapeutic diet, or that the resident needs supervision when the spouse is present during meals. 2. Resident #9's [MEDICATION NAME] had been discontinued and was still on the care plan. This is evidenced by: 1. On 09/30/15 at 7:40 a.m., Surveyor reviewed Resident #2's medical record. The resident has [DIAGNOSES REDACTED]. Resident #2's most recent Brief Interview for Mental Status (BIMS) score, dated 07/19/15, was a 07 out of 15 possible points. According to the BIMS assessment, a score of 07 indicates the resident has severe cognitive impairment. Surveyor reviewed Resident #2's nurses' notes, from 06/29/15 to 09/22/15. The notes state the following, in part: -07/20/15: .Describe focus area: safety .Resident's wife was giving him thin water from a water bottle after supper while they watched tv. When reminded he cannot have thin water because he may aspirated (sic--i.e. swallowing and/or breathing liquids into the airways)-she made a face and said I know and put it away. (Resident) Did cough for awhile after she put it away. -09/21/15: .Describe focus area: diet .Wife giving resident hard baby carrots . -09/21/15: Res (Resident) table moved to area close to CNAs (Certified Nursing Assistants) to be supervised. Surveyor reviewed the resident's comprehensive care plan. The care plan states the following, in part: Focus: Swallowing problem r/t Coughing or choking during meals or swallowing med (medication) .Date Initiated: 04/21/2015 . Interventions .Serve diet as prescribed/Dysphasia 3 with nectar thick liquids (A level 3 national dysphagia diet includes moist foods, in bite-size pieces. Food which is hard, sticky, crunchy, or very dry should be avoided). Date Initiated: 04/21/2015 . Focus: At risk for elopement r/t (related to) Impaired cognition, Independently mobile. Date Initiated: 06/05/2015 . Interventions .WANDER ALERT: Left wrist-code alert bracelet. Date Initiated: 06/04/2015 . The care plan does not identify Resident #2's spouse provides the resident foods not consistent with the ordered therapeutic diet, as well as the potential risks. The care plan does not identify Resident #2 requires staff supervision, when the spouse is present during meals. These interventions were stated in the nurses' notes. On 09/30/15 at 8:34 a.m., Surveyor observed the breakfast meal in the main dining room. Resident #2 was sitting in a wheelchair, at a dining room table which is close to the CNA assisted tables. Surveyor observed a wander alert device, attached to the back of Resident #2's wheelchair. There was no device on the resident's left wrist. At 8:43 a.m., Surveyor interviewed CNA J, who indicated Resident #2 no longer wears the wander alert device on the wrist, since the device is now tied to the back of the resident's wheelchair. At approximately 3:05 p.m., Surveyor discussed the above nurses' notes, and resident's diet, with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). Surveyor was present at this time. The NHA indicated Resident #2's spouse has cognitive deficits, and does not remember the resident is on a therapeutic diet with thickened liquids. The DON indicated the resident's care plan will be updated, to identify the resident needs staff supervision when the spouse visits, and the potential for Resident #2 to eat foods provided by his spouse, not consistent with the therapeutic diet. Surveyor discussed the above observation regarding Resident #2's wander alert device placement. The NHA indicated this should be updated on the resident's care plan. 2. On 10/01/15 at 8:00 a.m., Surveyor reviewed Resident #9's medical record and comprehensive care plan. A physician fax sheet, dated 09/24/15, identifies: [MEDICATION NAME] ([MEDICATION NAME] is for appetite) - causing over sedation feel need alternative for medication. Orders on the fax sheet were to discontinue the [MEDICATION NAME]. This information was faxed to pharmacy on 09/25/15. The comprehensive care plan, revision date 08/11/15, for nutrition risk or potential nutrition risk, includes, in part: intervention to administer multi-vitamin with minerals, vitamin D3, folic acid, [MEDICATION NAME] and other medications as ordered. On 10/05/15 at 9:25 a.m., Surveyor interviewed Registered Nurse (RN) D who is the MDS Coordinator. RN D said that sometimes she updates care plans. RN D said both dietary and nursing staff can update care plans. Surveyor reviewed Resident #9's comprehensive care plans with RN D, which included the intervention to administer [MEDICATION NAME] and physician order [REDACTED].

Based on record review and interview, the facility did not ensure 1 of 9 residents (Resident #5) reviewed for incontinence received the necessary assistance for toileting needs. As evidenced by: On 09/29/15 at 12:25 p.m., Surveyor reviewed the medical record for Resident #5 and noted the following: - Minimum Data Set (MDS), dated [DATE], stated Resident #5 was continent of bowel and was alert and oriented. - MDS, dated [DATE], stated Resident #5 was frequently incontinent of bowel and was alert and oriented. MDS states Resident #5 has a Stage II and Stage III pressure ulcer. - Resident #5 was admitted to the facility on [DATE], is his own person and is able to make his own decisions. Resident #5 has a [DIAGNOSES REDACTED]. - Certified Nursing Assistant (CNA) care plan, received 09/29/15, states Resident #5 is to be offered toileting before and after meals, at night and as needed and requires the assistance of two staff members due to needing to be transferred by a mechanical lift and having a right above the knee amputation. - Comprehensive nursing care plan, received 09/29/15, states Resident #5 is to be allowed