Every finding on record at Frankfort Trails

Based on observation, interview, record review, and review of the facility's policies, the facility failed to provide reasonable accommodation for resident needs for 4 out of 66 sampled residents, Resident (R) 69, R72, R88, and R89. Observations on 08/11/2026, 08/12/2026, and 08/13/2026 revealed the residents' call lights were out of their reach and could not be used by them to call staff for assistance.The findings include:Review of the facility's policy titled, Activities of Daily Living, last reviewed 03/20/2025, revealed the facility would, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in Activities of Daily Living (ADL) did not deteriorate unless deterioration was unavoidable. Further review revealed a resident who was unable to carry out ADLs would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility's policy titled, Resident Rights, last revised 02/15/2026, revealed the resident had the right to receive the services and/or items included in the plan of care.1. Observation of R69's room on 08/11/2026 at 9:05 AM revealed the resident's call light was hooked onto the headboard of R69's bed and out of the resident's physical reach. Further observation on 08/11/2026 at 11:02 AM revealed the call light remained hooked on R69's headboard and out of the resident's physical reach. During the second observation, R69 was actively calling out for assistance. Upon the State Survey Agency (SSA) Surveyor entering the room, R69 stated he required assistance with his brace but could not reach the call light.During an interview with State Registered Nurse Aide (SRNA) 1 on 08/11/2026 at 11:09 AM, she stated she was unsure of why the call light was not within the resident's reach. She stated it was important for residents to have access to their call lights so they could call out to staff for assistance.Review of Resident (R) 69's Face Sheet revealed the facility admitted the resident on 02/18/2026 with a diagnoses of acute osteomyelitis of the right foot and ankle, muscle weakness, and non-pressure chronic ulcer of the right heel and midfoot with necrosis of the muscle. On 08/16/2026 the resident had a right below the knee amputation.Review of R69's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/02/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 13 out of 15. This score indicated R69 was cognitively intact. Review of R69's Care Plan, dated 02/25/2026, revealed the facility care planned an intervention. The intervention was to keep call light in reach. 2. Observation of R89's room on 08/12/2026 at 9:42 AM revealed the resident was calling out for help. Upon the SSA Surveyor entering the room, the resident's call light was observed lying on the floor underneath the bed, completely out of the resident's physical reach. R89 stated she was screaming out for help because she needed assistance with her blankets.During an interview with SRNA6 on 08/12/2026 at 9:51 AM, she stated the call light should have been attached to the residents' pillowcase or blanket so she could have access to it. She stated R89 knocked it off the bed frequently. She further stated it was important for all residents to have access to their call lights so they could call out for assistance.Review of Resident R89's Face Sheet revealed the facility initially admitted R89 on 07/08/2022 with a readmission date of 06/07/2024. She had diagnoses which included age related cognitive decline, falls, and muscle weakness and contractures (bilateral hands, bilateral ankles, bilateral hips and bilateral knees). Review of R89's quarterly MDS, with an ARD of 05/11/2026, revealed the facility assessed the resident to have a BIMS score of nine out of 15. This score indicated R89 had moderate cognitive impairment.Review of R89's Care Plan, dated 08/09/2022 revealed the facility added a new intervention to the Care Plan. The intervention was to ensure the resident had a safe environment, and personal items were to be within R89's reach. 3. Observation on 08/12/2026 at 9:44 AM revealed R72's call light was lying in the floor at the head of the bed.Additional observation on 08/13/2026 at 11:46 AM revealed R72's call light was on the floor. Review of R72's Face Sheet revealed the facility admitted the resident on 07/11/2025. The diagnoses included depression, encephalopathy, and muscle weakness.Review of R72's annual MDS, with an ARD of 06/16/2026, revealed the facility assessed the resident to have a BIMS score of 15 out of 15. The score indicated R72 was cognitively intact.Review of R72's Care Plan, revealed an intervention, dated 04/26/2026, for call light zip tied to bed frame. An additional intervention, dated 07/11/2026, revealed to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Further review revealed on 07/21/2026, R72 was care planned to keep call light within reach.During an interview on 08/13/2026 at 11:46 AM with R72, she stated she was normally independent and did not have to use her call light. However, she stated, if she did need something, her roommate (R88) would push hers to make the staff aware. 4. Observation on 08/13/2026 at 11:46 AM revealed R88's call light was on the floor.Review of R88's Face Sheet revealed the facility admitted the resident on 08/02/2021. The diagnoses included bipolar disorder, muscle weakness, and chronic pain.Review of R88's quarterly MDS, with an ARD of 06/30/2026, revealed the facility assessed the resident to have a BIMS score of 15 out of 15. The score indicated the resident was cognitively intact.Review of R88's Care Plan revealed an intervention, dated 09/14/2022. The intervention was to educate and remind resident of safety awareness such as .call light use. and to keep frequently used items within reach.During an interview with R88 on 08/13/2026 at 11:46 AM, she stated she used her call light for herself and her roommate. However, she stated her call light was currently on the floor, and she had no way to call for help. R88 stated it must have fallen off her bed while she was sleeping. During an interview with the Director of Nursing (DON) on 08/12/2026 at 3:48 PM, she stated she assumed the Director of Nursing role on 07/19/2026. She stated she expected and the facility standard was for staff to perform resident checks every two hours and as needed in between. She stated all staff were expected to always follow the facility's policies and procedures during resident care. She stated, for residents unable to use a call light, staff must check on them every two hours. She stated the baseline expectation for call light response was 15 minutes, with a maximum threshold of 30 minutes. She stated responses might extend to one hour only during facility emergencies. She stated it was unacceptable for a resident not to have access to a call light. The DON further stated the call light was important to ensure the needs of the residents were being met. During an additional interview on 08/14/2026 at 7:16 PM with the DON, she again stated it was her expectation that all residents had their call lights within reach, even if they did not need them. She stated it was important for residents to be able to call out for help when they needed it. During an interview on 08/14/2026 at 7:25 PM with the Administrator, she stated residents should always have access to call for assistance when they needed it. She stated this was a safety concern if residents did not have a way to reach staff. During an additional interview with the Administrator on 08/14/2026 at 7:46 PM, she again stated it was her expectation of all staff in the facility to follow the facility's policies. She stated resident call lights should always be answered as promptly as possible, and call lights should always be within reach of the resident. The Administrator further stated under no circumstances was it acceptable for a resident not to have their call light within reach.

