Every finding on record at Mckenzie County Healthcare Systems Long Term Care

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 4 of 5 sampled residents (Resident #1, #7, #15, and #28) observed during cares. Failure to practice infection control standards related to hand hygiene and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 07/24/25. This policy, dated June 2023, stated, . The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of the facility policy titled Enhanced Barrier Precautions occurred on 07/24/25. This policy, dated April 2024, stated, . infection control intervention designed to reduce transmission of multidrug-resistant organism that employs targeted gown and glove use during high contact resident care activities. HAND HYGIENE - Observation on 07/21/25 at 4:15 p.m. showed an enhanced barrier precaution sign on an isolation cart outside of Resident #15's room. A certified nurse aide (CNA) (#5) applied a gown and gloves and entered the room. The CNA (#5) assisted Resident #15 to stand from the toilet, performed perineal cares, and assisted the resident to ambulate to the recliner. After assisting the resident to sit in the recliner, the CNA removed the soiled gloves and without performing hand hygiene placed the oxygen cannula in Resident #15's nose, removed the gown, performed hand hygiene, and exited the room. The CNA (#5) failed to perform hand hygiene after removing the soiled gloves and prior to placing Resident #15's oxygen cannula. - Observation on 07/21/25 at 4:45 p.m. showed two CNAs (#2 and #3) completed a brief change for Resident #7. The CNA (#3) cleansed the perineal area, changed gloves, applied a clean brief, and positioned the pillows and top sheet. The CNA (#3) failed to complete hand hygiene between glove changes. - Observation on 07/22/25 at 8:49 AM showed two CNAs (#3 and #4) completed a brief change for Resident #28. The CNA (#4) completed perineal care after an incontinent bowel movement, changed gloves, applied skin barrier cream, changed gloves, applied a clean brief, transferred the resident into the recliner chair, and placed the call light and bedside table within reach. The CNA (#4) failed to complete hand hygiene between glove changes. During an interview on 07/24/25 at 8:20 a.m., an administrative staff (#1) confirmed she expected staff to perform hand hygiene after glove removal and before touching other items. ENHANCED BARRIER PRECAUTIONS Review of Resident #1's medical record occurred on all days of survey. Diagnosis includes history of methicillin resistant staphylococcus aureus (MRSA) . The current care plan stated, . I am on enhanced barrier precautions related to history of MRSA. - Observation on 07/22/25 at 8:45 a.m. showed a CNA (#4) entered Resident #1's room without applying a gown and gloves to apply the resident's compression stockings and shoes. During an interview on the morning of 07/24/25, an administrative staff (#1) confirmed she expected staff to follow the EBP facility policy.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to assess a resident for self-administration of medications for 1 of 1 sampled resident (Resident #5) observed with medications at the bedside. Failure to evaluate the ability for residents to safely self-administer medications may result in medication errors and/or harm to the resident.Findings include: Review of the facility policy Self Administration of Medication occurred on 07/24/24. This policy, dated June 2024, stated, .resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Observations on all days of survey showed an unlabeled bottle of Calm Forte (sleep aid) on the top of a bedside shelf in Resident #5's room. Review of Resident #5's medical record occurred on all days of survey. The record lacked an assessment and a physician's order for Resident #5 to self-administer medications and lacked orders for the medication Calm Forte. During an interview on 07/23/25 at 10:13 a.m., a nurse (#6) confirmed the facility did not complete a self-administration of medication assessment for Resident #5 and was unaware of the medication being in his room. During an interview on the morning of 07/24/25, an administrative nurse (#1) confirmed the facility failed to complete an assessment and obtain a physician's order for Resident #5 to self-administer medications.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from unnecessary psychotropic medications for 1 of 1 sampled resident (Resident #22) who received an as needed (PRN) psychotropic. Failure to limit PRN psychotropic use to 14 days unless reevaluated by a practitioner placed the resident at risk of receiving unnecessary medications, experiencing adverse drug effects, and possible chemical restraint. Findings include:Review of the facility policy titled Use of Psychotropic Medications occurred on 07/24/25. This policy, dated 06/27/24, stated, . A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: . anti-anxiety . PRN orders for all psychotropic drugs shall be used only when the medication is necessary . and for a limited duration . If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order.Review of Resident #22's medical record occurred on all days of survey. Diagnoses included anxiety. A physician's order, dated 05/23/25, identified Lorazepam (an anti-anxiety medication) 0.25 mg (milligrams) every three hours PRN for anxiety. The provider discontinued the medication on 06/13/25 (21 days later). The facility failed to ensure the resident's PRN lorazepam was limited to 14 days and reevaluated for continued use.During an interview on 07/24/25 at 8:20 a.m., an administrative nurse (#1) confirmed facility staff failed to ensure Resident #22's PRN lorazepam order was limited to 14 days and reevaluated for continued use.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 1 sampled resident (Resident #15) receiving oxygen by nasal cannula. Failure to obtain a physician's order to administer oxygen may result in complications and compromise the residents' respiratory status.Findings include: Review of the facility policy titled Oxygene [sic] Administration occurred on 07/24/25. This policy, dated 06/01/19, stated, . Procedure: . Check physician's orders for liter flow and method of administration . Observation on all days of survey showed Resident #15 with continuous oxygen (O2) in place via a nasal cannula at 2 liters (L). Review of Resident #15's medical record occurred on all days of survey. Diagnoses included chronic obstructive pulmonary disease (COPD). The current care plan stated, . I have a need for oxygen therapy R/T [related to] Respiratory illness, COPD . OXYGEN SETTINGS: I have O2 via nasal prongs/mask @ [at] 2-3L to keep sats [saturations] >92% [greater than 92 percent] . The medical record lacked a physician's order to administer oxygen. During an interview on 07/22/25 at 4:00 p.m., an administrative nurse (#1) confirmed Resident #15's medical record lacked a physician's order for oxygen administration.

