Every finding on record at Presbyterian Communities Of South Carolina- Clinto

Based on interview and record review, the facility failed to report abuse allegations for 1 of 4 residents reviewed. Resident (R)1 reported a potential verbal abuse incident to Registered Nurse (RN)1 on 08/14/22, but the incident was not reported by the facility until the following day when the family filed a grievance regarding the potential verbal abuse. Findings include: Review of the facility's undated policy regarding abuse revealed Employees, facility consultants, and/or attending physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the Director of Nursing Services, such reports must be made to the nurse supervisor on duty. Any individual observing an incident of abuse or suspecting resident abuse must immediately report such incident to the administrator or Director of Nursing Services. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, Alzheimer's dementia, major depressive disorder, type 2 diabetes mellitus, and generalized idiopathic epilepsy. Review of a facility grievance on revealed family of R1 reported a concern to the Director of Social Services on 08/15/22 at 7:59 AM. Certified Nursing Aide (CNA)1 became upset with R1 for having an accidental bowel movement. The CNA said, I ought to make you clean yourself up since you s*** on yourself. The Director of Social Services interviewed R1 who confirmed the verbal abuse allegation. Review of Registered Nurse (RN)1's written statement revealed on 08/15/22 around 4 PM, R1 said that CNA1 fussed at her for making a mess and her nerves were tore up. An interview with the Administrator on 12/29/22 at approximately 10:50 AM confirmed the delayed reporting. Interview also revealed she expected staff to report potential abuse if a resident reported someone fussed at them and they felt tore up. An interview with the Director of Nursing (DON) on 12/29/22 at approximately 10:50 AM confirmed the delayed reporting. Interview also revealed RN1 had enough information to suspect abuse, and that she should have reported the incident. Review of an 08/15/22 disciplinary action for RN1 on 12/29/22 revealed RN1 was disciplined for not reporting the abuse allegation when the resident confided in her. The employee commented that I did not realize that 'fussed at' was an instance of verbal abuse and I should have. Multiple unsuccessful attempts were made to interview RN1.

Based on observations, interviews and record review, the facility failed to conduct employee qualitative fit testing for N95 masks, during the COVID-19 pandemic. The facility identified 28 staff members who worked on the skilled nursing unit, which consisted of Certified Nursing Assistants, Licensed Nurses, Director of Nursing (DON), Assistant Director of Nursing, Social Worker and Activities. The findings included: A review of the facility's Community PPE Inventory sheet, dated 06/15/20, indicated the facility currently had 85 N95 masks, and no KN95 masks. There were no current COVID positive residents in the facility. The census at the time of the survey was 5 residents. During an interview on 06/16/20 at 2:19 PM, the Director of Nursing (DON) confirmed they had 85 N95 masks. She indicated no one was currently wearing N95 masks on the unit. She stated if they have a confirmed COVID-19 case, then they would utilize the N95 masks. When questioned who would need to wear an N95, she stated anybody that would be in close contact with the COVID-19 positive resident would need to wear the mask. The DON indicated they had not performed any employee fit testing for the N95 masks, and there were no current plans in place to perform the fit testing. During an observation and interview on 06/16/20 at 2:28 PM, a Dietary Cook was observed wearing an N95 mask. She stated she got it from her mom, who worked in a doctor's office. The Dietary Cook verified it was an N95 mask and stated she had never been fit tested for the mask. A review of the Centers for Disease Control (CDC), Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, last updated 05/18/20, indicated, Filtering Facepiece Respirators (FFR) including N95 Respirators. A commonly used respirator in healthcare settings is a filtering facepiece respirator (commonly referred to as an N95). FFRs are disposable half facepiece respirators that filter out particles. To work properly, FFRs must be worn throughout the period of exposure and be specially fitted for each person who wears one. This is called fit testing and is usually done in a workplace where respirators are used. FFR users should also perform a user seal check to ensure proper fit each time an FFR is used. A review of CDC's guidelines titled, Preparing for COVID-19 in Nursing Homes, last updated 05/19/20, indicated, Facilities should have supplies of facemasks, respirators (if available and the facility has a respiratory protection program with trained, medically cleared, and fit-tested HCP), gowns, gloves, and eye protection (i.e., face shield or goggles). Implement a respiratory protection program that is compliant with the OSHA respiratory protection standard for employees if not already in place. The program should include medical evaluations, training, and fit testing.

Based on observations, interviews, review of staff records and Standards for Licensing Nursing Homes Regulation Number 61-17, the facility failed to provide qualified staff to operate 1 of 1 kitchen reviewed for dietary services. The facility did not employ a qualified food service supervisor. Findings: During a kitchen observation on 4/8/19 at approximately 10:10 AM it was noticed that the dietary supervisor and the food and nutrition assistant director were the only managerial staff present at the time. Neither one of them is a certified dietary manager. During an interview with the assistant director of food and nutrition services (chef) on 4/8/19 at 10:10 AM (s/he) stated that (s/he) doe hot hold a dietary manager certification that (s/he) is a chef by training and (s/he) holds a ServSafe certification good through 12/4/22. S/he also reported that the food and nutrition service director was on (his/her) way to the facility and that (s/he) is also ServSafe certified but is not a certified dietary manager (CDM). And that there is also a part-time registered dietitian that comes to the facility twice per week. The assistant director for food and nutritional services also stated that (s/he) has been working for the facility for four years through (name of company), a contract food service, and the food and nutrition director and the part-time dietitian also work for the facility through (name of company). The assistant director said that there is a full-time dietary supervisor that works through the facility (hired by the facility). The dietary supervisor also holds a ServSafe certification, but (s/he) is not a dietitian or a certified dietary manager. During an interview with the food and nutrition services director on 4/9/19 at approximately 3:40 PM (s/he) acknowledged that the facility does not have a CDM or a full-time dietitian. Review of Standards for Licensing Nursing Homes Regulation Number 61-17 states under 1405. Meal Service Staff (B.) The meal service operations shall be under the direction of a dietitian or qualified food service supervisor who shall be responsible for supervising the meal service staff, planning, preparation and serving of food and the maintenance of proper records. A staff member shall be designated, by name or position, to act in the absence of this person. (II) (C.) A qualified food service supervisor shall be a person who: (II) 1. Is a graduate of a dietetic technician training program approved by the American Dietetic Association; or 2. Is a graduate of a course of study meeting the requirements of the American Dietetic Association and approved by the state; or 3. Has at least three (3) years of training and experience in meal service supervision and management in a military service equivalent.