Based on observation, interview, record review, and review of the facility's documents and policies, the facility failed to carry out activities of daily living for residents so they received the necessary services to maintain good grooming and personal hygiene for 4 of 66 sampled residents, Resident (R) 15, R65, R77, and R97.The findings include:Review of the facility's policy titled, Activities of Daily Living [ADL] dated 03/20/2025, revealed the facility would provide care and services consistent with each resident's comprehensive assessment, needs, and choices. Further, the policy stated residents unable to perform activities of daily living would receive necessary services to maintain bathing, dressing, grooming, and personal hygiene.Review of the facility's policy titled, Resident Rights, last revised 02/15/2026, revealed the resident had a right to be treated with respect and dignity, including the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. 1. Observation on 08/11/2026 at 9:59 AM with R15 revealed R15 requested to Registered Nurse (RN) 1 that she trim his fingernails. RN1 informed the resident she would return later to complete the task. During an interview on 08/11/2026 at 9:59 AM with R15, the resident stated on multiple prior occasions, he requested that staff trim and clean his fingernails, He stated they were dirty, jagged, and snagging on items.Further observation of R15 on 08/12/2026 at 2:17 PM and on 08/13/2026 at 3:22 AM revealed the resident's fingernails remained untrimmed and dirty. Review of R15's Face Sheet revealed the facility admitted the resident on 10/08/2019. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, muscle weakness, and age related nuclear bilateral cataract and open angle glaucoma.Review of R15's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/23/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 11 out of 15. The score indicated R15 had moderate cognitive impairment.Review of R15's Care Plan, dated 10/16/2019, revealed R15 had a physical functioning deficit and self-care impairment related to mobility impairment and range-of-motion limitations. Interventions stated R15 staff to give nail care as needed, and the resident was dependent on staff for personal hygiene. Further review revealed R15 had actual skin breakdown and potential for pressure ulcers related to impaired mobility, incontinence, friction, and shearing. Interventions included to avoid scratching and keep fingernails short.During an interview on 08/13/2026 at 3:22 PM with RN1, she stated she had not completed the nailcare for R15 as requested due to oversight. She stated she should have completed the nailcare request after her morning medication administration but did not. During an interview with the Director of Nursing (DON) on 08/12/2026 at 3:58 PM, she stated nail care should be performed during scheduled shower/bath times, at the resident's request, or proactively when care staff saw a need for it.During an interview with the Administrator on 08/14/2026 at 7:46 PM, she stated a full shower included washing the hair, as well as cleaning and trimming fingernails and toenails, unless the resident was diabetic. The Administrator stated while an RN could perform nail care, if a resident's toenails were too thick, a podiatry referral must be utilized for trimming.Review of R77's admission Record revealed the facility admitted the resident on 10/12/2024. Diagnoses included bipolar disorder, left leg amputation, and generalized muscle weakness.Review of R77's quarterly MDS with an ARD of 07/22/2026, revealed the facility assessed the resident to have a BIMS score of 15 out of 15. The score indicated the resident has no cognitive impairment. Further review revealed R77 was also assessed as dependent for personal hygiene.Review of R77's Comprehensive Care Plan, last reviewed 07/13/2026, revealed the resident required assistance with ADLs related to weakness, pain, and left above-the-knee amputation. The care plan directed staff to provide partial assistance of one staff member with personal hygiene.Review of the facility's document South Shower Schedule, undated, revealed night shift staff was assigned to shower R77 on Sundays and Thursdays.Review of the facility's document Skin Monitoring: Comprehensive CNA [Certified Nurse Assistant] Shower Review, dated 07/30/2026, revealed nail care was not included. The review also showed the assigned staff members did not sign the sheet. Additionally, the facility could not provide shower sheets for 08/02/2026, 08/06/2026, and 08/09/2026.2. Observations on 08/11/2026 at 10:33 AM and 2:35 PM revealed R77's fingernails extended beyond the fingertips, with multiple nails appearing jagged and having a yellow substance underneath.During an interview on 08/11/2026 at 10:33 AM, R77 stated he had repeatedly asked staff to trim his fingernails because they were so long and embarrassing. He stated, Staff tell me they will be back to complete this, but they never come back. He also stated he had notified the Assistant Director of Nursing (ADON) a week prior that staff had failed to trim his nails.Further observations on 08/12/2026 at 10:00 AM and 4:00 PM again revealed R77's fingernails extended beyond the fingertips, with multiple nails appearing jagged and having a yellow substance underneath.During an interview on 08/12/2026 at 4:30 PM, the ADON stated R77 had notified her the prior week that his fingernails needed to be trimmed. She stated she assigned two State Registered Nurse Aides (SRNA) to trim his nails that day; however, the care was not provided. She further stated she did not investigate why the SRNAs did not provide nail care.During an interview on 08/12/2026 at 4:00 PM, SRNA8 stated during bathing, staff washed the resident's hair, body, and perineal area, and provided nail care if needed or requested. She stated for diabetic residents, only an RN should trim nails; otherwise, any staff member could perform nail care. SRNA8, referring to R77 stated, It should have been completed at his request or during his last shower. She further stated that nail care should be assessed by all staff daily.During an interview on 08/13/2026 at 3:35 AM, the Director of Nursing (DON) stated she expected all staff to assess and perform nail care.During an interview on 08/13/2026 at 3:45 AM, the Administrator stated staff should always assess residents' nails during showers. She also stated the ADON should have followed up to ensure R77 received nail care.Review of R65's admission Record revealed the facility admitted the resident on 10/07/2026. Diagnoses included hemiplegia, muscle weakness, and lymphedema. Review of R65's quarterly MDS, with an ARD of 05/08/2026, revealed the facility assessed the resident to have a BIMS score of 15 out of 15. The score indicated R65 was cognitively intact. Review of R65's Care Plan revealed the resident was care planned on 10/13/2025 for requiring assistance with ADLs. Interventions listed were assist with incontinent care, dated 10/07/2025, and dependent on staff for toileting and toileting hygiene, dated 10/13/2025.3. Observation on 08/12/2026 at 9:00 AM revealed R65's call light was lighting up outside of her room. SRNA4 entered room, the light went off, and SRNA4 exited the room and continued filling up water for residents on the North Short Hall. SRNA4 was not observed asking any staff member for help to clean R65. During an interview on 08/12/2026 at 10:09 AM with R65, she stated she was wet and needed to be cleaned up. She stated she pushed her call light at 9:00 AM, and SRNA4 came into her room and turned her light off without cleaning her up. She stated SRNA4 then left her room, and she waited another 15 minutes before pushing her call light again. She stated SRNA4 came into room again and turned her call light off without cleaning her up. R65 stated that it was an issue when SRNA4 was assigned to her. The State Survey Agency (SSA) Surveyor asked R65 to push her call light again