Every finding on record at Parkside Lutheran Home

Based on observation, review of professional reference, review of facility policy, and staff interview, the facility failed to ensure safe food practices and failed to maintain a clean and sanitary kitchen environment for 1 of 1 kitchen and 2 of 2 freezers on the Cozy Cottage Unit. Failure to properly store food items and maintain a clean and sanitary kitchen, food preparation, and storage areas has the potential for contamination of food and may result in a foodborne illness to residents, visitors, and staff. Findings Include: The 2022 Food and Drug Administration (FDA) Food Code, Chapter 3-16, Section 3-305.11 Food Storage, stated, . FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination . Annex 3 Page 100, stated, . 3-305.12 Food Storage, Prohibited Areas. Pathogens can contaminate and/or grow in food that is not stored properly. Drips of condensate . can be sources of microbial contamination for stored food. Chapter 4-6, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, stated, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Review of the facility policy Food Storage occurred on 12/10/25. This policy, revised January 2004, stated, . Staff foods/fluids will not be stored in the kitchen refrigerator/freezer . Observation on 12/08/25 at 11:45 a.m. with a dietary manager (#3) showed an accumulation of food/dirt/grime debris in the following areas in the kitchen; * The entire kitchen floor, the tiled baseboards on the wall, the grate of the ice machine, the grate below the front door of the reach-in refrigerator and freezer, and on the large flour and sugar containers.* All kitchen walls contained splashes of food particles with areas of a sticky yellow substance.* The walk-in cooler showed food storage racks had surface material peeling, coated with a dirt/rust or grime substance, and employee food items stored alongside resident food items.* The walk-in freezer showed the condenser line with thick ice and frost built up. Ice droplets formed in front of the ceiling fan and the ice particles, 2-inch-wide by 8-inch-long, dropped onto a package of food under the fan. Observation on 12/08/25 at 1:00 p.m. showed cold packs for resident use stored next to food items in the freezer on Cozy Cottage Unit. Observation of the kitchen on 12/10/25 at 12:34 p.m. with a dietary manager (#3) showed the following:* The base of a blender covered with food particles and a sticky substance.*Two beverage cup carts covered with dirt/debris.* A package of fried steak and a bag of cooked shrimp touched the ceiling in the walk-in freezer. During an interview on 12/10/25 at 12:34 p.m., the administrative dietary manager (#3) confirmed the kitchen needed thorough cleaning and understood the potential for food contamination.

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 5 of 12 sampled residents (Resident #2, #4, #5, #8, and #41). Failure to update care plans limited the staff's ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care Planning – Interdisciplinary Team occurred on 12/10/25. This policy, revised in December 2008, stated, . Each resident's comprehensive care plan is designed to: Incorporate identified problem areas; Incorporate risk factors . Reflect treatment goals . objectives . Aid in preventing or reducing declines in the resident's functional status . assessments of resident are ongoing, and care plans are revised as information about the resident and the resident's condition change. Review of the facility policy titled Smoking - Residents occurred on 12/11/25. This policy, revised April 2012, stated, . Any smoking-related privileges, restrictions, and concerns . shall be noted on the care plan . - Review of Resident #2's medical record occurred on all days of survey. Diagnoses included atypical facial pain, low back pain, polyosteoarthritis, and generalized abdominal pain. The admission Minimum Data Set (MDS), dated [DATE], indicated moderate and frequent pain. Current physician's orders identified acetaminophen (a pain reliever) used for pain. Resident #2's care plan failed to include problems, goals, and interventions for pain management. During an interview on 12/11/2025 at 2:45 p.m., an administrative nurse (#1) confirmed staff failed to update resident #2 care plan. - Review of Resident #4's medical record occurred on all days of survey. Urinary tract infections (UTI) were identified on 12/16/24, 1/28/25, 7/8/25, 9/15/25, 10/20/25, and 11/28/25. Resident #4's care plan failed to include problems, goals, and interventions for chronic urinary tract infections. During an interview on 12/11/25 at 2:41 p.m., an administrative nurse (#1) confirmed staff failed to revise Resident #4's care plan. - Review of Resident #5's medical record occurred on all days of survey. Diagnoses included left hip pain and other chronic pain. The significant change MDS, dated [DATE], identified pain almost constantly. Physician's orders included acetaminophen, Gabapentin (an anticonvulsant used to manage nerve pain), and Advil (a pain reliever) as needed for pain. A smoking assessment, dated 10/23/25, indicated Resident #5 as, safe to smoke without supervision. Resident has not been returning cigarettes to nurse each time she comes back from smoking like she has been told to. The progress notes, dated October 18-22, 2025, identified Resident #5 failed to obtain her cigarettes from the nurse and/or turn them in after each smoking episode. Staff explained this was a violation of their safe smoking privileges and a safety concern that may result in her smoking privileges being revoked. Resident #5's care plan failed to include problems, goals, and interventions addressing pain management and behaviors related to smoking. - Review of Resident #8's medical record occurred on all days of survey. Diagnoses included tobacco use. A smoking assessment, dated 12/21/24, stated, . He often times will not follow the policy/rules on where to smoke or returning his smoking materials to the nurse after he is done. Resident is safe to smoke but needs to be reminded of rules/policy around his smoking materials. Resident #8's care plan related to smoking failed to address behaviors related to smoking. - Review of Resident #41's medical record occurred on all days of survey. Diagnoses included ileostomy (a surgical created opening that allows stool and gas to exit). The care plan stated identified the presence of a colostomy (similar to an ileostomy). A progress note, dated 11/28/2025, stated, Res [Resident] returned to facility from medical stay at [name of hospital]. Res underwent ileostomy reversal . Resident #41's care plan failed to identify the ileostomy reversal. During an interview on 12/11/2025 at 2:45 p.m., an administrative nurse (#1) confirmed staff failed to update resident #41's care plan.

Based on record review, review of facility policy, and staff interviews, the facility failed to identify an incident of verbal abuse for 1 of 1 sampled resident (Resident #8) who was subjected to name calling and sworn at by a staff member. Failure to ensure residents were free from verbal abuse resulted in Resident #8's experiencing emotional distress and placed him and other vulnerable residents at risk of potential and/or continued verbal abuse.Findings include:Review of the facility policy Resident Abuse and Reporting occurred on 12/11/25. This policy, revised on 04/16/24, stated, . The resident has the right to be free from verbal . abuse . Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff . Verbal Abuse: Refers to any use of oral . language that includes disparaging and derogatory terms directed towards residents . regardless of their age, ability to comprehend, or disability. If abuse is witnessed . By the charge nurse or any member of the management team, the Administrator by means of this policy authorizes them to immediately suspend the employee which was seen abusing a resident.Review of Resident #8's medical record occurred on all days of survey. Diagnoses included anxiety, history of traumatic brain injury, major depressive disorder, and unspecified psychosis. The current care plan stated the following, . Observe for s/sx [signs/symptoms] of depression and/or anxiety (IE: . agitation . etc) document and report to CN [charge nurse] . Offer emotional support . I receive counseling through [name of clinic] every 2 wks [weeks] .A memo, dated 11/11/25 at 8:30 a.m., stated, . Writer heard hollering and banging coming from CC [Cozy Cottage Unit] DR [dining room], [Resident #8] and [certified nurse aide (CNA) (#2)] were having a loud disagreement. Alot of name calling and swearing going back and forth. Writer removed res [resident] from DR and CN visited with CNA. [Resident #8] was very upset with [CNA (#2)], he couldn't really explain how it started, but he wanted coffee.Another memo, dated 11/11/25, stated, During the meeting with [CNA (#2)], she stated that she was . waiting to serve breakfast to the residents . she glanced at her phone . and resident [#8] 'went off.' She was angry and started arguing back with him. She stated in hind sight [sic] she should have walked away from him and not engaged. She knows that it was wrong to have responded but he was calling her horrible names and using the 'N' [explicit content] word. I [Administrative Nurse (#1)] informed her that the correct action would have been to ensure that he was safe and walk away.The 24-hour reports showed CNA (#2) was assigned to care for Resident #8 on November 11th, 13th, December 4th, and 8th, 2025.During an interview on 12/10/25 at 4:00 p.m., an administrative nurse (#1) indicated she did not report the incident to the State due to the fact the resident and staff member were immediately separated. She later conceded that the CNA's behavior met the definition of verbal abuse.During an interview on 12/11/25 at 10:53 a.m., Resident #8 stated, I don't like that one girl [CNA (#2)].The facility failed to recognize a loud disagreement, name calling, and swearing as verbal abuse and protect Resident #2 during the investigation.

