Every finding on record at St Joseph Manor Health Care Inc

Based on observations, interviews, and record review, the facility failed to ensure care was provided to one Resident (#5), of 21 sampled residents, in accordance with professional standards of practice. Specifically, the facility failed to follow physician's orders to hold Resident #5's midodrine (prescription medication used to treat low blood pressure) per ordered parameters. Findings include:Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following:-The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Resident #5 was admitted to the facility in October 2021 with diagnoses which included end stage renal (kidney) disease (ESRD) and dependence on dialysis (a process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semi-permeable membrane). Review of Resident #5's Minimum Data Set (MDS) Assessment, dated 10/7/25, indicated he/she received dialysis. Review of Resident #5's Physician's Orders indicated but was not limited to:-Midodrine 10 milligrams (mg) by mouth on Mondays, Wednesdays and Fridays, hold for systolic blood pressure (SBP, the top number in a blood pressure reading, representing the pressure in your arteries when your heart contracts (beats) and pushes blood out) above 130, dated 10/19/22 Review of Resident #5's October, November, and December 2025 Medication Administration Record's (MAR) indicated his/her midodrine had been administered when his/her systolic blood pressure exceeded the ordered parameters and was above 130. Further review of Resident #5's October 2025 MAR indicated he/she was administered midodrine with a documented SBP greater than 130 on 11 occasions, as follows:-10/1/25: SBP of 137-10/3/25: SBP of 131-10/10/25: SBP of 149-10/13/25: SBP of 132-10/15/25: SBP of 142-10/17/25: SBP of 142-10/20/25: SBP of 159-10/22/25: SBP of 138-10/24/25: SBP of 140-10/27/25: SBP of 137-10/29/25: SBP of 145 Further review of Resident #5's November 2025 MAR indicated he/she was administered midodrine with a documented SBP greater than 130 on seven occasions, as follows:-11/3/25: SBP of 155-11/5/25: SBP of 139-11/7/25: SBP of 138-11/12/25: SBP of 148-11/19/25: SBP of 141-11/21/25: SBP of 136-11/28/25: SBP of 149 Further review of Resident #5's December 2025 MAR indicated he/she was administered midodrine with a documented SBP greater than 130 on four occasions, as follows:-12/3/25: SBP of 143-12/5/25: SBP of 138-12/8/25: SBP of 142-12/10/25: SBP of 149 During an interview on 12/10/25 at 4:36 P.M., Nurse #5 said Resident #5 was prescribed medication that had order parameters. Nurse # 5 said if Resident #5's systolic blood pressure was above 130, his/her midodrine should not have been administered. During an interview on 12/11/25 at 7:37 A.M., Nurse #2 said Resident #5 was ordered midodrine on days he/she went to dialysis. Nurse #2 said there was a parameter in place to ensure the medication was not administered if his/her systolic blood pressure was above 130. Nurse #2 said in the MAR there is a code to indicate that the medication was not administered because the vital signs exceeded the parameter. During an interview on 12/11/25 at 10:58 A.M., Unit Manager #1 said Resident #5 had an order for midodrine to be administered on days he/she went to dialysis and that it should not be administered if his/her systolic blood pressure was above 130. Unit Manager #1 said the nurse should document in the MAR that the medication was not administered due to the vital sign parameters. Unit Manager #1 reviewed Resident #5's MAR and said there were several dates that the midodrine was documented as administered when his/her systolic blood pressure was above 130. During an interview on 12/11/25 at 12:41 P.M., the Director of Nurses (DON) said she reviewed Resident #5's medical record and found documentation that midodrine was held on 11/24/25 and 11/26/25 but did not see any evidence in the medical record to show that the midodrine was not administered due to ordered parameters on any other dates. During an interview on 12/11/25 at 11:58 A.M., the DON said the expectation was for physician's orders to be followed as prescribed.

Based on records reviewed, document review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Specifically, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) while providing care to one Resident (#107), who was on contact precautions, to prevent the potential spread of infection. Findings include:Review of the facility's policy titled Transmission-Based Precautions, last revised March 2025, indicated but was not limited to:-Contact Precautions: Isolation gowns and gloves are required.-Contact Precautions are intended to prevent the transmission of infections that are spread by direct (person to person) or indirect (resident's environment and equipment).-Diseases/microorganisms requiring Contact Precautions include but are not limited to:-Vancomycin-Resistant Enterococci (VRE, Multi-Drug Resistant Organism (MDRO), a species of enterococcus which have developed resistance to the antibiotic, vancomycin.)Resident #107 was admitted to the facility in May 2025 with diagnoses including urinary tract infection (UTI).On 12/8/25 at 1:13 P.M., the surveyor observed a sign for Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of MDROs that employs targeted gown and glove use during high contact resident care activities) and for Contact Precautions outside of Resident #107's room.Review of the EBP sign indicated but was not limited to:- STOP ENHANCED BARRIER PRECAUTIONS- EVERYONE MUST:- Clean their hands, including before entering and when leaving the room.- PROVIDERS AND STAFF MUST ALSO:- Wear gloves and a gown for the following High-Contact Resident Care Activities.- Dressing- Bathing/Showering- Transferring- Changing Linens- Providing Hygiene- Changing briefs or assisting with toileting- Device care or use: central line, urinary catheter, feeding tube, tracheostomy- Wound Care: any skin opening requiring a dressingReview of the Contact Precaution sign indicated but was not limited to:-Contact Precautions (If you have questions go to Nurse Station)-EVERYONE MUST: -Clean hands when entering and leaving room -Follow Standard Precautions -Gown and gloves when entering roomDOCTORS AND STAFF MUST: -Use patient dedication or disposable equipment -Clean and disinfect shared equipmentOn 12/8/25 at 1:47 P.M., the surveyor observed Certified Nursing Assistant (CNA) #1 and CNA #2 enter Resident #107's room. Both CNAs performed hand hygiene and donned (put on) gloves and brought in a mechanical lift. CNA #1 and CNA #2 assisted Resident #107 back to bed using a mechanical lift. CNA #1 exited Resident #107 room doffed (took off) her gloves and took the mechanical lift into another resident's room, she failed to perform hand hygiene or wipe down the mechanical lift before bringing it into another resident's room. CNA #2 exited Resident #107's room doffed her gloves but failed to perform hand hygiene.On 12/9/25 at 3:40 P.M., the surveyor observed:-CNA #3 in Resident #107's room talking to him/her, she was not wearing gloves or a gown.-CNA #3 exited his/her room and failed to perform hand hygiene.On 12/9/25 at 3:57 P.M., the surveyor observed:-Nurse #3 enter Resident #107's room and move his/her bed.-Nurse #3 failed to don gloves and gown prior to entering the room.-Nurse #3 exited the room and failed to perform hand hygiene.-Nurse #3 then went up directly to another resident and touched him/her.On 12/9/25 at 4:00 P.M., the surveyor observed:-CNA #3 go into Resident #107's room she did not perform hand hygiene and did not don PPE prior to entering the room.-CNA #3 exited Resident #107's room did not perform hand hygiene and went directly to the clean linen cart.-CNA #3 re-entered Resident #107's room failing to perform hand hygiene and don PPE, and assisted him/her in bed-CNA #3 failed to perform hand hygiene after exiting the room.On 12/10/25 at 7:55 A.M., the surveyor observed:-CNA #4 bring a breakfast tray into Resident #107's room, failing to don PPE prior to entering room, position him/her in bed and set-up their breakfast tray.-CNA #4 exited his/her room and failed to perform hand hygiene.On 12/10/25 at 9:26 A.M., the surveyor observed:-CNA #2 don gloves and enter Resident #107's room, failing to perform hand hygiene prior to donning gloves and failed to don a gown.During an interview on 12/8/25 at 11:32 A.M., Unit Manager #2 said Resident #107 was on contact precautions for VRE in his/her urine. During an interview on 12/8/25 at 1:53 P.M, CNA #2 said Resident #107 had an infection in his/her urine and was on contact precautions. She said staff needed to wear gloves in Resident #107's room but needed a gown only when helping him/her with care that involved changing his/her brief. She said her and CNA #1 only helped Resident #107 into bed.During an interview on 12/8/25 at 1:57 P.M., CNA #1 said Resident #107 was on Contact Precautions for a UTI.During an interview on 12/9/25 at 3:44 P.M., CNA #3 reviewed the EBP and Contact Precaution signs outside of Resident #107's room and said Resident #107 was not on precautions.During an interview on 12/9/25 at 4:02 P.M., Nurse #3 reviewed the EBP and Contact Precaution signs outside of Resident #107's room and said he/she required contact precautions for VRE in their urine. She said CNA #3 should not have gone in and out of Resident #107's room without performing hand hygiene and donning PPE. She said CNA #3 should not have gone over to the linen cart without performing hand hygiene. She said that she did not have to don PPE because she had not done care for Resident #107 but had only moved his/her bed.During an interview on 12/10/25 at 9:26 A.M., CNA #2 said Resident #107 was on contact precautions and she needed to wear a gown and gloves when providing care for him/her and should have worn PPE but she did not.During an interview on 12/10/25 at 3:41 P.M., the Infection Perfectionist said Resident #107 was on Contact Precautions for VRE in his/her urine but is on EBP at baseline. She said all staff that entered Resident #107's room should have followed the more stringent precautions which, in his/her case, were contact precautions. She said all staff must perform hand hygiene and don and doff gloves and a gown upon entering and exiting Resident #107's room. She said all equipment must be wiped down when going from one resident's room to another's especially if they were on precautions.During an interview on 12/11/25 at 1:11 P.M., the Director of Nursing (DON) said all staff should follow the more stringent signs for precautions and must wear appropriate PPE.

Based on interview and record review, the facility failed to ensure the physician or nurse practitioner (NP) was notified timely of critical urinalysis culture & sensitivity (C&S) report for one Resident (#69), out of a total sample of 21 residents. Specifically, for Resident #69, their urinalysis C&S final report was reviewed with the NP on 12/1/25, four days after it was received in the facility on 11/27/25, resulting in Resident #69 receiving six doses of Macrobid (antibiotic) 100 milligrams (mg) before it was discontinued for a more effective antibiotic. Findings include: Review of the facility's policy titled Antibiotic Stewardship-Orders for Antibiotics, revised December 2016, indicated but was not limited to the following:1. Appropriate indications for use of antibiotics include:-Pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending).2. When a culture and sensitivity (C&S) Is ordered, it will be completed, and:-Lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. Resident #69 was admitted to the facility in October 2025 with diagnoses which included severe chronic obstructive pulmonary disease (COPD) oxygen dependent, coronary artery disease, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment, dated 10/21/25, indicated Resident #69 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #65 had moderate cognitive deficits. Review of Resident #69's Physician's Orders indicated:-May go on leave of absence (LOA) 11/26/25 Return 11/28/2025, May Take Medications.-Macrobid (antibiotic) Oral Capsule 100 mg (Nitrofurantoin Macro) Give 100 mg by mouth two times a day for positive urinary tract infection (UTI) for 5 days, order date 11/26/25 with start date 11/28/25 and discontinued 12/01/25.-Ertapenem (antibiotic) Sodium Injection Solution Reconstituted 1 gram (gm), inject 1 gm intramuscularly one time only for UTI Klebsiella (bacteria) for 10 days reconstitute with 3.2 milliliters (ml) 1% lidocaine, order date 12/1/25. Review of the November 2025 Medication Administration Record (MAR) indicated Resident #69 received Macrobid 100 mg on 11/28/25 at 10:00 P.M., 11/29/25 at 10:00 A.M. and 10:00 P.M., and 11/30/25 at 10:00 A.M. and 10:00 P.M. Review of the December 2025 MAR indicated Resident #69 received Macrobid 100 mg on12/1/25 at 10:00 A.M. Review of a Nursing Note, dated 11/24/25 at 12:47 P.M., indicated at 12:30 P.M. a urine sample was obtained for a repeat urinalysis (U/A) and C&S. Urine Dark Yellow. Specs Dated, Timed, Labeled, Lab made aware for pick up.Review of Lab/X-ray note, dated 12/1/25 at 1:56 P.M., indicated urine culture critical final report, dated 11/27/25 at 12:42 P.M., was positive for Klebsiella pneumonia urine greater than 100,000 colony-forming unit (cfu)/ml. NP Reviewed. New order to discontinue macrodantin, start ertapenem 1 gm with 3.2 ml lidocaine 1% intramuscular once daily for 10 days.Review of NP #1's progress note, dated 12/1/25, indicated Resident #69 recently started on antibiotics for UTI, was being treated with Macrobid however sensitivities revealed Klebsiella and more sensitive to ertapenem. During an interview on 12/11/25 at 10:55 A.M., Nurse Manager #3 said Resident #69 was symptomatic with UTI symptoms. She said the facility had received a call from the lab telling them the first urinalysis sample was not picked up in time, and they had to repeat the urinalysis on 11/24/25. She said she had notified the Physician who wanted to start Resident #69 on Macrobid when the Resident returned from their medical LOA on 11/28/25. Nurse Manager #3 reviewed the electronic medical urinalysis results which included the C&S, which indicated the collection date of 11/24/25 and the final results were reported 11/27/25. The report further indicated that it was accessed by the facility for the first time on 12/1/25. Nurse Manager #3 said the lab would have faxed and/or called over the C&S results on 11/27/25 and the C&S should have been reported to the on-call physician or NP, but it was not until 12/1/25. On 12/11/25 at 11:05 A.M., Resident #69's urinalysis C&S faxed results were in a wall folder at the nurses' station. The lab results had a fax time stamp of 11/27/25 at 10:46 A.M., and there was no written notation on the lab report indicating the results were read. During an interview on 12/11/25 at 11:17 A.M., Nurse Manager #3 said that when she returned to work on 12/1/25, the C&S was reviewed with NP #1. She said NP #1 then changed the antibiotics from the prescribed Macrobid to the more sensitive Ertapenem antibiotic. During an interview on 12/11/25 at 11:45 A.M., Nurse #7 said she was here on 11/27/25 and said she did not see the fax of the urinalysis and C&S. She said if she had, she would have called the Physician or NP and informed them of the sensitivity report and she would have written a note on their response. On 12/11/25 at 11:12 A.M., the surveyor left a voicemail message on NP #1's phone and did not get a return phone call.

Based on observation, interview, and record review, the facility failed to ensure all medications were stored and labeled in accordance with currently accepted professional standards. Specifically, the facility failed to ensure staff properly labeled and stored all medications in one of three medication carts reviewed.Findings include: Review of the facility's policy titled Medication Labeling and Storage, undated, indicated but was not limited to the following:-Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. -Medications are kept in the packaging in which they were dispensed by the pharmacy-Controlled substances and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detectedDuring an observation with interview on 12/10/25 at 11:30 A.M., the surveyor completed a review of the medication cart on the Applewood Unit with Nurse #3, and made the following observations:-In the top drawer there was one small, clear plastic medication cup, uncovered and not labeled, which contained seven loose pills.Nurse #3 said the medication cup with the loose pills was for Resident #76. She said she had prepared the morning medications and then realized the Resident was attending activities and had been keeping the medications in the top drawer until the Resident returned. She said she had not discarded the medications because there was a controlled substance in the cup. She said the standard practice was to discard the medications, as indicated, if the Resident was not available and she had not done this.Review of the Medication Administration Record (MAR) for Resident #76 indicated the following medications were scheduled for 9:00 A.M.:Aspirin 81 milligrams (mg)Losartan potassium tablet 50 mgMetformin HCl ER (extended release) 500 mg, give two tabletsMetoprolol succinate ER 25 mgMultivitaminPregabalin 100 mg (a controlled substance)During an interview on 12/11/25 at 11:57 A.M., the Director of Nurses said the nurse should not store medications in an unlabeled medication cup in the medication cart and the nurse should have followed the appropriate procedures to discard the medications.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure the main kitchen, main dining room steam table, and basement food storage area were clean and maintained in a sanitary manner to prevent potential food contamination; and 2. Maintain two of three kitchenettes in a clean and sanitary condition, and ensure food stored is not expired and stored at appropriate temperatures to prevent foodborne illness. Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised ,d+[DATE], indicated but was not limited to the following: ,d+[DATE].11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location. ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. ,d+[DATE].11 (D) Equipment is used for storage of packaged or unpackaged food such as a reach-in refrigerator and the equipment are cleaned at a frequency necessary to preclude accumulation of soil residues. ,d+[DATE].12 (A) Physical facilities shall be cleaned as often as necessary to keep them clean. 1. On [DATE] at 8:15 A.M., the surveyor made the following observations in the main kitchen, dry storage in the basement, and Main dining room off the kitchen: Main kitchen: -On the shelf below the main steam table there were numerous mouse droppings and food particles. -On the floor between the kitchen appliances and wall, there were numerous mouse droppings, dirt and debris. -Under the steam oven there was an open drain that was clogged with debris and grayish/black thick wet slime and there was standing water around the drain opening. -To the right of the walk-in refrigerator was a staff break area with debris and food particles on the floor. The wall was visibly dirty with dried liquid stains by the table. On the table was a white bag containing food, not labeled or dated. -The dish room floor mat was observed to have buildup of black wet debris in the cut-outs, and when the mat was lifted there was a large amount of wet black debris. -The main kitchen ice machine drip tray drain was clogged with debris. The drip tray had a buildup of black wet substance. The clear plastic cover where the ice is dispensed was dirty. Dry storage in the basement: -Borders of the entire room under the shelves had buildup of debris and mice droppings. Main dining room off the kitchen: -In the cabinet below the main steam table there were numerous mouse droppings. During an interview on [DATE] at 8:15 A.M. through 9:00 A.M., the Food Service Manager (FSM) said they had a problem with mice over a month ago, but the pest control company is here weekly, and we have not seen any sightings in the past month. The FSM said the kitchen, steam tables and the basement should have been cleaned of all mice droppings. The corners and behind the kitchen appliances, the drain under the steam table, and the ice machine should have been cleaned. 2. On [DATE] at 9:00 A.M., the surveyor observed Applewood dining room and kitchenette and made the following observations: -The kitchenette cabinets and drawers stored snacks, glasses, silverware, condiment packages and drinks. -The cabinet with the lazy [NAME] carousel had clothing and debris, and the shelves were soiled with dried liquid, and a large box of Oreo cookies. -The outside of the lower cabinet's doors was visibly stained and were tacky to the touch. -Inside the lower cabinet doors, the shelves were dirty with debris and numerous dried liquid stains and were tacky to touch in areas with stains. -The drawers were dirty with buildup of small particles of debris, dried liquid stains, and the inside and outside were tacky to touch. -The top cabinet shelves had old, dried liquid stains and debris and the drinking glasses and mugs were stored upside down on the shelves. -The floor along the border of the cabinets had a buildup of black debris and food particles. On [DATE] at 11:15 A.M., the surveyor observed the kitchenette on the [NAME] One Unit and made the following observations: -The upper left cabinet had nine individual containers of Nepro with an expiration date of [DATE], and three Thick and Easy containers with expiration date of [DATE]. -The bottom left drawer contained one TwoCal container with an expiration of [DATE], one Osmolite with an expiration of [DATE], and three containers of Nepro with an expiration of [DATE]. -In the refrigerator was a bowl of oatmeal and a glass of milk not dated or labeled. -Stored on the counter in the corner was a bowl containing two eggs, a paper cup with two eggs, a paper cup with four cooked sausages not stored with temperature control and not labeled or dated. During an interview on [DATE] at 2:15 P.M., the FSM said he was aware of the issues with the food storage in the kitchenettes and the expired supplement drinks. He said all food should be stored labeled and dated and discarded if they are expired.

