Every finding on record at Wellsprings of Gilbert

Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure a physician order for indwelling catheter use was obtained for two residents (#2 and #1) and for external female catheter use for one resident (#20). The deficient practice could increase the risk of complications including infections related to catheter use. Findings include: -Resident #2 was admitted on [DATE] with benign prostatic hyperplasia with lower urinary tract symptoms. The admission nursing evaluation dated July 14, 2023 revealed resident was admitted with a catheter type/size 16Fr (French) 10 cc (cubic centimeter); and that, the resident had recurrent urinary tract infections (UTI) as a result of the catheter. The 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 5 on the Brief Interview for Mental Status (BIMS) indicating resident had severe cognitive impairment. The assessment also included the resident had an indwelling catheter. The care plan dated July 24, 2023 included that resident had urinary retention. Intervention included catheter care. Despite documentation that the resident had indwelling catheter, the clinical record revealed no evidence of physician orders for indwelling catheter since July 24, 2023. An interview with resident #2 was attempted on August 7, 2023. Resident #2 stated he was having a bladder spasm and did not wish to speak to anyone. -Resident #1 was admitted on [DATE] with diagnosis of urinary tract infection. The admission nursing evaluation dated July 28, 2023 revealed the resident had an indwelling catheter; however, the indwelling catheter type and/or size was not identified. A nursing note dated July 28, 2023 at 10:14 p.m. revealed resident was alert and oriented x1 and responded to touch and voice. Per the documentation, the resident's Foley catheter was draining clear dark urine. A physician order dated July 28, 2023 included for an indwelling catheter; however, the order did not specify the size of catheter to be used. The medication administration record (MAR) for July 2023 revealed that the resident's indwelling catheter was changed on July 29, 2023. However, the documentation did not indicate the type and size of the indwelling catheter used. The admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 0 indicating the resident had severe cognitive impairment. The MDS also included that the resident had an indwelling catheter. Despite documentation that the resident had indwelling catheter, there was no evidence that type and size of the resident's indwelling catheter was verified with the physician from July 28 through August 6, 2023. A physician order dated August 7, 2023 included the indwelling catheter type and size needed for resident. The care plan revised on August 10, 2023 included for indwelling catheter management. The goal was that the resident will not experience UTI or Trauma to catheter site daily. Interventions included catheter care every shift with soap and water, encourage/offer fluids frequently, to insert catheter per MD order observing strict aseptic (infection prevention) technique, to keep catheter site clean and dry and pericare as needed. An observation was conducted on August 7, 2023 at 12:58 p.m. Resident #1 was in his room laying on his bed and his Foley catheter was in place and draining clear urine. An interview with a registered nurse (RN/staff #12) was conducted on August 9, 2023 at 9:34 a.m. The RN stated that a resident with an indwelling catheter need to have a physician order for its use and the order should include the size and type of catheter to be used. The RN stated that if there was no physician order and the resident has an indwelling catheter on, she would call the provider to get an updated order. Further, The RN said that she was not aware if the facility has a policy on catheters. In an interview conducted with another RN (staff #26) on August 10, 2023 at 9:42 a.m., the RN (staff #26) stated that a catheter would require a physician order; and, if there was no order for the indwelling catheter, the risk would include resident having negative side effect or an adverse reaction related to catheter use. During the interview, a review of the clinical record was conducted with the RN (staff #26) who stated that there was no physician order that included the indwelling catheter type and size to use for resident #1 prior to August 7, 2023. During an interview with the Director of Nursing (DON/Staff #48) conducted on August 10, 2023 at 10:29 a.m., the DON stated that a physician order with the type and size of the indwelling catheter should be obtained upon admission for any resident who entered the facility with an indwelling catheter such as Foley catheter. The DON stated that the expectation was for the admission nurse to review the incoming resident's indwelling catheter order; and, if order did not have information related to the type and size of catheter the provider should be contacted for clarification. She stated that by not having a physician order that include the type and size of catheter to use, there would be a risk of putting in the wrong size and this would cause trauma to the resident. A review of the clinical record was conducted with the DON who stated that the indwelling catheter order for resident #1 dated July 28, 2023 did not specify the size needed; and that, this did not meet her expectation. 48812 -Resident #20 was admitted on [DATE], with diagnoses of Parkinson's disease, muscle weakness, hypothyroidism, hypertension, fibromyalgia, and cellulitis of the left lower limb. The admission MDS assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The care plan dated August 3, 2023 revealed no mention of the use of a female external catheter. Review of the clinical record revealed no evidence of a physician order for use of a female external catheter. Further review of the clinical record revealed no evidence that care related to use of female external catheter was provided to resident #20. During an observation conducted on August 7, 2023, the resident was lying in bed, semi-covered with a gown and a catheter tubing was coming from in between resident's legs. The tubing extends to a cylinder of a female external catheter which was on the resident's nightstand. An interview was conducted on August 8, 2023, at 9:30 a.m. with a registered nurse (RN/Staff #45) who stated there should be an assessment done by the Director of Nursing (DON) and a physician order for the use of an external female catheter. The RN stated that the assessment and physician order should be in the resident's electronic record. Further, the RN stated that the facility does not provide external catheters to their residents; and that, the resident was responsible for providing themselves as well as its care and cleaning. During an interview with a DON (staff #31) conducted on August 10, 2023, at 11:30 a.m., the DON stated that it was her responsibility to do the initial assessment for the external female catheter per the facility policy. She stated that this assessment was to ensure that the resident was appropriate for the external catheter and that there are no contradicting factors. The DON stated the application/use of the external female catheter should be documented on the Treatment Authorization Request (TAR), and it would also require a physician order. The DON stated that upon review of the clinical record for resident #20, there was no evidence found related to a physician order or documentation on the TAR for the use and care for the female external catheter as expected per their policy. The undated facility policy on Appropriate Use of Indwelling Catheters revealed that a physician's orders was needed for a resident to have a catheter. The order also needed to specify the type and size of the catheter to be used. Review of the facility policy titled, External Catheter for Female Urinary Incontinence Management dated May 2023 revealed that an evaluation should be done by the Interdisciplinary Team to ensure the resident is appropriate for the catheter and that treatment orders are written per physician order.

Based on observation, clinical record review, staff interviews, and the Centers for Medicare and Medicaid Services (CMS) regulation, the facility failed to ensure that four residents (#12, #16, #125, #227) were offered and received education on the risks and benefits associated with the COVID-19 vaccine. Findings include: A review of the immunization records and the clinical records for residents #12, #16, #125 and #227, revealed no evidence that residents #12, #16, #125 and #227 were offered and educated on the risks and benefits associated with the COVID-19 vaccine. The clinical record of residents #12, #16, #125 and #227 revealed no documentation that these residents refused the COVID-19 vaccine. In an interview with a resident (#12) conducted on August 7, 2023, at 9:30 a.m. resident #12 stated that they were not offered nor were they provided any education in regards to the COVID-19 vaccine when they were admitted to the facility. An interview was conducted on August 7, 2023, at 11:30 a.m. with a registered nurse (RN/Staff #45) who stated that new residents are offered and educated regarding the COVID-19 vaccine starts on admission by the admitting nurse. The RN stated that the admitting nurse would ask the resident if they had been vaccinated; and if the resident said they have been vaccinated, the admitting nurse would ask the resident for documented proof and would document this in the electronic medical record. The RN said that if the resident says that they have not been vaccinated, the admitting nurse would offer the vaccine; and if the resident agrees, the resident would be scheduled for an appointment through a third party such as the pharmacy to administer the vaccine to the resident. During an interview with a Director of Nursing (RN/staff #31) conducted on August 10, 2023, at 11:30 a.m., the DON stated that when a new resident is admitted to the facility, they are screened for COVID- 19 vaccines as to whether they have received it or would like to receive it. She stated that this was solely done through verbal consent; and that, there was no documentation for offering or educating the resident for COVID-19. The DON stated that she was aware that the facility was not in regulatory compliance related to offering and educating residents on COVID-19 vaccine. The CMS regulation on COVID-19 immunizations included that the LTC (long term care) facility must develop and implement policies and procedures to ensure all the following: (i) When COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized; (ii) Before offering COVID-19 vaccine, all staff members are provided with education regarding the benefits and risks and potential side effects associated with the vaccine;(iii) Before offering COVID-19 vaccine, each resident or the resident representative receives education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine.

Based on clinical record review, staff interviews, and the facility's policy, the facility failed to ensure one resident (#126) was informed of the risks and benefits of a psychotropic medication prior to the administration of the medication. The deficient practice could result in not being informed and not able to exercise the right to choose the preferred option. Findings include: Resident #126 was admitted to the facility on [DATE], with diagnoses of dementia, anxiety, and mood disturbance. A physician's order dated August 3, 2023, revealed an order for Amitriptyline (antidepressant) 100 milligrams by mouth at bedtime for depression. Review of the MAR (Medication Administration Record) for August 2023 revealed the resident was administered Amitriptyline on August 3, 2023. However, review of the clinical record revealed no evidence the resident was informed of the risks and benefits prior to administration of Amitriptyline on August 3, 2023. An interview was conducted on August 10, 2023 at 10:49 a.m. with the director of nursing (DON/staff #48). She stated that the consent for the use of psychotropic medications that included explaining the risks and benefits must be obtained from the resident or the POA (power of attorney) and/or resident representative prior to the administration of the psychotropic medication. In an interview with a registered nurse (RN/staff #28) conducted on August 10, 2023 at 12:16 p.m., the RN stated that the process for psychotropic medication use included educating the resident or family of the risks and benefits before the medication was administered. She stated that if the resident cannot give consent, she would call the POA and get verbal consent with two nurses present. Further, the RN stated that if no consent was obtained, the psychotropic medication cannot be administered. The facility's policy on Use of Psychotropic Medication revealed residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The policy guidelines included, residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions.

