Every finding on record at Laredo Medical Center

Based on observation, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety for 1 of 1-unit refrigerators (resident refrigerator RR #1), 1 of 1 resident freezer (resident freezer RF #1) and 1 of 1 resident walk in pantry (walk in pantry WP#1) reviewed for storage, preparation and sanitation. -The facility failed to ensure a bag of chicken taquito were properly sealed and a loaf of bread wrapped in plastic wrap that was expired dated 11-21-25 was left in refrigerators beyond safe use by dates. -The facility failed to ensure bags of grapes, herbs, and celery were stored in the resident's refrigerator were placed in sealed containers protected from cross contamination and exposure to splash, dust, or other contamination. -The facility failed to ensure the coffee left on counter and sugar in the resident's dry food pantry were placed in sealed containers protected from contamination and exposure to splash, dust, or other contamination which compromises the integrity of the food until food is ready to use. -The facility failed to ensure DA #4, DA #5, DA#6, DA #7 and the chef wore and placed beard restraints correctly to prevent hair from contaminating food being prepared and ready for consumption. -The facility failed to ensure and maintain the safety of a cooking pan surface which had contact with food to prevent cross-contamination of pan coating particles in food ready for consumption. These failures could place residents who receive meals and/or snacks from the kitchen at risk for food contamination and food borne illness. Findings included: Observations during the initial tour of the kitchen on 12/02/25 at 8:00 am revealed one bag of sugar in the dry storage pantry, a package of coffee pouches on the counter opened and exposed to air. In the walking in refrigerator a container of celery opened was not properly sealed closed, a bag of fresh herbs was opened not properly sealed closed, a container full of bags of grapes were opened not properly sealed closed and in the freezer a bag of chicken taquitos and a loaf of bread was wrapped in plastic wrap dated 11/21/25 and was expired. In an interview and with DA#1 on 12/02/25 at 9:32 AM she said all kitchen staff were responsible for cleaning the refrigerator and made sure that all food was labeled, sealed, had not expired and had a use by date. DA#1 stated the refrigerator, and freezer were cleaned, and all expired food was thrown out daily. DA#1 could not explain why the grapes, celery, herbs, and chicken taquitos were not sealed correctly just that the staff must have thought they were sealed properly. DA#1 said the loaf of bread must have been pushed to the back of the rack when it was restocked and not was not notice so the expiration date of 11/21/25 was never checked. DA#1 said she did not know why the sugar and coffee was left open only the person might have been in hurry and did not properly store the items correctly. In an interview on 12/02/25 at 10:01 AM with DA#2 she stated she could not recall when the open bags of grapes, celery, herbs and chicken taquitos were not sealed correctly and placed in the refrigerator but knew that all items put in the refrigerator were to be sealed with a use by date. DA#2 stated the staff throw away all expired food daily and clean refrigerator and freezer weekly and did not know or see the expired bread. DA#2 stated the sugar and coffee were always store correctly but the person who last used them did not store them correctly, so the items were exposed and contaminated. In an observation and interview on 12/02/25 at 10:17 AM with DA #4 he stated he forgot to put on his beard restraint this morning but normally has it every day and he knows that hair can fall and contaminate the food.In an observation and interview on 12/02/25 at 10:25 AM with DA #5 he stated he forgot to put on his beard restraint this morning but has it on every day and he knew that hair could fall into the food and harm the residents. In an observation interview on 12/02/25 at 10:33 AM with DA #6 he stated he had just started working this morning and forgot to ask for a beard restraint but knew through his training he had to have it every day so hair cannot fall and contaminate the food. In an observation and interview on 12/02/25 at 10:42 AM with the chef he stated he did not realize his beard restraint was not over the rest of his beard this morning but normally has it on correctly every day and he knew that hair could fall and contaminate the food. The chef also stated he did not realize how bad the condition of the cooking pan had gotten. The Chef stated it was not safe to use a pan all scratched up and was rarely used but will have it replaced with a new one. The chef also stated he made sure all food was stored properly after use, so it did not become contaminated for the next use. The chef stated he made sure all employees had on the proper hair restraint when the staff are preparing food. In an interview with on 12/03/25 at 5:33 PM with the DM she said the supervisors, and the staff clean out the refrigerator daily and the celery, herbs, and bags of grapes must have been overlooked by staff therefore remained open. The DM said these open items had not been used in the menu recently for them to have been left open in the refrigerator. The DM said the chicken taquitos were in a bag place in a box with no lid and seemed protected but at closer inspection the bag inside the box was not sealed properly and the box was not enough protection from food being contaminated and was overlooked. The DM said the sugar and the coffee were used that morning and staff in rush did not ensure the proper closure of the sugar bag or put coffee away in a sealed container. The DM said she will do a retraining on dating items and making sure they are all covered and throwing out expired foods for all forms of storage. The DM also stated there will be an inventory of cooking utensils, pots and pans to inspect and replace any worn out or damage cookware. The DM said she will do an in-service on the importance of wearing hairnets and being hygienic in the kitchen. Record review of the facility's Dress Guidelines for good service management and clinical nutrition staff dated 01/2025 stated:Dress for food service management and clinical nutrition staff must be professional in appearance and function to portray a positive image of the department. -Hair restraints are worn by all when in the kitchen. Sanitation and Infection Prevention Control Policy: To prevent the contamination of food with infectious microorganism. Food and Nutrition Services associates are expected to observe the following Infection Prevention and Control PracticesFood Contact Surfaces:-Discard any food contact surfaces with chips, nicks or broken pieces etc. FDA Food Code 2022 Ch. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. to (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for dietary services. 1. The facility failed to ensure that the food items in the refrigerator were not expired. 2. The facility failed to ensure that the equipment used to prepare food was in good condition. These failures could place all residents who received their meals from the kitchen at risk for foodborne illnesses. The findings include: During an observation of the kitchen on [DATE] at 3:16 p.m. revealed 11 six-packs of 8 oz tomato juice cans that were expired in February of 2023. The DM said they did not use tomato juice that often and she thought they might have ordered the tomato juice for making drinks during a New Years Eve party and they forgot it was there. During an observation of the refrigerator on [DATE] at 3:17 p.m. revealed 40 one- gallon containers of various salad dressings with the expiration date of February 2024. During an interview on [DATE] at 3:20 PM the DM said the dressings should have been used before the new merchandise was used. The DM said it was the responsibility of the storeroom clerk to rotate the stock so that the older foods were used before the new foods. The DM said the storeroom clerk should know to rotate the food to reflect first in and first out, however the storeroom clerk quit. The DM said she did not know why the storeroom clerk did not dispose of the expired containers of salad dressing. The DM said they had a new storeroom clerk, but he was still in training. The DM said if they used food that was past its expiration date it could get a lot of people sick. The DM said the person in charge of the salad bar used salad dressing and she would be the one to know if the salad dressing was used on the salad bar. During an interview on [DATE] at 3:24 p.m., the DA A said she did not use the large containers of salad dressing; she used the small bottles for the salad bar. The Dietary Aide said she had not used the large containers of salad dressing in a long time. During an observation of the dishwashing area on [DATE] at 3:26 p.m. revealed two manual food mills (chinois) with mangled rims hanging on hooks on the wall. The food mills were bent and mangled. In an interview on [DATE] at 3:28 p.m. the Chef said the mills looked as if someone had banged them and they were no longer of use. The Chef said the mills were brand new and they could not use them. The Chef said little pieces of metal could be broken off into the food and hurt someone, or even cut whoever was using it because of the sharp edges. The Chef said he would throw them away. In an interview on [DATE] at 3:30 p.m. the DM said she would review the in-service the staff on food and supply storage, first in, first out and expiration dates. Record review of facility's Food and Supply Storage revised [DATE] revealed: Most, but not all, products contain an expiration date. do no sell products in retail areas or place on patient trays/resident trays past the date on product. Food past the use by, sell by, best by, or enjoy by date should be discarded. Date and rotate items; first in, first out (FIFO). Discard food past the use-by or expiration date. References: FDA Food Code 2022 Ch. 4, Part ,d+[DATE], Subpart ,d+[DATE] Cleanability, Section ,d+[DATE].11 Food-Contact Surfaces. (A) Multiuse food-contact surfaces shall be: (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections (3) Free of sharp internal angles, corners, and crevices (4) Finished to have smooth welds and joints.

Based on observation, interview and record review, the facility failed to ensure that resident environment remained free of accident hazards in twelve of twelve resident rooms in which water temperatures were tested . Hot water exceeded safe levels at the sink in resident rooms. This failure could affect all twelve residents and be a potential for skin burns. The findings were: Water temperatures in rooms were taken by surveyor on 05/20/19 at 2:30 p.m. to 3:00 p.m. - 2 sinks in every room Sink A - With mirror; Sink B - On Side wall: room [ROOM NUMBER] - Sink A - 134 - Sink B - 125.5 room [ROOM NUMBER] - Sink A - 138 - Sink B - 139 room [ROOM NUMBER] - Sink A - 137 - Sink B - 138 room [ROOM NUMBER] - Sink A - 141 - Sink B - 141 Water Temperatures were taken on 05/20/19 at 4:15 p.m. to 4:45 p.m., by Maintenance staff (MS) A with the facility's thermometer: room [ROOM NUMBER] - Sink A - 138 Sink B - 134 room [ROOM NUMBER] - Sink A - 120 Sink B - 122 room [ROOM NUMBER] - Sink A - 122 Sink B - 124 room [ROOM NUMBER] - Sink A - 130 Sink B - 124 room [ROOM NUMBER] - Sink A - 118 Sink B - 122 room [ROOM NUMBER] - Sink A - 132 Sink B - 132 room [ROOM NUMBER] - Sink A - 132 Sink B - 134 room [ROOM NUMBER] - Sink A - 138 Sink B - 140 room [ROOM NUMBER] - Sink A - 119 Sink B - 121 room [ROOM NUMBER] - Sink A - 138 Sink B - 140 room [ROOM NUMBER] - Sink A - 130 Sink B - 142 room [ROOM NUMBER] - Sink A - 130 Sink B - 140 During interview with MS A on 5/20/19 at 4:45 p.m. MS A was not sure of the safe water temperature and stated, 115-120? Review of facility's Hot Water Temperature Policy revision date 01/07/19 indicated Policy It is the policy of Laredo Medical Center to ensure the safety of patients and associates by regulating hot water water temperature, in accordance with State Health Department regulations. Purpose The purpose of this policy is to inform associates of the maximum allowable hot water temperatures in Laredo Medical Center. Procedure 1, The temperature of hot water used by patients (domestic hot water) in Laredo Medical Center shall be maintained in accordance with state health department regulations (DOH). Absent state regulations, the following limits shall apply: a. 95-110 degrees Fahrenheit in residential treatment building/spaces (e.g. Long Term Care Units). Review of Water Temperature records (daily check list) provided by the Director of Facilities (DF) C on 05/20/19 at 7:36 p.m. revealed the following: May 13,2019 domestic hot water domestic heater temp (temperature) at 117 May 14,2019 domestic hot water domestic heater temp (temperature) at 117 May 15,2019 domestic hot water domestic heater temp (temperature) at 129 May 16,2019 domestic hot water domestic heater temp (temperature) at 129 May 17,2019 domestic hot water domestic heater temp (temperature) at 129 May 18,2019 domestic hot water domestic heater temp (temperature) at 129 May 19,2019 domestic hot water domestic heater temp (temperature) at 129 May 20,2019 domestic hot water domestic heater temp (temperature) at 129 The facility's Chief Operating Officer (COO) B and DF C was also present on 05/20/19 at approximately 7:00 p.m. said after reviewing the data for the Domestic Heater Water Temperature it did not meet the Long Term Care Unit Standard of 95-110 degrees Fahrenheit. Review of the current American Burn Association Scald Injury Prevention Educator's Guide provided the following information. The basis of the information is from research conducted by Moritz, AR, Herriques, FC Jr. Studies of thermal injuries: II The relative importance of time and surface temperature in the causation of cutaneous burns. M J Pathol 1947; 23:695-720. and(NAME) M, Ahmed J,(NAME)J. The continuing risk of domestic hot water scalds to the elderly.[MEDICAL CONDITION]; 26:347-350.: .although [MEDICAL CONDITION] happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older Adults .Older adults, .have thinner skin so hot liquids cause [MEDICAL CONDITION] even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds .sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person ' s perception, memory, judgment or awareness may hinder the person ' s ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further review of the Guide revealed that 100 degree F. water was a safe temperature for bathing. Water at 120 degrees F. would cause a third degree burn (full thickness burn) in 5 minutes and 124 degrees F. water would cause a third degree burn in 3 minutes. The Guide further documented that water at 127 degrees F. caused third degree burns in 1 minute and water at 133 degrees F. caused third degree burns within 15 seconds. Water temperatures at 140 degrees F. caused third [MEDICAL CONDITION] 5 seconds.

