Every finding on record at Bowling Green Nursing and Rehabilitation Center

Based on observation, interview, and facility policy review, the facility failed to ensure medications, syringes, and lancets were properly secured and supervised on 1 of 4 medication carts.The findings include: A facility policy titled, Safety and Supervision Standard of Practice, revised 02/2021, revealed, Purpose: The facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision are facility-wide priorities. During an observation on 12/17/2025 at 8:02 PM, the surveyor noted a small, plastic, opened top caddy on top of a medication cart outside room [ROOM NUMBER] on the B Hall that contained 10 insulin pens, two bottles of Lantus insulin, one insulin syringe, one cup of alcohol pads, one cup of lancets, and one glucometer. The medication cart was not within sight of a nurse, and no residents were observed in the hallway. During an interview on 12/17/2025 at 8:05 PM, Registered Nurse (RN) 13 stated she normally did not leave insulin and insulin supplies out, but she had to go to the nurse's station to get her papers. RN 13 stated she should have taken the insulin and insulin supplies with her. During an interview on 12/19/2025 at 1:18 PM, the Assistant Director of Nursing (ADON) stated nurses should not leave medications on the medication cart. The ADON stated syringes and lancets should be locked in the medication room when not in use. The ADON stated she expected nurses not to leave medication, syringes, or lancets unattended. During an interview on 12/19/2025 at 1:50 PM, the Director of Nursing (DON) stated insulin and insulin supplies were to be stored when not in use. During an interview on 12/19/2025 at 2:09 PM, the Administrator stated he expected all medications and supplies to be locked in the medication cart or the medication room.

Based on interview, record review, and facility policy review, the facility failed to take action after receiving a pharmacy recommendation for one of five sampled residents (Resident (R) 6) reviewed for unnecessary medications. The findings include: A facility policy titled, Behavior and Psychoactive Medication Protocol, with a review date of 11/2020, revealed Purpose: The facility strives to enhance the Quality of Life and Quality of Care of residents experiencing behavior and receiving psychoactive medications through the Behavior and Psychoactive Medication review process. Each resident shall receive individualized care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Protocol: * The facility IDT [interdisciplinary team] works with the physician to determine the appropriate diagnosis associated with the resident's symptoms so the underlying causes of symptoms are recognized and treated appropriately. * Physician orders and pharmacist reviews clinically support the diagnosis and reason for the medication, including and evaluation of risk versus benefit of the medication to be shared with resident and/or responsible party. A review of R6's medical record which included the Admission Face Sheet revealed the facility admitted the resident on 08/15/2024. According to the Admission Face Sheet, the resident's medical history included diagnoses of Alzheimer's disease and dementia. Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/21/2024, revealed R6 had a Brief Interview for Mental Status (BIMS) of 4, which indicated the resident has severe cognitive impairment. The MDS indicated the resident received antipsychotic medication on a routine basis. Review of R6's care plan, titled Psychotropic Drug Use, established 08/24/2024, revealed the resident was at risk for complications as evidenced by the use of psychotropic medications and a history of falls related to a diagnosis of dementia. Review of R6's Medication Orders, revealed an order for risperidone (an antipsychotic medication) oral tablet 0.25 milligrams one tablet by mouth on the day shift between 2:00 PM and 5:00 PM. Review of R6's pharmacy recommendation report dated 08/16/2024, revealed a recommendation to Please clarify/document the approved diagnosis to justify use of Risperdal [risperidone] and update order in EMR [electronic medical record]. There was no outcome listed. Continued review of the pharmacy recommendation report for R6 dated 08/27/2024, revealed a recommendation to Please clarify/document the approved diagnosis to justify use of Risperdal and update order in EMR. The outcome was listed as No response 09/24/2024. Further review of the pharmacy recommendations report for R6 dated 10/28/2024, revealed a recommendation to Please clarify/document the approved diagnosis to justify use of Risperdal and update order in EMR. There was no outcome listed. During a telephone interview on 11/05/2024 at 2:44 PM, Pharmacist 7 stated the facility had not responded to the recommendations to add an approved diagnosis to the risperidone for R6, which was why she recommended it again at the end of October 2024. Pharmacist 7 stated she did not know why there had been no response to her identified irregularity, but stated sometimes recommendations fell through the cracks. During a telephone interview on 11/06/2024 at 12:39 PM, R6's primary physician stated if he had not responded to the pharmacy recommendation for R6, it must have been a miscommunication. During an interview on 11/07/024 at 9:03 AM, the Director of Nursing stated she expected staff to respond to irregularities identified in the medication regiment review.

Based on interview, record review, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure a significant change in status assessment (SCSA) Minimum Data Set (MDS) assessment was completed for one of two sampled resident (Resident (R) 4) reviewed for hospice. R4 was admitted to hospice care on 09/16/2024; however, a SCSA MDS had not been completed. The findings include: The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, dated 10//2024, specified, 03. Significant Change in Status Assessment (SCSA) The SCSA is a comprehensive assessment for a resident that must be completed when the IDT [interdisciplinary team] has determined that a resident meets the significant change guidelines for either major improvement or decline. Per the manual, An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program or changes hospice providers and remains a resident at the nursing home. The ARD [assessment reference date] must be within 14 days from the effective date of the hospice election. Review of R4's medical record on the Admission Face Sheet revealed the facility admitted the resident on 06/02/2017. According to the Admission Face Sheet, the resident had a medical history that included diagnoses of adult failure to thrive, anorexia, cerebral infarction, unspecified dementia, and intellectual disabilities. Review of R4's physician orders revealed an undated order that indicated the resident was on hospice. Review of R4's care plan, titled Advance Directive, established 04/06/2021, revealed an intervention with a start date of 09/16/2024, that indicated the resident was placed on hospice care. Further review of R4's medical record revealed no evidence to indicate a SCSA MDS assessment had been completed since the resident was admitted to hospice care on 09/16/2024. During an interview on 11/06/2024 at 9:01 AM, the MDS Coordinator stated she was not aware of the rule regarding the completion of a SCSA MDS following a resident being placed on hospice. The MDS Coordinator confirmed that a SCSA MDS was not completed when R4 was placed on hospice. During an interview on 11/07/2024 at 9:02 AM, the Director of Nursing (DON) stated her expectation was for staff to follow the state and federal guidelines for completing assessments timely. The DON stated she was not aware a SCSA MDS should have been completed when a resident was placed on hospice. During an interview on 11/07/2024 at 9:16 AM, the Administrator stated her expectation was for assessments to be completed per the RAI guidelines. The Administrator stated she was aware a SCSA MDS needed to be completed when R4 was placed on hospice; however, she was unaware the MDS Coordinator did not know about this rule.

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to revise the Comprehensive Care Plan following a behavioral change for Resident #2 (R2). Review of R2's Comprehensive Care Plan revealed the care plan was not revised to include interventions for change in behavior. The findings include: Review of the facility's policy titled, Comprehensive Care Plans Standard of Practice, dated 10/2020 and reviewed 10/2020, revealed an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs would be developed for each resident. The protocol stated care plans would be reviewed and updated when there was a significant change in the resident's condition or when a desired outcome was not met, and that assessments were ongoing and care plans would be revised as information about the resident and resident's condition may change. Review of R2's Facesheet revealed the facility admitted R2 on 04/27/2022 with diagnoses that included schizoaffective disorder, depressive type, cognitive communication deficit, and dementia in other diseases classified elsewhere. Review of R2's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/05/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. Further review of Section E (Behavior) of the MDS revealed R2 had not exhibited any behaviors during the review period. Review of the facility's Investigation Initial Report, dated 09/10/2024, revealed Certified Nursing Assistant (CNA) 1 witnessed R2 hit his roommate, R1 on the cheek. Review of the facility's Investigation Five Day Report, dated 09/16/2024, revealed R1 stated he had been bickering with R2 when R2 suddenly hit him on the cheek. R1 stated he was not injured and he did feel safe in the facility but he wanted a new roommate. Further review revealed R2 was moved to another room. The 5 day report further revealed staff stated R1 and R2 had been long time roommate and there had been no problems had been noted in the past. R2 was placed on every 15 minute checks for 24 hours to ensure no other behavioral variances occurred. R1 was monitored for pain, skin, and psychosocial distress, which none were noted. Review of R2's Care Plan revealed the facility developed a care plan for behaviors on 04/27/2022. However, further review of the document revealed there was no documented evidence the care plan was revised after the resident to resident altercation on 09/10/2024. During an interview with R2 on 10/01/2024 at 4:00 PM, he stated he moved rooms one-two months ago because he did not get along with his previous roommate very well. R2 stated R1 would do things to annoy him. R2 stated he didn't argue with R1 but he did not like things that R1 did such as rolling his tray around the room when it should have been left alone. R2 stated he never had a physical altercation with R1. R2 stated he had seen R1 in the hall and in the dining room since he changed rooms and there had not been any issues. During an interview with CNA 1 on 10/01/2024 at 3:25 PM, she stated she heard a loud noise such as an argument and went to R1 and R2's room. CNA 1 stated she observed R1 in his wheelchair at the bathroom door and R2 was standing over him and proceeded to slap R1 on the cheek. CNA 1 stated she immediately separated R1 and R2 and removed R1 from the room to keep him safe. CNA 1 stated she did not know of any arguments between the two residents in the past and none since this incident. CNA 1 stated R2 was moved to another room and do occasionally see each other in the hall but neither seem to even recognize the other due to their memory issues. CNA 1 further stated she did not think either resident even remembered the incident happening. During an interview with the Assistant Director of Nursing (ADON) on 10/02/2024 at 3:38 PM, she stated the care plan was to let everyone know how to care for the resident. The ADON stated if anything changed with the resident, the care plan should be revised immediately by the nurse on the floor or the person that found the problem. The ADON stated if the care plan was not revised, staff would have a hard time knowing how to care for the resident. During an interview with the MDS Coordinator on 10/02/2024 at 3:56 PM, she stated she was responsible for developing the comprehensive care plan, reviewing the care plan during clinical meeting and ensure the care plans had the appropriate interventions. The MDS coordinator stated R2's behavioral care plan should have been updated by the nurse on the floor. She further stated the Interdisciplinary team (IDT) should have discussed the incident during clinical meeting the following morning and if the care plan had not been updated or an intervention added, it should have been caught and added at that time. The MDS coordinator further stated if this was not done, R2 could have had continued behaviors that were not addressed. During an interview with the Director of Nursing on 10/03/2024 at 11:02 AM, she stated R2 should have had a problem of physical aggression added to his care plan with an appropriate intervention. The DON stated she expected the care plan to be updated and revised to allow staff to know how to care for and/or intervene with the resident correctly. The DON stated if the care plan was not revised, it could be detrimental to the resident and staff would not know how to provide care to the residents. The DON further stated the facility was in process of training the floor nurses to add interventions to the care plan. She continued to state that the IDT would discuss the care plan and edit with appropriate interventions if needed. During an interview with the Administrator on 10/03/2024 at 10/03/2024, she stated the care plan was to provide a guide for staff to instruct them on care for the residents. She stated if the care plan was not revised, staff may not know how to properly care for the residents. She further stated any of the nursing administration or floor staff could update a care plan and it should be done immediately.

Based on interview, record review, and review of the facility's policies, the facility failed to protect one of seven sampled residents (Resident (R)1) from physical abuse. On 09/10/2024 staff witnessed R2 hit R1 on the cheek. The findings include: Review of the facility's policy titled, Abuse Prohibition Standard of Practice, revised 07/2022, revealed the facility would prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property and to ensure reporting and investigating of alleged violations in accordance with Federal and State laws. Review of R2's Facesheet revealed the facility admitted R2 on 04/27/2022 with diagnoses that included schizoaffective disorder, depressive type, cognitive communication deficit, and dementia in other diseases classified elsewhere. Review of R2's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/05/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. Further review of Section E (Behavior) of the MDS revealed R2 had not exhibited any behaviors during the review period. Review of R1's Facesheet revealed the facility admitted R1 on 09/22/2022 with diagnoses that included alcohol dependence with alcohol-induced persisting amnestic disorder, psychotic disorder with delusions and dementia. Review of R1's Quarterly MDS with an ARD of 08/03/2024 revealed the R1 had a BIMS score of an eight out of 15, indicating moderate cognitive impairment. Review of the facility's Investigation Initial Report, dated 09/10/2024, revealed Certified Nursing Assistant (CNA) 1 witnessed R2 hit his roommate, R1 on the cheek. Review of R2's Care Plan revealed the facility developed a care plan for behaviors on 04/27/2022. However, further review of the document revealed there was no documented evidence the care plan was revised after the resident to resident altercation on 09/10/2024. Review of the facility's Investigation Five Day Report, dated 09/16/2024, revealed R1 stated he had been bickering with R2 when R2 suddenly hit him on the cheek. R1 stated he was not injured and he did feel safe in the facility but he wanted a new roommate. Further review revealed R2 was moved to another room. The 5 day report further revealed staff stated R1 and R2 had been long time roommate and there had been no problems had been noted in the past. R2 was placed on every 15 minute checks for 24 hours to ensure no other behavioral variances occurred. R1 was monitored for pain, skin, and psychosocial distress, which none were noted. During an interview with R2 on 10/01/2024 at 4:00 PM, he stated he moved rooms several months ago because he did not get along with his previous roommate very well. R2 stated R1 would do things to annoy him. R2 stated he didn't argue with R1 but he did not like things that R1 did such as rolling his tray around the room when it should have been left alone. R2 stated he never had a physical altercation with R1. R2 stated he had seen R1 in the hall and in the dining room since he changed rooms and there had not been any issues. During an interview with CNA 1 on 10/01/2024 at 3:25 PM, she stated she heard a loud noise such as an argument and went to R1 and R2's room. CNA 1 stated she observed R1 in his wheelchair at the bathroom door and R2 was standing over him and proceeded to slap R1 on the cheek. CNA 1 stated she immediately separated R1 and R2 and removed R1 from the room to keep him safe. CNA 1 stated she did not know of any arguments between the two residents in the past and none since this incident. CNA 1 stated R2 was moved to another room and do occasionally see each other in the hall but neither seem to even recognize the other due to their memory issues. CNA 1 further stated she did not think either resident even remembered the incident happening. During an interview with the Director of Nursing (DON) on 10/03/2024 at 11:02 AM, she stated R1 and R2 were separated immediately and R1 was brought to the nurses station and assessed immediately. The DON stated R1 denied any physical injuries but did not really have any recollection of the event. She stated R2 was moved to another hall. The DON stated R2 had no behavioral problems in the past and he had no recollection of anything happening between himself and R1. During an interview with the Administrator on 10/03/2024 at 10/03/2024, she stated R2 had no prior behavioral problems and had none since the incident with R1. She stated R2 denied hitting R1 immediately after the incident. The Administrator stated if CNA 1 had not witnessed the altercation, the facility would have unsubstantiated it.

Based on interviews, record review, the facility investigation, and facility policy review, it was determined the facility failed to protect residents from misappropriation of funds for three (3) of eleven (11) sampled residents (Resident #6, #10, and #11). Resident funds were found missing during a routine request by a resident's family member for funds to pay a bill. The investigation determined the facility had completed the corrective action on 06/24/2023, therefore it was determined to be past noncompliance with a compliance date of 06/25/2023. The findings include: Review of the facility's policy, Abuse Prohibition Standard of Practice, dated 07/2022 revealed the facility would prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property and ensure reporting and investigating of alleged violations in accordance with Federal and State laws. Further review of the policy revealed Misappropriation of Resident Property was the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of the resident's belongings or money without the resident's consent. 1. Review Resident #6's Face Sheet revealed the facility admitted the resident on 08/30/2018 with diagnoses which included Anxiety Disorder, Heredity and Idiopathic Neuropathy, and Chronic Pain. Review of Resident #6's Quarterly Minimum Data Set (MDS) assessment, dated 12/01/2023, revealed the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Review of the Facility Investigation and review of the Resident Fund Management Service (RFMS), dated 12/17/2021, revealed the a total of $11,523.80 had been removed from Resident #6's account by the former Business Office Manager. Review of Resident #6's RFMS account revealed a total amount missing of $11,523.80 was reimbursed to the resident's RFMS account. 2. Review of Resident #10's Face Sheet revealed the facility admitted the resident on 12/11/2019 with diagnoses which included Wernicke's Encephalopathy, Alcohol Abuse, Anxiety Disorder, and Seizures. Review of Resident #10's Quarterly MDS assessment, dated 01/12/2024, revealed the facility assessed the resident to have BIMS score of fourteen (14) out of fifteen, which indicated the resident was cognitively intact. Review of Resident #10's Resident Fund Management Service (RFMS) account document, not dated, revealed a total of $1861.84 had been removed from the resident's account. Further review of the document revealed that on 08/24/2022 $1861.24 had been refunded back to the resident's account. 3. Review of Resident #11's face sheet revealed the facility admitted the resident on 10/28/2015 with diagnoses which included Anxiety Disorder, End Stage Renal Disease, and Dependence on Renal Dialysis. Review of Resident #11's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen, indicating the resident was cognitively intact. Review of Resident #11's RFMS account document, not dated, revealed a total of $1354.00 had been removed from the resident's account. Further review of the account revealed $1354.00 had been refunded to the resident on 08/24/2022. Review of the former Business Office Manager's (BOM)personnel file revealed date of hire was 02/15/2019 and her last day of employment was 12/10/2021. Further review revealed there were no concerns with the criminal background check upon hire. The State Surveyor attempted telephone interviews with the former BOM on 02/27/2024 at 12:38 PM, 02/27/2024 at 1:46 PM and on 02/28/2024 at 4:05 PM, without success. In an interview with the Administrator on 02/27/2024 at 1:33 PM, she stated misappropriation of resident funds was discovered when the Regional Business Office Manager (BOM) took over the position after the previous staff member resigned on 12/10/2021. She stated that on December 17, 2021, a resident's family member had requested some money to pay the resident's bills. The Regional BOM reviewed the resident's account and found there was not enough money. The Administrator stated an investigation started at this time and other discrepancies were identified with resident accounts. She stated the former BOM had access to the employees' social security numbers, and she used those numbers to open several personal accounts at various banking institutions. The Administrator stated several staff members revealed personal accounts had been opened in their names without their knowledge or consent. She stated the former BOM would move money from one resident account to another so that it was not caught until after leaving employment from the facility. The Administrator further stated Resident #6 had never given anyone authorization to remove money from his/her account. She stated all money had been refunded back to the resident's accounts and law enforcement had been notified. In an interview with Detective #2, on 02/28/24 at 1:25 PM, stated he was the lead investigating officer for the alleged embezzlement, and he was expecting an indictment in the coming weeks to be handed down. He revealed the facility had been cooperative during the investigation and the money had been refunded to the individuals affected. In an interview with the Regional Business Office Manager, on 02/28/2024 at 2:44 PM she stated after the discovery resident funds were missing, she notified the police and a forensic accountant was brought in to investigate. The Regional Business Office Manager revealed her own investigation was completed in August 2022. The Forensic Accountant and Attorneys hired by the company continued their investigation which resulted in all money returned to the residents on 08/24/2022. *The facility implemented the following actions to correct the deficient practice: 1. Resident #6, Resident #10 and Resident #11's RFMS accounts were audited, and money missing was reimbursed back into accounts on 08/24/2022. 2. The facility initiated an investigation into resident funds on 12/17/2021. All current Resident RFMS accounts were audited by the Regional Business Officer Manager (BOM). 3. The Director of Nursing (DON) provided education to staff on the abuse policy and Misappropriation of Property. 4. Re-education was provided to the Administrator and BOMs in the facilities by the Regional BOM regarding resident trust procedures from the beginning of admission to discharge. 5. The facility uses a float Business Office Manager (BOM) who reviews random resident accounts to ensure resident funds are not misappropriated. 6. The Regional Business Office Manager provided education to the new Business Office Manager on required forms, authorization processes, how to handle direct deposit funds, the required forms for signatures, opening accounts in RFMS, and forms of incomes on the accounts. Further education was provided on closing accounts, and daily, monthly and quarterly reconciliation. 7. All identified issues are discussed during Quality Assurance Performance Improvement (QAPI) meetings for further recommendations. **The State Survey Agency Validated the corrective action by the facility as follows: 1. Review of all RFMS accounts revealed the missing money was refunded to Resident #6, Resident #10 and Resident #11's RFMS accounts on 08/24/2022. 2. In an interview with the Regional Business Officer Manager (BOM) on 02/28/2024 at 2:44 PM, she stated she completed her investigation was completed in August 2022. She further stated she had received education regarding the facility's abuse policy when she was hired. 3. Review of staff education documents revealed all current staff had been in-serviced on the facility's Abuse Policy. During interviews with Certified Nurse Aide (CNA) #1 on 02/27/24 at 9:15 AM, CNA #2 at 10:27 AM, Social Services Director at 9:33 AM, Registered Nurse (RN) #1 at 10:36 AM, CNA #3 at 10:45 AM, CNA #4 at 10:54 AM, Licensed Practical Nurse (LPN) #1 at 11:07 AM, and the Assistant Director of Nursing (ADON) at 11:15 AM, they stated they had received Abuse training from the Director of Nursing (DON). In an interview with the current BOM on 02/28/2024 at 2:00 PM, she stated she had received education regarding the facility's abuse policy when she was hired. 4. Review of Resident Trust Accounts binder and education revealed Administration had been educated on the accounting process involving resident funds. In an interview with the Regional BOM on 02/28/2024 at 2:00 PM, she stated she had educated the new Business Office Manager on the facility's process of resident accounts. She stated resident trust accounts were now kept on a share drive so that the Regional Field Accountant has access and audits were completed. 5. In an interview with the Payroll Clerk on 02/28/2024 at 2:23 PM, she revealed a float BOM comes to the facility unannounced to complete audits of resident accounts. 6. In an interview with the Regional BOM on 02/28/2024 at 2:00 PM, she stated she had educated the new Business Office Manager on the facility's process of resident accounts. 7. In interviews with the Administrator on 02/27/2024 at 1:33 PM and the Regional Business Office Manager on 02/28/2024 at 2:44 PM, they stated that any identified issues concerning resident accounts would be discussed during Quality Assurance Performance Improvement (QAPI) meetings for further recommendations.

