Every finding on record at Creekside Center for Rehabilitation and Healing

Based on policy review, medical record review, observation, and interview, the facility failed to promote dignity and respect for 1 of 28 sampled residents (Resident #80). Resident #80 had been assisted to his wheelchair and left partially dressed in a T-shirt and an adult brief. The findings include: Review of the policy titled, Resident Rights, dated 5/19/2023, revealed, . Federal and state laws guarantee certain basic rights to all residents of this facility .rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity . Review of medical records revealed Resident #80 was admitted to the facility on [DATE] with diagnoses which included Cellulitis of Back, Other Mechanical Complication of Internal Fixation Device of Left Femur, and Unspecified Abnormalities of Gait and Mobility. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #80 required Extensive Assistance with 2 person physical assist with transfers and dressing. Observation and interview on 7/12/2023 at 11:15 AM, revealed Resident #80 sitting in a wheelchair at the bedside dressed in a T-shirt and an adult brief. When the surveyor knocked on the resident's door and asked to enter the room Resident #80 answered yes and took the disposable incontinence pad from his bed and placed it over his lap. Resident #80 stated, I haven't had on pants today at all. I was told my pants are in the laundry. When asked if he preferred to be without pants on in his room, Resident #80 replied, Hell no it makes me feel like a baby sitting here in this diaper. That's why I grabbed this pad to put over my diaper. Observation and interview on 7/12/2023 at 11:28 AM revealed, Unit Manager/LPN (Licensed Practical Nurse) #8 observed Resident #80 in his wheelchair wearing a T-shirt and an adult brief. The Unit Manager/LPN #8 stated, [Resident #80] could have just gotten out of bed and the Certified Nursing Assistant [CNA] had not dressed him yet. Unit Manager/LPN #8 asked Resident #80 where his pants were and he replied, I guess my pants are in the laundry, that's what the tech said this morning. The Unit Manager confirmed Resident #80 required assistance with transfers and dressing.

Based on facility policy review, observations and interviews, the facility failed to ensure a safe and clean environment in 6 of 101 resident rooms (room [ROOM NUMBER], #99, #100, #103, #106, and #113) observed. The findings include: Review of the policy titled, Homelike Environment, dated 5/19/2023, revealed, .Residents are provided with a safe, clean, comfortable and homelike environment .facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting .clean, sanitary . Observation in room [ROOM NUMBER] on 7/9/2023 at 1:08 PM, revealed debris, which included food and paper scattered on the floor under B bed, behind B bedside table, and beside A bed. The A bed closet was missing lamination on the front of the door. The entrance door had multiple areas of damaged wood with splintered wood along the edge of the door below the door knob. The wall outside of the bathroom close to the floor had damaged finishes with black scuff marks. Continued observation revealed water and black substance around the bottom of the commode and floor in the bathroom. The bathroom had a strong urine odor present. Observation and interview in room [ROOM NUMBER] on 7/9/2023 at 1:38 PM, revealed the Housekeeping Director confirmed there was debris scattered around the floor, water and black mold like debris around the base of the commode and on the floor, and a strong urine odor present in the bathroom. While touching the commode during the observation, the Housekeeping Director confirmed the commode base was loose and leaking water. Observation and interview in room [ROOM NUMBER] on 7/9/2023 at 2:10 PM, revealed the Maintenance Assistant #1 confirmed the commode base was loose and moveable. Continued observation and interview revealed the Maintenance Assistant confirmed the missing lamination on A bed closet, the splintered wood on the entrance door edge, the damaged wall with scuff marks and black smudges. The Maintenance Assistant confirmed the splintered wood on the entrance door and the loose commode base was a safety concern for the residents residing in the room. During an interview on 7/12/2023 at 11:30 AM, revealed Housekeeper #2 stated she was assigned to the clean the rooms on the Capitol Hill Hall. She confirmed she began cleaning on the back of the hall (pointing towards the end of the hallway, room [ROOM NUMBER]) and she was finished with all but the one she currently was cleaning, room [ROOM NUMBER]. Observation and interview in room [ROOM NUMBER] on 7/12/2023 at 11:45 AM, revealed the Administrator observed the room and confirmed there was scattered debris on the floor including under both beds. Observation and interview in room [ROOM NUMBER] on 7/12/2023 at 11:47 AM, revealed the Administrator observed the room and confirmed there was trash/debris scattered on the floor, a call light on the floor under B bed and a small trash can with broken and large jagged edges in the corner beside B bed. Continued observation revealed the Administrator confirmed there was a bunch of hair in the bathroom floor and dried brown debris around the base of the toilet. Observation and interview in room [ROOM NUMBER] on 7/12/2023 at 11:50 AM, revealed the Administrator observed the room and confirmed there was a call light under B bed on the floor, gloves and trash behind a small trash can, and debris scattered under both beds and around the floor. Continued observation revealed the Administrator confirmed A bed had food from the breakfast meal scattered over the top cover of the bed and overbed table. Observation and interview in room [ROOM NUMBER] on 7/12/2023 at 11:55 AM, revealed the Administrator observed the room and confirmed there was debris scattered around the room including under both beds and brown debris around the base of the toilet in the bathroom. Observation and interview in room [ROOM NUMBER] on 7/12/2023 at 12:00 PM, revealed the Administrator observed the floor in the bathroom and confirmed brown/black debris around the toilet base and in multiple places around the bathroom floor. The Administrator confirmed there was a strong urine odor present in the bathroom. Continued observation revealed the Administrator observed the room entrance door and confirmed the putty placed in the holes below the doorknob had dried leaving a rough sharp edge present that could cause potential skin injury to a resident.

Based on facility policy review, facility document review, medical record review, and interview, the facility failed to conduct quarterly care conferences for 15 of 28 (Resident #9, #15, #17, #18, #22, #27, #31, #53, #65, #66, #72, #81, #93, #95 and #111) sample residents reviewed. The findings include: Review of the facility policy titled, Care Plans Comprehensive dated 5/18/2023 revealed, .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 .developed within 7 days of the completion of the Minimum Data Set (MDS) assessment .The resident is informed of his or her right to participate in his or her treatment, and provide advance notice of care planning conferences . Review of medical records revealed Resident #9 was admitted to the facility of 5/14/2023 with diagnoses which included Urinary Tract Infection(UTI), Hemiplegia and Hemiparesis following Cerebral Infarction Affecting and Type 2 Diabetes Mellitus Without Complications. Review of the Comprehensive MDS dated [DATE] revealed Resident #9 had a Brief Interview for Mental Status (BIMS) of 3 which indicated a severe Cognitive Impairment. Review of the Performance Improvement Plan (PIP) revealed Resident #9 had no quarterly care conference meeting. Review of medical records revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Encounter for Surgical Aftercare Following Surgery on the Digestive System, Fibromyalgia, Type 2 Diabetes Mellitus Without Complications, and Morbid (Severe) Obesity Due to Excess Calories. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #15 had a BIMS score of 15 which indicates no Cognitive Impairment. Review of the PIP revealed Resident #15 had no quarterly care conference. Review of medical records revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Congestive Heart Failure, Noninfective Gastroenteritis and Colitis, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Quarterly MDS assessment dated [DATE] revealed Resident #17 had a BIMS score of 13 which indicated no Cognitive Impairment. Review of the PIP revealed Resident #17 had the last care plan conference on 9/25/2022. Review of medical records revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Acute Embolism and Thrombosis of Right Femoral Vein and Schizoaffective Disorder, Bipolar Type. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #18 had a BIMS Score of 99 which indicated the resident was unable to complete the interview. Review of the PIP revealed Resident #18 had the last care conference on 1/17/2023. Review of medical records revealed Resident #22 was admitted to the facility on [DATE] with diagnoses which included Generalized Osteoarthritis, Chronic Kidney Disease Stage 3 and Obstructive and Reflux Uropathy. Review of the Quarterly MDS assessment dated [DATE] for Resident #22 revealed a BIMS score of 00 which indicated severe Cognitive Impairment and the resident was unable to complete the interview. Review of the PIP revealed Resident #22 had the last care conference on 8/7/2022. Review of medical records revealed Resident #27 was admitted to the facility on [DATE] with diagnoses which included Other Specified Complications of Vascular Prosthetic Devices, Implants and Grafts, Dependence on Renal Dialysis, and COPD. Review of the Annual MDS assessment dated [DATE] for Resident #27 revealed a BIMS score of 15 which indicated no Cognitive Impairment. Review of the PIP revealed Resident #27 had the last care conference on 8/24/2022. Review of medical records revealed Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included UTI, Hematuria, Acute Kidney Failure, and Rhabdomyolysis. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #31 had a BIMS score of 13 which indicates no Cognitive Impairment. Review of the PIP revealed Resident #31 had the last care conference on 3/2/2023. Review of medical records revealed Resident #53 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, COPD, and Chronic Respiratory Failure with Hypercapnia. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #53 had a BIMS score of 15 which indicated no Cognitive Impairment. Review of the PIP revealed Resident #53 had the last care conference on 10/23/2022. Review of medical records revealed Resident #65 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Encounter for Orthopedic Aftercare following Surgical Amputation, Peripheral Vascular Disease and Type 2 Diabetes Mellitus with Diabetic Neuropathy. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #65 had a BIMS score of 13 which indicated no Cognitive Impairment. Review of the PIP revealed Resident #65 had the last Care Conference on 8/7/2022. Review of medical records revealed Resident #66 was admitted to the facility on [DATE] with diagnoses which included Epilepsy with Status Epilepticus, Nontraumatic Intracerebral Hemorrhage in Hemisphere, and Type 2 Diabetes Mellitus without complications. Review of the Quarterly MDS assessment dated [DATE] for Resident #66 revealed a BIMS score of 15 which indicated no Cognitive Impairment. Review of the PIP revealed Resident #66 had the last care conference on 9/15/2022. Review of medical records revealed Resident #72 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Epilepsy, and Type 2 Diabetes Mellitus. Review of the Annual MDS assessment dated [DATE] for Resident #72 revealed a BIMS score of 99 which indicated severe Cognitive Impairment and the resident was unable to complete the interview. Review of the PIP revealed Resident #72 had the last care conference on 10/23/2022. Review of medical records revealed Resident #81 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Intervertebral Disc Stenosis Canal of Lumbar Region, COPD, and Hypothyroidism. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #81 had a BIMS score of 13 which indicated no Cognitive Impairment. Review of the PIP revealed Resident #81 had the last care conference on 12/16/2022. Review of medical records revealed Resident #93 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Morbid (Severe) Obesity due to Excess Calories, Other Speech and Language Deficits following Cerebral Infarction, and Dysphagia following other Cerebrovascular Disease. Review of the Quarterly MDS assessment dated [DATE] for Resident #93 revealed a BIMS score of 9 which indicated moderate Cognitive Impairment. Review of the PIP revealed Resident #93 had the last care conference on 10/23/2022. Review of medical records revealed Resident #95 was admitted to the facility on [DATE] with diagnoses which included Covid-19, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Dominant Side, and Type 2 Diabetes Mellitus without Complications. Review of the Quarterly MDS assessment dated [DATE] for Resident #95 revealed a BIMS score of 11 which indicated moderate Cognitive Impairment. Review of the PIP revealed Resident #95 had the last care conference on 6/9/2022 Review of medical records for Resident #111 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis Following Cerebral Infarction affecting Right Dominant Side, Other Sequelae of Cerebral Infarction, and Major Depressive Disorder Single Episode Mild. Review of the Quarterly MDS dated [DATE] revealed Resident #111 had a BIMS score of 99 which indicated severe Cognitive Impairment and the resident was unable to complete the interview. Review of the PIP revealed Resident #111 had a care conference on 9/12/2022 and then follow up conference was not done until 7/5/2023. During an interview with the Administrator on 7/11/2023 at 1:30 PM, the Administrator confirmed the facility had failed to schedule and conduct quarterly care conferences for the residents. She stated she discovered the lack of quarterly conferences in May of 2023 during a discussion with Social Services.

Based on facility policy review, record review and interviews the facility failed to ensure 100% of staff were up to date on Covid-19 vaccinations. Based on Centers for Medicare and Medicaid (CMS) guidelines, policy review, and interview, the facility failed to perform documentation and tracking of staff vaccinations for COVID-19 (an infectious disease caused by [CONDITION(S)]-CoV-2 virus) according to current guidance to prevent the spread of COVID-19. The findings include: Review of the facility's policy titled, Staff Covid 19 Vaccine Policy for States TN [Tennessee] and FL [Florida], dated 1/25/2022, revealed, To establish the process to comply with the Federal mandate that all staff are vaccinated against COVID-19 unless they have a medical or religious exemption to help reduce the risk residents and staff have of contracting and spreading COVID-19 .Fully Vaccinated is defined as being 2 weeks or more since completion of a primary vaccination series for COVID-19. A primary vaccination series is defined as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine .Staff refers to any individuals that work or volunteer in the Facility, regardless of clinical responsibility or resident contact .COVID-19 vaccine will be ordered from either our LTC [Long Term Care] pharmacy or local or state public health agency or arrangements will be made with a vaccine provider .staff can receive the vaccine at any community location offering the vaccine .All staff will be educat19 vaccine, or have pending request for, or have been granted qualifying exemption, or identified as having a temporary delay .By February 28, 2022, 100% of staff have received the necessary doses to complete the vaccine series .education on the COVID-19 vaccine they are offered . Review of the CDC [Centers for Medicare and Medicaid Services] memorandum QSO-22-09-ALL revealed, .Within 60 days after the issuance of this memorandum, if the facility demonstrates that: Policies and procedures are developed and implemented for ensuring all facility staff, regardless of clinical responsibility or patient or resident contact are vaccinated for COVID-19; and 100% of staff have received the necessary doses to complete the vaccine series (i.e., one dose of a single-dose vaccine or all doses of a multiple-dose vaccine series), or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is compliant under the rule; or Less than 100% of all staff have received at least one dose of a single-dose vaccine, or all doses of a multiple-dose vaccine series, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is non-compliant under the rule . Review of the National Healthcare Safety Network [NHSN] for the week ending 3/6/2022, revealed the facility reported the recent percentage of staff who are fully vaccinated at 100%. Review of the tracking documentation for staff Covid-19 vaccinations revealed, staff vaccinations had been documented in two different locations. Vaccinations had been recorded by two different Infection Control Preventionist [ICP] and was not consistent. Documentation of 2 of 16 staff members reviewed was not reported correctly to NHSN. Review of the COVID-19 Staff Vaccination Status for Providers matrix prepared by the Infection Control Preventionist [ICP] on 2/14/2022, revealed 6 employees had religious exemptions to the COVID-19 vaccine, 2 staff members were partially vaccinated and 151 staff members were up to date with the vaccinations. Review of the Covid-19 Vaccination Record Card for Certified Nursing Assistant [CNA] #1 revealed she received the first dose of Moderna vaccine on 10/20/2021 at the facility. Review of the facility document Patient Vaccination dated1/26/2022, revealed CNA #5 received her first dose of the Covid-19 vaccine on 1/19/2022. Further review revealed the second dose of vaccine was due on 2/9/2022. During an interview on 3/14/2022 at 3:05 PM, Certified Nursing Assistant [CNA] #1 stated, she had received on shot of Moderna vaccine in October 2021. She stated she did not receive a second dose of the vaccine. During an interview on 3/14/2022 at 5:00 PM, the ICP confirmed there were two staff members that were not up to date with the Covid-19 vaccination. The two employees, CNA #1 and CNA #5, had received only one of the two Moderna vaccinations. During continued interview the ICP confirmed the tracking of staff Covid-19 vaccinations was inconsistent and placed in two different areas of documentation. She confirmed the information reported to NHSN was incorrect due to inconsistent tracking methods.

Based on policy review, medical record review, and interview, the facility failed to notify the physician of Resident #1's change of condition. This affected 1 resident (Resident #1) of 3 residents reviewed for change of condition/hospitalization . The facility census was 125. Findings include: Review of the undated facility policy titled, Change in a Resident's Condition or Status, dated May 2017, revealed .The nurse will notify the resident's attending physician or physician on call when there has been .significant change in the resident's physical/emotional/mental condition .specific instruction to notify the physician of changes in the resident's condition .a significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting) .the nurse will record in the resident's medical record information relative to changes in the residents medical/mental condition or status . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #1 scored 11 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. No [CONDITION(S)], behaviors, or wandering noted. Limited, one-person physical assistance was required for bed mobility, transfers, and toileting. Review of the Care Plan, dated 3/4/2021, revealed the resident has impaired thought process related as evidenced by short-term and long-term memory loss, impaired decision-making skills with interventions including to administer medications as ordered, to identify yourself at each interaction, engage the resident in simple, structured activities, to observe for and assess as indicated/document/report to physician any changes in cognitive function, specifically changes in decision making ability, understanding others, level of consciousness, and mental status. Review of Resident #1's Tennessee Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Section A: Patient has no pulse and is not breathing: Do Not Attempt Resuscitation (DNR). When not in cardiopulmonary arrest, follow orders B, C, and D .Section B: Comfort Measures, relieve pain and suffering through the use of medication by any route, positioning, wound care and other measures. Use oxygen, suction, and manual treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Transfer only if comfort needs cannot be met in current location. treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] .Section D: Discussed with patient and patient preferences . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nursing Progress Note, dated 4/19/2021 at 3:11 AM, revealed .Resident has been asleep most of this shift. Resident took her medications crushed in applesauce with thin liquids .usually takes her medications whole .nonverbal .opens eyes .lethargic .no signs or symptoms of pain .blood pressure 162/122 .respirations 23 .oxygen saturation 93% room air .pulse 98 .temperature 98.0 .will have nurse practitioner (NP) to see resident in the AM. Discussed with resident's granddaughter tonight on the phone. Granddaughter to call back in the morning . Review of Nursing Progress Note, dated 4/19/2021 at 8:35 AM, revealed .resident sent to emergency room via 911 stretcher per family request related to altered mental status (AMS) .unresponsive except she followed me with her eyes weakly and declining condition, pulse 108, oxygen saturation 89% on room air (placed on 2 liters/minute of oxygen prior to pick-up), respiratory rate 24 labored, blood glucose 150, temperature 99.8, diaphoretic, unable to assess blood pressure before pick-up. Family, Nurse Practitioner (NP), Director of Nursing (DON), unit manager notified . During interview conducted on 6/15/2021 at 3:30 PM, the DON and Corporate DON #2, confirmed the nursing staff did not notify the on-call physician of Resident #1's lethargy, non-verbal status, and blood pressure of 162/122. Corporate DON #2 stated the resident had a DNR order and would not have wanted to be transferred to the hospital.

Amended 2/18/2021 This is an amended Statement of Deficiencies. Based on facility policy review, medical record review and interview, the facility failed to prevent a significant medication error for 1 of 4 residents (Resident #1) reviewed for medication administration. Actual Harm was identified related to the facility's failure to administer the correct prescribed medications when Resident #1 received previously discontinued medications causing the resident to become unresponsive. The findings include: Review of the facility policy titled, Discontinued Medications, dated April 2007, showed .Staff shall destroy discontinued medications or shall return them to the dispensing pharmacy in accordance with facility policy . Review of the facility policy titled, Administering Medications, dated December 2012, showed .Medications must be administered in a safe and timely manner, and as prescribed .Medications must be administered in accordance with the orders .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 . Review of the facility's documentation, Medication Occurrence Report, dated 6/27/2020, showed Resident #1 received .Wrong Drug .[MEDICATION(S)] [a medication to treat high blood pressure] 7.5 mg [milligram] po [by mouth] and [MEDICATION(S)] [a medication to treat Dementia] 10 mg po . Review of the medical record showed , Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessments dated 4/3/2020, 7/3/2020 and 1/13/2021, showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident had severe cognitive impairment. Review of Resident #1's Physician's Order Summary Report dated 12/1/2019 through 1/31/2021, showed .[MEDICATION(S)] 5 mg (Amlodipine Besylate) Give 5 mg one time a day .original date 12/6/2019 .discontinued date 12/12/2019 .[MEDICATION(S)] Tablet 2.5 MG (amlodipine besylate) Give 2.5 mg by mouth one time a day for [high blood pressure] .original date 12/12/2019 .discontinued date 4/2/2020 .[MEDICATION(S)] Tablet 5 MG (Donepezil HCL [hydrochloride] Give 5 mg by mouth at bedtime .original date 4/16/2019 .discontinued 6/5/2019 . Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review confirmed, resident #1 had not been prescribed the medication [MEDICATION(S)] or [MEDICATION(S)] during the month of 6/2020 when the medication error occured. Review of Resident #1's Nursing Progress Note dated 6/27/2020, showed .Charge nurse on this residents hallway went to lunch at approx. [approximately] 1:00 PM. This nurse held the med [medication] cart keys for Charge Nurse. At approx. 1:25 PM CNA [Certified Nurse Aide] paged a nurse STAT [immediately] to room [ROOM NUMBER] [Resident #1's room]. Upon entering room, resident was noted lethargic and unresponsive to verbal and tactile stimuli and sternal rubs. Vital signs unstable with BP [Blood Pressure]-54/33 P [Pulse]-64 T [Temperature]-97 O2% [saturation]-85 RR [Respiratory Rate]-12. Resident was sitting in w/c [wheelchair] at this time. This nurse applied 02 [Oxygen] at 2 LPM [Liters per minute] via NC [Nasal Cannula]. Resident transferred from w/c to bed and b/l [bilateral] feet placed above heart level. Vital signs at 1:30 PM BP-104/70 P-77 O2-98 T-97.3 RR 16. CNA remained at bedside. Charge nurse of unit returned and stated she made a med [medication] error. Nurse informed me that she administered [MEDICATION(S)] 10 mg and [MEDICATION(S)] 7.5 mg in AM [morning] med pass. This nurse notified MD [Medical Doctor] of change in status. MD ordered O2 and 2 L/min [liters per minute] via NC PRN [as needed] to keep O2 sats [saturation] above 92%, Monitor BP Q [every] 1 hour x [times] 6 hours and notify MD if systolic blood pressure < [less than] 100. Start PIV [Peripheral Intravenous] of 0.9% NS [Normal Saline] at 250 ml [milliliters] x 4 hours to equal a 1 L [liter] fluid bolus . During a telephone interview on 1/28/2021 at 8:26 AM, the complainant stated she received a call on 6/27/2020 from a nurse at the facility and was informed Resident #1 was given the medications [MEDICATION(S)] and [MEDICATION(S)] in error. During further interview she stated the resident had to be given IV (Intravenous) fluids after he received the discontinued medications. During an interview on 1/28/2021 at 12:05 PM the Director of Nursing (DON) stated Licensed Practical Nurse (LPN) #1 notified her on 6/27/2020 [LPN #5] gave Resident #1 the wrong medications. During further interview she confirmed the medications Resident #1 had received were discontinued and should not have been on the medication cart. During further interview she stated she expected any nurse who received an order to discontinue a medication to remove the medication from the medication cart and place it in the medication room to return to the pharmacy. During an interview on 1/28/2021 at 12:18 PM LPN #1, also the Unit Manager, stated she worked on 6/27/2020 when LPN #5 administered the discontinued medications to Resident #1. She stated CNA #1 reported to her that Resident #1 didn't seem right. During further interview she stated she assessed the resident and he was unresponsive. During further interview she stated she performed a sternal rub on the resident with no response then she stated she applied Oxygen and elevated his feet. She also stated when LPN #5 entered the resident's room, LPN #5 stated she had made a medication error and had given Resident #1 [MEDICATION(S)] and [MEDICATION(S)]. LPN #1 stated she notified the doctor of the medication error and received new orders to continue Oxygen, monitor blood pressure every hour for 6 hours, and administer a bolus of intravenous fluids. During further interview she stated she notified the DON and the resident's Family Member of the medication error. During a telephone interview on 2/1/2021 at 10:08 AM, the Pharmacist stated discontinued medications should be removed from the cart the same day they are discontinued and placed in a bag for the pharmacy to pick up. During a telephone interview on 2/1/2021 at 10:18 AM, the Medical Director stated he expected the nurses to check the orders before they administered medications to the residents and for discontinued medications to be removed from the cart and not given to the residents.

Based on facility policy review, observations, and interviews the facility failed to enforce hand hygiene practices of staff in direct patient care areas on 1 (green) of 5 hallways and failed to provide a safe/sanitary environment on the 1 (red zone) of 5 hallways extending to the outside of the building and in 20 of 48 resident rooms. The findings include: Review of facility policy Coronavirus (COVID - 19), dated 2/27/2020, revealed .The facility follows current guidelines and recommendations for the prevention and control of the Coronavirus (COVID - 19) as directed by CDC (Centers for Disease Control) and local regulatory agencies .the facility educates residents/representatives and staff on the prevention and control of any spread of infection as per those guidelines and recommendations as well as maintains close communication and collaboration with local and state health authorities. Standard precautions are practiced at all times .indirect contact transmission via hand transfer of the Coronavirus [MEDICAL CONDITION]-contaminated surfaces or objects to mucosal surfaces of the face may also occur .supplies to be used in the prevention and control of the Coronavirus COVID - 19 will be made available .supplies to perform hand hygiene will be available to all residents/visitors in common areas and in resident rooms .gloves, gowns and hand sanitizer will be available to all residents/visitors in common areas and in resident rooms .management of laundry, food service utensils and medical waste will also be performed in accordance with standard procedures . Review of facility policy, Infection Prevention and Control Program, revised August 2016, revealed .The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program .policies and procedures are utilized as the standards of the infection prevention and control program .prevention of infection include: educating staff and ensuring that they adhere to proper techniques and procedures .following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC) .improving compliance with hand hygiene . Review of facility documentation My Clean Hands Count for My Patients; undated, revealed .your patients count on you to clean your hands. Many potentially deadly germs spread from patient to patient on the hands of healthcare providers. Consider whether your actions put you or your patients at risk of infection . Observation on 6/22/2020 at 8:45 AM of the yellow zone, (observed for COVID-19 symptoms) no hand sanitizer stations were observed in the hallways or on the walls. There were hand sanitizers on the wall in the patient's rooms. Observation on 6/22/2020 at 10:05 AM of the green zone (negative symptom free) showed staff members entering and exiting the green zone and using a back coded door to exit near a dumpster. No hand sanitizer stations were observed in the hallways or on the walls. Observation on 6/22/2020 at 10:18 AM showed a house keeper taking out trash through the back coded door. She exited and put the trash in the dumpster and came back through the back door without sanitizing or washing her hands. During continued observation she returned to her cleaning cart and proceeded to clean a room. Observation on 6/22/2020 at 10:20 AM showed Rehabilitation Assistant/Central Office Supply employee take box of supplies out the back coded door and returned through the same door without using hand sanitizer or washing her hands. Observation on 6/22/2020 at 5:00 PM of the red zone (COVID-19 unit) showed approximately 20 of 48 rooms on the red hallways which were cluttered with clothes on hangers lying in chairs, drawers on floor or stacked up in a chair, and bags of Resident's belonging lying in the floor. Continued observation showed 2 cardboard boxes in the hallway being used for trash. One box had a trash bag in it and the other box did not. Both boxes had trash in them and were not covered. Observation on 6/22/2020 at 5:30 PM showed a trash barrel and a biohazard barrel on the outside of the building of the COVID unit were overfilled and 1 pair of used gloves were lying beside the trash container on the ground, 1-3 purple gloves were scattered in the grass, a dust pan with a handle containing trash, and a push broom was also observed in the grass area just outside the COVID unit, loose paper scattered about in the grass from the building to the street. During an interview on 6/22/2020 at 10:00 AM the DON stated she does not allow employees to carry hand sanitizer in their pockets as it could cause cross contamination. During continued interview she stated she relies on her unit managers to enforce infection control practices on all hallways in order to prevent cross contamination and prevent further COVID-19 outbreaks. During an interview on 6/22/2020 at 10:20 AM with Rehabilitation Assistant/Central Office Supply employee #1 she stated she took supplies to the red unit and delivered to a designated area and uses hand sanitizer she carries in her pocket. During an observation and interview on 6/22/2020 at 5:10 PM with the LPN #1, Unit Manager on the COVID unit, confirmed trash in boxes in the hallway on the red unit was unacceptable. During continued observation and interview with the unit manager, he confirmed gloves were to be discarded in the biohazard trash container and should not be found on the ground near the container and that the biohazard containers should not be overfilled. During an interview on 6/22/2020 at 7:05 PM with the DON, she confirmed she would expect employees to wash their hands or use hand sanitizer on all hallways and would expect the housekeeping staff to wash their hands or use hand sanitizer after taking trash outside to the dumpster before returning to the cleaning cart. During continued interview she confirmed that gloves should be discarded in the biohazard trash containers outside of the COVID unit and should not be found on the ground.

