Every finding on record at Elk River Health & Nursing Center of Winchester

Based on facility policy review, medical record review, observation, and interview, the facility failed to revise the comprehensive care plan for 1 resident (Resident #3) of 16 residents reviewed for care plans. The findings include:Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, 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 .Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .The interdisciplinary Team must review and update the care plan .when the resident has been readmitted to the facility from a hospital stay .Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Liver Cirrhosis, Peptic Ulcer Disease, Diabetes, and Schizophrenia. Further review revealed Resident #3 was admitted to the hospital on [DATE] and returned to the facility on 4/29/2025 with diagnoses including Acute Gastrointestinal Bleed.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 15 on the Brief Interview for Mental Stats (BIMS) assessment which indicated Resident #3 was cognitively intact. Review of the current Physician's Orders for Resident #3 dated 7/30/2025, revealed orders for Lactulose (medication used to treat liver cirrhosis by reducing level of ammonia in the blood by trapping it in the colon, where it can eliminated) and rifaximin (antibiotic used to treat intestinal disorders including liver cirrhosis by preventing bacteria from growing and spreading).Review of the current Comprehensive Care Plan for Resident #3, dated 10/19/2024, revealed the facility failed to revise the care plan to include the diagnosis of Liver Cirrhosis, a condition which requires monitoring and treatment. Review of the History and Physical for Resident #3 from the local hospital for the hospitalization stay of 4/19/2025 to 4/29/2025, revealed Resident #3 was admitted to the hospital for an Acute Gastrointestinal Bleed which required a blood transfusion, and the discontinuation of anticoagulant medication (medication used to help prevent blood clotting).Review of the current Comprehensive Care Plan for Resident #3, dated 10/19/2024, revealed no documentation the care plan had been revised following Resident #3's hospitalization for the GI Bleed on 4/29/2025, the monitoring and treatment, or after the anticoagulant medication had been discontinued.Review of a document titled, Vision Orders, for Resident #3 dated 5/27/2025, revealed new findings of a right eye Retinal Detachment (condition where the tissue in back of eye pulls away from its normal position), requesting referral to a Retinal Specialist.Review of a document titled, TN Retina Visit for Resident #3 dated 7/22/2025, revealed the physician discussed plans for eye surgery with the resident who consented to the procedure. Review of Physician Progress Note for Resident #3 dated 7/28/2025, revealed the eye surgery was scheduled for 8/2025.Review of the current Comprehensive Care Plan for Resident #3, dated 10/19/2024 and revised 7/30/2025, revealed no documentation the care plan had been revised with the changes in condition requiring monitoring and treatment, with a new diagnosis on 5/27/2025 of the right eye retinal detachment or pending surgical procedure. Review of a Physician Progress Note for Resident #3 dated 7/18/2025, revealed Resident #3 reported bloody drainage from the right ear, and antibiotic Cefdinir was started to treat Otitis Media (inner ear infection).Review of the current Comprehensive Care Plan for Resident #3, dated 10/19/2024 and revised 7/30/2025, revealed no documentation the care plan had been revised with the changes in condition which required monitoring and treatment with antibiotics for the Otitis Media.Review of a document titled, US [ultrasound], Scrotum and contents, dated 7/16/2025, revealed an Ultrasound (an xray technique using sound waves to take pictures inside the body) of the scrotum was performed with findings of a lesion in the right testicle.Review of a Physician Progress Note for Resident #3 dated 7/18/2025, revealed an ultrasound was performed, with findings of a right testicular lesion suspected to be testicular cancer.Review of a Physician Progress Note for Resident #3 dated 7/28/2025, revealed new findings of a testicular mass.Review of the current Comprehensive Care Plan for Resident #3, dated 10/19/2024 and revised 7/30/2025, revealed no documentation the care plan had been revised with the changes in condition which required the monitoring and treatment of a new diagnoses of a testicular mass on 7/18/2025. During an interview on 7/30/2025 at 11:00 AM, the Director of Nursing (DON) confirmed the Comprehensive Care Plan for Resident #3 had not been revised to include the diagnosis of Liver Cirrhosis, the hospitalization for the GI bleed, the treatment of an ear infection, the new diagnoses of the retinal detachment and testicular mass and treatments.

Based on facility policy review, Resident Assessment Instrument (RAI) Manual 3.0 review, medical record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (Resident #48) of 24 residents reviewed.The findings include:Review of the facility's policy titled, MDS Completion and Submission Timeframes, revised 7/2017, revealed .Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes .The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted .in accordance with current federal and state guidelines .Review of the RAI Manual 3.0 dated 10/2024 revealed .Feeding Tubes .focuses on the long-term .use of feeding tubes .feeding tubes can be associated with diverse complications that may further impair quality of life or adversely impact survival .When this CAA [Care Area Assessment] is triggered, nursing home staff should follow their facility's chosen protocol or policy .This CAA is triggered when the resident has a need for a feeding tube for nutrition .Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Diabetes Mellitus, Anoxic Brain Damage, and Vegetative State (with Percutaneous Endoscopic Gastrostomy (PEG) Tube (medical device inserted into the stomach through the abdominal wall, used for nutrition and medication).Review of the Physician's Orders for Resident #48 dated 9/20/2024, revealed enteral (a method of providing nutrition directly into the gastrointestinal tract when someone cannot eat or swallow) feed order two times a day via pump- Jevity 1.2 calories (cal) (liquid artificial nutrition) at 50 milliliters (ml) per hour for 22 hours daily via pump per PEG tube and water flush at 40 ml per hour. Review of a comprehensive care plan for Resident #48 dated 9/28/2024, revealed the resident required tube feedings related to an anoxic brain injury. Review of the annual MDS assessment dated [DATE], revealed Resident #48 was unable to complete a Brief Interview for Mental Status (BIMS) assessment due to severe cognitive impairment. Continued review revealed the MDS had not been coded for the use of a PEG tube. During an observation of Resident #48 on 7/28/2025 at 11:28 AM and on 7/29/2025 at 2:38 PM, in the resident's room, revealed the resident lying in bed with the head of the bed elevated 45 degrees with a PEG tube infusing via a pump with Jevity 1.2 cal at 50 ml and a water flush infusing at 40 ml per hour. During an interview on 7/29/2025 at 1:05 PM, the MDS Coordinator stated Resident #48 required use of a PEG tube for the primary means of nutrition, hydration, and medication. The MDS Coordinator confirmed the facility failed to accurately assess the resident's nutritional status for use of the PEG tube on the MDS assessment.During an interview on 7/30/2025 at 7:24 AM, the Director of Nursing (DON) stated Resident #48 had a PEG tube and confirmed the MDS was inaccurately assessed and coded for Resident #48.

Based on facility policy review, medical record review, facility investigation documentation review, and interviews, staff failed to report an allegation of resident-to-resident abuse to administration for 1 resident (Resident #13) of 4 residents reviewed for abuse. The findings include:Review of the facility's policy titled, Abuse & Neglect Prohibition, revised 11/2017, revealed .The facility will report all allegations and substantiated occurrences of abuse .to the administrator .not later than 24 hours after being notified of the allegation .Review of the facility's policy titled, Abuse Prevention Policy & Procedure, revised 5/2023, revealed .If a resident-to-resident incident occurs .Notify the Director of Nursing and the Administrator immediately .Notify the physician and family/guardian .Reporting/Investigation/Response Policy .Any complaint, allegation, observation or suspicion of resident abuse, mistreatment .whether physical .involuntary or voluntary, is to be thoroughly reported, investigated and documented .All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty . Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of Vertebral Column, Diabetes Mellitus, and Generalized Anxiety Disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Continued review of the MDS revealed no moods or behaviors were documented. Review of a comprehensive care plan dated 7/7/2025, revealed Resident #13 had no previous behaviors documented. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses including Dementia, Agitation, Anxiety, and Hypertension. Review of the medical record revealed the MDS assessment had not been completed for Resident #67 due to the recent admission date of 7/24/2025. Review of a baseline care plan dated 7/25/2025, revealed Resident #67 had no history of aggressive behaviors documented. During an interview on 7/28/2025 at 9:05 AM, the Administrator notified the State Survey Agency he had just been made aware of an allegation of a resident-to-resident altercation between Resident #13 (alleged victim) and Resident #67 (alleged perpetrator) by the Wound Care Licensed Practical Nurse (LPN) which had occurred on 7/27/2025.During an interview on 7/28/2025 at 9:35 AM, the Wound Care LPN stated she was providing care to Resident #13 when the resident informed her Resident #67 hit her in the head with her [Resident #13's] reacher (a tool used to grab objects up to 3 pounds-made of aluminum [NAME]) when she was asleep a few nights ago (actual occurrence 7/27/2025 at 2:00 AM). The Wound Care LPN stated she immediately informed the Administrator of the allegation. Review of the facility's incident report dated 7/28/2025, revealed on 7/27/2025 at approximately 2:00 AM, LPN A was notified by Certified Nursing Assistant (CNA) B Resident #67 hit Resident #13 on the head with a reacher. Resident #67 was removed from Resident #13's room and taken to the common area for 1:1 observation. Resident #13 was assessed with no injury or pain noted. LPN A did not feel the incident met the criteria of abuse because there were no injuries and did not report the incident to the Administrator or the DON. During a telephone interview on 7/28/2025 at 3:15 PM, CNA B stated she responded to Resident #13's call light on 7/27/2025 at approximately 2:00 AM. CNA B stated she entered the room and observed Resident #67 seated on Resident #13's bed and noticed the reacher on the bed. Resident #13 informed CNA B Resident #67 had struck her on the head with the reacher but the CNA did not observe the incident. CNA B stated LPN A entered Resident #13's room and she informed the LPN of the incident. Resident #67 was removed from the room by LPN A and was placed on 1:1 observation by staff for the duration of the shift. CNA B remained with Resident #13 until LPN A returned to the room and assessed Resident #13, who denied any pain or injury. During a telephone interview on 7/28/2025 at 3:30 PM, LPN A stated she was notified by CNA B at approximately 2:00 AM on 7/27/2025 of an incident between Resident #13 and Resident #67 as she was entering Resident #13's room. LPN A stated CNA B informed her Resident #67 sat on Resident #13's bed and then struck the resident over the head with the reacher. LPN A stated she removed Resident #67 from the room for 1:1 observation by staff. LPN A stated she assessed Resident #13 and Resident #67, neither had injuries and both denied pain. LPN A stated due to the residents not having any complaints, she did not consider the altercation abuse and did not report the incident to the Administrator or the DON. Review of an Incident Note for Resident #13 dated 7/27/2025 at 2:00 AM, revealed .Late Entry:[LPN A] reported that [Resident #67] was sitting on [Resident #13's] bed and had hit her over the top of her head with a reacher. [LPN A] .removed Resident [Resident # 67] from her room and brought her to the nurses' station. Resident [Resident #13] was assessed with no injuries noted .Review of an Initial Psychiatric Consult dated 7/28/2025, revealed Resident #67 .being seen today for an initial visit per social services and nursing staff request .A couple of nights ago, [Resident #67] wandered into [Resident #13's] room and sat at the foot of [Resident #13's] bed. [Resident #67] reportedly hit [Resident #13] over the head with a grabber stick .[Resident #13] was not injured and reports that nursing staff immediately intervened and redirected resident .She [Resident #67] is confused and completely disoriented to person, place, and time .During an interview on 7/28/2025 at 10:10 AM, Resident #13 stated a few nights ago Resident #67 came into the room and .hit me [Resident #13] in the head with my reacher . Resident #13 denied any pain or injury and stated she felt safe in the facility. Resident #13 stated she felt Resident #67 was just confused and did not mean to do it. Resident #13 stated she did not feel it was abuse or intentional and wished staff would just move on and stop asking questions about it.During an interview on 7/29/2025 at 2:45 PM, the Administrator stated the Wound Care LPN notified him of the incident between Resident #13 and Resident #67 on 7/28/2025. The Administrator stated while conducting the investigation he became aware the incident occurred Sunday morning (7/27/2025) at 2:00 AM. The Administrator stated he had not been notified of the event until Monday morning (7/28/2025, 1 day and 7 hours after the incident) at approximately 9:00 AM. The Administrator confirmed the allegations of abuse had not been reported by staff to administration timely. During an interview on 7/29/2025 at 3:05 PM, the DON stated she was made aware of the incident between Resident #13 and Resident #67 yesterday (Monday 7/28/2025 at 9:00 AM, 1 day and 7 hours after the incident) by the Wound Care LPN. The DON stated she immediately initiated an investigation, reported to the state and started obtaining witness statements. The DON confirmed the incident occurred on 7/27/2025 at 2:00 AM and LPN A failed to report the allegations to administration.

Based on facility policy review, observation, and interview, the facility failed to ensure food items were sealed properly and the facility failed to ensure the kitchen was maintained in a good-working and sanitary order, which had the potential to affect 57 of 58 residents. The findings include: Review of the facility's undated policy titled, [NAME] Kitchen Sanitization Policy, showed .All kitchen areas shall be kept clean .regular cleaning of kitchen and dining areas .maintain cleanliness throughout their work areas . Review of the facility's policy titled, Food Receiving and Storage, dated 10/2017, showed .Other opened containers must be dated and sealed or covered during storage . Observation of the food preparation room on 4/1/2024 at 9:05 AM, with the Certified Dietary Manager (CDM), showed the following items were not sealed and open to air : One 21-ounce (oz) bottle of garlic powder One 16-oz bottle of whole celery seed One 26-oz bottle of mesquite seasoning One 6-oz bottle of rubbed sage Observation of the dry storage area on 4/1/2024 at 9:20 AM, with the CDM , showed One 80-oz bag of Instant Grits, 1/2 full, was not sealed and open to air . Observation of the kitchen entry door area on 4/1/2024 at 9:25 AM, with the CDM , showed a thick, black dirt-like debris present to the bottom, inside corner of the doorway. Further observation showed the dry wall had chipped away from the wall and was matted to the floor and the entry door bottom crevice was observed to have dirt and food debris present. During an interview on 4/1/2024 at 9:40 AM, the CDM stated dry cereals and dried seasoning are to be fully sealed after use. The CDM confirmed the kitchen floors needed to be deep cleaned and the area around the kitchen entry door needed to be repaired. The CDM further confirmed the food items had not been stored properly and the kitchen floor was not maintained in a sanitary condition. During an interview on 4/2/2024 at 10:15 AM, the Maintenance Director confirmed the bottom wall on the kitchen entry door needed to be repaired and was not maintained in a good-working or sanitary condition.

Based on facility policy review, observation, and interview, the facility failed to ensure garbage and refuse were properly contained in 2 of 2 dumpsters (dumpster A and B). The findings include: Review of the facility's policy titled, Food-Related Garbage and Refuse Disposal, dated 10/2017, showed .Garbage and refuse containing food wastes .stored .in a manner .inaccessible to pests .kept closed and free of surrounding litter . Observation of the outside dumpster area on 4/1/2024 at 9:15 AM, with the Certified Dietary Manager (CDM), showed the facility had 2 dumpsters present for waste disposal. Further observation showed there were no intact drain plugs at the bottom of the dumpsters A and B. The open areas in each dumpster where the drain plugs were not intact, were approximately the size of a half a dollar. Observation showed the missing drain plugs in the dumpster left the waste contents open to air, elements, and potential exposure to pests. During an interview on 4/1/2024 at 9:30 AM, the CDM confirmed dumpster A and B's drain plugs were not intact and the garbage was not properly contained.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide tracheostomy (a surgical procedure where a tube is inserted in the neck to allow air to enter the lungs) care (a procedure performed routinely to keep the part of the tracheostomy tube/faceplate that is fixed against the neck, tracheostomy dressing, ties or straps, and surrounding area clean) according to the facilities policy and physicians order for 1 resident (Resident #45) of 1 resident reviewed for tracheostomy care. The findings include: Review of the facilities policy titled, Tracheostomy Care, revised 8/2013, showed .Remove neck ties [used to hold the tracheostomy tube in place] and replace with clean ones . Resident #45 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Type 2 Diabetes, Cardiac Arrest, Anoxic Brain Damage, Chronic Respiratory Failure, and Tracheostomy. Review of a physician's order dated 6/21/2021, showed .trach [tracheostomy] care every shift, include inner cannula [a tube within the outer tube which can be removed and cleaned] change every shift and trach collar [used to hold a tracheostomy tube in place] change once daily on day shift . Review of Resident #45's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had severe cognitive impairment and received tracheostomy care. Observation on 4/2/2024 at 1:30 PM, in Resident #45's room, showed Licensed Practical Nurse (LPN) #1, performed tracheostomy care. LPN #1 followed the facilities procedure to include: The LPN donned Personal Protective Equipment (equipment used to minimize exposure to hazards that can cause serious illness, to include gown, gloves, mask, and goggles), assessed and observed the resident's respiratory status, oxygen saturation and auscultated (listened to the residents breath sounds with a stethescope) the resident's lungs. Further observation showed LPN #1 performed endotracheal suctioning (common invasive procedure done to keep the airway patent by mechanically removing accumulated pulmonary secretions to all patients with artificial airways), The LPN removed the disposable inner cannula, cleaned and disinfected the stoma site (opening made in the skin in front of the neck to allow you to breathe), reinserted the new sterile inner cannula, and applied a new dressing to Resident #45's tracheostomy site. LPN #1 did not remove the residents neck ties and apply new ones or replace the resident's soiled tracheostomy collar. During an interview on 4/2/2024 at 3:09 PM, the Director of Nursing confirmed it was her expectation the nursing staff were to follow the facility's policy and physician orders related to providing tracheostomy care for Resident #45. During an interview on 4/2/2024 at 3:14 PM, LPN #1 confirmed she did not apply fresh neck ties or replace Resident #45's soiled tracheostomy collar during tracheostomy care.

Based on medical record review, observations, and interviews the facility failed to follow a physician's order for 1 resident (Resident #19) related to fall interventions and adaptive eating utensils for 1 resident (Resident #46) of 15 residents reviewed for physician orders. The findings include: Resident #19 was admitted to the facility on [DATE] with diagnoses including Parkinsonism and Repeated Falls. Review of a Fall Scene Investigation Report dated 1/11/2024, showed .Resident lost their balance .Ambulating .at time of fall .Alone and unattended .cause of the fall .unsteady Gait .interventions to prevent future falls .floor mats to bedside . Review of a nursing note dated 1/11/2024, showed .resident .was laying on the floor .going to the bathroom when he fell .no .report of injuries .Immediate .Action .Floor mats at right and left side of bed . Review of a physician's order dated 1/11/2024, showed .Floor mats to R [right] and L [left] side of bed . Review of Resident #19's comprehensive care plan dated 1/26/2024, showed .Potential for falls .related to falls .Intervention .1/11/24 Mats to bedside bilaterally .Intervention .2/12/24 Add [non-slip product used to prevent sliding] to w/c [wheelchair] seat . Review of a Fall Scene Investigation Report dated 2/12/2024, showed .Resident slipped .Lost strength .What was resident doing .prior to fall .Reaching for something .Slide out .fall from wheelchair .assistance .at time of fall .Alone and unattended . Review of a facility investigation report dated 2/12/2024, showed .recommendations .taken .add [nonslip product used to prevent sliding] to w/c . Review of a physician's order dated 2/13/2024, showed .[non-slip product used to prevent sliding] to w/c seat . During an observation on 4/1/2024 at 9:18 AM, Resident #19 was observed lying in bed, the w/c was at bedside, and the w/c did not contain a no non-slip product in the seat. Further observation showed a fall mat was placed on the floor at the resident's left side and there was no fall mat placed on the floor at the resident's right side. During an observation on 4/1/2024 at 4:19 PM, Resident #19 was observed lying in bed, the w/c was at bedside, and the w/c did not contain a no non-slip product in the seat. Further observation showed a fall mat was placed on the floor at the resident's left side and there was no fall mat placed on the floor at the resident's right side. During an interview on 4/2/2024 at 8:30 AM, Certified Nursing Assistant (CNA) #1 stated she was familiar with Resident #19 and cared for him routinely. CNA #1 stated .I have worked this hall for a year . I have never known him [Resident #19] to have [non-slip product] to his [Resident #19] wheelchair or for him to have fall mats on both sides [both sides of the bed] . During an interview on 4/2/2024 at 8:36 AM, the Director of Therapy (DOT) stated .I put the [non-slip product] in his wheelchair seat yesterday evening [4/1/2024] . During an interview on 4/3/2024 at 4:22 PM, the Director of Nursing (DON) confirmed the facility failed to follow physician orders for Resident #19 related to bilateral fall mats to both sides of the bed and a non-slip product to the wheelchair. 50407 Resident #46 was admitted to the facility on [DATE] with diagnoses including Need for Assistance with Personal Care, Osteoarthritis, Dementia with Agitation, and Lack of Coordination. Review of Resident #46's comprehensive care plan dated 3/22/2024, showed .built up utensils on tray with meals .[non-slip product used to prevent sliding] .under food .bowls with every meal to maximize independence with self feeding . Review of a physician's order dated 3/22/2024, showed .Built-up utensils .[non-slip product used to prevent sliding] under food .bowls .w [with] every meal to maximize independence w .self-feeding . Review of Resident #46's meal ticket (communication tool used to alert staff of dietary needs) showed no special assistive devices were documented to be utilized by Resident #46 during meals. Review of Resident #46's weights showed the resident's weights were stable and had a 1.67 % gain in 3/2024. Observation on 4/1/2024 at 1:11 PM, of Resident #46 in his room, during lunch, showed the resident was eating independently. The resident was served food in bowls and used regular eating utensils to consume his food. Further observation showed the resident did not have built-up eating utensils, and the resident did not have a non-slip product under his food bowls to prevent the bowls from sliding. Observation on 4/2/2024 at 8:12 AM, of Resident #46 in his room, during breakfast, showed the resident was eating independently. The resident was served food in bowls and used regular eating utensils to consume his food. Further observation showed the resident did not have built-up eating utensils, and the resident did not have a non-slip product under his food bowls to prevent the bowls from sliding. During an observation and interview on 4/2/2024 at 8:25 AM, in Resident #46's room with the DOT showed Resident #46 was eating independently. The resident was served food in bowls and used regular eating utensils to consume his food. Further observation showed the resident did not have built-up eating utensils, and the resident did not have a non-slip product under his food bowls to prevent the bowls from sliding. The DOT confirmed Resident #46 did not have built-up eating utensils or a non-slip product under his food bowls to prevent the bowls from sliding. During an interview on 4/2/2024 at 8:35 AM, CNA #1 stated she cared for Resident #46 routinely. She also stated the resident used a non-slip product under the food bowls to keep the bowls from sliding and the non-slip product was kept in a drawer in the resident's room. CNA #1 was not aware the resident had an order for built-up eating utensils to help maximize the resident's independence with self-feeding. The CNA stated the resident eats independently and .he [Resident #46] usually eats 100% . During an observation and interview in Resident #46's room on 4/2/2024 at 8:40 AM, the DOT provided the resident with built-up utensils and a non-slip product under the meal bowls. Resident #46 stated to the DOT and surveyors he liked the built-up utensils better than the regular eating utensils. During an interview on 4/2/2024 at 10:10 AM, the Occupational Therapist (OT) stated Resident #46 was currently receiving occupational therapy services for drop wrist (an impairment in hand extension at the wrist) and fine motor movement of bilateral upper extremities because staff reported the resident had a decline in self-feeding. The OT stated she ordered built-up eating utensils to maximize self-feeding and a non-slip product to be placed under the food bowls to prevent the bowls from sliding. During an interview on 4/2/2024 at 10:40 AM, the Dietary Manager stated she was not aware Resident #46 had a physician's order for built-up utensils to be utilized with every meal. During an interview on 4/3/2024 at 4:20 PM, the DON confirmed the facility failed to follow physician orders for a non-slip product under the food bowls to prevent the bowls from sliding and built-up eating utensils for Resident #46.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to implement a comprehensive person-centered care plan related to falls for 1 resident (Resident #19) and adaptive eating utensils for 1 resident (Resident #46) of 15 residents reviewed for comprehensive care plans. The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, showed . A comprehensive, person-centered care plan that includes measurable objectives and time tables to meet the resident's .needs is .implemented for each resident .The comprehensive person-centered care plan will .describe the services that are to be furnished to attain or maintain the resident's highest practicable .well-being . Review of the facility policy titled, Assistance with Meals, revised 7/2017, showed .Assistive Devices .Adaptive devices (special eating equipment and utensils) will be provided for residents who need to request them. These may include devices such as silverware with enlarged/padded handles . Resident #19 was admitted to the facility on [DATE] with diagnoses including Parkinsonism and Repeated Falls. Review of a Fall Scene Investigation Report dated 1/11/2024, showed .Resident lost their balance .Ambulating .at time of fall .Alone and unattended .cause of the fall .unsteady Gait .interventions to prevent future falls .floor mats to bedside . Review of a nursing note dated 1/11/2024, showed .resident .was laying on the floor .going to the bathroom when he fell .no .report of injuries .Immediate .Action .Floor mats at right and left side of bed . Review of Resident #19's comprehensive care plan dated 1/26/2024, showed .Potential for falls .related to falls .Intervention .1/11/24 [1/11/2024]Mats to bedside bilaterally .Intervention .2/12/24 [2/12/2024] Add [non-slip product used to prevent sliding] to w/c [wheelchair] seat . Review of a Fall Scene Investigation Report dated 2/12/2024, showed .Resident slipped .Lost strength .What was resident doing .prior to fall .Reaching for something .Slide out .fall from wheelchair .assistance .at time of fall .Alone and unattended . Review of a facility investigation report dated 2/12/2024, showed .recommendations .taken .add [non-slip product used to prevent sliding] to w/c . During an observation on 4/1/2024 at 9:18 AM, Resident #19 was observed lying in bed, the w/c was at bedside, and the w/c did not contain a no non-slip product in the seat. Further observation showed a fall mat was placed on the floor at the resident's left side and there was no fall mat placed on the floor at the resident's right side. During an observation on 4/1/2024 at 4:19 PM, Resident #19 was observed lying in bed, the w/c was at bedside, and the w/c did not contain a no non-slip product in the seat. Further observation showed a fall mat was placed on the floor at the resident's left side and there was no fall mat placed on the floor at the resident's right side. During an interview on 4/2/2024 at 8:30 AM, Certified Nursing Assistant (CNA) #1 stated she was familiar with Resident #19 and cared for him routinely. CNA #1 stated .I have worked this hall for a year . I have never known him [Resident #19] to have [non-slip product] to his [Resident #19] wheelchair or for him to have fall mats on both sides [both sides of the bed] . During an interview on 4/2/2024 at 8:36 AM, the Director of Therapy (DOT) stated .I put the [non-slip product] in his wheelchair seat yesterday evening [4/1/2024] . During an interview on 4/3/2024 at 4:22 PM, the Director of Nursing (DON) confirmed Resident #19's comprehensive care plan was not implemented to include bilateral fall mats to both sides of the bed and a non-slip product to the seat of the wheelchair. 50407 Resident #46 was admitted to the facility on [DATE] with diagnoses including Need for Assistance with Personal Care, Osteoarthritis, Dementia with Agitation, and Lack of Coordination. Review of Resident #46's comprehensive care plan dated 3/22/2024, showed .built up utensils on tray with meals .[non-slip product used to prevent sliding] .under food .bowls with every meal to maximize independence with self feeding . Review of a physician's order dated 3/22/2024, showed .Built-up utensils .[nonslip product used to prevent sliding] under food .bowls .w [with] every meal to maximize independence w .self-feeding . Review of Resident #46's weights showed the resident's weights were stable and had a 1.67 % gain in 3/2024. Observation on 4/1/2024 at 1:11 PM, of Resident #46 in his room, during lunch, showed the resident was eating independently. The resident was served food in bowls and used regular eating utensils to consume his food. Further observation showed the resident did not have built-up eating utensils, and the resident did not have a non-slip product under his food bowls to prevent the bowls from sliding. Observation on 4/2/2024 at 8:12 AM, of Resident #46 in his room, during breakfast, showed the resident was eating independently. The resident was served food in bowls and used regular eating utensils to consume his food. Further observation showed the resident did not have built-up eating utensils, and the resident did not have a non-slip product under his food bowls to prevent the bowls from sliding. During an observation and interview on 4/2/2024 at 8:25 AM, in Resident #46's room with DOT showed Resident #46 was eating independently. The resident was served food in bowls and used regular eating utensils to consume his food. Further observation showed the resident did not have built-up eating utensils, and the resident did not have a non-slip product under his food bowls to prevent the bowls from sliding. The DOT confirmed Resident #46 did not have built-up eating utensils or a non-slip product under his food bowls to prevent the bowls from sliding. During an interview on 4/2/2024 at 8:35 AM, CNA #1 stated she provided care for Resident #46 routinely. She also stated the resident used a non-slip product under the food bowls to prevent the food bowls from sliding and the non-slip product was kept in a drawer in the resident's room. CNA #1 was not aware the resident had an order for built-up eating utensils to help maximize the resident's independence with self-feeding. The CNA stated the resident eats independently and .he [Resident #46] usually eats 100% . During an observation and interview in Resident #46's room on 4/2/2024 at 8:40 AM, the DOT provided the resident with built-up eating utensils and a non-slip product under the meal bowls. Resident #46 stated to the DOT and surveyors he liked the built-up utensils better than the regular eating utensils. During an interview on 4/2/2024 at 10:10 AM, the Occupational Therapist (OT) stated Resident #46 was currently receiving occupational therapy services for drop wrist (an impairment in hand extension at the wrist) and fine motor movement of bilateral upper extremities because staff reported the resident had a decline in self-feeding. The OT stated she ordered built-up eating utensils to maximize self-feeding and a non-slip product to be placed under the food bowls to prevent the bowls from sliding. During an interview on 4/3/2024 at 4:20 PM, the DON confirmed Resident #46's comprehensive care plan was not implemented to include a non-slip product under the food bowls to prevent the bowls from sliding and built-up eating utensils.

Based on facility policy review, medical record review, observation, and interview, the facility failed to properly label an enteral feeding for 1 resident (Resident #5) of 3 residents reviewed with an enteral feeding. The findings included: Review of the facility policy, Enteral Nutrition, revised November 2018, revealed .check the enteral nutrition label against the order .Type of formula . Medical record review revealed Resident #5 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], showed the resident received tube feeding. Medical record review of the Physician's Orders dated December 2021, showed .[MEDICATION(S)] 1.2 CAL [calorie] LIQUID TUBE FEEDING 50 ML/HR [milliliters/hour] . During an observation on 12/12/2021 at 9:55 AM, in Resident #5's room, an enteral feeding was infusing and the bag had not been labeled with the type of formula. During an observation on 12/13/2021 at 11:08 AM, in Resident #5's room, an enteral feeding was infusing and the bag had not been labeled with the type of formula. Observation and interview on 12/14/2021 at 7:54 AM, in Resident #5's room, showed a label had not been placed on the bag to identify the type of enteral feeding. Licensed Practical Nurse (LPN) #1 confirmed Resident #5's enteral feedings had not been labeled and should be labeled with the type of formula. During an interview on 12/14/2021 at 9:15 AM, the Director of Nursing (DON) confirmed her expectation was for the staff to label enteral feeding bags with the physician ordered formula.

Based on facility policy review, observation, and interview, the facility failed to discard expired medical supplies; failed to ensure supplies were stored under clean and sanitary conditions, and failed to ensure refrigerator/freezer maintenance was completed in 1 of 1 medication storage rooms. The findings included: Review of the facility policy, Storage of Medications, revised ,[DATE] revealed .nursing staff shall be responsible for maintain medication storage AND preparation areas in a clean, safe, and sanitary manner . Review of the facility policy, Infection Prevention and Control Program, revised ,[DATE] revealed .elements of the infection prevention and control program consist of .oversight .prevention of infection and employee health and safety . Review of the facility policy, Refrigerators and Freezers, revised ,[DATE] revealed .facility will ensure safe refrigerator and freezer maintenance .sanitation .supervisors will inspect refrigerators and freezers .maintenance needs . Observation and interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 10:50 AM, in the Medication (Med) Storage Room, revealed in drawer #1 (under the countertop), 1 opened box of 1 by 2 ¾ inch [MEDICATION NAME] bandages (approximately 75) with an expiration date of ,[DATE], and 1 opened intravenous (IV) start kit, with an expiration date of ,[DATE]. Continued observation revealed 1 box cutter, multiple loose coins, and a biohazard kit. Observation of drawer #3 (under the counter top) at 11:00 AM, revealed 1 red top vacutainer expired [DATE], one 22 gauge syringe needle out of the plastic sheath, and multiple unpackaged/ loose cotton balls. Interview at this time with LPN #1 confirmed the facility failed to discard the expired medical supplies, and they remained available for resident use. Observation and interview with LPN #1 on [DATE] at 11:10 AM, in the same Med Storage Room, revealed in the bottom drawer of the lab cart, 48 red top vacutainers with an expiration date of [DATE]. Further observation revealed under the boxes of vacutainers, there were additional unpackaged/loose cotton balls, and unsecured red and purple top vacutainers. Interview with LPN #1 at this time confirmed the facility failed to discard the expired medical supplies available for resident use. Observation and interview with LPN #1 on [DATE] at 11:20 AM, in the Med Storage Room, under the working sink, revealed 4 large bags of urine collection tubes (approximately 200) and ½ box of urine cups (approximately 120), 1 empty box, and 1 empty sharps container. Interview confirmed the medical supplies were not stored in a sanitary manner. Observation and interview with LPN #1 on [DATE] at 11:30 AM, in the Med Storage Room, revealed in the bottom drawer of a 3 tier shelf, were 3 opened IV start kits. Interview confirmed the opened IV start kits were not discarded after partial use .they are taking the [MEDICATION NAME] out of them, and putting it back in there . referring to the drawer. Continued observation with LPN #1 on [DATE] at 11:30 AM, in the Med Storage Room, revealed the IV caddy had 1 red top vacutainer, with an expiration date of [DATE]. Further observation revealed opened [MEDICATION NAME] bandage, 1 dried brown, unpackaged, cotton ball attached to tape, opened alcohol pads, straws, rubber bands, 1 uncapped thermometer, and miscellaneous paper trash. Interview with LPN #1 at this time confirmed the expired medical supplies were not discarded and were available for resident use, concluding .it's disorganized and dirty . Observation and interview with LPN #1 on [DATE] at 11:40 AM, in the Med Storage Room of the medication refrigerator/freezer revealed an accumulation of ice extending from the freezer door to the top shelf of the refrigerator below the freezer. Interview confirmed the facility had failed to perform routine maintenance defrosting on the refrigerator/freezer. Observation and interview with the Director of Nursing and LPN #1 on [DATE] at 11:50 AM, in the Med Storage Room, confirmed the facility failed to discard expired medical supplies rendering them available for resident use; failed to ensure sanitary and orderly conditions were maintained in the Med Room; and failed to perform routine maintenance of the refrigerator/ freezer for the 1 medication storage room.

