Every finding on record at Focused Care at Fort Stockton

Based on observation, interview, and record review the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 1 of 3 (Resident #2) residents reviewed for accommodation of needs. The facility failed to ensure Resident #2 had their call light within reach. This failure could place residents at risk for not having their needs or preferences met. Findings included:Review of Resident #2's admission Record, dated 4/1/26, revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease and need for assistance with personal care. Review of Resident #2's Significant Change MDS Assessment, dated 3/27/26, revealed a BIMS of 9 on indicating she was moderately cognitively impaired and showed no signs of delirium. She needed set-up or stand by assistance with toileting and was frequently incontinent of bladder and occasionally incontinent of bowel. The MDS also indicated she was on dialysis. Review of Resident #2's Care Plan, revised on 1/9/20 revealed:Focus: Resident #2 was incontinent of Bowel and Bladder at times.Goal: Resident #2 would remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date.Focus: Resident #2 had an Activities of Daily Living self-care performance deficit related to impaired balance, weakness, and abnormal gait.Interventions: Encourage Resident #2 to use call light to call for assistance. Observation and interview on 3/31/26 at 2:44 p.m., showed Resident #2 in bed rocking back and forth saying ow repeatedly. Her call light was on her nightstand approximately three feet away from the bed. Resident #2 said she needed to have her brief changed. Resident #2 said her call light was out of reach all the time and she would just yell until someone came. Observation and interview on 3/31/26 at 2:58 p.m., showed Resident #2 still in bed. Resident #2 stated she received incontinent care and was waiting for staff to come back with some pillows. Resident #2's call light remained on the nightstand. Resident #2 stated she did not know why the staff left the call light out of reach. Observation on 4/1/26 at 1:33 p.m., showed Resident #2's call light still on the nightstand. Interview on 4/1/26 at 1:37 p.m., the DON stated the expectation was that call lights be answered promptly. The DON said she could not think of a situation where it would be acceptable to put a call light out of reach. The ADON who was also present said the aides should move the call light back in reach once the aides' completed rounds. When informed of the observations of Resident #2's call light on the nightstand out of reach of the resident, the ADON stated the aides should have put the light back in reach. The DON said the aides and nurses were both responsible for ensuring the call light remained in reach. The ADON said Resident #2 was not a resident who was always turning on the call light. Interview on 4/1/26 at 2:00 p.m., the Administrator was informed of the call light concern and surveyor requested the policy. Interview on 4/1/26 at 2:15 p.m., the DON said the Regional Nurse stated there was not a policy on call lights and the facility was just expected to follow the state regulations.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services.The facility failed on 3.24.26 to seal and date food items stored in refrigerator.This failure could place residents at risk for food contamination and foodborne illness. Findings included:During observations on 3.24.26 at 9:45 am to 10:45 am, during initial tour of the kitchen: Observation of the following stored in dry storage room:Large bag of white onions sitting directly on the floor.Four bread products sitting on top of the oven, not covered. Observation of the following stored in the refrigerator:Container with 37 cups of tea and ice filled, not covered.Container of ham and cheese sandwiches not covered.Package of ham not dated and opened. Observation of the following stored in the freezer:Box of yellow corn kernels opened and not covered.Bag of meat, not labeled and not dated.During an interview on 3.24.26 at 10:35 a.m., the DM stated all items in the refrigerator and in the storage, room were to be labelled with date opened and sealed. She stated anyone who puts food in the fridge for storage was responsible for dating and making sure it was sealed. The DM stated all staff were trained and safe serve certificates were all current for the kitchen staff. The DM stated the potential negative outcome could be bacteria in food and harmful to residents.During an interview on 3.24.26 at 10:55 a.m., the DON stated the DM and staff were responsible for dating items in the fridge and dry storage room and making sure all items were sealed. All staff were trained on food storage in the refrigerator and dry storage. The facility policy was to have all items sealed and dated. She stated the possible negative outcome could be serving infected food to residents.Record review of the facility's policy titled, Food Storage, dated 2.2026, indicated Food should be stored in a safe and sanitary method to prevent contamination and food-borne illness. All food should be stored according to local, state, and federal regulations. PROCEDURE:1. Dry storage roomsb. Bulk items that have been opened should be stored in covered containers orsealed bags and should be labeled and dated.2. Refrigeratorsc. Refrigerated food should be dated, labeled and sealed.Record review of the FDA Food Code 2022 reflected the federally established standards.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for one (Resident #44) of three residents reviewed for PASRR Level 1 screenings. The facility failed to ensure the accuracy of the PASRR Level 1 Screening for Resident #44. The PASRR Level 1 Screening dated 12/17/25 did not indicate a diagnosis of mental illness, although the diagnosis post-traumatic stress was present upon Resident #44's admission on [DATE]. This failure could place residents with mental illness at risk of not receiving a PASRR Evaluation, individualized care, or special services to meet their needs. Findings included: A record review of Resident #44's face sheet, dated 03/26/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included post-traumatic stress disorder chronic (a mental health condition triggered by experiencing or witnessing traumatic events), anxiety disorder, and chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs). A record review of Resident #44's quarterly MDS assessment dated [DATE], revealed a BIMS score of 99 which indicated Resident #44 did not complete the assessment. Resident #44's active diagnoses included anxiety, and post-traumatic stress disorder. No neurological diagnoses (disease that affects the brain or nerves), including dementia, were identified. A record review of Resident #44's comprehensive care plan, revised 02/11/2026, revealed in part, Focus - Anxiety related to cognitive deficit. Goals - The resident will not exhibit any signs or symptoms of anxiety throughout the review date. Interventions - Administer medications as ordered. Monitor/document side effects and effectiveness. A record review of Resident #44's PASRR Level 1 Screening completed on 12/17/2025 by the referring hospital revealed Resident #44 did not have a primary diagnosis of dementia and no indicator of mental illness. During an interview on 3/26/2026 at 12:00PM with Resident #44 she stated she has been at the facility since December 2025. Resident #44 stated prior to her admission to the facility she did receive some community services but could not recall what they were. During an interview on 3/26/2026 at 12:40 PM, the MDS Coordinator stated Resident #44 had a mental illness diagnosis, thus the PASRR screening was positive, not negative as reflected on the screening form. She stated a corrected screening should have been completed and sent to the local authority for evaluation. The MDS Coordinator stated PASRR was his responsibility and he would correct the issue. He stated the risk of PASRR not being accurate could be lack of services for the resident. During an interview on 03/27/26 at 4:49PM, the DON stated she expected the PASRRs to be accurate and timely. She stated if an error in a PASRR was later found, a corrected form was sent. DON stated the MDS Coordinator was responsible for the accuracy of PASRR documents. She stated residents may not have received the benefits or treatments they needed or were entitled to if the PASRR screening was inaccurate. The Administrator was not available for interview on 3/26/2026. During a record review of facility's policy dated 11/2023 titled PASRR revealed:6. Follow Texas PASRR Policy for all mandatory meetings and care coordination including any changes that may require a change in residents PASRR status. Review of the Texas Health and Human Services Detailed Item by Item Guide for Local Authorities and Nursing Facilities to Complete the PASRR Level 1 Screening Form, revised June 2023, and accessed at PASRR Forms and Instructions | Texas Health and Human Services revealed in part, The PASRR Level I (PL1) Screening Form is designed to identify individuals who are suspected of having mental illness (MI), intellectual disability (ID) or a developmental disability (DD). Developmental disabilities are also referred to as related conditions.If documentation entered on the PL1 Screening Form indicates a suspicion of MI, ID, or DD, a PASRR Evaluation (PE) must be completed to confirm PASRR eligibility. The PE is designed to confirm the suspicion of MI, ID or DD and ensure an individual is placed in the most integrated residential setting receiving the specialized services needed to improve and maintain an individual's level of functioning.Examples of MI diagnoses are:SchizophreniaMood Disorder (Bipolar Disorder, Major Depressive Disorder, or other mood disorder)Paranoid DisorderSevere Anxiety DisorderSchizoaffective DisorderPost-Traumatic Stress SyndromeWhat is not considered an MI:Neurocognitive Disorders, such as Alzheimer's disease, other types of dementia, Parkinson's disease, and Huntington's. (DSM-5*), Depression, unless diagnosed as Major Depression; and Anxiety, unless diagnosed as severe anxiety disorder.*Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for 1 of 10 residents (Residents #44) reviewed for care plans. The facility did not develop Resident #44's care plan related to diagnosis of Post-Traumatic Stress Disorder. These failures could place residents at risk for unmet care needs and decreased quality of care.Findings included: A record review of Resident #44's face sheet, dated 03/26/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included post-traumatic stress disorder chronic (a mental health condition triggered by experiencing or witnessing traumatic events, PTSD), anxiety disorder, and chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs). A record review of Resident #44's quarterly MDS assessment dated [DATE], revealed a BIMS score of 99 which indicated Resident #44 did not complete the assessment. Resident #44's active diagnoses included anxiety, and post-traumatic stress disorder. No neurological diagnoses (disease that affects the brain or nerves), including dementia, were identified. A record review on 3/26/2026 of Resident #44's care plan, revised on 2/11/2026, revealed no care plan for PTSD. During an interview on 3/26/2026 at 12:00pm with Resident #44 she stated she was admitted to the facility after several hospitalizations. She stated everyone treated her well at the facility. During an interview on 3/26/2026 at 1:40 p.m., the MDS Coordinator stated it was important to have Post Traumatic Stress Disorder in the care plan to communicate with the floor nurses. MDS Coordinator said he was not sure what the negative outcome could be because the resident was stable. MDS Coordinator stated it was his responsibility to develop the care plan based on the MDS triggers. During an interview on 3/26/2026 at 3:30 p.m. the DON stated PTSD should be care planned so that staff are aware of the residents' conditions. DON stated that staff followed the care plan to care for residents. DON said that the negative outcome could be not giving proper care to Resident #44 and not knowing her triggers for PTSD. DON stated it was the MDS Coordinator's responsibility to care plan diagnoses that were entered on the MDS. The Administrator was not available for interview on 3/26/2026. A Record review of the facility's policy titled Comprehensive Care Plans effective 1/20/2021, revealed, Policy: Every resident will have an individualized interdisciplinary plan of care in place. The care plan is revised every quarter, significant change of condition, annual or as the resident condition changes on an individualized basis.Procedure:5. The Interdisciplinary Team will review the healthcare practitioner's notes and orders and implement a Comprehensive Care Plan to meet the residents' immediate care needs including but not limited to:b. Physician orderse. Social Servicel. Psychosocial Mood State

Based on observations, interviews, and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 (Resident #54) of 11 residents observed for oxygen management. Resident #54 were on oxygen and did not have NO SMOKING sign posted outside of the bedroom. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Resident #54Record review of Resident #54's admission Record dated 3.26.26 revealed an admission on 3.18.25 with a diagnosis of chronic pulmonary edema (a long-term condition where fluid accumulates in the lungs leading to persistent breathing difficulties and chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe). Record review of Resident #54's Comprehensive MDS dated 12.12.25 revealed a BIMS score of 7, indicating severe cognitive impairment. Section J1100 was marked for shortness of breath. Record review of Resident #54's orders initiated 10.24.23, revealed O2 via n/c at 2 l/m PRN to maintain O2 saturation 92%. Record review of Resident #54's Care Plan dated 03.25.26, revealed O2 via n/c at 2 l/m PRN to maintain O2 saturation 92% for COPD. Observation on 3.24.26 at 2:58 PM revealed Resident #54 was receiving oxygen via nasal cannula. NO SMOKING sign was not placed outside Resident #54's room. During an interview on 3.26.26 at 5:30 PM, with the DON, she stated NO SMOKING signs should be placed outside of all rooms that have residents receiving oxygen no later than 1 day after the oxygen was started. The DON said it was the responsibility of the medical records staff member to place the NO SMOKING sign outside the resident's room. The DON said the medical records staff member was previously in-serviced verbally regarding the expectations for placing NO SMOKING signs on the door. The DON stated a consequence for not having the NO SMOKING signs placed correctly was injury to residents, staff, and visitors. Record review of the facility Oxygen Therapy policy dated 4.2021, revealed, Place NO SMOKING sign on the outside of door to resident's room.

Based on interview and record review, the facility failed to ensure in accordance with professional standards of practice, the medical records on each resident were accurately and completely documented for 1 of 13 residents (Resident #58) reviewed for accurate medical records. The facility failed to ensure correct and complete documentation for Resident #58 who was placed in the secure unit on 5.19.25. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.Record review of Resident #58's admission Record, dated 3.26.26, revealed a [AGE] year-old male, admitted 5.9.25, with a diagnosis of unspecified dementia (used when a patient shows clear signs of cognitive decline or impairment, but a specific cause cannot be determined). Record review of Resident #58's MDS Assessment, dated 1.13.26, revealed a BIMs score of 6, indicating severe cognitive impairment and problems with thinking and memory. Record review of Resident #58's Care Plan, dated 6.17.25, revealed the following: Focus - Resides in secure unit and was at risk for injury from wandering in an unsafe environment R/T dx of Dementia.Goal - Dignity will be maintained and resident will wander about unit without the occurrence of any injury over the next quarter.Interventions - Call by name when giving care, involve in care as much as possible. Explain procedures using terms/gestures resident can understand, repeat prn. Keep environment free from possible hazards. Review quarterly and prn continued need for secure unit. Record review of Resident #58's Order Summary Report, dated 3.26.26, revealed no order to be placed in the secure unit. During an interview on 3.26.26 at 4:37 p.m., the Medical Director said Resident #58 had a need to be in the secured unit. The Medical Director said he had given a verbal order for Resident #58 to be placed in the secured unit. The Medical Director said an order should be entered into Resident #58's chart after he gave the verbal order. During an interview on 3.26.26 at 5:18 p.m., the DON said she was not aware there wasn't an order for Resident #58 to be in the secure unit. The DON said if a verbal order was given, there would be an order placed in Resident #58's chart. The DON said it was the responsibility of the Charge Nurse or the DON to enter verbal orders into the resident's record. Record review of the facility's admission Screening for Placement on Memory Care Unit and Consent for Placement on Memory Care Unit policy, dated 5.5.21, revealed, Nursing department will contact physician for an order to place resident on Memory Care Unit.

Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to help prevent the development and transmission of disease and infection to include hand washing and enhanced precautions for 3 residents (Residents #1, #2, and #3) of 7 reviewed for infection control.The facility failed to place an Enhanced Barrier Precautions sign outside of Residents #1, #2, and #3's door on 3.24.26.This failure could place residents at risk for cross-contamination and the spread of infection.Record review of Resident #1's face sheet, dated 3.26.26, revealed a [AGE] year-old female, admitted 2.4.25, with a diagnosis of end stage renal disease, type 2 diabetes, and hypertension.Record review of Resident #1's Comprehensive MDS, dated 2.26.26, revealed a BIMS score of 5, indicating severe cognitive deficiency.Record review of Resident #2's face sheet, dated 3.26.26, revealed a [AGE] year-old male, admitted 10.20.21, with a diagnosis of Gangrene, hypertension, and dementia.Record review of Resident #2's Comprehensive MDS, dated 2.16.26, noted a BIMS score of 1, indicating severe cognitive deficiency.Record review of Resident #3's face sheet, dated 3.26.26, revealed a [AGE] year-old male, admitted 9.19.23, with a diagnosis of end stage renal disease, type 2 diabetes, and hypertension.Record review of Resident #3's Comprehensive MDS, dated 2.26.26, revealed a BIMS score of 1, indicating severe cognitive deficiency.During an observation and record review on 2.24.26 at 10:45 a.m., Residents #1 and #2 had no sign on the door or inside the room but a PPE bag hung inside of the room. Residents #2 and #3 were documented on EBP round tool provided by facility to be on EBP for wounds. Resident #3 did not have a PPE or signage on or inside the room. Resident #1 was documented on EBP round tool provided by facility indicated to be on EBP for dialysis.During an interview and observation on 3/25/2026 at 10:17 a.m., RN A, after completing wound care on Resident #2 she stated Resident #2 should have been on enhanced barrier precautions. RN A stated she would let upper management know that Resident #2 needed an EBP sign in his room. RN A stated the risk of not utilizing EBP precautions was the spread of infection. RN A stated she received training on EBP and anyone with an indwelling device, chronic wounds, or multi drug resistant organism was supposed to have EBP precautions. During an interview on 3.26.26 at 3:50 p.m., DON stated the EBP signs made staff aware of the precautions and PPE was needed to care for the residents. She stated all staff were trained and were aware of which residents required PPE. She stated there was no policy for postings, but the facility followed regulations. She stated there was no potential risk to residents if the EBP postings were not located outside residents' rooms.Record review of Facility policy titled, Infection Control-Enhanced Barrier Precautions, dated 4.1.24.POLICYEnhanced Barrier Precautions (EBP) are CDC guidance to reduce the transmission ofmulti-drug-resistant organisms (MDRO) in health care settings, including nursing homes.EBP require team members to wear a gown and gloves while performing high contactcare activities with residents who are infected or colonized with a targeted MDRO, orwho have open wounds or indwelling medical devices.PROCEDURE1. Determine residents MDRO status on admission to community. If residents are colonizedwith a targeted MDRO, Enhanced barrier precautions will be implemented.e CDC targeted MDRO's, Pan-resistant organisms, Carbapenemase-producing carbapenem-resistant Enterobacterales, Carbapenemase-producing carbapenem-resistant Pseudomonas spp., Carbapenemase-producing carbapenem-resistant Acinetobacter, baumannii, and Candida auris. 2. Determine if a resident has any wounds. Wounds generally include chronic wounds, notshorter-lasting wounds, such as skin breaks or skin tears covered with a band-aid orsimilar dressing. Examples of chronic wounds include, but are not limited to, pressureulcers, diabetic foot ulcers, unhealed surgical wounds, and venous statis ulcers.Determine if any of the following indwelling medical devices are in use: urinary catheter,g-tube, tracheostomy, central lines (peripheral IVs are not included in this category).EBP will be implemented if any of the above wounds or invasive medical devices arepresent. 3. Place signage on resident's closet door, maintain PPE in residents' room and assure all team members are aware of resident status and need for EBP during high contact care. 4. High contact resident care activities: Dressing, Bathing/Showering, Transferring, providing hygiene, changing linens, changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. Wound care: any skin opening requires dressing.

Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse or neglect, for 1 of 8 residents (Residents #46) and 5 of 5 residents in the surveyor's confidential resident group meeting reviewed for abuse and neglect. The facility failed to ensure staff did not talk ugly to residents in the resident council meeting or make residents feel bullied (Resident #46). The facility failed to ensure staff did not talk ugly to residents, did not [NAME] the resident when the staff thought resident made a complaint against the the staff, or played favorites with the residents This failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse. Findings included: Review of Resident #46's Admission Record, dated 11/12/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including depression and diabetes mellitus. Review of Resident #46's Quarterly MDS Assessment, dated 10/4/24 revealed: Resident #46 had a mental status score of 10 of 15. (Indicating moderate cognitive impairment) Review of Resident #46's care plan showed no history of making false allegations. Review of Resident #46's Electronic Record showed the facility completed a Customer Satisfaction Survey on 11/8/24. Resident #46 reported: Please rate your meal and or dining experience: dissatisfied: If dissatisfied with meals/dining, please let us know how we can improve: staffing bulling residents. Review of the 11/5/24 Resident Council Meeting Minutes dated, 11/5/24 revealed Resident #46 attended and the residents complainted there were issues with some staff members, still have having issues with two particular [NAME] CNA B is still an issues she picks and chooses who to shower, hears a lot of verbal abuse to depenendent residents anstate she's very unprofessional Interview on 11/11/24 at 2:53 p.m. the AD informed the surveyor that the residents had made some complaints about verbal abuse including Resident #46. The AD stated she reported it to the Administrator. The AD stated she did not feel the residents were blowing allegations out of proportion and were afraid to say something. During the confidential resident council meeting on 11/12/24 unprompted, two residents complained about staff playing favorites, being ugly to residents, making ugly faces at residents, and were rude to residents. One resident reported being shunned because the staff thought the resident complained and this made the resident feel bad. The resident said they did not report it because if they did the shunning/silent treatment would get worse. Residents reported staff talked down to them. One resident stated the facility took down the Ombudsman's card because they did not want the resident to have it. No resident knew where the abuse hotline number was posted and wanted to know where it was. Residents resported an aide took things away from a resident in the dining room intentionally making her scream, the residents reported they would give the resident a lollipop so she would quit screaming. Interview on 11/12/24 at 3:54 p.m. the SSD reported that residents reported being uncomfortable with CNA B since SSD started 1/31/24. The SSD stated the residents were uncomfortable because CNA B talked ugly and picked favorites and if she (CNA B) did not want to do something, she would not. The SSD stated families were afraid of retaliation. The SSD reported she had seen staff talk to residents ugly, and the cognitively impaired residents got talked to uglier. The SSD stated the definition of emotional abuse was yelling, cussing around them, belittling the residents. The SSD stated talking ugly to the resident was a way of belittling them, so yes, it would be a form of emotional abuse. The SSD stated she reported the aide's behavior to the previous DON probably twice and to the currently DON twice plus the family complaint on 11/6/24 (Resident #212). Interview on 11/12/24 at 4:48 p.m. the Resident Care Ambassador (RCA) stated she had been at the facility for three months. She stated she did surveys with the staff and families about staff treatment and satisfaction. The RCA reported she had received complaints about CNA B being mean and most of her staff complaints were about CNA B. The RCA stated she was aware of a situation when there was an (unidentified) resident buzzing (using the call light) for an hour and CNA B was the aide on the hall. The RCA stated CNA B told her (the RCA) that she knew the resident had activated the call light for an hour. The RCA stated she reported it to the administrator. The RCA stated aides talked ugly to residents and told residents that they were nasty because they lived in the facility. Interview on 11/12/24 at 5:17 p.m., the Administrator stated the October Resident Council minutes just had complaints about missing clothing. The Administrator stated apparently the CNA B situation had been a topic of disciplinary actions way before he got to the facility and had been going on for a year or more. The Administrator stated CNA B was currently suspended and they were going to terminate her because it was a never-ending cycle. He stated topics that kept coming up was her not cleaning up urine, there was a similar allegation that occurred during lunch while a family was there. The Administrator stated this was probably her normal behavior. The Administrator stated intentionally not providing care to resident could be interpreted as a form of neglect. The Administrator stated he received two or three formal complaints about CNA B but he did not have enough fingers to report the unofficial complaints he received from staff. The Administrator stated he received allegations she left a resident soiled and went to lunch. The Administrator stated the staff were taught not providing care was neglect. The Administrator stated not changing a resident intentionally was neglect. The Administrator stated he wasn't privy to documents because the staff were afraid they would be written up. Surveyor pointed out he had access to the Resident Council Minutes and the complaint book. Interview on 11/13/24 at 9:47 a.m. the ADON stated CNA B previously worked at the facility but the previous Administrator fired CNA B. The ADON did not know what the situation was - allegedly it was because CNA B was mean. Interview on 11/13/24 at 10:36 p.m., the DON stated the care complaints started in the last 2 weeks and it was because of some outside family dynamics. The DON stated the big, big complaint about CNA B was the way she talked to staff was a little aggressive and she may be a little aggressive to get residents to shower. The DON stated if she was a dependent resident, she might feel like CNA B was mean to her or that CNA B did not like them or stuff like that. The DON stated if anyone was afraid, no one had told her. The DON stated if a resident reported feeling bullied was an allegation was a hard question to answer. The DON said she guessed it would depend on how the resident perceived it. The DON said to investigate an allegation of bullying she would talk to staff and other residents until she found out what the cause was. The DON stated she was not aware a resident said that they felt bullied. The DON stated the only other complaint she received about CNA B was when CNA B drew blood on Resident #2. The DON said CNA B said the nurses were showing her. The DON said CNA B was not in a formal phlebotomy program or on a formal training course with the facility to draw blood. The DON stated if the resident did not give consent, it would be mistreatment (twice) and then louder said she did not know if the residents gave consent for the lab draw or not. The DON stated she did not know why residents did not feel safe reporting concerns to her. Interview on 11/14/24 at 10:08 a.m. CNA F stated CNA B liked to make funny jokes but was sloppy with the residents. CNA F stated she would believe a resident if a resident told her CNA B was ugly to the resident or played favorites. CNA F said CNA B liked to take things away from one of the cognitively impaired residents to make her scream in the dining room. CNA F said there was no point in reporting it because the ADON and DON had seen her do it. CNA F said the ADON or DON told CNA B to stop, and it did for a little while but then started again. Interview on 11/14/24 at 1:46 p.m. the Administrator stated the families did not report feeling unsafe for their loved ones in the facility and he did not know why surveyor's findings were so different. The Administrator stated when he became aware of the complaint with Resident #212 CNA B was suspended. The Administrator said when he found out CNA B took labs from the residents he was appalled at the situation and found the behavior was highly unsatisfactory. The Administrator said the labs were done with the consent of the residents. Review of the Resident Council Minutes dated 10/2/24 revealed 5 residents reported two particular CNAs making faces and making it uncomfortable asking for things. Written above it were CNA B and CNA H. Review of the Resident Council Minutes dated 11/5/24 revealed five different residents from the 10/2/24 Resident Council reported still having issues with two particular aides - CNA B is still an issue she picks and choses who to shower, hears a lot of verbal abuse to resident especially Resident #31 and state she's very unprofessional, CNA H gives a lot of attitude as well. Review of the complaint book revealed: 8/8/24, the administrator took a complaint that CNA H was rude to a resident while the resident was in the shower. The Administrator documented no signs or evidence of abuse were discovered. Review of the Resident Concern Log revealed: - 11/6/24 Resident's family voiced concern at loved one's care with staff. Resolution was DON re-educated all staff in-services sent out for abuse and neglect. All named staff have been properly reprimanded. - 8/20/24 Resident stated to our EDO (Administrator) verbal abuse from CNA Resolution: DON, ADON, and EDO suggested the specific CNA is not allowed in room alone. (Complaint not provided) - 4/2024 - 7/2024 complaint log missing. - 3/20/24 Resident's son came in with a complaint his mother stated being shoved back into bed. Resolution: Due to resident's foggy memory we spoke with all CNA Staff and educated them on Abuse and encouraged them to follow POA of resident. Review of CNA B's employee file did not have her previous employment or any of her previous verbal written counseling. Review of the facility's in-services included: 8/14/24 Customer Care 10/24/24 - Abuse and Neglect Undated - Workplace Behavior - four types of inappropriate behavior which included sexual relations, bullying, undiversified environment, and inappropriate behavior such as raising voices, talking over people, interrupting others making unreasonable demands. 10/29/24 - Abuse/Neglect/Exploitation - long term care provider letter 11/6/24 - all staff will perform their duties within their scope of practice. Nurses will make rounds every 2 hours to ensure CNAs are providing proper care for residents. Nurses will do more frequent rounds on residents on 24-hour report. Record review of the facility's Policy and Procedure on Abuse, revised 1/1/23, revealed: The purpose of this policy is to ensure that each resident has the right to free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property. The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policies and procedures and will follow the guidelines in the written policy and procedure. Abuse is the willful inflection of injury or negligent, unreasonable confinement, intimidation, or punishment with resulting physical or emotional pain to a resident. Residents will not be subjected to abuse by anyone, including but not limited to community staff. Procedure The administrator and/or designee are responsible for maintain ALL facility policies that prohibit abuse, neglect. - Train all employees. - Identification of possible problems that need investigation. - Protecting residents during investigation. Protection. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm.

Based on observations, interview, and record review, the failed to implement their written abuse prevention policy and investigate allegations for 2 of 11 Residents (Residents #23 and #46) of eight residents reviewed for resident abuse and 5 of 5 residents in the confidential group interview. 1. The facility failed to ensure the staff did not retaliate against family members of Resident #23 for allegedly making a report of abuse or neglect against a staff member . As a result, the family member was afraid to visit Resident #23. 2. The facility failed to ensure Resident #46 did not feel bullied by staff 3. The facility failed to have mechanism in place to ensure families and residents felt safe to report allegations of abuse, neglect, or misappropriation. 4. The facility failed to have the number for the HHS Hotline Posted. These failures places residents at risk of abuse along with allegations of abuse identified and investigated thoroughly. Findings included: Record review of the facility's Policy and Procedure on Abuse, revised 1/1/23, revealed The purpose of this policy is to ensure that each resident has the right to free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property. The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policies and procedures and will follow the guidelines in the written policy and procedure. Abuse is the willful inflection of injury or negligent, unreasonable confinement, intimidation, or punishment with resulting physical or emotional pain to a resident. Residents will not be subjected to abuse by anyone, including but not limited to community staff. Procedure The administrator and/or designee are responsible to maintain ALL facility policies that prohibit abuse, neglect. - Train all employees. - Identification of possible problems that need investigation. - Investigating allegations - Reporting incidents, investigations, and facility response to results of investigation within mandated time frames. - Protecting residents during investigation - Posting of HHS abuse hotline number Reporting the law requires the abuse coordinator/designee, or employee of the facility who believe that physical or mental health of welfare of a resident has been or may be adversely affected by abuse, neglect or exploitation caused by another person to report the abuse, neglect or exploitation. Upon notification of an allegation of physical or mental abuse, neglect or involuntary seclusion, the facility will conduct interviews that include documented statement summaries from the alleged perpetrator, the alleged victim, family members, visitors who may have made observations, roommates, and any staff who worked prior to and during the time of the incident. All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours of alleged violation. If the allegation does not involve abuse and the event does not result in serious bodily injury the allegation should be reported within 24 hours. Protection. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm. Upon notification of allegation, the Abuse Coordinator or designee will - Identify the perpetrator that is identified by eyewitnesses or during investigation and remove the perpetrator from further contact with the resident pending outcome of the investigation. Resident #23 Review of Resident #23's Admission Record dated 11/13/24 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis including dementia. Review of Resident #23's Quarterly MDS assessment dated [DATE], revealed: Resident #23 has a BIMS of 0 of 15 (indicating severe cognitive impairment) and resided on the secured unit. Interview on 11/11/24 at 4:54 PM Resident #23's family member stated the staff were not talking to the resident or the resident's family because CNA B was suspended a couple of weeks ago. Resident #23's family member stated Resident #23's oldest family member was not comfortable coming to the facility because CNA G (CNA B's sister) got in her (the oldest' s family member's) face and yelled at the oldest family member. Resident #23's family stated they did not why CNA B was suspended. Resident #23's family stated they did not report CNA G because they were afraid Resident #23's care would suffer. Resident #46 Review of Resident #46's Admission Record, dated 11/12/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including depression and diabetes mellitus. Review of Resident #46's Quarterly MDS Assessment, dated 10/4/24 revealed: Resident #46 had a mental status score of 10 of 15. (Indicating moderate cognitive impairment) Review of Resident #46's care plan showed no history of making false allegations. Review of Resident #46's Electronic Record showed the facility completed a Customer Satisfaction Survey on 11/8/24. Resident #46 reported: Please rate your meal and or dining experience: dissatisfied: If dissatisfied with meals/dining, please let us know how we can improve: staffing bulling residents. Review of the Resident Council Meeting Minutes dated 11/5/24 revealed Resident #46 attended. Resident #46 and 4 other residents reported old business: issues with some staff members. Clinical Services Department: Still having issues with aides: CNA B ise still and issue she picks and chooses who to shoawer, hears a lot of verbal abuse to resident especially dependent resident states she's very unprofessional. Interview on 11/11/24 at 2:53 p.m. the AD warned surveyor that the residents had made some complaints about verbal abuse, including Resident #46 The AD stated she reported it to the Administrator. The AD stated staff would report allegations and nothing would get done. The AD stated many allegations were brushed under the rug and if the staff said something they would get resentment. The AD stated she did not feel the residents were blowing allegations out of proportion and were afraid to say something. During the confidential resident council meeting on 11/12/24 unprompted two residents complained about staff playing favorites, being ugly to residents, making ugly faces at residents, and were rude to residents. One resident reported being shunned because the staff thought the resident complained and this made the resident feel bad. The resident said they did not report it because if they did the shunning/silent treatment would get worse. Residents reported staff talked down to them. One resident stated the facility took down the Ombudsman's card because they did not want the resident to have it. No resident knew where the abuse hotline number was posted and wanted to know where it was. The residents reported an aide would take things away from a resident in the dining room just to make her scream, the residents reported they would give the screaming resident a lollipop just to make her quit screaming. Observation and interview on 11/12/24 at 2:21 p.m. revealed the complaint hot line was not posted. At that time the ADON and DON confirmed it was not posted anywhere. Interview on 11/12/24 at 3:54 p.m. the SSD reported that residents reported being uncomfortable with CNA B since SSD started 1/31/24. The SSD stated the residents were uncomfortable because CNA B talked ugly and picked favorites and if she (CNA B) did not want to do something she would not. The SSD stated she reported it to the previous DON, and she was not sure how the previous DON handled it. The SSD said she reported it to the current DON who dealt with it by in-servicing all staff. The SSD stated families were afraid of retaliation. The SSD stated she got in trouble for reporting the allegation of neglect. The SSD said she got dirty looks from staff and the staff would not respond to requests to change the residents because she wasn't clinical. The SSD stated she did not know she could report abuse anonymously. She stated, they're not stupid, they're going to retaliate. The SSD reported she had seen staff talk to residents ugly, and the cognitively impaired residents got talked to uglier. The SSD stated the definition of emotional abuse was yelling, cussing around them, belittling the residents. The SSD stated talking ugly to the resident was a way of belittling them, so yes, it would be a form of emotional abuse. The SSD stated she reported the aide's behavior to the previous DON probably twice and to the currently DON twice plus the family complaint on 11/6/24. Interview on 11/12/24 15 4:07 p.m. the AD stated she was unaware she could report abuse to the State Agency without the Administration's involvement and/or anonymously. The AD stated every time she reported something, the Administrator stated he would handle it and the Regional Management could come and belittle or retaliate against her for reporting. Interview on 11/12/24 at 4:48 p.m. the Resident Care Ambassador (RCA) stated she had been at the facility for three months. She stated she did surveys with the staff and families about staff treatment and satisfaction. The RCA reported she had received complaints about CNA B being mean and most of her staff complaints were about CNA B. The RCA was told to keep her mouth shut or everyone would be against her. The RCA stated she brought up the results of the surveys in morning meeting to the Administrator, but nothing was done so she emailed the Director of Customer Relations (Corporate Position). Then the Regional Nurse became aware and a lot of aides became aware. The RCA stated there was an (unidentified) resident buzzing (using the call light) for an hour and CNA B was the aide on the hall. The RCA stated CNA B told her (the RCA) that she knew the resident had activated the call light for an hour. The RCA stated she kept reporting concerns and the facility kept sweeping it under the rug and nothing ever got done. The RCA stated aides talked ugly to resident and told residents that they were nasty because they lived in the facility. Interview on 11/12/24 at 5:17 p.m. the Administrator stated the October Resident Council minutes just had complaints about missing clothing. The Administrator stated apparently the CNA B situation had been a topic of disciplinary actions way before he got here and had been going on for a year or more. The Administrator stated CNA B was currently suspended and they were going to terminate her because it was a never-ending cycle. He stated topics that kept coming up was her not cleaning up urine, there was a similar allegation that occurred during lunch while a family was there. The Administrator stated this was probably her normal behavior. The Administrator stated intentionally not providing care to resident could be interpreted as a form of neglect. The Administrator stated he did an investigation. The Administrator stated he did not report the allegation to the State Office because after discussing with his superiors it was determined that it wasn't . The Administrator stated he received two or three formal complaints about CNA B but he did not have enough fingers to report the unofficial complaints he received from staff. The Administrator stated he received allegations she left a resident soiled and went to lunch. He stated he investigated that incident, and CNA B alleged she told the charge nurse. The Administrator stated he wrote CNA B and the nurse up. The Administrator stated the staff were taught not providing care was neglect. The Administrator stated not changing a resident intentionally was neglect. The Administrator stated he was not made aware of these allegations because the staff hid it from him and he had to uncover it. The Administrator stated he wasn't privy to documents because the staff were afraid they would be written up. Surveyor pointed out he had access to the Resident Council Minutes and the complaint book. Interview on 11/13/24 at 9:47 a.m. the ADON stated the Corporate RN stated she had to do an investigation because there was a complaint. The ADON stated CNA B previously worked here but the previous Administrator fired CNA B, but the ADON did not know what the situation was - allegedly it was because CNA B was mean. Interview on 11/13/24 at 10:36 p.m. the DON stated the care complaints started in the last 2 weeks and it was because of some outside family dynamics. The DON stated the big, big complaint about CNA B was the way she talked to staff was a little aggressive and she may be a little aggressive to get residents to shower The DON stated if she was a dependent resident, she might feel like CNA B was mean to her or that CNA B did not like them or stuff like that. The DON stated if anyone was afraid no one had told her. The DON stated if a resident reported feeling bullied was an allegation was a hard question to answer. The DON said she guessed it would depend on how the resident perceived it. The DON said to investigate an allegation of bullying she would talk to staff and other residents until she found out what the cause was. The DON stated she was not aware a resident said that they felt bullied. The DON stated she did not know why residents did not feel safe reporting concerns to her. The DON said staff training including SNF Clinic (electronic training) and verbal in-services. The DON stated they taught staff treatment of residents, resident rights, the proper way to take care of residents and how to talk to residents. The DON added the facility taught the staff to treat the residents like people. The DON stated the facility taught the staff the reporting chain of command was the Administrator and if he was not available to contact her (the DON) or the ADON. The DON added if that was not cleared up to report to the Regional RN. The DON stated they did teach staff to report to state but agreed if the number was not posted they could not. The DON stated CNA B was fired when she was a floor nurse, and the previous Administrator brought her back. Interview on 11/14/24 at 10:08 a.m. CNA F stated CNA B liked to make funny jokes but was sloppy with the residents. CNA F stated she would believe a resident if a resident told her CNA B was ugly to the resident or played favorites. CNA F said CNA B liked to take things away from one of the cognitively impaired residents to make her scream in the dining room. CNA F said there was no point in reporting it because the ADON and DON had seen her do it. CNA F said the ADON or DON told CNA B to stop and it did for a little while but then started again. Interview on 11/14/24 at 1:46 p.m. the Administrator stated the families did not report feeling unsafe for their loved ones in the facility and he did not know why surveyor's findings were so different. The Administrator stated when he became aware of the complaint with Resident #212 CNA B was suspended. He stated he did not report the incident because he knew what happened and the family was happy with the outcome of the facility's actions. The Administrator stated he did not know the family used the word neglect with the SSD. The Administrator stated it crossed his mind to notify the State Agency, but he did not because the facility knew what happened. The Administrator said when he found out CNA B took labs from the residents he was appalled at the situation and found the behavior was highly unsatisfactory. The Administrator said the labs were done with the consent of the residents. Interview on 11/14/24 at 2:23 p.m. the Regional RN Consultant stated any willful action should be reported within two hours. The Regional RN Consultant stated she was not aware of any reports made to the State Agency. The Regional RN Consultant said if a family alleged the staff were not emptying a catheter it was neglect and it was a reportable incident and the possible impact to the resident was infection. The Regional RN Consultant stated a staff member getting into a family member's face was abuse. Review of the Resident Council Minutes dated 10/2/24 revealed 5 residents reported two particular CNAs making faces and making it uncomfortable asking for things. Written above it were CNA B and CNA H. Review of the Resident Council Minutes dated 11/5/24 5 different resident residents from the 10/2/24 Resident Council reported still having issues with two particular aides - CNA B is still an issue she picks and choses who to shower, hears a lot of verbal abuse to resident especially Resident #31 and state she's very unprofessional, CNA H gives a lot of attitude as well. Review of the complaint book revealed: 8/8/24 the administrator took a complaint that CNA H was rude to a resident while the resident was in the shower. The Administrator documented no signs or evidence of abuse were discovered. Review of the Resident Concern Log revealed. 11/6/24 Resident's family voiced concern at loved one's care with staff. Resolution was DON re-educated all staff in-services sent out for abuse and neglect. All named staff have been properly reprimanded. 8/20/24 Resident stated to our EDO (Administrator) verbal abuse from CNA Resolution: DON, ADON, and EDO suggested the specific CNA is not allowed in room alone. (Complaint not provided) 4/2024 - 7/2024 complaint log missing. 3/20/24 Resident's son came in with a complaint his mother stated being shoved back into bed. Resolution: Due to resident's foggy memory we spoke with all CNA Staff and educated them on Abuse and encouraged them to follow POA of resident. Review of CNA B's employee file did not have her previous employment or any of her previous verbal written counseling. Review of the facility's in-services included: 8/14/24 Customer Care 10/24/24 - Abuse and Neglect Undated - Workplace Behavior - four types of inappropriate behavior which included sexual relations, bullying, undiversified environment, and inappropriate behavior such as raising voices, talking over people, interrupting others making unreasonable demands. 10/29/24 - Abuse/Neglect/Exploitation - long term care provider letter 11/6/24 - all staff will perform their duties within their scope of practice. Nurses will make rounds every 2 hours to ensure CNAs are providing proper care for residents. Nurses will do more frequent rounds on residents on 24-hour report. Resident rights

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, in 4 rooms (Rooms #101, #102, #104 and #113) out of sixteen resident rooms on 100 hall reviewed for accident hazards, in that; The facility failed to ensure that the hot water temperatures in the sinks for 5 resident rooms did not exceed the maximum of 110 degrees Fahrenheit. This failure could place residents at risk for injuries related to hot water temperatures. The findings included: Record review of Resident #18's admission record dated 11/13/2024 indicated he was admitted to facility on 02/20/2014 with diagnoses of dementia and muscle weakness. He was [AGE] years of age. Record review of Resident #18's MDS dated [DATE] indicated in part: BIMS = 0 indicating resident was severely impaired. Record review of Resident #37's admission record dated 11/13/2024 indicated he was admitted to facility on 08/30/2024 with diagnoses of dementia and muscle weakness. He was [AGE] years of age. Record review of Resident #37's MDS dated [DATE] indicated in part: BIMS = 2 indicating resident was severely impaired. Record review of Resident #57's admission record dated 11/13/2024 indicated he was admitted to facility on 09/17/2024 with diagnoses of lack of coordination and muscle weakness. He was [AGE] years of age. Record review of Resident #57's MDS dated [DATE] indicated in part: BIMS = 9 indicating resident was moderately impaired. Record review of Resident #58's admission record dated 11/13/2024 indicated she was admitted to facility on 10/11/2024 with diagnoses of lack of coordination and muscle weakness. She was [AGE] years of age. Record review of Resident #58's MDS dated [DATE] indicated in part: BIMS = 8 indicating resident was moderately impaired. During an observation and interview on 11/11/2024 at 11:54 AM, the water temperature was taken with the surveyors thermometer and was found to be 125 degrees F in resident room [ROOM NUMBER]'s sink. The water took 22 seconds to reach that temperature. Resident #18 who resided in that room said he had washed his hands in the sink but had not noticed the water was too hot nor had he burned himself. There was a total of 2 residents in that room. During an observation and interview on 11/11/2024 at 12:04 PM, the water temperature was taken with the surveyors thermometer and was found to be 124 degrees F in resident room [ROOM NUMBER]'s sink. The water took 22 seconds to reach that temperature. Resident #37 who resided in room [ROOM NUMBER] said he had washed his hands in his rooms sink and had never burned his hands and did not think the water was too hot. There was a total of 2 residents in that room. During an observation and interview on 11/11/2024 at 12:18 PM, the water temperature was taken with the surveyors thermometer and was found to be 123 degrees F in resident room [ROOM NUMBER]'s sink. The water took 20 seconds to reach that temperature. Resident #57 who resided in room [ROOM NUMBER] alone, said the water was not too hot that he had noticed and hot not burned his hands while washing. During an observation and interview on 11/11/2024 at 12:20 PM, the water temperature was taken with the surveyors thermometer and was found to be 122 degrees F in resident room [ROOM NUMBER]'s sink. The water took 20 seconds to reach that temperature. Resident #58 who resided in room alone, said the water at her sink was fine and had not noticed it being too hot nor had she burned herself with it. Record review of the facility's hot water temperature logs for October 2024 indicated in part: Day of the months from 1st thru the 28th indicated Temp 100 (Hall 100), Temp 200 (Hall 200), Temp 300 (Hall 300) and Temp 400 (Hall 400) were listed as temperatures ranging from 106 degrees F to 108 degrees F. None past 110 degrees F documented. During an interview on 11/11/2024 at 3:32 PM, the Administrator said that they currently did not have a maintenance person in the facility, and he was the one that monitored the water temperatures. The Administrator said that the previous maintenance person had left about a week ago and the regional maintenance person had currently been overseeing the facility. The Administrator said the previous maintenance person had conducted regular checks of the water temperature and would be providing a copy of the records. The Administrator said the water temperature was not to exceed 110 degrees Fahrenheit. The Administrator said if the water was higher than that, it could lead to residents getting burned. The Administrator was made aware of the water temperatures in hall 100. The Administrator said they had installed new water heaters and that could be the reason the temperatures were higher on hall 100. The Administrator said they had not had any issues with resident's getting burned with hot water. The Administrator said he was not aware of the water temperature being that high. During an interview on 11/12/2024 at 2:18 PM, the Administrator said that after the previous maintenance person had documented the water temperatures on 10/28/2024, they (water temperatures) had not been monitored anymore since the maintenance person had quit. The Administrator said that the facility had been monitored by the regional maintenance person since the maintenance person quit but the regional maintenance person had not been on site to check the water temperatures. The Administrator said the regional maintenance person would be there that day and he would adjust the temperature of the water heater. During an interview on 11/12/2024 at 4:24 PM, the Regional Maintenance person was at the facility and he said he was going to adjust the water temperature on the water heater to bring the temperature down to a safe level of about 100 degrees Fahrenheit. Record review of the facility's document titled Safety of water temperatures and dated 12/2009 indicated in part: Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Water heaters that service resident rooms, bathrooms, common areas and tub/shower areas shall be set to temperatures of no more than 110 degrees or the maximum allowable temperature per state regulation. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log.

Based on interview and record review , the facility failed to provide residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 of 2 (Resident #2 and Resident #5) residents reviewed for care, in that: The facility failed to ensure CNA B did not performed blood draws on Resident's #2 and #5 before becomingwithout being a certified phlebotomist and without the assistance of a nurse. This failure could affect residents by placing them at an increased and unnecessary risk of exposure to infections. Findings Included: Record review of Resident #2's admission record dated 11/13/2024 indicated he was admitted to facility on 10/18/2023 with diagnoses of reduced mobility and muscle weakness. He was [AGE] years of age. Record review of Resident #2's physician orders indicated in part: CBC,CMP,TSH, Lipid Panel, HgA1c Every 6 months for DX: DM, HTN, Hypothyroid, Afib. (November & May). (CBC - Complete Blood Count. CMP - Complete Metabolic Profile. TSH - Thyroid Stimulating Hormone. HgA1c - Hemoglobin check for sugar/glucose/diabetes. DX diagnosis. DM - Diabetes. HTN high blood pressure. Afib - Atrial Fibrillation - Heart disease.). Active 11/01/2023. Record review of Resident #2's care plan revised date 08/19/2024 indicated in part: Focus: Potential for complications, signs and symptoms (s/s) related to diagnosis of hypertension (high blood pressure). Resident receives anti-hypertensive and is at risk for side effects. Goals: Blood pressure will stay within their normal limits, will not have s/s of hyper/hypo tension throughout the review date. Interventions: Monitor labs as ordered. Report abnormalities to physician. Record review of Resident #2's MDS assessment dated [DATE] indicated in part: BIMS (Brief Interview Mental Status) = 10 indicating resident was moderately impaired. Record review of Resident #5's admission record dated 11/14/2024 indicated he was admitted to facility on 09/19/2023 with diagnoses of dementia, muscle wasting and atrophy. He was [AGE] years of age. Record review of Resident #5's physician orders indicated in part: Pre-Albumin every 3 months. (April, July, October, January) Active 04/05/2024. Record review of Resident #5's care plan revised date 06/25/2024 indicated in part: Focus: Potential for complications, Signs and symptoms (s/sx) related to diagnosis of hyperlipidemia Goals: Will remain free of s/sx or complications related to diagnosis of hyperlipidemia. Interventions: Monitor labs as ordered by MD (Medical Doctor) and notify promptly of abnormal values. Record review of Resident #5's MDS assessment dated [DATE] indicated in part: BIMS = 0 indicating resident was severely impaired. During an interview and an observation on 11/13/2024 at 03:10 PM, Resident #2 was in his bed resting awake and alert. Resident's left inner forearm was noted to have two areas that were bruised measuring approximately 2 inches by 2 inches each and at different stages of healing. Resident #2 said a staff member had come and drawn blood and filled 2 tubes of blood one from each bruises area. Resident #2 said he knew who the staff member was, but he could not remember her name. Resident #2 said it must have been the first time the staff member drew blood because she could not find a vein to draw it from. Resident #2 said the staff member was a CNA and that she worked at the facility. Surveyor asked if the staff's named sounded like CNA B's name and he said it could be, but he was not sure. Resident #2 said the blood drawn had occurred last Friday or Monday on the day shift. Resident #2 said the staff member had not told him that she was practicing blood drawing on him and that she just came in and told him she had to draw some blood. Resident #2 said he did find it odd that a CNA was drawing blood on him, but thought that maybe someone like the doctor had given her an order to do it. Resident #2 said he was not hurting or had suffered any injuries just that he had the bruising on his arm and that it would get better in a few weeks. Resident #2 said he did not blame the CNA for doing what she did because she might have been told to do it and she was just following orders. Resident #2 said beside the bruising the blood draw had gone fine and had no complaints about it. During an observation and interview on 11/14/24 at 03:10 PM, Resident #5 was in his room sitting up on his wheelchair awake and alert. Resident #5 was asked if he knew who CNA B was and he said he did know who she was. Resident #5 said that CNA B had drawn blood from him a few weeks ago in his room. Resident #5 again said he was sure the blood draw had happened in his room. Resident #5 said the blood draw went fine and had no complaints about it and the CNA had done a good job. During an interview on 11/13/2024 at 09:47 AM, the ADON stated Resident #2 was found with bruises on his arm., tThe DON did an investigation and found CNA B drew blood. The ADON stated she did not know if CNA B was qualified to do labs and did not know if nurses could delegate drawing labs. The ADON stated the DON did that part of the evaluation. During an interview on 11/13/2024 at 10:36 AM, the DON stated she received one complaint about CNA B doing a blood draw on Resident #2. The DON stated to delegate a blood draw, it would have to be a formal, written training program by an RN. The DON stated she did no such training because she would not be comfortable with an aide drawing blood under her license. The DON said it was not part of a CNA's job description to do lab draws. The DON said without the proper training the CNA was working outside the scope of her certification. The DON said as far as she was aware, it happened just that one time and she did not know of any issues before that. During an interview and an observation on 11/13/2024 at 03:10 PM Resident #2 was in his bed resting awake and alert. Resident's left inner forearm was noted to have two areas that were bruised measuring approximately 2 inches by 2 inches each and at different stages of healing. Resident #2 said a staff member had come and drawn blood and filled 2 tubes of blood one from each bruises area. Resident #2 said he knew who the staff member was, but he could not remember her name. Resident #2 said it must have been the first time the staff member drew blood because she could not find a vein to draw it from. Resident #2 said the staff member was a CNA and that she worked at the facility. Surveyor asked if the staff's named sounded like CNA B's name and he said it could be, but he was not sure. Resident #2 said the blood drawn had occurred last Friday or Monday on the day shift. Resident #2 said the staff member had not told him that she was practicing blood drawing on him and that she just came in and told him she had to draw some blood. Resident #2 said he did find it odd that a CNA was drawing blood on him but thought that maybe some like the doctor had given her an order to do it. Resident #2 said he was not hurting or had suffered any injuries just that he had the bruising on his arm and that it would get better in a few weeks. Resident #2 said he did not blame the CNA for doing what she did because she might have been told to do it and she was just following orders. Resident #2 said beside the bruising the blood draw had gone fine and had no complaints about it. During an interview on 11/13/24 at 10:08 AM, CNA F stated she saw CNA B draw blood one resident one time. CNA F stated she saw CNA B draw blood from Resident #2 one time and he did not look like he was in any pain or distress. CNA F stated she walked into Resident #2's room because his light was on and she (CNA B) was tapping on Resident #2's arm like she was looking for a vein and then poked Resident #2's arm with a needle. CNA F said she knew CNA B was in classes to be a phlebotomist at one time. CNA F said she asked CNA B what she was doing and CNA B just laughed. CNA F said she asked Resident #2 if he needed anything, and Resident #2 said no. CNA F said she did not report what she had seen becasue she believed CNA B was allowed to do blood draws. During an interview on 11/14/24 at 10:57 AM, LVN C said on a Sunday CNA B had told her that the DON had given her the names of residents that needed blood draws. LVN C said she was outside monitoring the resident's while they smoked. LVN C said CNA B told her to hold on as she first needed to call the ADON and ask her what labs had already been done. LVN C said she was not aware if CNA B was allowed to do lab work and that she had not asked her if she was allowed as well. LVN C said she recalled CNA B holding a Baggy which contained the tubes that needed to be filled with blood and orders for the blood draw. LVN C said the baggies were left at the nurse station and the bags contained the face sheet and lab orders and the tubes that need to be filled. LVN C said the last she heard CNA B was in phlebotomy class. During an interview on 11/14/2024 at 11:26 AM, the DON said she had never ordered CNA B to do blood draws., She said she was aware of CNA B wanting to be a phlebotomist, but as far as she knew, the CNA was not in the class. The DON said the lab cart was located in the middle area of the nurse's station and the lab book was there as well. The DON said that CNA B could have gotten the orders from there. During a telephone interview on 11/14/2024 at 11:46 AM, CNA B said that she was currently suspended from work and as far as she knew she was still employed there. CNA B said that she was supposed to take the phlebotomy class but had not because the Administrator gave her the run around about payment for the class. sSo she ended up dropping out of the class and not taking it. CNA B said that she had observed the nurses doing blood draws because she wanted to learn. CNA B said that she had drawn blood on two residents (Resident #5 and Resident #2) and that she was not a certified phlebotomist and she apologized for doing that and that she should have not done that. CNA B said the needles to conduct the blood draws and the lab sheets were located at the nurses station and that was where she got the orders and needles from. CNA B said that LVN C and LVN D were present when she had drawn Resident #5's blood and that LVN C had let her because she was unable to draw the resident's blood or at least not enough. CNA B said she had entered Resident #2's room and told him that she was there to draw some blood. CNA B said that the DON had not told her to do the blood draws and that she had taken it upon herself to just do the blood draw and she should have not done that. During an interview on 11/14/2024 at 12:37 PM, LVN C said she had drawn some blood on Resident #5 about 2 weeks ago on a Sunday and was only able to obtain a small amount of blood in the tube. LVN C said later CNA B called Resident #5 to go to the nurses station for halls 2 and 3 where LVN D was working at. LVN C said she went around to see what was going on and saw that CNA B had already started the blood draw on Resident #5. LVN C said she recalled seeing LVN D by the nurses station but did not know if LVN D was aware of what happened. During a telephone interview on 11/14/2024 at 01:22 PM, LVN D said she had never observed CNA B perform blood draws in the facility. LVN D said she had never trained CNA B to perform blood draws on the residents. LVN D said she recalled seeing CNA B at the nurse station about 2 weeks ago on a Sunday and had Resident #5 with her. LVN D said she had not noticed CNA B drawing blood from Resident #5. LVN D said she had asked CNA B why she was looking at Resident #5's veins and the CNA told her that she had been checked off on performing blood draws. LVN D said she did not recall who CNA B said had checked her off for conducting blood draws. LVN D said she had never given CNA B permission to conduct blood draws on the residents. During an observation and interview on 11/14/24 at 03:10 PM Resident #5 was in his room sitting up on his wheelchair awake and alert. Resident #5 was asked if he knew who CNA B was and he said he did know who she was. Resident #5 said that CNA B had drawn blood from him a few weeks ago in his room. Resident #5 again said he was sure the blood draw had happened in his room. Resident #5 said the blood draw went fine and had no complaints about it and the CNA had done a good job. During a telephone interview on 11/14/24 at 04:48 PM, the physician was made aware of the CNA drawing blood for Resident's #2 and #5. The physician said he had been at the facility and had seen both resident's as they were his patients. The physician said he had not noticed any bad outcome due to the CNA drawing the blood. The physician said he was aware of the bruising on Resident #2's arm but it was not a long-term consequence. The physician said neither of the 2 residents had suffered any consequences or complications that he noticed. The physician said the facility had to be more aware about who was drawing the blood. Record review of the facility's document titled Job descriptions dated 11/2020 indicated in part: Job title: Certified Nurse Aide. Reports to: Director of nursing. Position summary: Responsible for assisting residents with activities of daily living to promote resident independence and dignity. Must have current Nurse Aide Certification in the State of Texas. Essential functions: To assure resident safety. Bathe, shower, shampoo, shave, com, hair, dress appropriately, nail care of any residents assigned. Lift, move and transfer residents as required. Answer call lights in a timely manner. Assist or feed residents. Keep resident clean and dry, toileting or providing incontinent care. (Note: There were no indication where CNA was allowed to conduct blood draws).

Based on interviews, and record reviews, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 (Residents #212) reviewed for indwelling catheters. The facility failed to ensure Resident #212 indwelling catheter was emptied when full to prevent it from exploding. The failure could place residents at risk for discomfort, urethral trauma and urinary tract infections. Findings included: Review of Resident #212's Admission Record, dated 11/12/24 revealed she was an [AGE] year-old female admitted to the facility 11/8/24 with diagnosis including pneumonia, pressure ulcers. Review of Resident #212's complaint dated 11/6/24 revealed: The family stated they were upset with Resident #212 care lately . the family . noticed that Resident #212's foley bag was filled to the top and had not been emptied causing the bag to rip and leak out everywhere. The family called on the call light and CNA B came in and saw the bag spilling out. The Family stated CNA B said oh there's a hole let me tell the nurse and walked out. CNA B failed to clean it up the spilled urine on the floor. The family also documented it took a while for someone to get back in there to help clean it up. So the family ended up putting paper towels up to clean it up themself. The family stated they did make the DON aware and sent pictures, and also expressed her anger with the charge nurse. The family alleged via text, dated 11/6/24, to the SSD I know you're probably tired of hearing this but [Resident #212] pays to be taken care of not to be neglected like this like they leave there to Later in the exchange the family asked if the DON and ADON would know it was them who complained because they were sure it will get around and she was told CNA B was on the DON's good list. In an interview on 11/13/24 at 9:47 a.m., the ADON stated it would probably take approximately 24 hours for Resident #212's catheter bag to fill to bursting. Interview on 11/14/24 at 2:23 p.m. the Regional RN Consultant stated if a family alleged the staff were not emptying a catheter it was neglect and the possible impact to the resident was infection.

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 4 of 4 (Resident # 2, 7, 8, &9) rooms reviewed for environment. The facility window blinds in Resident #2, 7, 8, &9's rooms were inoperable and damaged. This failure could place residents at risk for diminished quality of life due to the lack of a well- kept environment. Findings included: Observation on 6/26/24 at 9:10 am revealed that in 4 rooms (Resident #2, 7, 8, 9's room) observed during initial rounds the white 1-inch vinyl blinds being used for window covering were damaged, had broken blades, missing blades, cords in knots, inoperable. Interview on 6/26/24 at 10:45am Resident #2, stated that the broken window blinds were already damaged when she arrived. Resident #2 stated it made the room look junky and cheap. Resident #2 stated she did not mention the damaged blinds to any staff but wished they would replace them. Interview on 6/26/24 at 1:30pm Resident #7, stated blinds were damaged when she admitted , and it makes the room look junky. Resident #7 stated that the facility has known about the blinds but has done nothing. Resident #7 stated staff are nice and respectful, food is good, and she likes the facility but wishes they would fix the blinds. Resident #7 stated she did not ask or tell anyone about the blinds because they can see they are broken themselves. Interview on 6/26/24 at 1:40pm Resident #8, stated the blinds were broken when she arrived at the facility, and they let too much light in. Resident #8 said she knows the facility knows about the blinds, and she wished they would repair them. She said she has not asked anyone to fix the blinds and thinks they should know to do this. Interview on 6/27/24 at 1:10pm Resident #9, stated the blinds have been broken since she has been here. Resident #9 stated she has told them she would like them to be replaced or fixed to keep out the light. Resident #9 stated she thinks she has told the nurse and maintenance man about the blinds. Interview on 6/27/24 at 10:05am CNA L stated she has noticed broken blinds in resident's rooms and has reported to charge nurse but did not write in the logbook. CNA L stated she has worked on night shift for most of her time at the facility and only started day shift. CNA L stated many of the blinds have been broken since she started 8 months ago. Interview on 6/27/24 at 10:35am LVN I stated when things need to be fixed or looked at you can tell the maintenance man or write it down in the Logbook at the nurse's station. LVN I stated she has noticed blinds being broken but stated residents have done this and they will continue to damage blinds even if replaced. LVN I stated she knew some residents would not break blinds, but have had broken blinds in their room before they arrived. LVN I stated yes the broken blinds need to be replaced. Record review of the Maintenance Logbook located at the nurse's station. Reviewed dates 6/26/24 back to 2/15/24. No request was made for broken window blinds in any resident rooms. Interview by phone on 6/27/24 at 2:45pm, Maintenance man stated any repairs are either written in the Maintenance Log or told to Maintenance man by staff. He said the maintenance log is checked throughout the day. Maintenance man stated he had trouble getting blinds ordered, and the company where the facility orders from did not have the size they needed in stock. Maintenance man stated the facility has a few new blinds in storage, but he has not been able to put them up at this time but will when he is back from vacation. Maintenance man stated he knows there are a lot of blinds in resident's rooms that need to be replaced. Interview on 6/27/24 at 3:05pm, Admin stated replacing the broken window blinds has been one of the things he has been working on. Admin stated they have some new blinds in storage but have not used them yet. Admin has noticed that there are a lot of window blinds in resident's rooms that are broken. Admin stated he understands it is important for the residents to live in a clean facility, have privacy, security, and have all repairs done in a timely manner. Record review of Maintenance Service Policy, no date reflected: 2. Functions of maintenance personnel include, but are not limited to: B. Maintaining the building in good repair and free from hazards.

Based on interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 2 of 20 residents (Resident # 38, Resident #61) reviewed for resident rights . The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #38 prior to administering Sertraline, an antidepressant used to treat depression. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #61 prior to administering Venlafaxine, an antidepressant used to treat depression. This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party. Findings include: Record review of Record review of Resident #38's face sheet revealed admitted [DATE] with diagnoses of chronic embolism (a blood clot that has formed a scar on vein and does not allow blood flow), Parkinson's disease (progressive disease of the nervous system), intellectual disabilities (affects the ability to acquire knowledge and skills needed for independent living), seizures (sudden burst of electrical activity in the brain), and psychosis (disorder causing delusions, hallucinations, agitation). She was [AGE] years of age. Record review of Resident #38's quarterly MDS, dated [DATE], indicated he had a BIMS score of 03, which indicated he was severely cognitively impaired. The MDS also indicated Resident #38 was receiving antidepression medications. Record review of Resident #38's care plan indicated, in part: Focus: resident is currently using antidepressant for depression. Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Intervention: Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness every shift. Record review of Resident #38's medication profile dated 07/09/23 indicated in part: Sertraline tablet 25 MG, give 1 tablet by mouth one time a day for depression. Record review of Resident #38's clinical records revealed no consent on file. Record review of Record review of Resident #61's face sheet revealed admitted [DATE] with diagnoses of major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), Type 2 Diabetes Mellitus (condition that effects the way body processes blood sugar). She was [AGE] years of age. Record review of Resident #61's admission MDS, dated [DATE], indicated she had a BIMS score of 10, which indicated she was minimally cognitively impaired. The MDS also indicated Resident #61 was diagnosed with major depressive disorder. Record review of Resident #61's care plan indicated, in part: Focus: Resident has impaired cognitive function or impaired thought processes related to BIMS of 10. Goal: The resident will be able to communicate basic needs daily through the review date. Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #61's medication profile dated 08/04/23 indicated in part: Venlafaxine capsule, give 150 mg by mouth once a day for depression. Seroquel Tablet, give 25 mg by mouth two times a day for mood disorder. Record review of Resident #61's clinical records revealed no consent on file. Interview on 10/05/2023 at 12:57pm, the ADON stated that the admitting nurses are responsible for obtaining consents for medications from residents or resident representatives on admission. If it is a new order, the nurse getting the order is responsible for obtaining consent. The ADON stated that the facility's system of ensuring that consents were obtained properly was not effective which lead to the failure. ADON stated that she was aware medication should not have been administered without obtaining consents first. Interview on 10/05/2023 at 2:00pm, the Administrator stated that nurses were responsible for obtaining consents on admission and upon receiving new orders. The Administrator stated that her expectations was that all nursing staff would review all residents during the daily morning meetings and discuss new orders to ensure proper consents were obtained. Per Administrator, the facility has no policy specific to the consenting process.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 of 2 medication carts reviewed for pharmacy services, in that: . The medication cart used for hall 100 had an insulin pen that had expired as indicated by the manufacturers recommendations. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. The findings were: During an interview and observation on 10/03/23 at 04:30 PM the hall one treatment cart was inspected with LVN A present. Inside the cart was one insulin pen with an open date of 08/27/2023 written on it. The insulin pen instructions indicated Use within 28 days after initial use. LVN A said the insulin pen should have been removed since it was expired and that she would remove it at this time. LVN A said as far as she knew it was every nurses job to remove any expired medications from the medication cart whenever they used it. LVN A said if a resident received and expired medication it could lead to a bad reaction or not the desired effect. During an interview on 10/05/23 11:45 AM the ADON said they would try to do weekly inspections of the medication carts and remove any expired medications. The ADON said there was no one specifically assigned to do that nor was it documented anywhere. The ADON said if a resident received an expired medication, then there was a possibility, they would not receive the desired effect. During an interview on 10/05/23 at 02:08 PM the Administrator was made aware of the expired insulin pen observed in the medication cart. The Administrator said nursing staff and the DON were responsible for monitoring the medication carts for expired medications and remove them. The Administrator said if a resident received and expired medication it might not be as effective. The Administrator said she believed the failure occurred because the staff failed to check the expiration date on the medications and removed them. Record review of policy titled Storage of Medications and dated August 2020 indicated in part: Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory. Certain medications or package types such as IV solutions multiple does injectable vials and blood sugar testing solutions and strips require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency.

