Every finding on record at Balch Springs Nursing Home

Based on observation, interview and record review, the facility failed to obtain documentation that the residents representative has been delegated the necessary authority to exercise the resident's rights and must verify that a court-appointed representative has the necessary authority for the decision-making at issue as determined by the court. For example, a court-appointed representative might have the power to make financial decisions, but not health care decisions. Additionally, the facility must make reasonable efforts to ensure that it has access to documentation of any change related to the delegation of rights, including a resident's revocation of delegated rights, to ensure that the resident's preferences are being upheld for 1 (Resident #13)of 5 residents (Resident #32, #40, #77, and #80) reviewed for resident representative rights.The facility failed to ensure Resident #13, who was cognitively impaired when admitted to the facility, had a representative who had the authority to make decisions on his behalf.This failure could lead to the facility making decisions without the resident's right to designate a surrogate or representative to make treatment or transfer decisions for the resident; and could deny the resident through the resident representative their wishes and preferences.The findings included:Record Review of Resident #13's face Sheet dated 05/06/2026 Revealed a [AGE] year-old male, and was initially admitted to the facility on [DATE] with diagnoses that included: Cerebral infarction (bleeding incident in the brain), Bipolar Disorder, Schizoaffective Disorder, Bipolar Type, Altered mental Status, Legal Blindness, Malignant Neoplasm of the Larynx (Abnormal/Cancerous Cells Develop in the Voice Box), Dementia, and Cognitive Communication Deficit. No listings were found for any family members or resident representatives.Record Review of Resident#13's Comprehensive Care Plan dated 04/17/2026, revealed goals and interventions that included: Cognitive Impairment: Resident [#13] has impaired cognition and is at risk for a further decline in cognitive and functional abilities related to dementia. Resident [#13] needs supervision/assistance with all decision making. Resident[#13] is dependent on staff for cognitive stimulation, activity attendance, and social interaction related to cognitive impairment and is at risk for isolation. Encourage ongoing family involvement. Invite the resident's family to attend special events, activities, and meals.Record Review of Resident #13's Nursing Home Comprehensive MDS, dated [DATE], revealed that Resident #13 had a BIMS score of 02 (Severe Cognitive Impairment), meaning Resident #13 required high-level supervision and support with daily activities. Record a Review of a Progress note dated 06/06/2023 at 1:33 PM and written by AD reflected that: [Resident #13] is a new admit 06/03/23, transfer from the Hospital [Resident #13] is alert resident is able to communicate seem[ed] to be confuse[d] at time[s] [Resident #13] is [a] blind resident require[ing] full care, no family member is listed on the admission sheet.In an observation on 05/05/2026 at 9:36 AM, Resident #13 was observed laying down on his bed with only his eyes exposed from a sheet covering him. Resident #13 appeared to be awake but would not respond to any questions from the surveyor.In an interview on 05/05/2026 at 10:52 AM, CNA B revealed that they had worked extensively with Resident #13. Resident #13 rarely spoke but could indicate some needs and if he was in pain. CNA B stated that he had never seen Resident #13 have any visitors and was not aware of any family members or a Resident Representative. In and interview on 05/05/2026 at 11:05 AM, CNA C stated That she had worked with Resident #13 many times. She stated that he is generally quiet, did not attempt to answer many questions. She stated that the staff were generally aware of his routine and could generally anticipate when he needed to be changed or to remove his food tray after he was assisted with feeding. She was not aware of Resident #13 having any family members or any type of Resident Representative.In an interview on 05/06/2026 at 10:07 AM, the SW revealed that Resident #13 had no known family members. She stated that the facility had not pursued getting a guardianship (Resident Representative]. She stated that the facility does do Care plan Meetings with Resident #13 in his room, but Resident #13 does not participate in the meeting. She stated that Resident #13 cannot make decisions for himself and that the facility should consider getting a Court Appointed Guardian for him.In an observation on 05/06/2026 at 2:34 PM, Resident #13 was observed in his room. He was not responsive to questions. Resident #13 was observed laying on his side, bed in low position, mostly covered in blankets, room cold/clean. No lingering foul odors. No obvious bruising on visible exposed skin.In an interview on 05/07/2026 at 10:41 AM, the DON stated that it was important for a resident that can't communicate to have a guardian or a representative to be able inform us (the staff) of the residents wishes and for proper care. Not having a representative could endanger the resident to isolation and possible lack of care. If they [the Resident] have no family or representative, then we [the facility] have to reach out to the physician and make sure that the resident has a representative. She stated that it was a state-run program for guardianship. She stated that she had dealt with getting guardians for residents before, and that it does not take too long to process.In an interview on 05/07/2026 at 11:29 AM NP revealed that Stated [Resident #13] can communicate immediate needs but not to the level of making decisions about care plans/activities. She stated that she had never seen any family members of any type, and she is unaware of any guardians [for Resident #13]. She stated that some benefits for Resident #13 to have a representative would be to advocate for him. She stated that [after reviewing orders) that there were no orders designating anyone as a guardian or representative [Resident #13's] orders. She stated that it may not be sufficient to have no one as a representative for him.Record review of facility's Resident Rights policy dated revised 05/2017 read: The Resident has the right: .to have a legal representative .

Based on interview and record review the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the residents through the means other than a postal service for 6 (confidential residents) of 75 residents reviewed for rights to forms of communication with privacy. The facility failed to deliver mail to the residents within twenty-four hours of delivery on premises or the facility's post office box according to their policy. This failure could place residents at risk of not receiving mail in a timely manner and could result in a decline in residents' psychosocial well-being and quality of life.The findings were: During a confidential group interview, 6 of 9 members in the group stated they never received mail 3 of 9 residents stated mail was not distributed at the facility on Saturdays because the Activity Director did not work on Saturdays. During an interview on 05/06/2026 at 11:47 a.m., the AD revealed that she is responsible for delivering mail. She stated that she passed residents' mail Monday through Friday. She stated that she is not here on the weekends and was not sure if there were any staff assigned to pass mail on Saturdays. The AD stated that when she arrived on Monday mail was in her box to pass out. During an interview on 05/06/2026 at 1:12 PM the Administrator stated that her expectation was for mailed to be passed on Saturday by the weekend staff. The Administrator stated that there was not just one person on the weekend staff assigned to pass mail, just the nursing staff in general. Attempted phone calls to staff who worked on weekends, but was unsuccessful. Record review of facility policy titled Resident Right to Privacy in Communication, revealed, Promptly, means delivery of mail or other materials to the resident within 24 hours of delivery by the postal service (including a post office box and delivery of outgoing mail to the postal office within 24 hours, except when there is no regularly scheduled postal delivery and pick-up service.

Based on interview and record review the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of the State Long-Term Care (LTC) Ombudsman of the residents' transfer or discharge and the reasons for the move for 1 resident (Resident #8) of 5 reviewed for notifying the LTC Ombudsman of the residents' discharge.The facility failed to ensure Resident #8 was not discharged on 04/13/2026 without a notice to the LTC state ombudsman.This failure could place residents at risk of not knowing their rights or receiving the services of the state LTC Ombudsman.The findings included:A record review of Resident #8's nursing home discharge MDS Assessment, dated 04/13/2026, reflected the Resident #8 was a [AGE] year old male who was admitted to the facility on [DATE]. Resident #8 had an active diagnosis of Ischemic cardiomyopathy (heart muscle becomes weakened and enlarged, reducing its ability to pump blood, caused by long-term damage from restricted blood flow) and the resident BIMS score was blank.During an interview on 05/05/2026 at 11:47 a.m., the Ombudsman revealed she had never received a discharge notification from the facility. She stated that the facility was required to submit discharge notification every time they do an involuntary discharge, transfer or present discharge paperwork to any resident related to discharge, they are supposed to notify the ombudsman and send a monthly discharge notification to the Ombudsman, but this facility does not ever send the notifications as required. During an interview on 05/06/2026 at 12:45 p.m., the SW stated she had been the facility's SW since February 2026. She stated she had no evidence for a report to the state Ombudsman for Resident #8's discharge. She stated that she was not aware she was supposed to send discharge notification to the Ombudsman monthly. During an interview on 05/07/2026 at 1:12 p.m., the Administrator stated she was unaware of the rule to notify the state ombudsman of any resident discharges. Record review of facility policy titled Transfer and discharge date d October 2017 revealed 7. Non-emergency transfer or discharges - initiated by the facility, return not anticipated. At least 30 days before the resident is transferred or discharged , the Social Services Director will notify the resident and the resident's representative in writing in a language and manner they understand. d. A copy of the notice shall be provided to the representative of the Office of the State Long-Term Care Ombudsman. k. Social Services Director, or designee shall provide notice of transfer to a representative of the State Long Term Care Ombudsman via monthly list.

Based on interview and record review, the facility failed to coordinate assessments with the PASRR program for 1 of 5 residents (Resident #55) reviewed for PASRR assessments. The facility failed to ensure Resident #55 was referred to the appropriate state-designated mental health authority for review when she received a new diagnosis of schizoaffective disorder, bipolar disorder and anxiety disorder. This failure could place residents at risk of not being evaluated and receiving needed PASRR services.Findings included: Record review of Resident #55's quarterly MDS Assessment, dated 02/10/2026, reflected the Resident #55 was a [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #55 had an active diagnosis of schizoaffective disorder (mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania), bipolar disorder (mental health condition characterized by extreme, dramatic shifts in mood, energy, and activity levels, alternating between intense highs (mania or hypomania) and lows) and anxiety (a natural human emotion characterized by feelings of worry, nervousness, or unease, typically about an event with an uncertain outcome), and the resident had severe cognitive impairment with a BIMS score of 13. Record review of Resident #55's Care plan, undated reflected Focus: Behavior Problem: Resident has a behavior problem as related to delusional with hallucinations, making false allegations toward others. Goal: The Residents behavior will not interfere with the delivery of care or services or result in harm to self or others through next review date. Interventions/Task: Psychiatric consult per indication or physician order, intervene as necessary to protect the rights and safety of others, and Administer medications as ordered. Monitor and document for effectiveness and potential adverse side effects. Record review of Resident #55's PASRR Level 1 Screening, dated 06/18/25, reflected she did not have a mental illness. PASRR Level 1 screening did not indicate Resident #55 had primary diagnosis of dementia, but had metal illness diagnoses of schizoaffective disorder, bipolar disorder, and anxiety. During an interview on 05/06/25 at 04:04PM, the DON stated if a new diagnosis was given to a resident a new PASRR evaluation should be completed. The DON stated the facility will not accept a resident without a PASRR. The DON stated that the MDS nurse is no longer at the facility and unable to state why a new PASRR had not been completed on Resident #55. The DON stated that the MDS Nurse is the primary person as they import each resident diagnosis onto the MDS. He stated The MDS nurses are monitored by regional MDS Nurse. During an interview on 05/07/2026 at 12:11 p.m., the Regional MDS Nurse stated the facility's MDS Nurse recently left the facility and she was over nine facilities. The Regional MDS Nurse stated that if a new mental health, Intellectual disability, or a developmental disability diagnosis was given to a resident a new PASRR Level 1 evaluation should be completed. The Regional MDS Nurse pulled up Resident #55's medical chart and reviewed her medical chart and stated Resident #55 did not have a Dementia diagnosis and had a diagnosis of schizoaffective disorder, bipolar disorder and anxiety disorder schizophrenia on 06/18/25. She pulled up Resident #55 PASRR Level 1 and stated it was completed on 06/18/2025 the day Resident #55 admitted to the facility. She stated Resident #55 PASRR Level 1 was negative, and she does not how Resident #55 had no next to mental health diagnoses. The Regional MDS Nurse stated she was unable to state why the MDS facility did not draft a new PASSRR Level 1 once new diagnoses were found. She stated she would generate one and submit it for Resident #55. She stated failure to perform screening and involving the authority's resident failed to get required assessments and could lead to her not receiving services that could have benefited her. The Regional MDS Nurses stated there were limited risk to Resident #55 she was already on medication, had psychiatric services and her core morbidities would limit her from activities outside the facility, but she would have missed the local authority visitation. During an interview on 05/07/2026 at 1:12 p.m., the ADM stated that it was her expectation that the MDS Nurse ensure residents have a PASRR completed prior to resident admission to the facility and to review for accuracy and if error found to send it back to the facility for them to fix. She stated we cannot admit a resident without a PL1. The ADM stated that if any resident while in the facility received a new MI, DI the facility MDS nurse was responsible for creating a PL1 to submit to the local authorities. The ADM stated that they currently do not have an MDS on-site and they utilize the Regional MDS Nurse. Record review of new PASRR Level 1 screening for Resident #55 completed on 05/07/2026. Record review facility PASRR policy dated June 2020 revealed, It is the intent of Advanced Health Care Solutions to meet and abide by all State and Federal regulations that pertain to resident preadmission and screening resident review rules. Referring Entity completes PASRR Level 1: If Negative (Preadmission, Exempted Hospital Discharge or Expedited):If the resident has a qualifying MI or ID diagnosis and the nursing facility feels resident should be positive, they should talk to the referring Entity and ask them to correct the PL1 or complete the 1012.What happens if a referring entity refuses to complete the PL1 Screening Form? The nursing facility must not accept admission from a hospital without a PL1. The nursing facility should contact the referring entity to let them know they cannot admit without the PL1.

Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #18) of five residents, reviewed for infection control. 1. The facility failed to ensure CNA A performed hand hygiene during incontinence care for Resident #18 and changed her soiled gloves before placing items in her pocket. This failure placed residents at risk for healthcare associated cross contamination and infections.Findings included: Record review of Resident #18's Quarterly MDS Assessment, dated 03/13/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her BIMS score was 13. Her cognitive skills for daily decision making were moderately impaired. Her diagnoses included end-stage renal failure and diabetes. Record review of Resident #18's Care Plans reflected:Revised 11/11/22 - Resident had an activity of daily living self-careperformance deficit.Facility interventions: Toileting - extensive assistance of two staff In an observation on 05/06/26 at 2:40 PM, CNA A prepared supplies to perform incontinence care for Resident #18. CNA A unfastened the brief, grabbed wipes, and cleaned the vaginal area of the resident. CNA A used the same soiled gloves to pick up trash bags, pulled one off, and laid it on the bed. CNA A then placed the roll of trash bags in her pocket. The resident was turned to her left side. CNA A cleaned the resident's buttocks and changed gloves but did not perform hand hygiene. CNA A placed a clean brief under the resident. In an interview on 05/06/26 at 2:50 PM, CNA A said she was supposed to perform hand hygiene when she changed her gloves. CNA A said she was trained to use hand sanitizer, but she forgot to; it slipped her mind. CNA A said she was not supposed to place clean trash bags in her pocket with soiled gloves. CNA A said failure to change soiled gloves and perform hand hygiene could cause infection. In an interview on 05/07/26 at 10:35 AM, the DON said staff were supposed to perform hand hygiene between glove changes and use clean gloves to place things in their pockets. The DON said past in-services with staff included return demonstrations of hand hygiene. He said he monitored staff daily for hand hygiene. Record review of the facility policy, Infection Prevention and Control Program, revised 03/26/24, reflected: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines.

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #1) of 14 residents reviewed for pressure ulcers. The facility failed to address Resident #1 required off-loading of heels and repositioning every two hours. Resident #1 developed a Stage 4 Pressure Wound. On 03/25/2026 at 6:22 p.m. an Immediate Jeopardy (IJ) was identified. The IJ template was provided to the facility on [DATE] at 6:22 PM. While the IJ was removed on 03/27/26 at 2:40 PM, the facility remained out of compliance at a scope of Isolated and severity level of No Actual Harm with a potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being.Findings included: Record review of Resident #1's Face Sheet, dated 03/24/2026, reflected a [AGE] year-old female, admitted [DATE], diagnosis included Malnutrition, Anxiety, Asthma-Chronic obstructive Pulmonary Disease, Toxic Encephalopathy (brain dysfunction caused by exposure to toxic chemicals), Alcohol Dependance, Muscle Wasting and Atrophy Lower Leg, Cognitive Communication Deficit, and Muscle Weakness. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 06 indicating severe cognitive impairment. Resident #1 was always incontinent of bowel and bladder, was dependent (required the assistance of two or more helpers) for tub/shower transfer, and Resident #1 either refused or was unable to: sit to lying, lying to sitting, sit to stand, chair/bed to chair transfer, toilet transfer or walk. Resident #1 had a pressure ulcer injury, a scar over bony prominence, or a non-removable dressing/device. Formal assessment instrument/tool and had been clinically assessed. Resident #1 was indicated at being at risk for pressure ulcer/injuries and had unhealed Pressure Ulcers/Injuries. Record review of Resident #1's Care Plan Report, dated 03/25/2026, reflected the following: Focus: Pressure Ulcer Risk: Resident has the potential for the development of a pressure ulcer. (Date initiated 01/12/2026). Goal: The Resident will be free of preventable breakdown through next review date. (Date initiated 01/12/2026, revised on 03/18/2026, target date 06/19/2026). Interventions: Check frequently for wetness and soiling, every two hours provide incontinent care as needed. (Date initiated 01/12/2026). Bathe per schedule. (Date initiated 01/12/2026). Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new skin conditions to the physician. (Date initiated 01/12/2026). Nutritional Status: Resident [#1] is on Mechanical soft, no added salt, with thin liquids. (Date initiated 12/30/2025). Record review of Resident#1's Order Summary Report dated 03/27/2026 revealed that Resident #1 did not have any orders to offload bilateral heels with pillows or heel protectors/boots while in bed every shift until 02/09/2026. No orders for an air pressure mattress were found. Record review of Resident #1's Braden Scale for Predicting Pressure Sore Risk assessment, dated 12/30/2026 and signed by RN ee rated Resident #1 as low risk with a score of 16 out of a possible 23 (higher score indicates higher risk). No other Braden Scale for Predicting Pressure Sore Risk assessment were found. Record review of Resident #1's EHR, dated 12/30/2025 through 03/30/2026 and accessed between 3/24/2026 and 03/30/2026, revealed there were no documented Skilled Observation Notes (what the facility claimed they used as skin assessments) from 01/01/2026 until 02/20/26. All Skilled Observation Notes after 02/26/2026 indicated the skin as warm, dry, skin intact, with no notable changes in skin condition. Record review of Resident #1's hospital document (from the hospital she was admitted to prior to being admitted to the facility) titled Wound Care Service, dated 12/22/25 at 4:29 p.m., indicated Resident #1 had orders that outlined Prevention Plan: Heels - Offload using Heel Protector Boot or pillows lengthwise. Record review of Resident #1's progress note, dated 12/30/25 at 8:26 p.m. and written by RN ee, revealed. No s/sx of acute distress noted at this time. Skin warm and dry; redness noted to buttocks and peri-area (an area of skin located between the sexual organ and the anus), abrasion noted to left inner thigh, and open area to buttocks. Record review of Resident #1's progress note dated 02/09/26 at 7:00 a.m. and written by RN ee wrote. blisters noted to bilat heels, HCP notified, spoke with [NAME] (NP) per routine visit. New orders received to apply skin prep to bilat[eral] heels blisters daily; offload bilat heels with heel protectors while in bed. Record review of Resident #1's Specialty Physician Initial Wound Evaluation & Management Summary, dated 02/17/2026 and signed by the Wound Care Physician revealed Resident #1 was diagnosed with an unstageable DTI of the right heel, undetermined thickness that measured 2.7 cm (length) x 3 cm (width) x unmeasurable cm (depth), with a total surface area of the wound measured at 8.10 cm squared, and an unstageable DTI of the left heel measuring 1.5 cm (length) x1 cm (width) not measurable depth cm, with a total surface area of the wound measured at 1.50 cm squared. It did not state in the document if the wounds had been avoidable or not. Record review of Resident #1's Specialty Physician Wound Evaluation & Management Summary, dated 3/10/2026 and signed by the Wound Care Physician reflected Resident #1 had a diagnosis of unstageable DTI of the right heel, undetermined thickness that was measured 1 cm (length) x 3 cm (width) x .06 cm (depth), with a total surface area of the wound measured at 3.90 cm squared, and a Stage 4 Pressure Wound of the Left heel, full thickness measuring 1 cm (length) x1.3 cm (width) not measurable depth cm, with a total surface area of the wound measured at 1.30 cm squared. Record review of Resident #1's MAR/TAR, accessed 03/27/2026 and dated 02/01/2026 to 02/28/2026, revealed Resident #1's orders to Offload bilat [both heels] with pillows or heel protectors/boots while in bed every shift with a start date of 02/09/2026. The MAR/TAR indicated Resident #1 did not have her heels offloaded during the 6:00 -a.m. to 2:00 p.m. shift on 2/10/26, 2/11/26, 2/12/26, 2/13/26 and 2/24/26. Further record review revealed Resident #1 no documentation her heels were offloaded during the 2:00 p.m. to 10:00 p.m. shift on 2/24/26 and 2/25/26. Record review further indicated Resident #1 had physician orders, initiated on 12/31/2025 reflected, Perform head to toe skin assessment. Document any changes in skin integrity in the medical record in the morning every Mon, Wed, Fri, Sun for wound prevention/early identification. Notify the physician of any changes in skin integrity. There was no evidence a head to toe skin assessment was performed on Wednesday 2/4/26, Monday 2/9/26, Wednesday 2/11/26, or Friday 2/13/26. Physician orders initiated on 02/10/2026, reflected, Apply Skin Prep to bilat [both] heels blisters every day shift, start date of 02/10/2026, D/C 03/17/2026. Record review revealed no evidence documented Resident #1 had Skin Prep applied to both heels on 2/10/26, 2/11/26, 2/12/26, 2/13/26 or 2/24/26. During an interview on 03/24/2026 at 12:00 p.m. Resident #1's family representative stated [Resident #1] had two little wounds on her backside that healed before she left the hospital and admitted to the facility. Resident #1's family representative stated Resident #1 didn't have any wounds on her heels when she discharged from the hospital and now Resident #1 had developed a pressure ulcer. During an interview on 03/24/2026 at 1:55 p.m., the NP stated Resident #1 admitted without pressure ulcers or DTIs. She stated she saw Resident #1 after Resident #1 had developed blisters on both of her heels on 02/09/2026 and that she had ordered for offloading [of the heels], and heel [boots] risers and had been told Resident #1 had been compliant with the heel protectors. She stated Resident #1 might have developed a pressure ulcer on her heel if the staff had not been repositioning/offloading her heels, or the resident might have been taking off her heel protectors. She stated that she had been unaware that Resident #1 had developed a stage 4 pressure ulcer on her heel. During an interview on 03/24/2026 at 4:03 p.m. CNA ff revealed she worked often with Resident #1 and that she had done peri-care 9cleaning of the area between the sexual organ and the anus) for Resident #1. She stated that Resident #1 never had a pressure ulcer on her bottom. She denied any knowledge of Resident #1 having any injuries to her feet. During an interview on 03/24/26 at 4:44 p.m. CNA U revealed she worked often with Resident #1 and that she had alerted the nurse about Resident #1's blisters on her heels. She stated that Resident #1 had had a scab on her bottom that had healed over quickly and that she would put the heel protectors on Resident #1's feet but that the nurses would take them (heel protectors) off and sometimes Resident #1 did not want to wear them. She stated that (after the blisters had burst) that she would often find that Resident #1's bandages had not been changed over the weekends and that she had informed the nurses about the bandages not being changed on the weekends. During an interview on 03/25/26 at 10:18 a.m. DON related that VOHRA (third party wound treatment consultant) gets referred too when wounds reach stage 2. She stated that Repositioning is not reflected on the TAR/MAR. She stated that there was no indication of any injuries to [Resident #1's] heels at the time of admission [to the facility]. She stated that the facility had not received heel riser boots yet for Resident #1. She stated that Resident #1 had come from the hospital with the cone shaped heel protectors, but that they had ordered heel boots [after the discovery of the heel blisters 02/09/26] but the facility had not received them yet. During an interview on 03/25/2026 at 10:20 a.m. ADON stated that the NP had ordered the wrong type of boot for Resident #1, so she only had the cone protectors. She stated that she had discovered the blisters on Resident #1's feet on 02/09/2026 as part of regular care, and had informed NP about it and new orders had been written [to offload heels apply treatment to the affected areas] . She stated that she might be able to provide the order slip for the boot protectors, but she did not provide the document/proof before exit from the facility on 03/30/2026. During an interview and observation on 03/25/2026 at 11:40 a.m. at the hospital where Resident #1 was currently admitted Resident #1 was observed having her bandages changed. Resident #1 was able to indicate that it was painful to turn but was unable to answer any questions. During an interview on 03/25/2026 at 11:50 a.m. DON stated that (in reference to Skilled Observation Notes) that it should have been reflected that the skin [for Resident #1] was not intact after acquisition of the pressure ulcers on the Skilled Assessments and that the section of the skilled assessment under skin was what the facility used for skin assessments. During an interview on 03/25/2026 at 12:30 p.m. Wound Care Physician stated that she had been seeing Resident #1 for her bilateral heel wounds since they developed [2/17/25]. She stated she had seen Resident #1 weekly and stated that Sometimes she [Resident #1] wouldn't be wearing the heel protectors. Wound Care Physician further related that Resident #1's wound development was related to immobility and general decline, she stated that being bedbound increases the risk of pressure so getting out of the bed would have been helpful. During an interview on 03/25/2026 at 4:40 p.m., ADON stated that skin assessments were not available in the EHR for surveyors to view. Residents' skin assessments documentation was requested, and she stated she and the administrator were working on getting them. During an interview on 03/25/2026 at 5:12 p.m., ADON stated that resident skin assessments were not documented but they were only signed off on the MAR/TAR when ordered. She stated only if there was a change in skin-integrity was there anything documented and it would be in a nursing progress note. During an interview on 03/26/2026 at 2:42 PM DON stated that after reviewing Resident #1's care plan she was unable to find interventions for offloading heels or repositioning Resident #1. Record review of the facility's Skin Integrity Management policy, revised October 10, 2020, reflected: Review the discharge records, transfer sheets or other data regarding the patients history of, or risk factors for skin alterations and pressure ulcer development.Reposition residents at risk for pressure sore or with pressure sores at least every two (2) hours, if unable to turn themselves.Use pillows or foam wedges to keep bony prominences from direct contact .The presence of a pressure-reducing device/specialty bed does not negate the need to turn/reposition the resident at least every two (2) hours in order to prevent pulmonary and renal complications as well as pressure sores .If eschar or necrotic tissue is present, debridement may be indicated. Physicians do surgical debridement only. Facility Name: [NAME] Springs Healthcare and RehabDate of IJ Notification: 03/25/2026 Date/Time IJ Identified by Surveyor: 03/25/2026 at 6:22 PM Plan of Removal - F686Tag: F686 - Treatment/Services to Prevent and Heal Pressure UlcersThe facility has failed to prevent new pressure ulcers and treating existing pressure ulcers.How the facility will identify other residents having the potential to be affected and take corrective actionThe DON/ADON conducted an audit of all current residents to determine what resident at risk for pressure injuries, including residents with limited mobility, dependence on staff for repositioning, malnutrition, existing wounds, or recent decline. We use this criterion to determine who is at risk for pressure injuries. After screening all 69 residents, based on the audit, 51 residents were identified to have the potential to be affected. Systemic Changes Made All identified at-risk residents received- completed by DON/MDS: Start date 3/25/26- updated skin assessments on the 69 residents, will be kept in the medical record under document tab- completion date 3/27/26verification of pressure-relieving devices- out of the 51 identified residents (physician order as required, Care planned and device in place)review of treatment orders- verified all at risk residents have treatment orders for all identified skin issues, any without treatment orders MD will be notified to receive orders.review of nutrition status- verified all at risk residents were reviewed to determine that nutritional status has been assessed, MD orders as needed, care plan update, and RD review.care plan review- all at risk residents were reviewed to ensure care plan addresses all concerns regarding skin- including identify wounds, treatment, pressure relieving devices, repositioning, nutrition, etc.Skin assessment findings lists are attached. The facility revised/reinforced its skin integrity and pressure injury prevention process to include: timely risk identification on admission and with condition change using the 24-hour report at nurse's station, DON/MDS will review every admission/condition change within 24/48 hours to ensure all conditions are identified and addressedweekly skin assessments completed by charge nurse and the ADON will audit after completion.physician notification- Charge nurse will notify within 2 hours of identifying skin issues-DON will audit physician notification daily through progress notes. wound consultant follow-up, ADON to round with Wound Physician weekly, ADON implement orders or new treatments within 2 hours.care plan revision- charge nurse/ADON/MDS will revise care plan immediately following the care plan change required- DON will audit care plan changes. heel offloading for applicable residents (see attached heel offloading list)- charge nurse/CNAs are in charge of offloading heels [NAME] are in bed- ADON/DON to validate daily but utilizing a monitoring sheet - DON is developing the list of residents that are requiring heel offloading, the list will be available when the systematic changes are complete by 3/26/26Systemic Changes were started on 3/25/26 at 9:30pm.Date of Completion: 3/26/26Education with Post Test for staffDON/ADON will re-educate licensed nurses and CNA staff on: pressure injury risk recognition, repositioning/offloading techniques, reporting skin changes immediately, documentation of skin checks on skin observation sheets, All nursing staff will be educated and staff not attending will not work until education has been completed. Administrator will be responsible for tracking attendance and completion of posttests.Education started on 3/25/26 at 9:30pm.Date of Completion: 3/26/26Monitoring to Ensure Ongoing ComplianceThe DON, ADON will audit: residents with current pressure injuries, residents at risk for skin breakdown, repositioning documentation, weekly skin assessments, wound treatment compliance, and care plan updates. DON/ADON will complete wound care and skin audits: Once daily (7 days per week) x 2 weeks 3 times each weekly x 2 weeks Once a weekly x 4 weeks Any negative findings will be corrected immediately, including staff counseling/re-education, resident reassessment, physician notification, and care plan revision as indicated. Audit findings and trends will be reported to the QAPI Committee for ongoing review and additional action if needed. Medical Director was notified of IJ, plan of removal was discussed and approved 3-25-26 9:15pmMonitoring was started on 3/27/26 Date of Completion: 3/27/26 On 03/27/2026 the investigator began monitoring if the facility implemented their plan of removal sufficiently to remove the IJ by the following: Audits for residents with pressure injuries, residents with skin breakdown, weekly skin assessments, wound treatment compliance, and care plan updates were reviewed. No new pressure injuries were found, two residents were found, Resident #12 with a slightly increased area of rash, and Resident #14 with a bruise under the 4th digit of her right foot. The Point of Contact System that CNA's use to document repositioning and off-loading heels was observed to be updated, with those areas now available and functioning. Skin assessments were completed for the entire resident population. EHR records for 14 identified residents with both pressure, venous wounds or requiring off-loading of heels were reviewed and residents were found to be receiving regular wound care. Interviews conducted with nursing staff scheduled on 03/26/26 to 3/30/26 from 6:00 a.m. to 9:00 p.m., these included PRN, and new hire staff of all shifts: [RN A, RN C, RN F, RN G, LVN H, RN I, LVN M, LVN O, LVN T, LVN bb, and LVN dd], and CNA's/CMA's [CMA B, CNA D, CNA E, CNA J, CNA K, CNA L, CNA N, CNA P, CNA Q, CMA R, CNA S, CNA U, CNA V, CMA X CNA Y, CNA Z, and CNA aa] indicated they participated in the mandatory in-service education about Pressure Injury Risk Recognition, Repositioning/Off-Loading, Reporting Skin Changes Immediately and Documentation of Skin Checks on Observation Sheets. The RNs, LVNs CNAs and CMAs summarized the topic of discussion which included policy, procedure, and the facility/leadership expectations. Each staff member stated in their own words the procedures for resident skin management to prevent pressure injury/ulcer development, importance of repositioning and off-loading heels. RNs/LVNs said that they would notify the ADON/DON and notify the physician immediately of resident change in condition and verbalized steps on how to notify attending physician/NP/physician designee and the wound physician, if applicable, including what actions to take if unable to contact a physician. CNA/CMAs identified where to find orders for repositioning/off-loading heels, how to document repositioning/off-loading and indicated that they would notify their RN/LVN or Charge Nurse of any change of skin condition. Observations and interviews of Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14 identified as requiring Pressure Devices, were observed and interviewed between 03/27/26 at 11:34 p.m. to 03/30/26 at 12:25 PM. Residents were observed to be either in possession of or actively using all ordered pressure device equipment. Residents reported that they generally tried to use their heel floating boots but were allowed to make a choice if boots got too hot or too uncomfortable. Residents reported general good compliance with repositioning/off-loading heels and had no other complaints of their present care or treatment at the facility. An observation on 03/25/2026 at 2:25 PM of a wound care/dressing change was observed of Resident #10 conducted by LVN M: ADON/LVN M was noted donning/doffing PPE appropriately and using hand hygiene and hand washing appropriately. ADON/LVN M used appropriate practice and infection control practices and followed the physician order. Resident #10 tolerated well. Resident #10 was noted with two foam wedges at the bedside and a cushion in her wheelchair. She was noted as confused and not interviewable. Her bed was in low position, and her call bell was in reach. An observation on 03/28/26 at 2:25 PM Wound care/dressing change was observed of Resident #2 conducted by RN G and assisted by CNA E:-Resident was under EBP for open wounds, RN G and CNA E observed donning gowns and gloves inside of room.-Bedside table prepped with clean absorbent pads and bandages /wound dressings staged. -Original bandage to be removed dated 3/27/26 by RN J.T. Bandage appeared clean with no signs of bleed through or discoloration. -Alginate pads dated 3/28/26.-Removal of bandage from Resident was accomplished with little to no discomfort. -Skin around wound appeared pale/with some redness at the top of the ankle where the gauze had creased with the skin, noted by RN G.-Medial ankle wound appeared to have definite borders with little to no edema and slight serosanguineous exudate, no purulence observed.-Under side of the heel was exposed, entire foot appeared to be swollen, but not from cellulitis, skin was pale but blanchable.-well defined borders to posterior calcaneus wound, with visible red/perfused blood on alginate pad.-both wound sites had been cleansed with NS and Alcohol/Pads.-New pads applied, gloves were changed between each wound.-Resident appeared to have tolerated procedure well. Record review on 3/30/26 at 9:00 a.m. of In-Service trainings titled Pressure Injury Risk Recognition, Repositioning/Offloading Techniques, Reporting Skin Changes Immediately, and Documentation of Skin Checks on Skin Observation Sheets found that 48 of 50 Nursing staff had been trained. Two other staff members were reported to have been out of the country at the time of the training. The ADM was informed the Immediate Jeopardy was removed on 03/27/2026 at 2:40 PM. The facility remained out of compliance at a scope of Isolated and severity level of No Actual Harm with a potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one (Resident #1) of 14 residents, reviewed for care plans. The facility failed to address Resident #1's required off-loading of heels and repositioning every two hours, as these orders were not reflected in Resident #1's Comprehensive Care Plan. Resident #1 developed a Stage 4 Pressure Wound. On 03/25/2026 at 6:22 p.m. an Immediate Jeopardy (IJ) was identified. The IJ template was provided to the facility on [DATE] at 6:22 PM. While the IJ was removed on 03/27/26 at 2:40 PM, the facility remained out of compliance at a scope of Isolated and severity level of No Actual Harm with a potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being.Findings included: A record review of Resident #1's Face Sheet dated 03/24/2026 reflected a [AGE] year-old female with an initial admittance date of 12/30/2025 with diagnosis that included: Malnutrition, Anxiety, Asthma-Chronic obstructive Pulmonary Disease, Toxic Encephalopathy (Brain dysfunction caused by exposure to toxic chemicals), Alcohol Dependance, Muscle Wasting and Atrophy Lower Leg, Cognitive Communication Deficit, and Muscle Weakness. A record review of Resident #1's Quarterly MDS dated [DATE], revealed a [AGE] year-old female that initially admitted to the facility on [DATE]. Resident #1 had medically complex conditions that included active diagnosis of Malnutrition, Anxiety, Asthma-Chronic obstructive Pulmonary Disease, Toxic Encephalopathy (Brain dysfunction caused by exposure to toxic chemicals), Alcohol Dependance, Muscle Wasting and Atrophy Lower Leg, Cognitive Communication Deficit, and Muscle Weakness. A BIMS Score of 06 (Severe Cognitive Impairment). Resident #1 was always incontinent of bowel and bladder, was dependent (required the assistance of two or more helpers) for tub/shower transfer, and Resident #1 either refused or was unable to: sit to lying, lying to sitting, sit to stand, chair/bed to chair transfer, toilet transfer or walk. A record review of Resident #1's Care Plan Report dated 03/25/2026 reflected the following: Focus: Pressure Ulcer Risk: Resident has the potential for the development of a pressure ulcer. (Date Initiated 01/12/2026). Goal: The Resident will be free of preventable breakdown through next review date. (Date Initiated 01/12/2026, Revision on 03/18/2026, Target Date 06/19/2026). Interventions: Check Frequently for wetness and soiling, every two hours provide incontinence care as needed. (Date Initiated 01/12/2026). Bathe per schedule. (Date Initiated 01/12/2026). Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new skin conditions to the physician. (Date Initiated 01/12/2026). The Care plan did not address off-loading of heels or repositioning the resident. Record Review of Resident #1's Braden Scale for Predicting Pressure Sore Risk dated 12/30/2025 at 8:26 p.m., and signed by RN ee rated Resident #1 as low risk with a score of 16 out of a possible 23 (Higher score indicates higher risk). Record review of Resident #1's EHR, dated 12/30/2025 through 03/30/2026 and accessed between 3/24/2026 and 03/30/2026, revealed there were no documented Skilled Observation Notes (what the facility claimed they used as skin assessments) from 01/01/2026 until 02/20/26. All Skilled Observation Notes after 02/26/2026 indicated the skin as warm, dry, skin intact, with no notable changes in skin condition. Record Review of a hospital document discovered in the facility EHR titled Wound Care Service, dated 12/22/25, and identifying Resident #1 as the recipient of services found that Resident #1 had orders under Prevention Plan: Heels - Offload using Heel Protector Boot or pillows lengthwise. Record review of a document titled Specialty Physician Initial Wound Evaluation & Management Summary, dated 02/17/2026 and signed by Wound Care Physician revealed that Resident #1 had been diagnosed with an unstageable DTI of the right heel, undetermined thickness that was measured at: 2.7 cm (length) x 3 cm (width) x unmeasurable cm (depth), with a total surface area of the wound measured at 8.10 cm squared, and an unstageable DTI of the left heel measuring 1.5 cm (length) x1 cm (width) not measurable depth cm, with a total surface area of the wound measured at 1.50 cm squared. Record review of a document titled Specialty Physician Wound Evaluation & Management Summary, dated 3/10/2026 and signed by Wound Care Physician reflected that Resident #1 had a diagnosis of unstageable DTI of the right heel, undetermined thickness that was measured at: 1. cm (length) x 3 cm (width) x .06 cm (depth), with a total surface area of the wound measured at 3.90 cm squared, and a Stage 4 Pressure Wound of the Left heel, full thickness measuring 1 cm (length) x1.3 cm (width) not measurable depth cm, with a total surface area of the wound measured at 1.30 cm squared. In an interview on 03/24/2026 at 12:00 p.m. with a family representative of Resident #1, he stated that [Resident #1] had had two little wounds on her that were healed before she had left the hospital [just prior to admitting to the facility], she [Resident #1] didn't have any wounds on her heels and now she has a pressure ulcer. He stated that he had visited Resident #1 many times and he had never seen her wearing any boots on her feet or that they had pillows under her legs until after they started putting bandages on her feet. In an interview on 03/24/2026 at 1:55 p.m. NP stated that Resident #1 had admitted with no Pressure Ulcers or DTI's. She stated that she had seen that Resident #1 had developed blisters on both of her heels on 02/09/2026 and that she had for offloading and heel [boots] risers and that she had been told Resident #1 had been compliant with them. She stated that Resident #1 might have developed a pressure ulcer on her heel if the staff had not been repositioning/offloading her heels, or the resident might have been taking of her heel protectors. She stated that she had been unaware that Resident #1 had developed a stage 4 pressure ulcer on her heel. In an interview on 03/24/2026 at 4:03 p.m. CNA ff revealed that she had worked often with Resident #1 and that she had done peri-care for Resident #1. She stated that Resident #1 never had a pressure ulcer on her bottom. She denied any knowledge of Resident #1 having any injuries to her feet. In an interview on 03/25/26 at 10:18 a.m. DON related that VOHRA (third party wound treatment consultant) gets referred too when wounds reach stage 2. She stated that Repositioning is not reflected on the TAR/MAR. She stated that there was no indication of any injuries to [Resident #1's] heels at the time of admission [to the facility]. She stated that the facility had not received heel riser boots yet for Resident #1. In an interview on 03/25/2026 at 10:20 a.m. ADON stated that the NP had ordered the wrong type of boot for Resident #1, so she only had the cone protectors. She stated that she had discovered the blisters on Resident #1's feet on 02/09/2026 as part of regular care, and had informed NP about it and new orders had been written. She stated that she might be able to provide the order slip for the boot protectors, but she did not provide the document/proof before exit from the facility on 03/30/2026. During an interview on 03/26/2026 at 2:42 PM DON stated that after reviewing Resident #1's care plan she was unable to find interventions for offloading heels or repositioning Resident #1. Record review of the facility's Comprehensive Care Plans Policy, dated 2/10/2021 and revised 9/4/2024 reflected that: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Policy Interpretation and ImplementationI. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.1. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.2. The IDT includes:a. The Attending Physician;b. A registered nurse who has responsibility for the resident;c. A nurse aide who has responsibility for the resident;d. A member of the food and nutrition services staff;e. The resident and the resident's legal representative (to the extent practicable); andf. Other appropriate staff or professionals as determined by the resident's needs or as requested by the resident.3. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to:a. Participate in the planning process;b. Identify individuals or roles to be included;c. Request meetings;d. Request revisions to the plan of care;e. Participate in establishing the expected goals and outcomes of care;f. Participate in determining the type, amount, frequency and duration of care;g. Receive the services and/or items included in the plan of care; andh. See the care plan and sign it after significant changes are made.4. The resident will be informed of his or her right to participate in his or her treatment.5. An explanation will be included in a resident's medical record if the participation of the resident and his/her resident representative for developing the resident's care plan is determined to not be practicable.6. The care planning process will:a. Facilitate resident and/or representative involvement;b. Include an assessment of the resident's strengths and needs; andc. Incorporate the resident's personal and cultural preferences in developing the goals of care.7. The comprehensive, person-centered care plan will:a. Include measurable objectives and timeframes;b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;d. Describe any specialized services to be provided as a result of PASARR recommendations;e. Include the resident's stated goals upon admission and desired outcomes;f. Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire;g. Incorporate identified problem areas;continues on next page h. Incorporate risk factors associated with identified problems;i. Build on the resident's strengths;j. Reflect the resident's expressed wishes regarding care and treatment goals;k. Reflect treatment goals, timetables and objectives in measurable outcomes;I. Identify the professional services that are responsible for each element of care;m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels;n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; [NAME]. Reflect currently recognized standards of practice for problem areas and conditions.8. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan.9. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.a. No single discipline can manage an approach in isolation.b. The resident's physician (or primary healthcare provider) is integral to this process.10. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.a. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers.b. Care planning individual symptoms in isolation may have little, if any, benefit for the resident.11. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment.12. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.13. The Interdisciplinary Team must review and update the care plan:a. When there has been a significant change in the resident's condition;b. When the desired outcome is not met;c. When the resident has been readmitted to the facility from a hospital stay; andd. At least quarterly, in conjunction with the required quarterly MDS assessment.14. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals will be documented in the resident's clinical record in accordance with established policies. Date of IJ Notification: 03/25/26/2026 Date/Time IJ Identified by Surveyor: 03/25/2026 at 6:22 PM Plan of Removal - F656Tag: F656 - Develop/Implement Comprehensive Person-Centered Care PlanThe facility has failed to develop and implement, a comprehensive centered care plan for each resident, consistent with resident rights that include measurable objectives and timeframes. How the facility will identify other residents having the potential to be affected and take corrective actionThe DON/ADON conducted an audit of all current residents to determine what residents are at risk for pressure injuries, including residents with limited mobility, dependence on staff for repositioning, malnutrition, existing wounds, or recent decline. We use this criterion to determine who is at risk for pressure injuries. After screening all 69 residents, based on the audit, 51 residents were identified to have the potential to be affected. Systemic Changes Made The DON/ADON conducted an audit of the 51 residents in high-risk skin breakdown determined by Braden scale score, below 10. The residents from the high risk audit and residents with current wounds and significant change of conditions were reviewed to validate that the comprehensive care plan was in place, addressing all issues, has appropriate interventions and update as needed. Any resident identified with missing, incomplete, or outdated care plan interventions had the care plan reviewed and revised immediately by the MDS Coordinator and DON (See attached list)MDS nurse has completed care plan updates, and a list will be attached (See attached list) Systemic Changes were started on 3/25/26 at 9:30pm.Date of Completion: 3/26/26 Education with posttest for staffDON/ADON will re-educate licensed nurses, MDS staff, and interdisciplinary team members (MDS Coordinator, Rehab Director, Social Worker, Activity Director, Dietary Manager) on:requirements for comprehensive person-centered care planning, care plan revision after new wounds or condition changes- care plan is to be revised as soon as issue is identified by ADON responsible for wound care. DON to validate care plan revision daily during morning meetingmeasurable objectives and individualized interventions- DON/ADON/MDS are responsiblecommunication of updated interventions to direct care staff through Kardex on the care plan and documentation of care plan review and implementation in the medical record under the document tab All staff will be educated and staff not attending will not work until education has been completed. Administrator will be responsible for tracking attendance and completion of posttests.Education was started on 3/25/26 at 9:30pm.Date of Completion: 3/26/26 Monitoring to Ensure Ongoing ComplianceThe DON, ADON, MDS Coordinator will audit residents with: new wounds, current pressure injuries, significant changes in condition, and identified skin risk factorsto verify the comprehensive care plan was revised timely and interventions were individualized and implemented.Audits will be completed: Once daily (7 days per week) x 2 weeks Once a week x 4 weeks Monthly thereafter through QAPI as indicated Any negative findings will be corrected immediately through care plan revision, staff re-education, and follow-up review. Results of the audits will be brought to the QAPI Committee for review, trend analysis, and additional corrective action as needed.Medical Director was notified of IJ, plan of removal was discussed and approved 3-25-26 9:15pm Monitoring was started on 3/27/26 Date of Compliance: 3/26/26 On 03/27/2026 the investigator began monitoring if the facility implemented their plan of removal sufficiently to remove the IJ by the following: Audits of all resident care plans were conducted from 03/252026 to 03/27/2026, results were reviewed, no other residents were found with discrepancies in their care plans when compared to physician orders and diagnosis. Interviews conducted with nursing staff scheduled from 03/26/26 at 6:00 a.m. to 3/30/26 at 3:00 p.m., these included PRN and new hire staff [RN A, RN C, RN F, RN G, LVN H, RN I, LVN M, LVN O, LVN T, LVN bb, and LVN dd], and CNA's/CMA's [CMA B, CNA D, CNA E, CNA J, CNA K, CNA L, CNA N, CNA P, CNA Q, CMA R, CNA S, CNA U, CNA V, CMA X CNA Y, CNA Z, and CNA aa] indicated they participated in the mandatory in-service education about Comprehensive Care Plans, Care Plan Revision, Measurable Objectives and Individualized Interventions, Communication of Updated Interventions to Direct Care Staff through the[POC] System, and Documentation of Care Plan Review. The RN's and LVN's summarized the topic of discussion which included policy, procedure, and the facility/leadership expectations. CNA's were able to explain and demonstrate where to find Care Plan information in the POC System. Observations and interviews of Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14 identified as requiring Pressure Devices, were observed and interviewed between 03/27/26 at 11:34 AM to 03/30/26 at 12:25 PM. Residents were observed to be either in possession of or actively using all ordered pressure device equipment. Residents reported that staff generally were on time with repositioning and that they had attended Care Plan meetings and had no other complaints of their present care or treatment at the facility. An observation and interview with CNA L on 3/27/2026 CNA L was observed using the POC system, she stated that she could look up the Kardex (Care Plan) for any resident in the facility. She was able to demonstrate looking up three different residents without issues. In an interview on 03/30/2026 at 12:33 PM MDS Coordinator/LVN H revealed that that there had been a communication issue regarding Resident #1's Care Plan, she stated that after the training there are many more redundancies to make sure that all information for each resident is given to her to be able to correctly and timely update the Care plans for each resident. Record review of In-Service trainings Titled Comprehensive Care Plans found that 48 of 50 Nursing staff had been trained. Two other staff members were reported to have been out of the country at the time of the trainings. The ADM was informed the Immediate Jeopardy was removed on 03/27/2026 at 2:40 PM. The facility remained out of compliance at a scope of Isolated and severity level of No Actual Harm with a potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure food items were accurately labeled and dated with the received or expiration date. 2. The facility failed to ensure dented cans were placed in a separate storage area. 3. The facility failed to ensure opened items were sealed or resealed effectively. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observation of dry storage on 03/04/2025 at 9:13am revealed the following: -1, 1lbs box of cream of wheat dated 02/08/2025 opened and exposed to the air. - 6 bags of hot dog buns with no use by or expiration date. -1, 3lbs can of cream of chicken dated 01/08/2027 was dented on bottom left. In an interview with the DM on 03/04/2025 at 9:30am she stated dented cans were stored in a separate area in the dry storage closet. She stated when dented cans were identified, she notified the vendor to receive a credit. She stated when she received bread delivery, the expiration date was printed on the outside of the package. She stated if the expiration date was not printed on the packaging, she wrote a use by or expiration date on the packaging. She stated all food items should be properly sealed. She stated food not stored and labeled properly could cause cross contamination. In an interview with [NAME] F on 03/05/2025 at 11:19am she stated all food items needed to be sealed properly and dated with the use by or expiration date. She stated dented cans are stored in a separate area and returned to the vendor. She stated if items are not sealed, labeled, and stored properly could cause cross contamination and residents could become sick. Record review of the facility's Food Storage Policy revised 8/11/ 2017 reflected, Policy Statement: Dry storage may be in a room or area for the storage of dry goods, such as single service items, canned goods, and packaged or containerized bulk food that is not PHF/TCS. 6. Products which do not have an imprinted use by or expiration date on the product, will be dated when received and rotated as new inventory is purchased. 9. All opened products must be resealed effectively and properly labeled, dated and rotated use. 11. Canned goods that have a compromised seal will be removed from service and stored in a separate area, until they are picked up by the distributor of discarded. Record review of the U.S. FDA Food Code 2022 reflected: Chapter 3 . section 3-101.11. Safe, Unadulterated, and Honestly Presented: . FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form. (c The specific artificial color used in a food shall be identified on the labeling when so required by regulation in part 74 of this chapter to assure safe conditions of use for the color additive.], 9 CFR 317 Labeling, [*(a) When, in an official establishment, any inspected and passed product is placed in any receptacle or covering constituting an immediate container, there shall be affixed to such container a label .Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. Section 3-302.12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section 3-501.17 . Commercial processed food: Open and hold cold . B . 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety . C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3 . Food Receiving and Storage - Section 3-302.11 Packaged and Unpackaged Food-Separation, Packaging, and Segregation Food shall be protected from cross contamination by: when combined as ingredients, separating raw animals' foods during storage, preparation, holding, and display.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received care and treatment consistent with professional standards of practice to promote healing and to prevent further development of skin breakdown or pressure ulcers for two (Resident #10 and Resident #32) of five residents reviewed for pressure ulcers. 1. The facility failed to ensure Resident #10 was repositioned every two hours as indicated in Resident #10's physician orders. 2. The facility failed to ensure Resident #32 was repositioned every two hours as indicated in Resident #32's care plan. These failures could place residents at risk for worsening pressure ulcers, new pressure ulcers, or infection. Findings included: 1. Record review of Resident #10's Annual MDS assessment dated [DATE] revealed Resident #10 was an [AGE] year-old female admitted to the facility on [DATE] and diagnoses included malnutrition, pressure ulcer of sacral region (lower back and upper buttocks), muscle wasting and muscle atrophy (decrease of muscle mass). Section C of the MDS indicated Resident #10's BIMS was 00 (indicated severe cognitive impairment). Section GG of Resident #10's MDS indicated Resident #10 was dependent (required assistance and was unable to help with activities) with all ADLs and was unable to roll to the left or right. Section M of Resident #10's MDS assessment indicated Resident #10 was at risk for developing pressure ulcers. Record review of Resident #10's care plan with a revision date of 1/13/2025 revealed Resident #10 had the potential to develop pressure ulcers and interventions included to reposition the resident frequently or more often as needed. Record review of Resident #10's wound evaluation and summary report dated 2/18/2025 revealed Resident #10's wound on her sacrum was healed and the wound had been present for more than 364 days. Record review of Resident #10's physician order dated 3/03/2025 revealed Resident #10 should be repositioned every two hours. In an observation on 3/04/2025 at 10:46 a.m., Resident #10 was observed laying flat on her back with one pillow under her head. No other pillows or wedges (foam wedge used for positioning) were observed in Resident #10's room. Resident #10 was unable to answer questions appropriately. In an observation on 3/04/2025 at 1:24 p.m., Resident #10 was observed in the same position on her back with one pillow under her head. No other pillows or wedges were observed in Resident #10's room. In an observation on 3/05/2025 at 11:05 a.m., Resident #10 was observed in the same position on her back with one pillow under her head. No other pillows or wedges were observed in Resident #10's room. In an observation on 3/05/2025 at 1:49 p.m., Resident #10 was observed in the same position on her back with one pillow under her head. No other pillows or wedges were observed in Resident #10's room. In an observation on 3/05/2025 at 3:36 p.m., Resident #10 was observed in the same position on her back with one pillow under her head. No other pillows or wedges were observed in Resident #10's room. In an observation on 3/06/2025 at 9:00 a.m., Resident #10 was observed in the same position on her back with one pillow under her head. No other pillows or wedges were observed in Resident #10's room. Record review of Resident #10's progress note dated 3/03/2025 at 1:54 p.m. by RN B, revealed an open area was noted to the coccyx (area near the top of the buttocks and the base of the spine). Measurements or wound type were not indicated. In an interview on 3/06/2025 at 2:30 p.m., ADON C stated the measurements for Resident #10's new wound was 0.5 x 0.5 cm. The doctor and hospice were notified on 3/03/2025. ADON C stated it was an open area and did not indicate the specific type of wound. 2. Record review of Resident #32's Quarterly MDS assessment dated [DATE] revealed Resident #32 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of diabetes, aphasia (inability to comprehend of formulate language), hemiplegia (partial paralysis of one side of the body) or hemiparesis (muscle weakness of one side of the body), and muscle wasting and muscle atrophy (decrease of muscle mass). Section C of the MDS assessment also revealed Resident #32 had severely impaired cognitive skills and was rarely/never understood. Section GG of Resident #32's MDS indicated Resident #32 was dependent (required assistance and was unable to help with activities) with all ADLs and was unable to roll to the left or right without assistance. Section M of Resident #32's MDS assessment indicated Resident #32 had one stage 4 pressure ulcer that was present upon admission and had not healed at the time of the assessment. Record review of Resident #32's care plan with a revision date of 2/06/2025 revealed Resident #32 had a pressure ulcer, and interventions included to reposition the resident every two hours or more often as needed or requested. Record review of Resident #32's wound evaluation and summary report dated 1/28/2025 revealed Resident #32 had a wound on her sacrum for more than 203 days with measurements of 4 x 2.5 x 1cm. Recommendations included to reposition per facility protocol and turn side to side in bed every one to two hours if able. Record review of Resident #32's wound evaluation and summary report dated 2/25/2025 revealed Resident #32 had a wound on her sacrum for more than 231 days with measurements of 4 x 2.5 x 1cm. Recommendations included to reposition per facility protocol and turn side to side in bed every one to two hours if able. In an observation on 3/04/2025 at 10:49 a.m., Resident #32 was observed lying flat on her back with two wedges observed stuck between the bed and the wall. One pillow was placed under the resident's head. Resident #32 was unable to answer questions due to a severe cognitive impairment. In an observation on 3/04/2025 at 1:26 p.m., Resident #32 was observed in the same position lying flat on her back with two wedges observed stuck between the bed and the wall. One pillow was placed under the resident's head. In an observation on 3/05/2025 at 10:58 a.m., Resident #32 was observed in the same position lying flat on her back with one wedge observed next to the resident on her right side (not under). Another wedge was observed stuck between the bed and the wall. One pillow was placed under the resident's head. In an observation on 3/05/2025 at 1:48 p.m., Resident #32 was observed in the same position lying flat on her back with one wedge observed next to the resident on her right side (not under). Another wedge was observed not placed under the resident and lying on the foot of the bed. In an observation on 3/05/2025 at 3:38 p.m., Resident #32 was observed in the same position lying flat on her back with one wedge observed next to the resident on her right side (not under). Another wedge was observed not placed under the resident and lying on the foot of the bed. In an observation on 3/06/2025 at 9:00 a.m., Resident #32 was observed in the same position lying flat on her back with one wedge observed next to the resident on her right side (not under). The other wedge was no longer in the room. In an interview on 3/05/2025 at 4:08 p.m., CNA A reported that pressure sores were prevented by rotating or turning the resident every two hours. CNA A stated some residents had extra pillows, and some residents had wedges to use for turning. CNA A stated that if a resident was not turned then sores could develop. CNA A stated Resident #32 and Resident #10 were turned every two hours to prevent sores from developing. In an interview on 3/06/2025 at 10:10 a.m., RN B reported if a resident was bedridden then they were repositioned every one to two hours. RN B reported they used pillows to help reposition residents, and the nurse was responsible for ensuring residents were repositioned. RN B stated if residents were not repositioned then it could cause skin breakdown (wounds). RN B stated Resident #10 was on an air mattress and was repositioned every one to two hours. RN B reported Resident #10 had wounds that did better some days and were worse on other days. RN B reported Resident #32 was repositioned with wedges, but she was not sure how often. RN B stated the wedges lifted Resident #32's bottom off the bed. RN B reported she was unsure if Resident #32's wounds had become worse because she had only worked at the facility for around six weeks. In an interview on 3/06/2025 at 11:16 a.m., ADON C stated Resident #10's wound was resolved, and Resident #10 had just developed a new wound. ADON C stated the wound care doctor monitored the status of wounds every Tuesday and documented any changes in the wound evaluation and summary report. ADON C stated Resident #32's wound would never heal because Resident #32 was receiving a low amount of nutrition via a tube feeding. ADON C reported Resident #32's wound was chronic and had not changed significantly. ADON C reported the dietician was monitoring Resident #32, and Resident #32 was unable to tolerate the tube feeding if it were increased. ADON C reported that Resident #32 and Resident #10 should have been repositioned every two hours and as needed. ADON C stated pillows and wedges were used for repositioning, and if residents were not repositioned then it could cause a pressure ulcer to form or reopen. ADON B reported that the nurses were responsible for monitoring if residents were turned every two hours. In an interview on 3/06/2025 at 11:55 a.m., the DON reported that dependent (requires assistance) residents should be turned everyone and a half to two hours and more frequently if they were in pain. The DON stated pillows or wedges were used for repositioning the residents. The DON stated Resident #10 was on hospice and wounds were not unexpected. The DON reported Resident #10 should still be repositioned every one to two hours. The DON reported Resident #32 had a wound and should be repositioned every one to two hours. The DON reported the nurses should monitor if residents were turned, and ADON C monitored the wound documentation to determine if wounds were progressing. Record review of facility's policy titled, Skin Management Policy, with a revision date of 2/01/2014, revealed If new skin alterations of any type are identified .physician orders are obtained. The patient is reviewed by the interdisciplinary team and a plan of care is initiated. A policy specific to repositioning residents for pressure ulcer prevention was not received at the time of exit.