Based on clinical record reviews, staff interviews, and review of policies and procedures, the facility failed to ensure that timely assessments and consistent treatments were provided to two residents (#1 and #3) with pressure ulcers. The deficient practice could result in additional residents not receiving timely assessments and consistent treatments for pressure ulcers. Findings included: -Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan dated January 25, 2019 for impaired skin integrity included a goal that resident #1 would regain integrity of the skin surface. The care plan listed interventions that were initiated on January 26, 2019 and included an alternating air mattress and topical treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A clinical record review revealed the following provider orders written on January 25, 2019: -Barrier cream to right and left buttock/sacrum every shift every day and night shift for Skin Prophylaxis -Float heels at all times when in bed or chair. An Admission Evaluation dated January 25, 2019 included that resident #1 had pressure ulcers on bilateral heels and a stage II injury to the sacrum that measured 1.2 cm. (Centimeters) in length and 0.1 cm. in depth. The assessment included that the resident was alert. The assessment included that resident #1 was incontinent once or more per shift with large amounts of urine day and night and that the resident was incontinent of stool. Review of the clinical record for resident #1 revealed that the initial care plan for impaired skin integrity was resolved on February 4, 2019. However, there was no additional documentation that a comprehensive skin assessment of the pressure injury on the left heel, right heel, or sacrum had been completed. During an interview conducted on July 27, 2022 at 1:05 pm with the Director of Nursing (DON/staff #70), the DON stated that the wound care provider at the time did assess resident #1's pressure injuries, and that the provider stated he did not see anything, and that all pressure injuries were resolved. The DON stated this assessment was conducted on January 27, 2019, and that a progress note is not in the records at the facility but may be in storage. A review of the clinical record for resident #1 did not reveal any additional documentation that the wound care provider had assessed the resident's pressure injuries on January 27, 2019. -Resident #3 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A clinical record review revealed the following provider orders: -Treatment to a groin and bilateral buttocks fungal rash: cleanse with soap and water, pat dry, and apply Antifungal cream every shift and prn (as needed) every shift for fungal rash and as needed for fungal rash care -Treatment to a sacral stage 3 pressure injury: cleanse and pat dry, apply Medi-honey to the wound bed, apply calcium alginate over the Medi-honey and cover with a dry dressing daily and prn when soiled or dislodged one time a day and as needed for soiling An MDS (Minimum Data Set) assessment dated [DATE] included that resident #3 had a BIMS (Brief Interview for Mental Status) of 13 which indicated that resident #3 was cognitively intact. The MDS assessment included that resident #3 had an unstageable pressure injury on admission. A weekly skin check dated July 11, 2022 included that resident #3 had fungal redness on the groin and sacrum. A Wound Progress note dated July 11, 2022 included that a sacral wound was a DTI (Deep Tissue Injury) which was persistent and non-blanchable deep red, maroon or purple pressure ulcer and was not healed. The wound measured 7 cm. length x 9.1 cm. width x 0.1 cm. depth. There was no drainage noted and the wound bed had 76-100% epithelialization. The peri wound skin exhibited: moist, maceration. The wound note included reposition per facility protocol and ROHO to chair if available offloading mattress. Review of the clinical record did not reveal any additional documentation that the ROHO to chair or offloading mattress had been provided. A Wound Progress note dated July 13, 2022 included that the sacral wound was a Stage 3 pressure injury, and measured 7 cm. length x 9.1 cm. width x 0.1 cm. depth. There was a small amount of serous drainage, and the wound bed had 51-75% epithelialization, 1-25% slough, and 1-25% pink granulation. The peri wound skin exhibited: Moist, Maceration. The wound note included reposition per facility protocol and ROHO to chair if available offloading mattress. Review of the clinical record did not reveal any additional documentation that the ROHO to chair or offloading mattress had been provided. A Wound Progress note dated July 15, 2022 included that the Stage 3 pressure wound on the sacrum measured 6.9 cm length x 9 cm width x 0.1 cm depth, and there was a small amount of serous drainage. The note included that the bed had 51-75% epithelialization, 1-25% slough, and 1-25% pink granulation. The wound note included reposition per facility protocol and ROHO to chair if available offloading mattress. Review of the clinical record did not reveal any additional documentation that the ROHO to chair or offloading mattress had been provided. A Wound Progress note dated July 18, 2022 included that Stage 3 pressure wound on the sacrum measured 6.7 cm. x 8.8 cm. width x 0.1 cm. depth, with a small amount of serous drainage, and the wound bed had 51-75% epithelialization, 1-25% slough, 1-25% pink granulation. The wound note included reposition per facility protocol and ROHO to chair if available offloading mattress. Review of the clinical record did not reveal any additional documentation that the ROHO to chair or offloading mattress had been provided. During an interview conducted on July 27, 2022 at 8:46 am with the DON Director of Nursing/staff #70), the DON stated that she did not know if the mattress had been ordered for resident #3, and that the facility does not provide ROHO cushions. The DON stated that the family or resident can request to have them ordered however resident #3 did not spend any time in a chair. The DON stated that the facility standard mattresses are Stage II mattresses and that resident #3 was currently using that mattress. The DON stated that the stage III wound has completely healed so they have not ordered a different mattress. An interview was conducted on July 27, 2022 at 9:17 am with a Wound Care Provider (staff #77). Staff #77 stated that resident #3 had a deep tissue injury on admission that presented typically with red/purple skin, and that resident #3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff #77 stated that barrier cream and repositioning was ordered on admission but that resident #3 had C-diff ([CONDITION(S)]) and a fungal infection which increased her risk for developing pressure ulcers. Staff #77 stated that the deep tissue injury opened up with slough which made the pressure injury a stage III. Staff #77 stated that the information in the notes would have been given to the floor nurse. During an interview conducted on July 27, 2022 at 9:52 am. with a Licensed Practical Nurse (LPN/staff #33), staff #33 stated that resident #3 has always had a regular mattress. A facility policy titled Skin Assessment included a statement that it is the policy of the facility to perform a full body skin assessment as part of pressure injury prevention and management. The policy included the following procedural guidelines for performing a full body skin assessment which included that a full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission, re-admission, and daily for three days, and weekly thereafter. The policy included that the assessment may also be performed after a change of condition or after any newly identified pressure injury, and to consider the general status of the resident's skin including the color, temperature, moisture status, sensory perception, skin texture, and perfusion. The policy included that documentation of a skin assessment would include document observations, document type of wound, describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain), document if resident refused assessment and why, and document other information as indicated or appropriate. A facility policy titled Wound Treatment Management included that the policy is to promote wound healing of various types of wounds, and it is the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. The policy included that wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change, and that in the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. The policy included that this may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse.

