Every finding on record at Aurora Health and Rehabilitation

Based on record review, staff interview and facility policy review, the facility failed to ensure residents were treated with respect and dignity when a staff member spoke rudely and in a disrespectful manner to one (1) of three (3) residents reviewed. Resident #2 Findings included:Record review of the facility policy titled, Resident Rights, revealed Standard, Employees shall treat all residents with kindness, respect and dignity .Record review of Grievance/Concern/Comment Report dated 1/29/26, revealed that Resident #2's family reported that Certified Nursing Assistant (CNA) #1 talked down to the resident and overheard CNA #1 state to the resident I told you that I was coming back to change you!An interview with the Social Services Director (SSD) on 5/20/26 at 8:35 AM, he stated he made a follow-up call to check on the resident after discharge and received report from the family that CNA #1 had talked down to the resident on the day of discharge. He stated he immediately reported the incident to the Director of Nursing (DON).An interview with the Administrator on 5/20/26 at 8:40 AM, she verified that the facility investigated the report and found that CNA #1 did not provide good customer service to Resident #2. The Administrator further verified that this meant that the CNA did not treat the resident with dignity and respect. She agreed that the resident should have been treated with dignity and respect.Record review of the admission Record revealed the facility admitted Resident #2 on 10/10/25 with diagnosis that included Acute Respiratory Failure and discharged the resident home on 1/18/26.

Based on staff interview, record review, and facility policy review the facility failed to ensure a resident was provided education and sufficient information regarding advance directives and the implications of assigning a Power of Attorney (POA) prior to obtaining the resident's agreement for one (1) of three (3) residents reviewed for advanced directives. Resident #1Findings Included:Record review of the facility policy titled, OBRA (Omnibus Budget Reconciliation Act) Resident Self-determination Checklist revealed, Policy.Every resident has the right to give informed consent before diagnosis or treatment. Advance Directives provide residents the ability to legally decide about their future medical treatment .Record review of Advance Health Care Directive, revealed the form was signed with Resident #1's name and notarized by the facility's Human Resources personnel on 2/19/26 making Resident #1's mother his health care agent.Record review of the admission Record revealed the facility admitted Resident #1 on 2/10/26 with diagnoses that included Aphasia follow Cerebral Infarction and Cognitive Communication Deficit. The admission Record listed Resident #1's spouse as his Responsible Party (RP).An interview on 5/20/26 at 10:08 AM, with Human Resources (HR) verified that she was a Notary Public. She stated that on 2/19/26 she was called to the business office and introduced to Resident #1's mother. The mother asked her to come to the room and notarize paperwork. She explained that Resident #1's mother stated that they had an Advance Directive (AD) for Resident #1 that an alternative facility required in order to transfer him to that facility. HR stated that she asked Resident #1 if it was ok for his mother to sign his name and he indicated that it was. She stated that she verified the mother's identification and then notarized the paperwork. HR verified that she did not know who the Resident's RP was because she did not check his medical record to determine who was listed. She further stated that Resident #1 was not provided any explanation or education of the details of the Advance Health Care Directive. She then added that the resident's ability to communicate waxed and waned throughout his stay indicating that the facility was unsure of his cognitive status. HR agreed that residents should receive education in order to make informed consent, she should have checked the chart to see who the RP was, and that she should not have notarized the Advance Health Care Directive.An interview with the Administrator on 5/20/26 at 12:46 PM she stated that facility staff are not to notarize any forms for residents and/or visitors and it was her expectation that HR would not have notarized the form.Record review of Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 2/17/26 revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating that the resident was severely cognitively impaired.

Based on observation, staff interview, and facility policy review the facility failed to ensure medications were stored in a safe and secure manner by leaving one (1) of eight (8) medication carts unlocked and unattended. Findings included:Record review of the facility policy, titled Medication Storage revealed Policy Explanation and Compliance Guidelines, 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts.).An observation on 5/19/26 at 3:30 PM, revealed a medication cart located midway down the hall that was unlocked. Licensed Practical Nurse (LPN) #1 was noted to be down the hall away from the unlocked cart.An interview with LPN #1 on 5/19/26 at 3:36 PM, he verified that it was his medication cart and he did leave the cart unlocked. He agreed that he should have locked the cart before he walked away from it. He verified that leaving the cart unlocked and unattended could allow resident access to medications that could cause harm.An interview with the Administrator on 05/19/26 at 7:00 PM, she stated that it was her expectation that LPN #1 would have locked the cart before walking away.

Based on observations, staff interviews, and facility policy review, the facility failed to maintain food service areas in a sanitary manner to prevent the potential for food contamination. Specifically, the facility failed to ensure ventilation ductwork was free from a black mold-like substance in areas located above food preparation and food storage locations on two (2) of (2) kitchen tours. Findings include:Review of facility policy titled Sanitation and Infection Control with no date, revealed, Standard: .to ensure sanitary conditions.in the dining service department.On 1/20/2026 at 10:21 AM, during an initial tour of the facility kitchen accompanied by the Dietary Manager revealed an observation of a black mold-like substance on the ventilation ductwork above the stove, with visible dark discoloration along the seams and underside of the duct. A similar black mold-like substance was also observed on the ductwork in the dry storage room, extending along multiple sections of the duct. Both locations were in close proximity to food preparation and food storage areas. The Dietary Manager confirmed the substance had been present for several months.During an observation of the ductwork in the kitchen on 1/20/2026 at 11:38 AM, with the Plant Operations Manager, he confirmed the presence of a black mold-like substance on the ductwork above the stove and food preparation areas and on the ductwork in dry storage room, which he stated increased the risk for food contamination.During an interview with the Administrator on 1/20/2026 at 3:30 PM, she confirmed there was a risk for foodborne illness related to the presence of the black mold-like substance above the stove and food preparation areas.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide personal hygiene for two (2) of the twenty-one sampled residents. Resident #66 and Resident #89. Findings include: A review of the facility policy titled, Resident Hygiene Care of Fingernails/Toenails with a revision date of 6/2022, revealed The purpose of this procedure is to clean the nail bed, to keep nails trimmed and to prevent infections. Nail care includes cleaning and trimming as needed. Proper nail care can aid in the prevention of skin problems around the nail bed. Resident #89 On 1/20/2026 at 2:55 PM, an observation and interview revealed Resident #89's fingernails were approximately one (1) inch long and jagged with a brown substance under them. Resident #89 revealed that she would like her fingernails to be trimmed and cleaned. On 1/21/2026 at 1:20 PM, an observation of Resident #89's fingernails remain long and jagged with a brown substance underneath them. During an interview and observation on 1/21/2026 at 3:50 PM, Certified Nurse Aide (CNA) #1 revealed we are responsible for cleaning the resident's fingernails when we clean them up each morning. She revealed the wound treatment nurse is responsible for cutting the nails if they are diabetic. CNA #1 confirmed that Resident #89's fingernails were long and jagged and stated, They are definitely dirty and need a good trimming. During an interview and observation on 1/21/2026 at 4:05 PM, the Director of Nurses (DON) revealed it is the responsibility of the CNA's to clean the residents' fingernails when they are providing daily care, and the nurses are responsible for ensuring the fingernails are adequately trimmed. The DON confirmed that Resident #89's fingernails were long and dirty, which could cause a skin tear and a possible infection. Record review of the admission Record revealed that Resident #89 was admitted to the facility on [DATE] with diagnoses that included a displaced oblique fracture of the shaft of the right ulna and muscle weakness. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 1/15/2026 revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated Resident #89 has moderate cognitive impairment. Resident #66 During an interview and observation on 1/20/26 at 12:40 PM, Resident #66 revealed he liked his nails kept short and smooth and would like for them to be trimmed. Nails were observed to be approximately 1/4 inch from nail bed with a brown substance under several nails noted. Nails were jagged and rough in multiple areas. On 1/21/26 at 3:50 PM, during an interview and observation, the Director of Nursing revealed her expectation was for each dependent resident to receive personal hygiene which included nail care. She acknowledged that Resident #66's nails were long, dirty, and jagged with sharp areas that could cause an injury to the skin. She confirmed the facility failed to maintain a resident's nails at an appropriate and safe length and in clean condition. Record review of admission Record revealed the facility admitted Resident #66 on 12/15/2020 with diagnosis of Metabolic Encephalopathy. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/6/25 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 which indicated a moderate cognitive impairment.

During observation, staff interviews, and facility policy/document review, the facility failed to ensure medications were secured properly to prevent unauthorized access for one (1) of three (3) days of survey.Findings include:Review of a Med Pass check off list with no date, revealed, .Medications locked within the cart when cart is out of direct line of vision. There was signature line for both the learner and observers' signature on the document.An observation on 1/20/2026 at 8:14 AM revealed an unlocked and unattended medication cart on the 200 unit with residents wandering in the immediate area. The medication cart contained various respiratory treatment medications used by the Respiratory Therapist. During an interview on 1/20/2026 at 8:15 AM, the Respiratory Therapist (RT) confirmed the medication cart was left unlocked and unattended. He further confirmed residents were wandering on the unit while the cart remained unlocked and unattended. He stated the importance of ensuring medications are stored in a locked cart or locked medication room and identified residents could be at risk if they accessed the unlocked cart. During an interview on 1/20/2026 at 10:30 AM, the Administrator confirmed all medication carts should be locked at all times unless in active use, particularly when left unattended. She further confirmed there was a risk if a resident accessed an unlocked medication cart.

Based on observations, resident and staff interviews, record review and facility policy review the facility failed to implement a comprehensive care plan related to applying a hand splint (Resident #61) and nail care (Resident #66, and #89) for three (3) of twenty four care plans reviewed. Findings include: Review of the facility care plan policy titled, Comprehensive Care Plan with a revision date of 4/2025, revealed It is the standard 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. Resident #66 Record review of Resident #66's Care Plan Report revealed Focus: (Proper name of Resident #66) has an ADL (Activities of Daily Living) self care performance deficit r/t (related to) increased weakness and limited mobility. Listed under Interventions/Tasks was Personal Hygiene/oral care: He requires set up and clean up assistance from 1 (one) staff to complete personal hygiene and oral care. During an interview and observation on 1/20/26 at 12:40 PM, Resident #66 revealed he liked his nails kept short and smooth and would like for them to be trimmed. Nails were observed to be approximately 1/4 inch from nail bed with a brown substance under several nails noted. Nails were jagged and rough in multiple areas. On 1/21/26 at 3:50 PM, during an interview and observation, the Director of Nursing revealed her expectation was for each dependent resident to receive personal hygiene which included nail care and acknowledged that Resident #66's nails were long, dirty, and jagged. She confirmed the facility failed to maintain a resident's nails at an appropriate and safe length and in clean condition and therefore did not follow the care plan for assistance with activities of daily living care. During an interview on 1/22/26 at 10:20 AM, the Registered Nurse (RN) Minimum Data Set (MDS) Coordinator revealed the purpose of the care plan was to inform the staff of the needs of the residents so these needs could be met. She acknowledged that nail care was a part of personal hygiene and was to be performed for the dependent residents. She confirmed the care plan for personal hygiene for nail care was developed but not implemented. Record review of admission Record revealed the facility admitted Resident #66 on 12/15/2020 with a diagnosis of Metabolic Encephalopathy. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/6/25 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 which indicated a moderate cognitive impairment. Resident #89 Record review of Resident #89's Care Plan Report revealed Resident #89 has a functional abilities (Self-care and mobility) deficit related to impaired balance and musculoskeletal impairment. Under Interventions.Personal Hygiene: She is dependent on 2 assistant to maintain personal hygiene. On 1/20/2026 at 2:55 PM, an observation and interview revealed Resident #89's fingernails were approximately one (1) inch long and jagged with a brown substance under them. Resident #89 revealed that she would like her fingernails to be trimmed and cleaned. On 1/21/2026 at 1:20 PM, an observation of Resident #89's fingernails remain long and jagged with a brown substance underneath them. During an interview and observation on 1/21/2026 at 3:50 PM, Certified Nurse Aide (CNA) #1 revealed we are responsible for cleaning the resident's fingernails when we clean them up each morning. She revealed the wound treatment nurse is responsible for cutting the nails if they are diabetic. CNA #1 confirmed that Resident #89's fingernails were long and jagged and stated, they are definitely dirty and need a good trimming. During an interview and observation on 1/21/2026 at 4:05 PM, the Director of Nurses (DON) revealed it is the responsibility of the CNA's to clean the residents' fingernails when they are providing daily care, and the nurses are responsible for ensuring the fingernails are adequately trimmed. The DON confirmed that Resident #89's fingernails were long and dirty, which could cause a skin tear and a possible infection. The DON confirmed that the resident's plan of care for her personal hygiene was not being followed and it should have been. Record review of the admission Record revealed that Resident #89 was admitted to the facility on [DATE] with diagnoses that included a displaced oblique fracture of the shaft of the right ulna and muscle weakness. Record review of the MDS Section C with an ARD of 1/15/2026 revealed a BIMS score of 8, which indicated Resident #89 has moderate cognitive impairment. Resident #61 Record review of Resident #61's Care Plans revealed under, Focus: (Proper name of Resident #61) has an ADL (activity of daily living) Self Care Performance Deficit r/t (related to) Stroke. Also revealed under, Intervention: She has contractures of bilateral hands, wash and dry bilateral hands, provide PROM (passive range of motion). Apply bilateral hand splints. Resident to wear bilateral hand splints for 8 hrs (hours) daily. During an observation of Resident #61 on 1/20/26 at 10:40 AM, she was lying in bed without hand splints. A hand/wrist splint was lying on the bedside dresser. An interview with a family member revealed staff did not apply them. On 1/21/26 at 9:48 AM, an observation of Resident #61 revealed there were no hand splints in place. On 1/22/26 at 8:36 AM, an observation revealed Resident #61 without hand splints. On 1/22/26 at 8:43 AM, an interview with Licensed Practical Nurse (LPN) #2 (Restorative Nurse) confirmed Resident #61's hand splints were not being applied as ordered. An interview with the Minimum Data Set (MDS) Nurse on 1/22/26 at 9:57 AM revealed the purpose of the care plan was to notify the staff of what care to provide for the residents. She confirmed Resident #61's care plan was not followed for the splints and stated there was a break in communication. Record review of the admission Record revealed the facility admitted Resident #61 on 2/26/24 with medical diagnoses that included Cerebral Infarction due to Embolism of Left Middle Cerebral Artery and Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/25 revealed under section C, Resident #61's cognitive skills for daily decision making were severely impaired.

Based on observation, family and staff interview, record review, and facility policy review, the facility failed to ensure prescribed splinting devices were applied as ordered for one (1) of (35) residents reviewed for range of motion impairments. Resident #61Findings Include:Record review of the facility policy titled Restorative Nursing Standard with a revision date of 3/19 revealed under, 4. Splints . Its purpose is to prevent deformities when an increase of tone is noted in hand and occasionally with a flaccid hand .On 1/20/26 at 10:40 AM, an observation of Resident #61 revealed she was lying in bed, nonverbal, with her eyes open. A hand/wrist splint was lying on the bedside dresser. She had contractures to both hands, with the left worse than the right. A soft hand roll was inside the left hand. An interview with a family member during this time revealed therapy previously applied hand splints to both hands; however, she no longer received therapy, and staff did not apply them. The family member stated he applies the right-hand splint for about an hour a day but does not apply the left-hand splint, confirming the resident still had both splints in the dresser drawer.An observation of Resident #61 on 1/21/26 at 9:48 AM, revealed there were no hand splints in place. Her left hand held a soft hand roll.Record review of Resident #61's Progress Notes dated 3/14/24 revealed a Restorative Care Referral was made to apply bilateral hand splints for 8 hours daily.Record review of Resident #61's Kardex revealed under, Restorative: .She has contractures of bilateral hands, wash and dry bilateral hands, provide PROM. (passive range of motion). Apply bilateral hands splints. Resident to wear bilateral hand splints for 8 (eight) hrs. (hours) daily.An interview with Certified Nurse Aide #2 on 1/22/26 at 8:34 AM, revealed she did not apply hand splints for Resident #61 and stated restorative was responsible.An observation on 1/22/26 at 8:36 AM, revealed Resident #61 without hand splints, with her left hand holding a soft hand roll.An interview with Licensed Practical Nurse (LPN) #2 (Restorative Nurse) on 1/22/26 at 8:43 AM, revealed the facility did not have a restorative program but was working to obtain staff to restart the program. She confirmed she did not apply Resident #61's splints and was not aware the resident was supposed to wear them. She stated she knew family was applying a splint at one time and confirmed if splints were not being applied as ordered, the contractures could worsen.An interview with the Rehabilitation Director on 1/22/26 at 9:10 AM, revealed the last time Resident #61 received occupational therapy for contractures and splinting was in February 2024. She revealed the resident was referred to restorative for splinting shortly thereafter and was screened quarterly with no changes in function identified. She confirmed if staff were not applying Resident #61's hand splints, her contractures could worsen.Record review of the admission Record revealed the facility admitted Resident #61 on 2/26/24 with medical diagnoses that included Cerebral Infarction due to Embolism of Left Middle Cerebral Artery and Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/25 revealed under section C, Resident #61's cognitive skills for daily decision making were severely impaired.

Based on observation, resident and staff interview, and facility policy review, the facility failed to ensure a resident's wheelchair was maintained in a safe manner for one (1) of 68 residents requiring a standard wheelchair for locomotion. Resident #12 Findings Include:Review of the facility policy titled Preventative Maintenance for Wheelchairs undated, revealed under, Policy: It is the practice of this facility to develop and implement a preventative maintenance program to ensure wheelchairs are maintained in a safe and operable manner. Also revealed under, Policy Explanation and Compliance Guidelines: . 4. Preventative maintenance should be performed weekly or as indicated: . e. Check seats, backs, arm rest and cushions for tears, cracks or missing screws-replace or repair if present.An observation and interview on 1/20/26 at 11:10 AM, revealed Resident #12 seated in her wheelchair with significant damage to both armrests. Each armrest was split in half, exposing the hard gray plastic interior. The black vinyl armrest covering was torn and hanging loosely from the sides, and a protruding silver screw was visibly present on the right armrest. The resident's arms were resting directly on the exposed plastic. She stated staff knew about the condition of the wheelchair and that the chair had been like that for a while.An observation and interview with the Administrator on 1/21/26 at 3:53 PM, revealed her expectations were for residents to have safe, operating equipment in good repair. She explained that aides were responsible for reporting broken or damaged equipment in the maintenance log so repairs could be made. The Administrator confirmed Resident #12 had broken wheelchair armrests in poor condition which could cause skin concerns.Record review of the admission Record revealed the facility admitted Resident #12 on 8/12/24 with diagnoses that included Schizoaffective Disorder, Bipolar Type, and Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #12 was cognitively intact.

Based on observations, staff interviews, record reviews, and facility policy review, the facility failed to ensure medications were accurately labeled and corresponded with the physician's order for two (2) of three (3) residents observed during medication pass. (Resident #5 and #20).Findings Include: Review of the pharmacy's policy titled Long Term Care Facilities/Pharmacy Operations/Medication Packaging: Strip Packaging with review date 04/2023, revealed: Strip packaging is provided for efficient and accurate medication administration and accountability of routine oral solid medications .Remember to always check your MAR prior to administering medications.Resident #5An observation during medication pass on 1/20/2026 at 9:44 AM revealed Licensed Practical Nurse (LPN) #5 retrieved a pharmacy-prepared multi-dose pouch labeled Omeprazole Oral Tablet Delayed Release 40 milligrams (mg) from the medication cart, opened the pouch and retrieved one (1) tablet, and administered it by mouth to Resident #5 along with other morning medications. During this observation, the January 2026 Medication Administration Record (MAR) did not match the Omeprazole Oral Tablet Delayed Release 40 mg tablets on hand in the multi-dose pouch, revealing a discrepancy between the physician's order and the labeled medication for Resident #5.Record review of Resident #5's January 2026 MAR revealed an order dated 8/22/2023 for Omeprazole Oral Tablet Delayed Release 20 mg, Give (2) tablets by mouth one time a day for Gastroesophageal Reflux Disease (GERD).Review of Resident #5's pharmacy-prepared multi-dose pouch dated for 1/20/2026 morning medication administration revealed, Omeprazole Oral Tablet Delayed Release 40 mg Give (1) tablet by mouth one time a day for GERD.During an interview on 1/20/26 at 9:45 AM, LPN #5 confirmed Resident #5's physician order and medication label did not match. She stated the discrepancy had been present for some time and stated, I've never thought to get it changed. During an interview on 1/20/26 at 2:30 PM, the Director of Nursing (DON) acknowledged the labeling inaccuracy created the possibility a nurse could administer an incorrect dose. She stated she was unaware of the discrepancy and that nursing staff should have reported so it could have been corrected.Record review of Resident #5's Face Sheet revealed the facility admitted the resident on 8/21/2023 with diagnoses including Metabolic Encephalopathy and Gastro-Esophageal Reflux Disease without Esophagitis. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/25 under section C revealed a Brief Interview for Mental Status (BIMS) summary score of 15 which indicated Resident #5 was cognitively intact.Resident #20An observation during medication pass on 1/20/26 at 8:22 AM revealed LPN #4 retrieved a pharmacy-prepared multi-dose pouch labeled Desmopressin Acetate Tablet 0.2 mg from the medication cart, opened the pouch and retrieved (1) tablet, and administered it via Percutaneous Endoscopic Gastronomy (PEG) tube to Resident #20 along with other morning medications. During this observation, the MAR did not match the Desmopressin Acetate Tablet 0.2 mg tablets on hand in the multi-dose packet, revealing a discrepancy between the physician order and the labeled medication for Resident #20.Record review of Resident #20's January 2026 MAR revealed an order dated 5/6/2020, Desmopressin Acetate Tablet 0.1 mg. Give (2) tablets via PEG-Tube three times a day for diabetes insipidus.Review of Resident #20's pharmacy-prepared multi-dose pouch dated for 1/20/2026 AM medication administration revealed, Desmopressin Acetate Tablet 0.2 mg Give one (1) tablet via PEG-Tube three times a day and Baclofen Tablet 10 mg Give 0.5 tablet via PEG-Tube two times a day for seizures. An interview with LPN #4 on 1/20/26 at 8:22 AM, confirmed Resident #20's physician order and medication label did not match. She stated this discrepancy could easily cause a nurse to administer the wrong amount. She further stated that the facility changed pharmacy providers a few months ago and she had noticed the variations but had not notified anyone to have the issue corrected.An interview with the DO) on 1/20/26 at 2:30 PM, acknowledged that the labeling inaccuracy created the possibility that a nurse could administer an incorrect dose. She stated she was unaware of the discrepancy, and the nurse should have reported so it could have been corrected.Record review of Resident #20's Face Sheet revealed the facility admitted the resident on 8/30/2019 with diagnoses including Unspecified Intracranial Injury with loss of consciousness of unspecified duration, subsequent encounter and Persistent Vegetative State.A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/2/25 revealed under section C that the BIMS was conducted by staff assessment for daily decision making and were coded as (3) indicating severely impaired-never/rarely made decisions.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide a safe, hazard-free environment for a resident when a portable heater was used in the resident's room and caused a burn to the resident's skin for one (1) of three (3) incidents reviewed. Resident #1. Based on corrective actions implemented 5/5/25, the State Agency determined this to be Past Non-Compliance. Findings include:Record review of facility policy titled, Incidents and Accidents Policy, undated, revealed, Accident - Any unexpected or unintentional incident which results, or may result, in injury or illness to a resident. Incident - An occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization. This can involve a visitor, vendor, or staff member.During an observation and interview on 8/25/25 at 1:20 PM, Resident #1 was observed in his room in his bed with his right elbow noted to be covered in a dressing. He stated he has a disorder that makes him sweat even when he is cold and he prefers to be uncovered and undressed since the clothing and covers retain the sweat moisture. He stated several months ago, he asked the Licensed Practical Nurse (LPN) #1 to use the heater his representative brought to him and the nurse was hesitant, but she did what he requested. Approximately an hour later, the next nurse came in and took the portable heater out of the room and noted redness and blisters on his right elbow and due to his spinal injury, he did not feel pain in this area. An interview with LPN #1 on 8/26/25 at 8:40 AM revealed she was asked by Resident #1 to use the heater that his family had brought him. She informed him that heaters were not allowed in the facility, but he convinced her that he had been using it and it was located in the closet. She acknowledged that she knew better than to do this, but against her better judgement, she set it up on a table approximately 3 feet from the resident as he requested. The time of this was approximately 11:00 PM, prior to her going home for the evening. Shortly after midnight, LPN #2 called her to ask her about the heater being by his bedside and informed her of the redness and blisters to his elbow. She acknowledged she made a mistake when she placed the heater in the resident's area and she knew better but was trying to do what the resident asked because he was cold.During a phone interview on 8/26/25 at 9:20 AM, LPN #2 revealed she and another Certified Nursing Assistant (CNA) made their initial rounds and noted the heater at Resident #1's bedside and the redness and blisters to the resident's right elbow. She stated the resident told her he was not in pain and was unaware that the injury occurred. During an interview with the Administrator on 8/26/25 at 1:30 PM, it was revealed that space heaters were not allowed in resident rooms due to the fire risk and burn risk. An employee used the heater that the resident's family brought, and the resident received a burn to his right elbow. She confirmed the facility failed to provide a safe and hazard free environment for Resident #1 when a space heater was set up at his bedside and caused a burn.Record review of Resident #1's Progress Note by the Medical Doctor dated 5/3/25 at 6:39 AM, revealed, Chief complaint.Patient seen for burn injury .noticed multiple blisters on right elbow, resident was not aware of them.Diagnosis Second degree burn of right elbow.Record review of wound culture dated 5/22/25 revealed results of bacteria of Enterococcus Faecalis.Record review of wound culture dated 6/19/25 revealed results of bacteria pathogens of Methicillin-Resistant Staphylococcus Aureus (MRSA) and Enterococcus Faecalis. Record review of the Order Summary Report revealed an order on 5/29/25 - 6/5/25 for Augmentin Oral Tablet 500-125 milligrams two times a day for right elbow wound infection for 7 days; order on 6/25/25 - 7/2/25 for Bactrim DS Oral Tablet 800-160 milligrams one tablet two times a day for right elbow wound infection; and an order on 6/27/25 - 7/11/25 for Doxycycline oral tablet 100 milligrams two times a day for right arm infection for 14 days.Record review of Resident #1's electronic Medication Administration Record revealed the resident received the antibiotics for the wound infections as ordered.Record review of Resident #1's admission Record revealed the resident was admitted to the facility initially on 3/27/24 with the most recent admission date of 10/1/24, with diagnoses that included Traumatic Subarachnoid Hemorrhage, Paraplegia, and Autonomic Dysreflexia.Record review of Resident #1's Minimum Data Set (MDS) Section C - Cognitive Patterns dated 7/2/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicted the resident was cognitively intact.The facility has documented evidence date of corrections prior to the state agency entrance, therefore, this is cited as past noncompliance. The facility implemented corrective actions on 05/5/25, including staff education, enhanced monitoring, and completed safety monitoring. Validation of the corrective actions were verified through staff interviews, record reviews and observations.

Based on observation, staff interview, record review and facility policy review the facility failed to prevent the possibility of an infection as evidence by a suction connecting tubing not being replaced after making contact with a trash can during respiratory care for one (1) of seven (7) residents direct care observations. Resident #47 Findings Include Review of the facility policy titled, Infection Control with a revision date of 5/2023 revealed under Standard Explanation and Compliance Guidelines #11. Equipment Protocol: e. All contaminated disposable items shall be discarded in a waste receptacle lined with a RED plastic bag. An observation and interview on 4/3/24 at 8:12 AM, revealed the Respiratory Therapist (RT) performed suctioning and trachea care on Resident #47. After the RT suctioned the resident's tracheostomy, she removed the suction connecting tubing that was placed inside the resident's trachea and placed it in the trash, allowing the suction tubing to fall and lay on the side of the resident's trash can that was full of trash. The RT went to the restroom, washed her hands, returned, placed gloves on and poured sterile water into a cup, picked up the suction tubing from the side of the trash can, suctioned some of the sterile water through the tubing and then wrapped the tubing around the suction canister and covered it in plastic. This observation revealed the suction canister was labeled and dated 4/1/24. An interview with the RT revealed she covered it to be used for the next suctioning. She stated the suction tubing and canister get changed weekly and is due to be changed on 4/8/24. She confirmed that the end of the suction tubing that would have connected to the suction connector had touched the trash can and could have caused an infection. She revealed the tubing should have been changed, instead of wrapping it up for it to be used the next time. An interview on 4/3/24 at 9:30 AM, with the Infection Preventionist confirmed the suction tubing touching the trash can in the resident's room should have been changed, because that would have been a break in infection control. She stated it was dirty and could have caused a problem. An interview on 4/3/24 at 12:05 PM, with Director of Nurses (DON) confirmed that the suction tubing used to connect to the suction connector should have been changed after the tip of the suction tubing touched the resident's trash can because that could have caused an infection. Record review of Resident #47's Order Summary Report revealed a physician's order dated 9/30/21 to ensure proper storage, stocking and covering of respiratory therapy equipment in residents' room every shift. Record review of Resident #47's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction and Tracheostomy Status.

Based on observation, resident and staff interview, record review, and facility policy review the facility failed to properly code a resident for a restraint on the Minimum Data Set (MDS) for one (1) of 21 residents MDS assessments reviewed during survey. Resident #56 Findings Include. A review of the facility policy revised 04/2019 titled Resident Assessment Instrument (RAI)/CARE PLANNING MANAGEMENT revealed it is the practice of this facility to conduct a comprehensive, accurate assessment of each resident's functional capacity. A record review of Resident #56's Minimum Data Set (MDS) Quarterly assessment dated [DATE] section P revealed used a trunk restraint less than daily. An observation and interview, on 04/02/24 at 10:29 AM, of Resident #56 revealed the resident lying in bed resting. The observation revealed that the resident did not have a restraint on. The resident confirmed that he does not have any type of restraint. An interview, on 04/02/24 at 10:40 AM with Registered Nurse (RN) #1 confirmed that Resident #56 has not had a restraint on that she can remember. A record review of Resident #56's Physicians' Orders revealed there is no order for restraint. An interview, on 04/03/24 at 10:10 AM, with Certified Nursing Assistant (CNA) #2 confirmed that Resident #56 has not had a restraint for the seven (7) years that she has worked here. An interview on 04/03/24 at 10:20 AM, with the MDS Nurse confirmed that under Section P of the MDS completed on 03/12/24 that trunk restraint was marked by mistake. MDS Nurse confirmed that Resident #56 has never had a restraint and that it was marked in error and that she will have to complete a modification to remove it. She confirmed that the purpose of the MDS is to gather knowledge about the resident through an assessment to guide the care that the resident received and payment for resident services. The MDS Nurse confirmed that coding the MDS incorrectly can affect the resident's level of care. An interview on 04/03/24 at 1:00 PM, with the Administrator confirmed that the purpose of the MDS is to determine the level of care that the resident needs and that coding it incorrectly could result in the resident receiving the wrong level of care. A review of the Admission Record for Resident #56 revealed that he was admitted to the facility on [DATE].