Based on record review, review of facility policy, and staff interviews, the facility failed to immediately report an incident of verbal abuse for 1 of 1 sampled resident (Resident #8) subjected to name calling and sworn at by a staff member. Failure to report the incident to the state survey agency (SSA) placed Resident #8 and other vulnerable residents at risk of potential and/or continued verbal abuse. Findings include:Review of the facility policy Resident Abuse and Reporting occurred on 12/11/25. This policy, revised on 04/16/24, stated, . Any staff . witnessing . any act . involving mistreatment . or abuse . must immediately notify the charge nurse. The charge nurse will immediately notify the Administrator, Social Services Designee and/or Director of Nursing. The ND Department of Health will also be notified of reports of allegations of abuse and that an investigation is pending. The facility will notify the ND Department of Health the results of the investigation with [sic] 5 working days. A memo, dated 11/11/25 at 8:30 a.m., stated, . Writer heard hollering and banging coming from CC [Cozy Cottage Unit] DR [dining room], [Resident #8] and [certified nurse aide (CNA) (#2)] were having a loud disagreement. Alot of name calling and swearing going back and forth. Writer removed res [resident] from DR and CN [charge nurse] visited with CNA. [Resident #8] was very upset with [CNA (#2)], he couldn't really explain how it started, but he wanted coffee. Another memo, dated 11/11/25, stated, During the meeting with [CNA (#2)], she stated that she was . waiting to serve breakfast to the residents . she glanced at her phone . and resident [#8] 'went off.' She was angry and started arguing back with him. She stated in hind sight [sic] she should have walked away from him and not engaged. She knows that it was wrong to have responded but he was calling her horrible names and using the 'N' [explicit content] word. I [Administrative Nurse (#1)] informed her that the correct action would have been to ensure that he was safe and walk away.During an interview on 12/10/25 at 4:00 p.m., an administrative nurse (#1) indicated she did not report the incident to the state.The facility failed to recognize a loud disagreement, name calling, and swearing as verbal abuse and report the allegation to the SSA.

Based on record review and review of facility policy, the facility failed to investigate an incident of verbal abuse for 1 of 1 sampled resident (Resident #8) who was subjected to name calling and sworn at by a staff member. Failure to thoroughly investigate the incident placed Resident #8 and other vulnerable residents at risk of potential and/or continued verbal abuse. Findings include:Review of the facility policy Resident Abuse and Reporting occurred on 12/11/25. This policy, revised on 04/16/24, stated, . All allegations must be thoroughly investigated by the designated department managers under the general direction of the Administrator. This may include, but is not limited to, interviewing all persons associated with the situation . The investigators will complete a written report and forward it to the Administrator or designee within 48 hours. A memo, dated 11/11/25 at 8:30 a.m., stated, . Writer heard hollering and banging coming from CC [Cozy Cottage Unit] DR [dining room], [Resident #8] and [certified nurse aide (CNA) (#2)] were having a loud disagreement. Alot of name calling and swearing going back and forth. Writer removed res [resident] from DR and CN [charge nurse] visited with CNA. [Resident #8] was very upset with [CNA (#2)], he couldn't really explain how it started, but he wanted coffee.Another memo, dated 11/11/25, stated, During the meeting with [CNA (#2)], she stated that she was . waiting to serve breakfast to the residents . she glanced at her phone . and resident [#8] 'went off.' She was angry and started arguing back with him. She stated in hind sight [sic] she should have walked away from him and not engaged. She knows that it was wrong to have responded but he was calling her horrible names and using the 'N' [explicit content] word. I [Administrative Nurse (#1)] informed her that the correct action would have been to ensure that he was safe and walk away.The facility failed to recognize a loud disagreement, name calling, and swearing as verbal abuse and failed to thoroughly investigate the incident, including interviewing other staff members and residents who were present in the dining room at the time of the incident.

Based on observation, record review, policy review, and staff interview, the facility failed to provide medication in accordance with professional standards for 1 of 1 resident (Resident #31) with a percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted through the skin and abdominal wall directly into the stomach) observed during medication administration. Failure to accurately transcribe provider's orders may result in adverse health effects. Findings include:Review of the facility policy titled, Physician Orders/Transcribing for New and re-admitted Residents occurred on 12/11/25. This undated policy, stated, . Each medication order must have a route, dose, frequency and related diagnosis. The nurse who received the orders, checks that all of the above have been followed through . A second nurse will check all the orders written in the computer to the orders received from the MD [medical doctor] and queue that they are correct.Review of Resident #31's medical record occurred on all days of survey and identified a PEG placement. A physician order, dated 12/08/25, included Morphine concentrate (a pain medication), administer buccally (area inside the mouth between the cheek and the gums) or per peg tube for pain or dyspnea.Review of Resident #31's December 2025 medication administration record (MAR) occurred on 12/10/25. The order entered on the MAR, dated 12/08/25, identified the route of administration as buccal and failed to include via PEG tube. Observation on 12/10/25 at 1:30 p.m. showed a nurse (#7) administered morphine through Resident #31's PEG tube. This administration route did not match the transcribed order in the MAR. During an interview on 12/11/25 at 2:45 p.m., an administrative nurse (#1) confirmed staff failed to transcribe the order accurately in the MAR.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the necessary treatment and services for 1 of 1 sampled resident (Resident #2) with a pressure ulcer. Failure to complete weekly assessments with measurements of pressure ulcers per facility policy, may result in new pressure ulcers, the deterioration of existing pressure ulcers, and delay healing.Findings include: Review of the facility policy titled Documentation of Wound Treatments occurred on 12/11/25. This undated policy, stated, . Wound assessments are documented upon admission, weekly, and as needed . The following elements are documented as part of a complete wound assessment: a. Type of wound . Stage of the wound . Measurements: height, width, depth . Description of wound characteristics . Weekly progress towards healing .Review of Resident #2's medical record occurred on all days of survey and identified a Stage 3 pressure ulcer to the right heel. Wound clinic assessments of Resident #2's right heel pressure injury showed the following:* 11/06/25 - 0.4 centimeter (cm) x 0.4 cm* 12/05/25 - 0.8 cm x 1 cm (29 days later) The medical record lacked weekly wound assessments of the right heel pressure ulcer with measurements. During interviews on 12/11/25 at 11:11 a.m. and 2:45 p.m., an administrative nurse (#1) confirmed Resident #2's medical record lacked weekly wound assessments and she expected staff to complete weekly wound assessments per wound treatment policy.