Based on review of the facility policy, review of Center for Disease Control (CDC) [MEDICATION NAME] (TB) Elimination Facilitator Guide, observation, and interview, the facility failed to maintain the medication storage room in a clean and orderly manner for 1 of 1 medicatation storage rooms observed. The findings included: Review of the facility policy Storage of Medications, revised ,[DATE] revealed .the facility shall store all drugs and biologics in a safe, secure, and orderly manner .medications requiring refrigeration must be stored in a refrigerator .facility shall not use discontinued, outdated .drugs .all such drugs shall be returned to the dispensing pharmacy or destroyed . Review of the CDC TB Elimination Facilitator Guide, dated ,[DATE] revealed .to avoid reducing the potency of the [MEDICATION NAME] store it inside a refrigerator so that it remains between 35 and 46 degrees Fahrenheit . Observation with Licensed Practical Nurse (LPN) #1 on [DATE] at 10:50 AM, in the Med (Medication) Storage Room, revealed in drawer 2 under the countertop 1 bottle of Aspirin 81 milligrams (mg) (36 tablets) expired ,[DATE]. Continued review revealed a [MEDICATION NAME] (blood thinner) syringe 50 units (u)/50 milliliters (ml). Further review of drawer 2 revealed staple extractors, 1 box cutter, multiple loose coins, a biohazard kit, 1 opened box of 1 by 2 and ¾ inch [MEDICATION NAME] bandages (approximately 75) expired ,[DATE] and 1 opened intravenous (IV) start kit, expired ,[DATE]. Observation with LPN #1 on [DATE] at 11:00 AM, in the Med Storage Room, revealed in drawer 3 under the countertop one 50 u of [MEDICATION NAME] Purified Protein Derivative (to determinate presence of [MEDICAL CONDITION]). Further review of drawer 3 revealed one 20 ml Sterile Water solution with loose cotton balls, 1 red top vacutainer expired [DATE], and one 22 gauge capped needle out of the plastic sheath. Interview with the LPN #1 and the Director of Nursing (DON) at 11:50 AM, in the Med Storage Room, confirmed the facility failed to discard the expired medication available for resident use, failed to store the [MEDICATION NAME] medication in the refrigerator to maintain the integrity of the medication, and failed to properly store the [MEDICATION NAME] and the Sterile Water solution in an orderly manner.

Based on review of the facility policy, observation and interview the facility failed to ensure expired foods were not available for resident use in 1 of 1 nourishment refrigerators and on 1 of 3 medication carts observed. The findings included: Review of the facility policy, Refrigerators and Freezers, revised ,[DATE] revealed .'Use by' dates will be completed with expiration dates on all prepared food in refrigerators .Supervisors will be responsible for ensuring food items in .refrigerators .are not expired or past perish dates . Review of the facility policy, Food Receiving and Storage, revised ,[DATE] revealed .All foods stored in the refrigerator will be labeled and dated ('use by' date) . Observation and interview with Registered Nurse (RN) #1 during medication pass on [DATE] at 8:55 AM revealed the RN prepared a resident's crushed medications in a container of applesauce dated [DATE]. The RN confirmed the applesauce was beyond the use by date. Observation on [DATE] at 8:49 AM, in the employee break room, with the Dietary Manager revealed a nourishment refrigerator for resident use with expired food items and no labeled use by dates. Observations revealed the following: Seven 6 oz (ounce) containers of peach yogurt labeled for Resident #27 with an expiration date of [DATE]. 1 slice of corn bread labeled for Resident #34 in a plastic bag dated [DATE] with no use by date. 2 slices of provolone cheese with no resident identifier with a best if used by date of [DATE]. 1 boxed red velvet cake (,[DATE] left in the box) with no resident identifier and a recommended use by date of [DATE]. 2 large styrofoam containers of green beans (one ,[DATE] full and one ,[DATE] full) with no resident identifier or expiration/use by date. 1 large Styrofoam container of cole slaw (,[DATE] full) with no resident identifier or expiration/use by date. 1 13.5 oz container of mild guacamole (,[DATE] left in container) with no resident identifier and a sell by date of [DATE]. 6 slices of pizza in a zip lock bag with no resident identifier and no expiration/use by date. 2 large brown bowls of applesauce with no resident identifier and no expiration/use by date. Interview with the Dietary Manager on [DATE] at 9:07 AM, in the employee break room, confirmed the nourishment refrigerator was used for the resident's food items. Further interview confirmed food items had expired, some were not labeled with resident identifiers or use by dates, and were available for resident use.

Based on medical record review and interview the facility failed to provide an evaluation and rationale for continued use of a PRN (as needed) antianxiety drug beyond 14 days for 1 resident (#18) of 5 residents reviewed for unnecessary medications of 19 sampled residents. The findings included: Medical record review revealed Resident #18 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] . (an anti-anxiety drug) was prescribed PRN (as needed). Medical record review of Physician's Progress Note revealed the physician failed to provide an evaluation and rationale for the continued use of the medication beyond 14 days. Interview with the Director of Nursing (DON) on 5/16/18 at 10:47 AM, in the DON's office, confirmed the PRN [MEDICATION NAME] should not have been prescribed for over 14 days and confirmed the facility failed to document rationale of the continued use of the PRN antianxiety medication beyond the 14 days.

Based on review of the facility policy, medical record review, observation, and interview the facility failed to provide privacy while providing direct patient care for 1 resident (#37) of 32 residents observed. The findings included: Review of the facility policy Quality of Life - Dignity revised 8/09 revealed .staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care . Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of a 12 (cognitively intact). Observation on 5/15/18 at 1:30 PM, inside Resident #15's room, revealed Resident #15 received direct personal care from Certified Nursing Assistant (CNA) #1. Further review revealed the privacy curtain had not been pulled around the resident, and the resident's pants were down to his ankles. Continued review revealed Resident #15's roommate was present in the room. Interview with CNA #1 on 5/15/18 at 1:35 PM, outside Resident #15's room, confirmed she had not provided privacy during direct resident care. Interview with the Director of Nursing on 5/15/18 at 1:40 PM, outside Resident #15's room, confirmed the facility failed to provide and protect resident privacy during direct resident care.

Based on medical record review and interview, the facility failed to follow a physician order [REDACTED].#26) of 25 residents reviewed. The findings included: Medical record review revealed Resident #26 was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician Telephone Order dated 3/10/17 revealed .Med Pass (nutritional supplement) 120 cc (cubic centimeters) po QD (by mouth every day) .Dx (diagnosis) weight decrease . Medical record review of the March and April 2017 Medication Administration Records (MAR) revealed no documentation addressing the Med Pass order dated 3/10/17 or the administration of the nutritional supplement. Interview with Licensed Practical Nurse (LPN) #1 on 4/12/17 at 12:45 PM at the nursing station confirmed she was assigned to Resident #26. When asked what the procedure was for transcribing a nutritional supplement from a telephone order, LPN #1 stated the supplement order would be .documented (transcibed) on the MAR and initialed by the nurse when administered . Further interview confirmed the March and April MARs failed to address the Med Pass and there was no documentation of the administration of the nutritional supplement. Interview with the Director of Nursing (DON) on 4/12/17 at 12:50 PM in the DON's office confirmed the facility failed to follow the physician order [REDACTED].

Based on medical record review, interview, and observation, the facility failed to accurately assess 2 residents (#69, #72) for urinary incontinence and 1 resident (#81) for assistance with eating of 25 residents reviewed. The findings included: Medical record review revealed Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 was always incontinent of urine (no episodes of continent voiding) during the 7 day look back period. Medical record review of the Bowel and Bladder Report for 1/12/17 to 1/18/17 revealed Resident #69 had 3 episodes of urinary continence. Medical record review of the Quarterly Urinary Continence Evaluation dated 1/18/17 revealed Resident #69 was .always incontinent (no episodes of continent voiding) . Interview with the MDS Coordinator on 4/12/17 at 1:18 PM in the MDS office, after reviewing the Quarterly MDS dated [DATE] and the Bowel and Bladder Report for 1/12/17 to 1/18/17, confirmed the resident had 3 continent episodes of urine during the 7 day look back period. Continued interview with the MDS Coordinator confirmed there was a coding error on the MDS and the facility failed to accurately assess the urinary continence for Resident #69. Medical record review revealed Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission MDS dated [DATE] revealed Resident #72 was cognitively intact and was frequently incontinent of bladder. Medical Record review of a Quarterly MDS dated [DATE] revealed the resident was cognitively intact and was always incontinent of bladder. Interview with Resident #72 on 4/10/17 at 11:25 AM in the resident's room revealed the resident confirmed she was incontinent of urine prior to entry in the facility. Medical record review of an Admission assessment dated [DATE] revealed the resident was dependent for toileting and incontinent. Medical record review of an Admission Urinary Continence Evaluation dated 10/26/16 revealed the resident had a history of [REDACTED]. Continued review revealed .If incontinent, approximately when did incontinency begin . was left unanswered. Medical record review of a Quarterly Urinary Continence Evaluation dated 2/1/17 revealed the resident had a history of [REDACTED]. The resident chose not to participate in a Bowel and Bladder program and was placed on a check and changed every 2-3 hours and as needed. Review of a Bowel and Bladder report for the 7 day look back period for the Admission MDS dated [DATE] revealed the following bladder status for Resident #72: 11/17/16-Continent x 4 Incontinent x 2 11/18/16 Incontinent x 5 11/19/16 Incontinent x 1 (no documentation on 1st or 2nd shift) 11/20/16 Incontinent x 7 11/21/16 Incontinent x 1 (no documentation on 1st or 2nd shift) 11/22/16 Continent x 5 Incontinent x 4 11/23/16 Incontinent x 7 Review of a Bowel and Bladder report for the 7 day look back period for the Quarterly MDS dated [DATE] revealed the following bladder status for the resident: 1/26/17 Incontinent x 2 (no documentation on 1st or 2nd shift) 1/27/17 Incontinent x 8 1/28/17 Incontinent x 3 (no documentation on 1st shift) 1/29/17 Incontinent x 6 1/30/17 Incontinent x 5 (no documentation on 1st shift) 1/31/17 Incontinent x 8 2/1/17 Incontinent x 7 Interview with Certified Nurse Aide (CNA) #5 on 4/12/17 at 1:25 PM in the conference room confirmed she cared for Resident #72 regularly. Continued interview confirmed the resident was always incontinent. Interview with LPN #1 on 4/12/17 at 4:30 PM at the Nurse Station confirmed she cared for the resident regularly, and the resident was always incontinent. Interview with Licensed Practical Nurse (LPN) #2 on 4/12/17 at 4:35 PM at the Nurse Station confirmed the resident had always been incontinent of urine. Interview with the MDS Coordinator on 4/12/17 at 4:50 PM in the Dining Room stated she would have investigated further to determine if Resident #72 was truly continent of urine on 11/17/16 and 11/22/16 according to the CNA documentation. Continued interview confirmed the Admission MDS dated [DATE] was inaccurate related to Resident #72's continent status. Medical record review revealed Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Admission MDS dated [DATE] revealed the resident was cognitively intact and required supervision and set-up help with eating. Medical record review of a 14 Day MDS dated [DATE] revealed the resident was cognitively intact and required limited assistance of 1 person for eating. Medical record review of a Nutritional Evaluation dated 2/9/17 and completed by the Registered Dietician revealed the resident was alert, was able to make himself understood, and was independent in the ability to feed himself. No adaptive equipment was required. Interview with CNA #1 on 4/12/17 at 8:20 AM in A hall confirmed Resident #81 was an independent diner and needed no assistance with meals. The CNA stated, We bring his tray and set it up and he takes care of the rest. Observation of Resident #81 on 4/12/17 at 8:25 AM in the resident's room revealed the resident had eaten 100% of his breakfast tray. Interview with the resident confirmed he required no assistance with eating and had not been sick and required assistance with eating at any time during his stay in the facility. Medical record review of nurses notes dated 2/9/17-2/16/17 revealed the resident was independent with eating and required supervision or set-up, or clean up assistance. The only exception was noted on 2/11/17 at 1:43 PM by LPN #3 who documented under .ADL's(Activities of Daily Living) Eating self performance : Extensive assistance and Eating support Provided: One person physical assist . Review of an ADL grid used for CNA documentation for eating and assistance required from 2/9/17-2/16/17 revealed the resident was coded Independent with set up help only, or supervision with set up help only with the exception of 1 time by CNA #6 who documented on 2/16/16 2nd shift the resident required limited assistance of 1 person for eating. Medical record review revealed the resident received Occupational Therapy (OT) services from 2/3/17-2/24/17. Interview with the Certified Occupational Therapy Assistant (COTA) on 4/12/17 at 9:50 AM in the C Hall confirmed Resident #81 never had any problems with eating and did not receive services by OT for dining. The COTA stated, He was very high functioning. That's why we only worked with him for such a short time. Interview with the MDS Coordinator on 4/12/17 at 10:05 AM in the MDS office revealed after reviewing the resident's medical record and asked if the 2/16/17 14 Day MDS was accurate, the MDS coordinator stated No it would not be. The MDS Coordinator confirmed the facility failed to provide Resident #81 with an accurate 14 Day MDS assessment.

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to follow their policy for controlled substances which allowed for misappropriation of narcotics for 1 resident (#1) of 3 residents reviewed for misappropriation. The findings included: Review of facility policy, Controlled Substances, revised ,[DATE] revealed, .The facility shall comply with all laws, regulations .required to handling, storage .of Schedule II and other controlled substances .Controlled substances must be stored in the medication cart under double lock .except when it is accessed to obtain medications for residents .Nursing staff must count controlled medications at the end of each shift . Review of facility policy, Storage of Medications, revised ,[DATE] revealed, .The facility shall store all drugs .in a safe, secure, manner .Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station .Narcotics requiring refrigeration should be secured to the inside of the refrigerator in a locked box . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident was placed on hospice on [DATE] and expired on [DATE]. Medical record review of a physician's orders [REDACTED]. The bottle contained 30 ml of the medication. Medical record review of the [DATE] Medication Administration Record [REDACTED]. The amount left to count was 29.5 ml. Review of a facility investigation with an occurrence date of [DATE] at 7:54 PM revealed during change of shift narcotic count of medication cart C, the oncoming Licensed Practical Nurse (LPN) #1 and off going LPN #2 discovered Resident #1's bottle of [MEDICATION NAME] was unable to be located. Telephone interview with LPN #1 on [DATE] at 9:35 AM revealed the LPN stated, I was counting with (LPN #2) and was told (Resident #1's) [MEDICATION NAME] had been moved from the cart to the refrigerator (in the medication room) a few days ago because it had been opened. I went to check the refrigerator and it wasn't there. Continued interview revealed the LPN stated, A few days later I went to the police station and observed a video the facility had given them. It showed me removing the [MEDICATION NAME] from the med (medication) cart on Tuesday ([DATE]) around 8:45 PM or so and going into (Resident #1's) with the bottle of [MEDICATION NAME]. I remembered he was so anxious and his head was at the foot of the bed. When I came out of the room I told my tech we needed to move him back to the head of the bed. I put the [MEDICATION NAME] back in its box when the tech called me into the room to help reposition the resident. I hadn't locked it back in the med cart, so I took the [MEDICATION NAME] in the room with me. I must have laid it down to help move the resident back to the head of the bed because I used 2 hands to do that and forgot to bring it out with me and lock it back up. When asked where she had laid the bottle of [MEDICATION NAME], LPN #1 stated, I really can't recall, but it must have been close to the resident. Either on the foot of the bed, or the bedside table. The LPN confirmed she was the last nurse to administer the [MEDICATION NAME] before it was determined to be missing. Interview with LPN #2 on [DATE] at 11:00 AM, in the conference room revealed LPN #3 had counted med cart C on [DATE] at 7:00 AM with LPN #3 and she told her the [MEDICATION NAME] had been moved to the refrigerator in the med room. LPN #2 stated, I failed to verify it was there. Continued interview revealed on [DATE] at 7:00 PM during the counting of the narcotics on the med cart with LPN #1 it was discovered the bottle of [MEDICATION NAME] was missing. Telephone interview with LPN #3 on [DATE] at 1:15 PM revealed she was told by LPN #4 on [DATE] at 7:00 PM during shift change and count of med cart C the [MEDICATION NAME] for the resident was moved to the refrigerator in the med room. The LPN stated, I did not check the refrigerator to see if it was there. LPN #3 confirmed the last time she saw the bottle of [MEDICATION NAME] was on [DATE]. Telephone interview with LPN #4 on [DATE] at 1:30 PM revealed I was told by (LPN #1) on Wednesday [DATE] at 7:00 AM shift change and count of med cart C that the [MEDICATION NAME] was moved to the refrigerator. The LPN confirmed she did not go check the refrigerator to verify the [MEDICATION NAME] was there and stated, I thought it was moved on Monday or Tuesday because (LPN #5) told us it's supposed to be stored in the refrigerator. I opened it on Sunday (,[DATE]) and gave some to the resident and put it back in the cart. I counted with (LPN #6) around 1 or 2 PM and the count was correct, and the [MEDICATION NAME] was there. Interview with the Director of Nursing (DON) on [DATE] at 3:00 PM in the conference room confirmed the facility failed to follow their policy and perform complete narcotic (controlled substance) counts and reconciliation from [DATE] at 7:00 AM through [DATE] at 7:00 AM., resulting in misappropriation of 29.5 mls of [MEDICATION NAME] for Resident #1.

Based on facility policy review, medical record review, observation, and interview, the facility failed to properly store liquid Ativan (Benzodiazepine medication used to treat anxiety) in the medication refrigerator according to manufacturer's recommendations and as labled by the pharmacy for 1 resident (#1) of 3 residents reviewed. The findings included: Review of facility policy, Storage of Medications, revised ,[DATE] revealed, .The facility shall store all drugs .in a safe, secure, manner .Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station .Narcotics (controlled substances) requiring refrigeration should be secured to the inside of the refrigerator in a locked box . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident was placed on hospice on [DATE] and expired on [DATE]. Medical record review of a Physicians order dated [DATE] revealed Lorazepam (also known as Ativan-Benzodiazepine used to treat anxiety) Intensol (solution) 2 mg/ml (milligrams per milliliter) give 0.25 ml sublingual every 6 hours as needed for anxiety. The bottle contained 30 ml of the medication. Observation of the medication room refrigerator on [DATE] at 9:30 AM, with the Director of Nursing (DON) revealed a locked refrigerator requiring a key to open and a clear plastic locked narcotic (controlled substance) box inside the refrigerator requiring a separate key. No narcotics were present at this time inside the narcotic box. Observation and interview with the Pharmacy Consultant and the DON on [DATE] at 9:00 AM, in the medication room revealed the disposal container for wasted medications was opened. Continued observation revealed a 30 ml bottle of Ativan inside the box for Resident #1. The box had a label added by the pharmacy that read Refrigerate in light blue letters located at the bottom of the box. Continued observation revealed instructions to store at ,[DATE] degrees Fahrenheit were included on the outside of the box of Ativan. The Pharmacy Consultant and DON confirmed the Ativan was to be stored in the medication refrigerator when it was received at the facility. Telephone interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 9:35 AM confirmed the Ativan for Resident #1 had been stored in the medication cart. Interview with LPN #2 on [DATE] at 11:00 AM, in the conference room revealed, After a dose of Ativan was given, it had been kept on the cart, not in the refrigerator. Telephone interview with LPN #3 revealed, The box (of Ativan) had a label on it to refrigerate. When asked why it was stored in the medication cart, the LPN stated, I'm not sure. They told us in an in-service to refrigerate it when it comes from the pharmacy. Telephone interview with LPN #4 on [DATE] at 1:30 PM revealed, I opened it (Ativan) on Sunday (,[DATE]), gave it, and put it back in the cart. When asked if the Ativan was labeled to refrigerate the LPN stated, I honestly didn't look. Interview with the DON on [DATE] at 3:00 PM, in the conference room confirmed the facility failed to store Ativan in the medication refrigerator as labeled for Resident #1.

Based on facility policy review, observation and interview the facility failed to maintain safe temperatures for milk and failed to prepare chicken in a safe and sanitary manner. The findings included: Review of the facility policy titled Food Services Manager, revised 12/08 revealed, .The daily functions of the Food Services Department are under the supervision of a qualified Food Services Manager and Dietitian .A Food Services Manager (who may be a working supervisor) will oversee the kitchen and all activities and personnel related to .preparing food .is responsible for the daily functions of the Food Services Department in accordance with the facility's department policies and procedures . Observation on 3/29/16 at 12:15 PM in the dietary department revealed the last 8 ounce carton of milk was sitting in approximately 1 inch of melted ice and water in a pan on a tray cart at the tray line. The milk carton temperature was checked by the Dietary Manager (DM) and found to be 46 degrees Fahrenheit (F). Observation on 3/29/16 at 12:20 PM in the dining room revealed a 1 gallon container of whole milk with approximately 1/2 gallon remaining and a 1/2 gallon of buttermilk with approx 1/3 remaining sitting in a pan of melted ice and water approximately 1/2-1 deep. The whole milk temperature was checked by the DM and found to be 47 degrees F and the buttermilk was 48 degrees F. The DM confirmed the milk and buttermilk were available for resident use and were too warm for safe consumption. The DM confirmed the facility failed to maintain the milk and buttermilk at the appropriate temperature. Observation on 3/29/16 at 1:55 PM in the dietary department with the DM present revealed 4 large bags of frozen chicken in the sink by the preparation table. The faucet was running continuously with cold water over 1 bag of chicken. Interview with the Corporate Dietary Director (CDD) and the consulting Registered Dietician for the facility on 3/30/16 at 4:40 PM in the dining room when asked if rotating 4 bags of frozen chicken in the sink with cold water running over 1 bag at a time was an acceptable manner to thaw chicken, the CDD stated, no it's not. The CDD confirmed the facility failed to prepare food for resident use in a safe and sanitary manner.

Based on facility policy review, observation, facility record review and interview, the facility failed to follow the menu for 4 of 4 residents ordered a pureed diet, 4 of 4 residents ordered a renal diet; failed to provide correct portions for 27 of 27 residents ordered a regular diet, and 4 of 4 residents ordered a pureed diet of the 35 residents reviewed. The findings included: Review of a facility policy titled Facility Nutrition Program, revised 12/08 revealed, .A facility Dietitian will .help the facility assure that it provides appropriate meals .A Food Services Manager .will oversee the activities and functions of the kitchen staff (i.e., those responsible for .preparing .meals), including .preparation, sanitation issues .menu planning and preparation . Review of a facility policy titled Kitchen Weights and Measures, revised 12/08 revealed, .Food Services staff will be trained in proper use of cooking and serving measurements to maintain portion control .Staff will be trained in the appropriate measurement and type of serving utensil to use for each food . Review of a facility policy titled Menus, revised 12/08 revealed, .Menus shall a) meet the nutritional needs of residents; b) be prepared in advance; and c) be followed .Menus for regular and therapeutic diets are written at least two (2) weeks in advance, and are dated and posted in the kitchen at least one (1) week in advance .Menus will .indicate standard portions at each meal . Observation on 3/29/16 at 7:30 AM in the dietary department, with the Dietary Manager (DM) and the dietary cook present, revealed the pureed diets were served the regular consistency oatmeal. Interview with the DM and dietary cook at the time of the observation confirmed the pureed diets were served a regular consistency oatmeal. Review of the Standard Long Term Care Diet Order Descriptions provided by the Corporate Dietary Director (CDD) revealed, The Puree diet reference is the National Dysphagia (difficulty swallowing) Diet Level 1. Review of the Pureed Diet (National Dysphagia Diet) Level 1 guide provided by the CDD revealed, .The Puree Diet .modified to a consistency that is 'pudding-like' . Continued review revealed oatmeal listed as a food to avoid on a pureed diet. Interview with the CDD and the consulting Registered Dietician (RD) on 3/30/16 at 4:40 PM in the dining room when asked if oatmeal was an appropriate menu choice for a pureed diet the CDD stated, No, I'll give you that one, you're right. The CDD confirmed there were 4 residents with a physician's orders [REDACTED]. Continued interview confirmed the facility failed to follow the menu. Observation on 3/29/16 at 11:45 AM in the dietary department with the DM present revealed the dietary cook was plating the mid day meal of beef stroganoff, green beans, mashed potatoes, and a roll for the regular diet. The pureed diet consisted of pureed stroganoff with the noodles included, green beans, mashed potatoes and bread. The dietary cook was serving the beef stroganoff on top of noodles with a #8 (4 ounce) scoop for the regular diet and a #10 (3-4 ounce) scoop for the pureed diets. Review of the Diet Spreadsheet dated 3/29/16, provided by the DM, revealed 6 oz (ounces) of beef stroganoff was to be served on top of noodles for residents ordered a regular diet; 6 oz of pureed beef stroganoff and 3-4 oz of pureed noodles were to be served to residents ordered a pureed diet. Beef tips au jus were to be prepared for residents ordered a renal diet. Interview with the CDD and the consulting RD on 3/30/16 at 4:40 PM in the dining room when shown copies of the Diet Spreadsheet for 3/29/16, confirmed it was the correct copy the facility used. Continued interview confirmed residents ordered a regular diet should have received 6 oz of beef stroganoff instead of 4 oz served. Continued interview confirmed the residents ordered a pureed diet should have received 9-10 oz of the beef stroganoff/noodle mixture instead of 3-4 oz served. When asked how many residents were ordered a renal diet, the CDD stated, 4. The CDD and RD confirmed the facility failed to prepare beef tips au jus for a renal diet per the menu. Continued interview confirmed the facility failed to provide the correct portion of beef stroganoff for residents ordered a regular diet, and failed to provide less than half of the correct portion of the beef stroganoff and noodle mixture for the residents ordered a pureed diet. Observation and interview with the dietary cook on 4/4/16 at 12:05 PM in the dietary department, when asked what she served for a renal diet, stated, [MEDICATION NAME] pie, peas, and carrots. Review of the current spreadsheet revealed beef patties and zucchini were listed for the renal diet menu. No beef patties or zucchini were observed. Interview with the CDD on 4/4/16 at 12:15 PM in the dietary department confirmed no beef patties or zucchini were prepared at the time of the meal service. The CDD confirmed the facility failed to follow the menu, and prepare foods for residents ordered a renal diet.

Based on medical record review, facility policy review, observation, interview and facility document review, the facility administration failed to ensure staff provided the necessary care to prevent pressure ulcers and prevent pressure ulcers from worsening. The facility's failure resulted in amputation of resident #95's left leg and resulted in the need for surgery on the resident's right leg to remove necrotic (dead) tissue. The facility's failure to ensure systems and processes were in place and consistently followed by staff for the provision of necessary care and services to prevent development of avoidable pressure ulcers and worsening of identified pressure ulcers placed Resident #95, #114, #35, and #73 and potentially any resident at risk for pressure ulcers in Immediate Jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death). The facility administration failed to ensure residents were safe in the facility by not investigating accidents; not determining causes of falls; not devising new interventions to prevent future falls; and not evaluating the new interventions. The facility failed to provide a system for management of falls and failed to follow the facility's fall policy, resulting in 22 residents experiencing 93 falls in 2013. This failure placed Resident #35 in Immediate Jeopardy who, after multiple falls, no investigation of the cause of the falls, and no new interventions, sustained a [MEDICAL CONDITION]. This failure placed Resident #73 in Immediate Jeopardy who, after several falls with no investigation of the cause of the falls, and no new interventions, sustained a clavicle fracture. The facility's failure placed all residents at risk for falls in Immediate Jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death). The facility Administrator failed to ensure a systematic approach was followed by nursing staff for receipt and destruction of medications which provided an environment to allow Licensed Practical Nurse #4 to potentially divert narcotics from any resident who was receiving narcotics. The Administrator's failure to implement a system to prevent diversion of narcotics constitutes Substandard Quality of Care. The Regional Vice President, Director of Clinical Services, Administrator, and Director of Nursing were informed of the Immediate Jeopardy on November 6, 2013, at 2:30 p.m., in the conference room. The Immediate Jeopardy was effective November 26, 2012. Substandard Quality of Care was cited under F224-F, F314-K and F323-K. The facility provided an acceptable Allegation of Compliance on November 22, 2013, and a revisit on November 26, 2013, revealed the corrective actions implemented on November 25, 2013, removed the Immediate Jeopardy. Noncompliance for F-490 continues at a "E" level citation. The findings included: Interview with the Administrator on October 3, 2013, at 12:30 p.m., in the Administrator's office, confirmed care plans were not updated to reflect changing needs of residents; measures were not implemented to prevent pressure ulcers or falls; falls were not investigated completely; and interventions not implemented to prevent further falls. Interview with the Administrator on October 3, 2013, at 4:10 p.m., in the Administrator's office, confirmed the facility had not identified issues with receipt and destruction of medications or possible drug diversion until Licensed Practical Nurse #4 self-reported to the facility a history of drug diversion. Interview with the Administrator on November 6, 2013, at 2:10 p.m., in the Administrator's office, confirmed three residents (#95, #35, #114) developed pressure ulcers which worsened in the facility. Continued interview confirmed two residents (#35, #73) had falls with significant injury, and the facility had not followed the facility's policy for falls. Continued interview with the Administrator revealed the Administrator stated did not feel there was a problem with falls or pressure ulcers. Refer to F224, F280, F314, F323 Validation of the Credible Allegation of Compliance was accomplished on-site November 26, 2013, by medical record review, review of facility documents, observation and interview with nursing and administrative staff. The facility provided evidence of new policy and procedures related to Fall Prevention, Pressure Ulcers, and Quality Assessment and Assurance activities and evidence the new policies were reviewed and approved by the facility administration and the new medical director. The facility provided evidence the survey findings were reviewed and shared with the facility leadership group and staff members. In-service training records including sign in sheets for all staff members related to the new policies and procedures were provided, including abuse. Review of facility documents revealed, the leadership group was involved in daily review of facility operations, and implementation of corrective measures to prevent falls and pressure ulcers. Observation at the facility on November 26, 2013, revealed, all fall related interventions were in place for residents (#17, #23, #26, #42, #52, #62). Medical record review of resident #35 revealed the resident was discharged from the facility on October 29, 2013. Medical record review of resident #73 revealed the fall risk assessment was completed, and the care plan was reviewed and updated with individualized interventions. Medical record review revealed resident #95 had been discharged from the facility on May 6, 2013. Medical record review and observations of residents #73 and #114 (in-house residents with pressure ulcers) confirmed the facility had conducted comprehensive skin assessments by the new Wound Care Nurse, treatments and interventions were in place, and preventative interventions were current on certified nursing assistant kardexs. Interview with the new facility Administrator (interim as of November 8, 2013, and new Administrator as of November 21, 2013) on November 26, 2013, at the facility, revealed the facility leadership group, the new Director of Nursing (as of October 29, 2013), and the new Medical Director (as of November 20, 2013), reviewed the findings of the survey and implemented follow up audit measures to assure compliance with corrective actions during a Quality Assessment and Assurance meeting. The facility will remain out of compliance at a Scope and Severity level "E" a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, until it provides an acceptable plan of correction.