Based on observation, interview, and record review, the facility failed to ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments for 1 of 1 medication storage compartments reviewed for labeling/storage of drugs and biologicals. The facility failed to ensure stored discontinued controlled medications and biologicals were separately locked and in a permanently affixed compartment kept in the DON's office. These failures could place the facility at risk of drug diversion and access to medications. Findings Include: During an observation on 10/04/23 at 09:18 AM the DON's office door was observed to be unlocked, open, unsupervised and no staff present. During an observation and interview on 10/04/23 at 10:44 AM the discontinued controlled medication storage was inspected with the DON present. The discontinued controlled medications were located in the DON's office on a free standing book shelf. The DON said she kept the controlled medications in a small safe that was stored in an unlocked cabinet. The cabinet nor the safe were permanently affixed to the wall or floor. The DON said she had just moved into this office like 2 months ago. The DON said the second lock was the office door and she kept it closed and locked when she was not in her office. The DON was made aware of the observation of the door open and the office unsupervised. The DON said she was not aware the door was left open and her office unattended and leaving the controlled medications behind one lock instead of two. The DON said they would get the safe secured immediately by adding 2 locks and have it affixed to the wall. The DON said if the controlled medications were not secured then someone could possibly just walk out with medications. Inside the safe were multiple blister containers and bottles of controlled medications. During an interview on 10/05/23 at 02:05 PM the Administrator was made aware of the observation mentioned above. The Administrator said it was the DON's and herself responsibility to make sure the controlled medications were kept behind 2 locks and permanently affixed. The Administrator said someone could walk away with the controlled medications if they were not secured. The Administrator said the failure probably occurred because the DON had just moved to the new office and the controlled medications had not been placed behind 2 locks and permanently affixed just yet. Record review of the facility policy titled Storage of Controlled Substances and indicated in part: Medications classified by the Drug Enforcement Administration (DEA) as controlled substances are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state and other applicable laws and regulations. Schedule II thru V medications and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other medications or per state regulations. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are retained in the facility in a securely locked area with restricted access until destroyed.

Based on interviews and record review, the facility failed to immediately consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status; a need to alter treatment significantly (a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for two (Resident #1 and #2) of three residents reviewed for Notification of Changes. The facility failed to notify the physician of Resident #1's wound care consultant's recommendation of a doppler study six (6 ) times on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] and a recommendation to refer to a vascular doctor/ podiatrist/ or orthopedic doctor five (5) times on [DATE], [DATE], [DATE], [DATE], and [DATE], resulting in a right below knee amputation on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE] at 2:55 p.m. While the IJ was removed on [DATE] at 12:25 p.m. the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. While not included in the immediate Jeopardy but still out of compliance at a scope of no actual harm: The facility failed to notify the physician of Resident #2's wound care consultant's recommendation of a vascular consult. This deficient practice placed residents at high risk of, or the likelihood of, serious injury, dismemberment, impairment, or death by not receiving treatment, developing complications, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: Review of Resident #1's Admission Record dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including malnutrition, uropathy (difficulty urinating due to a blocked urinary tract), cirrhosis of liver, and emphysema (damaged lungs). (The pressure ulcer to the heal was not listed) Review of Resident #1's Quarterly MDS Assessment, dated [DATE], revealed: He scored a 5 of 15 on his mental status exam. (Indicating severe cognitive impairment) Resident #1 had one stage III pressure ulcer that was present upon admission/entry and an other open lesion(s) on the foot. Review of Resident #1's Care Plan, initiated [DATE], revealed: Problem: The resident has an unstageable pressure injury to right heal related to disease process, history of ulcers and immobility. Updated on [DATE] revealed: wound now Stage III. The Goal was: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Identified approaches included: weekly treatment documentation to include measurement of each area of skin breakdown's width, length, type of tissue, and exudate initiated [DATE]. Review of Resident #1's admission note dated [DATE] revealed he was admitted to facility with an unstageable pressure ulcer to the right heel that was staged at the hospital. Resident #1's first documented assessment by the Wound Care Provider was [DATE] where the heel was staged as an unstageable approximately 3 cm length x 4.2 cm width x 0.1 cm depth with 100% necrotic tissue. Review of Resident #1's Wound Care Consultant's wound assessment, dated [DATE] , at 4:55 p.m., revealed the Wound Care Consultant #1 recommended Resident #1 see a vascular doctor. Review of Resident #1's Skin/Wound Note by the Treatment Nurse, dated [DATE] , at 4:55 p.m. documented: Resident #1 had no new orders at this time. (Nothing about the referral to a vascular doctor or notifying doctor of recommendation and a response) Review of Resident #1's Wound Care Consultant's wound assessment notes, dated [DATE] , at 5:19 p.m., revealed a recommendation for a Doppler Study and wound care orders. Review of Resident #1's Nurse Note by the Treatment Nurse dated [DATE] at 5:19 p.m., documented new order for Mupirocin 2% to be applied to right 4th toe. (Nothing about the referral to a vascular doctor or notifying doctor of recommendation and a response) Review of Resident #1's Wound Care Consultant assessment note dated [DATE] , at 9:25 a.m., documented recommendations to have a vascular consultant and a Doppler Study. Review of Resident #1's Skin/Wound Note by the treatment nurse dated [DATE] , at 9:25 a.m., revealed note received no new orders at this time. (Nothing about the referral to a vascular doctor or notifying doctor of recommendation and a response) Review of Resident #1's Wound Care Consultant note dated [DATE], at 5:33 p.m., revealed a recommendation for a Doppler Study. Review of Resident #1's Skin/Wound Note completed by the Treatment Nurse on [DATE] at 5:33 p.m., documented new orders to clean stage 3 to right heel with normal saline, pat dry with 4x4 gauze, apply anasept and collagen to wound bed and cover with supper absorptive dressing daily and as needed until healed. (Nothing about the recommendation for outside services). Review of Resident #1's Wound Consultant assessment note dated [DATE] revealed orders for: x-ray to right foot to rule out osteomyeliti s (bone infection), labs CBC, CMP, ESR, and CRP., a bone culture for pathology, refer a vascular surgeon to assess PAD/flow status, and once seen by vascular refer to podiatry or orthopedic for right 2nd toe. Review of Resident #1's Skin/Wound note completed by the Treatment Nurse, dated [DATE] at 5:10 p.m., revealed new wound care orders, to draw labs CBC, CMP, ESR and CPR complete a Bone pathology on bone, and an X-ray to right foot to rule out osteomyelitis. Review of Resident #1's Skin/wound note completed by the Treatment Nurse, dated [DATE], at 1:10 p.m. revealed a three-view x-ray to rule out osteomyelitis was completed. Review of Resident #1's Nurse note dated [DATE] at 1:48 p.m. revealed the facility received the lab results and they were forwarded to Resident #1's primary physician. Review of Resident #1's Wound Care Consultant Assessment Note dated [DATE] at 4:15 p.m. revealed recommendations for x-ray right foot, bone pathology, labs CBC, CMP, ESR, and CRP, refer vascular, podiatry/ orthopedic. Notes included: patient removed dressing ' heel wound dry, edges slight peeling no signs or symptoms of infection. Also wound cultures positive. Review of Resident #1's Skin/Wound note completed by the Treatment Nurse, dated [DATE], at 4:58 p.m., documented received no new orders at this time. Review of Resident #1's Wound Care Consultant Note dated [DATE], at 4:59 p.m., documented: MRI scheduled, seeing Vascular in July. There were no other notes. Review of Resident #1's Skin/Wound Notes completed by Treatment nurse, dated [DATE], at 4:59 p.m., revealed new wound care orders. Review of Resident #1's Skin/Wound Notes completed by the treatment nurse dated [DATE] at 5:19 a.m. revealed: no new orders. Review of Resident #1's skin/wound note dated [DATE], at 2:19 p.m. completed by the treatment nurse documented received no new orders Review of Resident #1's Nurse Notes dated [DATE], at 1:55 p.m., revealed: Resident complains of pain to right heel, states the pain is getting worse than it has been, medicated with as needed dose of tramadol, received orders for x-ray to right foot 3 views. Review of Resident #1's Consultant Wound Care Assessment Notes, dated [DATE], at 2:44 p.m. revealed: referrals: refer to podiatrist, following PAD assessment, please refer to vascular surgeon to evaluate PAD severity and revascularization. (This was a telehealth appointment). Review of Resident #1's Skin/Wound Note on [DATE] at 2:52 p.m., by the Treatment Nurse revealed, Received no new orders. Review of Resident #1's Consultant Wound Care Notes dated [DATE] at 8:00 a.m. by Wound Care Specialist B documented the appointment was telehealth. Review of Resident #1's Skin/Wound note dated [DATE] at 8:06 a.m. by the treatment nurse documented no new orders. Review of Resident #1's Wound Consultation Form Completed by Wound Care Specialist B dated [DATE] at 10:00 - 10:12 a.m. revealed it was a telehealth appointment and she recommended arterial studies. Review of Resident #1's Nurse notes dated [DATE] at 11:18 a.m. documented Resident #1 requested to go to emergency room for pain and drainage to right foot, reports he is not feeling well and has not been eating for days due to pain. Notified doctor of resident request to go to emergency room and received orders to send to emergency room for evaluation. Review of Resident #1's Nurse Notes dated [DATE] at 6:06 p.m. revealed: Called hospital for update on Resident #1, spoke with his hospital nurse. Resident admitted to hospital with diagnosis of right foot infection, they attempted an MRI but resident did not stay still so it was unsuccessful., Review of Resident #1's Hospital History and Physical dated [DATE] revealed Patient (Resident #1) reports he was in his usual state of health until approximately 4 months prior to admission when he had a foot ulcer at base of heel. Wound care had been done at nursing home once a week. Nursing home nurse reports patient had POOR compliance and he was nonadherent to advise and recommendations provided from nurses and wound care. Patient was on oral antibiotics at nursing home from ,d+[DATE] - ,d+[DATE] due to concern for MRSA on wound. Symptoms did not improve. Was going to be taken to city wound care, but today he complained of generalized foot pain, which he states had been present daily for months so he was unsure why he was brought to the local hospital. Subjective: Has necrotic heal and toe gangrene due to vascular insufficiency due to smoking. Review of Resident #1's Nurse's Notes dated [DATE] revealed: Arrived to facility, Wound to right below the knee stump intact/ wrapped. Wound with 17 staples. Interview on [DATE] at 4:15 p.m., the ADON stated Resident #1 was sent to the hospital. The ADON stated on [DATE] Resident #1 went to her and complained of a lot of pain to his right leg so they sent him to the emergency room . The ADON stated at the time of the interview Resident #1 was still in the hospital, but she was told he had a below the knee amputation. The ADON said she was unsure of the reason. The ADON stated Resident #1 had an infection that was being treated at the nursing facility with antibiotics. The ADON said Resident #1 would hang his foot off the edge of the bed instead of elevating it on a cushion. The ADON stated Resident #1 would refuse wound care; take the dressing off because he wanted the wound to air dry; and was a heavy smoker. The ADON said the facility tried to have a wound care consultation in the nearby city's wound care clinic prior to the amputation. Interview on [DATE] at 4:42 p.m., the DON stated Resident #1 was admitted to the hospital on [DATE] due to complaint of leg pain on the right side. The DON said Resident #1 was admitted to the facility with the wound and was seen by a wound care consultant company. The DON stated Resident #1 had labs and an x-ray done as well as wound cultures which showed MRSA . The DON said Resident #1's physician referred Resident #1 to a wound care center in a nearby city because they might have more things to treat Resident #1 with. The DON stated Resident #1 was sent to the hospital prior to that appointment. The DON stated she thought Resident #1 needed to go to the hospital because his foot was discolored, and Resident #1 would not keep his foot elevated. The DON denied Resident #1 being in constant pain. The DON said Resident #1 received daily wound care and the wound care orders came directly from the wound care specialist. Interview on [DATE] at 12:18 p.m., Resident #1's Responsible Party stated the facility kept him informed of the treatments they were doing. The Responsible Party said he did not know if the treatments worked but he was kept informed. The Responsible Party stated he wondered if Resident #1's amputation could have been prevented. The Responsible Party said the facility was in process of getting an appointment scheduled to see a wound care doctor but then Resident #1 went to the hospital on [DATE] due to leg pain and got it amputated while there thus the appointment was cancelled. Interview on [DATE] at 1:25 p.m., Resident #1's Doctor stated he was aware of the amputation. The physician stated Resident #1 had PAD and that could quickly turn into gangrene. The physician felt the wound care specialists whom was seeing the resident at the facility had a good plan going for the resident and he was happy with the plan. Interview on [DATE] at 2:28 p.m., the Treatment Nurse stated Resident #1 was admitted to the facility with an unstageable pressure ulcer. The Treatment Nurse stated she told the physician of the wound care consultant's recommendations. The Treatment Nurse stated the wound was stable and Resident #1 had wound care daily. The Treatment Nurse stated she did the wound care on [DATE] prior to Resident #1 going to the hospital and did not notice anything different with the wound. The Treatment Nurse stated Resident #1 complained of pain which was usual, but he had taken his pain medication at that time on [DATE]. The Treatment Nurse said the wound did not look like gangrene to her. The Treatment Nurse stated the wound care consultant would do appointments through tele med which was like Facetime with a cellphone. The Treatment Nurse explained she would take her cell phone into Resident #1's room and show the wound care consultant the wound and the consultant would say what it looked like. The Treatment Nurse was shown the Consultant's Noted dated [DATE] that documented a referral to a podiatrist or vascular doctor. The Treatment Nurse said she did recall the consultant asking for the referral but she just forgot to do it (contact the physician and set up the vascular consult). The Treatment Nurse said she remembered about the vascular consult appointment when the Ombudsman came and asked if it was done on [DATE] (19 days later) and that was when she started to set up the appointment but then the resident had his leg amputated. The Treatment Nurse stated she was aware the Wound Care Specialists recommended Resident #1 be seen by a vascular doctor and have a doppler study to the right foot on [DATE], [DATE], [DATE], and [DATE] but she forgot to get it done. Interview on [DATE] at 4:22 p.m., the Administrator and DON stated their expectation was for the wound care specialists' recommendations to be brought up to the physician by the Treatment Nurse. They stated the physician would usually approve recommendations or change the order as he wanted to. The DON stated she did not know there were orders for Resident #1 to be seen by a vascular doctor since [DATE]. The DON said she should have probably checked on the Treatment Nurse to make sure she was following the recommendations suggested by the wound care specialists. A phone interview on [DATE] at 12:58 p.m., the Wound Care Specialist A stated she recommended Resident #1 be seen by a vascular doctor numerous times and for the facility to get a doppler study done. The Wound Care Specialist stated she was told by facility staff that the physician refused the recommendations and the doppler study and had recommended Resident #1's foot just be monitored. The Wound Care Specialist stated she did not know if Resident #1 being seen by a vascular doctor would have prevented Resident #1's amputation but earlier intervention was better than no intervention at all. Phone interview on [DATE] at 1:14 p.m., Resident #1's physician stated he did not say no to the recommendations made by the wound care specialists. The physician said he would not just ask for the resident's leg to just be monitored. The physician stated he would have welcomed recommendations since the wound care specialist saw the wound in person and had a better idea of what to do next. Interview on [DATE] at 2:02 p.m., the DON confirmed there was the same order for a vascular doctor and doppler study for three months. The DON said the Treatment Nurse never turned in the wound care assessments. The DON stated when she asked the Treatment Nurse why it was not done the Treatment Nurse said she did not know how. Phone interview on [DATE] at 4:42 p.m., the Treatment Nurse stated Resident #1 received wound care daily and saw the wound care consultant weekly. The Treatment Nurse said in the beginning there were no recommendations. The Treatment Nurse stated at the end the wound care specialists were recommending a vascular, labs, x-rays, cultures - all of it. The Treatment Nurse said she did it all except for the vascular doctor. She said she did not know why did not do it. The Treatment Nurse did not answer when asked why it was not done for three months. The Treatment Nurse stated one time she told the ADON and the ADON told the treatment Nurse that doppler studies were not done in their city. At the end of the interview, the Treatment Nurse stated I don't know, I guess I thought I could take care of it myself and now it's too late. Non-IJ Review of Resident #2's Admission Record dated [DATE] reviewed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included orthopedic aftercare following surgical amputation, acquired absence of other right toe(s), reduced mobility, abnormal weight loss. Review of Resident #2's Quarterly MDS Assessment, dated [DATE], revealed: She scored a 0 of 15 on her mental status exam (indicating severe cognitive impairment). She had a stage III pressure ulcer. Review of Resident #2's Care Plan, initiated [DATE], revealed: Focus: Resident has a stage III to right lower lateral extremity. Goal: The resident's Pressure ulcer will signs of healing and remain free from infection through review date. The resident will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions: Assess/record/monitor wound healing daily. Measure length, width, and depth where possible weekly. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Follow facility policies/ protocols for the prevention/treatment of skin breakdown. Review of Resident #2's Order Summary Report, dated [DATE], revealed orders: Wound Care Consultant Company dated [DATE] Review of Resident #2's Wound Care Consultant report, dated [DATE], revealed refer to vascular surgery, evaluate Peripheral Artery Disease and potential treatment options. Review of Resident #2's Skin/Wound note dated [DATE] by the Treatment Nurse revealed: Wound care specialist evaluated via telemed at this time. Right lower lateral extremities measures approximately 3cm x 1.5cm x 0.4 cm. Wound tissue is 100% granulation. No new orders at this time. Interview on [DATE] at 1:03 p.m. the DON confirmed Resident #2's Wound Care Consultant Report and skin/wound notes did not match and there had been a referral made. Interview on [DATE] at 1:38 p.m. the DON agreed Resident #2's notes was another referral that was not reflected in the skin/wound notes. The DON stated she did not understand why everything in-house was completed but outside appointments were not made The DON re-iterated that out-of-town appointments were made Tuesday/ Thursday but the facility would go where they needed to go. The DON said she could not think of a reason why the referrals were not made. Review of the facility's policy and procedure on Change in Condition, dated [DATE], revealed: Policy - Corporation communities will use the interact definition for Change in Condition. It will be the policy that once the nurse has notified the physician for a change in condition, the resident/patient will be monitored for 1 hour until the physician has responded. The monitoring will included vital signs, pulse ox, and finger stick blood sugar if a diabetic (one time only). A physical assessment should be completed relative to the symptoms present a pain assessment. If you are unable to reach physician within 2 hours, repeat call. If you are still unable to reach the physician you may call the Medical Director. If the resident/patient condition appears emergent, transfer to local emergency room may occur with physician order. The Administrator and DON were informed an Immediate Jeopardy on [DATE] at 2:55 p.m., due to the above failures and provided the IJ template. A plan of removal was requested at that time. The Plan of Removal was accepted on [DATE] at 12:25 p.m.,. and included the following: All orders with wound care consultant company will be reviewed with DON within 24 hours of visit. The Administrator and DON will review all physician, pharmacy and support services recommendations to be reviewed within 20 hours of the recommendation and all orders sent, written and reviewed. DON or ADON will review all orders requiring physician and/or specialist referrals to ensure referrals are handled in a timely manner beginning [DATE]. The Medical Director, Licensed Nurses and wound care specialist will be provided in-service education related to the referral process. Physician referral process for sending residents to a specialist or outside physician services by obtaining the Medical Director's referral order beginning on [DATE] by DON or Designee which includes: 1. Notify DON to confirm need for resident referral. 2. Notify Physician of Referral Order Needed with details of the diagnosis and reason for referral. 3. Charge Nurse, Social Worker and/or designee to call in referral order, confirm insurance, and make appointment with Specialist and arrange for appropriate transportation. 4. Administrator to be notified if referrals are refused or denied by physician or Medical Director and reason for the denial. All current and newly hired nurses will receive in-service regarding physician referral to begin [DATE]. Validation/Monitoring Tools: DON or designee will validate staff knowledge base through random questioning [DATE]. DON and/or designee will review any referral orders documented by reviewing orders daily in the daily in clinical meeting to ensure appointments are being made. Referrals and appointment will be placed on the 24-hour report. Beginning [DATE]. DON and/or designee will review all wound care patient's progress and status for the need for referrals during Standards of Care Meeting weekly Beginning [DATE]. The Administrator, DON, and/or designee will review the action plan developed related to the Referral Process in QA meeting monthly during the next six months. Beginning [DATE]. DON/ADON/Regional RN auditing/reviewing all skin treatment orders, all wound care specialist's notes and recommendations, assessing appropriateness of orders for all skin issues. [DATE] (No further referrals or recommendations found). One wound care specialist recommendation sent to Medical Director. Immediate Action: The Administrator/DON provided one on one in-servicing to all on-duty staff on [DATE] and [DATE]. Immediate Action -Observation on [DATE] at 10:54 a.m. surveyor observed Administrator calling the Medical Doctor and handing the phone to the DON for the wound care specialist's recommendation on Resident #2. Facility provided signed one on one in-services by facility staff on [DATE]. Review of the 24-hour report for [DATE] and [DATE] revealed appointments needed to be made were written in red by the resident's name. If a follow up appoint was made it was written under it in a black pen. Review of the calendar on the ADON's wall on [DATE] at 12:00 revealed appointments were scheduled. Immediate Action - a 100% skin sweep was completed by the DON, the Corporate Compliance RN, the ADON and LVN C. No new pressure ulcers were identified. The administrator was notified the IJ was removed on [DATE] at 12:43 p.m., however the facility remained out of compliance, at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to continue to monitor the implementation and effectiveness of their Plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from neglect for 1 of 3 residents reviewed for neglect (Resident #1). The facility failed to ensure that the Treatment Nurse made the referral for a doppler study six times on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], or an orthopedic/ podiatrist/ and/or a vascular doctor five times on [DATE], [DATE], [DATE], [DATE], and [DATE]). This resulted in Resident #1 having a below the knee amputation on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:55 p.m. While the IJ was removed on [DATE] at 12:43 p.m., the facility remained out of compliance at actual harm with a potential for more than minimal harm at a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk for negative outcomes including decline in wounds, dismemberment, severe infection, and death. Findings included: Review of Resident #1's Admission Record dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including malnutrition, uropath y (difficulty urinating due to a blocked urinary tract), cirrhosis of liver, and emphysem a (damage of the lung tissue). (The pressure ulcer to the heal was not listed) Review of Resident #1's Quarterly MDS Assessment, dated [DATE], revealed: He scored a 5 of 15 on his mental status exam. (Indicating severe cognitive impairment) Resident #1 had one stage III pressure ulcer that was present upon admission/entry and an other open lesion(s) on the foot. Review of Resident #1's Care Plan, initiated [DATE], revealed: Problem: The resident has an unstageable pressure injury to right heal related to disease process, history of ulcers and immobility. Updated on [DATE] revealed: wound now Stage III. The Goal was: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Identified approaches included: weekly treatment documentation to include measurement of each area of skin breakdown's width, length, type of tissue, and exudate initiated [DATE]. Review of Resident #1's admission note dated [DATE] revealed he was admitted to facility with an unstageable pressure ulcer to the right heel that was staged at the hospital. Resident #1's first documented assessment by the Wound Care Provider was [DATE] where the heel was staged as an unstageable approximately 3 cm length x 4.2 cm width x 0.1 cm depth with 100% necrotic tissue. Review of Resident #1's Wound Care Consultant's wound assessment, dated [DATE], at 4:55 p.m. revealed the Wound Care Consultant #1 recommended Resident #1 see a vascular doctor. Review of Resident #1's Skin/Wound Note by the Treatment Nurse, dated [DATE], at 4:55 p.m. documented: no new orders at this time . Review of Resident #1's Wound Care Consultant's wound assessment notes, dated [DATE], at 5:19 p.m. revealed a recommendation for a Doppler Study . Review of Resident #1's Skin/Wound Note by the Treatment Nurse dated [DATE] at 5:19 p.m. p.m. documented new order for Mupirocin 2% (antibiotic ointment) to be applied to right 4th toe (there was nothing about the Doppler Study). Review of Resident #1's Wound Care Consultant assessment note dated [DATE] at 9:25 a.m., documented recommendations to have a vascular consultant and a Doppler Study for Resident #1. Review of the Skin/Wound Note for Resident #1, written by the treatment nurse dated [DATE] at 9:25 a.m. revealed note received no new orders at this time. Review of Resident #1's Wound Care Consultant assessment note dated [DATE] at 5:33 p.m. revealed a recommendation for a Doppler study. There was no corresponding nurse's or skin/wound note for Resident #1 on [DATE]. Review of Resident #1's Wound Care Consultant note dated [DATE] at 5:33 p.m., revealed a recommendation for a Doppler Study. Review of Resident #1's Skin/Wound Note completed by the Treatment Nurse on [DATE] at 5:33 p.m. documented new orders to clean stage 3 to right heel with normal saline, pat dry with 4x4 gauze, apply anasept and collagen to wound bed and cover with supper absorptive dressing daily and as needed until healed. (Nothing about the recommendation for outside services) Review of Resident #1's Wound Consultant assessment note dated [DATE] at 5:10 p.m. revealed orders for: x-ray to right foot to rule out osteomyelitis (bone infection), Labs CBC, CMP, ESR, and CRP., a bone culture for pathology, refer a vascular surgeon to assess PAD/flow status, and once seen by vascular refer to podiatry or orthopedic for right 2nd toe. Review of Resident #1's Skin/Wound note completed by the Treatment Nurse, dated [DATE] at 5:10 p.m., revealed new wound care orders, to draw labs CBC, CMP, ESR and CPR complete a Bone pathology on bone, and an X-ray to right foot to rule out osteomyelitis. Review of Resident #1's Skin/wound note completed by the Treatment Nurse, dated [DATE] at 5:10 p.m., revealed a three-view x-ray to rule out osteomyelitis was completed. Review of Resident #1's Nurse note dated [DATE] at 1:48 p.m. revealed the facility received the lab results and they were forwarded to Resident #1's primary physician. Review of Resident #1's Wound Care Consultant Assessment Note dated [DATE] at 4:15 p.m. revealed recommendations for x-ray right foot, bone pathology, labs CBC, CMP, ESR, and CRP, refer vascular, podiatry/ orthopedic. Notes included: patient removed dressing ' heel wound dry, edges slight peeling no signs or symptoms of infection. Also wound cultures positive. Review of Resident #1's skin/wound note completed by the Treatment Nurse, dated [DATE] at 4:58 p.m., documented received no new orders at this time. Review of Resident #1's Wound Care Consultant Note dated [DATE] at 4:59 p.m. documented: MRI scheduled, seeing Vascular in July. There were no other notes. Review of Resident #1's Skin/Wound Notes completed by Treatment nurse, dated [DATE] at 4:59 p.m., revealed new wound care orders. Review of Resident #1's Skin/Wound Notes completed by the treatment nurse dated [DATE] at 5:19 a.m. revealed: no new orders. Review of Resident #1's skin/wound note dated [DATE] at 2:19 p.m. completed by the treatment nurse documented received no new orders Review of Resident #1's Nurse's Notes dated [DATE] at 1:55 p.m. revealed: Resident complains of pain to right heel, states the pain is getting worse than it has been, medicated with as needed dose of tramadol, received orders for x-ray to right foot 3 views. Review of Resident #1's Consultant Wound Care Assessment Notes, dated [DATE] at 2:33 p.m., revealed: referrals: refer to podiatrist, following PAD assessment, please refer to vascular surgeon to evaluate PAD severity and revascularization. (This was a telehealth appointment). Review of Resident #1's Skin/Wound Note dated [DATE] at 2:52 p.m. revealed received no new orders. Review of Resident #1's Consultant Wound Care Notes dated [DATE] a 8:00 a.m. by Wound Care Specialist B documented the appointment was telehealth. Review of Resident #1's skin/wound note dated [DATE] at 8:06 a.m. by the treatment nurse documented no new orders. Review of Resident #1's Wound Consultation Form Completed by Wound Care Specialist B dated [DATE] at 10:00 a.m. - 10:12 a.m. revealed it was a telehealth appointment and she recommended arterial studies. Review of Resident #1's Nurse notes dated [DATE] at 11:18 a.m. documented Resident requesting to go to emergency room for pain and drainage to right foot, reports he is not feeling well and has not been eating for days due to pain. Notified doctor of resident request to go to emergency room and received orders to send to emergency room for evaluation. Review of the Nurse Notes dated [DATE] at 6:05 p.m. revealed: Called hospital for update on resident, spoke with his hospital nurse. Resident admitted to hospital with diagnosis of right foot infection, they attempted an MRI but resident did not stay still so it was unsuccessful, Review of Resident #1's Hospital History and Physical dated [DATE] revealed Patient reports he was in his usual state of health until approximately 4 months prior to admission when he had a foot ulcer at base of heel. Wound care had been done at nursing home once a week. Nursing home nurse reports patient had POOR compliance and he was nonadherent to advise and recommendations provided from nurses and wound care. Patient was on oral antibiotics at nursing home from ,d+[DATE] - ,d+[DATE] due to concern for MRSA on wound. Symptoms did not improve. Was going to be taken to city wound care, but today he complained of generalized foot pain, which he states had been present daily for months so he was unsure why he was brought to the local hospital. Subjective: Has necrotic heal and toe gangrene due to vascular insufficiency due to smoking. Review of Resident #1's Nurse Notes dated [DATE] at 3:45 p.m. revealed: Arrived to facility, Wound to right below the knee stump intact/ wrapped. Wound with 17 staples. Interview on [DATE] at 4:15 p.m., the ADON stated Resident #1 was sent to the hospital. The ADON stated on [DATE] Resident #1 went to her and complained of a lot of pain to his right leg so they sent him to the emergency room . The ADON stated at the time of the interview Resident #1 was still in the hospital, but she was told he had a below the knee amputation. The ADON said she was unsure of the reason. The ADON stated Resident #1 had an infection that was being treated at the nursing facility with antibiotics. The ADON said Resident #1 would hang his foot off the edge of the bed instead of elevating it on a cushion. The ADON stated Resident #1 would refuse wound care; take the dressing off because he wanted the wound to air dry; and was a heavy smoker. The ADON said the facility tried to have a wound care consultation in the nearby city's wound care clinic prior to the amputation. Interview on [DATE] at 4:42 p.m., the DON stated Resident #1 was admitted to the hospital on [DATE] due to complaint of leg pain on the right side. The DON said Resident #1 was admitted to the facility with the wound and was seen by a wound care consultant company. The DON stated Resident #1 had labs and an x-ray done as well as wound cultures which showed MRSA . The DON said Resident #1's physician referred Resident #1 to a wound care center in a nearby city because they might have more things to treat Resident #1 . The DON stated Resident #1 was sent to the hospital prior to that appointment. The DON stated she thought Resident #1 needed to go to the hospital because his foot was discolored, and Resident #1 would not keep his foot elevated. The DON denied Resident #1 being in constant pain. The DON said Resident #1 received daily wound care and the wound care orders came directly from the wound care specialist. Interview on [DATE] at 12:18 p.m., Resident #1's Responsible Party stated the facility kept him informed of the treatments they were doing. The Responsible Party said he did not know if the treatments worked but he was kept informed. The Responsible Party stated he wondered if Resident #1's amputation could have been prevented. The Responsible Party said the facility was in process of getting an appointment scheduled to see a wound care doctor but then Resident #1 went to the hospital on [DATE] due to leg pain and got it amputated while there thus the appointment was cancelled. Interview on [DATE] at 1:25 p.m. Resident #1's Doctor stated he was aware of the amputation. The physician stated Resident #1 had PAD and that could quickly turn into gangrene. The physician felt the wound care specialists who was seeing the resident at the facility had a good plan going for the resident and he was happy with the plan. Interview on [DATE] at 2:28 p.m. the Treatment Nurse stated Resident #1 was admitted to the facility with an unstageable pressure ulcer. The Treatment Nurse stated she told the physician of wound care consultant's recommendations. The Treatment Nurse stated the wound was stable and Resident #1 had wound care daily. The Treatment Nurse stated she did the wound care on [DATE] prior to Resident #1 going to the hospital and did not notice anything different with the wound. The Treatment Nurse stated Resident #1 complained of pain which was usual, but he had taken his pain medication at that time on [DATE]. The Treatment Nurse said the wound did not look like gangrene to her. The Treatment Nurse stated the wound care consultant would do appointments through telemed which was like Facetime with a cellphone. The Treatment Nurse explained she would take her cell phone into Resident #1's room and show the wound care consultant the wound and the consultant would say what it looked like. The Treatment Nurse was shown the Consultant's Noted dated [DATE] that documented a referral to a podiatrist or vascular doctor. The Treatment Nurse said she did recall the consultant asking for the referral but she just forgot to do it (contact the physician and set up the vascular consult). The Treatment Nurse said she remembered about the vascular consult appointment when the Ombudsman came and asked if it was done on [DATE] (19 days later) and that was when she started to set up the appointment but then the resident had his leg amputated. The Treatment Nurse stated she was aware the Wound Care Specialists recommended Resident #1 be seen by a vascular doctor and have a doppler study to the right foot on [DATE], [DATE], [DATE], and [DATE] but she forgot to get it done. Interview on [DATE] at 4:22 p.m., the Administrator and DON stated their expectation was for the wound care specialists' recommendations to be brought up to the physician by the Treatment Nurse. They stated the physician would usually approve recommendations or change the order as he wanted to. The DON stated she did not know there were orders for Resident #1 to be seen by a vascular doctor since [DATE]. The DON said she should have probably checked on the Treatment Nurse to make sure she was following the recommendations suggested by the wound care specialists. Phone interview on [DATE] at 12:58 p.m., Wound Care Specialist A stated she recommended Resident #1 be seen by a vascular doctor numerous times and for the facility to get a doppler study done. The Wound Care Specialist stated she was told by facility staff that the physician refused the recommendations and the doppler study and had recommended Resident #1's foot just be monitored. The Wound Care Specialist stated she did not know if Resident #1 being seen by a vascular doctor would have prevented Resident #1's amputation but earlier intervention was better than no intervention at all. Phone interview on [DATE] at 1:14 p.m. Resident #1's physician stated he did not say no to the recommendations made by the wound care specialists. The physician said he would not just ask for the resident's leg to just be monitored. The physician stated he would have welcomed recommendations since the wound care specialist saw the wound in person and had a better idea of what to do next. Interview on [DATE] at 1:04 p.m. the Administrator summarized that Resident #1 was admitted with a wound. The Administrator stated Resident #1 was a smoker and was non-compliant with elevating his foot. The Administrator said the Treatment Nurse was monitoring the wound. The Administrator stated fast forward the wound care specialists texted the Treatment Nurse recommendations of a referral to a vascular doctor and it was not done. The Administrator said it was not done and the Treatment Nurse said she missed it. The Administrator said the DON was not getting the wound care specialist's notes so would not get the recommendation. Interview on [DATE] at 2:02 p.m. the DON confirmed there was the same order for a vascular doctor and doppler study for three months. The DON said the Treatment Nurse never turned in the wound care assessments. The DON stated when she asked the Treatment Nurse why it was not done the Treatment Nurse said she did not know how. Phone interview on [DATE] at 3:58 p.m. Wound Care Specialist B stated the Treatment Nurse told her that vascular recommendation was not followed because it was a transportation issue. Wound Care Specialist B said she recommended the vascular doctor every week and she understood it was difficult. Wound Care Specialist B stated she mainly did telehealth appointments with the facility. The Wound Care Specialist stated to her knowledge the facility did not follow through with the recommendation, then the facility informed Wound Care Specialist B that Resident #1 went to the hospital, and they amputated his leg. Wound Care Specialist B said she made the recommendation weekly and the Treatment Nurse told her it was a transportation issue. Wound Care Specialist B said to her knowledge her recommendations were not done. Wound Care Specialist B said she understood the facility was in a rural area and the closest vascular doctor was an hour and half away in the closest city. Wound Care Specialist B said Resident #1's physician was involved because at some point Resident #1 was placed on an antibiotic she did not prescribe. Wound Care Specialist B said she (Wound Care Specialist B) and Wound Care Specialist A had similar recommendations. Wound Care Specialist B said she and the Treatment Nurse talked weekly, but the Treatment Nurse would not always inform her of every change. Treatment Nurse B was informed there was a referral made to the nearest city's wound care clinic and responded I can't imagine they would get a different result. Wound Care Specialist B repeated she recommended vascular studies and to her knowledge they were never followed up. Wound Care Specialist B stated the last time she saw Resident #1 was [DATE] and the wound looked the same and she made the same recommendation of a vascular consult. Wound Care Specialist B said she was trying to be patient for the facility to get it done and the Treatment Nurse just told her (Specialist B) that it was very difficult to get the tests done. Phone interview on [DATE] at 4:42 p.m. the Treatment Nurse stated Resident #1 received wound care daily and saw the wound care consultant weekly. The Treatment Nurse said in the beginning there were no recommendations. The Treatment Nurse stated at the end the wound care specialists were recommending a vascular, labs, x-rays, cultures - all of it. The Treatment Nurse said she did it all except for the vascular doctor. She said she did not know why did not do it. The Treatment Nurse did not answer when asked why it was not done for three months. The Treatment Nurse said she did not know why she told Wound Care Specialist B that it was a transportation issue, then added it was because she (the Treatment Nurse) overlooked it and did not know what to say. The Treatment Nurse stated one time she told the ADON and the ADON told the treatment Nurse that doppler studies were not done in their city. The Treatment Nurse said she did not know why she did not put the vascular appointment/ doppler study/ orthopedic / podiatrist referrals in her notes when all the other recommendations were in the notes. At the end of the interview, the Treatment Nurse stated, I don't know, I guess I thought I could take care of it myself and now it's too late. Interview on [DATE] at 4:59 p.m., the ADON stated she Resident #1 was noncompliant and smoked a lot. The ADON said the day she sent Resident #1 to the emergency room ; Resident #1 was complaining of a lot of pain to his foot and requested to go. The ADON stated that was the first time she sent Resident #1 to the emergency room for foot pain. The AODN stated there was a nurse's meeting every day and issues that came up were discussed; she said the Treatment Nurse would bring up that wounds were not healing because Resident #1 was noncompliant and would not use a heel cushion and hang his foot off the bed. The ADON stated she was not present if the Treatment Nurse brought up wound care recommendations. The ADON stated she was never told of any referrals. The ADON stated the doppler study statement made by Treatment Nurse was maybe because the facility tried to get a doppler study on another resident about a year ago and the ADON said the hospital at their city did not do them. The ADON stated she should have been made aware of the Wound Care Specialist's recommendations because she was the ADON. The ADON stated under the previous DON, the Treatment Nurse would talk to the ADON about the wounds because the previous DON did not know much about wound care. Interview on [DATE] at 5:14 p.m. the Administrator, stated whoever got the order for a referral was responsible for notifying the physician and putting in the order. The Administrator stated the facility did go as far as the nearest city. The Administrator stated typically the Transportation Aide would take the resident and a CNA. The Administrator stated appointments to other cities were done on Tuesdays and Thursdays because of the dialysis appointments on Monday/ Wednesday/ Friday. The DON said she was not made aware of any referrals to a vascular doctor, so she got the order for Resident #1 to go to the wound care clinic in the nearest city. The DON said Resident #1 was sent to the emergency room before the appointment could occur. Interview and record review on [DATE] at 12:07 p.m., the Transportation Aide stated she did the dialysis appointments on Monday/ Wednesday/ Friday but on Tuesday/ Thursday she took the residents to other appointments. The Transportation aide said the facility would go where the resident needed to go. The Transportation Aide said she did take residents to the nearest city at least weekly. The Transportation Aide said she did not remember taking Resident #1 to any appointments and she was never told to make an appointment for him. The Treatment Nurse handed over the calendar for 2023 and it did show other residents were taken to other cities for outside appointments. Review of the transportation schedule from [DATE] - [DATE] showed Resident #1 had no appointments made. Interview on [DATE] at 4:18 p.m., the DON stated the definition of neglect would be not meeting the resident's needs. She stated neglect did not have to be intentional and it could be subtle. The DON stated not getting the appointments for Resident #1 did meet the definition of neglect because the Treatment Nurse knew about it and did not get it. The DON said the facility could not say if the outcome to Resident #1 would be the same if Resident #1 got the referrals. The DON said the order should have been put into Resident #1's record. The DON said she could not wrap her head around the whole situation but did feel it was neglectful. Interview on [DATE] at 4:57 p.m., the Administrator stated the facility trained all staff that residents were to be from any type of abuse or neglect and if the staff felt the resident was being neglected, they needed to report up the chain of command. The Administrator said the referrals were overlooked but she could not argue that not having the referrals done did not meet the definition of neglect. Review of the facility's policy and procedure on Compliance with Abuse, revised [DATE] revealed: the purpose of this policy is to ensure that each resident has the right to be free from any form of abuse, neglect, intimidation, involuntary seclusion/confinement and or misappropriated of property Review of the facility's policy and procedure on Clinical Protocol on Abuse and Neglect, revised ,d+[DATE] revealed: Assessment and Recognition: 1. The nurse will assess the individual and document related findings. Assessment data will include: Injury assessment (bleeding, bruising, deformity, swelling etc.) 2. The nurse will report findings to they physician. As needed, the physician will assess the resident to verify or clarify such findings, especially if the cause or source of the problem is unclear. 3. As part of the initial assessment, the physician will help identify individuals who have a history of being abused or neglect, or those who might have been abused or neglected; for example, individuals admitted from home or the hospital with multiple pressure ulcers and severe under-nutrition. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of the facility's computer training (done on a rotating basis) on identifying Neglect revealed: Policy Statement: As part of the strategy to prevent abuse, neglect, mistreatment and exploitation of residents, volunteers, employees, and contractors hired by this facility are expected to be able to identify neglect as it may occur against residents. Policy Interpretation and Implementation: Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident are necessary to avoid physical harm, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference to or disregard for resident care, comfort, or safety results (or have resulted in) physical harm, pain, mental anguish, or emotional distress. Neglect may be a pattern of failures or may be the result of one or more failures involving one resident and one staff person. Neglect of goods or services may occur when staff are aware of, or should have been aware, of residents/' care needs based on assessment and care planning but are unable to meet the identified needs due to other circumstances. Goods and services that the resident needs are identified and addressed through the following: Oversight and monitoring of staff performance. Oversight and monitoring of contracted services or services provided under arrangement. Examples of failure to provide care and services to the resident that result in neglect include: Failure to identify, assess, and/or contact a physician and/or prescriber for an acute change in condition, and/or a change in condition that requires the plan of care to be revised to meet the resident's needs in a timely manner. Failure to ensure staff respond correctly to medical emergencies The Administrator and DON were informed an Immediate Jeopardy on [DATE] at 2:55 p.m., due to the above failures and provided the IJ template. A plan of removal was requested at that time. The Plan of Removal was accepted on [DATE] at 12:25 p.m. ,p.m., and indicated the following: DON or ADON and/or designee will review all orders requiring physician and/ or specialist referrals to ensure referrals are handled in a timely manner. Referrals will be documented on 24-hour until referral and/or appointment is completed. Beginning [DATE] The Medical Director, Licensed Nurses and wound care specialist will be provided in-service education related to the referral process. Physician referral process for sending residents to a specialist or outside physician services by obtaining the Medical Director's referral order beginning on [DATE] by DON or designee which includes: 1. Notify DON to confirm need for resident referral 2. Notify Physician of Referral Order Needed with details of the diagnosis and reason for referral. 3. Charge Nurse or Social Worker and/or designee to call in referral order, confirm insurance, and make appointment with Specialist and arrange for appropriate transportation. All referrals will be discussed and acknowledged in morning meetings. 4. All referrals will be kept on 24-hour report until appointment has been confirmed and/or attended. 5. Administrator to be notified if referrals are refused or denied by physician or Medical Director and reason for the denial. All current and/or newly hired nurses will be in-serviced regarding physician referral and contracted consultants beginning [DATE]. Validation/Monitoring Tools DON and/or designee will validate staff knowledge base through random questioning, education, and in-serving beginning [DATE]. DON or designee will review any referral orders documented by reviewing orders daily in clinical meeting to ensure appointments are being made. Beginning [DATE]. DON or designee will review any referral orders documented by reviewing orders daily in daily clinical meeting to ensure appointments are being made. Beginning [DATE]. DON or designee will review all wound care patient's progress and status and need for referrals during Standards of Care Meeting weekly. Beginning [DATE]. The Administrator, DON, or designee will review the action plan developed related to Referral Process in QA meetings monthly during the next six months. Beginning [DATE]. Audit was completed [DATE] on by clinical for missing referrals, notes and/or documentation by Regional Nurse. Consultant Wound Care Company will forward all clinical notes and referrals to DON and Regional Nurse beginning [DATE]. Observation on [DATE] at 10:54 a.m. surveyor observed Administrator calling the Medical Doctor and handing the phone to the DON for the wound care specialist's recommendation on Resident #2. Facility provided signed one on one in-services by facility staff on [DATE]. Review of the 24-hour report for [DATE] and [DATE] revealed appointments needed to be made were written in red by the resident's name. If a follow up appoint was made it was written under it in a black pen. Review of the calendar on the ADON's wall on [DATE] at 12:00 pm revealed appointments were scheduled. Immediate Action - a 100% skin sweep was completed by the DON, the Corporate Compliance RN, the ADON and LVN C. No new pressure ulcers were identified. Interview on [DATE] at 10:40 a.m. the Administrator stated all the floor nurses knew the referral process prior to the in-service, but all full-time staff had been in-serviced. The Administrator stated the in-service was done verbally and then the staff had to take a test on the facility's in-servicing program . The Administrator stated upcoming appointments were already on the morning meeting report so there was no reason to add it. The facility provided all one-on-one sign-in forms and the in-servicing program completion. The Treatment Nurse was unavailable to verify in-services and understanding of corrective action . The administrator was notified the IJ was removed on [DATE] at 12:43 p.m., however the facility remained out of compliance, at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy due to the facility's need to continue to monitor the implementation and effectiveness of their Plan of Removal.

Based on interview and record review the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents (Resident #1) reviewed for pressure ulcers. The facility failed to ensure the Treatment Nurse accurately transcribed the Wound Care Consultant's recommendation for Resident #1 to have a doppler study six (6) times on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] and/or see a vascular/orthopedic/ podiatrist doctor five (5) times on [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility failed to ensure Resident #1's physician was notified of the Wound Care Consultant's recommendations. The facility failed to ensure the recommended actions were followed through with. This resulted in Resident #1 having a below the knee amputation on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:55 PM. While the IJ was removed on [DATE] at 12:43 PM, the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. This failure placed residents at risk for improper wound management, the development of new pressure ulcers, deterioration, infection, pain, loss of limb, or death. Findings include: Review of Resident #1's Admission Record dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including malnutrition, uropathy, cirrhosis of liver, and emphysema. (The pressure ulcer to the heal was not listed) Review of Resident #1's Quarterly MDS Assessment, dated [DATE], revealed: He scored a 5 of 15 on his mental status exam. (Indicating severe cognitive impairment) Resident #1 had one stage III pressure ulcer that was present upon admission/entry and an other open lesion(s) on the foot. Review of Resident #1's Care Plan, initiated [DATE], revealed: Problem: The resident has an unstageable pressure injury to right heal related to disease process, history of ulcers and immobility. Updated on [DATE] revealed: wound now Stage III. The Goal was: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Identified approaches included: weekly treatment documentation to include measurement of each area of skin breakdown's width, length, type of tissue, and exudate initiated [DATE]. Review of Resident #1's admission note dated [DATE] revealed he was admitted to facility with an unstageable pressure ulcer to the right heel that was staged at the hospital. Resident #1's first documented assessment by the Wound Care Provider was [DATE] where the heel was staged as an unstageable approximately 3 cm length x 4.2 cm width x 0.1 cm depth with 100% necrotic tissue. Review of Resident #1's Wound Care Consultant's wound assessment, dated [DATE] at 4:55 p.m., revealed the Wound Care Consultant #1 recommended Resident #1 see a vascular doctor. Review of Resident #1's Skin/Wound Note by the Treatment Nurse, dated [DATE] at 4:55 p.m., documented: no new orders at this time Review of Resident #1's Wound Care Consultant's wound assessment notes, dated [DATE] at 5:19 p.m , revealed a recommendation for a Doppler Study. Review of Resident #1`s Skin/Wound Note by the Treatment Nurse dated [DATE] at 5:19 p.m. documented new order for Mupirocin 2% (antibiotic ointment) to be applied to right 4th toe (Nothing about the Doppler Study) Review of Resident #1's Wound Care Consultant assessment note dated [DATE] at 9:25 a.m., documented recommendations to have a vascular consultant and a Doppler Study. Review of the Skin/Wound Note by the treatment nurse dated [DATE] at 9:25 a.m. revealed note received no new orders at this time. Review of Resident #1's Wound Care Consultant note dated [DATE] at 5:33 p.m. revealed a recommendation for a Doppler Study. Review of Resident #1's Skin/Wound Note completed by the Treatment Nurse on [DATE] at 5:33 p.m. documented new orders to clean stage 3 to right heel with normal saline, pat dry with 4x4 gauze, apply anasept and collagen to wound bed and cover with supper absorptive dressing daily and as needed until healed. (Nothing about the recommendation for outside services) Review of Resident #1's Wound Consultant assessment note dated [DATE] at 5:10 p.m. revealed orders for: x-ray to right foot to rule out osteomyelitis (bone infection), Labs CBC, CMP, ESR, and CRP., a bone culture for pathology, refer a vascular surgeon to assess PAD/flow status, and once seen by vascular refer to podiatry or orthopedic for right 2nd toe. Review of Resident #1's Skin/Wound note completed by the Treatment Nurse, dated [DATE] at 5:10 p.m., revealed new wound care orders, to draw labs CBC, CMP, ESR and CPR complete a Bone pathology on bone, and an X-ray to right foot to rule out osteomyelitis. Review of Resident #1's Skin/wound note completed by the Treatment Nurse, dated [DATE] at 5:10 p.m., revealed order for a three-view x-ray to rule out osteomyelitis was completed. Review of Resident #1's Nurse's note dated [DATE] revealed the facility received the lab results and they were forwarded to Resident #1's primary physician. Review of Resident #1's Wound Care Consultant Assessment Note dated [DATE] at 4:15 p.m. revealed recommendations for x-ray right foot, bone pathology, labs CBC, CMP, ESR, and CRP, refer vascular, podiatry/ orthopedic. Notes included: patient removed dressing ' heel wound dry, edges slight peeling no signs or symptoms of infection. Also wound cultures positive. Review of Resident #1's Skin/Wound note completed by the Treatment Nurse, dated [DATE] at 4:58 p.m., documented received no new orders at this time. Review of Resident #1's Wound Care Consultant Note dated [DATE] at 4:59 p.m. documented: MRI scheduled, seeing Vascular in July. There were no other notes Review of Resident #1's Skin/Wound Notes completed by Treatment nurse, dated [DATE] at 4:59 p.m., revealed new wound care orders. Review of Resident #1's Skin/Wound Notes completed by the treatment nurse dated [DATE] at 5:19 a.m. revealed: no new orders. Review of Resident #1's skin/wound note dated [DATE] at 2:19 p.m. completed by the treatment nurse documented received no new orders Review of Resident #1's Nurse's Notes dated [DATE] at 1:55 p.m. revealed: Resident complains of pain to right heel, states the pain is getting worse than it has been, medicated with as needed dose of tramadol, received orders for x-ray to right foot 3 views. Review of Resident #1's Consultant Wound Care Assessment Notes, dated [DATE] at 2:44 p.m., revealed: referrals: refer to podiatrist, following PAD assessment, please refer to vascular surgeon to evaluate PAD severity and revascularization. (This was a telehealth appointment). Review of Resident #1's Skin/Wound Note dated [DATE] at 2:52 p.m. revealed received no new orders. Review of Resident #1's Consultant Wound Care Notes dated [DATE] at 8:00 a.m. by Wound Care Specialist B documented the appointment was telehealth. Review of Resident #1's skin/wound note dated [DATE] at 8:06 a.m. by the treatment nurse documented no new orders. Review of Resident #1's Wound Consultation Form Completed by Wound Care Specialist B dated [DATE] at 10:00 a.m. - 10:12 a.m. revealed it was a telehealth appointment and she recommended arterial studies. Review of Resident #1's Skin/Wound Note dated [DATE] at 10:12 a.m. revealed the Treatment Nurse documented Received no new orders. Review of Resident #1's Nurse's notes dated [DATE] at 11:18 a.m. documented Resident requesting to go to emergency room for pain and drainage to right foot, reports he is not feeling well and has not been eating for days due to pain. Notified doctor of resident request to go to emergency room and received orders to send to emergency room for evaluation. Review of Resident #1's Nurse's Notes dated [DATE] at 6:05 p.m. revealed: Called hospital for update on resident, spoke with his hospital nurse. Resident admitted to hospital with diagnosis of right foot infection, they attempted an MRI but resident did not stay still so it was unsuccessful, Review of Resident #1's Hospital History and Physical dated [DATE] revealed Patient reports he was in his usual state of health until approximately 4 months prior to admission when he had a foot ulcer at base of heel. Wound care had been done at nursing home once a week. Nursing home nurse reports patient had POOR compliance and he was nonadherent to advise and recommendations provided from nurses and wound care. Patient was on oral antibiotics at nursing home from ,d+[DATE] - ,d+[DATE] due to concern for MRSA on wound. Symptoms did not improve. Was going to be taken to city wound care, but today he complained of generalized foot pain, which he states had been present daily for months so he was unsure why he was brought to the local hospital. Subjective: Has necrotic heal and toe gangrene due to vascular insufficiency due to smoking. Review of Resident #1's Nurse's Notes dated [DATE] revealed: Arrived to facility, Wound to right below the knee stump intact/ wrapped. Wound with 17 staples. Interview on [DATE] at 4:15 p.m. the ADON stated Resident #1 was sent to the hospital. The ADON stated on [DATE] Resident #1 went to her and complained of a lot of pain to his right leg so they sent him to the emergency room . The ADON stated at the time of the interview Resident #1 was still in the hospital, but she was told he had a below the knee amputation. The ADON said she was unsure of the reason. The ADON stated Resident #1 had an infection that was being treated at the nursing facility with antibiotics. The ADON said Resident #1 would hang his foot off the edge of the bed instead of elevating it on a cushion. The ADON stated Resident#1 would refuse wound car; take the dressing off because he wanted the wound to air dry; and was a heavy smoker. The ADON said the facility tried to have a wound care consultation in the nearby city's wound care clinic prior to the amputation. Interview on [DATE] at 4:42 p.m. the DON stated Resident #1 was admitted to the hospital on [DATE] due to complaint of leg pain on the right side. The DON said Resident #1 was admitted to the facility with the wound and was seen by a wound care consultant company. The DON stated Resident #1 had labs and an x-ray done as well as wound cultures which showed MRSA. The DON said Resident #1's physician referred Resident #1 to a wound care center in a nearby city because they might have more things to treat Resident #1 with. The DON stated Resident #1 was sent to the hospital prior to that appointment. The DON stated she thought Resident #1 needed to go to the hospital because his foot was discolored and Resident #1 would not keep his foot elevated. The DON denied Resident #1 being in constant pain. The DON said Resident #1 received daily wound care and the wound care orders came directly from the wound care specialist. Interview on [DATE] at 12:18 p.m. Resident #1's Responsible Party stated the facility kept him informed of the treatments they were doing. The Responsible Party said he did not know if the treatments worked but he was kept informed. The Responsible Party stated he wondered if Resident #1's amputation could have been prevented. The Responsible Party said the facility was in process of getting an appointment scheduled to see a wound care doctor but then Resident #1 went to the hospital on [DATE] due to leg pain and got it amputated while there thus the appointment was cancelled. Interview on [DATE] at 1:25 p.m. Resident #1's Doctor stated he was aware of the amputation. The physician stated Resident #1 had PAD and that could quickly turn into gangrene. The physician felt the wound care specialists who Resident #1 was seeing at the facility had a good plan going for the resident and he was happy with the plan. Interview on [DATE] at 2:28 p.m. the Treatment Nurse stated Resident #1 was admitted to the facility with an unstageable pressure ulcer. The Treatment Nurse stated she told the physician of wound care consultant's recommendations. The Treatment Nurse stated the wound was stable and Resident #1 had wound care daily. The Treatment Nurse stated she did the wound care on [DATE] prior to Resident #1 going to the hospital and did not notice anything different with the wound. The Treatment Nurse stated Resident #1 complained of pain which was usual, but he had taken his pain medication at that time on [DATE]. The Treatment Nurse said the wound did not look like gangrene to her. The Treatment Nurse stated the wound care consultant would do appointments through telemed which was like Facetime with a cellphone. The Treatment Nurse explained she would take her cell phone into Resident #1's room and show the wound care consultant the wound and the consultant would say what it looked like. The Treatment Nurse was shown the Consultant's Noted dated [DATE] that documented a referral to a podiatrist or vascular doctor. The Treatment Nurse said she did recall the consultant asking for the referral but she just forgot to do it (contact the physician and set up the vascular consult). The Treatment Nurse said she remembered about the vascular consult appointment when the Ombudsman came and asked if it was done on [DATE] (19 days later) and that was when she started to set up the appointment but then the resident had his leg amputated. The Treatment Nurse stated she was aware the Wound Care Specialists recommended Resident #1 be seen by a vascular doctor and have a doppler study to the right foot on [DATE], [DATE], [DATE], and [DATE] but she forgot to get it done. Interview on [DATE] at 4:22 p.m. the Administrator and DON stated their expectation was for the wound care specialists' recommendations to be brought up to the physician by the Treatment Nurse. They stated the physician would usually approve recommendations or change the order as he wanted to. The DON stated she did not know there were orders for Resident #1 to be seen by a vascular doctor since [DATE]. The DON said she should have probably checked on the Treatment Nurse to make sure she was following the recommendations suggested by the wound care specialists . Phone interview on [DATE] at 12:58 p.m. Wound Care Specialist A stated she recommended Resident #1 be seen by a vascular doctor numerous times and for the facility to get a doppler study done. The Wound Care Specialist stated she was told by facility staff that the physician refused the recommendations and the doppler study and had recommended Resident #1's foot just be monitored. The Wound Care Specialist stated she did not know if Resident #1 being seen by a vascular doctor would have prevented Resident #1's amputation but earlier intervention was better than no intervention at all. Phone interview on [DATE] at 1:14 p.m. Resident #1's physician stated he did not say no to the recommendations made by the wound care specialists. The physician said he would not just ask for the resident's leg to just be monitored. The physician stated he would have welcomed recommendations since the wound care specialist saw the wound in person and had a better idea of what to do next. Interview on [DATE] at 1:04 p.m. the Administrator summarized that Resident #1 was admitted with a wound. The Administrator stated Resident #1 was a smoker and was non-compliant with elevating his foot. The Administrator said the Treatment Nurse was monitoring the wound. The Administrator stated fast forward the wound care specialists texted the Treatment Nurse recommendations of a referral to a vascular doctor and it was not done. The Administrator said it was not done and the Treatment Nurse said she missed it. The Administrator said the DON was not getting the wound care specialist's notes so would not get the recommendation. Interview on [DATE] at 2:02 p.m. the DON confirmed there was the same order for a vascular doctor and doppler study for three months. The DON said the Treatment Nurse never turned in the wound care assessments. The DON stated when she asked the Treatment Nurse why it was not done the Treatment Nurse said she did not know how. The DON said she never saw the Wound Care Specialist's reports so she dropped the ball in looking at them. The DON stated her expectation was for skin notes to be turned in and uploaded into the computer system. Phone interview on [DATE] at 3:58 p.m. Wound Care Specialist B stated the Treatment Nurse told her that vascular recommendation was not followed because it was a transportation issue. Wound Care Specialist B said she recommended the vascular doctor every week and she understood it was difficult. Wound Care Specialist B stated she mainly did telehealth appointments with the facility. The Wound Care Specialist stated to her knowledge the facility did not follow through with the recommendation, then the facility informed Wound Care Specialist B that Resident #1 went to the hospital, and they amputated his leg. Wound Care Specialist B said she made the recommendation weekly and the Treatment Nurse told her it was a transportation issue. Wound Care Specialist B said to her knowledge her recommendations were not done. Wound Care Specialist B said she understood the facility was in a rural area and the closest vascular doctor was an hour and half away in the closest city. Wound Care Specialist B said Resident #1's physician was involved because at some point Resident #1 was placed on an antibiotic she did not prescribe. Wound Care Specialist B said she (Wound Care Specialist B) and Wound Care Specialist A had similar recommendations. Wound Care Specialist B said she and the Treatment Nurse talked weekly, but the Treatment Nurse would not always inform her of every change. Treatment Nurse B was informed there was a referral made to the nearest city's wound care clinic and responded, I can't imagine they would get a different result. Wound Care Specialist B repeated she recommended vascular studies and to her knowledge they were never followed up. Wound Care Specialist B stated the last time she saw Resident #1 was [DATE] and the wound looked the same and she made the same recommendation of a vascular consult. Wound Care Specialist B said she was trying to be patient for the facility to get it done and the Treatment Nurse just told her (Specialist B) that it was very difficult to get the tests done. Phone interview on [DATE] at 4:42 p.m. the Treatment Nurse stated Resident #1 received wound care daily and saw the wound care consultant weekly. The Treatment Nurse said in the beginning there were no recommendations. The Treatment Nurse stated at the end the wound care specialists were recommending a vascular, labs, x-rays, cultures - all of it. The Treatment Nurse said she did it all except for the vascular doctor. She said she did not know why did not do it. The Treatment Nurse did not answer when asked why it was not done for three months. The Treatment Nurse said she did not know why she told Wound Care Specialist B that it was a transportation issue, then added it was because she (the Treatment Nurse) overlooked it and did not know what to say. The Treatment Nurse stated one time she told the ADON and the ADON told the treatment Nurse that doppler studies were not done in their city. The Treatment Nurse said she did not know why she did not put the vascular appointment/ doppler study/ orthopedic / podiatrist referrals in her notes when all the other recommendations were in the notes. At the end of the interview, the Treatment Nurse stated, I don't know, I guess I thought I could take care of it myself and now it's too late. Interview on [DATE] at 4:59 p.m. the ADON stated she Resident #1 was noncompliant and smoked a lot. The ADON said the day she sent Resident #1 to the emergency room ; Resident #1 was complaining of a lot of pain to his foot and requested to go. The ADON stated that was the first time she sent Resident #1 to the emergency room for foot pain. The AODN stated there was a nurse's meeting every day and issues that came up were discussed; she said the Treatment Nurse would bring up that wounds were not healing because Resident #1 was noncompliant and would not use a heel cushion and hang his foot off the bed. The ADON stated she was not present if the Treatment Nurse brought up wound care recommendations. The ADON stated she was never told of any referrals. The ADON stated the doppler study statement made by Treatment Nurse was maybe because the facility tried to get a doppler study on another resident about a year ago and the ADON said the hospital at their city did not do them. The ADON stated she should have been made aware of the Wound Care Specialist's recommendations because she was the ADON. The ADON stated under the previous DON, the Treatment Nurse would talk to the ADON about the wounds because the previous DON did not know much about wound care. Interview on [DATE] the DON and Administrator stated whoever got the order for a referral was responsible for notifying the physician and putting in the order. The Administrator stated the facility did go as far as the nearest city. The Administrator stated typically the Transportation Aide would take the resident and a CNA. The Administrator stated appointments to other cities were done on Tuesdays and Thursdays because of the dialysis appointments on Monday/ Wednesday/ Friday. The DON said she was not made aware of any referrals to a vascular doctor, so she got the order for Resident #1 to go to the wound care clinic in the nearest city. The DON said Resident #1 was sent to the emergency room before the appointment could occur. Interview and record review on [DATE] at 12:07 p.m. the Transportation Aide stated she did the dialysis appointments on Monday/ Wednesday/ Friday but on Tuesday/ Thursday she took the residents to other appointments. The Transportation aide said the facility would go where the resident needed to go. The Transportation Aide said she did take residents to the nearest city at least weekly. The Transportation Aide said she did not remember taking Resident #1 to any appointments and she was never told to make an appointment for him. The Treatment Nurse handed over the calendar for 2023 and it did show other residents were taken to other cities for outside appointments. Review of the transportation schedule from [DATE] - [DATE] showed Resident #1 had no appointments made. Review of the facility's policy and procedure on Skin Management: Prevention and Treatment of Wounds, effective [DATE] revealed: Policy: The purpose of this procedure is for prevention and treatment of skin breakdown such as pressure injuries, diabetic ulcers, arterial ulcers, and skin wounds. Procedure: Notification A licensed nurse will notify resident's physician, responsible part, and hospice nurse if on services, with new onset of wounds, deterioration in wound status. Communication of new wounds will be relayed during shift-to-shift report for 24 hours. Treatment: A licensed nurse will obtain order from physician for new skin wounds and transcribe into resident's treatment record for follow up. Review of the facility's online in-service program's for Caring for Pressure Injuries (completed on a rotating basis) revealed: Documentation: Report any deterioration in appearance of the injury to the nurse in charge or the health care provider. Record unexpected outcomes and related nursing interventions. Review of the facility's online in-service program's in-service for Assessing Wounds (completed on a rotating basis) revealed: Procedure Guideline for Assessing Wounds. Verify the health care provider's orders. Follow up: Compare the wound assessment to the previous assessment, and determine progress toward healing. If there is no improvement, or if you notice deterioration, consider a wound care consultation. Lack of wound healing is often related to infection. Notify the health care provider and wound, ostomy, and continence nurse or team. The Administrator and DON were informed an Immediate Jeopardy on [DATE] at 2:55 p.m., due to the above failures and provided the IJ template. A plan of removal was requested at that time. The Plan of Removal was accepted on [DATE] at 12:25 p.m,. and included the following: All orders with Wound Care Company will be reviewed with DON within 24 hours of visit. Wound care company will round with Treatment Nurse, DON, and/or ADON during visit. Wound Care Consultant will e-mail all orders, recommendations etc. to DON and Treatment nurse Administrator reviewed with DON all physician, pharmacy, and support services to be reviewed within 24-hours.; recommendations to be sent, orders written and received. Administrator will review all contracted orders and recommendations with DON and Interdisciplinary Team within 48 hours of exit. Administrator or DON will attempt to exit with all contracted support at end of each visit and/or will review upon receipt. DON/ADON will assist in reviewing all skin issues on a daily/weekly and as needed basis. Treatment nurse/ Charge Nurse will report all new skin issues immediately to DON/ADON immediately. Treatments and recommendations to be reviewed and entered that day. Intervention will be reviewed in morning nurse's meeting as to progress. Reviewed Morning Meeting, Standards of Care, Trends during QA meetings. DON/ADON will do spot checks on skin. Skin assessments by wound/charge nurses are to be completed daily; any skin issues that are discussed in nurse's meeting or on the 24-hour report will be addressed and noted. DON to monitor weekly. Treatment Nurse/Charge Nurse and/or MDS Nurse to ensure all treatments are care planned, orders written, documentation completed. Treatment Nurse/ Charge Nurse to document all new treatments, skin tears, rashes, bruises etc. Care Plan to be updated by nurse/ MDS nurse of treatments' clear documentation in facility's documentation program of notification to DON, Medical Director, and/or primary care physician. DON/ADON to monitor nursing meeting, stand up meeting, Standards of Care. Treatment Nurse, DON, ADON and/or designee may attend Infection Preventionist in-services and training. ADON/Infection Control Preventionist will educate and assist all wounds that have infections - monitoring and updating treatment to prevent spread. Wound log to be completed in a timely manner. Treatment Nurse and/or designee will attend QA/ Quality Improvement Performance Plan meetings. Quality Improvement Performance Plan Component will cover all skin issues, will review wounds and skin system. Theis will address meeting Quality Improvement Plan metrics. The component will be monitored by the entire interdisciplinary team for the next year with Quality Improvement Performance Plan until the facility is at goals set. To be used for preventative care. Observation on [DATE] at 10:54 a.m. surveyor observed Administrator calling the Medical Doctor and handing the phone to the DON for the wound care specialist's recommendation on Resident #2. Facility provided signed one on one in-services by facility staff on [DATE]. Review of the 24-hour report for [DATE] and [DATE] revealed appointments needed to be made were written in red by the resident's name. If a follow up appoint was made it was written under it in a black pen. Review of the calendar on the ADON's wall on [DATE] at 12:00 revealed appointments were scheduled. Immediate Action - a 100% skin sweep was completed by the DON, the Corporate Compliance RN, the ADON and LVN C. No new pressure ulcers were identified. Interview on [DATE] at 10:40 a.m. the Administrator stated all the floor nurses knew the referral process prior to the in-service, but all full-time staff had been in-serviced. The Administrator stated the in-service was done verbally and then the staff had to take a test on the facility's in-servicing program. The Administrator stated upcoming appointments were already on the morning meeting report so there was no reason to add it. The facility provided all one-on-one sign-in forms and the in-servicing program completion. The Treatment Nurse was unavailable to verify in-services and understanding of corrective action. The administrator was notified the IJ was removed on [DATE] at 12:43 p.m. however, the facility remained out of compliance, at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy due to the facility's need to continue to monitor the implementation and effectiveness of their Plan of Removal.

