Every finding on record at Aviata at Tallahassee

Based on record review, interviews, and facility policy review, the facility failed to submit an incident report within the required 2 hour timeframe for 2 of 2 reports reviewed for abuse and neglect.The findings include:1. Review of an allegation of physical abuse was conducted which revealed facility staff were made aware of the incident on 4/23/26 at 2:00 PM. Further review revealed the administrator was not notified by the staff until 4/23/26 at 6:30 PM. The report was not filed with the state agency until 4/23/26 at 9:05 PM. An interview was conducted with the facility Administrator on 5/12/26 at 9:00 AM concerning the delay in reporting this incident. He stated, I don't recall why I was late reporting this incident. It could be that I was collecting data for the report. Upon reviewing the investigation report times, he confirmed that the incident was reported later than the required 2-hour time frame. 2. Review of an allegation of neglect involving 17 residents who did not receive morning medications on 4/18/26 was performed. Review of the facility's investigation revealed on 4/18/26 at 6:40 AM, Staff A, Licensed Practical Nurse (LPN), and the Unit Manager were made aware of the incident. On 4/19/26 at 7:30 PM, the Administrator was notified by the Director of Nursing of the incident. On 4/20/26 at 4:11 PM, a preliminary incident report to the Agency was created. On 4/20/26 at 6:21 PM, the incident was reported to the Abuse Registry. An interview was conducted with the Administrator on 5/12/26 at 9:03 AM. He confirmed the report was not created until 4/20/26 at 6:21 PM despite being notified on 4/19/26 at 7:30 PM. The Administrator stated the facility was working with their corporate team and had waited to get some of the facts and statements from the staff. The Administrator further stated that the Unit Manager knew that she was supposed to come in, but she did absolutely nothing. An interview was conducted with the facility Regional Nurse Consultant on 5/12/26 at 9:35 AM. She stated the report was a very late report because the Assistant Director of Nursing (ADON) did absolutely nothing to act upon this information, although she knew it needed to be reported. The Regional Nurse Consultant further stated the ADON failed to notify the Administrator timely of the incident. Review of the facility policy titled Abuse, Neglect, Exploitation & Misappropriation (revised on 11/16/22) revealed, An employee or contracted service provided who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect . to a resident, is obligated to report such information immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. In the absence of the Executive Director, the Director of Nursing is the designated abuse coordinator.

Based on observations, record review, and staff interviews, the facility failed to maintain medical records that were accurate and complete for 1 of 1 resident sampled. (Resident #63)The findings include:On 9/15/2025 at 11:47 AM, an interview was conducted with Resident #63. He stated he had a wound on his back that healed and another one on left arm that had not healed yet. On 9/17/2025 at 11:33 AM, an observation was made of Resident #63 receiving a clean dressing on his left posterior forearm.A review of Resident #63's medical record was conducted. Resident #63 was admitted to the facility on [DATE] with diagnoses including villonodular synovitis pigmented, major depressive disorder, quadriplegia, and morbid obesity. Physician's orders stated, left forearm: cleanse with wound cleanser, apply xeroform then cover with dry dressing every day shift with a start date of 7/15/25. A review of the Treatment Administration Record (TAR) revealed documentation was left blank on 9/3/25, 9/7/25, 9/8/25, 9/11/25 and 9/13/25.On 9/17/2025 at 1:20 PM, an interview was conducted with the Director of Nursing (DON). She reviewed Resident #63's TAR related to left forearm wound care documentation and acknowledged that the TAR was left blank on 9/3/25, 9/7/25, 9/8/25, 9/11/25, and 9/13/25. The DON stated it should have been documented and not left blank.On 9/18/2025 at 11:14 AM, an interview was conducted with Staff C, Registered Dietitian (RD). The RD has worked full time at the facility and had known Resident #63 for over 3 years. She stated Resident #63 had never been diagnosed with morbid obesity. A review of Resident #63's medical record was conducted with the RD including a diagnosis of morbid obesity dated 8/17/23. She then stated the diagnosis was not accurate because Resident #63 had never been obese.

Based on interviews, record review, and policy review, the facility failed to ensure each resident receives adequate supervision and assistance to prevent accidents by not screening 1 of 1 resident sampled for smoking. (Resident #164)On 9/18/25, a chart review was conducted of the electronic medical record (EMR) for Resident #164. No safe smoker screening was documented in the record. On 9/18/25 at approximately 3:25 pm, an interview was conducted with the Director of Nursing (DON). She was asked about the facility process for screening residents for smoking safety. She stated a smoking screen is done on every resident on admission. If the resident smokes, teaching is provided to the resident. The resident is added to the smoking list kept by activities staff. Activities staff are responsible for providing supervision and assistance to residents who smoke. When asked about Resident #164's current smoking status, she stated that the resident does not smoke. If she does want to start smoking, she will then be screened for safe smoking, provided teaching, and set up with Activities staff. On 9/19/25 at approximately 11:02 am, an interview was conducted with Staff K (Activities Assistant), about the residents' current smoking status. She stated that she has observed Resident #164 smoking. When asked how the resident gets cigarettes, she stated that the resident had cigarettes in the lockbox used to store residents smoking supplies. When asked if the resident is on her smoking list, she states that she thinks the resident is on the list. A review of the typed smoking list then provided demonstrates Resident #164's name handwritten on the bottom of the page. The facility's undated policy entitled Smoking/Agreement/Notice of Policy stated: Patients electing to smoke will be provided a safe smoking assessment to determine an evaluate each patient's ability to safely smoke.

Based on record review and interview, the facility failed to administer prescribe pain medication and failed to refill pain medications for 1 of 1 residents sampled for pain medication. (Resident #52) On 9/16/25, a phone interview was performed with the daughter of Resident # 52. She stated that Resident #52 had not been receiving her nightly dose of MS Contin 75 ER for several days. A phone call was performed with the facility's pharmacy on 09/16/2025 at 1:36 PM. They stated that the facility requested a refill of MS Contin 75 mg ER for Resident # 52 on 7/2/2025 (25-day supply, ended 8/6/2025) and 8/4/2025 (25-day supply, ended 8/31/2025). No further refill requests had been received since then. On 09/16/2025 at 2:30 PM, the Director and Assistant Director of Nursing were interviewed. They demonstrated the procedure for refilling medications to prevent missing any days. They were shown on the Medication Administration Record that MS Contin was documented as given although no medication refill had been received. The staff stated that the facility had some extra dosages on hand to fulfill this order. The Medication Record also showed that Resident #52 did not receive the MS Contin on 9/10-25-9/13/25 with the record stating it was not available. The staff acknowledged the MS Contin 75 mg should have been reordered in a more timely manner

Based on observations, staff interviews, review of the electronic medical record (EMR), and review of the facilities policies and procedures, the facility failed to provide safe and secure storage of medications for 2 of5 residents observed for medication. (Residents # 24 and 42)The findings include:Resident # 24During an observation on 09/15/2025 at 12:00 PM, Resident # 24 playing had the following medications stored at their bedside table: Medicated body Power, 2 bottles of Isopropyl alcohol 91%, Vitamins A&D Ointment, Hydrocortisone Acetate 1% Cream, Olopatadine Hydrochloride (a medicine for itchy eyes), Ophtalmic solution 0.2%, and Voltaren Arthritis pain Cream. (Photographic evidence obtained). A repeat visit on 9/16/2025 at 1:37 PM, 9/17/2025 at 11:00 AM, and 9/19/2025 at 8:00 AM showed these medications were still in the bedside table. On 09/16/2025, a review of Resident #24's record shows no orders for self-administration of medications.Resident #42On 09/15/2025 at 12:30 PM, 09/16/2025 at 8:15 AM, 9/17/2025 at 11:00 AM, and 9/19/2025 at 8:00 AM, Resident #42 was observed with the following medications at their bedside: Allergy relief nasal spray and fluticasone propionate(glucocorticoid) 50 micrograms per spray (another nasal allergy relief spray).On 09/16/2025, a record review of Resident #42 confirmed they did not have orders for self administration of medications or physician orders for this medication.On 9/18/2025 at 8:45 AM, the Staff Educator was shown the medications in the rooms of Resident #24 and #42. The staff educator stated he would notify the Unit Manager to correct the situation.

Based on observations and interviews, the facility failed to maintain a clean, safe and home-like environment for 3 of 58 occupied rooms and 2 of 111 residents screened during the initial tour. (Rooms #126, #216, #200, and Residents #63 and #100)Room observations (Photographic evidence obtained of all issues) On 9/15/2025 at 11:53 AM, Room # 216 (which was occupied) bathroom's toilet lid had a crack. The room's entry area ceiling had a brown-colored rust-like metal between the tiles. On 9/16/2025 at 9:21 AM, room [ROOM NUMBER]'s wall had brown-colored stains and paint had scratches. The room was being occupied. 09/15/2025 at 12:00 PM, a small refrigerator in room [ROOM NUMBER] was observed and a foul odor was detected. Inside a spilled brown liquid was present along with two unfinished bottles of soda. The freezer compartment had ice cream spilled throughout. The resident confirmed that the refrigerator had not been cleaned in a long time. On 9/16/2025, 9/17/2025, and 9/19/2025, subsequent observations confirmed that the same refrigerator was still dirty. The resident stated she could not physically clean it due to physical limitations Resident #63 On 9/15/2025 at 1:47 PM, observed Resident # 63, who is bedbound, had a pillow and a board holding his cell phone. The pillow and board had stains and organic particles. On 9/17/2025 at 11:33 AM, Resident# 63's pillow and board remained stained. Resident #100 On 9/15/2025 at 12:08 PM, Resident #100 had a wheelchair with the right arm rest exposing foam. On 9/17/2025 at 11:34 AM, an interview was conducted with Staff A, Licensed Practical Nurse (LPN). She was asked about the process of cleaning the resident’s rooms and belongings. She stated Certified Nurse Assistants (CNAs) were supposed to wipe surfaces daily and as needed. On 09/19/2025 at 9:45 AM, a tour was conducted with the Administrator, Maintenance Director (MD), and Housekeeping Account Manager. They acknowledged the above issues and stated they would be addressed quickly.

Based on observations, record and policy review, and interviews, the facility failed to follow infection control practices for 1 of 1 resident sampled for wound care treatment (Resident #159), 1 of 2 residents sampled for droplet isolation precautions (Resident #34), and 1 of 1 resident sampled for contact isolation precautions. (Resident #107)Resident #107 A chart review conducted on Resident #107 revealed a physician order which stated, Isolation Type – CONTACT-methicillin resistant staphylococcus aureus (MRSA) every shift for monitoring. Observations of the resident’s room door revealed a sign for Enhanced Barrier Precautions (EBP) [a different category of contact precautions] hung on an over-the-door caddy containing Personal Protective Equipment (PPE) supplies such as gown, gloves, and masks. There was no signage for the ordered contact isolation precautions observed posted on the door. On 9/16/2025 at approximately 11:05 AM, an interview was conducted with the resident’s nurse Staff R, a Registered Nurse, about the resident’s current isolation status. He stated the resident is on enhanced barrier precautions. After consulting the resident’s record, he then stated that the resident does have an order for contact isolation precautions due to MRSA. Subsequent observations at 12:40 pm and 2:40 pm showed no change in posted signage. On 9/16/25 at approximately 1:30 pm, an interview was conducted with the Director of Nursing (DON). When asked about her expectations from nursing staff regarding a resident’s isolation status when isolation is ordered by the physician, she stated her expectations would be that the ordered isolation precaution signage would be verified posted on the resident’s door. She stated that the Assistant Director of Nursing (ADON) was responsible for posting isolation precautions when the physician placed an isolation order. On 9/16/25 at approximately 1:45 pm, an interview with the ADON was conducted. She was asked why the ordered contact isolation status was not posted. She stated that, because the resident had been on antibiotics to treat the infection, the risk of transmission is low and he was placed on EBP. The physician was not contacted for clarification on the order. The facility’s policy entitled “Isolation-Categories of Transmission-Based Precautions” last revised 2018 stated: Transmission-Based Precautions are initiated when a resident…has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. The policy Interpretation and Implementation stated 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door so that personnel and visitors are aware of the need for and the type of PPE…a. The signage informs the staff of Centers for Disease Control and Prevention (CDC) precautions, instructions for use of PPE. Resident #34 On 9/15/2025 at 1:44 PM, Resident #34's room was observed with signage stating Droplet Isolation. On 9/16/25, a review of the resident’s medical record was conducted. Resident #34 did receive a positive COVID-19 result on 9/11/25. Physician's orders included Paxlovid (150/100) twice a day for 5 days with a start date of 9/12/25. There were no orders for droplet isolation. On 9/17/2025 at 9:35 AM, an interview was conducted with Staff Q, Licensed Practical Nurse (LPN). She was asked if the resident was on droplet isolation and she confirmed Resident #34 was on droplet isolation. She was asked if residents that were on droplet isolation would have a physician order for droplet isolation precautions and she stated yes. She then reviewed Resident #34’s medical record and confirmed resident did not have a physician’s order for droplet isolation. Resident #159 On 9/16/25, a review of Resident #159’s physician’s orders was conducted. Orders included the following wound care treatments: Left schium: cleanse with wound cleanser, apply calcium alginate with silver, cover with Abdominal pad. Change daily and as needed. Right ischium: cleanse with wound cleanser, apply calcium Alginate with silver, cover with dry dressing. Change daily and as needed every night shift for wound care. Left upper thigh: cleanse with wound cleanser, apply xeroform, then cover with Abdominal pad daily and as needed every night shift for wound care. On 9/16/2025 at 4:33 PM to 5:57 PM, wound care was observed being performed by Staff D, Licensed Practical Nurse (LPN) and the unit manager, Staff E, Registered Nurse (RN) and Staff F, Certified Nurse Assistant (CNA). Staff D removed heavily soiled dressing. Linens are soiled as well. Staff D, LPN, asked Staff F, CNA, to perform skin care and linen change before continuing with wound care. Staff F, CNA, was observed cleaning Resident #159’s skin at wound site with a rag that had been inserted in soapy water. She was observed introducing the used rag inside the soapy water, squeezing the water out of the rag into the soapy water container and using the rag to clean the posterior thigh around the wound. At this moment, Staff E, RN, told Staff F, CNA, to stop, and educated her “When you use a rag you are supposed to discard it, you don't reuse it again.

Based on record review, policy review and staff interviews, the facility neglected to provide basic life support, including cardiopulmonary resuscitation (CPR) to 1 of 3 residents (Resident #1). The facility neglected the resident's needs for emergency care allowing the resident to expire despite a full code status.The findings include: A review of the electronic medical record (EMR) revealed Resident #1 expired on [DATE] at 1:05 PM and that CPR was not performed. Staff A, a Registered Nurse (RN), provided a statement of events that took place on [DATE]. At 1:05 PM, the nurse observed that the resident was not breathing. She checked vital signs with respirations 0, blood pressure 0, and oxygen saturation 0%. On 1:09 PM, Staff A notified the hospice nurse by phone to tell of Resident #1's death. At 3:00 PM, another nurse working in the facility noted Resident #1 was a full code. At 3:02 PM, 911 was called and CPR was started on Resident #1. At 3:06 PM, Paramedics arrived and continued CPR on Resident #1. At 3:25 PM, Paramedics declared Resident #1's death. In an interview with the Director of Nursing (DON) on [DATE] at approximately 3:30 PM, the DON stated it is the expectation of the nurse to complete a CPR flowsheet and document a timeline of events in a nursing note anytime CPR is completed. In an interview with Staff B, a Licensed Practical Nurse (LPN) on [DATE] at approximately 12:01 PM, the LPN was asked where the code status for any resident could be found. The LPN replied, the code status is in the EMR and the advance directives book at the nurses station. In an interview with Staff E, an LPN on [DATE] at approximately 4:11 PM, the LPN stated for an unresponsive resident you would always check for breathing and a pulse and verify the code status of the resident, found in the EMR and the advance directives book at the nurses station. In an interview with Staff F, an LPN on [DATE] at approximately 4:23 PM, the LPN stated that a yellow DNR form must be signed and completed in order to not perform CPR. If you have a resident that requires CPR you would document the timeline of events, starting with the condition of resident prior to the code, to the time the residents body is taken out of the facility. An order dated [DATE] for FULL CODE (FULL CODE indicates CPR is desired in the event a resident's heart stops beating) was observed in the EMR.The advance directive discussion document completed on [DATE] by social services indicated Resident #1 was a FULL CODE. Hospice nursing notes dated, [DATE] & [DATE] indicated Resident #1 was a FULL CODE. A review of Resident #1's care plan, revised on [DATE], stated Resident has an advanced directive: FULL CODE.A review of the EMR did not include a CPR flowsheet or a nurses note summarizing the event and timeline. A review of the facility policy named Florida Cardiopulmonary Resuscitation (CPR) (effective [DATE], revised on [DATE]) stated, Cardiopulmonary resuscitation (CPR) will be provided to all residents who are identified to be in cardiac arrest unless such resident has a fully executed Florida Do Not Resuscitate (DNR) order.

Based on review of resident records, interview, and review of facility policy, the facility failed to obtain consent for 1 of 2 psychotropic medications ordered for 1 of 3 residents reviewed for psychotropic medication usage. (Resident #3) The findings included: On 3/4/24, a review of the records for Resident #3 was conducted. A review of the Medication Administration Record in December 2024 indicated that, in addition to Mirtazapine (an antidepressant) 30 mg once a day, Resident #3 had been taking Trazadone (another antidepressant) 50 mg .5 tablet every 8 hours. Resident #3's record had a signed consent to take Mirtazapine 30 mg once a day. However, there was no consent for the Trazadone. A review of the psychiatric notes, dated 9/26/24, for Resident #3 was conducted. The psychiatry notes stated that Resident #3 was started on Trazodone due to an exacerbation of depression and mood disorder. The note indicated that medication changes were needed to stabilize his symptoms. The provider indicated that risks, benefits, and alternatives were discussed. The note does not clarify whom the risks, benefits, and alternatives were discussed and if consent was verbally obtained from the resident's representative. Trazodone 25 mg po three times a day was instantiated in addition to the Mirtazapine for agitation. A review of the psychiatric notes dated 11/21/2024 revealed, Prior to last visit, resident had excessive sedation and was not wanting to eat. Trazodone 25 mg three times a day (TID) as needed (PRN) was started for 30 days. Trazodone 25 mg by mouth three times a day was discontinued as per the patient representative request. There was no note indicating that risks, benefits, or consent was obtained when the Trazadone dosing was changed from three times a day (TID) to three times a day as needed (PRN). A review of the orders was conducted for Resident #3. An order was placed on 9/27/24 for Trazodone 25 mg by mouth three times a day for major depressive disorder. The order end date was on 10/17/24. On 10/17/24, there was an order for Trazodone 25 mg to be given by mouth every 8 hours as needed for major depressive disorder for 30 days. The order end date was 11/17/24. There was also an order for Trazodone 50 mg half a tablet by mouth every 8 hours for major depressive disorder, start date 11/23/24 and end date 12/4/24. On 12/2/24, there was an order to hold the medication until further notice. A note entered with the order indicated that the medication needed to be discontinued. The order and note was written by the medical provider. On 3/5/25 at 2:50 PM an interview was conducted with the Director of Nursing (DON). She was asked for a copy of the consent for the resident's Trazodone. The DON indicated that consent was not needed for Trazodone because it was an antidepressant. Although the facility had a consent for the Mirtazapine 30 mg once a day for depression, the DON reiterated that a consent was not needed for antidepressants. On 3/6/25 at approximately 9:30 AM, an interview conducted with the facility psychiatric nurse practitioner provider, who provided psychiatric services to Resident #3. She was informed about concerns regarding finding no consent for the Trazadone in the patients record. A consent for Mirtazapine was in the record of Resident #3, but not the Trazadone. The nurse practitioner indicated that she remembered the client and she explained the risks and the benefits of the medication Resident #3's representative before the Trazodone was initiated. The nurse practitioner indicated that the Trazadone was an antidepressant and therefore a psychotropic medication just like the Mirtazapine. On 3/6/25, a review of the facility policy and procedure titled Medication Management Psychotropic Medications, dated 10/24/2022, was conducted. The procedure section of the policy stated that residents receiving psychotropic medications will have the risk/benefits reviewed and consent completed prior to initiation of the medication. The policy further indicated that as needed (PRN) orders for psychotropic medications were to be limited for 14 days except when the prescribing practitioner believes that is appropriate to extend the medication beyond 14 days and documented the rationale and indicates the duration of the prn medication.

Based on observation and interview, the facility failed to maintain an adequately equipped call light system for the 100 hall of the building. The findings include: During the initial tour of the facility, it was noted that all the residents in the 100 hall were observed with hand held bells located at the bedside of each resident. When asked about this, the Administrator stated that the call light system was not working and these bells were being used in lieu of the call lights for now. He stated the call light system had been broken in the 100 hall for a very long time. However, it was noted upon looking in the rooms that there was no system of calling staff located in each of the bedrooms' private bathrooms. Upon further discussion, the Administrator stated the parts for the call light system had recently arrived and the repairs to the system should occur soon.

Based on record review and interviews, the facility failed to maintain accurate and updated medical records for 1 out of 8 residents sampled. (Resident #2) The findings include: On [DATE], it was decided by the family that Resident #2's code status would be changed to Do Not Resuscitate (DNR). The family started the process and the facility assisted in getting the order signed by the doctor that same day. The Social Service Assistant brought back the completed to the facility at approximately 4:45 PM. On [DATE], Resident #2 was observed in bed without respirations and cold to the touch. Staff F, a Licensed Practical Nurse (LPN), and Staff G, a Registered Nurse (RN), confirmed the advance directive on the electronic medical record, and it stated Resident #2 was a Full Code. Per facilities policy, they had to double check the Advance Directives book, located at the nurse's station, but it was not there. Staff F and G started cardiopulmonary resuscitation (CPR) until paramedics pronounced the resident expired. On [DATE] at approximately 9:20 AM, during an interview with Regional Director of Clinical Services, she was asked what the expectation was regarding the location of the Advance Directives book. She stated the book should never leave the nurses' station. When asked who was responsible for updating the orders when the completed DNR was received, she stated nurses are the only ones that can change orders. On [DATE] at approximately 12:36 PM, an interview was held with Staff E, a LPN, who was the nurse the day Resident #2 had the change in advance directives. When asked how she found out about the DNR order, she stated the social services assistant came back and announced she had received it, and she had witnessed her adding it to the book. When asked if that was the appropriate process, she stated that, before it gets added to the book, a nurse must update the orders. When asked if she had received a request to update the orders, she said she had not. She also stated she would never change those orders until she could verify the form was correct and had all signatures. On [DATE] at approximately 1:09 PM, an interview was held with Staff H, the Social Services Assistant (SSA). When asked if she had handed one of the nurses the completed DNR form, she stated she had announced to Staff E that she had the form while walking by her. She then put the form in the advance directives book. When asked if Staff E saw the form and was able to read it, the SSA stated she did not think so. She was asked if she had requested that Staff E update the electronic record, she replied, no, but it was understood. The DNR was updated to the electronic medical record after Resident #2 had expired

Based on observations, staff interviews, and policy review, the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety. There were issues found with the dish cleaning process, cold food storage, non-food items and personal drinks stored on food preparation stations and a lack of hair containment during food preparation. The findings include: A tour of the kitchen was conducted on 06/17/24 beginning at 12:01 PM. Upon entering the dishwasher room, the following was observed: -Two juice cups and one soup bowl were on the floor of the dishwasher room along with garbage, debris, and a large amount of water. -The ceiling above the dishwasher was rusted through and appeared to be falling apart. -A large amount of limescale buildup was observed on the front of the dishwasher. -The hose for the hand sprayer nozzle and a pipe located under the sink area were both observed with water flowing freely from them. -There was food matter falling under the sink and disposal area due to improper water flow through the drain and garbage disposal area. Staff were observed standing in puddles of water on the floor. -The outside of the garbage disposal had a large amount of rust present along with water and food particles. -Two baking sheets were present on the dish drying rack with pieces of parchment paper lying on them-the parchment paper had water and debris present on its surface. -The dish drying rack contained a large amount of rust on the surface. -A large pile of food particles was observed on the clean side of the dishwasher. -There was a rack of clean dishes which also contained a large buildup of food particles. An interview was conducted with the facility's Kitchen Manager during the observation. When asked if it was normal to have this amount of buildup of food particles on the clean side of the dishwasher, the Kitchen Manager stated, they should wipe that up. Continued tour found: -A silverware cart contained an employee identification badge, eyeglasses, a resident room television remote, and numerous rubber bands. -Two food preparation tables were observed, one of which contained two covered personal drinks, a personal cell phone, and a Bluetooth speaker and the other contained two uncovered personal drinks. -Mops were stored inside of a bucket in the storage closet preventing proper drying. -The sugar bucket in the dry storage room had a large buildup of a wet, brown substance on the inside and outside of the container. -The can shelving unit in the dry storage room had a buildup of glue and stains. -There was a broken shelf at the top center of the shelving unit in the dry storage room. -There was a large buildup of grease on the tops of the iced tea maker and ice machine along with a buildup of an unidentified black substance on the wall behind the ice machine. -The back outside entrance door of the kitchen was propped open with various bottles while exiting and re-entering the kitchen. -The handwashing sink lacked a garbage can with a foot pedal-operated lid. Closer observation revealed the closest garbage can was near a food preparation table approximately 15 steps away. This garbage can had a regular, lift-off lid. -A reach-in milk refrigerator contained cartons of milk did not feel cool to the touch. There was no thermometer in the refrigerator. (Photographic evidence obtained) Upon entering the walk-in refrigerator on 06/17/24 at 12:18 PM, it was observed that there was a large amount of water on the floor of the refrigerator and condensation build up on all containers in the refrigerator. It was also observed that the inner handle of the refrigerator door was broken and had come loose from the inside of the door. There was a large buildup of a black substance on the floor. There was a broken thermometer mounted on an inner wall of the refrigerator. The Kitchen Manager was asked if this was the thermometer the staff used to check the refrigerator's temperature daily. The Kitchen Manager stated this was the thermometer the staff used. The Kitchen Manager was shown that the thermometer was broken, missing approximately a half an inch of glass from the middle of the thermometer. She then stated there was a different thermometer that was used but she did not know where it was located within the refrigerator. Further inspection of the refrigerator revealed a thermometer that had fallen off a shelf next to the door. This thermometer stated the temperature in the refrigerator was 60 degrees F. Upon entering the walk-in freezer, located at the back of the walk-in refrigerator, the surveyor tripped over a buildup of ice on the floor on the inside of the freezer door, approximately 1.5 inches tall. The Kitchen Manager stated the buildup of ice had been there for some time. It was observed that there was a large build up of ice on the ducting and wiring of the cooling mechanism fan. The temperature in the freezer was 10 degrees F. The Kitchen Manager stated that the staff had been entering and exiting the refrigerator and freezer as they had recently finished lunch service. She stated it was very warm in the kitchen that day and that the refrigerator had trouble keeping its temperature when the temperature was warm. When asked how long this had been a concern, she stated it had been an issue for over a year. She stated she had spoken to the administration about her concern in the past but that nothing had been done. An interview was conducted with the facility's Kitchen Manager on 06/17/24 at 2:02 PM concerning the above areas of concern. She agreed the personal drinks, cell phone, and speaker should not have been present on the food preparation stations. She agreed the eyeglasses, TV remote, ID badge, and rubber bands should not have been present on the silverware cart. She stated she was not aware that the dishwasher was leaving food particles on the dishes but stated that the dishes would be re-washed prior to the next meal service. During a follow-up tour of the kitchen conducted on 06/18/24 at 11:13 AM, Staff R, Dietary Aide, was observed placing food onto plates from the service line. When asked if the temperatures had been taken prior to service, Staff R stated she did not know. She further stated there was a book on the preparation table that would include the temperatures taken by the cook (staff I). She said the cook was on break and unavailable for interview. When asked if she was told by Staff I (Cook) to begin plating the food, she stated she had not been told but that it was time to begin the meal service. During this interview, at 11:16 AM, Staff I, Cook, entered the kitchen. She confirmed she had just returned from her lunch break. She stated she was going to obtain the food temperatures prior to lunch service. Staff I was observed fastening her employee identification badge to her shirt. She then proceeded to don gloves to take food temperatures without first washing her hands. Staff I obtained a digital thermometer and cleaned it with an alcohol wipe prior to taking the food temperatures. Continued observation revealed Staff I obtained the temperatures of each food but between each food, she did not use a wipe to clean the thermometer but rather used the palm of the glove she was wearing. Closer observation revealed the wrist of the glove she was wearing dipped into the foods as she was obtaining the temperatures. It was noted that, while she was obtaining the temperatures of the foods, she was not documenting the temperatures on her log. Later review of the food temperature log conducted on 06/18/24 at 12:04 PM revealed that Staff I had not recorded the temperatures she had obtained. An interview was conducted with the kitchen District Manager on 06/18/24 at 12:05 PM. When showed that the temperature log was lacking the temperatures for the lunch meal, he stated the staff were nervous because we were there. When asked if the lack of documentation of temperatures was appropriate, he stated that it was not appropriate workflow and that there would be corrective action taken. Review of the facility's policy titled Environment, revised date 09/2017 revealed that all food preparation areas will be maintained in a clean and sanitary condition. Review of the facility's policy titled Food: Preparation, revised date 02/2023 revealed that temperature for foods will be recorded at time of service. Lack of Hair Containment: During the initial tour of the kitchen conducted on 06/17/24 at 12:01 PM, the surveyor observed Staff E, Dietary Aide, and Staff G, Dietary Aide, in the kitchen food preparation area without beard nets despite having facial hair. Staff I, Cook, was also observed with her hair not fully contained in a hair net in the food preparation area and dish washing area. Closer observation revealed Staff I had acrylic nails, approximately 1 inch long. Her acrylic nails were adorned with beads and jewels. An interview was conducted with Staff I on 06/18/24 at 10:28 AM. She stated her job duties as a cook at the facility included prepping food, cooking, doing dishes, keeping her preparation area clean, and serving food. While interviewing the Kitchen Manager on 06/17/24 at 1:20 PM, the facility Administrator was observed entering the kitchen and walking through the preparation area to the other side of the kitchen without wearing a hair net. Upon realizing he was being observed, the Administrator quickly turned and exited the kitchen. An interview was conducted with the facility's Kitchen Manager on 06/17/24 at 2:02 PM. The manager was asked about misuse of hair and beard nets by the staff. She stated the staff were aware that they should wear hair and beard nets while in the kitchen and that they were supposed to don their hair nets before entering the kitchen area. An additional observation conducted on 06/17/24 revealed Staff F, Dietary Aide, enter the kitchen and walk through the preparation area to the other side of the kitchen without wearing a hair net. When the Kitchen Manager asked him to don a hair net prior to entering the preparation area, he stated I just got here. Further observation revealed when he did don a hair net, he did not fully contain his hair within the hair net. Additional observations conducted on 06/18/24 revealed Staff E wearing a beard net improperly, in a manner which did not cover his facial hair but rather left the beard net was located under/behind his facial hair. Interviews were conducted with Staff E and Staff G on 06/18/24 at 10:30 AM. They stated their job duties as dietary aides included prepping food, doing dishes, taking out the garbage, working on the food service line, and pushing meal carts to the units. Review of the facility policy titled Authorized Kitchen Personnel, revised date 09/2017 revealed all authorized personnel must wear appropriate head covering while in the kitchen or production area. Review of the facility policy titled Staff Attire, revised date 10/2023 revealed the following: All staff members will have their hair confined in a hair net or cap and facial hair properly restrained Use of nail polish, acrylic and gel nails are not permitted Review of the facility policy titled Food: Preparation, revised date 02/2023 revealed all staff will practice proper hand washing techniques

