Every finding on record at Cimarron Place Health & Rehabilitation

Based on record review and interviews the facility failed to ensure that one (1) residents (Resident #1) of five residents reviewed for transfer or discharge was sent to the Ombudsman to ensure a safe and effective transition of care for the resident. The facility discharged Resident #1 to the hospital for an incident on 5/19/2026 and did not allow the resident to facility The facility discharged Resident #1 on 5/19/2026 without sending notification to the Ombudsman. This failure could place discharged residents at risk of being discharged from the facility causing a disruption in their care and/or services.Findings include:Review of Resident #1's face sheet date 6/2/2026 revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses that included Dementia (A group of thinking an social symptoms that interferes with daily functioning), Anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), Dementia (A group of thinking an social symptoms that interferes with daily functioning), Depression (a group of conditions associated with the elevation or lowering of a person's mood), Chronic Ischemia (a long-term condition where progressive plaque buildup or vessel damage severely restricts blood and oxygen supple to specific tissues). Review of Resident #1's Discharge MDS assessment dated [DATE] reflected he had a BIMS of 03 suggesting he was severely cognitive impairment and the discharge MDS dated [DATE] revealed rejection of care, wandering, and physical, verbal, and other behaviors directed at others were present at discharge to a short-term general hospital without return anticipated. Review of Resident #1's closed care plan dated 2/20/2026 revealed he was an elopement risk had wandering behaviors, had impaired cognitive and function impaired thought processes related to dementia, had limited physical mobility related to weakness and required the use of rolling walker for safe mobility. Resident #1 used antidepressant medication and was at risk for side effects for depression. Interventions included to observe, document and report to physician as needed for ongoing signs and symtoms of depression unaltered by antidepressant medications like sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative moods and comments, slowed movement , agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight, appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, and needing constant reassurance. Review of Resident #1's progress notes dated 3/18/2025 at 12:15 pm revealed: Resident #1 extremely agitated coming out of room and scared the one-to-one monitoring staff member and began to walk away from Resident#1 and he followed the staff member down the hall and chased CNA B attempting to hit and push her. Resident #1 refused to return to Residents #1's room. Hospice staff was called and notified, Resident Medicated with morphine 0.5 mL which all he has ordered at this time PRN. Resident did return to his room, slammed door and can be heard barricading furniture against door. Will not allow any staff in room DON notified. In an interview on 06/02/2026 at 4:35 pm with Ombudsman she stated the family was upset with the facility for not allowing the resident to return to the facility. The Ombudsman stated on 05/19/2026 the facility called police regarding an incident with Resident #1 having slapped a staff member that resulted in the resident being transferred to the hospital for observation and treatment of aggression. The Ombudsman stated the resident was being treated for urinary tract infection at the time the incident occurred which may have been the cause of the aggression. The Ombudsman stated before the police were called hospice was notified of Resident #1's aggressive behavior he was exhibiting and arrived at the facility and tried to calm him with medication. The Ombudsman stated the RP felt the at times the staff were antagonizing him; they did not know how to approach him and work with him. The Ombudsman stated when the resident was admitted on [DATE] and family had filled out an application for financial assistance and was dated February 25, 2026, but it was never submitted by the previous business manager who was no longer with the facility. The Ombudsman stated the new business manager resubmitted the Medicaid application in May of 2026. The Ombudsman stated an IDT meeting was held in early May and the BOM was present and she reported she had been billing the RP and the RP stated he did not receive any bills. The Ombudsman stated the RP had financial and medical power of attorney for Resident #1 and was told by the BOM the hold up with the Medicaid application had to do with the fact Resident #1 had an asset that consisted of an insurance policy valued at $8000.00 owned by the resident. The Ombudsman stated the RP was told the residents was being discharged for no payment but was put off for another week at her request to see if Medicaid would approve the Resident #1 once the RP dealt with ownership of the life insurance policy. The Ombudsman stated the hospital attempted to return resident back on 05/21/20226 to the facility, but the facility refused to readmit him because of previous aggressive behavior, the facility had not received payment and was considered a danger to the residents of the facility. The Ombudsman stated the DON told her she had emailed Resident #1's RP with notice of the discharge notice which stated the reasons the resident was not allowed to returned to the facility.The Ombudsman stated she had not received a notice of Resident #1 discharge from the facility. In a interview on 06/03/26 at 10:40 am with the Responsible Party/ family member he stated, he did not receive a 30-day notice of discharge, nor did I get an email stating he was being discharged . The RP stated he was informed by the hospital emergency room that the resident had been dropped off at the emergency room, and a police report was filed. The RP stated he was also informed by the hospital that the facility was not going to take him back. The RP stated the Administrator told the Ombudsman the facility was not going to readmit Resident #1 to the facility. The RP stated Resident #1 was accepted to another facility but would be admitted into a regular bed as there was no documentation to justify why he needed to go into memory care unit. The RP stated the facility would admit him as a regular patient and if he started exhibiting wandering or exit seeking behaviors they would escalate him to memory care. The RP stated the new facility notified him they no longer had a bed available for Resident #1. The RP stated at IDT meeting on 05/04/26 no discharge notification was discussed and told him if they appealed they were going to give him 30 days. 05/11/26 they conference no discussion of 30 days' notice. The RP decline any medications related to behavior and he was alarmed because they administered morphine. The RP stated there were a meeting on 05/04/26 or 05/11/26 with the facility, but there was never a discussion of discharge during meetings The RP state at one of the meetings was regarding the appeal process for Medicaid not a discharge but could not remember which one. The RP stated the ombudsman stated she was told by administrator he was going to discharge the resident for nonpayment and the ombudsman stated she would appeal has discharge and administrator stated he would work with family about payment. The Responsible Party/ family member he stated, he did not receive a 30-day notice of discharge, nor did I get an email stating he was being discharged . The RP stated he was informed by the hospital emergency room that the resident had been dropped off at the emergency room, and a police report was filed by the facility. The RP stated he was also informed by the hospital that the facility was not going to take him back. The RP stated the Administrator told the Ombudsman the facility was not going to readmit Resident #1 to the facility. The RP stated Resident #1 was accepted to another facility but would be admitted into a regular bed as there was no documentation to justify why he needed to go into memory care unit. The RP stated the facility would admit him as a regular patient and if he started exhibiting wandering or exit seeking behaviors they would escalate him to memory care. The RP stated the new facility notified him they no longer had a bed available for Resident #1. The RP stated at IDT meeting on 05/04/26 no discharge notification was discussed and told the RP if they appealed they were going to give the resident a 30-day notice. The RP stated on 05/11/26 they had a conference with no discussion of 30 days' notice. The RP stated there were a meeting on 05/04/26 or 05/11/26 with the facility, but there was never a discussion of discharge during meetings The RP state one of the meetings was regarding the appeal process for Medicaid not a discharge but could not remember which one. The RP stated the ombudsman stated she was told by administrator he was going to discharge the resident for nonpayment and the ombudsman stated she would appeal has discharge and administrator stated he would work with family about payment. In an interview on 06/03/26 at 3:40 pm with Director of Nursing (DON) stated Resident #1 started as a respite care resident and was transitioning to long term care. The DON stated she had notify physician of the discharge but failed to document it in the EMR and it was standard practice to notify physician of all discharges. The DON stated the discharge summary was the responsibility of social worker and the emergency discharge summary should have been done as well. The DON stated the Resident was sent to hospital as a police decision not the facility and that was why it was not considered to be a facility discharge and the confusion of how the discharge should have been handled. The DON stated the RP and the Ombudsman should have been notified . The DON stated Resident #1's family was trying to place him and his spouse together, because he had a difficult time separating from wife. The DON stated as the separation got more difficult he started to have behaviors, aggression, and was exit seeking. The DON stated hospice tried medication for behaviors, and it worked but then RP stated he was too sedating was not eating. The DON stated when the RP was here Resident #1 behaviors were calmer and did not exit seek, but when the RP was not present the resident would be walking all over the facility with his walker. The DON stated hospice nurse attempted to keep resident on medications, but the RP refused to let the lorazepam continue, so it was discontinued. The DON stated the aggression started escalating and he eventually fell. The DON stated Resident #1 was constantly wondering in the facility. The DON stated they had notified another family member about Resident #1 falling while he swung his walker at somebody. The DON stated they called hospice, EMS, and FM but, the FM did not want Resident #1 sent to hospital. The DON stated she met with the hospice nurse, but the RP refused to put him back on hospice. The DON stated at some point Resident #1 had roommate, but he started arguing with him, so son requested a private room. The DON stated the next day Resident was moved to a private room for the safety of roommate. The DON stated the RP considered placement in another facility where the RP lived. The DON stated Medicaid application was pending so finding placement for him was difficult. The DON stated she received a call at 1:30 am from one of nurses that Resident #1 was out of control and they could not calm him down. The DON stated she directed the staff to call Hospice and hospice came out and Resident #1 refused his PRN medications offered by hospice. The DON stated CCPD was called and Resident #1 was cussing and threatening police. The DON stated the weekend before the police came in and he calmed down, but this time it did not work. The DON stated the day the day of the incident Resident #1 had been on a 1:1 since 04/30/26 and the resident was stared on Depakote. The DON stated the facility had several emergency care plans to get medications on board to manage the behaviors of Resident #1. The DON stated Resident #1 had been doing okay with Depakote so the 1:1monitoring was discontinued and 30 minutes later he had an altercation with another resident. The DON stated Resident #1 approached her and staff intervened. The DON stated both residents were checked and no injuries were noted. The DON stated after that he went back to 1:1. The DON stated Resident #1 started barricading the door and they could hear him moving all the furniture. The DON stated this was the night police was called and he slapped the CNA shoved his walker at another CNA another. The DON stated the charge nurse called me to inform me of what had transpired. The DON stated she told the social worker and the hospice social worker about the incident and they talked about discharging him. The DON stated the police issued a warrant, but the facility does not don't have a copy. The DON stated Resident #1 was being held at the hospital by the for a psychiatric evaluation. The DON stated the policy for unplanned discharged in an emergency like this was not common and the facility had never had one. The DON stated the RP called back and they notified the facility he was transferred to [NAME]. The DON stated the RP was sent an email on 05/21/2026 and called several times about Resident #1 being discharged . The DON stated the Administrator also called the RP about Resident #1 being discharge but could not give the days the RP was not able to be reached. The DON stated several attempts were made to initiate the 30-day discharge plan and attempted to give one at one of the meeting but decided to gave RP a week to see what the status of the Medicaid application requested by ombudsman. The DON stated both the facility and hospice were trying to initiate the 30-day discharge. The DON stated RP was on the phone for the meeting and was sent an email about discharge. The DON stated the second time a discharge was considered it was put on hold because the RP was waiting for check to do a spend down in the life insurance the resident had in his name that had the Medicaid application pending and the resident had been accepted to another facility. The DON stated I did notify physician but failed to document it in the EMR and it is standard practice to notify physician. Discharge summary was the responsibility of social worker and the emergency discharge summary should have been done as well. The DON stated Resident #1 was sent to the hospital by the police and not a decision of the facility. The DON stated that was why Resident #1's discharge was not considered to be a facility discharge and the confusion was not handled correctly and the RP and the Ombudsman should have been notified as soon as possible. In an interview on 06/04/2026 at 5:16 PM the Administrator stated the Ombudsman was to be immediately notified of an emergency or planned discharge with a 30-day notice. The Administrator stated the doctor order be documented in orders section of the residents EMR to begin the discharge process. The Administrator stated the report was sent to the Ombudsman monthly by the social worker but Resident#1 discharge was accidentally left out but it was sent as soon as the error was found. The Administrator stated every day at the morning meeting all discharges are discussed and if needed are started if the resident or family has requested a discharge from the facility. The Administrator stated the discharge order should have been done by the doctor to release the resident from the facility. The Administrator stated the staff was in serviced twice a year on discharges and an in-service will be conducted immediately to reeducate the staff on the proper procedure according to the facility's policy. The Administrator stated the resident was being verbally abusive to staff and residents. The resident continued to behavior hostile and assaulted a staff member. The Administration stated the staff was properly monitoring Resident #1 with a 1 to 1 for another incident with aggressive behavior. The Administration stated the behavior escalated with Resident #1 barricading himself inside has room. The Administration stated the family was asked to come in and speak about relocating Resident#1 to a different to facility. The Administrative stated Resident #1 also had problems with has roommate. The Administrative stated Resident #1 slapped the CNA who was monitoring him and tried to hit another CNA with his walker. The Administrator stated the police were called at this time to calm him to down and then Resident #1 made threats to the police and EMS was called to take him to the hospital. The Administrator stated he was not know if the charge nurse called the RP but did call the MD. The Administrator stated normally in a discharged the family receive a 30 day notice and involved the ombudsman and they try to be discharged by the policy and procedure. The Administrator stated if the family had cooperated it would have helped the situation by extending the stay as the Ombudsman requested. The Administrator stated the discharge of the resident was discussed and he stated the 30-day discharge was in the future especially with his behavior had the incident not occurred. The Administrator stated the main concern was the resident community and the risk the admission of Resident #1 posed and he didn't feel Resident #1's admission was in the best interest for the residents in the facility. The Administrator stated the proper way for the residents to be discharged was to give a 30-day notice of discharge. The Administrator stated the Social Worker starts the was charge process by contacting the new facility or resident home and then contacting durable medical equipment agency if discharged at home. The Administrator stated Adult Protective Services was also contacted if the residents were not being discharged to a safe environment. The Administrator stated the ombudsman was to be immediately notified of an emergency or planned discharge with a 30-day notice. The Administrator stated the doctor order be documented in orders section of the residents EMR to begin the discharge process. The Administrator stated the report was sent to the Ombudsman monthly by the social worker but Resident#1 discharge was accidentally left out but it was sent as soon as the error was found. The Administrator stated every day at the morning meeting all discharges were discussed and if needed were started if the resident or family has requested a discharge from the facility. The Administrator stated the discharge order should have been done by the doctor to release the resident from the facility. The Administrator stated the staff was in serviced twice a year on discharges and an in-service will be conducted immediately to reeducate the staff on the proper procedure according to the facility's policy. In record review of the Long-Term Care Regulation Provider Letter states the Purpose of this letter is to provide guidance to NF's regarding resident discharges and discharge appeal hearing. Providing clear notice and documentation during a discharge are legal requirement and essential to protecting the rights and dignity of residents.2.2 Proper Discharge Notification If a NF initiates a resident discharge, the facility must provide written notification of the discharge in a language and manner the resident can understand to the resident, the resident representative (if Applicable) and a reaprsentive of the Long term Care Ombudsman Program, at least 30 days before the intended discharge date . The discharge must include :Contact information of the managing local ombudsman and the toll free number for the Long-Term Ombudsman Program. In record review of the facility policy and procedure undated stated 2.2 Proper Discharge Notification If a Nursing Facility initiates a resident discharge, the facility must provide written notification of the discharge in a language and manner the resident can understand to the resident, the resident representative (if Applicable) and a representative of the Long term Care Ombudsman Program, at least 30 days before the intended discharge date . The discharge must include :the reason for discharge;the effective date of the discharge

Based on observation, interview, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 residents reviewed for pharmacy services.The facility failed to ensure Resident #1 received their medications as ordered.These failures could place residents at risk of medical complications and prevent them from receiving the therapeutic effects of their medications. The findings included:Record review of Resident #1's face sheet revealed an [AGE] year-old female with an admission date of 06/01/25. Diagnoses included chronic obstructive pulmonary disease, high blood pressure, heart failure, polyneuropathy (a condition where multiple nerves become damaged or malfunctioning), depression, blindness, breast cancer, blood clots, muscle wasting, and a need for assistance with personal care. Her MDS dated [DATE] revealed a BIMS score of 02, indicating severe cognitive impairment.Record review of the facility's medication administration audits dated 04/21/26 revealed medications on the 6 am - 2 pm shift were administered 5 to 7 hours late by LVN A.Record review of the medication audit of the 6:00 am - 2:00 pm shift for the 500-hall dated 04/21/26 revealed LVN A medicated residents in the 500-hall. Scheduled times for the medications were 6:00 am. Residents received their medications from 11:11 am to 1:32 pm. In an interview with Resident #1 on 05/06/26 at 10:00 am, she said she did not recall any problems with her medications on 04/21/26. In an interview with the RP for Resident #1 on 05/06/26 at 12:31 pm, she said she was watching the in-room camera footage and saw LVN A take Resident #1's blood pressure and administer medications around noon on 04/21/24. She said a couple of hours later, she saw another nurse do the same thing around 1 pm and thought it was off. She said she called the DON and was told the DON would look into it. She said she found out from (unknown) there was no checklist to prevent medications being given too close together. She said LVN A had always been good but was running late and was behind that day. She said she spoke with LVN B who checked on it and told her she was right. She said she asked LVN B for the DON's phone number and suggested they call the doctor and inform them. She said LVN B told her she made the call and that the DON spoke with the MD and was told the dose was not dangerous. She said she wanted to know why there was no communication for the oncoming nurse who was running late. She said the medication had no harm to the resident. She said she was not happy about the whole deal. She said the facility needed to have some kind of checks and balances for making sure times were followed for medications and she thanked God there was no harm. She said she did not know the name of the male PRN LVN who administered the dose, and a female who administered it too close in time. She said she started monitoring the times meds were given, and there were no problems before or after that day (04/21/26). In an interview with the DON on 05/05/26 at 1:25 pm, she said she did a thorough investigation of all residents LVN A medicated during the time and day of complaints about medication times she received from the RP of Resident #1. She said the audits revealed 6 residents received their morning medications 5 -7 hours late. She said she identified six residents who received medications 3 times a day because they had closer dosing due to the medication error. The DON provided a medication audit report she conducted on 04/22/26 for the date of 04/21/26. She said she asked LVA A why he did not ask for help, and he told her, Everyone else had what they had going on and (he) did not want to bother them. She said there was no way the on-coming shift knew if the medication was given late because the computerized MAR turned green once it was completed/administered. She said the MAR on the computers showed medications on a white background. She said once a medication was in the timeframe of one hour until due, the background turned yellow. She said once a medication was in the timeframe of one hour past due, the background turned red and stayed red until the medication was given. She said the medical director was informed and discussed with all residents. She said the medical director said all 6 residents were ok with the late meds and the on-time/early meds given. She said she spoke with staff about TID meds to make sure of the times given and provided an in-service. She identified LVN A's name was not on the in-service, and said he was given the same packet that included the medication administration policy, medication storage, and medication carts.In a phone interview with LVN A on 05/06/26 at 1:15 pm, he said the DON spoke with him about late medicines to let them know if he was running late with meds. He said on 04/21/26 that he did not tell anyone he needed help. He said he passed meds when he got to the facility, and he had a lot of residents that day. He said the residents all had lots of questions- more than usual, needing help to the bathroom, wanting water, etc. He said he realized he was late when he got to his 2nd hall (500 Hall) because the computer was red. He said he was doing his best to get the meds to the residents. He said there were other nurses and med aides in the facility at the time. He said he had been a nurse for 13 years. He said he was giving morning medicine and that was what he was focused on. He only knew what he had to give and did not look to see what time the doses were to be given. Then he said he had passed meds at this facility before and he knew the med times because the computer showed it. He said as a nurse, meds were supposed to be scheduled BID (twice a day), Q8hrs (every 8 hours), or TID (three times a day) and have an hour before and an hour after the scheduled dosing time. He said he did not contact the doctor about giving the meds late. He said he did not let anyone know he was running late. He said he did not recall anyone asking him if he needed help because he would have taken the help. He said he was doing the morning meds that started at 6:00 am. He said he did not know what time it got to be when he started the second hall (500). He said he had been hopping around to both the 400 hall and the 500 hall passing meds. He said he did not have a routine down and could not explain it. He said he was doing the morning meds and knew the residents had not had anything overnight, so he had to get their medicines to them. He said he was asked by the DON about meds due at 6 am but given at 12 pm. He said every medicine was important and he did not know all of his medications. He said he was pushed into a situation meaning he did not know what he was doing. He said he did not look up medications he was not familiar with. He said none of the residents he medicated asked why the medication was late. He said he did not mention to the on-coming nurse, LVN B, that his medications had been given late.In an interview with LVN B on 05/06/26 at 2:30 pm, she said she was shocked when she heard from the DON that LVN A had given his medications very late. She said she had no idea, because the MAR only showed scheduled times. She said an audit had to be run in order to see actual times. She said the DON showed her the audit from 04/21/26. She said she was alerted to the med error by Resident #1's RP and immediately called the DON, and the DON called the MD. She said she received a call from the DON explaining her conversation with the MD and that there were no adverse reactions. In an interview with the MD on 05/06/26 at 3:00 pm, he said he recalled the situation on 04/21/26 and had spoken with the DON about it. He said that, with the help of the DON, he determined there were no immediate concerns and directed the DON to ensure the residents were monitored closely and to notify him of any concerns. Record review of Resident #1's progress notes dated 04/21/26, beginning at 6:18 pm, revealed the timeline of LVN B being notified of medication times by Resident #1's RP, the call to the DON, and the DON's communication with the MD. Record review of Grievances dated 02/01/26-04/30/26 revealed no identified concerns regarding medications. Record review of an in-service dated 04/22/26- Administering of Medications did not have LVN A's signature.Record review of the facility policy revised December 2012 titled, Administering Medications under policy statement, Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 7. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 18. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled and stored appropriately for 1 of 4 medication carts (300 Hall Nurse Med-Cart) reviewed for labeling and storage.The facility failed to ensure the 300 Hall Nurse Med-Cart was locked and secured, as well as failed to make sure all medications were labeled appropriately.This failure could have placed residents at risk of gaining access to unlocked medications which were not prescribed to them and could have caused them harm. The findings included:An observation on [DATE] at 3:12 PM of the 300 Hall Nurse Med-Cart parked at the nurses' station revealed an unlocked medication cart. The lock on the cart was popped out, and all drawers, except the narcotic drawer, were able to be accessed. There was also an unlabeled and undated tube of Permethrin Cream (a topical cream used to treat Scabies, a contagious skin infestation caused by tiny mites that burrow under the skin) in the med-cart. There were no staff observed at the cart, but there were multiple residents sitting out in the open area close to where the cart was parked. In an interview on [DATE] at 3:48 PM LVN-A stated the 300 Hall Nurse Med-Cart belonged to her, and she had not realized she had not locked the med-cart before walking away. She stated she was only gone a minute to run and grab something. LVN-A stated she knew she was not supposed to leave her med-cart unlocked when she walked away because if left unlocked, residents could have gotten into the med-cart and taken medications which had not belonged to them, which could have caused them harm. She stated she had been in-serviced on this previously, but she could not recall when the in-service was.In an interview on [DATE] at 7:40 PM, the ADON stated it was the nurse's (who was in possession of the med-cart) responsibility to check the cart for any expired or unlabeled medication on each shift. She also stated the nurses know they are supposed to lock their med-carts when they walk away from them so the residents do not get into medications that may harm them. In an interview on [DATE] at 8:15 PM, the DON stated nurses know not to leave their medication carts unlocked because residents could have gained access to the cart and ingested medications which did not belong to them, which could have possibly caused the residents harm. She stated the nurses have been in-serviced previously over locking their medication carts as well as checking their medication carts for expired or unlabeled medications. Record review of the facility's Storage of Medications policy, no date available, revealed 1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. 3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use.

Based on observation, interviews, and record reviews, the facility failed to ensure the resident's right to be free from misappropriation of resident property for one of four residents (Resident #1) reviewed for drug diversion. The facility failed to prevent the misappropriation of 23 Hydrocodone-Acetaminophen 10 mg tablets from being diverted and sold by LVN A for personal gain to LVN B for LVN B's own personal use. This failure could place residents at risk of misappropriation and not receiving their prescribed pain medication as ordered. Findings included:Record review of Resident #1's face sheet revealed an [AGE] year-old female with an admission date of 05/01/25 for a short-term stay for left hip device dislocation. Her discharge date was 08/09/25. Diagnoses included dislocation of the internal left hip prosthesis (artificial hip joint), presence of a left hip artificial hip joint, falls, muscle wasting and weakness, lack of coordination, need for assistance with personal care, and anxiety. Record review of Resident #1's quarterly MDS report dated 05/05/25 revealed Resident #1 had a BIMS score of 14, indicating minimal cognitive impairment, was independent with eating, required moderate assistance with upper body dressing, personal hygiene, and transfers. She required substantial assistance with oral hygiene, toileting, showering, lower body dressing, footwear, and positioning. Resident #1 was frequently incontinent of bladder and bowel. She received PRN pain medication for frequent pain that did not affect her sleep. She rated her average pain at a 6 on a scale from 0 (for no pain) to 10 (for worst pain). She was receiving an antidepressant and opioid pain medication. Record review of Resident #1's Care Plan dated 05/01/25 indicated the following: Date Initiated: 06/25/2025. She was at risk for pain. The resident will not have an interruption in normal activities due to pain through the review date.Date Initiated: 06/25/2025, the resident will not have discomfort related to side effects of analgesia through the review date. The interventions indicated the resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain, identify and record previous pain history and management of that pain and impact on function, and identify previous response to analgesia, including pain relief, side effects, and impact on function.Date Initiated: 06/25/2025: The resident has a surgical incision to the left hip r/t left hip ORIF (Open Reduction/Internal fixation). Date Initiated: 05/01/2025 The surgical wound will heal without complications by review date. The interventions initiated on 05/01/2025 indicated to monitor for signs of infection (redness, warmth, excessive drainage) and report changes to MD. Monitor pain before, during, and after wound care and perform wound care as ordered. Record review of Resident #1's active physician orders dated (started) 05/14/25 revealed Hydrocodone-Acetaminophen Oral Tablet 10-325 MG Give 1 tablet by mouth every 6 hours as needed for pain -Start Date- 05/14/2025 4:45 pm D/C (discontinue) Date-08/09/2025 4:00 pm (Date and time Resident #1 was discharged from the facility).Record review of the packing slip for Resident #1 dated 07/18/25 revealed a card of 60 10mg Norco tablets and a card of 18 10mg Norco tablets were delivered to the facility on [DATE].Record review of the packing slip for Resident #1 dated 08/08/25 revealed a card of 60 10mg Norco tablets and a card of 18 10mg Norco tablets were delivered to the facility on [DATE]. Record review of Resident #1's individual narcotic count sheet dated 08/09/25 revealed her discharge home with 60 tablets of hydrocodone 10-325 mg. There were no other narcotic count sheets for the Month of August 2025. Record review of the label on Resident #1's individual patient's narcotic record (count sheet) dated 08/09/25 lists 2 of 2, filled 08/07/25. Written on the sheet was Resident #1 discharged home 08/09/25 60 (tablets). Record review of Police Case Report #2508110071 revealed Officer #13841 contacted the ADM at the time by phone on 08/11/25 at 3:05 pm. The ADM stated on 08/07/25 a resident requested a pain pill and they were unable to locate the medication or the count sheet. He stated he was notified on 08/08/25 at 4:30 pm and after an internal investigation, he reported it to the state on 08/09/25. He stated both nurses working that night underwent a drug test, and both nurses tested positive however, only one was taking medication that could account for the positive result. He stated LVN A admitted to stealing the narcotics and LVN B admitted to purchasing the narcotics from LVN A for $200.00. He stated both nurses have been suspended. No other information. Record review of Resident #1's EHR (electronic health record) indicated she was no longer in the facility, having been discharged home on [DATE]. On 09/30/25 at 10:00 am, 10/01/25 at 3:10 pm, and 10/02/25 at 11:10 am, neither Resident #1 nor her RP responded to multiple attempts for interview via phone messages and email throughout the investigation. Record review of intake # 1029167 had a note that indicated tulip history identified a potential pattern regarding one of the AP's (alleged perpetrator). The reference was to LVN A at another facility. In an interview with RN K on 09/30/2025 at 3:09 pm, he said he identified the drug diversion involving Resident #1. He said Resident #1 had requested her Norco for pain, and when he went to get it, he did not find the card or the sheet in the binder or the medical records. He said he medicated Resident #1 with Norco he could get from the facility's emergency box. He said that was when he reported it to ADON F, ADON/LVN D, and DON J (at the time). He said over the next few days, several in-services were conducted regarding narcotics, counting, and reporting suspicion. He said DON H implemented a new way of documenting that followed best practices for documentation that included signing out narcotics on the computer and in the binder at the same time, and verifying the morning counts with the rest of the days. He said the verification sheets were for the whole week. In an interview with ADON F on 09/30/2025 at 2:00 pm, she said when RN K came in to work on 08/08/25, he discovered the missing narcotic and the missing count-down sheet for Resident #1. ADON F said she immediately called DON J (at the time), and the nurses were drug tested. ADON F said LVN B told her in the testing room that LVN A did it (stole the narcotic). She said LVN A and LVN B were suspended immediately after their drug tests were collected. She said RN K tested negative, but LVN A tested positive. She said LVN B's drug test was negative. ADON F said the amount was exactly what was missing (23). In an interview with ADON/LVN D on 09/30/2025 at 3:56 pm, she said RN K told her and ADON F Resident #1 was asking for her pain medication (Norco) and she did not have a blister pack or sign-out page. She said she called the pharmacy, and that was when they discovered Resident #1 should have had plenty of Norco left and they had been re-ordered that night by LVN A. She said she and DON J interviewed LVN A and said she told them she did not know where the sheet was and thought RN K had pulled it (indicating there were no more pills in the package). She said LVN B was taken to the office in front of DON J, herself, and ADON F, and LVN B told them she bought the Norco from LVN A, who said they belonged to her relative #3. LVN B told them LVN A popped them from a blister pack into a specimen cup at the facility, and that was how she received them. ADON/LVN D said LVN B told her she bought 23 pills for $200.00. She said LVN B was told to go home and get the pills and bring them back, then she never returned. ADON/LVN D said LVN B called the facility and told them she was not returning. ADON/LVN D said both were suspended and neither of them had come back. She said in-services and full audits were done on all six med carts. She said there were 3 nurse carts and 3 CMA carts. She said the new DON H implemented counting all the blister packs to the med sheets. She said before, they only looked at the number on the blister packs, and not how many blister packs there were. Now they match each blister pack with its own count sheet and its contents to each med sheet. In a phone interview with LVN A on 10/02/2025 at 9:50 am, she said on 08/08/25, someone told her Resident #1 wanted pain medicine. She said when she went to get it (Norco), there was no sheet or card, so she re-ordered it. She said DON J said everyone had to test because the card and count sheet were gone. She said she was called to the office because her drug test was positive. She said she did not think the medication was missing, it just wasn't there. She said the nurses were responsible for the narcotic sheets. She said the narcotic sheets were not in the bins. She said the last medication given should have been with the (empty) blister pack in the bin, but there was nothing there for Resident #1. She said she assumed Resident #1 had run out of the medication, so she called in the refill on 08/08/25. She said she worked Monday through Friday on the 2p-10p shift, and medicated Resident #1 the day before, but could not remember how many pills were in the blister pack. She said DON J told her there were over 50 Norco's not clicked out by her. She said DON J kept asking her about the narcotic sheet, but it was not there, it was not in the binder. She said they narrowed the missing Norco down to her and LVN B. She said ADON F told her LVN B showed them a screenshot from herself (LVN A) about her getting medication for LVN B, but the message was from Relative #3. She said the text message was about Norco. She said Relative #3 had a prescription for Norco but did not take them anymore. She said Relative #3 was using her as a middle person to get the Norco to LVN B. She said she did not know if LVN B ever got the drugs, then said Relative #3 told her LVN B never got the drugs. She said the screenshot she sent to LVN B was from Relative #3 and she gave LVN B Relative #3's phone number so they could do whatever they were going to do. She said there was no talk of money exchanged with her. In a phone interview with DON J on 10/02/2025 at 10:40 am, she said her last day of work at the facility was Friday, 08/08/25. She said on Friday, 08/08/25, near the end of shift, RN K went to ADON F to inform her that he could not find Resident #1's Norco, and it was not in the med cart. She said she asked RN K if it was possible Resident #1's blister pack had been exhausted. She said RN K said no, because he gave it yesterday to Resident #1, and she got it nearly the same time daily. DON J said she and RN K looked through all the carts & binders but found no blister pack or count sheet for Resident #1. She said at that time, she called the interim ADM and was told to begin drug testing. She said she and ADON F split up staff and LVN B went with ADON F. She said ADON F told her that LVN B said it was LVN A. DON J said she called LVN B to her office and was told it was LVN A, because LVN A offered to sell her 22-25 Norcos, and LVN A had been texting her about the deal. DON J said LVN B went on to say, she bought them (the pills) and they were at her house. DON J said they (ADON F and herself) sent LVN B home to get them. She said around 20 minutes later, LVN B called ADON F and told her she was not returning. DON J said at that time, we brought LVN A into her office and had to suspend her. DON J said LVN A refused to sign the counseling form. DON J said LVN A refused to write a statement at that time and told her she would do it at home and email it, but that never happened. She said she did not know how or when LVN A was terminated or quit. Attempts to contact LVN B for an interview were made on 10/01/25 at 5:30 pm, 10/01/25 at 6:30 pm, and 10/02/25 at 11:30 am. None of the calls were answered, and voice messages with a callback number were left on all attempts. In an interview with CMA G on 09/30/25 at 12:28 pm, she said there was an in-service around the time of the incident, including counting medications and new sheets to ensure all drugs were reconciled, as well as the narcotics. She said the narcotics were counted, and there was a sheet for every blister pack that also got counted. She said, Now they count the sheets and the blister packs. She said the nurses were the only ones allowed to give any PRN medications. In an interview with LVN E on 09/30/2025 at 3:25 pm, she said in-services, and a new narcotic sign-out process was introduced to ensure there was a sign-out sheet for each bubble pack. She said they were now counting the pills, the number of blister packs, and the number of sheets at the beginning and end of every shift. In an interview with DON H on 09/30/2025 at 12:58 pm, she said she formulated a spreadsheet to audit narcotics regularly. She said she implemented a new controlled substance/MAR change of shift audit on 09/23/25 that combined everything except the individual resident's narcotic record because that was kept on file. In an interview with CMA L on 09/30/2025 at 1:30 pm, she said DON H implemented a new spreadsheet for auditing the drugs in the carts a couple of weeks ago. She said there was an in-service around the time of the incident. She said the in-service was about counting medications and how to use the new sheets to ensure all drugs were reconciled. She said now they count the sheets and the blister packs. In an interview with the ADM on 10/02/2025 at 8:34 am, she said she was not at the facility at the time of the incident, and there was an interim ADM (unavailable). She said the facility was implementing increased pharmacist audits if concerns arose, as well as regular quarterly and monthly visits. She said department heads were now checking the narcotic counts at the carts with the nurses instead of just looking at the binder, which only contained the signatures. She said she received a phone call from regional that 2 nurses, LVNs A and B were suspended for drug diversion during the investigation and then were terminated. She said a sergeant from the Office of the Attorney General had already been to the facility, but she did not know what his findings were and provided a contact number. Record review of an email between the ADM and pharmacy dated 10/02/25 revealed, I listened to the call, and the nurse did not state her name when she was requesting a refill for Resident #1's Norco. However, we have identified her name from her phone number. The call is attached above. The nurse's name is [LVN A]. In an interview with DON H on 10/02/2025 at 10:30 am, she said she completed full audits of all narcotics on 08/09/25. She said on 10/01/25, she audited LVN A's MARs for July 2025 and August 2025, which revealed 27 instances of undocumented 10mg Norco for Resident #1 in July and 11 instances of 10mg Norco in August. She said she audited all medication carts daily for 4 weeks (08/09/25-09/06/25), then weekly. Record review of all staff in-services:-08/08/25-counting narcotics, documenting the count, verifying the morning counts with the rest of the days, signing out the computer & binder at the same time, resident rights, reporting suspected abuse, neglect, and misappropriation.- 08/19/25-MARS and TARS (treatment administration record), documentation, weekly skin checks, charting on antibiotics and incidents, change of conditions, point of care CNA documentation.- 09/23/25-new controlled substance and MAR change of shift audit sheets, verify the morning counts with the rest of the days. Record review of DON H's daily and weekly drug audits dated 08/09/25-10/01/25 revealed consistent auditing with no identified concerns. In an interview with the ADM on 10/02/25 at 3:00 pm, she said she had tried to call the interim ADM and the sergeant at the OAG as well, yesterday and today, but was unable to reach either of them. Record review of the Facility policy dated December 2012, titled Controlled Substances, revealed 9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. Record review of the facility policy dated October 2014, titled Discarding and destroying Medications, revealed 11. Completed medication disposition records shall be kept on file in the facility for at least two (2) years, or as mandated by state law governing the retention and storage of such records. 13. Staff shall contact the provider pharmacy if they are unsure of proper disposal methods for a medication. Record review of the facility policy dated December 2009, titled Reporting Abuse to Facility Management. Policy statement: It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. Under policy interpretation: 1. Our facility does not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, sponsors, other residents, friends, or other individuals. 2h. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on interview and record review, the facility failed to provide pain management to one resident (Resident#1), of five residents reviewed for pain management, that was consistent with professional standards of practice, her comprehensive person-centered care plan, and her goals and preferences.On 07/14/2025 the facility staff failed to recognize and address Resident #1's pain while providing incontinent care to Resident #1. On 07/14/2025 CNA A failed to alert RN A of Resident #1's expression and exhibition of pain. CNA A continued to provide incontinent care on 07/14/2025 even when Resident #1 exhibited signs and symptoms of pain. This failure could place residents at risk from receiving prompt pain management.The findings include:1. Record review of Resident #1's admission Record, dated 07/19/2025, revealed a [AGE] year-old-female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 was admitted with diagnoses which included cerebral infarction (stroke), altered mental status, muscle wasting and atrophy (tissue wasting), cognitive communication deficit, and thrombocytopenia (blood clotting irregularity). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 11, which meant moderate cognitive impairment. Resident #1 was partial/moderately reliant on staff for ADLs. Record review of Resident #1's care plan, date initiated 04/20/25, documented [Resident #1] has had an actual fall 4/20/25 related to: unsteady gait Actual fall 4/22/25 Actual fall 5/9/25 Actual fall 7/13/25 Goal: Will resume usual activities without further fall incident 4/20/25: grip strips to area in front of toilet. 4/22/25: Visual cues, Call don't fall signs in room. 5/9/25: therapy to assess for therapeutic modifications to wheelchair. 7/13/25: Dycem to wheelchair, pulmar cushion to wheelchair.Record review of Resident #1's progress note documented by RN B effective date 07/13/2025 20:50 (8:50PM) revealed Resident was watching TV in wheelchair in sitting area in front of nurses station. Resident was then observed on floor next to wheelchair on her right side. Resident did not cry out or request any help. Resident was alone in sitting area, no other employees or residents in residents' vicinity. This RN rushed to resident side, assessed for injuries, range of motion, obvious disfigurements, none observed. Resident offered prn pain medication and resident refused. Denies pain to any other areas. Resident assisted up to wheelchair by staff and taken to room, placed in bed. Brief changed and peri-care performed. Resident again observed for injury or deformities. None noted. Resident offered prn pain medication and denied again. Resident further assessed for any other injuries, Resident denies hitting her head or losing consciousness. [Provider] contacted and resident [family member] contacted. [Resident #1] and [family member] refused ER evaluation.Record review of Resident #1's progress note documented by RN A, effective date 07/14/2025 at 03:51 (3:51AM), revealed F/U Fall Day 1/3. No c/o pain/discomfort. No distress noted. No latent injuries noted. Sleeping with eyes closed. RRR, even and unlabored. VS WNL. Record review of Resident #1's progress note documented by RN A, effective date 07/14/2025 at 0:500 (5:00AM) at 0420 (4:20AM) CNA came to alert this nurse that resident was crying out in pain when CNA had to turn her to change her bed. Slight deformity noted to outer right hip area w/ bruising noted. Bruise noted to inside aspect of right knee. Resident is unable to pick up her right leg and screams out in pain every time she is moved or turned. VS - 125/78, 82, 16, 98.9. @ 0434 Called 911; @ 0437 Called [family member] LMOM. EMS arrives to transport resident. Assisted them w/ transfer to stretcher for resident's comfort. @ 0450 Called report to [ER]. Called [family member] back and spoke with her to let her know which hospital EMS was transporting [Resident #1] to. @ 0457 [physician] (notified). @ 0458 Notified DON. Record review of Resident #1's ER record dated 07/15/2025 revealed [AGE] year-old female fall out of wheelchair and sustained a right greater trochanter fracture. MRI completed and confirmed fracture does not show extension into the intertrochanteric area. Ortho deemed her non-operative and she is to follow up in their clinic in 2 weeks with x-rays. Mobilize/ambulate using assistive device. Due to this being an isolated orthopedic injury and is non-op, there are no further interventions or surgeries planned by our service. Tertiary survey was completed and was negative for any new issues, pains, or concerns. 2. Record review of Resident #2's admission Record, dated 07/20/2025, revealed a [AGE] year-old- female who was admitted to the facility on [DATE]. Resident #2 was admitted with diagnoses which included muscle wasting and atrophy (partial or complete wasting away or a part of the body), and lack of coordination. Record review of Resident #2's Quarterly MDS, dated [DATE], revealed Resident #2 had a BIMS score of 15, which meant Resident #2 was cognitively aware. Resident #2 was substantially/maximally reliant on staff for ADLs. Resident #2 was not coded for any neurological deficit that would indicate deficit in cognition. Record review of Resident #2's care plan, date initiated 05/02/2025, documented The resident has an ADL self-care performance deficit r/t left hand Arthritis with contracted fingers, weakness post hospital stay. Goal: The resident will improve current level of function in through the review date. Interventions: Provide the level of assistance resident requires in ADL care as follows: Bed Mobility: Assist X 1 Staff toileting: assist x 1 Staff transfers: assist x 1 Staff dressing/ grooming: assist x 1 staff Eating: limited assist X 1 Staff bathing: assist X 1 Staff M-W-F 6/2. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. PT/OT evaluation and treatment as per MD orders. Resident #2 was not care-planned for any cognition impairments. During an interview on 07/19/2025 at 4:47 PM and 07/20/2025 at 3:48 PM, Resident #2 stated she was Resident #1's roommate. Resident #2 stated she recalled the event on Sunday, 07/13/2025. Resident #2 stated, she recalled Resident #1 being transferred by wheelchair into the room and heard Resident #1 emoting an emotional response. Resident #2 stated the emotional response sounded like an outburst of moaning which indicated to her, Resident #1 was in pain. Resident #2 recalled on 07/13/2025, overhearing RN B (dayshift) on the phone with Resident #1's family member, telling the family member Resident #1 had fallen, but both the family member and Resident #1 voiced no desire for ER transfer. Resident #2 stated she recalled the night shift (10PM-6AM) CNA A enter the room on three separate occasions throughout the night. Resident #2 stated during CNA A's second round, CNA A entered the room, notified Resident #1 she was going to provide care, and overheard Resident #1 verbalizing moans and ow which indicated pain. Resident #2 stated she told CNA A Resident #1 was moaning throughout the night. Resident #2 stated after she notified CNA A, CNA A vacated the room. Resident #2 stated CNA A entered the room for a third round, and again Resident #1 verbalized an exhibition of pain, and Resident #2 stated to CNA A she believed Resident #1 may have broken something after her fall on 07/13/2025, to which CNA A vacated the room, and returned with a nurse. Resident #2 stated after the nurse entered the room, she overheard the nurse instruct CNA A to not move Resident #1, and Resident #1 needed to be sent to the emergency room as something might be broken. Resident #2 stated she recalled roughly around 5AM, EMS arrived and removed Resident #1 from the room. Resident #2 reiterated she saw CNA A enter the room on three separate occasions. Resident #2 stated the first occasion was roughly around 11PM on 07/13/2025, the second around 2-3AM and third around 4-5AM on 07/14/2025. Resident #2 stated on the second and third occasion she smelled bowel movement and stated that was her confirmation CNA A was providing incontinent care. Resident #2 stated Resident #1 was consistently and intermittently moaning throughout the night and voiced to the CNA on the second and third round, Resident #1 was verbally exhibiting pain of moaning. Resident #2 stated on the second occasion when CNA A entered the room and provided care, she overheard Resident #2 scream and complain about her leg hurting. Resident #2 stated it wasn't until the third round around roughly 4AM that she saw a nurse enter the room. During a phone interview on 07/19/2025 at 5:00 PM, CNA A stated when she arrived for her shift around 10:00 PM on 07/13/2025, she did not recall being notified of Resident #1's fall. CNA A stated she rounded on Resident #1 on three occasions. CNA A stated she rounded on Resident #1 around 10:20 PM on 07/13/2025, secondly around 2:30 AM and thirdly around 4:30 AM both on 07/14/2025. CNA A stated during her first round, she provided care to Resident #1, Resident #1 did not seem like herself, as she was quiet and not as talkative, but at the time she did not exhibit any signs or symptom of pain, and when she asked Resident #1 if anything was wrong, Resident #1 verbalized she was okay. CNA A stated during her second round, she provided incontinent care to Resident #1, and during the care Resident #1 was exhibiting signs and symptoms of pain and was moaning throughout incontinent care yet continued to gently complete the incontinent care. CNA A stated during the second round Resident #1 verbalized pain in her right hip. CNA A stated she did not report the pain to charge nurse because as soon as she completed the incontinent care and desisted with moving Resident #1, Resident #1 no longer exhibited pain, and therefore CNA A continued to care for other residents. CNA A stated while she attempted to recall the second and third round on 07/14/2025, Resident #1's pain appeared to get worse while she provided perineal and bowel movement care, and furthermore became difficult to turn Resident #1 as she was exhibiting pain and saying ow when CNA A attempted to turn Resident #1. CNA A stated during her third round, roughly around 4:30 AM, Resident #1 was exhibiting more pain during incontinent care. CNA A stated she was trying to clean Resident #1 without moving her, as an effort to minimize pain, but when she asked Resident #1 what hurt, Resident #1 stated her leg was hurting. CNA A reiterated round two consisted of Resident #1's complaint of pain of the hip area, and on the third round, the pain was of Resident #1's leg. CNA A stated she did not desist with attempting to provide care, as her reasoning was, she could not leave Resident #1 in bowel movement and urine. CNA A stated she was educated to notify the charge nurse when she notices anything irregular. CNA A stated had she had more information about Resident #1's fall, her actions would have been to notify the charge nurse during her second round. CNA A stated she had taken care of Resident #1 before, and Resident #1 was known to lightly moan when she was turned during incontinent care, and did not believe anything was irregular during her first round. CNA A stated she notified RN A on her third round when Resident #1 was exhibiting pain, but did not notify RN A during her second round because Resident #1, after completion of incontinent care, no longer exhibited signs of pain. CNA A stated during her third round, Resident #1 was attempting to assist with movement, as CNA A asked for Resident #1 to lift her buttock but was exhibiting severe pain, therefore could not assist CNA A with incontinent care. CNA A stated she did not desist with providing care on the third round because she needed to get the job done. CNA A stated after she completed Resident #1's incontinent care, she exited the room and went to notify RN A around 4-5AM timeframe. CNA A stated she notified RN A of Resident #1's exhibition of pain, to which she verbalized to RN A she believed something may have been broken. CNA A stated when RN A entered the room, RN A directed her not to move Resident #1, as an intervention to decrease any chance of an injury worsening. CNA A stated RN A stated Resident #1 was going to be transferred to the emergency room, and the paramedics would be transferring her shortly. CNA A stated after her shift was completed on 07/14/2025, she learned Resident #1 had a fall on 07/13/2025. CNA A stated she believed her actions were just and would not have changed the choices she made. CNA A reiterated she did not notify RN A regarding her second round, as Resident #1 discontinued signs and symptoms of pain after incontinent care was completed. CNA gave no definitive answer when asked, what could potentially occur if the charge nurses were not notified when residents exhibit signs and symptoms of pain. CNA A stated during her three rounds, while she was consistently within Resident #1's hallway, and throughout her shift, Resident #1's door was ajar, and never heard any loud outward expression of pain coming from Resident #1's room. During a phone interview on 07/19/2025 at 7:42 PM, RN A stated she worked on Sunday night (10PM-6AM), 07/13/2025. RN A stated on 07/13/2025, during bedside shift report, she was notified of Resident #1's fall, and that RN B (2PM-10PM) stated sometime around 9PM, the Resident #1 fell to the floor and never cried out, nor had any skin irregularities or noticeable contusions that warranted emergent interventions. RN A stated Resident #1 was scheduled for x-rays on 07/14/2025. RN A was told the mobile x-ray company did not have technicians after hours and would need to be completed in the morning on 07/14/2025. RN A stated she rounded on Resident #1 around 11PM and Resident #1 was not exhibiting any signs nor symptoms of pain. RN A stated she rounded on Resident #1 roughly 2-3 times between the hours of 11PM-1AM while assessing Resident #1's Neuro checks. RN A stated additionally she was quietly observing Resident #1 and without turning the light on, observed Resident #1 with her eyes closed, and was not exhibiting any signs nor symptoms of pain. RN A stated as part of the fall protocol neuro checks must be completed. RN A stated she checked vital signs and Neuro checks throughout the night from roughly 11:00PM (07/13/2025) thru 1:00AM (07/14/2025) and completed an assessment roughly around 3:00AM on 07/14/2025, however Resident #1 never verbalized any complaint of pain, or exhibited any signs of pain. RN A stated during her first initial round Resident #1 was not exhibiting any signs nor symptoms of pain. RN A stated it was not until 4-5AM timeframe when CNA A notified her Resident #1 was really hurting. RN A stated once she was notified, she commenced a head-to-toe assessment on Resident #1 and noticed not only a slight deformity to right hip but also exhibiting pain. RN A stated she noticed swelling on the outside of the right end of the femur that met the pelvis and had a purple/red discoloration. RN A stated she immediately called 9-1-1 because her findings were abnormal. RN A stated between the hours of 11:00PM on 07/13/2025 thru 4:00AM on 07/14/2025 she was not notified of any pain concerns for Resident #1. RN A reiterated she was in Resident #1's room consistently throughout the night completing neuro checks, vital signs, and additionally was in the hallway consistently to attend other residents, and never heard any loud outward expression of pain from Resident #1's open door room. RN A stated the protocol for all aides was if they noticed any irregularities including pain, they must notify the nurse. RN A stated the reason aides were mandated to notify the charge nurses of any irregularities was so the nurses could complete an assessment and if warranted would implement interventions to mitigate the issues. RN A stated additionally with every concern, especially pain, the physician must be notified, and the physician's directives would be executed. RN A stated she followed her protocol when she was notified of Resident #1's pain, she immediately called 9-1-1, then notified her managerial staff, physician, and responsible person. RN A stated if CNA A witnessed Resident #1 in pain, she should have been notified immediately and continued to state she directed Resident #1 not to be moved to minimize any further injury exacerbations, which potentially would prevent any negative outcome. RN A stated as a preventative measure she did not want to cause a potential dislodgement of Resident #1's lower extremity, and immediately called 9-1-1. RN A stated she was never notified of CNA A's second round findings regarding Resident #1. RN A stated the scheduled facility x-rays were not completed at the facility due to Resident #1 being transferred to the ER. During an interview at 07/20/2025 at 3:50 PM, the DON stated she was notified on 07/14/2025 by RN A that roughly around the 4-5AM timeframe, Resident #1 was exhibiting signs and symptoms of pain. The DON stated she was notified on 07/14/2025 by the night nurse RN A, via text, that during CNA A's last round roughly around the 4-5AM timeframe, when CNA A completed her last round of incontinent care, Resident #1 was exhibiting signs and symptoms of severe pain. The DON stated CNA A notified RN A she could not turn Resident #1 and was exhibiting pain during care. The DON stated when RN A completed her assessment, RN A observed bruising which warranted further evaluation and called 9-1-1 as the situated necessitated emergent services. The DON stated it was not until the 4-5AM timeframe on 07/14/2025, that she was notified of any additional concerns after Resident #1 fell around 9PM on 07/13/2025. The DON stated if CNA A witnessed any concerns regarding pain or any irregularity, she should have notified RN A immediately to advocate for Resident #1's safety. The DON stated aides were mandated to notify the clinical nurse so the nurses could complete a head-to-toe assessment and should their findings warrant an immediate intervention, the nurse could act swiftly to ensure the well-being of all residents. The DON stated she was unaware of CNA A's second round pain findings regarding Resident #1. The DON stated if RN A implemented a directive to not move Resident #1, it may have been due to precautionary measure to minimize further injury exacerbations. The DON stated potentially if CNA A did not notify RN A when she first witnessed Resident #1 exhibiting pain, there would be a potential for a negative outcome. The DON reiterated she was not notified of any additional pain concerns from when Resident #1 fell on [DATE] around 9PM, to when she was notified by RN A of the pain concern on 07/14/2025 around 4-5AM. The DON stated the physician was notified when Resident #1 had the fall on 07/13/2025 around 8:50PM and additionally when RN A was made aware of Resident #1's pain around 4-5AM on 07/14/2025. Record review of the facility's Acute Condition Changes-Clinical Protocol policy and procedure, date revised December 2015, revealed, .3. Direct care staff, including Nursing Assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse. A. Nursing assistant are encouraged to use the Stop and Watch Early Warning Tools to communicate subtle changes in the resident to the Nurse. Record review of Pain Assessment and Management policy and procedure revise dated March 2015, revealed Pain management is a multidisciplinary care process that includes the following b. Effectively recognizing the present of pain;.5.conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is on set of new pain or worsening of existing pain. 6. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes.