Based on record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon for two (Residents #19 and Resident #9) out of six residents and failed to ensure the Pharmacist Consultant reported irregularities to the Physician whose medications were reviewed. 1. Resident 19's Pharmacist consultant recommendation for a gradual dose reduction of Citalopram (antidepressant medication) had no physician rationale for continued use. 2. Resident 19's Pharmacist consultant recommendation for a gradual dose reduction of Quetiapine (antipsychotic medication) had no physician rationale for continued use. 3. Resident 9's Pharmacist consultant recommendation for a gradual dose reduction of Risperidone (antipsychotic medication) had no physician rationale for continued use. 4. Resident 9's Pharmacist consultant recommendation for a gradual dose reduction of Divalproex (antipsychotic medication) had no physician rationale for continued use. These failures could place residents at risk for adverse consequences and could cause a decline in their physical, mental, and psychosocial condition. Findings included: Resident #19 Record review of Resident #19's face sheet dated 03/06/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE] and re admitted on [DATE] with diagnoses which included Alzheimer's Disease, schizoaffective disorder, and dysphagia (difficulty swallowing). Record review of Resident #19's MDS assessment dated [DATE] revealed he had a BIMS score of 14 which indicated intact cognition. Resident #19 diagnoses included anxiety disorder, psychotic disorder, and schizophrenia. Resident #19 received antipsychotic and antidepressant medications and exhibited no behavioral symptoms. Record review of Resident #19's care plan dated 01/17/2025 revealed Resident #19 had a psychosocial well being problem r/t anxiety, schizophrenia, and depression. Goal: the resident will verbalize feelings related to emotional state .the resident will identify appropriate diversional activities. Interventions: give medication as ordered and monitor for side effects. Give positive reinforcement as initiative/involvement improves/attempts to solve conflict. Monitor/document resident's usual response to problems. Record review of Consultant Pharmacist Recommendation to Physician dated 10/31/2024 reflected: Dear Physician G, Resident #19 has been taking Citalopram 10mg QAM 04/23/2024 without a GDR. Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? If not, please indicate response below. The recommendation letter was not signed by Resident #19's Physician. There was no rationale documented for GDR of Citalopram. Record review of Consultant Pharmacist Recommendation to Physician dated 11/30/2024 reflected Dear Physician G, Resident #19 has been taking Quetiapine 50mg BID since 03/10/2024 without a GDR. Could we attempt a dose reduction at this time perhaps Quetiapine 25mg QAM and 50mg verify this resident is on the lowest possible dose? If not, please indicate response below. The recommendation letter was not signed by Resident #19's Physician. There was no rationale documented for GDR of Quetiapine. Record review of Resident #19's Physician orders dated 04/23/2024 by Physician G for Citalopram 20mg. Give one tablet by mouth in the morning for depression. Record review of Resident #19's Physician orders dated 03/10/2024 by Physician G for Quetiapine 50mg. Give one tablet by mouth two times a day related to schizophrenia. Dementia. Review of Resident #19's electronic record revealed there was no documentation a rationale for continuing the medications and not doing a GDR by the physician for Citalopram or Quetiapine. In an interview on 03/06/25 at 12:08 PM Interview with Resident #19 stated he take medication for gout, Motrin, and allergy medications. He stated he did not take any anti-depressants or any psychotropic medications. He stated he did not have any changes to his medications. Resident #9 Record review of Resident #9's face sheet dated 03/06/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE] with diagnosis of schizophrenia, and major depressive disorder. Record review of Resident #9's MDS assessment dated [DATE] revealed he had a BIMS score of 15 which indicated intact cognition. Resident #9 diagnosis included depression and schizophrenia. Resident #9 received antipsychotic medications and exhibited no behavioral symptoms. Record review of Resident #9's care plan dated revealed Resident #9 used psychotropic medications related to depression, schizophrenia. Goal: resident will maintain the highest level of function possible and not experience a decrease in functional abilities related to psychotropic drug use during the next 90 days. The resident will reduce the use of psychoactive medication over the next 90 days. Interventions: administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Consultant Pharmacist Recommendation to Physician dated 01/31/2025 reflected Dear Physician G, Resident #9 has been taking Divalproex 500mg BID since 07/03/2024 without a GDR. Could we attempt a dose reduction at this time to perhaps Divalproex 250mg QAM and 500mg to verify this resident is on the lowest possible dose? If not, please indicate response below. The recommendation letter was not signed by Resident #9's Physician. There was no rationale documented for GDR of Divalproex. Record review of Consultant Pharmacist Recommendation to Physician dated 09/30/2024 reflected Dear Physician G, Resident #9 has been taking Risperidone 2mg BID since 02/06/2024 without a GDR. Could we attempt a dose reduction at this time to perhaps Risperidone 1mg QAM and 2mg to verify this resident is on the lowest possible dose? If not, please indicate response below. The recommendation letter was not signed by Resident #9's Physician. There was no rationale documented for GDR of Risperidone. Record review of Resident #9's Physician orders dated 02/07/2024 by Physician G for Risperidone 2mg. Give one tablet by mouth twice daily for schizophrenia. Record review of Resident #9's Physician orders dated 07/04/2024 by Physician G for Divalproex 500mg. Give one tablet by mouth twice daily for schizophrenia. Review of Resident #9's electronic record revealed there was no documentation a rationale for continuing the medications and not doing a GDR by the physician for Risperidone or Divalproex. In an interview on 03/06/25 at 12:04pm with Resident #9 stated he took lisinopril and risperidone. He stated was unsure what dosage took but he took the same medication daily in the morning and evening. He stated he could not recall if he ever had a dosage reduction for any of his medications. In an interview on 03/06/2025 at 9:10am with the DON she stated she's been employed at the facility for 4 weeks. She stated she is unsure what the process was for the pharmacist recommendations. She stated since she's been in her position, she retrieved the pharmacist recommendations from the portal that she only had access to and send the recommendations to the physician. She stated she faxed the recommendations to the physician and the physician would review and sign the recommendations via fax or in person. In an interview on 03/06/2025 at 9:57am with the ADON she stated she's been employed at the facility since October 2024. She stated she was the interim DON prior to the current DON being hired. She stated when she was interim DON, she retrieved the pharmacist recommendations from the portal and send the recommendations to the physician. She stated the physician reviewed and signed the recommendations when she visited the facility once a week. She stated she tried retrieving the older pharmacist recommendations that included the physician's signature, but she was unable to retrieve the recommendations because the facility no longer had access to the prior DON's email. She stated she contacted Physician G and the physician stated she received pharmacist recommendations from the prior DON and reviewed, signed, and returned the recommendations to the facility. (The recommendations were not provided prior to exit.) In an interview on 03/06/2025 at 11:11am with Physician G she stated she visited the facility weekly. She stated the facility provided her copies of the pharmacist recommendations via email or in person when she visited. She stated after she reviewed and signed the recommendations she returned the forms to the facility. She stated once she returned the forms to the facility, she was unsure what the facility did with the forms once received from her. Record review of the facility's Unnecessary Drugs policy dated 10/24/2022 reflected, Policy Statement: It is the facility's policy that each resident's drug regiment is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being free from unnecessary drugs. 2. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with the resident and/or representatives, other professionals, and interdisciplinary team. Each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements: A. dose(including duplicate therapy) B. Duration of use C. Indications and clinical need for medication D. Adequate monitoring for efficacy and adverse consequences E. Preventing, identifying and responding to adverse consequences F. Any combination of reasons stated above.

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles for one (200 hall medication cart) of three medication carts reviewed for medication labeling. The facility failed to ensure two insulin pens (one Aspart insulin syringe and one Tresiba insulin syringe) on the 200 hall medication cart had open dates. The facility failed to ensure two insulin pens on the 200-hall medication cart were discarded 28 days after being opened. One Lyumjev insulin pen and one Admelog insulin pen had an open date of 1/20/2025 and was found in the cart on 3/04/2025 (46 days after being opened). These failures could place residents at risk for not receiving the intended therapeutic effects of prescribed medication. Findings included: In an interview and observation on 3/04/2025 at 8:55 a.m., the 200-hall medication cart contained one Aspart insulin syringe and one Tresiba insulin pen with no open dates. RN D stated these two insulin pens were not opened, but the seals were not present on the insulin pens (indicated they were open). The 200-hall medication cart also contained one Lyumjev insulin pen and one Admelog insulin pen that had an open date of 1/20/2025 (46 days after being opened), and RN D stated these insulin pens were good until the manufacturer's expiration date because they were long-acting insulins. RN D stated there was no risks to the residents, and that the nurses using the carts monitored the dates on medications. In an interview on 3/04/2025 at 9:50 a.m., the DON stated an open date was required for all insulins including the long-acting insulins. The DON reported insulin should be discarded after 28 days. The DON reported that not having an open date or using beyond 28 days could cause the medication to not be as effective. The DON reported the nurses administering medications and the ADONs were responsible for monitoring the dates on medications. The DON stated her expectation was for all insulins to have an open date and to be discarded after 28 days. In an interview on 3/06/2025 at 11:16 a.m., ADON C reported she checked the medication carts for dates on medications every Tuesday. ADON C stated insulin had to have an open date because it was only good for 28 days and then must be discarded. ADON C stated if an insulin pen did not have an open date, then it could not be used and must be discarded. When asked what the risks would be to the residents if insulin was not dated or used past 28 days, ADON C just stated that insulin could not be used after 28 days, and staff would not know when the insulin was opened without a date. Record review of the facility's policy titled Medication Storage, with a date of 1/20/2021, revealed It is the policy of this facility to ensure all medications housed on our premises will be stored, dated and labeled according to the manufacturer's recommendations. The policy also revealed medication carts are routinely inspected for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels.

Based on interviews and record reviews, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, such as usual body weight for one (Resident #99) of seven residents reviewed for nutrition. 1. The facility failed to complete an annual comprehensive nutritional assessment or a nutrition assessment after identified weight loss by the dietician on 8/12/2024 per facility policy. 2. The facility failed to implement dietary recommendations on 8/12/2024 that included ordering a magic cup and obtaining weekly weights for four weeks. These failures could place residents at risk for unplanned weight loss and place them at risk of not having their nutritional needs met. Findings included: Record review of Resident #99's Comprehensive MDS assessment dated [DATE] revealed Resident #99 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of muscle wasting and atrophy (decrease of muscle mass), dementia, and heart failure. Section C of the MDS assessment revealed a BIMS score of 00 (indicated severe cognitive impairment). Section K of the MDS assessment did not indicate a weight loss of 5% or more in the last month or a loss of 10% or more in the last 6 months. Record review of Resident #99's care plan with a revision date of 9/17/2024 revealed Resident #99 had a nutritional risk and interventions included for a registered dietitian to evaluate and make diet/supplement changes. The care plan also revealed supplements should be provided as ordered. Record review of Resident #99's nutritional assessments revealed the last comprehensive nutritional assessment was completed on 8/02/2023. Record review of Resident #99's progress note dated 8/12/2024 at 11:30 a.m. written by Dietician E revealed Resident #99 had an unintended weight loss with a goal to prevent further significant weight loss. This progress note also revealed Resident #99's weight was 176 lbs. on 8/07/2024. Interventions listed included to start magic cup with every lunch and dinner and to obtain weekly weights for four weeks. Record review of Resident #99's weight records from 8/12/2024 to 9/12/2024 revealed weights were not obtained weekly after 8/12/2024. Weights obtained included: 8/21/2024 177.6 lbs. 9/06/2024 174.6 lbs. (loss of 3 lbs. or 1.7%) Record review of Resident #99's physician orders on 3/06/2025 revealed there were no orders entered for a magic cup or to obtain weekly weights after 8/12/2024. In an interview on 3/05/2025 at 1:09 p.m., the Dietary Manager reported the dietician visited the facility every week. The Dietary Manager stated the dietician assessed the residents quarterly or if there were any changes. The Dietary Manager reported that the dietician would document the assessments on the computer under assessments and would write notes under the progress notes. The Dietary Manager stated if a resident was not eating or drinking well then the dietician would order supplements, and a magic cup was a supplement. The Dietary Manager stated if dietary recommendations were not followed then the residents could lose weight. The Dietary Manager stated she did not remember if Resident #99 had difficulty drinking fluids or a decreased appetite. The Dietary Manager reported that Resident #99 was assessed by her and the dietician, but the dietician was responsible for documenting the assessment. In an interview on 3/06/2025 at 11:16 a.m., ADON C reported the dietician came to the facility every week or two and assessed the residents. ADON C stated if the dietician discovered any changes, then the dietician would relay the information to the nurses. ADON C stated then the nurses would notify the doctor and obtain an order. ADON C reported that a magic cup is ice cream and if the dietician recommended a magic cup, then an order would be obtained. ADON C stated once an order for the magic cup was entered then it would show up on the TAR for the nurses to ensure it was administered. ADON C stated the dietician may order a magic cup for weight loss or if a resident was not eating well. ADON C reported she monitored and ensured orders were put in for dietary recommendations. ADON C was not asked the risk of not following the dietary recommendations. In an interview on 3/06/2025 at 11:55 a.m., the DON reported the dietician would send recommendations to the DON. The DON reported she would enter an order to obtain weekly weights and an order for a magic cup. The DON stated she ensured the orders were put in and if dietary recommendations were not followed then it could affect the resident's weight and wound healing. The DON was unsure how frequently nutrition assessments had to be completed but stated she would verify since she was new at the facility. In an interview on 3/06/2025 at 12:38 p.m., Dietician E stated she would email dietary recommendations to the DON, ADON, and the dietary manager. The dietician stated the DON, ADON, and dietary manager were responsible for ensuring the recommendations were implemented. Dietician E reported she expected recommendations to be followed. Dietician E stated she documented assessments on the computer under nutrition assessments and wrote notes in the progress notes section. Dietician E stated nutritional assessments were completed at the time of admission, readmission, annually, and if at risk. Dietician E stated she ensured that assessments were done. Dietician E reported weekly weights and magic cups were ordered for residents at risk for weight loss. Dietician E was not asked about Resident #99. In an interview on 3/06/2025 at 2:34 p.m., the DON reported nutritional assessments were expected to be completed on admission and yearly. The DON stated if they were not completed then they may miss a resident who was at nutritional risk. The DON stated that the dietician and the DON were responsible for ensuring all assessments were done for all the residents. Record review of facility's policy titled, Nutrition Documentation Instructions, updated February 2021, revealed The sooner interventions can be started the better results we can obtain for these residents. Table 1 on this policy revealed If weight loss or eating poorly . Refer to RD for nutrition assessment and under the Time Frame on this table revealed, On admission, annually and significant change of condition. In the same time frame as Comprehensive MDS.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident f The facility failed to document that Resident #1 was given insulin on 08/20/24, 08/21/24, 08/23/24. This failure could place residents at risk of medical complications and a decrease in therapeutic dosages of their medications as ordered by the physician. Findings included: Review of Resident #1's electronic face sheet printed 08/28/2024 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but not limited to type 2 diabetes and high blood pressure. Review of Resident #1's annual MDS dated [DATE] revealed a BIMS score of 15 which indicated the resident was cognitively intact. Review of Resident #1's care plan dated 08/26/2024 revealed Resident #1 had diabetes and was at risk for unstable blood sugar. Interventions included to administer diabetic medication as order by physician and administer diabetic medication according to a sliding scale. Review of Resident #1's physician's order dated 08/19/2024 revealed Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 180 = 0 units;181 - 240 = 3 units; 241 - 300 = 5 units; 301 - 400 = 10 units; 401 - 460 = 12 units Greater than 460mg/dL administer 12 units and call MD., subcutaneously(being, living, occurring, or administered under the skin( before meals and at bedtime for blood glucose control Review of Resident #1's MAR for the month of August 2024 reflected Resident #1's lispro was not administered on the following days -08/20/24, there was no documentation of the medication being given at 4PM or 9PM nor documentation of blood sugar being checked. -08/21/24, there was no documentation of the medication being given at 9PM documentation of blood sugar being checked -08/23/24, there was no documentation of medication given at 9PM documentation of blood sugar being checked Review of Resident #1's nursing notes from 08/19/2024-09/29/2024 revaealed no issues with blood sugar Interview on 08/28/2024 at 1:00 PM with Resident #1 revealed she had only been in the facility for 2 weeks and she was having trouble with her medication. Resident #1 stated LVN A did not give her insulin at night and she was not sure why. Resident #1 stated during LVN A's shift was the only time she was not getting her insulin. Resident #1 was not aware of any adverse effects due to not getting the medication. Interview on 08/28/2024 at 1:15 PM with the DON revealed she was not aware LVN A had not documented that the insulin was given to Resident #1. The DON stated she spoke with LVN A on 8/28/2024 before her shift began and she stated she did give Resident #1 the insulin however she forgot to document it. The DON stated LVN A would be in-serviced before beginning her shift regarding documentation. The DON stated the risk of LVN A not documenting that the medication was given would be that another nurse could see that the medication was not given and give an extra dose.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one of four (Medication Cart #1) medication carts reviewed for pharmacy services. The facility failed to ensure Medication Cart #1 was locked when unattended on 05/24/24. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. Findings included: In an observation and interview on 05/24/24 at 7:50 AM, Medication Cart #1 was observed unlocked and unattended, with the keys on top of the cart. Medication Cart #1 was facing the entrance of room [ROOM NUMBER], and the residents were in the room. Charge Nurse A was observed as he entered the hallway from the main area near the nurses' station and dining hall about 5 minutes later. Charge Nurse A stated he had to go assist with the food trays. He stated he was sorry for leaving the medication cart unlocked and unattended. Charge Nurse A stated the risk of the unlocked medication cart was a resident could get medications from the cart. In a telephone interview on 05/24/24 at 8:00 AM, Administrator stated it was a requirement to keep the medication carts locked. She stated anyone could get the medication off the cart. In an interview on 05/24/24 at 11:45 AM, Director of Nursing B stated her expectation was that all medication carts should be locked at all times. She stated all staff know the carts should be locked when unattended. Director of Nursing B stated the risk was anyone could get medications off the cart. Record review of the facility's policy titled, Medication Storage and dated 1/20/21, reflected the following: Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on interviews and record reviews, the facility failed to conduct and document a completed facility-wide assessment which included a current (EPP) Emergency Preparedness Plan to determine what resources were necessary to care for its residents competently during emergencies as necesarry and at least annually for one (facility) of one facility reviewed for Emergency service planning. The facility failed to review, revise and update their Emergency Preparedness Plan at least annually; the most current EPP was not in the EPP binder. And after inquiry on 02/14/24, the Administrator provided the surveyor a four-page EPP dated 01/17/23 by former Administrator G that was unsigned by anyone and without proof of all of the completed employee trainings and drills. This failure could place residents at risk of harm if the facility's emergency protocols were not properly implemented by the staff during an emergency, which could cause a delay in assistance, treatment and care to the residents, resulting in a decline in their health and psycho-social well-being. Findings included: Record review on 02/14/24 of the facility's Emergency Preparedness Plan with Former Administrator G's name on it was dated 01/17/23 revealed, A signature page of the department heads names were typed and dated 01/17/23 with no actual signatures from former Administrator G and other department heads, to confirm it was completed and reviewed. Record review on 02/14/24 of the facility's current undated staff roster consisted of Administrator hire date 10/11/23, Maintenance Director hire date 09/08/23 and DON hire date 08/15/23. Record review of a list of the resident's form was undated and provided by the Administrator on 02/14/24 revealed the facility currently had: One trachea resident (Resident #65) Three G-tube dependent residents (Residents #9, #39, #65) One dialysis resident (Resident #53) Four hospice residents (Residents #18, #22, #33, #39) Three contact isolation residents (Residents #16, #28 and #53) Interview on 02/14/24 at 10:38 am, Maintenance Director K stated their emergency preparedness plan was up to date. He stated when he first started working at this facility, he did an Elopement EPP and added he was not sure but maybe the facility did the whole EPP earlier in [AGE] year. He stated he was not sure why it was not in their EPP binder. He stated the Administrator and DON and himself was responsible for ensuring the EPP was updated annually. He stated the EPP needed to be updated yearly for anything going on like the hiring of new staff, new policies, and procedures to deal with emergencies. He stated the EPP ensured everyone, including the residents knew what to do. He stated if the EPP were not updated, they would not have correct information and the residents may be misinformed. He stated he was not sure what could happen to the residents and how it could affect them if the EPP was not updated annually. Interview on 02/14/24 at 10:49 am, the DON stated the last PPE meeting was last year before she started working at this facility and she was not sure how often the EPP needed to be done but believed it was annually. She stated the EPP needed to be updated to ensure what the staff needed to do in an emergency to protect the residents from disasters such as bad weather. She stated if the staff were not prepared for emergencies, they may not know what to do and it could cause fatalities if residents were not transferred to another setting. Interview on 02/14/24 at 10:55 am, the Administrator stated the EPP was up to date and was done before he started working at this facility and added he was not sure when it was last done but would contact corporate to get the most current EPP emailed to him. He stated Maintenance Director K was responsible for ensuring the EPP was updated. He stated the EPP was important so that the facility staff and everyone knew where to go in case of an emergency. Record review of the employees disaster preparedness trainings and drills were requested from the Administrator on 02/14/24 at 11:32 am and on 02/14/24 at 2:05 pm the Administrator provided an internal missing person drill date 04/28/23 conducted by former Maintenenance Director H. There were no other trainings and drills (weather, fire, infection control, power outage, flooding) included. Record review of the facility's Emergency Preparedness policy: Training and Testing policy dated 01/27/18 revealed, Policy: Education and Training, including drills and exercises are utilized in this facility to achieve proficiency during emergency response and ensure effectiveness of our (EOP) Emergency Operation Plan. In compliance with state and federal regulations, our facility conducts initial training on EOP during the orientation of new staff and annually to all staff .Fire drills are done quarterly, and disaster drill done is held every six months under varied conditions for each individual shift of facility personnel . Record review of the Facility's Emergency Preparedness Committee policy undated revealed, The facility has established an emergency preparedness committee (EPC). The committee is comprised of management, supervisory staff from all departments, nursing staff, and support staff. The Administrator is the designated committee chairman .The Administrator is responsible for maintaining and effective and current emergency preparedness plan and implementing procedures. All facility staff members are responsible for understanding the scope of the emergency plan and the role they play in implementing its procedures