Based on observations, review of the electronic medical record (EMR), interviews with staff and residents, and review of the facility policies and procedures, the facility failed to provide a dignified existence for 5 of 6 residents sampled for dignity. (Residents 104, 65, 116, 41, and 120) The findings include: Resident #104 During a tour of the facility conducted on 06/17/24 at 2:53 PM, Resident #104 was observed lying in bed in a hospital gown. When asked why Resident #104 was in a hospital gown, Resident #104 stated she had no clean clothes. She stated she had talked to housekeeping staff and to nursing staff and each told her the responsibility of resident's personal laundry fell on the other. Resident #104 gave the surveyor permission to open her closet, and inside the surveyor observed bags and piles of clothing. (Photographic evidence obtained with resident's verbal permission) Resident #104 verified these clothes were all dirty and in need of laundering. When asked if she was wearing a hospital gown due to her lack of clean clothing, she stated Yes, I only have one clean dress and I was going to wear it tomorrow. A review of records revealed the most recent Quarterly Minimum Data Set completed on 04/27/24 revealed Resident #104 had a Brief Interview of Mental Status Score of 7, which indicated she had cognitive impairment. An interview was conducted with the Housekeeping Administrator on 06/19/24 at 2:45 PM. She stated the staff responsible for transporting resident's personal laundry was the nursing staff, specifically the Certified Nursing Assistants (CNAs). She said the CNAs were responsible for bagging the resident's personal laundry and placing a paper slip in the laundry bag containing the resident's name and room number. She said the CNAs then either took the dirty laundry bag to the soiled utility room or directly to the laundry room for processing. She said the residents or their families were encouraged to label their own clothing so that it did not become lost at the facility. An interview was conducted with Staff M, CNA, on 06/20/24 at 1:12 PM. Staff M confirmed she was assigned to care for Resident #104 often. Staff M said she had spoken to Resident #104 numerous times regarding her personal laundry not being done. She said it was not her responsibility as a CNA to take a resident's laundry to the laundry room but rather it was the responsibility of the laundry staff to collect the soiled personal laundry from each resident's room. She said when the clothes were returned by the laundry staff, they sometimes hung the clothes in the resident's closets but other times the laundry staff placed a bag of clean clothes on the chair in the room and then the CNAs hung the clean clothes in the closets as they had time. She said resident's families often labeled the clothing but that if a resident's clothing was not labeled, they would place a paper inside the laundry bag so the laundry staff knew who the laundry belonged to. An interview was conducted with Resident #104 on 06/20/24 at 2:26 PM. She stated her clean clothes were hung in her closet on 06/19/24. During this interview, Resident #104 was lying in bed, fully dressed. She stated she was happy that she had her clean clothes hung in her closet. She further stated she was happy that she was able to wear her clothes instead of a hospital gown. 42756 Resident #65 and #116 On 06/18/24 at approximately 10:25 AM, an interview was conducted with Resident #65. He was wearing a patient gown. He indicated that he has no clothes to wear. He said he came to the facility without any clothes. He has had to wear a gown every day. Resident #65 was asked if he likes wearing a gown. He said no, and indicated that he would prefer to wear clothes instead of a gown. On 06/18/24 at approximately 5:07 PM, an observation was made of resident #65 wearing a gown. On 06/19/24 at approximately 9:19 AM, Resident #65 was once again observed wearing a patient gown. An interview on 06/18/24 with Resident #116 at approximately 10:45 AM revealed he also had no clean pants to wear. He explained that he often has to re-wear his pants because he only has a few pants and he does not get them back from laundry. He was wearing a pair of black pants. There was a small bag of soiled clothes in his room. Resident #116 said he had previously filed a grievance regarding this. On 6/19/24 at approximately 3:16 PM, observations were made in the laundry room. There were 5 extra-large bags on the floor. A sign above the bags said Please do not touch. Washing and sorting. Another shelf had bedspreads and pillows stored up to the ceiling. There was a rolling rack for hangers with clothes hung up and labeled by the room. The bottom shelf of the rack had unfolded clothes both bagged and out of bags piled up. There was another rack that had a clear bag of what appeared to be clothes lying on the floor. (photographic evidence obtained). The Laundry Services Supervisor was interviewed and indicated that the clothes in the bags lying on the floor had been washed and were waiting to be sorted. When the surveyor pointed out the bags were stored on the floor, she explained that clothes in the bags would be re-washed, dried, and sorted. The Laundry Services Supervisor indicated that they have been short staffed in laundry and have not had the staff to deal with sorting resident clothing. She explained that there are currently 3 staff working in the laundry. Two weeks ago the facility had only 2 people processing personal laundry. She indicated more of the clothes have just recently been reprocessed. She pointed at the folded clothing on the shelves. She explained that 6 people have been hired to work in laundry services in recent weeks. She explained that she has only worked for the facility for three months and they have been actively working to improve laundry services. The Laundry Services Supervisor indicated that resident's clothing has been a daily topic in the morning meetings. She indicated that the facility administration is aware and they are working together to correct the problem. The District Manager of Housekeeping Services was interviewed and explained that the expectation is that it takes no more than 48 hours to process items that come into the laundry room. The Director Of Nursing (DON) was asked to provide initial inventories of personal effects for Residents #65 and #116. She was also asked to provide a copy of the grievance completed by Resident #116. On 6/19/24 at approximately 4:40 PM, a review of the facility grievance log was conducted. The log indicated that a grievance was filed on 5/15/23 by Resident #116 regarding missing clothes. The resolution section on the log stated that the clothes had been found and returned and the complainant was notified of the resolution on 5/20/24. On 6/19/24 at approximately 5:28 PM, an interview was conducted with the Facility Administrator (FA). He indicated that the facility did have issues with laundry supplies about 6-7 months ago but it has been corrected since. The FA mentioned that they do clothing drives and supply clothes to the residents who need them. He explained that is the family's responsibility to label the clothing for residents. When items get lost, facility staff goes through everything trying to find the lost item. On 06/20/24 at approximately 8:30 AM, Resident #65 was once again observed in bed asleep wearing a patient gown. On 06/20/24 at approximately 11:30 AM, Resident #65 was awake and indicated that he has not received any clothes yet. The surveyor asked for permission to look in his closet. In the closet, there was a long sleeve sweater hanging and a pair of pants, but nothing else (photographic evidence obtained). Immediately afterwards, the other resident, #116 was observed to be wearing the same black pants on that he wore on 6/18/24. On 6/20/24, a review of the Inventory of Personal Effects form dated 4/27/23 for Resident #65 was conducted. The form indicated that he came to the facility with no personal belongings when he entered the facility. A review of the Inventory of Personal Effects form dated 4/27/23 for Resident #116 was conducted. Based on the inventory, the resident came into the facility with 2 pairs of shorts, 2 pairs of sweat pants, 1 pair of suit pants, and 1 pair of pants. On 06/20/24 at approximately 3:10 PM, an interview was conducted with the Director of Nursing (DON). She was notified that Resident #65 wore a gown every day of the survey. He came into the facility with no clothes and expressed wishes to have clothes to wear. The DON said the facility would go buy him clothes immediately. She was also notified about Resident #116 who said he has no pants to wear. On 06/20/24 at approximately 3:19 PM, an interview was conducted with the Regional Social Services Director (SSD) regarding the initial inventory for Resident #65. The SSD stated that he came into the facility on [DATE] with no clothes and has been wearing patient gowns everyday. The Resident reported that he wished to wear clothes instead of a gown. She indicated that clothes should be provided and this would be corrected. She said a grievance has been filed on behalf of resident #65 and #116. She indicated that resident #116 has 4 pairs of pants in his closet now. 35609 Resident #41 On 06/18/24 at 9:30 AM, Staff A, a Certified Nursing Assistant (CNA A), was observed moving Resident #41 in a mechanical lift taking the resident into the bathroom. The resident was observed to have their pants down around the ankles with their unclothed mid section to their ankles visible from the hallway. The door was open and the resident's wheelchair was in the doorway. On 6/18/24 at approximately 9:31 AM, an interview was conducted with CNA A, who was asked why she was providing toileting care with the door wide open. She stated she did not close the door because there wasn't enough room to close the door and the resident was rushing her. On 6/19/24 at 11:50 AM, an interview was conducted with Resident #41, who stated they wished the staff would close to door and did not like they were exposed naked from the waist down. On 6/19/24 at approximately 1:42 PM, an interview was conducted with the Director of Nursing (DON) who stated she expected staff to close the doors and close privacy curtains when care is provided. The DON stated the door should have been closed. On 6/19/24 a review of the facility policy, Privacy effective 11/30/14, states, Procedure: 1. The Nursing Home staff will recognize that residents and their families need a place of privacy. 2. Resident's privacy will always be respected. 3. Facility will provide time and space for privacy. 50082 Resident #120 On 6/17/2024 at approximately 10:50 AM, an observation of Resident #120's room revealed that the dresser and hanging clothing armoire are turned around with the doors and drawers facing the wall, prohibiting the resident access to belongings. (photographic evidence obtained) On 6/17/2024 at approximately 11:00 AM, an interview with staff V, a certified nursing assistant (CNA V), was performed, She stated that the dressers for Resident #120 were turned around to face the wall to limit the resident's access to them, as the resident is often getting into the clothing and changing several times a day. She indicates Resident #120's clothing is kept in the activities room on a hanging cart that the resident cannot access. On 6/18/2024 at approximately 07:43 AM, Resident #120 was observed wearing a sweat suit with her name written in large print on the front right chest in marker. On 06/19/2024 at approximately 03:30 PM, Resident #120 was observed wearing a shirt with her name labeled on the right front chest. On 06/20/2024 at approximately 08:00 AM, during an interview with Staff U, another CNA, she indicates that the facility does the laundry for Resident #120. Staff will label the clothing before it is sent to laundry. She indicates the process for labeling the clothing is with a marker and should be written on the back neckline near the tag. A review of the resident's record for Resident #120 reveals a care plan dated 9/22/2023 with goals related to self-care performance deficit. Interventions include assisting the resident to choose simple comfortable clothing that enhances the resident's ability to dress themself and allow sufficient time for dressing and undressing. The resident requires assistance by staff to dress. A review of the policy named Processing Resident Personal Clothing policy 6-33 dated 02/01/2003 indicates that all residents clothing for residents in Long Term Care facility must be labeled in a manner that is both practical and respects the dignity of the resident. A small permanent tag or label is placed in the most inconspicuous place on every article of clothing.

Based on observations, interviews, and policy reviews the facility failed to maintain food service related equipment in safe operating condition in the kitchen and food pantries. The findings included: Kitchen sink: During the initial tour of the kitchen conducted on 06/17/24 at 12:01 PM, upon entering the dishwasher room, it was observed that a large amount of water was present on the floor of this room. Closer observation revealed there was a sprayer nozzle hanging over a sink area which had a large amount of water coming out of the hose. It was also observed there was water pouring out of a pipe under the sink. Further observation revealed, on the right side of the dishwasher, that there was a large buildup of food particles present along with a rack of clean dishes which also contained a large buildup of food particles. An interview was conducted with the facility's Kitchen Manager at this time. The manager was asked to explain if this was the dirty side, where the dirty dishes entered the dishwasher. The Kitchen Manager stated this was the clean side, where the clean dishes exited the dishwasher. When asked if it was normal to have this amount of buildup of food particles on the clean side of the dishwasher, the Kitchen Manager stated, they should wipe that up. An additional observation of the dishwasher room was conducted on 06/17/24 at 1:20 PM during which Staff E, Dietary Aide, was rinsing dishes, placing them into racks, and putting the racks through the dishwasher while Staff G, Dietary Aide, was receiving the cleaned dishes on the other side of the dishwasher. Upon retrieving a rack of clean dishes, it was observed that there were soup bowls and coffee mugs present in a flat rack; there were no securing or stabilizing areas of the dish rack to hold the dishes properly in place. The surveyor observed the soup bowls were turned bowl-side up and contained water with soap bubbles and food particles. When asked if these dishes were clean, Staff G stated the dishes were clean as they had just come from the dishwasher. When asked if it was typical to have water with soap and food particles present in clean dishes, Staff G held up two soup bowls and stated, Its fine, I just shake the water out of them before I put them on the drying rack and demonstrated shaking the water and food particles onto the floor of the room before then placing the bowls onto the dish drying rack to his right. An interview was conducted with the facility's Kitchen Manager on 06/17/24 at 2:00 PM during which the above concerns were discussed. The Kitchen Manager stated the dishes would be rewashed prior to the next food service. An interview was conducted with the facility's Administrator on 06/17/24 at 4:49 PM. He stated he had heard there was a concern regarding the dishwasher that morning. He stated the staff had not assembled the dishwasher properly that morning and that there were supposed to be plastic curtains that hung down from the top of the machine on each side to stop the food particles from coming out. He stated the dishwasher had been properly reassembled and that the food particles would no longer be a concern. He further stated the sprayer nozzle had been fixed, so the floor would no longer have water on it. The Administrator was told that the concern was not only the sprayer nozzle but also the pipe under the sink which was leaking water onto the floor. The Administrator replied, Right, the sprayer nozzle was fixed. The following morning, the Administrator was asked for a copy of the policy which contained the proper disassembling and reassembling instructions the staff were trained to follow for the daily maintenance of the dishwasher. The Administrator stated he did not know what they were referring to and that the dishwasher was a leased machine and that the staff were not trained to disassemble or reassemble. An interview was conducted with the facility's Dietitian on 06/18/24 at 5:50 PM. She stated part of her responsibility as dietitian was to conduct weekly and monthly kitchen tours during which she ensured the equipment was maintained properly and that the kitchen was maintained in a clean manner. When asked if the facility's administration had explained to her the areas of concern in the kitchen, she stated they only told me there was a concern that some soapy water was found in a bowl that had just come out of the dishwasher. She stated she was unaware of additional concerns but that she would begin giving in-services to the staff. During a tour of the kitchen conducted on 06/19/24 at 9:45 AM, Staff E, Dietary Aide, was observed at the sink using the sprayer nozzle to clean dishes. Closer inspection revealed white tape had been used to wrap the hose of the sprayer nozzle. Additionally, white tape had also been used to wrap the pipe under the sink. Staff E stated the floor in the room was significantly dryer since the hose and pipe had been patched but that they were still leaking some. During this observation, it was observed that there were blue plastic curtains which hung down from each side of the dishwasher. The surveyor also observed dish racks with stabilizing posts were being used for the dishes and that the dishes being removed appeared to be clean. Kitchen refrigerator and freezer An initial tour of the facility's walk-in refrigerator was conducted with the Kitchen Manager on 06/17/24 at 12:18 PM. Upon entering the walk-in refrigerator, it was observed that there was a large amount of water on the floor of the refrigerator and condensation build up on all containers in the refrigerator. It was also observed that the inner handle of the refrigerator door was broken and had come loose from the inside of the door. There was a large buildup of a black substance on the floor. It was also observed that a broken thermometer was mounted on an inner wall of the refrigerator. The Kitchen Manager was asked if this was the thermometer the staff used to check the refrigerator's temperature daily. The Kitchen Manager stated this was the thermometer the staff used. The Kitchen Manager was shown that the thermometer was broken, missing approximately a half an inch of glass from the middle of the thermometer. She then stated there was a different thermometer that was used but she did not know where it was located within the refrigerator. Further inspection of the refrigerator revealed a thermometer that had fallen off a shelf next to the door. This thermometer stated the temperature in the refrigerator was 60 degrees F. Upon entering the walk-in freezer, located at the back of the walk-in refrigerator, the surveyor tripped over a buildup of ice on the floor on the inside of the freezer door, approximately 1.5 inches tall. The Kitchen Manager stated the buildup of ice had been there for some time. It was observed that there was a large build up of ice on the ducting and wiring of the cooling mechanism fan. The temperature in the freezer was 10 degrees F. The Kitchen Manager stated that the staff had been entering and exiting the refrigerator and freezer as they had recently finished lunch service. She stated it was very warm in the kitchen that day and that the refrigerator had trouble keeping its temperature when the temperature was warm. When asked how long this had been a concern, she stated it had been an issue for over a year. She stated she had spoken to the administration about her concern in the past but that nothing had been done. While touring the kitchen, there was a chest/reach-in refrigerator which contained cartons of milk. The temperature inside the refrigerator and the cartons of milk did not feel cool to the touch. The surveyor asked the Kitchen Manager if the thermometer on the outside of the refrigerator worked and was accurate, she stated it was not and that external thermometers were rarely accurate and were not used. When asked where the thermometer was inside the refrigerator, she stated she did not know. Further observation revealed there was no internal thermometer present inside this refrigerator. A second tour of the walk-in refrigerator was conducted on 06/17/24 at 12:38 PM. During this observation, the temperature was 50 degrees F. An interview was conducted with the District Kitchen Manager on 06/18/24 at 12:05 PM. He stated, as the district manager, he oversaw all tasks that fell under the realm of the kitchen. He stated he had not been aware of a refrigerator concern but that they had called a company to perform maintenance on the refrigerator to ensure it was in proper working condition. A tour of the walk-in refrigerator was conducted on 06/18/24 1:25 PM. During this observation, the surveyor found three thermometers present, each reading 40 to 41 degrees F. An interview was conducted with the facility's Dietitian on 06/18/24 at 5:50 PM. She stated part of her responsibility as dietitian was to conduct weekly temperature log checks of the refrigerator and freezer. She said she was not aware of concerns about the refrigerator's ability to keep a consistent temperature during warm weather. The surveyor asked the District Kitchen Manager to review the work orders for the walk-in refrigerator/freezer-no work orders from prior to the survey exit were provided. Pantry ice machines/refrigerators A tour was conducted on 06/17/24 at 4:30 PM of the facility's pantry rooms located on each resident care unit, three in total. In the pantry located on the 100-hall, a large ice machine was observed unplugged and not in service. There was a small refrigerator present in this pantry which contained a large buildup of ice along the back wall of the refrigerator, approximately 3 inches thick. In the pantry located on the 200-hall, a large working ice machine was observed. The surveyor noted the floor of the pantry was wet with water. Closer observation revealed the ice machine appeared to be the source of the water. It was found there were towels, a blanket, and paper towels under the ice machine along with dark gray/black biological build up under and behind the ice machine. While performing this observation, water was heard rushing from behind the ice machine. The surveyor observed water pouring out of a white L-shaped pipe that was located at the far back corner of the machine; this lasted approximately 10 seconds. Further observation in this pantry revealed a small refrigerator present which contained a large buildup of ice along the back wall of the refrigerator, approximately 3 inches thick and a large buildup of ice in the freezer compartment, approximately 1.5 inches thick. In the pantry located on the 300-hall, the surveyor observed a small refrigerator present which contained a large buildup of ice present in the freezer compartment, approximately 1.5 inches thick. The District Kitchen Manager explained that the facility's Plant Operations Manager was not present in the building, but that these areas of concern could be shown to the Plant Operations Manager that was overseeing the facility for the day. He explained this Plant Operations Manager was from a sister-facility in the area and had stepped in in the facility's Plant Operations Manager's absence. He further stated he and the kitchen staff were not responsible for overseeing the maintenance of the equipment found in the pantry rooms. A tour was conducted with the interim Plant Operations Manager on 06/17/24 at 4:50 PM. He stated he was not aware that the refrigerators and freezers were in need of de-frosting, that the one ice machine was not operational, or that the other ice machine was leaking. During the tour, the surveyor was able to show him the pipe that was leaking water. He stated that was likely a broken over-flow valve, which would be easy to fix. He stated he would tell the facility's Plant Operations Manager about these concerns. A tour was conducted on 06/18/24 at 8:42 AM of the facility's pantry rooms. The surveyor found no visible improvement in any of the identified areas of concern. A tour was conducted on 06/19/24 at 8:30 AM of the facility's pantry rooms. The surveyor found a new refrigerator present in the 100-hall pantry, but otherwise no visible improvement in the other identified areas of concern. During a facility-wide environmental tour conducted on 06/19/24 with the facility's Plant Operations Manager, these areas of concern were discussed. The surveyor asked if the interim Plant Operations Manager had told him about these areas of concerns, he stated he was not aware of these issues. The surveyor asked the District Kitchen Manager to review the work orders and maintenance logs for the refrigerators and ice machines. No work orders from prior to the survey entrance were provided. Review of the facility's policy titled Warewashing, revised date 02/2023 revealed the following: All dishware, serviceware, and utensils will be cleaned and sanitized after each use; The dining services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine. Review of the facility's policy titled Food Storage: Cold Foods, revised date 02/2023 revealed the following: All perishable foods will be maintained at a temperature of 41 degrees Fahrenheit (F) or below; An accurate thermometer will be kept in each refrigerator and freezer. Review of the facility's policy titled Equipment, revised date 09/2017 revealed the following: All foodservice equipment will be clean, sanitary, and in proper working order; All equipment will be routinely cleaned and maintained; All staff will be properly trained in the cleaning and maintenance of all equipment; Copies of service repairs and preventative maintenance reports will be submitted monthly. Review of the facility's policy titled Ice, revised date 10/2022 revealed the following: Ice will be prepared and distributed in a safe and sanitary manner; The Dining Services Director and/or Maintenance Director will ensure that all ice machines are plumbed from a potable water source and that air gap drains are appropriately maintained; The Dining Services Director will coordinate with the Maintenance Director to ensure the ice machines will be disconnected, cleaned, and sanitized quarterly and as needed.

Based on observations and staff interviews the facility failed to provide a safe, clean, and homelike environment in the laundry room, main hallway, and the 100 and 200 residential areas. The findings include: On 6/19/24 at 2:51 PM, a tour of the facility laundry services area was conducted with the Facility Administrator (FA), District Manager of Housekeeping Services, the Facility Laundry Services Supervisor, and the Plant Operations Director. Upon opening the door to the soiled laundry processing area, concerns were identified. On the right side of the room was a shelf overflowing and stacked with linens to the ceiling. A blue disposal can was directly in front of the shelf with linens stacked up on top. There were also linens on the floor below the shelf. The left side of the room had another shelf stacked with pillows to ceiling. There were several items on the soiled concrete floor including towels, sheets, and gowns in bags that were partially opened. There was a bed spread thrown on the floor. In between the washing machines, there were two large garbage disposal bins without lids. (photographic evidence obtained) On 6/19/24 at approximately 3:06 PM, interviews were conducted in the area. The Laundry Services Supervisor explained that the contents of both shelves were waiting to be discarded. She was asked why there were so many items stacked up. The Plant Operations Director indicated that sometimes floor staff use items stored on the shelves to do the floors. The District Manager of Housekeeping Services was asked about the garbage cans between the laundry room. He indicated that the cans should not be in the area and would be moved. On 6/19/24 at 3:16 PM, observations were made in the personal clothing room. There were 5 extra-large bags on the floor. A sign above the bags said Please do not touch. Washing and sorting. Another shelf had bed spreads and pillows stored up to the ceiling. There was a rolling rack for hangers with clothes hung up and labeled by the room. The bottom shelf of the rack had unfolded clothes both bagged and out of bags piled up. There was another rack that had a clear bag of what appeared to be clothes lying on the floor (photographic evidence obtained). The Laundry Services Supervisor indicated that the clothes in the bags lying on the floor had been washed and were waiting to be sorted. When the surveyor pointed out the bags were stored on the floor. She explained that clothes in the bags would be re-washed, dried, and sorted. The Laundry Services Supervisor indicated that they have been short staffed in laundry and have not had the staff to deal with sorting resident clothing. She explained that there are currently 3 staff working in the laundry. Two weeks ago, the facility had only 2 people processing personal laundry. She indicated more of the clothes have just recently been reprocessed. She pointed at the folded clothing on the shelves. She explained that 6 people have been hired to work in laundry services in recent weeks. She explained that she has only worked for the facility for three months and they have been actively working to improve laundry services. The District Manager of Housekeeping Services explained that the expectation is that it takes 48 hours is the goal to process items that come into the laundry room that is the goal. On 6/19/24 at approximately 4:41 PM, the District Manager of Housekeeping Services reported that the trash cans had been removed from next to the washing machines. Both shelves that were overstocked with linen and pillows in the soiled laundry room had been discarded. The shelves have been removed as well. He indicated that the facility will order sorting bins to be used in the future. A review of the facility Laundry Process dated 1/1/2000 was conducted. The policy indicated that soiled linen should be transported in containers or barrels marked soiled linen only. According to the process, soiled linen containers were to be lined with an impervious liner and contain a lid. The process indicated that containers should be checked frequently to prevent overflow of soiled laundry. As soon as linens are removed from the dryer they should be folded. The folding process must keep pace with the washers and dryer and there should never be a back up on clean linen waiting to be folded. A review of the Processing Resident Personal Clothing process dated 2/1/2003 was also conducted. The process indicated that clothing should not accumulate in the laundry. Unmarked clothing should be brought to the units for identification on a daily basis. Racks of hung and folded clothing should be delivered daily either by nursing personnel or laundry staff. 45951 During a tour of the facility conducted on 06/17/24 at 5:40 PM, six unidentified large brown/green semi-liquid piles were observed throughout a main hallway of the facility leading from the dining room door to the laundry room door. One pile appeared to have been tracked through with a wheel (photographic evidence obtained). While attempting to identify the substance, six facility employees were observed walking down the hallway past the piles, past the facility's administrator's office, and out the front door without alerting any staff of the issue. The surveyor also observed one resident walk through the area with a cane. The facility's administrator, Director of Nursing, and regional nurse were made aware of the piles of unidentified matter throughout the hallway posing a slipping hazard to anyone walking through the hallway. The Director of Nursing stated she would call housekeeping to clean up the piles. An environmental tour of the facility was conducted on 06/19/24 with two surveyors, the facility's Administrator, Plant Operations Manager, Housekeeping Administrator, and District Manager of Housekeeping Services. The following environmental concerns were observed (photographic evidence obtained): In room [ROOM NUMBER], the windowsill had fallen down and was lying on the floor; there was heavy wear on the wall near the room entrance with exposed metal. In room [ROOM NUMBER], there were 3 stained ceiling tiles above the bathroom and entrance of the room. In room [ROOM NUMBER], there were dark brown stains present on the privacy curtain and floor. In room [ROOM NUMBER], an armchair present near the room doorway was noted to be heavily soiled. There was heavy wear on the wall in the laundry room, causing exposed metal. In the shower room on the 100 hallway, the floor had unidentified brown matter present under a shower chair. In the shower room on the 200 hallway, the floor was chipping/peeling paint.

Based on observation, record review, and staff interview, the facility failed to properly store medications maintain medication carts, including disposal of expired medications and properly labeling medications in 3 of 3 medication carts reviewed. The findings included: A medication cart observation was conducted on 06/20/24 at 3:15 PM with Staff N, a Licensed Practical Nurse (LPN) for the Split Haven medication cart. The following areas of concern were identified (photographic evidence obtained): -4 white unidentified tablets were observed in the top left drawer of the medication cart. LPN N disposed of these medications into the sharp's container located on the side of the medication cart when this was brought to her attention. -4 multicolored tablets were observed in the 3rd drawer on the right side of the medication cart. LPN N disposed of these medications into the sharp's container located on the side of the medication cart when this was brought to her attention. -A Levemir insulin pen lacked an open date. It is unknown if this medication was used, however, per the pharmacy label, if it was unopened, it should have been refrigerated. -Dorzolamide eye drops lacked a pharmacy label/name and there was no received date from the pharmacy noted. An interview was conducted with LPN N at the end of this observation regarding the disposal of the loose medications found in the cart. LPN N confirmed that she disposed of the medication tablets into the sharp's container on the side of the medication cart. When asked if the facility provided a pill buster solution for the nurses to dispose pills into, she stated there was a bottle of pill buster solution in the medication storage room. She stated she was aware that she should have taken the tablets to the pill buster bottle for disposal. A medication cart observation was conducted on 06/20/24 at 3:46 PM with LPN O for the 100-hall medication cart. The following areas of concern were identified: -6 white unidentified tablets were observed in the top left drawer of the medication cart. LPN O disposed of these medications into the pill buster located in the medication room when brought to her attention. -An unidentified multi dose vial of Lidocaine was observed with no label from the pharmacy or date opened. -1 white unidentified tablet was observed in a drawer of the medication cart. LPN O disposed of these medications into the pill buster when brought to her attention. -Two Symbicort inhalers lacked a pharmacy label/name and had no received date from the pharmacy. -25 multicolored tablets were observed in the medication cart. LPN O disposed of these medications into the pill buster when brought to her attention. -A ProAir RespiClick inhaler lacked a pharmacy label/name and had no received date from the pharmacy. -A Multi dose vial of Novolog insulin was observed lying in the medication cart with no open date or received date from the pharmacy. -An Insulin Glargine pen lacking an open date, it is unknown if this medication was used, however, per the pharmacy label, if it was unopened, it should have been refrigerated. -A Novolin pen was observed lacking an open date, it is unknown if this medication was used, however, per the pharmacy label if it was unopened, it should have been refrigerated. A medication cart observation was conducted on 06/20/24 at 4:37 PM with LPN P for the 300-hall medication cart. The following areas of concern were identified: -1 unidentified tablet was observed at the bottom of the medication cart. LPN P verbalized she planned to flush this tablet down the toilet to dispose of it. When asked what the facility policy was for disposal of medications, she verbalized the policy was to use the pill buster solution. -A Glucose Gel was observed with an expiration date of 01/2023. An interview was conducted with the facility Director of Nursing (DON) on 06/20/24 at 5:30 PM in which the above areas of concern were discussed. The DON stated the pharmacist had come to the facility to conduct medication cart audits, during which he had audited each medication cart for expired or unlabeled medications. The DON provided to the surveyor a copy of audits conducted by the pharmacist, dated 06/12/24. Review of the facility policy titled Medication Storage, undated revealed the following: Medications will be stored in a manner that maintains the integrity of product and ensures the safety of the residents; Medications will be stored in an orderly, organized manner in a clean area; Medications will be stored in the original, labeled containers received from the pharmacy; Expired medications will be removed from the medication storage area and disposed of in accordance with facility policy.