Based on observation, record review and interviews the facility failed to review/revise or update the resident's care plan after each time the resident exhibited aggressive behavior directed toward others for one of six sampled residents reviewed for accidents. The facility admitted Resident #165 on 9/11/18 with [DIAGNOSES REDACTED]. Review of Resident #165's Nurse's notes on 4/9/19 at 11:02 AM revealed the following: On 9/22/18 Resident #165 alert with some confusion noted. The resident requires supervision with ambulation, transfer, and mobility. The resident attends the dining area for meals. Resident tends to get very agitated with (his/her) roommate. The staff has to supervise them closely when they are around each other. Resident #165 told room-mate that (s/he) was going to put a fist in (his/her) mouth if (s/he) didn't stop yelling. Resident #165 also motioned like (s/he) was going to shove a chair at the roommate when sitting at the nurse's station. On 9/23/18 Resident #165 separated from another resident in common areas and staff to watch closely to make sure the resident is not approaching residents or that other residents were near (him/her). The resident's roommate moved to another room. Medical Doctor (MD) and the Director of Nursing (DON) and the resident's daughter notified. On 9/23/18 Resident #165 alert with some confusion and aggressive behaviors including hitting another resident, attempting to knock things off the dining tables and kicking another resident's O2 concentrator-Resident sitting nurse's station to monitor behavior-MD notified -[MEDICATION NAME] increased to 20 mg per MD-family notified. On 10/26/18 the resident's (Resident #165) mental state changed: increased confusion, holding head (head-ache) trouble finding (hi/her) room and unclear speech. On 10/29/18 the resident (Resident #165) attempted to push another resident up the hallway. The nurse stopped the resident, and the resident cursed at the nurse. On 11/5/18 the resident (Resident #165) had some confusion at times. Need assistant finding (her/his) room. The resident is slightly agitated. The resident was transferred to an uncertified bed on 11/5/18. Care plan reviewed on 4/9/19 at 12:07 PM revealed that Resident #165's care plan did not reflect that (his/her) care plan was reviewed/revised or updated after each incident. An interview with the Minimum Data Set (MDS) Coordinator and the Assistant Director of Nursing (DON) on 4/10/19 at 11:08 AM the MDS Coordinator and DON both acknowledge that Resident #165's care plan was not updated after each incident.

Based on observation, record review, and interview, the facility failed to post staffing information for 1 of 1 facility. The staff postings did not identify registered and licensed nurses, and the hours worked were not filled out. The findings included: Observation of staff postings on 4/9/19 at approximately 10:50 AM revealed the hours worked by staff and the breakdown of licensed and registered staff had not been filled out on the posting. Observation of staff postings on 4/11/19 at 9:20 AM revealed the hours worked by staff and the breakdown of licensed and registered staff had not been filled out on the posting. Review of policy for Posting Direct Care Daily Staffing Numbers on 4/11/19 at approximately 10 AM revealed the facility was to post the total number of and actual hours worked by registered nurses, licensed practical nurses, and certified nursing aides. During an interview with Registered Nurse #1 on 4/11/19 at approximately 11:06 AM s/he confirmed the hours worked and breakdown of licensed and registered staff were not listed on the posting. RN #1 stated the staff form was not filled out until the end of the shift.

Based on record review, facility policy and interview, the facility failed to implement its protocol for antibiotic use and failed to monitor actual antibiotic use for Resident #1, 1 of 1 sampled resident reviewed for Respiratory Care. Resident #1 did not meet the facility's criteria for antibiotics and antibiotics were initiated. In addition, the resident's antibiotic use was not included in the monthly Infection Control logs. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review of Resident #1's physician's orders [REDACTED]. The [MEDICATION NAME] was ordered to be continued at a dose of 250mg for four additional days after the 500mg dose. Record review of Resident #1's Medication Administration Record [REDACTED]. Record review of Resident #1's chest x-ray result from 1/17/19, on 4/9/19 at 3:13 PM, revealed Resident #1 had a chest x-ray that indicated the lungs are clear. Record review of Resident #1's nurse practitioner's (NP) notes on 4/10/19 at 10:36 AM, revealed the resident was evaluated on 1/21/19 for continued cough and chest congestion. The note indicated the recent chest x-ray was negative. The NP diagnosed the resident with an Upper Respiratory Infection and ordered the [MEDICATION NAME] DM 3 times a day for 5 days and continued [MEDICATION NAME] nebulizer breathing treatments. Record review of the Infection Control reports for (MONTH) 2019 on 4/11/19 at 8:56 AM, revealed Resident #1's Upper Respiratory Infection was not documented in the monthly infection report. In addition, the resident's antibiotic use was not tracked in the log. During an interview with the Assistant Director of Nursing (ADON) 4/11/19 at 10:20 AM, the ADON confirmed Resident #1 received a five-day course of [MEDICATION NAME]. The ADON also confirmed s/he was the acting Infection Preventionist. When asked why the infection and antibiotic use were not documented in the Infection Control reports, the ADON stated it was not documented because the resident did not meet the facility's criteria for an Upper Respiratory Infection. When asked why antibiotics were initiated if the resident did not meet the criteria, the ADON stated the resident had been having respiratory symptoms since 1/11/19 and the NP must have determined antibiotics were necessary. The ADON stated the NP did not document a rationale for antibiotic use despite not meeting the criteria for antibiotic use. The ADON confirmed it was facility policy to track antibiotic use and monitor adherence to evidenced-based criteria as part of the facility's Antibiotic Stewardship Program. In addition, the ADON confirmed the NP did not identify infection criteria for antibiotic use and the facility did not contact the NP to identify a rationale for the ordered antibiotic. Review of the facility's Antibiotic Stewardship Program revealed: If indicated, based upon (identified) criteria, an antibiotic is ordered, the practitioner will identify the diagnoses/indication, the right antibiotic, proper dose, duration and route. In the event that the prescribing physician orders [REDACTED].

Based on observation and interview, the facility failed to post the survey results in an area readily accessible to residents, family members and legal representatives on 1 of 1 unit observed. The findings included: During Initial Tour of the facility on 4/8/19 at 10:12 AM, no survey results could be located on the unit. During additional observations on 4/9/19 at 9:39 AM and 4/10/19 at 9:49 AM, survey results could not be located on the unit. During an interview with the Assistant Director of Nursing (ADON) on 4/10/19 at 9:49 AM, the ADON confirmed the survey results were not posted on the unit. The ADON stated maintenance must have taken them down when they were getting ready to paint the halls. The ADON stated s/he did not know how long ago the survey results were removed from the unit. The ADON stated s/he did not know where the survey results were but would locate them. During an interview with the ADON on 4/10/19 at 9:52 AM, the ADON stated the survey results were found at the nurse's station. When asked if this was an area readily accessible to residents, family members and legal representatives, the ADON stated it was not.

Based on observation, interview, and record review the facility failed to store/prepare/serve food in a sanitary manner 2 of 2 unit kitchens. Multiple opened and undated food items were found in the refrigerator and freezer of the H Wing kitchen. The G Wing dishwasher did not meet appropriate temperature in wash cycle. The findings included: Observation of dishwashing on 5/8/18 at approximately 9:30 AM revealed the temperature gauge for the wash cycle did not reach 150 degrees Fahrenheit during the wash cycle as per the manufacterer's recommendations found on the dishwashing machine. During the wash cycle the temperature gauge never read above 140 degrees Fahrenheit. There was no concern with the rinse cycle which reached an appropriate 180 degrees Fahrenheit. Interview with Dining Worker #1 on 5/8/18 at approximately 9:30 AM confirmed the temperature gauge for the wash cycle did not reach 150 degrees Fahrenheit. Review of policy on 5/8/18 at approximately 10:10 AM revealed the wash cycle was supposed to reach 150 degrees - 165 degrees Fahrenheit. During Initial Tour of the Bistro kitchen on H Unit on 5/7/2018 at 10:05 AM, multiple food items were observed in the freezer and refrigerator that were opened and were not labeled with an open date or use by date. In the freezer, opened bags of chicken tenders and potato chips were observed and were not labeled with an opened date, use by date or expiration date. In addition, a zip lock bag of green beans was observed unlabeled in the freezer. In the Refrigerator, opened containers of strawberries and honey mustard dressing were not labeled with a opened date or use by date. In addition, American cheese was observed wrapped in saran wrap with no labeling. During an interview with the Interim Dining Services Director on 5/7/2018 at 10:10 AM, the Interim Dining Services Director confirmed the items were unlabeled. The Interim Dining Services Director proceeded to place labels on all of the items. The Interim Dining Services Director stated he/she just started working at the facility a week ago and stated he/she was aware labeling and dating opened food items was an issue with the kitchen staff. He/she also stated last Thursday he/she had told staff to go through the freezer and refrigerator and ensure all opened food items were properly labeled with an opened date and use by date. Review of the facility's Food Handling and Food Storage policies revealed policy addressed labeling prepared foods with dates prepared and use by dates, but did not address labeling and dating unprepared opened food items.