Based on observation, record review, policy review, review of a professional reference, and staff interview, the facility failed to provide appropriate toileting for 1 of 2 sampled residents (Resident #31) who required staff assistance with toileting. Failure to provide toileting may result in a loss of dignity and placed the resident at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and at risk for falls and/or injuries. Findings include:Review of the facility policy titled Incontinence occurred on 12/11/25. This undated policy, stated, . Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.Review of Resident #31's medical record occurred on all days of survey and included a diagnosis of cerebral infarction (stroke) and Alzheimer's disease. The Minimum Data Set (MDS), dated [DATE], identified substantial/maximal assistance with toileting, frequently incontinent of urine and occasionally incontinent of bowel. The care plan, dated 11/26/25, stated, . I need assistance with toileting.A nurse's note, dated 12/06/25 at 5:36 a.m., stated, . During toileting cares Resident urine has strong odor.Review of Resident 31's bladder elimination task record, dated November 27 through December 10, 2025, showed a toileting gap of three or more hours each day. November 27, 2025, showed an eight-hour toileting gap from 1:07 p.m. to 9:10 p.m., and December 2, 2025, showed an eight-hour toileting gap from 3:26 p.m. to 11:49 p.m.Observation on all days of survey identified a urine odor in Resident #31's room.Observation on 12/10/25 11:17 a.m. showed a certified nurse aide (CNA) (#2) assisted Resident #31 out of her and to the toilet. Resident #31's pants were visibly wet and smelled of urine and feces. The CNA (#2) removed the soiled pants and brief, completed perineal cares, applied a new incontinence brief and pants, and transferred Resident #31 to the recliner visibly wet from urine. The CNA (#2) failed to provide timely toileting assistance and failed to ensure a clean recliner.During interviews on 12/11/25 at 11:11 a.m. and 2:45 p.m., an administrative nurse (#1) stated she expected staff to assist residents with toileting needs every two to three hours and as needed unless they are independent with toileting, replace the wet recliner while the soiled recliner is cleaned, and at least a place a barrier between the resident and a wet recliner.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 2 residents (Resident #2 and #31) in enhanced barrier precautions (EBP). Failure to practice infection control standards related to EBP 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 12/11/25. This policy stated, . Initiation of Enhanced Barrier Precautions: . An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds . and/or indwelling medical devices . Implementation of Enhanced Barrier Precautions: . PPE (Personal Protective Equipment) for enhanced barrier precautions is only necessary when performing high-contact care activities . High-contact resident care activities include: . c. Transferring. d. Providing hygiene. f. Changing briefs or assisting with toileting. g. Device care or use: . feeding tubes . Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.Review of the facility policy titled Hand Hygiene occurred on 12/11/25. This policy, dated 10/2009, stated, . situations that require hand hygiene: . before and after resident contact . before and after handling peripheral vascular catheters and other invasive devices . before and after assisting a resident with toileting . after removing gloves . - Review of Resident #2's medical record occurred on all days of survey. The physician's orders, dated 10/01/25, stated, Advanced Barrier Precautions every shift .Observation on 12/08/25 at 2:01 p.m. showed two certified nurse aides (CNAs #5 and #6), performed hand hygiene, applied gloves, and without applying gowns, transferred Resident #2 from the wheelchair to the toilet using a mechanical lift, and assisted with toileting needs. The CNAs failed to apply gowns as per the EBP policy.- Review of Resident #31's medical records occurred on all days of survey. The physician's orders, dated 11/25/25, stated, Enhanced Barrier Precautions .Observation on 12/10/25 at 11:17 a.m. showed the CNA (#2) applied gloves, and without applying a gown assisted Resident #31 to the toilet. After completing perineal care, the CNA removed the soiled gloves and assisted the resident back to the recliner. Without performing hand hygiene, the CNA applied clean gloves, took garbage and dirty clothing bags down the hallway and placed them in appropriate bins. The CNA (#2) returned to room, removed the soiled gloves and performed hand hygiene. The CNA clipped the call light to the resident's sweatshirt sleeve, plugged the power cord back into the tube feeding device, and exited the room without performing hand hygiene. The CNA (#2) failed to wear a gown as per the EBP policy, failed to perform hand hygiene when removing soiled gloves and before applying clean glove, and before exiting the room.Observation on 12/10/25 at 1:20 p.m. showed a nurse (#7) entered Resident #31's room and administered medication through the percutaneous endoscopic gastrostomy (PEG) tube. The nurse failed to apply a gown as per EBP policy.During an interview on 12/11/25 at 2:45 p.m., an administrative nurse (#1) stated she expected staff to perform hand hygiene, wear gowns and gloves for residents on enhanced barrier precautions during all close contact care and medication administration through a PEG tube.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 5 of 13 sampled residents (Resident #11, #14, #25, #90, and #139) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions, urinary catheters, and hand hygiene has the potential to spread infection throughout the facility. Findings include: ENHANCED BARRIER PRECAUTIONS Review of the facility's policy titled Enhanced Barrier Precautions occurred on 08/08/24. This undated policy stated, . 'Enhanced barrier precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and gloves [sic] use during high contact resident care activities. An order for enhanced barrier precautions will be obtained for residents with any of the following . Wounds . chronic venous stasis ulcers . and/or indwelling medical devices . feeding tubes . catheters . even if the resident is not known to be infected or colonized with a MDRO . Make gowns and gloves available immediately near or outside of the resident's room. PPE [personal protective equipment] for enhanced barrier precautions is only necessary when performing high-contact care activities . High-contact resident care activities include . Device care or use . feeding tubes . urinary catheters . Wound care: any skin opening requiring a dressing . - Review of Resident #11's medical record occurred all days of survey. The medical record identified the following physician's orders for stasis ulcer dressing changes: * 03/28/24, Left Lower ankle wound one time a day for leg wound Wash w [with]/soap, water, and washcloth; Promogran [type of wound treatment] in wound; cover w/gauze pad and hold with rolled gauze. * 03/28/24, Right Lower Leg Wounds-daily one time a day for Wounds r/t [related to] Cellulitis of Rt LE [right lower extremity] Change daily; wash w/soap & H2O [water], protective oint [ointment] to lower leg, promogran to wounds--roll between fingers & poke into wounds w/Q tip; cover w/gauze & [and] tubigrip [a multi-purpose, elastic tubular bandage] size F single layer from toes to knees for compression; may wear at noc [night] if comfortable. * 07/24/24, Flush R [right] Hip wound with saline jet twice daily as needed. Poke & gently pack 14 inch idofor [sic] packing strip into deep tunneling (2.5cm) into wound with end of qtip [sic]. do not over stuff. Cover with gauze and tape as desired. two times a day for R groin wound. Observation on all days of survey showed Resident #11 with dressings to both lower extremities. The facility failed to place Resident #11 on EBP and failed to make PPE readily available to staff. During an interview on 08/08/24 at 10:40 a.m., a nurse (#6) reported gloves are commonly used when changing Resident #11's dressings. She further stated staff will wear a gown, gloves, mask, and eye protection if the facility suspects something [due to reddened skin or drainage]. - Review of Resident #90's medical record occurred all days of survey. The medical record indicated Resident #90 had an indwelling medical device - a feeding tube. Observation on 08/07/24 at 11:42 a.m. showed a nurse (#6) donned gloves and then flushed Resident #90's feeding tube. The facility failed to place Resident #90 on EBP and failed to make PPE readily available to staff. - Review of Resident #139's medical record occurred all days of survey. The medical record indicated Resident #139 had an indwelling medical device - a urinary catheter. Observation on 08/06/24 at 10:57 a.m. showed a certified nurse aide (CNA) (#9) donned gloves and performed Resident #139's catheter cares. The facility failed to place Resident #139 on EBP and failed to make PPE readily available to staff. During an interview on 08/08/24 at 11:17 a.m., an administrative nurse (#3) confirmed residents with an indwelling medical device need to be placed on EBP. CATHETER CARES/HAND HYGIENE Review of the facility's policy titled Catheter Care, Urinary occurred on 08/08/24. This policy, revised October 2010, stated, . Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. Be sure the catheter tubing and drainage bag are kept off the floor. Review of the facility's policy titled Hand Hygiene occurred on 08/08/24. This undated policy stated, . Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene . Before and after assisting a resident with toileting . After handling soiled equipment . After removing gloves . Observations showed the following: * 08/05/24 at 1:25 p.m., two CNAs (#7 and #10) donned gloves and laid Resident #139's urinary drainage bag on the floor while they placed the sling around the resident and attached it to the full body lift. The CNAs failed to keep the urinary drainage bag off the floor. * 08/06/24 at 10:57 a.m., a CNA (#9) donned gloves, drained Resident #139's urinary drainage bag, sanitized the drainage port, reconnected the tubing to the bag, and removed his gloves. Without performing hand hygiene, the CNA (#9) donned gloves and attempted to place the urinary drainage bag into a privacy bag. When the drainage bag got caught under the wheelchair, the CNA (#9) disconnected the drainage tube from the bag, dropped the end of the tube on the floor, picked it up, and reconnected it to the bag without sanitizing the end. Without performing hand hygiene, the CNA (#9) donned gloves, disconnected, sanitized, and reconnected the end of the tube to the bag, removed his gloves, and washed his hands prior to exiting the room. The CNA failed to keep the catheter bag and tubing off the floor, failed to sanitize the end of the tube prior to reconnecting it to the bag, and failed to sanitize his hands after handling soiled equipment. * On the afternoon of 08/06/24, two CNAs (#7 and #8) donned gloves and transferred Resident #14 into the bathroom. After the resident voided, one of the CNAs (#8) performed peri-cares, removed her gloves, transferred the resident into the wheelchair and then into bed, covered her with a blanket, placed the call light within reach, and exited the room without performing hand hygiene. The CNA (#8) failed to sanitize her hands after providing toileting cares and prior to exiting the room. * 08/06/24 at 4:20 p.m., two CNAs (#7 and #8) donned gloves and transferred Resident #25 into the bathroom. After the resident voided, one of the CNAs (#8) performed peri-cares, removed her gloves, transferred the resident into the wheelchair, and without performing hand hygiene, placed the call light within reach. The CNA failed to sanitize her hands after providing toileting cares and prior to performing other tasks. 27221 47896

Based on observation, record review, review of facility policy, and resident and staff interviews, the facility failed to ensure care and services were provided according to accepted standards of quality for 1 of 2 sampled residents (Resident #5) observed during stand-pivot transfers. Failure to ensure staff place call lights within the resident's reach placed residents at risk for falls and/or injury. Findings include: Review of the policy titled Answering the Call Light occurred on 08/08/24. This policy, revised October 2010, stated, . When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. - During interviews on 08/05/24 at 1:36 p.m. and 08/06/24 at 9:15 a.m., Resident #7 voiced her concerns regarding staff's interaction with her roommate (Resident #5). She stated, She [Resident #5] asks to go to the bathroom often. They tell her, 'You just went.' So many times, the light is not within her reach. At night, she'll call out and I turn on my light. What if I am not here? - Observation on 08/05/24 at 1:40 p.m., showed Resident #5 sitting in her wheelchair with the call light attached to the bed, out of the resident's reach. Resident #5 stated, I have to go to the bathroom. I'm looking for my call light. Review of Resident #5's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, dementia, osteoarthritis, and history of left femur fracture. The care plan identified, . I need assist for locomotion of w/c [wheelchair] . I need assist with transfers, assist prn [as needed] . During an interview on the afternoon of 08/08/24, an administrative nurse (#3) confirmed she expected staff to ensure call lights are within reach of the residents.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure each resident's entire drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for 1 of 5 sampled residents (Resident #14) reviewed for unnecessary medications. Failure to complete an Abnormal Involuntary Movement Scale (AIMS) screening for any resident receiving an antipsychotic medication may result in the resident experiencing an adverse reaction to the medication such as tardive dyskinesia [an involuntary movement disorder]. Findings include: Review of the facility's policy titled AIMS Screening occurred on 08/08/24. This policy, revised 04/23/02, stated, . It is the policy of Parkside Lutheran Home to do an AIMS screening on all residents using a neruoleptic (Antipsychotic) and other specified medications. AIMS screening . shall be the testing tool used to assess the absence or presence of tardive dyskinesia . While resident continues med [medication], testing shall be done every 6 months. Review of Resident #14's medical record occurred on all days of survey. The current physician's orders revealed Resident #14 received the antipsychotic medication Abilify daily for major depression and psychosis. The care plan stated, . Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects . adverse reactions of PSYCHOTROPIC medications . tardive dyskinesia . An AIMS, dated 07/07/23, identified no abnormal facial, trunk, or extremity movements at the time of the assessment. The medical record failed to include a January 2024 and July 2024 re-assessment. During an interview on the afternoon of 08/08/24, an administrative nurse (#3) confirmed she expected staff to reassess any resident receiving an antipsychotic medication every six months.

