Every finding on record at Hillsville Health & Rehab Center

Based on resident interview, staff interview, and clinical record review, the facility staff failed to provide respiratory care consistent with the comprehensive person-centered care plan and the medical provider orders for 1 of 14 sampled residents (Resident #46). The findings included: For Resident #46, the facility staff failed to administer supplemental oxygen as ordered by the provider. Resident #46's diagnosis list indicated diagnoses, which included, but not limited to Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease with Heart Failure, Multiple Sclerosis, Acute and Chronic Respiratory Failure, and Congestive Heart Failure. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/16/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #46's current comprehensive person-centered care plan included a focus area stating the resident was at risk for altered cardiac and respiratory status due to diagnoses including Chronic Obstructive Pulmonary Disease and Congestive Heart Failure with an intervention for oxygen as ordered. On 7/01/24 at 3:03 PM and 7/02/24 at 8:18 AM, surveyor observed Resident #46 in bed receiving oxygen via nasal cannula at the delivery rate of 3 liters per minute (l/m) per the oxygen concentrator setting. Resident #46's current provider orders included an order dated 3/28/24 to administer oxygen via nasal cannula continuously at 2 l/m. The resident's July 2024 Medication Administration Record (MAR) indicated the resident was receiving oxygen at 2 l/m. On 7/02/24 at 1:41 PM, surveyor observed Resident #46 sitting up in a wheelchair without the use of oxygen. When questioned, the resident stated they only use oxygen when needed. Surveyor asked the resident if they ever adjust the oxygen setting on the concentrator, the resident stated no and added they could not stand up. Surveyor spoke with the resident's nurse, licensed practical nurse (LPN) #1, who verified the resident's order was for oxygen at 2 l/m. On 7/02/24 at 4:30 PM, the survey team met with the Administrator, Director of Nursing, and Regional Director of Clinical Services and discussed the concern of Resident #46 receiving oxygen at the rate of 3 l/m instead of the ordered rate of 2 l/m. No further information regarding this concern was presented to the survey team prior to the exit conference on 7/03/24.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents receive treatment and care in accordance with the comprehensive person-centered care plan and medical provider orders for 2 of 18 sampled residents (Resident #157 and #11). The findings included: 1. For Resident #157, the facility staff failed to administer Paxlovid, an antiviral medication used to treat COVID-19, according to the medical provider orders on 8/09/22. This was a closed record review. Resident #157's diagnosis list indicated diagnoses, which included, but not limited to Pneumonia, Chronic Obstructive Pulmonary Disease, Gastrointestinal Hemorrhage, and Diverticulitis. The minimum data set (MDS) with an assessment reference date (ARD) of 8/01/22 assigned the resident a brief interview for mental status (BIMS) summary score of 8 out of 15 indicating the resident was moderately cognitively impaired. Resident #157's clinical record revealed the resident tested positive for COVID-19 on 8/08/22. Resident #157 was seen by the nurse practitioner (NP) on 8/08/22, the progress note read in part .Resident seen today on rounds as [he/she] has tested positive for COVID-19 virus this morning .Continues to have dry cough .To be started on COVID treatment with antivirals .Start Paxlovid 1 dose p.o. [by mouth] twice daily for 5 days . According to Resident #157's August 2022 Medication Administration Record (MAR), the first dose of Paxlovid was administered on 8/09/22 at 10:00 AM and no additional doses were documented as being administered on 8/09/22. The second 8/09/22 dose was scheduled to be given at 2:00 PM and the nurse documented a code of 19 indicating Other/See Nurse Notes instead of signing for administration. Surveyor was unable to locate a corresponding nursing note explaining why the Paxlovid was not administered at that time or rescheduled for a later time on the same day. Resident #157 received the second administration of Paxlovid the following day, 8/10/22 at 10:00 AM. On 8/10/22, the medication administration times were changed to 10:00 AM and 10:00 PM. On 7/02/24 at 4:13 PM, surveyor spoke with the Director of Nursing (DON) regarding the omission of the second dose of Paxlovid on 8/09/22. DON stated it appeared the second dose was initially scheduled to close to the 10:00 AM dose. Surveyor requested to speak with the nurse present on 8/09/22, however, they were no longer employed by the facility. Resident #157's comprehensive person-centered care plan included a focus area stating in part [Resident #157] has a respiratory infection r/t [related to] COVID-19 . with an intervention to Give medications as ordered. On 7/03/24 at 11:09 AM, the survey team met with the Administrator, DON, and Regional Director of Clinical Services and discussed the concern of Resident #157 only receiving one dose of Paxlovid on 8/10/22. No further information regarding this concern was presented to the survey team prior to the exit conference on 7/03/24. 49622 2. For Resident #11, the facility staff failed to follow the provider orders for no straws to promote the resident's swallowing safety to reduce the risk of aspiration. Resident #11's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease with late onset, Dysphagia-oropharyngeal phase, Moderate protein-calorie malnutrition, and Abnormal weight loss. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 06/27/24 assigned the resident a brief interview for mental status (BIMS) summary score of 5 out of 15 for cognitive abilities, indicating the resident was severely cognitively impaired. On 07/02/24 at 12:02 PM, surveyor observed Resident #11's room and observed a Styrofoam cup of ice water on resident's nightstand by the bed. Resident's name was written on the cup and a date of, 7/2/24 was written on the cup. The cup had a white plastic lid with a straw inserted into the cup. A review of Resident #11's provider orders included an active diet order with a start date of 03/07/24, that read in part, .No straws . Further review of the clinical record revealed an Observation Detail List Report dated 06/28/24, that read in part, .Medical Nutritional Therapy Observation .Adaptive feeding devices .Yes .no straws .Nutrition Goal .to tolerate diet consistency with no preventable s/s (signs and/or symptoms) aspiration through next review .Nutrition Interventions .no straws d/t (due to) dysphagia .Nutritional Monitoring meal/fluid intake, s/s aspiration . A review of the current care plan with a Last Reviewed/Revised date of, 06/28/2024, read in part, .Monitor for s/s of aspiration .provide diet per order . On 07/02/24 at 12:32 PM, surveyor interviewed registered nurse #1 (RN#1) and informed her that a straw was observed in Resident #11's bedside water cup. RN#1 stated she would take care of it. On 07/02/24 at 1:50 PM, surveyor observed the straw had been removed from Resident #11's cup on the nightstand in his room. Surveyor requested and received Resident #11's tray tickets for breakfast, lunch, and dinner for 07/02/24. All three tray tickets read in part, .no straws . On 07/02/24 at 4:50 PM, surveyor interviewed Other Staff #9 (OS#9) and she provided surveyor with a Diet Order Communication slip dated 3/7/24, that read in part, .NO Straws per SLP (speech-language pathologist) . Surveyor requested and received, a Speech Therapy Treatment Encounter Note dated 3/7/24, that read in part, .SLP targeted swallowing safety to reduce risk of aspiration. SLP trialed thin liquids. Pt (patient) with immediate cough noted following trials of thin liquids with straw. Pt. with functional swallow given cupside sips. Diet upgrade to thin liquids with no straws . This concern was reviewed with the Administrator, Director of Nursing, and the Regional Director of Clinical Services at the end of day meeting on 07/02/24 at 4:29 PM and again at the pre-exit meeting on 07/03/24 at 11:10 AM. Surveyor requested and received a facility policy titled, Physician/Provider Orders that read in part, .The Charge Nurse shall .review all physician/provider orders . No further information regarding this concern was presented to the survey team prior to the exit conference on 07/03/24.

Based on staff interview and clinical record review, the facility staff failed to provide treatment and care in accordance with the comprehensive person-centered care plan for one of 17 residents in the survey sample, Resident #2. For Resident #2, the facility staff failed to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Resident #2's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 10/13/21 assigned the resident a BIMS (brief interview for mental status) summary score of 14 out of 15 in section C, Cognitive Patterns, indicating Resident #2 was cognitively intact. Resident #2's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Reviewed Resident #2's clinical record for January 2022 failed to reveal evidence of staff monitoring the resident's SBP or pulse prior to each administration of [MEDICATION(S)]. The resident's SBP and pulse were only recorded prior to the 8:00 pm [MEDICATION(S)] administration on 1/03/22, 1/12/22, 1/13/22, 1/17/22, and 1/18/22. Resident #2's current comprehensive person-centered care plan included a focus area stating in part (Resident #2) is at risk for altered cardiac/resp [respiratory] status r/t (related to) a-fib ([CONDITION(S)]), chf (congestive heart failure), [CONDITION(S)] (hypertension), [CONDITION(S)] . with interventions stating in part medications as ordered and vs (vital signs) / weights as ordered and prn (as needed) . On 1/20/22 at 2:00 pm, the administrator, DON (director of nursing), regional director of clinical services, and the regional vice president of operations were notified of Resident #2's SBP and pulse not being monitored prior to the physicians orders for the administration of [MEDICATION(S)]. At 3:27 pm, the DON returned and stated Resident #2's clinical record including the MARS (medication administration record) did not have the ordered administration parameters documented and the parameters have now been discontinued. No further information regarding this issue was presented to the survey team prior to the exit conference on 1/21/22.