Based on record review and staff interview, the facility failed to provide the resident or the resident's representative a written notice of transfer for 5 of 5 sampled residents (Resident #3, #5, #10, #23, and #28) transferred to the hospital. Failure to provide a written copy of the transfer notice does not allow the resident and/or their representative to make an informed decision regarding their rights. Findings include: Review of Resident #3, #5, #10, #23, and #28's medical records occurred on all days of survey and identified the following hospital transfers: * Resident #3: 10/27/23 and 05/07/24. * Resident #5: 08/04/23. * Resident #10: 04/05/24 and 04/26/24. * Resident #23: 05/03/24. * Resident #28: 04/29/24. The above residents' medical records lacked evidence the facility provided the resident and/or representative with a written transfer notice. During an interview on 06/18/24 at 2:13 p.m., an administrative staff member (#1) stated the facility does not have a Hospital Transfer policy. During an interview on 06/18/24 at 5:15 p.m., an administrative staff member (#1) confirmed the facility failed to complete a hospital transfer for the residents. 13101 39685

Based on record review, review of facility policy, and staff interview, the facility failed to provide a bed hold notice upon transfer to the hospital for 5 of 5 sampled residents (Resident #3, #5, #10, #23, and #28) transferred to the hospital. Failure to provide a bed hold notice does not allow residents or their legal representatives to make informed choices regarding their readmission rights. Findings include: Review of the facility policy titled Bed Hold occurred on 06/19/24. This policy, dated 04/17/24, stated, It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold policies prior to transferring a resident to the hospital . Review of Resident #3, #5, #10, #23, and #28's medical records occurred on all days of survey and identified the following hospital transfers: * Resident #3: 10/27/23 and 05/07/24. * Resident #5: 08/04/23. * Resident #10: 04/05/24 and 04/26/24. * Resident #23: 05/03/24. * Resident #28: 04/29/24. The above residents' medical records lacked evidence the facility provided the resident and/or representative with a written bed hold notice. During an interview on 06/18/24 at 5:15 p.m., an administrative staff member (#1) stated they were unable to find written bed hold notices for the residents. 37620 39685

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise the care plan for 1 of 12 sampled residents (Resident #3). Failure to review and revise the care plan limited staff's ability to communicate needs, ensure continuity of care, and may negatively impact the care provided to the resident. Findings include: Review of the facility policy titled Comprehensive Care Plans occurred on 06/19/24. This policy, dated 11/08/22, stated, . The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [Minimum Data Set] assessment. Review of Resident #3's medical record occurred on all days of survey. A progress note, dated 04/07/24 at 11:04 a m., stated, Foley Cath [catheter] removed at 5 a.m. A quarterly MDS, dated [DATE], identified no Foley catheter, maximum assist required for transfers, not toileted, and no ambulation attempted. The current care plan identified Resident #3 had a Foley catheter and ambulated independently. During an interview on 06/19/24 at 5:01 p.m., an administrative staff member (#1) confirmed the facility failed to update Resident #3's care plan regarding removal of the Foley catheter and ambulation status.

Based on record review, review of the facility reported incident investigation, and resident and staff interview, the facility failed to ensure an environment free of hazards for 1 of 1 sampled resident (Resident #3) injured while consuming a hot beverage. Failure to provide assess and provide the appropriate cup for hot beverages may have contributed to Resident #3's injuries This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Finding include: Review of Resident #3's medial record occurred on 08/23/23 and identified the following: - 07/29/2023 16:11 [4:11 p.m.] General Note: Resident was served Tea upon her request. CNA [certified nurse aide] cooled [hot] water with cold water before serving. Resident picked it up off table when it slipped from her hands and spied [sic] causing burns to bilateral [both] knee areas. - 07/29/2023 20:37 [8:37 p.m.] . Skin Issue: Burns (second or third degree). Skin Issue Location: underside3 [sic] of left knee Length:3cm [centimeter] [sic] Width (cm): 3cm No wound odor. Tissue: Painful. Tissue: Warm. Skin Issue: Burns (second or third degree). Skin Issue Location: outer side of right knee Length: 4cm Width: 3cm No wound odor. Tissue: Painful. Tissue: Warm. CNA reported to nurse that resident had picked up her tea but it slipped and spilled causing burns to her bilateral knee. This nurse applied cold compresses to relieve burning informed POC [point of contact] and Dr. Dr. gave instructions to apply silvadene [sic] [a type of burn cream] 2X [times] daily with dressing. Clinical Suggestions: Evaluated for pain, discomfort. Dressing changes/treatments performed as ordered. Area evaluated for signs of infection: redness, warmth, swelling, increased temperature, drainage, etc. The facility's investigation report dated 08/03/23 included the following documentation: - On July 29, 2023, resident [#3] requested a hot cup of water for tea in her room in a Styrofoam cup. The resident was given cup with hot water with cool water added to it by a CNA who set the cup on the resident's bedside table and left the room. When [Resident #3] went to pick the cup up, the cup slipped and landed on her legs. Resident has pressed call light in her room and when staff entered, they found the resident in her private bathroom with pants down and bilateral legs red with blister already forming to the medial/posterior knee. Staff placed a cool compress on the site immediately and notified the medical provider who ordered Silvadene cream for the resident's burn. In the subsequent days, resident's burns were treated with Silvadene cream, telfa, and kerlix [types of dressings] with little pain noted only when trying to cross legs. During an interview on 08/23/23 at 11:45 a.m. two administrative staff members (#1 and #2) indicated no other resident had received burns in the last three months. During an interview on 08/23/23 at 1:13 p.m., Resident #3 indicated a preference for hot tea in a foam cup and now gets a hard cup. Resident #3 identified being burned by hot tea and rubbed over her pant legs to demonstrate where the injury occurred and reported they are almost healed and don't hurt any more. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented corrective actions for the deficient practice by: * Completing an investigation that determined the primary cause of accident (foam cup). * Providing 1 on 1 education immediately after the accident with involved staff to no longer use foam cups. The facility addressed measures put in place and implemented systemic changes to ensure the deficient practice doesn't recur by: * Providing education to all staff, stating dietary staff, and when dietary staff are not available, only the nurse may provide hot beverages for residents. * Implemented temping hot beverages prior to serving. * Removing foam cups from resident use and implementing use of blue cups with lids only. The surveyor determined a deficient practice existed on 07/29/23. The facility implemented corrective action and completed training to all staff on 07/30/23.

Based on staff interview, the facility failed to ensure 1 of 1 dietary manager (#1) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services has the potential to result in foodborne illness to residents, staff, and visitors. Findings include: During an interview on 07/17/23 at 12:00 p.m., the dietary manager (#1) confirmed he has not completed the necessary courses required for the director of food and nutrition services. The facility failed to ensure the dietary manager (#1) completed the required education for a certified dietary manager, certified food service manager, or a national certification for food service management and safety from a national certifying body

