Every finding on record at Pines Retirement Center of Baton Rouge

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility failed to ensure:1. The can opener was free of a dried, black substance and metal shavings;2. Ceiling vents in the kitchen were properly cleaned and free of black and brown substances; 3. Ceiling tiles above the steam table were secured and free of a gray fluffy substance;4. The Steamer drip pan was not overflowing a white, liquid substance onto the table and floor; and5. Milk was held at a safe temperature for consumption of 41 degrees Fahrenheit or below prior to being served to residents. This deficient practice had the potential to affect the 57 residents who were served food from the kitchen. Findings: Review of the facility's undated policy titled, Food: Handling and Preparation revealed the following, in part:Procedure:4. Use clean sanitized equipment. Clean and sanitize as you go. Don't wait until the end of the workday. On 09/08/2025 at 8:10 a.m., an initial tour was conducted of the kitchen with S4DM. The following observations were made:The can opener was observed with a large amount of metal shavings and a dried, black substance at the base;Five ceiling vents were observed with a moderate amount of a black substance; One large ceiling vent next to the walk-in cooler was observed with a large amount of a brown, fluffy substance; One tile above the steam table was observed unsecured;One tile above the steam table was observed with a string of a gray, fluffy substance hanging down from it; andThe steamer was observed leaking a white, liquid substance into a drip pan, which had overflowed onto the table and the floor underneath. On 09/08/2025 at 8:37 a.m., an interview was conducted with S4DM. He confirmed the above observations. He stated the kitchen staff were responsible for keeping the kitchen clean. He confirmed the can opener should have been cleaned after each use and had not been. He confirmed the ceiling vents should have been cleaned and had not been. He confirmed the ceiling tiles above the steam table should have been secured and free of a gray, fluffy substance and were not. He confirmed the drip pan underneath the steamer should have been emptied to prevent the overflow of the white, liquid substance onto the table and floor. On 09/08/2025 at 11:06 a.m., a follow-up visit was made of the kitchen with S4DM. An observation was made of dietary staff performing the temperature checks of milk from a plastic container on the serving line. Four 8 oz. plastic containers of milk were observed on the serving line prep table, not on ice, and being placed on resident meal trays. A recording of one milk temperature was measured at 43.2 degrees Fahrenheit. On 09/08/2025 at 11:13 a.m., an interview was conducted with S4DM. He confirmed the above observation and stated the milk on the serving line prep table was available to be served for resident consumption. He stated dairy products should have been maintained at a temperature at or below 41 degrees Fahrenheit. On 09/08/2025 at 1:00 p.m., an interview was conducted with S1ADM. He was made aware of the above observations made during the kitchen tours. He stated he expected the kitchen staff to keep the kitchen clean and sanitary. He confirmed dairy products should be kept at or below 41 degrees Fahrenheit for resident safety.

Based on observations, interviews, and record reviews, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure:1. Nursing staff followed physician's orders and obtained a resident's heart rate prior to medication administration for 1 (#33) of 3 (#19, #33, and #53) residents reviewed for medication administration; 2. Nursing staff followed manufacturer instructions for use of an inhaler to prevent side effects of the medication for 1 (#53) of 3 (#19, #33, and #53) residents reviewed for medication administration; and 3. Nursing staff primed insulin pen needles prior to administering insulin for 1 of 1 (#19) residents reviewed for insulin administration. Findings: Review of the facility's undated policy titled, Medications-Administering revealed, in part: 3. Medications must be administered in accordance with the orders, including any required time frame. 8. The following information must be checked/verified for each resident prior to administering medications.b. Vital signs, if necessary. 1. Review of Resident #33's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Atrial Fibrillation and Essential Hypertension. Review of Resident #33's current Physician Orders revealed the following: Start date: 08/12/2025 Carvedilol Oral Tablet 3.125 mg give one tablet by mouth two times a day. Hold for heart rate less than 50. On 09/09/2025 at 7:45 a.m., an observation was made of S6LPN administering Resident #33's medications. S6LPN administered Carvedilol 3.125 mg to Resident #33. S6LPN did not check Resident #33's heart rate prior to administering his Carvedilol 3.125 mg oral tablet. On 09/09/2025 at 7:48 a.m., an interview was conducted with S6LPN. She confirmed she did not check Resident #33's heart rate prior to administering his Carvedilol 3.125mg tablet as ordered and she should have. On 09/09/2025 at 8:39 a.m., an interview was conducted with S2DON. She was made aware of the above observation made during medication administration for Resident #33. She stated she expected nurses to check a resident's heart rate per physician orders prior to administering a medication. 2.Review of the facility's medication insert for Fluticasone Furoate-Vilanterol 100-25 mcg powder, revealed in part:After each dose, rinse your mouth with water and spit it out. Do not swallow the water. Review of Resident #53's Clinical Record revealed he was admitted to the facility on [DATE] with a diagnosis, which included Chronic Obstructive Pulmonary Disease. Review of Resident #53's current Physician Orders revealed the following: Start date: 07/16/2025 Fluticasone Furoate-Vilanterol 100-25 mcg one puff inhale orally one time a day. On 09/09/2025 at 8:10 a.m., an observation was made of S7LPN administering Resident #53's medications. She administered one inhalation of Fluticasone Furoate-Vilanterol 100-25mcg to Resident #53. S7LPN exited the room and did not offer or instruct Resident #53 to rinse her mouth with water after the inhaler was administered. On 09/09/2025 at 8:25 a.m., an interview was conducted with S7LPN. She confirmed she did not have Resident #53 rinse her mouth out with water after administration of the Fluticasone inhaler and should have. On 09/09/2025 at 8:39 a.m., an interview was conducted with S2DON. She was made aware of the above observation made during medication administration for Resident #53. She stated she expected the nurses to have residents rinse their mouth out with water after administration of an inhaled medication. 3. Review of the Humalog insulin pen manufacturer's guidelines revealed the insulin pen needle should always be primed with 2 units of insulin after applying the needle and prior to drawing up the insulin dose. Review of Resident #19's Clinical Record revealed he was admitted to the facility on [DATE] with a diagnosis, which included Type 2 Diabetes Mellitus with Hyperglycemia. Review of Resident #19's current Physician Orders revealed the following: Start date: 10/01/2024 Humalog Injection Solution 100 units/mL inject 15 units subcutaneously three times a day. On 09/09/2025 at 11:13 a.m., an observation was made of S6LPN administering Resident #19's Humalog 15 units subcutaneously. S6LPN applied the insulin pen needle, dialed up 15 units of insulin, and administered the insulin. S6LPN did not prime the insulin pen needle prior to administering the insulin. On 09/09/2025 at 11:18 a.m., an interview was conducted with S6LPN. She confirmed she did not prime the insulin pen needle prior to administering insulin to Resident #19 and was not aware she should have. On 09/09/2025 at 3:01 p.m., an interview was conducted with S2DON. She was made aware of the above observation made during medication administration for Resident #19. She stated she expected nurses to prime insulin pen needles prior to administering the ordered dose of insulin.

Based on observations and interviews, the facility failed to ensure garbage and waste were properly contained in the outdoor trash dumpsters.Findings:On 09/08/2025 at 8:48 a.m., an observation was made of the facilities dumpster area with S4DM. Two air conditioner window units, one mattress, one power chair, and multiple wooden crates and boxes were observed discarded on the ground surrounding two dumpsters. Scattered trash was observed on the ground next to and around the two dumpsters.On 09/08/2025 at 8:50 a.m., an interview was conducted with S4DM. He observed and confirmed the above findings in the dumpster area. He stated S5MS was responsible for keeping the dumpster area clean. On 09/08/2025 at 9:11 a.m., an interview was conducted with S5MS. He stated he was responsible for keeping the dumpster area clean. He observed the above findings and confirmed the dumpster area should be kept clean and was not. On 09/08/2025 at 8:54 a.m., an interview was conducted with S1ADM. He stated S5MS was responsible for keeping the dumpster area clean. He observed and confirmed the above findings. He confirmed the dumpster area should be kept clean and was not.

Based on observations, interviews and record review, the facility failed to provide services with reasonable accommodation of needs by failing to ensure a resident's call light was within reach for 1 (#5) of 16 residents reviewed in the final sample. Review of the facility's undated policy titled, Call Light, Answering, revealed the following, in part:Purpose: The purpose of this procedure is to respond to the resident's requests and needs. Key Procedural Points:5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.Steps in the Procedure:9. Position the call light within easy reach of the resident. Review of Resident #5's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses of Unsteadiness on Feet, Hemiplegia and Hemiparesis following Cerebral Infarction affecting right non-dominant side, Difficulty in Walking, Generalized Muscle Weakness, and Other Lack of Coordination. Review of Resident #5's current Care Plan revealed following, in part:Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit related to Hemiplegia and Hemiparesis following Cerebral Infarction affecting right non-dominant side and Impaired balance.Interventions: transfer: The resident requires assistance by 1 staff to move between surfaces daily and as necessary. Encourage the resident to use bell to call for assistance. Focus: The resident has an alteration in musculoskeletal status related to compression fracture of lumbar vertebrae.Interventions: Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. On 09/08/2025 at 10:08 a.m., an observation was made of Resident #5 in her room. She was lying in bed. The call light was observed lying on the floor at the foot of the bed. An interview was conducted with Resident #5 at that time, and Resident #5 confirmed she could not reach her call light. On 09/09/2025 at 8:39 a.m., an observation was made of Resident #5 in her room. She was lying in bed. The call light was observed lying on the floor at the foot of the bed and not within reach. On 09/09/2025 at 8:50 a.m., an observation was made of Resident #5 with S7LPN. An interview was conducted with S7LPN at that time. S7LPN confirmed Resident #5's call light was on the floor at the foot of the bed and not within reach. S7LPN confirmed Resident #5's call light should have been within reach. On 09/10/2025 at 11:29 a.m., an interview was conducted with S2DON. S2DON was notified of the above findings. S2DON confirmed Resident #5's call light should have been within reach at all times when in her room. S2DON confirmed call lights should never be on the floor and should always be within residents' reach.

Based on record review and interview, the facility failed to ensure residents with an identified mental health diagnosis were referred for a Pre-admission Screening and Resident Review (PASARR) Level II evaluation as required for 1 of 1 (#4) resident reviewed for PASARR.Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Type 2 Diabetes Mellitus. Further review revealed an additional medical diagnosis of Schizoaffective Disorder, Bipolar Type with an onset date of 10/01/2020.Review of Resident #4's PASARR Level I dated 05/06/2013 revealed no mental health diagnoses were selected. Further review revealed no review for a Level II evaluation and determination had been submitted for Resident #4 following his diagnosis of Schizoaffective Disorder, Bipolar Type.An interview was conducted on 09/09/2025 at 11:45 a.m. with S1ADM. He reviewed Resident #4's PASARR Level I dated 05/06/2013 and diagnoses. He stated Resident #4 had a diagnosis of Schizoaffective Disorder, Bipolar Type acquired on 10/01/2020 and should have been referred for a PASARR Level II evaluation.

Based on interviews and record review, the facility failed to develop a Comprehensive Person-Centered Care Plan for 1 of 1 (#53) residents reviewed for activities of daily living (ADL). Review of Resident #53's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Displaced Intertrochanteric Fracture of Left Femur.Review of Resident #53's current Care Plan revealed the following:Focus: The resident has an ADL self-care performance deficit related to activity intolerance.Interventions: Bed Mobility: The resident requires (specify what assistance) by (X) staff to turn and reposition in bed (specify frequency) and as necessary.Dressing: The resident requires (specify what assistance) by (X) staff to dress.Eating: The resident is able to: (specify).Personal hygiene/oral care: The resident is able to: (specify).Transfer: The resident is totally dependent on (X) staff for transferring.An interview was conducted on 09/09/2025 at 12:40 p.m. with S8MDS. She reviewed Resident #53's current Care Plan. She stated she was responsible for completing Resident #53's Care Plan. She confirmed the Comprehensive Person-Centered Care Plan for Resident #53 was incomplete and should have been completed.An interview was conducted on 09/09/2025 at 12:46 p.m. with S3RNCO. She reviewed Resident #53's current Care Plan. She confirmed the Comprehensive Person-Centered Care Plan for Resident #53 was incomplete and should have been completed.

Based on record review, observations, and interviews, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding by failing to ensure tube feeding formula, tubing, and free water bags were changed in appropriate timeframe for 1 (#8) of 3 (#6, #8, and #43) residents reviewed for tube feedings.Review of the facility's undated policy titled, Enteral Feedings-Safety Precautions revealed in part, the following:2. The facility will follow accepted best practices in enteral nutrition.5. Hang times:c. Closed-system enteral formulas have a hang time of 24-48 hours, per manufacturer's instructions.Review of the Clinical Record for Resident #8 revealed she was admitted to the facility on [DATE] with diagnoses, which included Dysphagia Following Cerebral Infarction. Further review revealed a diagnosis of Gastrostomy Status on [DATE].Review of the current Physician Orders for Resident #8 revealed, in part, the following:Jevity 1.5 at 45 mL/hr per gastrostomy tube daily.Change peg feeding bag every 24 hours.An observation was made on [DATE] at 8:15 a.m. of tube feeding solution spiked and hanging in Resident #8's room currently not infusing since Resident #8 was unavailable at this time. Further observations revealed the tube feeding solution bottle to be dated [DATE] with no time documented, and a written expiration date of [DATE] with no time documented. Observed the tube feeding solution bottle label read: Precautions: Hang product up to 48 hours after initial connection. Observed bag of free water label read: Do not use for greater than 24 hours.An observation was made on [DATE] at 10:10 a.m. of tube feeding solution spiked and hanging in Resident #8's room currently infusing. Further observations revealed the tube feeding solution bottle to be dated [DATE] with no time documented, and a written expiration date of [DATE] with no time documented. Observed the tube feeding solution bottle label read: Precautions: Hang product up to 48 hours after initial connection. Observed bag of free water label read: Do not use for greater than 24 hours. Observed brown, dried tube feeding formula inside the tube feeding solution bottle.An interview was conducted on [DATE] at 12:40 p.m. with S9LPN. She stated she provided care to Resident #8 on [DATE]. She stated when Resident #8 returned to the facility on [DATE], she initiated the already spiked tube feeding solution bottle that was already hanging and began infusing it. She confirmed a new tube feeding solution kit should have been used and it was not.An interview was conducted on [DATE] at 1:08 p.m. with S2DON. She observed Resident #8's tube feeding solution currently infusing with a label dated [DATE] with no time documented and an expired written date of [DATE] with no time documented. She confirmed nursing staff should follow manufactures guidelines in regard to tube feeding solution and supplies.

Based on observations, record review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure medication carts were free of loose pills for 1 of 1 (Cart A) medication carts reviewed.Findings: Review of the facility's undated policy titled, Medications-Storage, revealed, the following, in part:Policy:The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.Policy Interpretation and Implementation:1. Drugs and biologicals shall be stored in the packing, containers, or other dispensing systems in which they are received. On 09/08/2025 at 3:40 p.m., an observation was made of Cart A with S3RNCO, which revealed thirteen and a half loose pills on the bottom of the cart's drawers. On 09/08/2025 at 3:50 p.m., an interview was conducted with S3RNCO. She stated the nurses should check the medication carts daily for loose medications. S3RNCO confirmed the above pills were loose in the cart and should not have been. On 09/08/2025 at 4:10 p.m., an interview was conducted with S2DON. She stated she expected the nursing staff to perform medication cart checks daily, which included checking for any loose medications in the cart's drawers. She was made aware of the above observation and confirmed medications should not be loose in the cart.

Based on record reviews and interviews, the facility failed to ensure residents' Medication Administration Records (MAR) were accurately documented for 1 (#8) of 3 (#6, #8, and #43) residents reviewed for tube feedings.Review of the facility's undated policy titled, Documentation revealed in part, the following:12. Personnel will be expected to document timely, accurately, and completely.Review of the Clinical Record for Resident #8 revealed she was admitted to the facility on [DATE] with diagnoses, which included Dysphagia Following Cerebral Infarction. Further review revealed a diagnosis of Gastrostomy Status on [DATE].Review of the current Physician Orders for Resident #8 revealed in part, the following:Change gastrostomy feeding bag every 24 hours.Review of the [DATE] MAR for Resident #8 revealed in part, the following:Change peg feeding bag every 24 hours. Documented as completed on [DATE] at 5:00 a.m. by S9LPN.An observation was made on [DATE] at 10:10 a.m. of tube feeding solution spiked and hanging in Resident #8's room currently infusing. Observed tube feeding solution bottle to be dated [DATE]. Observed tube feeding solution bottle to have a written expiration date of [DATE].An interview was conducted on [DATE] at 12:40 p.m. with S9LPN. She stated she provided care to Resident #8 on [DATE] to [DATE]. She stated she did not change the tube feeding solution bottle on the morning of [DATE]. She stated she documented on the MAR that she did change it and should not have documented this task as completed since it was not completed.An interview was conducted on [DATE] at 1:08 p.m. with S2DON. She observed Resident #8's tube feeding solution currently infusing with a label dated [DATE] and an expired written date of [DATE]. She reviewed Resident #8's [DATE] MAR and confirmed nurses should not document tasks as completed unless they complete them.

Based on record review, observation, and interview, the facility failed to ensure posted nurse staffing data included the total number and the actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care per shift.This deficient practice had the potential to affect any of the 60 residents residing in the facility.Findings: Review of the Nursing Staffing Data form dated 09/08/2025 revealed the following: Resident Census: 61Total Number: CNA-16; LPN-8; RN-2; Totals-26Actual Hours: CNA-120; LPN-60; RN-15; Totals-195 On 09/08/2025 at 10:15 a.m., an observation was made of the bulletin board on the wall outside the Dining Room. The form titled Nurse Staffing Data dated 09/08/2025 was observed. The total number and actual hours worked for licensed and unlicensed staff directly responsible for resident care was not documented per shift. On 09/08/2025 at 10:30 a.m., an interview was conducted with S1ADM. He reviewed the Nurse Staffing Data Form dated 09/08/2025 and confirmed the total number and actual hours worked for licensed and unlicensed staff directly responsible for resident care was not documented per shift.

Based on record reviews, observation, and interviews, the facility failed to ensure services provided by the facility met professional standard of quality by failing to ensure nursing staff did not borrow medications from one resident to administer to another resident for 1 (#R2) of 7 (#1, #2, #3, #4, #R1, #R2 and #R3) residents reviewed for pharmaceutical services.Review of the facility's undated policy titled, Medications - Administering revealed the following, in part:Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation:7. The individual administering the medication must check the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.19. Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the Director of Nursing Services. Resident #R2Review of Resident #R2's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Type 2 Diabetes Mellitus. Review of Resident #R2's current Physician Orders revealed the following, in part:Start date: 03/05/2025 - Regular Insulin Injection Solution 100 unit/mL, inject as per sliding scale: if 0 - 200 = 0 do not administer; 201 - 250 = 2 units; 251 - 300 = 4 units; 301- 350 = 6 units; 351 - 400 = 8 units; 401 - 999 = 10 units and notify MD, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus. Resident #R3Review of Resident #R3's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Type 2 Diabetes Mellitus. Review of Resident #R3's current Physician Orders revealed the following, in part:Start date: 10/01/2024 - Regular Insulin Injection Solution 100 unit/mL, inject as per sliding scale: if 61 - 200 = 0 units; 60 or less notify MD; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 999 = 12 units and notify MD, subcutaneously four times a day related to Type 2 Diabetes Mellitus. An observation was made on 07/23/2025 at 10:30 a.m. of S2LPN administering medications to Resident #R2. S2LPN removed a vial of regular insulin, labelled with Resident #R3's name, from her medication cart. S2LPN withdrew insulin from Resident #R3's insulin vial to administer to Resident #R2. An interview was conducted with S2LPN at that time. S2LPN reviewed the insulin vial and package and confirmed the insulin belonged to Resident #R3. S2LPN stated Resident #R2's insulin vial was available in the facility's medication room. S2LPN confirmed she used Resident #R3's insulin vial to prepare an insulin dose for Resident #R2 and should not have. An interview was conducted with S1DON on 07/24/2025 at 11:41 a.m. S1DON stated every resident had their own insulin vial ordered from the pharmacy, and emergency house stock was available to use if a resident's vial was not available. S1DON was made aware of the above observation. S1DON stated a nurse should never use one resident's insulin vial to administer to a different resident.

Based on observations, interviews and record review, the facility failed to ensure it was free of significant medication errors for 1 (#R2) of 2 (#R1 and #R2) residents reviewed for medications. The deficient practice had the potential to affect the 56 residents residing in the facility who received medications.Review of the facility's undated policy titled, Medications - Administering revealed the following, in part:Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation:7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Resident #R2Review of Resident #R2's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Type 2 Diabetes Mellitus with Diabetic Neuropathic Arthropathy. Review of Resident #R2's current Physician Orders revealed the following, in part:Start date: 03/05/2025 - Regular Insulin Injection Solution 100 unit/mL, inject as per sliding scale: if 0 - 200 = 0 do not administer; 201 - 250 = 2 units; 251 - 300 = 4 units; 301- 350 = 6 units; 351 - 400 = 8 units; 401 - 999 = 10 units and notify MD, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus with Diabetic Neuropathic Arthropathy. An observation was made on 07/23/2025 at 10:34 a.m. of S2LPN administering medications to Resident #R2. S2LPN stated Resident #R2's blood glucose reading was 212 mg/dL, and Resident #R2 required 2 units of regular insulin per the sliding scale. S2LPN withdrew 5 units of regular insulin from a multi-dose vial. An interview was conducted with S2LPN at that time. S2LPN reviewed the syringe and stated she had drawn up 2 units. S2LPN placed the security cap over the needle for transport to Resident #R2's room. Prompt intervention was initiated and facility administration was sought. An interview was conducted with S5CRN on 07/23/2025 at 10:39 a.m. S5CRN observed the insulin syringe S2LPN withdrew, and confirmed the amount as 5 units. S5CRN confirmed preparation of 5 units when the insulin order was for 2 units was a medication error. An interview was conducted with S1DON on 07/24/25 at 11:41 a.m. S1DON stated insulin doses should be prepared to the amount of units ordered by the physician per the sliding scale. S1DON confirmed preparation of 5 units when the order is 2 units was not an acceptable practice.

Based on observations, interviews, and record reviews, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (#R4) of 8 (#1, #2, #3, #4, #R1, #R2, #R3, and #R4) residents observed for infection control practices. The facility failed to ensure:1. Staff used proper personal protective equipment when emptying Resident #R4's urinal; and2. Staff transported linens in a manner to prevent spread of infection.Review of the facility's policy, dated January 2025, titled, Infection Prevention and Control Program revealed the following, in part:Policy: This facility has established and maintains an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.Policy Explanation and Compliance Guidelines:5. All staff are responsible for following all policies and procedures related to the program.14. Linens:a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent the spread of infection. Review of the facility's policy, dated January 2025, titled, Enhanced Barrier Precautions revealed the following, in part:Policy: It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDRO).Definitions: Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).Policy Explanation and Compliance Guidelines:46. Enhanced Barrier Precautions-a. Nursing staff will place residents with any applicable conditions or devices on EBP. An order may be obtained. Applicable conditions and devices:i. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.48. High-contact resident care activities include:d. Providing hygienef. Changing briefs or assisting with toileting Review of Resident #R4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included: Other Fracture of Right Lower Leg, Initial Encounter for Open Fracture Type I or II with External Fixator to Right Lower Leg Review of Resident #R4's current Physician Orders revealed the following, in part:Order date 05/05/2025 Enhanced Barrier Precautions. On 07/23/2025 at 10:21 a.m., an observation was made of S3CNA entering Resident #R4's room. Enhanced Barrier Precaution sign observed hanging eye level on room door. S3CNA was observed to donn gloves. S3CNA did not donn a gown. S3CNA proceeded to remove Resident #R4's urinal from resident's bedside table and empty it into the toilet. On 07/23/2025 at 10:25 a.m., an observation was made of S3CNA removing clean linen from the linen cart on the hallway. S3CNA was observed carrying the clean linen, pressed against her clothing on her upper body, proceeding down the unit hallway, making entry into a resident's room. On 07/24/2025 at 11:30 a.m., an interview was conducted with S4CNA. S4CNA confirmed she provided care for Resident #R4. S4CNA stated she would donn gown and gloves for high-contact activities for Resident #R4, including emptying his urinal. S4CNA stated there were linen bags available on the linen cart to transport clean linen to a resident's room. S4CNA stated she would not have held clean linen against her body while transporting it to a resident's room. On 07/24/2025 at 11:48 a.m., an interview was conducted with S1DON. S1DON confirmed she would expect staff to follow Enhanced Barrier Precautions procedures during high-contact resident activities, including emptying a resident's urinal. S1DON confirmed clean linen should have been transported from the linen cart to a resident's room inside a clean linen bag and not pressed against a staff member's clothing.

Based on observations, interviews and record reviews the facility failed to ensure a resident's comprehensive plan of care was developed and implemented for 2 (#1 and #3) of 3 (#1, #2 and #3) residents reviewed for care plans. The facility failed to ensure: 1. Resident #1's care plan was revised for the use of a geri chair; 2. Resident #3's care plan was implemented for neurological assessments after two unwitnessed falls; and 3. Resident #3's care plan was revised for a fall on 12/07/2024. Findings: 1. Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses, which included Non-Alzheimer's Dementia, Muscle Weakness and Muscle Atrophy. Review of Resident #1's current care plan revealed no documented evidence to reflect the current use of Resident #1's geri chair. On 02/03/2025 observations were made throughout the day of Resident #1 sitting up in a geri chair in front of nurse's station. On 02/04/2025 at 2:30 p.m., an interview was conducted with S5LPN. She stated Resident #1 was bed bound and used a geri chair when out of bed due to poor trunk control. On 02/04/2025 at 1:45 p.m., an interview was conducted with S3MDS. She stated she was responsible for updating resident care plans to reflect their current needs. She stated Resident #1 used a geri chair due to poor trunk control. S3MDS reviewed Resident #1's care plan and confirmed the care plan had not been revised to reflect his current use of a geri chair and should have been. On 02/04/2025 at 3:25 p.m., an interview was conducted with S2DON. She stated Resident #1 used a geri chair due to poor trunk control. S2DON reviewed Resident #1's care plan and confirmed the care plan had not been revised to reflect his current use of a geri chair and should have been. 2. Review of the clinical record revealed Resident #3 was admitted to the facility on [DATE]. Resident #3 had diagnoses which included Liver Cell Carcinoma, Cirrhosis, Anxiety, Malnutrition, Insomnia and [NAME] Johnson's Syndrome. Review of the Admission MDS with an ARD of 11/19/2024, revealed Resident #3 had a BIMS of 9 which indicated moderate cognitive impairment. Review of Resident #3's Incident Reports revealed the following: 12/18/2024 at 7:30 p.m. - unwitnessed fall 12/19/2024 at 3:00 a.m. - unwitnessed fall Review of Resident #3's Care Plan revealed the following: Goal: Resident will be free of falls. Interventions: 12/18/2024- Neurological Assessments x72 hours. 12/19/2024- Neurological Assessments x72 hours. Review of Resident #3's neurological documentation revealed assessments were performed on the following dates and times: 12/18/2024-7:00 p.m. 12/19/2024- 3:00 a.m., 11:00 a.m. 12/20/2024- 11:00 a.m. On 02/04/2025 at 10:30 a.m., an interview was conducted with S2DON. She stated neurological assessments should be implemented with each separate fall, even if the falls occur back to back. She stated she expected nursing staff to follow the resident's care plan. S2DON reviewed Resident #3's current Care Plan, Incident Reports and Neurological Assessment sheets dated 12/18/2024 and 12/19/2024, and confirmed neurological assessments had not been completed for the full 72 hours. She stated the nursing staff did not implement the interventions on Resident #3's Care Plan and should have. 3. Review of Resident #3's nurse's notes dated 12/07/2024 revealed Resident #3 had a fall and was found on the floor with a laceration above his left eyebrow. Review of Resident #3's current care plan revealed he was at risk for falls. Further review revealed no documented evidence of a revision to include the fall which occurred on 12/07/2024. On 02/04/2025 at 1:45 p.m., an interview was conducted with S3MDS. She stated she was responsible for revising care plans. She stated every morning the Interdisciplinary Team met and reviewed nurse's notes to discuss any areas of concerns, including falls. She stated the process was to revise the care plan and place a new intervention with every fall. S3MDS reviewed the nurse's notes dated 12/07/2024 and confirmed Resident #3 had a fall with injury. She confirmed the care plan had not been revised to reflect the fall on 12/07/2024 and should have been. On 02/04/2024 at 3:25 p.m., an interview was conducted with S4DON. She reviewed Resident #3's care plan and nurse's notes dated 12/07/2024. S4DON confirmed Resident #3's care plan had not been revised to reflect the fall on 12/07/2024 and should have.

Based on interviews and record reviews, the facility failed to ensure all alleged violations of abuse were reported to the state survey agency. The facility failed to: 1. Ensure allegations of verbal and physical abuse were reported to the State Survey Agency, immediately but not later than 2 hours after the allegation was made for 5 (#35, #42, #46, #51, and #52) of 19 sampled residents reviewed for abuse; and 2. Report the results of the investigations within 5 working days with appropriate corrective actions implemented for 5 (#35, #42, #46, #51, and #52) of 19 sampled residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy situation on 09/04/2024 when multiple staff witnessed S4CNA and S5CNA curse, yell, and point in Resident #52's face. It continued on 09/14/2024, when Resident #46 witnessed and reported to S1ADM, S6CNA yelled and cursed at Resident #52 in the hallway. It continued on 09/23/2024, when Resident #42 reported S13LPN stood in front of her wheelchair, pointed and demanded she get off the hall. It continued on 09/24/2024 when S6CNA followed Resident #46 to her room, yelled, pointed her finger and threatened Resident #46. S1ADM did not report, investigate, report investigation findings or initiate any corrective actions for any of the above abuse allegations. S1ADM was notified of the Immediate Jeopardy Situation on 10/09/2024 at 1:53 p.m. The Immediate Jeopardy was removed on 10/10/2024 at 12:33 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal prior to the survey exit. This deficient practice continued at a potential for more than minimal harm for the other 59 residents residing in the facility. Cross Reference F600. Findings: Review of the facility's undated policy titled, Abuse Neglect and Exploitation revealed the following, in part: Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: b. Establish policies and procedures to investigate any such allegations VII. Reporting/Response A. The facility will have written procedures that include 1. Reporting of all alleged violations to the Administrator, state agency, and all other required agencies within specified time frames: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . 1. Resident #52 A review of Resident #52's Clinical Record revealed he was admitted to the facility on [DATE]. A review of Resident #52's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2024, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) of 15, which indicated Resident #52 was cognitively intact. A review of the facility's Self-Reported Incidents dated 09/25/2024 revealed the following: Incident Occurred: 09/05/2024 at 2:00 p.m. Incident Discovered: 09/25/2024 at 12:30 p.m. Incident Reported on: 09/25/2024 12:33 p.m. Incident Description: Resident #52 reported to S1ADM, S4CNA and S5CNA were asked to empty his urinal and refused. CNAs responded to Resident #52 that he capable of emptying his own urinal. Resident #52 alleged CNAs told him, tell your mammy to do it, yeah tell that b**** to do it. On 10/08/2024 at 10:15 a.m., an interview was conducted with S17SW. She stated on 09/04/2024 at approximately 5:30 p.m., she saw Resident #52 in the doorway of S2DON's office where S4CNA and S5CNA yelled, cursed, pointed their finger, and argued with Resident #52. She confirmed yelling, cursing, and pointing your finger at a residents face was abuse and she reported it to S1ADM on 09/05/2024. On 10/09/2024 at 8:37 a.m., an interview was conducted with S2DON. She stated staff cursing and pointing a finger at a resident was abuse and should be reported to administration immediately. She stated S1ADM was responsible for reporting to the State Agency. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated if staff witnessed Resident #52, S4CNA and S5CNA yell, argue and curse it should have been reported to him immediately. He stated the incident involving S4CNA, S5CNA, and Resident #52 was not reported to him until 09/25/2024. He stated any allegation of abuse should be reported to him immediately. He stated he was responsible for reporting the allegation to State Agency within 2 hours. A review of the facility's Self-Reported Incidents dated 09/24/2024 revealed the following: Incident Occurred: 09/14/2024 at 9:00 a.m. Incident Discovered: 09/24/2024 at 2:30 p.m. Incident Reported on: 09/25/2024 4:00 p.m. Incident Description: Resident #46 reported S6CNA and Resident #52 cursed and yelled at each other in the hall. On 10/08/2024 at 9:31 a.m., an interview was conducted with S20LPN. She stated on 09/14/2024 she witnessed S6CNA yell and curse at Resident #52. She confirmed arguing, yelling and cursing with a resident was abuse and she reported it to administration on 09/14/2024. On 10/08/2024 at 11:45 p.m., an interview was conducted with Resident #46, a cognitively intact resident. She stated on 09/14/2024, she was in the hall and witnessed S6CNA yell and curse at Resident #52. She stated S6CNA told Resident #52, F*** you. She stated she contacted S1ADM and reported the incident immediately. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated Resident #46 approached him on 09/14/2024 and notified him of the incident with S6CNA. He confirmed he did not report the allegation of abuse or conduct an investigation until 09/24/2024. Resident #42 A review of Resident #42's Clinical Record revealed Resident #42 was admitted to the facility on [DATE]. A review of Resident #42's Quarterly MDS with an ARD of 08/07/2024 revealed Resident #42 had a BIMS of 14, which indicated Resident #42 was cognitively intact. A review of the facility's Self-Reported Incidents dated September 2024 revealed no entries for the 09/22/2024 incident with Resident #42 and S13LPN. On 10/09/2024 at 3:28 p.m., an interview was conducted with Resident #42. She stated she and Resident #48 were friends and she visited Resident #48's room frequently. She stated on 09/22/2024, she was in her wheelchair, rolling down the hall, S13LPN stopped her, stood in front of her wheelchair and stated, Get off my hall, you're not allowed over here in a stern voice. Resident #42 stated she felt intimidated and threatened by S13LPN and reported the incident to S1ADM on 09/23/2024. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated Resident #42 notified him of the incident with S13LPN on 09/23/2024 and he completed a grievance. He confirmed he did not report or investigate the incident because it was a customer service issue. Resident #46 A review of Resident #46's Clinical Record revealed she was admitted to the facility on [DATE]. A review of Resident #46's Admission MDS, with an ARD of 07/11/2024, revealed Resident #46 had a BIMS of 15, which indicated Resident #46 was cognitively intact. A review of Resident #46's grievance, dated 09/24/2024, revealed the following: Statement of concern: Resident #46 stated S6CNA approached her and asked, If you have something to say, say it to me A review of the facility's Self-Reported Incidents revealed no entries for the 09/24/2024 incident with Resident #46 and S6CNA. On 10/08/2024 at 11:45 a.m., an interview was conducted with Resident #46. She stated on 09/24/2024, she and Resident #52 were talking in the hall. She stated when she finished talking with Resident #52, she went to her room, and S6CNA followed her to her room, stood in the doorway and yelled while shaking and pointing her finger toward her, if you have something to say, say it to my face. She stated she felt threatened by S6CNA and reported this to S1ADM the same day. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated Resident #46 notified him of the incident with S6CNA on 09/24/2024. He confirmed he did not report or investigate the incident. Resident #35 A review of Resident #35's Clinical Record revealed he was admitted to the facility on [DATE]. A review of Resident #35's Admission MDS with an ARD of 09/20/2024, revealed Resident #35 had a BIMS of 15, which indicated Resident #35 was cognitively intact. Resident #51 A review of Resident #51's Clinical Record revealed she was admitted to the facility on [DATE]. A review of Resident #51's Admission MDS with an ARD of 07/11/2024, revealed Resident #51 had a BIMS of 15, which indicated Resident #51 was cognitively intact. A review of the facility's Self-Reported Incidents dated October 2024 revealed no entries for the 10/02/2024 incident with Resident #35 and #51. On 10/08/2024 at 9:15 a.m., an interview was conducted with Resident #51. He stated about one week ago Resident #35 yelled at him and pushed him against the wall. He stated he reported it to S11LPN. On 10/08/2024 at 9:30 a.m., an interview was conducted with S11LPN. She stated on 10/02/2024 at approximately 10:00 a.m., she heard yelling as Resident #35 entered his shared room with Resident #51. S11LPN stated when she went into the room, Resident #51 told her Resident #35 grabbed him by the wrist and pushed him against the dresser. She stated she reported the incident on 10/02/2024 to S1ADM and S2DON immediately. On 10/09/2024 at 12:45 p.m., an interview was conducted with S1ADM. He stated he was aware of the incident on 10/02/2024 between Resident #35 and #51. He stated he did not feel that this incident rose to the reportable level, therefore he did not investigate or report. 2. On 10/09/2024 at 8:37 a.m., an interview was conducted with S2DON. She stated S1ADM was responsible for investigating abuse allegations. She confirmed no corrective actions were placed for any of the above incidents. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated he was responsible for conducting an investigation and reporting the investigation findings within 5 days following any allegations of abuse. He stated the following employees were not removed following the above incidents and continued to provide care to residents: S4CNA, S5CNA, S6CNA, and S13LPN. He confirmed he did not conduct an investigation or place any corrective actions for any of the above incidents. F609 Plan of Removal 1. On 10/9/24 Administrator has opened SIMS reports for all cited incidents. 2. All interviewable residents were assessed for signs of abuse or allegations of being mistreated by Administrator/ SSI)/ Designee on 10/9/24. Beginning on 10/7/24 and completing on 10/10/24 any non-interviewable residents were assessed by a weekly body audit and daily skin checks. Any abnormal findings will be documented by licensed staff and the Administrator/ DON will be notified. 3. Administrator will receive 1:1 education by Regional Administrator on 10/9/2024 on requirement of reporting allegations of verbal abuse to state survey agency within 2 hours. Administrator will be tested for understanding / competency. All staff will be re-trained by the Administrator on reporting abuse allegations in a timely manner. After retraining, staff will be tested for competency / understanding. No staff member will be allowed to work a shift without receiving re-training and successfully completing a competency test. All staff will receive abuse training on hire and at least annually, including training on reporting abuse allegations in a timely manner. 4. Beginning on 10/9/24, the Regional Administrator or Regional Nurse will review all allegations of abuse at least weekly for 8 weeks then randomly for an additional 8 weeks to ensure the reporting requirement is met. As of 10/9/24, the facility asserts the likelihood for serious harm to any recipient no longer exists. 43868 47546

Based on interviews and record reviews, the facility failed to ensure it was administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to have an effective system in place to: 1. Ensure residents remained free from verbal and mental abuse for 3 (#42, #46, and #52) of 7 (#18, #26, #42, #46, #51, #52, and #111) residents reviewed for abuse; and 2. Ensure allegations of verbal and physical abuse were reported to the State Survey Agency, immediately but not later than 2 hours after the allegation was made for 5 (#35, #42, #46, #51, and #52) of 19 sampled residents reviewed for abuse; and 3. Report the results of the investigations within 5 working days with appropriate corrective actions implemented for 5 (#35, #42, #46, #51, and #52) of 19 sampled residents reviewed for abuse. Cross Reference F600 and F609 This deficient practice resulted in an Immediate Jeopardy situation on 09/04/2024 when multiple staff witnessed S4CNA and S5CNA curse, yell, and point in Resident #52's face. It continued on 09/14/2024, when Resident #46 witnessed and reported to S1ADM, S6CNA yelled and cursed at Resident #52 in the hallway. It continued on 09/23/2024, when Resident #42 reported S13LPN stood in front of her wheelchair, pointed and demanded she get off the hall. It continued on 09/24/2024 when S6CNA followed Resident #46 to her room, yelled, pointed her finger and threatened Resident #46. It continued on 10/02/2024 when Resident #51 reported to staff Resident #35 grabbed him by the wrist and pushed him against the dresser. S1ADM did not report timely, report investigation findings or initiate any corrective actions for any of the above abuse allegations. The facility failed to protect residents from any further abuse following the incidents. S1ADM was notified of the Immediate Jeopardy situation on 10/09/2024 at 1:53 p.m. The Immediate Jeopardy was removed on 10/10/2024 at 12:33 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal prior to the survey exit. This deficient practice continued at a potential for more than minimal harm for the 59 residents currently residing in the facility. Findings: Review of the facility's undated policy titled, Abuse Neglect and Exploitation revealed the following, in part: Policy Statement: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Verbal Abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: b. Establish policies and procedures to investigate any such allegations; and VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, State agency, and all other required agencies within specified time frames: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by State agencies. Resident #52 A review of Resident #52's Clinical Record revealed he was admitted on [DATE] with diagnoses which included, Acquired Absence of Right Leg Above Knee, Acquired Absence Of Left Leg Above Knee, And Adjustment Disorder, Unspecified. A review of Resident #52's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2024, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) of 15, which indicated Resident #52 was cognitively intact. Review of the facility's Self-Reported Incident Reports, dated 09/05/2024, revealed the following: Occurred: 09/05/2024 at 2:00 p.m. Discovered: 09/25/2024 at 12:30 p.m. Incident Reported on: 09/25/2024 12:33 p.m. Description: Resident #52 reported to S1ADM S4CNA and S5CNA were asked to empty his urinal. CNA's responded with Resident #52 was capable of emptying his own urinal. Resident #52 became angry and began yelling. Resident #52 alleged CNA's told him, tell your mammy to do it, yea tell that b**** to do it. On 10/08/2024 at 10:15 a.m., an interview was conducted with S17SW. She stated on 09/04/2024 at approximately 5:30 p.m., she saw Resident #52 in the doorway of S2DON's office where S4CNA and S5CNA yelled, cursed, pointed their finger, and argued with Resident #52. She stated S2DON was in her office, could see and hear the altercation, and did not intervene. She confirmed yelling, cursing, and pointing your finger at a residents face was abuse and she reported it to S1ADM on 09/05/2024. On 10/08/2024 at 11:08 a.m., an interview was conducted with S18LPN. She stated on 09/04/2024, she saw Resident #52 in the doorway of S2DON's office in his wheelchair. She stated Resident #52, S4CNA and S5CNA yelled and cursed at each other. She stated S5CNA pointed her finger in Resident #52's face and told him he was capable of emptying his urinal. She stated S2DON was in her office, could see and hear the altercation, and did not intervene. She stated yelling, cursing and pointing a finger at a residents face is abuse. On 10/09/2024 at 8:37 a.m., an interview was conducted with S2DON. She stated on 09/04/2024, Resident #52 asked S4CNA to empty his urinal and she told him he could do it himself. She stated Resident #52 rolled his wheelchair to the doorway of her office, parked his wheelchair, and yelled and cursed at her and S4CNA. S2DON stated she did not hear the 2 CNAs yell or curse at the resident. She stated staff cursing and pointing a finger at a resident was abuse. She confirmed S4CNA continued to provide care to residents in the facility until 09/24/2024 and S5CNA continued to provide care to residents in the facility until 09/26/2024 when S1ADM removed them. She confirmed no additional education was provided to staff on de-escalation for residents with behaviors or monitoring completed following the incident on 09/04/2024. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated Resident #52 reported on 09/25/2024, he asked S4CNA on 09/05/2024 to empty his urinal. Resident #52 reported S4CNA refused to empty his urinal, yelled and cursed at her. S1ADM explained Resident #52 had aggressive behaviors, which included, yelling and cursing with other residents and staff. He stated S4CNA and S5CNA triggered Resident #52's behaviors so they were moved to another facility on 09/24/2024 and 09/26/2024, with a plan to return when Resident #52 was discharged . He stated S4CNA was not assigned to Resident #52 after 09/07/2024 but did provide care to other residents at the facility until 09/24/2024. He confirmed no additional education was provided to staff on de-escalation for residents with behaviors or monitoring completed following the incident on 09/04/2024. Review of the facility's Self-Reported Incident Reports dated 09/05/2024 revealed the following: Occurred: 09/14/2024 at 9:00 a.m. Discovered: 09/24/2024 at 2:30 p.m. Description: Resident #46 reported S6CNA and Resident #52 were cursing and yelling at each other in the hall. On 10/08/2024 at 11:45 p.m., an interview was conducted with Resident #46, a cognitively intact resident. She stated on 09/14/2024, she was in the hall and witnessed S6CNA yell and curse at Resident #52. She stated S6CNA told Resident #52, F*** you. She stated she reported the incident immediately to S1ADM. She stated S6CNA continued to provide care at the facility on her hall until 09/24/2024, when S6CNA threatened her. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated Resident #46 approached him on 09/14/2024 and notified him of the incident with Resident #52 and S6CNA. He stated S6CNA was not removed from the facility and continued to provide care to Resident #46 and Resident #52 until S6CNA was removed on 09/26/2024. He stated on 09/24/2024, S6CNA was involved in another incident with Resident #46 and S6CNA was terminated but not related to the allegation. He confirmed no additional education was provided to staff on de-escalation for residents with behaviors. He confirmed the last abuse training was conducted during the staff meeting on 10/01/2024 but S4CNA, S5CNA, S6CNA and S13LPN did not attend the meeting for the abuse training. Resident #42 A review of Resident #42's Clinical Record revealed Resident #42 was admitted to the facility on [DATE]. A review of Resident #42's Quarterly MDS with an ARD of 08/07/2024 revealed Resident #42 had a BIMS of 14, which indicated Resident #42 was cognitively intact. A review of the facility's Self-Reported Incidents dated September 2024 revealed no entries for the 09/22/2024 incident with Resident #42 and S13LPN. On 10/09/2024 at 3:28 p.m., an interview was conducted with Resident #42. She stated she and Resident #48 were friends and she visited Resident #48's room frequently. She stated on 09/22/2024, she was in her wheelchair, rolling down the hall, when S13LPN stopped her, stood in front of her wheelchair and stated, Get off my hall, you're not allowed over here in a stern voice. She stated on the same day after leaving the smoking patio and going back to her room, she heard S13LPN call her white trash. Resident #42 stated she felt intimidated and threatened by S13LPN and reported the incident to S1ADM on 09/23/2024. She stated again on 10/05/2024, S13LPN told her to get in Resident #48's room or get off the hall in a stern voice. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He said on 09/23/2024 Resident #42 reported that on 09/22/2024, S13LPN stopped her, stood in front of her wheelchair and stated, Get off my hall, you're not allowed over here in a stern voice. He confirmed Resident #42 should not have been stopped and been allowed to visit Resident #48. He stated he did not report it because it was a customer service issue and not abuse. He stated he was made aware of the 10/05/2024 incident by the state surveyor on 10/09/2024. He confirmed S13LPN was not removed from the facility after 09/22/2024 and provided care at the facility when another incident occurred on 10/05/2024. He confirmed abuse training was conducted during the staff meeting on 10/01/2024 but S4CNA, S5CNA, S6CNA and S13LPN did not attend the meeting for the abuse training. Resident #46 A review of Resident #46's Clinical Record revealed she was admitted on [DATE] with diagnoses which included, Depression and Weakness. A review of Resident #46's MDS, with an ARD of 07/11/2024, revealed Resident #46 had a BIMS of 15, which indicated Resident #46 was cognitively intact. On 10/08/2024 at 11:45 a.m., an interview was conducted with Resident #46. She stated on 09/24/2024, she and Resident #52 were talking in the hall. She stated when she finished talking with Resident #52, she went to her room, and S6CNA followed her to her room, stood in the doorway and yelled while shaking and pointing her finger toward her, if you have something to say, say it to my face. She stated she felt threatened by S6CNA and reported this to S1ADM immediately. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated Resident #46 notified him of the incident with S6CNA on 09/24/2024. He stated he did not report it because it was a customer service issue and not abuse. He confirmed abuse training was conducted during the staff meeting on 10/01/2024 but S4CNA, S5CNA, S6CNA and S13LPN did not attend the meeting for the abuse training. Resident #35 A review of Resident #35's Clinical Record revealed he was admitted on [DATE] with diagnoses which included, Unqualified Visual Loss of Left Eye and Depressive Episodes. A review of Resident #35's MDS, with an ARD of 09/20/2024, revealed Resident #35 had a BIMS of 15, which indicated Resident #35 was cognitively intact. Resident #51 A review of Resident #51's Clinical Record revealed he was admitted on [DATE] with diagnoses which included, Depressive Disorder, Anxiety Disorder, and Personal history of other Mental and Behavioral Disorders. A review of Resident #51's MDS, with an ARD of 07/11/2024, revealed Resident #51 had a BIMS of 15, which indicated Resident #51 was cognitively intact. On 10/08/2024 at 9:15 a.m., an interview was conducted with Resident #51. He stated about one week ago Resident #35 yelled at him and pushed him against the wall. On 10/08/2024 at 9:30 a.m., an interview was conducted with S11LPN. She stated on 10/02/2024 at approximately 10:00 a.m., she heard yelling as Resident #35 entered his shared room with Resident #51. She stated when she went into the room, Resident #51 told her Resident #35 grabbed him by the wrist and pushed him against the dresser. She stated she reported the incident on 10/02/2024 to S1ADM and S2DON. On 10/09/2024 at 12:45 p.m., an interview was conducted with S1ADM. He stated he was aware of the incident on 10/02/2024 between Resident #35 and #51. He stated he did not feel that this incident rose to the reportable level, therefore he did not investigate or report. On 10/09/2024 at 8:37 a.m., an interview was conducted with S2DON. She stated staff cursing, pointing a finger and intimidating a resident was abuse and should be reported to administration immediately. She stated S1ADM was responsible for reporting to the State Agency. She confirmed no corrective actions were placed for any of the above incidents. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated any allegation of abuse should be reported to him immediately. He stated he was responsible for reporting within 2 hours and reporting the investigation within 5 days. He stated the following employees were not removed following the above incidents and continued to provide care to residents: S4CNA, S5CNA, S6CNA, and S13LPN. He confirmed he did not report, conduct an investigation, or place any corrective actions for any of the above incidents. Plan of Removal: 1. On 10/09/2024 Residents #46 and #52 were re-assessed for any signs of psychosocial harm. Both residents declined any need for counseling or psychosocial services. S4CNA no longer works in the facility as of 09/24/2024. S5CNA no longer works in facility as of 09/25/2024. S6CNA no longer works in facility as of 09/26/2024. 2. All interviewable residents were assessed for signs of abuse or allegations of being mistreated by Administrator/SSD/Designee on 10/9/24. Beginning on 10/07/2024 and completing on 10/10/2024 any non-interviewable residents were assessed by a weekly body audit and daily skin checks. Any abnormal findings will be documented by licensed staff and the Administrator/DON will be notified. 3. All staff will be re-trained on verbal abuse including yelling, cursing, threatening residents as well as immediately reporting verbal abuse to the Administrator if it is witnessed. The Corporate Office retrained Administrator/Designee initially on 10/09/2024. The Corporate Office retrained the Administrator on verbal abuse on 10/09/2024. Administrator/Designee began retraining facility staff on 10/09/2024. After retraining, staff will be tested for competency / understanding. No staff member will be allowed to work a shift without receiving re-training and successfully completing a competency test. All staff will receive abuse training on hire and at least annually, including training on verbal abuse and reporting abuse allegations in a timely manner. All incidents and accidents and nurses notes will be reviewed by corporate to ensure that any potential incidents have been reported accurately and timely. This will begin on 10/10/2024 and continue for 8 weeks 3x per week then randomly for 8 weeks thereafter. 4. Beginning on 10/09/2024, Administrator/DON/ or SSD will interview 5 random residents weekly for 8 weeks then randomly for an additional 8 weeks with BIMS above 8 to ensure no allegations of abuse. As of 10/09/2024, The Pines Retirement Center of [NAME] asserts the likelihood for serious harm to any recipient no longer exists.