Based on review of facility policy, medical record review, review of the Fall Risk Evaluation forms, review of the facility fall reports, review of facility documentation, interview, and observation, the facility failed to investigate and develop new interventions to address falls for fourteen residents (#35, #73, #17, #24, #42, #119, #100, #62, #120, #26, #23, #113, #52, and #89) of twenty-two residents with falls reviewed. The facility's failure to investigate and develop new interventions to address falls placed residents #35 and #73 in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective on November 26, 2012, and is ongoing. The Regional Vice President, Director of Clinical Services, Administrator and Director of Nursing were informed of the Immedicate Jeopardy on November 6, 2013, at 2:30 p.m. in the conference room. The findings included: Review of the facility policy entitled Falls Management, effective on September 15, 2001, and revised on June 1, 2013, revealed, "...If patient falls...Update care plan to reflect new interventions..." Review of the facility policy entitled Falls Care Delivery Process, with revision date of June 1, 2013, revealed, "...response to a Patient Fall: ...Complete...Resident Incident report...to implement new interventions...Investigate fall circumstances...Implement immediate interventions after the fall...Complete Condition of Change Document...staff...Conduct interdisciplinary team meeting within 72 hours of patient fall to perform the following: ...Update care plan with new interventions as appropriate...Communicate interventions to staff..." Review of the facility policy entitled Falls Management, with revision date of June 1, 2013, revealed, "...If patient falls:...Perform Neurological Assessment for all unwitnessed falls and witnessed falls with head injury..." Review of the facility policy entitled Assessment: Neurological with revision date of October 1, 2012, revealed, "Neurological assessment will be performed as indicated or ordered. When a patient sustains an injury to the head and/or unwitnessed fall, neurological assessment will be performed: every 30 minutes x (for) two hours, then every one hour x four hours, then every four hours x 24 hours." Resident #35 was admitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident was readmitted [DATE], after an Open Reduction and Internal Fixation of a Right Hip Fracture. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Mental Status score of 14, indicating no cognitive impairment. Medical record review of the Fall Risk Evaluation completed on admission and at quarterly reviews on March 8, and June 8, 2013, revealed the resident was "high risk for falls." Medical record review of the physical therapy (PT) notes from admission through June 13, 2013, revealed the resident received PT for transfers and gait training. Review of the PT notes dated June 3, 2013, revealed, "...good progress with gait. However pt (patient) continues to demonstrate poor safety awareness and judgement...Patient continues to require minimal assist for sit to stand for transfers secondary to bilateral hip weakness. Pt's visual handicap will prevent gait independence..." Further review revealed the resident was able to ambulate up to 300 feet with a rolling walker and began a restorative nursing program on June 15, 2013, to continue ambulation with the rolling walker. Medical record review of facility fall reports and Care Plans (from December 2012 through September 2013) revealed the resident had a history of [REDACTED]. January 12, 2013, at 4:20 a.m., fell on the way to bathroom, unwitnessed, no neuro (neurological) checks (to assess for head injury) were done, no root cause or contributing factors identified, "Safety alarm..." was added to the resident's care plan; January 15, 2013, no facility report provided for review, no neuro checks were done, no root cause or contributing factors identified, no new intervention developed; March 6, 2013 at 7:50 a.m., the fall report was initiated March 6, 2013 and completed six months later, on October 1, 2013, by the Director of Nurses. Review revealed the resident was found "face down on the floor," complained of a headache, had a small skin tear of the right elbow, was seen in the emergency room , no neuro checks were done, no root cause or contributing factors identified, no new intervention developed; March 21, 2013, at 7:20 a.m., fall report related to the fall was not completed. Review revealed, "...asked resident what happened...stated 'I just changed seats was trying to go to the bathroom and slid out of the bed onto my bottom," no root cause or contributing factors identified, no new intervention developed; April 1, 2013, at 11:55 p.m., facility fall report was not completed. Review revealed the resident was seen in the emergency room for a hematoma at the back of head "the size of a baseball." No root cause or contributing factors identified. Review revealed a scoop mattress was care planned; May 21, 2013, at 4:15 p.m., facility fall report revealed this was a witnessed fall. An investigation of the falI was not completed. Review revealed the resident was assisted to the bathroom by a Certified Nurse Aide (CNA) who left the resident's side to assist the roommate and witnessed the resident stand, adjust clothing, tumble into the bathtub, and hit head. Review revealed the resident was not seen in the emergency room . No root cause or contributing factors were identified and no new intervention was developed; May 25, 2013, at 7:25 a.m., facility fall report revealed a CNA heard the safety alarm, saw the bathroom emergency call light blinking, and found the resident in the bathroom on the floor with bruises, a skin tear to the left arm. Review of subsequent facility documentation addressed a large bruise to the right hip, discovered on May 27, 2013, and the bruise was attributed to the fall of May 21, 2013. Review revealed the resident was seen in the emergency room . No neuro checks were done, no root cause or contributing factors identified, no new intervention developed; July 19, 2013, at 8:20 a.m., facility fall report was not initiated until October 1, 2013, by the DON. Review revealed the resident was found on the floor and "old skin tear re-opened." No neuro checks completed, no root cause or contributing factors identified. Review of the Care Plan revealed, "7/19/13 fall...Intervention...Reacher/grabber." Review of a Nurse's Note revealed a bruise was reported on July 20, 2013, with bruising of the left hip and left lower leg noted and attributed to the fall of July 19, 2013; August 12, 2013, at 3:40 a.m., facility fall report revealed "To resident room to answer call light, resident sitting in floor beside the bed...noted abrasion to right cheek and resident c/o (complained of) pain to right hip..." Interview by telephone on October 3, 2013, at 7:12 a.m., with registered nurse (RN) #3 (the RN on duty the night of August 12, 2013) revealed when the resident fell and broke the right hip, on the night of August 12, 2013, there were two nurses on duty, who were both "drawing blood" and the two CNAs on duty were "down another hall." Interview continued and revealed "I heard (resident #35) way down at the end of B hall...found her on the floor." Medical record review of a History and Physical on admission to the hospital on August 12, 2013, revealed, "..XXX[AGE] year-old...trying to get out of bed where a call light had been put on...did not get much help so...tried to get up by self and water spilled...slid and broke hip...Assessment and Plan: fall with right intertrochanteric fracture...still alert...wants surgery..." Review of the occupational therapy (OT) note dated August 21, 2013, revealed, "...patient is NWB (non-weight bearing/not able to walk) through RLE (right lower extremity) and has had a decline in ADL's (activities of daily living) and transfers..." Observation of the dining room at 12:30 a.m., on September 30, 2013, revealed the resident was brought to lunch in a wheelchair. Interview with the Director of Nurses (DON) and concurrent review of the fall reports was conducted at 7:45 a.m., on October 2, 2013, in the MDS office. Interview verified a fall report for the fall on January 15, 2013, was missing, a fall investigation for January 12, 2013, was not completed until March 25, 2013, and did not include a root cause or contributing factors, a fall report for the March 6, 2013, fall had been completed by the DON on October 1, 2013, six months after the fall, and none of the falls had complete investigation identifying the root cause and contributing factors. Interview continued and confirmed the falls were not investigated (required to be completed by an interdisciplinary team within 72 hours of a fall) for the eight falls sustained by the resident from January through July of 2013. Interview confirmed an investigation of the fall with fracture in August 2013 had not been done by an interdisciplinary team to date. Interview confirmed the August 12, 2013, fracture to the right hip requiring surgery, resulted in the resident being unable to walk, a lower ability to transfer, and a decline in the ability to perform activities of daily living. Medical record review of an Interdisciplinary Progress Note dated August 19, 2013, revealed the resident was readmitted on this date following right hip surgery. Medical record review of the Re-admission nursing assessment dated [DATE], revealed the resident returned from a hospitalization due to a Urinary Tract Infection. Medical record review of the Fall Risk Evaluation dated October 7, 2013, revealed a score of 13, "high risk for falls." Review of a fall report revealed the resident fell in the bathroom at 4:32 a.m., on October 9, 2013. Review of the resident's Care Plan and concurrent interview with the Director of Nurses (DON) in the conference room at 1:00 p.m., on October 28, 2013, confirmed the resident did not have individualized falls prevention interventions resumed upon returned to the facility October 7, 2013. Interview confirmed the Interdisciplinary Team did not investigate and develop new appoaches after the fall on August 12, 2013, resulting in the right hip fracture or after the October 9, 2013, fall. Resident #73 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Interdisciplinary Progress Notes dated October 19, 2012, at 1:00 p.m., revealed "...activity tray in place d/t (due to) decreased safety awareness...low bed with pressure sensitive alarm while in bed..." Medical record review of the Change of Condition Documentation dated December 8, 2012, revealed "...pt (patient) lying on her L (left) side on safety mat...bed alarm noted to be off...no injury...bed now in lowest position...safety mat in place..." Medical record review of the quarterly MDS (Minimum Data Set) dated January 9, 2013, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 2 (severe cognitive impairment). Further review of the MDS, revealed the resident was dependent on staff for bed mobility, transfers, bathing, dressing, toilet use, and personal hygiene. Medical record review of the Interdisciplinary Progress Notes dated December 9, 2012 for the fall occurring on December 8, 2012, revealed "...bed in lowest position...safety mats...pressure alarm..." Medical record review of the plan of care revealed no new interventions documented for the fall on December 8, 2012. Medical record review of the Change of Condition Documentation dated December 24, 2012, revealed "...in dining room lying on left side...had removed lap buddy...assisted to chair and taken to room...bed alarm in use...bed in low position with mat at bedside..." Medical record review of the plan of care revealed no new interventions documented for the fall on December 24, 2012. Medical record review of the Interdisciplinary Progress Notes dated December 28, 2012, revealed "...removed activity tray...safety alarm to chair and bed..." Medical record review of the care plan updated January 11, 2013, revealed Resident #73 was at risk for falls. Medical record review of the Change of Condition Documentation dated January 12, 2013, revealed "...removed lap buddy...missed chair...replaced lap buddy with another lap buddy..." Medical record review of the Pain Evaluation dated January 12, 2013, revealed the resident had pain in the right shoulder at an intensity of 3-4 (moderate pain). Medical record review of the plan of care revealed no new interventions documented for the fall on January 12, 2013. Medical record review of the Change of Condition Documentation dated, January 13, 2013, revealed "...rolled out of bed...c/o (complains of) pain to rt (right) shoulder..." Medical record review of the Pain Evaluation dated January 13 2013, revealed the resident had pain in the the right shoulder at an intensity of 1-2 (mild pain). Medical record review of the plan of care revealed no new interventions documented regarding the fall on January 13, 2013. Medical record review of the Interdisciplinary Progress Notes at 1:05 a.m., January 14, 2013, revealed "...c/o (complains of) R (right) shoulder pain..." Medical record review of the Interdisciplinary Progress Notes at 6:00 a.m., January 14, 2013, revealed, "...large area of purple and blue/green bruising to R (right) posterior shoulder...guarding area..." Medical record review of the Interdisciplinary Progres Notes at 8:00 a.m., January 14, 2013, revealed, "c/o R shoulder pain...large amount bruising...send to hospital..." Review of the hospital Discharge Summary dated January 18, 2013, revealed Resident #73 was admitted to the hospital with [REDACTED]. Review of the facility's policy titled "7.0 Falls Management" dated September 15, 2001 and revised June 1, 2013, revealed "...patients experiencing a fall will receive appropriate care...investigation of the cause...6.4 update care plan to reflect new interventions...6.5.3 document effectiveness of interventions..." Interview with the ADON (Assistant Director of Nursing) on October 3, 2013, at 8:15 a.m. in the admissions office, confirmed the facility had failed to follow the facility's policy to investigate the cause of the resident's falls and had failed to implement new interventions after the falls on December 8, 2012, December 24, 2012, January 12, 2013 and January 13, 2013 which resulted in a fractured right clavicle. Resident #17 was admitted on [DATE], with [DIAGNOSES REDACTED]. Observation at 10:00 a.m., and 4:00 p.m., revealed the resident in the bed napping with shoes in wheelchair at bedside on October 30, 2013. Medical record review of facility documentation revealed the resident had seven falls in 2013 as follows: March 3, 2013, at 3:15 pm - fell out of the wheel chair (w/c) an investigation was initiated, unwitnessed without neuro checks being done, but no root cause or contributing factor determined and no new interventions to address the fall were developed. March 23, 2013 - Interview on October 30, 2013, with LPN #1 at 10:30 a.m., in the conference room, confirmed no report of the fall, other than what was in the Nurse's Notes, could be found and confirmed there had not been an investigation or any care plan interventions developed after the fall. April 8, 2013, at 1:20 p.m., - fell in their room, out of the w/c and struck head, no neuro checks were done. No investigation was initiated, no new interventions to address falls other than re-educate to call for help. May 5, 2013, at 2:00 p.m. - fell out of the w/c, reaching to floor. No neuro checks were done. An investigation was initiated, but no root cause or contributing factors determined and no new interventions to address the fall were developed. May 12, 2013, at 3:00 a.m. - fell as attempting to toilet self. An investigation was initiated, but no root cause or contributing factors determined and no new interventions to address the fall were developed. June 8, 2013, at 8:30 a.m. - Slipped out of the w/c onto floor. No investigation was initiated, no new interventions to address the fall. June 23, 2013, at 8:45 a.m. - An investigation was done and determined "needs a reacher." Interview on October 30, 2013, with LPN #1 at 10:30 a.m., in the conference room, confirmed when the Interdisciplinary Team met and investigated the falls after the June 23, 2013, fall, the resident was provided a reacher and there had been no further falls. Resident #24 was admitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident was followed by Hospice and was able to return home on October 4, 2013. Review of the facility documentation revealed three falls had been reported and none of the falls had investigations initiated or completed. The three falls were reported as follows: April 14, 2013, at 11:45 a.m. - fell in the bathroom, swelling in the left elbow and pain left upper shoulder, xrays obtained at the facility with no fracture noted. A new intervention was care planned. July 7, 2013, at 8:10 a.m., Fall on the way to bathroom, the floor had been mopped and remained wet. The DON documented in the Intradisciplinary Team notes "current interventions working" and no new interventions to address falls were developed. September 18, 2013 - Sat on floor in front of the electric wheelchair on the way to the bathroom. Resident stated "started to slide." Nursing provided non-skid socks. Interview with LPN #1, in the conference room, on October 30, 2013, at 3:30 p.m.,confirmed no investigation of any of the three falls was done and no new individualized interventions were developed to address the last two falls. Resident #42 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Sets (MDS) dated [DATE], and May 25, 2013, revealed the resident was moderately impaired for daily decision making; required extensive assistance with bed mobility, transfers, and locomotion on unit; and required total dependence for locomotion off unit and toilet use. Medical record review of facility documentation revealed the resident had seven falls from January 2013 through August 2013 as follows: January 29, 2013, at 8:50 p.m. - fell from wheelchair (w/c) as "reaching out as if to pick something off of the floor" and hit head on the doorframe. Record review revealed an investigation was not completed and no root cause or contributing factors were identified. March 3, 2013, at 5:00 a.m. - Had been gotten up into the w/c by staff due to agitation and then fell out of the w/c, no witness. Record review revealed an investigation was not completed and no root cause or contributing factors were identified. March 3, 2013, at 12:15 p.m. - Found out of the w/c in dining room floor, lying on back. Record review revealed an investigation was not completed and no root cause or contributing factors were identified. March 12, 2013, at 2:15 p.m. - The resident stated "trying to get into bed" and fell to floor. Record review revealed an investigation was not completed and no root cause or contributing factors were identified. April 9, 2013, at 6:00 p.m. - Found lying on floor on the bedside floor mat, no mention of whether the resident had been in the bed or the w/c. Record review revealed an investigation was not completed and no root cause or contributing factors were identified. July 15, 2013, at 1:45 p.m. - Found between the toilet and the wall on hands and knees after a CNA heard the "pull away alarm." Record review revealed an investigation was not completed and no root cause or contributing factors were identified. July 25, 2013, at 12:20 pm - Stood up and fell from w/c in solarium, witnessed. Record review revealed an investigation was not completed and no root cause or contributing factors were identified. Interview at 2:20 p.m., on October 29, 2013, in the conference room, with LPN #1 confirmed the resident had one investigation completed for the seven falls from January 2013 through August 2013. Continued interview confirmed the resident did not have interventions developed to address the falls of March 12, 2013, and April 9, 2013. Resident # 119 was admitted to the facility on [DATE], with admitting [DIAGNOSES REDACTED]. Medical record review of facility Change of Condition Documentation fall dated January 5, 2013, "...pressure alarm sounding, resident found sitting on floor complained of bilateral hip pain...Golf-ball sized bruise noted on crown, no bleeding noted ...assisted to wheelchair; Nurse Practioner (NP) notified x-ray of bilateral hip. Medical record review of facility Change of Condition Documentation fall dated January 13, 2013, a facility report dated 1/15/13 "... resident was trying to transfer self from bed to chair and fell on floor, landed on bottom. No injuries observed. Alarm on and sounding. Resident was educated on using call light to ask for assistance for transfers..." Interview with the Administrator on October 29, 2013, at 3:30 p.m., in the conference room, with concurrent review of the resident's four falls, including a fall on February 10, 2013, and a fall on March 15, 2013, verified the following: The facility had a report completed immediately after the resident's four falls; the resident did not have injuries requiring transfer to the hospital; investigations were not completed to address the root cause and contributing factors to the four falls; and the resident was dismissed to home on May 5, 2013. Interview continued and the Administrator stated, "It has already been acknowledged there were system problems with falls..." Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the facility's fall report dated February 18, 2013, revealed "...to room...found resident sitting on floor beside bed...no injury...re-educated to call light usage...call light within reach...bed in lowest position...safety alarm placed..." Medical record review of the Care Plan dated February 18, 2013, revealed "...poor coordination due to recent aka (above knee amputation) of right leg/foot...encourage...to use handrails...have commonly used articles within easy reach..." Medical record review of the Change of Condition Documentation dated February 18, 2013, revealed "...summoned to patient's room...sitting on the floor bedside bed...no injury...re-educated to call light usage and call light placed within reach...bed in lowest position...safety alarm placed..." Medical record review of the Care Plan dated February 19, 2013, revealed "...low bed...safety alarm in bed/chair...remove all objects near bed to prevent injury...when resident in bed place all necessary personal items within reach...reinforce need to call for assistance...PT (Physical Therapy) evaluation...place call light within easy reach...ensure environment is free of clutter..." Medical record review of the facility's fall report dated February 21, 2013, revealed "...responded to call light...laying in floor next to bed...stated was trying to change TV (television) station...forgot I don't (do not) have a right leg anymore..." Medical record review of the Care Plan revealed no new interventions documented for the fall on February 21, 2013. Medical record review of the Change of Condition Documentation dated February 21, 2013, revealed "...observed laying on floor next to bed...going to change TV (television)...reinforce proper use of call light..." Medical record review of the facility's fall report dated February 23, 2013, revealed "...fell from wheelchair...found on floor...laying on chair alarm...bending over and fell out of wheelchair..." Medical record review of the Care Plan dated February 23, 2013, revealed "...teach resident to ask for help...bed in lowest position...safety mats..." Medical record review of the Interdisciplinary Notes dated February 23, 2013, revealed "...continues with therapy..." Medical record review of the Change of Condition Documentation dated February 23, 2013, revealed "...found laying in the floor on left side with bed alarm under (resident)...stated that (resident) was bending over and went to far..." Medical record review of an annual MDS (Minimum Data Set) dated February 25, 2013, revealed the resident was totally dependent for bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene. Further review of the MDS revealed, the resident had a BIMS (Brief Interview for Mental Status) score of 15 (no cognitive impairment). Medical record review of the Interdisciplinary Notes dated February 26, 2013, revealed "...alert with confusion...several falls since admission...self-propels while up in wheelchair...confused to thinking...able to ambulate..." Medical record review of Physician's Orders dated February 26, 2013, revealed "...Physical Therapy for wheelchair mobility and strength training..." Medical record review of the facility's fall report dated April 5, 2013, revealed "...sitting on floor at bedside...no pain..." Medical record review of the Care Plan dated April 5, 2013, revealed "...encourage to verbalize needs...encourage to use call light..." Medical record review of the Interdisciplinary Notes dated April 5, 2013, revealed "...increased confusion...new order to obtain labs and infuse Normal Saline at 65 cc/hr (cubic centimeters/ per hour) times one..." Medical record review of the Change of Condition Documentation dated April 5, 2013, revealed "...witnessed the resident sitting upright on the bed at his bedside...continue to monitor...no new orders..." Medical record review of the facility's fall report dated April 20, 2013, revealed "...sitting in floor...no injury...safety alarm in place..." Medical record review of the Care Plan addressing falls dated April 20, 2013, revealed "...mats on floor next to bl (bilateral) side of bed...; dated April 23, 2013, revealed "adjust level of care according to individual needs...allow sufficient time for dressing and undressing...baths and showers per schedule...encourage independence...encourage resident to do as much for self...ensure and assist with grooming needs...provide verbal cues...reinforce success for task accomplished..." Medical record review of the Change of Condition Documentation dated April 20, 2013 revealed, "...found sitting on floor...stated just rolled out of bed...safety alarm in place..." Medical record review of the facility's fall report dated May 2, 2013, revealed "...sitting on safety mat between bed and window holding trash can...nose bleeding...two raised areas on his forehead above each brow...to hospital for evaluation..." Medical record review of the Care Plan revealed no documentation for new interventions for the fall on May 2, 2013. Medical record review of the Interdisciplinary Progress Notes dated May 2, 2013, revealed "...slid forward and lowered self to mat..." Medical record review of the Change of Condition Documentation dated May 2, 2013, revealed "...bed alarm sounding...sitting on safety mat...holding trash can...nose was bleeding...had two raised areas on forehead above each brow...to the hospital for evaluation..." Medical record review of the diagnostic imaging report dated May 2, 2013, revealed "...no acute intracranial abnormality...no acute facial bone fracture..." Medical record review of the MDS dated [DATE], revealed Resident #100 required extensive assistance from the staff with bed mobility and transfers, required limited assistance with locomotion and was totally dependent on the staff for dressing, toilet use, personal hygiene and bathing. Further review of the MDS revealed, the resident had a BIMS score of 7 (cognitive impairment). Interview with the DON (Director of Nursing) on November 6, 2013, at 8:30 a.m., in the business office, confirmed the facility failed to follow facility's policy to investigate the cause of the resident's falls and failed to implement new interventions after the falls on February 21, 2013, and May 2, 2013. Resident #62 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems; required extensive assistance with one person physical assist for transfers, walk in corridor, dressing, personal hygiene and bathing; required extensive assistance with two plus person physical assistance for bed mobility and toilet use; and was continent of bowel and bladder and had no falls. Review of facility's fall report revealed the resident had a fall on January 13, 2013, at 5:00 a.m., from the bed with no injury. Further review revealed the "...bed was elevated..." Further review of the documentation revealed no investigation to determine the cause of the fall and failed to add interventions to prevent future falls. Medical record review of the Change of Condition Documentation form, dated January 13, 2013, at 7:25 a.m., revealed, "...bed alarm sounding and pt (patient) was lying on the floor beside the bed on...back with pillow between...knees. Pt has electric bed and the bed was in the highest position per pts (patient's) control...neuro (neurological) checks in place..." Review of facility's fall report revealed the resident had a fall from the bed with a laceration and was sent to the emergency roiagnom on [DATE], at 3:30 p.m. Further review of the documentation revealed no investigation to determine the cause of the fall and failed to add interventions to prevent future falls. Medical record review of the Change of Condition Documentation form, dated January 13, 2013, at 15:30 (3:30) p.m., revealed, "ZXX

Based on medical record review, review of facility documentation, observation, review of facility policy, and interview, the facility failed to revise the care plan following falls to include interventions for the staff to implement to prevent future falls for nine residents (#35, #73, #62, #120, #26, #93, #100, #52, #119) of twenty-two residents reviewed with falls; failed to revise the care plan addressing pressure ulcers for staff to implement care plans for four (#35, #73, #114, #79) of fourteen residents reviewed with pressure ulcers; and failed to revise the care plan with interventions for staff to implement after a sexual altercation for two residents (#77, #42) of sixty-five residents reviewed. The facility's failure to address interventions on the care plan for pressure ulcers for three residents (#35, #73, and #114) resulted in staff unfamiliar with the care to be provided placing residents in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or likely to cause serious injury, harm, impairment, or death). The failure of the facility to revise the care plans addessing falls with new interventions resulted in a [MEDICAL CONDITION] for one resident (#35) and a fractured clavicle for one resident (#73) placing the residents in Immediate Jeopardy. The Immediate Jeopardy was effective on November 26, 2012. The Regional Vice President, Director of Clinical Services, Administrator and Director of Nursing were informed of the Immediate Jeopardy on November 6, 2013, at 2:30 p.m. in the conference room. The facility provided and acceptable Allegation of Compliance on November 22, 2013, and a revisit on November 26, 2013, revealed the corrective actions implemented on November 25, 2013, removed the Immediate Jeopardy. Noncompliance for F-280 continues at an "E" level citation. The findings included: Resident #35 was admitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Mental Status score of 14, indicating no cognitive impairment. Medical record review of the Fall Risk Evaluation completed on admission and at quarterly reviews on March 8, and June 8, 2013, revealed the resident was "high risk for falls." Medical record review of facility falls reports and Care Plans (from December 2012 through October 2013) revealed the resident had a history of [REDACTED]. January 12, 2013, at 4:20 a.m., fell on the way to the bathroom and "Safety alarm" was care planned; January 15, 2013, no fall report provided for review and no new interventions care planned; March 6, 2013 at 7:50 a.m., fall report revealed fell on the way to the bathroom, new interventions care planned; March 21, 2013, at 7:20 a.m., fall report was not completed, no new interventions care planned; April 1, 2013, at 11:55 p.m., fall report revealed resident on the way to the bathroom, the Care Plan recorded a new intervention for a scoop mattress; May 21, 2013, at 4:15 p.m., fall report revealed this was a witnessed fall, no new interventions were implemented; May 25, 2013, at 7:25 a.m., fall report revealed a CNA heard the safety alarm, saw the bathroom emergency call light blinking, and found the resident in the bathroom on the floor with bruises, a skin tear to the left arm. Review of the Care Plan revealed no new interventions were implemented; July 19, 2013, at 8:20 a.m., fall report was not initiated until October 1, 2013, by the DON, during the annual survey, no investigation done. Review revealed the resident was found on the floor and "old skin tear re-opened." Review of the Care Plan revealed, "7/19/13 fall...Intervention 7/19/13 Reacher/grabber." August 12, 2013, at 3:40 a.m., fall report revealed "To resident room to answer call light, resident sitting in floor beside the bed...noted abrasion to right cheek and resident c/o (complained of) pain to right hip..." Medical record review of a History and Physical on admission to the hospital on August 12, 2013, revealed, "...Assessment and Plan: fall with right intertrochanteric (hip) fracture...still alert...wants surgery..." Medical record review of the an Interdisciplinary Progress Note dated August 19, 2013, revealed on this date the resident returned from the hospital following the surgery of the right hip. Medical record review of the Re-admission nursing assessment dated [DATE], revealed the resident returned from a hospitalization due to a Urinary Tract Infection. Medical record review of the Fall Risk Evaluation dated October 7, 2013, revealed a score of 13, "high risk for falls." Review of facility documentation revealed the resident fell in the bathroom at 4:32 a.m., on October 9, 2013. Review of the resident's Care Plan revealed the resident did not have the individualized interventions previously put into place resumed on re-admission. Interview with the Director of Nurses (DON) in the conference room at 1:00 p.m., on October 28, 2013, confirmed previous individualized interventions were not resumed when the resident returned to the facility October 7, 2013. Interview confirmed the Interdisciplinary Team did not complete an investigate and develop new appoaches after the October 9, 2013, fall. Medical record review of the Nursing Assessment completed for the readmission on August 19, 2013, revealed the resident did not have a pressure ulcer. Medical record review of the weekly skin checks recorded on the treatment record revealed the resident's skin was intact on August 20, 2013. Medical record review of the Skin Integrity Report, initiated for a right heel pressure ulcer, indicated the pressure ulcer was identified on August 25, 2013, and intially staged and measured on August 30, 2013, as a "Deep Tissue Injury" measuring 3 cm (centimeters) Legnth, 4 cm Width, and undetermined Depth due to the skin intact with "Appearance...deep purple." Medical record review of the physician's orders [REDACTED]." Observation of the resident at intervals on October 1, 2013, from 7:45 a.m., until 10:30 a.m., revealed the resident remained in the bed with the right heel pressure ulcer resting on the bed. Interview on October 2, 2013, at 9:00 a.m., in the resident's room with certified nurse aide (CNA) #9 revealed the CNA had cared for the resident during the previous two weeks. Interview included a review of the resident's Kardex/Care Card (provided for the CNA staff) and revealed the Kardex did not indicate the resident had a pressure ulcer of the right heel. Interview confirmed the CNA had not been told the resident had a pressure ulcer of the right heel and had not been given any instructions to maintain the right heel off of the bed. Interview by telephone on October 3, 2013, at 9:45 a.m., with the Registered Dietician (RD) revealed the RD had worked at the facility until September 20, 2013. Interview revealed the nursing home staff had not alerted the RD to the resident's pressure ulcer, and the RD verified nutritional interventions were not developed to address the right heel pressure ulcer. Interview and concurrent review of the Skin Integrity Report, with the Unit Manager/Wound Care Nurse in the conference room at 10:30 a.m., on October 2, 2013, confirmed the following: the right heel pressure ulcer had been identified on August 25, 2013, but the pressure ulcer had not been assessed until August 30, 2013; on August 30, 2013, the "pressure" wound was assessed as unstageable due to "deep tissue injury; and the pressure ulcer measurements did not change until the resident was admitted to the hospital on October 1, 2013, after 7:00 p.m. Interview continued and the Unit Manager stated from the time the right heel ulcer was identified on August 25, 2013, it was to be "floated off of the bed." Continued interview confirmed "floating the heels" off of the bed had not been placed on the CNA's Kardex or added to the Care Plan as a new intervention. Interview with the Director of Nurses at 11:00 a.m., on October 3, 2013, adjacent to the conference room, confirmed the resident did not have a pressure ulcer on admission to the facility; had developed a right heel pressure ulcer in the facility; the resident's Care Plan and Kardex did not include interventions to address the presence of a pressure ulcer. Resident #73 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS (Minimum Data Set) dated January 9, 2013, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 2 (severe cognitive impairment). Further review of the MDS, revealed the resident was dependent on staff for bed mobility, transfers, bathing, dressing, toilet use and personal hygiene. Medical record review of the care plan updated January 11, 2013, revealed resident #73 was care planned for at risk for falls. Medical record review of the Change of Condition Documentation, revealed resident #73 had falls/incidents documented on December 8, 2012, December 24, 2012, January 12, 2013 and January 13, 2013. Further review of the care plan, revealed no new interventions to address the resident's falls on December 8, 2012, December 24, 2012, January 12, 2013 and January 13, 2013. Review of the facility's policy titled "Falls Management", effective on September 15, 2001, and revised on June 1, 2013, revealed, "...If patient falls...Update care plan to reflect new interventions..." Review of the facility's policy titled "Falls Delivery Process", with revision date of June 1, 2013, revealed, "...Implement immediate interventions after the fall...Complete Condition of Change Document...Update care plan with new interventions as appropriate..." Interview with the ADON (Assistant Director of Nursing) on October 3, 2013, at 8:15 a.m., in the Admission's office, confirmed the facility had failed to revise the Care Plan to reflect new interventions to address the resident's falls. Medical record review of the quarterly MDS dated [DATE], revealed the resident was assessed with [REDACTED]. Medical record review of the wound management documentation, revealed a suspected deep tissue injury pressure ulcer had been identified on June 27, 2013, on the side of the left great toe and on the side of the left lateral foot. Medical record review of the Care Plan dated July 12, 2011 and revised August 1, 2013, revealed Resident #73 was care planned for the potential for complications due to skin breakdown. Review of the facility's policy titled, "14.6 Skin Integrity Management" revised October 1, 2010, revealed "...develop comprehensive, interdisciplinary plan of care...adjust plan of care, as indicated..." Interview with the DON (Director of Nursing) and the Wound Care Nurse on October 30, 2013, at 10:15 a.m., in the dining room, confirmed the facility had failed to revise the care plan to reflect new intervention to address the suspected deep tissue injury pressure ulcers located on the side of the left great toe and on the side of the left lateral foot at the time the pressure areas were identified on June 27, 2013. Resident #114 was admitted to the facility from the hospital on September 14, 2013, with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) with a reference date of September 21, 2013, revealed cognitive skills severely impaired, required two person assistance for bed mobility, always incontinent of urine, bowel continence not rated (had a rectal tube in place from admission), with one Stage 1 pressure ulcer and two Unstageable pressure ulcers. Medical record review of the Plan of Care developed on September 26, 2013, with additional information and interventions added through October 31, 2013 revealed the problem of Impaired Skin Integrity did not include the Stage I pressure ulcer assessed by the MDS and did not include the developement on October 1, 2013, of the sacral/coccyx pressure ulcer until October 16, 2013, when the sacral/coccyx ulcer had progressed to requiring a [MEDICATION NAME] agent. Review of the Plan of Care revealed the rectal tube was mentioned within the problem of "Self Care Deficit, "...Resident has a rectal tube with past medical history of [REDACTED]. Medical record review of the Wound Care physician's orders [REDACTED]. Do not use gerichair - may (increase) sacral wound." Medical record review of the Wound Care physician's orders [REDACTED]. Observation and interview at 1:50 p.m., on October 31, 2013, in the resident's room with the Wound Care Nurse, assisted by the Director of Nurses (DON), revealed the coccyx ulcer was not dressed. Observation revealed a dark area immediately to the right of the ulcer on the right buttock. Interview with the Wound Care Nurse revealed the area observed on the right buttock was "not there" when the coccyx pressure ulcer was measured two days earlier and stated the dark area was a "deep tissue injury." Interview continued and the Wound Care Nurse stated the coccyx wound was larger than when measured on October 29, 2013. Interview continued and the Wound Care Nurse verified there wasn't a dressing on the coccyx ulcer when the pressure ulcer was measured on October 29, 2013. Interview continued and the Wound Care Nurse and the DON stated the dressing was not staying adhered to the pressure ulcer "because of moisture from the "urinary incontinence." Interview verified the resident had worn an incontinent brief from admission to the present time. Interview with the Wound Care Physician, at the nursing station, on November 4, 2013, at 10:50 a.m., revealed, "...I will look at the wound (referring to the coccyx and right buttock) ...Yes, the dressing needs to stay on the sacrum at all times..." Interview at the nursing station, with Unit Manager on October 31, 2013, at 11:00 a.m., revealed the facility did not have the manufacturer's instructions for the rectal tube the resident had in place. Interview revealed the original date the rectal tube had been placed in the resident's rectal vault at the hospital had not been determined. Interview verified a plan of care for the rectal tube had not been developed. Interview with the Director of Nurses on November 4, 2013, at 1:30 p.m., in the conference room, confirmed an intervention had not been developed to address the problem identified on October 31, 2013, of non-adherence of the dressing to the sacral/coccyx pressure ulcer. Interview with the Wound Care Nurse on November 4, 2013, at 4:00 p.m., at the nursing station, confirmed the plan of care did not include an intervention for the Stage I pressure ulcer of the right buttock assessed on the MDS September 21, 2013, and treated with the Duoderm the first two weeks the resident was in the facility. Interview continued and verified on October 1, 2013, physician's orders [REDACTED]. of care. Interview confirmed the wound care treatment ordered by the Wound Care Physician on October 9, 2013, were not added to the resident's plan of care. Resident #79 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the nursing admission assessment dated [DATE], revealed the resident had a blanchable red area on the coccyx measuring 1.3 cm (centimeters) x 1.5 cm. Medical record review of the Pressure Ulcer Documentation Form dated March 19, 2013, revealed a wound was discovered on the coccyx which as a Stage 3 pressure ulcer measuring 3 cm (centimeters) x 1.5 cm x 0.2 cm, with 25% (percent) granulation and 50% slough. Medical record review of treatment records from admission through March 19, 2013, revealed documentation the resident's skin was intact when assessed weekly. Continued review of the form dated May 7, 2013, revealed the wound increased to a stage 4, measuring 6.5 cm x 4 cm x 1.5 cm with tunneling (open track from wound into tissue). Review of a physician's progress note dated May 8, 2013, revealed, "...pulse lavage saline to wound. Santyl (wound debrider) to coccyx wound when dressing. Start KCI wound vac (potassium chloride [DEVICE]) 125 mg (milligrams) intermittent every other day trial..." Medical record review of a hospital History and Physical dated May 23, 2013, revealed the resident underwent [REDACTED]. Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was dependent for transfers, bathing, dressing, grooming; had a Foley catheter; was incontinent of bowel; required two person assistance for transfers and Activities of Daily Living (ADLs); and had one stage 4 pressure ulcer and one unstageable pressure ulcer. Medical record review of a hospital admitted d September 9, 2013, revealed the resident underwent [REDACTED]. Review of the care plan initiated on January 16, 2013, and revised on September 20, 2013, revealed no documentation of the use of a suprapubic catheter or care of the catheter. Continued review of the care plan revealed no documentation of specific care for the sacral decubitus but stated "...continue with care..." Interview with the DON on October 3, 2013, at 1:40 p.m., in the nurses' station, confirmed the care plan did not reflect the resident's suprapubic catheter and its specific care nor did it reflect the wound care of the resident's decubitus. Resident # 62 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems; required extensive assistance of one person physical assistance for transfers, walk in corridor, dressing, personal hygiene and bathing; required extensive assistance of two plus person physical assistance for bed mobility and toilet use; was continent of bowel and bladder; and had no falls. Review of facility documentation revealed the resident had a fall from the bed with no injury on January 13, 2013, at 5:00 a.m. Review of the facility fall report revealed the resident had a fall from the bed with a laceration, was sent to the emergency roiagnom on [DATE], at 3:30 p.m. Medical record review of the Resident Fall Evaluation revealed the resident experienced two falls on January 13, 2013. Review of the facility fall report revealed the resident had a fall from the bed with no injury on January 20, 2013, at 10:00 p.m., and was sent to the emergency room due to complaints of a headache. Medical record review of the Resident Fall Evaluation revealed no documentation of a fall evaluation after the fall on January 20, 2013. Medical record review of the Nursing Note dated January 21, 2013, at 2:00 a.m., revealed there resident was readmitted to the facility from the hospital. Review of the Care Plan initiated on February 28, 2010, and updated on December 4, 2012, revealed a problem for "Risk for falls related to: unstable health condition, unsteady gait, history of falls...Goal: No significant injury with the target date of February 10, 2013. Further review revealed no additional interventions following the two falls on January 13, 2013, or for the fall on January 20, 2013. Review of the facility's policy titled "Falls Management Policy" dated September 15, 2001 and revised on June 1, 2013, revealed "...communicate patient's fall risk status to caregivers...develop individualized plan of care...review and revise care plan regularly...If the patient falls: Perform Neurological Assessment for unwitnessed falls and witnessed falls with head injury...Complete the Change of Condition Note...Patient Fall Investigation Form...Update care plan to reflect new interventions...Document...Effectiveness of interventions...Conduct Interdisciplinary Team meeting within 72 hours of fall...The Administrator and Director of Nursing will conduct a post fall review..." Further review revealed "Refer to Falls Care Delivery Process." Review of the Falls Care Delivery Process , revised on June 1, 2013, revealed "Response to a Patient Fall...Evaluate and monitor patient for 72 hours after the fall. Perform Neurological Assessments for all unwitnessed falls and witnessed falls with head injury. Complete change of condition note...Review patient's medical record and assessments to identify any causes that may have contributed to the fall...Investigate fall circumstances...Review "[MEDICATION NAME]/Extrinsic Fall Risk Factors" to implement new interventions or remove environmental risk factors to prevent future falls...Implement immediate interventions after the fall...Update care plan with new interventions as appropriate...Communicate interventions to staff...Conduct Interdisciplinary Team meeting within 72 hours of patient fall to perform the following: Review and complete...investigation form...Determine need for additional action/interventions. Add additional interventions to...care plan as indicated by investigation...Communicate information to staff and care plan team...The Director of Nursing (or designee) will: Complete the follow-up recommendations within five working days. Review for completion..." Observations on October 2, 2013, at 1:15 p.m., and October 3, 2013, at 7:45 a.m., revealed the resident in bed with a pad alarm attached, the call light within reach, and a locked wheel chair beside the bed. Interview with the Medical Records Director on October 3, 2013, at 11:00 a.m., in the conference room, confirmed the Care Plan initiated on February 28, 2010, and updated on December 4, 2012, was the only Care Plan used during January 2013 and was effective through the goal date on February 10, 2013. Interview on October 3, 2013, at 1:55 p.m. in the business office, with the Administrator and Director of Nursing, confirmed the Care Plan following the falls on January 13, 2013, 5:00 a.m. and 3:30 p.m., and on January 20, 2013, had not been updated with new interventions. Further interview confirmed the facility failed to follow their policy to revise the Care Plans after falls. Resident #120 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of facility falls report revealed the resident had five falls on the following dates: February 25, 2013, March 3, 12 and 22, 2013, and April 10, 2013. Medical record review of the care plan with the initial date of February 6, 2013, revealed a focus of "Risk for falls related to: unstable health condition." Further review revealed the approaches initiated on February 6, 2013, of "Have commonly used articles within easy reach. Resident to wear non-slip footwear." Further review of the care plan revealed an undated approach of "Encourage use of call light for assistance with transferring needs." Further review of the care plan revealed the facility failed to include new interventions after the falls on February 25, 2013, March 3, 2013, and April 10, 2013. Interview on November 5, 2013, at 3:15 p.m., in the Administrator's office, with the Administrator, Director of Clinical Services, and the Director of Nursing confirmed the facility failed to revise the care plan with new interventions after the falls on February 25, 2013, March 3, 12 and 22, 2013, and April 10, 2013. Resident #26 was initially admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the facility documentation revealed the resident had five falls on the following dates: July 4, 2013, at 8:45 a.m., and 9:00 a.m.; July 8, 2013; October 3, 2013, and October 19, 2013. Medical record review of the care plan with the initial date of June 7, 2013, revealed a focus of "Risk for falls related to: unsteady gait " Further review revealed the approaches initiated on June 7, 2013, of "Have commonly used articles within easy reach. Resident to wear non-slip footwear. Encourage resident to use handrails or assistive devices properly." Further review of the care plan revealed the facility failed to include new interventions after both falls on July 4, 2013; July 8, 2013, and on October 4, 2013. Interview with the Director of Nursing, Administrator, Director of Clinical Services, and the Regional Vice President, on November 6, 2013, at 10:35 a.m., in the conference room confirmed the facility failed to revise the care plan to include any new interventions after both falls on July 4, 2013; July 8, 2013, and on October 4, 2013. Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS (Minimal Data Set) dated April 16, 2013, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 4 indicating severe cognitive impairment. Further review of the MDS, revealed the resident was totally dependent for bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene. Medical record review of the facility's fall report, revealed resident #93 had falls/incidents documented on January 23, 2013, February 11, 2013, February 13, 2013, February 15, 2013, and February 25, 2013. Medical record review of the Care Plan updated January 31, 2013, April 16, 2013 and April 22, 2013, revealed resident #93 was care planned as being at risk for falls r/t (related to) unstable health condition. Further review of the Care Plan, revealed no new interventions had been added to address the resident's falls on February 11, 2013, February 13, 2013, February 15, 2013, and February 25, 2013. Interview with the DON (Director of Nursing) on November 5, 2013, at 12:20 p.m., in the conference room, confirmed the facility failed to revise the Care Plan to reflect new interventions to address the resident's falls occurring on February 11, 2013, February 13, 2013, February 15, 2013, and February 25, 2013. Resident #100 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of an annual MDS (Minimal Data Set) dated February 25, 2013, revealed the resident was dependent for bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene. Further review of the MDS revealed, the resident had a BIMS (Brief Interview for Mental Status) score of 15 (no cognitive impairment). Medical record review of a quarterly MDS dated [DATE], revealed the resident required extensive assistance for bed mobility and transfers, required limited assistance from for locomotion and was totally dependent for dressing, toilet use, personal hygiene and bathing. Further review of the MDS revealed, the resident had a BIMS score of 7 indicating severe cognitive impairment. Medical record review of the facility's fall reports, revealed Resident #100 had falls/incidents documented on February 18, 2013, February 21, 2013, February 23, 2013, April 5, 2013, April 20, 2013, and May 2, 2013. Medical record review of the Care Plan updated February 18, 2013, February 19, 2013, April 26, 2013, and July 31, 2013, revealed resident #100 was care planned for at risk for falls related to bilateral aka (above knee amputation), unstable health condition, pain, and decreased safety awareness. Further review of the care plan, revealed no new interventions to address the resident's falls on February 21, 2013, and May 2, 2013. Interview with the DON (Director of Nursing) on November 6, 2013, at 8:30 a.m., in the business office, confirmed the facility failed to revise the Care Plan to reflect new interventions to address the resident's falls occurring on February 21, 2013 and May 2, 2013. Resident #52 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems; had impaired decision-making; required assistance of one person for bathing, dressing, and grooming; required assistance with transfers; was incontinent of bowel and bladder; and had a fall since the last assessment. Medical record review of the physician's orders [REDACTED]. Medical record review of the facility fall report dated July 3, 2013, which was incorrect, revealed the resident had a fall in the past 30 days, and had no issues contributing to falls. Medical record review of Interdisciplinary Team Progress Notes revealed an entry dated August 8, 2013, "...reviewed d/t (due to) recent fall on August 4, 2013. Pt. was trying to transfer self from w/c (wheelchair) to another chair and fell in floor. Pt re-educated to ask for assistance before transferring..." This is an inappropriate intervention considering the resident had long and short term memory defi