Based on record review and staff interview, the facility failed to assess residents with a history of trauma and identify known triggers for 1 of 1 sampled resident (Resident #33) reviewed for Post-Traumatic Stress Disorder (PTSD). Failure to ensure staff assess residents with PTSD upon admission, identify known triggers, and provide appropriate person-centered treatment/services may result in re-traumatization. Findings include: The facility failed to provide a copy of a policy addressing PTSD. Review of Resident #33's medical record occurred on all days of survey. A psychiatry note, dated 06/04/24, identified, [Resident #33] . with a complex psychiatric history whose previous diagnoses include . PTSD . The medical record failed to include an assessment addressing past traumas. The current care plan identified, . I have diagnosis of . PTSD . Observe for s/sx [signs/symptoms] of depression and/or anxiety . document all mood symptoms and report to CN [charge nurse]. The care plan failed to identify known triggers and/or list interventions the facility put in place to prevent re-traumatization. During an interview on 08/07/24 at 1:20 p.m., an administrative nurse (#3) confirmed staff failed to assess residents with PTSD, identify their known triggers, and/or list interventions they put in place to prevent re-traumatization.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury for 1 of 2 sampled residents (Resident #14) observed during stand-pivot transfers. Failure to utilize a gait-belt during stand-pivot transfers placed residents at risk for falls and/or injury. Findings include: Review of the policy titled Gait Belts occurred on 08/08/24. This undated policy stated, . A gait belt will be utilized with all residents who require assistance with transfers and ambulation. To ensure safety from injury for both resident and nursing staff . Place the gait belt around the resident's waist and snug enough so it won't slip up . Snug the gait belt as the resident stands . - Observation on 08/05/24 at 1:40 p.m., showed a certified nurse aide (CNA) (#7) placed a gait belt around Resident #5's waist, tightened the belt, locked the brakes on the wheelchair, and assisted her to stand by pulling upward on the back of her pants. Review of Resident #5's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, dementia, osteoarthritis, and history of left femur fracture. The care plan identified, . I need assist with transfers . - Observation on the afternoon of 08/06/24 showed two CNAs (#7 and #8) toileted Resident #14. One of the CNAs (#8) placed a gait belt around Resident #14's waist, tightened the belt, locked the brakes on the wheelchair, and assisted her to stand by pulling upward on the back of her pants. Review of Resident #14's medical record occurred on all days of survey. Diagnoses included abnormalities of gait/mobility, disorders of bone density/structure, right hemiplegia following a cerebral infarction, and severe vascular dementia. The care plan identified, . I need assist of 1 to transfer . During an interview on the afternoon of 08/08/24, an administrative nurse (#3) confirmed she expected staff to utilize a gait belt when transferring residents.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow professional standards of practice regarding physician's orders for 1 of 1 sampled resident (Resident #139) with a catheter. Failure to ensure physician's orders are clearly understood, correctly transcribed, and entered in a timely manner may result in a resident receiving an inappropriate medication, test, treatment, and/or other intervention. Findings include: Review of the facility policy titled Orders (Verbal, Written, Telephone) occurred on 08/08/24. This policy, revised December 2008, stated, . Orders may only be received by licensed personnel (RN [registered nurse], LPN [licensed practicing nurse]) . faxed orders from primary care providers . will be reviewed and electronically signed by the ordering provider . Observation on 08/05/24 at 1:25 p.m. showed Resident #139 with a catheter bag under her wheelchair. Review of Resident #139's medical record occurred on all days of survey and identified a return from the hospital on dated 07/30/24 at 2:39 p.m. The care plan stated, . I have a foley catheter . The current physician's orders failed to include an order for Resident #139's foley catheter. During an interview on 08/07/24 at 2:40 p.m., an administrative nurse (#3) confirmed staff failed to enter an order for Resident #139's catheter. She indicated staff missed transcribing the order when Resident #139 returned from the hospital.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plans to reflect the current status for 1 of 13 sampled residents (Resident #5) and 2 supplemental residents (Resident #7 and #30). Failure to review and revise the care plans limited staff's ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care Planning - Interdisciplinary Team occurred on 08/08/24. This policy, revised December 2008, stated, . The care plan is based on the resident's comprehensive assessment and is developed by the Care Planning/Interdisciplinary Team . The resident, the resident's family and/or the resident's legal representative/guardian are encouraged to participate in the development of and revisions to the resident's care plan. - Review of Resident #5's medical record occurred on all days of survey. The quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #5 received a diuretic medication. The current physician's orders showed she received Lasix (a diuretic medication) daily. Resident #5's care plan failed to address the use of a diuretic medication. - Review of Resident #7's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified Resident #7 received an anticoagulant medication. The current physician's orders showed she received Eliquis (an anticoagulant medication) daily. Resident #7's care plan failed to address the use of an anticoagulant medication. - Review of Resident #30's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified Resident #30 received an antidepressant medication. The current physician's orders showed she received Mirtazapine (an antidepressant medication) daily. Resident #30's care plan failed to address the use of an antidepressant medication. 27221

Based on record review and staff interview, the facility failed to provide the resident or the resident's representative a written notice of bed hold for 1 of 3 residents (Resident #8) reviewed for hospital transfer. Failure to provide a written copy of the bed hold notice does not allow the resident and/or their representative to make an informed decision regarding their rights. Finding include: Review of Resident #8's medical record occurred on all days of survey and identified Resident #8 transferred to a hospital on 02/22/24. The medical record lacked documentation the facility provided the resident and/or representative with a written bed hold notice. During an interview on 08/08/24 at 11:17 a.m., an administrative staff member (#3) stated she expected staff to provide a bed hold notice to the resident and/or representative any time the resident is out of the facility overnight.

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 1 of 3 residents (Resident #8) reviewed for hospital transfer. 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. Finding include: Review of Resident #8's medical record occurred on all days of survey and identified Resident #8 transferred to a hospital on 02/22/24. The medical record lacked documentation the facility provided the resident and/or representative with a written notice of transfer. During an interview on 08/08/24 at 11:17 a.m., an administrative staff member (#3) stated she expected staff to provide a notice of transfer to the resident and/or representative any time the resident is hospitalized .