Based on observations, resident intervew, staff interview, review of meal tray tickets and electronic medical record (EMR) review, the facility failed to serve each resident a palatable diet and failed to address special dietary needs and physician orders for 3 of 7 residents sampled for food related concerns, Resident #22, #248 and #135). The findings include: Resident #22 On 06/17/24 at approximately 01:50 PM, Resident #22 was observed with a lunch tray in front of her. She indicated she just returned to the facility from dialysis. Resident #22 reported she does not get a bagged lunch on the days she is out of the facility for dialysis. On 06/18/24 at approximately 08:28 AM, Resident #22 stated she frequently does not get what is on her meal ticket, it often is missing cereal, jelly and margarine. Resident #22 stated her roommate's family provides snacks and individual microwave meals that she supplements with. An observation at this time of Resident #22's meal ticket indicates, NO MILK, but there were two cartons of milk observed on the tray, she received toast without the jelly and margarine. On 06/19/24 at approximately 08:10 AM, Resident #22 was observed sitting in her wheelchair. She had finished her breakfast which included 2 boiled eggs, raisin bran cereal with milk and oatmeal. The meal ticket still indicates NO MILK as well as 3 slices of bacon, which the resident did not receive. Resident #22 indicated she has never received the bag lunch on her dialysis days, which are Monday, Wednesday, and Friday. She reported she has lived at the facility for approximately 3 years. On 06/20/24 at approximately 08:24 AM, Resident #22 was observed sitting in her wheelchair in her room. The meal ticket once again indicated NO MILK, yet she had a bowl of raisin bran cereal with milk on her tray. A review of the EMR revealed Resident #22 had a diagnosis of dependence on renal dialysis and end stage renal disease (ESRD). A review of the physician's orders include orders dated 3/22/24 indicate to send a bagged lunch with the resident for dialysis. Resident 22's diet order states no dairy. On 06/20/24 at approximately 2:22 PM, the kitchen manager stated that the residents in the building that are on dialysis receive bag lunches on the days they go out. The van drivers will go to the kitchen and request the lunch bag before leaving the facility. Staff H indicates Resident #22 is served a large breakfast prior to leaving the facility on dialysis days. Staff H indicates that Resident #22 is always back from dialysis in time for lunch at the facility and always has a lunch tray delivered to her room, she also gets a lunch bag all three days. Staff H confirms that she is aware Resident #22's meal ticket indicates NO MILK. When asked about the observations of milk on the resident's tray for four days in a row, the kitchen manager stated that, if the resident is receiving milk on her tray, it is her kitchen staff not reading the ticket. Staff H stated that kitchen staff place condiments such as margarine and jelly on the carts in bulk when they are sent to the floor, it is the responsibility of the floor nursing staff to give the residents the condiments when they pass trays. 42756 Resident #248 On 06/17/24 at approximately 3:59 PM, an interview was conducted with Resident #248. She reported that the food is often cold and does not taste good. She often does not eat what is served at the facility because she had found the food to be overall unacceptable. She reported that she has told staff about this numerous times in the weeks she has lived at the facility. On 6/19/24 at approximately 8:00 AM, Resident #248 said again she did not eat her breakfast tray today or yesterday. She restated that she often does not eat the food. She stated that when she does eat the facility's food, her stomach gets upset and she gets diarrhea. She explained that the breakfast yesterday morning was not good and the she did not like the alternative offered by the facility which was cereal or warm milk. Her tray was still at the bedside. The ticket said 2 buttermilk pancakes, 1 diet syrup, 1 margarine, 2 slices of bacon, 6 oz of hot cereal, 8 oz of milk, 4 oz of orange juice, and 6 oz of coffee or hot tea. She reported that the milk was warm and she did not open it. She did not receive syrup or margarine or coffee/tea with her breakfast. The milk on the trays felt warm to touch . The Resident said she could not eat dry pancakes and dry cereal and warm milk. On 6/19/24 at approximately 11:32 AM, while Resident #248 was being escorted out of her room by Certified Nursing Assistant C, she could be heard in the hallway telling the nursing assistant not to bring her lunch tray. She explained that she did not want to eat her lunch because the food is terrible. On 06/20/24 at approximately 8:32 AM, Resident #248 said she had her own food for breakfast and did not want her breakfast tray today. Resident #135 On 06/19/24 at approximately 8:00 AM, an interview was conducted with Resident #135. She complained that the food was cold most of the time. She said sometimes the food appears to be undercooked. She said she was served Italian sausage that appeared to be raw the other day. The resident verbalized concerns for people who are disoriented or confused and unable to notice concerns with the food quality. She complained that trays are often missing condiments. The servings are often small. She explained the other day she got one small chicken wing for the meat portion of her meal. Resident #135 said the milk is often warm. She said she often gets diarrhea and wonders if the food might be contributing to the diarrhea. She showed the surveyor her tray. She had dry pancakes with no margarine or syrup to apply to the pancakes. The milk on the tray felt warm to touch. The ticket said 2 buttermilk pancakes,1 diet syrup, 1 margarine, 2 slices of bacon, 6 oz of hot cereal, 8 oz of milk, 4 oz of orange juice, and 6 oz of coffee or hot tea. (photograph evidence obtained). On 6/19/24 at approximately 12:45 PM an interview was conducted with CNA C. The surveyor mentioned Resident #248 and #135 had complaints about their breakfast that morning and the trays had no margarine or syrup on the trays. She explained that the margarine and syrup is on the side. CNA C replied that residents have to ask for the condiments and staff will get them whenever they ask.

Based on observations, staff interviews, and policy reviews the facility failed to maintain all garbage areas in a safe and sanitary manner. The findings include: Upon initial entrance of the facility on 06/17/24 at 11:35 AM, an observation of the dumpster area located at the side of the building in the main parking lot was made. It was observed that a moderate amount of garbage and medical waste was present on the ground in front of and surrounding the two dumpsters. The first dumpster appeared to be in clean condition. Further observation revealed approximately 12 wooden pallets were being stored behind or next to this dumpster. The second dumpster was observed to have a side access door open. Closer observation revealed a broken plastic cart, a broken and rusted metal cart, and a broken wooden table were being stored behind this dumpster. Later observations of the dumpster area conducted on 06/17/24 at 5:45 PM revealed the same amount of garbage and medical waste present on the ground in front of/surrounding the dumpsters. During this observation, the top plastic cover of the second dumpster was observed to be open. Additional observations conducted on 06/19/24 at 10:00 AM revealed an area alongside the building behind the dumpster area in which was found five garbage cans. Further inspection revealed three of these garbage cans housed bags of linens from inside the facility. In this same area, there were 2 broken plastic carts, a broken plastic shelving unit, and a broken wheelchair. In an area near by (approximately 10 steps away), the surveyor observed a broken plastic cart containing no less than 3 plastic milk crates along with other garbage, one plastic and one wooden pallet, a plastic structure, a pile of planting pots, and three broken toilets. An interview was conducted with the facility's Plant Operations Manager during this tour. He stated he was aware that there were pallets and broken tables and carts behind the dumpsters. He said that the pallets were picked up each week on Fridays. When asked when the pallets were last collected, he did not have an answer. When asked if twelve pallets were typical build up/expected for over a weekend, he did not answer. When asked how long the carts and table had been behind the second dumpster, he did not answer. When asked why there were bags of facility linens being stored in garbage cans behind the facility, he admitted he had seen the cans in front of an exit door and had asked a staff member to move them, but he did not specify to the staff member where to put them and he had not inspected the contents of the cans before they were moved; he said he did not follow up with the staff member to find out where the cans were moved to. When asked how long ago they had been placed behind the dumpster area, he did not answer. When asked how long the other items had been in this same area, he again did not answer. Review of the facility's policy titled Dispose of Garbage and Refuse, dated 08/2017 revealed the following: All garbage and refuse will be collected and disposed of in a safe and efficient manner; The area surrounding the exterior dumpster area is maintained in a manner free from rubbish or other debris; Appropriate lids are provided for all containers. Review of the facility's policy titled Environment, revised date 09/2017 revealed that all trash will be properly disposed of in external receptacles (dumpsters) and the surrounding area will be free of debris.

Based on observation, interview, policy review, and record review, the facility failed to ensure accuracy of Preadmission Screening and Resident Review (PASARR) for 3 of 3 residents sampled (Residents #18, #62, and #126). The findings include: Resident #18 On 6/19/24, a review of the PASARR for Resident #18, dated 3/3/17, was conducted. There was no evidence of a Level II being completed in the electronic record although the form did denote the resident had a primary diagnosis of dementia and suspected mental illness. On 06/20/24 at 9:37 AM, an interview was conducted with the Regional Social Services Director, who reviewed the electronic chart and verbally acknowledged the document and that there is no Level II review in the electronic record. She stated she it most likely got lost during the transition of the medical record migration and it was possible it just didn't get scanned into the electronic record. On 6/20/24 at 10:32 AM, an interview was conducted with the Regional Clinical Director, who stated they and could not locate a Level II PASARR for this resident. Resident #62 On 6/18/24 a record review was conducted for Resident #62. The PASARR, dated 1/18/23, indicated no suspected mental illness. A review of the resident's medical record had documented diagnoses of recurrent depressive disorders added on 1/25/23, schizophreniform disorder added on 6/15/23, anxiety disorder added on 4/20/23, generalized anxiety disorder added on 1/25/23, and brief psychotic disorder added on 4/7/23. There was no updated PASARR in the electronic medical record. On 6/20/24 at 2:30 PM, an interview was conducted with the Regional Director of Social Services, who reviewed Resident #62's list of diagnosis and the PASARR form. She verbally agreed the diagnoses were absent from the PASARR and stated a new Level I PASARR should have been completed as the one from the hospital was not accurate. 42756 Resident #126 On 6/19/24, a record review was conducted for Resident #126. The resident was admitted to the facility on [DATE]. The admission form indicated that Resident #126 had been diagnosed with bipolar disorder, recurrent depressive episodes, and schizoaffective disorder that were present upon admission. A review of the admission history and physical at the hospital indicated that Resident #126 had a past medical history of bipolar disorder and schizoaffective disorder. According to the history and physical, Resident #126 was prescribed the following psychotropic medications: Seroquel 100mg by mouth daily at bed time, Olanzapine 2.5 by mouth mg twice a day and Duloxetine 30 mg by mouth once a day. A review of the care plan indicated that Resident #126 uses psychotropic medications to treat bipolar disorder and schizoaffective disorder. On 6/20/24, the Director of Nursing (DON) was asked to provide the most recent PASARR form on file for Resident #126. A review of the PASARR form provided by the DON was conducted. The form was dated 3/14/24. Section I of the PASARR form did not indicate that the resident had been previously been diagnosed with bipolar disorder or schizoaffective disorder. Section IV of the PASARR indicated that Resident #126 had no diagnosis or suspicion of serious mental illness and that a level II PASARR evaluation was not required. There was no other documentation of an updated PASARR or evaluation in the record. On 06/20/24 03:19 PM, an interview was conducted with the Regional Social Services Director for the facility. When she was shown the PASARR on file at the facility, she indicated that the PASARR form would be corrected. A review of facility policy regarding PASARR forms dated 11/8/21 was conducted. The policy stated that it is the responsibility of the center to assess and assure the preadmission screenings are conducted and results obtained prior to admissions and are placed in the appropriate sections of the resident's record. If it is learned after admission that a PASARR Level II is indicated, it is the responsibility of Social Services to coordinate or inform the appropriate agency to conduct the screening. Results of screening evaluations will be incorporated into the individual resident's plan of care.

Based on observations, staff interviews, and review of the electronic medical record (EMR), the facility failed to develop a comprehensive care plan for anxiety for 1 of 2 residents sampled. (Resident #123) The findings include: On 6/17/2024 at approximately 2:30 PM, Resident #123 was heard calling out help me, I can't breathe. Nursing staff responded and placed oxygen on the resident. The resident continued to call out and appeared anxious. On 06/20/2024 at approximately 09:18 AM, during an interview with Staff S, a licensed practical nurse (LPN), she stated, The resident can become agitated at times but is usually easy to redirect. She does not have any PRN (as needed) medications for anxiety, just scheduled Trazadone. A review of the EMR revealed the resident was admitted on [DATE] and had a diagnosis of anxiety disorder. A review of physician orders found an order initiated on 06/13/2024 for Trazodone (a medication used to treat depression) 25 mg twice a day. An order was placed on 5/17/2024 for psychology and psychiatry as needed. An additional order for a psych consult was ordered on 5/30/2024 to evaluate and treat for medication management related to anxiety disorder. The resident's care plan, initiated on 5/17/2024, does not include a plan or interventions for monitoring the resident's mood, behavior, or anxiety. A psych noted dated 06/06/2024 from the Psychiatric Mental Health Nurse Practitioner indicated the resident's mood is agitated related to wound care, her appearance/behaviors are calm. It further indicates the resident has a past psychiatric history of depression and anxiety.

Based on staff interview and record review, the facility failed to ensure the appropriate care and services were provided to prevent development of avoidable pressure ulcers and to promote healing of pressure ulcers for 1 of 3 residents sampled for pressure ulcers (#35). Findings include: Resident #35's weekly wound assessments were reviewed and revealed only a current Stage IV pressure ulcer to the coccyx/sacral area identified on admission. Weekly measurements of this wound showed the following: 9/4/2017: 2 centimeters (cm) x 0.2cm x 0.3cm 9/11/2017: 1.8cm x 0.2cm x 0.2cm 9/18/2017: 7.2cm x 4.4cm x 0.2 cm 9/25/2017: 7.2cm x 4.4cm x 0.2cm 10/3/2017: 7.2cm x 4.4cm x 0.2 cm 10/9/2017: 2.3cm x 0.4cm x 0.2 cm 10/16/2017: 2.3cm x 0.3cm x 0.2cm 10/23/2017: 2cm x 0.5cm x 0.5cm 10/30/2017: 2.2cm x 0.4cm x 0.3cm 11/6/2017: 2.1cm x 0.3cm x 0.3cm The current care plan, implemented 3/5/2017, with a last revision date of 9/5/2017, for skin/wound indicated resident #35 had a potential for impaired skin integrity due to a history of pressure ulcers, immobility, fragile skin, and incontinence. The goal indicated wounds would show signs of healing and remain free from infection. It also stated she would not develop any additional skin integrity problems or wounds. Interventions in place were to provide weekly skin checks, placement of adaptive equipment, and follow physician orders [REDACTED]. The medical record further revealed a 9/28/2017 visit to the local wound healing center. It stated the resident was much stronger than she had been in the past, but had a new wound to her right buttock. It further stated the resident's sacral wound was only 3 millimeters from bone and the wound had become much more extended, doubling in size from the previous visit. In addition, a small wound to the left buttock was also noted. The physician's assessment stated Pressure ulcer of sacral region, stage IV was almost completely healed until dressing was changed away from every day, and patient began to be placed up in wheelchair without adequate pressure relief. Will return patient to bed rest status, and side to side turns done until healed to at least previous status. Need patient pressure relief Roho cushion and appropriately fitted wheelchair available before she can return to being up in chair. New pressure ulcer of right buttock is developed probably for similar reasons noted above. Urinary and fecal incontinence make contaminated wounds. Now that they have grown in size and will need to do dressing changes as needed in between regularly scheduled visits. Notes written by the physician on 9/28/2017 stated, They have been sitting the patient up to chair in a borrowed, small wheelchair frequently, which only has an egg crate cushion. Both the chair and the previous air cushion that have been specifically ordered for the patient appear to have been lost by the facility. The physician ordered a Roho cushion be placed in the chair each time the resident was up. The physician notes 10/12/2017 stated, Her Roho cushion still has not been found and no substitute has been provided. All the weekly wound sheets for the resident were reviewed and revealed no right buttock wound. Further, no documentation existed that the resident had a right buttock wound other than the wound care physician notes. An interview was conducted with the wound care nurse on 11/17/2017 at 10:03 AM. He confirmed the facility identified the wound a week or two prior to the physician visit on 9/28/2017. He stated he did complete pressure ulcer tracking for this wound, although no records could be produced by the facility. He stated he was not aware of any notes sent back from the wound care center. He stated he received copies of orders from the physician and would follow them, but never reviewed the notes the wound care center sent. He further stated he did not talk with any staff at the wound care center in regards to any issues the resident was experiencing. He also stated he could not remember any discussions from wound care about a cushion being needed for resident #35's wheelchair.

Based on observation, interview and record review, the facility failed to develop and implement appropriate plans of action to maintain correction of quality deficiencies related to resident care plans, provision of services to maintain well-being (including restorative services), care for residents with tube feedings, and prevention of urinary tract infections (UTIs). Findings include: The facility had a complaint survey completed on August 9, 2017 and were cited for failure to develop comprehensive care plans, failure to provide services to maintain resident well-being, failure to implement interventions to prevent complications (such as urinary tract infections) related to indwelling foley catheters, failure to provide appropriate treatment for [REDACTED]. During the course of the recertification survey process ending 11/17/2017, several concerns were identified that related to areas the facility was previously cited for and required to correct. Developing and following care plans: During the course of the survey process, several concerns were found related to developing and following care plans. The first concern was in regards to resident #106 not having a care plan in place for urinary incontinence. The second was in regards to resident #35 who had a care plan in place with specific interventions for prevention of pressure ulcer development that was not followed, and subsequently resulted in development of an additional pressure ulcer. The third concern dealt with resident #246 having a care plan in place for nutritional interventions if oral intake during meals was less than 50%. The resident regularly had intake lower than 50% but nutritional interventions were not implemented. An interview was conducted with the Executive Director (ED) on 11/17/2017 at 11:48 AM. She stated the Quality Assurance (QA) Program had identified concerns related to care plans. She stated, We recently have educated the nurses and certified nurse aides (CNA)s on the care plan process. We are trying to start getting them to update the care plan but haven't started that part yet. We have a process in the morning and afternoon meetings everyday where changes are discussed and the care plans are updated at that time. We have found some inconsistencies with them. Providing care/services for the highest practicable well being: During the investigation regarding resident #43 for [MEDICAL TREATMENT], a concern was identified related to the facility repeatedly not removing the pressure dressing to the resident's fistula. Multiple notes over the course of several months were observed from [MEDICAL TREATMENT] with frank statements that the facility was leaving the pressure dressing on for several days at a time. Per [MEDICAL TREATMENT] documentation, leaving the pressure on greater than 24 hours could cause permanent clotting of the fistula. This had the potential to result in loss of [MEDICAL TREATMENT], and an additional surgery for [REDACTED]. In addition, resident #271 came to the facility with a catheter. Per interview with the resident, peri-care was not provided routinely. On the date of interview, the resident expressed symptoms of a UTI. The catheter was removed and a urinalysis was obtained revealing a current UTI. The ED interview on 11/17/2017 at 11:48 AM did not reveal QA had identified any concerns related [MEDICAL TREATMENT] pressure dressings. The ED did state there was a current Performance Improvement Plan in place for urinary catheters. She stated the program should be identifying residents with catheters for orders and catheter care should be done every shift. She confirmed resident #271 was captured as part of this process but had not identified any concerns. During the course of the investigation for resident #106, it was revealed she was admitted to the facility with frequent urinary incontinence and throughout her admission further declined to being always incontinent of urine. No restorative services or services to prevent further decline were provided to the resident, and the resident was found to have a recent UTI resulting in a multi-day hospital stay. The ED was interviewed on 11/17/2017 at 11:48 AM and stated the QA program had not identified any concerns related to restorative programs not being initiated. The CMS Form 672, provided by the facility, revealed 85 residents occasionally or frequently incontinent of bladder with only 5 being on a bladder training program. Resident #35 was identified with a stage IV pressure ulcer to the sacrum that increased in size significantly from 1.8 centimeters (cm) x 0.2 cm. 0.2cm to 7.2cm x 4.4 cm x 0.2 cm over the period of one week. Wound Care Clinic notes revealed the wound was almost completely healed until the dressing order was changed away from every day and the patient was being placed in a wheelchair without adequate pressure relief. The physician further documented a new stage III pressure ulcer to the right buttock as well, although there was no documentation the facility did any wound measurements nor staging of the new area. The physician documented the facility lost the Roho cushion for the resident's wheelchair and did not obtain another, resulting in the resident being placed on bed rest until the wounds decreased in size. The ED stated on 11/17/2017 at 11:48 AM the facility was aware of concerns with treatments not being done. She confirmed trainings for the CNAs for turning and repositioning was provided. The current survey findings were discussed with the survey team. It was determined that non-compliance with F279 (care plans), F309 (highest practicable level of well-being), and F315 (care and services to prevent UTI) would be cited again for the current survey period ending 11/17/2017. The facility's repeated non-compliance with those areas reveal the ineffectiveness of the QA program to achieve and maintain compliance with 42 CFR 483, Requirements for Long Term Care Facilities.

Based on staff interviews, review of staff training records, and review of policy and procedures, the facility failed to provide evidence that licensed practical nurses administering Intravenous Therapy (IV) had the required certifications, specific competencies and skill sets necessary to care for resident needs (Refer to F309). This resulted in harm to resident #1, who was subsequently hospitalized secondary to an infection from the resident's urinary tract and central line insertion site. The facility also failed to provide evidence of training and education provided to nursing assistants regarding the provision of care for residents receiving enteral feedings (Refer to F322). The findings were: A review of the facility's protocol for midline catheter dressing changes and midline catheter flushes documented the application was for licensed nurses providing infusion therapy in the facility. The protocol documented it could be performed by licensed nurses in accordance with state law and facility policy, and with competency validation documented. A review of the facility's policy and procedure titled Intravenous Therapy (IV) Coverage documented a staffing pattern would be in place which provided for a minimum of one trained and certified clinical nurse on duty when a resident in house was receiving IV therapy, and the Director of Clinical Services would be responsible for ensuring that licensed nurses who provided IV infusion therapies were appropriately trained and licensed according to state specific guidelines for IV infusion. On 8/7/17 at approximately 11:30am, during an interview with the Director of Clinical Services (DCS), she stated, licensed practical nurses who have completed intravenous training can conduct central line flushes and registered nurses perform central line dressing changes. When asked if she had certificates of training and statement of proficiencies for the licensed practical nurses, she stated I am not sure. When asked if she had observed the LPNs providing care for a central line, she replied no. On 8/9/17 at approximately 10:30am, during an interview with the facility's Staff Development Nurse, she stated, only registered nurses can perform central line flushes and central line dressing changes. She stated through questioning the LPNs she had a list of those who were certified for intravenous therapy and had requested they bring in their certifications. She confirmed the facility did not currently have any LPN IV Certifications in their personnel folders. On 8/9/17, the facility's administrator provided a list of LPNs identified as being IV certified. Ten (10) randomly selected licensed practical nurses were presented to the facility's administrative staff with a request for documentation of their IV Training Certificate and Statement of Proficiency. The requested information had not been provided by the time of the survey exit on 8/9/17 at 3:00pm. The facility's policy and procedure titled enteral feeding/enteral nutrition pump was reviewed. The policy stated, licensed nurses, through the use of an enteral nutrition pump, will administer enteral feedings when volume control is indicated and as ordered by the physician. The policy failed to document the procedure for suspending the feeding when a resident receiving enteral feeding had to have the head of bed lowered for provision of care. On 8/8/17 at 11:05am resident #1 was observed receiving an enteral feeding (delivery of nutrition directly into the stomach infusing via a pump) at a rate of 50 milliliters(mls) per hour while lying flat in the bed. Employee J, CNA, indicated she had just provided care to the resident. An interview with Employee J (CNA) at the time of the observation was conducted. Employee J was asked if the feeding was turned off when laying the resident flat to provide care? She stated, I do not touch her tube feeding, she is a continuous feed. I only turn it off if it is beeping and then I get the nurse. When employee J was asked how long the resident had been lying flat, she stated about 15 minutes. She then stated I lay residents flat just to do care and then put them back up 30 degrees. An interview was conducted with Employee K (CNA) on 8/8/17 at approximately 12:15pm to determine her practice related to positioning residents while receiving enteral tube feeding. Employee K stated I lay them down flat while I do the care and then let their head back up to 65 degrees. When asked if the tube feeding was stopped when the residents were lying flat, she stated the only time I would turn off the tube feeding is if I am moving the resident. When asked again if the the nurse turns the tube feeding off for her to provide care, she stated, No, I lay the head down and do care and put them back up fast. When asked if she had any training from the facility, she stated, I will be honest, no, not from here. What I know is from school. On 8/8/17 at approximately 12:20pm, an interview was conducted with Employee E, (CNA) concerning care of residents with feeding tubes. Employee E was asked if the feeding was turned off when laying the resident flat to provide care, and stated, I turn the infusion pump off when laying residents flat to perform care, and then turn the pump back on after care has been provided. On 8/8/17 at approximately 12:30pm an interview was conducted with Employee F, (CNA). When asked how she managed the infusion pump when there was a need to lay a tube fed resident flat for care, she replied, I push the hold button on the infusion pump and after care has been provided I return the resident to the elevated position and resume the pump. On 8/8/17 at approximately 12:40pm, Employee G, (CNA) was asked how she managed the infusion pump when she needed to lay a tube fed resident flat for care, she replied I push the hold button. The employee went on to verbalize the tube feeding was turned off when the head of the bed was lowered to prevent aspiration. An interview with the Director of Clinical Services (DCS) was conducted on 8/8/17 at approximately 1:00pm. The DCS was informed of the resident observation (#1) and staff interviews. She stated the CNAs were not to turn off tube feeding pumps or put them on hold status. She stated that was the responsibility of the licensed nurses. A request for documentation of education and training received by nursing assistants regarding the provision of care for residents receiving enteral feedings was requested, but never produced by the facility.

Based on observations, interviews and record reviews, the facility failed to develop a comprehensive care plan related to the presence of an indwelling foley catheter for 1 of 5 sampled residents (resident #1), which resulted in harm to resident #1 who was subsequently admitted to an acute care hospital for treatment of [REDACTED]. The facility also failed to have care plans that described appropriate objectives to meet resident needs related to urinary catheters for 3 of 5 sampled residents (residents #1, #2 and #3). The findings were: Resident #1 A closed record review was conducted for resident #1 that documented care provided between 5/16/17 and 6/14/17. The medical record documented an indwelling foley catheter inserted on 5/16/17 per physician orders. An interview conducted on 8/7/17 at approximately 11:30am with the facility's Director of Clinical Services (DCS) revealed the catheter was inserted to promote healing of a groin wound. A review of the plan of care in place for resident #1 for the period of 5/16/17 through the discharge date of [DATE] was conducted. The care plan included a plan for Elimination GU (elimination [MEDICAL CONDITION]) that listed an intervention to monitor and report to physician as needed for signs and symptoms of urinary tract infection. The symptoms documented included, but were not limited to, nausea and vomiting, fever and cloudy urine. A review of the medical record failed to indicate the urine appearance was reported to the physician in accordance with the plan of care, and revealed a limited number of notes that documented an assessment of resident #1's foley catheter and urine appearance. A summary of findings during review of nursing documentation is as follows: 5/24/17- foley draining clear, dark yellow urine. 5/25/17- clear yellow urine. 5/28/17- urine appearance to be light amber. 5/29/17- amber urine. 5/31/17- foley to be intact. 6/1/17 - 6/11/17- There was no documentation for assessment of the resident's foley catheter and appearance of the resident's urine in the nurses' notes. 6/12/17- foley has cloudy dark yellow urine. 6/13/17 & 6/14/17- There was no documentation for assessment of the resident's foley catheter and appearance of the resident's urine in the nurses' notes. On 6/14/17 a physician order [REDACTED].#1 to Capital Regional Medical Center (an acute care hospital) for evaluation and treatment. A review of the hospital emergency department's records revealed resident #1 had a rectal temperature of 104.8 and an elevated heart rate of 171 upon admission with a milky white substance in the tubing of her urinary catheter upon arrival. Resident #1 was admitted to the acute care hospital with [DIAGNOSES REDACTED]. Resident #2 On 8/7/17 at approximately 11:30am, resident #2 was observed in bed with an indwelling urinary catheter draining dark yellow urine. Resident #2 stated he had a suprapubic catheter that was supposed to be changed every month, but he was unable to recall the last time it had been changed. When asked how often the catheter insertion site was cleansed, he stated about three times a week. There was no leg strap observed to be securing the catheter tubing to prevent pulling and dislodgement. An interview with the Licensed Practical Nurse (LPN), employee A, following the above observation, confirmed there should have been a leg strap in place. Additional observations made on 8/7/17 at approximately 3:30pm and at approximately 6:00pm revealed there was not a catheter securement device in place. The Director of Clinical Services (DCS) was informed of the findings following the 6:00pm observation, and confirmed the purpose of the catheter stabilization was to prevent pulling and trauma to the site, and to be used as an infection control measure. A review of the plans of care for elimination [MEDICAL CONDITION] documented the use of a suprapubic catheter for an urethrocatural fistula. The interventions included to perform catheter care as ordered. The plan of care failed to include interventions for changing the suprapubic catheter every month nor did it include to verify the leg strap was in place every shift until revisions were made on 8/7/17. Resident #3 Resident #3 was observed on 8/7/17 at approximately 11:45am in bed while employee E, Certified Nursing Assistant (CNA) was present assisting the resident with getting dressed to go to the dining room. There was not a leg strap observed to be securing the catheter tubing as confirmed by both the resident and the CNA. When asked if resident #3 had a leg strap to stabilize the catheter, the CNA stated there was sometimes one present. This statement was confirmed by the resident at the time of the observation. A review of resident #3's assessment, dated 7/12/17, documented the presence of an indwelling catheter for a [MEDICAL CONDITION] bladder. A review of the plan of care documented altered bladder elimination and the presence of an indwelling foley catheter. The care plan interventions included catheter care as ordered, but failed to include interventions to prevent tension and/or accidental dislodgement of the device, and failed to mention methods to prevent complications related to infection. On 8/8/17 at approximately 3:00pm, an interview was conducted with LPN, employee N. Employee N stated care plans were initiated and/or updated following the completion of Minimum Data Set (MDS) assessments of the residents. Employee N could not provide an explanation as to why the plan of care for resident #3 failed to include interventions to prevent complications related to infection or failure to stabilize the catheter tubing.