Based on facility policy review, medical record review, observation and interview, the facility failed to maintain clean fingernails for 1 resident (#97) of 26. The findings include: Review of facility policy, Care of Fingernails/Toenails, dated 2001, revised (MONTH) 2010, revealed .nail care cleaning during bath/shower and as needed (prn) and trimming as indicated . Medical record review revealed Resident #97 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 8, indicating moderate cognitive impairment, required extensive assistance for Activities of Daily Living with one person and limited assistance for personal hygiene. Medical record review of the Care Plan dated 4/15/19, Bathing Intervention dated 1/21/19, revealed .Activities of Daily Living Self Care Performance Deficit .Bathing: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . Observation of Resident #97 on 4/29/19 at 10:40 AM, 2:00 PM, 4/30/19 at 1:00 PM and 5/1/19 at 12:30 PM revealed Resident #97 with all fingernails having large amounts of dark brown debris underneath them. Interview with Certified Nurse Aide (CNA) #6 on 5/1/19 at 3:00 PM in the Capital Hill hallway confirmed personal hygiene care had been completed. Further interview with CNA #6 in the presence of Resident #97 in the Activity room confirmed dark debris under each nail. Interview with Licensed Practical Nurse #4 on 5/1/19 at 3:03 PM in Resident #97's room confirmed dark debris under each fingernail.

Based on facility policy, observation and interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections related to wash basins sitting on the bathroom floor unbagged for 6 of 24 residents (Resident # 37, Resident #46, Resident #79, Resident #112, Resident #117, and Resident #420) reviewed on Ingle Brook Way. Findings include: Review of facility policy, Infection Control-General Policies and Procedures dated 10/20/16, revealed .Develop prevention, surveillance, and control measures to protect residents and personnel from healthcare-associated infection . Medical record review revealed Resident #37 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 5/14/18 at 9:42 AM and at 2:44 PM in Resident #37's bathroom revealed wash basin sitting on the bathroom floor unbagged. Medical record review revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 5/14/18 at 10:00 AM and at 2:50 PM in Resident #46's bathroom revealed wash basin sitting on the bathroom floor unbagged. Medical record review revealed Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 5/14/18 at 9:45 AM and at 2:47 PM in Resident #79's bathroom revealed wash basin sitting on the bathroom floor unbagged. Medical record review revealed Resident #112 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 5/14/18 at 9:23 AM and at 2:40 PM in Resident #112's bathroom revealed wash basin sitting on the bathroom floor unbagged. Medical Record review revealed Resident #117 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 5/14/18 at 9:30 AM and at 2:37 PM in Resident #117's bathroom revealed wash basin sitting on the bathroom floor unbagged. Medical Record Review revealed Resident #420 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 5/14/18 at 9:06 AM and at 2:34 PM in Resident #420's bathroom revealed wash basin sitting on the bathroom floor unbagged. Interview with Certified Nursing Assistant (CNA) #2 on 5/14/18 at 2:55 PM in Resident #37's room revealed wash basins should be bagged in the bathroom placed between handrail and wall. Interview with Licensed Practical Nurse (LPN) #1 on 5/14/18 at 2:59 PM confirmed wash basins should be bagged and stored in residents bathroom not on the floor. Further interview with LPN confirmed the facility failed to maintain a sanitary environment.

Based on facility policy review, medical record review, observation and interview the facility failed to store 3 medications in a locked compartment for 1 resident (Resident #74) of 24 residents reviewed on the Inglebrook Way hall and failed to date 2 of 4 multi-dose vials of medication after being opened in one of three refrigerators. Findings include: Review of facility policy Storage and Expiration of Medications, Biologicals, Syringes and Needles with a revision date of 10/31/16 revealed .Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors .Once any medication or biological package is opened .facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened . Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 5/14/18 at 10:00 AM in Resident #74's room revealed one bottle of [MEDICATION NAME] HCL ([MEDICATION NAME] with sedative properties) 25 mg, one bottle [MEDICATION NAME] (nasal spray) 50mcg and a [MEDICATION NAME] Inhaler (breathing medication) in an open drawer of the bedside table. Observation and interview with Licensed Practical Nurse (LPN) #1 on 5/14/18 at 10:20 AM in Resident #74's room revealed an open drawer on the bedside table with one bottle of [MEDICATION NAME] HCL labeled for Resident #74 containing 50 tablets, one bottle of [MEDICATION NAME] nasal spray and one [MEDICATION NAME] inhaler. Continued interview with LPN #1 revealed It shouldn't be there and confirmed the resident had not been assessed to self administer medications. Continued interview with LPN #1 confirmed the facility failed to keep the 3 medications in a locked medication cart. Observation on 5/15/18 at 10:45 AM in the Ingle Brook Way medication room refrigerator revealed two multi-dose vials of [MEDICATION NAME] (Purified Protein Derivative for [MEDICATION NAME] testing) opened and undated. Interview with LPN #1 on 5/15/18 at 10:45 AM in the Ingle Brook Way medication room confirmed the two multi-dose vials of [MEDICATION NAME] should have been dated when opened. Interview with the Director of Nursing (DON) on 5/15/18 at 12:05 PM in her office confirmed multi-dose vials of medications should have been dated when opened. Further interview with DON confirmed the facility failed to date multi-dose vials when opened.

Based on observation and interview, the facility failed to provide nail care for 1 of 40 sampled residents (Resident #26) reviewed. Findings include: Medical record review revealed Resident #26 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #26 had a Brief Interview for Mental Status score of 5, indicating severe cognitive impairment. Continued review revealed the resident required extensive assistance of 2 persons for personal hygiene and required total dependence for bathing. Medical record review of the Discharge Assessment-Return Anticipated MDS dated [DATE] revealed Resident #26 had short term memory problem and was severely impaired cognitively. Continued review revealed the resident required total dependence for personal hygiene and bathing. Medical record review of the care plan dated 12/13/17 revealed Resident #26 required assistance with Activities of Daily Living due to both cognitive and physical deficits. Further review revealed the resident would receive a shower twice weekly and sponge bath alternate days. Medical record review of Physician order [REDACTED].#26 was placed on contact isolation related to [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA), a type of bacterial infection. Observation of Resident #26 on 5/14/18 at 12:06 PM, 5/14/18 at 10:00 AM, 5/14/18 at 4:30 PM and 5/15/18 at 8:10 AM revealed the resident's finger nails had blackened debri under them. Interview with Certified Nurse Aide (CNA) #4 on 5/15/18 at 3:10 PM at the Belle Meade nursing station revealed Resident #26 was scheduled to receive a bed bath on Tuesday and Saturday. CNA #4 stated she gave Resident #26 a bed bath today before lunch. Interview and observation with the Director of Nursing (DON) on 5/15/18 at 3:20 PM in Resident #26's room revealed blackened debri under the resident's the finger nails. The DON stated it means her hands weren't soaked. The DON confirmed the facility failed to provide nail care for Resident #26.

Based on medical record review and interview the facility failed to ensure a Significant Change Minimum Data Set (MDS) was assessed for 1 of 4 sampled residents (Resident #46) reviewed for hospice and failed to accurately assess a Quarterly MDS for 1 of 8 sampled residents (Resident #83) reviewed. Findings include: Medical record review revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Hospice services for Resident #46 were discontinued on 12/22/17. Further medical record review revealed no Minimum Data Set Assessment was completed for discontinued services of Hospice on 12/22/17. Interview with Licensed Practical Nurse (LPN) #6 on 5/16/18 at 10:35 AM in the MDS office confirmed significant change MDS Assessment for Resident #46 should have been completed when Hospice services were discontinued. Further interview revealed LPN #6 stated, I missed her significant change MDS when she came off Hospice in (MONTH) (YEAR). Further interview with LPN #6 confirmed the facility failed to complete a Significant Change MDS for Resident #46.

Based on review of facility policy, observation, and interview, the facility failed to maintian an environment free from accident hazards for 1 of 5 handrails in the corridor between the first and second floors and used by the majority of the residents in the facility. The findings included: Review of facility policy, TELS (computerized equipment maintenance audit process) revealed . At least once a week, or more often as required, check work orders to ensure deficiencies are being identified and addressed .On a weekly basis the Administrator should sit down with the Maintenance Director to review upcoming maintenance and life safety task for the week, month, and Quarter . Observation on 10/30/17 at 10:10 AM in the corridor between the first and second floors revealed the handrail leading up the inside corridor just past the exit door on the right, under the fire pull, had a chip in the wood with an exposed nailhead protruding from the damaged rail. Interview with Licensed Pratical Nurse #2 at the Belle Meade nurses station on 10/30/17 at 10:25 AM revealed .Residents do use the walkway, but most of our residents are assisted by the staff when they go up and down the walkway. Interview with the Maintenance Director on 10/30/17 at 3:12 PM in the corridor confirmed the handrail was chipped and a nail was protruding out of the damaged rail. Continued interview confirmed the facility failed to maintain an environment free from accident hazards for 1 of 5 handrails in the corridor between the first and second floors.

Based on review of facility policy, observation, and interview, the facility failed to ensure the facility corridors were equipped with firmly secured handrails for one of five handrails in the corridor between the first and second facility levels and used by the majority of the resident in the facility. The findings included: Review of the facility policy TELS (computerized equipment maintenance audit process) revealed .At least once a week, or more often as required, check work orders to ensure deficiencies are being identified and addressed .On a weekly basis the Administrator should sit down with the Maintenance Director to review upcoming maintenance and life safety task for the week, month, and Quarter . Observation on 10/29/17 at 3:20 PM in the corridor between the first and second floors of the facility revealed the handrail coming down the inside walkway from the second floor, last section of the handrail on the right was loose and moved when touched. Further observation on 10/30/17 at 10:10 AM revealed the handrail section remained loose. Interview with Licensed Practical Nurse #2 at the Belle Meade nurse station on 10/30/17 at 10:25 AM revealed Residents do use the walkway (corridor). Most of our residents are assisted by the staff when they go up or down the walkway. Interview with the Maintenance Director on 10/30/17 at 3:12 PM in the corridor confirmed the last section of the handrail along the right lower portion of the corridor coming from the second level down to the first level was loose. Interview with the Maintenance Director confirmed the facility failed to ensure the facility corridors are equipped with firmly secured handrails.

Based on review of facility policy, observation, and interview, the facility failed to provide a safe, functioning, and sanitary environment for 6 of 12 rooms on the Capital Hill floor. The findings included; Review of the facility policy TELS (computerized equipment maintenance audit process) revealed .At least once a week, or more often as required, check work orders to ensure deficiencies are being identified and addressed .On a weekly basis the Administrator should sit down with the Maintenance Director to review upcoming maintenance and life safety task for the week, month, and Quarter . Observation on 10/29/17 at 3:00 PM in the bathroom of room 116 revealed the commode was loose on the floor and moved on the floor when touched. Further observation at 3:03 PM in the bathroom of room 118 revealed the commode was loose on the floor and moved when touched. Observation on 10/30/17 at 08:11 AM in the bathroom of room 101 revealed the sink leaked and a bucket was underneath the sink and was half full of dirty, grey water with a soured smell. Further observation at 8:15 AM in the bathroom of room 112 revealed a bucket half full of dirty, grey water sitting under the sink. When the faucet was turned on water poured from the bottom of the sink pipes into the bucket. The bathroom in room 112 also smelled soured. Observation on 10/30/17 at 8:24 AM in the bathroom of room 103 revealed the faucet was leaking with the water continuously running and a yellow brown stain was observed on the sink basin. Continued observation in the bathroom of room 124 at 8:40 AM revealed the faucet had water dripping continously. Interview with Registered Nurse #1 on 10/30/17 at 9:14 AM at the Capitol Hill nurses station revealed .The Resident in room 116 does use the commode in her room with assist of a staff member . Observation and interview with the Maintenance Director on 10/30/17 beginning at 3:12 PM in rooms 101, 103, 112, 116, 118, and 124, confirmed the two sinks and two faucets were leaking. The buckets contained soured water and the two commodes were loose. Continued interivew revealed the Maintenance Director stated This is unacceptable. Interview with the Maintenance Director confirmed the facility failed to provide a safe, functioning, and sanitary environment for 6 of 12 rooms on the Capitol Hill floor.

Based on observation and interview, the facility failed to ensure posted staffing was updated daily for 4 of 7 days. The findings included: Observation on 10/29/17 at 2:41 PM at the front desk in the lobby revealed the Daily Staffing Form was posted and dated 10/25/17. Interview with Licensed Practical Nurse #1 on 10/29/17 at 2:45 PM at the front desk in the lobby confirmed the posted Daily Staffing Form was dated 10/25/17. Continued interview revealed the facility had failed to update the posting for 4 days.

Based on medical record review, observation, and interview, the facility failed to ensure residents were free of significant medication errors for 1 resident (#1) of 7 residents observed during medication pass. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Observation on 10/31/17 at 7:31 AM at the Capitol(NAME)medication cart (#2) revealed Registered Nurse #1 (RN) was preparing medications for Resident #1. Continued observation revealed Resident #1 had 11 medications ordered, one of which was [MEDICATION NAME]. Further observation revealed RN #1 administered the medications which included 1 tablet of [MEDICATION NAME] 25 mg. Interview with RN #1 on 10/31/17 at 7:36 AM at the Capitol(NAME)medication cart (#2) revealed the surveyor asked RN #1 to review the [MEDICATION NAME] order. RN #1 reviewed the order and stated should have been 2 tablets. Interview with the Director of Nursing (DON) on 10/31/17 at 9:13 AM in the Conference Room, after reviewing Resident #1's medications and diagnoses, the DON confirmed the [MEDICATION NAME] was for [MEDICAL CONDITION]. Continued interview with the DON confirmed the medication error by RN #1 would be considered a signification medication error. Interview with the DON confirmed the facility failed to ensure all residents were free of significant medication errors.

Based on review of facility policy, medical record review, and interview, the facility failed to honor the resident's preference for showers for 1 resident (#97) of 28 residents reviewed. The findings included: Review of facility policy, Resident Rights, revealed .It is our belief that you as a resident have the right to expect certain standards of care and considerations while at our facility .Considerate and respectful care, including consideration and respectful care, including consideration of psychosocial, spiritual, cultural, and safety needs . Medical record review revealed Resident #97 was readmitted on [DATE] with the current diagnosis, Personal History of Diseases of the Musculoskeletal system and Connective Tissue, other Sequelae of [MEDICAL CONDITION] Disease, Contracture, Unspecified Knee, Contracture of Left Wrist, Dysthymic Disorder, Unspecified Convulsions, Other Muscle Spasm, Pain, Unspecified. Medical record review of the Capital Hill shower book at the nurses station revealed Resident #97 was scheduled to receive a shower 2 times each week on Tuesday and Thursday in the evenings. Medical record review of the Nurses Notes dated 10/16/17-10/29/17 .revealed no documentation of residents refusing showers or baths . Medical record review of the Activities of Daily Living Care Plan revealed Resident #97 was to receive a shower 2 times a week on Tuesday and Thursday and PRN (as needed) on day shift. Interview with Resident #97 on 10/30/2017 at 8:30 AM in residents room revealed .I am supposed to get a shower twice a week in the evening, but that doesn't happen. I only received one shower the week before last. I would prefer a daily shower or at the least three showers each week and I have asked for this. Interview with the CNA #1 (Certified Nursing Assistant) on 10/30/17 at 9:55AM at the Capitol Hill nurses station revealed Residents (are) suppose to get 2 showers a week and some Residents get 3. They (are) suppose to get bed baths all other days. Further interview revealed the CNA's document the showers and baths in the Kiosk (wall mounted computer). Interview with the Director of Nursing (DON) on 10/31/17 at 12:30 PM in the conference room confimed Resident #97 has 2 showers documented for the past 16 days and no dosumentation of refusal. Continued interview with the DON confirmed the facility failed to honor Resident #97's preferences.

Based on facility policy review, observation, and interview, the facility dietary department failed to maintain food storage equipment and food preparation equipment in a sanitary manner. The findings included: Review of undated facility policy, Dietary - Nourishment Center/Nursing Units, revealed .Nursing Department is responsible for inventory and ordering of established par level items. All nursing staff are responsible for maintaining sanitary center and fresh snacks .Nursing is responsible for the Nourishment Center. Nursing will: a) Remove any items without resident's name and date .c) Discard expired nourishments . Observation and interview on 4/24/17 at 11:45 AM in the dietary department, with the Certified Dietary Manager (CDM) present, confirmed the following: 1 of 5 packages of strawberries was molded in the walk-in refrigerator. Ice build-up was on the walk-in freezer condenser piping. Observation and interview on 4/25/17 at 9:15 AM in the dietary department, with the CDM and Registered Dietitian (RD) present, confirmed the following: Walk-in refrigerator condenser fan grates and the ceiling area above the condenser had an accumulation of blackened debris. An uncovered rack with 4 trays of 12 plates on each tray was exposed to the possible contamination in the walk-in refrigerator. The top shelf of 1 of 6 storage shelving units, near door of the walk-in refrigerator, had an accumulation of blackened debris. 9 of 19 hamburger patties were exposed in an opened plastic bag in an opened box located on a shelf in the walk-in freezer and were available for use. 8 racks and the interior surfaces of the double-stack convection oven had a heavy accumulation of blackened debris. The range top spill pan was foil lined with an accumulation of greasy brown and blackened debris under the foil. The vent hood above range top had a heavy accumulation of greasy brown debris. The food slicer was covered with plastic. The food slicer support plate had dried food debris on the left edge. Interview with the CDM on 4/25/17 at 9:30 AM in the dietary department revealed the plastic cover on a piece of equipment meant the equipment was cleaned and ready for use. Further interview confirmed the food slicer was dirty. Observation on 4/26/17 at 9:55 AM on the Bell Meade nourishment room, with the Assistant Director of Nursing (ADON) present, confirmed the refrigerator for resident use had 4 of 4 yogurt containers dated 4/21/17 and 1 of 20 cartons of milk dated 4/23/17. Interview with the ADON confirmed the yogurt and milk were expired. Observation and interview on 4/26/17 at 10:33 AM in the Capital Hill nourishment room, with Licensed Practical Nurse (LPN) #2 present, revealed the following: A plastic bag with 2 unlabeled and undated foil lined plates of food was in the resident refrigerator. An unlabeled and undated insulated container was stored in the resident refrigerator. Interview with the LPN revealed the container belonged to an employee. Further interview with the LPN confirmed employee property was not to be stored in the resident refrigerator. An unlabeled and undated Starbucks Frappuccino and a Wendy's shake were stored in the resident freezer. Interview with the Director of Nursing on 4/26/17 at 1:30 PM in the conference room confirmed the facility failed to follow the policy to maintain the resident nourishment refrigerators.

Based on facility policy, observation, and interview the facility failed to provide effective housekeeping services to maintain a clean and sanitary interior for 52 of 86 residents. The findings included: Review of facility policy, Housekeeping and Maintenance Department Responsibilities, revealed, .It is important to maintain a clean, safe, and sanitary environment for our residents. This is accomplished by rigorous daily cleaning of all horizontal surfaces in the building .and by weekly cleaning of problem areas . Observation on 4/25/17 at 2:45 PM during a walk through of each room on Capitol Hill and Hermitage halls revealed 52 of 86 resident overbed lights and wooden headboards with accumulated dust and debris. Interview with Housekeeping Assistant #1 on 4/25/2017 at 3:19 PM on Hermitage hall revealed she is assigned a certain set of rooms each day she works and cleans them. Continued interview revealed she completed a full clean of the room including the blinds and beds once a week. Observation on 4/25/2017 at 3:22 PM during a general walk through of rooms on Capitol Hill and Hermitage halls, accompanied by the Maintenance and Housekeeping Supervisor, revealed overbed lights and wooden headboards with accumulated dust and debris. Interview with the Maintenance and Housekeeping Supervisor on 4/25/2017 at 3:45 PM on the Capitol Hill hall confirmed the findings of accumulated dust and debris were not acceptable. Continued interview confirmed the facility had failed to provide effective housekeeping services to maintain a clean and sanitary interior.