time and privacy to evacuate bowels and staff are to follow facility protocol for bowel management, which both are dated 07/30/15. Surveyor was unable to identify new interventions to assist in maintaining bowel function for Resident #5 after 07/30/15 when the above noted MDS, dated [DATE], indicated a decline of bowel function. On 10/05/15 at 12:50 p.m., Surveyor reviewed the facility bowel movement report for Resident #5 from 09/04/15 - 10/04/15 and noted the following: - Resident #5 was continent of bowel 51 out of 51 times charted during the daytime hours. - Resident #5 was incontinent of bowel 14 times out of 44 times charted during the evening hours. On 10/01/15, Surveyor reviewed the nurses' notes for Resident #5 from 07/14/15 - 10/01/15 and noted that Resident #5 developed a stage II pressure ulcer to his coccyx on 09/14/15, which was later staged by the wound clinic to be stage III on 09/17/15. During this time frame, Resident #5 was incontinent of bowel during the evening hours one time on 09/14/15, three times on 09/16/15 and two times on 09/18/15. On 10/01/15 at 9:25 a.m., Surveyor interviewed Resident #5 in his room. Resident #5 stated he is incontinent of bowel sometimes at night due to the facility not having enough staff. Resident #5 stated the facility only has two CNAs at night along with a nurse and because of some of the other residents requiring assistance from the staff, he often times has to wait for a long time after putting his call light on. Resident #5 stated, There isn't enough staff .only two aides (CNAs) and one nurse .I have been occasionally incontinent due to waiting .this makes me embarrassed and I don't like it. It makes me feel bad when I am incontinent and it seems to happen a lot. On 10/05/15 at approximately 12:50 p.m., Surveyor interviewed the Director of Nursing and the Nursing Home Administrator (NHA) in regard to the above noted concern. Surveyor discussed concerns of Resident #5 having to wait to be toileted and then becoming incontinent. Surveyor also discussed concerns with Resident #5 developing a stage III pressure ulcer on the coccyx, and being incontinent of stool that could aid in further skin breakdown and infection. The NHA stated she would immediately look into the situation. The log documenting call light wait times was requested. No further information provided to Surveyor .

Based on observation, interviews and record review, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 12 residents (Resident #3) reviewed for pain and for 1 of 12 residents reviewed with [MEDICAL CONDITION] and unmet psychosocial needs. Resident #3 had recently been hospitalized for [REDACTED]. A new jejunal tube was placed after [MEDICATION NAME] and opening up the dehisced area. She returned to the facility on [DATE]. The facility did not reassess the resident's pain after complications with the tube feeding started excoriating Resident #3's skin and did not medicate to effectively alleviate pain during the wound care. Resident #1 was admitted on [DATE] with recent hospitalization s for exacerbations with [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. The facility did not assess for signs and symptoms of [MEDICAL CONDITION] or [MEDICAL CONDITION] to prevent complications. Resident #1's experiences anxiety related to be alone in her room. The facility did not address or care plan for her anxiety. This is evidenced by: 1. Resident #3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident as severely impaired by staff assessment, on the Brief Interview for Mental Status (BIMS) assessment. Resident #8 is non verbal as a result of her [MEDICAL CONDITION]. The MDS shows she is dependent on staff for all activities of daily living. The Pain Management care plan dated 05/08/12 has the following interventions including but not limited to: -Assess for verbal and non-verbal signs and symptoms of distress or pain unrelieved by ordered treatments/medications. -Use alternative methods of communication, hand squeeze, communication board -Report to provider signs and symptoms of distress or pain unrelieved by ordered treatments/medications. -Observe during rest and movement for pain -Identify precipitating factors of pain Resident #3 had several hospitalization s related to replacing the J-tube (jejunum). On 10/13/12 she had dehiscence (a surgical complication in which a wound breaks open along surgical suture) of the newest j-tube surgical site. She was sent by ambulance to the emergency department. She returned to the facility on [DATE] with a wound vac for the abdominal wound that had been debrided during her hospital stay, and a new j-tube site that was being used for her tube feedings. She had orders for Tylenol (liquid)1000 mg per tube bid (twice a day) and Prn (as needed twice a day), and [MEDICATION NAME] 50 mg every 6 hours as needed for pain. The "Pain Data Collection and Assessment form dated 10/23/12 documented under VERBAL/NON-VERBAL/Non-cognitive signs of pain: Check marks beside vocalizations: crying/whining, gasping/sighing Facial Expressions: grimaces, winces Non-verbal cues/Behaviors: Restlessness, agitation Resident current conditions: Post surgery. What interventions to relieve pain: scheduled Tylenol and prn [MEDICATION NAME]. Pain location/type/frequency: Acute pain, occasionally Appearance of pain site: Red/pink, warm, Swollen. SUMMARY: Resident tearful and restless after return to facility via ambulance. Scheduled pain meds given with good results. Resident slightly restless with repositioning. There are no other Pain assessments found in the medical record after 10/23/12. The nurses notes show she returned to the facility at 1:00 p.m.; the only pain medication given was the scheduled Tylenol 1000 mg in the p.m. (evening) The nurses notes were reviewed by Surveyor and state the following: 10/24/12 at 10:00 p.m. ... "Tearful with cares." -No prn pain meds given. 