Based on observation, record review and interview, the facility failed to develop a comprehensive person-centered care plan for Resident #7, 1 of 1 sampled resident reviewed for range of motion. Resident #7's contractures were not care planned. Cross refer to F688 The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Resident #7 was observed in bed on 5/7/2018 at 1:31 PM. The resident's left arm and left hand appeared contracted. The resident had a rolled wash cloth to her/his contracted left hand. Record review of the Progress Notes on 5/7/2018 at 2:23 PM, revealed a physician note, from 12/29/2017, indicating the resident had contracturing of the left hand and has a roll in place. A nurse practitioner note from 4/12/2018 indicated Left arm/hand contracted to chest. Record review of the Care Plan on 5/7/2018 at 3:15 PM revealed the resident's left arm/hand contractures and range of motion were not care planned for. In addition, the Care Plan revealed no interventions for the left arm/hand contractures. During an interview with Registered Nurse (RN) #1 on 5/7/2018 at 3:40 PM, RN #1 confirmed that the resident's contractures were not care planned for and stated they should have been. RN #1 stated that staff open and wash the resident's contracted left hand and place a rolled wash cloth daily. RN #1 confirmed these interventions were not on the Care Plan. RN #1 also stated the resident had the contractures for as long as she/he had worked at the facility.

Based on observation, record review and interview, the facility failed to provide treatment/services to maintain or improve range of motion for Resident #7, 1 of 1 sampled resident reviewed for range of motion. The facility had no documentation of assessing, monitoring or measuring of the resident's range of motion and contractures. Cross refer to F656 The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Resident #7 was observed in bed on 5/7/2018 at 1:31 PM. The resident's left arm and left hand appeared contracted. The resident had a rolled wash cloth to her/his contracted left hand. Record review of the Progress Notes on 5/7/2018 at 2:23 PM, revealed a physician note, from 12/29/2017, indicating the resident had contracturing of the left hand and has a roll in place. A nurse practitioner note from 4/12/2018 indicated Left arm/hand contracted to chest. Record review of the Treatment Administration Record (TAR) on 5/7/2018 at 2:52 PM, revealed an order, dated 5/12/2016, to clean the left hand daily with dial soap. There were no other treatment orders for the resident's left arm/hand contractures, including no orders for the rolled wash cloth. Review of the Nurse's Notes on 5/7/2018 at 2:46 PM revealed no documentation of monitoring or assessing the resident's contractures. Additional review of the medical record revealed no documentation indicating the facility was assessing the resident's contractures to determine if the contractures were worsening, improving or unchanged. There were no measurements of the resident's extent of movement of her/his joints to identify any limitations. During an interview with Registered Nurse (RN) #1 and the Director of Nursing (DON) on 5/7/2018 at 4:09 PM, the DON stated there were no assessments or documentation of monitoring related to the resident's range of motion. When asked how the facility determines if the resident has any changes to her/his contractures or range of motion, both the DON and RN #1 stated they see the resident everyday and would be able to tell by looking at her/him if there were any changes to her/his range of motion/contractures. When asked if there was any documentation of this monitoring the DON stated there was not. The DON stated therapy had not done any evaluations of the resident's range of motion. The DON also stated they had no process in place to measure the resident's extent of movement in her/his joints to identify any limitations. During an interview with RN #1 on 5/8/2017 at 12:09 PM, RN #1 stated the resident had the contractures to the left arm/hand as long as she/he had worked at the facility. RN #1 stated that staff placed the rolled wash cloth to the resident's left hand daily and had been doing so since the resident had been in the facility. RN #1 confirmed there was no documentation of using the rolled wash cloth prior to 5/7/2018.

Based on observation, record review, interview and review of the facility's Administering Medications through an Enteral Tube policy, the facility failed to administer medications per Resident #161's gastrostomy tube (G tube) per policy, 1 of 1 sampled resident's reviewed with a G tube. Policy was not followed during medication administration. The findings included: The facility admitted Resident #161 with [DIAGNOSES REDACTED]. On 5/7/2018 at 3:22 PM, Licensed Practical Nurse (LPN) #1 was observed preparing [MEDICATION NAME] 50 milligrams for G tube administration for Resident #161. LPN #1 partially filled a medicine cup with water and added the crushed medication to the cup. LPN #1 was asked how she/he knows how much water to dilute the medication in. LPN #1 stated there were no orders for the amount of water. LPN #1 stated she/he added 20 milliliter (ml) of water to the medication cup and this was confirmed by observation. LPN #1 proceeded to Resident #161's room. Prior to administering the medication, LPN #1 stated we have orders to check tube placement every shift and she/he had done this earlier in the day. LPN #1 unclamped the resident's G tube and poured the 20 ml of water with the medication into the tube. LPN #1 then stated there are no orders to flush the G Tube during medication administration, but she/he was going to flush the G Tube. LPN #1 then flushed the G tube with 30 ml of water. The diluted medication and water flush flowed freely into the tube without complication. LPN #1 discarded used supplies, washed her/his hands and left the room. Review of the facility's Administering Medications through an Enteral Tube policy on 5/7/2018 at 3:45 PM revealed Dilute the crushed or split medication with 30 ml water (or prescribed amount). The policy also indicated that tube placement and gastric contents should be checked prior to medication administration. In addition, the policy indicated that the tube should be flushed with 30 ml of warm water (or prescribed amount) prior to and after medication administration. Record review of the physician orders [REDACTED]. During an interview with LPN #1, with the DON present, on 5/7/2018 at 3:48 PM, LPN #1 confirmed she/he did not dilute the medication in 30 ml of water, did not check the G tube for placement, did not check gastric contents and did not flush the tube prior to medication administration per facility policy. Resident #161 was reviewed for Tube Feeding with no other concerns identified.

Based on record review, interview and review of the facility's Infection Control Policy and Procedural Manual related to surveillance, the facility failed to track/document a resident on contact precautions for [MEDICAL CONDITIONS] on 2 of 6 monthly monitoring. Resident #5 with [MEDICAL CONDITION] in (MONTH) (YEAR) was not identified through the facility's tracking and trending process. The findings included: The facility admitted Resident #5 on 2/16/18 and readmitted the resident on 2/28/18 with [DIAGNOSES REDACTED]. A review of the medical record on 5/08/18 at approximately 10:07 AM revealed a physical and history with an electronic date of 3/01/18 that indicated Resident #5 was identified as being diagnosed with [REDACTED]. A nurse's note dated 3/01/18 revealed the resident was in the skilled unit due to a recent hospitalization due to fluid overload and [MEDICAL CONDITION] and remains on contact precaution due to [MEDICAL CONDITION]. Review of the facility's tracking and trending of communicable diseases for the months of (MONTH) and (MONTH) (YEAR) revealed Resident #5 was not documented as having [MEDICAL CONDITION] and there was no information related to when infection was identified or type of treatment given and for how long. An interview on 5/08/18 at approximately 12:06 PM with Registered Nurse #2 confirmed Resident #5 was not identified on the (MONTH) or (MONTH) (YEAR) tracking and trending forms related to being diagnosed as having [MEDICAL CONDITION]. RN #2 stated further the resident was not identified due to a new electronic operating system. Review of the facility's Infection Control Policy and Procedure Manual under #8 indicated The Infection Preventionist and Director of Nursing Services will be responsible for: (a) Receiving surveillance information and tabulating data; (b) Maintaining a line list of identified cases on the appropriate Line Listing Report; (e) Completing the Infection Treatment/Tracking Report form.