Based on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Perform a COVID-19 related investigation and conduct contact tracing to prevent, to the extent possible, the onset and spread of infection; and 2. Maintain an infection prevention and control program which included a complete and accurate system of surveillance to identify any trends or potential infections. Findings include: 1. Review of the facility's policy titled COVID-19 Policy and Procedure, dated as revised 3/23, indicated but was not limited to the following: -Perform outbreak testing of residents and staff as soon as possible when a case is identified. -If facility identifies that the resident or staff member's first exposure occurred less than 24 hours ago, then they should wait to test until 24 hours after any exposure. -Test exposed residents and staff at least every 48 hours on the affected unit until we go seven days without a new case -Residents and staff who are recovered from COVID-19 in the last 30 days can be excluded from this testing. Review of the facility's policy titled Infection Prevention and Control Program (IPCP), dated as revised 2018, indicated but was not limited to the following: -The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, and outbreak management -Outbreak Management is the process that consists of: Determining the presence of an outbreak, documenting information about the outbreak Review of CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, revised May 2023, indicated but was not limited to the following: -Healthcare facilities should have a plan for how SARS-CoV-2 exposures in a healthcare facility will be investigated and managed and how contact tracing will be performed. -A single new case of SARS-CoV-2 infection in any healthcare personnel (HCP) or resident should be evaluated to determine if others in the facility could have been exposed. -Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. During an interview on 11/4/24 at 10:05 A.M., the Infection Preventionist (IP) said she monitors any positive case of COVID-19 on a tracking sheet. Review of the most recent COVID-19 outbreak documentation provided by the IP on 11/4/24 at 10:34 A.M. titled Residents Illness Tracking Form, indicated the facility had two positive residents in January 2024, eight positive residents in February 2024, and one positive resident in March 2024. The tracking forms failed to indicate any contact tracing, testing of close contacts or evaluation of the outbreak to determine if other residents or staff may have been exposed to COVID-19. During an interview on 11/4/24 at 3:46 P.M., the IP said the COVID-19 outbreak began in January 2024 with one positive resident. She said the facility also had some positive staff members. The IP said all close contacts, including staff were tested on the affected unit day one, day two, and day five, until there were no more positive cases until day 10. She said resident testing is documented in the specific resident record, and she does not document positive staff on any tracking sheets. The IP said the staff are responsible for testing themselves and provide her with a photo if they test positive for COVID-19. She said she has no way of knowing if staff tested when required to do so. She does not keep track of the staff testing and has no further documentation regarding the COVID-19 outbreak in the facility. The surveyor and IP reviewed the facility provided COVID-19 procedure guidelines together. The IP said she was unaware of the updated guidelines and has not been following them. During an interview on 11/5/24 at 2:36 P.M., the Director of Nursing (DON) said her expectation is for the IP to conduct a complete investigation of a COVID-19 positive case per the facility guidelines. She said contact tracing and testing must be completed and documented to help determine the status of the outbreak and reduce the spread of COVID-19. 2. Review of the facility's policy titled Surveillance for Infections, dated as revised 9/2017, indicated but was not limited to the following: -The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. -The criteria for such infections are based on the current standard definitions of infections -The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms, and Healthcare-Associated infections, to guide appropriate interventions, and to prevent future infections. Review of the facility's policy titled Infection Prevention and Control Program (IPCP), dated as revised 2018, indicated but was not limited to the following: -Surveillance: Process surveillance (adherence to infection prevention and control practices) and outcome surveillance (incidence and prevalence of healthcare acquired infections) are used as measures of the IPCP effectiveness -Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices. Review of the facility's surveillance data sheets titled Monthly Infection Line Listing indicated but was not limited to the following: July 2024 -7 out of 20 residents met criteria for infection and 20 out of 20 residents were started on antibiotics. August 2024 -4 out of 19 residents met criteria for infection and 19 out of 19 residents were started on antibiotics. September 2024 -3 out of 17 residents met criteria for infection and 17 out of 17 residents were started on antibiotics. The monthly line listings failed to indicate any tracking of illness, not prescribed antibiotics, for surveillance of the potential spread of illnesses. During an interview on 11/4/24 at 3:46 P.M., the IP said the facility uses McGeer Criteria (set of guidelines used to identify HAIs) to determine if an illness meets criteria for infection. She said she reviews the residents' progress notes and the 24-hour shift report to determine if residents have signs and symptoms of an infection. The IP said she does not track or monitor any residents that do not require the use of antibiotics. During an interview on 11/5/24 at 2:36 P.M., the DON said her expectation is for the monthly line listings to include all illnesses, not just antibiotic use, to ensure proper tracking of illness and infections within the facility.

Based on record review and interview, the facility failed to provide indwelling catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care and management consistent with professional standards for one Resident (#98), out of a total sample of 22 residents. Specifically, the facility failed to ensure the Foley catheter was assessed for removal as soon as possible after returning from the hospital and failed to ensure he/she followed up with Urology as recommended. Findings include: Review of the facility's policy titled Catheter Care, Urinary, revised August 2022, indicated but was not limited to the following: -Nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is in place. Use standardized tool for documenting clinical indications for catheter use. -Remove the catheter as soon as it is no longer needed. Review of the facility's form titled Foley Catheter Assessment, undated, indicated but was not limited to the following: -The goal of this assessment is to determine if an indwelling catheter can be removed without detrimental consequences for the resident. -If none of the conditions apply, proceed with assessment as follows: 1. Notify physician to discontinue order. 2. If resident is incontinent after removal; proceed to bladder incontinent management program. Resident #98 was readmitted to the facility in May 2024 with diagnoses including neuromuscular dysfunction of bladder, quadriplegia cervical level 1-4 incomplete, cervical 2 spinal cord injury American Spinal Injury Association ([NAME]) D (Motor function is preserved below the neurological level at least half), cerebral infarction (stroke) with hemiplegia (weakness) involving right side. Review of the Minimum Data Set (MDS) assessment, dated 7/31/24, indicated Resident #2 scored 9 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had moderate cognitive impairment. During an interview on 11/05/24 at 1:35 P.M., with Resident #98 present, Family Member (FM) #1 said Resident #98 has not seen a urologist since admission to this facility. FM #1 said they have been asking for the Foley catheter to be removed and have spoken to multiple staff members, including Nurse #9. FM #1 said prior to Resident #98's initial admission to the hospital in December 2023, Resident #98 did not have a Foley catheter and when Resident #98 was in the Hospital in May 2024, they had removed the catheter but put it back in because Resident #98 was incontinent. Resident #98 and FM #1 said they would like to see if the catheter can be removed. Review of the Hospital Discharge Summary, dated 5/2/24, indicated but was not limited to the following: -Brief hospital course: intraventricular hemorrhage (stroke) patient presented with left sided neglect in hemi-inattention, balance difficulties with relatively preserved strength. - During his/her stay patient developed progressive dyspnea (shortness of breath). -He was treated with intravenous diuresis (medication to increase removal of fluid through the kidneys) and the patient's respiratory status markedly improved to his/her baseline and was converted to oral diuresis medication. -Urinary incontinence (loss of bladder control): Patient remained incontinent particularly at night. Given incontinence and now large dose of diuresis, plan on continuing Foley catheter. Review of the Foley Catheter Assessment, dated 5/2/24, indicated the form was blank except for a facility staff member's signature at the bottom. Review of the Comprehensive Care plan indicated Resident #98 had an indwelling catheter dated 5/16/24. Further review of the care plan did not indicate any assessment for removal or follow-up with a urologist (Physician who specializes in treatment of urinary function or disorders). Review of the Nursing Note, dated 5/30/24 at 3:39 P.M., indicated Veterans Administration (VA) in process of scheduling urology appointment. Review of the Nursing Note, dated 5/21/24 at 2:58 PM., indicated Resident #98 noted this morning with large continuous amounts of blood clots coming from penis. Nurse Practitioner (NP) made aware and new order to send to hospital for evaluation at 8:30 A.M., still being evaluated at this time. Review of the Nursing Note, dated 5/21/24 at 10:35 P.M., indicated Resident #98 returned from the hospital at 7:33 P.M. Discharge summary said urine shows no blood and is clear, no new order, follow-up with specialist. Family and on call notified. Review of the Nurse Practitioner's (NP) progress note, dated 5/28/24, indicated but was not limited to the following: History of Present Illness: - Patient is status post hospital transfer related to blood coming through urinary meatus (tip), however no hematuria (blood) noted. -Medical work-up without acute findings, urine negative for urinary tract infection and patient returned to facility, unable to locate any discharge summary but this was reported from nursing staff. -Will refer to urology for evaluation. Assessment/Plan: -Anemia: Patient with drop in hemoglobin (protein in red blood cells that carries oxygen) and hematocrit (percentage of red blood cells in total blood volume) (H&H) from admission, nursing reports clots from urinary meatus (tip of the urethra) but no hematuria, will refer to urology. Review of the NP's progress note, dated 6/14/24, indicated but was not limited to the following: -Patient with a drop in H&H from admission nursing staff report clots from urinary meatus, but no hematuria. Will refer to urology. Review of the Appointment book on the unit failed to indicate a urology appointment had been made. Further review of the medical record including Physician, NP and nursing notes, physician orders, and assessments failed to indicate that Resident #98 was evaluated for removal of the catheter, a voiding trial was attempted to remove the catheter, or was scheduled to see a urologist for evaluation of the catheter need.

Based on interview and observation, the facility failed to maintain a clean environment and in good repair in 5 bedrooms (rooms 214, 215, 216 , 217 and 222) on one resident unit ([NAME] II). Findings include: During observations of the [NAME] II resident unit on 8/2/23 at approximately 9:00 A.M. and on 8/03/23, at approximately 9:30 A.M., the surveyor observed the following: * room [ROOM NUMBER]: seal on the exterior window was broken and moisture and mildew had built up between the panes, causing the glass to become streaked and opaque. * rooms [ROOM NUMBERS] shared bathroom: strong urine-like odor permeating the bathroom and could be smelled from the bedrooms. * room [ROOM NUMBER]: seal on the exterior window was broken and moisture and mildew had built up between the panes, causing the glass to become streaked and opaque. * room [ROOM NUMBER]: wall plaster next to the resident's bed is gouged in approximately 15, 1 spots, covering a 3' x 3' area. During observations on 8/3/23 at 11:36 A.M., accompanied by the Administrator, maintenance staff and housekeeping staff, we entered room [ROOM NUMBER], the shared bathroom for rooms [ROOM NUMBERS], room [ROOM NUMBER], and room [ROOM NUMBER]. There had been no change to the windows in rooms [ROOM NUMBERS] or the gouged wall in room [ROOM NUMBER]. The bathroom shared by rooms [ROOM NUMBERS] had been cleaned sometime after the surveyor's observation that morning and while the urine-like odor was improved it still could be smelled from the bedrooms. During an interview with the Administrator on 8/3/23 at 11:55 A.M., he said the facility had plans in its Facility Assessment to refurbish the [NAME] II unit. Review of the Facility assessment dated [DATE], indicated a plan which included painting resident units, but did not reference repairing/cleaning windows, deodorizing bathrooms, or repairing wall plaster.

Based on observation, record review and interview, the facility failed to implement the plan of care for one Resident (#86), out of a total of 24 sampled residents. Specifically, the facility failed to ensure Resident #86's call light was within reach. Findings include: Resident #86 was admitted to the facility in December 2022 with diagnosis including hemiplegia and dysphagia. Review of Resident #86's Minimum Data Set assessment dated [DATE], indicated he/she is severely cognitively impaired and had impairment on one side of his/her upper and lower extremities. Review of Resident #86's fall care plan dated 12/21/22, indicated the following intervention: Be sure Resident #86's call light is within reach and encourage him/her to use it for assistance as needed. Resident needs prompt response to all requests for assistance. On 8/2/23 at 9:59 A.M., the surveyor observed Resident #86 in bed. There was a sign on the wall indicating for staff to keep call light in reach on his/her left side. There was a tap call light (a call light used for individuals with dexterity issues) wrapped on the wall out of reach and inaccessible to Resident #86. On 8/4/23 at 9:04 A.M., the surveyor observed Resident #86 in bed with his/her tap call light on the floor at the foot of the bed, inaccessible and out of reach. During an interview on 8/4/23 at 9:09 A.M., Unit Manager #3 said Resident #86's call light should be within reach.

Based on record review and interviews, the facility failed to revise the plan of care related to dialysis for one Resident (#72), out of a total sample of 24 residents. Findings include: Resident #72 was admitted to the facility in October 2021, with diagnoses including dependence on renal dialysis (a treatment used when kidneys fail to remove toxins from blood and extra fluid from the body), end stage renal disease and dementia. Review of the most recent Minimum Data Set assessment dated [DATE], indicated a Brief Interview for Mental Status score of 9 out of a possible 15 indicating moderate cognitive impairment. Further review indicated Resident #72 receives dialysis. Review of Resident #72's medical record indicated the following: -A physician order dated 10/7/22 to check bruit and thrill every shift related to arteriovenous fistula (a surgically created access point for dialysis usually located in the arm). -A care plan revision dated 10/8/22 indicated Resident #72 requires hemodialysis related to End Stage Renal Disease with interventions including a Tesio Catheter (An access point for renal dialysis located in the chest) to Right Chest Wall for Hemodialysis. During an interview on 8/3/23 at 1:04 P.M., Nurse #4 said Resident #72 has an AVF (arteriovenous fistula) and has not had a Tesio Catheter that she is aware of. Nurse #4 said the unit manager is responsible for updating the care plans. During an interview on 8/3/23 at 1:12 P.M., Unit Manager #2 said Resident #72 has an AVF and does not have a Tesio Catheter. Unit Manager #2 said the expectation is for care plans to be updated to reflect the residents' current interventions.

Based on interview, record review and policy review, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for two Residents ( #22 and #17) out of a total sample of 24 residents. Specifically, the facility failed to: 1. For Resident #22, ensure nursing staff administered Coumadin (anticoagulant) for Resident #22, who was recently diagnosed with a deep vein thrombosis (DVT). 2. For Resident #17, administer medications in accordance with standards of practice, and not crush enteric coated (EC) and extended release (ER) medications. Findings include: 1. Resident #22 was admitted to the facility in May 2023 with diagnoses including dementia, anemia, chronic kidney disease, and presence of vascular implants and grafts. Review of Resident #22's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 2 out of a possible 15, which indicated Resident #22 had severe cognitive impairment. Review of Resident #22's July 2023 Physician Orders, dated 7/22/23, indicated Coumadin Oral Tablet 2.5 mg (milligram) by mouth at bedtime on 7/22/23 and 7/23/23. Review of Resident #22's July 2023 Medication Administration Record (MAR), indicated on 7/23/23 the Coumadin 2.5 mg order was 5=Hold/See Progress Notes. Review of Resident #22's nursing progress note, dated 7/23/23, indicated Incident Note Late Entry: Note Text: Medication Warfarin (Coumadin) medication was not administered during this shift because this writer was told by the nurse handing off that it was on hold. Review of Resident #22's anticoagulant care plan, dated 5/8/2023, indicated 5/18/23 Resident #22 is positive for a DVT (deep vein thrombosis) to the Right Lower Extremity. Give medications as ordered. Monitor for side effects, effectiveness. During an interview on 8/03/23 at 1:23 P.M., the Director of Nurses said that the nurse did not administer the Coumadin medication as ordered and said she is not sure why the nurse did not. 46339 2. Resident #17 was admitted to the facility in February 2023 with diagnoses including hypertension and stroke. Review of facility policy titled 'Medication Administration General Guidelines', dated January 2021, indicated the following but not limited to: *Long-acting, extended release or enteric-coated dosage forms should generally not be crushed; an alternative should be sought. During an observation on 8/3/23 at 9:46 A.M., Nurse #2 prepared and administered the following medications for Resident #17: -Aspirin 81 mg (milligrams) EC (Enteric Coated) one tablet by mouth crushed in applesauce -Metoprolol 50 mg ER (Extended Release) one tablet by mouth crushed in applesauce. During an interview on 8/3/23 at 11:46 A.M., Nurse #2 said she should not have crushed the medications as they are not to be crushed. During an interview on 8/3/23 at 11:36 A.M., the Director of Nursing said the expectation is that nurses would not crush medications that are enteric coated or extended release.

Based on observations, records reviewed, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when one out of two nurses observed made three errors out of 29 opportunities resulting in a medication error rate of 10.34%. Those errors impacted two Residents (#59 and #17), out of 4 residents observed. Findings include: Review of facility policy titled 'Medication Administration General Guidelines', dated January 2021, indicated the following but not limited to: Policy: Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices and only legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Procedures: *If it is safe to do so, medication tablets may be crushed or capsule emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines and with a specific order from prescriber. *Long-acting, extended release or enteric-coated dosage forms should generally not be crushed; an alternative should be sought. *Check expiration date on package/container. No expired medication will be administered to a resident. 1. For Resident #59, Nurse #2 prepared to administer an expired Vitamin C 500 mg (milligram) On 8/3/23 at 8:57 A.M., Nurse #2 prepared the following medication and was ready to administer to Resident #59. -Vitamin C 500 mg (milligram) one tablet which had and expiration date of 2/23. During an interview on 8/3/23 at 9:13 A.M., Nurse #2 said she should not administer expired medications to the Resident. 2. For Resident #17, Nurse #2 crushed and administered medications that were enteric coated (a coated medication to prevent stomach irritations) and extended release (medication designed to last longer in the body over time) which were not supposed to be crushed. On 8/3/23 at 9:46 A.M., Nurse #2 prepared and administered the following medications for Resident #17. -Aspirin 81 mg EC (Enteric Coated) one tablet by mouth crushed in applesauce -Metoprolol 50 mg ER (Extended Release) one tablet by mouth crushed in applesauce. During an interview on 8/3/23 at 11:46 A.M., Nurse #2 said she should not have crushed the medications as they are not to be crushed. During an interview on 8/3/23 at 11:36 A.M., the Director of Nursing said the expectation is that nurses would not crush medications that are enteric coated or extended release.

Based on observations, policy review and interviews the facility failed to to ensure that 1. medications were stored securely on one unit and 2. Medications were not left on the medication cart unsecured. Findings include: Review of the facility policy titled Storage of Medication, dated 1/21, indicated Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. 1. On 8/2/23 at 8:42 A.M., the surveyor observed the treatment cart on the Cherry [NAME] Unit was unlocked with no nurse present. The surveyor observed multiple medications and treatment supplies in the cart. On 8/3/23 at 8:13 A.M., the surveyor observed the treatment cart on the Cherry [NAME] Unit was unlocked with no nurse present. The surveyor observed multiple medications and treatment supplies in the cart. During an interview on 8/3/23 at 8:13 A.M., Nurse #1 said that the treatment cart should always be locked if a nurse is not at the cart. During an interview on 8/3/23 at 8:51 A.M., Unit Manager #1 said the treatment cart should always be locked if a nurse is not present at the cart. 46339 2. During a medication pass on Apple [NAME] unit on 8/3/23 at 8:57 A.M., Nurse #2 was observed preparing the following medication for administration. -Miralax powder 17 GM (grams) mixed in eight ounces of water. Nurse #2 was observed walking away from the medication cart and left the water with medication on top of the medication cart. A resident was observed walking by the medication cart. During an interview on 8/3/23 at 9:19 A.M., Nurse #2 said she should not have left medication on top of the medication cart unattended. During an interview on 8/3/23 at 11:36 A.M., the Director of Nursing said nurses should secure medications before walking away from the medication cart.

Based on observation, policy review and interview the facility failed to ensure food items were stored and labeled in accordance with professional standards for food service safety in the kitchen. Findings include: Review of the facility's General Food Preparation and Handling policy, dated 2021, indicated: Leftovers must be dated, labeled, covered, cooled and stored in a refrigerator. Use leftovers within 72 hours or discard. On 8/2/23 at 7:23 A.M., the surveyor observed the following in the reach-in and walk-in refrigerators in the kitchen: *two containers of lactaid milk with an expiration date of 7/21/23 *wrapped cold cuts that were undated *an unknown food item wrapped in tinfoil undated *two styrofoam plates wrapped together together with plastic wrap with initials, but no date or indication what the food item was *a container of cooked scrambled eggs and peppers dated 7/12/23 *a container of pasta salad undated. During an interview on 8/4/23 at 7:45 A.M., the Food Service Director (FSD) said that items in the refrigerator need to be dated and disposed of after three days. The FSD said the observed items should have been discarded.

