Every finding on record at Ruth Wilson Hurley Manor

Based on observation and interview, the facility failed to maintain a clean ice machine. The administrator identified 29 residents who received ice from the kitchen. Findings: On 12/03/24 at 10:38 a.m., the DM stated the kitchen staff cleaned the storage chest of the ice machine weekly and removed all the ice and cleaned/sanitized the storage chest of the ice machine monthly. The DM stated the kitchen staff did not clean the mechanical workings of the ice machine. The DM stated there was a company which came and ran sanitizer through the ice machine, but did not know how often the company did so. On 12/06/24 at 2:21 p.m., the internal mechanics of the ice machine was observed to have a moist green and black substance along the edges of the water reservoir, covers, inlets, and tubing. On 12/06/24 at 2:22 p.m., the administrator observed the internal mechanics of the ice machine and stated the ice machine needed to be cleaned.

Based on record review and interview, the facility failed to care plan a resident's weight loss for one (#9) of one sampled resident whose care plan was reviewed for weight loss. The DON identified three residents with weight loss. Findings: Resident #9 had diagnoses which included dementia. The registered dietician's note, dated 11/19/24, documented the resident had weight loss of 12.5% in the last three months and 11.6% in the last six months. The note documented the resident received Megace, an appetite stimulant, as a physician ordered intervention for weight loss. On 12/06/24 at 4:40 p.m., Resident #9's clinical record was reviewed. There was no documentation weight loss was care planned. On 12/06/24 at 6:00 p.m., the MDS coordinator stated the resident's weight loss should have been care planned.

Based on record review and interview, the facility failed to accurately complete a level l PASARR for one (#20) of one sampled resident reviewed for PASARR. The administrator identified 29 residents resided in the facility. Findings: Resident #20 had diagnoses which included dementia with other behavioral disturbances, delusional disorders, and mood affective disorder. A level l PASARR assessment, dated 01/23/19, documented resident #20 did not have a diagnosis of a serious mental illness. On 12/06/24 at 2:56 p.m., the ADON reviewed the resident's level I PASARR form and stated the question regarding a diagnosis of serious mental illness was answered incorrectly. The ADON stated a level II PASARR referral should have been made to Oklahoma Health Care Authority.

Based on observation, record review, and interview, the facility failed to ensure residents' assessments were accurate for four (#3, 5, 12 and #18) of 16 sampled residents whose assessments were reviewed for accuracy. The Resident Census and Conditions of Residents, dated 08/21/23, documented a census of 36 residents. Findings: 1. Res #3 was admitted with diagnoses which included weakness and fracture of the right femur. On 08/20/23 at 4:00 p.m., Res #3 was observed sitting on the edge of the bed. A 1/8 side rail was up on the left side of bed. On 08/20/23 at 4:00 p.m., Res #3 reported they used the side rail to assist them in getting out of bed at times. The resident reported they had requested the rail a long time ago and the doctor had approved it. The resident reported they didn't feel the side rail restricted their movement. On 08/21/23 at 11:01 a.m., Res #3 was observed ambulating in the hallway with a rolling walker. On 08/22/23 at 2:40 p.m., the MDS coordinator reported they had documented the 1/8 side rails requested by Res #3 for positioning as restraints on the resident assessment. They reported Res #3 did not have restraints. A quarterly assessment, dated 06/22/23, documented Res #3 was cognitively intact, ambulatory with the use of a walker, and had no impaired range of motion. The assessment documented Res #3 used restraints daily in the form of side rails. 2. Res #5 was admitted with diagnoses which included cerebral palsy. On 08/21/23 at 9:35 a.m., Res #5 was observed in bed against the wall and 1/8 partial rail up one side. Res #5 frequently used the side rail for bed mobility and shifting their weight while in bed. A physician order, dated 06/16/21, read in part, Resident may have special half side rail added to HOB (head of bed) to promote bed mobility per self. A quarterly assessment, dated 07/24/23, documented the resident had impaired range of motion to both lower extremities and required extensive assistance with two person assist for bed mobility. The resident assessment also documented Res #5 used restraints in bed daily in the form of side rails. On 08/22/23 at 3:00 p.m., the MDS coordinator reported Res #5's partial bed rails were for positioning and did not act as a physical restraint for the resident. The MDS Coordinator reported they were not aware of the coding instructions for the restraint section of the resident assessment. 3. Res #12 was admitted with diagnoses which included weakness and polio. On 08/21/23 at 2:25 p.m., Res #12 was observed sitting on the side of the bed with 1/8 side rail up on left side of bed. On 08/22/23 at 9:45 a.m., Res #12 reported they had requested the side rail to assist them in getting out of bed and to reposition while in bed. The resident reported the side rail did not restrict their movements. A physician order, dated 08/13/21, documented, Resident may have 1/8 partial rails added to HOB to assist with self positioning, safety, and mobility. A quarterly assessment, dated 05/03/23, documented Res #12 was cognitively intact, non ambulatory, and required extensive assistance with transfers and bed mobility. The assessment documented Res #12 used restraints in bed daily in the form of side rails. On 08/22/23 at 3:00 p.m., the MDS coordinator reported Res #18's partial side rails were for positioning and did not act as a physical restraint for the resident. The MDS coordinator reported they were not aware of the coding instructions for the restraint section of the resident assessment. 4. Res #18 was admitted with diagnoses which included Parkinson's disease. On 08/21/23 at 8:45 a.m., Res #18 was observed in bed with 1/8 partial rails up on bed. Res #18 was able to use the partial rails for bed mobility. A physician order, dated 07/15/16, read in part, Resident may have 1/8 partial rails to the right and left upper side of bed to assist with self positioning, safety and mobility. On 08/22/23 at 3:00 p.m., the MDS coordinator reported Res #18's partial bed rails were for positioning and did not act as a physical restraint for the resident. The MDS coordinator reported they were not aware of the coding instructions for the restraint section of the resident assessment. On 08/22/23 at 3:10 p.m., the MDS coordinator reported the facility was a restraint free facility. The MDS coordinator reported they had misinterpreted the assessment manual instructions as documenting side rails were restraints. They reported all four residents documented as having restraints had 1/8 side rails per resident request, had a completed side rail assessment, and had signed a consent.

Based on observation, record review, and interview, the facility failed to ensure care plans were developed for three (#3, 5, and #18) of three sampled residents who used bed rails and one (#11) of one sampled resident reviewed for falls. The DON identified seven residents who used side rails and 19 residents who had fallen in the last six months. Findings: 1. Res #3 was admitted with diagnoses which included weakness and fracture of the right femur. On 08/20/23 at 4:00 p.m., Res #3 was observed sitting on the edge of the bed. A 1/8 side rail was up on the left side of bed. On 08/20/23 at 4:00 p.m., Res #3 reported they used the side rail to assist them in getting out of bed at times. The resident reported they had requested the rail a long time ago and the doctor had approved it. The resident reported they didn't feel the side rail restricted their movement. On 08/21/23 at 11:01 a.m., Res #3 was observed ambulating in the hallway with a rolling walker. On 08/22/23 at 2:40 p.m., the MDS coordinator reported they had documented the 1/8 side rails requested by Res #3 for positioning as restraints on the resident assessment. They reported Res #3 did not have restraints. A care plan with a review date of 03/04/23, did not document the use of side rails for Res #3. A quarterly resident assessment, dated 06/22/23, documented Res #3 was cognitively intact, ambulatory with the use of a walker, and had no impaired range of motion. The assessment documented Res #3 used restraints daily in the form of side rails. 2. Res #5 was admitted with diagnoses which included cerebral palsy. On 08/21/23 at 9:35 a.m., Res #5 was observed in bed against the wall and 1/8 partial rail up one side. Res #5 frequently used the side rail for bed mobility and shifting their weight while in bed. A physician order, dated 06/16/21, read in part, Resident may have special half side rail added to HOB to promote bed mobility per self. The side rails for Res #5 were not care planned. On 08/22/23 at 3:05 p.m., the MDS coordinator reported Res #5's side rails should have been care planned and were not. 3. Res #18 was admitted with diagnoses which included Parkinson's. On 08/21/23 at 8:45 a.m. Res #18 was observed in bed with 1/8 partial rails up on bed. Res #18 was able to use the partial rails for bed mobility. A physician order, dated 07/15/16, read in part, Resident may have 1/8 partial rails to the right and left upper side of bed to assist with self positioning, safety and mobility. On 08/22/23 at 3:05 p.m., the MDS coordinator reported Res #18's side rails should have been care planned and were not. 4. Res #11 was admitted with diagnoses which included anxiety disorder, hallucinations, unspecified dementia and depression. A care plan, last updated 07/24/23, documented in part, .ensure [name withheld] is wearing appropriate footwear (e.g. shoes, bedroom slippers, nonskid socks) when ambulating or up in chair . A care plan, last updated 08/18/23, documented in part, .Flag and identify [name withheld] is a high risk for falls. * Yellow star - High fall risk * Red star - [name withheld] has had a fall in the last 3 months . A nurse's note, dated 08/18/23 at 11:04 a.m., as a late entry, documented at 9:45 a.m., Res #11 was alone in the room trying to self transfer from the recliner to the bed and was found on their knees. A CNA and student nurse tried to assist the resident to bed, the resident refused, and was assisted to the floor. On 08/23/23 at 8:00 a.m., Res #11 was observed sitting in a recliner with bare feet. On 08/23/23 at 8:00 a.m., there was no yellow or red star on Res #11's doorway or outside the room to designate the resident was at risk for falls. On 08/20/23 at 8:05 a.m., CNA #1 was asked if there was a yellow or red star on Res #11's door to indicate the resident was at risk for falls. The CNA reported there was no signage to indicate fall risk for Res #11. On 08/20/23 at 8:10 a.m., the AD was asked if there was a yellow or red star on Res #11's door to indicate the resident was at risk for falls. The AD reported there was no signage to indicate fall risk for Res #11. On 08/20/23 at 8:15 a.m., the DON reported there was no yellow or red star on Res #11's door to indicate the resident was at risk for falls. The DON reported a red star should have been on the door as documented in the care plan, due to the resident falling earlier in the week. The DON also reported the resident should have been wearing nonskid socks as documented in the care plan to decrease the risk for falling.

Based on record review and interview, the facility failed to ensure a care plan was updated for one (#17) of one sampled resident who was reviewed for burns. The DON identified one resident who sustained burns within the last six months. Findings: Res #17 was admitted with diagnoses which included Parkinson's disease. A nurse note, dated 06/18/23 at 2:30 p.m., documented Res #17 sustained burns to their coccyx and thighs after spilling hot coffee on their lap. A Hot Liquids Risk Screening, dated 06/21/23, documented in part, .Hot Liquid Risk Interventions - with any hot beverage resident is to use a cup with a lid . An OSDH 283 form, dated 06/23/23, documented in part, .Part C - Sippy cup to prevent reoccurrence and lid coming off .Resident agreed to use sippy cup with all liquids to prevent spills and injury. Staff instructed to ensure hot liquids are cooled prior to giving to resident . Res #17's care plan did not include interventions to prevent burns from hot liquids. On 08/24/23 at 10:45 a.m., the MDS coordinator reported the care plan should have been updated to include interventions to prevent burns.

Based on record review and interview, the facility failed to establish and maintain a QAA committee. Findings: A QAPI attendance form, dated 03/31/22, documented the IP, DM and AD were the attendees. On 07/22/22 at 1:48 p.m., the IP reported the facility did not have a current QAPI plan. On 07/22/22 at 2:22 PM the administrator reported the QAPI plan was not current, the meetings were not regular and the committee was in the process of being re-vamped.

Based on record review and interview, the facility failed to develop a QAPI plan. Findings: A QAPI attendance form, dated 03/31/22, documented the IP, DM and AD were the attendees. On 07/22/22 at 1:48 p.m., the IP reported the facility did not have a current QAPI plan. On 07/22/22 at 2:22 p.m., the administrator reported the QAPI plan was not current, the meetings were not regular and the committee was in the process of being re-vamped.

Based on record review and interview the facility failed to provide residents with an advance directive acknowledgement for six (#1, 9, 19, 24, 36, and #190) of eight residents reviewed for advance directives. The Resident Census and Conditions of Residents documented 38 residents resided in the facility. Findings: An advance directive acknowledgement was not the paper or electronic health record (EHR) for residents #1, 9, 19, 24, 36, and #190. On 07/20/22 at 10:00 a.m., the BOM reported she was not aware they needed to give the residents an advance directive acknowlgement. She also reported the admission packet only contained the advance directive form.

Based on record review and interview, the facility failed to review and revise a care plan for two (#24 and #36) of six residents whose care plans were reviewed. The Resident Census and Conditions of Residents documented 38 residents resided in the facility. Findings: Res #24 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A care plan dated, 02/16/22, read in parts, . Blood sugars as ordered with sliding scale coverage; report to MD as indicated . The EHR did not include a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/21/22 at 11:37 a.m., the DON reported that Res #24 had not been on sliding scale insulin in a while and it should have been removed from the care plan. Res #36 was admitted to Hospice services on 06/14/21 for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan dated, 06/25/21, read in parts, .Hospice aide to provide shower as tolerated . On 07/22/22 at 11:39 a.m., the DON reported that Res #36 had not had a hospice aide in a long time and the care plan should have been updated to reflect that.

Based on record review and interview the facility failed to ensure the physician responded to the pharmacist reviews regarding anti-psychotic medications for two (#9 and #24) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents documented five residents had orders for anti-psychotic medication. Findings: Resident #9 was admitted with diagnoses which included Non-Alzheimer's dementia and dementia with behavioral disturbance. The pharmacist reviews dated, 12/28/21 and 06/20/22, read in parts, Is a dosage reduction attempt possible for any of the following: .[MEDICATION(S)] (an anti-psychotic medication) from 3mg to 1.5mg daily, [MEDICATION(S)] (an anti-psychotic medication) from 5mg to 2.5 mg daily? The pharmacist recommendations did not contain documented responses from the physician. Resident #24 was admitted with diagnoses which included dementia with behavioral disturbance. The pharmacist reviews dated 11/22/21 and 05/19/22, read in parts, Is a dosage reduction attempt possible for any of the following: .[MEDICATION(S)] from 2.5mg daily to every other day .[MEDICATION(S)] from 1.5mg daily to every other day . The forms did not contain documented responses from the physician. On 07/22/22 at 2:00 p.m., the DON, reported the physician did not respond to the pharmacist reviews, the DON stated she was aware they needed to address the pharmacist reviews with the physician and document their response.

Based on observation and interview, the facility failed to ensure controlled substances were stored in a permanently affixed compartment in the medication refrigerator for one (New Wing Medication Room) of two medication rooms. The DON reported controlled substances were stored in the refrigerator in one (New Wing Medication Room) of two medication rooms. Findings: On 07/22/22 at 11:10 a.m., a black plastic box on a shelf in the New Wing Medication Room refrigerator was not affixed to the refrigerator. The black plastic box contained two bottles of liquid [MEDICATION(S)] (a controlled substance). On 07/22/22 at 11:15 a.m., LPN #1 reported she was unaware the box should have been permanently affixed. On 07/22/22 at 11:20 a.m., the DON reported the facility had attempted to permanently affix the box without success.

Based on record review, observation, and interview, the facility failed to ensure a wound care plan was developed for one (#29) of one resident whose care plan was reviewed. The Matrix for Providers dated, 07/19/22, documented two residents with wounds. Findings: A comprehensive care plan dated, 06/04/22, did not document Res #29's wound to left foot. A history and physical from acute care dated, 06/18/22, read in parts, .left foot stage 3 ulcer . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .monitor top of left foot for S/S of infection daily. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/19/22 at 10:25 a.m., and throughout the survey, Res #29 was observed with a dressing to the top of their left foot. On 07/22/22, at 3:30 p.m., the DON reported the wound should have been care planned.

Based on record review and interview the facility failed to ensure the hospice chart was up to date for one (#36) of one resident who was reviewed for hospice services. The Matrix for Providers dated, 07/19/22, documented three residents were receiving hospice services. Findings: Res #36 was admitted to hospice services on 06/14/21 for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The last hospice nursing note in the hospice chart was dated 09/22/21 at 4:58 p.m. On 07/22/22 at 11:39 a.m., the DON reported the last hospice nursing note was from 09/22/21. On 07/22/22 at 2:38 p.m., LPN #1 reported if there were current hospice nursing notes in the chart she would have read them, LPN #1 also stated, I don't even know what the hospice nurse is assessing or finding if they don't tell me.

Based on observation, interview, and record review, it was determined the facility failed to ensure an antibiotic stewardship program was consistently implemented for two (#25 and #31) of five residents whose medications were reviewed. The facility failed to ensure appropriateness of antibiotics per results of culture and sensitivity reports. The director of nursing (DON) identified nine residents who received antibiotics over the previous three months. Findings: The facility policy for antibiotic stewardship documented the appropriate indications for antibiotic use included criteria met for clinical definition of active infection and pathogen susceptibility, based on culture and sensitivity (c/s), to antimicrobial (or therapy begun while culture was pending). 1. Resident #25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change in status assessment, dated 02/18/21, documented the resident was moderately impaired in cognition and required extensive assistance for most activities of daily living. The assessment documented the resident was frequently incontinent of urine and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] A urinalysis, obtained on 03/28/21, documented the resident's urine had 3+ bacteria. A physician order, dated 03/30/21, documented the facility was to administer [MEDICATION(S)] (an antibiotic medication) 100 milligrams (mg) twice daily by mouth for seven days for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A culture report, resulted on 04/03/21 for the 03/28/21 urinalysis, documented the presence of protius (a bacteria infection). The culture sensitivity report documented the organism was resistant to [MEDICATION(S)] but was susceptible to [MEDICATION(S)]. A physician order, dated 04/05/21, documented to discontinue [MEDICATION(S)] and begin [MEDICATION(S)] sodium injection solution one gram intramuscularly once daily for three days. On 04/14/21 at 8:52 AM, the infection control nurse (ICN) reported the facility had problems getting c/s reports in a timely manner. She stated she did not know why it took seven days to get a two day culture report. She stated the c/s report came on a Saturday and did not get acted on until Monday. She confirmed the resident did not start the correct antibiotic for nine days after the c/s was ordered. On 04/14/21 at 11:02 AM, the resident was observed awake and sitting in his chair. The resident was unable to be interviewed. 2. Resident #31 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 03/03/21, documented the resident was moderately impaired in cognition, required extensive assistance with most activities of daily living, and was always incontinent of bowel and bladder. A nurse note, dated 03/05/21, documented the resident had been vomiting dark brown emesis with large blood clots noted on the blankets and in the emesis bag. The note documented she was assessed and sent to the emergency department. A urinalysis by clean catch, collected at the hospital on 03/05/21, documented 3+ bacteria. A nurse note, dated 03/05/21, documented the nurse practitioner was notified of the urinalysis result and ordered [MEDICATION(S)] (antibiotic medications)100 milligrams (mg) twice daily for seven days. A culture and sensitivity (c/s) report, dated 03/06/21, documented the culture had mixed flora suggesting possible contamination and no further testing on the sample would be performed. The c/s report documented, if clinically indicated, to obtain another sample utilizing a method to minimize contamination. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/14/21 at 10:59 AM, the resident was observed sitting in bed watching television. The resident was unable to be interviewed. On 04/14/21 at 12:56 PM, the infection control nurse (ICN) stated she was unaware the c/s from the 03/05/21 urinalysis had been contaminated. She reported if the urine c/s was not usable, the facility would continue the course of antibiotics. On 04/15/21 at 8:31 AM, the director of nursing was interviewed regarding antibiotic stewardship. She reported due to the lack of resident clinical signs and symptoms of a urinary tract infection, contaminated urinalysis, and lack of c/s findings, the physician should have been contacted regarding the appropriateness of continuing the antibiotics.

Based on observation, interview, and record review, it was determined the facility failed to maintain sanitary conditions in the dietary department by ensuring the ice machine was clean. The facility identified a census of 40 residents. Findings: A review of ice machine cleaning schedule documented the last cleaning date was 11/17/20. On 04/12/21 at 10:40 AM, the ice machine was observed. The Dietary Manager (DM), using a clean white paper towel, wiped the inner white lip of the ice machine and a small amount of pink, blackish/brown substance was observed on the clean paper towel. The DM reported the ice machine was used for all residents. On 04/13/21 at 1:26 PM, the DM reported the ice machine was supposed to be cleaned every two weeks.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident received interventions to maintain nutritional status within acceptable parameters for one (#31) of two residents sampled for nutritional status. The facility failed to provide Med Pass and Ensure (protein/calorie supplements) as ordered by the physician. The dietary department identified 14 residents who received physician ordered calorie/protein supplements. Findings: Resident #31 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 06/01/20, documented the resident was moderately impaired in cognition, required set up and supervision with eating, weighed 85 pounds, and had no natural teeth. The care area assessment documented nutritional status had been triggered for care plan development. A dietary order, dated 12/02/20, documented the resident was on a regular diet and was to receive Med Pass 60 milliliters (ml) and Ensure twice daily. A hospital readmission order, dated 02/18/21, documented the resident was to receive Healthy Shot three times daily and one can of Ensure twice daily. A review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 03/03/21, documented the resident was moderately impaired in cognition, required set up and supervision with eating, weighed 97 pounds, and was on a physician prescribed weight gain program. A dietitian review, dated 03/29/21, documented the resident's weight as 85 pounds. The dietitian review documented the resident had a significant weight loss without skin issues of 15% during six months. The review documented the resident had orders to receive a regular diet along with Ensure and 60 mls of Med Pass twice a day. The dietitian recommended increasing Med Pass to 90 ml three times a day. The dietitian review and recommendation documented the resident's physician concurred with the recommendation on 03/30/21. A weight record, dated 03/30/21, documented the resident's weight as 88.8 pounds. A weight record, dated 04/13/21, documented the resident's weight as 84 pounds. The resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] On 04/15/21 at 8:30 AM, the resident was observed finishing her breakfast. No supplements were observed with the resident's morning meal. On 04/15/21 at 9:45 AM, dietary manager (DM) reported the dietitian reviewed the resident records and would make recommendations. She stated she then printed them out and gave them to the nursing staff. The DM reported the nursing staff entered the orders into the resident's electronic medical record. The DM reported the physician ordered supplements were documented on residents' MARs. She reported the nursing staff provided Ensure and Med Pass to those residents who had orders for them. She stated she had a record of all residents receiving supplements as the kitchen provided them to the nursing station. She reviewed the dietary records and confirmed the resident had not received Ensure or Med Pass and Med Pass had only been initiated on 04/13/20. On 04/15/21 at 10:10 AM, the assistant director of nursing (ADON) reviewed the resident's records and confirmed the resident had not received Ensure or Med Pass as ordered from 02/18/21 until 04/13/21 when Med Pass 90 ml three times daily had been added. She stated the dietitian should have looked at the MARs to see what the resident had been receiving prior to making recommendations. She stated the nursing staff should have reviewed the orders and the MAR for accuracy.