Based on observation, review of facility policy, review of a professional reference, and staff interview, the facility failed to provide adequate supervision and assistive devices necessary to prevent accidents for 2 of 2 sampled residents (Resident #12 and #18) and 2 supplemental residents (#4 and #21) observed during a gait belt transfer. Failure to properly use a gait belt during transfers placed the resident at risk of accidents and injury. Findings include: Review of the facility policy Use of Gait Belt occurred on 07/19/23. This policy, dated October 2022, stated, . To prevent accidents . use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety . [NAME], [NAME], and Frandsen, Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 10th edition, Pearson Education, Inc., New Jersey, page 1054, stated, . If the client is a low safety risk . use a gait/transfer belt for standby assist as needed and assistive devices as needed . and 1-2 caregivers. Make sure the belt is pulled snugly around the client's waist and fastened securely. Grasp the belt at the client's back . Observations showed the following: * 07/17/23 at 2:50 p.m., showed a certified nurse aide (CNA) (#6) transferred Resident #12 from the wheelchair to the toilet without a gait belt. The CNA held onto the waist band of the resident's pants and shirt during the transfer. * 07/17/23 at 2:55 p.m., a CNA (#4) transferred Resident #18 from the wheelchair to the toilet. During the transfer, the CNA held on to the resident's hips and shirt and failed to use the gait belt. * 07/17/23 at 4:00 p.m., two CNAs (#3 and #5) transferred Resident #21 from the wheelchair to the toilet. During the transfer, one CNA (#5) held on to the waistband of the resident's pants and the other CNA (#3) held on to the resident's waist. The CNAs failed to use the gait belt during the transfer. * 07/17/23 at 4:08 p.m., a CNA (#6) transferred Resident #4 from the wheelchair to the toilet. During the transfer, the CNA held onto the resident's waistband and failed to use the gait belt during the transfer. During an interview on 07/17/23 at 4:15 p.m., an administrative nurse (#2) stated she expects staff to use a gait belt with transfers.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 3 of 3 sampled residents (Resident #12, #13 and #32) and 1 supplemental resident (#30) with orders for enhanced barrier precautions (EBP), and 2 of 12 sampled residents (Residents #1 and #15) observed during cares. Failure to practice infection control standards related to use of personal protective equipment (PPE) and hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions occurred on 07/19/23. This undated policy, stated, . Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [multi drug resistant organism] as well as those at risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Clear signage will be posted outside of the resident room indicating the type of precautions required personal protective equipment (PPE), and high-contact resident care activities that require the use of gown and gloves. High-contact resident care activities include: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting . Review of the facility policy titled Hand Hygiene occurred on 07/19/23. This policy, dated June 2023, stated, .Hand hygiene is a general term for cleaning your hands by hand washing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. ENHANCED BARRIER PRECAUTIONS: -Review of Resident 12's medical record occurred on all days of survey. The physician's orders included Enhanced Barrier Precautions related to a MDRO. Observation on all days of survey showed a cart containing isolation gowns and gloves located outside Resident #12's room. On 07/17/23 at 2:50 pm., a certified nurse aide (CNA) (#3) failed to donn the appropriate PPE and perform hand hygiene before and after toileting cares. -Review of Resident #13's medical record occurred on all days of survey. The physician orders included Enhanced barrier precautions related to a MDRO and . wear appropriate PPE and perform hand hygiene . Observations showed the following: * 07/17/23 at 2:11 p.m., resident companions (RC) (#7 and #8) entered Resident #13's room to deliver a meal tray and handled items in the room The RCs failed to perform hand hygiene upon entering and exiting the room. * 07/18/23 at 7:57a.m., an RC (#7) entered Resident #13's room and delivered a meal tray and assisted with sitting the resident up in bed. The RC failed to don PPE or perform hand hygiene upon entering and exiting the room. * 07/18/23 at 8:58 p.m, an RC (#7) entered Resident #13's room to deliver a meal tray and assist with set up of the meal tray. The RC failed to perform hand hygiene upon entering and exiting the room. - Review of Resident 30's medical record occurred on all days of survey. The care plan included, . Enhanced Barrier Precautions related to fragile skin . breakdown . Observations on 07/17/23 showed the following: * At 9:10 a.m., a CNA (#4) entered Resident #30's room and performed toileting cares. The CNA failed to don PPE or perform hand hygiene upon entering or exiting the room. * At 12:32 p.m., a CNA (#9) entered Resident #30's room to deliver and assist with set up of the meal tray, adjusted the residents' blankets, bedside table, and call light. The CNA failed to perform hand hygiene upon entering and exiting the room. During an interview on 07/17/23 at 12:15 p.m., an administrative nurse, (#2) confirmed she would expect staff to perform hand hygiene and wear appropriate PPE when entering, exiting, and performing cares with residents on enhanced barrier precautions. - Review of Resident #32's medical record occurred on all days of survey. The physician's orders included, . Enhanced Barrier Precautions (per CDC) [centers for disease control and prevention]) related to medical device. Observation on all days of survey showed a cart containing isolation gowns and gloves located outside Resident #32's room. Staff failed to post signage outside of the resident room to indicate the type of precautions requiring PPE and the high-contact resident care activities that require the use of gown and gloves. During an interview the afternoon of 07/19/23, an administrative nurse (#2) confirmed staff failed to post EBP signage outside Resident #32's room. HAND HYGIENE: - Observation on 07/17/23 at 2:30 p.m. showed two CNAs (#3 and #4) donned gloves and completed a mechanical lift transfer with Resident #1 from the wheelchair to the bed. The CNA (#3) removed Resident #1's wet brief, completed perineal cares, removed her gloves, donned a clean pair of gloves, applied the resident's clean brief, repositioned the resident in the bed, placed the bed in the low position, placed a mat on the floor next to the bed and removed her gloves. The CNA (#3) failed to perform hand hygiene between glove changes. - Observation on 07/18/23 at 9:04 a.m. showed a CNA (#6) knocked and entered Resident #15's bathroom. The CNA (#6) donned gloves, removed the wet incontinent product, applied a clean incontinent product, removed her gloves, donned a clean pair of gloves, assisted the resident with her shoes, then placed the call light next to the resident. The CNA (#6) failed to perform hand hygiene between glove changes. - Observation on 07/18/23 at 9:24 a.m. showed two CNAs (#3 and #5) donned gloves and completed morning cares for Resident #1. Both CNAs assisted with washing, drying, and dressing Resident #1's upper body and legs. The CNA (#5) removed the wet brief and completed perineal cares. Both CNAs completed the brief change, removed their gloves, donned a clean pair of gloves, placed the mechanical lift sling under the resident, and completed a mechanical lift transfer from the bed to the wheelchair. The CNAs (#3 and #5) failed to perform hand hygiene between glove changes. During an interview the afternoon of 07/19/23, an administrative nurse (#2) confirmed she expected staff to complete hand hygiene between glove changes. 39685

Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the current status for 1 of 12 sampled residents (Resident #32). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care Plan Revisions occurred on 07/19/23. This policy, dated September 2022, stated, . the comprehensive care plan will be reviewed, and revised as necessary . the care plan will be updated with new or modified interventions . - Review of Resident #32's medical record occurred on all days of survey. A Physician's order, dated 06/22/23, stated, . foley catheter required for obstructive uropathy due to urinary retention. and included an order for Enhanced Barrier Precautions (EBP) (per CDC [centers for disease control and prevention]) related to medical device (indwelling catheter). The current care plan lacked goals and interventions related to Resident #32's indwelling catheter and EBP. During an interview on 07/19/23 at 9:20 a.m., an administrative nurse (#2) confirmed the facility staff failed to updated Resident #32's care plan with changes related to current conditions. 39685