Based on staff interview, record review and facility policy review the facility failed to make a referral for a resident with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #46 Findings Include: Review of the facility policy titled, Resident Assessment-coordination with the PASARR program with a revision date of 10/2019 revealed under Policy Explanation and Compliance Guidelines .#6. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Record review of the Pre-Admission Screening (PAS) Application for Long Term Care dated 3/5/19 revealed the resident did not have diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #46's Admission Record revealed the resident was admitted to the facility on [DATE]. A new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #46's Behavioral Medicine Evaluation and Management Notes dated 5/2/19 revealed the resident gave a verbal medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 11/8/22 at 1:28PM, with Social Services #1 revealed that Resident #46 should have had a new PASARR completed and sent in when the resident received the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She revealed she was responsible for doing the new PASARR and confirmed she did not do it. She revealed that the PASARR should have been resent after the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 11/9/22 at 9:00 AM, with the Psychiatric Nurse Practitioner confirmed that she gave Resident #46 a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 11/9/22 at 10:00 AM, with the Administrator confirmed that the PASARR should have been redone after Resident #46 received the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #46's Minimum Data Set with an Assessment Reference Date of 09/08/22 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident is cognitively intact and Section I revealed the resident has an Active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on staff interview, record review, observation and facility policy review, the facility failed to prevent the development of pressure ulcers and the worsening of existing pressure ulcers for one (1) of five (5) residents reviewed, (Resident #1). Findings include: Review of the facility's policy titled, Skin Management Standards - Routine Preventative Care, last updated ,d+[DATE], revealed, According to AHCPR (Agency for Healthcare Policy and Research) Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Vanguard requires .a minimum skin check of at least weekly by a licensed nurse. Findings will be documented in the medical record. Resident #1 Review of Resident #1's Long Term Care Evaluation V4's which include the weekly skin assessments revealed the following: [DATE] - skin assessment completed. [DATE] - skin assessment completed - nineteen (19) days between assessments. [DATE] - skin assessment completed - twenty-eight (28) days between assessments. [DATE] - skin assessment completed - fourteen (14) days between assessments. [DATE] - skin assessment completed. [DATE] - skin assessment completed. [DATE] - skin assessment completed - twenty (20) days between assessments. [DATE] - skin assessment completed. [DATE] - skin assessment completed. [DATE] - skin assessment completed - 14 days between assessments. [DATE] - skin assessment completed - 14 days between assessments. [DATE] - skin assessment completed - 14 days between assessments. [DATE] - skin assessment completed - 14 days between assessments. [DATE] - skin assessment completed. [DATE] - skin assessment completed. [DATE] - skin assessment completed. [DATE] - skin assessment completed. [DATE] - skin assessment completed. [DATE] - skin assessment completed [DATE] - skin assessment completed - 15 days between assessments. Review of Resident #1's Weekly Wound Evaluations revealed the following: [DATE] - a stage II pressure ulcer was noted to the right buttock [DATE] - a stage III pressure ulcer was noted to the right elbow Both wounds were found in the 19 days of missed weekly skin assessments between [DATE] and [DATE]. [DATE] - a Deep Tissue Injury (DTI) was noted to the right heel [DATE] - an Unstageable pressure ulcer was noted to the left heel Both wounds were found in the 28 days of missed weekly skin assessments between [DATE] and [DATE]. Review of Resident #1's medical record revealed a nurses note dated [DATE], that stated, the wound on Resident #1's left heel now has an odor and is being cultured. This occurred in the 14 days of missed weekly skin assessments between [DATE] and [DATE]. On [DATE], Resident #1 received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the Weekly Wound Evaluations revealed on [DATE] a new Suspected Deep Tissue Injury (SDTI) was noted to his right lateral heel. This wound was found during the 20 days of missed skin assessments between [DATE] and [DATE]. On [DATE], at 3:40 PM, wound care was observed for Resident #1's multiple wounds to his bilateral feet and sacrum. All wounds appear clean and are healing. There are no signs and symptoms currently of infection. There was no break in infection control techniques by RN #1, and the resident did not appear to experience any discomfort during the treatment session. Review of Resident #1's Minimum Data Set (MDS) assessments revealed he had not been discharged from the facility since February of 2020, which would have equated for missed weekly assessments. During an interview with the Director of Nursing (DON) on [DATE], at 2:45 PM, she stated the nurses were supposed to do a skin assessment weekly as part of the assessments within the Long Term Care Evaluations. She reviewed the Skin Assessment Log with the State Agency (SA) and verified there were several weeks between assessments, and there were no other places within the chart the documentation should occur. She indicated there seemed to be a pattern to the missed assessment, and that his wounds were all found within the weeks the assessments were not completed. During an interview with the MDS/Care Plan nurse, she stated there was no other place within the electronic medical record for the nurses to document weekly skin assessments other than within the Long Term Care Evaluation V4 assessment, unless they were a skilled resident, and Resident #1 was not skilled. The facility's failure to do weekly skin assessments for Resident #1 resulted in a Stage II pressure ulcer to his right buttock, a stage III pressure ulcer to his right elbow, Deep Tissue Injury (DTI) pressure ulcer to his right heel, and an unstageable pressure ulcer to his left heel that became infected and required antibiotics for 14 days. Review of the Admission Record for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review Resident #1's last annual MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of five (5). Resident #1 required total assistance of two staff members for his Activities of Daily Living (ADL's). Resident #1 is always incontinent of bowel and bladder.

Based on observation, staff interview, resident interview, and facility policy review, the facility failed to ensure Resident #82 rinsed his mouth out after the administration of a Metered-Dose Inhaler to prevent possible mouth and throat irritation. This was identified for one of two (1 of 2) residents observed for metered dose inhaler administration. Findings include: Review of the facility's policy titled, Medication Administration Guidelines, Oral Inhalation Administration, Revised 7/2019, revealed Purpose: TO allow for correct administration of oral inhalers to residents, and for instruction in proper technique for those residents able to administer the medication to themselves. Procedure: O. Have resident rinse his/her mouth and spit out the water. Review of Nursing Skills and Procedures, Perry and Potter, Eighth Edition, revealed page 274 #16 revealed: About 2 minutes after the last dose, instruct patient to rinse mouth with warm water and expel water. Inhaled [MEDICATION NAME][MEDICATION NAME] may cause dry mouth and taste alterations. Corticosteroids may alter flora of oral mucosa and lead to development of fungal infection. Review of the WebMD website, on 9/11/19 at 4:05 PM, titled, [MEDICATION NAME] Mist Inhaler, revealed: Rinse your mouth after using the inhaler to prevent dry mouth and throat irritation. On 8/27/19 at 10:54 AM, an observation during the medication administration pass revealed Licensed Practical Nurse (LPN) #1 administered [MEDICATION NAME] Respimat inhaler two (2) puffs to Resident #82, and failed to ask Resident #82 to rinse his mouth after administration of the inhaler. A review of Resident #82's Physician Orders, dated (MONTH) 27, 2019, revealed Resident #82 had orders for [MEDICATION NAME] Respimat Aerosol Solution 20-100 micrograms (mcg) two (2) puffs inhale orally three times a day related to [MEDICAL CONDITIONS]. Have resident to rinse mouth after inhalation and spit out rinse water. On 08/27/19 at 11:30 AM, an interview with LPN #1 confirmed she did not ask the resident to rinse his mouth after the administration of his inhaler. She stated she usually asked and the resident says no, and she didn't ask today. LPN #1 stated its important to rinse your mouth after the inhaler because residue will build up and it can lead to thrush and other complications. On 08/27/19 at 4:40 PM, an interview with the Director of Nursing (DON), revealed the facility had an in-service on administration of medications and the nurses were reminded at that time to have residents rinse their mouth after any inhaler treatments. The DON stated this is important to prevent adverse effects of the inhaler. Review of Resident #82's Care Plan, no date, revealed a Focus for [MEDICAL CONDITION] and Allergy Rhinitis. The Interventions/Tasks included [MEDICATION NAME] Respimat Aerosol Solution 20-100 micrograms (mcg) two (2) puffs inhale orally three times a day. The Care Plan did not address the need to rinse the mouth after the inhaler administration. A review of the Inservice Education, titled, Medication Administration Update, held on 8/9/19, revealed LPN #1 attended this in-service. Review of the Face Sheet revealed the facility admitted Resident #82, on 10/26/15, with the included [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/13/19, revealed Resident #82's Basis Interview for Mental Status (BIMS) score was 13, which indicated his cognition was intact.

Based on record review, staff interview, and facility policy review, the facility failed to notify the Physician of critical lab values for one (1) of four (4) resident's lab values reviewed, Resident #58. Labs were ordered for Resident #58 on [DATE], and drawn on [DATE], due to the resident's decline in mental/physical function. On [DATE], at approximately 1:05 AM, Registered Nurse (RN) #2 was notified per phone, by the laboratory, of critical values for Resident #58. Lab values included Blood Urea Nitrogen (BUN) elevated at 213 (normal value range is ,[DATE]), Creatinine elevated at 7.1 (normal value range is 0XXX,[DATE].3), and Potassium elevated at 8.2 (normal value range is 3XXX,[DATE].1). RN #2 did not report these critical labs to the Physician, but indicated that she would report these critical lab values to the oncoming shift in the morning. Approximately four (4) and one half (,[DATE]) hours later, on [DATE] at 5:36 AM, RN #2 was called to Resident #58's room by Certified Nursing Assistant (CNA) #1 and found the resident unresponsive and without a pulse or respirations. RN #2 notified the Coroner at 5:40 AM; Resident #58 expired in the facility. The facility's failure to notify the Physician of these critical lab values, when received, in order for the resident to receive appropriate treatment, placed this resident and other residents, who received any critical lab values, in a situation that was likely to cause serious injury, harm, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) that began on [DATE], when critical lab values were not reported to the Physician, when received, for Resident #58. The facility Administrator was notified of the IJ on [DATE]. The State Agency (SA) received an acceptable credible Allegation of Compliance (A[NAME]) on [DATE], in which the facility alleged all corrective actions were completed on [DATE], and the IJ removed as of [DATE]. The SA validated the A[NAME] and determined the IJ to be removed as of [DATE], prior to exit. Therefore the scope and severity for IJ at 42 CFR:483.50(a)(2)(i)(ii)-Lab Services (F773) was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy, Lab Notification to Medical Staff, revised ,[DATE], revealed: It is the standard of this facility to timely notify the Physician, Physician Assistant, Nurse Practitioner (NP) or Clinical Nurse Specialist of lab results. Review of a Nurse's Note, dated [DATE] at 6:13 PM, revealed: Situation: Resident noted with increased drowsiness and decline. Recommendation: NP called and new orders received for U/A (Urinalysis), CBC (Complete Blood Count, and CMP (Comprehensive Metabolic Panel). The Responsible Party (RP) was called and informed. Author: RN #6-Unit Manager. Review of RN #2's Nurse's Note, dated [DATE] at 2:35 AM, revealed: Lab called at 1:05 AM reporting that Resident #58 had critical values, BUN elevated at 213, Creatinine 7.1, and Potassium 8.2, will notify oncoming staff in AM for further treatment orders and continue to monitor. In a phone interview with RN #2, on [DATE] at 2:47 PM, she stated, Around 1:05 AM, the lab called and reported critical lab and she said they would have the paperwork sent over. I went down there and checked on him. He was resting. I documented that I would report in the morning on the lab instead of disturbing the doctor. This surveyor asked what the facility's procedure is for reporting critical lab values, she stated, During the day, it's pretty much notify when they call it in. On the night shift, depending on if its any distress or anything, they would pass it on and let them take care of it in the morning. When asked if she compared the lab results called in on [DATE] with any previous lab, she stated, No, I don't even know where I could go to look at any lab. It's not on the chart that I know of. I don't know how to go in the system and pull up lab work or anything. When asked what the possible complications of a critically high Potassium (K+) might be, RN #2 stated, [MEDICAL CONDITION], increased heart rate. She stated the Potassium level of 8.2 millimoles per litre (MMOL/L) would be considered critical, and after what happened to Resident #58, she stated she wished she would have called the Physician with the lab results. In an interview with Resident #58's Medical Doctor (MD), on [DATE], at 1:40 PM, he revealed that he was not notified of the critical lab values for Potassium, Blood Urea Nitrogen (BUN) and Creatinine until a few minutes prior to the interview, by the Nurse Practitioner. When asked if he felt that he should have been notified, he stated, Yes, myself or my Nurse Practitioner should have been notified immediately. The MD stated, I would have sent him to the hospital. Upon review of the lab from [DATE] and [DATE], he stated, He had perfectly normal kidney function in June. The labs don't appear that he was dehydrated. I can't say why he went into [MEDICAL CONDITION] within three (3) months. In an interview with the DON, on [DATE], at 3:20 PM, she revealed that any critical labs should be reported immediately and that any nurse could call the MD or Nurse Practitioner. She stated, I don't know why she didn't report it. When asked what possible complications could occur with a Potassium of 8.2 MMOL/L, she stated side effects from [MEDICAL CONDITION], nausea, vomiting, rapid heart rate, and the heart could stop. She stated that RN #2 had completed an annual competency check off which included physician notification of lab values and that RN #2 knew to notify the MD, but failed to do so. She confirmed that RN #2 did not follow facility policy related to reporting of labs to the MD. During an interview on [DATE] at 5:40 PM, the Administrator revealed that he was made aware by the DON, This morning, that critical lab results were not reported to the MD at the time the lab reported them to the Nurse. He said he did not understand why RN #2 didn't call the doctor and that he couldn't believe she was an RN and didn't act on that. He confirmed that the facility policy of reporting labs was not followed by RN #2 for Resident #58's critical labs. In an interview on [DATE] at 11:10 AM, Speech Language Pathologist #1 (SLP) stated (concerning Resident #58), He did great with Physical Therapy Thursday ([DATE]). Monday ([DATE]), he was shaking and pocketing food. We had to finger dig it out of his cheek. We tried pureed as a trial, but he could not initiate a swallow. SLP #2 called the Charge Nurse down during the evaluation because he was so tremulous. She assessed him, talked to his family, told them they had already drawn labs on him and were aware of the shaking. It was a slow shake. He'd never done that before. She stated that his family was present during most of the Evaluation. An interview with RN #6, Unit Manager, on [DATE] at 10:15 AM, revealed that she took an order from the NP, on [DATE], due to the resident exhibiting increased drowsiness and decline. She stated that she first noticed the change in him the morning of [DATE]. She stated, He was more drowsy than normal. He was fully conscious with in and out drowsiness. During an interview with LPN #4, Medication Nurse, on [DATE], at 3:03 PM, she stated, He just looked really drowsy and declined on Monday. Review of the Employee Competency Standard, Type: Annual, revealed that RN#2 completed the competency which included Identification of Changes in Condition .Lab values, Physician notification on [DATE]. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE], for the IJ. Review of the facility's A[NAME] revealed the facility took the following actions to remove the IJ: Brief Summary of Events: On [DATE], at 5:40 PM, the State Agent notified the facility of an immediate Jeopardy regarding Resident #58, a full code resident, due to failure to provide Cardio-Pulmonary Resuscitation (CPR) in a timely manner per physician order, advance directives, and care plan; and critical lab values were not reported to the Physician when the labs were received. Resident #58 expired. Registered Nurse (RN) #2 was made aware of critical values for Resident #58 on [DATE], at approximately 1:00 AM. Lab values included Blood Urea Nitrogen (BUN) elevated at 213 (normal value range is ,[DATE]), Creatinine elevated at 7.1 (normal value range is 0XXX,[DATE].3), and Potassium elevated at 8.2 (normal value range is 3XXX,[DATE].1). RN #2 did not report these critical labs to the Physician, but indicated that she would report lab values to oncoming shift. On [DATE], at 5:36 AM, RN #2 was called to Resident #58's room by Certified Nursing Assistant (CNA) #1. Resident was unresponsive and without a pulse or respiration. RN #2 notified the Coroner at 5:40 AM. CPR was not initiated until 5:48 AM. This was a lapse of approximately ,[DATE] minutes before CPR was initiated to Resident #58. At 6:17 AM, the Director of Nursing (DON) was notified of Resident #58's death. Facility Actions: 1. On [DATE], at 11:30 AM, a 100 percent (%) audit of all critical labs for the month of (MONTH) (2018) was performed by the Medical Records Director, with no other issues found. 2. On [DATE], at 12:00 PM, an audit of RN #2's employee file was completed by the DON. The audit revealed Annual Employee Competency check-offs were completed on [DATE], and that RN #2 had received training on Abuse and Neglect, Lab values, Physician Notification, Physical Assessment, CPR, Crash Cart Overview, Emergency Codes, Documentation, and Care Plans. 3. On [DATE], at 5:45 PM, the facility's Emergency Response Management, Lab Notification to Medical Staff, Freedom of Abuse and Neglect, and Advance Directives standards were reviewed by the Administrator and Director of Nursing; no revisions were made. 4. On [DATE], at 6:30 PM, an Emergency Quality Assurance (QA) Meeting was held at the facility with the Administrator, Director of Nursing, Unit Managers, Nurse Educator, Minimum Data Set (MDS) Coordinator, Minimum Data Set Nurse, Admission Coordinator, Business Office Manager, Rehabilitation Manager, Medical Record Director, Social Service Director, Environmental Service Director, Plant Operations Manager, Dietary Manager, and Restorative LPN. The Medical Director and Resident #58's Primary Physician attended the meeting via phone. The following items were discussed: Reporting critical lab values immediately to the Physician and initiating CPR immediately when a resident is found without a pulse and respirations. The QA team recommended continuing in-services and chart audits. 5. On [DATE], at 7:00 PM, the DON reviewed Resident #58's Advance Directive, Care Plan, and Physician Orders. No revisions were made and it was determined that Resident #58 was a full code. 6. On [DATE], at 7:05 PM, RN #2 was in-serviced by the DON on Abuse and Neglect, Following Resident Care Plans, Advance Directives, and Critical Lab reporting to the Medical Doctor. On [DATE], at 7:05 PM, RN #2 was suspended by the DON and Nurse Educator (NE) due to failure to notify the Physician of critical lab values and failure to initiate CPR when Resident #58 was found without a pulse and respiration, per facility protocol. 7. On [DATE], at 8:30 PM, a 100% audit of all resident's Advance Directives and Advance Directives Care Plans was completed by Unit Manager #1, MDS Coordinator, and MDS LPN to ensure accuracy. No issues were found. 8. On [DATE], at 7:00 PM, a 100% audit of all critical labs for the last three (3) months was performed by the Director of Nursing. No issues were found. 9. On [DATE], at 7:35 PM, a record review was performed by the MDS LPN for the seven (7) residents that expired in the facility in the last six (6) months to ensure accuracy of Advance Directives and that the Advance Directive Care Plan was followed. No issues were found. 10. The following in-service education was provided to staff: *On [DATE], at 2:00 PM, an in-service was initiated by the DON and NE for RNs and LPNs regarding the Critical Lab Notification to Medical Staff Standard, including notifying the Physician of any critical lab value at the time it is received. Twelve of 17 RNs and 12 of 22 LPNs have been in-serviced. *On [DATE], at 2:00 PM, an in-service was initiated by the DON and NE for RNs and LPNs on Emergency Response-CPR, to include initiating CPR immediately when a resident is found without a pulse or respirations and following the resident plan of care for Advance Directives. Twelve of 17 RNs and 12 of 22 LPNs have been in-serviced. *On [DATE], at 6:00 PM, an in-service was initiated by the DON and NE for all staff on the Freedom of Abuse Standard, to include following Advance Directives and if a resident is found without a pulse and respirations CPR must be started immediately and if not, it will be considered neglect. Four (4) of six (6) Administrative staff, 12 of 17 RNs, 12 of 22 LPNs, 25 of 54 CNAs, eight (8) of 12 Dietary staff, five (5) of ten (10) Housekeeping staff, two (2) of three (3) Laundry Staff, and two (2) of two (2) Plant Operations staff have been in-serviced. *No staff will be allowed to work until the in-service education is completed. 11. On [DATE], at 3:00 PM, the Attorney General was notified of the incident by the Director of Nursing. 12. On [DATE], at 4:00 PM, the State Department of Health was notified of the incident by the Director of Nursing. 13. On [DATE], at 7:20 PM, the Mississippi Board of Nursing was notified of the incident by the Director of Nursing. 14. The facility concludes that all corrective actions were completed as of [DATE], and the Immediate Jeopardy was removed on [DATE]. On [DATE], the State Agency (SA) validated the facility's A[NAME] by staff interviews, record reviews, review of in-service sign-in sheets, and review of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ: 1. The SA validated through interview with the DON and record review that a 100% audit of all critical labs for the month of (MONTH) was performed by the Medical Records Director on [DATE], with no other issues found. 2. The SA validated through interview with the DON and record review that an audit of RN #2's employee file was completed by the DON on [DATE]. The audit revealed Annual Employee Competency check-offs was completed on [DATE], and that RN #2 had received training on Abuse and Neglect, Lab values, Physician Notification, Physical Assessment, CPR, Crash Cart Overview, Emergency Codes, Documentation, and Care Plans. 3. The SA validated through interview with the DON and record review that the facility's Emergency Response Management, Lab Notification to Medical Staff, Freedom of Abuse and Neglect, and Advance Directives standards were reviewed by the Administrator and Director of Nursing on [DATE]; no revisions were made. 4. The SA validated through interview with the DON and record review of the staff sign-in sheet and agenda, that an Emergency QA Meeting was held at the facility on [DATE], with the Administrator, Director of Nursing, Unit Managers, Nurse Educator, Minimum Data Set (MDS) Coordinator, Minimum Data Set Nurse, Admission Coordinator, Business Office Manager, Rehabilitation Manager, Medical Record Director, Social Service Director, Environmental Service Director, Plant Operations Manager, Dietary Manager, and Restorative LPN. The Medical Director and Resident #58's Primary Physician attended meeting via phone. The following items were discussed: reporting critical lab values immediately to the Physician and initiating CPR immediately when a resident is found without a pulse and respirations. The QA team recommended continuing in-services and chart audits, which were validated. 5. The SA validated through interview with the DON and record review that the DON reviewed Resident #58's Advance Directive, Care Plan, and Physician Orders on [DATE]. No revisions were made and it was determined that Resident #58 was a full code. 6. The SA validated through interview with the DON and document review that RN #2 was in-serviced by the DON on Abuse and Neglect, Following Residents Care Plan, Advance Directives, and Critical Lab reporting to Medical Doctor. The SA validated RN #2 was suspended on [DATE], due to failure to notify the Physician of critical lab values and failure to initiate CPR when Resident #58 was found without a pulse and respirations, per facility protocol. 7. The SA validated through interview with the DON and MDS Coordinator, and record review, that a 100% audit of all resident's Advance Directives and Advance Directives Care Plans was completed on [DATE], by Unit Manager #1, MDS Coordinator, and MDS LPN to ensure accuracy. No issues were found. 8. The SA validated through interview with the DON and record review, that a 100% audit of all critical labs for the last three (3) months was performed by the Director of Nursing on [DATE]. No issues were found. 9. The SA validated through interview with the DON and MDS LPN, that a record review was performed by the MDS LPN on [DATE], for the seven (7) residents that expired in the facility in the last six (6) months to ensure accuracy of Advance Directives and that the Advance Directive Care Plan was followed. No issues were found. Review of the medical records of the seven (7) residents, confirmed no issues with Advance Directives. 10. The SA validated the following in-service education was provided to staff: *The SA validated through random staff interviews, interview with the DON, and record review that on [DATE], an in-service was initiated by the DON and NE for RNs and LPNs regarding the Critical Lab Notification to Medical Staff Standard, including notifying the Physician of any critical lab value at the time it is received. The SA verified that 12 of 17 RNs and 12 of 22 LPNs had been in-serviced. *The SA validated through interview with the DON, random staff interviews, and record review that on [DATE], an in-service was initiated by the DON and NE for RNs and LPNs on Emergency Response-CPR, to include initiating CPR immediately when a resident is found without a pulse or respirations and following the resident's plan of care for Advance Directives. The SA confirmed that 12 of 17 RNs and 12 of 22 LPNs had been in-serviced. *The SA validated through interview with the DON, random staff interviews, and record review, that on [DATE], an in-service was initiated by the DON and NE for all staff on Freedom of Abuse Standard, to include following Advance Directives and if a resident is found without a pulse and respirations CPR must be started immediately, and if not, it will be considered neglect. The SA confirmed four (4) of six (6) Administrative staff, 12 of 17 RNs, 12 of 22 LPNs, 25 of 54 CNAs, eight (8) of 12 Dietary staff, five (5) of ten (10) Housekeeping staff, two (2) of three (3) Laundry Staff, two (2) of two (2) Plant Operations staff had been in-serviced. *The SA validated through staff interview, interview with the DON, and review of the employee roster, that no staff was allowed to work until the in-service education was completed. 11. The SA validated through interview with the DON and document review that on [DATE], the Attorney General was notified of the incident by the Director of Nursing. 12. The SA validated through interview with the DON and document review that on [DATE], the State Department of Health was notified of the incident by the Director of Nursing. 13. The SA validated through interview with the DON and document review, that on [DATE], the Mississippi Board of Nursing was notified of incident by the Director of Nursing. 14. The SA validated that all corrective actions to remove the IJ had been completed as of [DATE], and the IJ removed on [DATE], prior to exit.