Based on interview, closed record review, hospital record review, review of Resident Assessment Instrument (RAI) Manual, and facility policy review, it was determined the facility failed to have an effective system in place to ensure care plans were developed and implemented to prevent skin breakdown for one (1) of five (5) sampled residents (Resident #1). The facility readmitted Resident #1 on [DATE] and care planned the resident for Skin Breakdown. An intervention was initiated that directed staff to assess the resident's skin and report redness, rashes, bruises, abrasions, and skin breakdown. State Registered Nurse Aide (SRNA) #1 reported she identified an area that looked like a bruise above the resident's buttock crack on [DATE] and reported the area to the nurse. However, there was no documented evidence the wound was reported to the nurse per facility policy, or that the nurse assessed the area prior to the resident being transferred to the hospital. On [DATE], Resident #1 had a change in condition and was transferred to the hospital. The resident was diagnosed with [REDACTED]. During triage at the hospital, staff obtained the resident's rectal temperature and identified large decubitus wounds. A sacrum wound measuring 4.4 centimeters (cm.) by 10.22 cm, a left buttock wound measuring 11.05 cm by 5.07 cm, and a right buttock wound that measured 4.24 cm by 6.70. The right hip and sacral wound had purulent drainage when palpitated. The large decubitus wounds were surgically debrided following admission. In addition, emergency room staff identified wounds on the right ankle, inner ankle, heel, sole of foot, lateral foot, great toe, fifth toe, lateral knee, and posterior rib; and the left toes. However, there was no documented evidence the facility had assessed and identified all the wounds prior to the resident going to the hospital; as the only wounds documented as present prior to the resident transfer to hospital were a wound to right ankle, and right second, third and fourth toes; and, excoriation to the buttocks. The resident was transferred to Hospice Care on [DATE] and passed on [DATE]. The facility's failure to have an effective system in place to ensure each resident's care plan interventions were implemented has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Interview with the Administrator on [DATE] at 1:51 PM, revealed the facility does not have a Care Plan policy but that they go by the Resident Assessment Instrument (RAI) Manual. Review of the RAI manual, dated [DATE] page ,[DATE] revealed the care delivery system in a nursing home was complex yet critical to successful resident care outcomes and was guided by both professional standards of practice and regulatory requirements. The delivery of care to meet the needs of a resident was based upon the completion of a comprehensive assessment and the development of a care plan based upon the assessment. Documentation of this assessment process was necessary to assure continuity of care and to identify declines, improvements, or maintenance of a resident's condition. The assessment process known as the RAI involves the completion of the MDS, the CAAs, and the development of a comprehensive care plan. The RAI process requires the facility staff to, at a minimum, complete standardized assessment data for each resident at regular intervals. The intent was to develop an individualized plan of care based on the identified needs, strengths, and preferences of the resident. Review of the facility's policy titled, Skin Care Guideline, dated [DATE], revealed the purpose was to provide a system for evaluation of skin to identify risk and individual interventions to address risk and process for care on changes/interruptions in skin integrity. Closed record review revealed the facility admitted Resident #1 on [DATE] and readmitted the resident on [DATE] after a hospital stay. The resident was admitted with diagnoses, which included Pressure Ulcers, Diabetes, Chronic Pain, Cerebral Infarction, [MEDICAL CONDITION] and [MEDICAL CONDITION], Neuromuscular Dysfunction of the Bladder, and COVID 19. Review of quarterly Minimum Data Set (MDS) assessment, dated [DATE] revealed the resident's cognition was severely impaired, and was at risk of pressure ulcers/injuries. The MDS revealed the facility assessed the resident to have one or more unhealed pressure ulcers and one unstageable ulcer. Review of the Comprehensive Care Plan, dated [DATE], revealed Resident #1 had the presence of skin breakdown or was at high risk for skin breakdown with an intervention for staff to assess skin and report redness, rashes, bruises, abrasions or skin breakdown. Interview with State Registered Nurse Aide (SRNA) #2, on [DATE] at 12:57 PM, revealed while providing incontinent care on [DATE], she observed an area above the resident's butt crack that looked like a bruise; and, she applied barrier cream and reported the area to the nurse. However, record review revealed there was no documented evidence the SRNA reported the area to the nurse, or the nurse assessed the area SRNA #2 identified prior to the resident's transfer to the emergency room , per care plan. Review of Progress Notes, dated [DATE] at 2:33 AM, revealed Resident #1 was identified to have a change condition and was sent out to the emergency room (ER). Review of Resident #1's emergency room Record, dated [DATE], revealed the resident arrived at the hospital and was triaged at 2:13 AM. The emergency room physician documented the resident is moaning and seems to be in pain. The room smells of rounded flesh when walking into the room and the resident has a severe back wound with necrosis draining purulent material, this seems to be the source of septic shock. The emergency room Discharge Summary, dated [DATE], revealed the resident was admitted with diagnoses, which included Acute Septic Shock, Decubitus Ulcers, Stage IV Acute on Chronic, [MEDICAL CONDITION] Fibrillation with Rapid Ventricular Response (RVR), Metabolic Acidosis, Acute [MEDICAL CONDITION], and Diabetes Mellitus Type II. In addition, review of hospital photographs with wound locations and measurements taken on [DATE] between 6:16 AM and 6:34 AM revealed Resident #1 was identified to have multiple wounds in the emergency room . The wounds were identified were on the Left Buttock wound,11.05 cm by 5.07 cm; Right Buttock, 4.24 cm by 6.70 cm; and Sacrum, 4.44 cm by 10.22 cm. Further review of the photographs revealed there was also wounds on the Right Ankle, 2.34 cm by 3.35 cm; Right Inner Ankle, 3.01 cm by 2.12 cm; Right Heel, 1.64 cm by 1.75 cm; Right Sole of Foot, 1.10 cm by 1.28 cm; Right Lateral Foot, 3.14 cm by 2.33 cm.; Right Great Toe, 1.39 cm by 1.66 cm; Right Pinky Toe, 2.02 cm by 2.33 cm; and Left Toes, 0.70 cm by 0.69 cm. There were also wounds to the Right Lateral Knee, 0.81 cm by 1.05 cm and Right Posterior Rib, 1.54 cm by 0.93 cm. However, review of facility Skin Assessment Grids, revealed the facility documented the sacrum wound healed [DATE], right plantar foot wound healed on [DATE], right great toe healed on [DATE], and right heel, right lateral foot and right buttock healed on [DATE]. There was no documented evidence the facility had identified these wounds had returned or any other wounds had developed. The only wounds documented as still present prior to transfer to hospital were a right ankle wound, wounds to right second, third and fourth toes, and excoriation to buttocks; which were documented as present on [DATE]. Interview with Licensed Practical Nurse (LPN) #4, on [DATE] at 9:00 AM, revealed Resident #1 had a change in condition the night he/she was sent to the hospital. She stated she did not remember a SRNA reporting anything on Resident #1's bottom or she would have done something. Interview with the Assistant Director of Nursing (ADON)/Wound Nurse, on [DATE] at 9:15 AM, on [DATE] at 1:21 PM, and on [DATE] at 5:00 PM, revealed she could not remember how Resident #1's wounds looked. Continued interview revealed she completed the resident wound assessments and measurements weekly and documented them on the Skin Assessment Grid sheet. She stated she last assessed Resident #1's skin on [DATE] and he/she had excoriation noted to the bilateral buttocks. She revealed the resident had many wounds that would come and go. She stated SRNA's and nurses should tell the wound nurse when they see redness or an area of concern. Interview with the Director of Nursing (DON), on [DATE] at 9:09 AM and on [DATE] at 4:32 PM, revealed Resident #1 did not have a wound when he/she went out on [DATE] as the wound to the sacrum/coccyx area had healed. The DON stated she would have expected the SRNA to notify the nurse if she had seen something on the resident's bottom per the resident's care plan. She further revealed if the SRNA identified a wound, she should have reported it to the nurse and the nurse should have assessed the wound, notified the physician, and started treatment as ordered. She stated she expected the staff to follow the care plan and if staff failed to follow the care plan, the wounds could worsen. Interview with the facility Administrator, on [DATE] at 1:51 PM, revealed she interviewed SRNA #2 during her investigation and the SRNA told her there was redness and irritation, but no open areas when she cleaned the resident. The Administrator stated the resident left at 1:40 AM and the nurse would have had the time to address any concerns with the skin so the information would have been included in the report to the ER. She stated she expected her staff to follow the care plan. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #1 was transferred to the emergency room and did not return to the facility. 2. Physical assessments were completed for current residents by licensed nurses. This assessment included vital signs and skin integrity audit. 3. The ADON/Wound nurse completed a full body skin assessment on all in-house residents on [DATE]. 4. Facility charge nurses obtained vital signs (including temperature, blood pressure, pulse, respirations, and oxygen saturation) for all in-house residents except one that refused, and was care planned for refusing care at times. For any identified concern one (1) resident, the MDS nurse verified that the concern was care planned with interventions for prevention/treatment. This was completed on [DATE]. 5. A review of all residents with skin concerns care plans was completed on [DATE] by the DON, ADON, and MDS Nurse, to verify each resident had appropriate interventions to address skin care needs. 6. The Regional Director of Operations (RDO) provided education to the Administrator (ADM), DON, ADON, and Staff Development Coordinator (SCD) on [DATE] regarding F656 and F686. 7. The education on F656 and F686 was then provided to the nursing staff (all licensed nurses and certified nursing assistants) by the DON, ADON and/or SDC. This was completed by [DATE]. 8. Verbal acknowledgement of understanding along with signed education was obtained after the education. 9. Any new nursing hire would receive this education prior to assuming duties. 10. An ad hoc Quality Assurance Process improvement (QAPI) meeting was held [DATE] to plan for a review of the facility's skin system and corresponding staff re-education. This meeting included the Administrator, DON, ADON, SDC; and, the Medical Director and RDO via phone. 11. An ad hoc Quality Assurance Process improvement (QAPI) meeting was held [DATE] to review the results of audits and status of the re-education being provided. This meeting included the Administrator, DON, ADON, and SDC; and, the Medical Director and RDO via phone. 12. Beginning the week of [DATE], the DON and/or ADON would review a minimum of five (5) residents weekly with skin integrity care plans to validate that interventions were being implemented as directed in the plan of care. This would include walking rounds with the SRNA's to validate residents' care plan intervention are being implemented. This would continue times four (4) weeks. 13. The DON and/or ADON would complete a look back/second review of ten (10) resident skin assessments weekly to validate the accuracy of the skin assessment findings. 14. The monitoring results would be followed in a weekly ad hoc QAPI while the facility remains out of compliance, as well as the facility monthly QAPI monthly for review and recommendation if indicated. The monthly QAPI was attended by, but not limited to, the Administrator, DON, ADON, SDC, Unit Manager, Social Services Director, Activities Director, Dietary Manager, Business Office Manager, and Therapy Director; and the Medical Director, a minimum of quarterly. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Resident #1's face sheet revealed the resident was admitted by the facility on [DATE]. Interview with Registered Nurse (RN) #5 on [DATE] at 1:22 PM revealed the resident expired on [DATE] at 10:04 PM at the hospital. 2. Review of binder provided by the Administrator revealed licensed staff completed physical assessments to include skin integrity audits and vital signs on all but one (1) resident (who declined) on [DATE]. Interviews on [DATE] with the DON at 2:26 PM, ADON/Wound Nurse at 2:51 PM, and SDC at 2:39 AM, and on [DATE] (Post Survey) with Administrator at 8:52 AM revealed they all worked as a team to complete the assessments. 3. Review of skin audit sheets dated [DATE] revealed the ADON/Wound Nurse completed a full body skin assessment on all in house residents. Interview with the ADON/Wound Nurse on [DATE] at 2:51 PM revealed she completed skin assessments on all but one (1) resident, who declined. She stated RN #6, DON, and SDC assisted her, with no concerns identified. 4. Review of skin audits sheets dated [DATE] revealed the facility charge nurses (RN #6, ADON/Wound Nurse, DON and SDC) obtained vital signs (including temperature, blood pressure, pulse, respirations, and oxygen saturation) for all in-house residents except one, that refused, and is care planned for refusing care at times. Review of skin assessment sheets revealed a concern was identified for one resident and the MDS nurse verified that the concern was care planned with interventions for prevention/treatment. Interview (Post Survey) with the MDS Nurse, on [DATE] at 8:10 AM, revealed she was the person that updated the care plan for the one (1) resident identified with concerns during the skin assessments. 5. Review of signed resident roster revealed the DON, ADON, and MDS Nurse reviewed all residents with skin concerns care plans on [DATE] to verify each resident had appropriate interventions to address skin care needs. Interviews on [DATE] with the Administrator at 2:17 PM, DON at 2:26 PM, and the ADON at 2:51 PM revealed the residents had appropriate interventions to address skin care needs. No concerns were identified. 6. Review of sign in roster dated [DATE] revealed the RDO provided education to the Administrator, DON, ADON, and SDC on the regulations at F656 and F686. Interviews on [DATE] with the Administrator at 2:17 PM, DON at 2:26 PM, and ADON at 2:51 PM revealed they were educated on the development and implementation of the Comprehensive care plan and interventions to prevent pressure wounds and for the risk of skin breakdown. 7. Review of Staff sign in roster dated [DATE] revealed the DON, ADON and SDC provided education to licensed nurses and SRNA's related to F656 and F686. Interviews on [DATE] with LPN #1 at 1:40 PM, SRNA #11 at 1:53 PM, SRNA #1 at 2:01 PM, LPN #8 at 2:05 PM, CMT #2 at 2:10 PM, and SRNA #12 at 2:36 PM, revealed they were educated to follow resident care plans related to treatment and services to prevent/heal pressure ulcers. The staff stated they were also educated to report all identified skin concerns to the nurse who would notify the MD of any new/change with skin concerns to obtain orders. The staff revealed they were to ensure that interventions for the prevention and treatment of [REDACTED]. 8. Review of the binder provided by the Administrator revealed all licensed staff and SRNA's signed a verbal acknowledgement of understanding and signed indicating education was received. Interviews on [DATE] with LPN #1 at 1:40 PM, SRNA #11 at 1:53 PM, SRNA #1 at 2:01 PM, LPN #8 at 2:05 PM, CMT #2 at 2:10 PM, and SRNA #12 at 2:36 PM revealed they received education on following care plans and the treatment/services to prevent/heal pressure ulcers. 9. Interview with the SDC, on [DATE] at 2:39 PM, revealed there were six (6) new hires since [DATE]. She stated any new hires would be required to have the education before working. Review of the education roster revealed six (6) new employees received the education. 10. Review of sign in sheets revealed an ad hoc Quality Assurance Process improvement (QAPI) meeting was held [DATE] to plan for a review of the facility's skin system and corresponding staff re-education. This meeting included the Administrator, Director of Nursing, Assistant Director of Nursing, the Staff Development Coordinator, and the Medical Director and Regional Director of Operations via phone. Interviews on [DATE] with the Administrator at 2:17 PM, DON at 2:26 PM, ADON at 2:51 PM. and SDC at 2:39 PM verified their attendance to the QAPI meeting. They stated they reviewed the facility wound system and developed a plan. 11. Review of sign in sheet revealed an ad hoc QAPI meeting was held on [DATE] to review audit results and status of education provided. Interviews on [DATE] with the Administrator at 2:17 PM, DON at 2:26 PM, ADON at 2:51 PM and SDC at 2:39 PM, revealed they reviewed and discussed the results from the audits from [DATE]. 12. Review of spreadsheet dated [DATE], [DATE] and [DATE], revealed the DON and/or ADON reviewed five (5) residents skin integrity care plans each week to validate that interventions were implemented as directed in the plan of care. These included walking rounds with the CNA's to validate residents' care plan intervention were being implemented. No concerns were noted. Interviews on [DATE] with the ADON at 2:51 PM, LPN #1 at 1:40 PM, Medical Records/SRNA at 1:53 PM, SRNA #1 at 2:01 PM, LPN # 8 at 2:05 PM, MT #2 at 2:10 PM, and SRNA #12 at 2:36 PM, revealed walking rounds and interactions with nursing staff were done to validate that care plan interventions were implemented. 13. Review of spreadsheet dated [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], revealed the DON and/or ADON completed a look back/second review of ten (10) resident skin assessments weekly to validate the accuracy of the skin assessment findings. Further review revealed there were no concerns identified. Interviews on [DATE] with the DON at 2:26 PM and ADON at 2:51 PM, revealed the lookbacks were completed on ten (10) residents weekly with no concerns identified. 14. Interview on [DATE] with the Administrator at 2:17 PM, revealed they had weekly QAPI meetings and would continue weekly meetings until the facility was back in compliance, then the meetings would be monthly. Attempts made to reach the Medical Director on [DATE] at 3:57 PM, [DATE] at 8:51 AM and 4:06 PM, and lastly on [DATE] at 8:06 AM. Did not receive a return call from the physician.