Based on interview and record review, it was determined the facility failed to report an allegation of abuse/mistreatment within two hours for one (#33) of three sampled residents reviewed for abuse. The facility identified a census of 40 residents. Findings: The facility abuse policy documented allegations of abuse were to be reported per Federal and State law. Resident #33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission assessment, dated 03/11/21, documented the resident was cognitively intact for daily decision making and required extensive assistance with activities of daily living. An abuse allegation state reportable, dated 04/09/21, reported the resident was hit on the side of the head with a water bottle by another resident. The facility reported there were no injuries sustained. The assaultive resident was removed from the facility to a Geri-psych facility. The transmittal facsimile report documented the the allegation of abuse was reported to the Oklahoma State Department of Health (OSDH) was notified on 04/10/21 at 12:02 p.m. On 04/14/21 at 9:00 AM, the director of nursing reported the abuse allegation was not submitted to OSDH within two hours of the incident.

Based on observation, interview, and record review, it was determined the facility failed to ensure a fall prevention care plan was revised to meet the needs of the resident for one (#31) of 23 sampled residents whose care plans were reviewed. The facility identified 10 residents who experienced a fall in the previous three months. Findings: Resident #31 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 06/01/20, documented the resident was moderately impaired in cognition and required limited assistance of two staff members while walking in the room. The care area assessment triggered falls to have been care planned. A care plan, dated 06/03/20, included plans for potential for injury related to [CONDITION(S)], and loss of consciousness or [CONDITION(S)], impaired physical mobility, high fall risk, and falls. A state reportable incident form, dated 08/15/20, documented the resident had attempted to ambulate without assistance and fell . The form documented a step to prevent reoccurrence was to place the resident on hourly rounding. The resident's care plan was not updated to include hourly rounding. A state reportable incident form, dated 01/27/21, documented the resident was found on the floor beside the bedside commode. The form documented the resident was transferred to the hospital. The resident's care plan was not updated to include fall prevention measures. A quarterly assessment, dated 03/03/21 documented the resident was moderately impaired in cognition, required extensive assistance with most activities of daily living. The resident's care plan did not include a date for review or any updates. On 04/14/21 at 9:02 AM, the resident was observed lying in bed. The bed was observed in low position and her call light was in reach. On 04/14/21 at 10:59 AM, The resident was observed to be awake and alert in her room and watching television. The resident was not interviewable. On 04/14/21 at 3:10 PM, the restorative aide (RA) reported the resident's care plan included many interventions she no longer needed as the resident was unable to get up by herself. On 04/15/21 at 8:31 AM, the director of nursing (DON) reviewed the resident's care plan and confirmed it had not been updated since 06/03/20. She stated the care plan should have been updated to reflect the current resident's status and needs.

Based on observation, interview, and record review, it was determined the facility failed to ensure the temperature in the medication storage room was monitored and recorded for one (#2) of two medication storage rooms. The facility identified a census of 40 residents. Findings: A facility policy, Medication Storage In The Facility, documented Safe medication storage includes the provision of appropriate environmental controls. Because many medications can be altered by exposure to improper temperature, light, or humidity, it is important that the facility implement procedures that address and monitor the safe storage and handling of medications in accordance with manufacturers' specifications, state requirements and standards of practice (e.g., United States Pharmacopeia (USP) standards). On 04/13/21 at 12:41 PM, medication room [ROOM NUMBER] was observed to be without a method to determine the temperature of the room. On 04/13/21 at 12:41 PM, licensed practical nurse (LPN) #2 reported there was not a method to determine or log the temperature of the room. On 04/14/21 at 12:32 PM, medication room [ROOM NUMBER] was observed to be without a method to determine the temperature of the room. On 04/14/21 at 12:32 PM, licensed practical nurse (LPN) #1 reported she had seen a thermometer in the medication room in the past, but it was no longer there. She reported there was not a log to record the temperature of the room. On 04/14/21 at 3:29 PM, the director of nurses (DON) reported she was unaware of the requirement to monitor and record the temperature of medication room. She reported she was not aware of a facility policy regarding monitoring and recording the temperature of the medication rooms. She further reported maintaining medication room temperatures were important to maintaining the integrity of medications.

On 01/26/15, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to follow their Infection Control policy and procedure for isolation techniques and Contact Precautions for an ESBL (Extended-Spectrum Beta-lactamase) infection of the urine. The facility failed to ensure their infection control policy and procedure for contact isolation was followed for resident #45 who had been diagnosed with [REDACTED]. a) Staff not wearing moisture barrier gowns while providing incontinent care and changing urine soiled sheets on the resident's bed diagnosed with [REDACTED]. b) Contaminated gloves were not changed after providing incontinent care, touching other personal items and before leaving the room. c) An immuno-compromised resident, not infected with ESBL of the urine, was cohorted with the resident infected with ESBL. d) The facility did not place a color coded sign on the door of resident #45 who had been diagnosed with [REDACTED]. e) The facility did not place a color coded label on the supply cart placed outside the resident's door containing isolation equipment. f) The facility staff were unaware of which residents were on isolation precautions and which steps they were to follow for isolation procedures. On 01/26/15 at 11:51 a.m., the Oklahoma State Department of Health (OSDH) was notified of the situation and the IJ was verified. On 01/26/15 at 11:59 a.m., the Director of Nursing (DON)was informed of the IJ situation. At 12:06 p.m., the Administrator (ADM) was informed of the IJ situation. On 01/26/15 at 5:01 p.m., the ADM and DON presented an acceptable plan of removal which documented: "Infection Control Plan of Removal 1/26/15 The facility will maintain an Infection Control Program to ensure a safe, sanitary environment and help prevent development and transmission of infection. All residents identified as symptomatic for infection will have physician notified to obtain orders immediately. Physician and nursing staff will determine appropriate treatment and procedures to help prevent further transmission. ie (example): isolation precautions, medication treatment, staff education. Any resident determined to be infected or colonized with micro-organisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces, equipment or resident care items will be placed on isolation precautions appropriate for that resident's condition, all color coded signs will be placed on door with the correct precautions and equipment to be utilized. PPE (personal protective equipment) will be provided for that condition per protocol. All equipment utilized in the care and/or monitoring of residents with infection and on isolation precautions will be dedicated to that resident if disposable equipment is unavailable. If disposable equipment is unavailable then equipment will be cleaned adequately and disinfected before use with another resident. Equipment included but not limited to is stethoscope, sphygmomanometer, thermometer, glucometer, IV (Intravenous) pole/pump, bedside commode, etc. (etcetera) All staff will be informed at the beginning of each shift via shift change report of all residents who are on isolation precautions with type of isolation and location of infection. ie: contact, standard, airborne, droplet. When a private room is not available, residents with the same infection with the same microorganism, but with no other infection may be cohorted or maintain spatial separation of at least 3 feet between the infected resident and other residents, visitors and resident equipment. Residents with UTI (Urinary Tract Infection) and are incontinent will be encouraged to continue with daily routine and participate in activities and life of facility while maintaining precautions to prevent transmission, ie: adult briefs, incontinent pads, F/C (Foley Catheter), do not utilize community cloth furniture. Residents in room [ROOM NUMBER]a and 45b have been determined to be at an increased risk for infections r/t (related to) disease process. These residents and family have been contacted and informed of risk factors and have agreed to relocate temporarily until resolution of infection. All staff will be inserviced today by 1159 pm on Infection Control Policy and Procedures and Isolation Precautions and proper procedures and equipment required for maintaining isolation to prevent transmission of infection. All staff will be inserviced today by 1159 pm on proper handwashing techniques to prevent transmission of infection by the Infection Control Coord. (Coordinator) @ Coal County General Hospital. All agency staff will be provided with facility policy and procedures for Infection control, Isolation Precautions and proper handwashing techniques to prevent transmission of infection before beginning their first shift in this facility. All staff not present for today's inservice will be notified via phone for instructions regarding Infection Control Policy and Procedure, Isolation Precautions and proper handwashing techniques today by 1159 pm. All residents identified to be symptomatic for infection and have physician orders [REDACTED]. All new orders and corresponding documentation will be reviewed daily by IDT (Inter-disciplinary Team) for compliance. IDT will monitor for Isolation Procedures to confirm compliance daily. Current residents with active infection and Isolation Precautions in place: (Name deleted resident #45) - ESBL urine- [MEDICATION NAME] po (by mouth) bid (twice a day) x 10 d (day). (Name deleted resident #48)- VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]) urine- no treatment recommended per infection control physician. (Name deleted resident #18)- ESBL- [MEDICATION NAME] completed 12/31/15 (sic) 2014. (Name deleted resident #30)- MRSA (Methicillin-resistant Staphylococcus) wound LLE (Left lower extremity) [MEDICATION NAME] completed 1/26/15. (Name deleted resident #55)- ESBL urine- [MEDICATION NAME] completed 1/22/15. (Name deleted resident #60)- ESBL urine- completed 1/12/15. (Name deleted resident #58)- ESBL urine- [MEDICATION NAME] completed 1/23/15." On 01/26/15 at 11:00 p.m., the IJ was removed after working staff were interviewed and were able to verbally identify which residents were on isolation precautions and the isolation techniques which were to be followed. The deficiency remained at no actual harm with potential for more than minimal harm, widespread. Based on record review, observation and interview, it was determined the facility failed to: a) Ensure the infection control policy and procedure was followed for a resident diagnosed with [REDACTED].#45) of four residents sampled on isolation. b) Ensure an immuno-compromised, un-infected resident was not cohorted with a resident diagnosed with [REDACTED].#45) of four sampled residents on isolation. c) Ensure the facility's infection control policy and procedure was followed by placing a color coded sign on the door to alert visitors to stop at the nurses' station before entering the resident's room who had been diagnosed with [REDACTED].#45) of four sampled residents on isolation precautions. d) Ensure a supply cart containing isolation supplies with a color coded label was placed outside the doorway for a resident diagnosed with [REDACTED].#45) of four sampled residents on isolation precautions. e) Ensure all facility and agency staff were knowledgeable of the type of isolation residents were ordered for one (#45) of four sampled residents on isolation. f) Ensure contaminated gloves were changed after providing incontinent care, touching personal items, and removed before leaving the room for two (#12 and #45) of four sampled residents observed receiving care. These had the potential to affect all 63 residents per the DON. g) Ensure pressure sore supplies were not placed on a contaminated surface and soiled dressings were not placed on an over-bed table for one (#58) of three sampled residents observed during pressure sore treatment. This had the potential to affect ten residents identified by the DON with pressure sores. h) Ensure the glucometer was sanitized with an anti-microbial agent between obtained FSBS (Finger Stick Blood Sugars) for two (#6 and #26) of two residents observed receiving FSBSs. This had the potential to affect 16 residents who received FSBS per the DON. i) Ensure the bedside commode (BSC) was emptied and sanitized for one (#58) of 15 residents sampled that utilized a BSC. This had the potential to affect 22 residents residing in the facility that utilized BSC per the ADON (Assistant Director of Nursing). j) Ensure bowel movement was not left on the walls or on the rails on the bedside commode for one (#58) of one sampled resident. This had the potential to affect 17 residents who were occasionally or frequently incontinent of bowel per the DON. k) Ensure bedpans were not placed on the floor for two (#14 and #88) of two sampled residents who used bedpans. This had the potential to affect two residents residing in the facility per the DON. l) Ensure the infection control log for December 2014, documented a resolution date for every infection. This had the potential to affect all 63 residents residing in the facility per the DON. Findings: The facility's policy and procedure (P&P) documented, "ESBL (Extended Spectrum Beta Lactamase) Policy: Purpose- The purpose of this procedure is to provide guidelines for appropriate precautions regarding individuals known or suspected to have ESBL infections or colonization. Preparation- Review the resident's care plan to assess for any special needs of the resident. Assemble the equipment and supplies needed. General- People who have ESBL producing E-coli(Escherichia coli) or [DIAGNOSES REDACTED] will be considered to have ESBL. Residents known or suspected to have ESBL infection or colonization will be placed on Contact Precautions and placed in a private room or cohabitated with another resident with the same infection if the attending physician, in conjunction with the infection control coordinator, judges the care to meet specific clinical criteria, including: ...the resident is incontinent of urine or stool, and cannot be contained...there is more than one documented case of ESBL in the facility and transmission is likely. Should a resident be placed on Contact Precautions implement the following: Consult appropriate isolation policy. Place an isolation cart with all supplies needed outside door... Place appropriate color-coded precaution signs on top of the isolation cart; a lady bug picture & precaution sign will be posted on the door... Ladybug signs will remain in place on residents door to alert staff to infection precautions. Residents who meet the criteria...above will remain on Contact Precautions until a clear culture reports shows that ESBL is not present... At the first indication that a resident may be infectious, Contact Precautions will be instituted... Employees are expected to use appropriate hand hygiene techniques to decrease the possibility of colonization or transient carriage of the organism. Isolation Precautions- Isolation Precautions: Policy Interpretation and Implementation- Transmission-based precautions have been established in order to ensure that appropriate techniques are implemented in this facility when necessary. Our facility currently uses the three types of transmission-based precautions (Airborne, Contact and Droplet) recommended by CDC (Centers for Disease Control)... In addition to Standard Precautions, Contact Precautions must be implemented for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or patient-care items in the resident's environment...examples of infections requiring Contact Precautions...ESBL... Resident placement: When a private room is not available, residents with the same infection with the same microorganism, but no other infection may be cohorted. Gloves and Handwashing: In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, nonsterile) when entering the room. During the course of caring, for a resident, change gloves after having contact with infective material that may contain high concentrations of microorganisms...Remove gloves before leaving the room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. After glove removal and handwashing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the resident's room. Gown: In addition to wearing a gown as outlined under Standard Precautions, wear a gown (clean, nonsterile) when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room, or if the resident is incontinent...Remove the gown before leaving the resident's environment...After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces..." The facility's policy for 'Bedpan/Urinal, Offering/Removing', documented, "...Clean the bedpan or urinal. Wipe dry with a clean paper towel. Discard paper towel into designated container. Store the bedpan or urinal. Do not leave it in the bathroom or on the floor...Discard soiled laundry into designated containers..." The facility's P&P on "Gloves" documented the following: "...Objectives - To prevent the spread of infection and disease to patients and employees; To protect wounds from contamination...Wash hands after removing gloves...gloves do not replace handwashing. Gloves should be removed before removing the mask and gown and discarded into the designated waste receptacle inside the room. When to use gloves: When touching excretions, secretions, blood, body fluids, mucous membranes or non-intact skin..." 1. A quarterly assessment, for resident #45, dated 10/31/14, documented the resident had severely impaired cognition, required extensive assistance with transferring between surfaces, ambulation, dressing and hygiene, was frequently incontinent of bowel and occasionally incontinent of bladder. On 10/31/14, the care plan documented, "Problem: Incontinence...Approach: Monitor for signs/symptoms of UTI, burning, pain, foul odor; if present obtain UA (urinalysis) and treat as indicated...Evaluate need for medication to help with incontinence..." A telephone physician's orders [REDACTED]. Dx (diagnosis) dark, foul urine." Three days later a urine culture was obtained on 01/23/15. The resident's medical record was reviewed for documentation of why the UA had not been obtained for three days. The record did not contain documentation of the UA having been collected. On 01/20/15 at 10:00 a.m., the resident was observed sitting in a recliner across from the nurses' station. On 01/23/15 at 3:00 p.m., the resident was observed sitting in a recliner across from the nurses' station. A laboratory report, dated 01/23/15, documented, "Culture, urine, routine...specimen source: cath...results: greater than 100,000 CFU/mL (Colony- forming unit) of Escherichia coli (ESBL)." On 01/26/15 at 9:45 a.m., the resident was observed lying in her bed. Two boxes containing red bags were observed in the room. A roommate was observed lying in her bed. Each of the residents had bedside commodes setting by their beds. At 10:00 a.m., CNA (Certified Nurses Aide) #4 and CNA #6 were observed preparing to provide personal care for the resident. The CNAs assisted the resident transferring to the BSC (bedside commode) next to her bed. CNA #6 was observed to change the linens on the resident's bed. The sheets were wet with urine. Neither of the CNAs had on moisture barrier gowns. CNA #6 removed the sheets that were wet with urine and placed clean sheets on the bed and did not change her gloves or wash her hands. After the resident had finished using the bathroom in the BSC, CNA #4 and CNA #6 were observed to assist the resident to a partially standing position and provided incontinent care. With the same gloves on, the two CNAs dressed the resident and placed her back into the bed. CNA #6 then placed a plastic bag over the BSC bowl, opened the resident's door by touching the door handle and went to the hopper room to clean the BSC bowl. The CNA contaminated the door handle of the resident's room with the soiled gloves. At 10:50 a.m., the DON was asked why the red boxes were in the resident's room. The DON reported the resident was suspected of having ESBL. At that time, a white piece of paper was observed taped to the door of the resident's room. The paper documented, "STOP Please check in at nurses' desk before entering room." No isolation supply cart was observed setting outside the resident's doorway. At 11:00 a.m., the DON presented a laboratory report and stated, "We just got this off the fax machine. We received it at nine this morning." At 11:15 a.m., a housekeeper was observed entering to clean the resident's room. After the housekeeper had finished cleaning the room, she left without washing her hands, proceeding to the next resident's room. At 11:30 a.m., the DON was informed of the cross contamination with the observed incontinent care. The DON was interviewed regarding the staff not following the facility's infection control policy and procedure, AEB not wearing moisture barrier gowns while providing incontinent care to a resident with ESBL, not changing gloves after providing incontinent care for a resident with ESBL, not cohorting of an uninfected resident with a resident diagnosed with [REDACTED]. The DON reported she would take care of the problems. 2. Resident #58 utilized a bedside commode (BSC) which was placed next to her bed. The resident was legally blind. On 01/20/15 at 12:56 p.m., a BSC was observed at the resident's bedside. A family member was interviewed. The family member reported the resident would attempt to use the BSC by herself. The family member pointed out BM (bowel movement) on the wall behind the BSC and on the BSC's handrails and said that BM was also on the resident's recliner. The family member reported no one had ever cleaned those things. The opened BSC also contained feces, urine and toilet paper visible in the bowl. On 01/21/15 at 8:59 a.m., the resident was observed asleep in bed. The lid of the BSC was open with urine and toilet paper observed in the bowl. On 01/21/15 at 10:11 a.m., the resident was observed in bed asleep. The BSC was open with urine and toilet paper visible in the bowl. The BSC rails had dried feces on them. The housekeeper had just left the resident's room after mopping the floor. On 01/23/15 at 9:01 a.m., the housekeeper cleaned the resident's room. The housekeeper mopped the resident's floor and emptied the BSC. She did not clean the BM off the BSC rails or the BM off the wall in the resident's room. On 01/23/15 at 9:44 a.m., LPN #6 was observed performing a pressure sore treatment for [REDACTED]. After using several 4x4's to dry off the pressure sore, she placed the contaminated 4x4's directly on the BST. She then removed the supplies and left the room without cleaning off the BST. On 01/23/15 at 1:38 p.m., the resident's BSC was open with urine and toilet paper visible in the bowl. The BSC rails had dried feces on them. The resident was observed lying in bed. On 01/26/15 at 9:00 a.m., the DON went into the resident's room with the surveyor after she had been informed of the BM on the wall and handrails of the BSC. The DON said she had told housekeeping to clean the wall, but she could see it still had BM on it. The DON tried to wipe the BM off the wall with her gloved hand and a wet cloth, but the BM was dried on the wall and she had to scrape it off with her gloved nails. The BM on the BSC rails rubbed easily off with the wet cloth. The DON was asked who was responsible for cleaning the bowl of the BSC. She said whoever helps the resident use the BSC should dump the bowl in the toilet in the bathroom and rinse out the bowl. She said the housekeeper should clean the rails on the BSC each time she cleans the room. The DON said there was a special disinfectant to clean the bowl after rinsing it out. The DON was informed of the observed pressure sore treatment and the unclean field the clean supplies had been laid on. She was also informed of the dirty 4x4's laid on the BST and the BST not being cleaned afterwards. The DON said there should have been a clean barrier placed on the BST such as a blue pad. She said the table should have been cleaned before and after use. On 01/26/15 at 9:13 a.m., the resident's BSC was open and urine and toilet tissue visible in the bowl. 3. On 01/23/15 at 3:45 pm., LPN (licensed practical nurse) #6 was asked when she was going to perform the treatment on resident #12. She stated she was on her way to do it now. As we were heading to the room she said the resident's aide was in trouble for not cleaning up the resident appropriately. LPN #6 and CNA #7 (certified nurse aide) donned gloves and attached the sling to the sit-to-stand lift. The resident was lifted-up and her pants lowered to perform incontinent care. The LPN began wiping the feces off of the resident's buttocks. After using all of the washcloths, she stated she did not have enough wash cloths. The LPN removed the feces soiled bed pad from the resident's wheelchair and placed it on the resident's bed. The LPN removed her gloves and left the room without washing her hands. The LPN then went to the medication cart and looked for more gloves. She then went to a linen cart and obtained a box of gloves and washcloths. The LPN was not observed to wash her hands prior to performing the incontinent care and before leaving the resident's room. LPN #6 returned to the room with the items and without washing her hands, she donned a new pair of gloves. She began cleaning the feces off the resident. After the incontinent care was performed, using the same gloves, the resident was dried off and the medication was applied to the resident's abdominal fold area. She then took off her gloves and laid them on the bedside table beside the clean supplies. The LPN donned new gloves, without washing her hands, and applied the [MEDICATION NAME] cream to the buttocks. The LPN left the room without washing her hands. She stated she had to perform a treatment on another resident. The LPN was observed to perform a fingerstick blood sugar on another resident without washing her hands. At 4:18 p.m., the LPN was asked if she had washed her hands before, during or after the incontinent care and application of the medication. She stated, "No". She stated she was too busy and did not have time to wash her hands. She was asked at what time should she have washed her hands. She said after the incontinent care. The LPN was asked if she had washed her hands before doing fingersticks on the resident. She stated, "No." 4. On 01/20/2015 at 3:27 PM, room [ROOM NUMBER]'s bathroom was observed. There was one bedpan setting directly on the floor and another bedpan setting inside a plastic basin which was setting directly on the floor under the sink. The bedpans were soiled with white residue and brown stain and the basin had a brown stain in the bottom of it. On 01/21/2015 at 10:32 AM, an observation of a used latex glove was observed on top of the resident's belongings on the resident's end table near foot of his bed. At 2:01 PM, room [ROOM NUMBER]'s bathroom was observed. A bedpan was observed setting directly on the floor underneath the sink. Linens were observed touching the floor in the resident's bathroom and a towel with a brown substance was laying on top of the linens. On 01/22/2015 at 2:37 PM, an observation was made of the bedpan on the bathroom floor of room [ROOM NUMBER]. At 2:38:00 PM, an observation was made of the bedpans and a plastic basin setting directly on the floor of room [ROOM NUMBER]. On 01/27/15 at 10:44, the ADON (assistant director of nursing) was informed of the bedpans in the residents' rooms which were dirty and setting directly on the floor. She said the bedpans and basins are not to be stored on the floor. She was also informed of the used latex glove left in the resident's room and the dirty linens left on the floor. She said the linens should have been put in a plastic bag along with the used glove and taken out of the resident's room. 5. Resident #6, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/02/14, documented the resident as requiring extensive assistance of two staff for all activities of daily living. The resident's current care plan documented the resident was at risk for hyper or [DIAGNOSES REDACTED] and to monitor blood sugars as ordered with sliding scale coverage. The resident's current finger sticks schedule documented staff were to complete finger sticks four times daily. On 01/26/15, at 10:40 a.m., an observation was made of LPN (licensed practical nurse) #1 entering the resident's room to check her fingerstick blood sugar. The LPN used the glucometer to check the resident's glucose and then exited the room. LPN #1 returned to the medication cart and reported she had used alcohol pads to clean the glucometer before entering the resident's room. The LPN was then observed to clean the glucometer with an alcohol pad after leaving the room. Resident #26, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A comprehensive assessment, dated 10/31/14, documented the resident as requiring limited assistance of one staff member for all activities of daily living (ADLs). The resident's current care plan documented the staff was to monitor blood sugars as ordered with sliding scale coverage. The resident's current finger stick schedule documented the fingerstick blood sugars were to be completed four times daily. On 01/26/15, at 11:00 a.m., an observation was made of LPN #1 taking the medication cart to the room of resident #26, immediately after leaving the room of resident #6 where she had performed a FSBS. She entered the room with the glucometer and supplies, telling the resident she was going to check her blood sugar. The surveyor asked the nurse to step to the door of the resident's room and asked the LPN to clarify how she had cleaned the glucometer. The LPN reported she had used an alcohol pad. She said she would consult with the Director of Nursing (DON). At 11:05 a.m., LPN #1 returned to the medication cart and reported she would be cleaning the glucometer between use of each resident with a 10:1 bleach mixture. The LPN was then observed to mix the bleach with water at a ratio of 10:1. LPN #1 then cleaned the glucometer with a 2x2 soaked in the bleach solution before and after using the glucometer on resident #26. LPN #1 then reported she had always cleaned the glucometer between resident uses with an alcohol pad. At 11:20 a.m., the DON was interviewed and reported the facility would inservice nursing staff on how to properly clean glucometers between resident use. 6. On 01/20/15 at 5:49 p.m., the infection control log was reviewed. The December 2014, infection control log form did not document the resolution date for every infection which had been identified and documented in the log. On 01/27/15 at 11:00 a.m., the DON (director of nursing) was interviewed regarding the infection control log not documenting a resolution date for every infection identified. She was asked who was in charge of the log. She said when she had been off sick, she had assigned the infection control log to the ADON (assist director of nursing). She stated, "(Name deleted ADON) was unable to maintain the log as it should have been, because she had so many other duties."