10/25/12 at 5:20 a.m...."Crying out at 4:45a.m. given [MEDICATION NAME] per prn... 5:30 a.m. resting quietly." 10/25/12 at 4:00 p.m...."Dressing change to feeding tube site x3, bile drainage moderate-large amounts-soaks gauze 4 x 4's, area excoriated, red, raw." -No prn pain med given after 4:45 a.m. 10/25/12 at 10:00 p.m....Daughter notified of resident condition. States she does not want resident hospitalized ...daughter okay with MD (Medical Doctor) ordering meds to keep resident comfortable." 10/26/12 at 5:00 a.m...."No crying during cares, but does look uncomfortable.." 10/26/12 at 12:30 p.m...."Dressing change done x3 to peg site-...Wound vac change done today" -No prn meds given today. 10/27/12 at 4:15 p.m...."excoriated circular area above rectal area around cheeks of buttocks-...daughter has stated on phone if needs something stronger for pain control get order from MD." -Resident #3 had [MEDICATION NAME] 50 mg at 9:30 a.m. No effectiveness of the medication is documented. 10/28/12 6:00 a.m..."resident weepy given [MEDICATION NAME] per prn order at 12:45a.m., was effective." 10/28/12 10:30 a.m..."Dressing change opsite to excoriated, raw area- around j-tube..." 10/28/12 1:00 p.m..."Orders [MEDICATION NAME] orders to pharmacy...wound vac changed...as seal not good r/t (related to incisional wound and j-tube leakage - site excoriation close together...spoke with MD surgeon, reviewed wound cares, bile very toxic per MD, bile secretions need digestion...Orders recd (received)[MEDICATION NAME] orders to pharmacy..." - The prn [MEDICATION NAME] was given at 12:45 a.m. and 7:30 a.m. today. There is no pain intensity or effectiveness charted for the second dose. 10/29/12 6:00 a.m. ..."dressing changed x 2 during shift. Resident weeping during cares." -[MEDICATION NAME] 50 mg given at 9:30 a.m. on 10/29. There is no pain location, pain intensity or effectiveness of the [MEDICATION NAME] documented. 10/30/12 5:30 a.m..."Resident crying given Tylenol supp and [MEDICATION NAME] ([MEDICATION NAME]) rectally at 1:45 a.m., was effective..." 10/30/12 4:00 p.m..."Wound vac dressing changed by DON (Director of Nursing)...Premedicated with [MEDICATION NAME] 10 mg at 1:15 p.m. Resident crying continually during procedure...Prn [MEDICATION NAME] given at 2:00 p.m." 10/30/12 8:00p.m...."Resident crying most of shift, especially during cares, prn [MEDICATION NAME] and Tylenol suppository given..." - No effectiveness of the [MEDICATION NAME] or prn Tylenol is documented. -[MEDICATION NAME] given at 7:00 p.m. per the tube, no pain location, pain intensity or effectiveness documented. 10/31/12 10:00p.m..."[MEDICATION NAME] 10 mg given after resident returned from appointment with Doctor...appeared effective..." There is no pain location or pain intensity documented. On 10/30/12 Surveyor observed Resident #3 at 10:38 a.m. with RN E. RN E lifted up the sheet to show the drainage from the j-tube was through 4- 4 x 4's, and soaked one-third of a hand towel with the green yellow thick drainage. RN A removed the soaked 4 x 4's and the towel. The drainage was under the opsite that was in place. The visible red excoriated area on the abdomen was very large. Surveyor requested a measurement of the area. When RN E asked how long the area had looked like that, she stated she was not sure because Resident had been in the hospital. RN E replaced the 4 x 4's over the tube site, leaving the rest of the dressing intact. At 12:25 p.m. Surveyor approached RN E again and asked about further dressing changes for the red area. She said there were no new orders, "we have [MEDICATION NAME] in the area around the ostomy site, we use skin prep spray before we put the opsite on." She gave Surveyor the measurements of 13 centimeters x 13 centimeters for the excoriated area. At 1:45 p.m. Surveyor went into Resident #3's room where the DON (Director of Nursing) and RN B had started the dressing change. The opsite was already off the excoriated area, it was open to air. The DON was applying [MEDICATION NAME] to the excoriated area, Resident #3 was crying, wincing and moaning. Resident #3 raised up her left arm and was clenching her fingers together. The DON proceeded with the wound care, cutting more pieces of the [MEDICATION NAME] to fit around the j-tube site as Resident #3 winced and groaned. As the DON applied her hand to the [MEDICATION NAME] to help adherence, Resident #3 became more vocal. Resident had been medicated with [MEDICATION NAME] 10 mg at 1:15 p.m. The peak of the [MEDICATION NAME] would be expected at about one hour. This was the first dose of [MEDICATION NAME] Resident #3 had been given since the order was obtained on 10/28/12. At 1:55 p.m. RN E said, "Maybe I should fax the MD for more pain medication, she has an hour to go before she can have more." At 1:57 p.m. Resident #3 starts crying out again, the dressing change was stopped while RN E held her hand, and gave her a stuffed animal to hold. At 2:00 p.m. RN E said she would go see if the Resident could have anything else. The DON went to get a tissue, came back and asked Resident #3, "Can I wipe your tear?" and then did so. At 2:05 p.m. RN E came and gave Resident #3 [MEDICATION NAME] 50 mg per the tube. At 2:15 p.m. they proceeded with the rest of the wound vac dressing change, to the surgical wound, there were no more observations of pain with this part of the wound care. On 