Based on observation, resident interview, staff interview, family interview, clinical record review, and facility document review, the facility staff failed to ensure implementation of infection control practices and precautions to prevent the spread of infection and communicable disease during an identified occurence of a respiratory illness. A facility staff member entered a resident room that was positive for the flu with no PPE (personal protective equipment) in place; failed to perform any hand hygiene prior to leaving this room; failed to implement the requirment for droplet precautions; failed to ensure the staff and surveyor were aware of who had the flu; and failed to ensure a visitor was given education in regards to wearing PPE when visiting a resident on contact isolation for 6 of 25 residents (Residents #15, #19, #32, #44, #45, and #59). The scope and severity was originally cited at Immediate Jeopardy, Level IV isolated and was reduced to a Level II isolated after the facility was cleared of Immediate Jeopardy. The interim Administrator, interim DON (director of nursing), RVPO (regional vice president of operations), and RDCS (regional director of clinical services) were notified on 03/01/2020 that the extended survey process had begun at 10:20 a.m., as the survey team had identified Immediate Jeopardy in the area of Infection Control. The findings included: A facility staff entered a room of a resident who was positive for type A flu with no PPE in place and after speaking with this resident walked to the roommate and spoke with them, exited the room without performing any hand hygiene, failed to identify a resident who had the flu to the surveyor which resulted in the surveyor entering the room and speaking with both residents in this room with no PPE in place, failed to ensure all direct care staff were aware of residents who were positive for the flu, and failed to ensure a visitor was given education in regards to visiting a resident on contact isolation for ESBL (extended spectrum beta-lactamases) a type of [CONDITION(S)] (urinary tract infection). Per the CDC (Centers for Disease Control and Prevention) website. Key Facts About Influenza (Flu) .Flu is a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs. It can cause mild to severe illness, and at times can lead to death. The best way to prevent flu is by getting a flu vaccine each year .Flu usually comes on suddenly. People who have the flu often feel some or all of these symptoms fever or feeling feverish/chills (It's important to note that not everyone with flu will have a fever) .Period of contagiousness: You may be able to spread flu to someone else before you know you are sick, as well as while you are sick. People with flu are most contagious in the first 3-4 days after their illness begins. Some otherwise healthy adults may be able to infect others beginning 1 day before symptoms develop and up to 5 to 7 days after becoming sick. Some people especially young children and people with weakened immune systems, might be able to infect others for an even longer time. Complications of the flu can include bacterial pneumonia .worsening of chronic medical conditions, such as [CONDITION(S)], asthma, or diabetes . [MEDICATION(S)] insert: Indications and usage treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Prophylaxis (action taken to prevent disease) of influenza A and B. Information regarding residents included in this citation: 1. Resident #15's face sheet included the diagnoses, Alzheimer's disease, age related cognitive decline, hypertension, and dysphagia. Section C (cognitive patterns) of the residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 12/20/2019 included a BIMS (brief interview for mental status) summary score of 3 out of a possible 15 points. Section G (functional status) was coded 0/0 in the areas of transfer, bed mobility, walk in room/corridor and toileting, indicating the resident was independent. The residents clinical record included a physicians order for [MEDICATION(S)] 30 mg two times a day for 10 administrations. This medication was started on 02/28/2020 at 10:00 a.m. The resident did not receive a flu shot Consent Refused. The surveyor did not find any progress notes to indicate this resident was symptomatic for the flu. During the observations of this resident, no problems were observed. 2. Resident #19's face sheet included the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C of the residents quarterly MDS assessment with an ARD of 12/28/2019 included a BIMS score of 12 out of a possible 15 points. Section G (functional status) was coded 0/0 in the areas of bed mobility, transfers, walk in room/corridor to indicate the resident was independent in these areas. Toilet use was coded 1/1 limited assistance with setup help only. The residents clinical record included a discharge summary dated 02/28/2020 that indicated this resident was admitted to the hospital on 02/27/2020 with influenza type A. The resident was readmitted to the facility on [DATE]. The discharge summary included information to indicate the resident received [MEDICATION(S)] (taniflu) at the hospital. Upon readmit to the facility LPN #1 documented an admitted and time of 02/28/2020 at 7:15 a.m. with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's current physicians orders included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order date was documented as 02/28/2020 with a start date of 02/29/2020. The [MEDICATION(S)] was started on 02/29/2020 at 10:00 a.m. Flu shot administered on 10/01/2019. This resident was not on isolation. Resident #19's care plan included the focus area resident positive for flu with [CONDITION(S)] sent to emergency department. Order transcribed on 03/01/2020 at 7:25 p.m. for Droplet isolation for influenza + A. Until completes [MEDICATION(S)] on 3/2/2020. D/C (discontinue) isolation on 3/3/2020. The isolation was started after the surveyors entered the building and identified that this resident was not on precautions. Resident #19 was observed by the surveyor to have a non-productive cough. Resident #19 verbalized to the surveyor that they were feeling better. Resident #15 and #19 were roommates. Numerous observations were made of these residents and the surveyor never observed the privacy curtain between these 2 residents to be shut. The residents also shared a bathroom. The bathroom door was located on Resident #19's side of the room. 3. Resident #32's clinical record included the diagnoses, chronic obstructive pulmonary disease, essential hypertension, and chronic pain syndrome. Section C of the Residents quarterly MDS assessment with an ARD of 01/16/2020 included a BIMS score of 15 out of a possible 15 points. A progress note documented on 02/27/2020 revealed that the resident had a temperature of 99.5 continued to feel bad, has croupy cough, wheezing throughout lung fields, productive cough with greenish sputum. Flu swab completed. The clinical record included a negative test screen for the flu type A and B dated 02/27/2020. The facility documented they notified the residents daughter of confirmed flu cases in the facility and that all residents were to be treated with [MEDICATION(S)]. Flu shot administered on 10/01/2019. The facility provided the surveyor with order summary report for all the residents in the facility that were on [MEDICATION(S)]. Resident #32 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Order date 02/27/2020 start date 02/28/2020. This resident denied feeling sick when observed by the surveyor. 4. Resident #44's face sheet included the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C of the resident's admission MDS assessment with an ARD of 01/31/2020 included a BIMS summary score of 11 out of a possible 15 points. Resident #44's care plan included the focus area admitted after acute care stay for [CONDITION(S)] related to ecoli infection [CONDITION(S)] (urinary tract infection) ESBL in urine. Interventions included contact isolation as ordered. The facility provided the surveyor with a copy of a lab report indicating the resident tested positive for ESBL on 02/25/2020. The clinical record included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order date was documented as 02/27/2020 with a start date of 02/28/2020. The [MEDICATION(S)] was started on 02/28/2020 at 10:00 a.m.; the resident was also receiving the antibiotic [MEDICATION(S)] (02/28/2020) 100 mg two times a day. Flu shot administered on 10/22/2019. Order for contact isolation (02/27/2020) for ESBL in urine. 5. Resident #45's face sheet included the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C of the resident's annual MDS assessment with an ARD of 02/05/2020 included a BIMS score of 12 out of a possible 15 points. This resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Order date 02/27/2020 and a start date of 02/28/2020. This medication was started on 02/28/2020. Flu shot administered on 10/01/2019. This resident was in the same room as Resident #59 who tested positive for the flu. This resident voiced no concerns to the surveyor to indicate they felt sick. 6. Resident #59's face sheet included the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C of the residents quarterly MDS assessment with an ARD of 02/21/2020 included a BIMS score of 3 out of a possible 15 points. Resident #59's care plan included the focus area positive for type A flu. Interventions included droplet isolation as ordered. The residents clinical record included a lab test dated (02/27/2020) stating the resident was positive for type A flu. Flu shot administered on 10/01/2019. The facility provided the surveyor with an order summary report for active orders as of 03/01/2020. This order summary did not include a physicians order for droplet isolation. It did include an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .Give 75 mg by mouth two times a day for Flu (+) A for 5 days. This order was dated 02/27/2020 with a start date of 02/28/2020. A review of the eMARs indicated this medication was started on 02/28/2020 at 9:00 a.m. The clinical record included a progress note to indicate the family was notified on 02/27/2020 that the resident had a confirmed case of the flu and would be treated with [MEDICATION(S)]. Three surveyors arrived at the facility on 03/01/2020 (Sunday) at approximately 8:25 a.m. Upon arrival, the surveyors observed a sign posted on the outside of the door reflecting the presence of the flu and requesting visitors to please refrain from visiting. This surveyor entered the front of the building and motioned for a staff person to come outside. This staff person was LPN (licensed practical nurse) #1. Upon exiting the building this staff person stated, they had 3 residents in the facility who had the flu. The survey team leader placed a call to the long-term care supervisor and permission was given to enter the building. The surveyors entered the building at 8:30 a.m. The census in this 60-bed facility was 58 indicating the facility had 2 empty beds. 03/01/20 at 8:39 a.m., the surveyor entered the facility kitchen. The surveyor observed 2 dietary staff in the kitchen dietary person #1 and #2. These staff stated they were not currently using the dining room due to the flu. When asked the procedure for residents in regards to dishes, dietary person #1 stated we do not know who has the flu and no one had advised us on what to do. The surveyor exited the kitchen and began initial tour on the 200 hall. This surveyor observed 3 carts outside resident rooms on 200 hall and proceeded down this hallway. The surveyor observed a cart with PPE located outside of a private room which was not assigned to this surveyor. This resident was identified to surveyor #2 as being on contact isolation for ESBL. 1. Residents #59 and #45: Upon approaching Resident #s 59 and 45's room , the surveyor observed a plastic cart that contained PPE and a sign indicating this resident was on droplet precautions. This sign read, STOP DROPLET PRECAUTIONS Visitors must report to Nursing Station before entering. There was a check mark beside these 3 statements Perform hand hygiene before entering and before leaving room, Wear mask when entering room Visitors and health care workers, and Dietary may not enter. The surveyor observed a staff person in this room with no PPE in place. The surveyor observed this staff person to speak to the resident (Resident #59) in the bed by the window (bed B), walk from this bed to the bed by the door (bed A) and speak with this resident (Resident #45). This staff person exited the room without performing any hand hygiene. Upon exiting the room, the staff person identified themselves as being the environmental service director. This staff person acknowledged they did not have any PPE in place and stated I probably should have put on a gown and mask. This staff person stated the resident in the bed A did not have the flu but the resident in the bed B did have the flu. When asked who they had spoken to in the room. This staff person stated they had spoken with the resident in bed B and the went up to the bedside of the roommate and spoke with them (bed A). This staff person was later identified to the surveyor as being the manager on duty. The surveyor did not enter the room at this time. 2. The surveyor continued initial tour and upon approaching Resident #s 32 and 44's room, the surveyor observed a red stop sign on the door frame that stated check with nurse before entering. Outside of this room, the surveyor observed a cart containing PPE. The surveyor did not enter the room at this time. CNA #1 was observed exiting the residents' room and when asked about PPE stated, they were unsure if you had to have PPE on when picking up food trays. 3, Residents #15 and #19. The surveyor continued with initial tour and entered Resident #s 15 and 19's room. CNA (certified nursing assistant) #1 entered the room also and stated I think I am following you. This CNA did not have any PPE in place and there was no signage or PPE outside the room to indicate anyone in this room was on precautions. The surveyor spoke with both residents in this room and exited the room. 03/01/2020 9:27 a.m., LPN #2 verbalized to the surveyor that Resident #19 had been readmitted from the hospital and they were unsure if they had the flu. The surveyor requested LPN #2 to check the EHR (electronic health record) for the current diagnosis. LPN #2 was unsure of where to find this information was told by the surveyor to check the discharge summary. The discharge summary located in the EHR revealed that Resident #19 had been readmitted to the facility on [DATE]. This discharge summary revealed that Resident #19 had been admitted to the hospital on 02/27/2020 with type A influenza and was placed on respiratory precautions. The resident was discharged back to the facility on [DATE] the discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor approached LPN #2 and asked for clarification regarding the residents on the hall. LPN #2 stated 2 Residents had the flu and identified these as being the resident in Resident #59's bed and Resident #32's bed. The surveyor was unsure who had exactly had the flu on this hallway after these observations and interviews. 03/01/2020 9:25 a.m., CNA #2 verbalized to the surveyor that no one on 100 hall had the flu. Then stated Resident #19 and Resident #59 had the flu and they thought Resident #32 was showing symptoms. 03/01/2020 9:32 a.m., RN (registered nurse) #1 was asked who had the flu and stated she was told one person had the flu but was not given the name of who this person was. RN #1 was from a sister facility. 03/01/2020 9:34 a.m., housekeeper #5 was asked how you would determine if someone was on isolation. Housekeeper #5 stated the way they knew is they would look at the door signs and the cart outside the room that contained PPE. 03/01/2020 9:35 a.m., LPN #1 stated identified Resident #19 and Resident #59 as having the flu. 03/01/2020 9:37 a.m., the interim DON (director of nursing) verbalized to the survey team that Resident #19 and #59 had the flu. The interim DON was notified that the environmental service director was in Resident #59's room with no PPE in place, that resident #19 did not have any signage or PPE outside their room, that the dietary department had no knowledge of who had the flu, and that the surveyor had entered Resident #s 15 and 19's room with no knowledge that a resident in this room had the flu. 03/01/2020 10:07 a.m., the surveyor and the interim DON walked to room Resident #19's room. No signage observed on door. No PPE in hallway outside this room. 03/02/2020 9:47 a.m., CNA #3, stated I know Resident #19 did have the flu, Resident #59 has the flu, and Resident #32 was showing signs of the flu. CNA #3 stated she knew to dress out when she saw precautions outside the room. CNA #3 stated she had not worked this hall (200) since Resident #19 had been readmitted . 03/02/2020 9:47 a.m., LPN #2 now stated Resident #59 and Resident #19 had the flu and that was all they were aware of. When asked why Resident #19 did not have any precautions outside their room LPN #2 stated she did not know. 03/01/2020 9:53 a.m., interview with laundry person #1 stated they did not know who in particular had the flu. However, knew the hall was 200 hall. An observation of the laundry room was completed with no problems identified. 