Based on observation, interviews and record reviews, the facility failed to provide appropirate treatment and services to prevent urinary tract infections for one resident (Resident #8) of three residents reviewed for catheter care. Resident #8's catheter drainage collection bag was left on the floor. Resident #8 has history of urinary tract infections. This deficient practice could affect residents with catheters and could result in cross contamination of germs and could result in a urinary tract infection (a painful infection of the urinary system, which includes the kidneys, bladder, urethra, and ureters). The findings included: Review of Resident #8's face sheet dated 04/06/2023, revealed resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #8's diagnoses include sepsis due to methicillin resistant staphylococcus aureus (staph infection that is difficult to treat because of resistance to some antibiotics), stroke, acute respiratory failure, neuromuscular dysfunction of bladder (urinary conditions in people who lack bladder control due to brain, spinal cord or never problem), repeated falls, dementia, cerebral aneurysm, type-2 diabetes, and hypertension (high blood pressure). Review of Resident #8's quarterly MDS assessment dated [DATE] revealed Resident #8 had a BIMS score of 0 which indicated he was severely impaired cognitively. Resident #8 with Indwelling catheter, always incontinent of both urinary and bowel continence. Review of Resident #8's care plan dated 4/6/2023 revealed Focus: resident has Foley Catheter and is at risk for Increased Urinary Tract Infections: Date Initiated: 10/05/2022. Interventions: CATHETER: The resident has 16fr catheter; Position catheter bag and tubing below the level of the bladder and away from entrance room door; Check tubing for kinks each shift; Monitor for signs and symptoms of discomfort on urination and frequency; Monitor/document for pain/discomfort due to catheter; Monitor/record/report to medical doctor for signs or symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 04/06/2023 at 9:45 a.m., HHSC Investigator walked by an opened door room [ROOM NUMBER] and observed Resident #8 lying in bed with a drainage collection bag lying flat on the floor next to his bed. Investigator knocked on the door and Resident #8 sound asleep. During an interview on 04/06/2023 at 9:50 a.m., RN C said that staff had just given Resident #8 a bed bath approximately 15 to 20 minutes before. RN C said that the drainage collection bag was supposed to be attached to the bed and not just left lying on the floor. RN C said the risk of the drainage collection bag left lying on the floor is infection control as urine may leak on the floor. RN C said Resident #8 was at risk of urinary tract infections and had history of urinary tract infections last noted during a hospital stay on November 30th, 2022. During an interview on 04/06/2023 at 3:30 p.m., DON said the drainage collection bag should never be left on the floor. DON said the collection bag should be attached to the side below bladder level of the resident. DON said the collection bag being on the floor is an infection control issue due to resident's risk of urinary tract infections. DON said that CNAs and Nurses were responsible to ensure that the collection bag is securely attached to the bed. DON said that monthly in-services are conducted with all facility staff to include infection control. Review of facility Infection Control policy revised 01/15/2022, reads in part this community's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of the infection control policies and practices are to prevent, detect, investigate, and control infections in the community. Review of facility policy Catheters-Insertion and Care dated 04/2021, reads in part it is the policy of this community that the resident with a urinary catheter will be provided services in a safe and appropriate manner to minimize the risks of urinary tract complications. Procedures include secure urinary drainage bag below the level of the bladder and keep off the floor.

Based on observation, interview, and record review the facility failed to ensure residents were free from neglect for 1 (Resident #3) of 3 residents whose care was reviewed for neglect as evidenced by: 1. The facility failed to have a system in place that insured the facility's only transportation van was in good working order and ensure manual wheelchair securement straps were in proper working order and failed to ensure proper working condition of the wheelchair lift. This resulted in Resident #3 having 2 falls one on [DATE] in which he fell inside the van with no injury and one on [DATE] in which he fell off the van lift which resulted in an occipital hematoma to the back of his head. 2. The facility failed to ensure staff were trained to ensure the wheelchair anti-tipping bars and the safety features on the van were in good repair, functional and used appropriately during transportation. These failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm, with a scope of isolated due to the facility needing more time to monitor the plan of removal for effectiveness. These failures placed the residents at risk for serious injury or death if not secured properly in the van or use of a wheelchair lift that was in poor working condition. Findings include: Record review of facility policy dated [DATE] titled Abuse Policy revealed: The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property . Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, care takers, friends, or other individuals . The administrator and/or designee are responsible for maintaining ALL Facility policies that prohibit abuse, neglect, and misappropriation of funds/personal belonging, involuntary seclusion, or corporal punishment . Train all employees Identification of possible problems that need investigation Investigation allegations . The facility is licensed under all applicable local, state, and federal laws and regulation, and will provide services in compliance with these laws as such to protect residents . Training: All employees are required to be trained in issues related to abuse prohibition practices . Prevention: The facility has in place policies and procedures to aid in the prevention of abuse, neglect, mistreatment, exploitation, involuntary seclusion, and misappropriation of resident property . Reporting/Investigation: The law requires the abuse coordinator/designee, or employee of the facility who believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect or exploitation caused by another person to report the abuse, neglect or exploitation . Investigations will focus on determining if the abuse occurred, the extent of the abuse, and potential cause(s) . Record review of Resident #3's electronic face sheet accessed on [DATE] revealed a [AGE] year old male with an orginal admission date of [DATE] with a most recent admission date of [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #3's most recent Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 which indicates an intact cognition. It also revealed Resident #3 vision is severely impaired and he does not wear corrective lenses. Resident #3 does not have a history of rejecting care per the MDS. Resident #3 requires extensive assistance with bed mobility 2 person assist, eating 1 person assist, and was totally dependent for transfers 2 person assist, dressing 2 person assist, and personal hygiene 2 person assist. The MDS also revealed Resident #3's mobility device was a wheelchair. Resident #3 was also always incontinent of bladder and bowel. Resident #3 had one fall coded in under J1900. The MDS also confirmed that Resident #3 was receiving [MEDICAL TREATMENT]. Record review of the facility investigation for the fall on [DATE] revealed the facility did not investigate the incident until the fall on [DATE]. Record review of facility investigations for the fall on [DATE] and [DATE] revealed Resident #3 was evaluated at theER on [DATE] and released with no special treatment needed and one minor injury noted; Resident #3's wheelchair was replaced on [DATE]; the facility van was benched the night of [DATE] and the facility received a loaner van [DATE]; In-servicing of Securing Residents in Van, Driver and Vehicle Safety Policy, was conducted [DATE];[DATE] they did a competency demonstration with the 3 drivers; in-serviced on anti-tippers, completed 1 to 1 in-service for operating lift of the van, and Abuse and Neglect in-servicing. On [DATE] they in-serviced on lift operation, 2 persons for all transfer (travel in pairs) and added another in-service covering Lift operation procedure, 2 person all transfers: related to using the loaner van; The facility inspected all other resident chairs and no modifications where needed; On [DATE] driver RCP A the driver from the fall on [DATE] was suspended but the driver RCP C from the fall on [DATE] was never suspended. Record review of Resident #3's progress notes revealed on [DATE] he fell in the van hitting his head, he was assessed by a nurse, given a PRN pain medication, and taken back to the [MEDICAL TREATMENT] center. Progress notes also revealed on [DATE] Resident #3 fell backwards of the facility van lift onto the pavement, hematoma was noted to the back of his head, he was sent via ambulance to the emergency room (ER), there he received x-rays and Computed [NAME]ography (CT) scan with no serious injuries found. After examination at the ER Resident #3 went to the [MEDICAL TREATMENT] center. Record review of Resident #3's electronic chart accessed on [DATE] revealed on [DATE] and [DATE] Resident #3 received a fall assessment and neuro checks In an interview on [DATE] at 9:47 a.m., Resident #3 stated on [DATE] it felt like the driver made a sudden stop but was not driving recklessly his chair fell backwards, he hit his head and it forced his head forward, but he never fell out of his chair. Resident #3 stated they have used two people to transport him since he has been at the facility. His understanding of why they use two people is to have one person drive and the other person is to take care of the people in the van. Resident #3 said that both people work together when using the lift for him. On [DATE] Resident #3 only remembers there being one person and just one person helping him on the lift. He does not know what made his chair fall, all he remembers is falling backwards and his chair falling with him. Resident #3 heard a lady say it was my fault and hearing a lot of people around him while he was on the ground, and them telling him an ambulance was coming. Resident #3 recalled being assessed at the hospital, going to [MEDICAL TREATMENT], and receiving a new chair to come home in. Resident #3 really likes his new chair. Record review of Resident #3's electronic care plan accessed on [DATE] revealed Resident #3 was at risk for falls as evidenced by falls on [DATE],[DATE], [DATE], and [DATE]. The following interventions where in place: Resident will use Broda chair for transportation/mobility. In a record review of Resident #3's care plan dated [DATE] and the following items had been initiated: A durable medical equipment company will inspect Broda chair monthly for routine maintenance and needed repairs, with an initiated date of [DATE]. Resident will have 2 persons at all times to assist with loading, transporting, and unloading from the facility van to ensure resident safety. 1 attendant will be at the lift beside the resident while the other attendant is operation the lift, with initiated date of [DATE]. Resident will use Broda chair for transportation/mobility, with an initiated date of [DATE]. Record review of Resident #3's order recap report dated [DATE] revealed the following: Monitor Hematoma to back of head every shift until healed, every day and evening shift for Hematoma with a start date of [DATE] with no stop date. [MEDICATION NAME] HCI 50 milligrams every 6 hours as needed for pain with a start date of [DATE] with no stop date. Record review of Resident #3's Medication Administration Record [REDACTED]. (Note the increase in pain level and frequency since the first fall on [DATE].) In an interview on [DATE] at 12:45 pm with Executive Director of Operation (EDO) observation of the van that was used to transport residents on [DATE] and [DATE] was requested. This investigator and the EDO went outside together to look at the van and EDO could not find the van. EDO stated it must have been removed by corporate when she was on vacation. (Note the van was parked out in the front parking lot, but the EDO was not aware of it). EDO could not produce any documentation of van, van lift, or wheelchair securement straps inspections. EDO could not provide evidence of staff training for the van, van lift, and wheelchair securement straps. At this time EDO informed me that earlier that day she had terminated the maintenance man and they could not find any of his in-service documentation or inspection logs. In an interview on [DATE] at 1:30 pm RCP A revealed she was the driver the day of [DATE] and she had a Hospitality Associate (HA) in the van with her due to the lift being broke since October. She stated Resident #3 was secure and when they stopped at a stop light he fell backwards. RCP A again stated Resident #3 was secure, and she is unsure how he was able to fall backwards. After the fall RCP A did notice the anti-tippers where not facing down as they should have been, but she was unaware of the need to check them or how they should be facing, since they had not been in serviced on the anti-tippers till the day of [DATE] and the last transportation training she had received prior to [DATE] was in (YEAR). RCP A feels when she started driving she had in servicing on proper securing of a wheelchair and she feels confident she had secured Resident #3 securely, and that she has been a driver for several years with no history of accidents. Observation [DATE] at 2:30 pm. RCP A accompanied this surveyor to the van and used her key to let us in. The van did appear to be an older model van that was not very clean on the inside with small bits of debris, small bits of trash, and stained torn gray carpet. The lift was accessed from double doors at the back of the van. Inspection of the wheelchair tie downs revealed two racket style tie downs for the back of the wheelchair that appeared to be in good working order. Two manual tie downs with a tension clasp for the front of the wheelchair, and the tension clasp was not in good working order. With little effort the straps could be pulled through the tension clasp in both directions. With vibration and movement of the chair as it is going down the road the straps could become loose and allow for more movement of a wheelchair. The electric control to the lift was also not in working order and facility staff had to use the backup manual pump lift to raise and lower the lift, and unless you are a tall person you would have to access this backup manual pump from inside the van leaving a wheelchair bound person alone on the lift. The lift also did not have a lift platform safely strap to help prevent a wheelchair from rolling off the lift or tilting backwards off the lift. When using the backup manual pump to work the lift it causes a delay in the engagement of the outer barrier latch and the raising of a lift barrier further increasing the chances of a wheelchair rolling backwards off the lift. In an interview on [DATE] at 2:45 pm HA A stated she has been an employee of the facility for 3 weeks. HA A stated she had never received training on transporting or securing residents during transport when she started and still to this day has not received training. [DATE] was the first time HA A had transported residents. HA A stated, on that day, RCP A loaded Resident #3 in the van and from what she could see he looked secure. She stated RCP A was not driving recklessly. HA A stated they came to a stop at a light and Resident #3 stated yelling for help. HA A stated there was no sound of a fall or something hitting the van, even the other ladies they where transporting heard nothing till he yelled out. RCP A pulled over on the side of the road, assessed Resident #3, and RCP A stayed in the back with Resident #3. HA A stated that she drove the ladies to [MEDICAL TREATMENT] and back to the facility. Resident #3 was assessed, took medications, and returned to [MEDICAL TREATMENT] with RCP A driving. (Note: HA A was not a certified nursing assistant, per facility policy a driver must be a certified nursing assistant.) Record review of Resident #3's electronic chart accessed on [DATE] revealed on [DATE] Resident #3 received a fall assessment that revealed he had fallen before, had an impaired gait, and was high risk for falls, along with nursing progress notes to confirm the falls. Record review of an undated facility policy received on [DATE] titled Van Policies revealed the following: A van driver must be a certified nursing assistant. A van driver must be CPR certified. A van driver will have a cell phone. It is the policy of all Focused Post-Acute Care that any resident transported in the facility van is secure . (Note the policy did not address ensuring safety features of the van which would include the wheelchair lift and wheelchair securement straps. The policy did not address a system of monitoring or checking the securement systems to ensure they were in safe, working condtion, and it did not address staff competency and training regarding safely transporting wheelchair bound residents in the van to include use of the lift and properly securing the resident.) In an interview and observation on [DATE] at 1:20 RCP C she stated she has been an employee of the facility for 6 years and has never held the title of a driver but has been transporting resident for all of her time employed at the facility and has never had an accident. RCP C said she is pretty sure she received in servicing of transporting residents and use of the van lift prior to any transporting of residents. RCP C stated 3 months ago they were in serviced on use of the lift because the electric switch to operate the lift was broken and they had to start using the backup manual pump. RCP C stated that the employees requested two people go for transporting of wheelchair residents once they had to start using the backup manual lift. RCP C stated they never in serviced the staff to use two people but the facility was aware they were using two people. RCP C stated on [DATE] [MEDICAL TREATMENT] had called and requested Resident #3 come early to [MEDICAL TREATMENT] and this was at the same time several staff take breaks and that administration has morning meeting. With no one available RCP C had to transport Resident #3 alone. RCP C is tall and is able to use the manual back up lift while standing outside the van, allowing her to be at the side of the wheelchair. RCP C stated that her and Resident #3 were singing laughing and talking while she was raising the lift and next thing she knew he was on the ground. RCP C is unsure how he fell but saw Resident #3 on the ground in in his chair laying on his back. RCP C recalls the DCO coming out and assessing Resident #3, and then he was sent to the ER via ambulance. She does not know if his wheel chair had anti-tippers that day or not. RCP C added that administration witnessed the fall because they were watching her use the lift from the conference room. Observation revealed there was a very clear view of van loading area from the conference room. In an interview on [DATE] at 2:25 pm DCO and RDCO it was revealed that the electrical action of the lift had been broken for less than a month, but that staff could use the backup manual lift. DCO was witness to the fall of Resident #3 off the van wheelchair lift on [DATE]. At the time of the fall she was sitting in the conference room for morning meeting which offers full view of the transportation van loading area. DCO stated Resident #3 chair tipped backwards and he fell backwards off the lift while still sitting in his chair. DCO said Resident #3 was sent to the ER via ambulance. Resident #3 was assessed and found to have no serious injuries and sent to [MEDICAL TREATMENT] after the fall. Resident #3 was transported back to the facility in the same facility van, but in a new Broda chair. DCO stated that Resident #3 had his wheelchair seat lowered and anti-tippers added to his wheel chair in (MONTH) of 2019 and there was no in-servicing given to staff on proper use of anti-tippers and the need for anti-tippers was never addressed in his care plan. DCO stated after the fall of Resident #3 on [DATE] that day they did a competency demonstration with the 3 drivers; in-serviced on anti-tippers, completed 1 to 1 in-service for operating lift of the van, and Abuse and Neglect in-servicing. On [DATE] they in-serviced on lift operation, 2 persons for all transfer (travel in pairs) and added another in-service covering Lift operation procedure, 2 person all transfers: related to using a different van. DCO also stated on [DATE] Resident #3 was assessed by Habilitation Therapy for a new chair and new Broda chair was recommended. They inspected all other resident chairs and no modifications where needed. On [DATE] corporate brought a loaner van from a sister facility and the old van was taken out of service and DCO is unsure as to why. DCO stated driver RCP C will not be suspended. As for the fall on [DATE] DCO stated Resident #3 was assessed at the facility, no inspection of the van's safe operation was conducted, no inspection of van wheelchair securement straps was completed, no inspection of Resident #3's wheelchair was completed, and no facility investigation was conducted. DCO said on [DATE] the maintenance man inspected the wheelchair and said it was fine. DCO confirmed there was also no in-servicing done after the fall on [DATE]. DCO said on [DATE] the driver RCP A was suspended for the fall on [DATE]. DCO stated the fall on [DATE] was not reported until [DATE] because there was no serious injury and there was no history of such events with this resident. DCO decided to report the [DATE] fall on [DATE] because both falls concerned the same resident, the same van, and for transparency purposes. In an interview on [DATE] at 3:30 pm EDO stated the electric controls to the van lift had only been broken for about a month and drivers where only required to use two people for transferring wheelchair resident since [DATE]. EDO stated they will continue to use two people with the current van, but when they receive a brand-new van the need for two people will be evaluated. EDO could not give a reason as to why on [DATE] there were two staff transporting (RCP A and HA A) Resident #3, if it was not being done prior to [DATE]. In an interview on [DATE] at 4:30pm, RDCO said the van was taken out of service for the whole facility as a precautionary step until they could determine safety of the van, and the reason it is not being placed back in service is because they can't 100% say the van is safe. RDCO explained a safety strap for the lift is a new item added to lifts and he is not aware they are a requirement. RDCO added he does not have access to the manufacturer's recommendations for the lift. In an interview on [DATE] at 5:54 p.m., RCP D stated she has been driving the van since 2019 and became a regular driver in (MONTH) or (MONTH) of 2019, she was in-serviced on strapping in residents, the lift, and how to use the safety belt but cannot recall when but feels it was in the summer. RCP D stated she cannot recall any transportation related in-servicing until [DATE]. RCP D stated she began asking for an assistant for transportation in (MONTH) 2019 and the facility was aware she was taking another person. RCP D stated it is to physically hard for one person with having to use the backup manual lift and that is not safe for the resident since you have to be inside the van during a manual lift. RCP D stated as far as she knows using two people will remain in place and she feels it is safer for the residents to have two people. RCP D stated she feels the newer van is much safer for transport of residents, the wheelchair straps are more secure and much easier to operate, and she likes the added safety feature of the lift strap on the newer van. In an interview on [DATE] at 9:39 a.m., Director of Habilitation Therapy (DOH) stated habilitation therapies did not make any recommendation for anti-tippers for Resident #3 wheelchair. DOH has seen the old chair which she feels was not a safe chair for a blind resident with bilateral [MEDICAL CONDITION] because balance is an issue with such a resident, and in her opinion the type of anti-tippers placed on the old chair where not an effective anti-tipper. In an interview on [DATE] at 11:35 a.m., Resident #1 recalls being in the van on [DATE]. Resident #1 states RCP A secured Resident #3 wheelchair. Resident #1 stated the driver was driving normal but when she broke for a red-light Resident #3 fell backwards. Resident #1 confirmed two people go to transport Resident #3 for the whole time she has gone to [MEDICAL TREATMENT] Resident #3 has gone also. In an interview on [DATE] at 1:30 pm the EDO stated they will have a new maintenance man starting in two weeks. She will have him check the van monthly and have the drivers check the van weekly, and they are in the process of creating a check off sheet. On [DATE] at 3:15 pm the Executive Director of Operations (EDO) and Director of Clinical Operation (DCO) were informed of the identification of an Immediate Jeopardy (IJ) situation and the need for a plan of removal. The EDO was given an IJ template. Review of the facility's Plan of Removal document received on [DATE] revealed: Incident: ,[DATE]/ 2020- During a transport to [MEDICAL TREATMENT] Resident #3 was in the back of the van strapped down and RCP A heard him say he fell when she stopped at a red light. She pulled over and her and the HA A that was in the van with her got Resident #3 back upright and brought him back to the facility to be assessed by the nurse. Investigation findings [DATE] In speaking to RCP A and HA A, Resident #3 was strapped down and his wheels were locked. Resident #3 states that he was strapped down but did not feel secure and that he told RCP A that he did not feel secure. Yesterday when we did safe surveys, he said that he felt safe in the van when he was secured in it properly. He does state that he felt a little confused but does understand that Friday was an accident. Incident [DATE] Resident #3 was being loaded into the van via the lift. The lift is a manual pump and RCP C was pumping the lift to raise Resident #3 up to the back of the van to place him in. During the pumping of the lift DCO was sitting in the morning meeting facing the front of the building and could see the van. DCO stated Resident #3 tipped over the back of the lift and fell off. He hit his head, and everyone rushed out to see if he was ok. Resident #3 was able to let DCO know that his back was hurting, and she observed a hematoma on the back of his skull. EMS was notified, and he was sent to the hospital for evaluation. Investigation findings [DATE] During the loading of Resident #3 with the lift on the van he went backwards and fell off the lift. His wheelchair fell backwards off of the lift which was about 5 inches off the ground when he fell over. He was sent to ER for evaluation and did not have any major injuries due to the fall. The wheelchair was locked, and anti-tippers were in place. Investigation revealed: On Thursday (MONTH) 16, 2020 EDO inspected facility van and checked seatbelts, anchoring ports, and the lift gate. After inspection by EDO B decommissioned the transportation van. After the incident, an in-service with return demonstration was provided to all Licensed Nurses and Certified Nurse Aides, and several ancillary staff on the safe techniques for transporting residents in the van. Resident #3 w/c was assessed by therapy and he was given a different w/c. All residents who are transported via the facility's van and are wheelchair bound have the potential to be affected by this alleged deficient practice. All licensed nursing staff and Certified Nurse Aides are trained and checked off for the proper safety technique for residents being transported in the facility's van. Training will occur upon hire during orientation and at least annually. The facility van lift and strapping mechanics was inspected for maintenance on [DATE] by EDO B. The van was placed out of service due to [DATE] and a different van was brought on site to use in all transportations. This van was last inspected straps and lift on (MONTH) 16, 2020 and mechanically inspected this (MONTH) 2020 by sister facility's Director of Plant Operations. The van will continue to be inspected on a routine basis every 6 months or upon 5000 miles or as needed. All w/c's will be checked for proper functioning every quarter by the Maintenance Director and/or designee. All Licensed Nurses and Certified Nurse Aides have been asked to perform a return demonstration on loading residents who use wheelchairs, boarding standees on the lift, securing residents in wheelchairs, and securing ambulatory riders. This training was completed on [DATE]-[DATE]. The facility will address corrective action by training and Inservice all license nurse and nurse aide/ medication aide on check list specific to the focused care van, on the skill check off, including loading riders who use wheelchairs, power chair vs. wheelchair, Boarding standees on the lift, procedures for securing wheelchair checklist, procedures on securing riders. DCO will monitor lead transportation personnel to ensure that quarterly check list for the van in additional to the quarterly skill care and the checklist entails details specifically to the community van. (Please see attached the community van checklist) DCO will monitor lead transportation personnel to ensure that quarterly check list for the van is being implemented. Quarterly Skill Care check off for Direct care staff. Maintenance Director will check the van lift every month to ensure proper functioning. The facility will conduct biweekly maintenance checks on seatbelts, anchors, lift, and all internal operational parts to ensure that community van is in compliance. All nursing staff will be trained on proper functioning and appearance of the lift and proper appearance and functioning of the safety straps. Staff will be educated if any of these items appear to be malfunctioning then they are to stop and not transport the resident. They will then contact the director of nursing or administrator to report the malfunction at which point the van will be inspected and if needed repairs will be made before another resident is transported, if transportation aide and/or assistant know the van lift and/or straps are not working properly to STOP, Report and Don't Transport. Director of Maintenance and/or any trained Administrative designee in-service and train all staff that will be providing transportation. Quarterly in-services will be conducted on transportation. Staff will be trained and in-services on proper inspection of transportation van, proper loading and unloading of Elders using wheelchairs for transportation, attendants will be in-services and trained on their role during loading/unloading and during transport. Facility administrator was counseled by regional RVPOWT regarding the need to correct concerns raised by staff. This counselling took place on (MONTH) 20th at which time the administrator was instructed to report and investigate all incident that took place within the community. Then on (MONTH) 23rd, the administrator was counselled on the need to follow up on all concerns raised by staff ensuring that they are addressed appropriately and in a timely manner. Residents who are transported in the facility van with special medical equipment needs; examples BROTA chair, anti-tippers, other durable medical equipment, will have a care plan addressing the specific transport need of the resident. All transportation training will be reviewed and monitored by the EDO and DCO in the facility's monthly QAPI meeting. The EDO, DCO, and/or trained designee will watch at least one resident transport weekly for the next 4 weeks to ensure proper procedures are being performed. POR Verification Record review on [DATE] at 11:47 am the facility had in-serviced on Use of check off/transport log for van which included a daily vehicle inspection sheet, transportation log, weekly vehicle inspection sheet, post trip inspection sheet, and monthly vehicle inspection sheet. The sign in sheet was dated [DATE] and included 10 signatures. 3 of the 10 signatures included night personal 2 Certified Nurse Aide (CNA) and 1 License Vocational Nurse (LVN). The other 7 signatures where day time employees and included 2 CNAs, 2 nurses, 2 office personal, and 1 house keeping personal. (Note RCP D and Employee A's signatures where on this in-service and in-servicing form [DATE] addressing Lift operation procedure, 2 person for all transfers (Travel in pairs).) In an observation and interview on [DATE] at 12:35 pm it was time to transport resident to a local [MEDICAL TREATMENT] center and included in this transport was Resident #3. The loaner van appeared newer, in better cosmetic condition, and much cleaner. All four wheelchair securement straps were a much newer easier to work system that self-tension and self-lock, and the seatbelt for a wheelchair resident had a shoulder belt as the old van only had a lap belt. Observed RCP D and Employee A follow the vehicle inspection checks and load Resident 1 who is ambulatory with a walker with no concerns. While RCP D moved the van to the loading area observation of Employee A he demonstrated correctly the loading/unloading and transportation of residents utilizing wheelchairs.was conducted. During observation [DATE] at 13:35 the lift did not work with the electrical controls and RCP D had to utilize the backup manual lift from inside the loaner van. When using the lift there was no engagement of the outer barrier latch which caused the need for the lift barrier to be engaged manually putting wheelchair residents at risk of rolling off the lift. Employee A manually raise the lift barrier. The loading of two residents began at 12:35 and was not completed till 1:20. Employee A was a last minute replacement because the facility could not find the employee who was to be the transportation attendant according to the EDO. In an interview [DATE] at 2:02 pm RCP [NAME] revealed she has been a transportation attendant twice since her employment and both times where to take [MEDICAL TREATMENT] residents. First time was with employee RCP D. The second time was with the terminated maintenance man she added on the way back from [MEDICAL TREATMENT] the van over heated and stopped running she believes this happened in (MONTH) of 2019. S

Based on observation, interview, and record review the facility failed to ensure the resident enviroment remained free of accident and hazards as possible for 1 (Resident #3) of 3 residents whose care was reviewed for accidents. 1. The facility failed to ensure the facility van was free from accident hazards by not ensuring the van lift and wheelchair safety straps were in working condition which resulted in Resident #3 having one fall in the van while being transported on [DATE] with no injury. On [DATE] Resident #3 fell off the van lift which resulted in an occipital hematoma to the back of his head. 2. The facility failed to ensure staff were trained to ensure wheelchair anti-tippers, the safety fasteners where functional and used appropriately during transportation. These failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of potential for more than minimal harm at a scope of isolated due to the facility needing more time to monitor the plan of removal for effectiveness. These failures placed the residents at risk for serious injury or death if not secured properly in the van or use of a wheelchair lift that was in poor working condition. Findings include: Record review of Resident #3's electronic face sheet accessed on [DATE] revealed a [AGE] year old male with an orginal admission date of [DATE] with a most recent admission date of [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #3's most recent Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 which indicates an intact cognition. It also revealed Resident #3 vision is severely impaired and he does not wear corrective lenses. Resident #3 does not have a history of rejecting care per the MDS. Resident #3 requires extensive assistance with bed mobility 2 person assist, eating 1 person assist, and was totally dependent for transfers 2 person assist, dressing 2 person assist, and personal hygiene 2 person assist. The MDS also revealed Resident #3's mobility device was a wheelchair. Resident #3 was also always incontinent of bladder and bowel. Resident #3 had one fall coded in under J1900. The MDS also confirmed that Resident #3 was receiving [MEDICAL TREATMENT]. Record review of the facility investigation for the fall on [DATE] revealed the facility did not investigate the incident until the fall on [DATE]. Record review of facility investigation dated [DATE] for the fall on [DATE] and [DATE] revealed Resident #3 was evaluated at theER on [DATE] and released with no special treatment needed and on minor injury noted; Resident #3's wheelchair was replaced on [DATE]; the facility van was benched the night of [DATE] and the facility received a loaner van [DATE]; In-servicing of Securing Residents in Van, Driver and Vehicle Safety Policy, was conducted [DATE];[DATE] they did a competency demonstration with the 3 drivers; in-serviced on anti-tippers, completed 1 to 1 in-service for operating lift of the van, and Abuse and Neglect in-servicing. On [DATE] they in-serviced on lift operation, 2 persons for all transfer (travel in pairs) and added another in-service covering Lift operation procedure, 2 person all transfers: related to using the loaner van; The facility inspected all other resident chairs and no modifications where needed; On [DATE] driver RCP A the driver from the fall on [DATE] was suspended but the driver RCP C from the fall on [DATE] was never suspended. Record review of Resident #3's progress notes revealed on [DATE] he fell in the van hitting his head, he was assessed by a nurse, given a PRN pain medication, and taken back to the [MEDICAL TREATMENT] center. Progress notes also revealed on [DATE] Resident #3 fell backwards of the facility van lift onto the pavement, hematoma was noted to the back of his head, he was sent via ambulance to the emergency room (ER), there he received x-rays and Computed [NAME]ography (CT) scan with no serious injuries found. After examination at the ER Resident #3 went to the [MEDICAL TREATMENT] center. Record review of Resident #3's electronic chart accessed on [DATE] revealed on [DATE] and [DATE] Resident #3 received a fall assessment and neuro checks In an interview on [DATE] at 9:47 a.m., Resident #3 stated on [DATE] it felt like the driver made a sudden stop but was not driving recklessly his chair fell backwards, he hit his head and it forced his head forward, but he never fell out of his chair. Resident #3 stated they have used two people to transport him since he has been at the facility. His understanding of why they use two people is to have one person drive and the other person is to take care of the people in the van. Resident #3 said that both people work together when using the lift for him. On [DATE] Resident #3 only remembers there being one person and just one person helping him on the lift. He does not know what made his chair fall, all he remembers is falling backwards and his chair falling with him. Resident #3 heard a lady say it was my fault and hearing a lot of people around him while he was on the ground, and them telling him an ambulance was coming. Resident #3 recalled being assessed at the hospital, going to [MEDICAL TREATMENT], and receiving a new chair to come home in. Resident #3 really likes his new chair. Record review of Resident #3's electronic care plan accessed on [DATE] revealed Resident #3 was at risk for falls as evidenced by falls on [DATE] and [DATE]. The following interventions where in place: Resident will use Broda chair for transportation/mobility. In a record review of Resident #3's care plan dated [DATE] revealed the following items had been initiated: A durable medical equipment company will inspect Broda chair monthly for routine maintenance and needed repairs, with an initiated date of [DATE]. Resident will have 2 persons at all times to assist with loading, transporting, and unloading from the facility van to ensure resident safety. 1 attendant will be at the lift beside the resident while the other attendant is operation the lift, with initiated date of [DATE]. Resident will use Broda chair for transportation/mobility, with an initiated date of [DATE]. Record review of Resident #3's order recap report dated [DATE] revealed the following: Monitor Hematoma to back of head every shift until healed, every day and evening shift for Hematoma with a start date of [DATE] with no stop date. [MEDICATION NAME] HCI 50 milligrams every 6 hours as needed for pain with a start date of [DATE] with no stop date. Record review of Resident #3's Medication Administration Record [REDACTED]. (Note the increase in pain level and frequency since the first fall on [DATE].) In an interview on [DATE] at 12:45 pm with Executive Director of Operation (EDO) observation of the van that was used to transport residents on [DATE] and [DATE] was requested. This investigator and the EDO went outside together to look at the van and EDO could not find the van. EDO stated it must have been removed by corporate when she was on vacation. (Note the van was parked out in the front parking lot, but the EDO was not aware of it). EDO could not produce any documentation of van, van lift, or wheelchair securement straps inspections. EDO could not provide evidence of staff training for the van, van lift, and wheelchair securement straps. At this time EDO informed me that earlier that day she had terminated the maintenance man and they could not find any of his in-service documentation or inspection logs. In an interview on [DATE] at 1:30 pm RCP A revealed she was the driver the day of [DATE] and she had a Hospitality Associate (HA) in the van with her due to the lift being broke since October. She stated Resident #3 was secure and when they stopped at a stop light he fell backwards. RCP A again stated Resident #3 was secure, and she is unsure how he was able to fall backwards. After the fall RCP A did notice the anti-tippers where not facing down as they should have been, but she was unaware of the need to check them or how they should be facing, since they had not been in serviced on the anti-tippers till the day of [DATE] and the last transportation training she had received prior to [DATE] was in (YEAR). RCP A feels when she started driving she had in servicing on proper securing of a wheelchair and she feels confident she had secured Resident #3 securely, and that she has been a driver for several years with no history of accidents. Observation [DATE] at 2:30 pm. RCP A knew where the van was and accompanied this surveyor to the van and used her key to let us in. The van did appear to be an older model van that was not very clean on the inside with small bits of debris, small bits of trash, and stained torn gray carpet. The lift was accessed from double doors at the back of the van. Inspection of the wheelchair tie downs revealed two racket style tie downs for the back of the wheelchair that appeared to be in good working order. Two manual tie downs with a tension clasp for the front of the wheelchair, and the tension clasps were not in good working order. With little effort the straps could be pulled through the tension clasp in both directions. With vibration and movement of the chair as it is going down the road the straps could become loose and allow for more movement of a wheelchair. The electric control to the lift was also not in working order and facility staff had to use the backup manual pump lift to raise and lower the lift, and unless you are a tall person you would have to access this backup manual pump from inside the van leaving a wheelchair bound person alone on the lift. The lift also did not have a lift platform safely strap to help prevent a wheelchair from rolling off the lift or tilting backwards off the lift. When using the backup manual pump to work the lift it causes a delay in the engagement of the outer barrier latch and the raising of a lift barrier further increasing the chances of a wheelchair rolling backwards off the lift. The lift also appeared not not be level, leaning in a direction that would further increase the chance of a wheelchair rolling backwards off the lift ramp. In an interview on [DATE] at 2:45 pm HA A reports she has been an employee of the facility for 3 weeks. HA A states she had never received training on transporting or securing residents during transport when she started and still to this day has not received training. [DATE] was the first time HA A had transported residents. On that day RCP A loaded Resident #3 in the van and from what she could see he looked secure. She stated RCP A was not driving recklessly. HA A states they came to a stop at a light and Resident #3 stated yelling for help. HA A there was no sound of a fall or something hitting the van, even the other ladies they where transporting heard nothing till he yelled out. RCP A pulled over on the side of the road, RCP A quickly assessed Resident #3, and RCP A stayed in the back with him while HA A drove the ladies to [MEDICAL TREATMENT] and back to the facility. Resident #3 was assessed, took medications, and returned to [MEDICAL TREATMENT] with RCP A driving. (HA A was not a certified nursing assistant, per facility policy a driver must be a certified nursing assistant.) Record review of Resident #3's electronic chart accessed on [DATE] revealed on [DATE] Resident #3 received a fall assessment that revealed he had fallen before, had an impaired gait, and was high risk for falls, along with nursing progress notes to confirm the falls. Record review of an undated facility policy received on [DATE] titled Van Policies revealed the following: A van driver must be a certified nursing assistant. A van driver must be CPR certified. A van driver will have a cell phone. It is the policy of all Focused Post-Acute Care that any resident transported in the facility van is secure . In an interview on [DATE] at 1:20 RCP C she states she has been an employee of the facility for 6 years and has never held the title of a driver but has been transporting resident for all of her time employed at the facility and has never had an accident. RCP C is pretty sure she received in servicing of transporting residents and use of the van lift prior to any transporting of residents. RCP C states 3 months ago they were in serviced on use of the lift because the electric switch to operate the lift was broken and they had to start using the backup manual pump. RCP C states that the employees requested two people go for transporting of wheelchair residents once they had to start using the backup manual lift. RCP C states they never in serviced the staff to use two people but the facility was aware they were using two people. RCP C stated on [DATE] [MEDICAL TREATMENT] had called and requested Resident #3 come early to [MEDICAL TREATMENT] and this was at the same time several staff take breaks and that administration has morning meeting. With no one available RCP C had to transport Resident #3 alone. RCP C is tall and is able to use the manual back up lift while standing outside the van, allowing her to be at the side of the wheelchair. RCP C states that her and Resident #3 were singing laughing and talking while she was raising the lift and next thing she knew he was on the ground. RCP C is unsure how he fell but saw Resident #3 on the ground in in his chair laying on his back. RCP C recalls the DCO coming out and assessing Resident #3, and then he was sent to the ER via ambulance. She does not know if his wheel chair had anti-tippers that day or not. RCP C added that administration witnessed the fall because they were watching her use the lift from the conference room. (Note there is a very clear view of van loading area from the conference room). In an interview on [DATE] at 2:25 pm DCO and RDCO it was revealed that the electrical action of the lift had been broken for less than a month, but that staff could use the backup manual lift. DCO was witness to the fall of Resident #3 off the van wheelchair lift on [DATE]. At the time of the fall she was sitting in the conference room for morning meeting which offers full view of the transportation van loading area. DCO stated Resident #3 chair tipped backwards and he fell backwards off the lift while still sitting in his chair. DCO confirmed Resident #3 was sent to the ER via ambulance. Resident #3 was assessed and found to have no serious injuries and sent to [MEDICAL TREATMENT] after the fall. Resident #3 was transported back to the facility in the same facility van, but in a new Broda chair. DCO stated that Resident #3 had his wheelchair seat lowered and anti-tippers added to his wheel chair in (MONTH) of 2019 and there was no in-servicing given to staff on proper use of anti-tippers and the need for anti-tippers was never addressed in his care plan. DCO stated after the fall of Resident #3 on [DATE] that day they did a competency demonstration with the 3 drivers; in-serviced on anti-tippers, completed 1 to 1 in-service for operating lift of the van, and Abuse and Neglect in-servicing. On [DATE] they in-serviced on lift operation, 2 persons for all transfer (travel in pairs) and added another in-service covering Lift operation procedure, 2 person all transfers: related to using a different van. DCO also included on [DATE] Resident #3 was assessed by Habilitation Therapy for a new chair and new Broda chair was recommended. They inspected all other resident chairs and no modifications where needed. On [DATE] corporate brought a loaner van from a sister facility and the old van was taken out of service and DCO is unsure as to why. DCO included driver RCP C will not be suspended. As for the fall on [DATE] DCO acknowledged Resident #3 was only assessed at the facility, no inspection of the van's safe operation was conducted, no inspection of van wheelchair securement straps was completed, no inspection of Resident #3's wheelchair was completed, and no facility investigation was conducted. On [DATE] the maintenance man inspected the wheelchair and said it was fine. DCO confirmed there was also no in-servicing done after the fall on [DATE]. On [DATE] the driver RCP A was suspended for the fall on [DATE]. DCO stated the fall on [DATE] was not reported until [DATE] because there was no serious injury and there was no history of such events with this resident. DCO decided to report the [DATE] fall on [DATE] because both falls concerned the same resident, the same van, and for transparency purposes. In an interview on [DATE] at 3:30 pm EDO stated the electric controls to the van lift had only been broken for about a month and drivers where only required to use two people for transferring wheelchair resident since [DATE]. EDO stated they will continue to use two people with the current van, but when they receive a brand-new van the need for two people will be evaluated. EDO could not give a reason as to why on [DATE] there was two staff transporting (RCP A and HA A) Resident #3, if it was not being done prior to [DATE]. In an interview on [DATE] at 4:30pm, RDCO said the van was taken out of service for the whole facility as a precautionary step until they could determine safety of the van, and the reason it is not being placed back in service is because they can't 100% say the van is safe. RDCO explained a safety strap for the lift is a new item added to lifts and he is not aware they are a requirement. RDCO added he does not have access to the manufacturer's recommendations for the lift. In an interview on [DATE] at 5:54 p.m., RCP D stated she has been driving the van since 2019 and became a regular driver in (MONTH) or (MONTH) of 2019, she was in-serviced on strapping in residents, the lift, and how to use the safety belt but cannot recall when but feels it was in the summer. RCP D stated she cannot recall any transportation related in-servicing until [DATE]. RCP D stated she began asking for an assistant for transportation in (MONTH) 2019 and the facility was aware she was taking another person. RCP D stated it is to physically hard for one person with having to use the backup manual lift and that is not safe for the resident since you have to be inside the van during a manual lift. RCP D stated as far as she knows using two people will remain in place and she feels it is safer for the residents to have two people. RCP D stated she feels the newer van is much safer for transport of residents, the wheelchair straps are more secure and much easier to operate, and she likes the added safety feature of the lift strap on the newer van. In an interview on [DATE] at 9:39 a.m., Director of Habilitation Therapy (DOH) stated habilitation therapies did not make any recommendation for anti-tippers for Resident #3 wheelchair. DOH has seen the old chair which she feels was not a safe chair for a blind resident with bilateral [MEDICAL CONDITION] because balance is an issue with such a resident, and in her opinion the type of anti-tippers placed on the old chair where not an effective anti-tipper. In an interview on [DATE] at 11:35 a.m., Resident #1 recalls being in the van on [DATE]. Resident #1 states RCP A secured Resident #3 wheelchair. Resident #1 stated the driver was driving normal but when she broke for a red-light Resident #3 fell backwards. Resident #1 confirmed two people go to transport Resident #3 for the whole time she has gone to [MEDICAL TREATMENT] Resident #3 has gone also. In an interview on [DATE] at 1:30 pm the EDO stated they will have a new maintenance man starting in two weeks. She will have him check the van monthly and have the drivers check the van weekly, and they are in the process of creating a check off sheet. On [DATE] at 3:15 pm the Executive Director of Operations (EDO) and Director of Clinical Operation (DCO) were informed of the identification of an Immediate Jeopardy (IJ) situation and the need for a plan of removal. The EDO was given an IJ template. Review of the facility's Plan of Removal document received on [DATE] at 8:25 am. Incident: ,[DATE]/ 2020- During a transport to [MEDICAL TREATMENT] Resident #3 was in the back of the van strapped down and RCP A heard him say he fell when she stopped at a red light. She pulled over and her and the HA A that was in the van with her got Resident #3 back upright and brought him back to the facility to be assessed by the nurse. Investigation findings [DATE] In speaking to RCP A and HA A, Resident #3 was strapped down and his wheels were locked. Resident #3 states that he was strapped down but did not feel secure and that he told RCP A that he did not feel secure. Yesterday when we did safe surveys, he said that he felt safe in the van when he was secured in it properly. He does state that he felt a little confused but does understand that Friday was an accident Incident [DATE] Resident #3 was being loaded into the van via the lift. The lift is a manual pump and RCP C was pumping the lift to raise Resident #3 up to the back of the van to place him in. During the pumping of the lift DCO was sitting in the morning meeting facing the front of the building and could see the van. DCO stated Resident #3 tipped over the back of the lift and fell off. He hit his head, and everyone rushed out to see if he was ok. Resident #3 was able to let DCO know that his back was hurting, and she observed a hematoma on the back of his skull. EMS was notified, and he was sent to the hospital for evaluation. Investigation findings [DATE] During the loading of Resident #3 with the lift on the van he went backwards and fell off the lift. His wheelchair fell backwards off of the lift which was about 5 inches off the ground when he fell over. He was sent to ER for evaluation and did not have any major injuries due to the fall. The wheelchair was locked, and anti-tippers were in place. Investigation revealed: On Thursday (MONTH) 16, 2020 EDO inspected facility van and checked seatbelts, anchoring ports, and the lift gate. After inspection by EDO B decommissioned the transportation van. After the incident, an in-service with return demonstration was provided to all Licensed Nurses and Certified Nurse Aides, and several ancillary staff on the safe techniques for transporting residents in the van. Resident #3 w/c was assessed by therapy and he was given a different w/c. All residents who are transported via the facility's van and are wheelchair bound have the potential to be affected by this alleged deficient practice. All licensed nursing staff and Certified Nurse Aides are trained and checked off for the proper safety technique for residents being transported in the facility's van. Training will occur upon hire during orientation and at least annually. The facility van lift and strapping mechanics was inspected for maintenance on [DATE] by EDO B. The van was placed out of service due to [DATE] and a different van was brought on site to use in all transportations. This van was last inspected straps and lift on (MONTH) 16, 2020 and mechanically inspected this (MONTH) 2020 by sister facility's Director of Plant Operations. The van will continue to be inspected on a routine basis every 6 months or upon 5000 miles or as needed. All w/c's will be checked for proper functioning every quarter by the Maintenance Director and/or designee. All Licensed Nurses and Certified Nurse Aides have been asked to perform a return demonstration on loading residents who use wheelchairs, boarding standees on the lift, securing residents in wheelchairs, and securing ambulatory riders. This training was completed on [DATE]-[DATE]. The facility will address corrective action by training and Inservice all license nurse and nurse aide/ medication aide on check list specific to the focused care van, on the skill check off, including loading riders who use wheelchairs, power chair vs. wheelchair, Boarding standees on the lift, procedures for securing wheelchair checklist, procedures on securing riders. DCO will monitor lead transportation personnel to ensure that quarterly check list for the van in additional to the quarterly skill care and the checklist entails details specifically to the community van. (Please see attached the community van checklist) DCO will monitor lead transportation personnel to ensure that quarterly check list for the van is being implemented. Quarterly Skill Care check off for Direct care staff. Maintenance Director will check the van lift every month to ensure proper functioning. The facility will conduct biweekly maintenance checks on seatbelts, anchors, lift, and all internal operational parts to ensure that community van is in compliance. All nursing staff will be trained on proper functioning and appearance of the lift and proper appearance and functioning of the safety straps. Staff will be educated if any of these items appear to be malfunctioning then they are to stop and not transport the resident. They will then contact the director of nursing or administrator to report the malfunction at which point the van will be inspected and if needed repairs will be made before another resident is transported, if transportation aide and/or assistant know the van lift and/or straps are not working properly to STOP, Report and Don't Transport. Director of Maintenance and/or any trained Administrative designee in-service and train all staff that will be providing transportation. Quarterly in-services will be conducted on transportation. Staff will be trained and in-services on proper inspection of transportation van, proper loading and unloading of Elders using wheelchairs for transportation, attendants will be in-services and trained on their role during loading/unloading and during transport. Facility administrator was counseled by regional RVPOWT regarding the need to correct concerns raised by staff. This counselling took place on (MONTH) 20th at which time the administrator was instructed to report and investigate all incident that took place within the community. Then on (MONTH) 23rd, the administrator was counselled on the need to follow up on all concerns raised by staff ensuring that they are addressed appropriately and in a timely manner. Residents who are transported in the facility van with special medical equipment needs; examples BROTA chair, anti-tippers, other durable medical equipment, will have a care plan addressing the specific transport need of the resident. All transportation training will be reviewed and monitored by the EDO and DCO in the facility's monthly QAPI meeting. The EDO, DCO, and/or trained designee will watch at least one resident transport weekly for the next 4 weeks to ensure proper procedures are being performed. POR Verification Record review on [DATE] at 11:47 am the facility had in-serviced [DATE] on Use of check off/transport log for van which included a daily vehicle inspection sheet, transportation log, weekly vehicle inspection sheet, post trip inspection sheet, and monthly vehicle inspection sheet. The sign in sheet was dated [DATE] and included 10 signatures. 3 of the 10 signatures included night personal 2 Certified Nurse Aide (CNA) and 1 License Vocational Nurse (LVN). The other 7 signatures where day time employees and included 2 CNAs, 2 nurses, 2 office personal, and 1 house keeping personal. (Note RCP D and Employee A's signatures where on this in-service and in-servicing form [DATE] addressing Lift operation procedure, 2 person for all transfers (Travel in pairs).) In an observation and interview on [DATE] at 12:35 pm it was time to transport resident to a local [MEDICAL TREATMENT] center and included in this transport was Resident #3. The loaner van appeared newer, in better cosmetic condition, and much cleaner. All four wheelchair securement straps were a much newer easier to work system that self-tensions and self-locks, and the seatbelt for a wheelchair resident had a shoulder belt as the old van only had a lap belt. I observed RCP D and Employee A follow the vehicle inspection checks and load Resident #1 who is ambulatory with a walker with no concerns. While RCP D moved the van to the loading area and interview with Employee A was conducted. Employee A revealed he was in-serviced 3 months ago to be the second person on the van, he remembers it was a very cold day. He revealed his role as a transportation attendant would be to alert the drive to unsafe things and to watch the back, to make sure buckles are done and the van is working. During the observation, on [DATE] at 12:35, Employee A correctly demonstrated his role when loading/unloading and transporting residents who utilize a wheelchair. During observation on [DATE] at 12:35 the lift did not work with the electrical controls and RCP D had to utilize the backup manual lift from inside the loaner van. When using the lift there was no engagement of the outer barrier latch which caused the need for the lift barrier to be engaged manually putting wheelchair residents at risk of rolling off the lift. Employee A manually raised the lift barrier. The loading of two residents began at 12:35 and was not completed till 1:20. Employee A was a last minute replacement because the facility could not find the employee who was to be the transportation attendant according to the EDO. In an interview [DATE] at 2:02 pm RCP [NAME] revealed she has been a transportation attendant twice since her employment and both times where to take [MEDICAL TREATMENT] residents. First time was with employee RCP D. The second time was with the terminated maintenance man she added on the way back from [MEDICAL TREATMENT] the van over heated and stopped running she believes this happened in (MONTH) of 2019. She has only received training on being a transportation attendant this am, and it was a demonstration training. RCP [NAME] gave the names of 6 fell ow employees that were present during training. RCP [NAME] could not recall anyone from maintenance, housekeeping, or kitchen staff being present for the training. (Note: Employee A is employed in housekeeping.) In an interview on [DATE] at 12:55 pm EDO and Regional Vice President of Operation West Texas (RVPOWT) revealed everyone on the floor except for two night shift employees have ben trained and in-serviced and everyone had to have a return demonstration. They confirmed the van in question is benched until the lift place fixes and inspects the van. They are still currently using a loaner van. As a backup plan for van failure they will utilize Trax for transporting of [MEDICAL TREATMENT] residents. They also have access to sister facility vans to borrow from. The local Emergency Medical Services (EMS) has also agree to transport if they are not busy. Record review on [DATE] revealed proof of in-servicing for Abuse Neglect, Wheelchair lift training/transport van training with 39 employee signatures. The facility also provided completed daily vehicle inspection check sheets for pre and post trip along with a weekly vehicle inspection sheet. In an interview [DATE] at 1:39 pm LVN B and RCP D were able to explain the process of van safety, securing a wheelchair resident, use of the lift and to manually raise lift barrier before lift is 6 inches off the ground, the role of the driver and the transportation attendant. Plan of removal verification completed [DATE]: van in question has been removed from service and facility is using a temporary replacement that meets safety requirements, all but two staff on the night shift have been trained on van safety checks, securement of wheelchair residents, safe use of van lift, duties of transportation attendant, and expectations of the fa

Based on interview and record review, the facility failed to ensure 1 of 5 residents (Resident #1) received treatment and care in accordance with professional standards of practice reviewed for quality of care. Licensed Vocational Nurse (LVN) A failed to follow physician orders [REDACTED].#1 had an unwitnessed fall on [DATE] at 9:00 p.m. LVN A assessed Resident #1 as lethargic and drowsy after the fall. Resident #1 had a second fall on [DATE] at approximately 7:00 a.m. which resulted in her being sent to the emergency room where she was diagnosed with [REDACTED]. This was determined to be immediate jeopardy at past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the investigation. This failure could affect the 23 residents at risk for falls, placing them at risk for a delay of appropriate medical treatment and a worsening of a resident's condition. The findings included: Resident #1's closed records: Review of Resident #1's admission record dated [DATE] documented she was admitted on [DATE], readmitted on [DATE], was [AGE] years of age, was admitted with [DIAGNOSES REDACTED]. Record Review of Resident #1's Minimum Data Set assessment dated [DATE] documented Resident #1 required assistance of 1 person with bed mobility and transfers. Resident #1 required limited assistance with 1 person for dressing, bathing and toileting. Resident #1 had a Brief interview for mental status (BIMS) of 10 which indicated she was moderately cognitive impaired. Review of Resident #1's Care Plan updated [DATE] documented in part: Resident #1 has had an actual fall (on [DATE]) due to poor balance, poor comprehension, unsteady gait, self transfers without assist and wears her pants/briefs lower than her waist. Approaches: Monitor/document /report as PRN (as needed), report to MD (medical doctor) for signs/symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation, Neuro-checks per facility policy, vital signs as ordered. Review of the Incident report for Resident #1 dated [DATE], revision date [DATE], documented in part: Certified nurse aide reported to this nurse (LVN A) that a resident (resident #1) was on the floor in her room. Upon arrival to residents room, noted resident on the floor beside the bed lying on her right side. Resident was able to move all extremities. Floor was clean, dry and free of clutter. Resident was wearing non-skid socks. Resident was unable to tell the nurse how the fall occurred. Level of consciousness was lethargic (drowsy)- Mobility: Ambulatory with assistance. No witnesses found. Review of the neurological review for Resident #1 dated [DATE] at 9:00 p.m. documented in part: Pupil response was sluggish, Verbal response was disoriented and Level of Consciousness was lethargic (sleep, drowsy). Review of Resident #1 neurological assessment flow sheet dated [DATE] documented in part: Level of consciousness at 9:00 p.m., 9:15 p.m. 9:30 p.m., and 9:45 p.m.-Resident #1 was drowsy and her pupils were sluggish. Review of a description by the Mayo Clinic ( ,[DATE] Mayo Foundation for Medical Education and Research, all right reserved) subarachnoid hemorrhage is bleeding in the space between your brain and the surrounding membrane (subarachnoid space). The primary symptom is a sudden, severe headache. The headache is sometimes associated with nausea, vomiting and a brief loss of consciousness. Bleeding usually results from the rupture of an abnormal bulge in a blood vessel (aneurysm) in your brain. Sometimes bleeding is caused by trauma, an abnormal tangle of blood vessels in your brain (arteriovenous malformation), or other blood vessel or health problems. Review of Resident #1's Investigation Report dated [DATE] documented in part: On (MONTH) the 16, at approximately 9:00 p.m. or so Resident #1 had an unwitnessed fall. She was found on the floor, next to her bed, lying on her right side. The treating nurse (LVN A) asked Resident #1 what happened and Resident #1 said she fell . LVN A assessed Resident #1 to be lethargic and drowsy. Resident #1 was able to move all her extremities and there no bruising or skin tear. LVN proceeded with Neuro-checks and observed Resident #1's pupils were sluggish. LVN A called Resident #1's physician and was given an order to send Resident #1 to the emergency room . On (MONTH) 17, (YEAR) Resident #1 had a subsequent fall around 7:00 a.m., had some bleeding to the head and was sent out to the emergency room . Resident #1 was sent to another hospital for further care due to results of a CT dated [DATE] indicating a small subaranachoid bleed in the left [MEDICATION NAME] region. During the course of the investigation on the morning of (MONTH) 19 around 7:00 a.m., it was discovered that Resident #1's physician had given orders for LVN A to send the resident (Resident #1) to the hospital on the evening of (MONTH) 16. LVN A failed to document any of the information regarding the fall and failed to follow doctors orders. LVN A reported she failed to do her job because she brought her three children to work with her since she did not have someone to watch them at home and began to feel over whelmed with everything going on. LVN A called the on call nurse to inform her that she had to leave the building to take her children home and did not give report regarding Resident #1's fall to the replacement nurse. The on-coming nurse (LVN C) did observe Resident #1 to be lethargic. Review of the History of her present illness, Resident #1's medical records from the emergency dated [DATE] documented in part: Chief Complaint: Decreased mental status and changed mental status. (resident was found lying on the floor at the nursing home.) The patient was found unresponsive. She has had a recent fall. Note -Test: CT of the head reveals small subaranachoid bleed in the left [MEDICATION NAME] region. Clinical Impression: Closed head injury. Traumatic subaranachoid hemorrhage. During an interview on [DATE] at 9:46 a.m. the assistant director of nurses (ADON) said LVN A was working the night Resident #1 fell . The ADON said LVN A noted Resident #1 was a little sluggish but her vital signs were good. The ADON said LVN A called Resident #1's doctor and he gave orders to send Resident #1 out (to the ER). She said LVN A did not write the physician telephone orders or do an incident report regarding Resident #1's fall. The ADON said LVN A called the on-call nurse and told her, she couldn't work because she had to take her kids home. The ADON said LVN A did not wait for the the nurse who was taking her place to get to the facility before she left. The ADON said LVN A had told LVN B about Resident #1's fall but did not mention the telephone order to send Resident #1's to the emergency room . The ADON said LVN C was not informed of Resident #1's fall when she replaced LVN A. The ADON said LVN C also noticed Resident #1 was sluggish. The ADON said LVN C tried to call Resident #1's doctor to let him know Resident #1 was sluggish but the doctor did not respond back. The ADON said the administrator was at the facility the evening Resident #1 fell . She said LVN A informed the administrator about Resident #1's fall but did not inform her about the order to send Resident #1 to the emergency room . The ADON said there was no documentation regarding Resident #1's fall on [DATE]. She said the next day, after Resident #1's second fall, LVN A was interviewed regarding Resident #1's fall. She said LVN A was asked for the documentation regarding Resident #1's fall for [DATE]. The ADON said LVN A said she had started vitals signs and would have to bring all information to the facility regarding Resident #1's fall. The ADON said after she got report of Resident #1 being drowsy from LVN C at 6:00 a.m. she went immediately to Resident #1's room and assessed Resident #1. The ADON said Resident #1 was a little drowsy and wasn't acting the same so she encouraged Resident #1 to drink water. The ADON said later that morning around 7:00 a.m. ([DATE]) Resident #1 fell again. The ADON said she entered Resident #1's room and there was a pool of blood on the floor. The ADON said the blood was from a laceration around Resident #1's eye she sustained from the fall. The ADON said she called Resident #1's doctor and informed him she was sending Resident #1 to the emergency room . The ADON said during the morning meeting on [DATE] (around 9:00 a.m.) it was brought to her attention that Resident #1 had fallen the night before. The ADON said Resident #1 returned to the facility on (MONTH) 22 for 4 or 5 days later and then had to be sent back out on (MONTH) 24 due to a decline in her health. The ADON said Resident #1 died at the hospital a few days later due to complication of kidney failure. During an interview on [DATE] at 10:42 a.m. LVN C said she was called to go to work on [DATE] at 11:00 p.m. because LVN A had left the facility to take her kids home and did not return. LVN C said when she walked into the facility, LVN B said here are the keys to 400 hall and that she wasn't sure if LVN A had finished passing out all of the mediations. LVN C said she was not given any report regarding resident #1's fall. LVN C said Resident #1 was lethargic but Resident #1 responded to questions appropriately. LVN C said she tried to get Resident #1 to take a drink of water but Resident #1 wouldn't suck on the straw. LVN C said she checked to see what Resident #1 was taking for pain and it was a pain ([MEDICATION NAME]) patch. LVN C said she thought it was too strong for Resident #1. LVN C said Resident #1 was still lethargic so she texted Resident #1's physician. LVN C said Resident #1's physician never responded to her. She said she continued to monitor Resident #1 and had the aide monitor her also. LVN C said she reported Resident #1 being lethargic to the ADON the following morning at approximately 6:00 a.m. LVN C said she had no prior knowledge of Resident #1's fall. During an interview on [DATE] at 1:08 p.m. LVN A said Resident #1 fell around 9 p.m. ([DATE], (YEAR)). LVN A said she and LVN B assessed Resident #1 after the fall. LVN A said Resident #1 was lethargic. LVN A said Resident #1 was not able to tell them how she fell . LVN A said she started Neuro's on Resident #1 and put her back to bed. LVN A said Resident #1 did not complain of pain. LVN A said she called Resident #1's doctor and he told her if she had time he wanted Resident #1 to go to the emergency room . LVN A said she had her young children at the facility while she was at work. LVN A said she called the on-call nurse to see if she could find someone to relieve her so she could take her kids home. LVN A said she couldn't handle her kids. LVN A said the on call nurse told her she would call and get someone to work for her. LVN A said about 30 minutes after Resident #1 fell , she got orders from Resident #1's physician to send Resident #1 out (meaning send to the emergency room ). LVN A said she texted the on call nurse and let her know she was leaving the facility to take her kids home (approximately 9:00 PM). LVN A said she gave report to the other nurse (referring to LVN B). LVN A said she did not write Resident #1's physician's telephone order to send out Resident #1 out. LVN A said she just left. LVN A said she had planned on returning to work but was not able because her husband was not home to watch the kids. LVN A said she should have called the director of nurses (DON) and should have done a lot of things different. LVN A said she had documented the Neuro's before she left but she didn't document anything else because she thought she would go back to work that evening. She said the documentation on the Neuro's was all she documented that night. LVN A said she did tell LVN B she had an order from the doctor to send Resident #1 to the emergency room . LVN A said the physician's telephone order to send Resident #1 out was not written down. LVN A said she had sent a text (approximately 10:00 PM) to the on-call nurse to let her know she would not return to work that evening. LVN A said I should have written the telephone orders to send Resident #1 out and I should have documented Resident #1's fall. During an interview on [DATE] at 1:14 p.m. LVN B said a resident informed LVN A that Resident #1 was on the floor. LVN B said she and LVN A assessed Resident #1. LVN B said when she entered the room she observed Resident #1 on floor lying on her side. LVN B said they asked Resident #1 if she hit her head and she said no. She said Resident #1 could follow commands. LVN B said she did not stay in the room for the full assessment and was not sure what LVN A documented and was not aware if LVN A called the doctor. LVN B said if she had known LVN A had gotten orders to send Resident #1 out, she would have sent her out to the ER. During an interview on [DATE] at 1:43 p.m. the on-call nurse said on [DATE] around 9:00 p.m. LVN A called and said she had to leave work to take her kids home. The on-call nurse said LVN A said she would return to work but later texted and said she could not return to work. During an interview on [DATE] at 9:25 a.m. the ADON said she didn't learn about the telephone orders from Resident #1's physician to send Resident #1 out on [DATE] until after the second fall (on [DATE]). The ADON said when she called to inform Resident #1's doctor of the fall on [DATE], he said he was confused and didn't understand because he had given LVN A orders to send Resident #1 out the night before. The ADON said when LVN A was interviewed on (MONTH) 19 she informed them she had gotten an order from Resident #1's physician to send Resident #1 out on (MONTH) 16th. During an interview on [DATE] at 9:42 a.m. the administrator said she found out during an interview on (MONTH) 19th around 10:00 a.m. that LVN A said Resident #1's physician had given her a telephone order to send Resident #1 to the emergency room (ER) on (MONTH) 16th at approximately 9:30 p.m. The administrator said LVN A told her she was so frustrated and had to leave the facility the night Resident #1 fell . The administrator said LVN A had a lot of excuses for not documenting anything. The administrator said LVN A said she did not tell LVN B she had gotten orders from Resident #1's physician to send Resident #1 out. The administrator said she talked to Resident #1's physician the day after Resident #1 fell on [DATE] and he said he had given orders to send that resident out. During an interview on [DATE] at 10:45 a.m. Resident #1's physician said he could not remember what time the nurse called regarding Resident #1's fall but he did remember the nurse saying Resident #1 was lethargic, non-responsive and did not look right. He said he knew that patient (referring to Resident #1) well and she always alert and responsive. He said he could tell from talking to the nurse, the seriousness of Resident #1. He said I told her (LVN A) to send that resident out. He said he was confused the next day when they called and said that Resident #1 had fallen again. He said what, I told the nurse last night to send that resident out. He said he believed if Resident #1 had been sent out the night before she would not have had the second fall the next day. During an interview on [DATE] at 1:14 p.m. LVN B said a resident informed LVN A that Resident #1 was on the floor. LVN B said she and LVN A assessed Resident #1. LVN B said when she entered the room she observed Resident #1 on floor lying on her side. LVN B said they asked Resident #1 if she hit her head and she said no. She said Resident #1 could follow commands. LVN B said she did not stay in the room for the full assessment and was not sure what LVN A documented and was not aware if LVN A called the doctor. LVN B said if she had known LVN A had gotten orders to send Resident #1 out, she would have sent her out to the ER. During an interview on [DATE] at 2:10 p.m. CNA D said LVN A called her to Resident #1's room on [DATE] at 9:00 PM because Resident #1 had fallen. CNA D said Resident #1 was lying on her back when she entered the resident's room. CNA D said Resident #1 sounded confused. CNA D said they had to ask a question two times before Resident #1 would respond. CNA D said she and LVN A helped Resident #1 back into bed. CNA D said LVN A said she was going to call the doctor because she thought the doctor would want to send Resident #1 out. During an interview on [DATE] at 2:14 p.m. LVN F said she stayed and worked on [DATE] until around 11:00 PM when LVN C came in to cover the rest of the shift for LVN A. LVN F said she didn't get a report because LVN A had already left and was supposed to come back to work. LVN F said she was aware of Resident #1's fall because she had heard one of the aides tell LVN A that Resident #1 had fallen. LVN F was not aware Resident #1's doctor had been called. LVN F said if she had of known there was an order to send Resident #1 out, she would have sent her out to the ER. During an interview on [DATE] at 2:35 p.m. CNA E said she was working in the secure unit the night Resident #1 fell . CNA E said LVN A had been working on the hall Resident #1 resided on and also worked on the secure unit. CNA E said LVN A told her Resident #1's physician gave orders to send Resident #1 to the emergency room . CNA E said she was not aware if Resident #1 was sent out because LVN A never returned to the secure unit. Review of the facility's policy dated, revised (MONTH) (YEAR), documented in part: Policy Statement: Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc). The nurse will notify the resident's attending physician on call when there has been a (an): Accident or incident involving the resident; Need to transfer the resident to a hospital /treatment center. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the facility's policy for Telephone orders dated revised on (MONTH) 2014, documented in part: Policy Statement: Verbal telephone orders may be accepted from each residents attending Physician. Policy Interpretation and Implementation: Verbal telephone orders may only be received by licensed personnel (e.g., RN (registered nurse), LVN (licensed vocational nurse, pharmacist, physician, etc.). Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record. The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information. Telephone orders must be countersigned by the physician during his or her next visit. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from [DATE] through [DATE]. The facility took the following actions to correct the non-compliance: Review of the Immediate Plan of Correction dated [DATE] documented in part: Plan of correction: In the event of a future unwitnessed fall, the resident will receive a full head to toe assessment by the charge. Depending on the assessment, Neuro checks will be conducted per policy. Physician and responsible party will be notified of the incident and documented accordingly. A complete investigation will be started/conducted by the same nurse serving the resident. If there are witnesses to the fall, statements will be collected and a review of the incident as part of the morning clinical meeting with the DON (director of nurses), unit manager, regional nurse, and executive director. Employees will not bring children to work during their designated shift hours. Identification: All resident who are at risk of falls. All nurses and CNA's (certified nurse aide) providing direct care to patients. System Changes: 100% audit of all resident who show a documented history (or could be potentially at risk) for falls by [DATE]. Review of a list provided by the Director of Nurses on [DATE] documented there were 23 residents at risk for fall. Assess identified residents for fall risk and BIMS. Upon identifying residents with potential fall risk, fall precautions (applicable to resident) will be implemented per facility policy necessary consultations by physical and occupational therapy screen evaluation will be requested and appropriate interventions, if any, will be recommended and/or started [DATE]. all resident's admission paperwork will be reviewed during prospective admission period, and if excepted , discussion with the family will take place about high probability of a need for a sitter or other interventions to reduce behaviors and/or falls by [DATE]. During morning meetings charts will be reviewed to confirm possible [DIAGNOSES REDACTED]. Identified fall risk residents will be discussed and reviewed during care plan meetings to ensure proper interventions are in place and outcomes from those interventions. The DON or designee will discuss the interventions and outcomes with the medical director at the monthly Quality Assurance and Performance Improvement meetings. Newly hired nursing staff-inclusive to RN's, LVN's and CNA's will be in-serviced upon hire, regarding the following: -Following telephone orders conducted by DON and/or designee. Change in resident condition/status-conducted by DON and or designee. Abuse and neglect-conducted by DON and/or designee. Falls- conducted by ADON and/or designee Abandonment of patients-conducted by the ADON or Administrator. Children at the work place-Conducted by the DON and/or designee. Following facilities policies and procedures director of nursing and/or designee. Documentation of in-services will remain of file. Results of the above findings will be reported monthly by the DON or designee to the Administrator. Done [DATE] DON and ADON will continue to provide ongoing oversight of timely documentation by nursing staff and facility protocol by being followed by patients who experience any falls. The Administrator will present the results to the QAPI Committee for the next two months for their review, oversight and direction with additional follow-up as needed. Review of a list provided by the Director of Nurses on [DATE] documented 23 residents were at risk for fall.