Based on facility policy review, medical record review, and interview, the facility failed to provide care in accordance with the resident's Plan of Care by failing to complete blood glucose testing as outlined in the care plan for 9 residents (#2, #3, #4, #5, #6, #7, #8, #9, #10) of 9 diabetic residents reviewed; failed to administer insulin as outlined in the care plan for 7 residents (#2, #3, #5, #6, #7, #8, #9) of 7 residents receiving insulin; failed to administer cardiac and blood pressure medications as outlined in the care plan for 3 residents (#3, #6, #7) of 3 residents reviewed for cardiac and blood pressure medications; failed to administer antidepressant and antianxiety medications as outlined in the care plan for 3 residents (#8, #9, #10) of 3 residents receiving antidepressants; and failed to follow guidelines for care of a resident with a wound vac for 1 resident (#18) of 1 resident with a wound vac. These failures placed all residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 10/24/16 at 3:25 PM, in the Conference Room. The findings included: Review of facility policy, Medication Administration, revised 3/16/15 revealed, .Administer medications within 60 minutes of the scheduled time . Review of facility policy, Diabetes, Nursing Care of the Adult Diabetes Mellitus Resident, undated, revealed, .The purpose of this guideline is .Prevent recurrence of [MEDICAL CONDITION]/[DIAGNOSES REDACTED] (high and low blood sugars). Recognize, assist and document the treatment of [REDACTED].obtain pre-meal fingerstick blood glucose within 60 minutes (maximum) of anticipated meal .The physician should be notified when the blood sugar falls above his/her specified blood sugar range and/or above 400 mg/dL (milligrams per deciliter) . Review of facility policy, Negative Pressure Wound Therapy (NPWT), undated, revealed, .Review health care provider's orders for frequency of dressing change, type of foam to use, amount of negative pressure and cycle (intermittent or continuous) .Routinely check that the vacuum level is set as prescribed and the dressing is properly sealed .Inspect condition of wound on ongoing basis; note drainage and odor .verify airtight dressing seal and correct negative pressure setting. Measure wound drainage output in canister .Chart in the nurses's notes the appearance of wound, color, characteristics of any drainage .NPWT pressure setting, dressing change, and resident response to dressing change . The Medical Director of the facility is the physician of record for all the residents. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 4 indicating the resident was severely cognitively impaired. She had continuous behaviors of inattention that did not change and had rejected care 1-3 days of the previous 7 days. Continued review revealed the resident received 51% or more of her calories, 500 cc (cubic centimeters) or more of fluid through a feeding tube, and received 7 injections of insulin during the previous 7 days. The resident was impaired to her bilateral lower extremities, and impaired on her left upper extremity. She used a wheelchair for ambulation. Medical record review of a comprehensive care plan for Resident #2 dated 6/8/16 revealed a problem of a PEG tube (Percutaneous Endoscopic Gastrostomy - feeding tube) for adequate nutritional intake. Interventions included: .Check placement before initiating my tube feedings; Check for residual before initiating my feeding; Tube feeding and flushes per order . Observation on 10/11/16 at 1:15 PM, in Resident #2's room revealed Licensed Practical Nurse (LPN) #1 was preparing to administer a bolus tube feeding to the resident. Continued observation revealed the LPN administered 300 cc of Glucerna 1.5 and 240 cc of water through the PEG tube without first checking placement, or checking for residual. Interview with LPN #1 on 10/11/16 at 1:25 PM at the medication cart outside room [ROOM NUMBER]B confirmed she did not check placement or residual prior to administering 300 cc of Glucerna 1.5 tube feeding or 240 cc of water. The LPN confirmed she did not follow the care plan as directed for Resident #2. Medical record review of a comprehensive care plan dated 6/7/16 revealed a problem of medical management for Diabetes Mellitus Type II. Interventions included, .Administer my scheduled insulin as ordered; Obtain my finger stick blood sugars as ordered . Medical record review of Physician's Orders dated 9/22/16 revealed an order for [REDACTED]. The scheduled administration time was 9:00 PM. Medical record review of the 9/2016 and 10/2016 Medication Administration Record [REDACTED]. Interview with Registered Nurse (RN) #2 by phone on 10/12/16 at 3:20 PM confirmed 21 Units of [MEDICATION NAME] was not administered to Resident #2 on 9/22/16 at 9:00 PM as ordered. Medical record review of a Physician's Order dated 6/4/16 revealed, .ACCUCHECKS (finger stick for blood sugar) BEFORE BOLUS FEEDINGS AND SSI (sliding scale insulin) AS FOLLOWS: 0-59 = CALL MD 60-150=0, 151-200=2u (units), 201-250=4u, 251-300=6u, 301-350=8u, 351-400 = 10u .NOTIFY MD AND RECHECK IN 15 MINUTES . The scheduled time was 6 AM, 12 PM, 6 PM, and 12 AM daily. Medical record review of Residnet #2's 6/2016 Medication Administration Record [REDACTED]. Continued review revealed blood sugars were checked 1-4 hours late 2 times for the month of 6/2016. Interview with Licensed Practical Nurse (LPN) #3 on 10/18/16 at 2:20 PM, in the conference room revealed he called Nurse Practitioner (NP) #2 on 6/4/16 regarding Resident's #2's blood sugar of 211 and was told to hold the SSI dose of 4 units. Continued interview with the LPN confirmed he did not write an order to hold the 4 units of insulin and he did not administer the dose per the sliding scale protocol. Medical record review of the 6/2016 Medication Administration Record [REDACTED] 591 on 6/4 at 7:30 AM 432 on 6/6 at 6:00 AM 401 on 6/7 at 12:00 AM High on 6/9 at 12:00 PM 456 on 6/12 at 6:00 AM 429 on 6/18 at 6:00 AM Medical record review revealed no notification of the MD or Nurse Practitioner (NP) regarding Resident #2's elevated blood sugars. Medical record review of the 7/2016 MAR indicated [REDACTED]. The time frame excludes the 60 minute window of time (60 minutes before and 60 minutes after the scheduled time) which is allowable to administer medication before or after the scheduled time. Medical record review of Resident #2's 7/2016 MAR indicated [REDACTED] 564 on 7/1 at 6:00 AM 441 on 7/1 at 12:00 PM 503 on 7/6 at 12:00 AM 489 on 7/9 at 12:00 PM 518 on 7/10 at 12:00 AM 511 on 7/10 at 12:00 PM 405 on 7/12 at 12:00 AM 466 on 7/25 at 6:00 AM 459 on 7/27 at 12:00 AM 436 on 7/31 at 6:00 PM Medical record review revealed no notification of the MD or NP regarding Resident #2's elevated blood sugars. Medical record review of the 8/16 MAR indicated [REDACTED] 475 on 8/1 at 12:00 AM 492 on 8/7 at 6:00 PM 456 on 8/20 at 6:00 PM 432 on 8/21 at 6:00 PM 493 on 8/25 at 6:00 PM Medical record review revealed no notification to the MD or NP regarding Resident #2's elevated blood sugars. Medical record review of the 9/2016 MAR indicated [REDACTED]. Continued medical record review of the 9/2016 MAR indicated [REDACTED]. There was no documentation the blood sugar was re-checked in 15 minutes after administration of the 10 units of SSI. Resident #2's blood sugar was not checked at 6:00 PM per order. The blood sugar was 327 at 12:00 AM on 9/23 and no SSI was administered; the blood sugar was 560 at 6:00 AM and no SSI was administered, the blood sugar was not re-checked in 15 minutes, and the physician was not notified. Continued review revealed no physician orders to hold accuchecks, or SSI in Resident #2's medical record. Telephone interview with LPN #5 on 10/18/16 at 4:00 PM revealed, (RN #2) gave me report to hold the insulin for lab work in the morning. I should have looked to see the order myself, and I did not call the Doctor when the sugar was 560. I was just going on what I was told. Interview with LPN #6 on 10/19/16 at 7:15 AM, in the conference room confirmed Resident #2's blood sugar was 47 on 9/7/16 and she failed to notify the physician. Medical record review of the 10/2016 MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 10/19/16 at 4:05 PM, in the conference room confirmed the facility policy was to notify the physician if a blood sugar was less than 60 or greater than 400. Continued interview revealed the DON was unaware accuchecks were up to 5 hours late. Further interview with the DON revealed I knew they were a little late but I had no idea they were 2 1/2-3 hours late. Continued interview with the DON confirmed the facility failed to check blood sugars as ordered, failed to follow the facility policy, and failed to notify the physician of Resident #2's elevated blood sugars. Interview with the DON on 10/19/16 at 4:05 PM, in the conference room confirmed not administering [MEDICATION NAME] as ordered on [DATE] and administering the insulin at 11:25 PM instead of 9:00 PM were medication errors. Continued interview with the DON confirmed the facility failed to follow physician orders. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission MDS dated [DATE] revealed the resident was severely cognitively impaired, had impairments to all extremities, received insulin 1 time over the previous 7 days and received 51% or greater of his calories and 501 cc per day of fluid through a feeding tube. Medical record review of the comprehensive care plan dated 7/19/16 revealed a problem of insulin dependent diabetes. Interventions included, .Administer my insulin according to my physician's orders; Monitor my blood sugars per my physician's orders . Medical record review of a physician's telephone order dated 9/22/16 revealed, .Accuchecks before meals and at bedtime . The scheduled time of administration was 7:30 AM, 12:00 PM, 5:00 PM, and 9:00 PM. The order did not include sliding scale insulin (SSI) orders. Medical record review of the 9/2016 MAR indicated [REDACTED]. Medical record review revealed no physician's telephone orders regarding accuchecks, SSI, or administration time changes. Medical record review of the Physician's Recapitulation Orders for 9/2016 revealed an order dated 9/23/16 for accuchecks with SSI. The scheduled times were 10:00 AM, 2:00 PM, 6:00 PM and 10:00 PM. Medical record review of the 9/2016 and 10/2016 MAR indicated [REDACTED] 9/24 scheduled at 10:00 AM checked at 3:05 PM 9/24 scheduled at 2:00 PM checked at 4:20 PM 9/25 scheduled at 10:00 AM checked at 3:38 PM 9/25 scheduled at 2:00 PM checked at 5:33 PM 9/25 scheduled at 10:00 PM checked at 11:23 PM 9/26 scheduled at 10:00 AM checked at 12:39 PM 9/26 scheduled at 2:00 PM checked at 3:28 PM 9/26 scheduled at 10:00 PM checked at 5:20 AM on 9/27 9/28 scheduled at 10:00 AM checked at 11:19 AM 9/28 scheduled at 2:00 PM checked at 4:04 PM 9/28 scheduled at 10:00 PM checked at 11:36 PM 9/29 scheduled at 10:00 AM checked at 3:19 PM 9/29 scheduled at 2:00 PM checked at 3:20 PM 10/4 scheduled at 2:00 PM checked at 6:08 PM Medical record review of the comprehensive care plan dated 7/19/16 revealed a problem of signs of [MEDICAL CONDITION]. Interventions included: .Administer my cardiac .meds (medications) as ordered . Medical record review of a physician's telephone order dated 9/12/16 revealed, .[MEDICATION NAME] HCL (used to treat low blood pressure) 5 mg tab (tablet) give one tab PT (per tube) before meals; BP (blood pressure) to be checked prior to administration, Hold for BP (systolic greater than 120 or diastolic greater than 80) . The order was written by LPN #4 and signed by NP #1. Medical record review of the Electronic Physician's Order dated 9/12/16 for [MEDICATION NAME] 5 mg revealed it was entered into the computer by LPN #4 at 7:00 PM. The electronic order contained a special requirement to check the blood pressure prior to administration and to hold if the systolic blood pressure was less than 120. Medical record review of 9/2016 MAR indicated [REDACTED].[MEDICATION NAME] HCL 5 MG TABLET give one tablet per tube before meals. CHECK BP (blood pressure) . There were no blood pressure parameters transcribed onto the MAR. Medical record review of the 9/2016 MAR indicated [REDACTED]. 9/12 at 10:00 PM. BP 149/90 9/13 at 10:00 AM. BP 152/82 9/13 at 2:00 PM. BP 125/64 9/13 at 6:00 PM BP 122/80 9/13 at 10:00 PM. BP 124/53 9/14 at 10:00 AM. BP 134/70 9/14 at 2:00 PM. BP 130/70 9/14 at 6:00 PM. BP 134/70 9/14 at 10:00 PM. BP 129/82 9/15 at 10:00 AM. BP 126/75 9/15 at 2:00 PM. BP 128/75 9/16 at 10:00 AM. BP 120/100 9/16 at 2:00 PM. BP 118/88 Continued review of an Electronic Physician's Order dated 9/16/16 revealed LPN #3 removed the parameter to hold the [MEDICATION NAME] 5mg if the systolic blood pressure was less than 120 on 9/16/16 at 5:01 PM. The original parameters from the 9/12/16 order to hold the medication if the systolic BP was greater than 120 or the diastolic BP was greater than 80 was not entered into the computer or transcribed onto the MAR. Medical record review of the MAR indicated [REDACTED]. Interview with the Regional Nurse on 10/24/16 at 2:00 PM in the conference room confirmed the facility failed to follow physician orders for Resident's #2 and #3. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders dated 7/26/16 revealed .Please give 8 ounces [MEDICATION NAME] 1.5 per tube as needed if meal intake is less than 50% . Continued review of physician orders dated 9/20/16 revealed .[MEDICATION NAME] 1.5 cal liquid, Give 8 ounces per tube BID (twice daily) between meals with 120 ml (milliliters) H2O flush before and after each bolus . Medical record review of the MAR for October 2016, revealed the 8 ounces of [MEDICATION NAME] were administered at 10:00 AM and 10:00 PM. Continued review revealed the 8 ounces to be given with food intake less than 50% was scheduled for 9:00 AM, 1:00 PM, and 7:00 PM. Further review of the MAR indicated [REDACTED]. Medical record review of nursing notes for October 2016 revealed no documentation the [MEDICATION NAME] was given between meals as ordered. Interview with LPN #7 on 10/17/16 at 3:05 PM, in the conference room revealed she documented the amount the resident ate and put a check mark to indicate she was aware of the amount the resident ate. Continued interview revealed if the resident ate less than 50% of the meal the nurse would administer [MEDICATION NAME] to the resident. Interview with LPN #3 on 10/17/16 at 3:11 PM, in the conference room revealed nurses place a check mark on the MAR indicated [REDACTED]. Continued interview revealed if the resident ate less than 50% the staff would give [MEDICATION NAME] because that was the order. Further interview revealed LPN #3 was not aware of any place to document the [MEDICATION NAME] when it was given. Continued interview revealed .If the amount the resident eats is less than 50% we assume the nurse administered the [MEDICATION NAME] . Medical record review of the care plan for Resident #4, revised 9/22/16 revealed a problem of I have labile blood sugars related to Type II Diabetes Mellitus. Continued review revealed Approaches included: a. Monitor my nutritional intake. b. Obtain my finger stick blood sugars as ordered. c. Administer my oral hypoglycemic agents as ordered. Medical record review of the MAR for October 2016 revealed: a. on 21 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Interim Care Plan initiated 10/9/16 revealed a problem of Resident required insulin injections to manager Diabetes. Continued review revealed Approaches included: a. Administer routine and sliding scale insulin as per physician's orders. b. Administer finger sticks as ordered and give sliding scale insulin as per physician's orders c. Observe for signs/symptoms of hypo/[MEDICAL CONDITION] and report to physician as per parameters. Medical record review of the MAR for 10/2016 revealed: a. on 7 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 4 occasions insulin was administered 1 1/2 - 2 hours past the scheduled window c. on 6 occasions [MEDICATION NAME] was administered 1 1/2 - 3 hours past the scheduled window. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan with a problem onset dated 9/30/16 of I am insulin dependent diabetic. Continued review of the care plan revealed Approaches included: a. Administer my insulin according to my physician's orders. b. Monitor my blood sugars per my physician's orders. c. Observe me for signs/ symptoms of hypo/[MEDICAL CONDITION] and report any noted to physician. Medical record review of the Care Plan revealed a problem onset of 5/19/14 of I am at risk for side effects from [MEDICAL CONDITION] drug use. Continued review revealed Approaches included: a. Administer my medication as ordered by physician. b. Observe me for adverse side effects, document, and report to my physician. Medical record review of the Medication Administration Record [REDACTED] a. on 22 occasions blood glucose monitoring was completed from 1 1/2 - 7 hours past the scheduled window b. on 12 occasions insulin was administered 1 1/2 - 7 hours past the scheduled window c. on 7 occasions [MEDICATION NAME] (antibiotic) was administered 2 - 8 1/2 hours past the scheduled window. Medical record review of the MAR for October 2016 revealed: a. on 33 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 2 occasions insulin was administered 1/2 - 1 1/2 hours past the scheduled window c. on 4 occasions [MEDICATION NAME] (antidepressant) was administered 2 - 3 hours past the scheduled window d. on 4 occasions [MEDICATION NAME] (antidepressant) was administered 1/2 - 3 hours past the scheduled window e. on 9 occasions [MEDICATION NAME] (anti-anxiety) was administered 1 1/2 - 4 hours past the scheduled window Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan revealed a problem onset of 10/12/16 of I am insulin dependent diabetic. Continued review revealed Approaches included: a. Administer my insulin according to my physician's orders. b. Monitor my blood sugars per my physician's orders. c. Observe me for signs/symptoms of hypo/[MEDICAL CONDITION] and report any noted to my physician. Medical record review revealed a problem onset of 10/12/16 of I am at risk for altered cardiac status related to Cor Pulmonale, Hypertension, and [MEDICAL CONDITION]. Continued review revealed Approaches of: a. Medication as ordered. b. Report signs/symptoms of side effects. Medical record review of the MAR for October 2016 revealed: a. on 18 occasions blood glucose monitoring was completed 1 1/2 - 3 hours past the scheduled window b. on 16 occasions insulin was administered 2 1/2 - 8 hours past the scheduled window c. on 5 occasions [MEDICATION NAME] (cardiac) was administered 3 1/2 - 6 hours past the scheduled window d. on 9 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 3 hours past the scheduled window e. on 5 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 3 hours past the scheduled window f. on 3 occasions [MEDICATION NAME] (antianxiety) was administered 1 1/2 - 2 1/2 hours past the scheduled window Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan revealed a problem onset of 8/4/16 of I am an insulin dependent diabetic. Continued review revealed Approaches included: a. Administer my insulin according to my physician's orders. b. Monitor my blood sugars per my physician's orders. c. Observe me for signs/symptoms of hypo/[MEDICAL CONDITION] and report any noted to my physician. Medical record review of the Care Plan revealed a problem onset of 8/4/16 of I am at risk for side effects from antidepressant drug use. Continued review revealed Approaches of: a. Administer my medication as ordered by physician. Medical record review of the MAR for 9/2016 revealed: a. on 54 occasions blood glucose monitoring was completed 1 1/2 - 8 1/2 hours past the scheduled window b. on 18 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 5 hours past the scheduled window c. on 13 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 1/2 hours past the scheduled window d. on 14 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 4 1/2 hours past the scheduled window e. on 3 occasions [MEDICATION NAME] (cardiac) was administered 1 1/2 - 2 1/2 hours past the scheduled window f. on 1 occasion [MEDICATION NAME] ([MEDICAL CONDITION]) and [MEDICATION NAME] (antacid) were administered 10 1/2 hours past the scheduled window Medical record review of the MAR for 10/2016 revealed: a. on 31 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 4 occasions insulin was administered 2 - 5 hours past the scheduled window c. on 20 occasions [MEDICATION NAME] was administered 1 1/2 - 7 /12 hours past the scheduled window d. on 11 occasions [MEDICATION NAME] was administered 2 - 3 hours past the scheduled window e. on 13 occasions [MEDICATION NAME] was administered 1 1/2 - 5 hours past the scheduled window. Medical record review revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan revealed a problem onset of 5/4/16 of I am an insulin dependent diabetic. Continued review revealed Approaches included: a. Administer my insulin according to my physician's orders. b. Monitor my blood sugars per my physician's orders. c. Observe me for signs/symptoms of hypo/[MEDICAL CONDITION] and report any noted to my physician. Medical record review of the Care Plan revealed a problem onset of 5/4/16 of I am at risk for side effects from [MEDICAL CONDITION] drug use related to antidepressant and antianxiety medication. Continued review revealed approaches of: a. Administer my medications as ordered by physician. Medical record review of the MAR for 9/2016 revealed: a. on 30 occasions blood glucose monitoring was completed 1 1/2 - 7 hours past the scheduled window b. on 20 occasions insulin was administered 1 1/2 - 7 hours past the scheduled window. c. on 43 occasions [MEDICATION NAME] (antianxiety) was administered 1 1/2 - 5 hours past the scheduled window d. on 16 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 hours past the scheduled window e. on 16 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 hours past the scheduled window. Medical record review of the MAR for 10/2016 revealed: a. on 13 occasions blood glucose monitoring was completed 1 1/2 - 4 hours past the scheduled window b. on 6 occasions insulin was administered 1 1/2 - 3 1/2 hours past the scheduled window c. on 19 occasions [MEDICATION NAME] was administered 1 1/2 - 2 1/2 hours past the scheduled window d. on 8 occasions [MEDICATION NAME] was administered 1 1/2 - 3 1/2 hours past the scheduled window e. on 8 occasions [MEDICATION NAME] was administered 1 1/2 hours - 3 1/2 hours past the scheduled window Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for 9/2016 revealed: a. on 47 occasions blood glucose monitoring was completed 1 1/2 - 7 hours past the scheduled window Medical record review of the MAR for 10/2016 revealed: a. on 34 occasions blood glucose monitoring was completed 1 1/2 - 7 1/2 hours past the scheduled window. Interview with the Director of Nursing (DON) on 10/20/16 at 4:40 PM, in the Conference Room confirmed medications were administered outside the window of 60 minutes before and 60 minutes after the scheduled time. Continued interview confirmed blood glucose monitoring and insulin administration occurred outside the window. Medical record review revealed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired, always incontinent of bowel and bladder and had a Stage IV pressure ulcer to the sacrum. Medical record review of a telephone physician's order dated 10/10/16 prescribed by NP #3 revealed, .Coccyx pressure area - NPWT to pack/fill woundbed & drape to seal .Continue AG Collagen to cover coccyx wound bed each Vac (change) . Medical record review of the Treatment Administration Record (TAR) for 10/16 revealed the order was not followed on 10/11 or 10/12. Observation of Resident #18 on 10/18/16 at 10:20 AM in the resident's room revealed the resident was in bed, eyes closed. A wound vac was present to the side rail with serous drainage noted. Interview with the Wound Nurse on 10/19/16 at 11:30 AM, in Hermitage Hall when asked when the resident's wound vac was placed stated, Friday. (10/14). Continued interview revealed when asked what the treatment order dated 10/10 meant the Wound Nurse stated, that the wound vac was there. Continued interview revealed the Wound Nurse confirmed she documented care of the resident and the wound vac on 10/13, 10/14, 10/17, 10/18, and 10/19. Further review revealed there was no additional documentation of when the wound vac was placed, the negative pressure setting, how often it was to be changed, amount and color of drainage or how the resident was tolerating it. The Wound Nurse stated, I should have documented all of that. Interview with the DON on 10/19/16 at 4:05 PM, in the conference room confirmed the Wound Nurse should have clarified the 10/10/16 treatment order for the wound vac to Resident #18 on 10/10/16, and most certainly when the wound vac was placed. Continued interview with the DON confirmed there should have been documentation of the amount, color and odor of drainage, how the resident was tolerating the wound vac, the amount of negative pressure the wound vac was set on, and the type of wound vac machine and there was not. Interview with LPN #8 on 10/20/16 at 1:00 PM, in the conference room confirmed she had cared for the resident on 10/15/16 and had documented on the TAR she had followed the treatment order dated 10/10/16. When asked what the protocol was for care of a resident with a wound vac she stated, It is changed every Monday, Wednesday, and Friday and it is done by the Treatment (Wound) Nurse. When asked what her documentation of the order meant, she stated, I've never changed a wound vac before. I checked that it was there. The LPN confirmed she did not provide any care, or documentation of the wound, or wound vac for Resident #18. Telephone interview with LPN #11 on 10/20/16 at 4:50 PM confirmed she had cared for the resident on 10/16/16. When asked what care she provided to the resident she stated, He had a wound vac to his sacrum. I changed the tape. The wound was exposed and I secured the dressing with tape. The LPN confirmed she did not change the dressing, or document the status of the wound, wound vac settings, drainage type and amount, or how the resident was tolerating the care. Refer to F157 K, F224 L SQC, F281 L.