Based on observation, interviews and record reviews, the facility failed to develop and implement resident care policies based upon current professional standards of practice for the preparation, insertion, administration, maintenance and discontinuance of an IV as well as for the prevention of infection at the site to the extent possible for one (Resident #231) of 8 residents review for IV therapy.The facility failed to provide Resident #231 with dressing changes, as ordered by his physician, to his right arm PICC line dressing. The PICC line dressing was dated 06/01/24 and was not changed until 06/24/24, despite the physician orders indicating to change the dressing every seven days.This deficient practice could result in infection or PICC line malfunction and infection.The findings included:Resident #231's Face Sheet dated 06/24/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of: osteomyelitis (bone infection an inflammation of the bone caused by infection, generally in the legs and arm or spine), Acquired absence of other left toe, diabetes mellitus due to underlying condition with foot ulcer, peripheral vascular disease, chronic kidney disease stage 2 mild and type 2 diabetes.Resident #231's admission Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #231 was still in progress. No information could be obtained from this MDS was from admission and the MDS dated [DATE] was still in progress. No information could be obtained from this MDS.Record review of Resident#231's Care Plan dated 06/11/25 revealed no mention of Resident#231's PICC line or the monitoring or maintenance of his line.Record review of Resident #231's Physician's Orders dated 06/24/25 reflected:- PICC [Peripherally Inserted Central Catheter - A long thin flexible tube inserted into a vein in the arm and threaded into a large vein near the heart right upper arm] change IV dressing every 7 days and PRN-Monitor IV insertion site Right upper arm for signs and symptoms of infection/infiltration every shift.Record review of Resident #231's June 2025 Medication Administration Record/Treatment Administration Record 06/26/25 Medication Administration Record/Treatment Administration Record reflected Resident #231's upper right upper arm PICC line dressing had been initialed to indicate the dressing was changed from 06/06/25-06/24/25.In an observation and interview on 06/24/25 at 10:50 AM with Resident #231 revealed he was observed lying in bed watching television. Resident #231 was alert and able to answer questions appropriately. Resident#231 was observed to have a PICC IV to his right upper arm with a dressing covering the insertion site that was dated 06/01/24. Resident #231 stated he told several staff members (although he was not able to provide names of staff) his dressing needed to be changed every 7 days as it was being done in the hospital.In an interview on 06/25/25 at 9:01 AM with RN A, he stated he did not have much contact with Resident #231 as he had just started working 06/24/25 in the hall the resident was currently staying and was aware that the dressing was changed.In an observation and interview on 06/25/25 at 10:30 AM revealed Resident #231 laid in bed and welcomed this surveyor in his room. Resident #231 said the nurse changed his PICC line dressing yesterday after this surveyor visited him on 06/24/25. Observation of Resident #231's right arm PICC line dressing revealed the dressing was intact and dated 06/24/25.In an interview on 06/26/25 at 9:00 AM with CNA F she said Resident #231 never mentioned to her about the IV dressing needing changing and if he had she would have told the charge nurse. CNA F said had seen the dressing several times and it looked fine her with no signs of infection. CNA F said it was her responsibility to inform the nurse if she saw anything out of the ordinary with the dressing or site.In an interview on 06/26/25 at 9:20 AM with RN H revealed she was not informed about the dressing needing to be changed but did know he had a PICC line. RN H said she noticed the dressing was dated 06/01/25 and she was going to change Resident #231's PICC line dressing on 06/20/25 but could not find the correct dressing to change it. RN H stated when she could not find the correct dressing she told the evening nurse, LVN E, about not being able to find the dressing and asked her if she could find the right one and change it.This surveyor attempted to contact LVN E on 06/26/25 and a text was sent to her on the same day, but no response was received throughout the survey.In an interview on 06/26/25 at 9:50 AM with ADON B she said Resident #231's PICC line dressing should have been changed every seven days according to the resident's orders. ADON B said the facility had the proper dressings for the PICC line and it should have been changed. ADON B said the nurses were responsible for making sure the PICC lines were changed. ADON B said she was not made aware of Resident #231's PICC lines dressings not being changed or of any unavailable dressings. The ADON said annual trainings/competencies that included PICC line dressing changes were performed by all nurses. ADON B said all nurses should dressing change skills and training when hired from nursing school and or previous employment. ADON B presented this surveyor with a new dressing change kit to prove there was no lack of dressing change kits. ADON B said the dressing changes and site care were important to reduce infection. ADON B said the facility has a supervisory called Ambassadors that conducted daily rounds that included daily an observation of any medical equipment/supplies the resident had. ADON B said Resident #231's outdated dressing should have not only been noticed and changed by the nurses caring for him on each shift but also should have been noticed by the Ambassador who saw the resident daily.In an interview on 06/26/25 at 10:35 AM with the DON, she said Resident #231's PICC line dressing should have been changed every seven days as ordered by the physician. The DON said all nurses should know how to change a PICC line dressing because they receive that training initially in nursing school and the facility provided them with annual competency trainings which she knew they passed or else they would not be working with the residents. The DON stated all the nurses who cared for Resident #231 since his admission should have been aware when to change his dressing first through the date on his dressing and by the TAR instruction. The DON said Resident #231's Ambassador was ADON B and she had no excuse as to why she did not notice the date on the dressing and when it should have been changed. The DON said the importance for changing the PICC line dressing every seven day and as the physician ordered was to monitor the insertion site and line for any discrepancy and to prevent infection and maintaining the catheter functionality. The DON also said an infection could travel to heart further compromising the residents health and cause major complications.Subsequently interview with ADON B on 06/26/25 at 1:30 PM she stated d she did not physically observe Resident #231's dressing, specifically the date on the dressing when she conducted her Ambassador daily rounds. She said she took it for granted that the charge nurse had changed the dressing.Record review of the facility's policy and procedure dated 04/2016 on PICC/ Central Venous Catheter Dressing Changes states the purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. Change transparent semi-permeable (TSM) dressings at least every 5-7 days and PRN (when wet, soiled or not intact). A physician order is not needed for this procedure.

Based on observations, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #62) of eight residents reviewed for accidents and hazards. The facility failed on 06/24/2025 to ensure floor mats were in place both sides of Resident #62's bed, as indicated on her current comprehensive care plan dated 03/27/25, Resident #62 had five previous falls in the last three months on 05/18/25, 05/24/25, and 06/01/2025. This failure could place residents at risk for injury. The findings included: Record review of Resident #62's face sheet, dated 06/25/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #62 had diagnoses which included Cerebral Infarction (a type of stroke that occurs when flood flow to the brain is blocked, leading to tissue damage due to lack of oxygen) muscle wasting and atrophy, muscle weakness, and lack of coordination. Record review of Resident #62's MDS assessment dated [DATE] indicated he had a BIMS (Brief Interview for Mental Status) score of 4 which indicated, severe cognitive impairment. The MDS also indicated he was dependent on staff for ADL's (Activities of Daily Living.) Record review of Resident #62's care plan dated 03/27/25 reflected the Following: The resident is at risk for falls related to left sided weakness, cognitive impairment. Date Initiated: 03/27/2025. Fall mats at bedside date initiated 03/27/2025. The resident was on pain medication therapy date initiated 03/27/2025. 05/18/25 unwitnessed fall- without injury. 05/24/25 unwitnessed fall without injury. 06/01/2025 unwitnessed fall with injury physician and patient representative notified. Record review of Resident #62's physician's order reflected no orders for fall mats were ordered before survey team entered the facility on 06/24/25. Record review of Resident #62's progress notes dated 05/27/2025 reflected F/U fall day 3 of 3, patient is in bed resting quietly with eyes closed. No signs or symptoms of pain or distress noted thus far. Uses hand bell, (cannot press call button given hand bell) to call for assistance, is within reach. Bed is in lowest position; floor mat is beside bed for safety. Record Review of Resident #62's Fall Risk Assessment/ Morse Fall Scale reflected no assessment had been conducted before survey team entered the facility on 06/24/25. Observation on 06/24/25 at 11:20 AM, revealed Resident #62 was lying in bed watching a football game. Resident #62 had a floor mat on the floor on the left side of his bed but not on his right side. In an interview on 06/25/25 at 4:46 PM with CNA D who stated she had just started employment 2 weeks ago and was not aware of the one fall mat not being in place. If the resident was to have fallen, he could have gotten seriously get hurt. She said the resident could get severely injured for example a broken bone, hit his head against floor or wall get a concussion, and obtain a tear to his skin. If the resident got severely hurt the fall could lead to death. CNA D said the last training she received on falls and accident prevention was two weeks ago. In an interview on 06/25/25 at 4:52 PM with CNA F who stated the resident was supposed to have fall mats by bed. Every staff member was responsible for making sure the fall mats are in place, but the charge nurse was the one responsible for ensuring fall mats are being placed according to residents orders and care plan. The resident could fall and hurt himself the mats are for safety. The resident could have broken a bone, obtained a back injury and gotten paralyzed, or have received head trauma. These injuries could result in death. She stated the resident has had some falls in past. The last time she had a training on falls accidents hazards was 3 months ago at her hiring. In an interview on 06/25/25 at 5:07 PM ADON C said all staff entering the room should be checking for fall mat placement by the bed when the resident was lying in bed. She said it was the nurse's responsibility for making sure the floor mats are in place correctly. Not having mats can be dangerous for resident as a fall can occur and could cause major injury to the resident. She said some of the major injuries could cause death. The last training for fall and accidents and hazards was a month ago. Record review of the facility's Fall Prevention Program Policy dated 09/22 reflected Based on the preceding assessment, the staff and physicians will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for two of six residents (Resident #10 and Resident #21) reviewed for medication errors in that:The facility failed to ensure MA I did not administer Resident #10's blood pressure/pulse altering medications (Metoprolol ER and Amiodarone) on 06/05/25 when her pulse was not within the required parameters per the two physician's orders. The facility failed to ensure MA J did not administer Resident #21's blood pressure/pulse altering medications (Losartan and Nifedipine ER) on 06/01/25, 06/07/25, 06/08/25, 06/09/25, 06/14/25 and 06/21/25 when her blood pressure/pulse was not within the required parameters per the two physician's orders. These failures could place residents who receive blood pressure/pulse altering medications at an increased risk for complications such as decreased blood pressure, decreased pulse, exacerbation of symptoms and disease process, and potential hospitalization.1. Record review of Resident #10's admission record reflected a [AGE] year-old female originally admitted to the facility on [DATE] and most recent admission on [DATE]. Her diagnoses included non-ST segment elevation MI (heart attack), sick sinus syndrome (heart rhythm problems that happen because the heart's natural pacemaker is not working properly causing it to beat too slow, too fast, or irregularly), atrial fibrillation (an irregular, often fast heartbeat), and hypertension (high blood pressure).Record review of Resident #10's annual MDS dated [DATE] reflected a BIMS score of 8 which indicated moderate cognitive impairment.Record review of Resident #10's physician orders on 06/25/25 reflected the following orders:Amiodarone HCl Tablet 200mg. Give 1 tablet by mouth two times a day for abnormal heart rhythm. Hold if BP is below 110/60 or pulse below 60. Start date 04/29/25.Metoprolol Succinate ER Tablet Extended Release 24 Hour 25mg. Give 1 tablet by mouth one time a day for HTN. Hold if BP below 110/60 or pulse below 60. Start date 04/30/25.Record review of Resident #10's June 2025 eMAR reflected on 06/05/25, MA I documented Resident #10's blood pressure as 142/67 and pulse as 54. MA I documented that she administered Resident #10's Amiodarone at 7:59 pm. 2. Record review of Resident #21's admission record reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), atrial fibrillation (an irregular, often fast heartbeat), atherosclerotic heart disease (buildup of fats and other substances in and on the artery walls of the heart causing decreased blood flow and/or clots), and type 2 diabetes (chronic condition that happens when blood sugar levels are persistently high which can lead to heart disease, kidney disease, and stroke). Record review of Resident #21's quarterly MDS dated [DATE] reflected a BIMS score of 12 which indicated mild cognitive impairment.Record review of Resident #21's physician orders on 06/25/25 reflected the following orders:Losartan Potassium Tablet 25mg. Give 1 tablet by mouth two times a day for hypertension. Hold if BP less than 110/60, pulse less than 60. Start date 03/05/25. Nifedipine ER Oral Tablet Extended Release 24 Hour 30mg. Give 1 tablet by mouth one time a day for HTN. Hold if BP is less than 110/60, pulse less than 60. Start date 05/28/25.Record review of Resident #21's June 2025 blood pressure and pulse summaries, June 2025 eMAR and progress notes dated 05/25/25 to 06/25/25 reflected the following:06/01/25 at 7:06 am, Resident #21's blood pressure was 134/74 and pulse was 48. MA J documented on the eMAR an X in the space for both blood pressure and pulse and she did not administer Resident #21's Nifedipine but did administer her Losartan. MA J documented in the progress notes, hold bp for the Nifedipine medication administration note. 06/07/25 there was no documentation of Resident #21's blood pressure or pulse. MA J documented in the eMAR she did not administer Resident #21's Nifedipine but did administer her Losartan. MA J documented in the progress notes, hold bp for the Nifedipine medication administration note. 06/08/25 at 6:29 am, Resident #21's blood pressure was 139/79 and pulse was 50. MA J documented on the eMAR she did not administer Resident #21's Nifedipine but did administer her Losartan. MA J documented in the progress notes, hold bp for the Nifedipine medication administration note.06/14/25 at 6:43 am, Resident #21's blood pressure was 147/78 and pulse was 45. MA J documented on the eMAR she did not administer Resident #21's Nifedipine but did administer her Losartan. MA J documented in the progress notes, hold bp for the Nifedipine medication administration note.06/21/25 at 6:59 am, Resident #21's blood pressure was 166/89 and pulse was 45. MA J documented on the eMAR she did not administer Resident #21's Nifedipine but did administer her Losartan. MA J documented in the progress notes, ?hold bp [sic] for the Nifedipine medication administration note.In an interview on 06/25/25 at 4:05pm, the DON stated if there was a space for the vital signs to be documented on the eMAR, then they should have been documented for each medication that has a space for it. It was not acceptable to put X or NA in the spaces. The DON stated she did not know how the system was allowing NA to be documented. The DON stated the nurse manager and IDT reviewed documentation in morning meetings and audited orders to ensure BP meds had parameters and such. The DON stated, We reviewed eMARs; if we ran reports that showed that a medication was missed, then we took that report and looked at the actual eMAR, but there was nothing flagged if NA or an X was documented instead of the actual vital signs. The DON stated in-services on medication administration and documentation was done often and they had just done an in-service on BP medications and documentation which included documentation if a medication was held due to being outside of parameters within the last couple of weeks. The DON stated they notified the provider if the BP or pulse was really high or really low or consistently high or low. The DON further stated if a blood pressure and or pulse were not checked, it could needlessly lower a resident's blood pressure or pulse which could cause bradycardia (slow heartbeat) or hypotension (low blood pressure).On 06/26/25 at 10:42 am an attempt was made to call MA J, however a recording stated phone was restricted and unable to leave a message.In an interview on 06/26/25, MA K stated it was important to check vital signs before giving medications that could affect them because if you gave a blood pressure medication and their blood pressure was low, you could drop the blood pressure lower which could lead to hypotension, falls, hospitalization and even death.On 06/26/25 at 2:47 pm an attempt was again made to call MA J, however a recording stated phone was restricted and unable to leave a message.Record review of the facility's Administering Medications policy dated 2001 and revised December 2012 reflected in part: 3. Medications must be administered in accordance with the orders, including any required time frame.8. The following information must be checked/verified for each resident prior to administering medications:a. Allergies to medications; andb. Vital signs, if necessary.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments on 1 of 8 medication carts reviewed for storage of drugs. The facility failed to ensure RN A's medication cart located by the nurse's station was locked when not in use on 06/25/2025.This deficient practice could affect residents who have medications on the nurse medication cart and could result in lost medications, drug diversion, or harm due to accidental ingestion of unprescribed medications.During an observation on 06/25/25 at 11:44 AM, a medication cart by the nurse's station appeared to be unlocked. This surveyor opened the top drawer recognizing the medication cart being unlocked while not in use. Multiple medications in bulk bottles and blister packs were easily assessable for removable. RN A was sitting behind the nurse's station and identified himself as being responsible for the unlocked medication cart.In an interview on 06/25/25 at 11:50 AM RN A stated the medication cart should be locked at all times to prevent unauthorized people from accessing the medications within the cart. RN A stated he was getting things out of the cart, went to go chart at the nurse's station and forgot to lock it. RN A stated there was no reason why it was unlocked, and he just forgot. RN A stated staff were in-serviced on locking medication carts when not in use frequently and the DON usually makes rounds throughout the day to ensure all carts are locked. In an interview on 06/25/25 at 04:03 PM the DON stated med carts were supposed to be locked when not in use for safety of the residents, staff, and to prevent a possible drug diversion. The DON stated there was daily in-servicing about ensuring medication carts being locked at all times when not in use. The DON stated she personally makes daily frequent rounds to ensure medication carts were locked. Record review of the facility's Storage of Medications policy dated April 2007 reflected:The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 7. Compartment (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, for 1 (Resident #1) of 5 residents reviewed for care plans. The facility failed to update Resident #1's care plan with the DNR code status after the OOH DNR order was signed by all appropriate parties on [DATE]. This failure could place residents at risk of receiving care out of line with their wishes. Findings included: Record review of Resident #1's face sheet dated [DATE] revealed an [AGE] year-old female with an initial admitted [DATE] and a current admitted [DATE]. Pertinent diagnosis included Unspecified Dementia (dementia without a specific diagnosis or a diagnosis that is not yet known). Resident #1 was discharged on [DATE] due to death. Record review of Resident #1's PPS MDS assessment dated [DATE] revealed a BIMS score of 0 (severe impairment). Record review of Resident #1's comprehensive care plan dated [DATE] revealed the focus [Resident #1] wishes to have CPR performed should the need arise initiated on [DATE] and cancelled on [DATE]. The goal listed for this focus included Resident, family, surrogate will have wishes respected initiated on [DATE] and cancelled on [DATE]. Interventions listed for the focus included: -Ensure chart is properly identified initiated on [DATE] and cancelled on [DATE]. -If resident has no pulse or respirations, initiate CPR initiated on [DATE] and cancelled on [DATE]. Record review of Resident #1's order summary revealed a discontinued order for DNR initiated on [DATE] and ended on [DATE]. Record review of Resident #1's OOH DNR order revealed the document was signed by Resident #1's RP and two non-staff witnesses on [DATE]. The document was signed by the physician on [DATE]. In an interview with LVN A on [DATE] at 9:27 AM, LVN A stated if she did not know a resident's code status, she would check the front page of the MAR. LVN A stated a resident's code status should be listed on the care plan as well. LVN A stated it was important to keep the care plan updated so everyone on the healthcare team knew how to care for the resident. LVN A stated if the code status was incorrect on the care plan it was possible for a resident with a signed OOH DNR to receive CPR or vice versa. In an interview with LVN B on [DATE] at 10:06 AM, LVN B stated if she needed to know the code status of a resident, she would check the resident's MAR or the binder at the nurse's station which contained the code status for all residents at the facility. LVN B stated she did look at resident's care plans to ensure she was up to date on how to care for her residents. LVN B stated if the code status was not accurate in the care plan, it was possible a resident with an active DNR order could receive CPR or a resident with a full code order could not receive CPR. In an interview with the ADON on [DATE] at 11:09 AM, the ADON stated, typically, the social worker updated the code status in the care plan for residents. The ADON stated it was a team effort to ensure the care plans were accurate. The ADON stated if the care plans did not accurately reflect a resident's code status, the resident could receive CPR unnecessarily or not get CPR when they wished to receive it. In an interview with the DON on [DATE] at 1:30 PM, the DON stated nurses could look in PCC or the binder at the nurse's station to determine a resident's code status. The DON stated when a resident wished to go from a full code status to DNR status, they met with the social worker who started the process. The DON stated once the OOH DNR form was signed by all parties, the social worker would inform the nurses to put the new DNR order in the resident's chart. The DON stated it was a team effort to ensure the care plan was updated appropriately. The DON stated if the care plan did not accurately reflect the resident's current plan of care, a nurse could provide inappropriate care to a resident such as using improper transfer methods or not taking a resident's behavior into account. In an interview with the LMSW on [DATE] at 2:24 PM, the LMSW stated she had meetings with families and residents about updating their code status. The LMSW stated once the form was signed by all parties, she informed the DON and charge nurses about the update to the resident's code status. The LMSW stated she was normally the one to update the care plan with the new code status if she uploaded the OOH DNR into PCC. The LMSW stated sometimes the MDS nurse uploaded the DNR into PCC. The LMSW stated she remembered Resident #1 was a DNR but did not know why Resident #1's care plan was not updated with the correct code status. The LMSW stated if a resident's care plan was not updated in a timely manner, staff may not know the current best way to care for a resident. Record review of the facility policy titled Care Plans, Comprehensive Person-Centered last revised on [DATE] revealed the following: .8. The comprehensive, person-centered care plan will: .e. Include the resident's stated goals upon admission and desired outcomes; .i. Reflect the resident's expressed wishes regarding care and treatment goals;

Based on interviews and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident needs, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 (Resident #1) of 4 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #1 to address her behaviors (e.g. yelling, banging on bed/table, throwing items, removing brief). The facility failed to care plan the fall mat for Resident #1. This failure could place the residents at risk of not receiving appropriate interventions and care to meet their current needs as indicated on the comprehensive care plans. The findings included: Record review of Resident #1's face sheet dated 03/06/25 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: traumatic subdural hemorrhage (brain bleed), hemiplegia (left side paralysis), muscle wasting and atrophy, unsteadiness on feet, cognitive communication deficit, type 2 diabetes (high levels of sugar in blood), unspecified dementia, cerebral infarction (stroke), and chronic kidney disease. Record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 7, indicating severe cognitive impairment. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) reflected no behaviors exhibited. Record review of Resident #1's care plan dated 03/06/25 reflected Resident #1 had an ADL self-care performance deficit related to cognitive deficit, weakness, and subdural hematoma. Date initiated: 02/13/25. Resident #1's care plan did not reflect behaviors (yelling, banging on bed/table, throwing items, removing brief). Resident #1 was at risk for falls related to history of falls with subdural hematoma. Date initiated: 02/13/25. Resident #1's care plan did not reflect the fall mat. Interview attempted with Resident #1 on 03/06/25 at 1:00 PM, revealed Resident #1 was discharged . Interview with MDS N on 03/13/25 at 11:00 AM, revealed MDS N said Resident #1 would yell out and was very vocal since she was admitted . MDS N said Resident #1 would mostly yell that she wanted to go home or would sometimes curse at others so it took a lot of redirection and reassuring. MDS N said since it was Resident #1's normal behaviors since admission, the behaviors would not need to be care planned. MDS N said if there was an increase in behaviors or change noted, then that would be care planned. MDS N said whenever they noticed an increase or change of behaviors, then at that point they would have to update the care plan as soon as possible. MDS N said the care plan was updated by the team as they discussed things every morning during their meeting and then decided what could be implemented. Interview with the DON on 03/13/25 at 3:10 PM, revealed the DON said when Resident #1 was first admitted , she would repetitively call out and said hello or I want to go home. The DON said Resident #1 also had behaviors of throwing items since admission. The DON said she recalled the hospital records indicated Resident #1 was on a 1:1 at the hospital and she speculated it was due to behaviors. The DON said Resident #1 would holler out, bang on the bed or table, and throw other items like her brief. The DON said she did not think Resident #1's behaviors had really increased during her stay but her behaviors fluctuated depending on the time of the day. The DON said Resident #1 was more vocal some days than others. The DON said Resident #1's behaviors would have been care planned. The DON said it was important for Resident #1's behaviors to be care planned so that staff were aware and knew what to do if Resident #1 exhibited behaviors. The DON said the care plan would have reflected the interventions implemented specific for Resident #1's behaviors. The DON said for Resident #1 it was a lot of redirection and distraction to address her behaviors. The DON said she was not sure why Resident #1's behaviors were not care planned. The DON said Resident #1 did not have any falls at the facility but they were aware of Resident #1's history of falls prior to admission so Resident #1 had a fall mat at her bedside and the bed low during her stay. The DON said fall mats were care planned for those residents at risk for falls as the fall mats were an intervention. The DON said Resident #1 was at risk for falls since admission. The DON said the fall mat was not care planned for Resident #1 and the DON said she did not know why not. The DON said the care plans were developed by the team. Record review of the facility's Care Plans, Comprehensive Person-Centered policy dated December 2016 reflected - Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 8.g. Incorporate identified problem areas, incorporate risk factors associated with identified problems. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on interviews and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for accuracy of records, in that: The facility failed to document in Resident #1's medical record when Resident #1 was sent to the hospital on 02/25/25 for a CT scan. The facility failed to document the physician's order for the CT scan. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care. The findings included: Record review of Resident #1's face sheet dated 03/06/25 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: traumatic subdural hemorrhage (brain bleed), hemiplegia (left side paralysis), muscle wasting and atrophy, unsteadiness on feet, cognitive communication deficit, type 2 diabetes (high levels of sugar in blood), unspecified dementia, cerebral infarction (stroke), and chronic kidney disease. Record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 7, indicating severe cognitive impairment. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) reflected no behaviors exhibited. Record review of Resident #1's care plan dated 03/06/25 reflected Resident #1 had an ADL self-care performance deficit related to cognitive deficit, weakness, and subdural hematoma. Date initiated: 02/13/25. Record review of Resident #1's orders for entire stay dated 03/06/25 reflected no physician's order documented for the CT scan ordered on 02/25/25. Record review of Resident #1's progress notes dated 03/06/25 reflected no progress notes documented when Resident #1 was sent to the hospital on 02/25/25 for a CT scan. Interview with LVN C on 03/12/25 at 2:00 PM, revealed LVN C said on 02/25/25, the MD ordered a CT scan for Resident #1 as Resident #1 exhibited increased behaviors. LVN C said she took over Resident #1's hall (hall 200) at about 5:45 PM and had to arrange the transport for Resident #1 to be taken to the hospital for the CT scan. LVN C said in between completing tasks and documenting for 2 halls, she forgot to document a progress note in Resident #1's medical record regarding the CT scan or transport. LVN C said the previous nurse, LVN D, had not documented either as that nurse had a personal emergency and left. LVN C said she was not aware if the CT scan order was entered or documented in Resident #1's orders. LVN C said she followed directives from the DON once she took over hall 200 to arrange Resident #1's transport. LVN C said Resident #1 was transported to the hospital on 02/25/25 at around 6 PM. Interview with the DON on 03/12/25 at 6:40 PM, revealed the DON said there was no physician's order documented for the CT scan ordered for Resident #1 on 02/25/25 as it was a verbal order communicated to the hospital staff. The DON said there would be no need to document the order in the chart. The DON said the nurse called in report and gave the hospital staff the information of what was needed and the hospital staff knew what Resident #1 was sent for. The DON said there would be a progress note to show that Resident #1 was sent to hospital for the CT scan and why. Interview attempted with LVN D on 03/12/25 at 7:00 PM. LVN D did not answer. LVN D was no longer employed by the facility. Interview with the DON on 03/13/25 at 3:10 PM, revealed the DON said on 02/25/25, Resident #1 was sent out to a small hospital to get a CT scan. The DON said she was not sure at what time Resident #1 was sent out. The DON said Resident #1 was supposed to come right back so the DON would not expect there to be a progress note documented in the medical record for when Resident #1 was sent out. The DON said she had seen in the past where they documented a progress note when the resident returned from what hospital or doctor's office, what occurred and if they received any new orders. The DON said Resident #1 never returned to them so there was no progress note entered. The DON said the charting and documenting policy indicated to document changes, labs, medications, but not necessarily document a note for sending a resident to the hospital for an in/out procedure like this CT scan for Resident #1. The DON said they had a meeting with the MD and the MD requested a CT scan to check how Resident #1 was doing in comparison to before her admission at the facility because she had a brain bleed. The DON said they never documented notes in the resident's medical record based on the meetings with providers. The DON said the policy for medication and treatment orders indicated that verbal orders must be recorded immediately in the resident's chart. The DON said they had not taken the CT scan as a verbal order, but the MD had requested it and they sent Resident #1 out. The DON said she did not know that an order needed to be inputted for Resident #1 to get a CT scan that was going to be in and out, outpatient procedure. Interview with the ADM on 03/13/25 at 4:00 PM, revealed the ADM said when they sent Resident #1 out to get the CT scan on 02/25/25, the nurse should have documented that Resident #1 was going out for a scan and should have documented the order. The ADM said it was important to have such things documented so the next shift knew what was being done and so they could follow up on test results. The ADM said it was important for the resident's medical record to be complete and accurately documented to ensure there was proper continuity of care. Record review of the facility's Medication and Treatment Orders policy dated July 2016 reflected - 7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and time of the order. Record review of the facility's Charting and Documentation policy dated July 2017 reflected - Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 3. Documentation in the medical record will be objective, complete, and accurate.