Based on staff interview, facility policy review, and record review, the facility failed to initiate Cardio-Pulmonary Resuscitation (CPR) in a timely manner for one (1) of eight (8) residents, that expired in the facility within the past six (6) months, Resident #58. Resident #58 had an order and Advance Directive for full code status and was found on [DATE] at 5:36 AM without pulse or respiration. CPR was not initiated until approximately 12 minutes later, at 5:48 AM. Equipment was not readily available (the back board and oxygen adaptor was not on the crash cart when it was taken to the room) to initiate the CPR, which also delayed the procedure. Resident #58 had elected and had orders for a full code status, CPR was not initiated timely, and the resident expired in the facility. The facility's failure to initiate CPR in a timely manner on a resident with an order for [REDACTED].#58. The facility Administrator was notified of the IJ on [DATE]. The State Agency (SA) received an acceptable credible Allegation of Compliance (A[NAME]) on [DATE], in which the facility alleged that all corrective actions were completed as of [DATE], and the Immediate Jeopardy was removed on [DATE]. The SA validated the facility's A[NAME] and determined the IJ to be removed as of [DATE], prior to exit. Therefore the scope and severity for IJ at 42 CFR(s):483.24(a)(3)-Cardio-Pulmonary Resuscitation (CPR), (F678) was lowered to a D, while the facility develops and implements a plan of correction and monitors effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy for Cardiopulmonary Resuscitation (CPR), revised ,[DATE], revealed the Standard of CPR: To ventilate and establish circulation on a resident with absence of respirations and pulse. Review of the Physician's Orders for (MONTH) (YEAR), revealed that Resident #58 had an order for [REDACTED]. Review of Registered Nurse (RN) #2's Nurse's Note, dated [DATE] at 5:49 AM, revealed that she was called to Resident #58's room by Certified Nursing Assistant (CNA) #1 at 5:36 AM. RN #2 noted that Resident #58 had no pulse or respiration. She documented that she notified the Coroner at 5:40 AM. CPR was initiated at 5:48 AM and 911 was called. The time lapse from finding the resident without vital signs of life, and initiating CPR, was 12 minutes. In an interview, per telephone, on [DATE], at 2:47 PM, RN #2 stated she was called to Resident #58's room by CNA #1 and the resident was lying on his back with no noticeable rise and fall of his chest. She stated that his hands were cool but his forearm was warm. She stated that she was in the resident's room for a few minutes and then went to the nurse's office where she looked at his chart, and the computer chart, and that was when she realized that he was a full code. She confirmed it was approximately ,[DATE] minutes between being called to the resident's room and the initiation of CPR. She state that Licensed Practical Nurse (LPN) #1, LPN #2, and LPN #3 started CPR after she verified the code status from the chart. She stated that she would not have know that the resident was a full code without looking at the chart. Interviews with LPN #1 on [DATE] at 3:40 PM, LPN #3 at 3:40 PM, and phone interview with LPN #2 at 4:20 PM, revealed that they did initiate CPR on Resident #58, but they were unsure about the time CPR was initiated. In a phone interview with LPN #2 on [DATE], at 4:20 PM, she stated that she assisted LPN #1 and LPN #3 perform CPR. She stated that the CPR board was not on the crash cart and that she had to go back down the hall to obtain it. She also stated that the oxygen adaptor for the Ambu Bag was not on the cart and that LPN #1 Ran out to get it. In an interview with the Director of Nursing (DON), on [DATE], at 5:05 PM, she stated that CPR should start immediately upon finding a resident unresponsive and determining that the resident is a full code. She stated that it would be neglectful to not start CPR immediately. She stated that a binder is kept on the crash cart with the code status of residents and that Medical Records kept it updated. In an interview with the Medical Doctor (MD), on [DATE] at 1:40 PM, he stated that CPR should begin as soon as possible after a [MEDICAL CONDITION] is found, if the resident is a full code. He acknowledged that Resident #58 did not receive CPR as directed by his full code status. On [DATE], at 10:25 AM, in a phone interview, CNA #1 stated at approximately 5:30 AM, she suspected Resident #58 had expired and she notified RN #2 to go to the room. She stated that she did not go back into Resident #58's room again. Review of the Order Summary Report for (MONTH) (YEAR), revealed the facility admitted Resident #58 on [DATE], with [DIAGNOSES REDACTED]. Record review revealed that RN #2 had a certificate of completion for CPR, AED (Automated External Defibrillator) & First Aid Course on [DATE]. The Employee Competency Standard, Type: Annual, record review revealed that RN #2 completed the competency, which included CPR, on [DATE]. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE], for the IJ. Review of the facility's A[NAME] revealed the facility took the following actions to remove the IJ: Brief Summary of Events: On [DATE], at 5:40 PM, the State Agent notified the facility of an immediate Jeopardy regarding Resident #58, a full code resident, due to failure to provide Cardio-Pulmonary Resuscitation (CPR) in a timely manner per physician order, advance directives, and care plan; and critical lab values were not reported to the Physician when the labs were received. Resident #58 expired. Registered Nurse (RN) #2 was made aware of critical values for Resident #58 on [DATE], at approximately 1:00 AM. Lab values included Blood Urea Nitrogen (BUN) elevated at 213 (normal value range is ,[DATE]), Creatinine elevated at 7.1 (normal value range is 0XXX,[DATE].3), and Potassium elevated at 8.2 (normal value range is 3XXX,[DATE].1). RN #2 did not report these critical labs to the Physician, but indicated that she would report lab values to oncoming shift. On [DATE], at 5:36 AM, RN #2 was called to Resident #58's room by Certified Nursing Assistant (CNA) #1. Resident was unresponsive and without a pulse or respiration. RN #2 notified the Coroner at 5:40 AM. CPR was not initiated until 5:48 AM. This was a lapse of approximately ,[DATE] minutes before CPR was initiated to Resident #58. At 6:17 AM, the Director of Nursing (DON) was notified of Resident #58's death. Facility Actions: 1. On [DATE], at 11:30 AM, a 100 percent (%) audit of all critical labs for the month of (MONTH) (2018) was performed by the Medical Records Director, with no other issues found. 2. On [DATE], at 12:00 PM, an audit of RN #2's employee file was completed by the DON. The audit revealed Annual Employee Competency check-offs were completed on [DATE], and that RN #2 had received training on Abuse and Neglect, Lab values, Physician Notification, Physical Assessment, CPR, Crash Cart Overview, Emergency Codes, Documentation, and Care Plans. 3. On [DATE], at 5:45 PM, the facility's Emergency Response Management, Lab Notification to Medical Staff, Freedom of Abuse and Neglect, and Advance Directives standards were reviewed by the Administrator and Director of Nursing; no revisions were made. 4. On [DATE], at 6:30 PM, an Emergency Quality Assurance (QA) Meeting was held at the facility with the Administrator, Director of Nursing, Unit Managers, Nurse Educator, Minimum Data Set (MDS) Coordinator, Minimum Data Set Nurse, Admission Coordinator, Business Office Manager, Rehabilitation Manager, Medical Record Director, Social Service Director, Environmental Service Director, Plant Operations Manager, Dietary Manager, and Restorative LPN. The Medical Director and Resident #58's Primary Physician attended the meeting via phone. The following items were discussed: Reporting critical lab values immediately to the Physician and initiating CPR immediately when a resident is found without a pulse and respirations. The QA team recommended continuing in-services and chart audits. 5. On [DATE], at 7:00 PM, the DON reviewed Resident #58's Advance Directive, Care Plan, and Physician Orders. No revisions were made and it was determined that Resident #58 was a full code. 6. On [DATE], at 7:05 PM, RN #2 was in-serviced by the DON on Abuse and Neglect, Following Resident Care Plans, Advance Directives, and Critical Lab reporting to the Medical Doctor. On [DATE], at 7:05 PM, RN #2 was suspended by the DON and Nurse Educator (NE) due to failure to notify the Physician of critical lab values and failure to initiate CPR when Resident #58 was found without a pulse and respiration, per facility protocol. 7. On [DATE], at 8:30 PM, a 100% audit of all resident's Advance Directives and Advance Directives Care Plans was completed by Unit Manager #1, MDS Coordinator, and MDS LPN to ensure accuracy. No issues were found. 8. On [DATE], at 7:00 PM, a 100% audit of all critical labs for the last three (3) months was performed by the Director of Nursing. No issues were found. 9. On [DATE], at 7:35 PM, a record review was performed by the MDS LPN for the seven (7) residents that expired in the facility in the last six (6) months to ensure accuracy of Advance Directives and that the Advance Directive Care Plan was followed. No issues were found. 10. The following in-service education was provided to staff: *On [DATE], at 2:00 PM, an in-service was initiated by the DON and NE for RNs and LPNs regarding the Critical Lab Notification to Medical Staff Standard, including notifying the Physician of any critical lab value at the time it is received. Twelve of 17 RNs and 12 of 22 LPNs have been in-serviced. *On [DATE], at 2:00 PM, an in-service was initiated by the DON and NE for RNs and LPNs on Emergency Response-CPR, to include initiating CPR immediately when a resident is found without a pulse or respirations and following the resident plan of care for Advance Directives. Twelve of 17 RNs and 12 of 22 LPNs have been in-serviced. *On [DATE], at 6:00 PM, an in-service was initiated by the DON and NE for all staff on the Freedom of Abuse Standard, to include following Advance Directives and if a resident is found without a pulse and respirations CPR must be started immediately and if not, it will be considered neglect. Four (4) of six (6) Administrative staff, 12 of 17 RNs, 12 of 22 LPNs, 25 of 54 CNAs, eight (8) of 12 Dietary staff, five (5) of ten (10) Housekeeping staff, two (2) of three (3) Laundry Staff, and two (2) of two (2) Plant Operations staff have been in-serviced. *No staff will be allowed to work until the in-service education is completed. 11. On [DATE], at 3:00 PM, the Attorney General was notified of the incident by the Director of Nursing. 12. On [DATE], at 4:00 PM, the State Department of Health was notified of the incident by the Director of Nursing. 13. On [DATE], at 7:20 PM, the Mississippi Board of Nursing was notified of the incident by the Director of Nursing. 14. The facility concludes that all corrective actions were completed as of [DATE], and the Immediate Jeopardy was removed on [DATE]. On [DATE], the State Agency (SA) validated the facility's A[NAME] by staff interviews, record reviews, review of in-service sign-in sheets, and review of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ: 1. The SA validated through interview with the DON and record review that a 100% audit of all critical labs for the month of (MONTH) was performed by the Medical Records Director on [DATE], with no other issues found. 2. The SA validated through interview with the DON and record review that an audit of RN #2's employee file was completed by the DON on [DATE]. The audit revealed Annual Employee Competency check-offs was completed on [DATE], and that RN #2 had received training on Abuse and Neglect, Lab values, Physician Notification, Physical Assessment, CPR, Crash Cart Overview, Emergency Codes, Documentation, and Care Plans. 3. The SA validated through interview with the DON and record review that the facility's Emergency Response Management, Lab Notification to Medical Staff, Freedom of Abuse and Neglect, and Advance Directives standards were reviewed by the Administrator and Director of Nursing on [DATE]; no revisions were made. 4. The SA validated through interview with the DON and record review of the staff sign-in sheet and agenda, that an Emergency QA Meeting was held at the facility on [DATE], with the Administrator, Director of Nursing, Unit Managers, Nurse Educator, Minimum Data Set (MDS) Coordinator, Minimum Data Set Nurse, Admission Coordinator, Business Office Manager, Rehabilitation Manager, Medical Record Director, Social Service Director, Environmental Service Director, Plant Operations Manager, Dietary Manager, and Restorative LPN. The Medical Director and Resident #58's Primary Physician attended meeting via phone. The following items were discussed: reporting critical lab values immediately to the Physician and initiating CPR immediately when a resident is found without a pulse and respirations. The QA team recommended continuing in-services and chart audits, which were validated. 5. The SA validated through interview with the DON and record review that the DON reviewed Resident #58's Advance Directive, Care Plan, and Physician Orders on [DATE]. No revisions were made and it was determined that Resident #58 was a full code. 6. The SA validated through interview with the DON and document review that RN #2 was in-serviced by the DON on Abuse and Neglect, Following Residents Care Plan, Advance Directives, and Critical Lab reporting to Medical Doctor. The SA validated RN #2 was suspended on [DATE], due to failure to notify the Physician of critical lab values and failure to initiate CPR when Resident #58 was found without a pulse and respirations, per facility protocol. 7. The SA validated through interview with the DON and MDS Coordinator, and record review, that a 100% audit of all resident's Advance Directives and Advance Directives Care Plans was completed on [DATE], by Unit Manager #1, MDS Coordinator, and MDS LPN to ensure accuracy. No issues were found. 8. The SA validated through interview with the DON and record review, that a 100% audit of all critical labs for the last three (3) months was performed by the Director of Nursing on [DATE]. No issues were found. 9. The SA validated through interview with the DON and MDS LPN, that a record review was performed by the MDS LPN on [DATE], for the seven (7) residents that expired in the facility in the last six (6) months to ensure accuracy of Advance Directives and that the Advance Directive Care Plan was followed. No issues were found. Review of the medical records of the seven (7) residents, confirmed no issues with Advance Directives. 10. The SA validated the following in-service education was provided to staff: *The SA validated through random staff interviews, interview with the DON, and record review that on [DATE], an in-service was initiated by the DON and NE for RNs and LPNs regarding the Critical Lab Notification to Medical Staff Standard, including notifying the Physician of any critical lab value at the time it is received. The SA verified that 12 of 17 RNs and 12 of 22 LPNs had been in-serviced. *The SA validated through interview with the DON, random staff interviews, and record review that on [DATE], an in-service was initiated by the DON and NE for RNs and LPNs on Emergency Response-CPR, to include initiating CPR immediately when a resident is found without a pulse or respirations and following the resident's plan of care for Advance Directives. The SA confirmed that 12 of 17 RNs and 12 of 22 LPNs had been in-serviced. *The SA validated through interview with the DON, random staff interviews, and record review, that on [DATE], an in-service was initiated by the DON and NE for all staff on Freedom of Abuse Standard, to include following Advance Directives and if a resident is found without a pulse and respirations CPR must be started immediately, and if not, it will be considered neglect. The SA confirmed four (4) of six (6) Administrative staff, 12 of 17 RNs, 12 of 22 LPNs, 25 of 54 CNAs, eight (8) of 12 Dietary staff, five (5) of ten (10) Housekeeping staff, two (2) of three (3) Laundry Staff, two (2) of two (2) Plant Operations staff had been in-serviced. *The SA validated through staff interview, interview with the DON, and review of the employee roster, that no staff was allowed to work until the in-service education was completed. 11. The SA validated through interview with the DON and document review that on [DATE], the Attorney General was notified of the incident by the Director of Nursing. 12. The SA validated through interview with the DON and document review that on [DATE], the State Department of Health was notified of the incident by the Director of Nursing. 13. The SA validated through interview with the DON and document review, that on [DATE], the Mississippi Board of Nursing was notified of incident by the Director of Nursing. 14. The SA validated that all corrective actions to remove the IJ had been completed as of [DATE], and the IJ removed on [DATE], prior to exit.

Based on record review, staff interview, and facility policy review, the facility failed to follow the comprehensive care plan for Advance Directives, provision of Cardiopulmonary Resuscitation (CPR) and reporting of critical lab values to the Medical Doctor for one (1) of 22 resident care plans reviewed, Resident #58. Registered Nurse (RN) #2 was notified of critical lab values for Resident #58 on [DATE], at approximately 1:05 AM. Resident #58's elevated critical lab values included: Blood Urea Nitrogen (BUN) was 213 (normal value range is ,[DATE]), Creatinine was 7.1 (normal value range is 0XXX,[DATE].3), and Potassium was 8.2 (normal value range is 3XXX,[DATE].1). RN #2 did not report these critical labs, per care plan, to the Physician. On [DATE], at 5:36 AM, RN #2 was called to Resident #58's room and noted the resident was without pulse or respirations. Resident #58 had a care plan for a full code directive, and Cardio-Pulmonary Resuscitation (CPR) was not initiated timely. CPR was not initiated until 5:48 AM, approximately 12 minutes after the resident was found without pulse or respiration. Resuscitation was not successful and Resident #58 expired in the facility. The facility's failure to follow the Care Plan for reporting of critical labs to the Medical Doctor (MD) and providing CPR in a timely manner, placed this resident and other residents with critical lab values and/or full code status in a situation that would likely cause serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ), which began on [DATE], when the facility failed to report critical lab values to the MD and failed to follow the Care Plan for Resident #58's full code status. The facility Administrator was notified of the IJ on [DATE]. The State Agency (SA) received an acceptable credible Allegation of Compliance (A[NAME]) on [DATE], in which the facility alleged that all corrective actions were completed as of [DATE], and the Immediate Jeopardy was removed on [DATE]. The SA determined the IJ to be removed as of [DATE], prior to exit. Therefore, the scope and severity for IJ at 42 CFR(s):483.21(b)(1)-Comprehensive Care Plan (F656) was lowered to a D, while the facility develops and implements a plan of correction and monitors effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility policy, provided by the Director of Nursing for Care Plans, revealed that the facility followed the Resident Assessment Instrument/Care Planning Management Process, revised ,[DATE], for their policy. This included implementation of the care plan. Review of the Care Plan, initiated on [DATE] and revised on [DATE], revealed Resident #58 had a full code status for CPR. Review of the Care Plan for [DIAGNOSES REDACTED] for Resident #58, initiated [DATE], revealed that he received Potassium Chloride (KCL) due to a [DIAGNOSES REDACTED]. Record review of RN #2's Nurse's Note, dated [DATE] at 2:35 AM, revealed the Lab called at 1:05 AM, reporting that Resident #58 had critical values, which included: BUN elevated at 213, Creatinine 7.1, and Potassium of 8.2, will notify oncoming staff in the AM for further treatment orders and continue to monitor. This note confirmed that significant, critical lab values, were not provided to the MD, per care plan. Review of Registered Nurse (RN) #2's Nurse's Note, dated [DATE], at 5:49 AM, revealed that she was called to Resident #58's room by Certified Nursing Assistant (CNA) #1 at 5:36 AM, and found Resident #58 unresponsive and without pulse or respiration. She documented that the Coroner was called at 5:40 AM, and CPR was initiated at 5:48 AM. This note confirmed that CPR was not initiated as ordered or care planned until approximately 12 minutes after Resident #58 was found without pulse or respiration. CPR was not successful and Resident #58 expired. In a phone interview on [DATE] at 2:47 PM, RN #2 confirmed that the lab had called her around 1:45 AM on the morning of [DATE], to report critical lab values of an elevated BUN of 213, Creatinine of 7.1, and Potassium of 8.2, for Resident #58. She confirmed she did not notify the MD, but decided to report the lab to the oncoming shift later that morning. She confirmed that Resident #58 was found without pulse or respiration on [DATE] at 5:36 AM, and CPR was not initiated for approximately ,[DATE] minutes later, after she confirmed from the medical record, that Resident #58 had orders and a care plan for a full code, which included CPR. In an interview with RN #3, Minimum Data Set (MDS) Coordinator, on [DATE], at 12:41 PM, she confirmed that RN #2 did not follow the care plans for Resident #58 for notifying the MD of the significant lab or providing CPR. She stated, The purpose of a care plan is to give them more of a picture of how to take care of the resident, what they need for their care. It paints a picture to give their care and better know what their deficits are and what they need help with. In an interview with Director of Nursing (DON), on [DATE], at 3:20 PM, she stated that the Care Plan for CPR was not followed in a timely manner and the care plan for reporting lab values was not followed by the nurse for Resident #58. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE], for the IJ. Review of the facility's A[NAME] revealed the facility took the following actions to remove the IJ: Brief Summary of Events: On [DATE], at 5:40 PM, the State Agent notified the facility of an immediate Jeopardy regarding Resident #58, a full code resident, due to failure to provide Cardio-Pulmonary Resuscitation (CPR) in a timely manner per physician order, advance directives, and care plan; and critical lab values were not reported to the Physician when the labs were received. Resident #58 expired. Registered Nurse (RN) #2 was made aware of critical values for Resident #58 on [DATE], at approximately 1:00 AM. Lab values included Blood Urea Nitrogen (BUN) elevated at 213 (normal value range is ,[DATE]), Creatinine elevated at 7.1 (normal value range is 0XXX,[DATE].3), and Potassium elevated at 8.2 (normal value range is 3XXX,[DATE].1). RN #2 did not report these critical labs to the Physician, but indicated that she would report lab values to oncoming shift. On [DATE], at 5:36 AM, RN #2 was called to Resident #58's room by Certified Nursing Assistant (CNA) #1. Resident was unresponsive and without a pulse or respiration. RN #2 notified the Coroner at 5:40 AM. CPR was not initiated until 5:48 AM. This was a lapse of approximately ,[DATE] minutes before CPR was initiated to Resident #58. At 6:17 AM, the Director of Nursing (DON) was notified of Resident #58's death. Facility Actions: 1. On [DATE], at 11:30 AM, a 100 percent (%) audit of all critical labs for the month of (MONTH) (2018) was performed by the Medical Records Director, with no other issues found. 2. On [DATE], at 12:00 PM, an audit of RN #2's employee file was completed by the DON. The audit revealed Annual Employee Competency check-offs were completed on [DATE], and that RN #2 had received training on Abuse and Neglect, Lab values, Physician Notification, Physical Assessment, CPR, Crash Cart Overview, Emergency Codes, Documentation, and Care Plans. 3. On [DATE], at 5:45 PM, the facility's Emergency Response Management, Lab Notification to Medical Staff, Freedom of Abuse and Neglect, and Advance Directives standards were reviewed by the Administrator and Director of Nursing; no revisions were made. 4. On [DATE], at 6:30 PM, an Emergency Quality Assurance (QA) Meeting was held at the facility with the Administrator, Director of Nursing, Unit Managers, Nurse Educator, Minimum Data Set (MDS) Coordinator, Minimum Data Set Nurse, Admission Coordinator, Business Office Manager, Rehabilitation Manager, Medical Record Director, Social Service Director, Environmental Service Director, Plant Operations Manager, Dietary Manager, and Restorative LPN. The Medical Director and Resident #58's Primary Physician attended the meeting via phone. The following items were discussed: Reporting critical lab values immediately to the Physician and initiating CPR immediately when a resident is found without a pulse and respirations. The QA team recommended continuing in-services and chart audits. 5. On [DATE], at 7:00 PM, the DON reviewed Resident #58's Advance Directive, Care Plan, and Physician Orders. No revisions were made and it was determined that Resident #58 was a full code. 6. On [DATE], at 7:05 PM, RN #2 was in-serviced by the DON on Abuse and Neglect, Following Resident Care Plans, Advance Directives, and Critical Lab reporting to the Medical Doctor. On [DATE], at 7:05 PM, RN #2 was suspended by the DON and Nurse Educator (NE) due to failure to notify the Physician of critical lab values and failure to initiate CPR when Resident #58 was found without a pulse and respiration, per facility protocol. 7. On [DATE], at 8:30 PM, a 100% audit of all resident's Advance Directives and Advance Directives Care Plans was completed by Unit Manager #1, MDS Coordinator, and MDS LPN to ensure accuracy. No issues were found. 8. On [DATE], at 7:00 PM, a 100% audit of all critical labs for the last three (3) months was performed by the Director of Nursing. No issues were found. 9. On [DATE], at 7:35 PM, a record review was performed by the MDS LPN for the seven (7) residents that expired in the facility in the last six (6) months to ensure accuracy of Advance Directives and that the Advance Directive Care Plan was followed. No issues were found. 10. The following in-service education was provided to staff: *On [DATE], at 2:00 PM, an in-service was initiated by the DON and NE for RNs and LPNs regarding the Critical Lab Notification to Medical Staff Standard, including notifying the Physician of any critical lab value at the time it is received. Twelve of 17 RNs and 12 of 22 LPNs have been in-serviced. *On [DATE], at 2:00 PM, an in-service was initiated by the DON and NE for RNs and LPNs on Emergency Response-CPR, to include initiating CPR immediately when a resident is found without a pulse or respirations and following the resident plan of care for Advance Directives. Twelve of 17 RNs and 12 of 22 LPNs have been in-serviced. *On [DATE], at 6:00 PM, an in-service was initiated by the DON and NE for all staff on the Freedom of Abuse Standard, to include following Advance Directives and if a resident is found without a pulse and respirations CPR must be started immediately and if not, it will be considered neglect. Four (4) of six (6) Administrative staff, 12 of 17 RNs, 12 of 22 LPNs, 25 of 54 CNAs, eight (8) of 12 Dietary staff, five (5) of ten (10) Housekeeping staff, two (2) of three (3) Laundry Staff, and two (2) of two (2) Plant Operations staff have been in-serviced. *No staff will be allowed to work until the in-service education is completed. 11. On [DATE], at 3:00 PM, the Attorney General was notified of the incident by the Director of Nursing. 12. On [DATE], at 4:00 PM, the State Department of Health was notified of the incident by the Director of Nursing. 13. On [DATE], at 7:20 PM, the Mississippi Board of Nursing was notified of the incident by the Director of Nursing. 14. The facility concludes that all corrective actions were completed as of [DATE], and the Immediate Jeopardy was removed on [DATE]. On [DATE], the State Agency (SA) validated the facility's A[NAME] by staff interviews, record reviews, review of in-service sign-in sheets, and review of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ: 1. The SA validated through interview with the DON and record review that a 100% audit of all critical labs for the month of (MONTH) was performed by the Medical Records Director on [DATE], with no other issues found. 2. The SA validated through interview with the DON and record review that an audit of RN #2's employee file was completed by the DON on [DATE]. The audit revealed Annual Employee Competency check-offs was completed on [DATE], and that RN #2 had received training on Abuse and Neglect, Lab values, Physician Notification, Physical Assessment, CPR, Crash Cart Overview, Emergency Codes, Documentation, and Care Plans. 3. The SA validated through interview with the DON and record review that the facility's Emergency Response Management, Lab Notification to Medical Staff, Freedom of Abuse and Neglect, and Advance Directives standards were reviewed by the Administrator and Director of Nursing on [DATE]; no revisions were made. 4. The SA validated through interview with the DON and record review of the staff sign-in sheet and agenda, that an Emergency QA Meeting was held at the facility on [DATE], with the Administrator, Director of Nursing, Unit Managers, Nurse Educator, Minimum Data Set (MDS) Coordinator, Minimum Data Set Nurse, Admission Coordinator, Business Office Manager, Rehabilitation Manager, Medical Record Director, Social Service Director, Environmental Service Director, Plant Operations Manager, Dietary Manager, and Restorative LPN. The Medical Director and Resident #58's Primary Physician attended meeting via phone. The following items were discussed: reporting critical lab values immediately to the Physician and initiating CPR immediately when a resident is found without a pulse and respirations. The QA team recommended continuing in-services and chart audits, which were validated. 5. The SA validated through interview with the DON and record review that the DON reviewed Resident #58's Advance Directive, Care Plan, and Physician Orders on [DATE]. No revisions were made and it was determined that Resident #58 was a full code. 6. The SA validated through interview with the DON and document review that RN #2 was in-serviced by the DON on Abuse and Neglect, Following Residents Care Plan, Advance Directives, and Critical Lab reporting to Medical Doctor. The SA validated RN #2 was suspended on [DATE], due to failure to notify the Physician of critical lab values and failure to initiate CPR when Resident #58 was found without a pulse and respirations, per facility protocol. 7. The SA validated through interview with the DON and MDS Coordinator, and record review, that a 100% audit of all resident's Advance Directives and Advance Directives Care Plans was completed on [DATE], by Unit Manager #1, MDS Coordinator, and MDS LPN to ensure accuracy. No issues were found. 8. The SA validated through interview with the DON and record review, that a 100% audit of all critical labs for the last three (3) months was performed by the Director of Nursing on [DATE]. No issues were found. 9. The SA validated through interview with the DON and MDS LPN, that a record review was performed by the MDS LPN on [DATE], for the seven (7) residents that expired in the facility in the last six (6) months to ensure accuracy of Advance Directives and that the Advance Directive Care Plan was followed. No issues were found. Review of the medical records of the seven (7) residents, confirmed no issues with Advance Directives. 10. The SA validated the following in-service education was provided to staff: *The SA validated through random staff interviews, interview with the DON, and record review that on [DATE], an in-service was initiated by the DON and NE for RNs and LPNs regarding the Critical Lab Notification to Medical Staff Standard, including notifying the Physician of any critical lab value at the time it is received. The SA verified that 12 of 17 RNs and 12 of 22 LPNs had been in-serviced. *The SA validated through interview with the DON, random staff interviews, and record review that on [DATE], an in-service was initiated by the DON and NE for RNs and LPNs on Emergency Response-CPR, to include initiating CPR immediately when a resident is found without a pulse or respirations and following the resident's plan of care for Advance Directives. The SA confirmed that 12 of 17 RNs and 12 of 22 LPNs had been in-serviced. *The SA validated through interview with the DON, random staff interviews, and record review, that on [DATE], an in-service was initiated by the DON and NE for all staff on Freedom of Abuse Standard, to include following Advance Directives and if a resident is found without a pulse and respirations CPR must be started immediately, and if not, it will be considered neglect. The SA confirmed four (4) of six (6) Administrative staff, 12 of 17 RNs, 12 of 22 LPNs, 25 of 54 CNAs, eight (8) of 12 Dietary staff, five (5) of ten (10) Housekeeping staff, two (2) of three (3) Laundry Staff, two (2) of two (2) Plant Operations staff had been in-serviced. *The SA validated through staff interview, interview with the DON, and review of the employee roster, that no staff was allowed to work until the in-service education was completed. 11. The SA validated through interview with the DON and document review that on [DATE], the Attorney General was notified of the incident by the Director of Nursing. 12. The SA validated through interview with the DON and document review that on [DATE], the State Department of Health was notified of the incident by the Director of Nursing. 13. The SA validated through interview with the DON and document review, that on [DATE], the Mississippi Board of Nursing was notified of incident by the Director of Nursing. 14. The SA validated that all corrective actions to remove the IJ had been completed as of [DATE], and the IJ removed on [DATE], prior to exit.