Based on observation, interview and record review, the facility failed to ensure 5 of 6 residents (Resident #1, #3,#4, #17 and #18) with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. The facility failed to: a) Perform skin assessments every shift per Resident #1's care plan dated 2/19/17 and to identify Resident #1 suspected deep tissue injury (SDTI) b) Accurately assess Resident #3 for pressure injuries. The assessments indicated he was a moderate risk for pressure injuries after he already had one. Resident #3 was assessed with [REDACTED]. c) Accurately assess Resident #4 for pressure injuries. The assessments indicated he was at moderate risk for pressure injuries after he already had one. Resident #4 was assessed with [REDACTED]. d) Accurately assess Resident ##17 for pressure injuries. The assessments indicated she was at risk for pressure injuries after she already had one. e) Accurately assess Resident #18 for pressure injuries. The assessments indicated he was at risk for pressure injuries after he already had one. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 4/6/17. While the IJ was lowered on 4/11/17 the facility remained out of compliance at a level of actual harm with a scope identified as a pattern because they had not had time to monitor for effectiveness. This deficient practice placed 13 residents at risk of not receiving wound care treatments, skin assessments or interventions and put them at risk of life threatening complications. Findings include: RESIDENT #1 Review of Resident #1's face sheet dated 1/31/17 documented she was [AGE] years of age admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] documented in part: -She scored 3 of 15 on the mental status exam (indicating severe cognitive impairment). -She showed no signs of [MEDICAL CONDITION]. -She rejected care. -She was dependent on staff for all Activities of Daily Living (AD's). -She was incontinent of bowel and bladder. -She was checked for at risk for pressure injuries. Review of Resident #1's Care Plan updated 2/19/17 documented: -Resident #1 had actual functional loss in transfers/bed mobility, used wheelchair and needed assistance with locomotion. Identified approaches included attempt to alleviate barriers to self performance of ADL's (activities of daily living), provide assistance with ADL's necessary to complete task. -Resident #1 had self care deficit and required total assistance with showers, hygiene, and dressing. Identified approaches were Resident #1 required total dependence assistance with hygiene and showering. -Resident #1 required a splint to her left leg (due to fracture). Identified approaches included to inspect skin to left leg, observe and report any red or broken areas. -Resident #1 was expected to have skin breakdown or/and pressure ulcers related to end stage. Identified approaches included to utilize heel protectors; position with pillows to elevate pressure points, turn and reposition every 2 hours or as needed, skin assessment and inspection every shift with close attention to heels. There was no documentation of skin assessments done every shift. Review of Resident #1's 2/2017 Physician order [REDACTED]. -Start date 5/23/14-heel protectors in place. Review of Resident #1's Braden Scale dated 4/04/17 documented she scored a 12 indicated she was high risk for developing a pressure ulcer. Review of the Weekly Wound Tracking Worksheet dated 3/10/17 documented in part: -Resident #1 had an acquired in house trauma injury that measured 0.7 x 0.3 x 0.2 centimeters (cm) on her left thigh with granulation tissue (pink or red with shiny moist granular appearance) identified on 2/14/17. Nutrition measures: Vitamin C , zinc every day, arginade twice a day, liquid protein 30 ml (milliliters) twice a day, super-cereal with breakfast and 60 ml of 2 cal three times a day. Braden Score 12 (high risk for pressure injuries). Support measures: Clean with normal saline, dry, apply abd pad everyday and as needed until healed. Splint left leg at all times. Heel protectors in place while in bed. Resident #1 had an in house acquired pressure ulcer (injury) identified on 2/28/17 to her right coccyx that measured 1.3 x 0.3 x 0.1 with granulation tissue. Nutrition measures: Vitamin C, zinc every day, arginade twice a day, liquid protein 30 ml (milliliters) twice a day, super-cereal with breakfast and 60 ml of 2 cal three times a day. Support measures: apply [MEDICATION NAME]. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages: Persistent non-blanchable deep red, maroon or purple discoloration). Review of the Weekly Wound Tracking Worksheet dated 3/17/17 documented in part: -Resident #1 had an acquired in house pressure injury that measured 1.5 x 0.5 x 0.1 centimeters (cm) on her coccyx area with granulation tissue (pink or red with shiny moist granular appearance) identified on 2/14/17. Braden Score 12 (high risk for pressure injuries). Support measures: Clean with normal saline, dry, apply collagen and dry dressing every of day and as needed until healed. -Resident #1 had an acquired in house trauma injury that measured 0.7 x 0.3 x 0.2 centimeters (cm) on her left thigh with granulation tissue (pink or red with shiny moist granular appearance) identified on 2/14/17. Braden Score 12 (high risk for pressure injuries). Support measures: Clean with normal saline, dry, apply abd pad everyday and as needed until healed. Splint left leg at all times. Heel protectors in place while in bed. -Resident #1 had an in house acquired pressure ulcer (injury) identified on 2/28/17 to her right coccyx that measured 0.7 x 0.5 x 0.1 cm. with [MEDICATION NAME] tissue (new skin or growing can be pink and shiny). Support measures: apply [MEDICATION NAME] twice a day and as needed until healed. -Resident #1 had an in house acquired pressure ulcer (injury) identified on 2/07/17 to her coccyx left that measured 0.7 x 0.3 x 0.1 cm. with [MEDICATION NAME] tissue (new skin or growing can be pink and shiny). Support measures: apply [MEDICATION NAME] twice and as needed until healed. Review of the Weekly Wound Tracking Worksheet dated 3/31/17 documented in part: Apply [MEDICATION NAME] to peri-area as needed until healed. DX (diagnosis): Stage 2 to left coccyx. Clean wound to left knee with Normal saline, dry apply to TAO (triple antibiotic ointment), abd pad until healed. DX: Wound to left knee. Clean unstageable to coccyx with normal saline, dry, with 4 x 4's, apply collagen and dry dressing every other day until healed. -Resident #1 had an in house acquired trauma injury identified on 2/14/17 to her right coccyx that measured 1.7 x 0.6 cm. with granulation tissue (pink or red with shiny moist granular appearance). Support measures: Clean with normal saline, dry, apply abd pad everyday and as needed until healed. Splint left leg at all times. Heel protectors in place while in bed. -Resident #1 had an in house acquired pressure ulcer (injury) identified on 2/28/17 to her coccyx (right and left coccyx pressure injury merged across the coccyx identified on 3/21/17) that measured 2.25 x 5.2 cm. with necrotic tissue (eschar, black, brown or tan tissue). Support measures: Clean with normal saline, dry, apply dry dressing every other day and as needed until healed. Review of Resident #1's 4/2017 Physician order [REDACTED]. Start date 4/04/17-Clean unstageable to right heel with [MEDICATION NAME], leave open to air every day and heel protectors in place at all times. DX (diagnosis) unstageable to right heel. (discontinued on 4/05/17) Review of the telephone physician orders [REDACTED]. DX: SDTI. Review of the Weekly Wound Tracking Worksheet dated 4/07/17 documented in part: -Resident #1 acquired in house deep tissue injury to her right heel that measured 4 x 2.5 cm. identified on 4/04/17. Support measures: Support measures: Clean with [MEDICATION NAME], dry, apply [MEDICATION NAME], heel dressing wrap with kling and secure with tape every other day and as needed. Heel protectors in place at all times. -Resident #1 had a deep tissue injury on her left posterior lower leg identified on 4/04/17 that measured 2 x 2. Support measures: Clean with normal saline, dry, apply foam dressing, change every three days and as needed until healed. Knee immobilizer to remain in place. -Resident #1 acquired an in house deep tissue injury to the top of her 2nd right toe that measured 0.6 x 0.7 cm. identified on 2/28/17. Support measures: Clean with [MEDICATION NAME] and lota every day or as needed. -Resident #1 acquired in house deep tissue injury to the top of her 3rd left toe that measured 0.6 x 0.6 cm. identified on 4/04/17. Support measures: Clean with [MEDICATION NAME] and lota every day or as needed. -Resident #1 had an in house acquired pressure ulcer (injury) identified on 2/28/17 to her coccyx (right and left buttock pressure injury merged across the coccyx on 3/21/17) that measured 5 x 5 cm. with necrotic tissue (eschar, black, brown or tan tissue. Support measures: Clean with dakins 0.25%, dry, apply aginate moistened with hydrogel and pack into wound. Apply [MEDICATION NAME] to peri-wound. Apply charcoal dressing and alleveyn dressing every day. During an observation on 4/04/17 at 11:38 a.m. Resident #1 was lying in bed and 2 hospice aides had just finished giving Resident #1 a bed bath. The surveyor asked them if Resident #1 had any skin issues. An aide lifted up Resident #1's right heel and said she has this and she also has one area on her buttock but it had a dressing on it. The right heel had a large dark purple black area (approximately the size of a large egg). The hospice aide said Resident #1 did not have any type of dressing on the heel. The hospice aides did not make the facility staff aware of Resident #1's right heel (SDTI) or the hospice nurse. The surveyor requested the facility's treatment nurse assess the right heel on 4/04/17 at 4:40 p.m. During an observation during wound care on 4/04/17 at 4:09 p.m. the treatment nurse got her supplies ready to do wound for Resident #1. The treatment nurse took off Resident #1's leg immobilizer and raised Resident #1's leg up to do a skin assessment of the leg. The treatment nurse changed the dressing to Resident #1's left knee and changed the dressing to the unstageable pressure injury on Resident #1's coccyx area. She said that was the only pressure injury resident #1 had at this time (indicating the wound to Resident #1's coccyx). While positioning Resident #1 in bed the treatment nurse had to put Resident #1's heel protectors back on. She raised the right lower leg and placed the heel protector on. The treatment nurse pointed out that Resident #1 had areas on her right 2nd and 3rd toe which she said they just cleansed the area but did not put dressing on them. The treatment nurse did not assess Resident #1's heels when she put the heel protectors back in position. The treatment nurse had finished her treatment and was walking out of Resident #1's room when the surveyor asked her to check Resident #1's right heel. The treatment nurse went to her medication cart and got out a measuring tape and re-entered Resident #1's room. The treatment nurse said she was unaware Resident #1 had anything to her right heel. She measured the area at 4 x 2.5 cm. She wrote the size on and appearance of the area on a scrap piece of paper and turned it into the Director of Nurses (DON) at 4:55 p.m. The treatment nurse said the said the DON would be the one to go in and stage the area. During an interview on 4/05/17 at 8:51 a.m. the DON said she first learned about Resident #1's right heel injury the day before (4/04/17) when the treatment nurse informed her around 5:00 p.m. She said she was not sure when Resident #1 acquired the pressure injury. She said she had talked to the hospice nurse to see if anyone had reported it to her and she said the hospice aides did not report any new issues to her. The DON said the hospice nurse informed her that she asked the hospice aides if there was any thing she needed to know about Resident #1 and the aides told her no. She said the hospice nurse did not assess Resident #1's heels when she came in yesterday because Resident #1 was asleep and she didn't want to wake her. The DON said if there are any changes the charge nurse for that resident was informed. She said the charge nurse for Resident #1 was not informed of any new issues. She said she did not do a full body skin assessment of Resident #1 on 4/04/17 but would get the treatment nurse and do it now. The DON said she would have to get the hospice aides notes faxed to her. During an interview on 4/06/17 at 9:48 a.m. hospice aides Q and R said they had just noticed Resident #1's right heel on Monday (4/04/17). They said they were supposed to report any resident changes to their hospice nurse. They said they did not report Resident #1's heel so they had to go to an in-service on reporting resident changes. The hospice aides said they had to report any thing different with the resident, like that resident's heel. They said they report changes immediately. During an interview on 4/06/17 at 11:07 a.m. the treatment nurse said skin assessments were to be done weekly. She said she did medication pass on Monday's and then Tuesday's she had to go to wound care in Midland with one of the residents so she did not do treatments or skin assessments on those days. She said she did skin assessments on what ever day the aides were giving showers so she could be in the shower room while the residents were showered. She said she would look to see where the shower aides were giving the showers and that would be the hall she would do skin assessments on that day. She said she does not know if that was the way skin assessments are supposed to be done but that was how it had been done since she had been there. She said the charge nurses were to do wound care on their halls when she got pulled off treatments. Review of a written statement dated 4/12/17 by the DON documented she spoke to the Hospice Director on 4/04/17. She said she made rounds (to see the hospice residents) on 4/04/17 and said the hospice aides did not report any new skin issues for Resident #1 to her. The Hospice Director said she did not assess Resident #1's heels on 4/04/17 because the resident seemed comfortable. The DON said she interviewed the facility staff regarding Resident #1's deep tissue injury and the staff denied observing any new areas of skin breakdown during their shift. Some of the staff members verbalized that Resident #1 tended to remove her heel protectors at times. Staff reported putting Resident #1's heel protectors back on, however they said they did not look at her heels. RESIDENT #3 Review of Resident #3's Face Sheet printed 4/11/17 documented he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's 5 Day MDS assessment dated [DATE] documented he was not at risk for pressure sores and did not have any. Review of Resident #3's MDS's assessment 4/03/17 documented in part: -He scored 1 of 15 on his mental status exam (indicating severe cognitive impairment). -He showed signs of [MEDICAL CONDITION]. -He required extensive assist from staff for transfers, dressing, eating and personal hygiene. He was dependent on staff for bathing. -He was incontinent of bowel and bladder. -He was checked to be not at risk for pressure ulcers. Review of Resident #3's care plan revised on 1/30/17 documented Resident #3 was at risk for skin breakdown related to incontinence, [MEDICAL CONDITION], limited mobility, over-weight, refuses care, and impaired cognition. The identified goal was Resident #3 will continue to have 0 breakdown through the review period. Identified approaches included: - Assess resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible. - Avoid shearing resident's skin during positioning, transferring, and turning. - Conduct a systematic skin inspection weekly, pay particular attention to bony prominence's. - Report any signs of skin breakdown (sore, tender, red, or broken areas.) Review of Resident #3's 3/27/17 Braden Scale documented he scored a 14 which was indicated he was a moderate risk. The nurse documented he had an open area to the left inner coccyx (5 x 1 cm), right buttocks (7 x 2), and an unstageable to the right heel 2 x 0. Review of Resident #3's 3/30/17 Skin Assessment by the Treatment Nurse documented in part: Resident continues with abrasion/ sheared area to Rt buttock, measures 1.5 x 0.6 x 0.1 cm. Open area in between buttocks, measures 7.0 x 0.5 x 0.1 cm almost abraded area. Resident has SDTI to Rt heel measures 5 x 6 cm, wound intact without drainage, redness or odor. Cushion applied to foot of bed to provide BLE(bilateral lower extremities) support and float heels. Resident encouraged to reposition q2 hours and prn to off load pressure/wt and use pillows to assist. Review of Resident #3's 4/06/17 Skin Assessment documented he had an SDTI/unstag (unstageable) to the Right Heel measuring 4.5 cm long by 5.5 cm width. The Treatment Nurse documented the tissue type was intact, bruised blister. Review of Resident #3's Braden Scale completed by the treatment nurse on 4/07/16 documented he scored a 14 which indicated he was at Moderate Risk for developing a pressure injury. During an observation on 4/05/17 at 3:21 p.m. the treatment nurse entered Resident #3's room and did wound care for an incision to Resident #3's left leg. The nurse had the certified nurse aide (CNA) hold up Resident #3's right and left heels. After the wound care the Treatment had the aides hold the both heels so golf ball sized purple/black areas on Resident #'#3 heels could be observed. Heels were floated off the bed. Resident #3 was only identified as a moderate risk for pressure ulcers. RESIDENT #4 Review of Resident #4's Resident Face Sheet dated 1/23/17 documented he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's 3/31/17 quarterly MDS documented: -He scored 7 of 15 on his mental status exam (indicating severe cognitive impairment). -He showed no signs of [MEDICAL CONDITION]. -He was dependent on staff for all ADL's. -He had a catheter and was incontinent of bowel. -He had one Stage I pressure ulcer and one Stage II pressure ulcer. Review of Resident #4's Care Plan updated 4/03/17 documented: Resident #4 had a pressure ulcer stage 2 (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister) to right heel and stage I (npuap-pressure-injury-stages: intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED]) to left heel. Area measures 4.2 x 4.5 cm with soft boggy tissue from blister. Red 0.5 x 0.5 red area, stage I to Lt (left) heel. Wound care clean stage II (intact blister) with [MEDICATION NAME], dry apply heel protector et (and) wrap with kerlix qd (every day) until healed. Resident #4 identified goal was Resident #4's pressure ulcers to both heels will heal without complications. Identified approaches included use padding on foot steps on wheelchair for pressure reduction when resident is in chair; use pillow and heel protectors to relieve pressure on the heels; Assess and record the condition of the skin surrounding the pressure ulcer; Assess the pressure ulcer for location, stage, size (length, width, and depth) presence/absence of granulation tissue and [MEDICATION NAME] daily and during treatment/dressing changes; conduct a systematic skin inspection daily. Report any signs of further skin breakdown; keep bony prominence's from direct contact with one another with: pillows, foam wedges etc. Review of Resident #4's Braden Scale dated 4/06/17 documented he scored a 15 indicating he was at moderate risk for developing a pressure ulcer. Review of Resident #4's 2/2017 Physician order [REDACTED]. 1/12/17 Stage I left heel - clean with [MEDICATION NAME], dry, apply heel protector, wrap with Kerlix until healed. Review of Resident 4's Physician order [REDACTED]. - 3/18/17 air mattress to bed - 3/18/17 clean unstageable open wound to right heel with normal saline, pat dry, apply santyl ointment to wound bed cover with tefla, secure with kerlix, change every day and PRN. - 3/18/17 clean unstageable open wound to left heel with normal saline, pat dry, apply santyl ointment to wound bed, cover with Tefla, secure with kerlix, change every day. - 1/12/17 Float heels in bed Review of Resident #4's Measurements (taken from the skin report) documented in part: Right Heel: 1/18/17 - no measurements; 1/19/17 6 x 5 right heel, intact, fluid filled blister; 1/23/17 Stage II 5.7 x 6 cm; 1/31/17 Stage II 5.2 x 5.5; 2/7/17 5.7 x 6 cm; 2/12/17 2 x 12 unstageable; 2/22/17 1.5 x 11 x 0.1; 3/06/16 1.8 x 1.1 x 0.1; 3/19/17 3 x 3 (unstageable); Stage III 3 x 2 x 0.2 Left Heel: 1/19/17 Stage I 0.5 x 0.5; 1/23/17 0.5 x 0.5; 1/31/17 Stage I 0.3 x 0.3; 2/7/17 .04 x 0.4; 2/12/170.4 .0.4. 4/06/17 unstageable 2 x 2. Blister lower right arm: 2/28/17 - 2 x 3 x 0.1; 3/06/17 - 2 x 1 x 0.1. During an observation on 4/04/17 at 5:00 p.m. the treatment nurse did wound care for Resident #4's unstageable to his left heel. The wound wound was the size of a baseball with a slight odor. Resident#4 had no other known skin issues at the time of observation. RESIDENT #17 Review of Resident 17's Face Sheet printed 4/04/17 documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #17's 2/03/17 annual MDS assessment documented -She had long and short term memory impairment with severely impaired decision making abilities. -She was dependent on staff for all ADL care. -She was incontinent of bowel and bladder. -There were no skin issues identified. Review of Resident #17's 1/02/17 Care Plan documented Resident # 17 had an 1 x 1 unstageable to her left toe, bunion area. The identified goal was Resident #7 will show healing within the review period. Identified approaches was: clean with [MEDICATION NAME], allow to dry, cover with foam dressing QD. Review of Resident # 17's 1/02/17 Care Plan documented Resident #17 was at risk for pressure ulcers due to moisture, required assistance, chair bound, and sensory deficit. Identified goal was intact skin without evidence of redness, irritation, maceration, or open areas through next quarter. Identified approaches included skin assessment and inspection every shift with close attention to heels per licensed staff. CNA to report any skin issues to charge nurse immediately. Review of Resident #17's 3/01/17 - 4/04/17 Physician order [REDACTED].>3/07/17 Clean Stage II to left outer heel with NS (normal saline), dry, apply collagen to wound et dry dressing qod (every other day) until healed. 3/07/16 Clean Stage II to right outer heel with NS, dry, apply collagen to wound et dry qod until healed. Review of Resident #17's 3/13/17 Pressure Ulcer Documentation documented she had an unstageable pressure ulcer (npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) with necrotic tissue to her right heel measuring 1.7 x 1.4 x 0.1. Review of Resident #17's 3/13/17 Braden Scale assessment documented she scored a 15 an indicated she was at low risk to develop a pressure ulcer. During an interview on 4/06/17 at 8:40 a.m. the treatment nurse informed the surveyor Resident #17's wound care had just been done. She said Resident #17 had a deep tissue injury on the right heel and a blister on the left heel. RESIDENT 18 Review of Resident #18's Face Sheet printed 4/04/17 documented he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's 3/29/17- 5 day MDS Assessment documented: He had long and short term memory impairment with severely impaired decision making skills -He was dependent on staff for ADL care. -He had no skin breakdown Review of Resident #18's 3/22/16 Care Plan documented a problem of potential for pressure ulcer or altered skin integrity related to incontinence, abnormal gait, and [MEDICAL CONDITION]. The identified goal was will have intact skin with minimal redness, blisters, or discoloration through review date. Identified approaches included: body audits at least weekly by licensed staff, notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathe or daily care; turn, reposition at least every 2 hours, more often as needed or requested. Review of Resident #18's Braden Scale dated 1/16/17 documented he scored a 15 an indicated he was at low risk of developing a pressure ulcer. Review of Resident #18's 4/06/17 Skin assessment documented he had a stage II pressure ulcer on his left great toe measuring 1.1 x 1 cm, a suspected deep tissue injury on the right second toe measuring 0.4 x 0.7. During an interview on 4/6/17 at 11:54 a.m. the Administrator was informed of the Immediate Jeopardy. She said she was not informed of Resident #1's unstageable pressure injury or that the surveyor had found it. The Administrator said the facility talked about skin issues every morning in stand-up meeting and she was not informed of Resident #1's new pressure injury. She said she received a copy of the facility's skin report and did not realize that 6 new pressure injuries had developed (close to 10% of the facility's census) in 2 months. She said that's too much. During an interview on 4/6/17 at 1:58 p.m. the Treatment Nurse said she had been the treatment nurse off and on for several years. She said this time she had been the treatment nurse for over a year. She said she got pulled treatments to do other jobs because of staffing issues. She said her Corporate Office had said she was not to be pulled. She said last week she had to go to wound care Monday and Friday and then Wednesday she was pulled to work the floor which gave her 2 days to do treatments and skin assessments. She said this week (4/3/17 - 4/7/17) she was pulled to the floor on 4/3 to be the medication nurse and 4/04/17 she had to transport a resident to wound care. She said she had talked to the DON about sending one resident with just two aides to wound care. She said she physically counted the number of wounds in the building when she did the skin report and was very aware of the number of residents with pressure injuries. She said the numbers seem up there. She said the aides were usually very good about reporting changes to her. The Treatment Nurse said she tried to do skin assessments on one hall a day. During an interview on 4/06/17 at 2:55 p.m. the Administrator said she was not informed of Resident #1's pressure injury until the next day. She said unstageable was the most explanation she got. The Administrator was informed that no full body assessment was completed until after 9 a.m. the day after the unstageable was discovered on Resident #1. The Administrator acknowledged the system had broken down. She said it appeared the problem started with the Hospice aides and not telling any of the staff. She said once the Treatment Nurse was notified she should have done a full assessment. The Administrator said the facility CNA's provided incontinent care and as needed bed baths. She said they provided care like repositioning and putting on the heel protectors that everyone kicks off. She said as they were repositioning Resident #1 she would think they would see the unstageable pressure injury. Review of the Certified Nursing Assistant Job Description (undated) documented, in part: Summary: Provide nursing care to the residents according to established policies and procedures and to ensure that the highest degree of quality of care is maintained at all times. Safety and Sanitation: Report all incidents and accidents immediately. Review of the facility's (MONTH) 2014 Policy and Procedure on Pressure Ulcer Risk Assessment documented, in part: Purpose: The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. Preparation: Review the resident's care plan to assess for any special needs of the resident. Once a pressure ulcer develops, it can be extremely difficult to heal. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor. Assessment: Skin Assessment: Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. Review of the facility's (MONTH) 2014 policy and procedure on Prevention of Pressure Ulcers documented, in part: Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. General Guidelines: Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. Use pillows, wedges or other off-loading devices to keep bony prominence's such as knees or ankles from touching each other. Do not massage bony prominence's. When in bed every attempt should be made to float heals (keep heels off the bed) by placing a pillow from knee to ankle or with other devices as recommended by clinical staff or by the physician. The facility's Plan of Removal Of Immediate Jeopardy was accepted on 4/04/17 and included the following: Prevention of Pressure Sores<BR/

Based on observation, interview and record review, the facility failed to ensure 5 of 6 residents (Resident #1, #3,#4, #17 and #18) with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. The facility failed to: a) Perform skin assessments every shift per Resident #1's care plan dated 2/19/17 and to identify Resident #1 suspected deep tissue injury (SDTI). b) Accurately assess Resident #3 for pressure injuries. The assessments indicated he was a moderate risk for pressure injuries after he already had one. Resident #3 was assessed with [REDACTED]. c) Accurately assess Resident #4 for pressure injuries. The assessments indicated he was at moderate risk for pressure injuries after he already had one. Resident #4 was assessed with [REDACTED]. d) Accurately assess Resident ##17 for pressure injuries. The assessments indicated she was at risk for pressure injuries after she already had one. e) Accurately assess Resident #18 for pressure injuries. The assessments indicated he was at risk for pressure injuries after he already had one. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 4/6/17. While the IJ was lowered on 4/11/17 the facility remained out of compliance at a level of actual harm with a scope identified as a pattern because they had not had time to monitor for effectiveness. This deficient practice placed 13 residents at risk of not receiving wound care treatments, skin assessments or interventions and put them at risk of life threatening complications. Findings include: RESIDENT #1 Review of Resident #1's face sheet dated 1/31/17 documented she was [AGE] years of age admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] documented in part: -She scored 3 of 15 on the mental status exam (indicating severe cognitive impairment). -She showed no signs of [MEDICAL CONDITION]. -She rejected care. -She was dependent on staff for all Activities of Daily Living (AD's). -She was incontinent of bowel and bladder. -She was checked for at risk for pressure injuries. Review of Resident #1's Care Plan updated 2/19/17 documented: -Resident #1 had actual functional loss in transfers/bed mobility, used wheelchair and needed assistance with locomotion. Identified approaches included attempt to alleviate barriers to self performance of ADL's (activities of daily living), provide assistance with ADL's necessary to complete task. -Resident #1 had self care deficit and required total assistance with showers, hygiene, and dressing. Identified approaches were Resident #1 required total dependence assistance with hygiene and showering. -Resident #1 required a splint to her left leg (due to fracture). Identified approaches included to inspect skin to left leg, observe and report any red or broken areas. -Resident #1 was expected to have skin breakdown or/and pressure ulcers related to end stage. Identified approaches included to utilize heel protectors; position with pillows to elevate pressure points, turn and reposition every 2 hours or as needed, skin assessment and inspection every shift with close attention to heels. There was no documentation of skin assessments done every shift. Review of Resident #1's 2/2017 Physician order [REDACTED]. -Start date 5/23/14-heel protectors in place. Review of Resident #1's Braden Scale dated 4/04/17 documented she scored a 12 indicated she was high risk for developing a pressure ulcer. Review of the Weekly Wound Tracking Worksheet dated 3/10/17 documented in part: -Resident #1 had an acquired in house trauma injury that measured 0.7 x 0.3 x 0.2 centimeters (cm) on her left thigh with granulation tissue (pink or red with shiny moist granular appearance) identified on 2/14/17. Nutrition measures: Vitamin C , zinc every day, arginade twice a day, liquid protein 30 ml (milliliters) twice a day, super-cereal with breakfast and 60 ml of 2 cal three times a day. Braden Score 12 (high risk for pressure injuries). Support measures: Clean with normal saline, dry, apply abd pad everyday and as needed until healed. Splint left leg at all times. Heel protectors in place while in bed. Resident #1 had an in house acquired pressure ulcer (injury) identified on 2/28/17 to her right coccyx that measured 1.3 x 0.3 x 0.1 with granulation tissue. Nutrition measures: Vitamin C, zinc every day, arginade twice a day, liquid protein 30 ml (milliliters) twice a day, super-cereal with breakfast and 60 ml of 2 cal three times a day. Support measures: apply [MEDICATION NAME]. Review of the Weekly Wound Tracking Worksheet dated 3/17/17 documented in part: -Resident #1 had an acquired in house pressure injury that measured 1.5 x 0.5 x 0.1 centimeters (cm) on her coccyx area with granulation tissue (pink or red with shiny moist granular appearance) identified on 2/14/17. Braden Score 12 (high risk for pressure injuries). Support measures: Clean with normal saline, dry, apply collagen and dry dressing every of day and as needed until healed. -Resident #1 had an acquired in house trauma injury that measured 0.7 x 0.3 x 0.2 centimeters (cm) on her left thigh with granulation tissue (pink or red with shiny moist granular appearance) identified on 2/14/17. Braden Score 12 (high risk for pressure injuries). Support measures: Clean with normal saline, dry, apply abd pad everyday and as needed until healed. Splint left leg at all times. Heel protectors in place while in bed. -Resident #1 had an in house acquired pressure ulcer (injury) identified on 2/28/17 to her right coccyx that measured 0.7 x 0.5 x 0.1 cm. with [MEDICATION NAME] tissue (new skin or growing can be pink and shiny). Support measures: apply [MEDICATION NAME] twice a day and as needed until healed. -Resident #1 had an in house acquired pressure ulcer (injury) identified on 2/07/17 to her coccyx left that measured 0.7 x 0.3 x 0.1 cm. with [MEDICATION NAME] tissue (new skin or growing can be pink and shiny). Support measures: apply [MEDICATION NAME] twice and as needed until healed. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages: Persistent non-blanchable deep red, maroon or purple discoloration) Review of the Weekly Wound Tracking Worksheet dated 3/31/17 documented in part: Apply [MEDICATION NAME] to peri-area as needed until healed. DX (diagnosis): Stage 2 to left coccyx. Clean wound to left knee with Normal saline, dry apply to TAO (triple antibiotic ointment), abd pad until healed. DX: Wound to left knee. Clean unstageable to coccyx with normal saline, dry, with 4 x 4's, apply collagen and dry dressing every other day until healed. -Resident #1 had an in house acquired trauma injury identified on 2/14/17 to her right coccyx that measured 1.7 x 0.6 cm. with granulation tissue (pink or red with shiny moist granular appearance). Support measures: Clean with normal saline, dry, apply abd pad everyday and as needed until healed. Splint left leg at all times. Heel protectors in place while in bed. -Resident #1 had an in house acquired pressure ulcer (injury) identified on 2/28/17 to her coccyx (right and left coccyx pressure injury merged across the coccyx identified on 3/21/17) that measured 2.25 x 5.2 cm. with necrotic tissue (eschar, black, brown or tan tissue). Support measures: Clean with normal saline, dry, apply dry dressing every other day and as needed until healed. Review of Resident #1's 4/2017 Physician order [REDACTED]. Start date 4/04/17-Clean unstageable to right heel with [MEDICATION NAME], leave open to air every day and heel protectors in place at all times. DX (diagnosis) unstageable to right heel. (discontinued on 4/05/17) Review of the telephone physician orders [REDACTED]. DX: SDTI. Review of the Weekly Wound Tracking Worksheet dated 4/07/17 documented in part: -Resident #1 acquired in house deep tissue injury to her right heel that measured 4 x 2.5 cm. identified on 4/04/17. Support measures: Support measures: Clean with [MEDICATION NAME], dry, apply [MEDICATION NAME], heel dressing wrap with kling and secure with tape every other day and as needed. Heel protectors in place at all times. -Resident #1 had a deep tissue injury on her left posterior lower leg identified on 4/04/17 that measured 2 x 2. Support measures: Clean with normal saline, dry, apply foam dressing, change every three days and as needed until healed. Knee immobilizer to remain in place. -Resident #1 acquired an in house deep tissue injury to the top of her 2nd right toe that measured 0.6 x 0.7 cm. identified on 2/28/17. Support measures: Clean with [MEDICATION NAME] and lota every day or as needed. -Resident #1 acquired in house deep tissue injury to the top of her 3rd left toe that measured 0.6 x 0.6 cm. identified on 4/04/17. Support measures: Clean with [MEDICATION NAME] and lota every day or as needed. -Resident #1 had an in house acquired pressure ulcer (injury) identified on 2/28/17 to her coccyx (right and left buttock pressure injury merged across the coccyx on 3/21/17) that measured 5 x 5 cm. with necrotic tissue (eschar, black, brown or tan tissue. Support measures: Clean with dakins 0.25%, dry, apply aginate moistened with hydrogel and pack into wound. Apply [MEDICATION NAME] to peri-wound. Apply charcoal dressing and alleveyn dressing every day. During an observation on 4/04/17 at 11:38 a.m. Resident #1 was lying in bed and 2 hospice aides had just finished giving Resident #1 a bed bath. The surveyor asked them if Resident #1 had any skin issues. An aide lifted up Resident #1's right heel and said she has this and she also has one area on her buttock but it had a dressing on it. The right heel had a large dark purple black area (approximately the size of a large egg). The hospice aide said Resident #1 did not have any type of dressing on the heel. The hospice aides did not make the facility staff aware of Resident #1's right heel (SDTI) or the hospice nurse. The surveyor requested the facility's treatment nurse assess the right heel on 4/04/17 at 4:40 p.m. During an observation during wound care on 4/04/17 at 4:09 p.m. the treatment nurse got her supplies ready to do wound for Resident #1. The treatment nurse took off Resident #1's leg immobilizer and raised Resident #1's leg up to do a skin assessment of the leg. The treatment nurse changed the dressing to Resident #1's left knee and changed the dressing to the unstageable pressure injury on Resident #1's coccyx area. She said that was the only pressure injury resident #1 had at this time (indicating the wound to Resident #1's coccyx). While positioning Resident #1 in bed the treatment nurse had to put Resident #1's heel protectors back on. She raised the right lower leg and placed the heel protector on. The treatment nurse pointed out that Resident #1 had areas on her right 2nd and 3rd toe which she said they just cleansed the area but did not put dressing on them. The treatment nurse did not assess Resident #1's heels when she put the heel protectors back in position. The treatment nurse had finished her treatment and was walking out of Resident #1's room when the surveyor asked her to check Resident #1's right heel. The treatment nurse went to her medication cart and got out a measuring tape and re-entered Resident #1's room. The treatment nurse said she was unaware Resident #1 had anything to her right heel. She measured the area at 4 x 2.5 cm. She wrote the size on and appearance of the area on a scrap piece of paper and turned it into the Director of Nurses (DON) at 4:55 p.m. The treatment nurse said the said the DON would be the one to go in and stage the area. During an interview on 4/05/17 at 8:51 a.m. the DON said she first learned about Resident #1's right heel injury the day before (4/04/17) when the treatment nurse informed her around 5:00 p.m. She said she was not sure when Resident #1 acquired the pressure injury. She said she had talked to the hospice nurse to see if anyone had reported it to her and she said the hospice aides did not report any new issues to her. The DON said the hospice nurse informed her that she asked the hospice aides if there was any thing she needed to know about Resident #1 and the aides told her no. She said the hospice nurse did not assess Resident #1's heels when she came in yesterday because Resident #1 was asleep and she didn't want to wake her. The DON said if there are any changes the charge nurse for that resident was informed. She said the charge nurse for Resident #1 was not informed of any new issues. She said she did not do a full body skin assessment of Resident #1 on 4/04/17 but would get the treatment nurse and do it now. The DON said she would have to get the hospice aides notes faxed to her. During an interview on 4/06/17 at 9:48 a.m. hospice aides Q and R said they had just noticed Resident #1's right heel on Monday (4/04/17). They said they were supposed to report any resident changes to their hospice nurse. They said they did not report Resident #1's heel so they had to go to an in-service on reporting resident changes. The hospice aides said they had to report any thing different with the resident, like that resident's heel. They said they report changes immediately. During an interview on 4/06/17 at 11:07 a.m. the treatment nurse said skin assessments were to be done weekly. She said she did medication pass on Monday's and then Tuesday's she had to go to wound care in Midland with one of the residents so she did not do treatments or skin assessments on those days. She said she did skin assessments on what ever day the aides were giving showers so she could be in the shower room while the residents were showered. She said she would look to see where the shower aides were giving the showers and that would be the hall she would do skin assessments on that day. She said she does not know if that was the way skin assessments are supposed to be done but that was how it had been done since she had been there. She said the charge nurses were to do wound care on their halls when she got pulled off treatments. Review of a written statement dated 4/12/17 by the DON documented she spoke to the Hospice Director on 4/04/17. She said she made rounds (to see the hospice residents) on 4/04/17 and said the hospice aides did not report any new skin issues for Resident #1 to her. The Hospice Director said she did not assess Resident #1's heels on 4/04/17 because the resident seemed comfortable. The DON said she interviewed the facility staff regarding Resident #1's deep tissue injury and the staff denied observing any new areas of skin breakdown during their shift. Some of the staff members verbalized that Resident #1 tended to remove her heel protectors at times. Staff reported putting Resident #1's heel protectors back on, however they said they did not look at her heels. RESIDENT #3 Review of Resident #3's Face Sheet printed 4/11/17 documented he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's 5 Day MDS assessment dated [DATE] documented he was not at risk for pressure sores and did not have any. Review of Resident #3's MDS's assessment 4/03/17 documented in part: -He scored 1 of 15 on his mental status exam (indicating severe cognitive impairment). -He showed signs of [MEDICAL CONDITION]. -He required extensive assist from staff for transfers, dressing, eating and personal hygiene. He was dependent on staff for bathing. -He was incontinent of bowel and bladder. -He was checked to be not at risk for pressure ulcers. Review of Resident #3's care plan revised on 1/30/17 documented Resident #3 was at risk for skin breakdown related to incontinence, [MEDICAL CONDITION], limited mobility, over-weight, refuses care, and impaired cognition. The identified goal was Resident #3 will continue to have 0 breakdown through the review period. Identified approaches included: - Assess resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible. - Avoid shearing resident's skin during positioning, transferring, and turning. - Conduct a systematic skin inspection weekly, pay particular attention to bony prominence's. - Report any signs of skin breakdown (sore, tender, red, or broken areas.) Review of Resident #3's 3/27/17 Braden Scale documented he scored a 14 which was indicated he was a moderate risk. The nurse documented he had an open area to the left inner coccyx (5 x 1 cm), right buttocks (7 x 2), and an unstageable to the right heel 2 x 0. Review of Resident #3's 3/30/17 Skin Assessment by the Treatment Nurse documented in part: Resident continues with abrasion/ sheared area to Rt buttock, measures 1.5 x 0.6 x 0.1 cm. Open area in between buttocks, measures 7.0 x 0.5 x 0.1 cm almost abraded area. Resident has SDTI to Rt heel measures 5 x 6 cm, wound intact without drainage, redness or odor. Cushion applied to foot of bed to provide BLE(bilateral lower extremities) support and float heels. Resident encouraged to reposition q2 hours and prn to off load pressure/wt and use pillows to assist. Review of Resident #3's 4/06/17 Skin Assessment documented he had an SDTI/unstag (unstageable) to the Right Heel measuring 4.5 cm long by 5.5 cm width. The Treatment Nurse documented the tissue type was intact, bruised blister. Review of Resident #3's Braden Scale completed by the treatment nurse on 4/07/16 documented he scored a 14 which indicated he was at Moderate Risk for developing a pressure injury. During an observation on 4/05/17 at 3:21 p.m. the treatment nurse entered Resident #3's room and did wound care for an incision to Resident #3's left leg. The nurse had the certified nurse aide (CNA) hold up Resident #3's right and left heels. After the wound care the Treatment had the aides hold the both heels so golf ball sized purple/black areas on Resident #'#3 heels could be observed. Heels were floated off the bed. Resident #3 was only identified as a moderate risk for pressure ulcers. RESIDENT #4 Review of Resident #4's Resident Face Sheet dated 1/23/17 documented he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's 3/31/17 quarterly MDS documented: -He scored 7 of 15 on his mental status exam (indicating severe cognitive impairment). -He showed no signs of [MEDICAL CONDITION]. -He was dependent on staff for all ADL's. -He had a catheter and was incontinent of bowel. -He had one Stage I pressure ulcer and one Stage II pressure ulcer. Review of Resident #4's Care Plan updated 4/03/17 documented: Resident #4 had a pressure ulcer stage 2 (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister) to right heel and stage I (npuap-pressure-injury-stages: intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED]) to left heel. Area measures 4.2 x 4.5 cm with soft boggy tissue from blister. Red 0.5 x 0.5 red area, stage I to Lt (left) heel. Wound care clean stage II (intact blister) with [MEDICATION NAME], dry apply heel protector et (and) wrap with kerlix qd (every day) until healed. Resident #4 identified goal was Resident #4's pressure ulcers to both heels will heal without complications. Identified approaches included use padding on foot steps on wheelchair for pressure reduction when resident is in chair; use pillow and heel protectors to relieve pressure on the heels; Assess and record the condition of the skin surrounding the pressure ulcer; Assess the pressure ulcer for location, stage, size (length, width, and depth) presence/absence of granulation tissue and [MEDICATION NAME] daily and during treatment/dressing changes; conduct a systematic skin inspection daily. Report any signs of further skin breakdown; keep bony prominence's from direct contact with one another with: pillows, foam wedges etc. Review of Resident #4's Braden Scale dated 4/06/17 documented he scored a 15 indicating he was at moderate risk for developing a pressure ulcer. Review of Resident #4's 2/2017 Physician order [REDACTED]. 1/12/17 Stage I left heel - clean with [MEDICATION NAME], dry, apply heel protector, wrap with Kerlix until healed. Review of Resident 4's Physician order [REDACTED]. - 3/18/17 air mattress to bed - 3/18/17 clean unstageable open wound to right heel with normal saline, pat dry, apply santyl ointment to wound bed cover with tefla, secure with kerlix, change every day and PRN. - 3/18/17 clean unstageable open wound to left heel with normal saline, pat dry, apply santyl ointment to wound bed, cover with Tefla, secure with kerlix, change every day. - 1/12/17 Float heels in bed Review of Resident #4's Measurements (taken from the skin report) documented in part: Right Heel: 1/18/17 - no measurements; 1/19/17 6 x 5 right heel, intact, fluid filled blister; 1/23/17 Stage II 5.7 x 6 cm; 1/31/17 Stage II 5.2 x 5.5; 2/7/17 5.7 x 6 cm; 2/12/17 2 x 12 unstageable; 2/22/17 1.5 x 11 x 0.1; 3/06/16 1.8 x 1.1 x 0.1; 3/19/17 3 x 3 (unstageable); Stage III 3 x 2 x 0.2 Left Heel: 1/19/17 Stage I 0.5 x 0.5; 1/23/17 0.5 x 0.5; 1/31/17 Stage I 0.3 x 0.3; 2/7/17 .04 x 0.4; 2/12/170.4 .0.4. 4/06/17 unstageable 2 x 2. Blister lower right arm: 2/28/17 - 2 x 3 x 0.1; 3/06/17 - 2 x 1 x 0.1. During an observation on 4/04/17 at 5:00 p.m. the treatment nurse did wound care for Resident #4's unstageable to his left heel. The wound wound was the size of a baseball with a slight odor. Resident#4 had no other known skin issues at the time of observation. RESIDENT #17 Review of Resident 17's Face Sheet printed 4/04/17 documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #17's 2/03/17 annual MDS assessment documented -She had long and short term memory impairment with severely impaired decision making abilities. -She was dependent on staff for all ADL care. -She was incontinent of bowel and bladder. -There were no skin issues identified. Review of Resident #17's 1/02/17 Care Plan documented Resident # 17 had an 1 x 1 unstageable to her left toe, bunion area. The identified goal was Resident #7 will show healing within the review period. Identified approaches was: clean with [MEDICATION NAME], allow to dry, cover with foam dressing QD. Review of Resident # 17's 1/02/17 Care Plan documented Resident #17 was at risk for pressure ulcers due to moisture, required assistance, chair bound, and sensory deficit. Identified goal was intact skin without evidence of redness, irritation, maceration, or open areas through next quarter. Identified approaches included skin assessment and inspection every shift with close attention to heels per licensed staff. CNA to report any skin issues to charge nurse immediately. Review of Resident #17's 3/01/17 - 4/04/17 Physician order [REDACTED].>3/07/17 Clean Stage II to left outer heel with NS (normal saline), dry, apply collagen to wound et dry dressing qod (every other day) until healed. 3/07/16 Clean Stage II to right outer heel with NS, dry, apply collagen to wound et dry qod until healed. Review of Resident #17's 3/13/17 Pressure Ulcer Documentation documented she had an unstageable pressure ulcer (npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) with necrotic tissue to her right heel measuring 1.7 x 1.4 x 0.1. Review of Resident #17's 3/13/17 Braden Scale assessment documented she scored a 15 an indicated she was at low risk to develop a pressure ulcer. During an interview on 4/06/17 at 8:40 a.m. the treatment nurse informed the surveyor Resident #17's wound care had just been done. She said Resident #17 had a deep tissue injury on the right heel and a blister on the left heel. RESIDENT 18 Review of Resident #18's Face Sheet printed 4/04/17 documented he was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's 3/29/17- 5 day MDS Assessment documented: He had long and short term memory impairment with severely impaired decision making skills -He was dependent on staff for ADL care. -He had no skin breakdown Review of Resident #18's 3/22/16 Care Plan documented a problem of potential for pressure ulcer or altered skin integrity related to incontinence, abnormal gait, and [MEDICAL CONDITION]. The identified goal was will have intact skin with minimal redness, blisters, or discoloration through review date. Identified approaches included: body audits at least weekly by licensed staff, notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathe or daily care; turn, reposition at least every 2 hours, more often as needed or requested. Review of Resident #18's Braden Scale dated 1/16/17 documented he scored a 15 an indicated he was at low risk of developing a pressure ulcer. Review of Resident #18's 4/06/17 Skin assessment documented he had a stage II pressure ulcer on his left great toe measuring 1.1 x 1 cm, a suspected deep tissue injury on the right second toe measuring 0.4 x 0.7. During an interview on 4/6/17 at 11:54 a.m. the Administrator was informed of the Immediate Jeopardy. She said she was not informed of Resident #1's unstageable pressure injury or that the surveyor had found it. The Administrator said the facility talked about skin issues every morning in stand-up meeting and she was not informed of Resident #1's new pressure injury. She said she received a copy of the facility's skin report and did not realize that 6 new pressure injuries had developed (close to 10% of the facility's census) in 2 months. She said that's too much. During an interview on 4/6/17 at 1:58 p.m. the Treatment Nurse said she had been the treatment nurse off and on for several years. She said this time she had been the treatment nurse for over a year. She said she got pulled treatments to do other jobs because of staffing issues. She said her Corporate Office had said she was not to be pulled. She said last week she had to go to wound care Monday and Friday and then Wednesday she was pulled to work the floor which gave her 2 days to do treatments and skin assessments. She said this week (4/3/17 - 4/7/17) she was pulled to the floor on 4/3 to be the medication nurse and 4/04/17 she had to transport a resident to wound care. She said she had talked to the DON about sending one resident with just two aides to wound care. She said she physically counted the number of wounds in the building when she did the skin report and was very aware of the number of residents with pressure injuries. She said the numbers seem up there. She said the aides were usually very good about reporting changes to her. The Treatment Nurse said she tried to do skin assessments on one hall a day. During an interview on 4/06/17 at 2:55 p.m. the Administrator said she was not informed of Resident #1's pressure injury until the next day. She said unstageable was the most explanation she got. The Administrator was informed that no full body assessment was completed until after 9 a.m. the day after the unstageable was discovered on Resident #1. The Administrator acknowledged the system had broken down. She said it appeared the problem started with the Hospice aides and not telling any of the staff. She said once the Treatment Nurse was notified she should have done a full assessment. The Administrator said the facility CNA's provided incontinent care and as needed bed baths. She said they provided care like repositioning and putting on the heel protectors that everyone kicks off. She said as they were repositioning Resident #1 she would think they would see the unstageable pressure injury. Review of the Certified Nursing Assistant Job Description (undated) documented, in part: Summary: Provide nursing care to the residents according to established policies and procedures and to ensure that the highest degree of quality of care is maintained at all times. Safety and Sanitation: Report all incidents and accidents immediately. Review of the facility's February 2014 Policy and Procedure on Pressure Ulcer Risk Assessment documented, in part: Purpose: The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. Preparation: Review the resident's care plan to assess for any special needs of the resident. Once a pressure ulcer develops, it can be extremely difficult to heal. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor. Assessment: Skin Assessment: Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. Review of the facility's February 2014 policy and procedure on Prevention of Pressure Ulcers documented, in part: Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. General Guidelines: Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. Use pillows, wedges or other off-loading devices to keep bony prominence's such as knees or ankles from touching each other. Do not massage bony prominence's. When in bed every attempt should be made to float heals (keep heels off the bed) by placing a pillow from knee to ankle or with other devices as recommended by clinical staff or by the physician. The facility's Plan of Removal Of Immediate Jeopardy was accepted on 4/04/17 and included the following: Prevention of Pressure Sores<B