Based on observations, resident and staff interviews, record reviews, and review of facility policies and procedures, the facility failed to ensure quality care to maintain the highest practicable physical well-being for 3 of 3 residents with peripherally inserted central catheters (PICC) (Residents #1, #6 and #7). This resulted in harm to resident #1, who was subsequently hospitalized with [DIAGNOSES REDACTED]. The findings were: A request for the facility's policy and procedure regarding Peripherally Inserted Central (PICC) lines was requested upon entrance. A PICC line is a long, thin tube that goes into your body through a vein in your upper arm and extends into a large vein near the heart. On 8/7/17 at approximately 11:17am, the facility's Director of Clinical Services (DCS) provided the OmniCare Infusion Manual protocols the facility follows for care of a PICC line. The facility's policy and procedure titled Intravenous (IV) Therapy Coverage documented the facility would use policies and procedures located within the OmniCare Infusion Manual for all IV and infusion related therapies. The protocol directed the following to be proper care of the PICC insertion site: sterile dressing changes using transparent dressing will be performed 24 hours post-insertion or upon admission, at least weekly, and if the integrity of the dressing has been compromised (wet, loose or soiled). When a transparent dressing is applied over a sterile gauze dressing it is considered a gauze dressing and is changed 24 hours post-insertion or upon admission, every 2 days, and if the integrity of the dressing has been compromised (wet, loose or soiled). The protocol also documented assessment of the vascular site is performed upon admission and during dressing changes, at least every 2 hours during continuous therapy, before and after the administration of intermittent infusion, and at least once every shift when not in use. Protocol for dressing change documentation included date, time, and the nurse's initials on the dressing, and notation of date and time, site assessment, length of external catheter, reason for dressing change, patient response to procedure, and patient/significant other teaching in the resident medical record. Resident #1 On 8/9/17 a review of the closed record for resident #1 revealed a verbal physician order [REDACTED]. Another physician order [REDACTED]. A subsequent physician order [REDACTED]. There were no observed physician orders [REDACTED].#1. A review of the May 2017 Medication Administration Record [REDACTED]. The facility failed to discontinue the PICC per physician orders [REDACTED]. The May 2017 MAR indicated [REDACTED]. The June 2017 MAR indicated [REDACTED]. A review of the medical record revealed there were no dressing changes performed on the central line insertion site after the 5/16/17 insertion date. Resident #1 was receiving skilled care with daily nursing notes for dates of 5/17/17 through 6/8/17. A review of nursing documentation failed to reveal PICC assessments were completed every shift in accordance with facility protocol. Review of the hospital records for resident #1 documented the resident presented to the emergency department (ED) on 6/14/17 for evaluation of decreased responsiveness, respiratory distress, and an elevated temperature of 103. Evaluation of resident #1 in the ED revealed the resident was a clearly septic, and dressing on left arm from PICC line placement was very dirty with photos obtained. Physician notes from the hospital regarding resident #1 stated Central line placed . obvious [MEDICAL CONDITION] severe volume depletion disgusting midline left in with no changes for dressing admitted to intensive care unit. The hospital's admission nursing assessment for resident #1 documented temperature 104.8 rectally, midline to left antecubital which has foul smelling bandages that are soiled with greenish black substance. Under the bandage is a gauze saturated with dried blood with area of midline warm to touch with redness and [MEDICAL CONDITION]. Blood cultures obtained on admission with ESBL Escherichia coli growth on final culture. A hospital physician progress notes [REDACTED]. Resident #1 was readmitted to the facility on [DATE] at 9:00pm with an admission note that documented a PICC to the resident's right upper arm with no redness, swelling or drainage noted, and dressing last changed on 7/23/17. The admission physician orders, dated 7/25/17, documented to flush the PICC line twice daily with normal saline and [MEDICATION NAME], change the PICC dressing every Monday and discontinue the PICC immediately after antibiotics were completed. A review of the July 2017 Medication Administration Record [REDACTED].) This date was not in compliance with facility's protocol to change dressing upon admission and every 7 days. The current dressing on the PICC insertion site at time of the survey was observed to have a change date of 8/7/17, which was 8 days from previous dressing change. On 8/8/17 at approximately 9:30am, a review of resident #1's medical record was conducted in the presence of the facility's Director of Clinical Services (DCS) to determine if assessments of the PICC site had been conducted every shift from admission date of [DATE] through 8/7/17 (date the PICC line was discontinued). The findings were as follows: 7/26/17 - 2 of 3 shifts documented assessment of the PICC site 7/27/17 - 2 of 3 shifts documented assessment of the PICC site 7/28/17 - 1 of 3 shifts documented assessment of the PICC site 7/29/17 - No documentation for the PICC site 7/30/17 - No documentation for the PICC site 7/31/17 - No documentation for the PICC site 8/1/17 - 1 of 3 shifts documented PICC site assessment 8/2/17 - No documentation for the PICC site 8/3/17 - 1 of 3 shifts documented PICC site assessment 8/4/17 - 1 of 3 shifts documented PICC site assessment 8/5/17 - 1 of 3 shifts documented PICC site assessment 8/6/17 - No documentation for the PICC site 8/7/17 - No documentation for the PICC site There was also no documentation of the removal of the PICC on 8/7/17, assessment of the line to ensure it was intact following removal, or insertion site assessment on that date. On 8/8/17 at approximately 2:30pm, the facility's designated Assistant Director of Nursing provided a nursing note that had not been in the medical record at the time of the earlier review, which did document the PICC removal. Resident #6 On 8/7/17 at approximately 11:00am, resident #6 was observed to have a PICC dressing in place with a date of 7/31/17. A record review was conducted for resident #6 which revealed the resident was admitted to the facility on [DATE] from an acute care hospital with treatments to include intravenous antibiotic therapy. Admission data collection, dated 6/29/17, documented a PICC in place to the resident's left upper arm with physician orders [REDACTED]. A review of the treatment record and Medication Administration Record [REDACTED]. The MAR for the month of June indicated the facility failed to perform a dressing change to the insertion site upon admission in accordance with their protocol. A review of the MAR for the month of July indicated a dressing change was conducted on 7/5/17, on 7/15/17 (10 days from the last dressing change), and again on 7/24/17 (9 days from last dressing change) as indicated by staff initials on the MAR. The MAR indicated [REDACTED]. These finding were confirmed by the Unit Manager (UM) on 8/7/17 at 1:45pm. She stated writing done on the MAR indicated [REDACTED]. A review of the nurse's notes, in the presence of the UM, failed to indicate a dressing change was conducted on those days. A review of nursing documentation for resident #6, to determine if PICC assessments were performed every shift, was conducted in the presence of the DCS and the Unit 300 UM. The review revealed resident #6 was admitted on [DATE] at 5:30pm. The nursing admission data collection documented a PICC to left the arm of resident #6 without redness, swelling or drainage. The record failed to include any nurse's notes again until the 11:00am-7:00pm shift on 7/1/17. Further review of the nursing documentation revealed the fourteen (14) days following the resident's admission the facility only included an assessment of the PICC site for 5 of the 14 days. None of the dressing changes included the assessments to be performed in conjunction with the dressing changes. These findings were confirmed by the facility's DCS. An interview was conducted with the Unit 300 UM on 8/8/17 at approximately 8:45am. The UM stated, assessments should be conducted every shift and documented in the nurse's notes. Resident #7 A record review revealed resident #7 was admitted on [DATE] with a PICC in place. An initial assessment of the site was conducted at the time of admission. A review of the medical record in the presence of the Assistant Director of Nursing (also Unit 300 Unit Manager) on 8/8/17 at approximately 10:40am, revealed 7 of the 13 days from 7/18/17 through 7/31/17 failed to have PICC assessments documented. The record also failed to document site assessments before and after intermittent infusions. These findings was also confirmed by the facility's Director of Clinical Services (DCS) at the time of the record review.

Based on observations, interviews, and record reviews, the the facility failed to ensure implementation of interventions to minimize complications from an indwelling urinary catheters for 4 of 5 sampled residents (Residents #1, #2, #3, #4). This resulted in harm to resident #1 who had to be transferred to a higher level of care for treatment of [REDACTED]. Findings: Resident #1 A closed record review was conducted for resident #1 that documented care provided between 5/16/17 and 6/14/17. The medical record documented an indwelling foley catheter inserted on 5/16/17 per physician orders. An interview conducted on 8/7/17 at approximately 11:30am with the facility's Director of Clinical Services (DCS) revealed the catheter was inserted to promote healing of a groin wound. A review of the plan of care in place for resident #1 for the period of 5/16/17 through the discharge date of [DATE] was conducted. The care plan included a plan for Elimination GU (elimination [MEDICAL CONDITION]) that listed an intervention to monitor and report to physician as needed for signs and symptoms of urinary tract infection. The symptoms documented included, but were not limited to, nausea and vomiting, fever and cloudy urine. A review of the medical record failed to indicate the urine appearance was reported to the physician in accordance with the plan of care, and revealed a limited number of notes that documented an assessment of resident #1's foley catheter and urine appearance. A summary of findings during review of nursing documentation is as follows: 5/24/17- foley draining clear, dark yellow urine. 5/25/17- clear yellow urine. 5/28/17- urine appearance to be light amber. 5/29/17- amber urine. 5/31/17- foley to be intact. 6/1/17 - 6/11/17- There was no documentation for assessment of the resident's foley catheter and appearance of the resident's urine in the nurses' notes. 6/12/17- foley has cloudy dark yellow urine. 6/13/17 & 6/14/17- There was no documentation for assessment of the resident's foley catheter and appearance of the resident's urine in the nurses' notes. On 6/14/17 a physician order [REDACTED].#1 to Capital Regional Medical Center (an acute care hospital) for evaluation and treatment. A review of the hospital emergency department's records revealed resident #1 had a rectal temperature of 104.8 and an elevated heart rate of 171 upon admission with a milky white substance in the tubing of her urinary catheter upon arrival. Resident #1 was admitted to the acute care hospital with [DIAGNOSES REDACTED]. Resident #2 On 8/7/17 at approximately 11:30am, resident #2 was observed in bed with an indwelling urinary catheter draining dark yellow urine. Resident #2 stated he had a suprapubic catheter that was supposed to be changed every month, but he was unable to recall the last time it was changed. When asked how often the catheter insertion site was cleansed, he stated about three times a week. There was no leg strap observed to secure the catheter tubing and this was confirmed by the resident. An interview with the Licensed Nurse, Employee A, following the above observation, confirmed there should be a leg strap in place. She stated I have not gotten around to doing care yet. Additional observations made on 8/7/17 at approximately 3:30pm and at approximately 6:00pm revealed there not to be a catheter securement device in place. The Director of Clinical Services (DCS) was informed of this finding following the 6pm observation. The DCS confirmed the purpose of the catheter stabilization was to prevent pulling and trauma to the site and as an infection control measure. A review of the treatment records for resident #2 for April, May, June, July, and August 2017 failed to document the provision of catheter care every shift. They also failed to demonstrate that the resident's catheter had been changed monthly in accordance with the monthly physician's orders [REDACTED]. Review of the August 2017 treatment record conducted on 8/8/17 at 3:00pm documented a suprapubic catheter change was conducted on 8/7/17. On 8/8/17 at approximately 3:15pm, the Unit Manager reviewed the medical record and confirmed there was no evidence the suprapubic catheter had been changed in accordance with the physician's orders [REDACTED]. Resident #3 Resident #3 was observed on 8/7/17 at approximately 11:45am in bed with employee E, (CNA) in attendance assisting the resident with dressing. There was no leg strap observed to be securing the catheter tubing as confirmed by both the resident and the CNA at the time of the observation. When asked if resident #3 had a leg strap to stabilize the catheter, employee E stated there was sometimes one present. A review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) for May 2017 included documentation of an antibiotic for 10 days for a [DIAGNOSES REDACTED]. The forms failed to document the provision of foley care for each shift in accordance with the physician's orders [REDACTED]. A review of the June 2017 MAR indicated [REDACTED]. The July and August 2017 MARs failed to document when the foley catheter was last changed. A review of the August 2017 treatment record for resident #3 documented foley catheter care to be conducted every shift and as needed. The record failed to indicate the care was provided on the 3:00pm-11:00pm shift on 8/6/17. There was a blank space without any initials for that shift. On 8/8/17 at 9:40am, resident #3 was observed in the presence of the licensed nurse, Employee N, not to have leg strap in place to secure the indwelling catheter. An interview with the assigned CNA, employee O, at the time of the observation revealed he had one in place yesterday when she provided care. She stated she also worked the 3:00pm-11:00pm shift and had showered the resident the night before, but she was unable to recall if the leg strap was reapplied following the shower. Resident #4 On 8/7/17 at approximately 11:45am, resident #4 was observed lying in bed with a urinary catheter tubing attached to a bedside drainage bag. A record review for resident# 4 revealed the resident was admitted to facility on 8/3/17 with primary [DIAGNOSES REDACTED]. A review of the admission nurses notes dated 8/3/17 documented an indwelling urinary catheter present at the time of admission, but failed to include an admission order on 8/3/17 for the immediate care of the catheter for resident #4. A physician order [REDACTED]. A review of the treatment record and review of nursing notes failed to document the initiation of catheter care at the time of the resident's admission. The treatment record also failed to indicate the catheter insertion date and failed to document a date for the catheter to be changed in accordance with the physician orders. An interview was conducted with the DCS on 8/7/17 at approximately 6:00pm. When asked how nursing knew when an indwelling urinary catheter was due to be changed, she stated that it should be indicated on the resident's MAR indicated [REDACTED].

Based on observation, nursing staff interview, interviews with the Assistant Administrator and Director of Nursing and clinical record reviews, the facility failed to provide administration that used resources safely and effectively. Administrative staff failed to ensure diabetic testing supplies were available for use by nursing staff to monitor blood glucose testing for 60 out of 67 residents with orders for blood glucose monitoring. (#3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 41, 42, 43, 44, 45, 47, 49, 50, 51, 52, 53, 54, 55, 57, 58, 59, 60, 61, 62, 63, 64, 66, 67, 69, 70). The current census was 177. This failure of the Administrative staff led to a finding of Immediate Jeopardy on 5/22/14. The facility's assistant administrator and Director of Nursing were notified of Immediate Jeopardy on 5/22/14 at 3:30 PM. Staff interviews were conducted and clinical records were reviewed for all 67 residents with orders for blood glucose monitoring. It was determined that the facility failed to conduct blood glucose monitoring for 60 residents during 24 days in April 2014, and 17 days in May of 2014. Immediate Jeopardy was determined to have begun dating back to April 2, 2014. Please see evidence at F281, F282 and F329. Immediate jeopardy was removed on 5/23/14 at 2:30 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower severity and scope of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place were effective. The findings are: The Administrator was unavailable for interview throughout the survey. On 5/22/14 at approximately 4:15pm, an interview was conducted with the assistant administrator regarding supplies. The assistant administrator stated there have been meetings and stand up meetings undocumented with the administrator about supplies. She stated the staff has stated in the past that the supplies were not there and they are found to have them in the cart such as blood glucose monitoring supplies. When asked what would be the disciplinary action against the nurse that did not do the blood glucose checks when supplies were available, she stated, "Consulate had a series of actions including write ups. It is expected that any discrepancies would be brought to the attention of the administrator or the director of nursing". On 5/23/14 at approximately 9:30am a follow-up interview with the assistant administrator was conducted after the facility was informed of the finding of Immediate Jeopardy. She stated she has been working at the facility for about 6 months and that Quality Assurance (QAA) has been her duty. She stated she is constantly on the floor talking with the staff to see if they have any concerns. She stated the ADON (Assistant Director of Nursing) is always on the floor checking. She stated the Administrator also talks with staff and listens to concerns. She stated that they had a meeting with the night shift in the last month or so, with corporate in attendance and no one had a concern. The assistant administrator neither confirmed nor denied that she was aware of the issue with blood glucose monitoring supplies. Record reviews for nursing documentation related to missing diabetic testing supplies and Director of Nursing (DON) and/or management notification was conducted for all 67 residents. Documents reviewed included Physician Orders, Medication Administration Records (MARs), and Nursing Notes. There was nursing documentation in multiple resident records dating back to 4/1/14 stating that the DON, management, administration and/or supervisor had been informed of missed blood sugar testing due to inadequate supplies. This documentation was as follows: 4/2/14: Nursing documented that the DON was notified for Residents #11, 12, 17, 18, 20, 24, 35, 53, 55, 57, 58, 62, 63, and 66. 4/10/14: The DON was notified - Resident #53 4/11/14: The DON was notified - Resident #5 4/13/14 and 4/17/14: The DON was notified - Resident #61 4/27/14: Weekend supervisor was notified for Resident #20 and 57 4/28/14: The DON was notified - Resident #35 4/30/14: The DON was notified - Resident #54 5/04/14: Supervisor or management documented as notified for resident #17, 20, 22, 52, 53, 54, 55, and 57. 5/1/14: The DON was notified - Resident #54, 55, and 57 5/11/14: The DON or management was notified - Resident #52, 55, 57, and 69 5/15/14: The DON was notified - Resident #53 5/16/14: The DON was notified - Resident #52 5/19/14: The DON was notified - Resident #54 On 5/21/14 at approximately 10:32am, during an observation of the facility's three (3) medication rooms it was discovered that there was not a supply of lancets or blood sugar testing strips stored for nurses to access in either of these rooms. An observation was conducted of the central supply and revealed that there were no blood sugar testing supplies stored. Interview with the Central Supply Staff at the time of observation revealed that all blood sugar supplies were kept in the Director of Nursing's (DON's) office. On 5/21/14 at approximately 10:40am, an observation was made of blood sugar testing supplies being kept in the DON's office. There were 9 boxes (100 count each) of lancets and 2 boxes (50 per box) of blood sugar strips available. An interview was conducted with the DON during the observation which revealed that she distributes lancets and blood sugar strips according to the number of residents that require checks. The DON revealed that she goes around to the stations at least twice a day and as needed to distribute the number of blood sugar testing supplies that are required. The DON revealed that this measure was put into place because of staff wastefulness and supplies disappearing. After hours if strips are required or have run out, the DON stated that staff were aware to contact her to come pass out more supplies. In the case of emergencies the DON revealed that she lives relatively close to the facility and can get to the facility in less than 10 minutes. She confirmed that there was definitely a breakdown in communication with staff and the facility did not have an effective protocol in place at the time. On 5/21/14 at approximately 10:50am an interview was conducted with Licensed Practical Nurse (LPN B). LPN B revealed that she gets a supply of lancets and blood sugar strips directly from the DON's office. LPN B revealed that if she runs out of diabetic testing supplies after hours during her shift, that the DON has to be called at home to come to the facility and give out more supplies. LPN B revealed that there was no effective protocol for obtaining supplies in emergency situations. LPN B reported that approximately a week ago she had an emergency with a resident ' s levels needing to be rechecked, but that she was unable to recheck because she did not have enough lancets or blood sugar strips. Staff B revealed that she documented on the resident 's Medication Administration Record [REDACTED]. On 5/21/14 at approximately 10:55am, an interview conducted with LPN C revealed that supply of lancets and blood sugar test strips are obtained from the DON when supplies are needed. The DON comes around and gives nurses a supply according to the number of residents that require blood sugar testing. Staff C revealed that there was not any blood sugar supplies kept for the nurses to access, except for when the DON was on site. On 5/21/14 at approximately 11:00am, an interview conducted with LPN D revealed that she has run out of lancets and blood sugar test strips often and had no access to get more. LPN D revealed that the DON keeps a supply of lancets and blood sugar test strips locked in her office and the supplies are only available through her. LPN D revealed that she has had to use flex pens instead of using lancets to stick the resident 's finger to test their blood sugar levels at times because she did not have access to supplies. LPN D revealed that she could recall several times residents missed blood sugar testing as ordered dating back for at least 2 months. LPN D revealed that the nurses were only given enough supplies for the residents that have blood sugar testing ordered not considering the fact that re-checks may have to be done or emergency situations could occur. LPN D revealed that management is well aware of nurses not having access to blood sugar testing supplies and told the staff it was because of the facility's budget. On 5/21/14 at approximately 11:08am, an interview conducted with Unit Manager H (Staff H) revealed that blood sugar testing supplies are kept in the DON's office and administered to nursing according to the number of residents' that require blood sugar testing. Staff H revealed that she does not have a key to get to supplies for nurses when they run out of supplies. Staff H revealed that if the DON is not in the building, she could call her to come to the facility to give more supplies. On 5/21/14 at approximately 11:15, an interview conducted with LPN E, revealed that she had run out of testing supplies that morning. LPN E stated that she had requested blood sugar testing supplies twice this morning (5/21/14) and had not received the supplies. She was unable to perform any Accu-checks prior to meals for residents with orders for blood sugar testing before meals. LPN E revealed that some residents had already begun their meals. LPN E revealed that she had asked LPN F on the unit to borrow some supplies but LPN F was out of supplies as well. LPN E revealed they have informed their unit managers of not having enough supplies to complete blood sugar testing for the morning of 5/21/14. LPN E revealed that supplies for blood sugar testing are provided to nurses based on the number of residents that require testing per shift. LPN E revealed that this was an ongoing issue. LPN E revealed that if supplies run out they were instructed by the DON to call her at home so she can come in and provide them with more supplies. An observation made of LPN E's medication cart revealed a count of 15 lancets and zero (0) blood sugar strips. On 5/21/14 at approximately 11:25am, and interview conducted with LPN F, revealed that this nurse was currently out of blood sugar testing supplies. LPN F revealed that there were no supplies on either medication cart on the unit at the time of the interview and that a request had been made to the DON twice for supplies this morning (5/21/14). LPN F explained that the 11:00pm-7:00am shift did not have supplies either and that as a result some residents did not receive their morning blood sugar testing as ordered. LPN F revealed that this was an ongoing problem and that the unit managers as well as the DON were aware of the fact that blood sugar testing supplies ran out all the time. LPN F revealed that this has been occurring for months and that the administration has failed to do anything about making testing supplies available. LPN F revealed there have been times in the past when she did not have lancets; so instead, she used insulin syringes and flex pens to stick the resident's finger. She also revealed that she has not completed her blood sugar testing for residents that require it at the time of this interview. She revealed that blood sugar testing would have to be completed post meal for those residents that had already received their trays and begun eating. An observation made of LPN F's medication cart revealed a count of 5 lancets and zero (0) blood sugar strips. On 5/21/14 at approximately 11:50am, an interview conducted with Staff J, Unit manager, revealed that she did not have access to blood sugar supplies because they were kept in the DON's office. Staff J revealed that the nurses request supplies needed for blood sugar testing directly from the DON. The DON makes rounds at which times she provides the nurses with blood sugar testing supplies. Staff J also revealed that the issue of staff running out of blood sugar testing supplies has been brought to the attention of the administration on several occasions. On 5/21/14 at approximately 3:30pm, an interview conducted LPN G, revealed that the DON counts out the blood sugar testing strips supplies to nurses, and that sometimes it does not include enough for errors. She revealed that it was an ongoing problem with not having enough supplies to complete blood sugar testing as ordered. She stated the DON had told her she was on a budget and she has to stick to her budget or she will loose her job, that is why she keeps the supplies. She stated that one day when supplies to check blood glucose (sugar) were not available she had used a CNA's (certified nursing assistants) personal blood glucose machine to take the resident's blood glucose because she had 3 residents that were very brittle. An interview with the director of nursing was conducted on 5/23/14 at approximately 9:51 AM. The DON confirmed that she was keeping the blood glucose lancets and testing strips locked in her office and was dispersing them out. The DON stated that she changed the process. The central supply person was putting the blood glucose supplies out on the shelves and we were running out. The unit managers were to let the staff know that they could come to me after the clinical meetings and I would give them the needed supplies. They are labeled in my office and I give them out twice a day. On the weekends I would put out more because I don't want to come back. She stated the unit managers on one occasion, maybe three weeks ago, said there was a nurse that documented the blood glucose was not done because there were no supplies. When asked who had been monitoring this since the reported incident she stated the unit managers should have been monitoring this and it was the responsibility of the unit managers to audit the Medication Administration Records (MARS) and they are to bring any concerns or issues to the DON. She stated the unit managers did not bring the issue to her; I would have expected them to report this. Position Job Descriptions for the Administrator, Assistant Administrator and the Director of Nursing were requested and reviewed. The Job Description for the Executive Director I (Administrator), undated, was reviewed. The section entitled "Purpose of Your Job Position" stated, "The primary purpose of the Executive Director is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times." The section entitled "Job Functions" stated, "As Executive Director I, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for day-to-day clinical and administrative activities of the facility, including profit and loss responsibility and ensures compliance with all state and federal regulations. Supervises Director of Clinical Services (DON)..." The Job Description for the Assistant Executive Director (Assistant Administrator), undated, was reviewed. The section entitled "Purpose of Your Job Position" stated, "The primary purpose of the Assistant Executive Director is to direct the day-to-day functions of their areas of responsibility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times and to assist the Executive Director in these areas for the entire facility. You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results." The section entitled "Job Functions" stated, "As Assistant Executive Director, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for assisting the Executive Director in day-to-day clinical and administrative activities of the facility, including profit and loss responsibility and ensures compliance with all state and federal regulations." "You will provide leadership to all facility staff in meeting the goal of providing quality resident care." The Job Description for the Director of Clinical Services I (Director of Nursing), undated, was reviewed. The section entitled "Purpose of Your Job Position" stated, "As a Consulate Health Care Director of Clinical Services, you are entrusted with the responsibility of caring for our residents, families, coworkers, visitors, and all others;"... "The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Executive Director to ensure that the highest degree of quality care is maintained at all times. You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results." The section entitled "Job Functions" stated, "As Director of Clinical Services I, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for planning, organizing and directing the functions for the nursing department. You will assume the primary role in ensuring the delivery of high quality, efficient nursing care." "In the absence of the Executive Director, you are charged with carrying out the resident care policies established by this facility." Credible Allegation of Compliance The facility's assistant administrator and Director of Nursing were notified of Immediate Jeopardy on 5/22/14 at 3:30 PM. The facility provided a credible allegation of compliance on 5/23/14 at 2:30 PM. The following interventions were put into place by the facility to remove the immediate Jeopardy. The facility conducted an audit of current in house residents with orders for blood glucose (sugar) monitoring. Current residents were assessed for signs and symptoms of hyper/[DIAGNOSES REDACTED]. The facility medical director was notified that the blood glucose monitoring was not done per physicians orders on residents and of the current plan for resolution and monitoring. The regional director of clinical services verified that adequate blood glucose monitoring supplies were available in the facility and on each medication cart and that each resident has an individual glucometer and a bottle of test strips at bedside. A supply of Lancets will be kept on each medication cart and in the medication room on each unit. An audit was done of residents with [DIAGNOSES REDACTED]. The assistant director of clinical services/designee was educated on the process for checking adequacy of blood glucose monitoring supplies. Nurses were re-educated on documenting results of blood glucose results obtained and how to document resident refusal as well as educating the residents on risks of not allowing the test. Nurses were re-educated that is is not acceptable not to follow physicians orders for blood glucose monitoring. On 5/23/14 39 of the staff nurses had received the education. Monitoring will be ongoing. The medication administration records of residents with orders for blood glucose monitoring will be audited each shift for evidence of documentation of results and notification of the attending physician for 1 week and the daily for 4 weeks and then weekly for 3 months. The results of the audits will be reviewed daily by the executive director/designee. A monitoring tool was designed to reflect the above audits. The central supply clerk will order blood glucose supplies weekly based on resident use. The executive director/designee will ensure the order is submitted timely. The facility held an ad hoc performance improvement meeting to review and implement this allegation of compliance on 5/23/14 and included the medical director. Immediate Jeopardy was removed on 5/23/14 at 2:30 PM when interviews with nursing staff revealed awareness of the process for blood glucose monitoring, and that they had received the in-service education. The nurses also revealed a supply of blood glucose monitoring supplies available on each medication cart and in each medication room on all three stations.