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow professional standards of practice for 1 of 1 observation of a nebulizer treatment (Resident #18). Failure to clean the nebulizer equipment after each use may result in possible bacterial growth. Findings include: Review of the facility policy Medi-Mist occurred on 03/23/22. The undated policy, stated, . Switch off. Remove the mouth piece, T piece and tubing from the nebulizer. Wash all parts in warm soapy water or a recommended solution. Rinse all parts thoroughly with fresh water and allow them to air dry. When dry, replace all parts in the storage area to keep clean for next use. Review of Resident #18's medical record identified a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Observation on 03/23/22 at 7:59 a.m., showed a facility nurse (#1) administer [MEDICATION(S)]-[MEDICATION(S)] Solution nebulizer to Resident #18. After completion of the treatment, the nurse (#1) removed the nebulizer mask and placed all the assembled nebulizer equipment in the storage bag. The nurse failed to disassemble the equipment, clean, and allow to air dry before placing in the storage bag as per the facility policy. During an interview on 03/23/22 at 8:32 a.m., an administration nurse (#2) confirmed staff are to rinse all nebulizer equipment after each use and let dry. During an interview on 03/23/22 at 11:39 a.m., a facility nurse (#1) stated she cleans the nebulizer at the end of her shift. The nurse (#1) stated she works 12 -16 hour day shifts and cleans the nebulizer at the end of her shift, clarifying all three nebulizer treatments could be given for that time period before cleaning.

Based on facility policy, review of the Centers for Disease Control and Prevention (CDC) guidelines and recommendations, record review, and staff interview, the facility failed to assess each resident's pneumococcal status and provide education to residents and/or their legal representatives regarding the benefits and potential side effects of receiving the vaccination for 3 of 5 residents (Resident #6, #20, and #35) reviewed for immunization status. Failure to offer pneumococcal vaccine to all residents, provide education to residents and their legal representatives, and document the administration or refusal has the potential for non-immunized residents to contact pneumonia and spread the infection to other residents, visitors, and staff. Findings included: Review of the facility policy titled INFLUENZA AND PNEUMOCOCCAL VACCINE occurred on 03/23/22. This policy, dated December 2009, stated, . Assessment: All new residents will be assessed by the long-term care staff, upon admission for status of influenza and pneumococcal immunization. Refusal of immunization: Resident and/or guardian must sign and date refusal. Each year, every resident will be offered the vaccination, even if it was refused the year prior. Review of the CDC: Vaccines and Preventable Diseases webpage(https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html), last reviewed December 6, 2017, stated, . CDC recommends pneumococcal vaccination (PCV13 or Prevnar13, and PPSV23 or Pneumovax23) for all adults [AGE] years or older: Give a dose of PCV13 to adults [AGE] years or older who have not previously received a dose. Then administer a dose of PPSV23 at least 1 year later. If the patient already received one or more doses of PPSV23, give the dose of PCV13 at least 1 year after they received the most recent dose of PPSV23. - Review of Resident #6's medical record occurred on 03/22/22. The record showed Resident #6's legal representative refused administration of the PPSV23 vaccine on the day of admission in 2017. The record lacked evidence the facility assessed the resident's pneumococcal immunization status for the PCV13 immunization and/or provided education to the resident and/or their legal representative. - Review of Resident #20's medical record occurred on 03/22/22. The record showed Resident #20 admitted in August 2020, received the PPSV23 vaccine on 01/13/20 (prior to admission). The record lacked evidence the facility assessed the resident's pneumococcal immunization status for the PCV13 immunization and/or provided education to the resident and/or their legal representative. - Review of Resident #35's medical record occurred on 03/22/22. The record showed Resident #35 admitted in May 2019, received the PCV13 vaccine on 12/09/18 (prior to admission). The record lacked evidence the facility assessed the resident's pneumococcal immunization status for the PPSV23 immunization and/or provided education to the resident and/or their legal representative. The facility failed to follow the CDC recommendations for pneumococcal vaccine administration and the facility's policy. During an interview on 03/23/22 at 11:25 a.m., two administrative nurses (#2 and #3) verified the facility failed to assess residents for pneumococcal immunization and/or follow the CDC recommendations for the pneumococcal vaccinations, and follow the facility policy.

Based on information from the complainant, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure residents remained free from significant medication errors for 1 of 4 closed records reviewed (Resident #37). Failure to administer the correct dosage of a diuretic and collect labs according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Information provided by the complainant indicated residents were hospitalized due to high sodium levels. Review of facility policy titled Dispensing Medications - [NAME] County occurred on 01/28/21. This policy, reviewed July 2019, stated, . Medications are administered in accordance with written orders of a medical provider . Berman, Snyder, and [NAME], Fundamentals of Nursing Concepts, Process, and Practice, 10th Edition, Copyright 2016 by [NAME] Education, Inc., New Jersey, pages 721, 1179, 1320, and 1322, stated, . Serum electrolytes also are routinely assessed for clients at risk in the community, for example, clients who are being treated with a diuretic for hypertension or heart failure. The most commonly ordered serum tests are for sodium . Diuretics . increase urine formation by preventing the reabsorption of water and electrolytes . Dehydration . occurs when water is lost from the body, leaving the client with excess sodium . Older adults are at particular risk for dehydration because of decreased thirst sensation. Nursing interventions: . Monitor laboratory findings (e.g., serum sodium). Review of Resident #37's medical record occurred on 01/28/21. Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Decrease [MEDICATION(S)] [a diuretic medication] to 2 mg [milligrams] by mouth [PO] every a.m. 3. Repeat BMP [basic metabolic panel] in one week. Nursing Notes showed the following: *12/21/20 at 8:44 a.m., Lab called to inform nurse of critical high sodium level. Dr. [Name] notified stated [he/she] would look at [his/her] chart. Called back with orders to sent [sic] to emergency room [ER] for further evaluation . labs show kidney failure. *12/21/20 at 12:35 p.m., Resident returned from ER. Orders received to stop all current medications. *12/24/20 at 10:54 a.m., . Resident had passed away at 1044, no pulse, heart sounds noted. A physician's progress note showed the following: *12/21/20 at 12/:01 p.m., . [resident] with discovered [CONDITION(S)] on routine BMP this morning. Skin: . with marked tenting and increased turgor [skin elasticity] . marked dehydration . return to nursing home. Stop all current medicines. Comfort care protocols. Resident #37's lab results showed basic metabolic panels to include blood sodium levels. Normal blood sodium levels are 136-145 milliequivalents/liter [meq/L]. Resident #37's blood sodium levels showed the following: *10/16/20: 147 meq/L *12/21/20: 162 meq/L (critically high) Resident #37's medical record lacked documentation of a BMP on 10/23/20, as ordered. Resident #37's medication administration records (MARs) dated 10/16/20-12/24/20 showed staff administered [MEDICATION(S)] 2mg PO two times a day. The resident received 63 doses of extra [MEDICATION(S)]. During an interview, on 01/28/21 at 12:40 p.m., an administrative nurse (#1) agreed the staff failed to implement orders to collect a BMP in one week and to decrease the dosage of [MEDICATION(S)] for Resident #37. The resident received 63 extra doses of a diuretic resulting in a significant medication error. The facility failed to collect the necessary labs ordered by the physician to monitor Resident #37's condition. When the facility staff collected the labs 60 days later, the sodium levels reported were critically high which potentially led to the resident's decline.