Based on review of the clinical record, staff interviews, and review of facility policies and procedures, the facility failed to ensure that one section (D) of a Minimum Data Set (MDS) assessment for one resident (#1) included the resident's depressive mood and anxiety, and that one section (M) included that the resident was at risk for developing pressure injuries. The deficient practice could result in residents not receiving care and services for depression, anxiety and pressure injuries. Findings include: Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan initiated on January 25, 2019 for impaired skin integrity with a stage I or II pressure ulcer included a goal that resident #1 would regain integrity of (the) skin surface. The interventions for this goal were initiated on January 26, 2019 and included an alternating air mattress and topical treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A clinical record review revealed the following provider orders written on January 25, 2019: -Barrier cream to right and left buttock/sacrum every shift every day and night shift for Skin Prophylaxis -Float heels at all times when in bed or chair. -Braden Scale Weekly for four (4) weeks from admission, one time a day every Friday for Braden Scale, Weekly x 4 weeks -Weekly skin checks one time a day every Sunday for Routine Skin Check. An Admission Evaluation dated January 25, 2019 at 4:51 pm included that resident #1 had pressure ulcers on her bilateral heels and a stage II injury to the sacrum. The assessment included that the resident was alert. The assessment included that resident #1 was incontinent once or more per shift with large amounts of urine day and night and that the resident was incontinent of stool. The assessment included that resident #1 required an assistive lift for transfers. The Admission Evaluation dated January 25, 2019 at 4:51 did not include any additional documentation of the resident's level of orientation. A Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] at 4:51 pm included that resident #1 was a very high risk with a score of 9. The assessment included that resident #1 had completely limited sensory perception, very moist skin, had complete immobility, inadequate nutrition intake, and a problem with friction/shear. Review of the clinical record review revealed the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - APP (alternating Positive Pressure) Mattress every shift - Cleanse Right FA (forearm) blister with NS (Normal Saline), cover with dry dressing, change daily one time a day Review of the clinical record review revealed the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Apply to BIL (Bilateral) heels topically every shift for skin [MEDICATION(S)] (Prophylaxis). A Physician's note dated January 28, 2019 at 5:03 pm included that the family reported resident #1 had significant anxiety and stress related to 3 recent deaths in the family including two [NAME] at separate times. The note included that resident #1 was alert with a flat affect, and that resident #1 had acute MDD (Major Depressive Disorder)/GAD (Generalized Anxiety Disorder) due to recent deaths in the family. An MDS (Admission Minimum Data Set) assessment dated [DATE] for resident #1 included a Brief Interview for Mental (BIMS) score of 3 which indicated severe cognitive impairment. Sections D and E of the assessment did not include that the resident had any moods or behaviors, and section M of the MDS assessment included that the resident did not have any pressure injuries on admission and was not at risk for developing pressure injuries. The MDS assessment included that the resident required extensive assistance for bed mobility, locomotion, dressing, eating, toilet use, and personal hygiene, and that the resident was always incontinent of urine and bowel without a training program. The clinical record revealed that the initial care plan for impaired skin integrity was resolved on February 4, 2019. A care plan initiated on February 4, 2019 for potential impairment to skin integrity included a goal that the resident would have no complications related to skin injury. The interventions for this goal included avoiding scratching, keeping hands/body parts from excessive moisture, and to keep skin clean and dry. Another care plan for impaired skin integrity, initiated on February 4, 2019, included a goal that resident #1's skin would remain intact. The interventions for this goal included keeping skin clean and dry, moisturize, and monitoring. An attempt was made on July 26, 2022 at 1:12 pm to contact the MDS coordinator (staff #10) who worked in January of 2019. No contact was made. During an interview conducted on July 26, 2022 at 2:20 pm with a Certified Nursing Assistant (CNA/staff #21), staff #21 stated that resident #1 required a Hoyer lift for transfers and was a total two person assist. Staff #21 also stated that resident #1 was incontinent of bowel and bladder. During an interview conducted on July 26, 2022 at 3:11 pm with a Registered Nurse/MDS coordinator (staff #4), staff #4 stated that on admission an assessment is completed with interviews of the resident and staff, review of the facility documentation and review of hospital records. Staff #4 stated that a care plan is based on the assessment and there is only one person at the facility that reviews them. During an interview conducted on July 27, 2022 at 2:00 pm with the Director of Nursing (DON/staff #70), the DON stated that the MDS coordinator will interview the resident and/or the resident representative, staff members, and review records as part of the assessment process. The DON stated that resident #1 was assessed by a provider on January 28, 2019 and that the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that is why depression was added as a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that resident #1 was at risk for developing pressure injuries related to her immobility and incontinence. A facility policy titled Resident Assessment included that the facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the Resident Assessment Instrument (RAI) specified by CMS (Center for Medicare Services). The policy included that the assessment will include at least the mood and skin conditions of the resident. The assessment process will include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts.

Based on clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure the comprehensive care plan was revised to include pressure injury preventative measures to decrease further breakdown for one resident (#3). The sample size was 32. The deficient practice could result in inaccurate/incomplete plans of care for residents. Findings included: -Resident #3 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS assessment dated [DATE] included that resident #3 had a BIMS of 13. The assessment included that resident #3 had an unstageable pressure injury on admission. A Wound Progress note dated July 11, 2022 included that Wound #1 Sacral is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration Pressure Ulcer and has received a status of Not Healed. The noted included that the injury measured 7 cm in length by 9.1 cm in width and 0.1 cm in depth. The note included a plan of treatment with interventions that included barrier cream ever shift, as needed offloading of the wound, reposition per facility protocol, a ROHO to chair if available, and an offloading Mattress. A care plan initiated on July 13, 2022 for risk for impaired skin integrity included a goal that resident #3 would report altered sensation or pain at risk areas. The interventions for this goal included educating the resident on the importance of turning while in bed to avoid pressure injuries. A review of the clinical record revealed no documentation of the added interventions ordered on July 13, 2022. Another Wound Progress note dated July 13, 2022 included that Wound #1 Sacral is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Review of the clinical record revealed no documentation of orders entered or discontinued for a ROHO to chair or offloading mattress. During an interview conducted on July 27, 2022 at 8:46 am with the DON (staff #70), the DON stated that she did know if the mattress had been ordered for resident #3. The DON stated that the facility does not provide ROHO cushions and that the family or resident can request to have them ordered however resident #3 did not spend time in a chair. The DON stated that the facility standard mattresses are rated Stage II and that resident #3 is currently on that mattress. The DON stated that the stage III wound has completely healed so they have not ordered a different mattress. During an interview conducted on July 27, 2022 at 9:52 am with a Licensed Practical Nurse (LPN/staff #33), staff #33 stated that she has rounded with the wound care provider but has never received an order during those rounds. Staff #33 stated that resident #3 has always had a regular mattress. A facility policy titled Comprehensive Care Plans included it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure that one resident (#1) was provided pain management services consistent with professional standards of practice. The deficient practice could result in unmanaged pain for residents. Findings included: -Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Pain Evaluation every shift with a Pain Scale of 0-10. - Document non-medication intervention for pain giving prior to administering PRN (as needed) pain medication. - [MEDICATION(S)] [MEDICATION(S)]) tablet 50 Mg. (milligrams) give 1 tablet by mouth every 4 hours as needed for a pain level of 1-5 AND give 2 tablets by mouth every 4 hours as needed for a pain level of 6-10. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . as needed for pain with a level of 1-5 dated January 7, 2019 at 7:41 pm. that documented resident #1 was provided one tablet of [MEDICATION(S)] 50 mg. for a pain with a level of 7 out of 10. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . as needed for pain with a level of 1-5 which included the following: -An entry dated February 3, 2019 at 10:35 pm. included that the resident was provided one tablet of [MEDICATION(S)] 50 mg. for a pain level of 6. -An entry dated February 4, 2019 at 9:35 pm. included that the resident was provided one tablet of [MEDICATION(S)] 50 mg. for a pain level of 7. During an interview conducted on July 27, 2022 at 2:00 pm with the Director of Nursing (DON/staff #70), the DON stated that the expectation is that clinical staff administer medications as ordered by the provider, and that the staff should ensure that the right medication is given at the right time for the right reason as it is ordered. A facility policy titled Medication Administration included that Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy included to administer medication as ordered in accordance with manufacturer specifications

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that one resident's (#1) medical records including wound assessments were readily accessible. The deficient practice could result in additional medical records that are not readily accessible. Findings include: -Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Evaluation dated January 25, 2019 included that resident #1 had pressure ulcers on bilateral heels and a stage II injury to the sacrum that measured 1.2 cm. (Centimeters) in length and 0.1 cm. in depth. The assessment included that the resident was alert. The assessment included that resident #1 was incontinent once or more per shift with large amounts of urine day and night and that the resident was incontinent of stool. During an interview conducted on July 27, 2022 at 1:05 pm with the Director of Nursing (DON/staff #70), the DON stated that the wound care provider at the time did assess resident #1's pressure injuries, and that the provider stated he did not see any pressure injuries and that all pressure injuries were resolved. The DON stated this assessment was conducted on January 27, 2019. The DON stated that a progress note is not in the records at the facility but may be in storage. The DON stated that she was unable to find the documentation at this time that the labs were collected or refused. Review of the clinical record for resident #1 did not reveal any additional documentation that a comprehensive skin assessment of the pressure injury on the left heel, right heel, or sacrum had been completed by the wound care provider on January 27, 2019. A facility policy titled Release of Medical Records included that 1. Medical Records are a collection of documents prepared and maintained during the course of a resident's stay in the facility that records the clinical/medical care of the resident, and that these documents can be written or electronic information and include progress notes, physician orders, nursing notes, consultations, laboratory and diagnostic reports, and plans of care. The policy included that nursing personnel should assist with gathering records from the active medical record, thinned records, and any other locations within the facility where records are maintained. The policy included that when documents are missing, the person assembling the record should make a notation of the items missing, and that government agencies involved in long term care may have access to a resident's medical record without authorization, if such review relates to licensure/certification requirements.