Based on observation, interview, and record review the facility failed to ensure services provided as outlined by the comprehensive care plan, meet professional standards of quality for one Resident (R #1) of five residents reviewed for professional standards of clinical practice. -RN D did not obtain and document a stage of R #1's pressure ulcer on the Admission Skin Assessment. RN G did not obtain and document a stage of R #1's pressure ulcer on the proceeding pressure ulcer assessments. -RN G did not ensure once the nurse established the presence of R #1's pressure ulcer upon admission, that a physician's orders for treatment was obtained and initiated. -RN A did not recognize/identify that R #1's Stage 2 pressure ulcer had deteriorated into an Unstageable pressure ulcer, until the surveyor's inquiry. R #1's pressure ulcer met the definition of an Unstageable pressure ulcer however, RN A continued to identify the ulcer as a Stage 2 instead of an unstageable. -RN A did not accurately identify or measure R #1's pressure ulcer as one pressure ulcer. RN A identified and measured R #1's pressure ulcer as three separate ulcers when in fact, the ulcer began as one ulcer. These failures could affect two residents with pressure ulcers and eight residents receiving preventative skin care and place them at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: The Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11, Standards of Nursing Practice states: The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; .(D) Accurately and completely report and document: (i) the clients status including signs and symptoms; (ii) nursing care rendered; .(v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client ' s status; .(H) Make reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations; . (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications ; .(O) Implement measures to prevent exposure to infectious pathogens and communicable conditions; .(U) Supervise nursing care provided by others for whom the nurse is professionally responsible; . The facility's Pressure ulcer and Skin Tear Prevention Management Policy and Procedure dated 03/2008 documented All patients will have an initial assessment for identification of risk and/or presence of pressure ulcers and/or skin tears using the Braden Pressure Ulcer Risk Screen. The patient will be managed by multipledisciplinary (IDT) health team members through initiation of physician orders or skin care management protocols. Braden Pressure Ulcer Risk Screen score will be totaled and a total score of 16 or less will trigger the nurse to initiate Wound Care Screen Referral. Procedure: 1. RN will complete the Braden Pressure Ulcer Risk Screen during the admission process. Appropriate interventions will be planned and implemented based on score or level of risk assessed. 2. If the RN establishes the presence of pressure ulcers and/or skin tears, the RN will perform a head to toe thorough assessment with documentation of the wounds. A wound care screen referral will be initiated. 3. Once the RN establishes the presence of pressure ulcers and/or skin tears, the RN/ wound Care Nurse will obtain and initiate physician's orders for treatment. 4. Ongoing risk assessment in acute care and skilled nursing must be completed with each concurrent shift nursing assessment. 5. Reassessment will be performed by the RN on a daily basis or as the patient's condition and/or appearance of existing wound changes. The reassessment will include the following: a. Completion of the Braden Scale for Pressure ulcer Risk and document score on the daily nurse's notes. b. Documentation of reassessment findings on a daily nursing notes or wound care daily note. c. Pictures of the wound will be taken every seven days or if wound's appearance changes . The facility's Physician Orders: Multidisciplinary participation in the Receipt and Implementation of Orders Policy and Procedure dated 06/2012 documented To provide a method for the acknowledgement, coordination and implementation of the diagnostic and therapeutic orders given by medical staff with privileges to practice .1. Physician's Orders may be communicated via computerized provider order entry, written, verbal, telephone and/or facsimile .The physician's orders will be used for the provision of care, treatment, and services to the patient. Anytime an order is in question, it must be clarified by the ordering physician . The facility's Wound Healing Definition Policy and Procedure dated 04/01/07 documented .Wounded Skin: a chronic wound is the visible evidence of pathological changes in the blood supply to dermal tissue. Usually it is a break in the integrity of the skin, but reddened skin that is not broken us classified as a Stage I pressure sore .D. Wound Assessment and Documentation: 1. Before you can heal a wound, it is important to assess the wound thoroughly. Assessment Criteria include: a. Location b. Stage and size c. Necrotic tissue d. Wound bed. surrounding skin and wound edges e, Exudate/drainage. 2. Location . 3. Stage and Size of pressure ulcers- the staging of pressure ulcers is based on the level of tissue development. a. Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure or shear. It may be proceeded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. b. Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from surrounding area. c. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as intact or open/ruptured serum filled-blister. d. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. e. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. f. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. R #1's Face Sheet dated 06/14/17 documented a [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #1's Care Plan dated 06/14/17 documented Skin Bundle: Stage 2. Linens free of wrinkles, Reposition frequently, Out of bed, Bed to Chair, Air Mattress, and Patient information . R #1's Admission Skin Assessment (performed by Registered Nurse- RN D) dated 06/14/17 revealed Sacral Ulcer covered with Mediplex dressing. Surgical Incisions to upper back with staples covered with gauze and paper tape. Pink bilateral heels. *The assessment did not include a description or stage of the pressure ulcer. R #1's Physician's Orders dated 06/14/17 documented Consult to wound care nurse to evaluate wound. *There was no evidence of orders for any treatment for [REDACTED]. R #1's consulted Initial Wound Care Photographic Record (Completed by Technician B) dated 06/16/17 documented Stage 2 Sacral Pressure Ulcer, multiple/irregular, minimal serosanguineous drainage, no odor. *The document did not include a thorough description or any measurement of the pressure ulcer. R #1's Systems Nursing Assessment (completed by RN G) dated 06/16/17 documented Sacrum Pressure Ulcer, Stage 2: -Abnormality Color: Red -Pressure Point: Bony Prominence -Dressing Type: Sensicare Cream -Dressing Assessment: drainage prominent -Wound Thickness: Partial -Pressure Ulcer present on admission: Yes -Exudate Amount: small -Exudate Type: Serosanguinous -Exudate Odor: none -Surrounding Tissue Condition: dry -Surrounding Tissue Color: Normal . *The document did not include a measurement of the pressure ulcer. R #1's Wound Care Progress Note (completed by RN G) dated 06/16/17 documented Sacral ulcer Stage 2 cleansed with normal saline/[MEDICATION NAME] rinsed with pat dry applied Sensicare protective cream (skin protective barrier cream). Floor nurses to continue to apply Sensicare with every diaper change . *There was no physician's order that confirmed the wound care nurse's recommendation to apply Sensicare cream. R #1's Braden Scale for Predicting Pressure Ulcer Risk dated 06/18/17 revealed a score of 15 (MILD RISK: Total Score 15-18). R #1's Admission Minimum Data (MDS) Set dated 06/20/17 documented R #1: -Made self understood and understood others. -Had a Brief Interview of Mental Status score of 15 (cognitively intact). -Required extensive assistance with two person physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. -Was always incontinent of urine and always incontinent of bowel. -Was at risk for pressure ulcer development and was admitted with one stage 2 pressure ulcer (Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as intact or open/ruptured serum filled-blister). -Skin and Ulcer Treatments: Pressure reducing device for bed, Pressure Ulcer care. Observation of R #1, while she received wound care, on 06/21/17 at 2:02 p.m. revealed R #1 was lying on an air mattress positioned on her right side. R #1's sacrum area had white cream evident all over the wound. After R #1's wound was cleaned of the white cream, the pressure ulcer extended over the left and right buttocks on the sacrum approximately the length of the surveyor's pointer finger with the width of approximately half the size of the surveyor's pointer finger. The bed of the wound was mostly white with some red specks of granulation tissue. The border of the ulcer was red. Within the left side of wound bed was a circular brown/black cap of tissue approximately the size of a small button. Within the right side of the wound bed was an elongated brown/black cap of tissue approximately the length of the surveyor's pen cap and the width approximately the size of the surveyor's pointer fingernail. There was some yellow tissue present in the right side of the wound bed with slight clear drainage. The outer outlining of the entire ulcer had pink tissue. There were two small areas (islands) of healed tissue within the wound bed. Registered Nurse (RN) A and Technician (Tech B) measured wound as three separate wounds with the left measuring 3.0 X 3.5 cm and the right 3.4 X 1.4 X 0.1 cm and on the right lower aspect of the wound measured 0.5 X 0.4 cm. RN A described the ulcer as Having granulation tissue with two spots of brown leathery caps, slight slough (yellow [MEDICATION NAME] tissue thought to be associated with bacterial activity), with three small areas of healing tissue and minimal serosanguinous drainage without odor. This surveyor asked RN A if R #1's pressure ulcer was one wound or two upon initial discovery and RN A responded One. This surveyor asked RN A why she was measuring the wound as three separate wounds rather than one and she responded Because there is a small island of healed tissue in the middle of the wound which makes the wound look like two separate wounds. Upon the surveyors request, RN A measured R #1's pressure ulcer as one ulcer stating It measures 5.5 X 5.5 X 0.1 cm. RN A applied Sensicare Cream over R #1's entire ulcer then covering it with a dressing. Further interview with RN A on 06/21/17 at 2:39 p.m. revealed she stated I agree it is a Stage 2. After reviewing R #1's Admission Skin assessment dated [DATE], Initial Wound Care Photographic Record dated 06/16/17, and Wound Care Progress Note dated 06/16/17 revealed she confirmed the documents should have clearly described the wound including measurements of the wound to be able to compare the initial with the following assessments in order to decide whether the wound is improving or deteriorating. RN A said R #1's wound was improving as far as size however, the ulcer was forming more darkened leathery tissue. RN A reviewed R #1's electronic documentation regarding her pressure ulcer and confirmed there were no measurements of the ulcer upon initial assessment. RN A said she could not find a physician's order to use Sensicare cream on R #1's ulcer but confirmed that she was using the cream for treatment. RN A stated I do not stage any ulcers, I assess the wound and I relay the description to the physician and the physician stages the ulcer and provides orders for treatment. RN A was asked in her professional opinion if the Sensicare protective barrier cream was an appropriate treatment for [REDACTED]. RN A said if R #1's wound had a change, which ever nurse identified the change would have to call and inform the physician. R #1's Wound Care Photographic Record (completed by RN A) dated 06/21/17 documented Sacral Pressure Ulcer-Stage 2. Size: 1.) 3.0 X 3.5 centimeters (cm.), 2.) 3.4 X 1.4 X 0.1 cm., 3.) 0.5 X 0.4 cm. Drainage: minimal serosanguinous, no odor. R #1's Wound Care Progress Note dated 06/21/17 documented .Wound to sacral Stage 2 with openings X 3 with islands in between wound bed, 50% [MEDICATION NAME] tissue, 30% granulation tissue, and 20 % slough noted, with scant serosanguinous drainage, no odor. Cleaned wound bed with normal saline and pat dried with gauze .Applied skin protectant to wound bed as ordered, followed by mepillex dressing to site . Interview with RN C on 06/21/17 at 3:10 p.m. revealed she identified herself as the facility's RN Case Manager. RN C said the facility protocol was that each resident was assessed upon admission from head to toe. RN C said if the resident presented with a pressure ulcer or an extensive wound, a referral would be sent to the wound care team. RN C said the wound care team would be the only staff to stage a pressure ulcer and take pictures of the wound then they would call the physician for specific treatment orders. RN C said the initial assessment must include description and measurement of the wound. RN C was shown R #1's Initial Wound Care Photographic Record and Wound Care Progress Notes dated 06/16/17 and asked if she agreed R #1's ulcer to be a Stage 2; RN C stated No, I can't agree because it has slough and deep tissue injury and I do not know what presents under those areas. I am not a wound care nurse but from my understanding of pressure ulcers, that is more extensive than a Stage 2. I would say it is an Unstageable. RN C reviewed R #1's initial assessments and physician orders regarding her pressure ulcer and confirmed the documentation lacked pressure ulcer measurements and physician orders for the Sensicare Cream. RN C said the negative effects would be that there were no initial measurements to compare to to evaluate whether the ulcer was smaller or bigger in size and the Sensicare cream may not be the best treatment for [REDACTED]. Interview with RN D on 06/21/17 at 4:18 p.m. revealed he conducted R #1's admitting assessment on 06/16/17. RN D confirmed he should have measured and better described the ulcer in his documentation. RN D said he sent as referral to the wound care team on 06/16/17. RN D stated one of the wound care team nurses that initially assessed R #1's ulcer on 06/16/17 made a communication note for the nursing staff to continue daily wound care using Sensicare cream as the treatment for [REDACTED]. RN D said R #1's ulcer was not a stage 2 and looked more like an Unstageable. After RN D compared R #1's Initial Wound Care Photographic Record and Wound Care Progress Notes dated 06/16/17 and Initial Wound Care Photographic Record and Wound Care Progress Notes dated 06/21/17 revealed he stated R #1's ulcer had deteriorated since he first saw it on 06/14/17. RN D said eschar was currently evident in two different areas in the ulcer. Interview with RN E on 06/21/17 at 5:25 p.m. revealed she identified herself as the Wound Care Team Director. RN E was informed of the surveyor's observations of R #1's pressure ulcer and the documentation of R #1's pressure ulcer. RN E said the facility protocol was that if a pressure ulcer was identified by the floor nurses, they create a referral to the wound care team. Once the wound care team assessed the ulcer, then the team staged the ulcer and informed the physician of the decription, stage, and received treatment orders from the physician. RN E reviewed R #1's physician's orders from admission to current date and confirmed there were no orders for treatment of [REDACTED]. RN E and the surveyor reviewed R #1's Wound Care Photographic Records and Wound Care Progress Notes dated 06/16/17 and 06/21/17; RN E said That is not a Stage 2, that is clearly an Unstageable, it has dry brownish slough or eschar. RN E verified R #1's ulcer clearly began as one ulcer I can't tell if initially it was a stage 2 or an Unstageable due to lack of description of the wound. After comparing R #1's Wound Care Photographic Records, RN E said It looks like it is getting worse but I have to see it for myself. RN E conducted an assessment of R #1's sacral pressure ulcer and said It is dry right now. It has 90% granulation, 10% slough with two separate areas with dry brownish leathery textured slough or eschar. It is an unstageable. By comparing the pictures, it looks like it has has gotten a little smaller but has worsened in that there is more slough growth. Its hard to say for sure that the size has decreased since we cannot compare initial measurements and current measurements. The entire ulcer measures length: 3.9 X width: 3.5 cm. The left darkened slough within the bed measures 0.8 X 0.7 cm and the right darkened slough measures: 2.0 X 1.0 cm. RN E said R #1's current treatment of [REDACTED]. RN E said she would immediately call the physician and inform him of the change of status of the wound. RN E stated the physician ordered Santyl (an enzymatic [MEDICATION NAME] ointment) to be applied on the wound bed and Sensicare cream surrounding the wound. RN E confirmed R #1's initial pressure ulcer assessments lacked definite descriptions, accurate staging, and measurements of the pressure ulcer. RN E confirmed a physician's order should have been retrieved and noted with specific treatment instructions of the pressure ulcer. RN E confirmed R #1's pressure ulcer deteriorated into an unstageable pressure ulcer. RN E confirmed the treatment (Sensicare Cream) currently used for R #1 was not entirely appropriate for the type of pressure ulcer R #1 incurred. RN E stated if R #1 did not receive the appropriate treatment for [REDACTED]. Interview with RN C on 06/22/17 at 10:00 a.m. revealed she confirmed there was no evidence that R #1's physician evaluated the pressure ulcer himself. More than likely he was treating using the nurses assessments/description of the ulcer told to him. Interview with RN F on 06/22/17 at 11:07 a.m. revealed she identified herself as the MDS Coordinator. RN F said she assessed R #1's pressure ulcer herself for the purpose of the MDS assessment. RN F said she documented R #1's pressure ulcer on her MDS as a Stage 2 because the specialists (referring to the wound care team) documented the ulcer as a Stage 2. RN F said she knew R #1's ulcer was not a Stage 2 because of the one necrotic area in the wound. RN F said R #1's pressure ulcer was an unstageable on 06/20/17, when she saw it. RN F said she did not inform the physician because she was waiting for the wound care team to re-assess it. RN F said she did not express her concerns of R #1's pressure ulcer staging to anyone. RN F said If the assessment is incorrect it could affect the wound healing process by not providing the correct treatment and maybe placing the patient at risk for wound deterioration. Yes, her (R #1) ulcer deteriorated compared to when she was initially admitted . The facility's Centers for Medicare and Medicaid Services (CMS) Form 672 identified two residents with pressure ulcers and eight residents receiving preventative skin care.