Based on medical record review, review of facility documentation, observation, review of facility policy, and interview, the facility failed to revise the care plan following falls to include interventions for the staff to implement to prevent future falls for nine residents (#35, #73, #62, #120, #26, #93, #100, #52, #119) of twenty-two residents reviewed with falls; failed to revise the care plan addressing pressure ulcers for staff to implement care plans for four (#35, #73, #114, #79) of fourteen residents reviewed with pressure ulcers; and failed to revise the care plan with interventions for staff to implement after a sexual altercation for two residents (#77, #42) of sixty-five residents reviewed. The facility's failure to address interventions on the care plan for pressure ulcers for three residents (#35, #73, and #114) resulted in staff unfamiliar with the care to be provided placing residents in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or likely to cause serious injury, harm, impairment, or death). The failure of the facility to revise the care plans addessing falls with new interventions resulted in a [MEDICAL CONDITION] for one resident (#35) and a fractured clavicle for one resident (#73) placing the residents in Immediate Jeopardy. The Immediate Jeopardy was effective on November 26, 2012, and is ongoing. The Regional Vice President, Director of Clinical Services, Administrator and Director of Nursing were informed of the Immediate Jeopardy on November 6, 2013, at 2:30 p.m. in the conference room. The findings included: Resident #35 was admitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Mental Status score of 14, indicating no cognitive impairment. Medical record review of the Fall Risk Evaluation completed on admission and at quarterly reviews on March 8, and June 8, 2013, revealed the resident was "high risk for falls." Medical record review of facility falls reports and Care Plans (from December 2012 through October 2013) revealed the resident had a history of [REDACTED]. January 12, 2013, at 4:20 a.m., fell on the way to the bathroom and "Safety alarm" was care planned; January 15, 2013, no fall report provided for review and no new interventions care planned; March 6, 2013 at 7:50 a.m., fall report revealed fell on the way to the bathroom, new interventions care planned; March 21, 2013, at 7:20 a.m., fall report was not completed, no new interventions care planned; April 1, 2013, at 11:55 p.m., fall report revealed resident on the way to the bathroom, the Care Plan recorded a new intervention for a scoop mattress; May 21, 2013, at 4:15 p.m., fall report revealed this was a witnessed fall, no new interventions were implemented; May 25, 2013, at 7:25 a.m., fall report revealed a CNA heard the safety alarm, saw the bathroom emergency call light blinking, and found the resident in the bathroom on the floor with bruises, a skin tear to the left arm. Review of the Care Plan revealed no new interventions were implemented; July 19, 2013, at 8:20 a.m., fall report was not initiated until October 1, 2013, by the DON, during the annual survey, no investigation done. Review revealed the resident was found on the floor and "old skin tear re-opened." Review of the Care Plan revealed, "7/19/13 fall...Intervention 7/19/13 Reacher/grabber." August 12, 2013, at 3:40 a.m., fall report revealed "To resident room to answer call light, resident sitting in floor beside the bed...noted abrasion to right cheek and resident c/o (complained of) pain to right hip..." Medical record review of a History and Physical on admission to the hospital on August 12, 2013, revealed, "...Assessment and Plan: fall with right intertrochanteric (hip) fracture...still alert...wants surgery..." Medical record review of the an Interdisciplinary Progress Note dated August 19, 2013, revealed on this date the resident returned from the hospital following the surgery of the right hip. Medical record review of the Re-admission nursing assessment dated [DATE], revealed the resident returned from a hospitalization due to a Urinary Tract Infection. Medical record review of the Fall Risk Evaluation dated October 7, 2013, revealed a score of 13, "high risk for falls." Review of facility documentation revealed the resident fell in the bathroom at 4:32 a.m., on October 9, 2013. Review of the resident's Care Plan revealed the resident did not have the individualized interventions previously put into place resumed on re-admission. Interview with the Director of Nurses (DON) in the conference room at 1:00 p.m., on October 28, 2013, confirmed previous individualized interventions were not resumed when the resident returned to the facility October 7, 2013. Interview confirmed the Interdisciplinary Team did not complete an investigate and develop new appoaches after the October 9, 2013, fall. Medical record review of the Nursing Assessment completed for the readmission on August 19, 2013, revealed the resident did not have a pressure ulcer. Medical record review of the weekly skin checks recorded on the treatment record revealed the resident's skin was intact on August 20, 2013. Medical record review of the Skin Integrity Report, initiated for a right heel pressure ulcer, indicated the pressure ulcer was identified on August 25, 2013, and intially staged and measured on August 30, 2013, as a "Deep Tissue Injury" measuring 3 cm (centimeters) Legnth, 4 cm Width, and undetermined Depth due to the skin intact with "Appearance...deep purple." Medical record review of the physician's orders [REDACTED]." Observation of the resident at intervals on October 1, 2013, from 7:45 a.m., until 10:30 a.m., revealed the resident remained in the bed with the right heel pressure ulcer resting on the bed. Interview on October 2, 2013, at 9:00 a.m., in the resident's room with certified nurse aide (CNA) #9 revealed the CNA had cared for the resident during the previous two weeks. Interview included a review of the resident's Kardex/Care Card (provided for the CNA staff) and revealed the Kardex did not indicate the resident had a pressure ulcer of the right heel. Interview confirmed the CNA had not been told the resident had a pressure ulcer of the right heel and had not been given any instructions to maintain the right heel off of the bed. Interview by telephone on October 3, 2013, at 9:45 a.m., with the Registered Dietician (RD) revealed the RD had worked at the facility until September 20, 2013. Interview revealed the nursing home staff had not alerted the RD to the resident's pressure ulcer, and the RD verified nutritional interventions were not developed to address the right heel pressure ulcer. Interview and concurrent review of the Skin Integrity Report, with the Unit Manager/Wound Care Nurse in the conference room at 10:30 a.m., on October 2, 2013, confirmed the following: the right heel pressure ulcer had been identified on August 25, 2013, but the pressure ulcer had not been assessed until August 30, 2013; on August 30, 2013, the "pressure" wound was assessed as unstageable due to "deep tissue injury; and the pressure ulcer measurements did not change until the resident was admitted to the hospital on October 1, 2013, after 7:00 p.m. Interview continued and the Unit Manager stated from the time the right heel ulcer was identified on August 25, 2013, it was to be "floated off of the bed." Continued interview confirmed "floating the heels" off of the bed had not been placed on the CNA's Kardex or added to the Care Plan as a new intervention. Interview with the Director of Nurses at 11:00 a.m., on October 3, 2013, adjacent to the conference room, confirmed the resident did not have a pressure ulcer on admission to the facility; had developed a right heel pressure ulcer in the facility; the resident's Care Plan and Kardex did not include interventions to address the presence of a pressure ulcer. Resident #73 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS (Minimum Data Set) dated January 9, 2013, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 2 (severe cognitive impairment). Further review of the MDS, revealed the resident was dependent on staff for bed mobility, transfers, bathing, dressing, toilet use and personal hygiene. Medical record review of the care plan updated January 11, 2013, revealed resident #73 was care planned for at risk for falls. Medical record review of the Change of Condition Documentation, revealed resident #73 had falls/incidents documented on December 8, 2012, December 24, 2012, January 12, 2013 and January 13, 2013. Further review of the care plan, revealed no new interventions to address the resident's falls on December 8, 2012, December 24, 2012, January 12, 2013 and January 13, 2013. Review of the facility's policy titled "Falls Management", effective on September 15, 2001, and revised on June 1, 2013, revealed, "...If patient falls...Update care plan to reflect new interventions..." Review of the facility's policy titled "Falls Delivery Process", with revision date of June 1, 2013, revealed, "...Implement immediate interventions after the fall...Complete Condition of Change Document...Update care plan with new interventions as appropriate..." Interview with the ADON (Assistant Director of Nursing) on October 3, 2013, at 8:15 a.m., in the Admission's office, confirmed the facility had failed to revise the Care Plan to reflect new interventions to address the resident's falls. Medical record review of the quarterly MDS dated [DATE], revealed the resident was assessed with [REDACTED]. Medical record review of the wound management documentation, revealed a suspected deep tissue injury pressure ulcer had been identified on June 27, 2013, on the side of the left great toe and on the side of the left lateral foot. Medical record review of the Care Plan dated July 12, 2011 and revised August 1, 2013, revealed Resident #73 was care planned for the potential for complications due to skin breakdown. Review of the facility's policy titled, "14.6 Skin Integrity Management" revised October 1, 2010, revealed "...develop comprehensive, interdisciplinary plan of care...adjust plan of care, as indicated..." Interview with the DON (Director of Nursing) and the Wound Care Nurse on October 30, 2013, at 10:15 a.m., in the dining room, confirmed the facility had failed to revise the care plan to reflect new intervention to address the suspected deep tissue injury pressure ulcers located on the side of the left great toe and on the side of the left lateral foot at the time the pressure areas were identified on June 27, 2013. Resident #114 was admitted to the facility from the hospital on September 14, 2013, with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) with a reference date of September 21, 2013, revealed cognitive skills severely impaired, required two person assistance for bed mobility, always incontinent of urine, bowel continence not rated (had a rectal tube in place from admission), with one Stage 1 pressure ulcer and two Unstageable pressure ulcers. Medical record review of the Plan of Care developed on September 26, 2013, with additional information and interventions added through October 31, 2013 revealed the problem of Impaired Skin Integrity did not include the Stage I pressure ulcer assessed by the MDS and did not include the developement on October 1, 2013, of the sacral/coccyx pressure ulcer until October 16, 2013, when the sacral/coccyx ulcer had progressed to requiring a [MEDICATION NAME] agent. Review of the Plan of Care revealed the rectal tube was mentioned within the problem of "Self Care Deficit, "...Resident has a rectal tube with past medical history of [REDACTED]. Medical record review of the Wound Care physician's orders [REDACTED]. Do not use gerichair - may (increase) sacral wound." Medical record review of the Wound Care physician's orders [REDACTED]. Observation and interview at 1:50 p.m., on October 31, 2013, in the resident's room with the Wound Care Nurse, assisted by the Director of Nurses (DON), revealed the coccyx ulcer was not dressed. Observation revealed a dark area immediately to the right of the ulcer on the right buttock. Interview with the Wound Care Nurse revealed the area observed on the right buttock was "not there" when the coccyx pressure ulcer was measured two days earlier and stated the dark area was a "deep tissue injury." Interview continued and the Wound Care Nurse stated the coccyx wound was larger than when measured on October 29, 2013. Interview continued and the Wound Care Nurse verified there wasn't a dressing on the coccyx ulcer when the pressure ulcer was measured on October 29, 2013. Interview continued and the Wound Care Nurse and the DON stated the dressing was not staying adhered to the pressure ulcer "because of moisture from the "urinary incontinence." Interview verified the resident had worn an incontinent brief from admission to the present time. Interview with the Wound Care Physician, at the nursing station, on November 4, 2013, at 10:50 a.m., revealed, "...I will look at the wound (referring to the coccyx and right buttock) ...Yes, the dressing needs to stay on the sacrum at all times..." Interview at the nursing station, with Unit Manager on October 31, 2013, at 11:00 a.m., revealed the facility did not have the manufacturer's instructions for the rectal tube the resident had in place. Interview revealed the original date the rectal tube had been placed in the resident's rectal vault at the hospital had not been determined. Interview verified a plan of care for the rectal tube had not been developed. Interview with the Director of Nurses on November 4, 2013, at 1:30 p.m., in the conference room, confirmed an intervention had not been developed to address the problem identified on October 31, 2013, of non-adherence of the dressing to the sacral/coccyx pressure ulcer. Interview with the Wound Care Nurse on November 4, 2013, at 4:00 p.m., at the nursing station, confirmed the plan of care did not include an intervention for the Stage I pressure ulcer of the right buttock assessed on the MDS September 21, 2013, and treated with the [MEDICATION NAME] the first two weeks the resident was in the facility. Interview continued and verified on October 1, 2013, physician's orders [REDACTED]. Interview confirmed the wound care treatment ordered by the Wound Care Physician on October 9, 2013, were not added to the resident's plan of care. Resident #79 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the nursing admission assessment dated [DATE], revealed the resident had a blanchable red area on the coccyx measuring 1.3 cm (centimeters) x 1.5 cm. Medical record review of the Pressure Ulcer Documentation Form dated March 19, 2013, revealed a wound was discovered on the coccyx which as a Stage 3 pressure ulcer measuring 3 cm (centimeters) x 1.5 cm x 0.2 cm, with 25% (percent) granulation and 50% slough. Medical record review of treatment records from admission through March 19, 2013, revealed documentation the resident's skin was intact when assessed weekly. Continued review of the form dated May 7, 2013, revealed the wound increased to a stage 4, measuring 6.5 cm x 4 cm x 1.5 cm with tunneling (open track from wound into tissue). Review of a physician's progress note dated May 8, 2013, revealed, "...pulse lavage saline to wound. Santyl (wound debrider) to coccyx wound when dressing. Start KCI wound vac (potassium chloride [DEVICE]) 125 mg (milligrams) intermittent every other day trial..." Medical record review of a hospital History and Physical dated May 23, 2013, revealed the resident underwent [REDACTED]. Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was dependent for transfers, bathing, dressing, grooming; had a Foley catheter; was incontinent of bowel; required two person assistance for transfers and Activities of Daily Living (ADLs); and had one stage 4 pressure ulcer and one unstageable pressure ulcer. Medical record review of a hospital admitted d September 9, 2013, revealed the resident underwent [REDACTED]. Review of the care plan initiated on January 16, 2013, and revised on September 20, 2013, revealed no documentation of the use of a suprapubic catheter or care of the catheter. Continued review of the care plan revealed no documentation of specific care for the sacral decubitus but stated "...continue with care..." Interview with the DON on October 3, 2013, at 1:40 p.m., in the nurses' station, confirmed the care plan did not reflect the resident's suprapubic catheter and its specific care nor did it reflect the wound care of the resident's decubitus. Resident # 62 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems; required extensive assistance of one person physical assistance for transfers, walk in corridor, dressing, personal hygiene and bathing; required extensive assistance of two plus person physical assistance for bed mobility and toilet use; was continent of bowel and bladder; and had no falls. Review of facility documentation revealed the resident had a fall from the bed with no injury on January 13, 2013, at 5:00 a.m. Review of the facility fall report revealed the resident had a fall from the bed with a laceration, was sent to the emergency roiagnom on [DATE], at 3:30 p.m. Medical record review of the Resident Fall Evaluation revealed the resident experienced two falls on January 13, 2013. Review of the facility fall report revealed the resident had a fall from the bed with no injury on January 20, 2013, at 10:00 p.m., and was sent to the emergency room due to complaints of a headache. Medical record review of the Resident Fall Evaluation revealed no documentation of a fall evaluation after the fall on January 20, 2013. Medical record review of the Nursing Note dated January 21, 2013, at 2:00 a.m., revealed there resident was readmitted to the facility from the hospital. Review of the Care Plan initiated on February 28, 2010, and updated on December 4, 2012, revealed a problem for "Risk for falls related to: unstable health condition, unsteady gait, history of falls...Goal: No significant injury with the target date of February 10, 2013. Further review revealed no additional interventions following the two falls on January 13, 2013, or for the fall on January 20, 2013. Review of the facility's policy titled "Falls Management Policy" dated September 15, 2001 and revised on June 1, 2013, revealed "...communicate patient's fall risk status to caregivers...develop individualized plan of care...review and revise care plan regularly...If the patient falls: Perform Neurological Assessment for unwitnessed falls and witnessed falls with head injury...Complete the Change of Condition Note...Patient Fall Investigation Form...Update care plan to reflect new interventions...Document...Effectiveness of interventions...Conduct Interdisciplinary Team meeting within 72 hours of fall...The Administrator and Director of Nursing will conduct a post fall review..." Further review revealed "Refer to Falls Care Delivery Process." Review of the Falls Care Delivery Process , revised on June 1, 2013, revealed "Response to a Patient Fall...Evaluate and monitor patient for 72 hours after the fall. Perform Neurological Assessments for all unwitnessed falls and witnessed falls with head injury. Complete change of condition note...Review patient's medical record and assessments to identify any causes that may have contributed to the fall...Investigate fall circumstances...Review "[MEDICATION NAME]/Extrinsic Fall Risk Factors" to implement new interventions or remove environmental risk factors to prevent future falls...Implement immediate interventions after the fall...Update care plan with new interventions as appropriate...Communicate interventions to staff...Conduct Interdisciplinary Team meeting within 72 hours of patient fall to perform the following: Review and complete...investigation form...Determine need for additional action/interventions. Add additional interventions to...care plan as indicated by investigation...Communicate information to staff and care plan team...The Director of Nursing (or designee) will: Complete the follow-up recommendations within five working days. Review for completion..." Observations on October 2, 2013, at 1:15 p.m., and October 3, 2013, at 7:45 a.m., revealed the resident in bed with a pad alarm attached, the call light within reach, and a locked wheel chair beside the bed. Interview with the Medical Records Director on October 3, 2013, at 11:00 a.m., in the conference room, confirmed the Care Plan initiated on February 28, 2010, and updated on December 4, 2012, was the only Care Plan used during January 2013 and was effective through the goal date on February 10, 2013. Interview on October 3, 2013, at 1:55 p.m. in the business office, with the Administrator and Director of Nursing, confirmed the Care Plan following the falls on January 13, 2013, 5:00 a.m. and 3:30 p.m., and on January 20, 2013, had not been updated with new interventions. Further interview confirmed the facility failed to follow their policy to revise the Care Plans after falls. Resident #120 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of facility falls report revealed the resident had five falls on the following dates: February 25, 2013, March 3, 12 and 22, 2013, and April 10, 2013. Medical record review of the care plan with the initial date of February 6, 2013, revealed a focus of "Risk for falls related to: unstable health condition." Further review revealed the approaches initiated on February 6, 2013, of "Have commonly used articles within easy reach. Resident to wear non-slip footwear." Further review of the care plan revealed an undated approach of "Encourage use of call light for assistance with transferring needs." Further review of the care plan revealed the facility failed to include new interventions after the falls on February 25, 2013, March 3, 2013, and April 10, 2013. Interview on November 5, 2013, at 3:15 p.m., in the Administrator's office, with the Administrator, Director of Clinical Services, and the Director of Nursing confirmed the facility failed to revise the care plan with new interventions after the falls on February 25, 2013, March 3, 12 and 22, 2013, and April 10, 2013. Resident #26 was initially admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the facility documentation revealed the resident had five falls on the following dates: July 4, 2013, at 8:45 a.m., and 9:00 a.m.; July 8, 2013; October 3, 2013, and October 19, 2013. Medical record review of the care plan with the initial date of June 7, 2013, revealed a focus of "Risk for falls related to: unsteady gait " Further review revealed the approaches initiated on June 7, 2013, of "Have commonly used articles within easy reach. Resident to wear non-slip footwear. Encourage resident to use handrails or assistive devices properly." Further review of the care plan revealed the facility failed to include new interventions after both falls on July 4, 2013; July 8, 2013, and on October 4, 2013. Interview with the Director of Nursing, Administrator, Director of Clinical Services, and the Regional Vice President, on November 6, 2013, at 10:35 a.m., in the conference room confirmed the facility failed to revise the care plan to include any new interventions after both falls on July 4, 2013; July 8, 2013, and on October 4, 2013. Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS (Minimal Data Set) dated April 16, 2013, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 4 indicating severe cognitive impairment. Further review of the MDS, revealed the resident was totally dependent for bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene. Medical record review of the facility's fall report, revealed resident #93 had falls/incidents documented on January 23, 2013, February 11, 2013, February 13, 2013, February 15, 2013, and February 25, 2013. Medical record review of the Care Plan updated January 31, 2013, April 16, 2013 and April 22, 2013, revealed resident #93 was care planned as being at risk for falls r/t (related to) unstable health condition. Further review of the Care Plan, revealed no new interventions had been added to address the resident's falls on February 11, 2013, February 13, 2013, February 15, 2013, and February 25, 2013. Interview with the DON (Director of Nursing) on November 5, 2013, at 12:20 p.m., in the conference room, confirmed the facility failed to revise the Care Plan to reflect new interventions to address the resident's falls occurring on February 11, 2013, February 13, 2013, February 15, 2013, and February 25, 2013. Resident #100 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of an annual MDS (Minimal Data Set) dated February 25, 2013, revealed the resident was dependent for bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene. Further review of the MDS revealed, the resident had a BIMS (Brief Interview for Mental Status) score of 15 (no cognitive impairment). Medical record review of a quarterly MDS dated [DATE], revealed the resident required extensive assistance for bed mobility and transfers, required limited assistance from for locomotion and was totally dependent for dressing, toilet use, personal hygiene and bathing. Further review of the MDS revealed, the resident had a BIMS score of 7 indicating severe cognitive impairment. Medical record review of the facility's fall reports, revealed Resident #100 had falls/incidents documented on February 18, 2013, February 21, 2013, February 23, 2013, April 5, 2013, April 20, 2013, and May 2, 2013. Medical record review of the Care Plan updated February 18, 2013, February 19, 2013, April 26, 2013, and July 31, 2013, revealed resident #100 was care planned for at risk for falls related to bilateral aka (above knee amputation), unstable health condition, pain, and decreased safety awareness. Further review of the care plan, revealed no new interventions to address the resident's falls on February 21, 2013, and May 2, 2013. Interview with the DON (Director of Nursing) on November 6, 2013, at 8:30 a.m., in the business office, confirmed the facility failed to revise the Care Plan to reflect new interventions to address the resident's falls occurring on February 21, 2013 and May 2, 2013. Resident #52 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems; had impaired decision-making; required assistance of one person for bathing, dressing, and grooming; required assistance with transfers; was incontinent of bowel and bladder; and had a fall since the last assessment. Medical record review of the physician's orders [REDACTED]. Medical record review of the facility fall report dated July 3, 2013, which was incorrect, revealed the resident had a fall in the past 30 days, and had no issues contributing to falls. Medical record review of Interdisciplinary Team Progress Notes revealed an entry dated August 8, 2013, "...reviewed d/t (due to) recent fall on August 4, 2013. Pt. was trying to transfer self from w/c (wheelchair) to another chair and fell in floor. Pt re-educated to ask for assistance before transferring..." This is an inappropriate inv\tervention considering the resident had long and short term memory deficits as well as impaired decision-making. Review of a facility fall report dated June 4, 2013 (incorrect date), revealed the resident was attempting to ambulate independently in the solarium from the wheelchair to another chair. Continued review of the docu