at 10:10 AM. SRNA5 and SRNA6 entered her room at 10:13 AM to clean R65.During an interview on 08/12/2026 at 10:16 AM with SRNA4, she stated she did clear R65's call light prior to performing the task, and she had to get help to clean R65. She stated R65 called out twice, and she went to clear the call light both times. She stated she informed R65 she needed to find another staff member to help her. SRNA4 stated clearing call lights before a task was complete is a common practice. She stated the call lights were monitored, and she cleared them as soon as she could. She stated she was filling water for residents on the hall and was waiting for another staff member to help her clean R65. During an interview on 08/14/2026 at 7:16 PM with the Director of Nursing (DON), she stated it was her expectation call lights be answered as soon as possible and not cleared before the task was completed. She stated if the call lights were cleared prematurely, staff might forget to go back to complete the task. During an interview on 08/14/2026 at 7:25 PM with the Administrator, she stated call lights should never be cleared prior to the resident being taken care of. She stated if several were going off then she expected staff to prioritize how they responded to them, but they should not be turned off until the task was complete. She stated answering and responding to call lights timely was important for resident safety. 4. Review of R97's admission Record, revealed the facility admitted the resident on 06/04/2026. R97's diagnoses included parkinsonism, generalized muscle weakness, and progressive supranuclear palsy (PSP).Review of R97's admission MDS with an ARD of 06/08/2026, revealed the facility assessed the resident to have a BIMS score of 10 out of 15. The score indicated the resident had moderate cognitive impairment.Review of R97's Care Plan Report, revealed R97 would remain clean, dry, dressed, groomed, and free of odors. The care plan also revealed R97 required assistance with activities of daily living related to weakness and debility. Interventions initiated on 06/08/2026 included maximum assistance with bathing and showers and assistance as needed with showers twice weekly.Review of R97's document Shower Sheets revealed R97 received a shower on 08/09/2026. The document was signed on that date by SRNA8. During an interview on 08/14/2026 at 5:55 PM, SRNA8 stated she had not provided R97 with a shower in approximately one month. SRNA8 also provided a sample of her signature, which did not match the signature documented on the shower sheet. During an interview with R97 on 08/11/2026 at 10:01 AM, R97 stated she had concerns about being ignored by staff and having her call light turned off before staff assisted her with her care needs. R97 also stated she had a bowel movement during the third shift the previous weekend, but no one assisted her until 9:00 AM.During an additional interview with R97 on 08/11/2026 at 10:56 AM, R97 stated (explaining about the incident the previous weekend on third shift) she had rung her call bell at 6:00 AM and expected assistance by 7:30 AM when the day shift arrived. R97 stated a female nurse entered the room but did not assist her with care. R97 stated she then managed her own care needs as much as she was physically able until a male staff member entered the room and assisted her at 9:00 AM. R97 stated she had hoped to receive a proper shower on Sunday, 08/09/2026, to resolve the issue, but the day-shift nurse told her the facility was short-staffed, and the bathing staff was already swamped.During an interview with R97's family member (F) 1 on 08/12/26 at 4:06 PM, she stated R97 did not receive a shower last weekend on the scheduled shower day of 08/09/2026. F1 stated R97 did not receive a shower until the following week. During an interview with the Director of Nursing (DON) on 08/14/2026 at 7:17 PM, the DON stated her expectation was for residents' call lights to be answered in a timely manner and for staff to provide care as soon as possible. The DON also stated showers should be completed on residents' scheduled shower days.During an additional interview with the DON on 08/12/2026 at 3:58 PM, she stated her expectation was all staff providing care to residents must follow the facility's policy.During an interview with the Administrator on 08/14/2026 at 7:43 PM, the Administrator stated her expectation was for showers to be performed on residents' scheduled shower days. She stated it was unacceptable for staff members to tell residents they could not receive a shower on their scheduled shower day or to document that a shower had been provided when it had not. She also stated it was her expectation for every staff member to follow the facility's policy when providing care to residents. The Administrator stated all ADLs must be completed for every resident.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to promote and maintain resident dignity for 1 of 1 sampled resident, Resident (R) 16. Observation on 08/11/2026 revealed R16 did not have a dignity bag covering her urinary catheter drainage bag.The findings include:Review of the facility's policy titled, Catheter Care, with a revision date of 08/12/2026, revealed the facility would ensure residents with indwelling catheters received appropriate care and maintained their dignity and privacy while indwelling catheters were in use. The policy also stated privacy bags would be available, and catheter drainage bags would always be covered while in use.Review of R16's admission Record, found in the resident's electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 07/08/2026. R16's diagnoses included fracture of unspecified part of neck of right femur, chronic obstructive pulmonary disease (COPD), and chronic kidney disease (CKD). Review of R16's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/12/2026, found in the resident's EMR, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, indicating intact cognition. Continued review of the MDS revealed R16 had an indwelling urinary catheter.Review of R16's Care Plan Report, dated 07/09/2026, found in the resident's EMR under the Care Plan tab, revealed a focus for a urinary catheter, initiated on 07/26/2026 and revised on 08/13/2026. According to the Care Plan, there was no mention of a dignity bag being utilized to maintain the dignity and privacy of the resident. Observation of R16 on 08/11/2026 at 10:32 AM revealed the resident's urinary catheter drainage bag was attached to the bed frame without a dignity bag cover. The drainage bag was visible from the hallway.Observation of R16 on 08/11/2026 at 1:31 PM revealed the resident's urinary catheter drainage bag was secured to the bed and touching the floor without a dignity cover in place. Continued observation from outside R16's room revealed staff had left the urinary drainage bag visible to individuals passing by the room.During an attempted interview with R16 on 08/12/2026 at 9:59 AM, the resident refused to allow the surveyor to enter the room and conduct an interview.An attempt made to interview R16's son by telephone on 08/12/2025 at 10:10 AM was unsuccessful.During an interview with State Registered Nurse Aide (SRNA) 5 on 08/13/2026 at 11:51 AM, she stated although she had received no recent training on catheter care, she recalled that urinary catheter drainage bags should be covered with a dignity bag because the resident had a right to privacy.During an interview with Registered Nurse (RN) 2 on 08/13/2026 at 12:05 PM, she stated urinary catheter drainage bags should always be covered with a dignity bag to maintain the resident's privacy and dignity.During an interview with the Director of Nursing (DON) on 08/14/2026 at 7:17 PM, she stated dignity bags should cover urinary drainage bags to protect the resident's privacy.During an interview with the Administrator on 08/14/2026 at 7:43 PM, she stated dignity bags should cover urinary drainage bags to maintain the resident's privacy.