Based on observation, interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status, for one Resident (R #1) of two residents reviewed for physician consultation issues, in that: -The facility did not ensure once the nurse established the presence of R #1's pressure ulcer upon admission, that a physician's order for treatment was obtained and initiated. There was no evidence R #1's physician was consulted for treatment of [REDACTED]. -The facility did not recognize/identify that R #1's Stage 2 pressure ulcer had deteriorated into an Unstageable pressure ulcer, until the surveyor's inquiry. R #1's pressure ulcer met the definition of an Unstageable pressure ulcer however, the Wound Care Nurse (RN A) continued to identify the ulcer as a Stage 2. R #1's physician was not consulted of R #1's pressure ulcer deteriorating, upon the initial signs of deterioration. These failures could affect two residents with pressure ulcers and eight residents receiving preventative skin care and place them at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: R #1's Face Sheet dated 06/14/17 documented a [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #1's Care Plan dated 06/14/17 documented Skin Bundle: Stage 2. Linens free of wrinkles, Reposition frequently, Out of bed, Bed to Chair, Air Mattress, and Patient information . R #1's Admission Skin assessment dated [DATE] revealed Sacral Ulcer covered with Mediplex dressing. Surgical Incisions to upper back with staples covered with gauze and paper tape. Pink bilateral heels. R #1's Physician's Orders dated 06/14/17 documented Consult to wound care nurse to evaluate wound. *There was no evidence of treatment orders for R #1's pressure ulcer. R #1's consulted Initial Wound Care Photographic Record dated 06/16/17 documented Stage 2 Sacral Pressure Ulcer, multiple/irregular, minimal serosanguineous drainage, no odor. *This document did not include a thorough description or any measurement of the pressure ulcer. R #1's Systems Nursing assessment dated [DATE] documented Sacrum Pressure Ulcer, Stage 2: -Abnormality Color: Red -Pressure Point: Bony Prominence -Dressing Type: Sensicare Cream -Dressing Assessment: drainage prominent -Wound Thickness: Partial -Pressure Ulcer present on admission: Yes -Exudate Amount: small -Exudate Type: Serosanguinous -Exudate Odor: none -Surrounding Tissue Condition: dry -Surrounding Tissue Color: Normal . *The document did not include a measurement of the pressure ulcer. R #1's Wound Care Progress Note dated 06/16/17 documented Sacral ulcer Stage 2 cleansed with normal saline/[MEDICATION NAME] rinsed with pat dry applied Sensicare protective cream (skin protective barrier cream). Floor nurses to continue to apply Sensicare with every diaper change . *There was no physician's order that confirmed the wound care nurse's recommendation to apply Sensicare cream. R #1's Braden Scale for Predicting Pressure Ulcer Risk dated 06/18/17 revealed a score of 15 (MILD RISK: Total Score 15-18). R #1's Admission Minimum Data (MDS) Set dated 06/20/17 documented R #1: -Made self understood and understood others. -Had a Brief Interview of Mental Status score of 15 (cognitively intact). -Required extensive assistance with two person physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. -Was always incontinent of urine and always incontinent of bowel. -Was at risk for pressure ulcer development and was admitted with one stage 2 pressure ulcer (Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as intact or open/ruptured serum filled-blister). -Skin and Ulcer Treatments: Pressure reducing device for bed, Pressure Ulcer care. Observation of R #1, while she received wound care, on 06/21/17 at 2:02 p.m. revealed R #1 was lying on an air mattress positioned on her right side. R #1's sacrum area had white cream evident all over the wound. After R #1's wound was cleaned of the white cream, the pressure ulcer extended over the left and right buttocks on the sacrum approximately the length of the surveyor's pointer finger with the width of approximately half the size of the surveyor's pointer finger. The bed of the wound was mostly white with some red specks of granulation tissue. The border of the ulcer was red. Within the left side of wound bed was a circular brown/black cap of tissue approximately the size of a small button. Within the right side of the wound bed was an elongated brown/black cap of tissue approximately the length of the surveyor's pen cap and the width approximately the size of the surveyor's pointer fingernail. There was some yellow tissue present in the right side of the wound bed with slight clear drainage. The outer outlining of the entire ulcer had pink tissue. There were two small areas (islands) of healed tissue within the wound bed. Registered Nurse (RN) A and Technician (Tech B) measured wound as three separate wounds with the left measuring 3.0 X 3.5 cm and the right 3.4 X 1.4 X 0.1 cm and on the right lower aspect of the wound measured 0.5 X 0.4 cm. RN A described the ulcer as Having granulation tissue with two spots of brown leathery caps, slight slough (yellow [MEDICATION NAME] tissue thought to be associated with bacterial activity), with three small areas of healing tissue and minimal serosanguinous drainage without odor. This surveyor asked RN A if R #1's pressure ulcer was one wound or two upon initial discovery and RN A responded One. This surveyor asked RN A why she was measuring the wound as three separate wounds rather than one and she responded Because there is a small island of healed tissue in the middle of the wound which makes the wound look like two separate wounds. Upon the surveyors request, RN A measured R #1's pressure ulcer as one ulcer stating It measures 5.5 X 5.5 X 0.1 cm. RN A applied Sensicare Cream over R #1's entire ulcer then covering it with a dressing. Further interview with RN A on 06/21/17 at 2:39 p.m. revealed she stated I agree it is a Stage 2. After reviewing R #1's Admission Skin assessment dated [DATE], Initial Wound Care Photographic Record dated 06/16/17, and Wound Care Progress Note dated 06/16/17 revealed she confirmed the documents should have clearly described the wound including measurements of the wound to be able to compare the initial with the following assessments in order to decide whether the wound is improving or deteriorating. RN A said R #1's wound was improving as far as size however, the ulcer was forming more darkened leathery tissue. RN A reviewed R #1's electronic documentation regarding her pressure ulcer and confirmed there were no measurements of the ulcer upon initial assessment. RN A said she could not find a physician's order to use Sensicare cream on R #1's ulcer but confirmed that she was using the cream for treatment. RN A stated I do not stage any ulcers, I assess the wound and I relay the description to the physician and the physician stages the ulcer and provides orders for treatment. RN A was asked in her professional opinion if the Sensicare protective barrier cream was an appropriate treatment for [REDACTED]. RN A said if R #1's wound had a change, which ever nurse identified the change would have to call and inform the physician. RN A said she had not contacted R #1's physician regarding R #1's pressure ulcer. R #1's Wound Care Photographic Record dated 06/21/17 documented Sacral Pressure Ulcer-Stage 2. Size: 1.) 3.0 X 3.5 centimeters (cm.), 2.) 3.4 X 1.4 X 0.1 cm., 3.) 0.5 X 0.4 cm. Drainage: minimal serosanguinous, no odor. R #1's Wound Care Progress Note dated 06/21/17 documented .Wound to sacral Stage 2 with openings X 3 with islands in between wound bed, 50% [MEDICATION NAME] tissue, 30% granulation tissue, and 20 % slough noted, with scant serosanguinous drainage, no odor. Cleaned wound bed with normal saline and pat dried with gauze .Applied skin protectant to wound bed as ordered, followed by mepillex dressing to site . Interview with RN C on 06/21/17 at 3:10 p.m. revealed she identified herself as the facility's RN Case Manager. RN C said the facility protocol was that each resident was assessed upon admission from head to toe. RN C said if the resident presented with a pressure ulcer or an extensive wound, a referral would be sent to the wound care team. RN C said the wound care team would be the only staff to stage a pressure ulcer and take pictures of the wound then they would call the physician for specific treatment orders. RN C said the initial assessment must include description and measurement of the wound. RN C was shown R #1's Initial Wound Care Photographic Record and Wound Care Progress Notes dated 06/16/17 and asked if she agreed R #1's ulcer to be a Stage 2; RN C stated No, I can't agree because it has slough and deep tissue injury and I do not know what presents under those areas. I am not a wound care nurse but from my understanding of pressure ulcers, that is more extensive than a Stage 2. I would say it is an Unstageable. RN C reviewed R #1's initial assessments and physician orders regarding her pressure ulcer and confirmed the documentation lacked pressure ulcer measurements and physician orders for the Sensicare Cream. RN C said the negative effects would be that there were no initial measurements to compare to to evaluate whether the ulcer was smaller or bigger in size and the Sensicare cream may not be the best treatment for [REDACTED]. Interview with RN D on 06/21/17 at 4:18 p.m. revealed he conducted R #1's admitting assessment on 06/16/17. RN D confirmed he should have measured and better described the ulcer in his documentation. RN D said he sent as referral to the wound care team on 06/16/17. RN D stated one of the wound care team nurses that initially assessed R #1's ulcer on 06/16/17 made a communication note for the nursing staff to continue daily wound care using Sensicare cream as the treatment for [REDACTED]. RN D said R #1's ulcer was not a stage 2 and looked more like an Unstageable. After RN D compared R #1's Initial Wound Care Photographic Record and Wound Care Progress Notes dated 06/16/17 and Initial Wound Care Photographic Record and Wound Care Progress Notes dated 06/21/17 revealed he stated R #1's ulcer had deteriorated since he first saw it on 06/14/17. RN D said eschar was currently evident in two different areas in the ulcer. Interview with RN E on 06/21/17 at 5:25 p.m. revealed she identified herself as the Wound Care Team Director. RN E was informed of the surveyor's observations of R #1's pressure ulcer and the documentation of R #1's pressure ulcer. RN E said the facility protocol was that if a pressure ulcer was identified by the floor nurses, they create a referral to the wound care team. Once the wound care team assessed the ulcer, then the team staged the ulcer and informed the physician of the decription, stage, and received treatment orders from the physician. RN E reviewed R #1's physician's orders from admission to current date and confirmed there were no orders for treatment of [REDACTED]. RN E and the surveyor reviewed R #1's Wound Care Photographic Records and Wound Care Progress Notes dated 06/16/17 and 06/21/17; RN E said That is not a Stage 2, that is clearly an Unstageable, it has dry brownish slough or eschar. RN E verified R #1's ulcer clearly began as one ulcer I can't tell if initially it was a stage 2 or an Unstageable due to lack of description of the wound. After comparing R #1's Wound Care Photographic Records, RN E said It looks like it is getting worse but I have to see it for myself. RN E conducted an assessment of R #1's sacral pressure ulcer and said It is dry right now. It has 90% granulation, 10% slough with two separate areas with dry brownish leathery textured slough or eschar. It is an unstageable. By comparing the pictures, it looks like it has has gotten a little smaller but has worsened in that there is more slough growth. Its hard to say for sure that the size has decreased since we cannot compare initial measurements and current measurements. The entire ulcer measures length: 3.9 X width: 3.5 cm. The left darkened slough within the bed measures 0.8 X 0.7 cm and the right darkened slough measures: 2.0 X 1.0 cm. RN E said R #1's current treatment of [REDACTED]. RN E said she would immediately call the physician and inform him of the change of status of the wound. RN E stated the physician ordered Santyl (an enzymatic [MEDICATION NAME] ointment) to be applied on the wound bed and Sensicare cream surrounding the wound. RN E confirmed R #1's initial pressure ulcer assessments lacked definite descriptions, accurate staging, and measurements of the pressure ulcer. RN E confirmed a physician's order should have been retrieved and noted with specific treatment instructions of the pressure ulcer. RN E confirmed R #1's physician should have been informed when R #1's pressure ulcer deteriorated into an unstageable pressure ulcer. RN E confirmed the treatment (Sensicare Cream) currently used for R #1 was not entirely appropriate for the type of pressure ulcer R #1 incurred. RN E stated if R #1 did not receive the appropriate treatment for [REDACTED]. Interview with RN C on 06/22/17 at 10:00 a.m. revealed she confirmed there was no evidence that R #1's physician had been contacted or that the physician evaluated the pressure ulcer himself. More than likely he was treating it using the nurses assessments/description of the ulcer told to him. The facility's Pressure ulcer and Skin Tear Prevention Management Policy and Procedure dated 03/2008 documented All patients will have an initial assessment for identification of risk and/or presence of pressure ulcers and/or skin tears using the Braden Pressure Ulcer Risk Screen. The patient will be managed by multipledisciplinary (IDT) health team members through initiation of physician orders or skin care management protocols. Braden Pressure Ulcer Risk Screen score will be totaled and a total score of 16 or less will trigger the nurse to initiate Wound Care Screen Referral. Procedure: 1. RN will complete the Braden Pressure Ulcer Risk Screen during the admission process. Appropriate interventions will be planned and implemented based on score or level of risk assessed. 2. If the RN establishes the presence of pressure ulcers and/or skin tears, the RN will perform a head to toe thorough assessment with documentation of the wounds. A wound care screen referral will be initiated. 3. Once the RN establishes the presence of pressure ulcers and/or skin tears, the RN/ wound Care Nurse will obtain and initiate physician's orders for treatment. 4. Ongoing risk assessment in acute care and skilled nursing must be completed with each concurrent shift nursing assessment. 5. Reassessment will be performed by the RN on a daily basis or as the patient's condition and/or appearance of existing wound changes. The reassessment will include the following: a. Completion of the Braden Scale for Pressure ulcer Risk and document score on the daily nurse's notes. b. Documentation of reassessment findings on a daily nursing notes or wound care daily note. c. Pictures of the wound will be taken every seven days or if wound's appearance changes . The facility's Physician Orders: Multidisciplinary participation in the Receipt and Implementation of Orders Policy and Procedure dated 06/2012 documented To provide a method for the acknowledgement, coordination and implementation of the diagnostic and therapeutic orders given by medical staff with privileges to practice .1. Physician's Orders may be communicated via computerized provider order entry, written, verbal, telephone and/or facsimile .The physician's orders will be used for the provision of care, treatment, and services to the patient. Anytime an order is in question, it must be clarified by the ordering physician . The facility's Centers for Medicare and Medicaid Services (CMS) Form 672 identified two residents with pressure ulcers and eight residents receiving preventative skin care.