Based on medical record review, review of facility policy, observation, and interview, the facility failed to prevent the development of avoidable pressure ulcers for four residents (#95, #114, #35, #73) of fourteen residents with pressure ulcers reviewed. The facility's failure to perform accurate assessments and obtain physician's orders placed residents #95, #114, #35 in Immediate Jeopardy (a situation in which the provider's non-compliance caused or is likely to cause serious injury, harm, impairment, or death). The systemic failure to ensure orders physician's orders for a medical device was obtained; skin assessments were performed correctly; pressure ulcers were assessed accurately; and treatments ordered by the physician were documented, was likely to place any resident at risk for pressure ulcers in Immediate Jeopardy. The Immediate Jeopardy was effective from November 26, 2012. The Regional Vice President, Director of Clinical Services, Administrator, and Director of Nursing were informed of the Immediate Jeopardy on November 6, 2013, at 2:30 p.m., in the conference room. The facility provided and acceptable Allegation of Compliance on November 25, 2013, and a revisit on November 26, 2013, revealed the corrective actions implemented on November 25, 2013, removed the Immediate Jeopardy. Noncompliance for F-314 continues at an "E" level citation. The findings included: Resident #95 was admitted to a Trauma Center on July 27, 2012, following an accident while burning brush in which there was an explosion. Two days later the family and friends were unable to contact the resident and a neighbor found the resident in the house, minimally responsive and lethargic. As a result of the accident the resident was a C6 quadriplegic (fracture of neck just above shoulders leaving resident unable to move from the neck down) [MEDICAL CONDITION] 15% (percent) of the body, including face, right arm, left arm, and bilateral lower extremities. Resident #95 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the discharge recommendations from Physical Therapy at an outside hospital, dated August 20, 2012, revealed "...the following anti-contracture devices were applied to patient: Multipodus boots BLEs (bilateral lower extremities) continuously when supine..." Interview with the Director of Nursing (DON) on October 3, 2013, at 12:50 p.m., at the nurses station, revealed the resident was admitted to the facility from the hospital on October 5, 2012, with a multipodus boot (for management of footdrop) in place on the left foot. Medical record review of the Interim Care Plan dated October 5, 2012, revealed, "...potential for pain related to wounds...alteration in skin integrity r/t (related to) Burn...report new open areas..." Medical record review of the admission nursing assessment dated [DATE], revealed the resident had an open area on the left knee, open/abrasion on the right lower extremity, reddened area to the scrotum area, sore/scabbed over area to the coccyx, reddened right lower extremity, and reddened area on the right side. Medical record review of the Admission Physician orders dated October 5, 2012, revealed, "...float heels...pressure reducing mattress to bed...weekly skin check by licensed nurse..." Medical record review of a Nurse's Note dated October 5, 2012, at 3:45 p.m., revealed, "...skin pink warm, multiple red areas D/T (due to)[MEDICAL CONDITION] total Norton plus score (11) (indicates very high risk)..." Medical record review of the Treatment Administration Record (TAR) dated October 5-31, 2012, revealed, "...open area to coccyx apply exuderm change q (every) 3 days (start date October 9, 2012)...Weekly skin check..." Continued review of the October TAR revealed no weekly skin assessments documented in October. Medical record review of an admission Minimum Data Set (MDS) dated [DATE], revealed the resident was moderately impaired for daily decision making; totally dependent for all Activities of Daily Living (ADL's); at risk for pressure ulcers; and had no pressure ulcers on admission. Medical record review revealed the resident was admitted to the hospital on October 24-29, 2012, for Altered Mental Status, Urinary Tract Infection, and for treatment of [REDACTED]. Medical record review of the Nursing Assessment Re-admitted d October 29, 2012, revealed "...Skin/Wound condition present: no...red area (coccyx)...scabbed area (right lower extremity) scab area (top of right foot)...red area (right forearm)...Norton Score 12 (very high risk)..." Medical record review of the Care Plan dated October 30, 2012, revealed, "...potential for pain related to wounds...alteration in skin integrity r/t Burn...report new open areas...10/30/12 coccyx shearing." Medical record review of the Care Plan dated October 31, 2012, revealed "...Skin (with) Stage II (partial loss of skin as shallow open ulcer)on coccyx..." Medical record review of Treatment Administration Records (TAR) dated November 2012, revealed the resident was ordered Exuderm on November 12, 2012, to be applied to coccyx and change every three days. Continued review of the TAR revealed the treatment was not documented as being administered on November 20, 23, and 29, 2012. Further review of the TAR revealed an order to apply skin prep to bilateral heels each shift. Further review of the TAR revealed no documentation this was administered on the night shift on November 26, 29, and 30, 2012. Medical record review of a Nurse's Note dated November 26, 2012, at 10:00 a.m., revealed, "...Blister noted to L (left) heel possibly caused by boot resident wears to prevent foot drop..." Medical record review of a Nurse Practitioner (NP) note on November 26, 2012, revealed "...Skin: normal..." Medical record review of the Physician's orders from admission on October 5, 2012, to discharge on May 1, 2013, revealed no order for a "boot." Medical record review of the resident's chart revealed no information regarding the application of the boot, the schedule of the boot, and/or the staff responsible for monitoring the boot. Medical record review of a Physician's order dated November 26, 2012, revealed, "...Skin prep (strengthen skin to prevent breakdown) bilateral heels q (every) shift..." Medical record review of a Physician's order dated November 26, 2012, revealed, "...cleanse blister to left heel..." Medical record review of an Interdisciplinary Progress Note (IDT) dated December 11, 2012, revealed, "...open area to coccyx..." and no documentation of the left heel blister. Medical record review of an IDT note dated December 18, 2012, revealed, "...wound care to L heel...area to coccyx healed..." Medical record review of Nutrition notes dated December 21, 2012, revealed "...gradual weight trending down. Remains on fortified food with meals; refused house shakes repeatedly; remains on decubivite..." Medical record review revealed no wound measurements for the left heel documented until December 27, 2012 (thirty-one days after discovery). Medical record review of a Pressure Ulcer Documentation Form dated December 27, 2012, revealed, "...Left Heel Stage U (unstageable - base of ulcer covered with slough or eschar)...Wound Measurements length 2 cm (centimeter) width 1.5 cm, (no depth documentation), no undermining, no tunneling, no odor, no exudate, no order change.." Review of the TAR dated December 2012, revealed an order to cleanse blister to left heel with wound cleanser; apply hydrogel, purachol, and wrap with roll gauze twice daily. Continued review of the TAR for December 2012, revealed no documentation the treatment was administered on December 6, 12, 20, 21, 23, and 30, 2012, on the day shift, and December 3, 11, 23, and 27, 2012, on the night shift. Further review of the December TAR revealed the order for skin prep bilateral heels each shift was not documented as being administered on December 14, 20, and 30, 2012, on days and December 3, 11, 17, 23, 24, and 27, 2012, on nights. Medical record review of a Pressure Ulcer Documentation Form dated January 3, 2013, revealed, "...Left Heel Stage U...Wound Measurements length 1.5 cm. width 1.5 cm, (no depth documentation), no undermining, no tunneling, no odor, no exudate, no order change..." Medical record review of a physician progress notes [REDACTED]. Medical record review of a Pressure Ulcer Documentation Form dated January 8, 2013, revealed, "...Left Heel Stage U...Wound Measurements length 1.5 cm. width 1 cm, (no depth documentation), no undermining, no tunneling, no odor, no exudate, no order change..." Continued review of nutrition note dated January 10, 2013, revealed "...left heel ulcer; protein powder BID (twice daily); snack BID; [MEDICATION NAME] started for appetite; [MEDICATION NAME] 2.7 (normal range 3.4 - 4.5); update food preferences..." Review of the TAR for January 2013, revealed an order to cleanse blister to left heel with wound cleanser; apply hydrogel, purachol; wrap with roll gauze. Continued review of the January TAR revealed no documentation the treatment was administered on January 13, 18, 25, 29, and 30, 2013, on days and December 29 and 30, 2012, on nights. Continued review of the TAR for January revealed an order for [REDACTED]. Medical record review of a quarterly MDS dated [DATE], revealed the resident was moderately impaired for daily decision making; totally dependent for all ADL's; at risk for pressure ulcers; had one Stage 1 pressure ulcer and no unstageable pressure ulcers. Medical record review of a Care Plan dated January 10, 2013, revealed, "...Alteration in skin integrity r/t (related to): foot ulcer (left heel) shearing to coccyx...date initiated: 10/29/12...Revision on: 1/10/2013..." Medical record review of a Pressure Ulcer Documentation Form dated January 16, 2013, revealed, "...Left Heel Stage U...Wound Measurements length 2 cm. width 1 cm, (no depth documentation), no undermining, no tunneling, no odor, no exudate, no order change..." Medical record review of a Pressure Ulcer Documentation Form dated January 23, 2013, revealed, "...Left Heel Stage U...Wound Measurements length 1.5 cm. width .5 cm, (no depth documentation), no undermining, no tunneling, no odor, no exudate, no order change..." Medical record review of a Pressure Ulcer Documentation Form dated January 30, 2013, revealed, "...Left Heel Stage U...Wound Measurements length 1.5 cm. width .5 cm, (no depth documentation), no undermining, no tunneling, no odor, no exudate, no order change..." Medical record review of an IDT note dated February 1, 2013, revealed, "...wound care with positive results..." Medical record review of a Pressure Ulcer Documentation Form dated February 5, 2013, revealed, "...Left Heel Stage DTI (deep tissue injury)(purple area of intact skin or blood-filled blister)...Wound Measurements length 1.5 cm. width 1.5 cm, no depth, no tunneling, no odor, exudates sm (small) type ser (serous), 100 % eschar (necrotic tissue), [MEDICAL CONDITION] present, no order change...no notification of change (to physician or family)..." Continued review revealed the wound now had serous drainage and the width of the ulcer had increased from 0.5 cm to 1.5 cm. Medical record review of a Pressure Ulcer Documentation Form dated February 12, 2013, revealed, "...Left Heel Stage DTI...no Wound Measurements, no tunneling, no odor, exudate sm type ser, 100% eschar, [MEDICAL CONDITION] present, no order change...no notification of change (to physician or family)..." Continued review revealed the wound continued to have drainage. Medical record review of nutrition notes dated February 15, 2013, revealed "...milk TID (three times daily); snacks BID (twice daily); protein powder BID; [MEDICATION NAME] (appetite stimulant); hydration encouraged throughout day..." Medical record review of a NP note on February 18, 2013, revealed no skin concerns. Medical record review of a Pressure Ulcer Documentation Form dated February 19, 2013, and March 1, 2013, revealed, "...Left Heel Stage DTI...no Wound Measurements, no tunneling, no odor, exudate sm type ser, 100 % eschar, [MEDICAL CONDITION] present, no order change...no notification of change (to physician or family)..." Continued review revealed the documentation was incomplete with no wound measurements. Medical record review of a Pressure Ulcer Documentation Form dated March 12, 2013, revealed, "...Left Heel Stage DTI...Wound Measurements Length 1.7 cm, width 1.6 cm no depth documentation, no odor, exudates sm type ser, 25% slough (necrotic tissue...in process of separating) 75% eschar, [MEDICAL CONDITION] present,...no notification of change (to physician or family)..." Continued review of the medical record revealed the ulcer had increased in size; still had drainage; and necrotic tissue was present in the wound. Medical record review of a Physician's order dated March 13, 2013, revealed, "...cleanse blister to left heel with wound cleanser...apply Santyl (removes necrotic tissue)..." Medical record review of a Pressure Ulcer Documentation Form dated March 19, 2013, revealed, "...Left Heel Stage DTI...Wound Measurements Length 2 cm, Width 1.8 cm, no depth documented, no tunneling, no odor, exudates sm type ser, 100% slough, no order change...no notification of change (to physician or family)..." Continued review revealed the wound had increased in size; still had drainage; and still had necrotic tissue. Review of the TAR for March 2013, revealed the order for skin prep bilateral heels each shift and the treatment was not documented as administered on March 2, 3, 4, 8, 11, 12, 17, 18, 21, 23, 24, 25, 27, 28, and 30, 2013, on the night shift. Continued review of the TAR for March 2013, revealed an order for [REDACTED]. Medical record review revealed no documentation of the left heel pressure ulcer after March 19, 2013, through April 3, 2013 (fifteen days). Medical record review of a Physician's order dated March 20, 2013, revealed, "...skin prep to bottom of left lateral foot and area under bottom of left small toe q (every) shift..." Medical record review of a IDT note dated March 21, 2013, revealed, "...new bed (with) air mattress which allows more room so (resident's) feet don't touch foot board d/t (due to) Pt (patient) sliding down in bed..." Medical record review of a physician progress notes [REDACTED]. Medical record review of a Physician's order dated March 22, 2013, revealed, "[MEDICATION NAME] 100 mg (milligram) po (by mouth) bid (twice daily) x (times) 10 days (wound infection)..." Medical record review of a NP note on April 1, 2013, revealed no documentation of skin concerns. Medical record review of an IDT note dated April 3, 2013, revealed, "...Left heel...2.8 x 2.2 cm tx (treatment) (with) Santyl..." Medical record review of nutrition notes dated April 4, 2013, revealed "...eats 75 - 100% of all meals; received fortified foods for extra calories and protein to promote healing..." Medical record review of a Physician's order dated April 8, 2013, revealed, "[MEDICATION NAME] (antibiotic) 875-125 mg by mouth every eight hours for seven days wound..." Medical record review of a Physician Order dated April 8, 2013, revealed, "...Wound care consult complex..." Medical record review of a Pressure Ulcer Documentation Form dated April 10, 2013, revealed "...left heel 3 x 2.6 x 1 with 100% slough; left lower posterior leg upper wound 2.8 x 0.1, stage II; left lower posterior leg lower wound - 1.7 x 1.1 - stage II..." Continued review revealed the heel ulcer had increased in size again. Further review revealed this is the first documentation of the two ulcers on the resident's left leg. Medical record review of a Diagnostic Imaging Report dated April 12, 2013, revealed, "...lower extremity arterial evaluation including brachial...values are normal..." Medical record review of a New Patient Medical History from the Wound Care Physician, dated April 12, 2013, revealed, "...Heel Ulcers/Leg Ulcers...L heel 2.3 x 2.7 x 1.0 cm (centimeters)..." Medical record review of an IDT note dated April 18, 2013, revealed, "...Left heel...5.2 x 2.5 x 1.5 cm 100 % slough tx to area (with) Santyl. Left lower leg lower ulcer 2.4 x 1.2 x 0.1, stage II; left lower leg upper ulcer 2.0 x 1.0 x 0.1, stage II..." Medical record review of a NP note on April 29, 2013, revealed no skin concerns. Review of the TAR for April 2013, revealed an order for [REDACTED]. Continued review of the TAR revealed these treatments were not documented on April 21, 24, 29, and 30, 2013. Medical record review of a Physician Order dated May 1, 2013, revealed, "...send to (hospital) for direct admit...wound debridement..." Medical record review of the hospital History and Physical dated May 1, 2013, revealed "...patient was seen in evaluation for multiple lower extremity ulcers, especially on the left heel. Patient was noted to have deep tissue injury and eschar that had slowly become more progressively exudative and was not adequately debrided at the bedside..." Medical record review of Magnetic Resonance Imaging of the left foot dated May 3, 2013, revealed "...evidence for osteo[DIAGNOSES REDACTED] (inflammation of the bone) in underlying calcaneous (heel bone), talar (ankle bone) head, neck; septic arthritis of tibiotalar (junction of large lower leg bone and ankle bone) joint; osteo[DIAGNOSES REDACTED] posterior malleolus (Protruberance on outside of ankle) tibia..." Medical record review of cultures of the wounds on the heel and lower extremities revealed "[MEDICAL CONDITION]" (multi drug resistant organism) in calf wound, ankle, and left talus bone..." Medical record review of a consultation by an Orthopedic Surgeon, dated May 3, 2013, revealed "...Ulceration on back of right leg 1 x 6 cm, full thickness necrosis with exposed fascia in the depth of the wound. Left foot with ulceration and drainage from wound on anterior aspect of ankle joint; ulceration over heel 5 x 5 cm with black necrotic tissue on lateral side and necrosis on medial side, lateral side with track going down to calcaneous with foul odor. I explained I would not be able to remove all the infected bone without performing an amputation..." Medical record review of the preoperative assessment dated [DATE], revealed "...osteo[DIAGNOSES REDACTED] left calcaneous, left talus; stage IV (full skin loss with bone, tendon, or muscle is exposed) left heel and dorsum of foot; septic arthritis left ankle joint; stage III (full skin loss with subcutaneoue fat visible) pressure ulcer right posterior leg..." Medical record review of the operative report dated May 5, 2013, revealed "...left [MEDICAL CONDITION] was performed along with excision and closure of stage III ulcer to right posterior leg, 6 x 1.5 cm..." Review of facility policy, Skin Integrity Management, dated October 1, 2010, revealed, "...Staff continually observes and monitors patients for changes and implements revisions to the plan of care...to prevent the occurrence of pressure ulcers...perform wound observations and measurements and complete skin integrity report...develop comprehensive, interdisciplinary plan of care...document appearance and condition of the wound weekly...assure all skin treatments are documented on MDS (Minimum Data Set)..." Interview with the Medical Records Director on October 3, 2013, at 7:30 a.m., in the Medical Records Department, confirmed there was no documentation of wound measurements prior to December 27, 2012. Interview with MDS nurse #1 on October 3, 2013, at 8:00 a.m., in the MDS Office, confirmed the MDS dated [DATE], and November 2012, did not include a comprehensive assessment of the resident's pressure ulcers. Continued interview confirmed the Care Plan had not been updated to reflect the resident's pressure ulcer treatments or assessments until March 12, 2013. Interview with Registered Nurse (RN) #1 on October 3, 2013, at 9:00 a.m., on the A-Wing, revealed RN #1 had no measurements prior to late February or early March 2013. Interview with the resident's physician on October 3, 2013, at 11:35 a.m., on the A-Wing, confirmed the physician expected the facility to obtain an order with specific instructions for application and maintenance of a multipodus boot (footdrop management). Continued interview confirmed the physician expected the facility to complete weekly skin assessments with wound measurements for all pressure ulcers and notify the physician with changes. Interview with the Director of Nursing (DON) on October 3, 2013, at 12:50 p.m., at the Nurse's Station, confirmed there was no physician order for [REDACTED]. Further interview confirmed the left heel ulcer was caused by the multipodus boot and no documentation the left heel was assessed until the blister was discovered on November 26, 2012. Telephone interview with the Wound Care Physician on November 4, 2013, at 3:44 p.m., revealed the physician was consulted on the resident "...about a month before the resident was admitted to the hospital..." Continued interview with the Wound Care Physician revealed the resident had an ulcer on the left heel and on both shins, described as the lateral side of the leg where the calf meets the side of the leg. Further interview with the Wound Care Physician revealed the physician debrided (removed dead tissue to allow wound healing) the ulcers while the resident was still in the facility but the physician felt the area was regressing and the resident needed an Orthopedic consult because the wounds were deeper than the Wound Care Physician could handle. Continued interview with the Wound Care physician revealed "...the foot was so gone from the pressure ulcers it had to be amputated..." Further interview with the Wound Care Physician revealed he/she had not observed the multipodus boot in place and the resident's feet were usually propped with pillows when the physician visited the resident. Interview with the Unit Manager/Wound Care Nurse on November 5, 2013, at 7:50 a.m., in the conference room, revealed the resident had ulcers on the left heel, left foot, small toe, right heel, lateral foot, scab on right great toe, 2 on back of left leg which were stage II. Further interview with the Wound Care Nurse revealed the right heel wound was the only wound noted on the right leg. Interview with the Assistant Director of Nursing (ADON) on November 5, 2013, at 7:58 a.m., in the conference room, revealed the resident had own multipodus boots from the hospital. Further interview with the ADON revealed the resident wore the multipodus boots at all times except for showers. Continued interview with the ADON revealed "...I can't remember exactly what the area looked like but there was stuff on both legs..." Interview with the resident's attending physician on November 7, 2013, at 12:38 p.m., in the conference room, revealed the physician remembered the resident as being quadriplegic and also remembered the multipodus boot. Continued interview with the physician revealed the physician did not recall writing an order for [REDACTED]. Continued interview with the physician revealed if the boot was not applied correctly it could cause problems including ulceration. Further interview with the physician revealed the physician "... brought the Wound Care Physician on board but couldn't remember exactly when, specifically to care for the wounds..." Continued interview with the physician revealed the facility usually called the Nurse Practitioner first with problems and if they could not reach the Nurse Practitioner then they would call the physician. In summary this fifty-eight year old resident was burning brush; an explosion occurred; two days later was found by a neighbor; and transferred to a trauma center where he was discovered to [MEDICAL CONDITION] 15% of the body and a neck fracture which rendered the resident a quadriplegic. The resident was admitted to the facility with a multipodus boot on the left foot to help prevent footdrop. The facility failed to obtain a physician's order for use of the multipodus boot and interview revealed the boot was on the resident's foot except for showers. A blister was noted to the left heel on November 26, 2012, but wound measurements were not begun until December 27, 2012. The wound became a pressure ulcer and the resident developed two decubitus ulcers on the left leg which were Stage II pressure ulcers. The resident developed a pressure ulcer on the back of the right leg which was not assessed by the facility. On May 1, 2013, the resident was transferred to the hospital after the Wound Care physician assessed the heel ulcer to be Stage IV; the right leg ulcer to be Stage III; and the left leg ulcers to be Stage II. Tests revealed the resident was [MEDICAL CONDITION] in the wounds and also had osteo[DIAGNOSES REDACTED] in the bones of the ankle. The Orthopedic Surgeon felt there was no way to save the foot so the resident underwent [REDACTED]. The facility failed to: 1. obtain a physician's order for use of the multipodus boot. 2. perform accurate assessments of the resident's skin, including the feet. 3. notify the physician of the development of a heel blister in a timely manner. 4. follow professional standards for care of the multipodus boot and the resident's foot. 5. follow physician orders as evidenced by many blanks in documentation of skin assessment weekly; application of exuderm to coccyx; application of skin prep to heels; and other treatments ordered by the physician. 6. document wound measurements on the heel ulcer for thirty-one days. 7. assess the resident appropriately until two stage II ulcers were discovered on the right leg. 8. recognize a stage III ulcer on the back of the resident's right leg (was not discovered until the resident was admitted to the hospital. These omissions led to a worsening of the ulcer ultimately requiring a below knee amputation. Resident #114 was admitted to the facility from the hospital on September 14, 2013, with [DIAGNOSES REDACTED]. Medical record review of the admission nursing assessment dated [DATE], revealed the resident had "excoriation" of the right buttock area, "black areas" of the left and right heels, and scored the pressure ulcer risk at 5 (indicating high risk on the Norton scale). Medical record review of the admission nursing note dated September 14, 2013, revealed, "...Heel protectors placed on bilateral feet d/t (due to) black areas on each heel...Skin very thin and easy to tear." Medical record review of the physician orders dated September 14, 2013, revealed, "Braden Skin assessment on admission/readmission and weekly x4 (for four weeks)...Pressure reducing mattress to bed...weekly skin check by licensed nurse..." Medical record review revealed the Braden Scale - For Predicting Pressure Sore Risk dated September 14, 2013, scored the resident an "8" which represented severe risk. Record review continued and revealed the Braden Skin assessment was not completed on the subsequent weekly intervals for the next three weeks. Medical record review of the initial Physical Therapy Evaluation dated September 16, 2013, revealed, "...Per patient's son...4 months (prior)...was ambulating, living in ALF (Assisted Living Facility)...had feeding tube placed 8-27-13 secondary to aspiration...presents with B (bilateral) UE & LE (upper and lower extremity) contractures...appears to have been bedbound for an extended period of time..." Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed cognitive skills severely impaired, required two person assistance for bed mobility, always incontinent of urine, with one Stage 1 pressure ulcer and two Unstageable pressure ulcers. Medical record review of the September 2013 Treatment Administration Record (TAR) revealed an entry for "Duoderm to Right Buttock every 3 days and PRN (as needed)." Review of the TAR revealed the treatment with Duoderm began on admission and continued through the end of the month of September. Review of the October TAR revealed the Duoderm treatment to the right buttock was not continued on the TAR in October 2013. Medical record review of the physician's History & Physical dated October 3, 2013, revealed no entry under physical examination, assessment, or plan related to the resident's skin integrity and/or pressure ulcers. Medical record review of the Wound Care Physician's orders dated October 1, 2013, after the resident was seen in the facility revealed, " ...Turn q (every) 2 hours. Do not use gerichair - may (increase) sacral wound." Medical record review of the Wound Care Physician's orders dated October 9, 2013, revealed, "Sacral wound...Cleanse wound with wound cleanser...Fill wound with: [MEDICATION NAME] dressing with: bordered gauze...change: Daily...Return to Center in 2 weeks..." Medical record review revealed the October 2013 Treatment Administration Record (TAR) or care plan did not include the Wound Care Physician's Orders from October 1 or 9, 2013. Medical record review revealed the tracking of the sacral/coccyx pressure ulcer began on October 15, 2013, fourteen days after the pressure ulcer was first assessed by the Wound Care Physician. Review of the tracking, on the Skin Integrity Report revealed, "Stage II, granulating, 2 cm (centimeters) Length, 1.2 cm Width, and 0.1 cm Depth. Medical record review of the Wound Care Physician's orders dated October 15, 2013, revealed, "Sacrum wound...Cleanse wound with wound cleanser...Apply Santyl (a [MEDICATION NAME] agent) to the wound bed...Cover wound with: [MEDICATION NAME] dressing with: Sacral foam adhesive...change: Daily...Return to Center in 2 weeks...area (refering to the pressure ulcer) 2.25 s

Based on medical record review, review of facility policy, observation, and interview, the facility failed to prevent the development of avoidable pressure ulcers for four residents (#95, #114, #35, #73) of fourteen residents with pressure ulcers reviewed. The facility's failure to perform accurate assessments and obtain physician's orders placed residents #95, #114, #35 in Immediate Jeopardy (a situation in which the provider's non-compliance caused or is likely to cause serious injury, harm, impairment, or death). The systemic failure to ensure orders physician's orders for a medical device was obtained; skin assessments were performed correctly; pressure ulcers were assessed accurately; and treatments ordered by the physician were documented, was likely to place any resident at risk for pressure ulcers in Immediate Jeopardy. The Immediate Jeopardy was effective from November 26, 2012, and is ongoing. The Regional Vice President, Director of Clinical Services, Administrator, and Director of Nursing were informed of the Immediate Jeopardy on November 6, 2013, at 2:30 p.m., in the conference room. The findings included: Resident #95 was admitted to a Trauma Center on July 27, 2012, following an accident while burning brush in which there was an explosion. Two days later the family and friends were unable to contact the resident and a neighbor found the resident in the house, minimally responsive and lethargic. As a result of the accident the resident was a C6 quadriplegic (fracture of neck just above shoulders leaving resident unable to move from the neck down) [MEDICAL CONDITION] 15% (percent) of the body, including face, right arm, left arm, and bilateral lower extremities. Resident #95 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the discharge recommendations from Physical Therapy at an outside hospital, dated August 20, 2012, revealed "...the following anti-contracture devices were applied to patient: Multipodus boots BLEs (bilateral lower extremities) continuously when supine..." Interview with the Director of Nursing (DON) on October 3, 2013, at 12:50 p.m., at the nurses station, revealed the resident was admitted to the facility from the hospital on October 5, 2012, with a multipodus boot (for management of footdrop) in place on the left foot. Medical record review of the Interim Care Plan dated October 5, 2012, revealed, "...potential for pain related to wounds...alteration in skin integrity r/t (related to) Burn...report new open areas..." Medical record review of the admission nursing assessment dated [DATE], revealed the resident had an open area on the left knee, open/abrasion on the right lower extremity, reddened area to the scrotum area, sore/scabbed over area to the coccyx, reddened right lower extremity, and reddened area on the right side. Medical record review of the Admission Physician orders dated October 5, 2012, revealed, "...float heels...pressure reducing mattress to bed...weekly skin check by licensed nurse..." Medical record review of a Nurse's Note dated October 5, 2012, at 3:45 p.m., revealed, "...skin pink warm, multiple red areas D/T (due to)[MEDICAL CONDITION] total Norton plus score (11) (indicates very high risk)..." Medical record review of the Treatment Administration Record (TAR) dated October 5-31, 2012, revealed, "...open area to coccyx apply exuderm change q (every) 3 days (start date October 9, 2012)...Weekly skin check..." Continued review of the October TAR revealed no weekly skin assessments documented in October. Medical record review of an admission Minimum Data Set (MDS) dated [DATE], revealed the resident was moderately impaired for daily decision making; totally dependent for all Activities of Daily Living (ADL's); at risk for pressure ulcers; and had no pressure ulcers on admission. Medical record review revealed the resident was admitted to the hospital on October 24-29, 2012, for Altered Mental Status, Urinary Tract Infection, and for treatment of [REDACTED]. Medical record review of the Nursing Assessment Re-admitted d October 29, 2012, revealed "...Skin/Wound condition present: no...red area (coccyx)...scabbed area (right lower extremity) scab area (top of right foot)...red area (right forearm)...Norton Score 12 (very high risk)..." Medical record review of the Care Plan dated October 30, 2012, revealed, "...potential for pain related to wounds...alteration in skin integrity r/t Burn...report new open areas...10/30/12 coccyx shearing." Medical record review of the Care Plan dated October 31, 2012, revealed "...Skin (with) Stage II (partial loss of skin as shallow open ulcer)on coccyx..." Medical record review of Treatment Administration Records (TAR) dated November 2012, revealed the resident was ordered Exuderm on November 12, 2012, to be applied to coccyx and change every three days. Continued review of the TAR revealed the treatment was not documented as being administered on November 20, 23, and 29, 2012. Further review of the TAR revealed an order to apply skin prep to bilateral heels each shift. Further review of the TAR revealed no documentation this was administered on the night shift on November 26, 29, and 30, 2012. Medical record review of a Nurse's Note dated November 26, 2012, at 10:00 a.m., revealed, "...Blister noted to L (left) heel possibly caused by boot resident wears to prevent foot drop..." Medical record review of a Nurse Practitioner (NP) note on November 26, 2012, revealed "...Skin: normal..." Medical record review of the Physician's orders from admission on October 5, 2012, to discharge on May 1, 2013, revealed no order for a "boot." Medical record review of the resident's chart revealed no information regarding the application of the boot, the schedule of the boot, and/or the staff responsible for monitoring the boot. Medical record review of a Physician's order dated November 26, 2012, revealed, "...Skin prep (strengthen skin to prevent breakdown) bilateral heels q (every) shift..." Medical record review of a Physician's order dated November 26, 2012, revealed, "...cleanse blister to left heel..." Medical record review of an Interdisciplinary Progress Note (IDT) dated December 11, 2012, revealed, "...open area to coccyx..." and no documentation of the left heel blister. Medical record review of an IDT note dated December 18, 2012, revealed, "...wound care to L heel...area to coccyx healed..." Medical record review of Nutrition notes dated December 21, 2012, revealed "...gradual weight trending down. Remains on fortified food with meals; refused house shakes repeatedly; remains on decubivite..." Medical record review revealed no wound measurements for the left heel documented until December 27, 2012 (thirty-one days after discovery). Medical record review of a Pressure Ulcer Documentation Form dated December 27, 2012, revealed, "...Left Heel Stage U (unstageable - base of ulcer covered with slough or eschar)...Wound Measurements length 2 cm (centimeter) width 1.5 cm, (no depth documentation), no undermining, no tunneling, no odor, no exudate, no order change.." Review of the TAR dated December 2012, revealed an order to cleanse blister to left heel with wound cleanser; apply hydrogel, purachol, and wrap with roll gauze twice daily. Continued review of the TAR for December 2012, revealed no documentation the treatment was administered on December 6, 12, 20, 21, 23, and 30, 2012, on the day shift, and December 3, 11, 23, and 27, 2012, on the night shift. Further review of the December TAR revealed the order for skin prep bilateral heels each shift was not documented as being administered on December 14, 20, and 30, 2012, on days and December 3, 11, 17, 23, 24, and 27, 2012, on nights. Medical record review of a Pressure Ulcer Documentation Form dated January 3, 2013, revealed, "...Left Heel Stage U...Wound Measurements length 1.5 cm. width 1.5 cm, (no depth documentation), no undermining, no tunneling, no odor, no exudate, no order change..." Medical record review of a physician progress notes [REDACTED]. Medical record review of a Pressure Ulcer Documentation Form dated January 8, 2013, revealed, "...Left Heel Stage U...Wound Measurements length 1.5 cm. width 1 cm, (no depth documentation), no undermining, no tunneling, no odor, no exudate, no order change..." Continued review of nutrition note dated January 10, 2013, revealed "...left heel ulcer; protein powder BID (twice daily); snack BID; [MEDICATION NAME] started for appetite; [MEDICATION NAME] 2.7 (normal range 3.4 - 4.5); update food preferences..." Review of the TAR for January 2013, revealed an order to cleanse blister to left heel with wound cleanser; apply hydrogel, purachol; wrap with roll gauze. Continued review of the January TAR revealed no documentation the treatment was administered on January 13, 18, 25, 29, and 30, 2013, on days and December 29 and 30, 2012, on nights. Continued review of the TAR for January revealed an order for [REDACTED]. Medical record review of a quarterly MDS dated [DATE], revealed the resident was moderately impaired for daily decision making; totally dependent for all ADL's; at risk for pressure ulcers; had one Stage 1 pressure ulcer and no unstageable pressure ulcers. Medical record review of a Care Plan dated January 10, 2013, revealed, "...Alteration in skin integrity r/t (related to): foot ulcer (left heel) shearing to coccyx...date initiated: 10/29/12...Revision on: 1/10/2013..." Medical record review of a Pressure Ulcer Documentation Form dated January 16, 2013, revealed, "...Left Heel Stage U...Wound Measurements length 2 cm. width 1 cm, (no depth documentation), no undermining, no tunneling, no odor, no exudate, no order change..." Medical record review of a Pressure Ulcer Documentation Form dated January 23, 2013, revealed, "...Left Heel Stage U...Wound Measurements length 1.5 cm. width .5 cm, (no depth documentation), no undermining, no tunneling, no odor, no exudate, no order change..." Medical record review of a Pressure Ulcer Documentation Form dated January 30, 2013, revealed, "...Left Heel Stage U...Wound Measurements length 1.5 cm. width .5 cm, (no depth documentation), no undermining, no tunneling, no odor, no exudate, no order change..." Medical record review of an IDT note dated February 1, 2013, revealed, "...wound care with positive results..." Medical record review of a Pressure Ulcer Documentation Form dated February 5, 2013, revealed, "...Left Heel Stage DTI (deep tissue injury)(purple area of intact skin or blood-filled blister)...Wound Measurements length 1.5 cm. width 1.5 cm, no depth, no tunneling, no odor, exudates sm (small) type ser (serous), 100 % eschar (necrotic tissue), [MEDICAL CONDITION] present, no order change...no notification of change (to physician or family)..." Continued review revealed the wound now had serous drainage and the width of the ulcer had increased from 0.5 cm to 1.5 cm. Medical record review of a Pressure Ulcer Documentation Form dated February 12, 2013, revealed, "...Left Heel Stage DTI...no Wound Measurements, no tunneling, no odor, exudate sm type ser, 100% eschar, [MEDICAL CONDITION] present, no order change...no notification of change (to physician or family)..." Continued review revealed the wound continued to have drainage. Medical record review of nutrition notes dated February 15, 2013, revealed "...milk TID (three times daily); snacks BID (twice daily); protein powder BID; [MEDICATION NAME] (appetite stimulant); hydration encouraged throughout day..." Medical record review of a NP note on February 18, 2013, revealed no skin concerns. Medical record review of a Pressure Ulcer Documentation Form dated February 19, 2013, and March 1, 2013, revealed, "...Left Heel Stage DTI...no Wound Measurements, no tunneling, no odor, exudate sm type ser, 100 % eschar, [MEDICAL CONDITION] present, no order change...no notification of change (to physician or family)..." Continued review revealed the documentation was incomplete with no wound measurements. Medical record review of a Pressure Ulcer Documentation Form dated March 12, 2013, revealed, "...Left Heel Stage DTI...Wound Measurements Length 1.7 cm, width 1.6 cm no depth documentation, no odor, exudates sm type ser, 25% slough (necrotic tissue...in process of separating) 75% eschar, [MEDICAL CONDITION] present,...no notification of change (to physician or family)..." Continued review of the medical record revealed the ulcer had increased in size; still had drainage; and necrotic tissue was present in the wound. Medical record review of a Physician's order dated March 13, 2013, revealed, "...cleanse blister to left heel with wound cleanser...apply Santyl (removes necrotic tissue)..." Medical record review of a Pressure Ulcer Documentation Form dated March 19, 2013, revealed, "...Left Heel Stage DTI...Wound Measurements Length 2 cm, Width 1.8 cm, no depth documented, no tunneling, no odor, exudates sm type ser, 100% slough, no order change...no notification of change (to physician or family)..." Continued review revealed the wound had increased in size; still had drainage; and still had necrotic tissue. Review of the TAR for March 2013, revealed the order for skin prep bilateral heels each shift and the treatment was not documented as administered on March 2, 3, 4, 8, 11, 12, 17, 18, 21, 23, 24, 25, 27, 28, and 30, 2013, on the night shift. Continued review of the TAR for March 2013, revealed an order for [REDACTED]. Medical record review revealed no documentation of the left heel pressure ulcer after March 19, 2013, through April 3, 2013 (fifteen days). Medical record review of a Physician's order dated March 20, 2013, revealed, "...skin prep to bottom of left lateral foot and area under bottom of left small toe q (every) shift..." Medical record review of a IDT note dated March 21, 2013, revealed, "...new bed (with) air mattress which allows more room so (resident's) feet don't touch foot board d/t (due to) Pt (patient) sliding down in bed..." Medical record review of a physician progress notes [REDACTED]. Medical record review of a Physician's order dated March 22, 2013, revealed, "[MEDICATION NAME] 100 mg (milligram) po (by mouth) bid (twice daily) x (times) 10 days (wound infection)..." Medical record review of a NP note on April 1, 2013, revealed no documentation of skin concerns. Medical record review of an IDT note dated April 3, 2013, revealed, "...Left heel...2.8 x 2.2 cm tx (treatment) (with) Santyl..." Medical record review of nutrition notes dated April 4, 2013, revealed "...eats 75 - 100% of all meals; received fortified foods for extra calories and protein to promote healing..." Medical record review of a Physician's order dated April 8, 2013, revealed, "[MEDICATION NAME] (antibiotic) 875-125 mg by mouth every eight hours for seven days wound..." Medical record review of a Physician Order dated April 8, 2013, revealed, "...Wound care consult complex..." Medical record review of a Pressure Ulcer Documentation Form dated April 10, 2013, revealed "...left heel 3 x 2.6 x 1 with 100% slough; left lower posterior leg upper wound 2.8 x 0.1, stage II; left lower posterior leg lower wound - 1.7 x 1.1 - stage II..." Continued review revealed the heel ulcer had increased in size again. Further review revealed this is the first documentation of the two ulcers on the resident's left leg. Medical record review of a Diagnostic Imaging Report dated April 12, 2013, revealed, "...lower extremity arterial evaluation including brachial...values are normal..." Medical record review of a New Patient Medical History from the Wound Care Physician, dated April 12, 2013, revealed, "...Heel Ulcers/Leg Ulcers...L heel 2.3 x 2.7 x 1.0 cm (centimeters)..." Medical record review of an IDT note dated April 18, 2013, revealed, "...Left heel...5.2 x 2.5 x 1.5 cm 100 % slough tx to area (with) Santyl. Left lower leg lower ulcer 2.4 x 1.2 x 0.1, stage II; left lower leg upper ulcer 2.0 x 1.0 x 0.1, stage II..." Medical record review of a NP note on April 29, 2013, revealed no skin concerns. Review of the TAR for April 2013, revealed an order for [REDACTED]. Continued review of the TAR revealed these treatments were not documented on April 21, 24, 29, and 30, 2013. Medical record review of a Physician Order dated May 1, 2013, revealed, "...send to (hospital) for direct admit...wound debridement..." Medical record review of the hospital History and Physical dated May 1, 2013, revealed "...patient was seen in evaluation for multiple lower extremity ulcers, especially on the left heel. Patient was noted to have deep tissue injury and eschar that had slowly become more progressively exudative and was not adequately debrided at the bedside..." Medical record review of Magnetic Resonance Imaging of the left foot dated May 3, 2013, revealed "...evidence for osteo[DIAGNOSES REDACTED] (inflammation of the bone) in underlying calcaneous (heel bone), talar (ankle bone) head, neck; septic arthritis of tibiotalar (junction of large lower leg bone and ankle bone) joint; osteo[DIAGNOSES REDACTED] posterior malleolus (Protruberance on outside of ankle) tibia..." Medical record review of cultures of the wounds on the heel and lower extremities revealed "[MEDICAL CONDITION]" (multi drug resistant organism) in calf wound, ankle, and left talus bone..." Medical record review of a consultation by an Orthopedic Surgeon, dated May 3, 2013, revealed "...Ulceration on back of right leg 1 x 6 cm, full thickness necrosis with exposed fascia in the depth of the wound. Left foot with ulceration and drainage from wound on anterior aspect of ankle joint; ulceration over heel 5 x 5 cm with black necrotic tissue on lateral side and necrosis on medial side, lateral side with track going down to calcaneous with foul odor. I explained I would not be able to remove all the infected bone without performing an amputation..." Medical record review of the preoperative assessment dated [DATE], revealed "...osteo[DIAGNOSES REDACTED] left calcaneous, left talus; stage IV (full skin loss with bone, tendon, or muscle is exposed) left heel and dorsum of foot; septic arthritis left ankle joint; stage III (full skin loss with subcutaneoue fat visible) pressure ulcer right posterior leg..." Medical record review of the operative report dated May 5, 2013, revealed "...left [MEDICAL CONDITION] was performed along with excision and closure of stage III ulcer to right posterior leg, 6 x 1.5 cm..." Review of facility policy, Skin Integrity Management, dated October 1, 2010, revealed, "...Staff continually observes and monitors patients for changes and implements revisions to the plan of care...to prevent the occurrence of pressure ulcers...perform wound observations and measurements and complete skin integrity report...develop comprehensive, interdisciplinary plan of care...document appearance and condition of the wound weekly...assure all skin treatments are documented on MDS (Minimum Data Set)..." Interview with the Medical Records Director on October 3, 2013, at 7:30 a.m., in the Medical Records Department, confirmed there was no documentation of wound measurements prior to December 27, 2012. Interview with MDS nurse #1 on October 3, 2013, at 8:00 a.m., in the MDS Office, confirmed the MDS dated [DATE], and November 2012, did not include a comprehensive assessment of the resident's pressure ulcers. Continued interview confirmed the Care Plan had not been updated to reflect the resident's pressure ulcer treatments or assessments until March 12, 2013. Interview with Registered Nurse (RN) #1 on October 3, 2013, at 9:00 a.m., on the A-Wing, revealed RN #1 had no measurements prior to late February or early March 2013. Interview with the resident's physician on October 3, 2013, at 11:35 a.m., on the A-Wing, confirmed the physician expected the facility to obtain an order with specific instructions for application and maintenance of a multipodus boot (footdrop management). Continued interview confirmed the physician expected the facility to complete weekly skin assessments with wound measurements for all pressure ulcers and notify the physician with changes. Interview with the Director of Nursing (DON) on October 3, 2013, at 12:50 p.m., at the Nurse's Station, confirmed there was no physician order for [REDACTED]. Further interview confirmed the left heel ulcer was caused by the multipodus boot and no documentation the left heel was assessed until the blister was discovered on November 26, 2012. Telephone interview with the Wound Care Physician on November 4, 2013, at 3:44 p.m., revealed the physician was consulted on the resident "...about a month before the resident was admitted to the hospital..." Continued interview with the Wound Care Physician revealed the resident had an ulcer on the left heel and on both shins, described as the lateral side of the leg where the calf meets the side of the leg. Further interview with the Wound Care Physician revealed the physician debrided (removed dead tissue to allow wound healing) the ulcers while the resident was still in the facility but the physician felt the area was regressing and the resident needed an Orthopedic consult because the wounds were deeper than the Wound Care Physician could handle. Continued interview with the Wound Care physician revealed "...the foot was so gone from the pressure ulcers it had to be amputated..." Further interview with the Wound Care Physician revealed he/she had not observed the multipodus boot in place and the resident's feet were usually propped with pillows when the physician visited the resident. Interview with the Unit Manager/Wound Care Nurse on November 5, 2013, at 7:50 a.m., in the conference room, revealed the resident had ulcers on the left heel, left foot, small toe, right heel, lateral foot, scab on right great toe, 2 on back of left leg which were stage II. Further interview with the Wound Care Nurse revealed the right heel wound was the only wound noted on the right leg. Interview with the Assistant Director of Nursing (ADON) on November 5, 2013, at 7:58 a.m., in the conference room, revealed the resident had own multipodus boots from the hospital. Further interview with the ADON revealed the resident wore the multipodus boots at all times except for showers. Continued interview with the ADON revealed "...I can't remember exactly what the area looked like but there was stuff on both legs..." Interview with the resident's attending physician on November 7, 2013, at 12:38 p.m., in the conference room, revealed the physician remembered the resident as being quadriplegic and also remembered the multipodus boot. Continued interview with the physician revealed the physician did not recall writing an order for [REDACTED]. specifics..." Further interview with the physician revealed the physician expected nursing to check the skin under the boot every shift; ensure the boot was applied properly; make sure the boot was clean; and ensure the ulcer was not worsening. Continued interview with the physician revealed if the boot was not applied correctly it could cause problems including ulceration. Further interview with the physician revealed the physician "... brought the Wound Care Physician on board but couldn't remember exactly when, specifically to care for the wounds..." Continued interview with the physician revealed the facility usually called the Nurse Practitioner first with problems and if they could not reach the Nurse Practitioner then they would call the physician. In summary this fifty-eight year old resident was burning brush; an explosion occurred; two days later was found by a neighbor; and transferred to a trauma center where he was discovered to [MEDICAL CONDITION] 15% of the body and a neck fracture which rendered the resident a quadriplegic. The resident was admitted to the facility with a multipodus boot on the left foot to help prevent footdrop. The facility failed to obtain a physician's order for use of the multipodus boot and interview revealed the boot was on the resident's foot except for showers. A blister was noted to the left heel on November 26, 2012, but wound measurements were not begun until December 27, 2012. The wound became a pressure ulcer and the resident developed two decubitus ulcers on the left leg which were Stage II pressure ulcers. The resident developed a pressure ulcer on the back of the right leg which was not assessed by the facility. On May 1, 2013, the resident was transferred to the hospital after the Wound Care physician assessed the heel ulcer to be Stage IV; the right leg ulcer to be Stage III; and the left leg ulcers to be Stage II. Tests revealed the resident was [MEDICAL CONDITION] in the wounds and also had osteo[DIAGNOSES REDACTED] in the bones of the ankle. The Orthopedic Surgeon felt there was no way to save the foot so the resident underwent [REDACTED]. The facility failed to: 1. obtain a physician's order for use of the multipodus boot. 2. perform accurate assessments of the resident's skin, including the feet. 3. notify the physician of the development of a heel blister in a timely manner. 4. follow professional standards for care of the multipodus boot and the resident's foot. 5. follow physician orders as evidenced by many blanks in documentation of skin assessment weekly; application of exuderm to coccyx; application of skin prep to heels; and other treatments ordered by the physician. 6. document wound measurements on the heel ulcer for thirty-one days. 7. assess the resident appropriately until two stage II ulcers were discovered on the right leg. 8. recognize a stage III ulcer on the back of the resident's right leg (was not discovered until the resident was admitted to the hospital. These omissions led to a worsening of the ulcer ultimately requiring a below knee amputation. Predicting Pressure Sore Risk" completed August 19, 2013, revealed the resident had a score of 15, indicating mild risk. Resident #114 was admitted to the facility from the hospital on September 14, 2013, with [DIAGNOSES REDACTED]. Medical record review of the admission nursing assessment dated [DATE], revealed the resident had "excoriation" of the right buttock area, "black areas" of the left and right heels, and scored the pressure ulcer risk at 5 (indicating high risk on the Norton scale). Medical record review of the admission nursing note dated September 14, 2013, revealed, "...Heel protectors placed on bilateral feet d/t (due to) black areas on each heel...Skin very thin and easy to tear." Medical record review of the physician orders dated September 14, 2013, revealed, "Braden Skin assessment on admission/readmission and weekly x4 (for four weeks)...Pressure reducing mattress to bed...weekly skin check by licensed nurse..." Medical record review revealed the Braden Scale - For Predicting Pressure Sore Risk dated September 14, 2013, scored the resident an "8" which represented severe risk. Record review continued and revealed the Braden Skin assessment was not completed on the subsequent weekly intervals for the next three weeks. Medical record review of the initial Physical Therapy Evaluation dated September 16, 2013, revealed, "...Per patient's son...4 months (prior)...was ambulating, living in ALF (Assisted Living Facility)...had feeding tube placed 8-27-13 secondary to aspiration...presents with B (bilateral) UE & LE (upper and lower extremity) contractures...appears to have been bedbound for an extended period of time..." Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed cognitive skills severely impaired, required two person assistance for bed mobility, always incontinent of urine, with one Stage 1 pressure ulcer and two Unstageable pressure ulcers. Medical record review of the September 2013 Treatment Administration Record (TAR) revealed an entry for "[MEDICATION NAME] to Right Buttock every 3 days and PRN (as needed)." Review of the TAR revealed the treatment with [MEDICATION NAME] began on admission and continued through the end of the month of September. Review of the October TAR revealed the [MEDICATION NAME] treatment to the right buttock was not continued on the TAR in October 2013. Medical record review of the physician's History & Physical dated October 3, 2013, revealed no entry under physical examination, assessment, or plan related to the resident's skin integrity and/or pressure ulcers. Medical record review of the Wound Care Physician's orders dated October 1, 2013, after the resident was seen in the facility revealed, " ...Turn q (every) 2 hours. Do not use gerichair - may (increase) sacral wound." Medical record review of the Wound Care Physician's orders dated October 9, 2013, revealed, "Sacral wound...Cleanse wound with wound cleanser...Fill wound with: [MEDICATION NAME] dressing with: bordered gauze...change: Daily...Return to Center in 2 weeks..." Medical record review revealed the October 2013 Treatment Administration Record (TAR) or care plan did not include the Wound Care Physician's Orders from October 1 or 9, 2013. Medical record review revealed the tracking of the sacral/coccyx pressure ulcer began on October 15, 2013, fourteen days after the pressure ulcer was first assessed by the Wound Care Physician. Review of the tracking, on the Skin Integrity Report revealed, "Stage II, granulating, 2 cm (centimeters) Length, 1.2 cm Width, and 0.1 cm Depth. Medical record review of the Wound Care Physician's orders dated October 15, 2013, revealed, "Sacrum wound...Cleanse wound with wound cleanser...Apply Santyl (a [MEDICATION NAME] agent) to the wound bed...Cover wound with: [MEDICATION NAME] dressing with: Sacral foam adhesive...change: Daily...Return to Center in 2 weeks...area (refering to the pressure ulcer) 2.25 square centimeters." Medical record review of the October 2013 TAR revealed the daily wound care to the sacrum/coccyx pressure ulcer was to be completed by the nigh