Based on observation, staff interview and clinical record review, the facility failed to provide services to meet professional standards of quality. The facility failed to consistently provide blood glucose monitoring for 60 out of 67 residents with physicians orders for blood glucose monitoring (#3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 41, 42, 43, 44, 45, 47, 49, 50, 51, 52, 53, 54, 55, 57, 58, 59, 60, 61, 62, 63, 64, 66, 67, 69, 70). The current census was 177. It was determined that the facility failed to conduct blood sugar monitoring for 60 residents on 24 different days in April 2014, and 17 days in May of 2014. No nursing documentation was found indicating that physicians were notified when testing was missed. This systemic failure led to a finding of Immediate Jeopardy on May 22, 2014. Immediate Jeopardy was determined to have begun dating back to April 2, 2014. Immediate jeopardy was removed on 5/23/14 at 2:30 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower severity and scope of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure that monitoring of systems put in place are effective. The findings: A review of the clinical records was conducted for blood sugar monitoring in accordance with physician orders [REDACTED]. Documents reviewed included Physician Orders, Medication Administration Records (MARs), and Nursing Notes. Nursing consistently documented that Accu-checks were not done, but only intermittently documented the reasons the tests were not completed. When nursing wrote narrative notes about the missed Accu-checks, they documented the reasons as either no lancets, no testing strips or both. There was nursing documentation in multiple resident records dating back to 4/1/14 stating that the Director of Nursing (DON), management, administration and/or supervisor had been informed of missed blood sugar testing due to inadequate supplies. There was no nursing documentation located in any of the 60 records indicating that physicians were notified when blood sugar testing was missed. Resident #3 had an order dated 8/21/13 for Accu-check (blood sugar testing) daily before breakfast. Resident #3 received [MEDICATION NAME] (long-acting insulin) 18 units sq (subcutaneously - under the skin) daily before breakfast A review of the MAR (medication administration record) revealed blood sugar testing was not performed on 4/10/14, 4/12/14, 4/24/14, 4/27/14, 4/30/14, 5/2/14, 5/5/14, 5/11/14 and 5/20/14. A review of the nursing documentation revealed no documentation for the missed blood sugar testing. Resident #5 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed no documentation for the month of April and one entry in May, date unreadable, that documented blood sugar not checked, lancet not available. Resident #6 had an order for [REDACTED]. A review of the nursing documentation revealed no documentation for the month of April. On 5/6/14 and 5/16/14 nursing documented that the blood sugar test not performed due to no lancet available. Resident #7 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed that on 4/23/14 and 4/27/14 the nurse documented no testing strip to check blood sugar. Resident #8 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed 4/23/14 the nurse documented that there were no strips to test blood sugar. On 5/1/14 the nurse documents no lancet to check blood sugar. There were 3 other notes with unreadable dates that indicated the Accu-checks were not done due to either strips or lancets unavailable. Resident #9 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed no documentation for the missed blood sugar tests. Resident #10 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed no documentation for the missed blood sugar tests. Resident #11 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation was conducted. On 4/2/14, a nurse documented that they were unable to perform an Accu-check due to no testing strips available. The nurse further documented that the director of nursing (DON) was aware. On 5/6/14, a nurse documented unable to perform Accu-check, no lancet available. Resident #12 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed on 4/2/14 the nurse documented that Accu-check not done due to no testing strips available and that the DON was aware. There was no further documentation for the missed blood sugar testing. Resident #13 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed (date unreadable) that Accu-check not done, DON aware. On 5/6/14 a nurse documented missing lancet. Resident #14 had an order for [REDACTED]. A review of the nursing documentation revealed no documentation for the missed blood glucose testing. Resident #15 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed no documentation for the missing blood sugar testing. Resident #16 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed one entry in April (date unreadable) that the nurse documented unable to do Accu-check due to no strips, and that the DON was aware. Resident #17 had an order for [REDACTED].#17 received [MEDICATION NAME] (insulin) 3 units sq after meals and sliding scale insulin coverage at 9PM. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed on 4/2/14, " unable to do Accu-check (DON) aware " . On 5/4/14 a nurse documented unable to complete Accu-check - no strips. Supervisor aware. On 5/6/14 and 5/16/14 the nurse documented that no lancet was available. Resident #18 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed on 4/2/14 unable to do Accu-check no strips, DON aware. Nursing further documented missed testing due to missing supplies on 5/1/14, 5/3/14, 5/5/14, 5/8/14 and 5/9/14. Resident #19 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed entries dated 4/23/14, 5/1/14, 5/5/14, 5/6/14 and 5/16/14 indicating no blood sugar testing due to missing supplies. Resident #20 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed on 4/2/14 a nurse documented unable to do no Accu-check due to lack of testing strips and that the DON was aware. On 4/27/14, " unable to perform accu-check, no strips available, weekend supervisor aware " . On 4/1/14, 4/2/14, 4/3/14, 5/4/14 and 5/5/14 nursing documented missed Accu-checks due to inadequate supplies. The supervisor was noted to be aware on 5/4/14 at 11:30. Resident #21 had an order dated 11/1/13 for Accu-check every morning and at bedtime and [MEDICATION NAME] N (a type of insulin) 7 units sq before meals or after meals. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed no documentation for the missing blood sugar testing. Resident #22 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed no documentation for the month of April. On 5/4/14 at 11:30am a nurse documented " unable to complete Accu-check, no strips, supervisor aware. Resident #23 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed entries on 4/1/14, 5/3/14, 5/4/14, 5/8/14 and 5/19/14 indicating testing not performed due to inadequate supplies. Resident #24 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation dated 4/2/14 revealed that no strips were available at 4:30 PM or 9:00pm and that the director of nursing was contacted. There was no further documentation for missed blood sugar testing. Resident #25 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Nursing documented missed Accu-checks due to unavailable supplies on 4/2/14, 5/4/14, 5/8/14 and 5/16/14. Resident #27 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed 4/2/14 " no Accu-check strips, held [MEDICATION NAME] (long-acting insulin) unable to check blood sugar. Resident #28 had an order for [REDACTED]. Sliding scale insulin coverage was order. A review of the MAR indicated [REDACTED]. Nursing documented missing testing strips on 4/1/14 and 5/4/14. Resident #29 had an order for [REDACTED]. A review of the nursing documentation was conducted. Nursing documented missed testing due to lack of testing strips and/or lancets on 4/1/14, 5/2/14, 5/4/14, 5/8/14, 5/18/14 and 5/19/14. On 4/2/14, a nurse documented that the testing strips were not available and that the [MEDICATION NAME] was held (not given). Resident #30 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation showed testing supplies unavailable on 4/2/14, 4/24/14, 5/4/14 and 5/12/14. Resident #31 had an order for [REDACTED]. Nurses documented missing supplies on 4/23/14, 4/24/14, 4/30/14, 5/4/14, and 5/16/14. Resident #32 had an order for [REDACTED]. On 4/2/14, a nurse documented that the testing strips were not available and that the [MEDICATION NAME] was held (not given). Resident #33 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Nursing documented the reason for missed testing was either missing lancets or testing strips on 4/21/14, 4/20/14, 5/4/14, 5/8/14, 5/16/14 and 5/19/14. Resident #34 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Nursing documented the reason as missing supplies on 4/2/14, 4/24/14, 4/30/14, 5/8/14, 5/18/14 and 5/19/14. Resident #35 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation dated 4/1/14 at 11:30am showed that no testing strips were available and that the DON was aware. On 4/2/14 at 11:30am, 4:30pm and 9:00pm nursing again wrote that no testing strips were available and that the DON was aware. On 4/28/14, nursing again documented that the testing strips were unavailable and that the DON was aware. Resident #36 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Nursing documented missing supplies as the reason for no Accu-checks on 4/23/14, 4/24/14 and 5/12/14. No further documentation. Resident #37 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Nursing documented missing supplies on 4/23/14. Resident #38 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Nursing documented missing supplies as the reason for no Accu-checks on 4/2/14, 4/23/14 and on 5/14/14 nursing documented missing insulin. Resident #39 had an order for [REDACTED]. A review of the nursing documentation date 4/23/14 revealed testing strip not available. There was no further documentation. Resident #41 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Nursing documented missing supplies on 4/23/14 and 4/24/14. Resident #42 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Nursing documented missing supplies on 4/23/14. There was no further documentation. Resident #43 had an order for [REDACTED]. Nursing documented missing supplies on 4/23/14 and 4/24/14. Resident #44 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Nursing documented missing supplies on 4/23/14, 4/24/14 and 5/12/14. Resident #45 had an order for [REDACTED].#45 received two different types of insulin, [MEDICATION NAME] 20 units at bedtime and [MEDICATION NAME] 70/30, 10 units, 30 minutes prior to a meal. A review of the MAR indicated [REDACTED]. Nursing documented missing supplies on 4/23/14 and 5/20/14. Resident #47 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Nursing documented missing supplies on 4/2/14, 4/21/14, and 5/12/14. Resident #49 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Nursing documented missing supplies on 4/2/14, and 5/16/14. Resident #50 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Nursing documented missing supplies on 4/30/14, 5/4/14, 5/18/14, and 5/19/14. Resident #51 had an order dated 4/27/14 for Accu-checks before meals and at bedtime with [MEDICATION NAME] sliding scale insulin coverage. A review of the MAR indicated [REDACTED]. Nursing documented missing supplies on 5/1/14, 5/4/14, 5/14/14, and 5/15/14. Resident #52 had an undated order for Accu-checks before meals and at bedtime. Sliding scale insulin coverage was ordered. A review of the MAR indicated [REDACTED]. Nursing documented that management was aware of the missing supplies on 5/4/14, and that the DON was aware of the missing supplies on 5/11/14 and 5/16/14. Resident #53 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed that the DON was aware of the missed Accu-checks due a lack of testing supplies on 4/2/14, 4/10/14 and 5/15/14 and that the supervisor was aware on 5/4/14. Resident #54 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed that the DON was notified of the missing testing supplies on 4/1/14, 4/2/14, 4/11/14, 4/30/14, 5/1/14, and 5/19/14. On 5/4/14 at 11:30 nursing documented that the supervisor was aware of the missing supplies. On 5/4/14 at 4:30pm, nursing documented that management was notified of the missing Accu-check supplies. Resident #55 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Nursing documented that either the DON, management and/or the nursing supervisor was notified of the missing supplies on 4/2/14, 5/1/14, 5/4/14, 5/4/14, 5/11/14 and 5/19/14. Resident #57 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed notification of the missing supplies to the DON, supervisor and/or management staff on 4/1/14, 4/2/14, 4/27/14, 5/1/14, 5/4/14, 5/11/14 and 5/16/14. Resident #58 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed entries on 4/1/14 and 4/2/14 that in-house administration was aware of the missing supplies. Resident #59 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. There was no nursing documentation related to the missed blood sugar testing. Resident #60 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. There was no nursing documentation related to the missed blood sugar testing. Resident #61 had an order dated 3/13/14 for Accu-check before meals and at bedtime with [MEDICATION NAME] sliding scale coverage. A review of the MAR indicated [REDACTED]. Nursing documented missing testing supplies on 4/2/14, 4/13/14, 4/17/14 and 4/18/14 and that the DON was notified on 4/13/14 and 4/17/14. Resident #62 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Nursing documented that management was aware of the missing testing supplies on 4/1/14 and 4/2/14. Resident #63 had an order dated 3/18/14 for Accu-check twice daily, and orders for [MEDICATION NAME] 50 units daily before breakfast and [MEDICATION NAME] 4 units with meals or after meals daily (both are types of insulins). A review of the MAR indicated [REDACTED]. Nursing documented missing testing strips on 4/1/14 and missing testing supplies and DON notification on on 4/2/14. Resident #64 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. There was no nursing documentation related to the missed blood sugar testing. Resident #66 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. On 4/2/14 nursing documented that management was aware of the missing testing supplies. Resident #67 had an undated order for Accu-check before meals and at bedtime. Sliding scale insulin coverage was ordered. A review of the MAR indicated [REDACTED]. There was no nursing documentation related to the missed blood sugar testing. Resident #69 had an undated order for Accu-check before meals and at bedtime. A review of the MAR indicated [REDACTED]. Nursing documented missing lancets as the reason for both days. Resident #70 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed no lancets available on 5/15/14, and missing supplies and DON notification for 5/19/14. On 5/21/14 at approximately 10:32am, during an observation of the facility's three (3) medication rooms it was discovered that there was not a supply of lancets or glucose (blood sugar) testing strips stored for nurses to access in any of these rooms. An observation was conducted of the central supply and revealed that there were no blood glucose testing supplies stored. Interview with the Central Supply Staff at the time of observation revealed that all blood glucose supplies were kept in the DON's office. On 5/21/14 at approximately 10:14am, an interview was conducted with the Director of Nursing (DON), the Assistant Administrator, and the central supply staff about the facility's process for ordering medical supplies and storing supplies in a designated area for staff to have accessibility. The DON revealed that nurses did not have access to lancets and blood glucose testing unless provided by her or the ADON (assistant director of nursing) because the supplies were in her office. The DON revealed that this protocol was put into place because of nurses' wastefulness with medical supplies, in particular, blood glucose testing supplies. On 5/21/14 between 10:45am-12:15pm observation was conducted for 6 of 6 medication carts on all three units in the facility (Station#1, #2, and #3) along with an interview of the 7am-3pm shift nurses assigned to a medication cart. The observations revealed the following: An observation was made of the medication cart assigned to Licensed Practical Nurse A, (LPN A). There was a count of 6 lancets and 1 blood sugar strips. There were 5 residents who required blood sugar testing during the 7am-3pm shift. An observation made of LPN B ' s medication cart revealed a count of 6 lancets and 6 blood sugar strips. Four (4) residents required blood sugar testing during the 7am-3pm shift. An observation made of LPN C ' s medication cart revealed a count of 7 lancets and 15 blood sugar strips. There were 3 residents that required blood sugar testing during the 7am-3pm shift. An observation made of LPN D ' s medication cart revealed a count of 5 lancets and 6 blood sugar strips. There were 13 residents on that unit that required blood sugar testing during the 7am-3pm shift. An observation made of LPN E ' s medication cart revealed a count of 15 lancets and zero (0) blood sugar strips. There were a total of 7 residents that required blood sugar testing durin

Based on observation, staff interview and clinical record review, the facility failed to ensure the residents' comprehensive plan of care was implemented for 58 of 67 sampled residents care plans reviewed (Residents #3, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #41, #42, #43, #44, #45, #47, #49, #50, #51, #52, #53, #54, #55, #57, #58, #59, #60, #61, #62, #63, #64, #66, and #69). The facility failed to consistently provide blood sugar monitoring for 58 residents with care plans and physicians orders for blood sugar monitoring. It was determined that the facility failed to conduct blood sugar monitoring on 24 different days in April 2014, and 17 days in May of 2014. This systemic failure led to a finding of Immediate Jeopardy on May 22, 2014. Immediate Jeopardy began on 4/2/14. Immediate jeopardy was removed on 5/23/14 at 2:30 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower severity and scope of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure that monitoring of systems put in place are effective. The findings are: A review of the clinical records was conducted for implementing the care plan for diabetic residents who had care plans developed. Documents reviewed included Care plans, Physician Orders, Medication Administration Records (MARs), and Nursing Notes. There was documentation in multiple resident records dating back to 4/1/14 showing diabetic care plans were not implemented as written. There was missed blood sugar testing due to inadequate supplies. A review conducted of Resident #3's care plan for diabetes revealed that this resident had type 2 diabetes with additional identified complications of Hypertension. Implementation of the care plan begun on 1/31/14 and was reviewed on 5/1/14. The interventions listed included but were not limited to blood glucose (sugar) monitoring as ordered, sliding scale coverage as ordered, and obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notifying the Medical Director (MD). Resident #3 had an order dated 8/21/13 for Accu-check (blood sugar testing) daily before breakfast. Resident #3 received [MEDICATION NAME] (long-acting insulin) 18 units sq (subcutaneously - under the skin) daily before breakfast A review of the MAR (medication administration record) revealed blood sugar testing was not performed on 4/10/14, 4/12/14, 4/24/14, 4/27/14, 4/30/14, 5/2/14, 5/5/14, 5/11/14 and 5/20/14. A review conducted of Resident #5's care plan for diabetes revealed that this resident had type 2 diabetes with additional identified complications of [MEDICAL CONDITION]. Implementation of the care plan begun on 2/28/14 and scheduled for review on 5/28/14. The interventions listed included but were not limited to blood glucose monitoring as ordered, sliding scale coverage as ordered, routine insulin coverage as ordered, and obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notifying the MD. Resident #5 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review conducted of Resident #6's care plan for diabetes revealed that this resident had type 1 diabetes with additional identified complications of Hypertension, [MEDICAL CONDITIONS], and Depression. Implementation of the care plan begun 12/19/13 and a review of the plan was completed on 3/19/14. The interventions listed included but were not limited to blood glucose monitoring as ordered, sliding scale coverage as ordered, and obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notifying the MD. Resident #6 had an order for [REDACTED]. A review conducted of Resident #7's care plan for diabetes revealed that this resident had type 2 diabetes with additional identified complications of Hypertension, [MEDICAL CONDITIONS], and Depression. Implementation of the care plan begun 7/12/13 and was last reviewed on 4/10/14 The interventions listed included but were not limited to blood glucose monitoring as ordered, sliding scale coverage as ordered, and obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notifying the MD. Resident #7 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review conducted of Resident #8's care plan for diabetes revealed that this resident had type 2 diabetes with additional identified complications of Hypertension, [MEDICAL CONDITIONS], High Cholesterol, Loss of Vision, and [MEDICAL CONDITION]. Implementation of the care plan begun 7/23/14 and last reviewed on 4/10/14. The interventions listed included but were not limited to blood glucose monitoring as ordered, sliding scale coverage as ordered, and obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notifying the MD. Resident #8 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review conducted of Resident #9's care plan for diabetes revealed that this resident had type 1 diabetes with additional identified complications of Hypertension. Implementation the care plan begun 9/13/13 and was last reviewed on 3/13/14. The interventions listed included but were not limited to blood glucose monitoring as ordered and if the blood glucose is less than 70 administer food or glucose gel per manufactures recommendations and notify MD if ordered. Also if the blood sugar is less than 70 and if unable to swallow administer intramuscular (IM) [MEDICATION NAME] per manufactures instructions obtained from the emergency drug kit (EDK). Recheck blood glucose in 15 minutes and notify MD. Other interventions listed included Sliding scale coverage as ordered, routine insulin coverage as ordered, and obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION]. Resident #9 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review conducted of Resident #10's care plan for diabetes revealed that this resident had type 1 diabetes with additional identified complications of Hypertension, [MEDICAL CONDITION], and Wound to Feet. Implementation of the care plan begun on 1/10/14 and was last reviewed on 4/10/14. The interventions listed included but were not limited to blood glucose monitoring as ordered, sliding scale coverage as ordered, routine insulin coverage as ordered, and obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notifying the MD. Resident #10 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review conducted of Resident #11's care plan for diabetes revealed that that there was no indication of the type of diabetes the resident was diagnosed with [REDACTED]. The interventions listed included but were not limited to blood glucose monitoring as ordered, sliding scale coverage as ordered, and obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notifying the MD. Resident #11 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review conducted of Resident #12's care plan for diabetes revealed that there was no indication of the type of diabetes that the resident was diagnosed with [REDACTED]. Implementation of the care plan started on 4/10/14 and scheduled to be reviewed on 7/10/14. The interventions listed included but were not limited to blood glucose monitoring as ordered, sliding scale coverage as ordered, and obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notifying the MD. Resident #12 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review conducted of Resident #13's care plan for diabetes revealed that the resident was diagnosed with [REDACTED]. Implementation of the care plan started 4/24/14 and scheduled to be reviewed on 7/24/14. The interventions listed included but not limited to blood glucose monitoring as ordered. Resident #13 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review conducted of Resident #14's care plan for diabetes revealed that the resident had type 1 diabetes with additional identified complications of hypertension, [MEDICAL CONDITION], loss of vision, and [MEDICAL CONDITION]. Implementation of the care plan started on 8/15/13 and was last reviewed on 5/15/14. The interventions listed included but were not limited to obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notify the MD, routine insulin coverage as ordered, blood glucose monitoring as ordered, and sliding scale coverage as ordered. Resident #14 had an order for [REDACTED]. A review conducted of Resident #15's care plan for diabetes revealed that the resident was diagnosed with [REDACTED]. Implementation of the care plan started 4/18/14 and scheduled to be reviewed 7/18/14. The interventions listed included but not limited to blood glucose monitoring as ordered. Resident #15 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review conducted of Resident #16's care plan for diabetes revealed that this resident had type 1 diabetes with additional identified complications of Hypertension, High Cholesterol, and Kidney Disease. Implementation of the care plan started on 10/11/13 and last reviewed on 4/11/14. The interventions listed included but were not limited to obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notify the MD; oral diabetic agents as ordered; routine insulin coverage as ordered; and sliding scale coverage as ordered. Other interventions included blood glucose monitoring as ordered and if the blood glucose is less than 70 administer food or glucose gel per manufactures recommendations and notify MD if ordered. Also if the blood sugar is less than 70 and if unable to swallow administer intramuscular (IM) [MEDICATION NAME] per manufactures instructions obtained from the emergency drug kit (EDK). Recheck blood glucose in 15 minutes and notify MD. Resident #16 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of conducted of Resident #17's care plan for diabetes revealed that this resident had type 2 diabetes with additional identified complications of [MEDICAL CONDITION]. Implementation of the care plan started on 1/24/14 and last reviewed on 4/24/14. The interventions listed included but were not limited to obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notify the MD; oral diabetic agents as ordered; routine insulin coverage as ordered; blood glucose monitoring as ordered; and sliding scale coverage as ordered. Resident #17 had an order for [REDACTED].#17 received [MEDICATION NAME] (insulin) 3 units sq after meals and sliding scale insulin coverage at 9PM. A review of the MAR indicated [REDACTED]. A review of Resident #18's care plan for diabetes revealed that this resident had type 2 diabetes with additional identified complications of Hypertension, [MEDICAL CONDITION], kidney disease and depression. Implementation of the care plan began 4/7/14 and is scheduled to be reviewed 7/7/14. The interventions listed included but were not limited to obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notify the MD; oral diabetic agents as ordered; routine insulin coverage as ordered; blood glucose monitoring as ordered; and sliding scale coverage as ordered. Resident #18 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of Resident #19's care plan for diabetes revealed that this resident had type 2 diabetes with additional identified complications of [MEDICAL CONDITION] and high cholesterol. Implementation of the care plan started 11/4/13 and was last reviewed on 5/4/14. The interventions listed included but were not limited to obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notify the MD; oral diabetic agents as ordered; blood glucose monitoring as ordered; and sliding scale coverage as ordered. Resident #19 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of Resident #20's care plan for diabetes revealed that this resident had type 2 diabetes with additional identified complications of hypertension and [MEDICAL CONDITION]. Implementation of the care plan started on 12/23/13 and as last reviewed on 3/23/14. The interventions listed included but were not limited to obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notify the MD; routine insulin coverage as ordered; blood glucose monitoring as ordered; and sliding scale coverage as ordered. Resident #20 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of Resident #21's care plan for diabetes revealed this resident was diagnosed with [REDACTED]. Implementation of the care plan started on 5/3/14 and scheduled to be reviewed on 8/3/14. The interventions listed included but not limited to blood glucose monitoring as ordered. Resident #21 had an order dated 11/1/13 for Accu-check every morning and at bedtime and [MEDICATION NAME] N (a type of insulin) 7 units sq before meals or after meals. A review of the MAR indicated [REDACTED]. A review of Resident #22's care plan for diabetes revealed this resident had type 2 diabetes with additional identified complications of hypertension, [MEDICAL CONDITION], and kidney disease. Implementation of the care plan started on 11/6/13 and was last reviewed on 5/6/14. The interventions listed included but were not limited to obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notify the MD and sliding scale coverage as ordered. Other interventions included blood glucose monitoring as ordered and if the blood glucose is less than 70 administer food or glucose gel per manufactures recommendations and notify MD if ordered. Also if the blood sugar is less than 70 and if unable to swallow administer intramuscular (IM) [MEDICATION NAME] per manufactures instructions obtained from the emergency drug kit (EDK). Recheck blood glucose in 15 minutes and notify MD. Resident #22 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of Resident #23's care plan for diabetes revealed this resident had type 2 diabetes with additional identified complications of hypertension, [MEDICAL CONDITIONS], and depression. Implementation of the care plan started on 3/19/14 and scheduled to be reviewed on 6/19/14. The interventions listed included but were not limited to obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notify the MD; oral diabetic agents as ordered; blood glucose monitoring as ordered; and sliding scale coverage as ordered. Resident #23 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of Resident #24's care plan for diabetes revealed this resident had type 2 diabetes. Implementation of the care plan started 4/14/14 and scheduled to be reviewed 7/14/14. The interventions listed included but not limited to blood glucose monitoring as ordered. Resident #24 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of Resident #25's care plan for diabetes revealed this resident had type 2 diabetes. Implementation of the care plan started 4/14/14 and scheduled to be reviewed 7/16/14. The interventions listed included but not limited to blood glucose monitoring as ordered. Resident #25 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of Resident #27's care plan for diabetes revealed this resident had type 2 diabetes with additional identified complications of hypertension, [MEDICAL CONDITION], high cholesterol, [MEDICAL CONDITION], and depression. Implementation of the care plan started on 11/8/13 and was last reviewed 5/8/14. The interventions listed included but were not limited to obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notify the MD; oral diabetic agents as ordered; routine insulin coverage as ordered; blood glucose monitoring as ordered; and sliding scale coverage as ordered. Resident #27 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of Resident #28's care plan for diabetes revealed this resident had type 2 diabetes with additional identified complication of hypertension, [MEDICAL CONDITIONS], high cholesterol, kidney disease, depression, and status [REDACTED]. Implementation of the care plan started on 4/3/14 and scheduled to be reviewed on 7/3/14. The interventions listed included but were not limited to obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notify the MD; routine insulin coverage as ordered; blood glucose monitoring as ordered; and sliding scale coverage as ordered. Resident #28 had an order for [REDACTED]. Sliding scale insulin coverage was order. A review of the MAR indicated [REDACTED]. A review of Resident #29's care plan for diabetes revealed this resident had type 2 diabetes with additional identified complication of hypertension, [MEDICAL CONDITION], kidney disease, [MEDICAL CONDITION], and depression. Implementation of the care plan started on 11/01/13 and was last reviewed on 4/30/14. The interventions listed included but were not limited to obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notify the MD; oral diabetic agents as ordered; routine insulin coverage as ordered; blood glucose monitoring as ordered; and sliding scale coverage as ordered. Resident #29 had an order for [REDACTED]. A review of Resident #30's care plan for diabetes revealed this resident had type 2 diabetes with additional identified complications of hypertension, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Implementation of the care plan started on 8/12/13 and was last reviewed on 5/12/14. The interventions listed included but were not limited to obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notify the MD; routine insulin coverage as ordered; blood glucose monitoring as ordered; and sliding scale coverage as ordered. Resident #30 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of Resident #31's care plan for diabetes revealed this resident had type 2 diabetes with additional identified complication of hypertension, [MEDICAL CONDITIONS], high cholesterol, and [MEDICAL CONDITION]. Implementation of the care plan started on 6/28/13 and was last reviewed on 3/28/14. The interventions listed included but were not limited to obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notify the MD; oral diabetic agents as ordered; routine insulin coverage as ordered; blood glucose monitoring as ordered; and sliding scale coverage as ordered. Resident #31 had an order for [REDACTED]. A review of Resident #32's care plan for diabetes revealed this resident had type 2 diabetes and had additional identified complications of hypertension, [MEDICAL CONDITIONS], high cholesterol, [MEDICAL CONDITION], and depression. Implementation of the care plan started 2/26/14 and scheduled to be reviewed on 5/26/14. The interventions listed included but were not limited to obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notify the MD; oral diabetic agents as ordered; routine insulin coverage as ordered; blood glucose monitoring as ordered; and sliding scale coverage as ordered. Resident #32 had an order for [REDACTED]. A review of Resident #33's care plan for diabetes revealed this resident had type 2 diabetes and has additional identified complications of hypertension, [MEDICAL CONDITION], high cholesterol, [MEDICAL CONDITION], and depression. Implementation of the care plan started on 2/5/14 and was last reviewed 5/5/14. The interventions listed included but were not limited to obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notify the MD; routine insulin coverage as ordered; blood glucose monitoring as ordered; and sliding scale coverage as ordered. Resident #33 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of Resident #34's care plan for diabetes revealed this resident had type 2 diabetes with additional complications of hypertension, [MEDICAL CONDITION], high cholesterol, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Implementation of the care plan started on 8/2/13 and was last reviewed on 4/30/14. The interventions listed included but were not limited to obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notify the MD; blood glucose monitoring as ordered; and sliding scale coverage as ordered. Resident #34 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of Resident #35's care plan for diabetes revealed that this resident was diagnosed with [REDACTED]. Implementation of the care plan started 4/9/14 and scheduled to be reviewed on 7/9/14. The interventions listed included but not limited to blood glucose monitoring as ordered. Resident #35 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of Resident #36's care plan for diabetes revealed this resident type 2 diabetes with additional identified complications of hypertension, [MEDICAL CONDITIONS], and high cholesterol. Implementation of the care plan started on 11/21/13 and was last reviewed on 5/21/14. The interventions listed included but were not limited to blood glucose monitoring as ordered and if the blood glucose is less than 70 administer food or glucose gel per manufactures recommendations and notify MD if ordered. Also if the blood sugar is less than 70 and if unable to swallow administer intramuscular (IM) [MEDICATION NAME] per manufactures instructions obtained from the emergency drug kit (EDK). Recheck blood glucose in 15 minutes and notify MD. Other interventions listed included Sliding scale coverage as ordered, routine insulin coverage as ordered, and obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION]. Resident #36 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of Resident #37's care plan for diabetes revealed this resident was diagnosed with [REDACTED]. Implementation of the care plan started on 4/16/14 and scheduled to be reviewed on 7/19/14. The interventions listed included but not limited to blood glucose monitoring as ordered. Resident #37 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of Resident #38's care plan for diabetes revealed this resident had type 2 diabetes with additional identified complications of hypertension and depression. Implementation of the plan started 8/30/13 and was last reviewed on 3/2/14. The interventions listed included but were not limited to obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notify the MD; routine insulin coverage as ordered; blood glucose monitoring as ordered; and sliding scale coverage as ordered. Resident #38 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of Resident #39's care plan for diabetes revealed this resident had type 2 diabetes with additional identified complications of hypertension, [MEDICAL CONDITIONS], high cholesterol, loss of vision, and depression. Implementation of the care plan started 10/15/13 and was last reviewed 4/13/14. The interventions listed included but were not limited to obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notify the MD; routine insulin coverage as ordered; blood glucose monitoring as ordered; and sliding scale coverage as ordered. Resident #39 had an order for [REDACTED]. A review of Resident #41's care plan for diabetes revealed this resident had type 2 diabetes with additional identified complications of hypertension, [MEDICAL CONDITIONS], high cholesterol, impaired vision, [MEDICAL CONDITION] and depression. Implementation of the care plan started on 9/4/13 and was last reviewed on 3/4/14. The interventions listed included but were not limited to obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notify the MD; routine insulin coverage as ordered; blood glucose monitoring as ordered; and sliding scale coverage as ordered. Resident #41 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of Resident #42's care plan for diabetes revealed this resident had type 2 diabetes with additional identified complications of hypertension, [MEDICAL CONDITION], high cholesterol, [MEDICAL CONDITION] and depression. Implementation of the care plan started on 8/1/13 and was last reviewed on 4/30/14. The interventions listed included but were not limited to obtaining blood glucose for symptoms of Hypo/[MEDICAL CONDITION] and notify the MD; routine insulin cove