Based on observation, record reviews and interviews, the facility failed to maintain accurate medical records for one Resident (#59) out of a total sample of 24 residents. Findings include: Resident #59 was admitted to the facility in September 2022 with diagnoses including dementia and pain in right foot. Review of Resident #59's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 5 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severely impaired cognition. The MDS further indicated that the Resident was on a scheduled pain medication regimen. On 8/3/23 at 9:24 A.M., during a medication pass the surveyor observed Nurse #2 remove a pain patch from Resident #59's lower back, the patch was dated 7/30. Review of Resident #59's physician orders indicated the following order dated 6/16/23: *Salonpas patch 3.1-6-10% (Camphor-Menthol-Methyl [NAME]) Apply to lower back topically one time a day for pain management remove at 5 PM and removed per schedule. Review of Resident #59's Medication Administration Record (MAR) dated 7/31/23, 8/1/23 and 8/2/23 indicated that the nurse marked the above order as complete. During an interview on 8/3/23 at 9:28 A.M., Nurse #2 said the patch should be applied and removed as ordered [daily], she further said nurses should not be signing off if a task is not complete. During an interview on 8/3/23 at 11:36 A.M., the Director of Nursing said nurses should only sign off on completed task.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose plan of care indicated he/she required physical assistance of two staff members for bed mobility including turning and repositioning during care, the Facility failed to ensure interventions from his/her plan of care were consistently implemented by staff, when a Certified Nurse Aide (CNA) repositioned Resident #1 without another staff member present to assist her, and he/she sustained a skin tear during care. Findings include: The Facility's Policy, titled Initial Resident Assessment and Reassessment, not dated, indicated each resident admitted shall receive a complete assessment so a plan of care can be developed to best meet the needs of the resident. The assessment of the care required to meet the needs of the resident will be ongoing throughout the resident's facility stay, with the assessment process individualized to meet the needs of the resident population. The Facility's Policy, titled Resident Care Policy, dated as reviewed on 1/27/21, indicated the interdisciplinary team responsibilities include the development and implementation of a comprehensive, individualized plan of care based on interdisciplinary assessments of the resident. Resident #1 was admitted to the Facility in August 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Care Plan related to Activities of Daily Living (ADL's), dated as revised on 3/14/22, indicated he/she had physical deficits related to immobility, and rigidity. Resident #1's Care Plan indicated for bed mobility, positioning and weight shifting, and that he/she required assistance of two staff members. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 3/21/22, indicated he/she required two person extensive physical assistance with the following ADL's; bed mobility, positioning, transfers, toileting needs, personal hygiene, and was totally dependent on two persons for bathing. The MDS indicated Resident #1 was wheelchair bound, and had functional limitations with range of motion to his/her upper and lower extremities. Review of a Nurse Progress Note, dated 5/04/22 at 12:42 P.M., indicated during the 11:00 P.M. to 7:00 A.M. shift (5/04/22) Resident #1 acquired a 1.25 inch left anterior hand skin tear. During an interview on 5/23/22 at 1:15 P.M., Certified Nurse Aide (CNA) #1 said she did not know that residents at the Facility had Care Plans. CNA #1 said she did not know where to find the Care Plans. CNA #1 said in the morning on 5/04/22, during the 11:00 P.M. to 7:00 A.M. shift she repositioned Resident #1 in bed to provide incontinent care, and said she did not have another staff member there to assist her. CNA #1 said she was unsure whether or not Resident #1 required a one or two person assist with being repositioned in bed. CNA #1 said she did not get another staff member to help her. CNA #1 said when she repositioned Resident #1 from his/her right side onto his/her back, Resident #1 tapped her with his/her right hand to show her he/she was bleeding from his/her left hand. CNA #1 said she left the room, found Nurse #1 and told him Resident #1 had a skin tear on his/her hand. CNA #1 said she does not know how Resident #1 obtained the skin tear to his/her left hand, but said he/she did have several long fingernails. CNA #1 said Resident #1 did not have the skin tear prior to repositioning him/her onto his/her right side, but said the skin tear was found immediately after she repositioned Resident #1 onto his/her back. Review of a Nurse Progress Note, dated 5/04/22 at 5:17 A.M., (written by Nurse #1) indicated during care Resident #1 scratched the back of his/her left hand with the long fingernails of his/her right hand causing a skin tear. The Nurse Progress Note indicated that a dressing was applied to Resident #1's hand. During an interview on 5/27/22 at 11:50 A.M., Nurse #1 said CNA #1 approached him at the nursing desk and reported that Resident #1 obtained a skin tear to the left hand. Nurse #1 said CNA #1 told him, she had a hard time turning Resident #1 in bed alone. Nurse #1 said Resident #1 can not turn him/herself in bed. Nurse #1 said it was unknown how Resident #1 actually obtained the skin tear to the top of his/her left hand while being repositioned, but said that CNA #1 told him that Resident #1 might have scratched him/herself while being repositioned. Nurse #1 said after he cleaned Resident #1's hand and applied a dressing, he assisted CNA #1 with repositioning Resident #1, so she could complete his/her care. During an interview on 5/31/22 at 12:20 P.M., the Director of Nurses said CNAs were educated upon hire to follow the Residents' Care Plan. The DON said Residents' Care Plans were readily available to be viewed on the computer. The DON said Resident Care Plans were also kept in the notebook where the other documentation completed during the shift by the CNAs, was kept.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required an extensive physical assist of two staff members for bed mobility which included the need for turning and repositioning during care, the facility failed to ensure he/she was provided with an adequate level of staff assistance to maintain his/her safety to prevent an incident/accident resulting in injury. On 5/04/22, while providing care to Resident #1, a Certified Nurse Aide (CNA) repositioned him/her unassisted by another staff member, and he/she sustained a skin tear to his/her left hand during care. Findings include: The Facility's Policy, titled Initial Resident Assessment and Reassessment, not dated, indicated each resident admitted shall receive a complete assessment so a plan of care can be developed to best meet the needs of the resident. The assessment of the care required to meet the needs of the resident will be ongoing throughout the resident's facility stay, with the assessment process individualized to meet the needs of the resident population. The Facility's Policy, titled Resident Care Policy, dated as reviewed on 1/27/21, indicated the interdisciplinary team responsibilities include the development and implementation of a comprehensive, individualized plan of care based on interdisciplinary assessments of the resident. Resident #1 was admitted to the Facility in August 2021, diagnoses included [CONDITION(S)] Disease of Nervous System, Type 2 Diabetes Mellitus, [CONDITION(S)], Spinal Cord Compression, Effusion of Left Knee, and Abdominal Rigidity. Review of Resident #1's Care Plan related to Activities of Daily Living (ADL's), dated as revised on 3/14/22, indicated he/she had physical deficits related to immobility, and rigidity. Resident #1's Care Plan indicated for bed mobility, weight shifting, and turning and repositioning, that he/she required assistance of two staff members. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 3/21/22, indicated he/she required two person extensive physical assistance with the following ADL's; bed mobility, positioning, transfers, toileting needs, personal hygiene, and was totally dependent on two persons for bathing. The MDS indicated Resident #1 was wheelchair bound, and had functional limitations with range of motion to his/her upper and lower extremities. Review of a Nurse Progress Note, dated 5/04/22 at 12:42 P.M., indicated during the 11:00 P.M. to 7:00 A.M. shift (5/04/22) Resident #1 acquired a 1.25 inch left anterior hand skin tear. During an interview on 5/23/22 at 1:15 P.M., Certified Nurse Aide (CNA) #1 said in the morning on 5/04/22, during the 11:00 P.M. to 7:00 A.M. shift she repositioned Resident #1 in bed to provide incontinent care, and said she did not have another staff member there to assist her. CNA #1 said she was unsure whether or not Resident #1 required a one or two person assist when being repositioned in bed. CNA #1 said she did not get another staff member to help her. CNA #1 said she stood on Resident #1's right side while he/she lay on his/her back in bed. CNA #1 said she reached over across Resident #1 to pull on the protective pad underneath Resident #1's left side, and rolled him/her towards her onto his/her right side. CNA #1 said she leaned forward across Resident #1, she placed a clean protective pad down and began to wash Resident #1's buttocks. CNA #1 said when she repositioned Resident #1 onto his/her back, Resident #1 tapped her with his/her right hand to show her he/she was bleeding from his/her left hand. CNA #1 said she left the room, found Nurse #1 and told him Resident #1 had a skin tear on his/her hand. CNA #1 said she does not know how Resident #1 obtained the skin tear to his/her left hand, but said he/she did have several long fingernails. CNA #1 said Resident #1 did not have the skin tear prior to repositioning him/her onto his/her right side, but said the skin tear was found immediately after she repositioned Resident #1 onto his/her back. Review of a Nurse Progress Note, dated 5/04/22 at 5:17 A.M., (written by Nurse #1) indicated during care Resident #1 scratched the back of his/her left hand with the long nails of his/her right hand causing a skin tear. The Nurse Progress Note indicated that a dressing was applied to Resident #1's left hand. During an interview on 5/27/22 at 11:50 A.M., Nurse #1 said CNA #1 approached him at the nursing desk and reported that Resident #1 obtained a skin tear to the left hand. Nurse #1 said CNA #1 told him, she had a hard time turning Resident #1 in bed alone. Nurse #1 said Resident #1 can not turn himself/herself in bed. Nurse #1 said it was unknown how Resident #1 actually obtained the skin tear to the top of his/her left hand while being repositioned, but said that CNA #1 told him that Resident #1 might have scratched him/herself while being repositioned. Nurse #1 said after he applied clean Resident #1's hand and applied a dressing, said he assisted CNA #1 with repositioning Resident #1, so she could complete his/her care. During an interview on 5/31/22 at 12:20 P.M., the Director of Nurses said CNAs were educated upon hire to follow the Care Plan. The DON said Residents' Care Plans were readily available to be viewed on the computer. The DON said Resident Care Plans are also kept in the notebooks that contain the other documentation to be completed by the CNA's during their shift.

Based on staff interviews and documentation review, the facility failed to designate a person who met the minimum qualifications to serve as the Director of Food and Nutrition Services to ensure the functioning of the dietary department. Findings include: During an interview on 6/23/21 at 9:45 A.M., the Food Service Manager (FSM) said she was in charge of the facility's dietary department. The FSM said she had completed a dietary manager training program. The FSM said the Registered Dietitian worked at the facility part-time. If a facility does not employ a full-time Registered Dietitian, the Certified Dietary Director credential is a requirement for the employee who serves as the Director of Food and Nutrition Services. Review of the FSM's personnel file indicated she was hired as the full-time FSM in September 2017. The personnel file also indicated that she does not have an advanced college degree, but she completed a nutrition & food service professional training program on 12/19/19, over a year and a half ago. In order to be certified, an individual must take and pass the dietary manager certification exam. During an interview on 6/24/21 at 1:00 P.M., the dietitian said that she works at the facility 20 hours per week. During an interview on 6/25/21 at 9:55 A.M., the Administrator said that the Food Service Manager had not taken the manager certification exam yet, and the dietitian works part time at 20 hours per week. He said that he thought the regulation had changed and that the Food Service Director was qualified.

Based on observation and interview, the facility failed to ensure that food was stored, prepared, and served in accordance with professional standards of food service safety. Specifically, the facility failed to: 1) Store food properly and ensure the general sanitation of the kitchen; and 2) Monitor food temperatures to ensure proper cooking and holding temperatures. Findings include: 1. Review of the facility's policies titled Food Storage, dated 2013, and General Sanitation of Kitchen, dated 2013 indicated, but is not limited to: -Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination -All stock must be rotated with each new order received; food should be dated as it is placed on the shelves -All foods are stored in covered containers or wrapped carefully and securely. Each item is clearly labeled, and dated before being refrigerated/frozen -Every refrigerator must be equipped with an internal thermometer -The staff shall maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule -Cleaning and sanitation tasks for the kitchen will be recorded -Tasks will be assigned to be the responsibility of specific positions -Frequency of cleaning for each task will be defined -Employees will initial and date tasks when completed On 6/23/20 at 9:45 A.M., the surveyor and the Food Service Manager (FSM) observed the following: Ice Cream Freezer: -No thermometer inside. -On the top shelf of the freezer, a large, clear plastic bag (opened), contained unidentified, irregular shaped tan colored pieces of food. The bag was unlabeled and undated. -On the second shelf, a small clear plastic bag (opened), contained multiple round tan colored pieces of food. The bag was unlabeled and undated. Beverage Fridge: -A clear, plastic pitcher contained a yellowish color liquid on the second shelf. The pitcher was unlabeled and undated. -A shallow cardboard box that contained pastry. Clear plastic wrap was not secure and the food was open to air. Cook's Box fridge: -No thermometer inside. -A large opened bag of shredded cheddar cheese was undated. -A small square shaped cellophane wrapped food item was unlabeled and undated. The refrigerator/freezer doors and handles had drips of multiple colored substances. A brownish/red sticky substance was observed to be adhered to the vents on the lower portion of all of the units. Beverage Center: -The coffee machine had dried, brown splatters and drips on the unit where the coffee is dispensed. The handle was encased in a dark brown crusty substance. -Two juice dispensers had shiny, sticky splatters of translucent red, orange, and brownish substance where cups are placed to dispense the juices. -Significant amount of food debris was on the counter top. -A blender was encrusted with brown, tan, and white substances dried on the sides. -A microwave on the countertop had tan and brown splatters on all inside surfaces. -The shelves underneath the beverage center had a significant amount of food debris. A metal pan was on the lower shelf and had a black and brown, burnt, oily substance in it. Steam Table in Kitchen: -Food splatters on all surfaces of the unit (front, sides, doors). Food Preparation Area: -The shelves had a significant amount of food crumbs, brown colored, sticky splatters on the shelves. -A sticky insect trap was on the lower shelf with multiple small insects adhered to its surface. Counter top and shelves opposite the double ovens: -The counter top had crumbs on it. -The shelf below had food crumbs, and sticky, reddish brown splatters on it. Lower shelf had a sticky insect trap with several insects adhered to it, food crumbs, and purplish/red sticky splatters on the shelf. Industrial stand mixer: -The safety guard cage and mixer unit was covered in dark colored splatters. During an interview on 6/23/21 at 10:21 A.M., the surveyor and FSM reviewed a notebook that contained the master cleaning schedule and daily cleaning assignment checklists. All of the checklists forms were blank. The FSM said that they have had a problem with low staff lately because of staff taking vacation time, and calling out, and that she has been lenient on staff cleaning the kitchen lately. 2. Review of the Food Temperature Records binder, a binder which contains documentation sheets that kitchen staff uses to record temperatures of food on the steam table in the main kitchen, indicated that there were no completed food temperature sheets in the binder, only blank forms. The 2013 Food and Drug Administration Food Code indicates that temperatures should be monitored to ensure proper cooking and holding temperatures. The Food Code is a model for safeguarding public health and ensuring food is safe for consumption. During an interview on 6/23/21 at 10:21 A.M., the FSM said that after three months, she throws away the temperature logs, but the current temperature logs should be in the book. She said that there was nowhere else they would be kept. During an interview on 6/23/21 at 10:25 A.M., with Diet Aide #4 and Cook #1, Diet Aide #4 said that she did not know where the temperature sheets were, and had not taken any food temperatures. The surveyor asked Cook #1 if he had taken food temperatures of the food this morning, and he said, No, and could not remember the last time he measured and logged the temperature of the food in the steam table in the kitchen.

Based on documentation review and staff interview, the facility failed to complete an accurate Facility-wide assessment to determine what resources are necessary to care for its residents and to plan for resources needed for both day-to-day operations and emergencies, including the public health emergency. Findings include: Review of the Facility Assessment tool, dated January 14, 2021, indicated the following inaccurate/missing information: a. The assessment failed to identify COVID-19 as an infection the facility was able to manage; failed to identify how the facility managed resident care and resources during the COVID-19 state of emergency, and failed to identify services that were not available to residents during the pandemic. The facility did not provide services that were identified as being available to residents during the pandemic. b. There was no specific information on the Infection Control program, infection prevention and control risk, and the Antibiotic Stewardship program. The assessment did not list any infection control education with specific information detailing an outline of the program. The assessment did not address resources needed to maintain an ongoing infection prevention and control program. c. There was no information related to competencies that are necessary to provide the level and types of care needed for the resident population, and no specific information related to the facility's training program to ensure any training needs are met for all new, existing, and contract staff. d. There was no information under the preventative maintenance needed for the installation of side rails, tracking and/or monitoring and maintenance of these devices. e. The assessment indicates that each resident in the facility is able to utilize a Nurse Call system to communicate with nursing staff via a telephone/speaker. The call system is not functional for many residents, who then must use a hand bell to alert staff that assistance is needed. f. There was no specific information related to the monitoring of the water system for water-borne pathogens (a bacteria or virus that can cause disease). g. The assessment indicated that the facility personnel included a full time Director of Food and Nutrition Services, when the facility did not employ a qualified Food Service Director. During a telephone interview on 7/2/21 at 9:22 A.M., the Administrator confirmed that the Facility Assessment was not updated to accurately reflect the status of the facility.

Based upon review of the medical record, observation, resident interview, staff interviews, external provider/agency's interviews and review of the policy and procedure manual, for 1 of 23 sampled residents (#7), the Facility failed to ensure that all residents were free from verbal and mental abuse, including intimidation, humiliation, threatening, disparaging and derogatory language, and failed to provide adequate and effective care and treatment of [REDACTED]. Findings include: Review of the Facility Policy and Procedure for Abuse, dated January 2012, indicated the resident had the right to be free from verbal, sexual, mental or physical abuse and that staff treatment of [REDACTED]. Resident #7 was admitted in 1/2016 and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated 2/1/16, and the Quarterly MDS (dated 7/28/16) indicated the Resident scored a 15 out of 15 on his/her BIMS (Brief Interview of Mental Status), was capable of making his/her needs known and understanding what was communicated to him/her. On 8/24/16 at 11:15 A.M., the Ombudsman notified the Survey team that Resident #7 had contacted her about an allegation of mental and verbal abuse by the Director of Nurses (DON). She said that the incident occurred on 7/29/16 and she was notified by the Resident on 8/1/16. Resident #7 informed the Ombudsman that he/she thought he/she was meeting with the DON, Social Worker (SW) #1 and Unit Manager (UM) #3 to provide more information for the report he/she had filed earlier in the week that alleged $1,100.00 was missing. Resident #7 stated that the DON was accusatory and described the encounter as an interrogation and used methods to wear him/her down and to victimize. The Resident stated to the Ombudsman that the DON's focus was on avoiding facility liability rather than advocating for the patients. The Resident stated that he/she was embarrassed, humiliated and intimidated by the line of questioning that the DON imparted on him/her. The Resident restated that the DON had made him/her feel that like he/she was guilty rather than the victim. The Resident stated that SW #1 and UM #3 stood by and observed the encounter and did nothing. The Resident said he/she had told SW #1 after the encounter how upset he/she was, but that no one had said anything to him/her for more than 2 days. The Ombudsman said that during the Resident's recounting of the abuse she (the Ombudsman) felt that the Resident still felt threatened and intimidated. The Ombudsman said that she had spoken with the Resident (on 8/24/16) and he/she asked to speak with a surveyor because he/she did not feel that the facility's investigation result would be positive and that the facility had not provided support to ensure he/she felt safe. The Ombudsman stated the Resident remained frustrated, upset and distressed over the Facility's lack of care and concern for his/her well being. The Ombudsman stated that the Facility Administrator had informed her he was waiting for the Ombudsman and DPH (Department of Public Health) investigation. At 12:05 P.M. on 8/24/16, the Administrator met with the survey team. He provided the survey team with the facility's full investigation. Review of the investigation indicated it was a linear representation of the events in the order in which they occurred. The investigation supported that the Resident alleged he/she was mentally and verbally abused by the DON. The investigation indicated that SW #1 witnessed the incident and did not stop the interaction and did not report, what she determined was verbal and mental abuse for almost 3 days after the incident occurred. During the 2 interviews with Resident #7 on 8/24/16 at 10:50 A.M. and 8/26/16 at 10:50 A.M., the Resident recounted the allegation of verbal and mental abuse. During the Resident's recounting of the abuse, the Resident was visibly distressed, angry and frustrated. The Resident said he/she had felt threatened and intimidated by the DON. The Resident said that the Facility had not provided any type of support to ensure his/her safety and said if he/she had not contacted outside resources the Facility would not have done anything. The Resident's account of the verbal abuse indicated that on Friday 7/29/16 at approximately 3:30 P.M., he/she was approached by the DON, SW #1 and UM #3 to complete (what the Resident had been told) the investigation of reported missing money. Resident #7 said that the conversation (directed by the DON) changed quickly from pleasantries to becoming overwhelming. The Resident said the DON's question became an interrogation. The DON repeated the same questions over and over again. The Resident said that he/she felt that he/she had already answered them, but the DON would repeat them again. The questions were focused on how much money he/she had and what he/she spent his/her money on. The Resident explained how much money he/she received monthly, how he/she received the money, how he/she managed, spent and stored the money. The Resident said that he/she had $1,100.00 and it had been locked in the lock box the facility had provided in his/her closet. Resident #7 said the lock box and money were gone. Resident #7 said the DON seemed to not hear or accept his/her response and continued to repeat the questions. The DON said that the Resident had been inconsistent in his/her explanation of how he/she spent the money monthly. The DON said that the Resident could not have as much money as he/she alleged because it was almost the end of the month. Resident #7 said he/she was frustrated with the questioning and when he/she tried to challenge the DON's line of questions, the DON said that he was just acting as the devil's advocate. The Resident said he was doing a good job. The Resident said that the DON's intent was to find inconsistencies in his/her accounting of the money. The Resident said the DON had no interest in the Resident but was concerned about the Facility's liability. The Resident said the DON made him/her feel that he had stolen his/her own money by badgering him/her with the interrogating questions. The Resident said that the DON said he had viewed the Facility video surveillance during the time frame the money went missing. The DON questions became focused on the Resident's visitors, the number of visitors, why did they and the Resident go in and out of his/her room frequently (which the Resident responded to use the urinal) etc. The Resident said that the DON also continued with repetitive questions regards to how the Resident spent his/her money. When the Resident would try to stop the DON, the DON would say just make me understand. The Resident said that he/she wanted to help in the investigation and therefore stayed, but that then the DON accused the Resident of purchasing inappropriate movies and downloading them onto to his/her phone for viewing. The Resident said that the DON said he saw the Resident viewing the inappropriate movies on the surveillance video. The Resident said the line of questioning along with disparaging remarks about his/her friends and the insinuation that he/she was downloading pornography was inappropriate, humiliating and abusive to him/her. The Resident said the questions had nothing to do with the investigation and it was just a mental tactic to wear him/her down. The Resident said that the SW and UM just stood there and watched the abuse. On 8/25/16 at 10:55 A.M., SW #1 was interviewed. SW #1 said that she had been asked to accompany the DON and UM in order to gather information for the report for misappropriation. SW #1 said the DON felt there were inconsistencies in the Resident's accounting of how he/she spent his money and that the amount could not be as much as the Resident reported. The SW said the questioning of the Resident was inappropriate and his intent was to find inconsistency so that the facility would not be liable. The SW said she observed the Resident being frustrated, angry, overwhelmed and stressed during the incident. The SW said the DON attacked the Resident (and his/her friends) character and integrity and made statements that were to evoke emotion and the Resident's accounting of the money. The SW said the DON told the Resident he had watched the Resident on video downloading inappropriate movies on video surveillance. The Resident was humiliated and embarrassed by the accusations. The SW said during the interaction she felt the questions were inappropriate and felt uncomfortable witnessing it. She said the Resident spoke with her after the interaction and voiced how upset he/she was and said that the DON interrogated him/her. The SW said that when the Resident asked what the DON was trying to do, the DON said he was playing the devil's advocate. The Resident responded you're doing a good job at it. The SW said the DON's voice and body movements were intimidating. She said the DON spoke in loud voice, shifted his body, leaned into the Resident across a table and paced around the Resident when talking. The SW said his movements were intimidating. The SW said she should have stopped the interaction, but had problems with the DON in the past. She said she felt the DON had verbally and mentally abused the Resident. SW #1 said she thought about the interaction all weekend and on the Monday after the incident she reviewed the Facility policy on abuse. SW #1 said she contacted the Administrator and informed him of the abuse and then called the DPH hotline to report the incident. During interview on 8/26/16 at 12:00 P.M., UM #3 said that she was asked to accompany SW #1 and the DON to Resident #7's room on 7/29/16 in the late afternoon. She said that she was not in the room the entire time, but that the DON did ask repetitive questions about what the Resident spent his/her money on during the month. She said the Resident answered the DON's questions, but the DON would ask them again and again. UM #3 said the DON did ask about the Resident's friends, downloading inappropriate movies, tools that the Resident might have been used to remove the lock box etc. UM #3 said the Resident became distressed when the DON questioned the Resident about his/her friends and the inappropriate movies. She said the DON told the Resident he was playing the devil's advocate. The UM was asked if she thought the DON was verbally and mentally abusive. UM#3 said the line of questioning could be perceived to be intimidating by the Resident. She said the Resident was upset about why the DON was asking these questions over and over again and became more distressed when the DON questioned the Resident about his/her friends and the inappropriate movies. During interview with the DON on 8/26/16 at 2:30 P.M., the DON said that he met with the Resident on 7/29/16 to do a follow up interview regarding the complaint of missing money. He said he never interviews alone and always brings witness and that was why he asked SW #1 and UM #3 to go with him. The DON said that he was trying to determine the amount of money the Resident had, because there had been some inconsistency in the Resident answers in how he spent money each month. The DON said that he did ask multiple questions and often repeated the questions so that he could understand. He said that during the interview the Resident became visibly upset and the Resident asked if the DON was accusing him/her of stealing the money. The DON said he told the Resident he was just trying to understand. He said he offered to stop the interview, but that the Resident agreed to finishing. The DON, subsequently continued asking questions to find out how much money the Resident had. He again said the Resident could not have had the amount he/she stated because it was almost the end of the month and according to his (the DON) accounting the Resident could not have had the amount stated. The DON said he did ask about the Resident's and his/her friends movement during the weekend the money was lost. He said he also inquired about inappropriate movies. The DON initially said that he had viewed the Facility's surveillance video, but later recanted and said he had not (apparently no one from the facility had viewed the surveillance video). The DON said he used the term devil's advocate because he was trying to get the Resident to make a mistake in his/her accounting of the money that was missing, to determine whether the Facility would not be responsible for the missing $1,100.00. The DON denied talking loudly or acting in an intimidating manner towards the Resident. The DON said he was not trying to abuse the Resident, but wanted to have the Resident explain the inconsistency in his/her answers. The DON was asked what some of the questions had to do with the investigation of misappropriation and ensuring the Resident was protected from abuse and associated stressors from an investigation, the DON said that he had no formal training on abuse investigations and interviewing.