Based on review of facility policy, medical record review, review of the Fall Risk Evaluation forms, review of the facility fall reports, review of facility documentation, interview, and observation, the facility failed to investigate and develop new interventions to address falls for fourteen residents (#35, #73, #17, #24, #42, #119, #100, #62, #120, #26, #23, #113, #52, and #89) of twenty-two residents with falls reviewed. The facility's failure to investigate and develop new interventions to address falls placed residents #35 and #73 in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective on November 26, 2012, and is ongoing. The Regional Vice President, Director of Clinical Services, Administrator and Director of Nursing were informed of the Immediate Jeopardy on November 6, 2013, at 2:30 p.m. in the conference room. The facility provided an acceptable Allegation of Compliance on November 22, 2013, and a revisit on November 26, 2013, revealed the corrective actions implemented on November 25, 2013, removed the Immediate Jeopardy. Noncompliance for F-323 continues at a "E" level citation. The findings included: Review of the facility policy entitled Falls Management, effective on September 15, 2001, and revised on June 1, 2013, revealed, "...If patient falls...Update care plan to reflect new interventions..." Review of the facility policy entitled Falls Care Delivery Process, with revision date of June 1, 2013, revealed, "...response to a Patient Fall: ...Complete...Resident Incident report...to implement new interventions...Investigate fall circumstances...Implement immediate interventions after the fall...Complete Condition of Change Document...staff...Conduct interdisciplinary team meeting within 72 hours of patient fall to perform the following: ...Update care plan with new interventions as appropriate...Communicate interventions to staff..." Review of the facility policy entitled Falls Management, with revision date of June 1, 2013, revealed, "...If patient falls:...Perform Neurological Assessment for all unwitnessed falls and witnessed falls with head injury..." Review of the facility policy entitled Assessment: Neurological with revision date of October 1, 2012, revealed, "Neurological assessment will be performed as indicated or ordered. When a patient sustains an injury to the head and/or unwitnessed fall, neurological assessment will be performed: every 30 minutes x (for) two hours, then every one hour x four hours, then every four hours x 24 hours." Resident #35 was admitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident was readmitted [DATE], after an Open Reduction and Internal Fixation of a Right Hip Fracture. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Mental Status score of 14, indicating no cognitive impairment. Medical record review of the Fall Risk Evaluation completed on admission and at quarterly reviews on March 8, and June 8, 2013, revealed the resident was "high risk for falls." Medical record review of the physical therapy (PT) notes from admission through June 13, 2013, revealed the resident received PT for transfers and gait training. Review of the PT notes dated June 3, 2013, revealed, "...good progress with gait. However pt (patient) continues to demonstrate poor safety awareness and judgement...Patient continues to require minimal assist for sit to stand for transfers secondary to bilateral hip weakness. Pt's visual handicap will prevent gait independence..." Further review revealed the resident was able to ambulate up to 300 feet with a rolling walker and began a restorative nursing program on June 15, 2013, to continue ambulation with the rolling walker. Medical record review of facility fall reports and Care Plans (from December 2012 through September 2013) revealed the resident had a history of [REDACTED]. January 12, 2013, at 4:20 a.m., fell on the way to bathroom, unwitnessed, no neuro (neurological) checks (to assess for head injury) were done, no root cause or contributing factors identified, "Safety alarm..." was added to the resident's care plan; January 15, 2013, no facility report provided for review, no neuro checks were done, no root cause or contributing factors identified, no new intervention developed; March 6, 2013 at 7:50 a.m., the fall report was initiated March 6, 2013 and completed six months later, on October 1, 2013, by the Director of Nurses. Review revealed the resident was found "face down on the floor," complained of a headache, had a small skin tear of the right elbow, was seen in the emergency room , no neuro checks were done, no root cause or contributing factors identified, no new intervention developed; March 21, 2013, at 7:20 a.m., fall report related to the fall was not completed. Review revealed, "...asked resident what happened...stated 'I just changed seats was trying to go to the bathroom and slid out of the bed onto my bottom," no root cause or contributing factors identified, no new intervention developed; April 1, 2013, at 11:55 p.m., facility fall report was not completed. Review revealed the resident was seen in the emergency room for a hematoma at the back of head "the size of a baseball." No root cause or contributing factors identified. Review revealed a scoop mattress was care planned; May 21, 2013, at 4:15 p.m., facility fall report revealed this was a witnessed fall. An investigation of the falI was not completed. Review revealed the resident was assisted to the bathroom by a Certified Nurse Aide (CNA) who left the resident's side to assist the roommate and witnessed the resident stand, adjust clothing, tumble into the bathtub, and hit head. Review revealed the resident was not seen in the emergency room . No root cause or contributing factors were identified and no new intervention was developed; May 25, 2013, at 7:25 a.m., facility fall report revealed a CNA heard the safety alarm, saw the bathroom emergency call light blinking, and found the resident in the bathroom on the floor with bruises, a skin tear to the left arm. Review of subsequent facility documentation addressed a large bruise to the right hip, discovered on May 27, 2013, and the bruise was attributed to the fall of May 21, 2013. Review revealed the resident was seen in the emergency room . No neuro checks were done, no root cause or contributing factors identified, no new intervention developed; July 19, 2013, at 8:20 a.m., facility fall report was not initiated until October 1, 2013, by the DON. Review revealed the resident was found on the floor and "old skin tear re-opened." No neuro checks completed, no root cause or contributing factors identified. Review of the Care Plan revealed, "7/19/13 fall...Intervention...Reacher/grabber." Review of a Nurse's Note revealed a bruise was reported on July 20, 2013, with bruising of the left hip and left lower leg noted and attributed to the fall of July 19, 2013; August 12, 2013, at 3:40 a.m., facility fall report revealed "To resident room to answer call light, resident sitting in floor beside the bed...noted abrasion to right cheek and resident c/o (complained of) pain to right hip..." Interview by telephone on October 3, 2013, at 7:12 a.m., with registered nurse (RN) #3 (the RN on duty the night of August 12, 2013) revealed when the resident fell and broke the right hip, on the night of August 12, 2013, there were two nurses on duty, who were both "drawing blood" and the two CNAs on duty were "down another hall." Interview continued and revealed "I heard (resident #35) way down at the end of B hall...found her on the floor." Medical record review of a History and Physical on admission to the hospital on August 12, 2013, revealed, "..XXX[AGE] year-old...trying to get out of bed where a call light had been put on...did not get much help so...tried to get up by self and water spilled...slid and broke hip...Assessment and Plan: fall with right intertrochanteric fracture...still alert...wants surgery..." Review of the occupational therapy (OT) note dated August 21, 2013, revealed, "...patient is NWB (non-weight bearing/not able to walk) through RLE (right lower extremity) and has had a decline in ADL's (activities of daily living) and transfers..." Observation of the dining room at 12:30 a.m., on September 30, 2013, revealed the resident was brought to lunch in a wheelchair. Interview with the Director of Nurses (DON) and concurrent review of the fall reports was conducted at 7:45 a.m., on October 2, 2013, in the MDS office. Interview verified a fall report for the fall on January 15, 2013, was missing, a fall investigation for January 12, 2013, was not completed until March 25, 2013, and did not include a root cause or contributing factors, a fall report for the March 6, 2013, fall had been completed by the DON on October 1, 2013, six months after the fall, and none of the falls had complete investigation identifying the root cause and contributing factors. Interview continued and confirmed the falls were not investigated (required to be completed by an interdisciplinary team within 72 hours of a fall) for the eight falls sustained by the resident from January through July of 2013. Interview confirmed an investigation of the fall with fracture in August 2013 had not been done by an interdisciplinary team to date. Interview confirmed the August 12, 2013, fracture to the right hip requiring surgery, resulted in the resident being unable to walk, a lower ability to transfer, and a decline in the ability to perform activities of daily living. Medical record review of an Interdisciplinary Progress Note dated August 19, 2013, revealed the resident was readmitted on this date following right hip surgery. Medical record review of the Re-admission nursing assessment dated [DATE], revealed the resident returned from a hospitalization due to a Urinary Tract Infection. Medical record review of the Fall Risk Evaluation dated October 7, 2013, revealed a score of 13, "high risk for falls." Review of a fall report revealed the resident fell in the bathroom at 4:32 a.m., on October 9, 2013. Review of the resident's Care Plan and concurrent interview with the Director of Nurses (DON) in the conference room at 1:00 p.m., on October 28, 2013, confirmed the resident did not have individualized falls prevention interventions resumed upon returned to the facility October 7, 2013. Interview confirmed the Interdisciplinary Team did not investigate and develop new appoaches after the fall on August 12, 2013, resulting in the right hip fracture or after the October 9, 2013, fall. Resident #73 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Interdisciplinary Progress Notes dated October 19, 2012, at 1:00 p.m., revealed "...activity tray in place d/t (due to) decreased safety awareness...low bed with pressure sensitive alarm while in bed..." Medical record review of the Change of Condition Documentation dated December 8, 2012, revealed "...pt (patient) lying on her L (left) side on safety mat...bed alarm noted to be off...no injury...bed now in lowest position...safety mat in place..." Medical record review of the quarterly MDS (Minimum Data Set) dated January 9, 2013, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 2 (severe cognitive impairment). Further review of the MDS, revealed the resident was dependent on staff for bed mobility, transfers, bathing, dressing, toilet use, and personal hygiene. Medical record review of the Interdisciplinary Progress Notes dated December 9, 2012 for the fall occurring on December 8, 2012, revealed "...bed in lowest position...safety mats...pressure alarm..." Medical record review of the plan of care revealed no new interventions documented for the fall on December 8, 2012. Medical record review of the Change of Condition Documentation dated December 24, 2012, revealed "...in dining room lying on left side...had removed lap buddy...assisted to chair and taken to room...bed alarm in use...bed in low position with mat at bedside..." Medical record review of the plan of care revealed no new interventions documented for the fall on December 24, 2012. Medical record review of the Interdisciplinary Progress Notes dated December 28, 2012, revealed "...removed activity tray...safety alarm to chair and bed..." Medical record review of the care plan updated January 11, 2013, revealed Resident #73 was at risk for falls. Medical record review of the Change of Condition Documentation dated January 12, 2013, revealed "...removed lap buddy...missed chair...replaced lap buddy with another lap buddy..." Medical record review of the Pain Evaluation dated January 12, 2013, revealed the resident had pain in the right shoulder at an intensity of 3-4 (moderate pain). Medical record review of the plan of care revealed no new interventions documented for the fall on January 12, 2013. Medical record review of the Change of Condition Documentation dated, January 13, 2013, revealed "...rolled out of bed...c/o (complains of) pain to rt (right) shoulder..." Medical record review of the Pain Evaluation dated January 13 2013, revealed the resident had pain in the the right shoulder at an intensity of 1-2 (mild pain). Medical record review of the plan of care revealed no new interventions documented regarding the fall on January 13, 2013. Medical record review of the Interdisciplinary Progress Notes at 1:05 a.m., January 14, 2013, revealed "...c/o (complains of) R (right) shoulder pain..." Medical record review of the Interdisciplinary Progress Notes at 6:00 a.m., January 14, 2013, revealed, "...large area of purple and blue/green bruising to R (right) posterior shoulder...guarding area..." Medical record review of the Interdisciplinary Progres Notes at 8:00 a.m., January 14, 2013, revealed, "c/o R shoulder pain...large amount bruising...send to hospital..." Review of the hospital Discharge Summary dated January 18, 2013, revealed Resident #73 was admitted to the hospital with [REDACTED]. Review of the facility's policy titled "7.0 Falls Management" dated September 15, 2001 and revised June 1, 2013, revealed "...patients experiencing a fall will receive appropriate care...investigation of the cause...6.4 update care plan to reflect new interventions...6.5.3 document effectiveness of interventions..." Interview with the ADON (Assistant Director of Nursing) on October 3, 2013, at 8:15 a.m. in the admissions office, confirmed the facility had failed to follow the facility's policy to investigate the cause of the resident's falls and had failed to implement new interventions after the falls on December 8, 2012, December 24, 2012, January 12, 2013 and January 13, 2013 which resulted in a fractured right clavicle. Resident #17 was admitted on [DATE], with [DIAGNOSES REDACTED]. Observation at 10:00 a.m., and 4:00 p.m., revealed the resident in the bed napping with shoes in wheelchair at bedside on October 30, 2013. Medical record review of facility documentation revealed the resident had seven falls in 2013 as follows: March 3, 2013, at 3:15 pm - fell out of the wheel chair (w/c) an investigation was initiated, unwitnessed without neuro checks being done, but no root cause or contributing factor determined and no new interventions to address the fall were developed. March 23, 2013 - Interview on October 30, 2013, with LPN #1 at 10:30 a.m., in the conference room, confirmed no report of the fall, other than what was in the Nurse's Notes, could be found and confirmed there had not been an investigation or any care plan interventions developed after the fall. April 8, 2013, at 1:20 p.m., - fell in their room, out of the w/c and struck head, no neuro checks were done. No investigation was initiated, no new interventions to address falls other than re-educate to call for help. May 5, 2013, at 2:00 p.m. - fell out of the w/c, reaching to floor. No neuro checks were done. An investigation was initiated, but no root cause or contributing factors determined and no new interventions to address the fall were developed. May 12, 2013, at 3:00 a.m. - fell as attempting to toilet self. An investigation was initiated, but no root cause or contributing factors determined and no new interventions to address the fall were developed. June 8, 2013, at 8:30 a.m. - Slipped out of the w/c onto floor. No investigation was initiated, no new interventions to address the fall. June 23, 2013, at 8:45 a.m. - An investigation was done and determined "needs a reacher." Interview on October 30, 2013, with LPN #1 at 10:30 a.m., in the conference room, confirmed when the Interdisciplinary Team met and investigated the falls after the June 23, 2013, fall, the resident was provided a reacher and there had been no further falls. Resident #24 was admitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed the resident was followed by Hospice and was able to return home on October 4, 2013. Review of the facility documentation revealed three falls had been reported and none of the falls had investigations initiated or completed. The three falls were reported as follows: April 14, 2013, at 11:45 a.m. - fell in the bathroom, swelling in the left elbow and pain left upper shoulder, xrays obtained at the facility with no fracture noted. A new intervention was care planned. July 7, 2013, at 8:10 a.m., Fall on the way to bathroom, the floor had been mopped and remained wet. The DON documented in the Intradisciplinary Team notes "current interventions working" and no new interventions to address falls were developed. September 18, 2013 - Sat on floor in front of the electric wheelchair on the way to the bathroom. Resident stated "started to slide." Nursing provided non-skid socks. Interview with LPN #1, in the conference room, on October 30, 2013, at 3:30 p.m.,confirmed no investigation of any of the three falls was done and no new individualized interventions were developed to address the last two falls. Resident #42 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Sets (MDS) dated [DATE], and May 25, 2013, revealed the resident was moderately impaired for daily decision making; required extensive assistance with bed mobility, transfers, and locomotion on unit; and required total dependence for locomotion off unit and toilet use. Medical record review of facility documentation revealed the resident had seven falls from January 2013 through August 2013 as follows: January 29, 2013, at 8:50 p.m. - fell from wheelchair (w/c) as "reaching out as if to pick something off of the floor" and hit head on the doorframe. Record review revealed an investigation was not completed and no root cause or contributing factors were identified. March 3, 2013, at 5:00 a.m. - Had been gotten up into the w/c by staff due to agitation and then fell out of the w/c, no witness. Record review revealed an investigation was not completed and no root cause or contributing factors were identified. March 3, 2013, at 12:15 p.m. - Found out of the w/c in dining room floor, lying on back. Record review revealed an investigation was not completed and no root cause or contributing factors were identified. March 12, 2013, at 2:15 p.m. - The resident stated "trying to get into bed" and fell to floor. Record review revealed an investigation was not completed and no root cause or contributing factors were identified. April 9, 2013, at 6:00 p.m. - Found lying on floor on the bedside floor mat, no mention of whether the resident had been in the bed or the w/c. Record review revealed an investigation was not completed and no root cause or contributing factors were identified. July 15, 2013, at 1:45 p.m. - Found between the toilet and the wall on hands and knees after a CNA heard the "pull away alarm." Record review revealed an investigation was not completed and no root cause or contributing factors were identified. July 25, 2013, at 12:20 pm - Stood up and fell from w/c in solarium, witnessed. Record review revealed an investigation was not completed and no root cause or contributing factors were identified. Interview at 2:20 p.m., on October 29, 2013, in the conference room, with LPN #1 confirmed the resident had one investigation completed for the seven falls from January 2013 through August 2013. Continued interview confirmed the resident did not have interventions developed to address the falls of March 12, 2013, and April 9, 2013. Resident # 119 was admitted to the facility on [DATE], with admitting [DIAGNOSES REDACTED]. Medical record review of facility Change of Condition Documentation fall dated January 5, 2013, "...pressure alarm sounding, resident found sitting on floor complained of bilateral hip pain...Golf-ball sized bruise noted on crown, no bleeding noted ...assisted to wheelchair; Nurse Practioner (NP) notified x-ray of bilateral hip. Medical record review of facility Change of Condition Documentation fall dated January 13, 2013, a facility report dated 1/15/13 "... resident was trying to transfer self from bed to chair and fell on floor, landed on bottom. No injuries observed. Alarm on and sounding. Resident was educated on using call light to ask for assistance for transfers..." Interview with the Administrator on October 29, 2013, at 3:30 p.m., in the conference room, with concurrent review of the resident's four falls, including a fall on February 10, 2013, and a fall on March 15, 2013, verified the following: The facility had a report completed immediately after the resident's four falls; the resident did not have injuries requiring transfer to the hospital; investigations were not completed to address the root cause and contributing factors to the four falls; and the resident was dismissed to home on May 5, 2013. Interview continued and the Administrator stated, "It has already been acknowledged there were system problems with falls..." Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the facility's fall report dated February 18, 2013, revealed "...to room...found resident sitting on floor beside bed...no injury...re-educated to call light usage...call light within reach...bed in lowest position...safety alarm placed..." Medical record review of the Care Plan dated February 18, 2013, revealed "...poor coordination due to recent aka (above knee amputation) of right leg/foot...encourage...to use handrails...have commonly used articles within easy reach..." Medical record review of the Change of Condition Documentation dated February 18, 2013, revealed "...summoned to patient's room...sitting on the floor bedside bed...no injury...re-educated to call light usage and call light placed within reach...bed in lowest position...safety alarm placed..." Medical record review of the Care Plan dated February 19, 2013, revealed "...low bed...safety alarm in bed/chair...remove all objects near bed to prevent injury...when resident in bed place all necessary personal items within reach...reinforce need to call for assistance...PT (Physical Therapy) evaluation...place call light within easy reach...ensure environment is free of clutter..." Medical record review of the facility's fall report dated February 21, 2013, revealed "...responded to call light...laying in floor next to bed...stated was trying to change TV (television) station...forgot I don't (do not) have a right leg anymore..." Medical record review of the Care Plan revealed no new interventions documented for the fall on February 21, 2013. Medical record review of the Change of Condition Documentation dated February 21, 2013, revealed "...observed laying on floor next to bed...going to change TV (television)...reinforce proper use of call light..." Medical record review of the facility's fall report dated February 23, 2013, revealed "...fell from wheelchair...found on floor...laying on chair alarm...bending over and fell out of wheelchair..." Medical record review of the Care Plan dated February 23, 2013, revealed "...teach resident to ask for help...bed in lowest position...safety mats..." Medical record review of the Interdisciplinary Notes dated February 23, 2013, revealed "...continues with therapy..." Medical record review of the Change of Condition Documentation dated February 23, 2013, revealed "...found laying in the floor on left side with bed alarm under (resident)...stated that (resident) was bending over and went to far..." Medical record review of an annual MDS (Minimum Data Set) dated February 25, 2013, revealed the resident was totally dependent for bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene. Further review of the MDS revealed, the resident had a BIMS (Brief Interview for Mental Status) score of 15 (no cognitive impairment). Medical record review of the Interdisciplinary Notes dated February 26, 2013, revealed "...alert with confusion...several falls since admission...self-propels while up in wheelchair...confused to thinking...able to ambulate..." Medical record review of Physician's Orders dated February 26, 2013, revealed "...Physical Therapy for wheelchair mobility and strength training..." Medical record review of the facility's fall report dated April 5, 2013, revealed "...sitting on floor at bedside...no pain..." Medical record review of the Care Plan dated April 5, 2013, revealed "...encourage to verbalize needs...encourage to use call light..." Medical record review of the Interdisciplinary Notes dated April 5, 2013, revealed "...increased confusion...new order to obtain labs and infuse Normal Saline at 65 cc/hr (cubic centimeters/ per hour) times one..." Medical record review of the Change of Condition Documentation dated April 5, 2013, revealed "...witnessed the resident sitting upright on the bed at his bedside...continue to monitor...no new orders..." Medical record review of the facility's fall report dated April 20, 2013, revealed "...sitting in floor...no injury...safety alarm in place..." Medical record review of the Care Plan addressing falls dated April 20, 2013, revealed "...mats on floor next to bl (bilateral) side of bed...; dated April 23, 2013, revealed "adjust level of care according to individual needs...allow sufficient time for dressing and undressing...baths and showers per schedule...encourage independence...encourage resident to do as much for self...ensure and assist with grooming needs...provide verbal cues...reinforce success for task accomplished..." Medical record review of the Change of Condition Documentation dated April 20, 2013 revealed, "...found sitting on floor...stated just rolled out of bed...safety alarm in place..." Medical record review of the facility's fall report dated May 2, 2013, revealed "...sitting on safety mat between bed and window holding trash can...nose bleeding...two raised areas on his forehead above each brow...to hospital for evaluation..." Medical record review of the Care Plan revealed no documentation for new interventions for the fall on May 2, 2013. Medical record review of the Interdisciplinary Progress Notes dated May 2, 2013, revealed "...slid forward and lowered self to mat..." Medical record review of the Change of Condition Documentation dated May 2, 2013, revealed "...bed alarm sounding...sitting on safety mat...holding trash can...nose was bleeding...had two raised areas on forehead above each brow...to the hospital for evaluation..." Medical record review of the diagnostic imaging report dated May 2, 2013, revealed "...no acute intracranial abnormality...no acute facial bone fracture..." Medical record review of the MDS dated [DATE], revealed Resident #100 required extensive assistance from the staff with bed mobility and transfers, required limited assistance with locomotion and was totally dependent on the staff for dressing, toilet use, personal hygiene and bathing. Further review of the MDS revealed, the resident had a BIMS score of 7 (cognitive impairment). Interview with the DON (Director of Nursing) on November 6, 2013, at 8:30 a.m., in the business office, confirmed the facility failed to follow facility's policy to investigate the cause of the resident's falls and failed to implement new interventions after the falls on February 21, 2013, and May 2, 2013. Resident #62 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems; required extensive assistance with one person physical assist for transfers, walk in corridor, dressing, personal hygiene and bathing; required extensive assistance with two plus person physical assistance for bed mobility and toilet use; and was continent of bowel and bladder and had no falls. Review of facility's fall report revealed the resident had a fall on January 13, 2013, at 5:00 a.m., from the bed with no injury. Further review revealed the "...bed was elevated..." Further review of the documentation revealed no investigation to determine the cause of the fall and failed to add interventions to prevent future falls. Medical record review of the Change of Condition Documentation form, dated January 13, 2013, at 7:25 a.m., revealed, "...bed alarm sounding and pt (patient) was lying on the floor beside the bed on...back with pillow between...knees. Pt has electric bed and the bed was in the highest position per pts (patient's) control...neuro (neurological) checks in place..." Review of facility's fall report revealed the resident had a fall from the bed with a laceration and was sent to the emergency roiagnom on [DATE], at 3:30 p.m. Further r

Based on medical record review, facility policy review, observation, interview and facility document review, the facility administration failed to ensure staff provided the necessary care to prevent pressure ulcers and prevent pressure ulcers from worsening. The facility's failure resulted in amputation of resident #95's left leg and resulted in the need for surgery on the resident's right leg to remove necrotic (dead) tissue. The facility's failure to ensure systems and processes were in place and consistently followed by staff for the provision of necessary care and services to prevent development of avoidable pressure ulcers and worsening of identified pressure ulcers placed Resident #95, #114, #35, and #73 and potentially any resident at risk for pressure ulcers in Immediate Jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death). The facility administration failed to ensure residents were safe in the facility by not investigating accidents; not determining causes of falls; not devising new interventions to prevent future falls; and not evaluating the new interventions. The facility failed to provide a system for management of falls and failed to follow the facility's fall policy, resulting in 22 residents experiencing 93 falls in 2013. This failure placed Resident #35 in Immediate Jeopardy who, after multiple falls, no investigation of the cause of the falls, and no new interventions, sustained a [MEDICAL CONDITION]. This failure placed Resident #73 in Immediate Jeopardy who, after several falls with no investigation of the cause of the falls, and no new interventions, sustained a clavicle fracture. The facility's failure placed all residents at risk for falls in Immediate Jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death). The facility Administrator failed to ensure a systematic approach was followed by nursing staff for receipt and destruction of medications which provided an environment to allow Licensed Practical Nurse #4 to potentially divert narcotics from any resident who was receiving narcotics. The Administrator's failure to implement a system to prevent diversion of narcotics constitutes Substandard Quality of Care. The Regional Vice President, Director of Clinical Services, Administrator, and Director of Nursing were informed of the Immediate Jeopardy on November 6, 2013, at 2:30 p.m., in the conference room. The Immediate Jeopardy was effective November 26, 2012, and is ongoing. Substandard Quality of Care was cited under F224-F, F314-K and F323-K. The findings included: Interview with the Administrator on October 3, 2013, at 12:30 p.m., in the Administrator's office, confirmed care plans were not updated to reflect changing needs of residents; measures were not implemented to prevent pressure ulcers or falls; falls were not investigated completely; and interventions not implemented to prevent further falls. Interview with the Administrator on October 3, 2013, at 4:10 p.m., in the Administrator's office, confirmed the facility had not identified issues with receipt and destruction of medications or possible drug diversion until Licensed Practical Nurse #4 self-reported to the facility a history of drug diversion. Interview with the Administrator on November 6, 2013, at 2:10 p.m., in the Administrator's office, confirmed three residents (#95, #35, #114) developed pressure ulcers which worsened in the facility. Continued interview confirmed two residents (#35, #73) had falls with significant injury, and the facility had not followed the facility's policy for falls. Continued interview with the Administrator revealed the Administrator stated did not feel there was a problem with falls or pressure ulcers. Refer to F224, F280, F314, F323

Based on review of medical record review, facility policy review, review of fall reports, observation and interview, the facility Quality Assurance (QA) Committee failed to identify the facility staff failure to follow facility policy and procedure for receipt and destruction of medications to prevent diversion of narcotics; failed to identify the facility's failure to prevent pressure ulcers or the facility's failure to provide treatment to prevent pressure ulcers from worsening as a problem; failed to identify the facility was not following the facility's fall policy; and failed to implement any action plans to address the issues. The facility QA Committee's failure to ensure staff provided the necessary care to prevent pressure ulcers and prevent pressure ulcers from worsening resulting in amputation of resident #95's left leg and resulting in the need for surgery on the resident's right leg to remove necrotic (dead) tissue. The facility QA committee's failure to ensure systems and processes were in place and consistently followed by staff for the provision of necessary care and services to prevent development of avoidable pressure ulcers and worsening of identified pressure ulcers placed Resident #95, #114, #35, and #73 and potentially any resident at risk for pressure ulcers in Immediate Jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death). The facility's QA Committee failed to ensure a system for management of falls and failed to identify the facility's failure to follow the facility's fall policy, resulting in 22 residents experiencing 93 falls in 2013. This failure placed Resident #35 in Immediate Jeopardy who, after multiple falls, no investigation of the cause of the falls, and no new interventions, sustained a [MEDICAL CONDITION]. This failure placed Resident #73 in Immediate Jeopardy who, after several falls with no investigation of the cause of the falls, and no new interventions, sustained a clavicle fracture. The facility's failure placed all residents at risk for falls in Immediate Jeopardy. The facility QA Committee's failure to ensure a systematic approach was followed by nursing staff was followed for receipt and destruction of medications provided an environment to allow Licensed Practical Nurse #4 to potentially divert narcotics from any resident who was receiving narcotics. The facility's failure to implement a system to prevent diversion of narcotics constitutes Substandard Quality of Care. The Regional Vice President, Director of Clinical Services, Administrator, and Director of Nursing were informed of the Immediate Jeopardy on November 6, 2013, at 2:30 p.m., in the conference room. The Immediate Jeopardy was effective November 26, 2012, and is ongoing. Substandard Quality of Care was cited under F224-F, F314-K and F323-K. The facility provided an acceptable Allegation of Compliance on November 25, 2013, and a revisit on November 26, 2013, revealed the corrective actions implemented on November 25, 2013, removed the Immediate Jeopardy. Noncompliance for F-520 continues at an "E" level citation The findings included: Interview with the Director of Quality Assurance, who was also the Administrator, on October 3, 2013, at 4:10 p.m., in the Administrator's office, revealed the committee looked at incidents, falls, grievances, and put plans into place when issues were identified. Continued interview with the Administrator revealed the committee had not identified any problems with tracking falls, missing incident reports, and/or care plan revisions. Further interview with the Administrator revealed the committee had not identified any problems with tracking or identifying pressure ulcers, or any problems with the measurement of wounds. Further interview with the Administrator confirmed the facility had not identified issues with receipt and destruction of medications or possible drug diversion until Licensed Practical Nurse #4 self-reported to the facility a history of drug diversion. Interview with the Administrator on October 3, 2013, at 12:30 p.m., in the Administrator's office, confirmed care plans were not updated to reflect changing needs of residents; measures were not implemented to prevent pressure ulcers or falls; falls were not investigated completely; and interventions not implemented to prevent further falls. Interview with the administrator/Director of QA on November 6, 2013 at approximately 9:30 a.m., in the conference room, stated the "former" Director of Nursing had not brought "all the info (information)" to the meetings so the whole "picture" was incomplete. Further interview revealed the fall QA was "not in depth as it needed to be and did not review the specifics of the falls in the meeting." Further interview revealed "...the meetings did not necessarily result in action taken (to address fall)..." Refer to F224, F280, F314, F323 Validation of the Credible Allegation of Compliance on-site November 26, 2013, was accomplished by medical record review, review of facility documents, observation and interview with nursing and administrative staff. The facility provided evidence of new policy and procedures related to Fall Prevention, Pressure Ulcer, and Quality Assessment and Assurance activities and evidence the new policies were reviewed and approved by the facility Administration and the new Medical Director (as of November 20, 2013). Interview with the Director of Clinical Services revealed the facility administration was in-serviced by the Regional Vice President, Director of Clinical Services, and/or new Director of Nursing (as of October 29, 2013) of the survey findings, and corrective actions to identify and prevent fall risks and pressure ulcers in addition to department head specific roles in Quality Assessment and Assurance duties relevant to monitoring the implementation of the new policies and procedures. In-service training records including sign in sheets for all staff members related to the new policies and procedures were provided. A review of the facility documentation revealed the measures contained in the Allegation of Compliance were in place, and ongoing monitoring was in progress. A review of the facility Audit Tools revealed the facility was involved in ongoing monitoring of the implementation of corrective actions as specified in the Allegation of Compliance. Interview with the Director of Clinical Services on November 26, 2013, at the facility, confirmed the facility leadership team had met with the new Medical Director on November 20, 2013, and discussed new policies and procedures to reduce falls and pressure ulcers in the facility, the role of the Medical Director, and the Quality Assessment and Assurance Meeting was scheduled for November 24, 2013, at 2:30 p.m. at the facility. Continued interview with the Director of Clinical Services revealed the new Medical Director was to meet with the Quality Assessment and Assurance Committee monthly to provide ongoing monitoring and evaluation of the facility's implementation of corrective actions to reduce falls, pressure ulcers and review audit of [MEDICAL CONDITION] medication usage. Review of the November 24, 2013 Quality Assurance Meeting minutes revealed the new Administrator (as of November 21, 2013), new Director of Nursing, new Medical Director and facility staff were in attendance and the Allegation of Compliance was discussed, in addition to the new policies and procedures implemented. Interviews with nursing staff members revealed the nursing staff were aware of the new interventions in place to address the falls, and pressure ulcers and observation of the residents revealed the specific interventions noted in the medical record were in place. The facility will remain out of compliance at a Scope and Severity level "E" a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, until it provides an acceptable plan of correction and the facility's corrective measures could be reviewed and evaluated by the Quality Assessment/Performance Improvement Committee.