Based on observation, record review and interview, the facility failed to provide pharmaceutical services (including the accurate administering of all drugs) to meet the needs of each resident for 1 (Resident #274) of 5 residents reviewed for medication administration. The facility failed to administer the correct dose of Resident #274's scheduled medication (Pramipexole) according to the physician orders. This failure could place residents at risk of not receiving the therapeutic benefits of their prescribed medications. Findings included: Record review of Resident #274's admission record revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included atrial fibrillation (irregular heartbeat), chronic pain syndrome, restless leg syndrome (condition that causes a very strong urge to move the legs), and ends stage renal disease. Record review of Resident #274's comprehensive MDS dated [DATE] revealed resident had a BIMS score of 15 which indicated no cognitive impairment. Observation of medication administration on 05/02/24 at 08:46 AM revealed MA A administered 1 tablet of Pramipexole 0.125mg (instead of 2 tablets to equal 0.25mg) by mouth to Resident #274 as ordered. Observation of the medication label revealed Pramipexole 0.125mg. Give 2 tablets (0.25mg) by mouth one time a day. Record review of Resident #274's physician orders revealed an order for Pramipexole 0.125mg, give 2 tablets (0.25mg) by mouth one time a day related to Parkinson's. In an interview on 05/02/24 at 09:07 AM, MA A stated that giving less than the prescribed dose of a medication could lead to the resident not getting the full desired effect of the medication. MA A said giving the wrong dose of important medications such as blood pressure medications or narcotics could lead to undesired side effects and hospitalization . In an interview on 05/02/24 at 02:48 PM, DON stated that a lower dose of some medications could cause the medication to not have its intended effects and giving a higher dose of some medications could cause adverse reactions. DON stated when a medication error occurs, the person who made the error or the person who discovered the error would initiate a medication error, assess the resident for signs/symptoms of an adverse reaction, and notify the physician. In an interview on 05/02/24 at 02:50 PM, ADON A stated depending on the medication error, the outcome could range from nothing all the way to serious adverse reactions. ADON A stated that anytime a medication error occurred, the physician is to be contacted. The physician would advise if any correction was necessary. Record review of facility's policy and procedure on Administering Medications dated 2021 and revised December 2022 stated in part: -Medications must be administered in accordance with the orders, including any required time frames. -The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

Based on observation and interview the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 8 medication carts (500 Hall Medication Cart) reviewed for medication storage. The facility failed to ensure the 500 Hall Medication Cart was locked when left unattended. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations. The findings included: During a medication administration observation on 05/01/24 at 02:44 PM, MA B was preparing to walk into a resident's room to administer medication when MA B failed to lock the 500 Hall medication cart and left the medication cart unattended. There were no residents in the hallway. In an interview on 05/01/24 at 02:48 PM, MA B came out of the resident's room and took ownership of the unlocked medication cart and stated she did not realize she had left the medication cart unlocked. MA B stated she always made sure to lock the medication cart when not in use and stated she became nervous and just forgot. MA B stated the medication cart should be locked at all times when not in use so unauthorized people could not have access to the medications located inside the medication cart. MA B stated staff are reminded frequently to keep unattended medication carts locked. In an interview on 05/02/24 at 11:30 AM the Administrator stated all medications carts should be locked due to resident safety and to keep the medications secure. The Administrator stated if the medication carts are not locked, anyone could have access to medications that do not belong to them and could cause a possible drug diversion. In an interview on 05/02/24 at 02:14 PM, ADON A stated all medication carts should not be unlocked due to possible drug diversion. ADON A stated staff are reminded often on locking medication carts and in-services on keeping medication carts locked while unattended are conducted quarterly and as needed. ADON A stated charge nurses, ADON's, and DON is responosble to make sure medication carts are locked at all time. In an interview on 05/02/24 02:23 PM, the DON stated all medication carts should be locked at all times when unattended due to possible drug diversion. Record review of Storage of Medications Policy dated 4/2007 stated: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 nutrition room reviewed for kitchen sanitation. 1. The facility failed to maintain a temperature log for the nutrition room freezer 2. The facility failed to ensure the nutrition room freezer had a thermometer 3. The facility failed to ensure the nutrition room freezer was monitored daily for correct temperatures These failures could place residents at risk of foodborne illnesses. Findings include: Observation of the nutrition room on 05/01/24 at 02:05 PM revealed the refrigerator/freezer did not have a thermometer in the freezer, nor a temperature log for the freezer. The nutrition room freezer had a gel-type ice pack in it. An interview with LVN C and the DON on 05/01/24 02:05 revealed they did not see a thermometer in the freezer, and neither could provide the freezer temperature log. LVN C stated the night shift was responsible for logging the freezer temperatures. The DON stated the freezer log was on top of the refrigerator. The DON showed this State Surveyor a temperature log titled, Refrigerator Log which had no spaces or references for freezer temperatures. The DON stated they did not use the freezer. The DON stated if the freezer went out, it could affect the refrigerator as well. When asked how the facility would know if the freezer was going out, the DON stated, Good point. In an interview with the RDM on 05/01/24 at 02:31 PM, she stated nursing staff was responsible for checking the temperatures of the nutrition room refrigerator and freezer and logging the results. The RDM stated the DON told her she assigned random night shift staff for this task. The RDM stated the nutrition room refrigerator was supposed to have a thermometer and a temperature log. The RDM stated the temperature of the freezer in the nutrition room should be monitored daily to ensure it was operating properly. The RDM stated the nutrition room freezer had not been monitored daily. The RDM stated it was important to keep a freezer log and a refrigerator log to make sure items in the refrigerator/freezer did not spoil and cause residents to become ill if they consumed somthing that was not properly cooled or frozen. In an interview with the ADM on 05/02/24 at 2:30 PM, she stated the facility never used that freezer in the nutrition room and was unaware of the regulation that required maintenance and monitoring of all temperature-controlled equipment. The ADM stated they put a thermometer in the freezer, created a log for it, and were now monitoring the freezer in the nutrition room. Record Review of the facility policy titled, Food Receiving and Storage revised 07/2014, reflected Policy Interpretation and Implementation-11. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the Food Service Manager or designee and documented according to state-specific requirements. References: https://www.fda.gov/food/buy-store-serve-safe-food/refrigerator-thermometers-cold-facts-about-food-safety CHILL. Refrigerate foods promptly. Use an appliance thermometer to be sure the temperature is consistently 40 F or below and the freezer temperature is 0 F or below.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for 1 of 6 residents (Resident #54) observed for infection control practices during personal care, in that: Wound Care nurse failed to perform hand hygiene for 20 seconds or greater and exposed Resident #54's wound to an uncleaned surface. This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections. The Findings included: Record review of Resident #54's face sheet dated 5/2/2024 reflected a [AGE] year-old-male with an original admitted [DATE]. Diagnoses included cerebral ischemia (insufficient amount of blood flow to the brain also known as a stroke), atrial fibrillation (abnormal rapid and irregular heart rhythm), and hypertension (high blood pressure). Record review of Resident #54's physician orders indicated: Dated 3/14/2024: stage 3 (pressure ulcer that affects the top two layers of skin as well as fatty tissue) left lateral (side of the body farther from the middle from the middle of the body) heel. every day shift treatment order: cleanse with wound cleanser pat dry apply santyl (topical medication used to treat skin ulcers by removing dead skin and aid in wound healing) then apply calcium alginate (wound dressing that is highly absorbent) then secure with abd (abdominal) pad (pads used for wounds requiring high absorbency) then wrap with kerlix and secure with tape and as needed. Dated 4/24/2024: stage 3 left pressure ulcer lateral calf. every day shift treatment order: cleanse with wound cleanser pat dry apply collagen flakes to wound bed then apply calcium alginate then secure with dry dressing and as needed. Dated 4/24/2024: stage 3 pressure ulcer right lateral foot. every day shift treatment order: cleanse with wound cleanser pat dry apply calcium alginate then secure with dry boarder dressing and as needed. During an observation on 05/02/24 08:42 AM of Resident # 54's wound care, the Wound Care Nurse Washed hands for approximately 15 seconds and put on gloves. After repositioning Resident #54, the Wound Care Nurse took off her gloves and washed her hands for approximately 8 seconds. The Wound Care Nurse put on a PPE gown, gloves, and began Resident #54's wound care to the left lateral heel. The Wound Care Nurse cut off Resident #54's previous bandages, removed and disposed of the PPE gown and gloves and washed hands for approximately 7 seconds and put on a new PPE gown and gloves. The Wound Care Nurse cleansed Resident #54's left lateral heel wound with normal saline and gauze as ordered. The Wound Care Nurse then removed gloves and washed hands for approximately 12 seconds and applied new gloves to pat dry Resident #54's wound. The Wound Care Nurse then applied santyl, calcium alginate and secured with abd pad then wrapped Resident #54's wound in kerlix and secured with tape as ordered. The Wound Care Nurse took off the PPE gown and gloves and washed hands for approximately 8 seconds. The Wound Care Nurse sanitized hands and went to wound care cart to grab the supplies for the next wound care on Resident #54. The Wound Care Nurse washed hands for approximately 13 seconds and put on a new PPE gown and gloves. The Wound Care Nurse removed Resident # 54'sprevious bandage to the left lateral calf, removed gloves and washed hands for approximately 5 seconds. The Wound Care Nurse then put on new gloves and proceeded with Resident #54's wound care as ordered. The Wound Care Nurse then removed gloves and washed hands for approximately 12 seconds and put on new gloves. The Wound Care Nurse removed previous bandages to Resident # 54's right lateral foot, removed gloves and washed hands for approximately 7 seconds. The Wound Care Nurse put on new gloves, propped up Resident #54's right foot on pillow to gain access to Resident #54's wound on the right later heel, removed previous bandage, removed gloves and washed hands for approximately 10 seconds. The Wound Care Nurse returned to Resident #54's bed which revealed Resident #54's right lateral foot wound had come in contact with mattress. The Wound Care Nurse propped up Resident # 54's right foot with a blanket to remove contact with bed, cleansed wound as ordered and removed gloves and washed hands for approximately 12 seconds. In an interview on 05/02/24 at 09:51 AM, the Wound Care Nurse stated she was nervous and that is why she did not wash hands for 20 seconds or greater and she miscounted. The Wound Care Nurse stated handwashing should be for about 20 seconds or greater to make sure to get any bacteria and organisms off the hands that could come in contact with wounds causing cross contamination. The Wound Care Nurse stated the last hand hygiene in-service was approximately a couple weeks ago. The Wound Care Nurse stated it was important to keep wounds away from a potentially contaminated surface, so bacteria and germs do not get into the wound and cause infections and harm the resident. In an interview on 05/02/24 at 11:35 AM, the Administrator stated staff should wash hands for about 30 seconds or greater or enough time to sing happy birthday twice. The Administrator statated it is important to wash hands correctly to stop the spread of germs. In an interview on 05/02/24 at 02:18 PM, ADON A stated hand washing should be 20 seconds or greater as to kill any bacteria and stop the spread of infection. ADON A stated the last in-service on hand hygiene and infection control was approximately a month or two ago. In an interview on 05/02/24 at 02:25 PM, the DON stated hand washing should be approximately 20 seconds are greater to stop the spread of infection for residents, staff and visitors. The DON stated making sure residents wounds are free from cross contamination is crucial to make sure the wound heals properly and not make the wound worse. Record review of Handwashing/Hand Hygiene policy dated 8/2015 stated: This facility considers hand hygiene the primary means to prevent the spread of infections. Washing Hands 1. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature. Hot water is unnecessarily rough on hands. Record review of Infection Control Policy dated 8/2007 stated: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. 2. The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate, and control infections in the facilty; b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public;

Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 2 of 2 grease barrels reviewed for garbage disposal. 1. The facility failed to ensure the grease barrels had tight fitting lids 2. The facility failed to ensure the grease barrel lids were secured 3. The facility failed to ensure the grease barrel lock rings were secured 4. The facility failed to ensure the grease barrels, lids, and lock rings were maintained in good working condition These failures could place residents at risk of infection from improperly disposed garbage. Findings include: Observation of the outdoor grease barrels on 04/30/24 at 10:55 PM revealed two, partially full 55-gallon metal drums of discarded grease. Both barrels had ill-fitting lids that were rusted and bent. Both barrels were missing the lock rings that kept the lids secured tightly. The lock rings were on the ground near the barrels. The lock rings were bent and rusted. In an interview with the RDM on 05/01/24 at 02:35 PM, she stated the facility did not have a regulation in place for the oil barrel rings, and should they get pushed over, it would be an environmental hazard, and cause cross contamination. The RMD stated they should have a policy on keeping the grease barrels safe. In an interview with the MS on 05/01/24 at 3:00 PM, he stated the locking rings on the oil barrels were very hard to place on the barrels for a while. The MS would not say precisely how long. The MS stated he was able to get the lock rings on, but it took him a while because they were bent, and the lids were rusty. The MS stated the lock rings were supposed to be on the barrels at all times except when pouring old grease into them. The MS stated, If the barrels got knocked over, the grease would spill on the ground and attract rodents and cause an environmental hazard because the grease should not be able to pour out onto the ground because it could get tracked back inside the building. In an interview with the ADM on 05/01/24 at 3:30 PM, she stated she looked at the grease barrels. The ADM stated the lids and lock rings were very hard to place on the barrels because the lids were bent and rusted. The ADM stated she was having them replaced. Record review of the facility's policy titled, Food-Related Garbage and Rubbish revised 12/2008, Policy Statement-Food -related garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters. Policy Interpretation and Implementation-2. All garbage and rubbish containers shall be provided with tight fitting lids or covers and must be kept covered when stored or not in continuous use.

Based on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 2 in 5 residents (Resident # 1 and Resident #2) Resident #1 and Resident #2 were given a donated bag with candy that contained a circular bar of soap. Both Resident #1 and Resident #2 ingested pieces of soap which caused reactions in both residents. Both residents required to be sent to the hospital. This failure could place residents at risk for injury or harm. The findings included: Record review of Resident #1's face sheet, dated 07/08/23, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease (progressive disease that destroys memory and other important mental functions), atherosclerotic heart disease of native coronary artery without angina pectoris (narrowed arteries caused by plaque buildup), hypertension (blood pressure that is higher than normal), and chronic kidney disease (damaged kidneys that cannot filter blood as they should) , stage 3 (mild to moderate damage to kidneys). Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1 had BIMS score of 03, indicating she had severe cognitive impairment. MDS also revealed Resident #1 required limited assistance for eating. Record review of Resident #1's care plan, retrieved 07/08/23 with a revised and initiated date of 10/01/2018, revealed, The resident has impaired thought process due to dementia. With an intervention of, cue, reorient and supervise as needed. Record review of Resident #1's nursing noted dated 07/03/23 at 11:51pm by LVN A revealed at approx. 2150 (9:50 PM) this nurse was walking down hallway and heard this resident yelling nurse!. Entered residents' rooms to find her sitting on her bed facing doorway. Immediately noted swelling to bottom lip. No talking or breathing deficits noted at this time. The same nursing note later stated, Resident was brought out nurses' station in wheelchair for closer monitoring while waiting for EMS. While at desk, swelling to residents' tongue/both lips drastically worsen. Resident was talking, then suddenly stopped and respiratory distress was noted. Record review of Resident #1's emergency room visit notes dated 07/03/23 at 11:23PM revealed a section titled Physical Exam Detail which stated, There Is significant soft tissue swelling with nonpitting edema of the upper and lower lips as well as the tongue and floor of the mouth. Record review of Resident #2's face sheet, dated 07/08/23, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: Rhabdomyolysis (breakdown of muscle tissue that releases a damaging protein into the blood), Chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), Parkinson's disease ( brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness and difficulty with balance and coordination), and schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly.) Record review of Resident #2's Medicare 5 day MDS, dated [DATE], revealed Resident #2 had BIMS score of 12, indicating she had a moderate cognitive impairment. MDS also revealed, Resident #2 required supervision for eating. Record review of Resident #2's care plan, retrieved 07/08/23 with a revised date of 07/05/23 and initiated date of 05/08/23, revealed, Resident #2 has impaired cognitive function/impaired thought processes HX (history) of eating items that appear to (be) food items 7/3/23 bit packaged and labeled soap. Record review of Resident #2's nursing note dated 07/04/23 at 12:08AM by LVN A stated, entered room to find resident lying in bed with swelling to bottom lip. Nursing note also stated, EMS came to transfer resident to local hospital. Record review of Resident #1's emergency room visit notes dated 07/03/23 at 11:23PM revealed a section titled Physical Exam Detail which stated, There Is significant soft tissue swelling with nonpitting edema of the upper and lower lips as well as the tongue and floor of the mouth. LVN A was attempted to be reached via telephone on 07/08/23 at 12:40pm, 1:05PM, 2:21PM and 6:05pm with no answer, and voicemail left detailing who was calling and reason for call. No phone call was returned as of 07/20/23 by LVN A. During an interview with Resident #2 on 07/08/23 at 12:45pm she stated she got a bag of candy and there was a piece of soap that she ate and made her sick. She stated had not been made aware that there was a piece of soap in the bag, she stated it looked like a donut and she ate the entire piece of soap. Resident #2 stated her lips got real big and stated the facility had to call an ambulance. She stated staff took the bag away from her. During an interview on 07/08/23 with The Activity Director at 1:57PM she stated on 07/03/23 residents were given bags with chips and candy donated from a youth group. The Activity Director stated that her department was responsible for opening donated bags or boxes to verify the contents. The Activity Director stated that before handing out the bags on 07/02/23 she went through only 1 bag to verify contents and saw chips and candy in the bag. The Activity Director stated she did not see any donut shaped pieces of soap in the one bag she checked. The Activity Director stated she believed only some bags contained pieces of soap in them. The Activity Director stated any staff member should have been able to verify the contents of the donated bags and stated she did look in 1 bag and assumed they were all the same. The Activity Director stated she was not aware or made aware that there was soap in the bags donated. The Activity Director stated because staff was not aware of soap in bags the residents were not made aware either. When asked if any residents had eaten pieces of soap she stated none in her presences but stated she had been made aware that Resident #1 and Resident #2 had an allergic reaction and were sent to the emergency room . The Activity Director stated Resident #1 was so so cognitively impaired and had poor safety awareness. The Activity Director stated she did not know if Resident #1's care plan stated she had impaired thought process due to dementia. When asked if it was safe for Resident #1 to receive a bag the Activity Director stated she only saw chips and candy and nothing hazardous which was okay for Resident #1 to receive. When the Activity Director was asked if Resident #2 was cognitively impaired she stated, I would say with certain things stating that in some situations yes and in others no. The Activity Director stated Resident #2 was not aware of any dangers. The Activity Director stated if she were to look in Resident #2's care plan she's aware it would mention that resident had impaired cognitive function. The Activity Director stated she had previously been trained over preventing accidents and keeping residents free of hazards and stated staff was also in serviced after this incident. The Activity Director stated nursing leadership was responsible for providing the training. The Activity Director was asked how she monitored and supervised residents to prevent accidents and to ensure their environment was free of hazards, The Activity Director stated by making sure residents were free from any items that were hazardous or were a hazard. When the Activity Director was asked what negative impact not appropriately monitoring and supervising residents to ensure they are from hazards could have on the residents, she stated, if you do not then anything can happen. During an interview with Resident #1 on 07/08/23 at 3:39pm when she returned from the hospital Resident #1 stated she thought she had gotten a bag with chips and candy but did not recall a donut, she stated she ate the entire bag and did not get sick. Resident #1 stated she thought she ate something small last week but did not get sick. Resident #1 was unable to recall where she had previously been. During an interview on 07/08/23 at 7:23PM with The Administrator she stated on 07/03/23 residents were provided bags of candy. The Administrator stated she was not aware of anyone checking contents of all bags and stated the Activity Director only checked a couple of bags and did not notice anything in them and assumed the rest were the same. The Administrator was not sure why the Activity Director did not check all the bags. The Administrator stated the Activity Director was responsible for verifying items in bags before handing them out to residents and should have done so. The Administrator stated she was not made aware of pieces of soap in bags and stated she did not know if residents were made aware. The Administrator stated the bags did not contain a piece of soap that looked like a donut but did contain a circular piece of bath soap that was labeled bath soap. The Administrator stated there were 2 residents Resident's #1 and #2 that attempted to eat the soap. The Administrator stated Resident #1 was cognitively impaired, had poor safety awareness and was not able to make her own decisions. The Administrator stated she and staff were aware of Resident #1's care plan stating she had impaired thought process. The Administrator stated Resident #2 was cognitively aware and stated when it came to safety awareness and ability to make her decisions Resident #2 did know it was soap one she took a bite. The Administrator stated she was later made aware by Resident #2's family that she had a history of eating items that look like food. The Administrator stated Resident #1 should not have received on of the bags as it was not safe for her. The Administrator stated she thought Resident #2 was okay to receive bag before she was made aware of her history of eating items that looked like food. The Administrator stated staff was in serviced after the incident and stated her self and DON were responsible for providing training to staff. The Administrator was asked how she monitored and supervised residents to prevent accidents and to ensure their environment was free of hazards, the Administrator stated by making nursing rounds, having managers perform rounds to check the environment for safety, going over incident and accident reports during their morning meetings, and checking for any new orders. When the Administrator was asked what negative impact not appropriately monitoring and supervising residents to ensure they are from hazards could have on the residents, she stated, you could have an accident. During an interview on 07/08/23 at 8:19PM with The DON stated she was not aware of what date the bags had been given to residents, stating she was out that day and was made aware after the fact. The DON stated the contents of the bags should have been checked by activities. The DON stated no staff member verified the contents of the bags before handing them out to residents and she did not know why. The DON stated staff should have verified bags before handing the out to residents. The DON stated she was told there was a piece of soap but did not know if staff or residents were made aware previously as she was not working that day. The DON stated there were 2 residents Resident's #1 and #2 that attempted to eat the soap. The DON stated Resident #1 was cognitively impaired, had poor safety awareness and was not able to make her own decisions. The DON stated she and staff were aware of Resident #1's care plan stating she had impaired thought process. The DON stated Resident #2 was cognitively aware, was able to make her own decisions and a still had some safety awareness intact. The DON stated her, and her staff were aware of Resident #2's care plan stating she had impaired cognitive function. The DON stated she was later made aware by Resident #2's family that she had a history of eating items that looked like food. When asked if it was safe for Resident #1 and #2 to receive one of the bags, the DON stated, the majority of items in the bag were fine for them. The DON stated staff had previously been in serviced over incidents and accidents and were also in serviced after the incident. The DON was asked how she monitored and supervised residents to prevent accidents and to ensure their environment was free of hazards, the DON stated by having department heads check rooms in the morning and report back any issues. When the DON was asked what negative impact not appropriately monitoring and supervising residents to ensure they are from hazards could have on the residents, she stated, if they were not monitoring and ensuring things are safe in the building, accidents can happen. The facility did not have any specific policy that contained verbiage regarding the screening and handling of donated items.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 1 of 1 kitchen reviewed in that: The deep fryer was full of odiferous grease and was inoperable A full-size sheet pan had baked-on brown substances The steamer oven was leaking water There was undated food in the dry storage area There was a container of food with a brown substance all over the outside of it in the dry storage area There was improperly stored food in the dry storage area There were dirty cups in the clean area There was an unlabeled, unidentified paper bag with food in it in the refrigerator There was a marred Teflon pan hanging on the pan rack The facility was not following a cleaning list The ice machine cover was broken The findings included: Initial tour observation on 03/07/23 beginning at 9:05 AM revealed the deep fryer was full of odiferous grease and had floating debris on the surface; the DM T stated it had been sitting since 03/05/23. There was a full-size sheet pan in one of the ovens with a baked-on brown substance. The central sink had been leaking and there were exposed wires in the floor, as the cap to cover them was sitting on the floor, on top of a drain. The steamer oven was leaking water and had a mop bucket to catch the water. There was a 5 lb. jar of peanut butter on the dry storage shelf that was open but had no open date and had peanut butter smeared on the outside of the jar. There were 2 unsealed gallon bags of cereal on the dry storage shelf. There were 30 plastic coffee cups with a powdery white substance in them on the clean rack; one of them had a greasy substance on the outside of it. There was an unlabeled folded paper bag in the refrigerator that contained a sandwich dated 03/06, and a drink. There was a non-stick frying pan hanging on a rack the non-stick surface was very marred and scratched. The DM T could not find the cleaning list. The ice machine cover was broken. An interview with the DM T on 03/07/23 at 9:15 AM stated the deep fryer had gone out on Sunday (03/05/23) and it was not heating properly and he just didn't get to it to empty the grease-it was normally emptied at least weekly. The DM T stated the full-size sheet pan had been used last night (03/06/23) as a drip pan and no one cleaned it or removed it from the oven, and he knew it was there. The DM T stated the gaskets on the steamer had been replaced recently, and now it dripped water out of the front of it. The DM T stated they empty the mop bucket under the steamer every night. The DM T stated he did not know why the peanut butter jar had peanut butter all over it or why it did not have an open date. The DM T stated all food items, whether in storage or under refrigeration, should be labeled with open dates. The DM T removed the 2 unsealed gallon bags of cereal from the dry storage shelf as the surveyor and DM T entered the pantry, stating these shouldn't be here. The DM T stated the coffee cups did not look clean. The DM T stated he checks the coffee cups every morning. The DM T stated the paper bag in the refrigerator was a snack for one of the dialysis patients left over from yesterday and could not say why it did not have a resident's name, date, or label of contents on it. The DM T stated the non-stick pan should have been thrown away long ago. The DM T could not say why the non-stick pan had not been thrown away and that it was not safe-that pieces of the Teflon could get into the food and cause illness. The DM T stated the pan was probably still being used since it was on the pan rack. The DM T stated the process for reporting equipment that needed to be fixed was to place a request in the electronic reporting system, the MS would fix whatever he could, and if the MS could not fix it, he would call the vendor for repairs. The DM T stated he placed a work order in the electronic reporting system for the deep fryer, the ice machine cover (in January, 2023), the central sink and the exposed wires in the floor, and the steamer oven. The DM T stated he did a walk-through every morning and evening to check the cleaning list, and he would clean if something was left undone. The DM T stated if something was not done, he would counsel the employee and take corrective actions, such as a write-up if the employee repeated the error(s). Interview with DM B on 03/07/23 at 9:30 AM stated there was no cleaning list for the staff to initial and she was going to make one. DM B stated she had only been at the facility since 03/02/23 because DM A had to leave for bereavement. DM B stated she was still trying to get a bearing on the facility's kitchen because she had never been there before. Interview with MS on 03/09/23 at 07:19 AM stated, I don't have any idea what is going on with the kitchen. The MS stated the process of reporting equipment that needed to be fixed was work orders go to the electronic reporting system and he had already fixed everything for the kitchen. The MS stated he fixed the light in the office a long time ago. The MS stated he did not know the light in the office was still broken. The MS stated he replaced the ice machine cover yesterday. The MS stated he did not know about the leaking sink or the wiring in the floor. The MS stated he knew about the deep fryer and the vendor was supposed to come yesterday but did not know if he did. The MS stated the restaurant company fixed the steamer oven. The MS stated he was unaware the steamer oven was leaking into a mop bucket. The MS stated the process to report repairs was to place a work order in the electronic reporting system, talk to them [kitchen staff], and discusses it in morning meetings at 9:00 AM every day. The MS stated if he couldn't fix it, he called the company and sometimes told the DM T to call them. The MS stated the DM T had been at the facility for 4 or 5 months. A record review of the electronic reports dated December 1, 2022, through March 9, 2023, revealed only the deep fryer needing repair from the kitchen. The other work orders the DM T stated he completed were not there. An interview with the ADM on 03/09/23 at 09:45 AM revealed there was no certified DM since before he started work at this facility on 02/12/23. The ADM stated there had been several DMs that he knew of, but none of them were full-time. He stated there was an RD that was also not full-time. An interview with DM B on 03/09/23 at 1:30 PM revealed she created and provided a 19-item cleaning list today (03/09/23). DM B stated the list was from this week. DM B stated the initials on the list were hers and DM A's. When asked why the staff was not initialing the list, DM B stated because it was not posted, that DM T kept it in the office. Record review of an undated, 19-item cleaning list revealed no date(s) and 17 initialed boxes of a possible 76. A record review of personnel files for DM A revealed the position she was hired into was for dietary aide on 06/20/16. There were adequate computer-based in-services and a certification for Food Service Managers dated 11/29/21. CMS recognizes the U.S. Food and Drug Administration's (FDA) Food Code and the Centers for Disease Control and Prevention's (CDC) food safety guidance as national standards to procure, store, prepare, distribute, and serve food in long-term care facilities in a safe and sanitary manner. http://www.FoodSafety.gov https://www.fda.gov/food/fda-food-code/food-code-2017

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #59) reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Residents #59's diagnosis of edema resulting in weight loss and gain. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings were: Record review of Resident #59's admission record, dated 03/09/23 revealed an admitted [DATE] and re-admitted [DATE] and was a [AGE] year old male with diagnoses that included sepsis (body's response to infections), acute kidney failure (kidneys suddenly become unable to filter waste products from blood), cauda equina syndrome (collection of nerve roots at bottom of spinal cord that affects legs and lower end of spinal cord), gout (arthritis causing sudden and severe attacks of pain), hydronephrosis (condition of the urinary tract where one or both kidneys swell), dementia (impaired ability to remember, think or make decisions), hypertension (high blood pressure), and depressive disorders (mood disorder characterized by sadness.) Record review of Resident #59's most recent MDS quarterly assessment dated [DATE] revealed the resident's cognitive status was moderately impaired for daily decision-making skills and required extensive assistance by two persons for bed mobility, transfers, dressing. Active diagnosis for Resident #59 included renal insufficiency, renal failure (kidneys lose the ability to filter waste from blood), or end stage renal disease (ESRD). Record review of Resident #59's physician's orders dated 03/09/23 revealed an order for a catheter for urine drainage due to the diagnosis of hydronephrosis with renal and ureteral calculous obstruction, start date, 02/23/23. Record review of Resident #59's care plan, last review/revision date 03/08/23 revealed resident has unplanned/unexpected weight loss r/t acute illness, recent hospitalization had 3 + edema to bilateral (both sides) upper and lower extremities. 2/16/23 -5% change over 30 day(s) [comparison weight 1/25/23, 191 lbs, -13.6%, -26 lbs]. 3/2/23-5% change over 30 day(s), [comparison weight 2/2/23, 190 lbs, -18.9%, -36 lbs.] Interventions included double portions with meals, liquid protein, RD to review and weekly weights until weight is stable. During an observation on 03/07/23 at Resident #59 was observed lying in bed and alert and oriented. Resident said he had lost weight off and on during his stay at the facility since he was admitted on [DATE]. Resident #59 said he had been placed with a catheter that helped drain his urine and the excess weight he had accumulated due to his diagnosis. Record review of Resident #59's weights and vitals indicated Resident #59's weights. 1/4/23 176.1 lbs 1/10/23 177.2 lbs 1/23/23 191.4 lbs 2/2/23 190.0 lbs 2/10/23 164.5 lbs 2/16/23 164.8 lbs 2/24/23 155.0 lbs 3/2/2023 153.5 Lbs Interview on 03/08/23 at 2:55 pm with ADON/LVN B revealed Resident #59 had been out to the hospital on two occasions and was readmitted to facility. ADON/LVN B said Resident #59 had edema +3 (swelling caused by a collection of fluid in the spaces that surround the body's tissues and organs with a level of 3.) ADON/LVN B said Resident #59 had been transferred to the hospital on 01/19/23 and was readmitted to facility on 01/25/23. Resident # 59 was also transferred to the hospital on 02/19/23 and readmitted back to the facility on [DATE]. ADON/LVN B said she had not developed a care plan to address the weight loss and gains for Resident #59 because Resident #59 had not had any weight loss when he was admitted on [DATE]. ADON/LVN A said she had documented on Resident #59's progress notes that addressed his weight loss due to edema. Record review of the progress notes for Resident #59 completed by ADON/LVN A; 02/02/23 Weight Change Note; Weight Warning; Value 190.0 lbs Vital Date; 2023-02-02 MDS: +5.0% change over 30 day(s) [8.0% ,14.0] readmitted [DATE] has edema has decreased weekly weight, POC 02/10/23 Weight Change Note; Weight Warning; Value 164.5 lbs Vital Date; 2023-02-10 MDS: -5% change over 30 day(s) [6.8%, 12.0] admitted with 3+ edema, edema has decreased, weight is back to about baseline will cont POC and RD to review. Interview on 03/09/23 at 8:54 am with MDS Coordinator B revealed ADON/LVN A was responsible to develop and implement the care plans that addressed weights, either loss or gain. An IDT including the charge nurse, DON, MDS Coordinator,team developed all the care plans, and they were updated by the IDT. Interview on 03/09/23 at 8:40 am with ADON/LVN A revealed she said she had not found a care plan that addressed Resident #59's fluctuating weights due to edema but she had just developed a care plan that addressed his weight variances after surveyor had identified there was no care plan to address the weight variance due to Resident #59's edema. ADON/LVN A said she should have developed a care plan to address his weight variance since his weights were varying during the last three months due to edema and after he went to hospital and returned. Resident #59 had edema that changed his weights regularly. The care plans should be developed to provide nurses and staff with goals, time frames for those goals and interventions. Interview on 03/09/23 at 9:02 am with the DON revealed when residents were admitted a baseline care plan was developed. Resident #59's initial admission did not include weight loss and this care area was not developed. ADON/LVN A was in charge of the weight system and care planning and MDS Coordinator B was charge of all care plans. Resident #59's weight variance had been monitored. The DON said the purpose of a care plan was to provide the care needed with interventions and goals with time frames to reach those goals. The DON said there should have been a care plan developed for resident's weight variance due to edema. Interview on 03/09/23 at 9:22 am with ADON/LVN A revealed Resident #59 was readmitted to the facility on [DATE] and between 02/02/23 Resident #59 lost approximately 26 pounds. ADON/LVN A said a care plan should have been developed to address the weight loss due to edema and she had not developed a care plan as needed. ADON/LVN A said she had entered documentation in Resident #59's progress notes and had dietary recommendations to address the weight variances. ADON/LVN A said the causes of edema for Resident #59 would be his diagnosis of hypertension, sepsis, and paralysis of lower extremities. These diagnoses were not care planned. Interview on 03/09/23 at 11:00 am with MDS Coordinator B revealed she was currently working on Resident #59's care plans after he was admitted on [DATE]. MDS Coordinator said she did not have a care plan for edema due to his diagnosis of hypertension, sepsis, and paralysis. MDS Coordinator B said she was responsible to develop these area of care plans for Resident #59 and she had not developed these care plans because she had overlooked this area. Interview on 03/09/23 at 1:15 pm with Resident #59 revealed he had edema due to urine retention. On his return from the hospital on 02/23/23 he had been ordered to use a catheter to help drain his urine. Resident #59 said his weight had fluctuated very much due to this urine retention that was due to health diagnosis. Resident #59 he was not sure how he gained or lost so much weight, but he had lost all the urine that had cause his weight back to what it was currently at. Records of Resident #59's weights and vital reviewed indicated Resident #59's last weight was 153.5 lbs on 03/02/23. Interview on 03/09/23 at 1:25 pm with LVN C revealed a care plan was developed to address the care that was to be provided to each resident. IDT placed their input into care plans to inform nurses and staff of the goals with interventions for the care to be provided to each resident. LVN C said she was not aware of any care plan developed for Resident #59's weight variances due to edema. Record review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated December 2016 indicated. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The Interdisciplinary Team must review and update the care plan when the resident has been readmitted to the facility from a hospital stay.

Based on observation, interview, and record review the facility failed to ensure each resident had the right to be free from neglect for two residents (R #2 and R #4) of 12 residents reviewed for abuse/neglect. The facility lacked structures and processes to prevent residents from harm due to falls. in that: -The facility did not implement their Fall Management Process policy/procedure. -The facility did not implement R #2 and R #4's low bed or floor mats deemed necessary after being assessed as moderately and high risk for falls. -The facility failed to specify which preventive/assistive devices were deemed necessary in R #2 and R #4's Care Plan in attempt to prevent/minimize injury. R #4 was identified as a high risk for falls at the time of his admission. R #4 had a fall two days after his admission, sustaining a laceration on his head requiring three staples. -The facility failed to determine if R #4's injury was due to the facility's failure to provide services, treatment or care. These failures have the potential to result in serious injury or death as a result of a fall and the facility's systems failure. The findings included: 1.) R #2 R #2's Face Sheet dated [DATE] documented a [AGE] year-old female admitted on [DATE] with the [DIAGNOSES REDACTED]. Hypertension, Generalized Muscle Weakness, Dementia, Abnormalities of Gait and Mobility, Heart Failure, and [MEDICAL CONDITION]. R #2 was receiving hospice services. R #2's Morse Fall Scale dated [DATE] identified a score of 25- Moderate Risk for Falling. R #2's Care Plan dated [DATE] documented The resident has an ADL self-care performance deficit r/t (related to) Activity Intolerance, Impaired balance . -BATHING/SHOWERING: The resident requires limited assist by 1 staff with showers. -BED MOBILITY: The resident requires extensive assist by 1 staff to turn and reposition in bed. -DRESSING: The resident requires extensive assist by 1 staff to dress. -PERSONAL HYGIENE: The resident requires extensive assist by 1 staff with personal hygiene and oral care. -TOILET USE: The resident requires extensive assist by 1 staff for toileting. The resident has impaired cognitive function/dementia r/t dementia . The resident has had an actual fall with \ Poor Balance, Poor communication/comprehension, Unsteady gait actual fall [DATE] . -Anticipate and meet the resident's needs. -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. -Ensure that the resident is wearing appropriate footwear non-skid shoes and or non-skid sock when ambulating or mobilizing in w/c. -Follow facility fall protocol. The resident has [MEDICAL CONDITION] r/t [MEDICAL CONDITION] stage 4: no [MEDICAL TREATMENT] services . Monitor and report changes in mental status: lethargy; tiredness; fatigue; tremors; [MEDICAL CONDITION]. The resident has a terminal prognosis and is on .Hospice services. R #2's Significant Change Minimum Data Set ((MDS) dated [DATE] documented R #2: -had short and long-term memory loss and moderately impaired cognitive skills for daily decision making. -required extensive assistance with one person physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. -no falls since admission, re-entry or prior assessment. R #2's undated MDS Kardex Report/CNA (Certified Nurse aide) Care Plan documented Not steady during transitions/walking: moving from seated to standing, walking, turning around, moving on and off the toilet, surface to surface transfer . Accidents- Fall Risk: (there was no documentation in this area) Assistive Devices: (there was nothing specified/documented in this area) R #2's Incident Report dated [DATE] documented [DATE] 10:30 PM - CNA alerted me to room, had found resident on floor. Resident was sitting up on floor in front of bed with walker beside her. Stated she was trying to go to the bathroom. Upper and lower extremities with full range of motion. Denied having pain. Assisted up to wheelchair. No visible injuries found. Immediate Action Taken: Assessed for pain/mobility. Obtained vital signs/neuros. assisted up to wheelchair X2. Floor mats placed and bed in the lowest position when resident in bed. R #2's Post Fall Evaluation dated [DATE] documented Resident Conditions: [MEDICAL CONDITION], Heart Problems, Dementia, Gait/Balance Problems, and Hearing Impairment; Mental Status: Alert; Position at Time of Fall: Walking; Activity at Time of Fall: Responding to bladder urgency; Assistive Devices: Walker. Gets up to restroom frequently, unassisted, bed in low position. HX: Dementia. Bed in low position, call button beside hand, toileted resident. R #2's (MONTH) (YEAR) Consolidated physician's orders [REDACTED]. Observation of R #2, upon initial rounds, on [DATE] at 2:55 PM revealed R #2 was lying in bed with her eyes closed. R #2 did not awaken to verbal stimuli. R #2's bed was of normal height (height of the bed was at the level of the surveyor's upper thighs). Two floor mats rested against the wall across from R #2's bed. Interview with Licensed Vocational Nurse (LVN) A on [DATE] at 2:56 PM revealed she entered R #2's room and verified R #2 was a fall risk. LVN A said R #2 should have had a mat on each side of her bed and her bed in the lowest position to prevent injury in case she falls. While LVN A was lowering the position of R #2's bed, she explained that the previous shift CNA should have put the fall mats in place and the bed in a low position after she put R #2 in bed. LVN A said she and the current CNA had just started their shift and had not finished their rounds to include an observation of R #2. LVN A then placed a mat on the floor of each side of R #2's bed. Interview with CNA B on [DATE] at 2:57 PM revealed she stated she had just begun her shift. CNA B said she had not seen R #2 until now. CNA B stated R #2 was supposed to have her bed in the lowest position when she was in bed and floor mats on each side of the bed because She is a fall risk, she has fallen out of bed before. CNA B said she knew R #2 was a fall risk because she had worked with R #2 for several months and because The mats are in her room. CNA B said she could look up R #2's Kardex electronically and that Kardex would list any devices she was supposed to use and the care she needed. R #2's Nurses Note dated [DATE] 10:48 AM documented had floor mat removed pt (patient) had been using since [DATE] for fall. pt no longer moves by herself she is total assist. floor mat removed due to possibly being a trip hazard for her ambulatory room mate. Interview with the Director of Nurses (DON) and Administrator on [DATE] at 2:11 PM revealed the DON confirmed R #2 was a fall risk and should have had floor mats on each side of her bed and her bed in a low position. The DON said after R #2 had her first fall, the Interdisciplinary Team met and discussed her fall and implemented the use of a low bed and fall mats to prevent injury in case of another fall. After the DON reviewed R #2's Care Plan she confirmed R #2's Care Plan did not include the interventions. The DON stated It should be in the Care Plan and Kardex so staff would know to implement the interventions and to provide continuity of care. The DON said the Assistant Director of Nurses (ADON) and the MDS Nurse/Coordinator were responsible for including the interventions in R #4's Care Plan. The DON and the Administrator were asked if either one of them reviewed or followed-up to ensure R #4's Care Plan was revised after her fall, both confirmed they had not done so. After the DON and Administrator were made aware of the surveyor's observations of R #4 not having her interventions in place, the DON said We discontinued the interventions yesterday since she has not attempted to get out of bed and she is total assist. The DON then confirmed on [DATE], the interventions were still active and should have had them in place. Referencing R #4's Care Plan and when asked what Follow the facility's Fall Protocol meant, the DON and Administrator said I'm not sure what that means, I am assuming it is referring to the Fall Management Process. 2.) R #4 R #4's Face Sheet dated [DATE] documented an [AGE] year-old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #4 expired on [DATE] in the facility. R #4's (MONTH) (YEAR) Consolidated physician's orders [REDACTED]. R #4's Baseline Care Plan dated [DATE] documented Risks for ADL/mobility impairments: [MEDICAL CONDITION], Cognitive deficits. Interventions: Assist with ADLs; Assist with mobility. Incontinent Risks: Impaired mobility; cognitive impairment .Risk Factors for Falls: Cognitive impairment. Resident Goals: Patient will be free of further skin breakdown. Condition: Risks for falls. Interventions: Encourage patient to use call bells, use fall mats PRN (as needed) and leave bed in low position. R #4's Nursing Progress Note dated [DATE] documented Alerted by patient yelling for help followed by a thud at approximately 11:11 PM. Upon entering patient room found patient laying on floor with scant amount of blood on floor and crown of head. Patient sat up and requested to sit in wheelchair assisted with ease and no complaints of pain. Cleaned head no active bleeding, notified provider at 11:15 PM with new order to send to (hospital) for evaluation and treat . The note did not include the use of preventive/assistive devices used for R #4. R #4's Incident Report dated [DATE] documented [DATE] 11:12 PM Alerted by patient yelling for help followed by a thud at approximately 11:11 PM, upon entering patient room, found patient lying on floor with scant amount of blood on floor and crown of head .Injuries: Laceration: Back of head .No witnesses found. The report did not include any use of preventive/assistive devices used for R #4. R #4's Nurse's Note dated [DATE] documented [DATE] 5:27 AM: Patient returned from emergency room at 5:10 AM, CT scans of head negative for any bleeding or fractures. Laceration to back of head was repaired with 3 staples .able to move all extremities, will continue to monitor. The note did not include the use of preventive/assistive devices used for R #4. R #4's Nurse's Notes dated [DATE] documented [DATE] 9:25 AM: Order received to x-ray spine/hip related to pain .Resident resting with bed in low position, call light in reach. Urinal in reach. Positioned for comfort. Fall mats to bilateral floor at bedside. R #4's physician progress notes [REDACTED]. A recommendation for lowered bed height and floor pads placed along side of the bed and frequent surveillance by nursing was made. Review of R #4's Nurse's Notes from [DATE]-[DATE] revealed there was no documentation of R #4 being provided a low bed or floor mats. R #4's Care Plan dated [DATE] documented The resident is moderate risk for falls related to confusion, gait/balance problems, incontinence, poor communication/comprehension .Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; Follow facility fall protocol; Review information on past falls and attempt to determine cause of falls. Record possible root causes. Remove any potential causes if possible . The resident has had an actual fall with poor balance, poor communication/comprehension, unsteady gait .Bed in lowest position; Check range of motion; Continue intervention on the at-risk plan; For no apparent acute injury, determine and address causative factors of the fall . There was no evidence of any revisions made to R #4's Care Plan after his fall on [DATE]. Interview with Certified Nurse Aide (CNA) C on [DATE] at 2:13 p.m. revealed she described R #4 as Confused and would continuously try to get out of bed. CNA C said she worked with R #4 the morning he returned from the emergency roiagnom on [DATE]. CNA C said she did not recall if R #4 had a low bed and said R #4 did not have any floor mats on the floor. CNA C said she knew R #4 was a fall risk prior to his fall because He was confused and tried to get out of bed. He was unsteady. CNA C was informed that R #4's care plan included interventions of a Fall Protocol and an At Risk Plan however, CNA C said she did not know what that was. Interview with CNA D on [DATE] at 2:52 p.m. revealed she stated she worked with R #4 on [DATE] and described R #4 as Confused, he tried to get up a lot, he would try to walk to his chair. I made sure his bed was low but I don't think he had any assistive devices. He may have had a fall mat on the left side of his bed, I am not sure. I would have to look at his Kardex to see if he was supposed to have any devices. CNA D was informed that R #4's care plan included interventions of a Fall Protocol and an At Risk Plan however, CNA D said she did not understand that those interventions were. CNA D said she had not been educated nor had she asked anyone what those interventions meant. Interview with Licensed Vocational Nurse (LVN) G on [DATE] at 8:34 a.m. revealed he stated he found R #4 on the floor on the day of his fall. LVN G said on [DATE], he heard a noise and a yell and upon entering R #4's room, he found R #4 on the floor in front of the foot of his bed on his back. LVN G said R #4 seemed to be walking because there was no chair next to him. LVN G said he was not positive but thought R #4 had a floor mat on the left side of his bed at the time of his fall. LVN G said he had seen R #4, during his rounds, approximately one hour prior to his fall. LVN G said R #4 was Definitely a fall risk, he had Dementia and frequently attempted to get out of bed and ambulate by himself. He had unsteady balance. When asked if he documented specific details of R #4's fall such as where he was found, his position upon discovery, what preventive/assistive devices were in place at the time of the call, the position of the bed, and the location of the call light, LVN G replied I don't believe I did. LVN G did not provide a response when asked why his documentation did not include the above detail of R #4's fall. Referencing R #4's care plan, LVN G was asked to explain what Fall Protocol and At Risk Plan meant however, LVN G said he did not know. Interview with the DON and Administrator on [DATE] at 2:19 PM revealed they said the facility did not need a physician's orders [REDACTED]. The DON explained once the Interdisciplinary Team agreed to a specific intervention, the intervention was written in the care plan, implemented, and in-servicing would be provided to staff to inform them of the change in the plan of care. The DON and Administrator said they did not know if R #4 used a low bed or floor mats. The DON said Case Manager (CM) K would know what devices R #4 used. At 2:28 p.m., CM K joined the DON, Administrator and the surveyor and said she was not sure but thought R #4 used one floor mat due to her bed being against the wall. CM K said she did not think R #4 had any floor mats prior to his fall. CM K said she would confirm with Central Supply about the floor mats. At 2:43 p.m., CM K returned and said a floor mat was placed on each side of the bed on [DATE]. After both DON and Administrator reviewed R #4's Care Plan and Nurses Notes, they both said they could not find any documentation that R #4 was provided with a low bed and floor mats on a consistent basis. The DON and Administrator acknowledged that R #4's preventive/assistive interventions should have been placed in the most current care plan and Kardex. The DON referenced to R #4's Baseline Care Plan that included Floor mats PRN. The DON said her understanding of Floor mats PRN was to put them in place when R #4 was in bed. The DON and Administrator agreed that that intervention was not clear and should have been verified by the nurse that wrote it and any other nurse that saw the intervention. The DON and Administrator did not provide an answer to why R #4's interventions were not included in the comprehensive care plan and Kardex created after the Baseline Care Plan. Referencing R #4's Care Plan dated [DATE], the DON and Administrator could not give a definite explanation of what Follow the facility's Fall Protocol and continue interventions on the At Risk Plan referred to. The DON said The Fall Protocol to me means follow the Fall Management Plan and well, we do not have a At Risk Plan. When asked why was an intervention included in R #4's care plan when it was not practiced by the facility, the DON and Administrator provided no response. The DON and Administrator also could not explain why R #2 and R #4's care plan included an intervention to follow the facility's Fall Protocol when neither the DON or Administrator could explain what the Fall Protocol entailed other than assuming it was the same protocol as the facility's Fall Management Process and the DON saying We should change the titles from Fall Protocol to Fall Management Process. The DON and Administrator agreed that staff probably did not know what those interventions meant since they did not know. At 3:18 p.m., the Chief Operating Officer (COO) provided the surveyor a copy of a blank At Risk Plan which she explained was Like a check-off of the specific interventions that particular resident was assessed as needing. The COO confirmed an At Risk Plan was not implemented for R #2 and R #4. The Administrator explained the interdisciplinary team met daily in the morning meetings Monday-Friday and discussed all incident reports from the prior day. The Administrator said the review of incident reports included a discussion of interventions, how the incident occurred, and why the incident occurred. The Administrator said if any interventions were added or changed, the care plan would be updated to include them. The DON said Other than visual observations during rounds that should be conducted by nursing staff and Administration we have no other procedure when asked what was the facility procedure to monitor correctiveness of care plans and implementation of interventions. At 3:20 p.m., the Administrator again reviewed R #4's care plan, nurses notes, and Incident Report regarding his fall on [DATE], the Administrator confirmed she could not assure any preventive/assistive interventions were in place at the time of the fall. The Administrator agreed that from the documentation, there was no detail information of R #4's position or environment at the time of his fall. The DON responded I don't know when asked if she knew what interventions were in place at the time of R #4's fall to prevent/minimize injury. The surveyor asked the Administrator if she felt that she thoroughly investigated R #4's fall and she responded I see what you mean, well no now I see that the documentation does not show the detail or interventions. The Administrator said she did not report R #4's fall to the state agency but after this interview I understand, I know I have to ask the who, what, why, when, where, and how during my investigation. The Administrator continued to say I did not report it because he was ambulatory. He was confused. It was not an unknown fall, I feel like your asking me to call in all falls. Continued interview with the DON, Administrator, and the COO on [DATE] at 5:40 p.m., revealed the Administrator said she understood and confirmed, We did not have adequate/detailed documentation, assessment or know what interventions or if any interventions were put in place. We did not have a monitoring system for those interventions or for care plan update. The care plan were not updated when they should have been including their interventions. The care plans included interventions that the facility no longer used or knew what they were. Investigation was not thorough and lacked witness statements and detail of the fall and interventions. The Administrator confirmed she and her Administrative team did not follow the facility's Fall Management System. The DON stated I lacked monitoring my nursing staff in ensuring interventions were implemented and lacked to show in our documentation what and when the intervention were put in place. I have no monitoring system to ensure that all this was done. I have don't have a system for follow-up of interventions or monitoring. The Administrator stated We have a system failure that we will immediately correct and restructure. The Administrator confirmed that not knowing if the interventions were in place at the time of the fall, not including the interventions in the care plan, and not having a structured monitoring system would meet the definition of neglect. The Administrator agreed that if she had found the above failures during her investigation, she would have called the state agency to report an allegation of possible Neglect. The Administrator confirmed the facility's investigation of R #4's fall was not thorough. The facility's undated Fall Management Process Policy documented Successful fall management requires a thorough clinical assessment of residents who fall or have a history of falls and their environment. Assist staff in assessing and managing individuals who have a recent history of falls or who are at risk for falling. Staff will help identify ways to modify some of the risk factors for falls, as well as identifying ways to adjust the resident's environment to minimize the risk of injury due to falls. Purpose: To promote an environment as free of accident hazards as possible and to minimize the risks of accidents through supervision and to provide alternatives to decrease injuries from falls while attempting to maintain/improve function .Procedure: 1. Resident is to be assessed for fall risk at time of admission, readmission, change of condition, or after a second fall and quarterly. Utilize Fall Risk Assessment. 2. The care plan should address identified [MEDICATION NAME] and/or extrinsic causes and interventions to eliminate or minimize the cause. The care plan should address identified risks and approaches to prevent falls. After a Fall: 1. Evaluate the resident promptly in order to identify and treat injuries. 2. Complete neuro checks if the fall was unobserved or if the resident hit their head, if loss of consciousness occurs. 3. Licensed nurse or designee- Initiate an incident/Accident Report. The Incident/Accident Report should be placed in the 25 hour report book until completion. 4. Identify the activity that the resident was engaged in at the time the fall occurred. 5. Notify family. 6. Notify physician of fall. 7. Document your fall investigation, notifications, neuro checks, etc in resident's medical record. Also note the fall in the 24 hour report book. 8. After the fall talk to the resident and witnesses to obtain the circumstances of the incident. 9. Investigate the surrounding area where the fall occurred. For example was the floor wet, did the resident have on socks without shoes, etc. If the fall was from the bed, how high was the bed, were the locks engaged on the bed, was the call light in reach, etc . 11. Does the resident have any unmet needs that contributed to the fall, such as, needing to go the rest room, or were they in pain or were they hungry? . 13. Chief Nursing Officer (Director of Nurses) and Executive Director should review the Incident/Accident Report along with the investigation to ensure completeness and make sure any new interventions are in place and effective. Care Planning: The fall management Care Plan should be utilized for all residents that fall. The Care Plan should be develop with resident centered interventions for fall prevention. Utilize data gathered from the Fall Investigation form to determine the root cause of the fall. Any new interventions put in place by the IDT must be communicated to all direct care staff to ensure the interventions stay in place and are effective . The facility's undated Reporting of Allegations of Abuse and Neglect documented Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The facility must determine if an injury, harm or death of a resident was due to facility failure to provide services, treatment or care to a resident. It is the responsibility of all employees to report neglect .