Based on record review, review of facility policy, and resident and staff interview, the facility failed to review and revise comprehensive care plans to reflect the current status for 2 of 12 sampled residents (Resident #13 and #16). 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 - Comprehensive occurred on 08/01/23. This undated policy stated, . care plans are revised as information about the resident and the resident's condition change. - During an interview on 07/30/23 at 2:19 p.m., Resident #13 stated, They used to use the stand lift now they use the hoyer [full body mechanical lift] because they say the stand lift isn't safe. When asked when the change was made Resident #13 stated about 3 weeks ago. Review of Resident #13's medical record occurred on all days of survey. The current care plan stated, . I need assist of 2 staff to transfer in & [and] out of bed with the Standup lift. A progress note dated 07/06/23, stated, . transfer eval [evaluation] completed today with 2 CNAs [certified nurse aides] transferring pt [patient] with a standing lift. Concerns raised by staff re [regarding] safety of the lift for pt. guidelines to use a standing lift pt needs to be able to bear weight thru LE [lower extremities] as well as have UE [upper extremities] strength. If these guidelines are not met then a standing lift not indicated and pt should be transferred via hoyer full body sling. Pt does not have adequate UE strength . He cannot appropriately and safely bear wt [weight] thru LE. During an interview on 08/01/23 at 5:00 p.m., administrative staff (#1 and #2) confirmed the change in transfer methods for Resident #13 due to safety concerns and agreed they expected the care plan to reflect the appropriate transfer method. - Review of Resident #16's medical record occurred on all days of survey and included a diagnosis of Diabetes Mellitus. The physician's orders included long and short-acting insulin, blood glucose monitoring, and diabetic nail care. Resident #16's current care plan lacked problem, goals and interventions related to diabetes mellitus. During an interview on 08/01/23 at 5:40 p.m., an administrative nurse (#1) confirmed staff failed to update Resident #16's care plan.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the necessary treatment/services to promote the healing of pressure ulcers for 1 of 1 sampled resident (Resident #35) and 1 of 1 closed record (Resident #38) identified with a pressure ulcer. Failure to routinely assess, monitor, and measure pressure ulcers may result in delayed healing of the pressure ulcer. Findings include: Review of the facility policy titled Pressure Sores - General occurred on 08/01/23. This undated policy stated, . 3. Document wound in IDP [interdisciplinary plan] notes and initiate a weekly pressure ulcer record; with all treatment recorded in the treatment sheets. 8. All pressure sores with be monitored weekly by wound care nurse . Review of the facility policy titled, Skin Assessment occurred on 08/01/23. This undated policy stated, . 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission. and weekly there after. Review of Resident #35's medical record occurred on all days of survey. Medical diagnosis included a stage 4 pressure ulcer to the sacral region. The care plan stated, . Follow facility policies/protocols for the prevention/treatment of skin breakdown. The medical record showed the facility staff completed a weekly wound record on 06/29/23 and again on 07/30/23, four weeks later. Review of Resident #38's medical record occurred on 08/01/23. Medical diagnosis included a stage 3 pressure ulcer to the sacral region. The care plan stated, . Dressing change as ordered. Reposition every 2hrs [hours] or more freq [frequently]. When in bed position side to side. The medical record showed the facility staff completed a weekly wound record on 04/24/23 and again on 06/08/23, six weeks later. The facility staff failed to complete weekly pressure ulcer documentation for Resident's # 35 and #38. During interview on 08/01/23 at 5:45 p.m., an administrative nursing staff member (#1) stated she expected staff to follow facility policy and complete weekly wound records with measurements and documentation for all residents with pressure ulcers. 42397 46964

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON MAY 25, 2011. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide necessary treatment and services to aid in the prevention of and promote the healing of pressure ulcers for 2 of 2 sampled residents with facility acquired pressure ulcers (Resident #1 and #2) and for 1 of 3 sampled residents with a history of pressure ulcers (Resident #8). Failure to adequately assess residents upon admission or re-entry into the facility, reposition residents, and properly use pressure relieving air mattresses contributed to the development of Resident #1 and #8's bilateral heel pressure ulcers; the need for surgical procedures to assist with healing of the pressure ulcers for Resident #1 and #8; avoidable heel pain for Resident #1; and placed Resident #2 at risk for continued skin breakdown and worsening of an existing pressure ulcer. Findings include: Review of the facility policy titled "Pressure Sores-General" occurred on 04/11/12. This policy, dated 05/27/11, stated, "POLICY: It is the policy of Parkside Lutheran Home to provide care to residents in order to prevent the occurrence of pressure sores or any other open areas. A resident who has pressure sores will receive the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. PROCEDURE: Routine skin checks will be done on all residents at admission, during cares and on bath days . . . 3. For prevention, utilize pressure redistribution devices as indicated . . . 7.a. Any reddened or open areas are to be documented by the licensed staff in the resident's record including size, location, action taken . . . ESSENTIAL POINTS: If a resident is at risk for developing a decubitus, open a problem on the care plan indicating the resident is at risk . . . Licensed nurse are to notify physician and apply treatments as ordered by physician and record. Pressure ulcers will be measured weekly by charge nurse or wound care nurse. Wound care nurse or Charge nurse will initiate and document wound care progress on pressure ulcer . . . ." On the afternoon of 04/09/12, the facility provided written documentation to the survey team which identified the presence of facility acquired pressure ulcers involving two residents (Resident #1- bilateral heels and Resident #2- Stage 3 to the coccyx). - Review of Resident #1's medical record occurred on April 09-12, 2012. Resident #1 sustained a fall at a basic care facility on 01/18/12, which resulted in a left [MEDICAL CONDITION]. The facility admitted the resident on 01/24/12. Medical [DIAGNOSES REDACTED]. Resident #1's admission Minimum Data Set (MDS), dated [DATE], identified the resident displayed severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 7; required extensive two person physical assistance with bed mobility, transfers, dressing, toilet use and personal hygiene; received PRN (as needed) pain medications and non-medication interventions during the 5-day look back period; the frequent presence of pain, rated as "06" on the 00-10 Numeric Rating Scale; two Stage 2 pressure ulcers identified on 02/01/12; pressure reducing devices for her chair and bed, turning/repositioning schedule, nutrition/hydration interventions, and pressure ulcer care. Resident #1's Nursing Care Assessment Areas (CAAs), dated 02/06/12 stated, ". . . Triggers ADL (Activities of Daily Living) Function d/t (due to) needs extensive assist with cares . . . Res (resident) isn't ambulating at this time . . . Triggers Pressure Ulcers d/t has break down . . . Res has 2 Stage II areas, one on each heel. Res is followed (sic) the Wound Nurse and Physician, treatment to change as needed. Precautionary items in place to prevent further break down . . . Proceed to care plan . . . ." Resident #1's 60-day MDS, dated [DATE], remained the same in all areas identified above except this MDS identified Resident #1 exhibited four unstable pressure ulcers due to slough and/or eschar and identified the presence of necrotic (eschar) tissue. Resident #1's care plan identified a problem, dated 01/24/12, of "Alteration in Skin Integrity R/T (related to) ORIF (and) heel breakdown and approaches of "Repos (reposition) Q (every) 2 (hours). The facility added approaches of "float heels when in bed," and heel lift boots to bilateral feet at all times on 02/22/12, almost one month later. The surveyor noted a discrepancy, with the date of 01/24/12 on the care plan, which identified the implementation of the problem of "Skin Integrity R/T . . . heel breakdown," as the Interdisciplinary Progress Note (IPN) of 01/30/12 is the first time facility staff documented and addressed the presence of Resident #1's heel pressure ulcers. Resident #1's physician orders included a copy titled "Standing Orders," signed by the physician on 10/13/08, which stated, "SKIN ASSESSMENT: Within 7 days of admission . . . Decubitus Care: 1. Decube/Pressure relief mattress on admission. 