Based on observation, staff interview, clinical record review and review of the facility policy and procedure, the facility failed to provide adequate monitoring for insulin and other diabetic medications for 57 of 64 total residents who had physician orders for blood sugar monitoring (Accu-checks) due to diabetic medications (#3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 17, 18, 19, 20, 21, 22, 23, 24, 25, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 41, 42, 43, 44, 45, 47, 49, 50, 51, 52, 53, 54, 55, 57, 58, 59, 60, 61, 62, 63, 64, 66, 67, 69). The current facility census was 177. This failure to adequately monitor insulin and other diabetic medications led to a finding of Immediate Jeopardy on 5/22/14. Staff interviews were conducted and clinical records were reviewed for all 64 residents with orders for blood sugar monitoring due to medications. It was determined that the facility failed to conduct blood sugar monitoring for 57 residents on 24 different days in April 2014, and 17 days in May of 2014. Immediate Jeopardy was determined to have begun dating back to April 2, 2014. Immediate Jeopardy was removed on 5/23/14 at 2:30 PM when the facility provided and implemented a credible allegation of compliance. The facility remained out of compliance at a lower severity and scope of E (no actual harm with potential for more than minimal harm that was not immediate jeopardy) to ensure monitoring of systems put in place were effective. The findings are: On 5/21/14 at approximately 10:32am, during an observation of the facility's three (3) medication rooms it was discovered that there was not a supply of lancets or blood sugar testing strips stored for nurses to access in either of these rooms. An observation was conducted of the central supply and revealed that there were no blood sugar testing supplies stored. Interview with the Central Supply Staff at the time of observation revealed that all blood sugar supplies were kept in the Director of Nursing's (DON's) office. On 5/21/14 between 10:45am-12:15pm observation was conducted for 6 of 6 medication carts on all three units in the facility (Station#1, #2, and #3) along with an interview of the 7am-3pm shift nurses assigned to a medication cart. The observations revealed the following: An observation was made of the medication cart assigned to Licensed Practical Nurse A, (LPN A). There was a count of 6 lancets and 1 blood sugar strips. There were 5 residents who required blood sugar testing during the 7am-3pm shift. An observation made of LPN B's medication cart revealed a count of 6 lancets and 6 blood sugar strips. Four (4) residents required blood sugar testing during the 7am-3pm shift. An observation made of LPN C's medication cart revealed a count of 7 lancets and 15 blood sugar strips. There were 3 residents that required blood sugar testing during the 7am-3pm shift. An observation made of LPN D's medication cart revealed a count of 5 lancets and 6 blood sugar strips. There were 13 residents on that unit that required blood sugar testing during the 7am-3pm shift. An observation made of LPN E's medication cart revealed a count of 15 lancets and zero (0) blood sugar strips. There were a total of 7 residents that required blood sugar testing during the 7am-3pm shift. An observation made of LPN F's medication cart revealed a count of 5 lancets and zero (0) blood sugar strips. There were a total of 10 residents that required blood sugar testing during the 7am-3pm shift. On 5/21/14 at approximately 10:40am, an observation was made of blood sugar testing supplies being kept in the DON's office. There were 9 boxes (100 count each) of lancets and 2 boxes (50 per box) of blood sugar strips available. During the course of the observation an interview was conducted with the DON and revealed that she distributes lancets and blood sugar strips according to the number of residents that require checks. The DON revealed that she goes around to the stations at least twice a day and as needed to distribute the number of blood sugar testing supplies that are required. The DON revealed that this measure was put into place because of staff wastefulness and supplies disappearing. After hours if strips are required or have run out, the DON stated that staff are aware to contact her to come pass out more supplies. In the case of emergencies the DON revealed that she lives relatively close to the facility and can get to the facility in less than 10 minutes. She revealed that she had speculations that staff was taking the supplies home with them. She confirmed that there is definitely a breakdown in communication with staff and the facility did not have an effective protocol in place at the time. On 5/21/14 at approximately 10:50am an interview was conducted with LPN B. LPN B revealed that she gets a supply of lancets and blood sugar strips directly from the DON's office. LPN B revealed that if she runs out of diabetic testing supplies after hours during her shift, that the DON has to be called at home to come to the facility and give out more supplies. LPN B revealed that there was no effective protocol for obtaining supplies in emergency situations. LPN B reported that approximately a week ago she had an emergency with a resident's levels needing to be rechecked, but that she was unable to recheck because she did not have enough lancets or blood sugar strips. Staff B revealed that she documented on the resident 's Medication Administration Record [REDACTED]. On 5/21/14 at approximately 10:55am, an interview conducted with LPN C revealed that supply of lancets and blood sugar test strips are obtained from the DON when supplies are needed. The DON comes around and gives nurses a supply according to the number of residents that require blood sugar testing. Staff C revealed that she had never had any emergency situations where she has needed either lancets or blood sugar strips, but if she did she would notify her supervisor and try to borrow the supplies from another unit or medication cart. Staff C revealed that there was not any blood sugar supplies kept for the nurses to access, except for when the DON was on site. On 5/21/14 at approximately 11:00am, an interview conducted with LPN D, revealed that she has run out of lancets and blood sugar test strips often and had no access to get more. LPN D revealed that the DON keeps a supply of lancets and blood sugar test strips locked in her office and the supplies are only available through her. LPN D revealed that she has had to use flex pens instead of using lancets to stick the resident 's finger to test their blood sugar levels at times because she did not have access to supplies. LPN D revealed that she could recall several times residents missed blood sugar testing as ordered dating back for at least 2 months. LPN D revealed that the nurses are only given enough supplies for the residents that have blood sugar testing ordered not considering the fact that re-checks may have to be done or emergency situations could occur. LPN D revealed that management is well aware of nurses not having access to blood sugar testing supplies and told the staff it was because of the facility's budget. On 5/21/14 at approximately 11:08am, an interview conducted with Unit Manager H (Staff H) revealed that blood sugar testing supplies are kept in the DON's office and administered to nursing according to the number of residents' that require blood sugar testing. Staff H revealed that she does not have a key to get to supplies for nurses when they run out of supplies. Staff H revealed that if the DON is not in the building, she could call her to come to the facility to give more supplies. On 5/21/14 at approximately 11:15, an interview conducted with LPN E, revealed that she had run out of testing supplies that morning. LPN E stated that she had requested blood sugar testing supplies twice this morning (5/21/14) and had not received the supplies. She was unable to perform any Accu-checks prior to meals for residents with orders for blood sugar testing before meals. LPN E revealed that some residents had already begun their meals. LPN E revealed that she had asked LPN F on the unit to borrow some supplies but LPN F was out of supplies as well. LPN E revealed they have informed their unit managers of not having enough supplies to complete blood sugar testing for the morning of 5/21/14. LPN E revealed that supplies for blood sugar testing are provided to nurses based on the number of residents that require testing per shift. LPN E revealed that this was an ongoing issue. LPN E revealed that if supplies run out they were instructed by the DON to call her at home so she can come in and provide them with more supplies. On 5/21/14 at approximately 11:25am, and interview conducted with LPN F, revealed that this nurse was currently out of blood sugar testing supplies. LPN F revealed that there were no supplies on either medication cart on the unit at the time of the interview and that a request had been made to the DON twice for supplies this morning (5/21/14). LPN F explained that the 11:00pm-7:00am shift did not have supplies either and that as a result some residents did not receive their morning blood sugar testing as ordered. LPN F revealed that this was an ongoing problem and that the unit managers as well as the DON was aware of the fact that blood sugar testing supplies ran out all the time. LPN F revealed that this has been occurring for months and that the administration has failed to do anything about making testing supplies available. LPN F revealed there have been times in the past when she did not have lancets; so instead, she used insulin syringes and flex pens to stick the resident's finger. She also revealed that she has not completed her blood sugar testing for residents that require it at the time of this interview. She revealed that blood sugar testing would have to be completed post meal for those residents that had already received their trays and begun eating. On 5/21/14 at approximately 11:50am, an interview conducted with Staff J, Unit manager, revealed that she did not have access to blood sugar supplies because they were kept in the DON's office. Staff J revealed that the nurses request supplies needed for blood sugar testing directly from the DON. The DON makes rounds at which times she provides the nurses with blood sugar testing supplies. Staff J also revealed that the issue of staff running out of blood sugar testing supplies has been brought to the attention of the administration on several occasions. On 5/21/14 at approximately 3:30pm, an interview conducted LPN G, revealed that the DON counts out the blood sugar testing strips supplies to nurses, and that sometimes it does not include enough for errors. She revealed that it was an ongoing problem with not having enough supplies to complete blood sugar testing as ordered. She stated the DON had told her she was on a budget and she has to stick to her budget or she will loose her job, that is why she keeps the supplies. She stated that one day when supplies to check blood glucose (sugar) were not available she had used a CNA's (certified nursing assistants) personal blood glucose machine to take the resident's blood glucose because she had 3 residents that were very brittle. An interview with the director of nursing was conducted on 5/23/14 at approximately 9:51 AM. The DON confirmed that she was keeping the blood sugar lancets and testing strips locked in her office and was dispersing them out. The DON stated that she changed the process because "when I started here, there was a free for all". The central supply person was putting the blood sugar supplies out on the shelves and we were running out, so I started to keep them in my office and dispersing them out. The unit managers were to let the staff know that they could come to me after the clinical meetings and I would give them the needed supplies. I give them out twice a day. On the weekends I would put out more because I don't want to come back. She stated the unit managers on one occasion, maybe three weeks ago, said there was a nurse that documented the blood sugar was not done because there were no supplies. When asked who had been monitoring this since the reported incident she stated the unit managers should have been monitoring this and it was the responsibility of the unit managers to audit the Medication Administration Records (MARS) and they are to bring any concerns or issues to the DON. She stated the unit managers did not bring the issue to her; I would have expected them to report this. A review of the clinical records was conducted for physician orders for insulin and other diabetic medications and blood sugar monitoring in accordance with physician orders. Documents reviewed included Physician Orders, Medication Administration Records (MARs), and Nursing Notes. Nursing documentation, when present, revealed that the reason for missed Accu-checks was either due to no lancets, no testing strips or both. There was nursing documentation in multiple resident records dating back to 4/1/14 stating that the DON, management, administration and/or supervisor had been informed of missed blood sugar testing due to inadequate supplies. Resident #3 had an order dated 8/21/13 for Accu-check (blood sugar testing) daily before breakfast. Resident #3 received [MEDICATION NAME] (long-acting insulin) 18 units sq (subcutaneously - under the skin) daily before breakfast A review of the MAR (medication administration record) revealed blood sugar testing was not performed on 4/10/14, 4/12/14, 4/24/14, 4/27/14, 4/30/14, 5/2/14, 5/5/14, 5/11/14 and 5/20/14. Resident #5 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #6 had an order for [REDACTED]. A review of the nursing documentation revealed no documentation for the month of April. Resident #7 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #8 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #9 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #10 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #11 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. On 4/2/14, a nurse documented that they were unable to perform an Accu-check due to no testing strips available and that the DON was aware. Resident #12 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed on 4/2/14 the nurse documented that Accu-check not done due to no testing strips available and that the DON was aware. Resident #13 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #15 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #17 had an order for [REDACTED].#17 received [MEDICATION NAME] (insulin) 3 units sq after meals and sliding scale insulin coverage at 9PM. A review of the MAR indicated [REDACTED]. On 4/2/14 nursing documented that they were unable to perform blood sugar testing, and that the DON was aware. On 5/4/14 a nurse documented unable to complete Accu-check - no strips and supervisor aware. Resident #18 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed an entry on 4/2/14 stating that unable to do Accu-check no strips, DON aware. Resident #19 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #20 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Nursing documented on 4/2/14, 4/27/14 and 5/4/14 that the DON or supervisor was aware of missed testing due to inadequate diabetic testing supplies. Resident #21 had an order dated 11/1/13 for Accu-check every morning and at bedtime and [MEDICATION NAME] N (a type of insulin) 7 units sq before meals or after meals. A review of the MAR indicated [REDACTED]. Resident #22 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. On 5/4/14 at 11:30am a nurse documented "unable to complete Accu-check, no strips, supervisor aware. Resident #23 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #24 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation dated 4/2/14 revealed that no strips were available at 4:30 PM or 9:00pm and that the director of nursing was contacted. Resident #25 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #27 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed 4/2/14 "no Accu-check strips, held [MEDICATION NAME] (long-acting insulin) unable to check blood sugar. Resident #28 had an order for [REDACTED]. Sliding scale insulin coverage was ordered. A review of the MAR indicated [REDACTED]. Resident #29 had an order for [REDACTED]. On 4/2/14, a nurse documented that the testing strips were not available and that the [MEDICATION NAME] was held (not given). Resident #30 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #31 had an order for [REDACTED]. Resident #32 had an order for [REDACTED]. On 4/2/14, a nurse documented that the testing strips were not available and that the [MEDICATION NAME] was held (not given). Resident #33 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #34 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #35 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation dated 4/1/14 at 11:30am showed that no testing strips were available and that the DON was aware. On 4/2/14 at 11:30am, 4:30pm and 9:00pm nursing again wrote that no testing strips were available and that the DON was aware. On 4/28/14, nursing again documented that the testing strips were unavailable and that the DON was aware. Resident #36 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #37 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #38 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #39 had an order for [REDACTED]. Resident #41 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #42 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #43 had an order for [REDACTED]. Resident #44 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #45 had an order for [REDACTED].#45 received two different types of insulin, [MEDICATION NAME] 20 units at bedtime and [MEDICATION NAME] 70/30, 10 units, 30 minutes prior to a meal. A review of the MAR indicated [REDACTED]. Resident #47 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #49 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #50 had an order for [REDACTED]. A review of the MAR indicated [REDACTED] Resident #51 had an order dated 4/27/14 for Accu-checks before meals and at bedtime with [MEDICATION NAME] sliding scale insulin coverage. A review of the MAR indicated [REDACTED]. Resident #52 had an undated order for Accu-checks before meals and at bedtime. Sliding scale insulin coverage was ordered. A review of the MAR indicated [REDACTED]. Nursing documented that management was aware of the missing supplies on 5/4/14, and that the DON was aware of the missing supplies on 5/11/14 and 5/16/14. Resident #53 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed that the DON was aware of the missed Accu-checks due a lack of testing supplies on 4/2/14, 4/10/14 and 5/15/14 and that the supervisor was aware on 5/4/14. Resident #54 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed that the DON was notified of the missing testing supplies on 4/1/14, 4/2/14, 4/11/14, 4/30/14, 5/1/14, and 5/19/14. On 5/4/14 at 11:30 nursing documented that the supervisor was aware of the missing supplies. On 5/4/14 at 4:30pm, nursing documented that management was notified of the missing Accu-check supplies. Resident #55 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Nursing documented that either the DON, management and/or the nursing supervisor was notified of the missing supplies on 4/2/14, 5/1/14, 5/4/14, 5/4/14, 5/11/14 and 5/19/14. Resident #57 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed notification of the missing supplies to the DON, supervisor and/or management staff on 4/1/14, 4/2/14, 4/27/14, 5/1/14, 5/4/14, 5/11/14 and 5/16/14. Resident #58 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the nursing documentation revealed entries on 4/1/14 and 4/2/14 that in-house administration was aware of the missing supplies. Resident #59 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]. Resident #60 had an order for [REDACTED]. A review of the MAR indicated [REDACTED]

Based on observation, staff interview, clinical record reviews and review of the Quality Assessment and Assurance (QAA) committee meeting minutes, the QAA committee failed to identify, develop and implement an action plan to correct an identified issue regarding the availability of blood glucose monitoring supplies. Per staff interviews and clinical record reviews, a member of the QAA committee, the Director of Nursing, was aware of the issue with the blood glucose monitoring supplies and did not report the issue to the QAA committee. This deficient practice affected 60 of 67 total residents with physician orders [REDACTED]. (#3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 41, 42, 43, 44, 45, 47, 49, 50, 51, 52, 53, 54, 55, 57, 58, 59, 60, 61, 62, 63, 64, 66, 67, 69, 70). This failure of the QAA committee led to a finding of Immediate Jeopardy on 5/22/14. Staff interviews were conducted and clinical records were reviewed for all 67 residents with orders for blood glucose monitoring. It was determined that the facility failed to conduct blood glucose monitoring for 60 residents during 24 days in April 2014, and 17 days in May of 2014. Immediate Jeopardy was determined to have begun dating back to April 2, 2014. Please see evidence at F281, F282 and F329. Immediate Jeopardy was removed on 5/23/14 at 2:30 PM when the facility provided and implemented an acceptable credible allegation of compliance. An emergency meeting of the QAA committee was conducted and an action plan developed outlining system changes and monitoring plans. The facility remains out of compliance at a lower severity and scope of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure newly outlined systems were put in place, monitored and were effective. The findings are: On 5/21/14 at approximately 10:32am, during an observation of the facility's three (3) medication rooms it was discovered that there was not a supply of lancets or blood sugar testing strips stored for nurses to access in either of these rooms. An observation was conducted of the central supply and revealed that there were no blood sugar testing supplies stored. Interview with the Central Supply Staff at the time of observation revealed that all blood sugar supplies were kept in the Director of Nursing's (DON's) office. On 5/21/14 at approximately 10:40am, an observation was made of blood sugar testing supplies being kept in the DON's office. There were 9 boxes (100 count each) of lancets and 2 boxes (50 per box) of blood sugar strips available. An interview was conducted with the DON during the observation which revealed that she distributes lancets and blood sugar strips according to the number of residents that require checks. The DON revealed that she goes around to the stations at least twice a day and as needed to distribute the number of blood sugar testing supplies that are required. The DON revealed that this measure was put into place because of staff wastefulness and supplies disappearing. After hours if strips are required or have run out, the DON stated that staff were aware to contact her to come pass out more supplies. In the case of emergencies the DON revealed that she lives relatively close to the facility and can get to the facility in less than 10 minutes. She confirmed that there was definitely a breakdown in communication with staff and the facility did not have an effective protocol in place at the time. On 5/21/14 at approximately 10:50am an interview was conducted with Licensed Practical Nurse B (LPN B). LPN B revealed that she gets a supply of lancets and blood sugar strips directly from the DON's office. LPN B revealed that if she runs out of diabetic testing supplies after hours during her shift, that the DON has to be called at home to come to the facility and give out more supplies. LPN B revealed that there was no effective protocol for obtaining supplies in emergency situations. LPN B reported that approximately a week ago she had an emergency with a resident's levels needing to be rechecked, but that she was unable to recheck because she did not have enough lancets or blood sugar strips. Staff B revealed that she documented on the resident 's Medication Administration Record [REDACTED]. On 5/21/14 at approximately 10:55am, an interview conducted with LPN C revealed that supply of lancets and blood sugar test strips are obtained from the DON when supplies are needed. The DON comes around and gives nurses a supply according to the number of residents that require blood sugar testing. Staff C revealed that there was not any blood sugar supplies kept for the nurses to access, except for when the DON was on site. On 5/21/14 at approximately 11:00am, an interview conducted with LPN D revealed that she has run out of lancets and blood sugar test strips often and had no access to get more. LPN D revealed that the DON keeps a supply of lancets and blood sugar test strips locked in her office and the supplies are only available through her. LPN D revealed that she has had to use flex pens instead of using lancets to stick the resident 's finger to test their blood sugar levels at times because she did not have access to supplies. LPN D revealed that she could recall several times residents missed blood sugar testing as ordered dating back for at least 2 months. LPN D revealed that the nurses were only given enough supplies for the residents that have blood sugar testing ordered not considering the fact that re-checks may have to be done or emergency situations could occur. LPN D revealed that management is well aware of nurses not having access to blood sugar testing supplies and told the staff it was because of the facility's budget. On 5/21/14 at approximately 11:08am, an interview conducted with Unit Manager H (Staff H) revealed that blood sugar testing supplies are kept in the DON's office and administered to nursing according to the number of residents' that require blood sugar testing. Staff H revealed that she does not have a key to get to supplies for nurses when they run out of supplies. Staff H revealed that if the DON is not in the building, she could call her to come to the facility to give more supplies. On 5/21/14 at approximately 11:15, an interview conducted with LPN E, revealed that she had run out of testing supplies that morning. LPN E stated that she had requested blood sugar testing supplies twice this morning (5/21/14) and had not received the supplies. She was unable to perform any Accu-checks prior to meals for residents with orders for blood sugar testing before meals. LPN E revealed that some residents had already begun their meals. LPN E revealed that she had asked LPN F on the unit to borrow some supplies but LPN F was out of supplies as well. LPN E revealed they have informed their unit managers of not having enough supplies to complete blood sugar testing for the morning of 5/21/14. LPN E revealed that supplies for blood sugar testing are provided to nurses based on the number of residents that require testing per shift. LPN E revealed that this was an ongoing issue. LPN E revealed that if supplies run out they were instructed by the DON to call her at home so she can come in and provide them with more supplies. An observation made of LPN E's medication cart revealed a count of 15 lancets and zero (0) blood sugar strips. On 5/21/14 at approximately 11:25am, and interview conducted with LPN F, revealed that this nurse was currently out of blood sugar testing supplies. LPN F revealed that there were no supplies on either medication cart on the unit at the time of the interview and that a request had been made to the DON twice for supplies this morning (5/21/14). LPN F explained that the 11:00pm-7:00am shift did not have supplies either and that as a result some residents did not receive their morning blood sugar testing as ordered. LPN F revealed that this was an ongoing problem and that the unit managers as well as the DON were aware of the fact that blood sugar testing supplies ran out all the time. LPN F revealed that this has been occurring for months and that the administration has failed to do anything about making testing supplies available. LPN F revealed there have been times in the past when she did not have lancets; so instead, she used insulin syringes and flex pens to stick the resident's finger. She also revealed that she has not completed her blood sugar testing for residents that require it at the time of this interview. She revealed that blood sugar testing would have to be completed post meal for those residents that had already received their trays and begun eating. An observation made of LPN F's medication cart revealed a count of 5 lancets and zero (0) blood sugar strips. On 5/21/14 at approximately 11:50am, an interview conducted with Staff J, Unit manager, revealed that she did not have access to blood sugar supplies because they were kept in the DON's office. Staff J revealed that the nurses request supplies needed for blood sugar testing directly from the DON. The DON makes rounds at which times she provides the nurses with blood sugar testing supplies. Staff J also revealed that the issue of staff running out of blood sugar testing supplies has been brought to the attention of the administration on several occasions. On 5/21/14 at approximately 3:30pm, an interview conducted LPN G, revealed that the DON counts out the blood sugar testing strips supplies to nurses, and that sometimes it does not include enough for errors. She revealed that it was an ongoing problem with not having enough supplies to complete blood sugar testing as ordered. She stated the DON had told her she was on a budget and she has to stick to her budget or she will loose her job, that is why she keeps the supplies. She stated that one day when supplies to check blood glucose (sugar) were not available she had used a CNA's (certified nursing assistants) personal blood glucose machine to take the resident's blood glucose because she had 3 residents that were very brittle. Record reviews for nursing documentation related to missing diabetic testing supplies and DON / management notification was conducted for all 67 sampled residents. Documents reviewed included Physician Orders, Medication Administration Records (MARs), and Nursing Notes. There was nursing documentation in multiple resident records dating back to 4/1/14 stating that the DON, management, administration and/or supervisor had been informed of missed blood sugar testing due to inadequate supplies. This documentation was as follows: 4/2/14: Nursing documented that the DON was notified for Residents #11, 12, 17, 18, 20, 24, 35, 53, 55, 57, 58, 62, 63, and 66. 4/10/14: The DON was notified - Resident #53 4/11/14: The DON was notified - Resident #5 4/13/14 and 4/17/14: The DON was notified - Resident #61 4/27/14: Weekend supervisor was notified for Resident #20 and 57 4/28/14: The DON was notified - Resident #35 4/30/14: The DON was notified - Resident #54 5/04/14: Supervisor or management documented as notified for resident #17, 20, 22, 52, 53, 54, 55, and 57. 5/1/14: The DON was notified - Resident #54, 55, and 57 5/11/14: The DON or management was notified - Resident #52, 55, 57, and 69 5/15/14: The DON was notified - Resident #53 5/16/14: The DON was notified - Resident #52 5/19/14: The DON was notified - Resident #54 On 5/22/14 at approximately 4:15pm, an interview was conducted with the assistant administrator regarding the Quality Assessment and Assurance committee (QAA). The assistant administrator stated the committee meets the first Monday of every month. She stated there have been no concerns brought to the QAA committee in the last several months related to supplies. She stated there have been meetings and stand up meetings undocumented with the administrator about supplies. She stated the staff has stated in the past that the supplies were not there and they are found to have them in the cart such as blood glucose monitoring supplies. When asked what would be the disciplinary action against the nurse that did not do the blood glucose checks when supplies were available, she stated, "Consulate had a series of actions including write ups. It is expected that any discrepancies would be brought to the attention of the administrator or the director of nursing". The QAA meeting minutes were provided by the facility for review. A review of the QAA identifies the assistant administrator as the point person. Other staff in attendance included, the Administrator, Assistant Director of Nursing (ADON), Director of Nursing (DON), Social Services, the Dietary Manager, Medical Director, Maintenance, Activities, plus others. A review of the minutes from April 2014 was conducted. There was no mention of blood glucose supply issues. The meeting minutes from the May 5, 2014 meeting have not been typed and place in the book at this time. On 5/23/14 at approximately 9:30 AM a follow-up interview with the assistant administrator was conducted after the facility was informed of the finding of Immediate Jeopardy. She stated she has been working at the facility for about 6 months and the QAA has been her duty. The assistant administrator was asked how issues were brought to the QAA committee and how the committee decided what projects were going to be done? The assistant administrator stated that when issues are brought forward we come together and make a 4 point plan and we monitor those issues to be addressed. When we are having meetings or stand-up we can determine at that time if we need to make a plan of action. She stated she is constantly on the floor talking with the staff to see if they have any concerns. She understands that staff are more comfortable in talking to certain people. She stated the ADON is always on the floor checking. She stated the Administrator also talks with staff and listens to concerns. She stated that they had a meeting with the night shift in the last month or so, with corporate in attendance and no one had a concern. Do you feel the blood glucose monitoring issue is something the DON or ADON should have brought to QAA? The assistant administrator stated, "Oh yes." An interview with the director of nursing was conducted on 5/23/14 at approximately 9:51 AM. When asked if she was part of the QAA committee she stated, "Yes". When asked how do you communicate with the QAA committee if there are quality issues discovered, "I would initiate by going through the administrator and then contact the medical director, via text or phone call to let them know my concerns. I am also in contact with my assistant and then it is brought to the committee " . The DON stated that she was keeping the blood glucose lancets and testing strips in her office and was dispersing them out. The DON stated that she changed the process because when I started here, there was a free for all. The central supply person was putting the blood glucose supplies out on the shelves and we were running out, so I started to keep them in my office and dispersing them out. The unit managers were to let the staff know that they could come to me after the clinical meetings and I would give them the needed supplies. They are labeled in my office and I give them out twice a day. On the weekends I would put out more because I don't want to come back. She stated the unit managers on one occasion, maybe three weeks ago, said there was a nurse that documented the blood glucose was not done because there were no supplies. When asked who had been monitoring this since the reported incident she stated the unit managers should have been monitoring this and it was the responsibility of the unit managers to audit the Medication Administration Records (MARS) and they are to bring any concerns or issues to the DON. She stated the unit managers did not bring the issue to her; I would have expected them to report this. The Administrator was unavailable for interview throughout the survey. Credible Allegation of Compliance The facility's assistant administrator and Director of Nursing were notified of Immediate Jeopardy on 5/22/14 at 3:30 PM. The facility provided a credible allegation of compliance on 5/23/14 at 2:30 PM. The following interventions were put into place by the facility to remove the immediate Jeopardy. The facility conducted an audit of current in house residents with orders for blood glucose (sugar) monitoring. Current residents were assessed for signs and symptoms of hyper/[DIAGNOSES REDACTED]. The facility medical director was notified that the blood glucose monitoring was not done per physicians orders on residents and of the current plan for resolution and monitoring. The regional director of clinical services verified that adequate blood glucose monitoring supplies were available in the facility and on each medication cart and that each resident has an individual glucometer and a bottle of test strips at bedside. A supply of Lancets will be kept on each medication cart and in the medication room on each unit. An audit was done of residents with [DIAGNOSES REDACTED]. The assistant director of clinical services/designee was educated on the process for checking adequacy of blood glucose monitoring supplies. Nurses were re-educated on documenting results of blood glucose results obtained and how to document resident refusal as well as educating the residents on risks of not allowing the test. Nurses were re-educated that is is not acceptable not to follow physicians orders for blood glucose monitoring. On 5/23/14 39 of the staff nurses had received the education. Monitoring will be ongoing. The medication administration records of residents with orders for blood glucose monitoring will be audited each shift for evidence of documentation of results and notification of the attending physician for 1 week and the daily for 4 weeks and then weekly for 3 months. The results of the audits will be reviewed daily by the executive director/designee. A monitoring tool was designed to reflect the above audits. The central supply clerk will order blood glucose supplies weekly based on resident use. The executive director/designee will ensure the order is submitted timely. The facility held an ad hoc performance improvement meeting to review and implement this allegation of compliance on 5/23/14 and included the medical director. Immediate Jeopardy was removed on 5/23/14 at 2:30 PM when interviews with nursing staff revealed awareness of the process for blood glucose monitoring, and that they had received the in-service education. The nurses also revealed a supply of blood glucose monitoring supplies available on each medication cart and in each medication room on all three stations.