Based on interview, record review, an email from the facility's pharmacy, and review of the facility's policies, the facility failed to follow established procedures for unavailable medications. The facility did not notify the physician of medication delays and the need for prior authorization to obtain direction or alternative therapy for 1 of 2 sampled residents for medication review, Resident (R) 117. The findings include:Review of the facility's policy titled, Pharmacy Services, implemented 02/01/2024 and reviewed/revised 02/14/2024, revealed the facility required staff to accurately acquire, receive, dispense, and administer routine and emergency drugs and biologicals to meet each resident's needs. The policy further directed staff and the pharmacist to request, receive, and administer medications promptly, as ordered by the prescriber.Review of the facility's policy titled, Unavailable Medications, dated 12/2017, revealed the facility required every effort to be made to ensure medications were available to meet each resident's needs. The policy directed nursing staff, when an ordered medication was unavailable, to notify the attending physician of the circumstances and expected availability of the medication and identify alternative therapy available. If nursing staff could not obtain a response from the attending physician, staff was directed to notify the nursing supervisor and contact the facility's Medical Director for orders and/or direction. The policy further directed staff to obtain a new order and discontinue the unavailable medication when an alternative medication was ordered and to notify the pharmacy of the replacement order.Review of R117's admission Record revealed the facility admitted the resident from an acute care hospital on [DATE] at 10:30 AM. The record identified diagnoses that included acute on chronic combined systolic and diastolic congestive heart failure , type 2 diabetes mellitus with foot ulcer, generalized anxiety disorder, and depression.Review of R117's November 2025 Medication Administration Record [MAR] revealed the following ordered medications were documented as unavailable during the resident's stay: atorvastatin calcium 40 milligrams (mg), one tablet by mouth once daily for hyperlipidemia; bumetanide 2 mg, two tablets by mouth three times daily for edema; and cariprazine HCl (Vraylar) 3 mg, one capsule by mouth once daily for mood.Review of R117's Progress Note, dated 11/07/2025 and documented by Licensed Practical Nurse (LPN) 6 at 1:05 AM, revealed an order for atorvastatin calcium 40 mg, one tablet by mouth once daily for hyperlipidemia. Nursing documentation stated, New admit med not unavailable.Review of R117's Progress Note, dated 11/07/2025 and documented by LPN6 at 2:12 PM, revealed an order for bumetanide 2 mg, two tablets by mouth three times daily for edema. Nursing documentation identified the medication as not available.Review of R117's Progress Note, dated 11/07/2025 and documented by LPN6 at 2:13 PM, revealed an order for cariprazine HCl (Vraylar) 3 mg, one capsule by mouth once daily for mood. Nursing documentation identified the medication as not available.Review of email correspondence from the facility's pharmacy, dated 08/14/2026 at 11:23 AM, revealed the pharmacy received R117's medication orders on 11/06/2025 and sent the medications the same day. The pharmacy reported Vraylar 3 mg was not dispensed because the medication required prior authorization (PA). The pharmacy identified liraglutide (an injectable for managing diabetes), with a start date of 11/16/2025, as the only other medication from the provided medication list that was not dispensed. Although the pharmacy reported that medications, except for Vraylar and the future-start liraglutide, were sent on 11/06/2025, R117's nursing documentation dated 11/07/2025 identified atorvastatin, bumetanide, and Vraylar as unavailable.Review of R117's clinical record revealed no documentation the physician was notified that Vraylar required prior authorization or was unavailable. There was also no documentation that physician direction was obtained regarding the medication delay or that alternative therapy was obtained.Review of R117's Progress Note, dated 11/08/2025, revealed the resident expressed a desire to leave the facility against medical advice (AMA). Further review of R117's Progress Note, dated 11/08/2025 at 5:18 PM, revealed an entry documenting AMA.During an interview with R117 on 08/13/2026 at 8:00 PM, the resident stated, I left the faciity on [DATE] against medical advice because it had been three days and I still didn't have all my medications.During an interview on 08/12/2026 at 3:00 AM, LPN3 stated newly admitted residents frequently complained about medications not being available and often waited two to three days to receive their medications. LPN 3 stated medication delays for newly admitted residents occurred frequently.An attempted interview with LPN6 on 08/14/2026 at 2:00 PM was unsuccessful. LPN6, who documented medication availability information during R117's stay, was no longer employed by the facility, and the telephone number provided for LPN6 was no longer in service.During an interview with the Nurse Practitioner (NP) on 08/14/2026 at 3:00 PM, the NP stated neither facility staff nor R117 reported medication availability issues during the resident's stay.During an interview with the Physician on 08/14/2026 at 4:00 PM, the Physician stated facility staff had not notified him that R117 had unavailable medications or that a medication required prior authorization. The Physician further stated it was important for staff to notify him of all medication delays so an alternative medication could be ordered. He stated alternative medications would maintain continuity of medication therapy and prevent potential complications associated with delays in treatment.During an interview with the Director of Nursing (DON) on 08/14/2026 at 7:00 PM, she stated she expected nursing staff to communicate all medication delays to the Physician. The DON stated this would prevent residents from going without their medications.During an interview with the Administrator on 08/14/2026 at 7:30 PM, she stated she expected residents to receive their ordered medications and expected nursing staff to notify the Nurse Practitioner (NP) or Physician of any unavailable medications. She stated then the issue could be addressed promptly.

Based on interview, record review, and review of the facility's policies, the facility failed to notify the resident and the resident's representative of the bed hold notice and the transfer or discharge and the reasons for the move in writing and in a language in manner they understood as soon as practicable. The facility further failed to ensure the notice included the reason, date, and location for the transfer as well as a statement of the resident's appeal rights and the contact information for the state long term care ombudsman. The deficient practice was identified for 4 out of 18 residents investigated for transfer and or discharge, Resident (R) 18, R24, R29, and R37.The findings include:Review of the facility's policy titled, Bed Hold Notice Upon Transfer, revised 03/05/2025, revealed, At the time of transfer for hospitalization or therapeutic leave the facility will provide to the residents and/or resident representative written notice which specifies the duration of the bed hold policy and addresses information explaining the return of the resident to the next available bed. The policy also revealed, In the event of an emergency transfer of a resident, the facility will provide within 24 hours written notice of the facility's bed hold policies, as stipulated in the State's plan. Per the policy, The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file.Review of the facility's policy titled, Transfer and Discharge (including AMA), revised 03/20/2025, revealed, The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge. b. the effective date of transfer or discharge. c. the specific location (such as name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged . d. An explanation of the right to appeal the transfer or discharge to the state. e. The name, address (mailing and email) and telephone number of the State entity which received such appeal hearing requests. f. Information on how to obtain an appeal