Based on observation, interview, and record review, it was determined the facility failed to identify pressure ulcers and have an effective system for the prevention and treatment of [REDACTED].#19 and #87) of six sampled residents who were reviewed for pressure ulcers. This resulted in actual harm for resident #19 when interventions were not implemented and one of the resident's pressure ulcers increased in size. The facility identified ten residents with pressure ulcers. Findings: The facility's procedure for pressure ulcer treatment, dated 10/12/10, documented, "...Stage II Protocol... Interventions/Care Strategies Clean, shallow, minimal drainage: 1. Protect 2. Manage drainage 3. Promote moist wound healing. Treatment: 1. Cleanse with normal saline or other skin cleanser in accordance with physician orders [REDACTED]. Apply barrier cream...3. Manage pain 4. Wound/Skin consult with wound care specialist..." 1. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan, updated 09/11/14, documented a problem related to the potential for and/or actual integrity impairment. The goal was the resident would have no skin breakdown. Approaches included to assess the skin per protocol and as needed; keep skin clean and dry; reposition every two hours and as needed; and to report changes in skin to the nurse immediately. A physician's orders [REDACTED]. A five day assessment, dated 11/27/14, documented the resident had long and short term memory problems; required extensive assistance for bed mobility, transfers, eating, toilet use, and personal hygiene; was incontinent of urine; and was at risk for pressure ulcers. It was documented the resident did not have a pressure ulcer or any other skin conditions. A Braden Scale form, dated 11/27/14 and used to predict pressure ulcer risk, documented the resident scored a 14. The form documented a score below 16 meant the resident was at risk for the development of pressure ulcers. A weekly wound sheet, dated 12/04/14, documented the resident had one stage II pressure ulcer to her coccyx. It was documented the pressure ulcer measured 1 cm (centimeter) x 1.5 cm, with no odor or drainage noted. It documented the color was red. A quarterly assessment, dated 12/12/14, documented the resident had long and short term memory problems; required extensive assistance for bed mobility, transfers, eating, toilet use, and personal hygiene; was incontinent of urine; and was at risk for pressure ulcers. It was documented the resident did not have a pressure ulcer or any other skin conditions. A weekly wound sheet, dated 12/12/14, documented the resident had one stage II pressure ulcer to her coccyx. It was documented the pressure ulcer measured 0.2 cm x 0.2 cm, with no odor or drainage noted. It was documented the color was pink. A weekly wound sheet, dated 01/09/15, documented the resident had one stage II pressure ulcer to her left buttock. It was documented the pressure ulcer measured 1.5 cm x 1.5 cm, with no odor or drainage noted. It was documented the color was pink. An electronic skin check form, dated 01/14/15, documented the resident had an open area on the left ischial tuberosity. It was noted a treatment was in place. There were no measurements or description of the wound documented. A weekly wound sheet, dated 01/16/15, documented the resident had one stage II pressure ulcer to her coccyx. It was documented the pressure ulcer measured 0.5 cm x 0.5 cm, with no odor or drainage noted. It was documented the color was pink. Daily shift reports, dated 01/19/15 for the 3 - 11 p.m. shift, documented, "...sheared area center of spine..." Daily shift reports, dated 01/21/15 on 11 p.m. to 7 a.m. shift, documented, "...sheared spine..." Review of the clinical record revealed no documentation the physician had been notified of the shear wound to the resident's spine. There were no treatment orders. There was no documentation of the shear wound in the clinical record. There was no documentation the physician had been notified of the stage II pressure ulcer or of any treatment orders for the stage II pressure ulcer. Treatment sheets, dated 01/01/15 through 01/20/15, documented the resident had received [MEDICATION NAME] ointment to her buttocks every shift. On 01/21/15 at 9:24 a.m., the resident was observed lying in bed on her back. A pillow was placed under her right shoulder. On 01/21/15 at 10:24 a.m., LPN (licensed practical nurse) #5 was asked if the resident had any pressure ulcers. She stated, "Yes." She stated the resident had a stage II pressure ulcer on her coccyx that measured 0.5 cm x 0.5 cm. She stated the pressure ulcer had no drainage or odor and was first identified on 01/16/15. On 01/21/15 at 10:30 a.m., 10:59 a.m., 1:45 p.m., and 3:00 p.m., the resident's position was observed unchanged. Daily shift reports, dated 01/22/15, documented, "...sheer (sic) on back..." Another daily shift report, dated 01/22/15 on the 11 p.m. to 7 a.m. shift, documented, "...ok..." On 01/22/15 at 9:50 a.m., 11:30 a.m., and 11:45 a.m., the resident was observed lying in bed on her back, in the same position. A pillow was placed under her right shoulder. On 01/23/15 at 8:22 a.m., the resident was observed lying in bed on her back. At that time, LPN #5 was asked to notify the surveyor before she completed any treatments or provided any services for the resident. On 01/23/15 at 9:36 a.m., the resident was observed seated in her wheelchair. She was sitting on a pillow, and there was no padding to the back of the wheelchair. CNA (certified nurse aide) #1 was observed in the resident's room. She stated she had just completed transferring the resident. An ammonia smell was noted in the room. CNA #1 was asked to spread out the incontinent pad that was on the bed. A large, dark yellow colored ring was noted on the center of the pad. A smaller, dark yellow ring was noted at the top of the pad. The resident's gown was on the bed. CNA #1 was asked to spread it out. A dark yellow stain was noted at the bottom of the gown. CNA #1 was asked what the stains were. She stated the large ring on the pad and the stain on the gown were urine stains. CNA #1 was asked what the small stain on the pad was. She stated it was from the "spot on her back." CNA #1 pulled the resident's blouse up. An area, approximately five cms long and shaped like a thermometer was noted on the resident's spine on the lower lumbar area of the resident's back. There was no dressing in place. The area had some open areas where a red wound bed could be seen. CNA #1 stated she had noticed the area "a few days ago" and had told LPN #5 about it. CNA #1 stated LPN #5 would treat the area. CNA #1 stated the resident also had another area on her "bottom." She stated it was not "really" on her bottom, but in an area that was difficult to explain. CNA #1 stated she would get the surveyor when she put the resident back into bed so the area could be observed. On 01/23/15 from 9:36 a.m. until 11:10 a.m., the resident was observed sitting in her wheelchair in the front lobby. At 11:10 a.m., the resident was transported to the nurses' station were she remained until 11:51 a.m.. At that time, she was transported to the dining room. From 11:51 a.m. until 12:48 p.m., the resident remained in the dining room. While in the dining room, the resident became restless in her chair. She was observed to lean back against the back of the wheelchair and then lean forward 29 times from 12:23 p.m. until 12:48 p.m., when she was transported out of the dining room to the nurses' station. From 12:48 p.m. until 1:41 p.m., the resident remained at the nurses' station. The resident had remained in her wheelchair and had not been toileted, checked for incontinence, or repositioned from 9:36 a.m. until 1:41 p.m. This was over four hours. On 01/23/15 at 1:41 p.m., CNAs #1 and #2 were observed transferring the resident from her wheelchair to her bed. A stage II pressure ulcer was noted to the resident's left ischial tuberosity area. There was no dressing on the pressure ulcer. The area was approximately 1 cm x 0.5 cm. The wound bed was red in color. No drainage was noted. The area on the resident's spine was unchanged from the previous observation. A discolored area was noted on the back of the resident's pants. CNA #1 was asked why the area was discolored. She stated it was the Vaseline she had placed on the resident's buttocks earlier that morning. She was asked why she had applied Vaseline. CNA #1 stated it was because aides could not apply [MEDICATION NAME] ointment. CNA #1 was asked if there had been any type of dressing on the pressure ulcer when she had dressed the resident that morning. She stated, "No." CNA #1 was asked if the resident was at risk for the development of pressure ulcers. She stated, "Yes, I would think so." She was asked what the nurses had told her to do to help prevent pressure ulcers. She stated, "Turn from side to side, watch their intake, do incontinent care." CNA #1 was asked when she had repositioned the resident after she placed her in the wheelchair at 9:36 a.m. until this time. She stated, "I didn't." She was asked why she did not reposition the resident. She stated, "It's been so busy. Between feeding and bathing and answering call lights, I haven't had the time." On 01/23/15 at 2:24 p.m., LPN #5 was asked if the resident was at risk for pressure ulcers. She stated, "Yes." She was asked what interventions were in place to prevent pressure ulcers. She stated the resident received [MEDICATION NAME] to her coccyx every shift and skin checks twice weekly. LPN #5 was asked if the resident had any pressure ulcers at this time. She stated, "Yes." She stated she had just observed one on the middle of the resident's back and another one just below the left buttock. She was asked if she was aware of the pressure ulcers before today. She stated, "No." She stated CNA #1 had told her to come and check the resident after she had been put back to bed and that is when she saw them. She stated, "I knew she had a red area." She was asked how resident information was relayed to the nurses. She stated most information was provided during shift reports. LPN #5 stated when CNA #1 had made her aware of the resident's pressure ulcers, she informed the DON, and the DON went and took pictures and assessed the resident's skin. LPN #5 was asked how she monitored the CNAs to ensure they were implementing interventions identified to aid in the prevention and treatment of [REDACTED]. LPN #5 was asked if she was aware the resident had not been repositioned in her wheelchair or checked for incontinence for over four hours. She stated, "No. I forgot they have to be repositioned in the wheelchair." She was asked how she ensured CNAs completed incontinent care so that urine and feces were not left for long periods on the residents' skin. She stated, "I hold them accountable. If I see someone is wet, I tell them they need to be changed." LPN #5 was shown the shift report from 01/22/15, and was asked if she had seen the documentation the resident had a skin shear. She stated, "Yes, I did. I just forgot." On 01/23/15 at 3:33 p.m., the DON (director of nursing) was asked if the resident was at risk for pressure ulcers. She stated, "Yes. She currently has a couple. They're not severe." She was asked what pressure ulcers the resident had. She stated, "Left hip, I believe it is a two (stage II). They just reported a shear to me on her back." The DON stated the left hip pressure ulcer was first reported to her during the first part of 12/2014. She stated it was reported first to measure 1 cm x 1 cm x 1.5 cm. She stated it improved to 0.2 cm x 0.2 cm. The DON was asked what the last measurement was prior to this day. She stated it had measured 0.5 cm x 0.5 cm on 01/16/15. The DON was asked what the pressure ulcer measured this day. She stated, "1.2 cm (centimeter) x 1.2 cm." The DON was asked what interventions had been identified and implemented to aid in the prevention and healing of pressure ulcers. She stated to turn every two hours, try to keep out of bed as much as possible, and keep the resident clean and dry. She was asked how she ensured the interventions were implemented. She stated through education, weekly wound measurement, and talking about wounds and peri care. She stated those topics were addressed at every inservice. The DON was asked how she ensured agency nurses were aware of residents' skin conditions and interventions. She stated they tried to keep the same nurses. The DON was asked if she was aware the area to the resident's spine was first identified on 01/19/15. She stated LPN #5 had told her that on this day. An electronic skin check form, dated 01/23/15 at 4:32 p.m., documented, "...4 x 3 cm abrasion/shear to mid back, red, scant amount drainage noted, no odor...open [MEDICAL CONDITION]/pressure ulcers...how many? 1...Location(s)...Left ischial tuberosity...Note 1x1 stage 2 pressure ulcer, pink wound bed, no [DIAGNOSES REDACTED], no drainage or odor noted. Improvement noted...Physician notified, verbal order received and noted. Staff instructed to ensure turn q 1 hour and prn for pressure relief..." 2. Resident #87 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's care plan, dated 01/05/15, documented a problem related to alteration in skin integrity. The goal was the resident would have no new skin breakdown. Approaches included to assess her skin per protocol and as needed; reposition every two hours and as needed; report changes in skin to the nurse immediately; and to provide treatments to any skin impairments per orders. It was documented staff was to communicate with the physician as indicated for any changes in condition. A skin check sheet, dated 01/05/15 at 11:14 p.m., documented the resident had a right heel pressure ulcer. No measurements or descriptions of the pressure ulcer were documented. A nurse's note, dated 01/06/15 at 3:54 a.m., "...New admit to SNF at 1625...ulcer to left heel to be evaluated for treatment orders..." A skin check sheet, dated 01/06/15 at 4:12 a.m., documented the resident had three scabbed areas to the coccyx. There was no documentation of any other skin breakdown. Physician orders, dated 01/06/15, documented the resident was to receive [MEDICATION NAME] spray to both heels every shift for pressure ulcer prevention and a heel protector to the right heel as a preventative measure. A weekly wound sheet, dated 01/09/15, documented the resident had one stage II pressure ulcer to her coccyx. There was no documentation of any other skin breakdown. An admission assessment, dated 01/12/15, documented the resident was cognitively intact for daily decision making; required extensive assistance of two people for bed mobility, transfers, walking, locomotion, toilet use, personal hygiene, and bathing; had an indwelling urinary catheter and was frequently incontinent of bowel; and had one stage II pressure ulcer. A weekly wound sheet, dated 01/16/15, documented the resident had a stage II pressure ulcer on her right heel. It was documented the pressure ulcer measured 2 cm x 0.5 cm., was red in color, and had no odor or drainage. Review of the clinical record revealed conflicting information as to whether the resident had a pressure ulcer to her left heel, right heel, or to both heels. There were no orders regarding cleaning a heel pressure ulcer. On 01/23/15 at 8:19 a.m., the resident was observed lying on her back. She was asked if she had any pressure ulcers. She stated she did not know. On 01/23/15 at 8:50 a.m., CNAs #1 and #2 were observed assisting the resident after her shower. The resident's skin was observed for breakdown. A stage II pressure ulcer, measuring approximately 2.5 cm x 0.5 cm, was observed on the medial aspect of the resident's posterior right heel. The wound bed was red and beefy appearing. No drainage or odor were noted. There was no dressing on the pressure ulcer. No other pressure ulcers were noted. The CNAs assisted the resident to bed and then placed a heel protector on the resident's right foot. They placed a pillow under the resident's lower right leg and then adjusted the resident's bed linens. No dressing was placed on the open stage II pressure ulcer. CNA #1 was asked if there had been a dressing on the resident's pressure ulcer before she was taken to the shower. She stated, "No." On 01/23/15 at 10:00 a.m., LPN #5 was asked who she had completed pressure ulcer treatments for. She named one other resident. She stated, "I haven't got to (Name deleted resident #87) yet." She looked down the hall and saw the resident was being discharged from the facility. She asked, "They are about to leave with her?" The resident was discharged from the facility without the pressure ulcer being cleaned or any type of treatment being completed. On 01/26/15 at 12:52 p.m., LPN #5 was asked if she had completed any pressure ulcer treatments for the resident before she left the facility. She stated, "No. I did not get to it." She was asked why she had not done the treatment. She stated, "I was busy with other residents. I go in order. Plus she left at 10 o'clock in the morning." On 01/27/15 at 9:21 a.m., the DON was asked if the resident had pressure ulcers on admission to the facility. She stated, "Yes." She was asked what type of pressure ulcers the resident had on admission to the facility. The DON stated the resident had a "pink area on her bottom" and "one to her lower left leg and to her right heel." She was asked again if they had been present at admission. She stated, "I was not here. She had a wound boot on with a dressing." She stated she knew she measured those wounds. She stated at first the resident would not allow staff to remove the boot and wrap the left leg, because hospital staff had told her not to take them off. The DON then stated that the pressure ulcer was not on the resident's right heel. She stated it was on her left heel and that it had been found when the resident finally allowed them to remove the dressing on the left foot. She stated, "It was the left heel and it was all underneath that boot." The DON was asked where the pressure ulcer documentation was from the resident's admission to the facility. She reviewed the clinical record and stated it was documented the resident had a right heel pressure ulcer on admission. She was asked if the documentation contained measurements and a description of the ulcer. She stated, "No." The DON was asked if there was a pressure ulcer on the right heel when the resident was admitted to the facility. She stated, "I don't know. I did not visualize her on the day of admission." The DON continued to review the record and stated, "She (the charge nurse) mentions a ulcer to left heel and then scabs to the coccyx." The DON continued to review the resident's clinical record. She was asked what ulcers the resident had on admission to the facility. She stated, "Coccyx and left heel." The DON was asked when the resident developed the pressure ulcer on the right heel. She stated, "There never was an ulcer to her right heel." The surveyor informed the DON she had observed an open, stage II pressure ulcer on the resident's right heel. The DON stated she had not been informed of the right heel pressure ulcer. The DON was referred to the weekly wound sheet, dated 01/16/15, where it was documented the resident had a pressure ulcer on the right heel. She was asked if she had completed the documentation on the sheet. She stated, "Yes." She was asked if it was documented the resident had a pressure ulcer on her right heel. She stated, "It was on the left. I don't know if people were looking at it and were confused with the right and left." The DON stated the resident had a left heel pressure ulcer, and that there was no pressure ulcer to the right heel. On 01/27/15 at 9:43 a.m., LPN #2 informed the DON the resident did have a pressure ulcer on the right heel. She stated that was why a heel protector was being used. On 01/27/15 at 9:50 a.m., the DON was asked if there were any physician orders [REDACTED]. She stated the orders she saw were for [MEDICATION NAME] and a heel protector. The DON was asked if the physician had been made aware of the pressure ulcer on the resident's right heel. She reviewed the clinical record and stated, "I'm not finding anything yet."

Based on observation, interview, and record review, it was determined the facility failed to allow an alert and oriented resident to keep her indwelling urinary catheter in place for one (#87) of 17 sampled residents who were interviewed regarding their right to make their own health care decisions. This had the potential to affect all 63 residents residing in the facility per the director of nursing (DON). Findings: Resident #87 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's date of birth was 11/27/44. An admission assessment, dated 01/12/15, documented the resident was cognitively intact for daily decision making. It was documented the resident required extensive assistance of two people for bed mobility, transfers, walking, locomotion, toilet use, personal hygiene, and bathing. It was also documented the resident had an indwelling urinary catheter and was frequently incontinent of bowel. A nurse's note, dated 01/15/15 at 10:48 a.m., documented, "...(family member) states she has been incontinent since age 25..." A nurse's note, dated 01/18/15 at 2:56 p.m., documented, "...Remains with incontinence. (Family member Name deleted) is here and verbalizes his concern that resident no longer has Foley cath in place and request that she has Foley back in place..." A nurse's note, dated 01/18/15 at 10:03 p.m., documented, "...(Family member Name deleted) reported c/o (complaint) and concerns that resident had Foley removed on 1/17/2015 and would like it to be replaced. He will f/u (follow-up) with DON on Mon. (Monday) or Tues. (Tuesday) regarding incontinence..." On 01/21/15 at 11:03 a.m., the resident was observed lying in bed. She did not have a urinary catheter. The resident was asked if she had been involved in decisions about her daily care. She stated, "No." She stated, "They came in and took out my catheter that the doctor in Alabama put in, without talking to me." The resident stated she had an injury during childhood that had caused problems with her bladder and kidneys. She said she had talked with her primary care physician who had agreed to let her have a urinary catheter as long as it was changed periodically. The resident said the staff at the nursing home "came in and told me they were going to retrain my kidneys." She said she explained why she had the catheter and that she did not want it removed. She stated, "Before I knew it, they were taking it out and I couldn't stop them." Resident #87 was asked if the staff had talked to her about why they wanted to remove the catheter. She said staff had told her 'State' would not allow a resident to have a catheter without having a medical diagnosis, and they (the staff) said she did not have one. The resident said again she did not want the catheter removed. On 01/23/15 at 8:50 a.m., CNA (certified nurse aide) #1 was observed assisting the resident. She was asked if the resident previously had a urinary catheter. She stated, "Yes." CNA #1, said the resident had received bladder training and was now on a bowel and bladder program. The CNA was asked what they did for the resident since she was on the bowel and bladder program. She stated, "We are supposed to come in here every two hours, offer the bed pan, and tell her to call us to use the bathroom. CNA #1 was asked if she was able to toilet the resident every two hours. She stated, "Well." She was asked how often she came to the resident's room to toilet her. She stated, "About every three hours." CNA #1 was asked if the resident was incontinent of urine. The CNA stated, "Yes." CNA #1 was asked if the resident was upset about the catheter being removed. She stated, "Oh yes, and so was her son." She said after she (the resident) had a catheter so long, 'you would think it would be hard for the bladder to operate correctly.' On 01/23/15 at 9:30 a.m., the resident's family member was interviewed. The family member was asked if the resident had a urinary catheter in the past. He stated, "Yes." He said she had it when she came to the facility, but the facility had removed it. The facility reported she did not have a [DIAGNOSES REDACTED]. The family member reported he had informed the staff that neither he nor the resident had wanted the catheter removed. The family member said the resident had been incontinent of urine for many years and the catheter helped increase her quality of life. The family member said he had been told by staff the catheter must be removed due to state regulations. The family member said what he did not understand was the fact the facility left the catheter in for about 12 days of the resident's stay and then removed it. On 01/23/15, at approximately 10:30 a.m., the MDS (minimum data set) Coordinator was asked if the resident had a urinary catheter on admission. She stated, "Yes." She was asked if the facility had removed it. She stated, "Yes." She was asked why they had removed the catheter. She stated, "Well, it is protocol to do a bowel and bladder assessment to evaluate." She said the resident had no documented [DIAGNOSES REDACTED]. She said the catheter had been left in for a week to monitor intake and outputs and to do the assessment. The MDS Coordinator was asked if the resident had told her she wanted the catheter left in. She stated, "Yes." She was asked what she did after the resident told her she did not want the catheter removed. She stated, "I explained the protocol and regulations and went ahead and DC'd (discontinued) the Foley (urinary catheter)." She said the resident was placed on 'check and change.' She stated, "She (resident #87) was totally incontinent." The MDS Coordinator was asked if the family had expressed they did not want the catheter taken out. She stated, "Yes." The MDS Coordinator said the facility had been cited previously for having catheters without a diagnosis. She was asked if she had explained to the resident and family member the risks of leaving the catheter in and documented the education. She stated, "No."