Based on interviews and record review for 1 (#7) resident out of 23 sampled residents, the Facility failed to ensure that during an investigation of misappropriation (reported by Resident #7) the interview conducted by the Facility staff was conducted in a manner that failed to ensure the resident did not suffer feelings of embarrassment, humiliation, intimidation and being threatened. Findings include: Resident #7 was admitted in 1/2016 and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated 2/1/16, and the Quarterly MDS (dated 7/28/16) indicated the Resident scored a 15 out of 15 on his/her BIMS (Brief Interview of Mental Status), was capable of making his/her needs known and understanding what was communicated to him/her. On 8/24/16 at 11:15 A.M., the Ombudsman notified the Survey team that Resident #7 had contacted her about an allegation of mental and verbal abuse by the Director of Nurses (DON). She said that the incident occurred on 7/29/16 and she was notified by the Resident on 8/1/16. Resident #7 informed the Ombudsman that he/she thought he/she was meeting with the DON, Social Worker (SW) #1 and Unit Manager (UM) #3 to provide more information for the report he/she had filed earlier in the week that alleged $1,100.00 was missing. Resident #7 stated that the DON was accusatory and described the encounter as an interrogation and used methods to wear him/her down and to victimize. The Resident stated to the Ombudsman the DON's focus was on avoiding facility liability rather than advocating for the patients. The Resident stated that he/she was embarrassed, humiliated and intimidated by the line of questioning that the DON imparted on him/her. The Resident restated that the DON had made him/her feel that like he/she was guilty rather than the victim. The Resident stated that SW #1 and UM #3 stood by and observed the encounter and did nothing. The Resident said he/she had told SW #1 after the encounter how upset he/she was, but that no one had said anything to him/her for more than 2 days. At 12:05 P.M. on 8/24/16, the Administrator met with the survey team. He provided the survey team with the facility's full investigation. Review of the investigation indicated it was a linear representation of the events in the order in which they occurred. The investigation indicated that DON, SW #1 and UM #3 met with the Resident on 7/29/16 to follow-up on the Resident's missing money complaint. The investigation indicated that on 8/1/16 Social Worker (SW) #2 met with the Resident. SW #2 said she had thought she was meeting about another issue, but was told by the Resident that he was furious with the DON over the interrogation related to his/her report of missing money. The Resident recounted the mental and verbal abuse made by the DON and said that the DON's focus was not on the investigation , but rather to avoid being accountable for the missing money. Resident #2 told SW #2 he/she was not comfortable with the Administration staff that was providing oversight into both investigation (money and abuse). SW #2 contacted SW #1 and discussed what the Resident had told her. SW #1 contacted the Administrator at 5:45 P.M., and stated that after witnessing the incident and reviewing the Facility's policy the DON had mentally and verbally abused the Resident during the conversation conducted on 7/29/16. Although, the Facility's investigation of the abuse allegation indicated the DON had been suspended for one and half days (8/2/16 at 2:45 P.M. through 8/4/16), there was no evidence that the Facility staff took responsibility and met with the Resident to ensure he/she was safe, felt comfortable and acknowledged his/her allegation of abuse was being addressed. Through interviews it was determined that the Facility had not notified the Resident of any action that was taken. The staff had not spoken with the Resident about the allegation of abuse and the Resident was not provided support or information of the investigation and what was being done by the Facility to ensure he/she felt safe in his/her environment. The Resident stated during an interview on 8/26/16 at 10:50 A.M., that he/she had not wanted to speak with the Administrator or DON because he/she felt that they were not interested in what happened and wanted to sweep everything under the carpet. Resident #7 said the Administration staff wanted to apologize and if he/she accepted the apology no one would address what had happened to him/her. The Resident he/she would have been agreeable to speak with other facility staff. Resident #7 said that he/she found out about the DON's suspension when he/she spoke to an outside agency that was assisting him/her in ALS care and support on 8/3/16 (not from the Facility staff). Resident #7 when he found out about the suspension he/she felt some relief. However, Resident #7 said that when he/she saw the DON on Friday 8/5/16 at 11:20 A.M. at the nurses station on his/her unit, he/she was shocked and did not know what to think. Resident #7 said he/she had not been informed that the DON had returned to work. Resident #7 said that he/she did not feel comfortable with the Facility and that he worried that they might try to do something else to him/her (retaliation). See F 223 and F 225.

Based on record review and interviews, for one of four sampled residents (Resident #1) the Facility failed to ensure that: 1) Resident #1 was transferred with the assistance of two staff as indicated in the care plan, when on 7/6/12 Certified Nurse Aide (CNA) #1 transferred Resident #1 out of bed by herself, Resident #1's left leg buckled, he/she was lowered to the floor, and Resident #1 sustained a fractured left ankle. 2) On 10/12/12, Resident #1, who was not cleared by physical therapy for transfer onto the commode and without the use of a mechanical lift, was transferred onto the commode by three CNAs. The three CNAs left Resident #1 alone on the commode, Resident #1 fell face down on the ground and sustained a head laceration that required seven staples to close the wound. Findings include: Resident #1 was admitted to the Facility July of 2012, and [DIAGNOSES REDACTED]. The nurse aide care card, dated 7/3/12, indicated that Resident #1 was at risk to fall and required two staff persons for transfers out of bed. The Surveyor interviewed Certified Nurse Aide (CNA) #1 on 11/8/12 at 11:10 A.M. CNA #1 said she was assigned to provide care to Resident #1 on 7/6/12, but did not look at the CNA care card. CNA #1 said she had transferred Resident #1 out of bed prior to 7/6/12, and she had another staff person assist her with that transfer. CNA #1 said on 7/6/12, she tried to transfer Resident #1 out of bed by herself, she put the gait belt on Resident #1, and when Resident #1 stood up, his/her knee buckled, so CNA #1 lowered Resident #1 to the ground. The Surveyor interviewed Resident #1 on 11/8/12 at 10:30 A.M. Resident #1 said when he/she fell the first time, the CNA tried to do the job of three people and transfer him/her alone. Resident #1 said when he/she stood up, his/her left knee gave out, CNA #1 tried to grab him/her and roughly tried to stop the fall. Resident #1 said when he/she was on the ground, CNA #1 kept saying words to the effect of "get up get up." The nurse's note and incident report, dated 7/6/12, indicated that at approximately 7:45 A.M., CNA #1 attempted to transfer Resident #1 from the bed to the wheelchair, when Resident #1's left leg buckled, and Resident #1 was lowered to the floor. The incident report indicated Resident #1 was assessed for injury, was transferred into the wheelchair with three staff persons, the Physician was notified, and the Physician ordered x-rays of Resident #1's bilateral knees and left ankle because of Resident #1's complaints of left ankle and left leg pain. The Surveyor interviewed the Director of Nurses (DON) on 11/8/12 at 8:30 A.M. The DON said Resident #1 should have been transferred with two staff persons. The x-ray report, dated 7/6/12 indicated that Resident #1 sustained a fractured left ankle. The clinical record indicated that Resident #1 was transferred to the Hospital and readmitted to the facility on [DATE] after an open reduction and internal fixation of the left ankle. The CNA care card, dated 7/10/12, indicated that Resident #1 was at risk to fall, required a mechanical lift and three staff persons for all transfers. The care plan, dated 7/10/12, indicated that Resident #1 was at risk to fall, he/she required a mechanical lift with the assistance of three staff persons until Resident #1 was cleared by physical therapy. The occupational therapy evaluation, dated 7/12/12, indicated that Resident #1 had poor posture that included kyphosis, poor balance, rounded shoulders and forward facing head. The occupational therapy evaluation indicated that Resident #1 required skilled occupational therapy to improve coordination, dynamic balance and activity tolerance. The Surveyor interviewed the Physical Therapist and the Certified Occupational Therapy Assistant (COTA) on 11/8/12, at 2:00 P.M. The Physical Therapist and the COTA said they started training the CNA staff on how to transfer Resident #1 from the wheelchair to the commode without the mechanical lift, but had not officially cleared staff to transfer Resident #1 to the commode. The Physical Therapist said the training was informal and she told staff to call her prior to any transfers. The Surveyor interviewed CNA #2 and CNA #3 on 11/8/12, CNA #2 at 2:10 P.M. and CNA #3 at 2:30 P.M. CNA #2 said she received no training regarding Resident #1 and the commode and was assigned to Resident #1 on 10/12/12. CNA #3 said she received training regarding transferring Resident #1 to the commode from the COTA. CNA #2 said she was told by CNA #3 that Resident #1 could be transferred to the commode without the mechanical lift. CNA #2 said she, CNA #1 and CNA #3 transferred Resident #1 to the commode in the morning (not sure of the exact time) and left Resident #1 in the room alone for privacy. The Surveyor interviewed the Unit Manager on 11/8/12 at 11:30 A.M. The Unit Manager said she was not trained or told by the therapy department that Resident #1 was safe to transfer to the commode, and the care plan reflected a mechanical lift for all Resident #1's transfers. The Unit Manager said Resident #1 used the bedpan in bed for toileting. The Surveyor interviewed Nurse #1 on 11/8/12 at 2:20 P.M. Nurse #1 said on 10/12/12 at approximately 9:50 A.M., she observed Resident #1's door closed, so she opened the door to see if Resident #1 was okay. Nurse #1 said Resident #1 was sitting on the commode and said she needed to stay on the commode a few more minutes. Nurse #1 said she left the room and closed the door. Resident #1 said he/she fell the off the commode after the CNAs left him/her on the commode, which wasn't very comfortable. Resident #1 said he/she was left alone, he/she had no call light, and no one checked on him/her for a while. Resident #1 said because the commode was uncomfortable, he/she tried to readjust on the commode and fell off the commode. The incident report and the nurse's note, dated 10/12/12, indicated that Resident #1 was found in the room by a Housekeeper, Nurse #1 observed Resident #1 face down on the floor and bleeding from a head wound. The incident report and the nurse's note indicated that Resident #1 was provided first aid, 911 was called, and Resident #1 was transported to the emergency room for treatment. The emergency room report, dated 10/12/12, indicated that Resident #1 required 7 staples to a head laceration. The DON said there was miscommunication between the therapy staff and the nursing staff regarding Resident #1's plan of care for transfers and toileting.

Based upon interviews and records reviewed, the Facility failed to ensure that the environment for one of one sampled resident (Resident #1) was free from an accident hazard when the Night Shift Nurse placed Resident #1's nebulizer machine on the bed rather than on Resident #1's bedside table because the Night Shift Nurse was in a hurry to leave duty. The Wound Physician said Resident #1 sustained second degree burns (burn in which damage extends through the outermost layer of the skin and into the next layer of skin) on the right upper thigh from the nebulizer machine . Findings included: The admission nursing assessment, dated 5/14/09, indicated that Resident #1 was disoriented, chair bound, and totally dependent for mobility. The [DIAGNOSES REDACTED]. Resident #1's plan of care interventions, dated 1/10/11, regarding a potential for an altered respiratory status due to pleural effusion and pneumonia included nebulizer treatments. Resident #1 had a physician's orders [REDACTED]. The Charge Nurse was interviewed at 11:30 AM on 2/8/11. The Evening Shift Nurse was interviewed at 4:30 PM on 2/8/11.The Charge Nurse and Evening Shift Nurse said the right side of Resident #1's bed was placed near the wall that had 5 plugs at the head of the bed and a bedside table was placed at the head of the left side of Resident #1's bed for the nebulizer machine. The Evening shift Nurse said following the 11:00 PM nebulizer treatment on 1/28/11, the nebulizer machine was left on the bedside table, and was plugged into one of the five outlets at the head of the bed. The Night Shift Nurse was interviewed at 5:15 PM on 2/8/11, The Night shift nurse said Resident #1 was administered a nebulizer treatment at 6:00 AM on 1/29/11; Resident #1 was left lying in bed and the nebulizer machine was placed on the bed near Resident #1's right thigh to ensure the nebulizer treatment mask reached Resident #1's face. The Night Shift Nurse said the nebulizer machine should have been plugged into an outlet at the head of the bed and placed on the bedside table; however, the Night Shift Nurse was in a hurry to leave the Facility. Certified Nurse Assistant (CNA) #1 was interviewed at 3:14 PM on 2/8/11. CNA #1 said this CNA #1 observed the nebulizer machine on Resident #1's bed during morning rounds, Resident #1 was repositioned, and CNA #1 reported to the Night Shift Nurse that the nebulizer machine was on the bed and the Night Shift Nurse said to leave the nebulizer machine on the bed and the Night Shift Nurse would remove it. The Night Shift Nurse said this Night Shift Nurse forgot to remove the machine from the bed because this Night Shift Nurse was completing required documentation and was in a hurry to leave the Facility. The Charge Nurse said after receiving the morning change of shift report on 1/29/2011, this Charge Nurse observed Resident #1 wearing a nebulizer mask and heard the nebulizer machine running.The Charge Nurse said this Charge Nurse had not observed the location of the nebulizer machine because the nebulizer machine was not on the empty bedside table. The Charge Nurse said this Charge Nurse walked around Resident #1's bed, found the nebulizer machine on Resident #1's bed next to Resident #1's right upper thigh, and observed that Resident #1's right upper thigh was blistered and reddened from the heat of the nebulizer machine that was still running. The Charge Nurse said the Night shift Nurse was summoned to Resident #1's bedside, first aid to the burn area was completed, the Physician and the Acting Director of Nurses were notified and a Facility internal investigation was initiated. The Night Shift Nurse said and the nurse's note, dated 1/29/11, indicated that Resident #1 sustained a burn to the right thigh area from the heat of the nebulizer machine that was placed on the bed by this Night Shift Nurse. The Night Shift Nurse said and the nurse's note indicated the Physician was notified that Resident #1 sustained a reddened area with three blisters on the right thigh measuring 10 centimeters (cm) by 20 cm, 10 cm by 30 cm, and 20 cm by 30 cm. The Night Shift nurse said the nebulizer machine was placed on top of the bed linen, but was found beneath the bed linen next to Resident #1's right thigh. The Night Shift Nurse said, and the nurse's note indicated that Silvadene (treatment for [REDACTED]. The incident report, dated 1/29/11, indicated Resident #1 sustained a burn on the right thigh that was caused by the nebulizer machine that was placed on Resident #1's bed. The incident report indicated that the nebulizer machine was running and Resident #1's right outer thigh was found leaning against the nebulizer machine. Resident #1 had a physician's telephone order, dated 1/29/11, for Silvadene (treatment for [REDACTED]. Resident #1 had a physician's telephone order, dated 1/31/11, to cleanse the burn areas with normal saline; apply Silvadene ointment and a protective dressing to Resident #1's right thigh two times daily until healed. The Wound Physician was interviewed at 3:00 PM on 2/8/11. The Wound Physician said and the Wound Physician's report, dated 1/31/11, indicated that Resident #1 sustained second degree burns from the nebulizer machine.