form. g. Information on obtaining assistance in completing and submitting the appeal hearing requests. h. The name, address (mailing and email), and phone number of the representative of the Office of the State Long Term Care Ombudsman. i. For nursing facility residents with an intellectual and developmental disabilities (or related disabilities) or with mental illness (or related disabilities), the notice will include the name, mailing and e-mail addresses and phone number of the state agency responsible for the protection and advocacy of these populations.1.Review of R18's admission Record revealed the facility admitted R18 on 03/03/2025 with diagnoses of autistic disorder, mild cognitive impairment, and intellectual disability.Review of the facility's Census revealed R18 was sent to the hospital on [DATE] and 04/06/2025.Review of R18's Bed Hold Notice, dated 04/02/2025, revealed it was left blank with a handwritten note reading ER visit only.Review of R18's Bed Hold Notice, dated 04/09/2025, revealed R18's Representative was notified verbally by the facility's Business Office Manager (BOM). The State Survey Agency (SSA) Surveyor requested, from the facility's staff on 07/08/2025 and 07/09/2025, R18's Transfer/Discharge Notice for the 04/02/2025 and 04/06/2025 hospital transfers, but neither was produced. Also, the SSA Surveyor was unable to find the forms in R18's electronic medical record (EMR). During an interview on 07/09/2025 at 11:32 AM with R18's Representative, he stated he emailed the facility to ask if R18 would be able to return to the facility for rehabilitation, but he had never received a Bed Hold Notice or Transfer/Discharge Notice via email or mail.2. Review of R24's admission Record revealed the facility admitted the resident on 12/23/2024 with diagnoses of diabetes, chronic kidney disease, and personality and behavior disorder.Review of the facility's Census revealed R24 was sent to the hospital on [DATE], 06/05/2025, and 06/22/2025.Review of R24's Bed Hold Notice for the transfer on 02/26/2025 revealed R24's Representative and the BOM signatures with no signature date.Review of R24's Bed Hold Notice for the transfer on 06/05/2025 revealed R24's Representative and the BOM signatures with no signature date.Review of R24's Bed Hold Notice for the transfer on 06/22/2025 revealed R24's Representative and the BOM signatures with no signature date and a handwritten note stating, ER Visit.The SSA Surveyor requested, from the facility's staff on 07/08/2025 and 07/09/2025, R24's Transfer/Discharge Notice for the 02/26/2025, 06/05/2025, and 06/22/2025 hospital transfers, but none was produced. Also, the SSA Surveyor was unable to find the forms in R24's EMR. However, the facility did provide the SNF/NF [Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form for the three dates, which included medical information.During an interview on 07/08/2025 at 7:14 PM with R24's Representative, she stated she had never been given any copies of Bed Hold Notice or Transfer/Discharge Notice. She stated the only thing she had ever received in the mail from the facility were bills. She stated she was asked to sign the Bed Hold Notice on 07/08/2025 for the three transfers over the last six months. She stated the BOM had her sign them today as she was walking out of the front door after visiting with R24.3. Review of R37's admission Record revealed the facility admitted the resident on 09/28/2022 with diagnoses of hypertension, depression, and Parkinson's disease.Review of the facility's Census revealed R37 was sent to the hospital on [DATE].Review of R37's Bed Hold Notice for the transfer on 03/08/2025 revealed R37's signature and the BOM's signature with no signature dates.The SSA Surveyor requested, from the facility's staff on 07/08/2025 and 07/09/2025, R37's Transfer/Discharge Notice for the 03/08/2025 hospital transfer, but it was not produced. Also, the SSA Surveyor was unable to find the form in R37's EMR. During an interview on 07/09/2025 at 8:31 AM with R37, he stated he did not recall receiving a written copy of a Bed Hold Notice or Transfer/Discharge Notice when he was sent to the hospital.4. Review of R29's admission Record revealed the facility admitted the resident on 10/18/2019 with diagnoses of cerebral infarction with hemiplegia and hemiparesis, heart disease, Alzheimer's, and type 2 diabetes. Review of R29's Change in Condition evaluation, dated 04/08/2025, revealed the resident had a complaint of chest pain and was sent out to the local hospital emergency room (ER) for evaluation and treatment.Review of R29's Progress Notes, dated 04/08/2025, revealed R29 returned to the facility via ambulance free of pain, with no new orders.Review of R29's EMR did not reveal a Transfer/Discharge Notice or Bed Hold Notice had been completed, signed, or mailed. The SSA Surveyor requested, from the Administrator on 07/09/2025, R29's Transfer/Discharge Notice for the 04/08/2025 hospital transfer, but it was not produced. The Administrator provided a copy of the Bed Hold Notice to the SSA Surveyor. Review of the Bed Hold Notice for R29 revealed the form had been completed and signed by R29 on 07/09/2025, the same date as requested. During an interview with R29 on 07/08/2025 at 9:16 AM, he stated he made his own medical decisions and did not recall signing any forms when transported to the hospital on [DATE]. He also stated he did not recall being informed about the bed hold policy. He stated he was told by staff he would be sent to the hospital. He stated, after being seen, the ambulance returned him to the facility, and he was placed back in the same room. During a follow up interview with R29 on 07/09/2025 at 4:00 PM, he stated a staff person came to his room and told him his signature was needed on a form they had forgotten to have signed. He stated he was unsure why the form needed to be signed on this date [07/09/2025] when his visit to the hospital had been months ago. During an interview on 07/08/2025 at 3:20 PM with the BOM, she stated she did not provide a written copy of the Bed Hold Notice to the resident or their representative each time a resident was sent out of the facility. She stated the resident, or their representative, signed a bed hold agreement upon admission. She stated she notified the majority of the representatives and made them aware verbally, but not all of them. During an interview on 07/08/2025 at 3:30 PM with the Director of Nursing (DON), she stated the E Interact Transfer Form was completed via point click care (PCC, a software) and sent with the resident to the hospital. She stated a written copy was not provided to the resident's representative unless the representative was present at the time of the transfer. During an additional interview on 07/09/2025 at 9:31 AM with the DON, she stated she was not aware that Bed Hold Notices and Transfer/Discharge Notices were supposed to be sent to both the resident and their representative. During an interview on 07/08/2025 at 3:45 PM with the Administrator, she stated if the resident was unable to sign the Bed Hold Notice, then an email was sent to the representative, or the notice was sent via certified mail. During an additional interview on 07/09/2025 at 10:30 AM with the Administrator, she stated it was her expectation that bed hold and transfer notices were completed timely, so the facility knew if they needed to hold the bed.