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 (Residents #53, #57, and #174) of 6 residents reviewed for infection control. 1. CNA D failed to put on PPE prior to entering three contact isolation rooms to serve the lunch trays. 2. CNA D failed to disinfect her hands while servicing food trays to the residents on Hall 100. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review of Resident #53's EHR on 02/14/24 revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including Diabetes (high blood sugar), End Stage Renal Failure (kidneys have stopped working), extended spectrum beta lactamase (infection bacteria in urine), and respiratory failure with chronic hypoxia (needs oxygen at times to breath). Review of Resident #53's admission MDS assessment, dated 02/04/2024, reflected a BIMs score of 15, indicating the resident was alert and oriented, able to make decisions. Her functional status indicate she needed one staff to complete her activities of daily living. Further review indicated she was incontinent of bowel and bladder (when she did produce urine). Review of Resident #53's physician orders dated 02/24/2024 reflected Resident #53 was to be placed in contact isolation due to extended spectrum beta lactamase. Review of Resident #57's EHR on 02/14/2024 revealed the resident was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses including Diabetes (high blood sugar), Influenzas (Flu), Arterial Fibrillation (fast heart rate), and Cardiovascular accident (stroke). Review of Resident #57's quarterly MDS, dated [DATE] revealed a BIMs score of 15, indicating he was alert and oriented, able to make decisions. His functional status indicate he needed one staff to complete his activities of daily living. Review of Resident #57's physician ordered dated 02/01/2024 reflected contact isolation due to influenza (flu). Review of Resident 174's EHR her on 02/14/2024 revealed the resident was an [AGE] year-old female that was admitted to the facility on [DATE], with diagnoses including cerebral infarction (stroke), hypertension (high blood pressure), and enterocolitis due to clostridium difficile (infection of the colon). Review of Resident #174's admission MDS, dated [DATE] revealed a BIMs score of 9, indicating she was cognitively moderately impaired and unable to make decisions. Her functional status indicated she needed maximum assist of one staff with her ADLs. Further review indicated she was incontinent of bowel and bladder. Review of Resident #174's admission physician orders dated 02/04/2024 reflected contact isolation for enterocolitis due to clostridium difficile. Observation on 02/12/2024 at 9:30 a.m. revealed on Hall 100 three contact isolation rooms with residents in the rooms. There were contact isolation instructions posted on the outside of the room, to place on full PPE (person Protection equipment) prior to entering the room. There was PPE bins avaible outside of each door. The bins were stocked with gowns, gloves, mask, and face protectors available for usage. Observation on 02/12/24 at 12:05 p.m., revealed CNA D delivered a lunch tray to Resident #57's contact isolation room. CNA D did not use hand sanitizer or wash her hands prior to entering the room. CNA D entered the contact isolation room without donning (putting on) PPE (mask, gown, gloves, and face shield). CNA D assisted Resident #57 in his wheelchair, pulled over his overbed table, then assisted him with set up of the lunch tray, touched him on his arm before leaving the room. Resident #57 was observed coughing when CNA D was in the room. CNA D exited the room. Observation on 02/12/2024 at 12:10 p.m., revealed CNA D delivered a lunch tray to Resident #53's contact isolation room. CNA D did not use hand sanitizer or wash her hands prior to entering the room. CNA D entered the contact isolation room without donning PPE. CNA D assisted Resident #53 with repositioning in her bed, pulling up her covers, then using the automatic bed adjustment to raise the head of the bed. CNA D then pulled the overbed table over to Resident #53 and assisted her with set up of the tray. Observation on 02/12/2024 at 12:17 p.m. revealed CNA D delivered a lunch tray to Resident #174's contact isolation room. CNA D did not use hand sanitizer or wash her hands prior to entering the room. CNA D entered the contact isolation room without donning PPE. CNA D repositioned the resident in the bed and then pulled the overbed table over to the resident's bedside, got a chair, sat down, and assisted the resident to eat her meal. CNA D assisted the resident to complete her meal, left the room approximately thirty minutes later, without washing her hands or using hand sanitizer. In an interview on 02/12/2024 at 1:00 p.m., CNA D stated she was aware she was supposed to put on PPE before going into the rooms and clean her hands between each room. CNA D stated I saw you watching me, and I got nervous. I was worried the food trays would not be served on time, so I just hurried through. I did not want Resident 174's food to get cold. CNA D stated she knew how-to put-on PPE and when she was supposed to put on PPE. She stated she had been recently in-serviced on PPE. CNA D stated if you do not use PPE, you can spread disease to other staff and residents. In an interview on 02/12/2024 at 2:00 p.m., LVN A stated that staff entering the contact isolation rooms must donn PPE. If the signs were on the door and the instructions, were outside, with the bin, the staff must place on everything in the bin. LVN A stated you can ask them a question from the doorway, but if you go beyond the doorway, you must donn PPE. LVN stated, that would include serving a meal tray. LVN A stated by not appropriately using PPE, you could spread infections to other residents and staff. In an interview on 02/13/2024 at 2:40 p.m., LVN B stated staff were to wear full PPE when entering the contact isolation rooms. LVN B stated the staff were in-serviced yesterday and many times before. LVN B stated the staff were to wear PPE to protect ourselves and others , from the spread of infections In an interview on 02/14/2024 at 4:00 p.m. the Administrator stated the staff had been in-serviced by the DON multiple times, since he started working at the facility in August. The staff should be aware of what to do concerning contact isolation rooms. The Administrator stated there was no excuse for not knowing what to do concerning infection control after the pandemic . The Administrator stated if the staff does not appropriately follow the rules for contact isolation, then they could spread the bacteria to other residents and they could get sick. In an interview on 02/14/2024 at 5:20 p.m., the DON stated that her expectation was that staff would sanitize their hands prior to serving meal trays to each room. The DON stated it was her expectation the staff follow all infection control guidelines, including the contact isolation room. She stated the staff were to donn PPE prior to entering the contact isolation rooms at all times, doffing prior to leaving, and washing their hands. The DON stated that the staff had been trained on infection control, including appropriately sanitizing your hands while serving trays at meals and contact isolation rooms. She stated that the instructions are posted outside all the doors, just in case they do not recall what to do. The DON stated she had only been here five months and the last in-service she gave on infection control was in January 2024. At that time, PPE and handwashing was discussed with return demonstration. The DON stated she thought she would have to do some further training . The DON stated if the staff does not follow the instructions for contact isolation, then the staff could spread the disease to other residents causing further outbreak. Review of the infection control in-services dated 10/07/2023, 01/10/2024, 02/13/2024, and 02/14/2024 reflected all staff in-services on donning PPE, doffing PPE, handwashing, and reported infection to the Administrator and the DON. Further review of the in-services reflected that CNA D had signed the in-service logs for all three in-services. Review of the facility's Policies and Procedure titled: Infection Prevention and control Program, dated October 24, 2022, reflected the following: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines . Standard Precautions: all staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. B. Hand hygiene shall be performed . c. All staff shall use personal protective equipment (PPE) according to the established facility policy . Staff Education: a. All staff shall receive training, relevant to their specific roles and responsibilities . b. All staff are expected to provide cate consistent with infection control practices .c. Direct care staff shall demonstrate competence in resident care procedures established by our facility . Policies/Procedures 1. The objectives of our infection control policies and practices are to: a. prevent, detect, investigate, and control infections in the community . b. maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public .e. provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment Review of facility's Policy and Procedure titled: Transmission-Based-(Isolation) Precautions, dated October 24 2022, reflected the following . It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogen . modes of transmission . Standard Precautions . gloves, gown, mask, eye protection and/or face shields . Contact. Gloves, gowns, mask, eye protection, and /or face shield .

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for hall 300, entry to the dining area, and one out of four resident door knobs not repaired that was observed for environment The facility failed to ensure the floor between room [ROOM NUMBER] and 309, and the right side entryway into the dining room . and the and door handles were in good repair. These failures could place residents at risk for diminished quality of life due to the lack of a well-kept environment and equipment. Findings included: An observation on 02/13/24 at 9:30 a.m. revealed a floor tile was noticed sticking up between rooms [ROOM NUMBERS] and caught the state surveyor's shoe. After stepping on the tile, it popped back up. An observation on 02/13/24 at 11:20 a.m. revealed a floor tile was observed to be curled at the edge of the dining hall entrance. This tile was near the nurses' station on the right side. An observation on 02/13/24 at 2:07 p.m. revealed the door knob to room [ROOM NUMBER] was connected, but very loose Interview on 02/15/24 at 11:25 a.m. with the Director of Nursing revealed that she had not noticed the loose tile or the loose doorknob. She stated she understood the risk of injury for the loose /sticking up tiles and the loose doorknob . Interview on 02/15/24 at 2:23 p.m. with the Maintenance Supervisor revealed he was aware the floor tiles needed to be fixed or replaced. He stated that he has been searching for matching material and he placed an order with local hardware company. He stated he has been looking for flooring, but they were trying to get a match. He stated that he can fix the doorknobs by tightening the screws. He stated they always get loose especially in an old building like this. He agreed that these issues could be a hazard in case of an emergency. He stated he does daily walk through's and he fixes things as he sees them. He stated in the morning meetings they discuss issues. He stated they do have a book to enter the work orders in and at this time he was unaware of the loose knob on room [ROOM NUMBER]. Interview on 04/20/22 at 1:15 p.m. with the Administrator revealed that he had been made aware of the issues with the flooring and the door. He stated that the flooring was on order and the door would be fixed that day. He was aware of the tripping hazards for the floor and the risk of the broken door handle. They have daily walk through's and a maintenance work order book. There was no notification of the broken doorknob . Review of the Policy and Procedure For Maintenance Inspection dated 04/11/2022 stated It is the policy of this facility to utilize a maintenance inspection checklist in order to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public .

Based on observations, interviews, and record review, the facility failed to ensure all assistive devices and overbed tables were maintained and free of hazards for five (Residents #10, #12, #19, #35 and #44) of eighteen residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #10, #12, #35 and #44. The facility failed to properly maintain overbed tables for Resident #19. These failures could place residents at risk for equipment that was in unsafe operating condition, which could cause injury. Findings included: Review of Resident #10's admission MDS assessment, dated 12/14/2023, reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Dementia (confusion and forgetfulness), generalized weakness, and anxiety (nervousness). Resident #10 had a BIMs score of 00 indicating she was severely cognitively impaired and unable to make decisions for herself. Review of the Resident #10's plan of care dated 12/19/2023 with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation on 02/12/2024 at 10:35 a.m. revealed Resident #10 was sitting in her wheelchair in the front lobby and had no skin problems. The wheelchair's left and right armrests were cracked with exposed foam. Review of Resident #35's quarterly MDS assessment, dated 01/20/2024, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses paranoid schizophrenia (mental illness) and muscles weakness. Resident #35 had a BIMs score of 10 reflecting she was moderately cognitively impaired and able to make decisions for herself. Review of the Resident #35's plan of care dated 01/23/2023 with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation on 02/12/2024 at 10:45 a.m. revealed Resident #35 was sitting in her wheelchair in the common area and had no skin problems. The wheelchair's left and right armrests were missing. In an attempt to interview on 02/12/2024 at 10:45 a.m. Resident #35 revealed she was not interested in talking about her wheelchair. Review of Resident #12's quarterly MDS assessment, dated 01/25/2024, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses hypertension (high blood pressure), Cardiovascular accident (stroke), seizures (brain disorder), and unsteady on feet (instability). Resident #12 had a BIMs score of 9 reflecting she was moderately cognitively impaired and able to make decisions for herself. Review of the Resident #12's plan of care dated 01/05/2024 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 02/12/2024 at 10:50 a.m. revealed Resident #12 sitting in her wheelchair, in the front lobby, the wheelchair's left and right armrests were missing. Resident #12 was asked about her wheelchair, and she stated, It was needing some work, and the wheelchair had been provided to her by the facility. Resident #12 stated she had told the charge nurse but could not recall when or which nurse. There were no skin tears on the arms. Review of Resident #44's quarterly MDS assessment, dated 01/17/2024, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses of cardio-obstructive pulmonary disease (breathing problems), cancer, and muscle weakness. Resident #44 had a BIMs score of 15 reflecting he was cognitively alert and oriented and able to make decisions for himself. Review of the Resident #44's updated plan of care dated 12/30/2023 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 02/12/2024 at 11:00 p.m. revealed Resident #44 in his wheelchair at the nurse's station. Resident #44 stated that his arm rests were broken. The wheelchair's right and left armrests were cracked with exposed foam. Resident #44 stated he had told the nurses that his wheelchair arms were broken, but nothing had been done. He stated that it was about three weeks ago, he thought that he told the staff, but he could not recall which staff member he told. Review of Resident #19's quarterly MDS assessment, dated 12/22/2023, reflected he was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of dementia (confusion and forgetfulness), Alzheimer's disease (confusion and forgetfulness), abnormality of gait and mobility, and general weakness. Resident #19 had a BIMs score of 4 reflecting she was severely cognitively impaired and unable to make decisions for herself. Observation on 02/12/2024 at 11:14 a.m. revealed Resident #19 was in her room in bed, with no skin problems. The overbed table was beside the bed, with the veneer missing surrounding the edge of the entire table, and the left end of the table had broken wood splintering out of the edge of the overbed table. In an interview on 02/12/2024 at 11:15 a.m. with Resident #19 revealed she did not answer any questions concerning her overbed table. In an interview on 02/12/2024 at 12:30 p.m. LVN C stated when a resident's wheelchair needed repair the staff were to tell the Maintenance Supervisor. He kept all the parts to fix them. LVN C stated he should tell the maintenance supervisor the wheelchairs needed new armrests. LVN C stated usually he would keep up with that but recently he had been too busy. LVN C stated that if the resident's wheelchairs were not in good repair, it could cause injuries. In an interview on 02/12/2024 at 1:27 p.m. CNA B stated when a resident's wheelchair or overbed tables needed repair the staff were to tell the charge nurse or the Maintenance Supervisor. CNA B stated she had not reported anything recently, concerning wheelchairs or overbed tables . In an interview on 02/14/2024 at 2:46 p.m. the Maintenance Supervisor stated that he was responsible for the repair of wheelchairs and if the residents needed other equipment replaced. He stated he kept a maintenance logbook at the nurse's station, but the staff tell him, they do not use the book. The Maintenance Supervisor stated he had not had any staff members tell him about any wheelchairs needing repair, until yesterday. The Administrator told him that the state was looking at the wheelchairs, so he showed me and repaired them all, but I knew nothing before then . The Maintenance Supervisor stated that if the equipment was not in working ordered it could cause injuries. In an interview on 02/14/2024 at 3:45 p.m. with the Administrator revealed the staff was supposed to report to the Maintenance Supervisor any equipment that needed repair. The Administrator stated all the armrests on the wheelchairs had been replaced, on yesterday (02/13/2024). He stated he saw the state surveyor looking at them, so he watched, and repaired all the wheelchairs that the state surveyor looked at. The Administrator stated the staff had not reported anything to the Maintenance Supervisor prior . The Administrator stated, if the equipment was not repaired appropriately then it could cause injuries. The Administrator stated the department heads were supposed to perform angel rounds every morning and this would something they should look at and then in the morning meeting it showed have been reported. The Administrator stated he would be reminding the department heads to follow-up. Record Review of the Maintenance log dated 11/01/2023 through 02/14/2024 at the nurse's station, reflected no entries for wheelchair armrest repair or overbed table replacement. A review of the facility's policy and procedure Adaptive Devices and Equipment dated December 2022 reflected Policy Statement Our facility maintains and supervises the use of assistive devices and equipment for residents . 6. The following factors and addressed to the extent possible to decrease the risk of available accidents associated with devices and equipment . c. Devices condition-devices and equipment are maintained on schedule and according to manufacturer's instructions. Defective or worn devices are discarded or repaired . 32581

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for two (Hall 200, and 300) of four halls observed for environment. The facility failed to ensure bathrooms on Hall 200 and 300, were clean, safe, and in good repair. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment and equipment. Findings included: An observation on 02/12/2024 at 9:57 a.m. in room [ROOM NUMBER] bathroom revealed loose dirt, food on the floor, and hair was balled up behind the toilet. The bathroom floor was saturated in a yellow substance and smelled of urine. An observation on 02/12/2024 at 10:00 a.m. in room [ROOM NUMBER] bathroom revealed there was a sticky floor, a brown substance smeared on the top of the toilet seat, and a large puddle of a yellow substance on the floor. An observation on 02/12/2024 at 10:03 a.m. in room [ROOM NUMBER]'s bathroom revealed the bathroom floor with used bandages on the floor, three paper towels with a brown substance on the floor, and an overflowing trashcan. An observation on 02/12/2024 at 10:05 a.m. in room [ROOM NUMBER] bathroom revealed a smell of urine with a puddle of liquid on the floor near the toilet. There was a white substance that was scattered across the floor and a dead bug in the corner by the door. An observation on 02/12/2024 at 10:09 a.m. in room [ROOM NUMBER]'s bathroom revealed the seal around the toilet was cracked and broken. The bathroom floor was sticky and there was a strong smell of urine. An observation on 02/12/2024 at 10:15 a.m. in room [ROOM NUMBER]'s bathroom revealed the bathroom floor was sticky with a strong smell of urine in the bathroom. An observation on 02/14/2024 at 10:18 a.m. in room [ROOM NUMBER]'s bathroom revealed the base of the toilet had a black dried substance. There were pieces of paper on the floor, and loose particles of food . In an interview with housekeeper A on 02/13/2024 at 9:55 a.m. revealed she was one of three housekeepers working the facility today. Housekeeper A stated, she cleans two halls (hall 200 and hall 300). Housekeeper A stated that on Monday after the weekend it was always a mess. There were two housekeepers over the weekend and one does mostly floors. Sometimes the supervisor will show up, but not all the time. We were supposed to go down our hallways, sweep and mop the rooms and bathrooms and collect the trash. She stated sometimes it will take all day to do just that. She stated we are supposed to make two rounds a day, but I do not usually get around to that. She stated she only cleans once. She stated she has spoken to her supervisor, but she just told her to speed up. Housekeeper A stated since the state is here they have extended our hours in the facility . Housekeeper A stated if the rooms and bathroom are not cleaned it could cause the residents to get sick. In an interview on 02/13/2024 at 10:30 a.m. during a confidential group meeting revealed one of the residents in attendance stated her bathroom was dirty, ill kept, and she was unhappy with the housekeeper because they did not always empty her trash. The resident stated she had said something to the Housekeeping Supervisor and sometimes it was better and sometimes it was not better . Interview on 2/14/2024 at 10:01 a.m. with the Housekeeping Supervisor revealed if the bathrooms needed cleaning, it was her and her crew's responsibility. She stated we clean the resident's room and the bathrooms every day. The Housekeeping Supervisor stated that she had a crew even on the weekend and she worked herself to help. The Housekeeping Supervisor stated that she was a part of the stand-up meetings in the morning, and she had not been made aware of any problems with bathrooms. The Housekeeping Supervisor stated there were more staff in the facility today because we have extended our hours during the state survey . The Housekeeping Supervisor stated it was her responsibility to make sure the rooms and the bathrooms were clean. She stated the crews make a morning and afternoon rounds. Interview on 02/14/2024 at 4:15 p.m. with the Administrator revealed the floors in the bathrooms were unacceptable. The Administrator stated that the bathrooms were supposed to be cleaned daily . The Administrator stated the Housekeeping Supervisor was responsible to make sure the rooms and bathrooms were clean. He stated he had no expectations on how many rounds the cleaning crews had to make as long as they stayed in budget, and the facility was clean. Review of the Policy and Procedure Maintenance Services dated revised December 2022 reflected Maintenance service shall be provided to all areas of the building . and equipment .1. The maintenance Department is responsible for maintaining the buildings in a safe and operating manner at all times .2. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines .maintaining the building in good repair and free from hazards .establishing priorities in providing repair services .providing routinely scheduled maintenance service to all areas .3 the Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the building . are maintained in a safe and operable manner .maintenance .shall follow established safety regulations to ensure the safety and well-being of all concerned . 32581

Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, for 1 (Resident #53) of 1 resident's reviewed for dialysis. The facility failed to ensure post-dialysis assessments were completed for Resident #53 after return from dialysis treatment. This failure could place residents at risk of inadequate post dialysis care. Findings included: Record review of Resident #53's, admission MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #53 had diagnoses which included end stage renal failure (when kidneys suddenly become unable to filter waste products from blood), Diabetes (increased blood sugar, dependence on renal dialysis, (procedure to cleanse the blood), and Hypertension (increased blood pressure). Resident #53 had a BIMs score of 15, reflecting she was cognitively alert and oriented and able to make decisions for herself. The MDS section O related to special treatments, procedures, and programs reflected Resident #53 received dialysis. Record review of Resident #53's care plan, dated 02/06/2024, reflected Resident #53 received dialysis related to renal failure and was at risk for the potential complications related to dialysis. Needed hemodialysis to rule out end stage renal failure. Resident #53 will have no signs of complication from dialysis through next review. Obtain vital signs and weight per protocol. Report significant changes in pulse, respiration, and blood pressure to the physician. Record review of Resident #53's physician's order, dated 01/30/2024, reflected Hemodialysis every Tuesday, Thursday, and Saturday at 11:00 a.m. Further review reflected no orders to assess the access area prior to dialysis or post dialysis. Record review of Resident #53's EHR reflected no nursing documentation regarding Resident #53's dialysis, monitoring of the resident's post-dialysis vital signs, or the assessment of the access area. Record review of Resident #53's dialysis communication forms reflected dialysis communication forms with no information on the resident assessment and observation post-dialysis section on 02/01/2024, 02/06/2024, 02/08/2024, 02/10/2024, 02/13/2024, and 12/14/23. Interview on 02/13/2024 at 10:30 a.m. with Resident #53 revealed when she returned from dialysis on the evening shifts, the nurses do not assess her access area. Resident #53 stated she knew they were supposed to assess the access area, but they never do. The staff were sometimes busy with dinner or their medication pass. Resident # 53 stated she has asked, but the staff forget. If my husband visits me, he will look at the area for me. Interview on 02/14/2024 at 1:10 PM with LVN A revealed she was aware she was supposed to send Resident #53 with the dialysis communication form when she left for dialysis. The nurse on the next shift would collect the form when the resident returned from dialysis. LVN A stated she knew she was supposed to take her vital signs before she left and check to make sure the dressing on the access area was intact. LVN A stated someone else obtained the resident's weight. LVN A stated she never removed the access dressing to look to see if the area was bleeding, red, or looked infected. She had not been told to do that. LVN A stated if the access area was not accessed there could be a negative outcome, such as bleeding or infection, for the resident. LVN A stated the responsibility should be the charge nurse, but thought that the assessment should occur after dialysis, rather than before. Interview on 02/14/2024 at 04:31 PM with the DON revealed it was the nurses' responsibility to send dialysis residents with a communication form to dialysis and get the form back when the resident returned to the facility. This was so, if there were orders from dialysis or changes, it was noted. She stated her expectation was for the nurses to perform post-dialysis assessments when the residents returned from dialysis and document on the dialysis communication forms on dialysis days. She stated failure to monitor the vital signs and access sight after dialysis, staff would not note the change of condition, bleeding, and whether the vitals were stable. She stated she had done training with the staff and the last in-service was when Resident #53 had admitted . The DON stated that if there were no orders given the nurses should call the physician and receive orders. It was basic nursing to know you must assess the access area before and after dialysis, as well as vital signs. She stated the risk for not assessing the vitals were that Resident #53 could be unstable and the permcath (special catheter used for short-term dialysis treatment) could be bleeding. She stated the facility will do another in-service and monitor. Interview on 02/14/2024 at 4:40 p.m. with LVN F revealed she was aware she was supposed to collect the dialysis communication form when the resident returned from dialysis. LVN F stated she was to monitor the dialysis access site for the bruit, thrill (a vibration caused by blood flowing through the fistula and can be felt by placing your fingers just above incision line), dressing for bleeding, and vital signs when Resident #53 came back from dialysis. She stated she was not consistent because when Resident #53 returned from dialysis in the afternoon, it would be during medication administration time, and sometimes during dinner. LVN F stated failure to monitor and assess Resident #53 post dialysis put her at risk of low blood pressure and bleeding. She stated she had done trainings, but she could not tell whether dialysis was one of them. Record review of the facility's policy, dated 12/22/2024, reflected the following, .19. Facility will monitor departures and returns from the dialysis center. The facility will document the resident's vital signs, general appearance, orientation, additional baseline data as needed. The resident clinical record will be documented wit this information. The date and time of the residents' return to the facility will be recorded by the nurse.

Based on interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of six residents reviewed for elopements. The facility failed to provide adequate supervision to Resident #1. As a result, he eloped from the facility and was observed by a staff member crossing the street and falling in median approximately 0.4 miles away from the facility on 03/25/22. It was determined a past non-compliance Immediate Jeopardy existed from 03/25/22 to 03/25/22. The Immediate Jeopardy was determined to have been removed on 03/25/22 due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation on 04/26/22. This failure could place residents at risk for injury related harm, accidents, falls, and lack of proper supervision. Findings included: Review of Resident #1's quarterly MDS, dated [DATE], revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]and discharged on [DATE]. His diagnoses included Alzheimer's disease, adult failure to thrive, and unsteadiness on feet. Further review reflected Resident #1 BIMs score of 5 (severe cognitive impairment). Review of Resident #1's Consolidated Physician Orders for March 2022 reflected the following: Wanderguard to right ankle for elopement risk and Check function/placement of wanderguard bracelet every shift dated 01/21/22 [sic]. Review of Resident #1's Elopement Risk assessment dated [DATE] revealed Resident #1 was a score of one: not at risk for elopement. Review of Resident #1's Elopement Risk assessment dated [DATE] revealed Resident #1 was a score of five: Becomes agitated, confused and/or disoriented or displays consistently poor judgement at risk to elope, engages in theme behavior (i.e., leaving for work, seeking his/her car, searching for children, seeking people/places from days/years gone by reflecting at risk for elopement. Review of Resident #1's Care Plan, dated 01/24/22, revealed Resident #1 was at risk for wandering . Interventions included Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book .provide structured activities walking, inside, reorientation strategies including signs, pictures, and memory boxes .monitor resident for tailgating when visitors are in the building . notify the immediate supervisor, physician and family if unable to locate resident . check for proper functioning of the audible alarm system . use audible system to alert staff or exit seeking behavior .resident prefers watching television, coffee, and music . Further review reflected 03/25/22 for goals and approaches for elopement. Review of Resident #1's March 2022, MAR revealed staff had checked the function of wander guard bracelet on 03/25/22 on the day/evening shift upon return to the facility. Review of Resident #1's Progress Notes revealed: - On 01/21/22: .res. has wandering, wander guard checked and order received placed on right wrist for safety. - On 01/22/22: .res on f/u for wanderguard monitoring, located to right wrist and functioning. Resident continues to come into hallways a with bags and pointing to front door. This nurse explained that family is not in facility and he will go back to his room . - On 01/23/22: resident continue on f/u for behaviors. Continue wander guard to right ankle. No behavior of wandering at this time. - On 02/02/22: resident has wanderguard to rt ankle . - On 02/09/22: Resident to desk states going home to go to work attempted to redirect resident cont to state going home had his things in a plastic bag to appease we offered to call son and let him speak with him Resident spoke to son for short time then was willing to go to room and go to bed - 02/15/22: Resident in bed up to desk 3 times in 1 hr holding his valentine gift like a lunch box said he has to go home and go to work redirected attempt to explain resident directed back to room - 02/18/22: .Wander guard to left ankle in place visible and intact - 03/25/22: .A staff ( unknown former staff) called the facility to inform that Resident was found walking along the street outside the facility. Resident was brought back the resident back to the facility by staff (DOR) in her car. Patient said he is going to her mother's house. Head to toe skin assessment completed. Very little abrasion observed to right knee. Cleaned with Normal saline, pat dry, triple antibiotic applied and covered with dry dressing. Vital signs: 114/67, 102, 97%, 97.5 and 18. His family member called and notified. The DON is present and is aware. The MD-notified and .At this point a decision was taken to transfer patient to . lock up unit Will continue to monitor resident for elopement episodes . - 03/25/22: .Resident left the facility at 1935 with all his personnel belongings and medications transferring to the secured unit In an interview on 04/2/21 at 9:00 a.m. with the LVN A revealed he was the nurse in charge of Resident #1 on 03/25/22 before he eloped from the facility. LVN A said Resident #1 was not having any behaviors that day and he had checked his wander guard at the beginning of his shift, and it was working. LVN A said Resident # 1 was easily redirected back to his room or to the dining room to drink coffee and watch television. LVN A said he was surprised when the Director of Rehabilitation brought him back to the facility, I had no idea he was gone. LVN A said the last time he saw Resident #1 was around lunch time. LVN A said Resident #1 was the only one with wandering behaviors. LVN A said he and never had to stop Resident #1 from going out the front door or any door, he would just come to the nurse's station asking to go to work. LVN A said he had training in elopement, abuse/neglect, and being aware of your surroundings when leaving the facility. The LVN indicated that he knew what to do concerning the in-service trainings for elopement, abuse/neglect, and awareness of surroundings when exiting the facility. In an interview on 04/26/22 at 10:00 a.m. with Social Worker revealed she knew Resident #1. She said he was a wandering resident, that wore a wander guard, but was easily redirected. SW said Resident #1 was the only resident with wandering behaviors. The SW said that she had been involved in the plan of care meeting (January) that was with the family to discuss him wearing wander guard, since his condition had changed. She said they addressed his behavior, he was reassessed and the physician was contacted and the wander guard placed on the resident. She was asked had she ever had to stop him from going out the door, she said no, he would just come to the nurse's station and ask about going to work. In an interview on 04/26/22 at 10:30 a.m. with CNA B revealed Resident #1 was the only resident in the facility that had wandering behaviors, he did not try to open or push the doors open. CNA B said that he would ask permission to go to work or to his mother's home and you could redirect him easily. The CNA said that she did take care of him on the day he left the facility. Resident #1 did not ask CNA B about leaving for work and he did not try to leave the facility. CNA B said the last time she had seen him was after lunch after 1:15 p.m. he was in his room lying in bed. CNA B said that she gets off work at 2:00 p.m. and Resident #1 left the facility around 3:00 p.m. she was told by her coworkers. CNA B said she had received in services on elopement, abuse/neglect and aware of surroundings when exciting facility. CNA B indicated she knew what to do, while exiting the facility and if a resident was exit seeking. In an interview on 04/26/22 at 10:55 a.m. with CNA C revealed Resident #1 was a pleasant resident who was confused but ask you if he could go to work or home. The CNA said that the training she had when Resident #1 had his wander guard placed on him in January helped to be able to redirect him so he would be safe. She said she did see him on the day that he left the facility sometime after lunch, he was walking down the hallway toward his room. The CNA was asked was there any other residents that had behaviors like Resident #1 she replied no. She said she had not seen the resident physically push open a door. CNA C indicated what to do if someone was exit seeking or how to be aware of her surroundings. In an interview on 04/26/22 at 11:25 a.m. with DOR revealed she had left to go home on 03/25/22 and was driving north on the street that the facility was on. She said it was after 3:00 p.m. maybe 3:15 p.m. I see Resident #1 crossing [NAME] road (about 0.4 miles from the facility) and stepping up on the median, he falls to his knees. I had already put on my emergency flashers and pulled my car up to him, I jumped out to assess him and try to get him in my car. Resident #1 was smiling after I got him in my car, he did not want to talk about what he was doing, he kept asking to call his brother and saying he was going to work. The road was busy that day. I remember a staff member that use to work at the facility stopped and helped. I told her to call the facility. I already had called the facility and could not get in touch with the DON or the Administrator, but she was able to tell one of the nurses. I took him back to the facility. The Administrator and DON were out front waiting on me and we got him out of the car into the facility. The DOR said the facility had already conducted a Silver alert drill to make sure all the other residents were there. He was transferred to another facility that same day. The DOR was asked had she seen Resident #1 exit seeking before, she replied, no. The DOR stated she had in-service training on 03/25/22 concerning exit seeking and awareness of her surroundings when leaving the facility. In an interview on 04/26/22 at 2:37 p.m. with Activities Director revealed she was in the dining room between 12:00 p.m. and 12:30 p.m. on 03/25/22 and she saw Resident #1 going past the nurse's station with a plastic zip lock bag and his jeans in the bag, toward the front door. The AD said she went and got Resident #1 and brought him to the dining room. She said she sat him down at his table and then realized he had already eaten all his lunch. She asked him if he was still hungry, and he said he was. AD told the Dietary Manager that he was still hungry. The AD was asked if she recall who she reported Resident #1 walking toward the front door, she did not recall reporting to anyone. The AD said Resident #1 was the only resident with wandering behaviors. The AD was asked if she had to stop Resident #1 from going out of any of the doors, she said no. The AD stated there had been multiple in-service trainings to include 03/25/22 on elopement risk, redirection, being aware of surroundings when leaving the facility, and elopement drills. In an interview on 04/26/22 at 2:37 p.m. with Dietary Manager revealed on 03/25/22 she did prepare a sandwich and gave it to Resident #1 with some coffee. She said he sat there at his table and watched television for a long time, after 1:00 p.m., then she made sure he got back to his room. The DM said that was the last time she saw Resident #1. when she was asked if she told the nurse in charge or the Administrator or DON, she said she did not. The DM stated Resident #1 was the only resident with wandering behaviors. The DM said her entire kitchen crew had been in-serviced on 03/25/22, exit seeking behaviors and who to report to and being aware of their surroundings when they leave the facility. In an interview on 04/26/22 at 3:15 p.m. with CNA D revealed Resident #1 on 03/25/22 was standing at the nurse's station at 3:00 p.m. CNA D said he was just standing there. The CNA said that she could not recall if anyone was at the nurse's station. CNA D said that when she came back by the nurse's station he was not there anymore. When CNA D was asked how much time had passed before she came back by, she said maybe five minutes. She said that the DON had conducted trainings on 03/25/22 for elopement, exit seeking behaviors, and to be aware of your surroundings when you leave the facility, to make sure no residents go out with you. In an interview on 04/26/22 at 3:30 p.m. with CNA E revealed she was working the day 03/25/22, that Resident #1 left the facility. CNA E said that she had been involved in the Silver alert (missing resident code), but she was not working on the hall that Resident #1 lived on. CNA E said Resident #1 would come up to the nurse's station and ask to go to work and you could give him a cup of coffee turn on the television and he would sit and watch it for a long time. CNA E said that his family would talk to him on the phone and come to get him and take him out on pass. When CNA E was asked to explain the in-service trainings she had since the elopement of Resident #1, she replied many trainings including elopement, , missing, residents, abuse/neglect, beware of your surrounding s when leaving the facility, and the CNA indicated she knew what to do. In an interview on 04/26/22 at 3:35 p.m. with ADON revealed 03/25/22, she was working as a charge nurse on the day that Resident #1 left the facility. She said it was shift change and we conducted a Silver Alert drill for missing residents, and during the drill the DOR returned with Resident #1. The ADON said Resident #1 was a pleasant resident who would come to the nurse's station and ask to go to work or go home so he could go to work. She said he was easy to redirect and was not aggressive in his exit seeking. When asked if she had seen him at the nurse's station around 3:00 p.m. on 03/25/22, she replied, no. The ADON said she had been in a meeting with the Administrator and DON after she had given report to the oncoming nurse, that was around 2:45 p.m. In an interview on 04/26/22 at 11:38 a.m. with the Maintenance Director revealed he had checked the exit doors of the facility the evening of 04/25/22, and they were all functioning properly. The Maintenance Director said he checks the exit doors and the system one time a week to make sure the doors, locks, and alarms were working properly. The Maintenance Director said when the code was placed in on the doors it disengages the door and the wander guard system, so if a resident wearing a wander guard follows someone out, the wander guard would not alarm. The Maintenance Director said that he was informed of the Resident #1 leaving the facility. He checked the system, and it was working. The wander guard Resident #1 was wearing was checked by him and it worked. The Maintenance Director said Resident #1 wore a wander guard which would alert staff that he was at risk of eloping/wandering from the facility . The Maintenance Director said the system was working when Resident #1 left the facility, the two staff members (NA F and NA G) had placed in the code, disengaging the system and the resident was able to follow them out. Review of the Direct Supply Tales dated January, February, March [03/25/22], and April reflected the doors, locks, and alarms operation were checked weekly, system all passed. On 04/26/22 at there was attempted to contact NA G at 1:24 p.m. the contact numbers provided did not work. In an interview on 04/26/22 at 2:50 p.m. with The Administrator revealed she was in a meeting 03/25/22 with the DON, when the ADON received a call from a former staff member reporting Resident #1 was out of the facility and the DOR was bringing the resident back. She said they initiated a silver alert (missing resident code) and made sure everyone else was accounted for. She said they placed Resident #1 on one-to-one monitoring and the nurses assessed him, he had some scraps on his knees. They contacted the family and explained that he would be transferred to another facility that had a secure unit. She said that Resident #1 sat with the DON until he left the facility. She said she began her investigation and the camera video that they had revealed that two staff members put the code in around 3:00 p.m. and left the facility through front door. Resident #1 was seen walking behind both. She said she contacted both nurse aides and they came in for training and counselling, they both said that they had no idea he was behind them. She said the nurse's aides did not return following the in-service and counseling. They attempted to contact both, but no return call. She said they in-serviced all the staff on elopement, abuse/neglect, missing residents, and beware of surroundings when exiting the facility to include the housekeeping a, laundry, therapy, and kitchen. The Administrator stated they continued to monitor the staffs understanding of the importance of being aware of their surroundings when they leave the facility. They also in-serviced on elopement drill, have those one-time a month, and abuse & neglect, and completed a posts test. In an interview on 04/26/22 at 3:11 p.m. with the DON revealed she was in a meeting on 03/25/22 with the Administrator when a past employee called the ADON and reported Resident #1 was out of the facility and the DOR was bringing him back in her car. The DON said she immediately called a Silver Alert, to ensure that the other residents were in the facility. The DON said Resident #1 did wear a wander guard. The DON said Resident #1 was not exit seeking or aggressive, trying to push open the doors. She said he would come up to the nurse's station and ask to go to work or go to his mother's house, he was easily redirected back to his room or the common areas. She said when Resident #1 admitted he did not wander, but his condition changed, and they met with the family after his reassessment for wandering and a wander guard was placed. The DON said all new admission were assessed on admission for elopement and then reassessed each quarter or if there was a condition change. The DON said at the time of Resident #1's elopement, the alarm for the wander guard did not sound, but she had been informed by the Maintenance Director about how the system disengage itself. The DON said the facility staff were in-serviced regarding what to do when a resident did elope, abuse/neglect, and beware of soundings when exciting the facility. The DON said the follow-up for monitoring their training, was complete by her. She said that she had multiple scenarios that she developed to assure the staff was paying attention to her in-services: to include, waiting on the staff in undisclosed location outside of the facility to see if they noticed her and wearing a wander guard (herself) without telling the staff and exciting the facility, or attempting to exit the facility. The DON said she had continued to have in-service concerning elopement and door awareness, as part of their QAPI meetings, they have been having monthly drills for elopement since she has worked here. In an interview on 04/26/22 at 4:14 p.m. with MA H revealed she had been in-serviced on abuse/neglect, elopement, and be aware of our surroundings. MA H said the DON gave the in-services and then followed-up on the training by creating scenarios i.e.: hiding outside to make sure we were looking around when we leave to make sure no one following us. In an interview on 04/26/22 at 4:15 p.m. with CNA I revealed she had been in-serviced on elopement, abuse/neglect, and being aware of your surroundings when you leave the facility. CNA I said the DON had put on a wander guard without telling anyone and tried to exit the facility, waiting to see what the staff would do. Then after the staff had determined she was exit seeking she watched what the staff did when she wandered out the front door behind some visitors. In an interview on 04/26/22 at 4:21 p.m. with NA F revealed she had worked on 03/25/22 and had left the facility with her co-worker that afternoon. The NA could not recall exact time when she left. The NA said she did recall talking with her co-worker about what she was going to do on her two days off. NA F said we were in the moment talking about our days off, she did not notice anyone behind them. When NA F was asked if she looked behind her or looked at her surroundings, she replied that she did not. NA said she was in-serviced on elopement when she started working at the facility. The NA said she knew who Resident #1 was but had not taken care of him. NA F was said she was aware that Resident #1 wore a wander guard.NA said it would mean he could leave the facility, but the wander guard bracelet was to alarm if he left , so if he left after us, then the bracelet was not working correctly. The NA said that she had been contacted by the Administrator and when she and her co-worker came to the facility, she (NA F) felt like she was being blamed for Resident #1 leaving the facility. NA F said she felt she had been disrespected, that was why she had left and had not returned. Interview on 04/27/22 at 10:00 a.m. with Housekeeper/laundry revealed she had been in-serviced on abuse/neglect, elopement, and awareness of surroundings when exciting the facility. The Housekeeper/laundry said that the DON put an elopement bracelet on and attempted to leave the facility with a group of people, the alarm sounded, and the staff had to redirect her. Interview on 04/27/22 at 10:30 a.m. with Housekeeping Supervisor revealed her entire department had been in-serviced by the DON about elopement, exit seeking behavior, abuse/neglect, and aware of surroundings when you leave the facility. The in-services were informative, and the follow-up examples given were very good, helping her to understand. Review of the in-service training record dated 03/28/22 reflected face to face training and counseling/coaching session signed by NAs F and G on watching for resident when exiting facility, making sure the door was closed when leaving the facility, and to check surroundings. Review of the Missing Resident Guidelines dated July 2021 reflected: to provide process steps, staff responds to possible missing patient concerns immediately . identify environmental circumstances that impacted the incident . change of shift . monitor behaviors . plan general and specific interventions to prevent future incidents .communicate interventions to staff .patient, family or responsible party and center staff are educated on prevention measures needed and interventions . Review of the facility's policy Incident/Accident Policy: dated December 2020 reflected: the resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents these include: 1. Identifying hazard (s) and risk (s) .a. all staff are to be involved in observing and characteristics and abilities of each resident .facility-based interventions .educating staff ensuring the interventions are implemented correctly and consistently . Review of the facility's provider investigation report for Intake # 1 revealed the facility self-reported Resident #1's elopement from the facility on 03/25/22. The Provider Response revealed: [Resident #1] was placed on 1:1 supervision until discharged to alternate placement with secured facility. [Resident #1]'s family member [was] notified. Facility doors were checked; locking; and alarmed. Head counts monitor[ed] by facility staff, Silver Alert. Physician notified. Facility staff re educat[ed] by DON and Administrator on elopement policy/incident/accident and wandering/exiting, abuse and neglect, doors and alarm functions. The Investigation Summary revealed: Based on [the facility's] investigation, it was determined the resident followed two staff members out of the facility. The Provider Action Taken Post-Investigation revealed: .Elopement risk assessments reviewed and updated for [Resident #1]. Care plans reviewed. [Resident #1] discharged safely to another facility with secured unit, transferred by the facility staff [DON] on 03/25/22. Head counts and door checks being completed. Education to facility staff on elopement policy/wandering/exit seeking/abuse and neglect/doors and alarms. Review of the plan of care dated 03/25/22 revealed the facility held a Standards of Care Meeting Data Review related to Resident #1's elopement. Review of an in-service dated 03/25/22 and titled Elopement/ Missing resident drill revealed staff were educated on the facility's elopement response policy and procedure. Review of an in-service dated 03/25/21 and titled Abuse/Neglect revealed staff were educated on the facility's abuse/neglect policy and procedure. Review of an in-service dated 03/25/22 and titled Making sure the door is closed when leaving the facility-ensuring there is no resident following behind you. Review of monitoring tools used to check the staffs understanding of awareness of surroundings revealed staff was monitored when leaving the facility 03/25/22. Review of monitoring tools used for Resident #1 on 03/25/22 revealed staff monitored him until 03/25/22 one on one until he transferred to the other facility. Review of monitoring tools used for head counts completed revealed staff monitored all residents until 03/25/22, when the Silver Alert for elopement drill was completed.