Based on interviews and record reviews, the facility failed to ensure each resident remained free from verbal and mental abuse for 3 (#42, #46, and #52) of 7 (#18, #26, #42, #46, #51, #52, and #111) residents reviewed for abuse. The facility failed to prevent: 1. S4CNA and S5CNA from yelling, cursing, and pointing at Resident #52 while surrounding the wheelchair and preventing the resident from getting away; and 2. S6CNA from yelling and cursing at Resident #52 in the hall; and 3. S13LPN from intimidating and threatening Resident #42; and 4. S6CNA from following and verbally threatened Resident #46 in her room. This deficient practice resulted in an Immediate Jeopardy situation for Resident #52 on 09/04/2024, when multiple staff witnessed S4CNA and S5CNA curse, yell, and point in Resident #52's face. Resident #52 reported he no longer felt safe in the facility. It continued on 09/14/2024, when Resident #46 witnessed and reported to S1ADM, S6CNA yelled and cursed at Resident #52 in the hallway. It continued on 09/23/2024, when Resident #42 reported S13LPN stood in front of her wheelchair, pointed and demanded she get off the hall. Resident #42 reported she felt intimidated by S13LPN. It continued on 09/24/2024 when S6CNA followed Resident #46 to her room, yelled, pointed her finger and threatened Resident #46. Resident #46 reported she felt threatened by S6CNA. S1ADM did not remove S4CNA, S5CNA, S6CNA and S13LPN from resident care, provide additional training or complete any monitoring following each individual incident. S1ADM was notified of the Immediate Jeopardy situation on 10/09/2024 at 9:35 a.m. The Immediate Jeopardy was removed on 10/10/2024 at 12:33 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at a potential for more than minimal harm for the other 59 residents residing in the facility. Findings: Review of the facility's undated policy titled Abuse, Neglect and Exploitation revealed the following, in part: Policy: it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. Definitions: Verbal Abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. 1. A review of Resident #52's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Acquired Absence of Right Leg Above the Knee, Acquired Absence of Left Leg Above the Knee and Adjustment Disorder. A review of Resident #52's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2024, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) of 15, which indicated Resident #52 was cognitively intact. On 10/07/2024 at 8:35 a.m., an interview was conducted with Resident #52. He stated a few weeks ago he asked S4CNA to empty his urinal and she told him he could do it himself. S4CNA told him, tell your mammy to empty it. Resident #52 responded by saying S4CNA could drink it, then S4CNA responded tell that b**** to empty it. He stated he and S4CNA continued verbally arguing. He stated he attempted to call S2DON but she did not answer the call, so he rolled his wheelchair to S2DON's office. He said when he got to S2DON's office, S4CNA and S5CNA were standing in front of S2DON's door and stopped him from entering. He stated S4CNA and S5CNA continued to yell and curse at him while he was outside of S2DON's office door. He stated S2DON was in her office and told S4CNA and S5CNA to just ignore him and he would go away. He stated he was angry, overwhelmed and felt intimidated. He stated S17SW intervened, and brought him outside to calm down. On 10/08/2024 at 10:15 a.m., an interview was conducted with S17SW. She stated on 09/04/2024 at approximately 5:30 p.m., she saw Resident #52 in the doorway of S2DON's office in his wheelchair. She reported S5CNA was standing in front of Resident #52 and S4CNA was standing behind Resident #52 preventing him from entering S2DON's office. She stated Resident #52, S4CNA, and S5CNA yelled and cursed at each other at the same time so loudly she did not know what they said only heard cursing back and forth. She stated S5CNA pointed her finger in Resident #52's face. She stated S2DON was in her office, could see and hear the altercation, and did not intervene. She stated she intervened, removed Resident #52, and brought him to the outside patio. She stated Resident #52 was upset and angry and she sat with him until he calmed down. She stated yelling, cursing and pointing a finger at a residents face is abuse and she reported it to S1ADM on the next day. She stated on 09/05/2024, she recommended S1ADM provide training on de-escalation and S1ADM responded, training was not needed because Resident #52 cursed at his staff. On 10/08/2024 at 11:08 a.m., an interview was conducted with S18LPN. She stated on 09/04/2024, she saw Resident #52 in the doorway of S2DON's office in his wheelchair. She reported S5CNA was standing in front of Resident #52 and S4CNA was standing behind Resident #52 preventing him from entering S2DON's office. She stated Resident #52, S4CNA and S5CNA yelled and cursed at each other at the same time so loudly she did not know what they said only heard cursing back and forth. She stated S5CNA pointed her finger in Resident #52's face and told him he was capable of emptying his urinal. She stated S2DON was in her office, could see and hear the altercation, and did not intervene. She stated she intervened and assisted S17SW with removing Resident #52, and bringing him to the outside patio. She stated yelling, cursing and pointing a finger at a residents face is abuse. She stated staff should not have treated Resident #52 in that manner and S4CNA, S5CNA continued to provide care at the facility. On 10/08/2024 at 11:16 a.m., an interview was conducted with S19CNA. She stated on 09/04/2024, she saw Resident #52 in the doorway of S2DON's office in his wheelchair. She reported S5CNA was standing in front of Resident #52 and S4CNA was standing behind Resident #52 preventing him from entering S2DON's office. She stated Resident #52, S4CNA and S5CNA yelled and cursed at each other at the same time so loudly she did not know what they said only heard cursing back and forth. She stated S5CNA pointed her finger in Resident #52's face and told him he was capable of emptying his urinal. She stated S2DON was in her office, could see and hear the altercation, and did not intervene. On 10/09/2024 at 4:20 p.m., an interview was conducted with S26OMB. She stated Resident #52 reported to her that he asked S4CNA to empty his urinal and she told him, Tell your mammy to do it and they argued back and forth. She stated Resident #52 reported he felt vulnerable because he does not have any legs and he did not feel safe at the facility after the incident. On 10/09/2024 at 4:30 p.m., an interview was conducted with S4CNA. She stated on 09/04/2024, Resident #52 told her to empty his urinal and make his bed immediately. She denied arguing, yelling or cursing at Resident #52. She stated 09/07/2024 was the last day she provided care to Resident #52, but continued to provide care to other residents in the facility until 09/24/2024. She stated her last abuse training was in June 2024. On 10/09/2024 at 4:35 p.m., an interview was conducted with S5CNA. She stated she was never assigned to Resident #52 but would help S4CNA with his care. She stated on 09/04/2024, Resident #52 told S4CNA to empty his urinal and make his bed immediately. She denied arguing, yelling or cursing at Resident #52. She stated she provided care to other residents in the facility until she was moved to another facility on 09/26/2024, with a plan to return to the facility when Resident #52 was discharged . She stated her last abuse training was in June 2024. On 10/09/2024 at 8:37 a.m., an interview was conducted with S2DON. She stated on 09/04/2024, Resident #52 asked S4CNA to empty his urinal and she told him he could do it himself. She stated Resident #52 rolled his wheelchair to the doorway of her office, parked his wheelchair, and yelled and cursed at her and S4CNA. S2DON stated she did not hear the 2 CNAs yell or curse at the resident. She stated staff cursing and pointing a finger at a resident was abuse. She confirmed S4CNA continued to provide care to residents in the facility until 09/24/2024 and S5CNA continued to provide care to residents in the facility until 09/26/2024 when S1ADM removed them. She confirmed no additional education was provided to staff on de-escalation for residents with behaviors or monitoring completed following the incident on 09/04/2024. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated Resident #52 reported on 09/25/2024, he asked S4CNA on 09/05/2024 to empty his urinal. Resident #52 reported S4CNA refused to empty his urinal, yelled and cursed at her. S1ADM explained Resident #52 had aggressive behaviors, which included, yelling and cursing with other residents and staff. He stated S4CNA and S5CNA triggered Resident #52's behaviors so they were moved to another facility on 09/24/2024 and 09/26/2024, with a plan to return when Resident #52 was discharged . He stated S4CNA was not assigned to Resident #52 after 09/07/2024 but did provide care to other residents at the facility until 09/24/2024. He confirmed no additional education was provided to staff on de-escalation for residents with behaviors or monitoring completed following the incident on 09/04/2024. 2. On 10/08/2024 at 9:31 a.m., an interview was conducted with S20LPN. She stated on 09/14/2024 she witnessed S6CNA yell and curse at Resident #52 but could not remember exactly what was said. She confirmed arguing, yelling and cursing with a resident was abuse and she reported it to administration. She further stated she had witnessed multiple staff curse at Resident #52 and some of those employees still worked at the facility even after notifying administration of the abuse. On 10/08/2024 at 9:54 a.m., an interview was conducted with S21CNA. She stated on 09/14/2024, she witnessed S6CNA curse and argue with Resident #52 but could not remember exactly what was said. She stated S1ADM was made aware of the incident. She confirmed cursing at a resident was abuse. On 10/08/2024 at 11:45 p.m., an interview was conducted with Resident #46, a cognitively intact resident. She stated on 09/14/2024, she was in the hall and witnessed S6CNA yell and curse at Resident #52. She stated S6CNA told Resident #52, F*** you. She stated she reported the incident immediately to S1ADM. She stated S6CNA continued to provide care at the facility on her hall until 09/24/2024, when S6CNA threatened her. On 10/09/2024 at 2:01 p.m., an interview was attempted with S6CNA, unable to leave a message. On 10/09/2024 at 4:45 p.m., an interview was attempted with S6CNA, unable to leave a message. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated Resident #46 approached him on 09/14/2024 and notified him of the incident with Resident #52 and S6CNA. He stated S6CNA was not removed from the facility and continued to provide care to Resident #46 and Resident #52 until S6CNA was removed on 09/26/2024. He stated on 09/24/2024, S6CNA was involved in another incident with Resident #46 and S6CNA was terminated but not related to the allegation. He confirmed no additional education was provided to staff on de-escalation for residents with behaviors. He confirmed the last abuse training was conducted during the staff meeting on 10/01/2024 but S4CNA, S5CNA, S6CNA and S13LPN did not attend the meeting for the abuse training. 3. A review of Resident #42's Clinical Records revealed Resident #42 was admitted to the facility on 01/16/2024 with diagnoses which included, Depression, Anxiety, and Muscle Wasting. A review of Resident #42's MDS with an ARD of 08/07/2024 revealed Resident #42 had a BIMS of 14, which indicated Resident #42 was cognitively intact. A review of Resident #42's grievance, dated 09/23/2024, revealed the following: Statement of concern: Resident #42 stated S13LPN displayed poor customer service and asked Resident #42 to leave the hall and return to her room. Investigation: Resident #48 was witness Conclusion: S13LPN educated on customer service and residents right to be invited to other rooms. On 10/09/2024 at 3:28 p.m., an interview was conducted with Resident #42. She stated she and Resident #48 were friends and she visited Resident #48's room frequently. She stated on 09/22/2024, she was in her wheelchair, rolling down the hall, when S13LPN stopped her, stood in front of her wheelchair and stated, Get off my hall, you're not allowed over here in a stern voice. She stated on the same day after leaving the smoking patio and going back to her room, she heard S13LPN call her white trash. Resident #42 stated she felt intimidated and threatened by S13LPN and reported the incident to S1ADM on 09/23/2024. She stated again on 10/05/2024, S13LPN told her to get in Resident #48's room or get off the hall in a stern voice. On 10/10/2024 at 2:26 p.m., an interview was conducted with Resident #48, a mildly cognitively impaired resident. He stated on 09/22/2024, he witnessed S13LPN stand in front of Resident #42's wheelchair and tell her You can't come down this hall in a stern voice. He stated again on 10/05/2024, S13LPN told him and Resident #42 to get in Resident #48's room or get off the hall in a stern voice. On 10/09/2024 at 3:53 p.m., an interview was conducted with S13LPN. She stated Resident #42 was loud, made too much noise on the hall and always visited Resident #48 on her hall. She stated on 09/22/2024 she told Resident #42 she could not go down the hall. She stated on 10/05/2024, Resident #42 was again visiting Resident #48 on her hall. She stated she told them either to get in Resident #48's room or get off the hall. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He said on 09/23/2024 Resident #42 reported that on 09/22/2024, S13LPN stopped her, stood in front of her wheelchair and stated, Get off my hall, you're not allowed over here in a stern voice. He confirmed Resident #42 should not have been stopped and been allowed to visit Resident #48. He stated he did not report it because it was a customer service issue and not abuse. He stated he was made aware of the 10/05/2024 incident by the state surveyor on 10/09/2024. He confirmed S13LPN was not removed from the facility after 09/22/2024 and provided care at the facility when another incident occurred on 10/05/2024. He confirmed abuse training was conducted during the staff meeting on 10/01/2024 but S4CNA, S5CNA, S6CNA and S13LPN did not attend the meeting for the abuse training. 4. A review of Resident #46's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included, Depression and Weakness. A review of Resident #46's MDS, with an ARD of 07/11/2024, revealed Resident #46 had a BIMS of 15, which indicated Resident #46 was cognitively intact. A review of Resident #46's grievance, dated 09/24/2024, revealed the following: Statement of concern: Resident #46 stated S6CNA approached her and asked, If you have something to say, say it to me Investigation: S6CNA confirmed Resident #46's statement Conclusion: S6CNA terminated On 10/08/2024 at 11:45 a.m., an interview was conducted with Resident #46. She stated on 09/24/2024, she and Resident #52 were talking in the hall. She stated when she finished talking with Resident #52, she went to her room, and S6CNA followed her to her room, stood in the doorway and yelled while shaking and pointing her finger toward her, if you have something to say, say it to my face. She stated she felt threatened by S6CNA and reported this to S1ADM the same day. On 10/09/2024 at 2:01 p.m., an interview was attempted with S6CNA, unable to leave a message. On 10/09/2024 at 4:45 p.m., an interview was attempted with S6CNA, unable to leave a message. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated Resident #46 notified him of the incident with S6CNA on 09/24/2024. He stated he did not report it because it was a customer service issue and not abuse. He confirmed abuse training was conducted during the staff meeting on 10/01/2024 but S4CNA, S5CNA, S6CNA and S13LPN did not attend the meeting for the abuse training. F-600 Plan of Removal 1. On 10/09/2024 Residents #46 and #52 were re-assessed for any signs of psychosocial harm. Both residents declined any need for counseling or psychosocial services. All interviewable residents were assessed for signs of abuse or allegations of being mistreated by Administrator/SSD/Designee on 10/9/24. Beginning on 10/07/2024 and completing on 10/10/2024 any non-interviewable residents were assessed by a weekly body audit and daily skin checks. Any abnormal findings will be documented by licensed staff and the Administrator/DON will be notified. 2. S4CNA no longer works in the facility as of 09/24/2024. S5CNA no longer works in facility as of 09/25/2024. S6CNA no longer works in facility as of 09/26/2024. 3. All staff will be re-trained on verbal abuse including yelling, cursing, threatening residents as well as immediately reporting verbal abuse to the Administrator if it is witnessed. The Corporate Office retrained Administrator/Designee initially on 10/09/2024 at 12:45pm. Administrator/Designee began retraining facility staff on 10/09/2024. After retraining, staff will be tested for competency / understanding. No staff member will be allowed to work a shift without receiving re-training and successfully completing a competency test. All staff will receive abuse training on hire and at least annually, including training on verbal abuse. 4. On 10/09/2024 Administrator/ DON/ or SSD will interview 5 random residents weekly with BIMS above 8 to ensure no allegations of abuse for 8 weeks and randomly thereafter. As of 10/09/2024, the facility asserts the likelihood for serious harm to any recipient no longer exists.

Based on record reviews and interview, the facility failed to notify the physician when a resident had aggressive behaviors toward staff and other residents for 1(#52) of 6 (#18, #26, #42, #51, #52, and #111) residents reviewed for behaviors. Findings: A review of the facility's undated policy, Change in a Resident's Condition or Status revealed the following: 1. The nurse supervisor/Charge Nurse will notify the resident's attending physician or on call physician when there has been: a. An accident or incident involving the resident; d. A significant change in the resident's physical/emotional/mental condition. A review of Resident #52's Clinical Records revealed he was admitted to the facility on [DATE] and diagnosed with Adjustment Disorder, Unspecified. A review of Resident #52's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2024, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) of 15, which indicated Resident #52 was cognitively intact. A review of Resident #52's Clinical Record revealed no documentation his psychiatric NP was notified of his aggressive behaviors toward other residents and staff beginning 08/15/2024 through 10/08/2024. Review of Resident #52's Psychiatric NP Notes revealed the following: Date: 08/15/2024 Diagnosis: Adjustment disorder, Unspecified. Staff reports improved behaviors. Date: 09/17/2024 Diagnosis: Adjustment disorder, Unspecified. Staff reports no behavior issues. On 10/08/2024 at 3:43 p.m., an interview was conducted with S1ADM. He confirmed Resident #52 had aggressive behaviors with multiple staff and residents. He stated he was not aware if S22NP had been notified but due to his aggressive behaviors he was issued a 30 day discharge. On 10/09/2024 at 8:37 a.m., an interview was conducted with S2DON. She confirmed Resident #52 had aggressive behaviors with multiple staff and residents. She further stated S22NP was made aware of his behaviors. On 10/10/2024 at 4:06 p.m., an interview was conducted with S22NP. She stated she was not aware Resident #52 was having behaviors and should have been made aware. She confirmed she was not aware of Resident #52 threatening staff.

Based on record reviews and interviews, the facility failed to ensure the resident's care plan was reviewed and revised for 2 (#5 and #52) of 19 sampled residents reviewed for care plans. The facility failed to ensure: 1. Resident #5's transfer status was documented on his care plan; and 2. Resident #52's care plan was reviewed and revised for behaviors. Findings: Review of the facility's undated policy titled Care Plans - Comprehensive revealed, in part: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 8. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. f. Resident specific interventions that reflect the resident's needs. 10. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 13. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. 1. Review of Resident #5's Clinical Records revealed he was admitted to the facility on [DATE] with diagnoses, which included: Cerebral Palsy, Muscle Weakness, History of Falling, and Unspecified Lack of Coordination. Review of Resident #5's most recent MDS, with ARD of 09/04/2024, revealed Resident #5 had a BIMS of 15, indicating he was cognitively intact. Further review of MDS Section GG revealed Resident #5 was dependent on staff for the following: Chair/bed-to-chair transfer, upper and lower body dressing, Personal hygiene, rolling left and right, and sit to lying. Review of Resident #5's Care Plan revealed the following, in part: Date: 05/10/2022 Resident Problem: ADLs: Requires assistance for ADLs Further review revealed there were no interventions noted for Resident #5's transfer status. 2. Review of Resident #52's Clinical Records revealed he was admitted to the facility on [DATE] with diagnoses, which included: Adjustment Disorder, Unspecified. Review of Resident #52's most recent MDS, with ARD of 08/05/2024, revealed Resident #52 had a BIMS of 15, indicating he was cognitively intact. Review of Resident #52's Care Plan revealed the following, in part: Date: 06/24/2024 Resident Problem: Behavior: Verbally aggressive behavior. Further review revealed there were no updated interventions noted for Resident #5's behavior/s. An interview was conducted on 10/10/2024 at 2:10 p.m. with S7RN and S16LPN. Both stated they were responsible for MDS and review and revision of care plans. S7RN stated she was not aware Resident #52 had behaviors. S7RN further stated Resident #5 required 2 person mechanical lift transfers. S7RN confirmed Resident #5 was not care planned for 2 person mechanical lift transfers, and Resident #52 had not had any behavior interventions updated, and should have. An interview was conducted on 10/10/2024 at 2:23 p.m. with S3CRN. S3CRN confirmed a resident's transfer status should be included in their care plan, and interventions should have be updated for Resident #52's behaviors. 47546

Based on record review and interviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 (#28) of 19 residents reviewed in the final sample. The facility failed to ensure Resident #28 received her required HIV medication. Findings: Review of Resident #28's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included HIV. Review of Resident #28's discharge instructions from a local rehabilitation center dated 06/19/2024 revealed an order for Bictegravir/Emtricitabine/Alafenamide 50mg/200mg/25mg one tablet by mouth daily. Review of Resident #28's MAR dated 06/10/2024-10/10/2024 revealed no documentation of Bictegravir/Emtricitabine/Alafenamide 50mg/200mg/25mg one tablet by mouth daily. On 10/10/2024 at 2:02 p.m., an interview was conducted with S8LPN. She stated Resident #28 had a diagnosis of HIV. She stated Resident #28's HIV medication was discontinued. She stated she discontinued the medication after the clinic visit. She reviewed Resident #28's orders and confirmed she did not see an order to discontinue HIV medication. On 10/10/2024 at 2:04 p.m., an interview was conducted with S2DON. She stated Resident #28 was readmitted to the facility from a rehabilitation center. She stated she was responsible for inputting admission orders. She stated she was unaware of discharge orders from local rehabilitation facility. She confirmed HIV medication for Resident #28 was not reordered. On 10/10/2024 at 2:30 p.m., a telephone interview was conducted with S12NP. He stated he was unaware of HIV medications for Resident #28. He reviewed the medication list and confirmed there was no order for HIV medication. On 10/10/2024 at 4:42 p.m., an interview was conducted with S13CRN. She reviewed Resident #28's physician orders along with the rehabilitation facility's discharge instructions dated 06/19/2024 and confirmed an order for the following HIV medication, Bictegravir/Emtricitabine/Alafenamide 50mg/200mg/25mg one tablet by mouth daily 2and further confirmed the medication was not reordered and should have been.

Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #1) of 8 (Resident #1, #2, #3, #4, #5, R1, R2, R3) residents reviewed for accidents. This deficient practice resulted in actual harm for Resident #1 on 04/25/2019 when S5CNA attempted to transfer the resident, who required two person assistance, from his wheelchair to his bed using a mechanical lift. During the transfer, a strap broke off of the lift sling and the resident fell to the floor. The resident was transferred to the hospital and was diagnosed with [REDACTED]. Findings: Review of facility policy entitled Lifting Machine, Using a Mechanical revealed the following, in part: Purpose: The purpose of this procedure is to establish general principles of safe lifting using a mechanical lifting device. General Guidelines: At least (2) nursing assistants are needed to safely move a resident with a mechanical lift. Steps in the procedure: Step #8- Make sure that all necessary equipment (slings, hooks, chains, straps, and supports) is on hand and in good condition. Review of the Manufacturer's Instructions and Manual for Use for the mechanical lift (brand name) Battery Powered Patient Lift revealed the following, in part: Operation: (Brand Name) recommends that two assistants be used for all lifting preparation and transferring to/from procedures. (All illustrations for use diagrams in the user manual depicted two persons operating the lift for patient use). Review of the Manufacturer's Instruction Manual for the Full Body Sling revealed the following, in part: Positioning the sling: With one assistant holding the patient, the second assistant pushes the folded sling under the patient without rolling him/her over. Refer to Detail B Figure 1 (all illustrations depicted use of the mechanical lift with sling demonstrated two persons operating the sling). Review of Resident #1's clinical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS with an ARD of 02/12/2019 revealed his BIMS summary score was assessed as 15, indicating he was cognitively intact. Functional Assessment revealed he was totally dependent for transfers, and required two+ person assist. Further review of the Functional assessment revealed he required extensive assistance for bed mobility, dressing, toilet, personal hygiene, and bathing. Review of Resident#1's Care Plan dated 04/26/2019 revealed the following, in part: Category: Body Systems: [MEDICAL CONDITION] right side; Staff assist me with ADLs. Category: ADL/Functional Rehabilitation: I require staff assist with ADLs r/t [MEDICAL CONDITION]. I require a mechanical lift for transfers. Category: Falls: I am at risk for falls and require assist with transfers. I remain at risk for falls r/t I require a mechanical lift for transfers. 04/25/2019- fall with major injury. Resident sent to ER. Review of Resident #1's Nurse's Notes dated 04/25/2019 revealed the following, in part: 1:30 p.m. Resident was being transferred via staff via mechanical lift. Strap broke patient c/o pain in right arm and left leg. Assisted to bed; NP notified. New order for x ray right arm and left leg. Resident talkative with staff. Signed by S3LPN. 2:10 p.m. X- rays done. 3:10 p.m. Resident transferred to hospital via ambulance. Review of Hospital Records dated 04/30/2019 revealed the following, in part: 04/25/2019 admitting complaint- Left Femur Fracture and Right Humerus Fracture Discharge Summary dated 04/30/2019 included: Discharge Diagnosis: [REDACTED]. presenting from (Facility Name) NH after sustaining a fall. Patient was on a mechanical lift being transferred when all of a sudden it broke and fell on his back. He did not hit his head or lose consciousness. X Rays in the NH showed [MEDICAL CONDITION] and displaced [MEDICAL CONDITION] humerus. On 05/20/2019 at 12:55 p.m., an interview was conducted with S4CNASup. She stated Resident #1 required the use of a mechanical lift for transfers. She stated Resident #1 had a fall with injury on 04/25/2019 when being transferred using the mechanical lift. She stated S5CNA was transferring the resident from his wheelchair to his bed using the mechanical lift, by herself. She stated she was on the hall where the resident resided when the incident occurred, S5CNA came and got her, she went to the room, and found Resident #1 on the floor. She stated when she questioned S5CNA regarding the incident, she told her the lift sling strap broke when she was transferring the resident. S4CNASup stated she saw the strap was broken off of the lift sling at the upper right corner of the sling. S4CNASup stated the policy required two staff for transferring residents with the mechanical lift. She stated S5CNA should have had another staff member present for the transfer. S4CNASup further stated S5CNA had received previous education on 03/28/2019 about use of the lift which included making sure the slings and lift were in good condition, and making sure two people were present for lift transfers. She further stated because S5CNA was alone when she was transferring the resident, she failed to follow the policy, and after the incident, she was placed on leave, then terminated the next day. On 05/21/2019 at 9:50 a.m., an interview was conducted with S1Adm. He stated he was aware of the incident on 04/25/2019 when Resident #1 fell during a transfer. He stated a CNA was transferring the resident using a mechanical lift when a sling strap broke during the transfer. He stated they could not determine the reason for the strap breaking. He verified there should have been two persons in the room when the mechanical lift was being operated, in accordance with facility policy. On 05/21/2019 at 3:26 p.m., an interview was conducted with S2DON. After reviewing the MDS for Resident #1, he verified the facility assessed the resident's functional status as totally dependent and required two person physical assist. He verified the current care plan approaches included the resident required a mechanical lift for transfers. He verified S5CNA was transferring Resident #1 alone on 04/25/2019 when the resident fell from the mechanical lift sling and sustained injuries. He stated according to the policy for use of the mechanical lift, she should have had another staff member assisting with the transfer. The facility implemented corrective actions prior to the State Agency's investigation on 05/21/2019; thus, it was determined to be a Past Noncompliance citation. The facility identified deficient practice and implemented the following Plan of Correction: 1. Immediately after incident on 04/25/19 S2DON performed assessment of the lift and all lift slings in the facility. 2. Review of a statement by S2DON revealed: Upon assessing the lift sling that was used during the transfer of Resident #1, the strap was noted to be broken on the black area of the sling that attaches to the lift itself. The sling showed no other signs of wear. The sling was immediately discarded, and replacement slings were ordered on [DATE]. 3. The CNA who was not following policy when operating the mechanical lift, was immediately placed on leave, then terminated on 04/26/2019. 4. S1Adm confirmed with the maintenance supervisor and reviewed documentation of maintenance Weekly Lift/Sling Inspection Checklist were completed. These checks included inspection of the general condition of the lift and lift slings for secure stitching of straps, tears, excessive wear, holes, fraying, fading, and function. The maintenance department was reeducated on sling checks with return competency demonstration on 04/25/2019. 5. S2DON immediately implemented staff education regarding proper use of the mechanical lift and lift slings for all nursing staff on 04/25/2019. 6. Maintenance will document weekly checks on a maintenance check log. The checks will include inspection of pad continuity and reporting of pads to be taken out of commission. 7. The DON or designee will document Mechanical Lift checks on a Quality Assurance Tool three times per week for four weeks. This check includes proper lift technique, lift and slings checked three times per week for any defects, and staff competence validation on reporting of any lift or lift pad defects on all lift pads. 8. All Quality Assurance information will be taken to the Quality Assurance Committee on 05/23/2019. 9. Review of records revealed Weekly Lift/Sling Inspection Checklists reflecting lift/sling inspections were completed three times weekly from 04/25/19 - 05/18/2019 as per the above P[NAME]. Staff training records entitled Proper Hoyer Lift Technique with Return Demonstration dated 04/25/2019 were reconciled with a personnel list of nurses and CNAs provided by the facility as verification of staff training for all employees who used the mechanical lift. Further review revealed completion of the quality assurance tool documentation entitled Hoyer Lift QA Tool from 04/29/2019 - 05/18/2019 as per the P[NAME]. 10. On 05/20/2019 and 05/21/2019, observations of residents being transferred using the mechanical lift, and observations of the facility mechanical lift and all resident lift slings revealed residents were being transferred properly, in accordance with policy, and the equipment was in good condition. Interviews conducted with CNAs on each hall and different shifts revealed they were knowledgeable of the facility policy for transferring residents safely with a mechanical lift. Interviews with staff, residents, and a family member revealed there were no further issues involving the mechanical lift or any other equipment. Record reviews included documents verifying corrective action plans had been implemented and ongoing monitoring was being performed. Throughout the survey from 05/20/19 to 05/21/19, random staff interviews revealed staff received training on the facility's policy and procedure for the use of the mechanical lift for resident transfers, and they were to ensure that all necessary equipment including slings, hooks, straps, and supports were on hand and in good condition.

Based on interviews and record reviews, the facility failed to ensure that adequate supervision/monitoring was in place for 1 (#50) of 6 (#7, #9, #15, #28, #50, #53) sampled residents reviewed for behaviors. The facility failed to have a system in place to: 1.) Ensure that Resident #50 was assessed and monitored for sharp objects following an incident on 5/29/18 when she was found to have a switchblade in her possession and stated she would use the switchblade on another resident; 2.) Ensure supervision/monitoring was increased for Resident #50, who had a switchblade in her possession and had stated she was going to use it on another resident on 5/29/18, and then stabbed a therapist with a seam ripper on 6/8/18; 3.) Identify and implement appropriate safety interventions for a cognitively impaired resident (#50); 4.) Ensure the director of nurses, physician, and administrator were notified that Resident #50 had possession of a switchblade and of her statement to use the switchblade on another resident on 5/29/18; 5.) Ensure all staff were made aware of Resident #50's aggressive behaviors; and 6.) Ensure staff were trained and competent to monitor Resident #50 for sharp objects that could harm others. The immediate jeopardy began on 5/29/18 at 6:50 p.m. when Resident #50 was found to have a switchblade in her possession and verbalized her intent to use it on another resident due to him entering her room. The nurse failed to notify the director of nurses, physician, and administrator of the incident. On 6/8/18 at 4:45 p.m., Resident #50 grabbed S23ST by her hair with one hand and used her other hand to stab S23ST in the back with a seam ripper. Interviews with staff revealed they were not aware of Resident #50's history of aggressive behavior and/or the need to monitor her for sharp objects. S1Administrator was notified of the Immediate Jeopardy on 7/20/18 at 3:36 p.m. regarding resident #50's aggressive behaviors. The Immediate Jeopardy ended on 7/20/18 at 5:00 p.m. when S1Administrator provided a written plan of removal, which read as follows: 1. What was identified? Staff education on monitoring resident behavior and monitoring for dangerous objects 2. Who else can be affected? Any other resident can be affected 3. Measures Staff were in-serviced on resident behaviors and monitoring. Staff also educated to notify ED and DON any time a threat is made or dangerous object is seen. In-services will happen weekly for 4 weeks. Resident will be placed on a 1:1 for monitoring X 72 hours. After 72 hours, resident will be monitored Q1h X 7 days. 4. Monitoring ED will round resident's room twice per week to search resident and resident room for dangerous objects. The deficit practice remains at a potential for more than minimal harm for all of the 64 residents in the facility. Findings: Review of the facility policy, Unmanageable Residents, revealed the following in part: 1. Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately: a. Provide for the safety of all concerned (i.e., move resident, equipment, etc.); b. Notify the resident's Attending Physician for instructions; c. Notify the Director of Nursing Services; 7. Complete documentation of the incident must be recorded in the resident's medical record and an incident report must be filed with the Administrator. Review of the facility policy, Accidents and Incidents - Investigating and Reporting, revealed the following in part: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 5. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. 6. The Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence. Review of the facility policy, Behavior Assessment and Monitoring, revealed the following in part: Assessment: 2. The nursing staff will identify, document, and inform the physician about an individual's mental status, behavior, and cognition including: a. Onset, duration and frequency of problematic behaviors or changes in behavior, cognition, or mood. Review of Resident #50's medical record revealed that the resident was a white female with an admission date of [DATE] and a date of birth of 1/14/38. It also revealed she had the following Diagnoses: [REDACTED]. Review of the quarterly MDS, with an ARD of 7/1/18, revealed a BIMS of 9, which indicated she was moderately cognitively impaired. Review of the nurses' notes revealed the following: 5/29/18 at 8:00 a.m. Alert and oriented times two. 5/29/18 at 6:50 p.m. Therapy notified nurse that resident had contraband (switchblade). Resident stated she was going to use it on another resident due to him entering her room. 6/4/18 at 3:30 p.m. Alert and confused. 6/4/18 at 8:00 p.m. Continues to be confused and having visual hallucinations. 6/6/18 at 4:00 p.m. Resident was in the hallway drinking some water from a cup. When she was done, she threw the cup at another resident. 6/8/18 at 2:30 a.m. Resident was out of bed, confused and in the hallway. She reported to the nurse that she was not going back into her room because a man was in there that went into the attic and by 2:45 a.m., she had refused to go back into her room and ended up sleeping in Room A Bed A. 6/8/18 at 5:05 p.m. Resident was in therapy gym and was reported to the nurse that she grabbed therapist by her hair and stabbed her in the back with a stitch ripper. 6/8/18 at 6:15 p.m. Resident left en route to local hospital via ambulance. 6/8/18 at 11:55 p.m. Resident returned to the facility via a cab. No new orders noted. 6/10/18 no time noted. Resident awake, alert, oriented times two. Audible delusions. 6/13/18 at 3:30 a.m. Resident reported three men were coming in her room. Shortly after this reported right before the nurse, Don't you see those men laughing at you? At 4:00 a.m., nurse noted the resident refused to go back in her room and was propelling herself in her wheelchair throughout the facility. 6/13/18 at 8:00 a.m. Resident alert oriented times two. Confusion noted. Resident hearing voices thinks some little men coming from out of the attic. 6/16/18 no time noted. Resident awake, alert and oriented times two. Audible delusions. 7/21/18 at 6:45 p.m. Addendum: Late entry for incident that occurred on 5/30/18. A therapist working with resident informed me (S33LPN) that resident had a knife on person. Nurse approached resident to confirm the accusation. Resident was asked if she had a knife. Resident stated she did have a knife. She reached in her top of her shirt and gave it to nurse without any resistance. The resident stated she had the knife for a resident who wanders in her room at night. Nurse searched resident purse that she had on person. No sharp or danger items were found. Nurse assured resident that a knife or any other object that may be use to harm another resident, herself or staff member was not needed and that she was not allowed to have such objects. Resident verbally stated that she agreed. Upon completing the assessment, nurse did not observe any aggressive or combative behaviors from the resident that would put herself or others in danger. She was calm and never posed any immediate threat to herself or others. The knife was placed on the nurse's cart. Resident remained at station until approximately 9:30 p.m. She did not exhibit any signs or symptoms of distress, aggression or combativeness. The incident was verbally reported to the oncoming nurse. Review of S33LPN's note addendum dated 7/21/18 at 6:45 p.m. revealed the switchblade was removed from Resident #50's possession on 5/30/18. However, S33LPN's original note revealed the switchblade was removed from Resident #50's possession on 5/29/18. Review of witness statements of incident, dated 6/8/18 at 4:45 p.m., revealed the following: S23ST recorded her witness of the event as follows: The weapon listed was a thread ripper. Resident #50 was finished with her session after working with S23ST when she emptied her purse and placed trash on the floor. S23ST communicated to resident it was time to eat dinner and they were done with therapy for today. She then bent down to pick the trash off the floor. Resident #50 immediately reached over, stabbed S23ST in the shoulder with a thread ripper with Resident #50's right hand, and grabbed S23ST by the hair with her left hand. Resident #50 caught S23ST off guard and jerked her with extreme force by the hair causing her neck to be completely rotated. She noted resident had a death grip to her hair and would not let go. S23ST was helped by nurse and therapy team members. S25OT recorded her witness of the event as follows: As the speech therapist was bending down beside Resident #50's wheelchair, she witnessed the resident grab the therapist aggressively by the ponytail and abruptly rotate her neck with her left hand. The resident proceeded to puncture her with a seam ripper in her upper trapezius. S25OT ran over to pull the resident's weapon away from the therapist (S23ST) and removed the seam ripper. Nursing was notified. The therapist (S23ST) was the victim that was attacked by the resident (#50). Review of the physician's orders revealed the following: 6/6/18 increase in [MEDICATION NAME] 2.5 mg PO BID from QD 6/7/18 Bactrim DS PO BID X 7 days 6/8/18 Send out to hospital for eval and treat. Review of Care Plan revealed the following: -Onset 6/08/18: I (Resident #50) display physically abusive behavior AEB I grabbed a staff member by her hair and punctured her neck with a seam ripper. -Goal: I will not display any physical aggressive behavior. -Interventions included: Resident transferred to local hospital for eval and treatment. Monitor and document any/all behaviors. Do not argue with resident. Remove resident from public area when behavior is disruptive and unacceptable. Reinforce with resident unacceptability of physical abuse. Educate that physical abuse will not be tolerated in facility. Therapy inservice that resident should not be treated without another staff member present at all times. Resident not to be left alone in therapy gym with another resident. Review of the (MONTH) (YEAR) Behavior/Intervention Monthly Flow Record revealed migraines were the only behavior being monitored. Review of the (MONTH) (YEAR) Behavior/Intervention Monthly Flow Record revealed [MEDICAL CONDITION] was the only behavior being monitored. Review of the (MONTH) (YEAR) Behavior/Intervention Monthly Flow Record revealed depression and agitation were behaviors being monitored. Review of Skilled Nursing Care Visit notes completed by S22NP revealed the following: 5/29/18 at 10:55 a.m. HPI [AGE] year old white female. Examination psychiatric - sleepy today. Impression/Plan - UTI/UA today positive. Patient lethargic but arouses. Start [MEDICATION NAME] 100mg BID X 7 days. 6/6/18 at 9:23 p.m. HPI [AGE] year old white female. She is pleasantly confused. Examination psychiatric - pleasantly confused. 6/7/18 at 10:31 p.m. HPI [AGE] year old white female. Outbursts yesterday with staff and other patients. [MEDICATION NAME] was increased to 2.5mg BID yesterday per Psych NP. She is pleasantly confused. Examination psychiatric - pleasantly confused. 6/12/18 10:41 a.m. Patient sent to ER over the weekend for aggressive behavior to staff. She stabbed therapist with seam ripper device. Patient was calm once she was at ER and no changes were made to her medications. Today she is calm, cooperative, oriented to self and time. She is pleasantly confused. Examination psychiatric - pleasantly confused. Impression/plan - aggressive behavior towards staff. Sent to ER over weekend for eval, no changes in meds. Outbursts yesterday with staff and patients, [MEDICATION NAME] dose increased. Review of the Visit Notes completed by the Psychiatric Nurse Practitioner revealed the following: 5/27/18 Review of Systems: (-) anxiety (-) depression, (+) auditory, tactile and visual hallucinations, (-) [MEDICAL CONDITION], (-) irritability, (+) memory change, (-) suicidal thoughts and ideation. Review of Examination Psychiatric - Black/African American patient appears of stated age. Patient's thought processes are organized and logical. She does not have any delusions, homicidal ideations or [MEDICAL CONDITION]. Patient has hallucinations of hearing, vision and smell but not taste and touch. Patient's immediate retention and recall is impaired. Review of Mental Status Exam revealed the following: -Thought Content (-) delusions (-) obsessions (-) [MEDICAL CONDITION] (-) homicidal ideations Review of the plan - continue current drug regimen, monitor behavior. 6/6/18 at 2:02 p.m. Review of History of Present Illness/Chief Complaint-patient seen in the hallway after she grabbed another patient. Review of Systems (+) irritability (+) paranoia (-) suicidal thoughts and ideation aggressive behavior toward another resident Review of Examination Psychiatric - general appearance Black/African American patient appears of stated age. She has delusions of persecution. She does not have any homicidal ideations. She does not have any [MEDICAL CONDITION]. Patient does not have any hallucinations. Review of Mental Status Exam revealed the following: -Thought Content (+) Delusions of Persecution (-) No Obsessions (-) No [MEDICAL CONDITION] (-) No Homicidal Ideations -Perception (-) No Audio or Visual Hallucinations (-) Illusions NOT present Review of the plan - adjust [MEDICATION NAME] 2.5mg bid and continue current drug regimen, monitor behavior. 6/8/18 at 8:01 a.m. Review of Systems: (-) anxiety (-) depression (-) [MEDICAL CONDITION] (-) paranoia confabulates Review of examination psychiatric no homicidal ideations or [MEDICAL CONDITION]. It also revealed she does not have any hallucinations. Review of Mental Status Exam revealed the following: -Though Content (+) delusions of confabulates (-) No Obsessions (-) No [MEDICAL CONDITION] (-) No Homicidal Ideations -Perception (-) No Audio or Visual Hallucinations (-) Illusions NOT present Review of the plan - continue current drug regimen, monitor behavior. Review of the Incident Logs dated (MONTH) (YEAR) - (MONTH) (YEAR) did not reveal Resident #50 had possession of a switchblade on 5/29/18 or stabbed a staff member with a seam ripper on 6/8/18. On 7/17/18 at 8:04 a.m., an observation was made of Resident #50 sitting in her wheelchair in her room alone, and she was eating breakfast with silverware. She was a well-groomed white female. On 7/19/18 at 12:16 p.m., an interview was held with S25OT, who stated she had worked at this facility for two and a half years. She stated she had worked closely with Resident #50 during her therapy. S25OT stated she was working with Resident #50 when she pulled a switchblade out of her blue purse. She explained when she asked the resident what she was doing with the switchblade she mumbled an answer that she could not understand and would not speak further. She stated she told the nurse at this time. S25OT stated she informed the nurse at this time. She stated the nurse told her Resident #50 verbalized she was going to use the knife on another resident that wandered into her room. She stated she witnessed the incident on 6/8/18 when Resident #50 stabbed S23ST. She stated she was working with another resident while Resident #50 was receiving therapy with S23ST. She stated the resident had her blue purse in her lap, as it was the end of the session. She stated the resident started rummaging through her purse pulling out papers and dropping them on the floor next to her wheelchair. She stated S23ST leaned down and started picking up the papers when Resident #50 grabbed S23ST by the ponytail with one hand and stabbed her in the shoulder with a seam ripper by the other hand. She explained she and another therapist ran to her assistance as S23ST was crying out for help and begging Resident #50 to let her go. She stated it was very difficult to remove her grip from S23ST's hair. She stated this attack was unprovoked and resulted in S23ST being injured from the stabbing and going to a local after hours emergent care center for treatment. She stated the therapy staff were inserviced on Resident #50's aggressive behaviors. She stated she did not know if the nurses and CNAs received inservices on Resident #50's aggressive behaviors. On 7/19/18 at 2:26 p.m., an interview was conducted with S8MDS. She stated she worked with Resident #50 since she was admitted to the facility. She stated she was not aware of Resident #50 having a switchblade in her possession on 5/29/18 and verbalizing her intent to use it on another resident because he kept wandering into her room. She stated that problems were recorded and communicated to administrative staff with incident reports and 24 hour reports. She stated there was no incident report regarding the switchblade on 5/29/18 and no staff conveyed this information to her verbally or by the 24 hour report. She stated this was the first she had heard of this incident. She stated she did not know about Resident #50 throwing a cup at another resident, hallucinating about a man being in her room trying to get into the attic or the hallucination of the three men at her window. She stated there had been a communication problem, and nursing service should work on a process for reporting these things to the MDS nurse and the DON. On 7/19/18 at 3:00 p.m., a telephone interview was conducted with S18DNP. She stated she could not recall Resident #50. S18DNP remained unable to recall Resident #50 after being asked if she was aware of the incidences of a switchblade being confiscated, the hallucinations of men in her room and the stabbing of a therapy staff member with a seam ripper. On 07/19/18 at 3:14 p.m., an interview was conducted with S2DON. She stated she had been the DON at this facility almost two years next month. She stated she did not know about the 5/29/18 incident where Resident #50 had a switchblade on her person and verbalized her intent to use it on another resident for coming into her room. She stated this was the first she had heard of the incident. She stated the nurse should have notified her of the incident by filing an incident report or entering a note on the 24 hour report but the nurse did not. She stated on 6/8/18 and 6/13/18 she knew of Resident #50 having incidences of hallucinations. She stated Resident #50 should have been care planned for the first incidence on 5/29/18 and was not. She stated the nurse failing to notify her or filing the incident on the 24 hour report was the break in the facility's notification system. She stated she did not know where Resident #50 would have gotten the weapons. She stated she did not know if the nurse took an accounting of what items were in her purse on the 5/29/18 switchblade incident. S2DON verified the facility had not monitored Resident #50 for aggressive behaviors or to see if the resident had sharp objects even after the 6/8/18 incident where she stabbed a therapist. After reviewing the clinical record, S2SDON confirmed the facility had not monitored Resident #50 for aggressive behaviors since she was admitted to the facility. On 7/19/18 at 3:45 p.m., a brief interview was conducted with S1Administrator. He verified that he did not know about the 5/29/18 incident where Resident #50 had a knife in her possession and verbalized she was going to use it on another resident. He stated there was not an incident report or a 24 hour report that he had seen. He verified he had just found out about it. On 7/20/18 at 5:30 a.m., an interview was conducted with S28CNA. She said she was assigned to C Hall. She verified Resident #50 resided on the C Hall. She stated to her knowledge no residents on C Hall were physically or verbally aggressive. She stated she had no training on aggression in the past few months. On 7/20/18 at 5:40 a.m., an interview was conducted with S29CNA. He stated he had worked at the facility for over two years. He verified he was assigned to Resident #50 on C Hall for this shift. He stated to his knowledge Resident #50 had never been physically or verbally aggressive. He stated he had to check on her every 2 hours to see if she needed anything. He stated no one had informed him Resident #50 was not allowed to have sharp objects. He stated he never had to check Resident #50 or her room for sharp objects. He stated he had not been instructed to change his care routine for Resident #50 in the last couple of months. He stated the facility had not provided training on aggressive behaviors in the last three months. On 7/20/18 at 5:45 a.m., an interview was conducted with S26LPN. She stated she had been working in the facility for almost seven years. She stated there was one incident that she received in report where the off-going nurse told her there was a switchblade in the narcotic drawer, and it belonged to Resident #50. She stated that Resident #50 was afraid of Resident #9 from the D Hall. She stated Resident #9 was going in her room. S26LPN explained the off-going nurse told her Resident #50 pulled a knife on Resident #9 and the knife was taken away from Resident #50 at that time. S26LPN stated she reported for duty another night when the off-going nurse told her about an incident regarding Resident #50 attacking a therapy staff. S26LPN said the off-going nurse explained that Resident #50 had an old timey fingernail file in her possession while in the therapy room, and Resident #50 pulled the therapist's ponytail and tried to stab her with the fingernail file. S26LPN stated the off-going nurse did not know what prompted the attack. S26LPN stated she had not personally searched Resident #50 or her room for any sharp objects at any time. S26LPN stated there was another incident on her shift where Resident #50 was hallucinating and seeing three men laughing and looking in her window. She stated Resident #50 would not go back in her room that night. S26LPN stated the nurses and CNAs were not and had not been monitoring Resident #50 for any sharp objects or aggressive behaviors. She stated there were no restrictions on what objects Resident #50 could have in her possession. S26LPN stated she had to monitor Resident #50 once a shift and the frequency of monitoring had not changed during Resident #50's stay at the facility. She stated if a new nurse or a PRN nurse was assigned to care for a resident they would only know that resident's history given in report or if they sat down to read their chart. She stated the way they communicate the behaviors being monitored for each resident was on the behavior monitoring form. After reviewing the behavior monitoring form, S26LPN verified Resident #50 was not being monitored for aggressive behaviors. She stated she had not received any training on aggressive behaviors in the last two months. She stated if there was a change in a resident's plan of care, there was no communication between her and the MDS nurse or management to notify her of the change. S26LPN stated she had not been notified to monitor Resident #50 for aggressive behaviors. On 7/20/18 at 6:17 a.m., an interview was conducted with S27CNA. She stated she had been working in the facility for two years and five months. She stated she had been working with Resident #50 since she was admitted . She stated she had never known her to be verbally or physically aggressive. She stated she did not know of any incidences involving Resident #50 being physically or verbally aggressive. She stated she did not know if Resident #50 was supposed to be monitored for aggressive behaviors, and she had not been notified to do so. She said she had never been notified to monitor Resident #50 or her room for sharp objects. On 7/20/18 at 6:39 a.m., an interview was conducted with S24CNA. She stated she had been working at the facility for two years. She stated she had worked with Resident #50 since she was admitted to the facility. She stated she had never seen or heard of Resident # 50 being physically or verbally aggressive. She stated she did not know of any incidents in the facility involving a resident stabbing anyone. She stated she was not notified of Resident #50 having a knife in her possession or trying to stab someone with a sharp object. She stated she did not have to monitor Resident #50 for sharp objects in her possession or in her room. She stated the facility had not provided any training on aggressive behaviors in the last three months. On 7/20/18 at 6:59 a.m., an interview was conducted with S30CNA. She stated she had been working at the facility for ten months. She stated she had worked with Resident #50 and described her as being confused at times. She stated Resident #50 was aggressive on one occasion in therapy with a butter knife and tried to stab a staff member but wasn't successful. She stated she did not monitor Resident #50 for possession of any sharp objects since she had not been instructed to do so. She stated she had not received any training on aggressive behaviors in the last three months. She stated she had not been notified to change the care she provided for Resident #50 in the last three months. On 7/20/18 at 7:25 a.m., an interview was conducted with S21CNA. She stated she was very familiar with Resident #50. She stated about a month ago Resident #50 was verbally abusive with her and cursing at her. She stated at this time Resident #50 was delusional by thinking S21CNA was plotting against her. She stated she did not know of any other incidences of Resident #50 being verbally or physically aggressive. She stated she had not been notified of any aggressive behaviors to monitor for or any item restrictions in relation to sharp objects with Resident #50. She stated she had not monitored Resident #50 or her room for sharp objects. She stated she had not had any training in the last two months related to aggressive behaviors. She stated there was no communication to let staff know how to care for their residents other than report. She stated she rounds on all her patients every two hours, and this would include Resident #50. On 7/20/18 at 8:01 a.m., an interview was conducted with S18LPN. She stated she had worked at this facility PRN for the last four years. She stated there was one incident she remembered where Resident #50 was confused and wandering. She stated she had not witnessed or been notified of Resident #50 being verbally or physically aggressive. She stated she could not recall monitoring her for aggressive behaviors. She stated she did not know of any item restrictions in relation to sharp objects regarding Resident #50. She stated she had not ever monitored Resident #50 or her room for sharp objects. She stated she was never notified to watch Resident #50 for any sharp objects in particular. She stated she had not had any training with the facility in the last two months on aggressive behaviors. She stated notification of a resident's care and needs were relayed by nurses during verbal report between shifts. On 7/20/18 at 10:55 a.m., an interview was conducted with Resident #50's niece, her responsible party. She stated her aunt lived with her family before she was admitted to the facility because she was experiencing some confusion. She stated the knife and the seam ripper were probably in her purse. She stated her aunt was a hoarder and likely brought those items from home. She stated the description of the knife by the staff was identical to the knife Resident #50's father had given her in the past. She stated her aunt was a very good seamstress in the past. She stated before her aunt was admitted to the facility she was always a calm person, [MEDICATION NAME] and honest. She stated she was never verbally or physically aggressive that she had ever known her to be. On 7/20/18 at 11:26 a.m., an interview was conducted with S14LPN. She stated the incident involving the switchblade was reported to her the next morning when she reported for duty. She stated the resident got upset that another resident had rolled in her room and the nurse removed the switchblade from her. She stated the nurse did not report where the knife came from. She stated that otherwise she had never known Resident #50 to be verbally or physically aggressive with anyone else. She stated she knew nothing about the stabbing of the therapist and was not notified. She stated she had not received notification of any change in Resident #50's care plan in relation to the stabbing incident. She stated they were not monitoring Resident #50 for aggressive behaviors because she did not have any. She stated she had not been notified about any object restrictions for Resident #50. She stated she could not recall any training in the last two months on aggressive behaviors. On 7/20/18 at 1:18 p.m., an interview was conducted with S22NP. She stated Resident #50 had been at this facility since (MONTH) (YEAR). She stated she had been caring for Resident #50 since she was admitted to the facility. She stated she was never notified and was unaware of the first incident with Resident #50 having a switchblade removed from her or threatening to use it on another resident because he was wandering into her room. She stated she was notified of Resident #50 stabbing a therapist with a seam ripper while in the therapy room. She stated Resident #50 was sent out for an emergent psychological evaluation and came back to the facility with no new orders. She stated, before the incident, there were new orders by the psych nurse practitioner to increase [MEDICATION NAME] 2.5 mg from once a day to twice a day. On 7/20/18 at 4:10 p.m., an interview was conducted with S31RegDir via telephone. He verified the staff should have been made aware of the incident on 5/29/18 when a switchblade was found on Resident #50's person as she verbalized her intent to use it on another resident because he was wandering into her room. He verified the staff should have been aware of the incident on 6/8/18 when Resident #50 stabbed a therapist in the shoulder with a seam ripper. He verified that staff should be monitoring Resident #50 for these behaviors. On 7/23/18 at 8:49 a.m., an interview was conducted with S2DON. She verified Resident #50 had an inventory list upon admit, dated 4/12/18, which revealed the following: 3 blouses, 2 nightgowns, 3 socks/hose, 3 underwear, 2 t-shirts, 2 jeans, 1 jogging pant, 1 case of medication, and 1 purse. She verified there were no notations of what the contents of her purse were. She verified that she would have been the one to perform staff trainings on aggressive behavior. She verified that there were no staff trainings in the last three months on aggressive behaviors. She verified the last training performed in the facility related to behaviors/dementia and reporting of incidents both took place on 4/26/18. She verified she did not feel like she needed to do staff training on aggressive behaviors with her staff because the incident happened in the therapy department. On 7/23/18 at 9:13 a.m., an interview was conducted with S31RegDir. He said staff had received training regarding Resident #50's behaviors. However, he verified the facility had no documentation to show that the nurses or CNAs had received training specifically for Resident #50's aggressive behaviors. He stated the facility could not produce documentation for who might have received training, who might have provided the training, when any trainings might have taken place or what the trainings en