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for two (R #2 and R #4) of three residents reviewed for accidents/falls. 1. The facility did not ensure R #2's preventive devices, such as floor mats and a low bed position were implemented while she layed in bed, as identified by the facility as a necessary intervention. The facility identified R #2 as a moderate risk for falls. 2. The facility failed to specify which preventive/assistive devices were deemed necessary in R #4's Care Plan to prevent/minimize injury. The facility failed to implement interventions, such as a low bed and fall mats, at the time R #4 had a fall on [DATE], which he sustained a laceration on his head requiring three staples. R #4 was identified as a high risk for falls at the time of his admission The facility failed to implement their Fall Management Process for R #4 that included a thorough investigation to evaluate and analyze if R #4 received adequate supervision and assistance devices at the time of his fall. The facility failed to reassess R #4 and his fall risks, determine root causes of fall, and revise the care plan interventions after a fall. These failures have the potential to result in serious injury or death as a result of a fall. The findings included: 1.) R #2 R #2's Face Sheet dated [DATE] documented a [AGE] year-old female admitted on [DATE] with the [DIAGNOSES REDACTED]. Hypertension, Generalized Muscle Weakness, Dementia, Abnormalities of Gait and Mobility, Heart Failure, and [MEDICAL CONDITION]. R #2 was receiving hospice services. R #2's Morse Fall Scale dated [DATE] identified a score of 25- Moderate Risk for Falling. R #2's Care Plan dated [DATE] documented The resident has an ADL self-care performance deficit r/t (related to) Activity Intolerance, Impaired balance . -BATHING/SHOWERING: The resident requires limited assist by 1 staff with showers. -BED MOBILITY: The resident requires extensive assist by 1 staff to turn and reposition in bed. -DRESSING: The resident requires extensive assist by 1 staff to dress. -PERSONAL HYGIENE: The resident requires extensive assist by 1 staff with personal hygiene and oral care. -TOILET USE: The resident requires extensive assist by 1 staff for toileting. The resident has impaired cognitive function/dementia r/t dementia . The resident has had an actual fall with \ Poor Balance, Poor communication/comprehension, Unsteady gait actual fall [DATE] . -Anticipate and meet the resident's needs. -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. -Ensure that the resident is wearing appropriate footwear non-skid shoes and or non-skid sock when ambulating or mobilizing in w/c. -Follow facility fall protocol. The resident has [MEDICAL CONDITION] r/t [MEDICAL CONDITION] stage 4: no [MEDICAL TREATMENT] services . Monitor and report changes in mental status: lethargy; tiredness; fatigue; tremors; [MEDICAL CONDITION]. The resident has a terminal prognosis and is on .Hospice services. R #2's Significant Change Minimum Data Set ((MDS) dated [DATE] documented R #2: -had short and long-term memory loss and moderately impaired cognitive skills for daily decision making. -required extensive assistance with one person physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. -no falls since admission, re-entry or prior assessment. R #2's undated MDS Kardex Report/CNA (Certified Nurse aide) Care Plan documented Not steady during transitions/walking: moving from seated to standing, walking, turning around, moving on and off the toilet, surface to surface transfer . Accidents- Fall Risk: (there was no documentation in this area) Assistive Devices: (there was nothing specified/documented in this area) R #2's Incident Report dated [DATE] documented [DATE] 10:30 PM - CNA alerted me to room, had found resident on floor. Resident was sitting up on floor in front of bed with walker beside her. Stated she was trying to go to the bathroom. Upper and lower extremities with full range of motion. Denied having pain. Assisted up to wheelchair. No visible injuries found. Immediate Action Taken: Assessed for pain/mobility. Obtained vital signs/neuros. assisted up to wheelchair X2. Floor mats placed and bed in the lowest position when resident in bed. R #2's Post Fall Evaluation dated [DATE] documented Resident Conditions: [MEDICAL CONDITION], Heart Problems, Dementia, Gait/Balance Problems, and Hearing Impairment; Mental Status: Alert; Position at Time of Fall: Walking; Activity at Time of Fall: Responding to bladder urgency; Assistive Devices: Walker. Gets up to restroom frequently, unassisted, bed in low position. HX: Dementia. Bed in low position, call button beside hand, toileted resident. R #2's (MONTH) (YEAR) Consolidated physician's orders [REDACTED]. Observation of R #2, upon initial rounds, on [DATE] at 2:55 PM revealed R #2 was lying in bed with her eyes closed. R #2 did not awaken to verbal stimuli. R #2's bed was of normal height (height of the bed was at the level of the surveyor's upper thighs). Two floor mats rested against the wall across from R #2's bed. Interview with Licensed Vocational Nurse (LVN) A on [DATE] at 2:56 PM revealed she entered R #2's room and verified R #2 was a fall risk. LVN A said R #2 should have had a mat on each side of her bed and her bed in the lowest position to prevent injury in case she falls. While LVN A was lowering the position of R #2's bed, she explained that the previous shift CNA should have put the fall mats in place and the bed in a low position after she put R #2 in bed. LVN A said she and the current CNA had just started their shift and had not finished their rounds to include an observation of R #2. LVN A then placed a mat on the floor of each side of R #2's bed. Interview with CNA B on [DATE] at 2:57 PM revealed she stated she had just begun her shift. CNA B said she had not seen R #2 until now. CNA B stated R #2 was supposed to have her bed in the lowest position when she was in bed and floor mats on each side of the bed because She is a fall risk, she has fallen out of bed before. CNA B said she knew R #2 was a fall risk because she had worked with R #2 for several months and because The mats are in her room. CNA B said she could look up R #2's Kardex electronically and that Kardex would list any devices she was supposed to use and the care she needed. R #2's Nurses Note dated [DATE] 10:48 AM documented had floor mat removed pt (patient) had been using since [DATE] for fall. pt no longer moves by herself she is total assist. floor mat removed due to possibly being a trip hazard for her ambulatory room mate. Interview with the Director of Nurses (DON) and Administrator on [DATE] at 2:11 PM revealed the DON confirmed R #2 was a fall risk and should have had floor mats on each side of her bed and her bed in a low position. The DON said after R #2 had her first fall, the Interdisciplinary Team met and discussed her fall and implemented the use of a low bed and fall mats to prevent injury in case of another fall. After the DON reviewed R #2's Care Plan she confirmed R #2's Care Plan did not include the interventions. The DON stated It should be in the Care Plan and Kardex so staff would know to implement the interventions and to provide continuity of care. The DON said the Assistant Director of Nurses (ADON) and the MDS Nurse/Coordinator were responsible for including the interventions in R #4's Care Plan. The DON and the Administrator were asked if either one of them reviewed or followed-up to ensure R #4's Care Plan was revised after her fall, both confirmed they had not done so. After the DON and Administrator were made aware of the surveyor's observations of R #4 not having her interventions in place, the DON said We discontinued the interventions yesterday since she has not attempted to get out of bed and she is total assist. The DON then confirmed on [DATE], the interventions were still active and should have had them in place. Referencing R #4's Care Plan and when asked what Follow the facility's Fall Protocol meant, the DON and Administrator said I'm not sure what that means, I am assuming it is referring to the Fall Management Process. 2.) R #4 R #4's Face Sheet dated [DATE] documented an [AGE] year-old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #4 expired on [DATE] in the facility. R #4's (MONTH) (YEAR) Consolidated physician's orders [REDACTED]. R #4's Baseline Care Plan dated [DATE] documented Risks for ADL/mobility impairments: [MEDICAL CONDITION], Cognitive deficits. Interventions: Assist with ADLs; Assist with mobility. Incontinent Risks: Impaired mobility; cognitive impairment .Risk Factors for Falls: Cognitive impairment. Resident Goals: Patient will be free of further skin breakdown. Condition: Risks for falls. Interventions: Encourage patient to use call bells, use fall mats PRN (as needed) and leave bed in low position. R #4's Nursing Progress Note dated [DATE] documented Alerted by patient yelling for help followed by a thud at approximately 11:11 PM. Upon entering patient room found patient laying on floor with scant amount of blood on floor and crown of head. Patient sat up and requested to sit in wheelchair assisted with ease and no complaints of pain. Cleaned head no active bleeding, notified provider at 11:15 PM with new order to send to (hospital) for evaluation and treat . The note did not include the use of preventive/assistive devices used for R #4. R #4's Incident Report dated [DATE] documented [DATE] 11:12 PM Alerted by patient yelling for help followed by a thud at approximately 11:11 PM, upon entering patient room, found patient lying on floor with scant amount of blood on floor and crown of head .Injuries: Laceration: Back of head .No witnesses found. The report did not include any use of preventive/assistive devices used for R #4. R #4's Nurse's Note dated [DATE] documented [DATE] 5:27 AM: Patient returned from emergency room at 5:10 AM, CT scans of head negative for any bleeding or fractures. Laceration to back of head was repaired with 3 staples .able to move all extremities, will continue to monitor. The note did not include the use of preventive/assistive devices used for R #4. R #4's Nurse's Notes dated [DATE] documented [DATE] 9:25 AM: Order received to x-ray spine/hip related to pain .Resident resting with bed in low position, call light in reach. Urinal in reach. Positioned for comfort. Fall mats to bilateral floor at bedside. R #4's physician progress notes [REDACTED]. A recommendation for lowered bed height and floor pads placed along side of the bed and frequent surveillance by nursing was made. Review of R #4's Nurse's Notes from [DATE]-[DATE] revealed there was no documentation of R #4 being provided a low bed or floor mats. R #4's Care Plan dated [DATE] documented The resident is moderate risk for falls related to confusion, gait/balance problems, incontinence, poor communication/comprehension .Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; Follow facility fall protocol; Review information on past falls and attempt to determine cause of falls. Record possible root causes. Remove any potential causes if possible . The resident has had an actual fall with poor balance, poor communication/comprehension, unsteady gait .Bed in lowest position; Check range of motion; Continue intervention on the at-risk plan; For no apparent acute injury, determine and address causative factors of the fall . There was no evidence of any revisions made to R #4's Care Plan after his fall on [DATE]. Interview with Certified Nurse Aide (CNA) C on [DATE] at 2:13 p.m. revealed she described R #4 as Confused and would continuously try to get out of bed. CNA C said she worked with R #4 the morning he returned from the emergency roiagnom on [DATE]. CNA C said she did not recall if R #4 had a low bed and said R #4 did not have any floor mats on the floor. CNA C said she knew R #4 was a fall risk prior to his fall because He was confused and tried to get out of bed. He was unsteady. CNA C was informed that R #4's care plan included interventions of a Fall Protocol and an At Risk Plan however, CNA C said she did not know what that was. Interview with CNA D on [DATE] at 2:52 p.m. revealed she stated she worked with R #4 on [DATE] and described R #4 as Confused, he tried to get up a lot, he would try to walk to his chair. I made sure his bed was low but I don't think he had any assistive devices. He may have had a fall mat on the left side of his bed, I am not sure. I would have to look at his Kardex to see if he was supposed to have any devices. CNA D was informed that R #4's care plan included interventions of a Fall Protocol and an At Risk Plan however, CNA D said she did not understand that those interventions were. CNA D said she had not been educated nor had she asked anyone what those interventions meant. Interview with Licensed Vocational Nurse (LVN) G on [DATE] at 8:34 a.m. revealed he stated he found R #4 on the floor on the day of his fall. LVN G said on [DATE], he heard a noise and a yell and upon entering R #4's room, he found R #4 on the floor in front of the foot of his bed on his back. LVN G said R #4 seemed to be walking because there was no chair next to him. LVN G said he was not positive but thought R #4 had a floor mat on the left side of his bed at the time of his fall. LVN G said he had seen R #4, during his rounds, approximately one hour prior to his fall. LVN G said R #4 was Definitely a fall risk, he had Dementia and frequently attempted to get out of bed and ambulate by himself. He had unsteady balance. When asked if he documented specific details of R #4's fall such as where he was found, his position upon discovery, what preventive/assistive devices were in place at the time of the call, the position of the bed, and the location of the call light, LVN G replied I don't believe I did. LVN G did not provide a response when asked why his documentation did not include the above detail of R #4's fall. Referencing R #4's care plan, LVN G was asked to explain what Fall Protocol and At Risk Plan meant however, LVN G said he did not know. Interview with the DON and Administrator on [DATE] at 2:19 PM revealed they said the facility did not need a physician's orders [REDACTED]. The DON explained once the Interdisciplinary Team agreed to a specific intervention, the intervention was written in the care plan, implemented, and in-servicing would be provided to staff to inform them of the change in the plan of care. The DON and Administrator said they did not know if R #4 used a low bed or floor mats. The DON said Case Manager (CM) K would know what devices R #4 used. At 2:28 p.m., CM K joined the DON, Administrator and the surveyor and said she was not sure but thought R #4 used one floor mat due to her bed being against the wall. CM K said she did not think R #4 had any floor mats prior to his fall. CM K said she would confirm with Central Supply about the floor mats. At 2:43 p.m., CM K returned and said a floor mat was placed on each side of the bed on [DATE]. After both DON and Administrator reviewed R #4's Care Plan and Nurses Notes, they both said they could not find any documentation that R #4 was provided with a low bed and floor mats on a consistent basis. The DON and Administrator acknowledged that R #4's preventive/assistive interventions should have been placed in the most current care plan and Kardex. The DON referenced to R #4's Baseline Care Plan that included Floor mats PRN. The DON said her understanding of Floor mats PRN was to put them in place when R #4 was in bed. The DON and Administrator agreed that that intervention was not clear and should have been verified by the nurse that wrote it and any other nurse that saw the intervention. The DON and Administrator did not provide an answer to why R #4's interventions were not included in the comprehensive care plan and Kardex created after the Baseline Care Plan. Referencing R #4's Care Plan dated [DATE], the DON and Administrator could not give a definite explanation of what Follow the facility's Fall Protocol and continue interventions on the At Risk Plan referred to. The DON said The Fall Protocol to me means follow the Fall Management Plan and well, we do not have a At Risk Plan. When asked why was an intervention included in R #4's care plan when it was not practiced by the facility, the DON and Administrator provided no response. The DON and Administrator also could not explain why R #2 and R #4's care plan included an intervention to follow the facility's Fall Protocol when neither the DON or Administrator could explain what the Fall Protocol entailed other than assuming it was the same protocol as the facility's Fall Management Process and the DON saying We should change the titles from Fall Protocol to Fall Management Process. The DON and Administrator agreed that staff probably did not know what those interventions meant since they did not know. At 3:18 p.m., the Chief Operating Officer (COO) provided the surveyor a copy of a blank At Risk Plan which she explained was Like a check-off of the specific interventions that particular resident was assessed as needing. The COO confirmed an At Risk Plan was not implemented for R #2 and R #4. The Administrator explained the interdisciplinary team met daily in the morning meetings Monday-Friday and discussed all incident reports from the prior day. The Administrator said the review of incident reports included a discussion of interventions, how the incident occurred, and why the incident occurred. The Administrator said if any interventions were added or changed, the care plan would be updated to include them. The DON said Other than visual observations during rounds that should be conducted by nursing staff and Administration we have no other procedure when asked what was the facility procedure to monitor correctiveness of care plans and implementation of interventions. At 3:20 p.m., the Administrator again reviewed R #4's care plan, nurses notes, and Incident Report regarding his fall on [DATE], the Administrator confirmed she could not assure any preventive/assistive interventions were in place at the time of the fall. The Administrator agreed that from the documentation, there was no detail information of R #4's position or environment at the time of his fall. The DON responded I don't know when asked if she knew what interventions were in place at the time of R #4's fall to prevent/minimize injury. The surveyor asked the Administrator if she felt that she thoroughly investigated R #4's fall and she responded I see what you mean, well no now I see that the documentation does not show the detail or interventions. The Administrator said she did not report R #4's fall to the state agency but after this interview I understand, I know I have to ask the who, what, why, when, where, and how during my investigation. The Administrator continued to say I did not report it because he was ambulatory. He was confused. It was not an unknown fall, I feel like your asking me to call in all falls. Continued interview with the DON, Administrator, and the COO on [DATE] at 5:40 p.m., revealed the Administrator said she understood and confirmed that in regards to R #2 and R #4, We did not have adequate/detailed documentation, assessment or know what interventions or if any interventions were put in place. We did not have a monitoring system for those interventions or for care plan update. The care plan were not updated when they should have been including their interventions. The care plans included interventions that the facility no longer used or knew what they were. Investigation was not thorough and lacked witness statements and detail of the fall and interventions. The Administrator confirmed she and her Administrative team did not follow the facility's Fall Management System. The DON stated I lacked monitoring my nursing staff in ensuring interventions were implemented and lacked to show in our documentation what and when the intervention were put in place. I have no monitoring system to ensure that all this was done. I have don't have a system for follow-up of interventions or monitoring. The Administrator stated We have a system failure that we will immediately correct and restructure. The facility's undated Fall Management Process Policy documented Successful fall management requires a thorough clinical assessment of residents who fall or have a history of falls and their environment. Assist staff in assessing and managing individuals who have a recent history of falls or who are at risk for falling. Staff will help identify ways to modify some of the risk factors for falls, as well as identifying ways to adjust the resident's environment to minimize the risk of injury due to falls. Purpose: To promote an environment as free of accident hazards as possible and to minimize the risks of accidents through supervision and to provide alternatives to decrease injuries from falls while attempting to maintain/improve function .Procedure: 1. Resident is to be assessed for fall risk at time of admission, readmission, change of condition, or after a second fall and quarterly. Utilize Fall Risk Assessment. 2. The care plan should address identified [MEDICATION NAME] and/or extrinsic causes and interventions to eliminate or minimize the cause. The care plan should address identified risks and approaches to prevent falls. After a Fall: 1. Evaluate the resident promptly in order to identify and treat injuries. 2. Complete neuro checks if the fall was unobserved or if the resident hit their head, if loss of consciousness occurs. 3. Licensed nurse or designee- Initiate an incident/Accident Report. The Incident/Accident Report should be placed in the 25 hour report book until completion. 4. Identify the activity that the resident was engaged in at the time the fall occurred. 5. Notify family. 6. Notify physician of fall. 7. Document your fall investigation, notifications, neuro checks, etc in resident's medical record. Also note the fall in the 24 hour report book. 8. After the fall talk to the resident and witnesses to obtain the circumstances of the incident. 9. Investigate the surrounding area where the fall occurred. For example was the floor wet, did the resident have on socks without shoes, etc. If the fall was from the bed, how high was the bed, were the locks engaged on the bed, was the call light in reach, etc . 11. Does the resident have any unmet needs that contributed to the fall, such as, needing to go the rest room, or were they in pain or were they hungry? . 13. Chief Nursing Officer (Director of Nurses) and Executive Director should review the Incident/Accident Report along with the investigation to ensure completeness and make sure any new interventions are in place and effective. Care Planning: The fall management Care Plan should be utilized for all residents that fall. The Care Plan should be develop with resident centered interventions for fall prevention. Utilize data gathered from the Fall Investigation form to determine the root cause of the fall. Any new interventions put in place by the IDT must be communicated to all direct care staff to ensure the interventions stay in place and are effective .

Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent accidents, for four Residents (R #1, # R #3, R #6 and R #12) of 12 residents reviewed for accidents and hazards. 1.)The facility failed to implement individualized interventions after R #3's first fall to decrease the occurrence of a subsequent fall. On [DATE], R #3 was discovered on the floor in her bedroom, was hospitalized with Subdural Hematoma due to a Blunt Head Trauma. R #3 died on [DATE]. 2.) The facility failed to implement appropriate individualized interventions for R #1. R #1 had a fall on [DATE] and was hospitalized due to a small left frontal subarachnoid hemorrhage. 3.) The facility failed to implement interventions to prevent additional fall(s) after each of R#12's falls. R #12 had a total of seventeen unwitnessed falls from [DATE] -[DATE] and [DATE] through [DATE]. 4.) R #6 had a history of [REDACTED]. -implement additional individualized interventions after each fall in attempt to prevent another fall. -ensure R #6's bed was in a low position as per her care plan. -ensure R #6 continually had floor mats as per her care plan R #6 had a total of eight falls in the facility within a two month period. On [DATE], R #6 fell out of her wheelchair and had injury to her left shoulder/arm. R #6 was discovered with a blood clot to her left arm, was not a candidate for anticoagulation therapy or placement of a Superior Vena Cava Filter. R #6 was placed on hospice services and deceased on [DATE]. These failures resulted in Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could affect 95 residents residing in the facility that were identified by the facility to be at fall risk and 54 residents residing in the facility that were identified by the facility to have impaired cognition at risk for serious injuries and/or death and create a loss of dignity and a diminished quality of life. The findings included: 1.) R #3 Record review of R #3's Face Sheet, dated [DATE], revealed R#3 was a [AGE] year old female who was admitted to the facility on [DATE]. R #3 had [DIAGNOSES REDACTED]. Record Review of R #3's Admission/Readmission Data Collection Summary dated [DATE] revealed R #3 was admitted with R (right) Hip replacement, Fracture of Right femur, Peripheral Vascular Disease (PVD), Hypertension (HTN), Colon Cancer, Liver Transplant, and Bronchitis. Further review of balance/gait assessment revealed R#3 required upper extremity support to rise from chair and had joint difficulties/indications or verbalized pain/discomfort. R #3 had a surgical incision her right thigh. R #3 required Oxygen 2 (O 2) 2 liters for bronchitis. Further review revealed R #3 had a Right femur fracture surgery [DATE], also H/O (history of) bilateral hip replacement, and right thigh surgical incision. Review of R #3's Fall Risk Assessment revealed more than three areas were checked, which indicated R #3 was at risk for falls. Implement interventions and complete a Fall Immediate Needs Care Plan. Record review of R #3's Admission Minimum Data Set ((MDS) dated [DATE] revealed R #3 Functional Status required Extensive Assistance (resident involved in activity, staff provide weight-being support) with bed mobility: self-performance and Two person physical assist with support provided. R #3 required Extensive assistance with transfer self-performance and Two person physical assist with transfer support provided. R #3's balance (moving from seated to standing position) was not steady, (only able to stabilize with staff assistance). R #3's balance (moving on and off toilet) was not steady. R #3 used a manual wheelchair for mobility. Record review of R #3's Consolidated Physician order [REDACTED].#3 had additional [DIAGNOSES REDACTED]. Record review of R #3's Interim Plan of Care, undated revealed Toileting done by staff due to recent Right hip fracture, surgical Incision right thigh, with multiple busies, assist to restroom if able to get up, Physical Therapy for Right ORIF (Open reduction internal fixation refers to a surgical procedure to fix a severe bone fracture or break. Open reduction means surgery is needed to realign the bone fracture into the normal position).Mobility: wheelchair, by staff, turn q (every) 2 hr and position, transfer, assist, requires 1 person assist. Review of R #3's Individual Resident Care Plan dated [DATE] revealed R #3 required one person to assist for locomotion/transfer/positioning , wt bearing status - Right partial weight bearing, one person assist with transfers, special equipment use of a wheelchair, and safety was listed as hip precautions. Record review of R #3's Care Plan admission date of [DATE] revealed: *(R #3) had a fractured hip and is at risk for increased pain and limited ambulation, problem onset of [DATE]. Approaches included: provide (R #3) with therapy and restorative care per order, monitor incision site for signs/symptoms of infections increased drainage, temperature, redness, etc-report to MD/RP, Assist with ADLs/repositioning q (every) 2 hours & PRN (as needed)- use positioning devices for proper body alignment . *(R #3) is at risk for falls, Approaches included: Encourage resident to ask for assistance from staff, ensure call light is in reach, answer promptly, therapy to eval and treat per orders, anticipate needs, provide prompt assistance, ensure lighting is adequate and areas are free of clutter. *(R #3) is at risk for side effects from antianxiety medication use, problem onset of [DATE]. R #3 has the potential due to daily diuretic use, problem onset of [DATE]. R #3 is at risk for pain related to FX to R hip, problem onset of [DATE]. * (R#3) requires extensive assist with ADLs, problem onset of [DATE]. Approaches included assist with transfers, turn/reposition every 2 hours and PRN, use padding between pressure areas and position devices for proper body alignment, call light in reach-answer promptly, provide comfort measures. * (R #3) has a [DIAGNOSES REDACTED]. Approaches included: Monitor resident for complaints of fatigue, pain skin, increase heart rate, shortness of breath, chest pain, dizziness, cognitive problems, cold hands/feet and/or headache. Monitor for abnormal bleeding, bruising, or weakness. Report abnormal findings to MD/RP. * (R #3) is frequently incontinent of bladder and bowel, problem onset of [DATE]. Approaches included Briefs or incontinent pad for protection prn, provided pericare after each incontinent episode, check frequently for wetness and soiling, Call bell in reach. Record review of R #3's Fall Risk Evaluation dated [DATE] documented R #3 had a score of 12. The assessment indicated total score of 10 or above represents HIGH RISK. Record review of R #3's 30 Day MDS assessment dated [DATE], revealed R #3 had Limitation of Range of Motion to her Lower extremity on one side. R #3 Health Condition was documented as having no falls since admission date of [DATE], however R #3's Incident Report dated [DATE] revealed R #3 had a fall in her bedroom. Record review of R #3's Resident Incident Report dated [DATE] completed by LVN R, revealed R #3 had a fall with no head injury. The fall occurred at 11:30 p.m. in R #3's bedroom. The Narrative of incident and description of injuries was documented as: Resident had to use the restroom. At the bedside she was pulling down her pants and upon standing she was informed that she was not in the restroom yet and that she would be assisted by the nurse as she turned to sit in the w/c the brake was not applied on both sides and the chair swang out from under her causing her to be guided to the floor. No injuries noted. Immediate Action taken was documented as: Resident was assisted up and assessed for injuries, none noted, MD and RP made aware, cont on the services. Resident condition at the time of incident documented R #3 had taken medications of Analgesics/Narcotics during last 8 hours. R #3's medical risk factors possibly related to the incident was documented as Anemia and B & B urgency. Record review of R #3's Resident Accident/Incident Report dated [DATE] at 11:30 p.m. completed by Licensed Vocational Nurse (LVN) R, revealed R #3 had a fall which occurred in R #3's bedroom. The nature of accident or incident and injuries received and treatment given was documented as: patient had to use the restroom, at bedside, she was pulling her pants down upon standing, informed her she was not in the restroom yet and I would assist her. She turned to sit in her wheelchair, as she attempted to sit, the brake closest to her bed was not applied and the w/c swung out from under her, I guided her to the floor carefully. No injuries noted, denied pain. Intervention documented as: patient was educated on locking brakes on w/c before and after transferring. Further review revealed the Report was not signed by the DON or the Adm. Record review of R #3's Witness Statement completed by LVN R on [DATE] at 11:30 p.m. revealed how the fall occurred as I was with (R#3) at bedside when she stood up from bed, attempted to pull her pants down at the bedside, she stated she had to use the restroom, she then turned to sit in her w/c, brake on the w/c closest to the bed was not in place and the w/c swung out under her and I guided her to the floor than called other nurse for assistance. R #3's reason for the fall was documented as patient had to go to the restroom; appeared slightly confused, brake on w/c was not applied on one side. Record review of R #3's Second Witness Statement completed by CNA Z on [DATE] at 11:30 p.m. revealed EC was summoned to R #3's room to assist with lifting (R#3) off the floor. The report documented according to (R #3) one brake was on and the other one was not. The document further stated R #3's fall occurred in R #3's room next to bed/in front of wheelchair. The reason for the fall was documented as (R #3) was trying to get up by herself to go to the bathroom. Record review of R #3's Accident Investigation Report completed by LVN X dated [DATE] revealed R #3 had a fall w/o injury. R #3 had contributing [DIAGNOSES REDACTED]. Comments from resident was documented as resident ha periods of confusion, is able to say that she attempted to sit down in her w/c w/o locking w/c brakes and fell . Denied any pain. Interventions implemented were documented as therapy referral is on caseload, was also given P O (by mouth) Norco at 11:00 p.m. Recommended inservices: reminded resident to lock w/c brakes prior to transferring. Ensure resident uses call light for assistance. Outcome of investigation: Resident had to use restroom and when she was pulling her pants down upon standing she turned to sit in her w /c as she attempted to sit down the brake was not applied and w/c swang out under her causing her to be guided to the floor. Denied any pain at time of fall. No injuries noted. MD and RP made aware, cont on therapy caseload. Record review of R #3's Fall Management Care Plan dated [DATE] revealed R #3 had an Actual fall r/t brake on w/c not in use, fall without injury, Intrinsic factors: confusion and narcotics. Extrinsic factors: both brakes on w/c must be applied. Approaches included:1) Physical assessment by license nurse to determine injury and treatment plan, 3) Accident/Injury Report complete, 4) Written statements form all staff involved in the fall, 6.) Fall risk assessment completed after each fall, 7) Notify family and M.D. 8) Notify DON for any interventions, 11) Assess to reduce/relieve physical discomfort, pain, or positioning, 12) Assess normal routines for consistency, 14) Night light on and working, 24) Toileting plan in place or implemented, 30) Assistive devices: wheelchair, 37) Continue ongoing assessments and interventional changes, and 39) Educated patient on correct use of brakes on w/c before/after transfers. Further review revealed #5) Investigation follow up complete, #10) Review medications, # 13) listed Gold star on ID card for fall risk,and # 18) Low bed with mats in place and room rearranged for safety, were NOT checked for R #3. Further review of R #3's clinical record revealed no documented evidence of R #3's Toileting plan. Record review of R #3's Daily Skilled Nurse's Notes, Telephone Order, and SBAR Communication Form all dated [DATE] revealed R #3 was sent to the hospital for H & H (Hemoglobin and Hematocrit) low (low hemoglobin is referred to as anemia, low hematocrit transports oxygen in the body) , abnormal labs. Record review of R #3's Daily Skilled Nurse's Notes dated [DATE] revealed R #3 required Max assist X 1 person with transfers /adl's d/t unsteady gait/weakness. Record review of R #3's Daily Skilled Nurse's Notes dated [DATE] revealed R #3 was to continue with assistance with ADls' d/t weakness, as per the day shift. The night shift documented R #3 required Max assist X 1 person with adls/transfers d/t weakness. Record review of R #3's Daily Skilled Nurse's Notes dated [DATE] revealed Resident returned from blood transfusion tired and placed in bed. Record review of R #3's 60 MDS assessment dated [DATE] revealed R #3 Functional Status required Extensive assistance with bed mobility self-performance and one person physical assist with support provided. R #3 required extensive assist with transfers self-performance and one person physical assist with support provided. R #3 required extensive assistance with toilet use self-performance and one person assist physical assist with support provided. R #3 made herself understood and had the ability to understand others. R #3 Brief Interview of Mental Status (BIMS) scored a 13. Record review of R #3's Daily Skilled Nursing Notes dated [DATE] revealed documentation that Family Member is concerned that (R#3) had not had an ammonia level in a while and is more confused than usual. Day shift staff notified MD and pending a response for new orders. The Night shift documented R #3 was noted to have an increase in weakness, pt struggles to pivot when transferring to and from chair. Record review of R #3's Daily Skilled Nurses Notes dated [DATE] revealed Day shift documented Pt is lethargic, unable to feed self, notified MD. The Night Shift documented increased general weakness. Record review of R #3's Lab results dated [DATE] revealed R #3's Ammonia was 101, (expected range ,[DATE]). (Ammonia processes nitrogen in the body and is excreted as waste in the urine, increased level of Ammonia in the blood contributes to muscle weakness, fatigue, or symptoms of liver and kidney damage or failure, allowing waste to remain in the body, can be poisonous and can affect the entire body). Record review of R 3's Daily Skilled Nurse's Notes dated [DATE] revealed documentation the Day Shift noted weakness, received lab results, Ammonia level high, notified MD, Lactulose (is used to treat constipation) increased. R #3 had labs drawn in A.M. Patient is incontinent at night unable to remember to turn on call light with ADL's to assist her. The Night Shift documented Requires maximum assist with transfers/ADLs d/t increased weakness. Record review of R #3's Daily Skilled Nurse's Note dated [DATE] revealed the Night Shift documented pt is lethargic and shows increased weakness. Pt is having a hard time transferring to and from bed. Appears to poss be oversedated, held 11:00 p.m. dose of Norco. Record review of R #3's Daily Skilled Nurse's Notes dated [DATE], the Night Shift documented R #3 continues to show s/s of lethargy and increased weakness. Ammonia results still pending. Record review of R#3's Daily Skilled Nurse's Notes dated [DATE] revealed the Night Shift documented R #3 increased weakness and lethargy noted. Incontinent of B&B (bowel and bladder) rendered by staff. Record review of R #3's Nurse's Notes dated [DATE] at 4:05 a.m. completed by LVN R, revealed LVN R entered R #3 room and observed R #3 crying and laying on the floor on her right side near the foot of her bed with her lower extremities extended. Her w/c was toppled over. When LVN R asked R #3 if she had hit her head, R #3 responded yes. When LVN R asked R #3 what she was going to do, R #3 responded going to the fiesta/reunion, they are coming for me. LVN R documented R #3 complained of pain to her Left clavicle and head. Blood was noted in her mouth. R #3 was assessed by LVN R and noted a small cut to R #3's bottom inner lip, also noted was a bump in the right partial side of R #3's head. NP was notified of incident, Telephone order was given to send R #3 to ER to eval and treat. LVN R attempted to notify DON, unsuccessful but will follow up. FM U was notified R #3 was being sent to a local hospital for evaluation and treatment. Record review of R #3's Resident Incident Report dated [DATE] at 4:05 a.m. completed by LVN X revealed R #3 had a fall w/head injury in R #3's room. The Narrative of incident and description of injures was documented as: Resident was observed laying on her right side on the floor near the foot of the bed with her wheelchair toppled over. Resident was confused and stated at time of the fall that she was going to a reunion/fiesta. Stated that she hit her head. Was on therapy caseload at the time of fall. MD gave order to send to ER and eval and treatment. Immediate Actions Taken documented R #3 was assessed, ROM MD and RP made aware. Resident Condition at Time of Incident documented medical risk factors possibly related to incident of Fall History, Confusion/Disorientation and B & B Urgency. Record review of R #3's Resident Accident/Incident Report dated [DATE] at 4:05 a.m. completed by LVN R revealed R #3 had a fall in R #3's bedroom. The nature of accident or incident and injuries received and treatment given was documented as Pt was observed laying on her right side on the floor near the foot of the bed with her wheelchair toppled over. She stated that she hit her head when asked where she was going in Spanish; she said the fiesta/reunion that they were coming for her. Oriented her to time and place, vs taken, neuro, ROM, incont care rendered. Intervention: called NP gave TO to send (R #3) out to ER to eval and treat vs taken, neuro, ROM /Incontinent care. Record review of R #3's Witness Statement dated [DATE] completed by CNA Z revealed R #3 had a fall approximately 4:05 a.m. in R #3's bedroom. Documentation noted pt got up by herself and fell , according to patient; she was getting up to go to a party/reunion. Record review of R #3's Second Witness Statement dated [DATE] completed by CNA AA revealed CNA AA clocked in from break while doing round found patient on floor. Documentation noted patient got herself out of bed and was confused. Record review of R #3's Third Witness Statement dated [DATE] completed by LVN R revealed R #3 had a fall in her room at 4:05 a.m. LVN R documented she observed R #3 laying on the floor near the foot of her bed and patient stated she was going to a fiesta/reunion. Record review of R #3's Accident Investigation Report dated [DATE] completed by LVN X revealed R #3's nature of incident was a fall with injury. [DIAGNOSES REDACTED]. Comments from the resident was documented as Resident has impaired cognition d/t Dementia and Anemia was unable to recall why she fell but at the time of fall stated she was going to the fiesta/reunion. Interventions implemented: therapy referral-on caseload. Recommended Inservices: MD was made aware and new order given to send to ER for eval and treat. Outcome of investigation Resident was observed laying on her right side on the floor near the foot of her bed with w/c toppled over. Stated that she hit her head when asked where she was going, she stated the fiesta/reunion. MD and RP made aware, was on therapy caseload at time of fall. Record Review of R #3's SBAR Communication Form dated [DATE] revealed R #3 had an unwitnessed fall with an injury. Primary Diagnoses: [REDACTED]. Mental Status Change Increased confusion, Decreased consciousness (sleepy, lethargic), documentation noted stated she (R#3) was going to a fiesta/reunion. Functional status changes include weakness, decreased mobility, and fall. Respiratory: R #3 was on O2 at 2 LPM (liters per minute) via NC (nasal cannula). GI/Abdomen: distended abdomen, and diarrhea. Assessment documented: confused stated she was as going to a fiesta/reunion, attempted to get out of bed without assistance. Request: monitor vital signs, transfer to the hospital. Nursing notes documented: Patient has had increased weakness/lethargy/confusion. Have re-directed patient numerous times to call for assistance using call light when needing assistance. Ammonia results have been pending; bruising to her right knee is noted as well as a bump behind the right side of her head. Record review of R #3's Fall Risk Evaluation dated [DATE] documented R #1 had a score of 14. The assessment indicated total score of 10 or above represents HIGH RISK. Record review of R #3's Fall Management Care Plan dated [DATE] revealed R #3 had an actual fall r/t confusion. R #3 had a fall with injury to the head. Approaches included: 27) W/C without foot rests to promote independence with mobility, 37) Continue ongoing assessments and interventional changes, R #3 was on therapy caseload at time of fall, and was sent to emergency room for eval and treat. Record Review of R #3's Physician's Telephone Orders dated [DATE] revealed R #3 was sent to the local hospital for evaluation and treatment due to a fall. Record review of R #3's, Transfer Summary, dated [DATE], completed by LVN R, revealed R #3 was transferred from the facility to a local hospital due to an unwitnessed fall with an injury. Pain location documented as head/ L (left) clavicle Risk alerts noted as Falls, and devices and treatments noted as: 02 at 2 L/Min by Nasal Cannula, Chronic. Treatments and Frequency was documented as Blood Transfusions, however the frequency was not documented. Further review revealed R #3 was receiving physical therapy with a goal to return home. Documentation revealed R #3 has had increased weakness/lethargy, unable to ambulate, incontinent B & B (bowel & bladder). Record review of R #3's Emergency Physician Record dated [DATE] revealed R #3 was seen at 0620. R #3 chief complaint: fall- injury to shoulder, hip and head, where: was documented at nursing home. Context documented: unwitnessed fall, nursing staff found her on floor,location of pain/injuries was documented as: head right shoulder, right hip, right knee, left knee, Associated symptoms: weakness, lethargy per nursing home staff, altered mental status was noted. Brief history: from nursing home, several days weakness, confusion, found on floor, unwitnessed. Record review of R #3's hospital records revealed R #3 was admitted to a local hospital emergency roiagnom on [DATE]. R #3's Principal Diagnosis: [REDACTED]. R #3 was a [AGE] year old female who brought into the hospital from the nursing facility via EMS after the staff found her down on the floor. (R #3) had an unwitnessed fall and had significant bruising to her right shoulder and knee. There were no fractures noted on the imaging; however, (R #3)'s head CT showed an acute extraaxial hematoma to the right frontotemporoparietal area along with a midline shift. Neurosurgeon was consulted and recommended that the patient be placed on Keppra (anticonvulsant) and a transfusion of platelets. R #3 was placed in ICU for closer monitoring. A repeat of R #3's CT scan of her head showed worsening of the hematoma and her hemoglobin and hematocrit continued to decline. Review of R #3's hospital Neurosurgeon Consultation dated [DATE] at 11:14 p.m., Reason for Consultation: Right frontoparietal subdural hematoma. She was in a nursing home when she sustained an unwitnessed fall. The found her down. She complained of right shoulder and knee pain. Images of her head did show that she had acute extraaxial hematoma as well as abnormal labs, which included her platelets were critically low at 59 and her PT (Prothrombin time-blood test that measures how long it takes blood to clot) was elevated at 12.8. The patient is currently in ICU, is drowsy and slurring her speech. She is still suffering the results of this. SKIN: Multiple bruises primarily on the right shoulder, left knee, right knee, and edema to the right parietal side of her head. IMAGING: Heat CT reveals extraaxial hematoma along the right frontoparietal region. The widest area measuring approximately 4 mm (millimeters) wide. There is associated mass effect with midline shift towards the left of about 4.6 mm. PLAN: The patient has received 10 packs of platelets and 2 units of FFPS (Fresh Frozen Plasma). ADDENDUM: Her platelets worsened despite receiving a 10 pak and decreased in HCT (Hematocrit). Her CT of head was repeated which showed worsening right subdural. Patient wishes to be comfort care. Comfort care initiated. Record review of R #3's Death Certificate from the Department of State Health Services Vital Statistics Unit revealed R #3 died on [DATE] at 11:16 a.m. R #3's Cause of Death was listed as Immediate Cause Subdural Hematoma Due to Blunt Head Trauma. Manner of Death documented Accident. The Approximate Interval Onset of Days documented Days. Date of Injury documented [DATE], time of injury documented 4:33 a.m., description of injury documented Decedent fell ; location of injury documented the name of facility. During an interview on [DATE] at 9:16 a.m. the VP of Clinical stated the facility did not have a policy on Care Planning. During a telephone interview on [DATE] at 1:55 p.m. R #3's FM U stated R#3 had a fall with a head injury at the facility on [DATE]. FM U stated R #3 informed FM U that she needed to go to the restroom and kept calling for help using the call light for staff to assist her, and when no one came to assist R #3; R #3 attempted to go to the restroom unassisted. FM U stated when R#3 fell ; her wheelchair hit her on the head. R #3 was sent to a local Hospital emergency room . FM U stated R #3 passed away on [DATE] from a head injury. During an interview on [DATE] at 3:40 p.m. FM T stated that on [DATE] R #3 had a fall at the facility. R #3 informed FM T she needed to go to the restroom and she called for staff assistance but staff never came to help her to the restroom. R #3 attempted to sit on her wheelchair but was unable too, R #3 held on to the wheelchair but then the wheelchair tilted and fell on top of R#3's head neck and shoulders. R #3 was taken to a local Hospital emergency room and was in the Intensive Care Unit (ICU). FM T stated R #3 became very depressed and could not walk. FM T stated it had been a nightmare, R #3 died on [DATE] because she needed to go to the restroom and facility staff did not assist her. During an interview on [DATE] at 5:30 p.m. with the ADM, DON, COO, and VPC when asked about Resident #3 regarding her two falls that had occurred. ADM stated on [DATE] R #3 was assisted to the ground with no injuries, therefore it was not considered a fall so no changes to #3's Care Plan were made at that time. ADM stated she was reminded to use her wheelchair locks break and to use the call light. The DON stated even though a resident may have cognitive impairment, their short term memory could be intact. On [DATE] at 4:05 R #3 was sent to the emergency room because the resident stated she hit her head when she fell . When asked if the facility followed up with the resident while she was at the hospital the DON replied, I think, maybe, I can't remember. The ADM stated, I don't believe we did. The COO stated, I think we did. The VPC stated, Her disease was progressing rapidly. I don't think she was admitted to the hospital for the fall I think it was the disease process. COO added, I think she passed away from the disease. The ADM stated, I know we sent a plant to the funeral like we always do for our residents that pass. The ADM stated, The resident has the right to fall. It is in the regulation. 2.) R #1 Record review of R#1's Face Sheet dated [DATE], revealed R#1 was a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. R #1's [DIAGNOSES REDACTED]. Record review of R #1's Consolidated physician's orders [REDACTED]. Record review of R #1's Fall Risk Evaluation dated [DATE] and [DATE] documented R #1 had a score of 10. The assessment indicated total score of 10 or above represents HIGH RISK. Record review of R #1's Fall Risk Evaluation dated [DATE] documented R #1 had a score of 14. The assessment indicated total score of 10 or above represents HIGH RISK. Record review of R #1's Care Plan dated [DATE] revealed R #1 had [DIAGNOSES REDACTED]. R #1 was at risk for injury, insomnia, depression, emotional distress, and coping deficiency. R #1 Cognition: Exhibits short term memory problems, with an onset date of [DATE]. Further review revealed R #1 was a High Risk for falls and had an onset date of [DATE]. The approaches documented included to ensure call bell is in reach, observe for dizziness and fatigue, r/t the use of mediations and assist with ADL's. Record review of R #1's Annual Minimum Data Set (MDS),dated [DATE] revealed R #1 Functional Status required Extensive Assistance (resident involved in activity, staff provide weight-bearing support ) with bed mobility: self-performance and One person physical assist with support provided. R #1 required Extensive assistance with transfer self-performance and one person physical assist with transfer support provided. R #1 required extensive assistance with toilet use self-performance and one person physical assist with support provided. R #1's balance (moving from seated to standing position) was not steady, (only able to stabilize with staff assistance).R #1's balance (moving on and off toilet) was not steady. R #1 used a manual wheelchair for mobility. R #1 had unclear speech. R #1 sometimes made self understood and usually understood others. R#1 was unable to recall. Record review of R #1's Quarterly MDS dated [DATE] revealed R #1 sometimes understood (ABILITY IS limited to making concrete requests). R #1 Functional Status required Extensive Assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility: self-performance and one person physical assist with support provided. R #1 required Extensive assistance with transfer self-performance and one person physical assist with transfer support provided. R #1 required extensive assistance with toilet use self-performance and one person physical assist with support provided. R #1's balance (moving from seated to standing position) was not steady, (only able to stabilize with staff assistance). R #1's balance (moving on and off toilet) was not stead