Based on interview, closed record review, hospital record review, and facility policy review, it was determined the facility failed to ensure skin and wound assessments were completed, and pressure ulcers treated according to standards of practice to prevent pressure ulcer development or further decline for one (1) of five (5) sampled residents, Resident #1. State Registered Nurse Aide (SRNA) #2 stated when providing incontinent care on [DATE], she noted a discolored area above resident's buttock crack that resembled a bruise. SRNA stated she reported the area to the nurse but could not recall which nurse. However, there was no documented evidence the facility assessed the discolored area on buttocks. On [DATE], Resident #1 was transferred to the hospital by Emergency Medical Services (EMS) and during the triage period hospital staff and EMS identified a sacral wound. The hospital assessed the resident to have multiple wounds with a Stage IV wound to the sacrum measuring 4.44 cm (length) centimeters (cm) by 10.22 cm (width), a left buttock wound measuring 11.05 cm by 5.07 cm, and a wound to the right buttock measuring 4.24 cm (length) by 6.70 cm (width). The resident was transferred to Hospice Care on [DATE] and passed on [DATE]. In addition, Resident #1 was identified to have wounds on the left toes, right heel and inner ankle, right fifth toe, right sole of foot, right great toe, right lateral foot and ankle, and right posterior rib. However, review of facility records revealed the facility had not identified the wounds to the resident's sacrum, right buttock, left toes, right heel, inner ankle, fifth right toe, right sole of foot, right great toe, right lateral foot, and right posterior rib, prior to being transferred the hospital. According to facility documentation, the only wounds the resident had were a right ankle wound, wounds to left toes, and excoriation to buttocks. Review of the Emergency Department physician progress notes [REDACTED].#1 was moaning and seemed to be in pain. The provider went on to write, the resident has a severe back wound with necrosis and draining purulent material. This seems to be the source of the resident's septic shock. The facility's failure to provide care consistent with professional standards of practice, to care for and prevent pressure ulcers has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Skin Care Guideline, dated [DATE], revealed the purpose of the policy was to provide a system for evaluation of skin, to identify risk and individual interventions to address risk, and process for care on changes/interruptions in skin integrity. If interruption in skin integrity was noted, a weekly evaluation of the wound should include location of wound; staging of the wound; size of wound; presence, location and extent of any undermining or tunneling/sinus tract; exudate with type, color odor and approximate amount. In addition, wound bed color, type of tissue; description of wound edges and surrounding tissue; and pain if present should be noted. Closed record review revealed the facility readmitted Resident #1 on [DATE] after a hospital stay. The resident was admitted with diagnoses, which included Pressure Ulcers, Diabetes, Chronic Pain, Cerebral Infarction, [MEDICAL CONDITION] and [MEDICAL CONDITION], Neuromuscular Dysfunction of the Bladder, and COVID 19. Review of quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1's cognition as severely impaired. Further review of the MDS revealed the resident was at risk for pressure ulcers/injuries and had one or more unhealed pressure ulcers and one unstageable ulcer. Review of the Braden Scale For Predicting Pressure Sore Risk, dated [DATE], revealed the facility assessed Resident #1 to be a mild risk for skin breakdown, with a score of fifteen (15). Review of the Comprehensive Care Plan, dated [DATE] and last updated [DATE], revealed Resident #1 had the presence of skin breakdown or was at high risk for skin breakdown, related to being bed/chair bound with head of bed elevated due to being tube fed, and the use of a nasal cannula to deliver oxygen. The goals were to maintain intact skin integrity, intermittent skin alterations would be free of infection and show evidence of healing until healed. Further review revealed interventions to assist the resident to turn and reposition upon rounds and as needed, provide a pressure reduction cushion and mattress, provide skin care regularly, heel protectors to lower extremities, and observe for abnormal bruising or bleeding and report. Review of the facility's Skin Assessment Grids, revealed the ADON/Wound Nurse assessed Resident #1's wounds on [DATE] and the following wounds were identified: 1. Buttocks Right (per care plan) - Stage II - 4 cm by 7 cm with 0.2 cm depth, with moist white in appearance, red surrounding tissue with no complaints of pain; 2. Right lateral foot - 3.3 cm by 1.6 cm, with slough (dead skin tissue that may have a yellow or white appearance), red surrounding tissue and no pain; 3. Right heel - unstageable, 1.8 cm by 1.7 cm, with no depth, Eschar (piece of dead tissue that is cast off from the surface of the skin usually black or brown in color) noted with intact surrounding tissue and no pain; 4. Right great toe, 1.5 cm by 1.0 cm, no depth, appearance black with intact surrounding tissue; with pain noted. 5. Right plantar foot, 1.5 cm by 1.5 cm, no depth, black in appearance with intact surrounding skin and no pain; 6. Right ankle, pressure ulcer (per care plan), 1.5 cm by 1.5 cm with no depth, red in appearance with surrounding tissue intact and no pain. 7. Sacrum wound - Stage I (per care plan) 4 cm by 3.9 cm, with no depth, red in appearance, red surrounding tissue, and no pain. Further review revealed the Sacrum wound healed on [DATE] (three {3} days later). In addition, review of a Skin Assessment Grid, dated [DATE], revealed wounds were identified on the right 2nd, 3rd, and 4th toes. However, the facility failed to document measurement of wounds, per facility policy. Further review of the grid revealed the wounds were red in appearance with red surrounding tissue, and were not painful. Further review of the Skin Assessment Grids, revealed the right plantar foot wound healed on [DATE]; the great toe wound healed on [DATE]; and, the right buttock, right lateral foot, and right heel healed on [DATE]. However, review of the [DATE] Treatment Administration Record (TAR), revealed staff continued to clean the right heel with wound cleaner and right great toe with normal saline, pat dry, and paint with [MEDICATION NAME], every shift until the resident went out to hospital, on [DATE], even though the order stated complete treatment until healed. In addition, the assessment revealed the buttocks continued to have some excoriation. Further review of the Skin Assessment Grids, dated [DATE], revealed the only remaining wounds documented as assessed, was the right second toe, third toe, fourth toe and right ankle. There were no measurements of the wounds on the toes but the wounds were described as slough with intact surrounding tissue. In addition, the right ankle wound measured 2.2 cm by 1.75 cm with 0.5 cm depth and was red in appearance with red surrounding tissue. Review of the Nurse/Skin Care Assessment (containing the front/back diagram picture) completed by the ADON/Wound Nurse, dated [DATE], revealed there was excoriation to the coccyx and bilateral buttocks. Review of Progress Note, dated [DATE] at 2:33 AM, revealed Resident #1's vital signs were obtained and were the following: respirations: 42 (normal:18), labored and used abdominal muscle to breathe; pulse: 145 (normal: 74), blood pressure: ,[DATE] (normal:,[DATE]), and oxygen saturation: 99% (normal: 98%). The resident's blood sugar was 347, skin was warm and clammy, and he/she responded by facial expression. Further review of the note, revealed the physician was notified and orders were received to send the resident out to the emergency room (ER). Emergency Medical Services (EMS) was notified as well as the resident's spouse, report was called to the ER, and EMS arrived to transfer the resident. Review of the EMS Patient Care Record, dated [DATE], revealed the ambulance was at the facility at 1:41 AM, with the resident at 1:43 AM, departed the scene at 1:58 AM, and arrived at the emergency room at 2:04 AM. Review of ER records, dated [DATE], revealed Resident #1's rectal temperature was obtained at 2:13 AM during triage. Interview (Post Survey) with the Manager of the Emergency Department, on [DATE] at 8:10 AM, revealed he was working and saw Resident #1's wounds on [DATE]. He stated he and other staff discovered the skin breakdown on the backside when they turned the resident over to take a rectal temperature during triage. He stated the resident had obvious breakdown with necrotic tissue and a foul odor to the buttocks/sacrum area with tunneling. He stated there was also scabbing on toes, a deep tissue injury to the right heel, and wound to the right ankle, and hip. Interview with transporting Paramedic, on [DATE] at 9:16 AM, revealed he assisted transferring Resident #1 and he heard the nurse and doctor mention the ulcers on the resident's back and the doctor saying something about this is elder abuse. He stated he went in to see the wounds and saw the wound on the resident's lower back. He revealed he remembered seeing a necrotic area, but it had been so long it was hard for him to describe it. He stated he did not remember an odor. Review of the Internal Medicine and emergency room Notes, dated [DATE], revealed Resident #1 was admitted to the hospital on [DATE], with diagnoses, which included Septic Shock, Unstageable Pressure Ulcer of Sacral Region, Skin Necrosis-Gangrene not elsewhere specified, Severe Dehydration, Coagulopathy, Acute Kidney Injury, Urinary Tract Infection, and [MEDICAL CONDITION]. The ER note stated the resident had a extremely high risk of mortality this admission and dismal prognosis. Review of the Emergency Department physician progress notes [REDACTED].#1 was moaning and seemed to be in pain. The provider went on to write, The room smells of rounded flesh when walking into the room and the resident has a severe back wound with necrosis and draining purulent material. This seems to be the source of the resident's septic shock. The progress noted Resident #1 had skin breakdown to bilateral heals also. Continued review of ER physician notes, dated [DATE], revealed Resident #1's Septic Shock was secondary to skin and soft tissue infection, the large decubitus ulcer with extensive necrotic region to the back, which had purulent drainage. Review of hospital photographs with wound locations and measurements taken, on [DATE] between 6:16 AM and 6:34 AM, revealed the following wounds were identified: Left Buttock, 11.05 cm by 5.07 cm; Right Great Toe 1.39 cm by 1.66 cm; Right Buttock 4.24 cm by 6.70 cm; Sacrum 4.44 cm by 10.22 cm; Right Heel 1.64 cm by 1.75 cm; Right Ankle 2.34 cm by 3.35 cm; Right Sole of Foot 1.10 cm by 1.28 cm; Right Pinky Toe 2.02 cm by 2.33 cm; Right Inner Ankle 3.01 cm by 2.12 cm; Left Toes 0.70 cm by 0.69 cm; Right Posterior Rib 1.54 cm by 0.93 cm; Right Lateral Knee 0.81 cm by 1.05 cm; Right Lateral Foot 3.14 cm by 2.33 cm. Interview with State Registered Nurse Aide (SRNA) #2, on [DATE] at 8:44 AM, and on [DATE] at 12:57 PM, revealed she did not think Resident #1 had any open areas on his/her backside the night he/she went to the hospital, just a couple of spots where he/she had scratched him/herself. She stated staff were putting cream on the resident's backside and his/her bottom stayed red. She revealed she could not remember very well but there was a dark discolored area around the flat bony area above the butt crack that she called coccyx. She stated she could not remember if there was an odor. She revealed she reported the area to the nurse who was working but she could not remember which nurse. Interview with Registered Nurse (RN)N #1, on [DATE] at 11:43 AM, and on [DATE] at 1:38 PM, revealed Resident #1 had some wounds on the toes and one on the right ankle. RN #1 stated she did not remember any other wounds but if treatments were marked as completed for day shift, on [DATE], for the right heel and right great toe, then she would have completed the treatments. She revealed if a wound had, an order to continue treatment until healed and she found that the wound was healed during treatment, she would write an order to discontinue the treatment. Interview with Licensed Practical Nurse (LPN) #4, on [DATE] at 9:00 AM and on [DATE] at 6:53 PM, revealed she did not remember what happened the night Resident #1 went out to the hospital, just that his/her condition declined. The LPN stated she did not remember a SRNA reporting an area to the resident's coccyx or she would have done something. Interview with the ADON/Wound Nurse, on [DATE] at 9:15 AM, on [DATE] at 1:21 PM, revealed she could not remember how Resident #1's wounds looked. She further revealed the resident was in poor health and his/her skin integrity was very fragile. She revealed she could not remember the last time she saw the resident's bottom, but she remembered redness and scratches where he/she scratched at the skin all the time. She stated she completed the resident wound assessments and measurements weekly and documented them on the Skin Assessment Grid sheet. The ADON/Wound nurse reported the resident's buttocks were excoriated and the sacral wound had healed when she last assessed Resident #1's skin, on [DATE]. She stated all wounds should be documented on the wound sheet. She revealed the resident had many wounds that would come and go and the wounds on his/her small toes would heal and return often. However, there was no documented evidence the wounds healed multiple times. She stated if wounds healed, she or the nursing staff would be responsible for discontinuing the treatment. Further interview with ADON/Wound Nurse, on [DATE] at 5:00 PM, revealed she used skin and wound care guidelines to describe and stage wounds. She stated wounds were different depending on how they looked, resident diagnoses, and location of the wound. She revealed When the resident was here, he/she did not have a place on the bottom. She further revealed SRNA's and nurses should tell the wound nurse when they see redness or an area of concern. Continued interview revealed she and other ADON reviewed wound sheets each month to make sure they were completed. She stated she would document if a wound had exudate, or had other descriptions on wound grid, and wounds were measured once a week. The ADON/Wound Nurse stated she followed facility policy as written. She revealed Skin Quality Assurance was completed weekly as an Interdisciplinary Team (IDT) Note in computer and IDT participants were dietary, activity, therapy, nursing, MDS, ADON's, DON, and Administrator. Interview with the hospital Surgeon who cared for Resident #1, on [DATE] at 11:30 AM, revealed according to the progress notes that he was referencing from [DATE], the wound on the sacrum had to have been in that area for three (3) months minimum. He revealed the wound on the sacrum should have been noticed and they would have had to be completely blind and stupid not to notice the wound. He stated the wound was debrided on [DATE]. He stated the resident did not have [DIAGNOSES REDACTED] but had a decubitus on his/her sacrum that either tunneled to the wound on the hip, or they each grew large enough that they connected. He stated this was tissue necrosis from decubitus. Interview with the Director of Nursing (DON), on [DATE] at 9:09 AM, revealed Resident #1 did not have a wound when he/she went out on [DATE]. The DON stated the resident had returned from a hospital stay on [DATE] with a wound to the sacrum/coccyx area and it had healed out. The DON revealed the SRNA's should notify the nurse if they saw any changes with a resident's condition. She described excoriation as a red skin irritation, almost like diaper rash to a baby's butt; and the nurse had told her the resident had excoriation. Continued interview revealed a wound assessment was completed at least every seven (7) days, and the ADON was responsible for measuring the wounds; and, keeping a wound grid and a body man page. She stated a resident that has a stage II should be on the wound grid but she was not sure about a stage I and would have to review the grid. She revealed nurses were not required to make an entry into the regular nurse's note but if there was a new wound identified, the ADON should be notified and would assess the resident. She stated [MEDICATION NAME] would be used to dry up an area of moist skin and reduce the risk of infection. Further interview with the DON, on [DATE] at 5:24 PM, revealed nurses had education on wounds at least annually. She stated excoriation was not measured. The DON revealed Resident #1's physician saw the resident in the facility; not via telehealth, but the Advanced Practice Registered Nurses (APRN) does use telehealth for visits. She revealed the wound sheet/laminate was used to stage wounds as a guide and the facility charted by exception, so if nothing was identified, then nothing would be documented. The DON was not aware that Resident #1 had been diagnosed with [REDACTED]. Interview with Resident #1's Physician, on [DATE] at 1:11 PM and on [DATE] at 12:50 PM, revealed the problem with people with recurrent wounds was that the superficial skin would heal over the previous wound. He stated it was well documented, that wounds were dependant on blood vessels and with pressure and the lack of blood flow, these wounds could break down within hours. He revealed this would happen if you have an open spot under healed skin especially, and he seen it often in elderly residents and paraplegics. He would not expect septic shock to occur that quickly, but they never expected septic shock. He stated it was common to have that sort of decline within hours and this particular resident was in poor health, especially since recovering from COVID, and had poor intake by mouth, as well. He stated if the resident had been diagnosed with [REDACTED]. He further revealed he did not expect the facility to contact him regarding excoriation if not improving with treatment; but if the skin was broken and a wound formed, he would expect to be contacted. He stated if the facility had contacted him about the excoriation, he would have told them to continue the treatment protocol that was already in place. When asked if he looked at Resident #1's bottom when he completed the assessment on [DATE], he reported that he was not sure, but he would have documented it if he had. Surveyor read him the physician progress notes [REDACTED]. Interview with the Administrator, on [DATE] at 1:51 PM, revealed she saw some of the pictures from the hospital, but she did not think the area on the bottom was open when Resident #1 left the building. The Administrator stated she interviewed SRNA #2 during her investigation and the SRNA told her that she had cleaned the resident up and applied barrier cream to the resident's bottom prior to the resident leaving to the hospital. She stated the SRNA said there was redness and irritation but there was no open areas. She stated the toe wounds were not measured because they all run together. The Administrator revealed the resident had very fragile skin and had to be turned and repositioned at least every two (2) hours and sometimes more often as needed. Continued interview revealed she stated every time the resident went out to the hospital, he/she would return with wounds or worsening wounds. She stated the initial sacral wound was hospital acquired and when the resident returned to the facility from a hospitalization on [DATE], the wound was even larger. The Administrator further revealed the resident laid in the emergency room for five (5) hours before the hospital took pictures and she thinks the resident was not turned during that time and EMS did not document any wounds or odors. She revealed the facility had access to Wound Care Technology, when a wound was not healing. She stated the physician was notified when a wound was not healing to get a change in treatment and the family was notified at the same time. She revealed the wound nurse only measured areas that were open, but does not measure excoriation. She further revealed the facility had a Quality Assurance Skin Meeting weekly (Wound nurse, DON) and they pulled all skin sheets to make sure all skin issues were addressed. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #1 was transferred to the emergency room and did not return to the facility. 2. Physical assessments were completed for current residents by licensed nurses. This assessment included vital signs and skin integrity audit. 3. The ADON/Wound nurse completed a full body skin assessment on all in-house residents on [DATE]. 4. Facility charge nurses obtained vital signs (including temperature, blood pressure, pulse, respirations, and oxygen saturation) for all in-house residents except one that refused, and was care planned for refusing care at times. For any identified concern one (1) resident, the MDS nurse verified that the concern was care planned with interventions for prevention/treatment. This was completed on [DATE]. 5. A review of all residents with skin concerns care plans was completed on [DATE] by the DON, ADON, and MDS Nurse, to verify each resident had appropriate interventions to address skin care needs. 6. The Regional Director of Operations (RDO) provided education to the Administrator (ADM), DON, ADON, and Staff Development Coordinator (SCD) on [DATE] regarding F656 and F686. 7. The education on F656 and F686 was then provided to the nursing staff (all licensed nurses and certified nursing assistants) by the DON, ADON and/or SDC. This was completed by [DATE]. 8. Verbal acknowledgement of understanding along with signed education was obtained after the education. 9. Any new nursing hire would receive this education prior to assuming duties. 10. An ad hoc Quality Assurance Process improvement (QAPI) meeting was held [DATE] to plan for a review of the facility's skin system and corresponding staff re-education. This meeting included the Administrator, DON, ADON, SDC; and, the Medical Director and RDO via phone. 11. An ad hoc Quality Assurance Process improvement (QAPI) meeting was held [DATE] to review the results of audits and status of the re-education being provided. This meeting included the Administrator, DON, ADON, and SDC; and, the Medical Director and RDO via phone. 12. Beginning the week of [DATE], the DON and/or ADON would review a minimum of five (5) residents weekly with skin integrity care plans to validate that interventions were being implemented as directed in the plan of care. This would include walking rounds with the SRNA's to validate residents' care plan intervention are being implemented. This would continue times four (4) weeks. 13. The DON and/or ADON would complete a look back/second review of ten (10) resident skin assessments weekly to validate the accuracy of the skin assessment findings. 14. The monitoring results would be followed in a weekly ad hoc QAPI while the facility remains out of compliance, as well as the facility monthly QAPI monthly for review and recommendation if indicated. The monthly QAPI was attended by, but not limited to, the Administrator, DON, ADON, SDC, Unit Manager, Social Services Director, Activities Director, Dietary Manager, Business Office Manager, and Therapy Director; and the Medical Director, a minimum of quarterly. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Resident #1's face sheet revealed the resident was admitted by the facility on [DATE]. Interview with Registered Nurse (RN) #5 on [DATE] at 1:22 PM revealed the resident expired on [DATE] at 10:04 PM at the hospital. 2. Review of binder provided by the Administrator revealed licensed staff completed physical assessments to include skin integrity audits and vital signs on all but one (1) resident (who declined) on [DATE]. Interviews on [DATE] with the DON at 2:26 PM, ADON/Wound Nurse at 2:51 PM, and SDC at 2:39 AM, and on [DATE] (Post Survey) with Administrator at 8:52 AM revealed they all worked as a team to complete the assessments. 3. Review of skin audit sheets dated [DATE] revealed the ADON/Wound Nurse completed a full body skin assessment on all in house residents. Interview with the ADON/Wound Nurse on [DATE] at 2:51 PM revealed she completed skin assessments on all but one (1) resident, who declined. She stated RN #6, DON, and SDC assisted her, with no concerns identified. 4. Review of skin audits sheets dated [DATE] revealed the facility charge nurses (RN #6, ADON/Wound Nurse, DON and SDC) obtained vital signs (including temperature, blood pressure, pulse, respirations, and oxygen saturation) for all in-house residents except one, that refused, and is care planned for refusing care at times. Review of skin assessment sheets revealed a concern was identified for one resident and the MDS nurse verified that the concern was care planned with interventions for prevention/treatment. Interview (Post Survey) with the MDS Nurse, on [DATE] at 8:10 AM, revealed she was the person that updated the care plan for the one (1) resident identified with concerns during the skin assessments. 5. Review of signed resident roster revealed the DON, ADON, and MDS Nurse reviewed all residents with skin concerns care plans on [DATE] to verify each resident had appropriate interventions to address skin care needs. Interviews on [DATE] with the Administrator at 2:17 PM, DON at 2:26 PM, and the ADON at 2:51 PM revealed the residents had appropriate interventions to address skin care needs. No concerns were identified. 6. Review of sign in roster dated [DATE] revealed the RDO provided education to the Administrator, DON, ADON, and SDC on the regulations at F656 and F686. Interviews on [DATE] with the Administrator at 2:17 PM, DON at 2:26 PM, and ADON at 2:51 PM revealed they were educated on the development and implementation of the Comprehensive care plan and interventions to prevent pressure wounds and for the risk of skin breakdown. 7. Review of Staff sign in roster dated [DATE] revealed the DON, ADON and SDC provided education to licensed nurses and SRNA's related to F656 and F686. Interviews on [DATE] with LPN #1 at 1:40 PM, SRNA #11 at 1:53 PM, SRNA #1 at 2:01 PM, LPN #8 at 2:05 PM, CMT #2 at 2:10 PM, and SRNA #12 at 2:36 PM, revealed they were educated to follow resident care plans related to treatment and services to prevent/heal pressure ulcers. The staff stated they were also educated to report all identified skin concerns to the nurse who would notify the MD of any new/change with skin concerns to obtain orders. The staff revealed they were to ensure that interventions for the prevention and treatment of [REDACTED]. 8. Review of the binder provided by the Administrator revealed all licensed staff and SRNA's signed a verbal acknowledgement of understanding and signed indicating education was received. Interviews on [DATE] with LPN #1 at 1:40 PM, SRNA #11 at 1:53 PM, SRNA #1 at 2:01 PM, LPN #8 at 2:05 PM, CMT #2 at 2:10 PM, and SRNA #12 at 2:36 PM revealed they received education on following care plans and the treatment/services to prevent/heal pressure ulcers. 9. Interview with the SDC, on [DATE] at 2:39 PM, revealed there were six (6) new hires since [DATE]. She stated any new hires would be required to have the education before working. Review of the education roster revealed six (6) new employees received the education. 10. Review of sign in sheets revealed an ad hoc Quality Assurance Process improvement (QAPI) meeting was held [DATE] to plan for a review of the facility's skin system and corresponding staff re-education. This meeting included the Administrator, Director of Nursing, Assistant Director of Nursing, the Staff Development Coordinator, and the Medical Director and Regional Director of Operations via phone. Interviews on [DATE] with the Administrator at 2:17 PM, DON at 2:26 PM, ADON at 2:51 PM. and SDC at 2:39 PM verified their attendance to the QAPI meeting. They stated they reviewed the facility wound system and developed a plan. 11. Review of sign in sheet revealed an ad hoc QAPI meeting was held on [DATE] to review audit results and status of education provided. Interviews on [DATE] with the Administrator at 2:17 PM, DON at 2:26 PM, ADON at 2:51 PM and SDC at 2:39 PM, revealed they reviewed and discussed the results from the audits from [DATE]. 12. Review of spreadsheet dated [DATE], [DATE] and [DATE], revealed the DON and/or ADON reviewed five (5) residents skin integrity care plans each week to validate that interventions were implemented as directed in the plan of care. These included walking rounds with the CNA's to validate residents' care plan intervention were being implemented. No concerns were noted. Interviews on [DATE] with the ADON at 2:51 PM, LPN #1 at 1:40 PM, Medical Records/SRNA at 1:53 PM, SRNA #1 at 2:01 PM, LPN # 8 at 2:05 PM, MT #2 at 2:10 PM, and SRNA #12 at 2:36 PM, revealed walking rounds and interactions with nursing staff were done to validate that care plan interventions were implemented. 13. Review of spreadsheet dated [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], revealed the DON and/or ADON completed a look back/second review of ten (10) resident skin assessments weekly to validate the accuracy of the skin assessment findings. Further review revealed there were no concerns identified. Interviews on [DATE] with the DON at 2:26 PM and ADON at 2:51 PM, revealed the lookbacks were completed on ten (10) residents weekly with no concerns identified. 14. Interview on [DATE] with the Administrator at 2:17 PM, revealed they had weekly QAPI meetings and would continue weekly meetings until the facility was back in compliance, then the meetings would be monthly. Attempts made to reach the Medical Director on [DATE] at 3:57 PM, [DATE] at 8:51 AM and 4:06 PM, and lastly on [DATE] at 8:06 AM. Did not receive a return call from the physician. (TRUNCATED)