Based on staffing record review and staff interview, the facility failed to designate a licensed nurse to serve as a charge nurse on each tour of duty (shift) for 4 of 4 days of survey (January 25-28, 2021). Failure to designate a charge nurse on each shift may result in inefficient or lack of coordination of care/services, lacks a central person as the administrative contact, and could lead to confusion in an emergency. Findings include: During an interview on 01/26/21 at 3:03 p.m., an administrative nurse (#6) stated their minimum core staffing is two nurses on each day, evening, and night shift (one nurse for each unit). This nurse stated the facility utilized traveling/contract nurses and certified nurse aides (CNAs). Review of the staffing schedule occurred on 01/26/21. The daily schedule showed the nurse and CNAs assigned to each nursing unit (200 and 300). Currently the facility also scheduled one nurse and one CNA for the COVID-designated area. The schedule lacked the designation of a charge nurse. During an interview on 01/26/21 at 3:58 p.m., when asked who was the designated charge nurse for each shift, an administrative nurse (#1) stated the CNAs assigned to the 200 hall (unit) report to the 200 hall nurse scheduled for that shift and the CNAs assigned to the 300 hall report to the 300 hall nurse. This nurse stated the two nurses would work together on any issues that would come up. She added when the COVID-designated area housed residents, the facility staffed an extra nurse and CNA just for that area, with that nurse in charge of that area. Nurse (#1) verified the facility designated no nurse as the single charge nurse. A failure to provide for a designated charge nurse may increase the potential for lack of appropriate care, services, and monitoring of residents consistent with their individualized plan of care.

Based on record review, staff interview, and information received from the complainant, the facility failed to ensure competent staff for 7 of 8 travel staff members reviewed (Staff A, B, C, D, E, F, and G). Failure to provide timely orientation may result in staff lacking competencies and skill sets and increases the risk of physical or psychological harm to the residents through improper care. Findings include: Information received from a complainant stated concern regarding facility staff's competency related to assessment skills, infection control practices, communication, provision of residents' needs, and notification of changes in resident condition. Upon entrance on 01/25/21, the survey team requested information regarding orientation of travel/contract staff and one travel certified nurse aide (CNA). Information provided by the facility included a form titled Orientation to the travelers for nurses and a Traveling Staff Checklist for CNAs which included the topics of Safety, Abuse, and Facility, which the facility completed for the requested CNA. During an interview on 01/27/21 at 10:40 a.m., when asked what orientation the facility provides for contract staff, a nurse administrator (#6) stated she is not 100% sure if they get any orientation on arrival and thinks they come ready to work. On the afternoon of 01/27/21, the survey team requested evidence of the orientation provided for the remaining seven (Staff A-G) of eight travel staff listed on the current staff roster and any other contract staff. Later the same day, an administrative nurse (#6) stated what she already provided for orientation was all the facility had. The nurse added, We know it [orientation] is something we need to work on. During an interview on 01/28/21 at 1:44 p.m., an administrative nurse (#1) stated, The DON [director of nursing] should have the orientation checklists for staff and travelers, but we have had a problem with orientations and may not have them. At 2:05 p.m., the nurse (#1) provided copies of two of the seven travel staff's (Staff F and G) orientation checklists, completed 11 and 8 days after their first day of work respectively. The nurse stated she found some old CNA orientation checklists and decided to use them to get a start on orientation as lacking in this area. The facility failed to provide evidence of any orientation for Travel Staff A, B, C, D, and E or for any other contract staff currently scheduled. Failure to provide orientation may increase the potential for lack of appropriate care, services, and monitoring of residents consistent with their individualized plan of care.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.14), and staff interview, the facility failed to ensure accurate coding of Minimum Data Sets (MDSs) for 3 of 13 sampled residents (Resident #20, #21, and #33). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs, and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: Section I: (Active Diagnoses) The Long-Term Care Facility RAI User's Manual, revised October 2019, page I-7 stated, . Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Do not include conditions that have been resolved, . Review of Resident #20's medical record occurred on all days of survey. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS dated [DATE] showed Section I1700 (active diagnosis) coded yes for Multidrug-Resistant Organism (MDRO). During an interview on 01/27/21 at 1:34 p.m., an administrative nurse (#1) confirmed Resident #20 did not have an active infection and facility staff coded Section I1700 incorrectly. Section M: (Skin Conditions) The Long-Term Care Facility RAI User's Manual, revised October 2019, page M-7 stated, M0300: Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage. Steps for completing M0300A-G . For each pressure ulcer, determine the deepest anatomical stage. Do not reverse or back stage. Review of Resident #21's medical record occurred on all days of survey. Review of a wound documentation form, dated 12/17/20, identified the following, Coccyx . 2 cm x 2.5 cm x .75 cm mod [moderate] drainage . stage 3. Review Resident #21's Quarterly MDS dated [DATE] showed section M0300B coded 1, indicating 1 stage 2 pressure ulcer. During an interview on 01/27/21 at 1:41 p.m., an administrative nurse (#1) agreed the MDS was coded incorrectly. Section N (Medications) The Long-Term Care Facility RAI User's Manual, revised October 2019, page N-7 stated, . N0410E, Anticoagulant (e.g., [MEDICATION(S)], [MEDICATION(S)], or low- molecular weight [MEDICATION(S)]): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, [MEDICATION(S)], or [MEDICATION(S)] here. Resident #33's Quarterly MDS dated [DATE], identified resident received three doses of anticoagulant medication during the 7 day look back period. Review of the January Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 01/27/21 at 2:11 p.m., an administrative nurse (#1) stated she reviewed the Quarterly MDS dated [DATE] regarding anticoagulant, and confirmed the MDS was coded incorrectly for anticoagulant use.