Based on facility policy review, medical record review, observation, and interview, the facility failed to meet professional standards to administer medications properly and in a timely fashion; to communicate a significant change in the resident's condition to the appropriate professional; and to implement a physician's, advanced nurse practitioner's, or physician's assistant's order in a timely fashion (Lippincott Manual of Nursing Practice, 10th Edition, published 2014) by failing to complete blood glucose testing as ordered by the physician for 9 residents (#2, #3, #4, #5, #6, #7, #8, #9, #10) of 9 diabetic residents reviewed; failed to administer insulin per physician's order for 7 residents (#2, #3, #5, #6, #7, #8, #9) of 7 residents receiving insulin; failed to administer cardiac and blood pressure medications as ordered by the physician for 3 residents (#3, #6, #7) of 3 residents reviewed for cardiac and blood pressure medications; failed to administer antidepressant and antianxiety medications as ordered by the physician for 3 residents (#8, #9, #10) of 3 residents receiving antidepressants; and failed to follow guidelines for care of a resident with a wound vac for 1 resident (#18) of 7 residents reviewed with wound care. These failures placed all residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 10/24/16 at 3:25 PM in the Conference Room. The findings included: Review of facility policy, Medication Administration, revised 3/16/15 revealed, .Administer medications within 60 minutes of the scheduled time . Review of facility policy, Diabetes, Nursing Care of the Adult Diabetes Mellitus Resident, undated, revealed, .The purpose of this guideline is .Prevent recurrence of [MEDICAL CONDITION]/[DIAGNOSES REDACTED] (high and low blood sugars). Recognize, assist and document the treatment of [REDACTED].obtain pre-meal fingerstick blood glucose within 60 minutes (maximum) of anticipated meal .The physician should be notified when the blood sugar falls above his/her specified blood sugar range and/or above 400 mg/dL (milligrams per deciliter) . Review of facility policy, Negative Pressure Wound Therapy (NPWT), undated, revealed, .Review health care provider's orders for frequency of dressing change, type of foam to use, amount of negative pressure and cycle (intermittent or continuous) .Routinely check that the vacuum level is set as prescribed and the dressing is properly sealed .Inspect condition of wound on ongoing basis; note drainage and odor .verify airtight dressing seal and correct negative pressure setting. Measure wound drainage output in canister .Chart in the nurses's notes the appearance of wound, color, characteristics of any drainage .NPWT pressure setting, dressing change, and resident response to dressing change . The Medical Director of the facility is the physician of record for all the residents. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 4 indicating the resident was severely cognitively impaired. She had continuous behaviors of inattention that did not change, and had rejected care 1-3 days of the previous 7 days. Continued review revealed the resident received 51% or more of her calories, 500 cc (cubic centimeters) or more of fluid through a feeding tube, and received 7 injections of insulin during the previous 7 days. The resident was impaired to her bilateral lower extremities, and impaired on her left upper extremity. She used a wheelchair for ambulation. Observation on 10/11/16 at 1:15 PM, in Resident #2's room revealed Licensed Practical Nurse (LPN) #1 was preparing to administer a bolus tube feeding to the resident. Continued observation revealed the LPN administered 300 cc of Glucerna 1.5 and 240 cc of water through the PEG tube without first checking placement or checking for residual. Interview with LPN #1 on 10/11/16 at 1:25 PM at the medication cart outside room [ROOM NUMBER]B confirmed she did not check placement or residual prior to administering 300 cc of Glucerna 1.5 tube feeding or 240 cc of water. The LPN confirmed she did not follow the care plan as directed for Resident #2. Medical record review of Physician's Orders for Resident #2 dated 9/22/16 revealed an order for [REDACTED]. The scheduled administration time was 9:00 PM. Medical record review of the 9/2016 and 10/2016 Medication Administration Record [REDACTED]. Interview with Registered Nurse (RN) #2 by phone on 10/12/16 at 3:20 PM confirmed 21 Units of [MEDICATION NAME] was not administered to Resident #2 on 9/22/16 at 9:00 PM as ordered. Medical record review of a Physician's Order dated 6/4/16 revealed, .ACCUCHECKS (finger stick for blood sugar) BEFORE BOLUS FEEDINGS AND SSI (sliding scale insulin) AS FOLLOWS: 0-59 = CALL MD 60-150=0, 151-200=2u (units), 201-250=4u, 251-300=6u, 301-350=8u, 351-400 = 10u .NOTIFY MD AND RECHECK IN 15 MINUTES . The scheduled time was 6 AM, 12 PM, 6 PM, and 12 AM daily. Medical record review of the 6/2016 Medication Administration Record [REDACTED]. Continued review revealed blood sugars were checked 1-4 hours late 2 times for the month of 6/2016. Interview with Licensed Practical Nurse (LPN) #3 on 10/18/16 at 2:20 PM, in the conference room revealed he called Nurse Practitioner (NP) #2 on 6/4/16 regarding Resident #2's blood sugar of 211 and was told to hold the SSI dose of 4 units. Continued interview with the LPN confirmed he did not write an order to hold the 4 units of insulin and he did not administer the dose per the sliding scale protocol. Medical record review of the 6/2016 Medication Administration Record [REDACTED] 591 on 6/4 at 7:30 AM 432 on 6/6 at 6:00 AM 401 on 6/7 at 12:00 AM High on 6/9 at 12:00 PM 456 on 6/12 at 6:00 AM 429 on 6/18 at 6:00 AM Medical record review revealed no notification of the MD or Nurse Practitioner (NP) regarding Resident #2's elevated blood sugars. Medical record review of the 7/2016 MAR indicated [REDACTED]. The time frame excludes the 60 minute window of time (60 minutes before and 60 minutes after the scheduled time) which is allowable to administer medication before or after the scheduled time. Medical record review of the 7/2016 MAR indicated [REDACTED] 564 on 7/1 at 6:00 AM 441 on 7/1 at 12:00 PM 503 on 7/6 at 12:00 AM 489 on 7/9 at 12:00 PM 518 on 7/10 at 12:00 AM 511 on 7/10 at 12:00 PM 405 on 7/12 at 12:00 AM 466 on 7/25 at 6:00 AM 459 on 7/27 at 12:00 AM 436 on 7/31 at 6:00 PM Medical record review revealed no notification of the MD or NP regarding Resident #2's elevated blood sugars. Medical record review of the 8/2016 MAR indicated [REDACTED] 475 on 8/1 at 12:00 AM 492 on 8/7 at 6:00 PM 456 on 8/20 at 6:00 PM 432 on 8/21 at 6:00 PM 493 on 8/25 at 6:00 PM Medical record review revealed no notification of the MD or NP regarding the elevated blood sugars. Medical record review of the 9/2016 MAR indicated [REDACTED]. Continued medical record review of the 9/2016 MAR indicated [REDACTED]. There was no documentation the blood sugar was re-checked in 15 minutes after administration of the 10 units of SSI. The blood sugar was not checked at 6:00 PM per order. The blood sugar was 327 at 12:00 AM on 9/23 and no SSI was administered; the blood sugar was 560 at 6:00 AM and no SSI was administered, the blood sugar was not re-checked in 15 minutes, and the physician was not notified. Continued review revealed no physician orders to hold accuchecks, or SSI in Resident #2's medical record. Telephone interview with LPN #5 on 10/18/16 at 4:00 PM revealed, (RN #2) gave me report to hold the insulin for lab work in the morning. I should have looked to see the order myself, and I did not call the Doctor when the sugar was 560. I was just going on what I was told. Interview with LPN #6 on 10/19/16 at 7:15 AM, in the conference room confirmed Resident #2's blood sugar was 47 on 9/7/16 and she failed to notify the physician. Medical record review of Resident #2's 10/2016 MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 10/19/16 at 4:05 PM in the conference room confirmed the facility policy was to notify the physician if a blood sugar was less than 60 or greater than 400. Continued interview revealed the DON was unaware accuchecks were up to 5 hours late. Further interview with the DON stated, I knew they were a little late but I had no idea they were 2 1/2-3 hours late. Continued interview with the DON confirmed the facility failed to check blood sugars as ordered, failed to follow the facility policy, and failed to notify the physician of the elevated blood sugars for Resident #2. Interview with the DON on 10/19/16 at 4:05 PM, in the conference room confirmed not administering [MEDICATION NAME] as ordered on [DATE] and administering the insulin at 11:25 PM instead of 9:00 PM were medication errors. Continued interview with the DON confirmed the facility failed to follow physician orders for Resident #2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission MDS dated [DATE] revealed the resident was severely cognitively impaired, had impairments to all extremities, received insulin 1 time over the previous 7 days and received 51% or greater of his calories and 501 cc per day of fluid through a feeding tube. Medical record review of a physician's telephone order dated 9/22/16 revealed, .Accuchecks before meals and at bedtime . The scheduled time of administration was 7:30 AM, 12:00 PM, 5:00 PM, and 9:00 PM. The order did not include sliding scale insulin (SSI) orders. Medical record review of the 9/2016 MAR indicated [REDACTED]. Medical record review revealed no physician's telephone orders regarding accuchecks, SSI, or administration time changes. Medical record review of Resident #3's Physician's Recapitulation Orders for 9/2016 revealed an order dated 9/23/16 for accuchecks with SSI. The scheduled times were 10:00 AM, 2:00 PM, 6:00 PM and 10:00 PM. Medical record review of the 9/2016 and 10/2016 MAR indicated [REDACTED] 9/24 scheduled at 10:00 AM checked at 3:05 PM 9/24 scheduled at 2:00 PM checked at 4:20 PM 9/25 scheduled at 10:00 AM checked at 3:38 PM 9/25 scheduled at 2:00 PM checked at 5:33 PM 9/25 scheduled at 10:00 PM checked at 11:23 PM 9/26 scheduled at 10:00 AM checked at 12:39 PM 9/26 scheduled at 2:00 PM checked at 3:28 PM 9/26 scheduled at 10:00 PM checked at 5:20 AM on 9/27 9/28 scheduled at 10:00 AM checked at 11:19 AM 9/28 scheduled at 2:00 PM checked at 4:04 PM 9/28 scheduled at 10:00 PM checked at 11:36 PM 9/29 scheduled at 10:00 AM checked at 3:19 PM 9/29 scheduled at 2:00 PM checked at 3:20 PM 10/4 scheduled at 2:00 PM checked at 6:08 PM Medical record review of a physician's telephone order dated 9/12/16 revealed, .[MEDICATION NAME] HCL (used to treat low blood pressure) 5 mg tab (tablet) give one tab PT (per tube) before meals; BP (blood pressure) to be checked prior to administration, Hold for BP (systolic greater than 120 or diastolic greater than 80) . The order was written by LPN #4 and signed by NP #1. Medical record review of the Electronic Physician's Order dated 9/12/16 for [MEDICATION NAME] 5 mg revealed it was entered into the computer by LPN #4 at 7:00 PM. The electronic order contained a special requirement to check the blood pressure prior to administration and to hold if the systolic blood pressure was less than 120. Medical record review of Resident #3's 9/2016 MAR indicated [REDACTED].[MEDICATION NAME] HCL 5 MG TABLET give one tablet per tube before meals. CHECK BP (blood pressure) . There were no blood pressure parameters transcribed onto the MAR. Medical record review of the 9/2016 MAR indicated [REDACTED]. 9/12 at 10:00 PM. BP 149/90 9/13 at 10:00 AM. BP 152/82 9/13 at 2:00 PM. BP 125/64 9/13 at 6:00 PM BP 122/80 9/13 at 10:00 PM. BP 124/53 9/14 at 10:00 AM. BP 134/70 9/14 at 2:00 PM. BP 130/70 9/14 at 6:00 PM. BP 134/70 9/14 at 10:00 PM. BP 129/82 9/15 at 10:00 AM. BP 126/75 9/15 at 2:00 PM. BP 128/75 9/16 at 10:00 AM. BP 120/100 9/16 at 2:00 PM. BP 118/88 Continued review of an Electronic Physician's Order dated 9/16/16 revealed LPN #3 removed the parameter to hold the [MEDICATION NAME] 5mg if the systolic blood pressure was less than 120 on 9/16/16 at 5:01 PM. The original parameters from the 9/12/16 order to hold the medication if the systolic BP was greater than 120 or the diastolic BP was greater than 80 was not entered into the computer or transcribed onto the MAR. Medical record review of the MAR indicated [REDACTED]. Interview with the Regional Nurse on 10/24/16 at 2:00 PM, in the conference room confirmed the facility failed to follow physician orders for Resident's #2 and #3. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders dated 7/26/16 revealed .Please give 8 ounces [MEDICATION NAME] 1.5 per tube as needed if meal intake is less than 50% . Continued review of physician orders dated 9/20/16 revealed .[MEDICATION NAME] 1.5 cal liquid, Give 8 ounces per tube BID (twice daily) between meals with 120 ml (milliliters) H2O flush before and after each bolus . Medical record review of the MAR for October 2016 revealed the 8 ounces of [MEDICATION NAME] were administered at 10:00 AM and 10:00 PM. Continued review revealed the 8 ounces to be given with food intake less than 50% was scheduled for 9:00 AM, 1:00 PM, and 7:00 PM. Further review of the MAR indicated [REDACTED]. Medical record review of nursing notes for 10/2016 revealed no documentation the [MEDICATION NAME] was given between meals as ordered. Interview with LPN #7 on 10/17/16 at 3:05 PM, in the conference room revealed she documented the amount the resident ate and put a check mark to indicate she was aware of the amount the resident ate. Continued interview revealed if the resident ate less than 50% of the meal the nurse would administer [MEDICATION NAME] to the resident. Interview with LPN #3 on 10/17/16 at 3:11 PM, in the conference room revealed nurses place a check mark on the MAR indicated [REDACTED]. Continued interview revealed if the resident ate less than 50% the staff would give [MEDICATION NAME] because that was the order. Further interview revealed LPN #3 was not aware of any place to document the [MEDICATION NAME] when it was given. Continued interview revealed .If the amount the resident eats is less than 50% we assume the nurse administered the [MEDICATION NAME] . Medical record review of the MAR for October 2016 revealed on 21 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for October revealed: a. on 7 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 4 occasions insulin was administered 1 1/2 - 2 hours past the scheduled window c. on 6 occasions [MEDICATION NAME] was administered 1 1/2 - 3 hours past the scheduled window. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED] a. on 22 occasions blood glucose monitoring was completed from 1 1/2 - 7 hours past the scheduled window b. on 12 occasions insulin was administered 1 1/2 - 7 hours past the scheduled window c. on 7 occasions [MEDICATION NAME] (antibiotic) was administered 2 - 8 1/2 hours past the scheduled window. Medical record review of the MAR for October 2016 revealed: a. on 33 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 2 occasions insulin was administered 1/2 - 1 1/2 hours past the scheduled window c. on 4 occasions [MEDICATION NAME] (antidepressant) was administered 2 - 3 hours past the scheduled window d. on 4 occasions [MEDICATION NAME] (antidepressant) was administered 1/2 - 3 hours past the scheduled window e. on 9 occasions [MEDICATION NAME] (anti-anxiety) was administered 1 1/2 - 4 hours past the scheduled window Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for October 2016 revealed: a. on 18 occasions blood glucose monitoring was completed 1 1/2 - 3 hours past the scheduled window b. on 16 occasions insulin was administered 2 1/2 - 8 hours past the scheduled window c. on 5 occasions [MEDICATION NAME] (cardiac) was administered 3 1/2 - 6 hours past the scheduled window d. on 9 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 3 hours past the scheduled window e. on 5 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 3 hours past the scheduled window f. on 3 occasions [MEDICATION NAME] (antianxiety) was administered 1 1/2 - 2 1/2 hours past the scheduled window Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for September revealed: a. on 54 occasions blood glucose monitoring was completed 1 1/2 - 8 1/2 hours past the scheduled window b. on 18 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 5 hours past the scheduled window c. on 13 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 1/2 hours past the scheduled window d. on 14 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 4 1/2 hours past the scheduled window e. on 3 occasions [MEDICATION NAME] (cardiac) was administered 1 1/2 - 2 1/2 hours past the scheduled window f. on 1 occasion [MEDICATION NAME] ([MEDICAL CONDITION]) and [MEDICATION NAME] (antacid) were administered 10 1/2 hours past the scheduled window Medical record review of the MAR for October 2016 revealed: a. on 31 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 4 occasions insulin was administered 2 - 5 hours past the scheduled window c. on 20 occasions [MEDICATION NAME] was administered 1 1/2 - 7 /12 hours past the scheduled window d. on 11 occasions [MEDICATION NAME] was administered 2 - 3 hours past the scheduled window e. on 13 occasions [MEDICATION NAME] was administered 1 1/2 - 5 hours past the scheduled window. Medical record review revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for September 2016 revealed: a. on 30 occasions blood glucose monitoring was completed 1 1/2 - 7 hours past the scheduled window b. on 20 occasions insulin was administered 1 1/2 - 7 hours past the scheduled window. c. on 43 occasions [MEDICATION NAME] (antianxiety) was administered 1 1/2 - 5 hours past the scheduled window d. on 16 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 hours past the scheduled window e. on 16 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 hours past the scheduled window. Medical record review of the MAR for October 2016 revealed: a. on 13 occasions blood glucose monitoring was completed 1 1/2 - 4 hours past the scheduled window b. on 6 occasions insulin was administered 1 1/2 - 3 1/2 hours past the scheduled window c. on 19 occasions [MEDICATION NAME] was administered 1 1/2 - 2 1/2 hours past the scheduled window d. on 8 occasions [MEDICATION NAME] was administered 1 1/2 - 3 1/2 hours past the scheduled window e. on 8 occasions [MEDICATION NAME] was administered 1 1/2 hours - 3 1/2 hours past the scheduled window Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for September 2016 revealed: a. on 47 occasions blood glucose monitoring was completed 1 1/2 - 7 hours past the scheduled window Medical record review of the MAR for October 2016 revealed: a. on 34 occasions blood glucose monitoring was completed 1 1/2 - 7 1/2 hours past the scheduled window. Interview with the Director of Nursing (DON) on 10/20/16 at 4:40 PM in the Conference Room, confirmed medications were administered outside the window of 60 minutes before and 60 minutes after the scheduled time. Continued interview confirmed blood glucose monitoring and insulin administration occurred outside the window. Medical record review revealed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired, always incontinent of bowel and bladder and had a Stage IV pressure ulcer to the sacrum. Medical record review of a telephone physician's order dated 10/10/16 prescribed by NP #3 revealed, .Coccyx pressure area - NPWT to pack/fill woundbed & drape to seal .Continue AG Collagen to cover coccyx wound bed each Vac (change) . Medical record review of the Treatment Administration Record (TAR) for 10/16 revealed the order was not followed on 10/11 or 10/12. Observation of Resident #18 on 10/18/16 at 10:20 AM in the resident's room revealed the resident was in bed, eyes closed. A wound vac was present to the side rail with serous drainage noted. Interview with the Wound Nurse on 10/19/16 at 11:30 AM in Hermitage Hall when asked when the resident's wound vac was placed stated, Friday. (10/14). Continued interview revealed when asked what the treatment order dated 10/10 meant the Wound Nurse stated, that the wound vac was there. Continued interview revealed the Wound Nurse confirmed she documented care of the resident and the wound vac on 10/13, 10/14, 10/17, 10/18, and 10/19. Further review revealed there was no additional documentation of when the wound vac was placed, the negative pressure setting, how often it was to be changed, amount and color of drainage or how the resident was tolerating it. The Wound Nurse stated, I should have documented all of that. Interview with the DON on 10/19/16 at 4:05 PM in the conference room confirmed the Wound Nurse should have clarified the 10/10/16 treatment order for the wound vac to Resident #18 on 10/10/16, and most certainly when the wound vac was placed. Continued interview with the DON confirmed there should have been documentation of the amount, color and odor of drainage, how the resident was tolerating the wound vac, the amount of negative pressure the wound vac was set on, and the type of wound vac machine and there was not. Interview with LPN #8 on 10/20/16 at 1:00 PM in the conference room confirmed she had cared for the resident on 10/15/16 and had documented on the TAR she had followed the treatment order dated 10/10/16. When asked what the protocol was for care of a resident with a wound vac she stated, It is changed every Monday, Wednesday, and Friday and it is done by the Treatment (Wound) Nurse. When asked what her documentation of the order meant, she stated, I've never changed a wound vac before. I checked that it was there. The LPN confirmed she did not provide any care, or documentation of the wound, or wound vac for Resident #18. Telephone interview with LPN #11 on 10/20/16 at 4:50 PM confirmed she had cared for the resident on 10/16/16. When asked what care she provided to the resident she stated, He had a wound vac to his sacrum. I changed the tape. The wound was exposed and I secured the dressing with tape. The LPN confirmed she did not change the dressing, or document the status of the wound, wound vac settings, drainage type and amount, or how the resident was tolerating the care. Refer to F157 K, F224 L SQC

Based on facility policy review, medical record review, observation of medication pass, and interview, the facility failed to prevent resident neglect when it failed to complete blood glucose monitoring at specified times; failed to administer insulin at scheduled times; failed to administer cardiac, blood pressure, and anti-[MEDICAL CONDITION] medications within the scheduled time frame; failed to notify physician of abnormal blood glucose values; failed to follow physician's orders to recheck blood glucose after an abnormal value was found; and failed to document interventions for 12 residents (#2,# 3,# 6,# 5, #7, #8, #9, #10, #4, #11, #12, #13 ) of 12 residents reviewed for medications. These failures placed all diabetic residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 10/24/16 at 3:15 PM in the Conference Room. F224 is Substandard Quality of Care The findings included: Review of facility policy, Medication Administration, revised 3/16/15 revealed, .Administer medications within 60 minutes of the scheduled time . Review of facility policy, Diabetes, Nursing care of the Adult Diabetes Mellitus Resident, undated, revealed, .The purpose of this guideline is .Prevent recurrence of [MEDICAL CONDITION]/[DIAGNOSES REDACTED] (high and low blood sugars). Recognize, assist and document the treatment of [REDACTED].obtain pre-meal fingerstick blood glucose within 60 minutes (maximum) of anticipated meal .The physician should be notified when the blood sugar falls above his/her specified blood sugar range and/or above 400 mg/dL (milligrams per deciliter) . Review of facility policy, Guidelines for Medications, undated, revealed .All blood sugars that are less than 60 or greater than 400 must be rechecked in 15 minutes and documented . The Medical Director of the facility is the physician of record for all the residents. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 4/10 due to the inability of the resident to complete the interview, indicating the resident was severely cognitively impaired. She received 51% or more of her calories, 500 cc (cubic centimeters) or more of fluid through a feeding tube, and received 7 injections of insulin during the previous 7 days. Medical record review of a Physician's Order for Resident #2 dated 6/4/16 revealed, .ACCUCHECKS (finger stick for blood sugar) BEFORE BOLUS FEEDINGS AND SSI (sliding scale insulin) AS FOLLOWS: 0-59 = CALL MD (Medical Doctor) 60-150=0, 151-200=2u (units), 201-250=4u, 251-300=6u, 301-350=8u, 351-400 = 10u .NOTIFY MD AND RECHECK IN 15 MINUTES . The scheduled time was 6 AM, 12 PM, 6 PM, and 12 AM daily. Medical record review of the 6/2016 Medication Administration Record [REDACTED]. Continued review revealed blood sugars were checked 1-4 hours late 2 times for the month of 6/16. Interview with Licensed Practical Nurse (LPN) #3 on 10/18/16 at 2:20 PM in the conference room revealed he called Nurse Practitioner (NP) #2 on 6/4/16 regarding Resident #2's blood sugar of 211 and was told to hold the SSI dose of 4 units. The LPN confirmed he did not write an order to hold the 4 units of insulin and he did not administer the dose per the sliding scale protocol. Medical record review of Resident #2's 7/2016 MAR indicated [REDACTED]. The time frame excludes the window of time which is allowable to administer medication 60 minutes before or 60 minutes after the scheduled time. Medical record review of Resident #2's 9/2016 MAR indicated [REDACTED]. Medical record review of the 10/2016 MAR for Resident #2 revealed blood sugars were checked 17 minutes-4 hours and 35 minutes late 8 times from 10/1-10/20/16 and checked 1 hour and 26 minutes early on 10/8/16. Medical record review of Resident #2's Physician's Orders for Resident #2 dated 9/22/16 revealed an order for [REDACTED]. The scheduled administration time was 9:00 PM. Continued medical record review of the 9/2016 MAR indicated [REDACTED]. There was no documentation the blood sugar was re-checked in 15 minutes after administration of the 10 units of SSI. The blood sugar was not checked at 6:00 PM per order and the 21 units of [MEDICATION NAME] was not administered at 9:00 PM on 9/22/16 per order. The blood sugar was 327 at 12:00 AM on 9/23 and no SSI was administered; the blood sugar was 560 at 6:00 AM and no SSI was administered, the blood sugar was not re-checked in 15 minutes, and the physician was not notified. Continued review revealed no physician orders to hold accuchecks, [MEDICATION NAME], or SSI in Resident #2's medical record. Medical record review of an e-MAR (electronic Medication Administration Record) narrative Administration Record note for Resident #2 dated 9/22/16 at 7:20 PM by Registered Nurse (RN) #2 revealed, .ACCUCHECK .scheduled for 09/22/2016 6:00 PM. verbally ordered to hold insulin per NP #1 . Continued review of a note dated 9/22/16 at 9:44 PM by RN #2 revealed, .[MEDICATION NAME] .scheduled for 09/22/2016 9:00 PM. Ordered to hold per NP #1 . Continued review revealed the blood glucose was 327 at 1:50 AM and a note dated 9/23/16 at 1:50 AM by LPN #5 revealed, .insulin held as ordered . The blood glucose was 560 at 5:16 AM and a note on 9/23/16 at 5:16 AM from LPN #5 revealed, .insulin held for lab work this am . Review of a physician's order dated 9/22/16 revealed A1C (blood test to determine average glucose over 3 months) in AM. Interview with NP #1 on 10/12/16 at 12:38 PM in the conference room revealed, when asked if insulin needed to be held prior to drawing A1C labwork, the NP stated, Absolutely not. Continued interview with the NP revealed she was aware the insulin had not been given to Resident #2 when she rounded (visited residents) on 9/23/16. The NP denied giving a verbal order to Registered Nurse (RN) #2 to hold insulin on the resident on 9/22/16. She stated, I only met (RN #2) the one time during shift change. (LPN #4) and I had been dealing with (Resident #2's) [MEDICAL CONDITION] (high blood sugar) issues during that day. I absolutely did not give a verbal order to hold insulin and no one called me when it was 560. What I wanted done was to wait until 7 PM to give the next tube feeding bolus as the previous one was given around 2 or 3 PM. I was here when the blood sugar was 501 and (LPN #4) gave 10 units, rechecked it and it was still high. I believe we may have given another 10 units of insulin after that. It makes no sense to hold insulin when the blood sugars had been high that day. Further interview and medical record review with the NP confirmed there was no written telephone order and no computerized order by LPN #4 to give another 10 units of insulin, no order to hold the [MEDICATION NAME] dose at 9:00 PM, and no order to hold any SSI (Sliding Scale Insulin - specific amount of insulin administered according to blood glucose result) at 12:00 AM or 6:00 AM. Interview with LPN #4 on 10/12/16 at 2:05 PM, in the conference room revealed she notified NP #1 on 9/22/16 when Resident #2's blood sugar was 501 and was told to give 10 units of insulin, wait 30 minutes and re-check it again. The LPN stated when she re-checked the blood glucose 30 minutes later the blood glucose was higher than 501 and the NP told her to give an additional 12 units of insulin and recheck it after that. Continued interview with LPN #4 revealed she checked it after administering 12 units and the blood glucose was in the 300's and stated she notified the NP and was told to go ahead and give the tube feeding now. The LPN was not sure of the exact time but stated it was around 2 or 3 in the afternoon. Further interview with LPN #4 revealed I told (RN #2) I didn't give the 6 o'clock tube feeding, and to give it at 7 PM because the 12 o'clock dose was given later in the afternoon because of the blood sugars. Continued interview with LPN #4 confirmed she failed to write an order to administer an additional 12 units of insulin on 9/22/16; failed to document the results of the blood sugars when she rechecked them twice; and failed to document she had notified the NP for a blood glucose of 501 and higher for Resident #2. Telephone interview with RN #2 on 10/12/16 at 3:20 PM revealed, The NP was rounding when I was taking over the cart around 6:30 or 7 PM. She told me to hold 1 dose of insulin for (Resident #2) because her blood sugar had been low. I don't know why the other nurse held the insulin as it is not indicated for an A1C. Continued interview with RN #2 confirmed he did not write a telephone order to hold 1 dose of insulin and did not put an order in the computer and stated, I didn't know how to make it a physician's order in the computer. Telephone interview with LPN #5 on 10/18/16 at 4:00 PM revealed, (RN #2) gave me report to hold the insulin for lab work in the morning. I should have looked to see the order myself, and I did not call the Doctor when (Resident #2's) sugar was 560. I was just going on what I was told. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission MDS dated [DATE] revealed the resident was severely cognitively impaired, had impairments to all extremities, received insulin 1 time over the previous 7 days, received 51% or greater of his calories, and 501 cc per day of fluid through a feeding tube. Medical record review of a telephone physician's order dated 9/22/16 revealed, .Accuchecks before meals and at bedtime . The scheduled time of administration was 7:30 AM, 12:00 PM, 5:00 PM, and 9:00 PM. The order did not include sliding scale insulin (SSI) orders. Medical record review of the 9/16 MAR indicated [REDACTED]. Medical record review revealed no telephone physician orders regarding accuchecks, SSI, or administration time changes. Medical record review of the Physician's Recapitulation Orders for 9/2016 revealed an order dated 9/23/16 for accuchecks with SSI. The scheduled times were 10:00 AM, 2:00 PM, 6:00 PM and 10:00 PM. Medical record review of the 9/2016 and 10/2016 MAR indicated [REDACTED] 9/24 scheduled at 10:00 AM checked at 3:05 PM 9/24 scheduled at 2:00 PM checked at 4:20 PM 9/25 scheduled at 10:00 AM checked at 3:38 PM 9/25 scheduled at 2:00 PM checked at 5:33 PM 9/25 scheduled at 10:00 PM checked at 11:23 PM 9/26 scheduled at 10:00 AM checked at 12:39 PM 9/26 scheduled at 2:00 PM checked at 3:28 PM 9/26 scheduled at 10:00 PM checked at 5:20 AM on 9/27 9/28 scheduled at 10:00 AM checked at 11:19 AM 9/28 scheduled at 2:00 PM checked at 4:04 PM 9/28 scheduled at 10:00 PM checked at 11:36 PM 9/29 scheduled at 10:00 AM checked at 3:19 PM 9/29 scheduled at 2:00 PM checked at 3:20 PM 10/4 scheduled at 2:00 PM checked at 6:08 PM Medical record review of a physician's telephone order dated 9/12/16 revealed, .[MEDICATION NAME] HCL (used to treat low blood pressure) 5 mg tab (tablet) give one tab PT (per tube) before meals; BP (blood pressure) to be checked prior to administration, Hold for BP (systolic greater than 120 or diastolic greater than 80) .The order was written by LPN #4 and signed by NP #1. Medical record review of the Electronic Physician's Order dated 9/12/16 for [MEDICATION NAME] 5 mg revealed it was entered into the computer by LPN #4 at 7:00 PM. The electronic order contained a special requirement to check the blood pressure prior to administration and to hold if the systolic blood pressure was less than 120. Medical record review of 9/2016 MAR indicated [REDACTED].[MEDICATION NAME] HCL 5 MG TABLET give one tablet per tube before meals. CHECK BP (blood pressure) . There were no blood pressure parameters transcribed onto the MAR. Medical record review of the 9/2016 MAR indicated [REDACTED]. 9/12 at 10:00 PM. BP 149/90 9/13 at 10:00 AM. BP 152/82 9/13 at 2:00 PM. BP 125/64 9/13 at 6:00 PM BP 122/80 9/13 at 10:00 PM. BP 124/53 9/14 at 10:00 AM. BP 134/70 9/14 at 2:00 PM. BP 130/70 9/14 at 6:00 PM. BP 134/70 9/14 at 10:00 PM. BP 129/82 9/15 at 10:00 AM. BP 126/75 9/15 at 2:00 PM. BP 128/75 9/16 at 10:00 AM. BP 120/100 9/16 at 2:00 PM. BP 118/88 Continued review of an Electronic Physician's Order dated 9/16/16 revealed LPN #3 removed the parameter to hold the [MEDICATION NAME] 5mg if the systolic blood pressure was less than 120 on 9/16/16 at 5:01 PM. The original parameters from the 9/12/16 order to hold the medication if the systolic BP was greater than 120 or the diastolic BP was greater than 80 was not entered into the computer or transcribed onto the MAR. Medical record review of the MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 10/19/16 at 4:05 PM, in the conference room revealed the DON was aware medications were being administered outside the 2 hour window, 60 minutes before and 60 minutes after the scheduled time allowed for medication administration. Continued interview with the DON confirmed administering medications greater than the 2 hour window was a medication error and stated It's not acceptable. The DON confirmed the blood pressure parameters for the 9/12/16 [MEDICATION NAME] 5mg order for Resident #3 had been entered into the computer incorrectly and the medication was administered to the resident when it should not have been. Continued interview confirmed the correct blood pressure parameters should have been entered on 9/16/16 and were not. Further interview revealed the DON confirmed when a blood sugar or blood pressure was not documented prior to administering or holding insulin or a blood pressure medication as ordered it was a medication error. The DON confirmed the facility failed to check blood sugars as scheduled, failed to follow the facility policy to administer medications within the 2 hour window, failed to enter BP orders into the computer correctly, and failed to document blood sugars and/or blood pressure readings, resulting in significant medication errors for Resident #2 and #3. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for October 2016 revealed: a. on 7 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 4 occasions insulin was administered 1 1/2 - 2 hours past the scheduled window. c. on 6 occasions [MEDICATION NAME] was administered 1 1/2 - 3 hours past the scheduled window. Medical record review of physician's admission orders [REDACTED]. Continued review revealed if the blood glucose was greater than 400 the nurse was to notify the physician. Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. Continued review revealed no documentation the blood glucose was rechecked in 15 minutes per physician orders and facility policy. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a History and Physical from the hospital dated 9/14/16 revealed Resident #6 was admitted for a blood sugar which was .measurable high . Continued review revealed the blood glucose in the Emergency Department was 500 and significant ketosis was present. Medical record review of the Medication Administration Record [REDACTED] a. on 22 occasions blood glucose monitoring was completed from 1 1/2 - 7 hours past the scheduled window of 60 minutes after the scheduled time b. on 12 occasions insulin was administered 1 1/2 - 7 hours past the scheduled window c. on 7 occasions [MEDICATION NAME] (antibiotic) was administered 2 - 8 1/2 hours past the scheduled window. Medical record review of the MAR for October 2016 revealed: a. on 33 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 2 occasions insulin was administered 1/2 - 1 1/2 hours past the scheduled window c. on 4 occasions [MEDICATION NAME] (antidepressant) was administered 2 - 3 hours past the scheduled window d. on 4 occasions [MEDICATION NAME] (antidepressant) was administered 1/2 - 3 hours past the scheduled window e. on 9 occasions [MEDICATION NAME] (anti-anxiety) was administered 1 1/2 - 4 hours past the scheduled window Medical record review of physician's admission orders [REDACTED]. Continued review revealed the order stated if the resident's blood glucose was greater than 400 the nurse was to administer 10 units of insulin and notify the physician. Medical record review of the blood glucose monitoring sheets and the Medication Administration Record [REDACTED] a. 9/20/16 blood glucose 593 at 9:00 PM b. 9/24/16 blood glucose 405 at 9:00 PM c. 9/29/16 blood glucose 421 at 1:00 PM d. 9/29/16 blood glucose 423 at 5:00 PM e. 10/4/16 blood glucose 405 at 6:15 PM Continued review revealed no documentation the physician was notified of any of these abnormal blood glucose results. Further review revealed no documentation the blood glucose was rechecked in 15 minutes on each of these occasions per physician order and facility policy. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for October 2016 revealed: a. on 7 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 4 occasions insulin was administered 1 1/2 - 2 hours past the scheduled window. c. on 6 occasions [MEDICATION NAME] was administered 1 1/2 - 3 hours past the scheduled window. Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for October 2016 revealed: a. on 18 occasions blood glucose monitoring was completed 1 1/2 - 3 hours past the scheduled window b. on 16 occasions insulin was administered 2 1/2 - 8 hours past the scheduled window c. on 5 occasions [MEDICATION NAME] (cardiac) was administered 3 1/2 - 6 hours past the scheduled window d. on 9 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 3 hours past the scheduled window e. on 5 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 3 hours past the scheduled window f. on 3 occasions [MEDICATION NAME] (antianxiety) was administered 1 1/2 - 2 1/2 hours past the scheduled window Medical record review of the physician's admission orders [REDACTED].blood glucose monitoring before meals and at bedtime. If BS (blood sugar) > (greater than) 400 notify MD and recheck in 15 minutes . Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. Continued review revealed no documentation the physician was notified of the abnormal blood glucose result and no documentation the blood glucose was rechecked after 15 minutes per physician orders and facility policy. Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for September 2016 revealed: a. on 54 occasions blood glucose monitoring was completed 1 1/2 - 8 1/2 hours past the scheduled window b. on 18 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 5 hours past the scheduled window c. on 13 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 1/2 hours past the scheduled window d. on 14 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 4 1/2 hours past the scheduled window e. on 3 occasions [MEDICATION NAME] (cardiac) was administered 1 1/2 - 2 1/2 hours past the scheduled window f. on 1 occasion [MEDICATION NAME] ([MEDICAL CONDITION]) and [MEDICATION NAME] (antacid) were administered 10 1/2 hours past the scheduled window Medical record review of the MAR for October 2016 revealed: a. on 31 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 4 occasions insulin was administered 2 - 5 hours past the scheduled window c. on 20 occasions [MEDICATION NAME] was administered 1 1/2 - 7 /12 hours past the scheduled window d. on 11 occasions [MEDICATION NAME] was administered 2 - 3 hours past the scheduled window e. on 13 occasions [MEDICATION NAME] was administered 1 1/2 - 5 hours past the scheduled window. Medical record review of physician's admission orders [REDACTED]. Continued review revealed if the blood glucose was greater than 400 the nurse was to notify the physician and recheck the blood glucose in 15 minutes. Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. Continued review revealed there was no documentation the physician was notified of the abnormal blood glucose result. Further review revealed no documentation the blood glucose was rechecked in 15 minutes per physician orders and the facility policy. Medical record review revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for September 2016 revealed: a. on 30 occasions blood glucose monitoring was completed 1 1/2 - 7 hours past the scheduled window b. on 20 occasions insulin was administered 1 1/2 - 7 hours past the scheduled window c. on 43 occasions [MEDICATION NAME] (antianxiety) was administered 1 1/2 - 5 hours past the scheduled window. d. on 16 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 hours past the scheduled window e. on 16 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 hours past the scheduled window Medical record review of the MAR for October 2016 revealed: a. on 13 occasions blood glucose monitoring was completed 1 1/2 - 4 hours past the scheduled window b. on 6 occasions insulin was administered 1 1/2 - 3 1/2 hours past the scheduled window c. on 19 occasions [MEDICATION NAME] was administered 1 1/2 - 2 1/2 hours past the scheduled window d. on 8 occasions [MEDICATION NAME] was administered 1 1/2 - 3 1/2 hours past the scheduled window e. on 8 occasions [MEDICATION NAME] was administered 1 1/2 hours - 3 1/2 hours past the scheduled window Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for September 2016 revealed: a. on 47 occasions blood glucose monitoring was completed 1 1/2 - 7 hours past the scheduled window. Medical record review of the MAR for October 2016 revealed: a. on 34 occasions blood glucose monitoring was completed 1 1/2 - 7 1/2 hours past the scheduled window. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for October 2016 revealed: a. on 21 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window Medical record review revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED] a. blood glucose check at 7:30 AM b. Humalog Insulin according to the blood glucose at 7:30 AM c. [MEDICATION NAME] (antacid) 150 milligrams (mg) due at 9:00 AM d. [MEDICATION NAME] ([MEDICAL CONDITION]) 600 mg due at 9:00 AM e. [MEDICATION NAME] ([MEDICAL CONDITION]) 250 mg due at 9:00 AM f. [MEDICATION NAME] (antibiotic)100 mg due at 10:00 AM g. Eliquis (anticoagulant) 10 mg due at 10:00 AM h. [MEDICATION NAME] (steroid) 5 mg due at 10:00 AM Observation during the medication pass which began at 11:00 AM, revealed RN #3 administered all of the medications and completed the blood glucose check at 11:15 AM. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED] a. [MEDICATION NAME] (diuretic) 37.5/25 mg at 8:00 AM b. [MEDICATION NAME] (diuretic) 40 mg at 9:00 am c. [MEDICATION NAME] (cardiac) 240 mg at 9:00 AM d. Potassium Chloride (replacement) 20 milliequivalents at 9:00 AM e. [MEDICATION NAME] (stool softener) 100 mg at 10:00 AM f. [MEDICATION NAME] (antibiotic) 100 mg at 10:00 AM g. [MEDICATION NAME] (antibiotic) 2 grams intravenously at 10:00 AM Observation during the medication pass revealed RN #3 administered all of the medications at 12:05 PM. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED] a. [MEDICATION NAME] (antihypertensive) 40 mg at 9:00 AM b. [MEDICATION NAME] (prevent blood clotting) 30 mg due at 9:00 AM Observation during the medication pass revealed RN #3 administered both medications at 11:45 AM. There were 21 medications given more than 1 hour before or 1 hour after the scheduled time with 32 medications observed during medication pass for a medication error rate of 65%. Interview with RN #3 on 10/19/16 at 12:30 PM on Hall #1 revealed she was aware she was late administering her medications but also stated .I would rather my residents be safe . Continued interview revealed RN #3 stated medications are signed off as soon as they are administered because to wait until the end of med pass would be too confusing and difficult to remember if any medications were held. Interview with the Director of Nursing (DON) on 10/19/16 at 4:05 PM in the conference room revealed she was aware medications were being administered outside the 2 hours window (60 minutes before and 60 minutes after the scheduled time) allotted for medication administration. Continued interview with the DON confirmed medications, blood glucose monitoring, and insulin were administered at times greater than the 2 hours window allowed. Further interview with the DON confirmed it was a medication error for medications to be administered more than 1 hour before or 1 hour after the scheduled time. Refer to F157 K