03/01/2020 10:12 a.m., CNA #9 stated she had been called in to work and stated she had worked on Friday 02/28/2020. When asked who had the flu she named Resident #19 and no one else that they were aware of. CNA #9 added they might have told them and it might have slipped their mind. 03/01/2020 10:20 a.m., supervisor made aware and IJ (Intermediate Jeopardy) was called. The interim DON, DON from sister facility, RN #1, and LPN #3 were notified of same. During this meeting the interim DON verbalized to the survey team that Resident #32 did not have the flu. The interim DON was asked their expectation of staff being aware of who had the flu. The interim DON stated of course the staff should know who has the flu and it should be communicated during report from the CNA and the nurse. The interim DON added dietary should be aware and it was discussed in the morning meeting (stand up meeting) on Friday. LPN #3 added that they were aware Resident #19 was positive for the flu in the meeting on Friday. Policies regarding infection control. Isolation Precautions/Isolation Meals. Date reviewed 06/03/2019 DON/Infection control nurse or designee will determine if isolation precautions are necessary .The combination of hot water and/or detergent used in dishwashers is sufficient to decontaminate dishware and eating utensils. No special precautions are needed for dishware such as use of disposable items. Infection Control-General. Date reviewed 07/19/2019 PURPOSE: To protect residents and staff by preventing the spread of infection .Staff shall by knowledgeable and adhere to all department and facility infection control policies. Staff shall by knowledgeable of Standard and Transmission-Based Precautions . Infection Prevention and Control Program for Employees, Contract Staff and volunteers. Date reviewed 07/19/2019. It is the policy of ______ Healthcare facilities to maintain an organized, effective facility-wide program designed to systematically prevent, identify, and control and reduce the risk of acquiring and transmitting infections among employees, volunteers, and contract healthcare workers; to conduct surveillance of communicable disease and infectious outbreaks, and employee health. This program involves the collaboration of many programs and services within the facility and is designed to meet the intent of regulatory guidance .In collaboration with the Director of Nursing and the facility Medical Director, the infection Preventionist has the authority to institute emergency medical and or administrative action when there is danger or threat to residents and/or personnel regarding infection prevention/control matters. This includes but may not be limited to: Isolate or cohort residents with known or suspected infectious diseases in an effort to reduce the risk of disease transmission .Infection Preventionist, in collaboration with other direct resident care providers, provides education to residents, families and volunteers as appropriate . Hand Washing Date revised August 2015. POLICY: Hand washing is the most important component for preventing the spread of infection. Use of gloves does not replace the need for hand cleaning by either hand rubbing or hand washing . Transmission Based Precautions revised date April 2016.Contact Precautions-intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment .Gloves-whenever touching the resident's intact skin or surfaces and articles in close proximity to the resident. Gowns when anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the resident .Room placement-single room when available .Droplet Precautions-intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions .A single patient room is preferred for residents who require Droplet Precautions .A mask is worn for close contact with infectious resident. Gloves, gown, eye protection are worn adhering to Standard Precaution guidelines .Resident and/or responsible party will be notified of the reasons for and education on Transmission-Based Precautions. A sign will be placed on the doorframe of the resident's room indicating that visitors should stop a Nurses Station before entering. Staff should educate visitors regarding donning appropriate Personal Protection Equipment while adhering to the resident's right for privacy protection . 03/01/2020 10:37 a.m., the dietary manager verbalized to the surveyor that Resident #19 and #59 had the flu and that there was nothing special required when the food trays went to the hall. However, the food trays should be wrapped with a trash bag when it came back to dietary and the tray is held until the end of the run. The dietary manager stated they did not say who had the flu in dietary due to HIPAA (privacy laws) and they had not returned to the dietary department after the morning meeting on Friday. The surveyor did observe the food tray from Resident #s 45 and 59's room being handed from a staff in the room to a staff outside the room on 03/03/2020 at 8:37 a.m. This tray was wrapped in what appeared to be a plastic bag. 03/01/2020 10:47 a.m., interim Administrator notified that the environmental service director was observed in Resident #s 45 and 59's room and Resident #59 was positive for the flu with no PPE in place and no hand hygiene was completed prior to leaving the room. The staff gave conflicting information over who had the flu, no signage of PPE outside of Resident #s 15 and 19'room when a resident in this room had been readmitted with the flu (Resident #19) and Intermediate Jeopardy had been called at 10:20 a.m. 03/01/2020 10:59 a.m., CNA #1, in regards to Resident #19, acknowledged she was in the room with no PPE in place and stated she honestly did not know the resident had the flu and she had just given them a bath on Friday. 03/01/2020 2:22 p.m., RVPO, RDCS, and the interim Administrator were notified of the issues regarding infection control. 03/01/2020 4:00 p.m., LPN #2 verbalized to the surveyor that she had administered Tylenol to Resident #59 for a tympanic (ear) temperature of 100.2 and aches and pain. Stating the resident stated she was aching/hurting all over. 03/01/2020 4:44 p.m., interim Administrator, RDCS, and the RVPO. Stated they had a kardex that was printed weekly from the care plan that staff could refer to. Resident #59's kardex had last been updated on 02/26/2020 and did not include any information regarding the resident being positive for the flu. 03/01/2020 Abatement plan provided to the survey team. 1. On 3/1/2020, at 1105 administrator was notified of IJ at 1020 for improper isolation signage for Flu, staff in room with isolation of Flu while not properly wearing PPE, and Staff not being aware of residents with the Flu. Resident had signage implemented immediately and all appropriate PPE placed outside of room. One on one education with Environmental Services Director on Isolation, Hand Hygiene, Proper Dawning and Doffing of PPE. 2. On 3/1/2020, the facility staff conducted assessment following Mcgeers guidelines on current resident to ensure no other signs and symptoms for new cases of the Flu. No additional signs and symptoms have been noticed for new cases of the Flu. No additional signs and symptoms have been noticed. Current residents have the potential to be affected by this noncompliance practice. 3. The facility Director of Nursing and designees immediately began to provide education for current staff regarding Isolation., Hand Hygiene, Proper Dawning and Doffing of PPE. Current staff will be educated prior to starting their next assignment on education. All remaining staff members not currently working, will not be permitted to work until education is received. On 3/1/2020, the Regional Director of Clinical Services provided education to the Director of Nursing and Nursing Home Administrator on Isolation, Hand Hygiene, Proper Dawning and Doffing of PPE. Education will be applied to New Hire Packets. 4. DON or designee will complete observation rounds daily to ensure Isolation signage and proper dawning and Doffing of PPE. Results of rounds will be brought to monthly Quality Assurance and Performance Improvement (QAPI) meetings for review and revision as necessary for the next 3 months. 5. Person responsible: NHA, ________ (name omitted) Action Complete Date March 1, 2020 6. Date of Correction: March 1, 2020 03/01/2020 6:15 p.m., spoke with supervisor regarding the abating of IJ. The IJ was abated at 6:15 p.m. Interim Administrator, RDCS, and the RVPO were notified of same. 03/02/2020 8:48 a.m., new admission Resident #211 was identified by surveyor #2 as not currently being on [MEDICATION(S)]. Interim DON and Administrator notified of same. Upon returning to the conference room, the interim Administrator verbalized to the surveyors that this resident was not admitted with any signs and symptoms of the flu and they were put on the admissions rounds to be seen on Monday (today). 03/02/2020 9:23 a.m., the surveyor entered Resident #44's room. This resident was on contact isolation for ESBL in their urine. The surveyor dressed out in a gown, mask, and gloves provided in plastic cart directly outside the resident's room. The surveyor observed a female person sitting in a chair at the bottom of the bed with a mask in place. No other PPE was observed. This person identified themselves as Resident 44's family. The Surveyor introduced themselves and then pointed to the PPE and asked if anyone had explained all of this to them. This family member stated no one had explained to them the reason for the isolation/PPE and she had also vistied with the resident yesterday at the facility. Two staff noted to be exiting the room when the surveyor entered. Upon removal of the PPE the surveyor was unable to locate the container for the used PPE. The family member moved a curtain and showed the surveyor the container. The family member was sitting within inches of the container. Interim Administrator and the RVPO were made aware. The Interim Administrator left the conference to speak with the family member and when they returned stated he had spoken with the family member and the family member told him that they knew the resident was on isolation but she thought as long as she was not touching anything it was okay. The interim administrator stated they were educating the family member now and let them know as soon as they crossed the threshold it should be implemented. 3/02/2020 9:34 a.m., interim Administrator provided the survey team with 2 in-service forms dated 03/02/20 titled Isolation Procedures Donning/Doffing PPE-When to Use indicating that they had educated/in-service the family member in the room and the family member voiced understanding with no questions. The facility had also in-serviced 2 other family members of others that were visiting in the facility at that time. 03/02/2020 9:42 a.m., LPN #4, stated the family member asked if she had to wear a gown and she told them she didn't have to wear it if she wasn't doing patient care. I did not think she had to wear one. Interim Administrator and the RVPO made aware of same. 03/02/2020 9:47 a.m., Interim Administrator verbalized to the surveyor that they had spoken with LPN #4 and they would do one on one education with them and do a verbal write up. The interim Administrator stated the precautions are for everyone and the nurse thought it was just for direct care. 03/02/2020 10:10 a.m., Interim Administrator provided a copy of the disciplinary action form and stated they were going to re-educate all the families. 03/02/2020 10:13 a.m., call placed to supervisor. At 10:35 a.m., the interim Administrator and RVPO was notified that the facility was still in IJ. The facility provided the surveyor with a copy of a sign that read CONTACT PRECAUTIONS Visitors must report to Nursing Station before entering. At the top of this sign, the facility staff had transcribed the Resident #s 32 and 44's room. There was a check mark beside these four statements SPECIAL [MEDICATION(S)] Perform hand hygiene before entering room AND wash hands with soap and water before leaving room, Wear gloves when entering room or cubicle, and whenever touching the patient's intact skin, surfaces, or articles in close proximity, Wear gown when entering room or cubicle and whenever anticipating that clothing will touch patient items or potentially contaminated environmental surfaces, and Use patient-dedicated or single-use disposable shared equipment or clean and disinfect shared equipment (BP [blood pressure] cuff, thermometers) between patients. The surveyor did not observe this sign to be outside of Resident #s 32 and 44's room on initial tour. However, there was a red sign attached to the doorframe that stated to check with nurse before entering and a plastic cart that contained PPE was positioned outside the door. 03/02/2020 10:43 a.m., LPN #4 was asked if they had received any information yesterday regarding isolation. LPN #4 stated they had. When asked if they had spoken with the family member in the room. LPN #4 stated they had and the family member wanted the resident sent out. LPN #4 stated the family member told her that lady said she had to wear a gown and they wanted to know if they had to wear one. LPN #4 stated she told the family member that if they were not providing patient care they did not have to. LPN #4 stated the infection was in the residents urine (ESBL) and they did not think they had wear one. LPN #4 then stated isolation applies to everyone and I knew that. 03/02/2020 11:00 a.m., CNA #10 stated isolations signs outside of the rooms are for nurses, visitors, everybody really. When asked if there was a family member present in Reside

2. For Resident #160, the facility staff failed to follow physicians orders in regards to the administration of [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. This was a closed record review. The clinical record was reviewed on 03/02 and 03/03/2020. The face sheet located in the clinical record included the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C (cognitive patterns) of the residents 5 day assessment with an ARD (assessment reference date) of 05/21/2019 included a BIMS (brief interview for mental status) summary score of 14 out of a possible 15 points. The residents clinical record included the following physician orders. [MEDICATION(S)] tablet 10 mg 1 tablet by mouth at bedtime for [CONDITION(S)], [MEDICATION(S)] 20 mg give 1 tablet by mouth in the evening for [CONDITION(S)], and [MEDICATION(S)] capsule 75 mg by mouth at bedtime for pain. All three of these medications had an order date and start date of 05/14/2019. A review of the residents eMARs (electronic medication administration records) for May 2019 revealed that the nursing staff had documented a 19 for the [MEDICATION(S)] on 05/14/2019 at 4:00 p.m. There was no documentation to indicate the medication [MEDICATION(S)] was administered on 05/20/2019 and 05/21/2019 and no documentation to indicate the [MEDICATION(S)] was administered on 05/14/2019 at 10:00 p.m. Per the preprinted code on the eMARs a 19=Other/See Nurses Notes. A review of the nurses notes revealed that for 05/14/2019 LPN (licensed practical nurse) #1 documented [MEDICATION(S)] Tablet 20 MG Give 1 tablet by mouth in the evening for [CONDITION(S)] awaiting on pharmacy. A review of the stat box list revealed that this medication was listed as being available in the stat box. On 03/03/2020 at 9:42 a.m., the interim DON (director of nursing) and interim Administrator were notified of the issues regarding Resident #160's medications. The DON verbalized that the dates the [MEDICATION(S)] and [MEDICATION(S)] were left blank an agency nurse had been working. In regards to the [MEDICATION(S)], the DON verbalized to the surveyor that they did have a backup pharmacy and named a local in town pharmacy. 05/14/2019 was a Tuesday indicating this pharmacy was open until 9:00 p.m. On 03/03/2020 at 10:10 a.m., LPN #1 reviewed the eMAR with the surveyor and stated I can not tell you why the [MEDICATION(S)] was not given. On 03/03/2020 at 12:40 p.m., the RDCS (regional director of clinical services) provided the surveyor with a copy of a policy titled, Medication Shortages/Unavailable Medications. This policy read in part, Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy .If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose . On 03/03/20 at 5:58 p.m., the interim DON, interim Administrator, and RVPO, and RDCS were notified of the issues regarding the residents medications. No further information regarding this issue was provided to the survey team prior to the exit conference. Based on staff interview and clinical record review, the facility staff failed to ensure the highest practicable well-being for 1 of 25 residents as evidenced by failure to provide needed treatment and care as ordered by the physician and/or nurse practitioner. (Resident #54 and #160) The findings included: 1. The facility staff failed to provide daily dressing changes for Resident #54 as ordered by the physician. Resident #54 was a resident in the nursing facility at the time of this survey from 3/1/2020 to 3/3/2020. Resident #54 had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent admission MDS (Minimum Data Set) the resident was coded as requiring extensive assistance of one staff member for dressing, personal hygiene and bathing. The clinical record review on Resident #54's record was conducted 3/2/2020 thru 3/3/2020 by the surveyor. The surveyor noted the following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Clean open area to coccyx with wound cleanser, pat dry, apply antimicrobial hydrogel, cover with bordered, composite every day shift . This order was started on 1/21/2020. .Apply [MEDICATION(S)] to right great toe Q (every) day, wrap with stretch gauze and secure with tape .: This order was started on 1/30/2020. The surveyor reviewed the TAR (Treatment Administration Record) for January and February 2020. The surveyor noted that on 1/26 and 1/30/2020, the boxes for these dates were left blank on the TAR's for the dressing change to the coccyx area. Also, the surveyor noted blanks for the dates of 2/22 and 2/29/2020 for the dressing change to the right great toe. The surveyor notified the RDCS (Regional Director of Clinical Services) nurse of the above documented findings on 3/3/2020 at approximately 4 pm. The surveyor asked the RDCS nurse what the blank boxes on the resident's TAR for January and February stood for. The RDCS nurse stated, If the box is blank, the treatment was not done and if this is the case, the nurse should have a nurses' note that explains why the treatment was not performed as ordered by the doctor. If the box has initials of the nurse that means the treatment was performed as ordered by the doctor. The surveyor notified the interim administrator, interim director of nursing, regional vice president of operations and the RDCS nurse of the above documented findings non 3/3/2020 at approximately 4:45 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 3/3/2020.