Based on record review, staff interview, and facility policy review, the facility failed to ensure a resident was free of neglect and provided the necessary care and services to avoid physical harm, as evidenced by failure to notify the Physician of critical lab values for one (1) of four (4) residents review with critical lab values; and failure to initiate Cardio-Pulmonary Resuscitation (CPR) in a timely manner for one (1) of eight (8) residents reviewed that expired in the facility within the last six (6) months, Resident #58. On [DATE], at approximately 1:05 AM, Registered Nurse #2 (RN) was notified by the lab of critical lab values for Resident #58. The critical values included Blood Urea Nitrogen (BUN), which was elevated at 213 (normal value range is ,[DATE]), Creatinine elevated at 7.1 (normal value range is 0XXX,[DATE].3), and Potassium elevated at 8.2 (normal value range is 3XXX,[DATE].1). RN #2 did not report these critical labs to the Physician, but documented that she would report the lab values to the oncoming shift. On [DATE], at 5:36 AM, RN #2 was called to Resident #58's room by Certified Nursing Assistant (CNA) #1. Resident #58 was unresponsive and without a pulse or respiration. RN #2 notified the Coroner at 5:40 AM, and did not initiate a full code, which included CPR. Resident #58 expired in the facility. RN #2 failed to initiate CPR until 12 minutes after the resident was found unresponsive. Resident #58 had Physician's orders and a care plan for a full code status. The facility's failure to ensure a resident's right to be free from neglect, placed this and other residents with critical lab values and/or full code status, in a situation that would likely cause serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ), which began on [DATE], when the facility failed to report critical lab values to the MD. And, failed to ensure CPR was initiated timely for a full code resident. The facility Administrator was notified of the IJ on [DATE]. The facility submitted an acceptable credible Allegation of Compliance (A[NAME]) on [DATE], in which the facility alleged all corrective actions were completed as of [DATE], and the Immediate Jeopardy was removed on [DATE]. The SA validated the A[NAME] and determined the IJ to be removed as of [DATE], prior to exit. Therefore, the scope and severity for the IJ at 42 CFR(s):483.12(a)(1)-Freedom from Abuse/Neglect, (F600), was lowered to a D, while the facility develops and implements a plan of correction and monitors effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Freedom of Abuse, Neglect and Exploitation Policy, dated ,[DATE], revealed the Standard Statement: This facility shall not condone any acts of resident mistreatment, neglect, by any facility staff member . The policy also revealed the definition of neglect as: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility policy Lab Notification to Medical Staff, revised ,[DATE], revealed: It is the standard of this facility to timely notify the Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist of lab results. Review of the facility policy, Cardiopulmonary Resuscitation (CPR), Revised ,[DATE], revealed that the facility is to follow the Standard: To ventilate and establish circulation on a resident with absence of respirations and pulse. Record review of RN #2's Nurse's Note, dated [DATE] at 2:35 AM, revealed: Lab called at 1:05 AM reporting that Resident #58 had critical values, BUN elevated at 213, Creatinine 7.1 and Potassium 8.2, will notify oncoming staff in AM for further treatment orders and continue to monitor. During a phone interview with RN #2 on [DATE], at 2:47 PM, she confirmed that the lab had called the facility around 1:45 AM on the morning of [DATE], to report critical lab values of the BUN elevated at 213, Creatinine level of 7.1 and Potassium level of 8.2, for Resident #58. RN #2 stated she decided to report the lab to the oncoming shift later that morning. She stated she checked on the resident around 1:30 AM, and he was resting quietly. She stated she would consider these values critical, and that possible complications of a critically high Potassium would be [MEDICAL CONDITION] or increased heart rate. She stated that after what happened, she wished she had called the Physician at the time she received the lab values. She stated that on the night shift, critically high lab values are usually passed on to the day shift if the resident is not in any distress. In an interview with Resident #58's Medical Doctor (MD), on [DATE], at 1:40 PM, he stated that he was not notified of the critical lab values of Potassium, BUN and Creatinine for Resident #58 until, A few minutes ago, by my Nurse Practitioner, and that he should have been notified immediately of these results. He stated that he would have sent the resident to the hospital at that time. In an interview with the DON, on [DATE], at 3:20 PM, she revealed it was the policy of this facility to report any critical labs immediately and that any nurse could make the report. She stated that RN #2 had completed an annual competency check off which included physician notification of lab values and that RN #2 knew to notify the MD, but failed to do so. She confirmed that RN#2 did not follow facility policy related to reporting of labs to the MD. She stated that possible complications of critically high Potassium could include nausea, vomiting, rapid heart rate, and [MEDICAL CONDITION]. Record review of an Advanced Directive and Resident Rights form for Resident #58, dated [DATE], revealed documentation that the resident wished to be a full code. This was signed by the Responsible Party and the MD. Record review of the Physicians Orders for (MONTH) (YEAR), revealed that Resident #58 had an order for [REDACTED]. Review of Registered Nurse (RN) #2's Nurse's Note, dated [DATE], at 5:49 AM, revealed that RN #2 was called to Resident #58's room by Certified Nursing Assistant (CNA) #1 at 5:36 AM. Resident #58 was noted to be unresponsive and without pulse or respiration. She documented that the Coroner was called at 5:40 AM and CPR was initiated at 5:48 AM. This was approximately 12 minutes after Resident #58 was found without vital signs of life. On [DATE], at 2:47 PM, during a phone interview, RN #2 stated after she found Resident #58 without pulse or respiration, she called the Coroner, then checked Resident #58's medical record and computer information and discovered the resident was a full code, and CPR was initiated at 5:48 AM. She confirmed that it was approximately ,[DATE] minutes between when the resident was found unresponsive, and CPR was initiated. During an interview with the Director of Nursing (DON), on [DATE], at 5:05 PM, she stated, CPR should have been started immediately on this resident when he was found unresponsive. The DON confirmed that the Advance Directive for CPR for Resident #58 and the facility policy was not followed. In an interview with the DON, on [DATE], at 3:20 PM, she stated that RN #2 knew to notify the MD of critical lab values in a timely manner and to start CPR immediately, but failed to do so. The DON acknowledged this was neglectful to Resident #58. Review of the Employee Competency Standard, Type: Annual, revealed that on [DATE], RN #2 completed the following competencies: Identification of Changes in Condition, Lab values, Physician notification and CPR. Review of the Order Summary Report dated (MONTH) (YEAR), for Resident #58, revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE], for the IJ. Review of the facility's A[NAME] revealed the facility took the following actions to remove the IJ: Brief Summary of Events: On [DATE], at 5:40 PM, the State Agent notified the facility of an immediate Jeopardy regarding Resident #58, a full code resident, due to failure to provide Cardio-Pulmonary Resuscitation (CPR) in a timely manner per physician order, advance directives, and care plan; and critical lab values were not reported to the Physician when the labs were received. Resident #58 expired. Registered Nurse (RN) #2 was made aware of critical values for Resident #58 on [DATE], at approximately 1:00 AM. Lab values included Blood Urea Nitrogen (BUN) elevated at 213 (normal value range is ,[DATE]), Creatinine elevated at 7.1 (normal value range is 0XXX,[DATE].3), and Potassium elevated at 8.2 (normal value range is 3XXX,[DATE].1). RN #2 did not report these critical labs to the Physician, but indicated that she would report lab values to oncoming shift. On [DATE], at 5:36 AM, RN #2 was called to Resident #58's room by Certified Nursing Assistant (CNA) #1. Resident was unresponsive and without a pulse or respiration. RN #2 notified the Coroner at 5:40 AM. CPR was not initiated until 5:48 AM. This was a lapse of approximately ,[DATE] minutes before CPR was initiated to Resident #58. At 6:17 AM, the Director of Nursing (DON) was notified of Resident #58's death. Facility Actions: 1. On [DATE], at 11:30 AM, a 100 percent (%) audit of all critical labs for the month of (MONTH) (2018) was performed by the Medical Records Director, with no other issues found. 2. On [DATE], at 12:00 PM, an audit of RN #2's employee file was completed by the DON. The audit revealed Annual Employee Competency check-offs were completed on [DATE], and that RN #2 had received training on Abuse and Neglect, Lab values, Physician Notification, Physical Assessment, CPR, Crash Cart Overview, Emergency Codes, Documentation, and Care Plans. 3. On [DATE], at 5:45 PM, the facility's Emergency Response Management, Lab Notification to Medical Staff, Freedom of Abuse and Neglect, and Advance Directives standards were reviewed by the Administrator and Director of Nursing; no revisions were made. 4. On [DATE], at 6:30 PM, an Emergency Quality Assurance (QA) Meeting was held at the facility with the Administrator, Director of Nursing, Unit Managers, Nurse Educator, Minimum Data Set (MDS) Coordinator, Minimum Data Set Nurse, Admission Coordinator, Business Office Manager, Rehabilitation Manager, Medical Record Director, Social Service Director, Environmental Service Director, Plant Operations Manager, Dietary Manager, and Restorative LPN. The Medical Director and Resident #58's Primary Physician attended the meeting via phone. The following items were discussed: Reporting critical lab values immediately to the Physician and initiating CPR immediately when a resident is found without a pulse and respirations. The QA team recommended continuing in-services and chart audits. 5. On [DATE], at 7:00 PM, the DON reviewed Resident #58's Advance Directive, Care Plan, and Physician Orders. No revisions were made and it was determined that Resident #58 was a full code. 6. On [DATE], at 7:05 PM, RN #2 was in-serviced by the DON on Abuse and Neglect, Following Resident Care Plans, Advance Directives, and Critical Lab reporting to the Medical Doctor. On [DATE], at 7:05 PM, RN #2 was suspended by the DON and Nurse Educator (NE) due to failure to notify the Physician of critical lab values and failure to initiate CPR when Resident #58 was found without a pulse and respiration, per facility protocol. 7. On [DATE], at 8:30 PM, a 100% audit of all resident's Advance Directives and Advance Directives Care Plans was completed by Unit Manager #1, MDS Coordinator, and MDS LPN to ensure accuracy. No issues were found. 8. On [DATE], at 7:00 PM, a 100% audit of all critical labs for the last three (3) months was performed by the Director of Nursing. No issues were found. 9. On [DATE], at 7:35 PM, a record review was performed by the MDS LPN for the seven (7) residents that expired in the facility in the last six (6) months to ensure accuracy of Advance Directives and that the Advance Directive Care Plan was followed. No issues were found. 10. The following in-service education was provided to staff: *On [DATE], at 2:00 PM, an in-service was initiated by the DON and NE for RNs and LPNs regarding the Critical Lab Notification to Medical Staff Standard, including notifying the Physician of any critical lab value at the time it is received. Twelve of 17 RNs and 12 of 22 LPNs have been in-serviced. *On [DATE], at 2:00 PM, an in-service was initiated by the DON and NE for RNs and LPNs on Emergency Response-CPR, to include initiating CPR immediately when a resident is found without a pulse or respirations and following the resident plan of care for Advance Directives. Twelve of 17 RNs and 12 of 22 LPNs have been in-serviced. *On [DATE], at 6:00 PM, an in-service was initiated by the DON and NE for all staff on the Freedom of Abuse Standard, to include following Advance Directives and if a resident is found without a pulse and respirations CPR must be started immediately and if not, it will be considered neglect. Four (4) of six (6) Administrative staff, 12 of 17 RNs, 12 of 22 LPNs, 25 of 54 CNAs, eight (8) of 12 Dietary staff, five (5) of ten (10) Housekeeping staff, two (2) of three (3) Laundry Staff, and two (2) of two (2) Plant Operations staff have been in-serviced. *No staff will be allowed to work until the in-service education is completed. 11. On [DATE], at 3:00 PM, the Attorney General was notified of the incident by the Director of Nursing. 12. On [DATE], at 4:00 PM, the State Department of Health was notified of the incident by the Director of Nursing. 13. On [DATE], at 7:20 PM, the Mississippi Board of Nursing was notified of the incident by the Director of Nursing. 14. The facility concludes that all corrective actions were completed as of [DATE], and the Immediate Jeopardy was removed on [DATE]. On [DATE], the State Agency (SA) validated the facility's A[NAME] by staff interviews, record reviews, review of in-service sign-in sheets, and review of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ: 1. The SA validated through interview with the DON and record review that a 100% audit of all critical labs for the month of (MONTH) was performed by the Medical Records Director on [DATE], with no other issues found. 2. The SA validated through interview with the DON and record review that an audit of RN #2's employee file was completed by the DON on [DATE]. The audit revealed Annual Employee Competency check-offs was completed on [DATE], and that RN #2 had received training on Abuse and Neglect, Lab values, Physician Notification, Physical Assessment, CPR, Crash Cart Overview, Emergency Codes, Documentation, and Care Plans. 3. The SA validated through interview with the DON and record review that the facility's Emergency Response Management, Lab Notification to Medical Staff, Freedom of Abuse and Neglect, and Advance Directives standards were reviewed by the Administrator and Director of Nursing on [DATE]; no revisions were made. 4. The SA validated through interview with the DON and record review of the staff sign-in sheet and agenda, that an Emergency QA Meeting was held at the facility on [DATE], with the Administrator, Director of Nursing, Unit Managers, Nurse Educator, Minimum Data Set (MDS) Coordinator, Minimum Data Set Nurse, Admission Coordinator, Business Office Manager, Rehabilitation Manager, Medical Record Director, Social Service Director, Environmental Service Director, Plant Operations Manager, Dietary Manager, and Restorative LPN. The Medical Director and Resident #58's Primary Physician attended meeting via phone. The following items were discussed: reporting critical lab values immediately to the Physician and initiating CPR immediately when a resident is found without a pulse and respirations. The QA team recommended continuing in-services and chart audits, which were validated. 5. The SA validated through interview with the DON and record review that the DON reviewed Resident #58's Advance Directive, Care Plan, and Physician Orders on [DATE]. No revisions were made and it was determined that Resident #58 was a full code. 6. The SA validated through interview with the DON and document review that RN #2 was in-serviced by the DON on Abuse and Neglect, Following Residents Care Plan, Advance Directives, and Critical Lab reporting to Medical Doctor. The SA validated RN #2 was suspended on [DATE], due to failure to notify the Physician of critical lab values and failure to initiate CPR when Resident #58 was found without a pulse and respirations, per facility protocol. 7. The SA validated through interview with the DON and MDS Coordinator, and record review, that a 100% audit of all resident's Advance Directives and Advance Directives Care Plans was completed on [DATE], by Unit Manager #1, MDS Coordinator, and MDS LPN to ensure accuracy. No issues were found. 8. The SA validated through interview with the DON and record review, that a 100% audit of all critical labs for the last three (3) months was performed by the Director of Nursing on [DATE]. No issues were found. 9. The SA validated through interview with the DON and MDS LPN, that a record review was performed by the MDS LPN on [DATE], for the seven (7) residents that expired in the facility in the last six (6) months to ensure accuracy of Advance Directives and that the Advance Directive Care Plan was followed. No issues were found. Review of the medical records of the seven (7) residents, confirmed no issues with Advance Directives. 10. The SA validated the following in-service education was provided to staff: *The SA validated through random staff interviews, interview with the DON, and record review that on [DATE], an in-service was initiated by the DON and NE for RNs and LPNs regarding the Critical Lab Notification to Medical Staff Standard, including notifying the Physician of any critical lab value at the time it is received. The SA verified that 12 of 17 RNs and 12 of 22 LPNs had been in-serviced. *The SA validated through interview with the DON, random staff interviews, and record review that on [DATE], an in-service was initiated by the DON and NE for RNs and LPNs on Emergency Response-CPR, to include initiating CPR immediately when a resident is found without a pulse or respirations and following the resident's plan of care for Advance Directives. The SA confirmed that 12 of 17 RNs and 12 of 22 LPNs had been in-serviced. *The SA validated through interview with the DON, random staff interviews, and record review, that on [DATE], an in-service was initiated by the DON and NE for all staff on Freedom of Abuse Standard, to include following Advance Directives and if a resident is found without a pulse and respirations CPR must be started immediately, and if not, it will be considered neglect. The SA confirmed four (4) of six (6) Administrative staff, 12 of 17 RNs, 12 of 22 LPNs, 25 of 54 CNAs, eight (8) of 12 Dietary staff, five (5) of ten (10) Housekeeping staff, two (2) of three (3) Laundry Staff, two (2) of two (2) Plant Operations staff had been in-serviced. *The SA validated through staff interview, interview with the DON, and review of the employee roster, that no staff was allowed to work until the in-service education was completed. 11. The SA validated through interview with the DON and document review that on [DATE], the Attorney General was notified of the incident by the Director of Nursing. 12. The SA validated through interview with the DON and document review that on [DATE], the State Department of Health was notified of the incident by the Director of Nursing. 13. The SA validated through interview with the DON and document review, that on [DATE], the Mississippi Board of Nursing was notified of incident by the Director of Nursing. 14. The SA validated that all corrective actions to remove the IJ had been completed as of [DATE], and the IJ removed on [DATE], prior to exit.

Based on record review, staff interviews, and facility policy review, the facility failed to ensure a resident's rights and wishes were honored per Advance Directive for one (1) of eight (8) residents reviewed that expired in the last six (6) months, as evidenced by: On [DATE], a facility Certified Nursing Assistant (CNA) found Resident #58 unresponsive and called the nurse to the room. The facility nurse checked for Resident #58's vital signs with no results and failed to initiate Cardiopulmonary Resuscitation (CPR) until 12 minutes after the resident was found unresponsive. Resident #58 had elected an Advance Directive for a full code status. Resident #58 expired in the facility. The facility's failure to ensure a resident's right for the Advance Directive for full code status was honored, placed this resident and other residents with a full code status in a situation that was likely to cause serious injury, harm, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ), that began on [DATE], when CPR was not initiated in a timely manner, per Advanced Directive, for Resident #58. The facility Administrator was notified of the IJ on [DATE]. The State Agency (SA) received an acceptable credible Allegation of Compliance (A[NAME]) on [DATE], in which the facility alleged that all corrective actions were completed as of [DATE], and the Immediate Jeopardy was removed on [DATE]. The SA determined the IJ to be removed as of [DATE], prior to exit. Therefore, the scope and severity for IJ at 42 CFR 483.10(c)(6)(8)(g)(12)(i)-(iv)-F578 Resident Rights-(Advanced Directive), was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Resident's Rights Regarding Treatment and Advance Directives policy, revised ,[DATE], revealed: It is the resident's right to formulate an Advance Directive, and to accept or refuse medical or surgical treatment. Review of Resident #58's Order Summary Report for (MONTH) (YEAR), revealed physician's orders [REDACTED]. Record review of the Advanced Directive and Resident Rights form, for Resident #58, dated [DATE], revealed Full Code was checked and Resuscitate-Yes was circled. This was signed by the Responsible Party and the Physician. Review of the Nurse's Note, dated [DATE], at 5:49 AM, by Registered Nurse (RN) #2, revealed the nurse was asked to come at 5:36 AM to Resident #58's room. Upon arrival, the resident was on his back, eyes closed, unresponsive, no pulse noted, and no respirations. CPR was initiated at 5:48 AM. CPR was not initiated until approximately 12 minutes after the resident was found pulseless and without respirations. On [DATE] at 2:47 PM, a phone interview with RN #2 revealed that she was called to Resident # 58's room by Certified Nursing Assistant (CNA) #1 at 5:36 AM. She stated, To look at him, you would have thought that he was asleep. His face was fixed in a resting state. He was lying on his back with no rise and fall of his chest. His hands were cool but his forearm was kind of warm. I was in the room a few minutes then came back and went in the nurse's office to get the binder with protocols. I pulled his chart and went into the computer. I saw that he was a full code. When asked about the lapse of 12 minutes between the time that she was called to Resident #58's room and the initiation of Cardiopulmonary Resuscitation (CPR), she stated It was probably 10 to 12 minutes. She stated (Licensed Practical Nurse #1 (LPN), LPN #2 and LPN #3) went to the room to start CPR while I called 911. The times I documented in my nurse's note were the times that I was notified and CPR was started. She stated the system in place to identify the code status of a resident: You have to go to the chart. I wouldn't have known if I hadn't gone to the chart. During an interview with the Director of Nursing (DON) on [DATE], at 5:05 PM, she stated, CPR should start immediately on this resident when he was found unresponsive. The DON confirmed that the Advance Directive for CPR for Resident #58 was not followed. In an interview with the DON, on [DATE], at 4:30 PM, she stated that RN #2 had completed an annual competency check off which included Physician notification, lab values, and CPR competencies. She stated that RN#2 knew to start CPR immediately, but failed to do so. In an interview with Resident #58's Medical Doctor (MD), on [DATE] at 1:40 PM, he revealed that the facility had notified him last night that the resident had expired. He stated that CPR should have been started as soon as possible, as soon as you know you have an arrest and that the patient is a full code. The MD state that the initiation of CPR would depend on the exact circumstances, but it should be started as soon as possible. He acknowledged that the Advance Directives for CPR was not followed. Review of the Order Summary Report, dated (MONTH) (YEAR), for Resident #58, revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Employee Competency Standard, Type: Annual, revealed that RN#2 completed the competency which included Advance Directives and CPR on [DATE]. Review of a certificate from (name of University) revealed RN #2 had completed CPR, AED (Automated External Defibrillator) & First Aid Course on [DATE]. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE], for the IJ. Review of the facility's A[NAME] revealed the facility took the following actions to remove the IJ: Brief Summary of Events: On [DATE], at 5:40 PM, the State Agent notified the facility of an immediate Jeopardy regarding Resident #58, a full code resident, due to failure to provide Cardio-Pulmonary Resuscitation (CPR) in a timely manner per physician order, advance directives, and care plan; and critical lab values were not reported to the Physician when the labs were received. Resident #58 expired. Registered Nurse (RN) #2 was made aware of critical values for Resident #58 on [DATE], at approximately 1:00 AM. Lab values included Blood Urea Nitrogen (BUN) elevated at 213 (normal value range is ,[DATE]), Creatinine elevated at 7.1 (normal value range is 0XXX,[DATE].3), and Potassium elevated at 8.2 (normal value range is 3XXX,[DATE].1). RN #2 did not report these critical labs to the Physician, but indicated that she would report lab values to oncoming shift. On [DATE], at 5:36 AM, RN #2 was called to Resident #58's room by Certified Nursing Assistant (CNA) #1. Resident was unresponsive and without a pulse or respiration. RN #2 notified the Coroner at 5:40 AM. CPR was not initiated until 5:48 AM. This was a lapse of approximately ,[DATE] minutes before CPR was initiated to Resident #58. At 6:17 AM, the Director of Nursing (DON) was notified of Resident #58's death. Facility Actions: 1. On [DATE], at 11:30 AM, a 100 percent (%) audit of all critical labs for the month of (MONTH) (2018) was performed by the Medical Records Director, with no other issues found. 2. On [DATE], at 12:00 PM, an audit of RN #2's employee file was completed by the DON. The audit revealed Annual Employee Competency check-offs were completed on [DATE], and that RN #2 had received training on Abuse and Neglect, Lab values, Physician Notification, Physical Assessment, CPR, Crash Cart Overview, Emergency Codes, Documentation, and Care Plans. 3. On [DATE], at 5:45 PM, the facility's Emergency Response Management, Lab Notification to Medical Staff, Freedom of Abuse and Neglect, and Advance Directives standards were reviewed by the Administrator and Director of Nursing; no revisions were made. 4. On [DATE], at 6:30 PM, an Emergency Quality Assurance (QA) Meeting was held at the facility with the Administrator, Director of Nursing, Unit Managers, Nurse Educator, Minimum Data Set (MDS) Coordinator, Minimum Data Set Nurse, Admission Coordinator, Business Office Manager, Rehabilitation Manager, Medical Record Director, Social Service Director, Environmental Service Director, Plant Operations Manager, Dietary Manager, and Restorative LPN. The Medical Director and Resident #58's Primary Physician attended the meeting via phone. The following items were discussed: Reporting critical lab values immediately to the Physician and initiating CPR immediately when a resident is found without a pulse and respirations. The QA team recommended continuing in-services and chart audits. 5. On [DATE], at 7:00 PM, the DON reviewed Resident #58's Advance Directive, Care Plan, and Physician Orders. No revisions were made and it was determined that Resident #58 was a full code. 6. On [DATE], at 7:05 PM, RN #2 was in-serviced by the DON on Abuse and Neglect, Following Resident Care Plans, Advance Directives, and Critical Lab reporting to the Medical Doctor. On [DATE], at 7:05 PM, RN #2 was suspended by the DON and Nurse Educator (NE) due to failure to notify the Physician of critical lab values and failure to initiate CPR when Resident #58 was found without a pulse and respiration, per facility protocol. 7. On [DATE], at 8:30 PM, a 100% audit of all resident's Advance Directives and Advance Directives Care Plans was completed by Unit Manager #1, MDS Coordinator, and MDS LPN to ensure accuracy. No issues were found. 8. On [DATE], at 7:00 PM, a 100% audit of all critical labs for the last three (3) months was performed by the Director of Nursing. No issues were found. 9. On [DATE], at 7:35 PM, a record review was performed by the MDS LPN for the seven (7) residents that expired in the facility in the last six (6) months to ensure accuracy of Advance Directives and that the Advance Directive Care Plan was followed. No issues were found. 10. The following in-service education was provided to staff: *On [DATE], at 2:00 PM, an in-service was initiated by the DON and NE for RNs and LPNs regarding the Critical Lab Notification to Medical Staff Standard, including notifying the Physician of any critical lab value at the time it is received. Twelve of 17 RNs and 12 of 22 LPNs have been in-serviced. *On [DATE], at 2:00 PM, an in-service was initiated by the DON and NE for RNs and LPNs on Emergency Response-CPR, to include initiating CPR immediately when a resident is found without a pulse or respirations and following the resident plan of care for Advance Directives. Twelve of 17 RNs and 12 of 22 LPNs have been in-serviced. *On [DATE], at 6:00 PM, an in-service was initiated by the DON and NE for all staff on the Freedom of Abuse Standard, to include following Advance Directives and if a resident is found without a pulse and respirations CPR must be started immediately and if not, it will be considered neglect. Four (4) of six (6) Administrative staff, 12 of 17 RNs, 12 of 22 LPNs, 25 of 54 CNAs, eight (8) of 12 Dietary staff, five (5) of ten (10) Housekeeping staff, two (2) of three (3) Laundry Staff, and two (2) of two (2) Plant Operations staff have been in-serviced. *No staff will be allowed to work until the in-service education is completed. 11. On [DATE], at 3:00 PM, the Attorney General was notified of the incident by the Director of Nursing. 12. On [DATE], at 4:00 PM, the State Department of Health was notified of the incident by the Director of Nursing. 13. On [DATE], at 7:20 PM, the Mississippi Board of Nursing was notified of the incident by the Director of Nursing. 14. The facility concludes that all corrective actions were completed as of [DATE], and the Immediate Jeopardy was removed on [DATE]. On [DATE], the State Agency (SA) validated the facility's A[NAME] by staff interviews, record reviews, review of in-service sign-in sheets, and review of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ: 1. The SA validated through interview with the DON and record review that a 100% audit of all critical labs for the month of (MONTH) was performed by the Medical Records Director on [DATE], with no other issues found. 2. The SA validated through interview with the DON and record review that an audit of RN #2's employee file was completed by the DON on [DATE]. The audit revealed Annual Employee Competency check-offs was completed on [DATE], and that RN #2 had received training on Abuse and Neglect, Lab values, Physician Notification, Physical Assessment, CPR, Crash Cart Overview, Emergency Codes, Documentation, and Care Plans. 3. The SA validated through interview with the DON and record review that the facility's Emergency Response Management, Lab Notification to Medical Staff, Freedom of Abuse and Neglect, and Advance Directives standards were reviewed by the Administrator and Director of Nursing on [DATE]; no revisions were made. 4. The SA validated through interview with the DON and record review of the staff sign-in sheet and agenda, that an Emergency QA Meeting was held at the facility on [DATE], with the Administrator, Director of Nursing, Unit Managers, Nurse Educator, Minimum Data Set (MDS) Coordinator, Minimum Data Set Nurse, Admission Coordinator, Business Office Manager, Rehabilitation Manager, Medical Record Director, Social Service Director, Environmental Service Director, Plant Operations Manager, Dietary Manager, and Restorative LPN. The Medical Director and Resident #58's Primary Physician attended meeting via phone. The following items were discussed: reporting critical lab values immediately to the Physician and initiating CPR immediately when a resident is found without a pulse and respirations. The QA team recommended continuing in-services and chart audits, which were validated. 5. The SA validated through interview with the DON and record review that the DON reviewed Resident #58's Advance Directive, Care Plan, and Physician order [REDACTED].#58 was a full code. 6. The SA validated through interview with the DON and document review that RN #2 was in-serviced by the DON on Abuse and Neglect, Following Residents Care Plan, Advance Directives, and Critical Lab reporting to Medical Doctor. The SA validated RN #2 was suspended on [DATE], due to failure to notify the Physician of critical lab values and failure to initiate CPR when Resident #58 was found without a pulse and respirations, per facility protocol. 7. The SA validated through interview with the DON and MDS Coordinator, and record review, that a 100% audit of all resident's Advance Directives and Advance Directives Care Plans was completed on [DATE], by Unit Manager #1, MDS Coordinator, and MDS LPN to ensure accuracy. No issues were found. 8. The SA validated through interview with the DON and record review, that a 100% audit of all critical labs for the last three (3) months was performed by the Director of Nursing on [DATE]. No issues were found. 9. The SA validated through interview with the DON and MDS LPN, that a record review was performed by the MDS LPN on [DATE], for the seven (7) residents that expired in the facility in the last six (6) months to ensure accuracy of Advance Directives and that the Advance Directive Care Plan was followed. No issues were found. Review of the medical records of the seven (7) residents, confirmed no issues with Advance Directives. 10. The SA validated the following in-service education was provided to staff: *The SA validated through random staff interviews, interview with the DON, and record review that on [DATE], an in-service was initiated by the DON and NE for RNs and LPNs regarding the Critical Lab Notification to Medical Staff Standard, including notifying the Physician of any critical lab value at the time it is received. The SA verified that 12 of 17 RNs and 12 of 22 LPNs had been in-serviced. *The SA validated through interview with the DON, random staff interviews, and record review that on [DATE], an in-service was initiated by the DON and NE for RNs and LPNs on Emergency Response-CPR, to include initiating CPR immediately when a resident is found without a pulse or respirations and following the resident's plan of care for Advance Directives. The SA confirmed that 12 of 17 RNs and 12 of 22 LPNs had been in-serviced. *The SA validated through interview with the DON, random staff interviews, and record review, that on [DATE], an in-service was initiated by the DON and NE for all staff on Freedom of Abuse Standard, to include following Advance Directives and if a resident is found without a pulse and respirations CPR must be started immediately, and if not, it will be considered neglect. The SA confirmed four (4) of six (6) Administrative staff, 12 of 17 RNs, 12 of 22 LPNs, 25 of 54 CNAs, eight (8) of 12 Dietary staff, five (5) of ten (10) Housekeeping staff, two (2) of three (3) Laundry Staff, two (2) of two (2) Plant Operations staff had been in-serviced. *The SA validated through staff interview, interview with the DON, and review of the employee roster, that no staff was allowed to work until the in-service education was completed. 11. The SA validated through interview with the DON and document review that on [DATE], the Attorney General was notified of the incident by the Director of Nursing. 12. The SA validated through interview with the DON and document review that on [DATE], the State Department of Health was notified of the incident by the Director of Nursing. 13. The SA validated through interview with the DON and document review, that on [DATE], the Mississippi Board of Nursing was notified of incident by the Director of Nursing. 14. The SA validated that all corrective actions to remove the IJ had been completed as of [DATE], and the IJ removed on [DATE], prior to exit.