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed ensure one (1) of eight (8) sampled residents was free from significant medication errors (Resident #3). Resident #3 had Physician order [REDACTED].>The findings include: Review of a summary of the [MEDICATION NAME] Risk Evaluation and Mitigation Strategy (REMS) Program revealed as of 02/28/19, prescribers will need to be certified by the [MEDICATION NAME] REMS Program to dispense [MEDICATION NAME]. Record review revealed the facility admitted Resident #3 on 02/28/17 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/23/19 revealed the facility assessed Resident #3's cognition as moderately impaired with a Brief Interview for Mental Status score of nine (9), which indicated the resident was interviewable. Interview of Resident #3, on 06/05/19 at 9:30 AM, revealed the resident denied having hallucinations or hearing voices while not receiving his/her [MEDICATION NAME]. Interview with the Resident #3's sister, on 06/06/19 at 9:25 AM, revealed Resident #3's physician was not certified to rewrite the [MEDICATION NAME] prescription until he obtained the certification. She could not recall the date she was notified that the medication wasn't available. The sister stated she could tell when the resident had not had her medication because she would hear voices and have hallucinations. Review of (MONTH) 2019 physician's orders [REDACTED]. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Review of notes from the Facility Pharmacy Vendor, revealed the facility had requested to have the medication refilled. On 03/30/19, the Pharmacy requested laboratory tests before filling the medication. The Complete Blood Count was completed by the laboratory on 04/01/19 at 5:12 PM. On 04/01/19, the pharmacy notified the facility the Physician was not certified to write the prescription for the medication. On 04/03/19 at 12:13 PM, a note by the pharmacy indicated they had faxed the Physician office regarding the need to get certified to write the medication. The pharmacy also noted on 04/03/19 at 12:26 PM the facility was notified again regarding the need for the physician to get certified. On 04/04/19 at 9:59 AM, the Pharmacy spoke with the Physician's office. The office staff reported she had given the paperwork to the Physician. The Physician's office reported they would notify the Pharmacy when the physician becomes certified. The Pharmacy made the facility aware the Physician cannot dispense the [MEDICATION NAME] until he becomes certified and that the resident was out of medication. A notation dated 04/07/19 at 2:51 PM, revealed the pharmacy spoke with a nurse at the facility who indicated the [MEDICATION NAME] was actually ordered by a different prescriber. The pharmacy made the facility aware that a new order would need to be written by that prescriber. Review of a physician's orders [REDACTED]. Further review of the notes from the Facility Pharmacy Vendor revealed on 04/23/19 at 3:20 PM, the pharmacy notes revealed the physician was supposed to get certified last week, but is still not certified and the physician's office had been notified several times. When the pharmacy checked, the physician was not certified as of the morning of 04/25/19. On 04/28/19 at 2:13 PM, the pharmacy revealed the physician was still not certified on the [MEDICATION NAME] Risk Evaluation and Mitigation Strategy (REMS). The physician was still not certified as of 05/07/19 at 5:59 PM. A notation was made that indicated the pharmacy could now dispense, that they were just waiting on current labs. A Dispense Rational Result printed by the pharmacy on 05/09/19 at 5:39 PM, indicated the pharmacy were authorized to dispense the [MEDICATION NAME] to Resident #3. An authorization number was noted. Further review of the April, and (MONTH) 2019 MAR's revealed the resident medication was withheld and continued not to be administered from 04/08/19-05/09/19. Review of text messages between the physician and the Administrator revealed a text from the physician (not dated) that this process has literally taken me probably twelve (12) hours over the last month, (For something that could be done in thirty (30) minutes). Another text dated, 05/09/19, revealed It's done. A text on 05/09/19 at 9:38 AM, revealed, I have done the training and have passed the test but they have not issued the certification yet. My nurse is talking to her now, to which the Administrator responds, she is doing fine though. A text, dated 05/09/19 at 9:49 AM, revealed, Please call the resident's sister and tell her I am trying to get the certification done for that program so that her sister can get his/her medicine. I have spent four hours on the phone with their physician support team this week trying to figure out why the certification is not going through. I have done the training and I have passed the test, but they have not issued the certification yet. Interview with the Pharmacy Director, on 06/07/19 at 1:04 PM, revealed as of 02/28/19, the physician had to be certified in order to prescribe the medication; however, the program allowed for a grace period. He stated Resident #3's Physician had not completed a renewal certification. The Pharmacy Director revealed the website only tells the pharmacy whether a physician is certified and whether the pharmacy can dispense the medication. He stated the pharmacy has to enter laboratory results and information and the system tells them whether or not they can dispense. He revealed the physician's office and facility were notified and fax reminders were also sent to the physician. Interview with the Director of Nursing (DON), on 06/05/19 at 11:00 AM revealed Resident #3 restarted the [MEDICATION NAME] on 05/10/19. Additional interview with the DON on 06/06/19 at 1:54 PM, revealed Resident #3 did not have the [MEDICATION NAME] for a month and ten (10) days. The DON revealed a monthly CBC is required by the pharmacy before filling the medication. The DON stated the pharmacy told her they needed a REM certified physician to prescribe the medication and the resident's physician could not access the website to complete the certification. The DON revealed other physician's in the area were contacted but none of them could or would refill the medication. The DON stated Resident #3 was monitored for behaviors while he/she was not receiving the medication and there were none noted and he/she was seen by Psychiatric provider twice during the time he/she was off of the medication. The DON stated the Physician that had originally prescribed the medication had passed away. Interview with Resident #3's Physician/facility Medical Director on 06/07/19 at 8:50 AM, revealed he does not recall when he was made aware of the need for the REMS certification. He stated he was having trouble with the website and getting the test taken and his certification to go through He revealed he saw the resident recently, in the past two-four (2-4) weeks and there were no concerns with behaviors or side effects. He stated the resident had also been seen by the APRN. Interview with the Administrator, on 06/05/19 at 9:30 AM, revealed the physician for Resident #3 was not able to order the [MEDICATION NAME] because he had to have a special certification which he was working on so that he could prescribe the medication. The facility attempted to get the prescription from a different provider but were unable to. The Administrator revealed she had received several texts from the Physician indicating he was trying to get the certification needed in order to write the prescription. Interview with the Administrator, on 06/05/19 at 9:55 AM, revealed while the resident was off of the medication, he/she did not display behaviors. Interview with the Administrator, on 06/07/19 at 9:18 AM, revealed Resident #3's sister was made aware that there was a problem with getting the [MEDICATION NAME]. The Administrator stated the resident was being monitored by the facility and Psychiatric Services and the sister. The Administrator revealed the facility charts by exception and there was no indication that the resident had behaviors and the resident denied hearing voices. The Administrator stated the resident has been on the medication for years and the Psychiatric Evaluation determined they could increase the residents [MEDICATION NAME] if needed, but that wasn't necessary.