Based on record review, observation and staff interview, it was determined the facility failed to provide appropriate steps to prevent reoccurrence of falls for two (#18 and #58) of four residents sampled for falls. This had the potential to affect 33 residents who had falls in the last three months per the assistant director of nursing. Findings: The facility's policy and procedure (P&P) for "Falls Prevention" documented the following: "It is the policy of this facility that all residents will have a Fall Risk Assessment performed on admit, readmit, and quarterly thereafter. Any resident scoring a "10" or greater will be placed on Fall Precautions. Fall Precautions will consist of placing a yellow star on the residents' door, wheelchair, etc. to alert staff of residents at risk. Chair alarms will be placed on all residents that have been reported as actually falling in the last 180 days. Low beds without rails will be provided for all residents at risk. Padding will be placed on floor beside bed of those residents who have actually fallen from bed in the last 180 days. Chair/bed alarms will be placed on all residents at risk. Batteries in alarms will be checked on each shift by charge nurse or designated CNA (certified nurse aide) for working order and replaced as needed. Physical Therapy and Restorative Nursing will be notified of falls and will head committee for falls prevention. Committee will meet at least once a month and as needed to devise a plan of care for those residents who have been reported as new or repeated falls." 1. A quarterly assessment, dated 10/15/14, for resident #58 documented the resident had severely impaired cognition, was continent of bowel and bladder, was not on a toileting program and had two falls with no injury since prior assessment. On 12/26/14, a 'Fall Risk' assessment was completed. The assessment identified the resident was disoriented, had 1 - 2 falls in the past 3 months, was ambulatory and incontinent, was legally blind, had a balance problem while standing or walking, had arthritis and osteoporosis. Her score was '18'. A total score above '10' represents 'HIGH RISK'. A quarterly assessment, dated 01/24/15, documented the resident had severely impaired cognition, was unsteady and only able to move on and off the toilet with staff assistance, was on a urinary toileting program, was occasionally incontinent of bowel and bladder, took an antidepressant everyday and had no falls. The current care plan for falls documented the following: "FALLS Problem: At Risk For Injuries From Falls Due To Recent History Of Falls Goal: Will not have a fall with injuries Approach: Monitor environment for wet spots or items placed below field of vision on the floor Assure that lighting is adequate Monitor for side effects from medications, labs, appetite as a cause for falls Call light close and answer promptly Monitor resident for steadiness and balance Instruct resident not to have any sudden position changes Encourage resident to call for assistance when ambulating Evaluate need for use of personal alarms to alert staff of unassisted rising Incontinence Toileting Problem: Alteration in Bladder Function Goal: Will be free of UTI (urinary tract infection) or breakdown due to incontinence Will be assessed for a toileting plan to enhance resident's ability to attain highest level of incontinence. Approach: ...Determine type of incontinence and place on toileting plan which best meets need... Occasional Episodes of Incontinence Problem: Prompt Voiding Goal: Improve quality of life... Approach: Monitor-asking @ (at) regular intervals if resident needs to void. Post toileting schedule where caregivers will see it.." The incident reports were reviewed. The following were incident reports regarding the resident's falls: An incident report (IR), dated 02/03/14 at 1:30 p.m., documented the resident's floor was wet of urine. The resident experienced no injury. Steps to prevent recurrence (STPR): Check more frequently for need of assistance. Resi (resident) is cognitively impaired with short term memory loss. Staff instructed to check more frequently. Instructed resident to request assist with transfers. An IR, dated 03/15/14, documented the resident fell but had no injury. STPR: Remind resident to use call light. An IR, dated 05/22/14 at 5:50 p.m., documented the resident fell with no injury. No STPR. An IR, dated 06/22/14 at 2:45 a.m., documented the resident slid off of bed and was tangled up in her covers. No STPR. An IR, dated 10/01/14 at 3:00 p.m., documented the resident's floor was wet and smelled of urine. "Brought her up front..cleaned the floor up and continue to monitor." An IR, dated 11/13/14 at 5:45 p.m., documented the resident was found on the floor lying between her recliner and her bed. She denies fall. "Said she made myself a pallet." No apparent injury. 'Confused.' STPR: Keep bed in lowest position bed/chair alarm on. An IR, dated 01/02/15 at 5:30 p.m.,documented the resident had a fall in her room with no injury. STPR was to put on a bed alarm along with non slip socks. Per the facility's fall P&P and the incident report on 01/02/15, the resident did not have a personal alarm put on her bed or her wheelchair. On 01/20/15 at 9:00 a.m., the resident was observed standing up by her bed. The resident had urinated all over the floor and was stepping in the pool of urine. She was attempting to pull off her wet adult brief. On 01/23/15 at 2:39 p.m., the DON (director of nursing) was interviewed. The DON was asked if she thought the incident reports had the appropriate steps to prevent further falls. The DON reported the resident was demented and she couldn't use the call light, so to remind the resident to use the call light was not an appropriate intervention. The DON was asked regarding the bed alarm on the resident. The DON reported she had never seen the resident with a bed alarm. She said it was an agency nurse who wrote the use of a bed alarm on the incident report. The DON was asked if the resident was on a toileting program. The incidents with the resident falling due to a wet floor could possibly be avoided with the resident being toileted every 1 - 2 hours while awake. The DON said the resident would get up to use the BSC (bedside commode) every 15 minutes to an hour. The DON was informed the surveyor had observed only one time from the first day of the survey to the present of the resident being toileted by a CNA (certified nurse aide). The DON said the resident had been closer to the nurses' station previously, but the family had wanted the resident to move down to the end of the hall she was on now. The DON said she was trying to locate the musical alarms other homes are placing on residents. 2. The physician's orders [REDACTED]. An incident report, dated 04/08/14 at 7:00 p.m., documented, "Resident sitting on buttocks in front of recliner, went to get out of recliner and slipped down in floor. No harm. STPR (steps to prevent reoccurrence) anticipate needs, request assistance, place call light in reach in room. An incident report, dated 04/29/14 at 2:00 p.m., documented, "Resident standing in the hall with walker talking. Lost her balance and fell on her right side. No apparent injury noted. Assisted resident up and back into her room to recliner. Family and Dr notified. STPR: Anticipate needs, reinforce instructing resident to ask for assistance." An incident report, dated 07/11/14 at 1:30 a.m., documented, "Found resident in floor up going to bathroom & fell on her buttocks, no apparent injury noted. STPR: Resident encouraged to use call light for assistance. Verbalized understanding." On 09/09/14, a care plan, documented: "Problem: At risk for falls due to recent history of falls. Interventions: ... keep call light close and answer promptly...Instruct resident not to have any sudden position changes. Encourage resident to call for assistance when ambulating. Evaluate need for use of personal alarms to alert staff of unassisted rising." An incident report, dated 10/21/14 at 6:00 p.m., documented, "Resident with constant yelling out, on her light. Demanding 02 (oxygen) checked, fan turned on, off, fan repositioned, water refilled, wheelchair moved over, and extra blanket. Wanting staff to stay in her room. CNA (name deleted) helped her with all this. Walked out of the room. She turned her light on. CNA went to another room. Within minutes she started yelling 'I'm in the floor' I came to her room and she was sitting on her bottom between her recliner and her wheelchair. Almost in the hallway. No injury. Moves all extremities. Said she was getting in her wheelchair. Call light was within reach. STPR: Bring her to nurses station when she is attention seeking." An incident report, dated 11/10/14 at 8:40 a.m., documented, "Resident noted sitting in floor on buttocks leaning back against her bed stated, 'I slipped off bedside commode by herself. Moves all four extremities within normal limits no s/s (signs or symptoms) of pain or distress. Resident assist to feet per CNA placed in W/C (wheelchair) tolerated well. STPR: Encourage resident to request assistance with needs before leaving room make sure call light is in reach." An incident report, dated 11/20/14 at 1:00 p.m., documented, "Resident in the floor in her room by her BSC...resident denies pain at this time MAEW (moves all extremities well). STPR: Anticipate resident needs remind resident to use her call light." A quarterly assessment, dated 12/11/14, documented, the resident had severely impaired cognition, required extensive assistance with bed mobility, transferring between surfaces, walking, dressing, toilet use and bathing. On 01/21/15 at 10:00 a.m., the resident was observed setting in a chair across from the nurses' station. The resident was talking to the staff. On 01/26/15 at 7:36 a.m., the resident was observed up in a recliner by the nurses' station eating breakfast. On 01/27/15 at 1:08 p.m., the DON (Director of Nursing) was interviewed. The DON was asked if the resident was cognitively able to remember to use her call light and remember instructions. The DON reported the resident could not remember to use the call light, that her memory had declined in the last three months. The incident reports were reviewed with the DON. She stated, "We are fixing to revise the system with falls and incident reports."

Based on record review, observation and staff interview, it was determined the facility failed to ensure the physician was notified when a change in the status of a pressure sore occurred and when the development of new pressure sores had been identified, for three (#2, 4 and #7) of five sampled residents identified with pressure sores. This had the potential to affect 4 residents identified by the DON as being bedfast all or most of time and 30 residents identified as being in a chair all or most of time. This deficiency was cited as actual harm due to the delay in obtaining a treatment and a decline in the status of wounds for residents #2 and #4. Findings: 1. Resident #4's significant change assessment, dated 07/05/11, documented the resident required total assistance of 2+ staff for bed mobility, hygiene/bathing, and was at risk of developing pressure sores. The resident's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]." A care plan, dated 07/17/11, documented the resident had a skin integrity problem with a goal for the resident's skin to remain intact. The approaches included skin assessments to be done 2 x weekly, turn & reposition Q 2 HRS, place a pillow between her legs & behind her back when lying on side, use a turn sheet to reposition the resident in bed and report any red or open areas..." On 07/25/11, the two areas on the right buttocks & the coccyx were documented on a skin assessment sheet as being closed. On 08/03/11, a skin assessment documented: "(R) cheek of buttock Stage II 3 cm x 5 cm Color: Red Surrounding tissue: Pink" This pressure sore was in-house acquired. There was no documentation the physician had been notified of the new pressure sore and no treatment had been obtained. Five days later, on 08/08/11, a skin assessment documented: "Coccyx Stage II 3.5 cm x 5 cm Color: Red/pink Surrounding Tissue: Pink The pressure sore was in-house acquired. The physician had not been notified of the newly opened coccyx area and a treatment had not been obtained. The August 2011, physician's orders [REDACTED]. A physician's orders [REDACTED]. Do tx TID until resolved." On 08/15/11, a skin assessment documented: "(L) Buttock Stage II 5 cm x 5 cm Color: Red Surrounding Tissue: Red (R) ^ Buttocks Stage II 3 cm x 2 cm Color: Red Surrounding Tissue: Red" A skin assessment had been due on the 15th, for the Stage II pressure sore on the resident's coccyx found on 08/08/11. There was no assessment completed for the coccyx pressure sore until 08/29/11, 21 days later as follows: "Coccyx Stage II 4 cm x 2 cm Color: Pink - red Drainage: Serous Surrounding Tissue: Pink-red" On 09/03/11, the resident was admitted to the hospital with [REDACTED]. A physician's hospital progress note, dated 09/10/11, documented, "...has decubitus on her buttocks..." On 09/15/11, the resident was readmitted to the nursing facility with orders to continue medications & TXs. On 09/15/11, a re-admit skin assessment documented, "Buttocks with 2 small abrasive areas noted. Has TX in LPN book..." The areas were not measured. A nurse's note, dated 09/15/11 at 1:35 p.m., documented, "...Open area to coccyx.." The area had not been assessed and measured. The September 2011, treatment sheet documented, "Cleanse wound on left buttocks with Normal Saline, pat dry, apply thin layer of Silver Hydrogel, then Collagen, cover with ABD pad daily @ 2100 and as needed for soiled or displaced." On 09/21/11, a physician's orders [REDACTED]. Do TX q shift until resolved..." On 09/26/11, 11 days since she had been readmitted to the facility, the first skin assessment with measurements documented: "(R) buttocks, Stage: III, 11 cm X 6 cm, Color: Red c yellow center, Drainage: Red mod amt, Surrounding Skin: Red; (possibly meant coccyx) (L) buttocks, Stage: II, 5 cm X 5 cm, Color: Red, Drainage: Red sml amt; Top (R) ear lobe, Stage II, 1 cm X 1 cm, Color: Red, Drainage: Red sml amt, Surrounding Skin: Red" The pressure sore on the resident's ear was in-house acquired. A quarterly assessment, dated 09/27/11, documented the resident had two Stage II's and one Stage III pressure sore. On 09/27/11, a telephone physician's orders [REDACTED]. Cleanse open wnd (wound) area top of (R) ear lobe c N/S, pat dry. Apply TAO, cover c sml (small) piece of 4X4 q shift until resolved." On 09/27/11, the resident was admitted to the hospital with [REDACTED]. On 10/04/11, the resident was readmitted back to the nursing home. A re-admission skin assessment, was completed at that time and documented: "(R) ear Stage II .75 cm x .75 cm x .5 cm Color: Red/scab Surrounding skin: Red [DIAGNOSES REDACTED]: yes Coccyx Stage III 4 cm x 2 cm x 1 cm Color: yellow Drainage: scant [MEDICAL CONDITION]: some [DIAGNOSES REDACTED]: yes admitted back from (Name of hospital deleted). Skin assessment reveals Stg III to coccyx c Stg II to surrounding tissue - Tx in place, Will continue & request wound consult." On 10/04/11, a discharge note from the hospital documented, "Discharge to Long term care. [MEDICATION NAME] 250 mg 1 PO twice a day x 7 days...Coccyx wound care Cleanse with NaCL 0.9% [MEDICATION NAME] AG to wound bed and secure c Island dressing." On 10/04/11, the October 2011, treatment sheet documented, "Cleanse buttocks with Normal Saline, apply Santyl to wound bed, cover with Foam dressing every shift until resolved." On 10/07/11, a skin assessment was completed for the coccyx. The nurse documented, "Unstageable. 3.50 cm x 4.00 cm x UTD (unable to determined) drainage - [MEDICAL CONDITION]. On 10/14/11, the October 2011, treatment sheet documented a change in the treatment, "Cleanse coccyx c NS, pat dry, apply thin layer of Santyl then apply Hydrogel gauze, cover with Bordered Foam daily @ HS." A physician's signed order could not be located for the above changed treatment. The treatment was started on 10/14/11. On 10/17/11, a nurse's note documented, "N/O to culture (R) ear and coccyx." On 10/17/11, a skin assessment documented: "Coccyx Stage: III 3 cm x 7 cm Color: red, pink Drainage: Scant" The coccyx had enlarged from 3.50 x 4.00 - UTD measured on the 7th to 3 cm x 7 cm measured on the 17th. The (R) ear had not been assessed since 10/04/11. On 10/18/11, a culture was obtained from the resident's (R) ear. The results were positive [MEDICAL CONDITION]. A culture was also obtained from the resident's buttocks. The results were positive [MEDICAL CONDITION]. On 10/21/11, a physician's telephone order documented, "Bactrim DS 1 PO BID X 10 days/MRSA wound. Cleanse (R) ear & buttocks with [MEDICATION NAME]. Apply [MEDICATION NAME] to (R) ear, may cover with Band-Aid or LOTA (leave open to air). Do TX to (R) ear q shift." There was no treatment obtained for the (R) ear pressure sore until 10/21/11. On 10/21/11, the October 2011, treatment sheet documented, "Cleanse buttocks & coccyx with [MEDICATION NAME] before above TX." The treatment was started on 10/21/11. A physician's signed order could not be located for the above changed treatment. On 10/28/11, at 3:00 p.m., the DON was asked when the physician should be notified on changes to the residents' skin conditions. She said the physician should be notified with new pressure sores or a decline in pressure sores. She stated there is a communication book for the staff to write down their concerns for the physician to read when he comes to the facility. 2. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. DX: Excoriation" The care plan, dated 09/26/11, documented, "Skin Integrity Impaired R/T Unstageable Pressure Ulcer to Coccyx: Approach: Cleanse bilateral buttocks with warm soapy water, rinse, pat dry, apply [MEDICATION NAME], then thin layer of [MEDICATION NAME] ointment every shift & as needed. DX: Excoriation Skin assessments 2x/weekly, Turn & reposition Q 2 hours. Pillow between legs & behind back when lying on side. Pressure relieving device to bed/chair as needed. Report any red or open areas...." An admission evaluation assessment, dated 09/26/11, documented, "Abrasion to buttocks, white areas which peel off with cleansing leaving dark pink areas open..." A nurse's note, dated 09/26/11, documented, "Resident very non-compliant...Has about a 3 cm x 3 cm area to coccyx. [MEDICATION NAME] applied." A nurse's note, dated 09/27/11 at 2:30 a.m., documented, "Buttocks & to mid-posterior thighs are purplish with excoriation. Open areas to upper buttocks and coccyx....Placed blue chux beneath LUE d/t weeping clear serous fluid. 0.5 cm blisters x 2 observed to posterior LUE. Scabbed excoriation observed to stump of LLE." The admit skin assessment, dated 09/27/11, documented, "... Red raw area to buttocks, [MEDICAL CONDITION] to left arm and hand, numerous scratches, scabs and abrasions to upper extremities. Skin very dry. Unstageable thick ulcer with slough to buttocks. Pink open areas to buttocks." No ulcer measurements documented on the assessment sheet. There was no documentation the physician had been notified about the LUE weeping blisters, excoriation to stump of LLE or about the slough in unstageable ulcer. A nurse's note, dated 09/28/11 at 1:00 a.m., documented, "Several small scabbed areas noted to BUE c [MEDICAL CONDITION] and serous drainage noted to LUE. 15 cm x 10 cm Stg II to coccyx and buttocks. Tx in progress c large amount of excoriation to entire buttocks and upper thighs. There was no documentation the physician had been notified about the [MEDICAL CONDITION] and serous drainage to LUE or about the increase in size of the pressure ulcer. A nurse's note, dated 09/29/11, at 1:30 a.m., documented, "...Tx to stg II to coccyx and excoriated areas done as per orders. A nurse's note, dated 09/30/11, at 8:00 a.m., documented, "...Stage II to (L) buttock is now dark brown almost black in color and larger." A skin assessment, dated 09/30/11, documented, "Wound #1 Location - R buttock/coccyx (Picture on assessment showing left buttock/coccyx) Stage - II Length - 6 cm Width - 6 cm Depth - epidermis Color - black to center Drainage - scant yellowish/serous Odor - ------ Surrounding Tissue - Excoriated/open [MEDICAL CONDITION] - no [DIAGNOSES REDACTED] - yes ...Buttocks c redness/purplish open areas. Lg area of black eschar to R buttock /lower coccyx. Tx in progress. 2 scabbed areas to L stump. 1- 1 cm reddish scab. 1- 1 cm yellowish scab." There was no documentation the physician had been notified about the yellow scab on stump or about the increase in size and change of color of the pressure ulcer on the coccyx. A nurse's note, dated 10/01/11, at 2:00 a.m., documented, "Pressure ulcer approx. 6 cm x 6 cm black area surrounded by reddish/purplish excoriation/open areas." There was no documentation the physician had been notified about the increase the size of the pressure ulcer. The initial assessment, dated 10/03/11, documented the resident was moderately cognitively impaired and had one unstageable pressure ulcer on admission. A physician's orders [REDACTED]. DX: Pressure ulcer" A new treatment was initiated for coccyx on 10/04/11. The ulcer was first documented with slough on 09/27/11. Eschar was was documented on 09/30/11. A nurse's note, dated 10/05/11, at 9:00 a.m., documented, "...Dressing to buttock changed, foul smelling yellowish blood drainage noted." A nurse's note, dated 10/05/11, at 3:00 p.m., documented, "Resident not eating very much. [MEDICATION NAME] was 4.3 - Dr. (name deleted) notified." (The [MEDICATION NAME] reference range is 21-43 mg/dl.) "Refusing to stay off decubitus buttocks. Drsg to buttocks changed - foul smelling bloody yellow drainage noted LG amount. No documentation could be located to show the physician had been notified about the foul smelling yellowish drainage. A nurse's note, dated 10/06/11, documented, "...Refuses to stay off sore on buttocks - Drsg to buttocks changed, foul smelling bloody yellow drainage noted LG amount. A wound care evaluation, by wound consultant, dated 10/07/11, documented, "Wound #1 Date Onset 9/8/2011 Assessment Date - 10/7/2011 Exudate - Min Thickness - Full Thickness Etiology - Pressure - Unstageable Size (L x W cm.) - 10.00 x 12.20 Depth - utd .......... Drainage Consistency - [MEDICAL CONDITION] Acquisition - Hospital Acquired Wound Bed: 80% thick tan adherent necrotic tissue. 20% thin moist yellow adherent slough. Periwound: Fragile, [DIAGNOSES REDACTED] Clinical Rationale/Wound Comments: Daily Santyl will enzymatically debride necrotic tissue. Hydrogel will promote a moist wound environment. Foam will promote thermal regulation as well as provide cushion to pressure sensitive area. Daily dressing changes required due to frequent incontinent episodes compromising dressing integrity in less than a 24 hour time frame. Treatment Intervention: Clean area with NS/Wound cleanser. Apply thin layer of Santyl. Apply Hydrogel gauze. Cover with Bordered Foam. Treatment to be performed daily... A skin assessment, dated 10/07/11, documented, "Wound #1 Location - L and slightly center L buttocks Stage - III Length - 6.5 cm Width - 5 cm Depth - multiple layers of epidermis/dermis Color - Black Drainage - Small amount serous/greenish Odor - -------------- Surrounding Tissue - red [MEDICAL CONDITION] - mild [DIAGNOSES REDACTED] - check mark" "Wound #2 Location - R buttock and slightly center Stage - II Length - 3 cm Width - 3 cm Depth - subdermal Color - Lt. cream/flesh Drainage - scant serous Odor - -------- Surrounding Tissue - red [MEDICAL CONDITION] - trace [DIAGNOSES REDACTED] - ---------" 1.5 cm x 1 cm scabbed area to bottom of stump" (picture showed left stump) There was no documentation the physician had been notified about the area on the (L) stump. The area had increased from 1.0 cm on 9/30/11 to 1.5 cm on 10/07/11. A nurse's note, dated 10/10/11, at 3:00 p.m., documented, "...Area to buttocks with no improvement noted...." A physicians order, dated 10/11/11, documented, "N/O to culture areas to buttocks - DX: brown foul drainage" A nurse's note, dated 10/12/11, documented, "...Scabbed area to L stump appears infected @ this X AEB greenish exudate of scant amount, moist appearing scab c 0.03 cm red surrounding tissue. Cleansed c NS, patted dry. Awaiting N/O." A physicians order, dated 10/12/11, documented, "Cleanse affected area to LLE c NS, pat dry, apply TAO, cover c folded 4 x 4 , secure c [MEDICATION NAME] tape daily and as needed for displacement until resolved - DX: Lesion The order to treat the area on the left stump was received 12 days later after it was originally seen on 09/30/11, as a yellowish scab. A nurse's note, dated 10/13/11, at 2:00 p.m., documented, "...Wound to buttocks has deteriorated..." A nurse's note, dated 10/14/11, at 5:15 p.m., documented, "N/O received from Dr. (name deleted) per wd consultant recommendation for wd care to sacrum." A skin assessment, dated 10/14/11, documented, "Wound #1 and #2 Location - R Buttocks/coccyx (picture shows left buttock/coccyx area) Stage - II Length - 6" (6 inches = 15 cm) Width - 5" (5 inches = 12.5 cm) Depth - 1/4 cm Color - white, brown, eschar Drainage - small amount Odor - foul Surrounding Tissue - ....red" "Wound #3 x 2 (New area) Location - L Buttocks Stage - I (should be Stage II) Length - round 1" (1 inch = 2.5 cm) Depth - ------- Color - white, brown Drainage - small amount Odor - -------- Surrounding tissue - red c white..." There was no documentation the physician had been notified about the two new pressure ulcers. A nursing note, dated 10/19/11, documented, "Large amount of foul smelling greenish yellow blood drainage noted on old dressing. Culture on wound came back negative.' There was no documentation the physician had been notified about the foul smelling greenish yellow drainage of coccyx ulcer. A nursing note, dated 10/20/11, documented, " Drsg to LLE changed. scant amount of yellowish drainage noted. Cleansed c NS - TAO applied - covered c foam - Drsg to sacrum changed Large amount of greenish yellow foul smelling drainage noted....." A skin assessment, dated 10/21/11, documented, "Wound #1 Location - Coccyx/L Buttock Stage - II Length - 5" (5 inches = 12.5 cm) Width - 3" (3 inches = 7.5 cm) Depth - 1" (1 inch = 2.5 cm) Color - off white/off green Drainage - small Odor - foul Surrounding Tissue - ...red & pink" "Wound #2 Location - R cheek Stage - I Length - 1 cm round Width - round Depth - surface Color - off white Drainage - -------- Odor - ----------- Surrounding Tissue - red, pink" "Wound #3 Location - R cheek Stage - I Length - 1 cm round Width - round Depth - surface Color - off white Drainage - -------- Odor - ----------- Surrounding Tissue - red, pink" There was no documentation of the physician being notified about the foul smelling white/green drainage of wound #1. On 10/28/11, at 2:13 p.m., LPN #1 was asked about the resident's weeping blisters and why the physician had not been notified. She stated, "He had weeping [MEDICAL CONDITION] in that arm but didn't notice any blisters." She said she didn't notify the physician and it cleared up in a few days. On 10/28/11, at 2:14 p.m., LPN #1 was asked if she notified the physician about changes in the resident's skin. She stated, "I don't call on new stage II ulcers. We just used the same treatment on the new ones as we did on the others." On 10/28/11, at 3:00 p.m., the DON was asked when the physician should be notified of changes to residents' skin. She said the physician should be notified with changes to the skin including new wounds, changes with wounds and blisters. She stated there is a communication book for the staff to write down their concerns for the physician to read. The DON was asked to bring book to the surveyor. She came back and said there was nothing written about the resident. 3. Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan, dated 09/21/11, documented, "Problem: Skin integrity, impaired: potential... Approach: Skin assessments 2 x/weekly..." A nursing assessment, dated 09/21/11, contained a diagram of the human body. The body contained a mark on the right buttock. Physician hospice orders, dated 09/26/11, documented: "[MEDICATION NAME] Butt Paste, [MEDICATION NAME] or [MEDICATION NAME] to reddened areas as needed... Follow (Name deleted) Home Health and Hospice Wound Care Protocol..." The resident's medical record did not contain orders for hospice wound care. An admission assessment, dated 09/28/11, documented the resident was totally dependent on staff for bed mobility, transferring between surfaces, had an indwelling urinary catheter, was incontinent of bowel and did not have a pressure sore, but was at risk for developing a pressure sore. A hospice note, dated 10/05/11, documented: "...Stage I area noted not open but purple/blue in color on (R) buttock with Stage II area noted coccyx area. Pt cleaned et [MEDICATION NAME] applied liberally. Repositioned on side et nursing home staff notified et instructed to turn q 2 hrs..." The physician was never notified regarding the Stage II pressure sore. A skin assessment, dated 10/17/11, documented, "...Wound #3- (R) buttocks, Stage II, length 2 cm, width 1 cm, depth Stg II, color: red, drainage: red, surrounding tissue: red. Wound #4- (L) buttocks, Stage II, length 2 cm, width 1 cm, depth: Stg II, color: red, drainage: red, surrounding tissue: red...Tx's in progress. Res. refused skin assessment to peri area. Doesn't want to turn et does refuse to be turned on side to side. States I'm not going to be around long enough for this. States has more raised lymph nodes." A skin assessment, dated 10/24/11, documented, "Nurse's notes: Resident with large red black tumor under (R) arm. Buttocks pink in color. Resident can not lay on his sides do to pain [MEDICAL CONDITION]. Tiny pink area to buttocks with top layer of skin off. Area resolving..." The skin assessment contained a picture of a human figure. On the figure a mark had been placed on the coccyx and stated, "Stage II, buttocks..." On 10/25/11 at 5:20 p.m., LPN #2 was asked to assess the resident's skin. An open area was observed on the resident's right buttocks. The LPN measured the area and reported it to be a Stage II and measured 1 X 0.5 cm. The LPN was then asked if she provided a treatment for [REDACTED]. A nurse's note, dated 10/25/11 at 6:30 p.m., documented, "N/O (new order) for [MEDICATION NAME] to (R) buttocks- Dx Stage II." On 10/26/11 at 10:00 a.m., LPN #1 was interviewed. The LPN had been the nurse that had completed the skin assessment on 10/17/11, when she had identified a Stage II pressure sore on the resident's buttock. She was asked if the physician had been notified of the skin issues for the resident. The LPN stated, "No, I didn't call the doctor." On 10/31/11 at 3:00 p.m., the DON was interviewed. She was asked who should have contacted the physician about the Stage II pressure sore. She reported the nurse that did the skin assessment. The DON reported the physician came to the facility every couple of days, so they usually documented it in a communication book for him to review. At 4:00 p.m., the DON reported she had reviewed the communication book and it did not contain documentation related to the resident having a Stage II pressure sore on his buttocks.