Based on facility policy review, medical record review, and interview, the facility failed to ensure medical records were complete and accurate for 7 (Resident #2, #3, #5, #6, #7,#8, #18) residents of 14 residents reviewed by failing to document physician notification of blood glucose results greater than 400; failing to document recheck of abnormal blood glucose values in 15 minutes; failing to document blood glucose monitoring and tube feedings as ordered by the physician; and failing to document tube feedings administered when a resident's meal intake was decreased. These failures resulted in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident) for all facility residents. The Administrator (NHA) was notified of the Immediate Jeopardy on 10/24/16 at 3:25 PM in the Conference Room. The findings included: Review of facility policy, Change in a Resident's Condition or Status, undated, revealed, .To insure the proper and timely .documentation of any changes in a resident's condition or status .The nurse will record in the resident's medical record any changes in the resident's medical condition or status . Review of facility policy, Diabetes, Nursing Care of the Adult Diabetes Mellitus Resident, undated, revealed, .The purpose of this guideline is .Prevent recurrence of [MEDICAL CONDITION]/[DIAGNOSES REDACTED] (high and low blood sugars) .document the treatment of [REDACTED]. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].ACCUCHECKS (finger stick for blood sugar) BEFORE BOLUS FEEDINGS AND SSI (sliding scale insulin) AS FOLLOWS: 0-59 = CALL MD(Medical Doctor) .351-400 = 10u .NOTIFY MD AND RECHECK IN 15 MINUTES . Medical record review of the 6/2016 Medication Administration Record [REDACTED] 591 on 6/4 at 7:30 AM 432 on 6/6 at 6:00 AM 401 on 6/7 at 12:00 AM High on 6/9 at 12:00 PM 456 on 6/12 at 6:00 AM 429 on 6/18 at 6:00 AM Medical record review revealed no documentation the MD or Nurse Practitioner (NP) were notified regarding the elevated blood sugars, and no documentation the blood sugars were re-checked in 15 minutes. Medical record review of the 7/2016 MAR indicated [REDACTED] 564 on 7/1 at 6:00 AM 441 on 7/1 at 12:00 PM 503 on 7/6 at 12:00 AM 489 on 7/9 at 12:00 PM 518 on 7/10 at 12:00 AM 511 on 7/10 at 12:00 PM 405 on 7/12 at 12:00 AM 466 on 7/25 at 6:00 AM 459 on 7/27 at 12:00 AM 436 on 7/31 at 6:00 PM Medical record review revealed no documentation the MD or NP were notified of Resident #2's elevated blood sugars, and no documentation the blood sugars were re-checked in 15 minutes. Medical record review of the 8/2016 MAR indicated [REDACTED] 475 on 8/1 at 12:00 AM 492 on 8/7 at 6:00 PM 456 on 8/20 at 6:00 PM 432 on 8/21 at 6:00 PM 493 on 8/25 at 6:00 PM Medical record review revealed no documentation the MD or NP were notified regarding the elevated blood sugars, and no documentation the blood sugars were re-checked in 15 minutes for Resident #2. Medical record review of the 9/2016 MAR indicated [REDACTED] 423 on 9/3 at 12:00 PM 487 on 9/4 at 6:00 PM 47 on 9/7 at 12:00 PM 452 on 9/10 at 12:00 PM 482 on 9/16 at 12:00 AM 434 on 9/17 at 6:00 AM 491 on 9/17 at 12:00 PM 501 on 9/22 at 12:00 PM 560 on 9/23 at 6:00 AM 474 on 9/23 at 12:00 PM 420 on 9/26 at 12:00 AM Medical record review revealed no documentation the MD or NP were notified regarding the elevated blood sugars, and no documentation Resident #2's blood sugars were re-checked in 15 minutes. Interview with LPN #6 on 10/19/16 at 7:15 AM in the conference room confirmed Resident #2's blood sugar was 47 on 9/7/16 and she failed to document the results of the blood sugar after rechecking it, and failed to document the physician was notified. Medical record review of the 10/16 MAR indicated [REDACTED]. Medical record review revealed no documentation the MD or NP was notified regarding Resident #2's elevated blood sugars, and no documentation the blood sugar was re-checked in 15 minutes. Interview with the Director of Nursing (DON) on 10/19/16 at 4:05 PM, in the conference room confirmed the facility failed to document the MD or NP were notified of the elevated blood sugars, and failed to document the blood sugar was re-checked 15 minutes after identifying it was greater than 400. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's telephone order dated 9/12/16 revealed, .[MEDICATION NAME] HCL (used to treat low blood pressure) 5 mg tab (tablet) give one tab PT (per tube) before meals; BP (blood pressure) to be checked prior to administration, Hold for BP (systolic greater than 120 or diastolic greater than 80) . The order was written by LPN #4 and signed by NP #1. Medical record review of the MAR indicated [REDACTED]. Interview with the DON on 10/19/16 at 4:05 PM, in the conference room confirmed the facility failed to follow their policy for documentation and failed to document blood sugar and/or blood pressure results per physician orders [REDACTED].#3. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's admission orders [REDACTED]. Continued review revealed if the blood glucose was greater than 400 the nurse was to notify the physician. Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. continued review revealed no documentation the blood glucose was rechecked in 15 minutes per physician orders [REDACTED]. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's admission orders [REDACTED]. Continued review revealed the order stated if the resident's blood glucose was greater than 400 the nurse was to administer 10 units of insulin and notify the physician. Medical record review of the blood glucose monitoring sheets and the MAR indicated [REDACTED] a. 9/20/16 blood glucose 593 at 9:00 PM b. 9/24/16 blood glucose 405 at 9:00 PM c. 9/29/16 blood glucose 421 at 1:00 PM d. 9/29/16 blood glucose 423 at 5:00 PM e. 10/4/16 blood glucose 405 at 6:15 PM Continued review revealed no documentation the physician was notified of any of these abnormal blood glucose results. Further review revealed no documentation the blood glucose was repeated in 15 minutes per physician order [REDACTED]. Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's admission orders [REDACTED].blood glucose monitoring before meals and at bedtime. If BS (blood sugar) > (greater than) 400 notify MD and recheck in 15 minutes . Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. Continued review revealed no documentation the physician was notified of the abnormal blood glucose result. Further review revealed no documentation the blood glucose was rechecked in 15 minutes per physician order [REDACTED]. Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's admission orders [REDACTED]. Continued review revealed if the blood glucose was greater than 400 the nurse was to notify the physician and recheck the blood glucose in 15 minutes. Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. Continued review revealed there was no documentation the physician was notified of the abnormal blood glucose result. Further review revealed no documentation the blood glucose was rechecked in 15 minutes per physician order [REDACTED]. Medical record review of physician's orders [REDACTED].Please give 8 ounces [MEDICATION NAME] (liquid feeding given via tube for residents who are unable to swallow) 1.5 per tube as needed if meal intake is less than 50% . Continued review of physician orders [REDACTED].[MEDICATION NAME] 1.5 cal liquid, Give 8 ounces per tube BID (twice daily) between meals with 120 ml (milliliters) H2O flush before and after each bolus . Medical record review of the Medication Administration Record [REDACTED]. Continued review revealed the 8 ounces to be given with food intake less than 50% was scheduled for 9:00 AM, 1:00 PM, and 7:00 PM. Further review of the MAR indicated [REDACTED]. Medical record review of nursing notes for 10/2016 revealed no documentation the [MEDICATION NAME] was given between meals as ordered. Interview with Licensed Practical Nurse (LPN) #7 on 10/17/16 at 3:05 PM in the conference room, revealed she documented the amount the resident ate and put a check mark to indicate she was aware of the amount the resident ate. continued interview revealed if the resident ate less than 50% of the meal the nurse would administer [MEDICATION NAME] to the resident. Interview with LPN #3 on 10/17/16 at 3:11 PM in the conference room revealed nurses place a check mark on the MAR indicated [REDACTED]. Continued interview revealed if the resident ate less than 50% the staff would give [MEDICATION NAME] because that was the order. Further interview revealed LPN #3 was not aware of any place to document the [MEDICATION NAME] when it it given. Continued interview revealed .If the amount the resident eats is less than 50% we assume the nurse administered the [MEDICATION NAME] . Review of facility policy, Negative Pressure Wound Therapy (NPWT), undated revealed, .Inspect condition of wound on ongoing basis; note drainage and odor .verify airtight dressing seal and correct negative pressure setting. Measure wound drainage output in canister .Chart in the nurses's notes the appearance of wound, color, characteristics of any drainage .NPWT pressure setting, dressing change, and resident response to dressing change . Medical record review revealed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired, always incontinent of bowel and bladder and had a Stage IV pressure ulcer to the sacrum. Medical record review of a physician's telephone order dated 10/10/16 prescribed by NP #3 revealed, .Coccyx pressure area - NPWT to pack/fill woundbed & drape to seal .Continue AG Collagen to cover coccyx wound bed each Vac (change) . Observation of Resident #18 on 10/18/16 at 10:20 AM, in the resident's room revealed the resident was in bed, eyes closed. A wound vac was present to the side rail with serous drainage noted. Interview with the Wound Nurse on 10/19/16 at 11:30 AM in Hermitage Hall when asked when the resident's wound vac was placed stated, Friday. (10/14). Continued interview revealed when asked what the treatment order dated 10/10 meant the Wound Nurse stated, that the wound vac was there. Continued interview revealed the Wound Nurse confirmed she documented care of the resident and the wound vac on 10/13, 10/14, 10/17, 10/18, and 10/19. Further review revealed there was no additional documentation of when the wound vac was placed, the negative pressure setting, how often it was to be changed, amount and color of drainage or how the resident was tolerating it. The Wound Nurse stated, I should have documented all of that. Interview with the DON on 10/19/16 at 4:05 PM in the conference room confirmed the Wound Nurse should have clarified the 10/10/16 treatment order for the wound vac to Resident #18 on 10/10/16, and most certainly when the wound vac was placed. Continued interview with the DON confirmed there should have been documentation of the amount, color and odor of drainage, how the resident was tolerating the wound vac, the amount of negative pressure the wound vac was set on, and the type of wound vac machine and there was not. Interview with LPN #8 on 10/20/16 at 1:00 PM in the conference room confirmed she had cared for the resident on 10/15/16 and had documented on the TAR she had followed the treatment order dated 10/10/16. When asked what the protocol was for care of a resident with a wound vac she stated, It is changed every Monday, Wednesday, and Friday and it is done by the Treatment (Wound) Nurse. When asked what her documentation of the order meant, she stated, I've never changed a wound vac before. I checked that it was there. Continued interview with the LPN confirmed she did not provide any care, or documentation of the wound, or wound vac for Resident #18. Telephone interview with LPN #11 on 10/20/16 at 4:50 PM confirmed she had cared for the resident on 10/16/16. When asked what care she provided to the resident she stated, He had a wound vac to his sacrum. I changed the tape. The wound was exposed and I secured the dressing with tape. Continued interview with the LPN confirmed she did not change the dressing, or document the status of the wound, wound vac settings, drainage type and amount, or how the resident was tolerating the care. Refer to F157 K, F224 L SQC, F281 L, F332 L SQC, F333 L SQC, F353 L, F490 L, F493 L, F501 L.