Based on observation, staff interview, and facility document review, the facility failed to discard food by the use by date and failed to obtain sanitization solution measurements. Findings included: The facility failed to discard outdated cooked chicken and opened thickened juice in the kitchen refrigerator and failed to obtain sanitization solution measurements. On 09/18/18 beginning at approximately 9:05 a.m., during initial tour of the facility, the surveyor toured the dietary department with dietary employee #1 (cook). During this observation, the surveyor observed a carton of thickened juice dated 08/15/18 in the facility refrigerator. Dietary employee #1 stated that needs to be thrown out. A second facility refrigerator contained a container of cooked chicken with a use by date of 09/16/18. Dietary employee #1 stated that needs to be thrown out as well. On 09/18/18 at approximately 10:15a.m., the surveyor reentered the dietary department to observe the dishwasher run through a wash and rinse cycle. During this wash and rinse cycle employee #2 (dietary manager) was present. The wash cycle temperature read 130 degrees, min is 120 degrees for wash and rinse per manufacturers guidelines posted on the wall next to dishwasher. Employee #2 stated that the dishwasher used a sanitation solution to ensure sanitization of dishes. Employee #3 (dishwasher) then stated a test strip to check the sanitation solution had not been used this morning. At the request of the surveyor employee #3 used a test strip to check the sanitization solution. This test strip indicated the solution was under 50 PPM. Per the manufactured guidelines posted on the dishwasher, a minimum of 50 PPM is adequate. Surveyor observed the dish machine log posted on the wall directly in front of dishwasher, the sanitation concentrate PPM column was blank for the entire month of September. On 09/18/18 at approximately 10:25 a.m., the surveyor asked employee #2 to test the sanitization solution in the three-compartment sink. The water temperature in the wash compartment measured at 108.8 degrees. Per the manufacturer's instructions, 75-90 degrees is recommended for this sanitizer. The test trip revealed the sanitizing solution was below 50 PPM. After this observation, employee #2 stated they would be using paper products until the sanitization issue was resolved. On 09/18/18 at approximately 10:37 a.m., the surveyor notified the DON (director of nursing) of the issue with the sanitization process in the dietary department. On 09/18/18 at approximately 10:45 a.m., the DON informed the surveyor that a vendor had been contacted regarding the sanitization issues and they were on the way to the facility. On 9/18/18 at approximately 4:11p.m., vendor #1 reported to this surveyor that the sanitizing solution was adequate in the dishwasher and three-compartment sink. He stated the facility was not using the correct test strips. A recheck of the dishwasher and three-compartment sink revealed that the sanitizing solution PPM was adequate and now measured between 200-400 PPM. On 09/19/18 9:44 a.m., the surveyor interviewed employee #3 regarding the dishwasher sanitizing solution testing. Employee #3 verbalized she was not shown how to test sanitizing solution and they were not doing it. On 09/19/18 at approximately 11:45 a.m., the surveyor requested from the DON the policy and procedure regarding use by dates on food items and manufacturer guidelines on the dishwasher. The facility policy/procedure titled Storage of Refrigerated Foods read in part under section # 14 Food that has been prepared in-house can be stored for a maximum of three days at 41 degrees or lower. Foods which are not potentially hazardous may be stored 7 days. (The date opened or made counts as the first day). Leftover food must be used within 3 days or discarded. Monitor daily expiration dates or use by dates and discard all outdated items immediately . The facility document titled Food Storage Guidelines-Reference revealed that fruit beverages can be refrigerated up to 3 weeks unopened, and Chicken 1-2 days refrigerated. No further information regarding these issues were given to the survey team prior to the exit conference.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to anchor and indwelling Foley catheter for 1 of 17 Residents, Resident #50. The findings included: For Resident #50 the facility staff failed to ensure Foley catheter tubing was anchored. Resident #50 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 07//18 coded the Resident as having both long and short term memory problems and severely impaired cognitive skills. This is an admission MDS. Resident #50's clinical record was reviewed on 09/18/18. It contained a physician's orders [REDACTED]. Resident #50 was observed by the surveyor on 09/19/18 at approximately 0820, along with LPN #1. Resident was resting in bed. Foley catheter drainage bag was observed lying in the floor beside the Resident's bed. Resident voiced a complaint to LPN #1 of I have a place on my leg and indicated groin area. LPN #1 checked Resident and stated That's your catheter. Surveyor observed that Resident's Foley catheter tubing was not anchored and was positioned in skin fold in Resident's groin area. Surveyor asked LPN #1 if Foley catheter should be anchored, and LPN #1 stated that it should, and stated that she would obtain a leg strap for Resident. The concern of the Foley catheter not being anchored was discussed with the administrative team during a meeting on 09/191/18 at approximately 1530. The surveyor requested a policy on catheter care at this time. The DON provided the surveyor with said policy entitled Catheter Care: Male/Female on 09/19/18 at approximately 0745. This policy read in part 18. Secure catheter utilizing a leg band. No further information was provided prior to exit.

Based on staff interview, clinical record review, the facility failed to ensure a level 1 PASRR (pre-admission screening and Resident review) was completed for two of 17 Residents, Resident #11 and #20. The findings included: 1. For Resident #11 the facility staff failed to ensure a level I PASRR was completed within 30 days of admission. Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 07/03/18 coded the Resident as 3 of 15 in section C, cognitive patterns. This is a quarterly MDS. Resident #11's clinical record was reviewed on 09/18/18. The surveyor could not locate a level I PASRR in the clinical record. The surveyor spoke with the previous social worker of the facility on 08/18/18 at approximately 1450. This social worker stated that, to her knowledge, only one Resident at the facility had a PASRR. Surveyor also spoke with the DON (director of nursing) on 09/18/18 at approximately 1500. DON stated that she did not know it was a state regulation for Residents to have a PASRR completed. The concern of the PASRR not being completed was discussed with the administrative team during a meeting on 09/191/18 at approximately 1530. The DON stated that the PASRR could not be located. No further information was provided prior to exit. 2. For Resident #20 the facility staff failed to obtain a level 1 PASRR (pre-admission screening and Resident review). Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment with an ARD (assessment reference date) of 07/12/18 coded the Resident as 15 out of 15 in section C, cognitive patterns. This is an annual MDS. Resident #20's clinical record was reviewed on 09/18/18. During this record review, the surveyor was unable to locate a level 1 PASRR. After the record review, the surveyor discussed the missing PASRR with SW (social worker) #1. During this interview, SW #1 stated that no PASRR had been completed for Resident #20. The concern of the missing PASRR was discussed with the administrative staff on 09/18/18 at approximately 3:46 p.m. On 09/19/18 at approximately 9:06 a.m., SW#2 confirmed that a PASRR had not been completed for this Resident. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to ensure medication was labeled correctly for 1 of 17 Residents, Resident #14, and failed to dispose of expired medications. The findings included: 1. For Resident #14 the facility staff failed to ensure the medication, [MEDICATION NAME], was labeled correctly. Resident #14 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 07/09/18 coded the Resident as 12 of 15 in section C, cognitive patterns. This is quarterly MDS. Surveyor observed LPN (licensed practical nurse) #2 during a medication pass and pour on 09/19/18 at approximately 0800. One of the mediations observed being administered was [MEDICATION NAME] 20 mg, 1 tablet. The medication card was labeled as [MEDICATION NAME] (generic for [MEDICATION NAME]) 20 mg tablet, Give 1 tablet by mouth one time a day and give 2 tablets by mouth one time a day for 3 days. The surveyor reconciled the Resident's medications with the clinical record on 09/19/18. The clinical record contained a physician's orders [REDACTED]. The eMAR (electronic medication administration record) included an entry which read in part [MEDICATION NAME] tablet 20 mg give 1 tablet by mouth one time a day for [MEDICAL CONDITION]-start date-03/24/18. The surveyor spoke with LPN #2 on 09/19/18 at approximately 0915 regarding the label on the [MEDICATION NAME]. LPN #2 stated that the current order was for one tablet one time a day. LPN #2 also stated the order for 2 tablets one time a day for three days was an old one time order, which have fell off. LPN #2 also stated that she did not know why the medication card was still labeled this way. The concern of the mislabeled medication card was discussed with the administrative team during a meeting on 09/191/8 at approximately 1530. On 09/2018 at approximately 0800, the DON (director of nursing) provided the surveyor with a copy of a corrected label. No further information was provided prior to exit. 2. For the medication cart on 200 hallway, the facility staff failed to dispose of expired insulin. The surveyor checked the medication cart on the 200 hallway on 09/19/18 at approximately 0850. It contained a [MEDICATION NAME]pen labeled with an opened on sticker dated 08/18/18. This sticker also read discard after 28 days. The surveyor asked LPN (licensed practical nurse) #1 to look at the pen. LPN #1 stated that the insulin needed to be discarded, and proceeded to do so. The surveyor requested and was provided with a copy of Insulin Storage Recommendations which read in part, [MEDICATION NAME] cartridge or pen unopened, refrigerated until expiration date, opened 28 days. The concern of the expired insulin was discussed with the administrative team during a meeting on 09/19/18 at approximately 1530. No further information was provided prior to exit.