Based on record review, observation and staff interview, it was determined the facility failed to: a) Ensure a pressure ulcer treatment was completed without cross contamination for two pressure sores, which had increased in size for one (#5) of five sampled residents with pressure sores. This had the potential to affect four residents identified by the DON, as having pressure sores. b) Ensure pressure sores were assessed weekly for improvement or decline, per the facility policy for three (#4, 5 and #11) of five sampled residents with pressure sores. This had the potential to affect four residents identified by the DON as having pressure sores. c) Ensure the physician was notified and a treatment obtained for pressure sores for two (#2 and #7) of five residents sampled with pressure sores. This had the potential to affect four residents, identified by the DON as having pressure sores. d) Ensure accurate pressure sore assessments were completed for two (#2 and #5) of five sampled residents with pressure sores. This had the potential to affect four residents identified by the DON, as having pressure sores. This deficiency resulted in actual harm for residents #2, #4 and #5. Findings: The facility's policy and procedure for 'Skin/Wound Protocol' documented: "Policy Interpretation and Implementation. Skin Risk Assessments will be implemented on admission, following a hospitalization and/or extended leave of absence of all residents. All residents will be assessed two times weekly and results documented. A physicians order will be obtained for treatment as indicated. The IDT (Interdisciplinary team) will monitor quarterly of increased pressure ulcer and any skin risk issues for all residents, and a Braden Scale tool will be completed by an RN or LPN. All skin and wound changes will be care planned. CMA may do minor skin treatments (i.e. skin tears abrasions, excoriations, etc.) Any treatment Stage III or IV decubs, infected wounds, recent surgical wounds, and/or wounds declining in status would be administered by an LPN or RN. The CMA may assist with the treatment as necessary. Consult with the Dietician prn regarding if skin impairment not showing improvement. Perineal care will be provided by CNA, CMA, and LPN for all residents on a daily basis. Those residents at risk (incontinent of Bowel and/or Bladder) will be cleansed with a vinegar/water solution after each incontinent episode and Vaseline will be applied as a moisture barrier to prevent skin break down." 1. Resident #4's significant change assessment, dated 07/05/11, documented the resident required total assistance of 2+ staff for bed mobility, hygiene/bathing, and was at risk of developing pressure sores. A physician's orders [REDACTED]." A care plan, dated 07/17/11, documented the resident had a skin integrity problem with a goal for the resident's skin to remain intact. The approaches included skin assessments to be done 2 x weekly, turn & reposition Q 2 HRS, place a pillow between her legs & behind her back when lying on side, use a turn sheet to reposition the resident in bed and report any red or open areas..." On 07/25/11, the two areas on the right buttocks & the coccyx were documented on a skin assessment sheet as being closed. On 08/03/11, a skin assessment documented: "(R) cheek of buttock Stage II 3 cm x 5 cm Color: Red Surrounding tissue: Pink" This pressure sore was in-house acquired. There was no documentation the physician had been notified of the new pressure sore and no treatment had been obtained. Five days later, on 08/08/11, a skin assessment documented: "Coccyx Stage II 3.5 cm x 5 cm Color: Red/pink Surrounding Tissue: Pink The pressure sore was in-house acquired. The physician had not been notified of the newly opened coccyx area and a treatment had not been obtained. The August 2011, physician's orders [REDACTED]. On 08/10/11, a Braden Scale had scored the resident a '6' which meant the resident was at a high risk for pressure sores. On 08/10/11, a weekly skin assessment was due for the Stage II pressure sore on the (R) buttock found on 08/03/11. The assessment had not been completed. A physician's orders [REDACTED]. Do tx TID until resolved." On 08/15/11, a skin assessment documented: "(L) Buttock Stage II 5 cm x 5 cm Color: Red Surrounding Tissue: Red (R) ^ Buttocks Stage II 3 cm x 2 cm Color: Red Surrounding Tissue: Red" A skin assessment was due on the 15th, for the stage II pressure sore on the resident's coccyx found on 08/08/11. There was no assessment completed for the coccyx pressure sore until 08/29/11, 21 days later which documented: "Coccyx Stage II 4 cm x 2 cm Color: Pink - red Drainage: Serous Surrounding Tissue: Pink-red" The coccyx pressure sore had enlarged in width from 3.5 cm to 4cm. A pressure sore assessment had been due again on 08/22/11, for the (L) and (R) buttocks pressure sores identified on 08/15/11. No assessment had been completed. On 08/24/11, a physician's orders [REDACTED]. Decreased appetite/wound. Do [MEDICATION NAME] level in 1 month/wound, decreased appetite." A pressure sore assessment had been due again on 08/29/11, for the (L) and (R) buttocks pressure sores. No assessment had been completed except for the pressure sore on the resident's coccyx area. On 09/03/11, the resident was admitted to the hospital with [REDACTED]. A physician's hospital progress note, dated 09/10/11, documented, "...has decubitus on her buttocks..." On 09/15/11, the resident was readmitted to the nursing facility with orders to continue medications & TXs. On 09/15/11, a re-admit skin assessment documented, "Buttocks with 2 small abrasive areas noted. Has TX in LPN book..." The areas were not measured. A nurse's note, dated 09/15/11, at 1:35 p.m., documented, "...Open area to coccyx.." The area had not been assessed and measured. The September 2011, treatment sheet documented, "Cleanse wound on left buttocks with Normal Saline, pat dry, apply thin layer of Silver Hydrogel, then Collagen, cover with ABD pad daily @ 2100 and as needed for soiled or displaced." The treatment for [REDACTED]. The resident returned from the hospital on [DATE]. The treatment had not been initialed as done on the 19th and the 20th. On 09/19/11, a Braden Scale scored the resident a '6' which meant the resident was at a high risk for pressure sores. On 09/21/11, a physician's orders [REDACTED]. Do TX q shift until resolved..." On 09/22/11, another skin assessment was due for the areas found on the buttocks on 09/15/11, and the coccyx area. No assessments were completed. These pressure sores had not been measured since the resident returned from the hospital on [DATE]. On 09/23/11, a [MEDICATION NAME] laboratory test was drawn as ordered by the physician. The test result was 17.7 mg/dl. Reference range for females was 17-34 mg/dl. On 09/26/11, 11 days since she had been readmitted to the facility, the first skin assessment including measurements was completed, and documented: "(R) buttocks, Stage: III, 11 cm X 6 cm, Color: Red c yellow center, Drainage: Red mod amt, Surrounding Skin: Red; (possibly meant coccyx) (L) buttocks, Stage: II, 5 cm X 5 cm, Color: Red, Drainage: Red sml amt; Top (R) ear lobe, Stage II, 1 cm X 1 cm, Color: Red, Drainage: Red sml amt, Surrounding Skin: Red" On 09/27/11, a telephone physician's orders [REDACTED]. Cleanse open wnd (wound) area top of (R) ear lobe c N/S, pat dry. Apply TAO, cover c sml (small) piece of 4X4 q shift until resolved." The pressure sore on the resident's ear was in-house acquired. The treatment had not been initialed as completed on the 26th or the 27th. There was no documentation in the nurses' notes the treatment had been completed on the 26th and the 27th. A quarterly assessment dated [DATE], documented the resident had two Stage II pressure sores and one Stage III pressure sore. On 09/27/11, the resident was admitted to the hospital with [REDACTED]. On 10/04/11, the resident was readmitted back to the nursing home. A re-admission skin assessment, was completed at that time and documented: "(R) ear Stage II .75 cm x .75 cm x .5 cm Color: Red/scab Surrounding skin: Red [DIAGNOSES REDACTED]: yes Coccyx Stage III 4 cm x 2 cm x 1 cm Color: yellow Drainage: scant [MEDICAL CONDITION]: some [DIAGNOSES REDACTED]: yes admitted back from (Name of hospital deleted). Skin assessment reveals Stg III to coccyx c Stg II to surrounding tissue - Tx in place, Will continue & request wound consult." On 10/04/11, a discharge note from the hospital documented, "Discharge to Long term care. [MEDICATION NAME] 250 mg 1 PO twice a day x 7 days...Coccyx wound care Cleanse with NaCL 0.9% [MEDICATION NAME] AG to wound bed and secure c Island dressing." On 10/04/11, the October 2011, treatment sheet documented, "Cleanse buttocks with Normal Saline, apply Santyl to wound bed, cover with Foam dressing every shift until resolved." The October 2011, physician's orders [REDACTED]. [MEDICATION NAME] Dissolve one packet in 6oz juice or water and give PO bid Dx pressure ulcer, Healthy Shot with Double protein mixed with 120cc juice or milk bid." On 10/05/11, a Braden Scale scored the resident a '6' which meant the resident was a high risk for pressure sores. On 10/07/11, a skin assessment was completed for the coccyx. The nurse documented, "Unstageable. 3.50 cm x 4.00 cm x UTD (unable to determine) drainage - [MEDICAL CONDITION]. On 10/14/11, the October 2011, treatment sheet documented a change in the treatment, "Cleanse coccyx c NS, pat dry, apply thin layer of Santyl then apply Hydrogel gauze, cover with Bordered Foam daily @ HS." A physician's signed order could not be located for the above treatment change. The treatment was started on 10/14/11. On 10/17/11, a nurse's note documented, "N/O to culture (R) ear and coccyx." On 10/17/11, a skin assessment documented: "Coccyx Stage: III 3 cm x 7 cm Color: red, pink Drainage: Scant" The coccyx had enlarged from 3.50 x 4.00 - UTD and measured on the 7th, to 3 cm x 7 cm measured on the 17th. On 10/18/11, a culture was obtained from the resident's (R) ear and buttocks. Both of the cultures were positive [MEDICAL CONDITION]. On 10/21/11, a physician's telephone order documented, "Bactrim DS 1 PO BID X 10 days/MRSA wound. Cleanse (R) ear & buttocks with [MEDICATION NAME]. Apply [MEDICATION NAME] to (R) ear, may cover with Band-Aid or LOTA (leave open to air). Do TX to (R) ear q shift." On 10/21/11, the October 2011, treatment sheet documented, "Cleanse buttocks & coccyx with [MEDICATION NAME] before above TX." The treatment was started on 10/21/11. A physician's signed order could not be located for the treatment change. A nurse's note, dated 10/22/11, at 11:00 p.m., documented, "...Resident continues on Bactrim DS for DX:[MEDICAL CONDITION] to wnd (wound) - Rt ear...Wound to rt buttock c good debridement results noted c decrease in necrotic tissue et eschar noted..." On 10/24/11, at 5:00 a.m., a nurse's note documented, "...Wound to (R) ear 1 cm X 0.4 cm. Dark pink to outer edges c yellowish to center. 0 drainage observed at this x..." The ear had not been assessed since 10/04/11, and had increased in size from .75 x .75 x .5 to 1 cm x 0.4 cm (depth not measured). A skin assessment for the coccyx pressure sore was due on the 24th. No assessment had been completed. On 10/24/11, at 10:10 a.m., LPN #3 was observed performing pressure sore treatment to the resident's (R) ear which had been cultured [MEDICAL CONDITION]. The pressure sore was identified as a Stage II. The wound nurse did not wash her hands before or after the treatment. The LPN used her bare hands to handle the ear cultured [MEDICAL CONDITION] and then handled the other ear without washing her hands. After the treatment, the DON was asked for the current assessment for the pressure sores. She was unable to locate any for the 24th. She said she would check with the nurses who did the assessments. On 10/25/11, at 5:35 p.m., LPN #5 was observed performing pressure sore treatment to the resident's coccyx which [MEDICAL CONDITION]. The pressure sore was a Stage III. A newly opened area was observed to the (R) buttock area. After the pressure sore treatment had been completed, the LPN was asked when an assessment of the pressure sores would be completed. She said she did not know. On 10/25/11, at 8:00 p.m., a nurse's note documented, "Res. noted c open wd to (R) cheek of buttocks. Dr. (Name deleted) notified. N/O received et noted..." On 10/26/11, the pressure sore assessments had been completed and given to the surveyor. The assessments documented: Dated 10/25/11, a skin assessment documented: "Top of (R) ear Stage II 1/2 cm x 1/2 cm Color: Red Drainage: Red (MRSA) (R) outer ear lobe Stage II 1 cm x 1/4 cm (NEW) Color: Red Drainage: Red Coccyx Stage III 3 cm x 7 cm Color: Yellow Drainage: Serous (MRSA) (R) cheek (Buttock) Stage II 1 cm x 1 cm Color: Red (MRSA) Buttocks Stage II (MRSA) 3 cm x 2 cm Color: Red" The care plan had not been updated since 07/17/11, to address all of the resident's pressure sores and interventions. On 10/26/11, at 4:00 p.m., LPN #7 was asked who was responsible for assessing the residents' pressure sores. The LPN said the nurses on the floor were to assess the pressure sores at least every week, then the CNAs were to inspect the skin every week during a shower. They should let a nurse know if there was a problem. On 10/26/11, at 4:05 p.m., LPN #2 was interviewed. She was one of the nurses assigned to measure the resident's pressure sores. The LPN was asked how she knew which resident she was to assess. The LPN said there was a monthly calendar for the nurses to go by, so they could see who they were to assess each week. The LPN was then asked if she always assessed the pressure sores when she was assigned to do so. She said the last time she had just looked at the resident's ear and put the medicine on it. She stated, "I did not measure it." On 10/31/11, at 10:30 a.m., the DON was informed of the lack of pressure sore assessments and the lack of physician ordered treatments being used to treat the pressure sores. The DON was informed of the pressure sore information that had been obtained. She said they (the nurses) know what to do. They know to contact the physician and get orders to treat any opened area. The 'Skin Risk Assessments' were not implemented following a hospitalization . The resident was not assessed two times weekly. The pressure sore changes were not care planned and the physician was not notified when a pressure sore worsened or when a new one was identified. 2. Resident #5 was admitted on [DATE], with [DIAGNOSES REDACTED]. An admission assessment, dated 06/20/11, documented the resident was cognitively intact, required set up assist with eating, extensive assist with dressing, hygiene and bathing and was continent of bowel. The resident's care plan, dated 06/13/11, documented: "Problem: Skin integrity, impaired. Goal: Area will be healed. Approach: Cleanse wound left lower extremity with normal saline, pat dry, apply [MEDICATION NAME] to wound bed cover with island dressing daily & as needed for soiled or displaced. Resolved. 8/23/11 - Cleanse wound buttocks & thighs & R armpit c NS, pat dry, apply small amt [MEDICATION NAME] q shift. Problem: Skin integrity, impaired potential. Goal: Will have skin intact. Approach: Skin assessments 2X weekly. Pressure relieving device bed/chair as needed..." A nurse's note, dated 08/13/11, documented open area on the resident's right buttocks measuring 2 1/2 X 2 cm. A skin assessment sheet, dated 08/13/11, documented: A Stage II pressure sore on the right buttocks/hip crease, measuring 6 cm X 2 cm. A Stage II on the resident's right buttocks which measured 2 1/2 cm X 2 cm area. A skin assessment sheet, dated 08/17/11, documented: A Stage II pressure sore on the right buttocks measuring 5 cm X 2 cm. A Stage II on left buttocks measuring 3 cm X 2 cm. (NEW) A Stage II on the left upper thigh measuring 6 cm X 2 cm. (NEW) The Stage II on the resident's right buttocks which measured 2 1/2 cm X 2 cm area was not identified on the skin assessment sheet. A skin assessment, dated 08/31/11, documented: A Stage II pressure sore to the (R) buttocks measuring 5 cm X 5 cm. (increased in size) A Stage I to the (L) buttocks measuring 4 cm X 3 cm. (increased in size) (R) cheek buttock with red blisters x 3. A Stage II to the back of (R) thigh measuring 5 cm X 5 cm. (increased in width) A quarterly assessment, dated 09/13/11, documented the resident was total assist with ADLs, was always incontinent of bowel, had an indwelling urinary catheter and had a stage II pressure sore. A skin assessment, dated 09/14/11, two weeks later, documented: A Stage II pressure sore (R) buttock measured 4 cm X 3 cm. A Stage II to back of the (L) back of thigh measured 4 cm X 1/4 cm. (The previous assessment had documented the pressure sore as being on the (R) side) The (L) buttocks was excoriated. The next skin assessment was dated 09/28/11, and documented: A Stage II pressure sore to the (L) buttocks measuring 2 cm X 2 cm (The previous assessment the pressure sore was documented as being on the (R) side.) A Stage I to the back of the (R) thigh measuring 4 cm X 5 cm. The assessment documented excoriation to bilateral buttocks. There was no assessment of the (R) buttock which had been measured as 4 cm x 3 cm on the previous assessment. There was no assessment completed until two weeks later on 10/12/11, which documented: A Stage II pressure sore to the (R) buttocks which measured 1 cm X 1 1/4 cm. A Stage II to the (L) buttocks which measured 3 cm X 1 cm. A physician's orders [REDACTED]. amt of [MEDICATION NAME], LOTA (leave open to air) q shift until resolved. DX: excoriation." The treatment order was for excoriation and not for the Stage II pressure sores, which were documented on the skin assessment sheets. A skin assessment, dated 10/19/11, documented: A Stage II pressure sore to the (L) buttocks measuring 3 cm X 2 cm. A Stage II to the right buttocks measuring 1 cm X 1 cm. A skin assessment, dated 10/25/11, documented: A Stage I to the (L) buttocks measuring 6 cm X 4 cm and A Stage I to the (R) buttocks measuring 9 cm X 5 cm. On 10/26/11, the pressure sores were remeasured after the surveyor had observed a treatment to the pressure sores on 10/26/11. On 10/26/11, the skin assessment documented: A Stage II pressure sore to the (L) buttocks measuring 7 cm X 3 cm. A Stage II to the (R) buttocks measuring 5 cm X 3 cm. The above skin assessments were not consistent in measuring the stages, sizes and locations of the wounds. The assessments were not completed two times weekly per the facility policy and the care plan. The depth of the pressure sores were never measured. On 10/26/11, at 9:40 a.m., the resident was observed in her bed during a pressure sore treatment to her buttocks. The resident required extensive assist with moving her upper extremities and turning onto her side. CNA #1 and CNA #2 were observed to turn the resident onto her (R) side. Red excoriation was observed on both her buttocks. There were Stage II pressure sores on her (R) and (L) buttocks. There were areas in the wound that contained small yellow colored tissue. The opened areas were red with signs of bloody drainage. LPN #3 gloved her hands and was observed to clean the areas under both of the resident's arms. The areas appeared to be excoriated. After applying the [MEDICATION NAME] to the resident's arms, the LPN changed her gloves. The LPN then obtained 4 X 4 gauze, wet with NS and wiped the opened area on the (R) buttock. The LPN wiped the area several times with the 4X4 gauze. The LPN then proceeded to the opened pressure sore on the (L) buttock. The LPN used the same 4 X 4 to wipe the opened pressure sore on the (L) buttock. The LPN then obtained a dry 4X4 gauze and patted both pressure sores dry with the same 4 X 4. The LPN cross contaminated the resident's pressure sores when cleaning and drying both areas with the same 4 X 4 gauze. The LPN changed her gloves and applied [MEDICATION NAME] cream to her gloved hand. The LPN then wiped the [MEDICATION NAME] over both areas using the same gloved hand. The LPN removed her gloves, gathered her trash and opened the door to the room. The LPN did not wash her hands after changing her gloves during the procedure or when the procedure had been completed. The LPN did not use an alcohol cleanser between glove changes. On 10/31/11, at 3:20 p.m., the DON was interviewed regarding the cross contamination of the resident's pressure sores. The DON reported the LPN should have used a different 4 X 4 when cleaning each wound. The DON was also informed of the observation of the LPN not washing her hands. The DON reported the LPN should have used an alcohol cleanser after removing her gloves and should have gone to the nearest sink to wash her hands. The DON was also informed of the inconsistencies of the pressure sore assessments. She reported the LPNs should have done the wound care assessments correctly. 3. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission skin assessment dated [DATE], documented, "Abrasion to buttocks, white areas which peel off with cleansing leaving dark pink areas open..." A physician's orders [REDACTED]. DX: Excoriation" The care plan, dated 09/26/11, documented, "Skin Integrity Impaired R/T Unstageable Pressure Ulcer to Coccyx: Approach: Cleanse bilateral buttocks with warm soapy water, rinse, pat dry, apply [MEDICATION NAME], then thin layer of [MEDICATION NAME] ointment every shift & as needed. DX: Excoriation Skin assessments 2x/weekly, Turn & reposition Q 2 hours. Pillow between legs & behind back when lying on side. Pressure relieving device to bed/chair as needed. Report any red or open areas...." A nurse's note, dated 09/26/11, documented, "Resident very non-compliant...Has about a 3 cm x 3 cm area to coccyx. [MEDICATION NAME] applied." There was no documentation of the physician being notified regarding the 3 x 3 area to the resident's coccyx. A nurse's note, dated 09/27/11 at 2:30 a.m., documented, "Buttocks & to mid-posterior thighs are purplish with excoriation. Open areas to upper buttocks and coccyx....Placed blue chux beneath LUE d/t weeping clear serous fluid. 0.5 cm blisters x 2 observed to posterior LUE. Scabbed excoriation observed to stump of LLE." An admission skin assessment, dated 09/27/11, documented, "... Red raw area to buttocks...Unstageable thick ulcer with slough to buttocks. Pink open areas to buttocks." There were no ulcer measurements documented on the assessment sheet. There was no documentation of notification of the physician about the unstageable ulcer with slough. A nurse's note, dated 09/28/11 at 1:00 a.m., documented, "Several small scabbed areas noted to BUE c [MEDICAL CONDITION] and serous drainage noted to LUE. 15 cm x 10 cm Stg II to coccyx and buttocks. Tx in progress c large amount of excoriation to entire buttocks and upper thighs. There was no documentation the physician had been notified about the [MEDICAL CONDITION] and serous drainage to LUE or about the increase in size of the pressure ulcer. A physician's progress note, dated 09/28/11, documented, "...Need antidepressant. No appetite." A nurse's note, dated 09/29/11, at 1:30 a.m., documented, "...Tx to stg II to coccyx and excoriated areas done as per orders. A nurse's note, dated 09/30/11, at 8:00 a.m., documented, "...Very non-compliant, refuses to turn side to side. Lays on back and stage II to (L) buttock is now dark brown almost black in color and larger." A skin assessment, dated 09/30/11, documented, "Wound #1 Location - R buttock/coccyx (Picture on assessment showing left buttock/coccyx) Stage - II Length - 6 cm Width - 6 cm Depth - epidermis Color - black to center Drainage - scant yellowish/serous Odor - ------ Surrounding Tissue - Excoriated/open [MEDICAL CONDITION] - no [DIAGNOSES REDACTED] - yes ...Buttocks c redness/purplish open areas. Lg area of black eschar to R buttock /lower coccyx. Tx in progress." There was no documentation the physician had been notified about the increase in size and change of color of the pressure ulcer on the coccyx. A nurse's note, dated 10/01/11, at 2:00 a.m., documented, "Pressure ulcer approx. 6 cm x 6 cm black area surrounded by reddish/purplish excoriation/open areas." There was no documentation the physician had been notified about the pressure ulcer. The admission assessment, dated 10/03/11, documented the resident was moderately cognitively impaired and had one unstageable pressure ulcer on admission. A nurse's note, dated 10/03/11, at 4:30 p.m., documented, "Dr. (Name deleted) here...New orders rec'd to DC the [MEDICATION NAME] and start [MEDICATION NAME] 30 mg PO every HS. Res continues non compliant c positioning in bed - buttocks wound not improving." A physician's orders [REDACTED]. DX: pressure ulcer/[MEDICAL CONDITION]. (2) Glucerna one 8 oz. can PO BID. Give at 10 am. & 2 pm Dietary Supplement. (3) Healthy Shot double protein - 2.5 oz PO qd..." A physician's orders [REDACTED]." A physician's orders [REDACTED]. DX: Pressure ulcer" A new treatment was initiated for the coccyx wound on 10/04/11. The ulcer was first documented with slough on 09/27/11. Eschar was documented on 09/30/11. A nurse's note dated 10/05/11, at 2:40 a.m., documented, "N/O for treatment to pressure ulcer rec'd earlier in shift. Redness to buttocks appears to be decreased, however, area of ulceration is black." A nurse's note, dated 10/05/11, at 9:00 a.m., documented, "...Dressing to buttock changed, foul smelling yellowish blood drainage noted." A nurse's note, dated 10/05/11, at 3:00 p.m., documented, "Resident not eating very much. [MEDICATION NAME] was 4.3 - (Dr. name deleted) notified." (The [MEDICATION NAME] reference range was 21-43 mg/dl.) "Refusing to stay off decubitus buttocks. Drsg to buttocks changed - foul smelling bloody yellow drainage noted LG amount. A nurse's note, dated 10/06/11, documented, "...Ensure offered after meal and for snacks...Refuses to stay off sore on buttocks - Drsg to buttocks changed, foul smelling bloody yellow drainage noted LG amount." No documentation was found of notification of the physician about the foul smelling yellowish drainage. A wound care evaluation, by wound consultant, dated 10/07/11, documented, "Wound #1 Date Onset 9/8/2011 Assessment Date - 10/7/2011 Exudate - Min Thickness - Full Thickness Etiology - Pressure - Unstageable Size (L x W cm.) - 10.00 x 12.20 Depth - utd .......... Drainage Consistency - [MEDICAL CONDITION] Acquisition - Hospital Acquired Wound Bed: 80% thick tan adherent necrotic tissue. 20% thin moist yellow adherent slough. Periwound: Fragile, [DIAGNOSES REDACTED] Clinical Rationale/Wound Comments: Daily Santyl will enzymatically debride necrotic tissue. Hydrogel will promote a moist wound environment. Foam will promote thermal regulation as well as provide cushion to pressure sensitive area. Daily dressing changes required due to frequent incontinent episodes compromising dressing integrity in less than a 24 hour time frame. Treatment Intervention: Clean area with NS/Wound cleanser. Apply thin layer of Santyl. Apply Hydrogel gauze. Cover with Bordered Foam. Treatment to be performed daily. Evaluation Comments: Pre-[MEDICATION NAME] results 4.3. Staff reports that resident is non adherent to positioning and diet, often refusing repositioning and refusing meals. Is on air mattress." A skin assessment, dated 10/07/11, documented, "Wound #1 Location - L and slightly center L buttocks Stage - III Length - 6.5 cm Width - 5 cm Depth - multiple layers of epidermis/dermis Color - Black Drainage - Small amount serous/greenish Odor - -------------- Surrounding Tissue - red [MEDICAL CONDITION] - mild [DIAGNOSES REDACTED] - check mark" "Wound #2 Location - R buttock and slightly center Stage - II Length - 3 cm Width - 3 cm Depth - subdermal Color - Lt. cream/flesh Drainage - scant serous Odor - -------- Surrounding Tissue - red [MEDICAL CONDITION] - trace [DIAGNOSES REDACTED] - ---------" Skin assessments were not consistent. The wound consultant documented the pressure sore was unstageable and measured 10 cm x 12.2 cm. The same day it was measured as 6.5 cm x 5 cm and a stage III ulcer by a facility LPN. A physician's orders [REDACTED]. DX: Stg II." The order for the 3 x 3 cm stage II was received two days after it's discovery. A nurse's note, dated 10/10/11, at 3:00 p.m., documented, "...Area to buttocks with no improvement noted...." A physicians order, dated 10/11/11, documented, "N/O to culture areas to buttocks - DX: brown foul drainage" The order for the culture of the coccyx wound was not obtained for six days after the yellow foul smelling drainage was noted on 10/05/11. A consent, dated 10/12/11, was obtained from the resident for wound debridement to the coccyx. The attached assessment, dated 10/12/11, documented, "11 x 8 size *1.5 cm depth brown serous drainage * surrounding skin pink." A nurse's note, dated 10/13/11, at 2:00 p.m., documented, "...Wound to buttocks has deteriorated. Dr. (name deleted) is doing sharp debridement once weekly." On 10/14/11, the 10/07/11 wound care evaluation was noted by LPN #4. The physician had documented the acceptance of the treatment recommendations and signed the evaluation. The physician's signature was not dated. This was a week after the wound consultant's assessment and recommendations. A skin assessment, dated 10/14/11, documented, "Wound #1 and #2 Location - R Buttocks/coccyx (picture shows left buttock/coccyx area) Stage - II Length - 6" (6 inches = 15 cm) Width - 5" (5 inches = 12.5 cm) Depth - 1/4 cm Color - white, brown, eschar Drainage - small amount Odor - foul Surrounding Tissue - ....red" "Wound #3 x 2 (New area) Location - L Buttocks Stage - I (should be Stage II) Length - round 1" (1 inch = 2.5 cm) Depth - ------- Color - white, brown Drainage - small amount Odor - -------- Surrounding tissue - red c white..." There was no documentation about wound #2 from the last skin assessment dated [DATE]. There was no documentation of notification of the physician about the two new pressure ulcers. According to the wound consultant, the ulcer on the coccyx was a full thickness tissue lo