Based on interviews and record reviews, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain and/or maintain the safety of each resident for 1 (#50) of 6 (#7, #9, #15, #28, #50 and #53) sampled residents reviewed for behaviors. Review of the Census and Condition Form dated 7/16/18 revealed a facility total census of 64 residents. The facility failed to: 1.) Implement its policies and procedures that direct staff to notify the physician, director of nurses, and administrator of hostile / assaultive behavior of resident; 2.) Ensure staff protect the residents in the facility from the potential of harm when they had knowledge that resident #50 possessed a switchblade and voiced threats to harm another resident; and 3.) Ensure staff were knowledgeable of resident #50's aggressive behaviors and competent on how to ensure the safety of the residents. The immediate jeopardy began on 5/29/18 at 6:50 p.m. when Resident #50 was found to have a switchblade in her possession and verbalized her intent to use it on another resident due to him entering her room. The nurse failed to notify the director of nurses, physician, and administrator of the incident. On 6/8/18 at 4:45 p.m., Resident #50 grabbed S23ST by her hair with one hand and used her other hand to stab S23ST in the back with a seam ripper. Interviews with staff revealed they were not aware of resident #50's history of aggressive behavior and/or to monitor her for sharp objects. The Administrator was notified of the Immediate Jeopardy on 7/20/18 at 3:36 p.m. regarding resident #50's behavior. The Immediate Jeopardy ended on 7/20/18 at 5:00 p.m. when S1Administrator provided a written plan of removal, which reads as follows: 1. What was identified? Staff education on monitoring resident behavior and monitoring for dangerous objects 2. Who else can be affected? Any other resident can be affected 3. Measures Staff were in-serviced on resident behaviors and monitoring. Staff also educated to notify ED and DON any time a threat is made or dangerous object is seen. In-services will happen weekly for 4 weeks. Resident will be placed on a 1:1 for monitoring X 72 hours. After 72 hours resident will be monitored Q1h X 7 days. 4. Monitoring ED will round resident's room twice per week to search resident and resident room for dangerous objects The deficit practice remains at a potential for more than minimal harm for all of the 64 residents in the facility. Findings: Refer to F689 Review of the facility policy, Unmanageable Residents, revealed the following in part: 1. Should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others the Nurse Supervisor/Charge Nurse must immediately: a. Provide for the safety of all concerned (i.e., move resident, equipment, etc.); b. Notify the resident's Attending Physician for instructions; c. Notify the Director of Nursing Services; 7. Complete documentation of the incident must be recorded in the resident's medical record and an incident report must be filed with the Administrator. Review of the facility policy, Accidents and Incidents - Investigating and Reporting, revealed the following in part: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 5. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. 6. The Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence. Review of the facility policy, Behavior Assessment and Monitoring, revealed the following in part: Assessment: 2. The nursing staff will identify, document, and inform the physician about an individual's mental status, behavior, and cognition, including: a. Onset, duration and frequency of problematic behaviors or changes in behavior, cognition, or mood. On 7/19/18 at 2:26 p.m., an interview was conducted with S8MDS. She stated she worked with Resident #50 since she was admitted to the facility. She stated she was not aware of Resident #50 having a switchblade in her possession on 5/29/18 and verbalizing her intent to use it on another resident because he kept wandering into her room. She stated that problems were recorded and communicated to the administrative staff with incident reports and 24 hour reports. She stated there was no incident report regarding the switchblade on 5/29/18 and no staff conveyed this information to her verbally or by the 24 hour report. She stated this was the first she had heard of this incident. She stated there had been a communication problem, and nursing service should work on a process for reporting these things to the MDS nurse and the DON. On 07/19/18 at 3:14 p.m., an interview was conducted with S2DON. She stated she had been the DON at this facility almost two years next month. She stated she did not know about the 5/29/18 incident, where Resident #50 had a switchblade on her person and verbalized her intent to use it on another resident for coming into her room. She stated this was the first she had heard of the incident. She stated the nurse should have notified her of the incident by filing an incident report or entering a note on the 24 hour report but the nurse did not. She stated the nurse failing to notify her or filing the incident in the 24 hour report was the break in the facility's notification system. On 7/19/18 at 3:45 p.m., a brief interview was conducted with S1Administrator. He verified that he did not know about the 5/29/18 incident where Resident #50 had a knife in her possession and verbalized she was going to use it on another resident. He stated there was not an incident report or a 24 hour report that he had seen. He verified he just found out about it. On 7/20/18 at 4:10 p.m., an interview was conducted with S31RegDir via telephone. He verified the staff should have been aware of the incident on 5/29/18 when a switchblade was found on Resident #50's person as she verbalized her intent to use it on another resident because he was wandering into her room. He verified the staff should have been aware of the incident on 6/8/18 when Resident #50 stabbed a therapist in the shoulder with a seam ripper. On 7/23/18 at 8:49 a.m., an interview was conducted with S2DON. She verified that she would have been the one to perform staff trainings on aggressive behavior. She verified that there were no staff trainings in the last three months on aggressive behaviors. She verified the last training performed in the facility related to behaviors/dementia and reporting of incidents, both took place on 4/26/18. She verified she did not feel like she needed to do staff training on aggressive behaviors with her staff because the incident regarding Resident #50 happened in the therapy department. On 7/23/18 at 11:07 a.m., an interview was conducted with S1Admin. He stated he was not notified of the incident on 5/29/18 with the switchblade and Resident #50 verbalizing her intent to use it on another resident wandering into her room. He stated the first he heard of the incidence was last week during this survey. He stated the break in the facility's reporting system with the 5/29/18 knife incident was that the nurse did not see any immediate danger. He stated he did not know if he would have wanted such an incident care planned or communicated to staff. He stated he did not feel like the administrative staff, management, nurse practitioner or MDS staff needed to know about the situation because he felt the nurse had handled it properly. He stated his current system for reporting had been in place since he began in this position about a year ago and had not undergone any changes.

Based on observations, record reviews, and interviews the facility failed to ensure the resident's physician was consulted with regarding wounds and pain from wounds for 3 (#1, #2, #8) of 10 residents (#1, #2, #3, #4, #6, #7, #8, #9, #10, #11) reviewed with wounds from a total sample of 11 residents. On 11/1/11, a Dermatologist lanced a fluid filled blister to Resident #2's right heel and ordered [MEDICATION NAME] BID and pressure relieving measures. Resident #2 was in Immediate Jeopardy after the 11/1/11 orders were received and the LPN treatment nurse and weekend treatment nurses failed to provide needed care and services including consultation with the physician regarding this right heel wound. For over 2 months, no one notified the physician or the RN supervisor. On 1/4/12, the right heel wound had progressed to an unstageable wound with eschar measuring 6cm (length) x 5cm (width) x 0.8cm (depth) with surrounding redness measuring 8cm (length) x 5cm (width). Resident #2 experienced untreated pain from the wound and grimaced and cried out when his right foot was touched. Resident #8 was admitted to the facility on [DATE] with eschar to the left foot on the 3rd, 4th, and 5th toes. He was in immediate jeopardy after admission on 10/7/11 when the LPN treatment nurse wrote orders for the wounds without consultation with the physician and no RN intervention occurred regarding consulting the physician. Resident #8 experienced an increase in wound severity with tunneling, drainage, and a foul odor. From 11/1/11 until 1/4/12, the staff the facility assigned to care for Resident #2, and from 10/7/11 until 1/4/12, the staff assigned to care for resident #8 and the ADON RN Supervisor, failed to: 1. notify and consult with the physician regarding changes in wound status (#2, #8); 2. notify and consult with the physician regarding pain from wounds (#2); 3. consult with the resident's physician to obtain wound care orders for resident #8 when the resident was admitted to the facility with eschar to his 3rd, 4th, and 5th toes of the left foot; 4. notify the physician of resident #1's refusal of wound treatment and dressing changes. This failure had the potential to harm six other residents with wounds (#4, #6, #7, #9, #10, #11 ) and placed them in Immediate Jeopardy. The administrator was notified of the Immediate Jeopardy on 1/6/12. The Immediate Jeopardy remained in place at exit. Findings: Review of the facility's policy entitled, "Policy and Procedure for the Prevention and treatment of [REDACTED]. Policy: It is the policy to properly identify and assess residents, either by an RN or under an RN's supervision, whose clinical conditions increase the risk for impaired skin integrity and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. II. treatment of [REDACTED]. If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented: 2. notify physician 3. notify supervisor 11. when a pressure ulcer is present, daily wound monitoring should include whether pain, if present , is being adequately controlled. 12. notify the physician, NP and supervisor if the ulcer(s) has not shown progress in 2-4 weeks and/or is deteriorating unexpectedly. Re-evaluate plan of care as appropriate. Resident #2: Review of the clinical record revealed resident #2 had a [DIAGNOSES REDACTED]. Review of the most recent MDS dated [DATE] revealed resident #2 had impaired range of motion to his upper and lower extremities and was totally dependent on staff for bed mobility and transfers. Review of the most recent Pressure Sore Risk assessment dated [DATE] revealed the resident scored a total score of "14" indicating he was a pressure sore risk. The resident was assessed as having "very limited" sensory perception - ability to respond meaningfully to pressure related discomfort. Review of the Nurse/Physician Communication Record completed by S3ADON on 10/25/11 revealed resident #2 had fluid filled blisters to multiple areas of the body that included the right heel. S3ADON further documented the resident had a temperature of 99.9 degrees axillary and was noted to be less alert than usual. Review of the Physician's Telephone Orders dated 10/25/11 included: 1. Cleanse blister areas with Normal Saline or Wound Cleanser, pat dry, apply Triple Antibiotic Ointment, cover with dressing, change every day. Diagnosis: [REDACTED]. 2. Dermatology consult... Diagnosis: [REDACTED]. Review of the Progress Note completed by the Nurse Practitioner on 10/26/11 revealed in part: Physical Examination: Skin: blister to ...heel Impression/Plan: [DIAGNOSES REDACTED] related to recent scabies - local care for now and follow up with Dermatologist. Review of the Nurse's Notes dated 10/27/11 revealed the resident had a temperature of 99.8 degrees axillary and was "not looking very well". The Nurse Practitioner was notified and ordered to send the resident to the emergency room for evaluation and treatment. Review of the hospital records revealed resident #2 was admitted to the hospital and treated for [REDACTED]. Review of the hospital's History and Physical dated 10/27/11 revealed in part: Dermatology: ... early pressure ulcers on his left foot as well as more prominent on his right heel. Review of the hospital Discharge Summary dated 10/30/11 included: Pressure Ulcers: The patient presented with multiple early pressure sites... Wound ostomy nurses were consulted and initiated treatment here which included turning every two hours, floating heels off the bed, having a specialty bed. Recommended cleaning the right heel with soap and water, apply Lidoflex pad to blister, cover with 4 x 4... Recommend continuing his wound care at the nursing home facility. Review of the hospital's Discharge Worksheet dated 10/30/11 and timed for 0915 (9:15 a.m.) included: Discharge Education and Instructions: (2) Wound care as outlined by our W.O.N. (wound ostomy nurse). Review of the discharge Medication List included Wound Care of the right heel as follows: Cleanse with soap and water, dry thoroughly, apply Lidoflex pad, cover with 4 x 4, wrap with conforming gauze, change every 48 hours. Review of the Admission and Physician's Telephone Orders dated 10/30/11 included no documentation of wound care for resident #2's right heel. Review of the Nurse's Note dated 10/30/11 revealed a re-admission skin assessment of resident #2. The resident's right heel was not mentioned within the note. Review of the Weekly Skin Condition Evaluation dated 10/30/11 revealed no documentation related to the resident's right heel. Review of the Nurse's Note made by S4LPN Treatment Nurse on 10/31/11 included resident #2's right heel was noted with a "100% blood filled blister". Review of the October 2011 Wound Treatment Evaluation Record revealed the treatment that was performed to resident #2's right heel on 10/31/11 was as follows: clean with wound cleaner or normal saline, pat dry, apply TAO, cover with DCD. On 11/1/11, resident #2 was seen by the Dermatologist as ordered on [DATE]. Review of the Dermatology Note dated 11/1/11 was noted by S4LPN Treatment Nurse and included: Large bullae to right heel medially. Impression: Pressure Bullae Recommendations: Drained; [MEDICATION NAME] ointment BID, pressure avoidance. Review of the Physician's Telephone Order dated 11/1/11 revealed in part: 1. D/C Triple Antibiotic Ointment 2. Apply [MEDICATION NAME] ointment BID to right heel Review of the Skin Risk Evaluation and Plan of Care included 11/1/11: Pressure Bullue to right heel - Goal date 2/1/12 There were no interventions on the Plan of Care related to the right heel. There was no documentation of "pressure avoidance" as recommended by the dermatologist. The Plan of Care did not indicate the resident was at risk of developing a pressure sore as determined on 10/17/11. Review of the Nurse's Notes made by S4LPN Treatment Nurse revealed in part the following: 11/1/11: Resident returned from Dermatology appointment ... Right heel Pressure Bullae was drained ... Right heel 50% tan and 50% purple wound bed with little bloody drainage. Excess skin covers wound bed. Area moist without odor noted ... 11/4/11: ... Right heel wound bed 80% tan dry tissue in center of wound with 20% purple dry tissue around wound edges ... Resident tolerated treatment well without complaints of pain ... 11/7/11: ... Right heel 100% dry purple tissue ... Resident tolerated well without complaints of pain ... 11/17/11: ... Right heel 75% dry purple skin and 25% dry tan skin ... Resident tolerated well without complaints of pain ... 11/23/11: ...Right heel wound bed 60% purple dry skin and 40% tan dry skin ... Resident tolerated well without complaints of pain ... 11/28/11: ...Right heel wound bed 90% purple dry skin and 10% tan dry skin ... No complaints of pain voiced by resident ... 12/1/11: ...Right heel 100% purple/tan dry skin ... Resident tolerated well without complaints of pain ... 12/7/11: ...Right heel wound bed 90% purple hard dry skin with 10% tan hard dry skin to center. No drainage ... Resident tolerated well without complaints of pain ... 12/12/11: ...Right heel wound bed 90% purple hard dry skin with 10% tan hard dry skin in center. No drainage ... Resident tolerated well without complaints of pain ... 12/13/11: ...70% of dry purple/tan hard skin fell off during dressing change. 70% of wound bed red moist tissue with 30% hard, dry purple/tan skin towards edges of wound bed. No drainage ... Resident tolerated well without complaints of pain ... 12/15/11: ...50% dry purple/tan tissue/skin to wound bed. Noted with faint amount of bloody drainage. Resident tolerated well without complaints of pain ... 12/20/11: ...Right heel wound bed 50% moist red tissue with 50% dry purple tissue. Tiny amount of bloody drainage ... Resident tolerated treatment well without complaints of pain ... 12/22/11: ...Right heel ... 70% dry purple skin tissue in center of wound bed and 30% moist red tissue surrounding dry purple scar tissue ... Resident tolerated well without complaints of pain ... 12/29/11: ...Right heel wound bed 50% hard purple skin with 50% moist red skin ... Resident tolerated well without complaints of pain ... 1/2/12: ...Right heel wound bed 50% hard purple skin tissue and 50% moist red skin tissue. No drainage ... Resident voiced no complaints of pain ... 1/4/12: ...Right heel wound bed 50% hard dry purple tissue with faint amount of brown drainage. 50% red moist tissue surrounding hard, dry purple tissue without drainage ... Resident tolerated treatment well with complaints of pain only when touched ... Review of the Wound Treatment Evaluation Records for October 2011 through January 2012 revealed no measurements were made of resident #2's right heel by S3ADON. On 1/4/12 at 9:20 a.m. an observation was made of resident #2's skin with S4LPN Treatment Nurse. Resident #2 mumbled when he saw S4LPN Treatment Nurse. She responded to the resident with, "I know you hate to see me because you know what I'm about to do will hurt". The resident was observed to be in the same position he had been in during the previous observation at 8:45 a.m. His right heel continued to be in direct contact with the mattress. In preparation of the treatment to the resident's right heel, S4LPN Treatment Nurse elevated his right heel off the mattress with a pillow. S4LPN Treatment Nurse removed the dressing to resident #2's right heel. There was a small amount of light brown drainage to the old dressing. The right medial heel was noted to have a large piece of eschar that was surrounded by reddened skin. The lower portion of the eschar, by the lower heel, had edges that were lifting. This left a small open area between the eschar edge and the surrounding red tissue. During the observation, an interview was held with S4LPN Treatment Nurse. She described resident #2's right heel as deep purple with surrounding red blanchable tissue. When S4LPN Treatment Nurse was asked specifically about the eschar to resident #2's right heel, she again responded that she classified the area as "deep purple". She further stated the right heel has had that appearance for three to four weeks. S4LPN Treatment Nurse proceeded to provide wound care, which consisted of cleaning the wound with normal saline, applying [MEDICATION NAME], covering the wound with clean gauze and wrapping with Perplex. Throughout the observation, resident #2 verbalized complaints of pain. The resident was noted with facial grimacing and cried out each time S4LPN Treatment Nurse touched his right foot. An interview was held with S4LPN Treatment Nurse on 1/4/12 at 10:00 a.m. She stated she worked Monday through Friday from 4:30 a.m. to 12:30 p.m. She stated she had been the treatment nurse for approximately six months. She said the facility provided wound training prior to her becoming the treatment nurse. She stated that she developed and revised skin related care plans. She said she updated resident's care plan when a new order was received. She explained that all wounds were measured and staged by S3ADON. She said that she notified S3ADON when a wound needed to be measured or staged. She said she and S3ADON communicated only verbally regarding wounds. She explained that resident #2's right heel had originated as a blister. She said the resident was seen by a Dermatologist and was diagnosed with [REDACTED]. She said "pressure bullae" was described to her as being an immune system illness. She further stated that resident #2's right heel was not considered to be a "pressure" wound since it was previously diagnosed as a "pressure bullae". She said the interventions ordered by the Dermatologist were [MEDICATION NAME] and pressure relief. She further stated that she had not notified S3ADON of resident #2's right heel wound because the wound was not a "pressure wound". When asked if she had notified the physician when the resident's right heel wound changed in appearance (according to her that was three to four weeks ago), S4LPN Treatment Nurse stated she had not notified the physician. She stated that the resident's right heel should be elevated off of the mattress to help with pressure relief. She explained that pillows, rolls, or wedges could be used to elevate the resident's right heel. She stated that resident #2 complained of pain each time she provided wound care. She said the resident "hated" to see her because he related her to pain. She stated the resident's medication nurse pre-medicated the resident prior to wound care. S4LPN Treatment Nurse stated that she did not know what medication the resident received for pain. She further stated that she had not notified the physician or the medication nurse when the resident continued to complain of pain during wound care. She verified she documented the resident did not complain of pain because she thought the resident was pre-medicated prior to wound care. She reviewed resident #2's skin plan of care and verified it had not been updated with interventions for the risk of pressure ulcers determined during his quarterly assessment on 10/17/11; the dermatology recommendations for pressure avoidance on 11/1/11; changes in wound appearance; or the resident's complaints of pain. On 1/4/12 at 11:20 a.m. an interview was held with S3ADON. She stated that she was responsible for weekly measurements of wounds and staging of pressure wounds. She stated that S4LPN Treatment Nurse notified her verbally of any wounds that needed assessing. S3ADON stated that she was not aware of resident #2 having a wound to his right heel. She recalled that "awhile back" the resident had multiple blisters. She stated that S4LPN Treatment Nurse had not informed her of resident's right heel wound. An observation was made of resident #2's right heel with S3ADON on 1/4/12 at 11:25 a.m. Resident #2 was observed to be lying in bed on his back with his right heel lying directly on the mattress in the same position the resident was in during previous observations at 8:45 a.m. and 9:20 a.m.. S3ADON removed the dressing from resident #2's right heel. Resident #2 was observed to have facial grimacing and verbalize complaints of pain each time S3ADON touched his right foot. S3ADON asked the resident if his foot hurt, and resident #2 responded "yes". S3ADON assessed the resident's right heel and when asked to describe the right heel wound, she replied, "That's eschar". S3ADON stated the surrounding tissue was red and the lower portion of the heel was "spongy" with a "deep purple" color. S3ADON measured the wound and the following measurements were noted: eschar measured 6cm (length) x 5cm (width) x 0.8cm (depth) and surrounding redness measured 8cm (length) x 5cm (width). S3ADON stated she should have been notified of the resident's heel wound. She stated that she did not feel that [MEDICATION NAME] was appropriate treatment for [REDACTED]. On 1/4/12 at 11:50 a.m. an interview was held with S12LPN. She verified she was the routine medication nurse for resident #2. She stated that resident #2 was not ordered any medications for pain. She said that the resident had not complained of pain to her. She further stated that S4LPN Treatment Nurse had not informed her that resident #2 needed pre-medicating for pain prior to wound care. Review of the November 2011 through January 2012 physician's orders [REDACTED].#2 during that time. Review of the Nurse's Note dated 1/4/12 and timed for 1150 (11:50 a.m.) revealed documentation of S3ADON's assessment of resident #2's heel. The Note included the following: Report received of right heel wound - area assessed. "Eschar 5cm x 6cm c (with) 1/8cm depth at inferior medial edge. Adjacent to that 5 x 8 crescent shaped area, red and blanchable at superior aspect, spongy purple at inferior aspect. Resident expressed pain upon palpitation ...". Review of the Physician's Telephone Orders dated 1/4/12 and timed for 1158 (11:58 a.m.) revealed the following orders for the right heel wound: 1. Cleanse area with wound cleanser and pat dry. 2. Apply Hydrogel. 3. Cover with Optiform or other foam dressing. 4. Change daily and PRN. 5. Foam heel booties to both feet at all times. 6. [MEDICATION NAME] (non-narcotic pain reliever) 1 per PEG tube every 6 hours PRN pain. An interview was held with S2DON on 1/5/12 at 8:30 a.m. She stated that S3ADON had informed her of resident #2 experiencing pain when his right foot was touched and that his right heel had eschar. S2DON verified that prior to 1/4/12 the resident's heel had only been treated with [MEDICATION NAME]. She also verified resident #2 did not have any medications ordered for pain relief prior to 1/4/12. She stated S4LPN Treatment Nurse should have notified the physician when the resident's heel declined and the treatment should have been changed. S2DON stated that if a wound had not made progress within a couple of weeks or if a wound declined suddenly, the physician should be notified. S2DON stated it was S4LPN Treatment Nurse responsibility to assess a resident for pain prior, during, and after wound care. She said S4LPN Treatment Nurse should notify the medication nurse of any reported pain and if the resident has pain medication ordered, then the resident should receive the medication, and if the resident does not have pain medication ordered, S4LPN Treatment Nurse should notify the physician. S2DON stated S4LPN Treatment Nurse was responsible for updating a resident's care plan when changes occurred with their skin or wound. She reviewed resident #2's care plan and verified it had not been updated on 11/1/11 with interventions of pressure relief for his right heel as recommended by the dermatologist, changes in wound appearance, or the pain related to the wound. S2DON verified S4LPN Treatment Nurse was provided wound care training prior to becoming the treatment nurse. On 1/5/12 at 9:25 a.m. an interview was held with S4LPN Treatment Nurse. She stated that she always informed the CNAs of skin care interventions specific for each resident. She stated she verbally communicated to the CNAs that resident #2's needed bilateral heel protectors on at all times. An observation was made of S13CNA providing assistance to resident #2 on 1/5/12 at 9:35 a.m. During the observation, resident #2 was sitting in a wheelchair as S13CNA combed his hair. The resident's wheelchair was observed to have one leg rest to the left side of the chair. Resident #2 was wearing socks and had his left foot positioned on the leg rest and his right foot positioned flat on the floor. An interview was held with S13CNA during the observation and she verified the resident had a wound to his right heel. When asked if there were any pressure relieving interventions provided for his heel, S13CNA stated that the resident was turned every two hours. When the question was rephrased and S13CNA was asked if the resident was supposed to wear heel protectors, she stated not that she knew of. On 1/5/12, observations were made of resident #2 sitting in a wheelchair near the nurses' station from 9:45 a.m. to 1:20 p.m. The resident's left foot was positioned on the leg rest of the wheelchair and his right foot was positioned on the floor. The resident was wearing socks, but he did not have on heel protectors. At 1:20 p.m., nursing staff applied heel protectors to the resident's bilateral heels. Observations continued of resident #2 on 1/5/12, and between 2:00 p.m. and 3:00 p.m. the resident was observed rubbing his right leg. During this time, the resident was passed by nursing staff, including S12LPN, who stopped the resident from pulling on his PEG tube, but did not ask him anything else. At 2:55 p.m., an interview was held with resident #2. During the interview, he continued to rub his right leg. The resident requested a pillow to place beneath his right foot. During the interview, S15CNA approached resident #2 and the resident informed S15CNA that he wanted a pillow to place beneath his right foot. S15CNA asked the resident if he was ready to return to bed, and the resident responded "yes". At 3:00 p.m., resident #2 was taken to his room. S9CNA Supervisor, S15CNA, S16CNA and S17LPN were in the resident's room. At 3:05 p.m., the resident was observed rubbing his right leg when S16CNA asked him if his leg was hurting. The resident responded "my foot hurts on the bottom" while pointing to his right foot. At 3:10 p.m., the resident was assisted to bed requiring total assistance during the transfer from the wheelchair to the bed. Once in bed, the resident was noted with facial grimacing and he continued to point at his right foot. With S17LPN at the resident's bedside observing the resident, S15CNA asked the resident what was wrong. The resident stated "my foot" while pointing at his right foot. At 3:20 p.m., S17LPN was observed to leave the room and go to the medication cart. An interview was held with S16CNA on 1/5/12 at 3:30 p.m. She stated that CNAs obtained knowledge of specific interventions for each resident by reviewing the resident's Kardex. She stated each resident had a Kardex specific to their needs that was maintained for the CNAs. She verified the Kardex would include if a resident should have heel protectors in place. S16CNA further stated that she would not know that resident #2 was to have heel protectors on unless she reviewed the Kardex. Upon request of resident #2's Kardex, S16CNA was unable to locate it. She further stated that she had not been notified by a nurse that he was to have heel protectors on at all times. On 1/5/12 at 3:45 p.m. an interview was held with S2DON. She verified each resident had a Kardex that included information specific to their needs. She explained the Kardex was to be utilized by the CNAs. Upon searching the nurses' station for resident #2's Kardex, she was unable to locate it. She questioned S9CNA Supervisor regarding the whereabouts of the Kardex for resident #2 and S9CNA Supervisor stated all Kardexs for that hall were in the DON/ADON's office. S2DON located resident #2's Kardex within her office and stated that the ADON was going to review each Kardex before placing them back on the unit. When asked how the CNAs were to know that resident #2 was to have heel protectors on at all times, S2DON stated the resident's nurse and treatment nurse should notify the CNAs when orders were received regarding pressure relief. She verified the order for heel protectors was received on 1/4/12 and that she had witnessed the resident without heel protectors on 1/5/12 while sitting near the nurses' station. S2DON further stated that each resident was to be assessed for pain by their assigned medication nurse during medication pass and upon rounds. She said if a resident complains of pain, the nurse was to assess the location and intensity of the pain prior to medication and after. She said the nurse should document a resident's complaints of pain on the medication record and nurse's notes. On 1/6/12, review of the January 2012 Medication Record revealed resident #2 was administered [MEDICATION NAME] for pain on 1/5/12 at 7:00 a.m. The resident had not been treated for [REDACTED]. Review of the Nurse's Notes revealed no documentation of an evaluation or interventions for resident #2's right foot pain for 1/5/12 at 3:05 p.m. Resident #8: Review of the Standing Nursing Home Orders revealed, in part, the following related to Skin Care: 3. Stage 1 Decutitus-redness 0 pressure to the area. Use pressure relieving devices as needed ... 4. Stages II, II, IV: notify MD/NP on routine rounds ? Without eschar (100% granulation tissue) clean daily with normal saline or Wound cleanser apply Hydrogel to area, cover with damp 4X4. Cover with dry, clean dressing ? With Slough (minimal drainage). Clean daily with wound cleanser or normal saline, apply calcium alginate or santyl. Cover with damp 4X4 and dry, clean dressing. ? With Slough (moderate to heavy drainage). Clean twice a day and as needed with normal saline or wound cleanser, apply calcium alginate or santyl and cover with dry, clean dressing. 6. Report all purulent wound drainage/odor ... Review of the clinical record for resident #8 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes for the resident dated 10/7/11, revealed the resident was admitted to the facility with eschar to the 3rd, 4th and 5th toes on his left foot. Review of the Wound Treatment Evaluations for the month of October 2011-January 2012, for the wounds to the 3rd, 4th, and 5th toes of the left foot, revealed the following: No entries were made regarding the wounds from 10/7/11 through 10/16/11. Entries were made dated 10/17/11 for the wounds to the 3rd, 4th, and 5th toes of the left foot by S3ADON. All three wounds were listed as "unstageable" under the section "If pressure ulcer-Stage". There were no other assessments or measurements documented, by S3ADON, of the toes to the left foot on the wound treatment record from 10/18/11 through 1/4/12. Entries were made by S4LPN Treatment Nurse dated 10/17/11 and 10/18/11 which described all three toe wounds as "Black". These same entries showed the wounds were treated on these dates with wound cleaner, normal saline, pat dry, apply Santyl, cover with a dry/clean dressing. Check daily, change every day and as needed. This treatment was discontinued on 10/19/11 and monitoring of all three toe wounds for changes every day and as needed was started. No treatments were preformed to the wounds of the 3rd, 4th, and 5th toes on the left foot from 10/19/11-12/14/11. Review of the MDS dated [DATE] revealed under Section M-Skin Conditions: F. 1). Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar- 1 2). Number of these unstageable pressure ulcers that were present upon admission/reentry-enter how many were noted at the time of admission- 1 Review of a Podiatrist Consultation, dated 12/7/11, for the resident revealed a sharp excision of loose eschar on 3rd and 4th toes of left foot was performed and [MEDICATION NAME] ointment was applied. Further review of the Wound Treatment Evaluations for the month of October 2011-January 2012, for the wounds to the 3rd, 4th, and 5th toes of the left foot, revealed the following: On 12/15/11, treatment was started again to the 3rd and 4th toes of the left foot with wound cleanser/normal saline, pat dry, apply Santyl and cover with dry, clean dressing. Check daily; change every day, and as needed. This treatment was documented daily from 12/15/11 through 12/29/11. Monitoring of the 5th toe continued without treatment. On 12/30/11-1/5/12 the treatment was changed to clean with wound cleanser/normal saline, pat dry, apply [MEDICATION NAME], cover with a dry clean dressing, change every day, and as needed. Review of the Nurse's Notes for the resident revealed no entries were made about the wounds to the toes on the left foot from 10/8/11 through 10/16/11. Further review of the Nurse's Notes revealed the following entries were made on the Nurse's Notes by S4LPN Treatment Nurse: 10/17/11 1:35 p.m. Informed by hall nurse that resident has something on his toes. Evaluated resident's toes with ADON and observed unstageable wounds to left foot 3rd, 4th, and 5th toes. All three toes wound beds covered in eschar. Cleaned with wound cleanser, pat dried, applied Santyl and covered with, dry, clean dressing. Will continue to monitor. 10/19/11 at 8:00 a.m. Order changes for left foot 3rd, 4th, and 5th toe; discontinue treatment of [REDACTED]. New orders are to monitor areas every day for changes per DON and ADON as discussed in morning nurses meeting. These areas are not pressures. They are unstageable wounds with complete eschar. No treatment is needed at this time. Wounds will be monitored daily for changes. Will continue to follow up. 10/21/11 7:45 a.m. Evaluated the following wounds on resident. Left foot 3rd, 4th and 5th toes. Top of all three toes still black with no changes. Texture is leathery without open areas... 11/1/11 9:45 a.m. ...left foot 3rd, 4th and 5th toes brown with macerated dry surrounding skin.. 11/17/11 7:50 a.m. ...left foot 3rd, 4th and 5th toes wound beds 100% brown eschar with macerated surrounding skin. No color/drainage noted. Will continue to monitor. 11/21/11 8:40 a.m. ... left foot 3rd, 4th and 5th toes wound beds 100% brown, leathery eschar with macerated surrounding skin. No odor/drainage noted. Will continue to monitor. 11/23/11 8:40 a.m. No change in appearance/condition of wounds. 12/5/11 10:30 a.m. ...left foot 3rd, 4th and 5th toes brown leathery eschar to all toes without odor/drainage noted... Will continue to monitor. 12/12/11 8:10 a.m. Left foot 3rd, 4th and 5th toes no change in appearance/condition to wounds. Will continue to monitor. 12/15/11 9:45 a.m. ...Orders changed to left foot 3rd and 4th toes. Left foot 3rd toe wound bed 60% yellow hard skin, 20% black hard skin and 20% red moist skin towards wound edges. Wound moist with tiny amount of purulent exudates. Left foot 4th toe is the same condition as the 3rd toe... 12/19/11 7:40 a.m. ... left foot 3rd toe wound bed 50% brown dry skin tissue in center of wound with 50% yellow moist skin tissue towards wound edges. Faint amount of purulent drainage noted. Left foot 4th toe wound bed 50% dry purple skin tissue wi