Based on observation and interview, the facility failed to ensure proper storage and preparation of food in accordance with professional standards for food service safety for 2 of 2 kitchens observed. The findings included: Tour of dry food storage in the main kitchen at 9:45 AM revealed 2 open/punctured boxes of 36 ox long grain wild rice. Interview with Greg Jackson, DDS, at 9:47 am confirmed they were punctured and said it probably was punctured when putting on the shelf. Tour of walk in refrigerator at 10:10 am revealed a 10 lb pack of ground turkey thawed with a pull date of 2/28/27 and good thru date as 2/7/17. Interview with DDS verified meat should have been disposed of and that policy mandates thawed meat must be used within 4 days of pulling from freezer. Further observation of walk in refrigerator revealed four 5lb packages of ground beef, 2 with a pull date of 2/24/17 with good thru date of 2/31/17 and 2 additional packages of hamburger meat that were not labeled with a pull date or an expiration date. One of the 5 pound packages of hamburger meat had a rip in it. Interview with DDS at 10:13 am verified none of the hamburger meat should be in the refrigerator and should have been disposed of. Further observation revealed a plastic container with cut beef tips with an expiration date of 3/6/17 and a whole ribeye thawed with no pull date and no good thru date. Interview with with DDS confirmed the Ribeye was pulled on Friday and was not labeled and should have been taken out. On 03/08/2017 at 12:25 PM, Dietary Aide #1 was observed with a heavy mitt donned over gloves. With the left hand, the aid cut a piece of fish, removed the mitt, placing it inside out on top of a dietary cart, and proceeded to plate the fish with the gloves still on. The aide then changed gloves before plating for the next resident. The aide held the chicken being plated for the next resident with gloved hands to break it off from the bone then removed gloves, re-gloved, placed the contaminated mitt over the gloved left hand then another glove over the mitt to cut up chicken. The aid then removed the top glove and mitt and then plated the chicken with the remaining gloves on her/his hand. Between uses, the mitt was placed inside out on the dietary cart. The dietary aid confirmed the findings and stated I see what you mean when asked if the gloves had been contaminated with the mitt.

Based on observation, interview, and review of the facility's policy, Discarding and Destroying Medications, the facility failed to ensure that expired medications were removed from the medication storage in 1 of 1 medication refrigerator reviewed. The findings included: On 03/07/2017 at 12:18 PM, review of the Medication Room revealed the following: Tuberculin, Purified Protein Derivative (PPD) with open date of 2/4/17 that expired 30 days after opening. Novolog 100 units/ ml (milliliter) with no open date and Novolin R 100 units/ ml with no open date During an interview at that time, Licensed Practical Nurse (LPN) #1 confirmed the PPD expired 30 days after opening and that the vial was expired. The LPN also confirmed the 2 open vials of insulin did not have open dates and that the Novolog expired 28 days after opening and the Novolin R expired 28 days after opening. The LPN confirmed both vials of insulin were expired and should have been discarded. Review of the facility's policy entitled Discarding and Destroying Medications revealed 1. Medication expiration dates will be observed on a daily/routine basis. Expired meds (medications) will be disposed of in the proper manner.

Based on observation and interview, the facility failed to store, prepare and distribute food under sanitary conditions. A carton of outdated milk was observed in the reach in cooler, a microwave was observed with build-up of debris and the floor had build-up around equipment. The findings included: During Initial Tour of the satellite kitchen with the Dietary Manager on 5/23/16 at approximately 11:45 AM, the surveyor noted a carton of milk that was out of date. The finding was confirmed with the Dietary Manager at the time of the finding. On 5/24/15 at approximately 10:47 AM and 5/25/16 at approximately 10:55 AM tour of the nourishment room revealed debris around equipment on the floor and the microwave had a build-up of debris. In an interview with the surveyor on 5/25/16 at approximately 11:00 AM, the Dietary Manager stated they stock the nourishment room but nursing is responsible for cleaning the microwave. The Dietary Manager was shown the areas of concern. In an interview with the DON on 5/25/16 at approximately 11:10 AM s/he stated dietary and the unit manager are responsible for cleaning the microwave. The DON stated they have talked with all staff about keeping the microwave clean.

Based on record review and interview, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week. One of one skilled unit. The findings included: The daily staff posting did not indicate if the nurse on duty was a registered nurse or a licensed practical nurse. There was also no notation to identify the registered nurse coverage for 8 hours per day as required. The surveyor reviewed 6 months of Registered Nurses schedules and noted that the facility did not have 8 consecutive hours of RN coverage 7 days a week for several days. In an interview with the surveyor on 05/25/2016 at approximately 11:18 AM the DON stated RN coverage is not on the posting sheet but is on the schedule. In an interview with the surveyor on 05/25/2016 at approximately 2:39 PM the DON confirmed that the facility did not have RN coverage 8 consecutive hours seven days a week. The facility did not have the required coverage on 3/20, 4/10, 5/1 and 5/8/16.