Based on observations, interviews, and record reviews the facility Administrator and Director of Nurses (DON) failed to provide oversight in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being for 1 of 6 residents identified with wounds (Resident #1). [NAME] The Director of Nurses (DON) failed to implement facility policies and procedures regarding pressure sore assessments and treatments when: (1) Resident #1's Deep Tissue Injury was not identified by facility staff. Resident #1 did not receive a full body assessment for additional wounds until the next day (4/5/17) after surveyor request. B. The Administrator failed to oversee the Director of Nurses to ensure she was monitoring the nursing staff on completing accurate and timely nursing assessments and treatments. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 4/6/17 at 11:54 p.m While the IJ was lowered on 4/11/17 at 12:02 p.m., the facility remained out of compliance at a level of actual harm with a scope identified as a pattern because they did not have time to monitor for effectiveness. This deficient practice affected the timely care and treatment of [REDACTED].#1 and could affect the other 12 residents with wounds by not providing therapeutic and timely treatments for wounds, and cause pain to residents during wound care. Findings include: RESIDENT #1 Review of Resident #1's face sheet dated 1/31/17 documented she was [AGE] years of age admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] documented in part: -She scored 3 of 15 on the mental status exam (indicating severe cognitive impairment). -She showed no signs of [MEDICAL CONDITION]. -She rejected care. -She was dependent on staff for all Activities of Daily Living (AD's). -She was incontinent of bowel and bladder. -She was checked for at risk for pressure injuries. Review of Resident #1's Care Plan updated 2/19/17 documented: -Resident #1 had actual functional loss in transfers/bed mobility, used wheelchair and needed assistance with locomotion. Identified approaches included attempt to alleviate barriers to self performance of ADL's (activities of daily living), provide assistance with ADL's necessary to complete task. -Resident #1 had self care deficit and required total assistance with showers, hygiene, and dressing. Identified approaches were Resident #1 required total dependence assistance with hygiene and showering. -Resident #1 required a splint to her left leg (due to fracture). Identified approaches included to inspect skin to left leg, observe and report any red or broken areas. -Resident #1 was expected to have skin breakdown or/and pressure ulcers related to end stage. Identified approaches included to utilize heel protectors; position with pillows to elevate pressure points, turn and reposition every 2 hours or as needed, skin assessment and inspection every shift with close attention to heels. There was no documentation of skin assessments done every shift. Review of Resident #1's 2/2017 Physician order [REDACTED]. -Start date 5/23/14-heel protectors in place. Review of Resident #1's Braden Scale dated 4/04/17 documented she scored a 12 indicated she was high risk for developing a pressure ulcer. Review of the Weekly Wound Tracking Worksheet dated 3/10/17 documented in part: -Resident #1 had an acquired in house trauma injury that measured 0.7 x 0.3 x 0.2 centimeters (cm) on her left thigh with granulation tissue (pink or red with shiny moist granular appearance) identified on 2/14/17. Nutrition measures: Vitamin C , zinc every day, arginade twice a day, liquid protein 30 ml (milliliters) twice a day, super-cereal with breakfast and 60 ml of 2 cal three times a day. Braden Score 12 (high risk for pressure injuries). Support measures: Clean with normal saline, dry, apply abd pad everyday and as needed until healed. Splint left leg at all times. Heel protectors in place while in bed. Resident #1 had an in house acquired pressure ulcer (injury) identified on 2/28/17 to her right coccyx that measured 1.3 x 0.3 x 0.1 with granulation tissue. Nutrition measures: Vitamin C, zinc every day, arginade twice a day, liquid protein 30 ml (milliliters) twice a day, super-cereal with breakfast and 60 ml of 2 cal three times a day. Support measures: apply [MEDICATION NAME]. Review of the Weekly Wound Tracking Worksheet dated 3/17/17 documented in part: -Resident #1 had an acquired in house pressure injury that measured 1.5 x 0.5 x 0.1 centimeters (cm) on her coccyx area with granulation tissue (pink or red with shiny moist granular appearance) identified on 2/14/17. Braden Score 12 (high risk for pressure injuries). Support measures: Clean with normal saline, dry, apply collagen and dry dressing every of day and as needed until healed. -Resident #1 had an acquired in house trauma injury that measured 0.7 x 0.3 x 0.2 centimeters (cm) on her left thigh with granulation tissue (pink or red with shiny moist granular appearance) identified on 2/14/17. Braden Score 12 (high risk for pressure injuries). Support measures: Clean with normal saline, dry, apply abd pad everyday and as needed until healed. Splint left leg at all times. Heel protectors in place while in bed. -Resident #1 had an in house acquired pressure ulcer (injury) identified on 2/28/17 to her right coccyx that measured 0.7 x 0.5 x 0.1 cm. with [MEDICATION NAME] tissue (new skin or growing can be pink and shiny). Support measures: apply [MEDICATION NAME] twice a day and as needed until healed. -Resident #1 had an in house acquired pressure ulcer (injury) identified on 2/07/17 to her coccyx left that measured 0.7 x 0.3 x 0.1 cm. with [MEDICATION NAME] tissue (new skin or growing can be pink and shiny). Support measures: apply [MEDICATION NAME] twice and as needed until healed. Review of the Weekly Wound Tracking Worksheet dated 3/31/17 documented in part: Apply [MEDICATION NAME] to peri-area as needed until healed. DX (diagnosis): Stage 2 to left coccyx. Clean wound to left knee with Normal saline, dry apply to TAO (triple antibiotic ointment), abd pad until healed. DX: Wound to left knee. Clean unstageable to coccyx with normal saline, dry, with 4 x 4's, apply collagen and dry dressing every other day until healed. -Resident #1 had an in house acquired trauma injury identified on 2/14/17 to her right coccyx that measured 1.7 x 0.6 cm. with granulation tissue (pink or red with shiny moist granular appearance). Support measures: Clean with normal saline, dry, apply abd pad everyday and as needed until healed. Splint left leg at all times. Heel protectors in place while in bed. -Resident #1 had an in house acquired pressure ulcer (injury) identified on 2/28/17 to her coccyx (right and left coccyx pressure injury merged across the coccyx identified on 3/21/17) that measured 2.25 x 5.2 cm. with necrotic tissue (eschar, black, brown or tan tissue). Support measures: Clean with normal saline, dry, apply dry dressing every other day and as needed until healed. Review of Resident #1's 4/2017 Physician order [REDACTED]. Start date 4/04/17-Clean unstageable to right heel with [MEDICATION NAME], leave open to air every day and heel protectors in place at all times. DX (diagnosis) unstageable to right heel. (discontinued on 4/05/17) Review of the telephone physician orders [REDACTED]. DX: SDTI. Review of the Weekly Wound Tracking Worksheet dated 4/07/17 documented in part: -Resident #1 acquired in house deep tissue injury to her right heel that measured 4 x 2.5 cm. identified on 4/04/17. Support measures: Support measures: Clean with [MEDICATION NAME], dry, apply [MEDICATION NAME], heel dressing wrap with kling and secure with tape every other day and as needed. Heel protectors in place at all times. -Resident #1 had a deep tissue injury on her left posterior lower leg identified on 4/04/17 that measured 2 x 2. Support measures: Clean with normal saline, dry, apply foam dressing, change every three days and as needed until healed. Knee immobilizer to remain in place. -Resident #1 acquired an in house deep tissue injury to the top of her 2nd right toe that measured 0.6 x 0.7 cm. identified on 2/28/17. Support measures: Clean with [MEDICATION NAME] and lota every day or as needed. -Resident #1 acquired in house deep tissue injury to the top of her 3rd left toe that measured 0.6 x 0.6 cm. identified on 4/04/17. Support measures: Clean with [MEDICATION NAME] and lota every day or as needed. -Resident #1 had an in house acquired pressure ulcer (injury) identified on 2/28/17 to her coccyx (right and left buttock pressure injury merged across the coccyx on 3/21/17) that measured 5 x 5 cm. with necrotic tissue (eschar, black, brown or tan tissue. Support measures: Clean with dakins 0.25%, dry, apply aginate moistened with hydrogel and pack into wound. Apply [MEDICATION NAME] to peri-wound. Apply charcoal dressing and alleveyn dressing every day. During an observation on 4/04/17 at 11:38 a.m. Resident #1 was lying in bed and 2 hospice aides had just finished giving Resident #1 a bed bath. The surveyor asked them if Resident #1 had any skin issues. An aide lifted up Resident #1's right heel and said she has this and she also has one area on her buttock but it had a dressing on it. The right heel had a large dark purple black area (approximately the size of a large egg). The hospice aide said Resident #1 did not have any type of dressing on the heel. The hospice aides did not make the facility staff aware of Resident #1's right heel (SDTI) or the hospice nurse. The surveyor requested the facility's treatment nurse assess the right heel on 4/04/17 at 4:40 p.m. During an observation during wound care on 4/04/17 at 4:09 p.m. the treatment nurse got her supplies ready to do wound for Resident #1. The treatment nurse took off Resident #1's leg immobilizer and raised Resident #1's leg up to do a skin assessment of the leg. The treatment nurse changed the dressing to Resident #1's left knee and changed the dressing to the unstageable pressure injury on Resident #1's coccyx area. She said that was the only pressure injury resident #1 had at this time (indicating the wound to Resident #1's coccyx). While positioning Resident #1 in bed the treatment nurse had to put Resident #1's heel protectors back on. She raised the right lower leg and placed the heel protector on. The treatment nurse pointed out that Resident #1 had areas on her right 2nd and 3rd toe which she said they just cleansed the area but did not put dressing on them. The treatment nurse did not assess Resident #1's heels when she put the heel protectors back in position. The treatment nurse had finished her treatment and was walking out of Resident #1's room when the surveyor asked her to check Resident #1's right heel. The treatment nurse went to her medication cart and got out a measuring tape and re-entered Resident #1's room. The treatment nurse said she was unaware Resident #1 had anything to her right heel. She measured the area at 4 x 2.5 cm. She wrote the size on and appearance of the area on a scrap piece of paper and turned it into the Director of Nurses (DON) at 4:55 p.m. The treatment nurse said the said the DON would be the one to go in and stage the area. During an interview on 4/05/17 at 8:51 a.m. the DON said she first learned about Resident #1's right heel injury the day before (4/04/17) when the treatment nurse informed her around 5:00 p.m. She said she was not sure when Resident #1 acquired the pressure injury. She said she had talked to the hospice nurse to see if anyone had reported it to her and she said the hospice aides did not report any new issues to her. The DON said the hospice nurse informed her that she asked the hospice aides if there was any thing she needed to know about Resident #1 and the aides told her no. She said the hospice nurse did not assess Resident #1's heels when she came in yesterday because Resident #1 was asleep and she didn't want to wake her. The DON said if there are any changes the charge nurse for that resident was informed. She said the charge nurse for Resident #1 was not informed of any new issues. She said she did not do a full body skin assessment of Resident #1 on 4/04/17 but would get the treatment nurse and do it now. The DON said she would have to get the hospice aides notes faxed to her. During an interview on 4/06/17 at 9:48 a.m. hospice aides Q and R said they had just noticed Resident #1's right heel on Monday (4/04/17). They said they were supposed to report any resident changes to their hospice nurse. They said they did not report Resident #1's heel so they had to go to an in-service on reporting resident changes. The hospice aides said they had to report any thing different with the resident, like that resident's heel. They said they report changes immediately. During an interview on 4/06/17 at 11:07 a.m. the treatment nurse said skin assessments were to be done weekly. She said she did medication pass on Monday's and then Tuesday's she had to go to wound care in Midland with one of the residents so she did not do treatments or skin assessments on those days. She said she did skin assessments on what ever day the aides were giving showers so she could be in the shower room while the residents were showered. She said she would look to see where the shower aides were giving the showers and that would be the hall she would do skin assessments on that day. She said she does not know if that was the way skin assessments are supposed to be done but that was how it had been done since she had been there. She said the charge nurses were to do wound care on their halls when she got pulled off treatments. Review of a written statement dated 4/12/17 by the DON documented she spoke to the Hospice Director on 4/04/17. She said she made rounds (to see the hospice residents) on 4/04/17 and said the hospice aides did not report any new skin issues for Resident #1 to her. The Hospice Director said she did not assess Resident #1's heels on 4/04/17 because the resident seemed comfortable. The DON said she interviewed the facility staff regarding Resident #1's deep tissue injury and the staff denied observing any new areas of skin breakdown during their shift. Some of the staff members verbalized that Resident #1 tended to remove her heel protectors at times. Staff reported putting Resident #1's heel protectors back on, however they said they did not look at her heels. During an interview on 4/6/17 at 11:54 a.m. the Administrator was informed of the Immediate Jeopardy. She said she was not informed of Resident #1's unstageable pressure injury or that the surveyor had found it. The Administrator said the facility talked about skin issues every morning in stand-up meeting and she was not informed of Resident #1's new pressure injury. She said she received a copy of the facility's skin report and did not realize that 6 new pressure injuries had developed (close to 10% of the facility's census) in 2 months. She said that's too much. During an interview on 4/6/17 at 1:58 p.m. the Treatment Nurse said she had been the treatment nurse off and on for several years. She said this time she had been the treatment nurse for over a year. She said she got pulled treatments to do other jobs because of staffing issues. She said her Corporate Office had said she was not to be pulled. She said last week she had to go to wound care Monday and Friday and then Wednesday she was pulled to work the floor which gave her 2 days to do treatments and skin assessments. She said this week (4/3/17 - 4/7/17) she was pulled to the floor on 4/3 to be the medication nurse and 4/04/17 she had to transport a resident to wound care. She said she had talked to the DON about sending one resident with just two aides to wound care. She said she physically counted the number of wounds in the building when she did the skin report and was very aware of the number of residents with pressure injuries. She said the numbers seem up there. She said the aides were usually very good about reporting changes to her. The Treatment Nurse said she tried to do skin assessments on one hall a day. During an interview on 4/06/17 at 2:55 p.m. the Administrator said she was not informed of Resident #1's pressure injury until the next day. She said unstageable was the most explanation she got. The Administrator was informed that no full body assessment was completed until after 9 a.m. the day after the unstageable was discovered on Resident #1. The Administrator acknowledged the system had broken down. She said it appeared the problem started with the Hospice aides and not telling any of the staff. She said once the Treatment Nurse was notified she should have done a full assessment. The Administrator said the facility CNA's provided incontinent care and as needed bed baths. She said they provided care like repositioning and putting on the heel protectors that everyone kicks off. She said as they were repositioning Resident #1 she would think they would see the unstageable pressure injury. During an interview on 4/06/17 at 3:35 p.m. the Administrator said she did not know how the breakdown in the facility processes happened. She said the staff did a skin assessment the previous Thursday (3/30/17) and there was no areas on her heels. She said they did a culture on the wound on Resident #1's coccyx and got her on an antibiotic for that. The Administrator acknowledged the Treatment nurse was pulled to the floor and did have to do wound care appointments. She said maybe it would be a good idea to have a second set of eyes to check skin. The Administrator said they did discuss skin at each QA meeting and it was constant training, follow-up, follow-up, and follow-up. She said she monitored to make sure the skin process remained effective by talking about it every week in the quality of care meetings where they talked about skin and weights. She said they failed to recognize the pattern of increased pressure injuries to the feet. The Administrator said she thought the biggest failure is people did not see how their jobs were connected and could cause a ripple effect through the entire building. The Administrator said the facility had a lot of falls/ reportable incidents she thought they lost focus on the pressure injuries and focused more on the falls and the focus came off the pressure injuries. During an interview on 4/10/17 at 3:57 p.m. the DON said she did not know how the IJ in pressure injuries happened. She said she had tried to keep up with it the best she could by going over daily orders and incident - accident reports. The DON said she was making sure measures were put in place with Resident #1 to prevent the pressure sore. The DON said she thought it was a communication issue with the Hospice Agency who did not report the breakdown to the facility Charge Nurse. She said to monitor to make sure the pressure injury process was effective was she talked to the Hospice Supervisor and they were now in-servicing the Hospice Team with the regular CNA's. The DON said the Hospice Aides now had a binder with skin report sheets just like the regular CNA's. She said she did not evaluate the facility's policies for effectiveness because she did not realize there was a problem. She thought the root cause of this IJ was a lack of communication. The DON acknowledged she had seen an overall increase in weight loss/ decrease in appetites in residents which contributed to the development of wounds. She said this was identified the last week of (MONTH) and there had not been time to monitor that for effectiveness. The DON said they identified three new pressure injuries when they did skin assessments. She said the facility and Hospice CNA's had been in-serviced on proper repositioning. The DON acknowledged half the pressure injuries were to resident heels and half of those residents were not bed bound so she was still trying to figure out how they occurred. She said they facility had an IJ in pressure injuries last year but it was confined to one person - this year it was prevention and identification and she could not identify a pattern to why they were developing. She was asked if she checked the Braden Assessments for accuracy and she said how did I miss that? We were all just so exhausted when we did those. During an interview on 4/7/17 the Regional Director said the facility did a clinical stand up meeting every day and did a really good job with it, but they were just not seeing trends in care. Review of the Certified Nursing Assistant Job Description (undated) documented, in part: Summary: Provide nursing care to the residents according to established policies and procedures and to ensure that the highest degree of quality of care is maintained at all times. Safety and Sanitation: Report all incidents and accidents immediately. Review of the facility's (MONTH) 2014 Policy and Procedure on Pressure Ulcer Risk Assessment documented, in part: Purpose: The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. Preparation: Review the resident's care plan to assess for any special needs of the resident. Once a pressure ulcer develops, it can be extremely difficult to heal. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor. Assessment: Skin Assessment: Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. Review of the facility's (MONTH) 2014 policy and procedure on Prevention of Pressure Ulcers documented, in part: Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. General Guidelines: Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. Use pillows, wedges or other off-loading devices to keep bony prominence's such as knees or ankles from touching each other. Do not massage bony prominence's. When in bed every attempt should be made to float heals (keep heels off the bed) by placing a pillow from knee to ankle or with other devices as recommended by clinical staff or by the physician. The facility's Plan of Removal Of Immediate Jeopardy was accepted on 4/04/17 and included the following: Prevention of Pressure Sores Nurses and CNA's re-educated on positioning, turning, preventative measures and reporting related to skin by DON. Date of Completion 4/07/17. In-service on going. Identification/interventions of Pressure Sores The DON, ADON (assistant director of nurses), treatment nurse and LVN (licensed vocational nurse) charge nurse conducted 100% skin Evaluation and Intervention Form. Risk Evaluation and intervention form. The Braden Scale was updated for all residents in the facility. Preventative interventions were put into place for all newly identified residents. They physician was notified of any new skin problems that were identified and orders obtained for treatment (s). The resident and/or responsible party was also notified of any newly identified pressure sores and the new orders that were obtained from the physician. Date of Completion: 4/06/17. Staff education related pressure sores The DON/designee in-serviced and education the Treatment Nurse on the prevention of pressure sores, ensuring proper turning and positioning of residents; identification and reporting any skin change noted during care. The treatment nurse was also in-serviced on proper documentation requirements related to a pressure sore and notification of the physician, resident,/responsible party and nurse DON/Designee when a resident has any change in condition. Completed on 4/07/17 Additional in-service with nursing staff was proved by the DON and the ADON on 4/07/17 addressing the prevention of pressures sores. Completed on 4/07/17 The Regional Nurse Consultant completed wound care competencies with the DON and Treatment Nurse which included return demonstrations. on 4/07/17 Monitoring of Pressure Sores The DON will check all known pressure sores at least once a week to evaluate the effectiveness of the treatment, to ensure that the treatment nurse is providing the treatments as ordered by the physician, and to evaluate the pressure reducing devices that are in place. The DON will or Designee will also complete random skin assessments on the least 3 individuals per week. Regional Nurse will review the DON Random Skin Audits at least once a month in the facility. Findings will be evaluated during the Weekly Quality of Care meeting and monthly during QA (quality assurance) & A for a minimum of 3 months and thereafter until the satisfaction of the QA & A committee is achieved. Started 4/06/17 In-serviced on 4/07/17 and distribution of the booklets on 4/07/17 The Certified Nursing Assistants (CNA) were in-serviced by the DON and the ADON on 4/07/17 about the continuous Pressure Ulcer Prevention booklets which provide the CNA's with a tool to document any noted skin change for a resident that they identify during routine daily resident care (see attached copy of the form and guidelines). The form is a triplicate copy with one distributed to the DON, one to the charge nurse and the other is kept by the CN[NAME] the CNA's were all given a set of the forms and guidelines which are included on 4/07/17. Initiated 4/07/17 Date of Completion 4/07/17 CNA's will complete a Daily CNA Shift Report Sheet. This will be completed on every shift and used as shift-to-shift communication tool between aides. Communication will include any observed changes in resident condition. CNA's are to notify the charge nurse as well. The sheets will be reviewed during the daily clinical meetings. Started 4/17/17 Shower aides were in-serviced by the ADON on completing skin observations and implementation of skin sheets for every resident showered whether skin issues are identified or not. Shower aides will bring and report on shower log, skin sheets and any other concerns at daily stand-up. This will ensure residents are not over looked for skin issues during showers. Monthly and ongoing Nursing Management will review all residents with changes of condition including pressure sores during the Daily Clinical Meeting. On-Going Skin Management System Resident will have a skin check and a Braden Scale completed on admission/readmission by the charge nurse who is completing the admission. Any identified pressure sore or there skin problem will be reported to the physician to obtain treatment orders and notify the resident/responsible part. The charge nurse will document all findings on the admission paperwork and the 24 hour report. Al new resident admissions/readmissions will be reviewed in the daily Clinical Meeting. The DON/designee will check the newly admitted /readmitted resident's skin within 24 hours of admission or on Monday following a weekend admission to ensure all skin problems are identified and addressed. On-going Starting 4/07/07 All resident that are admitted /readmitted will have a Braden scale completed by the charge nurse or treatment nurse on admission and then for 3 consecutive weeks for a total of 4 weeks to establish a baseline. The DON/Designee will verify completion at the Daily clinical meeting. In addition to the Braden scale, the Treatment Nurse will complete the Skin Risk Evaluation and Interventions form for all residents who have a Braden scale of 18 or less and/or the resident has a wound (refer to attached skin risk evaluation and intervention form attached). The resident plan of care related to an identified wound and/for a resident that is high risk for breakdown will be initiated with the interventions portion of the form. Initial Skin Risk Evaluation and Interventions form will be completed on the current resident with a Braden assessment of 18 or less and/or a resident with a wound by 4/07/17 then on-going. The treatment nurse will conduct weekly head to toe skin assessments on every resident in the facility. The treatment nurse will report any newly identified skin problem to the DON and the DON will ensure proper documentation, notifications and interventions are in place. The physician will be contacted for treatment orders and resident/responsible party will also be notified. The treatment nurse will initiate the treatment, note the skin problems and new order on the 24 hour report and document all the above in the nurses' progress notes. The ordered treatment will be noted on the current treatment documentation form. The Nurse Management team will check that all the above are completed in the daily Clinical meeting. On-going The treatment nurse will be responsible for providing the treatments for all residents as ordered by the physician in the event the treatment nurse is off, the charge nurse for each hall will be responsible for providing the physician ordered treatments to the residents on the assigned hall. On-going The Nurse Management Team will meet every week to complete the Weekly Quality of Care Review. The Nurse Management team will review all residents identified with new pressure sores in the last week to ensure that all appropriate treatments and pressure prevention measures are in place and completed as ordered. The Management Team at this time will also review the weekly skin assessment sheets to ensure all residents skins are assessed on a weekly basis. On-going The DON or Designee will repeat all afore mentioned in-services monthly for a minimum of 3 months and thereafter until the satisfaction of the QA & A committee is achieved. The Administrator was notified that the IJ was removed prior to exit on 4/07/16. The facility remained out of compliance at a scope of security level of Actual Harm that is not immediate jeopardy at a Pattern that was not IJ because the facility had not had time to implement and monitor their plan for effectiveness. DEFINITIONS (taken from State Operations Manual guidance on Pressure Ulcers revised 5/01/16): Pressure Ulcer - A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Although friction & shear are not primary causes of pressure ulcers, friction & shear are important contributing factors to the development of pressure ulcers. Assessment - An admission evaluation helps identify the resident at risk of developing a pressure ulcer, & the resident with existing pressure ulcer(s) or areas of skin that are at risk for breakdown. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified & have interventions implemented promptly to attempt to prevent pressure ulcers. The admission evaluation helps define those initial care approaches. While pressure ulcers on the sacrum remain the most common location, pressure ulcers on the heel are occurring more frequently, are difficult to assess & heal, & require early identification of skin compromise over the heel. (From the Minimum Data Set (MDS) assessment dated [DATE])) Unstageable - Deep Tissue: Suspected Deep tissue injury in evolution. Review of the form CMS 672 Resident Census and Conditions of Residents completed by RN [NAME] on 4/11/17 documented there were 13 residents with pressure ulcers in the building.

Based on observations, interviews, and record reviews the facility Administrator and Director of Nurses (DON) failed to provide oversight in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being for 1 of 6 residents identified with wounds (Resident #1). A. The Director of Nurses (DON) failed to implement facility policies and procedures regarding pressure sore assessments and treatments when: (1) Resident #1's Deep Tissue Injury was not identified by facility staff. Resident #1 did not receive a full body assessment for additional wounds until the next day (4/5/17) after surveyor request. B. The Administrator failed to oversee the Director of Nurses to ensure she was monitoring the nursing staff on completing accurate and timely nursing assessments and treatments. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 4/6/17 at 11:54 p.m While the IJ was lowered on 4/11/17 at 12:02 p.m., the facility remained out of compliance at a level of actual harm with a scope identified as a pattern because they did not have time to monitor for effectiveness. This deficient practice affected the timely care and treatment of [REDACTED].#1 and could affect the other 12 residents with wounds by not providing therapeutic and timely treatments for wounds, and cause pain to residents during wound care. Findings include: RESIDENT #1 Review of Resident #1's face sheet dated 1/31/17 documented she was [AGE] years of age admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] documented in part: -She scored 3 of 15 on the mental status exam (indicating severe cognitive impairment). -She showed no signs of [MEDICAL CONDITION]. -She rejected care. -She was dependent on staff for all Activities of Daily Living (AD's). -She was incontinent of bowel and bladder. -She was checked for at risk for pressure injuries. Review of Resident #1's Care Plan updated 2/19/17 documented: -Resident #1 had actual functional loss in transfers/bed mobility, used wheelchair and needed assistance with locomotion. Identified approaches included attempt to alleviate barriers to self performance of ADL's (activities of daily living), provide assistance with ADL's necessary to complete task. -Resident #1 had self care deficit and required total assistance with showers, hygiene, and dressing. Identified approaches were Resident #1 required total dependence assistance with hygiene and showering. -Resident #1 required a splint to her left leg (due to fracture). Identified approaches included to inspect skin to left leg, observe and report any red or broken areas. -Resident #1 was expected to have skin breakdown or/and pressure ulcers related to end stage. Identified approaches included to utilize heel protectors; position with pillows to elevate pressure points, turn and reposition every 2 hours or as needed, skin assessment and inspection every shift with close attention to heels. There was no documentation of skin assessments done every shift. Review of Resident #1's 2/2017 Physician order [REDACTED]. -Start date 5/23/14-heel protectors in place. Review of Resident #1's Braden Scale dated 4/04/17 documented she scored a 12 indicated she was high risk for developing a pressure ulcer. Review of the Weekly Wound Tracking Worksheet dated 3/10/17 documented in part: -Resident #1 had an acquired in house trauma injury that measured 0.7 x 0.3 x 0.2 centimeters (cm) on her left thigh with granulation tissue (pink or red with shiny moist granular appearance) identified on 2/14/17. Nutrition measures: Vitamin C , zinc every day, arginade twice a day, liquid protein 30 ml (milliliters) twice a day, super-cereal with breakfast and 60 ml of 2 cal three times a day. Braden Score 12 (high risk for pressure injuries). Support measures: Clean with normal saline, dry, apply abd pad everyday and as needed until healed. Splint left leg at all times. Heel protectors in place while in bed. Resident #1 had an in house acquired pressure ulcer (injury) identified on 2/28/17 to her right coccyx that measured 1.3 x 0.3 x 0.1 with granulation tissue. Nutrition measures: Vitamin C, zinc every day, arginade twice a day, liquid protein 30 ml (milliliters) twice a day, super-cereal with breakfast and 60 ml of 2 cal three times a day. Support measures: apply [MEDICATION NAME]. Review of the Weekly Wound Tracking Worksheet dated 3/17/17 documented in part: -Resident #1 had an acquired in house pressure injury that measured 1.5 x 0.5 x 0.1 centimeters (cm) on her coccyx area with granulation tissue (pink or red with shiny moist granular appearance) identified on 2/14/17. Braden Score 12 (high risk for pressure injuries). Support measures: Clean with normal saline, dry, apply collagen and dry dressing every of day and as needed until healed. -Resident #1 had an acquired in house trauma injury that measured 0.7 x 0.3 x 0.2 centimeters (cm) on her left thigh with granulation tissue (pink or red with shiny moist granular appearance) identified on 2/14/17. Braden Score 12 (high risk for pressure injuries). Support measures: Clean with normal saline, dry, apply abd pad everyday and as needed until healed. Splint left leg at all times. Heel protectors in place while in bed. -Resident #1 had an in house acquired pressure ulcer (injury) identified on 2/28/17 to her right coccyx that measured 0.7 x 0.5 x 0.1 cm. with [MEDICATION NAME] tissue (new skin or growing can be pink and shiny). Support measures: apply [MEDICATION NAME] twice a day and as needed until healed. -Resident #1 had an in house acquired pressure ulcer (injury) identified on 2/07/17 to her coccyx left that measured 0.7 x 0.3 x 0.1 cm. with [MEDICATION NAME] tissue (new skin or growing can be pink and shiny). Support measures: apply [MEDICATION NAME] twice and as needed until healed. Review of the Weekly Wound Tracking Worksheet dated 3/31/17 documented in part: Apply [MEDICATION NAME] to peri-area as needed until healed. DX (diagnosis): Stage 2 to left coccyx. Clean wound to left knee with Normal saline, dry apply to TAO (triple antibiotic ointment), abd pad until healed. DX: Wound to left knee. Clean unstageable to coccyx with normal saline, dry, with 4 x 4's, apply collagen and dry dressing every other day until healed. -Resident #1 had an in house acquired trauma injury identified on 2/14/17 to her right coccyx that measured 1.7 x 0.6 cm. with granulation tissue (pink or red with shiny moist granular appearance). Support measures: Clean with normal saline, dry, apply abd pad everyday and as needed until healed. Splint left leg at all times. Heel protectors in place while in bed. -Resident #1 had an in house acquired pressure ulcer (injury) identified on 2/28/17 to her coccyx (right and left coccyx pressure injury merged across the coccyx identified on 3/21/17) that measured 2.25 x 5.2 cm. with necrotic tissue (eschar, black, brown or tan tissue). Support measures: Clean with normal saline, dry, apply dry dressing every other day and as needed until healed. Review of Resident #1's 4/2017 Physician order [REDACTED]. Start date 4/04/17-Clean unstageable to right heel with [MEDICATION NAME], leave open to air every day and heel protectors in place at all times. DX (diagnosis) unstageable to right heel. (discontinued on 4/05/17) Review of the telephone physician orders [REDACTED]. DX: SDTI. Review of the Weekly Wound Tracking Worksheet dated 4/07/17 documented in part: -Resident #1 acquired in house deep tissue injury to her right heel that measured 4 x 2.5 cm. identified on 4/04/17. Support measures: Support measures: Clean with [MEDICATION NAME], dry, apply [MEDICATION NAME], heel dressing wrap with kling and secure with tape every other day and as needed. Heel protectors in place at all times. -Resident #1 had a deep tissue injury on her left posterior lower leg identified on 4/04/17 that measured 2 x 2. Support measures: Clean with normal saline, dry, apply foam dressing, change every three days and as needed until healed. Knee immobilizer to remain in place. -Resident #1 acquired an in house deep tissue injury to the top of her 2nd right toe that measured 0.6 x 0.7 cm. identified on 2/28/17. Support measures: Clean with [MEDICATION NAME] and lota every day or as needed. -Resident #1 acquired in house deep tissue injury to the top of her 3rd left toe that measured 0.6 x 0.6 cm. identified on 4/04/17. Support measures: Clean with [MEDICATION NAME] and lota every day or as needed. -Resident #1 had an in house acquired pressure ulcer (injury) identified on 2/28/17 to her coccyx (right and left buttock pressure injury merged across the coccyx on 3/21/17) that measured 5 x 5 cm. with necrotic tissue (eschar, black, brown or tan tissue. Support measures: Clean with dakins 0.25%, dry, apply aginate moistened with hydrogel and pack into wound. Apply [MEDICATION NAME] to peri-wound. Apply charcoal dressing and alleveyn dressing every day. During an observation on 4/04/17 at 11:38 a.m. Resident #1 was lying in bed and 2 hospice aides had just finished giving Resident #1 a bed bath. The surveyor asked them if Resident #1 had any skin issues. An aide lifted up Resident #1's right heel and said she has this and she also has one area on her buttock but it had a dressing on it. The right heel had a large dark purple black area (approximately the size of a large egg). The hospice aide said Resident #1 did not have any type of dressing on the heel. The hospice aides did not make the facility staff aware of Resident #1's right heel (SDTI) or the hospice nurse. The surveyor requested the facility's treatment nurse assess the right heel on 4/04/17 at 4:40 p.m. During an observation during wound care on 4/04/17 at 4:09 p.m. the treatment nurse got her supplies ready to do wound for Resident #1. The treatment nurse took off Resident #1's leg immobilizer and raised Resident #1's leg up to do a skin assessment of the leg. The treatment nurse changed the dressing to Resident #1's left knee and changed the dressing to the unstageable pressure injury on Resident #1's coccyx area. She said that was the only pressure injury resident #1 had at this time (indicating the wound to Resident #1's coccyx). While positioning Resident #1 in bed the treatment nurse had to put Resident #1's heel protectors back on. She raised the right lower leg and placed the heel protector on. The treatment nurse pointed out that Resident #1 had areas on her right 2nd and 3rd toe which she said they just cleansed the area but did not put dressing on them. The treatment nurse did not assess Resident #1's heels when she put the heel protectors back in position. The treatment nurse had finished her treatment and was walking out of Resident #1's room when the surveyor asked her to check Resident #1's right heel. The treatment nurse went to her medication cart and got out a measuring tape and re-entered Resident #1's room. The treatment nurse said she was unaware Resident #1 had anything to her right heel. She measured the area at 4 x 2.5 cm. She wrote the size on and appearance of the area on a scrap piece of paper and turned it into the Director of Nurses (DON) at 4:55 p.m. The treatment nurse said the said the DON would be the one to go in and stage the area. During an interview on 4/05/17 at 8:51 a.m. the DON said she first learned about Resident #1's right heel injury the day before (4/04/17) when the treatment nurse informed her around 5:00 p.m. She said she was not sure when Resident #1 acquired the pressure injury. She said she had talked to the hospice nurse to see if anyone had reported it to her and she said the hospice aides did not report any new issues to her. The DON said the hospice nurse informed her that she asked the hospice aides if there was any thing she needed to know about Resident #1 and the aides told her no. She said the hospice nurse did not assess Resident #1's heels when she came in yesterday because Resident #1 was asleep and she didn't want to wake her. The DON said if there are any changes the charge nurse for that resident was informed. She said the charge nurse for Resident #1 was not informed of any new issues. She said she did not do a full body skin assessment of Resident #1 on 4/04/17 but would get the treatment nurse and do it now. The DON said she would have to get the hospice aides notes faxed to her. During an interview on 4/06/17 at 9:48 a.m. hospice aides Q and R said they had just noticed Resident #1's right heel on Monday (4/04/17). They said they were supposed to report any resident changes to their hospice nurse. They said they did not report Resident #1's heel so they had to go to an in-service on reporting resident changes. The hospice aides said they had to report any thing different with the resident, like that resident's heel. They said they report changes immediately. During an interview on 4/06/17 at 11:07 a.m. the treatment nurse said skin assessments were to be done weekly. She said she did medication pass on Monday's and then Tuesday's she had to go to wound care in Midland with one of the residents so she did not do treatments or skin assessments on those days. She said she did skin assessments on what ever day the aides were giving showers so she could be in the shower room while the residents were showered. She said she would look to see where the shower aides were giving the showers and that would be the hall she would do skin assessments on that day. She said she does not know if that was the way skin assessments are supposed to be done but that was how it had been done since she had been there. She said the charge nurses were to do wound care on their halls when she got pulled off treatments. Review of a written statement dated 4/12/17 by the DON documented she spoke to the Hospice Director on 4/04/17. She said she made rounds (to see the hospice residents) on 4/04/17 and said the hospice aides did not report any new skin issues for Resident #1 to her. The Hospice Director said she did not assess Resident #1's heels on 4/04/17 because the resident seemed comfortable. The DON said she interviewed the facility staff regarding Resident #1's deep tissue injury and the staff denied observing any new areas of skin breakdown during their shift. Some of the staff members verbalized that Resident #1 tended to remove her heel protectors at times. Staff reported putting Resident #1's heel protectors back on, however they said they did not look at her heels. During an interview on 4/6/17 at 11:54 a.m. the Administrator was informed of the Immediate Jeopardy. She said she was not informed of Resident #1's unstageable pressure injury or that the surveyor had found it. The Administrator said the facility talked about skin issues every morning in stand-up meeting and she was not informed of Resident #1's new pressure injury. She said she received a copy of the facility's skin report and did not realize that 6 new pressure injuries had developed (close to 10% of the facility's census) in 2 months. She said that's too much. During an interview on 4/6/17 at 1:58 p.m. the Treatment Nurse said she had been the treatment nurse off and on for several years. She said this time she had been the treatment nurse for over a year. She said she got pulled treatments to do other jobs because of staffing issues. She said her Corporate Office had said she was not to be pulled. She said last week she had to go to wound care Monday and Friday and then Wednesday she was pulled to work the floor which gave her 2 days to do treatments and skin assessments. She said this week (4/3/17 - 4/7/17) she was pulled to the floor on 4/3 to be the medication nurse and 4/04/17 she had to transport a resident to wound care. She said she had talked to the DON about sending one resident with just two aides to wound care. She said she physically counted the number of wounds in the building when she did the skin report and was very aware of the number of residents with pressure injuries. She said the numbers seem up there. She said the aides were usually very good about reporting changes to her. The Treatment Nurse said she tried to do skin assessments on one hall a day. During an interview on 4/06/17 at 2:55 p.m. the Administrator said she was not informed of Resident #1's pressure injury until the next day. She said unstageable was the most explanation she got. The Administrator was informed that no full body assessment was completed until after 9 a.m. the day after the unstageable was discovered on Resident #1. The Administrator acknowledged the system had broken down. She said it appeared the problem started with the Hospice aides and not telling any of the staff. She said once the Treatment Nurse was notified she should have done a full assessment. The Administrator said the facility CNA's provided incontinent care and as needed bed baths. She said they provided care like repositioning and putting on the heel protectors that everyone kicks off. She said as they were repositioning Resident #1 she would think they would see the unstageable pressure injury. During an interview on 4/06/17 at 3:35 p.m. the Administrator said she did not know how the breakdown in the facility processes happened. She said the staff did a skin assessment the previous Thursday (3/30/17) and there was no areas on her heels. She said they did a culture on the wound on Resident #1's coccyx and got her on an antibiotic for that. The Administrator acknowledged the Treatment nurse was pulled to the floor and did have to do wound care appointments. She said maybe it would be a good idea to have a second set of eyes to check skin. The Administrator said they did discuss skin at each QA meeting and it was constant training, follow-up, follow-up, and follow-up. She said she monitored to make sure the skin process remained effective by talking about it every week in the quality of care meetings where they talked about skin and weights. She said they failed to recognize the pattern of increased pressure injuries to the feet. The Administrator said she thought the biggest failure is people did not see how their jobs were connected and could cause a ripple effect through the entire building. The Administrator said the facility had a lot of falls/ reportable incidents she thought they lost focus on the pressure injuries and focused more on the falls and the focus came off the pressure injuries. During an interview on 4/10/17 at 3:57 p.m. the DON said she did not know how the IJ in pressure injuries happened. She said she had tried to keep up with it the best she could by going over daily orders and incident - accident reports. The DON said she was making sure measures were put in place with Resident #1 to prevent the pressure sore. The DON said she thought it was a communication issue with the Hospice Agency who did not report the breakdown to the facility Charge Nurse. She said to monitor to make sure the pressure injury process was effective was she talked to the Hospice Supervisor and they were now in-servicing the Hospice Team with the regular CNA's. The DON said the Hospice Aides now had a binder with skin report sheets just like the regular CNA's. She said she did not evaluate the facility's policies for effectiveness because she did not realize there was a problem. She thought the root cause of this IJ was a lack of communication. The DON acknowledged she had seen an overall increase in weight loss/ decrease in appetites in residents which contributed to the development of wounds. She said this was identified the last week of March and there had not been time to monitor that for effectiveness. The DON said they identified three new pressure injuries when they did skin assessments. She said the facility and Hospice CNA's had been in-serviced on proper repositioning. The DON acknowledged half the pressure injuries were to resident heels and half of those residents were not bed bound so she was still trying to figure out how they occurred. She said they facility had an IJ in pressure injuries last year but it was confined to one person - this year it was prevention and identification and she could not identify a pattern to why they were developing. She was asked if she checked the Braden Assessments for accuracy and she said how did I miss that? We were all just so exhausted when we did those. During an interview on 4/7/17 the Regional Director said the facility did a clinical stand up meeting every day and did a really good job with it, but they were just not seeing trends in care. Review of the Certified Nursing Assistant Job Description (undated) documented, in part: Summary: Provide nursing care to the residents according to established policies and procedures and to ensure that the highest degree of quality of care is maintained at all times. Safety and Sanitation: Report all incidents and accidents immediately. Review of the facility's February 2014 Policy and Procedure on Pressure Ulcer Risk Assessment documented, in part: Purpose: The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. Preparation: Review the resident's care plan to assess for any special needs of the resident. Once a pressure ulcer develops, it can be extremely difficult to heal. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor. Assessment: Skin Assessment: Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. Review of the facility's February 2014 policy and procedure on Prevention of Pressure Ulcers documented, in part: Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. General Guidelines: Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. Use pillows, wedges or other off-loading devices to keep bony prominence's such as knees or ankles from touching each other. Do not massage bony prominence's. When in bed every attempt should be made to float heals (keep heels off the bed) by placing a pillow from knee to ankle or with other devices as recommended by clinical staff or by the physician. The facility's Plan of Removal Of Immediate Jeopardy was accepted on 4/04/17 and included the following: Prevention of Pressure Sores Nurses and CNA's re-educated on positioning, turning, preventative measures and reporting related to skin by DON. Date of Completion 4/07/17. In-service on going. Identification/interventions of Pressure Sores The DON, ADON (assistant director of nurses), treatment nurse and LVN (licensed vocational nurse) charge nurse conducted 100% skin Evaluation and Intervention Form. Risk Evaluation and intervention form. The Braden Scale was updated for all residents in the facility. Preventative interventions were put into place for all newly identified residents. They physician was notified of any new skin problems that were identified and orders obtained for treatment (s). The resident and/or responsible party was also notified of any newly identified pressure sores and the new orders that were obtained from the physician. Date of Completion: 4/06/17. Staff education related pressure sores The DON/designee in-serviced and education the Treatment Nurse on the prevention of pressure sores, ensuring proper turning and positioning of residents; identification and reporting any skin change noted during care. The treatment nurse was also in-serviced on proper documentation requirements related to a pressure sore and notification of the physician, resident,/responsible party and nurse DON/Designee when a resident has any change in condition. Completed on 4/07/17 Additional in-service with nursing staff was proved by the DON and the ADON on 4/07/17 addressing the prevention of pressures sores. Completed on 4/07/17 The Regional Nurse Consultant completed wound care competencies with the DON and Treatment Nurse which included return demonstrations. on 4/07/17 Monitoring of Pressure Sores The DON will check all known pressure sores at least once a week to evaluate the effectiveness of the treatment, to ensure that the treatment nurse is providing the treatments as ordered by the physician, and to evaluate the pressure reducing devices that are in place. The DON will or Designee will also complete random skin assessments on the least 3 individuals per week. Regional Nurse will review the DON Random Skin Audits at least once a month in the facility. Findings will be evaluated during the Weekly Quality of Care meeting and monthly during QA (quality assurance) & A for a minimum of 3 months and thereafter until the satisfaction of the QA & A committee is achieved. Started 4/06/17 In-serviced on 4/07/17 and distribution of the booklets on 4/07/17 The Certified Nursing Assistants (CNA) were in-serviced by the DON and the ADON on 4/07/17 about the continuous Pressure Ulcer Prevention booklets which provide the CNA's with a tool to document any noted skin change for a resident that they identify during routine daily resident care (see attached copy of the form and guidelines). The form is a triplicate copy with one distributed to the DON, one to the charge nurse and the other is kept by the CNA. the CNA's were all given a set of the forms and guidelines which are included on 4/07/17. Initiated 4/07/17 Date of Completion 4/07/17 CNA's will complete a Daily CNA Shift Report Sheet. This will be completed on every shift and used as shift-to-shift communication tool between aides. Communication will include any observed changes in resident condition. CNA's are to notify the charge nurse as well. The sheets will be reviewed during the daily clinical meetings. Started 4/17/17 Shower aides were in-serviced by the ADON on completing skin observations and implementation of skin sheets for every resident showered whether skin issues are identified or not. Shower aides will bring and report on shower log, skin sheets and any other concerns at daily stand-up. This will ensure residents are not over looked for skin issues during showers. Monthly and ongoing Nursing Management will review all residents with changes of condition including pressure sores during the Daily Clinical Meeting. On-Going Skin Management System Resident will have a skin check and a Braden Scale completed on admission/readmission by the charge nurse who is completing the admission. Any identified pressure sore or there skin problem will be reported to the physician to obtain treatment orders and notify the resident/responsible part. The charge nurse will document all findings on the admission paperwork and the 24 hour report. Al new resident admissions/readmissions will be reviewed in the daily Clinical Meeting. The DON/designee will check the newly admitted /readmitted resident's skin within 24 hours of admission or on Monday following a weekend admission to ensure all skin problems are identified and addressed. On-going Starting 4/07/07 All resident that are admitted /readmitted will have a Braden scale completed by the charge nurse or treatment nurse on admission and then for 3 consecutive weeks for a total of 4 weeks to establish a baseline. The DON/Designee will verify completion at the Daily clinical meeting. In addition to the Braden scale, the Treatment Nurse will complete the Skin Risk Evaluation and Interventions form for all residents who have a Braden scale of 18 or less and/or the resident has a wound (refer to attached skin risk evaluation and intervention form attached). The resident plan of care related to an identified wound and/for a resident that is high risk for breakdown will be initiated with the interventions portion of the form. Initial Skin Risk Evaluation and Interventions form will be completed on the current resident with a Braden assessment of 18 or less and/or a resident with a wound by 4/07/17 then on-going. The treatment nurse will conduct weekly head to toe skin assessments on every resident in the facility. The treatment nurse will report any newly identified skin problem to the DON and the DON will ensure proper documentation, notifications and interventions are in place. The physician will be contacted for treatment orders and resident/responsible party will also be notified. The treatment nurse will initiate the treatment, note the skin problems and new order on the 24 hour report and document all the above in the nurses' progress notes. The ordered treatment will be noted on the current treatment documentation form. The Nurse Management team will check that all the above are completed in the daily Clinical meeting. On-going The treatment nurse will be responsible for providing the treatments for all residents as ordered by the physician in the event the treatment nurse is off, the charge nurse for each hall will be responsible for providing the physician ordered treatments to the residents on the assigned hall. On-going The Nurse Management Team will meet every week to complete the Weekly Quality of Care Review. The Nurse Management team will review all residents identified with new pressure sores in the last week to ensure that all appropriate treatments and pressure prevention measures are in place and completed as ordered. The Management Team at this time will also review the weekly skin assessment sheets to ensure all residents skins are assessed on a weekly basis. On-going The DON or Designee will repeat all afore mentioned in-services monthly for a minimum of 3 months and thereafter until the satisfaction of the QA & A committee is achieved. The Administrator was notified that the IJ was removed prior to exit on 4/07/16. The facility remained out of compliance at a scope of security level of Actual Harm that is not immediate jeopardy at a Pattern that was not IJ because the facility had not had time to implement and monitor their plan for effectiveness. DEFINITIONS (taken from State Operations Manual guidance on Pressure Ulcers revised 5/01/16): Pressure Ulcer - A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Although friction & shear are not primary causes of pressure ulcers, friction & shear are important contributing factors to the development of pressure ulcers. Assessment - An admission evaluation helps identify the resident at risk of developing a pressure ulcer, & the resident with existing pressure ulcer(s) or areas of skin that are at risk for breakdown. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified & have interventions implemented promptly to attempt to prevent pressure ulcers. The admission evaluation helps define those initial care approaches. While pressure ulcers on the sacrum remain the most common location, pressure ulcers on the heel are occurring more frequently, are difficult to assess & heal, & require early identification of skin compromise over the heel. (From the Minimum Data Set (MDS) assessment dated [DATE])) Unstageable - Deep Tissue: Suspected Deep tissue injury in evolution. Review of the form CMS 672 Resident Census and Conditions of Residents completed by RN E on 4/11/17 documented there were 13 residents with pressure ulcers in the building.

Based on observation, interview, and record review the facility failed to have an effective communication process between the facility and the hospice provider to communicate a significant change in condition. This failure effected Resident #1. Resident #1 developed an unstageable pressure injury to her heel (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages: Persistent non-blanchable deep red, maroon or purple discoloration). The hospice aides were aware of the pressure injury on 4/04/17 and did not communicate it to any staff in the facility. This failure cause a delay in appropriate treatment, possible pain, and risk of further breakdown for Resident #1 or any of the 3 remaining residents on Hospice Services at the time of the survey. The findings included. RESIDENT #1 Review of Resident #1's face sheet dated 1/31/17 documented she was [AGE] years of age admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] documented in part: -She scored 3 of 15 on the mental status exam (indicating severe cognitive impairment). -She showed no signs of [MEDICAL CONDITION]. -She rejected care. -She was dependent on staff for all Activities of Daily Living (AD's). -She was incontinent of bowel and bladder. -She was checked for at risk for pressure injuries. Review of Resident #1's Care Plan updated 2/19/17 documented: -Resident #1 had actual functional loss in transfers/bed mobility, used wheelchair and needed assistance with locomotion. Identified approaches included attempt to alleviate barriers to self performance of ADL's (activities of daily living), provide assistance with ADL's necessary to complete task. -Resident #1 had self care deficit and required total assistance with showers, hygiene, and dressing. Identified approaches were Resident #1 required total dependence assistance with hygiene and showering. -Resident #1 required a splint to her left leg (due to fracture). Identified approaches included to inspect skin to left leg, observe and report any red or broken areas. -Resident #1 was expected to have skin breakdown or/and pressure ulcers related to end stage. Identified approaches included to utilize heel protectors; position with pillows to elevate pressure points, turn and reposition every 2 hours or as needed, skin assessment and inspection every shift with close attention to heels. During an observation on 4/04/17 at 11:38 a.m. Resident #1 was lying in bed and 2 hospice aides had just finished giving Resident #1 a bed bath. The surveyor asked them if Resident #1 had any skin issues. An aide lifted up Resident #1's right heel and said she has this and she also has one area on her buttock but it had a dressing on it. The right heel had a large dark purple black area (approximately the size of a large egg). The hospice aide said Resident #1 did not have any type of dressing on the heel. The hospice aides did not make the facility staff aware of Resident #1's right heel (SDTI) or the hospice nurse. The surveyor requested the facility's treatment nurse assess the right heel on 4/04/17 at 4:40 p.m. During an observation during wound care on 4/04/17 at 4:09 p.m. the treatment nurse got her supplies ready to do wound for Resident #1. The treatment nurse took off Resident #1's leg immobilizer and raised Resident #1's leg up to do a skin assessment of the leg. The treatment nurse changed the dressing to Resident #1's left knee and changed the dressing to the unstageable pressure injury on Resident #1's coccyx area. She said that was the only pressure injury resident #1 had at this time (indicating the wound to Resident #1's coccyx). While positioning Resident #1 in bed the treatment nurse had to put Resident #1's heel protectors back on. She raised the right lower leg and placed the heel protector on. The treatment nurse pointed out that Resident #1 had areas on her right 2nd and 3rd toe which she said they just cleansed the area but did not put dressing on them. The treatment nurse did not assess Resident #1's heels when she put the heel protectors back in position. The treatment nurse had finished her treatment and was walking out of Resident #1's room when the surveyor asked her to check Resident #1's right heel. The treatment nurse went to her medication cart and got out a measuring tape and re-entered Resident #1's room. The treatment nurse said she was unaware Resident #1 had anything to her right heel. She measured the area at 4 x 2.5 cm. She wrote the size on and appearance of the area on a scrap piece of paper and turned it into the Director of Nurses (DON) at 4:55 p.m. The treatment nurse said the said the DON would be the one to go in and stage the area. During an interview on 4/05/17 at 8:51 a.m. the DON said she first learned about Resident #1's right heel injury the day before (4/04/17) when the treatment nurse informed her around 5:00 p.m. She said she was not sure when Resident #1 acquired the pressure injury. She said she had talked to the hospice nurse to see if anyone had reported it to her and she said the hospice aides did not report any new issues to her. The DON said the hospice nurse informed her that she asked the hospice aides if there was any thing she needed to know about Resident #1 and the aides told her no. She said the hospice nurse did not assess Resident #1's heels when she came in yesterday because Resident #1 was asleep and she didn't want to wake her. The DON said if there are any changes the charge nurse for that resident was informed. She said the charge nurse for Resident #1 was not informed of any new issues. She said she did not do a full body skin assessment of Resident #1 on 4/04/17 but would get the treatment nurse and do it now. The DON said she would have to get the hospice aides notes faxed to her. During an interview on 4/06/17 at 9:48 a.m. hospice aides Q and R said they had just noticed Resident #1's right heel on Monday (4/04/17). They said they were supposed to report any resident changes to their hospice nurse. They said they did not report Resident #1's heel so they had to go to an in-service on reporting resident changes. The hospice aides said they had to report any thing different with the resident, like that resident's heel. They said they report changes immediately. During an interview on 4/06/17 at 11:07 a.m. the treatment nurse said skin assessments were to be done weekly. She said she did medication pass on Monday's and then Tuesday's she had to go to wound care in Midland with one of the residents so she did not do treatments or skin assessments on those days. She said she did skin assessments on what ever day the aides were giving showers so she could be in the shower room while the residents were showered. She said she would look to see where the shower aides were giving the showers and that would be the hall she would do skin assessments on that day. She said she does not know if that was the way skin assessments are supposed to be done but that was how it had been done since she had been there. She said the charge nurses were to do wound care on their halls when she got pulled off treatments. Review of a written statement dated 4/12/17 by the DON documented she spoke to the Hospice Director on 4/04/17. She said she made rounds (to see the hospice residents) on 4/04/17 and said the hospice aides did not report any new skin issues for Resident #1 to her. The Hospice Director said she did not assess Resident #1's heels on 4/04/17 because the resident seemed comfortable. The DON said she interviewed the facility staff regarding Resident #1's deep tissue injury and the staff denied observing any new areas of skin breakdown during their shift. Some of the staff members verbalized that Resident #1 tended to remove her heel protectors at times. Staff reported putting Resident #1's heel protectors back on, however they said they did not look at her heels. During an interview on 4/10/17 at 3:57 p.m. the DON said she did not know how the Immediate Jeopardy in pressure injuries happened. The DON said she was making sure measures were put in place with Resident #1 to prevent the pressure sore. The DON said she thought it was a communication issue with the Hospice Agency who did not report the breakdown to the facility Charge Nurse. She said to monitor to make sure the pressure injury process was effective was she talked to the Hospice Supervisor and they were now in-servicing the Hospice Team with the regular CNA's. The DON said the Hospice Aides now had a binder with skin report sheets just like the regular CNA's. DEFINITIONS (taken from State Operations Manual guidance on Pressure Ulcers revised on 5/01/15) Pressure Ulcer - A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Although friction & shear are not primary causes of pressure ulcers, friction & shear are important contributing factors to the development of pressure ulcers. Assessment - An admission evaluation helps identify the resident at risk of developing a pressure ulcer, & the resident with existing pressure ulcer(s) or areas of skin that are at risk for breakdown. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified & have interventions implemented promptly to attempt to prevent pressure ulcers. The admission evaluation helps define those initial care approaches. While pressure ulcers on the sacrum remain the most common location, pressure ulcers on the heel are occurring more frequently, are difficult to assess & heal, & require early identification of skin compromise over the heel. Review of the facility's 5/07/16 Contract with the Hospice Agency documented, in part: 1. Responsibilities of Hospice: 1.03 Information/ Documentation provided to Facility on admission and on-going: - Copies of clinical notes after each visit. 1.04 Coordination/ Continuity of Care - Maintain communication with facility staff, patient/ family and physician with appropriate documentation. - Designate a member of each IDT (Interdisciplinary Team) that is responsible for a patient who is a resident of the Facility. The designated member is responsible for: < Communicating with Facility representatives and other providers to ensure quality of care for the patient/ family. - Maintain professional management responsibly/ coordination of facility services and ensure services are furnished in a safe, timely, and effective manner, according to the Plan of Care. Responsible for the patient/ family assessments to include medical, nursing, psychosocial, and spiritual. 2. Responsibilities of the the Facility: 2.04 Notify Hospice if: - Significant change in patient's physical, mental, social, or emotional status occur; - Clinical complications appear that suggest need to alter the plan of care; - Need for changes in level of care due to patient's condition. Review of the form CMS 672 Resident Census and Conditions of Residents completed by RN E documented there were 4 residents receiving Hospice Services at the time of the visit.

Based on observation, interview and record review, the facility failed to provide the necessary treatment and services to prevent the development and promote the healing of pressure ulcers for 2 of 6 residents reviewed for pressure ulcers. (resident #1 and #9). a) The facility failed to identify and prevent Resident #9 from developing two un-stageable pressure ulcers on the right outer buttocks on 12/14/15 and one to the right upper buttocks on 12/20/15. Resident #9 was diagnosed with [REDACTED]. b) Resident #1 was identified with two stage II pressure ulcers on 3/19/16 to the buttocks area. The Treatment Nurse was not aware of the physician's orders [REDACTED].#1 did not receive ordered treatments on 3/22/16, 3/25/16 and 3/28/16. These deficient practices resulted in an Immediate Jeopardy (IJ) on 04/05/16. While the IJ was removed on 4/08/16 the facility remained out of compliance at a level of Actual Harm at a Pattern that was not IJ because the facility had not had time to implement and monitor policies and procedures. These failures resulted in pressure ulcer development for Resident #1 and #9 and could place the 12 residents with pressure ulcers at risk for developing new pressure ulcers or worsening of existing pressure ulcers. Findings included: RESIDENT#9 Review of Resident #9's (closed record) Admission Record, undated, indicated the resident was admitted on [DATE], readmitted on [DATE] and discharged to home on 2/11/16. He was admitted with [DIAGNOSES REDACTED]. He was [AGE] years of age. Review of Resident #9's Braden Risk Assessment Scale dated 6/30/15 documented a score of 17 (a score of 14-18 indicates moderate risk). Review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14 ( a score of 13-15 indicates cognitively intact). Resident #9 required extensive assistance with two person assistance with bed mobility, dressing, and personal hygiene and was dependent on staff for bathing. Resident #9 was impaired on both sides of his upper and lower extremities The resident was frequently incontinent of bowel and had an indwelling urinary catheter. The MDS documented Resident #9 had two Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) pressures ulcers (size and location not documented on the MDS) and two un-stageable pressure ulcers. Skin and Ulcer treatments documented Resident #9 had a pressure reducing device for chair, pressure reducing device for bed, nutrition or hydration intervention, pressure ulcer care and applications of ointments. Review of Resident #9's weekly skin assessments by the treatment nurse documented in part: 12/14/15-a Stage II/unstageable pressure ulcer to the right lower outer buttocks that measured 4.5 cm x 0.1 cm. 12/20/15- unstageable pressure ulcer to right outer buttocks that measured 4.5 cm x 0.1 cm and a Stage II/abrasion pressure ulcer to the right upper buttocks unstageable pressure ulcer to right outer buttocks that measured 4.5 cm x x 0.1 cm and a Stage II/abrasion pressure ulcer to the right upper buttocks unstageable pressure ulcer to right outer buttocks that measured 4.5 cm x 0.1 cm and a Stage II/abrasion pressure ulcer to the right upper buttocks unstageable pressure ulcer to right outer buttocks that measured 4.5 cm x x 0.1 cm and a Stage II/abrasion pressure ulcer to the right upper buttocks unstageable pressure ulcer to right outer buttocks that measured 4.5 cm x 0.1 cm and a Stage II/abrasion pressure ulcer to the right upper buttocks to the left heel that measured 2.2 cm. x 0.3 cm. x 0.1 cm.; a Stage II/unstageable pressure ulcer to right outer buttocks that measured 4.5 cm x x 0.1 cm and a Stage II/abrasion pressure ulcer to the right upper buttocks that measured 4.6 cm x 1 cm x 0.2 cm. 12/31/15- Back of left foot Stage II 3.6 x 4.5 x 0.1, outer right buttock un-stageable 2.5 x 4 x 0.2,un-stageable outer right un-stageable 3 x 6 x 0.3. Review of the Skin Grids-Pressure Only documented in part: 12/14/15-Right outer buttock-Stage-un-stageable; measurements 4.5 x 0.5 x 0.1; Drainage-None; Tissue type-necrotic tissue-black/brown/tan; Necrotic Tissue 75-100%; Granulation-no, worsened size-no, worsened depth-no, worsened drainage-no; Interventions: nutritional, pressure reducing mattress, turning. Comments-Resist repositioning states I turn myself. 12/20/15- Right outer buttock-Stage-un-stageable; measurements- 4 x 2 x 0.1; Drainage-None; Tissue Type-necrotic tissue; Necrotic tissue-75-100%; Granulation-no, worsened size-yes, worsened depth no, worsened drainage-no; Interventions: nutritional, pressure reducing cushion, pressure reducing mattress, turning-repositioning; Comments: blank. 12/20/15--Comments: Abrasion area to right upper outer buttock-(II is marked out)blank; Measurements: 3 x 6 x 0.1; Drainage; serous; Tissue Type-pink/red with shiny, moist granular appearance; Necrotic Tissue-None; Granulation-yes, worsened size-no, worsened depth-no, worsened drainage-no; Interventions: nutritional, pressure reducing cushion, pressure reducing mattress, turning-repositioning. Review of Resident #9's Care Plan dated 1/15/16 documented Resident #9 was at risk for pressure ulcers related to [MEDICAL CONDITION]. Goals were Resident #9's skin would remain intact. The approaches were to avoid shearing of resident's skin during position, transferring, and turning, to conduct a systematic skin inspection weekly, pay particular attention to the bony prominences, provide incontinence care, use moisture barrier product to the perineal area and to report any signs of skin breakdown (sore, tender, red or broken areas). Resident #9 had self-care deficit: required extensive assist for most ADL's (activities of daily living). Resident #9 had a potential nutritional problem. The approach was to observe, document, report to physician, as needed, provide and serve supplements as ordered, dietician to evaluate and make diet changes and recommendations as needed. Resident #9 was at risk for potential complications related to indwelling urinary catheter. The Care Plan did not address the unstageable pressure ulcer to the right lower outer buttocks found on the 12/14/15 and the unstageable pressure ulcer to the right outer buttock found on 12/20/15. Review of the Weekly Wound Tracking Worksheet documented in part: 12/18/15-Resident #9 Braden Scale 14, Support Measures vitamin C, zinc; Right outer buttock, onset 12/14/15. 2/25/15, Nutrition 60 cc 2 cal bid, CMP (dated 11/04/15) 3.4, Support Measures-vitamin C, zinc; Right outer buttock 2 x 4 x 0.1, Onset 12/14/15; Right outer upper buttock 3 x 6 x 0.1, Onset date 12/20/15. Review of the Medication Flow Sheet dated (MONTH) (YEAR) documented in part: Clean Stage II to right outer buttocks with NS (normal saline) (dated 12/14/15); Clean un-stageable to right outer buttocks with NS, dry, apply calcium alginate sheet to wound bed and cover with dressing (dated 12/16/15); Clean abrasion/stage II right upper outer buttocks with NS, dry, apply Collasorb to wound bed and cover with dressing; Clean unstageable to right upper outer buttocks with NS, dry, apply calcium alginate to wound bed and cover with dressing (dated 12/31/15). Review of the Medication Flow Sheet dated (MONTH) (YEAR) had no documentation of dressing changes for the right outer buttocks and the right upper outer buttocks on (MONTH) the 26th, 28th, and the 30th. Review of Physicians telephone orders dated 12/16/15 documented in part wound -vitamin C 500 mg. (milligrams) 1 tab by mouth twice a day, HypoAlbumenemax x 60 days, Pre-[MEDICATION NAME] level. Review of Lab results for Pre-[MEDICATION NAME] (Source:Drugs.com: pre-[MEDICATION NAME] is a protein and is an indicator of malnutrition.)dated 12/17/15 documented a result of 10 (Normal 17-42). Review of Resident #9's Physician's telephone orders dated 1/07/16 documented: Wound infection to coccyx-culture wound. Review of the wound culture results dated 1/07/16 documented: Organism #1 Eshericihia coli (bacteria); Organism #2 Pseudomonas aeruginosa (bacteria); Organism #3 Proteus mirabilis (bacteria) Review of Resident #9's Nurses Notes dated 1/10/16 at 10:30 a.m. documented: Resident #9's physician in facility, evaluated resident pressure sores to buttocks. Waiting culture from hospital to determine an accurate antibiotic to treat the bacterial infection. Review of Residents #9's Nurses Notes dated 1/11/16 at 4:00 p.m. documented: physician called and new order [MEDICATION NAME](antibiotic) for 10 days for [DIAGNOSES REDACTED]. Review of Resident #9's Physician's telephone orders dated 1/11/16 documented: 1. [MEDICAL CONDITION] Wound Healing-Cipro 500 mg, 1 by mouth twice a day for 10 days. 2. Arginade mix with water or juice twice a day. 3. Discontinue 0.2 Cal twice a day and increase to 0.2 Cal to three times a day with meals. Review of Resident #9's Physician's telephone orders dated 1/15/16 documented: [MEDICAL CONDITION]-Bactrim DS one tab twice a day by mouth for 10 days. During a telephone interview on 3/10/16 at 2:45 p.m. Resident #9 said he developed two stage IV pressure ulcer before the nurses' ever found the pressure ulcer. Resident #9 said he spent so much time on the commode (shower chair) that he developed the two pressure ulcers. He said he kept asking the nurses if his buttocks was ok and they kept telling him it was. He said the treatment nurse gave him his stimulation for bowel movements and she should have seen it(referring to pressure ulcers). He said he was on the bowel stimulation program every three days and the nurses at the facility should have seen the pressure sores before they had gotten so bad. He said he used to use a mirror and to check his buttocks to make sure he had no skin breakdown before coming to the facility. During an interview on 3/10/16 at 4:30 p.m. the Director of Nurses (DON) said the weekly wound tracking worksheet documented the onset for the unstageable right outer lower buttocks was 12/14/15 and the right outer upper pressure ulcer was 12/20/15. The DON said the only documentation of the pressure ulcers acquired in the facility was in (MONTH) and the pressure ulcers were in-house acquired. During an interview on 3/10/16 at 4:35 p.m. the Treatment Nurse said when she found Resident #9's pressure areas the areas were red. She said Resident #9's shower chair was rough and caused the pressure areas. She said the nurses and CNA's should have seen them (referring to the un-stageable pressure ulcers) sooner because staff had to do bowel stimulation and that would have been a good time to see them. During an interview on 4/04/16 at 11:20 a.m. Resident #9's physician said he remembered he looked at Resident #9's pressure ulcers but he couldn't remember when. He said received a call regarding the unstageable pressure ulcers but he could not recall exactly when but he thought it was when they assessed them. Resident #9's physician said the nurses were on top of things and usually called him. He said Resident #9 was a very knowledgeable resident. Resident #9's physician said the nurses were very apologetic about not finding the pressure ulcers until they were unstageable. Resident #9's physician said the nurse said she did not know how she missed the pressure ulcers until they were unstageable. He said they (referring to the nurses at the facility) should have noticed the pressure ulcer sooner but sometimes Resident #9 was on his back. During an interview on 4/05/16 at 10:25 a.m. Resident #9 said he did not remember how often the staff were doing the dressing changes for his pressure ulcers. He said they usually did the dressing when they did his bowel program every three days. He said he was told the pressure ulcers were just a skin abrasion and then he was told he had unstageable pressure ulcers. Resident #9 said he did not remember the date he was informed he had 2 un-stageable pressure ulcers. He said he noticed green/yellow drainage stains on his bed and noticed a foul odor. He said the nurses never changed his dressing like they were supposed to. Resident #9 said he was left on his shower chair for 2 to 3 hours during his bowel program. He said the nurses would try and wait for the next shift to put him to bed and he would be left in his shower chair for long periods of time. During an interview on 4/05/16 at 9:00 a.m. the Treatment Nurse said she did not know if Resident #9 was scheduled for dressing changes on (MONTH) the 26th, 28th, and the 30th for the unstageable pressure ulcers to this right outer buttock and the unstageable to his right upper outer buttocks. The Treatment Nurse said the Stage II pressure ulcer to his right outer buttocks changed to un-stageable because of there was a black area in the wound. She said did not know why she documented a Stage II pressure sore to the right outer buttocks on (MONTH) the 14th on the Medication Flow Sheet and unstageable on the Weekly Skin Assessment and Skin Grid. She said she documented the abrasion to the right upper outer buttock as Stage II and then got worried about it and staged it as a unstageable. She said she did not know why she documented the right upper outer buttocks as an unstageable on the Weekly Skin Assessments and the Skin Grid dated 12/20/15 and as an abrasion /Stage II on the Medication Flow Sheet. The Treatment Nurse said at the end of every week she would get together with the DON and go over the skin assessments. She said the DON would decide on the supplements the resident would need and would review the resident's Braden Scale at the same time. She said she discussed the resident's wound measurements with the DON and they would decide if the pressure ulcers were getting better or worse. The Treatment Nurse said measures were put in place for the plan of care to catch skin breakdown and to help pressure ulcers to heal. The Treatment Nurse said Resident #9 would sit on his shower chair during his bowel stimulations and watch movies or do things on his computer. She said she asked him once if he was getting tired of sitting on the shower chair and Resident #9 said no because he didn't feel anything down there. She said Resident #9 sat there one time for three hours. The Treatment Nurse said everything just hung down and was causing pressure to the buttocks area. She said she did not think any staff documented how long Resident #9 would sit on the shower chair for his bowel stimulation. She said staff had talked to with the person in medical record to order a new pad for his shower chair but it was after Resident #9 had developed the unstageable pressure ulcers. During an interview on 04/05/16 at 1:52 p.m. the Director of Nurses (DON) said she did not remember when she was told about Resident #9's pressure ulcer. The DON said she first observed the pressure ulcers they looked pretty bad and that she had never seen anything like that before (she was unsure of the date she first saw the ulcers). The DON said that it progressed from a stage 2 to an unstageable pretty fast. The DON said she did not remember when she first observed the pressure sore at a stage 2. The DON said that when it was at an unstageable stage, Resident #9 kept calling her to the room and that he had a lot of bleeding to the area. The DON said they called the doctor and he put Resident #9 on antibiotics she believed in December. The DON said she reviewed the treatment sheets in general not just Resident #9's sheets. The DON said when she saw the area; it was an abrasion, had necrotic tissue around it and guessed that was why they were calling it unstageable. The DON said it was her job to make sure the treatments were getting done. The DON said the doctor did not know how the sore progressed so fast. The DON said if it (referring to the documentation not being done for Resident #9's dressing changes) was not documented then it was not done. The DON said the system was to put on weekly skins assessments, update the grids, notify the dietician, put on weekly weights, RD (Registered Dietitian) orders, MD orders, notify the family, put on the 24hr report and notify the treatment nurse. The DON said if unstageable was found that all the mattresses were already special mattresses. The DON said they also updated the care plans and the MDS. The DON said she and the treatment nurse would get together and go over issues and a copy of that report would go to the Administrator, MDS, P.T. (Physical Therapy) and the ADON (Assistant Director of Nurses). RESIDENT #1 Record review of Resident #1's consolidated Physician order [REDACTED]. [DIAGNOSES REDACTED]. She was [AGE] years of age. Continued review of the physician Order Report dated 03/01/2016- 04/30/2016 included the following: · 06/02/14 - 60 cc (cubic centimeter) 2 Cal (supplement) TID (three times daily) with meals, Dx. (diagnosis) weight loss; · 01/26/15 - 1 scoop protein powder , three times daily, Dx: weight loss; · 07/13/15 - super cereal with breakfast daily, Dx. weight loss; · 02/22/16 - fortified pudding BID (twice daily) Review of Resident #1's annual MDS assessment dated [DATE], documented the resident had unclear speech, sometimes understood, sometimes understands others, had impaired vision and wore corrective lenses. Resident #1 had long term memory loss and cognitive skills for daily decision making was moderately impaired. Resident #1 required total assistance with two person assistance with bed mobility, transfers, dressing and bathing; required total assistance with one person for locomotion, eating and toilet use; required extensive assistance for personal hygiene. Resident #1 was always incontinent of bladder and bowel. The MDS documented Resident #1 was at risk of developing pressure ulcers; had an unhealed pressure ulcer at stage I or higher; had one stage I (intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching) pressure ulcer. Skin and Ulcer treatments: none of the above were provided was checked, indicating the facility did not provide a pressure reducing device for bed or chair, pressure ulce care, or applications of ointments. Review of Resident #1's Care Plans dated 02/25/16 documented Resident #1 was at risk for pressure ulcers due to friction, shear, activity, chair fast and moisture. Goal was: intact skin without evidence of redness, irritation, maceration or open areas. Approaches included: use moisture barrier ointments, consider pressure relief when positioning in wheelchair and check incontinence pads frequently and change as needed. Review of Resident #1's Braden Risk Assessment Scale documented on 01/03/16 and 03/03/16 a risk score of 11 (0-13 High Risk). During an observation on 03/30/16 at 11:30 a.m. Certified Nurse Aide (CNA) C and CNA N prepared to provide incontinent care for Resident #1. Resident #1 was in her room lying on her bed. CNA C cleaned Resident #1's buttocks. There were no dressings in place on Resident #1's buttocks. Observation of Resident #1's buttocks revealed the left buttock had an open ruptured blister approximately one by one centimeter. The right buttock and coccyx area had lighter colored skin that appeared to be scar tissue. After CNA C and CNA N finished with incontinent care they placed a clean brief on Resident #1, pulled up her pants and transferred her to her wheelchair with the mechanical lift (did not apply any moisture barrier cream/ointment). Review of Resident #1's Progress Notes (nurses notes) dated 03/19/16 at 1630 (4:30 p.m.) documented open area to L (left) buttocks 1 x 0.5 centimeters (cm), cleaned with N/S (normal saline), patted to dry, covered with spot dressing Q (every) 3 (days) and prn (as needed); open area to R (right) buttocks 1.5 x 1 cm. cleaned with N/S, patted to dry, covered with spot dressing Q-3 and prn. Open areas noted per CNA staff. Open areas treated as per MD (medical doctor) order. Resident husband aware of open areas and dressings to L and R buttocks. Review of Resident #1's Physician's telephone orders dated 03/19/16 at 1600 (4:00 p.m.) written by LVN O revealed: · R (right) buttock open area 1.5 x 1 cm. Clean with N/S, pat to dry, cover with spot dressing, change Q-3 days and prn until healed. · L (left) buttocks open area 1 x 0.5 cm. Clean with N/S, pat to dry, cover with spot dressing, change Q-3 days and prn until closed. Review of Hall 3's Nursing 24 hour report dated 3/19/16 revealed the above orders for Resident #1's left and right buttocks. During an interview on 03/30/16 at 11:20 a.m. Resident #1's family member said Resident #1 had a blister on her tailbone. The family member said It heals then it gets a blister, I keep an eye on it. The family member said he is at the facility daily. During an observation and interview on 03/30/16 at 5:35 p.m. the Treatment Nurse was sitting at the front of the nurse's station with her Resident Treatment books reviewing (MONTH) (YEAR) treatment orders for the next month. The Treatment Nurse was asked for Resident #1's treatment sheets for (MONTH) (YEAR). The Treatment Nurse said Resident #1 did not have any treatments. The Treatment Nurse said I was not aware of treatment orders written on 3/19/16 until today when I was going through Aprils (YEAR) treatment sheets. I put [MEDICATION NAME] on the area. Review of Resident #1's Treatment sheet, undated, documented the two above orders received on 3/19/16. There were only initials documented on 3/19/16 that the treatment was done by LVN O. There was no documentation the treatment was done (every 3 days) on 3/22/16, 3/25/16 and 3/28/16. Record review on 03/30/16 of Resident #1's Weekly Skin Assessment sheet documented by the Treatment Nurse revealed the following in part: (the treatment sheet form has 10 areas to document 10 weeks of skin assessments) · 2/01/16 - no new areas of skin impairment. · 2/09/16 - no new areas of skin impairment. · 2/15/16 - 3 small 1 cm. x 1 cm. bruises to L (left) FA (forearm). · 2/24/15 - Stage II blister to L buttock 1 x 0.1 x 0.1 [MEDICATION NAME] applied. · 2/29/16 - no new areas of skin impairment. [MEDICATION NAME] applied. Pre [MEDICATION NAME] drawn, vitamin C, zinc and [MEDICATION NAME] started. · 3/07/16 - [MEDICATION NAME] applied. Faded bruise R FA 2x2. · 3/14/16 - no new areas of skin impairment. There was no further skin assessments documented past 3/14/16. During an interview on 03/30/16 at 6:10 p.m. the Treatment Nurse said the weekend nurse gets orders and doesn't tell me about them. Usually the nurse leaves me the green copy of the telephone order. I do her (Resident #1) weekly skin assessments, the scar tissue opens and closes, it's very small, usually get it to close with putting [MEDICATION NAME] ointment on it. Have tried dressings, they don't stay on that area. Have done the 3/22/16 (skin assessment) but have not put it on her (Resident #1) skin assessment sheet. I get pulled to work the floor/charge nurse. The Treatment Nurse said CNA C reported to her today the area was open. During an interview on 3/31/16 at 10:34 a.m. LVN O said he worked weekends twice a month. When asked how he communicates new treatment orders to the Treatment Nurse he said the 24 hour report. LVN O said he also puts the green and yellow copies of the telephone order in the box at the nurse's station. LVN O said the green one goes to the lady that transcribes the orders and the yellow goes to the doctor to be signed. Record review on 04/06/16 of Resident #1's Weekly Skin Assessment sheet documented by the Treatment Nurse revealed the following in part: (same weekly skin assessment sheet as above) · 3/14/16 - [MEDICATION NAME] applied (added on form). · 3/22/16 - [MEDICATION NAME] applied. Excoriated area to upper buttocks, [MEDICATION NAME] applied. · 3/30/16 - R buttock 0.5 x 0.4 x 0.1 [MEDICATION NAME] applied. 3/31/16 [MEDICATION NAME] applied, order clarified on treatment to buttocks, [MEDICATION NAME] to be applied BID (twice daily). Review of Resident #1's Physician's telephone orders dated 03/31/16, written by the Treatment Nurse revealed: · Order Clarification - DC (discontinue) tx (treatment) to R (right) and L (left) buttocks dressing change. Clean area to L buttock with NS (normal saline), dry, apply [MEDICATION NAME] q (every) shift. Review of Resident #1's Medication Flowsheet/treatment sheet for (MONTH) (YEAR), documented the following: · 3/31/16 Clean buttocks with NS. Dry. Apply [MEDICATION NAME] q shift, 6:00 a.m. to 6:00 p.m. and 6:00 p.m. to 6:00 a.m. There was no documentation the treatment was done both shifts on 4/02/16 and 4/03/16 (weekend). During an interview on 4/05/16 at 2:20 p.m. the DON acknowledged new treatment orders for Resident #1 were put in the treatment book from the weekend nurse (LVN O). The DON said the Treatment Nurse did not check the 24 hour report or the treatment book. The DON acknowledged there were new orders (3/19/16) and were not found until 3/30/16. The DON said could have new pressure ulcer orders and not know. The DON acknowledged there needs to be a better communication system. Related to communication and treatment orders not known about the DON said it's unfortunate that it's gotten to this point. Review of the facility's policy on Pressure Ulcers/Skin Breakdown dated 2005 and revised on 2/2014 documented in part: Treatment/Management: -The physician will authorize pertinent orders related to wound treatments, including would cleanse and debridement approaches, dressing (occlusive, absorptive, etc.), and application of topical agents if indicated for type of skin. -The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing medical conditions, managing pain related to the wound or to the wound treatment. -The physician will help staff characterize the likelihood of wound healing, based on a review of pertinent factors. -As needed, the physician will help identify medical and ethical issues influencing wound healing. During an interview on 4/05/16 at 5:48 p.m., the Administrator was informed surveyors had identified an Immediate Jeopardy situation. The facility's Plan of Removal of Immediate Jeopardy was accepted on 4/08/16 at 2:52 p.m. and included the following: Identification of Pressure Sores The DON, ADON, Treatment Nurse, and or a LVN Charge Nurse conducted 100% skin evaluations of all residents in the facility on 4/05/16. The Braden Scale was updated for all residents with an identified pressure sore. The physician was notified of any new skin problems that were identified and physician was notified of any new skin problems that were identified and physician orders [REDACTED]. The resident and/or responsible party was also notified of any newly identified pressure sores and the new orders that were obtained from the physician. The DON reviewed the current physician orders [REDACTED]. The IDCPT reviewed the plan of care and updated as indicted. Date of Completion 4/06/16 Staff education related to pressure sores The DON/designee in-serviced all the nursing staff on the prevention of pressure sores, proper turning, and positioning of high-risk residents, identification and reporting any skin change noted during care. The licensed nurses were also in-serviced on the proper documentation requirements related to a pressure sore and notification of the physician and resident/responsible party when a resident has any change in condition. Completed on 4/06/16 Additional in-service with the nursing staff was provided on 4/07/16 addressing the prevention of pressure sores. Completed on 4/07/16 The Regional Nurse consultant completed skin evaluations on all known pressure sores and randomly checked residents without known pressure sores with the DON and Treatment Nurse to ensure that measuring and staging of wounds was completed. The Regional Nurse to ensure that measuring and staging of wounds was completed. The Regional Nurse Consultant also evaluated the pressure relief devices in use for the residents and items were ordered as appropriate. Completed on 4/0716 The Regional Nurse consultant completed wound care competencies on the DON and Treatment Nurse with return demonstration. Completed on 4/07/16 Monitoring of Pressure Sores The DON will check all known pressure sores at least once a week to evaluate the effectiveness of the treatment, to ensure that the treatment nurse is providing the treatments as ordered by the physician, and to evaluate the pressure reducing devices that are in place. Following this evaluation, the DON will contact the physician to discuss possible treatment changes and order/provide alternative pressure reducing devices if indicated. The DON will utilize the Weekly Wound Tracking form to document the assessment and this form will be presented to the Q A & A Committee at least monthly for review and recommendations. Started 4/06/16 Pressure relieving wheelchair cushions ordered 4/07/16 for all residents with known pressure sores or at high risk of pressure sores. The Certified Nursing Assistants (CNA) were in-serviced on 4/07/16 about the Continuous Pressure Ulcer Prevention booklets which provide the CNA's with a tool to document any skin change for a resident that they identify during routine daily resident care (See attached copy of the form and guidelines). The form is a triplicate copy with one distributed to the DON, one to the Charge Nurse, and other is kept by the CNA. The CNA's were all given a set of the forms and guidelines which are included on 4/07/16. Started 4/07/16 The facility will initiate the Daily Clinical Meeting to review all residents with a change of condition including pressure sores. Refer to attached Daily Clinical Meeting Guidelines and the form which is attached. The Daily Clinical Meeting Form will be submitted to the Q A & A Committee for review and intervention as the team deems necessary. Started 4/07/16 American Medical Technology (AMT) will conduct monthly visits that include checking the pressure sores with the Treatment Nurse and making recommendations for alternative treatments if necessary. Monthly and ongoing. The facility will have an outside wound care consultant do an in-service with the licensed nurses on 4/08/16. The in-service will include prevention of pressure sores, identification of pressure sores, staging pressure sores, and treatments. No later than 4/08/16 On-Going Skin Management System Residents will have a skin check and a Braden Scale completed on admission/readmission (within 4 hours) by the charge nurse who is completing the admission. Any identified pressure sore or other skin problem will be reported to the physician to obtain treatment orders and notify the resident/responsible party. The charge nurse will document all findings on the admission paper work and the 24-hour Report. All new resident admission/readmissions will be reviewed in the Clinical Meeting. The DON/designee will check the newly admitted /readmitted resident's skin within 24 hours of admission or on Monday following a weekend admission to ensure all skin problems are identified and addressed. Started 4/07/16 All residents that are admitted /readmitted will have (TRUNCATED)