Based on observation, interview, and record review the facility failed to ensure a resident who enters the facility without pressure ulcers does not develop pressure ulcers and a resident having pressure ulcers received the necessary care and services to promote healing and prevent new sores from developing for eight Residents (R #4, #5, R #6, R #7, R #8, R #9, R #10, and R #11) of nine residents reviewed for pressure ulcers. 1.) R #5 was admitted to the facility and assessed to have no impaired skin integrity on admission. The facility failed to: -ensure R #5's assessments to determine level of risk of pressure ulcer development was accurate. -ensure R #5's documentation of her pressure ulcer was accurate. The facility backstaged R #5's pressure ulcer from an Unstageable pressure ulcer to a Stage 3 pressure Ulcer. -order R #5 supplements for wound healing as per her Care Plan and the facility's policy; instead, the supplements were ordered 22 days after R #5's discovery of her pressure ulcer. -specify and educate the meaning of Other individualized interventions documented in R #5's Care Plan. -recommend a consult with the Wound Care Specialist when R #5 was discovered to have an unstageable pressure ulcer. The facility retrieved a Wound Care Specialist consult approximately one month after R #5's unstageable pressure ulcer deterioriorated to a Stage IV pressure ulcer. R #5 was being assessed to rule out Osteomylitis caused by the pressure ulcer. 2.) R #6 was admitted to the facility without any pressure ulcers. The facility failed to: -ensure R #6's specialty alternating pressure low air loss mattress was set on the correct settings. The facility had not educated staff on the functioning capabilities of R #6's specialized air mattress. -ensure R #6 was repositioned at least every two hours. -R #6 developed additional pressure ulcers. 3.) R #4 was admitted to the facility without any pressure ulcers. R #4 developed two separate Stage 2 pressure ulcers in the facility. The facility failed to: -ensure R #4's plan of care included repositioning interventions after admission when she was assessed as high risk for pressure ulcers. Repositioning interventions were ordered three days after R #4 was discovered with a Stage 2 pressure ulcer. -ensure R #4 was ordered supplements for wound healing as indictaed in her Care Plan and via the facility's policy; instead, R #4's supplements were ordered eight days after R #4 was discovered with a pressure ulcer. -ensure R #4's documentation included the identification or monitoring of her second facility acquired Stage 2 pressure ulcer. -accurately document R #4's surrounding skin around her pressure ulcer. 4.) R #9 was admitted to the facility without any pressure ulcers. R #9 developed a Stage 2 pressure ulcer in the facility that deteriorated to acquiring slough in the wound. The facility failed to: - ensure R #9's plan of care addressed the risk of developing pressure ulcers as identified by R #9's comprehensive resident assessment. -correctly Stage R #9's pressure ulcer. R #9's documentation included a Stage 2 with slough, which did not meet the definition of a Stage 2 pressure ulcer. 5.) R #7 was admitted to the facility without any pressure ulcers. R #7 developed an unstageable pressure ulcer to her right heel in the facility. The facility failed to: -ensure R #7's care plan addressed interventions to prevent the development of pressure ulcers, despite R #7's comprehensive assessment identified R #7 at risk for pressure ulcer development. -ensure R #7's plan of care included interventions for heel protectors immediately after R #7 was discovered with a pressure ulcer to her right heel. R #7's right heel pressure ulcer slightly grew in width. 6.) R #8 was admitted to the facility without any pressure ulcers. R #8 developed a Stage 2 pressure ulcer in the facility. The facility failed to: -document the identification or monitoring of R #8's second Stage 2 pressure ulcer. R #8's pressure ulcer grew in size. 7.) R #11's comprehensive resident assessment identified R #11 at risk for developing pressure ulcers. The facility failed to: -provide R #11 with positioning devices as indicated in her care plan. -ensure initial assessment of R #11's blanchable redness to her coccyx. heels, and left great toe were accurately documented. -ensure all staff were promptly educated on R #11's interventions to offload heels. 8.) The facility failed to ensure R #10's re-admission assessment documented a dressing to R #10's sacrum. R #10 was assessed to have redness to her left heel however, the assessment was not documented. These failures resulted in an identification of an Immediate Jeopardy (IJ) situation on 09/14/16. While the IJ was removed on 09/17/16, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. This deficient practice could place 21 residents with pressure ulcers and 82 residents receiving preventative skin care at risk of skin breakdown or worsening of pressure ulcers due to not receiving accurate assessments, care, and services needed to prevent delay in treatment, complications, hospitalization , and a decreased quality of life. The findings included: The facility's Weekly Pressure Ulcer Quality Improvement Log dated 09/09/16, provided by the Director of Nurses, documented eight residents with current Pressure Ulcers. Among those eight residents, R #5, R #7, R #8, and R #9 were identified as having current pressure ulcers R #5: R #5's Face Sheet dated 09/12/16 documented a [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]., Generalized Muscle Weakness, and Stiffness of Joints. R #5's Admission/Readmission Data Summary dated 08/05/16 documented ADL (Activity of Daily Living) Function At Time of Admission to Facility (Current Status): -Mobility- Required assistance of two. -Transfer- Required assistance of two. -Toilet Use- Incontinent of Bowel, has indwelling catheter. Skin Condition: Pressure Ulcer Detail. *There was no documentation of an existing pressure ulcer in the area of Skin Condition: Pressure Ulcer Detail or anywhere in the entire assessment. R #5's Care Plans dated 08/05/16 included: -Resident is frequently incontinent of bladder and bowel . -Resident is at risk for alteration in skin integrity related to decreased mobility .Place on pressure relieving device if indicated; Skin assessment weekly and PRN; Avoid pressure on bony prominence's; turn and reposition frequently (regularly or habitually; often); provide pericare after each incontinent episode. -Resident requires extensive assist with ADL's (activities of daily living) .Assist with transfers, turn/reposition every 2 hours and PRN (as needed), use padding between pressure areas and position devices for proper body alignment . R #5's Braden Scale- For Predicting Pressure Sore Risk dated 08/05/16 documented a score of 14. A score of 12 or less represents HIGH RISK; A score of 13-14 represents MODERATE RISK; A score of 15-18 represents MILD RISK. R #5's Weekly Pressure Ulcer Healing Report dated 08/10/16 documented Date First Observe: 08/10/16. Site/Location: Coccyx. -Unstageable (According to the National Pressure Ulcer Advisory Panel 2016-NPUAP: Unstageable Pressure Injury: Obscured full-thickness skin and tissue lossFull-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed) -Size in cm (centimeters) LxWxD (Length x Width, x Depth)- 9 x 8 x UTD (unable to determine) -Undermining (deep tissue damage around the wound margin)- none -Color- Red, black -Exudate (seepage of fluid) type- none -Exudate amount- none -Odor- No -Surrounding Skin- Normal for skin. Record review of R #5's entire clinical record revealed there was no documentary evidence of how often R #5 was assisted with repositioning. R #5's Alteration in Skin Integrity Care Plan dated 08/10/16 documented Related to immobility. Unstageable to coccyx. Goals: Wound will decrease in size, have increased granulation tissue and ultimately heal. Approaches: -Weekly head to toe assessment by Licensed Nurse, -CNA (Certified Nurse Aide) to check skin with shower and notify nurse of issue/concerns -TX (treatment) as ordered -Dietician consult as indicated -Supplements as ordered -Licensed Nurse to notify family and discuss treatment plan and interventions -Licensed Nurse to educate CNA on treatment plan -Monitor for pain, give medication per order, monitor for effectiveness -other individualized interventions -Hydrogel q (every) day. -Admit with: Yes. (NOTE: There was no documentary evidence that R #5 was admitted with a pressure ulcer. ) R #5's Physician Telephone Orders dated 08/11/16 documented Late Entry: Excoriation (the act of abrading or wearing off the skin) to coccyx: Clean with wound cleanser, pat dry, apply hydrogel, cover with dry dressing Q (every) day. R #5's Braden Scale- For Predicting Pressure Sore Risk dated 08/11/16 documented a score of 12, representing HIGH RISK. R #5's Physician's Progress Notes dated 08/13/16 at 5:00 p.m. documented Pt. is a little weaker than I saw her last week .Place in Prevalon boots. Generalized weakness Monitor closely. R #5's Weekly Pressure Ulcer Healing Report dated 08/17/16 documented Date First Observe: 08/10/16. Site/Location: Coccyx. -Unstageable -Size in cm. LxWxD- 9 x 8.0 cm -Undermining- none -Color- Red, yellow -Exudate type- None -Exudate amount- None -Odor- No -Surrounding Skin- Normal for skin. (NOTE: there was no documentation in any Weekly Pressure Ulcer Healing Reports or in the Nurse's Notes what happened or when the black discoloration of the wound changed or when exactly R #5 began to accumulate yellow in her wound) R #5's Weekly Pressure Ulcer Healing Report dated 08/23/16 documented Date First Observe: 08/10/16. Site/Location: Coccyx. -Unstageable -Size in cm. LxWxD- 9 x 7.8 cm -Undermining- none -Color- Red, yellow -Exudate type- None -Exudate amount- None -Odor- No -Surrounding Skin- Normal for skin. R #5's Physician Telephone Orders dated 08/23/16 documented DC (discontinue) hydrogel (high water content dressing which helps regulate fluid exchange from the wound surface) to coccyx (tailbone), begin clean with WC (wound cleanser), pat dry, apply Santyl (sterile enzymatic [MEDICATION NAME] ointment), cover with Calcium Alginate (water-insoluble, gelatinous, cream-colored substance) and dry dressing Q (every) day. R #5's Braden Scale- For Predicting Pressure Sore Risk dated 08/24/16 documented a score of 12. R #5's Physician's Progress Notes dated 08/25/16 documented Worsening of DU (Decubitus Ulcer/Pressure Ulcer) to sacrum. DU with slough, no s/s (signs and symptoms) of infection. R #5's Admission Minimum Data Set ((MDS) dated [DATE] documented: -Clear speech, -Made self understood and understood others, -Had a Brief Interview of Mental Status (BIMS) score of 13 out of 1-15. -Required extensive assistance with two person physical assist for bed mobility, -Was totally dependent with two person physical assistance for transfers, bathing, and toilet use, -Required extensive assistance with one person physical assist for locomotion on and off the unit, dressing, and eating, -Was frequently incontinent of bladder and bowel, -Is at risk for pressure ulcers. -Did not have any unhealed pressure ulcers at Stage 1 or higher. (NOTE: R #5 was discovered to have an unstageable pressure ulcer on 08/10/16. This comprehensive assessment documented R #5 did not have a pressure ulcer on 08/26/16.) R #5's Weekly Pressure Ulcer Healing Report dated 08/30/16 documented Date First Observe: 08/10/16. Site/Location: Coccyx. -Unstageable -Size in cm. LxWxD- 8 x 4.0 cm x UTD -Undermining- none -Color- Yellow (NOTE: the wound no longer had red healthy tissue as when initially discovered on 08/10/16) -Exudate type- None -Exudate amount- None -Odor- No -Surrounding Skin- Normal for skin. R #5's Physician's Telephone Orders dated 09/01/16 documented Vitamin C 500 mg (milligrams) BID (twice daily), Multivitamin with minerals one q day, Prostat (ready to drink Protein, Vitamin C, and Zinc Supplement) 30 ml (milliliters) TID. Dx: Wound healing. (NOTE: R #5's pressure ulcer was discovered on 08/10/16, 22 days later, R #5 was ordered the supplements for wound healing) R #5's Physician's Progress Notes dated 09/01/16 documented DU (Decubitus Ulcer/Pressure Ulcer) to sacrum decreased in size and improved. Continue treatment R #5's Physician's Progress Notes dated 09/08/16 documented DU to sacrum with slough .Calcium Alginate and Santyl, Consult (Wound Care Specialist), Specialty mattress, Prostat. R #5's Weekly Pressure Ulcer Healing Report dated 09/08/16 documented Date First Observe: 08/10/16. Site/Location: Coccyx. -Stage 3 (Stage III- A full thickness of skin loss exposing the subcutaneous tissues. Presents as a deep crater with or without undermining adjacent tissue) -Size in cm. LxWxD- 8.4 x 4.6 x 2.2 cm -Undermining- none -Color- Yellow-Exudate type- Serosanguinous (containing or relating to both blood and the liquid part of blood- serum). -Exudate amount- Moderate -Odor- No -Surrounding Skin- Normal for skin, Maceration (Softening of the tissues). R #5's Physician's Telephone Orders dated 09/12/16 documented Pt (patient) to be assessed by (Wound Care Specialist) for Sacral Wound. R #5's Braden Scale- For Predicting Pressure Sore Risk dated 09/13/16 documented a score of 15, MODERATE RISK. (NOTE: R #5 was assessed to be at moderate risk for developing pressure ulcers despite R #5 having had developed a current pressure ulcer) Interview with Licensed Vocational Nurse (LVN) E, whom identified himself as the Treatment Nurse, on 09/13/16 at 8:46 a.m. as he prepared to provide R #5 wound care, LVN E stated She began with an unstageable to her coccyx on 08/10/16. The wound was covered with slough but yesterday the wound opened up. Now we can see in the wound and it is clearly a Stage 3. The last time it was measured was on 09/08/16, it was 8.4 x 4.6 x 2.2 centimeters. I did not take measurements yesterday when it opened up. After accompanying LVN E and the Director of Nurses (DON) into R #5's room, observation of R #5 revealed R #5 lay on an overlay air mattress. R #5 was alert and oriented to person and place and was able to make needs known. R #5's perineum had a red rash. R #5's right buttock had a deep crater with yellow and white tissue within the crater and surrounding the crater. The yellow and white tissue was detaching from the wound bed and peri-wound. LVN E began to measure R #5's wound but clearly had trouble advancing the folded paper measuring tool into the wound (NOTE: possibly not accurately retrieving the most accurate measurement). LVN E stated out loud It is 8.4 x 4.0 x 1.6 centimeters. LVN E said the Wound Care Specialist was expected to arrive to the facility today and see (R #5). LVN E said interventions to prevent worsening of the pressure ulcer was an air mattress, frequent repositioning, ordered supplements, and treatment of [REDACTED]. After review of R #5's Care Plan, LVN E said I have no clue what that (Other individualized interventions) means, I had not noticed it. LVN E stated R #5's coccyx pressure ulcer was discovered to have the appearance of red and black. LVN E said on 08/17/16 and 08/23/16, R #5's coccyx pressure ulcer had more slough in the wound bed. LVN E said by 08/30/16, R #5's coccyx was completly covered with slough that red healthy tissue was not visible as it was when initially discovered. LVN E did not know when the black color in the wound as initally observed was no longer visible. R #5's Nurse's Note (documented by the Director of Nurses- DON) dated 09/13/16 documented Pt lying in bed .dressing to coccyx (originally identified as sacrum) intact. Small amount drainage yellowish and red in color, serous sanguineous. No odor, edge with redness appears granulated in areas. Wound measures 8.4 X 4 X 1.6 cm. Wound cleansed and treatment as ordered . R #5's Weekly Pressure Ulcer Healing Report dated 09/13/16 documented Date First Observe: 08/10/16. Site/Location: Coccyx. -Unstageable -Size in cm. LxWxD- 8.4 x 4.0 x 1.6 cm -Undermining- none -Color- Red, Yellow -Exudate type- Serous (of, resembling or producing serum) -Exudate amount- Small -Odor- No -Surrounding Skin- Normal for skin. R #5's Weekly Pressure Ulcer Healing Report dated 09/13/16 documented Date First Observe: 08/10/16. Site/Location: Coccyx. -Stage 4 (Stage IV: A full thickness loss of skin and subcutaneous tissue exposing muscle and/or bone) -Size in cm. LxWxD- 7.0 x 3.3 x 3.3 cm -Undermining- none -Color- Red, Yellow -Exudate type- Serous -Exudate amount- Moderate -Odor- No -Surrounding Skin- Normal for skin. Wound progress to a Stage 4. *R #5's wound had increased in depth with now full thickness loss of skin with increased drainage. Record review conducted on 09/14/16 at 10:30 a.m. of R #5's Nurse's Notes, physician's orders [REDACTED]. Interview with the DON on 09/14/16 at 10:33 a.m. revealed she did not know who the Wound Care Specialist saw during his rounds yesterday. The DON said the Wound Care Specialist visited his patients every Tuesday. Interview with LVN E on 09/14/16 at 11:08 a.m. revealed the Wound Care Specialist did not visit the facility on 09/13/16 as expected. LVN E said he spoke to the Wound Care Specialist and the plan was for him to make rounds on Friday. LVN E the Wound Care Specialist send LVN E a text message on 09/13/16 to inform LVN E that he was on his way to the facility however, LVN E told the Wound Care Specialist he was in a meeting so the Wound Care Specialist rescheduled his visit for 09/16/16. LVN E said he had not requested/recommended a consult for the Wound Specialist to assess R #5 prior to 09/12/16. LVN E said I should have requested the consult sooner. R #5's Weekly Pressure Ulcer Healing Report dated 09/15/16 documented Date First Observe: 08/10/16. Site/Location: Coccyx. -Unstageable -Size in cm. LxWxD- 8.5 x 7.5 x 1.0 cm -Undermining- 2.7 cm at 12 o'clock, 1.5 cm at 1 o'clock, and 1.0 cm at 3 o'clock with tunneling and undermining -Color- Red, Yellow -Exudate type- Serous -Exudate amount- Small -Odor- Yes -Surrounding Skin- Normal for skin. Interview with the DON on 09/16/16 at 12:32 p.m. revealed I Honestly don't have a clue what other individualized interventions means in R #5's Care Plan. The DON said the acronym N beneath Role beside the other individualized interventions in R #5's Care Plan meant NO. The DON said that intervention was not utilized. The surveyor asked the DON if the N acronym meant Nursing and the DON replied I don't know. The DON said the facility's policy for Pressure ulcers was if the ulcer was a stage three or higher, We order an air mattress, order supplements to help with wound healing, and ensure frequent turning. The DON said she had good staff and staff knew they had to turn residents every two hours. The DON said she did not have any in-service specific to R #5's care for prevention of further worsening of pressure ulcers. The DON said she did not know why R #5 was not ordered supplements immediately after she was discovered to have a pressure ulcer, instead of one month later. R #5's Wound Care Specialist Initial Evaluation dated 09/20/16 documented At the request of (the physician) this [AGE] year-old female was seen and evaluated today. She presents with a Stage 4 pressure (Full thickness tissue loss, through dermis and into subcutaneous tissue, muscle, bone and/or tendon are exposed) wound coccyx of at least 35 days duration. There is moderate serous exudate .Wound size: 7 x 3.3 x 3.3 cm. Moderate serous exudate .Base of wound bed has exposed ligament. Recommendation: X-ray to rule out [DIAGNOSES REDACTED] (inflammation of bone or bone marrow, usually due to infection), prior to wound vac placement . R #6: R #6's Face Sheet dated 08/31/16 documented an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] and 08/24/16 with the [DIAGNOSES REDACTED]. R #6's admission orders [REDACTED]. R #6's Care Plan dated 07/18/16 included: -At risk of muscle wasting and increased weakness due [MEDICAL CONDITION](Cardiovascular Accident); -Require assistance with my ADL's X 1 for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing . (NOTE: The Care Plan did not address potential for or impaired skin integrity including Pressure Ulcers) R #6's Braden Scale-For Predicting Pressure Sore Risk dated 07/18/16 documented a score of 11, indicating HIGH RISK. R #6's July 2016 ADL Sheet revealed each shift documented that Bed Mobility Support repositioning) was provided however, the document did not specify specific times or how many times the support was provided per shift. An undated Interim Care Plan documented: -Personal Hygiene: total care; -Toileting: Incontinent of B & B (bladder and bowel); -Staff does incontinent care -Eating: By staff; -Mobility: By staff; Turn q 2 hour and position, one person, non-weight bearing. Staff T & R (turn and reposition) q 2 hours and X 1 CNA to transfer- NWB (Non-Weight Bearing); Vision: Impaired [MEDICAL CONDITION] (a condition of increased pressure within the eyeball, causing gradual loss of sight)- left and right -Speech: Incoherent; -Behavioral/Mental Status: Alert, confused. *There was no mention of impaired skin integrity or pressure ulcer. R #6's Admission MDS dated [DATE] documented: -Unclear speech; -Sometimes made self understood and sometimes understood others; -Had impaired vision; -Had a BIMS score of 3 out of a total of 15; -Required extensive assistance with one person physical assistance for bed mobility, transfers, locomotion on and off unit, dressing, toilet use, bathing, and personal hygiene; -Required limited assistance with eating; -Was always incontinent of bladder and bowel; -Is not at risk of developing pressure ulcers; -Has no unhealed pressure ulcers at Stage 1 or higher; -62 inches and 116 pounds. R #6's Braden Scale-For Predicting Pressure Sore Risk dated 07/25/16 and 08/01/16 documented a score of 11, indicating HIGH RISK. R #6's August 2016 ADL Sheet revealed each shift documented that Bed Mobility Support was provided however, the document did not specify specific times or how many times the support was provided per shift. R #6's Admission/Readmission Data Collection Summary dated 08/24/16 at 7:54 p.m. documented ADL Function at Time of Admission to Facility (Current Status): -Mobility- No functional ability; -Transfer- Does not transfer; -Eating- Total assistance with meal; -Toilet Use- Incontinent of bladder and bowel. Skin Condition: Rash to abdominal folds. Pressure Ulcer Detail (There was a zero documented in this section). Continence: Incontinent of bladder and bowel. Nurses Note: Skin clear of pressure ulcers . R #6's admission orders [REDACTED]. R #6's Physician's Telephone Orders dated 08/31/16 revealed an order to admit R #6 to hospice for a [DIAGNOSES REDACTED]. R #6's undated Palliative Care Form documented Diagnosis: [REDACTED]. Expected with this resident: -Weight loss -Skin breakdown -Dehydration -Placement of Indwelling Catheter -Fecal Impactions -Gradual or rapid loss of the ability to move. Explain: Pt. is end stage on hospice- skin breakdown is UNAVOIDABLE. R #6's Non-Pressure Skin Condition Report dated 09/02/16 documented Date First Observed: 09/02/16. Site/Location: Right heel, condition is: Blister. -Size in cm. LxWxD- 8.5 x 5.0 x UTD -Color- tan -Exudate type- none -Odor- No -Progress: 1st visit -Treatment: [MEDICATION NAME]. R #6's Physician's Telephone Orders dated 09/02/16 documented [MEDICATION NAME] (a topical (applied to the skin) antimicrobial agent used to treat and prevent skin infections) cream apply to blisters on feet BID. R #6's Physician's Telephone Orders dated 09/02/16 documented Clarification: [MEDICATION NAME] cream apply to blister on foot. Clean with wound cleanser, pat dry, apply [MEDICATION NAME] cream, cover with foam dressing, wrap with kerlix BID. R #6's physician progress notes [REDACTED].Patient now with blistering to the heels . R #6's Weekly Pressure Ulcer Healing Report dated 09/04/16 documented Date First Observe: 09/04/16. Site/Location: DTI (DTI- Purple or maroon localized area of discolored intact skin or blood- filled blister due to damage of underlying soft tissue from pressure and/or shear) to Left heel. -DTI -Size in cm. LxWxD- 2.6 x 1.4 x 0 -Undermining- none -Color- Red -Exudate type- none -Exudate amount- none -Odor- No -Surrounding Skin- Normal for skin. R #6's Alteration in Skin Integrity related to (r/t) immobility and poor circulation, Deep Tissue Injury Care Plan to left heel dated 09/04/16 documented: -Weekly head to toe assessment by Licensed Nurse, -CNA to check skin with shower and notify nurse of issue/concerns -TX as ordered -Licensed Nurse to notify family and discuss treatment plan and interventions -Licensed Nurse to educate CNA on treatment plan -Monitor for pain, give medication per order, monitor for effectiveness -Keep physician and responsible party informed of resident's progress. *The Care Plan did not include an intervention to off-load heels. R #6's Physician's Telephone Order dated 09/08/16 documented Air Mattress. DX: Left heel skin breakdown. R #6's undated Physician's Telephone Order (documented directly beneath the above order for an air mattress) documented: DTI left heel: Cleanse with wound cleanser, pat dry, and apply Sure Prep daily until healed. Measurements: 2.6 x 1.4 x 1.0 cm. R #6's Non-Pressure Skin Condition Report dated 09/09/16 documented Date First Observed: 09/02/16. Site/Location: Right heel, condition is: Blister. -Size in cm. LxWxD- 8.5 x 5.0 x UTD -Color- red -Exudate type- none -Odor- No -Progress: no change -Treatment: Continue treatment. R #6's Weekly Pressure Ulcer Healing Report dated 09/11/16 documented Date First Observed: 09/11/16. Site/Location: Left Anterior Plantar (bottom of foot). -DTI -Size in cm. LxWxD- 2.6 x 2.0 x 0 -Undermining- none -Color- Red -Exudate type- none -Exudate amount- none -Odor- No -Surrounding Skin- Normal for skin. R #6's Weekly Pressure Ulcer Healing Report dated 09/11/16 documented Date First Observed: 09/11/16. Site/Location: Left Lateral Foot. -DTI -Size in cm. LxWxD- 1.5 x 0.6 x 0 -Undermining- none -Color- Red -Exudate type- none -Exudate amount- none -Odor- No -Surrounding Skin- Normal for skin. R #6's Physician's Telephone Orders dated 09/11/16 documented 1. DTI left lateral foot: Cleanse with wound cleanser, pat dry, apply Sure Prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films) daily. 2. DTI left anterior plantar: cleanse with wound cleanser, pat dry, apply Sure Prep daily. R #6's Alteration in skin integrity: DTI left lateral foot, left anterior plantar dated 09/11/16 documented: related to poor nutrition and poor circulation. Approaches: -Weekly head to toe assessment by Licensed Nurse, -CNA to check skin with shower and notify nurse of issue/concerns -TX as ordered -Dietician consult as indicated -Supplements as ordered -Licensed Nurse to notify family and discuss treatment plan and interventions -Licensed Nurse to educate CNA on treatment plan -Monitor for pain, give medication per order, monitor for effectiveness -other individualized interventions -Air mattress -Keep physician and responsible party informed of resident's progress. R #6's Braden Scale-For Predicting Pressure Sore Risk dated 09/13/16 documented a score of 9, representing HIGH RISK. R #6's Alteration in Skin Integrity r/t decreased mobility: DTI to left lateral foot Care Plan dated 09/13/16 documented: -Weekly head to toe assessment by Licensed Nurse, -CNA to check skin with shower and notify nurse of issue/concerns -TX as ordered -Dietician consult as indicated -Supplements as ordered -Licensed Nurse to notify family and discuss treatment plan and interventions -Licensed Nurse to educate CNA on treatment plan -Monitor for pain, give medication per order, monitor for effectiveness -other individualized interventions -off-load heels/feet (NOTE: This was the first time the intervention to off load heels was set in place despite R #6 was discovered to had a pressure ulcer to her right heel on 09/02/16) -Air mattress -Keep physician and responsible party informed of resident's progress. R #6's Alteration in Skin Integrity r/t decreased mobility, DTI to left anterior plantar dated 09/13/16 documented: -Weekly head to toe assessment by Licensed Nurse, -CNA to check skin with shower and notify nurse of issue/concerns -TX as ordered -Dietician consult as indicated -Supplements as ordered -Licensed Nurse to notify family and discuss treatment plan and interventions -Licensed Nurse to educate CNA on treatment plan -Monitor for pain, give medication per order, monitor for effectiveness -other individualized interventions -off-load heels/feet -Air mattress -Keep physician and responsible party informed of resident's progress. R #6's Alteration in Skin Integrity r/t decreased mobility, blister to right heel dated 09/13/16 documented: -Weekly head to toe assessment by Licensed Nurse, -CNA to check skin with shower and notify nurse of issue/concerns -TX as ordered -Dietician consult as indicated -Supplements as ordered -Licensed Nurse to notify family and discuss treatment plan and interventions -Licensed Nurse to educate CNA on treatment plan -Monitor for pain, give medication per order, monitor for effectiveness -other individualized interventions -off-load heels/feet -consult hospice -Air mattress to aide with healing and comfort -Keep physician and responsible party informed of resident's progress. R #6's Alteration in Skin Integrity r/t decreased mobility, DTI to left heel dated 09/13/16 documented: -Weekly head to toe assessm

Based on observation, interview and record review, the facility failed to implement their policy and procedures that prohibit neglect for one Resident (R #1) of seven Residents reviewed for therapeutic laboratory values. *The facility did not provide Laboratory (Lab) services for R #1. The therapeutic level of [MEDICATION NAME] ([MEDICATION NAME]) was not monitored by PT/INR levels for three weeks. The therapeutic level of [MEDICATION NAME] and BMP was not monitored by the facility for one week. *R #1 was admitted to the hospital with [REDACTED]. These failures contributed to R #1's hospitalization requiring FFP and Vitamin K to reverse the effect of [MEDICATION NAME] toxicity. This could have affected two residents prescribed [MEDICATION NAME] and 11 residents prescribed [MEDICATION NAME]. An IJ (Immediate Jeopardy) was determined to have existed from 07/06/15 through 07/28/15. The DON was made aware of the physician's orders [REDACTED]. Findings were: R #1's Face Sheet revealed R #1 was a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R #1's Admission Physician order [REDACTED].#1 was prescribed [MEDICATION NAME] 5 mg. (milligrams) every day by mouth (a medication used as a blood thinner) and [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] Fibrillation) 0.25 mg by mouth every day. R #1's Physician Telephone Orders dated 06/30/15 revealed a Laboratory (lab) blood draw for PT/INR ([MEDICATION NAME] time) INR (international normalized ratio) levels. (Blood test used to determine clotting tendency of blood) every Monday and a [MEDICATION NAME] blood Level ([MEDICATION NAME]-medication used to treat abnormal heart rhythms) and Basic Metabolic Panel (BMP) on Monday (07/06/15). There was no order to discontinue the PT/INR or the [MEDICATION NAME] Labs. R #1's Consolidated Physician order [REDACTED]. R #1's Medication Administration Record [REDACTED]. by mouth 06/28/15 through 06/30/15. R #1's MAR indicated [REDACTED]. by mouth 07/01/15 through 07/23/15. R #1 received [MEDICATION NAME] 5 mg. 26 times between June 28,2015 and July 24, 2015. R #1's 5 day Minimum Data Set ((MDS) dated [DATE] revealed R #1 was understood by others and had clear comprehension, had adequate vision and wore corrective lenses. R #1 had intact cognition, and it was very important to choose between a tub bath, shower, bed bath, or sponge bath. R #1 required limited assistance with walking in the room with one person assistance. R #1 required extensive assistance with the help of one person for personal hygiene, bathing and dressing. R #1 was continent of bowel and bladder. R #1 had received an Anticoagulant, Antibiotic and Diuretic medications during the past seven days. R #1's Care Plan dated 06/27/15 revealed Problem Onset: .I am at risk for bleeding due to anticoagulant therapy ([MEDICAL CONDITION] Fib) .*I will have no injury related to my medication usage/side effects .*I will maintain normal therapeutic PT/INR .*Administer my anticoagulant as ordered by my physician .*Coordinate my lab work as ordered. R #1's Communication Form and Progress Note dated 07/24/15 revealed R #1 had a pulse rate of 108 beats per minute and was described as having rectal bleeding and [MEDICAL CONDITION] (a rapid heart rate) .Notified (Nurse Practitioner) Recommended transfer to ER (emergency room ) . R #1's Hospital Lab Report dated 07/24/15 revealed, PT >100.0 seconds (normal range 9.5-13.2 seconds), INR >10.0 (normal range < 4) R #1's Hospital History and Physical dated 07/24/15 revealed, Chief Complaint: Blood per rectum, bright red for 1 day. History of Present illness: This [AGE] year old female .who is [MEDICATION NAME] ([MEDICATION NAME]) dependent .came into the hospital for an evaluation due to bright red blood per rectum for 1 day nonstop .In the emergency room her INR was more than 10 with a PT over 100 .Assessment And Plan: 1. [MEDICATION NAME] toxicity: PT/INR over 100 and over 10. She did receive FFP (Fresh Frozen Plasma) and vitamin K in the emergency room . 5. [MEDICAL CONDITION]: She has been on [MEDICATION NAME]. She received vitamin K and FFP. Will reassess the need, including risks and benefits of anticoagulation . R #1's Hospital [MEDICATION NAME] Consultation dated 07/25/15 revealed, .The patient is a [AGE] year old female .She states that she has been bleeding 3 to 4 days prior to admission. Upon admission, her PT/INR was greater than 10, and this was corrected with FFP as well as vitamin K. She has had no further bleeding since admission . Impression: Rectal Bleeding .This is likely precipitated by her over anticoagulation .I would keep her INR between 2 and 2.5 . On 07/29/15 at 1:30 p.m., interview with the facility's Director of Nurses (DON) revealed R #1's Laboratory work that was ordered by the NP on 06/30/15 was never done. The DON said the nurse that received the order never filled out a Laboratory Requisition or followed up on the orders. DON said the night shift nurses were to double check all new orders were transcribed but in the case of R #1 the night shift nurses missed the order. The DON said that now, all laboratory orders will be brought to the daily morning meeting and the managers will be responsible for following up to ensure the orders were transcribed and followed through. On 07/29/15 at 1:35 p.m., interview with the Administrator revealed there was a system failure with the Laboratory work not being done with R #1's Laboratory order but the DON discovered the error yesterday and corrected the problem. On 07/29/15 at 1:40 p.m., interview with the DON revealed she had read an email that was sent down from corporate office yesterday (07/28/15) and was brought to the DON's attention yesterday at approximately 5:20 p.m. The email was a complaint from R #1's Family Member (FM) F. The FM F had mentioned in the email R #1's INR lab was over 10 when admitted to the hospital. The DON said she checked R #1's Laboratory Orders and discovered the Laboratory work was never done. The DON said the PT/INR was never done for 07/06/15, 07/13/15 and 07/20/15, and R #1's [MEDICATION NAME] level or BMP was never done on 07/06/15. The DON said it was very important to monitor medications that required therapeutic blood level monitoring, because the patient could become toxic from the medication or not have enough of the medication in the patient's system to be therapeutic. The DON said she would always ask the Physician for lab orders for a baseline and to monitor therapeutic drug values. The DON stated she had already identified the problem and started an action plan. The DON said she had began a chart audit, and planned to meet with the Medical Directors to establish standardized orders, for those residents that required therapeutic monitoring. The DON said the contract laboratory company was onsite to audit all laboratory orders. On 07/30/15 at 1:25 p.m., the Administrator said he was unaware the facility did not have a system in place to make sure Labs orders were followed through prior to R #1 not getting Labs drawn. The Administrator said the LVN's were scared to question Physician Orders. On 07/30/15 at 1:35 p.m., interview with the DON revealed the facility did not have a policy and procedure specific to ordering laboratory work or therapeutic monitoring. It was determined these failures placed R #1 in an Immediate Jeopardy (IJ) situation from 07/06/15 through 07/28/15. The facility took the following actions to correct the non-compliance on 07/28/15: 1) All medications requiring laboratory monitoring will have standing lab orders. 2) Any medication requiring laboratory monitoring that do not have a routine lab order will require physician notification to request routine lab orders. 3) 100% chart audit will be done to identify any omitted lab orders for medications requiring monitoring 4) A list of medication requiring routine lab monitoring will be provided by pharmacy. 5) Chart audit and labs done. Review of Staff Development/Inservice Attendance Sheet dated 07/28/15 revealed Objectives: When you receive an order for [REDACTED]. Review of In-Service Training Record dated 07/28/15 revealed, Nurse Managers are to review all telephone orders after daily care meeting and review (with) MAR/TAR (Treatment Administration Record) to ensure procedure was followed correctly by receiving nurse. Each order for lab should be compared (with) lab manifest to ensure proper communication to lab company. On 07/29/15 at 2:10 p.m., in an interview with Licensed Vocational Nurse (LVN) K revealed she was on duty the day R #1 was sent to the hospital. LVN K said she assessed R #1 and noted a clot and blood from R #1's rectum, and R #1 had [MEDICAL CONDITION] LVN K said she called the NP regarding her assessment and was instructed by the NP to send R #1 to the ER. LVN K said when a nurse received an order for [REDACTED]. LVN K said that was how the nurse knew how the blood was drawn, by the pink copy. LVN K said when the Laboratory results come back abnormal the nurse should notify the Physician right away. On 07/29/15 at 2:40 p.m., interview with LVN P revealed he failed to follow up and write out the Laboratory Requisition for R #1's Physician order [REDACTED]. LVN P said I must have got busy and forgot, I feel bad for (R#1) she was a very nice lady. LVN P said he was trained by the facility on procedures for Laboratory work but, it was just my mistake. LVN P said it was important to monitor PT/INR values to ensure the patient was receiving a therapeutic dose of [MEDICATION NAME] because the patient could bleed out. LVN P stated he was in-serviced by the DON in laboratory procedures yesterday on a 1:1 after it was discovered he had failed to fill out the lab slip. On 07/29/15 at 4:25 p.m., interview with the Assistant Director of Nurses (ADON) L revealed she did not know if the family or the Physician was ever notified regarding the PT/INR, [MEDICATION NAME] and BMP Laboratory not done. ADON L said the nurses should know to ask the Physician for lab work orders on admission. On 07/29/15 at 4:45 p.m., in an interview with the DON she said she had not notified the daughter or Physician regarding the physician's orders [REDACTED]. On 07/30/15 at 9:15 a.m., interview with R #1 revealed she had told the nurse several times that her rectum was bleeding and the nurse just told R #1 that it was Hemorrhoids and not to worry. (The interview was conducted at another facility.) On 07/30/15 at 12:45 p.m., interview with the NP that ordered R #1's Laboratory work on 06/30/15 revealed she was notified R #1's Laboratory work was not done as ordered just yesterday (07/29/15). The NP said she had spoken with the DON in the past about Laboratory Orders not being done as ordered. The NP said hopefully this will be a wakeup call so the facility can have a system in place. The NP said she and the Physician count on the Nurses and Pharmacy Consultants to look for those medications that require therapeutic monitoring to ensure the Lab work was done. On 07/30/15 at 1:00 p.m., interview with the facility Pharmacy Consultant revealed he was not in the facility after R #1 was admitted . The Pharmacy Consultant said he would normally make Physician recommendations to order therapeutic PT/INR on residents taking [MEDICATION NAME] monthly if resident was on [MEDICATION NAME] in long term care. The Pharmacy Consultant said for residents in long term care that were stable on [MEDICATION NAME], he would recommend Laboratory Levels every six months to a year. On 07/30/15 at 3:00 p.m., LVN K said it was Best Practice to call the Physician to verify orders when a resident was admitted to the facility. LVN K said if she saw a resident was prescribed a medication that required therapeutic monitoring she would ask the Physician if they wanted Labs drawn and how often. On 07/30/15 at 1:45 p.m., LVN N said he would call the Physician to verify all orders when a resident was admitted to the facility. LVN N said if a resident was prescribed a medication that required therapeutic monitoring, or if a resident was admitted without laboratory orders, he would call the Physician and ask the Physician if they wanted to order Labs. On 08/07/15 at 2:20 p.m., the DON said she could not find any in-services conducted in laboratory procedures and obtaining Physician order [REDACTED]. On 08/07/15 at 4:21 p.m., ADON L said all the Medical Directors at the facility met with the DON and the Management staff to develop standardized lab orders on admission and every six months depending on the medication the resident was receiving. In the past, admission orders [REDACTED]. ADON L said the facility did not have a policy and procedure regarding labs. ADON L said as a result of the lab error that was discovered by the DON, each admitting Physician has their own orders as to how they want therapeutic drug monitoring and baseline lab work. The Facility Policy and Procedure (no date) titled Reporting Abuse and Neglect .Policy .Any facility staff member who has cause to believe that the physical or mental health or welfare of a resident has been, or may be adversely affected by abuse, neglect or exploitation caused by another person, is to report the abuse, neglect or exploitation immediately .Neglect 1. The facility must determine if an injury, harm or death of a resident was due to facility failure to provide services, treatment or care to a resident .Conduct an Investigation .4. Family and Physician should be notified of incident . According to Lippincott's Nursing Procedures Sixth Edition 2013, pp 230; Documentation is the process of preparing a complete record of a patient's care and is a vital tool for communication among health care team members. Accurate, detailed charting shows the extent and quality of care that nurses provide the outcomes of that care, and treatment and education that the patient still needs. Thorough, accurate documentation decreases the potential for miscommunication and errors. According to: http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/ 8s108lbl.pdf referenced 08/01/15: [MEDICATION NAME]® TABLETS ([MEDICATION NAME] Sodium Tablets, USP) [MEDICATION NAME]® FOR INJECTION ([MEDICATION NAME] Sodium for Injection, USP) Anticoagulant WARNING: BLEEDING RISK [MEDICATION NAME] sodium can cause major or fatal bleeding. Bleeding is more likely to occur during the starting period and with a higher dose (resulting in a higher INR). Risk factors for bleeding include high intensity of anticoagulation (INR >4.0), age =65, highly variable INRs, history of [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION] disease, serious [MEDICAL CONDITIONS], malignancy, trauma, [MEDICAL CONDITION], concomitant drugs (see PRECAUTIONS), and long duration of [MEDICATION NAME] therapy. Regular monitoring of INR should be performed on all treated patients. Those at high risk of bleeding may benefit from more frequent INR monitoring, careful dose adjustment to desired INR, and a shorter duration of therapy. Patients should be instructed about prevention measures to minimize risk of bleeding and to report immediately to physicians signs and symptoms of bleeding (see PRECAUTIONS: Information for Patients) Elderly Patients [AGE] years or older appear to exhibit greater than expected PT/INR response to the anticoagulant effects of [MEDICATION NAME]. The cause of the increased sensitivity to the anticoagulant effects of [MEDICATION NAME] in this age group is unknown. This increased anticoagulant effect from [MEDICATION NAME] may be due to a combination of pharmacokinetic and pharmacodynamic factors. Racemic [MEDICATION NAME] clearance may be unchanged or reduced with increasing age. Limited information suggests there is no difference in the clearance of S-[MEDICATION NAME] in the elderly versus young subjects. However, there may be a slight decrease in the clearance of R-[MEDICATION NAME] in the elderly as compared to the young. Therefore, as patient age increases, a lower dose of [MEDICATION NAME] is usually required to produce a therapeutic level of anticoagulation. WARNINGS The most serious risks associated with anticoagulant therapy with [MEDICATION NAME] sodium are hemorrhage in any tissue or organ12 (see BLACK BOX WARNING) PRECAUTIONS Periodic determination of PT/INR is essential. (See DOSAGE AND ADMINISTRATION: Laboratory Control.) Numerous factors, alone or in combination including changes in diet, medications, [MEDICATION NAME], and genetic variations in the CYP2C9 and VKORC1 enzymes (see CLINICAL PHARMACOLOGY: Pharmacogenomics) may influence the response of the patient to [MEDICATION NAME]. According to physician's orders [REDACTED].