THIS IS A REPEAT CITATION FROM THE STANDARD SURVEY CONDUCTED ON 11/06/19. 1. Insulin Administration Based on observation, record review, review of facility policy, review of manufacturer instructions, and staff interview, the facility failed to follow professional standards of practice for 1 of 1 observation of insulin pen preparation and administration (Resident #12). Failure to properly prepare insulin per policy/manufacturer recommendation may result in the resident receiving an inaccurate dose of insulin and failure to offer food within 5 to10 minutes after the administration of a rapid acting insulin may result in [CONDITION(S)] (low blood sugar). Findings include: Review of the facility policy titled Dispensing Medications occurred on 01/28/21. This policy reviewed, July 2019, stated, . When administering short [rapid] acting insulin. It should NOT be given more than 10-15 minutes prior to a meal, unless a snack is given within the 10-15 minute time frame. The manufacturers instructions for the NovoLog [MEDICATION(S)] found at www.novomedlink.com stated, . prime your pen: turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears. Give your injection: Insert the needle. Press and hold the dose button. After the dose counter reaches 0, slowly count to 6. Observation on 01/26/21 at 4:09 p.m. showed a licensed nurse (#7) cleansed and attached a needle to Resident #12's Novolog (rapid acting) insulin pen, without priming the insulin pen, selected 11 units of insulin, entered the resident's room, administered the insulin, and immediately removed the insulin pen after injection into Resident #12's arm. The licensed nurse (#7) provided no food or snack for Resident #12. Observation at 5:26 p.m. showed Resident #12 remained in his room with no food or snack. At 5:48 p.m. facility staff delivered a meal tray to Resident #12, one hour and 39 minutes after rapid acting insulin administered. Review of Resident #12's medical record occurred on 01/26/21. Medication orders included, NovoLOG [MEDICATION(S)] Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: . subcutaneously three times a day . ensure resident eats within 5-10 min after injection. The facility staff failed to prime the insulin pen, wait an appropriate time after insulin injection, and failed to offer food within 10 to15 minutes after rapid acting insulin administered. During an interview on 01/27/20 at 4:15 p.m., an administrative nurse (#6) confirmed staff did not follow facility policy and practice professional standards with insulin pen preparation and rapid acting insulin administration for Resident #12. 2. Physician Orders Based on information from complainant, record review, policy review, review of professional reference, and staff interview the facility failed to follow professional standards of practice for 1 of 4 closed records (Resident #37). Failure to observe and implement physician's orders to monitor labs and decrease the diuretic dosage resulted in adverse drug effects. Findings include: Information provided by the complainant indicated facility staff failed to carry out physician orders for lab work. Review of facility policy titled Dispensing Medications - [NAME] County occurred on 01/28/21. This policy, reviewed July 2019, stated, . Medications are administered in accordance with written orders of a medical provider . Review of Resident #37's medical record occurred on 01/28/21. A physician's order, dated 10/16/20, stated, 1. Decrease [MEDICATION(S)] [a diuretic medication] to 2 mg [milligrams] by mouth [PO] every a.m. 3. Repeat BMP [basic metabolic panel] in one week. Resident #37's medical record lacked documentation a BMP was completed one week from 10/16/20, as ordered. Resident #37's medication administration records (MARs), dated 10/16/20-12/24/20, showed staff administered [MEDICATION(S)] 2 mg PO two times a day and failed to decrease the frequency to daily. During an interview, on 01/28/21 at 12:40 p.m., an administrative nurse (#1) agreed the staff failed to implement orders to collect a BMP in one week and to decrease the dosage of the diuretic for Resident #37. Refer to F760

Based on observation, record review, review of facility policies, and information submitted by the complainant, the facility failed to evaluate nutrition/hydration status for 2 of 4 sampled residents (Resident #22 and #33) who had weight changes and 1 of 1 sampled resident (Resident #33) not offered fluid during cares. Failure to ensure accuracy of residents' weights may result in difficulty assessing actual weight loss/gain and failure to ensure staff assistance with fluid intake may result in dehydration, constipation, and urinary tract infections (UTIs). Findings include: Information provided by the complainant indicated the facility delayed or failed to implement recommended interventions for residents who experienced a decline in nutritional status. Review of the facility policy titled Weight Assessment and Intervention occurred on 01/28/21. This policy, dated May 2016, stated, . Any weight change of 5% or more since the last weight assessment will be retaken within 2 days for confirmation. Review of the facility policy titled, Dehydration Screening Tool occurred on 01/28/21. This policy, dated 06/01/2019, stated, . Dehydration screening tool will be completed on admission, with comprehensive assessment and quarterly. If two or more of the starred areas are marked, the policy on dehydration will be implemented . Areas considered starred are: Skin, Fluid intake, Risk Factors, Predisposing Factors. Review of the facility policy titled, Potential Dehydration occurred on 01/28/21. This policy, dated 06/01/19, stated, Purpose: To ensure resident's receive proper hydration and to prevent dehydration. If resident shows any signs or symptoms of dehydration or triggers on the dehydration screening tool, then the following should be done. Put water symbol at bedside . alerting staff to encourage fluid intake. - Review of Resident #22's medical record occurred on 01/28/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22's weight record from July 3, 2020 through January 4, 2021 identified the following: * 07/03/20 142 pounds (lbs.) * 08/01/20 131.2 lbs. (7% weight loss with no reweigh). * 09/02/20 135.6 lbs * 10/06/20 126.8 lbs (6% weight loss with no reweigh) * 11/02/20 117.8 lbs. (7% weight loss with no reweigh) * 12/03/20 135 lbs. (greater than 10% weight gain with no reweigh) * 01/04/21 126.6 lbs. (5.9% weight loss with no reweigh). The facility failed to reweigh Resident #22 per facility policy which may have resulted in inaccurate weight loss/gain assessments. - Review of Resident #33's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS, dated [DATE], identified weight loss and extensive assist of one with eating. Review of Resident #33's weight record from July 3, 2020 through January 2, 2021 identified the following: * 07/03/2020 132.6 lbs. * 08/02/2020 117.4 lbs. (11% weight loss with no reweigh). * 09/19/2020 114.5 lbs. * 10/13/2020 109.7 lbs. * 12/01/2020 104.6 lbs. * 01/02/2021 95.8 lbs. (8% weight loss with no reweigh). The facility failed to reweigh Resident #33 per facility policy which may have resulted in inaccurate weight loss/gain assessments. Review of Resident #33's Dehydration Risk Screener, dated 01/08/21, identified staff should implement the Dehydration policy. Observation on 01/27/21 at 10:13 a.m. showed two Certified Nurse Assistants (CNAs) (#2 and #3) assisted Resident #33 with cares. Staff failed to offer the resident fluids after cares. Observation on 01/27/21 at 4:57 p.m. showed two CNAs (#2 and #3) provided incontinent cares for Resident #33. Staff failed to offer the resident fluids after cares.