Based on review of medical record review, facility policy review, review of fall reports, observation and interview, the facility Quality Assurance (QA) Committee failed to identify the facility staff failure to follow facility policy and procedure for receipt and destruction of medications to prevent diversion of narcotics; failed to identify the facility's failure to prevent pressure ulcers or the facility's failure to provide treatment to prevent pressure ulcers from worsening as a problem; failed to identify the facility was not following the facility's fall policy; and failed to implement any action plans to address the issues. The facility QA Committee's failure to ensure staff provided the necessary care to prevent pressure ulcers and prevent pressure ulcers from worsening resulting in amputation of resident #95's left leg and resulting in the need for surgery on the resident's right leg to remove necrotic (dead) tissue. The facility QA committe's failure to ensure systems and processes were in place and consistantly followed by staff for the provision of necessary care and services to prevent development of avoidable pressure ulcers and worsening of identified pressure ulcers placed Resident #95, #114, #35, and #73 and potentially any resident at risk for pressure ulcers in Immediate Jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death). The facility's QA Committee failed to ensure a system for management of falls and failed to identify the facility's failure to follow the facility's fall policy, resulting in 22 residents experiencing 93 falls in 2013. This failure placed Resident #35 in Immediate Jeopardy who, after multiple falls, no investigation of the cause of the falls, and no new interventions, sustained a [MEDICAL CONDITION]. This failure placed Resident #73 in Immediate Jeopardy who, after several falls with no investigation of the cause of the falls, and no new interventions, sustained a clavicle fracture. The facility's failure placed all residents at risk for falls in Immediate Jeopardy. The facility QA Committee's failure to ensure a systematic approach was followed by nursing staff was followed for receipt and destruction of medications provided an environment to allow Licensed Practical Nurse #4 to potentially divert narcotics from any resident who was receiving narcotics. The facility's failure to implement a system to prevent diversion of narcotics constitutes Substandard Quality of Care. The Regional Vice President, Director of Clinical Services, Administrator, and Director of Nursing were informed of the Immediate Jeopardy on November 6, 2013, at 2:30 p.m., in the conference room. The Immediate Jeopardy was effective November 26, 2012, and is ongoing. Substandard Quality of Care was cited under F224-F, F314-K and F323-K. The findings included: Interview with the Director of Quality Assurance, who was also the Administrator, on October 3, 2013, at 4:10 p.m., in the Administrator's office, revealed the committee looked at incidents, falls, grievances, and put plans into place when issues were identified. Continued interview with the Administrator revealed the committee had not identified any problems with tracking falls, missing incident reports, and/or care plan revisions. Further interview with the Administrator revealed the committee had not identified any problems with tracking or identifying pressure ulcers, or any problems with the measurement of wounds. Further interview with the Administrator confirmed the facility had not identified issues with receipt and destruction of medications or possible drug diversion until Licensed Practical Nurse #4 self-reported to the facility a history of drug diversion. Interview with the Administrator on October 3, 2013, at 12:30 p.m., in the Administrator's office, confirmed care plans were not updated to reflect changing needs of residents; measures were not implemented to prevent pressure ulcers or falls; falls were not investigated completely; and interventions not implemented to prevent further falls. Interview with the administrator/Director of QA on November 6, 2013 at approximately 9:30 a.m., in the conference room, stated the "former" Director of Nursing had not brought "all the info (information)" to the meetings so the whole "picture" was incomplete. Further interview revealed the fall QA was "not in depth as it needed to be and did not review the specifics of the falls in the meeting." Further interview revealed "...the meetings did not necessarily result in action taken (to address fall)..." Refer to F224, F280, F314, F323

Based on medical record review, facility policy review, review of facility fall reports, observation and interview, the Medical Director failed to ensure the facility's fall policy and procedures were implemented and failed to coordinate the medical care provided to residents. The medical director's failure to ensure staff provided the necessary care to prevent pressure ulcers and prevent pressure ulcers from worsening ultimately resulting in amputation of resident #95's left leg and resulting in the need for surgery on the resident's right leg to remove necrotic (dead) tissue. The facility medical director's failure to ensure systems and processes were in place and consistantly followed by staff for the provision of necessary care and services to prevent development of avoidable pressure ulcers and worsening of identified pressure ulcers placed Resident #95, #114, #35, and #73 and potentially any resident at risk for pressure ulcers in Immediate Jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death). The medical director failed to ensure the facility implemented the facility's fall policy, resulting in 22 residents experiencing 93 falls. This failure placed Resident #35 in Immediate Jeopardy who, after multiple falls, no investigation of the cause of the falls, and no new interventions, sustained a [MEDICAL CONDITION]. This failure placed Resident #73 in Immediate Jeopardy who, after several falls with no investigation of the cause of the falls, and no new interventions, sustained a clavicle fracture. The facility's failure placed all residents at risk for falls in Immediate Jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death). The Regional Vice President, Director of Clinical Services, Administrator, and Director of Nursing were informed of the Immediate Jeopardy on November 6, 2013, at 2:30 p.m., in the conference room. The Immediate Jeopardy was effective November 26, 2012, and is ongoing. Substandard Quality of Care was cited under F314-K and F323-K. The findings included: Telephone interview with the Medical Director on November 6, 2013, at 11:10 a.m. revealed "...most of the falls occur at night due to short staffing..." Continued interview revealed at the monthly QA (Quality Assurance) meeting they review patient and family concerns; review pressure ulcers and falls. Interview with the Administrator on November 6, 2013, at 1:30 p.m., in the conference room, revealed "...if the Medical Director is not present at the Quality Meetings the Administrator would walk over to the Medical Director's office with the minutes for the Medical Director to review..." Continued Interview revealed the administrator stated "...reviewed info (information) with the medical director but never offered any suggestions..." Refer to F280, F314, F323

Based on medical record review, interview, and observation, and facility policy review, the facility failed to complete an accurate assessment for pressure ulcers for one resident, (#95) of fourteen residents with pressure ulcers reviewed; and failed to accurately assess the dental status for one resident (#28) of sixty-five residents reviewed. The facility's failure to assess the skin status and the multipodus boot placement resulted in the development of an unstageable pressure ulcer resulting in an amputation below the knee, placed resident #95 in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or likely to cause serious injury, harm, impairment, or death). The Immediate Jeopardy was effective on November 26, 2012, and is ongoing. The Regional Vice President, Diretor of Clinical Services, Administrator and Director of Nursing were informed of the Immediate Jeopardy on November 6, 2013, at 2:30 p.m. in the conference room. The facility provided and acceptable Allegation of Compliance on November 22, 2013, and a revisit on November 26, 2013, revealed the corrective actions implemented on November 25, 2013, removed the Immediate Jeopardy. Noncompliance for F-278 continues at an "D" level citation. The findings included: Resident #95 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission nursing assessment dated [DATE], revealed the resident had an open area on the left knee, open/abrasion on the right lower extremity, reddened area to the scrotum, sore/scabbed area to the coccyx, reddened right lower extremity, and a reddened area on the right side. Medical record review of the Interim Care Plan dated October 5, 2012, revealed, "...potential for pain related to wounds...alteration in skin integrity r/t (related to) Burn...report new open areas..." Medical record review of a Nurse's Notes dated October 5, 2012, at 3:45 p.m., revealed, "...skin pink warm, multiple red areas D/T (due to)[MEDICAL CONDITION] total Norton plus score of 11 (indicates very high risk)..." Medical record review of a physician's orders [REDACTED]. Medical record review of the Treatment Administration Record (TAR) dated October 5-31, 2012, revealed, "...open area to coccyx apply exuderm change q (every) 3 days (start date October 9, 2012). Medical record review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident was moderately impaired for daily decision making; totally dependent for all Activities of Daily Living (ADL's); at risk for pressure ulcers; and had no pressure ulcers on admission. Medical record review revealed the resident was admitted to the hospital October 24-29, 2012, for Altered Mental Status, Urinary Tract Infection, and for treatment of [REDACTED]. Medical record review of the Nursing Assessment Re-admitted d October 29, 2012, revealed, "...Skin/Wound condition present: no...red area (coccyx)...scabbed area (right lower extremity) scab area (top of right foot)...red area (right forearm)...(no areas on heels noted)...Norton Scale 12 (very high risk)..." Medical record review of the Care Plan dated October 30, 2012, revealed, "...potential for pain related to wounds...alteration in skin integrity r/t Burn...report new open areas...10/30/12 coccyx shearing." Medical record review of the Care Plan dated October 31, 2012, revealed, "...Skin (with) Stage II on coccyx..." Medical record review of the TAR dated November 1-30, 2012, revealed, "...open area to coccyx apply exuderm change q (every) 3 days..." Record review of the TAR revealed a start date of October 9, 2012, for this treatment order. Medical record review of a Nurse's Note dated November 26, 2012, at 10:00 a.m., revealed, "...Blister noted to L (left) heel..." Medical record review of a physician's orders [REDACTED]. Medical record review of an Interdisciplinary Progress Note (IDT) dated December 11, 2012, revealed, "...open area to coccyx..." and no documentation of the left heel. Medical record review of an IDT note dated December 18, 2012, revealed, "...wound care to L heel...area to coccyx healed..." Medical record review of the TAR dated December 1-31, 2012, revealed, "...open area to coccyx apply exuderm change q (every) 3 days...(start date October 9, 2012)...Cleanse blister to left heel...start date 11/26/2012..." Medical record review of a Pressure Ulcer Documentation Form dated December 27, 2012, revealed, "...Left Heel Stage U (unstageable)..." Medical record review of an IDT note dated December 28, 2012, revealed, "...wound care to L heel..." Medical record review of a Pressure Ulcer Documentation Form dated January 3, 2013, revealed "...Left Heel Stage U..." Medical record review of a Pressure Ulcer Documentation Form dated January 8, 2013, revealed, "...Left Heel Stage U..." Medical record review of the Care Plan dated January 10, 2013, revealed "...Alteration in skin integrity r/t: foot ulcer (left heel) shearing to coccyx...date initiated: 10/29/12...Revision on: 1/10/2013..." Medical record review of a quarterly MDS dated [DATE], revealed the resident was moderately impaired for daily decision making; totally dependent for all ADL's; at risk for pressure ulcers; had one Stage One pressure ulcer; and no unstageable pressure ulcers. Interview with MDS nurse #1 on October 3, 2013, at 8:00 a.m., in the MDS office, confirmed the MDS dated [DATE], and January 2013, did not include an accurate assessment of the resident's pressure ulcers. Validation of the Credible Allegation of Compliance was accomplished on-site November 26, 2013, through medical record review, review of facility documents, observations and interviews with nursing and administrative staff. The facility provided evidence of in-service training with sign-in sheets for all nursing staff related to pressure ulcer prevention and skin assessments. Medical record review revealed resident #95 had been discharged from the facility on May 6, 2013. Medical record review and observations of residents #73 and #114 (in-house residents with pressure ulcers) confirmed the facility had conducted comprehensive skin assessments by the new Wound Care Nurse, treatments and interventions were in place, and preventative interventions were current on certified nursing assistant kardexs. Interview with the new Wound Care Nurse on November 26, 2013, at the facility, and review of facility documentation confirmed the Wound Care Nurse had completed comprehensive skin assessments on all residents currently in the facility, and had reviewed treatments currently in place. Continued interview confirmed the new Wound Care Nurse had completed, and submitted a Pressure Ulcer Report log to the New Director of Nursing. Further interview with the Wound Care Nurse confirmed the nurse had completed in-service training to all licensed and certified nursing staff related to skin assessments and reporting of changes. Interviews conducted with licensed and certified nursing staff on November 26, 2013, confirmed the staff were able to verbalize skin assessment and reporting policies. Interview with the Minimum Data Set (MDS) Coordinators revealed they were provided the Pressure Ulcer Reports weekly, and had completed an audit for pressure ulcers compreprehensive assessment needs. Review of the Treatment Administration Records confirmed the facility had conducted an audit and were monitoring all residents with current pressure ulcers. Interviews conducted on November 26, 2013, with the Administrator and Regional Vice-President of Clinical Operations confirmed the facility had conducted a Quality Assurance Meeting which included discussion of pressure ulcer prevention, treatment and policy review with the new Medical Director. The facility will remain out of compliance at a Scope and Severity level "D" a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, until it provides an acceptable plan of correction. C/O # Resident #28 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], and the Annual MDS dated [DATE], revealed the resident was moderately impaired cognitively and had no dental issues. Medical record review of the Medical Nutritional Therapy Quarterly Assessments signed by the Registered Dietitian, dated November 1, 2012, and January 29, 2013, and the Medical Nutritional Therapy Annual Assessment signed by the Registered Dietitian and dated August 14, 2013, revealed, "...Oral/Dental: no pain, not edentulous, partial lower dentures, chewing ability WNL (within normal limits)..." Medical record review of the Nursing Readmission assessment dated [DATE]; and the Nursing Quarterly Assessments dated October 20, 2012, and April 30, 2013, revealed, "...1. Oral Problems: None...Teeth: upper right/left and lower right/left: Fair...Lower Dentures..." Medical record review of the Dental Progress Note dated January 6, 2012, revealed, "...Prosthesis: Upper...Other: No lower jaw for dentures..." Observation on September 30, 2013, at 1:08 p.m., revealed the resident was in the dining room. Further observation revealed the resident picked up a hamburger patty on two occasions with a hand and sucked or attempted to bite on the patty and placed the patty back on the hamburger bun. Further observation at 1:18 p.m., revealed a facility staff member asked the resident if the resident needed assistance or wanted something else to eat. Further observation revealed the resident refused the assistance and the alternative food. Further observation revealed none of the hamburger patty was consumed. Interview with the resident, in the resident's room, on October 1, 2013, at 7:58 a.m., and at 3:20 p.m., revealed the resident had lost the lower dentures in another facility and was having problems chewing food. Further interview revealed the resident could not recall if had told anyone in the facility of having difficulty chewing the food. Further interview and observation revealed the resident had a full upper denture in place. Further interview confirmed the resident was not able to chew the hamburger on September 30, 2013. Interview with the resident's direct care Certified Nurse Aide #9 on October 1, 2013, at 3:20 p.m., in the resident's room, revealed the resident "...has real teeth that I know of...I never knew (resident) had false teeth..." Interview with MDS Coordinator #2 on October 1, 2013, at 4:14 p.m., in the MDS office, confirmed the facility failed to accurately assess the resident's dental status.

Based on medical record review, interview, and observation, and facility policy review, the facility failed to complete an accurate assessment for pressure ulcers for one resident, (#95) of fourteen residents with pressure ulcers reviewed; and failed to accurately assess the dental status for one resident (#28) of sixty-five residents reviewed. The facility's failure to assess the skin status and the multipodus boot placement resulted in the development of an unstageable pressure ulcer resulting in an amputation below the knee, placed resident #95 in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or likely to cause serious injury, harm, impairment, or death). The Immediate Jeopardy was effective on November 26, 2012, and is ongoing. The Regional Vice President, Diretor of Clinical Services, Administrator and Director of Nursing were informed of the Immediate Jeopardy on November 6, 2013, at 2:30 p.m. in the conference room. The findings included: Resident #95 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission nursing assessment dated [DATE], revealed the resident had an open area on the left knee, open/abrasion on the right lower extremity, reddened area to the scrotum, sore/scabbed area to the coccyx, reddened right lower extremity, and a reddened area on the right side. Medical record review of the Interim Care Plan dated October 5, 2012, revealed, "...potential for pain related to wounds...alteration in skin integrity r/t (related to) Burn...report new open areas..." Medical record review of a Nurse's Notes dated October 5, 2012, at 3:45 p.m., revealed, "...skin pink warm, multiple red areas D/T (due to)[MEDICAL CONDITION] total Norton plus score of 11 (indicates very high risk)..." Medical record review of a physician's orders [REDACTED]. Medical record review of the Treatment Administration Record (TAR) dated October 5-31, 2012, revealed, "...open area to coccyx apply exuderm change q (every) 3 days (start date October 9, 2012). Medical record review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident was moderately impaired for daily decision making; totally dependent for all Activities of Daily Living (ADL's); at risk for pressure ulcers; and had no pressure ulcers on admission. Medical record review revealed the resident was admitted to the hospital October 24-29, 2012, for Altered Mental Status, Urinary Tract Infection, and for treatment of [REDACTED]. Medical record review of the Nursing Assessment Re-admitted d October 29, 2012, revealed, "...Skin/Wound condition present: no...red area (coccyx)...scabbed area (right lower extremity) scab area (top of right foot)...red area (right forearm)...(no areas on heels noted)...Norton Scale 12 (very high risk)..." Medical record review of the Care Plan dated October 30, 2012, revealed, "...potential for pain related to wounds...alteration in skin integrity r/t Burn...report new open areas...10/30/12 coccyx shearing." Medical record review of the Care Plan dated October 31, 2012, revealed, "...Skin (with) Stage II on coccyx..." Medical record review of the TAR dated November 1-30, 2012, revealed, "...open area to coccyx apply exuderm change q (every) 3 days..." Record review of the TAR revealed a start date of October 9, 2012, for this treatment order. Medical record review of a Nurse's Note dated November 26, 2012, at 10:00 a.m., revealed, "...Blister noted to L (left) heel..." Medical record review of a physician's orders [REDACTED]. Medical record review of an Interdisciplinary Progress Note (IDT) dated December 11, 2012, revealed, "...open area to coccyx..." and no documentation of the left heel. Medical record review of an IDT note dated December 18, 2012, revealed, "...wound care to L heel...area to coccyx healed..." Medical record review of the TAR dated December 1-31, 2012, revealed, "...open area to coccyx apply exuderm change q (every) 3 days...(start date October 9, 2012)...Cleanse blister to left heel...start date 11/26/2012..." Medical record review of a Pressure Ulcer Documentation Form dated December 27, 2012, revealed, "...Left Heel Stage U (unstageable)..." Medical record review of an IDT note dated December 28, 2012, revealed, "...wound care to L heel..." Medical record review of a Pressure Ulcer Documentation Form dated January 3, 2013, revealed "...Left Heel Stage U..." Medical record review of a Pressure Ulcer Documentation Form dated January 8, 2013, revealed, "...Left Heel Stage U..." Medical record review of the Care Plan dated January 10, 2013, revealed "...Alteration in skin integrity r/t: foot ulcer (left heel) shearing to coccyx...date initiated: 10/29/12...Revision on: 1/10/2013..." Medical record review of a quarterly MDS dated [DATE], revealed the resident was moderately impaired for daily decision making; totally dependent for all ADL's; at risk for pressure ulcers; had one Stage One pressure ulcer; and no unstageable pressure ulcers. Interview with MDS nurse #1 on October 3, 2013, at 8:00 a.m., in the MDS office, confirmed the MDS dated [DATE], and January 2013, did not include an accurate assessment of the resident's pressure ulcers. C/O # Resident #28 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], and the Annual MDS dated [DATE], revealed the resident was moderately impaired cognitively and had no dental issues. Medical record review of the Medical Nutritional Therapy Quarterly Assessments signed by the Registered Dietitian, dated November 1, 2012, and January 29, 2013, and the Medical Nutritional Therapy Annual Assessment signed by the Registered Dietitian and dated August 14, 2013, revealed, "...Oral/Dental: no pain, not edentulous, partial lower dentures, chewing ability WNL (within normal limits)..." Medical record review of the Nursing Readmission assessment dated [DATE]; and the Nursing Quarterly Assessments dated October 20, 2012, and April 30, 2013, revealed, "...1. Oral Problems: None...Teeth: upper right/left and lower right/left: Fair...Lower Dentures..." Medical record review of the Dental Progress Note dated January 6, 2012, revealed, "...Prosthesis: Upper...Other: No lower jaw for dentures..." Observation on September 30, 2013, at 1:08 p.m., revealed the resident was in the dining room. Further observation revealed the resident picked up a hamburger patty on two occasions with a hand and sucked or attempted to bite on the patty and placed the patty back on the hamburger bun. Further observation at 1:18 p.m., revealed a facility staff member asked the resident if the resident needed assistance or wanted something else to eat. Further observation revealed the resident refused the assistance and the alternative food. Further observation revealed none of the hamburger patty was consumed. Interview with the resident, in the resident's room, on October 1, 2013, at 7:58 a.m., and at 3:20 p.m., revealed the resident had lost the lower dentures in another facility and was having problems chewing food. Further interview revealed the resident could not recall if had told anyone in the facility of having difficulty chewing the food. Further interview and observation revealed the resident had a full upper denture in place. Further interview confirmed the resident was not able to chew the hamburger on September 30, 2013. Interview with the resident's direct care Certified Nurse Aide #9 on October 1, 2013, at 3:20 p.m., in the resident's room, revealed the resident "...has real teeth that I know of...I never knew (resident) had false teeth..." Interview with MDS Coordinator #2 on October 1, 2013, at 4:14 p.m., in the MDS office, confirmed the facility failed to accurately assess the resident's dental status.

Based on medical record review and interview, the facility failed to notify the physician of use of a multipodus boot (a rigid appliance to prevent the foot from extending to prevent foot drop) and failed to notify the physician of pressure ulcer progression for one resident (#95) of fourteen residents with pressure ulcers reviewed; and failed to notify the physician of [MEDICAL CONDITION] medication recommendations for one resident (#62) of sixty-five residents reviewed. The facility's failure to notify the physician in order to obtain orders for care and treatment of [REDACTED].#95 in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death). The Immediate Jeopardy was effective on November 26, 2012. The Regional Vice President, Director of Clinical Services, Administrator and Director of Nursing were informed of the Immediate Jeopardy on November 6, 2013, at 2:30 p.m. in the conference room. The facility provided an acceptable Allegation of Compliance on November 22, 2013, and a revisit on November 26, 2013, revealed the corrective actions implemented on November 25, 2013, removed the Immediate Jeopardy. Noncompliance for F-157 continues at a "D" level citation. The findings included: Resident #95 was admitted to a Trauma Center on July 27, 2012, following an accident while burning brush in which there was an explosion. Two days later the family and friends were unable to contact the resident and a neighbor found the resident in the house, minimally responsive and lethargic. As a result of the accident the resident was a C6 quadriplegic (fracture of neck just above shoulders leaving resident unable to move from the neck down) [MEDICAL CONDITION] 15% (percent) of the body, including face, right arm, left arm, and bilateral lower extremities. Resident #95 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the discharge recommendations dated August 20, 2012, from Physical Therapy at an outside hospital, revealed, "...the following anti-contracture devices were applied to patient: Multipodus boots BLEs (bilateral lower extremities) continuously when supine (lying on the back)..." Interview with the Director of Nursing (DON) on October 3, 2013, at 12:50 p.m., at the nurses station, revealed the resident was admitted to the facility from the hospital on October 5, 2012, with a multipodus boot in place on the left foot. Medical record review of an admission Minimum Data Set (MDS) dated [DATE], revealed the resident was moderately impaired for daily decision making; totally dependent for all Activities of Daily Living (ADL's); at risk for pressure ulcers; and had no pressure ulcers on admission. Medical record review of the Nursing Assessment Re-admitted d October 29, 2012, revealed, "...Skin/Wound condition present: no...red area (coccyx)...scabbed area (right lower extremity) scab area (top of right foot)...red area (right forearm)...Norton Score 12 (very high risk)..." Medical record review of the Physician's orders from admission on October 5, 2012, to discharge on May 1, 2013, revealed no order for a "boot." Medical record review of the resident's chart revealed no information regarding the application of the multipodus boot, the schedule of the multipodus boot, and/or the staff responsible for monitoring the multipodus boot. Interview with the Assistant Director of Nursing (ADON) on November 5, 2013, at 7:58 a.m., in the conference room, revealed the resident had on multipodus boots from the hospital. Further interview with the ADON revealed the resident wore the multipodus boots at all times except for showers. Medical record review of the Treatment Administration Record (TAR) dated November 1-30, 2012, revealed, "...open area to coccyx apply exuderm (cream to harden skin and prevent breakdown) change q (every) 3 days...weekly skin check by licensed nurse..." Continued review of the November TAR revealed weekly skin assessments completed on November 9, and 16, 2012, and no other skin assessments were documented. Medical record review of a Nurse's Note dated November 26, 2012, at 10:00 a.m., revealed, "...Blister noted to L (left) heel possibly caused by boot resident wears to prevent foot drop..." Medical record review of a Nurse Practitioner (NP) note on November 26, 2012, revealed "...Skin: normal..." Medical record review of a Physician's order dated November 26, 2012, revealed, "...Skin prep bilateral heels q (every) shift..." Continued medical record review of a Physician's order also dated November 26, 2012, revealed, "...cleanse blister to left heel..." Medical record review revealed no wound measurements for the left heel documented until December 27, 2012 (thirty-one days after discovery). Medical record review of Pressure Ulcer Documentation Forms dated December 27, 2012, through January 30, 2013, revealed the resident had an unstageable left heel ulcer with the following: December 27, "...length 2 cm (centimeter) width 1.5 cm...no undermining, no tunneling, no odor, no exudate..."; January 3, length 1.5 cm. width 1.5 cm; January 8, length 1.5 cm. width 1 cm; January 16, length 2 cm. width 1 cm; January 23, length 1.5 cm. width .5 cm; and January 30, "...length 1.5 cm. width .5 cm...no undermining, no tunneling, no odor, no exudate..." Continued review revealed no documentation the physician was notified of the lack of wound progress and no new orders were obtained for the wound. Medical record review of the physician's progress notes dated January 3, 2013, revealed the statement "...wounds healing nicely..." Medical record review of a quarterly MDS dated [DATE], revealed the resident was moderately impaired for daily decision making; totally dependent for all ADL's (activities of daily living); at risk for pressure ulcers; and had one Stage 1 pressure ulcer and no unstageable pressure ulcers. Medical record review of the Pressure Ulcer Documentation Form dated February 5, 2013, revealed the wound had changed to a Deep Tissue Injury (DTI) and "...length 1.5 cm. width 1.5 cm...100% eschar (necrotic tissue), [MEDICAL CONDITION] present, no order change...no notification of change (to physician)..." Medical record review of the Pressure Ulcer Documentation form dated February 12, through March 1, 2013, revealed the wound was staged as a DTI and no wound measurements were documented or notification to the physician. Medical record review of the Pressure Ulcer Documentation Form dated March 12, 2013, revealed, "...Left Heel Stage DTI...Wound Measurements length 1.7 cm, width 1.6 cm...25 % slough (necrotic tissue in process of separating), 75% eschar, [MEDICAL CONDITION] present, order change Santyl (wound debridement)..." (The first notification to the physician and new orders obtained for wound treatment). Medical record review of a Physician's order dated March 13, 2013, revealed, "...cleanse blister to left heel with wound cleanser...apply santyl (removes necrotic tissue)..." Medical record review of a Pressure Ulcer Documentation Form dated March 19, 2013, revealed, "...Left Heel Stage DTI...Wound Measurements Length 2 cm, Width 1.8 cm, no depth documented, no tunneling, no odor, exudates sm type ser, 100% slough, no order change...no notification of change (to physician or family)..." Review of the TAR for March 2013, revealed the order for skin prep bilateral heels each shift and the treatment was not documented as administered on March 2, 3, 4, 8, 11, 12, 17, 18, 21, 23, 24, 25, 27, 28, and 30, 2013, on the night shift. Continued review of the TAR for March 2013, revealed an order for [REDACTED]. Medical record review revealed no documentation of the left heel pressure ulcer after March 19, 2013, through April 3, 2013 (fifteen days). Medical record review of a IDT note dated March 21, 2013, revealed, "...new bed (with) air mattress which allows more room so (resident's) feet don't touch foot board d/t (due to) Pt (patient) sliding down in bed..." Medical record review of a physician progress notes [REDACTED]. Medical record review of an IDT note dated April 3, 2013, revealed, "...Left heel...2.8 x 2.2 cm tx (treatment) (with) Santyl..." Medical record review of a Physician's order dated April 8, 2013, revealed, "[MEDICATION NAME] (antibiotic) 875-125 mg by mouth every eight hours for seven days wound..." Medical record review of a Physician Order dated April 8, 2013, revealed, "...Wound care consult complex..." Medical record review of a Pressure Ulcer Documentation Form dated April 10, 2013, revealed "...left heel 3 x 2.6 x 1 with 100% slough; left lower posterior leg upper wound 2.8 x 0.1, stage II; left lower posterior leg lower wound - 1.7 x 1.1 - stage II..." Medical record review of a New Patient Medical History from the Wound Care Physician, dated April 12, 2013, revealed, "...Heel Ulcers/Leg Ulcers...L heel 2.3 x 2.7 x 1.0 cm (centimeters)..." Medical record review of an IDT note dated April 18, 2013, revealed, "...Left heel...5.2 x 2.5 x 1.5 cm 100 % slough tx to area (with) Santyl. Left lower leg lower ulcer 2.4 x 1.2 x 0.1, stage II; left lower leg upper ulcer 2.0 x 1.0 x 0.1, stage II..." Medical record review of a Physician Order dated May 1, 2013, revealed, "...send to (hospital) for direct admit...wound debridement..." Interview with the Medical Records Director on October 3, 2013, at 7:30 a.m., in the Medical Records Department, confirmed there was no documentation of wound measurements in the medical record prior to December 27, 2012. Interview with the resident's physician on October 3, 2013, at 11:35 a.m., on the A-Wing, confirmed the physician expected the facility to obtain an order with specific instructions for application and maintenance of a multipodus boot (footdrop management). Continued interview confirmed the physician expected the facility to complete weekly skin assessments with wound measurements for all pressure ulcers and notify the physician with changes. Interview with the Director of Nursing (DON) on October 3, 2013, at 12:50 p.m., at the Nurse's Station, confirmed there was no physician order for [REDACTED]. Further interview confirmed no documentation the physician and/or family were notified. Resident #62 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Psychiatric Progress Note dated January 17, 2013, and February 4, 2103, revealed, "...Recommendation :1) DC (discontinue) [MEDICATION NAME] non-use > (greater than) 30 days...2) DC [MEDICATION NAME] 10 mg po 2 x day...3) [MEDICATION NAME] 5 mg po 2 x day..." Medical record review of the Comprehensive Non-Psychiatric Progress Note dated March 4, 2013, revealed, "...Recommendation-1) DC [MEDICATION NAME] non-use >30 days...2) DC [MEDICATION NAME] po 10 mg 2 x day...3) [MEDICATION NAME] 5 mg po 2 x day...Informed consent for GDR (Gradual Dose Reduction) to [MEDICATION NAME], DC [MEDICATION NAME] NP (Nurse Practitioner) spoke with daughter..." Medical record review of the physician orders dated March 15, 2013, revealed the [MEDICATION NAME] 10 mg twice a day was discontinued, [MEDICATION NAME] 25 mg prn was discontinued, and [MEDICATION NAME] 5 mg bid was ordered (three months after the initial recommendation). Interview with Licensed Practical Nurse #1 on October 3, 2013, at 9:40 a.m., in the TV lounge, confirmed there was no documentation the physician was notified of the [MEDICAL CONDITION] medication recommendations initiated January 2013, and continued in February 2013. Further interview confirmed the physician was not notified of the [MEDICAL CONDITION] medication recommendations until after March 4, 2013. Validation of the Credible Allegation of Compliance was accomplished on-site November 26, 2013, through medical record review, review of facility documents, observation, and interviews with nursing and administrative staff. The facility provided evidence of in-service training with sign-in sheets for all licensed nursing staff related to notification of physicians of change in resident's status to include notifications related to abuse, accidents, acute illness, significant change in physical, mental or psychosocial status. The facility provided evidence of new auditing logs for [MEDICAL CONDITION] medications, skin assessments, and pressure ulcer reports. Review of auditing logs revealed the facility was utilizing, and monitoring the logs with appropriate notifications to physicians in a timely manner. Interviews with licensed nursing staff conducted on November 26, 2013, in the facility, revealed nursing staff were able to verbalize notification policies and procedures. Medical record review of resident #62 revealed all notifications had been completed. Interviews conducted with the Administrator and Regional Vice-President of Clinical Operations on November 26, 2013, in the facility, confirmed the facility had conducted a Quality Assurance Meeting which included discussion of physician notification policies with the new Medical Director. The facility will remain out of compliance at a Scope and Severity level "D" a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, until it provides an acceptable plan of correction.