Based on observations, staff interviews, policies and procedures and the Center for Disease Control (CDC) recommendations, the facility failed to ensure infection control standards were followed by failing to ensure the outside door to the COVID-19/Observation unit was secured and that signage was placed on the outside door indicating that it was the COVID-19/Observation unit, and regarding Personal Protective Equipment (PPE) reuse. The deficient practices could result in the spread of infection, including COVID-19 to residents and staff. Findings include: Regarding COVID-19/Observation unit: On February 1, 2021 at 9:37 a.m., the surveyor was directed to enter the COVID-19/Observation unit through the outside side entrance of the building. Upon arrival to the side of the building, three doors were observed. None of the doors contained any signage to indicate the COVID-19/Observation unit. An unmarked white door with an electric keypad next to it was observed with a concrete block positioned on the ground next to the door and the door was not closed completely. After several knocks on the door, a staff member opened the door and confirmed that the door was the entrance to the COVID-19/Observation unit. When told the door was opened and not secured, the staff member did not reply. An interview was conducted with a Registered Nurse (RN/staff #20) on February 1, 2021 at 9:39 a.m. The RN stated the staff are directed to use the unmarked white door on the outside of the building to enter and exit the COVID-19/Observation unit. The RN said the staff are not to enter the facility main entrance and enter the COVID-19/Observation unit through the inside double doors of the unit. Signage indicating the unit was a COVID-19/observation unit was observed on the double door access from the main lobby of the facility. In an interview conducted with the Director of Nursing (DON)/Infection Preventionist (IP/staff #3) on February 1, 2021 at 11:30 a.m., the DON/IP stated that the staff are to use the entrance on the outside of the building to access the COVID-19/Observation unit. The DON/IP stated the expectation is that the door be secured at all times and that the code be used to access that door. The DON/IP also stated signage regarding PPE and accessibility should be posted on the door. An interview was conducted with the administrator (staff #9) at 12:10 p.m. on February 1, 2021. The administrator stated the access door to the COVID-19/Observation unit on the outside of the building is temporary. The administrator stated this door should not be propped open at any time and should always be secured. Staff #9 stated only staff using the keypad should be granted access through that door. Staff #9 said signage should be displayed on the door. The administrator stated that the lack of signage on the door and the unsecured access to the unit is a safety issue. The facility COVID-19 Infection Control Procedural Update effective January 11, 2020 revealed all nursing staff are to enter and exit the COVID-19/Observation unit from the side door. The CDC Responding to Coronavirus (COVID-19) in Nursing Homes guidance dated April 30, 2020 stated to place signage at the entrance to the Covid-19 care unit that instructs health care personnel (HCP) that they must wear eye protection and an N-95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gloves and gowns are to be added when entering resident rooms. Regarding PPE: On February 1, 2021 at 9:37 a.m., an observation was conducted of the COVID-19/Observation unit. Two reusable gowns were observed hanging outside each resident private room on hooks. At 9:50 a.m., a Certified Nursing Assistant (CNA/staff #15) was observed to exit a resident room, doff the reusable gown, and hang the gown on hook #1 outside the resident room. The CNA then proceeded to the sink and washed her hands. An observation was conducted of the COVID-19/Observation unit on February 1, 2021 at 1:50 p.m. Two CNAs (staff # 4 and staff #51) were observed to enter the unit and be screened for COVID-19. Staff #4 washed her hands and proceeded to go room to room as she received report from the off-going CNA (staff #15). Staff #51 also washed his hands and began talking to the off-going CNA (staff #16). At 2:20 p.m., staff #4 was observed to don gown #1 and enter a resident room. At 2:24 p.m., staff #51 was observed to don gown #2 and enter the same resident room. The gowns were not observed to be replaced between shifts. On February 1, 2021 at 2:41 p.m., staff #4 was observed to don the gown from hook #1 outside the room of the resident room who staff #15 was observed to doff at 9:50 a.m. At 9:39 a.m. on February 1, 2021, an interview was conducted with a RN (staff #20). The RN stated the unit was a COVID-19/Observation unit and that full PPE (gowns, gloves, N-95 and eye protection) were required for care of all residents. Staff #20 stated the current staff on shift consisted of herself and two CNAs. She stated there were 15 residents on the unit and of those residents, 5 were confirmed COVID-19 positive. Staff #20 stated the facility policy was that each occupied resident room have two hooks on the wall adjacent to the room door. The RN stated that on those hooks, reusable gowns were placed for shared use on each shift. She stated the two gowns were used by all staff, nurse(s), CNA(s), and therapy, and that there were no assigned gowns. The RN also stated the two gowns are replaced at shift change. During an interview conducted with a CNA (staff #16) at 9:54 a.m. on February 1, 2021, the CNA stated that he can use either of the two gowns hanging outside the resident door to provide care for that resident. In an interview conducted with the CNA (staff #15) on February 1, 2021 at 9:57 a.m., the CNA stated that there were two gowns dedicated for each resident. Staff #15 stated the staff were always careful when doffing the gowns because other staff may reuse the gown. The CNA further stated the gowns are replaced between shifts. At 11:30 a.m. on February 1, 2021, an interview was conducted with the DON/IP (staff #3). Staff #3 stated that every occupied resident room in the COVID-19/Observation unit had two gowns on hooks hanging outside of the room for staff to use to enter the resident room and provide care. Staff #3 said the two gowns were there in case the resident required two-person assistance. The DON/IP stated the gowns are dedicated to the resident and shared by staff and that the gowns are replaced between shifts. The DON/IP stated they were short on disposable gowns so they were using the reusable gowns. Staff #3 stated they were not short on reusable gowns. In an interview conducted with the CNA (staff #16) at 2:41 p.m. on February 1, 2021, the CNA stated the gowns were replaced at the nurse change of shift. Staff #16 stated the CNAs work 8 hour shifts and the nurses work 12-hour shifts. The facility's Reuse and Extended use of PPE dated September 1, 2020 stated in times of severe shortages, such as during the Coronavirus disease 2019 outbreak, the facility will consider contingency measures for reuse and extended use of PPE. In general, extended use is preferred over reuse to reduce the risk of self-contamination from repeated donning (wearing) and doffing (removal) of the same equipment. Reuse refers to the practices of using the same PPE for multiple encounters with patients but doffing between each encounter. The equipment is safely stored in between patient encounters. Previously used PPE should never be taken outside of patient care areas unless the item is decontaminated or placed in a clean breathable container. During shortages of isolation gowns, consider using washable gowns that are laundered after use. Cloth gowns could be considered for reuse without washing if there was minimal to no direct physical contact with the patient or nearby surfaces (e.g. bedrails). The CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID 19) Pandemic updated December 14, 2020 stated that a clean isolation gown should be put on upon entry to the patient room or area. The guidance further stated that disposable gowns should be discarded after use and that reusable gowns (i.e. washable or cloth) gowns should be laundered after each use. Review of the CDC guidance titled Strategies for Optimizing the Supply of Isolation Gowns dated January 21, 2021 revealed the risk to healthcare personnel (HCP) and patient safety must be carefully considered before implementing a gown reuse strategy. Reusable gowns should not be reused before laundering, because reuse poses risks for possible transmission among HCP and patients that likely outweigh any potential benefits. Similar to extended gown use, gown reuse has the potential to facilitate transmission of organisms among patients. Unlike extended use, repeatedly donning and doffing a contaminated gown may increase the risk for HCP self-contamination.