Based on record review, observation and staff interview, the facility failed for 2 residents (#4, #8) of a total sample of 22 residents, to ensure that each resident receive proper care and treatment to prevent pressure sores. The findings included: 1. The facility had failed to follow their skin care protocol policy and failed to accurately recognize and assess a facility acquired pressure wound for this resident who was determined to be at high risk for developing pressure areas. Resident #8 was a long term care resident with multiple [DIAGNOSES REDACTED]. The medical record was reviewed 12/2/10. A review of the annual Minimum Data Set (MDS) assessment signed 2/24/10, indicated the resident had no memory problems and was modified independent for decision making. The resident was dependent on staff for all activities of daily living, incontinent of bowel, transferred with a mechanical lift and used an electric wheelchair. Additionally, the assessment indicated the resident had no pressure areas. The RAP (Resident Assessment Protocol) summary for pressure areas noted the resident was at risk for pressure areas due to immobility, impaired circulation, incontinence and skin is desensitized. Per review of the last quarterly MDS assessment signed 8/6/10 and the MDS assessment signed 11/3/10, both clinical assessments noted the resident had no pressure ulcer wounds. The resident's plan of care for skin integrity, dated 3/4/10, noted the resident was prone to skin tears and bruises and on 8/17/10 added the problem the resident was non compliant with positioning. The multiple approaches included to educate the resident of the importance of positioning, keep the resident clean and dry and weekly skin weeks. A professional standard of practice is to use a staging system to summarize characteristics of pressure areas is: Stage 1 - intact skin with persistent redness; Stage 2 - partial skin loss; Stage 3 - full thickness skin loss; Stage 4 - full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone. A review of the weekly skin checks and treatment records documentation included the following: 6/14/10 buttocks area slightly red and fragile. 7/12/10 buttocks skin intact and very red. 7/26/10 buttocks area open at 2 cm. {Note: this description is of a Stage II area.) 8/9/10 buttocks open area is 4 x 2 cm. 8/14/10 buttocks are Stage 1 and is 4 cm x 2 cm with a depth of 0.25 cm. (Note: the description of the area having a depth of .25cm depicts a Stage II not a Stage I area.) (The medical record had no other measurements to review until 9/28/10.) 9/28/10 the right buttocks has a 3 cm x 2 cm open area and the left buttocks has 1 cm x 1 cm open area. (Note: this describes now two stage II open wounds.) On 7/27/10, the facility had obtained physician orders [REDACTED]. However, on 7/26/10 the area was described as a 2cm open area (Stage II) which would call for a medicated ointment and dressing rather than just a protective ointment order. On 9/28/10 a new order was obtained to apply a [MEDICATION NAME] dressing to the buttocks area three times weekly until healed. There is no indication in the record that additional pressure relieving interventions where considered or implemented at this time for this resident who is parapalegic and unable to move self in the bed. This was also confirmed with the unit nurse leader. 10/5/10, noted the left buttocks area was a Stage 2 and measured 2 cm x 0.5 cm with a depth of 0.1 cm. The right buttocks area was a Stage 2 and measured 3.5 cm x 1.0 cm and had a depth of 0.5 cm. 10/19/10 noted the left and right buttocks area had merged and measured 3 cm x 3.5 cm with a depth of 0.25 cm. Another measurement of the area for the same day noted it was 4 cm x 2 cm. The nurse wrote the area had worsened and continued to refer to the wounds as non-pressure ulcers. 10/22/10 noted the left and right buttocks area open and the area is larger. The nurse wrote the area is a Stage 2 and measured 2.5 cm x 4.5 cm and a depth of 0.25 cm. 10/25/10 the nurse at 7:06 AM wrote the buttocks area had a necrotic area. At 1:03 PM a nurse wrote the buttocks area wound was a Stage 1 and measured 6 cm. x 2.5 cm. and no depth.(Describing this wound as a Stage I is inaccurate. Necrosis would indicate an unstageble area while a 6cm x 2.5 cm reflects an open area.) 10/28/10 the nurse noted the left and right buttocks area and referred to the areas as non-pressure ulcer and measured 2.5 cm x 3.0 cm with a depth of 0.25 cm. 11/9/10 the nurse noted the left and right buttocks area as a Stage 2 and is a non-pressure ulcer. 11/22/10 the nurse wrote the area was a "worsened" Stage 2 pressure ulcer on the right buttocks with eschar and measured 3.5 cm x 5 cm and now was unable to Stage the wound. The right an left areas now merged as one larger staged area. Only at this time on 11/23/10 was the pressure area acccurately assessed as a pressure area and orders obtained to debride the wound (Santyl) and to obtain a pressure relieving intervention (i.e., an air mattress.) On 12/2/10 the area was assessed to be 8 cm x 4 cm and unable to determine depth due to eschar on the left side of the wound area and had moderate amount of serosanguinous drainage. The Director of Nurses provided the surveyor with weekly wound tracking documentation, this information is used by the Director to review and track wound areas in the facility. Resident #8's tracking information records was only started on 9/28/10 and from 10/16/10 - 11/5/10, referred to the resident's wound area as non-pressure. The care plan for skin integrity was updated 11/23/10, and noted the wound as a "pressure ulcer" and added interventions of measuring and assessing the pressure area, treating the wound with a debridement ointment, putting an air mattress on the resident's bed and to encourage the resident to stay out of the bed for short periods. Interview with the Applewood unit nurse manager 12/2/10 at 4 PM, stated she had first assessed the wound 11/22/10 and determined the area due to pressure and she noted the area to have eschar and could not be staged at this point. She explained she had notified the physician to change the wound treatment and added the air mattress to the residents bed. Interview with Director of Nurses 12/2/10 at the same time, could not explain why the resident's medical record had referred to wound, from 7/10 - 11/21/10, as a non pressure area. She stated she had never seen the wound and relied on the previous unit nurse leader to assess the wound. The Director reviewed the record and on 12/3/10 at 12:30 PM returned to the surveyor to review the weekly wound tracking. The Director again stated the previous unit nurse had filled out the forms and had confirmed the inaccurate information for the wound staging, not identifying the area as pressure and the lack of interventions put in place for the resident. The wound was observed on 12/8/10 during wound care with the unit nurse. Per review of the clinical record prior to the treatment, facility nurses reported that the wound was "unstageable." Per observation, the resident had a large pressure sore on the left lower buttocks. The area was noted to have significant depth, with the erosion of the skin complete. Muscle and fat tissue was observed. During removal of the dressing, an area of undermining/tunneling was noted when part of the old dressing became lodged in the undermining, requiring the nurse to retrieve it using 2 Q-Tips to trap and remove the dressing. The Aplewood unit manager and facility Director of Nurses were interviewed after the treatment observation. The Applewood unit manager reported that because some eschar was noted inside the wound, the area was called unstageable. However, both acknowledged that, given the complete erosion of the skin, involvement of the muscle and area of undermining, the area had in fact deteriorated to a stage IV. The unit manager acknowledged that the undermining/tunneling had not been previously identified by the facility and no treatment or tracking of the undermining/tunneling had begun. Although the physician had been contacted, the facility could provide no evidence that the wound had been seen by the physician or nurse practitioner since it began its significant deterioration in November 2010. A review of the facility's wound and skin care policy, indicated the facility would designate a skin care team to focus and review all wounds on a regular basis. The plan of care for the resident would address problems, goals and interventions directed toward the treatment of [REDACTED]. The facility failed to follow their skin care protocol policy and failed to accurately recognize/identify and assess a facility acquired pressure wound for this resident who was at high risk for developing pressure areas. Additionally the facility failed to implement effective strategies to minimize on-going pressure deterioration to the wound and failed to obtain prompt treatment and interventions when the wound deteriorated. 2. Resident #4 had [DIAGNOSES REDACTED]. The resident's most recent quarterly Minimum Data Set Assessment (MDS) with a reference date of 9/19/10 indicated that the resident was cognitively impaired and was dependent on facility staff to complete the activities of daily living. During the initial tour of the facility, the resident was lying in bed on an air mattress. A bed extension was attached to the bottom of the bed. The extension was covered with a "gym" type mat. The resident's feet were observed. The resident's right heel was resting directly on the hard surface of the mat. The sheet was pulled tightly over the resident's left foot, which was positioned above the right foot. The resident's 1st (great) and 2nd toes were noted with scabs over the knuckle area of the toes. Facility staff repositioned the resident after observation by the surveyor. It was reported that the resident often slid forward when the head of the bed was raised. The resident's feet were observed in the same position with the heel on the mat and the sheet pulled tightly over the toes on 12/1/10 at 4 PM and on 12/2/10 at 11 AM and 3 PM. On 12/3/10 at 10:30 AM, the resident was observed with the unit manager. The resident's feet were reversed, as the left heel was resting on the mat and the right foot was positioned on top of the left. The sheet was pulled tightly over the right toes. After observation with the surveyor, the facility implemented a sheet cradle to keep pressure off the resident's toes. The facility subsequently changed the resident's air bed to ensure that the resident's heels were off-loaded. The Director of Nurses was interviewed on 12/7/10 at 4 PM. The Director reported that the second toe area dated back to June 2010 when the resident was injured while being transferred with a Hoyer lift. Per review of the nurses' notes, facility nursing staff first noted that the resident's left 1st toe was "red" on 11/17/10. On 11/20/10 a nurse described the area as "reddened at the knuckle with a scrape at the center." On 11/23/10 the 1st and 2nd toes were described as having "scabs." Per review of the resident's plan of care for potential for skin breakdown, developed 3/16/10, the facility failed to implement strategies to minimize pressure to the resident's toes and failed to relieve pressure on the resident's heels.

Not Corrected: Based on record review, observation and staff interview, the facility failed for 5 residents (#2, #3, #5, #8 and #14) of a total sample of 14 residents, to ensure that each resident have proper care and treatment for [REDACTED]. The findings included: 1. For Resident #14, the facility failed to complete treatments to an ulcerated toe as ordered by the physician, failed to provide proper pressure relief for the resident's heels and toes, failed to identify and treat new pressure ulcers as they developed, failed to provide separation for the resident's toes as recommended by the physician wound consultant and failed to complete a skin check as ordered by the physician. Resident #14 had [DIAGNOSES REDACTED]. The resident's most recent annual Minimum Data Set Assessment (MDS) with a reference date of 11/21/10 indicated that the resident was cognitively intact and needed extensive assistance from facility staff to complete the activities of daily living. The MDS indicated that the resident was at no risk for developing pressure sores and did not have any pressure sores at the time of the assessment. A care plan for pressure sores, created 12/14/11, included keeping the resident clean and dry, weekly skin checks, barrier cream on buttocks, repositioning and wound treatments as ordered. A subsequent Norton pressure ulcer risk assessment, completed 12/17/11 assessed the resident at high risk for developing pressure sores (Norton score 8- less than 10 is considered high risk.) Despite the findings of this assessment and that the residents vascular status placed the resident at greater risk, the facility failed to implement interventions to offload pressure to the resident's heels and toes Per record review, a facility nurse identified a fragile area on the resident's second toe (where it was in contact with the third toe) on 12/31/10. A treatment with a normal saline wash followed by a [MEDICATION NAME] dressing changed 3 times weekly on Monday, Wednesday and Friday was instituted that day. On 1/14/11, during a weekly assessment of the area, the left 2nd toe area was described as scabbed over. By the 1/21/11 weekly assessment of the left 2nd toe, the scab had fallen off. On 1/20/11, the treatment was changed to a normal saline wash followed by collagen gel covered with a Band-Aid to be changed daily. The team staged the wound as a stage II. On 1/24/11 and 1/30/11, the treatment was not signed as completed. The facility could not demonstrate that the dressing was completed as ordered. On 1/31/11, the facility wound physician (new to the facility as of 1/24/11) measured the wound at 0.8 cm x 0.4 cm x 0.1 cm with 30% thick adherent devitalized tissue. The physician described the wound as arterial in nature and contributing factors included [MEDICAL CONDITION] and that the toes were deformed and pushing together. During interview on 2/17/11 at 11:30 am, the wound physician confirmed that arterial and venous disease would increase the resident's risk for developing pressure sores and would delay healing, but that the wound was caused by the pressure of the toes rubbing together. The physician surgically debrided the wound at the bed side to 0.2 cm depth using a curette and local anesthetic. The physician ordered that the wound be packed with [MEDICATION NAME] packing and covered with a dry protective dressing 3 times weekly on Monday, Wednesday and Friday. The physician also ordered that gauze be used to separate the 2nd and 3rd toes on the left foot and that the resident use a shoe with a wide toe box. On 2/2/11 a facility nurse described in the treatment administration record that the wound looked worse, as it had increased redness. On 2/4/11 the treatment was signed as withheld because the resident was out of the building during the day shift. Despite being back for the 3-11 shift, the treatment was not completed. The toe was not redressed until 2/6/11, when a nurses' note reported that the family expressed concern about the resident's toe. The wound went without treatment from 2/2/11 (Wednesday) to 2/6/11 (Sunday) despite the noted decline identified by the nurse on 2/2/11. On 2/7/11 the facility wound team and wound physician described the wound as deteriorated. The physician measured the wound as 0.8 cm x 0.4 cm x 0.3 cm and reported that "bone was showing." The physician continued the same treatment and recommended that the toes be separated. Per record review, the facility could not demonstrate that the resident's toes were separated from the time it was first recommended by the wound physician on 1/31/11 until the time of record review on 2/10/11. During 3 days of observation (2/8/11-2/10/11) the resident's toes were not separated by gauze as recommended. On 1/23/11 a nurses' note reported that the resident's bilateral heels were soft and the left heel had a "small red area." The resident's physician ordered that skin-prep protective barrier be applied twice daily on the 7-3 and 3-11 shifts. A full body weekly skin check, due 2/4/11, was not completed as ordered. A nurse's note, dated 2/6/11 reported that the resident had a small necrotic area on the left heel. Skin prep was applied as per the previous order. The wound was not assessed any further. The facility could provide no evidence that the left heel was addressed by the wound physician during a visit on 2/7/11. The resident was observed on 2/8/11 at 3 PM in bed. The resident's heels were resting directly on the bed. A sheet and blanket were pulled directly over the resident's toes. There was no gauze between the resident's toes. The resident's feet were bare. Three pinpoint areas were noted on the top of the resident's left 3rd toe. The tips of the great toes on both feet were red. Both great toes and the left 3rd toe were in direct contact with the sheet and blanket. On 2/9/11 at 9:30 am and 3 PM, the resident was observed in bed. The resident's heels were resting directly on the bed. A sheet and blanket were pulled directly over the resident's toes. There was no gauze between the resident's toes. The resident's feet were bare. Red areas on the tip of both great toes remained and pinpoint areas on the left 3rd toe remained. On 2/10/11 at 11:15 am the surveyor observed the resident's feet with the unit manager. Upon entering the room, the resident's specialty mattress was deflated. After checking the equipment, the manager reported that it may need service. The resident was in bed dressed with socks on his feet. The resident's heels were resting directly on the bed. The resident's socks were removed. There was no gauze between the resident's toes on the left foot as recommended by the wound physician. The dry protective dressing that was to cover the wound on the left 2nd toe was not present. It was not found in the sock. During the 2/10/11 observation with the surveyor, the unit manager observed with the surveyor that the resident had 3 small open areas on the 3rd great toe that were noted by the surveyor 2 days earlier on 2/8/11. The unit manager acknowledged that the areas had not been identified by the facility and that no assessment, tracking or interventions had been implemented to prevent further breakdown of the toe. Also, an approximately 1.5 cm x 1.5 cm necrotic area was noted on the outer aspect of the left heel. The area was thickly calloused around the perimeter and had some apparent depth, indicating that it was not new. The unit manager acknowledged that the areas had not been identified and that no assessment, tracking or interventions that included proper pressure relief had been implemented to prevent further breakdown of the heel. The facility was revisited for an extended survey 2/16/11-2/17/11. On 2/16/11 the resident was observed at 9 AM and 1:15 PM. At both times the dry protective dressing on the left second toe was hanging off, leaving the wound exposed. No gauze was used between the toes to reduce pressure. The resident was noted to be wearing "blue gel booties" which had a open heel area that was to assist with offloading heel pressure. The booties were observed to be ill fitting. The resident's foot was positioned too high in the bootie, and both heels were resting directly on the inside of the bootie. 2. For Resident #3, the facility failed to ensure that treatments for a pressure ulcer were completed as ordered by the physician, and subsequently the pressure wound deteriorated. Staff also failed to ensure that the resident was not sitting on equipment that created pressure to the buttocks. Resident #3 had [DIAGNOSES REDACTED]. The resident's most recent annual Minimum Data Set Assessment (MDS) with a reference date of 11/21/10 indicated that the resident was cognitively impaired and needed extensive assistance from facility staff to complete the activities of daily living. The MDS indicated that the resident was at risk for developing pressure sores, but did not have any pressure sores at the time of the assessment. A care plan for a pressure sore to the coccyx, developed 12/7/10, called for a weekly wound assessment and measurement, pressure reduction in chair and bed, pain treatment, update physician as needed, wound treatment, supplements and incontinent care as appropriate. On 12/4/10, when the wound developed, the treatment initiated included a normal saline wash followed by a [MEDICATION NAME] dressing to be changed 3 times weekly on Monday, Wednesday and Friday. The wound was described as a 2 cm x 0.5 cm clean wound with white edges and a pink center. No depth was described. Per record review, on 1/6/11 the facility performed a weekly assessment of the resident's pressure sore. The team described the wound as a 1.5 cm x 0.5 cm x 0.1 cm (length, width, depth) Stage II pressure sore on the coccyx. The area was pink, without drainage and had granulation tissue. The team concluded that the area was healing. Per interview with the facility wound champion on 2/9/11 at 11 AM, the facility began using the pressure ulcer PUSH tool (The Pressure Ulcer Scale for Healing) in mid January 2011. The tool was designed to be able to tell, at a glance, whether the ulcer was healing, was unchanged, or was deteriorating. The tool included data about the wound size, exudate and a description of the tissue involved. The scale was 0 (healed) to 17 (worst.) On 1/14/11, the weekly assessment reported that the coccyx wound had declined. The measurement was 1.6 cm x 0.7 cm x 0.3 cm. No changes to the plan of care were implemented. The facility's PUSH assessment recorded the wound as a 5. On 1/21/11, the weekly assessment reported that the coccyx wound continued to decline. The measurement was 2.2 cm x 0.9 cm x 0.3 cm. The wound began to have evidence of light exudate. The facility's PUSH assessment recorded the wound as a 7. On 1/24/11 the resident was seen by the facility's newly contracted wound specialist. It was the first time the wound was seen by a physician since its development on 12/4/10. The wound physician described the wound as a healing stage III. The measurement was 2.2 cm x 0.5 cm x 0.1 cm. The physician described the wound as having 80% granulation tissue and 20% thick adherent devitalized tissue. The physician surgically debrided the wound at the bedside to 0.3 cm depth using a curette and local anesthetic. The treatment order included balmex to the surrounding skin, Iodosorb packing in the wound followed by an Allevyn cover dressing and the resident was referred to physical therapy to evaluate wheelchair positioning. On Wednesday, 1/26/11, the treatment was not signed as completed. The facility could not demonstrate that the dressing was completed as ordered. On Friday, 1/28/11, the dressing was signed as withheld due to the resident being "out of bed." The facility could not demonstrate that the dressing was completed later that day or throughout the weekend. On 1/31/11 the wound was evaluated by the wound physician. The wound physician described the wound as a healing stage III. The measurement was 2.2 cm x 0.5 cm x 0.3 cm. The physician described the wound as having 80% granulation tissue and 20% thick adherent devitalized tissue. The physician reported that the periwound was macerated and that the overall condition of the wound had deteriorated due to "the generalized decline of the patient." The physician again surgically debrided the wound at the bed side using a curette and local anesthetic. The dressing was changed to a daily dressing using Balmex on the surrounding skin, then Iodosorb (slough and exudate absorbing/ antimicrobial) in the wound and covered by an Allevyn ([MEDICATION NAME]) dressing with waterproof backing. The facility's PUSH assessment recorded the wound as a 8. On 2/1/11, a facility physical therapist recommended the resident be trialed in a Broda chair for better positioning. On Tuesday, 2/1/11, and Thursday, 2/3/11, the dressing was signed as withheld due to the resident being "out of bed." The facility could not demonstrate that the dressing was completed until the next scheduled times on 2/2/11 and 2/4/11 respectively. On 2/7/11 the wound was evaluated by the wound physician. The wound physician described the wound as a healing stage III. The measurement was 2.4 cm x 1.1 cm x 0.3 cm. The physician described the wound as having 80% granulation tissue and 20% thick adherent devitalized tissue. The wound had moderate sero-sanguinous drainage. The physician reported that the periwound was macerated and that the overall condition of the wound had deteriorated because the resident was non compliant with positioning and had a possible infection. The physician surgically debrided the wound at the bed side using a curette and local anesthetic. The dressing was changed to a daily dressing using Balmex on the surrounding skin, then [MEDICATION NAME] with silver in the wound covered by an Allevyn ([MEDICATION NAME]) dressing with waterproof backing. The physician recommended that the resident be started on the antibiotic [MEDICATION NAME] for 1 week. The facility's PUSH assessment recorded the wound as a 10. The primary physician refused the antibiotic, preferring to wait for a culture. The primary physician later discontinued the order for a culture, because nursing staff reported that there was "no drainage to culture." The wound physician was interviewed on 2/17/11 at 11:30 AM. The physician was unaware that dressings were not being completed as ordered and was concerned that missed dressings could have caused the wound to deteriorate. The wound physician was also unaware that the resident did not receive the recommended antibiotic because it was not reported to her. The wound was observed on 2/8/11. The wound presented as a deep slit on the resident's coccyx. During interview with the facility administrator, director of nurses and wound champion on 2/10/11, none were aware that treatments were not being completed as ordered. The facility could not explain why the treatment, which was ordered to be completed 3 times weekly from 1/24/11 to 1/31/11, was missed twice and why, when the wound deteriorated and the treatment was changed to daily on 1/31/11, the treatment was again missed twice. The resident was observed in a "Broda" chair on 2/16/11 at 1:30 PM. The resident was noted to be sitting on a Hoyer pad which was on top of a pressure reducing cushion. During interview with the facility rehabilitation department director on 2/16/11 at 2 PM, the director reported that staff had been inserviced the day before that resident's with "split" types of Hoyer pads should not sit on the pads, as the "belt" created pressure on the buttocks/ coccyx. The director reported that Resident #3 should not have been in the chair sitting on that pad. 3. For Resident #8, the facility failed to ensure that treatments for a pressure ulcer were completed as ordered by the physician, and subsequently the pressure wound deteriorated. Resident #8 had [DIAGNOSES REDACTED]. Per record review on 2/9/11, on 12/30/10 pressure sores discovered on the left and right buttock were treated with normal saline washes followed by a [MEDICATION NAME] dressing to be changed 3 times weekly on Monday, Wednesday and Friday. On Monday, 1/3/11, the treatment was not signed as completed. The facility could not demonstrate that the dressing was completed as ordered. On Wednesday, 1/5/11, the dressing was signed as refused due to the resident "wanting to get out of bed early." The facility could not demonstrate that the dressing was completed until the next scheduled time on 1/7/11. A care plan for pressure sores initiated on 1/3/11, called for a weekly wound assessment and measurement, pressure reduction in chair and bed, pain treatment, update physician as needed, wound treatment, supplements and incontinent care as appropriate. The facility weekly assessment on 1/7/11 reported that the left buttock was a stage II pressure sore that measured 2 cm x 2 cm. It had no drainage and the surrounding tissue was intact. The facility's PUSH assessment recorded the wound as a 7. The right buttock was a stage II pressure sore that measured 1.5 cm x 2 cm. It had no drainage and the surrounding tissue was intact. The facility's PUSH assessment recorded the wound as a 6. Per a 1/13/11 assessment, the areas separated into 5 different areas. Per record review the areas were spread into 2 treatments. Areas on the right and left buttocks were to be cleansed with peri-wash, then a thin protective layer of Balmex daily. The coccyx was to be washed with normal saline followed by a [MEDICATION NAME] dressing to be changed 3 times weekly on Monday, Wednesday and Friday. The coccyx area measured 2 cm x 1.5 cm x 0.25 cm. The coccyx pressure sore PUSH score was 6. On Friday, 1/14/11, both treatments were signed as withheld due to the resident being "out of bed." The facility could not demonstrate that the dressings were completed later that day or over the weekend. On Saturday 1/15/11 the right and left buttocks treatment was blank. The resident's most recent quarterly Minimum Data Set Assessment (MDS) with a reference date of 1/16/11 indicated that the resident was cognitively intact and needed extensive assistance from facility staff to complete the activities of daily living. The MDS indicated that the resident was at risk for developing pressure sores and had 2 stage II pressure sores. On Monday, 1/17/11, the coccyx dressing was signed as withheld due to the resident being "off the unit." The facility could not demonstrate that the dressings were completed later that day. On 1/17/11 the care plan was updated to include the use of a draw sheet and two staff when repositioning to minimize shearing. On Thursday, 1/20/11, the right and left buttocks treatment was signed as withheld due to the resident being "out of bed." The facility could not demonstrate that the dressing was completed later that day. The facility weekly assessment on 1/21/11 reported that the areas on the right and left buttocks were healed but the area on the coccyx had deteriorated. The coccyx was described as unstageable, as eschar/sloughing covered 80% of the wound. The slough was described as brown and moist. The wound had a moderate amount of tan colored drainage and a reddened/ macerated peri-wound. The area was measured at 2.2 cm x 0.9 cm x 1.98 cm. The coccyx pressure sore PUSH score was 9. As part of the 1/21/11 weekly assessment, the facility noted that the resident is very social and often it is difficult to get the resident to change position or get back to bed. The facility failed to note that the treatments to the coccyx/buttocks were not consistently completed as per physician order. On 1/21/11 the facility contacted the primary physician and the treatment was changed to normal saline wash, followed by wound gel (maintain wound moisture and debridement) and covered by Allevyn. The dressing was to be changed 3 times weekly on Monday, Wednesday and Friday. On 1/24/11, the resident was seen by the facility would physician. The coccyx wound was described as an unstageable, necrotic pressure sore that measured 4 cm x 3 cm x 0.3 cm. The wound had moderate sanguineous drainage, 100% thick adherent devitalized tissue and a peri-wound was described as having deep tissue injury that was purple/maroon in color. The physician surgically debrided the wound at the bed side using a curette and local anesthetic. The dressing was changed to [MEDICATION NAME] (alginate) followed by Allevyn changed daily. On 1/31/11, the physician reported the wound was stable. The physician described the wound as a stage III that measured 3 cm x 0.2 cm x 0.2 cm. The wound had moderate sanguineous drainage, 100% thick adherent devitalized tissue and a peri-wound was pink in color. The physician surgically debrided the wound at the bed side using a curette and local anesthetic. The same treatment was continued. The coccyx pressure sore PUSH score was 7. On 2/1/11 and 2/3/11, the coccyx dressing was signed as withheld due to the resident being "out of bed." The facility could not demonstrate that the dressings were ever completed. On 2/7/11, the physician described the wound as stable. The physician described the wound as a stage III that measured 2.5 cm x 1.4 cm x 0.3 cm. The wound had moderate sanguineous drainage, 100% thick adherent devitalized tissue and a peri-wound was pink in color. The physician surgically debrided the wound at the bed side using a curette and local anesthetic. The result was a 0.5 cm deep wound. The dressing was changed to a daily dressing using Balmex on the surrounding skin, then [MEDICATION NAME] with silver in the wound covered by an Allevyn ([MEDICATION NAME]) dressing with waterproof backing. The facility wound team reported that the wound had deteriorated and the wound had more sloughing. The coccyx pressure sore PUSH score was 9. The facility failed to complete 11 treatments as ordered by the physician over a 30 day period and subsequently the resident's wounds deteriorated. 4. The facility failed to ensure that a resident who was assessed to be at risk for the development of pressure ulcers, was provided with the necessary care, treatment, and preventative measures to prevent pressure ulcers from developing. Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 2/9/11 revealed an admission nursing assessment dated [DATE]. The assessment revealed that the resident was admitted with an incision with 29 staples in place to the right BKA site, a burn wound to the right knee, and a scab on the right elbow. Additionally, the assessment indicated that the resident's back was "covered in small red bumps of various sizes," and "multiple scars of various shapes and sizes" over the resident's entire body. No pressure ulcers were noted. On 1/5/11 at 12:33 PM, a Norton Pressure Ulcer Scale was conducted and indicated a score of "11." The Norton Pressure Ulcer Scale score placed the resident at risk for developing pressure ulcers. Further record review on 2/9/11, revealed that on 1/12/11, during weekly skin checks on the 3-11 shift with the CNA (certified nursing assistant), nursing discovered a "newly acquired pressure ulcer" on the resident's coccyx. Review of nursing documentation indicated that the area was "reddened," measured 1/2 inch in diameter with a "very small open area in center." The resident informed the nurse that it was "sore," and difficult to lay on his side, due to the pain experienced from the right leg amputation site. The resident described his pain as a "9," on a scale of 1-10. The resident was prescribed [MEDICATION NAME] sulfate 45 milligrams twice daily, and [MEDICATION NAME] 6-8 milligrams every two hours as needed for mild to severe pain. According to the nurse's note, the physician, nursing supervisor, and a member of the wound team were alerted of the resident's newly acquired pressure ulcer. The administrator was also made aware of the resident's newly acquired pressure ulcer. On 1/13/11, an initial assessment of the pressure ulcer was conducted. The coccyx wound was assessed to be a Stage II ulcer that measured 0.5 cm. (centimeter) long, by 1 cm. wide, by 0.25 cm. deep. The wound was documented to be pale at the wound bed, light pink at the perimeter, with a spot of sanguineous drainage. A treatment order was obtained which included cleansing the wound with normal saline, cover with [MEDICATION NAME] dressing, and change every three days until resolved. Additional nutritional interventions included arginate, sugar free house supplement, and zinc. The resident's plan of care for prevention of skin breakdown was updated on 1/13/11. Special instructions included "resident to sit on cushion when OOB (out of bed) in W/C (wheelchair)," and "assist resident to T & R (turn and reposition) Q2hrs (every two hours) when in bed." Although the facility provided a cushion to the resident's wheelchair, there was no documented evidence that additional pressure relief was considered for the resident's bed. According to the admission MDS (Minimum Data Set), signed as being completed 1/14/11, the resident was alert, oriented, and without cognitive deficits. The MDS indicated that the resident was at risk for developing pressure ulcers. However, no pressure ulcers were identified on the MDS. On 1/18/11, a weekly follow-up assessment of the wound was conducted. The coccyx wound remained at Stage II, and measured 0.5 cm. long, by 0.8 cm. wide, by 0.1 cm. deep. The wound exhibited 40% light pink and 60% grayish tissue. Light serosanguinous drainage was noted. The surrounding tissue was pink, and the wound was described as "improving-becoming measurably smaller and more shallow." On 1/27/11, the weekly follow-up assessment of the coccyx wound was conducted. The wound had declined to a Stage III. Documentation indicated "have to stage as 3 related to 20% yellow slough noted to wound bed, previously documented as a Stage II." Description of the ulcer status was noted as "worsening," "light" drainage, with surrounding tissue "intact," and granulation occurring 80% of wound bed. The current treatment was listed as "[MEDICATION NAME]." In spite of the 1/27/11 assessment, which detailed a decline in the clinical presentation of the coccyx pressure ulcer from Stage II to Stage III, no additional pressure off-loading measures were provided. On 2/4/11, the weekly follow-up assessment of the coccyx wound indicated that the ulcer remained at Stage III, "the same," with 90% granulation tissue, 10% yellow slough, and light serosanguinous drainage. "No change" in the wound healing status was noted. The wound measured 0.4 cm. long, by 1 cm. wide, by 0.1 cm. depth. The treatment with [MEDICATION NAME] dressing remained the same. Interview with the unit manager on 2/8/11 at 3:45 PM, confirmed that there were no pressure ulcers noted upon admission. He also acknowledged that the resident was assessed upon admission to be at risk for the development of pressure ulcers. The resident was observed and interviewed on 2/8/11 at 3:55 PM. He was found to be alert, oriented, and responded appropriately. The resident was observed lying flat on his back in bed. He indicated that his right stump incision was painful, and as a result, he had difficulty repositioning himself in bed. He stated that he was taking medication for the pain, and reported that pain relief was adequate. The resident also reported having a pressure ulcer on his coccyx that was causing him pain. He confirmed that the ulcer was being treated by nursing staff. The resident's bed was observed to have a thick, firm, foam-type mattress, with a thin, nylon-like cover. The resident indicated that the mattress was the same one that had been on the bed since he was admitted . The resident's wheelchair was positioned next to the bed and had a black cushion on it. The resident's coccyx pressure ulcer was observed on 2/9/11 at 2:03 PM, in the presence of the licensed nurse responsible for the resident's care. According to the nurse, the coccyx pressure ulcer measured approximately 1 cm. by 1 cm. The ulcer was observed to be triangular-shaped with measurable depth. The wound bed was pink and dry, and pink granulation tissue was noted at the margins of the ulcer. The resident's bed did not have any special pressure reduction features to it. Further interview with the unit manager on 2/16/11 at 1:30 PM, acknowledged that because of the resident's right leg amputation, increased pain, and decrease in bed mobility, he was considered to be at risk for the development of pressure ulcers. When interviewed regarding why additional pressure relief was not considered for this "at risk" resident, he replied, "Someone has to recommend it." He acknowledged that no one in the facility had made the recommendation for additional pressure reduction for the resident's bed. "I don't know if it's a cost thing." Additionally,The unit manager indicated that the resident would have benefited from additional pressure relief to his bed. The facility's incident investigation for this facility-acquired pressure ulcer was dated 1/18/11. The report noted that the incident was reviewed, and "area assessed by wound team on 1/13/11." The investigation indicated that the "Possible Cause" for the coccyx pressure ulcer was "pressure, as resident states it is difficult to turn and reposition due to leg amputation." The incident was reviewed by the administrator, the wound team, and the nursing unit manager. The investigation indicated, "Will continue to monitor." 5. For Resident #2, the facility failed to address repositioning needs and failed to provide adequate pressure relieving devices to effectively off load heel pressure to prevent the deterioration of a left heel pressure ulcer. Resident #2 had [DIAGNOSES REDACTED]. Review of the 12/9/10 minimum data set (MDS) assessment indicated that the resident was dependent on staff for transfers, mobility, incontinence care and most activities of daily living. The resident was coded with a stage 1 pressure ulcer. The resident had no previous history of pressure ulcers. There was no documented care plan to address the pressure ulcer. Per record review, on 1/3/11 the treatment nurse documented that the resident's pressure ulcer on the left heel had a moderate amount of drainage with no odor noted. Review of pressure ulcer care plan initiated 1/4/11 documented that the resident had "actual pressure ulcer" related to immobility even though on 12/9/10 the facility had identified the resident with a stage 1 pressure ulcer. The care plan listed that weekly wound observations and measurements would be performed by licensed staff and the wound team. There were no treatment wound assessments completed at the time of dressing change as per the facility policy, on 1/4/11, 1/5/11 and 1/6/11. On 1/7/11, the wound team identified the resident had a worsening stage 3 left heel pressure ulcer with "full thickness of skin lost... presents as a deep crater." The wound length measured 1.5 cm; (width) 1.0 cm and (depth) 0.5 cm. Daily wound care treatment included the use of calcium alginates and Santyl. Pressure reduction recommendations included "positioning with pillow to keep the left heel elevated." On 1/10/11, the wound team conducted another weekly follow-up and concluded that the wound was "becoming larger." The wound was unstageable because slough was covering 90% of the wound bed. The wound team documented to "float heel at all times" but there was no documented evidence of how the facility would do this. Daily wound care treatment included the addition of [MEDICATION NAME] powder. The next treatment wound assessment completed 1/13/11 documented that the resident's pressure ulcer healing progress was improved. On 1/16/11, the treatment nurse documented that the left heel periwound was intact w