Based on observations, record review and interview, the facility failed to ensure residents were free of accident hazards, and (Resident #1) received adequate supervision and assistance devices to prevent accidents. CNA A failed to provide Resident #1, a total care resident adequate supervision of two staff while providing incontinent care. On 2/20/18, Resident #1 rolled out of bed during incontinent care and sustained a hematoma to the forehead and a right frontal maxilla fracture. This failure placed 13 residents, who required assistance of two staff for care, at risk of not receiving the appropriate level of assistance with the potential for falls and/or injuries. This was determined to be past noncompliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the incident investigation. The deficient practiced occurred from 2/20/18 to 2/21/18. Findings included: Review of Resident #1's, undated face sheet revealed a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] revealed the resident required total assistance, two person assist for bed mobility, transfer, locomotion, dressing, and toileting. Review of CNA daily assignment sheet updated 01/09/18 for Resident#1 reflected she was bed bound and required two person assistance with mobility, baths, and transfers using a Hoyer lift. Review of Provider Investigation Report completed by the Administrator dated 02/21/18 revealed that on 2/20/18 at 6:10 PM resident sustained [REDACTED]. (CNA A) reached to the foot of bed to get more wipes resident continued rolling over, between wall and bed landing on floor. Investigation Summary: The investigation summary found that the fracture that (Resident #1) sustained was due staff rolled resident to her side, staff turned to get more wipes resident turned herself, fall resulting in a right maxilla fracture. Resident #1's hospital admission registration record face sheet dated 2/20/18 revealed, Reason for Visit: fall injury on [MEDICATION NAME] (an anticoagulant) Diagnosis: [REDACTED]. Resident #1 returned to the facility on [DATE] from the hospital. Observation of Resident #1 on 02/23/18 at 12:24 PM, revealed the resident was in a large geri chair at the nursing station. There was no bruising observed on resident face. Interview with CNA A on 02/23/18 at 4:28 PM revealed she was inside Resident #1's room providing incontinence care to the resident. She held the resident up with her right hand and reached for wipes with her left hand. She stated Resident #1 rolled towards the wall on to the floor. She stated the bed would not lock and the bed moved. She stated she immediately informed the nurse after the resident fell to the floor. LVN B assessed the resident and took her vitals. She stated she noticed Resident #1's left eye was swollen. She stated she, Nurse A, and a medication aide placed the resident back into bed. CNA A said the resident was transported to the hospital. During the interview with CNA A, she stated Resident #1's bed had not been locking and she had reported it to LVN B the week prior to the incident. She stated LVN B had replied okay, and that she would take care of it. CNA A reported that she took care of Resident #1 every day that she worked, and the resident's bed never moved while providing incontinence care. CNA A revealed this incident was not intentional. CNA A reported Resident #1 was a two person assist with the Hoyer lift, total care, two person assist with bathing, and transfer two person assist. CNA A stated the facility never specified if Resident #1 required one or two person assistance with bowel/bladder. CNA A revealed she always provided Resident #1 incontinence care by herself. CNA A revealed at the beginning of each shift, staff were to sign in next to their assignment on the sign-in sheet. She stated that on the day the incident happened, she did sign her name on the sign in sheet. She stated the assignment sheets informed the staff what assistance each resident required. On 3/12/18, attempted to contact CNA A at phone number that was provided by the facility on 2/23/18. The individual that answered the phone stated that the phone number did not belong to CNA A. Review of an undated witness statement attached to the facility self-report provided by LVN B revealed Date of alleged incident: 02/20/18 assigned aide notified me that resident (Resident #1) was on the floor in her room. Aide explained resident fell off her bed while aide was cleaning her. I blamed aide for attempting to clean resident alone. Resident assessed and transferred to her bed assist three staff. Nero checks. Hematoma noted on left eye. Nurse Practitioner notified, ordered CT scan. Resident transferred to hospital. ADON notified, and mother notified. Paramedics said resident would be taken to hospital down town because she is on blood thinners. During an interview with LVN B on 02/23/18 at 5:50 PM, she stated CNA A informed her around 6:00 PM on 02/20/18, that Resident #1 was on the floor. LVN B reported that was the first time Resident #1 fell during the shift that she worked. LVN B stated CNA A informed her that she tried to change the resident. LVN B said when she walked in the resident's room, she expected to see another aide in the resident's room. LVN B reported that Resident #1 required two persons' assistance, and sometimes she would help assist the aides when needed. LVN B said CNA A should not have provided resident incontinence care alone. She stated she assessed the resident for injuries, called the medication aide to assist her and CNA A to transfer the resident back into bed. LVN B reported Resident #1 sustained an injury to her left eye, and she notified the Nurse Practitioner, who gave the order to send the resident out for CT Scan, and further evaluation. LVN B reported Resident #1 was transported to the hospital downtown. She stated Resident #1 was totally dependent on staff for all care. LVN B revealed CNA A never informed her that Resident #1's bed would not lock, and that there had never been an issue regarding the resident's bed not locking. Interview with the Staffing Coordinator on 02/23/18 at 4:55 PM revealed the pink ADL sheet informed the staff how many people it took to assist residents with ADLs such as bathing, feeding, transfer, any behavioral issues and incontinence care. She stated when CNAs clocked in their shift, they were supposed to sign the sign-in sheet. The staffing coordinator revealed the sign-in sheet informed the CNAs their assignment for the day. The CNAs were also provided with the pink CNA daily assignment sheet. The Staffing Coordinator reported Resident# 1 required a mechanical lift for transfers, two person's assistance, and had always required two persons assistance with incontinence care. She revealed the facility had two people working on that hall that day. She stated CNA A was supposed to ask another staff for help with assistance and changing the residents. The Staffing Coordinator stated one aide was not supposed to change Resident #1. She stated CNA A never reported to her that Resident #1's bed was not locking. She stated the resident's bed always locked. During an interview with the DON on 02/23/18 at 5:12 PM, she stated she received a phone call from LVN B that Resident #1 had fallen on the floor while CNA A was providing incontinence care. She stated she was informed by LVN B that the CNA was cleaning Resident #1, reached over to get wipes and the resident rolled onto the floor. The DON reported that she interviewed CNA A regarding the incident. She stated the CNA informed her that while performing incontinence care the CNA reached towards the foot of the bed to get wipes while holding the resident, and the resident fell to the floor. The DON revealed she asked CNA A if she locked the bed and CNA A responded she did not because the bed did not lock. The DON revealed CNA A informed her that she was the only CNA in the room providing incontinence care to the resident. The DON reported that the next day she and the ADON performed bed audits on all the residents' beds to make sure they locked, and all beds locked properly. The DON revealed CNA A was suspended pending investigation. The DON stated Resident #1 required two person's assistance for incontinence care. The DON further said that after the incident, the facility updated the CNA daily assignment sheets on 2/21/18 to include Resident #1 required the assistance of two persons with bed mobility and incontinence care. DON stated that the CNA daily assignment sheet under the section bowel/bladder incontinence indicated yes. DON stated resident required total care with ADL's. DON reported that CNA A and other staff were provided in services regarding abuse/neglect, having all supplies available, making sure all beds locked, and to perform safety check. The DON revealed when she spoke with CNA A and informed her that Resident #1's bed did lock, CNA A informed her that she only tried to lock the bottom two locks, and that the residents' bed was still able to move. The DON stated the CNA A told her she did not lock the top locks. The DON also stated CNA A told her she (CNA A) did not know Resident #1 required the assistance of two persons for incontinence care. The DON reported the aides were instructed to follow their assignment sheet. She stated following the incident, they placed a floor mat on both sides of the resident's bed, and ordered a body pillow that was C-shaped. Further review of a Provider Investigation Report, completed by the Administrator and dated 02/21/18, revealed the facility corrected the noncompliance by implementing the following on 02/21/18: 1 .Suspended the alleged perpetrator CNA A pending investigation on 2/20/18. 2 .Updated Resident #1 care plan to reflect resident is a two person assist with all ADL's, fall mats on both sides of bed and bed in low position when not providing care. Facility purchased body pillow for resident. 3. Updated the CNA assignment sheet to reflect type of assistance needed for bed mobility and incontinent care. 4. Ordered positioning roll for Resident #1. 5. In-serviced all staff regarding abuse and neglect 6 .In-serviced housekeepers and CNA on insuring beds are locking correctly. 7. Provided one to one in-service to CNA A 8. Checked all facility beds to ensure they are operate appropriately. Observation of incontinent care, bed mobility, and transfer of Resident #1 on 03/12/18 at 10:50 AM revealed she was lying in bed with a bed roll on her left side. CNA C and CNA D were observed to provide incontinent care and roll resident in the bed while providing incontinent care. During this observation, CNA C and CNA D transferred Resident #1 out of her bed into a ger-chair with the use of the hoyer lift. CNA C and CNA D were both present and assisting throughout the observation of care. Observation of incontinent care and bed mobility of Resident #2 on 03/13/18 at 1:45 PM revealed CNA E and CNA F provided incontinent care and bed mobility. CNA E and CNA F were both present and assisting throughout the observation of care. Record review on 03/12/18 of Resident #1's care plan for Falls revealed it was updated on 02/21/18. During an interview with the Administrator on 03/12/18 at 12:05 PM she stated CNA A was no longer employed with the facility. Review of in-service training for ADL's, assignment sheets, and locking beds dated 02/20/18 and 02/21/18, revealed 62 employees attended the training, 28 of which were nursing employees (Nurses, CNAs, and MAs). Interviews were conducted on 03/13/18 with an LVN and four CNA's that revealed they were aware of how to identify the care each resident required and confirmed they had recently received in-service training regarding ADL care, falls, and neglect. The Administrator provided a census dated 03/12/18 reflecting there were thirteen residents that required two-person assistance.

Based on observation, interview and record review, it was determined the facility failed to implement its policies and procedures that prohibit neglect for eight (Residents #1 #2, #3, #4, #5, #6 #7 and #8) of 11 residents reviewed for neglect. 1. Staff failed to identify changes in Resident #1's condition and intervene or contact physician/PA when Resident #1 experienced symptoms of a change in condition including: a) abnormal laboratory values on 12/21/12, b) multiple low blood pressures in November 2012, December 2012 and January 2013, which resulted in [MEDICATION NAME] (anti-hypertensive) being held 68 of 89 days, c) the development of pressure sores. Resident #1, who was sent to the hospital on [DATE], was admitted the same day with seven identified pressure ulcers, when the facility had only identified three of them. c) decreased participation to no participation with Restorative Therapy, and d) the need for extensive staff assistance with ADLs. These failures affected Resident #1 resulting in [DIAGNOSES REDACTED]. 2) On 01/30/13, the facility had identified Resident #3 with four "shear" wounds, but following a second skin sweep, Resident #3 was identified as having ten Stage 2 pressure ulcers. The facility further failed to: 1. Provide accurate, timely and complete skin assessments for early detection and treatment of [REDACTED]. 2. Ensure complete and accurate descriptions of pressure ulcers, including staging for continued monitoring; 3. Ensure every skin area/pressure ulcer, once identified was documented with current descriptions and treatments; and 4. Ensure care plans were initiated and carried out. 3) On 12/05/12, Resident #2 had a pressure ulcer on her right heel identified by the Treatment Nurse, who failed to document the assessment or notify the physician until 12/13/13, eight days later. The facility further failed to: 1. Provide accurate, timely and complete skin assessments for early detection and treatment of [REDACTED]. 2. Ensure complete and accurate descriptions of pressure ulcers for continued monitoring; 3. Ensure pressure ulcers, once identified, were documented with current descriptions and treatments; 4. Notify the physician promptly for treatment orders; and 5. Ensure care plans were initiated and carried out. 4) Resident #7 was admitted to the facility on [DATE], but five Stage 2 pressure ulcers were not identified and treatments were not initiated until the following day at 5:45 PM. The facility further failed to: 1. Provide accurate skin assessments of pressure ulcers on admission; 2. Ensure Wound Care Physician orders [REDACTED]. 3. Ensure wound care was provided on admission; and 4. Ensure an interim care plan for pressure ulcers was initiated. 5) Resident #8 was identified with skin breakdown when admitted on [DATE], but there were never treatment orders or further head to toe assessments conducted as of 01/30/13. The facility further failed to: 1. Ensure wound care orders were obtained and treatment was provided on admission and thereafter, 2. Ensure complete and accurate descriptions of pressure ulcers, including staging for continued monitoring after admission. 3. Ensure care plans were developed and included a care plan to address possible skin problems. 4. Ensure skin assessments were conducted regularly. 6) Resident #4 was identified with a pressure ulcer on 01/12/13, which was not measured or described again. The facility failed to: 1. Complete accurate descriptions of a skin area, including measurements and where it was located; and 2. Ensure a care plan was initiated for the skin issue that was identified. 7) Resident #5 was admitted on [DATE] and assessed with [REDACTED]. The facility further failed to: 1. Provide accurate, timely and complete skin assessments for early detection and treatment of [REDACTED]. 2. Ensure complete and accurate descriptions of pressure ulcers for continued monitoring; 3. Ensure pressure ulcer, once identified, was documented with current descriptions and treatments; and 4. Ensure treatment were provided as ordered and promptly notify the physician of treatments and medications held. 8) Resident #6's laboratory results on 11/30/12 reflected a critically high potassium level, abnormally high blood urea nitrogen, Creatinine, BUN: CREAT RATIO, glucose level and a low eGFR Female level. Neither the PA nor the Physician were ever notified of these findings. Resident #6 was assessed on 10/25/13 with a Stage IV pressure ulcer on the heel, but she was not seen again by the wound doctor for assessment and treatment until 11/29/13. The facility further failed to: 1. Ensure the Treatment Nurse provided descriptions and measured the pressure ulcer when the wound doctor failed to assess the resident's pressure ulcer. 2. Ensure complete and accurate descriptions of pressure ulcers for continued monitoring; and 3. Ensure treatments were provided as ordered. An Immediate Jeopardy (IJ) was identified on 01/31/13. While the IJ was removed on 02/04/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. The failure to accurately assess/stage pressure ulcers, and consult with the residents physicians to obtain the physician's recommendations could result in the deterioration of existing pressure ulcers or cause the development of pressure ulcers for all 40 residents identified as receiving preventative skin care. These failures resulted in Resident #1's ICU hospitalization on [DATE] with [DIAGNOSES REDACTED]. Failure to implement policies and procedures that prevent neglect could affect any of the facility's 86 residents. Findings included: 1) Resident #1's MDS assessment dated [DATE] reflected the resident, a [AGE] year-old female, was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she made herself understood, understood others and had a BIMS score of 7, which indicated severe cognitive impairment. The MDS assessment also revealed she was incontinent of bowel and bladder, required extensive assistance with bed mobility, transfers, dressing and hygiene but only required supervision with meals. The MDS assessment reflected Resident #1 had no skin breakdown but was at risk for developing pressure ulcers. Review of Resident #1's Care Plans revealed she had no Care Plan related to her decline in condition, ADL decline or low blood pressures. Resident #1 was observed on 01/30/13 at 3:00 PM in the Intensive Care Unit (ICU) of a local hospital. She was lying in bed and was awake but very lethargic and was observed to have a [MEDICAL CONDITION] tube in place. An attempt to interview Resident #1 was unsuccessful as she did not answer any questions appropriately. Hospital staff stated she had impaired cognition since admission. During an interview on 01/31/13 at 9:20 AM, LVN W stated he usually worked the 2-10 PM shift with Resident #1. When he was asked about Resident #1's care needs, LVN W stated Resident #1 was usually alert and oriented, she required total assistance with transfers and repositioning, she had no contractures and full range of motion in all her extremities. When asked whether she could feed herself, LVN W stated, "Normally she would, but toward the end, when I gave her meds, I gave her water." When asked if he had to hold the cup to her mouth, LVN W stated he did. He added the staff fed her meals. When asked how long her decline had been, LVN W stated, "That Friday before (01/25/13), I assisted her. I wouldn't say declining. I gave her water with her meds so she wouldn't spill it." During an interview on 01/31/13 at 11:16 AM, the Treatment Nurse stated she saw Resident #1 with the Wound Physician on 01/28/13 at approximately 1:00 PM. She stated the resident was alert and her eyes were open, but she was not her normal self. The Treatment Nurse stated, "After the Wound Physician and I completed her treatments, I (Treatment Nurse) told the nurse to get her vital signs and call the PA and told him, 'She doesn't look right.' The nurse said her vital signs were good." During an interview on 01/31/13 at 9:26 AM, LVN S stated it was his second month to work with Resident #1 and he worked the day shift. LVN S stated Resident #1 was bedbound and had required total assistance as long as he had been at the facility. When asked how she was at meals, LVN S stated, "We feed her and give her water." When asked about her range of motion, LVN S stated if Resident #1 had enough sleep, she had full range of motion and was fine. If she missed even a little sleep, "...she wouldn't talk to you." LVN S stated he was working the day Resident #1 went out to the hospital. When asked what prompted her to be sent out, LVN S explained she was non-responsive and was over-sleeping. He stated she usually slept a lot but would answer you if you spoke to her, and on that day, she would not answer him. LVN S was asked whether he had ever notified the physician of Resident #1's low blood pressure readings and all the held doses of [MEDICATION NAME] (for hypertension). He stated, "It's got to be a lot to call the doctor." LVN S was shown the last three months of MARs and the counts of all the missed doses of [MEDICATION NAME]. LVN S stated it was not unusual for Resident #1 to have a low blood pressure, and he did not call the physician. LVN S stated the morning she went out, she was "just staring," and he called the PA later, after lunch. When asked if he knew how many pressure ulcers Resident #1 had when she went out to the hospital, LVN S replied, "I think two." (NOTE: Resident #1 had seven pressure ulcers identified by the hospital compared with the three known pressure ulcers identified by the facility) Resident #1's Nurse's Notes dated 01/28/13 at 12:25 PM reflected: "Resident in the bed, laying down (with) eye open. Resident is disoriented and not responsive to persons. She continued to be starring (sic) (without) blinking of eyes. She is not communicating, bed bound, total care, dependent for transfer, ADL, personal hygiene etc. Resident have (sic) a deep wound on coccyx area...AM care provided. No new order at this time...will continue to monitor." The entry was signed by LVN S. The next entry dated 01/28/13 at 1:40 PM reflected: "Resident was sent to the hospital for evaluation and tx (treatment) for multiple medical problems. (Family member) was notified and PA was also notified." The entry was signed by LVN S. Resident #1's Physician Telephone Orders dated 01/28/13 at 1:20 PM reflected: "Send (Resident #1) to the hosp (hospital) for evaluation & treatment." The entry was signed by LVN S. Resident #1's Consolidated Physician order [REDACTED]. Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Her blood pressure reached as low as 77/36. Resident #1's MAR for December 2012 reflected she had 15 doses (of a possible 31 doses) of [MEDICATION NAME] held because her blood pressure fell below 100/60. Her blood pressure reached as low as 76/52. Resident #1's MAR for January 2013 reflected she had 25 doses (of a possible 28 doses) of [MEDICATION NAME] held because her blood pressure fell below 100/60. Her blood pressure reached as low as 70/40. Interview with MA D on 02/01/13 at 8:52 AM revealed he had worked on Resident #1's hall for over a year. When MA D was asked whether he notified the charge nurse if a resident's blood pressure was low and a medication was held, MA D stated he told the nurse about Resident #1's blood pressure "Probably every other day." When he was asked about Resident #1's mental state, he described her as sometimes forgetful. When asked whether she could take her medication by herself, MA D stated at first she could, but the last week or so, he had to pour the pills into her mouth and put the water to her mouth. When asked if he had reported the change to the Charge Nurse, MA D stated he would ask LVN S, "What's going on with (Resident #1)?" He could not remember the LVN's responses. In an interview on 02/02/13 at 1:30 PM, LVN V stated she did remember a MA telling her Resident #1's B/P medication was held. LVN V stated there needed to be more communication from the MA. Review of Resident #1's laboratory results dated [DATE] revealed the following: A high White Blood Count of 11.3 10(3)/ul. Reference range was 4.0-10.8 10(3)/ul A critically low Hemoglobin of 7.8 g/dl. Reference range 11.0-15.8 g/dl. A low Hematocrit of 24.2 %. Reference range was 33.0-47.4% A high Potassium of 5.6 mmol/L. Reference range was 3.6-5.2 mmol/L. A high Blood Urea Nitrogen (BUN) of 46 mg/dl. Reference range was 7-17 mg/dl. A high Creatinine of 1.6 mg/dl. Reference range was 0.5-1.0 mg/dl. There were no initials on the lab report or any indication they had been reviewed with or faxed to the physician or PA. Review of the 24 Hour Report Book for December 2012 and January 2013 revealed only her Hemoglobin was mentioned. Resident #1's Skilled Nurse's Notes dated 12/21/12 at 3:20 PM reflected: "Received a call from (Laboratory) about a critical hemoglobin of 7.8. (PA) was notified. New Order: Recheck HG (hemoglobin) in 2 days, do iron study, reticulocyte study, and occult blood stool x (times) 3. Resident was notified." Further review of Resident #1's skilled Nurse's Notes revealed subsequent critical labs were called to the PA and addressed. There was no mention of any lab results. During an interview on 01/31/13 at 3:30 PM, when LVN W was asked whose responsibility it was to check the lab results, he stated it was the ADON's responsibility. LVN W was shown Resident #1's lab results dated 12/21/12 and asked whether he remembered seeing the report or calling the physician. LVN W stated he had not seen the lab results. He stated he called the critical hemoglobin to the PA, because it had been called to him from the lab. He stated whoever pulled the lab result was responsible for the follow-up and reporting the results. When LVN W was informed it had been faxed to the facility on his shift, he stated, "If I saw it, I would have initialed it and written it was faxed to the doctor. They print in the med room. I don't always see them." When asked who was responsible to follow up on labs after they were ordered, he stated the ADONs were responsible. When shown the high potassium and BUN results and asked whether he would have notified the physician, LVN W replied, "Absolutely I would've." When LVN W was shown Resident #1's MARs with the low blood pressure readings, he stated he was not aware her blood pressure had been running so low. When asked what he would have done had he been made aware of the readings, he stated he would have notified the physician after two or three low readings. During an interview on 01/31/13 at 3:45 PM, the ADON was asked who was responsible for the lab results and ensuring the physicians were made aware of abnormals. The ADON explained initially, the charge nurses were responsible for faxing and calling the results to the physicians. She further explained when the Physicians or Physician's Assistants came, she printed all the residents' labs since their last visit and they initialed them all. She stated she then replaced the old lab reports in the charts with the initialed ones. When the ADON was asked whether she had any lab reports, initialed by the PA or MD, that had not been charted yet, she stated she did not. In an interview on 02/04/13 at 9:00 AM, the surveyor asked LVN R how she checked for lab results, and LVN R stated, "That area was not good. That's why you (surveyors) are here." LVN R stated, "I look at the orders for my residents. Not everything gets written on the 24-hour report." During a meeting on 01/31/13 at 5:24 PM, the DON and Administrator were informed the PA had not been informed or Resident #1's laboratory results. When asked who was responsible for ensuring the laboratory results were relayed to the PA and physicians, the DON stated the charge Nurses were responsible for reviewing and faxing the lab reports to the physicians and the PA. Interview with CNA I on 01/31/13 at 11:00 AM revealed she had frequently worked with Resident #1. When asked about Resident #1, CNA I described her as "alert" and "with it" and stated she would laugh and talk during care. She said Resident #1 always received bed baths, because showers were uncomfortable for her. When asked whether Resident #1 could feed herself, CNA I stated she could for a while, but the past week or two, she (the CNA) had to feed her. She stated Resident #1, "Asked for water a lot" and over the past couple of weeks she had to put the glass of water to her mouth for her. When asked whether she had reported the change to anyone, CNA I stated she had told LVN S. During an interview on 01/31/13 at 9:15 AM, RA Q stated she had worked with Resident #1 doing Restorative Therapy. She explained she was helping her with her range of motion and transfers. When RA Q was asked whether Resident #1 was alert and able to answer questions appropriately, she stated she could answer appropriately but at the end, she would "go into a stare and wouldn't say anything...I would tell her like, 'How many fingers am I holding up?' at the end. She wouldn't tell me. She would tell me her name. She just got weaker." When asked whether or not Resident #1 could giver herself water, RA Q replied, "I would say no, for the past few weeks she couldn't raise her arms." RA Q stated she referred the resident back to the therapy department for more assistance. Resident #1's Physician's Telephone Orders dated 01/22/13 reflected, "OT (Occupational Therapy) to eval (evaluate) and treat." Review of Resident #1's OT Evaluation & Plan of Treatment dated 01/22/13 revealed the following: "Reason for Referral: Patient referred to OT due to new onset of decrease in range of motion, increased need for assistance from others, reduces ADL participation, reduced functional activity tolerance, decrease in strength, decrease in functional mobility and decrease in transfers indicating the need for OT to facilitate increased participation with functional daily activities...." PLOF (prior levels of functioning) revealed she was independent with self-feeding, needed minimum assistance with basic grooming and moderate assistance with upper extremity dressing. Interview with COTA/OT on 02/01/13 at 12:40 PM revealed Resident #1's occupational therapy had been restarted on 01/22/13 due to a decline in her condition. The COTA/OT stated, "Whenever that happens, we put them back on therapy." The COTA/OT stated when Resident #1 was discharged to Restorative Therapy, she was completely independent with feeding and could definitely give herself water. When asked if anyone from their department ever looked at the resident's clinical picture for explanations of their decline, she stated they did not, and it was not within their scope. Interview with RA P on 02/03/13 at 1:51 PM revealed she had worked with Resident #1 on range of motion and transfers. RA P stated. "She very rarely wanted to get up but got to a point where she couldn't get up. She got to the point she couldn't lift her arms." When asked if she had brought Resident #1's decline to anyone's attention, RA P replied, "Yes, several times. I can't pinpoint who I talked to." During another interview on 02/03/13 at 2:10 PM, RA Q was asked if she reported Resident #1's decline in condition to anyone other than the therapy department. RA Q stated, "We had told the nurses." When asked what nurse she had spoken with, RA Q stated, "It's different nurses." RA Q went on to explain they documented their findings in the kiosk computer system. The surveyor showed RA Q a print out of her notes and asked her who had access to the information she entered into the kiosk. RA Q stated she did not know. Review of the restorative therapy Weekly Progress Notes for December 2012 and January 2013 revealed the following entries: 12/07/12 - "(Resident #1) is active w/arom (with active range of motion)/dress/bed mobility doing well." 12/08/12 - "Removing resident from Restorative dining. She is independent in dining." 12/21/12 - "(Resident #1) is participating in all goal and is making progress." 12/28/12 - "(Resident #1) is participating with restorative program and is making progress toward her goal." 01/01/13 - "refused in trans. (transfer) did not feel well." 01/02/13- "(Resident #1) refused trans. Did not feel well." 01/04/13 at 9:29 AM - "(Resident #1) is active in trans/dressing/groo (grooming)/eating/swallowing and is making progress toward her goal." 01/04/13 at 12:57 PM - "refused trans (Resident #1) said she was to (sic) tired." 01/07/13 - "Refused trans. did not feel well." 01/08/13 - "refused due to bed sore/sleepness (sic)/tired." 01/09/13 - "did very little r.o.m.(range of motion) do (sic) to weakness/tire also with dress/groo/trans having problems." 01/10/13 - "(Resident #1) is very weak do very little and refused trans. very little groo/dress and eats with assist." 01/11/13 - "(Resident #1) has not been feeling well and not participating in program." 01/14/13 - "very weak." 01/16/13 - "refused r.o.m. but we did massage upper/lower/arm/leg." 01/18/13 - "(Resident #1) is not meeting her goals, she is becoming total care, can not feed self at the moment. Refuse to get out of bed." 01/21/13 - "(Resident #1) refused r.o.m. due to weakness in hands." 01/25/13 - "(Resident #1) is not strong enough to do a.r.o.m. (active range of motion) do (sic) to pain in arms but is still participating in all other goal and is making very little progress." 01/26/13 - "refused trans/r.o.m." 01/28/13 - "refused trans./a.r.o.m. refused do(sic) to weakness." During an interview on 02/03/13 at 3:30 PM, the DON was asked if the Restorative Aide's notes were reviewed by the charge nurses. The DON stated they were not, and she was the only one to review the entries, and she was only looking for specific information like bowel movements, showers, and meals. She stated she had not read the Restorative Aide's notes related to Resident #1. Review of Resident #1's emergency room records dated 01/28/13 revealed the following laboratory results: --White Blood Count was high at 14.4 x10(3)/mcL. Reference range was 4.8-10.8 x10(3)/mcL. --Potassium was high at 5.9 mEq/L. Reference range was 3.5-5.1 mEq/L. --BUN was high at 82 mg/dl. Reference range was 7-21 mg/dl. --Creatinine level was high at 2.1 mg/dl. Reference range was 0.5-1.2 mg/dl. Resident #1's blood pressure upon arrival to the emergency room was very low at 88/47 (normal 120/80) and her heart rate was high at 101 (normal 70-80). Resident #1's hospital History and Physical Report dated 01/28/13 revealed the following: --Reason for Admission: "Septic [MEDICAL CONDITION] and urinary tract infection with decubitus wound and possible infection." --Chief Complaint: "Confusion." --Medical Decision Making: "1.[MEDICAL CONDITION] based on end-organ damage with altered level of consciousness, [MEDICAL CONDITION] (low blood pressure), [MEDICAL CONDITION] fever ...The likely source is urinary tract infection and she is at risk for nosocomial infection such [MEDICAL CONDITION] and pseudomonas both with this and possible superinfection of her wound. We will admit her to the step-down unit and give her fluid resuscitation and IV antibiotics with [MEDICATION NAME] (antibiotic) and [MEDICATION NAME] (antibiotic) to cover nosocomial organisms. 2. Cardiomegaly. We will check an echocardiogram in the morning to assess her left ventricular function because of the cardiomegaly noted on chest x-ray, as this will help guide how aggressively we can hydrate her. She does not have any known history of heart failure. 3. [MEDICAL CONDITION]. She is on [MEDICATION NAME] and [MEDICATION NAME], so I would infer, based on her clinical presentation that this would be acute [MEDICAL CONDITION] and acute renal impairment because [MEDICAL CONDITION] and volume depletion with dehydration. We will hydrate her and see how she does. Foley catheter to monitor urine output... 6. [MEDICAL CONDITION] (high potassium) secondary to dehydration, acute renal impairment and exacerbated possibly by ACE inhibitor. We will give her a single dose of [MEDICATION NAME] 9. We will consult with infectious disease. 10. We will consult with (surgeon) as she may need surgical debridement of the wound...." A hospital Consultation Report for Resident #1, dated 01/29/13, reflected the following: Reason for Consultation: ."I have been asked to see the patient for evaluation of acute kidney injury in the setting of septic shock and volume depletion." Diagnostic Impression: "1. Acute kidney injury in the setting of volume depletion [MEDICAL CONDITION] and [MEDICAL CONDITION] 2. [MEDICAL CONDITION] (increased sodium levels) and water deficits. 3. Metabolic acidosis secondary to acute kidney injury [MEDICAL CONDITION] 4. [MEDICAL CONDITION], likely secondary to [MEDICAL CONDITION] and [MEDICAL CONDITION]. 5. Urosepsis with E. coli. 6. Multiple decubitus wounds. Plan: 1. IV fluids. 2. IV alkali. 3. NG ([MEDICAL CONDITION]) tube placement. 4. Provide free water via NG tube. 5. Antibiotic therapy. 6. Wound Care. 7. Follow intake and output and serum electrolytes daily. We will follow." 2) The facility's current policy and procedure entitled "Laboratory Services," dated 10/11/08 reflected: "Policy - It is policy of the facility to obtain all laboratory test ordered by the attending physician to ensure that prompt appropriate action is taken if indicated for the resident's care... Procedure - ...5. Lab results be will collected from the lab by the DON or designee every tour of duty before daily start-up. 6. The DON or designee will review ALL lab results... 9. The charge nurse will call the physician for any abnormal lab results... The facility's licensed nursing staff will assess the resident's condition. Should a resident experience an abnormal response or complication, the licensed nurse will document the changes and notify the attending physician promptly." The facility's current policy and procedure "Hydration Fluid Maintenance," dated October 2010 reflected: "Fundamental Information ...In the elderly, most fluid/electrolyte imbalances present initially with nonspecific symptoms such as lethargy, confusion, or a decline in function that may be abrupt... Process 1. All residents will be offered 2 to 3 beverages of choice at each meal... 3. Additional fluids will be offered during medication passes... 8. Residents who require assistance and encouragement with drinking will receive assistance and encouragement from CNAs, Licensed nurses and or paid feeding assistants, under the supervision of a licensed nurse... 11. For residents who are dependent in drinking or who require cueing and/or encouragement to drink, staff should offer, cue, assist resident to drink as necessary on each staff/resident contact." The facility's current policy and procedure entitled "Condition Change of the Resident" (undated) reflected: "PURPOSE - To observe, record and report any condition change to the attending physician so proper treatment will be implemented... PROCEDURE - 1. After all resident falls, injuries or condition changes, monitor following... f. Observe for alteration in consciousness... i. Observe for generalized weakness ...Recognition of Change in Condition 1. Criteria: Resident eats or drinks less than usual, is less talkative, is sleepier, more confused, or more agitation, needs more help with ADL's ...2. If 'Yes' response to any of the above: Suspect Illness 3. Assess the Resident ...4. Contact the attending physician or designee ...5. Receive orders from physician or designee 6. Implement order 7. Provide nursing care 8. Continue assessment as listed above for AT LEAST every 8 hours for 72 hours." 3) An undated Comprehensive Plan of Care for Resident #1 indicated she was at risk for skin breakdown, but no "Problems" were identified. Approaches included: "1) Monitor for incont. (Incontinence) Q (every) 2 hrs and prn (as needed), change promptly 2) Assist with repositioning as needed, using padding between pressure areas 3) Encourage p.o. (oral) and fluid intake 4) Give meds per order, monitor labs-report abn's (abnormals) to M.D. (Medical Doctor) 5) Monitor for skin breakdown, report to M.D. and R.P. (responsible party) 6) Provide pressure relieving and positioning devices as needed 7) Assess skin weekly and record findings 8) Turn and reposition Q2H (every two hours) 9) Prevent shearing forces and friction during transfers 10) Use non-irritating soaps 11) Keep bed free of wrinkles crumbs, and other sources of pressure." Resident #1's Nutrition Progress Notes dated 10/12/12 reflected: "[MEDICATION NAME] 10.5 L (10/9/2012) ...Resident at increased risk for skin breakdown due to low [MEDICATION NAME]. Recommend: 1. Request Prostat sugar-free 30 cc BID (twice a day) x 30 d (for 30 days)...." (NOTE: Physician Telephone orders reflected Prostat was not ordered until 01/17/13, three months later.) During an interview with the Dietician on 02/01/13 at 11:00 AM, when asked whether she always checked to see if her recommendations had been followed, she replied, "I try to." The dietician explained when she made recommendations, she posted them online. She stated the DON and the ADON received email notifications when the recommendations were posted, and she also placed them in the chart. The dietician added she always came to see Resident #1 and stated she was usually compliant with orders. Resident #1's Daily Skilled Nurse's Notes dated 11/14/12 reflected the following: "Pressure ulcers noted under the right leg with a measurement of 0.8 x 0.9 cm and 0.3 cm x 0.5 cm respectively. (PA) and (family member) notified. New order of tx (treatment) noted." Resident #1's TAR for November 2012 included an order to cleanse the pressure ulcers under the right leg with NS, pat dry, apply TAO twice daily and as needed until healed. The order was signed as completed from 11/14/12 through 11/20/12. Resident #1's "Skin Condition Record" (weekly head to toe assessments) reflected the following for 11/14/12: --Date First Observed: 11/14/12 --Site/Location: Right Leg (under) Pressure Sore 1. 0.8 x 0.9 cm, 2. 0.3 cm x 0.5 cm --Identify Site on diagram below: A diagram of the back of a body reflected two X's marked on the back of the left leg and a circle on the buttocks. --Reassessment Frequency: Weekly --measurements only, no staging or description was written. Exudate (drainage) Type/Odor/Amount, Wound Bed and Surrounding Tissue/Wound Edges were marked with "?(no)." Entered by LVN W. Resident #1's Physician Telephone Orders dated 11/19/12 reflected to "D/C previous treatment to back of leg Start: Calf # (sic) cleanse with NS Pat dry apply [MEDICATION NAME] Ag and dsg (dressing) QD & PRN Calf #2: Cleanse with NS Pat Dry apply [MEDICATION NAME] Ag and dsg QD and PRN. Vitamin C 500 mg 1 tab PO QD, Multivitamin 1 tab PO QD, [MEDICATION NAME] Q 3 months, Zinc Sulfate 220 mg po daily." Resident #1's Daily Skilled Nurse's Notes dated 11/20/12 reflected: "...New order-D/C previous treatment to back of leg. Start Calf # 1 cleanse with NS pat dry apply [MEDICATION NAME] AG dsg (dressing) QD (every day) & PRN (as need