Based on observation, interview, and record review the facility failed to ensure residents who entered the facility having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further deterioration or development of skin breakdown of pressure ulcers for one resident (R #1) of two residents reviewed for pressure ulcers. The facility did not: -obtain and document a thorough stage of R #1's pressure ulcer on the Admission Skin Assessment or the proceeding assessments. -ensure once the nurse established the presence of R #1's pressure ulcer upon admission, that a physician's orders for treatment was obtained and initiated. There was no evidence R #1 had a physician's order for treatment from admission, until the surveyor's inquiry. -recognize/identify that R #1's Stage 2 pressure ulcer had deteriorated into an Unstageable pressure ulcer, until the surveyor's inquiry. R #1's pressure ulcer met the definition of an Unstageable pressure ulcer however, the Wound Care Nurse (RN A) continued to identify the ulcer as a Stage 2 instead of an unstageable. -accurately identify or measure R #1's pressure ulcer as one pressure ulcer. RN A identified and measured R #1's pressure ulcer as three separate ulcers when in fact, the ulcer began as one ulcer. These failures could affect two residents with pressure ulcers and eight residents receiving preventative skin care and place them at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: R #1's Face Sheet dated 06/14/17 documented a [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #1's Care Plan dated 06/14/17 documented Skin Bundle: Stage 2. Linens free of wrinkles, Reposition frequently, Out of bed, Bed to Chair, Air Mattress, and Patient information . R #1's Admission Skin assessment dated [DATE] revealed Sacral Ulcer covered with Mediplex dressing. Surgical Incisions to upper back with staples covered with gauze and paper tape. Pink bilateral heels. *The assessment did not include a description or stage of the pressure ulcer. R #1's Physician's Orders dated 06/14/17 documented Consult to wound care nurse to evaluate wound. *There was no evidence of orders for any treatment for [REDACTED]. R #1's consulted Initial Wound Care Photographic Record dated 06/16/17 documented Stage 2 Sacral Pressure Ulcer, multiple/irregular, minimal serosanguineous drainage, no odor. *The document did not include a thorough description or any measurement of the pressure ulcer. R #1's Systems Nursing assessment dated [DATE] documented Sacrum Pressure Ulcer, Stage 2: -Abnormality Color: Red -Pressure Point: Bony Prominence -Dressing Type: Sensicare Cream -Dressing Assessment: drainage prominent -Wound Thickness: Partial -Pressure Ulcer present on admission: Yes -Exudate Amount: small -Exudate Type: Serosanguinous -Exudate Odor: none -Surrounding Tissue Condition: dry -Surrounding Tissue Color: Normal . *The document did not include a measurement of the pressure ulcer. R #1's Wound Care Progress Note dated 06/16/17 documented Sacral ulcer Stage 2 cleansed with normal saline/[MEDICATION NAME] rinsed with pat dry applied Sensicare protective cream (skin protective barrier cream). Floor nurses to continue to apply Sensicare with every diaper change . *There was no physician's order that confirmed the wound care nurse's recommendation to apply Sensicare cream. R #1's Braden Scale for Predicting Pressure Ulcer Risk dated 06/18/17 revealed a score of 15 (MILD RISK: Total Score 15-18). R #1's Admission Minimum Data (MDS) Set dated 06/20/17 documented R #1: -Made self understood and understood others. -Had a Brief Interview of Mental Status score of 15 (cognitively intact). -Required extensive assistance with two person physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. -Was always incontinent of urine and always incontinent of bowel. -Was at risk for pressure ulcer development and was admitted with one stage 2 pressure ulcer (Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as intact or open/ruptured serum filled-blister). -Skin and Ulcer Treatments: Pressure reducing device for bed, Pressure Ulcer care. Observation of R #1, while she received wound care, on 06/21/17 at 2:02 p.m. revealed R #1 was lying on an air mattress positioned on her right side. R #1's sacrum area had white cream evident all over the wound. After R #1's wound was cleaned of the white cream, the pressure ulcer extended over the left and right buttocks on the sacrum approximately the length of the surveyor's pointer finger with the width of approximately half the size of the surveyor's pointer finger. The bed of the wound was mostly white with some red specks of granulation tissue. The border of the ulcer was red. Within the left side of wound bed was a circular brown/black cap of tissue approximately the size of a small button. Within the right side of the wound bed was an elongated brown/black cap of tissue approximately the length of the surveyor's pen cap and the width approximately the size of the surveyor's pointer fingernail. There was some yellow tissue present in the right side of the wound bed with slight clear drainage. The outer outlining of the entire ulcer had pink tissue. There were two small areas (islands) of healed tissue within the wound bed. Registered Nurse (RN) A and Technician (Tech B) measured wound as three separate wounds with the left measuring 3.0 X 3.5 cm and the right 3.4 X 1.4 X 0.1 cm and on the right lower aspect of the wound measured 0.5 X 0.4 cm. RN A described the ulcer as Having granulation tissue with two spots of brown leathery caps, slight slough (yellow [MEDICATION NAME] tissue thought to be associated with bacterial activity), with three small areas of healing tissue and minimal serosanguinous drainage without odor. This surveyor asked RN A if R #1's pressure ulcer was one wound or two upon initial discovery and RN A responded One. This surveyor asked RN A why she was measuring the wound as three separate wounds rather than one and she responded Because there is a small island of healed tissue in the middle of the wound which makes the wound look like two separate wounds. Upon the surveyors request, RN A measured R #1's pressure ulcer as one ulcer stating It measures 5.5 X 5.5 X 0.1 cm. RN A applied Sensicare Cream over R #1's entire ulcer then covering it with a dressing. Further interview with RN A on 06/21/17 at 2:39 p.m. revealed she stated I agree it is a Stage 2. After reviewing R #1's Admission Skin assessment dated [DATE], Initial Wound Care Photographic Record dated 06/16/17, and Wound Care Progress Note dated 06/16/17 revealed she confirmed the documents should have clearly described the wound including measurements of the wound to be able to compare the initial with the following assessments in order to decide whether the wound is improving or deteriorating. RN A said R #1's wound was improving as far as size however, the ulcer was forming more darkened leathery tissue. RN A reviewed R #1's electronic documentation regarding her pressure ulcer and confirmed there were no measurements of the ulcer upon initial assessment. RN A said she could not find a physician's order to use Sensicare cream on R #1's ulcer but confirmed that she was using the cream for treatment. RN A stated I do not stage any ulcers, I assess the wound and I relay the description to the physician and the physician stages the ulcer and provides orders for treatment. RN A was asked in her professional opinion if the Sensicare protective barrier cream was an appropriate treatment for [REDACTED]. RN A said if R #1's wound had a change, which ever nurse identified the change would have to call and inform the physician. R #1's Wound Care Photographic Record dated 06/21/17 documented Sacral Pressure Ulcer-Stage 2. Size: 1.) 3.0 X 3.5 centimeters (cm.), 2.) 3.4 X 1.4 X 0.1 cm., 3.) 0.5 X 0.4 cm. Drainage: minimal serosanguinous, no odor. R #1's Wound Care Progress Note dated 06/21/17 documented .Wound to sacral Stage 2 with openings X 3 with islands in between wound bed, 50% [MEDICATION NAME] tissue, 30% granulation tissue, and 20 % slough noted, with scant serosanguinous drainage, no odor. Cleaned wound bed with normal saline and pat dried with gauze .Applied skin protectant to wound bed as ordered, followed by mepillex dressing to site . Interview with RN C on 06/21/17 at 3:10 p.m. revealed she identified herself as the facility's RN Case Manager. RN C said the facility protocol was that each resident was assessed upon admission from head to toe. RN C said if the resident presented with a pressure ulcer or an extensive wound, a referral would be sent to the wound care team. RN C said the wound care team would be the only staff to stage a pressure ulcer and take pictures of the wound then they would call the physician for specific treatment orders. RN C said the initial assessment must include description and measurement of the wound. RN C was shown R #1's Initial Wound Care Photographic Record and Wound Care Progress Notes dated 06/16/17 and asked if she agreed R #1's ulcer to be a Stage 2; RN C stated No, I can't agree because it has slough and deep tissue injury and I do not know what presents under those areas. I am not a wound care nurse but from my understanding of pressure ulcers, that is more extensive than a Stage 2. I would say it is an Unstageable. RN C reviewed R #1's initial assessments and physician orders regarding her pressure ulcer and confirmed the documentation lacked pressure ulcer measurements and physician orders for the Sensicare Cream. RN C said the negative effects would be that there were no initial measurements to compare to to evaluate whether the ulcer was smaller or bigger in size and the Sensicare cream may not be the best treatment for [REDACTED]. Interview with RN D on 06/21/17 at 4:18 p.m. revealed he conducted R #1's admitting assessment on 06/16/17. RN D confirmed he should have measured and better described the ulcer in his documentation. RN D said he sent as referral to the wound care team on 06/16/17. RN D stated one of the wound care team nurses that initially assessed R #1's ulcer on 06/16/17 made a communication note for the nursing staff to continue daily wound care using Sensicare cream as the treatment for [REDACTED]. RN D said R #1's ulcer was not a stage 2 and looked more like an Unstageable. After RN D compared R #1's Initial Wound Care Photographic Record and Wound Care Progress Notes dated 06/16/17 and Initial Wound Care Photographic Record and Wound Care Progress Notes dated 06/21/17 revealed he stated R #1's ulcer had deteriorated since he first saw it on 06/14/17. RN D said eschar was currently evident in two different areas in the ulcer. Interview with RN E on 06/21/17 at 5:25 p.m. revealed she identified herself as the Wound Care Team Director. RN E was informed of the surveyor's observations of R #1's pressure ulcer and the documentation of R #1's pressure ulcer. RN E said the facility protocol was that if a pressure ulcer was identified by the floor nurses, they create a referral to the wound care team. Once the wound care team assessed the ulcer, then the team staged the ulcer and informed the physician of the decription, stage, and received treatment orders from the physician. RN E reviewed R #1's physician's orders from admission to current date and confirmed there were no orders for treatment of [REDACTED]. RN E and the surveyor reviewed R #1's Wound Care Photographic Records and Wound Care Progress Notes dated 06/16/17 and 06/21/17; RN E said That is not a Stage 2, that is clearly an Unstageable, it has dry brownish slough or eschar. RN E verified R #1's ulcer clearly began as one ulcer I can't tell if initially it was a stage 2 or an Unstageable due to lack of description of the wound. After comparing R #1's Wound Care Photographic Records, RN E said It looks like it is getting worse but I have to see it for myself. RN E conducted an assessment of R #1's sacral pressure ulcer and said It is dry right now. It has 90% granulation, 10% slough with two separate areas with dry brownish leathery textured slough or eschar. It is an unstageable. By comparing the pictures, it looks like it has has gotten a little smaller but has worsened in that there is more slough growth. Its hard to say for sure that the size has decreased since we cannot compare initial measurements and current measurements. The entire ulcer measures length: 3.9 X width: 3.5 cm. The left darkened slough within the bed measures 0.8 X 0.7 cm and the right darkened slough measures: 2.0 X 1.0 cm. RN E said R #1's current treatment of [REDACTED]. RN E said she would immediately call the physician and inform him of the change of status of the wound. RN E stated the physician ordered Santyl (an enzymatic [MEDICATION NAME] ointment) to be applied on the wound bed and Sensicare cream surrounding the wound. RN E confirmed R #1's initial pressure ulcer assessments lacked definite descriptions, accurate staging, and measurements of the pressure ulcer. RN E confirmed a physician's order should have been retrieved and noted with specific treatment instructions of the pressure ulcer. RN E confirmed R #1's pressure ulcer deteriorated into an unstageable pressure ulcer. RN E confirmed the treatment (Sensicare Cream) currently used for R #1 was not entirely appropriate for the type of pressure ulcer R #1 incurred. RN E stated if R #1 did not receive the appropriate treatment for [REDACTED]. Interview with RN C on 06/22/17 at 10:00 a.m. revealed she confirmed there was no evidence that R #1's physician evaluated the pressure ulcer himself. More than likely he was treating using the nurses assessments/description of the ulcer told to him. Interview with RN F on 06/22/17 at 11:07 a.m. revealed she identified herself as the MDS Coordinator. RN F said she assessed R #1's pressure ulcer herself for the purpose of the MDS assessment. RN F said she documented R #1's pressure ulcer on her MDS as a Stage 2 because the specialists (referring to the wound care team) documented the ulcer as a Stage 2. RN F said she knew R #1's ulcer was not a Stage 2 because of the one necrotic area in the wound. RN F said R #1's pressure ulcer was an unstageable on 06/20/17, when she saw it. RN F said she did not inform the physician because she was waiting for the wound care team to re-assess it. RN F said she did not express her concerns of R #1's pressure ulcer staging to anyone. RN F said If the assessment is incorrect it could affect the wound healing process by not providing the correct treatment and maybe placing the patient at risk for wound deterioration. Yes, her (R #1) ulcer deteriorated compared to when she was initially admitted . The facility's Pressure ulcer and Skin Tear Prevention Management Policy and Procedure dated 03/2008 documented All patients will have an initial assessment for identification of risk and/or presence of pressure ulcers and/or skin tears using the Braden Pressure Ulcer Risk Screen. The patient will be managed by multipledisciplinary (IDT) health team members through initiation of physician orders or skin care management protocols. Braden Pressure Ulcer Risk Screen score will be totaled and a total score of 16 or less will trigger the nurse to initiate Wound Care Screen Referral. Procedure: 1. RN will complete the Braden Pressure Ulcer Risk Screen during the admission process. Appropriate interventions will be planned and implemented based on score or level of risk assessed. 2. If the RN establishes the presence of pressure ulcers and/or skin tears, the RN will perform a head to toe thorough assessment with documentation of the wounds. A wound care screen referral will be initiated. 3. Once the RN establishes the presence of pressure ulcers and/or skin tears, the RN/ wound Care Nurse will obtain and initiate physician's orders for treatment. 4. Ongoing risk assessment in acute care and skilled nursing must be completed with each concurrent shift nursing assessment. 5. Reassessment will be performed by the RN on a daily basis or as the patient's condition and/or appearance of existing wound changes. The reassessment will include the following: a. Completion of the Braden Scale for Pressure ulcer Risk and document score on the daily nurse's notes. b. Documentation of reassessment findings on a daily nursing notes or wound care daily note. c. Pictures of the wound will be taken every seven days or if wound's appearance changes . The facility's Physician Orders: Multidisciplinary participation in the Receipt and Implementation of Orders Policy and Procedure dated 06/2012 documented To provide a method for the acknowledgement, coordination and implementation of the diagnostic and therapeutic orders given by medical staff with privileges to practice .1. Physician's Orders may be communicated via computerized provider order entry, written, verbal, telephone and/or facsimile .The physician's orders will be used for the provision of care, treatment, and services to the patient. Anytime an order is in question, it must be clarified by the ordering physician . The facility's Wound Healing Definition Policy and Procedure dated 04/01/07 documented .Wounded Skin: a chronic wound is the visible evidence of pathological changes in the blood supply to dermal tissue. Usually it is a break in the integrity of the skin, but reddened skin that is not broken us classified as a Stage I pressure sore .D. Wound Assessment and Documentation: 1. Before you can heal a wound, it is important to assess the wound thoroughly. Assessment Criteria include: a. Location b. Stage and size c. Necrotic tissue d. Wound bed. surrounding skin and wound edges e, Exudate/drainage. 2. Location . 3. Stage and Size of pressure ulcers- the staging of pressure ulcers is based on the level of tissue development. a. Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure or shear. It may be proceeded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. b. Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from surrounding area. c. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as intact or open/ruptured serum filled-blister. d. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. e. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. f. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. The facility's Centers for Medicare and Medicaid Services (CMS) Form 672 identified two residents with pressure ulcers and eight residents receiving preventative skin care.