Based on medical record review and interview, the facility failed to notify the physician of use of a multipodus boot (a rigid appliance to prevent the foot from extending to prevent foot drop) and failed to notify the physician of pressure ulcer progression for one resident (#95) of fourteen residents with pressure ulcers reviewed; and failed to notify the physician of [MEDICAL CONDITION] medication recommendations for one resident (#62) of sixty-five residents reviewed. The facility's failure to notify the physician in order to obtain orders for care and treatment of [REDACTED]. The Immediate Jeopardy was effective on November 26, 2012, and is ongoing. The Regional Vice President, Director of Clinical Services, Administrator and Director of Nursing were informed of the Immediate Jeopardy on November 6, 2013, at 2:30 p.m. in the conference room. The findings included: Resident #95 was admitted to a Trauma Center on July 27, 2012, following an accident while burning brush in which there was an explosion. Two days later the family and friends were unable to contact the resident and a neighbor found the resident in the house, minimally responsive and lethargic. As a result of the accident the resident was a C6 quadriplegic (fracture of neck just above shoulders leaving resident unable to move from the neck down) [MEDICAL CONDITION] 15% (percent) of the body, including face, right arm, left arm, and bilateral lower extremities. Resident #95 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the discharge recommendations dated August 20, 2012, from Physical Therapy at an outside hospital, revealed, "...the following anti-contracture devices were applied to patient: Multipodus boots BLEs (bilateral lower extremities) continuously when supine (lying on the back)..." Interview with the Director of Nursing (DON) on October 3, 2013, at 12:50 p.m., at the nurses station, revealed the resident was admitted to the facility from the hospital on October 5, 2012, with a multipodus boot in place on the left foot. Medical record review of an admission Minimum Data Set (MDS) dated [DATE], revealed the resident was moderately impaired for daily decision making; totally dependent for all Activities of Daily Living (ADL's); at risk for pressure ulcers; and had no pressure ulcers on admission. Medical record review of the Nursing Assessment Re-admitted d October 29, 2012, revealed, "...Skin/Wound condition present: no...red area (coccyx)...scabbed area (right lower extremity) scab area (top of right foot)...red area (right forearm)...Norton Score 12 (very high risk)..." Medical record review of the Physician's orders from admission on October 5, 2012, to discharge on May 1, 2013, revealed no order for a "boot." Medical record review of the resident's chart revealed no information regarding the application of the multipodus boot, the schedule of the multipodus boot, and/or the staff responsible for monitoring the multipodus boot. Interview with the Assistant Director of Nursing (ADON) on November 5, 2013, at 7:58 a.m., in the conference room, revealed the resident had on multipodus boots from the hospital. Further interview with the ADON revealed the resident wore the multipodus boots at all times except for showers. Medical record review of the Treatment Administration Record (TAR) dated November 1-30, 2012, revealed, "...open area to coccyx apply exuderm (cream to harden skin and prevent breakdown) change q (every) 3 days...weekly skin check by licensed nurse..." Continued review of the November TAR revealed weekly skin assessments completed on November 9, and 16, 2012, and no other skin assessments were documented. Medical record review of a Nurse's Note dated November 26, 2012, at 10:00 a.m., revealed, "...Blister noted to L (left) heel possibly caused by boot resident wears to prevent foot drop..." Medical record review of a Nurse Practitioner (NP) note on November 26, 2012, revealed "...Skin: normal..." Medical record review of a Physician's order dated November 26, 2012, revealed, "...Skin prep bilateral heels q (every) shift..." Continued medical record review of a Physician's order also dated November 26, 2012, revealed, "...cleanse blister to left heel..." Medical record review revealed no wound measurements for the left heel documented until December 27, 2012 (thirty-one days after discovery). Medical record review of Pressure Ulcer Documentation Forms dated December 27, 2012, through January 30, 2013, revealed the resident had an unstageable left heel ulcer with the following: December 27, "...length 2 cm (centimeter) width 1.5 cm...no undermining, no tunneling, no odor, no exudate..."; January 3, length 1.5 cm. width 1.5 cm; January 8, length 1.5 cm. width 1 cm; January 16, length 2 cm. width 1 cm; January 23, length 1.5 cm. width .5 cm; and January 30, "...length 1.5 cm. width .5 cm...no undermining, no tunneling, no odor, no exudate..." Continued review revealed no documentation the physician was notified of the lack of wound progress and no new orders were obtained for the wound. Medical record review of the physician's progress notes dated January 3, 2013, revealed the statement "...wounds healing nicely..." Medical record review of a quarterly MDS dated [DATE], revealed the resident was moderately impaired for daily decision making; totally dependent for all ADL's (activities of daily living); at risk for pressure ulcers; and had one Stage 1 pressure ulcer and no unstageable pressure ulcers. Medical record review of the Pressure Ulcer Documentation Form dated February 5, 2013, revealed the wound had changed to a Deep Tissue Injury (DTI) and "...length 1.5 cm. width 1.5 cm...100% eschar (necrotic tissue), [MEDICAL CONDITION] present, no order change...no notification of change (to physician)..." Medical record review of the Pressure Ulcer Documentation form dated February 12, through March 1, 2013, revealed the wound was staged as a DTI and no wound measurements were documented or notification to the physician. Medical record review of the Pressure Ulcer Documentation Form dated March 12, 2013, revealed, "...Left Heel Stage DTI...Wound Measurements length 1.7 cm, width 1.6 cm...25 % slough (necrotic tissue in process of separating), 75% eschar, [MEDICAL CONDITION] present, order change Santyl (wound debridement)..." (The first notification to the physician and new orders obtained for wound treatment). Medical record review of a Physician's order dated March 13, 2013, revealed, "...cleanse blister to left heel with wound cleanser...apply santyl (removes necrotic tissue)..." Medical record review of a Pressure Ulcer Documentation Form dated March 19, 2013, revealed, "...Left Heel Stage DTI...Wound Measurements Length 2 cm, Width 1.8 cm, no depth documented, no tunneling, no odor, exudates sm type ser, 100% slough, no order change...no notification of change (to physician or family)..." Review of the TAR for March 2013, revealed the order for skin prep bilateral heels each shift and the treatment was not documented as administered on March 2, 3, 4, 8, 11, 12, 17, 18, 21, 23, 24, 25, 27, 28, and 30, 2013, on the night shift. Continued review of the TAR for March 2013, revealed an order for [REDACTED]. Medical record review revealed no documentation of the left heel pressure ulcer after March 19, 2013, through April 3, 2013 (fifteen days). Medical record review of a IDT note dated March 21, 2013, revealed, "...new bed (with) air mattress which allows more room so (resident's) feet don't touch foot board d/t (due to) Pt (patient) sliding down in bed..." Medical record review of a physician progress notes [REDACTED]. Medical record review of an IDT note dated April 3, 2013, revealed, "...Left heel...2.8 x 2.2 cm tx (treatment) (with) Santyl..." Medical record review of a Physician's order dated April 8, 2013, revealed, "[MEDICATION NAME] (antibiotic) 875-125 mg by mouth every eight hours for seven days wound..." Medical record review of a Physician Order dated April 8, 2013, revealed, "...Wound care consult complex..." Medical record review of a Pressure Ulcer Documentation Form dated April 10, 2013, revealed "...left heel 3 x 2.6 x 1 with 100% slough; left lower posterior leg upper wound 2.8 x 0.1, stage II; left lower posterior leg lower wound - 1.7 x 1.1 - stage II..." Medical record review of a New Patient Medical History from the Wound Care Physician, dated April 12, 2013, revealed, "...Heel Ulcers/Leg Ulcers...L heel 2.3 x 2.7 x 1.0 cm (centimeters)..." Medical record review of an IDT note dated April 18, 2013, revealed, "...Left heel...5.2 x 2.5 x 1.5 cm 100 % slough tx to area (with) Santyl. Left lower leg lower ulcer 2.4 x 1.2 x 0.1, stage II; left lower leg upper ulcer 2.0 x 1.0 x 0.1, stage II..." Medical record review of a Physician Order dated May 1, 2013, revealed, "...send to (hospital) for direct admit...wound debridement..." Interview with the Medical Records Director on October 3, 2013, at 7:30 a.m., in the Medical Records Department, confirmed there was no documentation of wound measurements in the medical record prior to December 27, 2012. Interview with the resident's physician on October 3, 2013, at 11:35 a.m., on the A-Wing, confirmed the physician expected the facility to obtain an order with specific instructions for application and maintenance of a multipodus boot (footdrop management). Continued interview confirmed the physician expected the facility to complete weekly skin assessments with wound measurements for all pressure ulcers and notify the physician with changes. Interview with the Director of Nursing (DON) on October 3, 2013, at 12:50 p.m., at the Nurse's Station, confirmed there was no physician order for [REDACTED]. Further interview confirmed no documentation the physician and/or family were notified. Resident #62 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Psychiatric Progress Note dated January 17, 2013, and February 4, 2103, revealed, "...Recommendation :1) DC (discontinue) [MEDICATION NAME] non-use > (greater than) 30 days...2) DC [MEDICATION NAME] 10 mg po 2 x day...3) [MEDICATION NAME] 5 mg po 2 x day..." Medical record review of the Comprehensive Non-Psychiatric Progress Note dated March 4, 2013, revealed, "...Recommendation-1) DC [MEDICATION NAME] non-use >30 days...2) DC [MEDICATION NAME] po 10 mg 2 x day...3) [MEDICATION NAME] 5 mg po 2 x day...Informed consent for GDR (Gradual Dose Reduction) to [MEDICATION NAME], DC [MEDICATION NAME] NP (Nurse Practitioner) spoke with daughter..." Medical record review of the physician orders dated March 15, 2013, revealed the [MEDICATION NAME] 10 mg twice a day was discontinued, [MEDICATION NAME] 25 mg prn was discontinued, and [MEDICATION NAME] 5 mg bid was ordered (three months after the initial recommendation). Interview with Licensed Practical Nurse #1 on October 3, 2013, at 9:40 a.m., in the TV lounge, confirmed there was no documentation the physician was notified of the [MEDICAL CONDITION] medication recommendations initiated January 2013, and continued in February 2013. Further interview confirmed the physician was not notified of the [MEDICAL CONDITION] medication recommendations until after March 4, 2013. .

Based on medical record review, and interview, the facility failed to provide pharmaceutical services to relieve pain and anxiety for one resident (#33), of sixty-five residents reviewed. This failure resulted in harm to resident #33 The findings included: Resident #33 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Nurse's Admission Note dated May 3, 2013, at 8:10 p.m., revealed "...C/O (complained of) pain/anxiety..." Medical record review of the Admission Physician order [REDACTED].-325 mg (5 mg of Hydrocodone and 325 mg of Acetaminophen per each tablet) 1 tab every 6 hours as needed..." Medical record review of the Medication Administration Record [REDACTED] Interview with the resident on September 25, 2013, at 8:00 a.m., in the resident's room, revealed the resident had a short stay in the hospital and when the resident returned in May 2013, the resident could not get pain medications until the next morning. Continued interview revealed the resident stated, "I was miserable; I finally got my medicine about 6:00 a.m." Interview with the Director of Nursing (DON) on September 26, 2013, at 10:35 a.m., in the conference room, revealed the resident complained of pain and anxiety on admission. Continued interview confirmed the facility failed to provide the resident's pain and anxiety medications for six hours and twenty minutes after the resident's complaint of pain and anxiety. C/O #

Based on medical record review, review of manufacturer's instructions, observation, and interview, the facility failed to follow physician orders [REDACTED].#114) of sixty-five residents reviewed. The findings included: Resident #33 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 was cognitively intact; required extensive assistance with all Activities of Daily Living (ADL's); and had frequent pain that limited daily activities and made it hard to sleep at night. Medical record review of the Care Plan dated May 3, 2013, revealed the resident had a self care deficit related to change in mobility, anxiety, and pain; a potential for pain related to wounds; and use of drugs that altered the mind. Medical record review of the admission Physician order [REDACTED].-325 mg 1 tab every 6 hours as needed..." Medical record review of a Nurse's Admission Note dated May 3, 2013, at 8:10 p.m., revealed, "...C/O (complain) of pain/anxiety..." Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Interview with the resident on September 25, 2013, at 8:00 a.m., in the resident's room, revealed the resident had a short stay in the hospital and when the resident returned in May 2013, the resident could not get pain medications until the next morning. Continued interview revealed "I was miserable; I finally got my medicine about 6:00 a.m." Interview with the Director of Nursing (DON) on September 26, 2013, at 10:35 a.m., in the conference room, revealed the resident complained of pain and anxiety on admission and the resident had a [MEDICATION NAME] Patch 100 mcg in place on admission from the hospital dated May 1, 2013. Continued interview revealed the resident was administered pain and anxiety medication on May 4, 2013, at 2:30 a.m. (six hours later) and the [MEDICATION NAME] Patch was changed on May 6, 2013, (scheduled every 72 hours, but applied 5 days after the last application). Further interview confirmed the facility had failed to follow physician orders [REDACTED]. [REDACTED].#33 who experienced unrelieved pain and anxiety. Resident #114 was admitted to the facility from the hospital on September 14, 2013, with [DIAGNOSES REDACTED]. Review of the manufacturer's instructions for the use of the rectal tube revealed, "...Contraindications...1. This product is not intended for use for more than 29 consecutive days...Precautions 1. Close attention should be exercised with the use of the device in patients who have [MEDICAL CONDITION] bowel conditions...4. The use of the device is not indicated for solid or soft-formed stool...the following adverse events could occur...Rectal/anal bleeding due to pressure necrosis or ulceration of rectal or anal mucosa; Peri-anal skin breakdown; Temporary loss of anal sphincter muscle tone; Infection; Bowel Obstruction; Perforation of the bowel..." Medical record review of the admission nursing assessment dated [DATE], revealed, "...Bowel Elimination...Rectal tube to BSB (bedside bag). Medical record review of the physician orders [REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed cognitive skills severely impaired, always incontinent of urine, bowel continence not rated (had a rectal tube in place from admission). Medical record review of a Nurse's Note dated October 29, 2013, revealed, "Resident out to wound care per ambulance. Will also have a new rectal seal placed..." Observation on October 31, 2013, at 10:40 a.m., in the resident's room revealed the resident lying on back in an air bed with son at the bedside. Interview with the son, during the observation, revealed the resident had a rectal tube in place and the son stated "(Resident) has not had any stool from the tube for two days now..." Interview at the nursing station, with the Unit Manager/Registered Nurse (RN) #1, on October 31, 2013, at 11:00 a.m., revealed the facility did not have the manufacturer's instructions for the rectal tube. Interview revealed the original date the rectal tube had been placed at the hospital had not been determined by the nursing home staff. Interview verified a plan of care for the rectal tube had not been developed. Interview on October 31, 2013, at 1:30 p.m., in the nursing station with RN #1, revealed the rectal tube had been in place since September 3, 2013. Interview confirmed the resident had a [DIAGNOSES REDACTED]. Interview continued and confirmed the manufacturer's instructions indicated the rectal tube should not be used continuously beyond 29 days and the resident's had been used continuously for 58 days. Interview confirmed the nursing staff had requested the rectal tube be replaced while at the hospital's Wound Care Center on October 29, 2013, due to dislodging on the same day. Interview in nursing station with the Wound Care Physician on November 4, 2013, at 10:50 a.m., revealed, "I apologize for having the rectal tube replaced last week, I didn't know how long it had been in."

Based on medical record review, review of manufacturer's instructions, observation, and interview, the facility failed to follow physician orders [REDACTED].#33) resulting in harm to the resident and failed to follow the recommended use of a rectal tube for one resident (#114) of sixty-five residents reviewed. The findings included: Resident #33 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 was cognitively intact; required extensive assistance with all Activities of Daily Living (ADL's); and had frequent pain that limited daily activities and made it hard to sleep at night. Medical record review of the Care Plan dated May 3, 2013, revealed the resident had a self care deficit related to change in mobility, anxiety, and pain; a potential for pain related to wounds; and use of drugs that altered the mind. Medical record review of the admission Physician order [REDACTED].-325 mg 1 tab every 6 hours as needed..." Medical record review of a Nurse's Admission Note dated May 3, 2013, at 8:10 p.m., revealed, "...C/O (complain) of pain/anxiety..." Medical record review of the Medication Administration Record [REDACTED] Interview with the resident on September 25, 2013, at 8:00 a.m., in the resident's room, revealed the resident had a short stay in the hospital and when the resident returned in May 2013, the resident could not get pain medications until the next morning. Continued interview revealed "I was miserable; I finally got my medicine about 6:00 a.m." Interview with the Director of Nursing (DON) on September 26, 2013, at 10:35 a.m., in the conference room, revealed the resident complained of pain and anxiety on admission and the resident had a [MEDICATION NAME] Patch 100 mcg in place on admission from the hospital dated May 1, 2013. Continued interview revealed the resident was administered pain and anxiety medication on May 4, 2013, at 2:30 a.m. (six hours later) and the [MEDICATION NAME] Patch was changed on May 6, 2013, (scheduled every 72 hours, but applied 5 days after the last application). Further interview confirmed the facility had failed to follow physician orders [REDACTED]. The facility's failure to follow physician's orders [REDACTED].#33 who experienced unrelieved pain and anxiety. Resident #114 was admitted to the facility from the hospital on September 14, 2013, with [DIAGNOSES REDACTED]. Review of the manufacturer's instructions for the use of the rectal tube revealed, "...Contraindications...1. This product is not intended for use for more than 29 consecutive days...Precautions 1. Close attention should be exercised with the use of the device in patients who have [MEDICAL CONDITION] bowel conditions...4. The use of the device is not indicated for solid or soft-formed stool...the following adverse events could occur...Rectal/anal bleeding due to pressure necrosis or ulceration of rectal or anal mucosa; Peri-anal skin breakdown; Temporary loss of anal sphincter muscle tone; Infection; Bowel Obstruction; Perforation of the bowel..." Medical record review of the admission nursing assessment dated [DATE], revealed, "...Bowel Elimination...Rectal tube to BSB (bedside bag). Medical record review of the physician orders [REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed cognitive skills severely impaired, always incontinent of urine, bowel continence not rated (had a rectal tube in place from admission). Medical record review of a Nurse's Note dated October 29, 2013, revealed, "Resident out to wound care per ambulance. Will also have a new rectal seal placed..." Observation on October 31, 2013, at 10:40 a.m., in the resident's room revealed the resident lying on back in an air bed with son at the bedside. Interview with the son, during the observation, revealed the resident had a rectal tube in place and the son stated "(Resident) has not had any stool from the tube for two days now..." Interview at the nursing station, with the Unit Manager/Registered Nurse (RN) #1, on October 31, 2013, at 11:00 a.m., revealed the facility did not have the manufacturer's instructions for the rectal tube. Interview revealed the original date the rectal tube had been placed at the hospital had not been determined by the nursing home staff. Interview verified a plan of care for the rectal tube had not been developed. Interview on October 31, 2013, at 1:30 p.m., in the nursing station with RN #1, revealed the rectal tube had been in place since September 3, 2013. Interview confirmed the resident had a [DIAGNOSES REDACTED]. Interview continued and confirmed the manufacturer's instructions indicated the rectal tube should not be used continuously beyond 29 days and the resident's had been used continuously for 58 days. Interview confirmed the nursing staff had requested the rectal tube be replaced while at the hospital's Wound Care Center on October 29, 2013, due to dislodging on the same day. Interview in nursing station with the Wound Care Physician on November 4, 2013, at 10:50 a.m., revealed, "I apologize for having the rectal tube replaced last week, I didn't know how long it had been in."

Based on medical record review, and interview, the facility failed to provide pharmaceutical services to relieve pain and anxiety for one resident (#33), of sixty-five residents reviewed. This failure resulted in harm to resident #33 The findings included: Resident #33 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Nurse's Admission Note dated May 3, 2013, at 8:10 p.m., revealed "...C/O (complained of) pain/anxiety..." Medical record review of the Admission Physician order [REDACTED].-325 mg (5 mg of Hydrocodone and 325 mg of Acetaminophen per each tablet) 1 tab every 6 hours as needed..." Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Interview with the resident on September 25, 2013, at 8:00 a.m., in the resident's room, revealed the resident had a short stay in the hospital and when the resident returned in May 2013, the resident could not get pain medications until the next morning. Continued interview revealed the resident stated, "I was miserable; I finally got my medicine about 6:00 a.m." Interview with the Director of Nursing (DON) on September 26, 2013, at 10:35 a.m., in the conference room, revealed the resident complained of pain and anxiety on admission. Continued interview confirmed the facility failed to provide the resident's pain and anxiety medications for six hours and twenty minutes after the resident's complaint of pain and anxiety. C/O #

Based on medical record review, facility policy review, observation, and interview, the facility failed to supervise, and failed to provide clothing protection/assistive devices for one resident known to drop lit cigarettes (#76); and failed to follow the facility's smoking policy for one resident (#120) of seven residents identified as smokers. The facility's failure placed resident #76, in Immediate Jeopardy (situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death). The Nursing Home Administrator (NHA) and the Director of Nursing (DON) were notified of the Immediate Jeopardy on April 25, 2012, at 1:30 p.m., in the Conference Room. The findings included: Resident # 76 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was cognitively intact, and had an impairment of the right upper extremity. Medical record review of the Care Plan initiated September 24, 2011, revealed "...smokes cigarettes and is found to be safe with smoking...observe for burn holes in clothes...will continue to exhibit safe smoking habits..." Medical record review of the Safe Smoking Evaluation dated February 14, 2012, revealed "...Can light, hold and extinguish smoking materials...personal belongings free from evidence of burn holes...history free from smoking related incidents..." Review of the facility's Smoking Policy (undated) revealed "...residents are permitted to smoke, supervised..." Observation on April 24, 2012, at 10:15 a.m., in the television room, revealed Resident #76 sitting in a wheelchair with cigarette ashes (black and white debris) on the resident's shirt, on the upper right arm. Observation on April 24, 2012, at 10:50 a.m., in the designated smoking area outside, revealed resident #76 sitting in a wheelchair holding a lit cigarette in the left hand. Continued observation revealed resident #76 dropped the cigarette; the lit cigarette hit the upper right thigh, and landed on the ground. Further observation at this time revealed resident #102 picked up the cigarette and handed it to resident #76. Interview with the Central Supply Specialist, supervising the residents, on April 24, 2012, at 10:55 a.m., outside in the designated smoke area, confirmed the following: 1) the resident dropped cigarettes frequently; 2) the staff were aware the resident dropped cigarettes; 3) the residents were to be supervised during smoke breaks; and 4) the Central Supply Specialist did not witness resident #76 dropping the cigarette due to assisting another resident. Interview with the Central Supply Specialist on April 24, 2012, at 5:35 p.m., in the Nurse's Station, confirmed the resident dropped cigarettes and had witnessed the resident dropping cigarettes at least two times each smoke break. Continued interview at this time confirmed smoke aprons were available and were not used for resident #76 and the nursing staff had been informed the resident dropped cigarettes frequently. Interview with Certified Nurse Aide (CNA) #1 on April 24, 2012, at 5:38 p.m., in the 300 hallway, confirmed the resident had dropped cigarettes and had witnessed the resident dropping cigarettes when CNA #1 was assigned to supervise smokers and the nursing staff had been informed. Interview with Licensed Practical Nurse (LPN) #1 on April 24, 2012, at 5:45 p.m., in the nurse's station, confirmed LPN #1 had supervised smoking, and was aware resident #76 had dropped cigarettes while smoking. Interview with LPN #2 on April 24, 2012, at 5:35 p.m., confirmed LPN #2 completed the Safe Smoking Evaluation for resident #76, on April 24, 2012. The evaluation revealed "...can light, hold, and extinguish smoking materials...personal belongings free from burn holes...history free from smoking related incidents...", and confirmed the assessment was not accurate due to the resident dropped cigarettes, and the resident had a known history of dropping cigarettes. Observation and interview with the Director of Nursing (DON) on April 24, 2012, at 5:55 p.m., of resident #76 seated in the TV room, confirmed three burn holes on the upper right area of resident #76's brown pants. Interview and observation with the DON on April 25, 2012, at 7:45 a.m., in resident #76's room, confirmed five of fifteen pairs of pants belonging to resident #76 had burn holes, and one of the five pairs were blue nylon pants with several burn holes (an open area in the fabric with brown crusty areas). Resident #120 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was cognitively intact and able to make decisions. Medical record review of the Interdisciplinary Care Plan initiated February 14, 2012, revealed "...Smoking material to be stored by nursing...explain the smoking policy and procedures..." Review of facility policy Smoking Policy undated revealed "...residents are permitted to smoke, supervised...under no circumstance may...lighters or cigarettes be kept in a resident's room, all smoking materials will be maintained at Nurse's Station...scheduled times 8:30 a.m., 10:30 a.m., 1:30 p.m., 3:30 p.m., 6:30 p.m., 8:30 p.m..." Observation on April 24, 2012, at 10:50 a.m., in the designated smoke area, revealed resident #120 with a pack of cigarettes in the resident's back pocket of the pants. Observation on April 25, 2012, at 9:30 a.m., in the designated smoke area outside, revealed the resident smoking a cigarette unsupervised. Interview with resident #120 on April 24, 2012, at 10:50 a.m., confirmed the staff allowed the resident to keep cigarettes; the resident smoked without supervision; and the staff provided a lighter during unsupervised smoking. Interview with the Nursing Home Administrator (NHA) on April 25, 2012, at 11:09 a.m., in the Conference Room, confirmed the facility had not implemented any interventions to prevent resident #76 from burning clothing/self, and resident #120 had been allowed to keep cigarettes and smoke unsupervised. Interview with the NHA on April 25, 2012, at 1:30 p.m., in the Conference Room, confirmed the facility failed to follow the facility policy on smoking. The Immediate Jeopardy was effective from April 24, 2012, through April 25, 2012, and was removed on April 26, 2012. An acceptable Allegation of Compliance, which removed the immediacy of the Jeopardy, was received and corrective actions were validated on-site by the survey team on April 26, 2012, through review of facility documents, staff interviews, and observations. The survey team verified the allegation of compliance by: 1.) Verifying resident #76 had been reassessed, and the Safe Smoking Evaluation revised to accurately reflect the resident's unsafe smoking habits; and verifying the other residents who smoke at the facility had accurate Safe Smoking Evaluations. Accuracy of the Safe Smoking assessments were confirmed by the survey team through observation during smoking sessions and supervised inspection of the resident's wardrobe for burn holes in clothing. 2.) Verifying resident #120 had been educated on the facility's revised policy including the storage of all smoking materials to be kept at the nurse's station. The survey team verified the information with resident #120 through observation and interview on April 26, 2012. 3.) Verifying the revision of the facility's policy, titled, Smoking, with an effective date of April 26, 2012, the Smoking Contract for Independent Smokers, and the facility's addendum to the Smoking policy, individualized to the center's specific practices to ensure the safe smoking environment for all smokers. 4.) Verification by the survey team on April 26, 2012, ensured by interviews with multidisciplinary staff, and review of inservice logs confirmed the staff received information regarding the facility's Smoking policy revision including the location of smoking materials, interventions for smokers deemed unsafe, designated smoking areas, designated smoking times, and how to monitor for safety during smoke breaks including but not limited to; 1) observation of holes in the resident's clothing; 2) new marks on skin or change in skin condition; 3) embers on clothing; 4) difficulty in handling lit cigarettes; 5) changes in smoking behavior; and 6) any other observation that causes concern or is perceived by staff to be an unsafe practice. Staff interviews confirmed sound knowledge of the facility's expectations regarding supervised smoke breaks for the residents, observation during the smoke breaks, accountability for the smoking materials, and whom to report unsafe smoking practices. 5.) Verifying the smoking residents' care plans and Certified Nurse Assistants care cards had been updated to reflect the safety needs for resident's who smoke, including the use of smoking aprons on resident #76 as indicated by the Safe Smoking Evaluation assessments. Non-Compliance continues at a "D" level for monitoring corrective actions. The facility is required to submit a Plan of Correction.

Based on medical record review, interview, and observation, the facility failed to accurately assess one resident (#76) for safe smoking ability of seven residents identified as smokers. The facility's failure to accurately assess Resident #76 resulted in Immediate Jeopardy (likely to cause serious injury, harm, impairment, or death). The findings included: Resident #76 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record of the Minimum Data Set, dated dated dated [DATE], revealed the resident was cognitively intact, and had an impairment of the right upper extremity. Medical record review of the Care Plan initiated September 24, 2011, revealed "...smokes cigarettes and is found to be safe with smoking...observe for burn holes in clothes...will continue to exhibit safe smoking habits..." Medical record review of the Safe Smoking Evaluation dated February 14, 2012, revealed "...Can light, hold and extinguish smoking materials...personal belongings free from evidence of burn holes...history free from smoking related incidents..." Observation on April 24, 2012, at 10:15 a.m., in the television room, revealed Resident #76 sitting in a wheelchair with cigarette ashes (black and white debris) on the resident's shirt, on the upper right arm. Observation on April 24, 2012, at 10:50 a.m., in the designated smoking area outside, revealed resident #76 sitting in a wheelchair holding a lit cigarette in the left hand. Continued observation revealed resident #76 dropped the cigarette; the lit cigarette hit the upper right thigh, and landed on the ground. Further observation at this time revealed resident #120 picked up the cigarette and handed it to resident #76. Interview with the Central Supply Specialist, supervising the residents, on April 24, 2012, at 10:55 a.m., outside in the designated smoke area, confirmed the following: 1) the resident dropped cigarettes frequently; 2) the staff were aware the resident dropped cigarettes; 3) the residents were to be supervised during smoke breaks; and 4) the Central Supply Specialist did not witness resident #76 dropping the cigarette due to assisting another resident. Interview with the Central Supply Specialist on April 24, 2012, at 5:35 p.m., in the Nurse's Station, confirmed the resident dropped cigarettes and had witnessed the resident dropping cigarettes at least two times each smoke break. Continued interview at this time confirmed smoke aprons were available and were not used for resident #76 and the nursing staff had been informed the resident dropped cigarettes frequently. Interview with Certified Nurse Aide (CNA) #1 on April 24, 2012, at 5:38 p.m., in the 300 hallway, confirmed the resident had dropped cigarettes and had witnessed the resident dropping cigarettes when CNA #1 was assigned to supervise smokers and the nursing staff had been informed. Interview with Licensed Practical Nurse (LPN) #1 on April 24, 2012, at 5:45 p.m., in the nurse's station, confirmed LPN #1 had supervised smoking, and was aware resident #76 had dropped cigarettes while smoking. Continued interview at this time revealed Central Supply Specialist had informed LPN #1 resident #76 dropped a lit cigarette on April 24, 2012. Interview with LPN #2 on April 24, 2012, at 5:35 p.m., confirmed LPN #2 completed the Safe Smoking Evaluation for resident #76, on April 24, 2012. The evaluation revealed "...can light, hold, and extinguish smoking materials...personal belongings free from burn holes...history free from smoking related incidents...", and confirmed the assessment was not accurate due to the resident dropped cigarettes, and the resident had a known history of dropping cigarettes. Further interview at this time revealed LPN #1 had informed LPN #2, resident #76 dropped a lit cigarette on April 24, 2012. Observation and interview with the Director of Nursing (DON) on April 24, 2012, at 5:55 p.m., of resident #76 seated in the TV room, confirmed three burn holes on the upper right area of resident #76's brown pants. Interview and observation with the DON on April 25, 2012, at 7:45 a.m., in resident #76's room, confirmed five of fifteen pairs of pants belonging to resident #76 had burn holes, and one of the five pairs were blue nylon pants with several burn holes (an open area in the fabric with brown crusty areas). The Immediate Jeopardy was effective from April 24, 2012, through April 25, 2012, and was removed on April 26, 2012. An acceptable Allegation of Compliance, which removed the immediacy of the Jeopardy, was received and corrective actions were validated on-site by the survey team on April 26, 2012, through review of facility documents, staff interviews, and observations. The survey team verified the allegation of compliance by: 1.) Verifying resident #76 had been reassessed, and the Safe Smoking Evaluation revised to accurately reflect the resident's unsafe smoking habits; and verifying the other residents who smoke at the facility had accurate Safe Smoking Evaluations. Accuracy of the Safe Smoking assessments were confirmed by the survey team through observation during smoking sessions and supervised inspection of the resident's wardrobe for burn holes in clothing. 2.) Verifying the revision of the facility's policy, titled, Smoking, with an effective date of April 26, 2012, the Smoking Contract for Independent Smokers, and the facility's addendum to the Smoking policy, individualized to the center's specific practices to ensure the safe smoking environment for all smokers. 3.) Verification by the survey team on April 26, 2012, ensured by interviews with multidisciplinary staff, and review of inservice logs confirmed the staff received information regarding the facility's Smoking policy revision including the location of smoking materials, interventions for smokers deemed unsafe, designated smoking areas, designated smoking times, and how to monitor for safety during smoke breaks including but not limited to; 1) observation of holes in the resident's clothing; 2) new marks on skin or change in skin condition; 3) embers on clothing; 4) difficulty in handling lit cigarettes; 5) changes in smoking behavior; and 6) any other observation that causes concern or is perceived by staff to be an unsafe practice. Staff interviews confirmed sound knowledge of the facility's expectations regarding supervised smoke breaks for the residents, observation during the smoke breaks, accountability for the smoking materials, and whom to report unsafe smoking practices. 4.) Verifying the smoking residents' care plans and Certified Nurse Assistants care cards had been updated to reflect the safety needs for resident's who smoke, including the use of smoking aprons on resident #76 as indicated by the Safe Smoking Evaluation assessments. Non-Compliance continues at a "D" level for monitoring corrective actions. The facility is required to submit a Plan of Correction.