Based on record review, observation, and staff interview, it was determined the facility failed to: a) Ensure a physician's order was obtained and a medical reason documented for the placement of an indwelling urinary catheter for one (#1) of 11 sampled residents in the facility with indwelling urinary catheters. b) Ensure re-assessments of indwelling urinary catheters were completed for the continued need when the residents' medical condition had changed, for three (#3, 5 and #9) of 11 sampled residents in the facility with indwelling urinary catheters. c) Ensure attempts were made to remove indwelling urinary catheters, when the residents' medical condition had changed, for three (#3, 5 and #9) of 11 sampled residents in the facility with indwelling urinary catheters. d) Ensure indwelling urinary catheter care was provided in a manner to thoroughly clean the catheter tubing for one (#5) of 11 sampled residents in the facility with indwelling urinary catheters. The DON identified 11 residents as having an indwelling urinary catheter. These failed practices caused harm for residents #3 and #9. Findings: 1. The medical record for resident #9 documented the resident had [DIAGNOSES REDACTED]. A physician's order, dated 06/25/09, documented the resident was to have a F/C to promote wound healing. The resident's bladder incontinence evaluation documented in 2008, the resident was on scheduled toileting. In 2009, it documented the resident had a F/C. A notation on 08/24/10, documented the resident continued to have a F/C for promotion of skin/wound healing. The last notation, dated 02/16/11, documented the catheter continued due to [MEDICAL CONDITION]. A quarterly assessment, dated 05/05/11, documented he required total assist of two for bathing, hygiene and toileting, had limitations to bilateral lower extremities, was occasionally incontinent of bowel, had an indwelling urinary catheter and had no pressure sores. An annual assessment, dated 07/29/11, documented the same information as the quarterly assessment dated [DATE]. The resident's care plan, dated 08/05/11, documented the resident had a problem due to having an indwelling urinary catheter. The goal documented bladder elimination would be maintained through the indwelling catheter and he would have no S/S of a UTI. Approaches documented to observe for clinical signs of UTI, to monitor I & O, change catheter per physician order and encourage fluids. A lab report, dated 08/10/11, documented the results of a UA with C&S. The organism present in the UA was documented as Escherichia coli. The resident's skin sheets for 2011, were reviewed for documentation of a wound which would require an indwelling urinary catheter. The skin sheets documented frequent redness to the buttocks. The only wound documented was to the resident's lower extremities. The resident had had an indwelling urinary catheter from 06/25/09, for wound healing. The only documentation regarding any attempt to remove the catheter was found on the bladder incontinence evaluation, on 02/16/11, which documented the resident had retention. There was no documentation of any attempts to check the resident for residual or attempt to discontinue the F/C since the notation on 02/16/11. On 10/25/11, at 11:20 a.m., the resident was observed in his room. The resident had an indwelling urinary catheter and no cover bag. The drainage bag was observed setting on the foot rest of the overbed table. Sediment was observed in the tubing. A nurse's note, dated 10/25/11, at 4:00 p.m., documented the resident had slurred speech and decrease LOC, was voicing complaints of feeling funny and dizzy. An order was received to transfer the resident to the hospital. The hospital records were reviewed for documentation regarding the resident's transfer. A UA with C&S report drawn on 10/25/11, and reported on 10/27/11, documented the presence of Escherichia coli in the urine. A CMP drawn on 10/26/11, documented: BUN 27 high - reference range 17-18 NA 129 low - reference range 136-145 CL 89 low - reference range 101-111 BUN/Crea 31.20 high - reference range 10.00-20.00 On 10/31/11, at 3:20 p.m., the DON was interviewed regarding the resident having a F/C since 2009, for wound healing and the resident's only wounds during 2011, were to his lower extremities. The DON reported they had tried to remove it, but he could not void. The DON was also informed of the F/C drainage bag resting on the foot rest of the overbed table. The DON reported the catheter should have been in a cover bag and not touching the foot rest. The DON was then interviewed regarding the residents with indwelling catheters who had frequent UTIs. The DON was informed that there were no new interventions in the resident's care plans to address the prevention of future UTIs. She was also informed the care plans did not always address the use of the indwelling catheters or the UTIs for all of the residents. The DON reported the nursing staff should be revising the careplans to address the catheters and UTIs. The DON reported the documentation regarding the residents with F/Cs and the frequent UTIs was there in the medical records and she could not argue the fact. She reported the nursing staff didn't see the big picture. They should start bladder training as soon as the resident's come back with a F/C and get it out as soon as possible. 2. Resident #3 had [DIAGNOSES REDACTED]. A bladder incontinence evaluation documented: On 05/14/08 at 10:30 a.m., "Res had F/C dc'd 5-6-08 d/t no skin breakdown. Will keep check on & change protocol d/t incont of B&B. Will monitor skin for redness." On 05/28/08, "F/C place for (L) buttock wound." On 08/24/10, "Resident cont to require F/C for [MEDICAL CONDITION]" On 11/17/10, "Res cont to have [MEDICAL CONDITION] & require FC..." On 05/18/11, "FC for [MEDICAL CONDITION]" A care plan, dated 02/16/11, and revised on 07/27/11, documented, "Problem: Foley catheter for UTI/retention... Approach: Observe for clinical signs of UTI, fever, Hematuria, cloudiness, sediment." A telephone physician's order, dated 07/23/11, documented, "Specimen source: urine (catheter collected) Results: 10,000-50,000 CFU/ ml of Proteus mirabilis." A telephone physician's order, dated 07/26/11, documented, "[MEDICATION NAME] 1 gram IM X 5 days. Dx: UTI." A quarterly assessment, dated 07/29/11, documented the resident had an indwelling urinary catheter, was incontinent of bowel, had no pressure sore, but was at risk of developing pressure sores. The October 2011, physician's orders documented, "...Foley catheter for UTI & retention..." On 10/24/11, at 10:30 a.m., during the initial tour of the facility, the resident was observed lying in her bed. An indwelling urinary catheter bag was observed hanging on the side of the resident's bed. On 10/27/11, at 9:10 a.m., the DON was interviewed. The DON was asked about the resident's [DIAGNOSES REDACTED]. She was asked if the facility had followed up on the [MEDICAL CONDITION] and tried to discontinue the use of the indwelling urinary catheter. The DON reported the facility had tried several times to remove the catheter. She reported they had to put the catheter back in, because the resident had a large amount of sediment in her urine. 3. The medical record for resident #1 documented the resident had [DIAGNOSES REDACTED]. A significant change assessment, dated 01/24/11, documented required extensive assist of two with bathing, total assist with hygiene, was frequently incontinent of bowel and bladder. The assessment did not identify the resident had a UTI. The resident's care plan, dated 02/02/11, documented: "Problem: Infection R/T urinary tract. Goal: Infection will be resolved. Approach: Insure(ensure) correct perineal cleansing. Administer medication as ordered. Encourage to drink all liquids on meal trays with additional liquids between meals." A nurse's note, dated 05/04/11, at 6:00 p.m., documented the resident had a new physician's order for a direct admit to the hospital for [MEDICAL CONDITION] and uncontrolled back pain. A urinalysis completed while in the hospital showed she had e-coli in her urine. admission orders [REDACTED]. The admission nurse's note, dated 05/09/11, documented the resident had an indwelling urinary catheter. The admission physician's orders did not contain an order for [REDACTED]. The nurses' notes documented the resident continued to have an indwelling urinary catheter from 05/09/11, through 05/19/11, without an order or medical condition which would justify the use of the indwelling urinary catheter. On 10/17/11, at 6:00 p.m., a nurse's note documented, "Start [MEDICATION NAME] 100 mg 1 po bid X 10 days DX: UTI." A physician's order, dated 10/19/11, at 6:00 p.m., documented, "N/O to send to (Name deleted hospital) for direct admit for DX: [MEDICAL CONDITION] and UTI..." A nurse's note, dated 10/24/11, at 9:45 a.m., documented the resident returned to the facility with an indwelling urinary catheter. The physician's orders were reviewed for documentation of why the resident was to have an indwelling urinary catheter. There was not an order or a medical reason for the use of the indwelling urinary catheter. On 10/24/11, at 12:20 p.m., the resident was observed in her bed. An indwelling urinary catheter bag was observed with a cover bag. The bag and the drainage tubing were laying on the floor. At 5:15 p.m., the resident was observed in the bed. Again, the bag and the drainage tubing were laying on the floor. CNA #3 and CNA #7 were observed to provide incontinent care for the resident. During the care, the indwelling urinary catheter bag was placed on the floor. CNA # 7 was observed to step on the catheter drainage bag while assisting with turning the resident. At 5:30 p.m., LPN #7 was interviewed regarding the resident having an indwelling urinary catheter and no order or medical justification. The LPN reported the resident had come back from the hospital with the catheter. She reviewed the physician's orders and reported she could not see a [DIAGNOSES REDACTED]. The LPN reported the physician's orders documented a [DIAGNOSES REDACTED]. On 10/25/11, at 9:00 a.m., the DON was interviewed regarding the resident having an indwelling urinary catheter without an order or justification. The DON reported the hospital puts an indwelling urinary catheter in the residents when they are admitted to the hospital. The DON reported the hospital sends the residents back to the nursing home with the catheters in place. The DON reported they should do bladder training as soon as the residents come back and then DC the catheter or notify the physician for a diagnosis. The DON reported she had the evening shift DC the resident's catheter. On 10/31/11, at 3:20 p.m., the DON was interviewed regarding the tubing laying on the floor and the CNA stepping on the drainage bag. The DON reported the tubing should be coiled so it does not touch anything. She reported the bag should never be on the floor. 4. Resident #5 was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. An admission assessment, dated 06/20/11, documented the resident required assistance with hygiene and bathing and was continent of bowel. The resident's care plan, dated 06/13/11, documented: "Problem: Skin integrity, impaired. Goal: Area will be healed. Approach: Cleanse wound left lower extremity with normal saline, pat dry, apply [MEDICATION NAME] to wound bed..." The nurses' notes, dated 06/17/11, documented on the night shift and the morning shift the resident was continent of bladder and used the BSC. At 3:00 p.m., a nurse's note documented the indwelling urinary catheter had been placed for very poor voiding of 75 cc three times in eight hours. A lab report for a UA with C&S, collected on 07/16/11, and reported on 07/18/11, documented the resident had Escherichia coli present in her urine. A nurses' note, dated 07/18/11, documented the resident continued to have the indwelling urinary catheter. At 5:45 p.m., a nurse's note documented the resident had gross [MEDICAL CONDITION], complained of severe itching, had jerking of upper extremities and increased anxiety. A new order was received to send the resident to the hospital. A nurse's note, dated 08/13/11, documented the resident returned to the facility from the hospital. The resident had continued to have an indwelling urinary catheter from 06/13/11, to 08/13/11, without any attempts to remove the catheter or to check for residual. The resident's care plan, dated 08/14/11, documented, "Foley catheter for monitoring I&O DX: [MEDICAL CONDITION] for clinical signs of UTI...Intake and output Q shift...Foley catheter care per protocol daily..." A quarterly assessment, dated 09/13/11, documented the resident required assistance with hygiene and bathing, was always incontinent of bowel, had an indwelling urinary catheter and had a Stage II pressure sore. The assessment did not identify the resident with a UTI in the past 30 days. On 10/26/11, at 3:40 p.m., the resident was observed in her bed. LPN #5 was observed to provide indwelling urinary catheter care for the resident. The LPN was observed to clean the catheter insertion site and then apply TAO at the site. The LPN did not clean down the tubing, past the insertion site. During the procedure, CNA #3 and CNA #4 assisted with repositioning the resident. The CNAs were observed to place the catheter drainage bag on the bed over the resident's legs. CNA #4 then lifted the drainage bag up above the level of the bladder and placed it on the other side of the bed. At 3:45 p.m., the LPN was interviewed regarding the indwelling urinary catheter care. The LPN was asked how she had been trained to provide the catheter care. The LPN reported she was supposed to clean down the tubing. She stated, "I just forgot." On 10/31/11 at 3:20 p.m., the DON was interviewed regarding the observation of the catheter care. The DON reported the LPN should have cleaned the peri area with soap and water and then started at the meatus and cleaned down the tubing using 4X4 gauze. The DON reported the LPN did not follow the facility's policy.