2. Pressure relief cushions/gel socks when indicated. 3. Apply [MEDICATION NAME] when indicated. Notify doctor or PA (Physician Assistant). Change q (every) 3 days and PRN. If wound shows no improvement in 2 weeks or if s/s (signs/symptoms) of infection notify MD or PA immediately . . . ." Resident #1's "Admission Nursing Assessment" form, dated 01/24/12, showed facility staff assessed and documented the skin condition (at the time of admission to the facility) to include "IV (intravenous) site bruises" to the right arm and hand, a "fluid filled ecchymotic area" to the left anticubital area, a "birthmark" to her lower back, a "reddened" area to left lower back, and a "bandage and staples" to the left hip. This Admission Nursing Assessment failed to document the presence of any redness or bogginess to Resident #1's bilateral heels. Review of Resident #1's IPNs from January 24-29, 2012, lacked documentation of any redness or bogginess to the resident's bilateral heels. An IPN, dated 01/30/12 at 9:30 a.m., stated, "Noted resident (left) heel fluid filled blister 3.8 (L) (length) x 2 cm (centimeters) (W) (width). Blister intact - area surrounding heel spongy et (and) dusky in color. (Right) heel 7.5 (L) x 4.5 cm (W) fluid filled blister intact (with) dk (dark) color area in middle measuring 2.5 (L) x 2 cm (W). Blister intact. Heel spongy, pink surrounding blister . . . Gel heel socks applied to feet bilaterally. Also, pressure relieving mattress put on bed. Resident also to wear heel lifter boots while in bed." Further IPNs, dated January 31-April 10, 2012, show evidence of facility staff assessing and monitoring Resident #1's bilateral heel pressure ulcers, applying a pressure relieving mattress to her bed and other interventions to promote the off loading of pressure to her heels, the implementation of dietary interventions to aid in the healing of the pressure ulcers, and wound care as ordered by the medical provider. Review of the facility form titled, "Hourly Flow Record," showed the facility implemented an every two-three hour repositioning schedule for Resident #1 on February 1, after the discovery of her bilateral heel blisters. Resident #1's medical record lacked evidence the facility initiated, reminded, or assisted Resident #1 with frequent repositioning/turning from January 24-January 31, 2012. Resident #1's Weekly Pressure Ulcer Records stated: Left heel - 01/30/12 - Stage 2 measuring 3.8 x 2.0 cm (L x W) with an intact blister. Treatments/Comments of: "heel gel socks applied, air mattress to bed, heel lifter boots in bed." - 02/01/12 - Stage 2 measuring 2 x 7 cm with an intact blister. Treatments/Comments of: "Heel elevator boots on at all times." - 02/08/12 - Stage identified as "intact blister" measuring 3 x 6 cm. - 02/15/12 - Stage identified as "(not) intact blister" measuring 3 x 7 cm. - 02/22/12 - Stage identified as "unstageable" measuring 3 x 7 cm with "dried blacked [MEDICATION NAME] tissue." Treatments/Comments of: "Appt (appointment) to be seen for debridement of [MEDICATION NAME] tissue." The medical provider debrided Resident #1's left heel pressure ulcer on 02/23/12. - 02/23/12 - Stage 2 - measuring 3.5 x 0.4 cm, depth of 0.2 cm with a "red and blood" wound bed. - 02/28/12 - Stage "unstageable" measuring 3.5 x 0.4 cm, depth of 0.2 cm with a "black and dry" wound bed. - 03/07/12 - Stage "unstageable" measuring 4.0 x 1.2 cm, with a "tan and yellow" wound bed. Treatments/Comments of: PolyMem as ordered. Will update Dr (doctor) (with) request to consider changing treatment." - 03/14/12 - Stage "unstageable" measuring 3.5 x 1.0 cm, depth 0.2 cm, with a "yellow and wet" wound bed. Treatments/Comments of: PolyMem d/c (discontinued) on 03/08. Tender-Wet (dressing) started daily. - 03/21/12 - Stage "unstageable" measuring 2.0 x 1.6 cm, depth 0.2 cm, with yellow slough to the wound bed. - 03/28/12 - Stage "unstageable" measuring 2.8 x 1.0 cm, depth 0.2 cm, with "90% white slough, 10% granulation" to the wound bed. - 04/04/12 - Stage 3 measuring 0.5 x 2.0 cm, depth of 0.2 cm, wound bed as "pink (with) 15% white slough." - 04/11/12 - Stage 3 measuring 0.5 x 2.0 cm, depth of 0.2 cm, wound bed as "pink (with) 10% white slough." Right heel - 01/30/12 - Stage 2 measuring 7.5 x 4.5 cm with an intact blister. Treatments/Comments of: "Heel gel socks, heel lifter boots in bed." - 02/01/12 - Stage 2 measuring 4.5 x 7.0 cm with an intact blister. Treatments/Comments of: "Heel elevator boots on (at) all times." The surveyor identified a discrepancy in the measurement from 01/30/12, as recorded by the licensed nurse two days prior. - 02/07/12 - Stage as "unstageable" measuring 1.0 x 2.2 cm, wound bed "black." - 02/15/12 - Stage as "unstageable" measuring 0.5 x 2.0 cm, wound bed "black." - 02/22/12 - Stage as "unstageable" measuring 0.5 x 2.0 cm, with "black" wound bed. Treatments/Comments of: "Appt for debridement." The medical provider debrided Resident #1's right heel pressure ulcer on 02/23/12. - 02/23/12 - Stage 2 - measuring 4 cm (did not indicate if this is a length or width measurement), with a "red and bloody" wound bed. - 02/28/12 - Stage "unstageable" measuring 4 cm (did not indicate if this is a length or width measurement), with a "black and dry" wound bed. - 03/07/12 - Stage "unstageable" measuring 3.3 x 2.5 cm, with a "pink/red/tan/dry" wound bed. - 03/14/12 - Stage "unstageable" measuring 2.7 x 2.5 cm, depth 0.1 cm, with a "yellow and wet" wound bed. Treatments/Comments of: "Will fax update to Dr. re: (regarding) yellow/wet wound bed if (change) in treatment recommended." - 03/21/12 - Stage "unstageable" measuring 2 cm (did not indicate if this is a length or width measurement), with "green/yellow slough" to wound bed. - 03/28/12 - Stage "unstageable" measuring 2 cm (did not indicate if this is a length or width measurement), with 90% yellow slough, 10% granulation" to wound bed. - 04/04/12 - Stage "unstageable" measuring 2 cm (did not indicate if this is a length or width measurement), wound bed as "80% slough - 20% granulation." - 04/11/12 - Stage "unstageable" measuring 2 cm (did not indicate if this is a length or width measurement), wound bed as "80% slough - 20% granulation." A physician progress notes [REDACTED]. . . The patient did come back from the hospital with blister on the heels . . . ." (However, Resident #1's record lacked evidence of the presence of any blisters, redness or boggy heels based on her skin assessment at the time of her admission to facility on 01/24/12.) This progress note identified the resident has a "blister to the right heel which quite significant . . . does measure at least 3 cm in diameter . . . ." The medical provider recommended "continue with avoiding any extra pressure to the heels. Monitor quite closely. Continue with pain pill as needed. Patient will continue with physical therapy." A physician progress notes [REDACTED]. . . The patient has ulcers of both heels that have started to peel and are blackened in color and it was requested by nursing staff to have these debrided . . . On examination of the heels, the right heel has a large area of blackened tissue that does flake off easily. A #15 blade scalpel was used to debride the wound and there is pink tissue noted on the sides of the heel and on the very posterior aspect of the heel there is an ulceration that is noted that does have slight amount of blood oozing from it that looks to be about a Stage 2 ulcer through the superficial layers of the skin . . . On examination of the left heel there is some darkened black skin that flacks off easily with using a 15-blade scalpel to debride the area. These is an ulceration of about 4 mm (sic) by 3.5 cm on the lateral side of the left heel as well as a smaller ulceration noted on the posterior aspect of the heel grade Staging 2-3. On the ulceration of the posterior aspect of the heel there is a yellowish discharge overlying this and a culture was taken . . . no [DIAGNOSES REDACTED]tous tissue or swelling is noted. No bleeding is noted . . . ." The medical provider recommended a Flexigel dressing be placed to the bilateral heels and for the dressing to be changed daily and await final culture results. On 02/25/12, the final culture report showed "normal skin flora." On 02/29/12, the medical provider documented the size of the Resident #1's left heel ulcer as "about 2 cm in length and 1 cm in width," and the right heel ulcer "right in the middle which measures about 1.5 cm in diameter as well as length." The medical provider attempted to once again perform ulcer