Based on observations, record reviews, and interviews the facility failed to ensure the resident's physician was consulted with regarding wounds and pain from wounds for 3 (#1, #2, #8) of 10 residents (#1, #2, #3, #4, #6, #7, #8, #9, #10, #11) reviewed with wounds from a total sample of 11 residents. On 11/1/11, a Dermatologist lanced a fluid filled blister to Resident #2's right heel and ordered [MEDICATION NAME] BID and pressure relieving measures. Resident #2 was in Immediate Jeopardy after the 11/1/11 orders were received and the LPN treatment nurse and weekend treatment nurses failed to provide needed care and services including consultation with the physician regarding this right heel wound. For over 2 months, no one notified the physician or the RN supervisor. On 1/4/12, the right heel wound had progressed to an unstageable wound with eschar measuring 6cm (length) x 5cm (width) x 0.8cm (depth) with surrounding redness measuring 8cm (length) x 5cm (width). Resident #2 experienced untreated pain from the wound and grimaced and cried out when his right foot was touched. Resident #8 was admitted to the facility on [DATE] with eschar to the left foot on the 3rd, 4th, and 5th toes. He was in immediate jeopardy after admission on 10/7/11 when the LPN treatment nurse wrote orders for the wounds without consultation with the physician and no RN intervention occurred regarding consulting the physician. Resident #8 experienced an increase in wound severity with tunneling, drainage, and a foul odor. From 11/1/11 until 1/4/12, the staff the facility assigned to care for Resident #2, and from 10/7/11 until 1/4/12, the staff assigned to care for resident #8 and the ADON RN Supervisor, failed to: 1. notify and consult with the physician regarding changes in wound status (#2, #8); 2. notify and consult with the physician regarding pain from wounds (#2); 3. consult with the resident's physician to obtain wound care orders for resident #8 when the resident was admitted to the facility with eschar to his 3rd, 4th, and 5th toes of the left foot; 4. notify the physician of resident #1's refusal of wound treatment and dressing changes. This failure had the potential to harm six other residents with wounds (#4, #6, #7, #9, #10, #11 ) and placed them in Immediate Jeopardy. The administrator was notified of the Immediate Jeopardy on 1/6/12. On January 20, 2012, the facility presented a plan or removal which included physician consultation. Surveyors determined the Immediate Jeopardy was removed on January 23, 2012. The deficient practice continues at patterns of actual harm for residents #2 and #8 and a potential for more than minimal harm for residents #4, #6, #7, #9, #10, and #11. Findings: Review of the facility's policy entitled, "Policy and Procedure for the Prevention and treatment of [REDACTED]. Policy: It is the policy to properly identify and assess residents, either by an RN or under an RN's supervision, whose clinical conditions increase the risk for impaired skin integrity and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. II. treatment of [REDACTED]. If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented: 2. notify physician 3. notify supervisor 11. when a pressure ulcer is present, daily wound monitoring should include whether pain, if present , is being adequately controlled. 12. notify the physician, NP and supervisor if the ulcer(s) has not shown progress in 2-4 weeks and/or is deteriorating unexpectedly. Re-evaluate plan of care as appropriate. Resident #2: Review of the clinical record revealed resident #2 had a [DIAGNOSES REDACTED]. Review of the most recent MDS dated [DATE] revealed resident #2 had impaired range of motion to his upper and lower extremities and was totally dependent on staff for bed mobility and transfers. Review of the most recent Pressure Sore Risk assessment dated [DATE] revealed the resident scored a total score of "14" indicating he was a pressure sore risk. The resident was assessed as having "very limited" sensory perception - ability to respond meaningfully to pressure related discomfort. Review of the Nurse/Physician Communication Record completed by S3ADON on 10/25/11 revealed resident #2 had fluid filled blisters to multiple areas of the body that included the right heel. S3ADON further documented the resident had a temperature of 99.9 degrees axillary and was noted to be less alert than usual. Review of the Physician's Telephone Orders dated 10/25/11 included: 1. Cleanse blister areas with Normal Saline or Wound Cleanser, pat dry, apply Triple Antibiotic Ointment, cover with dressing, change every day. Diagnosis: [REDACTED]. 2. Dermatology consult... Diagnosis: [REDACTED]. Review of the Progress Note completed by the Nurse Practitioner on 10/26/11 revealed in part: Physical Examination: Skin: blister to ...heel Impression/Plan: [DIAGNOSES REDACTED] related to recent scabies - local care for now and follow up with Dermatologist. Review of the Nurse's Notes dated 10/27/11 revealed the resident had a temperature of 99.8 degrees axillary and was "not looking very well". The Nurse Practitioner was notified and ordered to send the resident to the emergency room for evaluation and treatment. Review of the hospital records revealed resident #2 was admitted to the hospital and treated for [REDACTED]. Review of the hospital's History and Physical dated 10/27/11 revealed in part: Dermatology: ... early pressure ulcers on his left foot as well as more prominent on his right heel. Review of the hospital Discharge Summary dated 10/30/11 included: Pressure Ulcers: The patient presented with multiple early pressure sites... Wound ostomy nurses were consulted and initiated treatment here which included turning every two hours, floating heels off the bed, having a specialty bed. Recommended cleaning the right heel with soap and water, apply Lidoflex pad to blister, cover with 4 x 4... Recommend continuing his wound care at the nursing home facility. Review of the hospital's Discharge Worksheet dated 10/30/11 and timed for 0915 (9:15 a.m.) included: Discharge Education and Instructions: (2) Wound care as outlined by our W.O.N. (wound ostomy nurse). Review of the discharge Medication List included Wound Care of the right heel as follows: Cleanse with soap and water, dry thoroughly, apply Lidoflex pad, cover with 4 x 4, wrap with conforming gauze, change every 48 hours. Review of the Admission and Physician's Telephone Orders dated 10/30/11 included no documentation of wound care for resident #2's right heel. Review of the Nurse's Note dated 10/30/11 revealed a re-admission skin assessment of resident #2. The resident's right heel was not mentioned within the note. Review of the Weekly Skin Condition Evaluation dated 10/30/11 revealed no documentation related to the resident's right heel. Review of the Nurse's Note made by S4LPN Treatment Nurse on 10/31/11 included resident #2's right heel was noted with a "100% blood filled blister". Review of the October 2011 Wound Treatment Evaluation Record revealed the treatment that was performed to resident #2's right heel on 10/31/11 was as follows: clean with wound cleaner or normal saline, pat dry, apply TAO, cover with DCD. On 11/1/11, resident #2 was seen by the Dermatologist as ordered on [DATE]. Review of the Dermatology Note dated 11/1/11 was noted by S4LPN Treatment Nurse and included: Large bullae to right heel medially. Impression: Pressure Bullae Recommendations: Drained; [MEDICATION NAME] ointment BID, pressure avoidance. Review of the Physician's Telephone Order dated 11/1/11 revealed in part: 1. D/C Triple Antibiotic Ointment 2. Apply [MEDICATION NAME] ointment BID to right heel Review of the Skin Risk Evaluation and Plan of Care included 11/1/11: Pressure Bullue to right heel - Goal date 2/1/12 There were no interventions on the Plan of Care related to the right heel. There was no documentation of "pressure avoidance" as recommended by the dermatologist. The Plan of Care did not indicate the resident was at risk of developing a pressure sore as determined on 10/17/11. Review of the Nurse's Notes made by S4LPN Treatment Nurse revealed in part the following: 11/1/11: Resident returned from Dermatology appointment ... Right heel Pressure Bullae was drained ... Right heel 50% tan and 50% purple wound bed with little bloody drainage. Excess skin covers wound bed. Area moist without odor noted ... 11/4/11: ... Right heel wound bed 80% tan dry tissue in center of wound with 20% purple dry tissue around wound edges ... Resident tolerated treatment well without complaints of pain ... 11/7/11: ... Right heel 100% dry purple tissue ... Resident tolerated well without complaints of pain ... 11/17/11: ... Right heel 75% dry purple skin and 25% dry tan skin ... Resident tolerated well without complaints of pain ... 11/23/11: ...Right heel wound bed 60% purple dry skin and 40% tan dry skin ... Resident tolerated well without complaints of pain ... 11/28/11: ...Right heel wound bed 90% purple dry skin and 10% tan dry skin ... No complaints of pain voiced by resident ... 12/1/11: ...Right heel 100% purple/tan dry skin ... Resident tolerated well without complaints of pain ... 12/7/11: ...Right heel wound bed 90% purple hard dry skin with 10% tan hard dry skin to center. No drainage ... Resident tolerated well without complaints of pain ... 12/12/11: ...Right heel wound bed 90% purple hard dry skin with 10% tan hard dry skin in center. No drainage ... Resident tolerated well without complaints of pain ... 12/13/11: ...70% of dry purple/tan hard skin fell off during dressing change. 70% of wound bed red moist tissue with 30% hard, dry purple/tan skin towards edges of wound bed. No drainage ... Resident tolerated well without complaints of pain ... 12/15/11: ...50% dry purple/tan tissue/skin to wound bed. Noted with faint amount of bloody drainage. Resident tolerated well without complaints of pain ... 12/20/11: ...Right heel wound bed 50% moist red tissue with 50% dry purple tissue. Tiny amount of bloody drainage ... Resident tolerated treatment well without complaints of pain ... 12/22/11: ...Right heel ... 70% dry purple skin tissue in center of wound bed and 30% moist red tissue surrounding dry purple scar tissue ... Resident tolerated well without complaints of pain ... 12/29/11: ...Right heel wound bed 50% hard purple skin with 50% moist red skin ... Resident tolerated well without complaints of pain ... 1/2/12: ...Right heel wound bed 50% hard purple skin tissue and 50% moist red skin tissue. No drainage ... Resident voiced no complaints of pain ... 1/4/12: ...Right heel wound bed 50% hard dry purple tissue with faint amount of brown drainage. 50% red moist tissue surrounding hard, dry purple tissue without drainage ... Resident tolerated treatment well with complaints of pain only when touched ... Review of the Wound Treatment Evaluation Records for October 2011 through January 2012 revealed no measurements were made of resident #2's right heel by S3ADON. On 1/4/12 at 9:20 a.m. an observation was made of resident #2's skin with S4LPN Treatment Nurse. Resident #2 mumbled when he saw S4LPN Treatment Nurse. She responded to the resident with, "I know you hate to see me because you know what I'm about to do will hurt". The resident was observed to be in the same position he had been in during the previous observation at 8:45 a.m. His right heel continued to be in direct contact with the mattress. In preparation of the treatment to the resident's right heel, S4LPN Treatment Nurse elevated his right heel off the mattress with a pillow. S4LPN Treatment Nurse removed the dressing to resident #2's right heel. There was a small amount of light brown drainage to the old dressing. The right medial heel was noted to have a large piece of eschar that was surrounded by reddened skin. The lower portion of the eschar, by the lower heel, had edges that were lifting. This left a small open area between the eschar edge and the surrounding red tissue. During the observation, an interview was held with S4LPN Treatment Nurse. She described resident #2's right heel as deep purple with surrounding red blanchable tissue. When S4LPN Treatment Nurse was asked specifically about the eschar to resident #2's right heel, she again responded that she classified the area as "deep purple". She further stated the right heel has had that appearance for three to four weeks. S4LPN Treatment Nurse proceeded to provide wound care, which consisted of cleaning the wound with normal saline, applying [MEDICATION NAME], covering the wound with clean gauze and wrapping with Perplex. Throughout the observation, resident #2 verbalized complaints of pain. The resident was noted with facial grimacing and cried out each time S4LPN Treatment Nurse touched his right foot. An interview was held with S4LPN Treatment Nurse on 1/4/12 at 10:00 a.m. She stated she worked Monday through Friday from 4:30 a.m. to 12:30 p.m. She stated she had been the treatment nurse for approximately six months. She said the facility provided wound training prior to her becoming the treatment nurse. She stated that she developed and revised skin related care plans. She said she updated resident's care plan when a new order was received. She explained that all wounds were measured and staged by S3ADON. She said that she notified S3ADON when a wound needed to be measured or staged. She said she and S3ADON communicated only verbally regarding wounds. She explained that resident #2's right heel had originated as a blister. She said the resident was seen by a Dermatologist and was diagnosed with [REDACTED]. She said "pressure bullae" was described to her as being an immune system illness. She further stated that resident #2's right heel was not considered to be a "pressure" wound since it was previously diagnosed as a "pressure bullae". She said the interventions ordered by the Dermatologist were [MEDICATION NAME] and pressure relief. She further stated that she had not notified S3ADON of resident #2's right heel wound because the wound was not a "pressure wound". When asked if she had notified the physician when the resident's right heel wound changed in appearance (according to her that was three to four weeks ago), S4LPN Treatment Nurse stated she had not notified the physician. She stated that the resident's right heel should be elevated off of the mattress to help with pressure relief. She explained that pillows, rolls, or wedges could be used to elevate the resident's right heel. She stated that resident #2 complained of pain each time she provided wound care. She said the resident "hated" to see her because he related her to pain. She stated the resident's medication nurse pre-medicated the resident prior to wound care. S4LPN Treatment Nurse stated that she did not know what medication the resident received for pain. She further stated that she had not notified the physician or the medication nurse when the resident continued to complain of pain during wound care. She verified she documented the resident did not complain of pain because she thought the resident was pre-medicated prior to wound care. She reviewed resident #2's skin plan of care and verified it had not been updated with interventions for the risk of pressure ulcers determined during his quarterly assessment on 10/17/11; the dermatology recommendations for pressure avoidance on 11/1/11; changes in wound appearance; or the resident's complaints of pain. On 1/4/12 at 11:20 a.m. an interview was held with S3ADON. She stated that she was responsible for weekly measurements of wounds and staging of pressure wounds. She stated that S4LPN Treatment Nurse notified her verbally of any wounds that needed assessing. S3ADON stated that she was not aware of resident #2 having a wound to his right heel. She recalled that "awhile back" the resident had multiple blisters. She stated that S4LPN Treatment Nurse had not informed her of resident's right heel wound. An observation was made of resident #2's right heel with S3ADON on 1/4/12 at 11:25 a.m. Resident #2 was observed to be lying in bed on his back with his right heel lying directly on the mattress in the same position the resident was in during previous observations at 8:45 a.m. and 9:20 a.m.. S3ADON removed the dressing from resident #2's right heel. Resident #2 was observed to have facial grimacing and verbalize complaints of pain each time S3ADON touched his right foot. S3ADON asked the resident if his foot hurt, and resident #2 responded "yes". S3ADON assessed the resident's right heel and when asked to describe the right heel wound, she replied, "That's eschar". S3ADON stated the surrounding tissue was red and the lower portion of the heel was "spongy" with a "deep purple" color. S3ADON measured the wound and the following measurements were noted: eschar measured 6cm (length) x 5cm (width) x 0.8cm (depth) and surrounding redness measured 8cm (length) x 5cm (width). S3ADON stated she should have been notified of the resident's heel wound. She stated that she did not feel that [MEDICATION NAME] was appropriate treatment for [REDACTED]. On 1/4/12 at 11:50 a.m. an interview was held with S12LPN. She verified she was the routine medication nurse for resident #2. She stated that resident #2 was not ordered any medications for pain. She said that the resident had not complained of pain to her. She further stated that S4LPN Treatment Nurse had not informed her that resident #2 needed pre-medicating for pain prior to wound care. Review of the November 2011 through January 2012 physician's orders [REDACTED].#2 during that time. Review of the Nurse's Note dated 1/4/12 and timed for 1150 (11:50 a.m.) revealed documentation of S3ADON's assessment of resident #2's heel. The Note included the following: Report received of right heel wound - area assessed. "Eschar 5cm x 6cm c (with) 1/8cm depth at inferior medial edge. Adjacent to that 5 x 8 crescent shaped area, red and blanchable at superior aspect, spongy purple at inferior aspect. Resident expressed pain upon palpitation ...". Review of the Physician's Telephone Orders dated 1/4/12 and timed for 1158 (11:58 a.m.) revealed the following orders for the right heel wound: 1. Cleanse area with wound cleanser and pat dry. 2. Apply Hydrogel. 3. Cover with Optiform or other foam dressing. 4. Change daily and PRN. 5. Foam heel booties to both feet at all times. 6. [MEDICATION NAME] (non-narcotic pain reliever) 1 per PEG tube every 6 hours PRN pain. An interview was held with S2DON on 1/5/12 at 8:30 a.m. She stated that S3ADON had informed her of resident #2 experiencing pain when his right foot was touched and that his right heel had eschar. S2DON verified that prior to 1/4/12 the resident's heel had only been treated with [MEDICATION NAME]. She also verified resident #2 did not have any medications ordered for pain relief prior to 1/4/12. She stated S4LPN Treatment Nurse should have notified the physician when the resident's heel declined and the treatment should have been changed. S2DON stated that if a wound had not made progress within a couple of weeks or if a wound declined suddenly, the physician should be notified. S2DON stated it was S4LPN Treatment Nurse responsibility to assess a resident for pain prior, during, and after wound care. She said S4LPN Treatment Nurse should notify the medication nurse of any reported pain and if the resident has pain medication ordered, then the resident should receive the medication, and if the resident does not have pain medication ordered, S4LPN Treatment Nurse should notify the physician. S2DON stated S4LPN Treatment Nurse was responsible for updating a resident's care plan when changes occurred with their skin or wound. She reviewed resident #2's care plan and verified it had not been updated on 11/1/11 with interventions of pressure relief for his right heel as recommended by the dermatologist, changes in wound appearance, or the pain related to the wound. S2DON verified S4LPN Treatment Nurse was provided wound care training prior to becoming the treatment nurse. On 1/5/12 at 9:25 a.m. an interview was held with S4LPN Treatment Nurse. She stated that she always informed the CNAs of skin care interventions specific for each resident. She stated she verbally communicated to the CNAs that resident #2's needed bilateral heel protectors on at all times. An observation was made of S13CNA providing assistance to resident #2 on 1/5/12 at 9:35 a.m. During the observation, resident #2 was sitting in a wheelchair as S13CNA combed his hair. The resident's wheelchair was observed to have one leg rest to the left side of the chair. Resident #2 was wearing socks and had his left foot positioned on the leg rest and his right foot positioned flat on the floor. An interview was held with S13CNA during the observation and she verified the resident had a wound to his right heel. When asked if there were any pressure relieving interventions provided for his heel, S13CNA stated that the resident was turned every two hours. When the question was rephrased and S13CNA was asked if the resident was supposed to wear heel protectors, she stated not that she knew of. On 1/5/12, observations were made of resident #2 sitting in a wheelchair near the nurses' station from 9:45 a.m. to 1:20 p.m. The resident's left foot was positioned on the leg rest of the wheelchair and his right foot was positioned on the floor. The resident was wearing socks, but he did not have on heel protectors. At 1:20 p.m., nursing staff applied heel protectors to the resident's bilateral heels. Observations continued of resident #2 on 1/5/12, and between 2:00 p.m. and 3:00 p.m. the resident was observed rubbing his right leg. During this time, the resident was passed by nursing staff, including S12LPN, who stopped the resident from pulling on his PEG tube, but did not ask him anything else. At 2:55 p.m., an interview was held with resident #2. During the interview, he continued to rub his right leg. The resident requested a pillow to place beneath his right foot. During the interview, S15CNA approached resident #2 and the resident informed S15CNA that he wanted a pillow to place beneath his right foot. S15CNA asked the resident if he was ready to return to bed, and the resident responded "yes". At 3:00 p.m., resident #2 was taken to his room. S9CNA Supervisor, S15CNA, S16CNA and S17LPN were in the resident's room. At 3:05 p.m., the resident was observed rubbing his right leg when S16CNA asked him if his leg was hurting. The resident responded "my foot hurts on the bottom" while pointing to his right foot. At 3:10 p.m., the resident was assisted to bed requiring total assistance during the transfer from the wheelchair to the bed. Once in bed, the resident was noted with facial grimacing and he continued to point at his right foot. With S17LPN at the resident's bedside observing the resident, S15CNA asked the resident what was wrong. The resident stated "my foot" while pointing at his right foot. At 3:20 p.m., S17LPN was observed to leave the room and go to the medication cart. An interview was held with S16CNA on 1/5/12 at 3:30 p.m. She stated that CNAs obtained knowledge of specific interventions for each resident by reviewing the resident's Kardex. She stated each resident had a Kardex specific to their needs that was maintained for the CNAs. She verified the Kardex would include if a resident should have heel protectors in place. S16CNA further stated that she would not know that resident #2 was to have heel protectors on unless she reviewed the Kardex. Upon request of resident #2's Kardex, S16CNA was unable to locate it. She further stated that she had not been notified by a nurse that he was to have heel protectors on at all times. On 1/5/12 at 3:45 p.m. an interview was held with S2DON. She verified each resident had a Kardex that included information specific to their needs. She explained the Kardex was to be utilized by the CNAs. Upon searching the nurses' station for resident #2's Kardex, she was unable to locate it. She questioned S9CNA Supervisor regarding the whereabouts of the Kardex for resident #2 and S9CNA Supervisor stated all Kardexs for that hall were in the DON/ADON's office. S2DON located resident #2's Kardex within her office and stated that the ADON was going to review each Kardex before placing them back on the unit. When asked how the CNAs were to know that resident #2 was to have heel protectors on at all times, S2DON stated the resident's nurse and treatment nurse should notify the CNAs when orders were received regarding pressure relief. She verified the order for heel protectors was received on 1/4/12 and that she had witnessed the resident without heel protectors on 1/5/12 while sitting near the nurses' station. S2DON further stated that each resident was to be assessed for pain by their assigned medication nurse during medication pass and upon rounds. She said if a resident complains of pain, the nurse was to assess the location and intensity of the pain prior to medication and after. She said the nurse should document a resident's complaints of pain on the medication record and nurse's notes. On 1/6/12, review of the January 2012 Medication Record revealed resident #2 was administered [MEDICATION NAME] for pain on 1/5/12 at 7:00 a.m. The resident had not been treated for [REDACTED]. Review of the Nurse's Notes revealed no documentation of an evaluation or interventions for resident #2's right foot pain for 1/5/12 at 3:05 p.m. Resident #8: Review of the Standing Nursing Home Orders revealed, in part, the following related to Skin Care: 3. Stage 1 Decutitus-redness 0 pressure to the area. Use pressure relieving devices as needed ... 4. Stages II, II, IV: notify MD/NP on routine rounds ? Without eschar (100% granulation tissue) clean daily with normal saline or Wound cleanser apply Hydrogel to area, cover with damp 4X4. Cover with dry, clean dressing ? With Slough (minimal drainage). Clean daily with wound cleanser or normal saline, apply calcium alginate or santyl. Cover with damp 4X4 and dry, clean dressing. ? With Slough (moderate to heavy drainage). Clean twice a day and as needed with normal saline or wound cleanser, apply calcium alginate or santyl and cover with dry, clean dressing. 6. Report all purulent wound drainage/odor ... Review of the clinical record for resident #8 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes for the resident dated 10/7/11, revealed the resident was admitted to the facility with eschar to the 3rd, 4th and 5th toes on his left foot. Review of the Wound Treatment Evaluations for the month of October 2011-January 2012, for the wounds to the 3rd, 4th, and 5th toes of the left foot, revealed the following: No entries were made regarding the wounds from 10/7/11 through 10/16/11. Entries were made dated 10/17/11 for the wounds to the 3rd, 4th, and 5th toes of the left foot by S3ADON. All three wounds were listed as "unstageable" under the section "If pressure ulcer-Stage". There were no other assessments or measurements documented, by S3ADON, of the toes to the left foot on the wound treatment record from 10/18/11 through 1/4/12. Entries were made by S4LPN Treatment Nurse dated 10/17/11 and 10/18/11 which described all three toe wounds as "Black". These same entries showed the wounds were treated on these dates with wound cleaner, normal saline, pat dry, apply Santyl, cover with a dry/clean dressing. Check daily, change every day and as needed. This treatment was discontinued on 10/19/11 and monitoring of all three toe wounds for changes every day and as needed was started. No treatments were preformed to the wounds of the 3rd, 4th, and 5th toes on the left foot from 10/19/11-12/14/11. Review of the MDS dated [DATE] revealed under Section M-Skin Conditions: F. 1). Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar- 1 2). Number of these unstageable pressure ulcers that were present upon admission/reentry-enter how many were noted at the time of admission- 1 Review of a Podiatrist Consultation, dated 12/7/11, for the resident revealed a sharp excision of loose eschar on 3rd and 4th toes of left foot was performed and [MEDICATION NAME] ointment was applied. Further review of the Wound Treatment Evaluations for the month of October 2011-January 2012, for the wounds to the 3rd, 4th, and 5th toes of the left foot, revealed the following: On 12/15/11, treatment was started again to the 3rd and 4th toes of the left foot with wound cleanser/normal saline, pat dry, apply Santyl and cover with dry, clean dressing. Check daily; change every day, and as needed. This treatment was documented daily from 12/15/11 through 12/29/11. Monitoring of the 5th toe continued without treatment. On 12/30/11-1/5/12 the treatment was changed to clean with wound cleanser/normal saline, pat dry, apply [MEDICATION NAME], cover with a dry clean dressing, change every day, and as needed. Review of the Nurse's Notes for the resident revealed no entries were made about the wounds to the toes on the left foot from 10/8/11 through 10/16/11. Further review of the Nurse's Notes revealed the following entries were made on the Nurse's Notes by S4LPN Treatment Nurse: 10/17/11 1:35 p.m. Informed by hall nurse that resident has something on his toes. Evaluated resident's toes with ADON and observed unstageable wounds to left foot 3rd, 4th, and 5th toes. All three toes wound beds covered in eschar. Cleaned with wound cleanser, pat dried, applied Santyl and covered with, dry, clean dressing. Will continue to monitor. 10/19/11 at 8:00 a.m. Order changes for left foot 3rd, 4th, and 5th toe; discontinue treatment of [REDACTED]. New orders are to monitor areas every day for changes per DON and ADON as discussed in morning nurses meeting. These areas are not pressures. They are unstageable wounds with complete eschar. No treatment is needed at this time. Wounds will be monitored daily for changes. Will continue to follow up. 10/21/11 7:45 a.m. Evaluated the following wounds on resident. Left foot 3rd, 4th and 5th toes. Top of all three toes still black with no changes. Texture is leathery without open areas... 11/1/11 9:45 a.m. ...left foot 3rd, 4th and 5th toes brown with macerated dry surrounding skin.. 11/17/11 7:50 a.m. ...left foot 3rd, 4th and 5th toes wound beds 100% brown eschar with macerated surrounding skin. No color/drainage noted. Will continue to monitor. 11/21/11 8:40 a.m. ... left foot 3rd, 4th and 5th toes wound beds 100% brown, leathery eschar with macerated surrounding skin. No odor/drainage noted. Will continue to monitor. 11/23/11 8:40 a.m. No change in appearance/condition of wounds. 12/5/11 10:30 a.m. ...left foot 3rd, 4th and 5th toes brown leathery eschar to all toes without odor/drainage noted... Will continue to monitor. 12/12/11 8:10 a.m. Left foot 3rd, 4th and 5th toes no change in appearance/condition to wounds. Will continue to monitor. 12/15/11 9:45 a.m. ...Orders changed to left foot 3rd and 4th toes. Left foot 3rd toe wound bed 60% yellow hard skin, 20% black hard skin and 20% red moist skin towards wound edges. Wound moist with tiny amount of purulent exudates. Left foot 4th toe i

Based on observations, record reviews, and interviews, the facility neglected to provide necessary goods and services to 2 (#2, #8) of 8 (#2, #4, #6, #7, #8, #9, #10, #11) residents receiving wound care from a total sample of 11 residents. On 11/1/11, a Dermatologist lanced a fluid filled blister to Resident #2's right heel and ordered [MEDICATION NAME] BID and pressure relieving measures. Resident #2 was in Immediate Jeopardy after the 11/1/11 orders were received and the LPN treatment nurse and weekend treatment nurses neglected to provide needed care and services including consultation with the physician regarding this right heel wound. For over 2 months, no one assessed this wound other than the LPN treatment nurse and the weekend nurses and no one notified the physician or the RN supervisor. On 1/4/12, the right heel wound had progressed to an unstageable wound with eschar measuring 6cm (length) x 5cm (width) x 0.8cm (depth) with surrounding redness measuring 8cm (length) x 5cm (width). Resident #2 experienced untreated pain from the wound and grimaced and cried out when his right foot was touched. Resident #8 was admitted to the facility on [DATE] with eschar to the left foot on the 3rd, 4th, and 5th toes. He was in immediate jeopardy after admission on 10/7/11 when the LPN treatment nurse wrote orders for the wounds and neglected to consult with the physician, treatments were not conducted from 10/19/11-12/14/11, and no RN intervention occurred. Resident #8 experienced an increase in wound severity with tunneling, drainage, and a foul odor. From 11/1/11 until 1/4/12, the staff the facility assigned to care for Resident #2, and from 10/7/11 until 1/4/12, the staff assigned to care for resident #8, neglected to provide the following needed care and services and there was no intervention by the ADON RN Supervisor to ensure the following needed care and services were provided: 1.) consult with the residents' physicians regarding changes in wound status (#2, #8); 2.) assess and communicate changes in status to other nurses and supervisors (#2, #8); 3.) assess, consult with the physician, and treat pain related to wounds (#2); 4.) implement pressure relieving interventions to prevent wounds from deteriorating (#2, #8)); 5.) ensure the plan of care was updated with interventions to prevent skin breakdown and/or heal skin wounds (#2, #8); 6.) ensure CNAs were aware of pressure relieving measures (#2, #8); 7. ensure the ADON had knowledge of residents with wounds and assessed these wounds (#2, #8); 8.) ensure the ADON clinically supervised the LPN treatment nurse and weekend nurses to ensure orders were followed and care was provided following professional standards of practice (#2, #8); 9.) consistently measure wounds (#2, #8); 10.) ensure the LPN treatment nurse did not write orders for treatments to wounds and obtained orders from the physician (#8); 11.) obtain treatment orders for wounds upon admission (#8); 12.) recognize that the standing orders did not address wounds with eschar (#8); 13.) include in the policy and procedure for wounds instructions to nurses regarding pain from ulcers other than pressure ulcers (#2). This failure had the potential to harm six other residents with wounds (#4, #6, #7, #9, #10, #11 ) and placed them in Immediate Jeopardy. The administrator was notified of the Immediate Jeopardy on 1/6/12. The Immediate Jeopardy remained in place at exit. Findings: Review of the facility's policy entitled, "Policy and Procedure for the Prevention and treatment of [REDACTED]. Policy: It is the policy to properly identify and assess residents, either by an RN or under an RN's supervision, whose clinical conditions increase the risk for impaired skin integrity and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. Procedures include: A. it is important to individualize each resident's turning and repositioning schedule. B. the care plan for skin integrity is to be evaluated and revised based on response, outcomes, and needs of the resident. II. treatment of [REDACTED]. If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented: 2. notify physician 3. notify supervisor 6. re-evaluate turning and repositioning intervals 8. re-evaluate interventions per risk factors identified 10. initiate weekly wound documentation progress sheet 11. when a pressure ulcer is present, daily wound monitoring should include whether pain, if present , is being adequately controlled. 12. notify the physician, NP and supervisor if the ulcer(s) has not shown progress in 2-4 weeks and/or is deteriorating unexpectedly. Re-evaluate plan of care as appropriate. Resident #2: Review of the clinical record revealed resident #2 had a [DIAGNOSES REDACTED]. Review of the most recent MDS dated [DATE] revealed resident #2 had impaired range of motion to his upper and lower extremities and was totally dependent on staff for bed mobility and transfers. Review of the most recent Pressure Sore Risk assessment dated [DATE] revealed the resident scored a total score of "14" indicating he was a pressure sore risk. The resident was assessed as having "very limited" sensory perception - ability to respond meaningfully to pressure related discomfort. Review of the Nurse/Physician Communication Record completed by S3ADON on 10/25/11 revealed resident #2 had fluid filled blisters to multiple areas of the body that included the right heel. S3ADON further documented the resident had a temperature of 99.9 degrees axillary and was noted to be less alert than usual. Review of the Physician's Telephone Orders dated 10/25/11 included: 1. Cleanse blister areas with Normal Saline or Wound Cleanser, pat dry, apply Triple Antibiotic Ointment, cover with dressing, change every day. Diagnosis: [REDACTED]. 2. Dermatology consult... Diagnosis: [REDACTED]. Review of the Progress Note completed by the Nurse Practitioner on 10/26/11 revealed in part: Physical Examination: Skin: blister to ...heel Impression/Plan: [DIAGNOSES REDACTED] related to recent scabies - local care for now and follow up with Dermatologist. Review of the Nurse's Notes dated 10/27/11 revealed the resident had a temperature of 99.8 degrees axillary and was "not looking very well". The Nurse Practitioner was notified and ordered to send the resident to the emergency room for evaluation and treatment. Review of the hospital records revealed resident #2 was admitted to the hospital and treated for [REDACTED]. Review of the hospital's History and Physical dated 10/27/11 revealed in part: Dermatology: ... early pressure ulcers on his left foot as well as more prominent on his right heel. Review of the hospital Discharge Summary dated 10/30/11 included: Pressure Ulcers: The patient presented with multiple early pressure sites... Wound ostomy nurses were consulted and initiated treatment here which included turning every two hours, floating heels off the bed, having a specialty bed. Recommended cleaning the right heel with soap and water, apply Lidoflex pad to blister, cover with 4 x 4... Recommend continuing his wound care at the nursing home facility. Review of the hospital's Discharge Worksheet dated 10/30/11 and timed for 0915 (9:15 a.m.) included: Discharge Education and Instructions: (2) Wound care as outlined by our W.O.N. (wound ostomy nurse). Review of the discharge Medication List included Wound Care of the right heel as follows: Cleanse with soap and water, dry thoroughly, apply Lidoflex pad, cover with 4 x 4, wrap with conforming gauze, change every 48 hours. Review of the Admission and Physician's Telephone Orders dated 10/30/11 included no documentation of wound care for resident #2's right heel. Review of the October 2011 Wound Treatment Evaluation Record revealed no treatments were performed to the resident's right heel on 10/30/11. Review of the Nurse's Note dated 10/30/11 revealed a re-admission skin assessment of resident #2. The resident's right heel was not mentioned within the note. Review of the Weekly Skin Condition Evaluation dated 10/30/11 revealed no documentation related to the resident's right heel. Review of the Nurse's Note made by S4LPN Treatment Nurse on 10/31/11 included resident #2's right heel was noted with a "100% blood filled blister". Review of the October 2011 Wound Treatment Evaluation Record revealed the treatment that was performed to resident #2's right heel on 10/31/11 was as follows: clean with wound cleaner or normal saline, pat dry, apply TAO, cover with DCD. On 11/1/11, resident #2 was seen by the Dermatologist as ordered on [DATE]. Review of the Dermatology Note dated 11/1/11 was noted by S4LPN Treatment Nurse and included: Large bullae to right heel medially. Impression: Pressure Bullae Recommendations: Drained; [MEDICATION NAME] ointment BID, pressure avoidance. Review of the Physician's Telephone Order dated 11/1/11 revealed in part: 1. D/C Triple Antibiotic Ointment 2. Apply [MEDICATION NAME] ointment BID to right heel Review of the Skin Risk Evaluation and Plan of Care included 11/1/11: Pressure Bullue to right heel - Goal date 2/1/12 There were no interventions on the Plan of Care related to the right heel. There was no documentation of "pressure avoidance" as recommended by the dermatologist. The Plan of Care did not indicate the resident was at risk of developing a pressure sore as determined on 10/17/11. Review of the Nurse's Notes made by S4LPN Treatment Nurse revealed in part the following: 11/1/11: Resident returned from Dermatology appointment ... Right heel Pressure Bullae was drained ... Right heel 50% tan and 50% purple wound bed with little bloody drainage. Excess skin covers wound bed. Area moist without odor noted ... 11/4/11: ... Right heel wound bed 80% tan dry tissue in center of wound with 20% purple dry tissue around wound edges ... Resident tolerated treatment well without complaints of pain ... 11/7/11: ... Right heel 100% dry purple tissue ... Resident tolerated well without complaints of pain ... 11/17/11: ... Right heel 75% dry purple skin and 25% dry tan skin ... Resident tolerated well without complaints of pain ... 11/23/11: ...Right heel wound bed 60% purple dry skin and 40% tan dry skin ... Resident tolerated well without complaints of pain ... 11/28/11: ...Right heel wound bed 90% purple dry skin and 10% tan dry skin ... No complaints of pain voiced by resident ... 12/1/11: ...Right heel 100% purple/tan dry skin ... Resident tolerated well without complaints of pain ... 12/7/11: ...Right heel wound bed 90% purple hard dry skin with 10% tan hard dry skin to center. No drainage ... Resident tolerated well without complaints of pain ... 12/12/11: ...Right heel wound bed 90% purple hard dry skin with 10% tan hard dry skin in center. No drainage ... Resident tolerated well without complaints of pain ... 12/13/11: ...70% of dry purple/tan hard skin fell off during dressing change. 70% of wound bed red moist tissue with 30% hard, dry purple/tan skin towards edges of wound bed. No drainage ... Resident tolerated well without complaints of pain ... 12/15/11: ...50% dry purple/tan tissue/skin to wound bed. Noted with faint amount of bloody drainage. Resident tolerated well without complaints of pain ... 12/20/11: ...Right heel wound bed 50% moist red tissue with 50% dry purple tissue. Tiny amount of bloody drainage ... Resident tolerated treatment well without complaints of pain ... 12/22/11: ...Right heel ... 70% dry purple skin tissue in center of wound bed and 30% moist red tissue surrounding dry purple scar tissue ... Resident tolerated well without complaints of pain ... 12/29/11: ...Right heel wound bed 50% hard purple skin with 50% moist red skin ... Resident tolerated well without complaints of pain ... 1/2/12: ...Right heel wound bed 50% hard purple skin tissue and 50% moist red skin tissue. No drainage ... Resident voiced no complaints of pain ... 1/4/12: ...Right heel wound bed 50% hard dry purple tissue with faint amount of brown drainage. 50% red moist tissue surrounding hard, dry purple tissue without drainage ... Resident tolerated treatment well with complaints of pain only when touched ... Review of the Wound Treatment Evaluation Records for October 2011 through January 2012 revealed no measurements were made of resident #2's right heel by S3ADON. An observation was made on 1/4/12 at 8:45 a.m. of resident #2 lying in bed. The resident was positioned on his back with the head of the bed elevated. He was observed leaning to his left side. The resident's right foot was noted to have a Perplex dressing wrapped around his heel and ankle. The right heel was in direct contact with the mattress. On 1/4/12 at 9:20 a.m. an observation was made of resident #2's skin with S4LPN Treatment Nurse. Resident #2 mumbled when he saw S4LPN Treatment Nurse. She responded to the resident with, "I know you hate to see me because you know what I'm about to do will hurt". The resident was observed to be in the same position he had been in during the previous observation at 8:45 a.m. His right heel continued to be in direct contact with the mattress. In preparation of the treatment to the resident's right heel, S4LPN Treatment Nurse elevated his right heel off the mattress with a pillow. S4LPN Treatment Nurse removed the dressing to resident #2's right heel. There was a small amount of light brown drainage to the old dressing. The right medial heel was noted to have a large piece of eschar that was surrounded by reddened skin. The lower portion of the eschar, by the lower heel, had edges that were lifting. This left a small open area between the eschar edge and the surrounding red tissue. During the observation, an interview was held with S4LPN Treatment Nurse. She described resident #2's right heel as deep purple with surrounding red blanchable tissue. When S4LPN Treatment Nurse was asked specifically about the eschar to resident #2's right heel, she again responded that she classified the area as "deep purple". She further stated the right heel has had that appearance for three to four weeks. S4LPN Treatment Nurse proceeded to provide wound care, which consisted of cleaning the wound with normal saline, applying [MEDICATION NAME], covering the wound with clean gauze and wrapping with Perplex. Throughout the observation, resident #2 verbalized complaints of pain. The resident was noted with facial grimacing and cried out each time S4LPN Treatment Nurse touched his right foot. An interview was held with S4LPN Treatment Nurse on 1/4/12 at 10:00 a.m. She stated she worked Monday through Friday from 4:30 a.m. to 12:30 p.m. She stated she had been the treatment nurse for approximately six months. She said the facility provided wound training prior to her becoming the treatment nurse. She stated that she developed and revised skin related care plans. She said she updated resident's care plan when a new order was received. She explained that all wounds were measured and staged by S3ADON. She said that she notified S3ADON when a wound needed to be measured or staged. She said she and S3ADON communicated only verbally regarding wounds. She explained that resident #2's right heel had originated as a blister. She said the resident was seen by a Dermatologist and was diagnosed with [REDACTED]. She said "pressure bullae" was described to her as being an immune system illness. She further stated that resident #2's right heel was not considered to be a "pressure" wound since it was previously diagnosed as a "pressure bullae". She said the interventions ordered by the Dermatologist were [MEDICATION NAME] and pressure relief. She further stated that she had not notified S3ADON of resident #2's right heel wound because the wound was not a "pressure wound". When asked if she had notified the physician when the resident's right heel wound changed in appearance (according to her that was three to four weeks ago), S4LPN Treatment Nurse stated she had not notified the physician. She stated that the resident's right heel should be elevated off of the mattress to help with pressure relief. She explained that pillows, rolls, or wedges could be used to elevate the resident's right heel. She stated that resident #2 complained of pain each time she provided wound care. She said the resident "hated" to see her because he related her to pain. She stated the resident's medication nurse pre-medicated the resident prior to wound care. S4LPN Treatment Nurse stated that she did not know what medication the resident received for pain. She further stated that she had not notified the physician or the medication nurse when the resident continued to complain of pain during wound care. She verified she documented the resident did not complain of pain because she thought the resident was pre-medicated prior to wound care. She reviewed resident #2's skin plan of care and verified it had not been updated with interventions for the risk of pressure ulcers determined during his quarterly assessment on 10/17/11; the dermatology recommendations for pressure avoidance on 11/1/11; changes in wound appearance; or the resident's complaints of pain. On 1/4/12 at 11:20 a.m. an interview was held with S3ADON. She stated that she was responsible for weekly measurements of wounds and staging of pressure wounds. She stated that S4LPN Treatment Nurse notified her verbally of any wounds that needed assessing. S3ADON stated that she was not aware of resident #2 having a wound to his right heel. She recalled that "awhile back" the resident had multiple blisters. She stated that S4LPN Treatment Nurse had not informed her of resident's right heel wound. An observation was made of resident #2's right heel with S3ADON on 1/4/12 at 11:25 a.m. Resident #2 was observed to be lying in bed on his back with his right heel lying directly on the mattress in the same position the resident was in during previous observations at 8:45 a.m. and 9:20 a.m.. S3ADON removed the dressing from resident #2's right heel. Resident #2 was observed to have facial grimacing and verbalize complaints of pain each time S3ADON touched his right foot. S3ADON asked the resident if his foot hurt, and resident #2 responded "yes". S3ADON assessed the resident's right heel and when asked to describe the right heel wound, she replied, "That's eschar". S3ADON stated the surrounding tissue was red and the lower portion of the heel was "spongy" with a "deep purple" color. S3ADON measured the wound and the following measurements were noted: eschar measured 6cm (length) x 5cm (width) x 0.8cm (depth) and surrounding redness measured 8cm (length) x 5cm (width). S3ADON stated she should have been notified of the resident's heel wound. She stated that she did not feel that [MEDICATION NAME] was appropriate treatment for [REDACTED]. On 1/4/12 at 11:50 a.m. an interview was held with S12LPN. She verified she was the routine medication nurse for resident #2. She stated that resident #2 was not ordered any medications for pain. She said that the resident had not complained of pain to her. She further stated that S4LPN Treatment Nurse had not informed her that resident #2 needed pre-medicating for pain prior to wound care. Review of the November 2011 through January 2012 physician's orders [REDACTED].#2 during that time. Review of the Nurse's Note dated 1/4/12 and timed for 1150 (11:50 a.m.) revealed documentation of S3ADON's assessment of resident #2's heel. The Note included the following: Report received of right heel wound - area assessed. "Eschar 5 x 6cm c (with) 1/8cm depth at inferior medial edge. Adjacent to that 5 x 8 crescent shaped area, red and blanchable at superior aspect, spongy purple at inferior aspect. Resident expressed pain upon palpitation ...". Review of the Physician's Telephone Orders dated 1/4/12 and timed for 1158 (11:58 a.m.) revealed the following orders for the right heel wound: 1. Cleanse area with wound cleanser and pat dry. 2. Apply Hydrogel. 3. Cover with Optiform or other foam dressing. 4. Change daily and PRN. 5. Foam heel booties to both feet at all times. 6. [MEDICATION NAME] (non-narcotic pain reliever) 1 per PEG tube every 6 hours PRN pain. On 1/5/12 at 8:25 a.m. an observation was made of resident #2 lying in bed with his eyes closed. The head of the bed was elevated at a high position and the resident's bilateral heels were observed to be in direct contact with the mattress. The resident's right ankle/heel was wrapped with a dressing. There was no heel protectors noted to the resident's bilateral heels. An interview was held with S2DON on 1/5/12 at 8:30 a.m. She stated that S3ADON had informed her of resident #2 experiencing pain when his right foot was touched and that his right heel had eschar. S2DON verified that prior to 1/4/12 the resident's heel had only been treated with [MEDICATION NAME]. She also verified resident #2 did not have any medications ordered for pain relief prior to 1/4/12. She stated S4LPN Treatment Nurse should have notified the physician when the resident's heel declined and the treatment should have been changed. S2DON stated that if a wound had not made progress within a couple of weeks or if a wound declined suddenly, the physician should be notified. S2DON stated it was S4LPN Treatment Nurse responsibility to assess a resident for pain prior, during, and after wound care. She said S4LPN Treatment Nurse should notify the medication nurse of any reported pain and if the resident has pain medication ordered, then the resident should receive the medication, and if the resident does not have pain medication ordered, S4LPN Treatment Nurse should notify the physician. S2DON stated S4LPN Treatment Nurse was responsible for updating a resident's care plan when changes occurred with their skin or wound. She reviewed resident #2's care plan and verified it had not been updated on 11/1/11 with interventions of pressure relief for his right heel as recommended by the dermatologist, changes in wound appearance, or the pain related to the wound. S2DON verified S4LPN Treatment Nurse was provided wound care training prior to becoming the treatment nurse. On 1/5/12 at 9:25 a.m. an interview was held with S4LPN Treatment Nurse. She stated that she always informed the CNAs of skin care interventions specific for each resident. She stated she verbally communicated to the CNAs that resident #2's needed bilateral heel protectors on at all times. An observation was made of S13CNA providing assistance to resident #2 on 1/5/12 at 9:35 a.m. During the observation, resident #2 was sitting in a wheelchair as S13CNA combed his hair. The resident's wheelchair was observed to have one leg rest to the left side of the chair. Resident #2 was wearing socks and had his left foot positioned on the leg rest and his right foot positioned flat on the floor. An interview was held with S13CNA during the observation and she verified the resident had a wound to his right heel. When asked if there were any pressure relieving interventions provided for his heel, S13CNA stated that the resident was turned every two hours. When the question was rephrased and S13CNA was asked if the resident was supposed to wear heel protectors, she stated not that she knew of. On 1/5/12, observations were made of resident #2 sitting in a wheelchair near the nurses' station from 9:45 a.m. to 1:20 p.m. The resident's left foot was positioned on the leg rest of the wheelchair and his right foot was positioned on the floor. The resident was wearing socks, but he did not have on heel protectors. At 1:20 p.m., nursing staff applied heel protectors to the resident's bilateral heels. Observations continued of resident #2 on 1/5/12, and between 2:00 p.m. and 3:00 p.m. the resident was observed rubbing his right leg. During this time, the resident was passed by nursing staff, including S12LPN, who stopped the resident from pulling on his PEG tube, but did not ask him anything else. At 2:55 p.m., an interview was held with resident #2. During the interview, he continued to rub his right leg. The resident requested a pillow to place beneath his right foot. During the interview, S15CNA approached resident #2 and the resident informed S15CNA that he wanted a pillow to place beneath his right foot. S15CNA asked the resident if he was ready to return to bed, and the resident responded "yes". At 3:00 p.m., resident #2 was taken to his room. S9CNA Supervisor, S15CNA, S16CNA and S17LPN were in the resident's room. At 3:05 p.m., the resident was observed rubbing his right leg when S16CNA asked him if his leg was hurting. The resident responded "my foot hurts on the bottom" while pointing to his right foot. At 3:10 p.m., the resident was assisted to bed requiring total assistance during the transfer from the wheelchair to the bed. Once in bed, the resident was noted with facial grimacing and he continued to point at his right foot. With S17LPN at the resident's bedside observing the resident, S15CNA asked the resident what was wrong. The resident stated "my foot" while pointing at his right foot. At 3:20 p.m., S17LPN was observed to leave the room and go to the medication cart. An interview was held with S16CNA on 1/5/12 at 3:30 p.m. She stated that CNAs obtained knowledge of specific interventions for each resident by reviewing the resident's Kardex. She stated each resident had a Kardex specific to their needs that was maintained for the CNAs. She verified the Kardex would include if a resident should have heel protectors in place. S16CNA further stated that she would not know that resident #2 was to have heel protectors on unless she reviewed the Kardex. Upon request of resident #2's Kardex, S16CNA was unable to locate it. She further stated that she had not been notified by a nurse that he was to have heel protectors on at all times. On 1/5/12 at 3:45 p.m. an interview was held with S2DON. She verified each resident had a Kardex that included information specific to their needs. She explained the Kardex was to be utilized by the CNAs. Upon searching the nurses' station for resident #2's Kardex, she was unable to locate it. She questioned S9CNA Supervisor regarding the whereabouts of the Kardex for resident #2 and S9CNA Supervisor stated all Kardexs for that hall was in the DON/ADON's office. S2DON located resident #2's Kardex within her office and stated that the ADON was going to review each Kardex before placing them back on the unit. When asked how the CNAs were to know that resident #2 was to have heel protectors on at all times, S2DON stated the resident's nurse and treatment nurse should notify the CNAs when orders were received regarding pressure relief. She verified the order for heel protectors was received on 1/4/12 and that she had witnessed the resident without heel protectors on 1/5/12 while sitting near the nurses' station. S2DON further stated that each resident was to be assessed for pain by their assigned medication nurse during medication pass and upon rounds. She said if a resident complains of pain, the nurse was to assess the location and intensity of the pain prior to medication and after. She said the nurse should document a resident's complaints of pain on the medication record and nurse's notes. On 1/6/12, review of the January 2012 Medication Record revealed resident #2 was administered [MEDICATION NAME] for pain on 1/5/12 at 7:00 a.m. The resident had not been treated for [REDACTED]. Review of the Nurse's Notes revealed no documentation of an evaluation or interventions for resident #2's right foot pain for 1/5/12 at 3:05 p.m. Resident #8: Review of the Standing Nursing Home Orders revealed, in part, the following related to Skin Care: 3. Stage 1 Decutitus-redness 0 pressure to the area. Use pressure relieving devices as needed ... 4. Stages II, II, IV: notify MD/NP on routine rounds ? Without eschar (100% granulation tissue) clean daily with normal saline or Wound cleanser apply Hydrogel to area, cover with damp 4X4. Cover with dry, clean dressing ? With Slough (minimal drainage). Clean daily with wound cleanser or normal saline, apply calcium alginate or santyl. Cover with damp 4X4 and dry, clean dressing. ? With Slough (moderate to heavy drainage). Clean twice a day and as needed with normal saline or wound cleanser, apply calcium alginate or santyl and cover with dry, clean dressing. 6. Report all purulent wound drainage/odor ... Review of the clinical record for resident #8 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes for the resident dated 10/7/11, revealed the resident was admitted to the facility with eschar to the 3rd, 4th and 5th toes on his left foot. Review of the Wound Treatment Evaluations for the month of October 2011-January 2012, for the wounds to the 3rd, 4th, and 5th toes of the left foot, revealed the following: No entries were made regarding the wounds from 10/7/11 through 10/16/11. Entries were made dated 10/17/11 for the wounds to the 3rd, 4th, and 5th toes of the left foot by S3ADON. All three wounds were listed as "unstageable" under the section "If pressure ulcer-Stage". There were no other assessments or measurements documented, by S3ADON, of the toes to the left foot on the wound treatment record from 10/18/11 through 1/4/12. Entries were made by S4LPN Treatment Nurse dated 10/17/11 and 10/18/11 which described all three toe wounds as "Black". These same entries showed the wounds were treated on these dates with wound cleaner, normal saline, pat dry, apply Santyl, cover with a dry/clean dressing. Check daily, change every day and as needed. This treatment was discontinued on 10/19/11 and monitoring of all three toe wounds for changes every day and as needed was started. No treatments were preformed to the wounds of the 3rd, 4th, and 5th toes on the left foot from 10/19/11-12/14/11. Review of the MDS dated [DATE] revealed under Section M-Skin Conditions: F. 1). Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar- 1 2). Number of these unstageable pressure ulcers that were present upon admission/reentry-enter how many were noted at the time of admission- 1 Review of a Podiatrist Consultation, dated 12/7/11, for the resident revealed a sharp excision of loose eschar on 3rd and 4th toes of left foot was performed and [MEDICATION NAME] ointment was applied. Further review of the Wound Treatment Evaluations for the month of October 2011-January 2012, for the wounds to the 3rd, 4th, and 5th toes of the left foot, revealed the following: On 12/15/11, treatment was started again to the 3rd and 4th toes of the left foot with wound cleanser/normal saline, pat dry, apply Santyl and cover with dry, clean dressing. Check daily; change every day, and as needed. This treatment was documented daily from 12/15/11 through 12/29/11. Monitoring of the 5th toe continued without treatment. On 12/30/11-1/5/12 the treatment was changed to clean with wound cleanser/normal saline, pat dry, apply [MEDICATION NAME], cover with a dry clean dressing, change every day, and as needed. Review of the Nurse's Notes for the resident revealed no entries were made about the wounds to the toes on the left foot from 10/8/11 through 10/16/11. Further review of the Nurse's Notes revealed the following entries were made on the Nurse's Notes by S4LPN Treatment Nurse: 10/17/11 1:35 p.m. Informed by hall nurse that resident has something on his toes.