Based on record review, observation and staff interview, it was determined the facility failed to provide thorough incontinent care for one (#5) of two incontinent sampled residents. This had the potential to affect 27 residents identified by the DON as being incontinent of bowel and/or bladder. Findings: The [DIAGNOSES REDACTED]. A care plan, dated 02/16/11, documented the following: "Problem: Bowel incontinence.... Approach: Perineal care AM, PM & after each incontinence with vinegar water & apply Vaseline to buttocks/peri area for barrier..." A quarterly assessment, dated 10/22/11, documented the resident had inadequate short and long term memory, had severely impaired cognition, was totally dependent on staff for bed mobility, transferring between surfaces, all ADLs and was incontinent of bowel. On 01/17/12, at 10:00 a.m., the resident was observed lying in her bed. On 01/17/12, at 1:30 p.m., CNA # 1 and CNA #3 were observed to provide incontinent care for the resident. The DON was present in the room during the observation. The CNAs were observed to turn the resident onto her right side. The resident had been incontinent of bowel. The CNAs had a plastic container filled with water, vinegar and wash cloths. The CNAs cleaned the bowel movement from the resident's buttocks and rolled the resident onto her left side. They then cleaned the other buttock and changed the soiled pad under the resident. The CNAs then gathered their soiled supplies and prepared to leave the room. The CNAs were asked if they were finished with the incontinent care. They reported they were finished. At that time, the DON was asked why the resident's pubic area and front perineal area had not been cleaned. She reported she had cleaned the resident earlier and so had the CNAs. The DON then obtained a wet wash cloth and cleaned each side of the resident's groin areas. The clean wash cloth was observed to have feces removed from the resident's right groin. The DON reported it was bowel movement. The DON was asked if the CNAs should have cleaned the areas more thoroughly than they had. She reported the CNAs should have cleaned all the feces off the resident.

Based on record review, observation and staff interview, it was determined the facility failed to ensure residents received appropriate fluids to maintain adequate hydration and failed to ensure measures were put in place when residents were identified with frequent UTIs and lab reports indicative of dehydration for two (#1 and #4) of five sampled residents identified with UTIs and abnormal labs which were indicative of dehydration. This had the potential to affect all 54 residents residing in the facility identified by the DON as being at risk for dehydration. This failed practice caused harm for resident #1, who was hospitalized for [REDACTED]. The facility had no hydration plan in effect to increase the resident's fluid intake. Findings: 1. A significant change assessment for resident #1 , dated 01/24/11, documented the resident required limited assist with eating. The assessment did not identify the resident with a UTI in the past 30 days. The resident's care plan, dated 02/02/11, documented: "Problem: Infection R/T urinary tract. Goal: Infection will be resolved. Approach: Insure(ensure) correct perineal cleansing. Administer medication as ordered. Encourage to drink all liquids on meal trays with additional liquids between meals." A five day assessment, dated 09/26/11, documented the resident as having a UTI in the past 30 days. The resident's medical record was reviewed for documentation regarding the UTIs. The following documentation was found: A UA C&S report, dated 01/11/11, documented the resident had Escherichia coli present. The report had a hand written notation which documented, "On [MEDICATION NAME] 100 mg BID X 10 days started 1-10-11." The UA was collected on 01/08/11. A nurse's note, dated 02/06/11, at 12:50 p.m., documented, "Urine specimen collected. Urine was noted to be cloudy c foul odor." A physician's orders [REDACTED]. DX: UTI." A nurse's note, dated 03/04/11, at 3:45 p.m., documented the resident's physician was there regarding the resident's UTI. The physician wrote an order to send the resident to the hospital for an unresolved UTI. A UA C&S report, dated 03/06/11, documented the resident had Escherichia coli present. A handwritten notation documented the resident was on Cipro. The UA was drawn on 03/04/11. A physician's orders [REDACTED].O. Bid X 10 days. DX: UTI." On 03/07/11, another order documented to [MEDICATION NAME] mg and start [MEDICATION NAME] 100 mg BID X 10 days for a UTI. A physician's orders [REDACTED]." A UA C&S report, dated 04/09/11, documented the resident had Escherichia coli present. A handwritten notation documented the resident was started on [MEDICATION NAME] 100 mg BID X 10 days on 04/08/11. The UA was drawn on 04/07/11. A UA C&S report, dated 05/10/11, documented the resident had Escherichia coli present. The UA was drawn on 05/07/11. A nurse's note, dated 06/07/11, at 7:00 p.m., documented the resident had dark foul urine. A physician's orders [REDACTED]. A UA C&S report, dated 06/10/11, documented the resident had Escherichia coli present. The UA was drawn on 06/08/11. A physician's orders [REDACTED]." A physician's orders [REDACTED].O. Bid X 10 days. [MEDICATION NAME] gm 1 IM a HS X 3 days. DX UTI." A UA C&S report, dated 07/21/11, documented the resident had Escherichia coli present. A handwritten notation documented the resident was on [MEDICATION NAME] injections. The UA was drawn on 07/19/11. A physician's orders [REDACTED]. A nurse's note, dated 08/12/11, at 5:00 p.m., documented, "Dr (Name deleted) here & N/O to start [MEDICATION NAME] 100 mg PO BID X 10 days UA with UTI." A physician's orders [REDACTED]." Lab reports documented the following: 09/16/11 H (high) BUN 27 reference range 7-18 H CREA 1.77 reference range 0.44-1.00 L (low) EGFR 27 normal range (greater than) 60ml/min/1.73m2 L EGFRAA 33 normal range (greater than) 60ml/min/1.73m2 09/23/11 H BUN 49 reference range 7-18 H CREA 1.91 reference range 0.44-1.00 H K (potassium) 5.3 reference range 3.5-5.1 H CO2 33 reference range 22-28 L (low) EGFR 25 reference range (greater than) 60ml/min/1.73m2 L EGFRAA 30 reference range (greater than) 60ml/min/1.73m2 H BUN/CREA 25.80 reference range 10.00-20.00 The above lab reports indicated the resident had dehydration. A nurse's notes, dated 09/26/11, documented the resident was lethargic up in W/C. The resident was placed in bed and the nurse documented she could not get the resident's V/S due to the resident having tremors. The nurse's note documented an abnormal lab dated 09/23/11, was faxed to the physician. An order was received to send the resident to the hospital. 09/29/11, at 1:45 p.m., documented the resident had returned from the hospital with a new order [MEDICATION NAME] mg BID until a urine culture came back. A nurse's note, dated 10/15/11, at 9:30 p.m., documented, "New order rec'd - Cath UA c C&S if indicated DX: lethargy, dark foul urine." A physician's orders [REDACTED]. A physician's orders [REDACTED]. DX - UTI / [MEDICAL CONDITION]" A UA C&S report, dated 10/21/11, documented the resident had Escherichia coli present. The UA had been drawn on 10/16/11. A nurse's note, dated 10/24/11, at 9:45 a.m., documented the resident returned to the facility from the hospital with an indwelling urinary catheter. The resident had a UTI every month from January 2011, through October 2011. The bacteria present in the urine was identified as Escherichia coli on seven different C&S reports. The resident's lab indicated the resident had signs of dehydration. The care plan had not been revised to address the dehydration. There was no plan in place to ensure the resident had adequate fluid intake. On 10/24/11 at 12:20 p.m., the resident was observed resting in her bed. There was not a water pitcher in the resident's room. On 10/26/11 at the noon meal, the resident was observed leaving the dining room. The resident's plate and remaining fluids were observed. The resident had drank only half of her tea and 1/3 of her glass of water. A CNA was observed to remove the resident from the dining room. On 10/27/11 at 1:15 p.m., a family member was interviewed regarding the resident's decreased fluid intake. The family member reported the resident was on thickened liquids, but she would drink her fluids without difficulty, if the staff would offer her small sips. On 10/31/11 at 3:20 p.m., the DON was interviewed regarding the lab reports documenting the resident was dehydrated. The DON was informed there was no documentation or care planning to reduce the resident's risk for dehydration or to provide additional interventions to provide fluids. The DON reported the resident was on thickened liquids and a water pitcher had not been placed in her room. The DON was asked if the resident had been placed on a special hydration schedule as a preventive measure to reduce the risk of dehydration. The DON reported the staff had discussed the issue, but they had not had time to put anything into affect yet. 2. The quarterly assessment for resident #4, dated 09/27/11, identified the resident had severely impaired cognition, had a UTI the past 30 days, had an indwelling urinary catheter, had ROM impairment of upper extremities and required total assistance with eating/drinking. There was nothing in the care plan related to dehydration such as interventions to increase & encourage fluid intake. The laboratory results, out-of-range for the CMPs ordered by the physician, follows: BUN - reference range 7-18 mg/dl 03/15/11 - (H) 23 03/31/11 - (H) 24 05/07/11 - (H) 28 05/18/11 - (H) 36 [MEDICATION NAME] - reference range 3.5-5.0 g/dl 03/15/11 - (L) 3.2 05/07/11 - (L) 2.9 05/18/11 - (L) 3.0 The laboratory results for the resident's Urinalysis are as follows: 07/05/11 - [MEDICATION NAME] + WBCs 1-5 Bacteria 3+ 09/03/11 - [MEDICATION NAME] + WBCs Large 8-10 Bacteria - Moderate 09/25/11 - [MEDICATION NAME] + WBCs TNTC Bacteria - Few 10/22/11 - [MEDICATION NAME] + WBCs TNTC Bacteria - 4+ Documentation of a 'Resident Office Visit', dated 05/06/11, documented, "...C/O not voiding as often as she should. Not eating, drinking...Impression: failure to thrive, dehydration. A nurse's note, dated 05/18/11, at 8:00 a.m., "N/O for CMP, (arrow pointing down) appetite & fluid intake..." A nurse's note, dated 05/27/11, at 6:15 p.m., documented, "(arrow pointing down) in fluid intake..." Resident had been admitted to hospital on [DATE], with a [DIAGNOSES REDACTED]. The resident had been re-admitted to the facility on [DATE]. A nurse's note, dated 06/17/11, at 11:30 a.m., documented, "... continuing to take fluids better than meals but taking nothing adequately..." A nurse's note, dated 06/30/11, at 11:45 a.m., "(Son's Name deleted) returned phone call at this time. Discussed resident refusing meals, meds & fluids, discussed peg tube & decision that needed to be made by DPOA. Instructed on resident's declining condition. (Name deleted) took (Physician's name deleted) # & stated that (Other son's Name deleted) would call (Physician's Name deleted) tomorrow to discuss resident's condition & the options to be considered." A nurse's note, dated 07/01/11 at 8:30 a.m., documented, "(Physician's Name deleted) nurse called & (Resident's son's Name deleted) had talked to her this am & sons do not want peg tube..." The resident had been admitted to the hospital on [DATE]. A physician's hospital progress note, dated 07/06/11, documented, "Patient came in last night from the nursing home. Patient was congested and running a low grade temperature. Patient is here with dehydration. She has a UTI and leukocytosis...Patient has an elevation of her BUN...Sodium is high...She is on [MEDICATION NAME] IV and she has IV fluids running at 80cc an hour..." A physician's hospital progress note, dated 07/07/11, documented, "...BNP is up a little bit since we are hydrating her. HGB is 10.5...Patient is not eating. We will add MVI since she is not eating and put her on Ensure." The resident had been re-admitted to the facility on [DATE]. A nurse's note, dated 07/15/11, at 12:30 p.m., documented, "...Continues to take fluids but refuses all meds...Hand fed by staff & needs lots of encouragement to take anything by mouth..." A nurse's note, dated 08/12/11 at 10:00 a.m., documented, "Res appears reddish in face, Protective pad is very wet c apparently sweat...temperature is 101. Refused Tylenol..." There was no documentation the resident had been offered fluids. The resident was admitted to the hospital on [DATE], then re-admitted to the facility on [DATE]. A nurse's note, dated 09/15/11 at 6:00 p.m., documented, "..Hand fed but appetite & fluid intake poor this pm... The I & O flow sheet records for the months of September and October, 2011, were not totaled every day. October's, I & O's were not totaled for the following days: 7th, 10th, 11th, 12th, 13th, 16th, 17th, 18th, 19th, 20th, 23rd, 24th, 25th and the 26th. A nurse's note, dated 09/24/11, at 8:20 p.m., documented, "Noted large quantity of blood visible in Foley cath tubing et in cath bag...obtain Cath UA c C&S if indicated in the am. Dx: Hematuria/foul odor..." A 'Resident Office Visit Communication' form, dated 09/26/11, documented, "Illness, follow up on UA that showed (+) [MEDICATION NAME]. Plan/Treatment: [MEDICATION NAME]" A nurse's note, dated 09/27/11 at 9:00 p.m., documented, "Res lying in bed face flushed. Skin w/touch (warm to touch) lethargic. F/C to BSD (bedside drainage) c DK (dark) red tinged urine return...102.2 (temperature)..." There was no mention of offering the resident fluids. The resident was sent to the hospital. The resident was admitted to the hospital on [DATE], for an increased temperature and a UTI. The resident had been re-admitted to the facility on [DATE]. A nurse's note, dated 10/06/11, at 12:40 a.m., documented, "...F/C patent & drng (draining) dark amber urine to BSD. Continues on Pen ([MEDICATION NAME]) G for "VRE" in urine..." A nurse's note, dated 10/06/11, "Late entry 10-5-11 7-3...Appetite is poor, fluid intake is fair..." A nurse's note, dated 10/09/11, at 3:00 p.m., documented, "...Takes fluids c encouragement..." A 'Resident Office Visit Communication' form, dated 10/21/11, documented, "Illness...finished PCN shots for VRE 10-15-11..." A physician's telephone order, dated 10/22/11, documented, "Obtain a cath UA in the am c C&S if indicated. DX: Hematuria" On 10/24/11, at 10:10 a.m., LPN #3 was observed providing wound care for the resident. The LPN never offered the resident a drink of water. The resident's water pitcher was observed full of water setting next to her bed. The resident was totally dependant on staff to give her drinks. On 10/24/11, at 11:00 a.m., CNA #1 and CNA #2 were interviewed. They were asked when would the resident be offered a drink of water. The CNAs said they offered her a drink everytime they went into her room, but she would usually refuse. On 10/25/11, at 5:35 p.m., CNA #5 and LPN #5 were observed providing wound care for the resident. Before and after the care, the LPN nor the CNA were observed to offer the resident a drink. The resident's pitcher was full of water and was setting on a table beside her bed. On 10/27/11, at 10:45 a.m., CNA #5 was asked when she offered the resident a drink of water. She said when she turned her about every two hours. The 'CNA - ADL Tracking Form' for October, 2011, documented 'Fluids Offered.' The CNAs were to record the amount of ml's offered and the amount of ml's consumed. On some days the amounts were not recorded. There was nothing documented on the following days: October 7th, 8th, 12th,15th, 16th, 19th, 20th, 21st, and the 24th. On 10/31/11 at 11:00 a.m., the DON was interviewed regarding the resident's fluid intake. The DON said she refused fluids most of the time when offered. The DON was asked why the dehydration and fluid consumption had not been addressed in the resident's care plan. She said she did not know, but it should be. The DON went on to say the family had refused a peg tube, so they did the best they could to offer her things by mouth.