Complaint Investigation (CI) MS # Based on observation, interview, record review and policy review the facility failed to ensure that appropriate measures/systems were in place to help prevent pressure sores from developing/worsening for ten (10) of ten (10) sampled residents and two (2) of four (4) unsampled residents as evidenced by not having appropriate wound assessments by a Registered Nurse (RN), lack of supervision of the treatment nurse, not identifying/staging wounds correctly, not notifying the physician/Responsible Party about wound/treatment changes, and changing treatments without a physician's orders [REDACTED].#2, #3, #4, #5, #6, #7, #8, #9 and #10 and Residents #B and #D. Three (3) residents were found to have undocumented wounds on 6/26/12, Residents #1, #5, and #9. Four (4) residents, Residents #3, #6, #7 and #8 had worsened wounds than were documented during the previous weeks (with 06/26/12 being the reference point). Residents #2, #3, #4, #6, #7, #8, #10, #B and #D had no routinely documented RN assessments of their pressure ulcers. The failure to properly assess, identify, notify the physician and obtain appropriate treatment for [REDACTED]. The facility's failure to adequately assess, notify, and procure treatment orders for these aforementioned (identified) Residents was deemed an Immediate Jeopardy (IJ) on 6/29/12 at 9:50 a.m. The IJ began on 5/17/12 and was determined to be removed on 7/3/12. The Administrator was notified of the IJ on 6/29/12 at 10:00 a.m. The facility provided a credible Allegation of Compliance (AoC) on 7/3/12. Based on the facility's implementation of corrective actions and an acceptable Aoc, the IJ was removed as of 7/3/12 and lowered to a scope/severity of a "F" level (SQC) which constitutes no actual harm with potential for more than minimal harm. Resident #1: Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/6/12, revealed that no decubitus were present. Resident #1 had severe cognitive impairment. Resident #1 was totally dependent, required assistance for all Activities of Daily Living (ADLs). Resident #1 was incontinent of bowel and bladder. Observation and interview with Resident #1 on 6/26/12 at 10:35 a.m. with Licensed Practical Nurse (LPN) #1 and LPN #3 present, revealed that she had a denuded area to the right coccyx approximately 3 centimeter (cm) x 2 cm that was reddened with no drainage. There was a small area to the left coccyx less than 0.5 cm. LPN #1 stated that there had not been any open areas the day before, that it had only been excoriated. The Director of Nurses (DoN) was called to the room at 10:45 a.m. to assess Resident #1's coccyx and he stated that it wasn't open the day before when he looked at it, only excoriated, now would be classified as a stage II. Interview with CNA (Certified Nursing Assistant) #3 on 6/28/12 at 10:46 a.m. revealed that Resident #1's bottom had a blistered like area on Saturday (6/23/12) and then on Sunday (6/24/12) it was like the blister had burst. CNA #3 stated that she notified LPN #1 and that LPN #1 did a treatment. Review of Resident #1's Pressure Sore Risk assessment dated [DATE] revealed a score of 11. A score of 8 or higher is designated as high risk. Review of the "Skin Report" dated 6/17/12-6/23/12 revealed that Resident #1 had excoriation to left mid buttock, onset date 6/17/12, that measured .8 cm x .8 cm and no depth. On 6/20/12 Resident #1's left mid buttock wound measured .8 cm x .8 cm and no depth. On 6/25/12 Resident #1's left mid buttock wound measured 3.0 cm x 5.0 cm x .1 cm. Resident #1's follow-up assessment was not documented by the DON until 6/28/12 which revealed excoriation progressed to Stage II pressure ulcer to coccyx measuring 3.0 cm x 5.0 cm x .1 cm. Review of Resident #1's Nurse's Notes and weekly skin assessments (body audits) dated 6/13/12 at 6:26 a.m. and 6/20/12 at 1:33 a.m. revealed that Resident #1 had no skin problems or [MEDICAL CONDITION] present. (Excoriation had already been identified on 6/17/12 by LPN #1). Review of Resident #1's June 2012 Medication Administration/Treatment Administration Record (MAR/TAR) revealed [MEDICATION NAME] dressing to left inner buttock every three days on 6/17/12 ([MEDICATION NAME] is on facility's protocol for a stage II). On 6/25/12 the treatment was changed to skin prep and dry dressing to right and left middle buttock b.i.d (twice daily). There was no documented physician's orders [REDACTED]. There was no documented evidence that the physician was notified of the wound on 6/17/12. Resident #2 Resident #2 was re-admitted [DATE] and had [DIAGNOSES REDACTED]. Resident #2 had a stage III sacral decubitus. Observation of Resident #2's treatment by LPN #1 on 6/26/12 at 11:00 a.m. revealed a stage II decubitus to the coccyx which measured approximately 2 cm x 2 cm x 0 cm. with no odor or drainage. LPN #1 stated that Resident #2 had gone to the hospital several times and came back with a stage III and was now healing. Review of Resident #2's MDS with an ARD of 6/11/12 revealed that he was cognitively impaired and required limited to total assistance with ADLs. Resident #2 was incontinent of bowel/bladder. The MDS was coded with a stage III pressure ulcer that measured 3 cm x 2 cm x 0.1 cm. Review of Resident #2's Nurse's notes dated 4/16/12 revealed no Registered Nurse (RN) assessment of his sacral wound upon admission. A note from LPN #1 on 4/16/12 at 2:58 p.m. revealed a stage III pressure ulcer 7.4 cm x 3.8 cm x 0 cm. Worsened stage III with slough occurring. Weekly documentation and description/measurements of the sacral wound from 4/16/12-6/25/12 was by LPN #1, treatment nurse. There were no RN assessments/documentation of Resident #2's sacral wound. Review of the "Skin Report" dated 6/17/12-6/23/12 revealed that Resident #2's sacral wound was 2.0 cm x 2.0 x0.1. On 6/27/12 Resident #2's sacral wound was documented in the nurse's notes as 2.0 cm x 1.5 cm x 0 cm. Review of Resident #2's physician's orders [REDACTED]. Review of Resident #2's June 2012 Medication Treatment Record/Treatment Administration Record (MAR/TAR) revealed that the treatment was changed on 6/1/12 to Santyl and dry dressing to sacrum b.i.d (twice daily). The treatment was changed again on 6/12/12 to hydrogel and dry dressing to sacrum b.i.d. There was no documented physician's orders [REDACTED]. There was no documented evidence that the physician was notified of the wound/treatment changes. Interview with the QIC on 6/30/12 at 3:00 p.m. revealed that no RN assessments had been documented for Resident #2's sacral wound. The QIC stated that the policy was for an RN to do the admission assessment for wounds and there should have been a documented RN assessment weekly. The QIC stated that there was not a physician's orders [REDACTED]. Resident #3 Resident #3 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's MDS with an ARD on 4/26/12 revealed that he had severely cognitive impairment and required total assistance with ADLs and was incontinent of bowel with a indwelling suprapubic catheter. The MDS revealed no decubitus were present. Observation and interview of Resident #3 and DON on 6/26/12 at 10:08 a.m. . revealed the following wounds: Pressure Ulcer to buttocks unstageable measuring 6.0 cm x 6.0 cm, no depth, redden area; left heel ulcer with purple discoloration measuring 3.0 cm x 3.0 cm, no depth. The DON stated that Resident #3 had increased blood sugars over the weekend and his condition had deteriorated over the past few weeks. Resident #3 was not responsive, had oxygen at 2 liters via trach, Glucerna 1.2 at 65 cc/hr via feeding tube and was on a specialty mattress. Resident #3 had pillows for positioning and heels floated and cradle intact. Observation of Resident #3 with DON present on 6/27/12 at 12:35 p.m. revealed left heel Deep Tissue Injury (DTI) -measuring 3.0 cm x 3.5 cm, no depth; right heel unstageable measuring 3.5 cm x 5.0 cm, no depth. The DON stated unsure why areas on heels developed, heels may not be up at all times due to slipping off pillows, but knows that CNA turns resident and tries to keep foot cradle intact and heels floated. The DON stated the resident's disease process has deteriorated and areas are unavoidable, doing all we can. Review of weekly skin report revealed information about Resident #3's wound documentation: -5/7/12 at 7:33 a.m., documented by LPN #1 revealed that Resident #3 had a pressure ulcer Stage I to right posterior heel, onset date 5/3/12, redden area measuring 3.0 cm x 1.0 cm, with no depth. There was no documented evidence that the Physician was notified of the wound/treatments. There was no RN assessment/documentation of Resident #3's right heel ulcer. -5/14/12 at 3:19 p.m. documented by LPN #1 revealed that Resident #3 had a Stage I pressure ulcer to right posterior heel measuring 3.0 cm x 1.0 cm, with no depth. -5/18/12 at 9:24 a.m. documented by LPN #1 revealed that Resident #3 had a Stage II to right mid buttock, onset date 5/18/12, reddened area measuring 2.0 cm x 2.0 cm, with no depth. There was no documented physician's orders [REDACTED]. There was no documented evidence that the physician was notified of the wound/treatments. There was no RN assessment/documentation of Resident #3's right mid buttock pressure ulcer. -6/4/12 at 2:32 p.m. documented by LPN #1 revealed that Resident #3 had a Stage II to right mid buttock, reddened area measuring 2.0 cm x 2.0 cm, with no depth. -6/4/12 at 2:32 p.m. documented by LPN #1 revealed that Resident #3 had a Stage I to right posterior heel, measuring 2.0 cm x 1.0 cm, with no depth. -6/11/12 at 2:18 p.m. documented by LPN #1 revealed that Resident #3 had a Stage I to right posterior heel, measuring 2.0 cm x 1.0 cm, no depth. -6/11/12 at 2:18 p.m. documented by LPN #1 revealed that Resident #3 had a Stage II to right mid buttock, reddened area measuring 2.0 cm x 1.8 cm, no depth. 6/14/12 treatment changed to hydrogel and dry dressing. There is no documented physician's orders [REDACTED]. -6/18/12 at 3:07 p.m. documented by LPN #1 revealed that Resident #3 had a Stage II to right mid buttock, reddened area measuring 2.0 cm x 1.0 cm, no depth. -6/25/12 at 11:28 a.m. documented by LPN #1 revealed the Resident #3 had a Stage 1 to right posterior heel, measuring 1 cm x 1 cm, with no depth. -6/25/12 at 11:28 a.m. documented by LPN revealed that Resident #3 had a Stage 1 to right posterior heel , healed. -6/25/12 at 11:34 a.m. documented by LPN #1 revealed that Resident #3 had a unstageable, blue/black color, "worsened" stage II to right mid buttock, measuring 6.0 cm x 6.0 cm , with no depth. Review of Resident #3's May and June MAR/TAR revealed treatment of [REDACTED]. Treatment changed to skin prep and a dry dressing on 6/18/12. Review of Resident #3's physician's orders [REDACTED]. There was no documented evidence that the Physician was notified of the wounds/treatments. Review of Nurse's notes reveal there was no RN assessment/documentation of Resident #3's right heel ulcer. On 5/18/12 documented treatments of extra protective cream to right mid buttock (coccyx) b.i.d on May 2012 (MAR/TAR). On 5/24/12 the treatment changed to skin prep and a dry dressing on May 2012 (MAR/TAR). There was no documented physician's orders [REDACTED]. There was no documented evidence that the physician was notified of the wound/treatments. Review of Nurse's notes revealed there was no RN assessment/documentation of Resident #3's right mid buttock pressure ulcer. On 6/14/12 treatment changed to hydrogel and a dry dressing to b.i.d There is no documented physician's orders [REDACTED]. Interview with Physician #1 on 6/27/12 at 5:35 p.m. revealed that there wasn't a lot more that could be offered to Resident #3 due to his multiple medical problems, that he'd done better than actually expected. Physician #1 stated that Resident #3's wounds were unavoidable and that she had talked with family about his condition (documented). Physician #1 stated that there should be orders for treatments and RN's looking at wounds. Interview with the QIC on 6/28/12 at 4:35 p.m. revealed that she reviewed Resident #3's chart and couldn't find documentation of where the physician was always notified of wounds/changes. The QIC stated that she didn't see orders for all of the treatments. The QIC stated that LPN #1 had made some bad decisions about just putting orders in with no documentation about the changes in treatment. Resident #4: Resident #4 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/18/12, revealed that no decubitus ulcers were present. Resident #4 had long/short term memory problems and had severe cognitive impairment. Resident #4 required total assistance for all Activities of Daily Living (ADLs). Resident #4 was incontinent of bowel and bladder. Review of a Nutritional assessment dated [DATE] revealed that Resident #4 had no skin concerns, and that nutritional needs were being met by tube feeding. An updated note dated 5/21/12 revealed that Resident #4 had an "area to the coccyx". The current treatment was continued. Review of Resident #4's Nurse's admission notes dated 5/10/12 at 9:21 p.m., documented by RN #5, revealed that the treatment nurse had assessed the resident's skin with no noted open areas or pressure areas noted. Further note on 5/10/12 at 9:27 p.m. , by RN #5, revealed that Resident #4 had no skin problems or [MEDICAL CONDITION] present. Review of further Nurse's notes for the following times and dates revealed information about Resident #4's skin: - 5/13/12 at 12:52 a.m. revealed a Pressure Sore Risk Assessment score of 14 for Resident #4. A score of 8 or higher is designated as high risk. -5/17/12 at 11:24 a.m., documented by LPN #1 (treatment nurse), revealed that Resident #4 had excoriation to the coccyx, onset date 5/17/12, that measured 4 centimeters (cm) in length, and 3 cm in width with no depth with healing in progress. (treatment of [REDACTED]. -5/21/12 at 3:27 p.m., documented by LPN #1, revealed that Resident #4 continued to have excoriation to the coccyx area that measured 4 cm. x 3 cm and no depth and that it appeared more clean. -5/24/12 at 3:09 p.m., documented by LPN #3, revealed a weekly skin assessment for Resident #4 with excoriation to the right/left lower buttock coccyx; treatment of [REDACTED]. -5/29/12 at 2:25 p.m., documented by LPN #1, revealed that Resident #4 continued to have excoriation to the coccyx, reddened surrounding tissue, improving, more clean area that measured 4 cm x 3 cm with no depth. -5/31/12 at 10:38 a.m., documented by LPN #2, revealed a "coccyx decub" for Resident #4 with no description and with a treatment of [REDACTED]. There was no documented evidence that Resident #4's coccyx/wound was assessed on development or weekly by a Registered Nurse (RN) as required. Review of a Nurse's note dated 6/3/12 at 10:30 a.m., documented by RN#5, revealed that Resident #4 was transferred to the ER/Acute care hospital at 9:50 a.m. for evaluation. A further Nurse's note dated 6/3/12 at 10:53 a.m. by RN #5 revealed that Resident #4 was tachypnic to periods of apnea about 5-10 seconds with irregular patterns noted. It was documented that the nurse initiated an IV as ordered related to a preliminary wound culture report without success. Resident #4's temperature was 100.3 axillary, pulse 67, respirations 32, oxygen saturation of 97% on room air, and blood pressure of 142/64. There had been no previous documentation of a wound culture, or that the physician had ordered a wound culture for Resident #4. There was no documented evidence that the physician or family had been notified of a wound on Resident #4's coccyx or any treatment in process prior to Resident #4's discharge to the hospital. Review of a Nurse's note dated 6/3/12 at 1:21 p.m. revealed that a wound culture from Resident #4's coccyx area revealed numerous gram positive cocci and moderate gram negative bacilli. There was no documentation of the culture being ordered or when it was collected. Review of a laboratory report for Resident #4 with a collection date of 6/1/12 from a "coccyx wound" revealed the following organisms reported on 6/5/12: 1. Proteus mirabilis, Gram negative bacilli 2. Gram bacilli 3, [MEDICAL CONDITION], and [MEDICATION NAME] sensitive [MEDICATION NAME] faecalis. There was no documentation of a physician's orders [REDACTED]. Review of the hospital History and Physical for Resident #4 dated 6/4/12 revealed that Resident #4 had a large sacral decubitus ulcer present on admission (6/3/12). Review of the hospital "Flowsheet" dated 6/3/12 at 3:00 p.m. revealed that Resident #4 had a pressure wound to the coccyx that was unstageable and measured 15 cm x 9 cm with a moderate foul odor. Review of Resident #4's Medication Administration Record/Treatment Administration Record (MAR/TAR) revealed that a treatment of [REDACTED]. There was no documented evidence of a description of the wound, the reason for change in treatment, and no documented evidence that the physician or family was notified of the treatment/wound. There was no documented evidence of a signed physician's orders [REDACTED]. Review of Resident #4's physician's orders [REDACTED]. On 5/17/12 there was a documented physician's orders [REDACTED]. On 6/3/12 Resident #4 had a physician's orders [REDACTED]. Review of computerized physician's orders [REDACTED].#1. The order was to clean with wound cleanser, apply Calcium Alginate and dry dressing to coccyx twice daily; first date 5/17/12, until resolved. There was no documented evidence that the physician or family had been notified of the wound and/or treatment. There was no evidence that the physician had actually given the order for the Calcium Alginate treatment for [REDACTED]. (Refer to the interview with Physician #2 on 6/27/12 at 2:55 p.m. which revealed that he had not been aware that Resident #4 had a decubitus ulcer on the coccyx and had not given orders for treatment of [REDACTED]. Review of Activity of Daily Living (ADL) documentation on 5/21/12 at 5:31 p.m., by Certified Nursing Assistant (CNA) #1, revealed an open area to Resident #4's buttocks/coccyx. (Refer to interview with CNA #1 on 6/28/12 at 12:25 p.m. which revealed that she had seen and had informed the nurse about the open wound on Resident #4. Review of the weekly team meeting notes dated 5/18/12, 5/24/12, and 6/1/12, attended by the Director of Nursing (DON), Treatment Nurse, MDS Coordinator, Care Plan Coordinator, and Dietary Manager revealed that Resident #4 had in-house excoriations. There was no mention of decubitus for Resident #4 or culture, or treatment changes in the weekly team meetings. Review of Resident #4's care plan dated 5/10/12 revealed a potential for impaired skin integrity with approaches for skin assessment per policy and note changes in level of risk for skin breakdown and to report changes to the nurse. Resident #4's care plan was updated on 5/18/12 to include impaired skin integrity manifested by excoriation to the coccyx on admission (no documented evidence of skin problems on admission). There was no documented evidence that Resident #4's care plan was reviewed and revised to include treatment/culture/documentation of a pressure ulcer prior to Resident #4 going to the hospital on [DATE]. Interview with the DON on 6/26/12 at 9:15 a.m. with the Quality Improvement Consultant (QIC) and Administrator present, stated that Resident #4's family came to the facility and was angry about her condition deteriorating so quickly and wanted to know if they were aware of her breakdown. The DON stated that the family had been aware of Resident #4's excoriation to start and it was facility policy to let the family know of any changes in status or breakdown. Interview with LPN #1 Treatment Nurse, on 6/26/12 at 11:20 a.m. revealed that Resident #4 was admitted with a reddened area (coccyx) and within a few days it had darkened but was not opened. LPN #1, with the Quality Improvement Consultant (QIC) present, stated that she was observing Resident #4 daily Monday through Friday and Resident #4 had some [MEDICAL CONDITION] and didn't look right. LPN #1 stated that she had cultured Resident #4's (coccyx) area, more of a bruised hardened area, because that's what the DON told her to do. When the consultant questioned LPN #1 as to why she would culture something that was not open LPN #1 just replied that she had not wanted the area to get bad and again stated that the area wasn't open. Further interview with LPN #1 on 6/26/12 at 12:10 p.m. revealed that Resident #4's area on her bottom was not open but was weepy and that she had put Calcium Alginate to dry it up. LPN #1 admitted to not notifying the physician or Responsible Party (RP) about the area on Resident #4's coccyx and had not called the physician for an order for [REDACTED]. LPN #1 stated that it was usually the charge nurse who notified the MD/RP (of changes). Further interview with LPN #1 on 6/26/12 at 1:45 p.m., with the Consultant present, revealed that she was having trouble with anything sticking to Resident #4's (bottom) so she had asked the DON about using Calcium Alginate to try to protect and keep the area from getting worse. The DON was present on 6/26/12 (2:10 p.m.) during the interview with LPN #1 and denied knowledge of LPN #1 asking him about the Calcium Alginate for Resident #4. LPN #1 stated that she had cultured the area on Resident #4's coccyx because the resident was getting worse and that she thought this area on Resident #4's bottom might be considered (as a source). LPN #1 admitted that she had not contacted the physician for the culture order or the Calcium Alginate order, that she had just put the orders in the computer. The Consultant informed LPN #1 that the physician still had to be notified of a change in condition and give the order, that she couldn't just put an order in the computer. LPN #1 stated that there were times that she would change a treatment and did not notify the physician because she just used the(wound) protocol. LPN #1 stated that she did all of the wound evaluations and measurements. LPN #1 stated that she did usually let the family know of any changes but that it might not always be documented. LPN #1 admitted to not notifying the family/MD of Resident #4's coccyx area. The DON, still present, stated that there probably would not be any documented RN assessments of any resident's wounds other than when admitted , that he had not documented any assessments himself, that he had left it up to LPN #1 to do the treatments, measurements and documentation. The DON stated that he had not notified the MD/RP of Resident #4's wound to her coccyx except when the family had came in and asked about it (after resident in hospital) and he told them it had been an excoriation (according to medical record). Interview with the DON on 6/26/12 at 11:40 a.m. with the QIC present, revealed that he had looked at Resident #4's bottom on 5/31/12 for the high risk meeting and it was extremely red, but that he had seen no opening, but it was moist and weepy. The QIC reminded the DON that the Calcium Alginate was ordered on [DATE] so according to protocol the wound had to be open. The DON again stated that he did not see the wound open, only a big red area. Interview with the DON on 6/26/12 at 4:15 p.m. as he was reviewing Resident #4's medical record, revealed that he saw no order for the wound culture on 6/1/12. The DON stated that he was not aware that a culture had been done on Resident #4 at the time. The DON stated that if a culture was obtained the physician should be called for the order and the order entered (into computer) and printed out, not necessary to have a handwritten order, but should have. The DON stated that he didn't see a handwritten or printed order for the Calcium Alginate on 5/31/12. With review of LPN #2's skin assessment (body audit) note on 5/31/12 for the coccyx decubitus, the DON stated that the area should have been described and he saw nothing in any of the notes where the MD/RP had been notified of the coccyx area or wound. The DON stated that Calcium Alginate would not have been the protocol for an excoriation. The DON stated that he had not seen Resident #4 on 5/31/12 or 6/1/12 (he previously had said he saw her on 5/31/12), it would have been on 5/28/12 or 5/29/12 before the team meeting where the team talked about each wound. The DON stated that the two (2) MDS Nurses, Dietary, the Wound Nurse (LPN#1) and himself was usually at the meeting. The DON stated that Resident #4 still had excoriation and that it was hard to get creams and dressings to stick to the area. The DON stated that they continued treatment to keep it clean/dry and that he didn't recall any discussion about Calcium Alginate in the meeting. The DON stated that they had not done a very good job of documentation. Interview with the QIC on 6/26/12 at 3:15 p.m. revealed that LPN #1 should have notified the MD/RP of any changes or have the RN call for any wound/excoriation and not just write an order unless it was the protocol. The QIC stated that Calcium Alginate was not the protocol for an excoriation; it would be for a Stage III or higher wound. Interview with the QIC on 6/26/12 at 4:15 p.m. revealed that LPN #1 was being suspended for an investigation into documentation which included writing physician orders [REDACTED]. Interview with RN #5 on 6/26/12 at 2:30 p.m. revealed that she had gone with LPN #1 to look at Resident #4 upon admit and didn't recall any wounds. RN #5 stated that she recalled being told that Resident #4 had developed some redness on her butt. RN #5 stated that she recalled going with RN #9 on a weekend to look at Resident #4's bottom and stated that the bottom was red, maybe emacerated but not sure. RN #5 stated that there was a treatment already in place. RN #5 stated that she was present when #4 was sent to the hospital (6/3/12) but did not do a skin assessment because the resident was real sick and tachypnic. RN #5 stated that she had seen the wound culture report of the coccyx the morning that Resident #4 was sent to the hospital but did not know who had done the culture. RN #5 stated that she did not recall anyone telling her of any wound change or change in treatment for [REDACTED]. RN #5 stated that she did not assess wounds except on admit/readmit, that the treatment nurse did the rest of the time. Interview with RN# 9 on 6/27/12 at 6:45 p.m. revealed that the Treatment Nurse usually called the MD/RP of any change in wound/skin and the Charge Nurse could too. RN #9 stated that she had worked the weekend of 5/19/12 and 5/20/12 doing treatments and had observed Resident #4's bottom for the first time. RN #9 stated that Resident #4 had an open wound at that time on her sacral area, stage II about the size of a half dollar. RN #9 stated that it was more like a blistered area with the top off. RN #9 stated that the treatment was skin prep and a bandage, doesn't recall any drainage. RN # 9 stated that the next time she saw Resident #4's wound was 6/2/12 and it had looked a little worse and a little bigger. RN # 9 stated that the treatment had been changed for Resident #4 and she assumed that LPN # 1 had changed the treatment after notifying the MD/RP. RN #9 stated that she did not notify the MD/RP herself because she had assumed that it had been done by LPN #1 during the week since the treatment had changed. RN #9 stated that she did the treatment that was ordered and didn't recall the wound looking infected. RN #9 stated that RN #5 had looked at Resident #4 with her at one time but could not recall exactly when. RN #9 stated that Calcium Alginate would not be an appropriate treatment for [REDACTED].#4's wound on 6/3/12 before being sent to the hospital. RN # 9 stated that when a resident was admitted that the RN would assess the skin/wounds but after that the treatment nurse would do the weekly measurements/documentation of wounds. Interview with LPN #2 on 6/28/12 at 3:40 p.m. revealed that she had done a weekly body audit on Resident #4 and there was a wound on the coccyx with redness around the edges and white areas with a darkish green color. LPN #2 stated that the wound had some drainage coming from it that smelled awful. LPN #2 described the size of the wound around 8 cm x 5 cm with moisture. LPN #2 stated that this was around 5/31/12 when she saw the wound after Resident #4's bandage had come off (coccyx area) and that CNA #1 was in the room with her. LPN #2 stated that LPN #1 came in the room to do Resident #4's treatment while she (LPN #2) and CNA #1 was there and so she (LPN #2) thought that LPN #1 would notify the MD and get the treatment changed if needed and document. On 6/28/12 at 4:20 p.m. LPN #2 stated that she had not been aware that a culture was done on Resident #4 until the results came in. LPN #2 stated that usually the treatment nurse did everything with the wounds; treatments, changes, notification, orders and documentation. Interview with LPN # 4 on 6/28/12 at 4:00 p.m. revealed that she had been the charge nurse on 5/31/12 and that LPN #1 had told her that Resident #4's wound was "going south" and that she was going to leave her bottom open for awhile. LPN #4 stated that she had not looked at Resident #4's wound that day, because typically the treatment nurse took care of her own orders, calling MD/RP, assessing and documentation of wounds. LPN #4 stated tha