debridement to the bilateral heel pressure ulcers, but discontinued the procedure due to "the patient complained of too much pain." The medical provider recommended Resident #1 be seen at the clinic for debridement of the heel ulcers under local anesthetic. Review of Resident #1's Treatment Records from February-April 2012 identified the following dressing changes in response to the resident's bilateral heel ulcers: *02/01/12 - [MEDICATION NAME] to open blister area right medial foot, change every third day and PRN. *02/09/12 - Check both heels daily - dressing change daily PRN to both heels. *02/23/12 - Flexigel dressing to both heels - change daily. *03/02/12 - PolyMem to bilateral heel ulcers - change daily, update the provider in one week, and foam boots to bilateral lower extremities. *03/08/12 - Continue PolyMem to right heel ulcer - change daily. Tender-Wet dressing daily to left heel ulcer. Foam boots on while sitting in recliner or wheelchair at while lying in bed. *03/15/12 - Tender-Wet dressing to right heel ulcer - change daily. *03/20/12 - [MEDICATION NAME] to right heel, change daily. Upon admission to the facility, the medical provider initiated an order Physical Therapy (PT) and Occupational Therapy (OT) services for Resident #1. Review of OT Daily Flowsheets from March 2012 identified Resident #1 stated on March 14 ". . . (Bilateral) heels are still painful," on March 15 stated "Hip doesn't hurt today. Heels do hurt still," and on March 19 states "heels are painful . . . ." PT Daily Flowsheets from April 03-10, 2012 identified Resident #1 complained of heel pain on four days (April 03, 04, 09, and 10). On April 04, the PT note stated, "Pt (patient) appeared less attentive than normal today. Mentions poor sleep due to feet." Resident #1 verbalized pain and discomfort related to her bilateral heel pressure ulcers and received the following pain medications: *Tylenol (also known as [MEDICATION NAME], an over- the-counter (OTC) pain medication, ordered on [DATE]) 650 milligrams (mg) every four hours (hrs) as needed. The resident received the medication twelve times in February (twice on the 16 and 18, four times on the 19, once on 20-22, and on the 25) and twice on April 8. *[MEDICATION NAME] (also known as [MEDICATION NAME], a narcotic/opoid pain medication, ordered on [DATE]) 50 mg every six hrs as needed. The resident received the medication five times in February (once on the 23, twice on the 24 and 26). On February 27, the medical provider changed the order to provide the [MEDICATION NAME] twice daily to Resident #1 and continue with the PRN dosing. Record review showed that in addition to the scheduled [MEDICATION NAME], Resident #1 received PRN doses 10 times in March (twice on the 2, once on 3, 7, 10, 11, 23, twice on the 24, and once on the 29) and nine times in April (1-6, and 8-10). On 03/02/12, the provider discontinued the twice daily dosing of [MEDICATION NAME] related to Resident #1 displaying increased confusion. *Advil (also known as [MEDICATION NAME], an OTC nonsteroidal anti-[MEDICAL CONDITION] (NSAID) medication, implemented from the facility's standing orders on 03/03/12) 400 mg every four hrs as needed. The resident received the medication 17 times in March (5-6, 8, 10-16, 18-19, 21-22, 24, 27-28). Observation of Resident #1's bilateral heel pressure ulcers occurred on 04/10/12 at 11:05 a.m. A strong, foul odor was noted upon the removal of the [MEDICATION NAME] dressing to the right heel pressure ulcer. The old dressing contained yellow drainage. Observation showed the right heel pressure ulcer size as approximately 3.5 cm by 3.5 cm. The left heel pressure ulcer omitted no odor or drainage. Observation showed the left heel pressure ulcer size as approximately 2.5 cm by 1.0 cm. During an interview on 04/11/12 at 7:45 a.m., an administrative nurse (#4) confirmed Resident #1's bilateral heel ulcers developed after admission to this facility. This administrative nurse stated the facility initially placed a pressure relieving air mattress to Resident #1's bed prior to her admission (on January 24) but "somehow" the air mattress was removed (the exact date is unknown) and facility staff again placed an air mattress on February 1, 2012 (after the bilateral heel blisters were identified). Failure of the facility to routinely assess Resident #1's heels during cares as per policy and for six consecutive days (January 24-30) following admission to the facility and ensure the immediate implementation of pressure relieving devices, contributed to the development of bilateral heel pressure ulcers and her verbalizations of heel pain. - Review of Resident #8's medical record occurred on April 11-12, 2012. Resident #8 sustained a fall at the facility on 07/27/11, which resulted in a left [MEDICAL CONDITION]. Resident #8 was hospitalized from July 27-30, 2011 and returned to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. Resident #8's significant change MDS, dated [DATE], and quarterly MDS, dated [DATE], identified the resident displayed severe cognitive impairment as evidenced by a BIMS score of 3; required extensive two person physical assistance with bed mobility, transfers, dressing, toilet use and personal hygiene; one Stage 1 and one Stage 2 pressure ulcer identified on 08/09/11; and pressure reducing device on the bed, turning/repositioning schedule, and nutrition/hydration interventions. Resident #8's care plan identified a problem, dated 08/01/11, of "Alteration in Skin Integrity R/T fx (fractured) hip and (decreased) activity," the addition of "Stage 1 on heels" added on 08/08/11 and approaches of "Reposition (every) 2 (hours) or more freq (frequently), gel socks to bilateral heels at all times." The care plan lacked dates of when facility staff actually implemented these approaches. Review of Resident #8's Interdisciplinary Progress Notes (IPNs) from July 30 (when the resident returned from hospital) through August 04, 2011, lacked documentation of any redness or bogginess to the resident's bilateral heels. These notes stated Resident #8 needed assistance for transfers (with three persons) and repositioning, and complained of pain. On 07/31/11 at 1:45 p.m., an IPN identified facility staff implemented the intervention of repositioning Resident #8 every two hours. Resident #8's IPNs stated: *08/05/11 at 5:00 a.m. - "Removed socks noted (left) heel darkened (and) spongy . . . ." Further documentation at 10:00 a.m., stated, "Skin assessed. Noted Stage 1 pressure area on (left) heel. (Left) heel off loaded (and) gel socks on bilaterally." Resident #8's medical record identified the facility placed an air mattress on her bed on 08/06/11. *08/09/11 at 10:00 a.m. - "Noted Stage 1 pressure ulcer on (right) heel. Cont (continued) (with) Stage 2 intact blister on the (left) heel. Cont (with) gel socks bil (bilaterally) . . . Transfers (with) three . . . Repositioned (every) 2 hours." *08/17/11 at 1:10 p.m. - "Skin assessed. Cont. (with) Stage 2 intact blister on (left) heel. (Right) heel firm (and) blanches well, (no) red areas." *08/22/11 at 4:00 p.m. - "Skin assessed. Blister on (left) heel dry (and) intact. Black in color. Noted heel firm, (with) center of blister area boggy. Periwound pink (and) blanch well. Will cont (with) gel sock on (at) all times . . . ." *08/27/11 at 1:30 p.m. - "Skin assessed. Noted heel firm under blister area. Blister dried, (and) dk (dark) brown in color. (No) tenderness (with) palpitation." *08/30/11 at 3:30 p.m. - "Skin assessed. Area on (left) heel has blackened hard tissue covering, area unstageable. Area stable, (with) periwound pink (and) blanches well. Heel firm. (No) tenderness to touch." *09/12/11 at 10:00 a.m. - "CNA had nurse look at (left) heel. Nurse noticed clear drainage (with) odor on heel. 6 cm long x 4 cm wide (with) tunneling noticed. No blister present. Resident has appt (with) . . . NP (nurse practitioner) today. No (complaints of) pain at this time. Nurse noticed dark spots around sore." *09/13/11 at 2:00 p.m. - "Noted (two) dk unstageable area on (left) heels . . . (left) heel pink (and) firm. Noted dk hard tissue was debrided from heel. Dry drsg (dressing) applied as ordered. Keflex (an oral antibiotic) given as ordered" *09/20/11 at 1:35 p.m. - "Skin assessed. Unstageable area cont. 0.2 x 0.8 cm stable (left) heel pink (and) blanches well. Cont (with) gel sock on (left) heel (and) float heels when in recliner/bed." *09/29/11 at 7:00 a.m. - "Skin assessed. (Left) heel, blanches well. Unstageable area 0.2 cm. Cont. (with) gel sock on (and) heel floating." *10/11/11 at 1:30 p.m. - "Noted unstageable area on (left) heel open to Stage 2. 