Based on observations, facility documentation, staff interviews, review of the Center for Disease Control (CDC) recommendations and policies and procedures, the facility failed to ensure that infection control standards were maintained. The deficient practice could result in the spread of infection, including COVID-19. Findings include: -The survey team entered the facility on May 19, 2020 at 9:15 a.m. Once inside of the lobby area, the owner of the facility instructed the surveyors to use hand sanitizer, answer questions regarding symptoms related to COVID-19, and to take their own temperatures orally and document the temperature on the COVID-19 Screening Tool. The owner provided N95 masks and directed the team to wear them while we were in the facility. An interview was conducted on May 19, 2020 at 10:20 a.m. with the Assistant Director of Nursing (ADON/staff #42). The ADON stated staff working the unit that did not have residents with COVID-19 enters the unit through the back of the building through the door where the therapy room is located. A screening station was not observed by the door. The ADON pointed to a sink that was across the room and said that staff wash their hands at the sink and then put on their N95 masks, which were stored in individual brown paper bags on a table located to the left of the sink. She said there is not enough staff to have someone screen staff, so staff are screening themselves. The ADON then walked down the hallway to the unit without COVID-19 residents. The ADON stated that when staff enters the unit, they are required to take their temperature and document the temperature in the binder that was observed at the nurses' station. A thermometer was not observed on the counter with the binder. The ADON looked in the drawer, but was unable to locate a thermometer and said that a thermometer was supposed to be there. She said that she spot checks temperature documentation and reviews all the documentation once a week. She acknowledged that having staff take their temperature after they have entered the unit increases the risk of spreading COVID-19. The ADON stated that she would set up a screening station by the back door in the therapy room right away. An interview was conducted with the Director of Nursing (DON/staff #79) on May 19, 2020 at 11:00 a.m. He said that the staff takes their temperatures three times a day: at the beginning of the shift, in the middle of the shift, and at the end of the shift. He said the expectation is that temperature documentation be checked daily. The DON said it is the responsibility of the DON, ADON, and the charge nurse to review the documentation. The DON further stated that he did not feel staff taking their temperatures once they entered the unit increased the risk of spreading COVID-19 because staff are wearing their masks. On May 19, 2020 at 11:00 a.m., it was observed that a screening station with an oral thermometer had been set up at the back entrance by the therapy room for staff working on the unit. -On May 19, 2020 at 9:30 a.m., an interview was conducted outside of the internal entrance to the COVID-19 unit with the Director of Nursing (DON/staff/#79), who is also the Infection Preventionist. He stated that this entrance is for any diagnostic, hospice, or phlebotomy vendors, and that staff for this unit enter through the southwest outside entrance. He stated that to be on this unit, a N95 mask was required and that direct resident care required a gown, gloves and eye protection. On the entrance doors, there was no sign to inform those entering to check with staff or a sign which stated the PPE that was required, prior to entering. During this interview, an observation of the outside staff entrance to this unit was also conducted. It was observed that there was no screening station inside or outside of the southwest staff entrance. The DON stated there is not enough staff to have someone screen staff, so the staff screen themselves at the nurse's station inside of the unit. Additional observations revealed that there was no signage posted on the entrance doors notifying staff of the required PPE. The DON said that signs were posted at the main entrance and that no one was allowed entry into the facility without being screened. Once inside of the COVID-19 unit, a binder was observed on the nurse's station desk. The DON stated that staff record their temperatures in the binder three times a day: at the beginning, middle, and end of the shift. Review of the documentation in the binder revealed that a temperature had not been documented prior to the start of shift for a Registered Nurse (staff/#91), who was working on the unit. Staff #91 was asked where the required temperature documentation was located. Staff #91 stated that the temperature had been taken, but mistakenly was not recorded. The DON asked staff #91 to retake their temperature and document the results. Staff #91 was observed entering the medication room behind the nurse's station and removed their N95 mask and took their temperature orally. Staff #91 replaced their N95 mask and documented the temperature in the binder. At 9:45 a.m., an interview was conducted with staff #91 who confirmed they had received training regarding COVID-19, including staff screening requirements and proper PPE use. Staff #91 stated the staff screening requirements include that staff are required to take and document their temperature, prior to the start of shift. Staff #91 acknowledged that not following COVID-19 screening requirements or PPE policies could contribute to the spread of spread of COVID-19 to staff, residents and the community. At 10:00 a.m., an interview was conducted with the Assistant Director of Nursing (staff/#42). When questioned about no signage posted on the doors to the COVID-19 unit instructing those entering to contact staff and of notifying those who enter of the PPE requirements, she stated there were signs posted outside the facility main entrance, and no one was allowed in the facility without being screened, and that the doors were locked at all times. She acknowledged that the lack of posted signage outside of the COVID-19 unit could increase the risk of spreading COVID-19 to others. Regarding the staff screening policy, staff #42 stated that staff should be documenting their temperature prior to starting their shift. She acknowledged that by staff taking their temperature after they enter the unit was not following their staff screening policy, which could contribute to the spread of COVID-19 to others. A follow up interview was conducted on May 19, 2020 at 10:15 a.m., with the Director of Nursing. He stated there were signs posted outside the facility main entrance, and that no one was allowed in the facility without being screened, and that the doors were locked at all times. He stated that staff should be documenting their temperature prior to starting their shift. He acknowledged that by having staff take their temperature after they enter the unit was not following their policy and could contribute to the spread of spread of COVID-19 to others. He further acknowledged that by not having signs posted outside of the COVID-19 unit, could increase the risk of spreading COVID-19 to others. Review of the CDC recommendations regarding Infection Prevention and Control Assessment Tool for Nursing Homes Preparing for COVID-19 dated May 8, 2020, revealed that all health care providers, including ancillary staff such as dietary, housekeeping, and consultant personnel are screened at the beginning of their shift for fever and symptoms of COVID-19, and actively record their temperatures and documents that they do not have a fever. Review of a policy titled, Responding to Coronavirus (COVID-19) in Nursing Homes/CDC dated April 2, 2020, revealed to place signage at the entrance to the COVID-19 care unit that instructs healthcare personnel that they must wear eye protection and a N95 or higher level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms. Review of the policy regarding [MEDICAL CONDITION] Outbreak, Infection Control Measures dated April 2, 2020 revealed if an outbreak of [DIAGNOSES REDACTED] CoV2 occurs within the facility, strict adherence to standard and transmission based precautions and other infection control measures will be implemented according to the most current CDC recommendations. The CDC recommendations for the Coronavirus Disease 2019 included that infection control procedures including administrative rules and engineering controls, environmental hygiene, correct work practices and appropriate use of PPE, are all necessary to prevent infections from spreading during healthcare delivery. All healthcare facilities must ensure that their personnel are correctly trained and capable of implementing infection control procedures, and that individual healthcare personnel should ensure they understand and adhere to infection control requirements.

Based on observation, staff interviews and policy review, the facility failed to ensure that food was stored in the freezer according to professional standards for food safety. Improperly stored food items increases the risk of foodborne illness. Findings include: During an initial kitchen observation conducted on 2/18/20 at 8:56 AM, a plate with two raw fish fillets was observed uncovered and unlabeled in the freezer. An interview was conducted on 2/20/20 at 1:32 PM, with the kitchen manager (staff #4). Staff #4 stated that food items should never be left uncovered or unlabeled in the refrigerator or freezer. Staff #4 stated that this was a mistake by one of his staff. An interview was conducted on 2/20/20 at 1:39, with the Director of Nursing (staff#69). Staff #69 stated that it is not the facilities policy to leave food items unlabeled and uncovered. Staff #69 stated this should not have happened. A review of the Food Handling policy revealed that food will be stored so the risk of foodborne illness is minimized. It also included that food items should be stored in accordance with good sanitary practice.

Based on staff interviews, clinical record review, and policy review, the facility failed to ensure MDS assessments were accurate for 4 residents (#17, #14, #22, #26). Findings include: Resident #17 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission MDS (Minimum Data Set) assessment dated (MONTH) 21, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. Review of an informed consent form dated (MONTH) 15, (YEAR), revealed that the resident had agreed to use the sidebars for the duration of his stay to increase mobility and promote independence. Review of the admission MDS assessment dated (MONTH) 21, (YEAR), revealed the assessment was coded for the daily use of a bedrail as a restraint. An interview was conducted with the MDS Coordinator (staff #4) on (MONTH) 12, (YEAR) at 11:28 a.m. She stated that the facility was not coding side bars as a restraint back in July. She stated that she received a notice from an agency stating that anything adjacent or attached to the bed is considered a restraint, so she began coding the side bars as a restraint on the MDS assessment as instructed by the facility's administrator. The MDS Coordinator stated that the side bars were not restricting the movement of the resident, but was installed as an aid so that the resident could reposition himself and get out of bed. After referring to the Resident Assessment Instrument for the MDS assessments regarding restraints, she stated that the coding of the side bars was incorrect. -Resident #14 was admitted to the facility on (MONTH) 7, (YEAR) with a [DIAGNOSES REDACTED]. Review of the clinical record revealed a wound note dated (MONTH) 27, (YEAR) that the resident acquired an unstageable pressure ulcer to the sacrum while in the facility. The discharge MDS assessment dated (MONTH) 1, (YEAR), revealed the resident had no pressure ulcers. An interview was conducted with the MDS Coordinator (staff #4) on (MONTH) 12, (YEAR) at 11:29 AM. Staff #4 stated that she usually looks at the wound notes for pressure ulcers. She stated that the documentation is in the clinical record that the resident did have a pressure ulcer. Staff #4 further stated that the discharge MDS assessment was coded incorrectly and that she had no explanation for it. -Resident #22 was admitted to the facility on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The physician's history and physical dated (MONTH) 21, (YEAR) revealed the resident had MDD (major [MEDICAL CONDITION]). The admission MDS (minimum data set) assessment date (MONTH) 27, (YEAR), revealed a score 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact. The assessment did not include the [DIAGNOSES REDACTED]. An interview was conducted on (MONTH) 11, (YEAR) with the MDS coordinator (staff #4). She stated that she reviews a resident's history and physical to obtain information to code the MDS assessments for diagnoses. She also stated that she should have coded the [DIAGNOSES REDACTED]. An interview was conducted with the administrator (staff #41) on (MONTH) 12, (YEAR) at 8:37 AM. She stated that the hospital history and physical indicates the resident has depression. The administrator stated that the facility's policy is that the MDS assessments are accurate. -Resident #26 was admitted to the facility on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. A health status progress note dated (MONTH) 2, (YEAR), revealed the resident was discharged home. Review of the discharge MDS assessment dated (MONTH) 2, (YEAR), revealed the resident was discharged to an acute hospital. An interview was conducted with the MDS Coordinator (staff #4) on (MONTH) 11, (YEAR) at 3:10 p.m. She stated that the discharge information in the MDS assessment would be based on review of the physician's discharge order. She stated that the physician's orders [REDACTED]. She stated that the discharge MDS assessment should not have been coded that the resident was discharged to an acute hospital, because the resident was discharged home. Review of the facility's policy titled Certifying Accuracy of the Resident Assessment revealed that all personnel who complete any portion of the resident assessment (MDS) must sign and certify the accuracy of that portion of the assessment. Additionally, individuals who certify false statements in a resident assessment are subject to disciplinary actions.