Based on observation, interview and record review, the facility failed to follow their written policy and procedures that prohibit neglect for one Resident (R #1) of seven Residents reviewed for therapeutic laboratory values. *The facility did not provide Laboratory services for R #1. The therapeutic level of [MEDICATION NAME] was not monitored by PT/INR levels for three weeks. The therapeutic level of [MEDICATION NAME] and BMP was not monitored by the facility for one week. *R #1 was admitted to the hospital with [REDACTED]. These failures contributed to R #1's hospitalization requiring FFP and Vitamin K to reverse the effect of [MEDICATION NAME] toxicity. This could have affected two residents prescribed [MEDICATION NAME] and 11 residents prescribed [MEDICATION NAME]. An IJ (Immediate Jeopardy) was determined to have existed from 07/06/15 through 07/28/15. The DON was made aware of the physician's orders [REDACTED]. Findings were: The Facility Policy and Procedure (no date) titled Reporting Abuse and Neglect .Policy .Any facility staff member who has cause to believe that the physical or mental health or welfare of a resident has been, or may be adversely affected by abuse, neglect or exploitation caused by another person, is to report the abuse, neglect or exploitation immediately .Neglect 1. The facility must determine if an injury, harm or death of a resident was due to facility failure to provide services, treatment or care to a resident .Conduct an Investigation .4. Family and Physician should be notified of incident . According to Lippincott's Nursing Procedures Sixth Edition 2013, pp 230; Documentation is the process of preparing a complete record of a patient's care and is a vital tool for communication among health care team members. Accurate, detailed charting shows the extent and quality of care that nurses provide the outcomes of that care, and treatment and education that the patient still needs. Thorough, accurate documentation decreases the potential for miscommunication and errors. According to: http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/ 8s108lbl.pdf referenced 08/01/15: [MEDICATION NAME]® TABLETS ([MEDICATION NAME] Sodium Tablets, USP) [MEDICATION NAME]® FOR INJECTION ([MEDICATION NAME] Sodium for Injection, USP) Anticoagulant WARNING: BLEEDING RISK [MEDICATION NAME] sodium can cause major or fatal bleeding. Bleeding is more likely to occur during the starting period and with a higher dose (resulting in a higher INR). Risk factors for bleeding include high intensity of anticoagulation (INR >4.0), age =65, highly variable INRs, history of [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION] disease, serious [MEDICAL CONDITIONS], malignancy, trauma, [MEDICAL CONDITION], concomitant drugs (see PRECAUTIONS), and long duration of [MEDICATION NAME] therapy. Regular monitoring of INR should be performed on all treated patients. Those at high risk of bleeding may benefit from more frequent INR monitoring, careful dose adjustment to desired INR, and a shorter duration of therapy. Patients should be instructed about prevention measures to minimize risk of bleeding and to report immediately to physicians signs and symptoms of bleeding (see PRECAUTIONS: Information for Patients) Elderly Patients [AGE] years or older appear to exhibit greater than expected PT/INR response to the anticoagulant effects of [MEDICATION NAME]. The cause of the increased sensitivity to the anticoagulant effects of [MEDICATION NAME] in this age group is unknown. This increased anticoagulant effect from [MEDICATION NAME] may be due to a combination of pharmacokinetic and pharmacodynamic factors. Racemic [MEDICATION NAME] clearance may be unchanged or reduced with increasing age. Limited information suggests there is no difference in the clearance of S-[MEDICATION NAME] in the elderly versus young subjects. However, there may be a slight decrease in the clearance of R-[MEDICATION NAME] in the elderly as compared to the young. Therefore, as patient age increases, a lower dose of [MEDICATION NAME] is usually required to produce a therapeutic level of anticoagulation. WARNINGS The most serious risks associated with anticoagulant therapy with [MEDICATION NAME] sodium are hemorrhage in any tissue or organ12 (see BLACK BOX WARNING) PRECAUTIONS Periodic determination of PT/INR is essential. (See DOSAGE AND ADMINISTRATION: Laboratory Control.) Numerous factors, alone or in combination including changes in diet, medications, [MEDICATION NAME], and genetic variations in the CYP2C9 and VKORC1 enzymes (see CLINICAL PHARMACOLOGY: Pharmacogenomics) may influence the response of the patient to [MEDICATION NAME]. R #1's Face Sheet revealed R #1 was a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R #1's Admission Physician order [REDACTED].#1 was prescribed [MEDICATION NAME] 5 mg. (milligrams) every day by mouth (a medication used as a blood thinner) and [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] Fibrillation) 0.25 mg by mouth every day. R #1's Physician Telephone Orders dated 06/30/15 revealed a Laboratory (lab) blood draw for PT/INR ([MEDICATION NAME] time) INR (international normalized ratio) levels. (Blood test used to determine clotting tendency of blood) every Monday and a [MEDICATION NAME] blood Level ([MEDICATION NAME]-medication used to treat abnormal heart rhythms) and Basic Metabolic Panel (BMP) on Monday (07/06/15). There was no order to discontinue the PT/INR or the [MEDICATION NAME] Labs. R #1's Consolidated Physician order [REDACTED]. R #1's Medication Administration Record [REDACTED]. by mouth 06/28/15 through 06/30/15. R #1's MAR indicated [REDACTED]. by mouth 07/01/15 through 07/23/15. R #1 received [MEDICATION NAME] 5 mg. 26 times between June 28,2015 and July 24, 2015. R #1's 5 day Minimum Data Set ((MDS) dated [DATE] revealed R #1 was understood by others and had clear comprehension, had adequate vision and wore corrective lenses. R #1 had intact cognition, and it was very important to choose between a tub bath, shower, bed bath, or sponge bath. R #1 required limited assistance with walking in the room with one person assistance. R #1 required extensive assistance with the help of one person for personal hygiene, bathing and dressing. R #1 was continent of bowel and bladder. R #1 had received an Anticoagulant, Antibiotic and Diuretic medications during the past seven days. R #1's Care Plan dated 06/27/15 revealed Problem Onset: .I am at risk for bleeding due to anticoagulant therapy ([MEDICAL CONDITION] Fib) .*I will have no injury related to my medication usage/side effects .*I will maintain normal therapeutic PT/INR .*Administer my anticoagulant as ordered by my physician .*Coordinate my lab work as ordered. R #1's Communication Form and Progress Note dated 07/24/15 revealed R #1 had a pulse rate of 108 beats per minute and was described as having rectal bleeding and [MEDICAL CONDITION] (a rapid heart rate) .Notified (Nurse Practitioner) Recommended transfer to ER (emergency room ) . R #1's Hospital Lab Report dated 07/24/15 revealed, PT >100.0 seconds (normal range 9.5-13.2 seconds), INR >10.0 (normal range < 4) R #1's Hospital History and Physical dated 07/24/15 revealed, Chief Complaint: Blood per rectum, bright red for 1 day. History of Present illness: This [AGE] year old female .who is [MEDICATION NAME] ([MEDICATION NAME]) dependent .came into the hospital for an evaluation due to bright red blood per rectum for 1 day nonstop .In the emergency room her INR was more than 10 with a PT over 100 .Assessment And Plan: 1. [MEDICATION NAME] toxicity: PT/INR over 100 and over 10. She did receive FFP (Fresh Frozen Plasma) and vitamin K in the emergency room . 5. [MEDICAL CONDITION]: She has been on [MEDICATION NAME]. She received vitamin K and FFP. Will reassess the need, including risks and benefits of anticoagulation . R #1's Hospital [MEDICATION NAME] Consultation dated 07/25/15 revealed, .The patient is a [AGE] year old female .She states that she has been bleeding 3 to 4 days prior to admission. Upon admission, her PT/INR was greater than 10, and this was corrected with FFP as well as vitamin K. She has had no further bleeding since admission . Impression: Rectal Bleeding .This is likely precipitated by her over anticoagulation .I would keep her INR between 2 and 2.5 . On 07/29/15 at 1:30 p.m., interview with the facility's Director of Nurses (DON) revealed R #1's Laboratory work that was ordered by the NP on 06/30/15 was never done. The DON said the nurse that received the order never filled out a Laboratory Requisition or followed up on the orders. DON said the night shift nurses were to double check all new orders were transcribed but in the case of R #1 the night shift nurses missed the order. The DON said that now, all laboratory orders will be brought to the daily morning meeting and the managers will be responsible for following up to ensure the orders were transcribed and followed through. On 07/29/15 at 1:35 p.m., interview with the Administrator revealed there was a system failure with the Laboratory work not being done with R #1's Laboratory order but the DON discovered the error yesterday and corrected the problem. On 07/29/15 at 1:40 p.m., interview with the DON revealed she had read an email that was sent down from corporate office yesterday (07/28/15) and was brought to the DON's attention yesterday at approximately 5:20 p.m. The email was a complaint from R #1's Family Member (FM) F. The FM F had mentioned in the email R #1's INR lab was over 10 when admitted to the hospital. The DON said she checked R #1's Laboratory Orders and discovered the Laboratory work was never done. The DON said the PT/INR was never done for 07/06/15, 07/13/15 and 07/20/15, and R #1's [MEDICATION NAME] level or BMP was never done on 07/06/15. The DON said it was very important to monitor medications that required therapeutic blood level monitoring, because the patient could become toxic from the medication or not have enough of the medication in the patient's system to be therapeutic. The DON said she would always ask the Physician for lab orders for a baseline and to monitor therapeutic drug values. The DON stated she had already identified the problem and started an action plan. The DON said she had began a chart audit, and planned to meet with the Medical Directors to establish standardized orders, for those residents that required therapeutic monitoring. The DON said the contract laboratory company was onsite to audit all laboratory orders. On 07/30/15 at 1:25 p.m., the Administrator said he was unaware the facility did not have a system in place to make sure Labs orders were followed through prior to R #1 not getting Labs drawn. The Administrator said the LVN's were scared to question Physician Orders. On 07/30/15 at 1:35 p.m., interview with the DON revealed the facility did not have a policy and procedure specific to ordering laboratory work or therapeutic monitoring. It was determined these failures placed R #1 in an Immediate Jeopardy (IJ) situation from 07/06/15 through 07/28/15. The facility took the following actions to correct the non-compliance on 07/28/15: 1) All medications requiring laboratory monitoring will have standing lab orders. 2) Any medication requiring laboratory monitoring that do not have a routine lab order will require physician notification to request routine lab orders. 3) 100% chart audit will be done to identify any omitted lab orders for medications requiring monitoring 4) A list of medications requiring routine lab monitoring will be provided by pharmacy. 5) Chart audit and labs done. Review of Staff Development/Inservice Attendance Sheet dated 07/28/15 revealed Objectives: When you receive an order for [REDACTED]. Review of In-Service Training Record dated 07/28/15 revealed, Nurse Managers are to review all telephone orders after daily care meeting and review (with) MAR/TAR (Treatment Administration Record) to ensure procedure was followed correctly by receiving nurse. Each order for lab should be compared (with) lab manifest to ensure proper communication to lab company. On 07/29/15 at 2:10 p.m., interview with Licensed Vocational Nurse (LVN) K revealed she was on duty the day R #1 was sent to the hospital. LVN K said she assessed R #1 and noted a clot and blood from R #1's rectum, and R #1 had [MEDICAL CONDITION] LVN K said she called the NP regarding her assessment and was instructed by the NP to send R #1 to the ER. LVN K said when a nurse received an order for [REDACTED]. LVN K said that was how the nurse knew how the blood was drawn, by the pink copy. LVN K said when the Laboratory results come back abnormal the nurse should notify the Physician right away. On 07/29/15 at 2:40 p.m., interview with LVN P revealed he failed to follow up and write out the Laboratory Requisition for R #1's Physician order [REDACTED]. LVN P said I must have got busy and forgot, I feel bad for (R#1) she was a very nice lady. LVN P said he was trained by the facility on procedures for Laboratory work but, it was just my mistake. LVN P said it was important to monitor PT/INR values to ensure the patient was receiving a therapeutic dose of [MEDICATION NAME] because the patient could bleed out. LVN P stated he was in-serviced by the DON in laboratory procedures yesterday on a 1:1 after it was discovered he had failed to fill out the lab slip. On 07/29/15 at 4:25 p.m., interview with the Assistant Director of Nurses (ADON) L revealed she did not know if the family or the Physician was ever notified regarding the PT/INR, [MEDICATION NAME] and BMP Laboratory not done. ADON L said the nurses should know to ask the Physician for lab work orders on admission. On 07/29/15 at 4:45 p.m., in an interview with the DON she said she had not notified the daughter or Physician regarding the physician's orders [REDACTED]. On 07/30/15 at 9:15 a.m., interview with R #1 revealed she had told the nurse several times that her rectum was bleeding and the nurse just told R #1 that it was Hemorrhoids and not to worry. (The interview was conducted at another facility.) On 07/30/15 at 12:45 p.m., interview with the NP that ordered R #1's Laboratory work on 06/30/15 revealed she was notified R #1's Laboratory work was not done as ordered just yesterday (07/29/15). The NP said she had spoken with the DON in the past about Laboratory Orders not being done as ordered. The NP said hopefully this will be a wakeup call so the facility can have a system in place. The NP said she and the Physician count on the Nurses and Pharmacy Consultants to look for those medications that require therapeutic monitoring to ensure the Lab work was done. On 07/30/15 at 1:00 p.m., interview with the facility Pharmacy Consultant revealed he was not in the facility after R #1 was admitted . The Pharmacy Consultant said he would normally make Physician recommendations to order therapeutic PT/INR on residents taking [MEDICATION NAME] monthly if resident was on [MEDICATION NAME] in long term care. The Pharmacy Consultant said for residents in long term care that were stable on [MEDICATION NAME], he would recommend Laboratory Levels every six months to a year. On 07/30/15 at 3:00 p.m., LVN K said it was Best Practice to call the Physician to verify orders when a resident was admitted to the facility. LVN K said if she saw a resident was prescribed a medication that required therapeutic monitoring she would ask the Physician if they wanted Labs drawn and how often. On 07/30/15 at 1:45 p.m., LVN N said he would call the Physician to verify all orders when a resident was admitted to the facility. LVN N said if a resident was prescribed a medication that required therapeutic monitoring, or if a resident was admitted without laboratory orders, he would call the Physician and ask the Physician if they wanted to order Labs. On 08/07/15 at 2:20 p.m., the DON said she could not find any in-services conducted in laboratory procedures and obtaining Physician order [REDACTED]. On 08/07/15 at 4:21 p.m., ADON L said all the Medical Directors at the facility met with the DON and the Management staff to develop standardized lab orders on admission and every six months depending on the medication the resident was receiving. In the past, admission orders [REDACTED]. ADON L said the facility did not have a policy and procedure regarding labs. ADON L said as a result of the lab error that was discovered by the DON, each admitting Physician has their own orders as to how they want therapeutic drug monitoring and baseline lab work. According to physician's orders [REDACTED].

Based on interview and record review the facility failed to follow the Physician Plan of Care (Physician's Orders) and the resident's Plan of Care for one Resident (R #1) of seven residents reviewed for plans of care. *The facility did not provide Laboratory services for R #1. The therapeutic level of [MEDICATION NAME] ([MEDICATION NAME]) was not monitored by PT/INR levels for three weeks. The therapeutic level of [MEDICATION NAME] and BMP was not monitored by the facility for one week. *R #1 was admitted to the hospital with [REDACTED]. These failures contributed to R #1's hospitalization requiring FFP and Vitamin K to reverse the effect of [MEDICATION NAME] toxicity. This could have affected two residents prescribed [MEDICATION NAME] and 11 residents prescribed [MEDICATION NAME]. An IJ (Immediate Jeopardy) was determined to have existed from 07/06/15 through 07/28/15. The DON was made aware of the Physician's Orders not being followed and implemented an Action Plan prior to the beginning of the survey. The findings were: According to Lippincott's Nursing Procedures Sixth Edition 2013, pp 230; Documentation is the process of preparing a complete record of a patient's care and is a vital tool for communication among health care team members. Accurate, detailed charting shows the extent and quality of care that nurses provide the outcomes of that care, and treatment and education that the patient still needs. Thorough, accurate documentation decreases the potential for miscommunication and errors. According to: http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/ 8s108lbl.pdf referenced 08/01/15: [MEDICATION NAME]® TABLETS ([MEDICATION NAME] Sodium Tablets, USP) [MEDICATION NAME]® FOR INJECTION ([MEDICATION NAME] Sodium for Injection, USP) Anticoagulant WARNING: BLEEDING RISK [MEDICATION NAME] sodium can cause major or fatal bleeding. Bleeding is more likely to occur during the starting period and with a higher dose (resulting in a higher INR). Risk factors for bleeding include high intensity of anticoagulation (INR >4.0), age =65, highly variable INRs, history of [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION] disease, serious [MEDICAL CONDITIONS], malignancy, trauma, [MEDICAL CONDITION], concomitant drugs (see PRECAUTIONS), and long duration of [MEDICATION NAME] therapy. Regular monitoring of INR should be performed on all treated patients. Those at high risk of bleeding may benefit from more frequent INR monitoring, careful dose adjustment to desired INR, and a shorter duration of therapy. Patients should be instructed about prevention measures to minimize risk of bleeding and to report immediately to physicians signs and symptoms of bleeding (see PRECAUTIONS: Information for Patients) Elderly Patients [AGE] years or older appear to exhibit greater than expected PT/INR response to the anticoagulant effects of [MEDICATION NAME]. The cause of the increased sensitivity to the anticoagulant effects of [MEDICATION NAME] in this age group is unknown. This increased anticoagulant effect from [MEDICATION NAME] may be due to a combination of pharmacokinetic and pharmacodynamic factors. Racemic [MEDICATION NAME] clearance may be unchanged or reduced with increasing age. Limited information suggests there is no difference in the clearance of S-[MEDICATION NAME] in the elderly versus young subjects. However, there may be a slight decrease in the clearance of R-[MEDICATION NAME] in the elderly as compared to the young. Therefore, as patient age increases, a lower dose of [MEDICATION NAME] is usually required to produce a therapeutic level of anticoagulation. WARNINGS The most serious risks associated with anticoagulant therapy with [MEDICATION NAME] sodium are hemorrhage in any tissue or organ12 (see BLACK BOX WARNING) PRECAUTIONS Periodic determination of PT/INR is essential. (See DOSAGE AND ADMINISTRATION: Laboratory Control.) Numerous factors, alone or in combination including changes in diet, medications, [MEDICATION NAME], and genetic variations in the CYP2C9 and VKORC1 enzymes (see CLINICAL PHARMACOLOGY: Pharmacogenomics) may influence the response of the patient to [MEDICATION NAME]. R #1's Face Sheet revealed R #1 was a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R #1's Admission Physician Orders dated 06/27/15 revealed R #1 was prescribed [MEDICATION NAME] 5 mg. (milligrams) every day by mouth (a medication used as a blood thinner) and [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] Fibrillation) 0.25 mg by mouth every day. R #1's Physician Telephone Orders dated 06/30/15 revealed a Laboratory (lab) blood draw for PT/INR ([MEDICATION NAME] time) INR (international normalized ratio) levels. (Blood test used to determine clotting tendency of blood) every Monday and a [MEDICATION NAME] blood Level ([MEDICATION NAME]-medication used to treat abnormal heart rhythms) and Basic Metabolic Panel (BMP) on Monday (07/06/15). There was no order to discontinue the PT/INR or the [MEDICATION NAME] Labs. R #1's Consolidated Physician Orders dated July 2015 did not have Laboratory Orders. R #1's Medication Administration Record [REDACTED]. by mouth 06/28/15 through 06/30/15. R #1's MAR indicated [REDACTED]. by mouth 07/01/15 through 07/23/15. R #1 received [MEDICATION NAME] 5 mg. 26 times between June 28,2015 and July 24, 2015. R #1's 5 day Minimum Data Set ((MDS) dated [DATE] revealed R #1 was understood by others and had clear comprehension, had adequate vision and wore corrective lenses. R #1 had intact cognition, and it was very important to choose between a tub bath, shower, bed bath, or sponge bath. R #1 required limited assistance with walking in the room with one person assistance. R #1 required extensive assistance with the help of one person for personal hygiene, bathing and dressing. R #1 was continent of bowel and bladder. R #1 had received an Anticoagulant, Antibiotic and Diuretic medications during the past seven days. R #1's Care Plan dated 06/27/15 revealed Problem Onset: .I am at risk for bleeding due to anticoagulant therapy ([MEDICAL CONDITION] Fib) .*I will have no injury related to my medication usage/side effects .*I will maintain normal therapeutic PT/INR .*Administer my anticoagulant as ordered by my physician .*Coordinate my lab work as ordered. R #1's Communication Form and Progress Note dated 07/24/15 revealed R #1 had a pulse rate of 108 beats per minute and was described as having rectal bleeding and [MEDICAL CONDITION] (a rapid heart rate) .Notified (Nurse Practitioner) Recommended transfer to ER (emergency room ) . R #1's Hospital Lab Report dated 07/24/15 revealed, PT >100.0 seconds (normal range 9.5-13.2 seconds), INR >10.0 (normal range < 4) R #1's Hospital History and Physical dated 07/24/15 revealed, Chief Complaint: Blood per rectum, bright red for 1 day. History of Present illness: This [AGE] year old female .who is [MEDICATION NAME] ([MEDICATION NAME]) dependent .came into the hospital for an evaluation due to bright red blood per rectum for 1 day nonstop .In the emergency room her INR was more than 10 with a PT over 100 .Assessment And Plan: 1. [MEDICATION NAME] toxicity: PT/INR over 100 and over 10. She did receive FFP (Fresh Frozen Plasma) and vitamin K in the emergency room . 5. [MEDICAL CONDITION]: She has been on [MEDICATION NAME]. She received vitamin K and FFP. Will reassess the need, including risks and benefits of anticoagulation . R #1's Hospital [MEDICATION NAME] Consultation dated 07/25/15 revealed, .The patient is a [AGE] year old female .She states that she has been bleeding 3 to 4 days prior to admission. Upon admission, her PT/INR was greater than 10, and this was corrected with FFP as well as vitamin K. She has had no further bleeding since admission . Impression: Rectal Bleeding .This is likely precipitated by her over anticoagulation .I would keep her INR between 2 and 2.5 . On 07/29/15 at 1:30 p.m., interview with the facility's Director of Nurses (DON) revealed R #1's Laboratory work that was ordered by the NP on 06/30/15 was never done. The DON said the nurse that received the order never filled out a Laboratory Requisition or followed up on the orders. DON said the night shift nurses were to double check all new orders were transcribed but in the case of R #1 the night shift nurses missed the order. The DON said that now, all laboratory orders will be brought to the daily morning meeting and the managers will be responsible for following up to ensure the orders were transcribed and followed through. On 07/29/15 at 1:35 p.m., interview with the Administrator revealed there was a system failure with the Laboratory work not being done with R #1's Laboratory order but the DON discovered the error yesterday and corrected the problem. On 07/29/15 at 1:40 p.m., interview with the DON revealed she had read an email that was sent down from corporate office yesterday (07/28/15) and was brought to the DON's attention yesterday at approximately 5:20 p.m. The email was a complaint from R #1's Family Member (FM) F. The FM F had mentioned in the email R #1's INR lab was over 10 when admitted to the hospital. The DON said she checked R #1's Laboratory Orders and discovered the Laboratory work was never done. The DON said the PT/INR was never done for 07/06/15, 07/13/15 and 07/20/15, and R #1's [MEDICATION NAME] level or BMP was never done on 07/06/15. The DON said it was very important to monitor medications that required therapeutic blood level monitoring, because the patient could become toxic from the medication or not have enough of the medication in the patient's system to be therapeutic. The DON said she would always ask the Physician for lab orders for a baseline and to monitor therapeutic drug values. The DON stated she had already identified the problem and started an action plan. The DON said she had began a chart audit, and planned to meet with the Medical Directors to establish standardized orders, for those residents that required therapeutic monitoring. The DON said the contract laboratory company was onsite to audit all laboratory orders. On 07/30/15 at 1:25 p.m., the Administrator said he was unaware the facility did not have a system in place to make sure Labs orders were followed through prior to R #1 not getting Labs drawn. The Administrator said the LVN's were scared to question Physician Orders. On 07/30/15 at 1:35 p.m., interview with the DON revealed the facility did not have a policy and procedure specific to ordering laboratory work or therapeutic monitoring. It was determined these failures placed R #1 in an Immediate Jeopardy (IJ) situation from 07/06/15 through 07/28/15. The facility took the following actions to correct the non-compliance on 07/28/15: 1) All medications requiring laboratory monitoring will have standing lab orders. 2) Any medication requiring laboratory monitoring that do not have a routine lab order will require physician notification to request routine lab orders. 3) 100% chart audit will be done to identify any omitted lab orders for medications requiring monitoring 4) A list of medication requiring routine lab monitoring will be provided by pharmacy. 5) Chart audit and labs done. Review of Staff Development/Inservice Attendance Sheet dated 07/28/15 revealed Objectives: When you receive an order for [REDACTED]. Review of In-Service Training Record dated 07/28/15 revealed, Nurse Managers are to review all telephone orders after daily care meeting and review (with) MAR/TAR (Treatment Administration Record) to ensure procedure was followed correctly by receiving nurse. Each order for lab should be compared (with) lab manifest to ensure proper communication to lab company. On 07/29/15 at 2:10 p.m., interview with Licensed Vocational Nurse (LVN) K revealed she was on duty the day R #1 was sent to the hospital. LVN K said she assessed R #1 and noted a clot and blood from R #1's rectum, and R #1 had [MEDICAL CONDITION] LVN K said she called the NP regarding her assessment and was instructed by the NP to send R #1 to the ER. LVN K said when a nurse received an order for [REDACTED]. LVN K said that was how the nurse knew how the blood was drawn, by the pink copy. LVN K said when the Laboratory results come back abnormal the nurse should notify the Physician right away. On 07/29/15 at 2:40 p.m., interview with LVN P revealed he failed to follow up and write out the Laboratory Requisition for R #1's Physician Orders for the PT/INR. LVN P said I must have got busy and forgot, I feel bad for (R#1) she was a very nice lady. LVN P said he was trained by the facility on procedures for Laboratory work but, it was just my mistake. LVN P said it was important to monitor PT/INR values to ensure the patient was receiving a therapeutic dose of [MEDICATION NAME] because the patient could bleed out. LVN P stated he was in-serviced by the DON in laboratory procedures yesterday on a 1:1 after it was discovered he had failed to fill out the lab slip. On 07/29/15 at 4:25 p.m., interview with the Assistant Director of Nurses (ADON) L revealed she did not know if the family or the Physician was ever notified regarding the PT/INR, [MEDICATION NAME] and BMP Laboratory not done. ADON L said the nurses should know to ask the Physician for lab work orders on admission. On 07/29/15 at 4:45 p.m., in an interview with the DON she said she had not notified the daughter or Physician regarding the Physician's Orders not being followed but would call the Physician right away. On 07/30/15 at 9:15 a.m., interview with R #1 revealed she had told the nurse several times that her rectum was bleeding and the nurse just told R #1 that it was Hemorrhoids and not to worry. (The interview was conducted at another facility.) On 07/30/15 at 12:45 p.m., interview with the NP that ordered R #1's Laboratory work on 06/30/15 revealed she was notified R #1's Laboratory work was not done as ordered just yesterday (07/29/15). The NP said she had spoken with the DON in the past about Laboratory Orders not being done as ordered. The NP said hopefully this will be a wakeup call so the facility can have a system in place. The NP said she and the Physician count on the Nurses and Pharmacy Consultants to look for those medications that require therapeutic monitoring to ensure the Lab work was done. On 07/30/15 at 1:00 p.m., interview with the facility Pharmacy Consultant revealed he was not in the facility after R #1 was admitted . The Pharmacy Consultant said he would normally make Physician recommendations to order therapeutic PT/INR on residents taking [MEDICATION NAME] monthly if resident was on [MEDICATION NAME] in long term care. The Pharmacy Consultant said for residents in long term care that were stable on [MEDICATION NAME], he would recommend Laboratory Levels every six months to a year. On 07/30/15 at 3:00 p.m., LVN K said it was Best Practice to call the Physician to verify orders when a resident was admitted to the facility. LVN K said if she saw a resident was prescribed a medication that required therapeutic monitoring she would ask the Physician if they wanted Labs drawn and how often. On 07/30/15 at 1:45 p.m., LVN N said he would call the Physician to verify all orders when a resident was admitted to the facility. LVN N said if a resident was prescribed a medication that required therapeutic monitoring, or if a resident was admitted without laboratory orders, he would call the Physician and ask the Physician if they wanted to order Labs. On 08/07/15 at 2:20 p.m., the DON said she could not find any in-services conducted in laboratory procedures and obtaining Physician Orders for laboratory work for those residents on medications that require therapeutic monitoring prior to 07/28/15. On 08/07/15 at 4:21 p.m., ADON L said all the Medical Directors at the facility met with the DON and the Management staff to develop standardized lab orders on admission and every six months depending on the medication the resident was receiving. In the past, admission orders [REDACTED]. ADON L said the facility did not have a policy and procedure regarding labs. ADON L said as a result of the lab error that was discovered by the DON, each admitting Physician has their own orders as to how they want therapeutic drug monitoring and baseline lab work. According to Physician's Order List dated 07/30/15 there were two residents prescribed [MEDICATION NAME] and 11 residents prescribed [MEDICATION NAME].

Based on record review, and interview, the facility failed to ensure each resident's drug regimen was free from the administration of unnecessary drugs (for excessive duration, without adequate indication for its use or adequate monitoring), for one Resident (R#1), of seven residents whose medications were reviewed for therapeutic laboratory monitoring. *The facility did not provide Laboratory services for R #1. The therapeutic level of [MEDICATION NAME] was not monitored by PT/INR levels for three weeks. The therapeutic level of [MEDICATION NAME] and BMP was not monitored by the facility for one week. *R #1 was admitted to the hospital with [REDACTED]. These failures contributed to R #1's hospitalization requiring FFP and Vitamin K to reverse the effect of [MEDICATION NAME] toxicity. This could have affected two residents prescribed [MEDICATION NAME] and 11 residents prescribed [MEDICATION NAME]. An IJ (Immediate Jeopardy) was determined to have existed from 07/06/15 through 07/28/15. The DON was made aware of the physician's orders [REDACTED]. The findings were: According to Lippincott's Nursing Procedures Sixth Edition 2013, pp 230; Documentation is the process of preparing a complete record of a patient's care and is a vital tool for communication among health care team members. Accurate, detailed charting shows the extent and quality of care that nurses provide the outcomes of that care, and treatment and education that the patient still needs. Thorough, accurate documentation decreases the potential for miscommunication and errors. According to: http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/ 8s108lbl.pdf referenced 08/01/15: [MEDICATION NAME]® TABLETS ([MEDICATION NAME] Sodium Tablets, USP) [MEDICATION NAME]® FOR INJECTION ([MEDICATION NAME] Sodium for Injection, USP) Anticoagulant WARNING: BLEEDING RISK [MEDICATION NAME] sodium can cause major or fatal bleeding. Bleeding is more likely to occur during the starting period and with a higher dose (resulting in a higher INR). Risk factors for bleeding include high intensity of anticoagulation (INR >4.0), age =65, highly variable INRs, history of [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION] disease, serious [MEDICAL CONDITIONS], malignancy, trauma, [MEDICAL CONDITION], concomitant drugs (see PRECAUTIONS), and long duration of [MEDICATION NAME] therapy. Regular monitoring of INR should be performed on all treated patients. Those at high risk of bleeding may benefit from more frequent INR monitoring, careful dose adjustment to desired INR, and a shorter duration of therapy. Patients should be instructed about prevention measures to minimize risk of bleeding and to report immediately to physicians signs and symptoms of bleeding (see PRECAUTIONS: Information for Patients) Elderly Patients [AGE] years or older appear to exhibit greater than expected PT/INR response to the anticoagulant effects of [MEDICATION NAME]. The cause of the increased sensitivity to the anticoagulant effects of [MEDICATION NAME] in this age group is unknown. This increased anticoagulant effect from [MEDICATION NAME] may be due to a combination of pharmacokinetic and pharmacodynamic factors. Racemic [MEDICATION NAME] clearance may be unchanged or reduced with increasing age. Limited information suggests there is no difference in the clearance of S-[MEDICATION NAME] in the elderly versus young subjects. However, there may be a slight decrease in the clearance of R-[MEDICATION NAME] in the elderly as compared to the young. Therefore, as patient age increases, a lower dose of [MEDICATION NAME] is usually required to produce a therapeutic level of anticoagulation. WARNINGS The most serious risks associated with anticoagulant therapy with [MEDICATION NAME] sodium are hemorrhage in any tissue or organ12 (see BLACK BOX WARNING) PRECAUTIONS Periodic determination of PT/INR is essential. (See DOSAGE AND ADMINISTRATION: Laboratory Control.) Numerous factors, alone or in combination including changes in diet, medications, [MEDICATION NAME], and genetic variations in the CYP2C9 and VKORC1 enzymes (see CLINICAL PHARMACOLOGY: Pharmacogenomics) may influence the response of the patient to [MEDICATION NAME]. R #1's Face Sheet revealed R #1 was a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R #1's Admission Physician order [REDACTED].#1 was prescribed [MEDICATION NAME] 5 mg. (milligrams) every day by mouth (a medication used as a blood thinner) and [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] Fibrillation) 0.25 mg by mouth every day. R #1's Physician Telephone Orders dated 06/30/15 revealed a Laboratory (lab) blood draw for PT/INR ([MEDICATION NAME] time) INR (international normalized ratio) levels. (Blood test used to determine clotting tendency of blood) every Monday and a [MEDICATION NAME] blood Level ([MEDICATION NAME]-medication used to treat abnormal heart rhythms) and Basic Metabolic Panel (BMP) on Monday (07/06/15). There was no order to discontinue the PT/INR or the [MEDICATION NAME] Labs. R #1's Consolidated Physician order [REDACTED]. R #1's Medication Administration Record [REDACTED]. by mouth 06/28/15 through 06/30/15. R #1's MAR indicated [REDACTED]. by mouth 07/01/15 through 07/23/15. R #1 received [MEDICATION NAME] 5 mg. 26 times between June 28,2015 and July 24, 2015. R #1's 5 day Minimum Data Set ((MDS) dated [DATE] revealed R #1 was understood by others and had clear comprehension, had adequate vision and wore corrective lenses. R #1 had intact cognition, and it was very important to choose between a tub bath, shower, bed bath, or sponge bath. R #1 required limited assistance with walking in the room with one person assistance. R #1 required extensive assistance with the help of one person for personal hygiene, bathing and dressing. R #1 was continent of bowel and bladder. R #1 had received an Anticoagulant, Antibiotic and Diuretic medications during the past seven days. R #1's Care Plan dated 06/27/15 revealed Problem Onset: .I am at risk for bleeding due to anticoagulant therapy ([MEDICAL CONDITION] Fib) .*I will have no injury related to my medication usage/side effects .*I will maintain normal therapeutic PT/INR .*Administer my anticoagulant as ordered by my physician .*Coordinate my lab work as ordered. R #1's Communication Form and Progress Note dated 07/24/15 revealed R #1 had a pulse rate of 108 beats per minute and was described as having rectal bleeding and [MEDICAL CONDITION] (a rapid heart rate) .Notified (Nurse Practitioner) Recommended transfer to ER (emergency room ) . R #1's Hospital Lab Report dated 07/24/15 revealed, PT >100.0 seconds (normal range 9.5-13.2 seconds), INR >10.0 (normal range < 4) R #1's Hospital History and Physical dated 07/24/15 revealed, Chief Complaint: Blood per rectum, bright red for 1 day. History of Present illness: This [AGE] year old female .who is [MEDICATION NAME] ([MEDICATION NAME]) dependent .came into the hospital for an evaluation due to bright red blood per rectum for 1 day nonstop .In the emergency room her INR was more than 10 with a PT over 100 .Assessment And Plan: 1. [MEDICATION NAME] toxicity: PT/INR over 100 and over 10. She did receive FFP (Fresh Frozen Plasma) and vitamin K in the emergency room . 5. [MEDICAL CONDITION]: She has been on [MEDICATION NAME]. She received vitamin K and FFP. Will reassess the need, including risks and benefits of anticoagulation . R #1's Hospital [MEDICATION NAME] Consultation dated 07/25/15 revealed, .The patient is a [AGE] year old female .She states that she has been bleeding 3 to 4 days prior to admission. Upon admission, her PT/INR was greater than 10, and this was corrected with FFP as well as vitamin K. She has had no further bleeding since admission . Impression: Rectal Bleeding .This is likely precipitated by her over anticoagulation .I would keep her INR between 2 and 2.5 . On 07/29/15 at 1:30 p.m., interview with the facility's Director of Nurses (DON) revealed R #1's Laboratory work that was ordered by the NP on 06/30/15 was never done. The DON said the nurse that received the order never filled out a Laboratory Requisition or followed up on the orders. DON said the night shift nurses were to double check all new orders were transcribed but in the case of R #1 the night shift nurses missed the order. The DON said that now, all laboratory orders will be brought to the daily morning meeting and the managers will be responsible for following up to ensure the orders were transcribed and followed through. On 07/29/15 at 1:35 p.m., interview with the Administrator revealed there was a system failure with the Laboratory work not being done with R #1's Laboratory order but the DON discovered the error yesterday and corrected the problem. On 07/29/15 at 1:40 p.m., interview with the DON revealed she had read an email that was sent down from corporate office yesterday (07/28/15) and was brought to the DON's attention yesterday at approximately 5:20 p.m. The email was a complaint from R #1's Family Member (FM) F. The FM F had mentioned in the email R #1's INR lab was over 10 when admitted to the hospital. The DON said she checked R #1's Laboratory Orders and discovered the Laboratory work was never done. The DON said the PT/INR was never done for 07/06/15, 07/13/15 and 07/20/15, and R #1's [MEDICATION NAME] level or BMP was never done on 07/06/15. The DON said it was very important to monitor medications that required therapeutic blood level monitoring, because the patient could become toxic from the medication or not have enough of the medication in the patient's system to be therapeutic. The DON said she would always ask the Physician for lab orders for a baseline and to monitor therapeutic drug values. The DON stated she had already identified the problem and started an action plan. The DON said she had began a chart audit, and planned to meet with the Medical Directors to establish standardized orders, for those residents that required therapeutic monitoring. The DON said the contract laboratory company was onsite to audit all laboratory orders. On 07/30/15 at 1:25 p.m., the Administrator said he was unaware the facility did not have a system in place to make sure Labs orders were followed through prior to R #1 not getting Labs drawn. The Administrator said the LVN's were scared to question Physician Orders. On 07/30/15 at 1:35 p.m., interview with the DON revealed the facility did not have a policy and procedure specific to ordering laboratory work or therapeutic monitoring. It was determined these failures placed R #1 in an Immediate Jeopardy (IJ) situation from 07/06/15 through 07/28/15. The facility took the following actions to correct the non-compliance on 07/28/15: 1) All medications requiring laboratory monitoring will have standing lab orders. 2) Any medication requiring laboratory monitoring that do not have a routine lab order will require physician notification to request routine lab orders. 3) 100% chart audit will be done to identify any omitted lab orders for medications requiring monitoring 4) A list of medication requiring routine lab monitoring will be provided by pharmacy. 5) Chart audit and labs done. Review of Staff Development/Inservice Attendance Sheet dated 07/28/15 revealed Objectives: When you receive an order for [REDACTED]. Review of In-Service Training Record dated 07/28/15 revealed, Nurse Managers are to review all telephone orders after daily care meeting and review (with) MAR/TAR (Treatment Administration Record) to ensure procedure was followed correctly by receiving nurse. Each order for lab should be compared (with) lab manifest to ensure proper communication to lab company. On 07/29/15 at 2:10 p.m., interview with Licensed Vocational Nurse (LVN) K revealed she was on duty the day R #1 was sent to the hospital. LVN K said she assessed R #1 and noted a clot and blood from R #1's rectum, and R #1 had [MEDICAL CONDITION] LVN K said she called the NP regarding her assessment and was instructed by the NP to send R #1 to the ER. LVN K said when a nurse received an order for [REDACTED]. LVN K said that was how the nurse knew how the blood was drawn, by the pink copy. LVN K said when the Laboratory results come back abnormal the nurse should notify the Physician right away. On 07/29/15 at 2:40 p.m., interview with LVN P revealed he failed to follow up and write out the Laboratory Requisition for R #1's Physician order [REDACTED]. LVN P said I must have got busy and forgot, I feel bad for (R#1) she was a very nice lady. LVN P said he was trained by the facility on procedures for Laboratory work but, it was just my mistake. LVN P said it was important to monitor PT/INR values to ensure the patient was receiving a therapeutic dose of [MEDICATION NAME] because the patient could bleed out. LVN P stated he was in-serviced by the DON in laboratory procedures yesterday on a 1:1 after it was discovered he had failed to fill out the lab slip. On 07/29/15 at 4:25 p.m., interview with the Assistant Director of Nurses (ADON) L revealed she did not know if the family or the Physician was ever notified regarding the PT/INR, [MEDICATION NAME] and BMP Laboratory not done. ADON L said the nurses should know to ask the Physician for lab work orders on admission. On 07/29/15 at 4:45 p.m., in an interview with the DON she said she had not notified the daughter or Physician regarding the physician's orders [REDACTED]. On 07/30/15 at 9:15 a.m., interview with R #1 revealed she had told the nurse several times that her rectum was bleeding and the nurse just told R #1 that it was Hemorrhoids and not to worry. (The interview was conducted at another facility.) On 07/30/15 at 12:45 p.m., interview with the NP that ordered R #1's Laboratory work on 06/30/15 revealed she was notified R #1's Laboratory work was not done as ordered just yesterday (07/29/15). The NP said she had spoken with the DON in the past about Laboratory Orders not being done as ordered. The NP said hopefully this will be a wakeup call so the facility can have a system in place. The NP said she and the Physician count on the Nurses and Pharmacy Consultants to look for those medications that require therapeutic monitoring to ensure the Lab work was done. On 07/30/15 at 1:00 p.m., interview with the facility Pharmacy Consultant revealed he was not in the facility after R #1 was admitted . The Pharmacy Consultant said he would normally make Physician recommendations to order therapeutic PT/INR on residents taking [MEDICATION NAME] monthly if resident was on [MEDICATION NAME] in long term care. The Pharmacy Consultant said for residents in long term care that were stable on [MEDICATION NAME], he would recommend Laboratory Levels every six months to a year. On 07/30/15 at 3:00 p.m., LVN K said it was Best Practice to call the Physician to verify orders when a resident was admitted to the facility. LVN K said if she saw a resident was prescribed a medication that required therapeutic monitoring she would ask the Physician if they wanted Labs drawn and how often. On 07/30/15 at 1:45 p.m., LVN N said he would call the Physician to verify all orders when a resident was admitted to the facility. LVN N said if a resident was prescribed a medication that required therapeutic monitoring, or if a resident was admitted without laboratory orders, he would call the Physician and ask the Physician if they wanted to order Labs. On 08/07/15 at 2:20 p.m., the DON said she could not find any in-services conducted in laboratory procedures and obtaining Physician order [REDACTED]. On 08/07/15 at 4:21 p.m., ADON L said all the Medical Directors at the facility met with the DON and the Management staff to develop standardized lab orders on admission and every six months depending on the medication the resident was receiving. In the past, admission orders [REDACTED]. ADON L said the facility did not have a policy and procedure regarding labs. ADON L said as a result of the lab error that was discovered by the DON, each admitting Physician has their own orders as to how they want therapeutic drug monitoring and baseline lab work. According to physician's orders [REDACTED].