Based on observations, record reviews, and interviews, the facility neglected to provide necessary goods and services to 2 (#2, #8) of 8 (#2, #4, #6, #7, #8, #9, #10, #11) residents receiving wound care from a total sample of 11 residents. On 11/1/11, a Dermatologist lanced a fluid filled blister to Resident #2's right heel and ordered [MEDICATION NAME] BID and pressure relieving measures. Resident #2 was in Immediate Jeopardy after the 11/1/11 orders were received and the LPN treatment nurse and weekend treatment nurses neglected to provide needed care and services including consultation with the physician regarding this right heel wound. For over 2 months, no one assessed this wound other than the LPN treatment nurse and the weekend nurses and no one notified the physician or the RN supervisor. On 1/4/12, the right heel wound had progressed to an unstageable wound with eschar measuring 6cm (length) x 5cm (width) x 0.8cm (depth) with surrounding redness measuring 8cm (length) x 5cm (width). Resident #2 experienced untreated pain from the wound and grimaced and cried out when his right foot was touched. Resident #8 was admitted to the facility on [DATE] with eschar to the left foot on the 3rd, 4th, and 5th toes. He was in immediate jeopardy after admission on 10/7/11 when the LPN treatment nurse wrote orders for the wounds and neglected to consult with the physician, treatments were not conducted from 10/19/11-12/14/11, and no RN intervention occurred. Resident #8 experienced an increase in wound severity with tunneling, drainage, and a foul odor. From 11/1/11 until 1/4/12, the staff the facility assigned to care for Resident #2, and from 10/7/11 until 1/4/12, the staff assigned to care for resident #8, neglected to provide the following needed care and services and there was no intervention by the ADON RN Supervisor to ensure the following needed care and services were provided: 1.) consult with the residents' physicians regarding changes in wound status (#2, #8); 2.) assess and communicate changes in status to other nurses and supervisors (#2, #8); 3.) assess, consult with the physician, and treat pain related to wounds (#2); 4.) implement pressure relieving interventions to prevent wounds from deteriorating (#2, #8)); 5.) ensure the plan of care was updated with interventions to prevent skin breakdown and/or heal skin wounds (#2, #8); 6.) ensure CNAs were aware of pressure relieving measures (#2, #8); 7. ensure the ADON had knowledge of residents with wounds and assessed these wounds (#2, #8); 8.) ensure the ADON clinically supervised the LPN treatment nurse and weekend nurses to ensure orders were followed and care was provided following professional standards of practice (#2, #8); 9.) consistently measure wounds (#2, #8); 10.) ensure the LPN treatment nurse did not write orders for treatments to wounds and obtained orders from the physician (#8); 11.) obtain treatment orders for wounds upon admission (#8); 12.) recognize that the standing orders did not address wounds with eschar (#8); 13.) include in the policy and procedure for wounds instructions to nurses regarding pain from ulcers other than pressure ulcers (#2). This failure had the potential to harm six other residents with wounds (#4, #6, #7, #9, #10, #11 ) and placed them in Immediate Jeopardy. The administrator was notified of the Immediate Jeopardy on 1/6/12. On January 20, 2012, the facility presented a plan or removal which included assessing and treating the wounds, physician consultation, having RN supervision of the wound care, implementing pressure relieving devices, and pain management measures. Surveyors determined the Immediate Jeopardy was removed on January 23, 2012. The deficient practice continues at patterns of actual harm for residents #2 and #8 and a potential for more than minimal harm for residents #4, #6, #7, #9, #10, and #11. Findings: Review of the facility's policy entitled, "Policy and Procedure for the Prevention and treatment of [REDACTED]. Policy: It is the policy to properly identify and assess residents, either by an RN or under an RN's supervision, whose clinical conditions increase the risk for impaired skin integrity and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. Procedures include: A. it is important to individualize each resident's turning and repositioning schedule. B. the care plan for skin integrity is to be evaluated and revised based on response, outcomes, and needs of the resident. II. treatment of [REDACTED]. If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented: 2. notify physician 3. notify supervisor 6. re-evaluate turning and repositioning intervals 8. re-evaluate interventions per risk factors identified 10. initiate weekly wound documentation progress sheet 11. when a pressure ulcer is present, daily wound monitoring should include whether pain, if present , is being adequately controlled. 12. notify the physician, NP and supervisor if the ulcer(s) has not shown progress in 2-4 weeks and/or is deteriorating unexpectedly. Re-evaluate plan of care as appropriate. Resident #2: Review of the clinical record revealed resident #2 had a [DIAGNOSES REDACTED]. Review of the most recent MDS dated [DATE] revealed resident #2 had impaired range of motion to his upper and lower extremities and was totally dependent on staff for bed mobility and transfers. Review of the most recent Pressure Sore Risk assessment dated [DATE] revealed the resident scored a total score of "14" indicating he was a pressure sore risk. The resident was assessed as having "very limited" sensory perception - ability to respond meaningfully to pressure related discomfort. Review of the Nurse/Physician Communication Record completed by S3ADON on 10/25/11 revealed resident #2 had fluid filled blisters to multiple areas of the body that included the right heel. S3ADON further documented the resident had a temperature of 99.9 degrees axillary and was noted to be less alert than usual. Review of the Physician's Telephone Orders dated 10/25/11 included: 1. Cleanse blister areas with Normal Saline or Wound Cleanser, pat dry, apply Triple Antibiotic Ointment, cover with dressing, change every day. Diagnosis: [REDACTED]. 2. Dermatology consult... Diagnosis: [REDACTED]. Review of the Progress Note completed by the Nurse Practitioner on 10/26/11 revealed in part: Physical Examination: Skin: blister to ...heel Impression/Plan: [DIAGNOSES REDACTED] related to recent scabies - local care for now and follow up with Dermatologist. Review of the Nurse's Notes dated 10/27/11 revealed the resident had a temperature of 99.8 degrees axillary and was "not looking very well". The Nurse Practitioner was notified and ordered to send the resident to the emergency room for evaluation and treatment. Review of the hospital records revealed resident #2 was admitted to the hospital and treated for [REDACTED]. Review of the hospital's History and Physical dated 10/27/11 revealed in part: Dermatology: ... early pressure ulcers on his left foot as well as more prominent on his right heel. Review of the hospital Discharge Summary dated 10/30/11 included: Pressure Ulcers: The patient presented with multiple early pressure sites... Wound ostomy nurses were consulted and initiated treatment here which included turning every two hours, floating heels off the bed, having a specialty bed. Recommended cleaning the right heel with soap and water, apply Lidoflex pad to blister, cover with 4 x 4... Recommend continuing his wound care at the nursing home facility. Review of the hospital's Discharge Worksheet dated 10/30/11 and timed for 0915 (9:15 a.m.) included: Discharge Education and Instructions: (2) Wound care as outlined by our W.O.N. (wound ostomy nurse). Review of the discharge Medication List included Wound Care of the right heel as follows: Cleanse with soap and water, dry thoroughly, apply Lidoflex pad, cover with 4 x 4, wrap with conforming gauze, change every 48 hours. Review of the Admission and Physician's Telephone Orders dated 10/30/11 included no documentation of wound care for resident #2's right heel. Review of the October 2011 Wound Treatment Evaluation Record revealed no treatments were performed to the resident's right heel on 10/30/11. Review of the Nurse's Note dated 10/30/11 revealed a re-admission skin assessment of resident #2. The resident's right heel was not mentioned within the note. Review of the Weekly Skin Condition Evaluation dated 10/30/11 revealed no documentation related to the resident's right heel. Review of the Nurse's Note made by S4LPN Treatment Nurse on 10/31/11 included resident #2's right heel was noted with a "100% blood filled blister". Review of the October 2011 Wound Treatment Evaluation Record revealed the treatment that was performed to resident #2's right heel on 10/31/11 was as follows: clean with wound cleaner or normal saline, pat dry, apply TAO, cover with DCD. On 11/1/11, resident #2 was seen by the Dermatologist as ordered on [DATE]. Review of the Dermatology Note dated 11/1/11 was noted by S4LPN Treatment Nurse and included: Large bullae to right heel medially. Impression: Pressure Bullae Recommendations: Drained; [MEDICATION NAME] ointment BID, pressure avoidance. Review of the Physician's Telephone Order dated 11/1/11 revealed in part: 1. D/C Triple Antibiotic Ointment 2. Apply [MEDICATION NAME] ointment BID to right heel Review of the Skin Risk Evaluation and Plan of Care included 11/1/11: Pressure Bullue to right heel - Goal date 2/1/12 There were no interventions on the Plan of Care related to the right heel. There was no documentation of "pressure avoidance" as recommended by the dermatologist. The Plan of Care did not indicate the resident was at risk of developing a pressure sore as determined on 10/17/11. Review of the Nurse's Notes made by S4LPN Treatment Nurse revealed in part the following: 11/1/11: Resident returned from Dermatology appointment ... Right heel Pressure Bullae was drained ... Right heel 50% tan and 50% purple wound bed with little bloody drainage. Excess skin covers wound bed. Area moist without odor noted ... 11/4/11: ... Right heel wound bed 80% tan dry tissue in center of wound with 20% purple dry tissue around wound edges ... Resident tolerated treatment well without complaints of pain ... 11/7/11: ... Right heel 100% dry purple tissue ... Resident tolerated well without complaints of pain ... 11/17/11: ... Right heel 75% dry purple skin and 25% dry tan skin ... Resident tolerated well without complaints of pain ... 11/23/11: ...Right heel wound bed 60% purple dry skin and 40% tan dry skin ... Resident tolerated well without complaints of pain ... 11/28/11: ...Right heel wound bed 90% purple dry skin and 10% tan dry skin ... No complaints of pain voiced by resident ... 12/1/11: ...Right heel 100% purple/tan dry skin ... Resident tolerated well without complaints of pain ... 12/7/11: ...Right heel wound bed 90% purple hard dry skin with 10% tan hard dry skin to center. No drainage ... Resident tolerated well without complaints of pain ... 12/12/11: ...Right heel wound bed 90% purple hard dry skin with 10% tan hard dry skin in center. No drainage ... Resident tolerated well without complaints of pain ... 12/13/11: ...70% of dry purple/tan hard skin fell off during dressing change. 70% of wound bed red moist tissue with 30% hard, dry purple/tan skin towards edges of wound bed. No drainage ... Resident tolerated well without complaints of pain ... 12/15/11: ...50% dry purple/tan tissue/skin to wound bed. Noted with faint amount of bloody drainage. Resident tolerated well without complaints of pain ... 12/20/11: ...Right heel wound bed 50% moist red tissue with 50% dry purple tissue. Tiny amount of bloody drainage ... Resident tolerated treatment well without complaints of pain ... 12/22/11: ...Right heel ... 70% dry purple skin tissue in center of wound bed and 30% moist red tissue surrounding dry purple scar tissue ... Resident tolerated well without complaints of pain ... 12/29/11: ...Right heel wound bed 50% hard purple skin with 50% moist red skin ... Resident tolerated well without complaints of pain ... 1/2/12: ...Right heel wound bed 50% hard purple skin tissue and 50% moist red skin tissue. No drainage ... Resident voiced no complaints of pain ... 1/4/12: ...Right heel wound bed 50% hard dry purple tissue with faint amount of brown drainage. 50% red moist tissue surrounding hard, dry purple tissue without drainage ... Resident tolerated treatment well with complaints of pain only when touched ... Review of the Wound Treatment Evaluation Records for October 2011 through January 2012 revealed no measurements were made of resident #2's right heel by S3ADON. An observation was made on 1/4/12 at 8:45 a.m. of resident #2 lying in bed. The resident was positioned on his back with the head of the bed elevated. He was observed leaning to his left side. The resident's right foot was noted to have a Perplex dressing wrapped around his heel and ankle. The right heel was in direct contact with the mattress. On 1/4/12 at 9:20 a.m. an observation was made of resident #2's skin with S4LPN Treatment Nurse. Resident #2 mumbled when he saw S4LPN Treatment Nurse. She responded to the resident with, "I know you hate to see me because you know what I'm about to do will hurt". The resident was observed to be in the same position he had been in during the previous observation at 8:45 a.m. His right heel continued to be in direct contact with the mattress. In preparation of the treatment to the resident's right heel, S4LPN Treatment Nurse elevated his right heel off the mattress with a pillow. S4LPN Treatment Nurse removed the dressing to resident #2's right heel. There was a small amount of light brown drainage to the old dressing. The right medial heel was noted to have a large piece of eschar that was surrounded by reddened skin. The lower portion of the eschar, by the lower heel, had edges that were lifting. This left a small open area between the eschar edge and the surrounding red tissue. During the observation, an interview was held with S4LPN Treatment Nurse. She described resident #2's right heel as deep purple with surrounding red blanchable tissue. When S4LPN Treatment Nurse was asked specifically about the eschar to resident #2's right heel, she again responded that she classified the area as "deep purple". She further stated the right heel has had that appearance for three to four weeks. S4LPN Treatment Nurse proceeded to provide wound care, which consisted of cleaning the wound with normal saline, applying [MEDICATION NAME], covering the wound with clean gauze and wrapping with Perplex. Throughout the observation, resident #2 verbalized complaints of pain. The resident was noted with facial grimacing and cried out each time S4LPN Treatment Nurse touched his right foot. An interview was held with S4LPN Treatment Nurse on 1/4/12 at 10:00 a.m. She stated she worked Monday through Friday from 4:30 a.m. to 12:30 p.m. She stated she had been the treatment nurse for approximately six months. She said the facility provided wound training prior to her becoming the treatment nurse. She stated that she developed and revised skin related care plans. She said she updated resident's care plan when a new order was received. She explained that all wounds were measured and staged by S3ADON. She said that she notified S3ADON when a wound needed to be measured or staged. She said she and S3ADON communicated only verbally regarding wounds. She explained that resident #2's right heel had originated as a blister. She said the resident was seen by a Dermatologist and was diagnosed with [REDACTED]. She said "pressure bullae" was described to her as being an immune system illness. She further stated that resident #2's right heel was not considered to be a "pressure" wound since it was previously diagnosed as a "pressure bullae". She said the interventions ordered by the Dermatologist were [MEDICATION NAME] and pressure relief. She further stated that she had not notified S3ADON of resident #2's right heel wound because the wound was not a "pressure wound". When asked if she had notified the physician when the resident's right heel wound changed in appearance (according to her that was three to four weeks ago), S4LPN Treatment Nurse stated she had not notified the physician. She stated that the resident's right heel should be elevated off of the mattress to help with pressure relief. She explained that pillows, rolls, or wedges could be used to elevate the resident's right heel. She stated that resident #2 complained of pain each time she provided wound care. She said the resident "hated" to see her because he related her to pain. She stated the resident's medication nurse pre-medicated the resident prior to wound care. S4LPN Treatment Nurse stated that she did not know what medication the resident received for pain. She further stated that she had not notified the physician or the medication nurse when the resident continued to complain of pain during wound care. She verified she documented the resident did not complain of pain because she thought the resident was pre-medicated prior to wound care. She reviewed resident #2's skin plan of care and verified it had not been updated with interventions for the risk of pressure ulcers determined during his quarterly assessment on 10/17/11; the dermatology recommendations for pressure avoidance on 11/1/11; changes in wound appearance; or the resident's complaints of pain. On 1/4/12 at 11:20 a.m. an interview was held with S3ADON. She stated that she was responsible for weekly measurements of wounds and staging of pressure wounds. She stated that S4LPN Treatment Nurse notified her verbally of any wounds that needed assessing. S3ADON stated that she was not aware of resident #2 having a wound to his right heel. She recalled that "awhile back" the resident had multiple blisters. She stated that S4LPN Treatment Nurse had not informed her of resident's right heel wound. An observation was made of resident #2's right heel with S3ADON on 1/4/12 at 11:25 a.m. Resident #2 was observed to be lying in bed on his back with his right heel lying directly on the mattress in the same position the resident was in during previous observations at 8:45 a.m. and 9:20 a.m.. S3ADON removed the dressing from resident #2's right heel. Resident #2 was observed to have facial grimacing and verbalize complaints of pain each time S3ADON touched his right foot. S3ADON asked the resident if his foot hurt, and resident #2 responded "yes". S3ADON assessed the resident's right heel and when asked to describe the right heel wound, she replied, "That's eschar". S3ADON stated the surrounding tissue was red and the lower portion of the heel was "spongy" with a "deep purple" color. S3ADON measured the wound and the following measurements were noted: eschar measured 6cm (length) x 5cm (width) x 0.8cm (depth) and surrounding redness measured 8cm (length) x 5cm (width). S3ADON stated she should have been notified of the resident's heel wound. She stated that she did not feel that [MEDICATION NAME] was appropriate treatment for [REDACTED]. On 1/4/12 at 11:50 a.m. an interview was held with S12LPN. She verified she was the routine medication nurse for resident #2. She stated that resident #2 was not ordered any medications for pain. She said that the resident had not complained of pain to her. She further stated that S4LPN Treatment Nurse had not informed her that resident #2 needed pre-medicating for pain prior to wound care. Review of the November 2011 through January 2012 physician's orders [REDACTED].#2 during that time. Review of the Nurse's Note dated 1/4/12 and timed for 1150 (11:50 a.m.) revealed documentation of S3ADON's assessment of resident #2's heel. The Note included the following: Report received of right heel wound - area assessed. "Eschar 5 x 6cm c (with) 1/8cm depth at inferior medial edge. Adjacent to that 5 x 8 crescent shaped area, red and blanchable at superior aspect, spongy purple at inferior aspect. Resident expressed pain upon palpitation ...". Review of the Physician's Telephone Orders dated 1/4/12 and timed for 1158 (11:58 a.m.) revealed the following orders for the right heel wound: 1. Cleanse area with wound cleanser and pat dry. 2. Apply Hydrogel. 3. Cover with Optiform or other foam dressing. 4. Change daily and PRN. 5. Foam heel booties to both feet at all times. 6. [MEDICATION NAME] (non-narcotic pain reliever) 1 per PEG tube every 6 hours PRN pain. On 1/5/12 at 8:25 a.m. an observation was made of resident #2 lying in bed with his eyes closed. The head of the bed was elevated at a high position and the resident's bilateral heels were observed to be in direct contact with the mattress. The resident's right ankle/heel was wrapped with a dressing. There was no heel protectors noted to the resident's bilateral heels. An interview was held with S2DON on 1/5/12 at 8:30 a.m. She stated that S3ADON had informed her of resident #2 experiencing pain when his right foot was touched and that his right heel had eschar. S2DON verified that prior to 1/4/12 the resident's heel had only been treated with [MEDICATION NAME]. She also verified resident #2 did not have any medications ordered for pain relief prior to 1/4/12. She stated S4LPN Treatment Nurse should have notified the physician when the resident's heel declined and the treatment should have been changed. S2DON stated that if a wound had not made progress within a couple of weeks or if a wound declined suddenly, the physician should be notified. S2DON stated it was S4LPN Treatment Nurse responsibility to assess a resident for pain prior, during, and after wound care. She said S4LPN Treatment Nurse should notify the medication nurse of any reported pain and if the resident has pain medication ordered, then the resident should receive the medication, and if the resident does not have pain medication ordered, S4LPN Treatment Nurse should notify the physician. S2DON stated S4LPN Treatment Nurse was responsible for updating a resident's care plan when changes occurred with their skin or wound. She reviewed resident #2's care plan and verified it had not been updated on 11/1/11 with interventions of pressure relief for his right heel as recommended by the dermatologist, changes in wound appearance, or the pain related to the wound. S2DON verified S4LPN Treatment Nurse was provided wound care training prior to becoming the treatment nurse. On 1/5/12 at 9:25 a.m. an interview was held with S4LPN Treatment Nurse. She stated that she always informed the CNAs of skin care interventions specific for each resident. She stated she verbally communicated to the CNAs that resident #2's needed bilateral heel protectors on at all times. An observation was made of S13CNA providing assistance to resident #2 on 1/5/12 at 9:35 a.m. During the observation, resident #2 was sitting in a wheelchair as S13CNA combed his hair. The resident's wheelchair was observed to have one leg rest to the left side of the chair. Resident #2 was wearing socks and had his left foot positioned on the leg rest and his right foot positioned flat on the floor. An interview was held with S13CNA during the observation and she verified the resident had a wound to his right heel. When asked if there were any pressure relieving interventions provided for his heel, S13CNA stated that the resident was turned every two hours. When the question was rephrased and S13CNA was asked if the resident was supposed to wear heel protectors, she stated not that she knew of. On 1/5/12, observations were made of resident #2 sitting in a wheelchair near the nurses' station from 9:45 a.m. to 1:20 p.m. The resident's left foot was positioned on the leg rest of the wheelchair and his right foot was positioned on the floor. The resident was wearing socks, but he did not have on heel protectors. At 1:20 p.m., nursing staff applied heel protectors to the resident's bilateral heels. Observations continued of resident #2 on 1/5/12, and between 2:00 p.m. and 3:00 p.m. the resident was observed rubbing his right leg. During this time, the resident was passed by nursing staff, including S12LPN, who stopped the resident from pulling on his PEG tube, but did not ask him anything else. At 2:55 p.m., an interview was held with resident #2. During the interview, he continued to rub his right leg. The resident requested a pillow to place beneath his right foot. During the interview, S15CNA approached resident #2 and the resident informed S15CNA that he wanted a pillow to place beneath his right foot. S15CNA asked the resident if he was ready to return to bed, and the resident responded "yes". At 3:00 p.m., resident #2 was taken to his room. S9CNA Supervisor, S15CNA, S16CNA and S17LPN were in the resident's room. At 3:05 p.m., the resident was observed rubbing his right leg when S16CNA asked him if his leg was hurting. The resident responded "my foot hurts on the bottom" while pointing to his right foot. At 3:10 p.m., the resident was assisted to bed requiring total assistance during the transfer from the wheelchair to the bed. Once in bed, the resident was noted with facial grimacing and he continued to point at his right foot. With S17LPN at the resident's bedside observing the resident, S15CNA asked the resident what was wrong. The resident stated "my foot" while pointing at his right foot. At 3:20 p.m., S17LPN was observed to leave the room and go to the medication cart. An interview was held with S16CNA on 1/5/12 at 3:30 p.m. She stated that CNAs obtained knowledge of specific interventions for each resident by reviewing the resident's Kardex. She stated each resident had a Kardex specific to their needs that was maintained for the CNAs. She verified the Kardex would include if a resident should have heel protectors in place. S16CNA further stated that she would not know that resident #2 was to have heel protectors on unless she reviewed the Kardex. Upon request of resident #2's Kardex, S16CNA was unable to locate it. She further stated that she had not been notified by a nurse that he was to have heel protectors on at all times. On 1/5/12 at 3:45 p.m. an interview was held with S2DON. She verified each resident had a Kardex that included information specific to their needs. She explained the Kardex was to be utilized by the CNAs. Upon searching the nurses' station for resident #2's Kardex, she was unable to locate it. She questioned S9CNA Supervisor regarding the whereabouts of the Kardex for resident #2 and S9CNA Supervisor stated all Kardexs for that hall was in the DON/ADON's office. S2DON located resident #2's Kardex within her office and stated that the ADON was going to review each Kardex before placing them back on the unit. When asked how the CNAs were to know that resident #2 was to have heel protectors on at all times, S2DON stated the resident's nurse and treatment nurse should notify the CNAs when orders were received regarding pressure relief. She verified the order for heel protectors was received on 1/4/12 and that she had witnessed the resident without heel protectors on 1/5/12 while sitting near the nurses' station. S2DON further stated that each resident was to be assessed for pain by their assigned medication nurse during medication pass and upon rounds. She said if a resident complains of pain, the nurse was to assess the location and intensity of the pain prior to medication and after. She said the nurse should document a resident's complaints of pain on the medication record and nurse's notes. On 1/6/12, review of the January 2012 Medication Record revealed resident #2 was administered [MEDICATION NAME] for pain on 1/5/12 at 7:00 a.m. The resident had not been treated for [REDACTED]. Review of the Nurse's Notes revealed no documentation of an evaluation or interventions for resident #2's right foot pain for 1/5/12 at 3:05 p.m. Resident #8: Review of the Standing Nursing Home Orders revealed, in part, the following related to Skin Care: 3. Stage 1 Decutitus-redness 0 pressure to the area. Use pressure relieving devices as needed ... 4. Stages II, II, IV: notify MD/NP on routine rounds ? Without eschar (100% granulation tissue) clean daily with normal saline or Wound cleanser apply Hydrogel to area, cover with damp 4X4. Cover with dry, clean dressing ? With Slough (minimal drainage). Clean daily with wound cleanser or normal saline, apply calcium alginate or santyl. Cover with damp 4X4 and dry, clean dressing. ? With Slough (moderate to heavy drainage). Clean twice a day and as needed with normal saline or wound cleanser, apply calcium alginate or santyl and cover with dry, clean dressing. 6. Report all purulent wound drainage/odor ... Review of the clinical record for resident #8 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes for the resident dated 10/7/11, revealed the resident was admitted to the facility with eschar to the 3rd, 4th and 5th toes on his left foot. Review of the Wound Treatment Evaluations for the month of October 2011-January 2012, for the wounds to the 3rd, 4th, and 5th toes of the left foot, revealed the following: No entries were made regarding the wounds from 10/7/11 through 10/16/11. Entries were made dated 10/17/11 for the wounds to the 3rd, 4th, and 5th toes of the left foot by S3ADON. All three wounds were listed as "unstageable" under the section "If pressure ulcer-Stage". There were no other assessments or measurements documented, by S3ADON, of the toes to the left foot on the wound treatment record from 10/18/11 through 1/4/12. Entries were made by S4LPN Treatment Nurse dated 10/17/11 and 10/18/11 which described all three toe wounds as "Black". These same entries showed the wounds were treated on these dates with wound cleaner, normal saline, pat dry, apply Santyl, cover with a dry/clean dressing. Check daily, change every day and as needed. This treatment was discontinued on 10/19/11 and monitoring of all three toe wounds for changes every day and as needed was started. No treatments were preformed to the wounds of the 3rd, 4th, and 5th toes on the left foot from 10/19/11-12/14/11. Review of the MDS dated [DATE] revealed under Section M-Skin Conditions: F. 1). Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar- 1 2). Number of these unstageable pressure ulcers that were present upon admission/reentry-enter how many were noted at the time of admission- 1 Review of a Podiatrist Consultation, dated 12/7/11, for the resident revealed a sharp excision of loose eschar on 3rd and 4th toes of left foot was performed and [MEDICATION NAME] ointment was applied. Further review of the Wound Treatment Evaluations for the month of October 2011-January 2012, for the wounds to the 3rd, 4th, and 5th toes of the left foot, revealed the following: On 12/15/11, treatment was started again to the 3rd and 4th toes of the left foot with wound cleanser/normal saline, pat dry, apply Santyl and cover with dry, clean dressing. Check daily; change every day, and as needed. This treatment was documented daily from 12/15/11 through 12/29/11. Monitoring of the 5th toe continued without treatment. On 12/30/11-1/5/12 the treatment was changed to clean with wound cleanser/normal saline, pat dry, appl

Based on observations, record reviews, and interviews the facility failed to ensure that services were provided according to professional standards of care for 4 (#2, #4, #7, #8) of 8 (#2, #4, #6, #7, #8, #9, #10, #11) residents that received wound care from a total sample of 11 residents.Policy and Procedure for the Prevention and treatment of [REDACTED]. On 11/1/11, a Dermatologist lanced a fluid filled blister to Resident #2's right heel and ordered [MEDICATION NAME] BID, and pressure relieving measures. Resident #2 was in Immediate Jeopardy after the 11/1/11 orders were received and the LPN treatment nurse and weekend treatment nurses failed to provide needed care and services including consultation with the physician regarding this right heel wound. For over 2 months, no one assessed this wound other than the LPN treatment nurse and the weekend nurses and no one notified the physician or the RN supervisor. On 1/4/12 the right heel wound had progressed to an unstageable wound with eschar measuring 6cm (length) x 5cm (width) x 0.8cm (depth) with surrounding redness measuring 8cm (length) x 5cm (width). Resident #2 experienced untreated pain from the wound and grimaced and cried out when his right foot was touched. Resident #8 was admitted to the facility on [DATE] with eschar to the left foot on the 3rd, 4th, and 5th toes. He was in immediate jeopardy after admission on 10/7/11 when the LPN treatment nurse wrote orders for the wounds without consultation with the physician, treatments were not conducted from 10/19/11-12/14/11, and no RN intervention occurred. Resident #8 experienced an increase in wound severity with tunneling, drainage, and a foul odor. From 11/1/11 until 1/4/12, the staff the facility assigned to care for Resident #2, and from 10/7/11 until 1/4/12, the staff assigned to care for resident #8, were unable or unprepared to provide the following needed care and services and there was no intervention by the ADON RN Supervisor to ensure the following needed care and services were provided: 1.) consult with the residents' physicians regarding changes in wound status (#2, #8); 2.) assess and communicate changes in status to other nurses and supervisors (#2, #8); 3.) assess, consult with the physician, and treat pain related to wounds (#2); 4.) implement pressure relieving interventions to prevent wounds from deteriorating (#2, #8)); 5.) ensure the plan of care was updated with interventions to prevent skin breakdown and/or heal skin wounds (#2, #8); 6.) ensure CNAs were aware of pressure relieving measures (#2, #8); 7. ensure the ADON had knowledge of residents with wounds and assessed these wounds (#2, #8); 8.) ensure the ADON clinically supervised the LPN treatment nurse and weekend nurses to ensure orders were followed and care was provided following professional standards of practice (#2, #8); 9.) consistently measure wounds (#2, #8); 10.) ensure the LPN treatment nurse did not write orders for treatments to wounds and obtained orders from the physician (#8); 11.) obtain treatment orders for wounds upon admission (#8); 12.) recognize that the standing orders did not address wounds with eschar (#8). 13.) include in the policy and procedure for wounds instructions to nurses regarding pain from ulcers other than pressure ulcers (#2). 14.) follow physician's orders [REDACTED]. 15.) notify the physician of abnormal lab results (#4); 16.) consult with the physician and obtain wound care orders after a hospital return (#7); 17.) provide accurate documentation regarding wound assessment and care (#7). This failure had the potential to harm six other residents with wounds (#4, #6, #7, #9, #10, #11 ) and placed them in immediate jeopardy. The administrator was notified of the Immediate Jeopardy on 1/6/12. The Immediate Jeopardy remained in place at exit. Findings: According to the National Federation of Licensed Practical Nurses, Nursing Practice Standards, the plan for nursing care is put into practice to achieve the stated goals and includes: 1). observing, recording and reporting significant changes which require intervention or different goals. 2.) applying nursing knowledge and skills to promote and maintain health, to prevent disease and disability and to optimize functional capabilities of an individual patient. According to the Louisiana Administrative Code, title 46, Professional and Occupational Standards Practice, Part XLVII, Nurse, Subpart 2, data concerning an individual's health status must be systematically and continuously collected, recorded and communicated... Standard Number 7: The registered nurse demonstrates the following professional nursing practice behaviors: Makes assignments to others that take into consideration patient safety and which are commensurate with the educational preparation experience, authorized scope of practice, knowledge and ability of the persons to whom the assignments are made. Review of the facility's policy entitled, "Policy and Procedure for the Prevention and treatment of [REDACTED]. Policy: It is the policy to properly identify and assess residents, either by an RN or under an RN's supervision, whose clinical conditions increase the risk for impaired skin integrity and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. Procedures include: A. it is important to individualize each resident's turning and repositioning schedule. B. the care plan for skin integrity is to be evaluated and revised based on response, outcomes, and needs of the resident. II. treatment of [REDACTED]. If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented: 2. notify physician 3. notify supervisor 6. re-evaluate turning and repositioning intervals 8. re-evaluate interventions per risk factors identified 10. initiate weekly wound documentation progress sheet 11. when a pressure ulcer is present, daily wound monitoring should include whether pain, if present , is being adequately controlled. 12. notify the physician, NP and supervisor if the ulcer(s) has not shown progress in 2-4 weeks and/or is deteriorating unexpectedly. Re-evaluate plan of care as appropriate. Resident #2: Review of the clinical record revealed resident #2 had a [DIAGNOSES REDACTED]. Review of the most recent MDS dated [DATE] revealed resident #2 had impaired range of motion to his upper and lower extremities and was totally dependent on staff for bed mobility and transfers. Review of the most recent Pressure Sore Risk assessment dated [DATE] revealed the resident scored a total score of "14" indicating he was a pressure sore risk. The resident was assessed as having "very limited" sensory perception - ability to respond meaningfully to pressure related discomfort. Review of the Nurse/Physician Communication Record completed by S3ADON on 10/25/11 revealed resident #2 had fluid filled blisters to multiple areas of the body that included the right heel. S3ADON further documented the resident had a temperature of 99.9 degrees axillary and was noted to be less alert than usual. Review of the Physician's Telephone Orders dated 10/25/11 included: 1. Cleanse blister areas with Normal Saline or Wound Cleanser, pat dry, apply Triple Antibiotic Ointment, cover with dressing, change every day. Diagnosis: [REDACTED]. 2. Dermatology consult... Diagnosis: [REDACTED]. Review of the Progress Note completed by the Nurse Practitioner on 10/26/11 revealed in part: Physical Examination: Skin: blister to ...heel Impression/Plan: [DIAGNOSES REDACTED] related to recent scabies - local care for now and follow up with Dermatologist. Review of the Nurse's Notes dated 10/27/11 revealed the resident had a temperature of 99.8 degrees axillary and was "not looking very well". The Nurse Practitioner was notified and ordered to send the resident to the emergency room for evaluation and treatment. Review of the hospital records revealed resident #2 was admitted to the hospital and treated for [REDACTED]. Review of the hospital's History and Physical dated 10/27/11 revealed in part: Dermatology: ... early pressure ulcers on his left foot as well as more prominent on his right heel. Review of the hospital Discharge Summary dated 10/30/11 included: Pressure Ulcers: The patient presented with multiple early pressure sites... Wound ostomy nurses were consulted and initiated treatment here which included turning every two hours, floating heels off the bed, having a specialty bed. Recommended cleaning the right heel with soap and water, apply Lidoflex pad to blister, cover with 4 x 4... Recommend continuing his wound care at the nursing home facility. Review of the hospital's Discharge Worksheet dated 10/30/11 and timed for 0915 (9:15 a.m.) included: Discharge Education and Instructions: (2) Wound care as outlined by our W.O.N. (wound ostomy nurse). Review of the discharge Medication List included Wound Care of the right heel as follows: Cleanse with soap and water, dry thoroughly, apply Lidoflex pad, cover with 4 x 4, wrap with conforming gauze, change every 48 hours. Review of the Admission and Physician's Telephone Orders dated 10/30/11 included no documentation of wound care for resident #2's right heel. Review of the October 2011 Wound Treatment Evaluation Record revealed no treatments were performed to the resident's right heel on 10/30/11. Review of the Nurse's Note dated 10/30/11 revealed a re-admission skin assessment of resident #2. The resident's right heel was not mentioned within the note. Review of the Weekly Skin Condition Evaluation dated 10/30/11 revealed no documentation related to the resident's right heel. Review of the Nurse's Note made by S4LPN Treatment Nurse on 10/31/11 included resident #2's right heel was noted with a "100% blood filled blister". Review of the October 2011 Wound Treatment Evaluation Record revealed the treatment that was performed to resident #2's right heel on 10/31/11 was as follows: clean with wound cleaner or normal saline, pat dry, apply TAO, cover with DCD. On 11/1/11, resident #2 was seen by the Dermatologist as ordered on [DATE]. Review of the Dermatology Note dated 11/1/11 was noted by S4LPN Treatment Nurse and included: Large bullae to right heel medially. Impression: Pressure Bullae Recommendations: Drained; [MEDICATION NAME] ointment BID, pressure avoidance. Review of the Physician's Telephone Order dated 11/1/11 revealed in part: 1. D/C Triple Antibiotic Ointment 2. Apply [MEDICATION NAME] ointment BID to right heel Review of the Skin Risk Evaluation and Plan of Care included 11/1/11: Pressure Bullue to right heel - Goal date 2/1/12 There were no interventions on the Plan of Care related to the right heel. There was no documentation of "pressure avoidance" as recommended by the dermatologist. The Plan of Care did not indicate the resident was at risk of developing a pressure sore as determined on 10/17/11. Review of the Nurse's Notes made by S4LPN Treatment Nurse revealed in part the following: 11/1/11: Resident returned from Dermatology appointment ... Right heel Pressure Bullae was drained ... Right heel 50% tan and 50% purple wound bed with little bloody drainage. Excess skin covers wound bed. Area moist without odor noted ... 11/4/11: ... Right heel wound bed 80% tan dry tissue in center of wound with 20% purple dry tissue around wound edges ... Resident tolerated treatment well without complaints of pain ... 11/7/11: ... Right heel 100% dry purple tissue ... Resident tolerated well without complaints of pain ... 11/17/11: ... Right heel 75% dry purple skin and 25% dry tan skin ... Resident tolerated well without complaints of pain ... 11/23/11: ...Right heel wound bed 60% purple dry skin and 40% tan dry skin ... Resident tolerated well without complaints of pain ... 11/28/11: ...Right heel wound bed 90% purple dry skin and 10% tan dry skin ... No complaints of pain voiced by resident ... 12/1/11: ...Right heel 100% purple/tan dry skin ... Resident tolerated well without complaints of pain ... 12/7/11: ...Right heel wound bed 90% purple hard dry skin with 10% tan hard dry skin to center. No drainage ... Resident tolerated well without complaints of pain ... 12/12/11: ...Right heel wound bed 90% purple hard dry skin with 10% tan hard dry skin in center. No drainage ... Resident tolerated well without complaints of pain ... 12/13/11: ...70% of dry purple/tan hard skin fell off during dressing change. 70% of wound bed red moist tissue with 30% hard, dry purple/tan skin towards edges of wound bed. No drainage ... Resident tolerated well without complaints of pain ... 12/15/11: ...50% dry purple/tan tissue/skin to wound bed. Noted with faint amount of bloody drainage. Resident tolerated well without complaints of pain ... 12/20/11: ...Right heel wound bed 50% moist red tissue with 50% dry purple tissue. Tiny amount of bloody drainage ... Resident tolerated treatment well without complaints of pain ... 12/22/11: ...Right heel ... 70% dry purple skin tissue in center of wound bed and 30% moist red tissue surrounding dry purple scar tissue ... Resident tolerated well without complaints of pain ... 12/29/11: ...Right heel wound bed 50% hard purple skin with 50% moist red skin ... Resident tolerated well without complaints of pain ... 1/2/12: ...Right heel wound bed 50% hard purple skin tissue and 50% moist red skin tissue. No drainage ... Resident voiced no complaints of pain ... 1/4/12: ...Right heel wound bed 50% hard dry purple tissue with faint amount of brown drainage. 50% red moist tissue surrounding hard, dry purple tissue without drainage ... Resident tolerated treatment well with complaints of pain only when touched ... Review of the Wound Treatment Evaluation Records for October 2011 through January 2012 revealed no measurements were made of resident #2's right heel by S3ADON. An observation was made on 1/4/12 at 8:45 a.m. of resident #2 lying in bed. The resident was positioned on his back with the head of the bed elevated. He was observed leaning to his left side. The resident's right foot was noted to have a Perplex dressing wrapped around his heel and ankle. The right heel was in direct contact with the mattress. On 1/4/12 at 9:20 a.m. an observation was made of resident #2's skin with S4LPN Treatment Nurse. Resident #2 mumbled when he saw S4LPN Treatment Nurse. She responded to the resident with, "I know you hate to see me because you know what I'm about to do will hurt". The resident was observed to be in the same position he had been in during the previous observation at 8:45 a.m. His right heel continued to be in direct contact with the mattress. In preparation of the treatment to the resident's right heel, S4LPN Treatment Nurse elevated his right heel off the mattress with a pillow. S4LPN Treatment Nurse removed the dressing to resident #2's right heel. There was a small amount of light brown drainage to the old dressing. The right medial heel was noted to have a large piece of eschar that was surrounded by reddened skin. The lower portion of the eschar, by the lower heel, had edges that were lifting. This left a small open area between the eschar edge and the surrounding red tissue. During the observation, an interview was held with S4LPN Treatment Nurse. She described resident #2's right heel as deep purple with surrounding red blanchable tissue. When S4LPN Treatment Nurse was asked specifically about the eschar to resident #2's right heel, she again responded that she classified the area as "deep purple". She further stated the right heel has had that appearance for three to four weeks. S4LPN Treatment Nurse proceeded to provide wound care, which consisted of cleaning the wound with normal saline, applying [MEDICATION NAME], covering the wound with clean gauze and wrapping with Perplex. Throughout the observation, resident #2 verbalized complaints of pain. The resident was noted with facial grimacing and cried out each time S4LPN Treatment Nurse touched his right foot. An interview was held with S4LPN Treatment Nurse on 1/4/12 at 10:00 a.m. She stated she worked Monday through Friday from 4:30 a.m. to 12:30 p.m. She stated she had been the treatment nurse for approximately six months. She said the facility provided wound training prior to her becoming the treatment nurse. She stated that she developed and revised skin related care plans. She said she updated resident's care plan when a new order was received. She explained that all wounds were measured and staged by S3ADON. She said that she notified S3ADON when a wound needed to be measured or staged. She said she and S3ADON communicated only verbally regarding wounds. She explained that resident #2's right heel had originated as a blister. She said the resident was seen by a Dermatologist and was diagnosed with [REDACTED]. She said "pressure bullae" was described to her as being an immune system illness. She further stated that resident #2's right heel was not considered to be a "pressure" wound since it was previously diagnosed as a "pressure bullae". She said the interventions ordered by the Dermatologist were [MEDICATION NAME] and pressure relief. She further stated that she had not notified S3ADON of resident #2's right heel wound because the wound was not a "pressure wound". When asked if she had notified the physician when the resident's right heel wound changed in appearance (according to her that was three to four weeks ago), S4LPN Treatment Nurse stated she had not notified the physician. She stated that the resident's right heel should be elevated off of the mattress to help with pressure relief. She explained that pillows, rolls, or wedges could be used to elevate the resident's right heel. She stated that resident #2 complained of pain each time she provided wound care. She said the resident "hated" to see her because he related her to pain. She stated the resident's medication nurse pre-medicated the resident prior to wound care. S4LPN Treatment Nurse stated that she did not know what medication the resident received for pain. She further stated that she had not notified the physician or the medication nurse when the resident continued to complain of pain during wound care. She verified she documented the resident did not complain of pain because she thought the resident was pre-medicated prior to wound care. She reviewed resident #2's skin plan of care and verified it had not been updated with interventions for the risk of pressure ulcers determined during his quarterly assessment on 10/17/11; the dermatology recommendations for pressure avoidance on 11/1/11; changes in wound appearance; or the resident's complaints of pain. On 1/4/12 at 11:20 a.m. an interview was held with S3ADON. She stated that she was responsible for weekly measurements of wounds and staging of pressure wounds. She stated that S4LPN Treatment Nurse notified her verbally of any wounds that needed assessing. S3ADON stated that she was not aware of resident #2 having a wound to his right heel. She recalled that "awhile back" the resident had multiple blisters. She stated that S4LPN Treatment Nurse had not informed her of resident's right heel wound. An observation was made of resident #2's right heel with S3ADON on 1/4/12 at 11:25 a.m. Resident #2 was observed to be lying in bed on his back with his right heel lying directly on the mattress in the same position the resident was in during previous observations at 8:45 a.m. and 9:20 a.m.. S3ADON removed the dressing from resident #2's right heel. Resident #2 was observed to have facial grimacing and verbalize complaints of pain each time S3ADON touched his right foot. S3ADON asked the resident if his foot hurt, and resident #2 responded "yes". S3ADON assessed the resident's right heel and when asked to describe the right heel wound, she replied, "That's eschar". S3ADON stated the surrounding tissue was red and the lower portion of the heel was "spongy" with a "deep purple" color. S3ADON measured the wound and the following measurements were noted: eschar measured 6cm (length) x 5cm (width) x 0.8cm (depth) and surrounding redness measured 8cm (length) x 5cm (width). S3ADON stated she should have been notified of the resident's heel wound. She stated that she did not feel that [MEDICATION NAME] was appropriate treatment for [REDACTED]. On 1/4/12 at 11:50 a.m. an interview was held with S12LPN. She verified she was the routine medication nurse for resident #2. She stated that resident #2 was not ordered any medications for pain. She said that the resident had not complained of pain to her. She further stated that S4LPN Treatment Nurse had not informed her that resident #2 needed pre-medicating for pain prior to wound care. Review of the November 2011 through January 2012 physician's orders [REDACTED].#2 during that time. Review of the Nurse's Note dated 1/4/12 and timed for 1150 (11:50 a.m.) revealed documentation of S3ADON's assessment of resident #2's heel. The Note included the following: Report received of right heel wound - area assessed. "Eschar 5 x 6cm c (with) 1/8cm depth at inferior medial edge. Adjacent to that 5 x 8 crescent shaped area, red and blanchable at superior aspect, spongy purple at inferior aspect. Resident expressed pain upon palpitation ...". Review of the Physician's Telephone Orders dated 1/4/12 and timed for 1158 (11:58 a.m.) revealed the following orders for the right heel wound: 1. Cleanse area with wound cleanser and pat dry. 2. Apply Hydrogel. 3. Cover with Optiform or other foam dressing. 4. Change daily and PRN. 5. Foam heel booties to both feet at all times. 6. [MEDICATION NAME] (non-narcotic pain reliever) 1 per PEG tube every 6 hours PRN pain. On 1/5/12 at 8:25 a.m. an observation was made of resident #2 lying in bed with his eyes closed. The head of the bed was elevated at a high position and the resident's bilateral heels were observed to be in direct contact with the mattress. The resident's right ankle/heel was wrapped with a dressing. There was no heel protectors noted to the resident's bilateral heels. An interview was held with S2DON on 1/5/12 at 8:30 a.m. She stated that S3ADON had informed her of resident #2 experiencing pain when his right foot was touched and that his right heel had eschar. S2DON verified that prior to 1/4/12 the resident's heel had only been treated with [MEDICATION NAME]. She also verified resident #2 did not have any medications ordered for pain relief prior to 1/4/12. She stated S4LPN Treatment Nurse should have notified the physician when the resident's heel declined and the treatment should have been changed. S2DON stated that if a wound had not made progress within a couple of weeks or if a wound declined suddenly, the physician should be notified. S2DON stated it was S4LPN Treatment Nurse responsibility to assess a resident for pain prior, during, and after wound care. She said S4LPN Treatment Nurse should notify the medication nurse of any reported pain and if the resident has pain medication ordered, then the resident should receive the medication, and if the resident does not have pain medication ordered, S4LPN Treatment Nurse should notify the physician. S2DON stated S4LPN Treatment Nurse was responsible for updating a resident's care plan when changes occurred with their skin or wound. She reviewed resident #2's care plan and verified it had not been updated on 11/1/11 with interventions of pressure relief for his right heel as recommended by the dermatologist, changes in wound appearance, or the pain related to the wound. S2DON verified S4LPN Treatment Nurse was provided wound care training prior to becoming the treatment nurse. On 1/5/12 at 9:25 a.m. an interview was held with S4LPN Treatment Nurse. She stated that she always informed the CNAs of skin care interventions specific for each resident. She stated she verbally communicated to the CNAs that resident #2's needed bilateral heel protectors on at all times. An observation was made of S13CNA providing assistance to resident #2 on 1/5/12 at 9:35 a.m. During the observation, resident #2 was sitting in a wheelchair as S13CNA combed his hair. The resident's wheelchair was observed to have one leg rest to the left side of the chair. Resident #2 was wearing socks and had his left foot positioned on the leg rest and his right foot positioned flat on the floor. An interview was held with S13CNA during the observation and she verified the resident had a wound to his right heel. When asked if there were any pressure relieving interventions provided for his heel, S13CNA stated that the resident was turned every two hours. When the question was rephrased and S13CNA was asked if the resident was supposed to wear heel protectors, she stated not that she knew of. On 1/5/12, observations were made of resident #2 sitting in a wheelchair near the nurses' station from 9:45 a.m. to 1:20 p.m. The resident's left foot was positioned on the leg rest of the wheelchair and his right foot was positioned on the floor. The resident was wearing socks, but he did not have on heel protectors. At 1:20 p.m., nursing staff applied heel protectors to the resident's bilateral heels. Observations continued of resident #2 on 1/5/12, and between 2:00 p.m. and 3:00 p.m. the resident was observed rubbing his right leg. During this time, the resident was passed by nursing staff, including S12LPN, who stopped the resident from pulling on his PEG tube, but did not ask him anything else. At 2:55 p.m., an interview was held with resident #2. During the interview, he continued to rub his right leg. The resident requested a pillow to place beneath his right foot. During the interview, S15CNA approached resident #2 and the resident informed S15CNA that he wanted a pillow to place beneath his right foot. S15CNA asked the resident if he was ready to return to bed, and the resident responded "yes". At 3:00 p.m., resident #2 was taken to his room. S9CNA Supervisor, S15CNA, S16CNA and S17LPN were in the resident's room. At 3:05 p.m., the resident was observed rubbing his right leg when S16CNA asked him if his leg was hurting. The resident responded "my foot hurts on the bottom" while pointing to his right foot. At 3:10 p.m., the resident was assisted to bed requiring total assistance during the transfer from the wheelchair to the bed. Once in bed, the resident was noted with facial grimacing and he continued to point at his right foot. With S17LPN at the resident's bedside observing the resident, S15CNA asked the resident what was wrong. The resident stated "my foot" while pointing at his right foot. At 3:20 p.m., S17LPN was observed to leave the room and go to the medication cart. An interview was held with S16CNA on 1/5/12 at 3:30 p.m. She stated that CNAs obtained knowledge of specific interventions for each resident by reviewing the resident's Kardex. She stated each resident had a Kardex specific to their needs that was maintained for the CNAs. She verified the Kardex would include if a resident should have heel protectors in place. S16CNA further stated that she would not know that resident #2 was to have heel protectors on unless she reviewed the Kardex. Upon request of resident #2's Kardex, S16CNA was unable to locate it. She further stated that she had not been notified by a nurse that he was to have heel protectors on at all times. On 1/5/12 at 3:45 p.m. an interview was held with S2DON. She verified each resident had a Kardex that included information specific to their needs. She explained the Kardex was to be utilized by the CNAs. Upon searching the nurses' station for resident #2's Kardex, she was unable to locate it. She questioned S9CNA Supervisor regarding the whereabouts of the Kardex for resident #2 and S9CNA Supervisor stated all Kardexs for that hall was in the DON/ADON's office. S2DON located resident #2's Kardex within her office and stated that the ADON was going to review each Kardex before placing them back on the unit. When asked how the CNAs were to know that resident #2 was to have heel protectors on at all times, S2DON stated the resident's nurse and treatment nurse should notify the CNAs when orders were received regarding pressure relief. She verified the order for heel protectors was received on 1/4/12 and that she had witnessed the resident without heel protectors on 1/5/12 while sitting near the nurses' station. S2DON further stated that each resident was to be assessed for pain by their assigned medication nurse during medication pass and upon rounds. She said if a resident complains of pain, the nurse was to assess the location and intensity of the pain prior to medication and after. She said the nurse should document a resident's complaints of pain on the medication record and nurse's notes. On 1/6/12, review of the January 2012 Medication Record revealed resident #2 was administered [MEDICATION NAME] for pain on 1/5/12 at 7:00 a.m. The resident had not been treated for [REDACTED]. Review of the Nurse's Notes revealed no documentation of an evaluation or interventions for resident #2's right foot pain for 1/5/12 at 3:05 p.m. Resident #8: Review of the Standing Nursing Home Orders revealed, in part, the following related to Skin Care: 3. Stage 1 Decutitus-redness 0 pressure to the area. Use pressure relieving devices as needed ... 4. Stages II, II, IV: notify MD/NP on routine rounds ? Without eschar (100% granulation tissue) clean daily with normal saline or Wound cleanser apply Hydrogel to area, cover with damp 4X4. Cover with dry, clean dressing ? With Slough (minimal drainage). Clean daily with wound cleanser or normal saline, apply calcium alginate or santyl. Cover with damp 4X4 and dry, clean dressing. ? With Slough (moderate to heavy drainage). Clean twice a day and as needed with normal saline or wound cleanser, apply calcium alginate or santyl and cover with dry, clean dressing. 6. Report all purulent wound drainage/odor ... Review of the clinical record for resident #8 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes for the resident dated 10/7/11, revealed the resident was admitted to the facility with eschar to the 3rd, 4th and 5th toes on his left foot. Review of the Wound Treatment Evaluations for the month of October 2011-January 2012, for the wounds to the 3rd, 4th, and 5th toes of the left foot, revealed the following: No entries were made regarding the wounds from 10/7/11 through 10/16/11. Entries were made dated 10/17/11 for the wounds to the 3rd, 4th, and 5th toes of the left foot by S3ADON. All three wounds were listed as "unstageable" under the section "If pressure ulcer-Stage". There were no other assessments or measurements documented, by S3ADON, of the toes to the left foot on the wound treatment record from 10/18/11 through 1/4/12. Entries were made by S4LPN Treatment Nurse dated 10/17/11 and 10/18/11 which described all three toe wounds as "Black". These same entries showed the wounds were treated on these dates with wound cleaner, normal saline, pat dry, apply Santyl, cover with a dry/clean dressing. Check daily, change every day and as needed. This treatment was discontinued on 10/19/11 and monitoring of all three toe wounds for changes every day and as needed was started. No treatments were preformed to the wounds of the 3rd, 4th, and 5th toes on the left foot from 10/19/11-12/14/11. Review of the MDS dated [DATE] revealed un