Complaint Investigation (CI) MS Based on observation, interview, record review and policy review the facility failed to ensure that standards of practice were maintained for 8 of 10 sampled residents, Resident #1, #2, #3, #4, #6, #7, #8, and #10 and two (2) Unsampled residents, Resident #B and Resident #D as evidenced by not having written physician's orders [REDACTED]. Residents #1, #2, #3, #4, and #8 had documented treatments without documented physician's orders [REDACTED].#7, #8, #10, #B and #D had no RN assessments of their wounds as required. The failure to properly assess and obtain appropriate physician orders [REDACTED]. The facility's failure to adequately assess and procure treatment orders for residents was deemed an Immediate Jeopardy (IJ) on 6/29/12 at 9:50 a.m. The IJ began on 5/17/12 and was determined to be removed on 7/3/12. The Administrator was notified of the IJ on 6/29/12 at 10:00 a.m. The facility provided a credible Allegation of Compliance (AoC) on 7/3/12. Based on the facility's implementation of corrective actions and an acceptable Aoc, the IJ was removed as of 7/3/12 and lowered to a scope/severity of a "F" level which constitutes no actual harm with potential for more than minimal harm. Findings included: Resident #1 Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/6/12, revealed that no decubitus were present. Resident #1 had severe cognitive impairment. Resident #1 was totally dependent, required assistance for all Activities of Daily Living (ADLs). Resident #1 was incontinent of bowel and bladder. Observation and interview with Resident #1 on 6/26/12 at 10:35 a.m. with Licensed Practrical Nurse (LPN) #1 and LPN #3 present, revealed that she had a denuded area to the right coccyx approximately 3 centimeter (cm) x 2 cm that was reddened with no drainage. There was a small area to the left coccyx less than 0.5 cm. LPN #1 stated that there had not been any open areas the day before, that it had only been excoriated. The DON was called to the room at 10:45 a.m. to assess Resident #1's coccyx and he stated that it wasn't open the day before when he looked at it, only excoriated, now would be classified as a stage II. Interview with Certified Nursing Assistant (CNA) #3 on 6/28/12 at 10:46 a.m. revealed that Resident #1's bottom had a blistered like area on Saturday (6/23/12) and then on Sunday (6/24/12) it was like the blister had bursted. CNA #3 stated that she notified LPN #1 and that LPN #1 did a treatment. Review of Resident #1's Pressure Sore Risk assessment dated [DATE] revealed a score of 11. A score of 8 or higher is designated as high risk. Review of the "Skin Report" dated 6/17/12-6/23/12 revealed that Resident #1 had excoriation to left mid buttock, onset date 6/17/12, that measured .8 cm x .8 cm and no depth. On 6/20/12 Resident #1's left mid buttock wound measured .8 cm x .8 cm and no depth. On 6/25/12 Resident #1's left mid buttock wound measured 3.0 cm x 5.0 cm x .1 cm. Resident #1's follow-up assessment was not documented by the DON until 6/28/12 which revealed excoriation progressed to Stage II pressure ulcer to coccyx measuring 3.0 cm x 5.0 cm x .1 cm. Review of Resident #1's Nurse's Notes and weekly skin assessments (body audits) dated 6/13/12 at 6:26 a.m. and 6/20/12 at 1:33 a.m. revealed that Resident #1 had no skin problems or [MEDICAL CONDITION] present. (excoriation had already been identified on 6/17/12 by LPN #1) Review of Resident #1's June 2012 Medication Administration/Treatment Administration Record (MAR/TAR) revealed [MEDICATION NAME] dressing to left inner buttock every three days on 6/17/12 ([MEDICATION NAME] is on facility's protocol for a stage II). On 6/25/12 the treatment was changed to skin prep and dry dressing to right and left middle buttock b.i.d (twice daily). There was no documented physician's orders [REDACTED]. There was no documented evidence that the physician was notified of the wound on 6/17/12. Resident #2 Resident #2 was re-admitted [DATE] and had [DIAGNOSES REDACTED]. Resident #2 had a stage III sacral decubitus. Observation of Resident #2's treatment by LPN #1 on 6/26/12 at 11:00 a.m. revealed a stage II decubitus to the coccyx which measured approximately 2 cm x 2 cm x 0 cm. with no odor or drainage. LPN #1 stated that Resident #2 had gone to the hospital several times and came back with a stage III and was now healing. Review of Resident #2's MDS with an ARD of 6/11/12 revealed that he was cognitively impaired and required limited to total assistance with ADLs. Resident #2 was incontinent of bowel/bladder. The MDS was coded with a stage III pressure ulcer that measured 3 cm x 2 cm x 0.1 cm. Review of Resident #2's Nurse's notes dated 4/16/12 revealed no RN assessment of his sacral wound upon admission. A note from LPN #1 on 4/16/12 at 2:58 p.m. revealed a stage III pressure ulcer 7.4 cm x 3.8 cm x 0 cm. Worsened stage III with slough occurring. Weekly documentation and description/measurements of the sacral wound from 4/16/12-6/25/12 was by LPN #1, treatment nurse. There were no RN assessments/documentation of Resident #2's sacral wound. Review of the "Skin Report" dated 6/17/12-6/23/12 revealed that Resident #2's sacral wound was 2.0 cm x 2.0 x0.1. On 6/27/12 Resident #2's sacral wound was documented in the nurse's notes as 2.0 cm x 1.5 cm x 0 cm. Review of Resident #2's physician's orders [REDACTED]. Review of Resident #2's June 2012 Medication Treatment Record/Treatment Administration Record (MAR/TAR) revealed that the treatment was changed on 6/1/12 to Santyl and dry dressing to sacrum b.i.d (twice daily). The treatment was changed again on 6/12/12 to hydrogel and dry dressing to sacrum b.i.d. There was no documented physician's orders [REDACTED]. There was no documented evidence that the physician was notified of the wound/treatment changes. Interview with the Quality Improvement Consultant (QIC) on 6/30/12 at 3:00 p.m. revealed that no RN assessments had been documented for Resident #2's sacral wound. The QIC stated that the policy was for an RN to do the admission assessment for wounds and there should have been a documented RN assessment weekly. The QIC stated that there was not a physician's orders [REDACTED]. Resident #3: Resident #3 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's MDS with an ARD on 4/26/12 revealed that he had severely cognitive impairment and required total assistance with ADLs and was incontinent of bowel with a indwelling suprapubic catheter. The MDS revealed no decubitus were present. Observation and interview of Resident #3 and DON on 6/26/12 at 10:08 a.m. . revealed the following wounds: Pressure Ulcer to buttocks unstageable measuring 6.0 cm x 6.0 cm, no depth, redden area; left heel ulcer with purple discoloration measuring 3.0 cm x 3.0 cm, no depth. The DON stated that Resident #3 had increased blood sugars over the weekend and his condition had deteriorated over the past few weeks. Resident #3 was not responsive, had oxygen at 2 liters via trach, Glucerna 1.2 at 65 cc/hr via feeding tube and was on a specialty mattress. Resident #3 had pillows for positioning and heels floated and cradle intact. Observation of Resident #3 with DON present on 6/27/12 at 12:35 p.m. revealed left heel Deep Tissue Injury (DTI) -measuring 3.0 cm x 3.5 cm, no depth; right heel unstageable measuring 3.5 cm x 5.0 cm, no depth. The DON stated unsure why areas on heels developed, heels may not be up at all times due to slipping off pillows, but knows that CNA turns resident and tries to keep foot cradle intact and heels floated. The DON stated the resident's disease process has deteriorated and areas are unavoidable, doing all we can. Review of weekly skin report revealed information about Resident #3's wound documentation: -5/7/12 at 7:33 a.m., documented by LPN #1 revealed that Resident #3 had a pressure ulcer Stage I to right posterior heel, onset date 5/3/12, redden area measuring 3.0 cm x 1.0 cm, with no depth. There was no documented evidence that the Physician was notified of the wound/treatments. There was no RN assessment/documentation of Resident #3's right heel ulcer. -5/14/12 at 3:19 p.m. documented by LPN #1 revealed that Resident #3 had a Stage I pressure ulcer to right posterior heel measuring 3.0 cm x 1.0 cm, with no depth. -5/18/12 at 9:24 a.m. documented by LPN #1 revealed that Resident #3 had a Stage II to right mid buttock, onset date 5/18/12, reddened area measuring 2.0 cm x 2.0 cm, with no depth. There was no documented physician's orders [REDACTED]. There was no documented evidence that the physician was notified of the wound/treatments. There was no RN assessment/documentation of Resident #3's right mid buttock pressure ulcer. -6/4/12 at 2:32 p.m. documented by LPN #1 revealed that Resident #3 had a Stage II to right mid buttock, reddened area measuring 2.0 cm x 2.0 cm, with no depth. -6/4/12 at 2:32 p.m. documented by LPN #1 revealed that Resident #3 had a Stage I to right posterior heel, measuring 2.0 cm x 1.0 cm, with no depth. -6/11/12 at 2:18 p.m. documented by LPN #1 revealed that Resident #3 had a Stage I to right posterior heel, measuring 2.0 cm x 1.0 cm, no depth. -6/11/12 at 2:18 p.m. documented by LPN #1 revealed that Resident #3 had a Stage II to right mid buttock, reddened area measuring 2.0 cm x 1.8 cm, no depth. 6/14/12 treatment changed to hydrogel and dry dressing. There is no documented physician's orders [REDACTED]. -6/18/12 at 3:07 p.m. documented by LPN #1 revealed that Resident #3 had a Stage II to right mid buttock, reddened area measuring 2.0 cm x 1.0 cm, no depth. -6/25/12 at 11:28 a.m. documented by LPN #1 revealed the Resident #3 had a Stage 1 to right posterior heel, measuring 1 cm x 1 cm, with no depth. -6/25/12 at 11:28 a.m. documented by LPN revealed that Resident #3 had a Stage 1 to right posterior heel , healed. -6/25/12 at 11:34 a.m. documented by LPN #1 revealed that Resident #3 had a unstageable, blue/black color, "worsened" stage II to right mid buttock, measuring 6.0 cm x 6.0 cm , with no depth. Review of Resident #3's May and June MAR/TAR revealed treatment of [REDACTED]. Treatment changed to skin prep and a dry dressing on 6/18/12. Review of Resident #3's physician's orders [REDACTED]. There was no documented evidence that the Physician was notified of the wounds/treatments. Review of Nurse's notes reveal there was no RN assessment/documentation of Resident #3's right heel ulcer. On 5/18/12 documented treatments of extra protective cream to right mid buttock (coccyx) b.i.d on May 2012 (MAR/TAR). On 5/24/12 the treatment changed to skin prep and a dry dressing on May 2012 (MAR/TAR). There was no documented physician's orders [REDACTED]. There was no documented evidence that the physician was notified of the wound/treatments. Review of Nurse's notes revealed there was no RN assessment/documentation of Resident #3's right mid buttock pressure ulcer. On 6/14/12 treatment changed to hydrogel and a dry dressing to b.i.d There was no documented physician's orders [REDACTED]. Interview with Physician #1 on 6/27/12 at 5:35 p.m. revealed that there wasn't a lot more that could be offered to Resident #3 due to his multiple medical problems, that he'd done better than actually expected. Physician #1 stated that Resident #3's wounds were unavoidable and that she had talked with family about his condition (documented). Physician #1 stated that there should be orders for treatments and RN's looking at wounds. Interview with the QIC on 6/28/12 at 4:35 p.m. revealed that she reviewed Resident #3's chart and couldn't find documentation of where the physician was always notified of wounds/changes. The QIC stated that she didn't see orders for all of the treatments. The QIC stated that LPN #1 had made some bad decisions about just putting orders in with no documentation about the changes in treatment. Resident #4: Resident #4 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/18/12, revealed that no decubitus ulcers were present. Resident #4 had long/short term memory problems and had severe cognitive impairment. Resident #4 required total assistance for all Activities of Daily Living (ADLs). Resident #4 was incontinent of bowel and bladder. Review of a Nutritional assessment dated [DATE] revealed that Resident #4 had no skin concerns, and that nutritional needs were being met by tube feeding. An updated note dated 5/21/12 revealed that Resident #4 had an "area to the coccyx". The current treatment was continued. Review of Resident #4's Nurse's admission notes dated 5/10/12 at 9:21 p.m., documented by RN #5, revealed that the treatment nurse had assessed the resident's skin with no noted open areas or pressure areas noted. Further note on 5/10/12 at 9:27 p.m. ,by RN #5, revealed that Resident #4 had no skin problems or [MEDICAL CONDITION] present. Review of Nurse's notes for the following times and dates revealed information about Resident #4's skin: - 5/13/12 at 12:52 a.m. revealed a Pressure Sore Risk Assessment score of 14 for Resident #4. A score of 8 or higher is designated as high risk. -5/17/12 at 11:24 a.m., documented by LPN #1 (treatment nurse), revealed that Resident #4 had excoriation to the coccyx, onset date 5/17/12, that measured 4 centimeters (cm) in length, and 3 cm in width with no depth with healing in progress. (treatment of [REDACTED]. -5/21/12 at 3:27 p.m., documented by LPN #1, revealed that Resident #4 continued to have excoriation to the coccyx area that measured 4 cm. x 3 cm and no depth and that it appeared more clean. -5/24/12 at 3:09 p.m., documented by LPN #3, revealed a weekly skin assessment for Resident #4 with excoriation to the right/left lower buttock coccyx; treatment of [REDACTED]. -5/29/12 at 2:25 p.m., documented by LPN #1, revealed that Resident #4 continued to have excoriation to the coccyx, reddened surrounding tissue, improving, more clean area that measured 4 cm x 3 cm with no depth. -5/31/12 at 10:38 a.m., documented by LPN #2, revealed a "coccyx decub" for Resident #4 with no description and with a treatment of [REDACTED]. There was no documented evidence that Resident #4's coccyx/wound was assessed on development or weekly by a Registered Nurse (RN) as required. Review of a Nurse's note dated 6/3/12 at 10:30 a.m., documented by RN#5, revealed that Resident #4 was transferred to the ER/Acute care hospital at 9:50 a.m. for evaluation. A further Nurse's note dated 6/3/12 at 10:53 a.m. by RN #5 revealed that Resident #4 was tachypnic to periods of apnea about 5-10 seconds with irregular patterns noted. It was documented that the nurse initiated an IV as ordered related to a preliminary wound culture report without success. Resident #4's temperature was 100.3 axillary, pulse 67, respirations 32, oxygen saturation of 97% on room air, and blood pressure of 142/64. There had been no previous documentation of a wound culture, or that the physician had ordered a wound culture for Resident #4. There was no documented evidence that the physician or family had been notified of a wound on Resident #4's coccyx or any treatment in process prior to Resident #4's discharge to the hospital. Review of a Nurse's note dated 6/3/12 at 1:21 p.m. revealed that a wound culture from Resident #4's coccyx area revealed numerous gram positive cocci and moderate gram negative bacilli. There was no documentation of the culture being ordered or when it was collected. Review of a laboratory report for Resident #4 with a collection date of 6/1/12 from a "coccyx wound" revealed the following organisms reported on 6/5/12: 1. Proteus mirabilis, Gram negative bacilli 2. Gram bacilli 3. [MEDICAL CONDITION], and [MEDICATION NAME] sensitive [MEDICATION NAME] faecalis. There was no documentation of a physician's orders [REDACTED]. Review of the hospital History and Physical for Resident #4 dated 6/4/12 revealed that Resident #4 had a large sacral decubitus ulcer present on admission (6/3/12). Review of the hospital "Flowsheet" dated 6/3/12 at 3:00 p.m. revealed that Resident #4 had a pressure wound to the coccyx that was unstageable and measured 15 cm x 9 cm with a moderate foul odor. Review of Resident #4's Medication Administration Record/Treatment Administration Record (MAR/TAR) revealed that a treatment of [REDACTED]. There was no documented evidence of a description of the wound, the reason for change in treatment, and no documented evidence that the physician or family was notified of the treatment/wound. There was no documented evidence of a signed physician's orders [REDACTED]. Review of Resident #4's physician's orders [REDACTED]. On 5/17/12 there was a documented physician's orders [REDACTED]. On 6/3/12 Resident #4 had a physician's orders [REDACTED]. Review of computerized physician's orders [REDACTED].#1. The order was to clean with wound cleanser, apply Calcium Alginate and dry dressing to coccyx twice daily; first date 5/17/12, until resolved. There was no documented evidence that the physician or family had been notified of the wound and/or treatment. There was no evidence that the physician had actually given the order for the Calcium Alginate treatment for [REDACTED]. (Refer to the interview with Physician #2 on 6/27/12 at 2:55 p.m. which revealed that he had not been aware that Resident #4 had a decubitus ulcer on the coccyx and had not given orders for treatment of [REDACTED]. Review of Activity of Daily Living (ADL) documentation on 5/21/12 at 5:31 p.m., by Certified Nursing Assistant (CNA) #1, revealed an open area to Resident #4's buttocks/coccyx. (Refer to interview with CNA #1 on 6/28/12 at 12:25 p.m. which revealed that she had seen and had informed the nurse about the open wound on Resident #4. Review of the weekly team meeting notes dated 5/18/12, 5/24/12, and 6/1/12, attended by the Director of Nursing (DON), Treatment Nurse, MDS Coordinator, Care Plan Coordinator, and Dietary Manager revealed that Resident #4 had in-house excoriations. There was no mention of decubitus for Resident #4 or culture, or treatment changes in the weekly team meetings. Review of Resident #4's care plan dated 5/10/12 revealed a potential for impaired skin integrity with approaches for skin assessment per policy and note changes in level of risk for skin breakdown and to report changes to the nurse. Resident #4's care plan was updated on 5/18/12 to include impaired skin integrity manifested by excoriation to the coccyx on admission (no documented evidence of skin problems on admission). There was no documented evidence that Resident #4's care plan was reviewed and revised to include treatment/culture/documentation of a pressure ulcer prior to Resident #4 going to the hospital on [DATE]. Interview with the Director of Nursing (DON) on 6/26/12 at 9:15 a.m. with the Quality Improvement Consultant (QIC) and Administrator present, stated that Resident #4's family came to the facility and was angry about her condition deteriorating so quickly and wanted to know if they were aware of her breakdown. The DON stated that the family had been aware of Resident #4's excoriation to start and it was facility policy to let the family know of any changes in status or breakdown. Interview with Licensed Practical Nurse (LPN) #1 Treatment Nurse, on 6/26/12 at 11:20 a.m. revealed that Resident #4 was admitted with a reddened area (coccyx) and within a few days it had darkened but was not opened. LPN #1, with the Quality Improvement Consultant (QIC) present, stated that she was observing Resident #4 daily Monday through Friday and Resident #4 had some [MEDICAL CONDITION] and didn't look right. LPN #1 stated that she had cultured Resident #4's (coccyx) area, more of a bruised hardened area, because that's what the DON told her to do. When the consultant questioned LPN #1 as to why she would culture something that was not open LPN #1 just replied that she had not wanted the area to get bad and again stated that the area wasn't open. Further interview with LPN #1 on 6/26/12 at 12:10 p.m. revealed that Resident #4's area on her bottom was not open but was weepy and that she had put Calcium Alginate to dry it up. LPN #1 admitted to not notifying the physician or Responsible Party (RP) about the area on Resident #4's coccyx and had not called the physician for an order for [REDACTED]. LPN #1 stated that it was usually the charge nurse who notified the MD/RP (of changes). Further interview with LPN #1 on 6/26/12 at 1:45 p.m., with the Consultant present, revealed that she was having trouble with anything sticking to Resident #4's (bottom) so she had asked the DON about using Calcium Alginate to try to protect and keep the area from getting worse. The DON was present on 6/26/12 (2:10 p.m.) during the interview with LPN #1 and denied knowledge of LPN #1 asking him about the Calcium Alginate for Resident #4. LPN #1 stated that she had cultured the area on Resident #4's coccyx because the resident was getting worse and that she thought this area on Resident #4's bottom might be considered (as a source). LPN #1 admitted that she had not contacted the physician for the culture order or the Calcium Alginate order, that she had just put the orders in the computer. The Consultant informed LPN #1 that the physician still had to be notified of a change in condition and give the order, that she couldn't just put an order in the computer. LPN #1 stated that there were times that she would change a treatment and did not notify the physician because she just used the(wound) protocol. LPN #1 stated that she did all of the wound evaluations and measurements. LPN #1 stated that she did usually let the family know of any changes but that it might not always be documented. LPN #1 admitted to not notifying the family/MD of Resident #4's coccyx area. The DON, still present, stated that there probably would not be any documented RN assessments of any resident's wounds other than when admitted , that he had not documented any assessments himself, that he had left it up to LPN #1 to do the treatments, measurements and documentation. The DON stated that he had not notified the MD/RP of Resident #4's wound to her coccyx except when the family had came in and asked about it (after resident in hospital) and he told them it had been an excoriation (according to medical record). Interview with the DON on 6/26/12 at 11:40 a.m. with the QIC present, revealed that he had looked at Resident #4's bottom on 5/31/12 for the high risk meeting and it was extremely red, but that he had seen no opening, but it was moist and weepy. The QIC reminded the DON that the Calcium Alginate was ordered on [DATE] so according to protocol the wound had to be open. The DON again stated that he did not see the wound open, only a big red area. Interview with the DON on 6/26/12 at 4:15 p.m. as he was reviewing Resident #4's medical record, revealed that he saw no order for the wound culture on 6/1/12. The DON stated that he was not aware that a culture had been done on Resident #4 at the time. The DON stated that if a culture was obtained the physician should be called for the order and the order entered (into computer) and printed out, not necessary to have a handwritten order, but should have. The DON stated that he didn't see a handwritten or printed order for the Calcium Alginate on 5/31/12. With review of LPN #2's skin assessment (body audit) note on 5/31/12 for the coccyx decubitus, the DON stated that the area should have been described and he saw nothing in any of the notes where the MD/RP had been notified of the coccyx area or wound. The DON stated that Calcium Alginate would not have been the protocol for an excoriation. The DON stated that he had not seen Resident #4 on 5/31/12 or 6/1/12 (he previously had said he saw her on 5/31/12), it would have been on 5/28/12 or 5/29/12 before the team meeting where the team talked about each wound. The DON stated that the two (2) MDS Nurses, Dietary, the Wound Nurse (LPN#1) and himself was usually at the meeting. The DON stated that Resident #4 still had excoriation and that it was hard to get creams and dressings to stick to the area. The DON stated that they continued treatment to keep it clean/dry and that he didn't recall any discussion about Calcium Alginate in the meeting. The DON stated that they had not done a very good job of documentation. Interview with the QIC on 6/26/12 at 3:15 p.m. revealed that LPN #1 should have notified the MD/RP of any changes or have the RN call for any wound/excoriation and not just write an order unless it was the protocol. The QIC stated that Calcium Alginate was not the protocol for an excoriation; it would be for a Stage III or higher wound. Interview with the QIC on 6/26/12 at 4:15 p.m. revealed that LPN #1 was being suspended for an investigation into documentation which included writing physician orders [REDACTED]. Interview with RN #5 on 6/26/12 at 2:30 p.m. revealed that she had gone with LPN #1 to ook at Resident #4 upon admit and didn't recall any wounds. RN #5 stated that she recalled being told that Resident #4 had developed some redness on her butt. RN #5 stated that she recalled going with RN #9 on a weekend to look at Resident #4's bottom and stated that the bottom was red, maybe emacerated but not sure. RN #5 stated that there was a treatment already in place. RN #5 stated that she was present when #4 was sent to the hospital (6/3/12) but did not do a skin assessment because the resident was real sick and tachypnic. RN #5 stated that she had seen the wound culture report of the coccyx the morning that Resident #4 was sent to the hospital but did not know who had done the culture. RN #5 stated that she did not recall anyone telling her of any wound change or change in treatment for [REDACTED]. RN #5 stated that she did not assess wounds except on admit/readmit, that the treatment nurse did the rest of the time. Interview with RN# 9 on 6/27/12 at 6:45 p.m. revealed that the Treatment Nurse usually called the MD/RP of any change in wound/skin and the Charge Nurse could too. RN #9 stated that she had worked the weekend of 5/19/12 and 5/20/12 doing treatments and had observed Resident #4's bottom for the first time. RN #9 stated that Resident #4 had an open wound at that time on her sacral area, stage II about the size of a half dollar. RN #9 stated that it was more like a blistered area with the top off. RN #9 stated that the treatment was skin prep and a bandage, doesn't recall any drainage. RN # 9 stated that the next time she saw Resident #4's wound was 6/2/12 and it had looked a little worse and a little bigger. RN # 9 stated that the treatment had been changed for Resident #4 and she assumed that LPN # 1 had changed the treatment after notifying the MD/RP. RN #9 stated that she did not notify the MD/RP herself because she had assumed that it had been done by LPN #1 during the week since the treatment had changed. RN #9 stated that she did the treatment that was ordered and didn't recall the wound looking infected. RN #9 stated that RN #5 had looked at Resident #4 with her at one time but could not recall exactly when. RN #9 stated that Calcium Alginate would not be an appropriate treatment for [REDACTED].#4's wound on 6/3/12 before being sent to the hospital. RN # 9 stated that when a resident was admitted that the RN would assess the skin/wounds but after that the treatment nurse would do the weekly measurements/documentation of wounds. Interview with LPN #2 on 6/28/12 at 3:40 p.m. revealed that she had done a weekly body audit on Resident #4 and there was a wound on the coccyx with redness around the edges and white areas with a darkish green color. LPN #2 stated that the wound had some drainage coming from it that smelled awful. LPN #2 described the size of the wound around 8 cm x 5 cm with moisture. LPN #2 stated that this was around 5/31/12 when she saw the wound after Resident #4's bandage had come off (coccyx area) and that CNA #1 was in the room with her. LPN #2 stated that LPN #1 came in the room to do Resident #4's treatment while she (LPN #2) and CNA #1 was there and so she (LPN #2) thought that LPN #1 would notify the MD and get the treatment changed if needed and document. On 6/28/12 at 4:20 p.m. LPN #2 stated that she had not been aware that a culture was done on Resident #4 until the results came in. LPN #2 stated that usually the treatment nurse did everything with the wounds; treatments, changes, notification, orders and documentation. Interview with LPN # 4 on 6/28/12 at 4:00 p.m. revealed that she had been the charge nurse on 5/31/12 and that LPN #1 had told her that Resident #4's wound was "going south" and that she was going to leave her bottom open for awhile. LPN #4 stated that she had not looked at Resident #4's wound that day, because typically the treatment nurse took care of her own orders, calling MD/RP, assessing and documentation of wounds. LPN #4 stated that LPN #1 never mentioned anything about Calcium Alginate or another treatment to her. The QIC was present and stated that a change of condition should have been done, physician notified and a wound assessment done by the RN. Interview with CNA # 1 on 6/28/12 at 12:25 p.m. revealed that the dressing had been off Resident #1's bottom one day and she had seen an open wound and it had a foul smell. CNA # 1 stated that she had notified LPN #1 and LPN #2 and they had looked