Based on observations, interviews, and record reviews the facility failed to ensure the residents received necessary care and treatment according to professional standards of quality to prevent the development and promote the healing of avoidable pressure ulcers for 5 of 5 sampled residents. (#1, #2, #3, #4, and #5) The findings include: Professional Standard of Care is defined in Chapter 766.102 as, " the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers " . The Florida Nurse Practice Act, Chapter 464.003 defines the " practice of professional nursing " as " the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner " practice of practical nursing " as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirmed and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. 1. A review of the medical record for resident #1 revealed resident #1 has an unstageable pressure ulcer to the coccyx and 3 deep tissue injuries to the left inner, middle, and lateral aspects of the heel. The resident went out to the hospital on [DATE] for an upper respiratory infection and returned on 3/19/11 with the pressure ulcers to her coccyx and left heel. Documentation shows starting 3/28/11 through 4/4/11 that the coccyx wound is draining a moderate amount of serous yellow drainage and states there is no odor. Observation of the wound on 4/7/11 revealed there is a very strong foul smell coming from the wound. The resident's care plan stated the resident's physician should be notified if wound got worse and the resident should be repositioned at least every 2 hrs. The medical record contained no communication with the physician of the continued foul smelling drainage. Documentation on re-admission from the hospital on [DATE] stated resident #1's pressure ulcer to the coccyx was a stage 4 and the measurements were 4 cm. X 4 cm. A review of resident #1's skin grid revealed, on 3/21/11 the wound was documented as unstageable and the measurements were 6.1 cm. in length, 6.5 cm. in width, and 1 cm. deep with a surface area of 39.65 cm. There is no documentation that the resident's doctor was notified the wound was getting worse. On 3/28/11 the wound is still unstageable and is documented to be 6 cm. in length, 7 cm. in width, and 1 cm. deep with a surface area of 42 cm. On 4/4/11 the wound is still unstageable with 6 cm. in length, 7 cm. width, and 1 cm. deep with surface area of 42 and there is slough tissue around the wound, the wound bed is red with undermining at 12:00 and the length of the undermining is 1.5 cm., no tunneling, a moderate amount of serous yellow drainage, and no odor. The resident's wound to the left heel had red areas but no open areas on admission 3/19/11. A review of resident #1 ' s skin grid of the left heel revealed the resident ' s wound had gotten worse. The documentation for the wound on the left inner heel stated that on 3/21/11 the wound is a deep tissue injury with measurements of 0.4 cm. in length, 1.3 cm. in width, 0 depth, and surface area of 0.52. On 4/4/11 deep tissue injury, 0.4 cm. in length, 1.3 cm. width, 0 depth, and surface area of 0.52 cm. The documentation for the wound on the resident's left middle heel dated 3/21/11 shows deep tissue injury, 1.2 cm. in length, 2.5 cm. width, 0 depth, with a surface area of 3 cm. On 4/4/11 deep tissue injury, 1.2 cm. in length, 2.5 cm. width, 0 depth, and surface area of 3 cm. Documentation of the wound to the resident's left lateral heel on 3/21/11 stated deep tissue injury, 1 cm. in length, 3.2 cm. in width, 0 depth, and surface area of 3.2 cm. On 4/4/11 documentation stated, deep tissue injury, 1 cm. in length, 3.2 cm. width, 0 depth, and surface area of 3.2 cm. Documentation on all the days mentioned above revealed the wounds were purple in color, wound edges are firm, no undermining, tunneling, drainage or odor. The wounds were measured weekly and continued to reveal an increase in wound size and the wound to the coccyx had foul odor with a moderate amount of yellow drainage but there is no documentation noted in resident #1's medical record the doctor was notified the wounds were getting worse. On 4/7/11 at 11:05 a.m. an interview with the wound care nurse was conducted. The nurse stated resident #1 went to the hospital in March with a stage III pressure ulcer to the coccyx and returned on 3/19/11 with an unstageable pressure wound to the coccyx and a stage III pressure wound to the heel. The wound care nurse stated she is providing wound care daily to the resident. The wound care nurse stated there is a protocol that is followed for wound care with pressure ulcers and if the treatment is not working and ulcer gets worse then the doctor is notified. The nurse stated that she feels like the resident is being turned and repositioned as ordered. The surveyor asked the nurse, if the resident is being provided care, why did the wounds continue to get worse after admission on 3/19/11, and why the resident's doctor was not notified. The nurse stated, " I did talk to the hospice nurse about the resident's wounds on 4/5/11 and the hospice nurse said ok so I was going to let hospice handle it. " The wound care nurse also stated, " there have been some problems with the residents, who have pressure wounds, not being changed and repositioned like they should and there were times she has found the residents wet and the dressings would be gone when she came to do dressing changes. " The wound care nurse stated that she reported the incidents to the Unit Managers and the resident's nurse. The wound care nurse stated she started checking the residents with wounds more often and changed their dressing changes to daily. On 4/7/11 at 12:10 p.m. An interview with the aide caring for the resident was conducted. The aide stated, " the residents are to be turned at least every 2 hrs. but if the resident has a bad wound, they were instructed to turn the resident every hr. " The aide stated if she noted the dressing was missing, she would notify the nurse caring for the resident or the wound care nurse. 4/7/11 at 12:30 p.m. an interview was conducted with resident #1's daughter. The daughter is concerned because the wounds are getting worse. The daughter stated she is in the facility 3 times a week for several hrs. and the resident was not turned every hr. 4/7/11 at 2:00 p.m. observation of the resident's wounds and wound care were made. Wound care was provided as ordered. The wound does appear as measured on 4/4/11. There is a moderate amount of yellow drainage and a strong foul odor coming from the wound. 2. A record review was conducted on 4/7/11 for resident #2. This record review revealed, resident #2 is a bilateral above the knee [MEDICAL CONDITION] and has a stage III pressure ulcer to the coccyx. The resident was readmitted to the facility with the coccyx wound on 2/17/11. The skin grid documentation for the resident revealed that on 3/7/11 the resident had a stage III pressure ulcer and the measurements were 2.7 cm. in length, 2.1 cm. in width, 2.1 cm. depth, and a surface area of 5.67 cm. the wound bed color is red and there is tunneling at 9:00 of 2.6cm. in length, and undermining at 12:00 of 2.3 cm. in length, there is small amount of serosanguinous pink/red drainage with an odor. On 3/14/11 the wound appears to have gotten worse and documentation stated the wound is still a stage III, is 3 cm. in length, 1.6 cm. in width, 2.6 cm. in depth, with a surface area of 4.8 cm. the wound bed is red, there is undermining at 12:00 of 3 cm. in length and tunneling at 9:00 of 3.2 cm. in length, the drainage is serosanguinous pink/red with odor. On 3/21/11 the wound is still a stage III, 2.6 cm. in length, 2 cm. in width, and 2.5 cm. in depth, with a surface area of 5.2, the wound bed is red, the drainage is serosanguinous small amount of pink/red drainage with odor, there is undermining of 3cm. in length, and tunneling of 2.8 cm. in length ( no documentation as to exactly where the tunneling and undermining is). On 3/28/11 the wound is stage III, 2.8 cm. in length, 2.8 cm. in width, 2.1 cm. depth, and the surface area is 7.84 cm. the wound bed is red, again the documentation is missing for exactly where the undermining and tunneling are, but the undermining length is 2.6 cm. and the tunneling length is 2.8 cm. On 4/4/11 documentation shows the resident's wound is still a stage III, 2.8 cm. in length, 1.5 cm. in width and 2.3 cm. depth, the surface area of the wound is 4.20 cm., the wound bed is red, the undermining is 3.1 cm. in length and tunneling is 2.8 cm. in length and there is a moderate amount of serosanguinous drainage pink/red with odor present ( again there is no documentation where the undermining and tunneling are). The wound was cultured on 2/8/11 and showed no growth for bacteria. The care plan stated the resident's physician should be notified if wound got worse and the resident should be repositioned every 2 hours. The resident is being seen by the wound care center monthly with the facility providing the care between visits to the wound care center. On 4/7/11 at 11:50 a.m. an interview was conducted with the wound care nurse. The nurse stated resident #2 went to the hospital in February and returned from the hospital with a stage III pressure ulcer to the coccyx. The wound care nurse stated she is providing wound care daily to the resident. The wound care nurse stated there is a protocol that is followed for wound care with pressure ulcers and if the treatment is not working and ulcer gets worse then the doctor is notified. The nurse stated that she feels like the resident is being turned and repositioned as ordered. The wound care nurse stated, " again, there have been some problems with the residents, who have pressure wounds, not being changed and repositioned like they should and there were times she has found the residents wet and the dressings would be gone when she came to do dressing changes. " The wound care nurse stated she found resident #2 soiled yesterday and the dressing was soiled with feces for quite some time prior to her finding this. The wound care nurse stated that she reported the incidents to the Unit Managers and the resident's nurse. On 4/7/11 at 2:40 p.m. an interview was conducted with the nurse caring for the resident. This interview revealed that the resident has been found wet from incontinence. The nurse stated, " the resident uses the urinal and will spill some occasionally. " The nurse stated she has talked to the aides about making sure the resident is turned frequently and is not wet. On 4/7/11 at 5:10 p.m. an interview with the CNA caring for the resident was conducted. The aide stated that the resident should be turned every 2 hrs. or sooner if needed. On 4/7/11 at 5:30 p.m. an interview with the resident's daughter was conducted. The daughter stated she was here all day on Sunday and the resident was left sitting up in his chair all day. The daughter stated no one came in to change or re-position the resident the entire time she was in the facility. On 4/7/11 at 2:30 p.m. observations were made of the resident sitting in his wheelchair. On 4/7/11 at 3:30 p.m.observations of the resident revealed the resident was in bed on his left side facing the door. On 4/7/11 at 5:30 p.m. resident was observed in the same position he was in at 3:30 p.m. On 4/7/11 at 6:30 p.m. resident was observed in the same position he was in at 5:30 p.m. On 4/7/11 at 6:45 p.m. observation of wound care for resident #2. The resident's diaper was wet when the nurse went to provide wound care. The resident's bandage was soiled and coming off. There was a foul odor noted during dressing change. The resident was pre-medicated with pain medication about an hour prior to the dressing change, but still complained of pain during the dressing change. The nurse followed infection control measures during dressing change. 3. On 4/7/11 a record review was conducted for resident #3. This record review revealed the resident is a quadriplegic with an unstageable pressure ulcer to the coccyx. In February the resident's wound was a stage II and the most current documentation on 4/4/11 stated the resident's wound has gotten worse and is now unstageable. The care plan for this resident stated the resident has a stage II pressure ulcer and should be repositioned at least every 2 hrs. and to notify physician if wound gets worse. This resident was transferred to the hospital for respiratory distress this morning. Review of the skin grids for resident #3 revealed that on 3/8/11 the resident's wound was unstageable and the length of the wound was documented 4.2 cm. in length, 4.5 cm. in width, and 0.1 depth, with a surface area of 18.9 cm., there is slough tissue with a yellow wound bed, no tunneling or undermining, and a large amount of serous yellow drainage and no odor. On 3/15/11 the wound is Unstageable, 4.5 cm. in length, 5.1 cm. width, 0.1 cm. depth, with a surface area of 22.95 cm., slough tissue, yellow wound bed, no tunneling and undermining, small amount of serous yellow drainage without odor. On 3/22/11 the wound is still unstageable, 4.5 cm. in length, 5.5 cm. in width, 1 cm. in depth, and a surface area of 24.75 cm., with slough tissue, yellow wound bed, no tunneling or undermining, and a small amount of serous yellow drainage. On 3/29/11 the wound is unstageable, 4.5 cm. in length, width is 5.5 cm., 1 cm. depth, and a surface area of 24.75 cm., with slough tissue, yellow wound bed, no tunneling or undermining, moderate amount of serous yellow drainage. On 4/4/11 the wound is unstageable, 4.4 cm. in length, 5 cm. in width, 1 cm. depth, with a surface area of 22 cm., there is slough tissue, with red and yellow wound bed, no tunneling or undermining, moderate amount of serous yellow drainage. There is no evidence that when the wound got worse, the doctor was notified as care planned. The care plan stated the resident's wound was still a stage II. On 4/7/11 at 11:50 a.m. the The wound care nurse stated she is providing wound care daily to the resident. The wound care nurse stated there is a protocol that is followed for wound care with pressure ulcers and if the treatment is not working and ulcer gets worse then the doctor is notified. The wound care nurse stated, " again, there have been some problems with the residents, who have pressure wounds, not being changed and repositioned like they should and there were times she has found the residents wet and the dressings would be gone when she came to do dressing changes. " The wound care nurse stated that she reported the incidents to the Unit Managers and the resident ' s nurse. The wound care nurse stated she started checking the residents with wounds more often and changed their dressing changes to daily. The wound care nurse stated that she felt like the resident's wound got worse due to the resident not being changed when soiled and repositioned as directed at least every 2 hrs. 4. On 4/7/11 a record review was done for resident #4. This record review revealed the resident is incontinent of bowel and bladder and is a total assist due to a left above the knee amputation and the resident is confused and does not communicate. Documentation also revealed, the resident has a stage II pressure ulcer to the coccyx and a deep tissue injury pressure ulcer to the right heel. Documentation on the resident's skin grid dated 4/5/11 stated the resident has a deep tissue injury to the right heel that was not present on admission. On 4/5/11 the length of the wound is 6 cm. the width is 7.3 cm. and the depth is 0, the surface area of the wound is 43.8 cm., there is no undermining or tunneling and no drainage. The skin grid documentation for the pressure ulcer to the coccyx stated the wound is a stage II and is 5 cm. in length, 7cm. in width, 0 depth, with a surface area of 35 cm., there is no tunneling or undermining and no drainage or odor. The weekly skin sweeps stated there are no new skin impairments. On 4/7/11 at 11:50 a.m. an interview with the wound care nurse was conducted. The wound care nurse stated that resident was getting a bath and on 4/5/11 and the aide and nurse caring for the resident called her in to look at the wound to the resident's coccyx (stage II). The wound care nurse stated she then did a skin sweep to check the resident for any additional skin changes and found another stage II pressure wound on the resident's right heel. The wound care nurse stated the wound is considered an in-house wound which means the resident acquired the wound while staying in the facility. The resident's wound care is done every 3 days or as needed. The wound care nurse is not sure about the resident being left incontinent too long because she had no contact with the resident prior to 4/5/11. The wound care nurse stated there is a protocol that is followed for wound care with pressure ulcers and if the treatment is not working and ulcer gets worse then the doctor is notified. The nurse acknowledged the resident was not on a pressure relieving mattress as care planned. On 4/7/11 at 5:00 p.m. an interview was conducted with the resident's nurse. The resident's nurse stated that the resident is total care and needs to be turned every 2 hrs. due to a pressure ulcer on her coccyx. On 4/7/11 at 5:15 p.m. an interview with the aide caring for the resident. The aide stated the resident should be turned every 2 hrs. or sooner because she has a pressure ulcer and she is total assist. On 4/7/11 at 6:00 p.m. an interview was conducted with the resident's daughter. The resident's daughter stated that her mother is not turned on a regular basis. The daughter stated she has stayed all day some days and no one came and turned her mother all day. On 4/7/11 at 2:15 p.m. Observations of resident #4 revealed the resident is not on a pressure relieving mattress. The resident is sitting up in bed at a 40 degree angle on her back. The resident's heels are not floating and are flat on the mattress. On 4/7/11 at 6:10 p.m. resident is still in the same position she was in at 4:15 PM. On 4/7/11at 6:30 p.m. resident is still in the same position she was in at 4:15 PM. 4/7/11 at 6:30 p.m. observations of wound care were made and the care was given as ordered. The wound is as documented on 4/5/11. 5. On 4/7/11 a record review for resident #5 was done. This record review revealed the resident was not initially admitted with the pressure ulcer. The resident was sent out to the hospital on [DATE] and when the resident came back from the hospital on [DATE] the resident had a stage II pressure ulcer to the coccyx. Review of skin grid documentation for resident #5 revealed the length of the wound is 2 cm. and the width of the wound is 1.5 cm. and the depth is 0, there is no tunneling or undermining and no drainage. The resident's care plan stated the resident should be on a pressure reducing mattress and the resident should be changed and repositioned every 2 hrs. On 4/7/11 at 5:15 p.m. an interview with resident #5 was conducted. During the interview the resident stated the staff do not turn the resident every 2 hrs. "I wish they would turn me every 2 hrs." The resident stated that the resident can't turn and is dependent on staff for care. The resident stated, " I usually wait for 20-30 minutes before someone will change me after I have soiled my diaper. " On 4/7/11 at 11:50 a.m. An interview with the wound care nurse was conducted. The nurse stated that the resident was recently in the hospital and was admitted with the pressure ulcer to the coccyx. The nurse acknowledged the resident was not on a pressure relieving mattress as care planned. The wound care nurse stated there is a protocol that is followed for wound care with pressure ulcers and if the treatment is not working and ulcer gets worse then the doctor is notified. On 4/7/11 at 5:20 p.m. an interview was conducted with the nurse caring for the resident. The nurse stated the resident is total care and needs to be turned every 2 hours. On 4/7/11 at 5:25 p.m. an interview with the aide caring for resident #5 revealed the aide is aware the resident is total care and needs to be turned every 2 hrs. On 4/7/11 at 5:10 p.m. Observations of resident #5 were made at this time. The resident is not on a pressure relieving mattress and the resident is in bed on her back with a diaper on. On 4/7/11 at 6:30 p.m. observation of the resident at this time revealed the resident is in the same position she was at 5:10 p.m. On 4/7/11 at 7:00 p.m. observations of the resident at this time revealed the resident is in the same position she was at 6:30 p.m.

Based on record review, observation, and interview the facility failed to ensure the resident's care plan was followed for 5 of 5 sampled residents with pressure ulcers. (#1, #2, #3, #4, and #5) The findings include: 1. A review of the medical record for resident #1 revealed resident #1 has an unstageable pressure ulcer to the coccyx and 3 deep tissue injuries to the left inner, middle, and lateral aspects of the heel. The resident went out to the hospital on [DATE] for an upper respiratory infection and returned on 3/19/11 with the pressure ulcers to her coccyx and left heel. Documentation shows starting 3/28/11 through 4/4/11 that the coccyx wound is draining a moderate amount of serous yellow drainage and states there is no odor. Observation of the wound on 4/7/11 revealed there is a very strong foul smell coming from the wound. The resident's care plan stated the the care plan is to be evaluated every 2 weeks, and the physician should be notified if wound got worse. The care plan also states the resident should be repositioned at least every 2 hrs. The medical record contained no communication with the physician of the continued foul smelling drainage. On 4/7/11 at 11:05 a.m. an interview with the wound care nurse was conducted. The nurse stated resident #1 went to the hospital in March with a stage III pressure ulcer to the coccyx and returned on 3/19/11 with an unstageable pressure wound to the coccyx and a stage III pressure wound to the heel. The wound care nurse stated she is providing wound care daily to the resident. The wound care nurse stated there is a protocol that is followed for wound care with pressure ulcers and if the treatment is not working and ulcer gets worse then the doctor is notified. The nurse stated that she feels like the resident is being turned and repositioned as ordered. The surveyor asked the nurse, if the resident is being provided care, why did the wounds continue to get worse after admission on 3/19/11, and why the resident's doctor was not notified. The nurse stated, " I did talk to the hospice nurse about the resident's wounds on 4/5/11 and the hospice nurse said ok so I was going to let hospice handle it." The wound care nurse also stated, "there have been some problems with the residents, who have pressure wounds, not being changed and repositioned like they should and there were times she has found the residents wet and the dressings would be gone when she came to do dressing changes." The wound care nurse stated that she reported the incidents to the Unit Managers and the resident's nurse. The wound care nurse stated she started checking the residents with wounds more often and changed their dressing changes to daily. 4/7/11 at 12:30 p.m. an interview was conducted with resident #1 ' s daughter. The daughter is concerned because the wounds are getting worse. The daughter stated she is in the facility 3 times a week for several hrs. and the resident was not turned every hr. 4/7/11 at 2:00 p.m. observation of the resident's wounds and wound care were made. Wound care was provided as ordered. The wound does appear as measured on 4/4/11. There is a moderate amount of yellow drainage and a strong foul odor coming from the wound. 2. A record review was conducted on 4/7/11 for resident #2. This record review revealed, resident #2 is a bilateral above the knee [MEDICAL CONDITION] and has a stage III pressure ulcer to the coccyx. The resident was readmitted to the facility with the coccyx wound on 2/17/11. The skin grid documentation for the resident revealed that on 3/7/11 the resident had a stage III pressure ulcer and the measurements were 2.7 cm. in length, 2.1 cm. in width, 2.1 cm. depth, and a surface area of 5.67 cm. the wound bed color is red and there is tunneling at 9:00 of 2.6cm. in length, and undermining at 12:00 of 2.3 cm. in length, there is small amount of serosanguinous pink/red drainage with an odor. On 3/14/11 the wound appears to have gotten worse and documentation stated the wound is still a stage III. On 4/4/11 documentation shows the resident's wound is still a stage III, 2.8 cm. in length, 1.5 cm. in width and 2.3 cm. depth, the surface area of the wound is 4.20 cm., the wound bed is red, the undermining is 3.1 cm. in length and tunneling is 2.8 cm. in length and there is a moderate amount of serosanguinous drainage pink/red with odor present (there is no documentation where the undermining and tunneling are). The care plan stated the resident's physician should be notified if wound got worse and the resident should be repositioned every 2 hours. The resident is being seen by the wound care center monthly with the facility providing the care between visits to the wound care center. On 4/7/11 at 11:50 a.m. an interview was conducted with the wound care nurse. The nurse stated resident #2 went to the hospital in February and returned from the hospital with a stage III pressure ulcer to the coccyx. The wound care nurse stated she is providing wound care daily to the resident. The wound care nurse stated there is a protocol that is followed for wound care with pressure ulcers and if the treatment is not working and ulcer gets worse then the doctor is notified. The nurse stated that she feels like the resident is being turned and repositioned as ordered. The wound care nurse stated, " again, there have been some problems with the residents, who have pressure wounds, not being changed and repositioned like they should and there were times she has found the residents wet and the dressings would be gone when she came to do dressing changes. " The wound care nurse stated she found resident #2 soiled yesterday and the dressing was soiled with feces for quite some time prior to her finding this. The wound care nurse stated that she reported the incidents to the Unit Managers and the resident's nurse. The wound care nurse stated she started checking the residents with wounds more often and changed their dressing changes to daily. 3. On 4/7/11 a record review was conducted for resident #3. This record review revealed the resident is a quadriplegic with an unstageable pressure ulcer to the coccyx. In February the resident's wound was a stage II and the most current documentation on 4/4/11 stated the resident's wound has gotten worse and is now unstageable. The care plan for this resident stated the resident has a stage II pressure ulcer and should be repositioned at least every 2 hrs. and to notify physician if wound gets worse. The care plan had not been updated to reflect the pressure ulcer was now unstageable. This resident was transferred to the hospital for respiratory distress this morning. On 4/4/11 the wound is unstageable, 4.4 cm. in length, 5 cm. in width, 1 cm. depth, with a surface area of 22 cm., there is slough tissue, with red and yellow wound bed, no tunneling or undermining, moderate amount of serous yellow drainage. There is no evidence that when the wound got worse, the doctor was notified as care planned. The care plan stated the resident's wound was still a stage II. 4. On 4/7/11 a record review was done for resident #4. This record review revealed the resident is incontinent of bowel and bladder and is a total assist due to a left above the knee amputation and the resident is confused and does not communicate. Documentation also revealed, the resident has a stage II pressure ulcer to the coccyx and a deep tissue injury pressure ulcer to the right heel. Documentation on the resident 's skin grid dated 4/5/11 stated the resident has a deep tissue injury to the right heel that was not present on admission. On 4/5/11 the length of the wound is 6 cm. the width is 7.3 cm. and the depth is 0, the surface area of the wound is 43.8 cm., there is no undermining or tunneling and no drainage. The skin grid documentation for the pressure ulcer to the coccyx stated the wound is a stage II and is 5 cm. in length, 7cm. in width, 0 depth, with a surface area of 35 cm., there is no tunneling or undermine and no drainage or odor. The weekly skin sweeps stated there are no new skin impairments. Review of the plan of care revealed interventions to evaluate the wounds every 2 weeks, notify the physician if no improvement noted. use pressure relieving mattress, and to reposition the resident every 2 hours. On 4/7/11 at 11:50 a.m. an interview with the wound care nurse was conducted. The wound care nurse stated there is a protocol that is followed for wound care with pressure ulcers and if the treatment is not working and ulcer gets worse then the doctor is notified. The nurse acknowledged the resident was not on a pressure relieving mattress as care planned. On 4/7/11 at 5:00 p.m. an interview was conducted with the resident's nurse. The resident's nurse stated that the resident is total care and needs to be turned every 2 hrs. due to a pressure ulcer on her coccyx. 5:15 p.m. an interview with the aide caring for the resident. The aide stated the resident should be turned every 2 hrs. or sooner because she has a pressure ulcer and she is total assist. On 4/7/11 at 6:00 p.m. an interview was conducted with the resident's daughter. The resident's daughter stated that her mother is not turned on a regular basis. The daughter stated she has stayed all day some days and no one came and turned her mother all day. On 4/7/11 at 4:15 p.m. Observations of resident #4 revealed the resident is not on a pressure relieving mattress. The resident is sitting up in bed at a 40 degree angle on her back. The resident's heels are not floating and are flat on the mattress. On 4/7/11 at 6:10 p.m. resident is still in the same position she was in at 4:15 PM. On 4/7/11at 6:30 p.m. resident is still in the same position she was in at 4:15 PM. 5. On 4/7/11 a record review for resident #5 was done. This record review revealed the resident was not initially admitted with the pressure ulcer. The resident was sent out to the hospital on [DATE] and when the resident came back from the hospital on [DATE] the resident had a stage II pressure ulcer to the coccyx. Review of skin grid documentation for resident #5 revealed the length of the wound is 2 cm. and the width of the wound is 1.5 cm. and the depth is 0, there is no tunneling or undermining and no drainage. The resident's care plan stated the resident should be on a pressure reducing mattress and the resident should be changed and repositioned every 2 hrs. On 4/7/11 at 5:15 p.m. an interview with resident #5 was conducted. During the interview the resident stated the staff do not turn the resident every 2 hrs. "I wish they would turn me every 2 hrs." The resident stated that the resident can't turn and is dependent on staff for care. The resident stated, " I usually wait for 20-30 minutes before someone will change me after I have soiled my diaper. " On 4/7/11 at 11:50 a.m. An interview with the wound care nurse was conducted. The nurse stated that the resident was recently in the hospital and was admitted with the pressure ulcer to the coccyx. The nurse acknowledged the resident was not on a pressure relieving mattress as care planned. On 4/7/11 at 5:10 p.m. Observations of resident #5 were made at this time. The resident is not on a pressure relieving mattress and the resident is in bed on her back with a diaper on. On 4/7/11 at 6:30 p.m. observation of the resident at this time revealed the resident is in the same position she was at 5:10 p.m. On 4/7/11 at 7:00 p.m. observations of the resident at this time revealed the resident is in the same position she was at 6:30 p.m.