Based on observation, interview, record review and the review of facility policy, it was determined the facility failed to notify the representative of one (1) of eight (8)sampled residents when there was a need to alter the treatment regimen (Resident #3). Resident #3's [MEDICATION NAME] (antipsychotic) was unable to be refilled on 03/31/19, and was withheld on 04/07/19; however, the resident's family was not notified Resident #3 was not receiving the [MEDICATION NAME]. The findings include: Interview with the Administrator on 06/07/19 at 9:18 AM, revealed the facility does not have a policy in regards to family notification. Record review revealed the facility admitted Resident #3 on 02/28/17 with [DIAGNOSES REDACTED]. Review of (MONTH) 2019 physician's orders [REDACTED]. Further review of the notes, revealed on 03/30/19, the Pharmacy requested laboratory tests before filling the medication and the Complete Blood Count was completed by the laboratory on 04/01/19 at 5:12 PM. On 04/01/19, the pharmacy notified the facility the Physician was not certified to write the prescription for the medication. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. In addition, review of a Physician order [REDACTED]. However, further review of the record to include Nurse's Notes documented from 03/31/19 through 05/08/19 revealed there was no documented evidence Resident #3's family member was made aware the medication was not able to be filled on 03/31/19 or the medication was withheld until available on 04/08/19. Interview with Resident #3's sister, on 06/06/19 at 9:25 AM, revealed Resident #3's physician was not certified to rewrite the [MEDICATION NAME] prescription until he obtained the certification. She stated she could not recall what day she was notified about unavailability of the medication but when she came in to see the resident she could tell that she had not had the medication. She reported that the resident had been on the medication for a long time and she could tell when she had not had it. She revealed that the resident heard voices when he/she did not have the medication. Interview with Licensed Practical Nurse (LPN) #1, on 06/20/19 at 4:30 PM, revealed he contacted Resident #1's sister on 04/01/19 to make her aware they had to get labs and that they were out of the [MEDICATION NAME], and the sister came to the facility after the conversation with the nurse. The LPN further stated he called the sister shortly after that date, and discussed the fact that the [MEDICATION NAME] was not available for administration and the sister was upset with him because the resident could not get the medication as ordered. Interview with the Director of Nursing (DON), on 06/05/19 at 11:00 AM, revealed the nurse had notified the sister that the medication was not available on 04/01/19.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure one (1) of seventeen (17) sampled residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan related to surgery wound. Observation of wound care on 08/13/18 revealed staff failed provide wound care in accordance to follow physician orders for wound care and also failed to follow the Comprehensive care plan as written. The findings include: Review of the facility policy, Wound Care, last reviesed (MONTH) 2002 revealed the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation included to verify the Physician's Order for the procedure, review the resident's care plan to assess for any special needs of the resident and assemble the equipment and supplies as needed. Equipment and supplies included to perform the procedure: Dressing material as indicated, Disposable cloths as indicated, Antiseptic, and Personal Protective Equipment. Steps of the procedure include: establish clean field and place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. Wash and dry hands thoroughly. Position resident. As needed, place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. Put on exam glove. Loosen tape and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. Put on gloves. Cleanse and apply treatments as indicated. Dress wound. Mark tape with initials, time, and date and apply to dressing. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. Reposition the bed covers. Make the resident comfortable. Use clean field saturated with alcohol to wipe overbed table. Return the overbed table to its proper position. Wash and dry your hands thoroughly. Record review revealed the facility admitted Resident #24 on 06/02/18 after spending several weeks in a trauma hospital where the resident underwent [REDACTED]. [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #24's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of 9 which indicated the resident was interviewable. Review of Resident #24's Comprehensive Care Plan for Impaired Skin Integrity dated 08/08/18 revealed the skin will remain intact related to the Left Lower Extremity with surgical wounds and splint with an intervention for treatment as ordered Review of Resident #24's Physician Orders dated (MONTH) (YEAR) revealed a wound care order to clean left lower extremity with Normal Saline (NS) and place NS Wet to Dry on the inner aspect of left leg. Wrap with Kerlix and Ace wrap daily. Observation of wound care on 08/13/18 at 9:30 AM to the left and right ankles by Registered Nurse (RN) #1 revealed she placed the clean dressings on the overbed table without cleaning the table or placing down a barrier. She then washed her hands prior to start of wound care and donned gloves. She pulled a pair of scissors from her uniform pocket and immediately started removing the old dressings without cleaning the scissors, then dropped the dressings in the bedside trash receptacle. RN #1 failed to place a barrier under the resident's lower extremities prior to wound care. She then removed her gloves and immediately donned another pair of gloves without washing her hands. RN #1 was then observed to use her dirty scissors to cut a gauze to cover the wet to dry wound and wet the resident's bed with saline that she moistened the gauze dressing with. She then took paper towels and placed them under the resident's feet and failed to wash her hands after applying the dressing. She also failed to clean the overbed table after using it and left the resident with wet bedding after the dressing change. She touched the resident's overbed table and privacy curtain with dirty gloves. The RN then removed her gloves, washed her hands and left the room. The RN left the dirty dressings in the trash receptacle at the resident's bed side. Interview with RN #1 on 08/13/18 at 9:50 AM revealed she was not aware of any concerns with the wound care performed. She stated she may have forgotten something but was unable to remember at the time. She revealed she was not sure what information the facility's policy on wound care and hand washing contained. and was not sure what the resident's care plan said regarding wound care. She also revealed she did not look at the physician orders prior to doing the dressing change. Interview with the Assistant Director of Nursing (ADON)/Infection Control Nurse on 08/13/18 at 10:05 AM revealed she expected staff to use the policy and procedures for wound care and to follow the Comprehensive Care Plan as written. She also revealed that once a month each staff has training, which includes infection control education. Interview with Director of Nursing (DON) on 08/14/18 at 8:28 AM revealed she expected the staff to follow physician orders and care plans. She stated wounds should always be cleaned prior to dressing placement. She revealed handwashing should be completed upon entering the room, when gloves are soiled, when changing gloves and after wound care is completed.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to implement a comprehensive person-centered care plan for one (1) of seventeen (17) sampled residents (Resident #24). Resident #34 was care planned for wound care which included cleaning wound on left lower extremity with Normal Saline (NS); however, observation on 08/13/18 revealed the licensed nurse failed to clean the wound prior to treatment. The findings include: Review of the facility's Comprehensive Care Plans, Standard of Practice, last revised (MONTH) (YEAR) revealed it was the practice of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan should describe the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to resident's exercise of his or her right to refuse treatment. c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations. d. Medically related. g. The resident's goals for admission, desired outcomes, and preferences for future discharge. Record review revealed the facility admitted Resident #24 on 06/02/18 after spending several weeks in a trauma hospital where the resident underwent [REDACTED]. [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #24's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of 9 which indicated the resident was interviewable. Review of Resident #24's Comprehensive Care Plan with Problem Impaired Skin Integrity dated 08/08/18 revealed the skin will remain intact related to the Left Lower Extremity with surgical wounds and splint. Resident has a risk for impaired skin integrity related to resident being bed/chair bound due to non weight bearing status, overweight for height with skin folds. Dependent with mobility. The Goal is for the skin to remain intact with no date noted. Approaches included: Treatment as ordered, assess effectiveness and notify Physician for alternate treatment as needed. Review of Resident #24's Physician order [REDACTED]. Wrap with Kerlix and Ace wrap daily. However, observation of the wound dressing change on 08/13/18 at 9:30 AM, revealed Registered Nurse (RN) #1 did not cleanse the wound with Normal Saline and no cleansing was performed at all to the wound. Interview with RN #1 on 08/13/18 at 9:50 AM revealed she was not aware of any concerns with the wound care performed. She stated she may have forgotten something but was unable to remember at the time. She revealed she was not sure what information the facility's policy on wound care and hand washing contained. She stated she was not sure what the resident's care plan said regarding wound care and she did not look at the physician orders [REDACTED]. Interview with the Assistant Director of Nursing (ADON))/Infection Control Nurse on 08/13/18 at 10:05 AM revealed she expected staff to use the policy and procedures for wound care and to follow the Comprehensive Care Plan as written. She stated each staff has training once a month which included infection control education. Interview with Director of Nursing (DON) on 08/14/18 at 8:28 AM revealed she expected the staff to follow physician orders [REDACTED]. She stated staff should also follow the care plans as written.

Based on interview and review of staff posting, it was determined the facility failed to ensure staffing information was posted in a prominent place readily accessible to residents and visitors and staffing information was accurate and or current. Observation on 08/12/18 (Sunday) at 9:15 AM, revealed a Daily Staffing posted that was dated 08/10/18 (Friday). The findings include: Interview with facility Administrator on 08/14/18 at 11:15 AM, revealed the facility did not have a specific policy related to Nursing Staff Information being posted, but the facility followed the State and Federal guidelines. Observation on 08/12/18 (Sunday) at 9:15 AM, revealed a Daily Staffing posted, dated 08/10/18 (Friday). Interview with Licensed Practical Nurse (LPN) #1 on 08/14/18 at 3:34 PM, revealed staff used to write out the daily staffing by hand and post it daily; however; since the facility went to the computer version Day Shift took over the responsibility. She stated she had never been shown how to complete the staffing in the computer system. She revealed she was under the impression Day Shift was supposed to print out one for Saturday and Sunday, clip them to the metal frame on the wall, near the exit door, next to the copy room; and If there were any changes in the staff assignment the staff on duty would change the numbers by ink pen. She stated she did not feel it was her responsibility to post the staffing as she was never educated on the computer system and she was never instructed to print off the staffing sheet, nor was she instructed to ensure it was posted. Interview with the Director of Nursing (DON) on 08/13/18 at 10:32 AM, revealed the daily staffing information was required to be posted daily. She stated the night nurses were responsible to ensure it was posted every night on their shift for Saturday and Sunday. She revealed the night shift nurse that worked this past Friday night, generally worked days, and possibly could not get into the on shift staffing program and that may have been the possible reason it would not have been posted. She further stated she would have expected either nurse to ensure the most current up to date staffing was posted, for the weekend. Interview with the facility Administrator on 08/13/18 at 1:32 PM, revealed the facility recently got tagged by their corporate nurse for not posting the staffing daily during the week, and she had only addressed it with the day shift weekly nurses, and not with the night shift staff, which still seems to be the problem. The Administrator stated, the night nurses had not been educated on the computer system and weekends were still a problem. She stated the nurses on the weekend do not have access to On Shift desk top (computer system); however, they could have written one by hand to ensure it was posted.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents receive care to prevent pressure ulcers for one (1) of six (6) sampled residents (Resident #1). Staff failed to conduct weekly assessment and failed to implement interventions after Resident #1 was identified with an unstageable pressure ulcer to the sacrum. The findings include: 24 hour post admission skin protocol 1. Complete head to toe skin assessment. 2. Document any skin concerns on skin assessment. 3. If skin is intact do nothing more, if not complete wound assessment. 4. Notify family and physician of any skin concerns. 5. If system does not allow to document skin condition then you must make nurse's note on skin condition. Weekly skin assessment 1. Complete head to toe skin assessment on each resident weekly. 2. Document any skin concerns on skin assessment. 3. If skin is intact do nothing more, if not complete wound assessment. 4. Notify family and physician of any skin concerns. 5. If system does not allow to document skin condition then you must make nurse's note on skin condition. 1. Closed record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the resident was admitted from a local Rehab Hospital status [REDACTED].#1's cognition as intact with a Brief Interview of Mental Score (BIMS) sore of fifteen (15) which indicated the resident was interviewable. Further review of the MDS assessment revealed the resident was at risk for developing pressure ulcers and had no breakdown of skin on admission. Review of Resident #1's Admission Skin Assessment, dated [DATE], revealed the resident had no skin breakdown and the skin was intact. Review of Interim Admission Care Plan, dated [DATE] revealed Resident #1 was At Risk for Impaired Skin with goals for the resident to remain free from new areas of skin breakdown over the next thirty (30) days. Further review revealed interventions to complete weekly skin assessments, and report changes in skin status to Physician. Review of the Interim Care Plan for Self-care Deficit due to back pain, dated [DATE], with a goal to have reduced risk regarding complications related to decreased mobility and will be appropriately groomed and dressed; however, there were no interventions. Review of the Daily Care Guide, not dated, revealed a Certified Nurse Aide (CNA) Care Plan to provide assistance as follows: transfer/bed mobility-assistance of two (2) persons physical assistance and toilet-two (2) persons physical assist. Review of the Weekly Skin Assessment, dated [DATE], revealed the document was blank and did not indicate if the resident's skin was intact or not. Review of a Skin Assessment, dated [DATE] revealed Resident #1's skin was not intact with existing skin breakdown; however, interview with Registered Nurse (RN) #1 on [DATE] at 3:30 PM, revealed she did not observe the wound until [DATE]. RN #1 thinks she must have hit the wrong information in the Wound Program. Review of a Wound Assessment, dated [DATE], revealed an unstagable decubitus ulcer with measurements of 8.0 centimeters (cm) by 7.8 cm by 0.1 cm. Slough, eschar, and moderate serous drainage noted. Distinct border definition. Review of the Comprehensive Care Plan for impaired skin integrity, dated [DATE], revealed interventions for weekly skin checks, promote adequate hygiene and nutrition, dietician consult, physical therapy screen as needed for positioning concerns, pressure redistributing mattress or wheelchair cushioning, treatment as ordered, assess effectiveness and notify physician if alternate treatment is needed, and notify physician, family, responsible party of changes as needed. Further review revealed a Care Plan for Self Care Deficit, dated [DATE], due to limited mobility due to pain with movement, with interventions to encourage resident to participate to ability, set up, cue and assist as needed with hygiene, PT/OT as needed, provide weight bearing assist with peri hygiene after BM, getting legs in and out of bed, keep walker within reach, adjust daily routine as needed to promote independence, education provided on the turning/reposition and activity. Review of a Nursing Note, dated [DATE] at 12:31 PM, revealed the resident was instructed on the need to keep off of back and the need to get out of bed. However, there was no evidence the facility addressed any changes to the resident's mattress to increase the ability to relieve pressure while in bed or the fact that according to the MDS assessment, Daily Care Guide, the resident required the assistance of two (2) staff for bed mobility. Review of a Service Document dated [DATE], revealed a flotation mattress was placed on the bed on [DATE] which was thirteen (13) days after the large unstagable pressure ulcer was identified on the resident's sacrum and two (2) days prior to hospitalization . Review of the Wound Assessment, dated [DATE], revealed the wound had not changed and still measured 8.0 cm by 7.8 cm by 0.1 cm with eschar, sloughing moderate serous drainage. Further review revealed the next skin assessment was not completed until [DATE] (one day late), with no new areas identified and no further skin assessments were conducted prior the the resident transfer to the hospital on [DATE]. Review of the Nurse's Notes revealed, on the morning of [DATE], Resident #1 became lethargic and hypotensive. The facility physician was called and the resident was transferred to a local hospital. Review of hospital records dated [DATE] revealed the Wound Care Nurse assessment at 4:08 PM revealed the resident had an unstagable sacral wound with undermining around the edges of the wound with measurements of 6 cm by 8.5 cm by 5.5 cm. She described large amount of eschar and sloughing hanging from wound. Also there was a foul odor with increased drainage. Further review of the Discharge Summary dated [DATE] by the physician revealed the resident expired with [DIAGNOSES REDACTED]. Interview with Resident #1's hospital physician on [DATE] at 11:30 AM revealed the resident was most likely septic from the wound on sacrum. He stated the growth from the wound culture on the sacrum grew a gram negative rod Morganella which most likely was due to wound contamination. He revealed the decubitus ulcer on the sacrum was unstagable and needed debrieding to enhance wound healing. He further stated the resident should have had interventions to make sure this did not have a bad outcome. Interview with the Wound Care Nurse at the local hospital on [DATE] at 12:30 PM revealed Resident #1's sacral wound were terrible especially the sacral wound. She revealed there was 75% of the wound was necrotic tissue and 25% of wound was pale pink. It was unstagable and very foul smelling. She revealed she was very concerned that this resident had not been on a flotation mattress to alleviate pressure. Interview with CNA #1 on [DATE] at 2:45 PM revealed she had cared for Resident #1 and resident was very smart and aware of what was going on. She revealed she had first saw the sacral wound and was about three inches round and appeared bruised. She revealed it was not open. She also revealed she told someone but doesn't remember who she told. She cannot recall the date she first saw the wound or when she saw drainage coming from wound. She also revealed the resident required minimum assistance at beginning of admission and became at times totally dependent on staff for mobility and transfers. Interview with CNA #5, [DATE] at 12:50 PM, revealed when first admitted Resident #1 needed minimal assistance in bed but became more dependent with care and needed two (2) people for transfers and moving in bed. Interview with CNA #7 on [DATE] at 10:10 AM revealed Resident #1 needed minimum assistance for personal care and mobility. As time went by, he/she became more dependent for care and at times would be dependent for mobility and toileting. She also related Resident #1 was very particular about his/her care when first admitted . He/She was adamant on getting better and going home. She also revealed something happened during his/her stay and he/she seemed to give up. She also revealed she did not know what had happened. She related this information to her charge nurse about his/her care. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 3:40 PM revealed she had seen the wound on the [DATE]. She stated the wound was open and had a foul odor. She revealed it had sloughing and drainage. She could not answer why a wound assessment was not done on [DATE]. Interview with the Director of Nursing on [DATE] at 1:00 PM revealed she did not believe the wound appeared until [DATE], however, she could not explain the other interviews with staff. She also revealed she believed the facility had done everything that could be done for Resident #1. Interview (Post Survey) with the MDS Coordinator on [DATE] at 9:13 AM revealed she had completed Resident #1's Admission MDS and revealed the resident needed extensive assist with mobility and transfers. She stated she observed the resident requiring assistance with placing his/her feet and legs on the bed when lying down in bed. She also confirmed per the Nursing Admission assessment dated [DATE], the resident did not have any skin breakdown and that she uses the Nursing Admission Assessment to complete the skin condition section of the MDS. Interview with the Administrator on [DATE] at 1:30 PM revealed the floatation mattress for Resident #1's bed was ordered earlier but she could not give a specific date ordered. The invoice revealed the mattress was placed on [DATE] which was thirteen (13) days after the wound was identified.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to prevent the spread of infection by properly performing hand hygiene when performing wound dressing changes for two (2) of six (6) sampled residents (Resident #2 and #3). The findings include: Review of the Infection Control Program Standard of Practice policy updated on 11/2016 revealed the Standard of Practice is to prevent the spread of infection and provide appropriate education for staff and residents concerning infection control. Hand washing, clinical equipment disinfecting, and isolation guidelines are included and intended to meet standards of CDC guidelines for long term care. Review of the Wound Care policy dated 2001 and Revised January 2002 revealed staff should establish a clean field and place all items to be used during procedure on the clean field then wash and dry hands thoroughly before providing any care. The staff should then position resident, put on exam glove prior to loosening the tape and removing the dressing, and then pull glove over dressing and discard into appropriate receptacle. The staff then should proceed to wash and dry hands thoroughly, put on gloves, cleanse and apply treatments, dress wound, and discard disposable items into the designated container and discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Staff should remove disposable gloves and discard into designated container, then wash and dry hands thoroughly. Staff should then reposition the bed covers and make the resident comfortable. The staff also should then use clean field saturated with alcohol to wipe over the bed table, return the over the bed table to its proper position, and wash and dry hands thoroughly. 1. Record review revealed the facility admitted Resident #2 on 03/19/14 with [DIAGNOSES REDACTED]. Observation of a wound assessment and wound dressing change for Resident #2 on 09/20/17 at 9:30 AM revealed the Director of Nursing (DON) failed to follow the facility policy related to infection control when providing wound care. The DON gathered her supplies and placed them on the over the bed table without cleaning the table. She donned gloves without washing her hands and removed the resident's clothing and the old dressing. She then applied another pair of gloves without washing her hands. The DON then reached with her gloved hand into her pocket and retrieved a measurement guide and measured the wound. Taking her measuring guide, she folded it length wise, inserted it into the wound, took the measurement, then placed the contaminated measurement guide directly on the over the bed table. She then placed another pair of gloves on and sprayed the wound with wound cleanser. She patted the wound dry and applied the dressing. She then took off her gloves and did not wash her hands, and pulled the privacy curtain away from resident. She picked up the supplies from the bedside table but neglected to clean the table. She also straightened the bedding and resident before washing her hands. 2. Record review revealed the facility admitted Resident #3 on 02/10/17 with [DIAGNOSES REDACTED]. Observation of a wound assessment and wound dressing change for Resident #3 on 09/20/17 at 10:05 AM, revealed the DON did not clean the bedside table before setting the supplies on it. The DON washed her hands, put on gloves, then removed the old dressing. After removing her gloves, the DON did not wash her hands. She replaced her gloves and proceeded to cleanse the wound with wound cleanser. She then removed her gloves and washed her hands, applied clean gloves and applied the dressing. After the dressing was complete, she picked up the supplies left on the bed side table and threw them in trash but failed to clean the bedside table. She then picked up the resident's glasses and placed them on the bedside table. She pulled the privacy curtain back, still wearing the soiled gloves and then removed the dirty gloves and washed her hands. Interview with the DON, on 09/21/17 at 1:00 PM, revealed she should follow the wound care policy and the infection control policy. Interview with the Administrator on 09/28/17 at 1:00 PM revealed she expects her staff to follow the wound care and infection control policy related to wound care.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide services by qualified persons in accordance with the resident's written plan of care for one (1) of six (6) sampled residents (Resident #1). Resident #1 was care planned to receive weekly skin assessments; however, licensed staff failed to conduct a skin assessment on 08/01/17 and 08/23/17. In addition, licensed staff conducted the skin assessment that was due on 08/15/17 on 08/16/17 (one day late). The findings include: Review of the facility policy Comprehensive Care Plans Standard of Practice undated revealed, It is the practice of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. Closed record review revealed the facility admitted Resident #1 on 07/25/17 with [DIAGNOSES REDACTED]. The resident was admitted from a local Rehab Hospital status [REDACTED]. Review of the Interim Care Plan for at risk for impaired skin, dated 07/25/17, revealed an intervention for staff to conduct a weekly skin assessment; however, review of the weekly skin assessments revealed a skin assessment, dated 08/01/17, that did not indicate if the resident's skin was intact or not. Further review revealed a skin assessment that was supposed to be completed on 08/15/17 was not completed until 08/16/17, and there was no documented evidence a skin assessment was completed on 08/23/17. The resident was sent to the hospital on [DATE]. Interview with Registered Nurse (RN) #1, 09/25/17 at 3:30 PM, revealed she was the nurse who should have completed the skin assessments for Resident #1. She stated the skin assessments should be completed weekly. She also revealed the Skin Assessment Program in the computer is hard to maneuver and she has made mistakes on the program. She revealed she could not recall if she had completed the skin assessment on 08/01/17 or not. Interview with the Director of Nursing (DON), on 09/26/17 at 3:17 PM, revealed Skin assessments are to be completed weekly, no exceptions. Interview with the Administrator, on 09/28/17 at 1:30 PM, revealed she expected there to be Weekly Skin Assessments. She stated if the skin was not intact then a wound assessment should be completed.