Based on interview and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one Resident (R #1) of seven residents reviewed for laboratory services. *The Administrator failed to develop and implement policies and procedures to ensure residents received laboratory services for therapeutic blood level monitoring. * The DON failed to supervise staff to ensure laboratory orders were transcribed and implemented. *R #1 was admitted to the hospital with [REDACTED]. These failures contributed to R #1's hospitalization requiring FFP and Vitamin K to reverse the effect of [MEDICATION NAME] ([MEDICATION NAME]) toxicity. This could have affected two residents prescribed [MEDICATION NAME] and 11 residents prescribed [MEDICATION NAME]. An IJ (Immediate Jeopardy) was determined to have existed from 07/06/15 through 07/28/15. The DON was made aware of the physician's orders [REDACTED]. The findings were: R #1's Face Sheet revealed R #1 was a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R #1's Admission Physician order [REDACTED].#1 was prescribed [MEDICATION NAME] 5 mg. (milligrams) every day by mouth (a medication used as a blood thinner) and [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] Fibrillation) 0.25 mg by mouth every day. R #1's Physician Telephone Orders dated 06/30/15 revealed a Laboratory blood draw for PT/INR ([MEDICATION NAME] time) INR (international normalized ratio) levels. (Blood test used to determine clotting tendency of blood) every Monday and a [MEDICATION NAME] blood Level ([MEDICATION NAME]-medication used to treat abnormal heart rhythms) and Basic Metabolic Panel (BMP) on Monday (07/06/15). There was no order to discontinue the PT/INR or the [MEDICATION NAME] Labs. R #1's Consolidated Physician order [REDACTED]. On 07/29/15 at 1:30 p.m., interview with the facility's Director of Nurses (DON) revealed R #1's Laboratory work that was ordered by the NP on 06/30/15 was never done. The DON said the nurse that received the order never filled out a Laboratory Requisition or followed up on the orders. DON said the night shift nurses were to double check all new orders were transcribed but in the case of R #1 the night shift nurses missed the order. The DON said that now, all laboratory orders will be brought to the daily morning meeting and the managers will be responsible for following up to ensure the orders were transcribed and followed through. On 07/29/15 at 1:35 p.m., interview with the Administrator revealed there was a system failure with the Laboratory work not being done with R #1's Laboratory order but the DON discovered the error yesterday and corrected the problem. On 07/29/15 at 1:40 p.m., interview with the DON revealed she had read an email that was sent down from corporate office yesterday (07/28/15) and was brought to the DON's attention yesterday at approximately 5:20 p.m. The email was a complaint from R #1's Family Member (FM) F. The FM F had mentioned in the email R #1's INR lab was over 10 when admitted to the hospital. The DON said she checked R #1's Laboratory Orders and discovered the Laboratory work was never done. The DON said the PT/INR was never done for 07/06/15, 07/13/15 and 07/20/15, and R #1's [MEDICATION NAME] level or BMP was never done on 07/06/15. The DON said it was very important to monitor medications that required therapeutic blood level monitoring, because the patient could become toxic from the medication or not have enough of the medication in the patient's system to be therapeutic. The DON said she would always ask the Physician for lab orders for a baseline and to monitor therapeutic drug values. The DON stated she had already identified the problem and started an action plan. The DON said she had began a chart audit, and planned to meet with the Medical Directors to establish standardized orders, for those residents that required therapeutic monitoring. The DON said the contract laboratory company was onsite to audit all laboratory orders. On 07/30/15 at 1:25 p.m., the Administrator said he was unaware the facility did not have a system in place to make sure Labs orders were followed through prior to R #1 not getting Labs drawn. The Administrator said the LVN's were scared to question Physician Orders. On 07/30/15 at 1:35 p.m., interview with the DON revealed the facility did not have a policy and procedure specific to ordering laboratory work or therapeutic monitoring. On 07/29/15 at 2:10 p.m., interview with Licensed Vocational Nurse (LVN) K revealed she was on duty the day R #1 was sent to the hospital. LVN K said she assessed R #1 and noted a clot and blood from R #1's rectum, and R #1 had [MEDICAL CONDITION] LVN K said she called the NP regarding her assessment and was instructed by the NP to send R #1 to the ER. LVN K said when a nurse received an order for [REDACTED]. LVN K said that was how the nurse knew how the blood was drawn, by the pink copy. LVN K said when the Laboratory results come back abnormal the nurse should notify the Physician right away. On 07/29/15 at 2:40 p.m., interview with LVN P revealed he failed to follow up and write out the Laboratory Requisition for R #1's Physician order [REDACTED]. LVN P said I must have got busy and forgot, I feel bad for (R#1) she was a very nice lady. LVN P said he was trained by the facility on procedures for Laboratory work but, it was just my mistake. LVN P said it was important to monitor PT/INR values to ensure the patient was receiving a therapeutic dose of [MEDICATION NAME] because the patient could bleed out. LVN P stated he was in-serviced by the DON in laboratory procedures yesterday on a 1:1 after it was discovered he had failed to fill out the lab slip. On 07/29/15 at 4:25 p.m., interview with the Assistant Director of Nurses (ADON) L revealed she did not know if the family or the Physician was ever notified regarding the PT/INR, [MEDICATION NAME] and BMP Laboratory not done. ADON L said the nurses should know to ask the Physician for lab work orders on admission. On 07/29/15 at 4:45 p.m., in an interview with the DON she said she had not notified the daughter or Physician regarding the physician's orders [REDACTED]. On 07/30/15 at 9:15 a.m., interview with R #1 revealed she had told the nurse several times that her rectum was bleeding and the nurse just told R #1 that it was Hemorrhoids and not to worry. (The interview was conducted at another facility.) On 07/30/15 at 12:45 p.m., interview with the NP that ordered R #1's Laboratory work on 06/30/15 revealed she was notified R #1's Laboratory work was not done as ordered just yesterday (07/29/15). The NP said she had spoken with the DON in the past about Laboratory Orders not being done as ordered. The NP said hopefully this will be a wakeup call so the facility can have a system in place. The NP said she and the Physician count on the Nurses and Pharmacy Consultants to look for those medications that require therapeutic monitoring to ensure the Lab work was done. On 07/30/15 at 1:00 p.m., interview with the facility Pharmacy Consultant revealed he was not in the facility after R #1 was admitted . The Pharmacy Consultant said he would normally make Physician recommendations to order therapeutic PT/INR on residents taking [MEDICATION NAME] monthly if resident was on [MEDICATION NAME] in long term care. The Pharmacy Consultant said for residents in long term care that were stable on [MEDICATION NAME], he would recommend Laboratory Levels every six months to a year. On 07/30/15 at 3:00 p.m., LVN K said it was Best Practice to call the Physician to verify orders when a resident was admitted to the facility. LVN K said if she saw a resident was prescribed a medication that required therapeutic monitoring she would ask the Physician if they wanted Labs drawn and how often. On 07/30/15 at 1:45 p.m., LVN N said he would call the Physician to verify all orders when a resident was admitted to the facility. LVN N said if a resident was prescribed a medication that required therapeutic monitoring, or if a resident was admitted without laboratory orders, he would call the Physician and ask the Physician if they wanted to order Labs. On 08/07/15 at 2:20 p.m., the DON said she could not find any in-services conducted in laboratory procedures and obtaining Physician order [REDACTED]. On 08/07/15 at 4:21 p.m., ADON L said all the Medical Directors at the facility met with the DON and the Management staff to develop standardized lab orders on admission and every six months depending on the medication the resident was receiving. In the past, admission orders [REDACTED]. ADON L said the facility did not have a policy and procedure regarding labs. ADON L said as a result of the lab error that was discovered by the DON, each admitting Physician has their own orders as to how they want therapeutic drug monitoring and baseline lab work. R #1's Medication Administration Record [REDACTED]. by mouth 06/28/15 through 06/30/15. R #1's MAR indicated [REDACTED]. by mouth 07/01/15 through 07/23/15. R #1 received [MEDICATION NAME] 5 mg. 26 times between June 28,2015 and July 24, 2015. R #1's 5 day Minimum Data Set ((MDS) dated [DATE] revealed R #1 was understood by others and had clear comprehension, had adequate vision and wore corrective lenses. R #1 had intact cognition, and it was very important to choose between a tub bath, shower, bed bath, or sponge bath. R #1 required limited assistance with walking in the room with one person assistance. R #1 required extensive assistance with the help of one person for personal hygiene, bathing and dressing. R #1 was continent of bowel and bladder. R #1 had received an Anticoagulant, Antibiotic and Diuretic medications during the past seven days. R #1's Care Plan dated 06/27/15 revealed Problem Onset: .I am at risk for bleeding due to anticoagulant therapy ([MEDICAL CONDITION] Fib) .*I will have no injury related to my medication usage/side effects .*I will maintain normal therapeutic PT/INR .*Administer my anticoagulant as ordered by my physician .*Coordinate my lab work as ordered. R #1's Communication Form and Progress Note dated 07/24/15 revealed R #1 had a pulse rate of 108 beats per minute and was described as having rectal bleeding and [MEDICAL CONDITION] (a rapid heart rate) .Notified (Nurse Practitioner) Recommended transfer to ER (emergency room ) . R #1's Hospital Lab Report dated 07/24/15 revealed, PT >100.0 seconds (normal range 9.5-13.2 seconds), INR >10.0 (normal range < 4) R #1's Hospital History and Physical dated 07/24/15 revealed, Chief Complaint: Blood per rectum, bright red for 1 day. History of Present illness: This [AGE] year old female .who is [MEDICATION NAME] ([MEDICATION NAME]) dependent .came into the hospital for an evaluation due to bright red blood per rectum for 1 day nonstop .In the emergency room her INR was more than 10 with a PT over 100 .Assessment And Plan: 1. [MEDICATION NAME] toxicity: PT/INR over 100 and over 10. She did receive FFP (Fresh Frozen Plasma) and vitamin K in the emergency room . 5. [MEDICAL CONDITION]: She has been on [MEDICATION NAME]. She received vitamin K and FFP. Will reassess the need, including risks and benefits of anticoagulation . R #1's Hospital [MEDICATION NAME] Consultation dated 07/25/15 revealed, .The patient is a [AGE] year old female .She states that she has been bleeding 3 to 4 days prior to admission. Upon admission, her PT/INR was greater than 10, and this was corrected with FFP as well as vitamin K. She has had no further bleeding since admission . Impression: Rectal Bleeding .This is likely precipitated by her over anticoagulation .I would keep her INR between 2 and 2.5 . It was determined these failures placed R #1 in an Immediate Jeopardy (IJ) situation from 07/06/15 through 07/28/15. The facility took the following actions to correct the non-compliance on 07/28/15: 1) All medications requiring laboratory monitoring will have standing lab orders. 2) Any medication requiring laboratory monitoring that do not have a routine lab order will require physician notification to request routine lab orders. 3) 100% chart audit will be done to identify any omitted lab orders for medications requiring monitoring 4) A list of medication requiring routine lab monitoring will be provided by pharmacy. 5) Chart audit and labs done. Review of Staff Development/Inservice Attendance Sheet dated 07/28/15 revealed Objectives: When you receive an order for [REDACTED]. Review of In-Service Training Record dated 07/28/15 revealed, Nurse Managers are to review all telephone orders after daily care meeting and review (with) MAR/TAR (Treatment Administration Record) to ensure procedure was followed correctly by receiving nurse. Each order for lab should be compared (with) lab manifest to ensure proper communication to lab company. According to: http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/ 8s108lbl.pdf referenced 08/01/15: [MEDICATION NAME]® TABLETS ([MEDICATION NAME] Sodium Tablets, USP) [MEDICATION NAME]® FOR INJECTION ([MEDICATION NAME] Sodium for Injection, USP) Anticoagulant WARNING: BLEEDING RISK [MEDICATION NAME] sodium can cause major or fatal bleeding. Bleeding is more likely to occur during the starting period and with a higher dose (resulting in a higher INR). Risk factors for bleeding include high intensity of anticoagulation (INR >4.0), age =65, highly variable INRs, history of [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION] disease, serious [MEDICAL CONDITIONS], malignancy, trauma, [MEDICAL CONDITION], concomitant drugs (see PRECAUTIONS), and long duration of [MEDICATION NAME] therapy. Regular monitoring of INR should be performed on all treated patients. Those at high risk of bleeding may benefit from more frequent INR monitoring, careful dose adjustment to desired INR, and a shorter duration of therapy. Patients should be instructed about prevention measures to minimize risk of bleeding and to report immediately to physicians signs and symptoms of bleeding (see PRECAUTIONS: Information for Patients) Elderly Patients [AGE] years or older appear to exhibit greater than expected PT/INR response to the anticoagulant effects of [MEDICATION NAME]. The cause of the increased sensitivity to the anticoagulant effects of [MEDICATION NAME] in this age group is unknown. This increased anticoagulant effect from [MEDICATION NAME] may be due to a combination of pharmacokinetic and pharmacodynamic factors. Racemic [MEDICATION NAME] clearance may be unchanged or reduced with increasing age. Limited information suggests there is no difference in the clearance of S-[MEDICATION NAME] in the elderly versus young subjects. However, there may be a slight decrease in the clearance of R-[MEDICATION NAME] in the elderly as compared to the young. Therefore, as patient age increases, a lower dose of [MEDICATION NAME] is usually required to produce a therapeutic level of anticoagulation. WARNINGS The most serious risks associated with anticoagulant therapy with [MEDICATION NAME] sodium are hemorrhage in any tissue or organ12 (see BLACK BOX WARNING) PRECAUTIONS Periodic determination of PT/INR is essential. (See DOSAGE AND ADMINISTRATION: Laboratory Control.) Numerous factors, alone or in combination including changes in diet, medications, [MEDICATION NAME], and genetic variations in the CYP2C9 and VKORC1 enzymes (see CLINICAL PHARMACOLOGY: Pharmacogenomics) may influence the response of the patient to [MEDICATION NAME]. According to physician's orders [REDACTED].

Based on interview, and record review the facility failed to provide or obtain laboratory services to meet the needs of one (R #1) of seven residents. The facility is responsible for the quality and timeliness of the services. *The facility did not provide Laboratory services for R #1. The therapeutic level of [MEDICATION NAME] was not monitored by PT/INR levels for three weeks. The therapeutic level of [MEDICATION NAME] and BMP was not monitored by the facility for one week. *R #1 was admitted to the hospital with [REDACTED]. These failures contributed to R #1's hospitalization requiring FFP and Vitamin K to reverse the effect of [MEDICATION NAME] ([MEDICATION NAME]) toxicity. This could have affected two residents prescribed [MEDICATION NAME] and 11 residents prescribed [MEDICATION NAME]. An IJ (Immediate Jeopardy) was determined to have existed from 07/06/15 through 07/28/15. The DON was made aware of the physician's orders [REDACTED]. The findings were: R #1's Face Sheet revealed R #1 was a [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R #1's Admission Physician order [REDACTED].#1 was prescribed [MEDICATION NAME] 5 mg. (milligrams) every day by mouth (a medication used as a blood thinner) and [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] Fibrillation) 0.25 mg by mouth every day. R #1's Physician Telephone Orders dated 06/30/15 revealed a Laboratory (lab) blood draw for PT/INR ([MEDICATION NAME] time) INR (international normalized ratio) levels. (Blood test used to determine clotting tendency of blood) every Monday and a [MEDICATION NAME] blood Level ([MEDICATION NAME]-medication used to treat abnormal heart rhythms) and Basic Metabolic Panel (BMP) on Monday (07/06/15). There was no order to discontinue the PT/INR or the [MEDICATION NAME] Labs. R #1's Consolidated Physician order [REDACTED]. R #1's Medication Administration Record [REDACTED]. by mouth 06/28/15 through 06/30/15. R #1's MAR indicated [REDACTED]. by mouth 07/01/15 through 07/23/15. R #1 received [MEDICATION NAME] 5 mg. 26 times between June 28,2015 and July 24, 2015. R #1's 5 day Minimum Data Set ((MDS) dated [DATE] revealed R #1 was understood by others and had clear comprehension, had adequate vision and wore corrective lenses. R #1 had intact cognition, and it was very important to choose between a tub bath, shower, bed bath, or sponge bath. R #1 required limited assistance with walking in the room with one person assistance. R #1 required extensive assistance with the help of one person for personal hygiene, bathing and dressing. R #1 was continent of bowel and bladder. R #1 had received an Anticoagulant, Antibiotic and Diuretic medications during the past seven days. R #1's Care Plan dated 06/27/15 revealed Problem Onset: .I am at risk for bleeding due to anticoagulant therapy ([MEDICAL CONDITION] Fib) .*I will have no injury related to my medication usage/side effects .*I will maintain normal therapeutic PT/INR .*Administer my anticoagulant as ordered by my physician .*Coordinate my lab work as ordered. R #1's Communication Form and Progress Note dated 07/24/15 revealed R #1 had a pulse rate of 108 beats per minute and was described as having rectal bleeding and [MEDICAL CONDITION] (a rapid heart rate) .Notified (Nurse Practitioner) Recommended transfer to ER (emergency room ) . R #1's Hospital Lab Report dated 07/24/15 revealed, PT >100.0 seconds (normal range 9.5-13.2 seconds), INR >10.0 (normal range < 4) R #1's Hospital History and Physical dated 07/24/15 revealed, Chief Complaint: Blood per rectum, bright red for 1 day. History of Present illness: This [AGE] year old female .who is [MEDICATION NAME] ([MEDICATION NAME]) dependent .came into the hospital for an evaluation due to bright red blood per rectum for 1 day nonstop .In the emergency room her INR was more than 10 with a PT over 100 .Assessment And Plan: 1. [MEDICATION NAME] toxicity: PT/INR over 100 and over 10. She did receive FFP (Fresh Frozen Plasma) and vitamin K in the emergency room . 5. [MEDICAL CONDITION]: She has been on [MEDICATION NAME]. She received vitamin K and FFP. Will reassess the need, including risks and benefits of anticoagulation . R #1's Hospital [MEDICATION NAME] Consultation dated 07/25/15 revealed, .The patient is a [AGE] year old female .She states that she has been bleeding 3 to 4 days prior to admission. Upon admission, her PT/INR was greater than 10, and this was corrected with FFP as well as vitamin K. She has had no further bleeding since admission . Impression: Rectal Bleeding .This is likely precipitated by her over anticoagulation .I would keep her INR between 2 and 2.5 . On 07/29/15 at 1:30 p.m., interview with the facility's Director of Nurses (DON) revealed R #1's Laboratory work that was ordered by the NP on 06/30/15 was never done. The DON said the nurse that received the order never filled out a Laboratory Requisition or followed up on the orders. DON said the night shift nurses were to double check all new orders were transcribed but in the case of R #1 the night shift nurses missed the order. The DON said that now, all laboratory orders will be brought to the daily morning meeting and the managers will be responsible for following up to ensure the orders were transcribed and followed through. On 07/29/15 at 1:35 p.m., interview with the Administrator revealed there was a system failure with the Laboratory work not being done with R #1's Laboratory order but the DON discovered the error yesterday and corrected the problem. On 07/29/15 at 1:40 p.m., interview with the DON revealed she had read an email that was sent down from corporate office yesterday (07/28/15) and was brought to the DON's attention yesterday at approximately 5:20 p.m. The email was a complaint from R #1's Family Member (FM) F. The FM F had mentioned in the email R #1's INR lab was over 10 when admitted to the hospital. The DON said she checked R #1's Laboratory Orders and discovered the Laboratory work was never done. The DON said the PT/INR was never done for 07/06/15, 07/13/15 and 07/20/15, and R #1's [MEDICATION NAME] level or BMP was never done on 07/06/15. The DON said it was very important to monitor medications that required therapeutic blood level monitoring, because the patient could become toxic from the medication or not have enough of the medication in the patient's system to be therapeutic. The DON said she would always ask the Physician for lab orders for a baseline and to monitor therapeutic drug values. The DON stated she had already identified the problem and started an action plan. The DON said she had began a chart audit, and planned to meet with the Medical Directors to establish standardized orders, for those residents that required therapeutic monitoring. The DON said the contract laboratory company was onsite to audit all laboratory orders. On 07/30/15 at 1:25 p.m., the Administrator said he was unaware the facility did not have a system in place to make sure Labs orders were followed through prior to R #1 not getting Labs drawn. The Administrator said the LVN's were scared to question Physician Orders. On 07/30/15 at 1:35 p.m., interview with the DON revealed the facility did not have a policy and procedure specific to ordering laboratory work or therapeutic monitoring. It was determined these failures placed R #1 in an Immediate Jeopardy (IJ) situation from 07/06/15 through 07/28/15. The facility took the following actions to correct the non-compliance on 07/28/15: 1) All medications requiring laboratory monitoring will have standing lab orders. 2) Any medication requiring laboratory monitoring that do not have a routine lab order will require physician notification to request routine lab orders. 3) 100% chart audit will be done to identify any omitted lab orders for medications requiring monitoring 4) A list of medication requiring routine lab monitoring will be provided by pharmacy. 5) Chart audit and labs done. Review of Staff Development/Inservice Attendance Sheet dated 07/28/15 revealed Objectives: When you receive an order for [REDACTED]. Review of In-Service Training Record dated 07/28/15 revealed, Nurse Managers are to review all telephone orders after daily care meeting and review (with) MAR/TAR (Treatment Administration Record) to ensure procedure was followed correctly by receiving nurse. Each order for lab should be compared (with) lab manifest to ensure proper communication to lab company. On 07/29/15 at 2:10 p.m., interview with Licensed Vocational Nurse (LVN) K revealed she was on duty the day R #1 was sent to the hospital. LVN K said she assessed R #1 and noted a clot and blood from R #1's rectum, and R #1 had [MEDICAL CONDITION] LVN K said she called the NP regarding her assessment and was instructed by the NP to send R #1 to the ER. LVN K said when a nurse received an order for [REDACTED]. LVN K said that was how the nurse knew how the blood was drawn, by the pink copy. LVN K said when the Laboratory results come back abnormal the nurse should notify the Physician right away. On 07/29/15 at 2:40 p.m., interview with LVN P revealed he failed to follow up and write out the Laboratory Requisition for R #1's Physician order [REDACTED]. LVN P said I must have got busy and forgot, I feel bad for (R#1) she was a very nice lady. LVN P said he was trained by the facility on procedures for Laboratory work but, it was just my mistake. LVN P said it was important to monitor PT/INR values to ensure the patient was receiving a therapeutic dose of [MEDICATION NAME] because the patient could bleed out. LVN P stated he was in-serviced by the DON in laboratory procedures yesterday on a 1:1 after it was discovered he had failed to fill out the lab slip. On 07/29/15 at 4:25 p.m., interview with the Assistant Director of Nurses (ADON) L revealed she did not know if the family or the Physician was ever notified regarding the PT/INR, [MEDICATION NAME] and BMP Laboratory not done. ADON L said the nurses should know to ask the Physician for lab work orders on admission. On 07/29/15 at 4:45 p.m., the DON said she had not notified the daughter or Physician regarding the physician's orders [REDACTED]. On 07/30/15 at 9:15 a.m., interview with R #1 revealed she had told the nurse several times that her rectum was bleeding and the nurse just told R #1 that it was Hemorrhoids and not to worry. (The interview was conducted at another facility.) On 07/30/15 at 12:45 p.m., interview with the NP that ordered R #1's Laboratory work on 06/30/15 revealed she was notified R #1's Laboratory work was not done as ordered just yesterday (07/29/15). The NP said she had spoken with the DON in the past about Laboratory Orders not being done as ordered. The NP said hopefully this will be a wakeup call so the facility can have a system in place. The NP said she and the Physician count on the Nurses and Pharmacy Consultants to look for those medications that require therapeutic monitoring to ensure the Lab work was done. On 07/30/15 at 1:00 p.m., interview with the facility Pharmacy Consultant revealed he was not in the facility after R #1 was admitted . The Pharmacy Consultant said he would normally make Physician recommendations to order therapeutic PT/INR on residents taking [MEDICATION NAME] monthly if resident was on [MEDICATION NAME] in long term care. The Pharmacy Consultant said for residents in long term care that were stable on [MEDICATION NAME], he would recommend Laboratory Levels every six months to a year. On 07/30/15 at 3:00 p.m., LVN K said it was Best Practice to call the Physician to verify orders when a resident was admitted to the facility. LVN K said if she saw a resident was prescribed a medication that required therapeutic monitoring she would ask the Physician if they wanted Labs drawn and how often. On 07/30/15 at 1:45 p.m., LVN N said he would call the Physician to verify all orders when a resident was admitted to the facility. LVN N said if a resident was prescribed a medication that required therapeutic monitoring, or if a resident was admitted without laboratory orders, he would call the Physician and ask the Physician if they wanted to order Labs. On 08/07/15 at 2:20 p.m., the DON said she could not find any in-services conducted in laboratory procedures and obtaining Physician order [REDACTED]. On 08/07/15 at 4:21 p.m., ADON L said all the Medical Directors at the facility met with the DON and the Management staff to develop standardized lab orders on admission and every six months depending on the medication the resident was receiving. In the past, admission orders [REDACTED]. ADON L said the facility did not have a policy and procedure regarding labs. ADON L said as a result of the lab error that was discovered by the DON, each admitting Physician has their own orders as to how they want therapeutic drug monitoring and baseline lab work. According to: http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/ 8s108lbl.pdf referenced 08/01/15: [MEDICATION NAME]® TABLETS ([MEDICATION NAME] Sodium Tablets, USP) [MEDICATION NAME]® FOR INJECTION ([MEDICATION NAME] Sodium for Injection, USP) Anticoagulant WARNING: BLEEDING RISK [MEDICATION NAME] sodium can cause major or fatal bleeding. Bleeding is more likely to occur during the starting period and with a higher dose (resulting in a higher INR). Risk factors for bleeding include high intensity of anticoagulation (INR >4.0), age =65, highly variable INRs, history of [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION] disease, serious [MEDICAL CONDITIONS], malignancy, trauma, [MEDICAL CONDITION], concomitant drugs (see PRECAUTIONS), and long duration of [MEDICATION NAME] therapy. Regular monitoring of INR should be performed on all treated patients. Those at high risk of bleeding may benefit from more frequent INR monitoring, careful dose adjustment to desired INR, and a shorter duration of therapy. Patients should be instructed about prevention measures to minimize risk of bleeding and to report immediately to physicians signs and symptoms of bleeding (see PRECAUTIONS: Information for Patients) Elderly Patients [AGE] years or older appear to exhibit greater than expected PT/INR response to the anticoagulant effects of [MEDICATION NAME]. The cause of the increased sensitivity to the anticoagulant effects of [MEDICATION NAME] in this age group is unknown. This increased anticoagulant effect from [MEDICATION NAME] may be due to a combination of pharmacokinetic and pharmacodynamic factors. Racemic [MEDICATION NAME] clearance may be unchanged or reduced with increasing age. Limited information suggests there is no difference in the clearance of S-[MEDICATION NAME] in the elderly versus young subjects. However, there may be a slight decrease in the clearance of R-[MEDICATION NAME] in the elderly as compared to the young. Therefore, as patient age increases, a lower dose of [MEDICATION NAME] is usually required to produce a therapeutic level of anticoagulation. WARNINGS The most serious risks associated with anticoagulant therapy with [MEDICATION NAME] sodium are hemorrhage in any tissue or organ12 (see BLACK BOX WARNING) PRECAUTIONS Periodic determination of PT/INR is essential. (See DOSAGE AND ADMINISTRATION: Laboratory Control.) Numerous factors, alone or in combination including changes in diet, medications, [MEDICATION NAME], and genetic variations in the CYP2C9 and VKORC1 enzymes (see CLINICAL PHARMACOLOGY: Pharmacogenomics) may influence the response of the patient to [MEDICATION NAME]. According to physician's orders [REDACTED].