Based on record review, observations and staff interviews, it was determined the facility failed to: a) Ensure a resident was free of pain during a treatment for one (#4) of three sampled residents observed receiving pressure sore treatments. This deficient practice caused harm to resident #4 who experienced pain during a pressure sore treatment without pain medication being offered prior to the treatment. The DON stated a total of four residents received pressure sore treatments. b) Ensure skin assessments were completed and accurate; and ensure an IM antibiotic, [MEDICATION NAME], had been initiated within 24 hours after obtaining the order from the physician, for one (#3) of four sampled residents identified [MEDICAL CONDITION] in a wound. c) Ensure an order for [REDACTED]. The DON stated 13 residents required skin treatments. Findings: 1. Resident #4's significant change assessment, dated 07/05/11, documented the resident was identified at risk for pressure sores and had severe pain daily. The care plan, dated 07/17/11, documented the following: "Problem Comfort, altered, pain Goal Will be comfortable as evidenced by relaxed facial expression during personal care Approach (01) Organize care to allow for rest & periods of uninterrupted sleep (02) Administer pain medication as ordered (03) Report S/SX of pain I.E. flinching, moaning, crying (04) Assess efficacy of meds, contact MD RE (regarding) change in dosage, scheduling, route, or classification of drug (05) Divert attention through activities as tolerated (06) Position for comfort. Report C/O pain" A quarterly assessment, dated 09/27/11, documented the resident had two Stage IIs and one Stage III pressure sore. The area on the assessment designated for pain had been left blank. The CAA, dated 10/04/11, documented the resident had indicators of pain almost daily aeb (as evidenced by) yelling out with care. "Care Plan factors: Assess contributing factors of pain, administer medication per orders, adjust as indicated, be aware of non-verbal s/s of pain, administer pain med or relief measures before pain too severe. Needs new care plan." The October 2011, physician's orders [REDACTED]. 2 tablets PO every 6 hours as needed for pain or temp (temperature). The October 2011, MAR, documented the resident had received no [MEDICATION NAME] during the month of October 2011. On 10/24/11, at 10:10 a.m., LPN #3 was observed providing pressure sore treatment to the resident's (R) ear. During the treatment, the resident complained of pain and told the nurse to hurry with the treatment. When the LPN moved the resident's (R) ear to look behind it for breakdown, the resident flinched and said, "That hurts!" On 10/25/11 at 5:35 p.m., LPN #5 was observed providing treatment for the Stage III pressure sore on the resident's coccyx. During the treatment, the resident was heard to moan and complain of pain. When the LPN had completed the treatment she was asked if the resident always complained of the treatment being painful. The LPN replied, "Sometimes it hurts her." On 10/28/11 at 10:45 a.m., the resident was heard yelling from her room. The resident was asked where she hurt and she stated she was, "hurting all over." Two CNAs, #2 and #5, were observed going in and out of the resident's room. Neither CNA reported to the charge nurse the resident had stated she was in pain. On 10/28/11 at 11:30 a.m., the resident told LPN #2 she was hurting all over. The LPN turned the resident more to her side, relieving the pressure to the Stage III pressure sore. The LPN then asked the resident if that was better. The resident stated, "A little." On 10/31/11 at 10:15 a.m., the DON was interviewed regarding the resident's pain management of only Tylenol. The DON was informed of the pressure sore treatment observation and how during the treatment the resident had moaned and told the staff to hurry up. The DON stated, "We probably should see about something stronger than Tylenol." The DON was informed the Tylenol had not been administered to the resident in October. 2. An annual assessment for resident #3, dated 02/09/11, identified the resident required total assistance with all ADLs, had a gastrostomy tube (G/T), an indwelling urinary catheter and was incontinent of bowel. A care plan, dated 02/16/11, and revised 07/27/11, documented: "Problem: Skin integrity, impaired: potential...Approach: ...report any red or open areas... Skin assessments 2 x/weekly..." A nurse's note, dated 06/06/11 at 4:00 p.m., documented, "Res returned to facility...noted 2 cm X 1 cm purple blood blister (L) cheek of buttocks, 1/8 cm X 1/8 cm open wound c yellow center to top of (L) ear lobe..." A skin assessment, dated 06/06/11, documented: "Wound #1: Location: (L) cheek buttocks. Stage: II Length: 2 cm. Width: 1 cm. Color: purple blood blister. Surrounding tissue: pink. Wound #2: Location: Top of (L) ear lobe. Stage: II Length: 1/8 cm. Width: 1/8 cm. Color: Open area c yellow center. Drainage: Scnt (scant). Surrounding tissue: Red...Dr. (Name deleted) notified N/O received et noted." A skin assessment, dated 06/14/11, documented, "...continues c blood blister to buttocks, tx in place..." The skin assessment did not contain documentation of staging and/or measurements of the Stage II pressure sore on the resident's buttocks identified on 06/06/11. The assessment did not address the Stage II pressure sore on the resident's (L) ear first identified on 06/06/11. A skin assessment, dated 06/21/11, documented, "0 skin bk noted. A physician's telephone order, dated 06/24/11, documented, "DC tx to (Lt) ear, area resolved. A physician's telephone order, dated 07/23/11, documented, "...Wd culture to pustule areas to pubic area." A nurses' note, dated 07/23/11, documented, "Res. lying in bed alert to verbal et tactile stimuli. Noted white vag discharge, yellow pustules X2 to pubic areas. Dr. (Name deleted) notified, N/O received et noted." A laboratory report, collected on 07/24/11, documented, "Specimen source: vulva pustules." A physician's orders [REDACTED]. DX: UTI." A skin assessment, dated 07/26/11, documented, "0 skin breakdown noted." The assessment did not contain documentation about the vulva pustules. No treatment had been located in the medical records. The final laboratory results, dated 07/28/11, documented, "Light growth of Proteus mirabilis, heavy growth of [MEDICAL CONDITION] (MRSA)." On the laboratory results, received and noted on 07/28/11, was a handwritten note which documented, "On [MEDICATION NAME] IM x 5 days." [MEDICATION NAME] was documented as "S" Susceptible for P. Mirabilis but documented "*" underneath [MEDICAL CONDITION] which implied had not been tested [MEDICAL CONDITION]. A quarterly assessment, dated 07/29/11, documented the resident was totally dependent on staff for bed mobility, transferring between surfaces and all ADLs. The resident had no pressure sore, but was at risk of developing pressure sores and had a feeding tube. A skin assessment, dated 08/02/11, documented: "Wound # 1 Location: Inner rt thigh...Area approx 1.5 cm in diameter." No description was documented regarding the inner (R) thigh. A skin assessment, dated 08/04/11, documented, "Nurse's notes: 0 skin bk noted." This skin assessment was completed two days after a wound had been identified on 08/02/11. The wound was not addressed on any future assessments. No further documentation on the vulva pustules [MEDICAL CONDITION] was located. The October 2011, physician's orders [REDACTED]. "Skin assessment 2 X weekly... Foley catheter for UTI & retention..." A nurse's note, dated 10/01/11, at 11:30 a.m., documented, "Noted small papule to res left pubis area..." An October 2011 flow sheet, documented, "Apply warm moist heat for 5 minutes, dry then apply [MEDICATION NAME]. LOTA q shift until resolved. 10/01/11 - Left pubic papule." A nurse's note, dated 10/02/11 at 11:00 p.m., documented, "Area to Lt groin, decreased in size, et not raised at this time..." A skin assessment, dated 10/04/11, documented, "...Ingrown hair to peri area almost healed, tx continues." A skin assessment, dated 10/12/11, 8 days later, documented: "Wound #1: pubic area. Stage: excoriation. Length: 2 1/2 cm. Width: 1 1/2 cm. Color: red. Wound #2: (R) buttocks. Stage: excoriation. Length: 2 cm. Width: 1 cm. Color: red. ...Vaseline applied." There was no documentation the physician had been notified of the excoriated areas nor a treatment obtained. A nurses' note, dated 10/13/11 at 5:30 p.m., documented, "Noted new small, purple papula to right labia, N/O noted..." The October 2011, flow sheet documented, "Apply warm, moist heat x 5 minutes to right, outer Labia, dry then apply [MEDICATION NAME] q shift. 10 - 13- 11" A skin assessment, dated 10/18/11, documented: "...Area to peg tube red-pink slight drainage, tx in place. Continues c small purple like area to pubic area." Nothing was documented regarding the excoriated areas on the pubic area and the (R) buttock. A nurses' note, dated 10/21/11 at 4:00 p.m., documented, "Resident conts with pustule to labia. Has [MEDICATION NAME] red, yellow drainage, moderate amount. N/O for culture & to start cleanse with [MEDICATION NAME] q shift & apply [MEDICATION NAME]." A telephone physician's orders [REDACTED]. Cleanse (R) labia with [MEDICATION NAME] & apply [MEDICATION NAME] q shift until resolved." A laboratory report, dated 10/22/11, documented: "Specimen source: Rt side of labia. Result: Moderate growth of Proteus mirabilis. Heavy growth of [MEDICAL CONDITION] resistance Staphylococcus aureus (MRSA)..." A physician's telephone order, dated 10/22/11, documented, "Culture Rt eye. DX: Lg amt of yellow drainage c redness to eye lid & eye." A laboratory report from an eye specimen collected 10/23/11, documented: "Specimen source: Rt eye yellow drainage. Result: heavy growth of ...MRSA..." The results were not received until after the resident had been discharge to the hospital on [DATE]. A telephone physician's orders [REDACTED].@ H.S. X 5 days. Dx: Wd. infection." A nurse's note, dated 10/25/11 at 8:00 p.m., documented, "Res. started on [MEDICATION NAME] 1 gm IM, for wd (wound) infection." A nurse's note, dated 10/26/11 at 11:00 a.m., documented, "Lab results telephoned by (Name deleted) hospital c critical WBC value of 24.2. Dr. (Name deleted) notified c N/O for direct admit to (Hospital) for Leukocytosis." On 10/28/11 at 3:00 p.m., the DON was interviewed. The DON was shown the inconsistency with the resident's skin assessments. The resident had [MEDICAL CONDITION] of the eye and in a wound on her labia. There was no documentation the resident's skin had been assessed twice weekly as ordered by the physician. [MEDICATION NAME] IM had been ordered on [DATE], but the resident did not receive the initial dose until the evening hours on 10/25/11. The DON reported she would try to take care of the problems. She reported the facility had been having to use a lot of agency nurses and it was making it harder to monitor everything. 3. The care plan for resident #2, dated 09/26/11, documented, "Skin Integrity Impaired Skin assessments 2x/weekly, Turn & reposition Q 2 hours. Pillow between legs & behind back when lying on side. Report any red or open areas...." A nurse's note, dated 09/27/11 at 2:30 a.m., documented, "...Placed blue chux beneath LUE d/t weeping clear serous fluid. 0.5 cm blisters x 2 observed to posterior LUE. Scabbed excoriation observed to stump of LLE." The admission skin assessment, dated 09/27/11, documented, "... [MEDICAL CONDITION] to left arm and hand, numerous scratches, scabs and abrasions to upper extremities. Skin very dry..." There was no documentation of notification to the physician about the LUE weeping blisters or the excoriation to the stump of LLE. A nurse's note, dated 09/28/11 at 1:00 a.m., documented, "Several small scabbed areas noted to BUE c [MEDICAL CONDITION] and serous drainage noted to LUE..." There was no documentation of notification to the physician about the [MEDICAL CONDITION] and serous drainage to LUE. A skin assessment, dated 09/30/11, documented: "...2 scabbed areas to L stump. 1- 1 cm reddish scab. 1- 1 cm yellowish scab." There was no documentation of notification to the physician about the yellow scab on the stump. The initial assessment, dated 10/03/11, documented the resident was moderately cognitively impaired, had one unstageable pressure sore. No other skin problems were identified. A skin assessment, dated 10/07/11, documented, "...1.5 cm x 1 cm scabbed area to bottom of stump" (picture shows left stump)" The physician was not notified about the area on the left stump increasing from 1.0 cm to 1.5 cm since 9/30/11. A nurse's note, dated 10/12/11, documented, "...Scabbed area to L stump appears infected @ this X AEB greenish exudate of scant amount, moist appearing scab c 0.03 cm red surrounding tissue. Cleansed c NS, patted dry. Awaiting N/O." A physician's orders [REDACTED]. The order to treat the area on the left stump was received 12 days after the area was originally seen on 09/30/11, as a yellowish scab. A skin assessment, dated 10/14/11, contained a picture with an arrow drawn toward the LLE stump. The only documentation was "Drsg". There was no actual assessment for the sore on the stump. A skin assessment, dated 10/21/11, was completed. There was no detailed assessment of the left stump ulcer. There was a drawing of a human with a line pointing to the (L) stump area noting a dressing in place. The assessment documented the wound was not assessed due to a dressing covering the area. A skin assessment, dated 10/26/11, documented, "Wound #1 Location - L stump Stage - II Length - 1.5 cm Width - 1.5 cm (LARGER) Depth - no Color - dark pink yellow Drainage - serous yellow Odor - no Surrounding Tissue - natural/dark pink" On 10/26/11 at 12:45 p.m., the resident was observed in his bed. Wound care was observed to the resident's (L) stump performed by LPN #1. The wound appeared approximately 1.5 cm x 1.5 cm, pink in color without drainage. The LPN treated the wound with TAO and then covered the wound with a dressing. On 10/28/11 at 2:13 p.m., LPN #1 was asked about the resident's weeping blisters and notification of the physician. She stated, "He had weeping [MEDICAL CONDITION] in that arm, but I didn't notice any blisters." She reported she didn't notify the physician and it had cleared up in a few days. She replied, "Dr. (Name deleted) is here four to five times a week. He could have been told verbally about the blisters." The LPN was asked if she notified the physician about changes in residents' skin. She stated, "I don't call on new stage II ulcers. We just used the same treatment on the new ones as we did on the others." On 10/28/11 at 3:00 p.m., the DON was asked when the physician should be notified regarding changes to residents' skin. She said the physician should be notified with changes to the skin including new wounds, changes with wounds and blisters. She said there was a communication book for the staff to write down their concerns for the physician to read. The DON was asked to bring the book to the surveyor. She came back and said there was nothing written regarding the resident.

Based on record review, observation and staff interview, it was determined the facility failed to ensure acceptable parameters of nutrition were monitored and maintained for one (#3) of seven residents sampled for weight and or nutrition. This caused harm for resident #3 who had inadequate nutrition evidenced by feeding tube rate of 50% less than required by dietary assessment, low [MEDICATION NAME], multiple UTIs, infections to skin and eye and significant weight loss. Findings: The [DIAGNOSES REDACTED]. An annual assessment, dated 02/09/11, and a quarterly assessment, dated 07/29/11, documented the resident was totally dependent on staff for bed mobility, transferring between surfaces, all ADLs, had an indwelling urinary catheter and had a feeding tube. A dietary progress note, dated 01/13/11, documented, "Weight 157.2 lbs, Jan wt. Cont on [MEDICATION NAME] 1.5 tolerating. Needs are met. Skin intact. Monitor." At that time, the rate of the [MEDICATION NAME] was 30 cc/hr, via a gastrostomy tube. A laboratory test, dated 02/08/11, documented, "Specimen source: peg site. Results: light growth of ...MRSA." A dietary progress note, dated 02/18/11, documented, "Weight: 156 lbs. Feb wt. Stable. Tolerating [MEDICATION NAME] 1.5. Needs are met..." A dietary progress note, dated 03/29/11, documented: "Type of assessment: annual Weight: 154 lbs...70 kg Total Calorie: 1300-1515... Total protein: 70-91... Total fluids: 1750 cc, 25 cc/kg... fluid flush: 250 cc QID. Diet order: [MEDICATION NAME] 1.5 30 cc/hr c 25 cc auto flush... Supplement: Healthy Shot qd... Oral/nutrition intake; food: 83% cal, 81% pro. TF provides: 720 cc, 45 g Pro, 1080 cal, 576 cc free water, total fluid: 2176... High risk secondary to high BMI, low Alb ([MEDICATION NAME]), TF Receives [MEDICATION NAME] 1.5 30 cc/hr c 25 cc H2O flush. 250 cc flush QID. Healthy Shots QD increase 75% needs met. Alb 2.6; last year PAB (pre-[MEDICATION NAME]) 14. Per staff can not tolerate higher rates / different formulas. Consider PAB level to compare c last years. If no improvement change Healthy Shots to BID or change to double shots which provide 24 g pro (protein)per 2.5 oz." A dietary progress note, dated 04/28/11, documented, "Weight 158.1 lbs. April wt. Stable. Tolerating TF. April PAB WNL..." A dietary progress note, dated 05/24/11, documented, "In hospital." A nurse's note, dated 06/06/11, at 4:00 p.m., documented, "Res returned to [MEDICATION NAME] feeding 1.5 started @ 15 cc/hr per N/O..." On 06/06/11, when the resident had been readmitted from the hospital the rate of the [MEDICATION NAME] had been decreased to 15 cc/hr, decreasing the resident's nutritional supply by half the amount previously received. The [MEDICATION NAME] amount had been decreased to 15 cc/hr due to an exacerbation of [MEDICAL CONDITION] while in the hospital. A dietary progress note, dated 06/29/11, documented, "144.3. June wt down 13.3 % 1 month. Secondary to TF being decreased d/t [MEDICAL CONDITION]. Doctor aware. Discussed c ADON. Needs not met. [MEDICAL CONDITION] is improving. Current rate 15 cc/hr. Cont to monitor." A dietary progress note, dated 07/19/11, documented, "147.5 Jly (July) wt tolerating TF. Noted wt change, wt up 3 # this month." The [MEDICATION NAME] reduction to 15 cc/hr was not addressed by the dietician. A telephone physician's orders [REDACTED]. The laboratory culture report, dated 07/24/11, documented, "...Heavy growth of ...MRSA..." A physician's telephone order, dated 07/27/11, documented, "Pre-[MEDICATION NAME] today. Dx: low [MEDICATION NAME]." A care plan, with a revision date of 07/27/11, documented: "Problem: Alteration in nutrition related to tube... Approach: Tube feeding per MD order: [MEDICATION NAME] 1.5 @ 15 cc/hr with 25 cc/hr water flush." A telephone physician's orders [REDACTED]." A laboratory report, dated 08/25/11, documented, "[MEDICATION NAME] 7.1 L(low) reference range 17-34 mg/dl." A note on the bottom of the report documented, "On Double Protein Healthy Shots will recheck." A dietary progress note, dated 08/30/11, documented, "150 August wt. Wt ranged 144-158 over past 6 mos. Tolerating TF. Monitor." A dietary progress note, dated 09/17/11, documented, "152 Sept wt. Stable. Cont c [MEDICATION NAME] 1.5 @ 30 cc/hr. Healthy double shots via TF d/t low PAB. Skin intact. Monitor." The resident was receiving [MEDICATION NAME] 1.5 @ 15 cc/hr, not [MEDICATION NAME] 1.5 @ 30 cc/hr. The October 2011, physician's orders [REDACTED]. "Weigh and record weekly...Hormel Healthy Shot double protein. Give 2.5 oz per tube twice daily. Give at 10 am and 10 pm. Dx: Low pre-[MEDICATION NAME]. [MEDICATION NAME] 1.5 @ 15 cc/hr via peg tube with water flush @ 25 cc/hr. Skin assessment 2 X weekly...Foley catheter for UTI & retention..." A nurses' note, dated 10/13/11 at 5:30 p.m., documented, "Noted new small, purple papula to right labia, N/O noted..." A telephone physician's orders [REDACTED]. A telephone physician's orders [REDACTED]. Dx: lg amt of yellow drainage c redness to eye lid & eye." A laboratory culture, dated 10/23/11, documented, "Specimen source: Rt side 0 labia...Heavy growth of ...MRSA..." A laboratory report from a specimen collected 10/23/11, documented, "Specimen source: Rt eye yellow drainage. Result: heavy growth of ...MRSA..." A laboratory report, dated 10/26/11, documented the resident's BUN as 46 with a reference range of 7-18 mg/dl and a WBC of 24.2 with a reference range of 4.5-10.5. A nurse's note, dated 10/26/11 at 11:00 a.m., documented, "Lab results telephoned by (Name deleted) hospital c critical WBC value of 24.2. Dr. (Name deleted) notified c N/O for direct admit to (Name deleted) hospital for Leukocytosis." The last weight obtained at the facility was dated the second week of October 2011. The weight was recorded @ 155.0 lbs. A hospital admit weight dated, 10/27/11, documented the resident's weight as 139.2 lbs. On 10/24/11, at 10:30 a.m., during the initial tour of the facility, the resident was observed lying in her bed. A gastrostomy feeding tube pump was observed to be administering [MEDICATION NAME] 1.5 @ 15 cc/hr with water flush @ 25 cc/hr. On 10/27/11, at 4:30 p.m., the RD was interviewed. She was shown the low pre-[MEDICATION NAME] laboratory report. The RD stated, "It should of been rechecked to determined if the test results were accurate." The RD reported she was not familiar with the resident due to the fact she was filling in for the regular RD who was not working due to a sickness in her family. On 10/27/11, at 5:20 p.m., the DON was interviewed. She was asked if the pre-[MEDICATION NAME] had been rechecked after it had tested low on 08/25/11. The DON stated, "I don't see where the pre-[MEDICATION NAME] was rechecked." She didn't know why it had not been rechecked. The DON was asked why the [MEDICATION NAME] feeding had been reduced to 15 cc/hr from the 30 cc/hr. The DON said the hospital had reduced the feeding due to an exacerbation of [MEDICAL CONDITION]. On 10/28/11, at 10:30 a.m., LPN #2, the charge nurse for day shift was also working as the CMA for the evening shift. LPN #2 was asked to obtain a container of the Healthy Shot. The LPN went into the nurses' supply area and obtained a bottle of the Healthy Shot from a drawer in the refrigerator. The container the LPN had obtained was labeled, "Healthy shot, High protein beverage." The label on the back of the container documented: "Servings per container: 1 Calories: 110... Protein: 12 g." The LPN and CMA #3 were both present at the time of the interview. The LPN and CMA were asked if this was the Healthy Shots administered to this specific resident. The LPN stated, "Yes, that is the only ones we have." CMA #3 was asked if she had noticed the resident's [MEDICATION NAME] intake being reduced to 15 cc/hr from the 30 cc/hr. The CMA said the resident had come back from the hospital with the decrease in [MEDICATION NAME] due to the resident experiencing an exacerbation of [MEDICAL CONDITION]. On 10/28/11, at 3:00 p.m., the DON was interviewed. The DON was informed of the staff reporting they were administering the Healthy Shot high protein and not the Healthy Shot double protein to the resident. The DON and the surveyor went into the nursing supply room. The DON opened the the drawer inside the refrigerator. The drawer contained both the Double Protein Healthy Shots and the High Protein Healthy Shots. At that time, the DON reported the staff had mixed the two kinds of protein Health Shots together. She then reported they were supposed to be separated because one was high protein the other was double protein.

Based on record review, observation and staff interview, it was determined the facility failed to: a) Ensure indwelling urinary catheter care was implemented for two (#9 and #11) of six sampled residents with indwelling urinary catheters. b) Ensure an indwelling urinary catheter was not utilized without a valid medical justification for one (#9) of six sampled residents with an indwelling urinary catheter. This had the potential to affect seven residents identified by the DON as utilizing an indwelling urinary catheter, four of which had been readmitted from the hospital since 12/16/11, with an indwelling urinary catheter. Findings: 1. A quarterly assessment, dated 11/22/11, for resident #11, documented the resident had inadequate short and long term memory, had severely impaired cognition, required limited assistance with bed mobility, transferring between surfaces, toilet use, personal hygiene, and was occasionally incontinent of bowel and bladder. The January 2012, physician's orders [REDACTED]. A nurses note, dated 01/09/12 at 2:00 p.m., documented, "Resident returned from (Name deleted hospital) via W/C with hospital staff..." physician's orders [REDACTED]. "...Foley Cath..." The treatment record dated, January 2012, did not contain documentation of the resident receiving care for the indwelling urinary catheter. On 01/18/12, at 2:30 p.m., the resident was observed to have an indwelling urinary catheter. A collection bag connected to the catheter contained a moderate amount of clear amber urine. LPN #1 was observed to provide indwelling urinary catheter care. On 01/17/12, at 3:00 p.m., the ADON was shown the treatment records. She was asked if the resident was receiving indwelling urinary catheter care. She reported she did not see it on the treatment record. She then took the treatment record and documented, "F/C care per protocol daily on 11-7 shift. F/C change monthly & as needed for displaced." 2. Resident #9 was admitted to the facility on [DATE], with an indwelling urinary catheter and a [DIAGNOSES REDACTED]. The care plan dated 01-09-12, documented the problem as, "Foley catheter for GU IRRIGANT FOR UTI." The goal documented, "Bladder elimination will be maintained safely through indwelling catheter. No S/S UTI." The interventions included, "...Change catheter per physician order, Encourage fluids, Foley catheter care per protocol & orders, Evaluate for eliminatio (sic) of foley catheter when irrigant complete..." A physician's orders [REDACTED].@ 9A & 9P X 7 days DX: UTI." The resident was observed on 01-17-12, at 2:30 p.m. to have an indwelling urinary catheter. The DON was interviewed on 01-17-12, at 3:40 p.m. and was asked why the resident had an indwelling urinary catheter. She stated the resident lived at home with her son before she was admitted to the hospital and then subsequently admitted to the facility. She stated the resident had the catheter while living with her son. She stated she talked with the resident's son and found out the catheter was being used for convenience due to the care giver not being able to move the resident. The DON stated she had planned on starting bladder training to remove the catheter with the physician's approval. She was asked if there was documentation to show this, or if she had a physician's orders [REDACTED]." She then showed the surveyor an 'Admission Evaluation and Interim Care Plan' dated 01-09-12, which documented, "Need to DC (discontinue) FC." On 01-17-12, at 4:20 p.m. LPN #4 was interviewed concerning the care of the indwelling urinary catheter. She was asked where the staff documented the care of the catheter. She looked at the January 2012, flow record and could not find any documentation showing the catheter was being cared for. She then stated, "I'll get that on there right now." The resident continued to have an indwelling urinary catheter as of 01-19-12.