Based on clinical record review, staff interviews, and policy review, the facility failed to provide services consistent with professional standards for one resident (#14) with a pressure ulcer. Findings include: Resident #14 was admitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The care plan dated (MONTH) 12, (YEAR), revealed the resident was at risk for impaired skin integrity related to alteration in skin turgor, altered sensation, mechanical forces, and the need for assistance with bed mobility. Interventions included monitoring the skin condition daily for changes and educating the resident on the importance of turning while in bed to avoid pressure. A Weekly Skin Check dated (MONTH) 13, (YEAR), revealed the sacrum was red, blanchable, and intact. A review of a Braden Scale dated (MONTH) 15, (YEAR) revealed the resident was at high risk for developing pressure ulcers. Review of the Weekly Skin Check dated (MONTH) 20, (YEAR), revealed to continue the current treatment to the sacrum but did not include a description of the sacrum. The admission Minimum Data Set (MDS) assessment dated (MONTH) 21, (YEAR) revealed a BIMS (Brief Interview for Mental Status) score of 12, which indicated the resident had moderately impaired cognition. The assessment included the resident required extensive assistance for bed mobility and transfers. The MDS assessment also included the resident was at risk for pressure ulcers but did not have any pressure ulcers. Review of the Treatment Administration Record (TAR) dated (MONTH) (YEAR) revealed the barrier cream was applied as ordered. A physician's orders [REDACTED]. Review of a Daily Skilled Note dated (MONTH) 23, (YEAR) revealed there was redness and an open area to the sacrum. The note included daily dressing changes as ordered but did not include documentation of the condition of the wound, staging, or measurements. Additional review of the clinical record from (MONTH) 14 - 26, (YEAR) (13 days) did not reveal documentation of the wound description or measurements until the resident was seen by the wound doctor on Tuesday, (MONTH) 27, (YEAR). Review of a wound note dated (MONTH) 27, (YEAR), revealed the wound was unstageable with 50% slough and 50% granulation tissue and measured 3.0 centimeters (cm) x 1.0 cm. The note also included the resident slides down when being transferred from the bed to the chair creating friction on the sacrum and that there is a new order to limit the time the resident is in the chair to one hour. The note included the resident had an APP mattress and a ROHO cushion in the wheel chair. A review of the physician's orders [REDACTED]. The Weekly Skin Check dated (MONTH) 27, (YEAR), revealed to continue the treatment as ordered to the sacrum and that the wound doctor is following. Review of the TAR dated (MONTH) (YEAR) revealed the wound treatment was administered as ordered. The resident was discharged to the hospital on (MONTH) 1, (YEAR) and readmitted on (MONTH) 5, (YEAR). Review of the physician's orders [REDACTED]. Review of the Admission Nursing Evaluation dated (MONTH) 5, (YEAR), revealed the resident had a pressure ulcer to the sacrum but did not include an assessment or measurements of the pressure ulcer. Review of the physician's orders [REDACTED]. The Weekly Skin Check dated (MONTH) 10, (YEAR) revealed an open area/pressure ulcer to the sacrum but did not include measurements or an assessment of the wound. Further review of the clinical record did not reveal documentation of the wound description or measurements until the resident was seen by the wound doctor on Tuesday, (MONTH) 11, (YEAR), six days after admission. A physician's note dated (MONTH) 11, (YEAR) revealed the sacral wound measured 1.8 cm x 0.5 cm, with 25% slough and 75% granulation tissue, no undermining or tracts, periwound is intact, no bone exposure, minimal drainage, and no odor. The note included the pressure ulcer had improved. Review of the TAR dated (MONTH) (YEAR) revealed the revealed the wound treatment was administered as ordered. An interview was conducted with a Licensed Practical Nurse (LPN/staff #83) on (MONTH) 11, (YEAR) at 1:00 PM. Staff #83 stated that when the resident was discharged to the hospital, he had a tiny open spot like a slit in the crease of his buttocks, but when he returned from the hospital it was bigger. She stated that when a skin issue is identified, she documents a note but does not describe the skin issue in detail. She stated that the wound nurse is notified and the wound nurse will evaluate, measure, and document the skin issue details. The LPN stated that this way the wound is always measured by the same person so that the documentation is accurate. The LPN stated that today is the first Tuesday since the resident was readmitted , which is the day the wound doctor makes rounds. During an interview conducted with the Assistant Director of Nursing/wound nurse (ADON/staff#3) on (MONTH) 11, (YEAR) at 3:00 PM, staff #3 stated when she is notified of a new skin issue, she will usually see the resident within 24 hours. She stated that she will notify the wound doctor who makes rounds on Tuesdays and obtain orders. Staff #3 stated that the treatment will be continued until the wound doctor sees the resident. She also stated that she keeps a binder with all the wound measurements in it. The ADON stated that on (MONTH) 22, (YEAR), the floor nurse contacted the attending physician and obtained the treatment order for the wound. An interview was conducted with the Director of Nursing (DON/#2) on (MONTH) 12, (YEAR) at 12:07 PM. The DON stated that once a pressure ulcer is identified, the nurse should obtain a treatment order from the physician and notify the wound nurse. He stated that the wound nurse will evaluate the wound to ensure proper treatment is in place and will notify the wound doctor who makes rounds on Tuesdays. The DON stated that the floor nurse needs to observe the wound every day and document their observation. He stated that the wound nurse or the wound doctor will measure and stage the wound to alleviate inaccuracies. The DON stated a baseline description of the wound was not obtained when the resident was admitted or when the resident was readmitted , but since the pressure ulcer did not get worse, the timeframe for evaluating the ulcer is not a concern. He stated that if the wound had gotten worse, then he would say the wound should have been evaluated sooner. The facility's policy regarding pressure injury/skin integrity revealed the nursing staff and the attending physician will assess and document a resident's significant risk factors for developing pressure injuries. The policy further included that in addition, the nurse shall describe and document/report the following: Full assessment of pressure injury including location, length, width and depth, presence of exudates or necrotic tissue.

Based on observation, interviews, policy review, manufacturer's instructions, and the CDC (Center for Disease Control and Prevention) guidelines, the facility failed to ensure that a glucometer designated for multi-resident use was disinfected between resident use. Findings include: An observation was conducted on (MONTH) 10, (YEAR) at 12:12 p.m., of a licensed practical nurse (LPN/staff #81) using a glucometer to perform a blood glucose test on a resident. When the test was completed, staff #81 cleaned the glucometer with an alcohol pad. The LPN was then observed to use the glucometer to perform a blood glucose test on another resident. Staff #81 cleaned the glucometer with an alcohol pad prior to performing the blood glucose test on this resident and used an alcohol pad to clean the glucometer after the test. The LPN then returned the glucometer to the medication cart. During an interview conducted with staff #81 on (MONTH) 10, (YEAR) at 1:46 p.m., she stated that the glucometer was designated for multi-resident use. She stated that her process is to clean the glucometer before and after each resident use, and that she always use alcohol pads to clean the glucometer. The LPN also stated that she was not sure of the facility's policy regarding the cleaning of glucometers. An interview was conducted with the Director of Nursing (DON/staff #2) on (MONTH) 11, (YEAR) at 10:54 a.m. He stated that with the exception of residents on transmission-based precautions, the facility's glucometers were designated for multi-resident use. He stated that nurses should clean the glucometers before and after performing a blood glucose test. The DON stated that a 70% alcohol pad would be sufficient to use to clean and disinfect the glucometer. He stated that bleach wipes or similar commercially prepared wipes would be used as an added precaution to disinfect glucometers that had been used for residents on transmission-based precautions. Review of the facility's policy for cleaning and disinfecting resident care equipment revealed that reusable items such as glucometers are cleaned and disinfected between residents. The policy further included reusable equipment will be cleaned and disinfected according to current and manufacturer's standards. The manufacturer's instructions for the glucometer revealed that glucometers should be cleaned and disinfected between each resident test in order to avoid cross-contamination issues. The instructions stated to use a 70-80% [MEDICATION NAME] alcohol to clean the outside of the meter. The instructions included to disinfect the meter, use a solution of 0.5-0.6% bleach, or a commercially available 1:10 quaternary/alcohol wipe, or another EPA registered wipe that complies with CDC guidelines. The CDC guidelines revealed that infectious agents, such as the [MEDICAL CONDITION] virus (HBV) can be transmitted through indirect contact transmission, even in the absence of visible blood. Indirect contact transmission is defined as the transfer of an infectious agent (e.g. HBV) from one patient to another through a contaminated intermediate object (e.g. blood glucose meter). The CDC guidelines revealed a reference to FDA instructions which included meters must be properly cleaned and disinfected after every use. The disinfection solvent you choose should be effective [MEDICAL CONDITION].[MEDICAL CONDITION], and HBV. Please note that 70% [MEDICATION NAME] solutions are not effective against [MEDICAL CONDITION] bloodborne pathogens.