10/31/12 at 10:45 a.m. Surveyor observed positioning of Resident #3 by RN E and CNA B. Resident #3's head of the bed was elevated greater than 80 degrees, there is a sign posted at the head of the bed that says, "Head of Bed elevated at 30 degrees at all times" CNA B was on the left side of the bed and used the lift sheet to pull Resident #3 towards her, Resident #3 was moaning during the repositioning. RN E removed the Allevyn from the Left buttock stage 2 ulcer, saying "Resident #3 doesn't like this so I will be careful." Resident #3 moaned when dressing removed. RN E removed the allevyn from wound on coccyx (stage 2), again Resident #3 moaned. Surveyor interviewed CNA B on 10/31/12 at 10:55 a.m. and asked about what Resident #3's usual response is to repositioning. CNA B state, "She cries out with cares and repositioning." When asked if CNA B thinks it is because of pain, she stated, "Yes." Surveyor interviewed CNA C at 11:05 a.m. on 10/31/12 about cares with Resident #3, CNA C states, "She has not been getting up much since she came back from the hospital, Resident #3 is in a lot of pain. When we touch her she starts crying." Surveyor asked if that is reported to the nurse. CNA C said, "Sometimes." Surveyor at 1:00 p.m. went and checked the Medication Administration Record, [REDACTED]. Surveyor then asked RN E where else one would find the pain meds that had been given, she stated "the narcotic book." Surveyor looked in the narcotic book, no meds were signed out since yesterday 10/30/12 at 7:00p.m. Surveyor reviewed the MAR indicated [REDACTED]. On 11/01/12 Surveyor received the facility's policy/procedure, "Pain Management" dated as revised July 2012 which states, "All residents are initially screened for pain upon admission, quarterly, with a significant change in condition that may cause an onset or increase in pain and any time it is suspect a resident is in pain..." Residents are also screened for pain regularly through observing the resident during daily care and/or observing for signs and symptoms of pain. PROCEDURE: 10. Record an administered scheduled and/or Prn (as needed) [MEDICATION NAME]. Include data regarding resident pain intensity, intervention and effectiveness of interventions to manage pain on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 15. Evaluate and document effectiveness of pain management interventions on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 16. Notify provider if interventions are not effective in achieving resident comfort and/or function goals within 24 hours. 17. Reassess resident status as indicated... -Level of pain relief -side effect management -effectiveness of interventions -Need for increasing/decreasing amount of mediation due to tolerance or side effects. Surveyor interviewed the DON on 10/31/12 at 9:20 a.m. about the indwelling catheter use for Resident #3. The DON stated, "It is because of her pressure ulcers and because of the pain with positioning that she needs to have it." She also informed Surveyor that Resident #3 was going out to see the wound physician today at around 12:30 p.m. Surveyor interviwed the DON after more observations informing her of the concerns with pain. When asked if she thought Resident #3 had pain during the wound care on 10/30/12 she stated, "Yes, it was painful, she had the [MEDICATION NAME] at 1:15 p.m." Did that seem effective to you? The DON stated, "No, but it took longer than we thought because the wound vac representative had been here first, and then you were there watching us. Resident #3 has similar reactions to a lot of things from her [MEDICAL CONDITION], for example if you try to put ointment in her nares where the oxygen tubing is she pulls back. Resident #3 has a history of crying out due to depression. Her [MEDICATION NAME] was just recently discontinued on 10/24/12 that may be a factor." Surveyor asked about the appointment today with the wound doctor. Surveyor asked if they would be doing the dressing change at the appointment? DON stated, "Yes, that is why she is going is to have it reevaluated." Surveyor asked if she knew what pain meds she had before going on the ride to the appointment and prior to the procedure? The DON stated, "NO." Surveyor informed her no other meds had been given other than the scheduled Tylenol this morning. The DON stated she was not aware of that. During the exit conference on 11/01/12, no further information was provided by the facility. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set ((MDS) dated [DATE] has the Brief Interview for Mental Status at a score of 14, meaning she is alert and oriented and able to answer questions appropriately most of the time. Resident #1 scores of 2 for mood, showing on 10/05/12 she was not showing any symptoms with trouble falling or staying asleep. Resident #1 has no behavior symptoms marked on the 10/05/12 MDS assessment, such as verbal/vocal symptoms like screaming , disruptive sounds. There is nothing marked in the rejection of care area, where it asks if the resident rejects evaluation or care that is necessary to achieve the resident's goals for health and well being. Her functional status indicates she needs assist of 2 for transfers and bed mobility. The care plan titled Cardiovascular/Circulatory: Plan of Care dated 07/11/12 has: Potential for alteration in circulation R/T [MEDICAL CONDITION](hypertension), [MEDICAL CONDITION] Goal:Will be free from sign/symptoms of increased SOB, dyspnea, chest pain, or other sign/symptoms of cardiac distress daily. Interventions dated 10/13 include but are not limited to: -meds/tx as ordered -update physician /family as needed -labs as ordered -monitor for signs/symptoms of [MEDICAL CONDITION] -lung sounds prn (as needed) The American Medical Directors Association (AMDA) Clinical Practice Guideline for Heart Failure in the Long-Term Care Setting includes the signs that suggest heart failure...