Based on observation, staff interview, and clinical record review, the facility staff failed to provide an effective infection control program for 1 of 17 Residents, Resident #50. The findings included: For Resident #50 the facility staff failed to ensure the Foley catheter drainage tubing and bag did not touch/rest on the floor. Resident #50 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 07//18 coded the Resident as having both long and short term memory problems and severely impaired cognitive skills. This is an admission MDS. Surveyor observed Resident #50 on 09/18/18 at approximately 0935. Resident was seated in wheelchair in her bedroom. Surveyor observed Foley catheter drainage bag attached to bottom of wheelchair. The drainage tubing was observed lying on the floor under the wheelchair. The surveyor observed Resident #50 again on 09/18/18 at approximately 0940. Resident was propelling self up the hallway in wheelchair. The surveyor observed Foley catheter drainage tubing dragging along the floor, under Resident's wheelchair. The surveyor observed Resident #50 in the activity room on 09/18/18 at approximately 1100. Resident was seated in wheelchair, with Foley drainage bag attached to bottom of wheelchair. The Foley drainage tubing was resting on a rug on the floor. The surveyor observed Resident #50 on 09/18/18 at approximately 1345. Resident was outside on the sidewalk with a staff member. Resident's Foley catheter drainage tubing was observed dragging along the sidewalk, under wheelchair. The surveyor observed Resident #50 on 09/19/18 at approximately 0820. Resident was resting in her bed. Surveyor observed Resident's Foley catheter drainage bag resting on the floor, beside the bed. Surveyor observed Resident on 09/19/18 at approximately 1130. Resident was up in wheelchair, Foley catheter drainage bag was observed touching the floor, under Resident's wheelchair. Surveyor observed Resident again on 09/19/18 at approximately 1400. Resident was propelling self in hallway. Resident's Foley catheter drainage bag was rubbing along the floor under the wheelchair. The surveyor spoke with the infection control nurse on 09/19/18 at approximately 1610. Infection control nurse stated that the Resident's Foley drainage tubing or bag should be in the floor. The surveyor reviewed the facility infection control policy and could not locate anything specific to catheter usage. The concern of the Foley catheter drainage bag/tubing being in the floor was discussed with the administrative team during a meeting on 09/19/18 at approximately 1530. No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to ensure accurate DDNR's (durable do not resuscitate) orders for 2 of 17 Residents, Residents #12 and #54. The findings included: 1. For Resident #12, the facility staff failed to ensure the Residents DDNR was complete. The Resident or the Resident's authorized representative had not signed the DDNR and section's 1 and 2 had been left blank. The clinical record review revealed that Resident #12 had been admitted to the facility 03/29/18. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 07/06/18 included a BIMS (brief interview for mental status) summary score of 3 out of a possible 15 points. The Residents clinical record included a DDNR order form from the Virginia Department of Health. This form was dated 03/29/18 and read in part. Under section 1 I further certify (must check 1 or 2): 1. The patient is CAPABLE of making an informed decision . 2. The patient is INCAPABLE of making an informed decision . Neither box had been checked. Section 2 read, If you checked 2 above, check A, B, or C below . All three boxes had been left blank. This form had not been signed by the Resident or the Residents authorized representative. The DON (director of nursing) and the vice president of operations were made aware of the above findings during a meeting with the survey team on 9/20/18 at 11:28 a.m. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #54, the facility staff failed to ensure the Residents DDNR was complete. Section 1 and 2 had been left blank. The clinical record review revealed that Resident #54 had been admitted to the facility 05/02/18. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 05/09/18 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. The Residents clinical record included a DDNR order form from the Virginia Department of Health. This form was dated 05/03/18 and read in part. Under section 1 I further certify (must check 1 or 2): 1. The patient is CAPABLE of making an informed decision . 2. The patient is INCAPABLE of making an informed decision . Neither box had been checked. Section 2 read, If you checked 2 above, check A, B, or C below . All three boxes had been left blank. The DON (director of nursing) and the vice president of operations were made aware of the above findings during a meeting with the survey team on 9/20/18 at 11:28 a.m. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to ensure an accurate MDS (minimum data set) assessment for 1 of 17 Residents, Resident #55. The findings included: For Resident #55, the MDS coordinator coded the Resident as being discharged to an acute hospital when in fact he had been discharged home. The record review revealed that Resident #55 had been admitted to the facility 04/05/18. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 04/12/18 coded the Resident as 4 out of 15 in section C, cognitive patterns. This is an admission MDS. The Resident had been discharged home on[DATE]. The Residents discharge MDS assessment with an ARD of 06/23/18 had been coded to indicate the Resident had been discharged to an acute hospital. The clinical record included a plan of care note dated 06/25/18 read This Resident discharged home on[DATE] with daughter. On 09/20/18 at 8:49 a.m., the surveyor reviewed the discharge MDS with the MDS coordinator. After reviewing the MDS, the MDS coordinator stated she had marked acute hospital in error and she would get it fixed. The DON (director of nursing) was notified of the inaccurate MDS assessment on 09/20/18 at approximately 8:50 a.m. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for 2 of 17 Residents, Residents #17 and #54. The findings included. 1. For Resident #17, the facility staff failed to review and revise the Residents comprehensive care plan to include the Resident's sippy cup. The record review revealed that Resident #17 had been admitted to the facility 01/12/17. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 04/09/28 had been coded 1/1/3 to indicate the Resident had problems with long and short term memory and was severely impaired in cognitive skills for daily decision making. The surveyor observed Resident #17 eating lunch on 09/18/18 at 12:45 p.m., during this observation the surveyor reviewed the Residents diet slip. This diet slip included the adaptive device Sippy Cup. A review of the Residents nutritional CCP (comprehensive care plan) was completed and the surveyor was unable to locate any information regarding the sippy cup. A review of the Residents physician's orders [REDACTED]. In fact, the surveyor was unable to locate any information regarding the sippy cup in the Residents EHR (electronic health record) or the hard chart. On 09/20/18 at 8:36 a.m., the surveyor reviewed the Resident's CCP with the MDS coordinator. After reviewing the CCP, the MDS coordinator verbalized to the surveyor that she was unable to locate any information regarding the sippy cup. On 09/20/18 at 9:23 a.m., the surveyor interviewed the DON (director of nursing). The DON stated the sippy cup idea came from a CNA (certified nursing assistant) who saw the Resident struggling and spoke with the dietary personnel and no one else was made aware. The surveyor observed the sippy cup being used at two of three meals. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #54, the facility staff failed to review and revise the Resident's CCP (comprehensive care plan) to include the Residents DDNR (durable do not resuscitate) order. The clinical record review revealed that Resident #54 had been admitted to the facility 05/02/18. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 05/09/18 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. The Residents clinical record included a DDNR. The Residents CCP did not include any information to indicate that the Resident had a DDNR in place. On 09/20/18 at 8:34 a.m., the MDS coordinator and the surveyor reviewed the Residents CCP. After reviewing the CCP, the MDS coordinator verbalized to the surveyor that this information was not included in the Residents CCP. The DON (director of nursing) and the vice president of operations were made aware of the above findings during a meeting with the survey team on 9/20/18 at 11:28 a.m. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to follow physician orders [REDACTED]. The findings included, The facility staff failed to administer the Residents insulin per the physicians order. The facility nursing staff held the Residents insulin two times in the month of (MONTH) (YEAR). The record review revealed that Resident #15 had been admitted to the facility 06/24/13. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents annual MDS (minimum data set) assessment with an ARD (assessment reference date) of 07/06/18 had been coded 1/1/3 to indicate the Resident had problems with long and short term memory and was severely impaired in cognitive skills for daily decision making. The Residents clinical record included a physicians order for 10 units of bassaglar insulin at bedtime for diabetes. A review of the Residents eMARs (electronic medication administration records) revealed that for the month of (MONTH) (YEAR) LPN (licensed practical nurse) #1 held this insulin on 08/08 and again on 08/17. The clinical record included a nursing entry on 08/08 that read Resident's BS (blood sugar) was 113. Insulin was held. and on 08/17 Resident's BS was only 111. Did not give insulin because her BS drops during the night. The surveyor was unable to locate any information indicating the physician had been notified of the insulin being held. The Residents CCP (comprehensive care plan) included the focus area of diabetes. Interventions included, but were not limited to, administer my medications as ordered and report to physician/nurse practitioner as indicated. The nursing staff had documented the Residents BS on 08/09 and on 08/18 at 6:00 a.m. as 102. The DON (director of nursing) and vice president of operations were notified of the above during a meeting with the survey team on 09/19/18 at 3:39 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review the facility staff failed to ensure a complete and accurate Care Area Assessment (CAA's) for 1 of 16 Residents, Resident #7. The findings included: For Resident #7 the facility staff failed to accurately name the date and location of CAA (care area assessment) documentation. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The most recent comprehensive MDS with an ARD (assessment reference date) of 02/13/17 coded the Resident as having both short and long term memory impairment with severely impaired skills for daily decision making. This is a significant change MDS. Section V of the MDS, care area assessment, was reviewed. The facility staff had not identified the date and location of the CAA information used to determine the care plans for cognitive loss or communication. The only documentation was see CAA worksheet dated 02/21/17. The CAA worksheets were reviewed and the information could not be located. The concern of the missing documentation was discussed with the administrative team during a meeting on 06/28/17 at approximately 1600. No further information was provided prior to exit.