Based on observation, interview and record review, the facility failed to provide the necessary treatment and services to prevent the development and promote the healing of pressure ulcers for 2 of 6 residents reviewed for pressure ulcers. (resident #1 and #9). a) The facility failed to identify and prevent Resident #9 from developing two un-stageable pressure ulcers on the right outer buttocks on 12/14/15 and one to the right upper buttocks on 12/20/15. Resident #9 was diagnosed with [REDACTED]. b) Resident #1 was identified with two stage II pressure ulcers on 3/19/16 to the buttocks area. The Treatment Nurse was not aware of the physician's orders [REDACTED].#1 did not receive ordered treatments on 3/22/16, 3/25/16 and 3/28/16. These deficient practices resulted in an Immediate Jeopardy (IJ) on 04/05/16. While the IJ was removed on 4/08/16 the facility remained out of compliance at a level of Actual Harm at a Pattern that was not IJ because the facility had not had time to implement and monitor policies and procedures. These failures resulted in pressure ulcer development for Resident #1 and #9 and could place the 12 residents with pressure ulcers at risk for developing new pressure ulcers or worsening of existing pressure ulcers. Findings included: RESIDENT#9 Review of Resident #9's (closed record) Admission Record, undated, indicated the resident was admitted on [DATE], readmitted on [DATE] and discharged to home on 2/11/16. He was admitted with [DIAGNOSES REDACTED]. He was [AGE] years of age. Review of Resident #9's Braden Risk Assessment Scale dated 6/30/15 documented a score of 17 (a score of 14-18 indicates moderate risk). Review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14 ( a score of 13-15 indicates cognitively intact). Resident #9 required extensive assistance with two person assistance with bed mobility, dressing, and personal hygiene and was dependent on staff for bathing. Resident #9 was impaired on both sides of his upper and lower extremities The resident was frequently incontinent of bowel and had an indwelling urinary catheter. The MDS documented Resident #9 had two Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) pressures ulcers (size and location not documented on the MDS) and two un-stageable pressure ulcers. Skin and Ulcer treatments documented Resident #9 had a pressure reducing device for chair, pressure reducing device for bed, nutrition or hydration intervention, pressure ulcer care and applications of ointments. Review of Resident #9's weekly skin assessments by the treatment nurse documented in part: 12/14/15-a Stage II/unstageable pressure ulcer to the right lower outer buttocks that measured 4.5 cm x 0.1 cm. 12/20/15- unstageable pressure ulcer to right outer buttocks that measured 4.5 cm x 0.1 cm and a Stage II/abrasion pressure ulcer to the right upper buttocks unstageable pressure ulcer to right outer buttocks that measured 4.5 cm x x 0.1 cm and a Stage II/abrasion pressure ulcer to the right upper buttocks unstageable pressure ulcer to right outer buttocks that measured 4.5 cm x 0.1 cm and a Stage II/abrasion pressure ulcer to the right upper buttocks unstageable pressure ulcer to right outer buttocks that measured 4.5 cm x x 0.1 cm and a Stage II/abrasion pressure ulcer to the right upper buttocks unstageable pressure ulcer to right outer buttocks that measured 4.5 cm x 0.1 cm and a Stage II/abrasion pressure ulcer to the right upper buttocks to the left heel that measured 2.2 cm. x 0.3 cm. x 0.1 cm.; a Stage II/unstageable pressure ulcer to right outer buttocks that measured 4.5 cm x x 0.1 cm and a Stage II/abrasion pressure ulcer to the right upper buttocks that measured 4.6 cm x 1 cm x 0.2 cm. 12/31/15- Back of left foot Stage II 3.6 x 4.5 x 0.1, outer right buttock un-stageable 2.5 x 4 x 0.2,un-stageable outer right un-stageable 3 x 6 x 0.3. Review of the Skin Grids-Pressure Only documented in part: 12/14/15-Right outer buttock-Stage-un-stageable; measurements 4.5 x 0.5 x 0.1; Drainage-None; Tissue type-necrotic tissue-black/brown/tan; Necrotic Tissue 75-100%; Granulation-no, worsened size-no, worsened depth-no, worsened drainage-no; Interventions: nutritional, pressure reducing mattress, turning. Comments-Resist repositioning states I turn myself. 12/20/15- Right outer buttock-Stage-un-stageable; measurements- 4 x 2 x 0.1; Drainage-None; Tissue Type-necrotic tissue; Necrotic tissue-75-100%; Granulation-no, worsened size-yes, worsened depth no, worsened drainage-no; Interventions: nutritional, pressure reducing cushion, pressure reducing mattress, turning-repositioning; Comments: blank. 12/20/15--Comments: Abrasion area to right upper outer buttock-(II is marked out)blank; Measurements: 3 x 6 x 0.1; Drainage; serous; Tissue Type-pink/red with shiny, moist granular appearance; Necrotic Tissue-None; Granulation-yes, worsened size-no, worsened depth-no, worsened drainage-no; Interventions: nutritional, pressure reducing cushion, pressure reducing mattress, turning-repositioning. Review of Resident #9's Care Plan dated 1/15/16 documented Resident #9 was at risk for pressure ulcers related to [MEDICAL CONDITION]. Goals were Resident #9's skin would remain intact. The approaches were to avoid shearing of resident's skin during position, transferring, and turning, to conduct a systematic skin inspection weekly, pay particular attention to the bony prominences, provide incontinence care, use moisture barrier product to the perineal area and to report any signs of skin breakdown (sore, tender, red or broken areas). Resident #9 had self-care deficit: required extensive assist for most ADL's (activities of daily living). Resident #9 had a potential nutritional problem. The approach was to observe, document, report to physician, as needed, provide and serve supplements as ordered, dietician to evaluate and make diet changes and recommendations as needed. Resident #9 was at risk for potential complications related to indwelling urinary catheter. The Care Plan did not address the unstageable pressure ulcer to the right lower outer buttocks found on the 12/14/15 and the unstageable pressure ulcer to the right outer buttock found on 12/20/15. Review of the Weekly Wound Tracking Worksheet documented in part: 12/18/15-Resident #9 Braden Scale 14, Support Measures vitamin C, zinc; Right outer buttock, onset 12/14/15. 2/25/15, Nutrition 60 cc 2 cal bid, CMP (dated 11/04/15) 3.4, Support Measures-vitamin C, zinc; Right outer buttock 2 x 4 x 0.1, Onset 12/14/15; Right outer upper buttock 3 x 6 x 0.1, Onset date 12/20/15. Review of the Medication Flow Sheet dated December 2015 documented in part: Clean Stage II to right outer buttocks with NS (normal saline) (dated 12/14/15); Clean un-stageable to right outer buttocks with NS, dry, apply calcium alginate sheet to wound bed and cover with dressing (dated 12/16/15); Clean abrasion/stage II right upper outer buttocks with NS, dry, apply Collasorb to wound bed and cover with dressing; Clean unstageable to right upper outer buttocks with NS, dry, apply calcium alginate to wound bed and cover with dressing (dated 12/31/15). Review of the Medication Flow Sheet dated December 2015 had no documentation of dressing changes for the right outer buttocks and the right upper outer buttocks on December the 26th, 28th, and the 30th. Review of Physicians telephone orders dated 12/16/15 documented in part wound -vitamin C 500 mg. (milligrams) 1 tab by mouth twice a day, HypoAlbumenemax x 60 days, Pre-[MEDICATION NAME] level. Review of Lab results for Pre-[MEDICATION NAME] (Source:Drugs.com: pre-[MEDICATION NAME] is a protein and is an indicator of malnutrition.)dated 12/17/15 documented a result of 10 (Normal 17-42). Review of Resident #9's Physician's telephone orders dated 1/07/16 documented: Wound infection to coccyx-culture wound. Review of the wound culture results dated 1/07/16 documented: Organism #1 Eshericihia coli (bacteria); Organism #2 Pseudomonas aeruginosa (bacteria); Organism #3 Proteus mirabilis (bacteria) Review of Resident #9's Nurses Notes dated 1/10/16 at 10:30 a.m. documented: Resident #9's physician in facility, evaluated resident pressure sores to buttocks. Waiting culture from hospital to determine an accurate antibiotic to treat the bacterial infection. Review of Residents #9's Nurses Notes dated 1/11/16 at 4:00 p.m. documented: physician called and new order [MEDICATION NAME](antibiotic) for 10 days for [DIAGNOSES REDACTED]. Review of Resident #9's Physician's telephone orders dated 1/11/16 documented: 1. [MEDICAL CONDITION] Wound Healing-Cipro 500 mg, 1 by mouth twice a day for 10 days. 2. Arginade mix with water or juice twice a day. 3. Discontinue 0.2 Cal twice a day and increase to 0.2 Cal to three times a day with meals. Review of Resident #9's Physician's telephone orders dated 1/15/16 documented: [MEDICAL CONDITION]-Bactrim DS one tab twice a day by mouth for 10 days. During a telephone interview on 3/10/16 at 2:45 p.m. Resident #9 said he developed two stage IV pressure ulcer before the nurses' ever found the pressure ulcer. Resident #9 said he spent so much time on the commode (shower chair) that he developed the two pressure ulcers. He said he kept asking the nurses if his buttocks was ok and they kept telling him it was. He said the treatment nurse gave him his stimulation for bowel movements and she should have seen it(referring to pressure ulcers). He said he was on the bowel stimulation program every three days and the nurses at the facility should have seen the pressure sores before they had gotten so bad. He said he used to use a mirror and to check his buttocks to make sure he had no skin breakdown before coming to the facility. During an interview on 3/10/16 at 4:30 p.m. the Director of Nurses (DON) said the weekly wound tracking worksheet documented the onset for the unstageable right outer lower buttocks was 12/14/15 and the right outer upper pressure ulcer was 12/20/15. The DON said the only documentation of the pressure ulcers acquired in the facility was in December and the pressure ulcers were in-house acquired. During an interview on 3/10/16 at 4:35 p.m. the Treatment Nurse said when she found Resident #9's pressure areas the areas were red. She said Resident #9's shower chair was rough and caused the pressure areas. She said the nurses and CNA's should have seen them (referring to the un-stageable pressure ulcers) sooner because staff had to do bowel stimulation and that would have been a good time to see them. During an interview on 4/04/16 at 11:20 a.m. Resident #9's physician said he remembered he looked at Resident #9's pressure ulcers but he couldn't remember when. He said received a call regarding the unstageable pressure ulcers but he could not recall exactly when but he thought it was when they assessed them. Resident #9's physician said the nurses were on top of things and usually called him. He said Resident #9 was a very knowledgeable resident. Resident #9's physician said the nurses were very apologetic about not finding the pressure ulcers until they were unstageable. Resident #9's physician said the nurse said she did not know how she missed the pressure ulcers until they were unstageable. He said they (referring to the nurses at the facility) should have noticed the pressure ulcer sooner but sometimes Resident #9 was on his back. During an interview on 4/05/16 at 10:25 a.m. Resident #9 said he did not remember how often the staff were doing the dressing changes for his pressure ulcers. He said they usually did the dressing when they did his bowel program every three days. He said he was told the pressure ulcers were just a skin abrasion and then he was told he had unstageable pressure ulcers. Resident #9 said he did not remember the date he was informed he had 2 un-stageable pressure ulcers. He said he noticed green/yellow drainage stains on his bed and noticed a foul odor. He said the nurses never changed his dressing like they were supposed to. Resident #9 said he was left on his shower chair for 2 to 3 hours during his bowel program. He said the nurses would try and wait for the next shift to put him to bed and he would be left in his shower chair for long periods of time. During an interview on 4/05/16 at 9:00 a.m. the Treatment Nurse said she did not know if Resident #9 was scheduled for dressing changes on December the 26th, 28th, and the 30th for the unstageable pressure ulcers to this right outer buttock and the unstageable to his right upper outer buttocks. The Treatment Nurse said the Stage II pressure ulcer to his right outer buttocks changed to un-stageable because of there was a black area in the wound. She said did not know why she documented a Stage II pressure sore to the right outer buttocks on December the 14th on the Medication Flow Sheet and unstageable on the Weekly Skin Assessment and Skin Grid. She said she documented the abrasion to the right upper outer buttock as Stage II and then got worried about it and staged it as a unstageable. She said she did not know why she documented the right upper outer buttocks as an unstageable on the Weekly Skin Assessments and the Skin Grid dated 12/20/15 and as an abrasion /Stage II on the Medication Flow Sheet. The Treatment Nurse said at the end of every week she would get together with the DON and go over the skin assessments. She said the DON would decide on the supplements the resident would need and would review the resident's Braden Scale at the same time. She said she discussed the resident's wound measurements with the DON and they would decide if the pressure ulcers were getting better or worse. The Treatment Nurse said measures were put in place for the plan of care to catch skin breakdown and to help pressure ulcers to heal. The Treatment Nurse said Resident #9 would sit on his shower chair during his bowel stimulations and watch movies or do things on his computer. She said she asked him once if he was getting tired of sitting on the shower chair and Resident #9 said no because he didn't feel anything down there. She said Resident #9 sat there one time for three hours. The Treatment Nurse said everything just hung down and was causing pressure to the buttocks area. She said she did not think any staff documented how long Resident #9 would sit on the shower chair for his bowel stimulation. She said staff had talked to with the person in medical record to order a new pad for his shower chair but it was after Resident #9 had developed the unstageable pressure ulcers. During an interview on 04/05/16 at 1:52 p.m. the Director of Nurses (DON) said she did not remember when she was told about Resident #9's pressure ulcer. The DON said she first observed the pressure ulcers they looked pretty bad and that she had never seen anything like that before (she was unsure of the date she first saw the ulcers). The DON said that it progressed from a stage 2 to an unstageable pretty fast. The DON said she did not remember when she first observed the pressure sore at a stage 2. The DON said that when it was at an unstageable stage, Resident #9 kept calling her to the room and that he had a lot of bleeding to the area. The DON said they called the doctor and he put Resident #9 on antibiotics she believed in December. The DON said she reviewed the treatment sheets in general not just Resident #9's sheets. The DON said when she saw the area; it was an abrasion, had necrotic tissue around it and guessed that was why they were calling it unstageable. The DON said it was her job to make sure the treatments were getting done. The DON said the doctor did not know how the sore progressed so fast. The DON said if it (referring to the documentation not being done for Resident #9's dressing changes) was not documented then it was not done. The DON said the system was to put on weekly skins assessments, update the grids, notify the dietician, put on weekly weights, RD (Registered Dietitian) orders, MD orders, notify the family, put on the 24hr report and notify the treatment nurse. The DON said if unstageable was found that all the mattresses were already special mattresses. The DON said they also updated the care plans and the MDS. The DON said she and the treatment nurse would get together and go over issues and a copy of that report would go to the Administrator, MDS, P.T. (Physical Therapy) and the ADON (Assistant Director of Nurses). RESIDENT #1 Record review of Resident #1's consolidated Physician order [REDACTED]. [DIAGNOSES REDACTED]. She was [AGE] years of age. Continued review of the physician Order Report dated 03/01/2016- 04/30/2016 included the following: · 06/02/14 - 60 cc (cubic centimeter) 2 Cal (supplement) TID (three times daily) with meals, Dx. (diagnosis) weight loss; · 01/26/15 - 1 scoop protein powder , three times daily, Dx: weight loss; · 07/13/15 - super cereal with breakfast daily, Dx. weight loss; · 02/22/16 - fortified pudding BID (twice daily) Review of Resident #1's annual MDS assessment dated [DATE], documented the resident had unclear speech, sometimes understood, sometimes understands others, had impaired vision and wore corrective lenses. Resident #1 had long term memory loss and cognitive skills for daily decision making was moderately impaired. Resident #1 required total assistance with two person assistance with bed mobility, transfers, dressing and bathing; required total assistance with one person for locomotion, eating and toilet use; required extensive assistance for personal hygiene. Resident #1 was always incontinent of bladder and bowel. The MDS documented Resident #1 was at risk of developing pressure ulcers; had an unhealed pressure ulcer at stage I or higher; had one stage I (intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching) pressure ulcer. Skin and Ulcer treatments: none of the above were provided was checked, indicating the facility did not provide a pressure reducing device for bed or chair, pressure ulce care, or applications of ointments. Review of Resident #1's Care Plans dated 02/25/16 documented Resident #1 was at risk for pressure ulcers due to friction, shear, activity, chair fast and moisture. Goal was: intact skin without evidence of redness, irritation, maceration or open areas. Approaches included: use moisture barrier ointments, consider pressure relief when positioning in wheelchair and check incontinence pads frequently and change as needed. Review of Resident #1's Braden Risk Assessment Scale documented on 01/03/16 and 03/03/16 a risk score of 11 (0-13 High Risk). During an observation on 03/30/16 at 11:30 a.m. Certified Nurse Aide (CNA) C and CNA N prepared to provide incontinent care for Resident #1. Resident #1 was in her room lying on her bed. CNA C cleaned Resident #1's buttocks. There were no dressings in place on Resident #1's buttocks. Observation of Resident #1's buttocks revealed the left buttock had an open ruptured blister approximately one by one centimeter. The right buttock and coccyx area had lighter colored skin that appeared to be scar tissue. After CNA C and CNA N finished with incontinent care they placed a clean brief on Resident #1, pulled up her pants and transferred her to her wheelchair with the mechanical lift (did not apply any moisture barrier cream/ointment). Review of Resident #1's Progress Notes (nurses notes) dated 03/19/16 at 1630 (4:30 p.m.) documented open area to L (left) buttocks 1 x 0.5 centimeters (cm), cleaned with N/S (normal saline), patted to dry, covered with spot dressing Q (every) 3 (days) and prn (as needed); open area to R (right) buttocks 1.5 x 1 cm. cleaned with N/S, patted to dry, covered with spot dressing Q-3 and prn. Open areas noted per CNA staff. Open areas treated as per MD (medical doctor) order. Resident husband aware of open areas and dressings to L and R buttocks. Review of Resident #1's Physician's telephone orders dated 03/19/16 at 1600 (4:00 p.m.) written by LVN O revealed: · R (right) buttock open area 1.5 x 1 cm. Clean with N/S, pat to dry, cover with spot dressing, change Q-3 days and prn until healed. · L (left) buttocks open area 1 x 0.5 cm. Clean with N/S, pat to dry, cover with spot dressing, change Q-3 days and prn until closed. Review of Hall 3's Nursing 24 hour report dated 3/19/16 revealed the above orders for Resident #1's left and right buttocks. During an interview on 03/30/16 at 11:20 a.m. Resident #1's family member said Resident #1 had a blister on her tailbone. The family member said It heals then it gets a blister, I keep an eye on it. The family member said he is at the facility daily. During an observation and interview on 03/30/16 at 5:35 p.m. the Treatment Nurse was sitting at the front of the nurse's station with her Resident Treatment books reviewing April 2016 treatment orders for the next month. The Treatment Nurse was asked for Resident #1's treatment sheets for March 2016. The Treatment Nurse said Resident #1 did not have any treatments. The Treatment Nurse said I was not aware of treatment orders written on 3/19/16 until today when I was going through Aprils 2016 treatment sheets. I put [MEDICATION NAME] on the area. Review of Resident #1's Treatment sheet, undated, documented the two above orders received on 3/19/16. There were only initials documented on 3/19/16 that the treatment was done by LVN O. There was no documentation the treatment was done (every 3 days) on 3/22/16, 3/25/16 and 3/28/16. Record review on 03/30/16 of Resident #1's Weekly Skin Assessment sheet documented by the Treatment Nurse revealed the following in part: (the treatment sheet form has 10 areas to document 10 weeks of skin assessments) · 2/01/16 - no new areas of skin impairment. · 2/09/16 - no new areas of skin impairment. · 2/15/16 - 3 small 1 cm. x 1 cm. bruises to L (left) FA (forearm). · 2/24/15 - Stage II blister to L buttock 1 x 0.1 x 0.1 [MEDICATION NAME] applied. · 2/29/16 - no new areas of skin impairment. [MEDICATION NAME] applied. Pre [MEDICATION NAME] drawn, vitamin C, zinc and [MEDICATION NAME] started. · 3/07/16 - [MEDICATION NAME] applied. Faded bruise R FA 2x2. · 3/14/16 - no new areas of skin impairment. There was no further skin assessments documented past 3/14/16. During an interview on 03/30/16 at 6:10 p.m. the Treatment Nurse said the weekend nurse gets orders and doesn't tell me about them. Usually the nurse leaves me the green copy of the telephone order. I do her (Resident #1) weekly skin assessments, the scar tissue opens and closes, it's very small, usually get it to close with putting [MEDICATION NAME] ointment on it. Have tried dressings, they don't stay on that area. Have done the 3/22/16 (skin assessment) but have not put it on her (Resident #1) skin assessment sheet. I get pulled to work the floor/charge nurse. The Treatment Nurse said CNA C reported to her today the area was open. During an interview on 3/31/16 at 10:34 a.m. LVN O said he worked weekends twice a month. When asked how he communicates new treatment orders to the Treatment Nurse he said the 24 hour report. LVN O said he also puts the green and yellow copies of the telephone order in the box at the nurse's station. LVN O said the green one goes to the lady that transcribes the orders and the yellow goes to the doctor to be signed. Record review on 04/06/16 of Resident #1's Weekly Skin Assessment sheet documented by the Treatment Nurse revealed the following in part: (same weekly skin assessment sheet as above) · 3/14/16 - [MEDICATION NAME] applied (added on form). · 3/22/16 - [MEDICATION NAME] applied. Excoriated area to upper buttocks, [MEDICATION NAME] applied. · 3/30/16 - R buttock 0.5 x 0.4 x 0.1 [MEDICATION NAME] applied. 3/31/16 [MEDICATION NAME] applied, order clarified on treatment to buttocks, [MEDICATION NAME] to be applied BID (twice daily). Review of Resident #1's Physician's telephone orders dated 03/31/16, written by the Treatment Nurse revealed: · Order Clarification - DC (discontinue) tx (treatment) to R (right) and L (left) buttocks dressing change. Clean area to L buttock with NS (normal saline), dry, apply [MEDICATION NAME] q (every) shift. Review of Resident #1's Medication Flowsheet/treatment sheet for April 2016, documented the following: · 3/31/16 Clean buttocks with NS. Dry. Apply [MEDICATION NAME] q shift, 6:00 a.m. to 6:00 p.m. and 6:00 p.m. to 6:00 a.m. There was no documentation the treatment was done both shifts on 4/02/16 and 4/03/16 (weekend). During an interview on 4/05/16 at 2:20 p.m. the DON acknowledged new treatment orders for Resident #1 were put in the treatment book from the weekend nurse (LVN O). The DON said the Treatment Nurse did not check the 24 hour report or the treatment book. The DON acknowledged there were new orders (3/19/16) and were not found until 3/30/16. The DON said could have new pressure ulcer orders and not know. The DON acknowledged there needs to be a better communication system. Related to communication and treatment orders not known about the DON said it's unfortunate that it's gotten to this point. Review of the facility's policy on Pressure Ulcers/Skin Breakdown dated 2005 and revised on 2/2014 documented in part: Treatment/Management: -The physician will authorize pertinent orders related to wound treatments, including would cleanse and debridement approaches, dressing (occlusive, absorptive, etc.), and application of topical agents if indicated for type of skin. -The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing medical conditions, managing pain related to the wound or to the wound treatment. -The physician will help staff characterize the likelihood of wound healing, based on a review of pertinent factors. -As needed, the physician will help identify medical and ethical issues influencing wound healing. During an interview on 4/05/16 at 5:48 p.m., the Administrator was informed surveyors had identified an Immediate Jeopardy situation. The facility's Plan of Removal of Immediate Jeopardy was accepted on 4/08/16 at 2:52 p.m. and included the following: Identification of Pressure Sores The DON, ADON, Treatment Nurse, and or a LVN Charge Nurse conducted 100% skin evaluations of all residents in the facility on 4/05/16. The Braden Scale was updated for all residents with an identified pressure sore. The physician was notified of any new skin problems that were identified and physician was notified of any new skin problems that were identified and physician orders [REDACTED]. The resident and/or responsible party was also notified of any newly identified pressure sores and the new orders that were obtained from the physician. The DON reviewed the current physician orders [REDACTED]. The IDCPT reviewed the plan of care and updated as indicted. Date of Completion 4/06/16 Staff education related to pressure sores The DON/designee in-serviced all the nursing staff on the prevention of pressure sores, proper turning, and positioning of high-risk residents, identification and reporting any skin change noted during care. The licensed nurses were also in-serviced on the proper documentation requirements related to a pressure sore and notification of the physician and resident/responsible party when a resident has any change in condition. Completed on 4/06/16 Additional in-service with the nursing staff was provided on 4/07/16 addressing the prevention of pressure sores. Completed on 4/07/16 The Regional Nurse consultant completed skin evaluations on all known pressure sores and randomly checked residents without known pressure sores with the DON and Treatment Nurse to ensure that measuring and staging of wounds was completed. The Regional Nurse to ensure that measuring and staging of wounds was completed. The Regional Nurse Consultant also evaluated the pressure relief devices in use for the residents and items were ordered as appropriate. Completed on 4/0716 The Regional Nurse consultant completed wound care competencies on the DON and Treatment Nurse with return demonstration. Completed on 4/07/16 Monitoring of Pressure Sores The DON will check all known pressure sores at least once a week to evaluate the effectiveness of the treatment, to ensure that the treatment nurse is providing the treatments as ordered by the physician, and to evaluate the pressure reducing devices that are in place. Following this evaluation, the DON will contact the physician to discuss possible treatment changes and order/provide alternative pressure reducing devices if indicated. The DON will utilize the Weekly Wound Tracking form to document the assessment and this form will be presented to the Q A & A Committee at least monthly for review and recommendations. Started 4/06/16 Pressure relieving wheelchair cushions ordered 4/07/16 for all residents with known pressure sores or at high risk of pressure sores. The Certified Nursing Assistants (CNA) were in-serviced on 4/07/16 about the Continuous Pressure Ulcer Prevention booklets which provide the CNA's with a tool to document any skin change for a resident that they identify during routine daily resident care (See attached copy of the form and guidelines). The form is a triplicate copy with one distributed to the DON, one to the Charge Nurse, and other is kept by the CNA. The CNA's were all given a set of the forms and guidelines which are included on 4/07/16. Started 4/07/16 The facility will initiate the Daily Clinical Meeting to review all residents with a change of condition including pressure sores. Refer to attached Daily Clinical Meeting Guidelines and the form which is attached. The Daily Clinical Meeting Form will be submitted to the Q A & A Committee for review and intervention as the team deems necessary. Started 4/07/16 American Medical Technology (AMT) will conduct monthly visits that include checking the pressure sores with the Treatment Nurse and making recommendations for alternative treatments if necessary. Monthly and ongoing. The facility will have an outside wound care consultant do an in-service with the licensed nurses on 4/08/16. The in-service will include prevention of pressure sores, identification of pressure sores, staging pressure sores, and treatments. No later than 4/08/16 On-Going Skin Management System Residents will have a skin check and a Braden Scale completed on admission/readmission (within 4 hours) by the charge nurse who is completing the admission. Any identified pressure sore or other skin problem will be reported to the physician to obtain treatment orders and notify the resident/responsible party. The charge nurse will document all findings on the admission paper work and the 24-hour Report. All new resident admission/readmissions will be reviewed in the Clinical Meeting. The DON/designee will check the newly admitted /readmitted resident's skin within 24 hours of admission or on Monday following a weekend admission to ensure all skin problems are identified and addressed. Started 4/07/16 All residents that are admitted /readmitted will have

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 4 of 9 residents (Resident #2, #25, #26, and #27) reviewed for quality of care in that: a) Resident #2 had physician orders [REDACTED]. Resident #2 ran out of his [MEDICATION NAME] pain medication the morning of 4/16/15 and it was not available to be given until the afternoon on 4/21/15 (4 days). Resident #2 ran out of his [MEDICATION NAME] pain medication and did not receive his scheduled [MEDICATION NAME] on 4/30/15 p.m. dose, 5/01/15 a.m. and p.m. dose, 5/02/15 a.m. dose (48 hours). Resident #2 ran out of his [MEDICATION NAME] pain medication the night of 5/31/15 and it was not available until 6/03/15 (unavailable for 3 days). Resident #2 ran out of his [MEDICATION NAME] pain medication the night of 5/31/15. Resident #2 did not receive his [MEDICATION NAME] on 6/01/15 a.m. and p.m. dose. Resident #2 was sent to the hospital on [DATE] for pain management, 14 hours after his a.m. dose was to be given. Resident #2 returned to the facility from the hospital on [DATE]. Resident #2 did not receive his [MEDICATION NAME] on 6/02/15 p.m. dose or 6/03/15 a.m. scheduled dose. Resident #2 did not receive his scheduled dose until 16 hours after it was to be given. Resident #2 experienced pain at an 8 (0 - 10 pain scale). b) Resident #25 had physician orders [REDACTED]. Resident #25 ran out of his scheduled Pregabalin medication on 5/19/15 and it was not available until 5/22/15. Resident #25 missed 6 consecutive doses of Pregabalin. Resident #25 ran out of his [MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication) on 4/05/15 and it was not available until 4/14/15. The order was changed on 4/12/15 to once a day at bed time. The [MEDICATION NAME]-[MEDICATION NAME] was not available until 4/14/15. Resident #25 missed 18 consecutive doses. c) Resident #26 had physician orders [REDACTED]. Resident #26 ran out of her [MEDICATION NAME]-[MEDICATION NAME] medication on 5/22/15. The [MEDICATION NAME]-[MEDICATION NAME] was not available until 6/03/15. Resident #26 missed 21 doses. d) Resident #27 had physician orders [REDACTED]. Resident #27 missed two consecutive doses. These deficient practices resulted in an Immediate Jeopardy (IJ) on 6/05/15. While the IJ was removed prior to exit on 6/11/15 the facility remained out of compliance at a level of Actual Harm at a Pattern that was not IJ because the facility had not had time to implement and monitor policies and procedures. These failures to ensure pain medication was reordered timely and to assess the resident for pain could place the 25 residents on a Schedule II narcotic pain medication and 26 residents on a Schedule IV pain medication, who had either routine or PRN pain medication ordered by their physician at risk for unrelieved pain and discomfort. This could result in decreased nutritional intake, unplanned weight loss, alteration in sleep patterns, decreased socialization, serious medical complications, a delay for appropriate interventions to be implemented and could result in the need for increased medication and possible admission to the hospital for pain relief treatment. Findings included: Resident #2 Review of Resident #2's face sheet dated 4/13/15, documented Resident #2 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's 14 day Minimum Data Set (MDS) assessment dated [DATE], documented his mental status was 15 of 15 (cognitively intact), needed extensive assistance with all activities of daily living, was on a scheduled and as needed (PRN) pain medication. Resident #2's MDS documented he was in constant pain which interfered with his ability to sleep; Resident #2 rated the pain 5 out of 10. Resident #2's Care Plan dated 6/04/15, documented he received an [MEDICATION NAME] medication (a type of pain reliever). The goals were use pain rating scale of 1 - 10 to identify current level of pain intensity and determine comfort/ functional goal and resident will verbalize adequate pain relief. Interventions included: - Administer meds (medications) and treatments to improve these functions if necessary; - assume that pain is present and treat accordingly if I have a pathological condition or if I am undergoing a procedure thought to be painful; - and assess my pain level using the pain scale 1 - 10. Resident #2's Pain assessment dated [DATE], documented he experienced no pain and had his own pain medications with him. The Pain Assessment was updated on 3/30/15 with no changes. Resident #2's Care Plan dated 6/04/15, documented an alteration in comfort: pain due to contractures to hands and being immobile. The goal was Resident/Patient will verbalize adequate pain control. Identified interventions included: - ask resident to rate the pain (0 - 5) if able to verbalize symptoms of pain; - complete a pain assessment if symptoms of pain noted/upon significant change in condition; - encourage resident to report symptoms of pain when at a low intensity in order for pain medications to have maximal effect; - medicate PRN with pain medications to control pain; - Administer routine pain medications per MD (medical doctor) order. Notify MD if pain management not effective; - Monitor for nonverbal symptoms of pain such as increased irritability, change in appetite, motor restlessness, agitation, moaning, crying, changes in sleep pattern, grimacing, withdrawal from activities. Review of Resident #2's History and Physical dated 5/14/15, documented, in part: patient to be evaluated for chronic pain. It began years ago. On a scale of 1 to 10, it is rated a 7 in intensity. Pertinent medical history includes MVA (motor vehicle accident). Patient is a quadriplegic. Current medications: [REDACTED]. - [MEDICATION NAME] 30 mg Tablet one table every 12 hours. Orders: Refill of: [MEDICATION NAME] ([MEDICATION NAME] HCL) 4 mg Tablet 1 TAB q (every) 6 hrs (hours) PRN Pain. #30 (Thirty) tablet(s) Refills: 1. (a prescription was included) Review of Resident #2's consolidated April 2015 Physician order [REDACTED]. - 3/27/15 [MEDICATION NAME] (MS) 30 mg (milligram) twice a day; - 3/27/15 [MEDICATION NAME] ([MEDICATION NAME]) 2 mg, 2 tabs = 4 mg every 6 hours PRN Review of Resident #2's Physician Telephone Orders documented: - 4/26/15 Pain: [MEDICATION NAME] 60 mg every 12 hours as needed; [MEDICATION NAME] 30 mg extra dose x 1 dose. - 4/26/15 Severe pain: send to ER (emergency room ) for treatment and evaluation. - 5/02/15 a prescription for [MEDICATION NAME] 30 mg BID 60 (sixty) signed by the physician. During an interview on 6/05/15 at 10:40 a.m. Resident #2 said the first time the facility ran out of the medications he complained and it got fixed. (4/16/15) He said he talked to the Administrator who said he would take care of it. Resident #2 said and then it happened again and he had his mother give them his stash of [MEDICATION NAME] (4/30/15). He said the last time it happened he ran out of the [MEDICATION NAME] and then he ran out of the [MEDICATION NAME] (5/31/15). He said he was sweaty and his stomach was upset, and it was an all around yucky feeling. He said because of the nerve damage he was in pain all the time, constantly and if his pain level was at a 5 he was happy. He said on 5/31/15 it got up to an an 8. Resident #2 said his legs hurt and it felt like someone was standing on his testicles and his hands and toes burned. He said if he missed two doses he started getting a pounding headache like he was waiting for a blood vessel to pop (as he pointed to his head.) He said he never told any of the staff he was in no pain. Resident #2 said the first time the facility ran out of the [MEDICATION NAME] they went to the emergency room in the van and he was up in his wheelchair. He said it started hurting bad and he wanted to lay down. He said the two aides who were with him would not talk to the admission clerk about someplace to lay down. He said he hurt so much they came back to the facility and they gave him an extra dose of the [MEDICATION NAME] and [MEDICATION NAME] (nonsteroidal anti-[MEDICAL CONDITION]) shot. He said he was stressed out about it happening again. He said when it happened again he talked to the Administrator who said he would have a meeting with the Director of Nurses (DON). Resident #2 said the Administrator never got back with him about it. He said when he talked to the Administrator, the Administrator told him don't even think I have an excuse. Review of Resident #2's Nursing Documentation Records documented, in part: - 5/01/15 2300 (11:00 p.m.)- Will inform next nurse to obtain triplicate for [MEDICATION NAME] sulfate on 5/02/15 from doctor at clinic. Resident voices no complaints of pain. - 5/02/15 0900 (9:00 a.m.)- [MEDICATION NAME] triplicate in fax to pharmacy. [MEDICATION NAME] expected to arrive at facility end of shift. Resident without complaint of pain at this time. - 5/02/15 2300- (11:00 p.m.) [MEDICATION NAME] sulfate arrived from (contracted pharmacy). Review of Resident #2's medication Count Sheet dated 3/27/15 for [MEDICATION NAME] ([MEDICATION NAME]) indicated the bottle had 18 tablets. The last dose given was documented 4/16/15 at 11:00 a.m. Review of Resident #2's next medication Count Sheet dated 4/21/15 (five days after the last count sheet) for PRN [MEDICATION NAME] indicated 10 tablets were received. Dose was given on 4/21/15 at 12:50 p.m. The last dose was documented 4/26/15 at 3:55 a.m. (Resident #2 went 4/16/15 - 4/21/15 without his PRN [MEDICATION NAME] available.) Review of Resident #2's medication Count Sheets dated 3/27/15 for [MEDICATION NAME] 30 mg. indicated bottle #1 had 46 pills and bottle #2 had 21 pills. The last dose of [MEDICATION NAME] 30 mg. was documented on 4/30/15 at 7:00 a.m. Review of Resident #2's medication Count Sheet dated 5/02/15 indicated 60 [MEDICATION NAME] tablets were received. The first dose was given on 5/02/15 at 7:00 p.m. (Resident #2 missed four (4) doses of his [MEDICATION NAME]. The time between the scheduled doses was 48 hours.) Review of Resident #2's Physician Telephone Orders documented: - 5/28/15 send to Dr. Z's office on Sunday (5/31/15). - 6/02/15 prescriptions for [MEDICATION NAME] 30 mg BID and [MEDICATION NAME] 2 mg, 2 tabs every 6 hours PRN. Review of Resident #2's Nursing Documentation Records documented, in part: - 5/28/15 New Order send to Dr. Z office on Sunday (5/31/15). - 6/01/15 1400 (2:00 p.m.) Resident out of MS ([MEDICATION NAME]) and [MEDICATION NAME]. Dr. Z called and message left for triplicate to be written so meds could be ordered. Last dose [MEDICATION NAME] 5/31/15 at 2300. (11:00 p.m.) - 6/01/15 1450 (2:50 p.m.) called Dr. Z for triplicate prescription. Advised he was completely out of MS at this time and [MEDICATION NAME]. Dr. Z said he could come in AM. Asked what he wanted us to give him for pain management at this time - advised him resident was very upset and waiting to go to his office for his shot to his shoulder. Dr. Z replied that he had waited for him on Sunday at his office and would see him tomorrow. Administration advised. - 6/01/15 2010 (8:10 p.m.) CNA (Certified Nurse Aide) notified this nurse Resident wanted to speak with her. Resident upset, shaking, started yelling. Stated I am really upset because I have not gotten my [MEDICATION NAME] and [MEDICATION NAME]. I've been out for two days and I'm hurting. I want to go to ER now! (Local) Pharmacy called. Dr. Z called, got new order to send to ER as indicated. 2035 (8:35 p.m.) ER took resident at 2045 (8:45 p.m.) Resident admitted to local hospital with [DIAGNOSES REDACTED]. (Autonomic Dysreflexia (AD), also known as Hyperreflexia, is a potentially dangerous complication of spinal cord injury (SCI). In AD, an individual's blood pressure may rise to dangerous levels and if not treated can lead to stroke and possibly death. Individuals with SCI at the T-6 level or above are at greater risk. AD usually occurs because of a noxious (irritating) stimulus below the level of the injury. Symptoms include headache, facial flush, perspiration, and a stuffy nose.- From http://www.spinalcord.org/resource-center/askus/index.php?pg=kb.page&id=248) - 6/01/15 Pain Management: no complaints. - 6/02/15 Pain Management: (dashes) (no time) Resident readmitted to facility to room. No new orders. Resident alert and oriented times three. No complaints at this time. Scripts (prescriptions) in and faxed to pharmacy. No complaints of pain at this time. Review of Resident #2's Prehospital Patient Care Report, undated (Emergency Medical Services report): En Route: 2036 (8:36 p.m.) Hospital: 2058 (8:58 p.m.) Chief Complaint: pain all over. Signs and Symptoms: pain to extremities, back, total body. Pain Scale: 5 Review of Resident #2's Emergency Department notes dated 6/01/15, documented, in part: Arrival: 21:00 (9:00 p.m.) - Chief Complaint: pain all over. Nursing home ran out of [MEDICATION NAME] and [MEDICATION NAME] XR. History of Present Illness. Chief Complaint: Abdominal Pain and diffuse pain. At its maximum, severity described as severe. When seen in the E.D. (emergency department) severity described as severe. It is described as sharp, stabbing and cramping. This started today. Pt (patient) states nursing home ran out of his pain meds and is still present. Clinical Impression: Acute generalized abdominal pain. Acute abdominal pain. Autonomic Dysreflexia. Medications given in the Emergency Department: 2132 (11:32 p.m.) [MEDICATION NAME] ER (extended release) 30 mg, 21:33 (11:33 p.m.) [MEDICATION NAME] 0.2 mg 21:40 (11:40 p.m.) [MEDICATION NAME] 50 mg. Review of Resident #2's History and Physical from the hospital dated 6/01/15, documented Resident #2 came into the emergency room with complaints of generalized abdominal pain. He also has a history of musculoskeletal problems and back pain. He is out of his medication, so he is going to be admitted to the hospital for pain management. The plan of management was admit him for observation and pain control. Review of Resident #2's Hospital Discharge Summary dated 6/02/15, documented, in part: Admission Diagnoses: [REDACTED]. Hospital Course He was given pain medication and has done well. No major complaints. Plan: Usual home medications including [MEDICATION NAME]. Review of Resident #2's 6/01/15 - 6/02/15 Hospital Medication Administration Record [REDACTED] 6/01/15 [MEDICATION NAME] 23:41 (11:41 p.m.) 6/02/15 [MEDICATION NAME] 50 mg 05:13 a.m. 6/2/15 [MEDICATION NAME] mg at 9:04 a.m. discharged from the hospital, back to facility on 6/02/15 at 15:20 (3:20 p.m.) per the hospital nurse's notes. Review of Resident #2's Medication Flowsheet dated 6/01/15 - 6/03/15 revealed the following documentation for the [MEDICATION NAME] sulfate 30 mg BID: - 6/01/15 7:00 a.m./p.m. (2 doses circled as missed) - 6/02/15 7:00 p.m. (1 dose circled as missed). - 6/03/15 7:00 a.m. dose was initialed as given. (Narcotic sheet documented the dose was given at 11:00 a.m.) Review of Resident #2's Medication Flowsheet dated 6/01/15 - 6/30/15 revealed the following documentation for the [MEDICATION NAME] 2 mg, 2 tabs = 4 mg every 6 hours PRN: Received dose of [MEDICATION NAME] 6/04/15 at 11:30 a.m. Received dose of [MEDICATION NAME] on 6/07/15 (no time indicated) Received dose of [MEDICATION NAME] on 6/08/15 at 2350 (11:50 p.m.) Review of Resident #2's medication Count Sheet dated 5/02/15 indicated 60 [MEDICATION NAME] tablets were received. The last dose of [MEDICATION NAME] 30 mg. was documented on 5/31/15 at 8:00 p.m. (Resident #2 arrived at the hospital 6/01/15 at 9:00 p.m., 14 hours after his scheduled [MEDICATION NAME] pain medication was ordered to be given and had run out. Resident #2 left the hospital on [DATE] at 3:20 p.m.) Review of Resident #2's medication Count Sheet dated 6/03/15 indicated 60 [MEDICATION NAME] tablets were received. The first dose was given on 6/03/15 at 11:00 a.m., (16 hours after it was scheduled). Review of Resident #2's medication Count Sheet dated 4/27/15 for [MEDICATION NAME] indicated 30 tablets were received. The last dose was documented 5/31/15 at 11:00 p.m. (Resident #2 arrived at the hospital 6/01/15 at 9:00 p.m., 16 hours after he could have received his as needed [MEDICATION NAME] pain medication but he had run out. Resident #2 left the hospital on [DATE] at 3:20 p.m.) Review of Resident #2's medication Count Sheet dated 6/03/15 for [MEDICATION NAME] indicated 100 tablets were received. The first as needed dose was given on 6/03/15 at 11:00 a.m. Review of the Pharmacy Reorder faxes documented the facility sent in a request for medications on: 5/28/15 [MEDICATION NAME] 6/01/15 [MEDICATION NAME] 30 mg BID and [MEDICATION NAME] 2 mg 2 tabs - 4 mg every hours PRN. Review of the 24 Hour Communication book from 5/09/15 - 6/04/15 documented, in part: -6/01/15 Resident #2 to Dr. Z's office Monday (6/01/15), out of MS ([MEDICATION NAME] sulfate) and [MEDICATION NAME]. - 6/01/15 Resident #2 out of [MEDICATION NAME] and [MEDICATION NAME]. admitted to hospital dx (diagnosis) autonomic dysreflexia at 2234 (10:45 p.m.) - notify POA. - 6/02/15 Readmit continue with medication. Dr. Z to take triplicate to (local) pharmacy. Review of the Grievance Log documented on 6/03/15 Resident #2 had a concern about the staff reordering his pain medication. The resolution was nursing needs to re-order medication within a week of resident running out of medication. During an interview on 6/5/15 at 12:25 p.m. with the Director Of Nurses (DON) and Administrator. The DON said the facility would contact the pharmacy for a refill seven days before the facility ran out. She said the pharmacy would contact the doctor for the triplicate. She said the delay in Resident #2's medication had to do with the doctor getting them the triplicate. The DON said the facility began requesting the triplicate prescriptions on 5/28/15. She explained Dr. Z had a house about an hour and a half away, so he was not here to give the triplicate prescription. The DON said when this happened in April the facility asked Dr. Z's partner to write the prescription and he originally refused. She said they told the partner the resident was in pain and needed it and he wrote it for a one time only. The DON said they asked the partner this time and he refused to write it. She said Dr. Z did not get to town until 6/02/15. She said the pharmacy faxed the triplicate request on 5/28/15 but when they called Dr. Z he said it would just have to wait until he got to town. When asked what was done to correct the issue, the DON said she talked to all the nurses to make sure they were ordering ahead of time. She said she talked to the Corporate Nurse (CN) about it. She said Resident #2 did not run out of medication until Monday (6/01/15) morning. She said she did not know when the doctor was in or out of town. The DON said she felt the doctor was responsible for not getting the triplicate to the facility on time. The DON said I'll start calling Dr. Z myself ahead of time. The main thing I want to make sure it doesn't come upon a weekend. She said the prescriptions were written for 30 days and the last time they received any [MEDICATION NAME] was 5/02/15. The DON said the staff found a bottle of [MEDICATION NAME] on him (Resident #2) shortly after he was admitted . She said he had them hidden in his room. The DON said the family could have brought it in but the nurse found the medication with him. The DON said we just told him he could not have it in his room. The DON said there was nothing written about ordering. She said she talked to the nurses the first time Resident #2 ran out of medications and spoke to them again this week. The DON said there was no written plan to prevent the residents from running out of medications again. She said the facility would talk to Dr. Z to see if there was something they could do to get the medications set up. She said Dr. Z usually came in Thursday nights around 8-ish and would leave something in her door. She said she did not get anything last week. The Administrator said he had not talked to Dr. Z either. The DON repeated she thought the breakdown was Dr. Z and the triplicate. The DON said the facility had a contract pharmacist through a pharmacy company out of Houston. She said she was not aware of him (pharmacist) looking at the ordering/reordering process. She said the pharmacist never said anything about a triplicate issue. The DON verified she had not consulted with the pharmacist about how to prevent narcotic/triplicate medications from running out. During an interview on 6/05/15 at 3:55 p.m. Licensed Vocational Nurse (LVN) M said she called Dr. Z last Monday (6/01/15) and told him the facility was out of Resident #2's MS and [MEDICATION NAME] and his last dose was at 11 p.m. LVN M said Dr. Z said Resident #2 would have to wait until Tuesday because Dr. Z waited on Resident #2 all day Sunday. She said she did not work on Sunday so she did not know if transportation was available. She said she informed the DON and she believed the DON talked to the Administrator about it, LVN M said Resident #2 never complained of pain to her. She said she did not know how often the facility ran out of Resident #2's medications because the nurses rotated halls. During an interview on 6/05/15 at 5:08 p.m. the Corporate Nurse was informed of the current findings. She said it was a wonder Resident #2 did not go into withdrawal. During an interview on 6/08/15 at 11:55 a.m. Resident #2's mother said they always kept a few [MEDICATION NAME] back on Resident #2's wheelchair for when his [MEDICATION NAME] failed. She said when the facility failed to order it she reminded him it was there so the staff took that to use (4/2015). She said even after that they did not reorder the [MEDICATION NAME] and he ran out again. She said there could not have been more than 6 pills (3 doses) on the wheelchair. The mother said she talked to the Administrator about it who said he talked to Resident #2 and nothing was being done. She said she talked to the Administrator on the day Resident #2 got back from the hospital (6/2/15). She said he was very apologetic and would see that the medications were ordered and then they were not. She said it's just not too much to ask that he get his medications. He's taken narcotics for so long he goes through horrific withdrawals. Resident #25 Review of Resident #25's undated Resident Admission Record documented he was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #25's consolidated Physician order [REDACTED]. - 11/14/14 order for [MEDICATION NAME] -[MEDICATION NAME] 10 -325 mg every 6 hours as needed for pain; - 4/14/15 for [MEDICATION NAME]-[MEDICATION NAME] 10 - 325 mg hour of sleep (HS); -10/16/14 order for pregabalin 75 mg twice a day (7:00 a.m. and 7:00 p.m.). Review of Resident #25's Pain assessment dated [DATE] documented he had constant, aching, burning, sharp pain and medication and/or repositioning helped relieve the pain. The assessing nurse documented Resident #25's worst pain in the 24 hours prior to the assessment was a 7 out of 10 and the resident's current pain (at the time of the assessment) was 2 of 10. There was no follow up for addressing the pain. Review of Resident #25's 5/19/15 quarterly MDS Assessment documented he scored a 14 of 15 (indicating he was cognitively intact); was independent with his ADL's and was on scheduled pain medications. Review of Resident #25's Nurses Notes documented a note written 4/13/15 called Houston (contract pharmacy) on status of [MEDICATION NAME] - states a triplicate is needed. Will inform day nurse to call Dr. Z for triplicate and to fax. Review of Resident #25's May 2015 Medication Flowsheet documented: 5/20/15 - 5/22/15 7:00 a.m. and 7:00 p.m. pregabalin 75 mg were initialed and circled as missed. (6 consecutive doses) Review of Resident #25's April 2015 Medication Flowsheet documented Resident #25 had an order for [REDACTED]. A note was written 4/12/15 [MEDICATION NAME] on order. Review of Resident #25's medication Count Sheets documented he did not have the [MEDICATION NAME] - [MEDICATION NAME] 5/12/15 - 5/16/15 (three consecutive missed doses). Review of Resident #25's medication Count Sheets for pregabalin 75 mg documented one narcotic sheet's last date was 5/20/15 (7 a.m.). The next Narcotic sheet for pregabalin was dated 5/22/15 (7 p.m.). (5 consecutive missed doses) During an interview on 6/11/15 at 9:50 a.m. Resident #25 said he has gone up to three days without his medications. He said the nurses turned in the refill early enough but the pharmacy did not send it in. He said he could not remember the last time that it happened exactly. He said he complained about not getting his medications and his Power of Attorney did too but nothing got done. He said, ain't no use to it, it's the drug company. He said the pharmacy was out of Houston and it got flown into the nearest airport (2 hours away) and then it got loaded up and brought to the facility. Resident #25 said Dr. Z came every Thursday. RESIDENT #26 Review of Resident #26's Resident Admission Record, undated, documented she was a [AGE] year old female, admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #26's quarterly MDS assessment dated [DATE], revealed her Brief Interview for Mental Status (BIMS) score was 14 (13-15 cognitively intact). Required extensive assistance with bed mobility, transfers, eating, toileting, personal hygiene and bathing. Had one sided limitation of range of motion with the upper and lower extremity. Used a wheelchair for mobility. Was incontinent of bladder and bowel. Indicated no pain in the last five days. Review of Resident #26's consolidated Physician order [REDACTED]. - 03/18/14 [MEDICATION NAME]-[MEDICATION NAME] tablet; 10-325 mg; one tablet; orally; twice a day; 9:00 a.m. & 5:00 p.m. Dx (diagnosis) pain. Review of Resident #26's Medications Flowsheet dated 5/01/15 - 5/31/15 revealed the following documentation for the [MEDICATION NAME]-[MEDICATION NAME] tablet; 10-325 mg; one tablet, orally, twice a day: - 9:00 a.m. dose had circled initials from 5/23/15 through 5/31/15 (9 doses); (circled initials indicated the medication was not given). - 5:00 p.m. dose was marked through and 1900 (7:00 p.m.) was written beside it. This 7:00 p.m. dose had circled initials from 5/22/15 through 5/31/15 (10 doses). Review of Resident #26's Medication Flowsheet dated 6/01/15 - 6/30/15 revealed the following documentation for the [MEDICATION NAME]-[MEDICATION NAME] tablet; 10-325 mg; one tablet, orally, twice a day: - 9:00 a.m. dose had circled initials on 6/01/15, 6/02/15 and 6/03/15 (3 doses); - 5:00 p.m. dose was marked through and 8:00 p.m. was written beside it. This 8:00 p.m. dose had circled initials on 6/01/15 and 6/02/15 (2 doses). Review of Resident #26's medication Count Sheet dated 4/22/15 indicated 60 [MEDICATION NAME] - [MEDICATION NAME] tablets were received. The last dose documented as given was 5/22/15 at 7:00 a.m. Review of Resident #26's medication Count Sheet dated 6/03/15 indicated 60 [MEDICATION NAME]-[MEDICATION NAME] tablets were received. The first dose was given on 6/03/15 at 7:00 p.m. During an observation and interview on 6/05/15 at 4:12 p.m. Resident #26 was resting on her bed. Resident #26 said when the weather is cold her arm will hurt. During an interview on 6/09/15 at 8:45 a.m. LVN O said if the facility needed a triplicate they called the doctor and had him write one. She said if a narcotic did not come in they were supposed to let the ADON and DON know. She said the last time they ran out of a narcotic it was one of Dr. Z's patients. She said she called Dr. Z, went and got the prescription, took it to the local pharmacy and got it filled. She said it was last week and it was Resident # 26. She said she did not know why the facility ran out of narcotics. She said the medication was [MEDICATION NAME] - [MEDICATION NAME] and someone told her they had ordered it and it would be delivered, but it was not. During an interview on 6/11/15 at 9:30 a.m. LVN L said she had worked at the facility for three months. LVN L said there had been problems getting medications from the pharmacy. LVN L said the pharmacy the facility used was in Houston. LVN L said when she would call the pharmacy about a resident's medication she would be put on hold, be told the medication was ordered or that the medication would be delivered that night. LVN L said the next day she would come in and the medication would not be there. LVN L said she had reported this to the DON and Administrator but nothing had changed. LVN L acknowledged Resident #26 was out of her [MEDICATION NAME] - [MEDICATION NAME] pain medication 5/22/15 through 6/03/15. RESIDENT #27 Review of Resident #27's undated Resident Admission Record documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #27's consolidated Physician order [REDACTED]. There was an order dated 10/04/14 for [MEDICATION NAME] (a narcotic-like pain reliever used to treat moderate to severe pain) 50 mg three times a day for pain. Review of Resident #27's 5/05/15 quarterly MDS Assessment documented she scored a 5 of 15 (severe cognitive impairment), was independent with ADL's and was on scheduled pain medications. Review of Resident #27's 11/04/14 care plan on increased pain/discomfort documented the goal was to maintain current ADLs (Activities of Daily Living) and pain/discomfort will be controlled within on hour of intervention over next 90 days. Identified approaches included: monitor for signs and symptoms of pain/discomfort - assess resident for possible causes, give meds, tx (treatments), physical and relaxation modalities, etc - assess for relief, assist with ADL's and comfort measures - as appropriate. Allow to verbalize feelings of pain and discomfort. [MEDICATION NAME] and [MEDICATION NAME]. Review of Resident #27's 6/01/15 - 6/30/15 Medication Flowsheet documented Resident #27 missed her 6/09/15, 9:00 a.m. and 1:00 p.m. dose of [MEDICATION NAME]. During an interview on 6/09/15 at 9:10 a.m. LVN I said most of the time she did not let her residents run out of medications. She said this lady is out and I need to call the pharmacy. LVN I showed surveyor Resident #27's empty [MEDICATION NAME] medication card. She said when the medication got to the blue box the nurses were supposed to reorder medications by pulling the sticker and putting it on the reorder form. LVN I said when the residents got half way through the blue box she called the pharmacy and they check