Based on observations, record reviews, and interviews the facility failed to ensure that services were provided according to professional standards of care for 4 (#2, #4, #7, #8) of 8 (#2, #4, #6, #7, #8, #9, #10, #11) residents that received wound care from a total sample of 11 residents.Policy and Procedure for the Prevention and treatment of [REDACTED]. On 11/1/11, a Dermatologist lanced a fluid filled blister to Resident #2's right heel and ordered [MEDICATION NAME] BID, and pressure relieving measures. Resident #2 was in Immediate Jeopardy after the 11/1/11 orders were received and the LPN treatment nurse and weekend treatment nurses failed to provide needed care and services including consultation with the physician regarding this right heel wound. For over 2 months, no one assessed this wound other than the LPN treatment nurse and the weekend nurses and no one notified the physician or the RN supervisor. On 1/4/12 the right heel wound had progressed to an unstageable wound with eschar measuring 6cm (length) x 5cm (width) x 0.8cm (depth) with surrounding redness measuring 8cm (length) x 5cm (width). Resident #2 experienced untreated pain from the wound and grimaced and cried out when his right foot was touched. Resident #8 was admitted to the facility on [DATE] with eschar to the left foot on the 3rd, 4th, and 5th toes. He was in immediate jeopardy after admission on 10/7/11 when the LPN treatment nurse wrote orders for the wounds without consultation with the physician, treatments were not conducted from 10/19/11-12/14/11, and no RN intervention occurred. Resident #8 experienced an increase in wound severity with tunneling, drainage, and a foul odor. From 11/1/11 until 1/4/12, the staff the facility assigned to care for Resident #2, and from 10/7/11 until 1/4/12, the staff assigned to care for resident #8, were unable or unprepared to provide the following needed care and services and there was no intervention by the ADON RN Supervisor to ensure the following needed care and services were provided: 1.) consult with the residents' physicians regarding changes in wound status (#2, #8); 2.) assess and communicate changes in status to other nurses and supervisors (#2, #8); 3.) assess, consult with the physician, and treat pain related to wounds (#2); 4.) implement pressure relieving interventions to prevent wounds from deteriorating (#2, #8)); 5.) ensure the plan of care was updated with interventions to prevent skin breakdown and/or heal skin wounds (#2, #8); 6.) ensure CNAs were aware of pressure relieving measures (#2, #8); 7. ensure the ADON had knowledge of residents with wounds and assessed these wounds (#2, #8); 8.) ensure the ADON clinically supervised the LPN treatment nurse and weekend nurses to ensure orders were followed and care was provided following professional standards of practice (#2, #8); 9.) consistently measure wounds (#2, #8); 10.) ensure the LPN treatment nurse did not write orders for treatments to wounds and obtained orders from the physician (#8); 11.) obtain treatment orders for wounds upon admission (#8); 12.) recognize that the standing orders did not address wounds with eschar (#8). 13.) include in the policy and procedure for wounds instructions to nurses regarding pain from ulcers other than pressure ulcers (#2). 14.) follow physician's orders [REDACTED].#2); 15.) notify the physician of abnormal lab results (#4); 16.) consult with the physician and obtain wound care orders after a hospital return (#7); 17.) provide accurate documentation regarding wound assessment and care (#7). This failure had the potential to harm six other residents with wounds (#4, #6, #7, #9, #10, #11 ) and placed them in immediate jeopardy. The administrator was notified of the Immediate Jeopardy on 1/6/12. On January 20, 2012, the facility presented a plan or removal which included assessing and treating the wounds, physician consultation, having RN supervision of the wound care, implementing pressure relieving devices, and pain management measures. Surveyors determined the Immediate Jeopardy was removed on January 23, 2012. The deficient practice continues at patterns of actual harm for residents #2 and #8 and a potential for more than minimal harm for residents #4, #6, #7, #9, #10, and #11. Findings: According to the National Federation of Licensed Practical Nurses, Nursing Practice Standards, the plan for nursing care is put into practice to achieve the stated goals and includes: 1). observing, recording and reporting significant changes which require intervention or different goals. 2.) applying nursing knowledge and skills to promote and maintain health, to prevent disease and disability and to optimize functional capabilities of an individual patient. According to the Louisiana Administrative Code, title 46, Professional and Occupational Standards Practice, Part XLVII, Nurse, Subpart 2, data concerning an individual's health status must be systematically and continuously collected, recorded and communicated... Standard Number 7: The registered nurse demonstrates the following professional nursing practice behaviors: Makes assignments to others that take into consideration patient safety and which are commensurate with the educational preparation experience, authorized scope of practice, knowledge and ability of the persons to whom the assignments are made. Review of the facility's policy entitled, "Policy and Procedure for the Prevention and treatment of [REDACTED]. Policy: It is the policy to properly identify and assess residents, either by an RN or under an RN's supervision, whose clinical conditions increase the risk for impaired skin integrity and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. Procedures include: A. it is important to individualize each resident's turning and repositioning schedule. B. the care plan for skin integrity is to be evaluated and revised based on response, outcomes, and needs of the resident. II. treatment of [REDACTED]. If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented: 2. notify physician 3. notify supervisor 6. re-evaluate turning and repositioning intervals 8. re-evaluate interventions per risk factors identified 10. initiate weekly wound documentation progress sheet 11. when a pressure ulcer is present, daily wound monitoring should include whether pain, if present , is being adequately controlled. 12. notify the physician, NP and supervisor if the ulcer(s) has not shown progress in 2-4 weeks and/or is deteriorating unexpectedly. Re-evaluate plan of care as appropriate. Resident #2: Review of the clinical record revealed resident #2 had a [DIAGNOSES REDACTED]. Review of the most recent MDS dated [DATE] revealed resident #2 had impaired range of motion to his upper and lower extremities and was totally dependent on staff for bed mobility and transfers. Review of the most recent Pressure Sore Risk assessment dated [DATE] revealed the resident scored a total score of "14" indicating he was a pressure sore risk. The resident was assessed as having "very limited" sensory perception - ability to respond meaningfully to pressure related discomfort. Review of the Nurse/Physician Communication Record completed by S3ADON on 10/25/11 revealed resident #2 had fluid filled blisters to multiple areas of the body that included the right heel. S3ADON further documented the resident had a temperature of 99.9 degrees axillary and was noted to be less alert than usual. Review of the Physician's Telephone Orders dated 10/25/11 included: 1. Cleanse blister areas with Normal Saline or Wound Cleanser, pat dry, apply Triple Antibiotic Ointment, cover with dressing, change every day. Diagnosis: [REDACTED]. 2. Dermatology consult... Diagnosis: [REDACTED]. Review of the Progress Note completed by the Nurse Practitioner on 10/26/11 revealed in part: Physical Examination: Skin: blister to ...heel Impression/Plan: [DIAGNOSES REDACTED] related to recent scabies - local care for now and follow up with Dermatologist. Review of the Nurse's Notes dated 10/27/11 revealed the resident had a temperature of 99.8 degrees axillary and was "not looking very well". The Nurse Practitioner was notified and ordered to send the resident to the emergency room for evaluation and treatment. Review of the hospital records revealed resident #2 was admitted to the hospital and treated for [REDACTED]. Review of the hospital's History and Physical dated 10/27/11 revealed in part: Dermatology: ... early pressure ulcers on his left foot as well as more prominent on his right heel. Review of the hospital Discharge Summary dated 10/30/11 included: Pressure Ulcers: The patient presented with multiple early pressure sites... Wound ostomy nurses were consulted and initiated treatment here which included turning every two hours, floating heels off the bed, having a specialty bed. Recommended cleaning the right heel with soap and water, apply Lidoflex pad to blister, cover with 4 x 4... Recommend continuing his wound care at the nursing home facility. Review of the hospital's Discharge Worksheet dated 10/30/11 and timed for 0915 (9:15 a.m.) included: Discharge Education and Instructions: (2) Wound care as outlined by our W.O.N. (wound ostomy nurse). Review of the discharge Medication List included Wound Care of the right heel as follows: Cleanse with soap and water, dry thoroughly, apply Lidoflex pad, cover with 4 x 4, wrap with conforming gauze, change every 48 hours. Review of the Admission and Physician's Telephone Orders dated 10/30/11 included no documentation of wound care for resident #2's right heel. Review of the October 2011 Wound Treatment Evaluation Record revealed no treatments were performed to the resident's right heel on 10/30/11. Review of the Nurse's Note dated 10/30/11 revealed a re-admission skin assessment of resident #2. The resident's right heel was not mentioned within the note. Review of the Weekly Skin Condition Evaluation dated 10/30/11 revealed no documentation related to the resident's right heel. Review of the Nurse's Note made by S4LPN Treatment Nurse on 10/31/11 included resident #2's right heel was noted with a "100% blood filled blister". Review of the October 2011 Wound Treatment Evaluation Record revealed the treatment that was performed to resident #2's right heel on 10/31/11 was as follows: clean with wound cleaner or normal saline, pat dry, apply TAO, cover with DCD. On 11/1/11, resident #2 was seen by the Dermatologist as ordered on [DATE]. Review of the Dermatology Note dated 11/1/11 was noted by S4LPN Treatment Nurse and included: Large bullae to right heel medially. Impression: Pressure Bullae Recommendations: Drained; [MEDICATION NAME] ointment BID, pressure avoidance. Review of the Physician's Telephone Order dated 11/1/11 revealed in part: 1. D/C Triple Antibiotic Ointment 2. Apply [MEDICATION NAME] ointment BID to right heel Review of the Skin Risk Evaluation and Plan of Care included 11/1/11: Pressure Bullue to right heel - Goal date 2/1/12 There were no interventions on the Plan of Care related to the right heel. There was no documentation of "pressure avoidance" as recommended by the dermatologist. The Plan of Care did not indicate the resident was at risk of developing a pressure sore as determined on 10/17/11. Review of the Nurse's Notes made by S4LPN Treatment Nurse revealed in part the following: 11/1/11: Resident returned from Dermatology appointment ... Right heel Pressure Bullae was drained ... Right heel 50% tan and 50% purple wound bed with little bloody drainage. Excess skin covers wound bed. Area moist without odor noted ... 11/4/11: ... Right heel wound bed 80% tan dry tissue in center of wound with 20% purple dry tissue around wound edges ... Resident tolerated treatment well without complaints of pain ... 11/7/11: ... Right heel 100% dry purple tissue ... Resident tolerated well without complaints of pain ... 11/17/11: ... Right heel 75% dry purple skin and 25% dry tan skin ... Resident tolerated well without complaints of pain ... 11/23/11: ...Right heel wound bed 60% purple dry skin and 40% tan dry skin ... Resident tolerated well without complaints of pain ... 11/28/11: ...Right heel wound bed 90% purple dry skin and 10% tan dry skin ... No complaints of pain voiced by resident ... 12/1/11: ...Right heel 100% purple/tan dry skin ... Resident tolerated well without complaints of pain ... 12/7/11: ...Right heel wound bed 90% purple hard dry skin with 10% tan hard dry skin to center. No drainage ... Resident tolerated well without complaints of pain ... 12/12/11: ...Right heel wound bed 90% purple hard dry skin with 10% tan hard dry skin in center. No drainage ... Resident tolerated well without complaints of pain ... 12/13/11: ...70% of dry purple/tan hard skin fell off during dressing change. 70% of wound bed red moist tissue with 30% hard, dry purple/tan skin towards edges of wound bed. No drainage ... Resident tolerated well without complaints of pain ... 12/15/11: ...50% dry purple/tan tissue/skin to wound bed. Noted with faint amount of bloody drainage. Resident tolerated well without complaints of pain ... 12/20/11: ...Right heel wound bed 50% moist red tissue with 50% dry purple tissue. Tiny amount of bloody drainage ... Resident tolerated treatment well without complaints of pain ... 12/22/11: ...Right heel ... 70% dry purple skin tissue in center of wound bed and 30% moist red tissue surrounding dry purple scar tissue ... Resident tolerated well without complaints of pain ... 12/29/11: ...Right heel wound bed 50% hard purple skin with 50% moist red skin ... Resident tolerated well without complaints of pain ... 1/2/12: ...Right heel wound bed 50% hard purple skin tissue and 50% moist red skin tissue. No drainage ... Resident voiced no complaints of pain ... 1/4/12: ...Right heel wound bed 50% hard dry purple tissue with faint amount of brown drainage. 50% red moist tissue surrounding hard, dry purple tissue without drainage ... Resident tolerated treatment well with complaints of pain only when touched ... Review of the Wound Treatment Evaluation Records for October 2011 through January 2012 revealed no measurements were made of resident #2's right heel by S3ADON. An observation was made on 1/4/12 at 8:45 a.m. of resident #2 lying in bed. The resident was positioned on his back with the head of the bed elevated. He was observed leaning to his left side. The resident's right foot was noted to have a Perplex dressing wrapped around his heel and ankle. The right heel was in direct contact with the mattress. On 1/4/12 at 9:20 a.m. an observation was made of resident #2's skin with S4LPN Treatment Nurse. Resident #2 mumbled when he saw S4LPN Treatment Nurse. She responded to the resident with, "I know you hate to see me because you know what I'm about to do will hurt". The resident was observed to be in the same position he had been in during the previous observation at 8:45 a.m. His right heel continued to be in direct contact with the mattress. In preparation of the treatment to the resident's right heel, S4LPN Treatment Nurse elevated his right heel off the mattress with a pillow. S4LPN Treatment Nurse removed the dressing to resident #2's right heel. There was a small amount of light brown drainage to the old dressing. The right medial heel was noted to have a large piece of eschar that was surrounded by reddened skin. The lower portion of the eschar, by the lower heel, had edges that were lifting. This left a small open area between the eschar edge and the surrounding red tissue. During the observation, an interview was held with S4LPN Treatment Nurse. She described resident #2's right heel as deep purple with surrounding red blanchable tissue. When S4LPN Treatment Nurse was asked specifically about the eschar to resident #2's right heel, she again responded that she classified the area as "deep purple". She further stated the right heel has had that appearance for three to four weeks. S4LPN Treatment Nurse proceeded to provide wound care, which consisted of cleaning the wound with normal saline, applying [MEDICATION NAME], covering the wound with clean gauze and wrapping with Perplex. Throughout the observation, resident #2 verbalized complaints of pain. The resident was noted with facial grimacing and cried out each time S4LPN Treatment Nurse touched his right foot. An interview was held with S4LPN Treatment Nurse on 1/4/12 at 10:00 a.m. She stated she worked Monday through Friday from 4:30 a.m. to 12:30 p.m. She stated she had been the treatment nurse for approximately six months. She said the facility provided wound training prior to her becoming the treatment nurse. She stated that she developed and revised skin related care plans. She said she updated resident's care plan when a new order was received. She explained that all wounds were measured and staged by S3ADON. She said that she notified S3ADON when a wound needed to be measured or staged. She said she and S3ADON communicated only verbally regarding wounds. She explained that resident #2's right heel had originated as a blister. She said the resident was seen by a Dermatologist and was diagnosed with [REDACTED]. She said "pressure bullae" was described to her as being an immune system illness. She further stated that resident #2's right heel was not considered to be a "pressure" wound since it was previously diagnosed as a "pressure bullae". She said the interventions ordered by the Dermatologist were [MEDICATION NAME] and pressure relief. She further stated that she had not notified S3ADON of resident #2's right heel wound because the wound was not a "pressure wound". When asked if she had notified the physician when the resident's right heel wound changed in appearance (according to her that was three to four weeks ago), S4LPN Treatment Nurse stated she had not notified the physician. She stated that the resident's right heel should be elevated off of the mattress to help with pressure relief. She explained that pillows, rolls, or wedges could be used to elevate the resident's right heel. She stated that resident #2 complained of pain each time she provided wound care. She said the resident "hated" to see her because he related her to pain. She stated the resident's medication nurse pre-medicated the resident prior to wound care. S4LPN Treatment Nurse stated that she did not know what medication the resident received for pain. She further stated that she had not notified the physician or the medication nurse when the resident continued to complain of pain during wound care. She verified she documented the resident did not complain of pain because she thought the resident was pre-medicated prior to wound care. She reviewed resident #2's skin plan of care and verified it had not been updated with interventions for the risk of pressure ulcers determined during his quarterly assessment on 10/17/11; the dermatology recommendations for pressure avoidance on 11/1/11; changes in wound appearance; or the resident's complaints of pain. On 1/4/12 at 11:20 a.m. an interview was held with S3ADON. She stated that she was responsible for weekly measurements of wounds and staging of pressure wounds. She stated that S4LPN Treatment Nurse notified her verbally of any wounds that needed assessing. S3ADON stated that she was not aware of resident #2 having a wound to his right heel. She recalled that "awhile back" the resident had multiple blisters. She stated that S4LPN Treatment Nurse had not informed her of resident's right heel wound. An observation was made of resident #2's right heel with S3ADON on 1/4/12 at 11:25 a.m. Resident #2 was observed to be lying in bed on his back with his right heel lying directly on the mattress in the same position the resident was in during previous observations at 8:45 a.m. and 9:20 a.m.. S3ADON removed the dressing from resident #2's right heel. Resident #2 was observed to have facial grimacing and verbalize complaints of pain each time S3ADON touched his right foot. S3ADON asked the resident if his foot hurt, and resident #2 responded "yes". S3ADON assessed the resident's right heel and when asked to describe the right heel wound, she replied, "That's eschar". S3ADON stated the surrounding tissue was red and the lower portion of the heel was "spongy" with a "deep purple" color. S3ADON measured the wound and the following measurements were noted: eschar measured 6cm (length) x 5cm (width) x 0.8cm (depth) and surrounding redness measured 8cm (length) x 5cm (width). S3ADON stated she should have been notified of the resident's heel wound. She stated that she did not feel that [MEDICATION NAME] was appropriate treatment for [REDACTED]. On 1/4/12 at 11:50 a.m. an interview was held with S12LPN. She verified she was the routine medication nurse for resident #2. She stated that resident #2 was not ordered any medications for pain. She said that the resident had not complained of pain to her. She further stated that S4LPN Treatment Nurse had not informed her that resident #2 needed pre-medicating for pain prior to wound care. Review of the November 2011 through January 2012 physician's orders [REDACTED].#2 during that time. Review of the Nurse's Note dated 1/4/12 and timed for 1150 (11:50 a.m.) revealed documentation of S3ADON's assessment of resident #2's heel. The Note included the following: Report received of right heel wound - area assessed. "Eschar 5 x 6cm c (with) 1/8cm depth at inferior medial edge. Adjacent to that 5 x 8 crescent shaped area, red and blanchable at superior aspect, spongy purple at inferior aspect. Resident expressed pain upon palpitation ...". Review of the Physician's Telephone Orders dated 1/4/12 and timed for 1158 (11:58 a.m.) revealed the following orders for the right heel wound: 1. Cleanse area with wound cleanser and pat dry. 2. Apply Hydrogel. 3. Cover with Optiform or other foam dressing. 4. Change daily and PRN. 5. Foam heel booties to both feet at all times. 6. [MEDICATION NAME] (non-narcotic pain reliever) 1 per PEG tube every 6 hours PRN pain. On 1/5/12 at 8:25 a.m. an observation was made of resident #2 lying in bed with his eyes closed. The head of the bed was elevated at a high position and the resident's bilateral heels were observed to be in direct contact with the mattress. The resident's right ankle/heel was wrapped with a dressing. There was no heel protectors noted to the resident's bilateral heels. An interview was held with S2DON on 1/5/12 at 8:30 a.m. She stated that S3ADON had informed her of resident #2 experiencing pain when his right foot was touched and that his right heel had eschar. S2DON verified that prior to 1/4/12 the resident's heel had only been treated with [MEDICATION NAME]. She also verified resident #2 did not have any medications ordered for pain relief prior to 1/4/12. She stated S4LPN Treatment Nurse should have notified the physician when the resident's heel declined and the treatment should have been changed. S2DON stated that if a wound had not made progress within a couple of weeks or if a wound declined suddenly, the physician should be notified. S2DON stated it was S4LPN Treatment Nurse responsibility to assess a resident for pain prior, during, and after wound care. She said S4LPN Treatment Nurse should notify the medication nurse of any reported pain and if the resident has pain medication ordered, then the resident should receive the medication, and if the resident does not have pain medication ordered, S4LPN Treatment Nurse should notify the physician. S2DON stated S4LPN Treatment Nurse was responsible for updating a resident's care plan when changes occurred with their skin or wound. She reviewed resident #2's care plan and verified it had not been updated on 11/1/11 with interventions of pressure relief for his right heel as recommended by the dermatologist, changes in wound appearance, or the pain related to the wound. S2DON verified S4LPN Treatment Nurse was provided wound care training prior to becoming the treatment nurse. On 1/5/12 at 9:25 a.m. an interview was held with S4LPN Treatment Nurse. She stated that she always informed the CNAs of skin care interventions specific for each resident. She stated she verbally communicated to the CNAs that resident #2's needed bilateral heel protectors on at all times. An observation was made of S13CNA providing assistance to resident #2 on 1/5/12 at 9:35 a.m. During the observation, resident #2 was sitting in a wheelchair as S13CNA combed his hair. The resident's wheelchair was observed to have one leg rest to the left side of the chair. Resident #2 was wearing socks and had his left foot positioned on the leg rest and his right foot positioned flat on the floor. An interview was held with S13CNA during the observation and she verified the resident had a wound to his right heel. When asked if there were any pressure relieving interventions provided for his heel, S13CNA stated that the resident was turned every two hours. When the question was rephrased and S13CNA was asked if the resident was supposed to wear heel protectors, she stated not that she knew of. On 1/5/12, observations were made of resident #2 sitting in a wheelchair near the nurses' station from 9:45 a.m. to 1:20 p.m. The resident's left foot was positioned on the leg rest of the wheelchair and his right foot was positioned on the floor. The resident was wearing socks, but he did not have on heel protectors. At 1:20 p.m., nursing staff applied heel protectors to the resident's bilateral heels. Observations continued of resident #2 on 1/5/12, and between 2:00 p.m. and 3:00 p.m. the resident was observed rubbing his right leg. During this time, the resident was passed by nursing staff, including S12LPN, who stopped the resident from pulling on his PEG tube, but did not ask him anything else. At 2:55 p.m., an interview was held with resident #2. During the interview, he continued to rub his right leg. The resident requested a pillow to place beneath his right foot. During the interview, S15CNA approached resident #2 and the resident informed S15CNA that he wanted a pillow to place beneath his right foot. S15CNA asked the resident if he was ready to return to bed, and the resident responded "yes". At 3:00 p.m., resident #2 was taken to his room. S9CNA Supervisor, S15CNA, S16CNA and S17LPN were in the resident's room. At 3:05 p.m., the resident was observed rubbing his right leg when S16CNA asked him if his leg was hurting. The resident responded "my foot hurts on the bottom" while pointing to his right foot. At 3:10 p.m., the resident was assisted to bed requiring total assistance during the transfer from the wheelchair to the bed. Once in bed, the resident was noted with facial grimacing and he continued to point at his right foot. With S17LPN at the resident's bedside observing the resident, S15CNA asked the resident what was wrong. The resident stated "my foot" while pointing at his right foot. At 3:20 p.m., S17LPN was observed to leave the room and go to the medication cart. An interview was held with S16CNA on 1/5/12 at 3:30 p.m. She stated that CNAs obtained knowledge of specific interventions for each resident by reviewing the resident's Kardex. She stated each resident had a Kardex specific to their needs that was maintained for the CNAs. She verified the Kardex would include if a resident should have heel protectors in place. S16CNA further stated that she would not know that resident #2 was to have heel protectors on unless she reviewed the Kardex. Upon request of resident #2's Kardex, S16CNA was unable to locate it. She further stated that she had not been notified by a nurse that he was to have heel protectors on at all times. On 1/5/12 at 3:45 p.m. an interview was held with S2DON. She verified each resident had a Kardex that included information specific to their needs. She explained the Kardex was to be utilized by the CNAs. Upon searching the nurses' station for resident #2's Kardex, she was unable to locate it. She questioned S9CNA Supervisor regarding the whereabouts of the Kardex for resident #2 and S9CNA Supervisor stated all Kardexs for that hall was in the DON/ADON's office. S2DON located resident #2's Kardex within her office and stated that the ADON was going to review each Kardex before placing them back on the unit. When asked how the CNAs were to know that resident #2 was to have heel protectors on at all times, S2DON stated the resident's nurse and treatment nurse should notify the CNAs when orders were received regarding pressure relief. She verified the order for heel protectors was received on 1/4/12 and that she had witnessed the resident without heel protectors on 1/5/12 while sitting near the nurses' station. S2DON further stated that each resident was to be assessed for pain by their assigned medication nurse during medication pass and upon rounds. She said if a resident complains of pain, the nurse was to assess the location and intensity of the pain prior to medication and after. She said the nurse should document a resident's complaints of pain on the medication record and nurse's notes. On 1/6/12, review of the January 2012 Medication Record revealed resident #2 was administered [MEDICATION NAME] for pain on 1/5/12 at 7:00 a.m. The resident had not been treated for [REDACTED]. Review of the Nurse's Notes revealed no documentation of an evaluation or interventions for resident #2's right foot pain for 1/5/12 at 3:05 p.m. Resident #8: Review of the Standing Nursing Home Orders revealed, in part, the following related to Skin Care: 3. Stage 1 Decutitus-redness 0 pressure to the area. Use pressure relieving devices as needed ... 4. Stages II, II, IV: notify MD/NP on routine rounds ? Without eschar (100% granulation tissue) clean daily with normal saline or Wound cleanser apply Hydrogel to area, cover with damp 4X4. Cover with dry, clean dressing ? With Slough (minimal drainage). Clean daily with wound cleanser or normal saline, apply calcium alginate or santyl. Cover with damp 4X4 and dry, clean dressing. ? With Slough (moderate to heavy drainage). Clean twice a day and as needed with normal saline or wound cleanser, apply calcium alginate or santyl and cover with dry, clean dressing. 6. Report all purulent wound drainage/odor ... Review of the clinical record for resident #8 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes for the resident dated 10/7/11, revealed the resident was admitted to the facility with eschar to the 3rd, 4th and 5th toes on his left foot. Review of the Wound Treatment Evaluations for the month of October 2011-January 2012, for the wounds to the 3rd, 4th, and 5th toes of the left foot, revealed the following: No entries were made regarding the wounds from 10/7/11 through 10/16/11. Entries were made dated 10/17/11 for the wounds to the 3rd, 4th, and 5th toes of the left foot by S3ADON. All three wounds were listed as "unstageable" under the section "If pressure ulcer-Stage". There were no other assessments or measurements documented, by S3ADON, of the toes to the left foot on the wound treatment record from 10/18/11 through 1/4/12. Entries were made by S4LPN Treatment Nurse dated 10/17/11 and 10/18/11 which described all three toe wounds as "Black". These same entries showed the wounds were treated