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (Resident #1) of 11 residents reviewed for quality of care. Resident #1 experienced symptoms of a change in condition around the beginning of January 2013. The facility failed to: -Assess, monitor and report to the physician/PA when the resident experienced cognitive changes, increased weakness, required increased assistance with ADLs and overall decline. -Keep the physician apprised of the resident's continued change in condition, her fatigue, low blood pressure readings, the holding of [MEDICATION NAME] (for treatment of [REDACTED]. -Ensure appropriate orders and treatments were received for the resident. -Communicate with facility staff to ensure awareness of the resident's condition with appropriate monitoring and assessments. -Address her decline in condition on her Care Plan. An Immediate Jeopardy (IJ) was identified on 01/31/13. While the IJ was removed on 02/04/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. These failures affected Resident #1 resulting in [DIAGNOSES REDACTED]. These failures could affect the facility's 86 residents, placing them at risk for not being assessed when experiencing a decline in health, not having their physician notified of their decline, and not receiving the necessary treatment and services to maintain their health, which could result in the potential need for hospitalization and/or possibly resulting in death. Findings included: Resident #1's MDS assessment dated [DATE] reflected the resident, a [AGE] year-old female, was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she made herself understood, understood others and had a BIMS score of 7, which indicated severe cognitive impairment. The MDS assessment also revealed she was incontinent of bowel and bladder, required extensive assistance with bed mobility, transfers, dressing and hygiene but only required supervision with meals. The MDS assessment reflected Resident #1 had no skin breakdown but was at risk for developing pressure ulcers. Review of Resident #1's Care Plans revealed she had no Care Plan related to her decline in condition, ADL decline or low blood pressures. Resident #1 was observed on 01/30/13 at 3:00 PM in the Intensive Care Unit (ICU) of a local hospital. She was lying in bed and was awake but very lethargic and was observed to have a [MEDICAL CONDITION] tube in place. An attempt to interview Resident #1 was unsuccessful as she did not answer any questions appropriately. Hospital staff stated she had impaired cognition since admission. During an interview on 01/31/13 at 9:20 AM, LVN W stated he usually worked the 2-10 PM shift with Resident #1. When he was asked about Resident #1's care needs, LVN W stated Resident #1 was usually alert and oriented, she required total assistance with transfers and repositioning, she had no contractures and full range of motion in all her extremities. When asked whether she could feed herself, LVN W stated, "Normally she would, but toward the end, when I gave her meds, I gave her water." When asked if he had to hold the cup to her mouth, LVN W stated he did. He added the staff fed her meals. When asked how long her decline had been, LVN W stated, "That Friday before (01/25/13), I assisted her. I wouldn't say declining. I gave her water with her meds so she wouldn't spill it." During an interview on 01/31/13 at 11:16 AM, the Treatment Nurse stated she saw Resident #1 with the Wound Physician on 01/28/13 at approximately 1:00 PM. She stated the resident was alert and her eyes were open, but she was not her normal self. The Treatment Nurse stated, "After the Wound Physician and I completed her treatments, I (Treatment Nurse) told the nurse to get her vital signs and call the PA and told him, 'She doesn't look right.' The nurse said her vital signs were good." During an interview on 01/31/13 at 9:26 AM, LVN S stated it was his second month to work with Resident #1 and he worked the day shift. LVN S stated Resident #1 was bedbound and had required total assistance as long as he had been at the facility. When asked how she was at meals, LVN S stated, "We feed her and give her water." When asked about her range of motion, LVN S stated if Resident #1 had enough sleep, she had full range of motion and was fine. If she missed even a little sleep, "...she wouldn't talk to you." LVN S stated he was working the day Resident #1 went out to the hospital. When asked what prompted her to be sent out, LVN S explained she was non-responsive and was over-sleeping. He stated she usually slept a lot but would answer you if you spoke to her, and on that day, she would not answer him. LVN S was asked whether he had ever notified the physician of Resident #1's low blood pressure readings and all the held doses of [MEDICATION NAME] (for hypertension). He stated, "It's got to be a lot to call the doctor." LVN S was shown the last three months of MARs and the counts of all the missed doses of [MEDICATION NAME]. LVN S stated it was not unusual for Resident #1 to have a low blood pressure, and he did not call the physician. LVN S stated the morning she went out, she was "just staring," and he called the PA later, after lunch. When asked if he knew how many pressure ulcers Resident #1 had when she went out to the hospital, LVN S replied, "I think two." (NOTE: Resident #1 had seven pressure ulcers identified by the hospital compared with the three known pressure ulcers identified by the facility) Resident #1's Nurse's Notes dated 01/28/13 at 12:25 PM reflected: "Resident in the bed, laying down (with) eye open. Resident is disoriented and not responsive to persons. She continued to be starring (sic) (without) blinking of eyes. She is not communicating, bed bound, total care, dependent for transfer, ADL, personal hygiene etc. Resident have (sic) a deep wound on coccyx area...AM care provided. No new order at this time...will continue to monitor." The entry was signed by LVN S. The next entry dated 01/28/13 at 1:40 PM reflected: "Resident was sent to the hospital for evaluation and tx (treatment) for multiple medical problems. (Family member) was notified and PA was also notified." The entry was signed by LVN S. Resident #1's Physician Telephone Orders dated 01/28/13 at 1:20 PM reflected: "Send (Resident #1) to the hosp (hospital) for evaluation & treatment." The entry was signed by LVN S. Resident #1's Consolidated Physician order [REDACTED]. Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Her blood pressure reached as low as 77/36. Resident #1's MAR for December 2012 reflected she had 15 doses (of a possible 31 doses) of [MEDICATION NAME] held because her blood pressure fell below 100/60. Her blood pressure reached as low as 76/52. Resident #1's MAR for January 2013 reflected she had 25 doses (of a possible 28 doses) of [MEDICATION NAME] held because her blood pressure fell below 100/60. Her blood pressure reached as low as 70/40. Interview with MA D on 02/01/13 at 8:52 AM revealed he had worked on Resident #1's hall for over a year. When MA D was asked whether he notified the charge nurse if a resident's blood pressure was low and a medication was held, MA D stated he told the nurse about Resident #1's blood pressure "Probably every other day." When he was asked about Resident #1's mental state, he described her as sometimes forgetful. When asked whether she could take her medication by herself, MA D stated at first she could, but the last week or so, he had to pour the pills into her mouth and put the water to her mouth. When asked if he had reported the change to the Charge Nurse, MA D stated he would ask LVN S, "What's going on with (Resident #1)?" He could not remember the LVN's responses. In an interview on 02/02/13 at 1:30 PM, LVN V stated she did remember a MA telling her Resident #1's B/P medication was held. LVN V stated there needed to be more communication from the MA. Review of Resident #1's laboratory results dated [DATE] revealed the following: A high White Blood Count of 11.3 10(3)/ul. Reference range was 4.0-10.8 10(3)/ul A critically low Hemoglobin of 7.8 g/dl. Reference range 11.0-15.8 g/dl. A low Hematocrit of 24.2 %. Reference range was 33.0-47.4% A high Potassium of 5.6 mmol/L. Reference range was 3.6-5.2 mmol/L. A high Blood Urea Nitrogen (BUN) of 46 mg/dl. Reference range was 7-17 mg/dl. A high Creatinine of 1.6 mg/dl. Reference range was 0.5-1.0 mg/dl. There were no initials on the lab report or any indication they had been reviewed with or faxed to the physician or PA. Review of the 24 Hour Report Book for December 2012 and January 2013 revealed only her Hemoglobin was mentioned. Resident #1's Skilled Nurse's Notes dated 12/21/12 at 3:20 PM reflected: "Received a call from (Laboratory) about a critical hemoglobin of 7.8. (PA) was notified. New Order: Recheck HG (hemoglobin) in 2 days, do iron study, reticulocyte study, and occult blood stool x (times) 3. Resident was notified." Further review of Resident #1's skilled Nurse's Notes revealed subsequent critical labs were called to the PA and addressed. There was no mention of any lab results. During an interview on 01/31/13 at 3:30 PM, when LVN W was asked whose responsibility it was to check the lab results, he stated it was the ADON's responsibility. LVN W was shown Resident #1's lab results dated 12/21/12 and asked whether he remembered seeing the report or calling the physician. LVN W stated he had not seen the lab results. He stated he called the critical hemoglobin to the PA, because it had been called to him from the lab. He stated whoever pulled the lab result was responsible for the follow-up and reporting the results. When LVN W was informed it had been faxed to the facility on his shift, he stated, "If I saw it, I would have initialed it and written it was faxed to the doctor. They print in the med room. I don't always see them." When asked who was responsible to follow up on labs after they were ordered, he stated the ADONs were responsible. When shown the high potassium and BUN results and asked whether he would have notified the physician, LVN W replied, "Absolutely I would've." When LVN W was shown Resident #1's MARs with the low blood pressure readings, he stated he was not aware her blood pressure had been running so low. When asked what he would have done had he been made aware of the readings, he stated he would have notified the physician after two or three low readings. During an interview on 01/31/13 at 3:45 PM, the ADON was asked who was responsible for the lab results and ensuring the physicians were made aware of abnormals. The ADON explained initially, the charge nurses were responsible for faxing and calling the results to the physicians. She further explained when the Physicians or Physician's Assistants came, she printed all the residents' labs since their last visit and they initialed them all. She stated she then replaced the old lab reports in the charts with the initialed ones. When the ADON was asked whether she had any lab reports, initialed by the PA or MD, that had not been charted yet, she stated she did not. In an interview on 02/04/13 at 9:00 AM, the surveyor asked LVN R how she checked for lab results, and LVN R stated, "That area was not good. That's why you (surveyors) are here." LVN R stated, "I look at the orders for my residents. Not everything gets written on the 24-hour report." During a meeting on 01/31/13 at 5:24 PM, the DON and Administrator were informed the PA had not been informed or Resident #1's laboratory results. When asked who was responsible for ensuring the laboratory results were relayed to the PA and physicians, the DON stated the charge Nurses were responsible for reviewing and faxing the lab reports to the physicians and the PA. Interview with CNA I on 01/31/13 at 11:00 AM revealed she had frequently worked with Resident #1. When asked about Resident #1, CNA I described her as "alert" and "with it" and stated she would laugh and talk during care. She said Resident #1 always received bed baths, because showers were uncomfortable for her. When asked whether Resident #1 could feed herself, CNA I stated she could for a while, but the past week or two, she (the CNA) had to feed her. She stated Resident #1, "Asked for water a lot" and over the past couple of weeks she had to put the glass of water to her mouth for her. When asked whether she had reported the change to anyone, CNA I stated she had told LVN S. During an interview on 01/31/13 at 9:15 AM, RA Q stated she had worked with Resident #1 doing Restorative Therapy. She explained she was helping her with her range of motion and transfers. When RA Q was asked whether Resident #1 was alert and able to answer questions appropriately, she stated she could answer appropriately but at the end, she would "go into a stare and wouldn't say anything...I would tell her like, 'How many fingers am I holding up?' at the end. She wouldn't tell me. She would tell me her name. She just got weaker." When asked whether or not Resident #1 could giver herself water, RA Q replied, "I would say no, for the past few weeks she couldn't raise her arms." RA Q stated she referred the resident back to the therapy department for more assistance. Resident #1's Physician's Telephone Orders dated 01/22/13 reflected, "OT (Occupational Therapy) to eval (evaluate) and treat." Review of Resident #1's OT Evaluation & Plan of Treatment dated 01/22/13 revealed the following: "Reason for Referral: Patient referred to OT due to new onset of decrease in range of motion, increased need for assistance from others, reduces ADL participation, reduced functional activity tolerance, decrease in strength, decrease in functional mobility and decrease in transfers indicating the need for OT to facilitate increased participation with functional daily activities...." PLOF (prior levels of functioning) revealed she was independent with self-feeding, needed minimum assistance with basic grooming and moderate assistance with upper extremity dressing. Interview with COTA/OT on 02/01/13 at 12:40 PM revealed Resident #1's occupational therapy had been restarted on 01/22/13 due to a decline in her condition. The COTA/OT stated, "Whenever that happens, we put them back on therapy." The COTA/OT stated when Resident #1 was discharged to Restorative Therapy, she was completely independent with feeding and could definitely give herself water. When asked if anyone from their department ever looked at the resident's clinical picture for explanations of their decline, she stated they did not, and it was not within their scope. Interview with RA P on 02/03/13 at 1:51 PM revealed she had worked with Resident #1 on range of motion and transfers. RA P stated. "She very rarely wanted to get up but got to a point where she couldn't get up. She got to the point she couldn't lift her arms." When asked if she had brought Resident #1's decline to anyone's attention, RA P replied, "Yes, several times. I can't pinpoint who I talked to." During another interview on 02/03/13 at 2:10 PM, RA Q was asked if she reported Resident #1's decline in condition to anyone other than the therapy department. RA Q stated, "We had told the nurses." When asked what nurse she had spoken with, RA Q stated, "It's different nurses." RA Q went on to explain they documented their findings in the kiosk computer system. The surveyor showed RA Q a print out of her notes and asked her who had access to the information she entered into the kiosk. RA Q stated she did not know. Review of the restorative therapy Weekly Progress Notes for December 2012 and January 2013 revealed the following entries: 12/07/12 - "(Resident #1) is active w/arom (with active range of motion)/dress/bed mobility doing well." 12/08/12 - "Removing resident from Restorative dining. She is independent in dining." 12/21/12 - "(Resident #1) is participating in all goal and is making progress." 12/28/12 - "(Resident #1) is participating with restorative program and is making progress toward her goal." 01/01/13 - "refused in trans. (transfer) did not feel well." 01/02/13- "(Resident #1) refused trans. Did not feel well." 01/04/13 at 9:29 AM - "(Resident #1) is active in trans/dressing/groo(grooming)/eating/swallowing and is making progress toward her goal." 01/04/13 at 12:57 PM - "refused trans (Resident #1) said she was to (sic) tired." 01/07/13 - "Refused trans. did not feel well." 01/08/13 - "refused due to bed sore/sleepness (sic)/tired." 01/09/13 - "did very little r.o.m.(range of motion) do (sic) to weakness/tire also with dress/groo/trans having problems." 01/10/13 - "(Resident #1) is very weak do very little and refused trans. very little groo/dress and eats with assist." 01/11/13 - "(Resident #1) has not been feeling well and not participating in program." 01/14/13 - "very weak." 01/16/13 - "refused r.o.m. but we did massage upper/lower/arm/leg." 01/18/13 - "(Resident #1) is not meeting her goals, she is becoming total care, can not feed self at the moment. Refuse to get out of bed." 01/21/13 - "(Resident #1) refused r.o.m. due to weakness in hands." 01/25/13 - "(Resident #1) is not strong enough to do a.r.o.m. (active range of motion) do (sic) to pain in arms but is still participating in all other goal and is making very little progress." 01/26/13 - "refused trans/r.o.m." 01/28/13 - "refused trans./a.r.o.m. refused do(sic) to weakness." During an interview on 02/03/13 at 3:30 PM, the DON was asked if the Restorative Aide's notes were reviewed by the charge nurses. The DON stated they were not, and she was the only one to review the entries, and she was only looking for specific information like bowel movements, showers, and meals. She stated she had not read the Restorative Aide's notes related to Resident #1. During an interview on 01/31/13 at 3:46 PM, when the PA was asked if he was aware of Resident #1's skin condition, he stated he did not know about any pressure ulcers other than the ones on her sacrum and leg. When shown Resident #1's MARs and asked if he had been made aware of her low blood pressures and all the held doses of [MEDICATION NAME], he stated he had not. The PA was shown Resident #1's laboratory results dated [DATE] and asked if he recalled being notified. The PA explained he had been made aware of the low blood counts only and had addressed it. When asked if he knew about the elevated potassium levels and BUN, he replied, "No. I can't say I was." When asked whether he would have done anything differently, the PA stated he probably would have ordered [MEDICATION NAME] (a medication given to lower potassium levels) and would have wanted to push fluids especially with a low blood pressure. When the PA was asked if it was fair to say he had not been made aware of her decreasing blood pressures over the past few months, he stated he had not been informed about the blood pressure readings and stated he probably would have given her intravenous fluids. When asked if that was something that could be done at the facility, he stated it was. The PA stated he had seen Resident #1 last on 01/16/13, and she seemed a little sluggish but without the other data (low blood pressures and lab values), he would not have thought much of it at the time. The PA was asked when he would expect to be notified about low blood pressure readings with held medication and he replied, "Three to five days in a row if it is out of the norm." When asked if a resident's potassium was high, and he did not find out until weeks later, whether he felt that was a problem, the PA replied, "Absolutely." When the PA was asked whether the staff brought him any lab reports to review during his visit on 01/16/13, he stated if he had reviewed a lab report, he would have initialed it. Review of Resident #1's emergency room records dated 01/28/13 revealed the following laboratory results: --White Blood Count was high at 14.4 x10(3)/mcL. Reference range was 4.8-10.8 x10(3)/mcL. --Potassium was high at 5.9 mEq/L. Reference range was 3.5-5.1 mEq/L. --BUN was high at 82 mg/dl. Reference range was 7-21 mg/dl. --Creatinine level was high at 2.1 mg/dl. Reference range was 0.5-1.2 mg/dl. Resident #1's blood pressure upon arrival to the emergency room was very low at 88/47 (normal 120/80) and her heart rate was high at 101 (normal 70-80). Resident #1's hospital History and Physical Report dated 01/28/13 revealed the following: --Reason for Admission: "Septic [MEDICAL CONDITION] and urinary tract infection with decubitus wound and possible infection." --Chief Complaint: "Confusion." --Medical Decision Making: "1.[MEDICAL CONDITION] based on end-organ damage with altered level of consciousness, [MEDICAL CONDITION] (low blood pressure), [MEDICAL CONDITION] fever ...The likely source is urinary tract infection and she is at risk for nosocomial infection such [MEDICAL CONDITION] and pseudomonas both with this and possible superinfection of her wound. We will admit her to the step-down unit and give her fluid resuscitation and IV antibiotics with [MEDICATION NAME] (antibiotic) and [MEDICATION NAME] (antibiotic) to cover nosocomial organisms. 2. Cardiomegaly. We will check an echocardiogram in the morning to assess her left ventricular function because of the cardiomegaly noted on chest x-ray, as this will help guide how aggressively we can hydrate her. She does not have any known history of heart failure. 3. [MEDICAL CONDITION]. She is on [MEDICATION NAME] and [MEDICATION NAME], so I would infer, based on her clinical presentation that this would be acute [MEDICAL CONDITION] and acute renal impairment because [MEDICAL CONDITION] and volume depletion with dehydration. We will hydrate her and see how she does. Foley catheter to monitor urine output... 6. [MEDICAL CONDITION] (high potassium) secondary to dehydration, acute renal impairment and exacerbated possibly by ACE inhibitor. We will give her a single dose of [MEDICATION NAME] 9. We will consult with infectious disease. 10. We will consult with (surgeon) as she may need surgical debridement of the wound...." A hospital Consultation Report for Resident #1, dated 01/29/13, reflected the following: Reason for Consultation: ."I have been asked to see the patient for evaluation of acute kidney injury in the setting of septic shock and volume depletion." Diagnostic Impression: "1. Acute kidney injury in the setting of volume depletion [MEDICAL CONDITION] and [MEDICAL CONDITION] 2. [MEDICAL CONDITION] (increased sodium levels) and water deficits. 3. Metabolic acidosis secondary to acute kidney injury [MEDICAL CONDITION] 4. [MEDICAL CONDITION], likely secondary to [MEDICAL CONDITION] and [MEDICAL CONDITION]. 5. Urosepsis with E. coli. 6. Multiple decubitus wounds. Plan: 1. IV fluids. 2. IV alkali. 3. NG ([MEDICAL CONDITION]) tube placement. 4. Provide free water via NG tube. 5. Antibiotic therapy. 6. Wound Care. 7. Follow intake and output and serum electrolytes daily. We will follow." 3. The facility's current policy and procedure entitled "Laboratory Services," dated 10/11/08 reflected: "Policy - It is policy of the facility to obtain all laboratory test ordered by the attending physician to ensure that prompt appropriate action is taken if indicated for the resident's care... Procedure - ...5. Lab results be will collected from the lab by the DON or designee every tour of duty before daily start-up. 6. The DON or designee will review ALL lab results... 9. The charge nurse will call the physician for any abnormal lab results... The facility's licensed nursing staff will assess the resident's condition. Should a resident experience an abnormal response or complication, the licensed nurse will document the changes and notify the attending physician promptly." The facility's current policy and procedure "Hydration Fluid Maintenance," dated October 2010 reflected: "Fundamental Information ...In the elderly, most fluid/electrolyte imbalances present initially with nonspecific symptoms such as lethargy, confusion, or a decline in function that may be abrupt... Process 1. All residents will be offered 2 to 3 beverages of choice at each meal... 3. Additional fluids will be offered during medication passes... 8. Residents who require assistance and encouragement with drinking will receive assistance and encouragement from CNAs, Licensed nurses and or paid feeding assistants, under the supervision of a licensed nurse... 11. For residents who are dependent in drinking or who require cueing and/or encouragement to drink, staff should offer, cue, assist resident to drink as necessary on each staff/resident contact." The facility's current policy and procedure entitled "Condition Change of the Resident" (undated) reflected: "PURPOSE - To observe, record and report any condition change to the attending physician so proper treatment will be implemented... PROCEDURE - 1. After all resident falls, injuries or condition changes, monitor following... f. Observe for alteration in consciousness... i. Observe for generalized weakness ...Recognition of Change in Condition 1. Criteria: Resident eats or drinks less than usual, is less talkative, is sleepier, more confused, or more agitation, needs more help with ADL's ...2. If 'Yes' response to any of the above: Suspect Illness 3. Assess the Resident ...4. Contact the attending physician or designee ...5. Receive orders from physician or designee 6. Implement order 7. Provide nursing care 8. Continue assessment as listed above for AT LEAST every 8 hours for 72 hours." Review of the facility's current policy and procedure, "Non-Pressure Ulcer & Skin Care Management" dated July 2008, revealed: "Policy A resident having a non-pressure related wound or other type of skin condition will receive the necessary treatment and services to promote healing and reduce the risk for other complications such as further skin breakdown or infection... Procedure 1. A licensed nurse will assess all skin/wound conditions and contact the physician for appropriate treatment orders... 2. The licensed nurse will document a thorough assessment of the skin/wound condition... 5. An Interdisciplinary Plan of Care based on the response, outcomes, and needs of the resident will be developed. 6. The Licensed Nurse will re-evaluate the wound for progression in healing weekly and implement treatment changes as indicated. Documentation 1. The licensed nurse will complete the Skin Condition Report every week... 3. The Interdisciplinary Team will revise the Resident Care Plan based on the resident's response, which will include the approaches, interventions and outcomes for the skin condition...." On 01/31/13 at 2:26 PM, an IJ was identified. At that time, the Administrator and DON were notified of the IJ, and a Plan of Removal for the IJ was requested. The facility's Plan of Removal was accepted on 02/01/13 at 1:20 PM and contained the following: A. Resident #1 would be reassessed by a Licensed Nurse upon readmission to the facility, including a full body skin assessment and appropriate physician orders. A full skin sweep would be conducted beginning on 01/31/13 and would be completed on 02/01/13 by the facility RNs. Residents identified with new skin issues will be reported to the dietician for necessary recommendations. Weekly skin assessments will be completed on all residents by the DON for 4 weeks. Directed in-service training would be given to the facility Treatment Nurse by the DON, with competency on 02/01/13. The training would include assessments, proper staging of pressure ulcers, measurements, management of pressure and non-pressure areas, communication with the attending physician and the Wound Physician with changes in the wound's condition. The facility will provide wound care training to the Treatment Nurse by a wound care consultant by 02/15/13. Ongoing training and support will be provided to the Treatment Nurse by the wound care consultant and/or wound care specialist. The Treatment Nurse will conduct weekly skin assessments following wound care training and demonstrated competency. Any new sites or skin issues will be documented. The DON will be notified immediately of her assessment, and the physician will be notified of all new areas for treatment orders. B. The DON, ADON, Treatment Nurse and MDS Nurses will ensure transcription of all new physician orders [REDACTED]. All treatment orders will be reviewed at the Daily Start Up meeting to ensure orders are correct and on the TAR. Daily Start Up Report will also include close review of the 24 hour nursing report. C. The DON, ADON, Treatment Nurse, MDS Nurse and Administrator will review TARs at the Daily Start UP meeting to ensure documentation is accurate as of 01/31/13 and will be on-going. D. As of 01/31/13, all licensed nursing staff and CNAs will be re-inserviced by the DON and Regional Nurse in accordance to the facility policy and procedures regarding identification, measuring and identifying and reporting treatment of [REDACTED]. In-service training will include review of the Braden Scale to ensure residents are assessed accurately. The CNAs will be re-educated on the utilization of the Early Warning and Skin ID Tool. E. All residents identified with wounds will be seen by the DON or ADON for four weeks. Residents with wound treatments will be randomly assessed during daily rounds to ensure treatments are done timely. All residents assessed as high risk for pressure ulcer development based on the Braden Scale will be seen by the DON and ADM monthly. Results of skin audits and facility monitoring tools will be reviewed monthly in QA meeting to determine trends, the need for interventions, training, and/or corrective action related to wounds and/or pressure ulcers. F. Competency based training will be conducted by the DON, ADON, or RNC beginning 02/01/13 and ongoing. Any deficient care will be addressed immediately and the employee will be detained. G. An audit of resident labs will be conducted by the DON, ADON or Administrator to ensure abnormal labs are called in to the attending physician for appropriate action if indicated. The DON or ADON will review all lab results and reconcile the lab vendors tracking system with facility's manual lab tracking system. Lab results will be collected from lab by the DON or designee every tour of duty before daily start up, beginning February 1. 2013 and ongoing. The charge nurse will call the physician with any abnormal labs. Critical lab values will be called to the physician immediately to obtain orders for intervention. All nursing staff will be inserviced on the facility's policy and procedures for labs on February 1, 2013 by the Administrator. Results of lab monitoring tools will be reviewed in QA by committee to determine trends, the need for interventions, training and/or corrective action related to labs. H. An audit of all resident MARS will be conducted by the DON, ADON or Administrator by February 1, 2013 to ensure residents receiving medication, which required monitoring of vital signs were within parameters as ordered by the physician. Vital signs noted outside normal parameters for periods greater than 72 hours w