Based on observation, interview, and review of the facility's documents and policy, the facility failed to provide a safe, clean, comfortable and homelike environment for the long hall on the North Unit. Observations on 07/07/2025, 07/08/2025, and 07/09/2025 revealed a lingering odor of urine throughout the area. During the Resident Council meeting on 07/08/2025 at 2:00 PM, Residents (R) 52, R54, and R65 stated the area smelled of feces, and it needed air freshener. The residents also stated they had to cover their faces because of the odor. This had the potential to affect the 30 residents residing on the long hall of the North Unit.The findings include:Review of the facility's policy titled, Safe and Homelike Environment, dated 02/01/2024, revealed housekeeping services would be provided as necessary to maintain a sanitary, orderly, and comfortable environment. Per the policy, general considerations to minimize odors were for staff to dispose of soiled linens promptly and report lingering odors and uncleaned bathrooms to the housekeeping department. Review of the facility's policy titled, Resident/Patient Room Cleaning, dated 02/01/2025, revealed cleaning and disinfecting must be performed in a manner that minimized the chance of dirt/germs contacting a surface that had already been cleaned or disinfected.Review of the facility's document Floor Plan, undated, revealed 30 residents resided on the long hall of the North Unit.Review of the facility's document Grievance Form, dated 05/01/2025, revealed the Resident Council attendees voiced concern that resident bathrooms were dirty and needed to be cleaned twice daily instead of once daily. Observation on 07/07/2025 at 10:44 AM during the initial tour of the long hall of the North Unit revealed the odor of urine, starting from room [ROOM NUMBER] to room [ROOM NUMBER]. This odor of urine lasted throughout the day. Observation on 07/08/2025 at 8:00 AM, 10:15 AM, and until 1:15 PM of the long hall of the North Unit revealed a very strong odor of urine.Observation on 07/09/2025 at 7:39 AM of the long hall of the North Unit revealed the odor of urine.Observation on 07/09/2025 at 8:05 AM of the long hall of the North Unit revealed urine odor was present, and at 8:45 AM the urine odor was stronger toward the end of the hallway. Observation on 07/09/2025 at 10:25 AM of the long hall of the North Unit revealed the urine odor remained in the hallway near the nurse's station. Observation on 07/09/2025 at 1:20 PM of the long hall of the North Unit revealed the urine odor remained in the hallway.Review of R52's admission Record revealed the facility admitted the resident on 01/10/2023 with diagnoses of major depression and anemia. Review of R52's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 05/08/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, indicating intact cognition.Review of R54's admission Record revealed the facility admitted the resident on 01/16/2023 with diagnoses of major depression, post-traumatic stress disorder, and anxiety. Review of R54's quarterly MDS, with an ARD of 07/07/2025, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating intact cognition. Review of R65's admission Record revealed the facility admitted the resident on 05/03/2024 with diagnoses of cerebral palsy, depression, and anemia.Review of R65's quarterly MDS, with an ARD of 04/16/2025, revealed the facility assessed the resident to have a BIMS score of 14 out of 15, indicating intact cognition. In an interview with the Resident Council attendees on 07/08/2025 at 2:00 PM, all seven residents in attendance stated their concern with the odor of urine in the long hallway of the North Unit. Resident 52 stated it smells like poop and pee in the hallway. R54 stated when she went into the hallway, she had to cover her face due to the smell, and R65 stated he asked for air freshener, and no one brought it. Review of R49's admission Record revealed the facility admitted the resident on 09/20/2023 with diagnoses of hypertension and cerebral vascular accident (stroke) with left hemiparesis. Review of R49's quarterly MDS, with an ARD of 04/16/2025, revealed the facility assessed the resident to have a BIMS score of zero out of 15, indicating severe cognitive impairment. In an interview with the Environmental Services (EVS) Manager on 07/09/2025 at 8:50 AM, she stated R49 missed the urinal in his room when he urinated, and the urine got into the wax on the floor. She stated he tried to empty his own urinal into the trash can. The EVS Manager stated they controlled the odors in the hallway and concentrated on cleaning certain rooms, in the mornings. She stated these were focus rooms, with residents who urinated around the floor. She stated the housekeeping staff checked the residents' focus rooms morning and night. She stated other male residents also missed the toilet or bedside commode. She stated housekeeping tried to daily mop, clean high touch areas, strip and wax the floor in these rooms to control the odor. She stated the housekeepers on the North Unit had been instructed on those special focus rooms and how to clean them. In an interview with Certified Nurse Assistant (CNA) 4 on 07/09/2025 at 4:30 PM, she stated Resident (R) 49 refused bath/showers, tried to urinate in the room using a urinal and poured the urine into his trash can. She stated he refused changes and showers. In an interview with the Director of Nursing (DON) on 07/09/2025 at 1:24 PM, she stated her expectation was to provide residents with a home like environment. She stated staff tried to encourage showers and the use of urinals.In an interview with the Administrator on 07/09/2025 at 1:14 PM, she stated there was a resident on the North Unit who did not want to be changed, and staff would change out the mattress and try to encourage more brief changes.

Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or a centralized staff work area from each resident's bedside. Observation on 07/07/2025 at 10:40 AM, revealed the call light for the resident room, bed 1 and bed 2, where Resident (R) 387 and R18 resided was not working. During an interview with R387, the resident stated their call light had not worked since Saturday, 07/05/2025.The findings include:During an interview on 07/09/2025 at 9:31 AM with the Director of Nursing (DON), she stated there was no facility call light policy.Review of R387 admission Record revealed the facility admitted the resident on 07/03/2025 with diagnoses of stroke, diabetes mellitus type 2, and congestive heart failure (CHF).Review of R387's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/07/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, indicating R387 was cognitively intact. Review of R18's admission Record revealed the facility admitted the resident on 03/03/2025 with diagnoses of autistic disorder, intellectual disability, and depression. Review of R18's admission MDS, with an ARD of 06/16/2025, revealed the facility assessed the resident to have a BIMS score of zero out of 15, indicating R18 was severely cognitively impaired. Observation on 07/07/2025 at 10:40 AM, revealed the call light for R387 and R18's room for bed 1 and bed 2 was not working. During an interview on 07/07/2025 at 10:40 AM with R387, he stated the call light had not worked since Saturday (07/05/2025). He stated he let staff know, but he could not remember the name of the staff member. He stated the staff member he informed told him they would make maintenance aware. He stated he was not offered an alternative way to call out for assistance.The State Survey Agency (SSA) Surveyor was unable to interview R18 due to his cognitive status and being nonverbal. During an interview on 07/07/2025 at 10:50 AM with Licensed Practical Nurse (LPN) 3 and Registered Nurse (RN) 3, they stated they were not aware of the call light for R387 and R18 not working. Both stated they were unsure how long it had not been working. During an interview on 07/09/2025 at 9:06 AM with the Maintenance Director, he stated the call light system was not capable of running reports of call light histories. He stated he was not aware of the call light not working since Saturday. He stated he received work orders after they were entered into the TELS system (facility's software) for him to fix. During continued interview on 07/09/2025 at 9:31 AM with the DON, she stated her expectation was that call lights were answered timely. She stated she did not know if/when they were checked, and she would need to check with maintenance. She stated she had not done any call light audits, but she had only been at the facility a couple of months. She stated it was important to have working call lights, and they be answered timely to keep residents safe and to meet their needs. During an interview on 07/09/2025 at 10:30 AM with the Administrator, she stated there were not call light audits or a policy on them. She stated it was her expectation that call lights were answered as quickly as possible. She stated call lights were checked to make sure they worked prior to every admission. She stated if any issues were found with malfunctioning call lights, then it should be entered into TELS for maintenance to fix promptly. She stated if call lights were not working, an alternative device to call for assistance should be offered for resident safety.