[MEDICAL CONDITION], rales on lung exam, [MEDICAL CONDITION] ... and weight gain. It continues with monitoring for [MEDICAL CONDITION]: "Ongoing monitoring of the patient's condition and response to treatment is imperative. Assess fluid volume status by monitoring weight at least three times per week (more frequently if the patient's condition is unstable), Weight gain in a known heart failure patient is an important 'clue' the patient may be going into heart failure. The practitioner should specify the weight change at which he or she should be notified (generally 3-5 pounds.)" The nurses notes were reviewed and state the following: 10/05/12 at 3:30 a.m. "Resident observed to have large amount of grayish colored sputum on side of mouth and neck. resident decreased responsiveness...spO2 (saturated percent oxygen) 70%, 911 called...ambulance arrived 3:00 a.m. and left with resident at 3:20 a.m." 10/08/12 at 1:45 p.m. Resident returned from BAMC (Baldwin Area Medical Center). The Nursing comprehensive Admission data collection and Assessment was completed showing: [MEDICAL CONDITION] ankles and feet are both marked as zero [MEDICAL CONDITION]. Breath sounds is not filled out O2(oxygen) Saturation is 90% The readmission orders [REDACTED]. On 10/11/12 is the next documentation for any signs and symptom of [MEDICAL CONDITION] with an O2 Sat of 94% On 10/16/12 8:30 a.m., "Resident out to neuro appointment. at 11:30 a.m...call from SCF- admitted -..." Upon review of the medical record from 10/08/12 to present the assessment of lung sounds or [MEDICAL CONDITION] was not done to assess for [MEDICAL CONDITION] from 10/11/12 -10/16/12 despite the fact that the resident had returned from the hospital on [DATE] without an order for [REDACTED]. Resident #1 returned to the facility on [DATE] with discharge [DIAGNOSES REDACTED]. Exacerbation of [MEDICAL CONDITION] 2. Chronic bilateral lower extremity weakness 3. Chronic venous stasis and [MEDICAL CONDITION], present on admission. 4. [MEDICAL CONDITION] 5. [MEDICAL CONDITION] present on admission. Nursing note on 10/23/12 states, "resident returned to facility... O2 sat 96%" On 10/23/12 at 3:00 p.m. the Nursing Comprehensive Admission Data collection and Assessment was completed. It shows under [MEDICAL CONDITION]: Ankles nothing marked, feet Right tr (trace) Left tr (trace), Breath sounds Clear, Wheezes right and left. On 10/24/12 "O2 sat is 96 % RA (room air)" 10/25/12 at 10:30 a.m. "Sats 95%" On 10/28/12 at 3:15 a.m. " Resident up in w/c (wheelchair) since start of shift, c/o restless legs...4-5 + [MEDICAL CONDITION], enc (encouraged) to lay down to elevate legs. resident refused." On 10/29/12 at 5:00 a.m..."Resident starting yelling/screaming "RLS I can not, RLS." Resident legs were cold with +4 [MEDICAL CONDITION]. Resident refusing to have legs propped on pillows..." 10/29/12 at 10:15 a.m... "Continue 4+ [MEDICAL CONDITION] and refuses to lay down and elevate legs..." At 10:00 p.m..."+4 [MEDICAL CONDITION] in LE (lower extremity) resident assisted to bed to elevate extremities. resident extremely restless at 10:00 p.m. Calling out and swearing..." 10/30/12 3:30 a.m..."O2 sat 93%... Up in recliner in dayroom refused to go to bed. Legs elevated in wheelchair 4+ [MEDICAL CONDITION]" 10/31/12 2:30 a.m..."O2 sat 92 % RA... 4+ [MEDICAL CONDITION] remains to BLE (both lower extremities)" No assessment was done for lungs and [MEDICAL CONDITION] on 10/24 and 10/25/12. No nursing documentation is found for 10/26 and 10/27/12. There was no assessment of lung sounds from 10/28/12 - 10/31/12 to assess for signs or symptoms of [MEDICAL CONDITION]. The nursing documentation shows a trace of [MEDICAL CONDITION] on the readmitted [DATE] then +4 [MEDICAL CONDITION] noted on 10/28/12 with no new intervention put in place. The +4 [MEDICAL CONDITION] is documented every day until Surveyor 's observation of Resident #1 during the survey. On 10/31/2012 Surveyor observed Resident #1's legs to be very [MEDICAL CONDITION], they were dependent, very full of fluid and shiny on the lower 2/3 of the calves. The Left lower leg was bright red, with an indentation in the lateral calve that did not go away. Surveyor asked if Resident #1 would be alright with elevating her legs, she said, "Yes." Surveyor asked if anyone had ever talked to her about risks of skin problems with her legs on foot pedals and on hard surfaces. She said , "No, not until now." Surveyor asked if she could get a Certified Nursing Assistant (CNA) to help her with better positioning for her legs, Resident #1 said, "That would be alright." Surveyor could not find a CNA, but went to the DON at 2:00 p.m. to ask if she could find some help for Resident #1. The DON said there were no recliners available in the front lobby area and Resident #1 does not like to go to her room and get in her chair. The DON then elevated the right foot rest 12-14 inches, and went to find a footrest for the left side of the chair. The DON then elevated both legs about 14 inches and left Resident #1. Surveyor interviewed the DON in her office on 10/31/12 at 3:05 p.m. about the above concerns with the [MEDICAL CONDITION] and anxiety. The DON states the physician took her off of [MEDICATION NAME] a while ago and is reluctant to restart. Surveyor asked when the last time he was contacted about the [MEDICAL CONDITION], the DON states, "I am not sure, I will check