Based on interview and record review, it was determined the facility failed to notify the attending physician of abnormal lab results for two (Residents #1 and #6) of 11 residents reviewed for lab results. Resident #1's laboratory results on 12/21/12 reflected she an abnormally high white blood count, potassium level, blood urea nitrogen and Creatinine level. Neither the PA nor the attending physician was notified of these abnormal laboratory results until surveyor intervention on 02/04/13. Resident #6's laboratory results on 11/30/12 reflected a critically high potassium level, abnormally high blood urea nitrogen, Creatinine, BUN: CREAT RATIO, glucose level and a low eGFR Female level. Neither the PA nor the Physician were ever notified of these findings. An Immediate Jeopardy (IJ) was identified on 01/31/13. While the IJ was removed on 02/04/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. These failures affected Residents #1 and #6, and resulted in a delay in treatment for [REDACTED]. These failures could affect the facility's 86 residents and placed them at risk for the potential of having abnormal labs and not having their physician notified, resulting in a delay in medical intervention necessary to stabilize the residents. Findings included: 1. Resident #1 was a [AGE] year-old female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's laboratory results revealed on 12/21/12, she had the following: A high White Blood Count of 11.3 10*3/ul. Reference Range was 4.0-10.8 10*3/ul; A critically low Hemoglobin of 7.8 g/dl. Reference range 11.0-15.8 g/dl; A low Hematocrit of 24.2 %. Reference range was 33.0-47.4%; A high Potassium of 5.6 mmol/L. Reference range was 3.6-5.2 mmol/L; A high Blood Urea Nitrogen (BUN) of 46 mg/dl. Reference range was 7-17 mg/dl; and A high Creatinine of 1.6 mg/dl. Reference range was 0.5-1.0. There were no initials on the lab report or any indication they had been reviewed or faxed to the physician or PA. Review of the 24 Hour Report Book for the months of December 2012 and January 2013 revealed only her Hemoglobin was mentioned. Resident #1's Skilled Nurse's Notes dated 12/21/12 at 3:20 PM reflected: "Received a call from (Laboratory) about a critical hemoglobin of 7.8. (PA) was notified. New Order: Recheck HG (hemoglobin) in 2 days, do iron study, reticulocyte study, and occult blood stool x (times) 3. Resident was notified." Further review of Resident #1's skilled Nurse's Notes revealed subsequent critical labs were called to the PA and addressed. There was no mention of any lab result. During an interview on 01/31/13 at 3:30 PM, when LVN W was asked whose responsibility it was to check the lab results, he stated it was the ADON's responsibility. LVN W was shown Resident #1's lab results dated 12/21/12 and asked whether he remembered seeing the report or calling the physician. LVN W stated he had not seen the lab results. He stated he called the critical hemoglobin to the PA because it had been called to him from the lab. He stated whoever pulled the lab result was responsible for the follow-up and reporting the results. When LVN W was informed it had been faxed to the facility on his shift, he stated, "If I saw it, I would have initialed it and written it was faxed to the doctor. They print in the med room, I don't always see them." When asked who was responsible to follow up on labs after they were ordered, he stated the ADONs were responsible. When shown the high potassium and BUN results and asked whether he would have notified the physician, LVN W replied, "Absolutely I would've." During an interview on 01/31/13 at5 3:45 PM, The ADON was asked who was responsible for the lab results and ensuring the physicians were made aware of abnormals. The ADON explained that initially, the charge nurses were responsible for faxing and calling the results. She further explained when the Physicians or Physician's Assistants come, she printed all the resident's labs since their last visit and they initial them all. She stated she then replaced the old lab reports in the charts with the initialed ones. When the ADON was asked whether she had any lab reports, initialed by the PA or MD that had not been charted yet, she stated she did not. During an interview on 01/31/13 at 3:46 PM, when the PA was shown Resident #1's laboratory results dated [DATE] and asked if he recalled being notified. The PA explained he had been made aware of the low hemoglobin and hematocrit blood counts only and had addressed it. When asked if he knew about the elevated potassium levels and BUN, he replied, "No, I can't say I was." When asked whether he would have done anything differently, the PA stated he probably would have ordered [MEDICATION NAME] (a medication given to lower potassium levels) and would have wanted to push fluids especially with a low blood pressure. When the PA was asked if it was fair to say he had not been made aware of her decreasing blood pressures over the past few months, he stated he had not been informed about the blood pressure readings and stated he probably would have given her intravenous fluids. When asked if that was something that could be done at the facility, he stated it was. The PA stated he had seen Resident #1 last on 01/16/13 and she seemed a little sluggish but without the other data (low blood pressure and lab values) he wouldn't have thought much of it at the time. When asked if a resident's potassium was high and he did not find out until weeks later, whether he felt that was a problem, the PA replied, "Absolutely." When the PA was asked whether the staff brought him any lab reports to review during his visit on 01/16/13, he stated if he had reviewed a lab report he would have initialed it. During a meeting on 01/31/13 at 5:24 PM, the DON and Administrator were informed the PA had not been informed or Resident #1's laboratory results. When asked who was responsible for ensuring the laboratory results were relayed to the PA and physicians. The DON stated the charge Nurses were responsible for reviewing and faxing the lab reports. During an interview on 02/04/13 at 3:10 PM, the Medical Director (also Resident #1's attending physician) was asked if he was aware of Resident #1's decline in condition. The Medical Director stated, "I was aware of her decline, that much of a decline I wasn't aware" The medical Director explained the facility staff typically shared their concerns with the PA and the PA relayed the information to him. The Medical Director stated he had been made aware of Resident #1's low hemoglobin levels but had not been told about the other abnormal laboratory values, low blood pressures or other symptoms. Review of Resident #1's emergency room records dated 01/28/13 revealed the following laboratory results: White Blood Count was high at 14.4 x10(3)/mcL. Reference range was 4.8-10.8 x10(3)/mcL. Potassium was high at 5.9 mEq/L. Reference range was 3.5-5.1 mEq/L. BUN was high at 82 mg/dl. Reference range was 7-21 mg/dl. Creatinine level was high at 2.1 mg/dl. Reference range was 0.5-1.2 mg/dl. Resident #1's blood pressure upon arrival to the emergency room was very low at 88/47; her heart rate was high at 101. Resident #1's hospital History and Physical Report dated 01/28/13 revealed the following: Reason for Admission: "Septic [MEDICAL CONDITION] and urinary tract infection with decubitus wound and possible infection." Chief Complaint: "Confusion." Medical Decision Making: "1.[MEDICAL CONDITION] based on end-organ damage with altered level of consciousness, [MEDICAL CONDITION] (low blood pressure), [MEDICAL CONDITION] fever ...The likely source is urinary tract infection and she is at risk for nosocomial infection such [MEDICAL CONDITION] and pseudomonas both with this and possible superinfection of her wound. We will admit her to the step-down unit and give her fluid resuscitation and IV antibiotics with [MEDICATION NAME] and [MEDICATION NAME] to cover nosocomial organisms. 2. Cardiomegaly. We will check an echocardiogram in the morning to assess her left ventricular function because of the cardiomegaly noted on chest x-ray, as this will help guide how aggressively we can hydrate her. She does not have any known history of heart failure. 3. [MEDICAL CONDITION]. She is on [MEDICATION NAME] and [MEDICATION NAME], so I would infer, based on her clinical presentation that this would be acute [MEDICAL CONDITION] and acute renal impairment because [MEDICAL CONDITION] and volume depletion with dehydration. We will hydrate her and see how she does. Foley catheter to monitor urine output ... 6. [MEDICAL CONDITION] (high potassium) secondary to dehydration, acute renal impairment and exacerbated possibly by ACE inhibitor. We will give her a single dose of [MEDICATION NAME] ... 9. We will consult with infectious disease ..." A hospital Consultation Report for Resident #1, dated 01/29/13, reflected the following: Reason for Consultation: "I have been asked to see the patient for evaluation of acute kidney injury in the setting of septic shock and volume depletion." Diagnostic Impression: "1. Acute kidney injury in the setting of volume depletion [MEDICAL CONDITION] and [MEDICAL CONDITION] ... 2. [MEDICAL CONDITION] (increased sodium levels) and water deficits. 3. Metabolic acidosis secondary to acute kidney injury [MEDICAL CONDITION] ... 4. [MEDICAL CONDITION], likely secondary to [MEDICAL CONDITION] and [MEDICAL CONDITION]. 5. Urosepsis with E. coli ... Plan: 1. IV fluids. 2. IV alkali. 3. NG ([MEDICAL CONDITION]) tube placement. 4. Provide free water via NG tube. 5. Antibiotic therapy ... 7. Follow intake and output and serum electrolytes daily. We will follow." 2.Resident #6 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per her Quarterly MDS assessment dated [DATE]. The MDS further revealed she was severely impaired cognitively, required extensive assistance with transfers, dressing and hygiene but was able to ambulate with supervision. She was incontinent of bowel and bladder. The assessment reflected she had one Stage IV Pressure Ulcer that measured 3.3 x 1.5 x 0.2 cm. Resident #6 was not a current resident at the facility. Resident #6's closed record was reviewed. Review of Resident #6's laboratory results revealed on 11/27/12, she had the following: A critically high Potassium of 5.8 mmol/L. Reference range was 3.6-5.2 mmol/L; A high Blood Urea Nitrogen (BUN) of 41 mg/dl. Reference range was 7-17 mg/dl; A high Creatinine of 1.2 mg/dl. Reference range was 0.5-1.0; A high BUN:CREAT RATIO of 34 Ratio. Reference range was 6-28 Ratio; A high Glucose of 124 mg/dl. Reference range was 65-105 mg/dl; and A low eGFR Female of 48mL/min. Reference range was > (greater than) 60. Further review of this laboratory report, under the Potassium results, revealed "**Verified by repeat analysis** No hemolysis noted. Critical results call & faxed to____(Treatment Nurse) ...LVN at 1206 on:11/27/12 Tech ____ (initials of tech).Results read back correctly. (Potassium)" A handwritten note on the laboratory result page reflected: "T.O (telephone order) [MEDICATION NAME] (medication to lower potassium levels)30 cc BID X 3 days. repeat BMP (Basic Metabolic Panel) in 3 days." Review of Resident #6's Physician Telephone Orders dated 11/27/13 revealed the order for [MEDICATION NAME] and repeat BMP . Review of Resident #6's laboratory results revealed on 11/30/12, she had the following: A critically high Potassium of 5.8 mmol/L. Reference range was 3.6-5.2 mmol/L; A high Blood Urea Nitrogen (BUN) of 41 mg/dl. Reference range was 7-17 mg/dl; A high Creatinine of 1.4 mg/dl. Reference range was 0.5-1.0; A high BUN:CREAT RATIO of 29 Ratio. Reference range was 6-28 Ratio; A high Glucose of 164 mg/dl. Reference range was 65-105 mg/dl; and A low eGFR Female of 40mL/min. Reference range was > (greater than) 60. Further review of this laboratory report, under the Potassium results, revealed "**Verified by repeat analysis** No hemolysis noted. Critical results call & faxed to (LVN T) at 1045 on:11/30/12 Tech ____ (initials of tech).Results read back correctly. (Potassium)" There were no initials on the lab report or any indication they had been reviewed or faxed to the physician or PA. During an interview on 02/04/13 at 3:50 PM, LVN T was asked if she remembered receiving a phone call about a critical potassium level on Resident #6. LVN T was told the call was made on 11/30/13. LVN T stated she did not recall whether she worked that day then was informed she was on the schedule. LVN T stated she did not remember receiving the call from the laboratory. Review of Resident #6's physician progress notes [REDACTED]." Interview with LVN R on 02/04/13 at 2:05 PM revealed she had been Resident #6's Charge Nurses on the evening of 11/30/12. She stated she had not reviewed Resident #6's lab results and was unaware of the critical and abnormal laboratory values. Interview with the Treatment Nurse on 02/04/13 at 2:11 PM revealed she was Resident #6's Charge Nurse on 11/30/12 when the resident's laboratory results were faxed from the lab. She stated she never reviewed Resident #6's lab results and denied being told by LVN T about the critical potassium level. 3. Review of the facility's current policy and procedure, "Laboratory Services," dated 10/11/08 revealed: "Policy - It is policy of the facility to obtain all laboratory test ordered by the attending physician to ensure that prompt appropriate action is taken if indicated for the resident's care... Procedure ...5. Lab results will be collected from the lab by the DON or designee every tour of duty before daily start-up. 6. The DON or designee will review ALL lab results... 9. The charge nurse will call the physician for any abnormal lab results... The facility's licensed nursing staff will assess the resident's condition. Should a resident experience an abnormal response or complication, the licensed nurse will document the changes and notify the attending physician promptly." 4. On 01/31/13 at 2:26 PM, an IJ was identified. At that time, the Administrator and DON were informed of the Immediate Jeopardy situation and a Plan of Removal was requested for the removal of the IJ. 5. The facility's Plan of Removal was accepted on 02/01/13 at 1:20 PM and contained the following: An audit of all resident labs will be conducted by the DON, ADON, or Administrator to ensure abnormal labs are called in to the attending physician for appropriate action if indicated. This audit will be completed before end of business on 02/01/13. Responsible party will be notified of abnormal lab and action taken per physician. The DON or ADON will review all lab results and reconcile Lab vendors tracking system with facility ' s manual lab tracking system by 02/01/13. Lab results will be collected from the lab by the DON Or designee every tour of duty before daily start up, beginning 02/01/13 and ongoing. Lab orders and measures taken will be recorded on a lab tracking tool, which indicates lab order, date drawn, results and physician notification. The charge nurse will notify the attending physician by fax all normal labs. The charge nurse will call the physician with any abnormal labs. Critical lab values will be called to the physician immediately to obtain orders for intervention. The ADON, DON, and Administrator will review all labs ordered weekly and ongoing to ensure procedures are followed regarding labs. All nursing staff will be inserviced on facility policy and procedures for labs on 02/01/13 by the Administrator. Any nursing personnel that cannot attend the 02/01/13 inservice will not be allowed to return to work until inservice training has been completed by the Administrator or designee. Results of lab monitoring tools will be reviewed in QA by committee to determine trends, need for interventions, training, and/or corrective action related to labs. The need for continue monitoring will be determined by QA committee based upon compliance. 6. Review of a Record of In-Service dated 02/01/13, conducted in response to the survey process revealed objectives included: "1) New lab orders will be transcribed in lab book as appropriate per physician orders, Results (a) STAT orders call lab for off cycle lab draw results received within 4 hours. Review results, document in nurses notes, notify responsible party and physician as indicated (b) NORMAL results may be faxed: sign, Date & time and/or attach confirmation page (c) ABNORMAL must be called by end Of shift/may fax to physician BUT must follow up with phone call to ensure receipt. Critical Lab MUST BE CALLED IMMEDIATELY. (a) Lab will notify facility (b) assess resident (c) Start SBAR (d) Repeat calls to attending as needed until physician response received. Escalate to nest level if no response received in 30 minutes (e) Write T/O and transcribe appropriately (f) Notify RP (g) document in nurses notes and care plan as indicated or needed (h) Notify DON of critical results." 7. In an interview on 02/02/13 at 1:30 PM, LVN V stated she attended training related to notifying and faxing the PA with any critical and abnormal lab results. If the PA did not answer within 5 minutes she would call him again. If the PA still did not answer she would call the physician. If the physician did not answer within 5 minutes she would send the resident to the emergency room . LVN V stated each of the nurses would monitor the fax machine, where the lab results were faxed. LVN V stated all new orders were to be written in the 24-hour report. In a second interview on 02/03/13 at 1:50 PM, LVN V stated she was re-in-serviced on labs and was taught to fax and call the physician and DON critical and abnormal lab results, wait 10 minutes and call again. In an interview on 02/02/13 at 3:13 PM, RN Z stated he had attended in-services related to critical and abnormal lab values, faxed and called to the physician. RN Z stated if he could not reach the physician he would call the DON. RN Z stated he also was in-serviced to notify the physician if a significant medication was held. RN Z further stated if a resident had a change in condition, he wound do an SBAR and notify the physician of the resident ' s condition at that time. In an interview on 02/03/13 at 3:00 PM, LVN X stated he had attended in-services related to critical and abnormal lab results needed to be faxed to the physician and followed up with a phone call. LVN X stated he also wound notified the DON. LVN X further stated any changes in a resident's condition, lethargy, change in level of consciousness, acting unusual; he wound get a set of vital signs, do an assessment and call the PA. LVN X stated if the PA did not respond he wound notify the DON/ADM. In an interview on 02/04/13 at 9:00 AM, LVN R stated she had attended in-services related to medications that needed monitoring to make sure it was on the 24-hour report. LVN R stated she was fax and call the physician for all critical and abnormal lab results. "Make sure we are looking for results (lab)." LVN R stated my MA will let me know if she has abnormal vital signs. "I call the doctor with any abnormal blood pressures, we have parameters. " In an interview on 02/04/13 at 12:20 PM, LVN S stated he had attended in-services related to make lab results, "A priority." LVN S stated he would fax lab results with any abnormal lab results. The surveyor asked LVN S what if the physician didn't answer his call; LVN S stated he would call the DON. In an interview on 02/04/13 at 12:35 PM, LVN Y stated the in-services reviewed if a resident had abnormal and critical lab results she would call and fax the physician the results. LVN Y stated she would continue to call the physician until the physician answers. In an interview on 02/04/13 at 2:30 PM, LVN U stated she had attended in-services related to if a resident had a change in condition; she would take the resident's vital sign, do an assessment and call the physician. LVN U stated all abnormal and critical lab results would be faxed and called to the physician. LVN U further stated if the physician did not respond she would call the DON. LVN U stated if a resident's significant medication was held two significant times she would notify the physician. In an interview on 02/04/13 at 2:58 PM, LVN W stated he had attended in-services related to immediately reporting any changes in a resident's condition to the resident's physician and the DON. LVN W stated he learned to be effective and act immediately. LVN W stated if medications were held for greater than 24 hours, he would notify the resident's physician and the DON. "The MA will definitely be telling us everything now. We are being trained to be the eyes and ears of each other." LVN W stated the nurses needed to thoroughly check the lab results; all lab results will be faxed to the physician, if any lab results are critical or abnormal the nurse will call the physician and the DON. The nurse will continue to call the physician until he answers. On 02/03/13 at 12:12 PM, when the Administrator was asked how the IJ occurred, she replied the " the absence of one ADON. " The surveyor asked how two ADON ' s would have been different and the ADM stated she felt there was a lack of communication between the nurses and the ADON, " if the nurses had communicated issues, she (ADON) would ' ve known (about Resident #1 ' s condition). " When asked what type of procedures were there to make sure the nursing needs of resident ' s were being met, the ADM stated they have a clinical Start-Up process. During the Start-Up the nursing managers, and or assigned staff reviewed the 24-hour report, checked labs and physician orders. The ADM further stated the ADON ' s followed up to ensure all labs, and physician orders were done; as well as weekly monitoring of medications, MAR ' s/TARSs. " The ADON looked at things; like was the doctor and family notified (of the lab results and physician orders). " The ADM stated she randomly " spot checked. " When the ADM was asked about the Treatment Nurse ' s training, she replied " We talked about getting her training; we had a wound doctor in place who was working with her. " On 02/03/13 at 12:12 PM, when the DON was asked how the IJ occurred, she replied the " system broke. " The DON stated the nurses received wound care in-services on the computer. She made resident rounds every day and assisted the staff with hands on care. The DON stated the nurses ' were competent in wound care; they had computer training and their training in school. When asked what types of plans were in place to monitor the resident ' s wounds, she replied the wound nurse was doing resident rounds and caring for the wounds. She stated she reviewed the Incident Reports and 24 hour report in the Stand-Up meetings. During an interview on 02/04/13 at 3:10 PM, the Medical Director (also Resident #1's attending physician) stated he had been made aware of the IJ by the Administrator. When asked what his involvement would be to help the facility correct the failures found, the Medical Director stated different procedures needed to be put into place. He used laboratory services as an example and stated it would be ideal for the DON or ADON to go through every lab then they could track and document each nurse and physician involved. The Medical Director also stated he would like to see a policy implemented where pictures of wounds would be taken. The Medical Director stated he was involved in the facility's QA process and attended the meetings monthly. He added the facility's administration had changed recently and he expected things to improve soon. 8) While the IJ was removed on 02/04/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. 9) The CMS Form-672 (Resident Census and Conditions of Residents) dated 01/30/13 and signed by CMM A reflected a census of 86 residents.

Based on observation, interview and record review, it was determined the facility failed to implement its policies and procedures that prohibit neglect for eight (Residents #1 #2, #3, #4, #5, #6 #7 and #8) of 11 residents reviewed for neglect. 1. Staff failed to identify changes in Resident #1's condition and intervene or contact physician/PA when Resident #1 experienced symptoms of a change in condition including: a) abnormal laboratory values on 12/21/12, b) multiple low blood pressures in November 2012, December 2012 and January 2013, which resulted in [MEDICATION NAME] (anti-hypertensive) being held 68 of 89 days, c) the development of pressure sores. Resident #1, who was sent to the hospital on [DATE], was admitted the same day with seven identified pressure ulcers, when the facility had only identified three of them. c) decreased participation to no participation with Restorative Therapy, and d) the need for extensive staff assistance with ADLs. These failures affected Resident #1 resulting in [DIAGNOSES REDACTED]. 2) On 01/30/13, the facility had identified Resident #3 with four "shear" wounds, but following a second skin sweep, Resident #3 was identified as having ten Stage 2 pressure ulcers. The facility further failed to: 1. Provide accurate, timely and complete skin assessments for early detection and treatment of [REDACTED]. 2. Ensure complete and accurate descriptions of pressure ulcers, including staging for continued monitoring; 3. Ensure every skin area/pressure ulcer, once identified was documented with current descriptions and treatments; and 4. Ensure care plans were initiated and carried out. 3) On 12/05/12, Resident #2 had a pressure ulcer on her right heel identified by the Treatment Nurse, who failed to document the assessment or notify the physician until 12/13/13, eight days later. The facility further failed to: 1. Provide accurate, timely and complete skin assessments for early detection and treatment of [REDACTED]. 2. Ensure complete and accurate descriptions of pressure ulcers for continued monitoring; 3. Ensure pressure ulcers, once identified, were documented with current descriptions and treatments; 4. Notify the physician promptly for treatment orders; and 5. Ensure care plans were initiated and carried out. 4) Resident #7 was admitted to the facility on [DATE], but five Stage 2 pressure ulcers were not identified and treatments were not initiated until the following day at 5:45 PM. The facility further failed to: 1. Provide accurate skin assessments of pressure ulcers on admission; 2. Ensure Wound Care Physician orders [REDACTED]. 3. Ensure wound care was provided on admission; and 4. Ensure an interim care plan for pressure ulcers was initiated. 5) Resident #8 was identified with skin breakdown when admitted on [DATE], but there were never treatment orders or further head to toe assessments conducted as of 01/30/13. The facility further failed to: 1. Ensure wound care orders were obtained and treatment was provided on admission and thereafter, 2. Ensure complete and accurate descriptions of pressure ulcers, including staging for continued monitoring after admission. 3. Ensure care plans were developed and included a care plan to address possible skin problems. 4. Ensure skin assessments were conducted regularly. 6) Resident #4 was identified with a pressure ulcer on 01/12/13, which was not measured or described again. The facility failed to: 1. Complete accurate descriptions of a skin area, including measurements and where it was located; and 2. Ensure a care plan was initiated for the skin issue that was identified. 7) Resident #5 was admitted on [DATE] and assessed with [REDACTED]. The facility further failed to: 1. Provide accurate, timely and complete skin assessments for early detection and treatment of [REDACTED]. 2. Ensure complete and accurate descriptions of pressure ulcers for continued monitoring; 3. Ensure pressure ulcer, once identified, was documented with current descriptions and treatments; and 4. Ensure treatment were provided as ordered and promptly notify the physician of treatments and medications held. 8) Resident #6's laboratory results on 11/30/12 reflected a critically high potassium level, abnormally high blood urea nitrogen, Creatinine, BUN: CREAT RATIO, glucose level and a low eGFR Female level. Neither the PA nor the Physician were ever notified of these findings. Resident #6 was assessed on 10/25/13 with a Stage IV pressure ulcer on the heel, but she was not seen again by the wound doctor for assessment and treatment until 11/29/13. The facility further failed to: 1. Ensure the Treatment Nurse provided descriptions and measured the pressure ulcer when the wound doctor failed to assess the resident's pressure ulcer. 2. Ensure complete and accurate descriptions of pressure ulcers for continued monitoring; and 3. Ensure treatments were provided as ordered. An Immediate Jeopardy (IJ) was identified on 01/31/13. While the IJ was removed on 02/04/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. The failure to accurately assess/stage pressure ulcers, and consult with the residents physicians to obtain the physician's recommendations could result in the deterioration of existing pressure ulcers or cause the development of pressure ulcers for all 40 residents identified as receiving preventative skin care. These failures resulted in Resident #1's ICU hospitalization on [DATE] with [DIAGNOSES REDACTED]. Failure to implement policies and procedures that prevent neglect could affect any of the facility's 86 residents. Findings included: 1) Resident #1's MDS assessment dated [DATE] reflected the resident, a [AGE] year-old female, was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she made herself understood, understood others and had a BIMS score of 7, which indicated severe cognitive impairment. The MDS assessment also revealed she was incontinent of bowel and bladder, required extensive assistance with bed mobility, transfers, dressing and hygiene but only required supervision with meals. The MDS assessment reflected Resident #1 had no skin breakdown but was at risk for developing pressure ulcers. Review of Resident #1's Care Plans revealed she had no Care Plan related to her decline in condition, ADL decline or low blood pressures. Resident #1 was observed on 01/30/13 at 3:00 PM in the Intensive Care Unit (ICU) of a local hospital. She was lying in bed and was awake but very lethargic and was observed to have a [MEDICAL CONDITION] tube in place. An attempt to interview Resident #1 was unsuccessful as she did not answer any questions appropriately. Hospital staff stated she had impaired cognition since admission. During an interview on 01/31/13 at 9:20 AM, LVN W stated he usually worked the 2-10 PM shift with Resident #1. When he was asked about Resident #1's care needs, LVN W stated Resident #1 was usually alert and oriented, she required total assistance with transfers and repositioning, she had no contractures and full range of motion in all her extremities. When asked whether she could feed herself, LVN W stated, "Normally she would, but toward the end, when I gave her meds, I gave her water." When asked if he had to hold the cup to her mouth, LVN W stated he did. He added the staff fed her meals. When asked how long her decline had been, LVN W stated, "That Friday before (01/25/13), I assisted her. I wouldn't say declining. I gave her water with her meds so she wouldn't spill it." During an interview on 01/31/13 at 11:16 AM, the Treatment Nurse stated she saw Resident #1 with the Wound Physician on 01/28/13 at approximately 1:00 PM. She stated the resident was alert and her eyes were open, but she was not her normal self. The Treatment Nurse stated, "After the Wound Physician and I completed her treatments, I (Treatment Nurse) told the nurse to get her vital signs and call the PA and told him, 'She doesn't look right.' The nurse said her vital signs were good." During an interview on 01/31/13 at 9:26 AM, LVN S stated it was his second month to work with Resident #1 and he worked the day shift. LVN S stated Resident #1 was bedbound and had required total assistance as long as he had been at the facility. When asked how she was at meals, LVN S stated, "We feed her and give her water." When asked about her range of motion, LVN S stated if Resident #1 had enough sleep, she had full range of motion and was fine. If she missed even a little sleep, "...she wouldn't talk to you." LVN S stated he was working the day Resident #1 went out to the hospital. When asked what prompted her to be sent out, LVN S explained she was non-responsive and was over-sleeping. He stated she usually slept a lot but would answer you if you spoke to her, and on that day, she would not answer him. LVN S was asked whether he had ever notified the physician of Resident #1's low blood pressure readings and all the held doses of [MEDICATION NAME] (for hypertension). He stated, "It's got to be a lot to call the doctor." LVN S was shown the last three months of MARs and the counts of all the missed doses of [MEDICATION NAME]. LVN S stated it was not unusual for Resident #1 to have a low blood pressure, and he did not call the physician. LVN S stated the morning she went out, she was "just staring," and he called the PA later, after lunch. When asked if he knew how many pressure ulcers Resident #1 had when she went out to the hospital, LVN S replied, "I think two." (NOTE: Resident #1 had seven pressure ulcers identified by the hospital compared with the three known pressure ulcers identified by the facility) Resident #1's Nurse's Notes dated 01/28/13 at 12:25 PM reflected: "Resident in the bed, laying down (with) eye open. Resident is disoriented and not responsive to persons. She continued to be starring (sic) (without) blinking of eyes. She is not communicating, bed bound, total care, dependent for transfer, ADL, personal hygiene etc. Resident have (sic) a deep wound on coccyx area...AM care provided. No new order at this time...will continue to monitor." The entry was signed by LVN S. The next entry dated 01/28/13 at 1:40 PM reflected: "Resident was sent to the hospital for evaluation and tx (treatment) for multiple medical problems. (Family member) was notified and PA was also notified." The entry was signed by LVN S. Resident #1's Physician Telephone Orders dated 01/28/13 at 1:20 PM reflected: "Send (Resident #1) to the hosp (hospital) for evaluation & treatment." The entry was signed by LVN S. Resident #1's Consolidated Physician order [REDACTED]. Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Her blood pressure reached as low as 77/36. Resident #1's MAR for December 2012 reflected she had 15 doses (of a possible 31 doses) of [MEDICATION NAME] held because her blood pressure fell below 100/60. Her blood pressure reached as low as 76/52. Resident #1's MAR for January 2013 reflected she had 25 doses (of a possible 28 doses) of [MEDICATION NAME] held because her blood pressure fell below 100/60. Her blood pressure reached as low as 70/40. Interview with MA D on 02/01/13 at 8:52 AM revealed he had worked on Resident #1's hall for over a year. When MA D was asked whether he notified the charge nurse if a resident's blood pressure was low and a medication was held, MA D stated he told the nurse about Resident #1's blood pressure "Probably every other day." When he was asked about Resident #1's mental state, he described her as sometimes forgetful. When asked whether she could take her medication by herself, MA D stated at first she could, but the last week or so, he had to pour the pills into her mouth and put the water to her mouth. When asked if he had reported the change to the Charge Nurse, MA D stated he would ask LVN S, "What's going on with (Resident #1)?" He could not remember the LVN's responses. In an interview on 02/02/13 at 1:30 PM, LVN V stated she did remember a MA telling her Resident #1's B/P medication was held. LVN V stated there needed to be more communication from the MA. Review of Resident #1's laboratory results dated [DATE] revealed the following: A high White Blood Count of 11.3 10(3)/ul. Reference range was 4.0-10.8 10(3)/ul A critically low Hemoglobin of 7.8 g/dl. Reference range 11.0-15.8 g/dl. A low Hematocrit of 24.2 %. Reference range was 33.0-47.4% A high Potassium of 5.6 mmol/L. Reference range was 3.6-5.2 mmol/L. A high Blood Urea Nitrogen (BUN) of 46 mg/dl. Reference range was 7-17 mg/dl. A high Creatinine of 1.6 mg/dl. Reference range was 0.5-1.0 mg/dl. There were no initials on the lab report or any indication they had been reviewed with or faxed to the physician or PA. Review of the 24 Hour Report Book for December 2012 and January 2013 revealed only her Hemoglobin was mentioned. Resident #1's Skilled Nurse's Notes dated 12/21/12 at 3:20 PM reflected: "Received a call from (Laboratory) about a critical hemoglobin of 7.8. (PA) was notified. New Order: Recheck HG (hemoglobin) in 2 days, do iron study, reticulocyte study, and occult blood stool x (times) 3. Resident was notified." Further review of Resident #1's skilled Nurse's Notes revealed subsequent critical labs were called to the PA and addressed. There was no mention of any lab results. During an interview on 01/31/13 at 3:30 PM, when LVN W was asked whose responsibility it was to check the lab results, he stated it was the ADON's responsibility. LVN W was shown Resident #1's lab results dated 12/21/12 and asked whether he remembered seeing the report or calling the physician. LVN W stated he had not seen the lab results. He stated he called the critical hemoglobin to the PA, because it had been called to him from the lab. He stated whoever pulled the lab result was responsible for the follow-up and reporting the results. When LVN W was informed it had been faxed to the facility on his shift, he stated, "If I saw it, I would have initialed it and written it was faxed to the doctor. They print in the med room. I don't always see them." When asked who was responsible to follow up on labs after they were ordered, he stated the ADONs were responsible. When shown the high potassium and BUN results and asked whether he would have notified the physician, LVN W replied, "Absolutely I would've." When LVN W was shown Resident #1's MARs with the low blood pressure readings, he stated he was not aware her blood pressure had been running so low. When asked what he would have done had he been made aware of the readings, he stated he would have notified the physician after two or three low readings. During an interview on 01/31/13 at 3:45 PM, the ADON was asked who was responsible for the lab results and ensuring the physicians were made aware of abnormals. The ADON explained initially, the charge nurses were responsible for faxing and calling the results to the physicians. She further explained when the Physicians or Physician's Assistants came, she printed all the residents' labs since their last visit and they initialed them all. She stated she then replaced the old lab reports in the charts with the initialed ones. When the ADON was asked whether she had any lab reports, initialed by the PA or MD, that had not been charted yet, she stated she did not. In an interview on 02/04/13 at 9:00 AM, the surveyor asked LVN R how she checked for lab results, and LVN R stated, "That area was not good. That's why you (surveyors) are here." LVN R stated, "I look at the orders for my residents. Not everything gets written on the 24-hour report." During a meeting on 01/31/13 at 5:24 PM, the DON and Administrator were informed the PA had not been informed or Resident #1's laboratory results. When asked who was responsible for ensuring the laboratory results were relayed to the PA and physicians, the DON stated the charge Nurses were responsible for reviewing and faxing the lab reports to the physicians and the PA. Interview with CNA I on 01/31/13 at 11:00 AM revealed she had frequently worked with Resident #1. When asked about Resident #1, CNA I described her as "alert" and "with it" and stated she would laugh and talk during care. She said Resident #1 always received bed baths, because showers were uncomfortable for her. When asked whether Resident #1 could feed herself, CNA I stated she could for a while, but the past week or two, she (the CNA) had to feed her. She stated Resident #1, "Asked for water a lot" and over the past couple of weeks she had to put the glass of water to her mouth for her. When asked whether she had reported the change to anyone, CNA I stated she had told LVN S. During an interview on 01/31/13 at 9:15 AM, RA Q stated she had worked with Resident #1 doing Restorative Therapy. She explained she was helping her with her range of motion and transfers. When RA Q was asked whether Resident #1 was alert and able to answer questions appropriately, she stated she could answer appropriately but at the end, she would "go into a stare and wouldn't say anything...I would tell her like, 'How many fingers am I holding up?' at the end. She wouldn't tell me. She would tell me her name. She just got weaker." When asked whether or not Resident #1 could giver herself water, RA Q replied, "I would say no, for the past few weeks she couldn't raise her arms." RA Q stated she referred the resident back to the therapy department for more assistance. Resident #1's Physician's Telephone Orders dated 01/22/13 reflected, "OT (Occupational Therapy) to eval (evaluate) and treat." Review of Resident #1's OT Evaluation & Plan of Treatment dated 01/22/13 revealed the following: "Reason for Referral: Patient referred to OT due to new onset of decrease in range of motion, increased need for assistance from others, reduces ADL participation, reduced functional activity tolerance, decrease in strength, decrease in functional mobility and decrease in transfers indicating the need for OT to facilitate increased participation with functional daily activities...." PLOF (prior levels of functioning) revealed she was independent with self-feeding, needed minimum assistance with basic grooming and moderate assistance with upper extremity dressing. Interview with COTA/OT on 02/01/13 at 12:40 PM revealed Resident #1's occupational therapy had been restarted on 01/22/13 due to a decline in her condition. The COTA/OT stated, "Whenever that happens, we put them back on therapy." The COTA/OT stated when Resident #1 was discharged to Restorative Therapy, she was completely independent with feeding and could definitely give herself water. When asked if anyone from their department ever looked at the resident's clinical picture for explanations of their decline, she stated they did not, and it was not within their scope. Interview with RA P on 02/03/13 at 1:51 PM revealed she had worked with Resident #1 on range of motion and transfers. RA P stated. "She very rarely wanted to get up but got to a point where she couldn't get up. She got to the point she couldn't lift her arms." When asked if she had brought Resident #1's decline to anyone's attention, RA P replied, "Yes, several times. I can't pinpoint who I talked to." During another interview on 02/03/13 at 2:10 PM, RA Q was asked if she reported Resident #1's decline in condition to anyone other than the therapy department. RA Q stated, "We had told the nurses." When asked what nurse she had spoken with, RA Q stated, "It's different nurses." RA Q went on to explain they documented their findings in the kiosk computer system. The surveyor showed RA Q a print out of her notes and asked her who had access to the information she entered into the kiosk. RA Q stated she did not know. Review of the restorative therapy Weekly Progress Notes for December 2012 and January 2013 revealed the following entries: 12/07/12 - "(Resident #1) is active w/arom (with active range of motion)/dress/bed mobility doing well." 12/08/12 - "Removing resident from Restorative dining. She is independent in dining." 12/21/12 - "(Resident #1) is participating in all goal and is making progress." 12/28/12 - "(Resident #1) is participating with restorative program and is making progress toward her goal." 01/01/13 - "refused in trans. (transfer) did not feel well." 01/02/13- "(Resident #1) refused trans. Did not feel well." 01/04/13 at 9:29 AM - "(Resident #1) is active in trans/dressing/groo (grooming)/eating/swallowing and is making progress toward her goal." 01/04/13 at 12:57 PM - "refused trans (Resident #1) said she was to (sic) tired." 01/07/13 - "Refused trans. did not feel well." 01/08/13 - "refused due to bed sore/sleepness (sic)/tired." 01/09/13 - "did very little r.o.m.(range of motion) do (sic) to weakness/tire also with dress/groo/trans having problems." 01/10/13 - "(Resident #1) is very weak do very little and refused trans. very little groo/dress and eats with assist." 01/11/13 - "(Resident #1) has not been feeling well and not participating in program." 01/14/13 - "very weak." 01/16/13 - "refused r.o.m. but we did massage upper/lower/arm/leg." 01/18/13 - "(Resident #1) is not meeting her goals, she is becoming total care, can not feed self at the moment. Refuse to get out of bed." 01/21/13 - "(Resident #1) refused r.o.m. due to weakness in hands." 01/25/13 - "(Resident #1) is not strong enough to do a.r.o.m. (active range of motion) do (sic) to pain in arms but is still participating in all other goal and is making very little progress." 01/26/13 - "refused trans/r.o.m." 01/28/13 - "refused trans./a.r.o.m. refused do(sic) to weakness." During an interview on 02/03/13 at 3:30 PM, the DON was asked if the Restorative Aide's notes were reviewed by the charge nurses. The DON stated they were not, and she was the only one to review the entries, and she was only looking for specific information like bowel movements, showers, and meals. She stated she had not read the Restorative Aide's notes related to Resident #1. Review of Resident #1's emergency room records dated 01/28/13 revealed the following laboratory results: --White Blood Count was high at 14.4 x10(3)/mcL. Reference range was 4.8-10.8 x10(3)/mcL. --Potassium was high at 5.9 mEq/L. Reference range was 3.5-5.1 mEq/L. --BUN was high at 82 mg/dl. Reference range was 7-21 mg/dl. --Creatinine level was high at 2.1 mg/dl. Reference range was 0.5-1.2 mg/dl. Resident #1's blood pressure upon arrival to the emergency room was very low at 88/47 (normal 120/80) and her heart rate was high at 101 (normal 70-80). Resident #1's hospital History and Physical Report dated 01/28/13 revealed the following: --Reason for Admission: "Septic [MEDICAL CONDITION] and urinary tract infection with decubitus wound and possible infection." --Chief Complaint: "Confusion." --Medical Decision Making: "1.[MEDICAL CONDITION] based on end-organ damage with altered level of consciousness, [MEDICAL CONDITION] (low blood pressure), [MEDICAL CONDITION] fever ...The likely source is urinary tract infection and she is at risk for nosocomial infection such [MEDICAL CONDITION] and pseudomonas both with this and possible superinfection of her wound. We will admit her to the step-down unit and give her fluid resuscitation and IV antibiotics with [MEDICATION NAME] (antibiotic) and [MEDICATION NAME] (antibiotic) to cover nosocomial organisms. 2. Cardiomegaly. We will check an echocardiogram in the morning to assess her left ventricular function because of the cardiomegaly noted on chest x-ray, as this will help guide how aggressively we can hydrate her. She does not have any known history of heart failure. 3. [MEDICAL CONDITION]. She is on [MEDICATION NAME] and [MEDICATION NAME], so I would infer, based on her clinical presentation that this would be acute [MEDICAL CONDITION] and acute renal impairment because [MEDICAL CONDITION] and volume depletion with dehydration. We will hydrate her and see how she does. Foley catheter to monitor urine output... 6. [MEDICAL CONDITION] (high potassium) secondary to dehydration, acute renal impairment and exacerbated possibly by ACE inhibitor. We will give her a single dose of [MEDICATION NAME] 9. We will consult with infectious disease. 10. We will consult with (surgeon) as she may need surgical debridement of the wound...." A hospital Consultation Report for Resident #1, dated 01/29/13, reflected the following: Reason for Consultation: ."I have been asked to see the patient for evaluation of acute kidney injury in the setting of septic shock and volume depletion." Diagnostic Impression: "1. Acute kidney injury in the setting of volume depletion [MEDICAL CONDITION] and [MEDICAL CONDITION] 2. [MEDICAL CONDITION] (increased sodium levels) and water deficits. 3. Metabolic acidosis secondary to acute kidney injury [MEDICAL CONDITION] 4. [MEDICAL CONDITION], likely secondary to [MEDICAL CONDITION] and [MEDICAL CONDITION]. 5. Urosepsis with E. coli. 6. Multiple decubitus wounds. Plan: 1. IV fluids. 2. IV alkali. 3. NG ([MEDICAL CONDITION]) tube placement. 4. Provide free water via NG tube. 5. Antibiotic therapy. 6. Wound Care. 7. Follow intake and output and serum electrolytes daily. We will follow." 2) The facility's current policy and procedure entitled "Laboratory Services," dated 10/11/08 reflected: "Policy - It is policy of the facility to obtain all laboratory test ordered by the attending physician to ensure that prompt appropriate action is taken if indicated for the resident's care... Procedure - ...5. Lab results be will collected from the lab by the DON or designee every tour of duty before daily start-up. 6. The DON or designee will review ALL lab results... 9. The charge nurse will call the physician for any abnormal lab results... The facility's licensed nursing staff will assess the resident's condition. Should a resident experience an abnormal response or complication, the licensed nurse will document the changes and notify the attending physician promptly." The facility's current policy and procedure "Hydration Fluid Maintenance," dated October 2010 reflected: "Fundamental Information ...In the elderly, most fluid/electrolyte imbalances present initially with nonspecific symptoms such as lethargy, confusion, or a decline in function that may be abrupt... Process 1. All residents will be offered 2 to 3 beverages of choice at each meal... 3. Additional fluids will be offered during medication passes... 8. Residents who require assistance and encouragement with drinking will receive assistance and encouragement from CNAs, Licensed nurses and or paid feeding assistants, under the supervision of a licensed nurse... 11. For residents who are dependent in drinking or who require cueing and/or encouragement to drink, staff should offer, cue, assist resident to drink as necessary on each staff/resident contact." The facility's current policy and procedure entitled "Condition Change of the Resident" (undated) reflected: "PURPOSE - To observe, record and report any condition change to the attending physician so proper treatment will be implemented... PROCEDURE - 1. After all resident falls, injuries or condition changes, monitor following... f. Observe for alteration in consciousness... i. Observe for generalized weakness ...Recognition of Change in Condition 1. Criteria: Resident eats or drinks less than usual, is less talkative, is sleepier, more confused, or more agitation, needs more help with ADL's ...2. If 'Yes' response to any of the above: Suspect Illness 3. Assess the Resident ...4. Contact the attending physician or designee ...5. Receive orders from physician or designee 6. Implement order 7. Provide nursing care 8. Continue assessment as listed above for AT LEAST every 8 hours for 72 hours." 3) An undated Comprehensive Plan of Care for Resident #1 indicated she was at risk for skin breakdown, but no "Problems" were identified. Approaches included: "1) Monitor for incont. (Incontinence) Q (every) 2 hrs and prn (as needed), change promptly 2) Assist with repositioning as needed, using padding between pressure areas 3) Encourage p.o. (oral) and fluid intake 4) Give meds per order, monitor labs-report abn's (abnormals) to M.D. (Medical Doctor) 5) Monitor for skin breakdown, report to M.D. and R.P. (responsible party) 6) Provide pressure relieving and positioning devices as needed 7) Assess skin weekly and record findings 8) Turn and reposition Q2H (every two hours) 9) Prevent shearing forces and friction during transfers 10) Use non-irritating soaps 11) Keep bed free of wrinkles crumbs, and other sources of pressure." Resident #1's Nutrition Progress Notes dated 10/12/12 reflected: "[MEDICATION NAME] 10.5 L (10/9/2012) ...Resident at increased risk for skin breakdown due to low [MEDICATION NAME]. Recommend: 1. Request Prostat sugar-free 30 cc BID (twice a day) x 30 d (for 30 days)...." (NOTE: Physician Telephone orders reflected Prostat was not ordered until 01/17/13, three months later.) During an interview with the Dietician on 02/01/13 at 11:00 AM, when asked whether she always checked to see if her recommendations had been followed, she replied, "I try to." The dietician explained when she made recommendations, she posted them online. She stated the DON and the ADON received email notifications when the recommendations were posted, and she also placed them in the chart. The dietician added she always came to see Resident #1 and stated she was usually compliant with orders. Resident #1's Daily Skilled Nurse's Notes dated 11/14/12 reflected the following: "Pressure ulcers noted under the right leg with a measurement of 0.8 x 0.9 cm and 0.3 cm x 0.5 cm respectively. (PA) and (family member) notified. New order of tx (treatment) noted." Resident #1's TAR for November 2012 included an order to cleanse the pressure ulcers under the right leg with NS, pat dry, apply TAO twice daily and as needed until healed. The order was signed as completed from 11/14/12 through 11/20/12. Resident #1's "Skin Condition Record" (weekly head to toe assessments) reflected the following for 11/14/12: --Date First Observed: 11/14/12 --Site/Location: Right Leg (under) Pressure Sore 1. 0.8 x 0.9 cm, 2. 0.3 cm x 0.5 cm --Identify Site on diagram below: A diagram of the back of a body reflected two X's marked on the back of the left leg and a circle on the buttocks. --Reassessment Frequency: Weekly --measurements only, no staging or description was written. Exudate (drainage) Type/Odor/Amount, Wound Bed and Surrounding Tissue/Wound Edges were marked with "?(no)." Entered by LVN W. Resident #1's Physician Telephone Orders dated 11/19/12 reflected to "D/C previous treatment to back of leg Start: Calf # (sic) cleanse with NS Pat dry apply [MEDICATION NAME] Ag and dsg (dressing) QD & PRN Calf #2: Cleanse with NS Pat Dry apply [MEDICATION NAME] Ag and dsg QD and PRN. Vitamin C 500 mg 1 tab PO QD, Multivitamin 1 tab PO QD, [MEDICATION NAME] Q 3 months, Zinc Sulfate 220 mg po daily." Resident #1's Daily Skilled Nurse's Notes dated 11/20/12 reflected: "...New order-D/C previous treatment to back of leg. Start Calf # 1 cleanse with NS pat dry apply [MEDICATION NAME] AG dsg (dressing) QD (every day) & PRN (as neede