Complaint Investigation (CI) MS # Based on observation, interview, record review and policy review the facility failed to ensure that the physician and/or Responsible Party (RP) were notified of significant changes in resident skin conditions/pressure sore and/or changes in treatment for [REDACTED].#2, #3, #4, #6, and #8 and one (1) Unsampled Resident, Resident #B. The failure to notify the physician of pressure ulcer development/changes in order to provide the appropriate treatments put these seven (7) residents at risk for significant harm. The facility's failure to notify the physician/RP of Resident #1, #2, #3, #4, #6, #8 and #B's wound development and treatment changes was deemed an Immediate Jeopardy (IJ) on 6/29/12 at 9:50 a.m. The IJ began on 5/17/12 and was determined to be removed on 7/3/12. The Administrator was notified of the IJ on 6/29/12 at 10:00 a.m. The facility provided a credible Allegation of Compliance (AoC) on 7/3/12. Based on the facility's implementation of corrective actions and an acceptable AoC, the Immediate Jeopardy was removed as of 7/3/12 and lowered to an "E" level which constitutes no actual harm with potential for more than minimal harm. Findings included: Resident #1 Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/6/12, revealed that no decubitus were present. Resident #1 had severe cognitive impairment. Resident #1 was totally dependent, required assistance for all Activities of Daily Living (ADLs). Resident #1 was incontinent of bowel and bladder. Observation and interview with Resident #1 on 6/26/12 at 10:35 a.m. with LPN #1 and LPN #3 present, revealed that she had a denuded area to the right coccyx approximately 3 centimeter (cm) x 2 cm that was reddened with no drainage. There was a small area to the left coccyx less than 0.5 cm. LPN #1 stated that there had not been any open areas the day before, that it had only been excoriated. The DON was called to the room at 10:45 a.m. to assess Resident #1's coccyx and he stated that it wasn't open the day before when he looked at it, only excoriated, now it would be classified as a stage II. Interview with CNA #3 on 6/28/12 at 10:46 a.m. revealed that Resident #1's bottom had a blistered like area on Saturday (6/23/12) and then on Sunday (6/24/12) it was like the blister had burst. CNA #3 stated that she notified LPN #1 and that LPN #1 did a treatment. Review of Resident #1's Pressure Sore Risk assessment dated [DATE] revealed a score of 11. A score of 8 or higher is designated as high risk. Review of the "Skin Report" dated 6/17/12-6/23/12 revealed that Resident #1 had excoriation to left mid buttock, onset date 6/17/12, that measured .8 cm x .8 cm and no depth. On 6/20/12 Resident #1's left mid buttock wound measured .8 cm x .8 cm and no depth. On 6/25/12 Resident #1's left mid buttock wound measured 3.0 cm x 5.0 cm x .1 cm. Resident #1's follow-up assessment was not documented by the DON until 6/28/12 which revealed excoriation progressed to Stage II pressure ulcer to coccyx measuring 3.0 cm x 5.0 cm x .1 cm. Review of Resident #1's Nurse's Notes and weekly skin assessments (body audits) dated 6/13/12 at 6:26 a.m. and 6/20/12 at 1:33 p.m. revealed that Resident #1 had no skin problems or [MEDICAL CONDITION] present. (excoriation had already been identified on 6/17/12 by LPN #1) Review of Resident #1's June 2012 Medication Administration/Treatment Administration Record (MAR/TAR) revealed [MEDICATION NAME] dressing to left inner buttock every three days on 6/17/12 ([MEDICATION NAME] is on facility's protocol for a stage II). On 6/25/12 the treatment was changed to skin prep and dry dressing to right and left middle buttock b.i.d (twice daily). There was no documented physician's orders [REDACTED]. There was no documented evidence that the physician was notified of the wound on 6/17/12. Resident #2: Resident #2 was re-admitted [DATE] and had [DIAGNOSES REDACTED]. Resident #2 had a stage III sacral decubitus. Observation of Resident #2's treatment by LPN #1 on 6/26/12 at 11:00 a.m. revealed a stage II decubitus to the coccyx which measured approximately 2 cm x 2 cm x 0 cm. with no odor or drainage. LPN #1 stated that Resident #2 had gone to the hospital several times and came back with a stage III and was now healing. Review of Resident #2's MDS with an ARD of 6/11/12 revealed that he was cognitively impaired and required limited to total assistance with ADLs. Resident #2 was incontinent of bowel/bladder. The MDS was coded with a stage III pressure ulcer that measured 3 cm x 2 cm x 0.1 cm. Review of Resident #2's Nurse's notes dated 4/16/12 revealed no RN assessment of his sacral wound upon admission. A note from LPN #1 on 4/16/12 at 2:58 p.m. revealed a stage III pressure ulcer 7.4 cm x 3.8 cm x 0 cm. Worsened stage III with slough occurring. Weekly documentation and description/measurements of the sacral wound from 4/16/12-6/25/12 was by LPN #1, treatment nurse. There were no RN assessments/documentation of Resident #2's sacral wound. Review of the "Skin Report" dated 6/17/12-6/23/12 revealed that Resident #2's sacral wound was 2.0 cm x 2.0 x0.1. On 6/27/12 Resident #2's sacral wound was documented in the nurse's notes as 2.0 cm x 1.5 cm x 0 cm. Review of Resident #2's physician's orders [REDACTED]. Review of Resident #2's June 2012 Medication Treatment Record/Treatment Administration Record (MAR/TAR) revealed that the treatment was changed on 6/1/12 to Santyl and dry dressing to sacrum b.i.d (twice daily). The treatment was changed again on 6/12/12 to hydrogel and dry dressing to sacrum b.i.d. There was no documented physician's orders [REDACTED]. There was no documented evidence that the physician was notified of the wound/treatment changes. Interview with the Quality Improvement Consultant (QIC) on 6/30/12 at 3:00 p.m. revealed that no RN assessments had been documented for Resident #2's sacral wound. The QIC stated that the policy was for an RN to do the admission assessment for wounds and there should have been a documented RN assessment weekly. The QIC stated that there was not a physician's orders [REDACTED]. Resident #3: Resident #3 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's MDS with an ARD on 4/26/12 revealed that he had severely cognitive impairment and required total assistance with ADLs and was incontinent of bowel with a indwelling suprapubic catheter. The MDS revealed no decubitus were present. Observation and interview of Resident #3 and DON on 6/26/12 at 10:08 a.m. revealed the following wounds: Pressure Ulcer to buttocks unstageable measuring 6.0 cm x 6.0 cm, no depth, redden area; left heel ulcer with purple discoloration measuring 3.0 cm x 3.0 cm, no depth. The DON stated that Resident #3 had increased blood sugars over the weekend and his condition had deteriorated over the past few weeks. Resident #3 was not responsive, had oxygen at 2 liters via trach, Glucerna 1.2 at 65 cc/hr via feeding tube and was on a specialty mattress. Resident #3 had pillows for positioning and heels floated and cradle intact. Observation of Resident #3 with DON present on 6/27/12 at 12:35 p.m. revealed left heel Deep Tissue Injury (DTI) -measuring 3.0 cm x 3.5 cm, no depth; right heel unstageable measuring 3.5 cm x 5.0 cm, no depth. The DON stated unsure why areas on heels developed, heels may not be up at all times due to slipping off pillows, but knows that CNA turns resident and tries to keep foot cradle intact and heels floated. The DON stated the resident's disease process has deteriorated and areas are unavoidable, doing all we can. Review of weekly skin report revealed information about Resident #3's wound documentation: -5/7/12 at 7:33 a.m., documented by LPN #1 revealed that Resident #3 had a pressure ulcer Stage I to right posterior heel, onset date 5/3/12, redden area measuring 3.0 cm x 1.0 cm, with no depth. There was no documented evidence that the Physician was notified of the wound/treatments. There was no RN assessment/documentation of Resident #3's right heel ulcer. -5/14/12 at 3:19 p.m. documented by LPN #1 revealed that Resident #3 had a Stage I pressure ulcer to right posterior heel measuring 3.0 cm x 1.0 cm, with no depth. -5/18/12 at 9:24 a.m. documented by LPN #1 revealed that Resident #3 had a Stage II to right mid buttock, onset date 5/18/12, reddened area measuring 2.0 cm x 2.0 cm, with no depth. There was no documented physician's orders [REDACTED]. There was no documented evidence that the physician was notified of the wound/treatments. There was no RN assessment/documentation of Resident #3's right mid buttock pressure ulcer. -6/4/12 at 2:32 p.m. documented by LPN #1 revealed that Resident #3 had a Stage II to right mid buttock, reddened area measuring 2.0 cm x 2.0 cm, with no depth. -6/4/12 at 2:32 p.m. documented by LPN #1 revealed that Resident #3 had a Stage I to right posterior heel, measuring 2.0 cm x 1.0 cm, with no depth. -6/11/12 at 2:18 p.m. documented by LPN #1 revealed that Resident #3 had a Stage I to right posterior heel, measuring 2.0 cm x 1.0 cm, no depth. -6/11/12 at 2:18 p.m. documented by LPN #1 revealed that Resident #3 had a Stage II to right mid buttock, reddened area measuring 2.0 cm x 1.8 cm, no depth. 6/14/12 treatment changed to hydrogel and dry dressing. There is no documented physician's orders [REDACTED]. -6/18/12 at 3:07 p.m. documented by LPN #1 revealed that Resident #3 had a Stage II to right mid buttock, reddened area measuring 2.0 cm x 1.0 cm, no depth. -6/25/12 at 11:28 a.m. documented by LPN #1 revealed the Resident #3 had a Stage 1 to right posterior heel, measuring 1 cm x 1 cm, with no depth. -6/25/12 at 11:28 a.m. documented by LPN revealed that Resident #3 had a Stage 1 to right posterior heel , healed. -6/25/12 at 11:34 a.m. documented by LPN #1 revealed that Resident #3 had a unstageable, blue/black color, "worsened" stage II to right mid buttock, measuring 6.0 cm x 6.0 cm , with no depth. Review of Resident #3's May and June MAR/TAR revealed treatment of [REDACTED]. Treatment changed to skin prep and a dry dressing on 6/18/12. Review of Resident #3's physician's orders [REDACTED]. There was no documented evidence that the Physician was notified of the wounds/treatments. Review of Nurse's notes reveal there was no RN assessment/documentation of Resident #3's right heel ulcer. On 5/18/12 documented treatments of extra protective cream to right mid buttock (coccyx) b.i.d on May 2012 (MAR/TAR). On 5/24/12 the treatment changed to skin prep and a dry dressing on May 2012 (MAR/TAR). There was no documented physician's orders [REDACTED]. There was no documented evidence that the physician was notified of the wound/treatments. Interview with the QIC on 6/28/12 at 4:35 p.m. revealed that she reviewed Resident #3's chart and couldn't find documentation of where the physician was always notified of wounds/changes. Resident #4: Resident #4 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/18/12, revealed that no decubitus ulcers were present. Resident #4 had long/short term memory problems and had severe cognitive impairment. Resident #4 required total assistance for all Activities of Daily Living (ADLs). Resident #4 was incontinent of bowel and bladder. Review of a Nutritional assessment dated [DATE] revealed that Resident #4 had no skin concerns, and that nutritional needs were being met by tube feeding. An updated note dated 5/21/12 revealed that Resident #4 had an "area to the coccyx". The current treatment was continued. Review of Resident #4's Nurse's admission notes dated 5/10/12 at 9:21 p.m., documented by RN #5, revealed that the treatment nurse had assessed the resident's skin with no noted open areas or pressure areas noted. Further note on 5/10/12 at 9:27 p.m., by RN #5, revealed that Resident #4 had no skin problems or [MEDICAL CONDITION] present. Review of further Nurse's notes for the following times and dates revealed information about Resident #4's skin: - 5/13/12 at 12:52 a.m. revealed a Pressure Sore Risk Assessment score of 14 for Resident #4. A score of 8 or higher is designated as high risk. -5/17/12 at 11:24 a.m., documented by LPN #1 (treatment nurse), revealed that Resident #4 had excoriation to the coccyx, onset date 5/17/12, that measured 4 centimeters (cm) in length, and 3 cm in width with no depth with healing in progress. (treatment of [REDACTED]. -5/21/12 at 3:27 p.m., documented by LPN #1, revealed that Resident #4 continued to have excoriation to the coccyx area that measured 4 cm. x 3 cm and no depth and that it appeared more clean. -5/24/12 at 3:09 p.m., documented by LPN #3, revealed a weekly skin assessment for Resident #4 with excoriation to the right/left lower buttock coccyx; treatment of [REDACTED]. -5/29/12 at 2:25 p.m., documented by LPN #1, revealed that Resident #4 continued to have excoriation to the coccyx, reddened surrounding tissue, improving, more clean area that measured 4 cm x 3 cm with no depth. -5/31/12 at 10:38 a.m., documented by LPN #2, revealed a "coccyx decub" for Resident #4 with no description and with a treatment of [REDACTED]. Review of a Nurse's note dated 6/3/12 at 10:30 a.m., documented by RN#5, revealed that Resident #4 was transferred to the ER/Acute care hospital at 9:50 a.m. for evaluation. A further Nurse's note dated 6/3/12 at 10:53 a.m. by RN #5 revealed that Resident #4 was tachypnic to periods of apnea about 5-10 seconds with irregular patterns noted. It was documented that the nurse initiated an IV as ordered related to a preliminary wound culture report without success. Resident #4's temperature was 100.3 axillary, pulse 67, respirations 32, oxygen saturation of 97% on room air, and blood pressure of 142/64. There had been no previous documentation of a wound culture, or that the physician had ordered a wound culture for Resident #4. There was no documented evidence that the physician or family had been notified of a wound on Resident #4's coccyx or any treatment in process prior to Resident #4's discharge to the hospital. Review of a Nurse's note dated 6/3/12 at 1:21 p.m. revealed that a wound culture from Resident #4's coccyx area revealed numerous gram positive cocci and moderate gram negative bacilli. There was no documentation of the culture being ordered or when it was collected. Review of a laboratory report for Resident #4 with a collection date of 6/1/12 from a "coccyx wound" revealed the following organisms reported on 6/5/12: 1. Proteus mirabilis, Gram negative bacilli 2. Gram bacilli 3. [MEDICAL CONDITION], and [MEDICATION NAME] sensitive [MEDICATION NAME] faecalis. There was no documentation of a physician's orders [REDACTED]. Review of the hospital History and Physical for Resident #4 dated 6/4/12 revealed that Resident #4 had a large sacral decubitus ulcer present on admission (6/3/12). Review of the hospital "Flowsheet" dated 6/3/12 at 3:00 p.m. revealed that Resident #4 had a pressure wound to the coccyx that was unstageable and measured 15 cm x 9 cm with a moderate foul odor. Review of Resident #4's Medication Administration Record/Treatment Administration Record (MAR/TAR) revealed that a treatment of [REDACTED]. There was no documented evidence of a description of the wound, the reason for change in treatment, and no documented evidence that the physician or family was notified of the treatment/wound. There was no documented evidence of a signed physician's orders [REDACTED]. Review of Resident #4's physician's orders [REDACTED]. On 5/17/12 there was a documented physician's orders [REDACTED]. On 6/3/12 Resident #4 had a physician's orders [REDACTED]. Review of computerized physician's orders [REDACTED].#1. The order was to clean with wound cleanser, apply Calcium Alginate and dry dressing to coccyx twice daily; first date 5/17/12, until resolved. There was no documented evidence that the physician or family had been notified of the wound and/or treatment. There was no evidence that the physician had actually given the order for the Calcium Alginate treatment for [REDACTED]. (Refer to the interview with Physician #2 on 6/27/12 at 2:55 p.m. which revealed that he had not been aware that Resident #4 had a decubitus ulcer on the coccyx and had not given orders for treatment of [REDACTED]. Review of Activity of Daily Living (ADL) documentation on 5/21/12 at 5:31 p.m., by Certified Nursing Assistant (CNA) #1, revealed an open area to Resident #4's buttocks/coccyx. (Refer to interview with CNA #1 on 6/28/12 at 12:25 p.m. which revealed that she had seen and had informed the nurse about the open wound on Resident #4. Interview with the Director of Nursing (DON) on 6/26/12 at 9:15 a.m. with the Quality Improvement Consultant (QIC) and Administrator present, stated that Resident #4's family came to the facility and was angry about her condition deteriorating so quickly and wanted to know if they were aware of her breakdown. The DON stated that the family had been aware of Resident #4's excoriation to start with and it was facility policy to let the family know of any changes in status or breakdown. Interview with LPN #1 Treatment Nurse, on 6/26/12 at 11:20 a.m. revealed that Resident #4 was admitted with a reddened area (coccyx) and within a few days it had darkened but was not opened. LPN #1, with the Quality Improvement Consultant (QIC) present, stated that she was observing Resident #4 daily Monday through Friday and Resident #4 had some [MEDICAL CONDITION] and didn't look right. LPN #1 stated that she had cultured Resident #4's (coccyx) area, more of a bruised hardened area, because that's what the DON told her to do. When the consultant questioned LPN #1 as to why she would culture something that was not open LPN #1 just replied that she had not wanted the area to get bad and again stated that the area wasn't open. Further interview with LPN #1 on 6/26/12 at 12:10 p.m. revealed that Resident #4's area on her bottom was not open but was weepy and that she had put Calcium Alginate to dry it up. LPN #1 admitted to not notifying the physician or Responsible Party (RP) about the area on Resident #4's coccyx and had not called the physician for an order for [REDACTED]. LPN #1 stated that it was usually the charge nurse who notified the MD/RP (of changes). Further interview with LPN #1 on 6/26/12 at 1:45 p.m., with the Consultant present, revealed that she was having trouble with anything sticking to Resident #4's (bottom) so she had asked the DON about using Calcium Alginate to try to protect and keep the area from getting worse. The DON was present on 6/26/12 (2:10 p.m.) during the interview with LPN #1 and denied knowledge of LPN #1 asking him about the Calcium Alginate for Resident #4. LPN #1 stated that she had cultured the area on Resident #4's coccyx because the resident was getting worse and that she thought this area on Resident #4's bottom might be considered (as a source). LPN #1 admitted that she had not contacted the physician for the culture order or the Calcium Alginate order, that she had just put the orders in the computer. The Consultant informed LPN #1 that the physician still had to be notified of a change in condition and give the order, that she couldn't just put an order in the computer. LPN #1 stated that there were times that she would change a treatment and did not notify the physician because she just used the (wound) protocol. LPN #1 stated that she did all of the wound evaluations and measurements. LPN #1 stated that she did usually let the family know of any changes but that it might not always be documented. LPN #1 admitted to not notifying the family/MD of Resident #4's coccyx area. The DON, still present, stated that there probably would not be any documented RN assessments of any resident's wounds other than when admitted , that he had not documented any assessments himself, that he had left it up to LPN #1 to do the treatments, measurements and documentation. The DON stated that he had not notified the MD/RP of Resident #4's wound to her coccyx except when the family had came in and asked about it (after resident in hospital) and he told them it had been an excoriation (according to medical record). Interview with the DON on 6/26/12 at 4:15 p.m. as he was reviewing Resident #4's medical record, revealed that he saw no order for the wound culture on 6/1/12. The DON stated that he was not aware that a culture had been done on Resident #4 at the time. The DON stated that if a culture was obtained the physician should be called for the order and the order entered (into computer) and printed out, not necessary to have a handwritten order, but should have. The DON stated that he didn't see a handwritten or printed order for the Calcium Alginate on 5/31/12. With review of LPN #2's skin assessment (body audit) note on 5/31/12 for the coccyx decubitus, the DON stated that the area should have been described and he saw nothing in any of the notes where the MD/RP had been notified of the coccyx area or wound. The DON stated that Calcium Alginate would not have been the protocol for an excoriation. Interview with the QIC on 6/26/12 at 4:15 p.m. revealed that LPN #1 was being suspended for an investigation into documentation which included writing physician orders [REDACTED]. Interview with RN #5 on 6/26/12 at 2:30 p.m. revealed that she had gone with LPN #1 to look at Resident #4 upon admit and didn't recall any wounds. RN #5 stated that she recalled being told that Resident #4 had developed some redness on her butt. RN #5 stated that she recalled going with RN #9 on a weekend to look at Resident #4's bottom and stated that the bottom was red, maybe macerated but not sure. RN #5 stated that there was a treatment already in place. RN #5 stated that she was present when #4 was sent to the hospital (6/3/12) but did not do a skin assessment because the resident was really sick and tachypnic. RN #5 stated that she had seen the wound culture report of the coccyx the morning that Resident #4 was sent to the hospital but did not know who had done the culture. RN #5 stated that she did not recall anyone telling her of any wound change or change in treatment for [REDACTED]. RN #5 stated that she did not assess wounds except on admit/readmit, that the treatment nurse did the rest of the time. Interview with RN# 9 on 6/27/12 at 6:45 p.m. revealed that the Treatment Nurse usually called the MD/RP of any change in wound/skin and the Charge Nurse could too. RN #9 stated that she had worked the weekend of 5/19/12 and 5/20/12 doing treatments and had observed Resident #4's bottom for the first time. RN #9 stated that Resident #4 had an open wound at that time on her sacral area, Stage II about the size of a half dollar. RN #9 stated that it was more like a blistered area with the top off. RN #9 stated that the treatment was skin prep and a bandage, doesn't recall any drainage. RN # 9 stated that the next time she saw Resident #4's wound was 6/2/12 and it had looked a little worse and a little bigger. RN # 9 stated that the treatment had been changed for Resident #4 and she assumed that LPN # 1 had changed the treatment after notifying the MD/RP. RN #9 stated that she did not notify the MD/RP herself because she had assumed that it had been done by LPN #1 during the week since the treatment had changed. RN #9 stated that she did the treatment that was ordered and didn't recall the wound looking infected. RN #9 stated that RN #5 had looked at Resident #4 with her at one time but could not recall exactly when. RN #9 stated that Calcium Alginate would not be an appropriate treatment for [REDACTED]. Interview with LPN #2 on 6/28/12 at 3:40 p.m. revealed that she had done a weekly body audit on Resident #4 and there was a wound on the coccyx with redness around the edges and white areas with a darkish green color. LPN #2 stated that the wound had some drainage coming from it that smelled awful. LPN #2 described the size of the wound around 8 cm x 5 cm with moisture. LPN #2 stated that this was around 5/31/12 when she saw the wound after Resident #4's bandage had come off (coccyx area) and that CNA #1 was in the room with her. LPN #2 stated that LPN #1 came in the room to do Resident #4's treatment while she (LPN #2) and CNA #1 was there and so she (LPN #2) thought that LPN #1 would notify the MD and get the treatment changed if needed and document. On 6/28/12 at 4:20 p.m. LPN #2 stated that she had not been aware that a culture was done on Resident #4 until the results came in. LPN #2 stated that usually the treatment nurse did everything with the wounds: treatment changes, notification, orders and documentation. Interview with LPN # 4 on 6/28/12 at 4:00 p.m. revealed that she had been the charge nurse on 5/31/12 and that LPN #1 had told her that Resident #4's wound was "going south" and that she was going to leave her bottom open for awhile. LPN #4 stated that she had not looked at Resident #4's wound that day, because typically the treatment nurse took care of her own orders, calling MD/RP, assessing and documentation of wounds. LPN #4 stated that LPN #1 never mentioned anything about Calcium Alginate or another treatment to her. The QIC was present and stated that a change of condition should have been done, physician notified and a wound assessment done by the RN. Interview with CNA # 1 on 6/28/12 at 12:25 p.m. revealed that the dressing had been off Resident #1's bottom one day and she had seen an open wound and it had a foul smell. CNA # 1 stated that she had notified LPN #1 and LPN #2 and they had looked at Resident #4's bottom and maybe RN #3. CNA #1 stated that she had documented in the ADLs but couldn't recall the exact date. Interview with RN #3 on 6/27/12 at 2:10 p.m. revealed that the normal procedure when a resident was admitted was to do a head-toe assessment and if wounds were present assess/stage along with the treatment nurse, then the treatment nurse would generally do the documentation. RN #3 stated that she didn't do weekly wound assessments but would look at a wound if the treatment nurse asked her to. RN #3 stated that the treatment nurse normally called the MD/RP about any changes in the skin/wound. RN #3 stated that LPN #1 had asked her to look at Resident #4's bottom one time and there was a reddened area, possibly a stage II, more like incontinent [MEDICAL CONDITION]. RN #3 stated that she didn't recall being asked about Calcium Alginate and was not specifically told about any changes to Resident #4's skin by the treatment nurse. RN #3 stated that she was not involved in the weekly skin meetings but depended on the nurses to report any skin issues. Interview with the QIC, on 6/28/12 at 2:00 p.m., revealed that the documentation on the ADL from CNA #1 on 5/21/12 at 5:31 p.m. that Resident #4 had an open area to the coccyx made more sense as to why the Calcium Alginate was used. The QIC stated that LPN #1 had just made some bad mistakes in using her own judgment about treating (wounds) and not notifying the physician/ DON about the wounds and putting orders in the computer and not on a hard copy. The QIC stated that someone should have assessed, documented, care planned and notified (MD/RP) of Resident #4's wound. Interview with Resident #4's physician, Physician #2, on 6/27/12 at 2:55 p.m. revealed that he had not been notified of Resident #4 having any pressure areas or of a wound culture. Physician #2 stated that he had not looked at the protocols for wounds in a long time. Physician #2 stated that he wanted to be notified about any skin issues of his residents. Physician #2 stated that the wound protocol was okay to follow for things like stage I-barrier creams/skin prep and stage II-[MEDICATION NAME] but the physician still needed to be notified of the wound/treatment to get any further instructions. Physician #2 stated that the physician should be called for a lab order, that staff shouldn't take it upon themselves to do any order, that the physician gives the order. Physician #2 stated that staff called his Nurse Practitioner at times. Nurse Practitioner was not available for interview. (LPN #1 had admitted to not notifying the MD for orders/wound). Physician #2 stated that Calcium Alginate was not appropriate for excoriations or Stage II wounds. Interview with Physician #1, Medical Director, on 6/27/12 at 5:35 p.m. revealed that Calcium Alginate was expected to be used on wounds that were moist with slough. Physician #1 stated that skin concerns should be assessed/documented and the physician/family notified. Physician #1 stated that she had attended QA meeting and was made aware of the wound problems that the facility was working on. Attempts were made to contact Resident #4's family members without success on 6/25/12 at 7:00 p.m., 6/26/12 at 8:00 a.m. and 10:00 a.m., 6/27/12 at 1:05 p.m., 6/28/12 at 6:00 p.m. and 6/29/12 at 5:20 p.m. Resident #6: Resident #6 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's most recent MDS with an ARD of 6/13/12 revealed that he had severe cognitive impairment and required extensive assistance with ADLs. Resident #6 was incontinent of bowel/bladder and had a documented stage II pressure ulcer Observation and interview with Resident #6 on 6/28/12 at 6/28/12 with the DON present revealed that he was alert and oriented to person and had a pressure relief boot intact which was removed by the DON. Resident #6 had a stage III to the right heel which measured 1 cm x 1 cm x 0.3 cm. with slight serosanguinous dr

Complaint Investigation (CI) MS Based on interview, record review and policy review the facility failed to ensure that one (1) of 10 sampled residents, Resident #4, was not neglected as evidenced by failure to provide appropriate assessments for pressure sores by a Registered Nurse, failure to notify the physician/family of pressure ulcer development, failure to procure appropriate physician orders [REDACTED]. Resident #4 was diagnosed with [REDACTED]. Resident #4 had a large unstageable sacral decubitus ulcer measuring 15 centimeters (cm) x 9 cm. that was present on admission to the hospital on [DATE]. Resident #4 had results of a wound culture that revealed infection to the wound on her sacral area. There was no documentation in the medical record that Resident #4 had a decubitus prior to transport to the hospital. Resident #4 expired at the hospital on [DATE]. The facility's failure to prevent Resident #4's neglect by not providing proper wound assessments, treatments and notification to the physician was deemed an Immediate Jeopardy (IJ) on [DATE] at 9:50 a.m. The IJ began on [DATE] and was determined to be removed on [DATE]. The Administrator was notified of the IJ on [DATE] at 10:00 a.m. The facility provided a credible Allegation of Compliance (AoC) on [DATE]. Based on the facility's implementation of corrective actions and an acceptable Aoc, the IJ was removed as of [DATE] and lowered to a scope/severity of a "D" which constitutes no actual harm with potential for more than minimal harm. Findings included: Resident #4 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed that no decubitus ulcers were present. Resident #4 had long/short term memory problems and had severe cognitive impairment. Resident #4 required total assistance for all Activities of Daily Living (ADLs). Resident #4 was incontinent of bowel and bladder. Review of a Nutritional assessment dated [DATE] revealed that Resident #4 had no skin concerns, and that nutritional needs were being met by tube feeding. An updated note dated [DATE] revealed that Resident #4 had an "area to the coccyx". The current treatment was continued. Review of Resident #4's Nurse's admission notes dated [DATE] at 9:21 p.m., documented by Registered Nurse (RN) #5, revealed that the treatment nurse had assessed the resident's skin with no noted open areas or pressure areas noted. Further note on [DATE] at 9:27 p.m.,by RN #5, revealed that Resident #4 had no skin problems or [MEDICAL CONDITION] present. Review of further Nurse's notes for the following times and dates revealed information about Resident #4's skin: - [DATE] at 12:52 a.m. revealed a Pressure Sore Risk Assessment score of 14 for Resident #4. A score of 8 or higher is designated as high risk. -[DATE] at 11:24 a.m., documented by Licensed Practical Nurse (LPN) #1 (treatment nurse), revealed that Resident #4 had excoriation to the coccyx, onset date [DATE], that measured 4 centimeters (cm) in length, and 3 cm in width with no depth with healing in progress. (treatment of [REDACTED]. -[DATE] at 3:27 p.m., documented by LPN #1, revealed that Resident #4 continued to have excoriation to the coccyx area that measured 4 cm. x 3 cm and no depth and that it appeared more clean. -[DATE] at 3:09 p.m., documented by LPN #3, revealed a weekly skin assessment for Resident #4 with excoriation to the right/left lower buttock coccyx; treatment of [REDACTED]. -[DATE] at 2:25 p.m., documented by LPN #1, revealed that Resident #4 continued to have excoriation to the coccyx, reddened surrounding tissue, improving, more clean area that measured 4 cm x 3 cm with no depth. -[DATE] at 10:38 a.m., documented by LPN #2, revealed a "coccyx decub" for Resident #4 with no description and with a treatment of [REDACTED]. There was no documented evidence that Resident #4's coccyx/wound was assessed on development or weekly by a Registered Nurse (RN) as required. Review of a Nurse's note dated [DATE] at 10:30 a.m., documented by RN#5, revealed that Resident #4 was transferred to the ER/Acute care hospital at 9:50 a.m. for evaluation. A further Nurse's note dated [DATE] at 10:53 a.m. by RN #5 revealed that Resident #4 was tachypnic to periods of apnea about ,[DATE] seconds with irregular patterns noted. It was documented that the nurse initiated an IV as ordered related to a preliminary wound culture report without success. Resident #4's temperature was 100.3 axillary, pulse 67, respirations 32, oxygen saturation of 97% on room air, and blood pressure of ,[DATE]. There had been no previous documentation of a wound culture, or that the physician had ordered a wound culture for Resident #4. There was no documented evidence that the physician or family had been notified of a wound on Resident #4's coccyx or any treatment in process prior to Resident #4's discharge to the hospital. Review of a Nurse's note dated [DATE] at 1:21 p.m. revealed that a wound culture from Resident #4's coccyx area revealed numerous gram positive cocci and moderate gram negative bacilli. There was no documentation of the culture being ordered or when it was collected. Review of a laboratory report for Resident #4 with a collection date of [DATE] from a "coccyx wound" revealed the following organisms reported on [DATE]: 1. Proteus mirabilis, Gram negative bacilli 2. Gram bacilli 3. [MEDICAL CONDITION], and [MEDICATION NAME] sensitive [MEDICATION NAME] faecalis. There was no documentation of a physician's orders [REDACTED]. Review of the hospital History and Physical for Resident #4 dated [DATE] revealed that Resident #4 had a large sacral decubitus ulcer present on admission ([DATE]). Review of the hospital "Flowsheet" dated [DATE] at 3:00 p.m. revealed that Resident #4 had a pressure wound to the coccyx that was unstageable and measured 15 cm x 9 cm with a moderate foul odor. Review of Resident #4's Medication Administration Record/Treatment Administration Record (MAR/TAR) revealed that a treatment of [REDACTED]. There was no documented evidence of a description of the wound, the reason for change in treatment, and no documented evidence that the physician or family was notified of the treatment/wound. There was no documented evidence of a signed physician's orders [REDACTED]. Review of Resident #4's physician's orders [REDACTED]. On [DATE] there was a documented physician's orders [REDACTED]. On [DATE] Resident #4 had a physician's orders [REDACTED]. Review of computerized physician's orders [REDACTED].#1. The order was to clean with wound cleanser, apply Calcium Alginate and dry dressing to coccyx twice daily; first date [DATE], until resolved. There was no documented evidence that the physician or family had been notified of the wound and/or treatment. There was no evidence that the physician had actually given the order for the Calcium Alginate treatment for [REDACTED]. (Refer to the interview with Physician #2 on [DATE] at 2:55 p.m. which revealed that he had not been aware that Resident #4 had a decubitus ulcer on the coccyx and had not given orders for treatment of [REDACTED]. Review of Activity of Daily Living (ADL) documentation on [DATE] at 5:31 p.m., by Certified Nursing Assistant (CNA) #1, revealed an open area to Resident #4's buttocks/coccyx. (Refer to interview with CNA #1 on [DATE] at 12:25 p.m. which revealed that she had seen and had informed the nurse about the open wound on Resident #4. Review of the weekly team meeting notes dated [DATE], [DATE], and [DATE], attended by the Director of Nursing (DON), Treatment Nurse, MDS Coordinator, Care Plan Coordinator, and Dietary Manager revealed that Resident #4 had in-house excoriations. There was no mention of decubitus for Resident #4 or culture, or treatment changes in the weekly team meetings. Review of Resident #4's care plan dated [DATE] revealed a potential for impaired skin integrity with approaches for skin assessment per policy and note changes in level of risk for skin breakdown and to report changes to the nurse. Resident #4's care plan was updated on [DATE] to include impaired skin integrity manifested by excoriation to the coccyx on admission (no documented evidence of skin problems on admission). There was no documented evidence that Resident #4's care plan was reviewed and revised to include treatment, culture, or documentation of a pressure ulcer prior to Resident #4 going to the hospital on [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 9:15 a.m. with the Quality Improvement Consultant (QIC) and Administrator present, stated that Resident #4's family came to the facility and was angry about her condition deteriorating so quickly and wanted to know if they were aware of her breakdown. The DON stated that the family had been aware of Resident #4's excoriation to start and it was facility policy to let the family know of any changes in status or breakdown. Interview with LPN #1 Treatment Nurse, on [DATE] at 11:20 a.m. revealed that Resident #4 was admitted with a reddened area (coccyx) and within a few days it had darkened but was not opened. LPN #1, with the Quality Improvement Consultant (QIC/RN #7) present, stated that she was observing Resident #4 daily Monday through Friday and Resident #4 had some [MEDICAL CONDITION] and didn't look right. LPN #1 stated that she had cultured Resident #4's (coccyx) area, more of a bruised hardened area, because that's what the DON told her to do. When the consultant questioned LPN #1 as to why she would culture something that was not open LPN #1 just replied that she had not wanted the area to get bad and again stated that the area wasn't open. Further interview with LPN #1 on [DATE] at 12:10 p.m. revealed that Resident #4's area on her bottom was not open but was weepy and that she had put Calcium Alginate to dry it up. LPN #1 admitted to not notifying the physician or Responsible Party (RP) about the area on Resident #4's coccyx and had not called the physician for an order for [REDACTED]. LPN #1 stated that it was usually the charge nurse who notified the MD/RP (of changes). Further interview with LPN #1 on [DATE] at 1:45 p.m., with the Consultant present, revealed that she was having trouble with anything sticking to Resident #4's (bottom) so she had asked the DON about using Calcium Alginate to try to protect and keep the area from getting worse. The DON was present on [DATE] (2:10 p.m.) during the interview with LPN #1 and denied knowledge of LPN #1 asking him about the Calcium Alginate for Resident #4. LPN #1 stated that she had cultured the area on Resident #4's coccyx because the resident was getting worse and that she thought this area on Resident #4's bottom might be considered (as a source). LPN #1 admitted that she had not contacted the physician for the culture order or the Calcium Alginate order, that she had just put the orders in the computer. The Consultant informed LPN #1 that the physician still had to be notified of a change in condition and give the order, that she couldn't just put an order in the computer. LPN #1 stated that there were times that she would change a treatment and did not notify the physician because she just used the(wound) protocol. LPN #1 stated that she did all of the wound evaluations and measurements. LPN #1 stated that she did usually let the family know of any changes but that it might not always be documented. LPN #1 admitted to not notifying the family/MD of Resident #4's coccyx area. The DON, still present, stated that there probably would not be any documented RN assessments of wounds other than when admitted , that he had not documented any assessments himself, that he had left it up to LPN #1 to do the treatments, measurements and documentation. The DON stated that he had not notified the MD/RP of Resident #4's wound to her coccyx except when the family had came in and asked about it (after resident in hospital) and he told them it had been an excoriation (according to medical record). Interview with the DON on [DATE] at 11:40 a.m. with the QIC present, revealed that he had looked at Resident #4's bottom on [DATE] for the high risk meeting and it was extremely red, but that he had seen no opening, but it was moist and weepy. The QIC reminded the DON that the Calcium Alginate was ordered on [DATE] so according to protocol the wound had to be open. The DON again stated that he did not see the wound open, only a big red area. Interview with the DON on [DATE] at 4:15 p.m. as he was reviewing Resident #4's medical record, revealed that he saw no order for the wound culture on [DATE]. The DON stated that he was not aware that a culture had been done on Resident #4 at the time. The DON stated that if a culture was obtained the physician should be called for the order and the order entered (into computer) and printed out, not necessary to have a handwritten order, but should have. The DON stated that he didn't see a handwritten or printed order for the Calcium Alginate on [DATE]. With review of LPN #2's skin assessment (body audit) note on [DATE] for the coccyx decubitus, the DON stated that the area should have been described and he saw nothing in any of the notes where the MD/RP had been notified of the coccyx area or wound. The DON stated that Calcium Alginate would not have been the protocol for an excoriation. The DON stated that he had not seen Resident #4 on [DATE] or [DATE] (he previously had said he saw her on [DATE]), it would have been on [DATE] or [DATE] before the team meeting where the team talked about each wound. The DON stated that the two (2) MDS Nurses, Dietary, the Wound Nurse (LPN#1) and himself was usually at the meeting. The DON stated that Resident #4 still had excoriation and that it was hard to get creams and dressings to stick to the area. The DON stated that they continued treatment to keep it clean/dry and that he didn't recall any discussion about Calcium Alginate in the meeting. The DON stated that they had not done a very good job of documentation. Interview with the Quality Improvement Consultant (QIC) on [DATE] at 3:15 p.m. revealed that LPN #1 should have notified the MD/RP of any changes or have the RN call for any wound/excoriation and not just write an order unless it was the protocol. The QIC stated that Calcium Alginate was not the protocol for an excoriation; it would be for a Stage III or higher wound. Interview with the QIC on [DATE] at 4:15 p.m. revealed that LPN #1 was being suspended for an investigation into documentation which included writing physician orders [REDACTED]. Interview with RN #5 on [DATE] at 2:30 p.m. revealed that she had gone with LPN #1 to look at Resident #4 upon admit and didn't recall any wounds. RN #5 stated that she recalled being told that Resident #4 had developed some redness on her butt. RN #5 stated that she recalled going with RN #9 on a weekend to look at Resident #4's bottom and stated that the bottom was red, maybe emacerated but not sure. RN #5 stated that there was a treatment already in place. RN #5 stated that she was present when #4 was sent to the hospital ([DATE]) but did not do a skin assessment because the resident was real sick and tachypnic. RN #5 stated that she had seen the wound culture report of the coccyx the morning that Resident #4 was sent to the hospital but did not know who had done the culture. RN #5 stated that she did not recall anyone telling her of any wound change or change in treatment for [REDACTED]. RN #5 stated that she did not assess wounds except on admit/readmit, that the treatment nurse did the rest of the time. Interview with RN# 9 on [DATE] at 6:45 p.m. revealed that the Treatment Nurse usually called the MD/RP of any change in wound/skin and the Charge Nurse could too. RN #9 stated that she had worked the weekend of [DATE] and [DATE] doing treatments and had observed Resident #4's bottom for the first time. RN #9 stated that Resident #4 had an open wound at that time on her sacral area, stage II about the size of a half dollar. RN #9 stated that it was more like a blistered area with the top off. RN #9 stated that the treatment was skin prep and a bandage, doesn't recall any drainage. RN # 9 stated that the next time she saw Resident #4's wound was [DATE] and it had looked a little worse and a little bigger. RN # 9 stated that the treatment had been changed for Resident #4 and she assumed that LPN # 1 had changed the treatment after notifying the MD/RP. RN #9 stated that she did not notify the MD/RP herself because she had assumed that it had been done by LPN #1 during the week since the treatment had changed. RN #9 stated that she did the treatment that was ordered and didn't recall the wound looking infected. RN #9 stated that RN #5 had looked at Resident #4 with her at one time but could not recall exactly when. RN #9 stated that Calcium Alginate would not be an appropriate treatment for [REDACTED].#4's wound on [DATE] before being sent to the hospital. RN # 9 stated that when a resident was admitted that the RN would assess the skin/wounds but after that the treatment nurse would do the weekly measurements/documentation of wounds. Interview with LPN #2 on [DATE] at 3:40 p.m. revealed that she had done a weekly body audit on Resident #4 and there was a wound on the coccyx with redness around the edges and white areas with a darkish green color. LPN #2 stated that the wound had some drainage coming from it that smelled awful. LPN #2 described the size of the wound around 8 cm x 5 cm with moisture. LPN #2 stated that this was around [DATE] when she saw the wound after Resident #4's bandage had come off (coccyx area) and that CNA #1 was in the room with her. LPN #2 stated that LPN #1 came in the room to do Resident #4's treatment while she (LPN #2) and CNA #1 was there and so she (LPN #2) thought that LPN #1 would notify the MD and get the treatment changed if needed and document. On [DATE] at 4:20 p.m. LPN #2 stated that she had not been aware that a culture was done on Resident #4 until the results came in. LPN #2 stated that usually the treatment nurse did everything with the wounds; treatments, changes, notification, orders and documentation. Interview with LPN # 4 on [DATE] at 4:00 p.m. revealed that she had been the charge nurse on [DATE] and that LPN #1 had told her that Resident #4's wound was "going south" and that she was going to leave her bottom open for awhile. LPN #4 stated that she had not looked at Resident #4's wound that day, because typically the treatment nurse took care of her own orders, calling MD/RP, assessing and documentation of wounds. LPN #4 stated that LPN #1 never mentioned anything about Calcium Alginate or another treatment to her. The QIC was present and stated that a change of condition should have been done, physician notified and a wound assessment done by the RN. Interview with CNA # 1 on [DATE] at 12:25 p.m. revealed that the dressing had been off Resident #1's bottom one day and she had seen an open wound and it had a foul smell. CNA # 1 stated that she had notified LPN #1 and LPN #2 and they had looked at Resident #4's bottom and maybe RN #3. CNA #1 stated that she had documented in the ADLs but couldn't recall the exact date. Interview with RN #3 on [DATE] at 2:10 p.m. revealed that the normal procedure when a resident was admitted was to do a head-toe assessment and if wounds were present assess/stage along with the treatment nurse, then the treatment nurse would generally do the documentation. RN #3 stated that she didn't do weekly wound assessments but would look at a wound if the treatment nurse asked her to. RN #3 stated that the treatment nurse normally called the MD/RP about any changes in the skin/wound. RN #3 stated that LPN #1 had asked her to look at Resident #4's bottom one time and there was a reddened area, possibly a stage II, more like incontinent [MEDICAL CONDITION]. RN #3 stated that she didn't recall being asked about Calcium Alginate and was not specifically told about any changes to Resident #4's skin by the treatment nurse. RN #3 stated that she was not involved in the weekly skin meetings but depended on the nurses to report any skin issues. Interview with the QIC on [DATE] at 2:00 p.m., revealed that the documentation on the ADL from CNA #1 on [DATE] at 5:31 p.m. that Resident #4 had an open area to the coccyx made more sense as to why the Calcium Alginate was used. The QIC stated that LPN #1 had just made some bad mistakes in using her own judgment about treating (wounds) and not notifying the physician/ DON about the wounds and putting orders in the computer and not on a hard copy. The QIC stated that someone should have assessed, documented, care planned and notified (MD/RP) of Resident #4 ' s wound. Interview with Resident #4's physician, Physician #2, on [DATE] at 2:55 p.m. revealed that he had not been notified of Resident #4 having any pressure areas or of a wound culture. Physician #2 stated that he had not looked at the protocols for wounds in a long time. Physician #2 stated that he wanted to be notified about any skin issues of his residents. Physician #2 stated that the wound protocol was okay to follow for things like stage I-barrier creams/skin prep and stage II-[MEDICATION NAME] but the physician still needed to be notified of the wound/treatment to get any further instructions. Physician #2 stated that the physician should be called for a lab order, that staff shouldn't take it upon themselves to do any order, that the physician gives the order. Physician #2 stated that staff called his Nurse Practitioner at times. Nurse Practitioner was not available for interview. (LPN #1 had admitted to not notifying the MD for orders/wound). Physician #2 stated that Calcium Alginate was not appropriate for excoriations or stage II wounds. Interview with Physician #1, Medical Director, on [DATE] at 5:35 p.m. revealed that Calcium Alginate was expected to be used on wounds that were moist with slough. Physician #1 stated that skin concerns should be assessed/documented and the physician/family notified. Physician #1 stated that she had attended QA meeting and was made aware of the wound problems that the facility was working on. Interview with Registered Dietician (RD) #1 on [DATE] at 2:40 p.m. revealed that she had done an assessment on Resident #4 on [DATE] for high risk due to tube feeding. RD #1 stated that Resident #4 had no decubitus documented on the list that was received from the facility used to do the reviews and recommendations. RD #1 stated that Resident #4 was getting sufficient fluids/calories at the time of her assessment on [DATE]. RD #1 stated that if she didn't know about wounds or if they had worsened then she couldn't do an assessment for them. Interview with the MDS Coordinator, RN #4, on [DATE] at 11:00 a.m. revealed that she went by the information given to her by the treatment nurse for wounds and measurements to develop/update care plans. RN #4 stated that she pulled the 24 hour reports on all new orders every morning and updated the care plans from that as well. RN #4 stated that Resident #4 had excoriation documented for the weekly skin meetings and she didn't recall any order for Calcium Alginate because she would have questioned that being used for excoriation. RN #4 stated that the care plan should be updated for changes or wounds specific to where the wound is and the stage of the wound. Attempts were made to contact Resident #4's family members without success on [DATE] at 7:00 p.m., [DATE] at 8:00 a.m. and 10:00 a.m., [DATE] at 1:05 p.m., [DATE] at 6:00 p.m. and [DATE] at 5:20 p.m. Review of the facility's policy "Abuse Prevention, Investigating and Reporting", with a revised date of 2010, revealed that each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. The policy defined neglect as "failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. "Neglect" is clarified by inclusion of the reasonably prudent person standard, which is now used to determine what action is necessary by the caretaker, to maintain the vulnerable adult's mental and physical health. Again, only a single incident is necessary for a determination of neglect. An example of this is not following the care-plan ..." The facility submitted an acceptable AoC on [DATE] as follows: "This serves as the facility's written credible allegation of compliance for the immediate management/supervision of wound care of Resident #4 and how the facility identified and implemented assessment and wound care for other resident's at risk. On [DATE] Resident #4, an 88 y/o female was admitted to our facility following a hospitalization for PEG placement. On admission a Pressure Ulcer Risk Assessmsent was completed by RN #1 with a Risk Score of 14 with no current wounds noted. On [DATE] preventive measures implemented on Resident #4's care plan were pressure reduction mattress, turn every 2 hours, heel protectors, minimize pressure on bony prominences, pillows for support, shift position every hour while up in wheelchair and move resident with lift sheet when changing position in bed. On [DATE] there was as physician order [REDACTED]. On [DATE] at 11:24am a 3cm x 4cm excoriation to coccyx area was noted by LPN #1. A physician's orders [REDACTED]. The order was to "apply skin prep and dry dressing to coccyx daily until resolved". Resident #4's Nurses notes on [DATE] did not reflect that the physician or responsible party was notified of the change in skin integrity by LPN #1 or RN #2. Resident #4's weekly wound assessment completed by LPN #1 on [DATE] was unchanged from previous assessment completed by LPN #1 on [DATE] the day prior to the wound care meeting. The assessment on [DATE] did not reflect the excoriation area. On [DATE] the interdisciplinary team, the DON, RN MDS Coordinator, treatment nurse, and Dietary Manager, met and noted in house excoriations on Resident #4 and recommended to continue same preventive measures with the addition of skin prep. On [DATE] the treatment order for Resident #4 was changed by LPN #1 to "Clean with Wound Cleanser, Apply Calcium Alginate and dry dressing to coccyx bid" in the electronic charting system only. Resident #4's medical record did not have a hand written physician order [REDACTED].#1 on wound measurements on [DATE] and [DATE] were unchanged from the previous assessment completed by LPN #1 on [DATE]. There is no documentation that a Registered nurse had assessed Resident #4's skin since [DATE]. Resident #4's care plan was not updated to reflect the change in the status of any wound or the new treatment order. On [DATE] a wound culture on Resident #4 was done by LPN #1 without a written physician's orders [REDACTED]. There was also no documentation in Resident #4's Nurses Notes that the responsible party was notified of the change in status of any wound. On [DATE] 9:00 AM the Nurse Practitioner #1 was notified by RN #5 regarding the wound culture result of numerous Gram Positive Cocci. At 9:24am Resident #4 was noted to have generalized [MEDICAL CONDITION] with periods of apnea, Nurse Practitioner #1 was notified by RN #5. An order was received to transfer to acute care hospital [DATE]. On the History and Physical completed at the acute hospital on [DATE] at 16:35 by Physician #3 it was noted that resident #4 had a large sacral wound. Resident #4 acute care hospital nurses notes on [DATE] documented an unstageable pressure ulcer to the coccyx area measuring 15cm x 9cm with foul odor. During the investigation it was discovered that weekly wound assessments were not completed by an RN for residents with wounds. Treatment nurse, LPN #1 completed weekly documentation ,[DATE], [DATE], [DATE] and [DATE]. LPN #1 changed physician orders [REDACTED].#4. Physician order [REDACTED]. LPN #1 failed to notify physician of any wound changes, or obtain a treatment order from Physician #2 or Nurse Practitioner #1 for Resident #4. LPN #1 admitted to the Quality Improvement Consultant that she had not called the physician or responsible party with the changes of condition or treatments on Resident #4. LPN #1 continued to state that the coccyx area was not an open wound. The DON which is the RN designated responsible for monitoring LPN #1 stated that he reviewed wounds weekly but he could not always get the review completed timely. Statements given during the invesigation by LPN #2 and CNA #1 indicated that Resident #4 had an open wound to her coccyx area that had an odor. Resident #4's Care plan had not been updated to reflect a change of any wound, the physician order [REDACTED]. The facility's immediately response to the skin/wound system failure: 1. The in-service for licensed nurses was initiated by the Administrator on [DATE] with policies provided by the Quality Immprovement Consultant regarding: *Skin Management including assessment, wound protocol, weekly meetings *Change of Condition, following physician orders, *Notification of Physician-with any change of condition of any wound reporting wound or changes to the physician *Notification of Responsible party-with any change of condition of any wound or changes to the resident treatment. Care plans-updated with change of condition wounds and treatment orders 2. On [DATE] a body audit assessment was done on all current 93 in-house residents by RNs #7, #8, #4, #5 and #6. Three residents were found to have undocumented wounds- *Resident #5 - Stage II to coccyx, *#9-DTI to Left heel, *#1 - Stage II to coccyx area. Four residents had wounds to decline since last weekly measurement * Resident #3 - coccyx wound increased in size, * #8 - increased in size * #7 - increased in size * #6 -increased in size *These pressure ulcers had not been assessed by an RN during the weekly wound as