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving and administering of all drugs and biologicals) to meet the needs of each resident for 8 of 9 residents reviewed for pharmacy services. (Resident #2, #7, #25 #26, #27, #28, #30, and #31) a) Resident #2, #25, #26, #27 did not receive their prescribed pain medication. b) Resident #7 and Resident #30 did not receive their prescribed antibiotic when the initial dose was due. c) Resident #2, #28, #30, and #31 did not receive their prescribed zinc to help with wound healing. These deficient practices resulted in an Immediate Jeopardy (IJ) on 6/05/15. While the IJ was removed prior to exit on 6/11/15 the facility remained out of compliance at a level of Actual Harm at a Pattern that was not IJ because the facility had not had time to implement and monitor policies and procedures. This deficient practice placed 25 residents on a Schedule II narcotic pain medication and 26 residents who received Schedule IV pain medication at risk for unrelieved pain, all residents on antibiotics, and placed 12 residents on zinc at risk for not receiving their mineral supplement and/or delayed wound healing. Findings included: _____PAIN MEDICATION_____ Resident #2 Review of Resident #2's face sheet dated 4/13/15, documented Resident #2 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's 14 day Minimum Data Set (MDS) assessment dated [DATE], documented his mental status was 15 of 15 (cognitively intact), needed extensive assistance with all activities of daily living, was on a scheduled and as needed (PRN) pain medication. Resident #2's MDS documented he was in constant pain which interfered with his ability to sleep; Resident #2 rated the pain 5 out of 10. Resident #2's Care Plan dated 6/04/15, documented he received an analgesic medication (a type of pain reliever). The goals were use pain rating scale of 1 - 10 to identify current level of pain intensity and determine comfort/ functional goal and resident will verbalize adequate pain relief. Interventions included: - Administer meds (medications) and treatments to improve these functions if necessary; - assume that pain is present and treat accordingly if I have a pathological condition or if I am undergoing a procedure thought to be painful; - and assess my pain level using the pain scale 1 - 10. Resident #2's Pain assessment dated [DATE], documented he experienced no pain and had his own pain medications with him. The Pain Assessment was updated on 3/30/15 with no changes. Resident #2's Care Plan dated 6/04/15, documented an alteration in comfort: pain due to contractures to hands and being immobile. The goal was Resident/Patient will verbalize adequate pain control. Identified interventions included: - ask resident to rate the pain (0 - 5) if able to verbalize symptoms of pain; - complete a pain assessment if symptoms of pain noted/upon significant change in condition; - encourage resident to report symptoms of pain when at a low intensity in order for pain medications to have maximal effect; - medicate PRN with pain medications to control pain; - Administer routine pain medications per MD (medical doctor) order. Notify MD if pain management not effective; - Monitor for nonverbal symptoms of pain such as increased irritability, change in appetite, motor restlessness, agitation, moaning, crying, changes in sleep pattern, grimacing, withdrawal from activities. Review of Resident #2's History and Physical dated 5/14/15, documented, in part: patient to be evaluated for chronic pain. It began years ago. On a scale of 1 to 10, it is rated a 7 in intensity. Pertinent medical history includes MVA (motor vehicle accident). Patient is a quadriplegic. Current medications: [REDACTED]. - Morphine Sulfate (MS) 30 mg Tablet one table every 12 hours. Orders: Refill of: hydromorphone (Hydromorphone HCL) 4 mg Tablet 1 TAB q (every) 6 hrs (hours) PRN Pain. #30 (Thirty) tablet(s) Refills: 1. (a prescription was included) Review of Resident #2's consolidated April 2015 Physician order [REDACTED]. - 3/27/15 Morphine Sulfate (MS) 30 mg (milligram) twice a day; - 3/27/15 hydromorphone (Dilaudid) 2 mg, 2 tabs = 4 mg every 6 hours PRN Review of Resident #2's Physician Telephone Orders documented: - 4/26/15 Pain: Tramadol 60 mg every 12 hours as needed; Morphine Sulfate 30 mg extra dose x 1 dose. - 4/26/15 Severe pain: send to ER (emergency room ) for treatment and evaluation. - 5/02/15 a prescription for Morphine Sulfate 30 mg BID 60 (sixty) signed by the physician. During an interview on 6/05/15 at 10:40 a.m. Resident #2 said the first time the facility ran out of the medications he complained and it got fixed. (4/16/15) He said he talked to the Administrator who said he would take care of it. Resident #2 said and then it happened again and he had his mother give them his stash of hydromorphone (4/30/15). He said the last time it happened he ran out of the morphine and then he ran out of the hydromorphone (5/31/15). He said he was sweaty and his stomach was upset, and it was an all around yucky feeling. He said because of the nerve damage he was in pain all the time, constantly and if his pain level was at a 5 he was happy. He said on 5/31/15 it got up to an an 8. Resident #2 said his legs hurt and it felt like someone was standing on his testicles and his hands and toes burned. He said if he missed two doses he started getting a pounding headache like he was waiting for a blood vessel to pop (as he pointed to his head.) He said he never told any of the staff he was in no pain. Resident #2 said the first time the facility ran out of the hydromorphone they went to the emergency room in the van and he was up in his wheelchair. He said it started hurting bad and he wanted to lay down. He said the two aides who were with him would not talk to the admission clerk about someplace to lay down. He said he hurt so much they came back to the facility and they gave him an extra dose of the morphine and toradol (nonsteroidal anti-inflammatory) shot. He said he was stressed out about it happening again. He said when it happened again he talked to the Administrator who said he would have a meeting with the Director of Nurses (DON). Resident #2 said the Administrator never got back with him about it. He said when he talked to the Administrator, the Administrator told him don't even think I have an excuse. Review of Resident #2's Nursing Documentation Records documented, in part: - 5/01/15 2300 (11:00 p.m.)- Will inform next nurse to obtain triplicate for morphine sulfate on 5/02/15 from doctor at clinic. Resident voices no complaints of pain. - 5/02/15 0900 (9:00 a.m.)- Morphine Sulfate triplicate in fax to pharmacy. Morphine expected to arrive at facility end of shift. Resident without complaint of pain at this time. - 5/02/15 2300- (11:00 p.m.) Morphine sulfate arrived from (contracted pharmacy). Review of Resident #2's medication Count Sheet dated 3/27/15 for Dilaudid (hydromorphone) indicated the bottle had 18 tablets. The last dose given was documented 4/16/15 at 11:00 a.m. Review of Resident #2's next medication Count Sheet dated 4/21/15 (five days after the last count sheet) for PRN Dilaudid indicated 10 tablets were received. Dose was given on 4/21/15 at 12:50 p.m. The last dose was documented 4/26/15 at 3:55 a.m. (Resident #2 went 4/16/15 - 4/21/15 without his PRN Dilaudid available.) Review of Resident #2's medication Count Sheets dated 3/27/15 for Morphine 30 mg. indicated bottle #1 had 46 pills and bottle #2 had 21 pills. The last dose of Morphine 30 mg. was documented on 4/30/15 at 7:00 a.m. Review of Resident #2's medication Count Sheet dated 5/02/15 indicated 60 Morphine tablets were received. The first dose was given on 5/02/15 at 7:00 p.m. (Resident #2 missed four (4) doses of his Morphine. The time between the scheduled doses was 48 hours.) Review of Resident #2's Physician Telephone Orders documented: - 5/28/15 send to Dr. Z's office on Sunday (5/31/15). - 6/02/15 prescriptions for Morphine Sulfate 30 mg BID and hydromorphone 2 mg, 2 tabs every 6 hours PRN. Review of Resident #2's Nursing Documentation Records documented, in part: - 5/28/15 New Order send to Dr. Z office on Sunday (5/31/15). - 6/01/15 1400 (2:00 p.m.) Resident out of MS (Morphine Sulfate) and hydromorphone. Dr. Z called and message left for triplicate to be written so meds could be ordered. Last dose hydromorphone 5/31/15 at 2300. (11:00 p.m.) - 6/01/15 1450 (2:50 p.m.) called Dr. Z for triplicate prescription. Advised he was completely out of MS at this time and hydromorphone. Dr. Z said he could come in AM. Asked what he wanted us to give him for pain management at this time - advised him resident was very upset and waiting to go to his office for his shot to his shoulder. Dr. Z replied that he had waited for him on Sunday (5/31/15) at his office and would see him tomorrow. Administration advised. - 6/01/15 2010 (8:10 p.m.) CNA (Certified Nurse Aide) notified this nurse Resident wanted to speak with her. Resident upset, shaking, started yelling. Stated I am really upset because I have not gotten my morphine and hydromorphone. I've been out for two days and I'm hurting. I want to go to ER now! (Local) Pharmacy called. Dr. Z called, got new order to send to ER as indicated. 2035 (8:35 p.m.) ER took resident at 2045 (8:45 p.m.) Resident admitted to local hospital with [DIAGNOSES REDACTED]. (Autonomic Dysreflexia (AD), also known as Hyperreflexia, is a potentially dangerous complication of spinal cord injury (SCI). In AD, an individual's blood pressure may rise to dangerous levels and if not treated can lead to stroke and possibly death. Individuals with SCI at the T-6 level or above are at greater risk. AD usually occurs because of a noxious (irritating) stimulus below the level of the injury. Symptoms include headache, facial flush, perspiration, and a stuffy nose.- From http://www.spinalcord.org/resource-center/askus/index.php?pg=kb.page&id=248) - 6/01/15 Pain Management: no complaints. - 6/02/15 Pain Management: (dashes) (no time) Resident readmitted to facility to room. No new orders. Resident alert and oriented times three. No complaints at this time. Scripts (prescriptions) in and faxed to pharmacy. No complaints of pain at this time. Review of Resident #2's Prehospital Patient Care Report, undated (Emergency Medical Services report): En Route: 2036 (8:36 p.m.) Hospital: 2058 (8:58 p.m.) Chief Complaint: pain all over. Signs and Symptoms: pain to extremities, back, total body. Pain Scale: 5 Review of Resident #2's Emergency Department notes dated 6/01/15, documented, in part: Arrival: 21:00 (9:00 p.m.) - Chief Complaint: pain all over. Nursing home ran out of hydromorphone and Morphine XR. History of Present Illness. Chief Complaint: Abdominal Pain and diffuse pain. At its maximum, severity described as severe. When seen in the E.D. (emergency department) severity described as severe. It is described as sharp, stabbing and cramping. This started today. Pt (patient) states nursing home ran out of his pain meds and is still present. Clinical Impression: Acute generalized abdominal pain. Acute abdominal pain. Autonomic Dysreflexia. Medications given in the Emergency Department: 2132 (11:32 p.m.) Morphine Sulfate ER (extended release) 30 mg, 21:33 (11:33 p.m.) Clonidine 0.2 mg 21:40 (11:40 p.m.) Demerol 50 mg. Review of Resident #2's History and Physical from the hospital dated 6/01/15, documented Resident #2 came into the emergency room with complaints of generalized abdominal pain. He also has a history of musculoskeletal problems and back pain. He is out of his medication, so he is going to be admitted to the hospital for pain management. The plan of management was admit him for observation and pain control. Review of Resident #2's Hospital Discharge Summary dated 6/02/15, documented, in part: Admission Diagnoses: [REDACTED]. Hospital Course He was given pain medication and has done well. No major complaints. Plan: Usual home medications including MS Contin and hydromorphone. Review of Resident #2's 6/01/15 - 6/02/15 Hospital Medication Administration Record [REDACTED] 6/01/15 hydromorphone 23:41 (11:41 p.m.) 6/02/15 Tramadol 50 mg 05:13 a.m. 6/2/15 MS Contin 30 mg at 9:04 a.m. discharged from the hospital (to the nursing home) on 6/02/15 at 15:20 (3:20 p.m.) per the hospital nurse's notes. Review of Resident #2's Medication Flowsheet dated 6/01/15 - 6/03/15 revealed the following documentation for the morphine sulfate 30 mg BID: - 6/01/15 7:00 a.m./p.m. (2 doses circled as missed) - 6/02/15 7:00 p.m. (1 dose circled as missed). - 6/03/15 7:00 a.m. dose was initialed as given. (Narcotic sheet documented the dose was given at 11:00 a.m.) Review of Resident #2's Medication Flowsheet dated 6/01/15 - 6/30/15 revealed the following documentation for the hydromorphone 2 mg, 2 tabs = 4 mg every 6 hours PRN: Received dose of hydromorphone 6/04/15 at 11:30 a.m. Received dose of hydromorphone on 6/07/15 (no time indicated) Received dose of hydromorphone on 6/08/15 at 2350 (11:50 p.m.) Review of Resident #2's medication Count Sheet dated 5/02/15 indicated 60 Morphine tablets were received. The last dose of Morphine 30 mg. was documented on 5/31/15 at 8:00 p.m. (Resident #2 arrived at the hospital 6/01/15 at 9:00 p.m., 14 hours after his scheduled Morphine pain medication was ordered to be given and had run out. Resident #2 left the hospital on [DATE] at 3:20 p.m.) Review of Resident #2's medication Count Sheet dated 6/03/15 indicated 60 Morphine tablets were received. The first dose was given on 6/03/15 at 11:00 a.m. (16 hours after it was scheduled). Review of Resident #2's medication Count Sheet dated 4/27/15 for Dilaudid indicated 30 tablets were received. The last dose was documented 5/31/15 at 11:00 p.m. (Resident #2 arrived at the hospital 6/01/15 at 9:00 p.m., 16 hours after he could have received his as needed Dilaudid pain medication but he had run out. Resident #2 left the hospital on [DATE] at 3:20 p.m.) Review of Resident #2's medication Count Sheet dated 6/03/15 for Dilaudid indicated 100 tablets were received. The first as needed dose was given on 6/03/15 at 11:00 a.m., (14 hours after Resident #2 returned from the hospital.) Review of the Pharmacy Reorder faxes documented the facility sent in a request for medications on: 5/28/15 Morphine Sulfate 6/01/15 Morphine Sulfate 30 mg BID and Hydromorphone 2 mg 2 tabs - 4 mg every hours PRN. Review of the 24 Hour Communication book from 5/09/15 - 6/04/15 documented, in part: -6/01/15 Resident #2 to Dr. Z's office Monday, out of MS (morphine sulfate) and Dilaudid. - 6/01/15 Resident #2 out of Morphine and Dilaudid. admitted to hospital dx (diagnosis) autonomic dysreflexia at 2234 (10:45 p.m.) - notify POA. - 6/02/15 Readmit continue with medication. Dr. Z to take triplicate to (local) pharmacy. Review of the Grievance Log documented on 6/03/15 Resident #2 had a concern about the staff reordering his pain medication. The resolution was nursing needs to re-order medication within a week of resident running out of medication. During an interview on 6/5/15 at 12:25 p.m. with the Director Of Nurses (DON) and Administrator. The DON said the facility would contact the pharmacy for a refill seven days before the facility ran out. She said the pharmacy would contact the doctor for the triplicate. She said the delay in Resident #2's medication had to do with the doctor getting them the triplicate. The DON said the facility began requesting the triplicate prescriptions on 5/28/15. She explained Dr. Z had a house about an hour and a half away, so he was not here to give the triplicate prescription. The DON said when this happened in April the facility asked Dr. Z's partner to write the prescription and he originally refused. She said they told the partner the resident was in pain and needed it and he wrote it for a one time only. The DON said they asked the partner this time and he refused to write it. She said Dr. Z did not get to town until 6/02/15. She said the pharmacy faxed the triplicate request on 5/28/15 but when they called Dr. Z he said it would just have to wait until he got to town. When asked what was done to correct the issue, the DON said she talked to all the nurses to make sure they were ordering ahead of time. She said she talked to the Nurse Consultant about it. She said Resident #2 did not run out of medication until Monday (6/01/15) morning. She said she did not know when the doctor was in or out of town. The DON said she felt the doctor was responsible for not getting the triplicate to the facility on time. The DON said I'll start calling Dr. Z myself ahead of time. The main thing I want to make sure it doesn't come upon a weekend. She said the prescriptions were written for 30 days and the last time they received any morphine was 5/02/15. The DON said the staff found a bottle of hydromorphone on him (Resident #2) shortly after he was admitted . She said he had them hidden in his room. The DON said the family could have brought it in but the nurse found the medication with him. The DON said we just told him he could not have it in his room. The DON said there was nothing written about ordering. She said she talked to the nurses the first time Resident #2 ran out of medications and spoke to them again this week. The DON said there was no written plan to prevent the residents from running out of medications again. She said the facility would talk to Dr. Z to see if there was something they could do to get the medications set up. She said Dr. Z usually came in Thursday nights around 8-ish and would leave something in her door. She said she did not get anything last week. The Administrator said he had not talked to Dr. Z either. The DON repeated she thought the breakdown was Dr. Z and the triplicate. The DON said the facility had a contract pharmacist through a pharmacy company out of Houston. She said she was not aware of him (pharmacist) looking at the ordering/reordering process. She said the pharmacist never said anything about a triplicate issue. The DON verified she had not consulted with the pharmacist about how to prevent narcotic/triplicate medications from running out. During an interview on 6/05/15 at 3:55 p.m. Licensed Vocational Nurse (LVN) M said she called Dr. Z last Monday (6/01/15) and told him the facility was out of Resident #2's MS and hydromorphone and his last dose was at 11 p.m. LVN M said Dr. Z said Resident #2 would have to wait until Tuesday because Dr. Z waited on Resident #2 all day Sunday. She said she did not work on Sunday so she did not know if transportation was available. She said she informed the DON and she believed the DON talked to the Administrator about it, LVN M said Resident #2 never complained of pain to her. She said she did not know how often the facility ran out of Resident #2's medications because the nurses rotated halls. During an interview on 6/05/15 at 5:08 p.m. the Corporate Nurse was informed of the current findings. She said it was a wonder Resident #2 did not go into withdrawal. During an interview on 6/08/15 at 11:55 a.m. Resident #2's mother said they always kept a few hydromorphone back on Resident #2's wheelchair for when his morphine failed. She said when the facility failed to order it she reminded him it was there so the staff took that to use (4/2015). She said even after that they did not reorder the hydromorphone and he ran out again. She said there could not have been more than 6 pills (3 doses) on the wheelchair. The mother said she talked to the Administrator about it who said he talked to Resident #2 and nothing was being done. She said she talked to the Administrator on the day Resident #2 got back from the hospital (6/2/15). She said he was very apologetic and would see that the medications were ordered and then they were not. She said it's just not too much to ask that he get his medications. He's taken narcotics for so long he goes through horrific withdrawals. Resident #25 Review of Resident #25's undated Resident Admission Record documented he was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #25's consolidated Physician order [REDACTED]. - 11/14/14 order for hydrocodone -acetaminophen 10 -325 mg every 6 hours as needed for pain; - 4/14/15 for hydrocodone-acetaminophen 10 - 325 mg hour of sleep (HS); -10/16/14 order for pregabalin 75 mg twice a day (7:00 a.m. and 7:00 p.m.). Review of Resident #25's Pain assessment dated [DATE] documented he had constant, aching, burning, sharp pain and medication and/or repositioning helped relieve the pain. The assessing nurse documented Resident #25's worst pain in the 24 hours prior to the assessment was a 7 out of 10 and the resident's current pain (at the time of the assessment) was 2 of 10. There was no follow up for addressing the pain. Review of Resident #25's 5/19/15 quarterly MDS Assessment documented he scored a 14 of 15 (indicating he was cognitively intact); was independent with his ADL's and was on scheduled pain medications. Review of Resident #25's Nurses Notes documented a note written 4/13/15 called Houston (contract pharmacy) on status of hydrocodone - states a triplicate is needed. Will inform day nurse to call Dr. Z for triplicate and to fax. Review of Resident #25's May 2015 Medication Flowsheet documented: 5/20/15 - 5/22/15 7:00 a.m. and 7:00 p.m. pregabalin 75 mg were initialed and circled as missed. (6 consecutive doses) Review of Resident #25's April 2015 Medication Flowsheet documented Resident #25 had an order for [REDACTED]. A note was written 4/12/15 hydrocodone on order. Review of Resident #25's medication Count Sheets documented he did not have the hydrocodone - acetaminophen 5/12/15 - 5/16/15 (three consecutive missed doses). Review of Resident #25's medication Count Sheets for pregabalin 75 mg documented one narcotic sheet's last date was 5/20/15 (7 a.m.). The next Medication Count Sheet for pregabalin was dated 5/22/15 (7 p.m.). (5 consecutive missed doses) During an interview on 6/11/15 at 9:50 a.m. Resident #25 said he has gone up to three days without his medications. He said the nurses turned in the refill early enough but the pharmacy did not send it in. He said he could not remember the last time that it happened exactly. He said he complained about not getting his medications and his Power of Attorney did too but nothing got done. He said, ain't no use to it, it's the drug company. He said the pharmacy was out of Houston and it got flown into the nearest airport (2 hours away) and then it got loaded up and brought to the facility. Resident #25 said Dr. Z came to the facility every Thursday. RESIDENT #26 Review of Resident #26's Resident Admission Record, undated, documented she was a [AGE] year old female, admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #26's quarterly MDS assessment dated [DATE], revealed her Brief Interview for Mental Status (BIMS) score was 14 (13-15 cognitively intact). Required extensive assistance with bed mobility, transfers, eating, toileting, personal hygiene and bathing. Had one sided limitation of range of motion with the upper and lower extremity. Used a wheelchair for mobility. Was incontinent of bladder and bowel. Indicated no pain in the last five days. Review of Resident #26's consolidated Physician order [REDACTED]. - 03/18/14 hydrocodone-acetaminophen tablet; 10-325 mg; one tablet; orally; twice a day; 9:00 a.m. & 5:00 p.m. Dx (diagnosis) pain. Review of Resident #26's Medications Flowsheet dated 5/01/15 - 5/31/15 revealed the following documentation for the hydrocodone-acetaminophen tablet; 10-325 mg; one tablet, orally, twice a day: - 9:00 a.m. dose had circled initials from 5/23/15 through 5/31/15 (9 doses); (circled initials indicated the medication was not given). - 5:00 p.m. dose was marked through and 1900 (7:00 p.m.) was written beside it. This 7:00 p.m. dose had circled initials from 5/22/15 through 5/31/15 (10 doses). Review of Resident #26's Medication Flowsheet dated 6/01/15 - 6/30/15 revealed the following documentation for the hydrocodone-acetaminophen tablet; 10-325 mg; one tablet, orally, twice a day: - 9:00 a.m. dose had circled initials indicating the medication was not given on 6/01/15, 6/02/15 and 6/03/15 (3 doses); - 5:00 p.m. dose was marked through and 8:00 p.m. was written beside it. This 8:00 p.m. dose had circled initials on 6/01/15 and 6/02/15 (2 doses). Review of Resident #26's medication Count Sheet dated 4/22/15 indicated 60 hydrocodone - acetaminophen tablets were received. The last dose documented as given was 5/22/15 at 7:00 a.m. Review of Resident #26's medication Count Sheet dated 6/03/15 indicated 60 hydrocodone-acetaminophen tablets were received. The first dose was given on 6/03/15 at 7:00 p.m. During an observation and interview on 6/05/15 at 4:12 p.m. Resident #26 was resting on her bed. Resident #26 said when the weather is cold her arm will hurt. During an interview on 6/09/15 at 8:45 a.m. LVN O said if the facility needed a triplicate they called the doctor and had him write one. She said if a narcotic did not come in they were supposed to let the ADON and DON know. She said the last time they ran out of a narcotic it was one of Dr. Z's patients. She said she called Dr. Z, went and got the prescription, took it to the local pharmacy and got it filled. She said it was last week and it was Resident # 26. She said she did not know why the facility ran out of narcotics. She said the medication was hydrocodone - acetaminophen and someone told her they had ordered it and it would be delivered, but it was not. During an interview on 6/11/15 at 9:30 a.m. LVN L said she had worked at the facility for three months. LVN L said there had been problems getting medications from the pharmacy. LVN L said the pharmacy the facility used was in Houston. LVN L said when she would call the pharmacy about a resident's medication she would be put on hold, be told the medication was ordered or that the medication would be delivered that night. LVN L said the next day she would come in and the medication would not be there. LVN L said she had reported this to the DON and Administrator but nothing had changed. LVN L acknowledged Resident #26 was out of her hydrocodone - acetaminophen pain medication 5/22/15 through 6/03/15. RESIDENT #27 Review of Resident #27's undated Resident Admission Record documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #27's consolidated Physician order [REDACTED]. There was an order dated 10/04/14 for Tramadol (a narcotic-like pain reliever used to treat moderate to severe pain) 50 mg three times a day for pain. Review of Resident #27's 5/05/15 quarterly MDS Assessment documented she scored a 5 of 15 (severe cognitive impairment), was independent with ADL's and was on scheduled pain medications. Review of Resident #27's 11/04/14 care plan on increased pain/discomfort documented the goal was to maintain current ADLs (Activities of Daily Living) and pain/discomfort will be controlled within on hour of intervention over next 90 days. Identified approaches included: monitor for signs and symptoms of pain/discomfort - assess resident for possible causes, give meds, tx (treatments), physical and relaxation modalities, etc - assess for relief, assist with ADL's and comfort measures - as appropriate. Allow to verbalize feelings of pain and discomfort. Ibuprofen and Tramadol. Review of Resident #27's 6/01/15 - 6/30/15 Medication Flowsheet documented Resident #27 missed her 6/09/15, 9:00 a.m. and 1:00 p.m. dose of Tramadol. During an interview on 6/09/15 at 9:10 a.m. LVN I said most of the time she did not let her residents run out of medications. She said this lady is out and I need to call the pharmacy. LVN I showed surveyor Resident #27's empty Tramadol medication card. She said when the medication got to the blue box the nurses were supposed to reorder medications by pulling the sticker and putting it on the reorder form. LVN I said when the residents got half way through the blue box she called the pharmacy and they check to see if they got it or not. She said if it did not come in she could call the local pharmacy and get a couple of doses and they would go pick it up. She said everyone was responsible for reordering medications. Any nurse could reorder medications She said the night nurse normally did the reordering. LVN I said some of the staff believed only the night nurses were responsible for ordering medications. During an observation on 6/09/15 at 9:10 a.m. LVN I showed surveyor Resident #27's Tramadol 50 mg three times a day medicine card was empty. LVN I checked the narcotic drawer and there was not an additional card. At that time in an interview LVN I said Resident #27's last dose of Tramadol was last night (6/08/15). LVN I said Resident #27 also had a scheduled dose of ibuprofen at 1:00 p.m. She said if the Ibuprofen was not helping enough she would call the Nurse Practitioner (NP). During an interview on 6/09/15 at 9:20 a.m. the Corporate Nurse (CN) was shown Resident #27's empty card of Tramadol. She acknowledged it was empty and Resident #27 missed a dose that morning. The CN instructed LVN I to get some Tramadol out of the emergency kit and to recheck the reordering sheet. During an interview on 6/09/15 at 9:25 a.m. LVN I returned and said the ADON said narcotics were not in the emergency kit. During a follow-up interview on 6/09/15 at 9:30 a.m. LVN I said a long time ago the emergency kit had a kit with narcotics in it but it was not through this pharmacy provider. During an observation on 6/09/15 at 9:31 a.m. LVN I went to check on Resident #27. Resident #27 was agreeable and chatty. She was sitting in a chair with her feet propped up. LVN I asked Resident #27 if she was in any pain and Resident #27 said no. When LVN I asked Resident #27 if there were any problems whatsoever Resident #27 said her legs hurt. LVN I told Resident #27 she would call the doctor to see if there was anything she could have. LVN I left Resident #27's room and called the ADON for information about the NP's standing orders. LVN I was flipping through the 24 hour report and found the medication reordering sheet dated 6/06/15 with Resident #27's Tramadol on it. During an interview at that time, LVN I said she did not know if

Based on interview, observation and record review, the Administrator and Director of Nurses (DON) failed to ensure the facility was administered in a manner, which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for 8 of 9 residents (Resident #2, #7, #25, #26, #27, #28, #30 and #31) reviewed for medication administration. 1) The Administrator failed to supervise the Director of Nurses to ensure the facility's policy and procedure on pharmacy services was implemented. 2) The Director of Nurses failed to supervise the nursing staff to ensure Residents #2, #25, #26, and #27 received their physician ordered medications to treat pain. 3) The Director of Nurses failed to supervise the availability of pharmacy medications to ensure Resident #7 and #30 had antibiotics available in the emergency pharmacy supply when the initial dose was due. 4) The Director of Nurses failed to supervise the ordering and availability of over-the-counter medications (zinc) for residents who had ordered zinc for supplement or wound healing to include Resident #2, #28, #30, and #31. An Immediate Jeopardy (IJ) was identified on 6/05/15. While the IJ was removed prior to exit on 6/11/15 the facility remained out of compliance at a level of Actual Harm at a Pattern that was not IJ because the facility had not had time to implement and monitor their Plan of Removal for effectiveness. The failure of Administrative Staff to effectively manage the resources of the facility placed 25 residents on a Schedule II narcotic pain medication and 26 residents residents who received Schedule IV pain medication at risk for unrelieved pain, any resident with a new antibiotic, and 12 residents on zinc at risk for delayed wound healing. Findings included: During an interview on 6/5/15 at 12:25 p.m. with the DON and Administrator, the DON said the facility would contact the pharmacy for a refill seven days before the facility ran out. She said the pharmacy would contact the doctor for the triplicate. The DON said the facility had a contract pharmacist through a pharmacy company out of Houston. She said she was not aware of him (pharmacist) looking at the ordering/reordering process. She said the pharmacist never said anything about a triplicate issue. The DON verified she had not consulted with the pharmacist about how to prevent narcotic/triplicate medications from running out. During an interview on 6/07/15 at 1:40 p.m. the DON said there were other issues with the contract pharmacy. She said she had been trying since February to have the pharmacy company come in and teach her how to use their scanner system so she could know which medications were returnable and which needed to be destroyed. She said someone was supposed to come in that week (6/01/15 - 6/05/15) but did not. She said she had told the Administrator and the Corporate Nurse (CN) about it. During an interview on 6/10/15 at 2:45 p.m. the Administrator said the facility had not had a meeting about the pharmacy services as a group, just a discussion between him and the DON. He said he told the DON to put something in place so this did not happen again. During an interview on 6/10/15 at 2:55 p.m. the Corporate Nurse said there was no accountability with the pharmacy. The Pharmacist was only doing paper compliance. This was a total system failure. During an interview on 6/11/15 at 9:30 a.m. LVN L said she had worked at the facility for three months. LVN L said there had been problems getting medications from the pharmacy. LVN L said the pharmacy the facility used was in Houston. LVN L said when she would call the pharmacy about a resident's medication she would be put on hold, be told the medication was ordered or that the medication would be delivered that night. LVN L said the next day she would come in and the medication would not be there. LVN L said she had reported this to the DON and Administrator but nothing had changed. During an interview on 6/05/15 at 3:55 p.m. LVN M said Dr. Z was not in on Mondays. She said she would call on Tuesdays with triplicate requests. She said he would fax it in to the pharmacy and it would be ready that night. She said if the facility would let the pharmacy know by sending in the sticker (on the medication card) then the pharmacy would send the request to him. LVN M said if the facility called and Dr. Z was in town it was quicker to go by and pick up the triplicates because she was not sure if the office staff delivered the messages. She said she knew Dr. Z was in town Tuesday through Thursday and was not sure about Fridays. She said when Dr. Z was unavailable they would go after the partner and if that did not work they could go to the Medical Director. She said the Charge Nurse was responsible for chasing down the doctors. During an interview on 6/05/15 at 4:30 p.m. the Medical Director's Nurse Practitioner (NP) said between the Medical Director and Dr. Z's partner that Dr. Z's patients were covered when Dr. Z was out of town. She said they were supposed to have advanced coverage but the facility had some problems before. She said schedule II medications could only be filled for 30 days and could not be filled early. She said Dr. Z was available Tuesdays, Thursdays, and Fridays so if something happens we're in trouble. She said it gets very difficult. The NP said the only way to handle it was to get the prescription early and get coverage. She said if it was Monday through Friday the Medical Director would write a prescription for a few days if the resident absolutely had to have it. The NP said she had offered to Dr. Z to see his patients and he said absolutely not and no matter what was suggested the answer was always no. During an interview on 6/10/15 at 11:03 a.m. the Corporate Nurse said if a resident missed a dose of medication then the nurse was supposed to circle the missed dose and document the reason why on the back of the medication sheet. During an interview on 6/05/15 at 4:45 p.m. the DON said they called the pharmacist who told them Dr. Z could write a couple of triplicate prescriptions and complete the earliest fill date on it so the pharmacy could fill the pain medication on that specified date, before it ran out. During an interview on 6/11/15 at 10:20 a.m. the Assistant Director of Nurses (ADON) said sometimes the staff would have to argue with the pharmacy if a medication was reordered or not. She said it could be 1 - 2 hours before a pharmacy tech called them back. She said since day one the staff noticed a difference in the pharmacy service. She said they were harder to access, like the narcotics in the emergency kit. Resident #2 Review of Resident #2's face sheet dated 4/13/15, documented Resident #2 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's 14 day Minimum Data Set (MDS) assessment dated [DATE], documented his mental status was 15 of 15 (cognitively intact), needed extensive assistance with all activities of daily living, was on a scheduled and as needed (PRN) pain medication. Resident #2's MDS documented he was in constant pain which interfered with his ability to sleep; Resident #2 rated the pain 5 out of 10. Resident #2's Care Plan dated 6/04/15, documented he received an [MEDICATION NAME] medication (a type of pain reliever). The goals were use pain rating scale of 1 - 10 to identify current level of pain intensity and determine comfort/ functional goal and resident will verbalize adequate pain relief. Interventions included: - Administer meds (medications) and treatments to improve these functions if necessary; - and assess my pain level using the pain scale 1 - 10. Resident #2's Care Plan dated 6/04/15, documented an alteration in comfort: pain due to contractures to hands and being immobile. The goal was Resident/Patient will verbalize adequate pain control. Identified interventions included: - ask resident to rate the pain (0 - 5) if able to verbalize symptoms of pain; - complete a pain assessment if symptoms of pain noted/upon significant change in condition; - medicate PRN with pain medications to control pain; - Administer routine pain medications per MD (medical doctor) order. Notify MD if pain management not effective. Review of Resident #2's History and Physical dated 5/14/15, documented, in part: patient to be evaluated for chronic pain. It began years ago. On a scale of 1 to 10, it is rated a 7 in intensity. Pertinent medical history includes MVA (motor vehicle accident). Patient is a quadriplegic. Review of Resident #2's consolidated April 2015 Physician order [REDACTED]. - 3/27/15 [MEDICATION NAME] (MS) 30 mg (milligram) twice a day; - 3/27/15 [MEDICATION NAME] ([MEDICATION NAME]) 2 mg, 2 tabs = 4 mg every 6 hours PRN During an interview on 6/05/15 at 10:40 a.m. Resident #2 said the first time the facility ran out of the medications he complained and it got fixed. (4/16/15) He said he talked to the Administrator who said he would take care of it. Resident #2 said and then it happened again and he had his mother give them his stash of [MEDICATION NAME] (4/30/15). He said the last time it happened he ran out of the [MEDICATION NAME] and then he ran out of the [MEDICATION NAME] (5/31/15). He said he was sweaty and his stomach was upset, and it was an all around yucky feeling. He said because of the nerve damage he was in pain all the time, constantly and if his pain level was at a 5 he was happy. He said on 5/31/15 it got up to an an 8. Resident #2 said his legs hurt and it felt like someone was standing on his testicles and his hands and toes burned. He said if he missed two doses he started getting a pounding headache like he was waiting for a blood vessel to pop (as he pointed to his head.) He said he never told any of the staff he was in no pain. Resident #2 said the first time the facility ran out of the [MEDICATION NAME] they went to the emergency room in the van and he was up in his wheelchair. He said it started hurting bad and he wanted to lay down. He said the two aides who were with him would not talk to the admission clerk about someplace to lay down. He said he hurt so much they came back to the facility and they gave him an extra dose of the [MEDICATION NAME] and [MEDICATION NAME] (nonsteroidal anti-[MEDICAL CONDITION]) shot. He said he was stressed out about it happening again. He said when it happened again he talked to the Administrator who said he would have a meeting with the Director of Nurses (DON). Resident #2 said the Administrator never got back with him about it. He said when he talked to the Administrator, the Administrator told him don't even think I have an excuse. Review of Resident #2's Nursing Documentation Records documented, in part: - 5/01/15 2300 (11:00 p.m.)- Will inform next nurse to obtain triplicate for [MEDICATION NAME] sulfate on 5/02/15 from doctor at clinic. Resident voices no complaints of pain. - 5/02/15 0900 (9:00 a.m.)- [MEDICATION NAME] triplicate in fax to pharmacy. [MEDICATION NAME] expected to arrive at facility end of shift. Resident without complaint of pain at this time. - 5/02/15 2300- (11:00 p.m.) [MEDICATION NAME] sulfate arrived from (contracted pharmacy). Review of Resident #2's medication Count Sheet dated 3/27/15 for [MEDICATION NAME] ([MEDICATION NAME]) indicated the bottle had 18 tablets. The last dose given was documented 4/16/15 at 11:00 a.m. Review of Resident #2's next medication Count Sheet dated 4/21/15 (five days after the last count sheet) for PRN [MEDICATION NAME] indicated 10 tablets were received. Dose was given on 4/21/15 at 12:50 p.m. The last dose was documented 4/26/15 at 3:55 a.m. (Resident #2 went 4/16/15 - 4/21/15 without his PRN [MEDICATION NAME] available.) Review of Resident #2's medication Count Sheets dated 3/27/15 for [MEDICATION NAME] 30 mg. indicated bottle #1 had 46 pills and bottle #2 had 21 pills. The last dose of [MEDICATION NAME] 30 mg. was documented on 4/30/15 at 7:00 a.m. Review of Resident #2's medication Count Sheet dated 5/02/15 indicated 60 [MEDICATION NAME] tablets were received. The first dose was given on 5/02/15 at 7:00 p.m. (Resident #2 missed four (4) doses of his [MEDICATION NAME]. The time between the scheduled doses was 48 hours.) Review of Resident #2's Nursing Documentation Records documented, in part: - 5/28/15 New Order send to Dr. Z office on Sunday (5/31/15). - 6/01/15 1400 (2:00 p.m.) Resident out of MS and [MEDICATION NAME]. Dr. Z called and message left for triplicate to be written so meds could be ordered. Last dose [MEDICATION NAME] 5/31/15 at 2300. (11:00 p.m.) - 6/01/15 1450 (2:50 p.m.) called Dr. Z for triplicate prescription. Advised he was completely out of MS at this time and [MEDICATION NAME]. Dr. Z said he could come in AM. Asked what he wanted us to give him for pain management at this time - advised him resident was very upset and waiting to go to his office for his shot to his shoulder. Dr. Z replied that he had waited for him on Sunday (5/31/15) at his office and would see him tomorrow. Administration advised. - 6/01/15 2010 (8:10 p.m.) CNA (Certified Nurse Aide) notified this nurse Resident wanted to speak with her. Resident upset, shaking, started yelling. Stated I am really upset because I have not gotten my [MEDICATION NAME] and [MEDICATION NAME]. I've been out for two days and I'm hurting. I want to go to ER now! (Local) Pharmacy called. Dr. Z called, got new order to send to ER as indicated. 2035 (8:35 p.m.) ER took resident at 2045 (8:45 p.m.) Resident admitted to local hospital with [DIAGNOSES REDACTED]. (Autonomic Dysreflexia (AD), also known as Hyperreflexia, is a potentially dangerous complication of spinal cord injury (SCI). In AD, an individual's blood pressure may rise to dangerous levels and if not treated can lead to stroke and possibly death. Individuals with SCI at the T-6 level or above are at greater risk. AD usually occurs because of a noxious (irritating) stimulus below the level of the injury. Symptoms include headache, facial flush, perspiration, and a stuffy nose.- From http://www.spinalcord.org/resource-center/askus/index.php?pg=kb.page&id=248) - 6/02/15 Pain Management: (dashes) (no time) Resident readmitted to facility to room. No new orders. Resident alert and oriented times three. No complaints at this time. Scripts (prescriptions) in and faxed to pharmacy. No complaints of pain at this time. Review of Resident #2's Prehospital Patient Care Report, undated (Emergency Medical Services report): En Route: 2036 (8:36 p.m.) Hospital: 2058 (8:58 p.m.) Chief Complaint: pain all over. Signs and Symptoms: pain to extremities, back, total body. Pain Scale: 5 Review of Resident #2's Emergency Department notes dated 6/01/15, documented, in part: Arrival: 21:00 (9:00 p.m.) - Chief Complaint: pain all over. Nursing home ran out of [MEDICATION NAME] and [MEDICATION NAME] XR. History of Present Illness. Chief Complaint: Abdominal Pain and diffuse pain. At its maximum, severity described as severe. When seen in the E.D. (emergency department) severity described as severe. It is described as sharp, stabbing and cramping. This started today. Pt (patient) states nursing home ran out of his pain meds and is still present. Clinical Impression: Acute generalized abdominal pain. Acute abdominal pain. Autonomic Dysreflexia. Medications given in the Emergency Department: 2132 (11:32 p.m.) [MEDICATION NAME] ER (extended release) 30 mg, 21:33 (11:33 p.m.) [MEDICATION NAME] 0.2 mg 21:40 (11:40 p.m.) [MEDICATION NAME] 50 mg. Review of Resident #2's Hospital Discharge Summary dated 6/02/15, documented, in part: Admission Diagnoses: [REDACTED]. Hospital Course He was given pain medication and has done well. No major complaints. Plan: Usual home medications including [MEDICATION NAME]. Review of Resident #2's 6/01/15 - 6/02/15 Hospital Medication Administration Record [REDACTED] - 6/02/15 [MEDICATION NAME] mg at 9:04 a.m. discharged from the hospital on [DATE] at 15:20 (3:20 p.m.) per the hospital nurse's notes. Review of Resident #2's Medication Flowsheet dated 6/01/15 - 6/03/15 revealed the following documentation for the [MEDICATION NAME] sulfate 30 mg BID: - 6/01/15 7:00 a.m./p.m. (2 doses circled as missed) - 6/02/15 7:00 p.m. (1 dose circled as missed). - 6/03/15 7:00 a.m. dose was initialed as given. (Narcotic sheet documented the dose was given at 11:00 a.m.) Review of Resident #2's medication Count Sheet dated 5/02/15 indicated 60 [MEDICATION NAME] tablets were received. The last dose of [MEDICATION NAME] 30 mg. was documented on 5/31/15 at 8:00 p.m. (Resident #2 arrived at the hospital 6/01/15 at 9:00 p.m., 14 hours after his scheduled [MEDICATION NAME] pain medication was ordered to be given and had run out. Resident #2 left the hospital on [DATE] at 3:20 p.m.) Review of Resident #2's medication Count Sheet dated 6/03/15 indicated 60 [MEDICATION NAME] tablets were received. The first dose was given on 6/03/15 at 11:00 a.m., (16 hours after it was scheduled). Review of Resident #2's medication Count Sheet dated 4/27/15 for [MEDICATION NAME] indicated 30 tablets were received. The last dose was documented 5/31/15 at 11:00 p.m. (Resident #2 arrived at the hospital 6/01/15 at 9:00 p.m., 16 hours after he could have received his as needed [MEDICATION NAME] pain medication but he had run out. Resident #2 left the hospital on [DATE] at 3:20 p.m.) Review of Resident #2's medication Count Sheet dated 6/03/15 for [MEDICATION NAME] indicated 100 tablets were received. The first as needed dose was given on 6/03/15 at 11:00 a.m., (14 hours after Resident #2 returned from the hospital.) Review of the Grievance Log documented on 6/03/15 Resident #2 had a concern about the staff reordering his pain medication. The resolution was nursing needs to re-order medication within a week of resident running out of medication. During an interview on 6/05/15 at 3:55 p.m. Licensed Vocational Nurse (LVN) M said she called Dr. Z last Monday (6/01/15) and told him the facility was out of Resident #2's MS and [MEDICATION NAME] and his last dose was at 11 p.m. LVN M said Dr. Z said Resident #2 would have to wait until Tuesday because Dr. Z waited on Resident #2 all day Sunday. She said she did not work on Sunday so she did not know if transportation was available. She said she informed the DON and she believed the DON talked to the Administrator about it, LVN M said Resident #2 never complained of pain to her. She said she did not know how often the facility ran out of Resident #2's medications because the nurses rotated halls. During an interview on 6/05/15 at 5:08 p.m. the Corporate Nurse was informed of the current findings. She said it was a wonder Resident #2 did not go into withdrawal. During an interview on 6/08/15 at 11:55 a.m. Resident #2's mother said she talked to the Administrator on the day Resident #2 got back from the hospital (6/2/15). She said he told her he would see that the medications were ordered and then they were not. She said it's just not too much to ask that he get his medications. He's taken narcotics for so long he goes through horrific withdrawals. Resident #25 Review of Resident #25's undated Resident Admission Record documented he was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #25's consolidated Physician order [REDACTED]. - 11/14/14 order for [MEDICATION NAME] -[MEDICATION NAME] 10 -325 mg every 6 hours as needed for pain; - 4/14/15 for [MEDICATION NAME]-[MEDICATION NAME] 10 - 325 mg hour of sleep (HS); -10/16/14 order for pregabalin 75 mg twice a day (7:00 a.m. and 7:00 p.m.). Review of Resident #25's Pain assessment dated [DATE] documented he had constant, aching, burning, sharp pain and medication and/or repositioning helped relieve the pain. The assessing nurse documented Resident #25's worst pain in the 24 hours prior to the assessment was a 7 out of 10 and the resident's current pain (at the time of the assessment) was 2 of 10. There was no follow up for addressing the pain. Review of Resident #25's Nurses Notes documented a note written 4/13/15 called Houston (contract pharmacy) on status of [MEDICATION NAME] - states a triplicate is needed. Will inform day nurse to call Dr. Z for triplicate and to fax. Review of Resident #25's May 2015 Medication Flowsheet documented: 5/20/15 - 5/22/15 7:00 a.m. and 7:00 p.m. pregabalin 75 mg were initialed and circled as missed. (6 consecutive doses) Review of Resident #25's April 2015 Medication Flowsheet documented Resident #25 had an order for [REDACTED]. A note was written 4/12/15 [MEDICATION NAME] on order. Review of Resident #25's medication Count Sheets documented he did not have the [MEDICATION NAME] - [MEDICATION NAME] 5/12/15 - 5/16/15 (three consecutive missed doses). Review of Resident #25's medication Count Sheets for pregabalin 75 mg documented one medication Count Sheet's last date was 5/20/15 (7 a.m.). The next medication Count Sheet for pregabalin was dated 5/22/15 (7 p.m.). (5 consecutive missed doses) During an interview on 6/11/15 at 9:50 a.m. Resident #25 said he has gone up to three days without his medications. He said the nurses turned in the refill early enough but the pharmacy did not send it in. He said he could not remember the last time that it happened exactly. He said he complained about not getting his medications and his Power of Attorney did too but nothing got done. He said, ain't no use to it, it's the drug company. He said the pharmacy was out of Houston and it got flown into the nearest airport (2 hours away) and then it got loaded up and brought to the facility. Resident #25 said Dr. Z came every Thursday. RESIDENT #26 Review of Resident #26's Resident Admission Record, undated, documented she was a [AGE] year old female, admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #26's consolidated Physician order [REDACTED]. - 03/18/14 [MEDICATION NAME]-[MEDICATION NAME] tablet; 10-325 mg; one tablet; orally; twice a day; 9:00 a.m. & 5:00 p.m. Dx (diagnosis) pain. Review of Resident #26's Medications Flowsheet dated 5/01/15 - 5/31/15 revealed the following documentation for the [MEDICATION NAME]-[MEDICATION NAME] tablet; 10-325 mg; one tablet, orally, twice a day: - 9:00 a.m. dose had circled initials from 5/23/15 through 5/31/15 (9 doses); (circled initials indicated the medication was not given). - 5:00 p.m. dose was marked through and 1900 (7:00 p.m.) was written beside it. This 7:00 p.m. dose had circled initials from 5/22/15 through 5/31/15 (10 doses). Review of Resident #26's Medication Flowsheet dated 6/01/15 - 6/30/15 revealed the following documentation for the [MEDICATION NAME]-[MEDICATION NAME] tablet; 10-325 mg; one tablet, orally, twice a day: - 9:00 a.m. dose had circled initials on 6/01/15, 6/02/15 and 6/03/15 (3 doses); - 5:00 p.m. dose was marked through and 8:00 p.m. was written beside it. This 8:00 p.m. dose had circled initials on 6/01/15 and 6/02/15 (2 doses). Review of Resident #26's medication Count Sheet dated 4/22/15 indicated 60 [MEDICATION NAME] - [MEDICATION NAME] tablets were received. The last dose documented as given was 5/22/15 at 7:00 a.m. Review of Resident #26's medication Count Sheet dated 6/03/15 indicated 60 [MEDICATION NAME]-[MEDICATION NAME] tablets were received. The first dose was given on 6/03/15 at 7:00 p.m. During an interview on 6/05/15 at 4:12 p.m. Resident #26 said when the weather is cold her arm will hurt. During an interview on 6/09/15 at 8:45 a.m. LVN O said if the facility needed a triplicate they called the doctor and had him write one. She said if a narcotic did not come in they were supposed to let the Assistant Director of Nurses (ADON) and DON know. She said the last time they ran out of a narcotic it was one of Dr. Z's patients. She said she called Dr. Z, went and got the prescription, took it to the local pharmacy and got it filled. She said it was last week and it was Resident #26. She said she did not know why the facility ran out of narcotics. She said the medication was [MEDICATION NAME] - [MEDICATION NAME] and someone told her they had ordered it and it would be delivered, but it was not. During an interview on 6/11/15 at 9:30 a.m. LVN L acknowledged Resident #26 was out of her [MEDICATION NAME] - [MEDICATION NAME] pain medication 5/22/15 through 6/03/15. RESIDENT #27 Review of Resident #27's undated Resident Admission Record documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #27's consolidated Physician order [REDACTED]. There was an order dated 10/04/14 for [MEDICATION NAME] (a narcotic-like pain reliever used to treat moderate to severe pain) 50 mg three times a day for pain. Review of Resident #27's 6/01/15 - 6/30/15 Medication Flowsheet documented Resident #27 missed her 6/09/15, 9:00 a.m. and 1:00 p.m. dose of [MEDICATION NAME]. During an interview on 6/09/15 at 9:10 a.m. LVN I said most of the time she did not let her residents run out of medications. She said this lady is out and I need to call the pharmacy. LVN I showed surveyor Resident #27's empty [MEDICATION NAME] medication card. She said when the medication got to the blue box the nurses were supposed to reorder medications by pulling the sticker and putting it on the reorder form. LVN I said when the residents got half way through the blue box she called the pharmacy and they check to see if they got it or not. She said if it did not come in she could call the local pharmacy and get a couple of doses and they would go pick it up. She said everyone was responsible for reordering medications. Any nurse could reorder medications She said the night nurse normally did the reordering. LVN I said some of the staff believed only the night nurses were responsible for ordering medications. During an observation and interview on 6/09/15 at 9:10 a.m. LVN I showed surveyor Resident #27's [MEDICATION NAME] 50 mg three times a day medicine card was empty. LVN I checked the narcotic drawer and there was not an additional card. LVN I said Resident #27's last dose of [MEDICATION NAME] was last night (6/08/15). LVN I said Resident #27 also had a scheduled dose of [MEDICATION NAME] at 1:00 p.m. She said if the [MEDICATION NAME] was not helping enough she would call the Nurse Practitioner (NP). During an interview on 6/09/15 at 9:20 a.m. the Corporate Nurse was shown Resident #27's empty card of [MEDICATION NAME]. She acknowledged it was empty and Resident #27 missed a dose that morning. The Corporate Nurse instructed LVN I to get some [MEDICATION NAME] out of the emergency kit and to recheck the reordering sheet. During an interview on 6/09/15 at 9:25 a.m. LVN I returned and said the ADON said narcotics were not in the emergency kit. During a follow-up interview on 6/09/15 at 9:30 a.m. LVN I said a long time ago the emergency kit had a kit with narcotics in it but it was not through this pharmacy provider. During an observation on 6/09/15 at 9:31 a.m. LVN I went to check on Resident #27. Resident #27 was agreeable and chatty. She was sitting in a chair with her feet propped up. LVN I asked Resident #27 if she was in any pain and Resident #27 said no. When LVN I asked Resident #27 if there were any problems whatsoever Resident #27 said her legs hurt. LVN I told Resident #27 she would call the doctor to see if there was anything she could have. LVN I left Resident #27's room and called the ADON for information about the NP's standing orders. LVN I was flipping through the 24 hour report and found the medication reordering sheet dated 6/06/15 with Resident #27's [MEDICATION NAME] on it. During an interview at that time, LVN I said she did not know if the 6/06/15 pharmacy reordering sheet was faxed or not. During an interview on 6/09/15 at 9:40 a.m. the Corporate Nurse said there was no [MEDICATION NAME] in the emergency kit and she was unaware of that. During an interview on 6/09/15 at 5:30 p.m. LVN I informed surveyor Resident #27 got her 1:00 p.m. dose of [MEDICATION NAME]. She said they had the NP call in a prescription to the local pharmacy and went and picked her up 6 tablets (two days worth). During an interview on 6/04/15 at 2:55 p.m. the ADON said residents had scheduled and as needed medications. She said the scheduled pain medications were documented on the back of the MAR (medication administration record) if it was effective for pain relief. She said residents were assessed for pain on admission, quarterly, and with a change of condition. She said there were different scales for residents who were cognitively intact and cognitively impaired. She said indicators for residents who were cognitively impaired included grimacing and moaning - it was all on the FACES scale (pain management scale developed for children often used with cognitively impaired residents). She said the staff had been in-serviced on assessing for pain assessments but she did not remember when the last one was. ANTIBIOTIC (Deficient practice found after the IJ was identified) Resident #7 Review of Resident #7's undated Resident Admission Record documented Resident #7 was a [AGE] year old female admitted to the facility 11/17/06 with [DIAGNOSES REDACTED]. Review of the NP visit note dated 6/05/15 documented, in part: - Assessment: unspecified [MEDICAL CONDITION]. - Orders: [MEDICATION NAME] (generic for Keflex) 500 mg capsules 1 tablet by mouth every 8 hours for 10 days, thirty capsules. Review of Resident #7's Physician Telephone Orders dated 6/05/15 documented an order for [REDACTED]. Review of the 6/05/15 Progress Notes completed by the nurses documented: - 6/05/15 at 10:00 a.m. Resident seen by NP, refused to have her right hand touched. NP states I'll put her on an antibiotic. - 6/06/15 6:00 a.m. - 6:00 p.m. Keflex not started today due to not here and not any in the emergency kit, hand continues with foul smell, cleaned daily but resident does not let staff open it very much due to discomfort, treatment being done daily. - 6/07/15 1300 (1:00 p.m.) ID (initial dose) of Keflex 500 mg given at this time. Change order as follow DC Keflex 500 mg by mouth every 8 hours for 10 days on 6/05/15. Start Keflex 500 mg by mouth every 8 hours for 10 days on 6/07/15. Per NP. Attempt four times to call Houston (contract pharmacy) no response to change order of Keflex. Review of Resident #7's Physician Telephone Orders dated 6/07/15 documented an order to DC (discontinue) Keflex 500 mg every 8 hours for 10 days on 6/05/15. Start Keflex 500 mg every 8 hours for 10 days on 6/07/15. Resident #30 Review of Resident #30's undated Resident Admission Record documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review