into it." The DON says we try to reposition, but she refuses, we have tried to put shoes on but she will not accept. Surveyor shared her observation from cares this morning that the CNAs tried to put on her white tennis shoes, but they were too tight, so they had to put on the gray slippers. The DON does not know if she has other shoes available that will fit. Surveyor asked if the refusals are care planned and if she has been educated about the risks for her skin is she does not keep her heels protected and elevate her legs. The DON said she would look for documentation of the above, no documentation was provided to Surveyor . On 11/01/12 Surveyor and RN D went into Resident #1's room at 11:00 a.m. Resident #1 was sitting in her recliner with her feet elevated below the level of her heart. RN D examined her heels to measure the area on the right heel. She did not comment on the Left edemetous, very bright red lower left leg. Surveyor asked what was going on with the left leg. RN said it look like [MEDICAL CONDITION]. Surveyor had RN D go into an empty room to ask about standard of practice for [MEDICAL CONDITION]. RN D did not know of anything specific. She stated, "Normally we look back at old meds and compare. Resident #1 came back without [MEDICATION NAME] on 10/08/12, we should have caught that." When asked if there was a temporary care plan for the recent [MEDICAL CONDITION], she said she could not find one. RN D got the weight log for Resident #1 who was to be on daily weights. No weights are recorded on 10/27 and 10/28. Her weigh on 10/26/12 was 126.2. The next weight obtained was 10/29/12 with a weight of 131.7#, an increase of 5.5# Surveyor interviewed Resident #1 at 3:45 p.m. to ask if any symptoms of shortness of breath or chest pain had been noticed. Resident #1 said, "No." Surveyor also asked Resident #1 if she was having any pain in her left lower leg, Resident #1 stated, "Not really". 3. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set ((MDS) dated [DATE] has the Brief Interview for Mental Status at a score of 14, meaning she is alert and oriented and able to answer questions appropriately most of the time. The Care Area Assessment (CAA) summary has Psychosocial Well-Being care area triggered, with no check mark to proceed with care planning. The CAA has the following information checked under the CAA 07 Psychosocial Well-Being -Resident has conflicts with family, friends, roommate.. -was lifestyle more satisfactory to the resident prior to admission to the nursing home? -decline in activities of daily living -Health problems such as as falls, pain fatigue -Mood behavior problem that impacts interpersonal relationships -change in communication -change in residence leading to loss of autonomy and reduced self-esteem STRENGTHS- none of the above Care Plan? No is marked. Resident #1 had been hospitalized [DATE] and returned to the facility on [DATE]. She had an as needed order for [MEDICATION NAME] 0.5 mg every HS (hour of sleep) prior to this hospital stay. Her return orders did not include any orders for the [MEDICATION NAME]. Resident #1 scores a 2 for mood on the Minimum Data Set (MDS) showing on 10/05/12 she was not showing any symptoms with trouble falling or staying asleep. Resident #1 has no behavior symptoms marked on the 10/05/12 MDS assessment, such as verbal/vocal symptoms like screaming, disruptive sounds. There is nothing marked in the rejection of care area, where it asks if the resident rejects evaluation or care that is necessary to achieve the resident's goals for heath and well being. The social service progress note dated 10/11/12 states Resident #1 is on Trazadone for [MEDICAL CONDITION], and [MEDICATION NAME] for pain and depression. No other meds are listed for anxiety on the physician orders. The nurses notes were reviewed and contain the following information: On 10/15/12 at 3:30 a.m. "Resident refused to be put to bed until 3:30 a.m. Resident sitting in w/c by nurses station crying out for cigarette repeatedly. Sleeping on and off in w/c but refusing to go to bed." On 10/15/12 At 10:30 p.m., "Resident hollering out "AHH, restless legs" and moaning until 5:30 p.m., resident given [MEDICATION NAME] and trazadone with relief. Resident put to bed and continued to rest.." On 10/25/12 at 4:30 a.m. "...Yelling out early in shift c/o pain/ restless legs given oxy per prn order was effective..." On 10/28/12 at 3:15 a.m. "Resident up in w/c (wheelchair) since start of shift, c/o restless legs...4-5 + [MEDICAL CONDITION], enc to lay down to elevate legs. resident refused." 10/29/12 at 10:15 a.m... Continue 4+ [MEDICAL CONDITION] and refuses to lay down and elevate legs... 10/30/12 3:30 a.m...O2 sat 93%... Up in recliner in dayroom refused to go to bed. Legs elevated in wheelchair 4+ [MEDICAL CONDITION] Surveyor did a resident interview with Resident #1 on 10/31/12 at 1:50 p.m. When Surveyor asked about activities of daily living and if she is encouraged to do as much as she can, she stated, "I do as much as I can but it is harder all the time." When asked , Do you feel you get help when you need it? Resident #1 stated, "Sometimes I panic, I'm afraid they will not come." At this point Resident #1 started crying, tears rolling down her face. Surveyor asked if that had ever happened that no one had come when she needed help, she stated, "No, I am just afraid it will, I feel trapped when I am in my room with my restless leg problem." Resident #1 stopped crying after 1-2 minutes, Surveyor asked if she wanted to stop the interview, Resident #1 said, "No, it feels better to be able to talk about it." Surveyor interviewed the DON (Director of Nursing) and asked if the DON was aware of the anxiety and fear Resident #1 felt about being in her room alone. The DON stated, "It started after her last hospital stay, I think about 1 month ago. She does not want to go to her room or eat in the dining room." Surveyor asked if there was any care planning related to this, the DON said I will look. No care plan was provided. When asked what meds were being used to treat the anxiety, the DON said, "I don't think she is on anything other than the antidepressant." Surveyor asked if the DON feels this should be addressed, she stated, "Yes, this is real to her." Surveyor asked if the physician has been notified about the panic anxiety issue and how it is affecting her ability to elevate her legs since she does not want to go to her room. The DON said she would check, but she does not think so. The nurses notes on 10/31/12 at 6:00p.m. state, "Call placed to Westfields ER (emergency room ). ER nurse requesting fax be sent." 7:00 p.m.-"Fax back orders for [MEDICATION NAME] 20 mg po (by mouth) x 1, and [MEDICATION NAME] 0.5 mg po x 1" Surveyor was not provided a care plan for psychosocial needs for Resident #1. The above concerns were shared with the facility administration at the exit meeting on 11/01/12.

Based on interview, medical record review and policy review the facility did not provide assistance devices or supervision to prevent accidents for 1 of 10 residents reviewed for falls. Resident #2 fell from her wheelchair on 07/03/12 and sustained a nasal fracture and a right proximal index finger phalanx fracture. The Certified Nursing Assistants (CNAs) who had assisted Resident #2 up into her wheelchair that morning did not apply her alarmed seat belt as Resident #2's care plan directed. Each CNA thought the other had applied the seat belt. The facility identified the power was out at the facility the morning of 07/03/12 due to the weather and felt this played a large role in the incident, despite the Nursing Home Administrator (NHA) identifying the back up generator was working and the staff had access to many flashlights. This is evidenced by: The facility policy and procedure titled "Accidents and Incidents: Report, Investigation, Follow-up, and Final Disposition" dated 04/2012 read in part: Extendicare Health Services, Inc. (EHSI) strives to provide an environment that is free from hazards over which the center has control and provides supervision and assistance devices to each resident to prevent avoidable accidents. Implement interventions including adequate supervision consistent with resident goals, needs, plan of care and current standard of practice. Assistance/Assitive Devices Any device used by or in care of a resident to promote, supplement, or enhance the resident function and/or safety e.g. handrails, grab bars, transfer lift, canes, wheelchairs. The facility procedure titled "Daily Worksheet for the Nursing Assistant, Nursing Assistant Responsibilities" dated 07/2012 read in part: 1. Review the Care Delivery Guide at the beginning of the shift. 2. Use the information to provide individualized care. and 1. Review the Nursing Assistant Assignment Worksheet at the beginning of the shift. 2. Use the information to provide individualized care. The above documents are the CNA care plan. Resident #2 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #2's 01/11/2012, annual Minimum Data Set (MDS) assessment identified she required extensive assistance to total dependence of one to two staff for the majority of her activities of daily living (ADL's) including bed mobility, transfers and hygiene needs. This same MDS identified Resident #2 had severe cognitive impairment related to the dementia. On the afternoon of 10/30/12 Surveyor began review of Resident #2's medical record. A progress note dated 07/03/12 read in part "Clinical team review of residents fall out of w/c (wheelchair) in front lounge this am. Was stabilized and sent to ER (emergency room ) via ambulance. Did sustain a fractured nose, possible right index finger fx (fracture). Superficial skin tears to left FA (forearm). Was treated and returned via ambulance. Doesn't appear seat belt was fastened in w/c. ... Staff communication sent out, in regards to use of seat belt at all times when in w/c. MD (medical doctor) and family aware. Root cause of fall appears to have been the seat belt not in use." After reading the above progress note Surveyor requested the facility's incident report and investigation related to Resident #2's fall on 07/03/12. During further review of Resident #2's medical record, Surveyor read the nurses' progress note from 07/03/12 regarding Resident #2's fall. This read in part: "Res (resident) found on the floor in dayroom at 0615 Am (6:15 a.m.) face down bleeding from nose, skin tear left arm, a .4 cm (centimeter) x .6 cm, pointer finger ... right /c (with) some bruising." On 10/31/12 Surveyor reviewed the incident report and investigation regarding Resident #2's fall on 07/03/12. Page 6 of 9 read in part "Was use of the Equipment per POC (plan of care)? No. Reason: seat belt not fastened. Was this Equipment functioning appropriately? No. Reason: alarm did not sound that seat belt was not fastened." Page 7 of 9 of Resident #2's incident report regarding her 07/03/12 fall read in part: "What action(s) were taken following the incident? Education - Staff, staff discussion regarding use of seat belt." Under Investigation Summaries on page 8, the incident report read in part "Summary of Corrective Action Taken: staff discipline and education to all." Surveyor requested the education provided to all staff and evidence