Based on record review, interview and facility policy review, the facility failed to accurately and completely document the care and services provided in accordance with current professional standards and practices related to two (2) missing and incorrect documentation of weights and only two (2) skin assessments from onset of wound date 08/09/17 to transfer date of 08/24/17 for one (1) resident (Resident #1) from sampled size of six (6). The findings include: Review of the facility Weight Policy, last updated September 2015, revealed the Process of Weights and nutritional status are monitored by the Weight Committee and the Consultant Dietitian. The Director of Nursing (DON) or designee is responsible to see that weights are obtained regularly for all residents. Any weights reflecting possible medical condition changes should be brought to the attention of the supervisor immediately and Interact processes to be completed as needed. Each week the weight history log, Weight Change Alert and monthly weight record from the electronic health record must be incorporated to provide necessary information needed for committee discussion. The Facility Registered Dietitian recommendations are to be reviewed weekly during the Weight Variance Meeting and any deviation should be discussed and documented. Resident weights will be obtained and monitored as follows: 6. All admission heights and weights must be obtained and recorded in the electronic health record at the time of admission by the admitting nurse or designee. 7. The weight will be verified by the designated staff member assigned to weights. 8. New admissions/readmissions: Weekly weights times 4 weeks. 9. Thereafter, monthly weights will be obtained by nursing and entered into the electronic health record. 14. Weekly weights are to be entered into the electronic health record and reviewed by the Weight Variance Committee until variance issues have stabilized. Review of the Weekly Skin Assessment Protocol (undated) revealed: 1. Complete head to toe skin assessment on each resident weekly. 2. Document any skin concerns on skin assessment. 3. If skin is intact do nothing more, if not complete wound assessment. 4. Notify family and physician of any skin concerns. 5. If system does not allow to document skin condition then you must make nurse's note on skin condition. Interview with the Administrator on 09/25/17 at 9:30 AM revealed she did not have a documentation policy. She stated, the nurses are to chart what is seen. Also the Certified Nurse Aides (CNA) are to use the Stop and Watch form for anything new. Record review revealed the facility admitted Resident #1 on 07/25/17 with [DIAGNOSES REDACTED]. Review of the Skin Inspection Report from Resident #1's record on 08/01/17, the skin status was missing. The skin status on 08/08/17 stated, skin not intact-Existing; however, there was no documentation of a wound assessment. The skin status for 08/16/17 revealed a skin status of skin intacthowever, review of the first Wound Assessment Report, dated 08/09/17 and 08/14/17, revealed Resident #1 had an Unstageable sacral wound measuring 8.0 centimeters (cm) by 7.8 cm by 0.1 cm. Review of Resident #1's weekly weight chart revealed weekly weights were obtained on 08/01/17 and 08/22/17; however, there were no weekly weights for 08/08/17, 08/15/17 or 08/29/17. Interview with Registered Nurse (RN) #1 on 09/26/17 at 2:45 PM revealed she had done three skin assessments on the resident and had failed to chart properly. She revealed she was relatively new to the facility and the skin assessment program was difficult to maneuver through. Interview with the Director of Nursing (DON), on 09/21/17 at 8:50 AM revealed when a resident is first admitted to the facility, the resident should have weekly weights times four (4) weeks, then monthly if stable. Interview with the DON on 09/26/17 at 3:17 PM revealed Skin and Wound Assessments were to be completed with no exceptions. She stated the nurses soul do the skin assessments weekly and chart accurately all information found on skin.

Based on interview, record review and a written statement, it was determined the facility failed to obtain laboratory services to meet the needs of the resident for two (2) of (15) fifteen sampled residents (Resident #5 and Resident #9). The facility failed to obtain Physician Ordered labs for Resident #9 in March 2017 and Resident #5 in May 2017. The findings include: Review of the Administrator's written statement provided on 06/08/17 revealed there was no policy available related to physician orders [REDACTED]. 1. Record review revealed the facility admitted Resident #9 on 09/14/16 with [DIAGNOSES REDACTED]. Review of a Telephone Physician Order, dated 03/05/17, revealed to obtain a Complete Blood Count (CBC), Basic Metabolic Panel (BMP)), and Glycosylated Hemoglobin (A1c) every three (3) months; a Complete Metabolic Panel (CMP) and Lipid Profile every six (6) months; and a ([MEDICAL CONDITION] Stimulating Hormone (TSH) with free [MEDICATION NAME] (T4) every year. However, review of Laboratory Results for Resident #9 revealed the last A1c and Lipid Panel was obtained on 09/29/16, the last CMP was obtained on 11/08/16, and the last BMP was recorded on 11/11/16. There were no laboratory Reports that indicated any labs were obtained in March 2017. Review of Laboratory Calendar revealed there was no documented evidence any labs were obtained for Resident #9 for the month of March 2017 per physician order. 2. Record review revealed the facility admitted Resident #5 on 08/01/16 with [DIAGNOSES REDACTED]. Review of the June 2017 Physician order [REDACTED]. However, review of Resident #5's Laboratory Results revealed there was no documented evidence the CBC and BMP was obtained in May 2017. Interview with Registered Nurse (RN) #1, on 06/07/17 at 1:45 PM, revealed after the RN reviewed Resident #5's record she stated she was unable to find any documented evidence a CBC and BMP was obtained. RN #1 stated labs are kept up with in a lab book and after reviewing the lab book she stated she did not find Resident #5's name logged on any of the thirty-one (31) days of May 2017 to have a CBC and BMP obtained. Interview with the Assistant Director of Nursing (ADON) after reviewing the Lab Calendar, on 06/08/17 at 11:05 AM, 2:00 PM and 4:00 PM, revealed she was amazed Resident #9's labs were not put on the calendar. The ADON stated she expected nurses to follow the physician orders. Interview with the Director of Nursing (DON), on 06/08/17 at 3:40 PM, 5:00 PM, and 5:15 PM revealed the physician orders [REDACTED].

Based on interview, record review, and review of hospital emergency room (ER) records, it was determined the facility failed to provide adequate assistance for transfers and assistive devices to prevent accidents for one (1) of three (3) sampled residents (Resident #1). Resident #1 was assessed and care planned for the use of a mechanical lift with the assistance of two (2) staff for transfers; however, on 12/11/16 Certified Nurse Aide (CNA) #1 transferred the resident without another staff's assistance and failed to ensure the resident's wheelchair back was in a full upright position. The resident was not properly positioned in the wheelchair when caused the wheelchair to flip backwards with the resident in it onto the floor. The resident sustained [REDACTED]. The findings include: Interview with Director of Nursing (DON) on 01/11/17 at 11:25 AM, revealed the facility does not have a policy to address falls but the facility follows State and Federal Guidelines. Closed record review revealed the facility admitted Resident #1 on 10/27/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/08/16, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of thirteen (13) which indicated the resident was interviewable. Further review of the MDS revealed the resident required extensive assistance of two (2) persons for transfers. Review of Resident #1's Falls Risk Data Sheet, dated 12/11/16, revealed the facility assessed this resident as a high risk for falls. Review of Resident #1's Comprehensive Care Plan, dated 08/18/16, revealed the resident requires assistance of two (2) staff for transfers with a mechanical lift. Review of a Nurse's Note, dated 12/11/16 at 12:47 PM, revealed Resident #1 was observed in floor, medical doctor notified and resident sent to emergency room for evaluation and treatment. Review of the facility's Investigative Report, dated 12/11/16, revealed Resident #1 fell from wheelchair and the fall was unwitnessed. Further review revealed an intervention was put in place to add rear anti-tippers to Resident #1's wheelchair Review of the emergency room (ER) Report, dated 12/11/16, revealed Resident #1 was seen in the ER due to hitting head during a fall. A Computed Topography (CT) scan was completed with no injury identified and the resident was transferred back to the Nursing Home. Interview with CNA #1, on 01/11/16 at 10:57 AM, revealed she used a mechanical lift by herself and transferred Resident #1 to his/her wheelchair with the wheelchair reclined. She stated she knew Resident #1 was supposed to have assistance of two (2) staff for transfers and did not have a reason as to why she did not have another staff to assist her with the mechanical lift transfer of Resident #1. She revealed she transferred Resident #1 to his/her reclined wheelchair and as she turned around to move the mechanical lift, she heard a noise and when she looked the wheelchair had tipped over backwards with the resident in it. She further stated she believed Resident #1 fell from the wheelchair because the wheelchair back was reclined to far back and she was not able to place the resident in the chair properly due to doing the transfer by herself. Interview with the Physical Therapist Assistant (PTA) Rehab Director, on 01/11/16 at 08:20 AM, revealed therapy had set Resident #1 up with a reclining wheelchair, but had failed to do a therapy to nursing communication related to the appropriate amount to recline Resident #1's wheelchair that would be safe for this resident. She stated it was not safe to have Resident #1's wheelchair reclined any when transferring this resident to the wheelchair. She revealed she would have expected therapy to have done a therapy to nursing communication for Resident #1's reclining wheelchair. She stated therapy was going to immediately start inservicing nursing related to reclining wheelchairs and the safety of them. Interview with Occupational Therapist (OT) #1, on 01/11/17 at 9:25 AM, revealed she did not remember doing a therapy to nursing communication after discharging the resident off of the therapy caseload. She stated a communication is standard and should have been done so nursing would have known not to have Resident #1's wheelchair reclined any during a mechanical lift transfer to the reclining wheelchair. She also stated due to Resident #1's lower extremity amputation and poor trunk control he/she had balance issues and the likely-hood of Resident #1 flipping backwards in the reclined wheelchair if it was reclined when he/she was being transferred to it would be very possible. Interview with the Director of Nursing (DON), on 01/11/16 at 11:25 AM, revealed she expected all nursing staff to know it takes a minimum of two (2) staff to perform any mechanical lift transfer and any less would be unsafe and inappropriate. She stated it was unacceptable CNA #1 did not have at least one (1) more staff assist her with the transfer for Resident #1 on the day he fell from his/her wheelchair. Interview with the Administrator, on 01/11/17 at 9:00 AM, revealed she would have expected all nursing staff to know a mechanical lift takes a minimum of two (2) staff to assist in a transfer for safety reasons. She stated it was unacceptable CNA #1 did a mechanical lift transfer of Resident #1 by herself. She revealed she would have expected therapy to have done a therapy to nursing communication related to Resident #1's reclining wheelchair to explain the safety of the use of the reclining wheelchair and how far back it could be safely reclined for this particular resident.

Based on interview, and record review it was determined the facility failed to provide services in accordance with each resident's written plan of care for one (1) of three (3) sampled residents (Resident #1). Resident #1 was care planned for the use of a mechanical lift with the assistance of two (2) staff for transfers; however, on 12/11/16 Certified Nurse Aide (CNA) #1 transferred the resident without another staff's assistance. When the CNA placed the resident in the wheelchair, the wheelchair flipped backwards due to poor positioning of the resident in the wheelchair due to no assistance from another staff. The resident hit his/her head with no injury noted. The findings include: Interview with Director of Nursing (DON) on 01/11/17 at 11:25 AM, revealed the facility does not have a policy to address care plans but the facility follows State and Federal Guidelines. Closed record review revealed the facility admitted Resident #1 on 10/27/15 with [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan, dated 08/18/16, revealed the resident required the assistance of two (2) staff for transfers with a mechanical lift; However, interview with CNA #1, on 01/11/16 at 10:57 AM, revealed she transferred Resident #1 with a mechanical lift to the wheelchair on 12/11/16, but without the assistance of another staff. She stated when she turned around to move the mechanical lift, the wheelchair flipped backwards with the resident in it. CNA #1 stated she believed Resident #1 fell from the wheelchair because the wheelchair was reclined to far back and she was not able to place the resident in the chair properly due to doing the transfer by herself. She revealed she knew she was supposed to have assistance of another staff for transfers and did not have a reason as to why she did not have another staff to assist her with the mechanical lift transfer of Resident #1. Review of the emergency room (ER) Report, dated 12/11/16, revealed a Computed Tomography CT) scan was completed with no injury identified and the resident was transferred back to the Nursing Home. Interview with the Director of Nursing (DON), on 01/11/16 at 11:25 AM, revealed she expected all nursing staff to follow the care plans and it was unacceptable to disregard the interventions. Interview with the Administrator, on 16 at 1/11/17 at 9:00 AM, revealed she expected all nursing staff to follow the care plans.

Based on interview, record review and review of the facility's policy and procedure it was determined the facility failed to follow its policy and procedure related to clarification and accurately transcribing physician's orders [REDACTED].#14). The facility failed to ensure an order for [REDACTED]. On 02/06/14, Resident #14 was identified as having a volume depletion was a high sodium and low potassium level. The physician ordered [MEDICATION NAME] five and one-half percent (5 1/2%) Normal Saline (NS) with 10 milliequivalent (meq) of Potassium (K) at 150 cc/hr (cubic centimeters per hour) after the current bag of NS had completed infusing. However, the order did not specify how much or for how long to infuse the [MEDICATION NAME] 5 1/2 percent NS and the licensed staff failed to clarify the order to include the amount of fluid or the duration to infuse the fluids. The licensed staff infused only one bag of the fluid from 02/06/14-02/07/14. On 02/08/14, the resident was directly admitted to the hospital with [REDACTED]. In addition, the facility failed to transcribe an order for [REDACTED]. The findings include: Review of the the facility's policy and procedure titled, New Orders for Non-Controlled Substances, not dated, revealed the facility should ensure all resident information is complete and accurate, has been reconciled and is verified by Physician/Prescriber before faxing or transmitting orders to the pharmacy. The facility should ensure medication orders include medication name, strength, dose, route, frequency, indication for use (to reduce medication errors), and stop order, or administration parameters. Once a Physician/Prescriber has signed the monthly order, a new medication order cannot be added. In this situation, an interim order form or telephone order form should be completed for additional medication orders. Record review revealed the facility admitted Resident #14 on 07/01/12 with [DIAGNOSES REDACTED]. Review of a Laboratory Report, dated 02/06/14, revealed Resident #14's Blood Urea Nitrogen (BUN) was 76 mg/dl (normal 7-22); Sodium was 167 mmol/l (normal 136-146); and, Potassium was 2.8 mmol/l (normal 3.3-5.5). Review of the physician's orders [REDACTED]. The order did not specify how much or for how long to infuse the [MEDICATION NAME] 5 1/2 percent NS. Further review of the physician's orders [REDACTED]. Interview with Licensed Practical Nurse (LPN) #4, on 02/22/14 at 11:00 AM, revealed on 02/06/14 she received an order from the physician to change the intravenous fluids from NS to D 5 1/2 NS with 10 meq of K to begin after the current bag of IV fluids infused due to a laboratory report that showed the resident's potassium was depleted. The LPN revealed the resident received one (1) bag of the D 5 1/2 meq with K which was administered on 02/06/2014. LPN #4 stated she failed to clarify the total amount of fluids to infuse or the duration of the order with the resident's physician. Review of the Nurse's Notes, dated 02/08/14 at 10:28 PM, revealed the resident's son spoke to the nurse stating he wished to speak to the resident's physician. The nurse called the physician and gave the phone to the son. The resident was very lethargic and the following vital signs were obtained: temperature: 97.6 degrees Fahrenheit (F)(normal 97.5), heart rate 101 (normal 80s), respirations 20 (normal 20) and blood pressure 130/78 (normal around 172/74) and a oxygen saturation level of 92 % (normal 95-96 %). The physician gave an order to direct admit the resident to the hospital. Interview, on 02/20/14 at 12:42 PM, with Resident #14's family member revealed Resident #14 had IVs ordered due to his/her declining status on Wednesday, 02/05/14; and, when they visited him/her on 02/07/14, the IV had been discontinued. The family member stated he/she phoned the physician on 02/08/14 to inform him of Resident #14's status and was told that was why the IV fluids had been ordered. The family member stated he/she informed the physician that Resident #14 had not had an IV since 02/06/14 and the resident had only received the IV fluids for 24 hours. The family member stated the physician ordered the resident to be directly admitted to the hospital. Interview with Licensed Practical Nurse (LPN) #4, on 02/22/14 at 11:00 AM, revealed the physician ordered NS IV at 75 cc/hr per pump x three (3) liters; and, on 02/06/14 the physician changed the order to NS to D 5 1/2 NS with 10 meq K to begin after the current bag of IV fluids infused. LPN #4 stated she failed to clarify the duration of the order with the resident's physician and only infused one bag of NS D 5 1/2 NS with 10 meq. of K. Review of the hospital's History and Physical, dated 02/08/14, revealed Resident #14 was admitted to the hospital on [DATE] with an impression of Severe Electrolyte Disturbance with a serum sodium of 177 mmol/l indicating Dehydration. Interview with the Physician, on 02/21/14 at 11:00 AM, revealed he had ordered D 5 1/2 NS with 10 meq of K and had intended for the fluids to be continuous. He stated he would have expected the nurse to clarify the order before discontinuing the fluids especially due to the resident's already fragile state. Interview with the Director of Nursing, on 02/21/14 at 9:30 AM, revealed LPN #4 should have clarified the order to ensure the correct total amount of fluids were administered or the fluids were administered for the intended duration. Interview with the Administrator, on 02/22/14 at 9:40 AM, revealed he expected the nurse to clarify an order that did not specify an end date. 2. Further review of Resident #14's November 2013 Physician orders [REDACTED]. Review of a Psychiatric Follow-up Evaluation, dated 10/31/13, revealed a dose reduction was recommended to reduce the [MEDICATION NAME] to 25 mg at 3:00 PM and 50 mg at bedtime. Review of physician's orders [REDACTED]. Further review of the November 2013 Medication Administration Record [REDACTED]. Record review revealed Resident #14 was admitted to the hospital on [DATE] and was readmitted to the facility on [DATE]. Review of the hospital physician's orders [REDACTED]. However, review of the facility's physician order [REDACTED]. Review of the December 2013, January and February 2014 physician orders [REDACTED]. Interview with the DON, on 02/22/14 at 1:40 PM, revealed the nurse was supposed to transcribe the readmission orders [REDACTED]. In addition, the Pharmacist should review the medications on a monthly basis and ensure the orders had been transcribed correctly. She stated she did not know how this could have happened. Interview with the Administrator, on 02/22/14 at 9:40 AM, revealed it was his expectation for two (2) nurses to sign off on the admission/readmission orders [REDACTED]. Interview with the Physician, on 02/21/14 at 11:00 AM, revealed he had ordered the gradual dose reduction and he would have expected the facility to follow the orders correctly.