Based on observation, resident, family and staff interview, facility document review and clinical record review it was determined the facility staff failed to provide treatment and services necessary to address the psychosocial issues (failure to adjust to the facility, anxiety, fear and depression due to loss of independence/dignity) for 1 of 16 residents (Resident #1). Findings: The facility staff failed to provide treatment and services necessary to address the psychosocial/adjustment issues for Resident #1. The resident's clinical record was reviewed on 6/27/17 at 3:00 PM. Resident #1 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was admitted for surgical aftercare and physical therapy to restore mobile function. The resident had a history of [REDACTED]. The initial MDS (minimum data set) assessment dated [DATE] coded the resident with slight cognitive impairment due to her inability to consistently make herself understood and her inability to consistently understand others. Her hearing was assessed as adequate on this assessment. She required assistance with all the ADLs (activities of daily living) and was frequently incontinent of bowel and bladder. The latest quarterly MDS (minimum data set) assessment, dated 4/7/17, coded the resident with moderate cognitive impairment due to her inability to recall items during a short-term memory test to assess mental status. Her memory was coded as unimpaired. The resident was coded with significant hearing impairment on this assessment. The resident was coded as not having a hearing aid. The latest MDS assessment coded the resident as requiring the assistance of nursing staff for all ADLs (activities of daily living), with the exception of eating, which required set up only. She was completely continent of bowel, but her bladder function had declined to always incontinent. The latest CCP (comprehensive care plan) reviewed and revised on 4/11/17 documented the resident had the following care issues concerning the complaint allegation: 1. Alteration in bowel elimination r/t (related to) decreased mobility. The interventions included: Scheduled toileting program as ordered. 2. The resident has an ADL self-care performance deficit related to recent surgery. Interventions: Assist with ADLs as needed . ***The resident was careplanned for scheduled toileting (in bathroom) every two hours or as needed--but there was no documented evidence this schedule was followed. 3. Alteration in thought process (initiated 3/6/17) related to a history of hallucinations during infections and believing she is wet when in reality she is not. Interventions: .Ensure routines are followed as closely as possible on each shift Provide pleasant interactions which reassure the resident when confused .Staff to check resident every two hours and as needed for incontinence . 4. Alteration in behavior (initiated 3/6/17) related to history of making false accusations against staff regarding care received. Interventions: Cries often and speaks in high pitched squeaky voice when requesting assistance, provide assistance as needed and speak to resident in normal voice .social services to visit frequently to assess/review any concerns the resident might have 5. Resident is afraid of dark. The interventions included: Staff to leave the light on at all times per the resident's request. (Subsequent interviews with the resident and family members indicate this was not consistently implemented. 6. Alteration in bowel elimination r/t (related to) decreased mobility. The interventions included: Scheduled toileting program as ordered. 7. The resident will be a long term care individual. Interventions did not include plans to address her problems adjusting to loss of independence/wish to return home or inability to adjust to long term care. (There was nothing in the CCP to address these ongoing issues.) 8. Moderately impaired hearing. Does not wear hearing aide (initiated 4/12/17). Interventions: .Speak directly with resident in clear audible tones. Speak slightly slower and enunciate words . 9. The resident has an ADL self-care performance deficit related to recent surgery. Interventions: Assist with ADLs as needed . 10. The resident uses antidepressant medication related to [MEDICAL CONDITION]. Interventions: .Promote quiet environment to allow sleep. ******The CCP, at no time, addressed the resident's actual anxiety/depression over being admitted permanently to the facility. The CCP did not address psychiatric intervention for her on-going psycho-social adjustment issues--other than to document her undesirable behaviors which were symptoms of depression and anxiety. (These behaviors were actually only assessed and care planned after APS (Adult Protective Services) investigated an incident on 2/28/17 that the resident had been told by a staff member to urinate in her brief instead of assisting her to the toilet. The allegation was substantiated by this surveyor--but reported to be unsubstantiated to this surveyor's office.) She was initially admitted for aftercare and physical therapy following surgery for [REDACTED]. On admission, she was careplanned for eventual return to her home, but, since then has become a permanent resident due to lack of home services to assist with her daily care requirements. The physician's orders [REDACTED]. 1. 2/9/17 - [MEDICATION NAME] tablet 0.5 mg. Give one tablet by mouth every 12 hours for anxiety. 2. 5/23/17 -[MEDICATION NAME] HCL tablet. Give 75 mg by mouth at bedtime related to [MEDICAL CONDITION]. 3. 1/27/17 - May have oxygen O2 on at 2L/minute via NC (nasal cannula) as needed for SOB (shortness of breath)/maintaining O2 saturation above 90%. On 6/28/17 at 11:00 AM Resident #1 was interviewed. She told the surveyor that a nursing staff member had told her to go in her pants and she would come back to clean her up later. The resident said she was calling for help because she had to pee and staff would not answer her call light. Resident #1 stated, They told me to shut-up because I was wet. I never use the light unless I need something .It hurt my feelings. I cried. I didn't say anything. I never bother anyone. Why would they be so mean when you can't help when you have to go? The resident told the surveyor she would sit in her chair and pray the girl would learn to talk to someone without hurting their feelings. (The CNA was no longer at the facility and not available for interviews.) The resident told the surveyor that prior to her admission, she lived at home by herself and knew when she had to use the bathroom. She never got anxious or called her daughters in the middle of the night. She tearfully, told the surveyor she just wanted to go home. FMI (family member #1) was present during this interview. She told the surveyor the incident about being asked to pee in her pants was reported to APS (Adult Protective Services) on 2/28/17. FMI stated, They came in to investigate, but nothing was done. FMI acknowledged Resident #1 was happy and content living at home prior to her admission. She never called us crying or anxious like she does now. FM I said she and other family members had talked to the staff about the issues that began on her admission, and just didn't know what to do at this point. The surveyor reviewed a facility reported incident and the subsequent investigation results sent in by the ADON (assistant director of nursing) on 2/28/17 and 3/4/17. The initial report documented the resident and family members complained to APS regarding the resident's incontinence care not being performed and the staff instructing the resident to urinate in her brief instead of assisting her to the toilet. The follow-up report, transmitted to the surveyor's office by the ADON on 3/4/17, indicated an investigation had been conducted and the allegation of neglect was unsubstantiated. The follow-up statement did not address the staff telling the resident to urinate in her pants. The surveyor reviewed the investigation results and the written statements of the CNAs involved in her care. CNA I stated the following about the incident, which occurred on 2/27/17 during 3rd shift. When I came in at 11 PM, after a few minutes (name of CNA II) came in and asked how (Resident #1) transferred. I questioned her why she was getting resident up, she told me in return that patient had requested to go to the bathroom, although she'd already told patient just to use her depend (name of briefs used) and she'd change her. She said resident told her she couldn't and requested to go again to the bathroom. I went down to assist her in transferring . CNA II's statement on the same event, (Name of resident #1) put her call light on. I went back there to see what she needed and she said she wanted to get up to use the bathroom .I told her I needed to first go get help because I did not know if she was a two-person assist I told her if she needed to go really bad, that when I got back I would change her brief The facility investigation results included a mandatory in-service held for all nurses and CNAs on 3/3/17. The content and objectives included: Under no circumstances are you allowed to instruct a resident to be incontinent. We are here to keep them continent! Not force them to be incontinent. This is unacceptable and if you are reported you will be written up. On 6/29/17 at 8:00 AM the surveyor interviewed the SW (Social Worker) about her interventions regarding the resident's on-going adjustment issues and her follow-up support after the 2/27/17 incident. The SW said Resident #1 had cried a lot since she first came in and called out begging the daughters to come back and stay with her. SW stated, She's had trouble adjusting. I spent time with the daughters to find out what's going on. Sometimes they're ok, sometimes they aren't happy. The SW was asked if she'd provided counseling or comfort to the resident since her admission or the February incident. She told the surveyor, she hadn't really documented anything or actually counseled the resident, I knew the nurses had her on rounds and she should have medication for anxiety by now. I felt she needed medication to adjust, but I haven't addressed that I don't feel like we've done all we can for her. She should've had psych services. The SW notes were reviewed. She had addressed the family's concerns and documented them. There was no documentation she provided any support to Resident #1. On 6/29/17 at 11:00 AM, FM II was interviewed. She had numerous complaints and was primarily focused on the on-going adjustment issues and the lack of staff support and psychiatric services at the facility. FM II stated, I have asked them if they could schedule a psychiatric eval for her. I think she needs it. She's just not happy and I'm unable to take her home and care for her by myself. They told me they are in the process of that, but its a long, drawn out process. FM II told the surveyor she asked if she could bring in a psychiatrist herself and was told she could not. She said the facility, currently, had no one to provide psychiatric services to the residents. She said the [MEDICATION NAME] had helped some, but the resident was still anxious and fearful of being in the facility alone. She said, They tell her to shut-up when she calls out for help. One night her oxygen fell off and she got short of breath and anxious. She called for help when no one answered her call light. They finally came in and put her oxygen back on and told her only to call if it was an emergency. Isn't it an emergency if you can't breath? FM II said most of Resident #1's anxiety/fears focused on the night shift (3rd) after the family was gone. She told the surveyor she didn't know what else to do because she couldn't stay at the facility 24 hours a day. FM II stated, It's always her fault, and I'm tired of them blaming it on her behaviors .They want to keep her quiet, but they are not addressing her issues. On 6/29/17 at 12:40 PM the facility administrator and DON were informed of the findings and asked for evidence the facility had provided psychosocial support to address Resident #1's anxiety, fears and adjustment issues. The DON stated, We have been trying to get psychiatric services for quite some time. We're changing our doctor services but it's a long process. The new doctor is going to be more help with psychiatric services. The DON added they had started watching CNAs closer and popping in at different hours to check on care since the February incident. No additional information was provided prior to the survey team exit. This was a complaint allegation deficiency.

Based on resident and staff interview, facility document review and clinical record review it was determined the facility staff failed to provide care and services to assist 1 of 16 residents (Resident #1) to maintain and enhance his/her dignity, self-esteem and self-worth. The staff told the resident to urinate in her brief and they would come back and clean her up later. Findings: Facility staff failed to provide care and services to assist Resident #1 to maintain and enhance his/her dignity, self-esteem and self-worth. The resident's clinical record was reviewed on 6/27/17 at 3:00 PM. Resident #1 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was admitted for surgical aftercare and physical therapy to restore mobile function. The initial MDS (minimum data set) assessment dated [DATE] coded the resident with slight cognitive impairment due to her inability to consistently make herself understood and her inability to consistently understand others. Her hearing was assessed as adequate on this assessment. She required assistance with all the ADLs (activities of daily living) and was frequently incontinent of bowel and bladder. The latest quarterly MDS (minimum data set) assessment, dated 4/7/17, coded the resident with moderate cognitive impairment due to her inability to recall items during a short-term memory test to assess mental status. Her memory was coded as unimpaired. The resident was coded with significant hearing impairment on this assessment. The resident was coded as not having a hearing aid. The latest MDS assessment coded the resident as requiring the assistance of nursing staff for all ADLs (activities of daily living), with the exception of eating, which required set up only. She was completely continent of bowel, but her bladder function had declined to always incontinent. The latest CCP (comprehensive care plan) reviewed and revised on 4/11/17 documented the resident had the following care issues concerning the complaint allegation: 1. Alteration in bowel elimination r/t (related to) decreased mobility. The interventions included: Scheduled toileting program as ordered. 2. The resident has an ADL self-care performance deficit related to recent surgery. Interventions: Assist with ADLs as needed . ***The resident was careplanned for scheduled toileting every two hours or as needed. 3. Alteration in thought process (initiated 3/6/17) related to a history of hallucinations during infections and believing she is wet when in reality she is not. Interventions: .Ensure routines are followed as closely as possible on each shift Provide pleasant interactions which reassure the resident when confused .Staff to check resident every two hours and as needed for incontinence . On 6/28/17 at 11:00 AM Resident #1 was interviewed. She told the surveyor that a nursing staff member had told her to go in her pants and she would come back to clean her up later. The resident said she was calling for help because she had to pee and staff would not answer her call light. Resident #1 stated, They told me to shut-up because I was wet. I never use the light unless I need something .It hurt my feelings. I cried. I didn't say anything. I never bother anyone. Why would they be so mean when you can't help when you have to go.? The resident told the surveyor she would sit in her chair and pray the girl would learn to talk to someone without hurting their feelings. The resident told the surveyor that prior to her admission, she lived at home by herself and knew when she had to use the bathroom. She never got anxious or called her daughters in the middle of the night. FMI (family member #1) was present during this interview. She told the surveyor the incident about being asked to pee in her pants was reported to APS (Adult Protective Services) on 2/28/17. FMI stated, They came in to investigate, but nothing was done. FMI acknowledged Resident #1 was happy and content living at home prior to her admission. She never called us crying or anxious like she does now. The surveyor reviewed the facility reported incident sent in by the ADON (assistant director of nursing) on 2/28/17 and 3/4/17. The initial report documented the resident and family members complained to APS regarding the resident's incontinence care not being performed and the staff instructing the resident to urinate in her brief instead of assisting her to the toilet. The follow-up report, transmitted to the surveyor's office by the ADON on 3/4/17, indicated an investigation had been conducted and the allegation of neglect was unsubstantiated. The follow-up statement did not address the staff telling the resident to urinate in her pants. The surveyor reviewed the investigation results and the written statements of the CNAs involved in her care. CNA I stated the following about the incident, which occurred on 2/27/17 during 3rd shift. When I came in at 11 PM, after a few minutes (name of CNA II) came in and asked how (Resident #1) transferred. I questioned her why she was getting resident up, she told me in return that patient had requested to go to the bathroom, although she'd already told patient just to use her depend (name of briefs used) and she'd change her. She said resident told her she couldn't and requested to go again to the bathroom. I went down to assist her in transferring . CNA II's statement on the same event, (Name of resident #1) put her call light on. I went back there to see what she needed and she said she wanted to get up to use the bathroom .I told her I needed to first go get help because I did not know if she was a two-person assist I told her if she needed to go really bad, that when I got back I would change her brief The facility investigation results included a mandatory in-service held for all nurses and CNAs on 3/3/17. The content and objectives included: Under no circumstances are you allowed to instruct a resident to be incontinent. We are here to keep them continent! Not force them to be incontinent. This is unacceptable and if you are reported you will be written up On 6/29/17 at 12:40 PM the facility administrator and DON were informed of the findings and asked if the matter had been taken to the QA (quality assurance) committee for review and follow-up. The DON said it had not, but they had started watching CNAs closer and popping in at different hours to check on care. No additional information was provided prior to the survey team exit. This was a deficiency based on a complaint allegation.