Based on observation, record review and interview, the facility failed to ensure residents received the necessary treatment and services to prevent worsening of existing wounds/pressure ulcers, promote healing and prevent new ulcers from developing by not: * correctly assessing and staging pressure ulcers, * consulting with physicians to obtain physician's recommendations and * providing appropriate treatment/service which resulted in two sample residents developing avoidable Stage 4 pressure ulcers (SR #12, #13) and three residents identified with non-pressure related skin issues being identified with new Stage 2 pressure ulcers (SR #14, #16 and #18) from a sample of 18 Sample Residents. 1. Treatment Nurse/LVN "A" failed to: - accurately assess SR#12's pressure ulcer to the left buttock from 11/08/10 to 12/01/10; -consult with SR#12's physician to obtain the physician's recommendations when the wound worsened; -obtain treatment of [REDACTED].#12"s wound to left buttock from sheering on 11/08/10 to a Stage 4 pressure ulcer on 12/01/10. On 12/01/10 was identified with a Stage 4 pressure ulcer (full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle or bone) to the left buttocks. Treatment Nurse/Licensed Vocational Nurse (LVN 'A") assessed this as sheering to left buttocks on the facility's Skin condition Variance Report on 11/25/10. On 12/01/10, SR#12 was identified with a new Stage 2 pressure ulcer (partial skin loss involving the epidermis and dermis, superficial and may present as an abrasion, blister or shallow crater) to the right buttock not identified by facility staff. 2. SR#13 had a right upper back Stage 4 pressure ulcer . Treatment Nurse/LVN "A assessed this as a ruptured blister from 09/07/10 to 11/29/10 and listed it under the Abrasion/Excoriation section on the facility's Skin Condition Variance Report. On 12/01/10 SR#13 was identified with 3 Stage 2 pressure ulcer (a right buttock, coccyx and left buttock). Surveyor observed these new Stage 2 pressure ulcers on 12/01/10 during perineal care. SR#13's entire sacral area was purplish in color and blanchable. Treatment Nurse/LVN "A" failed to: -consult with SR#13's physician to obtain the physician's recommendations when the wound worsened from a "ruptured blister" on 09/07/10 to a Stage 4 pressure ulcer on 11/29/10. 3. On 12/01/10, SR #14's was identified with a new Stage 2 pressure ulcers on SR #14's right and left buttock. 4. On 12/01/10 SR#16 was identified with a Stage 2 pressure ulcer to the coccyx. The facility treatment nurse had identified this area on the Skin Condition Variance Log as an "upper crevice buttock" and had not treated it as a pressure ulcer. Treatment Nurse/LVN "A" failed to correctly assess this as a pressure ulcer; failed to notify SR#16's physician to obtain treatment orders specific for a Stage II pressure ulcer. 5. On 12/01/10, SR#18 a Stage 2 pressure ulcer was discovered to SR #18's right buttock that the facility treatment nurse had not identified and had not treated. An Immediate Jeopardy (IJ) was identified on 12/01/10. While the IJ was removed on 12/03/10, the facility remained out of compliance at a scope of Pattern and a severity level of Actual Harm because all staff had not received scheduled training on identifying skin irregularities, staging of pressure ulcers, terminology, proper procedure for communicating issues for follow up, prevention and documentation. The facility identified 26 residents as high risk for pressure ulcer development. Failure to accurately assess/stage pressure ulcer, and consult with residents' physicians to obtain the physicians' recommendations could result in the deterioration of existing pressure ulcers or cause the development of pressure ulcers for all 26 residents at high risk for developing pressure ulcers. The findings were: Review of the facility's Pressure Ulcer Treatment Protocols dated January 2007 revealed: *Stage 2 = notify physician cleanse wound with saline and administer treatment as ordered by Physican *Stage 3-4 = notify physician notify physician if no improvement is apparent in 14 days or if expected healing is not occurring. If there is any worsening of the wound at any time, notify physician for change of treatment. If eschar or slough (necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft and moist.) present: *cleanse wound and administer treatment as ordered by physician *notify physician if no improvement is apparent in 14 days Upon entry, the facility provided surveyor with the Weekly Pressure Ulcer Quality Indicator Log, identifying two residents with pressure ulcers. Weekly Pressure Ulcer Quality Indicator Log consisted of residents with pressure ulcer identified by Treatment Nurse/LVN "A". Facility later provided surveyor with the Centers for Medicare and Medicaid Services form 802 which listed eight other residents with pressure ulcers. Surveyor asked for clarification of discrepancy and the facility stated residents pressure ulcers on the 802 were resolved. Surveyor was provided with a copy of the facility's Skin Condition Variance Report ( a report of the facility that reflected skin conditions other than pressure ulcers) dated 11/25/10. On 12/01/10 after observations of perineal care were completed, surveyor asked Director of Nurses (DON) to verify the correctness of the Skin Condition Variance Log by making observations of the residents on the Variance Log. The DON, Assistant Director of Nurse (ADON "D") and surveyor, checked residents from the Variance Log. 1. SR#12: SR#12's Face Sheet dated 09/08/06 revealed SR#12 was admitted with [DIAGNOSES REDACTED]. Above Knee Amputation, Hypertension, Pain, and [MEDICAL CONDITION] (inability to speak). SR#12's Minimum (MDS) data set [DATE] indicated: SR#12's cognitive level was severely impaired (never/rarely made decisions) and SR#12 required assistance of one to two staff with activities of daily living (ADLs - bathing, toileting, transfers and ambulation). SR#12 was mechanical lifted from bed to chair and was turned and repositioned by staff. SR#12's November 2010 physician's orders [REDACTED]. On 12/01/10 at 9:00 a.m., surveyor observed Certified Nurse Aides (CNAs "B" and "C") provide perineal care for SR#12. When the adult brief was removed, surveyor observed [MEDICATION NAME] (transparent wound dressing) to SR#12's whole sacral area. There was feces under the dressing and when CNA "C" removed the soiled [MEDICATION NAME], surveyor observed black, necrotic tissue with slough on SR#12's left buttocks and a Stage 2 pressure ulcer on SR#12's right buttocks. According to the facility's Skin Protocol for Stage 4 pressure ulcers, [MEDICATION NAME] was not an appropriate treatment for [REDACTED]. SR#12's Weekly Skin Assessment Data Collection dated: 08/06/10 = indicated no skin issues to buttocks documented by LVN "A" 08/09/10 = same as above by LVN "A" 08/13/10 = same as above LVN "A" 08/16/10 = Stage 2 to bilateral buttocks documented by LVN "E" 08/23/10 = Right buttocks-Stage 1 (an observable, pressure-related alteration of intact skin, whose indicators as compared to adjacent or opposite area on body may include changes in one or more of the following parameters: skin temperature, tissue consistency, sensation; and/or a defined area of persistent red, blue, or purple hues.) Left buttocks-Stage 2 Sacrum-Stage 2 times two LVN "A" 08/30/10 = Right buttock- healed Left buttock-Stage 2 Sacrum- resolved Right upper buttock-sheering LVN "A" 09/06/10 = Sheering, smaller (diagram of resident body indicated skin issue was to the resident's left buttocks) Right buttocks-Stage 2 (diagram indicated right side) LVN "A" 09/13/10 = Sheering (the interaction of both gravity and friction against the surface of the skin; occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches) left buttocks LVN "E" 09/20/10 = Left buttocks-Stage 2 Right and Left buttocks-sheering LVN "A" 09/27/10 = All but one Stage 2 healed (diagram indicated left lower buttocks) LVN "A" 10/04/10 = Buttocks resolved (diagram indicated clear skin).LVN "A" 10/11/10 = Redness and sheering continues with [MEDICATION NAME] intact (diagram indicated left and right buttocks. Stage 2 left buttock documented by LVN "E" 10/18/10 = Left buttock-Stage 2 smaller LVN "A" 10/25/10 = Left buttocks healed LVN "A" 11/01/10 = no entry LVN "A" 11/08/10 = Sheering bilateral buttocks (diagram indicated bilateral buttocks). [MEDICATION NAME] applied. LVN "A" 11/15/10 = bilateral sheering LVN "E" 11/22/10 = Sheering, new treatment of [REDACTED]. Review of the facility's Skin Condition Variance Report dated 11/25/10 indicated SR#12 had sheering to coccyx with the treatment of [REDACTED]. Skin Condition Variance Report ( a report of the facility that reflected skin conditions other than pressure ulcers) consisted of: Stasis/Arterial Ulcer, Diabetic Ulcer, Surgical Site, Rash Abrasion/Excoriation and Other. SR#12's Weekly Skin Assessment Data Collection dated: 11/29/10 = left buttocks-sheering, continue with treatment and improving. (diagram left buttocks). LVN "E" 12/01/10 = Sheering area noted to have darkened areas/appears to have maceration (wetness/white around the area) to periphery. Due to increased slough with necrosis noted, wound to left side upper buttocks Stage 4. Wound measured 4.4 by 4.2 centimeters. Right buttocks measured 1.6 by 0.8. initialed by LVN "A" and identified as a Stage 4 by ADON "D" documented by Treatment Nurse/LVN "A." The assessment was conducted at request of surveyor during an audit of residents listed from the facility's Skin Variance log. SR#12's Telephone physician's orders [REDACTED]. Dermavase (Zinc Oxide) ointment to right upper buttock every (q) shift times 14 days then reassess. Clean left side upper buttock/coccyx with wound cleanser, pat dry, apply Santyl, [MEDICATION NAME] Blue, 2 x 2 (gauze), cover q day times 14 days, then reassess. Insert Foley Catheter (tube inserted into bladder to drain urine) due to wound Stage 4 ulcer. On 12/01/10 at 4:40 p.m., surveyor interviewed Treatment Nurse/LVN "A" about SR#12's buttocks areas. Treatment Nurse/LVN "A" said SR#12's sheering started on 11/08/10 with open areas to the buttocks. Treatment Nurse/LVN "A" said she did not measure the area but applied [MEDICATION NAME] per facility's protocol. On 11/22/10, the buttocks area started looking a little worse with the open area a little larger and she said she started using Santyl. Surveyor asked if SR#12's Physician had been called to come to examine the area. Treatment Nurse/LVN "A" said SR#12 had not been seen by the Physician or Physician's Assistant. Treatment Nurse/LVN "A" said she would call the Physican's Assistant tonight for orders. Surveyor asked Treatment Nurse/LVN "A" to explain the staging of wounds. Treatment Nurse/LVN "A" said: "Stage 1 = redness, non blanchable Stage 2 = open area, below top layer of skin Stage 3 = more than a II without slough Stage 4 = with slough, necrotic, unstageable." Surveyor asked Treatment Nurse/LVN "A" to summarize her treatment to SR#12's buttocks area. She said "on 11/08/10 and 11/15 assessments, I noted sheering to upper buttocks and applied [MEDICATION NAME]. On 11/22/10, the sheering continued with no healing and had an open area a little larger. I started Santyl and covered the area with gauze. On 11/29/10 the area appeared to be healing. On 12/01/10, sheering with darkened area to wound bed. Changed to Stage 4 due to slough with necrotic tissue." Surveyor asked Treatment Nurse/LVN "A" to describe sheering and excoriation. She said sheering was "to pull up in bed, and the skin is taken off and excoriation was scattered open areas, pinpoint, in buttocks, multiple areas maybe from loose stools." Surveyor asked Treatment Nurse/LVN "A" if she had attended any pressure ulcer training or inservice's. Treatment Nurse/LVN "A" said "our training's are computer based," and provided surveyor with copies of certificates. Surveyor reviewed the six certificates titled: Current Concepts in Wound Care Pressure Ulcers Pressure Ulcer Prevention Wound Assessment and Documentation Differentiating Various Types of Ulcers and Back to the Basics of Wound Healing. Although Treatment Nurse/LVN "A" had training on wound assessment and differentiating various types of ulcers, Treatment Nurse/LVN "A" failed to accurately assess SR#12's pressure ulcer to the left buttock as sheering from 11/08/10 to 12/01/10 when identified as a Stage 4 pressure ulcer by ADON "D." Surveyor asked what was the product Dermavase. Treatment Nurse/LVN "A" provided surveyor with a tube of Dermavase which indicated it was Zinc Oxide ointment. Treatment Nurse/LVN "A" said "it's a skin barrier used without dressing." Surveyor asked if facility used a Wound Specialist and Treatment Nurse/LVN "A" said "no, we use a medical supplier that is a (Registered Nurse and Wound Care Specialist) that comes here monthly and when I have questions, they come and consult with me. They check the pressure ulcer list and ask if I need anything. If they think I need to change the orders, they recommend it and I call and get the orders." 2. SR#13: SR#13's Face Sheet indicated SR#13 was admitted [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITIONS], Chronic Obstructive Airway ([MEDICAL CONDITION]), Pain and Dysphagia (difficulty swallowing). SR#13's MDS dated [DATE], June 2010 and October 2010 indicated no pressure ulcers. SR#13's Cognitive skills were moderately impaired (decisions poor, supervision required). SR#13 required extensive assistance of one or two person to perform her ADLs (bathing, transfers, ambulation). SR#13's November 2010 physician's orders [REDACTED]. On 12/01/10 at 9:15 a.m., surveyor observed CNAs "B" and "C" provide perineal care for SR#13. When SR#13 was turned to her side, she cried out. CNA "B" said SR#13 had a "sore" on her back and it hurt SR#13 when they turned her. When CNA "B" and "C" turned SR#13 completely over to her side, surveyor observed a dressing half off. Surveyor observed a wound over the right scapula area with a crater type wound under the dressing. The wound to the right upper back was noted to have a blue foam packing. Surveyor observed CNAs "B" and "C" provide perineal care and observed three small (approximately 1/2 inch by 1/2 inch) open areas on the buttocks area. One open area on each buttocks and one open area in the coccyx/sacral area. Review of the facility's Skin Condition Variance Report for SR#13 dated 11/25/10 indicated SR#13's wound was listed as a "ruptured blister right side back." SR#13's Weekly Skin Assessment Data Collection dated: 09/07/10 = ruptured blister upper right back. Not measured. Documented by LVN "A". SR#13's Assessment of Pressure Sore Potential dated 09/10/10 indicated a score of 12 (high risk for pressure ulcer) with instructions to: follow pressure ulcer protocol. SR#13's Weekly Skin Assessment Data Collection dated 09/14/10 = ruptured blister back. LVN "A". SR#13's Interdisciplinary Care Plan Conference dated 09/15/10 indicated: Areas Reviewed: Skin = "No problems/rash under bilateral breasts" Dated 10/11/10 = Areas Reviewed: Skin = Blank (no comment noted). SR#13's Weekly Skin Assessment Data Collection dated: 09/21/10 = open area dark with slough back. Documented by LVN "A." 09/28/10 = open area dark soft slough back. LVN "A". 10/03/10 = open wound back right side. Documented by LVN "F". 10/08/10 = area to back-dark slough. LVN "A". SR#13's Determination of Unavoidable Pressure Ulcer dated 10/14/10 indicated: [DIAGNOSES REDACTED]. SR#13's Weekly Skin Assessment Data Collection dated: 10/15/10 = ruptured blister dark slough noted back. Documented by LVN "A." 10/25/10 = buttocks-excoriation, Back-dark slough to ruptured blister area LVN "A". 11/01/10 = Back-dark slough-yellowish to periphery of wound bed Buttocks-redness. LVN "A". SR#13's Wound Care (WC) * Skin Integrity * Evaluation dated 11/05/10 (performed by Consultant Wound Care Company) indicated: Back right = Full thickness 100% moist black eschar (dead tissue). Interventions: Santyl (topical chemical debrider). [MEDICATION NAME] blue packing (medicated foam packing.) SR#13's Weekly Skin Assessment Data Collection dated: 11/08/10 = Buttocks = excoriation Back = slough separating from wound bed. Documented by LVN "A." 11/15/10 = Buttocks = excoriation Back = slough separating from wound bed. Documented by LVN "E." 11/22/10 = Back = wound bed to right side back continues with slough separating from wound bed. Approximately 40% slough to approximately 60% granulating tissue. No redness to periphery. Buttocks = excoriation dissipating. LVN "A". 11/29/10 = Back = wound has approximately 75% slough with 25% granulating tissue. Wound edge to proximal aspect of wound noted with necrotic tissue and noted sagging over to upper to be undermining (tissue destruction under intact skin). Buttocks = continue with excoriation. Due to increase in slough with necrosis noted, wound to right side back staged to 4. Wound to back measured 3.3 by 2.4. LVN "E". 12/01/10 = Back = Stage 4 Buttocks = Stage 2 to bilateral buttocks Stage 2 to crevice of Buttocks (marks on diagram indicated coccyx) "Overall buttocks/sacral/coccyx area=red/purple discoloration (blanchable to reddened areas)." Documented by LVN "E." Treatment Nurse/LVN "A" did not assess SR#13's Stage 4 pressure ulcer as a Stage 4. The wound was not identified as a Stage 4 pressure ulcer until 12/01/10 after surveyor intervention. SR#13's WC Skin Integrity Evaluation dated 12/02/10 indicated: Back right side = full thickness Stage 4, wound bed 10% moist black eschar, 40% moist yellow slough, 50% pale red granulation. Continue with current treatment plan. Coccyx = 100% pink and moist. Stage 2. Moisture barrier cream to protect and allow healing. Leave open to air. SR#13's Physician's Telephone Orders dated 12/01/10 indicated: Back = Clean right side back with wound cleanser, pat dry, apply Santyl, [MEDICATION NAME] Blue, cover with 2 x 2 (gauze), cover site q day for 14 days, then reassess. Buttocks = Start Dermavase ointment to bilateral buttocks q shift for 14 days, then reassess. On 12/01/10 at 1:30 p.m. surveyor observed facility housekeeping/maintenance staff removing SR#13's regular air mattress and replacing it with a speciality mattress (low air loss mattress). On 12/01/10 at 4:50 p.m. surveyor interviewed Treatment Nurse/LVN "A" about SR#13's pressure ulcers to the back and coccyx. Treatment Nurse/LVN "A" stated "I did not measure the back wound or stage it because it was not over a bony area. I considered it a blister and then a ruptured blister and not a pressure area." "When the blister first ruptured, I did not measure or stage the wound due to the fact that I did not feel that was a pressure ulcer." Surveyor asked what was the course of treatment for [REDACTED]. Treatment Nurse/LVN "A" said "When the blister ruptured, I started [MEDICATION NAME] (antibiotic ointment), then when there was slough, I started Santyl. When the area declined, I started [MEDICATION NAME] (thick honey product). When that did not help any, I restarted Santyl with [MEDICATION NAME] Blue foam." On 12/02/10 at 8:15 a.m., surveyor asked whether SR#13's Physician had come to examine the wound on SR #13's back. Treatment Nurse/LVN "A" said "For wound care treatment, I notify the Nurse Practitioner with suggestions for changes and he ordered then." On 12/02/10 at 10:40 a.m., surveyor interviewed Treatment Nurse/LVN "A" about the Wound Consultant Company's evaluation. Treatment Nurse/LVN "A" said, "I called them and told them of the ruptured blister on (SR#13's) back, and they sent me a typed report and ordered the supplies for us to use. They referred to the wound as full thickness, open wound. But I still contend it's a ruptured blister." On 12/02/10 at 1:30 p.m., surveyor interviewed the Wound Consultant (WC) Company Representative about SR#13's back pressure ulcer. The WC said "(Treatment Nurse/LVN "A") called the area a ruptured blister when she called me for supplies. (Treatment Nurse/LVN "A") said it had slough. I ordered Santyl. I called it full thickness from Treatment Nurse/LVN "A"'s description. That area was a Stage 4 by depth . When you see the outline of a bone, it's a Stage 4. I have printed out the National Pressure Ulcer Associations Guidelines on determining staging and I have started to train (Treatment Nurse/LVN "A") today. I will do a pressure ulcer inservice in the near future about staging." On 12/03/10 at 2:30 p.m., surveyor interviewed Treatment Nurse/LVN "A" about the air mattress for SR#13's bed. Treatment Nurse/LVN "A" said we use low air loss mattresses for Stage 3 or 4's and regular air mattresses for Stage 1 or 2's as preventative. We changed (SR#13's) mattress when we changed the back wound to a Stage 4." The facility had not been using the specific specialized low air loss mattress for SR#13 until surveyor intervened and the pressure ulcer deteriorated from a ruptured blister to a Stage 4 pressure ulcer. SR#14: SR#14's Face Sheet identified she was admitted to facility on 07/30/10 with [DIAGNOSES REDACTED]. SR#14's MDS dated [DATE] indicated: SR#14's cognitive level as moderately impaired and totally dependent on one or two persons for provision of ADLs (activities of daily living). SR#14's December 2010 physician's orders [REDACTED]. On 12/01/10 at 1:35 p.m., DON accompanied by surveyor identified one Stage 2 pressure ulcer to SR #14's sacral area and one Stage 2 to SR #14's right buttocks. In an interview with the DON at that time, surveyor asked what the areas were. The DON said "Stage 2's." SR#14's Weekly Skin Assessment Data Collection dated indicated: 07/30/10 = redness (diagram indicated sacral area) 08/06/10 = redness (diagram indicated sacral area) LVN "E" From 08/30/10 to 09/17/10 = no documentation or entry of skin impairment noted. 09/24/10 =redness (diagram indicated sacral area) LVN "A" 10/01/10 = redness-blanchable (diagram had no markings on it) LVN "A" From 10/08/10 to 10/29/10 = no areas of skin impairment noted. SR#14's Determination of Unavoidable Pressure Ulcer dated 10/14/10 indicated : Severe [MEDICAL CONDITION] [MEDICAL CONDITION] Chronic Urinary Incontinence, Hospice, Chronic Bowel Incontinence. 11/02/10 = self inflicted scratches (no documentation on sacral area) 11/05/10 = self inflicted scratches (no documentation on sacral area) 11/12/10 = redness-blanchable (diagram indicated sacral area) SR#14's Assessment of Pressure Sore Potential dated 11/16/10 indicated a score of 19 (high risk) with instructions to: Follow Pressure Sore Protocol. 11/19/10 = continue redness (blanchable) (diagram indicated no documentation on sacral area) 11/26/10 = no areas of skin impairment 12/01/10 = Stage 2 coccyx Lt. Stage 2 coccyx Rt (diagram identifying location of ulcers indicated buttocks) (unable to read LVN's name) SR#14's Physician's Telephone Orders dated 12/01/10 indicated: "Dermavase to coccyx Stage 2 x 2 q shift x 14 d (days) then reassess." SR#16: SR#16's Face Sheet dated 04/20/07 with readmission on 09/20/08 indicated SR#16's [DIAGNOSES REDACTED]. SR#16's MDS dated [DATE] indicated SR#16's cognitive level as severely impaired (never/rarely made decisions). SR#16 also required assistance of one or two persons to perform ADLs (bathing, toileting, transfers and ambulation.) SR#16's Assessment of Pressure Sore Potential dated 10/26/09 to 07/28/10 indicated SR#16 was high risk for the development of pressure ulcers with instructions to follow the Pressure Sore Protocol. SR#16's November 2010 physician's orders [REDACTED]. Review of the facility's Skin Condition Variance Report dated 11/25/10 listed SR#16's as an "upper crevice buttock" use Dermavase. SR#16's Weekly Skin assessment dated : 10/22/10 and 11/29/10 = indicated no entry of skin impairment. 12/01/10 = "open area smaller to upper crevice Stage 2" (diagram indicated coccyx) Right buttocks Stage 2. Documented by LVN "A" On 12/01/10 at 10:20 a.m., the DON accompanied by the surveyor identified SR#16 to have one Stage 2 (vertical open area) to the coccyx and one Stage 2 (small open area) to the inner buttocks right side. In an interview with the DON at that time, surveyor asked what the areas were. The DON said "Stage 2 pressure ulcers." SR#16's Shower Communication Sheet dated 12/01/10 at 1:50 p.m. indicated "Crevice and inner right buttock-Stage 2's (easy graphed , measured (form used by facility to measure pressure ulcers) (Dermavase being applied to upper crease). Will add new area to treatments" signed by Treatment Nurse/LVN "A." SR#16's Telephone physician's orders [REDACTED]." SR#18: SR#18's Face Sheet indicated SR#18 was admitted [DATE] and re-admitted on [DATE]. SR#18's [DIAGNOSES REDACTED]. SR#18's MDS dated [DATE] revealed SR#18's cognitive level was moderately impaired (decisions poor). SR#18 was totally dependant on one person to provide ADLs and had no skin problems listed. SR#18's November 2010 physician's orders [REDACTED]. On 12/01/10 at 1:40 p.m., DON accompanied by surveyor identified SR#18 to have redness to the entire sacral/coccyx area with a Stage 2 pressure ulcer on the right buttocks. At that time, surveyor asked the DON what the area on the right buttocks would be called and the DON said, "a Stage 2 pressure ulcer." SR#18's Weekly Skin assessment dated and indicated: 08/04/10 = no entry (blank, no areas of skin impairment). Documented by LVN "E." 08/11/10 = redness (diagram represented the coccyx area). Documented by LVN "A." 08/18/10 = same as above. LVN "E". 08/25/10 = same. LVN "E". 09/02/10 = resolved (no markings on diagram) = redness (diagram represented the coccyx area). LVN "A". 09/09/10 = redness (diagram represented the coccyx area). LVN "E". 09/16/10 =no entry. LVN "A" all dates below to 10/25/10 SR#18's Assessment of Pressure Sore Potential dated 01/20/10 to 09/20/10 listed SR#18 as high risk (17-20) with instructions to Follow Pressure Sore Protocol. From 09/23/10 to 10/21/10 = no entry of skin impairment. 10/25/10 = redness (diagram represented the coccyx area ).LVN "A" From 10/28/10 to 11/25/10= redness. LVN "E" and "A". 12/01/10 = Stage 2 coccyx Stage 2 lower perineum (diagram indicating location of pressure ulcer). documented by the DON. SR#18's Wound Care Measurement and Assessment Graph dated 12/01/10 indicated SR#18 had a Stage 2 pressure ulcer to the coccyx and Stage 2 pressure ulcer to the perineal area. SR#18's Telephone physician's orders [REDACTED]. Dermavase to coccyx q shift times 14 days then reassess. Dermavase to perineum Stage 2 q shift times 14 days then reassess. On 12/01/10 at 6:00 p.m. surveyor interviewed the DON about Treatment Nurse/LVN "A"'s assessing and staging pressure ulcers as excoriation rather than pressure ulcers and using non-medical terminology to describe wounds/body parts. The DON said "(Treatment Nurse/LVN "A") needs to be more concise when writing her orders and staging decubitus (pressure) ulcers. She (Treatment Nurse/LVN "A") needs to be more technical with her medical terminology. In the future, myself or the ADON will be monitoring weekly skin rounds. I have not been monitoring the weekly skin rounds since (Treatment Nurse/LVN "A") has been the treatment nurse for years and I trusted her judgement." Surveyor asked if weekly assessments were discussed in the morning stand up meetings. The DON said "(Treatment Nurse/LVN "A") brings the weekly Skin Variance Reports and we discuss that." The DON said she was aware of the ruptured blister on the back of SR#13, but (Treatment Nurse/LVN "A") reported the area on the back under the Skin Variance report, not under the weekly pressure ulcer QI log. The DON said she knew that SR#12's area on the buttocks was listed on the Skin Variance Report as sheering. On 12/03/10 at 4:00 p.m., surveyor requested the facility's Policy and Procedure for skin treatments from the DON. The surveyor was provided with a booklet titled Skin Integrity Management Program dated January 2007 that included: Purpose: 1. "To provide a system of assessment, evaluation and monitoring of residents' skin integrity. 2. To identify risk factors specific to individual residents who need prevention. 3. To implement measures aimed at preventing the development of pressure ulcers and possibly other skin problems 4. To manage treatment of [REDACTED]. 5. To reduce the prevalence of pressure ulcers through education programs." Monitoring System: f. "Random checks of the weekly skin assessments, appropriate treatments, notifications, dot system (colored dots on door to indicate skin integrity) and documentation will be completed weekly by the DON/Manager on all residents identified at risk for pressure ulcers." QA (Quality Assessment): c. "DON/Manager will view all pressure ulcers weekly." Pressure Ulcer Treatment Protocols: Staging: "Stage I= An observable pressure related alteration of intact skin whose indicators compared to adjacent or opposite area on the body may include changes in one or more of the following: temperature (warmth or coolness), tissue consistency(firm or boggy feel), sensation (pain or itching). Stage II=Partial skin loss involving epidermis and or dermis. The ulcer is superficial and may present as an abrasion, blister, or shallow crater. Stage III: Full thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to but not through underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Wound base is generally not painful. Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures such as tendons or joint capsules. Undermining and sinus tracts may also be associated with Stage IVs. Wound base is not painful." On 12/01/10 at 6:15 p.m., an IJ was identified and the Administrator and DON were informed of the IJ at 6:15 p.m. The facility's Plan of Removal was accepted on 12/03/10 at 6:30 p.m. and contained the following: 1. 100% skin audit of all residents by nursing staff. 2. Treatment orders received for all new identified pressure ulcers. Care Plan (CP) updated to reflect new areas of concern. CP's double checked for completeness. 3. CNAs were inserviced to identify skin issues, complete a Skin Communication Sheet and report to charge nurse who will follow up with 24 hour report, treatment sheet, notify Physician,

Based on observation, record review and interview, the facility was not administered in a manner that ensured the highest practicable physical well-being of their residents. The Director of Nurses (DON) did not: 1. did not supervise/monitor Treatment Nurses to ensure they performed accurate skin assessments, correctly staged pressure ulcers and provided treatments according to the physician's orders [REDACTED]. 2. implement facility's Policy/Procedure and Protocol to ensure treatment nurses were providing services as identified in the facility's policy/procedure and protocol for five of 18 Sample Residents (SR#12, 13, 14, 16 and 18). SR#12 developed an avoidable Stage 4 (full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle or bone) to the left buttocks. SR#13 developed an avoidable Stage 4 pressure sore to her back. SR#14, 16 and 18 developed new Stage 2 (partial skin loss involving the epidermis and dermis, superficial and may present as an abrasion, blister or shallow crater) pressure sores not identified by facility staff until 12/01/10 after surveyor intervention. Failure to implement the facility's Policy and Procedures related to skin management could result in the development of new pressure ulcers or deterioration of existing pressure ulcers on 26 residents identified by the facility as high risk residents for the development of pressure ulcer. An Immediate Jeopardy (IJ) was identified on 12/01/10. While the IJ was removed on 12/03/10, the facility remained out of compliance at a scope of Pattern and a severity level of Actual Harm because all staff had not received scheduled training on identifying skin irregularities, proper procedure for communicating issues for follow up, prevention, staging, terminology and documentation. The findings were: Review of the facility's Pressure Ulcer Treatment Protocols dated January 2007 revealed: *Stage 2 = notify physician cleanse wound with saline and administer treatment as ordered by Physican *Stage 3-4 = notify physician notify physician if no improvement is apparent in 14 days or if expected healing is not occurring. If there is any worsening of the wound at any time, notify physician for change of treatment. If eschar or slough (necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft and moist.) present: *cleanse wound and administer treatment as ordered by physician *notify physician if no improvement is apparent in 14 days Upon entry, the facility provided surveyor with the Weekly Pressure Ulcer Quality Indicator Log, identifying two residents with pressure ulcers. Weekly Pressure Ulcer Quality Indicator Log consisted of residents with pressure ulcer identified by Treatment Nurse/LVN "A". Facility later provided surveyor with the Centers for Medicare and Medicaid Services form 802 which listed eight other residents with pressure ulcers. Surveyor asked for clarification of discrepancy and the facility stated residents pressure ulcers on the 802 were resolved. Surveyor was provided with a copy of the facility's Skin Condition Variance Report ( a report of the facility that reflected skin conditions other than pressure ulcers) dated 11/25/10. On 12/01/10 after observations of perineal care were completed, surveyor asked Director of Nurses (DON) to verify the correctness of the Skin Condition Variance Log by making observations of the residents on the Variance Log. The DON, Assistant Director of Nurse (ADON "D") and surveyor, checked residents from the Variance Log. 1. SR#12: SR#12's Face Sheet dated 09/08/06 revealed SR#12 was admitted with [DIAGNOSES REDACTED]. Above Knee Amputation, Hypertension, Pain, and [MEDICAL CONDITION] (inability to speak). SR#12's Minimum (MDS) data set [DATE] indicated: SR#12's cognitive level was severely impaired (never/rarely made decisions) and SR#12 required assistance of one to two staff with activities of daily living (ADLs - bathing, toileting, transfers and ambulation). SR#12 was mechanical lifted from bed to chair and was turned and repositioned by staff. SR#12's November 2010 physician's orders [REDACTED]. On 12/01/10 at 9:00 a.m., surveyor observed Certified Nurse Aides (CNAs "B" and "C") provide perineal care for SR#12. When the adult brief was removed, surveyor observed [MEDICATION NAME] (transparent wound dressing) to SR#12's whole sacral area. There was feces under the dressing and when CNA "C" removed the soiled [MEDICATION NAME], surveyor observed black, necrotic tissue with slough on SR#12's left buttocks and a Stage 2 pressure ulcer on SR#12's right buttocks. According to the facility's Skin Protocol for Stage 4 pressure ulcers, [MEDICATION NAME] was not an appropriate treatment for [REDACTED]. SR#12's Weekly Skin Assessment Data Collection dated: 08/06/10 = indicated no skin issues to buttocks documented by LVN "A" 08/09/10 = same as above by LVN "A" 08/13/10 = same as above LVN "A" 08/16/10 = Stage 2 to bilateral buttocks documented by LVN "E" 08/23/10 = Right buttocks-Stage 1 (an observable, pressure-related alteration of intact skin, whose indicators as compared to adjacent or opposite area on body may include changes in one or more of the following parameters: skin temperature, tissue consistency, sensation; and/or a defined area of persistent red, blue, or purple hues.) Left buttocks-Stage 2 Sacrum-Stage 2 times two LVN "A" 08/30/10 = Right buttock- healed Left buttock-Stage 2 Sacrum- resolved Right upper buttock-sheering LVN "A" 09/06/10 = Sheering, smaller (diagram of resident body indicated skin issue was to the resident's left buttocks) Right buttocks-Stage 2 (diagram indicated right side) LVN "A" 09/13/10 = Sheering (the interaction of both gravity and friction against the surface of the skin; occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches) left buttocks LVN "E" 09/20/10 = Left buttocks-Stage 2 Right and Left buttocks-sheering LVN "A" 09/27/10 = All but one Stage 2 healed (diagram indicated left lower buttocks) LVN "A" 10/04/10 = Buttocks resolved (diagram indicated clear skin).LVN "A" 10/11/10 = Redness and sheering continues with [MEDICATION NAME] intact (diagram indicated left and right buttocks. Stage 2 left buttock documented by LVN "E" 10/18/10 = Left buttock-Stage 2 smaller LVN "A" 10/25/10 = Left buttocks healed LVN "A" 11/01/10 = no entry LVN "A" 11/08/10 = Sheering bilateral buttocks (diagram indicated bilateral buttocks). [MEDICATION NAME] applied. LVN "A" 11/15/10 = bilateral sheering LVN "E" 11/22/10 = Sheering, new treatment of [REDACTED]. Review of the facility's Skin Condition Variance Report dated 11/25/10 indicated SR#12 had sheering to coccyx with the treatment of [REDACTED]. Skin Condition Variance Report ( a report of the facility that reflected skin conditions other than pressure ulcers) consisted of: Stasis/Arterial Ulcer, Diabetic Ulcer, Surgical Site, Rash Abrasion/Excoriation and Other. SR#12's Weekly Skin Assessment Data Collection dated: 11/29/10 = left buttocks-sheering, continue with treatment and improving. (diagram left buttocks). LVN "E" 12/01/10 = Sheering area noted to have darkened areas/appears to have maceration (wetness/white around the area) to periphery. Due to increased slough with necrosis noted, wound to left side upper buttocks Stage 4. Wound measured 4.4 by 4.2 centimeters. Right buttocks measured 1.6 by 0.8. initialed by LVN "A" and identified as a Stage 4 by ADON "D" documented by Treatment Nurse/LVN "A." The assessment was conducted at request of surveyor during an audit of residents listed from the facility's Skin Variance log. SR#12's Telephone physician's orders [REDACTED]. Dermavase (Zinc Oxide) ointment to right upper buttock every (q) shift times 14 days then reassess. Clean left side upper buttock/coccyx with wound cleanser, pat dry, apply Santyl, [MEDICATION NAME] Blue, 2 x 2 (gauze), cover q day times 14 days, then reassess. Insert Foley Catheter (tube inserted into bladder to drain urine) due to wound Stage 4 ulcer. On 12/01/10 at 4:40 p.m., surveyor interviewed Treatment Nurse/LVN "A" about SR#12's buttocks areas. Treatment Nurse/LVN "A" said SR#12's sheering started on 11/08/10 with open areas to the buttocks. Treatment Nurse/LVN "A" said she did not measure the area but applied [MEDICATION NAME] per facility's protocol. On 11/22/10, the buttocks area started looking a little worse with the open area a little larger and she said she started using Santyl. Surveyor asked if SR#12's Physician had been called to come to examine the area. Treatment Nurse/LVN "A" said SR#12 had not been seen by the Physician or Physician's Assistant. Treatment Nurse/LVN "A" said she would call the Physican's Assistant tonight for orders. Surveyor asked Treatment Nurse/LVN "A" to explain the staging of wounds. Treatment Nurse/LVN "A" said: "Stage 1 = redness, non blanchable Stage 2 = open area, below top layer of skin Stage 3 = more than a II without slough Stage 4 = with slough, necrotic, unstageable." Surveyor asked Treatment Nurse/LVN "A" to summarize her treatment to SR#12's buttocks area. She said "on 11/08/10 and 11/15 assessments, I noted sheering to upper buttocks and applied [MEDICATION NAME]. On 11/22/10, the sheering continued with no healing and had an open area a little larger. I started Santyl and covered the area with gauze. On 11/29/10 the area appeared to be healing. On 12/01/10, sheering with darkened area to wound bed. Changed to Stage 4 due to slough with necrotic tissue." Surveyor asked Treatment Nurse/LVN "A" to describe sheering and excoriation. She said sheering was "to pull up in bed, and the skin is taken off and excoriation was scattered open areas, pinpoint, in buttocks, multiple areas maybe from loose stools." Surveyor asked Treatment Nurse/LVN "A" if she had attended any pressure ulcer training or inservice's. Treatment Nurse/LVN "A" said "our training's are computer based," and provided surveyor with copies of certificates. Surveyor reviewed the six certificates titled: Current Concepts in Wound Care Pressure Ulcers Pressure Ulcer Prevention Wound Assessment and Documentation Differentiating Various Types of Ulcers and Back to the Basics of Wound Healing. Although Treatment Nurse/LVN "A" had training on wound assessment and differentiating various types of ulcers, Treatment Nurse/LVN "A" failed to accurately assess SR#12's pressure ulcer to the left buttock as sheering from 11/08/10 to 12/01/10 when identified as a Stage 4 pressure ulcer by ADON "D." Surveyor asked what was the product Dermavase. Treatment Nurse/LVN "A" provided surveyor with a tube of Dermavase which indicated it was Zinc Oxide ointment. Treatment Nurse/LVN "A" said "it's a skin barrier used without dressing." Surveyor asked if facility used a Wound Specialist and Treatment Nurse/LVN "A" said "no, we use a medical supplier that is a (Registered Nurse and Wound Care Specialist) that comes here monthly and when I have questions, they come and consult with me. They check the pressure ulcer list and ask if I need anything. If they think I need to change the orders, they recommend it and I call and get the orders." 2. SR#13: SR#13's Face Sheet indicated SR#13 was admitted [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITIONS], Chronic Obstructive Airway ([MEDICAL CONDITION]), Pain and Dysphagia (difficulty swallowing). SR#13's MDS dated [DATE], June 2010 and October 2010 indicated no pressure ulcers. SR#13's Cognitive skills were moderately impaired (decisions poor, supervision required). SR#13 required extensive assistance of one or two person to perform her ADLs (bathing, transfers, ambulation). SR#13's November 2010 physician's orders [REDACTED]. On 12/01/10 at 9:15 a.m., surveyor observed CNAs "B" and "C" provide perineal care for SR#13. When SR#13 was turned to her side, she cried out. CNA "B" said SR#13 had a "sore" on her back and it hurt SR#13 when they turned her. When CNA "B" and "C" turned SR#13 completely over to her side, surveyor observed a dressing half off. Surveyor observed a wound over the right scapula area with a crater type wound under the dressing. The wound to the right upper back was noted to have a blue foam packing. Surveyor observed CNAs "B" and "C" provide perineal care and observed three small (approximately 1/2 inch by 1/2 inch) open areas on the buttocks area. One open area on each buttocks and one open area in the coccyx/sacral area. Review of the facility's Skin Condition Variance Report for SR#13 dated 11/25/10 indicated SR#13's wound was listed as a "ruptured blister right side back." SR#13's Weekly Skin Assessment Data Collection dated: 09/07/10 = ruptured blister upper right back. Not measured. Documented by LVN "A". SR#13's Assessment of Pressure Sore Potential dated 09/10/10 indicated a score of 12 (high risk for pressure ulcer) with instructions to: follow pressure ulcer protocol. SR#13's Weekly Skin Assessment Data Collection dated 09/14/10 = ruptured blister back. LVN "A". SR#13's Interdisciplinary Care Plan Conference dated 09/15/10 indicated: Areas Reviewed: Skin = "No problems/rash under bilateral breasts" Dated 10/11/10 = Areas Reviewed: Skin = Blank (no comment noted). SR#13's Weekly Skin Assessment Data Collection dated: 09/21/10 = open area dark with slough back. Documented by LVN "A." 09/28/10 = open area dark soft slough back. LVN "A". 10/03/10 = open wound back right side. Documented by LVN "F". 10/08/10 = area to back-dark slough. LVN "A". SR#13's Determination of Unavoidable Pressure Ulcer dated 10/14/10 indicated: [DIAGNOSES REDACTED]. SR#13's Weekly Skin Assessment Data Collection dated: 10/15/10 = ruptured blister dark slough noted back. Documented by LVN "A." 10/25/10 = buttocks-excoriation, Back-dark slough to ruptured blister area LVN "A". 11/01/10 = Back-dark slough-yellowish to periphery of wound bed Buttocks-redness. LVN "A". SR#13's Wound Care (WC) * Skin Integrity * Evaluation dated 11/05/10 (performed by Consultant Wound Care Company) indicated: Back right = Full thickness 100% moist black eschar (dead tissue). Interventions: Santyl (topical chemical debrider). [MEDICATION NAME] blue packing (medicated foam packing.) SR#13's Weekly Skin Assessment Data Collection dated: 11/08/10 = Buttocks = excoriation Back = slough separating from wound bed. Documented by LVN "A." 11/15/10 = Buttocks = excoriation Back = slough separating from wound bed. Documented by LVN "E." 11/22/10 = Back = wound bed to right side back continues with slough separating from wound bed. Approximately 40% slough to approximately 60% granulating tissue. No redness to periphery. Buttocks = excoriation dissipating. LVN "A". 11/29/10 = Back = wound has approximately 75% slough with 25% granulating tissue. Wound edge to proximal aspect of wound noted with necrotic tissue and noted sagging over to upper to be undermining (tissue destruction under intact skin). Buttocks = continue with excoriation. Due to increase in slough with necrosis noted, wound to right side back staged to 4. Wound to back measured 3.3 by 2.4. LVN "E". 12/01/10 = Back = Stage 4 Buttocks = Stage 2 to bilateral buttocks Stage 2 to crevice of Buttocks (marks on diagram indicated coccyx) "Overall buttocks/sacral/coccyx area=red/purple discoloration (blanchable to reddened areas)." Documented by LVN "E." Treatment Nurse/LVN "A" did not assess SR#13's Stage 4 pressure ulcer as a Stage 4. The wound was not identified as a Stage 4 pressure ulcer until 12/01/10 after surveyor intervention. SR#13's WC Skin Integrity Evaluation dated 12/02/10 indicated: Back right side = full thickness Stage 4, wound bed 10% moist black eschar, 40% moist yellow slough, 50% pale red granulation. Continue with current treatment plan. Coccyx = 100% pink and moist. Stage 2. Moisture barrier cream to protect and allow healing. Leave open to air. SR#13's Physician's Telephone Orders dated 12/01/10 indicated: Back = Clean right side back with wound cleanser, pat dry, apply Santyl, [MEDICATION NAME] Blue, cover with 2 x 2 (gauze), cover site q day for 14 days, then reassess. Buttocks = Start Dermavase ointment to bilateral buttocks q shift for 14 days, then reassess. On 12/01/10 at 1:30 p.m. surveyor observed facility housekeeping/maintenance staff removing SR#13's regular air mattress and replacing it with a speciality mattress (low air loss mattress). On 12/01/10 at 4:50 p.m. surveyor interviewed Treatment Nurse/LVN "A" about SR#13's pressure ulcers to the back and coccyx. Treatment Nurse/LVN "A" stated "I did not measure the back wound or stage it because it was not over a bony area. I considered it a blister and then a ruptured blister and not a pressure area." "When the blister first ruptured, I did not measure or stage the wound due to the fact that I did not feel that was a pressure ulcer." Surveyor asked what was the course of treatment for [REDACTED]. Treatment Nurse/LVN "A" said "When the blister ruptured, I started [MEDICATION NAME] (antibiotic ointment), then when there was slough, I started Santyl. When the area declined, I started [MEDICATION NAME] (thick honey product). When that did not help any, I restarted Santyl with [MEDICATION NAME] Blue foam." On 12/02/10 at 8:15 a.m., surveyor asked whether SR#13's Physician had come to examine the wound on SR #13's back. Treatment Nurse/LVN "A" said "For wound care treatment, I notify the Nurse Practitioner with suggestions for changes and he ordered then." On 12/02/10 at 10:40 a.m., surveyor interviewed Treatment Nurse/LVN "A" about the Wound Consultant Company's evaluation. Treatment Nurse/LVN "A" said, "I called them and told them of the ruptured blister on (SR#13's) back, and they sent me a typed report and ordered the supplies for us to use. They referred to the wound as full thickness, open wound. But I still contend it's a ruptured blister." On 12/02/10 at 1:30 p.m., surveyor interviewed the Wound Consultant (WC) Company Representative about SR#13's back pressure ulcer. The WC said "(Treatment Nurse/LVN "A") called the area a ruptured blister when she called me for supplies. (Treatment Nurse/LVN "A") said it had slough. I ordered Santyl. I called it full thickness from Treatment Nurse/LVN "A"'s description. That area was a Stage 4 by depth . When you see the outline of a bone, it's a Stage 4. I have printed out the National Pressure Ulcer Associations Guidelines on determining staging and I have started to train (Treatment Nurse/LVN "A") today. I will do a pressure ulcer inservice in the near future about staging." On 12/03/10 at 2:30 p.m., surveyor interviewed Treatment Nurse/LVN "A" about the air mattress for SR#13's bed. Treatment Nurse/LVN "A" said we use low air loss mattresses for Stage 3 or 4's and regular air mattresses for Stage 1 or 2's as preventative. We changed (SR#13's) mattress when we changed the back wound to a Stage 4." The facility had not been using the specific specialized low air loss mattress for SR#13 until surveyor intervened and the pressure ulcer deteriorated from a ruptured blister to a Stage 4 pressure ulcer. SR#14: SR#14's Face Sheet identified she was admitted to facility on 07/30/10 with [DIAGNOSES REDACTED]. SR#14's MDS dated [DATE] indicated: SR#14's cognitive level as moderately impaired and totally dependent on one or two persons for provision of ADLs (activities of daily living). SR#14's December 2010 physician's orders [REDACTED]. On 12/01/10 at 1:35 p.m., DON accompanied by surveyor identified one Stage 2 pressure ulcer to SR #14's sacral area and one Stage 2 to SR #14's right buttocks. In an interview with the DON at that time, surveyor asked what the areas were. The DON said "Stage 2's." SR#14's Weekly Skin Assessment Data Collection dated indicated: 07/30/10 = redness (diagram indicated sacral area) 08/06/10 = redness (diagram indicated sacral area) LVN "E" From 08/30/10 to 09/17/10 = no documentation or entry of skin impairment noted. 09/24/10 =redness (diagram indicated sacral area) LVN "A" 10/01/10 = redness-blanchable (diagram had no markings on it) LVN "A" From 10/08/10 to 10/29/10 = no areas of skin impairment noted. SR#14's Determination of Unavoidable Pressure Ulcer dated 10/14/10 indicated : Severe [MEDICAL CONDITION] [MEDICAL CONDITION] Chronic Urinary Incontinence, Hospice, Chronic Bowel Incontinence. 11/02/10 = self inflicted scratches (no documentation on sacral area) 11/05/10 = self inflicted scratches (no documentation on sacral area) 11/12/10 = redness-blanchable (diagram indicated sacral area) SR#14's Assessment of Pressure Sore Potential dated 11/16/10 indicated a score of 19 (high risk) with instructions to: Follow Pressure Sore Protocol. 11/19/10 = continue redness (blanchable) (diagram indicated no documentation on sacral area) 11/26/10 = no areas of skin impairment 12/01/10 = Stage 2 coccyx Lt. Stage 2 coccyx Rt (diagram identifying location of ulcers indicated buttocks) (unable to read LVN's name) SR#14's Physician's Telephone Orders dated 12/01/10 indicated: "Dermavase to coccyx Stage 2 x 2 q shift x 14 d (days) then reassess." SR#16: SR#16's Face Sheet dated 04/20/07 with readmission on 09/20/08 indicated SR#16's [DIAGNOSES REDACTED]. SR#16's MDS dated [DATE] indicated SR#16's cognitive level as severely impaired (never/rarely made decisions). SR#16 also required assistance of one or two persons to perform ADLs (bathing, toileting, transfers and ambulation.) SR#16's Assessment of Pressure Sore Potential dated 10/26/09 to 07/28/10 indicated SR#16 was high risk for the development of pressure ulcers with instructions to follow the Pressure Sore Protocol. SR#16's November 2010 physician's orders [REDACTED]. Review of the facility's Skin Condition Variance Report dated 11/25/10 listed SR#16's as an "upper crevice buttock" use Dermavase. SR#16's Weekly Skin assessment dated : 10/22/10 and 11/29/10 = indicated no entry of skin impairment. 12/01/10 = "open area smaller to upper crevice Stage 2" (diagram indicated coccyx) Right buttocks Stage 2. Documented by LVN "A" On 12/01/10 at 10:20 a.m., the DON accompanied by the surveyor identified SR#16 to have one Stage 2 (vertical open area) to the coccyx and one Stage 2 (small open area) to the inner buttocks right side. In an interview with the DON at that time, surveyor asked what the areas were. The DON said "Stage 2 pressure ulcers." SR#16's Shower Communication Sheet dated 12/01/10 at 1:50 p.m. indicated "Crevice and inner right buttock-Stage 2's (easy graphed , measured (form used by facility to measure pressure ulcers) (Dermavase being applied to upper crease). Will add new area to treatments" signed by Treatment Nurse/LVN "A." SR#16's Telephone physician's orders [REDACTED]." SR#18: SR#18's Face Sheet indicated SR#18 was admitted [DATE] and re-admitted on [DATE]. SR#18's [DIAGNOSES REDACTED]. SR#18's MDS dated [DATE] revealed SR#18's cognitive level was moderately impaired (decisions poor). SR#18 was totally dependant on one person to provide ADLs and had no skin problems listed. SR#18's November 2010 physician's orders [REDACTED]. On 12/01/10 at 1:40 p.m., DON accompanied by surveyor identified SR#18 to have redness to the entire sacral/coccyx area with a Stage 2 pressure ulcer on the right buttocks. At that time, surveyor asked the DON what the area on the right buttocks would be called and the DON said, "a Stage 2 pressure ulcer." SR#18's Weekly Skin assessment dated and indicated: 08/04/10 = no entry (blank, no areas of skin impairment). Documented by LVN "E." 08/11/10 = redness (diagram represented the coccyx area). Documented by LVN "A." 08/18/10 = same as above. LVN "E". 08/25/10 = same. LVN "E". 09/02/10 = resolved (no markings on diagram) = redness (diagram represented the coccyx area). LVN "A". 09/09/10 = redness (diagram represented the coccyx area). LVN "E". 09/16/10 =no entry. LVN "A" all dates below to 10/25/10 SR#18's Assessment of Pressure Sore Potential dated 01/20/10 to 09/20/10 listed SR#18 as high risk (17-20) with instructions to Follow Pressure Sore Protocol. From 09/23/10 to 10/21/10 = no entry of skin impairment. 10/25/10 = redness (diagram represented the coccyx area ).LVN "A" From 10/28/10 to 11/25/10= redness. LVN "E" and "A". 12/01/10 = Stage 2 coccyx Stage 2 lower perineum (diagram indicating location of pressure ulcer). documented by the DON. SR#18's Wound Care Measurement and Assessment Graph dated 12/01/10 indicated SR#18 had a Stage 2 pressure ulcer to the coccyx and Stage 2 pressure ulcer to the perineal area. SR#18's Telephone physician's orders [REDACTED]. Dermavase to coccyx q shift times 14 days then reassess. Dermavase to perineum Stage 2 q shift times 14 days then reassess. On 12/01/10 at 6:00 p.m. surveyor interviewed the DON about Treatment Nurse/LVN "A"'s assessing and staging pressure ulcers as excoriation rather than pressure ulcers and using non-medical terminology to describe wounds/body parts. The DON said "(Treatment Nurse/LVN "A") needs to be more concise when writing her orders and staging decubitus (pressure) ulcers. She (Treatment Nurse/LVN "A") needs to be more technical with her medical terminology. In the future, myself or the ADON will be monitoring weekly skin rounds. I have not been monitoring the weekly skin rounds since (Treatment Nurse/LVN "A") has been the treatment nurse for years and I trusted her judgement." Surveyor asked if weekly assessments were discussed in the morning stand up meetings. The DON said "(Treatment Nurse/LVN "A") brings the weekly Skin Variance Reports and we discuss that." The DON said she was aware of the ruptured blister on the back of SR#13, but (Treatment Nurse/LVN "A") reported the area on the back under the Skin Variance report, not under the weekly pressure ulcer QI log. The DON said she knew that SR#12's area on the buttocks was listed on the Skin Variance Report as sheering. On 12/03/10 at 4:00 p.m., surveyor requested the facility's Policy and Procedure for skin treatments from the DON. The surveyor was provided with a booklet titled Skin Integrity Management Program dated January 2007 that included: Purpose: 1. "To provide a system of assessment, evaluation and monitoring of residents' skin integrity. 2. To identify risk factors specific to individual residents who need prevention. 3. To implement measures aimed at preventing the development of pressure ulcers and possibly other skin problems 4. To manage treatment of [REDACTED]. 5. To reduce the prevalence of pressure ulcers through education programs." Monitoring System: f. "Random checks of the weekly skin assessments, appropriate treatments, notifications, dot system (colored dots on door to indicate skin integrity) and documentation will be completed weekly by the DON/Manager on all residents identified at risk for pressure ulcers." QA (Quality Assessment): c. "DON/Manager will view all pressure ulcers weekly." Pressure Ulcer Treatment Protocols: Staging: "Stage I= An observable pressure related alteration of intact skin whose indicators compared to adjacent or opposite area on the body may include changes in one or more of the following: temperature (warmth or coolness), tissue consistency(firm or boggy feel), sensation (pain or itching). Stage II=Partial skin loss involving epidermis and or dermis. The ulcer is superficial and may present as an abrasion, blister, or shallow crater. Stage III: Full thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to but not through underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Wound base is generally not painful. Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures such as tendons or joint capsules. Undermining and sinus tracts may also be associated with Stage IVs. Wound base is not painful." On 12/01/10 at 6:15 p.m., an IJ was identified and the Administrator and DON were informed of the IJ at 6:15 p.m. The facility's Plan of Removal was accepted on 12/03/10 at 6:30 p.m. and contained the following: 1. 100% skin audit of all residents by nursing staff. 2. Treatment orders received for all new identified pressure ulcers. Care Plan (CP) updated to reflect new areas of concern. CP's double checked for completeness. 3. CNAs were inserviced to identify skin issues, complete a Skin Communication Sheet and report to charge nurse who will follow up with 24 hour report, treatment sheet, notify Physician, Responsible Party and implement any orders received. 4. On-going inservice's to identify skin issues. 5. DON/ADON will monitor treatment nurse weekly at random and monthly performance reviews to ensure treatment nurse's understanding of all training. 6. 10% CNAs will have random return demonstration on reporting skin issues. 7. Re-enforce skin integrity Polices and Procedure 8. Weekly head to toe skin assessments performed according to new summary schedule and issues will be brought to QA meetings. 9. Keep the Physician updated on all skin issues. Through observations, interviews and record review conducted, the surveyor determined that the interventions documented in the facility's plan of removal were implemented and the IJ was removed effective 12/03/10 at 6:30 p.m. The facility remained out of compliance at a scope and severity of a pattern of actual harm that was not IJ due to the two resident who developed avoidable Stage 4 pressure ulcers. The non-compliance continued based on the facility's need to monitor its corrective action for effectiveness and to ensure all staff received all scheduled training. On 12/03/10 at 6:45 p.m., the Administrator was given the opportunity to provide any additional information regarding pressure ulcers and nothing further was provided. On 11/30/10 the facility provided a list of two residents with pressure ulcers.