Based on record review and interview, the facility failed to accurately assess each resident. Resident #39's weekly skin assessments were not not completed. Resident #39's skin integrity was not noted on the MDS though present on admission. One of one observed pressure ulcer. The findings included: Review of Resident #39's medical record revealed a Weekly Skin and Pain assessment dated [DATE] as a correction of 5/21/16 that indicated the resident had 4 pressure ulcers. A Stage 1 area to the left buttock that measured 1.5x2, a Stage 1 area to the right buttock that measured 0.6x3, a Stage 2 area to the coccyx that measured 1.6x0.7 and a Stage 2 area to the coccyx that measured 0.3x1.7. Review of the Weekly Pressure Ulcer Record dated 5/24/16 revealed Resident #39 was documented as having 6 pressure ulcers that were all documented as Stage 2s. An area to the right upper sacrum that measured 0.3x0.5x0.1, an area to the left upper sacrum that measured 1x1.1x0.1, an area to the coccyx that measured 1.9x0.5x0.1, an area to the coccyx that measured 0.5x0.3x0.1, an area to the coccyx that measured 0.8x0.2x0.1 and an area to the left heel that measured 4x6. The Weekly Pressure Ulcer Record dated 5/24/16 was the only Pressure Ulcer Record in Resident #39's medical record. Review of the resident's Physician order [REDACTED]. An order dated 5/9/16 was also noted to apply skin prep to the left and right heels twice daily. Review of the Resident 39's medical record revealed there were no body audits completed on 5/7/16 or 5/14/16. The results of the body audit from 5/21/16 were not available, only the electronically corrected version dated 5/24/16 was available for review. Review of Resident #39's Admission Nursing assessment dated [DATE] revealed the resident had a scratch to the top of the left buttock. No other areas were noted to the resident's coccyx or sacrum. Review of Resident #39's Physician order [REDACTED]. Another order dated 5/24/16 indicated Cleanse right and left upper sacrum with wound cleanser, pat dry, apply skin prep around peri wound allow to dry, then cover with [MEDICATION NAME] Border Lite. Review of Resident #39's Progress Notes revealed a noted dated 5/14/16 that a mushy dark area was noted on the resident's left heel and a 4x2 light colored soft area was noted on the right heel. The Progress Notes dated 5/15/16 indicated EPC was applied to open areas on the resident's buttock and sacrum. Review of the facility's Wound Care Protocol and Standing MD Orders revealed Stage 1 and Stage 2 areas should be reported to the physician. In an interview with the surveyor on 5/25/16 at approximately 5:29 PM, the DON stated the area to the buttock was noted as a scratch on admission. They were putting protective cream on the area when they would clean the resident. CNAs were using the cream so there was no order. RN #1 follows wounds and measures them. The week before last week the area was an abrasion. It looked like it was drying and healing before s/he left for a week off. The weekly body audit information is filled out on the weekly skin assessment. The forms should be in the computer. The form pops up and it is initialed that it is done. It is initialed as done on the treatment record. Some of the nurses do it on a piece of paper in the room, don't take the computer in the room, and then come out and put the information in the computer. Weekly body audit signed as completed on 5/7, 5/14 and 5/21. The DON confirmed the completed assessment forms were not in the resident's computerized medical record. In an interview with the surveyor on 5/25/16 at approximately 5:41 PM, RN #1 stated they have been doing EPC cream on the area to the buttock. They started using EPC the week before last when s/he looked at the area. RN #1, the wound nurse, thought the area was still healing, and stated no one reported to him/her it was getting worse. The area was noted as a pressure ulcer on Saturday 5/21/16. RN #1 looked through the assessments and saw where it was documented as a pressure ulcer on Monday 5/23/16. S/he was working on the floor on another unit. RN #1 came over to the unit and resident had gone to an appointment and didn't get back until late. RN #1 did not have a chance to look at the areas on Monday. The Weekly Skin & Pain assessment corrected from 5/21 on 5/24 is all the information that the LPN entered when s/he completed the assessment on Saturday 5/21/16. The only correction was entered by RN #1, it was a comment that s/he went back and reassessed the areas on 5/24 since an LPN can't stage the areas. RN #1 did not change the measurements but the measurements were bigger than what she assessed on 5/24/16. When RN #1 looked at Resident #39's skin on 5/24 s/he entered the measurements on the weekly pressure ulcer record. RN #1 reviewed the Nurses Notes from 5/21/16 and confirmed there was no documentation related to physician notification of the pressure ulcers. In an interview with the surveyor on 5/25/16 at approximately 5:55 PM, the DON stated CNAs use the barrier cream. S/he stated normally the nurse calls the MD to get orders when an area is identified. The DON stated they do have skin protocols. The DON stated the nurse should have notified the MD when the areas were identified In an interview with the surveyor on 5/25/16 at approximately 6:05 PM, the DON stated the protocol sheet is for worse wounds than what the resident had. The DON stated the week before last the area was scabbed and almost healed. There was no place on the right buttock or on the crack

Based on record review and interview, the facility failed to ensure that a resident with pressure sores received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Resident # 39 was noted to develop pressure ulcers with no physician notification upon identification. There was no ongoing monitoring of the resident's skin integrity. One of one observed pressure ulcers. The findings included: Review of Resident #39's medical record revealed a Weekly Skin and Pain assessment dated [DATE] as a correction of 5/21/16 that indicated the resident had 4 pressure ulcers. A Stage 1 area to the left buttock that measured 1.5x2, a Stage 1 area to the right buttock that measured 0.6x3, a Stage 2 area to the coccyx that measured 1.6x0.7 and a Stage 2 area to the coccyx that measured 0.3x1.7. Review of the Weekly Pressure Ulcer Record dated 5/24/16 revealed Resident #39 was documented as having 6 pressure ulcers that were all documented as Stage 2s. An area to the right upper sacrum that measured 0.3x0.5x0.1, an area to the left upper sacrum that measured 1x1.1x0.1, an area to the coccyx that measured 1.9x0.5x0.1, an area to the coccyx that measured 0.5x0.3x0.1, an area to the coccyx that measured 0.8x0.2x0.1 and an area to the left heel that measured 4x6. The Weekly Pressure Ulcer Record dated 5/24/16 was the only Pressure Ulcer Record in Resident #39's medical record. Review of the resident's Physician order [REDACTED]. An order dated 5/9/16 was also noted to apply skin prep to the left and right heels twice daily. Review of the Resident 39's medical record revealed there were no body audits completed on 5/7/16 or 5/14/16. The results of the body audit from 5/21/16 were not available, only the electronically corrected version dated 5/24/16 was available for review. Review of Resident #39's Admission Nursing assessment dated [DATE] revealed the resident had a scratch to the top of the left buttock. No other areas were noted to the resident's coccyx or sacrum. Review of Resident #39's Physician order [REDACTED]. Another order dated 5/24/16 indicated Cleanse right and left upper sacrum with wound cleanser, pat dry, apply skin prep around peri wound allow to dry, then cover with [MEDICATION NAME] Border Lite. Review of Resident #39's Progress Notes revealed a note dated 5/14/16 that a mushy dark area was noted on the resident's left heel and a 4x2 light colored soft area was noted on the right heel. The Progress Notes dated 5/15/16 indicated EPC was applied to open areas on the resident's buttock and sacrum. Review of the facility's Wound Care Protocol and Standing MD Orders revealed Stage 1 and Stage 2 areas should be reported to the physician. In an interview with the surveyor on 5/25/16 at approximately 5:29 PM, the DON stated the area to the buttock was noted as a scratch on admission. They were putting protective cream on the area when they would clean the resident. CNAs were using the cream so there was no order. RN #1 follows wounds and measures them. The week before last week the area was an abrasion. It looked like it was drying and healing before s/he left for a week off. The weekly body audit information is filled out on the weekly skin assessment. The forms should be in the computer. The form pops up and it is initialed that it is done. It is initialed as done on the treatment record. Some of the nurses do it on a piece of paper in the room, don't take the computer in the room, and then come out and put the information in the computer. Weekly body audit signed as completed on 5/7, 5/14 and 5/21. The DON confirmed the completed assessment forms were not in the resident's computerized medical record. In an interview with the surveyor on 5/25/16 at approximately 5:41 PM, RN #1 stated they have been doing EPC cream on the area to the buttock. They started using EPC the week before last when s/he looked at the area. RN #1, the wound nurse, thought the area was still healing, and stated no one reported to him/her it was getting worse. The area was noted as a pressure ulcer on Saturday 5/21/16. RN #1 looked through the assessments and saw where it was documented as a pressure ulcer on Monday 5/23/16. S/he was working on the floor on another unit. RN #1 came over to the unit and resident had gone to an appointment and didn't get back until late. RN #1 did not have a chance to look at the areas on Monday. The Weekly Skin & Pain assessment corrected from 5/21 on 5/24 is all the information that the LPN entered when s/he completed the assessment on Saturday 5/21/16. The only correction was entered by RN #1, it was a comment that s/he went back and reassessed the areas on 5/24 since an LPN can't stage the areas. RN #1 did not change the measurements but the measurements were bigger than what she assessed on 5/24/16. When RN #1 looked at Resident #39's skin on 5/24 s/he entered the measurements on the weekly pressure ulcer record. RN #1 reviewed the Nurses Notes from 5/21/16 and confirmed there was no documentation related to physician notification of the pressure ulcers. In an interview with the surveyor on 5/25/16 at approximately 5:55 PM, the DON stated CNAs use the barrier cream. S/he stated normally the nurse calls the MD to get orders when an area is identified. The DON stated they do have skin protocols. The DON stated the nurse should have notified the MD when the areas were identified In an interview with the surveyor on 5/25/16 at approximately 6:05 PM, the DON stated the protocol sheet is for worse wounds than what the resident had. The DON stated the week before last the area was scabbed and almost healed. There was no place on the right buttock or on the crack