that all staff were educated. Surveyor was provided with a copy of the "Nursing Assistant Communication Tool" dated 07/03/12. This read (Resident #2) Please ensure seat belt is applied when up in w/c." The form was initialed at the bottom by 18 staff members. There were no dates by the initials. Surveyor requested a list of the CNAs and nurses employed by the facility in 07/2012. The list provided identified 25 CNAs and 15 nurses, a total 40. On 11/01/12 the Nursing Home Administrator (NHA) told Surveyor a copy of the Nursing Assistant Communication Tool was given to the nurses but she did not have it with their initials. The facility did not have evidence that the nurses received the education as they had not kept the form given to the nurses. A facility document dated 07/03/12 signed by the NHA read "Spoke with (CNA J) regarding resident fall where she admitted ly had not buckled residents seatbelt per care plan. Extenuating circumstances with power outage, however, discussed importance of following residents' care plans and ensuring that safety interventions are in place. (CNA J) voices understanding." After reviewing the above documents Surveyor met with the NHA and asked if the CNAs involved had signed the re-education counseling that she had done with them. The NHA stated no, she did not have them sign anything. The NHA wrote a late entry on 10/31/12 both CNA K and CNA J's forms that read "Writer personally counseled (CNA J) and (CNA K) regarding incident where she did not buckle a residents seat belt. Reviewed policy and procedure for not following a residents care plan. Writer explained that a written notice of counseling would be placed in her personnel file." Resident #2's "SAFETY DEVICE PLAN OF CARE" read "Apply Safety Device (date) 12/08 Type: ASRSB (alarmed self release seat belt). Time: w/c." Resident #2 was not able to self release the seat belt as identified in the Care Area Assessment (CAA) below. Resident #2's CAA for physical restraints dated 01/16/12 read in part "Has alarming seat belt in w/c to help reduce risk of falls, Unable to release on command. Is repositioned by staff all needs are anticipatdd (spelling incorrect (sic)). leans much in w/c even with frequent positioning. would be more dangerous if she did not have belt on." On 10/31/12 Surveyor reviewed the facility investigation regarding Resident #2's fall of 07/03/12. This read in part "Immediate investigation revealed that the resident's seat belt had not been applied as directed in her care plan." On 10/31/12 Surveyor read the statement written by CNA J, one of the CNAs who had gotten Resident #2 up the morning of 07/03/12 and had not fastened her alarmed seat belt. CNA J wrote "(CNA K) and I had gotton (sic) (Resident #2) ready and up in her chair for breakfast. It was very dark in all the rooms, because of the power being out from the weather. After we transferred (Resident #2) in her chair. I combed her hair. (CNA K) I saw was putting on her foot petals (sic) on. I was starting to make (Resident #2's) bed. (CNA K) took (Resident #2) out of the room into the lounge area. After a couple mins (minutes), pushing other residents out into the lounge area, I saw that (Resident #2) was on the floor with the nurses looking after her. Then I noticed the seat bealt (sic) not being connected. (CNA K) and I feel terrible about what happened. I guess with all that was going on, we both assumeed (sic) or thought we buckled the seat bealt (sic)..." The other CNA involved, CNA K wrote the following "On 7/3/12 (Resident #2) fell out of her wheel chair due to her belt not being buckled correctly. Honestly this never happens when I'm working with (Resident #2). The power was out at the American Heritage Care Center, rooms were very dark. (CNA J) & I got (Resident #2) into her wheelchair. Usually right away the first thing we do is buckle her belt. I went to put her foot rests on (CNA J) went to make her bed. I know it's not right to assume but we both did assume that her belt was buckled, it is equally both our faults..." At 12:50 p.m. on 11/01/12 Surveyor informed the NHA of the concerns Surveyor had regarding Resident #2's fall on 07/03/12. The NHA was asked why the incident was not reported to the state (Office of Caregiver Quality). The NHA stated they did the investigation, she wasn't trying to hide it, we took a look at the circumstances, the power was out, both of the aides felt horrible. The NHA stated she consulted with Wisconsin Health Care Association (WHCA) Legal Counsel G, Corporate Nurse Consultant H and Regional Corporate Consultant I about reporting the incident and they determined it was not reportable. On 11/01/12 at 1:00 p.m. Surveyor asked the NHA what the cause of the power outage was and how long the power was off. The NHA stated she would need to check. The NHA was asked if their back up generator worked. The NHA stated "Yes it did." The NHA was asked if staff had flashlights available to use. The NHA stated "Yes, many." Surveyor said to the NHA, the alarmed seat belt that Resident #2 used had a red light that flashed when it was on, and that should have been seen even with low lighting. Surveyor showed the NHA page 8 of 9 of Resident #2's 07/03/12 incident report that read "Describe the final outcome: resident seat belt changed out d/t (due to) not properly alarming all the time." Surveyor pointed out the facility investigation had determined the alarmed seat belt was not on, it had not been identified that it was not working properly. The NHA stated they are to test an alarm anytime they use it. Surveyor stated it apparently had not been tested on the morning of the fall.