Based on medical record review, committee minutes review, and interview, the Quality Assurance and Performance Improvement Committee failed to identify quality deficiencies and develop/implement plans of action to correct those deficiencies by failing to ensure physicians were notified of abnormal blood glucose results; failing to ensure care plans were followed for diabetic residents; failure to prevent significant medication errors; failure to prevent neglect of residents with medication not administered according to physician orders; and failure to ensure accurate and complete documentation. These failures placed all residents of the facility in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 10/24/16 at 3:25 PM in the Conference Room. The findings included: Interview with the Administrator and the Director of Nursing (DON). on 10/24/16 at 11:15 AM, in the Conference Room revealed they had identified some medications were not administered within the time lines and had done inservices with the staff. Continued interview revealed they were unaware of the magnitude of the medication errors. Refer to F157 K, F224 L SQC, F332 L SQC, F333 L SQC, F353 L, F490 L, F493 L, F501 L, F514 L.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure 8 (Resident #2, #3, #4, #5, #7, #8, #9, #10) residents of 12 residents reviewed were free from significant medication errors; failed to ensure blood glucose monitoring was completed as ordered; failed to ensure insulin was administered at scheduled times; failed to administer medications to control blood pressure, behaviors, and [MEDICAL CONDITION] within the scheduled time frame; and failed to administer antibiotics as ordered. These failures placed all residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 10/24/16 at 3:25 PM in the Conference Room. F333 is Substandard Quality of Care. The findings included: Review of facility policy, Medication Administration revised 3/16/15 revealed, .Administer medications within 60 minutes of the scheduled time .for example, if the medication is ordered for 8:00 a.m., it must be give between 7:00 a.m. and 9:00 a.m. in order to be considered timely . Review of facility policy, Diabetes, Nursing Care of the Adult Diabetes Mellitus Resident, undated, revealed, .The purpose of this guideline is .Prevent recurrence of [MEDICAL CONDITION]/[DIAGNOSES REDACTED] (high and low blood sugars). Recognize, assist and document the treatment of [REDACTED].obtain pre-meal fingerstick blood glucose within 60 minutes (maximum) of anticipated meal .The physician should be notified when the blood sugar falls above his/her specified blood sugar range and/or above 400 mg/dL (milligrams per deciliter) . The Medical Director of the facility is the physician of record for all the residents. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician's Order dated 6/4/16 revealed, .ACCUCHECKS (finger stick for blood sugar) BEFORE BOLUS FEEDINGS AND SSI (sliding scale insulin) AS FOLLOWS: 0-59 = CALL MD 60-150=0, 151-200=2u (units), 201-250=4u, 251-300=6u, 301-350=8u, 351-400 = 10u .NOTIFY MD AND RECHECK IN 15 MINUTES . The scheduled time was 6 AM, 12 PM, 6 PM, and 12 AM daily. Medical record review of the 6/2016 Medication Administration Record [REDACTED]. Continued review revealed blood sugars were checked 1-4 hours late 2 times for the month of 6/2016. Interview with Licensed Practical Nurse (LPN) #3 on 10/18/16 at 2:20 PM, in the conference room stated he called Nurse Practitioner (NP) #2 on 6/4/16 regarding the blood sugar of 211 for Resident #2 and was told to hold the SSI dose of 4 units. Continued interview with the LPN confirmed he did not write an order to hold the 4 units of insulin, and he did not administer the dose per the sliding scale protocol. Medical record review of the 7/2016 MAR indicated [REDACTED]. Medical record review of the 9/2016 MAR indicated [REDACTED]. Medical record review of Resident #2's Physician's Orders dated 9/22/16 revealed an order for [REDACTED]. The scheduled administration time was 9:00 PM. Medical record review of the 9/2016 MAR for Resident #2 revealed [MEDICATION NAME] 21 units was not administered on 9/22/16 at 9:00 PM per physician's order. Continued medical record review of the 9/2016 MAR indicated [REDACTED]. The blood sugar was not checked at 6:00 PM per order. The blood sugar was 327 at 12:00 AM on 9/23 and no SSI was administered; the blood sugar was 560 at 6:00 AM and no SSI was administered. Medical record review revealed NO physician orders to hold accuchecks, [MEDICATION NAME], or SSI for Resident #2 on 9/22 and 9/23/16. Interview with NP #1 on 10/12/16 at 12:38 PM, in the conference room confirmed there were no written telephone orders or computerized orders to hold the [MEDICATION NAME] dose at 9:00 PM, and no order to hold any SSI at 12:00 AM or 6:00 AM on 9/22 and 9/23 for Resident #2. Interview with LPN #4 on 10/12/16 at 2:05 PM, in the conference room revealed she notified NP #1 on 9/22/16 when Resident #2's blood sugar was 501 and was told to give 10 units of insulin, wait 30 minutes and re-check it again. Continued interview with the LPN revealed when she re-checked the blood glucose 30 minutes later the blood glucose was higher than 501 and the NP told her to give an additional 12 units of insulin and recheck it after that. Further interview with LPN #4 revealed she checked it after administering 12 units and the blood glucose was in the 300's. Continued interview with the LPN confirmed she failed to write an order to administer an additional 12 units of insulin to the resident on 9/22/16. Telephone interview with RN #2 on 10/12/16 at 3:20 PM confirmed he did not write a telephone order to hold Resident #2's [MEDICATION NAME] 21 units of insulin and did not put an order in the computer on 9/22/16. Telephone interview with LPN #5 on 10/18/16 at 4:00 PM revealed (Named RN #2) gave me report to hold the insulin for lab work in the morning. I should have looked to see the order myself, and I did not call the Doctor when the sugar was 560. I was just going on what I was told. Continued interview with the LPN confirmed she failed to administer SSI per the physicians order to Resident #2 on 9/23 at 12:00 AM and 6:00 AM. Medical record review of the 10/2016 MAR indicated [REDACTED]. Medical record review of a physician's order dated 7/25/16 for Resident #2 revealed, [MEDICATION NAME] (blood pressure medication, used for Hypertension) 10 MG (milligrams) CAPSULE GIVE ONE CAPSULE PER [DEVICE] EVERY 8 HOURS The scheduled time of administration was 6:00 AM, 2:00 PM, and 10:00 PM. Medical record review of the 7/16 MAR indicated [REDACTED]. Medical record review revealed no physician orders to hold the [MEDICATION NAME] on 7/25 or 7/27, and no physician orders with parameters to hold the [MEDICATION NAME] for a blood pressure of 102/58. Medical record review of the 8/16 MAR indicated [REDACTED]. Medical record review revealed no physician orders for parameters to hold the [MEDICATION NAME] if the systolic blood pressure was less than 110. Continued review revealed no physician orders to hold the [MEDICATION NAME] on 8/19 or 8/22/16. Medical record review of the 9/2016 MAR indicated [REDACTED]. Medical record review revealed no physician's order to hold the [MEDICATION NAME] on 9/16/16 at 6:00 AM for Resident #2. Interview with NP #2 on 10/24/16 at 12:20 PM, in the conference room revealed, I don't give parameters for calcium channel blockers ([MEDICATION NAME] is a calcium channel blocker), and I did not give any orders for blood pressure medicines to be held. Medical record review of the 10/2016 MAR indicated [REDACTED] 10/12 scheduled for 10:00 PM; administered at 12:33 AM on 10/13 10/13 scheduled for 2:00 PM; administered at 4:23 PM 10/13 scheduled for 10:00 PM; administered at 11:32 PM 10/14 scheduled for 10:00 PM; administered at 11:41 PM 10/15 scheduled for 2:00 PM; administered at 3:14 PM Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a telephone physician's order dated 9/22/16 revealed, .Accuchecks before meals and at bedtime . The scheduled time of administration was 7:30 AM, 12:00 PM, 5:00 PM, and 9:00 PM. The order did not include sliding scale insulin (SSI) orders. Medical record review of the 9/2016 MAR indicated [REDACTED]. Medical record review revealed no telephone physician orders regarding accuchecks, SSI, or administration time changes. Medical record review of the physician's recapitulation orders for 9/2016 revealed an order dated 9/23/16 for accuchecks with SSI. The scheduled times were 10:00 AM, 2:00 PM, 6:00 PM and 10:00 PM. Medical record review of the 9/2016 and 10/2016 MAR indicated [REDACTED] 9/24 scheduled at 10:00 AM checked at 3:05 PM 9/24 scheduled at 2:00 PM checked at 4:20 PM 9/25 scheduled at 10:00 AM checked at 3:38 PM 9/25 scheduled at 2:00 PM checked at 5:33 PM 9/25 scheduled at 10:00 PM checked at 11:23 PM 9/26 scheduled at 10:00 AM checked at 12:39 PM 9/26 scheduled at 2:00 PM checked at 3:28 PM 9/26 scheduled at 10:00 PM checked at 5:20 AM on 9/27 9/28 scheduled at 10:00 AM checked at 11:19 AM 9/28 scheduled at 2:00 PM checked at 4:04 PM 9/28 scheduled at 10:00 PM checked at 11:36 PM 9/29 scheduled at 10:00 AM checked at 3:19 PM 9/29 scheduled at 2:00 PM checked at 3:20 PM 10/4 scheduled at 2:00 PM checked at 6:08 PM Medical record review of a physician's telephone order dated 9/12/16 revealed, .[MEDICATION NAME] HCL (used to treat low blood pressure) 5 mg tab (tablet) give one tab PT (per tube) before meals; BP (blood pressure) to be checked prior to administration, Hold for BP (systolic greater than 120 or diastolic greater than 80) .The order was written by LPN #4 and signed by NP #1. Medical record review of the Electronic Physician's Order dated 9/12/16 for [MEDICATION NAME] 5 mg revealed it was entered into the computer by LPN #4 at 7:00 PM. The electronic order contained a special requirement to check the blood pressure prior to administration and to hold if the systolic blood pressure was less than 120. Medical record review of 9/2016 MAR indicated [REDACTED].[MEDICATION NAME] HCL 5 MG TABLET give one tablet per tube before meals. CHECK BP (blood pressure) . There were no blood pressure parameters transcribed onto the MAR. Medical record review of the 9/2016 MAR indicated [REDACTED]. 9/12 at 10:00 PM. BP 149/90 9/13 at 10:00 AM. BP 152/82 9/13 at 2:00 PM. BP 125/64 9/13 at 6:00 PM BP 122/80 9/13 at 10:00 PM. BP 124/53 9/14 at 10:00 AM. BP 134/70 9/14 at 2:00 PM. BP 130/70 9/14 at 6:00 PM. BP 134/70 9/14 at 10:00 PM. BP 129/82 9/15 at 10:00 AM. BP 126/75 9/15 at 2:00 PM. BP 128/75 9/16 at 10:00 AM. BP 120/100 9/16 at 2:00 PM. BP 118/88 Continued review of an Electronic Physician's Order dated 9/16/16 revealed LPN #3 removed the parameter to hold the [MEDICATION NAME] 5mg if the systolic blood pressure was less than 120 on 9/16/16 at 5:01 PM. The original parameters from the 9/12/16 order to hold the medication if the systolic BP was greater than 120 or the diastolic BP was greater than 80 was not entered into the computer or transcribed onto the MAR. Medical record review of the MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 10/19/16 at 4:05 PM, in the conference room revealed the DON was aware medications were being administered outside the 2 hour window, 60 minutes before and 60 minutes after the scheduled time allowed for medication administration. Continued interview with the DON confirmed administering medications greater than the 2 hour window was a medication error and stated It's not acceptable. The DON confirmed the blood pressure parameters for the 9/12/16 [MEDICATION NAME] 5mg order for Resident #3 had been entered into the computer incorrectly and the medication was administered to the resident when it should not have been. Continued interview confirmed the correct blood pressure parameters should have been entered on 9/16/16 and were not. Further interview revealed the DON confirmed when a blood sugar or blood pressure was not documented prior to administering or holding insulin or a blood pressure medication as ordered it was a medication error. The DON confirmed the facility failed to check blood sugars as scheduled, failed to follow the facility policy to administer medications within the 2 hour window, failed to enter BP orders into the computer correctly, and failed to document blood sugars and/or blood pressure readings, resulting in significant medication errors for Resident #2 and #3. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for 10/2016 revealed: a. on 21 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for 9/2016 revealed: a. on 22 occasions blood glucose monitoring was completed from 1 1/2 - 7 hours past the scheduled window b. on 12 occasions insulin was administered 1 1/2 - 7 hours past the scheduled window c. on 7 occasions [MEDICATION NAME] (antibiotic) was administered 2 - 8 1/2 hours past the scheduled window. Medical record review of the MAR for 10/2016 revealed: a. on 33 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window. b. on 2 occasions insulin was administered 1/2 - 1 1/2 hours past the scheduled window c. on 4 occasions [MEDICATION NAME] (antidepressant) was administered 2 - 3 hours past the scheduled window d. on 4 occasions [MEDICATION NAME] (antidepressant) was administered 1/2 - 3 hours past the scheduled window e. on 9 occasions [MEDICATION NAME] (anti-anxiety) was administered 1 1/2 - 4 hours past the scheduled window. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for 10/2016 revealed: a. on 7 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window c. on 6 occasions [MEDICATION NAME] was administered 1 1/2 - 3 hours past the scheduled window Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for 10/2016 revealed: a. on 18 occasions blood glucose monitoring was completed 1 1/2 - 3 hours past the scheduled window b. on 16 occasions insulin was administered 2 1/2 - 8 hours past the scheduled window c.on 5 occasions [MEDICATION NAME] (cardiac) was administered 3 1/2 - 6 hours past the scheduled window d. on 9 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 3 hours past the scheduled window e. on 5 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 3 hours past the scheduled window window f. on 3 occasions [MEDICATION NAME] (antianxiety) was administered 1 1/2 - 2 1/2 hours past the scheduled window Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for 9/2016 revealed: a. on 54 occasions blood glucose monitoring was completed 1 1/2 - 8 1/2 hours past the scheduled window b. on 18 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 5 hours past the scheduled window c. on 13 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 1/2 hours past the scheduled window d. on 14 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 4 1/2 hours past the scheduled window e. on 3 occasions [MEDICATION NAME] (cardiac) was administered 1 1/2 - 2 1/2 hours past the scheduled window f. on 1 occasion [MEDICATION NAME] ([MEDICAL CONDITION]) and [MEDICATION NAME] (antacid) were administered 10 1/2 hours past the scheduled windowe Medical record review of the MAR for 10/2016 revealed: a. on 31 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 4 occasions insulin was administered 2 - 5 hours past the scheduled window c. on 20 occasions [MEDICATION NAME] was administered 1 1/2 - 7 /12 hours past the scheduled window d. on 11 occasions [MEDICATION NAME] was administered 2 - 3 hours past the scheduled window e. on 13 occasions [MEDICATION NAME] was administered 1 1/2 - 5 hours past the scheduled window. Medical record review revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for 9/2016 revealed: a. on 30 occasions blood glucose monitoring was completed 1 1/2 - 7 hours past the scheduled window b. on 20 occasions insulin was administered 1 1/2 - 7 hours past the scheduled window c. on 43 occasions [MEDICATION NAME] (antianxiety) was administered 1 1/2 - 5 hours past the scheduled window. d. on 16 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 hours past the scheduled window e. on 16 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 hours past the scheduled window. Medical record review of the MAR for 10/2016 revealed: a. on 13 occasions blood glucose monitoring was completed 1 1/2 - 4 hours past the scheduled window c. on 19 occasions [MEDICATION NAME] was administered 1 1/2 - 2 1/2 hours past the scheduled window d. on 8 occasions [MEDICATION NAME] was administered 1 1/2 - 3 1/2 hours past the scheduled window e. on 8 occasions [MEDICATION NAME] was administered 1 1/2 hours - 3 1/2 hours past the scheduled window Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for 9/2016 revealed: a. on 47 occasions blood glucose monitoring was completed 1 1/2 - 7 hours past the scheduled window Medical record review of the MAR for 10/2016 revealed: a. on 34 occasions blood glucose monitoring was completed 1 1/2 - 7 1/2 hours past the scheduled window. Interview with Nurse Practitioner (NP) #2 on 10/24/16 at 12:20 PM in the Conference Room confirmed she was aware medications were being administered several hours late and it had been going on at least 6 months. Continued interview revealed residents would tell her they had not received their morning medications when she rounded in the afternoon. Refer to F157 K, F224 L SQC, F281 L, F282 L, F332 L SQC.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide adequate nursing services to meet the needs of 2 (Resident #2, #3) residents of 2 residents reviewed as evidenced by checking blood sugars and administering medications consistently late, resulting in significant medication errors, failure to follow facility policies, care plans, physician orders, and failure to document pertinent findings in resident's medical record. These failures placed all residents in Immediate Jeopardy (a situation in which one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident.) The Administrator (NHA) was informed of the Immediate Jeopardy on 10/24/16 at 3:25 PM in the Conference Room. The findings included: Review of facility policy, Medication Administration, revised 3/16/15 revealed, .Administer medications within 60 minutes of the scheduled time . Review of facility policy, Guidelines for Medications, undated revealed .All blood sugars that are less than 60 or greater than 400 must be rechecked in 15 minutes and documented . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a comprehensive care plan dated 6/7/16 revealed a problem of medical management for Diabetes Mellitus Type II. Interventions included, .Administer my scheduled insulin as ordered; Obtain my finger stick blood sugars as ordered . Observation and interview with Licensed Practical Nurse (LPN) #1 on 10/11/16 at 1:15 PM, in Resident #2's room revealed the LPN checked the resident's blood sugar and was administering a bolus tube feeding scheduled at 12:00 PM. The LPN confirmed the tube feeding was administered a little late. Continued interview with LPN #1 in the hallway outside of the resident's room when asked if there was enough staff available to meet the needs of the resident's stated, I've been a nurse for [AGE] years, we're always short staffed. When asked if medications were administered consistently late the LPN stated, I can not lie, when (Resident #3's) tube feedings were every 2 hours and (Resident #2's) are every 6 hours, it was impossible. I've had 30 patients some days. Medical record review of a physician's orders [REDACTED].ACCUCHECKS (finger stick for blood sugar) BEFORE BOLUS FEEDINGS AND SSI (sliding scale insulin) AS FOLLOWS: 0-59 = CALL MD 60-150=0, 151-200=2u (units), 201-250=4u, 251-300=6u, 301-350=8u, 351-400 = 10u .NOTIFY MD AND RECHECK IN 15 MINUTES . The scheduled time was 6 AM, 12 PM, 6 PM, and 12 AM daily. Medical record review of the 6/2016 Medication Administration Record [REDACTED]. Continued review revealed blood sugars were checked 1-4 hours late 2 times for the month of 6/16. Medical record review of the 7/2016 MAR indicated [REDACTED]. The time frame excludes the 60 minute window of time which is allowable to administer medication before or after the scheduled time. Medical record review of Resident #2's 9/2016 MAR indicated [REDACTED]. Medical record review of the 10/2016 MAR for Resident #2 revealed blood sugars were checked 17 minutes-4 hours and 35 minutes late 8 times from 10/1-10/20/16 and checked 1 hour and 26 minutes early on 10/8/16. Telephone interview with RN #2 on 10/12/16 at 3:20 PM confirmed he did not write a telephone order to hold 1 dose of insulin and did not put an order in the computer on 9/22/16 for Resident #2. The RN stated, I'm new to learning the system, it was only my second time working on the floor. I didn't know how to make it a physician's orders [REDACTED]. Telephone interview with LPN #5 on 10/18/16 at 4:00 PM revealed, (RN #2) gave me report to hold the insulin for lab work in the morning. I should have looked to see the order myself, and I did not call the Doctor when (Resident #2's) sugar was 560. I was just going on what I was told. Continued interview revealed, We were so short staffed and he (RN #2) left at 11:30 PM. I had all the patients on Capitol(NAME)and half of the middle section. I had 25 patients from 7-11 (PM) and 37 patients from 11-7 (11 PM-7AM). We were very busy, and we didn't have enough help. Half the time the 3rd nurse leaves at 11 PM and with only 2 nurses on the(NAME) its really difficult to get things done. The first med pass takes 4-5 hours alone. Any nurse will verify how short we are. Medical record review of the 9/2016 MAR indicated [REDACTED]. Interview with LPN #6 on 10/19/16 at 7:15 AM, in the conference room revealed the LPN was tearful. The LPN stated, I had a bad night last night. I had 19 residents and I was the only nurse on Bellmeade (skilled unit). The evening supervisor stayed until 3 AM and she usually leaves at 11 PM because I had an admission at 6:30 PM and I was downing in paperwork. Continued interview revealed when asked about Resident #2's blood sugar of 47 the LPN confirmed she did not document the blood glucose after following the [DIAGNOSES REDACTED] protocol and rechecking it 15 minutes later and should have. LPN #6 stated, I was orienting and that was the 1st time I was by myself. I followed (LPN #8) the day before, but because they were short staffed I had patients and was by myself that day. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated 7/19/16 revealed a problem of insulin dependent diabetes. Interventions included, .Administer my insulin according to my physician's orders [REDACTED]. Medical record review of a telephone physician's orders [REDACTED].Accuchecks before meals and at bedtime . The scheduled time of administration was 7:30 AM, 12:00 PM, 5:00 PM, and 9:00 PM. The order did not include sliding scale insulin (SSI) orders. Medical record review of the 9/2016 MAR indicated [REDACTED]. Medical record review revealed no telephone physician orders [REDACTED]. Medical record review of the Physician's recapitulation orders for 9/2016 revealed an order dated 9/23/16 for accuchecks with SSI. The scheduled times were 10:00 AM, 2:00 PM, 6:00 PM and 10:00 PM. Medical record review of the 9/2016 and 10/2016 MAR indicated [REDACTED] 9/24 scheduled at 10:00 AM checked at 3:05 PM 9/24 scheduled at 2:00 PM checked at 4:20 PM 9/25 scheduled at 10:00 AM checked at 3:38 PM 9/25 scheduled at 2:00 PM checked at 5:33 PM 9/25 scheduled at 10:00 PM checked at 11:23 PM 9/26 scheduled at 10:00 AM checked at 12:39 PM 9/26 scheduled at 2:00 PM checked at 3: 28 PM 9/26 scheduled at 10:00 PM checked at 5:20 AM on 9/27 9/28 scheduled at 10:00 AM checked at 11:19 AM 9/28 scheduled at 2:00 PM checked at 4:04 PM 9/28 scheduled at 10:00 PM checked at 11:36 PM 9/29 scheduled at 10:00 AM checked at 3:19 PM 9/29 scheduled at 2:00 PM checked at 3:20 PM 10/4 scheduled at 2:00 PM checked at 6:08 PM Medical record review of the comprehensive care plan dated 7/19/16 revealed a problem of signs of [MEDICAL CONDITION]. Interventions included, .Administer my cardiac .meds (medications) as ordered . Medical record review of a physician's telephone order dated 9/12/16 revealed, .[MEDICATION NAME] HCL (used to treat low blood pressure) 5 mg tab (tablet) give one tab PT (per tube) before meals; BP (blood pressure) to be checked prior to administration, Hold for BP (systolic greater than 120 or diastolic greater than 80) . The order was written by LPN #4 and signed by NP #1. Medical record review of the 9/2016 MAR for Resident #3 revealed [MEDICATION NAME] 5 mg was administered to the resident with the following BP documented. 9/12 at 10:00 PM. BP 149/90 9/13 at 10:00 AM. BP 152/82 9/13 at 2:00 PM. BP 125/64 9/13 at 6:00 PM BP 122/80 9/13 at 10:00 PM. BP 124/53 9/14 at 10:00 AM. BP 134/70 9/14 at 2:00 PM. BP 130/70 9/14 at 6:00 PM. BP 134/70 9/14 at 10:00 PM. BP 129/82 9/15 at 10:00 AM. BP 126/75 9/15 at 2:00 PM. BP 128/75 9/16 at 10:00 AM. BP 120/100 9/16 at 2:00 PM. BP 118/88 Interview with the ADON on 10/18/16 at 4:45 PM, in the conference room revealed, I've observed 4 staff members that need to go back to orientation due to lack of basic nursing skills. I've looked at charts and seen lack of documentation. I've stayed until 10:00 PM helping to get admissions admitted because the nurses can't do the med cart, chart, care for the residents, work on new orders, assessments or NP orders all at the same time. Interview with NP #1 on 10/19/16 at 2:45 PM, in the conference room when asked if she was aware accuchecks and medications were being administered up to 5 hours late, stated, No. I can see how busy the nurses are trying to pass meds, care for the residents, deal with the families, and chart, so I can see how they are late. It's a lot. I've always felt like they were short staffed. The acuity is so high, especially on IBW (skilled) unit. The shortage of staff is my big concern. Interview with the DON on 10/19/16 at 4:05 PM, in the conference room acknowledged staffing was an issue and stated a nurse told her she was so stressed because they are now expected to do things they hadn't done for the last 1 1/2 years. The DON stated, I told her it was basic nursing that should have been happening all along. Interview with NP #2 on 10/24/16 at 2:20 PM, in the conference room when asked if she was aware accuchecks and medications were being administered up to 5 hours late shook her head and stated, Yes, it's been ongoing for about 6 months. I hear it from the patients consistently that they are still waiting to receive their meds. Nurses go past the time frame for meds due to the amount of patients they have. They say they are too busy and can't get it all done. They have to do orders, patient care, meds, charting and new admissions. Refer to F157 K, F224 L SQC, F 281 L, F 332 L SQC, F333 L SQC.

Based on facility policy review, medical record review, and interview, the facility failed to be administered in a manner to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the residents by failing to ensure physicians were notified of abnormal blood glucose results; failing to ensure care plans were followed for diabetic residents; failing to prevent significant medication errors; failure to prevent neglect of residents with medication not administered according to physician orders; and failure to ensure accurate and complete documentation. These failures placed all residents of the facility in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 10/24/16 at 3:25 PM in the Conference Room. The findings included: Interview with the Administrator on 10/24/16 at 3:25 PM, in the Conference Room revealed he was unaware of the magnitude of the medication errors. Continued interview revealed he was aware some medications were being given late and in-services had been conducted. Refer to F157 K, F224 L SQC, F281 L, F332 L SQC, F333 L SQC, F353 L.

Based on medical record review and interview, the Governing Body failed to oversee the facility and the safety of the residents in an appropriate manner by failing to ensure physicians were notified of abnormal blood glucose results; failing to ensure care plans were followed for diabetic residents; failing to prevent significant medication errors; failure to prevent neglect of residents with medication not administered according to physician orders; and failure to ensure accurate and complete documentation. These failures placed all residents of the facility in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 10/24/16 at 3:25 PM in the Conference Room. The findings included: Interview with the Administrator and the Corporate Nurse on 10/24/16 in the Conference Room revealed they were aware some medications were administered later than they were scheduled but were not aware such actions constituted medication errors. Continued interview revealed they were aware physicians were not being notified of abnormal blood glucose results. Refer to F157 K, F224 L SQC, F281 L, F332 L SQC, F333 L SQC, F353 L, F490 L.

Based on facility policy review, medical record review, observation of medication pass, and interview, the facility failed to ensure the medication error rate was less than 5% for the facility with 21 medications given more than one hour before and one hour after the scheduled time with 32 medications observed during medication pass for a medication error rate of 65%. The facility's failure to ensure safe medication administration placed all residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 10/24/16 at 3:25 PM in the Conference Room. F332 is Substandard Quality of Care. The findings included: Review of facility policy, Medication Administration, revised 3/16/15 revealed, .Administer medications within 60 minutes of the scheduled time .for example, if the medication is ordered for 8:00 a.m., it must be give between 7:00 a.m. and 9:00 a.m. in order to be considered timely . The Medical Director of the facility is the physician of record for all the residents. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation and interview with Licensed Practical Nurse (LPN) #1 on 10/11/16 at 1:15 PM, in Resident #2's room revealed the LPN checked the resident's blood sugar and was administering a bolus tube feeding scheduled at 12:00 PM. Interview with the LPN confirmed the tube feeding was administered a little late, but I get it all done. Medical record review revealed a physician's orders [REDACTED]. The scheduled administration time was 9:00 PM. Medical record review of the Medication Administration Record [REDACTED] 10/8 administered at 10:26 PM 10/9 administered at 10:30 PM 10/10 administered at 11:43 PM 10/11 administered at 10:32 PM 10/12 administered at 12:33 AM on 10/13 10/13 administered at 11:32 PM 10/14 administered at 11:41 PM 10/18 administered at 12:30 AM on 10/19 10/19 administered at 11:25 PM Interview with the DON on 10/19/16 at 4:05 PM, in the conference room revealed the DON was unaware [MEDICATION NAME] was being administered consistently late to Resident #2. Continued interview with the DON confirmed the facility failed to follow the policy to administer medications within the 60 minute time frame before and after the scheduled time resulting in medication errors for Resident #2. Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED] Tylenol ([MEDICATION NAME]) 650 mg due at 9:00 AM Aspirin 81 mg due at 9:00 AM [MEDICATION NAME] (antidepressant) 40 mg due at 9:00 AM [MEDICATION NAME] (over-active bladder) 5 mg due at 9:00 AM [MEDICATION NAME] ([MEDICAL CONDITION]) 1000 mg due at 9:00 AM Floastor ([MEDICATION NAME]) 250 mg due at 9:00 AM Observation during medication pass which began at 11:00 AM, revealed LPN #7 administered all of the medications at 11:10 AM. Medical record review revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED] a. blood glucose check at 7:30 AM b. Humalog Insulin according to the blood glucose at 7:30 AM c. [MEDICATION NAME] (antacid) 150 milligrams (mg) due at 9:00 AM d. [MEDICATION NAME] ([MEDICAL CONDITION]) 600 mg due at 9:00 AM e. [MEDICATION NAME] ([MEDICAL CONDITION]) 250 mg due at 9:00 AM f. [MEDICATION NAME] (antibiotic)100 mg due at 10:00 AM g. Eliquis (anticoagulant) 10 mg due at 10:00 AM h. [MEDICATION NAME] (steroid) 5 mg due at 10:00 AM Observation during the medication pass revealed Registered Nurse (RN) #3 administered all of the medications and completed the blood glucose check at 11:15 AM. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED] a. [MEDICATION NAME] (diuretic) 37.5/25 mg at 8:00 AM b. [MEDICATION NAME] (diuretic) 40 mg at 9:00 am c. [MEDICATION NAME] (cardiac) 240 mg at 9:00 AM d. Potassium Chloride (replacement) 20 milliequivalents at 9:00 AM e. [MEDICATION NAME] (stool softener) 100 mg at 10:00 AM f. [MEDICATION NAME] (antibiotic) 100 mg at 10:00 AM g. [MEDICATION NAME] (antibiotic) 2 grams intravenously at 10:00 AM Observation during the medication pass revealed RN #3 administered all of the medications at 12:05 PM. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED] a. [MEDICATION NAME] (antihypertensive) 40 mg at 9:00 AM b. [MEDICATION NAME] (prevent blood clotting) 30 mg due at 9:00 AM Observation during the medication pass revealed RN #3 administered both medications at 11:45 AM. Interview with RN #3 on 10/19/16 at 12:30 PM on the IBW hall revealed she was aware she was late administering her medications but also stated .I would rather my residents be safe . Continued interview revealed RN #3 stated medications are signed off as soon as they are administered because to wait until the end of med pass would be too confusing and difficult to remember if any medications were held. Interview with the Director of Nursing (DON) on 10/19/16 at 4:05 PM, in the conference room revealed she was aware medications were being administered outside the 2 hours window (60 minutes before and 60 minutes after the scheduled time) allotted for medication administration. Continued interview with the DON confirmed medications, blood glucose monitoring, and insulin were administered at times greater than the 2 hours window allowed. Further interview with the DON confirmed it was a medication error for medications to be administered more than 1 hour before or 1 hour after the scheduled time. Refer to F157 K, F224 L SQC, F281 L, F282 L.

Based on medical record review and interview, the facility failed to ensure the Medical Director assisted the facility to identify, evaluate, and address/resolve medical and clinical concerns/issues that affect resident care and quality of life by failing to ensure physicians were notified of abnormal blood glucose results; failing to ensure care plans were followed for diabetic residents; failure to prevent significant medication errors; failure to prevent neglect of residents with medication not administered according to physician orders; and failure to ensure accurate and complete documentation. These failures resulted in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident) for all facility residents. The Administrator (NHA) was notified of the Immediate Jeopardy on 10/24/16 at 3:25 PM in the Conference Room. The findings included: The Medical Director of the facility is the physician of record for all the residents. Interview with the Medical Director on 10/19/16 at 2:30 PM in the Conference Room revealed he was sure the staff were notifying the Nurse Practitioners of abnormal blood sugar results Continued interview revealed he had reviewed all residents with a [DIAGNOSES REDACTED]. Refer to F157 K, F224 L SQC, F281 L, F332 L SQC, F333 L SQC, F353 L, F490 L, F493 L.