Based on observations and interviews, the facility failed to ensure that environmental hazards were securely maintained in one of one satellite kitchen. The kitchen was left open and unattended on two occasions with dishwashing chemicals and gas stove accessible. The findings included: During the Initial Tour on 5-23-16 at 9:49 AM, the satellite kitchen was found open, unattended, and accessible to residents. The 6-burner gas stove's grill was on and set at 275 degrees Fahrenheit. Oasis 165 MULTIQUAT SANITIZER was on the floor in the dishwashing area. Medical Records verified that the dining room (Bistro) door was ajar and did not lock, the kitchen door was unlocked, and that the grill was on and set at 275 degrees. At 9:56 AM, the Dietary Manager verified access to the chemicals and grill. S/he stated, The door should have been shut and the dining room door should have self-closure. At 7:34 PM on 5-24-16, the kitchen door was again found ajar. Licensed Practical Nurse #1 verified that the 6 burner gas stove and chemicals were accessible. LPN #1 and Registered Nurse #2 were initially unable to lock the door because the latch was stuck inside the door panel and would not reset.

Based on record review and interview, the facility failed to ensure that a resident with pressure sores received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Resident # 39 was noted to develop pressure ulcers with no treatment ordered upon identification. There was no ongoing monitoring of the resident's skin integrity. One of one observed pressure ulcer. The findings included: Review of Resident #39's medical record revealed a Weekly Skin and Pain assessment dated [DATE] as a correction of 5/21/16 that indicated the resident had 4 pressure ulcers. A Stage 1 area to the left buttock that measured 1.5x2, a Stage 1 area to the right buttock that measured 0.6x3, a Stage 2 area to the coccyx that measured 1.6x0.7 and a Stage 2 area to the coccyx that measured 0.3x1.7. Review of the Weekly Pressure Ulcer Record dated 5/24/16 revealed Resident #39 was documented as having 6 pressure ulcers that were all documented as Stage 2s. An area to the right upper sacrum that measured 0.3x0.5x0.1, an area to the left upper sacrum that measured 1x1.1x0.1, an area to the coccyx that measured 1.9x0.5x0.1, an area to the coccyx that measured 0.5x0.3x0.1, an area to the coccyx that measured 0.8x0.2x0.1 and an area to the left heel that measured 4x6. The Weekly Pressure Ulcer Record dated 5/24/16 was the only Pressure Ulcer Record in Resident #39's medical record. Review of the resident's Physician order [REDACTED]. An order dated 5/9/16 was also noted to apply skin prep to the left and right heels twice daily. Review of the Resident 39's medical record revealed there were no body audits completed on 5/7/16 or 5/14/16. The results of the body audit from 5/21/16 were not available, only the electronically corrected version dated 5/24/16 was available for review. Review of Resident #39's Admission Nursing assessment dated [DATE] revealed the resident had a scratch to the top of the left buttock. No other areas were noted to the resident's coccyx or sacrum. Review of Resident #39's Physician order [REDACTED]. Another order dated 5/24/16 indicated Cleanse right and left upper sacrum with wound cleanser, pat dry, apply skin prep around peri wound allow to dry, then cover with [MEDICATION NAME] Border Lite. Review of Resident #39's Progress Notes revealed a noted dated 5/14/16 that a mushy dark area was noted on the resident's left heel and a 4x2 light colored soft area was noted on the right heel. The Progress Notes dated 5/15/16 indicated EPC was applied to open areas on the resident's buttock and sacrum. Review of the facility's Wound Care Protocol and Standing MD Orders revealed Stage 1 and Stage 2 areas should be reported to the physician. In an interview with the surveyor on 5/25/16 at approximately 5:29 PM, the DON stated the area to the buttock was noted as a scratch on admission. They were putting protective cream on the area when they would clean the resident. CNAs were using the cream so there was no order. RN #1 follows wounds and measures them. The week before last week the area was an abrasion. It looked like it was drying and healing before s/he left for a week off. The weekly body audit information is filled out on the weekly skin assessment. The forms should be in the computer. The form pops up and it is initialed that it is done. It is initialed as done on the treatment record. Some of the nurses do it on a piece of paper in the room, don't take the computer in the room, and then come out and put the information in the computer. Weekly body audit signed as completed on 5/7, 5/14 and 5/21. The DON confirmed the completed assessment forms were not in the resident's computerized medical record. In an interview with the surveyor on 5/25/16 at approximately 5:41 PM, RN #1 stated they have been doing EPC cream on the area to the buttock. They started using EPC the week before last when s/he looked at the area. RN #1, the wound nurse, thought the area was still healing, and stated no one reported to him/her it was getting worse. The area was noted as a pressure ulcer on Saturday 5/21/16. RN #1 looked through the assessments and saw where it was documented as a pressure ulcer on Monday 5/23/16. S/he was working on the floor on another unit. RN #1 came over to the unit and resident had gone to an appointment and didn't get back until late. RN #1 did not have a chance to look at the areas on Monday. The Weekly Skin & Pain assessment corrected from 5/21 on 5/24 is all the information that the LPN entered when s/he completed the assessment on Saturday 5/21/16. The only correction was entered by RN #1, it was a comment that s/he went back and reassessed the areas on 5/24 since an LPN can't stage the areas. RN #1 did not change the measurements but the measurements were bigger than what she assessed on 5/24/16. When RN #1 looked at Resident #39's skin on 5/24 s/he entered the measurements on the weekly pressure ulcer record. RN #1 reviewed the Nurses Notes from 5/21/16 and confirmed there was no documentation related to physician notification of the pressure ulcers. In an interview with the surveyor on 5/25/16 at approximately 5:55 PM, the DON stated CNAs use the barrier cream. S/he stated normally the nurse calls the MD to get orders when an area is identified. The DON stated they do have skin protocols. The DON stated the nurse should have notified the MD when the areas were identified In an interview with the surveyor on 5/25/16 at approximately 6:05 PM, the DON stated the protocol sheet is for worse wounds than what the resident had. The DON stated the week before last the area was scabbed and almost healed. There was no place on the right buttock or on the crack.