Based on observation, record review, policy review, professional reference, and staff and resident interview, the facility failed to provide the care and services to prevent pressure ulcers and/or promote healing for 2 of 2 sampled residents (Resident #3 and #4) identified with a pressure ulcer. Failure to assess, correctly stage, implement and revise interventions, and evaluate the effectiveness of treatment resulted in the development of new pressure ulcers and delayed the healing process, causing unnecessary pain. Findings include: The Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, Version 3.0, dated April 2012, page M-08 - M-18, defines stages of pressure ulcers and types of necrotic tissue, including: * Stage 2 pressure ulcer, "Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured blister." * Stage 3 pressure ulcer, "Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. . . ." * Stage 4 pressure ulcer, "Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling." * Undermining, "The destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface." * Slough tissue, "Non-viable yellow, tan, gray, green or brown tissue: usually moist, can be soft, stringy an mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed." * Eschar tissue, "Dead or devitalized tissue that is hard or soft in texture: usually black, brown, or tan in color, and may appear scab-like. . . ." * Unstageable pressure ulcers related to slough and/or eschar, "Pressure ulcers that present as unstageable require care planning that includes, in the absence of ischemia, debridement of necrotic and dead tissue and restaging once the necrotic tissue is removed." * Suspected Deep Tissue Injury, "Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. . . . Planning for care: Suspected deep tissue injury requires vigilant monitoring because of the potential for rapid deterioration. . . ." Review of the facility policy titled "Skin Care Protocol" occurred on 08/23/12. This undated policy stated, "Policy Statement: The following guidelines will be utilized to attend to resident needs that arise on an intermittent basis. Policy interpretation and implementation: . . . IV. Skin Care . . . c. Pressure reducing measures - appropriate mattress, chair cushion, etc. V. Decubiti Care: a. Pressure reducing measures. b. Dietary supplements as recommended by licensed dietitian. c. Bioclusive dressing to prevent further breakdown. d. Medication as ordered by the physician." Review of the facility policy titled "Prevention of skin breakdown" occurred on 08/23/12. This undated policy stated, "Purpose: It is the intent of this policy to assist in preventing any skin breakdowns on resident's (sic) if they become bedridden for more than 24 hours. Procedure: 1. Nurse must complete skin integrity form on any resident who is bedridden for more than 24 hours. 2. Place resident on turning schedule. 3. Use preventive equipment to aid in decreasing the chance of pressure ulcer's (sic). Such as air mattress, float boots, etc. . . ." Review of the facility policy titled "Checklist for New or Recurrent Pressure/Stasis Ulcers" occurred on 08/23/12. This policy, dated 02/22/08, stated, ". . . 2. Start Lesion sheet. 3. Start weekly lesion record (give to DON (Director of Nursing)). 4. Dietary Department will be notified by DON or ADON (Assistant Director of Nursing)." Kozier and Erb's, "Fundamentals of Nursing," Ninth Edition, Pearson Education Inc, New Jersey, page 941, stated, "Cleaning Wounds: Wound cleaning involves the removal of . . . excess slough, necrotic tissue, bacteria, and other microorganisms . . . Recommended guidelines for cleaning wounds are shown in the accompanying Practice Guidelines . . . Chapter 37." Chapter 37, page 989 stated, "Discard the soiled dressings . . . Remove and discard gloves . . . Perform hand hygiene . . . Clean the wound if indicated. . . ." - During the initial tour of the facility, on 08/20/12 at 12:10 p.m. a social services staff member (#13) identified Resident #4 had either a pressure sore or diabetic ulcer on his heel (which heel not identified). Following the entrance conference, the facility provided a list of residents with pressure sores. Resident #4's name did not appear on the list, nor did the roster matrix identify the pressure sore. Resident #4's medical record, reviewed on all days of survey, identified [DIAGNOSES REDACTED]. A quarterly MDS, dated [DATE], identified Resident #4 required supervision with bed mobility and transfers, extensive assistance of 1 person with dressing, toilet use, and personal hygiene, and had no unhealed pressure sores or diabetic ulcers. Review of Resident #4's progress notes identified the following: * 08/12/12 at 4:57 a.m. "Res (resident) showed this nurse a blister on inside of L (left) heel and open area on bottom of heel cleaned with NS (normal saline) applied ointment and covered with nonadherent pad and gauze wrap." * 08/13/12 at 10:00 a.m. "Checked the left foot as it is reported that he has a sore. Removed the kling (gauze wrap). Found loose tissue that is white in color over the blister site. The loose tissue is whitis (sic). The area is irregular and rectangle shape. 6 cm x 6 cm. Center of left sole of the heel has a small opening: 1 cm round, shallow. Both sites were washed with soap and water; covered with a dry dressing." * 08/14/12 at 1:36 p.m. "Orders received earlier to culture wound on left foot. Dry culture of the wound performed. Previous dressing had a medium am't (amount) of sero-sanguinous drainage noted. Dry dressing applied." * 08/16/12 at 9:40 p.m. "Drsg (dressing) changed to left foot. Resident c/o (complained of) a lot of pain to heal (sic). Wound on side of heal (sic) is beefy red and moderate amount bloody drainage noted on drsg. Left wound open to air times 1 hr (hour). Cleansed wound and redressed wound. Instructed resident to keep shoe off when in bed and to wear socks to prevent rubbing on shoes." * 08/20/12 at 3:03 p.m. "Dressing change to left foot/heel. Measurements: 8.0 cm x 6 cm x 0.3 cm deep, wound bed red/black in color, small amount of bloody drainage noted. Scant foul odor present to old dressing. Resident tolerated dressing change well. Heels floated." Wound culture results, dated 08/17/12, identified heavy growth of Staphylococcus aureus, Pseudomonas aeruginosa, and Beta Streptococcus all susceptible to [MEDICATION NAME] (an antibiotic). The record identified, at 11:17 a.m., when staff notified the provider of the results, he/she stated "that the results are incorrect due to sample contamination." However, the record indicated, at 4:10 p.m. the provider gave a telephone order for Keflex (an antibiotic) 500 milligrams four times a day for 10 days. Observation on 08/21/12 at 3:00 p.m. showed Resident #4 lying in bed with his heels resting on the mattress. A Physical Therapist (PT) (#10) gowned and gloved and removed the dressing from Resident #4's left foot. The drainage on the dressing gave off a foul odor. The PT used a forceps to remove dead tissue from the wound on the left medial heel. Observation showed the wound base extended under the wound edge at the 3:00 position (indicating undermining). Observation showed the wound base dark red. Without changing his gloves and/or performing hand hygiene, the PT then cleansed the wounds and dried them with a 4 x 4 gauze. The PT removed the new dressing from the sterile packaging and applied it to the wounds. Following the dressing change, the PT placed Resident #4's left leg on a pillow to float his heels, removed his gown and gloves, and left the room without performing hand hygiene. A late entry progress note,written on 08/23/12 at 10:02 a.m. for 08/21/12 at 3:00 p.m. stated,". . . PMH (past medical history): DM (diabetes mellitus), R (right) forefoot amputation 