Based on observation, interview, and record review, the facility failed to establish and maintain an Infection Prevention and Control Program designed to help prevent the standard and transmission-based precautions to be followed to prevent spread of infections or diseases, for one Resident (R #1) of six residents observed receiving a wound care, in that: Registered Nurse (RN) A did not perform hand hygiene according to the facility's policy and procedure while providing wound care for R #1. These failures could place two residents identified as receiving wound care for pressure ulcers at risk for exposure to infections. The findings included: The facility's Hand Hygiene Policy and Procedure dated 02/01/17 documented Hand washing is the single most important means of preventing the spread of infection. Hand hygiene is necessary to remove dirt, organic materials, transient microorganisms, and to reduce resident flora. It is part of a comprehensive approach to providing the patient with a sanitary environment thus reducing the risk of infection When hand hygiene is necessary, personnel will follow hand hygiene practices in accordance with the following current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or World Health Organization (WHO) Hand Hygiene Guidelines A. Types of Hand Hygiene: Hand wash- Purpose: To remove soil or transient microorganisms. Method: Soap for at least 15 seconds . Indications for Hand Hygiene: 1. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood orother body fluids, WASH HANDS with either a non-anyimicrobial soap and water or an antimicrobial soap and water 7. WASH HANDS after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings . According to the CDC (Centers for Disease Control-www.cdc) and WHO (World Health Organization-www.who.org) reviewed on 06/30/17 revealed Hand Washing Guidelines in Healthcare Settings: When to wash hands: 1. Before patient contact; 2. Before aseptic task; 3. After body fluid exposure risk; 4. After patient contact; 5. After contact with patient surroundings (including inanimate objects and medical equipment). Hand Washing Procedure: -Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap. -Lather your hands by rubbing them together with the soap. Be sure to lather the backs of your hands, between your fingers, and under your nails. -Scrub your hands for at least 20 seconds. Need a timer? Hum the Happy Birthday song from beginning to end twice. -Rinse your hands well under clean, running water. -Dry your hands using a clean towel or air dry them. R #1's Face Sheet dated 06/14/17 documented a [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #1's Admission Minimum Data (MDS) Set dated 06/20/17 documented R #1: -Made self understood and understood others. -Had a Brief Interview of Mental Status score of 15 (cognitively intact). -Required extensive assistance with two person physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. -Was always incontinent of urine and always incontinent of bowel. -Was at risk for pressure ulcer development and was admitted with one stage 2 pressure ulcer (Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as intact or open/ruptured serum filled-blister). -Skin and Ulcer Treatments: Pressure reducing device for bed, Pressure Ulcer care. Observation of R #1, while she received wound care, on 06/21/17 at 2:02 p.m. revealed R #1 was lying on an air mattress positioned on her right side. RN A removed R #1's dressing from her sacral pressure ulcer. RN A removed her gloves and scrubbed her hands with soap for a total of 10 seconds. R #1's sacrum area had white cream evident all over the wound. RN A assisted in cleaning R #1's wound of the white cream then removed her gloves and scrubbed her hands with soap for a total of eight seconds. After RN A applied the treatment cream to R #1's ulcer she removed her gloves and scrubbed her hands with soap for a total of 11 seconds before rinsing with water. Interview with RN A on 06/21/17 at 2:39 p.m. revealed she stated she was taught the hand washing process was for at least 15 seconds. The facility's Centers for Medicare and Medicaid Services (CMS) Form 672 identified two residents with pressure ulcers.

Based on observation, interview, and record review the facility failed to develop a comprehensive care plan to meet the medical, nursing, mental, and psychosocial needs for two residents (R #1 and R #7) out of eight residents reviewed for care plans. R #1 and R #7's current Care Plans did not include the goods and services to be provided for Activities. This deficient practice could affect five residents whom the facility found to not have an Activity Care Plan at risk of not attaining or maintaining the resident's highest practicable mental and psychosocial well-being. The findings included: R #1: R #1's Face Sheet dated 05/18/16 documented a [AGE] year-old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #1's Initial Minimum Data Set ((MDS) dated [DATE] documented R #1 was able to make self understood, understood others, and was able to recall. R #1 required extensive assistance for dressing, bathing, and personal hygiene. R #1's Care Plans dated 05/26/16 did not include the goods and services to be provided for Activities. Interview with Registered Nurse (RN) A on 06/01/16 at 5:12 p.m. revealed she introduced herself as the facility's unit manager. RN A revised R #1's Care Plans and verified R #1 did not include a description the goods and services for Activities. RN A said every resident should have an Activity Care Plan. RN A said the admitting nurse was responsible for activating an Activity Care Plan. RN A said the facility recently went through the process of converting from paper documentation to electronic documentation; RN A said the new process may have contributed to the omission of the Activity Care Plan. R #7: R #7's Face Sheet dated 05/18/16 documented a [AGE] year-old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #7's Admission MDS dated [DATE] documented R #7 had clear speech, was able to make self understood, understood others, and was able to recall. R #7 required extensive assistance for dressing, bathing, and personal hygiene. R #7's current Care Plans dated 06/01/16 revealed the goods and services to be provided for Activities was initiated on 06/01/16, after the surveyor's inquiry. Interview with RN A on 06/02/16 at 1:46 p.m. revealed R #7's Activity Care Plan was created and initiated on 06/01/16 after she was made aware by the surveyor that R #1 did not have an Activity Care Plan. RN A said a couple of residents, including R #7, were found to not have an Activity Care Plan created however, each of their care plans would be revised. According to RN A on 06/02/16 at 1:46 p.m., there were five residents identified by the facility as not having an Activity Care Plan.

Based on observation, interview, and record review, the facility failed to implement and maintain an Infection Prevention and Control Program in order to prevent, recognize, and control, to the extent possible, the onset and spread of infection in that: 1) Registered Nurse (RN) "A" did not wash her hands for the amount of time per the facility's policy and procedure and as recommended by the Centers for Disease Control (CDC). 2) Licensed Vocational Nurse (LVN) "B" did not wash her hands after handling a dirty wound dressing, between changing gloves, and before administering an injection. These failures could expose all staff and residents to infections. The findings included: 1.) On 05/19/15 at 5:17 p.m., the surveyor observed RN "A" provide wound care to R #3. After sanitizing R #3's bedside table, RN "A" scrubbed her hands with soap and water for 12 seconds. After cleaning the wound, RN "A" doffed her gloves and then scrubbed her hands with soap and water for 14 seconds. After RN "A" applied medication to R #3's wound, RN "A" doffed her gloves and scrubbed her hands with soap and water for 12 seconds, donned gloves and then applied clean dressings to R #3's wound. After RN "A" doffed her gloves, she scrubbed her hands with soap and water for 11 seconds and rinsed her hands under running water for 10 seconds. RN "A" did not wash her hands with soap and water for at least 20 seconds. On 05/19/15 at 5:30 p.m., RN "A" stated the entire handwashing process should not be less than 15 seconds. 2.) On 05/20/15 at 8:42 a.m., the surveyor observed LVN "B" enter R #9's room with her rolling computer and medications. LVN "B" sanitized her hands, donned gloves, and lifted R #9's left knee dirty dressing. LVN "B" retrieved some paper tape and re-taped R #9's dressing. LVN "B" sanitized her hands for four seconds, donned clean gloves, and administered R #9 her [MEDICATION NAME] (blood thinner) injection to R #9's abdomen. LVN "B" doffed her gloves and scrubbed her hands with soap and water for 14 seconds and rinsed her hands under running water for three seconds. LVN "B" did not wash her hands with soap and water for at least 20 seconds, did not wash her hands after handling R #9's wound dressing or before administering R #9 an injection, and did not rub hand sanitizer throughout her hands for at least 20 seconds. On 05/20/15 at 8:50 a.m., LVN "B" stated the facility hand hygiene policy and procedure was to sanitize or handwash for 15 seconds. LVN "B" stated it was acceptable to use hand sanitizer instead of soap and water after dressing a wound and before administering an injection to a resident. The facility's Hand Hygiene Policy and Procedure dated 05/1992 documented "(The facility) personnel will follow hand hygiene practices in accordance with the following current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines...Procedure: A. Hand wash with soap for 15 seconds. B. 7. WASH HANDS after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings. 8. WASH HANDS if moving from a contaminated-body site to a clean-body site during patient care. C. Technique for Handwashing: Wash hands vigorously for 15 seconds, using friction to cover all surfaces of the hand, with particular attention to fingertips and nails. E. Hand Antisepsis: Hand antisepsis can also be achieved by using alcohol-based hand rubs for at least 20 seconds..." On 05/20/15 at 10:11 a.m., Infection Control RN "C" stated the facility policy was to rub hands with soap and water for a total of 15 seconds. Infection Control RN "C" said with any dressing change, handwashing is definite. Infection Control RN "C" said it was acceptable to use hand sanitizer to administer injections if hands were not soiled. According to the CDC (Centers for Disease Control), the CDC recommends the following handwashing procedure be used. "Wet your hands with clean, running water. Lather your hands by rubbing them together with the soap. Be sure to lather the backs of your hands, between your fingers, and under your nails. Scrub your hands for at least 20 seconds, Need a timer? Hum the 'Happy Birthday' song from beginning to end twice. Rinse your hands well under clean, running water. Dry your hands using a clean towel or air dry them with a clean paper towel turn off the water." The facility's Center for Medicare and Medicaid Services (CMS) Form 672 dated 05/19/15 documented a census of 17 residents.