Based on observation, resident, family and staff interview and clinical record review it was determined the facility staff failed to accommodate dietary requests/choices for 1 of 16 residents (Resident #1). Findings: Facility dietary staff failed to accommodate diet choices for Resident #1. The resident's clinical record was reviewed on 6/27/17 at 3:00 PM. Resident #1 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was admitted for surgical aftercare and physical therapy to restore mobile function. The latest quarterly MDS (minimum data set) assessment, dated 4/7/17, coded the resident with moderate cognitive impairment due to her inability to recall items during a short-term memory test to assess mental status. Her memory was coded as unimpaired. The MDS assessment coded the resident as requiring the assistance of nursing staff for all ADLs (activities of daily living), with the exception of eating, which required set up only. Resident #1's CCP did not reflect dietary choices. Resident #1's physician's orders [REDACTED]. The order was for a regular diet, regular texture and regular consistency. On 6/28/17 at 11:00 AM Resident #1 was interviewed regarding her dietary choices/selections. She told the surveyor she loved buttermilk, but her doctor wouldn't let her have any. She told the surveyor she would like to have a glass of buttermilk every day at lunch. On 6/28/17 at 11:45 AM the surveyor relayed the resident's request for buttermilk daily at lunch to DM I (local dietary manager) and DM II (corporate dietary manager). DM II told the surveyor the resident's preference would not be a problem as the resident was on a regular diet with no restrictions. On 6/28/17 at 1:30 PM the resident told the surveyor she had received her buttermilk at lunch. She stated, It was so good! I'm so happy they're going to let me have it. The resident actually clapped her hands with glee at the prospect. On 6/29/17 at 1:30 PM the surveyor spoke to Resident #1. Resident #1 told her she did not get her buttermilk on her lunch tray, she only got regular milk. On 6/29/17 at 2:18 PM DM I was informed of the surveyor's findings. DM I replied, She should have gotten it at lunch. I will check on it. At 2:20 PM DM I returned to inform the surveyor that a dietary staff member informed him that they put buttermilk on her lunch tray that day. He told the surveyor it was not on her lunch tray ticket, but someone had remembered she wanted it--so they provided it. DM I added he had entered the request into the computer and it should, thereafter, appear as a resident choice on her meal ticket. On 6/29/17 at 2:25 PM the surveyor returned to Resident #1's room and again asked the resident and FM II (family member II) what kind of milk was on the lunch tray that day. The resident repeated regular milk. FM II said she was in the room during lunch and the resident received sweet milk--no buttermilk. The DON was in the resident's room at this time and heard the conversation. She said she would check on it. On 6/29/17 at 2:45 PM the findings were reported to the facility administrator, DON and corporate nurse. No additional information was provided prior to the survey team exit.

Based on observation, staff interview and clinical record review, it was determined that the facility staff failed to follow physician orders [REDACTED].# 4. The Findings Included: For Resident #4 the facility staff failed to apply physician ordered TED hose. Resident #4 was an [AGE] year old female who was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) located in the clinical record was a Quarterly MDS assessment with an Assessment Reference Date (ARD) of 6/8/17. The facility staff coded that Resident #4 had short and long term memory loss (1/1) and was severely impaired (3) with daily decision making regarding Activities of Daily Living (ADL's). The facility staff also coded that Resident #4 required total nursing care (4/2) with ADL's. On June 27, 2017 at 2:35 p.m. the surveyor observed Resident #4 lying on her bed on top of the bed linens. The surveyor did not observe that Resident #4 had on TED hose. On June 27, 2017 at 3 p.m. the surveyor observed Resident #4 lying in her bed and on top of the bed linens. The surveyor did not observe that Resident #4 had on TED hose. On June 27, 2017 at 3:30 p.m. the surveyor reviewed Resident #4's clinical record. Review of the clinical record produced signed physician orders [REDACTED]. To be removed Q HS (every evening at bedtime) every shift for [MEDICAL CONDITION]. (sic) On June 27, 2017 at 4:10 p.m. the surveyor observed Resident #4 sitting in her wheelchair. The surveyor did not observe that Resident #4 had on the physician ordered TED hose. The surveyor observed that Resident #4 had on white socks that came up just above her ankles. On June 28, 2017 at 9:45 a.m. the surveyor notified the Director of Nurses (DON) that Resident #4 had a physician order [REDACTED].#4 did not have on the physician ordered TED hose. On June 29, 2017 at 9:45 a.m. the survey team met with the Administrator (Adm), DON, and the Human Resources/Payroll Department Head. The surveyor notified the Administrative Team (AT) that Resident #4 had a physician order [REDACTED].#4 did not have on the physician ordered TED hose on multiple observations on June 27, 2017. No additional information was provided prior to exiting the facility as to why the facility staff failed to apply the physician ordered TED hose to Resident #4.

Based on observation and staff interview it was determined the facility staff failed to store, prepare, distribute and serve food under sanitary conditions in the facility kitchen. Findings: On 7/26/16 at 1:30 PM, during the initial tour of the kitchen the following issues were observed: 1. The stove was observed to have four pots boiling for food preparation. The hood above the stove top (over top of the pots) was observed to have accumulated dust on the (two) light bulbs. The sprinkler system was observed to have built up dust or smut taggles hanging from it. DM I (dietary manager) said she could get maintenance to clean the fixtures. 2. The dry goods storage was reviewed and the surveyor observed the food items were commingled with non-food items on the shelving. Styrofoam plates were on shelving with pasta, cake mixes and chocolate syrup. DM I said she didn't have enough room to store the non-food items at the time. Several shelves were noted to have non-food items on them and had additional space for/and available for non-food item storage. 3. Two gallon dented cans of food were observed on the shelving available for food for resident consumption. DM I stated. I need to put them in my office--the staff knows not to serve anything from a dented can. On 7/27/16 at 11:30 AM the kitchen was reviewed. The dusty bulbs and sprinkler heads were still dirty. Food was again on the stove top in pots for preparation to the residents. The dented cans in dry storage had still not been removed. The administrator and DON (director of nursing) were informed 7/27/16 at 4:30 PM of the surveyor's observations. They promised to follow up the next day. On 7/28/16 at approximately 8:30 AM the DON told the surveyor all the issues had been cleaned up in the kitchen. We got the dented cans out of the dry goods and the dust has been cleaned from the fixtures over the stove. No additional info was provided.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to implement physician's orders, failed to implement recognized care planned interventions and failed to monitor a resident's skin to prevent the development of new pressure ulcers (**deep tissue injuries) and prevent the redevelopment of old pressure wounds for 2 of 17 residents (Residents #8 and #2.) 1. Resident #2's did not received the required unrelieved pressure from lying on the surface of the bed and from the heel lift device straps that were not padded and therefore pressure sore development was avoidable. 2. Facility staff failed to follow Resident #8's physician's orders for the use of heel protectors while in bed. Findings: ? ww***www.npuap.org/DOCS/DTI.doc ? DOC file Deep tissue injury is a term proposed by NPAUP (The National Ulcer Pressure Advisory Panel) to describe a unique form of pressure ulcers. These ulcers have been described by clinicians for many years with terms such as purple pressure ulcers, ulcers that are likely to deteriorate and bruises on bony prominences (Ankrom, 2005). NPAUP ' s proposed definition, is " A pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment. " (NPAUP, 2002). 1. The facility staff failed to implement physician orders and recognized careplanned interventions and failed to monitor Resident #2's skin to prevent the development of new pressure ulcers. Resident #2's clinical record was reviewed on 10/12/11 at 9:00 AM. Resident #2 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The latest MDS (minimum data set) assessment dated [DATE] coded the resident with cognitive impairment and as having the ability to communicate with staff. The resident required the assistance of at least one staff member for bed mobility and did not ambulate. The resident required the assistance of at least one facility staff member for all additional activities of daily living. Resident #2 was coded as being at risk for pressure ulcers and also as having had one stage three ulcer at the time of this assessment. This was coded as an admission/reentry wound. The MDS worksheet documented she developed a stage II pressure area on her right lateral heel, first noted on 6/7/11 and was later staged as a stage III. Resident #2 was coded for a specialty mattress on her bed and as having assistance (every) 1 hour with her bed mobility when in bed.....She was also to have a gel cushion in her wheelchair seat when up out of bed. Nursing notes from 5/21/11 until present were reviewed for hospitalization s and discharge/reentry. The documentation indicates the resident was continuously/daily under the care of the facility nursing staff and no admission/reentry was documented from 5/21/11 until the first pressure area on the resident's right heel was observed on 6/7/11. (The survey team concluded this pressure ulcer was sustained in-house) : "6/7/11 1235 P Stage II pressure area on R lateral heel. Area measures 0.9 x 0.8 x 0 wound is covered with dry tissue in appearance of a ruptured blister....Order received for [MEDICATION NAME] to R lateral heel change q three days and prn until resolved......orders for H&H an [MEDICATION NAME] due to new pressure area on R lateral heel...." "6/15/11 1015 D/C Prostat.....Skin breakdown healed." "6/16/11 1030 A Resident is reported to have skin breakdown (per family)...T&P q (Turn and Position every) 1 hour--breakdown on heel noted for new orders. H&H [MEDICATION NAME] (checked) on 6/13/11 within normal limits." (These labs are an indicator of overall health and nutritional status--and were normal at this time.) "7/11/11 1015 AM ....resident ambulation skills have declined since development of pressure area on R heel. Will ask PT to screen res." ***On 7/21/11 the nursing staff documented the resident's refusal to feed herself. Prior to this the resident was eating independently with oversight from staff. On 7/24/11 the resident was sent to the ER of the local hospital, diagnosed with [REDACTED].**** "7/27/11 1540 R lateral heel stage II pressure area has declined in status to Stage III........" "8-10-11 4 PM L heel noted a suspected deep tissue injury measures 6 x 5 x VTD cm. Outer edges red c deep purple & black center....fluid filled blister....heel lift suspension boots ordered also, R buttocks has white maceration. L buttocks with [DIAGNOSES REDACTED]. [MEDICATION NAME] ordered for preventive measures (to buttocks)......" "8/18/11 0500 Dressing intact to left heel........Able to feed self with extensive assist x 1....." "8/29/11 3 PM R lateral heel Stage III pressure area continues to improve.....Heels floated at all times in heel lift suspension boots.....L heel suspected deep tissue injury ...is current tx (changed) Q (every) 3 days and as needed. L heel tissue remains intact with darkened black epithelium that is hard to the touch...." "8/31/11 10:50 AM Resident is doing really well this week with a really high level of intake of 75% and close to 100% without choking on her food......." "9/15/11 1315 R lateral heel resolving Stage III pressure area has closed fully....wound is dark pink, non-blanching....1715 [MEDICATION NAME] removed....found two stage II pressure areas to L sacrum....." "9/22/11 0830 R lateral heel pressure area has resolved.....A suspected deep tissue injury is also noted to the R heel measuring 3 cm x 4.8 cm x unable to determine depth. Color is deep purple.......L buttocks stage II measures 0.5 cm x < 0.1 cm....." "9/27/11 1645 Suspected deep tissue injuries continue to R & L heels........Both remain deep purple/black in color......Stage II pressure area remains to L buttock......Stage II area to L sacrum resolved.....remaining tissue pink and blanching..." "10/4/11 1920 L buttock stage II resolved....." The CNA ADL (activities of daily living) sheets for Resident #2 were filled out every shift on a daily basis and were reviewed from 6/11 through the present time. Each sheet contained the following information related to Resident #2's skin care which had been signed off by facility nursing assistants: 1. "Turn and reposition q2h and prn." 2. "I have read and followed the daily care guide." The "Daily Care Guide," for the CNAs, implemented on 8/25/11 for Resident #2, was reviewed and observed to contain the following instructions related to Resident #2's skin care: "Assist to turn and reposition in bed q 2 hours when in bed." (Role: CNA) Resident #2's CCP (comprehensive care plan), implemented on 8/11/11, contained the following problems related to skin integrity: 1. Has a suspected deep tissue injury to her left heel 2. Has developed a stage three pressure area on her right lateral heel (Documented as resolved.) 3. Potential for even more skin integrity issues due to bed mobility difficulties and bowel and bladder incontinence. 