Based on interview, record review and review of the facility's policy and procedure it was determined that the facility failed to ensure one (1) of fourteen (14) sampled residents (Resident #14) was free of significant medication errors related to intravenous (IV) fluids not administered for the correct amount; and, an incorrect dose of [MEDICATION NAME] (antidepressant) administered for three (3) months. On 02/05/15, Resident #14 began showing symptoms of an infection. The physician was made aware and orders were received to infuse three (3) liters of Normal Saline (NS) intravenously. On 02/06/14, laboratory results were received that indicated Resident #14's sodium and potassium were at critical levels. The physician was notified and orders were received to infuse [MEDICATION NAME] five and a half percent (D 5 1/2%) NS with 10 milliequivalent (meq) of Potassium (K) at 150 cc/hr after current bag of IV fluids was infused. The physician's order did not specify the total amount or duration for infusing the intravenous fluids, and the nurse failed to clarify the order to ensure the correct amount of intravenous fluid was infused. Resident #14 received one (1) liter of D 5 1/2% NS. On 02/08/14, the physician was made aware by the family that IV fluids had not been administered since 02/06/14. The physician gave an order to have the resident directly admitted to the hospital. Resident #14 was admitted to the hospital and diagnosed with [REDACTED]. The findings include: Review of the facility's policy and procedure titled, New Orders for Non-Controlled Substances, not dated, revealed the facility should ensure all resident information is complete and accurate, has been reconciled and is verified by the Physician/Prescriber before faxing or transmitting orders to the pharmacy. The facility should ensure medication orders include medication name, strength, dose, route, frequency, indication for use (to reduce medication errors), a stop order, or administration parameters. Once a Physician/Prescriber has signed the monthly order, a new medication order cannot be added. In this situation, an interim order form or telephone order form should be completed for additional medication orders. 1. Record review revealed the facility admitted Resident #14 on 07/01/12 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/19/14 revealed the facility assessed Resident #14 to have severe cognitive impairment. Review of the Nursing Notes, dated 02/05/14 at 4:56 PM for 8:30 AM, revealed Resident #14 was moaning when touched, unresponsive to name, skin was warm to touch and lung sounds were diminished. The resident was very lethargic. There was a greenish discharge noted from the resident's eyes. The physician was notified and orders were received for an antibiotic intramuscularly times one (1), an antibiotic orally daily, a urinalysis (UA) and culture and sensitivity (C & S). The resident's family was made aware. Further review of the Nurse's Notes, dated 02/05/14 at 7:26 PM, and a physician's order, dated 02/05/14, revealed orders were received to start intravenous fluids of NS at 75 ml/hr per pump times three (3) liters. Review of the Nurse's Notes, dated 02/06/14 at 7:03 AM, revealed the resident continued to moan, was non-responsive to name, respirations were diminished and a congested cough was noted at times. At 8:00 AM, the son was at the bedside and it was difficult to arouse the resident to eat breakfast. The physician was notified and orders were received for a Complete Blood Count (CBC) and Basis Metabolic Profile (BMP). At 2:59 PM, the lab results were received and there were critical values for a high sodium and low potassium. Review of a Laboratory Report, dated 02/06/14, revealed Resident #14's Blood Urea Nitrogen (BUN) was 76 milligrams/deciliter (mg/dl) (normal 7-22); Sodium was 167 millimoles per liter (mmol/l) (normal 136-146); and, Potassium was 2.8 mmol/l (normal 3.3-5.5) Review of a Physician's Order, dated 02/06/14, revealed an order for [REDACTED]. Further review revealed no documented evidence the licensed staff clarified the order to ensure the resident received the intended amount of fluids the physician wanted to order. Further review of the Nurse's Notes, dated 02/07/14 at 5:33 AM, revealed the bag of 1/2 NS with 10 meq of Potassium had infused and the IV was converted to a [MEDICATION NAME] lock. Review of the Nurse's Notes, dated 02/08/14 at 10:22 PM for 5:30 PM, revealed Resident #14's son wanted to speak to the physician. The nurse called the physician and the son explained to him about the resident's IV fluids. The physician ordered the resident to be sent to the hospital as a direct admission. Interview with Resident #14's Family Member, on 02/20/14 at 12:42 PM, revealed Resident #14's physician had ordered the IVs due to the resident's inability to take in fluids and his/her declining status; on Wednesday, 02/05/14; and when they visited him/her on 02/07/14, the IV had been discontinued. The family member stated they phoned the physician on 02/08/14 to inform him of Resident #14's status and was told that was why the IV fluids had been ordered. The Family Member revealed after they spoke with the physician, the physician ordered for the resident to be admitted to an acute care hospital. The Family Member stated Resident #14 was discharged for m the acute care hospital to Hospice on 02/19/14 and he/she was receiving comfort measures only. Review of the hospital History and Physical, dated 02/08/14, revealed Resident #14 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Interview with Licensed Practical Nurse (LPN) #4, on 02/22/14 at 11:00 AM, revealed Resident #14 normally went to the dining room and normally would eat and drink approximately seventy-five (75) percent of his/her meals. The LPN stated on 02/05/14, the resident was difficult to arouse and had a greenish drainage coming from both eyes. The LPN stated the physician ordered NS IV at 75 cc/hr per pump x three (3) liters; and, on 02/06/14 the physician changed the order from NS to D 5 1/2 NS with 10 meq K to begin after the current bag of IV fluids infused. LPN #4 stated she failed to clarify the duration of the order with the resident's physician and only infused one bag of NS D 5 1/2 NS with 10 meq. of K. Interview with the Director of Nursing, on 02/21/14 at 9:30 AM, revealed she expected LPN #4 to have clarified the order to obtain the intended duration of the infusion of the IV fluids. Interview with the Physician, on 02/21/14 at 11:00 AM, revealed he ordered D 5 1/2 NS with 10 meq of K and had intended for the fluids to be continuous. He stated he would have expected the nurse to clarify the order before discontinuing the fluids especially due to the resident's already fragile state. Interview with the Administrator, on 02/22/14 at 9:40 AM, revealed he expected the nurses to clarify orders when they do not state the duration or total amount of the medication to be administered. 2. Further review of Resident #14's physician orders revealed an order for [REDACTED]. Review of a Psychiatric Follow Up Evaluation, dated 10/31/13, revealed the Psychiatrist recommended a dose reduction of the [MEDICATION NAME] to 25 mg at 3:00 PM and 50 mg at bedtime. Review of the Physician's orders, dated 11/01/13, revealed the [MEDICATION NAME] was reduced to 25 mg at 3:00 PM and [MEDICATION NAME] 50 mg. at bedtime. Review of Physician's Orders from a hospital readmission to the facility, dated 11/19/13, revealed the resident was to continue the [MEDICATION NAME] 25 mg at 3:00 PM and 50 mg at bedtime. However, review of the facility's admission orders [REDACTED]. Further review of the December 2013, January 2014 and February 2014 Medication Administration Records (MARs) revealed the resident received the higher dose of [MEDICATION NAME] for three (3) months which was a significant medication error. Interview with the DON, on 02/22/14 at 1:40 PM, revealed the nurse transcribes the admission and readmission orders [REDACTED]. She stated she expected the Pharmacist to review the orders against the original order. She stated she was not sure how this happened. Interview with the Administrator, on 02/22/14 at 9:40 AM, revealed he expected two (2) nurses to have checked the orders and signed off on the admission/readmission orders [REDACTED].

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to immediately consult with the resident's physician a need to alter treatment for one resident (#1) in the sample of fourteen (14) residents (Resident #1). The facility failed to notify the physician of unrelieved pain during treatments. During a dressing change, on 06/12/13 at 1:15 PM, and on 06/13/13 at 10:00 AM, Resident #1 exhibited verbal/non-verbal signs of pain; however, the nurse continued the treatment without further intervention. On 06/12/13 at 1:15 PM, Resident #1 winced with pain while tears rolled down his/her face as the nurse attempted to remove an old dressing to the right leg. Additionally, on 06/13/13 at 10:15 AM, Resident #1 began complaining of left heel pain. The nurse assessed the resident as having a "red, mushy" area to the left heel with a darkened scabbed area to the left second toe; however, the nurse failed to notify the physician of the pain to the left heel, or the new areas identified. The findings include: Review of the Notification of Resident Change in Condition policy/procedure, undated, revealed clinicians would immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status. Review of the Pain Management Process, dated 03/11, revealed the physician and family would be notified when pain levels were outside normal levels for each individual resident and could not be relieved or interfered with the resident's goal or functional ability. Review of the Skin System policy/procedure, revised 08/08, revealed the physician and family would be notified of any changes of skin condition. Record review revealed the facility admitted Resident #1 on 03/20/13, with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set, dated dated [DATE], revealed the facility identified the resident as moderately cognitively impaired. Review of the Pressure Ulcer Risk Assessment, dated 03/20/13, revealed the facility identified the resident at high risk for pressure ulcers. Review of the Comprehensive Pain Assessment Form, dated 05/20/13, revealed the resident indicated having frequent pain, making it hard to sleep at night and limiting day-to-day activities. The pain assessment indicated the resident's medication/treatments moderately relieved his/her pain. The resident's pain intensity goal was a "4" (four) on the pain scale of 0-10. Review of the Risk for Alteration in Comfort Care Plan, dated 05/20/13, revealed to report unrelieved or unacceptable levels of pain to the physician as needed. Observation of a dressing change, on 06/12/13 at 1:15 PM, with Registered Nurse #1 (RN) revealed a moderate amount of yellow/bloody drainage to the right leg wound dressing. During the removal of the dressing, the resident was observed wincing in pain with facial grimacing. The dressing appeared to be stuck to the resident's leg and difficult to remove. The resident began to cry, with visible tears rolling down the resident's face, as RN #1 continued to remove the dressing. RN #1 indicated the resident had been "pre-medicated" and continued the dressing removal without any other intervention. Observation of a dressing change, on 06/13/13 at 10:00 AM, revealed old dressings were removed from four (4) wounds on the resident's right side. Resident #1 continuously stated "Oh" during the treatment, dressing change of the wounds. Further observation revealed the resident with facial grimacing and complaints of pain during the treatment. The resident was rolled to the other side while continuously stating "Oh God, please." Observation revealed dressings were removed from three (3) wounds on the resident's left side. During treatment of these wounds, facial grimacing was observed with the resident stating "Oh, please." Throughout the treatment of the wounds, RN #1 stated "Is the pain pill not helping?" and "We are almost done. It's hard on you, isn't it?" Observation, on 06/13/13 at 10:15 AM, revealed Resident #1 continuously complained of pain to the left heel. RN #1 observed the heel to be red and "mushy." She stated "We need to prop that heel up." RN #1 additionally observed a darkened scabbed area to the left second toe. Interview with Resident #1, on 06/13/13 at 5:30 PM, revealed the pain medications were not effective during treatments. He/she revealed the rate of pain during the treatment on 06/13/13 was an "8" eight out of "10" (ten). The resident indicated that was "pretty bad" pain. Observation of Resident #1, on 06/14/13 at 10:45 AM, revealed a red, non-blanchable area to the left heel per assessment of the Assistant Director of Nursing (ADON). She indicated the area was "boggy" underneath. At approximately 10:55 AM, a blister had ruptured on the left heel with serous drainage noted. Additionally, an unstageable area to the left second toe measured 1 x 1.4 centimeters (cm). Record review, on 06/14/13, revealed no documentation related to the left heel/left second toe. Further review revealed no documented evidence new orders were initiated. Interview with RN #1, on 06/14/13 at 10:10 AM, revealed she had not notified the resident's physician of unrelieved pain. She indicated Resident #1 always had pain during treatments. She stated the resident feared the treatment before it even started. RN #1 stated the resident had anxiety disorder, which was "a lot of the problem." When a resident complained of pain before touching them, it had to be determined anxiety. She revealed the resident's pain management was effective for him/her as the resident's behavior during treatments on 06/12/13 and 06/13/13 was "typical." Continued interview with RN #1, on 06/14/13 at 10:10 AM, revealed she had not noticed the red, "mushy" area to the resident's left heel prior to the assessment, on 06/13/13. She did not report the resident's pain to the left heel as she did not feel it was significant. She revealed the ADON was notified of the area; however, interview with the ADON, on 06/14/13 at 3:50 PM, revealed she had no knowledge of the area prior to observation with the state surveyor. Further interview with RN #1 revealed she did not report the area to the left second toe; however, she should have made the ADON aware. She stated it was "up in the air" whose responsibility it was to notify the physician of the new areas. She revealed it was "probably" her responsibility since she found the new areas. Interview with the Director of Nursing (DON), on 06/14/13 at 4:45 PM, revealed she expected staff to try other measures for relief during treatments and call the physician if pain continued. An attempted interview with Resident #1's primary physician, on 06/14/13 at 10:35 AM, revealed he was not available for interview. Interview with the ADON, on 06/14/13 at 10:45 AM, revealed if a new wound was discovered, it would be the nurse's responsibility to notify the physician. Interview with the DON, on 06/14/13 at 4:45 PM, revealed she expected the nurse to assess, document, and notify the physician of any new areas identified. Interview with the Medical Director, on 06/14/13 at 2:00 PM, revealed he would expect staff to notify the physician of any new areas identified on a resident. Continued interview with the Medical Director, revealed he would expect staff to notify the physician if pain medication was not effective during a treatment.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the plan of care for one (1) of fourteen (14) sampled residents (Resident #1). On 06/12/13, Resident #1 complained of unrelieved pain three (3) hours after pain medication was given; however, he/she did not receive any further intervention until the next "as needed" dose of medication could be given. During a wound treatment, on 06/12/13 at 1:15 PM, Resident #1 was observed wincing in pain with tears rolling down his/her face; however, the nurse continued the treatment with no further intervention. Resident #1 exhibited non-verbal and verbal signs of pain during a wound treatment, on 06/13/13 at 10:00 AM; however, the nurse continued the treatment without further intervention. Additionally, the facility failed to assess and document the resident's pain before and after pain medication was administered. The findings include: Review of the Pain Management Process policy/procedure, dated 03/11, revealed the facility would react to the resident's pain control needs based on the resident's goals for pain relief and the resident's goals for functional ability. The facility's goal was to ensure all residents received appropriate pain relief measures to assure that the residents' pain did not affect their ability to function within their designated goals for functional ability. Documentation of pain intensity would be recorded along with the intervention for pain reduction using appropriate facility forms. A post intensity evaluation would be assessed and documented in a timely manner. Upon follow-up, if the intervention was ineffective, the process should be repeated until the resident indicated adequate relieve and/or functional goals were met. Record review revealed the facility admitted Resident #1 on 03/20/13, with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set, dated dated [DATE], revealed the facility identified the resident as moderately cognitively impaired and required extensive assistance with bed mobility and transfer. Review of the Comprehensive Pain Assessment Form, dated 05/20/13, revealed the resident indicated having frequent pain, making it hard to sleep at night and limiting day-to-day activities. The pain assessment indicated the resident's medication/treatments moderately relieved his/her pain. The resident's pain intensity goal was a "4" on the pain scale of 0-10. Review of the physician's orders [REDACTED]. 1. [MEDICATION NAME] (controlled pain medication) 100 microgram (mcg)/hour patch, one patch topically every seventy-two (72) hours 2. [MEDICATION NAME] ([MEDICATION NAME], controlled pain medication) 4 milligram (mg) tablet every six (6) hours, as needed, and 3. [MEDICATION NAME] (pain medication) 325 mg tablet every four (4) hours, as needed Review of the Risk for Alteration in Comfort Care Plan, dated 05/20/13, revealed to identify the location and rate of pain prior to and after any interventions. Report unrelieved or unacceptable levels of pain to the physician as needed. Review of the Controlled Substance Proof of Use sheet, dated 06/12/13, revealed Registered Nurse (RN) #1 administered [MEDICATION NAME] 4 mg to Resident #1 at 7:05 AM. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the MAR indicated [REDACTED]. Observation, on 06/12/13 at 10:00 AM, revealed Resident #1 was sitting up in his/her room, after completing physical therapy. The resident complained of his/her "bottom" hurting and appeared uncomfortable. Observation, on 06/12/13 at 10:15 AM, revealed a staff member reported the resident's pain to Registered Nurse (RN) #1 with the state surveyor present. At 10:30 AM, the resident remained in the wheelchair with facial grimacing. Further observation, on 06/12/13 at 11:50 AM, revealed Resident #1 remained up in his/her room. The resident revealed his/her "bottom" was still hurting "pretty bad." Review of the Controlled Substance Proof of Use sheet, dated 06/12/13, revealed RN #1 administered [MEDICATION NAME] 4 mg at 12:40 PM. Review of the MAR, dated June 2013, revealed no documentation of the location, rate of pain, or effectiveness of the medication given at 12:40 PM. Review of the Impaired Skin Integrity Care Plan, dated 05/20/13, revealed if there was complaints of pain during a treatment, stop the treatment, leave the resident safe, and seek pain relief. Return to complete the treatment when the pain was reported as acceptable. Observation of a dressing change, on 06/12/13 at 1:15 PM, revealed a moderate amount of yellow/bloody drainage to the right leg wound dressing. During the removal of the dressing, the resident was wincing in pain with facial grimacing. Further observation revealed the dressing appeared to be stuck to the resident's leg and was difficult to remove. The resident began to cry, with visible tears rolling down the resident's face, as RN #1 continued to remove the dressing. RN #1 indicated the resident had been "pre-medicated" and continued removing the dressing without implementing any other intervention. Review of the Controlled Substance Proof of Use sheet, dated 06/13/13, revealed RN #1 administered [MEDICATION NAME] 4 mg at 8:00 AM. Review of the MAR, dated June 2013, revealed no documentation of the location, rate of pain, or effectiveness of the medication given at 8:00 AM. Observation of a dressing change, on 06/13/13 at 10:00 AM, revealed old dressings were removed from four (4) wounds on the resident's right side. Further observation revealed Resident #1 continuously stated "Oh" during the treatment/dressing of the wounds. Observation revealed facial grimacing and complaints of pain during the treatment. The resident was rolled to the other side while continuously stating "Oh God, please." Dressings were removed from three (3) wounds on the resident's left side. During treatment of [REDACTED]." Throughout the treatment of [REDACTED].?" and "We are almost done. It's hard on you, isn't it?" Interview with Resident #1, on 06/13/13 at 5:30 PM, revealed pain medications were not effective during treatments. The resident stated it may be better if staff give him/her pain medications before the pain was so bad. He/she revealed the rate of pain during the treatment on 06/13/13 was an "8" out of "10." The resident indicated that was "pretty bad" pain. Interview with Resident #1's husband, on 06/13/13 at 5:30 PM, revealed the pain had actually improved as the resident used to "squawl out" during treatments. He indicated the resident sometimes had to ask three (3) times before getting pain medications. Interview with RN #1, on 06/14/13 at 10:00 AM and 3:00 PM, revealed pain medication was not given when asked on 06/12/13 as it was not time for the medication. She revealed the resident was assessed and informed that it was not time for pain medication. Further interview with RN#1 revealed she had not notified the resident's physician of the resident's unrelieved pain. She indicated Resident #1 always had pain during treatments. She stated the resident feared the treatment before it even starts. She stated the resident had anxiety disorder, which was "a lot of the problem." She stated when a resident complained of pain before touching them, then it had to be due to the resident's anxiety. She revealed documentation of pain medications included the location of the pain pain, rate of pain, and effectiveness; however, she was unsure of the reason it was not documented on 06/12/13 or 06/13/13. She revealed the resident's pain management was effective for him/her as the resident's behavior during treatments on 06/12/13 and 06/13/13 was "typical." Interview with the Director of Nursing (DON), on 06/14/13 at 4:45 PM, revealed documentation of pain included the rate of pain. The DON stated she expected staff to reassess and document within the hour after a pain medication was given. She felt the interventions on Resident #1's care plan were generic and should have been more individualized; however, she still expected staff to follow the interventions. She stated staff should try non-pharmalogical interventions if it was not time for pain medication but if a resident continued to complain of pain, the physician should be notified. She expected staff to try other measures for relief during treatments and call the physician if pain continued. An attempt to interview Resident #1's primary physician, on 06/14/13 at 10:35 AM, revealed he was not available for interview. Interview with the Medical Director, on 06/14/13 at 2:00 PM, revealed he would expect staff to notify the physician if the pain medication was not effective during a treatment.