Based on facility policy review, medical record review, and interview, the facility failed to notify the physician of residents with a blood glucose greater than 400 for 5 (Resident #2, #6,#5, #7, #8) of 12 residents reviewed for Diabetes Mellitus. These failures placed all diabetic residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death or a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 10/24/16 at 3:15 PM in the Conference Room. The findings included: Review of facility policy, Change in Resident's Condition or Status, undated, revealed, .To insure the proper and timely reporting and documentation of any changes in a resident's condition or status .Nursing services will notify the resident's attending physician when .there is a significant change in the resident's physical, mental or psychosocial status .there is a need to alter the resident's treatment .Deemed necessary or appropriate in the best interest of the resident . Review of facility policy, Diabetes, Nursing Care of the Adult Diabetes Mellitus Resident, undated revealed, .The physician should be notified when the blood sugar falls above his/her specified blood sugar range and/or above 400 mg/dL (milligrams per deciliter). The Medical Director of the facility is the physician of record for all the residents. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].ACCUCHECKS (finger stick for blood sugar) BEFORE BOLUS FEEDINGS AND SSI (sliding scale insulin) AS FOLLOWS: 0-59 = CALL MD (Medical Doctor) .351-400 = 10u .NOTIFY MD AND RECHECK IN 15 MINUTES . Medical record review of the 6/2016 Medication Administration Record [REDACTED] 591 on 6/4 at 7:30 AM 432 on 6/6 at 6:00 AM 401 on 6/7 at 12:00 AM High on 6/9 at 12:00 PM 456 on 6/12 at 6:00 AM 429 on 6/18 at 6:00 AM Medical record review revealed no notification of the MD or Nurse Practitioner (NP) regarding the elevated blood sugars. Medical record review of the 7/16 MAR indicated [REDACTED] 564 on 7/1 at 6:00 AM 441 on 7/1 at 12:00 PM 503 on 7/6 at 12:00 AM 489 on 7/9 at 12:00 PM 518 on 7/10 at 12:00 AM 511 on 7/10 at 12:00 PM 405 on 7/12 at 12:00 AM 466 on 7/25 at 6:00 AM 459 on 7/27 at 12:00 AM 436 on 7/31 at 6:00 PM Medical record review revealed no notification of the MD or NP regarding the elevated blood sugars. Medical record review of the 8/16 MAR indicated [REDACTED] 475 on 8/1 at 12:00 AM 492 on 8/7 at 6:00 PM 456 on 8/20 at 6:00 PM 432 on 8/21 at 6:00 PM 493 on 8/25 at 6:00 PM Medical record review revealed no notification of the MD or NP regarding the elevated blood sugars. Medical record review of the 9/16 MAR indicated [REDACTED] 423 on 9/3 at 12:00 PM 487 on 9/4 at 6:00 PM 47 on 9/7 at 12:00 PM 452 on 9/10 at 12:00 PM 482 on 9/16 at 12:00 AM 434 on 9/17 at 6:00 AM 491 on 9/17 at 12:00 PM 501 on 9/22 at 12:00 PM 560 on 9/23 at 6:00 AM 474 on 9/23 at 12:00 PM 420 on 9/26 at 12:00 AM Medical record review revealed no notification of the MD or NP regarding the elevated blood sugars or the low blood sugar on 9/7/16. Telephone interview with Licensed Practical Nurse (LPN) #5 on 10/18/16 at 4:00 PM revealed, I did not call the Doctor when the sugar was 560 on 9/23/16. Interview with LPN #6 on 10/19/16 at 7:15 AM, in the conference room confirmed Resident #2's blood sugar was 47 on 9/7/16 and she failed to notify the physician. Medical record review of the 10/2016 MAR indicated [REDACTED]. Medical record review revealed no notification of the MD or NP regarding the elevated blood sugar. Interview with the Director of Nursing (DON) on 10/19/16 at 4:05 PM, in the conference room confirmed the facility policy was to notify the physician if a blood sugar was less than 60 or greater than 400. Continued interview with the DON confirmed the facility failed to follow the policy and notify the physician of the elevated blood sugars for Resident #2. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's admission orders [REDACTED]. Continued review revealed the order stated if the resident's blood glucose was greater than 400 the nurse was to administer 10 units of insulin and notify the physician. Medical record review of a History and Physical from the hospital dated 9/14/16 revealed Resident #6 was admitted for a blood sugar which was .measurable high . Continued review revealed the blood glucose in the Emergency Department was 500 and significant ketosis was present. Medical record review of the blood glucose monitoring sheets and the Medication Administration Record [REDACTED] a. 9/20/16 blood glucose 593 at 9:00 PM b. 9/24/16 blood glucose 405 at 9:00 PM c. 9/29/16 blood glucose 421 at 1:00 PM d. 9/29/16 blood glucose 423 at 5:00 PM e. 10/4/16 blood glucose 405 at 6:15 PM Continued review revealed no documentation the physician was notified of any of these abnormal blood glucose results. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's admission orders [REDACTED]. Continued review revealed if the blood glucose was greater than 400 the nurse was to notify the physician. Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's admission orders [REDACTED].blood glucose monitoring before meals and at bedtime. If BS (blood sugar) > (greater than) 400 notify MD and recheck in 15 minutes . Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. Continued review revealed no documentation the physician was notified of the abnormal blood glucose result. Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's admission orders [REDACTED]. Continued review revealed if the blood glucose was greater than 400 the nurse was to notify the physician and recheck the blood glucose in 15 minutes. Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. Continued review revealed there was no documentation the physician was notified of the abnormal blood glucose result. Interview with the Administrator and new Director of Nursing (DON) on 10/24/16 at 11:15 AM, in the Conference Room revealed they had been working on this tag since the last survey with continued education about notification. Continued interview revealed the DON stated she could not say why nurses were still not documenting physician notification. Interview with Nurse Practitioner (NP) #2 on 10/24/16 at 12:20 PM in the conference room revealed she had never been notified of any medications being administered late. Continued interview revealed NP #2 stated if a blood glucose was greater than 400 she would expect the nurse to recheck in 15 to 30 minutes and notify her if it was still elevated.

Based on facility policy review, medical record review, and interview, the facility failed to notify the physician of a pressure ulcer for 1 (Resident #1) resident of 12 residents reviewed for pressure ulcers. The facility's failure to notify the physician of the pressure ulcer resulted in Actual Harm to Resident #1. The findings included: Facility policy review titled Wound Care Management, dated 3/13/15 revealed, .Notify the .physician .of the presence of the wound and if the resident .has a negative change in the wound appearance . Medical record review revealed Resident #1 was admitted to the facility on [DATE], discharged on [DATE], readmitted on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 15/15 indicating the resident was cognitively intact. Continued review of the MDS revealed the resident had no pressure ulcers and was always incontinent of urine and bowel. Medical record Review of the POS [REDACTED]. Medical record review of the Nursing Admission assessment dated [DATE] at 4:27 AM by Licensed Practical Nurse (LPN) #1, revealed documentation of the presence of a Pressure Ulcer in the skin portion of the assessment for Resident #1. Medical record review of the Departmental Notes dated 3/17/16 at 10:39 AM, by LPN #2, documented .late entry for 3/16/16: resident also has noted open area on coccyx . Medical record review of the Skin Concerns Roster dated 3/17/16 at 5:27 PM by RN #1 revealed, Yes skin concern-nurse notified. Medical record review of the Skin Inspection Report for Resident #1 dated 2/15/16 through 5/4/16 revealed the following: 3/17/16 Skin Not Intact-Existing by LPN #3 4/22/16 Skin Not Intact-New by RN #2 4/27/16 Skin Not Intact-Existing by LPN #4 5/4/16 Skin Not Intact-Existing by LPN #4 Medical record review of the Wound Assessment Report by LPN #5 dated 4/19/16 revealed Resident #1 had an abrasion to the coccyx that was identified on 4/19/16. There was no drainage; the wound measured 1.50 cm (centimeters) in length, 2.70 cm in width, and had a depth of 0.10 cm. Medical record review of the Wound Assessment Report completed by the Wound Nurse dated 5/4/16 revealed the wound type was an abrasion; wound location was coccyx; wound status was deteriorated; a small amount of serosanguinous (yellowish with small amounts of blood) drainage was present; the wound measured 4.00 cm in length, 4.50 cm in width and 0.10 cm in depth; description of the skin irritation/excoriation was documented as Red or darker pink, moderate irritation. Medical record review of the Wound Assessment Report completed by the Wound Nurse, dated 5/9/16, revealed the wound status was unchanged; the wound type was an abrasion; wound location was the coccyx; a small amount of serosanguinous drainage and was documented as to have no infection or pain. The measurements remained unchanged from the previous assessment on 5/4/16. Medical record review revealed no documentation in the physician progress notes [REDACTED].#1 by the physician or nurse practitioner. Telephone interview with the Medical Director (MD) on 5/19/16 at 7:54 AM revealed the MD was unaware of any type of wound for Resident #1. The MD was asked if the Wound Nurse had contacted him on 4/19, 4/27, 5/4 and 5/9 regarding a wound to the coccyx with an increase in size and drainage for Resident #1. The MD stated, No, I definitely was not called 4 times. I was not aware of any problems until the Director of Nursing (DON) called me yesterday to ask me if I knew anything about a shearing problem for (named Resident #1). I told her no, this is the first I've heard of it. Interview with Nurse Practitioner (NP) #2 on 5/19/16 at 9:45 AM, in the Physician's Office at the facility, revealed the NP was present in the facility 5 days a week. The NP stated, I never knew of any wound to (named Resident #1) and I work very closely with (named MD) and I can attest that he never knew anything either. (Named MD) and I rounded on Sunday 5/8/16 and (named Resident #1) was somnolent but arousable over 5/7/16 and 5/8/16. She had a gradual decline over the last week. I absolutely did not know about this. Interview with NP #3 on 5/19/16 at 10:00 AM in the Physician's Office at the facility revealed NP #3 had no knowledge of an abrasion, wound or pressure ulcer to Resident #1. Telephone interview with NP #1 on 5/19/16 at 11:40 AM revealed the NP was nationally certified as a Wound Care and Ostomy Specialist. The NP denied having any knowledge of an abrasion, wound, or pressure ulcer to the coccyx of Resident #1. The NP referred to her notes and stated she had treated the resident for leg pain but no other problems were brought to her attention. The NP was asked if she was notified on 5/4/16 by the Wound Nurse regarding the increase in size and drainage to the wound on the resident, the NP stated, No, I knew nothing about it. I received a list on 5/6/16 with (named resident) name on it to round on for Tuesday 5/10/16 but it is circled because I never saw her, and I thought she was at [MEDICAL TREATMENT]. The NP continued to state she was present at the facility on Monday 5/2/16, Friday 5/6/16, and on Monday 5/9/16 and nothing was ever communicated to her about a wound or any other concern with the resident. The NP stated, I only know if the staff communicate to me or another NP, but I had no knowledge of this. Further interview with NP #1 on 5/24/16 at 7:37 AM revealed the NP stated, I depend on the nurses to let me know there is a problem. There is a Communication Book for the NP's that the nurses can write their problems or concerns, but (named Resident #1) wasn't listed and I never got anything on her. Review of the Hermitage Nurse Station Communication Book dated 3/16/16-5/9/16 revealed no skin concerns were documented for Resident #1. Interview with the Wound Nurse on 6/14/16 at 8:40 AM in the Conference Room, when asked if the MD or NP were notified of a wound for Resident #1 at any time the resident was in the facility, revealed the Wound Nurse stated, No, not from me. The facility's failure to notify the physician of a pressure ulcer resulted in Actual Harm to Resident #1.

Based on facility policy and protocol review, medical record review, interview, and hospital medical record review, the facility failed to timely identify, provide treatment and prevent deterioration of a pressure ulcer for 1 (Resident #1) resident of 12 residents reviewed for pressure ulcers. The facility's failure to timely identify, provide treatment and prevent deterioration of a pressure ulcer resulted in Actual Harm to Resident #1. The findings included: Review of the facility policy titled Skin Program Policy, undated, revealed, Skin problems are minimized to the greatest extent possible through an aggressive approach consisting of four components. They are: 1. Prevention, evaluation and screening 2. Ongoing surveillance 3. Treatment orders 4. Treatment protocol .Each resident is evaluated for .skin care at the time of admission .all residents receive a weekly skin integrity check performed by licensed personnel .all disciplines are alerted immediately if the resident .is at risk for the development of skin breakdown. The nursing department coordinates the response to the resident needs (in the area of skin integrity) by the following means .With an array of preventative measures practiced on the resident's behalf when the resident has been identified as being at risk .The admitting nurse completes a Braden skin and Pressure risk assessment .shows the resident to be 'at risk' or prone to skin breakdown .the Pressure Ulcer Prevention Checklist is implemented. Protocols for prevention of skin breakdowns are included on the Pressure Ulcer Prevention Checklist that should be completed .With each dressing change or at least on a weekly assessment will be made addressing at least the following per policy and procedure. 1. Site 2. Stage I, II, III, IV, Deep Tissue Injury, Unstageable 3. Size, diameter, depth and edges 4. Presence or absence of drainage, undermining 5. Presence or absence of odor, {necrotic} tissue type or amount 6. Skin color surrounding wound 7. {Peripheral} Tissue [MEDICAL CONDITION] 8. {Peripheral} Tissue Induration 9. Granulation Tissue 10. [MEDICATION NAME] 11. Response to treatment or progress 12. Dietary and physician notified 13. Responsible Party Notified . Review of the facility protocol titled Pressure Ulcer Protocol, undated, revealed, Prevention Protocol: Pressure relief; Skin care .Assessment; Incontinence Status; Resident Mobility; Resident and Family Education .Intervention .Repositioning in bed every 1-2 hours and in chair every 30 minutes; Wrinkle and debris free linen .Bowel and bladder management regimen .Educate resident .weight shifting in bed and chair, teach to turn if possible .Chart initial assessment of pressure ulcer noting: location, stage, size, depth, absence or presence of pain, absence or presence of pressure, exudate (if present), wound bed, description of wound edges. Daily monitoring includes .Evaluation of dressing if present .The presence of complications such as signs of increasing areas of ulcerations or infections or leaking around the wound . Review of the Hartmann Wound Care Protocol attached to the Pressure Ulcer Protocol provided by the facility revealed, Category/Stage I: Non-blanchable [DIAGNOSES REDACTED] Epidermis is intact .Treatment objective: Prevent any further damage to the resident's skin .Treatment Option 1 .*Appropriate support service for Stage 1 *Moisturizing cream or ointment .Treatment Option 2 *Appropriate support surface .Thin [MEDICATION NAME] dressing, a gel sheet dressing or a transparent film dressing .Category/Stage II: Partial thickness ulcer penetrating the epidermis and possibly into, but not through the dermis .*Sacral wounds* Use PermaFoam DO NOT use [MEDICATION NAME] .Treatment Objective: Prevent furter damage and create an environment conducive to re-[MEDICATION NAME] .Treatment Option 2 Stage II- Abrasion or shallow crater wound producing a minimal to moderate amount of drainage .*[MEDICATION NAME] dressing, gel sheet dressing or foam dressing .Gently cleanse the wound with normal saline or wound cleanser .Place the dressing over the center of the wound .Change the dressing every 3-4 days or if the dressing begins to leak .Turn the resident every 2 hours . Review of the facility prevention policy attached to the Pressure Ulcer Protocol and the Hartmann Wound Care protocol provided by the facility titled Protecting Against the Adverse Effects of External Mechanical Forces, Pressure, Friction and Shear is another goal in the prevention of pressure ulcers .Any individual in bed who is assessed to be at risk for developing pressure ulcers should be REPOSITIONED at least every 2 hours .A written plan for systematically turning and repositioning .should be used .Using LIFTING DEVICES such as a trapeze or bed linen to move (rather than drag) individuals in bed who cannot assist during transfers and position changes .A written plan for the use of positioning devices is helpful for chair-bound individuals. Medical record review revealed Resident #1 was admitted to the facility on [DATE], discharged on [DATE], readmitted on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Medical record review the Post hospitalization Transition Discharge Instructions from the discharging hospital dated 3/16/16 revealed documentation of a Sacrum Stage one pressure ulcer, treated with repositioning and a [MEDICATION NAME] (foam dressing). Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 15/15 indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance for bed mobility and transfers, had no pressure ulcers and was always incontinent of urine and bowel. Medical record review of the comprehensive care plan dated 2/16/16 revealed the resident was at risk for skin breakdown. Continued review of the comprehensive care plan revealed no care plan for the care and treatment of [REDACTED]. Medical record review of the Nursing Admission assessment dated [DATE] at 4:27 AM by Licensed Practical Nurse (LPN) #1 revealed documentation of the presence of a Pressure Ulcer for Resident #1. Medical record review of the Nursing Risk assessment dated [DATE] at 9:51 AM revealed it was completed by Registered Nurse (RN) #1. Continued review of the Nursing Risk Assessment revealed a Visual Body Map that documented Resident #1 had an abrasion to the left gluteal coccyx area (low buttock/back area). Medical record review of the Departmental Notes dated 3/17/16 at 10:39 AM revealed LPN #2 documented .late entry for 3/16/16: resident also has noted open area on coccyx . Medical record review of the Skin Concerns Roster dated 3/17/16 at 5:27 PM by RN #1 revealed Yes skin concern-nurse notified. Medical record review of the Skin Inspection Report for Resident #1 revealed the following: 3/17/16 Skin Not Intact-Existing by LPN #3 4/22/16 Skin Not Intact-New by RN #2 4/27/16 Skin Not Intact-Existing by LPN #4 5/4/16 Skin Not Intact-Existing by LPN #4 Continued medical record review revealed no physician's order to treat the open area on the coccyx until 4/19/16. Medical record review of the Wound Assessment Report by LPN #5 dated 4/19/16 revealed Resident #1 had an abrasion to the coccyx that was identified on 4/19/16. There was no drainage; the wound measured 1.50 cm (centimeters) in length, 2.70 cm in width, and had a depth of 0.10 cm. Interview with LPN #5 on 5/18/16 at 8:40 AM in the day room on Unit 5 revealed the LPN stated she was notified by a Certified Nurse Aide (CNA) about the wound to Resident #1's coccyx area on 4/19/16. Medical record review of the Physician's Telephone Order dated 4/19/16 revealed clean coccyx buttocks (with) wc (wound cleanser), pat dry & apply [MEDICATION NAME] q (every) 3 days. Medical record review of the Wound Assessment Report completed by the Wound Nurse dated 5/4/16 revealed the wound type was an abrasion; wound location was coccyx; wound status was deteriorated; a small amount of serosanguinous (yellowish with small amounts of blood) drainage was present; the wound measured 4.00 cm in length, 4.50 cm in width and 0.10 cm in depth; description of the skin irritation/excoriation was documented as Red or darker pink, moderate irritation. Medical record review of the Wound Assessment Report completed by the Wound Nurse dated 5/9/16 revealed the wound status was unchanged; the wound type was an abrasion; wound location was the coccyx; a small amount of serosanguinous drainage and was documented as to have no infection, or pain. The measurements remained unchanged from the previous assessment on 5/4/16. Interview with the Wound Nurse on 5/18/16 at 8:00 AM in the Day room on Unit 5 confirmed the wound got bigger by a couple of centimeters. Continued interview revealed the Wound Nurse stated I did include (named Resident #1) on the list to round on for Tuesday 5/10/16 because I was concerned the wound grew bigger, and had drainage, and was not responding to treatment. Further interview revealed the Wound Nurse stated, I should have changed it to a Stage II on 5/4, but I was waiting to round with the NP on 5/10 to make sure what it was. Interview with CNA #1 on 5/18/16 at 10:40 AM in the Conference Room revealed the CNA stated, She did have a pink spot on her bottom, then an abrasion with a layer of skin gone. I'm not sure how it happened. Continued interview revealed the wound did open up some. She did have a wound on her coccyx and it got worse . Telephone interview with the Medical Director, (MD) on 5/19/16 at 7:54 AM revealed the MD was unaware of any type of wound for Resident #1. The MD was asked if the Wound Nurse had contacted him on 4/19/16, 4/27/16, 5/4/16 and 5/9/16 as documented on the Wound Assessment Reports for those dates. The MD stated, No, I definitely was not called 4 times. I was not aware of any problems until the Director of Nursing (DON) called me yesterday to ask me if I knew anything about a shearing problem for (named Resident #1). I told her no, this is the first I've heard of it. Interview with NP #2 on 5/19/16 at 9:45 AM in the Physician's Office at the facility revealed the NP was present in the facility 5 days a week. The NP stated, I never knew of any wound to (named Resident #1), and I work very closely with (named MD), and I can attest that he never knew anything either. (Named MD) and I rounded on Sunday 5/8/16 and (named Resident #1) was somnolent but arousable over 5/7/16 and 5/8/16. She had a gradual decline over the last week. I absolutely did not know about this. Interview with NP #3 on 5/19/16 at 10:00 AM in the Physician's Office at the facility stated she had no knowledge of any abrasion, wound or pressure ulcer to Resident #1. Medical record review revealed no documentation in the physician progress notes [REDACTED].#1 by the physician or nurse practitioner. Interview with the DON on 5/19/16 at 10:18 AM in the Conference room revealed the DON was shown the documentation from the transferring hospital on the Post hospitalization Transition Discharge Instructions for Resident #1 dated 3/16/16 that documented under Skin and/or Wound care, Sacrum; Stage one pressure ulcer, treated with repositioning and a [MEDICATION NAME]. Further interview revealed the DON was asked about the nursing documentation by 4 different nurses that had documented on 3/17/16 the resident had a pressure ulcer, open area on the coccyx, skin not intact-existing, and skin concern nurse notified. The DON did not respond. Telephone interview with NP #1 on 5/19/16 at 11:40 AM revealed the NP was nationally certified as a Wound Care and Ostomy Specialist. The NP denied having any knowledge of an abrasion, wound or pressure ulcer to the coccyx of Resident #1. The NP referred to her notes and stated she had treated the resident for leg pain but no other problems were brought to her attention. The NP was asked if she was notified on 5/4/16 by the Wound Nurse regarding the increase in size and drainage to the wound on the resident, the NP stated, No, I knew nothing about it. I received a list on 5/6/16 with (named resident) name on it to round on for Tuesday 5/10/16 but it is circled because I never saw her, and I thought she was at [MEDICAL TREATMENT]. The NP continued to state she was in the facility on Monday 5/2/16, Friday 5/6/16, and on Monday 5/9/16, and nothing was ever communicated to her about a wound or any other concern with the resident. The NP stated, I only know if the staff communicate to me or another NP, but I had no knowledge of this. Review of the hospital Emergency Provider Report dated 5/9/16 revealed the resident arrived at the emergency room at 11:33 AM for complaint of decreased alertness. The resident was admitted to the hospital at 2:25 PM. Review of the hospital Consultation Report from an Infectious Disease Physician dated 5/10/16 revealed the reason for the consultation was Sepsis with infected decubitus ulcer. Continued review revealed .She has now been found also to have a very necrotic foul-smelling decubitus in the sacral gluteal area and wound care and infectious consultation has been requested .Examination of the sacral coccygeal gluteal area shows necrotic skin with mushy fluctuant tissues under the skin and an open hanging out fatty tissue in the coccygeal area with various foul malodorous drainage, obtained cultures .This will need to be surgically debrided for source control . Continued review revealed an Assessment/Plan by the infectious disease physician dated 5/11/16 which stated, .Septic shock/[MEDICAL CONDITION] .Decubitus ulcer of coccygeal region, unstageable, likely stage 4 infected .Continued review of the hospital medical record revealed a Hospitalist Progress Note dated 5/13/16 which documented, Decubitus Ulcer of coccygeal region unstageable .PRESENT ON ADMISSION .5/10 WOUND (Culture) (E-COLI, ESBL) (bacteria that normally lives in the intestines of people; resistant bacteria) . Telephone Interview with NP #1 on 5/24/16 at 7:37 AM revealed NP #1 when asked about the abrasion to the coccyx area, the NP stated, An abrasion is a Stage II pressure ulcer in that location. The NP was asked if a Stage II pressure ulcer can develop into a Stage IV pressure ulcer with foul, odorous smelling drainage with tissue hanging out in an 8-10 hour time frame. The NP stated, No. I think the ulcer was already there when the resident was at the facility and had been there. When explored you will find a Stage III or Stage IV. I suspect this was the scenario for (named resident). It looked like an abrasion, but obscured by the skin color. It doesn't happen quick. The wound nurses didn't recognize what they were seeing, it was a knowledge deficit. They thought it was simple but it was not. The NP was asked if she was aware of a skin problem for Resident #1 and she stated, I was not. No one notified me. I depend on the nurses to let me know there is a problem. There is a Communication Book for the NP's that the nurses can write their problems or concerns, but (name resident) wasn't listed and I never got anything on her. Review of the Hermitage Nurse Station Communication Book dated 3/16/16-5/9/16 revealed no skin concerns were documented for Resident #1. Telephone interview with the Infectious Disease Physician on 6/16/16 at 1:00 PM revealed the physician had consulted on Resident #1 on 5/10/16 at the hospital the facility discharged the resident to on 5/9/16. Continued interview revealed the Physician stated the pressure ulcer to the coccyx had to be a pre-existing condition for sure with necrotic tissue underneath. It can be stable to a point, but it doesn't happen from an abrasion. It must have been from a deep tissue injury, but not from an abrasion. The facility's failure to timely identify, provide treatment and prevent deterioration of a pressure ulcer resulted in Actual Harm to Resident #1.