On the days of the survey, based on record reviews, interviews and review of the facility's policy entitled Pressure Ulcer Treatment- Stage I and Deep Tissue Injury Policy and Procedure, the facility failed to indentify/prevent and treat pressure areas for 2 of 3 residents reviewed for Pressure Ulcers. Resident # 11 was admitted with a Stage I to the coccyx which progressed to a Stage II and Resident #20 was admitted with no pressure areas, developed pressure areas on both heels and required treatment at a Wound Clinic. The findings included: On 5/29/13 at 1:15 PM, during review of the Resident #11's medical chart, the resident's care plan dated 4/29/13, indicated that the resident had risk of skin breakdown due to incontinence and decreased mobility. The care plan also stated that the resident had an open area on his/her sacrum at the time the care plan was initated on 4/29/13 An interim care plan, with the same date, contained conflicting documentation that the resident had a red area on the sacrum and left ankle. An addition was entered on 5/27/13 to include a treatment which indicated the area on the sacrum should be cleansed with wound cleanser, a 2 X 2 Polymem dressing should be applied, change every 3 days and PRN (as needed) X 14 days, check every shift to ensure dressing intact. The resident's Minimum Data Set ((MDS) dated [DATE] and 5/13/13 documented the resident had no pressure areas. The Nursing Admission assessment dated [DATE] indicated that the resident had no open areas to the sacrum. The weekly body audit for the resident dated 5/9/13 had no pressure area marked and no documentation of a reddened area on the sacrum. The body audit contained documentation of a pressure area on the sacrum on 5/16/13 and 5/23/13 with no measurements and/or treatments. A form entitled "Skin Assessment" was provided by the Director of Nursing (DON) on 5/29/13 with a charting date of 5/28/13 at 11:30 AM which indicated that the resident had a Partial Thickness Wound which was a Pressure Ulcer caused by pressure. Review of Resident #11's Nurse's Notes dated 4/29/13 at 2:00 PM, stated that the resident had a reddened area to the sacrum with no breakdown noted. No treatment was documented. On 4/30/13 at 8:35 PM, the notes stated "sacrum remains red."; no treatment documented. On 5/1/13, the notes indicated "blanchable redness to sacrum", no treatment noted at 3:15 PM, at 8 PM, "Sacrum remains red". On 5/1/13 at 3:15 PM notes indicated that the red area to the sacrum remained blanchable and at 8:00 PM, there was a red area on the left lateral ankle. 5/2/13 at 8AM, noted blanchable redness to sacrum and at 8:15 PM,sacrum pink, no treatment documented. On 5/3/13 at 4:15 PM, sacrum remains red, no treatment noted. Nursing notes from 5/4/13- 5/11/13, contained no documentation related to sacrum. The next entry on the Nurse's Notes related to the sacral area was dated 5/12/13 at 2:00 PM which stated "Noted open area to sacrum Cleaned with (c) wound cleanser, applied protective ointment." There was no documentation related to contacting the physician nor wound measurements. On 5/14/13 at 11:00 AM per the nurse's documentation , the sacrum was slightly pink with a small amount of slough in the wound bed, resident voiced discomfort at times. There was no documentation related to follow up on the resident's discomfort was noted on 5/14/13. On 5/15/13 at 2:00 PM (thee days after being opened) the wound was measured at 1 cm (centimeter) X .5 cm. The resident also was documented as complaining of pain in the sacral area, new orders received and processed. The notes indicated that the resident did not receive medications for pain for 27 hours. On 5/16/13 at 5:00 PM, the wound was measured at 0.4 X 1.6 cm. On 5/17/13 at 3:30 PM an entry was noted to indicate that the resident's dressing had became "detached" from the sacrum. The area was cleansed and redressed. The resident denied pain except in sacral area. There was no documentation of administering pain medication noted at that time. At 8:10 PM on 5/17/13, the resident complained of buttock pain and was given medication, dressing was noted as being intact. On 5/18/13 at 7:15 PM, the resident complained of buttock pain, he/she rated the pain level at an 8 and was given medication. No entry related to the sacral wound was noted. The notes dated 5/20/13 at 8:45 PM indicated that the resident had buttock pain and was treated. The dressing had also became soiled and replaced. On 5/23/13 at 8:25 PM, the resident complained of buttock pain, he/she rated the pain as a 10. Medication was given. On 5/24/13 at 8:30 PM the resident was treated for [REDACTED]." On 5/26/13 there was one entry noted related to the sacral wound at 9:10 PM stating that the dressing was intact. There were 2 entries for 5/27/13. At 4 PM the dressing was changed and at 8:00 PM the resident was treated for [REDACTED]. On 5/28/13 at 9:15 AM, an entry was made by Registered Nurse (RN) #2 who was also the wound nurse. RN #2 assessed, measured and documented the wound. She/he also notified the resident's responsible party. The resident was again treated for [REDACTED]. A physician's orders [REDACTED]. The new orders for 5/15/13 written were for [MEDICATION NAME] 2.5/500 mg (milligrams)- 1 tablet every 4-6 hours as needed for pain and clean sacrum with wound cleanser, apply a 2 X 2 Polymem dressing. change every 3 days and as needed. A History and Physical was provided by the DON with a date of 5/20/13 which indicated that the physician had seen the wound on 5/20/13. The documentation revealed that the resident had a Pressure Ulcer and stated the problem had been ongoing for 3 weeks. He/she documented that the problem was moderate and associated with pain but no discharge. Review of the medical chart for Resident #20 indicated that the resident was admitted to the facility on [DATE] with no pressure areas and was admitted to the Wound Clinic on 1/14/13 for treatment of [REDACTED]. The Admission Nursing Assessment indicated that the resident had no pressure areas on admission. Weekly body audits dated 12/8/13 through 2/7/13 indicated that the resident had no pressure areas to the heels until 2/7/13. The weekly body audits indicated that the resident had on 12/20/13 developed "dark areas" on the heels bilaterally. The Nurse's Notes for Resident #20 dated 12/8/12 contained no documentation indicating that the resident was admitted to the facility with pressure areas to the heels. On 12/24/13 the notes contained documentation which indicated that the resident had developed dark/dark soft areas to both heels. No other documentation related to the resident's heels was noted until 2/22/13 when dark areas were noted on left heel with a small amount of bleeding. On 2/28/13 a small amount of yellow drainage was documented coming from the right heel. On 3/2/13 the documentation revealed that the resident had a small amount of bleeding from the right heel and the dressings were changed to both heels. On 3/3/13, both dressings were dry and intact. The resident's Nutrition Risk assessment dated [DATE] indicated that the resident's [MEDICATION NAME] level was 21.7 and within normal limits and the [MEDICATION NAME] level was low at 2.6. The resident weighed 126.8 pounds on admission. She/he was recieving a No Added Salt Diet, Medpass, 90 ml (milliters) three times a day for 3 days to provide 23 grams of protein daily. The Nutritional Care Progress Notes dated 12/28/13 to 1/8/13 indicated that the resident ate 80-100% of her/his meals and snacked all day. The medpass had been decreased to 60 ml three times a day to provide 15 grams of protein on 12/28/13. On 1/8/13 the resident weighted 146.2 pounds. On 1/8/13 the medpass was discontinued and Prostat 101- 30 ml daily was started to provide 15 grams of protein daily. On 1/16/13 the dietary notes indicated that the resident was going to the wound center for suspected deep tissue injury to the heels. Prostat was discontinued on 1/25/13 and Prostat 64 30 ml twice a day was ordered to provide 30 grams of protein daily. The resident's weight on 2/6/13 was 170.4. The resident was sent to the wound clinic for the heel wounds and admitted to the clinic was 1/7/13. The documentation dated 1/7/13 indicated that the resident had "what appeared" to be dried blood blister on both heels. The left measured 4 cm in diameter and the right 2 cm in diameter. The impression was documented as Partial Thickness Blisters of both heels secondary to pressure. On 1/14/13 the Wound Clinic documentation indicated that the blisters were secondary to trauma. On 1/28/13 the center indicated that the right calcaneus had a cluster of ulcerations and the initial measurement was 6.0 X 7.3 X 0.1. Debridement was performed. On 2/11/13 the notes from the clinic indicated that the left heel wound was 3.2 X 3.4 X 0.1 and had a small amount of granulation tissue with some black eschar over about 1 cm area of the wound. On 2/18/13 the left heel wound was debrided due to eschar and yellow [MEDICATION NAME] tissue. On 2/26/13 per the wound center notes the left heel had became a Stage III. The wound contained necrotic tissue through out the wound and a "very small" amount of granulation tissue around the edges. On 3/5/13, the left wound was classified as a Stage III measuring 2.1 X 2.0 X 0.4 and was debrided. The Braden Score for the resident which was conducted at the facility, scored the resident as 16 indicating a low risk for Pressure Sores. On 5/29/13 at approximately 11:00 AM, review of the resident's medical record, The 12/14/12, Admission Minimum Data Set (MDS), under section M0210 indicated that the resident had no Stage 1 or higher pressure ulcers. and M0900 indicated that she/he had no healed pressure areas. The 12/21/12, 14 day MDS, also indicated no pressure ulcers. The 1/4/13 MDS indicated in section M0210 that the resident has an unstageable pressure ulcer with suspected deep tissue injury in evolution. The 2/8/13 MDS also coded the resident as having 1 (one) unstageable pressure ulcer with suspected deep tissue injury in evolution. The resident was care planned for 1-2 person assist for transfers, toiliting, bed mobility, bathing and dressing. She/he was also care planned for being at risk for skin breakdown. The care plan included an update for profo boot to left heel while in bed and [MEDICATION NAME] spray to bilat heels on 12/24/12. The boots and [MEDICATION NAME] were discontinued on 12/30/13. The additional orders care planned included: 12/29/13: Paint both heels with [MEDICATION NAME] every shift for 14 days, wound center consult. 1/7/13: Clean both heels with normal saline, apply foam dressing to both heels, wrap with gauze, secure with tape, float heels. 2/17/13: Foam 4 inch dressing to right plantar, wrap with gauze, secure with tape. 2/18/13: Foam 4 inch dressing, roll gauze, secure with tape to right foot plantar after cleansing with normal saline every other day. Foam pad to right heel, roll gauze after cleansing with normal saline every other day. Santyl and foam pad to left heel, roll gauze after cleansing with normal saline every other day. 2/26/13: Multpttus splint to left foot daily, single layer tube grips to both legs- on in AM, off in PM. 3/5/13:Apply [MEDICATION NAME] to left heel after cleansing with normal saline then apply foam pad, 4 inch gauze, secure with tape, apply foam pad to right heel after cleansing with normal saline every other day. In an interview on 5/30/13 at approximately 10:15 AM with RN #2, Wound Nurse (WN), she/he stated that she/he was absent from work when Resident #11 had been admitted and was not aware of the resident having a wound until 5/27/13 and saw the wound on 5/28/13. When asked who was responsible for wound care in her/his absence, she/he stated the DON and she/he had not done it. The WN stated that all areas should be measured weekly. The WN stated that the facility goes by a standard protocol for writing wound orders and treating wounds but should notify the physician for orders if the wound is not healing or is getting worse. She/he stated that Resident #11 now has a Stage II Pressure Ulcer. The WN also stated that she/he does not measure the wounds for residents going to the wound clinic and does not remember Resident #20. In an interview with the DON on 5/30/13 at approximately 10:30 AM, the DON stated that the wound nurse had been absent from work for the previous two weeks. When asked who was responsible for monitoring, staging and treating wounds when the wound nurse was absent, the DON stated that the facility did not have a designated person to do the wounds. In an interview with Certified Nursing Assistant (CNA) #1 at approximately 11:25 AM, she/he stated that the CNAs can apply protective creams without an order. She/he stated that when they discover a reddened area they inform the nurse on duty and the nurse should assess the area. On 5/30/13 at approximately 11:27 AM, during an interview with CNA #2, she/he stated when they discover a reddened area they notify the nurse who assesses and measures the area. The CNA then applies a protective cream to the area. Review of the facility's policy entitled Pressure Ulcer Treatment- Stage I and Deep Tissue Injury Policy and Procedure did not indicate at what point the physician should be notified. The policy revealed "...ASSESS AND DOCUMENT WOUND CHARACTISTICS NO LESS THAN EACH DRESSING CHANGE..."