0.5 cm x 1 cm. Will have Dr assess on NH (nursing home) rounds." The medical provider ordered a multivitamin, zinc, Opti-Foam dressing to left heel, and an OT consult. On 10/12/11, the occupational therapist recommended discontinuing the gel sock and use heel suspension boot in bed." *10/17/11 at 10:00 a.m. - "Skin assessed. Noted Stage 2 0.8 cm x 1.5 cm noted dk areas, drsg scan amount bloody drainage. (Left) heel firm (and) pink. Blanches well." On 10/18/11, the facility made an appointment for Resident #8 to be seen by the medical provider. *10/19/11 at 4:00 p.m. - "Res returned from appt . . . Continue (with) same tx. Debridement of (left) heel . . . ." *10/23/11 at 3:00 p.m. - "Skin assessed. Drsg (change) to (left) heel. Noted (two) areas, (one) 0.2 cm on lateral side (and) (one) 0.4 cm on medial side. Both wound bases epithealized. Periwounds pink (with) (left) heel firm (and) blanches well." The medical record identified Resident #8's left heel pressure ulcers healed on 10/27/11. Resident #8's Weekly Pressure Ulcer Records stated: Left heel - 08/17/11 - Stage 2 "intact blister," measuring 3.5 x 6.0 cm. - 08/22/11 - Stage 2 measuring 3.5 x 6.0 cm, wound bed "dry blister." - 08/30/11 - Stage "unstageable," measuring 3.5 x 6.0 cm. - 09/07/11 - Stage "unstageable," measuring 3.5 x 6.0 cm, surrounding tissue wound edges "dried." (The medical provider debrided the left heel ulcer on 09/12/11 and ordered an antibiotic.) - 09/14/11 - Stage "unstageable," measuring 0.2 x 0.8 cm. - 09/20/11 - Stage "unstageable," measuring 0.2 x 0.8 cm. - 09/29/11 - Stage "unstageable," measuring 0.2 cm. - 10/05/11 - Stage "unstageable," measuring 0.2 cm. - 10/11/11 - Stage 2, measuring 0.5 x 1.0 cm, wound bed "dk purple/red." - 10/17/11 - Stage 2, measuring 0.5 x 1.5 cm, "bloody" exudate and "dk purple/red" wound bed. The medical provider debrided the left heel ulcer on 10/19/11. - 10/23/11 - Stage 2, "(two) areas measuring "0.2 cm" and "0.4 cm," wound bed "pink." Review of a hand-written physician progress notes [REDACTED]. Dry dressing to left heel - monitor daily . . . ." The medical provider debrided the left heel ulcer, ordered laboratory testing and the initiation of Keflex (an oral antibiotic) to treat a suspected left heel ulcer infection. On 09/28/11, Resident #8 returned to the medical provider for a recheck of the left heel ulcer. The medical provider stated, ". . . There is the ulceration on the left heel which is almost heeled (sic) . . . ." The medical provider requested an update of Resident #8's status in two weeks. On 10/19/11, a form titled "Referral and Treatment Request," for Resident #8 stated, ". . . Complaint: (check) area on (left) heel - has gotten bigger compared to last wk (week). Sm (small) amt (amount) bld (bloody) drainage. (Name of another provider) ordered [MEDICATION NAME] (after) assessing area on 10/11/11. (wondering) if can be debrided . . . ." This form identified the medical provider once again debrided the left heel pressure ulcer and wrote orders to continue with the [MEDICATION NAME] dressing until healed. Resident #8's record identified this left heel pressure ulcer as healed on 10/27/11, (after approximately two months). Resident #8 re-entered the facility following a [MEDICAL CONDITION] on 07/30/11. Resident #8's medical record lacked evidence the resident presented on 07/30/11 with any redness or bogginess to her bilateral heels. Resident #8's "Nurses Assistant Flowsheet" identified the facility initiated a consistent repositioning schedule on August 6 (five days after the resident returned to the facility following a [MEDICAL CONDITION]). Failure of the facility to routinely assess Resident #8's heels (from August 01-04) following readmission to the facility and failure to ensure the immediate implementation of pressure relieving devices, contributed to the development of this resident's bilateral heel pressure ulcers and the need for surgical debridement (twice) in an effort to aid in the healing of the pressure ulcers. - Review of Resident #2's medical record occurred on April 09-12, 2012. Medical [DIAGNOSES REDACTED]. Resident #2's quarterly MDS, dated [DATE], identified the resident displayed severe cognitive impairment as evidenced by a BIMS score of 2; required extensive two person physical assistance with bed mobility, transfers, dressing, toilet use and personal hygiene; and the absence of any pressure ulcers. Resident #2's physician orders included a copy titled "Standing Orders," signed by the physician on 10/03/08, which stated, ". . . 11. Skin Irritation: . . . . [MEDICATION NAME] to affective area bid PRN . . . Decubitus Care: 1. Decube/Pressure relief mattress on admission. 2. Pressure relief cushions/gel socks when indicated. 3. Apply [MEDICATION NAME] when indicated. Notify doctor or PA (Physician Assistant). Change q (every) 3 days and PRN. If wound shows no improvement in 2 weeks or if s/s (signs/symptoms) of infection notify MD or PA immediately . . . ." Review of an IPN, dated 03/16/12, for Resident #2 identified an "open area (right) side of coccyx - 0.5 cm in diameter. [MEDICATION NAME] placed to promote healing. (no) drainage noted." An IPN, dated 03/21/12, stated, "Skin assessed. Noted 1 cm x 0.2 cm gluteal slit on coccyx (with) 0.2 cm Stage 2 open area to (right) coccyx. Periwound skin moist (and) macerated. Rx (treatment) changed to [MEDICATION NAME] ointment bid (twice daily) til healed. Pressure redistribution cushion/recliner. Res repositioned per res request. Res amb (ambulatory) (with) FWW (front wheeled walker) (and) assist . . . ." The application of "[MEDICATION NAME]" ointment to an open area contradicts with the identified use of [MEDICATION NAME] as stated on Resident #2's standing orders. Facility staff notified Resident #2's medical provider of the Stage 2 open area on 03/21/12 and no additional treatment orders were received from the provider. An IPN, dated 03/28/12, identified the gluteal slit as "healed," but Resident #2's "open area" to the right coccyx remained and progressed to a "Stage 3" pressure ulcer measuring "1 cm x 0.5 cm" with "white slough covering the wound base." The facility placed Resident #2 on a repositioning schedule, (side to side when in bed) and continued to apply [MEDICATION NAME] to the opened area on the coccyx. Resident #2's record lacked evidence facility staff notified the medical provider of the progression of the coccyx ulcer to a Stage 3. Resident #2's care plan identified a problem, dated 03/22/12, of "Alteration in Skin Integrity R/T Potential for Breakdown on her heels (and) coccyx" and approaches of "Gel socks to bilateral feet (and) float heels when in bed." The facility added approaches of "Reposition schedule (every) 2 (hours) or more freq (frequently), lay res (resident) in bed (after) meals (and) reposition side to side till healed" on 03/28/12. The facility added an air mattress to the resident's bed on 03/29/12. IPN, dated 04/04/12, stated the "Stage 3 open area on coccyx healing well. Area 0.5 cm. Wound base pink (with) white slough noted. Edges pink. Cont (continue) (with) [MEDICATION NAME] (and) pressure redistribution devices. Res remains on reposition schedule." On March 28 and April 04, 2012 facility nursing staff identified Resident #2's right coccyx wound progressed to a Stage 3, but the record lacked evidence the facility contacted the medical provider to request a treatment/order change. An IPN, dated 04/11/12, identified the Stage 3 open area on Resident #2's coccyx decreased in size to "0.3 cm" and plan to continue with current interventions and treatments. Observations of Resident #2 on 04/09/12 at 3:05 p.m. and 04/10/12 at 10:15 a.m., showed the resident laying supine in her bed with a bedspread, sheet, and a disposable pad between her and the pressure relieving air mattress and the resident's heels laying directly on the mattress. The presence of multiple layers of bed linens directly on top of the air mattress prevents the airflow components of the mattress from working effectively. Observation on 04/10/12 at 11:40 a.m. showed two certified nurse aides (CNAs) (#7 and #8) assisted the resident to use the toilet. Observation of Resident #2's buttock/coccyx area showed a thick layer of a white ointment covering the upper portion of the buttock area, identified by the CNAs as [MEDICATION NAME]. The CNA (#7) stated, "She has an open area here" and pointed to the crevice at the top of the buttock area. During an interview on 04/11/12 at 7:45 a.m., an administrative nurse (#4) stated for the airflow mattress to work effectively, only a sheet and a disposable pad should be between Resident #2 and the mattress and facility staff need to float the resident's heels to prevent breakdown to her heels. During an interview on 04/12/12 at 12:00 p.m., a medical provider (#9) stated [MEDICATION NAME] ointment is a preventative or barrier ointment and should not be used on open areas or to treat heel or coccyx pressure ulcers. Failure to follow the facility's "Standing Orders" for Decubitus Care, failure to utilize the air overlay mattress c