Based on medical record review, review of facility incident reports, interview, and review of facility policy, the facility failed to assess the safe transfer needs for 1 resident (#210) and failed to complete a comprehensive assessment for the urinary continence status for 6 residents (#131, #67, #86, #281, #43, #7) of 41 residents reviewed. The facility's failure to assess the transfer needs for Resident #210 resulted in Harm to the resident. The findings included: Medical record review revealed Resident #210 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Risk assessment dated [DATE] revealed, under the section Transfer Needs Assessment, Registered Nurse (RN) #2 chose Dependent. Continued review revealed the Risk Assessment defined dependent as requires staff to lift more than 35 lbs. (pounds) of the resident's weight or resident is unpredictable in the amount of assistance needed. In this case assistive devices should be used. Further review revealed the next section required the Unit Coordinator to assess Weight-bearing capability - Full, Partial, or None. Review revealed the weight-bearing assessment was not done. Continued review revealed a section titled, Appropriate lift/transfer devices needed: (answer based on appropriate Transfer Need Algorithm (a guided decisionmaking tool)). Continued review revealed 10 options were available and RN #2 chose Stand and Pivot with gait belt (although the weight bearing ability of the resident had not been assessed). Medical record review of the Admission/Interim Care Plan revealed ADLS (activities of daily living), dated 7/7/15, and Potential for ADL Decline as evidenced by increased need for assistance .Complete .Lift Program Lift/Transfer Assessment Form and report findings to ADON (Assistant Director of Nurses) as per instructions of appropriate use - communicate findings to CNA (Certified Nurse Aide). Review revealed no documentation the Lift/Transfer Assessment was completed. Medical record review of the Occupational Therapy Screen dated 7/7/15 revealed, Pt (patient) is dependent for all functional ADL and does not present with recent change in functional status . Medical record review of the Physical Therapy Screen dated 7/8/15 revealed, Pt is dependent for all moving. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment; and required extensive assistance to total dependence for all ADLS, with extensive physical assistance of 1 person for bed mobility and transfer. Medical record review of the Care Area Assessment (CAA) Summary dated 7/12/15 revealed, .05. ADL Functional/Rehabilitation Potential was not triggered for a decision to care plan the CAA. Continued review revealed the CAA Worksheet for ADLS was not completed. Review revealed the CAA was not completed for the resident's most dependent ADL Self-Performance, Input from Resident or Family, Analysis of Findings, or Care Plan Considerations. Medical record review of the Physical Therapy Screen dated 10/29/15 revealed, Total assist bed mobility, 2 person transfer .No changes in functional status at this time .per nsg (nursing). Medical record review of the Occupational Therapy Screen dated 10/29/15 revealed, Total care. Medical record review of the Quarterly MDS dated [DATE] revealed the resident required extensive assistance to total dependence for ADLS, with extensive physical assistance of 2 persons for bed mobility and transfer, and had no impairment of the range of motion for upper and lower extremities. Review of the facility's Resident Incident Report for Resident #210, dated 1/15/16 revealed, .Incident Type: Other, Type of Injury: Fracture, Location: Resident's room, Associate Involved: (CNA #5), Incident Reported by: Certified Tech, Report Prepared by: (LPN #2) . Review of a written statement revealed it had been obtained from CNA #4, the CNA assigned to care for the resident on 1/14/16 on the evening shift, I had pt. (Resident #210) on 1/14/16 on the 3-11 shift pt. was put to bed by me and she was normal just the no, no, stop like she always does. Medical record review of the stat mobile xray report dated 1/15/16 at 5:01 AM, revealed, SIGNIFICANT FINDINGS .Acute spiral mildly displaced fractures of the distal diaphysis and metadiaphysical junctions of the tibia and fibula. Overlying soft tissue [MEDICAL CONDITION] and swelling .Impression: Acute mildly displaced fractures of the distal diaphysis and metadiaphyseal junctions of the tibia and fibula (fractures of the 2 bones in the lower leg) . Medical record review of the Physician's Telephone Orders dated 1/15/16 at 6:15 AM, revealed 1. Send to the ER (emergency room ) .for ortho (orthopedic) evaluation and treatment of [REDACTED]. Medical record review of the ER xrays, dated 1/15/16 at 8:41 AM, revealed, Impression 1. Comminuted spiral fracture distal tibia metadiaphysical. No significant angulation or displacement. 2. Spiral [MEDICAL CONDITION] diaphysis extending to the distal metaphysis. Medical record review of the ER Physician's History and Physical dated 1/15/16 revealed, History of Present Illness .severely demented .has contractures of her left knee and left hip .from nursing home with left tibia and fibula fracture. There is no real documentation when she suffered her fall. Per daughter she is non-ambulatory and in a wheelchair .Physical Examination .Noted contracture of her left lower extremity with flexion contracture of her knee of approximately 90 degrees and a flexion contracture of the left hip .Assessment and Plan .suffered an unfortunate event that was not witnessed, resulting in a left minimally displaced comminuted spiral pattern mid shaft tibia fracture, which extends intraarticularly with a posterior malleolus (ankle) fracture as well as minimally displaced comminuted fracture of her left distal fibular shaft . Interview with the Director of Nurses (DON) on 3/30/16 at 9:35 AM, in the conference room, confirmed the DON had not completed a root cause analysis to determine the cause of the incident that lead to the spiral [MEDICAL CONDITION] and fibula bones of the lower left leg. Interview with the DON on 3/30/16 at 3:35 PM, in the conference room, confirmed the staff nurse completing the Interim Care Plan included the approach/intervention Complete .Lift Program Lift/Transfer Assessment Form . Interview confirmed a mechanical lift was not assessed for use with the resident. Interview by telephone with the Medical Director (MD) on 3/31/16 at 11:45 AM, confirmed the spiral fractures (of the tibia and fibula) indicated the ankle was twisted. The MD stated the fractures could have occurred as the resident was transferred to bed and the pain didn't happen until the care during the night .if the fractures possibly displaced at that time. Interview with MDS Coordinator #1 on 4/1/16 at 9:00 AM, in the conference room, confirmed the Quarterly MDS completed 1/10/16 did not identify the contractures of Resident #210's left knee and hip as assessed by the emergency room Physician on 1/15/16. Interview with the Regional Nurse, with the Administrator present, on 4/1/16 at 10:30 AM, in the conference room, confirmed the resident's need for assistance for all activities of daily living, including transfer needs, was not addressed in the required Care Area Assessment. Interview with the DON on 4/1/16 at 3:35 PM, in the conference room, confirmed RN #2 did not assess Resident #210's weight-bearing status on the Nursing Risk Assessment prior to determining the resident's method of transfer was to Stand an pivot with gait belt. Review of the facility policy, Bladder and Bowel Assessment Policy, undated, revealed .1. Implement Bladder and Bowel (B&B) assessment on all Residents at the time of admission, quarterly, and when there is a change in cognition, physical ability or urinary tract or bowel function. 2. Record Resident bladder and bowel patterns for 72 hours using the Bladder and Bowel Record. 3. Following completion of the 72 hour Bladder and Bowel Record and the Bladder and Bowel Assessment which includes a targeted history, physical examination (if applicable), urinalysis and post void residual (if indicated) will be completed by qualified staff. Assessment will be forwarded to MDS (Minimum Data Set) Coordinator/Care Plan Coordinator . Medical record review revealed Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Risk Assessments dated 11/3/15, 12/3/15, and 12/29/15, revealed multiple unanswered questions for the Incontinence Risk Assessment section. The assessments dated 11/3/15 and 12/29/15 did not indicate if the resident was continent or incontinent. The assessment dated [DATE] indicated the resident was incontinent of urine. Further review revealed a 72 hour Bladder and Bowel Record had not been completed. Medical record review of the Admission MDS dated [DATE], section H (Bowel and Bladder), revealed Resident #131 had not had a trial toileting program, was frequently incontinent of urine, occasionally incontinent of bowel, and was not currently on a toileting program. The resident's Brief Interview for Mental Status (BIMS) score was a 15 out of 15 (cognitively intact), and section G (Functional Status) revealed the resident required extensive assistance of 2 for transfers and extensive assistance of 1 assist for toileting. Medical record review of the Significant Change MDS completed on 1/4/16 revealed the resident was frequently incontinent of urine and always incontinent of bowel, had a BIMS score of 15, and required extensive assistance of 2 for transfers and extensive assistance of 1 for toileting. Interview with the Director of Nursing (DON) on 4/1/16 at 10:48 AM, in the conference room, confirmed the facility had failed to complete a Bladder and Bowel assessment and failed to complete a 72 Hour Bladder and Bowel Record for Resident #131. Medical record review revealed Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Risk Assessments dated 11/26/15, 3/9/16, and 3/14/16, revealed the Incontinence Risk Assessment sections had multiple unanswered questions. All three assessments indicated the resident was incontinent, but the assessments were incomplete for contributing factors and causes, and implementation to improve bladder function. Further review revealed the 72 hour Bladder and Bowel Record had not been completed. Medical record review of the Admission MDS dated [DATE], section H, revealed Resident #67 had not been placed on a trial toileting program, was frequently incontinent of urine and bowel, and had no current toileting program. The resident scored a 10 on the BIMS, indicating a moderate impairment. Continued review of section G, revealed the resident required extensive assistance of 1 for transfers and extensive assistance of 1 for toileting. Medical record review of the Bowel and Bladder Continence Roster for 3/24/16 through 3/31/16 revealed the resident was frequently incontinent of urine and continent of bowel. Interview with the DON on 4/1/16 at 10:48 AM, in the conference room, confirmed the facility had failed to complete the Bladder and Bowel assessment and failed to complete a 72 Hour Bladder and Bowel Record for Resident #67. Medical record review revealed Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Risk Assessments dated 10/16/15 and 11/16/15 revealed the Incontinence Risk Assessment section contained multiple unanswered questions. The assessment dated [DATE] did not indicate if the resident was continent or incontinent and the assessment dated [DATE] indicated the resident was continent. Further review revealed the 72 hour Bladder and Bowel Record had not been completed. Medical record review of the Admission MDS dated [DATE], revealed the resident scored 10 on the BIMS, indicating moderately impaired cognition, had not had a trial toileting program, was occasionally incontinent of bladder, frequently incontinent of bowel, and currently not on a toileting program. Continued review revealed the resident required assistance of 1 for transfers and toileting. Medical record review of the Quarterly MDS dated [DATE] revealed the resident scored 11 on the BIMS, was always incontinent of urine and frequently incontinent of bowel, and required assistance of 1 for transfers and toileting. Medical recored review revealed there was not a Nursing Risk Assessment completed with the Quarterly MDS on 2/22/16. Interview with the Assistant Director of Nursing (ADON) on 3/31/16 at 8:30 AM, in the Director of Nursing office, confirmed Resident #86 did not have the Nursing Risk Assessment completed for the Quarterly MDS dated [DATE]. Interview with the DON on 4/1/16 at 10:48 AM, in the conference room, confirmed the facility had failed to complete the Bladder and Bowel assessment and failed to complete a 72 Hour Bladder and Bowel Record for Resident #86. Medical record review revealed Resident #281 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Risk Assessment Urinary Continence Status dated 3/18/16 revealed the assessment did not indicate whether the resident was continent or incontinent of urine. Continued review revealed the assessment was incomplete with multiple questions unanswered. Further review revealed a 72 hour Bladder and Bowel Record had not been completed for Resident #281. Medical record review of the Admission MDS dated [DATE] revealed Resident #281 had a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Continued review revealed the resident was frequently incontinent of urine. Interview with MDS Coordinator #1 on 3/30/16 at 10:15 AM, in the MDS office, confirmed there were no 72 hour bladder and bowel patterns, initial bladder assessments, or quarterly bladder assessments completed. Interview with the DON on 4/1/16 at 10:48 AM, in the conference room, confirmed the facility had failed to complete the Nursing Risk Assessment for Bladder and Bowel and failed to complete a 72 Hour Bladder and Bowel Record for Resident #281. Medical record review revealed Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed the resident scored 13 out of 15 on the BIMS, indicating the resident was cognitively intact. Continued review revealed the resident was frequently incontinent of urine. Medical record review revealed a Bladder and Bowel assessment and a 72 hour Bladder and Bowel Record had not been completed upon admission for Resident #43. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #43 was always incontinent (no episodes of continent voiding) and was not on a urinary toileting program. Interview with MDS Coordinator #1 on 3/30/16 at 10:15 AM, in the MDS office, confirmed there were no 72 hour bladder and bowel patterns, initial bladder assessments, or quarterly bladder assessments completed. Interview with the DON on 4/1/16 at 10:48 AM, in the conference room, confirmed the facility had failed to complete the Nursing Risk Assessment for Bladder and Bowel and failed to complete a 72 Hour Bladder and Bowel Record for Resident #43. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated 6/19/15, revealed .incont (incontinent) of b (bladder) . Medical record review of the Nursing Risk assessment dated [DATE] revealed the resident was assessed as continent of urine. Medical record review of the Admission MDS dated [DATE] revealed the resident had a BIMS score of 6 (indicating the resident had severe cognitive impairment); required extensive assistance of 1 person for toilet use; and was always incontinent of urine. Medical record review of the Quarterly MDS dated [DATE] revealed the resident had a BIMS of 0, was totally dependent on staff for toilet use, and was occasionally incontinent of urine. Medical record review revealed a 72 hour bladder assessment to assess the resident's continence status and patterns was not completed. Medical record review revealed the resident's continence was not reassessed on a quarterly basis per policy. Interview with MDS Coordinator #1 on 4/1/16 at 8:21 AM, in the conference room, confirmed the facility had not completed a 72 hour bladder pattern assessment for the resident. Continued interview confirmed the facility failed to reassess the resident's continence status on a quarterly basis. Interview with MDS Coordinator #1 on 3/30/16 at 10:15 AM, in the MDS office, confirmed there were no 72 hour bladder and bowel patterns, initial bladder assessments, or quarterly bladder assessments completed. MDS Coordinator #1 stated .knew there were problems in that area and they were working on them . Interview with the DON on 4/1/16 at 10:48 AM, in the conference room, confirmed the facility had failed to complete Bladder and Bowel assessments per facility policy. Refer to F-315 and F-323

Based on medical record review, interview, review of facility incident report and investigation, and observation, the facility failed to provide supervision for safe transfers for 1 resident (#210); and failed to maintain a bed alarm intervention to address falls for 1 resident (#182) of 41 residents reviewed. The facility's failure to provide supervision resulted in harm for Resident #210. The findings included: Medical record review revealed Resident #210 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Risk assessment dated [DATE] revealed, under the section Transfer Needs Assessment, Registered Nurse (RN) #2 chose Dependent. Continued review revealed the Risk Assessment defined dependent as requires staff to lift more than 35 lbs. (pounds) of the resident's weight or resident is unpredictable in the amount of assistance needed. In this case assistive devices should be used. Further review revealed the next section required the Unit Coordinator to assess Weight-bearing capability - Full, Partial, or None. Review revealed the weight-bearing assessment was not done. Continued review revealed a section titled, Appropriate lift/transfer devices needed: (answer based on appropriate Transfer Need Algorithm (a guided decisionmaking tool)). Continued review revealed 10 options were available and RN #2 chose Stand and Pivot with gait belt (although the weight bearing ability of the resident had not been assessed). Medical record review of the Admission/Interim Care Plan dated 7/7/15, revealed Complete .Lift Program Lift/Transfer Assessment Form and report findings to ADON (Assistant Director of Nurses) as per instructions of appropriate use - communicate findings to CNA (Certified Nurse Aide). Continued medical record review revealed the assessment was not completed. Medical record review of the Occupational Therapy Screen dated 7/7/15 revealed, Pt (patient) is dependent for all functional ADL and does not present with recent change in functional status . Medical record review of the Physical Therapy Screen dated 7/8/15 revealed, Pt is dependent for all moving. Medical record review of the Physical Therapy Screen dated 10/29/15 revealed, Total assist bed mobility, 2 person transfer .No changes in functional status at this time .per nsg (nursing). Medical record review of the Quarterly MDS dated [DATE], revealed the resident had a BIMS score of 2, indicating severe cognitive impairment, required extensive assistance to total dependence for ADLS, with extensive physical assistance of 2 persons for bed mobility and transfer, had no impairment of the range of motion for upper and lower extremities, no falls since admission in July 2015, and was not being treated for [REDACTED]. Medical record review of the Quarterly Physical Therapy Screen dated 1/13/16 revealed Resident #210 required Extensive assistance for bed mobility and transfers and Occupational Therapy assessed Total care related to Limited UE (upper extremity) Joint Motion. Interview with the Administrator and review of the resident's electronic medical record on 3/31/16 at 4:20 PM, in the conference room, revealed the Administrator had a screen shot (a picture of part of the electronic medical record) dated 7/6/15 showing Approaches .Assist me with all transfers. Interview confirmed there was no other intervention care planned to address the resident's assessed need for extensive to total dependence for transfer with the physical assistance of two persons. Medical record review of a night shift Licensed Practical Nurse (LPN #2) entry in Departmental Notes dated 1/15/16 revealed, Received report from resident's care giver (CNA) of c/o (complaint of) pain .guarding her left leg/foot .follow-up assessment .+2 edema (swelling) to left ankle region (more notable to lateral aspect), trace redness noted .pain only notable with position change .NP (Nurse Practitioner) called .stat (as soon as possible) xray (mobile) ordered. Medical record review of the stat mobile xray report dated 1/15/16 at 5:01 AM, revealed, SIGNIFICANT FINDINGS .Acute spiral mildly displaced fractures of the distal diaphysis and metadiaphysical junctions of the tibia and fibula. Overlying soft tissue edema and swelling .Impression: Acute mildly displaced fractures of the distal diaphysis and metadiaphyseal junctions of the tibia and fibula (fractures of the 2 bones in the lower leg) . Medical record review of the Physician's Telephone Orders dated 1/15/16 at 6:15 AM, revealed 1. Send to the ER (emergency room ) .for ortho (orthopedic) evaluation and treatment of [REDACTED]. Medical record review of the ER xrays, dated 1/15/16 at 8:41 AM, revealed, Impression 1. Comminuted spiral fracture distal tibia metadiaphysical. No significant angulation or displacement. 2. Spiral fracture of the fibula diaphysis extending to the distal metaphysis. Medical record review of the ER Physician's History and Physical dated 1/15/16 revealed, History of Present Illness .severely demented .has contractures of her left knee and left hip .from nursing home with left tibia and fibula fracture. There is no real documentation when she suffered her fall. Per daughter she is non-ambulatory and in a wheelchair .Physical Examination .Noted contracture of her left lower extremity with flexion contracture of her knee of approximately 90 degrees and a flexion contracture of the left hip .Assessment and Plan .suffered an unfortunate event that was not witnessed, resulting in a left minimally displaced comminuted spiral pattern mid shaft tibia fracture, which extends intraarticularly with a posterior malleolus (ankle) fracture as well as minimally displaced comminuted fracture of her left distal fibular shaft . Medical record review of the Discharge/Aftercare Instructions dated 1/15/16 at 10:58 AM revealed, .you have fractured both the tibia and fibula bones .This injury often happens when the ankle is twisted strongly . Review of the facility's Resident Incident Report for Resident #210, dated 1/15/16, revealed, .Incident Type: Other, Type of Injury: Fracture, Location: Resident's room, Associate Involved: (CNA #5), Incident Reported by: Certified Tech, Report Prepared by: (LPN #2) . Review of the first written statement that accompanied the Incident Report revealed it was recorded on a Fall Scene Investigation Report not dated or timed with the following: Upon arrival at 11:00 pm I checked on (Resident #210) and she was dry so there was no need to change her so on the next round at 1:00 AM she was wet and I go to change her she complains of pain in her left leg screaming 'it hurts' I finished changing her and immediately got the nurse to examine her (signed by CNA #5, assigned to the resident's care on the night of 1/15/16). Review of the written statement of the second CNA (#3) assigned to Resident #210's unit revealed, While doing my first rounds I was in room 114. I heard screaming. I peeped in the hall to see where it was coming from. As I was walking towards the screams (CNA #5) yelled out to go get the nurse because (Resident #210) was not acting like herself while she attempted to change her. I got (LPN #2). We all entered the room to assess the situation. She yelled and cried the whole time. Review of the written statement made by LPN #2, signed and dated 1/15/16 revealed, Writer assessed resident (#210) at 0145 (AM) for c/o (complaint) of pain to L (left) (lower) ext (extremity) with findings of +1-+2 edema of Left lower extremity. Trace pink color noted to left foot-with guarding of left foot with movement . Review of the fourth written statement revealed it had been obtained from CNA #4, the CNA assigned to care for the resident on 1/14/16 on the evening shift, I had pt. (Resident #210) on 1/14/16 on the 3-11 shift pt. was put to bed by me and she was normal just the no, no, stop like she always does. Medical record review of a Progress Note dated 1/17/16, by the Medical Director, revealed, .seen for readmission H&P (history and physical) .has returned to the facility .fracture sustained . Interview with the DON on 3/30/16 at 9:35 AM, in the conference room, revealed, I investigated the incident .the fracture occurred because the resident had osteoporosis . Interview confirmed the DON had not completed a root cause analysis to determine the cause of the incident that lead to the spiral fracture of the tibia and fibula bones of the lower left leg. Interview with the Director of Nurses (DON) on 3/30/16 at 3:35 PM, in the conference room, confirmed the staff nurse completing the Interim Care Plan did include the intervention Complete .Lift Program Lift/Transfer Assessment Form and report findings to ADON as per instructions of appropriate use - communicate findings to CNA but the mechanical lift assessment was not done. Interview by telephone on 3/30/16 at 9:40 PM, with evening shift CNA #4, caring for the resident on the evening of 1/14/16, revealed CNA #4 did not usually care for the resident. Interview confirmed the CNA had transferred the resident to the bed from the wheelchair without assistance, .she has always been transferred with one person. Further interview revealed the resident went to bed between 8:00-9:00 PM and was dried one time before I went off and she didn't complain of any pain . Interview with the Administrator on 3/30/16 at 4:25 PM, in the conference room, revealed the Administrator stated she had completed the investigation of Resident #210's left lower leg fractures. Interview confirmed she had not conducted a root cause analysis. The Administrator stated the resident's osteoporosis had led to the fractures. Further interview revealed, I'm not saying the fracture was spontaneous .when you are changing someone they have to be turned .it happened as care was being given, because of the osteoporosis. The Administrator was asked if her statement meant the fractures were pathological and she said no. Interview confirmed physical therapy staff and nursing staff had assessed Resident #210 as needing physical assistance of two for transfers in October 2015 and again in January 2016 and this need for 2 persons for safe transfer was not included in the care plan. Interview by telephone with LPN #2 on 3/31/16 at 4:26 PM, revealed the LPN came on duty at 7:00 PM the evening of 1/14/16. Interview revealed the LPN stated Resident #210 was already in the bed when he arrived. Interview included the question of the number of persons required to safely transfer the resident and the LPN stated, Not sure .in the bed normally when I come on at 7:00 PM. Interview revealed LPN #2 became aware of the resident's pain when the 2 techs (CNAs) came down the hall to get me . Interview with Resident #62 on 3/31/16 at 10:05 AM, in the resident's room, revealed the resident was alert and oriented to person, place, and time and was the roommate of Resident #210 from 7/5/15 through 1/20/16 and from 1/26-1/29/16. Interview revealed Resident #62 stated her roommate, Resident #210, was put to bed by 1 CNA with a stand and pivot on the evening of 1/14/16, .around 8:00 (PM) . Interview confirmed the observed transfer was how she normally saw Resident #210 transferred. Continued interview revealed, I am a night owl and I was awake when (the CNA) began to turn (Resident #210) .took hold behind her knee like they do when they turn me and (Resident #210) screamed like I had never heard her scream .no, didn't act like she was in any pain before that .went right to sleep . Resident #62 was asked if anything unusuaI happened with Resident #210 when the CNA first began to change her, and Resident #62 answered, No .she didn't yell until she began to be turned .I think it happened when she was transferred to bed .I never saw a lift used to transfer her .they never brought a lift in here to get her out of bed, that is what they have to use to get me out of the bed. Interview with RN #2, the Unit Coordinator, on 1/31/16 at 10:45 AM, at the Capital Hill nursing desk, confirmed Resident #210 resided on her unit during the 7 months of the resident's stay and revealed RN #2 was not able recall if the resident required 1 or 2 persons for physical assistance for transfer. Interview and review in the Smart Chart used by the CNA staff as a care guide, confirmed the RN could not bring up the resident's CNA care guide. Interview confirmed the CNAs had recorded transferring Resident #210 to and from the bed with the assistance of 1 or 2 persons on different dates. Interview confirmed RN #2 did not know if Resident #210 had the mechanical lift care planned. Interview by telephone with the Medical Director (MD) on 3/31/16 at 11:45 AM, revealed the MD stated he had received a phone call from Nursing Administration and had replied to inquiries about the cause of Resident #210's fractures, .osteoporosis is beside the point, how did the fractures happen? Further interview confirmed the spiral fractures (of the tibia and fibula) indicated the ankle was twisted. The MD stated the fractures could have occurred as the resident was transferred to bed and the pain didn't happen until the care during the night .if the fractures possibly displaced at that time. Interview with the Administrator on 3/31/16 at 4:00 PM, in the conference room, confirmed Resident #210's Care Plan included Staff to transfer resident with a hoyer lift and two staff. The Administrator stated this intervention was not developed until 1/21/16, 6 days after Resident #210 had returned to the facility from the ER with discharge instructions for the resident to be non-weight bearing for the left lower extremity. Interview revealed the Administrator could not provide an intervention that was care planned to address the resident's assessed need for extensive to total dependence for transfer with the physical assistance of two persons prior to 1/21/16. Medical record review revealed Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Post-Incident Actions dated 3/9/16 revealed .Immediate Post-Incident Action: Bed Alarm (alarm) . Further review of the Resident Incident Followup revealed .Pressure pad alarm to bed to alert staff to unassisted transfer attempts . Medical record review of the care plan revised 3/9/16 revealed .FYI (for your information) Immediate Post-Incident Action: Bed alarm Pressure pad alarm . Observation on 3/30/16 at 9:23 AM, in the resident's room, revealed the resident lying on his back on the bed with no bed alarm pressure pad in place. Observation on 3/30/16 at 2:00 PM, in the resident's room, revealed the bed alarm pressure pad was not on the bed and the resident was seated in a chair. Observation on 3/30/16 at 2:08 PM, in Resident #128's room, revealed CNA #1 opened a new bed pressure pad alarm package and placed the alarm on the bed. Interview with the resident's wife on 3/30/16 at 2:00 PM, in the resident's room, confirmed the resident had an alarm but she had not seen it lately, possibly since he got his new mattress. Interview with CNA #1 on 3/30/16 at 2:05 PM, in the resident's room, confirmed there was no alarm on the resident's bed. Continued interview confirmed CNA #1 was not certain if the resident had an alarm; and it was not on the electronic Smart Charting (electronic charting for the CNAs) to acknowledge the alarm was in place. Interview with the Assistant Director of Nursing on 3/30/16 at 2:10 PM, at the Heritage Nurses Station, confirmed the resident did not have the alarm on the bed.