Based on observations, staff interviews, facility documentation and policies and procedures, the facility failed to ensure that food items were labeled and/or dated, failed to ensure that multiple food items were discarded by their use by date, and failed to ensure two dietary staff members ( #41 and #45) had a food handlers card. Findings include: Regarding food labeling: During the initial kitchen tour conducted on September 5, 2017 at 8:20 a.m., the following was observed: -In the reach in refrigerator there was one pitcher of iced tea with a date of August 20, 2017 and a use by date of August 22, 2017. There was also one pitcher of lemonade with a preparation date of August 14, 2017 and a use by date of August 22, 2017. -In the walk in refrigerator there was an unlabeled container of brown gravy; there were approximately twenty cartoons of whole milk with a use by date of September 1, 2017; and there was a container of pureed bread with a preparation date of August 24, 2017, however, it was not labeled with a use by date. An interview with the Dietary Manager (staff #41) was conducted on September 5, 2017 at 8:23 a.m. Staff #41 stated the lemonade and tea should have been labeled with a use by date of seven days and that the milk was expired and needed to be discarded. Staff #41 stated the gravy should have been labeled and was unsure of how long the pureed bread could be stored, and that it should have been labeled appropriately. An interview was conducted on September 6, 2017 at 8:53 a.m., with the consulting dietitian (staff #94). She stated that the recommended storage for pureed bread was 1-2 weeks in the refrigerator. A review of the Trayline Refrigerated Leftover Storage policy revealed a leftover is a product that has been on the trayline one time, and the procedure is to date the container with the use by date. The policy further included that juice, broth based gravy and breads have a 1-3 day storage timeframe. Regarding the food handlers cards: Review of facility documentation revealed that a dietary aide (staff #45) was hired on July 12, 2017, and the dietary manager (staff #41) was hired on January 20, 2017. Review of the current food handlers cards revealed that staff #45 and #41, did not have food handlers cards. An interview was conducted on September 6, 2017 at 8:50 a.m. with staff #41. He stated his food handlers card had expired. An interview was conducted later that day at 11:27 a.m., with the consulting dietitian (staff #94). She stated that staff #41 became the interim dietary manager on August 1, 2017. She further stated that dietary staff are required by Maricopa County to have a food handlers card. During a follow up interview with staff #41 on September 6, 2017 at 11:51 a.m., he stated that the previous dietary manager had not been enforcing food handlers cards. He stated his food handlers card had expired in 2016. A review of the facility's job description for cooks and the dietary manager revealed both positions are to observe all facility policies and procedures. Review of the facility's policy and procedures for health examinations revealed in counties where it is required dietary employees have only 30 days from hire to obtain a food handlers permit.

Based on observations, staff interviews, facility documentation and policy review, the facility failed to ensure expired medications were not available for use. Findings include: During an observation of the medication storage room on Station 2 on September 6, 2017 at 1:05 p.m., a set of large plastic storage drawers were on the counter next to the refrigerator. On top of the drawers were two large plastic bags which contained over 100 heparin flush syringes. On further inspection, approximately 50% of the syringes in the plastic bags had expired dates, some with April 1, 2017 and others with September 1, 2017. During an observation of the medication storage room on Station 1 on September 6, 2017 at 1:15, an opened bottle of tuberculin skin test solution was observed in the medication refrigerator, with an open date written on the bottle of August 4, 2017. Attached to the front door of the refrigerator was a refrigerator temperature log that included a typed statement on the bottom which read, Insulin and Tuberculin vials expire 30 days after opening. All others expire six months after opening. In an interview conducted on September 6, 2017 at 1:25 p.m., with the Assistant Director of Nursing (registered nurse/ADON/staff #80), the ADON stated that the expired flushes should have been discarded and should not have been available for use. The ADON also stated that the Tuberculin solution should have been discarded on September 3. An interview was conducted on September 6, 2017 at 1:40 p.m. with the DON (Director of Nursing/staff #34), who stated that he did not know why the outdated heparin flushes were in the medication room. Review of a policy titled, Storage of Medications revealed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on clinical record review, staff interviews and policy and procedures, the facility failed to ensure one resident's (#185) drug regimen was be free of unnecessary drugs, by failing to ensure that mood and behavior monitoring was completed. Findings include: Resident #185 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 6 on the Brief Interview for Mental Status (BIMS), which indicated the resident had severe cognitive impairment. The MDS also indicated that the resident did not have any behavioral or mood issues during the look-back period. A physician's orders [REDACTED]. The order did not include any specific behaviors to monitor, which were associated with the [DIAGNOSES REDACTED]. Review of the resident's care plans revealed the resident was identified to have a mood disorder. The care plan interventions included the following: monitor and document the side effects and effectiveness of the [MEDICATION NAME] acid medication; monitor/record/report to physician acute episode of sadness, loss of pleasure, loss of interest in activities, feelings of worthlessness or guilt, change in appetite/eating habits, change in sleep patterns, diminished ability to concentrate, and change in psychomotor skills. The interventions also included to monitor/record/report to physician the risk for harming others: increased anger, labile mood or agitation, feeling threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons; and observe for signs and symptoms [MEDICAL CONDITION] hypomania: racing thoughts or euphoris, increased irritability, frequent mood changes, flight of ideas, marked change in need for sleep, agitation or [MEDICAL CONDITION]. Review of the Medication Administration Record [REDACTED]. However, there was no evidence on the MAR indicated [REDACTED]. Review of the clinical record revealed no documentation that the resident was being monitored for behaviors related to a mood disorder and regarding the care plan concerns. There was also no evidence that the effectiveness of the medication was being monitored. An interview was conducted with a Licensed Practical Nurse (LPN/staff #17) at 10:30 a.m. on September 6, 2017. She stated that when a resident receives psychoactive medications such as antipsychotic or antianxiety medications, there is an area on the MAR indicated [REDACTED]. In an interview with the Director of Nursing (DON/staff #34) at 10:40 a.m. on September 6, 2017, he said the [MEDICATION NAME] acid was being used as a mood stabilizer and that the nurses should be monitoring the resident's mood/behaviors. A later interview was conducted with staff #34 at 1:55 p.m. The DON stated that he did not know why the order did not include to monitor the resident's mood. He said he spoke with the physician who now included specific behaviors to monitor to determine if the medication is effective. Review of a medication policy and procedure revealed that medication use shall be consistent with an individual's condition, prognosis, and responses to such treatments. The policy further included that all medication orders will be supported by appropriate care processes and practices and that all decisions related to medications shall include appropriate elements; such as adequately detailed assessment; review of causes of symptoms; and consideration of the clinical relevance of symptoms. The policy also noted that upon admission and periodically thereafter, the staff and practitioner will review an individual's current medication regimen to identify whether there is a clear indication for treating the individual with the medication.