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status and a need to alter treatment significantly for four (Residents #1, #6, #7 and #8) of 11 residents reviewed for a change in condition. 1) Staff failed to consult Resident #1's physician/PA when Resident #1 experienced a change in condition including: a) abnormal laboratory values on 12/21/12, b) multiple low blood pressures in November 2012, December 2012 and January 2013, which resulted in [MEDICATION NAME] (anti-hypertensive) being held 68 of 89 days, c) decreased participation to no participation with Restorative Therapy, and d) the need for extensive staff assistance with ADLs. 2) Staff failed to consult Resident #6's physician for critical and abnormal lab values. 3) Staff failed to consult Resident #7's physician for wound care orders when the resident was admitted with five pressure ulcers, because she did not think it was "critical.". 4) Staff failed to consult Resident #8's physician for wound care orders when the resident was admitted with an open area, which had drainage. An Immediate Jeopardy (IJ) was identified on 01/31/13. While the IJ was removed on 02/04/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. These failures resulted in Resident #1's ICU hospitalization on [DATE] with [DIAGNOSES REDACTED]. The failure to consult the physician with a change in condition, abnormal lab results, and for orders to provide wound care could affect any of the facility's 86 residents, including Residents #6, #7 and #8, and placed them at risk not having their needs met, a delay in needed medical care and treatment, the potential for deterioration in their clinical condition, increasing the length of time needed for healing, development of [DIAGNOSES REDACTED]. Findings included: 1) Resident #1's MDS assessment dated [DATE] reflected the resident, a [AGE] year-old female, was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she made herself understood, understood others and had a BIMS score of 7, which indicated severe cognitive impairment. The MDS assessment also revealed she was incontinent of bowel and bladder, required extensive assistance with bed mobility, transfers, dressing and hygiene but only required supervision with meals. The MDS assessment reflected Resident #1 had no skin breakdown but was at risk for developing pressure ulcers. Resident #1 was observed on 01/30/13 at 3:00 PM in the Intensive Care Unit (ICU) of a local hospital. She was lying in bed and was awake but very lethargic and was observed to have a [MEDICAL CONDITION] tube in place. An attempt to interview Resident #1 was unsuccessful as she did not answer any questions appropriately. Hospital staff stated she had impaired cognition since admission. During an interview on 01/31/13 at 9:20 AM, LVN W stated he usually worked the 2-10 PM shift with Resident #1. When he was asked about Resident #1's care needs, LVN W stated Resident #1 was usually alert and oriented, she required total assistance with transfers and repositioning, she had no contractures and full range of motion in all her extremities. When asked whether she could feed herself, LVN W stated, "Normally she would, but toward the end, when I gave her meds, I gave her water." When asked if he had to hold the cup to her mouth, LVN W stated he did. He added the staff fed her meals. When asked how long her decline had been, LVN W stated, "That Friday before (01/25/13), I assisted her. I wouldn't say declining. I gave her water with her meds so she wouldn't spill it." During an interview on 01/31/13 at 11:16 AM, the Treatment Nurse stated she saw Resident #1 with the Wound Physician on 01/28/13 at approximately 1:00 PM. She stated the resident was alert and her eyes were open, but she was not her normal self. The Treatment Nurse stated, "After the Wound Physician and I completed her treatments, I (Treatment Nurse) told the nurse to get her vital signs and call the PA and told him, 'She doesn't look right.' The nurse said her vital signs were good." During an interview on 01/31/13 at 9:26 AM, LVN S stated it was his second month to work with Resident #1 and he worked the day shift. LVN S stated Resident #1 was bedbound and had required total assistance as long as he had been at the facility. When asked how she was at meals, LVN S stated, "We feed her and give her water." When asked about her range of motion, LVN S stated if Resident #1 had enough sleep, she had full range of motion and was fine. If she missed even a little sleep, "...she wouldn't talk to you." LVN S stated he was working the day Resident #1 went out to the hospital. When asked what prompted her to be sent out, LVN S explained she was non-responsive and was over-sleeping. He stated she usually slept a lot but would answer you if you spoke to her, and on that day, she would not answer him. LVN S was asked whether he had ever notified the physician of Resident #1's low blood pressure readings and all the held doses of [MEDICATION NAME] (for hypertension). He stated, "It's got to be a lot to call the doctor." LVN S was shown the last three months of MARs and the counts of all the missed doses of [MEDICATION NAME]. LVN S stated it was not unusual for Resident #1 to have a low blood pressure, and he did not call the physician. LVN S stated the morning she went out, she was "just staring," and he called the PA later, after lunch. When asked if he knew how many pressure ulcers Resident #1 had when she went out to the hospital, LVN S replied, "I think two." (NOTE: Resident #1 had seven pressure ulcers identified by the hospital compared with the three known pressure ulcers identified by the facility) Resident #1's Nurse's Notes dated 01/28/13 at 12:25 PM reflected: "Resident in the bed, laying down (with) eye open. Resident is disoriented and not responsive to persons. She continued to be starring (sic) (without) blinking of eyes. She is not communicating, bed bound, total care, dependent for transfer, ADL, personal hygiene etc. Resident have (sic) a deep wound on coccyx area...AM care provided. No new order at this time...will continue to monitor." The entry was signed by LVN S. The next entry dated 01/28/13 at 1:40 PM reflected: "Resident was sent to the hospital for evaluation and tx (treatment) for multiple medical problems. (Family member) was notified and PA was also notified." The entry was signed by LVN S. Resident #1's Physician Telephone Orders dated 01/28/13 at 1:20 PM reflected: "Send (Resident #1) to the hosp (hospital) for evaluation & treatment." The entry was signed by LVN S. Resident #1's Consolidated Physician order [REDACTED]. Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Her blood pressure reached as low as 77/36. Resident #1's MAR for December 2012 reflected she had 15 doses (of a possible 31 doses) of [MEDICATION NAME] held because her blood pressure fell below 100/60. Her blood pressure reached as low as 76/52. Resident #1's MAR for January 2013 reflected she had 25 doses (of a possible 28 doses) of [MEDICATION NAME] held because her blood pressure fell below 100/60. Her blood pressure reached as low as 70/40. Interview with MA D on 02/01/13 at 8:52 AM revealed he had worked on Resident #1's hall for over a year. When MA D was asked whether he notified the charge nurse if a resident's blood pressure was low and a medication was held, MA D stated he told the nurse about Resident #1's blood pressure "Probably every other day." When he was asked about Resident #1's mental state, he described her as sometimes forgetful. When asked whether she could take her medication by herself, MA D stated at first she could, but the last week or so, he had to pour the pills into her mouth and put the water to her mouth. When asked if he had reported the change to the Charge Nurse, MA D stated he would ask LVN S, "What's going on with (Resident #1)?" He could not remember the LVN's responses. In an interview on 02/02/13 at 1:30 PM, LVN V stated she did remember a MA telling her Resident #1's B/P medication was held. LVN V stated there needed to be more communication from the MA. Review of Resident #1's laboratory results dated [DATE] revealed the following: A high White Blood Count of 11.3 10(3)/ul. Reference range was 4.0-10.8 10(3)/ul A critically low Hemoglobin of 7.8 g/dl. Reference range 11.0-15.8 g/dl. A low Hematocrit of 24.2 %. Reference range was 33.0-47.4% A high Potassium of 5.6 mmol/L. Reference range was 3.6-5.2 mmol/L. A high Blood Urea Nitrogen (BUN) of 46 mg/dl. Reference range was 7-17 mg/dl. A high Creatinine of 1.6 mg/dl. Reference range was 0.5-1.0 mg/dl. There were no initials on the lab report or any indication they had been reviewed with or faxed to the physician or PA. Review of the 24 Hour Report Book for December 2012 and January 2013 revealed only her Hemoglobin was mentioned. Resident #1's Skilled Nurse's Notes dated 12/21/12 at 3:20 PM reflected: "Received a call from (Laboratory) about a critical hemoglobin of 7.8. (PA) was notified. New Order: Recheck HG (hemoglobin) in 2 days, do iron study, reticulocyte study, and occult blood stool x (times) 3. Resident was notified." Further review of Resident #1's skilled Nurse's Notes revealed subsequent critical labs were called to the PA and addressed. There was no mention of any lab results. During an interview on 01/31/13 at 3:30 PM, when LVN W was asked whose responsibility it was to check the lab results, he stated it was the ADON's responsibility. LVN W was shown Resident #1's lab results dated 12/21/12 and asked whether he remembered seeing the report or calling the physician. LVN W stated he had not seen the lab results. He stated he called the critical hemoglobin to the PA, because it had been called to him from the lab. He stated whoever pulled the lab result was responsible for the follow-up and reporting the results. When LVN W was informed it had been faxed to the facility on his shift, he stated, "If I saw it, I would have initialed it and written it was faxed to the doctor. They print in the med room. I don't always see them." When asked who was responsible to follow up on labs after they were ordered, he stated the ADONs were responsible. When shown the high potassium and BUN results and asked whether he would have notified the physician, LVN W replied, "Absolutely I would've." When LVN W was shown Resident #1's MARs with the low blood pressure readings, he stated he was not aware her blood pressure had been running so low. When asked what he would have done had he been made aware of the readings, he stated he would have notified the physician after two or three low readings. During an interview on 01/31/13 at 3:45 PM, the ADON was asked who was responsible for the lab results and ensuring the physicians were made aware of abnormals. The ADON explained initially, the charge nurses were responsible for faxing and calling the results to the physicians. She further explained when the Physicians or Physician's Assistants came, she printed all the residents' labs since their last visit and they initialed them all. She stated she then replaced the old lab reports in the charts with the initialed ones. When the ADON was asked whether she had any lab reports, initialed by the PA or MD, that had not been charted yet, she stated she did not. In an interview on 02/04/13 at 9:00 AM, the surveyor asked LVN R how she checked for lab results, and LVN R stated, "That area was not good. That's why you (surveyors) are here." LVN R stated, "I look at the orders for my residents. Not everything gets written on the 24-hour report." During a meeting on 01/31/13 at 5:24 PM, the DON and Administrator were informed the PA had not been informed or Resident #1's laboratory results. When asked who was responsible for ensuring the laboratory results were relayed to the PA and physicians, the DON stated the charge Nurses were responsible for reviewing and faxing the lab reports to the physicians and the PA. Interview with CNA I on 01/31/13 at 11:00 AM revealed she had frequently worked with Resident #1. When asked about Resident #1, CNA I described her as "alert" and "with it" and stated she would laugh and talk during care. She said Resident #1 always received bed baths, because showers were uncomfortable for her. When asked whether Resident #1 could feed herself, CNA I stated she could for a while, but the past week or two, she (the CNA) had to feed her. She stated Resident #1, "Asked for water a lot" and over the past couple of weeks she had to put the glass of water to her mouth for her. When asked whether she had reported the change to anyone, CNA I stated she had told LVN S. During an interview on 01/31/13 at 9:15 AM, RA Q stated she had worked with Resident #1 doing Restorative Therapy. She explained she was helping her with her range of motion and transfers. When RA Q was asked whether Resident #1 was alert and able to answer questions appropriately, she stated she could answer appropriately but at the end, she would "go into a stare and wouldn't say anything...I would tell her like, 'How many fingers am I holding up?' at the end. She wouldn't tell me. She would tell me her name. She just got weaker." When asked whether or not Resident #1 could giver herself water, RA Q replied, "I would say no, for the past few weeks she couldn't raise her arms." RA Q stated she referred the resident back to the therapy department for more assistance. Resident #1's Physician's Telephone Orders dated 01/22/13 reflected, "OT (Occupational Therapy) to eval (evaluate) and treat." Review of Resident #1's OT Evaluation & Plan of Treatment dated 01/22/13 revealed the following: "Reason for Referral: Patient referred to OT due to new onset of decrease in range of motion, increased need for assistance from others, reduces ADL participation, reduced functional activity tolerance, decrease in strength, decrease in functional mobility and decrease in transfers indicating the need for OT to facilitate increased participation with functional daily activities...." PLOF (prior levels of functioning) revealed she was independent with self-feeding, needed minimum assistance with basic grooming and moderate assistance with upper extremity dressing. Interview with COTA/OT on 02/01/13 at 12:40 PM revealed Resident #1's occupational therapy had been restarted on 01/22/13 due to a decline in her condition. The COTA/OT stated, "Whenever that happens, we put them back on therapy." The COTA/OT stated when Resident #1 was discharged to Restorative Therapy, she was completely independent with feeding and could definitely give herself water. When asked if anyone from their department ever looked at the resident's clinical picture for explanations of their decline, she stated they did not, and it was not within their scope. Interview with RA P on 02/03/13 at 1:51 PM revealed she had worked with Resident #1 on range of motion and transfers. RA P stated. "She very rarely wanted to get up but got to a point where she couldn't get up. She got to the point she couldn't lift her arms." When asked if she had brought Resident #1's decline to anyone's attention, RA P replied, "Yes, several times. I can't pinpoint who I talked to." During another interview on 02/03/13 at 2:10 PM, RA Q was asked if she reported Resident #1's decline in condition to anyone other than the therapy department. RA Q stated, "We had told the nurses." When asked what nurse she had spoken with, RA Q stated, "It's different nurses." RA Q went on to explain they documented their findings in the kiosk computer system. The surveyor showed RA Q a print out of her notes and asked her who had access to the information she entered into the kiosk. RA Q stated she did not know. Review of the restorative therapy Weekly Progress Notes for December 2012 and January 2013 revealed the following entries: 12/07/12 - "(Resident #1) is active w/arom (with active range of motion)/dress/bed mobility doing well." 12/08/12 - "Removing resident from Restorative dining. She is independent in dining." 12/21/12 - "(Resident #1) is participating in all goal and is making progress." 12/28/12 - "(Resident #1) is participating with restorative program and is making progress toward her goal." 01/01/13 - "refused in trans. (transfer) did not feel well." 01/02/13- "(Resident #1) refused trans. Did not feel well." 01/04/13 at 9:29 AM - "(Resident #1) is active in trans/dressing/groo(grooming)/eating/swallowing and is making progress toward her goal." 01/04/13 at 12:57 PM - "refused trans (Resident #1) said she was to (sic) tired." 01/07/13 - "Refused trans. did not feel well." 01/08/13 - "refused due to bed sore/sleepness (sic)/tired." 01/09/13 - "did very little r.o.m.(range of motion) do (sic) to weakness/tire also with dress/groo/trans having problems." 01/10/13 - "(Resident #1) is very weak do very little and refused trans. very little groo/dress and eats with assist." 01/11/13 - "(Resident #1) has not been feeling well and not participating in program." 01/14/13 - "very weak." 01/16/13 - "refused r.o.m. but we did massage upper/lower/arm/leg." 01/18/13 - "(Resident #1) is not meeting her goals, she is becoming total care, can not feed self at the moment. Refuse to get out of bed." 01/21/13 - "(Resident #1) refused r.o.m. due to weakness in hands." 01/25/13 - "(Resident #1) is not strong enough to do a.r.o.m. (active range of motion) do (sic) to pain in arms but is still participating in all other goal and is making very little progress." 01/26/13 - "refused trans/r.o.m." 01/28/13 - "refused trans./a.r.o.m. refused do(sic) to weakness." During an interview on 02/03/13 at 3:30 PM, the DON was asked if the Restorative Aide's notes were reviewed by the charge nurses. The DON stated they were not, and she was the only one to review the entries, and she was only looking for specific information like bowel movements, showers, and meals. She stated she had not read the Restorative Aide's notes related to Resident #1. During an interview on 01/31/13 at 3:46 PM, when the PA was asked if he was aware of Resident #1's skin condition, he stated he did not know about any pressure ulcers other than the ones on her sacrum and leg. When shown Resident #1's MARs and asked if he had been made aware of her low blood pressures and all the held doses of [MEDICATION NAME], he stated he had not. The PA was shown Resident #1's laboratory results dated [DATE] and asked if he recalled being notified. The PA explained he had been made aware of the low blood counts only and had addressed it. When asked if he knew about the elevated potassium levels and BUN, he replied, "No. I can't say I was." When asked whether he would have done anything differently, the PA stated he probably would have ordered [MEDICATION NAME] (a medication given to lower potassium levels) and would have wanted to push fluids especially with a low blood pressure. When the PA was asked if it was fair to say he had not been made aware of her decreasing blood pressures over the past few months, he stated he had not been informed about the blood pressure readings and stated he probably would have given her intravenous fluids. When asked if that was something that could be done at the facility, he stated it was. The PA stated he had seen Resident #1 last on 01/16/13, and she seemed a little sluggish but without the other data (low blood pressures and lab values), he would not have thought much of it at the time. The PA was asked when he would expect to be notified about low blood pressure readings with held medication and he replied, "Three to five days in a row if it is out of the norm." When asked if a resident's potassium was high, and he did not find out until weeks later, whether he felt that was a problem, the PA replied, "Absolutely." When the PA was asked whether the staff brought him any lab reports to review during his visit on 01/16/13, he stated if he had reviewed a lab report, he would have initialed it. Review of Resident #1's emergency room records dated 01/28/13 revealed the following laboratory results: --White Blood Count was high at 14.4 x10(3)/mcL. Reference range was 4.8-10.8 x10(3)/mcL. --Potassium was high at 5.9 mEq/L. Reference range was 3.5-5.1 mEq/L. --BUN was high at 82 mg/dl. Reference range was 7-21 mg/dl. --Creatinine level was high at 2.1 mg/dl. Reference range was 0.5-1.2 mg/dl. Resident #1's blood pressure upon arrival to the emergency room was very low at 88/47 (normal 120/80) and her heart rate was high at 101 (normal 70-80). Resident #1's hospital History and Physical Report dated 01/28/13 revealed the following: --Reason for Admission: "Septic [MEDICAL CONDITION] and urinary tract infection with decubitus wound and possible infection." --Chief Complaint: "Confusion." --Medical Decision Making: "1.[MEDICAL CONDITION] based on end-organ damage with altered level of consciousness, [MEDICAL CONDITION] (low blood pressure), [MEDICAL CONDITION] fever ...The likely source is urinary tract infection and she is at risk for nosocomial infection such [MEDICAL CONDITION] and pseudomonas both with this and possible superinfection of her wound. We will admit her to the step-down unit and give her fluid resuscitation and IV antibiotics with [MEDICATION NAME] (antibiotic) and [MEDICATION NAME] (antibiotic) to cover nosocomial organisms. 2. Cardiomegaly. We will check an echocardiogram in the morning to assess her left ventricular function because of the cardiomegaly noted on chest x-ray, as this will help guide how aggressively we can hydrate her. She does not have any known history of heart failure. 3. [MEDICAL CONDITION]. She is on [MEDICATION NAME] and [MEDICATION NAME], so I would infer, based on her clinical presentation that this would be acute [MEDICAL CONDITION] and acute renal impairment because [MEDICAL CONDITION] and volume depletion with dehydration. We will hydrate her and see how she does. Foley catheter to monitor urine output... 6. [MEDICAL CONDITION] (high potassium) secondary to dehydration, acute renal impairment and exacerbated possibly by ACE inhibitor. We will give her a single dose of [MEDICATION NAME] 9. We will consult with infectious disease. 10. We will consult with (surgeon) as she may need surgical debridement of the wound...." A hospital Consultation Report for Resident #1, dated 01/29/13, reflected the following: Reason for Consultation: ."I have been asked to see the patient for evaluation of acute kidney injury in the setting of septic shock and volume depletion." Diagnostic Impression: "1. Acute kidney injury in the setting of volume depletion [MEDICAL CONDITION] and [MEDICAL CONDITION] 2. [MEDICAL CONDITION] (increased sodium levels) and water deficits. 3. Metabolic acidosis secondary to acute kidney injury [MEDICAL CONDITION] 4. [MEDICAL CONDITION], likely secondary to [MEDICAL CONDITION] and [MEDICAL CONDITION]. 5. Urosepsis with E. coli. 6. Multiple decubitus wounds. Plan: 1. IV fluids. 2. IV alkali. 3. NG ([MEDICAL CONDITION]) tube placement. 4. Provide free water via NG tube. 5. Antibiotic therapy. 6. Wound Care. 7. Follow intake and output and serum electrolytes daily. We will follow." The facility's current policy and procedure "Hydration Fluid Maintenance," dated October 2010 reflected: "Fundamental Information ...In the elderly, most fluid/electrolyte imbalances present initially with nonspecific symptoms such as lethargy, confusion, or a decline in function that may be abrupt... Process 1. All residents will be offered 2 to 3 beverages of choice at each meal... 3. Additional fluids will be offered during medication passes... 8. Residents who require assistance and encouragement with drinking will receive assistance and encouragement from CNAs, Licensed nurses and or paid feeding assistants, under the supervision of a licensed nurse... 11. For residents who are dependent in drinking or who require cueing and/or encouragement to drink, staff should offer, cue, assist resident to drink as necessary on each staff/resident contact." The facility's current policy and procedure entitled "Condition Change of the Resident" (undated) reflected: "PURPOSE - To observe, record and report any condition change to the attending physician so proper treatment will be implemented... PROCEDURE - 1. After all resident falls, injuries or condition changes, monitor following... f. Observe for alteration in consciousness... i. Observe for generalized weakness ...Recognition of Change in Condition 1. Criteria: Resident eats or drinks less than usual, is less talkative, is sleepier, more confused, or more agitation, needs more help with ADL's ...2. If 'Yes' response to any of the above: Suspect Illness 3. Assess the Resident ...4. Contact the attending physician or designee ...5. Receive orders from physician or designee 6. Implement order 7. Provide nursing care 8. Continue assessment as listed above for AT LEAST every 8 hours for 72 hours." 2) Resident #6 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per her Quarterly MDS assessment dated [DATE]. The MDS further revealed she was severely impaired cognitively, required extensive assistance with transfers, dressing and hygiene but was able to ambulate with supervision. She was incontinent of bowel and bladder. The assessment reflected she had one Stage IV Pressure Ulcer that measured 3.3 x 1.5 x 0.2 cm. Resident #6 was not a current resident at the facility. Resident #6's closed record was reviewed. Review of Resident #6's laboratory results revealed on 11/27/12, she had the following: A critically high Potassium of 5.8 mmol/L. Reference range was 3.6-5.2 mmol/L; A high Blood Urea Nitrogen (BUN) of 41 mg/dl. Reference range was 7-17 mg/dl; A high Creatinine of 1.2 mg/dl. Reference range was 0.5-1.0; A high BUN:CREAT RATIO of 34 Ratio. Reference range was 6-28 Ratio; A high Glucose of 124 mg/dl. Reference range was 65-105 mg/dl; and A low eGFR Female of 48mL/min. Reference range was > (greater than) 60. Further review of this laboratory report, under the Potassium results, revealed "**Verified by repeat analysis** No hemolysis noted. Critical results call & faxed to____ (Treatment Nurse) ...LVN at 1206 on: 11/27/12 Tech ____ (initials of tech). Results read back correctly. (Potassium)" A handwritten note on the laboratory result page reflected: "T.O (telephone order) [MEDICATION NAME] (medication to lower potassium levels) 30 cc BID X 3 days. repeat BMP (Basic Metabolic Panel) in 3 days." Review of Resident #6's Physician Telephone Orders dated 11/27/13 revealed the order for [MEDICATION NAME] and the repeat BMP . Review of Resident #6's laboratory results revealed on 11/30/12, she had the following: A critically high Potassium of 5.8 mmol/L. Reference range was 3.6-5.2 mmol/L; A high Blood Urea Nitrogen (BUN) of 41 mg/dl. Reference range was 7-17 mg/dl; A high Creatinine of 1.4 mg/dl, an increase of 0.2 mg/dl. Reference range was 0.5-1.0; A high BUN:CREAT RATIO of 29 Ratio. Reference range was 6-28 Ratio; A high Glucose of 164 mg/dl. Reference range was 65-105 mg/dl; and A low eGFR Female of 40 ml/min. Reference range was > (greater than) 60. Further review of this laboratory report, under the Potassium results, revealed "**Verified by repeat analysis** No hemolysis noted. Critical results call & faxed to (LVN T) at 1045 on: 11/30/12 Tech ____ (initials of tech). Results read back correctly. (Potassium)" There were no initials on the lab report or any indication they had been reviewed or faxed to the physician or PA. During an interview on 02/04/13 at 3:50 PM, LVN T was asked if she remembered receiving a phone call about a critical potassium level on Resident #6. LVN T was told the call was made on 11/30/13. LVN T stated she did not recall whether she worked that day. She was then informed she was on the schedule. LVN T stated she did not remember receiving the call from the laboratory. Review of Resident #6's physician progress notes [REDACTED]." Interview with LVN R on 02/04/13 at 2:05 PM revealed she had been Resident #6's Charge Nurse on the evening of 11/30/12. She stated she had not reviewed Resident #6's lab results and was unaware of the critical and abnormal laboratory values. Interview with the Treatment Nurse on 02/04/13 at 2:11 PM revealed she was Resident #6's Charge Nurse on 11/30/12 when the resident's laboratory results were faxed from the lab. She stated she never reviewed Resident #6's lab results and denied being told by LVN T about the critical potassium level. 3) Resident #7's Admission Record, with a print date of 01/30/13 reflected the resident, a [AGE] year-old female, was admitted to the facility on [DATE]. Review of Resident #7's hospital records dated 01/27/13 revealed the resident had Metastatic [MEDICAL CONDITION] to the Spine. The resident had refused treatment including surgery and [MEDICAL CONDITION] oncology. Resident #7's Admission Nurses' Note dated 01/29/13 reflected "decubitus wound" was not identified. The Note further reflected, "Resident is paraplegic ...with the assistance of two CNAs while trying to measure resident's coccyx resident would not allow us to put head of bed down to be able to turn her. Beginning (pressure) ulcer on coccyx, possible stage 2...." Resident #7's Skin Condition Record reflected: DATE FIRST OBSERVED: 01/29/13. SITE LOCATION: 1) [MEDICAL CONDITION] scar, 2) old scar scab," identified on anatomical picture on right knee, "3) 2 small black spots," drawn on the anatomical picture on outside of right foot, "4) pinball size growth" drawn on the anatomical picture near left breast, "5) beginning (pressure) ulcer possible stage 2" the areas marked on the anatomical picture were on sacrum/coccyx. This form did not include any measurements, description of wound beds, surrounding tissue or skin color. During an interview on 02/01/13 at 5:15 PM, when queried about an incomplete admission assessment, the ADON stated it was critical for the Admission Nurse to do a full assessment, "It is our policy." During an interview on 02/01/13 at 5:17 PM, LVN U stated, "I couldn't assess her (Resident #7's) wounds. She refused...She wouldn't let us lower the head of the bed, she wouldn't turn over all the way, couldn't see all of her bottom." Review of Resident #7's Braden Scale dated 01/30/13 revealed a score of 13, which indicated, "Moderate Risk." Review of Resident #7's admission physician orders [REDACTED]. Wound care orders were obtained on 01/30/13. On 02/01/13 at 1:05 PM, the surveyor observed wound care being provided to Resident #7. Two staff members assisted by holding the resident on her side while the Treatment Nurse provided the treatment. The surveyor did not see the breast wound per the resident's request. The wounds were measured by the Treatment Nurse per the surveyor's request. One pressure ulcer on the sacrum measured 0.6 x 0.5 x 0.2 cm; three pressure ulcers on the buttocks measured 1.4 x 0.5 cm, 1.3 x 0.6 cm, and 0.5 x 0.7 cm; and one pressure ulcer on the left buttock measured 1.2 x 0.5 cm. The facility RNs completed a facility skin sweep on 02/01/13 and did not identify Resident #7's sacral pressure ulcer. During an interview o