Not Corrected: Based on record review, observation and staff interview, the facility failed for 3 residents (#3, #4, #7) of a total sample of 13 residents, to ensure that each resident have proper care and treatment for [REDACTED]. The findings included: 1. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 4/6/22 revealed that the resident had wound areas on the bilateral lower extremities and had been followed by the facility's physician wound consultant. On 3/21/11, a follow up visit by the wound consultant documented that the resident's left second toe wound, Site 1, was "stable." The wound consultant indicated that the objective for the wound was to "control infection and manage pain." Wound measurements listed in the consultant's report were as follows: "Size: (L x W x D) 0.9 x 0.8 x 0.3 cm." The treatment recommended by the wound consultant was [MEDICATION NAME] packing every two days. Additional Information listed on the consultant's report included "[MEDICAL CONDITIONS], plus toe deformities and 2 toes pushed together, bone continues to be visible, no pain." On 3/28/11, an additional follow up visit by the wound consultant was made. The objective for the resident's wound remained "control infection and manage pain." The wound consultant documented that the wound to the resident's left second toe was as follows: Size (L x W x D) 0.9 x 0.8 x 0.3 The wound consultant also indicated in the consultant report that "[MEDICAL CONDITION], plus toe deformities and 2 toes pushed together (i.e. pressure is a contributing factor), bone continues to be visible, no pain, comfort measures only." The wound dressing remained [MEDICATION NAME] packing to the left second toe every two days. Interview with the administrator on 4/5/11, revealed that the wound consultant's services for evalution and treatment of [REDACTED]. The administrator indicated that the facility's wound care team would provide ongoing evaluation, assessment, and treatment for [REDACTED]. The administrator also indicated that the facility would refer residents to an outside, hospital-based, wound consultant if necessary. On 4/6/11, the facility's wound care team documented the following for the resident's left, second toe: -facility acquired 12/31/11, Stage 4, length (cm) 1.4, width (cm) 1.0, depth (cm) 0.6. The facility's documentation for the wound indicated a "Current Treatment" of normal saline wash followed by [MEDICATION NAME] packing, cover with DPD (dry protective dressing), lambs wool between toes, change every other day and PRN (as needed) Interventions listed for this resident included a foot cradle, specialty seat cushion, specialty mattress APM (alternating pressure mattress), and specialty shoes with open wide toe box. Wound progress for the left, second toe, was listed as "length slightly longer, width and depth stable." On 4/6/11 at 11:15 AM, observation of the treatment by LPN #1 to the resident's left, second toe was made. The resident was lying in bed, positioned on the back, with an alternating pressure mattress and foot cradle on the bed. LPN #1 spread out brown paper towels on the overbed table as the dressing field, and placed a suture removal kit, gauze pads, [MEDICATION NAME] packing, and a Band-Aid on the paper towels. LPN #1 had also obtained a bottle of SAF-Clens AF dermal wound cleanser, and placed it on the overbed table. LPN #1 informed the resident that the left second toe dressing was going to be changed. The nurse removed the bandaid covering the left second toe wound, removed the soiled, blood-tinged [MEDICATION NAME] packing from the wound, and discarded it in a plastic bag. The wound was crater-like in appearance, with reddened tissue noted throughout the inner portion. A small area of white bone was visible at the center. LPN #1 then irrigated the wound with a spray bottle of SAF-Clens solution, cleansed around the wound with gauze, and dried off any remaining solution. LPN #1 then began packing the wound with the [MEDICATION NAME] gauze packing using the forceps from the suture removal kit. While LPN #1 was packing the left second toe wound, the resident withdrew his left foot back multiple times, made a facial grimace, and verbalized pain to the nurse. At one point, the resident drew his right foot back and motioned to kick the nurse. LPN #1 apologized to the resident, and continued trying to pack the [MEDICATION NAME] packing into the wound with the forceps. LPN #1 finally cut off a portion of the end of the [MEDICATION NAME] packing with scissors. The nurse then packed the remainder of the [MEDICATION NAME] packing into the toe wound, and covered the wound with a bandaid. LPN #1 was interviewed after the dressing change about whether the resident had received anything for pain prior to the treatment. LPN #1 indicated that the resident had an order for [REDACTED]. LPN #1 was also questioned about the treatment order, specifically, why the wound had been cleansed the with SAF-Clens AF solution instead of the physician-ordered normal saline solution. LPN #1 indicated that because of the location of the wound, and the difficulty in cleansing it effectively, SAF-Clens AF spray was used instead of normal saline. The nurse acknowledged that there was no physician order to cleanse the wound with SAF-Clens AF solution. Interview with Unit Manager #1 on 4/6/11 at 2:15 PM, confirmed that LPN #1, who performed the treatment to the resident's left, second toe, should not have used the SAF-Clens AF dermal wound cleaner instead of normal saline. Unit Manager #1 acknowledged that a physician's order for the SAF-Clens must be obtained prior to it being used to cleanse the resident's wound. Unit Manager #1 also confirmed that the normal saline solution cleansing agent was the cleanser recommended by the wound consultant, and that the SAF-Clens AF was not the equivalent of normal saline. Unit Manager #1 acknowledged that the ingredients of SAF-Clens consisted of purified water, [MEDICATION NAME] solution, polakamer, coco [MEDICATION NAME], PG -dimonium chloride, sodium chloride, potassium [MEDICATION NAME], monobasic, DMDM hydantoin, citric acid, and sodium [MEDICATION NAME], NF, which may be added for pH adjustment. Unit Manager #1 later showed the surveyor a spray can of normal saline that the facility had on hand at the time the treatment to the resident's left second toe wound was conducted. Additionally, Unit Manager #1 acknowledged that minimizing the resident's pain during dressing changes was an important component of the resident's plan of care. Unit Manager #1 also acknowledged that the resident had not received any pain medication prior to the dressing change. The unit manager indicated that s/he would contact the nurse practitioner, who was at the facility at the time, to obtain an order to pre-medicate the resident with an [MEDICATION NAME] prior to dressing changes. During interview with the administrator, clinical consultants, Director of Nursing, nursing unit managers, and staff nurses, on 4/7/11 at 3:30 PM, all present acknowledged that the facility failed to carry out the treatment to the resident's left, second toe wound per the physician's order. They acknowledged that the resident's wound had deteriorated from 3/28/11 to 4/6/11. Additionally, the facility failed to provide adequate pain control for the resident prior to the dressing change on 4/6/11 at 11:15 AM. (Please refer to F 309 example 1.) 2. Resident #7 had [DIAGNOSES REDACTED]. The resident's most recent quarterly Minimum Data Set Assessment (MDS) with a reference date of 1/23/11 indicated that the resident was cognitively impaired and was dependent on facility staff to complete the activities of daily living. The facility failed to identify a decline in the condition of the resident's pressure sore on the back of the right knee. The facility also failed to ensure that the nursing staff accurately evaluated the wound. Per record review, in January 2011, the resident developed a pressure area on the back of the right knee related to the use of a brace. The treatment order, dated 2/21/11, was a normal saline wash, followed by calcium alginate gel with silver to the wound and covered with [MEDICATION NAME] foam dressing and abdominal pad every other day. A wound assessment, completed by the wound physician on 3/28/11, described the wound as a Stage III pressure sore that was 1.6 cm x 1.3 cm x 0.2 cm deep. The wound had 15% "thick adherent devitalized tissue," and was characterized as making stable progress. The physician reported that, after debridement, the wound depth was 0.3 cm. Subsequently, the wound physician's services were discontinued by the facility administration. During interview with the facility administrator and nurse consultant on 4/5/11 at 2PM, the facility reported that all wounds were reassessed by facility staff after the wound physician's last visit on 3/28/11. The facility assessment of the area, completed 3/28/11 after the wound physician's visit, reported that the wound was 2 cm x 1.7 cm x 0.1 cm deep. The facility reported that the wound was "becoming more shallow." The dressing was noted with light sero-sanguineous drainage. On 4/1/11 the resident's physician ordered the resident to be seen at a local wound clinic for evaluation. The appointment was scheduled for 4/6/11. On 4/4/11, the facility obtained an order for [REDACTED]. On 4/4/11, the facility reassessed the wound. A nurses' note, written 4/5/11, that described the 4/4/11 observation included that the wound had light drainage with no odor and was improving. The note documented the wound measurement as 2 cm x 1.5 cm x 0.1 cm deep. Wound care was observed on 4/6/11 at 8:30am. The resident was noted with a right leg contracture that limited the range of motion at approximately 30 degrees making access to the wound difficult. The wound appeared to the surveyor to be the approximate length and width as the facility's 4/4/11 assessment. However, the wound appeared to have much greater depth than 0.1 cm (which would be a superficial wound.) The wound was observed by the surveyor to be a full thickness wound with underlying tissue/structures visible. The wound had enough depth that the nurse had a difficult time cleansing the wound with gauze saturated with normal saline. During interview after the treatment, the LPN staff nurse #1 that completed the treatment, agreed that the wound was deeper than 0.1 cm. The facility failed to accurately assess and evaluate the wound. Later, on 4/6/11. the resident was seen at the wound clinic. The wound clinic assessed the wound as a Stage III that measured 2.5 cm x 1.3 cm x 0.7 cm deep with an exposed tendon. The facility failed to identify that the wound had deteriorated between the 3/28/11 physician visit and 4/6/11. (Please refer to F 309 example 2.) 3. Resident #3 had [DIAGNOSES REDACTED]. For Resident #3, the facility failed to follow physician orders for wound management of a stage 4 heel ulcer. Per record review, according to a 4/1/11 physician orders, the following treatment was ordered for the resident's left heel wound: normal saline wash followed by loose packing with [MEDICATION NAME] with silver, cover with [MEDICATION NAME] XC, and change Monday, Wednesday, Friday and as necessary. On 4/6/11 at 2:30 PM, LPN #1 was observed performing a left heel wound treatment for [REDACTED]. LPN #1 removed the blood-tinged [MEDICATION NAME] packing from the wound and discarded it in a plastic bag. A small area with depth was observed on the left lateral heel. During this observation, the LPN #1 cleansed the resident's stage 4 heel wound with a spray bottle of SAF-CLENS AF solution, not the normal saline wash as ordered by the physician. The staff LPN completed the remainder of the wound care as ordered. Unit Manager #1 was interviewed on 4/6/11 at 2:45 PM and confirmed that the physician had ordered a normal saline wash to cleanse the wound site. Unit Manager #1 confirmed that LPN #1, who performed the treatment, should not have used the SAF-CLENS AF dermal wound cleaner in place of the normal saline without physician order. Following review of the SAF-CLENS AF product information the Unit Manager confirmed that the SAF- CLENS was not the equivalent of normal saline.