On the days of the survey, based on record review and interview, the facility failed to provide prompt pain relief for a resident expressing pain. There was no evidence prompt pain relief was provided for Resident # 11. Additionally, the facility failed to follow physician orders [REDACTED]. There was missing evidence of the resident having been monitored for vital signs, venous Access, thrill and bruit before and after [MEDICAL TREATMENT] treatments per physician's orders [REDACTED]. The findings included: Review of Resident #11's Nurse's Notes dated 5/12/13 at 2:00 PM which stated "Noted open area to sacrum Cleaned with (c) wound cleanser, applied protective ointment." On 5/14/13 at 11:00 AM per the nurse's documentation , the sacrum was slightly pink with a small amount of slough in the wound bed, resident voiced discomfort at times. There was no documentation related to follow up on the resident's discomfort was noted on 5/14/13. On 5/15/13 at 2:00 PM, the resident also was documented as complaining of pain in the sacral area, new orders received and processed. The notes indicated that the resident did not receive medications for pain for 27 hours. On 5/17/13 at 3:30 PM an entry was noted to indicate that the resident's dressing had became "detached" from the sacrum. The area was cleansed and redressed. The resident denied pain except in sacral area. There was no documentation of administering pain medication noted at that time. A physician's orders [REDACTED]. A History and Physical was provided by the DON with a date of 5/20/13 which indicated that the physician had seen the wound on 5/20/13. The documentation revealed that the resident had a Pressure Ulcer and stated the problem had been ongoing for 3 weeks. He/she documented that the problem was moderate and associated with pain but no discharge. The facility admitted Resident #115 with a [DIAGNOSES REDACTED]. The care plan further indicated the resident received [MEDICAL TREATMENT] services on Tuesdays, Thursdays and Saturdays. A Nurse's Note dated 5/25/13 indicated Resident #115 went to [MEDICAL TREATMENT] on 5/25/13. Review of a vital sheet dated 5/25/13 indicated vital signs and weight was not documented after the resident returned from [MEDICAL TREATMENT]. A Nurse's Note dated 5/28/13 indicated the resident went to [MEDICAL TREATMENT]. There was no documentation to indicate the vital signs/weights were taken before resident went to [MEDICAL TREATMENT]. There was no documentation to indicate weights were taken after the resident came back from [MEDICAL TREATMENT]. Further record review revealed a physician's orders [REDACTED]. Review of Nurse's Notes and Treatment Record revealed there was no documentation to indicate the fistula dressing to left upper arm was checked on morning shift of 5/27/13 and 5/28/13. An interview on 5/29/13 with the Director of Nursing confirmed the findings. The Director of Nursing further stated there was no documentation in the 24 hours report to indicate that vitals were completed.