Based on interview and record review the facility failed to ensure that two of two nurses implemented the policy and procedures that prohibit neglect for 1 of 5 residents (Resident #1) reviewed for neglect: Licensed Vocational Nurse (LVN) A and LVN B did not call emergency services timely after noting Resident #1 had abnormal responses to the neuro-checks after a fall ( vomiting, increased help with transferring, pupils "sluggish", decreased level of consciousness, no grip, decreased responsiveness). These failures placed 65 residents on [DATE] who resided on the non-secured portion of the facility at risk of not receiving care and services, delay in treatment, complications, hospitalization , or death. Findings Include: RESIDENT #1 Review of Resident #1's [DATE] Face Sheet documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the [DATE] Nurse Practitioner Notes documented an additional [DIAGNOSES REDACTED]. Review of Resident #1's [DATE] quarterly MDS assessment documented she had a mental status score of 3 of 15 (indicating severe cognitive impairment) and was independent with all activities of daily living. Resident #1 was continent. Resident #1 was on anti-coagulant medication (medication used to thin the blood) 7 of 7 days prior to the assessment. Review of the Nurse's Notes documented, in part: - [DATE] at 8:00 a.m. Resident "sitting on the floor in room near sink, floor dry and free of clutter wearing only one sock, wash cloth in hand, not wearing her glasses or hearing aide, stated she was going to wash up her hand and had lost her step and missed grabbing on to the sink. Vital Signs taken, resident able to move all extremities assisted off the floor and onto recliner, resident upset stating she does not understand why she fell if she was only washing up, resident family and doctor called and notified of fall, voiced understanding, neuro checks initiated. Resident encouraged to use quad-cane with ambulation, to wear glasses at all times." - [DATE] at 4:30 p.m. "During shower resident complained of being sad states 'feels like I'm going to die!' Nurse Practitioner called for Doctor and message left." - [DATE] at 12:45 p.m. CNA (Certified Nurse Aide) heard resident call "help." Assessed resident on floor beside bed laying on side, noticed floor rug beside bed, noted wet floor beside the floor rug. Resident has no shoes, no socks. Assessed for injuries none found, states she was getting back in bed. Neuro's restarted. -[DATE] at 8:30 p.m. Resident on floor next to bed wearing only underclothes and pants, no shoes, no socks crying out, states her back is hurting her. Vital signs taken and assessed, able to move all extremities, assisted off the floor and to the bed, assisted out of pants refused gown, when asked what had happened she states she got up from the recliner and was going to walk to the bed but her pain was too great so she fell to the floor. Resident medicated with as needed medication, family called and notified of incident, voiced understanding, doctor notified, no new orders at this time, neuro checks initiated. - Review of Resident #1's [DATE] - [DATE] Neurological Assessment Form (Neuro-checks) documented all vital signs, pupils, motor functions, level of consciousness, and pain response were normal. - [DATE] 5:30 a.m. CNA notified this nurse resident was on floor. Resident on floor in left lateral position wearing own gown. Vitals taken. Resident sat up x3 assist while laying in left lateral position and while checking blood pressure, resident had projectile vomiting, brownish in color, no odor of bowel movement, no injuries noted. Resident pupil sluggish (right), notified Nurse Practitioner no new orders at this time, will have next shift nurse notify power of attorney. No more vomiting noted at this time. (by LVN A) - LATE ENTRY [DATE] for 5:40 a.m. Resident was on floor between both beds, head of resident on roommate's mat. Resident laying in left lateral position. Resident shaky, x3 assist up. Resident held onto my hand with her hand and Resident's gown on left had vomit brownish in color. Resident had own gown and non-skid socks on. Resident's feet were facing her side of bed. When CNA, other nurse and this nurse put her in bed, CNA noticed vomit on bedspread. Bedspread changed and there was also vomit on right side of cushion to wheelchair, against wall by foot of resident's bed. Neuro's started. (by LVN A) - Review of Resident #1's Neurological Assessment Flowsheet documented on [DATE] at 5:30 a.m., 5:45 a.m., and 6 a.m. documented her right pupil was sluggish (her left pupil was normal); her level of consciousness was "stuporous"; and her conversation was "confused". (by LVN A) -[DATE] 6:20 a.m. Resting with eyes closed, lying on left side in bed. Unable to wake resident. Moans in response to vigorous stimuli. Right pupil sluggish with little response - no grips. When eyelid lifted to check for response, resident swatted at my hand listlessly. Doesn't open eyes. Resident repositioned and back rubbed noted some faint red bruising x2 to outer lateral area of right back. No vomiting noted - noted some dry emesis in her hair. Attempted to clean. No response from resident. Doctor to be here for rounds. Will continue to monitor. Resident moving arms and legs at random - small amounts. (by LVN B) -[DATE] 6:40 a.m. During pupil checks no response from resident. Resident repositioned with slight moan in response - very little extremity movement per resident. Doctor called message left to send resident out for further evaluation. Ambulance called and report given. Hospital called and report given. (by LVN B) - Review of Resident #1's [DATE] Neurological Assessment Flow Sheet documented at 6:15 a.m. and 6:45 a.m. documented both pupils were "sluggish"; resident was unable to follow commands with hand grips; there were "random uncoordinated movements" in her extremities; her level of consciousness was "stuporous"; Resident #1's best verbal response was "incomprehensible", and her best response to pain was "moans with stimuli." (by LVN B) - [DATE] (no time documented) Resident sent out via EMS (emergency medical services) with back board and neck brace in place. Pulse difficult to assess - faint. No random movement with extremities. Pupils sluggish. Respirations increased labored breathing, pursed breathing after EMS arrived. (by LVN B) Review of Resident #1's [DATE] - [DATE] Physician order [REDACTED]. Review of the Physician Telephone Orders documented an order on [DATE] for an x-ray to the upper and lower back and the pelvic area due to a fall. Review of the [DATE] Chest, Abdomen and Pelvic CT scan documented the resident had prominent osteopenia but no fractures. It also documented "there is a large mass like structure in the lateral right breast measuring over 3 cm (centimeters) with overlying skin thickening, also right axillary adenopathy worrisome for right breast [MEDICAL CONDITION] (cancer) with metastic adenopathy." Review of Resident's #1's [DATE] Care plan documented Resident #1 had a fall on [DATE] due to cognitive impairment. The goal was resident will be "free from injury or trauma." The identified approaches were: encourage resident to ask for help from staff as needed; ensure call light is within reach, answer promptly; anticipate needs of resident; and assure lighting is adequate and areas are clear of clutter. Review of Resident #1's Hospital Records documented, in part: [DATE] Ambulance Report: Dispatched 7:28 a.m. Enroute: 7:30 a.m. Ambulance on Location: 07:33 a.m. Patient Contact: 07:35 a.m. Depart Location: 8:02 a.m. Arrive at Hospital: 8:08 a.m. In-Service: 8:32 a.m. [DATE] Physician order [REDACTED]. Consult Hospice for possible placement in the morning. [DATE] Emergency Department Notes: 8:12 a.m. Facility Staff states that patient had an unwitnessed fall from bed at approximately 5:30 am. on [DATE]. Facility Staff is unsure if loss of consciousness occurred, but states patient vomited after fall. Facility staff states that patient has an altered level of consciousness and only responds to painful stimuli. Patient is normally able to walk with cane. Narrative: 8:12 a.m. Patient arrived to ER by ambulance on stretcher. Patient has C-collar and back board in place. Patient is obtuneded and has snoring respirations. Patient alert and oriented x 0, and is responsive only to painful stimuli. Pupils constricted. Patient taken to ER Bed via stretcher [DATE] History and Physical (Resident #1 was seen by the same doctor in the hospital as in the nursing home) Chief Complaint: Confusion post fall. History of Present Illness: The patient is a [AGE] year-old female that came in from the nursing home status [REDACTED]. She had 1 episode of vomiting. The fall was unwitnessed, and she was lying next to her bed. Assessment: 1. Intracranial intraparenchymal hemorrhage (bleeding within the brain) 2. Subdural hemorrhage. 3. History of [MEDICAL CONDITION] on anticoagulation. [DATE] Discharge Summary (Resident #1 was seen by the same doctor in the hospital as in the nursing home): Discharge Diagnosis: [REDACTED]. I am not certain if the patient had had a blood pressure which caused the intracrainial hemorrhage leading to a fall or it was the other way around. Hospital Course: The patient is a [AGE] year old female that was brought into the ER (emergency room ) from the nursing home status [REDACTED]. Her condition worsened after being admitted . Her INR ( international normalized ratio - lab value used to determine the clotting tendency of blood) was extremely elevated. This was brought down using vitamin K and FFP (fresh frozen plasma). Nonetheless, she never really improved. I did have extensive discussions with her daughter who lives out of town about further resuscitation. With the patient's age and poor status we decided to hold off on any heroic measures trying to make this patient feel any better. The patient was then transferred to Hospice care and slowly she got worse and did not get any better. She stopped breathing and was declared deceased this morning ([DATE]). During an interview on [DATE] at 3:10 p.m. the Assistant Director of Nurses (ADON) said she was unaware if the facility had a policy and procedure on Neuro-checks and Emergency Procedures. She said the doctor relied on the nurses to use "nursing judgement" and if the nurse believed the resident needed to be sent out to send them out as long as the staff let the doctor know why and when they were sent out. She said the facility was to report neuro checks results when there was any kind of changes, the staff were to check if the eyes were dilated; if the resident was talking and then not; not moving; the blood pressure increases and then falls; hand grips and if equal. The ADON read Resident #1's [DATE] 5:30 a.m. nurse's notes and said three people to assist Resident #1 up was not normal. She then read the [DATE] 6:20 a.m. and 6:40 a.m. nurse's notes. She said when the nurse noticed the eyes were sluggish, she notified the nurse practitioner. The ADON said "I would have sent her out at 6:20 a.m. She was not responsive, she should have been sent out then." During an interview on [DATE] at 3:25 p.m. LVN B confirmed she was the day-time nurse for Resident #1 on [DATE]. LVN B described Resident #1 as "up walking around, hard of hearing, always had her hearing aids on, always had on her glasses, had dentures, always well dressed, and always carried her purse with her." LVN B said before [DATE] Resident #1 had some falls. She said Resident #1 was declining in the few weeks before the fall, she was beginning to use the four-pronged cane. During the same 3:25 p.m. interview, LVN B said on [DATE] Resident #1 had a fall the previous shift and that shift started neuro-checks. She said LVN A told her LVN A did not like the way Resident #1 looked. She said the night shift told her they did not know if she fell because she was getting up to vomit or if she had slipped in the vomit. She said at shift change LVN B told LVN A she would send Resident #1 out to the emergency room . During the same 3:25 p.m. interview LVN B said when she checked Resident #1 she (LVN B) did not like the way Resident #1 looked. She said she did not remember when she called 911 but thought it was shortly after shift change. She said they came fairly quickly. She said she began charting on Resident #1 at 6:20 a.m. She said if she charted that she called 911 at 6:40 a.m. it was probably 7 a.m. when EMS left. In the same 3:25 p.m. interview, LVN B also said the staff had to call the doctor or the nurse practitioner before they send any resident out. LVN B acknowledged the findings to Resident #1's neuro-checks were abnormal. She said it was not usual for Resident #1 to need three people to assist her to get up She said she would call the nurse practitioner and let her know but she was going to send her out. LVN B said she did not know why she did not send Resident #1 out at 6:20 a.m. she said she was in the process of doing paperwork, calling the Nurse Practitioner and getting the paperwork together (copy of the Medication Administration Record [REDACTED]. During an interview on [DATE] at 11:00 a.m. the Director of Nurses (DON) said when a resident fell she expected the staff to start neuro checks depending on the neuro-checks the nurse would send out the resident if they needed to. She said a nurse should be in the room the entire time to monitor the resident. During a follow up interview on [DATE] at 11:20 a.m. the DON said if a resident fell and vomited, the neuro checks would determine if the resident went to the hospital. The DON was informed of the [DATE] nurse's notes and said Resident #1 "should have gone out". The DON said her working definition of neglect was the resident not being taken care of. When asked if the resident's needs were taken care of on [DATE] she said "I would have called (911) immediately." She said when she reviewed the record for the facility incident reporting she did not notice the delay in calling the ambulance. Surveyor attempted to contact Resident #1's physician on [DATE] at noon and left a message at his office. The physician was seeing patients and could not respond to the call. During an interview on [DATE] at 2:20 p.m. the Nurse Practitioner said Resident #1 had several falls. She said when she heard the state agency was in the building she checked her text messages and saw where they notified her that they shipped Resident #1 out. She said usually the facility was very good about calling her and notifying her of changes. She said she did not remember getting a call from the facility at 5:30 a.m. because if they told her Resident #1 was vomiting she would send them out. She said she thought she would remember getting that call. She said on [DATE] the ADON asked her if the staff called and she said no, but when she double checked the phone someone had texted her. She said the facility would text because if she was with a patient she would not be able to respond. The Nurse Practitioner said she received the text at 1:14 in the afternoon (on [DATE]). During the same interview the Nurse Practitioner was informed Resident #1 fell at 5:30 a.m. and the ambulance was not called until 7:28 a.m. She said she did not know if the two hours would make a difference or not. She said Resident #1 had had multiple falls. The Nurse Practitioner said one time Resident #1 had a fall and was sent to the emergency room , but the emergency room did not do a CT scan ([DATE]). (Records indicate x-rays were taken or Resident #1's back and pelvis.) She said the doctor was not happy. She said the next fall ([DATE]) was when the doctor did a CT scan and found the bleed. She said he could not determine if it happened that day ([DATE]) or from the previous fall ([DATE]). The nurse practitioner said she did not know if it would have made a difference or not because Resident #1 had been on [MEDICATION NAME] "forever" and the last month of her life she had "given up." During an interview on [DATE] at 2:45 p.m. LVN A confirmed she was the nurse on duty on [DATE] at 5:30 a.m. She described Resident #1 as coming to the nurse's station to get batteries for her hearing aide, always wore rings, walked up and down the hallways always dressed up. She said at the end Resident #1 complained of back pain so they would have to sit her up in the recliner. She said at the end she began using a wheelchair at night when she never used the wheelchair before. During the same interview, LVN A said there was nothing unusual about Resident #1 the night before the fall, she would come out of her room and sit outside of the door and just watch staff doing their job. She said they called her early morning on [DATE] while she was on the secured unit, and told her there was a resident on the floor. She said when she entered the room a CNA was with her as well as the other nurse. She said when she asked what happened, the CNA explained she went into the room to change the roommate and found Resident #1 on the floor. She said when she walked into the room, they got Resident #1's blood pressure, checked her pupils, and saw if she could hold hands. LVN B said she remembered Resident #1's blood pressure as ok but one of her pupils was "a little sluggish." LVN B said Resident #1 was "kind of moaning at us" when they were moving her, but LVN B thought it was Resident #1's back hurting. LVN B said Resident #1 was just looking at her, not really talking or seeing her. LVN B said Resident #1 did not look like she hit her head, there was no bruising, no hematoma, and no bleeding. LVN B said Resident #1 was able to hold onto her hands when she got up that morning and was "kind of" responsive when she tried to talk to Resident #1. She said the staff picked her up and looked at her face and there was nothing there (no blood, bruising, or other obvious sign of trauma). She said when they sat her up to make the bed it looked like she vomited on the side of the bed. She said the CNA reported there was some vomit on the side of the wheelchair so maybe she was getting up to go to the bathroom. She said she stayed with Resident #1 to do the neuro-checks and when she came out of the room the next shift was there. She said she notified the on-coming nurse (LVN B) to try and get a hold of the Nurse Practitioner. LVN A said she tried texting her but did not get a response. LVN A said "she does not like for us to call." LVN A said usually the Nurse Practitioner responded within 10 - 15 minutes, but by that time the next shift was already in the building. At this time LVN A showed surveyor a text that went out [DATE] at 6:07 a.m. that reported resident did not have any injuries but did have "projectile vomiting" that was brownish in color, resident was pale in color, and that resident responded to painful stimuli. The text said she was leaving for the day so to call the facility if there were any new orders. There was no response from the Nurse Practitioner. During the same 2:45 p.m. interview LVN A said the point to neuro-checks was to know if the resident had altered mental status. She said "I believe she had an altered mental status" and she called to see if she could send Resident #1 out but the next shift was already here. LVN A said the on-coming nurse (LVN B) said she would try to contact the nurse practitioner. She said Resident #1's doctor was supposed to be in at 6 a.m. to do rounds at the facility and the on-coming nurse would let him know as soon as he came in. During the same interview LVN B said she did not call 911 because she was trying to get a hold of the Nurse Practitioner because there were times when the nurse's had gotten in trouble for sending residents to the emergency room prior. During a follow-up interview on [DATE] at 3:30 p.m. the Nurse Practitioner called and said she had talked to Resident #1's doctor. She said he did not think the two hours made a difference. The Nurse Practitioner explained if it was a quick bleed Resident #1 would have died that day. She explained since Resident #1 held on for another four days, the doctor thought it was a slow bleed which was why he was not sure if the bleed was a result of the [DATE] fall or the [DATE] fall. During an interview on [DATE] at 4:10 p.m. the Administrator said in a critical emergency situation he expected his nursing staff to call 911, then notify the doctor, the family, the DON, and the Administrator. He defined critical as finding the resident with an injury, "evident" head trauma with blood present, if the resident was unresponsive. He said staff communicated with the doctor or Nurse Practitioner by phone or by text. He said they would call and if the call went to voice mail they would text. He described Resident #1 as "pleasant, didn't talk much, was slow moving." He said she walked with a quad cane, and was independent with her activities of daily living. He was read the [DATE] 5:30 a.m. entry where LVN A documented Resident #1 needed three staff to get her up. He acknowledged that was a change in condition. He was read the [DATE] 6:20 a.m. entry where the resident had sluggish pupils with little response and no grips. He acknowledged that was a change in condition. He was read the 6:40 a.m. entry where the resident's pupils had no response. He acknowledged that was a change in condition. The Administrator said he did not know why the nurse would not call, he would hope they would use the critical thinking skills they were taught in nursing school to do that sort of thing. He acknowledge the doctor or nurse practitioner should have been called and not texted. The administrator said his working definition of neglect was the resident should get the care and services they needed. He said "in his opinion" the resident did not get the care and services she needed between 5:30 a.m. and 7:30 a.m. on [DATE]. Review of the facility's [DATE] Abuse, Neglect, and Exploitation Statement documented, in part: Neglect was defined as "the failure of a care taker of the resident themselves to provide goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide such goods or services." Review of the facility's [DATE] policy and procedure for Falls and Injuries documented, in part: The facility strives to reduce the risk for falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Program. Residents/patients are assessed for fall risk factors. The interdisciplinary team works with the resident/ patient and family to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Review of the facility's [DATE] Procedure on Neurological Assessments documented, in part: Standard: Resident/ patients with conditions resulting in changes, or potential changes, in their neurological status will be assessed for potential transfer out of the long term care facility. Neurological assessments will be completed by qualified licensed nurse. Purpose: 1. To assess central nervous system status of a resident/patient. 2. To assess level of consciousness after traumatic injury to the head (i.e. during a fall). Procedure: Assess and documented following: a. Vital Signs - Blood pressure and pulse - Respirations - Temperature b. Eyes - Check pupils for size and reaction to light - shine penlight at pupils and note contraction and equality; observe size - Check eye movement - ask resident/patient to follow your finger up, down, sideways and to their nose; observe for matched movements. - New assessment of fixed and dilated is an emergency situation. c. Motor functions - Evaluate speech - Slurred - Halting - Aphasic - Evaluate extremity strength: - Give commands to open and squeeze eyes, stick out tongue, raise and lower arms and legs. - Use your hand to create resistance for resident/patient to pull or push against. - Have resident/ patient extend arms with palms up. Assess for arm drift. - Grasp and release fingers. d. Level of Consciousness - Verbal Stimulus - call by name - Verbal and tactile stimulus - call by name and shake shoulder - Pain Stimulus - Push thumbnail against resident's/patient's nailbed or thumb against their suprabital ridge. e. Mental Status - Notify physician of any changes. Review of the facility's [DATE] policy and procedure on Emergency Physician Care documented, in part: "The facility will ensure that Physician services are available at all times to provide necessary resident/patient care. This included provisions for emergency care when needed. Transport resident/patient immediately, while waiting on Physician response, if condition warrants emergency care. Review of the facility's [DATE] census documented there were 65 residents residing on the non-secured portion of the facility.

Based on interview and record review, the facility failed to ensure two of two nurses provided the necessary care and services to attain or maintain the highest practicable physical, well-being for one of five residents with falls (Resident #1). Licensed Vocational Nurse (LVN) A and LVN B did not respond timely when they noticed Resident #1 had abnormal results to neuro checks after sustaining a fall ( vomiting, increased help with transferring, pupils "sluggish", decreased level of consciousness, no grip, decreased responsiveness). This failure resulted in the physician not being involved in the diagnosing and/or management of critical medical conditions/crises for Resident #1. This failure could place 65 residents residing on the non-secured unit at risk for delay in treatment, serious complications and/or death. Findings included: RESIDENT #1 Review of Resident #1's [DATE] Face Sheet documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the [DATE] Nurse Practitioner Notes documented an additional [DIAGNOSES REDACTED]. Review of Resident #1's [DATE] quarterly MDS assessment documented she had a mental status score of 3 of 15 (indicating severe cognitive impairment) and was independent with all activities of daily living. Resident #1 was continent. Resident #1 was on anti-coagulant medication (medication used to thin the blood) 7 of 7 days prior to the assessment. Review of the Nurse's Notes documented, in part: - [DATE] at 8:00 a.m. Resident "sitting on the floor in room near sink, floor dry and free of clutter wearing only one sock, wash cloth in hand, not wearing her glasses or hearing aide, stated she was going to wash up her hand and had lost her step and missed grabbing on to the sink. Vital Signs taken, resident able to move all extremities assisted off the floor and onto recliner, resident upset stating she does not understand why she fell if she was only washing up, resident family and doctor called and notified of fall, voiced understanding, neuro checks initiated. Resident encouraged to use quad-cane with ambulation, to wear glasses at all times." - [DATE] at 4:30 p.m. "During shower resident complained of being sad states 'feels like I'm going to die!' Nurse Practitioner called for Doctor and message left." - [DATE] at 12:45 p.m. CNA (Certified Nurse Aide) heard resident call "help." Assessed resident on floor beside bed laying on side, noticed floor rug beside bed, noted wet floor beside the floor rug. Resident has no shoes, no socks. Assessed for injuries none found, states she was getting back in bed. Neuro's restarted. -[DATE] at 8:30 p.m. Resident on floor next to bed wearing only underclothes and pants, no shoes, no socks crying out, states her back is hurting her. Vital signs taken and assessed, able to move all extremities, assisted off the floor and to the bed, assisted out of pants refused gown, when asked what had happened she states she got up from the recliner and was going to walk to the bed but her pain was too great so she fell to the floor. Resident medicated with as needed medication, family called and notified of incident, voiced understanding, doctor notified, no new orders at this time, neuro checks initiated. - Review of Resident #1's [DATE] - [DATE] Neurological Assessment Form (Neuro-checks) documented all vital signs, pupils, motor functions, level of consciousness, and pain response were normal. - [DATE] 5:30 a.m. CNA notified this nurse resident was on floor. Resident on floor in left lateral position wearing own gown. Vitals taken. Resident sat up x3 assist while laying in left lateral position and while checking blood pressure, resident had projectile vomiting, brownish in color, no odor of bowel movement, no injuries noted. Resident pupil sluggish (right), notified Nurse Practitioner no new orders at this time, will have next shift nurse notify power of attorney. No more vomiting noted at this time. (by LVN A) - LATE ENTRY [DATE] for 5:40 a.m. Resident was on floor between both beds, head of resident on roommate's mat. Resident laying in left lateral position. Resident shaky, x3 assist up. Resident held onto my hand with her hand and Resident's gown on left had vomit brownish in color. Resident had own gown and non-skid socks on. Resident's feet were facing her side of bed. When CNA, other nurse and this nurse put her in bed, CNA noticed vomit on bedspread. Bedspread changed and there was also vomit on right side of cushion to wheelchair, against wall by foot of resident's bed. Neuro's started. (by LVN A) - Review of Resident #1's Neurological Assessment Flowsheet documented on [DATE] at 5:30 a.m., 5:45 a.m., and 6 a.m. documented her right pupil was sluggish (her left pupil was normal); her level of consciousness was "stuporous"; and her conversation was "confused". (by LVN A) -[DATE] 6:20 a.m. Resting with eyes closed, lying on left side in bed. Unable to wake resident. Moans in response to vigorous stimuli. Right pupil sluggish with little response - no grips. When eyelid lifted to check for response, resident swatted at my hand listlessly. Doesn't open eyes. Resident repositioned and back rubbed noted some faint red bruising x2 to outer lateral area of right back. No vomiting noted - noted some dry emesis in her hair. Attempted to clean. No response from resident. Doctor to be here for rounds. Will continue to monitor. Resident moving arms and legs at random - small amounts. (by LVN B) -[DATE] 6:40 a.m. During pupil checks no response from resident. Resident repositioned with slight moan in response - very little extremity movement per resident. Doctor called message left to send resident out for further evaluation. Ambulance called and report given. Hospital called and report given. (by LVN B) - Review of Resident #1's [DATE] Neurological Assessment Flow Sheet documented at 6:15 a.m. and 6:45 a.m. documented both pupils were "sluggish"; resident was unable to follow commands with hand grips; there were "random uncoordinated movements" in her extremities; her level of consciousness was "stuporous"; Resident #1's best verbal response was "incomprehensible", and her best response to pain was "moans with stimuli." (by LVN B) - [DATE] (no time documented) Resident sent out via EMS (emergency medical services) with back board and neck brace in place. Pulse difficult to assess - faint. No random movement with extremities. Pupils sluggish. Respirations increased labored breathing, pursed breathing after EMS arrived. (by LVN B) Review of Resident #1's [DATE] - [DATE] Physician order [REDACTED]. Review of the Physician Telephone Orders documented an order on [DATE] for an x-ray to the upper and lower back and the pelvic area due to a fall. Review of the [DATE] Chest, Abdomen and Pelvic CT scan documented the resident had prominent osteopenia but no fractures. It also documented "there is a large mass like structure in the lateral right breast measuring over 3 cm (centimeters) with overlying skin thickening, also right axillary adenopathy worrisome for right breast [MEDICAL CONDITION] (cancer) with metastic adenopathy." Review of Resident's #1's [DATE] Care plan documented Resident #1 had a fall on [DATE] due to cognitive impairment. The goal was resident will be "free from injury or trauma." The identified approaches were: encourage resident to ask for help from staff as needed; ensure call light is within reach, answer promptly; anticipate needs of resident; and assure lighting is adequate and areas are clear of clutter. Review of Resident #1's Hospital Records documented, in part: [DATE] Ambulance Report: Dispatched 7:28 a.m. Enroute: 7:30 a.m. Ambulance on Location: 07:33 a.m. Patient Contact: 07:35 a.m. Depart Location: 8:02 a.m. Arrive at Hospital: 8:08 a.m. In-Service: 8:32 a.m. [DATE] Physician order [REDACTED]. Consult Hospice for possible placement in the morning. [DATE] Emergency Department Notes: 8:12 a.m. Facility Staff states that patient had an unwitnessed fall from bed at approximately 5:30 am. on [DATE]. Facility Staff is unsure if loss of consciousness occurred, but states patient vomited after fall. Facility staff states that patient has an altered level of consciousness and only responds to painful stimuli. Patient is normally able to walk with cane. Narrative: 8:12 a.m. Patient arrived to ER by ambulance on stretcher. Patient has C-collar and back board in place. Patient is obtuneded and has snoring respirations. Patient alert and oriented x 0, and is responsive only to painful stimuli. Pupils constricted. Patient taken to ER Bed via stretcher [DATE] History and Physical (Resident #1 was seen by the same doctor in the hospital as in the nursing home) Chief Complaint: Confusion post fall. History of Present Illness: The patient is a [AGE] year-old female that came in from the nursing home status [REDACTED]. She had 1 episode of vomiting. The fall was unwitnessed, and she was lying next to her bed. Assessment: 1. Intracranial intraparenchymal hemorrhage (bleeding within the brain) 2. Subdural hemorrhage. 3. History of [MEDICAL CONDITION] on anticoagulation. [DATE] Discharge Summary (Resident #1 was seen by the same doctor in the hospital as in the nursing home): Discharge Diagnosis: [REDACTED]. I am not certain if the patient had had a blood pressure which caused the intracrainial hemorrhage leading to a fall or it was the other way around. Hospital Course: The patient is a [AGE] year old female that was brought into the ER (emergency room ) from the nursing home status [REDACTED]. Her condition worsened after being admitted . Her INR ( international normalized ratio - lab value used to determine the clotting tendency of blood) was extremely elevated. This was brought down using vitamin K and FFP (fresh frozen plasma). Nonetheless, she never really improved. I did have extensive discussions with her daughter who lives out of town about further resuscitation. With the patient's age and poor status we decided to hold off on any heroic measures trying to make this patient feel any better. The patient was then transferred to Hospice care and slowly she got worse and did not get any better. She stopped breathing and was declared deceased this morning ([DATE]). During an interview on [DATE] at 3:10 p.m. the Assistant Director of Nurses (ADON) said she was unaware if the facility had a policy and procedure on Neuro-checks and Emergency Procedures. She said the doctor relied on the nurses to use "nursing judgement" and if the nurse believed the resident needed to be sent out to send them out as long as the staff let the doctor know why and when they were sent out. She said the facility was to report neuro checks results when there was any kind of changes, the staff were to check if the eyes were dilated; if the resident was talking and then not; not moving; the blood pressure increases and then falls; hand grips and if equal. The ADON read Resident #1's [DATE] 5:30 a.m. nurse's notes and said three people to assist Resident #1 up was not normal. She then read the [DATE] 6:20 a.m. and 6:40 a.m. nurse's notes. She said when the nurse noticed the eyes were sluggish, she notified the nurse practitioner. The ADON said "I would have sent her out at 6:20 a.m. She was not responsive, she should have been sent out then." During an interview on [DATE] at 3:25 p.m. LVN B confirmed she was the day-time nurse for Resident #1 on [DATE]. LVN B described Resident #1 as "up walking around, hard of hearing, always had her hearing aids on, always had on her glasses, had dentures, always well dressed, and always carried her purse with her." LVN B said before [DATE] Resident #1 had some falls. She said Resident #1 was declining in the few weeks before the fall, she was beginning to use the four-pronged cane. During the same 3:25 p.m. interview, LVN B said on [DATE] Resident #1 had a fall the previous shift and that shift started neuro-checks. She said LVN A told her LVN A did not like the way Resident #1 looked. She said the night shift told her they did not know if she fell because she was getting up to vomit or if she had slipped in the vomit. She said at shift change LVN B told LVN A she would send Resident #1 out to the emergency room . During the same 3:25 p.m. interview LVN B said when she checked Resident #1 she (LVN B) did not like the way Resident #1 looked. She said she did not remember when she called 911 but thought it was shortly after shift change. She said they came fairly quickly. She said she began charting on Resident #1 at 6:20 a.m. She said if she charted that she called 911 at 6:40 a.m. it was probably 7 a.m. when EMS left. In the same 3:25 p.m. interview, LVN B said the staff had to call the doctor or the nurse practitioner before they send any resident out. LVN B acknowledged the findings to Resident #1's neuro-checks were abnormal. She said it was not usual for Resident #1 to need three people to assist her to get up She said she would call the nurse practitioner and let her know but she was going to send her out. LVN B said she did not know why she did not send Resident #1 out at 6:20 a.m. she said she was in the process of doing paperwork, calling the Nurse Practitioner and getting the paperwork together (copy of the Medication Administration Record [REDACTED]. During an interview on [DATE] at 11:00 a.m. the Director of Nurses (DON) said when a resident fell she expected the staff to start neuro checks depending on the neuro-checks the nurse would send out the resident if they needed to. She said a nurse should be in the room the entire time to monitor the resident. During a follow up interview on [DATE] at 11:20 a.m. the DON said if a resident fell and vomited, the neuro checks would determine if the resident went to the hospital. The DON was informed of the [DATE] nurse's notes and said Resident #1 "should have gone out". When asked if the resident's needs were taken care of on [DATE] she said "I would have called (911) immediately." She said when she reviewed the record for the facility incident reporting she did not notice the delay in calling the ambulance. Surveyor attempted to contact Resident #1's physician on [DATE] at noon and left a message at his office. The physician was seeing patients and could not respond to the call. During an interview on [DATE] at 2:20 p.m. the Nurse Practitioner said Resident #1 had several falls. She said when she heard the state agency was in the building she checked her text messages and saw where they notified her that they shipped Resident #1 out. She said usually the facility was very good about calling her and notifying her of changes. She said she did not remember getting a call from the facility at 5:30 a.m. because if they told her Resident #1 was vomiting she would send them out. She said she thought she would remember getting that call. She said on [DATE] the ADON asked her if the staff called and she said no, but when she double checked the phone someone had texted her. She said the facility would text because if she was with a patient she would not be able to respond. The Nurse Practitioner said she received the text at 1:14 in the afternoon (on [DATE]). During the same interview the Nurse Practitioner was informed Resident #1 fell at 5:30 a.m. and the ambulance was not called until 7:28 a.m. She said she did not know if the two hours would make a difference or not. She said Resident #1 had had multiple falls. The Nurse Practitioner said one time Resident #1 had a fall and was sent to the emergency room , but the emergency room did not do a CT scan ([DATE]). (Records indicate x-rays were taken or Resident #1's back and pelvis.) She said the doctor was not happy. She said the next fall ([DATE]) was when the doctor did a CT scan and found the bleed. She said he could not determine if it happened that day ([DATE]) or from the previous fall ([DATE]). The nurse practitioner said she did not know if it would have made a difference or not because Resident #1 had been on [MEDICATION NAME] "forever" and the last month of her life she had "given up." During an interview on [DATE] at 2:45 p.m. LVN A confirmed she was the nurse on duty on [DATE] at 5:30 a.m. She described Resident #1 as coming to the nurse's station to get batteries for her hearing aide, always wore rings, walked up and down the hallways always dressed up. She said at the end Resident #1 complained of back pain so they would have to sit her up in the recliner. She said at the end she began using a wheelchair at night when she never used the wheelchair before. During the same interview, LVN A said there was nothing unusual about Resident #1 the night before the fall, she would come out of her room and sit outside of the door and just watch staff doing their job. She said they called her early morning on [DATE] while she was on the secured unit, and told her there was a resident on the floor. She said when she entered the room a CNA was with her as well as the other nurse. She said when she asked what happened, the CNA explained she went into the room to change the roommate and found Resident #1 on the floor. She said when she walked into the room, they got Resident #1's blood pressure, checked her pupils, and saw if she could hold hands. LVN B said she remembered Resident #1's blood pressure as ok but one of her pupils was "a little sluggish." LVN B said Resident #1 was "kind of moaning at us" when they were moving her, but LVN B thought it was Resident #1's back hurting. LVN B said Resident #1 was just looking at her, not really talking or seeing her. LVN B said Resident #1 did not look like she hit her head, there was no bruising, no hematoma, and no bleeding. LVN B said Resident #1 was able to hold onto her hands when she got up that morning and was "kind of" responsive when she tried to talk to Resident #1. She said the staff picked her up and looked at her face and there was nothing there (no blood, bruising, or other obvious sign of trauma). She said when they sat her up to make the bed it looked like she vomited on the side of the bed. She said the CNA reported there was some vomit on the side of the wheelchair so maybe she was getting up to go to the bathroom. She said she stayed with Resident #1 to do the neuro-checks and when she came out of the room the next shift was there. She said she notified the on-coming nurse (LVN B) to try and get a hold of the Nurse Practitioner. LVN A said she tried texting her but did not get a response. LVN A said "she does not like for us to call." LVN A said usually the Nurse Practitioner responded within 10 - 15 minutes, but by that time the next shift was already in the building. At this time LVN A showed surveyor a text that went out [DATE] at 6:07 a.m. that reported resident did not have any injuries but did have "projectile vomiting" that was brownish in color, resident was pale in color, and that resident responded to painful stimuli. The text said she was leaving for the day so to call the facility if there were any new orders. There was no response from the Nurse Practitioner. During the same interview LVN A said the point to neuro-checks was to know if the resident had altered mental status. She said "I believe she had an altered mental status" and she called to see if she could send Resident #1 out but the next shift was already here. LVN A said the on-coming nurse (LVN B) said she would try to contact the nurse practitioner. She said Resident #1's doctor was supposed to be in at 6 a.m. to do rounds at the facility and the on-coming nurse would let him know as soon as he came in. During the same interview LVN B said she did not call 911 because she was trying to get a hold of the Nurse Practitioner because there were times when the nurse's had gotten in trouble for sending residents to the emergency room prior. During a follow-up interview on [DATE] at 3:30 p.m. the Nurse Practitioner called and said she had talked to Resident #1's doctor. She said he did not think the two hours made a difference. The Nurse Practitioner explained if it was a quick bleed Resident #1 would have died that day. She explained since Resident #1 held on for another four days, the doctor thought it was a slow bleed which was why he was not sure if the bleed was a result of the [DATE] fall or the [DATE] fall. During an interview on [DATE] at 4:10 p.m. the Administrator said in a critical emergency situation he expected his nursing staff to call 911, then notify the doctor, the family, the DON, and the Administrator. He defined critical as finding the resident with an injury, "evident" head trauma with blood present, if the resident was unresponsive. He said staff communicated with the doctor or Nurse Practitioner by phone or by text. He said they would call and if the call went to voice mail they would text. He described Resident #1 as "pleasant, didn't talk much, was slow moving." He said she walked with a quad cane, and was independent with her activities of daily living. He was read the [DATE] 5:30 a.m. entry where LVN A documented Resident #1 needed three staff to get her up. He acknowledged that was a change in condition. He was read the [DATE] 6:20 a.m. entry where the resident had sluggish pupils with little response and no grips. He acknowledged that was a change in condition. He was read the 6:40 a.m. entry where the resident's pupils had no response. He acknowledged that was a change in condition. The Administrator said he did not know why the nurse would not call, he would hope they would use the critical thinking skills they were taught in nursing school to do that sort of thing. He acknowledge the doctor or nurse practitioner should have been called and not texted. Review of the facility's [DATE] Abuse, Neglect, and Exploitation Statement documented, in part: Neglect was defined as "the failure of a care taker of the resident themselves to provide goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide such goods or services." Review of the facility's [DATE] policy and procedure for Falls and Injuries documented, in part: The facility strives to reduce the risk for falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Program. Residents/patients are assessed for fall risk factors. The interdisciplinary team works with the resident/ patient and family to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Review of the facility's [DATE] Procedure on Neurological Assessments documented, in part: Standard: Resident/ patients with conditions resulting in changes, or potential changes, in their neurological status will be assessed for potential transfer out of the long term care facility. Neurological assessments will be completed by qualified licensed nurse. Purpose: 1. To assess central nervous system status of a resident/patient. 2. To assess level of consciousness after traumatic injury to the head (i.e. during a fall). Procedure: Assess and documented following: a. Vital Signs - Blood pressure and pulse - Respirations - Temperature b. Eyes - Check pupils for size and reaction to light - shine penlight at pupils and note contraction and equality; observe size - Check eye movement - ask resident/patient to follow your finger up, down, sideways and to their nose; observe for matched movements. - New assessment of fixed and dilated is an emergency situation. c. Motor functions - Evaluate speech - Slurred - Halting - Aphasic - Evaluate extremity strength: - Give commands to open and squeeze eyes, stick out tongue, raise and lower arms and legs. - Use your hand to create resistance for resident/patient to pull or push against. - Have resident/ patient extend arms with palms up. Assess for arm drift. - Grasp and release fingers. d. Level of Consciousness - Verbal Stimulus - call by name - Verbal and tactile stimulus - call by name and shake shoulder - Pain Stimulus - Push thumbnail against resident's/patient's nailbed or thumb against their suprabital ridge. e. Mental Status - Notify physician of any changes. Review of the facility's [DATE] policy and procedure on Emergency Physician Care documented, in part: "The facility will ensure that Physician services are available at all times to provide necessary resident/patient care. This included provisions for emergency care when needed. Transport resident/patient immediately, while waiting on Physician response, if condition warrants emergency care. Review of the facility's [DATE] census documented there were 65 residents residing on the non-secured portion of the facility.

Based on interview, and record review, the facility failed to notify the resident's responsible party (RP), medical doctor (MD), food service supervisor (FSS) or registered dietician (RD) for a need to alter treatment and repair dentures for 1 of 16 residents reviewed for denture/swallow/accidents (Resident #1). a) Resident #1's dentures were lose fitting and later broken. This was identified by the facility on [DATE]. Resident #1 choked on some food [DATE] due to eating a regular texture diet without any dentures and later passed away at the hospital. This deficient practice could place the 9 residents with dentures at risk for their RP, MD, RD or FSS not being notified and informed about the danger of choking or change in treatment. Findings include: Record review of Resident #1's record of admission documented that he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #1 was [AGE] years old. Review of Resident #1's physician orders [REDACTED]. ? Order date [DATE]: Diet, Regular no added sugar. Review of Resident #1 [DATE] and [DATE] Minimum Data Set (MDS) Assessment indicated in part; ? Oral/Dental = No natural teeth or tooth fragments. Review of the Resident #1's initial admission nutritional evaluation history and data collection dated [DATE] and signed by the FSS indicated in part; ? Date of admission: [DATE]. ? Diet order: Regular ? Dentures: upper and lower, able to feed self. Review of Resident #1's nutritional assessment dated [DATE] indicated in part; ? Diet order: Regular. Review of Resident #1's nurses' notes indicated in part; ? [DATE]. Dentures fitting poorly keep falling when resident attempting to talk or eat. Resident removed dentures during meal and placed them on tray. Social services referral made. (No documentation that RP, MD, FSS, or RD was notified of the loose dentures.) ? [DATE]. Daughter here visiting and states to get broken dentures fixed and she will pay for them. ? [DATE]. Ate (regular) diet well without assist of dentures. Signed by Licensed Vocational Nurse (LVN) Q. Review of social services referral dated [DATE] indicated in part; ? Resident #1: Dentures not fitting properly, dental referral needed. Signed and dated by treatment nurse on [DATE]. ? Social Worker (SW) response: Nursing will need to schedule, SW only here on weekends. Review of the facility's resident concern report dated [DATE] indicated in part; ? Person filing concern: Resident #1's daughter. ? Nature of concern: Bottom teeth are broken. ? Investigation report: Dentures are broken but he continues to eat 100% of his meals. ? Resolution ad deposition: Family taking resident to get dentures (lower) fixed. Facility modifying diet till this happens. (There was no documentation that this change was initiated.) ? Signed and dated by the administrator on [DATE]. Review of the secure unit's 24 hour report from [DATE] through [DATE] did not indicate Resident #1's family were notified of the broken or lose fitting dentures or a suggestion for diet change. Review of the [DATE] facility's provider investigation report regarding Resident #1 indicated in part; ? Provider response: Resident at all times wanted to feed himself. Lower dentures were broken and scheduled to be fixed. Resident continued to eat 100% of his meals without difficulty. Signed and dated by the administrator on [DATE]. INTERVIEWS During a telephone interview on [DATE] at 2:22 p.m. LVN Q said she was the charge nurse in the secure unit the day Resident #1 choked. LVN Q said she was in the secure unit dining room assisting one of the residents during lunch when the certified nursing assistants (CNAs) told her "He's choking" (Resident #1). LVN Q said Resident #1 was coughing and she told him to cough and tapped on his back while he was coughing. LVN Q said she started doing the [MEDICATION NAME] maneuver while the resident was sitting on his wheelchair and then had to lay him down on the floor because he became unconscious. LVN Q said she continued to perform the [MEDICATION NAME] maneuver on Resident #1 while he was on the floor. LVN Q said she had looked in Resident #1's mouth but could not see anything. LVN Q said they had started CPR due to the resident continued to be unresponsive. LVN Q said that when the Emergency Medical Services (EMS) had arrived at the facility they had used some kind of tool to remove a quarter size piece of meat from Resident#1's airway. During a telephone interview on [DATE] at 3:50 p.m. CNA U said she worked the evening shift in the secure unit on [DATE]. CNA U said that when she had assisted Resident #1 to bed she had removed his dentures. CNA U said that's when she noticed Resident #1 had only his upper dentures in and found the lower ones in the denture cup and that they were broken. CNA U said she reported it to LVN C. During a telephone interview on [DATE] at 8:50 p.m. Resident #1's daughter said the facility never called to tell her about the broken dentures or to change his diet. She said they did not notify her that his dentures were not fitting well. Resident #1's daughter said they told her that they offered Resident #1 a different texture diet but that he had refused. She said they had told her this after he had choked (after the incident). Resident #1's daughter said he passed away in the hospital later that same day he had choked. During a telephone interview on [DATE] at 9:40 p.m. Resident #1's granddaughter (A) said she had spoken on the phone with the administrator regarding the broken dentures. The granddaughter said the administrator told her that Resident #1's dentures were broken but that he could still eat "just fine." During a telephone interview on [DATE] at 9:21 a.m. Resident #1's granddaughter (B) said her and her mother had gone to visit Resident #1 at the facility on [DATE]. The granddaughter said that was when they noticed the dentures were broken. During an interview on [DATE] at 10:50 a.m. LVN Q said Resident #1 was not wearing any dentures during lunch time on [DATE] when he choked in the dining room. During an interview on [DATE] at 11:15 a.m. the Assistant Director Of Nurses (ADON) said she was not aware Resident #1's dentures were broken. During an interview on [DATE] at 1:30 p.m. the FSS said the nursing staff never asked her to change Resident #1's diet. The FSS said Resident #1 was always on a regular texture diet. During an interview on [DATE] at 2:19 p.m. CNA T said Resident #1 ate his meals without his dentures in place on more than one occasion. (CNA T was aware Resident #1 did not have dentures.) During an interview on [DATE] at 2:45 p.m. the nurse practioner (NP) said the facility never notified or called her to request a diet change for Resident #1 due to his broken dentures. During an interview on [DATE] at 3:00 p.m. LVN Q said Resident #1 had at other times eaten regular texture food without any dentures on and had not choked. (LVN Q was aware Resident #1 did not have dentures.) During an interview on [DATE] at 3:05 p.m. the treatment nurse said Resident #1 had at times taken out his dentures and eaten his meals without them. The treatment nurse said Resident #1's dentures fit him losely and he would at times remove them. The treatment nurse said she had left a note on the SW's notebook on [DATE] regarding the lose fitting dentures but had not heard anything after that. The treatment nurse said the SW would only come out to the facility on the weekends. (The treatment nurse was aware Resident #1 did not have dentures.) During an interview on [DATE] at 10:30 a.m. The ADON and the director of nurses (DON) said they "should have documented" that Resident #1 refused a diet change. The DON said the staff probably did not change the texture of his diet to keep him from getting agitated. The DON said the staff should have reported the dentures were broken to the family. During an interview on [DATE] at 2:20 p.m. CNA W said Resident #1 was not wearing any of his dentures the day he choked. CNA W said she was in the dining room when he choked. During an interview on [DATE] at 3:20 p.m. the DON said she rechecked Resident #1's chart and was unable to find any documentation regarding his broken dentures. During an interview on [DATE] at 3:45 p.m. the RD said she had not been made aware of any diet changes for Resident #1 before the choking incident. During a telephone interview on [DATE] at 5:10 p.m. LVN C said CNA U reported to her that Resident #1's dentures were broken or missing on [DATE]. LVN C said she did not remember calling the family to report the problem with the dentures or documenting it anywhere. During an interview on [DATE] at 5:45 p.m. LVN R said she had not reported to Resident #1's family the dentures were broken or missing because sometimes other residents go into other rooms and "take other residents dentures and stuff." LVN R said that perhaps some other resident had taken them and "they would turn up sooner or later." During an interview on [DATE] at 6:00 p.m. LVN D said when she was training to be the treatment nurse she noticed that Resident #1 had a sore on his gum. LVN D said Resident #1 would take out his dentures because of the sore. She said the staff gave him some pureed food which he refused to eat. LVN D said she had not documented this but had told the charge nurse in the secure unit which she did not remember who it was since it was a long time ago. During an interview on [DATE] at 9:00 a.m. LVN P said that on [DATE] CNA U told her that she had reported Resident #1's broken dentures to LVN C. LVN P said CNA U told her as well because CNA U did not want to get blamed for not reporting it. LVN P said she did not tell the family because she thought LVN C had done it. During a telephone interview on [DATE] at 11:45 a.m. the SW said she remembered reading the note regarding Resident #1's lose fitting dentures. The SW said she told the charge nurse that she did not schedule dental appointments because she was only there on the weekends. The SW said she told the nurse in the secure unit about it but did not remember who it was. Review of the facility's policy and procedures titled condition changes dated ,[DATE] indicated in part; ? The facility will document change in a resident ' s condition or significant resident care issues each shift until the resident condition is stabilized or the situation is otherwise resolved. ? Enter the date and time of occurrence. ? Notify the physician, date and time physician notified. ? Notify the family, date and time family notified, name of family member. Review of the facility's policy and procedures titled nutrition management program dated ,[DATE] indicated in part; ? Resident and family education is designed to help the individual develop cognitive, effective and psychomotor skills for managing their nutrition. ? Identify and evaluate the following risk factors as they apply to the resident including, but not limited to: Oral health problems, missing teeth, lack of suitable dentures. ? Implement individualized interventions based on interdisciplinary assessments and resident and family goals which promote the highest level of function and dignity. ? Educate the resident and family in effective nutritional practices as applicable. During the exit conference on [DATE] the facility was given the opportunity to provide any additional information and was unable to do so. A list provided by the DON on [DATE] indicated there were 9 residents with dentures in the facility.

Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accidents, hazards, and provided adequate supervision for 2 of 16 residents reviewed for safety. (Resident #1 and Resident #4) The facility failed to ensure: a) To have preventive steps in place to prevent Resident #1 from choking. b) To initiate and/or implement any new interventions or safety measures to prevent choking. Failure to provide adequate supervision or preventive measures could place 9 residents with dentures at a chance for choking. c) Certified Nurse Aides (CNA's) were properly trained to use the proper technique when transferring residents using gait belts. This failure could effect 22 residents that required assistance of two employees with transfers and supervision during ambulation, at risk for falls and injuries. Finding Included: CHOKING: Record review of Resident #1's record of admission documented that he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. He was [AGE] years old. Review of Resident #1's physician orders [REDACTED]. ? Order date [DATE]: Diet, Regular no added sugar. Review of Resident #1's [DATE] Minimum Data Set (MDS) Assessment indicated in part; ? Oral/Dental = No natural teeth or tooth fragments. Review of the Resident #1's initial admission nutritional evaluation history and data collection dated [DATE] and signed by the food service supervisor (FSS) indicated in part; ? Date of admission: [DATE]. ? Diet order: Regular ? Dentures: upper and lower, able to feed self. Review of Resident #1's nutritional assessment dated [DATE] indicated in part; ? Diet order: Regular. Review of Resident #1's nurses' notes indicated in part; ? [DATE]. Dentures fitting poorly keep falling when resident attempting to talk or eat. Resident removed dentures during meal and placed them on tray. Social services referral made. (Staff were aware Resident #1's dentures were not fitting properly.) ? [DATE]. Daughter here visiting and states to get broken dentures fixed and she will pay for them. ? [DATE]. Ate diet well without assist of dentures. Signed by Licensed Vocational Nurse (LVN) Q. - [DATE] 12:35 p.m. Resident #1 was eating in dining room. Note Resident #1 began to cough. (LVN Q) encouraged him to continue coughing while (LVN Q) patted him on the back. After several attempts noted resident was not coughing out any object causing obstructive airway. Hemilich Manuever was performed while resident in wheelchair. Not effective. Assisted resident to floor. Opened mouth, unable to visualize object in mouth. Resident became unresponsive. Called for assist from other charge nurse while awaiting, staff continued to perform Hemilich Manuever on floor. Charge nurse arrived to assist, pulse became weak and thready. CNA instructed to call 911 and CPR (Cardio Pulmonary Resuscitation) began. Chest compressions with respiration via ambu-bag. CPR continued for 2 minutes, resident continued with no pulse, no respirations. CPR resumed, EMS (Emergency Medical Service) arrived after 10 - 15 minutes. Report given to EMS while CPR continued. EMS took over CPR at 12:42 p.m. EMS continued care and exited building with resident while provide rescue breaths via ambu-bag. Notified MD (Medical Doctor) and family. Signed by LVN Q. Review of social services referral dated [DATE] indicated in part; ? Resident #1: Dentures not fitting properly, dental referral needed. Signed and dated by treatment nurse on [DATE]. ? Social Worker(SW) response: Nursing will need to schedule, SW only here on weekends. Review of the facility's resident concern report dated [DATE] indicated in part; ? Person filing concern: Resident #1's daughter. ? Nature of concern: Bottom teeth are broken. ? Investigation report: Dentures are broken but he continues to eat 100% of his meals. ? Resolution and deposition: Family taking residents to get dentures (lower) fixed. Facility modifying diet till this happens. ? Signed and dated by the administrator on [DATE]. Review of the secure unit's 24 hour report from [DATE] through [DATE] did not indicate Resident #1's family were notified of the broken or lose fitting dentures or a suggestion for diet change. Review of the facility's [DATE] provider investigation report regarding Resident #1 indicated in part; ? Provider response: Resident at all times wanted to feed himself. Lower dentures were broken and scheduled to be fixed. Resident continued to eat 100% of his meals without difficulty. Signed and dated by the administrator on [DATE]. Review of Resident #1's emergency medical services records dated [DATE] indicated in part; ? Upon arrival found patient lying supine on floor CPR in progress, patient noted to be pulseless and apneic (not breathing). On visualization of the oral cavity a large amount of food found occluding the trachea, foreign body was removed clearing the airway. Review of Resident #1's hospital records dated [DATE] indicated in part; ? Resident arrived at hospital via EMS at 1:06 p.m., vitals low and weak pulse, respiration spontaneous, possible transfer via aero but not sure due to resident not doing well, Spoke with Resident's Son and power of attorney conferred with him that he is to unstable to transfer by air, Son voices understanding, explained that his prognosis is poor, Son voices that he would like to stop life saving measures. ? Clinical impression: deceased , Asphyxia (Deficiency of oxygen and excess of carbon dioxide in the blood and body tissues). Time of death 4:35 p.m. on [DATE]. INTERVIEWS During a telephone interview on [DATE] at 2:22 p.m. LVN Q said she was the charge nurse in the secure unit the day Resident #1 choked. LVN Q said she was in the secure unit dining room assisting one of the residents during lunch when the CNAs told her "He's choking" (Resident #1). LVN Q said Resident #1 was coughing and she told him to cough. She said she tapped on his back while he was coughing. LVN Q said she started doing the Heimlich maneuver while the resident was sitting on his wheelchair and then had to lay him down on the floor because he became unconscious. LVN Q said she continued to perform the Heimlich maneuver on Resident #1 while he was on the floor. LVN Q said she looked in Resident #1's mouth but could not see anything. LVN Q said they started CPR due to the resident continued to be unresponsive. LVN Q said that when the EMS had arrived at the facility they had used some kind of tool to remove a quarter size piece of meat from Resident #1's airway. During a telephone interview on [DATE] at 2:35 p.m. CNA T said she worked in the secure unit when Resident #1 choked. CNA T said she saw LVN Q performing the Heimlich maneuver on Resident #1 while he was in his wheelchair. CNA T said LVN Q lowered Resident #1 to the floor and continued the Heimlich maneuver then CPR. CNA T said she called 911. CNA T said LVN S came into the secure unit to assist LVN Q. CNA T said when EMS arrived they removed a "lime sized" piece of meat from Resident #1's throat "with some kind of hook." During a telephone interview on [DATE] at 2:55 p.m. LVN S said she worked on the day Resident #1 choked. LVN S said she was at the main nurses' station and heard that a resident was choking in the secure unit. LVN S said she went and helped LVN Q with performing the Heimlich maneuver and CPR on Resident #1. LVN S said the EMS removed a "lemon sized" piece of meat from Resident #1's airway. During a telephone interview on [DATE] at 3:50 p.m. CNA U said she worked the evening shift in the secure unit on [DATE]. CNA U said when she assisted Resident #1 to bed she removed his dentures. CNA U said that was when she noticed Resident #1 had only his upper dentures in and found the lower ones in the denture cup and that they were broken. CNA U said she had reported it to LVN C. (The staff were aware Resident #1 did not have dentures.) During a telephone interview on [DATE] at 9:40 p.m. Resident #1's granddaughter (A) said she spoke on the phone with the administrator regarding the broken dentures. The granddaughter said the administrator told her that Resident #1's dentures were broken but that he could still eat "just fine." During a telephone interview on [DATE] at 9:21 a.m. Resident #1's granddaughter (B) said her mother and her went to visit Resident #1 at the facility on [DATE]. The granddaughter said that was when they noticed the dentures were broken. (Eight days prior to the choking incident.) During an interview on [DATE] at 10:50 a.m. LVN Q said Resident #1 was not wearing any dentures during lunch time on [DATE] when he choked in the dining room. During an interview on [DATE] at 11:15 a.m. the ADON said she was not aware Resident #1's dentures were broken. During an interview on [DATE] at 1:30 p.m. the FSS said they had never asked her to change Resident #1's diet. The FSS said Resident #1 was always on a regular texture diet. During an interview on [DATE] at 2:19 p.m. CNA T said Resident #1 had eaten his meals without his dentures in place in more than one occasion. During an interview on [DATE] at 2:45 p.m. the Nurse Practioner (NP) said the facility had never notified or called her to request a diet change for Resident #1 due to his broken dentures. During an interview on [DATE] at 3:00 p.m. LVN Q said Resident #1 had at other times eaten regular texture food without any dentures on and had not choked. During an interview on [DATE] at 3:05 p.m. the treatment nurse said Resident #1 had at times taken out his dentures and eaten his meals without them. The treatment nurse said Resident #1's dentures fitted him lose and would at times remove them. The treatment nurse said she had left a note on the SW notebook on [DATE] regarding the lose fitting dentures but had not heard anything after that. The treatment nurse said the SW would only come out to the facility on the weekends. During an interview on [DATE] at 10:30 a.m. The ADON and the director of nurses (DON) said they should have documented that Resident #1 was refusing a diet change. The DON said the staff probably did not change the texture of his diet to keep him from getting agitated. The DON said the staff should have reported the dentures were broken to the family. During an interview on [DATE] at 11:25 a.m. the administrator said he had talked to the DON about the family requesting the dentures needed to be repaired. The administrator said Resident #1 was a good eater and ate 100% of the meals. The administrator said "If could do it all over again, I would have forced an order to change his diet." During an interview on [DATE] at 2:20 p.m. CNA W said Resident #1 was not wearing any of his dentures the day he choked. CNA W said she was in the dining room when he had choked. During an interview on [DATE] at 3:20 p.m. the DON said she had rechecked Resident #1's chart and was unable to find any documentation regarding his broken dentures. During an interview on [DATE] at 3:45 p.m. the RD (registered dietician) said she had not been made aware of any diet changes for Resident #1 before the choking incident. During a telephone interview on [DATE] at 5:10 p.m. LVN C said CNA U had reported to her that Resident #1's dentures were broken or missing on [DATE]. LVN C said she did not remember calling the family to report the problem with the dentures or documenting it anywhere. During an interview on [DATE] at 5:45 p.m. LVN R said she had not reported to Resident #1's family the dentures were broken or missing because sometimes other residents go into other rooms and take other residents dentures and stuff. LVN R said that perhaps some other resident had taken them and they would turn up sooner or later. During an interview on [DATE] at 6:00 p.m. LVN D said when she was training to be the treatment nurse she had noticed that Resident #1 had a sore in his gum. LVN D said Resident #1 would take out his dentures because of the sore and they had given him some pureed food which he refused to eat. LVN D said she had not documented this but had told the charge nurse in the secure unit which she did not remember who it was since it was a long time ago. During an interview on [DATE] at 9:00 a.m. LVN P said that on [DATE] CNA U had told her that she had reported Resident #1's broken dentures to LVN C. LVN P said CNA U had told her as well because CNA U did not want to get blamed for not reporting it. LVN P said she did not tell the family because she thought LVN C had done it. During a telephone interview on [DATE] at 11:45 a.m. the SW said she remembered reading the note regarding Resident #1's lose fitting dentures. The SW said she had told the charge nurse that she did not schedule dental appointments because she was only there on the weekends. The SW said she had told the nurse in the secure unit about it but did not remember who it was. Review of the facility's policy and procedures titled nutrition management program dated ,[DATE] indicated, in part; ? Resident and family education is designed to help the individual develop cognitive, effective and psychomotor skills for managing their nutrition. ? Identify and evaluate the following risk factors as they apply to the resident including, but not limited to: Oral health problems, missing teeth, lack of suitable dentures. ? Implement individualized interventions based on interdisciplinary assessments and resident and family goals which promote the highest level of function and dignity. ? Educate the resident and family in effective nutritional practices as applicable. TRANSFERS Review of Resident #4's Record of admitted d [DATE] documented he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years old. Review of the Care Plan last updated [DATE] documented Resident #4 needed assistance with transfers, ambulation, and positioning. He needed two person assistance with transfers. During an observation on [DATE] at 1:10 p.m. CNA N and CNA AA washed their hands and put on gloves to prepare for transferring Resident #4 to his geri-chair. CNA N and CNA AA put a gait belt loosely around Resident #4's waist. The CNA's put one hand on the gait belt and the other arm they hooked under Resident #4's arm pit. The CNA's counted to three and lifted Resident #4 up and into his geri-chair. The gait belt rode up to Resident #4's arm pit area during the transfer. In an interview on [DATE] at 10:25 a.m. CNA N said "it was not correct to grab the resident under his arm pits. We were suppose to grab the gait belt from the back and the front. You don't grab the arm pits. You could cause damage or break something (referring to transfers using the arm pits). I know to use the gait belt. I told (CNA AA) we had messed up because we grabbed him by the arm pits." In an interview on [DATE] at 10:40 a.m. the DON said "we use a gait belt based on the Care Plan. The staff are to use gait belts if it is a one or two person transfer. We have in-serviced the staff on transfers this year. We in-serviced them not to use the arm pits instead to use gait belts." Review of the Policy and Procedure dated [DATE] documented, in part: Procedure 1. Identify resident/patient, explain procedure, and provide privacy. 2. Fasten the gait belt securely around the resident'/patient's waist with the buckle at the side. The belt should not come in contact with the resident/patient's skin. 3. Position one hand under the buckle, 4. Position the other hand under the belt. The belt should be snug. 5. Transfer the resident/patient using proper body mechanics. 6. Assist resident/patient as needed to a comfortable position with call light within reach. The facility was given the opportunity to provide any additional information during the exit conference on [DATE] and was unable to do so. Review of a list by the DON and the ADON on [DATE] documented there were 22 residents that required the assistance of two for transfers. A list provided by the DON on [DATE] indicated there were 9 residents with dentures in the facility.

Based on observation, interviews and record review, the facility failed to ensure the resident environment remained as free of accidents hazards as is possible; and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of 3 residents identified on Hall 100 requiring supervision due to poor safety awareness as evidenced by: a) Resident #1 was discovered on 6/01/12 at 4:03 p.m. outside on the back porch of Hall 100 and was found unresponsive in his wheelchair. Resident #1 had been outside and unsupervised for an unknown amount of time. Resident #1 was admitted to the hospital with [REDACTED]. This failure resulted in one resident sustaining heat exhaustion, dehydration and second degree burns that required hospitalization . This failure places all 3 residents identified on the hall as having poor safety awareness at risk of injuries due to lack of assistance or supervision. The findings include: A review of Resident #1's Record of Admission Face Sheet documented Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was a [AGE] year old male. A review of Resident #1's Nursing Comprehensive Admission Data form dated 8/20/08 documented in part, Impaired Cognition: Confused at times. A review of Resident #1's Physicians Orders for 6/01/12 through 6/30/12 with print date of 5/31/12 documented having additional [DIAGNOSES REDACTED]. A review of Resident #1's CNA Activities of Daily Living Flow Sheets dated June 2012 documented in part Resident #1 required one person assistance with transferring, toileting, and bed mobility. A review of Resident #1's Care Plan dated 4/30/12 documented in part, Potential for injuries: Falls. Related to: Cognitive deficits with poor safety awareness. Review of Resident #1's Progress Notes dated 6/04/12 at 1603 (4:03 p.m.) documented in part: Called to Rsd (Resident) Rm (Room). Rsd sat outside for awhile had robe on. When staff checked on Rsd, he was diaphoretic, warm, non-responsive. Took Rsd to Rm. Took off robe. Cooled him off with wet cold towels. Rsd started to respond. CBG 218. Able to get Rsd to drink full glass of OJ (orange juice). Becoming more alert. Continue to cool body off. Had blister to (L) Left shoulder. Skin intact no fld (fluid) build up only skin moveable. Sent to ER (emergency room ) to be evaluated. Review of Resident #1's Accident/Incident Report dated 6/04/12 documented in part: Rsd propelled self outside, propped door open. Sat outside under porch. When staff went outside to bring him in, he was drooling and eyes were open. Very sweaty. Had long wool robe on. Pulse 121 (high). Injury: Burn - Sun. Review of Resident #1's Accident/Incident Final Disposition Reported dated 6/09/12 documented in part: State Cause: Self Inflicted Injuries. Rsd. very non-compliant. Goes outside at different times throughout day. Rsd was sent to hospital and admitted for dehydration and heat exhaustion. Rsd returned back to the facility on [DATE]. Review of Resident #1's hospital ED (Emergency Department) Assessment Sheet dated 6/04/12 documented in part: 1648 (4:48 p.m.) pt brought in with complaint of unresponsive due to outside 3 - 4 hours at nursing facility. Was out in the sun today for approximately 3 - 4 hours, pt has burns to L shoulder, L back of neck, and L great toe, erythemia (redness) to these places also. MD notified of increasing size of blisters. Blisters lanced and painted with Benzoin. Review of Resident #1's Nursing Documentation Record dated 6/09/12 at 1650 (4:50 p.m.) documented in part: Resident #1 readmitted to the facility. Wounds to (L) shoulder 20 cm (centimeters) with 2 blisters intact 1 cm x 1 cm and 2.5 cm x 1.5 cm. (L) side of neck 1 cm x .5 cm. .5 cm x .5 cm blister intact. .5 cm and 1 cm x .5 cm. Top of head with a 6 x 3 cm raised red crusted area. (R) Right foot on top with 2 lg (large) blisters intact 7 cm x 5 cm. (L) foot upper ankle .5 cm x .7 cm, lower foot 2 cm x 1.5 cm intact blister. (L) great toe to neck of toe 1 cm x .5 cm on top of great toe by nail. 8 cm x .5 cm busted blisters. Silvadene to sunburned wounds qd (everyday) until healed. Observation on 6/13/12 at 11:08 a.m. revealed Resident #1 in his room sitting in his wheelchair. Resident #1 had gauze bandages wrapped around both feet and ankles, and a large non-adherent dressing on the back of the neck. Resident #1 was observed with a white ointment on the top of his head but dark red areas were observed to the top of the head and scalp. When Resident #1 was asked what had happened, he stated, "I was in a different nursing home and I could not get back into the house. I was out for a long time." (Resident #1 was not orientated to place and had not been at a different nursing facility). Observation of Resident #1's burns on 6/14/12 at 11:24 a.m. revealed large opened burn blisters on the top of both the left and right feet. The blisters had burst and were draining clear fluid from the burn sites. The top of Resident #1's left shoulder had a very large burn with yellow exudates and slough observed. The upper layers of skin on the shoulder were completely absent due to the burn. The back of Resident #1's neck was observed with a large broken blister and was very red. Resident #1 had a red broken blister on the top of his head and observed red areas on the back of his head and scalp. In an interview on 6/13/12 at 10:10 a.m. the Director of Nurses (DON) stated Resident #1 would come in and out and he loved to be outside. The DON stated they did not realize that we was outside and they had not checked on him during that time frame. The DON further stated they could not confirm how long Resident #1 had been outside but suspected that it could have been 2 to 3 hours. In an interview on 6/13/12 at 1:15 p.m. the Assistant Director of Nurses (ADON) stated Resident #1 was found outside unsupervised in a flannel robe. The ADON stated she was responsible for the incident/accident reports and tracking and the management reviews the incident reports in the morning standup meetings. The ADON stated they did an investigation and wrote up the charge nurse on duty for failure to supervise but did not report the incident to DADS. In an interview on 6/13/12 at 1:25 p.m. the DON stated, " I did not think it was that bad." (In regards to Resident #1's incident and injuries). "I guess we should have called it in." In an interview on 6/13/12 at 5:00 p.m. LVN A stated Resident #1 use to go outside all the time and read. LVN A stated he had gotten weaker and had stopped going out as much but would still go out at times. LVN A stated the nurse aide informed her that he had gone outside earlier on 6/04/12 and the aide had brought him back in. LVN A stated Resident #1 would prop the door open. LVN A stated on that day she observed him outside with the door propped open and him sitting in his wheelchair in the shade around 2:50 p.m. LVN A stated she took her break from 3:00 p.m. to 4:00 p.m. and the ADON had relieved her during her break. LVN A said at 4:03 p.m. ADON called her that Resident #1 was outside. She said when she went down the hall the aides had already gotten Resident #1 back to his room. LVN A said the ADON and the treatment nurse were taking off Resident #1's robe and putting cold compresses on his skin. LVN A stated she observed Resident #1's skin was moveable on his shoulders when they removed his robe but did not notice any blisters on his feet. LVN A further stated she called the hospital and was informed by the hospital that they admitted Resident #1 for dehydration and sunburns. In an interview on 6/13/12 at 5:19 p.m. CNA B stated on 6/04/12 between 12 noon and 1:00 p.m. she observed Resident #1 heading outside. CNA B stated that she told Resident #1 that it was too hot but he still wanted to go outside. CNA B said she propped the door open and got him situated in the shade and went back in the facility to finish picking up the lunch trays. CNA B stated about 30 minutes later she observed him coming back into the facility and going into his room. CNA B said she did not see Resident #1 again until she discovered him outside around 3:45 p.m. / 3:50 p.m. while she was getting residents to the day room for supper. CNA B stated she noticed the door propped open and him outside with his head down and drooling. CNA B said he was barefoot and was wearing a thick robe and brief when she found him. CNA B stated she brought him back into the facility and to his room and got the nurses to come. CNA B further stated she noticed Resident #1 was very sweaty and when they took his robe off, she noticed his skin moving on his shoulders. In an interview on 6/14/12 at 8:55 a.m. the ADON confirmed that she relieved LVN A for her break on 6/04/12 from 3:00 p.m. to 4:00 p.m. The ADON stated she was at the nurses station while LVN A took her break. The ADON said she did not see Resident #1 go outside but confirmed she did not go down Hall 100 and make rounds during that time period. In an interview on 6/14/12 at 2:00 p.m. the DON and ADON stated they were aware of Resident #1's second degree burns on 6/05/12 when the ADON had called the hospital to check on the status of Resident #1. The DON stated that Resident #1 was not confused and was able to make his own decisions but then acknowledged that Resident #1 had poor safety awareness and required supervision. The facility was given the opportunity to provide any additional information during the exit conference on 6/14/12 and were unable to do so. Review of undated resident list provided by the DON on 6/14/12 documented three residents including Resident #1 residing on Hall 100 as requiring supervision due to poor safety awareness.