Based on observations, interviews, and record reviews the facility failed to ensure the residents received necessary care and treatment to prevent the development and promote the healing of an avoidable pressure ulcers for 5 of 5 sampled residents. (#1, #2, #3, #4, and #5) The findings include: 1. A review of the medical record for resident #1 revealed resident #1 has an unstageable pressure ulcer to the coccyx and 3 deep tissue injuries to the left inner, middle, and lateral aspects of the heel. The resident went out to the hospital on [DATE] for an upper respiratory infection and returned on 3/19/11 with the pressure ulcers to her coccyx and left heel. Documentation shows starting 3/28/11 through 4/4/11 that the coccyx wound is draining a moderate amount of serous yellow drainage and states there is no odor. Observation of the wound on 4/7/11 revealed there is a very strong foul smell coming from the wound. The medical record contained no communication with the physician of the continued foul smelling drainage. Documentation on re-admission from the hospital on [DATE] stated resident #1's pressure ulcer to the coccyx was a stage 4 and the measurements were 4 cm. X 4 cm. A review of resident #1's skin grid revealed, on 3/21/11 the wound was documented as unstageable and the measurements were 6.1 cm. in length, 6.5 cm. in width, and 1 cm. deep with a surface area of 39.65 cm. There is no documentation that the resident's doctor was notified the wound was getting worse. On 3/28/11 the wound is still unstageable and is documented to be 6 cm. in length, 7 cm. in width, and 1 cm. deep with a surface area of 42 cm. On 4/4/11 the wound is still unstageable with 6 cm. in length, 7 cm. width, and 1 cm. deep with surface area of 42 and there is slough tissue around the wound, the wound bed is red with undermining at 12:00 and the length of the undermining is 1.5 cm., no tunneling, a moderate amount of serous yellow drainage, and no odor. The resident's wound to the left heel had red areas but no open areas on admission 3/19/11. A review of resident #1's skin grid of the left heel revealed the resident's wound had gotten worse. The documentation for the wound on the left inner heel stated that on 3/21/11 the wound is a deep tissue injury with measurements of 0.4 cm. in length, 1.3 cm. in width, 0 depth, and surface area of 0.52. On 4/4/11 deep tissue injury, 0.4 cm. in length, 1.3 cm. width, 0 depth, and surface area of 0.52 cm. The documentation for the wound on the resident's left middle heel dated 3/21/11 shows deep tissue injury, 1.2 cm. in length, 2.5 cm. width, 0 depth, with a surface area of 3 cm. On 4/4/11 deep tissue injury, 1.2 cm. in length, 2.5 cm. width, 0 depth, and surface area of 3 cm. Documentation of the wound to the resident's left lateral heel on 3/21/11 stated deep tissue injury, 1 cm. in length, 3.2 cm. in width, 0 depth, and surface area of 3.2 cm. On 4/4/11 documentation stated, deep tissue injury, 1 cm. in length, 3.2 cm. width, 0 depth, and surface area of 3.2 cm. Documentation on all the days mentioned above revealed the wounds were purple in color, wound edges are firm, no undermining, tunneling, drainage or odor. The wounds were measured weekly and continued to reveal an increase in wound size and the wound to the coccyx had foul odor with a moderate amount of yellow drainage but there is no documentation noted in resident #1's medical record the doctor was notified the wounds were getting worse. On 4/7/11 at 11:05 a.m. an interview with the wound care nurse was conducted. The nurse stated resident #1 went to the hospital in March with a stage III pressure ulcer to the coccyx and returned on 3/19/11 with an unstageable pressure wound to the coccyx and a stage III pressure wound to the heel. The wound care nurse stated she is providing wound care daily to the resident. The wound care nurse stated there is a protocol that is followed for wound care with pressure ulcers and if the treatment is not working and ulcer gets worse then the doctor is notified. The nurse stated that she feels like the resident is being turned and repositioned as ordered. The surveyor asked the nurse, if the resident is being provided care, why did the wounds continue to get worse after admission on 3/19/11, and why the resident's doctor was ' not notified. The nurse stated, " I did talk to the hospice nurse about the resident ' s wounds on 4/5/11 and the hospice nurse said ok so I was going to let hospice handle it. " The wound care nurse also stated, " there have been some problems with the residents, who have pressure wounds, not being changed and repositioned like they should and there were times she has found the residents wet and the dressings would be gone when she came to do dressing changes. " The wound care nurse stated that she reported the incidents to the Unit Managers and the resident ' s nurse. The wound care nurse stated she started checking the residents with wounds more often and changed their dressing changes to daily. On 4/7/11 at 12:10 p.m. An interview with the aide caring for the resident was conducted. The aide stated, " the residents are to be turned at least every 2 hrs. but if the resident has a bad wound, they were instructed to turn the resident every hr. " The aide stated if she noted the dressing was missing, she would notify the nurse caring for the resident or the wound care nurse. 4/7/11 at 12:30 p.m. an interview was conducted with resident #1's daughter. The daughter is concerned because the wounds are getting worse. The daughter stated she is in the facility 3 times a week for several hrs. and the resident was not turned every hr. 4/7/11 at 2:00 p.m. observation of the resident's wounds and wound care were made. Wound care was provided as ordered. The wound does appear as measured on 4/4/11. There is a moderate amount of yellow drainage and a strong foul odor coming from the wound. 2. A record review was conducted on 4/7/11 for resident #2. This record review revealed, resident #2 is a bilateral above the knee [MEDICAL CONDITION] and has a stage III pressure ulcer to the coccyx. The resident was readmitted to the facility with the coccyx wound on 2/17/11. The skin grid documentation for the resident revealed that on 3/7/11 the resident had a stage III pressure ulcer and the measurements were 2.7 cm. in length, 2.1 cm. in width, 2.1 cm. depth, and a surface area of 5.67 cm. the wound bed color is red and there is tunneling at 9:00 of 2.6cm. in length, and undermining at 12:00 of 2.3 cm. in length, there is small amount of serosanguinous pink/red drainage with an odor. On 3/14/11 the wound appears to have gotten worse and documentation stated the wound is still a stage III, is 3 cm. in length, 1.6 cm. in width, 2.6 cm. in depth, with a surface area of 4.8 cm. the wound bed is red, there is undermining at 12:00 of 3 cm. in length and tunneling at 9:00 of 3.2 cm. in length, the drainage is serosanguinous pink/red with odor. On 3/21/11 the wound is still a stage III, 2.6 cm. in length, 2 cm. in width, and 2.5 cm. in depth, with a surface area of 5.2, the wound bed is red, the drainage is serosanguinous small amount of pink/red drainage with odor, there is undermining of 3cm. in length, and tunneling of 2.8 cm. in length ( no documentation as to exactly where the tunneling and undermining is). On 3/28/11 the wound is stage III, 2.8 cm. in length, 2.8 cm. in width, 2.1 cm. depth, and the surface area is 7.84 cm. the wound bed is red, again the documentation is missing for exactly where the undermining and tunneling are at, but the undermining length is 2.6 cm. and the tunneling length is 2.8 cm. On 4/4/11 documentation shows the resident's wound is still a stage III, 2.8 cm. in length, 1.5 cm. in width and 2.3 cm. depth, the surface area of the wound is 4.20 cm., the wound bed is red, the undermining is 3.1 cm. in length and tunneling is 2.8 cm. in length and there is a moderate amount of serosanguinous drainage pink/red with odor present ( again there is no documentation where the undermining and tunneling are). The wound was cultured on 2/8/11 and showed no growth for bacteria. The resident is being seen by the wound care center monthly with the facility providing the care between visits to the wound care center. On 4/7/11 at 11:50 a.m. an interview was conducted with the wound care nurse. The nurse stated resident #2 went to the hospital in February and returned from the hospital with a stage III pressure ulcer to the coccyx. The wound care nurse stated she is providing wound care daily to the resident. The wound care nurse stated there is a protocol that is followed for wound care with pressure ulcers and if the treatment is not working and ulcer gets worse then the doctor is notified. The nurse stated that she feels like the resident is being turned and repositioned as ordered. The wound care nurse stated, " again, there have been some problems with the residents, who have pressure wounds, not being changed and repositioned like they should and there were times she has found the residents wet and the dressings would be gone when she came to do dressing changes. " The wound care nurse stated she found resident #2 soiled yesterday and the dressing was soiled with feces for quite some time prior to her finding this. The wound care nurse stated that she reported the incidents to the Unit Managers and the resident ' s nurse. The wound care nurse stated she started checking the residents with wounds more often and changed their dressing changes to daily. On 4/7/11 at 2:40 p.m. an interview was conducted with the nurse caring for the resident. This interview revealed that the resident has been found wet from incontinence. The nurse stated, "the resident uses the urinal and will spill some occasionally " The nurse stated she has talked to the aides about making sure the resident is turned frequently and is not wet. On 4/7/11 at 5:10 p.m. an interview with the CNA caring for the resident was conducted. The aide stated that the resident should be turned every 2 hrs. or sooner if needed. On 4/7/11 at 5:30 p.m. an interview with the resident's daughter was conducted. The daughter stated she was here all day on Sunday and the resident was left sitting up in his chair all day. The daughter stated no one came in to change or re-position the resident the entire time she was in the facility. On 4/7/11 at 2:30 p.m. observations were made of the resident sitting in his wheelchair. On 4/7/11 at 3:30 p.m.observations of the resident revealed the resident was in bed on his left side facing the door. On 4/7/11 at 5:30 p.m. resident was observed in the same position he was in at 3:30 p.m. On 4/7/11 at 6:30 p.m. resident was observed in the same position he was in at 5:30 p.m. On 4/7/11 at 6:45 p.m. observation of wound care for resident #2. The resident's diaper was wet when the nurse went to provide wound care. The resident's bandage was soiled and coming off. There was a foul odor noted during dressing change. The resident was pre-medicated with pain medication about an hour prior to the dressing change, but still complained of pain during the dressing change. The nurse followed infection control measures during dressing change. 3. On 4/7/11 a record review was conducted for resident #3. This record review revealed the resident is a quadriplegic with an unstageable pressure ulcer to the coccyx. In February the resident ' s wound was a stage II and the most current documentation on 4/4/11 stated the resident ' s wound has gotten worse and is now unstageable. This resident was transferred to the hospital for respiratory distress this morning. Review of the skin grids for resident #3 revealed that on 3/8/11 the resident's wound was unstageable and the length of the wound was documented 4.2 cm. in length, 4.5 cm. in width, and 0.1 depth, with a surface area of 18.9 cm., there is slough tissue with a yellow wound bed, no tunneling or undermining, and a large amount of serous yellow drainage and no odor. On 3/15/11 the wound is Unstageable, 4.5 cm. in length, 5.1 cm. width, 0.1 cm. depth, with a surface area of 22.95 cm., slough tissue, yellow wound bed, no tunneling and undermining, small amount of serous yellow drainage without odor. On 3/22/11 the wound is still unstageable, 4.5 cm. in length, 5.5 cm. in width, 1 cm. in depth, and a surface area of 24.75 cm., with slough tissue, yellow wound bed, no tunneling or undermining, and a small amount of serous yellow drainage. On 3/29/11 the wound is unstageable, 4.5 cm. in length, width is 5.5 cm., 1 cm. depth, and a surface area of 24.75 cm., with slough tissue, yellow wound bed, no tunneling or undermining, moderate amount of serous yellow drainage. On 4/4/11 the wound is unstageable, 4.4 cm. in length, 5 cm. in width, 1 cm. depth, with a surface area of 22 cm., there is slough tissue, with red and yellow wound bed, no tunneling or undermining, moderate amount of serous yellow drainage. There is no evidence that when the wound got worse, the doctor was notified as care planned. The care plan stated the resident 's wound was still a stage II. On 4/7/11 at 11:50 a.m. the The wound care nurse stated she is providing wound care daily to resident #3. The wound care nurse stated there is a protocol that is followed for wound care with pressure ulcers and if the treatment is not working and ulcer gets worse then the doctor is notified. The wound care nurse stated, "again, there have been some problems with the residents, who have pressure wounds, not being changed and repositioned like they should and there were times she has found the residents wet and the dressings would be gone when she came to do dressing changes." The wound care nurse stated that she reported the incidents to the Unit Managers and the resident's nurse. The wound care nurse stated she started checking the residents with wounds more often and changed their dressing changes to daily. The wound care nurse stated that she felt like the resident's wound got worse due to the resident not being changed when soiled and repositioned as directed at least every 2 hrs. 4.On 4/7/11 a record review was done for resident #4. This record review revealed the resident is incontinent of bowel and bladder and is a total assist due to a left above the knee amputation and the resident is confused and does not communicate. Documentation also revealed, the resident has a stage II pressure ulcer to the coccyx and a deep tissue injury pressure ulcer to the right heel. Documentation on the resident ' s skin grid dated 4/5/11 stated the resident has a deep tissue injury to the right heel that was not present on admission. On 4/5/11 the length of the wound is 6 cm. the width is 7.3 cm. and the depth is 0, the surface area of the wound is 43.8 cm., there is no undermining or tunneling and no drainage. The skin grid documentation for the pressure ulcer to the coccyx stated the wound is a stage II and is 5 cm. in length, 7cm. in width, 0 depth, with a surface area of 35 cm., there is no tunneling or undermine and no drainage or odor. The weekly skin sweeps stated there are no new skin impairments. On 4/7/11 at 11:50 a.m. an interview with the wound care nurse was conducted. The wound care nurse stated that resident #4 was getting a bath and on 4/5/11 and the aide and nurse caring for the resident called her in to look at the wound to the resident's coccyx (stage II). The wound care nurse stated she then did a skin sweep to check the resident for any additional skin changes and found another stage II pressure wound on the resident's right heel. The wound care nurse stated the wound is considered an inhouse wound which means the resident acquired the wound while staying in the facility. The resident's wound care is done every 3 days or as needed. The wound care nurse is not sure about the resident being left incontinent too long because she had no contact with the resident prior to 4/5/11. The wound care nurse stated there is a protocol that is followed for wound care with pressure ulcers and if the treatment is not working and ulcer gets worse then the doctor is notified. The nurse acknowledged the resident was not on a pressure relieving mattress as care planned. On 4/7/11 at 5:00 p.m. an interview was conducted with the resident's nurse. The resident's nurse stated that the resident is total care and needs to be turned every 2 hrs. due to a pressure ulcer on her coccyx. On 4/7/11 at 5:15 p.m. an interview with the aide caring for the resident. The aide stated the resident should be turned every 2 hrs. or sooner because she has a pressure ulcer and she is total assist. On 4/7/11 at 6:00 p.m. an interview was conducted with the resident's daughter. The resident's daughter stated that her mother is not turned on a regular basis. The daughter stated she has stayed all day some days and no one came and turned her mother all day. On 4/7/11 at 4:15 p.m. Observations of resident #4 revealed the resident is not on a pressure relieving mattress. The resident is sitting up in bed at a 40 degree angle on her back. The resident's heels are not floating and are flat on the mattress. On 4/7/11 at 6:10 p.m. resident is still in the same position she was in at 4:15 p.m. On 4/7/11at 6:30 p.m. resident is still in the same position she was in at 4:15 p.m. 4/7/11 at 6:30 p.m. observations of wound care were made and the care was given as ordered. The wound is as documented on 4/5/11. 5. On 4/7/11 a record review for resident #5 was done. This record review revealed the resident was not initially admitted with the pressure ulcer. The resident was sent out to the hospital on [DATE] and when the resident came back from the hospital on [DATE] the resident had a stage II pressure ulcer to the coccyx. Review of skin grid documentation for resident #5 revealed the length of the wound is 2 cm. and the width of the wound is 1.5 cm. and the depth is 0, there is no tunneling or undermining and no drainage. On 4/7/11 at 5:15 p.m. an interview with resident #5 was conducted. During the interview the resident stated the staff do not turn the resident every 2 hrs. "I wish they would turn me every 2 hrs." The resident stated that the resident can't turn and is dependent on staff for care. The resident stated, " I usually wait for 20-30 minutes before someone will change me after I have soiled my diaper. " On 4/7/11 at 11:50 a.m. An interview with the wound care nurse was conducted. The nurse stated that the resident was recently in the hospital and was admitted with the pressure ulcer to the coccyx. The nurse acknowledged the resident was not on a pressure relieving mattress as care planned. The wound care nurse stated there is a protocol that is followed for wound care with pressure ulcers and if the treatment is not working and ulcer gets worse then the doctor is notified. On 4/7/11 at 5:20 p.m. an interview was conducted with the nurse caring for the resident. The nurse stated the resident is total care and needs to be turned every 2 hours. On 4/7/11 at 5:25 p.m. an interview with the aide caring for resident #5 revealed the aide is aware the resident is total care and needs to be turned every 2 hrs. On 4/7/11 at 5:10 p.m. Observations of resident #5 were made at this time. The resident is not on a pressure relieving mattress and the resident is in bed on her back with a diaper on. On 4/7/11 at 6:30 p.m. observation of the resident at this time revealed the resident is in the same position she was at 5:10 p.m. On 4/7/11 at 7:00 p.m. observations of the resident at this time revealed the resident is in the same position she was at 6:30 p.m.

Based on observation, interview and record review, the facility failed to complete accurate skin assessments in accordance with professional standards of quality. The facility failed to identify the occurrence of new wounds, and failed to identify the presence of existing wounds upon admission for 2 of 4 residents sampled for wound care, #1 and #2. The findings: 1. On 02/01/11 at approximately 12:35 p.m., an observation of current wounds was conducted with the Wound Care Nurse for Resident #1. The Wound Care Nurse identified 7 wounds on the resident ' s coccyx (tail bone) and legs. The Wound care nurse identified: 1. An open wound to the coccyx. The wound was surrounded by scar tissue and showed evidence of granulation 2. A small healing wound to the right shin. The wound appeared to be a small laceration measuring approximately 2 cm long, 3 mm wide and 2 mm deep. 3. A wound to the right second toe. The wound measured approximately 0.5 cm in diameter, and was blackish in color. 4. A wound with eschar (black area) to the right inner heel measuring about 1.5 cm. 5. A deep tissue injury to the right outer heel. The area was about 2 cm round, blackish in color, and peeling. 6. A wound to the left outer heel, blackish in color, and measuring about 1.5 cm round. 7. A wound covered by a dressing to the left calf. The dressing was dated as last changed on 01/26/11 - six days earlier. The dressing was removed to reveal a small open and draining wound about 1.5 cm in diameter with a black ring around the wound edges. On 02/01/11 at approximately 1:00 PM., an interview was conducted with the wound care nurse after the wound observation. The nurse stated that she performs a full baseline skin assessment on all residents that are referred to her for wound care. These assessments are conducted within 72 hours after admission. Resident #1 was readmitted to the facility from the hospital on [DATE]. The wound care nurse looked at the resident ' s current medical record. The wound care nurse stated that prior to this observation, only the wounds to the coccyx and right shin were identified. No other wounds had been documented. There were no current physician orders for wound care. The wound care nurse stated that no 'Skin Grids' had been initiated. The Skin Grid is the form used to document the type, size and characteristics of wounds. The wound care nurse stated that she would now initiate the Skin Grid forms, review the treatment protocol, and obtain physician orders for wound care. A record review to determine the date of onset, assessment and treatment for [REDACTED]. Resident #1 was originally admitted to the facility in 2010. On 01/17/11, Resident #1 was sent to the hospital for difficulty breathing. On 1/21/11, Resident #1 returned to the facility. Resident #1 remained in the facility for 2 days, and was sent back to the hospital on [DATE]. On 1/29/11, Resident #1 was readmitted to the facility. The facility treated each admission as a separate occurrence, and initiated a new medical record with each admission. Medical records from the previous admissions were obtained and reviewed. On 1/17/11, Resident #1 was residing in the facility. A record review for wound assessments was conducted. The ' Skin Sweep ' form was reviewed. The ' Skin Sweep ' is the form used to document weekly skin assessments by nursing. The 'Skin Sweep' forms from 12/7/10 through 1/17/11 were reviewed. The forms showed weekly skin assessments to a wound on the coccyx. The Skin Sweep forms did not identify any other observed wounds. The nurses ' notes from 12/1/10 through 1/17/11 were reviewed. There was no indication of any skin wounds. Resident #1 was sent to the hospital on [DATE] for difficulty breathing. The emergency room physician documented that Resident #1 had "Several unstagable heel sores" and a stage 3 pressure ulcer to the tail bone area. The hospital identified and photographed multiple skin wounds including unstagable wounds to the heels, an unstagable wound to the right second toe, an unstagable wound to the top of the left foot, an unstagable wound to the left calf below the knee, and a stage 3 pressure ulcer to the coccyx (tail bone). Only the coccyx wound had been previously identified by the facility prior to hospitalization . Resident #1 returned to the facility on [DATE]. The facility completed an admission assessment. The skin assessment identified wounds consistent with the wounds identified at the hospital. On 01/23/11, Resident #1 again returned to the hospital for difficulty breathing. This was also a closed record review. Resident #1 was re-admitted to the facility on [DATE]. The current medical record was reviewed. The nurse completed the Admission-Readmission Data Collection and Initial Plan of Care 3:15 p.m. The nurse only documented 2 skin wounds. 1. An open area-bony prominence left lower extremity just below the knee, anterior outer area (however, on the body image the right extremity was checked) 2. An open area-coccyx/center bony area The nurse failed to identify or assess the other wounds as identified in the hospital admissions and the previous facility admission. A further current record review was conducted on 02/01/11. There were no physician orders for wound care. The Progress Notes (nursing) were reviewed from admission on 01/29/11 through the present date of 02/01/11 at approximately 12:30 p.m. There were no other skin wounds identified. There was no further documentation of the identified wounds on the leg and coccyx. There were no measurements, the wounds were not identified as to type, and they were not staged. On 02/01/11 at approximately 3:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON confirmed that a 'Skin Grid' should have been initiated for all wounds. The admitting nurse was responsible for wound assessment to include type, size and characteristics. This should not be left for the wound care nurse to initiate. The DON confirmed that physician orders should have been obtained. The DON stated that the facility had identified concerns in the area of wound assessment, and that they had had recently in-serviced all nursing personnel on wound assessment. 2. Resident #2 had inaccurate and inconsistent skin and wound assessments. A closed record review was conducted for Resident #2. Weekly skin assessments showed "no new skin impairment' from 11/9/10 through 01/11/11. On 01/17/11 a nurse documented new skin impairments to the left shin and left heel. The form stated to see progress note for details. Progress notes for Resident #2 were reviewed. On 01/17/11 a nurse wrote that she identified a 3 cm blackened area to the left knee with redness surrounding the blackened area. There was no drainage. The nurse also identified a 2 cm blackened area to the left heel. The nurse notified the physician and the wound care nurse. On 1/18/11 a nurse documented that Resident #2 had wounds to the left heel and knee as noted the day before. In addition, the nurse also identified a wound to the resident's left shin. The 'Skin Grids' for pressure and non-pressure related wounds were reviewed. Only one of the three identified wounds was documented on a Skin Grid. The Skin Grid documented an unstagable wound to the left heel on 1/15/11, two days prior to the initial nursing assessment. The wound measured 0.8 by 1.3 cm and was black in color without drainage. This form was not updated after the initial assessment. Physician orders were obtained to clean and dress the left heel wound daily. There were no physician orders for the wounds to the left shin and left knee. The care plan was updated on 1/15/11. The care plan identified an "Unstagable" wound to the left heel, and and "Unstagable wounds to the left knee/shin. There were no Skin Grids developed for the wounds to the left shin and knee. There were no further assessments in nursing notes to the wound on the left shin. On 01/23/11, Resident #2 was sent to the hospital for decreased mental status. The emergency room (ER) physician identified four leg wounds. The ER physician documented 1. A 5-6 cm circular ulcer with eschar formation (black scab like covering) over the left knee, 2. A 3-4 cm ulcer with eschar on the left shin (several inches below the knee) 3. A 3-4 cm ulcer with eschar on the left heel with mild surrounding redness 4. A stage 1 decubitus pressure ulcer to the right heel. On 02/01/11 at approximately 3:45 p.m. an interview was conducted with the Wound Care nurse. The nurse stated that she examined the wounds to the knee, shin and heel. She obtained a wound culture of the knee on 1/18/11. The wound did not appear new to her. She stated that the floor nurses were taking care of the knee and shin wounds as they were scabbed. She was treating the heel wound. On 02/01/11 at approximately 4:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON confirmed that no wounds had been documented by nursing prior to 01/17/11. The DON stated that Skin Grids should have been initiated for ongoing and consistent assessment and physician orders should have been obtained. The DON stated that extensive inservices on wound assessment had occurred on 01/14/11, and the facility was monitoring this. Professional Standard of Care is defined in Chapter 766.102 as, "the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers". The Florida Nurse Practice Act, Chapter 464.003 defines Professional and Practical Nursing. The Act states: (3)(a) "Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. The supervision and teaching of other personnel in the theory and performance of any of the above acts. (b) "Practice of practical nursing" means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing.

Based on observation, interview and record review, the facility failed to identify, assess, treat, and obtain physician orders for wound care for 3 of 4 sampled residents, #1, #2, and #3. The findings: 1. On 02/01/11 at approximately 12:35 p.m., an observation of current wounds was conducted with the Wound Care Nurse for Resident #1. The Wound Care Nurse identified 7 wounds on the resident ' s coccyx (tail bone) and legs. The Wound care nurse identified: 1. An open wound to the coccyx. The wound was surrounded by scar tissue and showed evidence of granulation 2. A small healing wound to the right shin. The wound appeared to be a small laceration measuring approximately 2 cm long, 3 mm wide and 2 mm deep. 3. A wound to the right second toe. The wound measured approximately 0.5 cm in diameter, and was blackish in color. 4. A wound with eschar (black area) to the right inner heel measuring about 1.5 cm. 5. A deep tissue injury to the right outer heel. The area was about 2 cm round, blackish in color, and peeling. 6. A wound to the left outer heel, blackish in color, and measuring about 1.5 cm round. 7. A wound covered by a dressing to the left calf. The dressing was dated as last changed on 01/26/11 - six days earlier. The dressing was removed to reveal a small open and draining wound about 1.5 cm in diameter with a black ring around the wound edges. On 02/01/11 at approximately 1:00 PM., an interview was conducted with the wound care nurse after the wound observation. The nurse stated that she performs a full baseline skin assessment on all residents that are referred to her for wound care. These assessments are conducted within 72 hours after admission. Resident #1 was readmitted to the facility from the hospital on [DATE]. The wound care nurse looked at the resident ' s current medical record. The wound care nurse stated that prior to this observation, only the wounds to the coccyx and right shin were identified. No other wounds had been documented. There were no current physician orders for wound care. The wound care nurse stated that no 'Skin Grids' had been initiated. The Skin Grid is the form used to document the type, size and characteristics of wounds. The wound care nurse stated that she would now initiate the Skin Grid forms, review the treatment protocol, and obtain physician orders for wound care. A record review to determine the date of onset, assessment and treatment for [REDACTED]. Resident #1 was originally admitted to the facility in 2010. On 01/17/11, Resident #1 was sent to the hospital for difficulty breathing. On 1/21/11, Resident #1 returned to the facility. Resident #1 remained in the facility for 2 days, and was sent back to the hospital on [DATE]. On 1/29/11, Resident #1 was readmitted to the facility. The facility treated each admission as a separate occurrence, and initiated a new medical record with each admission. Medical records from the previous admissions were obtained and reviewed. On 1/17/11, Resident #1 was residing in the facility. A record review for wound assessments was conducted. The ' Skin Sweep ' form was reviewed. The ' Skin Sweep ' is the form used to document weekly skin assessments by nursing. The 'Skin Sweep' forms from 12/7/10 through 1/17/11 were reviewed. The forms showed weekly skin assessments to a wound on the coccyx. The Skin Sweep forms did not identify any other observed wounds. The nurses ' notes from 12/1/10 through 1/17/11 were reviewed. There was no indication of any skin wounds. Resident #1 was sent to the hospital on [DATE] for difficulty breathing. The emergency room physician documented that Resident #1 had "Several unstagable heel sores" and a stage 3 pressure ulcer to the tail bone area. The hospital identified and photographed multiple skin wounds including unstagable wounds to the heels, an unstagable wound to the right second toe, an unstagable wound to the top of the left foot, an unstagable wound to the left calf below the knee, and a stage 3 pressure ulcer to the coccyx (tail bone). Only the coccyx wound had been previously identified by the facility prior to hospitalization . Resident #1 returned to the facility on [DATE]. The facility completed an admission assessment. The skin assessment identified wounds consistent with the wounds identified at the hospital. On 01/23/11, Resident #1 again returned to the hospital for difficulty breathing. This was also a closed record review. Resident #1 was re-admitted to the facility on [DATE]. The current medical record was reviewed. The nurse completed the Admission-Readmission Data Collection and Initial Plan of Care 3:15 p.m. The nurse only documented 2 skin wounds. 1. An open area-bony prominence left lower extremity just below the knee, anterior outer area (however, on the body image the right extremity was checked) 2. An open area-coccyx/center bony area The nurse failed to identify or assess the other wounds as identified in the hospital admissions and the previous facility admission. The Treatment Administration Record was reviewed. The nurse initiated treatment to the wound on the coccyx. The Treatment record had an order that read to cleanse coccyx with normal saline and apply [MEDICATION NAME] dressing. Change dressing every 3-4 days and as needed. The nurse failed to obtain physician orders for this treatment. A further current record review was conducted on 02/01/11. There were no physician orders for wound care. The Progress Notes (nursing) were reviewed from admission on 01/29/11 through the present date of 02/01/11 at approximately 12:30 p.m. There were no other skin wounds identified. There was no further documentation of the identified wounds on the leg and coccyx. There were no measurements, the wounds were not identified as to type, and they were not staged. A review of the facility's protocol for wound care was conducted. The protocol stated to select the treatment protocol based on the type/stage of wound, depth and drainage, then obtain a physician's order. On 02/01/11 at approximately 3:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON confirmed that a 'Skin Grid' should have been initiated for all wounds. The admitting nurse was responsible for wound assessment to include type, size and characteristics. This should not be left for the wound care nurse to initiate. The DON confirmed that physician orders should have been obtained. The DON stated that the facility had identified concerns in the area of wound assessment, and that they had had recently in-serviced all nursing personnel on wound assessment. 2. On 02/01/11 at approximately 1:50 PM, a wound observation was conducted with a floor nurse for Resident #3. Resident #3 had a wound to the left foot. The dressing on the resident's foot was dated 01/30/11, 2 days earlier. The nurse removed the dressing and stated that the wound looked better. A record review for the left foot wound on Resident #3 was conducted. On 1/15/11, the physician had ordered daily dressing changes for 2 weeks. On 1/19/11 the physician ordered an antibiotic, Bactrim, for 10 days due to [MEDICAL CONDITION] (skin infection) of the left foot. On 1/28/11, the physician re-ordered the antibiotic as the wound had not completely healed. The orders for daily dressing changes were not extended or re-ordered. The dressing change orders had ended on 1/29/11. An interview was conducted with the floor nurse on 02/01/11 at approximately 2:10 PM. The nurse stated that the orders for the dressing change should have been renewed. The nurse stated that she was going to obtain physician orders prior to re-dressing the wound. 3. Resident #2 had inaccurate and inconsistent skin and wound assessments. A closed record review was conducted for Resident #2. Weekly skin assessments showed "no new skin impairment' from 11/9/10 through 01/11/11. On 01/17/11 a nurse documented new skin impairments to the left shin and left heel. The form stated to see progress note for details. Progress notes for Resident #2 were reviewed. On 01/17/11 a nurse wrote that she identified a 3 cm blackened area to the left knee with redness surrounding the blackened area. There was no drainage. The nurse also identified a 2 cm blackened area to the left heel. The nurse notified the physician and the wound care nurse. On 1/18/11 a nurse documented that Resident #2 had wounds to the left heel and knee as noted the day before. In addition, the nurse also identified a wound to the resident's left shin. The 'Skin Grids' for pressure and non-pressure related wounds were reviewed. Only one of the three identified wounds was documented on a Skin Grid. The Skin Grid documented an unstagable wound to the left heel on 1/15/11, two days prior to the initial nursing assessment. The wound measured 0.8 by 1.3 cm and was black in color without drainage. This form was not updated after the initial assessment. Physician orders were obtained to clean and dress the left heel wound daily. There were no physician orders for the wounds to the left shin and left knee. The care plan was updated on 1/15/11. The care plan identified an "Unstagable" wound to the left heel, and and "Unstagable wounds to the left knee/shin. There were no Skin Grids developed for the wounds to the left shin and knee. There were no further assessments in nursing notes to the wound on the left shin. On 01/23/11, Resident #2 was sent to the hospital for decreased mental status. The emergency room (ER) physician identified four leg wounds. The ER physician documented 1. A 5-6 cm circular ulcer with eschar formation (black scab like covering) over the left knee, 2. A 3-4 cm ulcer with eschar on the left shin (several inches below the knee) 3. A 3-4 cm ulcer with eschar on the left heel with mild surrounding redness 4. A stage 1 decubitus pressure ulcer to the right heel. On 02/01/11 at approximately 3:45 p.m. an interview was conducted with the Wound Care nurse. The nurse stated that she examined the wounds to the knee, shin and heel. She obtained a wound culture of the knee on 1/18/11. The wound did not appear new to her. She stated that the floor nurses were taking care of the knee and shin wounds as they were scabbed. She was treating the heel wound. On 02/01/11 at approximately 4:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON confirmed that no wounds had been documented by nursing prior to 01/17/11. The DON stated that Skin Grids should have been initiated for ongoing and consistent assessment and physician orders should have been obtained. The DON stated that extensive inservices on wound assessment had occurred on 01/14/11, and the facility was monitoring this.