2011, multiple wounds from DM, Smoker . . . Location: L heel plantar surface (DM), L medial calcaneous (heel) (pressure sore) Size: DM wound: 2 cm by 3 cm. Pressure wound: 9 cm by 6 cm. No Tunneling undermining present. Exudate: Moist w(with)/ moderate drainage for both and serosanguineous drainage. . . ." Resident #4's record identified a PT order, dated 08/21/12 at 3:25 p.m., stating, ". . . Don't allow shoes on (L) foot to prevent shearing forces on wound." The interdisciplinary care plan, dated 08/14/12, stated, "Focus: Has 2 cm (centimeter) diabetic ulcer to bottom of left foot . . . Interventions: . . . Physical therapist here to evaluate and treat ulcer, PT to do wound care 1 time a week. Nursing to do wound care the rest of the week." The care plan failed to identify Resident #4 had a pressure sore on his left medial heel and lacked interventions for pressure relief/treatment of [REDACTED]. Observations on all days of survey identified Resident #4 lying in bed with his feet/heels resting on the mattress, not floated. Observations failed to identify staff members encouraging/assisting Resident #4 to change positions in bed and/or to float his heels, other than after the dressing change on 08/21/12. An interview with an administrative nurse (#7) occurred on 08/21/12 at 2:25 p.m. The nurse stated Resident #4's pressure sore likely resulted from "rubbing on his shoe." The nurse stated Resident #4 refuses to wear socks with his shoes. During an interview on 08/22/12 at 2:25 p.m., a licensed nurse (#2) and a Certified Nursing Assistant (#11) stated Resident #4 has refused to get out of bed during the days of the survey. They further stated the resident won't allow staff to float his heels. The medical record lacked evidence staff consistently encouraged Resident #4 to implement interventions for pressure relief such as floating his heels, wearing socks, and not wearing shoes to bed and/or educated the resident regarding the risks of noncompliance with these interventions. Facility staff failed to consistently prompt/encourage Resident #4 to implement pressure relieving interventions, failed to educate the resident regarding the risks of his noncompliance, failed to implement appropriate infection control practices during dressing changes, and failed to accurately assess the presence of undermining. Resident #4 had no open areas during the assessment period for the 07/23/12 MDS. Staff did not identify the pressure sore for this resident, who required extensive assistance with dressing and personal hygiene, until 08/12/12 when Resident #4 showed the nurse his blister. At that time, the blister measured 6 x 6 cm. These failures contributed to the development of the pressure ulcer and to the increase in size to 9 x 6 cm on 08/21/12. - Review of Resident #3's medical record occurred on all days of survey. The admission Minimum Data Set (MDS), dated [DATE], indicated intact cognition, extensive assistance of 1 person for bed mobility and transfers, a risk of pressure ulcers, no unhealed pressure ulcers, and pressure reducing devices for the chair and bed. The quarterly MDS, dated [DATE], indicated intact cognition, limited assistance of one person for bed mobility and two or more people for transfers, a risk of pressure ulcers, one unhealed Stage 2 pressure ulcer, a pressure reducing device for the bed, ulcer care, and dressings to feet. Resident #3's care plan, dated 05/21/12, stated, "Focus: The resident has, risk of pressure ulcer or potential for pressure ulcer development r/t (related to) immobility specifically on heels and buttocks . . . Interventions: The resident needs monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. . . . (dated 08/20/12) Drsg (dressing) change per order to stage 1 pressure ulcer on left heel. Physical therapist to do wound care 1 time a week." The care plan, dated 05/31/12, stated, "Focus: Open area on left heel. . . . Interventions: [MEDICATION NAME] offered TID (three times daily)." The current Certified Nurse Aide (CNA) Care Card listed, "Attempt keep pressure off heels when in recliner" and "Float Lt (left) - Rt (right) heels as she allows (dated 08/22/12)." On 08/21/12 at 10:20 a.m., observation showed Resident #3 in her recliner with feet elevated. A licensed nurse (#6) completed the dressing change to the resident's left posterior heel ulcer. Observation showed an approximately 1-1/2 to 2 centimeter (cm) round open area, 0.1 cm depth, and pink granulation tissue. Resident #3 stated she has had the ulcer all summer and it is getting better. The resident added she got the ulcer from her recliner which she sleeps in, and now uses a pillow behind her calves to keep pressure off her heels. The licensed nurse stated a physical therapist (PT) orders treatment (for the ulcer) and sees the resident every Tuesday. She added the ulcer did have a lot of drainage, but now has a very small amount of drainage. Review of Resident #3's progress notes included the following: * 05/26/12 @ (at) 8:59 a.m. "Aide reported resident to have a sore to the back of left heel. . . . Area red and dark purple in color approx (approximately) 2cm in size . . ." * 06/12/12 @ 4:21 p.m. "area on lt heel open and has sm amt drainage nonoderous. Has black area about 3-3.5cm. . . ." * 07/09/12 @ 1:58 p.m. ". . . wound edges with yellow slough, dark brown slough to middle of wound, no drainage noted. . . ." * 07/10/12 @ 3:16 p.m. PT note ". . . min/mod (minimal to moderate) drainage w/ (with) tough slough covering the wound. Unable to remove w/ forceps . . ." * 07/16/12 @ 4:30 a.m. ". . . Wound is yellow with dark matter in the middle and white around the edges. . . ." * 07/16/12 @ 7:40 a.m. ". . . Fresh dressing to the left heal (sic). . . . ulcer is 1.5 cm diameter. pink center and edges are smooth. . . ." * 07/19/12 @ 3:19 p.m. PT note ". . . min/mod serous drainage, mod tough slough covering wound bed. We were able to SD (sharp debridement) w/ forceps today. . . . wound looks much better upon debridement of dead tissue . . ." * 08/14/12 @ 9:03 a.m. PT note ". . . Measurements: Length=2 cm, width=2 cm, depth=superficial. Drainage: Min serous drainage. . . ." * 08/15/12, Multidisciplinary Care Conference note ". . . continue have Stage 1 pressure ulcer to left heel. . . ." * 08/21/12 @ 9:12 a.m. PT note " . . . measurements: length=1 1/2cm, width: 1 1/2 cm, depth: superficial. Drainage: min and serous. Wound and wound edges: free of slough or dead tissue and edges remain healthy. . . ." Facility staff recorded only two entries on Resident #3's "Weekly Pressure Ulcer Record. The first entry, dated 07/20/12, showed a Stage 2 Lt heel ulcer measuring 3.2 x (by) 3.2 cm x 0.5 cm deep, with scant amount of purulent drainage and a yellow/pink wound bed. The second entry, dated 08/11/12, showed a Stage 2 Lt heel ulcer measuring 2.4 x 3.5 cm x 0.2 cm deep, with no drainage and a pink wound bed. Facility staff failed to complete the weekly lesion record per facility policy for 10 weeks from May 26 to August 23, 2012. Failure to accurately assess and regularly record Resident #3's left heel ulcer for Stage (with documentation indicating the ulcer began as a suspected deep tissue injury and progressed to a Stage 3 or Unstageable), size, exudate, odor, wound bed, surrounding skin color, surrounding tissue/wound bed, response to treatment, etc does not allow the facility to track the status of the ulcer, the effectiveness of the treatments, whether the ulcer is improving or declining, inhibits the facility's ability to implement new interventions, and potentially delayed healing of the ulcer. During an interview on the morning of 08/23/12, an administrative nurse (#7) verified staff have not consistently completed the weekly pressure ulcer record and assessment for Resident #3.