Based on observation, interview and record review, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary environment, and to help prevent transmission of disease and infection for three Residents (R#5, R#6, and R#9) of three residents reviewed for showers/bathing, catheter/ incontinent care, and finger stick to check blood sugar level. Certified Nurse Aide (CNA) "B" did not wash her hands with an acceptable technique/duration or between changing gloves when R #5 was provided catheter care and incontinent care. CNA "A" - did not wash her hands with an acceptable technique/duration or between changing gloves when R #9 was assisted with a shower - did not wash her hands with an acceptable technique/duration between changing gloves when R#6 was assisted with bed pan -did not wash her hands with an acceptable technique/duration before and after R#6's blood sugar level was checked via a finger stick. Environment Services Aide (ESA) "C" did not follow the directions to ensure R#9's shower room and equipment was sanitized. These failures could affect 6 residents who required assistance with showers on 05/29/14; 6 residents who required incontinent care, 2 residents who required catheter care, 6 residents who required finger sticks to check their blood sugar levels by placing them at risk for exposure to diseases and infections that could compromise their health. The findings were: Excerpts from the facility's Handwashing policy effective date May 1992 and most recent review dated April 2012 indicated: "HAND HYGIENE I. Purpose: Hand washing is the single most important means of preventing the spread of infection. Hand hygiene is necessary to remove dirt, organic materials, transient microorganisms, and to reduce resident flora. It is part of a comprehensive approach to providing the patient with a sanitary environment thus reducing the risk of infection. II. Policy: When hand hygiene is necessary, (facility) personnel will follow hand hygiene practices in accordance with following current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or World Health Organization (WHO) Hand Hygiene Guidelines. ... IV. Procedure ...B. Indications for hand hygiene: ...3) Decontaminate hands before having direct contact with patients. ...8) Wash Hands if moving from a contaminated-body site to a clean-body site during patient care. ...10) Decontaminate hands after removing gloves and prior to donning another pair of gloves. C. Technique for Handwashing: ...3. Wet hand under running water. 4. Keep hands lower than elbows and apply soap or antiseptic. 5. Wash hands vigorously for 15 seconds, using friction to cover all surfaces of the hand, with particular attention to fingertips and nails. 6. Rinse under running water ... CDC (Centers for Disease Control) recommends the following procedure be used. "Wet your hands with clean, running water. Lather your hands by rubbing them together with the soap. Be sure to lather the backs of your hands, between your fingers, and under your nails. Scrub your hands for at least 20 seconds, Need a timer? Hum the 'Happy Birthday' song from beginning to end twice. Rinse your hands well under clean, running water. Dry your hands using a clean towel or air dry them. With a clean paper towel turn off the water." R#5: R#5's Face Sheet indicated she was admitted to the facility on [DATE] with an admission [DIAGNOSES REDACTED]. R#5's physician orders [REDACTED]. Surveyor used own watch with second hand to time handwashing. On 05/28/14 at 3:45 p.m., CNA "B" provided catheter care to R#5. CNA "B" removed her gloves after catheter care was provided and donned new gloves without washing her hands or using sanitizer. R#5 was incontinent of bowel. CNA "B" used wet wipes to clean R#5's buttock area. CNA "B" then removed her gloves without washing her hands or using sanitizer. CNA "B" donned a clean pair of gloves and applied a barrier cream ointment to R#5's buttock area. CNA "B" rolled up the soiled pad and assisted R#5 to reposition on her side so the soiled pad could be removed and placed a clean pad. CNA "B" removed her gloves and donned a clean pair of gloves without washing or sanitizing her hands. CNA "B" then assisted with positioning and covering R#5 with blankets. CNA "B" then removed the trash bag from the trash container and placed it in a cabinet inside R#5's room. On 05/28/14 at 4:03 p.m., CNA "B" stated the cabinet in the room is designated to store the trash until Environmental Services comes to pick it up. CNA "B" stated "We're supposed to wash our hands between glove changes." Surveyor asked CNA "B" if she washed her hands between glove changes when she provided R#5 catheter and incontinent care. CNA "B" stated "Not at that time, but I do it sometimes." R#9: R#9's Face Sheet indicated she was admitted to the facility on [DATE] with an admission [DIAGNOSES REDACTED].#9's initial assessment revealed she required one person assistance with bathing. On 05/29/14 at 8:53 a.m., surveyor was accompanied by CNA "A" down the hallway to R#9's room. CNA "A" did not use the sanitizer foam before entering R#9's room. CNA "A" did not wash her hands or use sanitizer before she donned gloves. After R#9's shower, CNA "A" removed her gloves and washed her hands for eight seconds before donning new gloves. CNA "A" picked up the soiled wash cloths and wet towels and placed them in the covered laundry container. CNA "A" removed her gloves and washed her hands for ten seconds, donned gloves and assisted R#9 with getting dressed. CNA "A" removed her gloves and washed her hands for eight seconds. CNA "A" stated that she does not clean the shower area and planned to call environmental services to clean R#9's shower room. On 05/29/14 at 9:22 a.m. Environmental Services Aide (ESA "C") entered R#9's room. ESA "C" used sanitizer and donned gloves and proceeded to clean R#9's bedroom area. ESA "C" went into the shower room. ESA "C" held the disinfectant spray with her left hand and the hand held shower device with her right hand. ESA "C" sprayed disinfectant spray on the top of the shower chair seat and immediately rinsed it off with the hand held shower sprayer. ESA "C" did not disinfectant the back, sides or underneath the shower chair. ESA "C" then used the disinfectant spray on the shower grab bar, lower shower stall walls, floor, and immediately rinsed the disinfectant spray off with water within a couple of seconds. The disinfectant spray had a brand name printed on the plastic bottle with the following : "One step cleaner and deodorant. Directions: Remove gross filth. Apply use solution to hard nonporous surfaces. Allow to remain wet for 10 minutes. Wipe or let air dry. On 05/29/14 at 9:45 a.m., surveyor asked if this is her usual method of cleaning the shower chair. ESA "C" stated "I only clean the top and sides, sometimes I use a brush underneath." ESA "C" confirmed that she had not cleaned the sides, back or underneath the shower chair. Surveyor asked ESA "C" what was the duration to leave the sanitizer spray on the equipment, shower area. ESA "C" stated "this is how I always do it." ESA "C" stated that she had not read the printed directions on the disinfectant spray bottle. R#6: R#6 face sheet indicated she was admitted to the Skilled Nursing Unit on 05/28/14 at 8:40 p.m. with the following Diagnoses: [REDACTED]. R#6's admission orders [REDACTED]. On 05/29/14 at 11:53 a.m., during wound care, R#6 stated she needed to use the restroom. CNA "A" entered the room and donned gloves without washing her hands. CNA "A" handed R#6 a plastic bedpan to use. After R#6 finished using the bedpan, CNA "A" removed the bedpan. CNA "A" removed her gloves and washed her hands for eight seconds. On 05/29/14 at 12:02 p.m., CNA "A" washed her hands for eight seconds, donned gloves then she used a lancet to check R#6 blood sugar level. CNA "A" removed her gloves and washed her hands for ten seconds and donned clean gloves to use disinfectant wipes to clean the accu-check device. After cleaning the accu-check device, CNA "A" removed her gloves and washed her hands 12 seconds before exiting R#6's room. On 05/30/14 at 08:25 a.m., surveyor asked CNA "A" prior to surveyor entry when was the most recent in-service training on hand washing and infection control. CNA "A" said "On skill day about a month ago in April. We see videos and have in-services." CNA "A" stated that staff were told "Alcohol gel is good too. Handwashing is 15 to 20 seconds. We're supposed to wash our hands from room to room, and every time we change our gloves." CNA "A" confirmed that she had not washed her hands upon entering R#6's room and was not sure how long the actual duration she washed her hands. On 05/29/14 at 4:13 p.m., the Infection Preventionist (IP) was asked when and how long (duration) staff are trained on hand hygiene. IP said "15 seconds (duration) and any time we have contact. Hand gel is okay when walking into the room." On 05/30/14, the facility provided a copy of the Cleaning Responsibilities & Schedule form effective dates May 1992 and February 2012. It indicated to spray (brand name) disinfectant on the shower chair and leave it on for 10 minutes. On 05/28/14, the facility provided a copy of the Patient (census) List that listed 13 residents. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to infection control. As of exit on 05/30/14 at 10:45 a.m., the facility provided no further information.

Based on observation, interview and record review, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary environment, and to help prevent transmission of disease and infection for three Residents (R#5, R#6, and R#9) of three residents reviewed for showers/bathing, catheter/ incontinent care, and finger stick to check blood sugar level. Certified Nurse Aide (CNA) "B" did not wash her hands with an acceptable technique/duration or between changing gloves when R #5 was provided catheter care and incontinent care. CNA "A" - did not wash her hands with an acceptable technique/duration or between changing gloves when R #9 was assisted with a shower - did not wash her hands with an acceptable technique/duration between changing gloves when R#6 was assisted with bed pan -did not wash her hands with an acceptable technique/duration before and after R#6's blood sugar level was checked via a finger stick. These failures could affect 6 residents who required assistance with showers on 05/29/14; 6 residents who required incontinent care, 2 residents who required catheter care, 6 residents who required finger sticks to check their blood sugar levels by placing them at risk for exposure to diseases and infections that could compromise their health. The findings were: Excerpts from the facility's Handwashing policy effective date May 1992 and most recent review dated April 2012 indicated: "HAND HYGIENE I. Purpose: Hand washing is the single most important means of preventing the spread of infection. Hand hygiene is necessary to remove dirt, organic materials, transient microorganisms, and to reduce resident flora. It is part of a comprehensive approach to providing the patient with a sanitary environment thus reducing the risk of infection. II. Policy: When hand hygiene is necessary, (facility) personnel will follow hand hygiene practices in accordance with following current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or World Health Organization (WHO) Hand Hygiene Guidelines. ... IV. Procedure ...B. Indications for hand hygiene: ...3) Decontaminate hands before having direct contact with patients. ...8) Wash Hands if moving from a contaminated-body site to a clean-body site during patient care. ...10) Decontaminate hands after removing gloves and prior to donning another pair of gloves. C. Technique for Handwashing: ...3. Wet hand under running water. 4. Keep hands lower than elbows and apply soap or antiseptic. 5. Wash hands vigorously for 15 seconds, using friction to cover all surfaces of the hand, with particular attention to fingertips and nails. 6. Rinse under running water ... CDC (Centers for Disease Control) recommends the following procedure be used. "Wet your hands with clean, running water. Lather your hands by rubbing them together with the soap. Be sure to lather the backs of your hands, between your fingers, and under your nails. Scrub your hands for at least 20 seconds, Need a timer? Hum the 'Happy Birthday' song from beginning to end twice. Rinse your hands well under clean, running water. Dry your hands using a clean towel or air dry them. With a clean paper towel turn off the water." R#5: R#5's Face Sheet indicated she was admitted to the facility on [DATE] with an admission [DIAGNOSES REDACTED]. R#5's physician orders [REDACTED]. Surveyor used own watch with second hand to time handwashing. On 05/28/14 at 3:45 p.m., CNA "B" provided catheter care to R#5. CNA "B" removed her gloves after catheter care was provided and donned new gloves without washing her hands or using sanitizer. R#5 was incontinent of bowel. CNA "B" used wet wipes to clean R#5's buttock area. CNA "B" then removed her gloves without washing her hands or using sanitizer. CNA "B" donned a clean pair of gloves and applied a barrier cream ointment to R#5's buttock area. CNA "B" rolled up the soiled pad and assisted R#5 to reposition on her side so the soiled pad could be removed and placed a clean pad. CNA "B" removed her gloves and donned a clean pair of gloves without washing or sanitizing her hands. CNA "B" then assisted with positioning and covering R#5 with blankets. CNA "B" then removed the trash bag from the trash container and placed it in a cabinet inside R#5's room. On 05/28/14 at 4:03 p.m., CNA "B" stated the cabinet in the room is designated to store the trash until Environmental Services comes to pick it up. CNA "B" stated "We're supposed to wash our hands between glove changes." Surveyor asked CNA "B" if she washed her hands between glove changes when she provided R#5 catheter and incontinent care. CNA "B" stated "Not at that time, but I do it sometimes." R#9: R#9's Face Sheet indicated she was admitted to the facility on [DATE] with an admission [DIAGNOSES REDACTED].#9's initial assessment revealed she required one person assistance with bathing. On 05/29/14 at 8:53 a.m., surveyor was accompanied by CNA "A" down the hallway to R#9's room. CNA "A" did not use the sanitizer foam before entering R#9's room. CNA "A" did not wash her hands or use sanitizer before she donned gloves. After R#9's shower, CNA "A" removed her gloves and washed her hands for eight seconds before donning new gloves. CNA "A" picked up the soiled wash cloths and wet towels and placed them in the covered laundry container. CNA "A" removed her gloves and washed her hands for ten seconds, donned gloves and assisted R#9 with getting dressed. CNA "A" removed her gloves and washed her hands for eight seconds. CNA "A" stated that she does not clean the shower area and planned to call environmental services to clean R#9's shower room. R#6: R#6 face sheet indicated she was admitted to the Skilled Nursing Unit on 05/28/14 at 8:40 p.m. with the following Diagnoses: [REDACTED]. R#6's admission orders [REDACTED]. On 05/29/14 at 11:53 a.m., during wound care, R#6 stated she needed to use the restroom. CNA "A" entered the room and donned gloves without washing her hands. CNA "A" handed R#6 a plastic bedpan to use. After R#6 finished using the bedpan, CNA "A" removed the bedpan. CNA "A" removed her gloves and washed her hands for eight seconds. On 05/29/14 at 12:02 p.m., CNA "A" washed her hands for eight seconds, donned gloves then she used a lancet to check R#6 blood sugar level. CNA "A" removed her gloves and washed her hands for ten seconds and donned clean gloves to use disinfectant wipes to clean the accu-check device. After cleaning the accu-check device, CNA "A" removed her gloves and washed her hands 12 seconds before exiting R#6's room. On 05/30/14 at 08:25 a.m., surveyor asked CNA "A" prior to surveyor entry when was the most recent in-service training on hand washing and infection control. CNA "A" said "On skill day about a month ago in April. We see videos and have in-services." CNA "A" stated that staff were told "Alcohol gel is good too. Handwashing is 15 to 20 seconds. We're supposed to wash our hands from room to room, and every time we change our gloves." CNA "A" confirmed that she had not washed her hands upon entering R#6's room and was not sure how long the actual duration she washed her hands. On 05/29/14 at 4:13 p.m., the Infection Preventionist (IP) was asked when and how long (duration) staff are trained on hand hygiene. IP said "15 seconds (duration) and any time we have contact. Hand gel is okay when walking into the room." The facility In-service sign in sheet dated 01/17/14 for 'Key Concepts of Infection Control & Prevention' revealed CNA "A" and "B" were in attendance. The facility course dated 01/24/14 on 'Hand Hygiene' revealed CNA "A" completed the course. The facility course dated 04/29/14 on 'Hand Hygiene' revealed CNA "B" completed the course. On 05/28/14, the facility provided a copy of the Patient (census) List that listed 13 residents. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to infection control. As of exit on 05/30/14 at 10:45 a.m., the facility provided no further information.

Based on interview and record review, the facility failed to immediately report an allegation of abuse involving Resident (R #8) and within five working days report the results of the abuse investigation, in accordance with State law, to the Department of Aging and Disability Services for one of one investigations reviewed. The facility did not report an allegation of sexual abuse made by a female resident (R #8). This failure could affect the nine female residents in the facility. The findings were: R #8 was admitted to the facility on [DATE] and discharged from the facility on 03-14-14, according to admission and discharge data. R #8's History and Physical, dated 02-15-14 revealed [DIAGNOSES REDACTED]. R #8's Admission Minimum (MDS) data set [DATE] indicated that according to the Brief Interview for Mental Status (BIMS) score, R #8 was cognitively intact. R #8 also required extensive assistance with her activities of daily living, such as transfers, dressing, personal hygiene, and bathing. According to facility complaint report provided on 05-28-14, on 03-03-14, R #8's family member reported to the Director that on the previous night, R #8 stated a "young, white gentleman came into her room claiming to be the doctor..." R #8 stated she "...was touched all over her body and kissed all over her neck and lips..." The family member reported R #8 was "very scared" and did not want to be alone. The Director conducted an investigation into the allegation, including interviews with R #8, family members, nursing staff and R #8's primary physician. R #8 was moved closer to the nurse's station in order to better monitor visitors. The report indicated R #8's cognitive status was possibly altered as a result of an ongoing wound infection, along with the administration of a potent narcotic medication. The investigation concluded the allegation of abuse could not be substantiated. Corporate legal staff had an opinion the incident was not reportable to either the State hospital licensing agency, Department of State Health Services, since there was no cause to believe that the allegation was true or DADS (Department of Aging and Disability Services) since the facility was not a nursing facility. At 3:20 p.m. on 05-29-14, the Director informed surveyor that the family member of R #8 did report an allegation of abuse and that an investigation into the allegation was conducted. The Director stated that the allegation was unsubstantiated. The Director stated that the facility had not had an abuse allegation in a number of years. The Director indicated that the incident was not considered reportable under hospital licensing regulations, after consulting with Risk Management and legal. Facility Abuse surveillance policy, revised 12-21-10, indicated that "...Alleged violations and all substantiated incidences will be reported to the state agency as required. Necessary corrective actions will be taken depending on the results of the investigation. (The facility) will ensure that all alleged violations involving neglect, abuse or mistreatment of [REDACTED]. Health and Safety Code ?242.122 and 40 Texas Administrative Code (TAC) ?19.602(a) require any facility staff member who has cause to believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation caused by another person to report the abuse, neglect, or exploitation. Facilities are required at 40 TAC ?19.601(c)(2) to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, are reported immediately to DADS. Facilities are also required to report certain other incidents, which may or may not constitute abuse, neglect, or exploitation. Certified facilities are required by 42 Code of Federal Regulations (CFR) ?483.13(c)(2) and (4) to report alleged violations involving mistreatment, neglect, or abuse, including injuries of an unknown source and misappropriation of resident property, and the results of the investigation conducted by the facility to the state survey and certification agency. The facility or facility staff member must report incidents to the Consumer Rights and Services Section, DADS State Office, Austin, Texas, immediately (within 24 hours) upon learning of the incident and send a written investigation report to the Consumer Rights and Services Section no later than the fifth working day after the oral report. The facility must use the Provider Investigation Report to document facility investigations. The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. If the alleged violation is substantiated, appropriate corrective action must be taken. Patient List, provided on 05-28-14, identified nine female residents. At the exit conference at 10:45 a.m. on 05-30-14, the facility was provided an opportunity to provide additional information related to reporting of abuse. No additional information was provided.