CI MS #9325 Based on observation, record review and staff interview, the facility failed to ensure that staff used the appropriate lift to transfer one (1) of four (4) resident's reviewed (Resident #1). Resident #1 was transferred using a sit to stand lift and not a total lift as care planned. Resident #1 was identified on the care plan and care guide as requiring transfers with the use of a hoyer total lift. On 5/4/11, Resident #1 complained of pain to the right leg. On 5/9/11, an xray was ordered that revealed a fracture to the right femur. CNA #1 and CNA #2 transferred Resident #1 to the shower chair using the sit to stand lift. CNA #1 was assigned to care for Resident #1 and confirmed that she always used to sit to stand lift when transferring Resident #1. Findings Include: Record Review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Assessment Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/18/11 that Resident #1 was severely impaired in cognitive skills for daily decision making. Resident #1 required total assistance of two (2) persons with bed mobility and transfers. Review of a Lift Assessment for Resident #1 dated 06/05/10 revealed: "TRANSFERRING: Requires two assist to transfer to lift the resident during transfers." "TRANSFER MODES: lifted mechanically." Review of a care plan for Resident #1 revealed on 08/04/2010 (a). Transfers 4 = Assist x 2; (b) Ambulation = n/a (not applicable); (c) Bed mobility 5 = Dependent; 1-2 person assist 8=none; Weight bearing ability =None. "ADAPTIVE EQUIPMENT - The Resident uses the following adaptive equipment: Recliner/Gerichair Hoyer lift". Review of the Care Plan for use by the Certified Nursing Assistants (CNA's) revealed an implementation date of 02/23/11 stating: "Assist with ADL's (Activities of Daily Living); 1 person assist with oral hygiene; grooming; bathing; feeding; toileting; 1-2 person assist with repositioning; 2 person assist with transfers and hoyer lift give total assistance; check/reposition q 2h (every two hours); ROM (Range of Motion) with cares; call light in reach. "On 05/13/11 that information was changed to read: "2 person assist with transfers and hoyer lift (sling lift)". Review of a document titled "CNA CARE CARD" revealed on "05/13/2011 - Nurse Aide-Assist with ADL's; 2 person assist with oral hygiene; grooming; bathing; feeding; toileting; 1-2 person assist with repositioning; 2 person assist with transfers and hoyer lift (sling lift) give total assistance, check/reposition q 2h ROM with cares call light in reach." On 06/01/2011 Nurse Aide- "Non-weight bearing NOC (night), AM (morning)." On 05/13/2011 "Transfer with 2 person assistance with hoyer/sling lift." Review of the Physician order [REDACTED]. On "5/9/11 - X-Ray to (R) (right) knee. Then apply ice to area." On "5/10/11 - Send to ER (emergency room )." Review of an investigation conducted by the facility revealed: "Resident's History: The resident, a [AGE] year old black female, was admitted to (Name of Facility) on 06/05/2010 from (Name of Hospital). She has short and long term memory impairments and is severly (severely) impaired for daily decision making. She is non-ambulatory and has history of pathological fractures. Resident has a history of chronic pain and was admitted in Jun 2010 with both Fentanyl and Lortab prescribed." "Notes of interest: 5/04/11-Resident complained of pain to her right knee. She was assessed by LPN (Licensed Practical Nurse #1), and no bruising or swelling was noted. Resident also complained on 5/5/11. 5/07/11-- (CNA #1) and (CNA #2) transferred resident to shower chair, using a Sit-to-stand lift. 5/07/11-- On 5/7/11 on 7:00 p.m. -7:00 a.m. shift, resident complained of pain to leg to two CNA's. (CNA #8) stated resident did not want us to touch her leg. 5/07/11-(Registered Nurse {RN} #3 assessed resident resident's right knee and stated her right knee was swollen. 5/09/11-Resident would not allow staff to get near her leg. RN Team Leader, (RN #1), called to room to assess resident's knee. Assessment showed a small puffy area to (R) side of knee. Physician was notified and an order was obtained for and (an) x-ray of right knee." On "5/10/11 - Portable x-ray was completed and the findings were: comminuted fracture of the distal femoral metaphysic with overriding of fracture fragments. There is an oblique component and a vertical component extending into the metaphysic of the femur. There does not appear to be intraarticular extension although this is difficult to exclude." "Impression: Comminuted distal metaphyseal fracture of the right femur. Fracture appears acute." "5/12/11 (LPN #2) informed Administrator during interview that she thought CNAs had transferred (Resident #1) on 5/7/11 to the shower chair using the wrong type lift. " "5/13/11-Resident informed (Social Services) and (CNA, transporter #4) while visiting her in the hospital that " they had her in between rails with black knobs on it and I fell and broke my leg, and they knew I couldn't stand up." Interviews: "(LPN #1), stated on 5/4/11 resident complained of knee pain. She was assessed and no evidence of bruising or injury was noted. (LPN #1) stated resident frequently complains of her knees hurting and was on scheduled pain medication (Lortab). (LPN #1) stated she was getting ready to administer the Lortab on 5/4/11, when resident initially complained of pain in her right knee. (LPN #1) stated on 5/5/11, resident continued to complain of pain in her right knee. (LPN #1) stated at this point there was nothing unusual based on resident history. However, on 5/9/11, (LPN #1) stated it was evident that something was different, that something had happened, and her refusal to allow staff to touch her was very unusual." "(LPN #2) stated on 5/7/11, that she thought two CNAs had transferred (Resident #1) to the shower chair using the wrong type lift. (LPN #2) stated after the fact, she thought she had seen them take the Sit-to stand lift in her room, but couldn't swear to it. She stated this is something you may want to check on." "(CNA #1) stated on 5/7/11, that she and (CNA #2) had transferred (Resident #1) to the shower chair using a Sit-to-stand lift. When asked what type of lift she was supposed to use for (Resident #1) CNA was uncertain. CNA stated she did not review resident care card and had always used the Sit-to stand lift with (Resident #1) since her return to work in February. When asked if she knew where the CNA care cards were located, she stated she had just recently found this out. (CNA #1) denied anything happening during the transfer, however, she stated the resident kept lifting one leg, she didn't remember which one, and she had to keep telling her to keep her foot down." "(CNA #2), stated on 5/7/11, that she helped (CNA #1) to transfer (Resident #1) to the shower chair. (CNA #1) stated they used a Sit-to-stand lift. When asked what type of lift she was supposed to use for (Resident #1), she was uncertain. CNA stated this was the first time she had ever assisted with this resident. CNA stated she did not review resident care card prior to assisting (CNA #1) transfer a resident who had not previously been assigned to her. (CNA #2) stated she did not know where the care cards were located. (CNA #2) denied anything happening during the transfer, however, she also stated resident kept shifting weight to one leg, but didn't remember which one." "(RN #1) stated on 5/7/11 resident stated her right knee was hurting. (RN #1) stated she examined (Resident #1)'s right knee and her knee was swollen. She stated she relayed this information to (RN #4), RN, on the oncoming shift." "(RN #4), stated on 5/8/11, she was informed by (RN #3) that resident had been having right knee pain, however, during her 12 hour shift, the only complain resident had of pain, was her shoulder." Review of the xray report on 5/10/11 revealed: "There is a severely comminuted fracture involving the distal metaphysis of the femur. I believe one of the fracture lines extend into the knee joint." The right knee xray revealed: "Comminuted distal metaphyseal fracture of the right femur. Fracture appears acute." The facility's findings stated: "Based on staff interviews, statements, and social services interview with resident, ( CNA #1) and (CNA #2), transferred (Resident #1) to the shower chair using a Sit-to-stand lift, when the CNA care card stated the resident should be " 2 person assist with transfers and hoyer lift give total assistance " . (The resident was describing the sit-to -stand lift when she said: " between two rails with black knobs). According to the resident, during this transfer, she fell and broke her leg, although there is no way to substantiate this. On the night of 5/7/11 resident did complain of pain and (RN #3) did observe swelling in her right knee. Resident complained of pain again on 5/09/11, at which point an ice pack and x-ray were ordered. (Resident was on scheduled pain medication, Lortab 10 mg (milligram), three times per day, and Fentanyl 25 mcg (micrograms) patch, that may have masked some of the pain she was experiencing.) An x-ray was conducted on 5/10/11 & fracture discovered. The physician was notified, and resident was transferred to the hospital and admitted . Possible contributing factors: 1. CNAs used Sit-to-stand lift which required resident to bear weight when resident should have received total assistance. (Resident's care card accurately reflected 2 person assist with transfers & hoyer lift, give total assistance.) 2. Resident has a history of pathological fractures. Observation on 06/01/11 at 10:55 a.m. revealed that Resident #1 was seated in a chair in her room. Resident #1 stated that she fell and all she could remember is that she broke her leg. Interview on 06/01/11 at 01:25 p.m. with the Admissions/Social Services staff member confirmed that Resident #1 had told her at the hospital that she had been stood up between two (2) rails that had black knobs and she had hurt her leg. Interview on 06/01/11 at 11:30 a.m. with CNA #2 revealed that she was asked by CNA #1 to assist in getting Resident #1 transferred to the shower chair with the use of a stand up lift. The Resident stood up, pivoted, taken to shower. She confirmed that the stand up lift was used to transfer Resident #1 from the shower chair to her wheelchair. CNA #2 stated: "That was my first day working with her. I only got fired cause (I) used wrong lift " She stated that information about the type of lift to use would be in the ADL book and on the Care Plan. She stated that she did not check to see which lift to use. CNA #2 stated: "I know how to use lift, but, I did not know which lift to use, other person (CNA #1) said she always got her (Resident #1) up with stand up (lift)." Interview conducted on 06/01/11 at 01:35 p.m. with CNA #1 confirmed that she was no longer employed by the facility because she "used wrong lift" to transfer Resident #1. CNA #1 stated: "I've always used two (2) people and the stand up lift." " I started end of February (2011) and no one ever corrected me."

CI MS #9273 Based on record review and staff interview, the facility failed to ensure that physician orders [REDACTED].#1). On 4/23/11, Resident #1 was transferred to the emergency room due to low oxygen saturation levels. Resident had an order for [REDACTED].#1 unplugged the oxygen and plugged the suction in. After RN #1 suctioned Resident #1, she did not plug the oxygen back in. Around 11:45 p.m. a family member asked the Nurse to come check on Resident #1. The oxygen saturations (O2 Sats) were 70% and never got above 85% after the oxygen was turned back on. Findings Include: Cross refer findings to F-309 for the facility's failure to ensure that Resident #1 had continuous oxygen [MEDICAL CONDITION] at 2 liters per minute. The oxygen was not flowing from 9:30 p.m. until 11:45 p.m. Resident #1 was transferred to the emergency room by ambulance due to low oxygen saturations.

CI MS #9273 Based on observation, record review, staff interview and facility policy review, the facility failed to ensure that one (1) of four (4) resident's reviewed (Resident #1) received the appropriate care and services as by the failure to ensure that oxygen was administered as ordered by the Physician. On 4/23/11, Resident #1 was transferred to the emergency room due to low oxygen saturation levels. Resident had an order for [REDACTED].#1 unplugged the oxygen and plugged the suction in. After RN #1 suctioned Resident #1, she did not plug the oxygen back in. Around 11:45 p.m. a family member asked the Nurse to come check on Resident #1. The oxygen saturations (O2 Sats) were 70% and never got above 85% after the oxygen was turned back on. Findings Include: Record review revealed that Resident #1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 02/04/11 revealed that Resident #1 was severely impaired in cognitive skills for daily decision making. Review of Resident #1's physician's orders [REDACTED]. Administer 02 @2L [MEDICAL CONDITION] continuously. [MEDICAL CONDITION] (as needed) to clear secretions." There was a physician's orders [REDACTED]." Review of the Investigation by the facility revealed: "Diagnosis: [REDACTED]. History of tracheotomy in 2008. History of [MEDICAL CONDITIONS] in 2008. Diabetes; Hypertension; [MEDICAL CONDITION];[MEDICAL CONDITION](gastro [MEDICAL CONDITION] reflux disease); [MEDICAL CONDITION]; [MEDICAL CONDITION]; and Kyphosis." The concern on the investigation stated: "While providing suctioning care the nurse in charge unplugged the oxygen and failed to turn it back on. The time frame for the resident not having oxygen via [MEDICAL CONDITION] mask is not definite. The resident was experiencing respiratory difficulty and despite the oxygen being turned back on, the oxygen saturations did not go above 85% and was therefore transferred and readmitted to the hospital with [REDACTED]. " "The resident, (name of Resident #1), was originally admitted to (facility) on 1/7/2009 from (name of hospital) with a [DIAGNOSES REDACTED]. She has [MEDICAL CONDITION] and occasionally makes eye contact; however she is not able to make her needs and wants known. She is total care for all activities of daily living. She was fed by staff for all meals and was given supplemental tube feeding if her oral intake doesn't meet the requirements as ordered by the physician. While at Aurora this resident developed cough and congestion with decreased oxygen saturations and was transferred to (name of hospital) on 4/13/2011 and was admitted with health care associated pneumonia which was reported as resolved prior to her return. During the course of her stay she required mechanical ventilation and a tracheotomy due to [MEDICAL CONDITION]. The [MEDICAL CONDITION] was performed on 04/21/2011. The resident returned to (name of facility) on 4/22/2011 at 12 noon and had orders for oxygen at 2L (liters)/min (minute) [MEDICAL CONDITION]. (Name of oxygen provider for facility) came in and set up the oxygen and a compressor with humidification prior to the residents' arrival back to the facility." "(The Quality Advisor of the facility) contacted myself (DON) on 4/23/2011 and voiced a concern that her oxygen. He described the nurse as a young blond but he didn ' t know her (Name of nephew, resident's son) had voiced to her regarding the nurse leaving off his mother's oxygen. She informed me that (Resident #1) had been readmitted to the hospital early that am (morning) with an elevated white blood count and pneumonia." "Interview with the Team Leader on duty for 7a-7p for 4/23/2011 confirmed that (Resident #1) was readmitted to the hospital sometime after midnight. She also verified the RN's on shift during the transfer. (Names of RN) stated It had been reported to her that (Resident #1) had developed respiratory distress and low oxygen saturations before MN (midnight) and was transferred to (Name of Hospital) by EMS (Emergency Medical Services)." "Interview with (RN #3) Team Leader indicated that at around 9:30 p.m. (Resident #1) required suctioning and (RN #1) unplugged the oxygen machine to plug in the suction machine. (RN #3) did not indicate why (RN #1) had done this. (RN #3) indicated that she had been in the room and had later suctioned the resident after this but had not noticed that the oxygen was off. She states that before midnight that (name of family member) came and requested his mother be checked. At that time, when (RN#1) went in to assess the resident, she stated that she realized she had not turned back on the oxygen and conveyed this to the resident's son. (Resident #1's) sats were noted to be in the 70's and did not get above 85%. The resident was transported back to (name of hospital) after midnight." "Interview with (RN #4) indicated that she had went into the room with (RN#1) around 11:45 p.m. and that (Resident #1) was having respiratory difficulty and that thick bloody secretions were suctioned from her trach. She states the oxygen saturation was low and (RN #1) raised the head of the bed and that the oxygen cord was laying across the compressor and was not plugged into the outlet. (RN #4) states that she heard (RN #1) state, "I forgot to plug it back in." She states that (RN #1) had worked with (Resident #1) to attempt to get her stable and that the oxygen was increased. (RN #4) did indicate the air compressor, which helped deliver the humidification had been on the entire time to the best of her knowledge. She stated that despite her efforts that (RN #1) could not assist the resident to get her sats out of the 80's. (Resident #1) was sent back to the hospital by EMS and the son remained with her." "Interview with (RN #1) indicated that she had unplugged the oxygen around 11 p.m. to plug in a suction machine prior to providing suctioning for the resident. She states that after providing suctioning she called the respiratory therapist at the hospital because she was concerned about the bloody clots that were noted and stated that the female therapist told her that this was normal for a new trach. She stated that about 15-20 minutes later that the resident's son came to the nurses' station and was concerned about his mother and so she went down to check. When asked about the time frame again (RN #1) agreed that it could have been longer than 20 minutes. She states that she checked her sats and that the oxygen sat was 69-74% and she began to check the equipment and noticed that she had not turned back on the oxygen machine. (RN #1) stated that she had plugged the machine back in but had however forgot to turn it on. She states that the time lapsed was 15-20 minutes prior to her discovering her error. (RN #1) stated, " I messed up, forgot to turn 02 back on and it won't happen again." She stated that she felt that (Resident #1) was sent back too soon from the hospital and that she later found out in the shift that she had been readmitted to the hospital with [REDACTED]. The facility's findings stated: "(1). Resident did have her oxygen turned off by (RN #1). The time that oxygen was off was from < (less than) 1-3 hours based on interviews. (2). (RN #1) admitted turning off the oxygen machine and states it off 15-20 min but did acknowledge that the time could have been longer when questioned further. (3). (RN #1) did not complete a nurse's note for 4/22/11 or 4/23/11. (4). She did not inform the Director of Nursing of the incident. (5). It cannot be determined if the incident regarding the oxygen being turned off by (RN #1) lead to the hospitalization . However, it appears it could be a contributing factor. " (6). (Resident #1) was readmitted to (hospital) after being in the facility for only 12 hours and 26 minutes per the medical record with [DIAGNOSES REDACTED]. It should be noted that (Resident #1) was <24 hours post-op tracheotomy prior to her return to (facility). Originally her planned discharge was to be the 25th or 26th of April per the case manager and the physician's decided that she was stable enough to return on Friday, the 22nd. (7). (Resident #1) returned to (facility) on 4/27/2011. Her history and physical from the hospital on [DATE] stated that she was discharged back from the hospital after a 9 day hospital stay and upon return to the hospital she was noted to have a white count that had increase to 20,000 and she required aggressive suctioning and her chest x-ray showed no improvement. She was readmitted for health care associated pneumonia and more aggressive [MEDICAL CONDITION] care per the H & P (History and Physical). " Possible contributing factors: (1). (RN #1) got distracted in the room and failed to turn on the oxygen machine. (2). (Resident #1) had pneumonia that contributed to her decline in respiratory status." The facility's Plan of Action stated: "(RN #1) was terminated on 4/25/2011 for failure to follow a physicians order to deliver continuous oxygen and failure to deliver resident care that reflects professional nursing practice." The Investigation was signed by the Director of Nursing on 4/27/11. That document was signed by the Director of Nursing on 04/27/2011. On 04/23/11 at 12:20 a.m. there was an order written [REDACTED]." Review of the Nurses Notes revealed that Resident #1's 02 saturation was checked at 06:07 p.m. on 04/23/11 with a reading of 99%. At 06:24 p.m. there was a notation that RESP (Respiratory) condition noted: breathing pattern is normal. TRACHEOTOMY: no difficulty COUGH; to clear secretions SPUTUM: small amount. BREATH SOUNDS: diminished upon auscultation oxygen 2 liters/minute [MEDICAL CONDITION]." On 4/23/2011 at 12:28 a.m. "TRANSFER/DC: 04/23/11 Time of Departure: 12:26 AM via ambulance. To ER O2 SATURATION 84 ON 2 5 L of oxygen." At 12:37 a.m. "RESPIRATORY COMPLAINT: Late Entry: 04/23.11 at 12:00 a.m. TRACHEOTOMY: labored, SPUTUM: large amount, bloody, red, PROCEDURE RESP (RESPIRATORY) ACTIONS: suctioned. Resp. TX administered: 15 Resp. TX Pulse: Pre treatment Pulse: 95 Mid treatment Pulse: 95 Post Procedure Pulse 95." "PROCEDURE RESULTS: ineffective OXYGEN USED LITERS): 5 via track mask. PROCEDURE RESULTS: Procedure ineffective unchanged ACTION: Transfer resident to ER for evaluation." At 3:57 a.m. prn med result: 12:00 a.m. resident sent to ER. At 2:58 p.m. resident admitted to the hospital with [REDACTED]." Review of the Emergency Services Record dated 04/23/11 at 00:18 (12:15 a.m.) for Resident #1 revealed: "911 response called for a reported Breathing Problem at (address). On arrival found a [AGE] year White/Female, Chief complaint of SOB (Shortness of Breath). Events surrounding incident: ACUTE ONSET SOB. The patient was found IN BED SEIM FOWLERS. Initial assessment revealed the patient had a GCS (Glascow Coma Scale of (blank), Sp02 (oxygen saturation) -100%, Lungs- Inspiratory Wheezing, Skin 0 Normal." " Other significant physical exam findings: ALERT IN RESPIRATORY DISTRESS, WITH LOW O2 SATURATION. Treatments were administered as follows: Airway- Positive Pressure Ventilation successfully. Oxygen 10 LPM (Liters per minute) Inhalation Any changes: O2 SATURATION AND BREATHING RETURNS TO NORMAL AFTER TREATMENT. " There was no documented evidence that the attending physician, who was also the Medical Director, was notified of the lack of oxygen administration to Resident #1 until after the termination of RN #1 on 04/25/11. An interview with the Physician on 05/11/11 at 10:11 a.m. revealed that he was not notified until after RN #1 was terminated on 04/29/11. The Director of Nursing confirmed that information in an interview conducted on 05/11/11 at 11:00 a.m. when she stated that the physician was notified in a meeting held after the Quality Assurance meeting on 04/29/11. Interview conducted with RN #1 on 05/11/11 at 09:32 a.m. revealed: " Son came and said check mom at approximately 9-9:30 p.m. Went down, (she) needed suctioning, RN was going to suction, started putting gloves on and I said; "No" turn on suction machine first. Turned on suction machine and it would not come on. Unplugged the oxygen concentrator. I said " don't let me forget to plug back up." RN #1 stated at 9:00 - 9:30 a.m. "I plugged it in." RN #1 stated that it was about 2 ? hours later when the son came back and wanted us to check mom. RN #1 stated that she checked the O2 sat and it was in the low 70's." RN #1 stated that Resident #1's nail was painted, dark pink or red. She started suctioning and then realized that she had not turned O2 back on. RN #1 stated that the son came in and she explained what had happened - asked him what do you want me to do? He said: "Send to hospital." RN #1 stated that the Oxygen 2 L [MEDICAL CONDITION]- was [MEDICAL CONDITION](mask) but not turned on." RN #1 stated that she called the doctor that night but did not get an answer or leave a message for him. When asked about why there were no nurse's notes describing the incident RN #1 stated that since she was training and that was (RN #3 's) side she did the notes. The other was a brand new RN and had never sent anyone to the ER. RN #1 stated; "I walked her through it (sending resident to ER)."