Based on record review and interviews, the facility failed for 1 (#2) of 22 sampled residents, to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, with regard to the management of break-through pain for this resident. The findings are: Resident #2, a long term care resident had a [MEDICAL CONDITION] with necrosis and osteo[DIAGNOSES REDACTED], additional [DIAGNOSES REDACTED]. For Resident #2, the facility failed to implement an effective pain management program to address the resident's on-going break-through pain as evident by the frequent administration of the PRN Vicodan. Review of the 9/24/10 quarterly minimum data set assessment revealed that the resident was alert and oriented, required assistance with transfers, bathing and toileting and was coded with moderate pain less than daily. Per record review, the resident was being followed by a tone management clinic consultant for [MEDICATION NAME] injections due to spastic [MEDICAL CONDITION] from a stroke. Review of a 6/15/10 progress note, revealed that physician consultant noted that the resident was having new left lower extremity pain from the dorsum of the foot up to the knee that the resident described as a burning type pain with mild swelling. The consultant recommended to increase the resident's [MEDICATION NAME] (for treatment of [REDACTED]. On 7/6/10, the primary care physician wrote that the resident continues to struggle with issue of disability and chronic pain. [MEDICATION NAME] increased,"some effect, overall improved." Continue follow-up with pain (tone) clinic. According to July 2010 Medication Administration Record, [REDACTED]. In addition, the resident had a PRN order for [MEDICATION NAME] every four hours as needed for break through pain. Further review of the July 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 7/17/10 the nurse wrote that the resident was medicated with [MEDICATION NAME] for a "pain level of 10 (scale 1 - 10 with a 10 the worst possible pain), in the left foot. Pain level reduced to 8: actions: continue to observe." On 7/29/10 the resident fell on the 11-7 shift and sustained a laceration to the head and required subsequent transport to the emergency room for sutures. Review of the facility incident report revealed that the resident fell attempting to stand on the floor to get relief from painful spasms of the left foot. Review of a quarterly pain management assessment completed on 7/29/10 at 2:54 PM revealed that the resident told staff that her left foot pain range was, at its worst: 10, at its best: 2 and her current pain was: 4. The nurse documented that the resident's acceptable level of pain was: 2. The treatment goal was to have no pain. Despite the pain assessment findings, which indicated that the resident's foot pain was not being effectively managed, there was no evidence that this information was communicated to the Nurse Practitioner who had visited the resident on 7/29/10 following her return from the emergency room . (see F157) On 8/18/10, the resident had a follow-up visit with the physician consultant at the tone/pain clinic for scheduled [MEDICATION NAME] injections. Review of the nursing referral, as confirmed by the Director of Nurses on 12/6/10, was incomplete and made no reference to the resident's pain or current pain medication regimen in order for the consultant physician to have a baseline for making treatment recommendations. Review of the August, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review revealed the staff failed to utilize the pain scale, as per facility policy, in order to gauge the effectiveness of the medication administered in order to determine if the resident had adequate pain control. For example, on 8/19/10 the nurse documented that the resident had "9 out of 10 pain in the left foot, medicated with PRN [MEDICATION NAME]. There was no quantification if the "results" indicated that the resident acceptable level of pain identified as a "2" was met and that the resident was comfortable. On 9/1/10, a psychotherapist consultant following the resident for depression documented the the resident "continues to complain of breakthrough pain of the left foot" and recommended for staff to monitor for pain. Review of the September Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 9/29/10, the resident was visited again by the psychotherapist consultant. The consultant documented that "per nursing some continued intermittent episodes of breakthrough pain of the left foot." The consultant reported that the resident continued to complain of left foot pain. The resident told the consultant that the pain comes and goes, she felt down and frustrated at times. The consultant recommended to "continue to assess for the effectiveness of the pain regimen." Further review of documentation revealed that on 9/30/10 the Nurse Practitioner had visited the resident for complaints of increased foot pain in the "AM for about a week now." New orders were given to initiate scheduled [MEDICATION NAME] in the morning. The Nurse Practitioner, who was interviewed on 12/7/10, confirmed that she had visited the resident on 9/30/10. The Nurse Practitioner stated that she was unaware that the resident had increasing requests for PRN [MEDICATION NAME] since August due to severe pain. When the surveyor informed the Nurse Practitioner that the resident had requested PRN medication on 23 occasions in September the Nurse Practitioner replied that she was "never made aware of that." The resident was hosptalized on [DATE] for a left above the knee amputation due to osteo[DIAGNOSES REDACTED] of the left foot and subsequently readmitted on [DATE]. During resident interview on 12/7/10, the resident stated that she was doing better since her readmission and that it was good to be "back home." The resident told the surveyor that she had to make a difficult decision to have the doctors remove her leg because of an infection in her foot. I had so much pain. The resident stated she had pain and spasms in her leg and had been in "terrible terrible" (shaking her head) pain for a few months. The resident spoke about her 7/29/10 fall that happened because her leg spasms were so painful that she fell getting out of bed in an attempt to put her foot on the floor, like they told me to do, to stop the spasms. When asked if the pain medication helped, the resident replied that they (the nurses) gave me pills but they didn't always help, often times I would stay in my room and cry. The resident stated that when she was in pain all she wanted to do was to be left alone.

Based on record review, observation and staff interview, the facility failed for 5 sampled residents (#4, #5, #6, #7, #10) of a total sample of 13 residents, to ensure that each resident have proper care and treatment. For 4 sampled residents with pain at wound sites (#4, #5, #7 and #10) the facility failed to provide proper pain relief. For resident #6, the facility failed to provide proper care for the resident's [MEDICAL CONDITION]. The findings included: 1. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 4/6/11 revealed that the resident had a pressure ulcer to the left, second toe that measured 1.4 cm long x 1.0 cm wide x 0.6 cm deep. The pressure ulcer was facility acquired, and determined by the wound consultant to have been caused by the 2nd and 3rd toes pressing up against each other. On 4/6/11 at 11:15 AM, LPN #1 was observed changing the dressing to the resident's left, second toe. During the dressing change, the resident withdrew his left foot back multiple times, made a facial grimace, and verbalized pain to the nurse. At one point, the resident drew his right foot back and motioned that he was going to kick the nurse. LPN #1 apologized to the resident, and continued trying to pack the [MEDICATION NAME] packing into the wound with forceps, in spite of the resident's verbalized pain. LPN #1 was interviewed after the dressing change about the resident's observed pain. During the interview, LPN #1 confirmed that the resident appeared to be in pain during the dressing change. The nurse also acknowledged that the resident had an order for [REDACTED]. Unit Manager #1 was interviewed on 4/6/11 at 2:15 PM. The unit manager acknowledged that minimizing the resident's pain during dressing changes was an important component of the resident's plan of care for the lower extremity wounds . She acknowledged that the resident had not received any PRN (as needed) [MEDICATION NAME] prior to the dressing change. Review of the MAR (medication administration record) on 4/6/11, confirmed that no PRN [MEDICATION NAME] for pain relief had been given prior to the dressing change on 4/6/11, or, for the entire month of April, 2011. Unit Manager #1 indicated that the nurse practitioner, who was in the building at the time, would be contacted to address the resident's pain. The nurse practitioner subsequently ordered [MEDICATION NAME] PRN prior to each dressing change to the left 2nd toe. Interview with the administrator, clinical consultants, Director of Nursing, nursing unit managers, and staff nurses on 4/7/11 at 3:30 PM, acknowledged the facility's failure to provide effective pain relief for the resident during the dressing change observed on 4/6/11 at 1:15 AM. (Please refer to F 314, example #1) 2. Resident #7 had [DIAGNOSES REDACTED]. The resident's most recent quarterly Minimum Data Set Assessment (MDS) with a reference date of 1/23/11 indicated that the resident was cognitively impaired and was dependent on facility staff to complete the activities of daily living. The facility failed to provide the necessary care and treatment to prevent and control the resident's pain. In January 2011, the resident developed a pressure area on the back of the right knee related to the use of a brace. The resident's care plan for actual skin breakdown, created 1/25/11, included that regular assessment for pain related to the wound be conducted by nursing staff and that pain medication be evaluated for effectiveness. The facility pain management policy included that residents at risk for pain would be evaluated every shift. The policy dictated that residents at risk for pain would be evaluated for the presence and level of pain and that the pain level be recorded each shift. The facility utilized a numeric pain scale to evaluate the intensity of pain, with the most severe pain identified as a "10". The resident's MEDICATION ORDERS FOR [REDACTED]. The resident also had orders for [MEDICATION NAME] (narcotic) 50 mg by gastrointestinal tube every 6 hours as needed for pain and [MEDICATION NAME] 650 mg by gastrointestinal tube every 4 hours as needed for pain. The resident also had a physician's orders [REDACTED]. On 3/27/11 at 1:54 am, a nurses' note reported that the resident was medicated for pain at a level 10 of 10 (most severe pain) in the area of the right knee (where the resident had a pressure sore) with [MEDICATION NAME] 50 mg/APAP 650 mg PRN (as needed) as ordered. Per review of the record, it was not until 24 hours later on 3/28/11 at 12:52 am that the nurse wrote that the resident's pain was reduced to 3 (mild) after the PRN medication. On 3/28/11 at 2:07 am, a nurses' note reported that the resident was medicated for pain at a level 7 (moderate/severe) of 10 in the area of the right knee with [MEDICATION NAME] 50 mg/APAP 650 mg PRN (as needed) as ordered. The nurse reported that the pain reduced to 0 at 6:32 am. On 3/28/11 at 11:50 am, a facility nurse wrote in the nurses' notes that the resident's current pain regimen included [MEDICATION NAME] (benzodiazepine) 5 mg by mouth twice daily at 6 am and PM, as well as the scheduled [MEDICATION NAME]/APAP. The nurse noted that the regimen seemed to be less effective. The nurse reported that the physician was faxed about the problem. Despite that the resident had reached breakthrough pain levels of 7 (moderate/severe) and 10 (most severe) on 3/27/11 and 3/28/11, the facility failed to implement any new strategies to manage the resident's pain. No further discussion was attempted with the resident's physician, other than the fax sent on 3/28/11, was attempted. No descriptive information about the resident's pain was recorded between 3/28/11 and 4/6/11. On 4/6/11 at 5:37 am a facility nurse wrote in the nurses' notes that the resident was medicated for a pain level of 10 (most severe) of 10 with the [MEDICATION NAME] 50 mg/APAP 650 mg PRN. At 6:27 am the nurse documented that the resident's pain level remained a 6 (moderate) of 10. No further treatment of [REDACTED]. Wound care was observed on 4/6/11 at 8:30am. The resident was noted with a right leg contracture that limited the range of motion at approximately 30 degrees, making access to the wound difficult. A deep, circular wound was observed. During the treatment, the resident retracted the leg and grimaced several times when the wound was touched. The wound care nurse was asked about pain management. The nurse acknowledged that the resident seemed to be in pain and that the resident was on scheduled pain management. However, the nurse reported that another nurse was giving medications that day and was not aware of when the medication was scheduled. Per review of the medication record, the resident's scheduled and PRN [MEDICATION NAME] were not scheduled or connected with the resident's dressing change. The [MEDICATION NAME] was scheduled for 10 am and 6 PM daily. The resident was seen at the wound clinic later in the day on 4/6/11. The wound clinic assessed the wound as a Stage III that measured 2.5 cm x 1.3 cm by 0.7 cm deep with an exposed tendon. The clinic reported that the resident had intermittent pain at level 5 (1-10 scale). Per review of the clinical record, the facility failed to document the resident's pain level each shift as per policy. Instead, nurses initialed on the MAR indicated [REDACTED]. No details of the monitoring were recorded. Actual pain scale leveling only occurred when the resident was administered PRN pain medication. (Please refer to F 314, example #2). 3. Resident #10 had [DIAGNOSES REDACTED]. For Resident #10, the facility failed to implement and complete treatments to the lower extremities as recommended by the physician wound consultant; failed to inform the physician when there was deterioration in the left foot wound and failed to treat the resident's pain. Staff also failed to ensure the resident's legs were elevated as ordered to treat bilateral lower extremity [MEDICAL CONDITION]. The resident's most recent quarterly Minimum Data Set Assessment (MDS) with a completion date of 3/10/11 indicated that the resident was alert and oriented, had rejected care on 1 - 3 occasions and required physical assistance from staff for transfer, bathing and toileting. The MDS reflected that the resident was at risk for ulcers/wounds and skin breakdown but the resident did not have any ulcers or other areas at the time of assessment. Per record review, on 3/21/11 the physician wound consultant visited the resident for a follow-up wound care assessment for a proximal left lower leg wound initially identified on 3/12/11. The physician described the wound as a mixed arterial- venous ulcer with reddened [MEDICAL CONDITION] tissue. The wound measured 1.5 cm x 0.7 cm x 0.3 cm with 40 % thick adherent devitalized tissue. The physician surgically debrided the wound and listed wound progress as stable. The physician ordered to continue the current wound treatment every 2 days: Silver Hydrogel dry protective dressings with the application of an elastic ace wrap to left leg, toes to knee, including the heel. Review of treatment sheet documentation on 3/23/11 indicated the left shin venous ulcer wound bed was open and moist with "slough 75% drainage." The nurse described the healing progress as sloughing with increasing drainage. The nurse documented that the left leg wound was cleansed, dressing changed and wrapped with kling. The nurse also documented that the resident had refused the elastic ace wraps. There was no evidence that the nurse obtained orders for substituting kling in place of the elastic ace wrap. A care plan for "actual" venous ulcer, created 3/25/11, listed approaches that included: wound treatment as ordered; weekly reevaluation of wound treatment modalities; assess for pain related to wound; update physician when needed; monitor skin condition daily and report changes. On 3/25/11, Unit Manager #3 documented that the left shin venous ulcer was moist, painful with yellow/green slough. The wound bed contained 90% slough. The healing progress was listed as "sloughing worsened more slough." The resident refused the elastic ace wraps. There was no documented evidence that the resident was medicated for a complaint of pain as documented by the nurse during wound care on 3/25/11. Review of physician orders [REDACTED]. According to facility policy, staff are to utilize a numeric pain scale to evaluate the intensity of the pain, medicate the resident and reassess the resident within one hour to determine the effectiveness of the pain medication. Review of the 3/25/11 treatment sheets revealed that staff nurse #1 checked off that he/she "monitored" the resident for pain. Further review revealed that staff nurse #1 assessed the resident's pain at 8:04 AM. There was no documented evidence that Unit Manager #3 reassessed the resident's need for pain medication prior to initiation of wound treatment at 11:18 AM. Per the nurses notes on 3/26/11 at 1:57 PM, the resident refused the ace bandage telling the nurse "it's uncomfortable." Review of the medication/treatment administration record for 3/26/11 failed to identify a numeric pain scale quantification for the resident's complaint of being uncomfortable. Further review revealed that [MEDICATION NAME] and/or [MEDICATION NAME] were not offered to the resident. On 3/27/11 the treatment nurse #1 described the left leg wound as "moist, sensitivity to touch, slightly painful, wound bed slough 90%. The healing progress listed: "sloughing more drainage." The nurse documented that she changed the dressing, wrapped with kling and then applied the ace wrap to the leg except the toes. Treatment nurse #1 documented that the resident had 3+ [MEDICAL CONDITION] in the right lower extremity and 2+ [MEDICAL CONDITION] in the left lower extremity. The facility could provide no evidence that the physician was informed regarding the change in resident status. Review of the 3/27/11 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 3/28/11 the physician wound consultant conducted a wound care assessment. According to the facility consultant on 4/5/11 at 2:00 PM, the administrator and medical director had chosen to discontinue the services of the physician wound consultant effective 3/28/11. The wound physician described the left leg wound progress as stable. The wound measured 2.1 cm x 0.8 cm x 0.3 cm with 40% thick adherent devitalized tissue that was surgically debrided. The left lower extremity (LLE) dressing orders, including elastic ace wrap were to continue every 2 days. The wound physician also noted that the resident had new moderate [MEDICAL CONDITION] of both right and left lower extremities with stasis [MEDICAL CONDITION]. The physician consultant recommended [MEDICATION NAME] (steroidal cream) to the affected areas twice daily for 7 days. Review of the 3/28/11 nurses notes indicated that the attending physician was contacted and gave new orders to discontinue the ace wraps and elevate the legs. There was no documented evidence that the 3/28/11 wound physician's findings and recommendations for treatment of [REDACTED]. Review of the physician's orders [REDACTED]. On 3/30/11, Unit Manager #3 documented the left venous ulcer as moist, open, red and [MEDICAL CONDITION] with the healing progress "worsened." Treatment orders date 3/30/11 included silver Hydrogel topical cover with [MEDICATION NAME] dressing followed by cling every other day. There was no documented evidence that the right leg [MEDICAL CONDITION] and stasis [MEDICAL CONDITION] was assessed by the nurse following the physician consultant's assessment of 3/28/11. On 4/1/11 the Unit Manager #3 documented that the LLE wound progress had improved. The resident's right leg [MEDICAL CONDITION] and stasis [MEDICAL CONDITION] was not assessed. On 4/3/11 the LLE ulcer was assessed as "moist, open, sensitivity to touch." The healing progress of the ulcer was listed as improving. The right leg [MEDICAL CONDITION] and stasis [MEDICAL CONDITION] was still was not assessed. A weekly wound team assessment conducted 4/4/11 revealed that the left wound ulcer had 25% slough and the surrounding tissue was red and [MEDICAL CONDITION]. The left wound ulcer healing process was described as "stable" with measurements listed as at 1 cm x 1 cm x 0.2. Further review revealed that the resident's right leg [MEDICAL CONDITION] and stasis [MEDICAL CONDITION] was not assessed by nursing staff since the 3/28/11 physician wound consultant's assessment and recommendations. On 4/6/11 the physician visited the resident and noted the resident had severe leg swelling with stasis [MEDICAL CONDITION] and ulceration. Ulceration (left leg) is healing with treatment." (Patient) with positional [MEDICAL CONDITION] (bilaterally) with gross swelling." Continue dressing changes plus leg elevation. On 4/7/11 at 8:15 AM resident #10 was observed out of bed in a wheelchair sitting in the hallway outside of his room. There were no foot rests on the wheelchair and the resident's feet were resting directly on the floor. The resident smiled when greeted and easily engaged in conversation. Resident #10 stated that he had already washed and dressed since early morning and was waiting for breakfast: "I'm an early bird." The resident was observed wearing sweat pants that exposed the lower portion of both legs from the shin to the ankles. The exposed areas were red and extremely [MEDICAL CONDITION]. The resident's feet were covered with socks and the resident was wearing slippers. The treatment nurse #1 was interviewed on 4/7/11 at 8:20 AM and was asked if there were any planned interventions to control the leg [MEDICAL CONDITION]. Treatment nurse #1 replied that the resident received wound care to a left leg ulcer at 7:30 AM and reported that left leg ulcer was "improving" but did not comment on the status of the leg [MEDICAL CONDITION]. Treatment nurse #1 stated that the resident "likes to self propel" in the wheelchair. Treatment nurse #1 observed the resident's feet in the presence of the surveyor and stated that the resident's feet should be elevated but was unable to explain how this would be accomplished as there were no available wheelchair legs on the unit. The resident's primary CNA #1 was interviewed at 8:30 AM in the presence of Unit Manager #3. The CNA stated that the resident is an early "get-up" and was already out of bed to the wheelchair by 7 AM. CNA #1 stated the resident would not be put back to bed until "sometime after lunch." CNA #1 confirmed there were no available wheelchair legs on the unit in order to elevate the resident's legs. Unit Manager #3 confirmed on 4/6/11 at 9:15 AM that existing physician orders [REDACTED]. Unit Manager #3 stated that the resident was noncompliant with leg elevation but could not explain what was the cause of the resident's noncompliance. Unit Manager #3 was unable to identify any strategies that staff had implemented to improve the resident's compliance with leg elevation. On 4/7/11 at 1:30 PM the resident was again observed by the surveyor sitting at the bedside in a wheelchair with the feet resting on the floor. The resident stated that "they are putting me into the recliner to get my feet up." At 1:45 PM the surveyor and Unit Manager #3 observed the resident resting in the bedside recliner chair. The Unit Manager was asked to assess the resident's legs. The left lower leg was observed with an intact dressing on the proximal left side. The resident had 2+ [MEDICAL CONDITION] with redness from the ankles to below the knee. The socks were removed with significant induration and flaking of the skin. The right leg was bright red with 3+ [MEDICAL CONDITION] and significant induration and flaking of skin when the socks were removed. The Unit Manager stated that the "right leg looked worse." Unit Manager #3 stated that following surveyor inquiry, the facility social worker met with the resident and the resident agreed to elevating his legs when in the wheelchair. Unit Manager #3 stated that the rehabilitation department was contacted to provide wheelchair legs. 4. For Resident #6 the facility failed to obtain timely blood glucose levels leading to a delay in administration of a stat (immediate) sliding scale insulin order. The facility also failed to monitor and reassess the resident's [MEDICAL CONDITION]. Resident #6 had [DIAGNOSES REDACTED]. The resident's most recent minimum data set (MDS) assessment with a reference date of 2/17/11 indicated that the resident was cognitively impaired and was dependant on staff to complete activities of daily living. Review of the clinical record including medication administration and treatment records indicated that the resident had orders for scheduled [MEDICATION NAME] (long-acting) insulin to be administered every morning at 6:30 AM. In addition, the resident had orders for blood glucose levels to be completed twice daily at 6:30 AM and 4:30 PM. Based on the results of the blood glucose levels, [MEDICATION NAME] R (short-acting insulin)100 units per milliliter was to be administered based on the following sliding scale: Blood Glucose < 60 call MD 150 - 200 = 2 units 201 - 250 = 4 units 251- 300 = 6 units 301 -350 = 8 units 351 - 400 = 10 units > 400 call MD On 3/24/11, review of physician's interim orders revealed the following order issued by a covering Nurse Practitioner at 5:45 AM: give 12 units regular insulin now x 1 subcutaneous. Recheck blood glucose in 1 hour. Review of the 3/24/11 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]> 600. There was no available documentation of the resident status during this hyperglycemic episode. At 6:30 AM, the resident was administered [MEDICATION NAME]34 units as scheduled. The covering Nurse Practitioner was contacted again at 6:45 AM and gave orders to administer 10 units regular insulin x 1 now (blood sugar reported as 535) and recheck the blood glucose in 1 hour. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation regarding the resident's status following this repeated administration of [MEDICATION NAME] insulin. There was no documentation that the resident's blood glucose was rechecked at 7:45 AM as ordered by the covering Nurse Practitioner. However, at 8:15 AM, the Nurse Practitioner gave an interim order: "Give 10 unit's regular insulin x 1 now (8:15 AM). Increase [MEDICATION NAME] (insulin) 38 units subcutaneous in AM." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to the 3/24/11 nurses notes, a blood glucose was not completed until 8:35 AM with a result of 482. Review of the 3/24/11 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no available documented assessment of the resident's status following the 9 AM insulin administration. In addition to 34 units of scheduled [MEDICATION NAME]at 6:30 AM the resident had received 32 units of regular insulin over the course of three hours. According to the 3/24/11 nurses notes the Nurse Practitioner provided an in house consult. Staff confirmed that as of 4/6/11 the Nurse Practitioner visit was unavailable for review. On 4/7/11 at 3:00 PM the Director of Nurses was interviewed and confirmed that the blood glucose levels were not completed as ordered and that there was a 45 minute delay in administering a stat insulin order. The Director of Nurses confirmed that there was no documented monitoring and reassessment for a resident with [MEDICAL CONDITION]. 5. Resident #5 had [DIAGNOSES REDACTED]. The resident's most recent annual Minimum Data Set Assessment (MDS) with a reference date of 3/20/11 indicated that the resident was cognitively impaired and was dependent on facility staff to complete the activities of daily living. For Resident #5, a resident with significant circulatory compromise in the lower extremities, the facility failed to identify new areas of concern on the resident's foot. The facility also failed to implement a consistent and accurate monitoring system for suspicious/actual areas of skin compromise on the resident's feet in order to determine the progress and or deterioration of the resident's clinical condition. The resident's left foot was observed at 8:30AM on 4/6/11. The resident was noted with a necrotic area on the tip of the left great toe, the tip of the left 3rd toe, a "scabbed area" on the left 2nd toe and 3 small lightly scabbed areas in close proximity on the top of the left foot. Per record review, the facility had no ongoing monitoring and evaluation of all but the area on the left 2nd toe. On 12/28/10 and 1/13/11, the resident was seen by a vascular surgeon for evaluation of the left second toe and "gangrene of the left foot." The resident was noted to have poor circulation with absent pedal pulses. The surgeon concluded that the resident was not a candidate for surgical intervention due to the clinical condition and family wishes. The surgeon recommended that the resident be seen again if the "situation of the foot should deteriorate." The facility nurse practitioner reviewed the consultation and ordered that the facility continue "assessments of the bilateral lower extremity toes daily." On 1/10/11, a facility nurses note reported that the resident had a 0.5 x 0.4 cm scab on the great toe and 0.3 x 0.4 cm scab on the 3rd toe. Per record review and interview with the facility Director of Nurses and nurse consultant on 4/6/11, the facility failed to institute any routine evaluation and measurement of the areas on the left great and left 3rd toes. In addition, the three areas observed on the top of the left foot were not identified by the facility. The facility could not explain when or how the areas occurred.