Based on observation, interview, record review, review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User Manual, and review of the facility's policy, the facility failed to ensure the Minimum Data Set [MDS] assessment accurately reflected the resident's status for 2 of 18 sampled residents, Resident (R) 28 and R57.Review of R28's admission MDS, with an Assessment Reference Date (ARD) of 05/14/2024, inaccurately documented the resident was admitted with a catheter.Review of R57's two quarterly MDS, with an ARD of 02/28/2025 and 05/29/2025, both documented active diagnoses of pneumonia and septicemia without any evidence of treatment for the diagnoses. Additionally, R57's annual MDS, with an ARD of 12/11/2024, quarterly MDS, with an ARD of 02/28/2025, and quarterly MDS, with an ARD of 05/29/2025, incorrectly coded the COVID-19 and influenza vaccine status.The findings include:Review of the RAI 3.0 Manual Version 1.19.1, dated 10/2024, revealed the RAI process required that the assessment accurately reflected the resident's status, and a registered nurse conducted or coordinated each assessment with the appropriate participation of health professionals. Further review revealed the definition of active diagnoses was physician documented diagnoses in the last 60 days that had a direct relationship to the resident's current functional status, medical treatment, and nursing monitoring during the seven-day look back period. Continued review revealed for septicemia to be coded there had to be documented evidence of inflammation due to sepsis and evidence of a microbial process in the medical record.Review of facility's policy titled, MDS 3.0 Completion, dated 02/01/2024, revealed the facility conducted accurate and standardized assessments of each resident according to the federal regulations, using the RAI specified by the State. Per the policy, responsibility of sections would be clearly assigned based on discipline, and persons completing the assessment must attest to the accuracy of the section they completed.1. Review of R57's admission Record revealed the facility admitted the resident on 12/08/2023 with diagnoses of chronic obstructive pulmonary disease (COPD), abscess of lung with pneumonia, and severe sepsis.a. Review of R57's Physician Progress Note, dated 01/08/2025, revealed active diagnoses of COPD, high blood pressure, type 2 diabetes, and morbid obesity.Review of R57's quarterly MDS, with an ARD of 02/28/2025, revealed the facility assessed the resident with active diagnoses of pneumonia and septicemia.Review of R57's Physician Progress Note, dated 02/28/2025, revealed active diagnoses of COPD, high blood pressure, type 2 diabetes, and morbid obesity.Review of R57's Physician Progress Note, dated 04/17/2025, revealed active diagnoses of COPD, high blood pressure, type 2 diabetes, and morbid obesity.Review of R57's quarterly MDS, with an ARD of 05/29/2025, revealed the facility assessed the resident with active diagnoses of pneumonia and septicemia.In an interview with R57 on 07/08/2025 at 9:14 AM, she stated she had a history of lung infection and sepsis prior to admission to the facility but could not recall any infections requiring antibiotics or hospital treatment for some time.In an interview with the MDS Coordinator on 07/09/2025 at 3:07 PM, she stated she had the responsibility for completing assessments, gathering data, reviewing hospital records, verifying diagnoses, and entering information obtained into the MDS assessment. She stated diagnoses were added to assessments when there had been active treatments or a diagnosis within the past 30 days prior to the reporting date. She stated she could not provide a reason for adding diagnoses of pneumonia and septicemia on R57's past two quarterly MDS without being active diagnoses. However, she stated it could had been due to being three months behind and going back and reviewing charts, then adding information.b. Review of R57's annual MDS, with an ARD of 12/11/2024, as well as two quarterly MDS, with ARDs of 02/28/2025 and 05/29/2025, revealed staff documented that R57 did not receive the influenza vaccine during the year's influenza vaccination season. For each of these three MDS assessments, staff documented that the vaccine was offered and declined. However, review of R57's vaccination records revealed the resident received the influenza vaccine on 10/04/2024.Further review of these three MDS assessments revealed they documented that R57's COVID-19 vaccination status was not up to date. However, review of R57's vaccination records revealed R57 received the COVID-19 vaccine on 11/21/2024.In an interview with the MDS Coordinator on 07/09/2025 at 2:15 PM, she stated those three MDS assessments did not accurately reflect R57's immunization status. She stated she used the facility's immunization records for coding the MDS, noting that these records included both electronic and paper documents (which the facility was in the process of uploading). She stated the facility was going to an all-electronic system, and the immunization records were currently in several different places. The MDS Coordinator stated the MDS errors occurred because of the multiple locations where the records were stored, adding, to confirm the resident's immunization status, I was not looking in the right place. 2. Review of R28's, admission Record revealed the facility initially admitted the resident on 04/07/2025 with diagnoses including Alzheimer's disease, acute kidney failure, and Crohn's disease. Review of R28's admission MDS, with an ARD of 04/11/2025, revealed the resident was assessed for an indwelling catheter. Review of R28's Nursing admission Evaluation and Baseline Care Plan, dated 04/07/2025, revealed the resident was assessed for urinary incontinence. Further review revealed the section that addressed the presence of a urinary catheter was marked No.Review of R28' s Comprehensive Care Plan Report, initiated on 04/09/2025, revealed a focus for alteration in elimination related to incontinence with interventions for assistance with daily toileting needs, incontinence care every shift and as needed, and peri-care after incontinent episodes as needed.Review of R28's Skilled Nursing Documentation, dated 04/07/2025, revealed documentation that specified the absence of genitourinary (GU) appliances.Review of R28's hospital Discharge summary, dated [DATE], revealed no documented evidence of an indwelling catheter. Review of R28's Nursing Assessment re-admission Evaluation, dated 06/10/2025, revealed the resident was assessed for urinary incontinence. Further review revealed the section that addressed the presence of a urinary catheter was marked No.Review of R28's admission MDS, (following a hospitalization) with an ARD of 06/14/2025, revealed the resident was assessed for an indwelling catheter. Review of R28's Skilled Nursing Documentation, dated 06/23/2025, revealed documentation that specified the absence of genitourinary (GU) appliances. Observation of R28 on 07/08/2025 at 4:12 PM revealed the resident asleep in bed; an indwelling urinary catheter was not observed. Additional observation on 07/09/2025 at 2:27 PM revealed R28 in a wheelchair near the North Hall nurse's station; an indwelling urinary catheter was not observed. In an interview with the North Hall Unit Manager (UM) on 07/08/2025 at 4:19 PM, she stated R28 did not have an indwelling urinary catheter.In an interview with the MDS Coordinator on 07/09/2025 3:10 PM, she stated prior to completion of a resident's MDS, she verified diagnoses, obtained hospital records, reviewed medical records, and assessed the resident. She further stated she reviewed medications and reviewed nursing documentation. The MDS Coordinator stated she clarified any questionable documentation with the appropriate staff. The MDS Coordinator stated in order to assess a resident's bowel and bladder function, she reviewed the Certified Nurse Aide's charting, talked to the resident, talked to nursing, and reviewed any other documentation related to incontinence. The MDS Coordinator stated it was her responsibility to ensure the accuracy of a resident's MDS. She further stated MDS accuracy was important because it guided a resident's care. When asked about R28's bowel and bladder assessment, the MDS Coordinator stated the resident was incontinent and wore a brief; however, she was not aware the resident was coded for an indwelling urinary catheter. In an interview with the Director of Nursing (DON) on 07/09/2025 at 4:25 PM, she stated the accuracy of MDS reporting was important to provide an accurate picture of a resident's current status, drove the care plan, and thus the treatment for a resident. She stated the MDS Coordinator was responsible for entering accurate information and verifying that other disciplines entered accurate information.In an interview with the Administrator on 07/09/2025 at 4:30 PM, she stated the MDS reflected a resident's status and guided the care of a resident. She stated the facility had used a contracted service for MDS reporting prior to the current MDS Coordinator, who began in 01/2025, and believed there was a back log of information upon filling the position. She stated it was very important to ensure accuracy of information on the MDS to ensure proper care, reporting, and reimbursement.