Based on record review and interview, the facility failed to ensure that, when the facility anticipated discharge of a Resident (R#8), there was a discharge summary that included a recapitulation of the resident's stay, for one of one closed record reviewed. A discharge summary was not completed for R#8, who was discharged in March 2014. This failure could result in incorrect, incomplete or misleading information being recorded regarding discharged residents, which could affect all 13 residents. The findings included: Review of the facility's Discharge Summary form for R#8 revealed the discharge summary form was in the record, however, the entire form was blank. Further review of R#8's clinical record revealed that she was admitted to the skilled nursing unit on 02/21/14 for rehabilitation related to a surgical procedure (open reduction internal fixation) to her left wrist. According to physician orders [REDACTED].#8 was discharged home on[DATE] with orders to "resume same home health." Interview with the Director on 05/30/14 at 08:55 a.m. confirmed that the discharge summary for R#8 was blank. The Director further stated that the facility's Health Information Manager located in the medical records department was responsible to review the medical record and ensure the physician filled out the discharge summary within 30 days of the resident's discharge. During an interview with the facility Health Information Manager on 05/30/14 at 9:10 a.m., she stated discharge summaries are to be completed within 30 days of discharge and any time after that the chart is delinquent. The Health Information Manager stated that when the 30 days is exceeded that she does the following: -Chief of Staff is notified -Notices are sent out daily to the physician -Start calling MD's (Medical Doctors) to get the chart completed. "We keep track of attempts for chart completion. Do that on a daily basis." Patient List, provided on 05-28-14, indicated a census of 13 residents. At the exit conference at 10:45 a.m. on 05-30-14, the facility was provided an opportunity to provide additional information related to discharge summary completion. No additional information was provided.

Based on observation, interview and record review, the facility failed to develop comprehensive plans of care that included measurable objectives to meet residents individual needs as identified in the comprehensive assessments for three Residents (R#6, 8 and 9) of nine residents reviewed for care plans. R#6 and 9 were on contact isolation precautions. The Care Plan (CP) did not indicate any problem area/interventions regarding isolation procedures. R#8 had a total knee replacement. The CP did not address the surgical site, inflammation, reddness or care of surgical site. Failure to address individual needs in the CP could affect all 17 residents in the facility by delaying care and treatment. The findings were: R#6: R#6's Admission Face Sheet dated 04/18/13 indicated the [DIAGNOSES REDACTED]. R#6's laboratory results dated [DATE] indicated: Sputum and Urine positive with Multi-Drug Resistant (MDR). R#6's physician's orders [REDACTED]. "Place patient on contact isolation. Diagnosis-MDR Accenobactor (different types of bacteria)." On 04/29/13 at 1:00 p.m., observed a sign on R#6's door that indicated, "Contact Precautions. Perform Hand Hygiene. Put on Gown. Put on Gloves." Review of R#6's CP dated 04/18/13 indicated: "Infection Potential- Actual/Potential, related to Peripheral IV (tube inserted into a vein for access to give medications, blood or nutrition)." The CP did not address contact isolation or precautions related to isolation. R#9: R#9's Admission Face Sheet dated 04/23/13 indicated [DIAGNOSES REDACTED]. Review of R#9's admitting orders indicated "Contact Isolation [MEDICAL CONDITIONS] of Nares (nose)." Review of R#9's CP dated 04/23/13 indicated: "Infection Potential- Actual/Potential, related to Peripheral IV." The CP did not address contact isolation or precautions/interventions related to isolation. R#8: R#8's Admission Face Sheet dated 04/22/13 indicated [DIAGNOSES REDACTED]. Review of R#8's CP dated 04/22/13 indicated: "Infection Potential- Actual/Potential, related to Peripheral IV." The CP did not address the surgical site, sutures, reddness, inflammation, bleeding, dressing or [MEDICAL CONDITION]. In an interview on 05/01/13 at 2:00 p.m., the unit Director said the admitting Registered Nurse (RN) initiated the CP. The contact isolation and the knee precautions should have been added to the infection area of the CP. The Director said "our CPs address general infection control and don't address individual interventions." The facility's Centers for Medicare and Medicaid Services form 672 dated 04/29/13 indicated a census of 17 residents. At the exit conference on 05/01/13 at 3:15 p.m., the facility was given the opportunity to provide any additional information related to CPs and none was given.

Based on observation, interview and record review, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the transmission of disease and infection for two Residents (R#6 and 9) of two Residents observed for infection control. Housekeeper (HSK) "C" did not wear a gown when entering R#6's room. R#6 was on contact isolation precautions. Registered Nurses (RN) "A" and "B" removed a notebook, without sanitizing it, from R#6 and 9's room. R#6 and 9 were on contact isolation precautions. The failure to maintain an Infection Control Program could result in the transmission of infectious agents throughout the unit and affect all 17 residents by placing them at risk for facility acquired diseases or infection. The findings were: Facility's Policy and Procedure dated April 1998, Contact Precautions: "In addition to standard precautions, contact precautions are to be used for patients known or suspected to be infected with microorganisms. These microorganisms can be transmitted by direct contact with the patient or through indirect contact with patient's environment. 4. GLOVES AND GOWN must be worn when entering the room of a patient on contact precautions. 7. If use of common equipment is unavoidable, then adequately clean and disinfect items with a hospital-approved disinfectant before use for another patient." R#6: R#6's Admission Face Sheet dated 04/18/13 indicated the [DIAGNOSES REDACTED]. R#6's laboratory results dated [DATE] indicated: Sputum and Urine positive with Multi-Drug Resistant (MDR). R#6's physician's orders [REDACTED]. "Place patient on contact isolation. Diagnosis-MDR Accenobactor (different types of bacteria)." On 04/29/13 at 1:00 p.m., observed a sign on R#6's door that indicated, "Contact Precautions. Perform Hand Hygiene. Put on Gown. Put on Gloves." On 04/29/13 at 3:00 p.m. observed HSK "C" stop at R#6's door and put on gloves. Without wearing a gown, HSK entered R#6's room, removed the trash bags liners, brought them out to the central barrel and re-entered the room. Again she came out with more trash bags, placed the trash bags in the central trash barrel, removed her gloves and proceeded to the next room where she put on gloves and entered that room. During an interview on 05/01/13 at 1:15 p.m. HSK "C" said she forgot to put on the gown. HSK "C" said she had been trained on precautions. In an interview on 05/01/13 at 1:30 p.m., The unit Director said "all staff should wear PPE (personal protective equipment-includes gown, gloves, mask)" referring to contact isolation. On 04/30/13 at 9:30 a.m., observed RN "B" enter R#6's room to administer his medications. RN "B" placed a notebook (Medication Administration Record-MAR) on the sink counter during the procedure. Afterwards, RN "B" wiped the notebook cover with a sanitizing agent and then she laid the same notebook back on the counter. RN "B" removed the notebook from R#6's room without sanitizing it and went to the medication room where she laid the notebook on the counter. During an interview on 05/01/13 at 2:30 p.m., RN "B" said she thought she did wipe the notebook. RN "B" said she did not realize she laid the notebook back down again on the same counter in R#6's room. On 05/01/13 at 9:00 a.m., observed RN "A" enter R#6's room to administer medications. RN "A" placed a notebook on the overbed table next to R#6's bed. After administering the medications, RN "A" picked up the notebook, left R#6's room without sanitizing it and placed the notebook on the counter in the medication room. In an interview on 05/01/13 at 2:15 p.m., RN "A" said "Oh, gosh, I didn't think" referring to cross contamination between the notebook and the counter. R#9: Review of R#9's admitting orders indicated "Contact Isolation for MRSA of Nares (nose)." On 04/30/13 at 8:30 a.m., RN "A" entered R#9's room to administer his medications. RN "A" laid the notebook on the overbed table next to R#9's bed. After administering the medications, RN "A" picked up the notebook and left R#9's room without sanitizing the notebook. RN "A" returned the notebook back to the medication room counter. In an interview on 05/01/13 at 1:30 p.m., The Director said " We are going to have to come up with something for the notebook" referring to a way to sanitize it or leave it outside the rooms. The facility's Center for Medicare and Medicaid form 672 dated 04/29/13 indicated a census of 17 residents and two on contact isolation. At the exit conference on 05/01/13 at 3:15 p.m., the facility was given the opportunity to provide any additional information regarding infection control and none was given.

Based on observation, interview, and record review the facility failed to provide the services to prevent aspiration pneumonia for two Residents (R#3 and 6) of two Residents with gastrostomy tubes observed during medication administration. Registered Nurses' (RN) "A" and "B" administered gastrostomy tube (gt) medications to R#3 and 6 without checking for placement of the gt and residual. Failure to check placement of the gt and residual prior to administration of medications could affect all three residents who were nourished via gt placing them at risk for possible aspiration into the lungs of instilled fluids. The findings were: R#3: R#3's Admission Face Sheet dated 04/24/13 indicated [DIAGNOSES REDACTED]. R#3's May 2013 physician's orders [REDACTED].) daily and Aspirin 81 mg. via gt. (tube inserted through abdomen into stomach to administer fluids/nutrition/medications) daily. On 04/30/13 at 9:00 a.m., observed RN "B" enter R#3's room to administer medications per gt. RN "B" did not check for placement of the gt nor residual (amount of fluid in stomach) prior to administering the medications. R#6: R#6's Admission Face Sheet dated 04/18/13 indicated the [DIAGNOSES REDACTED]. R#6's May 2013 physician's orders [REDACTED].(Dementia), [MEDICATION NAME] 5mg. (Alzheimers), [MEDICATION NAME] 25 mg. (anti-nausea), [MEDICATION NAME] 25 mg. (Antipsychotic) and [MEDICATION NAME] 100 mg. (Diabetic) per gt. On 04/30/13 at 9:30 a.m., observed RN "B" enter R#6's room to administer medications per gt. RN "B" did not check for placement of gt or residual prior to administering the medications. In an interview on 05/01/13 at 10:45 a.m., RN "B" said, "I know better," referring to checking placement and residual. On 05/01/13 at 9:00 a.m., observed RN "A" enter R#6's room to administer his medications via gt. RN "A" did not check for placement of gt or residual prior to administering the medications. In an interview on 05/01/13 at 10:50 a.m. RN "A" said "Darn, I was trying to do everything right and forgot to do that" referring to checking placement and residual. Facility's Policy and Procedure Medication Administration: [MEDICAL CONDITION] Tube or Enteral Tube prior to delivering medications: 12. Check placement of feeding tube 13. Check for [MEDICAL CONDITION] residual. The facility's Center for Medicare and Medicaid form 672 dated 04/29/13 indicated a census of 17 residents. Three residents received their medications via gt. At the exit conference on 05/01/13 at 3:15 p.m., the facility was given the opportunity to provide any additional information regarding medications via gt and none was given.