Based on clinical record review, staff interviews, facility policy and procedure, and the Resident Assessment Instrument, (RAI) the facility failed to ensure that two minimum data set (MDS) assessments were accurately coded for pressure ulcers for two residents (#153 and #2). Findings include: -Resident #153 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] indicated that the resident was admitted with a stage 1 pressure ulcer on her left buttock. A treatment order dated August 1, 2016 indicated that barrier cream was to be used on the resident's buttocks every shift. A skin observation dated August 2, 2016 revealed that the resident had developed a right buttock wound measuring 1 centimeters (cm), no depth was provided. Another treatment order dated August 2, 2016 indicated to clean the right buttock wound with normal saline, pat dry, and apply a dry dressing. According to a skin assessment dated [DATE], the resident had skin issues including a left buttock chaffed area measuring 3.5 cm by 2 cm with an additional 5 cm pressure ulcer. She also had a crack on her buttocks which was noted to be a pressure ulcer measuring 1.3 cm by 0.2 cm. She had an additional area above the buttocks which was coded as a pressure ulcer measuring 0.8 cm. and another area on the left buttocks measuring 5 cm by 5.3 cm. The assessment did not indicate what stage these pressure ulcers were, and no was depth documented. On August 12, 2016, the order to clean the right buttock wound with normal saline was discontinued leaving only the order to apply barrier cream as an active order for skin treatment. Review of the 14-day minimum data set (MDS) assessment dated [DATE] revealed that the resident was coded as having two stage 3 pressure ulcers. Review of the nursing notes, the resident's care plan, and the physician's orders [REDACTED]. An interview was conducted with the administrator (staff #12) at 2:20 p.m. on October 12, 2016. She stated that the MDS was likely coded incorrectly because the resident had wounds, but not a stage 3 pressure ulcer. Staff #12 further stated the MDS coordinator was not available to review this assessment, In an interview with the director of nursing (DON/staff #73) at 10:10 a.m. on October 13, 2016, he stated that he witnessed the extent of the resident's wounds; that they were superficial and never would have qualified to be stage 3 pressure ulcers. He stated that the MDS was coded incorrectly. During an interview with a registered nurse (RN/staff #70) at 10:15 a.m. on October 13, 2016, she stated that she had completed some of the skin assessments for this resident. She stated the resident did not have any stage 3 pressure ulcers that her wounds were superficial. -Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A health status note was written on August 29, 2016 which included that the resident had a decubitus ulcer to the coccyx. A nutritional care plan initiated August 30, 2016 indicated that the resident was identified to have a pressure ulcer on the coccyx/sacrum on September 4, 2016. However, an MDS (Minimum Data Set) admission assessment dated [DATE] and a 14-day MDS assessment dated [DATE] was coded the resident did not have a pressure ulcer. A wound care consultation was done on September 15, 2016 which described the resident having an unstageable pressure ulcer to the sacrum. In an interview with a Registered Nurse (RN/staff #70) on October 12, 2016 at 1:06 p.m. she stated that when a resident is admitted to the facility a head to toe assessment is performed which included looking at the skin. If the resident is found to have a suspected pressure ulcer upon that assessment, then the wound doctor is contacted to do a consult. The MDS Coordinator was unavailable. In an interview on October 13, 2016 at 11:13 a.m., with the Administrator (staff #12) and the Director of Nursing (DON/staff #73) it was stated that the MDS coordinator has access to all areas of the resident's clinical record and should have concluded that the resident did have a pressure ulcer when the MDS was coded. A facility policy titled Certifying Accuracy of the Resident Assessment included all personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment. The Resident Assessment Instrument manual for the MDS included .the importance of accurately completing and submitting the MDS cannot be over-emphasized. The MDS is the basis for the development of an individualized care plan . Further, Federal regulations require that the assessment accurately reflects the resident's status.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident (#182) who was admitted with a pressure sore, received the necessary care and services to promote healing and prevent infection and failed to prevent a new pressure ulcer from developing. Findings include: Resident #182 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was alert, but was cognitively impaired, was incontinent of urine and stool and required extensive assistance of two persons for bed mobility. A physician's order dated August 27, 2015 included for the resident to have a wedge cushion between her legs, post hip surgery. Review of the Admission Nursing Evaluation dated August 27, 2015, revealed the resident had multiple areas of bruising, one scab, and one abrasion. A Braden Scale assessment completed on August 27, 2015, indicated that the resident was at moderate risk for skin breakdown. Regarding the coccyx pressure ulcer: Review of the Weekly Skin Check dated August 27, 2015, revealed a shearing wound was present to the coccyx, which measured 6.0 x 6.0 x 0.3, and was purple, with deep red discoloration. No further wound description was noted. A treatment order was obtained upon admission for the coccyx pressure ulcer. Despite the above documentation, an August 28, 2015 physician progress notes [REDACTED]. On August 31, 2015, dietary recommendations included that the resident needed med pass 4 ounces four times daily to provide (800 kcal and 40 grams protein) and for 8 ounces of extra fluids between meals, pending MD approval. However, there was no documentation that the above dietary recommendations were implemented. According to the physician's Wound Care Initial Consultation note dated September 1, 2015, the resident had a pressure ulcer to the sacrum, which was present on admission. The wound measured 4.0 by 2.0, and the depth was unable to be determined. The wound bed was now described as having slough (yellow/black color) and had exudate. A Weekly Wound Pressure Ulcer Evaluation dated September 1, 2015 (written as a late entry) noted the resident had an unstageable pressure ulcer on the coccyx. The wound measured 4.0 by 2.0, depth was unable to be determined, and there was no drainage or odor present. The documentation further noted that the area was present on admission, continue treatment orders, and a new order was obtained for a low air loss mattress. A clarification order was written on September 3, 2015, by the Director of Nursing (DON), who also serves as the wound nurse supervisor. The order noted that the wound on the coccyx was not shearing, but was actually an unstageable pressure ulcer. A Dietary Progress Note dated September 4, 2015, reflected that the resident has an unstageable area on the coccyx. Recommendations were to follow up on the August 31, recommendations for med pass, and extra fluids between meals. The note also recommended for Vitamin C and Multivitamins with Minerals daily. Review of a physician's follow up note dated September 8, 2015, revealed the wound physician documented the presence of a foul smelling, infected sacral pressure ulcer, which measured 8.0 by 7.0, and the depth was unable to be determine. The wound bed was described as having slough, with a moderate amount of drainage. Per this note, the physician called the resident's primary facility physician, and they decided to send the resident to an acute care hospital to be seen by a specialist for debridement of the sacral wound. Regarding the left buttocks pressure ulcer: A nurse's note dated September 1, 2015, included that an additional area on the resident's left buttocks had opened up. A treatment order was obtained, and the wound nurse was notified of the new skin breakdown. A physician Wound Care Initial Consultation note dated September 1, 2015, included the resident had a left buttocks pressure ulcer, which was present on admission. However, the above nurse's note dated the same day included the left buttocks was found on September 1. The consultation note included that the left buttocks wound measured 6.0 by 2.5, and the depth was unable to be determined. The wound bed was described as having slough (yellow/ black color) and had minimal exudate. A September 2, 2015 Weekly Wound Pressure ulcer Evaluation included the left buttocks pressure ulcer measured 6.0 by 2.5 and the depth was unable to be determined. However, a September 2, 2015 physician progress notes [REDACTED]. According to the admission Minimum Data Set assessment dated [DATE], the resident was assessed to have two unstageable pressure ulcers with slough and/or eschar present. The assessment also included that only one pressure ulcer was present upon admission. A Dietary Progress Note dated September 4, 2015 included the resident now has a new wound to the left buttocks. Recommendations were to follow up on the August 31, 2015 recommendations for med pass and for extra fluids between meals. The recommendations also included for Vitamin C and Multivitamins with Minerals daily. Review of a task list report which included directions for the certified nursing assistants to complete revealed to reposition the resident and encourage the resident to change positions every 2 hours. The report noted that the resident had two pressure ulcers on her bottom. However, the documentation showed that this task was not initiated until September 7, 2015. In a physician's follow up note dated September 8, 2015, there was no documentation regarding the pressure ulcer to the left buttocks, upon transfer to the hospital for an infected coccyx wound. An interview was conducted with the DON on September 8, 2015 at 2 p.m. She stated that the resident was admitted with one unstageable pressure ulcer on the coccyx, and had developed a stage 2 ulcer on the left buttock. However, despite the above physician's follow up note and the interview with the DON that the resident had a stage 2 to the left buttocks, a Health Status Note dated September 8, 2015 included that the buttocks wound had bloody drainage and was necrotic. An interview with a certified nursing assistant (CNA) was conducted on September 9, 2015 at 10 a.m. She stated that she had been involved in the resident's care prior to her going to the hospital. She stated that the resident required extensive assistance of two persons for bed mobility and transfers and the resident was non-ambulatory. The CNA stated that the resident was cognitively impaired, was incontinent of urine and stool, and was difficult to reposition in bed, due to having a wedge cushion between her legs. She stated that she was aware that the resident had some degree of skin breakdown, but the resident was not on a formal turning and repositioning schedule. A second interview was held with the DON on September 9, 2015 at 1 p.m. She confirmed that the resident had been admitted to the hospital the prior evening, as a result of the wound physician's clinical assessment. She confirmed that the resident had been admitted to the facility with one pressure ulcer, which had worsened and had become infected. She further stated that it was her responsibility to ensure that dietary recommendations from August 31, were implemented and that a turning and repositioning program should have been implemented in a timely manner. A review of the facility policy for Pressure Ulcer Risk Assessment, the Clinical Protocol for Pressure Ulcers/Skin Breakdown, Prevention of Pressure Ulcers and Pressure Ulcer Treatment revealed that for a person in bed: Change position at least every two hours or more frequently if needed. It also stated that a resident should be placed on a minimum of an every 2 hour check and change program. Additional interventions included to administer vitamins, mineral and protein supplements in accordance with physician orders and dietician recommendations. The policy also described a stage 2 pressure ulcers as follows: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough or bruising.

Based on observations, staff interviews, clinical record review, and policy and procedures, the facility failed to ensure that three residents' (#'s 45, 166, and 167) urinary catheter drainage bags and/or tubing were not touching the floor. Findings include: -Resident #167 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. During a dining observation conducted at 12:00 p.m. on September 8, 2015, the resident was observed sitting in a wheelchair in the dining area on Pod A. The resident's Foley catheter tubing was touching the floor under the wheelchair. During the observation, two certified nursing assistants (CNAs) were observed in the area delivering lunch to the resident. A registered nurse (RN) was also observed working in the area. Another observation was conducted at 1:30 p.m. on September 8, 2015, of the resident being pushed in the wheelchair. The Foley catheter tubing was observed dragging on the floor. During the observation, a RN and the Director of Nursing (DON) were both observed walking past the resident. A third observation was conducted at 2:05 p.m. on September 9, 2015. The resident was observed sitting in a recliner in his room. The catheter drainage bag was in a privacy bag which was laying on the floor, and the catheter tubing was also touching the floor. During an interview conducted at 2:10 p.m. on September 9, 2015, a CNA stated the catheter bag was not supposed to be on the floor. The CNA also stated that to allow the tubing to touch the floor was an infection control problem. During an interview conducted on September 10, 2015, the RN stated that he did not see the resident's catheter tubing touching the floor. He stated that it was his responsibility to ensure that the CNAs position the resident's catheter tubing so it is not touching or dragging on the floor. -Resident #45 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Per the clinical record documentation, the resident was admitted with a suprapubic catheter. An observation of catheter care was conducted on September 10, 2015 at 8:05 a.m., with a registered nurse (RN) and a CNA present. At this time, the resident's suprapubic catheter drainage bag was attached to the side of the bed. The drainage port on the lower portion of the drainage bag and the catheter tubing were observed resting on the floor. The resident's bed was then raised for staff to perform catheter care. Afterwards, staff returned the bed to a lower position, resulting in the drainage port, bag and tubing once again resting on the floor. -Resident #166 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Per the clinical record, the resident had an indwelling urinary catheter. An observation of catheter care was conducted on September 10, 2015 at 8:20 a.m., with a RN and a CNA present. The resident's indwelling urinary catheter drainage bag was attached to the side of the bed. The drainage port and lower portion of the drainage bag were resting on the floor. The resident's bed was raised for staff to perform catheter care. Afterwards, staff lowered the bed, resulting in the drainage bag again resting on the floor. In an interview conducted with the CNA on September 10, 2015 at 8:50 a.m., the CNA stated that the bags and tubing should be off the floor. In an interview, the DON stated that the catheter bag and tubing should be off the floor. Review of facility policy and procedure titled, Catheter Care, Urinary indicated the purpose of this procedure is to prevent catheter-associated urinary tract infections. Under the section titled Infection Control, the procedure directed staff to be sure the catheter tubing and drainage bag are kept off the floor.