Based on record review, observation and staff interview, the facility failed for 2 residents (#10, #11) of a total sample of 22 residents, to ensure that each resident receive proper care and treatment to prevent unintended weight loss. The findings include: The facility policy for weight management included that 5% loss in 1 month, 7.5% loss in 3 months or 10% loss in 6 months were considered significant weight loss. Any subsequent weight loss was termed "severe weight loss." The policy required that reweighs be obtained if weights were "not within range" During interview with the dietician, it was reported that any variance of 3 pounds or greater required notification. CNA's were to notify nurses of any intake less than 50%. 1. The facility failed to identify a weight loss greater that 5% in 1 month and failed to implement timely interventions and provide assistance to mitigate the weight loss. Resident #11 had [DIAGNOSES REDACTED]. The resident's most recent quarterly Minimum Data Set Assessment (MDS) with a reference date of 10/31/10 indicated that the resident was cognitively impaired and was dependent on facility staff to complete most of the activities of daily living. The resident was coded as needing minimal assistance with eating. The resident was prescribed a low lactose ground texture diet three times daily and a bedtime snack. A dietary assessment completed 8/17/10, reported that the resident's weight was 117.3 pounds. The assessment targeted the resident's ideal body weight at 122 pounds +/- 5 pounds (117-127 pounds.) The assessment included that the resident received a "house supplement" 4oz twice daily and that the resident required supervision/cues to eat and that the resident usually consumed 50-100% of meals. Additionally, the care plan indicated that staff were to offer the resident high caloric options from the selective menu. At the end of August 2010, the resident's [MEDICATION NAME] (appetite stimulant) was discontinued after a pharmacy recommendation. On 9/26/10, 10/11/10 and 11/7/10, the resident was treated for [REDACTED]. The resident's weight, on 10/8/10, was 118 pounds. Per review of the weight sheets, the resident's weight on 10/15/10 dipped to 115 pounds. No reweight was completed. On 10/22/10 the weight decreased to 111.6 pounds (5.4% significant weight loss since 10/8/10) and on 10/29/10 the weight decreased to 110.9 pounds. (6% significant weight loss since 10/8/10) No reweights were recorded for either the 10/22/10 or 10/29/10 weights. Per review of the intake sheets from 10/4/10- 10/31/10, staff recorded intakes for 75 of 84 meals. The resident consumed 50% for 14 meals, 25% for 20 meals and refused 14 meals. There was no evidence that the facility identified the resident's poor intake during the month. It was not until 11/4/10 that the unit manager requested that a dietary consultation be ordered for weight loss. On 11/4/10 the resident was evaluated by the dietician. The dietician noted the resident's weight of 110.9 pounds. The dietician reported that the resident was able to eat independently, but required cues and supervision. The dietician also noted the resident's poor intake at meals. The dietician's plan was to reinforce to the CNA's the need to encourage high caloric choices at mealtime and to suggest to the physician that the [MEDICATION NAME] (antidepressant) be increased as an appetite stimulant. The resident's weights through November/ December 2010 included 112.3 pounds on 11/12/10, 112.1 pounds on 11/19/10, 112.1 pounds on 11/26/10 and 111.5 pounds on 12/3/10. The dietician's recommendation to increase the [MEDICATION NAME] was not completed until 11/25/10. The resident was observed during lunch on 12/6/10 and 12/7/10. On 12/6/10 the resident sat in the day room with 3 other residents. One of the other residents at the table was fed 1:1 by a hospice aide. Resident #11 was observed throughout the meal. The resident placed a utensil into the food, but did not attempt to eat. Staff in the room offered no cueing or assistance to the resident and the meal was removed with the resident eating next to nothing. While the resident ate a little better on 12/7/10, only approximately 25% of the meal was consumed. Again, staff offered no encouragement or cueing for the resident to eat. The facility failed to implement the recommendation for [MEDICATION NAME] as an appetite simulant in a timely manner, to ensure timely dietary assessment and intervention based upon the weekly weights evidencing weekly weight loss and ensuring assistance, encouragement and cueing with meals resulting in an unplanned weight significant weight loss. 2. Resident #10 was admitted to the facility on [DATE] following a hospitalization for the repair of a non displaced fracture to the left patella. Initial record review on 12/3/10 of the dietary assessment notes, dated 6/18/10, indicated that the resident had an admission weight of 192.4 pounds with an ideal body weight of 124 pounds +/- 5 pounds. The assessment indicated that the resident received a No Added Salt regular consistency diet with small portions. The dietary notes indicated that the diet order was appropriate for convalescence and consider a modest caloric restriction (e.g. House Consistent Carbohydrate (HCC) diet) if weight gain was noted. Dietary notes, dated 7/8/10, indicated that the resident had a blood draw on 6/24/10, with results showing a high HgbA1C (6.7) and a low [MEDICATION NAME] (3.1). The physician ordered a protein powder on 6/25/10 to address the resident's low [MEDICATION NAME] count, but after 3- 4 days the resident would vomit after consuming the protein powder drink and refused to accept it again. The physician was informed of the refusals on 7/6/10 and subsequently ordered Ensure (a high calorie supplement) twice a day. The resident had gained 4 pounds since her admission so the dietitian recommended to discontinue the Ensure supplement, add a HCC diet restriction for weight management and change the portion size of meat to large at mealtime. The physician agreed with these recommendations. Dietary notes, dated 8/23/10, indicated that the resident weight had dropped from 184.3 (7/10) to 177.4 (8/16/10) to 174.8 (8/23/10) a weight loss of 9.5.pounds in 1 month. The dietitian noted that the resident had been placed on small portion, with large portions of meat in early July when a HCC restriction was added. The resident remains "clinically obese", but the pace of loss was concerning. The dietitian noted that the resident's meal intake was at least 50% for most meals and recommended to discontinue small portions, but continue large portions of meat and recommend a recheck of the resident's TSH ([MEDICAL CONDITION] status) in January 2011. Dietary notes, dated 9/9/10, indicated that the resident's weight had stabilized at 176.4 pounds. No recommendations were made at this time. Subsequently, the resident lost an additional 12.4 lbs during the month of October to through November. There were no further dietary assessments and interventions documented until a 12/6/10 dietary note. Review of the weekly weight log on 12/3/10 indicated that the resident's weights ranged from 176.4 to 174.8 for the months of September and October. Recorded weights indicated that the resident weighed 174.8 at the end of October. However, the November weekly weights indicated that the resident's weight went from 174.8 end of October) to 172.4 to 168.8 to 166 .8 to 162.4 ( 12 2 10) showing a 12.4 unplanned weight loss during this period. Interview with the unit nurse supervisor on 12/3/10 indicated that the resident had not been seen by the dietitian since 9/9/10 to address this 12.4 pound weight loss. Observations of the resident during survey revealed the resident to vary with regard to her independence with eating. During a lunch on 12/1/10 she was observe in the dining room by herself with intermittent cueing by staff. She ate approximately 50% of the meal. On 12/2/10 the resident was in bed asleep and only her bowl of hot cereal with the rest of the meal untouched. Additional record review on 12/6/10 indicated that the dietitian had made an entry on that day regarding the resident's unplanned weight loss (5.9% loss in 30 days). The note indicated that the resident had been requiring more assistance with oral intake and was being fed increasingly more often. The note also indicated that the resident had developed on 12/3/10 a stage 1 area to the left heel measuring 0.6 centimeters by 1 centimeter. Recommendations were made to obtain lab work (CMP and TSH), add a dietary supplement at hour of sleep and to discontinue the HCC diet restriction. In addition a Nutrition care plan was added on 12/6/10 to address the resident's unplanned weight loss. In summary, the facility failed to assess and develop strategies to address the resident's gradual decline (12.4 pounds) from October to December that resulted in a weight loss of 5.9% in 30 days.

Not Corrected: Based on staff interview and the record review of 1 (#11) of 15 sampled residents, the facility failed to implement or modify dietary recommendations regarding Resident #11's history of weight loss. Findings included: Resident #11 had [DIAGNOSES REDACTED]. Review on 2/8/11 of the signed monthly physician orders, dated 1/13/11, noted that the resident had a No Added Salt regular diet with super cereal (a high caloric meal) at breakfast, a house supplement of 4 ounces at hour of sleep, and a house supplement of 8 ounces to be offered to the resident when meal intake was below 50%. Review of the annual Minimum Data Set, completed on 11/11/10, and the Quarterly assessment, completed on 2/11/11, indicated that the resident had short term memory deficits and the resident's weight went from 142 pounds (annual assessment) to 131 pounds (quarterly assessment) reflecting a weight loss of 11 pounds. Review of the annual dietary assessment, dated 11/11/10, indicated that the resident's ideal body weight range was 140 pounds +/- 3 pounds and usual body weight range was 135 pounds +/- 5 pounds. Review of the resident's weekly weight log indicated that the resident had a documented weight of 138.2 pounds on 1/6/11 and a documented reweigh of 140.3 on 1/11/11. On 1/13/11, the resident had a documented weight of 131.6 and a documented reweigh of 130 on 1/17/11, which reflected a weight loss of 10.3 pounds in a one week period (1/11/11 to 1/17/11). Documented weights on 1/20/11, 1/27/11, 2/3/11 and 2/10/11 were 130.4, 131.4, 131 and 132.2 respectively. In summary, review of the weight log indicated that the resident lost 8.1 pounds (140.3 pounds to 132.2 pounds) from 1/11/11 to 2/10/11, which reflected a 5.7% weight loss in a 4 week period. Review of the dietary note, dated 1/20/11, described that Resident #11 had a weight loss without any apparent precipitant. The note also indicated that the resident's intake was good at breakfast, variable at lunch and poor at supper. Based on the dietitian's recommendation, a physician's orders [REDACTED]. The dietary note, dated 2/7/11, indicated that the resident continued to receive a house supplement 4 ounces three times a day and a house supplement of 8 ounces when meal intake was less than 50%. The note indicated that weights were stable since the most recent increase in supplements (1/21/11). Review of the meal intake record, from 1/1/11 to 2/8/11, indicated that the resident had refused 24 meals, which included 3 at breakfast, 2 at lunch, and 15 at supper. The record also identified that the resident had 25% meal intake for 25 meals, which included 8 at breakfast, 10 at lunch, and 7 at supper. This review reflected a total of 49 meal opportunities, where the resident ate less than 50% of the meals. There was no documented evidence that this intervention was included on the nurse aide care plan and the review of the nurse aide flow sheets, for this time period, showed no entry that described an offering of the house supplement when the resident's meal intake was below 50%. Observation on 2/9/11 at 9:40 AM, showed Resident #11 in bed with the meal tray on the bed side table. Meal observation showed that the resident had apparently eaten a cup of super cereal, but had not eaten any of the pancakes. The resident stated to the surveyor that she didn't eat the pancakes because she didn't want to get fat. At 9:45 AM, this observation was shared with unit nurse manager #1. The unit manager stated that Resident #11 was routinely offered a choice of meals and that staff was aware that a supplement was to be offered to Resident #11 when the resident's meal intake was below 50%. The unit manager explained, however, that data regarding the offering of the supplement was not formally documented anywhere by the aides. At 9:47 AM on 2/9/11, a nurse aide was observed removing the meal tray from Resident #11's room. At 9:50 AM, the resident was observed asleep in bed with no meal tray or any type of nourishment at the bedside. Review on 2/17/11 of the dietary note, dated 2/17/11, showed a recommendation to discontinue the offering of the house supplement when meal intake was below 50% and to start offering a scheduled supplement (2 cal HN 60 c.c. (2 ounces) with medication pass) three times a day. In conclusion, Resident #11 had a significant weight loss of 8.1 pounds (140.3 to 132.2) from 1/11/11 to 2/10/11, which reflected a 5.7% weight loss in a 4 week period. There was no documented evidence that the facility staff offered the recommended supplement to the resident when meal intake was below 50 % or that the dietitian assessed the effectiveness of this intervention until 2/17/11.

Based on record review and interviews, the Facility failed for one of one sampled resident (Resident #1) to prevent the dislodging of Resident #1's [MEDICAL CONDITION], and subsequent transfer to two Hospitals for replacement. On 11/6/10, Certified Nurse Aide (CNA) #1 removed Resident #1's [MEDICAL CONDITION] prior to giving Resident #1 a shower and the [MEDICAL CONDITION] was unable to be reinserted by the nursing staff. Resident #1 was transferred to a local hospital on [DATE], whose staff were unable to reinsert the [MEDICAL CONDITION] and Resident #1 was then transferred to a Hospital in Boston for the replacement of the [MEDICAL CONDITION]. Findings include: Resident #1 was admitted to the Facility October of 2010, and [DIAGNOSES REDACTED]. The initial care plan, dated 10/28/10, indicated that Resident #1 had an alteration in respiratory status due to the [MEDICAL CONDITION] placement. The physician's orders [REDACTED]. The Unit Manager was interviewed on 11/23/10 at 10:30 AM. The Unit Manager said Resident #1 was admitted to the Facility with a #7 cuffless [MEDICAL CONDITION], that had no inner cannula. Certified Nurse Aide (CNA) #1 was interviewed on 11/23/10 at 11:15 AM. CNA #1 said on 11/6/10, on the 7:00 AM to 3:00 PM shift, CNA #1 was assigned to provide care to Resident #1, who had a [MEDICAL CONDITION]. CNA #1 said this was the first time CNA #1 had provided care to a resident with a [MEDICAL CONDITION] and CNA #1 was not provided any instructions prior to caring for Resident #1. CNA #1 said Resident #1 was scheduled for a shower, and CNA #1 wanted to keep Resident #1's [MEDICAL CONDITION] site dry. CNA #1 said prior to giving Resident #1 a shower, CNA #1 untied the [MEDICAL CONDITION] ties around Resident #1's neck and pulled out the [MEDICAL CONDITION]. CNA #1 said CNA #1 covered Resident #1's [MEDICAL CONDITION] site with a towel to prevent water from entering the [MEDICAL CONDITION] site. CNA #1 said after the shower, CNA #1 asked one of the nurses to replace Resident #1's [MEDICAL CONDITION] and that was when the nurse told CNA #1 the [MEDICAL CONDITION] should not have been removed. Nurse #1 was interviewed on 11/23/10 at 2:35 PM. Nurse #1 said on 11/6/10, Nurse #1 was assigned to provide care to Resident #1 and told CNA #1 that Resident #1 wanted a shower. Nurse #1 said there were no further instructions given to CNA #1 about Resident #1's [MEDICAL CONDITION]. Nurse #1 said at approximately 11:30 AM, CNA #1 requested assistance in the shower room and upon entering the shower room, Nurse #1 observed CNA #1 holding Resident #1's [MEDICAL CONDITION] with the ties attached. Nurse #1 said CNA #1 asked Nurse #1 to reinsert the [MEDICAL CONDITION]. Nurse #1 said Resident #1 was immediately assessed for any respiratory distress, Resident #1's oxygen saturation level (measured the amount of oxygen in the blood) was 99% on room air, another nurse had unsuccessfully attempted to reinsert the [MEDICAL CONDITION], Emergency Medical Services were initiated, and the Nurse Practitioner was notified of the incident. The Nursing Supervisor was interviewed on 11/23/10 at 11:30 AM. The Nursing Supervisor said on 11/6/10, the Nursing Supervisor was called to the unit at approximately 12:00 PM and found that Resident #1's [MEDICAL CONDITION] was removed by CNA #1 before Resident #1's shower. The Nursing Supervisor said because two nurses had attempted to replace the [MEDICAL CONDITION], 911 was called, and the Nurse Practitioner was notified of the incident. The Nursing Supervisor said Resident #1 was stable and Resident #1 was never in any respiratory distress. The nurse's note, dated 11/6/10, indicated that at 12:29 PM, Resident #1 was transferred to the Hospital for replacement of the [MEDICAL CONDITION]. The nurse's note indicated that Resident #1's condition remained stable, with an oxygen saturation level of 99% on room air. (reference greater than 90%) The Staff Development Nurse was interviewed on 11/23/10 at 1:15 PM. The Staff Development Coordinator said the Facility policy for [MEDICAL CONDITION] care did not specify that nurses only provide [MEDICAL CONDITION] care. The Staff Development Nurse said that all staff were educated upon hire to only use equipment after training on the specific equipment, and all staff signed an aknowledgement of Facility policy. The Director of Nurses (DON) was interviewed on 11/23/10 at 7:45 AM. The DON said CNA #1 was educated regarding the error on 11/6/10, and CNA #1 indicated that the intent was to keep Resident #1's [MEDICAL CONDITION] site dry. The DON said Resident #1's condition was stable during the incident and Resident #1 required a trip to two different Hospitals for replacement of the [MEDICAL CONDITION]. The nurse's note, dated 11/6/10 at 2:27 PM, indicated that the local Hospital could not reinsert Resident #1's [MEDICAL CONDITION] so Resident #1 was transferred to a Boston Hospital and returned to the Facility at 11:04 PM.