Based on observations, record reviews, and interviews, the facility failed to ensure residents maintained their highest level of well-being regarding wounds for 2 (#2, #8) of 8 (#2, #4, #6, #7, #8, #9, #10, #11) residents receiving wound care from a total sample of 11 residents. On 11/1/11, a Dermatologist lanced a fluid filled blister to Resident #2's right heel and ordered [MEDICATION NAME] BID and pressure relieving measures. Resident #2 was in Immediate Jeopardy after the 11/1/11 orders were received and the LPN treatment nurse and weekend treatment nurses failed to provide needed care and services including consultation with the physician regarding this right heel wound. For over 2 months, no one assessed this wound other than the LPN treatment nurse and the weekend nurses and no one notified the physician or the RN supervisor. On 1/4/12, the right heel wound had progressed to an unstageable wound with eschar measuring 6cm (length) x 5cm (width) x 0.8cm (depth) with surrounding redness measuring 8cm (length) x 5cm (width). Resident #2 experienced untreated pain from the wound and grimaced and cried out when his right foot was touched. Resident #8 was admitted to the facility on [DATE] with eschar to the left foot on the 3rd, 4th, and 5th toes. He was in immediate jeopardy after admission on 10/7/11 when the LPN treatment nurse wrote orders for the wounds without consultation with the physician, treatments were not conducted from 10/19/11-12/14/11, and no RN intervention occurred. Resident #8 experienced an increase in wound severity with tunneling, drainage, and a foul odor. From 11/1/11 until 1/4/12, the staff the facility assigned to care for Resident #2, and from 10/7/11 until 1/4/12, the staff assigned to care for resident #8, were unable or unprepared to provide the following needed care and services and there was no intervention by the ADON RN Supervisor to ensure the following needed care and services were provided: 1.) consult with the residents' physicians regarding changes in wound status (#2, #8); 2.) assess and communicate changes in status to other nurses and supervisors (#2, #8); 3.) assess, consult with the physician, and treat pain related to wounds (#2); 4.) implement pressure relieving interventions to prevent wounds from deteriorating (#2, #8)); 5.) ensure the plan of care was updated with interventions to prevent skin breakdown and/or heal skin wounds (#2, #8); 6.) ensure CNAs were aware of pressure relieving measures (#2, #8); 7. ensure the ADON had knowledge of residents with wounds and assessed these wounds (#2, #8); 8.) ensure the ADON clinically supervised the LPN treatment nurse and weekend nurses to ensure orders were followed and care was provided following professional standards of practice (#2, #8); 9.) consistently measure wounds (#2, #8); 10.) ensure the LPN treatment nurse did not write orders for treatments to wounds and obtained orders from the physician (#8); 11.) obtain treatment orders for wounds upon admission (#8); 12.) recognize that the standing orders did not address wounds with eschar (#8); 13.) include in the policy and procedure for wounds instructions to nurses regarding pain from ulcers other than pressure ulcers (#2). This failure had the potential to harm six other residents with wounds (#4, #6, #7, #9, #10, #11 ) and placed them in Immediate Jeopardy. The administrator was notified of the Immediate Jeopardy on 1/6/12. The Immediate Jeopardy remained in place at exit. Findings: Review of the facility's policy entitled, "Policy and Procedure for the Prevention and treatment of [REDACTED]. Policy: It is the policy to properly identify and assess residents, either by an RN or under an RN's supervision, whose clinical conditions increase the risk for impaired skin integrity and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. Procedures include: A. it is important to individualize each resident's turning and repositioning schedule. B. the care plan for skin integrity is to be evaluated and revised based on response, outcomes, and needs of the resident. II. treatment of [REDACTED]. If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented: 2. notify physician 3. notify supervisor 6. re-evaluate turning and repositioning intervals 8. re-evaluate interventions per risk factors identified 10. initiate weekly wound documentation progress sheet 11. when a pressure ulcer is present, daily wound monitoring should include whether pain, if present , is being adequately controlled. 12. notify the physician, NP and supervisor if the ulcer(s) has not shown progress in 2-4 weeks and/or is deteriorating unexpectedly. Re-evaluate plan of care as appropriate. Resident #2: Review of the clinical record revealed resident #2 had a [DIAGNOSES REDACTED]. Review of the most recent MDS dated [DATE] revealed resident #2 had impaired range of motion to his upper and lower extremities and was totally dependent on staff for bed mobility and transfers. Review of the most recent Pressure Sore Risk assessment dated [DATE] revealed the resident scored a total score of "14" indicating he was a pressure sore risk. The resident was assessed as having "very limited" sensory perception - ability to respond meaningfully to pressure related discomfort. Review of the Nurse/Physician Communication Record completed by S3ADON on 10/25/11 revealed resident #2 had fluid filled blisters to multiple areas of the body that included the right heel. S3ADON further documented the resident had a temperature of 99.9 degrees axillary and was noted to be less alert than usual. Review of the Physician's Telephone Orders dated 10/25/11 included: 1. Cleanse blister areas with Normal Saline or Wound Cleanser, pat dry, apply Triple Antibiotic Ointment, cover with dressing, change every day. Diagnosis: [REDACTED]. 2. Dermatology consult... Diagnosis: [REDACTED]. Review of the Progress Note completed by the Nurse Practitioner on 10/26/11 revealed in part: Physical Examination: Skin: blister to ...heel Impression/Plan: [DIAGNOSES REDACTED] related to recent scabies - local care for now and follow up with Dermatologist. Review of the Nurse's Notes dated 10/27/11 revealed the resident had a temperature of 99.8 degrees axillary and was "not looking very well". The Nurse Practitioner was notified and ordered to send the resident to the emergency room for evaluation and treatment. Review of the hospital records revealed resident #2 was admitted to the hospital and treated for [REDACTED]. Review of the hospital's History and Physical dated 10/27/11 revealed in part: Dermatology: ... early pressure ulcers on his left foot as well as more prominent on his right heel. Review of the hospital Discharge Summary dated 10/30/11 included: Pressure Ulcers: The patient presented with multiple early pressure sites... Wound ostomy nurses were consulted and initiated treatment here which included turning every two hours, floating heels off the bed, having a specialty bed. Recommended cleaning the right heel with soap and water, apply Lidoflex pad to blister, cover with 4 x 4... Recommend continuing his wound care at the nursing home facility. Review of the hospital's Discharge Worksheet dated 10/30/11 and timed for 0915 (9:15 a.m.) included: Discharge Education and Instructions: (2) Wound care as outlined by our W.O.N. (wound ostomy nurse). Review of the discharge Medication List included Wound Care of the right heel as follows: Cleanse with soap and water, dry thoroughly, apply Lidoflex pad, cover with 4 x 4, wrap with conforming gauze, change every 48 hours. Review of the Admission and Physician's Telephone Orders dated 10/30/11 included no documentation of wound care for resident #2's right heel. Review of the October 2011 Wound Treatment Evaluation Record revealed no treatments were performed to the resident's right heel on 10/30/11. Review of the Nurse's Note dated 10/30/11 revealed a re-admission skin assessment of resident #2. The resident's right heel was not mentioned within the note. Review of the Weekly Skin Condition Evaluation dated 10/30/11 revealed no documentation related to the resident's right heel. Review of the Nurse's Note made by S4LPN Treatment Nurse on 10/31/11 included resident #2's right heel was noted with a "100% blood filled blister". Review of the October 2011 Wound Treatment Evaluation Record revealed the treatment that was performed to resident #2's right heel on 10/31/11 was as follows: clean with wound cleaner or normal saline, pat dry, apply TAO, cover with DCD. On 11/1/11, resident #2 was seen by the Dermatologist as ordered on [DATE]. Review of the Dermatology Note dated 11/1/11 was noted by S4LPN Treatment Nurse and included: Large bullae to right heel medially. Impression: Pressure Bullae Recommendations: Drained; [MEDICATION NAME] ointment BID, pressure avoidance. Review of the Physician's Telephone Order dated 11/1/11 revealed in part: 1. D/C Triple Antibiotic Ointment 2. Apply [MEDICATION NAME] ointment BID to right heel Review of the Skin Risk Evaluation and Plan of Care included 11/1/11: Pressure Bullue to right heel - Goal date 2/1/12 There were no interventions on the Plan of Care related to the right heel. There was no documentation of "pressure avoidance" as recommended by the dermatologist. The Plan of Care did not indicate the resident was at risk of developing a pressure sore as determined on 10/17/11. Review of the Nurse's Notes made by S4LPN Treatment Nurse revealed in part the following: 11/1/11: Resident returned from Dermatology appointment ... Right heel Pressure Bullae was drained ... Right heel 50% tan and 50% purple wound bed with little bloody drainage. Excess skin covers wound bed. Area moist without odor noted ... 11/4/11: ... Right heel wound bed 80% tan dry tissue in center of wound with 20% purple dry tissue around wound edges ... Resident tolerated treatment well without complaints of pain ... 11/7/11: ... Right heel 100% dry purple tissue ... Resident tolerated well without complaints of pain ... 11/17/11: ... Right heel 75% dry purple skin and 25% dry tan skin ... Resident tolerated well without complaints of pain ... 11/23/11: ...Right heel wound bed 60% purple dry skin and 40% tan dry skin ... Resident tolerated well without complaints of pain ... 11/28/11: ...Right heel wound bed 90% purple dry skin and 10% tan dry skin ... No complaints of pain voiced by resident ... 12/1/11: ...Right heel 100% purple/tan dry skin ... Resident tolerated well without complaints of pain ... 12/7/11: ...Right heel wound bed 90% purple hard dry skin with 10% tan hard dry skin to center. No drainage ... Resident tolerated well without complaints of pain ... 12/12/11: ...Right heel wound bed 90% purple hard dry skin with 10% tan hard dry skin in center. No drainage ... Resident tolerated well without complaints of pain ... 12/13/11: ...70% of dry purple/tan hard skin fell off during dressing change. 70% of wound bed red moist tissue with 30% hard, dry purple/tan skin towards edges of wound bed. No drainage ... Resident tolerated well without complaints of pain ... 12/15/11: ...50% dry purple/tan tissue/skin to wound bed. Noted with faint amount of bloody drainage. Resident tolerated well without complaints of pain ... 12/20/11: ...Right heel wound bed 50% moist red tissue with 50% dry purple tissue. Tiny amount of bloody drainage ... Resident tolerated treatment well without complaints of pain ... 12/22/11: ...Right heel ... 70% dry purple skin tissue in center of wound bed and 30% moist red tissue surrounding dry purple scar tissue ... Resident tolerated well without complaints of pain ... 12/29/11: ...Right heel wound bed 50% hard purple skin with 50% moist red skin ... Resident tolerated well without complaints of pain ... 1/2/12: ...Right heel wound bed 50% hard purple skin tissue and 50% moist red skin tissue. No drainage ... Resident voiced no complaints of pain ... 1/4/12: ...Right heel wound bed 50% hard dry purple tissue with faint amount of brown drainage. 50% red moist tissue surrounding hard, dry purple tissue without drainage ... Resident tolerated treatment well with complaints of pain only when touched ... Review of the Wound Treatment Evaluation Records for October 2011 through January 2012 revealed no measurements were made of resident #2's right heel by S3ADON. An observation was made on 1/4/12 at 8:45 a.m. of resident #2 lying in bed. The resident was positioned on his back with the head of the bed elevated. He was observed leaning to his left side. The resident's right foot was noted to have a Perplex dressing wrapped around his heel and ankle. The right heel was in direct contact with the mattress. On 1/4/12 at 9:20 a.m. an observation was made of resident #2's skin with S4LPN Treatment Nurse. Resident #2 mumbled when he saw S4LPN Treatment Nurse. She responded to the resident with, "I know you hate to see me because you know what I'm about to do will hurt". The resident was observed to be in the same position he had been in during the previous observation at 8:45 a.m. His right heel continued to be in direct contact with the mattress. In preparation of the treatment to the resident's right heel, S4LPN Treatment Nurse elevated his right heel off the mattress with a pillow. S4LPN Treatment Nurse removed the dressing to resident #2's right heel. There was a small amount of light brown drainage to the old dressing. The right medial heel was noted to have a large piece of eschar that was surrounded by reddened skin. The lower portion of the eschar, by the lower heel, had edges that were lifting. This left a small open area between the eschar edge and the surrounding red tissue. During the observation, an interview was held with S4LPN Treatment Nurse. She described resident #2's right heel as deep purple with surrounding red blanchable tissue. When S4LPN Treatment Nurse was asked specifically about the eschar to resident #2's right heel, she again responded that she classified the area as "deep purple". She further stated the right heel has had that appearance for three to four weeks. S4LPN Treatment Nurse proceeded to provide wound care, which consisted of cleaning the wound with normal saline, applying [MEDICATION NAME], covering the wound with clean gauze and wrapping with Perplex. Throughout the observation, resident #2 verbalized complaints of pain. The resident was noted with facial grimacing and cried out each time S4LPN Treatment Nurse touched his right foot. An interview was held with S4LPN Treatment Nurse on 1/4/12 at 10:00 a.m. She stated she worked Monday through Friday from 4:30 a.m. to 12:30 p.m. She stated she had been the treatment nurse for approximately six months. She said the facility provided wound training prior to her becoming the treatment nurse. She stated that she developed and revised skin related care plans. She said she updated resident's care plan when a new order was received. She explained that all wounds were measured and staged by S3ADON. She said that she notified S3ADON when a wound needed to be measured or staged. She said she and S3ADON communicated only verbally regarding wounds. She explained that resident #2's right heel had originated as a blister. She said the resident was seen by a Dermatologist and was diagnosed with [REDACTED]. She said "pressure bullae" was described to her as being an immune system illness. She further stated that resident #2's right heel was not considered to be a "pressure" wound since it was previously diagnosed as a "pressure bullae". She said the interventions ordered by the Dermatologist were [MEDICATION NAME] and pressure relief. She further stated that she had not notified S3ADON of resident #2's right heel wound because the wound was not a "pressure wound". When asked if she had notified the physician when the resident's right heel wound changed in appearance (according to her that was three to four weeks ago), S4LPN Treatment Nurse stated she had not notified the physician. She stated that the resident's right heel should be elevated off of the mattress to help with pressure relief. She explained that pillows, rolls, or wedges could be used to elevate the resident's right heel. She stated that resident #2 complained of pain each time she provided wound care. She said the resident "hated" to see her because he related her to pain. She stated the resident's medication nurse pre-medicated the resident prior to wound care. S4LPN Treatment Nurse stated that she did not know what medication the resident received for pain. She further stated that she had not notified the physician or the medication nurse when the resident continued to complain of pain during wound care. She verified she documented the resident did not complain of pain because she thought the resident was pre-medicated prior to wound care. She reviewed resident #2's skin plan of care and verified it had not been updated with interventions for the risk of pressure ulcers determined during his quarterly assessment on 10/17/11; the dermatology recommendations for pressure avoidance on 11/1/11; changes in wound appearance; or the resident's complaints of pain. On 1/4/12 at 11:20 a.m. an interview was held with S3ADON. She stated that she was responsible for weekly measurements of wounds and staging of pressure wounds. She stated that S4LPN Treatment Nurse notified her verbally of any wounds that needed assessing. S3ADON stated that she was not aware of resident #2 having a wound to his right heel. She recalled that "awhile back" the resident had multiple blisters. She stated that S4LPN Treatment Nurse had not informed her of resident's right heel wound. An observation was made of resident #2's right heel with S3ADON on 1/4/12 at 11:25 a.m. Resident #2 was observed to be lying in bed on his back with his right heel lying directly on the mattress in the same position the resident was in during previous observations at 8:45 a.m. and 9:20 a.m.. S3ADON removed the dressing from resident #2's right heel. Resident #2 was observed to have facial grimacing and verbalize complaints of pain each time S3ADON touched his right foot. S3ADON asked the resident if his foot hurt, and resident #2 responded "yes". S3ADON assessed the resident's right heel and when asked to describe the right heel wound, she replied, "That's eschar". S3ADON stated the surrounding tissue was red and the lower portion of the heel was "spongy" with a "deep purple" color. S3ADON measured the wound and the following measurements were noted: eschar measured 6cm (length) x 5cm (width) x 0.8cm (depth) and surrounding redness measured 8cm (length) x 5cm (width). S3ADON stated she should have been notified of the resident's heel wound. She stated that she did not feel that [MEDICATION NAME] was appropriate treatment for [REDACTED]. On 1/4/12 at 11:50 a.m. an interview was held with S12LPN. She verified she was the routine medication nurse for resident #2. She stated that resident #2 was not ordered any medications for pain. She said that the resident had not complained of pain to her. She further stated that S4LPN Treatment Nurse had not informed her that resident #2 needed pre-medicating for pain prior to wound care. Review of the November 2011 through January 2012 physician's orders [REDACTED].#2 during that time. Review of the Nurse's Note dated 1/4/12 and timed for 1150 (11:50 a.m.) revealed documentation of S3ADON's assessment of resident #2's heel. The Note included the following: Report received of right heel wound - area assessed. "Eschar 5 x 6cm c (with) 1/8cm depth at inferior medial edge. Adjacent to that 5 x 8 crescent shaped area, red and blanchable at superior aspect, spongy purple at inferior aspect. Resident expressed pain upon palpitation ...". Review of the Physician's Telephone Orders dated 1/4/12 and timed for 1158 (11:58 a.m.) revealed the following orders for the right heel wound: 1. Cleanse area with wound cleanser and pat dry. 2. Apply Hydrogel. 3. Cover with Optiform or other foam dressing. 4. Change daily and PRN. 5. Foam heel booties to both feet at all times. 6. [MEDICATION NAME] (non-narcotic pain reliever) 1 per PEG tube every 6 hours PRN pain. On 1/5/12 at 8:25 a.m. an observation was made of resident #2 lying in bed with his eyes closed. The head of the bed was elevated at a high position and the resident's bilateral heels were observed to be in direct contact with the mattress. The resident's right ankle/heel was wrapped with a dressing. There was no heel protectors noted to the resident's bilateral heels. An interview was held with S2DON on 1/5/12 at 8:30 a.m. She stated that S3ADON had informed her of resident #2 experiencing pain when his right foot was touched and that his right heel had eschar. S2DON verified that prior to 1/4/12 the resident's heel had only been treated with [MEDICATION NAME]. She also verified resident #2 did not have any medications ordered for pain relief prior to 1/4/12. She stated S4LPN Treatment Nurse should have notified the physician when the resident's heel declined and the treatment should have been changed. S2DON stated that if a wound had not made progress within a couple of weeks or if a wound declined suddenly, the physician should be notified. S2DON stated it was S4LPN Treatment Nurse responsibility to assess a resident for pain prior, during, and after wound care. She said S4LPN Treatment Nurse should notify the medication nurse of any reported pain and if the resident has pain medication ordered, then the resident should receive the medication, and if the resident does not have pain medication ordered, S4LPN Treatment Nurse should notify the physician. S2DON stated S4LPN Treatment Nurse was responsible for updating a resident's care plan when changes occurred with their skin or wound. She reviewed resident #2's care plan and verified it had not been updated on 11/1/11 with interventions of pressure relief for his right heel as recommended by the dermatologist, changes in wound appearance, or the pain related to the wound. S2DON verified S4LPN Treatment Nurse was provided wound care training prior to becoming the treatment nurse. On 1/5/12 at 9:25 a.m. an interview was held with S4LPN Treatment Nurse. She stated that she always informed the CNAs of skin care interventions specific for each resident. She stated she verbally communicated to the CNAs that resident #2's needed bilateral heel protectors on at all times. An observation was made of S13CNA providing assistance to resident #2 on 1/5/12 at 9:35 a.m. During the observation, resident #2 was sitting in a wheelchair as S13CNA combed his hair. The resident's wheelchair was observed to have one leg rest to the left side of the chair. Resident #2 was wearing socks and had his left foot positioned on the leg rest and his right foot positioned flat on the floor. An interview was held with S13CNA during the observation and she verified the resident had a wound to his right heel. When asked if there were any pressure relieving interventions provided for his heel, S13CNA stated that the resident was turned every two hours. When the question was rephrased and S13CNA was asked if the resident was supposed to wear heel protectors, she stated not that she knew of. On 1/5/12, observations were made of resident #2 sitting in a wheelchair near the nurses' station from 9:45 a.m. to 1:20 p.m. The resident's left foot was positioned on the leg rest of the wheelchair and his right foot was positioned on the floor. The resident was wearing socks, but he did not have on heel protectors. At 1:20 p.m., nursing staff applied heel protectors to the resident's bilateral heels. Observations continued of resident #2 on 1/5/12, and between 2:00 p.m. and 3:00 p.m. the resident was observed rubbing his right leg. During this time, the resident was passed by nursing staff, including S12LPN, who stopped the resident from pulling on his PEG tube, but did not ask him anything else. At 2:55 p.m., an interview was held with resident #2. During the interview, he continued to rub his right leg. The resident requested a pillow to place beneath his right foot. During the interview, S15CNA approached resident #2 and the resident informed S15CNA that he wanted a pillow to place beneath his right foot. S15CNA asked the resident if he was ready to return to bed, and the resident responded "yes". At 3:00 p.m., resident #2 was taken to his room. S9CNA Supervisor, S15CNA, S16CNA and S17LPN were in the resident's room. At 3:05 p.m., the resident was observed rubbing his right leg when S16CNA asked him if his leg was hurting. The resident responded "my foot hurts on the bottom" while pointing to his right foot. At 3:10 p.m., the resident was assisted to bed requiring total assistance during the transfer from the wheelchair to the bed. Once in bed, the resident was noted with facial grimacing and he continued to point at his right foot. With S17LPN at the resident's bedside observing the resident, S15CNA asked the resident what was wrong. The resident stated "my foot" while pointing at his right foot. At 3:20 p.m., S17LPN was observed to leave the room and go to the medication cart. An interview was held with S16CNA on 1/5/12 at 3:30 p.m. She stated that CNAs obtained knowledge of specific interventions for each resident by reviewing the resident's Kardex. She stated each resident had a Kardex specific to their needs that was maintained for the CNAs. She verified the Kardex would include if a resident should have heel protectors in place. S16CNA further stated that she would not know that resident #2 was to have heel protectors on unless she reviewed the Kardex. Upon request of resident #2's Kardex, S16CNA was unable to locate it. She further stated that she had not been notified by a nurse that he was to have heel protectors on at all times. On 1/5/12 at 3:45 p.m. an interview was held with S2DON. She verified each resident had a Kardex that included information specific to their needs. She explained the Kardex was to be utilized by the CNAs. Upon searching the nurses' station for resident #2's Kardex, she was unable to locate it. She questioned S9CNA Supervisor regarding the whereabouts of the Kardex for resident #2 and S9CNA Supervisor stated all Kardexs for that hall was in the DON/ADON's office. S2DON located resident #2's Kardex within her office and stated that the ADON was going to review each Kardex before placing them back on the unit. When asked how the CNAs were to know that resident #2 was to have heel protectors on at all times, S2DON stated the resident's nurse and treatment nurse should notify the CNAs when orders were received regarding pressure relief. She verified the order for heel protectors was received on 1/4/12 and that she had witnessed the resident without heel protectors on 1/5/12 while sitting near the nurses' station. S2DON further stated that each resident was to be assessed for pain by their assigned medication nurse during medication pass and upon rounds. She said if a resident complains of pain, the nurse was to assess the location and intensity of the pain prior to medication and after. She said the nurse should document a resident's complaints of pain on the medication record and nurse's notes. On 1/6/12, review of the January 2012 Medication Record revealed resident #2 was administered [MEDICATION NAME] for pain on 1/5/12 at 7:00 a.m. The resident had not been treated for [REDACTED]. Review of the Nurse's Notes revealed no documentation of an evaluation or interventions for resident #2's right foot pain for 1/5/12 at 3:05 p.m. Resident #8: Review of the Standing Nursing Home Orders revealed, in part, the following related to Skin Care: 3. Stage 1 Decutitus-redness 0 pressure to the area. Use pressure relieving devices as needed ... 4. Stages II, II, IV: notify MD/NP on routine rounds ? Without eschar (100% granulation tissue) clean daily with normal saline or Wound cleanser apply Hydrogel to area, cover with damp 4X4. Cover with dry, clean dressing ? With Slough (minimal drainage). Clean daily with wound cleanser or normal saline, apply calcium alginate or santyl. Cover with damp 4X4 and dry, clean dressing. ? With Slough (moderate to heavy drainage). Clean twice a day and as needed with normal saline or wound cleanser, apply calcium alginate or santyl and cover with dry, clean dressing. 6. Report all purulent wound drainage/odor ... Review of the clinical record for resident #8 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes for the resident dated 10/7/11, revealed the resident was admitted to the facility with eschar to the 3rd, 4th and 5th toes on his left foot. Review of the Wound Treatment Evaluations for the month of October 2011-January 2012, for the wounds to the 3rd, 4th, and 5th toes of the left foot, revealed the following: No entries were made regarding the wounds from 10/7/11 through 10/16/11. Entries were made dated 10/17/11 for the wounds to the 3rd, 4th, and 5th toes of the left foot by S3ADON. All three wounds were listed as "unstageable" under the section "If pressure ulcer-Stage". There were no other assessments or measurements documented, by S3ADON, of the toes to the left foot on the wound treatment record from 10/18/11 through 1/4/12. Entries were made by S4LPN Treatment Nurse dated 10/17/11 and 10/18/11 which described all three toe wounds as "Black". These same entries showed the wounds were treated on these dates with wound cleaner, normal saline, pat dry, apply Santyl, cover with a dry/clean dressing. Check daily, change every day and as needed. This treatment was discontinued on 10/19/11 and monitoring of all three toe wounds for changes every day and as needed was started. No treatments were preformed to the wounds of the 3rd, 4th, and 5th toes on the left foot from 10/19/11-12/14/11. Review of the MDS dated [DATE] revealed under Section M-Skin Conditions: F. 1). Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar- 1 2). Number of these unstageable pressure ulcers that were present upon admission/reentry-enter how many were noted at the time of admission- 1 Review of a Podiatrist Consultation, dated 12/7/11, for the resident revealed a sharp excision of loose eschar on 3rd and 4th toes of left foot was performed and [MEDICATION NAME] ointment was applied. Further review of the Wound Treatment Evaluations for the month of October 2011-January 2012, for the wounds to the 3rd, 4th, and 5th toes of the left foot, revealed the following: On 12/15/11, treatment was started again to the 3rd and 4th toes of the left foot with wound cleanser/normal saline, pat dry, apply Santyl and cover with dry, clean dressing. Check daily; change every day, and as needed. This treatment was documented daily from 12/15/11 through 12/29/11. Monitoring of the 5th toe continued without treatment. On 12/30/11-1/5/12 the treatment was changed to clean with wound cleanser/normal saline, pat dry, apply [MEDICATION NAME], cover with a dry clean dressing, change every day, and as needed. Review of the Nurse's Notes for the resident revealed no entries were made about the wounds to the toes on the left foot from 10/8/11 through 10/16/11. Further review of the Nurse's Notes revealed the following entries were made on the Nurse's Notes by S4LPN Treatment Nurse: 10/17/11 1:35 p.m. Informed by hall

Based on observations, record reviews, and interviews, the facility failed to ensure residents maintained their highest level of well-being regarding wounds for 2 (#2, #8) of 8 (#2, #4, #6, #7, #8, #9, #10, #11) residents receiving wound care from a total sample of 11 residents. On 11/1/11, a Dermatologist lanced a fluid filled blister to Resident #2's right heel and ordered [MEDICATION NAME] BID and pressure relieving measures. Resident #2 was in Immediate Jeopardy after the 11/1/11 orders were received and the LPN treatment nurse and weekend treatment nurses failed to provide needed care and services including consultation with the physician regarding this right heel wound. For over 2 months, no one assessed this wound other than the LPN treatment nurse and the weekend nurses and no one notified the physician or the RN supervisor. On 1/4/12, the right heel wound had progressed to an unstageable wound with eschar measuring 6cm (length) x 5cm (width) x 0.8cm (depth) with surrounding redness measuring 8cm (length) x 5cm (width). Resident #2 experienced untreated pain from the wound and grimaced and cried out when his right foot was touched. Resident #8 was admitted to the facility on [DATE] with eschar to the left foot on the 3rd, 4th, and 5th toes. He was in immediate jeopardy after admission on 10/7/11 when the LPN treatment nurse wrote orders for the wounds without consultation with the physician, treatments were not conducted from 10/19/11-12/14/11, and no RN intervention occurred. Resident #8 experienced an increase in wound severity with tunneling, drainage, and a foul odor. From 11/1/11 until 1/4/12, the staff the facility assigned to care for Resident #2, and from 10/7/11 until 1/4/12, the staff assigned to care for resident #8, were unable or unprepared to provide the following needed care and services and there was no intervention by the ADON RN Supervisor to ensure the following needed care and services were provided: 1.) consult with the residents' physicians regarding changes in wound status (#2, #8); 2.) assess and communicate changes in status to other nurses and supervisors (#2, #8); 3.) assess, consult with the physician, and treat pain related to wounds (#2); 4.) implement pressure relieving interventions to prevent wounds from deteriorating (#2, #8)); 5.) ensure the plan of care was updated with interventions to prevent skin breakdown and/or heal skin wounds (#2, #8); 6.) ensure CNAs were aware of pressure relieving measures (#2, #8); 7. ensure the ADON had knowledge of residents with wounds and assessed these wounds (#2, #8); 8.) ensure the ADON clinically supervised the LPN treatment nurse and weekend nurses to ensure orders were followed and care was provided following professional standards of practice (#2, #8); 9.) consistently measure wounds (#2, #8); 10.) ensure the LPN treatment nurse did not write orders for treatments to wounds and obtained orders from the physician (#8); 11.) obtain treatment orders for wounds upon admission (#8); 12.) recognize that the standing orders did not address wounds with eschar (#8); 13.) include in the policy and procedure for wounds instructions to nurses regarding pain from ulcers other than pressure ulcers (#2). This failure had the potential to harm six other residents with wounds (#4, #6, #7, #9, #10, #11 ) and placed them in Immediate Jeopardy. The administrator was notified of the Immediate Jeopardy on 1/6/12. On January 20, 2012, the facility presented a plan or removal which included assessing and treating the wounds, physician consultation, having RN supervision of the wound care, implementing pressure relieving devices, and pain management measures. Surveyors determined the Immediate Jeopardy was removed on January 23, 2012. The deficient practice continues at patterns of actual harm for residents #2 and #8 and a potential for more than minimal harm for residents #4, #6, #7, #9, #10, and #11. Findings: Findings: Review of the facility's policy entitled, "Policy and Procedure for the Prevention and treatment of [REDACTED]. Policy: It is the policy to properly identify and assess residents, either by an RN or under an RN's supervision, whose clinical conditions increase the risk for impaired skin integrity and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. Procedures include: A. it is important to individualize each resident's turning and repositioning schedule. B. the care plan for skin integrity is to be evaluated and revised based on response, outcomes, and needs of the resident. II. treatment of [REDACTED]. If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented: 2. notify physician 3. notify supervisor 6. re-evaluate turning and repositioning intervals 8. re-evaluate interventions per risk factors identified 10. initiate weekly wound documentation progress sheet 11. when a pressure ulcer is present, daily wound monitoring should include whether pain, if present , is being adequately controlled. 12. notify the physician, NP and supervisor if the ulcer(s) has not shown progress in 2-4 weeks and/or is deteriorating unexpectedly. Re-evaluate plan of care as appropriate. Resident #2: Review of the clinical record revealed resident #2 had a [DIAGNOSES REDACTED]. Review of the most recent MDS dated [DATE] revealed resident #2 had impaired range of motion to his upper and lower extremities and was totally dependent on staff for bed mobility and transfers. Review of the most recent Pressure Sore Risk assessment dated [DATE] revealed the resident scored a total score of "14" indicating he was a pressure sore risk. The resident was assessed as having "very limited" sensory perception - ability to respond meaningfully to pressure related discomfort. Review of the Nurse/Physician Communication Record completed by S3ADON on 10/25/11 revealed resident #2 had fluid filled blisters to multiple areas of the body that included the right heel. S3ADON further documented the resident had a temperature of 99.9 degrees axillary and was noted to be less alert than usual. Review of the Physician's Telephone Orders dated 10/25/11 included: 1. Cleanse blister areas with Normal Saline or Wound Cleanser, pat dry, apply Triple Antibiotic Ointment, cover with dressing, change every day. Diagnosis: [REDACTED]. 2. Dermatology consult... Diagnosis: [REDACTED]. Review of the Progress Note completed by the Nurse Practitioner on 10/26/11 revealed in part: Physical Examination: Skin: blister to ...heel Impression/Plan: [DIAGNOSES REDACTED] related to recent scabies - local care for now and follow up with Dermatologist. Review of the Nurse's Notes dated 10/27/11 revealed the resident had a temperature of 99.8 degrees axillary and was "not looking very well". The Nurse Practitioner was notified and ordered to send the resident to the emergency room for evaluation and treatment. Review of the hospital records revealed resident #2 was admitted to the hospital and treated for [REDACTED]. Review of the hospital's History and Physical dated 10/27/11 revealed in part: Dermatology: ... early pressure ulcers on his left foot as well as more prominent on his right heel. Review of the hospital Discharge Summary dated 10/30/11 included: Pressure Ulcers: The patient presented with multiple early pressure sites... Wound ostomy nurses were consulted and initiated treatment here which included turning every two hours, floating heels off the bed, having a specialty bed. Recommended cleaning the right heel with soap and water, apply Lidoflex pad to blister, cover with 4 x 4... Recommend continuing his wound care at the nursing home facility. Review of the hospital's Discharge Worksheet dated 10/30/11 and timed for 0915 (9:15 a.m.) included: Discharge Education and Instructions: (2) Wound care as outlined by our W.O.N. (wound ostomy nurse). Review of the discharge Medication List included Wound Care of the right heel as follows: Cleanse with soap and water, dry thoroughly, apply Lidoflex pad, cover with 4 x 4, wrap with conforming gauze, change every 48 hours. Review of the Admission and Physician's Telephone Orders dated 10/30/11 included no documentation of wound care for resident #2's right heel. Review of the October 2011 Wound Treatment Evaluation Record revealed no treatments were performed to the resident's right heel on 10/30/11. Review of the Nurse's Note dated 10/30/11 revealed a re-admission skin assessment of resident #2. The resident's right heel was not mentioned within the note. Review of the Weekly Skin Condition Evaluation dated 10/30/11 revealed no documentation related to the resident's right heel. Review of the Nurse's Note made by S4LPN Treatment Nurse on 10/31/11 included resident #2's right heel was noted with a "100% blood filled blister". Review of the October 2011 Wound Treatment Evaluation Record revealed the treatment that was performed to resident #2's right heel on 10/31/11 was as follows: clean with wound cleaner or normal saline, pat dry, apply TAO, cover with DCD. On 11/1/11, resident #2 was seen by the Dermatologist as ordered on [DATE]. Review of the Dermatology Note dated 11/1/11 was noted by S4LPN Treatment Nurse and included: Large bullae to right heel medially. Impression: Pressure Bullae Recommendations: Drained; [MEDICATION NAME] ointment BID, pressure avoidance. Review of the Physician's Telephone Order dated 11/1/11 revealed in part: 1. D/C Triple Antibiotic Ointment 2. Apply [MEDICATION NAME] ointment BID to right heel Review of the Skin Risk Evaluation and Plan of Care included 11/1/11: Pressure Bullue to right heel - Goal date 2/1/12 There were no interventions on the Plan of Care related to the right heel. There was no documentation of "pressure avoidance" as recommended by the dermatologist. The Plan of Care did not indicate the resident was at risk of developing a pressure sore as determined on 10/17/11. Review of the Nurse's Notes made by S4LPN Treatment Nurse revealed in part the following: 11/1/11: Resident returned from Dermatology appointment ... Right heel Pressure Bullae was drained ... Right heel 50% tan and 50% purple wound bed with little bloody drainage. Excess skin covers wound bed. Area moist without odor noted ... 11/4/11: ... Right heel wound bed 80% tan dry tissue in center of wound with 20% purple dry tissue around wound edges ... Resident tolerated treatment well without complaints of pain ... 11/7/11: ... Right heel 100% dry purple tissue ... Resident tolerated well without complaints of pain ... 11/17/11: ... Right heel 75% dry purple skin and 25% dry tan skin ... Resident tolerated well without complaints of pain ... 11/23/11: ...Right heel wound bed 60% purple dry skin and 40% tan dry skin ... Resident tolerated well without complaints of pain ... 11/28/11: ...Right heel wound bed 90% purple dry skin and 10% tan dry skin ... No complaints of pain voiced by resident ... 12/1/11: ...Right heel 100% purple/tan dry skin ... Resident tolerated well without complaints of pain ... 12/7/11: ...Right heel wound bed 90% purple hard dry skin with 10% tan hard dry skin to center. No drainage ... Resident tolerated well without complaints of pain ... 12/12/11: ...Right heel wound bed 90% purple hard dry skin with 10% tan hard dry skin in center. No drainage ... Resident tolerated well without complaints of pain ... 12/13/11: ...70% of dry purple/tan hard skin fell off during dressing change. 70% of wound bed red moist tissue with 30% hard, dry purple/tan skin towards edges of wound bed. No drainage ... Resident tolerated well without complaints of pain ... 12/15/11: ...50% dry purple/tan tissue/skin to wound bed. Noted with faint amount of bloody drainage. Resident tolerated well without complaints of pain ... 12/20/11: ...Right heel wound bed 50% moist red tissue with 50% dry purple tissue. Tiny amount of bloody drainage ... Resident tolerated treatment well without complaints of pain ... 12/22/11: ...Right heel ... 70% dry purple skin tissue in center of wound bed and 30% moist red tissue surrounding dry purple scar tissue ... Resident tolerated well without complaints of pain ... 12/29/11: ...Right heel wound bed 50% hard purple skin with 50% moist red skin ... Resident tolerated well without complaints of pain ... 1/2/12: ...Right heel wound bed 50% hard purple skin tissue and 50% moist red skin tissue. No drainage ... Resident voiced no complaints of pain ... 1/4/12: ...Right heel wound bed 50% hard dry purple tissue with faint amount of brown drainage. 50% red moist tissue surrounding hard, dry purple tissue without drainage ... Resident tolerated treatment well with complaints of pain only when touched ... Review of the Wound Treatment Evaluation Records for October 2011 through January 2012 revealed no measurements were made of resident #2's right heel by S3ADON. An observation was made on 1/4/12 at 8:45 a.m. of resident #2 lying in bed. The resident was positioned on his back with the head of the bed elevated. He was observed leaning to his left side. The resident's right foot was noted to have a Perplex dressing wrapped around his heel and ankle. The right heel was in direct contact with the mattress. On 1/4/12 at 9:20 a.m. an observation was made of resident #2's skin with S4LPN Treatment Nurse. Resident #2 mumbled when he saw S4LPN Treatment Nurse. She responded to the resident with, "I know you hate to see me because you know what I'm about to do will hurt". The resident was observed to be in the same position he had been in during the previous observation at 8:45 a.m. His right heel continued to be in direct contact with the mattress. In preparation of the treatment to the resident's right heel, S4LPN Treatment Nurse elevated his right heel off the mattress with a pillow. S4LPN Treatment Nurse removed the dressing to resident #2's right heel. There was a small amount of light brown drainage to the old dressing. The right medial heel was noted to have a large piece of eschar that was surrounded by reddened skin. The lower portion of the eschar, by the lower heel, had edges that were lifting. This left a small open area between the eschar edge and the surrounding red tissue. During the observation, an interview was held with S4LPN Treatment Nurse. She described resident #2's right heel as deep purple with surrounding red blanchable tissue. When S4LPN Treatment Nurse was asked specifically about the eschar to resident #2's right heel, she again responded that she classified the area as "deep purple". She further stated the right heel has had that appearance for three to four weeks. S4LPN Treatment Nurse proceeded to provide wound care, which consisted of cleaning the wound with normal saline, applying [MEDICATION NAME], covering the wound with clean gauze and wrapping with Perplex. Throughout the observation, resident #2 verbalized complaints of pain. The resident was noted with facial grimacing and cried out each time S4LPN Treatment Nurse touched his right foot. An interview was held with S4LPN Treatment Nurse on 1/4/12 at 10:00 a.m. She stated she worked Monday through Friday from 4:30 a.m. to 12:30 p.m. She stated she had been the treatment nurse for approximately six months. She said the facility provided wound training prior to her becoming the treatment nurse. She stated that she developed and revised skin related care plans. She said she updated resident's care plan when a new order was received. She explained that all wounds were measured and staged by S3ADON. She said that she notified S3ADON when a wound needed to be measured or staged. She said she and S3ADON communicated only verbally regarding wounds. She explained that resident #2's right heel had originated as a blister. She said the resident was seen by a Dermatologist and was diagnosed with [REDACTED]. She said "pressure bullae" was described to her as being an immune system illness. She further stated that resident #2's right heel was not considered to be a "pressure" wound since it was previously diagnosed as a "pressure bullae". She said the interventions ordered by the Dermatologist were [MEDICATION NAME] and pressure relief. She further stated that she had not notified S3ADON of resident #2's right heel wound because the wound was not a "pressure wound". When asked if she had notified the physician when the resident's right heel wound changed in appearance (according to her that was three to four weeks ago), S4LPN Treatment Nurse stated she had not notified the physician. She stated that the resident's right heel should be elevated off of the mattress to help with pressure relief. She explained that pillows, rolls, or wedges could be used to elevate the resident's right heel. She stated that resident #2 complained of pain each time she provided wound care. She said the resident "hated" to see her because he related her to pain. She stated the resident's medication nurse pre-medicated the resident prior to wound care. S4LPN Treatment Nurse stated that she did not know what medication the resident received for pain. She further stated that she had not notified the physician or the medication nurse when the resident continued to complain of pain during wound care. She verified she documented the resident did not complain of pain because she thought the resident was pre-medicated prior to wound care. She reviewed resident #2's skin plan of care and verified it had not been updated with interventions for the risk of pressure ulcers determined during his quarterly assessment on 10/17/11; the dermatology recommendations for pressure avoidance on 11/1/11; changes in wound appearance; or the resident's complaints of pain. On 1/4/12 at 11:20 a.m. an interview was held with S3ADON. She stated that she was responsible for weekly measurements of wounds and staging of pressure wounds. She stated that S4LPN Treatment Nurse notified her verbally of any wounds that needed assessing. S3ADON stated that she was not aware of resident #2 having a wound to his right heel. She recalled that "awhile back" the resident had multiple blisters. She stated that S4LPN Treatment Nurse had not informed her of resident's right heel wound. An observation was made of resident #2's right heel with S3ADON on 1/4/12 at 11:25 a.m. Resident #2 was observed to be lying in bed on his back with his right heel lying directly on the mattress in the same position the resident was in during previous observations at 8:45 a.m. and 9:20 a.m.. S3ADON removed the dressing from resident #2's right heel. Resident #2 was observed to have facial grimacing and verbalize complaints of pain each time S3ADON touched his right foot. S3ADON asked the resident if his foot hurt, and resident #2 responded "yes". S3ADON assessed the resident's right heel and when asked to describe the right heel wound, she replied, "That's eschar". S3ADON stated the surrounding tissue was red and the lower portion of the heel was "spongy" with a "deep purple" color. S3ADON measured the wound and the following measurements were noted: eschar measured 6cm (length) x 5cm (width) x 0.8cm (depth) and surrounding redness measured 8cm (length) x 5cm (width). S3ADON stated she should have been notified of the resident's heel wound. She stated that she did not feel that [MEDICATION NAME] was appropriate treatment for [REDACTED]. On 1/4/12 at 11:50 a.m. an interview was held with S12LPN. She verified she was the routine medication nurse for resident #2. She stated that resident #2 was not ordered any medications for pain. She said that the resident had not complained of pain to her. She further stated that S4LPN Treatment Nurse had not informed her that resident #2 needed pre-medicating for pain prior to wound care. Review of the November 2011 through January 2012 physician's orders [REDACTED].#2 during that time. Review of the Nurse's Note dated 1/4/12 and timed for 1150 (11:50 a.m.) revealed documentation of S3ADON's assessment of resident #2's heel. The Note included the following: Report received of right heel wound - area assessed. "Eschar 5 x 6cm c (with) 1/8cm depth at inferior medial edge. Adjacent to that 5 x 8 crescent shaped area, red and blanchable at superior aspect, spongy purple at inferior aspect. Resident expressed pain upon palpitation ...". Review of the Physician's Telephone Orders dated 1/4/12 and timed for 1158 (11:58 a.m.) revealed the following orders for the right heel wound: 1. Cleanse area with wound cleanser and pat dry. 2. Apply Hydrogel. 3. Cover with Optiform or other foam dressing. 4. Change daily and PRN. 5. Foam heel booties to both feet at all times. 6. [MEDICATION NAME] (non-narcotic pain reliever) 1 per PEG tube every 6 hours PRN pain. On 1/5/12 at 8:25 a.m. an observation was made of resident #2 lying in bed with his eyes closed. The head of the bed was elevated at a high position and the resident's bilateral heels were observed to be in direct contact with the mattress. The resident's right ankle/heel was wrapped with a dressing. There was no heel protectors noted to the resident's bilateral heels. An interview was held with S2DON on 1/5/12 at 8:30 a.m. She stated that S3ADON had informed her of resident #2 experiencing pain when his right foot was touched and that his right heel had eschar. S2DON verified that prior to 1/4/12 the resident's heel had only been treated with [MEDICATION NAME]. She also verified resident #2 did not have any medications ordered for pain relief prior to 1/4/12. She stated S4LPN Treatment Nurse should have notified the physician when the resident's heel declined and the treatment should have been changed. S2DON stated that if a wound had not made progress within a couple of weeks or if a wound declined suddenly, the physician should be notified. S2DON stated it was S4LPN Treatment Nurse responsibility to assess a resident for pain prior, during, and after wound care. She said S4LPN Treatment Nurse should notify the medication nurse of any reported pain and if the resident has pain medication ordered, then the resident should receive the medication, and if the resident does not have pain medication ordered, S4LPN Treatment Nurse should notify the physician. S2DON stated S4LPN Treatment Nurse was responsible for updating a resident's care plan when changes occurred with their skin or wound. She reviewed resident #2's care plan and verified it had not been updated on 11/1/11 with interventions of pressure relief for his right heel as recommended by the dermatologist, changes in wound appearance, or the pain related to the wound. S2DON verified S4LPN Treatment Nurse was provided wound care training prior to becoming the treatment nurse. On 1/5/12 at 9:25 a.m. an interview was held with S4LPN Treatment Nurse. She stated that she always informed the CNAs of skin care interventions specific for each resident. She stated she verbally communicated to the CNAs that resident #2's needed bilateral heel protectors on at all times. An observation was made of S13CNA providing assistance to resident #2 on 1/5/12 at 9:35 a.m. During the observation, resident #2 was sitting in a wheelchair as S13CNA combed his hair. The resident's wheelchair was observed to have one leg rest to the left side of the chair. Resident #2 was wearing socks and had his left foot positioned on the leg rest and his right foot positioned flat on the floor. An interview was held with S13CNA during the observation and she verified the resident had a wound to his right heel. When asked if there were any pressure relieving interventions provided for his heel, S13CNA stated that the resident was turned every two hours. When the question was rephrased and S13CNA was asked if the resident was supposed to wear heel protectors, she stated not that she knew of. On 1/5/12, observations were made of resident #2 sitting in a wheelchair near the nurses' station from 9:45 a.m. to 1:20 p.m. The resident's left foot was positioned on the leg rest of the wheelchair and his right foot was positioned on the floor. The resident was wearing socks, but he did not have on heel protectors. At 1:20 p.m., nursing staff applied heel protectors to the resident's bilateral heels. Observations continued of resident #2 on 1/5/12, and between 2:00 p.m. and 3:00 p.m. the resident was observed rubbing his right leg. During this time, the resident was passed by nursing staff, including S12LPN, who stopped the resident from pulling on his PEG tube, but did not ask him anything else. At 2:55 p.m., an interview was held with resident #2. During the interview, he continued to rub his right leg. The resident requested a pillow to place beneath his right foot. During the interview, S15CNA approached resident #2 and the resident informed S15CNA that he wanted a pillow to place beneath his right foot. S15CNA asked the resident if he was ready to return to bed, and the resident responded "yes". At 3:00 p.m., resident #2 was taken to his room. S9CNA Supervisor, S15CNA, S16CNA and S17LPN were in the resident's room. At 3:05 p.m., the resident was observed rubbing his right leg when S16CNA asked him if his leg was hurting. The resident responded "my foot hurts on the bottom" while pointing to his right foot. At 3:10 p.m., the resident was assisted to bed requiring total assistance during the transfer from the wheelchair to the bed. Once in bed, the resident was noted with facial grimacing and he continued to point at his right foot. With S17LPN at the resident's bedside observing the resident, S15CNA asked the resident what was wrong. The resident stated "my foot" while pointing at his right foot. At 3:20 p.m., S17LPN was observed to leave the room and go to the medication cart. An interview was held with S16CNA on 1/5/12 at 3:30 p.m. She stated that CNAs obtained knowledge of specific interventions for each resident by reviewing the resident's Kardex. She stated each resident had a Kardex specific to their needs that was maintained for the CNAs. She verified the Kardex would include if a resident should have heel protectors in place. S16CNA further stated that she would not know that resident #2 was to have heel protectors on unless she reviewed the Kardex. Upon request of resident #2's Kardex, S16CNA was unable to locate it. She further stated that she had not been notified by a nurse that he was to have heel protectors on at all times. On 1/5/12 at 3:45 p.m. an interview was held with S2DON. She verified each resident had a Kardex that included information specific to their needs. She explained the Kardex was to be utilized by the CNAs. Upon searching the nurses' station for resident #2's Kardex, she was unable to locate it. She questioned S9CNA Supervisor regarding the whereabouts of the Kardex for resident #2 and S9CNA Supervisor stated all Kardexs for that hall was in the DON/ADON's office. S2DON located resident #2's Kardex within her office and stated that the ADON was going to review each Kardex before placing them back on the unit. When asked how the CNAs were to know that resident #2 was to have heel protectors on at all times, S2DON stated the resident's nurse and treatment nurse should notify the CNAs when orders were received regarding pressure relief. She verified the order for heel protectors was received on 1/4/12 and that she had witnessed the resident without heel protectors on 1/5/12 while sitting near the nurses' station. S2DON further stated that each resident was to be assessed for pain by their assigned medication nurse during medication pass and upon rounds. She said if a resident complains of pain, the nurse was to assess the location and intensity of the pain prior to medication and after. She said the nurse should document a resident's complaints of pain on the medication record and nurse's notes. On 1/6/12, review of the January 2012 Medication Record revealed resident #2 was administered [MEDICATION NAME] for pain on 1/5/12 at 7:00 a.m. The resident had not been treated for [REDACTED]. Review of the Nurse's Notes revealed no documentation of an evaluation or interventions for resident #2's right foot pain for 1/5/12 at 3:05 p.m. Resident #8: Review of the Standing Nursing Home Orders revealed, in part, the following related to Skin Care: 3. Stage 1 Decutitus-redness 0 pressure to the area. Use pressure relieving devices as needed ... 4. Stages II, II, IV: notify MD/NP on routine rounds ? Without eschar (100% granulation tissue) clean daily with normal saline or Wound cleanser apply Hydrogel to area, cover with damp 4X4. Cover with dry, clean dressing ? With Slough (minimal drainage). Clean daily with wound cleanser or normal saline, apply calcium alginate or santyl. Cover with damp 4X4 and dry, clean dressing. ? With Slough (moderate to heavy drainage). Clean twice a day and as needed with normal saline or wound cleanser, apply calcium alginate or santyl and cover with dry, clean dressing. 6. Report all purulent wound drainage/odor ... Review of the clinical record for resident #8 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes for the resident dated 10/7/11, revealed the resident was admitted to the facility with eschar to the 3rd, 4th and 5th toes on his left foot. Review of the Wound Treatment Evaluations for the month of October 2011-January 2012, for the wounds to the 3rd, 4th, and 5th toes of the left foot, revealed the following: No entries were made regarding the wounds from 10/7/11 through 10/16/11. Entries were made dated 10/17/11 for the wounds to the 3rd, 4th, and 5th toes of the left foot by S3ADON. All three wounds were listed as "unstageable" under the section "If pressure ulcer-Stage". There were no other assessments or measurements documented, by S3ADON, of the toes to the left foot on the wound treatment record from 10/18/11 through 1/4/12. Entries were made by S4LPN Treatment Nurse dated 10/17/11 and 10/18/11 which described all three toe wounds as "Black". These same entries showed the wounds were treated on these dates with wound cleaner, normal saline, pat dry, apply Santyl, cover with a dry/clean dressing. Check daily, change every day and as needed. This treatment was discontinued on 10/19/11 and monitoring of all three toe wounds for changes every day and as needed was started. No treatments were preformed to the wounds of the 3rd, 4th, and 5th toes on the left foot from 10/19/11-12/14/11. Review of the MDS dated [DATE] revealed under Section M-Skin Conditions: F. 1). Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar- 1 2). Number of these unstageable pressure ulcers that were present upon admission/reentry-enter how many were noted at the time of admission- 1 Review of a Podiatrist Consultation, dated 12/7/11, for the resident revealed a sharp excision of loose eschar on 3rd and 4th toes of left foot was performed and [MEDICATION NAME] ointment was applied. Further review of the Wound Treatment Evaluations for the month of October 2011-January 2012, for the wounds to the 3rd, 4th, and 5th toes of the left foot, revealed the following: On 12/15/11, treatment was started again to the 3rd and 4th toes of the left foot with wound cleanser/normal saline, pat dry, apply Santyl and cover with dry, clean dressing. Check daily; change every day, and as needed. This treatment was documented daily from 12/15/11 through 12/29/11. Monitoring of the 5th toe continued without treatment. On 12/30/11-1/5/12 the treatment was change