Based on observation, record review and interview, the facility failed to develop a comprehensive care plan for three of eight Sample Residents (SR#2, 6 and 7): 1. SR#2 was admitted with a skin tear to the right buttocks. While in the facility, the skin tear deteriorated into a pressure ulcer and the care plan did not indicate this or any intervention for the wound. 2. SR#6 experienced weight loss and the weight loss was not care planned. SR#6 had bilateral amputations which were not care planned. SR#6 had a drainage tube in the left amputated stump for infection that was not care planned. SR#6 received antibiotics for the infection and the medications were not care planned. SR#6 had pressure ulcers on admission. These were not addressed in the care plan. 3. SR#7 received [MEDICAL TREATMENT] treatments, which was not care planned. Failure to develop comprehensive care plans that include measurable objectives and timetables could affect all 18 residents in the facility. The findings were: 1. On entrance to the facility on [DATE], surveyor was provided with a list of residents with pressure ulcers. SR#2 was listed as having a Stage 2 (partial thickness tissue loss) pressure ulcer to the right buttocks. On 04/13/11 at 10:00 a.m., surveyor observed perineal care for SR#2. When SR#2 was repositioned on her side, surveyor observed a dried scab to the right buttocks. There was white barrier cream over most of the buttocks area. SR#2's Face Sheet dated 03/29/11 indicated this was the date of admission and that SR#2 had [DIAGNOSES REDACTED]. SR#2's Adult Admission Information sheet dated 03/29/11 indicated SR#2 was admitted with a skin tear to her right buttocks. SR#2's care plan did not indicate the skin tear or any interventions to care for the skin tear. The care plan also did not indicate any change to the skin tear, any treatments for the skin tear, or when/if the skin tear changed into a pressure ulcer. In an interview with the Director of the Skilled Nursing Unit (SNU) Registered Nurse (RN) "A" on 04/15/11 at 1:35 p.m., surveyor asked about care plans and what should be included on them. RN "A" said the care plans were very general. Surveyor asked who instructed the staff to write care plans that way. RN "A" said he was taught that way in orientation. Surveyor asked how staff were to know how to care for someone if there were no plans of care written. RN "A" said "the nurses would ask him." Surveyor asked RN "A" if there was documentation regarding SR#2's skin and he said "No." Interview with the Assistant Chief Nurse Officer RN "B" on 04/15/11 at 3:00 p.m. revealed "care plans are for the patient while they are here in the unit. The care plans should be individualized to the patient. The care plan should reflect our care and updated to each condition as it occurred." 2. SR#6's Admission Face Sheet, dated 03/23/11, indicated SR#6 was admitted on that date with a [DIAGNOSES REDACTED]. 24 Hour Medication Orders sheet, dated 03/28/11, indicated that SR#6 was being administered an enteral formula (liquid nutrition delivered directly into the gastrointestinal tract through a tube) Glucerna 1.2 at 75 ml (milliliters) per hour for 18 hours daily. 24 Hour Medication Orders sheet, dated 03/31/11, indicated that SR#6 was being administered [MEDICATION NAME] 4.25%-10% intravenously at 60 ml per hour. [MEDICATION NAME] is an amino acid/electrolyte/[MEDICATION NAME] nutritional formula. SR#6's Care Plan dated 03/23/11 under the section of Nutrition indicated Fluid/Electrolyte Imbalance: Administer tube feedings as ordered. Administer intravenous (IV) fluids as ordered. The tube feedings and content of feedings were not addressed in care plan nor were the type of IV fluids. 24 Hour Medication Orders sheet, dated 04/01/11, indicated that SR#6 was receiving an intravenous antibiotic, [MEDICATION NAME], 500 mg (milligrams) every 8 hours. physician's orders [REDACTED]. physician's orders [REDACTED]. 24 Hour Medication Orders sheet, dated 04/08/11, indicated that drainage from SR#6's left stump was to noted every shift. The Care Plan section Infection indicated an actual infection: Change peripheral IV every 72 hours. Antibiotics were not addressed in the care plan. Amputated stump drain was not addressed in the care plan. SR#6 had a pressure ulcer on the sacral area, according to a list provided by the facility on 04/12/11. During initial tour at 12:15 p.m. on 04/12/11, SR#6 was observed to have a [DEVICE] in place. The Care Plan section: Skin Integrity The sacral pressure ulcer was not addressed in the care plan. Review of SR#6's Progress Notes dated 04/14/11 by the Registered Dietitian (RD) indicated: Supplemental feeding ratio due to weight loss. Increase feedings and reduce flush. Continue ProMod (protein supplement). Goal: limit weight loss. Review of SR#6's weight log indicated: 03/23/11-149.1 (admission) 03/24/11-149.1 03/25/11-155 03/28/11-157.3 03/30/11-158.7 04/02/11-152.7 04/04/11-151.3 04/06/11-150.4 04/08/11-149.5 04/10/11-142.4 04/12/11-141.5 04/14/11-137.2. The Care Plan section Nutrition: SR#6's weight loss was not addressed in the care plan. Surveyor and RN "A" reviewed SR#6's care plan on 04/15/11 at 2:00 p.m. RN "A" acknowledged that SR#6's care plan had not been updated to reflect weight loss, tube feedings, stump drain or antibiotics. 3. Record review of SR#7's Face Sheet dated 04/05/11 revealed he was admitted into the facility on [DATE] with the [DIAGNOSES REDACTED]. Interview with Licensed Vocational Nurse (LVN) "C" on 04/12/11 at approximately 1:20 p.m. revealed SR#7 was not in his room at present, due to him being at [MEDICAL TREATMENT]. LVN "C" added SR#7 had an infection to his right foot and was unable to bear weight. When asked on 04/15/11 at 10:25 a.m. about what issues would be care planned for the residents, RN "A" reported "all their individual needs, for example skin issues, pain, activities." When asked if SR#7's care plan would include [MEDICAL TREATMENT]. RN "A" responded that SR#7's [MEDICAL TREATMENT] should be care planned to look at his vital signs, weights and labs, as ordered by the physician. When asked to check SR#7's care plan for [MEDICAL TREATMENT], RN "A" responded, "it's not entered; the nurse that admits the patient should include that as part of the care plan." The facility census was 18 residents, according to Station Census form, dated 04/12/11. At the exit conference on 04/15/11 at 3:00 p.m., RN "A" was given the opportunity to provide any additional information and none was provided.

Based on record review and interview, the facility failed to follow the Physician's Plan of Care (Physician's Orders) for one of eight Sample Residents (SR#6) with orders for a protein supplement to be administered. The facility failed to follow Physician's Orders for SR#6 to receive ProMod twice a day from 03/28/11 to 04/04/11 and again from 04/09/11 to 04/14/11. Failure to follow Physician's Orders could result in residents not receiving needed care and could affect all 18 residents in the facility. The findings were: SR#6's Face Sheet dated 03/23/11 indicated [DIAGNOSES REDACTED]. SR#6 had a pressure ulcer to the sacral area, according to a list provided by the facility on 04/12/11. During initial tour at 12:15 p.m. on 04/12/11, SR#6, who was in isolation, was noted to have an indwelling urinary catheter (tube inserted through the urethra to the urinary bladder for passage of urine), [DEVICE], and a [MEDICAL CONDITION] (a surgical procedure that brings one end of the large intestine out through the abdominal wall. Stools moving through the intestine drain into a bag attached to the abdomen). Review of SR#6's Nutritional Orders Alert, dated 03/28/11 indicated Nutrition Assessment: Increased Nutrient Needs. Recommendation - ProMod 30 milliliters (ml) in 60 ml water via PEG (percutaneous endoscopic gastrostomy) tube, a tube inserted into the stomach to deliver liquid nutrition, twice a day (BID). SR#6's daily Medication Administration Record (MAR) dated: 03/29/11-ProMod 30 ml via PEG tube bid was administered, however, from 03/31/11 through 04/04/11 ProMod was not administered as ordered because the order was not transcribed to the MARs Review of SR#6's Nutrition Orders Alert, dated 04/04/11, indicated Nutrition Assessment: Increased nutrient needs, Sacral wound. Recommendation - ProMod 30 ml in 60 ml flush water via PEG tube two times a day. SR#6's daily MARs dated: 04/08/11-ProMod 30 ml in 60 ml water bid was administered, however, from 04/09/11 through 04/13/11 ProMod was not administered as ordered because the order was not transcribed to the MARs Review of SR#6's Nutrition Orders Alert, dated 04/14/11, indicated Nutrition Assessment: Continue ProMod the same. On 04/15/11 at 8:00 a.m., RN "A" provided surveyor with a signed statement which stated: "One of our patients (SR#6) had a recommendation by our dietitian for ProMod. The Physician ordered for ProMod to be given as recommended by our dietitian bid (BID). ProMod was transcribed into the patients MAR and begun as ordered. The ProMod was transcribed correctly for 2 days and then dropped and not transcribed over the third, forth and fifth day. ProMod was again ordered and then transcribed into the MAR once again. Then on the next day the ProMod was not transcribed onto the MARs." Review of SR#6's Progress Notes, dated 04/14/11, by the Registered Dietician (RD) indicated: Suboptimal feeding rate due to weight loss. Increase the rate of formula and reduce flush. Continue ProMod. Goal: limit weight loss. Review of SR#6's weight log indicated: 03/23/11-149.1 (admission) 03/24/11-149.1 03/25/11-155 03/28/11-157.3 03/30/11-158.7 04/02/11-152.7 04/04/11-151.3 04/06/11-150.4 04/08/11-149.5 04/10/11-142.4 04/12/11-141.5 04/14/11-137.2. Review of SR#6's Incident Report date of occurrence 04/10/11 indicated: "Patient had an order to receive ProMod 30 ml bid. On 04/10/11, the order was not transcribed. Patient has not received it until present at 11:30 a.m. on 04/14/11." During an interview on 04/14/11 at 1:00 p.m., the RD said, "ProMod provides 200 calories a day and that was what was missed when the doses were skipped. 200 calories each day can make a difference to someone who is protein deprived and has pressure ulcers. Protein helps wound healing. 500 calories equals one pound a day, so 200 calories is about 1/2 pound a day lost. (SR#6) had IVs running until 04/08/11 then he was given [MEDICATION NAME] (diuretic) to overcome the extra fluids accumulated." Surveyor conducted an interview with the Director of the Unit, Registered Nurse (RN) "A" on 04/14/11 at 2:00 p.m. regarding SR#6's ProMod order. Surveyor asked how the dietician's recommendations were transcribed. RN "A" said his assistant writes the recommendations and tells the nurses of any new orders. Surveyor asked who was ultimately responsible for the orders being carried out and RN "A" said, "I am." Surveyor asked what happened with the ProMod order and RN "A" said "we dropped the ball." The census was 18 residents, according to Station Census form, dated 04/12/11. At exit conference on 04/15/11 at 3:30 p.m., RN "A" was given the opportunity to provide any additional information and none was provided.

Based on interview and record review, the quality assurance (QA) committee failed to meet at least quarterly. The last documented QA meeting was on 04/07/10. Failure to meet quarterly could result in not identifying issues and developing action plans to correct the issues affecting all 18 residents. The findings were: During an interview with Registered Nurse (RN) "A" the Director of the Skilled Nursing Unit (SNU) on 04/15/11 at 1:35 p.m., surveyor asked if there were QA meetings held for the SNU and how often were they held. RN "A" said the meetings were held annually. RN "A" provided surveyor with the sign-in sheet from the last QA meeting, dated 04/07/10. The census was 18 residents according to Station Census form, dated 04/12/11. At the exit conference on 04/15/11 at 3:30 p.m., RN "A" was given the opportunity to provide any additional information and none was provided.

Based on record review and interview, the facility failed to ensure a resident maintained acceptable parameters of nutrition and received a supplement to prevent weight loss for one of eight Sample Residents (SR#6) reviewed for weight loss. The facility did not follow physician's orders [REDACTED].#6, from 03/28/11 to 04/04/11 and again from 04/09/11 to 04/14/11. This failure to provide SR#6's protein supplement likely contributed to his weight loss and could result in continued weight loss for SR#6 and two other residents identified with weight loss. The findings were: SR#6's Face Sheet dated 03/23/11 indicated [DIAGNOSES REDACTED]. SR#6 had a pressure ulcer to the sacral area, according to a list provided by the facility on 04/12/11. During initial tour at 12:15 p.m. on 04/12/11, SR#6, who was in isolation, was noted to have an indwelling urinary catheter (tube inserted through the urethra to the urinary bladder for passage of urine), [DEVICE], and a [MEDICAL CONDITION] (a surgical procedure that brings one end of the large intestine out through the abdominal wall. Stools moving through the intestine drain into a bag attached to the abdomen). Review of SR#6's Nutritional Orders Alert, dated 03/28/11 indicated Nutrition Assessment: Increased Nutrient Needs. Recommendation - ProMod 30 milliliters (ml) in 60 ml water via PEG (percutaneous endoscopic gastrostomy) tube, a tube inserted into the stomach to deliver liquid nutrition, twice a day (BID). SR#6's daily Medication Administration Record (MAR) dated: 03/29/11-ProMod 30 ml via PEG tube bid was administered, however, from 03/31/11 through 04/04/11 ProMod was not administered as ordered because the order was not transcribed to the MARs Review of SR#6's Nutrition Orders Alert, dated 04/04/11, indicated Nutrition Assessment: Increased nutrient needs, Sacral wound. Recommendation - ProMod 30 ml in 60 ml flush water via PEG tube two times a day. SR#6's daily MARs dated: 04/08/11-ProMod 30 ml in 60 ml water bid was administered, however, from 04/09/11 through 04/13/11 ProMod was not administered as ordered because the order was not transcribed to the MARs Review of SR#6's Nutrition Orders Alert, dated 04/14/11, indicated Nutrition Assessment: Continue ProMod the same. On 04/15/11 at 8:00 a.m., RN "A" provided surveyor with a signed statement which stated: "One of our patients (SR#6) had a recommendation by our dietitian for ProMod. The Physician ordered for ProMod to be given as recommended by our dietitian bid (BID). ProMod was transcribed into the patients MAR and begun as ordered. The ProMod was transcribed correctly for 2 days and then dropped and not transcribed over the third, forth and fifth day. ProMod was again ordered and then transcribed into the MAR once again. Then on the next day the ProMod was not transcribed onto the MARs." Review of SR#6's Progress Notes, dated 04/14/11, by the Registered Dietician (RD) indicated: Suboptimal feeding rate due to weight loss. Increase the rate of formula and reduce flush. Continue ProMod. Goal: limit weight loss. Review of SR#6's weight log indicated: 03/23/11-149.1 (admission) 03/24/11-149.1 03/25/11-155 03/28/11-157.3 03/30/11-158.7 04/02/11-152.7 04/04/11-151.3 04/06/11-150.4 04/08/11-149.5 04/10/11-142.4 04/12/11-141.5 04/14/11-137.2. Review of SR#6's Incident Report date of occurrence 04/10/11 indicated: "Patient had an order to receive ProMod 30 ml bid. On 04/10/11, the order was not transcribed. Patient has not received it until present at 11:30 a.m. on 04/14/11." During an interview on 04/14/11 at 1:00 p.m., the RD said, "ProMod provides 200 calories a day and that was what was missed when the doses were skipped. 200 calories each day can make a difference to someone who is protein deprived and has pressure ulcers. Protein helps wound healing. 500 calories equals one pound a day, so 200 calories is about 1/2 pound a day lost. (SR#6) had IVs running until 04/08/11 then he was given [MEDICATION NAME] (diuretic) to overcome the extra fluids accumulated." Surveyor conducted an interview with the Director of the Unit, Registered Nurse (RN) "A" on 04/14/11 at 2:00 p.m. regarding SR#6's ProMod order. Surveyor asked how the dietician's recommendations were transcribed. RN "A" said his assistant writes the recommendations and tells the nurses of any new orders. Surveyor asked who was ultimately responsible for the orders being carried out and RN "A" said, "I am." Surveyor asked what happened with the ProMod order and RN "A" said "we dropped the ball." The facility identified three residents with weight loss, according to a list provided on 04/12/11. At exit conference on 04/15/11 at 3:30 p.m., RN "A" was given the opportunity to provide any additional information and none was provided.