4. Has developed two small areas on her left sacrum and another on her left buttock--stage II pressure areas. (Noted resolved 10/4/11.) 5. Has suspected deep tissue injury to her right heel. Resident #2's CCP contained the following interventions to address the aforementioned problems: 1. Turning and repositioning Q 1 hour when in bed. 2. Specialty mattress 3. Heel lift suspension boots at all times. Resident #2's physician's orders, signed and dated by the doctor on 10/5/11 contained the following directions to staff regarding the resident's skin care and pressure ulcer treatment: 1. Turn and position Q 1 hour (ordered 6/16/11.) 2. Check skin Q shift (ordered 3/2/11.) 3. Elevate heels when in bed (ordered 3/2/11.) 4. Heel lift suspension boots at all times (ordered 9/22/11.) 5. Specialty mattress (ordered 1/27/11.) 6. Gel cushion when up in wheelchair (3/28/11.) 7. Wrap kerlix to left heel suspected deep tissue injury 8. Cleanse right heel pressure area with NS. Apply BD and kerlix to protect wound. Change q 5 days and prn until resolved or inappropriate for wound. Resident #2's treatment records for 6/11 through the present time were reviewed and observed to contain the doctor's orders as prescribed since the resident first developed the initial heel ulcer. The treatment nurse had documented implementation as ordered--including the intervention to "turn and position Q 1 hours." On 10/12/11 at 10:00 AM the ADON assisted the surveyor to observe Resident #2's heels. The ADON removed the foam rubber heel lift device from the resident's right foot and exposed an uncovered wound on the right outside lateral leg, where the canvas straps of the heel lift device had formed deep depressions across the lower right leg. The wound was about the size of a quarter and black, without drainage observed. When the surveyor asked the ADON how long the undocumented wound had been there--the ADON said she "didn't know" and would have to ask the treatment nurse. The dressing on the right heel was intact and dated 10/11/11 (as was the dressing on the right heel.) The ADON left the room with the heel lift device in her hand and disappeared down the hall. The rest of the resident's skin was unaccessible at that time. On 10/12/11 at 12:30 PM the TX nurse was interviewed about the undocumented wound on the resident's right leg. She stated, "It look like friction against it caused by the strap when the boot was "dispositioned.". That boot gets dispositioned (moved around) and she has a deep tissue wound from it." The surveyor asked the TX nurse if she observed the area the day before when she dressed the right heel ulcer. The TX nurse stated, "No, I was dressing her foot from the left side of the bed and didn't see it on the right side of her leg. It measured 1.6 x 1.0 cm and is a suspected deep tissue injury covered by a scab." On the morning of 10/13/11 Resident #2's physician came to the facility (the day after the surveyors had found the new deep tissue injury on the resident's right lateral leg). He signed off on new orders for the treatment of [REDACTED]." On 10/13/11 at 9:00 AM the surveyor observed the resident was lying on her left side facing the window with a pillow behind her back. On 10/13/11 at 10:00 AM during Resident #2's second skin assessment the DON assisted the TX nurse by pulling back the covers and helping with positioning the resident for the assessment. The resident was observed to be lying on her left side with a pillow propped against her back to keep her in place. The DON removed the pillow and pulled the covers back. The sheets and "chuck" underneath the resident were observed to be wadded up against her sacral area. The DON remarked the covers were "bunched up" under her and pulled all the bedding out to straighten it and make the resident more comfortable. The TX nurse stated, "I staged another pressure ulcer on her left sacrum. The area had healed and reopened. I found it this morning and it is a stage II." The sacral area was observed to be covered by a [MEDICATION NAME] dated 10/13/11 and the nurse declined to remove it because it would compromise the integrity of the skin in the area. The surveyor told the nursing staff members she needed to assess the skin and that was not possible with a [MEDICATION NAME] in place. The TX nurse said she didn't know the surveyor wanted to see the treatments on Resident #2's heels and also declined to do them at that time. She said she would do it "later" when she got her supplies together. The DON put the resident back in the same position she was found in and left the room. On 10/13/11 at 11:18 AM two members of the survey team observed the dressing change on Resident #2's heels At this time the resident was still on her left side with the pillow still behind her back. The dressing was removed from the newly observed area on her right lateral leg, caused by the boot strap attached to the heel lift. The dressing had blood on it and some drainage was evident. The wound was measured at 2 cm at the longest point and 1 cm at the shortest. The TX nurse said she believed the strap on the boot caused friction and caused it. She said she believed it was a scab rather than eschar because of the drainage. The TX nurse told the surveyors that she was the only one that ever removed the heel lift booties from the resident's feet and that she looked at her feet and legs every "3-5 days during the dressing changes." She told the surveyors that the CNAs would put bags on her feet during the twice weekly showers--so they never looked at her heels or the skin on her feet and legs under the booties. When asked how often the resident was repositioned, the TX nurse said the CNAs reposition her every hour. The sheets on the bed were observed to be wrinkled up under the resident's feet and were not pulled down across the end of the bed like a fitted sheet should be. The mattress of the bed was exposed at the foot of the bed under the resident's feet. The heels on both the right and left feet were blackened and appeared to be necrotic tissue, or eschar. The right heel wound measured 3.1 x 5 cm. The left heel wound measured 4 x 4.6 cm. The tx nurse said she believed the suspected deep tissue injuries on both feet were resolving blood blisters. The skin around the blackened wound bed was flaky and dry. The treatments were performed per the physician's order and the resident was left in the bed in the same position she was found in at 11:45 AM. On 10/13/11 at 2:45 PM Resident #2's CNA I was interviewed. She was asked what care she provided for the resident during the shift. CNA I stated, "I come in and wash her face....I give her a complete bed bath--wash her head to toe." CNA I told the surveyor that she was turned and repositioned every two hours by the CNAs on duty. "I don't document it, there's no way of doing that. You get into the routine of turning her every two hours. I repositioned her at 1:30..." The resident was observed to be on her back with a pillow under her right hip. CNA I told the surveyor that the resident had been "pretty sick" a couple of months ago--but she was now doing much better. "She is eating a lot better. We were worried about her--she was having some trouble swallowing when she was sick (pneumonia) but she is eating pretty well now." CNA I told the surveyor that she found a new pressure area on the resident's bottom on Tuesday (10/11/11.) "I found a problem area on her bottom. It was a tiny red spot, the skin was broken. It had a [MEDICATION NAME] on it and it had wrinkled back and the charge nurse came in and removed it. She cleaned it and put a new one ([MEDICATION NAME]) on. I take skin issues very seriously." (***The surveyor noted this was the same pressure area that the treatment nurse had reported she had "discovered" earlier this morning--and had placed a [MEDICATION NAME] on it--precluding the skin assessment by the survey team. Documentation in the nursing notes indicated the reopened sacral ulcer was found on 10/11 and not on the morning of 10/13/11--as reported by the treatment nurse.) The CNA said she got her resident care directions for all the residents from the ADL tracker sheets and the ADL flow sheets. "They have everything on them from total lift to personal alarm on them." At this point Resident #2 asked CNA I to get her up and put her in her chair. CNA I told the resident she could not get her up because she had a sore on her bottom and the nurses wanted her to stay in bed. CNA I told the surveyor, "We normally like to get her up in her recliner but when her bottom breaks down, we have no choice but to leave her in bed. She has a gel cushion to put in her chair." CNA I was asked if she ever removed the heel lift booties. CNA I said they were to remain on the resident at all times--even when she took a shower. CNA I said she did not take them off to observe the skin underneath the boots- at any time. On 10/13/11 at 3:30 PM the administrator, DON and corporate consultant were informed that the surveyors received information that through interviews the surveyour received information that Resident #2's did not received the required unrelieved pressure from lying on the surface of the bed and from the heel lift device straps that were not padded and therefore were avoidable. The staff presented no evidence to the contrary to this prior to the survey team exit. On 10/17/11 at 1:25 PM Resident #2's CNA II was interviewed. CNA II told the surveyor that she turned and repositioned the resident every two hours. She said she received her directions for the resident's daily care from the assignment sheet for daily care requirements (The Daily Care Guide.) CNA II said she never removed the heel lift booties from the resident--that they were to remain on her. The survey team members determined the CNAs were not following the physician's orders or the nursing care plans to "turn and reposition" the resident every hour. In addition, the resident's skin integrity was not being assessed every shift per the physician's order. According to the TX nurse--no one was removing the heel lift booties and looking at the resident's skin underneath but once every 3-5 days when the dressing changes were done. The CNAs said the booties were never removed to assess her skin integrity. The following info regarding avoidable and unavoidable pressure areas was pulled from: <http://npuap.org/OWM2011_Black_0.pdf> (The National Pressure Ulcer Advisory Panel) "Avoidable pressure ulcer. An avoidable pressure ulcer can develop when the provider did not do one or more of the following: evaluate the individual ' s clinical condition and pressure ulcer risk factors; define and implement interventions consistent with individual needs, individual goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Unavoidable pressure ulcer. An unavoidable pressure ulcer can develop even though the provider evaluated the individual ' s clinical condition and pressure ulcer risk factors; defined and implemented interventions consistent with individual needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate." "Mobility and activity limitations are strong independent predictors of pressure ulcers. The recent NPUAP-EPUAP guideline3 states that if the individual is bedfast or chairfast and immobile, he/she is considered to be risk for pressure ulcers. Other factors (eg, nutrition, moisture) may have an impact on risk status, but activity and mobility limitations are the primary considerations. Turning or repositioning the immobile individual helps reperfuse ischemic skin, temporarily removing pressure from vulnerable tissues.4 Repositioning may include partial turns or small body movements that do not always remove pressure from the sacrum or heels rather than full turns of 30? or more that lift the sacrum from the bed." ***Other unavoidable indicators, [MEDICAL CONDITION], perfusion/hemodynamic instability of skin tissue or terminal illness/end of life stages were not documented or presented to the survey team during their onsite survey. These indicators were not observed during the clinical record review either. 2. Facility staff failed to follow Resident #8's physician's orders for the use of heel protectors while in bed. Resident #8's clinical record was reviewed on 10/11/11 at 2:45 PM. Resident #8 was admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. The resident was admitted to the facility with a stage IV pressure ulcer on her buttocks. The latest MDS (minimum data set) assessment, dated 9/19/11, coded the resident as cognitively intact. Resident #8 needed the assistance of at least one staff member for all the activities of daily living and a set-up only for eating. The resident did not have any pressure ulcers coded at present, but was coded at risk for their development because of her prior history. She was coded as having a therapeutic diet. Resident #8's current physician orders, signed and dated 10/5/11, contained an order for [REDACTED]. Resident #8's current CCP (comprehensive care plan) updated on 10/7/11 documented the problem "High risk for skin integrity complications r/t having had pressure areas, difficulty with bed mobility, and being incontinent of bowel secondary to being a paraplegic." One of the interventions listed was "wear heel protectors when in bed." Resident #8's daily care guide, used by the CNAs to determine resident's daily needs, contained these directions to nursing staff: "I am to wear heel lift suspension boots at all times." On 10/11/11 at 3:15 Resident #8 was interviewed in her room. The resident was lying in her bed. The surveyor observed the resident did not have on heel protectors and asked her if she used any. Resident #8 stated, "No, they haven't used them on me in awhile. I don't even think there's any in the room anymore." Subsequent observations on 10/12/11 and 10/13/11 yielded the same finding. The resident was not being provided with heel protection while she was in bed. On 10/13/11 at 3:30 PM the administrator, the DON and the corporate nurse were informed the nursing staff was not following the doctor's order to use heel protection on the resident when she was in bed. No additional information was provided prior to the survey team exit.