Based on interview and record review, it was determined the facility failed to fully implement the bowel and bladder program to include the bowel protocol. The facility failed to monitor resident bowel movements and address with interventions those residents care needs per the protocol for four (4) of nineteen (19) sampled residents (Resident #1, #8, #11 and #12). On 01/26/11 the facility assessed Resident #8 as restless, having abdomen distention, bowel sounds diminished, and noted the resident grimaced upon palpitation of the abdomen. The facility transferred Resident #8 to the hospital and was subsequently admitted with a [DIAGNOSES REDACTED]. The facility assessed Resident #11at risk for constipation, however, failed to implememt the bowel protocol to prevent constipation. On 02/14/11 Resident #11 complained of constipation after having no bowel movement since 02/10/11 and the facility taking no action. Resident #11 was noted to complain of constipation prior to any intervention. The findings include: Review of the Bowel and Bladder Program Procedure (Revised January 2009) provided by the nursing facility included the following points to be addressed to manage constipation: include resident goals and interventions on the Alteration in Bowel Elimination/Plan of Care, Initiate/Update the Alteration in Bowel Elimination/Plan of Care on all residents identified with constipation, and document elimination results using the Care Tracker. Further review of the program revealed the facility did not include a process to monitor the results of the Care Tracker data/information; therefore, the nursing staff did not have access to a system of notification when residents did not have a bowel movement for three (3) days. The nursing staff would not know when to initiate or implement an intervention(s). A bowel protocol document was not provided. Interview with the Regional Nurse Consultant on 02/23/11 at 1:50pm revealed there had been a problem with the nursing staff documenting residents bowel movements. She stated this problem was identified during the investigation of Resident #8's fecal impaction on 01/26/11. She acknowledged staff were not documenting in the Care Tracker consistently whenever a resident had a bowel movement. She indicated education was provided and the nursing assistants are supposed to record each bowel movement in the Care Tracker system. (The in-service training record provided addressed nursing staff and not the nursing assistants.) The nurse is suppose to pull the Bowel Chart Detail Reports and if a resident has not had a bowel movement within three (3) days, the facility's Bowel Protocol is suppose to be implemented. However, there was no documented evidence the nurses were utilizing the Bowel Detail Reports. The Nurse Consultant stated the sheets the nurses use to determine which resident may need interventions are thrown away after the nurse's shift. Continued interview revealed there was no documentation kept on residents that have been noted in the past to have gone three (3) or more days without a bowel movement. Interview on 02/23/11 at 9:20am with LPN #1 revealed the bowel protocol followed by the facility is to give the resident Milk of Magnesia (MOM) after three (3) days with no bowel movement. If the resident does not have an order for [REDACTED]. However, the facility could provide evidence that this monitoring was completed. Interview on 02/23/11 at 2:20pm with LPN #2 revealed the bowel protocol is charted in the kiosk (computer touch screen located on the wall). If the resident fails to have a bowel movement in three (3) days, MOM or a laxative is given. It was further revealed the nurses print off the list of those residents that have not had a bowel movement or small stool only within three (3) days. However, there was no documented evidence the facility implemented this process with Resident #8 when the resident went 5 days with no bowel movement or had only a small bowel movement prior to the resident's transfer to the hospital with a fecal impaction. Interview on 02/23/11 at 2:25pm, with RN #1 revealed if the nurses did not have the bowel report, someone had failed to print them. It was revealed there is no log or method of documentation to assure the bowel protocol is being followed. Interview on 02/24/11 at 8:10am with CNA #5 revealed the bowel and bladder program for the resident is on their care plan. The care plan is updated daily and as needed. 1. Resident #8 was admitted on [DATE] to the facility with a [DIAGNOSES REDACTED]. Review of the last annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #8 with severe cognition impairment, requiring extensive assistance with toileting and extensive assistance with eating and drinking. Review of the nutritional care plan dated 02/01/11 revealed Resident #8 at risk for constipation. The care plan detailed the resident's history of constipation under the problem list for Alteration in Bowel Elimination. Interventions on the care plan included monitoring bowel elimination with the Care Tracker and provide medication as ordered to aid in elimination. Review of the bowel record for Resident #8 revealed the resident had no bowel movement or only a small bowel movement in 2010 on December 9, 10, 11, 12, 13 with no intervention, December 23, 24, 25 with no intervention, December 26, 27, 28 with no intervention, continuing on December 29, 30, 31 with no intervention. Repeatedly, no action or follow up. In January 2011, on the following dates, there were no bowel movements: 1, 4, 5, 6 with no intervention, 7, 8, 9 with no intervention, 16, 17, 18 with no intervention, 22, 23, 24, 25 and through second shift on January 26, with no intervention until the resident was transported by ambulance to the emergency room . Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. However, there was no documented evidence the facility administered medication on any of the days the resident did not have a documented bowel movement. Review of nurse's notes on 01/26/11 at 1:10pm revealed Resident #8 was restless, the abdomen was distended, bowel sounds were sluggish and the resident was grimacing. The physician was notified and orders were received to transport the resident to the Emergency Department for evaluation. Review of the Transfer form completed by LPN #3 on 01/26/11 at 12:45pm revealed the reason for the transfer was the resident had no bowel sounds, abdominal distention (swelling) and rebound tenderness (when you press in on the belly then let go it causes pain). Review of The Emergency Physician Record dated 01/26/11 revealed the resident was documented as having pain in the lower mid abdomen, decreased bowel sounds and a fever. A Computerized Tomography (CT) scan dated 01/26/11 revealed a "massive rectal and sigmoid (the part of the colon immediately above the rectum) fecal impaction." The resident was hospitalized from [DATE] through 01/31/11. The discharge summary electronically signed by the physician dated 02/14/11 noted the resident was placed on a bowel regimen which required several days to provide significant results. Hospital document dated 01/30/11 shows the impaction resolved. The final [DIAGNOSES REDACTED]. 2. Resident #11 was admitted on [DATE] with the [DIAGNOSES REDACTED]. The current MDS assessment dated [DATE] revealed the facility assessed the resident as requiring extensive assistance with toileting. Review of the medical record revealed a physician's orders [REDACTED]. Review of the Bowel and Bladder Chart Detail Report revealed Resident #11 had no bowel movement in 2011 on January 2, 3, 4, 5 and 6 with no intervention. No bowel movement January 11, 12, 13 and 14 with no intervention and none on January 25, 26, 27, 28 with no intervention. No bowel movement on February 4, 5, 6, 7 and 8 with no intervention. No bowel movement February 11, 12, 13 and first shift on the 14th. Review of the resident's clinical record revealed a nurses' note dated 02/14/11 at 9:55am where the resident complained of constipation. Review of the January 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the MAR for February 2011 revealed due to Resident #11's continued complaints of constipation, the physician ordered another laxative to be given routinely on 02/10/11. The physician ordered [MEDICATION NAME], 17grams, to be taken in eight ounces of water at 7am each morning . This is documented in the MAR indicated [REDACTED]. However, Resident #11 complained of constipation on 02/14/11 and review of the bowel records revealed no documented bowel movements on February 11, 12, 13, and first shift of the 14th. 3. Review of Resident #12's clinical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the 09/01/10 Resident Assessment Protocol Summary (RAPS) revealed the facility identified Resident #12 as having the potential for dehydration. Review of the Bowel Data assessment dated [DATE] revealed the resident was frequently incontinent of bowel and received Calcium channel blockers, antidepressants, diuretics, and NSAIDS. However, review of the current care plan revealed no documented evidence the facility identified the potential for constipation. The care plan had checked for diarrhea. Record review revealed no documented evidence the facility took any action related to Resident #12 having no bowel movement for six (6) days. The Care Tracker on 02/23/11 revealed no bowel movement on 01/16, 01/17, 01/18, 01/19, 01/20, and 01/21/2011. Interview with the Director of Nursing (DON) on 02/14/11 at 10:30am revealed that each nurse should print a daily Care Tracker report and provide the report to the medication nurse. The medication nurse will review the report and give medication for constipation to residents with no bowel movements for three (3) days. The DON revealed she would take responsibility to ensure the bowel status is monitored, as this had not been done previously. The DON stated she had only been at the facility for two (2) weeks. 4. Review of Resident #1's clinical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED].The facility assessed Resident #1 at risk for constipation related to taking pain medications ([MEDICATION NAME] 10/325 every 6 hours/as needed and MS 30mg twice a day). The physician ordered a stool softener daily for constipation. The resident was in the hospital 11/18/2010 through 11/29/2010 for wound skin graft. Review of hospital documentation revealed a physician note dated 11/22/10 where the resident experienced a fecal impaction that had to be manually removed. Review of the Resident Assessment Protocol Summary (RAPS) dated 09/24/10 revealed the facility assessed the resident being at risk for dehydration, incontinent of bowel and requiring extensive assist of two persons to toilet. Observation of Resident #1 revealed the resident sat in a wheelchair for extended periods of the day on 02/22/11 and 02/23/11. Review of the bowel record on the Care Tracker revealed Resident #1 had no bowel movement on December (2010) 12, 13, 14, 15, 16, 18, 19, 20, 21, 26, 27, 28, 29, and 29th. January (2011) 10, 11, 12, 13, 14,16, 17, 18, 19, 20, 21, 22, 24, 25, and 26th. In addition, no bowel movements were documented from January 31-February 8, 2011 (9 days). Review of the care plan revealed the facility was to monitor bowel movements and administer stool softener as ordered. Interview with the Regional Nurse Consultant on 02/23/11 at 1:50pm revealed there had been a problem with the nursing staff documenting residents bowel movements. She acknowledged staff were not documenting in the Care Tracker consistently whenever a resident had a bowel movement. She indicated education was provided and the nursing assistants are suppose to record each bowel movement in the Care Tracker system. The nurse is suppose to pull the Bowel Chart Detail Reports and if a resident has not had a bowel movement within three (3) days, the facility's Bowel Protocol is suppose to be implemented. However, Resident #1's Bowel Chart Detail Reports revealed the resident had no documented bowel movements for nine (9) days from 01/31/11 through 02/08/11. This was after the in-service training provided by the Nurse Consultant in January 26, 2011.

Based on interview, record review, and observation, it was determined the facility failed to develop a comprehensive plan of care for two (2) of nineteen (19) sampled residents (#8 and #10). The facility failed to implement care plan interventions for Resident #8. Bowel movements documented on the Care Tracker were not monitored. The failure to monitor the bowel movements resulted in the facility not implementing the intervention of providing medication to the resident to aid in bowel elimination. This failure resulted in the hospitalization of Resident #8 with a fecal impaction, pain and fever. The facility further failed to include the treatments for head lice ordered on Resident #10 into the care plan. The findings include: 1. The facility policy on Plan of Care (Revised October 2008) revealed a complete care plan includes realistic and measurable resident goals. It will include specific individualized interventions. It is further revealed, the care plan may include pre-printed pages with goals listed which require being checked off (place a check in a pre-printed box) to constitute an active goal. Interview on 02/24/11 at 9:27am with the Clinical Reimbursement Coordinator revealed only the items checked on the pre-printed care plan forms are active goals for the resident. Hand written goals may be included. Resident #8's care plan had no written goals. Resident #8 did have listed as interventions "Monitor bowel elimination using Care Tracker" and "Provide medication as ordered to aid in elimination". Resident #8 was originally admitted on [DATE] to the facility with a [DIAGNOSES REDACTED]. Review of the last annual Minimum Data Set (MDS) ,Version 2.0 dated 06/04/10, revealed the resident has severe cognition impairment, requires extensive assistance with toileting and extensive assistance to eat and drink. The resident is on the medication [MEDICATION NAME] and aspirin. There is also a history of constipation. Review of the care plan dated 02/07/11 for Resident #8 revealed Alteration in Bowel Elimination as being identified as a problem. Noted on the care plan the identifying factors which make bowel elimination a problem are: history of constipation and incontinence, the medications [MEDICATION NAME] and aspirin, a [DIAGNOSES REDACTED]. Interventions included monitor bowel elimination using Care Tracker and provide medication as ordered to aid in elimination. Review of the Care Tracker revealed the facility failed to monitor the bowel movement results for Resident #8. The resident had no bowel movement or only a small bowel movement on December 9, 10, 11, 12, 13, 23, 24, 25, 26, 27, 28, 29, 30, 31/2010. In January 2011, on the following dates, there were no bowel movements: 1, 4, 5, 6, 7, 8, 9, 16, 17, 18, 22, 23, 24, 25 and through second shift on January 26, when the resident was transported by ambulance to the emergency room . Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. However, the medication was never administered on any of the days the resident did not have a documented bowel movement as was an intervention on the care plan. On 01/26/11 at 1:10pm record review revealed documented in the nurses notes, Resident #8 was restless, abdomen distended and bowel sounds sluggish. The resident had facial grimace upon palpitation of the abdomen. The resident was transported to the emergency room . 01/26/11 at 1:30pm the emergency record revealed "abdominal distention" (swelling), pain and fever. Resident #8 was admitted with a fecal impaction. Hospital documentation further revealed it required several days to provide significant results and relief to the resident. Hospital documentation dated 01/30/11revealed the impaction was resolved; five (5) days after the resident was initially admitted . Interview on 02/22/11 at 3:05pm with the daughter of the resident revealed the resident is "total care", is not involved in any activities and is bed ridden. Interview on 02/24/11 at 7:50am with RN#3 revealed the purpose of the care plan is to know how to take care of the residents and what interventions the staff needs to put in place. Interview with the Assistant Director of Nursing on 02/24/11 at 8:55am revealed the purpose of the care plan is to identify potential problems, set a reachable goal, and have interventions in place to prevent the problem from occurring. 2. Record review of Resident #10 revealed an admission on 07/20/06 with the [DIAGNOSES REDACTED]. The facility assessed the resident as cogitively impaired on the quarterly minimal (MDS) data set [DATE]. Record review of the physician orders [REDACTED]. Record review of physician orders [REDACTED]. Record review of Resident #10's resident care plan (RCP), revised 02/21/11, revealed the resident's treatment plan did not address head lice treatments in the RCP, nor was the RCP updated anytime between 02/21/11 through 02/24/11 to reflect the treatment plan. Observation on 02/23/11 at 6:50am revealed a treatment cart placed at the entrance of Resident #10's door with a container labeled for this resident's treatment of [REDACTED]. Interview with LPN #3 on 02/23/11 at 7:15am revealed the nursing staff does take off the physician orders [REDACTED]. Interview with the Clinical Reimbursement Coordinator (CRC), on 02/24/11 at 9:25am, revealed she is responsible to complete a comprehensive care plan for each resident. She reported the nurses taking off any new orders are to care plan the orders at the time the order is received, and she would review to ensure each of the triggers were care planned as well as any orders when she does her reviews, if they are not already care planned. Interview with the Director of Nursing (DON) on 02/24/11 at 9:50am revealed the nurses are to update the resident care plan when the physician orders [REDACTED]. She reported there is not a tracking tool or audits in place to ensure the care plans are updated when the orders are transcribed.