Based on observations, record reviews, and interviews the facility failed to administer staff and resources in a manner to ensure that a resident maintained their highest level of well being regarding wounds for 2 (#2, #8) of 8 (#2, #4, #6, #7, #8, #9, #10, #11) residents that received wound care from a total sample of 11 residents. On 11/1/11, a Dermatologist lanced a fluid filled blister to Resident #2's right heel and ordered [MEDICATION NAME] BID and pressure relieving measures. Resident #2 was in Immediate Jeopardy after the 11/1/11 orders were received and the LPN treatment nurse and weekend treatment nurses failed to provide needed care and services including consultation with the physician regarding this right heel wound. For over 2 months, no one assessed this wound other than the LPN treatment nurse and the weekend nurses and no one notified the physician or the RN supervisor. On 1/4/12, the right heel wound had progressed to an unstageable wound with eschar measuring 6cm (length) x 5cm (width) x 0.8cm (depth) with surrounding redness measuring 8cm (length) x 5cm (width). Resident #2 experienced untreated pain from the wound and grimaced and cried out when his right foot was touched. Resident #8 was admitted to the facility on [DATE] with eschar to the left foot on the 3rd, 4th, and 5th toes. He was in immediate jeopardy after admission on 10/7/11 when the LPN treatment nurse wrote orders for the wounds without consultation with the physician, treatments were not conducted from 10/19/11-12/14/11, and no RN intervention occurred. Resident #8 experienced an increase in wound severity with tunneling, drainage, and a foul odor. From 11/1/11 until 1/4/12, the staff the facility assigned to care for Resident #2, and from 10/7/11 until 1/4/12, the staff assigned to care for resident #8, were unable or unprepared to provide the following needed care and services and there was no intervention by the ADON RN Supervisor to ensure the following needed care and services were provided: 1.) consult with the residents' physicians regarding changes in wound status (#2, #8); 2.) assess and communicate changes in status to other nurses and supervisors (#2, #8); 3.) assess, consult with the physician, and treat pain related to wounds (#2); 4.) implement pressure relieving interventions to prevent wounds from deteriorating (#2, #8); 5.) ensure the plan of care was updated with interventions to prevent skin breakdown and/or heal skin wounds (#2, #8); 6.) ensure CNAs were aware of pressure relieving measures (#2, #8); 7. ensure the ADON had knowledge of residents with wounds and assessed these wounds (#2, #8); 8.) ensure the ADON clinically supervised the LPN treatment nurse and weekend nurses to ensure orders were followed and care was provided following professional standards of practice (#2, #8); 9.) consistently measure wounds (#2, #8); 10.) ensure the LPN treatment nurse did not write orders for treatments to wounds and obtained orders from the physician (#8); 11.) obtain treatment orders for wounds upon admission (#8); 12.) recognize that the standing orders did not address wounds with eschar (#8); 13.) include in the policy and procedure for wounds instructions to nurses regarding pain from ulcers other than pressure ulcers (#2). 14.) ensure the DON and ADON reviewed standing orders for wounds with eschar (#8) 15.) ensure the DON and ADON consulted the physician regarding the wounds with eschar (#8) This failure had the potential to harm six other residents with wounds (#4, #6, #7, #9, #10, #11 ) and placed them in Immediate Jeopardy. The administrator was notified of the Immediate Jeopardy on 1/6/12. The Immediate Jeopardy remained in place at exit. Findings: Review of the facility's policy entitled, "Policy and Procedure for the Prevention and treatment of [REDACTED]. Policy: It is the policy to properly identify and assess residents, either by an RN or under an RN's supervision, whose clinical conditions increase the risk for impaired skin integrity and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. Procedures include: A. it is important to individualize each resident's turning and repositioning schedule. B. the care plan for skin integrity is to be evaluated and revised based on response, outcomes, and needs of the resident. II. treatment of [REDACTED]. If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented: 2. notify physician 3. notify supervisor 6. re-evaluate turning and repositioning intervals 8. re-evaluate interventions per risk factors identified 10. initiate weekly wound documentation progress sheet 11. when a pressure ulcer is present, daily wound monitoring should include whether pain, if present , is being adequately controlled. 12. notify the physician, NP and supervisor if the ulcer(s) has not shown progress in 2-4 weeks and/or is deteriorating unexpectedly. Re-evaluate plan of care as appropriate. Resident #2: Review of the clinical record revealed resident #2 had a [DIAGNOSES REDACTED]. Review of the most recent MDS dated [DATE] revealed resident #2 had impaired range of motion to his upper and lower extremities and was totally dependent on staff for bed mobility and transfers. Review of the most recent Pressure Sore Risk assessment dated [DATE] revealed the resident scored a total score of "14" indicating he was a pressure sore risk. The resident was assessed as having "very limited" sensory perception - ability to respond meaningfully to pressure related discomfort. Review of the Nurse/Physician Communication Record completed by S3ADON on 10/25/11 revealed resident #2 had fluid filled blisters to multiple areas of the body that included the right heel. S3ADON further documented the resident had a temperature of 99.9 degrees axillary and was noted to be less alert than usual. Review of the Physician's Telephone Orders dated 10/25/11 included: 1. Cleanse blister areas with Normal Saline or Wound Cleanser, pat dry, apply Triple Antibiotic Ointment, cover with dressing, change every day. Diagnosis: [REDACTED]. 2. Dermatology consult... Diagnosis: [REDACTED]. Review of the Progress Note completed by the Nurse Practitioner on 10/26/11 revealed in part: Physical Examination: Skin: blister to ...heel Impression/Plan: Bulbous Pemphigoid related to recent scabies - local care for now and follow up with Dermatologist. Review of the Nurse's Notes dated 10/27/11 revealed the resident had a temperature of 99.8 degrees axillary and was "not looking very well". The Nurse Practitioner was notified and ordered to send the resident to the emergency room for evaluation and treatment. Review of the hospital records revealed resident #2 was admitted to the hospital and treated for [REDACTED]. Review of the hospital's History and Physical dated 10/27/11 revealed in part: Dermatology: ... early pressure ulcers on his left foot as well as more prominent on his right heel. Review of the hospital Discharge Summary dated 10/30/11 included: Pressure Ulcers: The patient presented with multiple early pressure sites... Wound ostomy nurses were consulted and initiated treatment here which included turning every two hours, floating heels off the bed, having a specialty bed. Recommended cleaning the right heel with soap and water, apply Lidoflex pad to blister, cover with 4 x 4... Recommend continuing his wound care at the nursing home facility. The facility Policy and Procedure for the Prevention and treatment of [REDACTED]. Review of the hospital's Discharge Worksheet dated 10/30/11 and timed for 0915 (9:15 a.m.) included: Discharge Education and Instructions: (2) Wound care as outlined by our W.O.N. (wound ostomy nurse). Review of the discharge Medication List included Wound Care of the right heel as follows: Cleanse with soap and water, dry thoroughly, apply Lidoflex pad, cover with 4 x 4, wrap with conforming gauze, change every 48 hours. Review of the Admission and Physician's Telephone Orders dated 10/30/11 included no documentation of wound care for resident #2's right heel. Review of the October 2011 Wound Treatment Evaluation Record revealed no treatments were performed to the resident's right heel on 10/30/11. Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. Review of the Nurse's Note dated 10/30/11 revealed a re-admission skin assessment of resident #2. The resident's right heel was not mentioned within the note. Review of the Weekly Skin Condition Evaluation dated 10/30/11 revealed no documentation related to the resident's right heel. The facility Policy and Procedure for the Prevention and treatment of [REDACTED]. Review of the Nurse's Note made by S4LPN Treatment Nurse on 10/31/11 included resident #2's right heel was noted with a "100% blood filled blister". Review of the October 2011 Wound Treatment Evaluation Record revealed the treatment that was performed to resident #2's right heel on 10/31/11 was as follows: clean with wound cleaner or normal saline, pat dry, apply TAO, cover with DCD. On 11/1/11, resident #2 was seen by the Dermatologist as ordered on [DATE]. Review of the Dermatology Note dated 11/1/11 was noted by S4LPN Treatment Nurse and included: Large bullae to right heel medially. Impression: Pressure Bullae Recommendations: Drained; [MEDICATION NAME] ointment BID, pressure avoidance. Review of the Physician's Telephone Order dated 11/1/11 revealed in part: 1. D/C Triple Antibiotic Ointment 2. Apply [MEDICATION NAME] ointment BID to right heel Review of the Skin Risk Evaluation and Plan of Care included 11/1/11: Pressure Bullue to right heel - Goal date 2/1/12 There were no interventions on the Plan of Care related to the right heel. There was no documentation of "pressure avoidance" as recommended by the dermatologist. The Plan of Care did not indicate the resident was at risk of developing a pressure sore as determined on 10/17/11. The facility failed to follow the Facility's Policy and Procedure for the Prevention and treatment of [REDACTED]. The Facility's Policy and Procedure for the Prevention and treatment of [REDACTED]. Review of the Nurse's Notes made by S4LPN Treatment Nurse revealed in part the following: 11/1/11: Resident returned from Dermatology appointment ... Right heel Pressure Bullae was drained ... Right heel 50% tan and 50% purple wound bed with little bloody drainage. Excess skin covers wound bed. Area moist without odor noted ... 11/4/11: ... Right heel wound bed 80% tan dry tissue in center of wound with 20% purple dry tissue around wound edges ... Resident tolerated treatment well without complaints of pain ... 11/7/11: ... Right heel 100% dry purple tissue ... Resident tolerated well without complaints of pain ... 11/17/11: ... Right heel 75% dry purple skin and 25% dry tan skin ... Resident tolerated well without complaints of pain ... 11/23/11: ...Right heel wound bed 60% purple dry skin and 40% tan dry skin ... Resident tolerated well without complaints of pain ... 11/28/11: ...Right heel wound bed 90% purple dry skin and 10% tan dry skin ... No complaints of pain voiced by resident ... 12/1/11: ...Right heel 100% purple/tan dry skin ... Resident tolerated well without complaints of pain ... 12/7/11: ...Right heel wound bed 90% purple hard dry skin with 10% tan hard dry skin to center. No drainage ... Resident tolerated well without complaints of pain ... 12/12/11: ...Right heel wound bed 90% purple hard dry skin with 10% tan hard dry skin in center. No drainage ... Resident tolerated well without complaints of pain ... 12/13/11: ...70% of dry purple/tan hard skin fell off during dressing change. 70% of wound bed red moist tissue with 30% hard, dry purple/tan skin towards edges of wound bed. No drainage ... Resident tolerated well without complaints of pain ... 12/15/11: ...50% dry purple/tan tissue/skin to wound bed. Noted with faint amount of bloody drainage. Resident tolerated well without complaints of pain ... 12/20/11: ...Right heel wound bed 50% moist red tissue with 50% dry purple tissue. Tiny amount of bloody drainage ... Resident tolerated treatment well without complaints of pain ... 12/22/11: ...Right heel ... 70% dry purple skin tissue in center of wound bed and 30% moist red tissue surrounding dry purple scar tissue ... Resident tolerated well without complaints of pain ... 12/29/11: ...Right heel wound bed 50% hard purple skin with 50% moist red skin ... Resident tolerated well without complaints of pain ... 1/2/12: ...Right heel wound bed 50% hard purple skin tissue and 50% moist red skin tissue. No drainage ... Resident voiced no complaints of pain ... 1/4/12: ...Right heel wound bed 50% hard dry purple tissue with faint amount of brown drainage. 50% red moist tissue surrounding hard, dry purple tissue without drainage ... Resident tolerated treatment well with complaints of pain only when touched ... Review of the Wound Treatment Evaluation Records for October 2011 through January 2012 revealed no measurements were made of resident #2's right heel by S3ADON. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. An observation was made on 1/4/12 at 8:45 a.m. of resident #2 lying in bed. The resident was positioned on his back with the head of the bed elevated. He was observed leaning to his left side. The resident's right foot was noted to have a Perplex dressing wrapped around his heel and ankle. The right heel was in direct contact with the mattress. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. On 1/4/12 at 9:20 a.m. an observation was made of resident #2's skin with S4LPN Treatment Nurse. Resident #2 mumbled when he saw S4LPN Treatment Nurse. She responded to the resident with, "I know you hate to see me because you know what I'm about to do will hurt". The resident was observed to be in the same position he had been in during the previous observation at 8:45 a.m. His right heel continued to be in direct contact with the mattress. In preparation of the treatment to the resident's right heel, S4LPN Treatment Nurse elevated his right heel off the mattress with a pillow. S4LPN Treatment Nurse removed the dressing to resident #2's right heel. There was a small amount of light brown drainage to the old dressing. The right medial heel was noted to have a large piece of eschar that was surrounded by reddened skin. The lower portion of the eschar, by the lower heel, had edges that were lifting. This left a small open area between the eschar edge and the surrounding red tissue. During the observation, an interview was held with S4LPN Treatment Nurse. She described resident #2's right heel as deep purple with surrounding red blanchable tissue. When S4LPN Treatment Nurse was asked specifically about the eschar to resident #2's right heel, she again responded that she classified the area as "deep purple". She further stated the right heel has had that appearance for three to four weeks. S4LPN Treatment Nurse proceeded to provide wound care, which consisted of cleaning the wound with normal saline, applying [MEDICATION NAME], covering the wound with clean gauze and wrapping with Perplex. Throughout the observation, resident #2 verbalized complaints of pain. The resident was noted with facial grimacing and cried out each time S4LPN Treatment Nurse touched his right foot. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. was not followed regarding RN supervision of wound assessment. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. failed to include instructions to nurses regarding ensuring the physician was consulted with regarding pain related to wounds; notification of the RN supervisor regarding pain related to wounds, and treating pain related to wounds. An interview was held with S4LPN Treatment Nurse on 1/4/12 at 10:00 a.m. She stated she worked Monday through Friday from 4:30 a.m. to 12:30 p.m. She stated she had been the treatment nurse for approximately six months. She said the facility provided wound training prior to her becoming the treatment nurse. She stated that she developed and revised skin related care plans. She said she updated resident's care plan when a new order was received. She explained that all wounds were measured and staged by S3ADON. She said that she notified S3ADON when a wound needed to be measured or staged. She said she and S3ADON communicated only verbally regarding wounds. She explained that resident #2's right heel had originated as a blister. She said the resident was seen by a Dermatologist and was diagnosed with [REDACTED]. She said "pressure bullae" was described to her as being an immune system illness. She further stated that resident #2's right heel was not considered to be a "pressure" wound since it was previously diagnosed as a "pressure bullae". She said the interventions ordered by the Dermatologist were [MEDICATION NAME] and pressure relief. She further stated that she had not notified S3ADON of resident #2's right heel wound because the wound was not a "pressure wound". When asked if she had notified the physician when the resident's right heel wound changed in appearance (according to her that was three to four weeks ago), S4LPN Treatment Nurse stated she had not notified the physician. She stated that the resident's right heel should be elevated off of the mattress to help with pressure relief. She explained that pillows, rolls, or wedges could be used to elevate the resident's right heel. She stated that resident #2 complained of pain each time she provided wound care. She said the resident "hated" to see her because he related her to pain. She stated the resident's medication nurse pre-medicated the resident prior to wound care. S4LPN Treatment Nurse stated that she did not know what medication the resident received for pain. She further stated that she had not notified the physician or the medication nurse when the resident continued to complain of pain during wound care. She verified she documented the resident did not complain of pain because she thought the resident was pre-medicated prior to wound care. She reviewed resident #2's skin plan of care and verified it had not been updated with interventions for the risk of pressure ulcers determined during his quarterly assessment on 10/17/11; the dermatology recommendations for pressure avoidance on 11/1/11; changes in wound appearance; or the resident's complaints of pain. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. failed to address RN clinical supervision to ensure pressure relieving measures were implemented. On 1/4/12 at 11:20 a.m. an interview was held with S3ADON. She stated that she was responsible for weekly measurements of wounds and staging of pressure wounds. She stated that S4LPN Treatment Nurse notified her verbally of any wounds that needed assessing. S3ADON stated that she was not aware of resident #2 having a wound to his right heel. She recalled that "awhile back" the resident had multiple blisters. She stated that S4LPN Treatment Nurse had not informed her of resident's right heel wound. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. was not followed regarding RN supervision of wound assessment. An observation was made of resident #2's right heel with S3ADON on 1/4/12 at 11:25 a.m. Resident #2 was observed to be lying in bed on his back with his right heel lying directly on the mattress in the same position the resident was in during previous observations at 8:45 a.m. and 9:20 a.m.. S3ADON removed the dressing from resident #2's right heel. Resident #2 was observed to have facial grimacing and verbalize complaints of pain each time S3ADON touched his right foot. S3ADON asked the resident if his foot hurt, and resident #2 responded "yes". S3ADON assessed the resident's right heel and when asked to describe the right heel wound, she replied, "That's eschar". S3ADON stated the surrounding tissue was red and the lower portion of the heel was "spongy" with a "deep purple" color. S3ADON measured the wound and the following measurements were noted: eschar measured 6cm (length) x 5cm (width) x 0.8cm (depth) and surrounding redness measured 8cm (length) x 5cm (width). S3ADON stated she should have been notified of the resident's heel wound. She stated that she did not feel that [MEDICATION NAME] was appropriate treatment for [REDACTED]. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. On 1/4/12 at 11:50 a.m. an interview was held with S12LPN. She verified she was the routine medication nurse for resident #2. She stated that resident #2 was not ordered any medications for pain. She said that the resident had not complained of pain to her. She further stated that S4LPN Treatment Nurse had not informed her that resident #2 needed pre-medicating for pain prior to wound care. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. Review of the November 2011 through January 2012 physician's orders [REDACTED].#2 during that time. Review of the Nurse's Note dated 1/4/12 and timed for 1150 (11:50 a.m.) revealed documentation of S3ADON's assessment of resident #2's heel. The Note included the following: Report received of right heel wound - area assessed. "Eschar 5 x 6cm c (with) 1/8cm depth at inferior medial edge. Adjacent to that 5 x 8 crescent shaped area, red and blanchable at superior aspect, spongy purple at inferior aspect. Resident expressed pain upon palpitation ...". Review of the Physician's Telephone Orders dated 1/4/12 and timed for 1158 (11:58 a.m.) revealed the following orders for the right heel wound: 1. Cleanse area with wound cleanser and pat dry. 2. Apply Hydrogel. 3. Cover with Optiform or other foam dressing. 4. Change daily and PRN. 5. Foam heel booties to both feet at all times. 6. [MEDICATION NAME] (non-narcotic pain reliever) 1 per PEG tube every 6 hours PRN pain. On 1/5/12 at 8:25 a.m. an observation was made of resident #2 lying in bed with his eyes closed. The head of the bed was elevated at a high position and the resident's bilateral heels were observed to be in direct contact with the mattress. The resident's right ankle/heel was wrapped with a dressing. There was no heel protectors noted to the resident's bilateral heels. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. An interview was held with S2DON on 1/5/12 at 8:30 a.m. She stated that S3ADON had informed her of resident #2 experiencing pain when his right foot was touched and that his right heel had eschar. S2DON verified that prior to 1/4/12 the resident's heel had only been treated with [MEDICATION NAME]. She also verified resident #2 did not have any medications ordered for pain relief prior to 1/4/12. She stated S4LPN Treatment Nurse should have notified the physician when the resident's heel declined and the treatment should have been changed. S2DON stated that if a wound had not made progress within a couple of weeks or if a wound declined suddenly, the physician should be notified. S2DON stated it was S4LPN Treatment Nurse responsibility to assess a resident for pain prior, during, and after wound care. She said S4LPN Treatment Nurse should notify the medication nurse of any reported pain and if the resident has pain medication ordered, then the resident should receive the medication, and if the resident does not have pain medication ordered, S4LPN Treatment Nurse should notify the physician. S2DON stated S4LPN Treatment Nurse was responsible for updating a resident's care plan when changes occurred with their skin or wound. She reviewed resident #2's care plan and verified it had not been updated on 11/1/11 with interventions of pressure relief for his right heel as recommended by the dermatologist, changes in wound appearance, or the pain related to the wound. S2DON verified S4LPN Treatment Nurse was provided wound care training prior to becoming the treatment nurse. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. On 1/5/12 at 9:25 a.m. an interview was held with S4LPN Treatment Nurse. She stated that she always informed the CNAs of skin care interventions specific for each resident. She stated she verbally communicated to the CNAs that resident #2's needed bilateral heel protectors on at all times. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. failed to include written communication to CNAs regarding specific pressure relieving measures for residents. An observation was made of S13CNA providing assistance to resident #2 on 1/5/12 at 9:35 a.m. During the observation, resident #2 was sitting in a wheelchair as S13CNA combed his hair. The resident's wheelchair was observed to have one leg rest to the left side of the chair. Resident #2 was wearing socks and had his left foot positioned on the leg rest and his right foot positioned flat on the floor. An interview was held with S13CNA during the observation and she verified the resident had a wound to his right heel. When asked if there were any pressure relieving interventions provided for his heel, S13CNA stated that the resident was turned every two hours. When the question was rephrased and S13CNA was asked if the resident was supposed to wear heel protectors, she stated not that she knew of. On 1/5/12, observations were made of resident #2 sitting in a wheelchair near the nurses' station from 9:45 a.m. to 1:20 p.m. The resident's left foot was positioned on the leg rest of the wheelchair and his right foot was positioned on the floor. The resident was wearing socks, but he did not have on heel protectors. At 1:20 p.m., nursing staff applied heel protectors to the resident's bilateral heels. Observations continued of resident #2 on 1/5/12, and between 2:00 p.m. and 3:00 p.m. the resident was observed rubbing his right leg. During this time, the resident was passed by nursing staff, including S12LPN, who stopped the resident from pulling on his PEG tube, but did not ask him anything else. At 2:55 p.m., an interview was held with resident #2. During the interview, he continued to rub his right leg. The resident requested a pillow to place beneath his right foot. During the interview, S15CNA approached resident #2 and the resident informed S15CNA that he wanted a pillow to place beneath his right foot. S15CNA asked the resident if he was ready to return to bed, and the resident responded "yes". At 3:00 p.m., resident #2 was taken to his room. S9CNA Supervisor, S15CNA, S16CNA and S17LPN were in the resident's room. At 3:05 p.m., the resident was observed rubbing his right leg when S16CNA asked him if his leg was hurting. The resident responded "my foot hurts on the bottom" while pointing to his right foot. At 3:10 p.m., the resident was assisted to bed requiring total assistance during the transfer from the wheelchair to the bed. Once in bed, the resident was noted with facial grimacing and he continued to point at his right foot. With S17LPN at the resident's bedside observing the resident, S15CNA asked the resident what was wrong. The resident stated "my foot" while pointing at his right foot. At 3:20 p.m., S17LPN was observed to leave the room and go to the medication cart. An interview was held with S16CNA on 1/5/12 at 3:30 p.m. She stated that CNAs obtained knowledge of specific interventions for each resident by reviewing the resident's Kardex. She stated each resident had a Kardex specific to their needs that was maintained for the CNAs. She verified the Kardex would include if a resident should have heel protectors in place. S16CNA further stated that she would not know that resident #2 was to have heel protectors on unless she reviewed the Kardex. Upon request of resident #2's Kardex, S16CNA was unable to locate it. She further stated that she had not been notified by a nurse that he was to have heel protectors on at all times. On 1/5/12 at 3:45 p.m. an interview was held with S2DON. She verified each resident had a Kardex that included information specific to their needs. She explained the Kardex was to be utilized by the CNAs. Upon searching the nurses' station for resident #2's Kardex, she was unable to locate it. She questioned S9CNA Supervisor regarding the whereabouts of the Kardex for resident #2 and S9CNA Supervisor stated all Kardexs for that hall was in the DON/ADON's office. S2DON located resident #2's Kardex within her office and stated that the ADON was going to review each Kardex before placing them back on the unit. When asked how the CNAs were to know that reside

Based on observations, record reviews, and interviews the facility failed to administer staff and resources in a manner to ensure that a resident maintained their highest level of well being regarding wounds for 2 (#2, #8) of 8 (#2, #4, #6, #7, #8, #9, #10, #11) residents that received wound care from a total sample of 11 residents. On 11/1/11, a Dermatologist lanced a fluid filled blister to Resident #2's right heel and ordered [MEDICATION NAME] BID and pressure relieving measures. Resident #2 was in Immediate Jeopardy after the 11/1/11 orders were received and the LPN treatment nurse and weekend treatment nurses failed to provide needed care and services including consultation with the physician regarding this right heel wound. For over 2 months, no one assessed this wound other than the LPN treatment nurse and the weekend nurses and no one notified the physician or the RN supervisor. On 1/4/12, the right heel wound had progressed to an unstageable wound with eschar measuring 6cm (length) x 5cm (width) x 0.8cm (depth) with surrounding redness measuring 8cm (length) x 5cm (width). Resident #2 experienced untreated pain from the wound and grimaced and cried out when his right foot was touched. Resident #8 was admitted to the facility on [DATE] with eschar to the left foot on the 3rd, 4th, and 5th toes. He was in immediate jeopardy after admission on 10/7/11 when the LPN treatment nurse wrote orders for the wounds without consultation with the physician, treatments were not conducted from 10/19/11-12/14/11, and no RN intervention occurred. Resident #8 experienced an increase in wound severity with tunneling, drainage, and a foul odor. From 11/1/11 until 1/4/12, the staff the facility assigned to care for Resident #2, and from 10/7/11 until 1/4/12, the staff assigned to care for resident #8, were unable or unprepared to provide the following needed care and services and there was no intervention by the ADON RN Supervisor to ensure the following needed care and services were provided: 1.) consult with the residents' physicians regarding changes in wound status (#2, #8); 2.) assess and communicate changes in status to other nurses and supervisors (#2, #8); 3.) assess, consult with the physician, and treat pain related to wounds (#2); 4.) implement pressure relieving interventions to prevent wounds from deteriorating (#2, #8); 5.) ensure the plan of care was updated with interventions to prevent skin breakdown and/or heal skin wounds (#2, #8); 6.) ensure CNAs were aware of pressure relieving measures (#2, #8); 7. ensure the ADON had knowledge of residents with wounds and assessed these wounds (#2, #8); 8.) ensure the ADON clinically supervised the LPN treatment nurse and weekend nurses to ensure orders were followed and care was provided following professional standards of practice (#2, #8); 9.) consistently measure wounds (#2, #8); 10.) ensure the LPN treatment nurse did not write orders for treatments to wounds and obtained orders from the physician (#8); 11.) obtain treatment orders for wounds upon admission (#8); 12.) recognize that the standing orders did not address wounds with eschar (#8); 13.) include in the policy and procedure for wounds instructions to nurses regarding pain from ulcers other than pressure ulcers (#2). 14.) ensure the DON and ADON reviewed standing orders for wounds with eschar (#8) 15.) ensure the DON and ADON consulted the physician regarding the wounds with eschar (#8) This failure had the potential to harm six other residents with wounds (#4, #6, #7, #9, #10, #11 ) and placed them in Immediate Jeopardy. The administrator was notified of the Immediate Jeopardy on 1/6/12. On January 20, 2012, the facility presented a plan or removal which included assessing and treating the wounds, physician consultation, having RN supervision of the wound care, implementing pressure relieving devices, and pain management measures. Surveyors determined the Immediate Jeopardy was removed on January 23, 2012. The deficient practice continues at patterns of actual harm for residents #2 and #8 and a potential for more than minimal harm for residents #4, #6, #7, #9, #10, and #11. Findings: Review of the facility's policy entitled, "Policy and Procedure for the Prevention and treatment of [REDACTED]. Policy: It is the policy to properly identify and assess residents, either by an RN or under an RN's supervision, whose clinical conditions increase the risk for impaired skin integrity and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. Procedures include: A. it is important to individualize each resident's turning and repositioning schedule. B. the care plan for skin integrity is to be evaluated and revised based on response, outcomes, and needs of the resident. II. treatment of [REDACTED]. If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented: 2. notify physician 3. notify supervisor 6. re-evaluate turning and repositioning intervals 8. re-evaluate interventions per risk factors identified 10. initiate weekly wound documentation progress sheet 11. when a pressure ulcer is present, daily wound monitoring should include whether pain, if present , is being adequately controlled. 12. notify the physician, NP and supervisor if the ulcer(s) has not shown progress in 2-4 weeks and/or is deteriorating unexpectedly. Re-evaluate plan of care as appropriate. Resident #2: Review of the clinical record revealed resident #2 had a [DIAGNOSES REDACTED]. Review of the most recent MDS dated [DATE] revealed resident #2 had impaired range of motion to his upper and lower extremities and was totally dependent on staff for bed mobility and transfers. Review of the most recent Pressure Sore Risk assessment dated [DATE] revealed the resident scored a total score of "14" indicating he was a pressure sore risk. The resident was assessed as having "very limited" sensory perception - ability to respond meaningfully to pressure related discomfort. Review of the Nurse/Physician Communication Record completed by S3ADON on 10/25/11 revealed resident #2 had fluid filled blisters to multiple areas of the body that included the right heel. S3ADON further documented the resident had a temperature of 99.9 degrees axillary and was noted to be less alert than usual. Review of the Physician's Telephone Orders dated 10/25/11 included: 1. Cleanse blister areas with Normal Saline or Wound Cleanser, pat dry, apply Triple Antibiotic Ointment, cover with dressing, change every day. Diagnosis: [REDACTED]. 2. Dermatology consult... Diagnosis: [REDACTED]. Review of the Progress Note completed by the Nurse Practitioner on 10/26/11 revealed in part: Physical Examination: Skin: blister to ...heel Impression/Plan: Bulbous Pemphigoid related to recent scabies - local care for now and follow up with Dermatologist. Review of the Nurse's Notes dated 10/27/11 revealed the resident had a temperature of 99.8 degrees axillary and was "not looking very well". The Nurse Practitioner was notified and ordered to send the resident to the emergency room for evaluation and treatment. Review of the hospital records revealed resident #2 was admitted to the hospital and treated for [REDACTED]. Review of the hospital's History and Physical dated 10/27/11 revealed in part: Dermatology: ... early pressure ulcers on his left foot as well as more prominent on his right heel. Review of the hospital Discharge Summary dated 10/30/11 included: Pressure Ulcers: The patient presented with multiple early pressure sites... Wound ostomy nurses were consulted and initiated treatment here which included turning every two hours, floating heels off the bed, having a specialty bed. Recommended cleaning the right heel with soap and water, apply Lidoflex pad to blister, cover with 4 x 4... Recommend continuing his wound care at the nursing home facility. The facility Policy and Procedure for the Prevention and treatment of [REDACTED]. Review of the hospital's Discharge Worksheet dated 10/30/11 and timed for 0915 (9:15 a.m.) included: Discharge Education and Instructions: (2) Wound care as outlined by our W.O.N. (wound ostomy nurse). Review of the discharge Medication List included Wound Care of the right heel as follows: Cleanse with soap and water, dry thoroughly, apply Lidoflex pad, cover with 4 x 4, wrap with conforming gauze, change every 48 hours. Review of the Admission and Physician's Telephone Orders dated 10/30/11 included no documentation of wound care for resident #2's right heel. Review of the October 2011 Wound Treatment Evaluation Record revealed no treatments were performed to the resident's right heel on 10/30/11. Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. Review of the Nurse's Note dated 10/30/11 revealed a re-admission skin assessment of resident #2. The resident's right heel was not mentioned within the note. Review of the Weekly Skin Condition Evaluation dated 10/30/11 revealed no documentation related to the resident's right heel. The facility Policy and Procedure for the Prevention and treatment of [REDACTED]. Review of the Nurse's Note made by S4LPN Treatment Nurse on 10/31/11 included resident #2's right heel was noted with a "100% blood filled blister". Review of the October 2011 Wound Treatment Evaluation Record revealed the treatment that was performed to resident #2's right heel on 10/31/11 was as follows: clean with wound cleaner or normal saline, pat dry, apply TAO, cover with DCD. On 11/1/11, resident #2 was seen by the Dermatologist as ordered on [DATE]. Review of the Dermatology Note dated 11/1/11 was noted by S4LPN Treatment Nurse and included: Large bullae to right heel medially. Impression: Pressure Bullae Recommendations: Drained; [MEDICATION NAME] ointment BID, pressure avoidance. Review of the Physician's Telephone Order dated 11/1/11 revealed in part: 1. D/C Triple Antibiotic Ointment 2. Apply [MEDICATION NAME] ointment BID to right heel Review of the Skin Risk Evaluation and Plan of Care included 11/1/11: Pressure Bullue to right heel - Goal date 2/1/12 There were no interventions on the Plan of Care related to the right heel. There was no documentation of "pressure avoidance" as recommended by the dermatologist. The Plan of Care did not indicate the resident was at risk of developing a pressure sore as determined on 10/17/11. The facility failed to follow the Facility's Policy and Procedure for the Prevention and treatment of [REDACTED]. The Facility's Policy and Procedure for the Prevention and treatment of [REDACTED]. Review of the Nurse's Notes made by S4LPN Treatment Nurse revealed in part the following: 11/1/11: Resident returned from Dermatology appointment ... Right heel Pressure Bullae was drained ... Right heel 50% tan and 50% purple wound bed with little bloody drainage. Excess skin covers wound bed. Area moist without odor noted ... 11/4/11: ... Right heel wound bed 80% tan dry tissue in center of wound with 20% purple dry tissue around wound edges ... Resident tolerated treatment well without complaints of pain ... 11/7/11: ... Right heel 100% dry purple tissue ... Resident tolerated well without complaints of pain ... 11/17/11: ... Right heel 75% dry purple skin and 25% dry tan skin ... Resident tolerated well without complaints of pain ... 11/23/11: ...Right heel wound bed 60% purple dry skin and 40% tan dry skin ... Resident tolerated well without complaints of pain ... 11/28/11: ...Right heel wound bed 90% purple dry skin and 10% tan dry skin ... No complaints of pain voiced by resident ... 12/1/11: ...Right heel 100% purple/tan dry skin ... Resident tolerated well without complaints of pain ... 12/7/11: ...Right heel wound bed 90% purple hard dry skin with 10% tan hard dry skin to center. No drainage ... Resident tolerated well without complaints of pain ... 12/12/11: ...Right heel wound bed 90% purple hard dry skin with 10% tan hard dry skin in center. No drainage ... Resident tolerated well without complaints of pain ... 12/13/11: ...70% of dry purple/tan hard skin fell off during dressing change. 70% of wound bed red moist tissue with 30% hard, dry purple/tan skin towards edges of wound bed. No drainage ... Resident tolerated well without complaints of pain ... 12/15/11: ...50% dry purple/tan tissue/skin to wound bed. Noted with faint amount of bloody drainage. Resident tolerated well without complaints of pain ... 12/20/11: ...Right heel wound bed 50% moist red tissue with 50% dry purple tissue. Tiny amount of bloody drainage ... Resident tolerated treatment well without complaints of pain ... 12/22/11: ...Right heel ... 70% dry purple skin tissue in center of wound bed and 30% moist red tissue surrounding dry purple scar tissue ... Resident tolerated well without complaints of pain ... 12/29/11: ...Right heel wound bed 50% hard purple skin with 50% moist red skin ... Resident tolerated well without complaints of pain ... 1/2/12: ...Right heel wound bed 50% hard purple skin tissue and 50% moist red skin tissue. No drainage ... Resident voiced no complaints of pain ... 1/4/12: ...Right heel wound bed 50% hard dry purple tissue with faint amount of brown drainage. 50% red moist tissue surrounding hard, dry purple tissue without drainage ... Resident tolerated treatment well with complaints of pain only when touched ... Review of the Wound Treatment Evaluation Records for October 2011 through January 2012 revealed no measurements were made of resident #2's right heel by S3ADON. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. An observation was made on 1/4/12 at 8:45 a.m. of resident #2 lying in bed. The resident was positioned on his back with the head of the bed elevated. He was observed leaning to his left side. The resident's right foot was noted to have a Perplex dressing wrapped around his heel and ankle. The right heel was in direct contact with the mattress. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. On 1/4/12 at 9:20 a.m. an observation was made of resident #2's skin with S4LPN Treatment Nurse. Resident #2 mumbled when he saw S4LPN Treatment Nurse. She responded to the resident with, "I know you hate to see me because you know what I'm about to do will hurt". The resident was observed to be in the same position he had been in during the previous observation at 8:45 a.m. His right heel continued to be in direct contact with the mattress. In preparation of the treatment to the resident's right heel, S4LPN Treatment Nurse elevated his right heel off the mattress with a pillow. S4LPN Treatment Nurse removed the dressing to resident #2's right heel. There was a small amount of light brown drainage to the old dressing. The right medial heel was noted to have a large piece of eschar that was surrounded by reddened skin. The lower portion of the eschar, by the lower heel, had edges that were lifting. This left a small open area between the eschar edge and the surrounding red tissue. During the observation, an interview was held with S4LPN Treatment Nurse. She described resident #2's right heel as deep purple with surrounding red blanchable tissue. When S4LPN Treatment Nurse was asked specifically about the eschar to resident #2's right heel, she again responded that she classified the area as "deep purple". She further stated the right heel has had that appearance for three to four weeks. S4LPN Treatment Nurse proceeded to provide wound care, which consisted of cleaning the wound with normal saline, applying [MEDICATION NAME], covering the wound with clean gauze and wrapping with Perplex. Throughout the observation, resident #2 verbalized complaints of pain. The resident was noted with facial grimacing and cried out each time S4LPN Treatment Nurse touched his right foot. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. was not followed regarding RN supervision of wound assessment. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. failed to include instructions to nurses regarding ensuring the physician was consulted with regarding pain related to wounds; notification of the RN supervisor regarding pain related to wounds, and treating pain related to wounds. An interview was held with S4LPN Treatment Nurse on 1/4/12 at 10:00 a.m. She stated she worked Monday through Friday from 4:30 a.m. to 12:30 p.m. She stated she had been the treatment nurse for approximately six months. She said the facility provided wound training prior to her becoming the treatment nurse. She stated that she developed and revised skin related care plans. She said she updated resident's care plan when a new order was received. She explained that all wounds were measured and staged by S3ADON. She said that she notified S3ADON when a wound needed to be measured or staged. She said she and S3ADON communicated only verbally regarding wounds. She explained that resident #2's right heel had originated as a blister. She said the resident was seen by a Dermatologist and was diagnosed with [REDACTED]. She said "pressure bullae" was described to her as being an immune system illness. She further stated that resident #2's right heel was not considered to be a "pressure" wound since it was previously diagnosed as a "pressure bullae". She said the interventions ordered by the Dermatologist were [MEDICATION NAME] and pressure relief. She further stated that she had not notified S3ADON of resident #2's right heel wound because the wound was not a "pressure wound". When asked if she had notified the physician when the resident's right heel wound changed in appearance (according to her that was three to four weeks ago), S4LPN Treatment Nurse stated she had not notified the physician. She stated that the resident's right heel should be elevated off of the mattress to help with pressure relief. She explained that pillows, rolls, or wedges could be used to elevate the resident's right heel. She stated that resident #2 complained of pain each time she provided wound care. She said the resident "hated" to see her because he related her to pain. She stated the resident's medication nurse pre-medicated the resident prior to wound care. S4LPN Treatment Nurse stated that she did not know what medication the resident received for pain. She further stated that she had not notified the physician or the medication nurse when the resident continued to complain of pain during wound care. She verified she documented the resident did not complain of pain because she thought the resident was pre-medicated prior to wound care. She reviewed resident #2's skin plan of care and verified it had not been updated with interventions for the risk of pressure ulcers determined during his quarterly assessment on 10/17/11; the dermatology recommendations for pressure avoidance on 11/1/11; changes in wound appearance; or the resident's complaints of pain. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. failed to address RN clinical supervision to ensure pressure relieving measures were implemented. On 1/4/12 at 11:20 a.m. an interview was held with S3ADON. She stated that she was responsible for weekly measurements of wounds and staging of pressure wounds. She stated that S4LPN Treatment Nurse notified her verbally of any wounds that needed assessing. S3ADON stated that she was not aware of resident #2 having a wound to his right heel. She recalled that "awhile back" the resident had multiple blisters. She stated that S4LPN Treatment Nurse had not informed her of resident's right heel wound. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. was not followed regarding RN supervision of wound assessment. An observation was made of resident #2's right heel with S3ADON on 1/4/12 at 11:25 a.m. Resident #2 was observed to be lying in bed on his back with his right heel lying directly on the mattress in the same position the resident was in during previous observations at 8:45 a.m. and 9:20 a.m.. S3ADON removed the dressing from resident #2's right heel. Resident #2 was observed to have facial grimacing and verbalize complaints of pain each time S3ADON touched his right foot. S3ADON asked the resident if his foot hurt, and resident #2 responded "yes". S3ADON assessed the resident's right heel and when asked to describe the right heel wound, she replied, "That's eschar". S3ADON stated the surrounding tissue was red and the lower portion of the heel was "spongy" with a "deep purple" color. S3ADON measured the wound and the following measurements were noted: eschar measured 6cm (length) x 5cm (width) x 0.8cm (depth) and surrounding redness measured 8cm (length) x 5cm (width). S3ADON stated she should have been notified of the resident's heel wound. She stated that she did not feel that [MEDICATION NAME] was appropriate treatment for [REDACTED]. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. On 1/4/12 at 11:50 a.m. an interview was held with S12LPN. She verified she was the routine medication nurse for resident #2. She stated that resident #2 was not ordered any medications for pain. She said that the resident had not complained of pain to her. She further stated that S4LPN Treatment Nurse had not informed her that resident #2 needed pre-medicating for pain prior to wound care. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. Review of the November 2011 through January 2012 physician's orders [REDACTED].#2 during that time. Review of the Nurse's Note dated 1/4/12 and timed for 1150 (11:50 a.m.) revealed documentation of S3ADON's assessment of resident #2's heel. The Note included the following: Report received of right heel wound - area assessed. "Eschar 5 x 6cm c (with) 1/8cm depth at inferior medial edge. Adjacent to that 5 x 8 crescent shaped area, red and blanchable at superior aspect, spongy purple at inferior aspect. Resident expressed pain upon palpitation ...". Review of the Physician's Telephone Orders dated 1/4/12 and timed for 1158 (11:58 a.m.) revealed the following orders for the right heel wound: 1. Cleanse area with wound cleanser and pat dry. 2. Apply Hydrogel. 3. Cover with Optiform or other foam dressing. 4. Change daily and PRN. 5. Foam heel booties to both feet at all times. 6. [MEDICATION NAME] (non-narcotic pain reliever) 1 per PEG tube every 6 hours PRN pain. On 1/5/12 at 8:25 a.m. an observation was made of resident #2 lying in bed with his eyes closed. The head of the bed was elevated at a high position and the resident's bilateral heels were observed to be in direct contact with the mattress. The resident's right ankle/heel was wrapped with a dressing. There was no heel protectors noted to the resident's bilateral heels. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. An interview was held with S2DON on 1/5/12 at 8:30 a.m. She stated that S3ADON had informed her of resident #2 experiencing pain when his right foot was touched and that his right heel had eschar. S2DON verified that prior to 1/4/12 the resident's heel had only been treated with [MEDICATION NAME]. She also verified resident #2 did not have any medications ordered for pain relief prior to 1/4/12. She stated S4LPN Treatment Nurse should have notified the physician when the resident's heel declined and the treatment should have been changed. S2DON stated that if a wound had not made progress within a couple of weeks or if a wound declined suddenly, the physician should be notified. S2DON stated it was S4LPN Treatment Nurse responsibility to assess a resident for pain prior, during, and after wound care. She said S4LPN Treatment Nurse should notify the medication nurse of any reported pain and if the resident has pain medication ordered, then the resident should receive the medication, and if the resident does not have pain medication ordered, S4LPN Treatment Nurse should notify the physician. S2DON stated S4LPN Treatment Nurse was responsible for updating a resident's care plan when changes occurred with their skin or wound. She reviewed resident #2's care plan and verified it had not been updated on 11/1/11 with interventions of pressure relief for his right heel as recommended by the dermatologist, changes in wound appearance, or the pain related to the wound. S2DON verified S4LPN Treatment Nurse was provided wound care training prior to becoming the treatment nurse. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. On 1/5/12 at 9:25 a.m. an interview was held with S4LPN Treatment Nurse. She stated that she always informed the CNAs of skin care interventions specific for each resident. She stated she verbally communicated to the CNAs that resident #2's needed bilateral heel protectors on at all times. The Facility Policy and Procedure for the Prevention and treatment of [REDACTED]. failed to include written communication to CNAs regarding specific pressure relieving measures for residents. An observation was made of S13CNA providing assistance to resident #2 on 1/5/12 at 9:35 a.m. During the observation, resident #2 was sitting in a wheelchair as S13CNA combed his hair. The resident's wheelchair was observed to have one leg rest to the left side of the chair. Resident #2 was wearing socks and had his left foot positioned on the leg rest and his right foot positioned flat on the floor. An interview was held with S13CNA during the observation and she verified the resident had a wound to his right heel. When asked if there were any pressure relieving interventions provided for his heel, S13CNA stated that the resident was turned every two hours. When the question was rephrased and S13CNA was asked if the resident was supposed to wear heel protectors, she stated not that she knew of. On 1/5/12, observations were made of resident #2 sitting in a wheelchair near the nurses' station from 9:45 a.m. to 1:20 p.m. The resident's left foot was positioned on the leg rest of the wheelchair and his right foot was positioned on the floor. The resident was wearing socks, but he did not have on heel protectors. At 1:20 p.m., nursing staff applied heel protectors to the resident's bilateral heels. Observations continued of resident #2 on 1/5/12, and between 2:00 p.m. and 3:00 p.m. the resident was observed rubbing his right leg. During this time, the resident was passed by nursing staff, including S12LPN, who stopped the resident from pulling on his PEG tube, but did not ask him anything else. At 2:55 p.m., an interview was held with resident #2. During the interview, he continued to rub his right leg. The resident requested a pillow to place beneath his right foot. During the interview, S15CNA approached resident #2 and the resident informed S15CNA that he wanted a pillow to place beneath his right foot. S15CNA asked the resident if he was ready to return to bed, and the resident responded "yes". At 3:00 p.m., resident #2 was taken to his room. S9CNA Supervisor, S15CNA, S16CNA and S17LPN were in the resident's room. At 3:05 p.m., the resident was observed rubbing his right leg when S16CNA asked him if his leg was hurting. The resident responded "my foot hurts on the bottom" while pointing to his right foot. At 3:10 p.m., the resident was assisted to bed requiring total assistance during the transfer from the wheelchair to the bed. Once in bed, the resident was noted with facial grimacing and he continued to point at his right foot. With S17LPN at the resident's bedside observing the resident, S15CNA asked the resident what was wrong. The resident stated "my foot" while pointing at his right foot. At 3:20 p.m., S17LPN was observed to leave the room and go to the medication cart. An interview was held with S16CNA on 1/5/12 at 3:30 p.m. She stated that CNAs obtained knowledge of specific interventions for each resident by reviewing the resident's Kardex. She stated each resident had a Kardex specific to their needs that was maintained for the CNAs. She verified the Kardex would include if a resident should have heel protectors in place. S16CNA further stated that she would not know that resident #2 was to have heel protectors on unless she reviewed the Kardex. Upon request of resident #2's Kardex, S16CNA was unable to locate it. She further stated that she had not been notified by a nurse that he was to have heel protectors on at all times. On 1/5/12 at 3:45 p.m. an interview was held with S2DON. She verified each resident had a Kardex that included information specific to their needs. She explained the Kardex was to be utilized by the CNAs. Upon searching