Based on observation, interview and record review, the facility failed to ensure residents received the necessary treatment and services to promote healing and prevent new pressure ulcers from developing for eight (Residents #1, #2, #3, #4, #5,#6, #7 and #8) of 11 residents reviewed for pressure ulcers. 1) Resident #1, who was sent to the hospital on [DATE], was admitted the same day with seven identified pressure ulcers, when the facility had only identified three of them. The facility further failed to: 1. Provide accurate, timely and complete skin assessments for early detection and appropriate treatment of [REDACTED]. 2. Ensure when new treatments were ordered, previous treatments no longer to be used were discontinued. 3. Ensure complete and accurate descriptions of pressure ulcers for continued monitoring; 4. Ensure pressure ulcers, once identified, were documented with current descriptions and treatments; 5. Notify the physician promptly for treatment orders; and 6. Ensure care plans were initiated and carried out. 2) On 01/30/13, the facility had identified Resident #3 with four "shear" wounds, but following a second skin sweep, Resident #3 was identified as having ten Stage 2 pressure ulcers. The facility further failed to: 1. Provide accurate, timely and complete skin assessments for early detection and treatment of [REDACTED]. 2. Ensure complete and accurate descriptions of pressure ulcers, including staging for continued monitoring; 3. Ensure every skin area/pressure ulcer, once identified was documented with current descriptions and treatments; and 4. Ensure care plans were initiated and carried out. 3) On 12/05/12, Resident #2 had a pressure ulcer on her right heel identified by the Treatment Nurse, who failed to document the assessment or notify the physician until 12/13/13, eight days later. The facility further failed to: 1. Provide accurate, timely and complete skin assessments for early detection and treatment of [REDACTED]. 2. Ensure complete and accurate descriptions of pressure ulcers for continued monitoring; 3. Ensure pressure ulcers, once identified, were documented with current descriptions and treatments; 4. Notify the physician promptly for treatment orders; and 5. Ensure care plans were initiated and carried out. 4) Resident #7 was admitted to the facility on [DATE], but five Stage 2 pressure ulcers were not identified and treatments were not initiated until the following day at 5:45 PM. The facility further failed to: 1. Provide accurate skin assessments of pressure ulcers on admission; 2. Ensure Wound Care Physician orders [REDACTED]. 3. Ensure wound care was provided on admission; and 4. Ensure an interim care plan for pressure ulcers was initiated. 5) Resident #8 was identified with skin breakdown when admittend on 01/10/13, but there were never treatment orders or further head to toe assessments conducted as of 01/30/13. The facility further failed to: 1. Ensure wound care orders were obtained and treatment was provided on admission and thereafter, 2. Ensure complete and accurate descriptions of pressure ulcers, including staging for continued monitoring after admission. 3. Ensure care plans were developed and included a care plan to address possible skin problems. 4. Ensure skin assessments were conducted regularly. 6) Resident #4 was identified with a pressure ulcer on 01/12/13, which was not measured or described again. The facility failed to: 1. Complete accurate descriptions of a skin area, including measurements and where it was located; and 2. Ensure a care plan was initiated for the skin issue that was identified. 7) Resident #5 was admitted on [DATE] and assessed with [REDACTED]. The facility further failed to: 1. Provide accurate, timely and complete skin assessments for early detection and treatment of [REDACTED]. 2. Ensure complete and accurate descriptions of pressure ulcers for continued monitoring; 3. Ensure pressure ulcer, once identified, was documented with current descriptions and treatments; and 4. Ensure treatment were provided as ordered and promptly notify the physician of treatments and medications held. 8) Resident #6 was assessed on 10/25/13 with a Stage IV pressure ulcer on the heel, but she was not seen again by the wound doctor for assessment and treatment until 11/29/13. The facility further failed to: 1. Ensure the Treatment Nurse provided descriptions and measured the pressure ulcer when the wound doctor failed to assess the resident's pressure ulcer. 2. Ensure complete and accurate descriptions of pressure ulcers for continued monitoring; and 3. Ensure treatments were provided as ordered. An Immediate Jeopardy (IJ) was identified on 01/31/13. While the IJ was removed on 02/04/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. The failure to accurately assess/stage pressure ulcers, and consult with the residents' physicians could affect the facility's 40 residents identified receiving preventive skin care, the two residents initially identified with pressure ulcers, including Residents #1, #2, #3, #4, #5,#6, #7 and #8, which placed them at risk for potential deterioration of existing pressure ulcers and the development of new pressure ulcers, which could result in increased time for healing, infection,[MEDICAL CONDITION], discomfort, pain, and the potential need for hospitalization . Findings included: On 01/30/13 at 9:55 AM, during entrance conference, the DON stated there was one resident in the facility with a pressure ulcer, Resident #2. Note: the DON was not aware Resident #7 was admitted the night before with pressure ulcers. During an interview on 01/30/13 at 1:20 PM with the Treatment Nurse, she stated she became the facility Treatment Nurse at the end of November 2012. She stated she was responsible for the weekly pressure ulcer records, and the Charge Nurses were responsible to complete the weekly head to toe assessments. She stated the weekly head to toe assessments were to include the resident's pressure ulcers; and her weekly pressure ulcer records only included pressure ulcers. Both of these records were kept in the Treatment Nurses book. The Treatment Nurse stated she had little training, and the previous Treatment Nurse (who quit in the early part of November 2012) showed her how to pull Wound Care Physician notes, which contained wound measurements off the computer. She stated he taught her to use biohazard bags, when to wash her hands, to assess for pain and how to fill out the weekly pressure ulcer healing records. The Treatment Nurse stated if a Charge Nurse found a pressure ulcer, she (the Treatment Nurse) did an assessment, staged the wound, looked for drainage, odor, and wound bed, measured the wound and filled out the weekly pressure ulcer healing records. After the assessment, she called the PA who gave her an initial treatment and an order to call the wound doctor for a wound consult. She stated the wound doctor came to the facility weekly. She stated she had never seen a Stage 4 pressure ulcer or a deep tissue injury until Resident #1's, at the end of December 2012. 1) Resident #1's MDS assessment dated [DATE] reflected the resident, a [AGE] year-old female, was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she made herself understood, understood others and had a BIMS score of 7, which indicated severe cognitive impairment. The MDS assessment also revealed she was incontinent of bowel and bladder, required extensive assistance with bed mobility, transfers, dressing and hygiene but only required supervision with meals. The MDS assessment reflected Resident #1 had no skin breakdown but was at risk for developing pressure ulcers. An undated Comprehensive Plan of Care for Resident #1 indicated she was at risk for skin breakdown, but no "Problems" were identified. Approaches included: "1) Monitor for incont. (Incontinence) Q (every) 2 hrs and prn (as needed), change promptly 2) Assist with repositioning as needed, using padding between pressure areas 3) Encourage p.o. (oral) and fluid intake 4) Give meds per order, monitor labs-report abn's (abnormals) to M.D. (Medical Doctor) 5) Monitor for skin breakdown, report to M.D. and R.P. (responsible party) 6) Provide pressure relieving and positioning devices as needed 7) Assess skin weekly and record findings 8) Turn and reposition Q2H (every two hours) 9) Prevent shearing forces and friction during transfers 10) Use non-irritating soaps 11) Keep bed free of wrinkles crumbs, and other sources of pressure." Resident #1's Nutrition Progress Notes dated 10/12/12 reflected: "[MEDICATION NAME] 10.5 L (10/9/2012) ...Resident at increased risk for skin breakdown due to low [MEDICATION NAME]. Recommend: 1. Request Prostat sugar-free 30 cc BID (twice a day) x 30 d (for 30 days)...." (NOTE: Physician Telephone orders reflected Prostat was not ordered until 01/17/13, three months later.) During an interview with the Dietician on 02/01/13 at 11:00 AM, when asked whether she always checked to see if her recommendations had been followed, she replied, "I try to." The dietician explained when she made recommendations, she posted them online. She stated the DON and the ADON received email notifications when the recommendations were posted, and she also placed them in the chart. The dietician added she always came to see Resident #1 and stated she was usually compliant with orders. Resident #1's Daily Skilled Nurse's Notes dated 11/14/12 reflected the following: "Pressure ulcers noted under the right leg with a measurement of 0.8 x 0.9 cm and 0.3 cm x 0.5 cm respectively. (PA) and (family member) notified. New order of tx (treatment) noted." Resident #1's TAR for November 2012 included an order to cleanse the pressure ulcers under the right leg with NS, pat dry, apply TAO twice daily and as needed until healed. The order was signed as completed from 11/14/12 through 11/20/12. Resident #1's "Skin Condition Record" (weekly head to toe assessments) reflected the following for 11/14/12: --Date First Observed: 11/14/12 --Site/Location: Right Leg (under) Pressure Sore 1. 0.8 x 0.9 cm, 2. 0.3 cm x 0.5 cm --Identify Site on diagram below: A diagram of the back of a body reflected two X's marked on the back of the left leg and a circle on the buttocks. --Reassessment Frequency: Weekly --measurements only, no staging or description was written. Exudate (drainage) Type/Odor/Amount, Wound Bed and Surrounding Tissue/Wound Edges were marked with "?(no)." Entered by LVN W. Resident #1's Physician Telephone Orders dated 11/19/12 reflected to "D/C previous treatment to back of leg Start: Calf # (sic) cleanse with NS Pat dry apply [MEDICATION NAME] Ag and dsg (dressing) QD & PRN Calf #2: Cleanse with NS Pat Dry apply [MEDICATION NAME] Ag and dsg QD and PRN. Vitamin C 500 mg 1 tab PO QD, Multivitamin 1 tab PO QD, [MEDICATION NAME] Q 3 months, Zinc Sulfate 220 mg po daily." Resident #1's Daily Skilled Nurse's Notes dated 11/20/12 reflected: "...New order-D/C previous treatment to back of leg. Start Calf # 1 cleanse with NS pat dry apply [MEDICATION NAME] AG dsg (dressing) QD (every day) & PRN (as needed). Calf #2: cleanse with NS pat dry apply [MEDICATION NAME] ag and dsg QD and PRN. Vitamin C 500 mg 1 tab (tablet) PO QD. Multivitamin 1 tab po QD. [MEDICATION NAME] Q 3 months. Zinc Sulfate 220 mg PO daily." A Physician Telephone Orders dated 11/27/12 reflected: "Wound consult needed." Resident #1's "Skin Condition Record" (weekly head to toe assessments) reflected the following for 11/28/12: "Calf 1 1 cm x 2 cm, Calf 2 0.5 cm ? exudate, ? odor." Entered by LVN T. Resident #1's Wound Care Physician Evaluation dated 11/29/12 reflected the following: --Site 1 - Shear Wound of Right, Proximal, Lateral Leg that measured 1.5 x 1.2 x not measureable cm. There was Thick Adherent Black Necrotic Tissue (Eschar): "100%." A Physician Telephone Orders dated 11/30/12 reflected: "1) Rt calf #1 & Rt calf #2. DC prior tx 2) Rt calf ...Apply skin prep BID." Resident #1's "Skin Condition Record" dated 12/05/12 reflected - no measurements and no exudate. Entered by LVN S. Resident #1's Wound Care Physician Evaluations dated 12/06/12 reflected the following: --Site 1 - Shear Wound of Right, Proximal, Lateral Leg that measured 2.0 x 1.0 x Not Measureable cm. There was 100% eschar. Resident #1's "Skin Condition Record" dated 12/12/12 reflected - Calf 0.5 x 1 cm and no exudate. Entered by LVN T. Resident #1's Wound Care Physician Evaluations dated 12/13/12 reflected the following: --Site 1 - Shear Wound of Right, Proximal, Lateral Leg that measured 1.4 x 0.7 x Not Measureable cm. There was 100% eschar. Resident #1's "Skin Condition Record" dated 12/19/12 reflected - no description, treatment order only. Entered by Treatment Nurse. Resident #1's Physician Telephone Orders dated 12/20/12 reflected: "1) Rt. Calf ...D/C skin prep BID. 2) Rt. Calf ...clean (with) NS, pat dry, apply Santyl, [MEDICATION NAME] AG QD & PRN until healed." Resident #1's Wound Care Physician Evaluations dated 12/20/12 reflected the following: --Site 1 - Shear Wound of Right, Proximal, Lateral Leg that measured 1.2 x 0.6 x 0.2 cm. There was 100% eschar. There was light serous drainage. Resident #1's "Skin Condition Record" dated 12/26/12 reflected - "not changed" was marked. And "Cont. (Continue) treatment on the coccyx area (with) santyl, [MEDICATION NAME] AG daily." No signature. The Second Skin Condition Record with the "Date First Observed" as 12/26/12 reflected: Site Location: A) DTI, B) Shear. Resident #1's Nurse's Notes dated 12/27/12 reflected the following: "Resident lying in bed with eyes closed ...redness noted on buttocks of resident by aide. Laniseptic cream applied as told by nurse...." Resident #1's Nutrition Progress Notes dated 12/27/12 reflected: "Skin intact w/o (without) pressure ulcers per 12/19/2012 skin report." A Progress Note dated 12/28/12 at 5:30 AM and signed by LVN X reflected: "Nurse Aide reported to this nurse that there is a sore noted on the sacral area of the buttocks of the resident. This nurse went to assess the sore and noted a big sore between the creases. (PA) called and notified via phone message and awaiting a response from him. Wound cleaned with NS and TAO applied ...resident denies pain at this time, call light and water within reach, wctm (will continue to monitor)." During a telephone interview on 01/31/13 at 8:03 AM, LVN X described Resident #1 as nice, bedbound most of the time, incontinent and it took two or more staff members to turn and reposition her. LVN X stated the resident could make her needs known, was alert and oriented x 2, could push the button for the call light and could reach for her water pitcher. LVN X stated, as a night nurse, he was not assigned to do resident head to toe skin assessments. The surveyor reviewed a Nurses Note LVN X wrote on Resident #1 dated 12/28/12. LVN X stated, "A CNA called me into Resident #1's room. I (LVN X) assessed Resident #1's bottom and there was an open area approximately 0.1 x 0.2 cm, no drainage, red in color" and he did not remember if he actually did measurements. He stated he did not do a skin sheet. Resident #1's Wound Care Physician Evaluations dated 12/28/12 reflected the following: --Site 1 - Shear Wound of Right, Proximal, Lateral Leg that measured 1.5 x 0.9 x 0.4 cm. There was Thick Adherent Black Necrotic Tissue: "100%." There was light serous drainage. --Site 2 - Unstageable DTI (deep tissue injury) of the Sacrum, Etiology: "Pressure;" Wound Size: 9.5 x 6.0 x Not Measureable cm. Resident #1's Physician Telephone Orders dated 12/28/12 reflected: --"Clean wound between creases of buttocks (with) NS, pat dry, apply TAO and cover (with) dressing BID till healed." --"Wound consult for buttocks needed." --"1) Sacrum: cleanse (with) NS, pat dry, apply Santyl, [MEDICATION NAME] Ag, foam, dry protective dressing once daily & PRN... Turn & reposition resident Q2H... DC cleanse wound between buttocks creases (with) NS, pat dry, apply TAO and cover (with) dressing BID till healed." Resident #1's "Weekly Pressure Ulcer Healing Record," completed by the facility Treatment Nurse, reflected a new pressure ulcer to the sacrum was identified with a date of onset 12/28/12 and reflected - the pressure ulcer measured 9.5 x 6.0 cm, was "unstageable" with no odor or drainage and wound bed was identified as "Normal." Resident #1's Comprehensive Plan of Care dated 12/28/12 reflected: Problems included: "Resident has a Pressure area: Stage: 4 Location: Sacrum R/T (related to) Debridement by Wound Dr. Prior to wound debridement, sacrum (pressure ulcer) was a DTI." Approaches included: "1) Perform treatment per order, if no improvement with in two weeks-report to M.D. 2) Encourage P.O. and fluid intake with in dietary limits ...4) Assist with turn/repositioning every two hours and prn 5) Use padding between pressure areas and positioning devices for proper body alignment ...7) Monitor labs and report abn's to MD 8) Dietary consult for proper nutrition to resolve pressure area." Resident #1's TAR for December 2012 reflected the following entries: --"Clean wound between creases of buttocks (with) NS, pat dry, apply TAO and cover (with) dressing BID till healed." The order was signed as done on 12/28/12, then discontinued. --"Sacrum: Cleanse (with) NS, pat dry, Apply Santyl, [MEDICATION NAME] AG, foam dry protective dressing once daily and PRN." The entry was signed as done on 12/29/12, 12/30/12 and 12/31/12. Resident #1's "Skin Condition Record" dated 01/02/13 - "not changed" was marked. No signature. The Second Skin Condition Record dated 01/02/13 - 9.5 x 6.0 cm "DTI on sacrum shear on calf." Entered by the Treatment Nurse. Resident #1's Wound Care Physician Evaluations dated 01/03/13 reflected the following: --Site 1 - Shear Wound of Right, Proximal, Lateral Leg that measured 1.5 x 1.3 x 0.5 cm. Thick Adherent Black Necrotic Tissue: "50%" and Granulation Tissue: 50%. There was light serous drainage. --Site 2 - Unstageable (Due to Necrosis) of the sacrum that measured 10.3 x 5.0 x Not Measureable cm. Thick adherent devitalized necrotic tissue: "100%." There was moderate serous drainage. Resident #1's "Weekly Pressure Ulcer Healing Record," completed by the facility Treatment Nurse dated 01/04/13 reflected - the pressure ulcer measured 9.5 x 6.0 cm, was "unstageable" with a moderate amount of serous drainage and the wound bed had black/brown eschar. The Second Skin Condition Record dated 01/09/13 - 8.8 x 7.0 cm, depth 3.5 cm. "Unstageable on sacrum unstageable on calf." Entered by the Treatment Nurse. Resident #1's Wound Care Physician Evaluations dated 01/10/13 reflected the following: --Site 1 - Shear Wound of Right, Proximal, Lateral Leg that measured: 2.2 x 1.3 x Not Measureable cm. Thick Adherent Black Necrotic Tissue (Eschar): "100%." There was light serous drainage. --Site 2 - Stage IV Pressure Wound of the Sacrum that measured 8.8 x 7.0 x 3.5 cm. Thick, Adherent Devitalized Necrotic Tissue: "100%." There was heavy serous drainage, odor and maceration around the wound. Resident #1's "Weekly Pressure Ulcer Healing Record," completed by the facility Treatment Nurse dated 01/10/13 reflected - the pressure ulcer measured 8.8 x 7.0 cm with a depth of 3.5 cm. It was identified as Stage IV and had a large amount of foul-smelling, serosanguinous drainage. Resident #1's "Skin Condition Record" dated 01/10/13 reflected - "8 cm x 5 cm" Depth cm no exudate. Surrounding Tissue/Wound Edges "yellowish white." Entered by LVN S. Resident #1's Braden Scale-For Predicting Pressure Sore Risk revealed the last entry was dated 01/11/13 and reflected a score of "14 " which indicated "Moderate Risk." Resident #1's Nutrition Progress Notes dated 01/14/13 reflected: Skin Update: stage IV sacrum - 8.8 x 7.0 x 3 .5 cm per 1/10/2013 skin report ...Labs include: [MEDICATION NAME] 14.4 L. (12/21/12), improved ...Recommend: 1. Request Prostat sugar-free 30 cc BID until wound healed." During an interview on 02/01/13 at 10:15 AM, the Dietician was shown Resident #1's low [MEDICATION NAME] level and asked whether she talked to the staff about her increased risk for skin breakdown. The dietician stated she had spoken to the staff about it and spoke with Resident #1 as well. She stated the resident was very alert on her last visit (01/14/13) and she had encouraged her to drink Prostat. The Second Skin Condition Record dated 01/16/13 - depth 2.5 cm. "Stage 4 on sacrum unstageable on calf." Entered by the Treatment Nurse. Resident #1's Physician Telephone Orders dated 01/16/13 reflected: "Apply [MEDICATION NAME] cream to bil (bilateral) feet daily." Resident #1's Physician Telephone Orders dated 01/17/13 reflected: "Prostat sugar free 30 cc BID until wound healed." (three days following the recommendation) Resident #1's Physician Telephone Orders dated 01/17/13 reflected: "1) Sacrum ...D/C cleanse (with) NS, pat dry, apply Santyl, [MEDICATION NAME] Ag, and cover QD & PRN. 2) Sacrum ...start cleanse (with) Dakins Solution ? Strength, wet to dry, & cover BID & PRN. 1) Rt. Buttock ...cleanse (with) NS, Pat dry, apply Santyl, [MEDICATION NAME] Ag, & cover QD & PRN." Resident #1's TAR for January 2013 reflected --"Sacrum...cleanse (wit) NS, pat dry, apply Santyl, [MEDICATION NAME] Ag. Foam &dry dressing daily & PRN." The entry was signed as done from 01/01/13 through 01/17/13. Resident #1's TAR for January 2013 reflected --"Sacrum...Cleanse (with) Dakins solution ? strength. Wet to dry & cover BID & PRN." The entry was signed as done from 01/18/13 through 01/28/13. Resident #1's Wound Care Physician Evaluations dated 01/17/13 reflected the following: --Site 1 - Unstageable (Due to Necrosis) of the Right, Proximal, Lateral Calf, Etiology: "Pressure" that measured 2.0 x 1.2 x 0.8 cm. Thick, Adherent Devitalized Necrotic Tissue: "100%." There was moderate serous drainage. --Site 2 - Stage 4 Pressure Wound of the Sacrum that measured 9.5 x 8.5 x 2.5 cm. Thick, Adherent Devitalized Necrotic Tissue: "100%." There was heavy serous drainage. --Site 3 - Unstageable DTI of the Right Buttock: "Etiology: Pressure" that measured 3.2 x 1.8 x Not Measureable cm. There was moderate serous drainage. Resident #1's "Weekly Pressure Ulcer Healing Record," completed by the facility Treatment Nurse dated 01/17/13 - the pressure ulcer measured 9.5 x 8.5 cm, with a depth of 2.5 cm, was Stage IV, and had a large amount of serosanguinous drainage. Resident #1's "Skin Condition Record" dated 01/18/13 reflected - the same entry as 01/10/13. Entered by LVN S. The Second Skin Condition Record dated 01/21/13 - 8.5 x 7.1cm, depth 2.0 cm. "Stage 4 on sacrum, unstageable on calf, DTI on Rt. Buttock." Entered by the Treatment Nurse. Resident #1's Wound Care Physician Evaluations dated 01/24/13 reflected the following: --Site 1 - Unstageable (Due to Necrosis) of the Right, Proximal, Lateral Calf: Wound Size: 2.2 x 1.0 x 0.7 cm. Thick, Adherent Devitalized Necrotic Tissue: "100%." There was moderate serous drainage. --Site 2 - Stage 4 Pressure Wound of the Sacrum that measured 8.5 x 7.0 x 2.0 cm. Thick, Adherent Devitalized Necrotic Tissue: "20%" Slough/[MEDICATION NAME]: "40%" Granulation Tissue: "40%" There was heavy serous drainage. --Site 3 - Unstageable DTI of the Right Buttock: Etiology: "Pressure" that measured 4.8 x 3.2 x Not Measureable cm. There was moderate serous drainage. Resident #1's "Weekly Pressure Ulcer Healing Record," completed by the facility Treatment Nurse dated 01/24/13 - the pressure ulcer measured 8.5 x 7.0 cm with a depth of 2.0 cm, was Stage IV and had a large amount of foul-smelling serosanguinous drainage. An ADL (Activities of Daily Living) Detail Report for the month of January 2013 reflected Resident #1 had received bed baths on 01/26/13 and 01/27/13 by CNA O. In an interview on 02/01/13 at 10:50 AM, CNA O stated she had bathed Resident #1 on 01/26/13 and 01/27/13. When asked why she bathed her two days in a row, she replied, "The way it (pressure ulcer) was smelling, I had to give her one." When asked what was smelling, the CNA replied, "Wound on her butt." CNA O stated her bed baths were always head to toe. When asked if she had noticed anything on Resident #1's feet or ankles, CNA O stated she had a sore area on her left ankle "...where it had been laying against the bed." When asked why her leg was against the bed, CNA O stated they always propped her legs up with pillows but, "I guess when they changed her, they took it out." When asked if she reported the ankle to anyone, CNA O stated she had told LVN V. She stated she did not document the area on a skin sheet because the sheets were in the shower room and she did not want to leave the resident to get one. CNA O denied seeing any areas of concern on Resident #1's right ankle or her heels. In an interview on 02/02/13 at 1:30 PM, the surveyor showed LVN V Resident #1's January 2013 TARs. LVN V verified her initials on 01/26/13 and 01/27/13 for the resident's wound care. LVN V stated she did her residents' treatments on the weekends. LVN V stated the sacral pressure ulcer looked worse, so she called the Treatment Nurse. LVN V stated the Treatment Nurse told her, "(the pressure ulcer) Looks worse after debridement." LVN V stated she put Santyl in the pressure ulcer, then applied TAO on top of the Santyl, put TAO around the outside of the pressure ulcer and covered it with a dressing. The surveyor then showed LVN V Resident #1's TAR with the [MEDICATION NAME] Cream ordered to her feet. LVN V stated she put the [MEDICATION NAME] cream on both feet in the morning. She denied seeing any pressure ulcers on the resident's ankles or feet and stated, "Her feet were real dry." The surveyor asked LVN V if a CNA had told her about redness to Resident #1's ankle, and LVN V stated she didn't recall the CNA telling her anything. LVN V stated she didn't know Resident #1 very well, they (facility staff) could turn her with two people. LVN V stated a restorative aide thought during the weekend of 01/26/13 - 01/27/13, Resident #1 was getting lazy; she(Resident #1) could lift weights higher in the past. LVN V stated she had to give the resident her water and put the straw in her mouth. Resident #1's TAR for January 2013 reflected --"Cleanse wound between creases of buttocks with NS pat dry apply TAO and cover with dressing BID till healed." The entry was signed as done from 01/01/13 through 01/28/13. During an interview on 02/01/13 at 5:45 PM, LVN W was asked about the treatment orders he had signed as done for Resident #1, specifically, and why the order for TAO to her sacrum was still on the TAR when the order had been changed twice since it was initiated. LVN W stated he did the first order but the treatment had changed after the debridement. He did not remember doing the treatment after the first one. During an interview on 02/01/13 at 11:10 AM, LVN S was asked about the TAO order still on the TAR, and his initials indicating it was done. LVN S stated he initialed the treatment records, but the Treatment Nurse did the treatments. When asked how he knew she did the treatment, LVN S replied, "When she is on the hall." When asked when he saw the treatment cart on the hall, if he assumed she did the treatments, LVN S replied, "Yes." During an interview on 02/01/13 at 11:50 AM, the facililty's only ADON was shown Resident #1's TARs and asked about the order for TAO to the sacrum. The ADON stated the order should have been discontinued when newer orders were written. During an interview on 01/30/13 at 1:20 PM, the Treatment Nurse stated one of the charge nurses (on 12/28/12) on the day shift told her Resident #1 had something on her behind she needed to look at. "I went to look at it." She stated there was dark bruising on her buttocks. The night shift had called the PA, received a TAO order, and she (the Treatment Nurse) called the Wound Physician for a consult. The Treatment Nurse stated she had never seen a DTI (Deep Tissue Injury) before. There were no open areas. The Wound Physician came that day; he look looked at the DTI and wrote orders. Resident #1's Wound Care Physician Evaluations dated 01/28/13 reflected the following: --Site 1 - Unstageable (Due to Necrosis) of the Right, Proximal, Lateral Calf that measured 2.4 x 1.2 x 0.7 cm. Thick, Adherent Devitalized Necrotic Tissue: "100%." There was moderate serous drainage. --Site 2 - Stage 4 Pressure Wound of the Sacrum that measured 9.5 x 8.0 x 2.8 cm. Thick, Adherent Black Necrotic Tissue (Eschar): 20%, Thick, Adherent Devitalized Necrotic Tissue: "20%" Slough/[MEDICATION NAME]: "30%" Granulation Tissue: "30%" There was heavy serous drainage. --Site 3 - Unstageable DTI of the Right Buttock: Etiology: Pressure Wound that measured 4.1 x 3.0 x Not Measureable cm. Thick, Adherent Devitalized Necrotic Tissue: "100%." There was moderate serous drainage. During an interview on 01/31/13 at 9:26 AM, LVN S said he was the day shift charge nurse for Resident #1, and it was his "second month." When LVN S was asked to provide Resident #1's weekly head to toe skin assessments, he identified her "Skin Condition Record" as the document used when conducting the assessments. When asked if he was assigned to conduct her weekly skin assessments, LVN S confirmed he was. When asked why many of the entries were not his, including the entry on 01/28/13, LVN S explained he was assigned to her, but if he was unable to get it done, he would flag the chart and someone else would do it. He pointed out the other entries and stated someone else had done them. When LVN S was asked how many wounds Resident #1 had when she left the faciity on [DATE], he replied, "I think two." Resident #1's TAR for January 2013 reflected --"Apply [MEDICATION NAME] cream to feet daily." The entry was signed as done from 01/18/13 through 01/28/13. During an interview on 02/01/13 at 11:10 AM, when LVN S was queried about the order for [MEDICATION NAME] Cream and whether he had applied it to Resident #1's feet on 01/28/13. He stated he had (applied the [MEDICATION NAME] cream to her feet). When asked if he remembered seeing any pressure ulcers on her heels and ankles that day, he pointed to his Achilles tendon area and stated she had a pressure ulcer there that was being treated by the Treatment Nurse. He did not recall Resident #1 having pressure ulcers on her ankles or heels. Resident #1's hospital Photographic Wound Documentation dated 01/28/13 reflected the following: --Right heel - a 4 cm X 1.5 cm pressure ulcer, which was identified as a Deep Tissue Injury. The photograph indicated a dark discoloration, surrounded by bright pink skin with a bruised looking area on one side. The surface of the pressure ulcer appeared indented and not flush with surrounding skin. --Left ankle - a 1 cm x 1 cm Stage II pressure ulcer. The photograph indicated a dark pink wound bed covered more than half with yellow/tan slough (soft, dead tissue). The edges of the pressure ulcer were uneven and the pressure sore did not present a smooth appearance. --Right ankle - a 2.5 cm x 1.0 cm Unstageable pressure ulcer. The skin discoloration was pink on the outer edges becoming darker red towards the center of the pressure ulcer, which was covered with black eschar (hard, dead tissue). The area of the pressure ulcer not covered by eschar did not present a smooth appearance. --Left heel - a 3X

Based on observation, interview and record review, the facility failed to provide each resident with sufficient fluid intake to maintain proper hydration and health for one (Resident #1) of eleven residents reviewed for hydration. Staff failed to notify the physician and PA of abnormal lab levels and the resident's low blood pressures. The PA would have ordered IV fluids to address both issues, providing the resident with hydration. The physician and the PA were not aware of the severity of Resident #1's decline until she was hospitalized , and the PA would have responded differently to the resident's lassitude if he had been aware of all of her symptomology. Staff failed to update Resident #1's Care Plan to address the resident's need for extensive staff assistance with ADLs including being unable to lift a cup of water to her mouth and give herself fluids when she was thirsty. These failures resulted in Resident #1 being admitted to the hospital on [DATE] with diagnoses, which included Volume Depletion with Dehydration and Acute [MEDICAL CONDITION]. These failures could affect the nine residents, who were dependent on staff for hydration, by placing them at risk for not having symptoms of dehydration being identified and reported to their physicians resulting in the potential for developing dehydration, causing kidney damage, and the need for hospitalization . Findings included: 1. Resident #1's MDS assessment dated [DATE] reflected the resident, a [AGE] year-old female, was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she made herself understood, understood others and had a BIMS score of 7, which indicated severe cognitive impairment. The MDS assessment also revealed she was incontinent of bowel and bladder, required extensive assistance with bed mobility, transfers, dressing and hygiene but only required supervision with meals. The MDS assessment reflected Resident #1 had no skin breakdown but was at risk for developing pressure ulcers. Review of Resident #1's Care Plans revealed she had no Care Plan related to her decline in condition or her ADL decline related to her inability to feed herself. Resident #1 was observed on 01/30/13 at 3:00 PM in the Intensive Care Unit (ICU) of a local hospital. She was lying in bed and was awake but very lethargic and was observed to have a [MEDICAL CONDITION] tube in place. An attempt to interview Resident #1 was unsuccessful as she did not answer any questions appropriately. Hospital staff stated she had impaired cognition since admission. 2. During an interview on 01/31/13 at 9:20 AM, LVN W stated he usually worked the 2-10 PM shift with Resident #1. When he was asked about Resident #1's care needs, LVN W stated Resident #1 was usually alert and oriented, required total assistance with transfers and repositioning, had no contractures and had full range of motion in all her extremities. When asked whether she could feed herself, LVN W stated, "Normally she would, but toward the end, when I gave her meds, I gave her water." When asked if he had to hold the cup to her mouth, LVN W stated he did. He added staff had also been feeding her. When asked how long her decline had been, LVN W stated, "That Friday before (01/25/13) I assisted her. I wouldn't say declining. I gave her water with her meds so she wouldn't spill it." Interview with CNA I on 01/31/13 at 11:00 AM revealed she had frequently worked with Resident #1. When asked about Resident #1, CNA I described her as "alert" and "with it" and stated she would laugh and talk during care. She stated Resident #1 always received bed baths because showers were uncomfortable for her. When asked whether Resident #1 could feed herself, CNA I stated she could for a while but the past week or two, she had to feed her. She stated Resident #1, "asked for water a lot" and over the past couple of weeks she had to put the water to her mouth for her. When asked whether she had reported the change to anyone, CNA I stated she had told LVN S. During an interview on 01/31/13 at 11:16 AM, the Treatment Nurse stated she saw Resident #1 with the Wound Physician on 01/28/13 at approximately 1:00 PM. She stated the resident was alert and her eyes were open, but she was not her normal self. The Treatment Nurse stated, "After the Wound Physician and I completed her treatments, I (Treatment Nurse) told the nurse to get her vital signs and call the PA and told him, 'She doesn't look right.' The nurse said her vital signs were good." During an interview on 01/31/13 at 9:26 AM, LVN S stated it was his second month to work with Resident #1 and he worked the day shift. LVN S stated Resident #1 was bedbound and had required total assistance as long as he had been at the facility. When asked how she was at meals, LVN S stated, "We feed her and give her water." When asked about her range of motion, LVN S stated if Resident #1 had enough sleep, she had full range of motion and was fine. If she missed even a little sleep, "...she wouldn't talk to you." LVN S stated he was working the day Resident #1 went out to the hospital. When asked what prompted her to be sent out, LVN S explained she was non-responsive and was over-sleeping. He stated she usually slept a lot but would answer you if you spoke to her, and on that day, she would not answer him. LVN S was asked whether he had ever notified the physician of Resident #1's low blood pressure readings and all the held doses of [MEDICATION NAME] (for hypertension). He stated, "It's got to be a lot to call the doctor." LVN S was shown the last three months of MARs and the counts of all the missed doses of [MEDICATION NAME]. LVN S stated it was not unusual for Resident #1 to have a low blood pressure, and he did not call the physician. LVN S stated the morning she went out, she was "just staring," and he called the PA later, after lunch. When asked if he knew how many pressure ulcers Resident #1 had when she went out to the hospital, LVN S replied, "I think two." (NOTE: Resident #1 had seven pressure ulcers identified by the hospital compared with the three known pressure ulcers identified by the facility on 01/28/13.) Resident #1's Nurse's Notes dated 01/28/13 at 12:25 PM reflected: "Resident in the bed, laying down (with) eye open. Resident is disoriented and not responsive to persons. She continued to be starring (sic) (without) blinking of eyes. She is not communicating, bed bound, total care, dependent for transfer, ADL, personal hygiene etc. Resident have (sic) a deep wound on coccyx area...AM care provided. No new order at this time...will continue to monitor." The entry was signed by LVN S. The next entry dated 01/28/13 at 1:40 PM reflected: "Resident was sent to the hospital for evaluation and tx (treatment) for multiple medical problems. (Family member) was notified and PA was also notified." The entry was signed by LVN S. Resident #1's Physician Telephone Orders dated 01/28/13 at 1:20 PM reflected: "Send (Resident #1) to the hosp (hospital) for evaluation & treatment." The entry was signed by LVN S. 3. Resident #1's Consolidated Physician order [REDACTED]. Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Her blood pressure reached as low as 77/36. Resident #1's MAR for December 2012 reflected she had 15 doses (of a possible 31 doses) of [MEDICATION NAME] held because her blood pressure fell below 100/60. Her blood pressure reached as low as 76/52. Resident #1's MAR for January 2013 reflected she had 25 doses (of a possible 28 doses) of [MEDICATION NAME] held because her blood pressure fell below 100/60. Her blood pressure reached as low as 70/40. Interview with MA D on 02/01/13 at 8:52 AM revealed he had worked on Resident #1's hall for over a year. When MA D was asked whether he notified the charge nurse if a resident's blood pressure was low and a medication was held, MA D stated he told the nurse about Resident #1's blood pressure "Probably every other day." When he was asked about Resident #1's mental state, he described her as sometimes forgetful. When asked whether she could take her medication by herself, MA D stated at first she could, but the last week or so, he had to pour the pills into her mouth and put the water to her mouth. When asked if he had reported the change to the Charge Nurse, MA D stated he would ask LVN S, "What's going on with (Resident #1)?" He could not remember the LVN's responses. In an interview on 02/02/13 at 1:30 PM, LVN V stated she did remember a MA telling her Resident #1's B/P medication was held. LVN V stated there needed to be more communication from the MA. 4. Retrieved on 02/12/13 from http://www.medscape.com/viewarticle/ 8_5, "Dehydration in Geriatrics: Important Symptoms and Laboratory Measures," which reflected: "Traditionally, (abnormally elevated) serum creatinine, blood urea nitrogen (BUN), and the BUN/creatinine ratio are advocated as useful laboratory measurements in detecting dehydration and other pre-renal pathology. Creatinine has proven to be the most sensitive measure." Review of Resident #1's laboratory results dated [DATE] revealed the following: A high White Blood Count of 11.3 10(3)/ul. Reference range was 4.0-10.8 10(3)/ul A critically low Hemoglobin of 7.8 g/dl. Reference range 11.0-15.8 g/dl. A low Hematocrit of 24.2 %. Reference range was 33.0-47.4% A high Potassium of 5.6 mmol/L. Reference range was 3.6-5.2 mmol/L. A high Blood Urea Nitrogen (BUN) of 46 mg/dl. Reference range was 7-17 mg/dl. A high Creatinine of 1.6 mg/dl. Reference range was 0.5-1.0 mg/dl. There were no initials on the lab report or any indication they had been reviewed with or faxed to the physician or PA. Review of the 24 Hour Report Book for December 2012 and January 2013 revealed only her Hemoglobin was mentioned. Resident #1's Skilled Nurse's Notes dated 12/21/12 at 3:20 PM reflected: "Received a call from (Laboratory) about a critical hemoglobin of 7.8. (PA) was notified. New Order: Recheck HG (hemoglobin) in 2 days, do iron study, reticulocyte study, and occult blood stool x (times) 3. Resident was notified." Further review of Resident #1's skilled Nurse's Notes revealed subsequent critical labs were called to the PA and addressed. There was no mention of any lab results. During an interview on 01/31/13 at 3:30 PM, when LVN W was asked whose responsibility it was to check the lab results, he stated it was the ADON's responsibility. LVN W was shown Resident #1's lab results dated 12/21/12 and asked whether he remembered seeing the report or calling the physician. LVN W stated he had not seen the lab results. He stated he called the critical hemoglobin to the PA, because it had been called to him from the lab. He stated whoever pulled the lab result was responsible for the follow-up and reporting the results. When LVN W was informed it had been faxed to the facility on his shift, he stated, "If I saw it, I would have initialed it and written it was faxed to the doctor. They print in the med room. I don't always see them." When asked who was responsible to follow up on labs after they were ordered, he stated the ADONs were responsible. When shown the high potassium and BUN results and asked whether he would have notified the physician, LVN W replied, "Absolutely I would've." When LVN W was shown Resident #1's MARs with the low blood pressure readings, he stated he was not aware her blood pressure had been running so low. When asked what he would have done had he been made aware of the readings, he stated he would have notified the physician after two or three low readings. During an interview on 01/31/13 at 3:45 PM, the ADON was asked who was responsible for the lab results and ensuring the physicians were made aware of abnormals. The ADON explained initially, the charge nurses were responsible for faxing and calling the results to the physicians. She further explained when the Physicians or Physician's Assistants came, she printed all the residents' labs since their last visit and they initialed them all. She stated she then replaced the old lab reports in the charts with the initialed ones. When the ADON was asked whether she had any lab reports, initialed by the PA or MD, that had not been charted yet, she stated she did not. In an interview on 02/04/13 at 9:00 AM, the surveyor asked LVN R how she checked for lab results, and LVN R stated, "That area was not good. That's why you (surveyors) are here." LVN R stated, "I look at the orders for my residents. Not everything gets written on the 24-hour report." 5. During an interview on 01/31/13 at 3:46 PM, when the PA was shown Resident #1's MARs and asked if he had been made aware of her low blood pressures and all the held doses of [MEDICATION NAME], he stated he had not. The PA was shown Resident #1's laboratory results dated [DATE] and asked if he recalled being notified. The PA explained he had been made aware of the low blood counts only and had addressed it. When asked if he knew about the elevated potassium levels and BUN, he replied, "No, I can't say I was." When asked whether he would have done anything differently, the PA stated he probably would have ordered [MEDICATION NAME] (a medication given to lower potassium levels) and would have wanted to push fluids especially with a low blood pressure. When the PA was asked if it was fair to say he had not been made aware of her decreasing blood pressures over the past few months, he stated he had not been informed about the blood pressure readings and stated he probably would have given her intravenous fluids. When asked if that was something that could be done at the facility, he stated it was. The PA stated he had seen Resident #1 last on 01/16/13 and she seemed a little sluggish but without the other data (low blood pressure and lab values) he would not have thought much of it at the time. The PA was asked after how many held doses of a medication would he expect to be notified and he replied, "three to five days in a row if it is out of the norm." When asked if a resident's potassium was high and he did not find out until weeks later, and whether he felt that was a problem, the PA replied, "Absolutely." When the PA was asked whether the staff brought him any lab reports to review during his visit on 01/16/13, he stated if he had reviewed a lab report he would have initialed it. During a meeting on 01/31/13 at 5:24 PM, the DON and Administrator were informed the PA and the physician had not been informed or Resident #1's laboratory results. When asked who was responsible for ensuring the laboratory results were relayed to the PA and physicians, the DON stated the charge Nurses were responsible for reviewing and faxing the lab reports to the physicians and the PA. 6. During an interview on 01/31/13 at 9:15 AM, RA Q, who provided Restorative Therapy, stated she had worked with Resident #1. She explained she was helping her with her range of motion and transfers. When RA Q was asked whether Resident #1 was alert and able to answer questions appropriately, she stated she could answer appropriately but at the end (of therapy), she would "go into a stare and wouldn't say anything...I would tell her like, 'how many fingers am I holding up?' At the end, she wouldn't tell me. She would tell me her name. She just got weaker." When asked whether or not Resident #1 could give herself water, RA Q replied, "I would say no, for the past few weeks she couldn't raise her arms." RA Q stated she referred her back to the therapy department for more assistance. Resident #1's of Physician's Telephone Orders dated 01/22/13 reflected, "OT (Occupational Therapy) to eval (evaluate) and treat." Review of Resident #1's OT Evaluation & Plan of Treatment dated 01/22/13 revealed the following: "Reason for Referral: Patient referred to OT due to new onset of decrease in range of motion, increased need for assistance from others, reduces ADL participation, reduced functional activity tolerance, decrease in strength, decrease in functional mobility and decrease in transfers indicating the need for OT to facilitate increased participation with functional daily activities...." PLOF (prior levels of functioning) revealed she was independent with self-feeding, needed minimum assistance with basic grooming and moderate assistance with upper extremity dressing. Interview with COTA/OT on 02/01/13 at 12:40 PM revealed Resident #1's occupational therapy had been restarted on 01/22/13 due to a decline in her condition. The COTA/OT stated, "Whenever that happens, we put them back on therapy." The COTA/OT stated when Resident #1 was discharged to Restorative Therapy, she was completely independent with feeding and could definitely give herself water. When asked if anyone from their department ever looked at the resident's clinical picture for explanations of their decline, she stated they did not, and it was not within their scope. Interview with RA P on 02/03/13 at 1:51 PM revealed she had worked with Resident #1 on range of motion and transfers. RA P stated. "She very rarely wanted to get up but got to a point where she couldn't get up. She got to the point she couldn't lift her arms." When asked if she had brought Resident #1's decline to anyone's attention, RA P replied, "Yes, several times. I can't pinpoint who I talked to." During another interview on 02/03/13 at 2:10 PM, RA Q was asked if she reported Resident #1's decline in condition to anyone other than the therapy department. RA Q stated, "We had told the nurses." When asked what nurse she had spoken with, RA Q stated, "It's different nurses." RA Q went on to explain they documented their findings in the kiosk computer system. The surveyor showed RA Q a print out of her notes and asked her who had access to the information she entered into the kiosk. RA Q stated she did not know. Review of the restorative therapy Weekly Progress Notes for December 2012 and January 2013 revealed the following entries: 12/07/12 - "(Resident #1) is active w/arom (with active range of motion)/dress/bed mobility doing well." 12/08/12 - "Removing resident from Restorative dining. She is independent in dining." 12/21/12 - "(Resident #1) is participating in all goal and is making progress." 12/28/12 - "(Resident #1) is participating with restorative program and is making progress toward her goal." 01/01/13 - "refused in trans. (transfer) did not feel well." 01/02/13- "(Resident #1) refused trans. Did not feel well." 01/04/13 at 9:29 AM - "(Resident #1) is active in trans/dressing/groo(grooming)/eating/swallowing and is making progress toward her goal." 01/04/13 at 12:57 PM - "refused trans (Resident #1) said she was to (sic) tired." 01/07/13 - "Refused trans. did not feel well." 01/08/13 - "refused due to bed sore/sleepness (sic)/tired." 01/09/13 - "did very little r.o.m.(range of motion) do (sic) to weakness/tire also with dress/groo/trans having problems." 01/10/13 - "(Resident #1) is very weak do very little and refused trans. very little groo/dress and eats with assist." 01/11/13 - "(Resident #1) has not been feeling well and not participating in program." 01/14/13 - "very weak." 01/16/13 - "refused r.o.m. but we did massage upper/lower/arm/leg." 01/18/13 - "(Resident #1) is not meeting her goals, she is becoming total care, can not feed self at the moment. Refuse to get out of bed." 01/21/13 - "(Resident #1) refused r.o.m. due to weakness in hands." 01/25/13 - "(Resident #1) is not strong enough to do a.r.o.m. (active range of motion) do (sic) to pain in arms but is still participating in all other goal and is making very little progress." 01/26/13 - "refused trans/r.o.m." 01/28/13 - "refused trans./a.r.o.m. refused do(sic) to weakness." The Restorative Aide's notes indicate as early as 01/01/13, Resident #1 began refusing to participate in transfers. By 01/11/13, the RA was documenting Resident #1 was not participating in the therapy program, complaining of not feeling well. Documentation indicated Resident #1 continued to refuse to participate, reporting fatigue, weakness, and pain. On 01/16/12, the RA was only able to provide a massage to Resident #1's arms and legs. Resident #1 continued to refuse to participate due to continuing weakness up until 01/28/13, when she was transferred to the hospital. During an interview on 02/03/13 at 3:30 PM, the DON was asked if the Restorative Aide's notes were reviewed by the charge nurses. The DON stated they were not, and she was the only one to review the entries, and she was only looking for specific information like bowel movements, showers, and meals. She stated she had not read the Restorative Aide's notes related to Resident #1. 7. During an interview on 02/04/13 at 3:10 PM, the Medical Director was asked if he was aware of Resident #1's decline in condition. The Medical Director stated, "I was aware of her decline, that much of a decline I wasn't aware." The Medical Director explained the facility staff typically shared their concerns with the PA and the PA relayed the information to him. The Medical Director stated he had been made aware of Resident #1's low hemoglobin levels but had not been told about the other abnormal laboratory values, low blood pressures or other symptoms. When asked what his involvement would be to help the facility correct the failures found, the Medical Director stated different procedures needed to be put into place. He used laboratory services as an example and stated it would be ideal for the DON or ADON to go through every lab then they could track and document each nurse and physician involved. The Medical Director also stated he would like to see a policy implemented where pictures of wounds would be taken. The Medical Director stated he was involved in the facility's QA process and attended the meetings monthly. He added the facility's administration had changed recently and he expected things to improve soon. 8. Review of Resident #1's emergency room records dated 01/28/13 revealed the following laboratory results: White Blood Count was high at 14.4 x10(3)/mcL. Reference range was 4.8-10.8 x10(3)/mcL. Potassium was high at 5.9 mEq/L. Reference range was 3.5-5.1 mEq/L. BUN was high at 82 mg/dl. Reference range was 7-21 mg/dl. Creatinine level was high at 2.1 mg/dl. Reference range was 0.5-1.2 mg/dl. Resident #1's blood pressure upon arrival to the emergency room was very low at 88/47, her heart rate was high at 101. Resident #1's hospital History and Physical Report dated 01/28/13 revealed the following: Reason for Admission: "Septic [MEDICAL CONDITION] and urinary tract infection with decubitus wound and possible infection." Chief Complaint: "Confusion." Medical Decision Making: "1.Sepsis based on end-organ damage with altered level of consciousness, [MEDICAL CONDITION] (low blood pressure), [MEDICAL CONDITION] fever ...The likely source is urinary tract infection and she is at risk for nosocomial infection such [MEDICAL CONDITION] and pseudomonas both with this and possible superinfection of her wound. We will admit her to the step-down unit and give her fluid resuscitation and IV antibiotics with [MEDICATION NAME] and [MEDICATION NAME] to cover nosocomial organisms. 2. Cardiomegaly. We will check an echocardiogram in the morning to assess her left ventricular function because of the cardiomegaly noted on chest x-ray, as this will help guide how aggressively we can hydrate her. She does not have any known history of heart failure. 3. [MEDICAL CONDITION]. She is on [MEDICATION NAME] and [MEDICATION NAME], so I would infer, based on her clinical presentation that this would be acute [MEDICAL CONDITION] and acute renal impairment because [MEDICAL CONDITION] and volume depletion with dehydration. We will hydrate her and see how she does. Foley catheter to monitor urine output ... 6. [MEDICAL CONDITION] (high potassium) secondary to dehydration, acute renal impairment and exacerbated possibly by ACE inhibitor. We will give her a single dose of [MEDICATION NAME] ... 9. We will consult with infectious disease. 10. We will consult with (surgeon) as she may need surgical debridement of the wound ..." A hospital Consultation Report for Resident #1, dated 01/29/13, reflected the following: Reason for Consultation: "I have been asked to see the patient for evaluation of acute kidney injury in the setting of septic shock and volume depletion." Diagnostic Impression: "1. Acute kidney injury in the setting of volume depletion [MEDICAL CONDITION] and [MEDICAL CONDITION] ... 2. [MEDICAL CONDITION] (increased sodium levels) and water deficits. 3. Metabolic acidosis secondary to acute kidney injury [MEDICAL CONDITION] ... 4. [MEDICAL CONDITION], likely secondary to [MEDICAL CONDITION] and [MEDICAL CONDITION]. 5. Urosepsis with E. coli. 6. Multiple decubitus wounds. Plan: 1. IV fluids. 2. IV alkali. 3. NG ([MEDICAL CONDITION]) tube placement. 4. Provide free water via NG tube. 5. Antibiotic therapy. 6. Wound Care. 7. Follow intake and output and serum electrolytes daily. We will follow." 9. The facility's current policy and procedure "Hydration Fluid Maintenance" dated October 2010 reflected: "Fundamental Information...In the elderly, most fluid/electrolyte imbalances present initially with nonspecific symptoms such as lethargy, confusion, or a decline in function that may be abrupt...Process 1. All residents will be offered 2 to 3 beverages of choice at each meal... 3. Additional fluids will be offered during medication passes... 8. Residents who require assistance and encouragement with drinking will receive assistance and encouragement from CNAs Licensed nurses and or paid feeding assistants, under the supervision of a licensed nurse... 11. For residents who are dependent in drinking or who require cueing and/or encouragement to drink, staff should offer, cue, assist resident to drink as necessary on each staff/resident contact. 10. A Resident Roster dated 02/04/13 provided by the ADON identified nine residents who were dependent upon staff for hydration.