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to an effective system in place to safeguard against any misappropriation of a resident's funds. One (1) of thirteen (13) sampled residents (Resident #35) relied on facility staff for shopping and community expenditures. However, the facility failed to ensure maintenance of documentation of these expenditures, by facility staff, on the resident's behalf, which might have contributed to an allegation of misappropriation by Resident #35. The findings include: Review of the facility's policy titled, Management of Residents' Personal Funds, revised 2017, revealed residents had the option of: a) managing their own personal funds; b) designating a representative to manage their personal funds; c) applying to the Social Security Administration to have a representative payee designated for federal and state benefits to which they might be entitled; or d) have the facility hold, safeguard, and manage their personal funds. The policy did not cover the facility's documentation of expenditures made with the resident's funds when the resident was responsible for managing his/her personal funds and requested the facility to shop for him/her. Review of Resident #35's medical record revealed he/she was admitted to the facility, on 03/16/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #35's Admission Minimum Data Set (MDS) Assessment, dated 03/24/2020, revealed the facility assessed the resident with the Brief Interview for Mental Status (BIMS). The resident scored six (6) out of fifteen (15) which indicated severe cognitive impairment. Review of Resident #35's Admission History and Physical, dated 04/02/2020, revealed the resident was admitted for rehabilitation and physical therapy following a hospitalization . Further review of Resident #35's admission documentation revealed the resident did not desire the facility to manage his/her funds. Continued review of Resident #35's medical record revealed an Annual MDS Assessment, dated 01/28/2022, with a BIMS' score of fourteen (14) which indicated no cognitive impairment. Review of a Social Service Progress Note, dated 07/09/2020, revealed Social Services #1 met with Resident #35 regarding social security benefits. The progress note stated she called the Social Security Office, which revealed Resident #35's social security money had been loaded onto a Direct Express Card. The resident stated he/she no longer had possession of the card. The progress note also stated Social Services #1 was to assist in reporting the card as lost or stolen, so Resident #35 could get another card. Review of Resident #35's medical record revealed a Social Services Progress Note, dated 02/09/2022, in which the Social Services Director (SSD) met with Resident #35 to attempt to resolve his/her account issues. Per the note, the SSD and Resident #35 spoke with a bank customer service representative on the phone and were informed the resident had no money in his/her account, as withdrawals had been made from the account recently and over the last few months. The progress note also stated Resident #35's current card was canceled, a new card was to be issued, and bank statements were to be mailed to the resident. Per the note, Resident #35 desired to make a police report. Review of a Long Term Care Facility Self-Reported Incident Form, dated 02/08/2022, revealed Resident #35 reported an allegation of misappropriation because no money was in his/her account. Per the report, two (2) prior transactions had documented that there was a payout to Social Services #2, who had resigned from the position on 08/23/2021. Review of Social Services #2's employee file revealed she started work at the facility, on 07/29/2020, in activities. Per the file, she then moved to the position of Social Services #2, when it became vacant. Social Services #2's employee file revealed she had been trained on the facility's policies of Misappropriation of Resident Property, Abuse and Neglect, and Resident Dignity on 07/29/2020. Interview with Resident #35, on 02/10/2022 at 10:51 PM and again on 02/11/2022 at 7:42 AM, revealed when at the hospital prior to admission, the hospital lost everything, his/her clothing, wallet, everything. The resident stated Social Services #2, who previously worked in activities, helped him/her get a new card and went shopping for him/her, as well as to the store and restaurants for other residents. Resident #35 stated when he/she tried to order a pizza recently, his/her card was declined due to lack of funds. Additionally, he/she stated, although not certain of the amount, Resident #35 estimated there should be around $4,000.00 in his/her account. Resident #35 stated that on a call he/she had with the customer service representative at the bank, he/she and the SSD were told the last two (2) withdrawals, in January and February 2022, were for $30. This was the amount he/she received each month. The payouts were listed as payouts to Social Services #2. Resident #35 stated Social Services #2, who was no longer at the facility, had access to his/her card number and also his/her PIN (personal identification number). Social Services #2 had this information in order to shop for him/her. Resident #35 stated that even though Social Services #2 did not take his/her card, she could have ordered a second card since she had access to information about the card. Resident #35 concluded by noting that in addition to the SSD, the police were also looking into the situation. Interview with the Social Services Director (SSD), on 02/10/2022 at 8:37 AM, revealed she started working at the facility on 11/01/2021. She stated Resident #35 had informed her he/she had tried to use his/her debit card and found there was no money on the card. She stated she and Resident #35 spoke with a customer service representative, who informed them there was no money in Resident #35's account, with the most recent withdrawal being on 02/03/2022 to Social Services #2, and a prior withdrawal in early January also to Social Services #2. The SSD stated the customer service representative (CSR) canceled Resident #35's card and would send out a new one. Also, the SSD stated the CSR was going to send out a statement for the prior six (6) months for Resident #35 to review, so any monies not spent by Resident #35 could be reimbursed. The SSD stated she and Resident #35 immediately spoke with the Administrator and then called the police. Further interview revealed she had not been shopping for residents and was uncertain who was responsible for shopping for residents. Interview with the Business Office Manager (BOM), on 02/10/2022 at 8:58 AM, revealed residents had the option to enroll in a resident account. She stated Resident #35 always handled his/her money. The BOM stated that previously Social Services #2 went shopping for residents. She stated the process was that SS #2 would get a list together from residents. If they had a resident account, money would be taken from a cash fund, then replaced from the residents' accounts upon review of the receipt from shopping. She stated for residents with accounts, records were kept of expenditures, which she maintained in her office. For residents without resident accounts, she was uncertain how long records were maintained. She revealed Social Services #2 and her assistant had created a form to document shopping lists and to keep receipts with the form. The BOM was only able to provide one (1) form with receipts. The last form completed by the assistant for Social Services #2, who did the shopping for Resident #35, revealed $50.08 was spent shopping for grocery items, on 10/14/2021, and $14.17 spent at a local restaurant, on 10/15/2021. This form was initialed by Resident #35 that his/her card had been returned following completion of shopping. The BOM stated this was the only form she had, as any prior ones had been given to Social Services #2 for disposition. Interview with the Recreation Services Director, on 02/10/2022 at 11:33 AM, revealed she had just started in this role on 12/15/2021. She revealed she shopped for residents, but had not yet been shopping for Resident #35. She stated she let residents know in advance when she was planning a shopping trip, and for residents with no resident trust account, they would put their cards or cash (along with a note indicating how much cash) in an envelope, with their card PIN written on the inside of the envelope in case it was required. Further interview revealed she kept account of transactions and provided residents with receipts. She stated no residents had ever complained to her about missing money. The Recreation Services Director stated there had been office changes recently, and she was unaware of any previous record of expenditures for residents without resident trust accounts made by the facility's staff at the resident's request. Interview with the Executive Director (ED), on 02/11/2022 at 11:00 AM, revealed his expectation that staff followed the facility's policy in managing residents' funds and that residents' funds only be used for resident expenditures. Regarding documentation, he stated he expected staff to also follow the facility's policy. He stated he was unaware of any issues with residents' funds prior to the report by Resident #35. The ED stated the policy did not address a staff member's use of a resident's personal funds or debit card with the PIN number. He stated he did not think it was the facility's responsibility to monitor these transactions, even though the facility's staff was involved in the monetary transaction. He also stated the report by Resident #35 was still under investigation by police, and the facility was still in the process of their own investigation as well.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to store food in accordance with professional standards for food service safety. Observation on 12/15/2021, revealed the North Unit resident nourishment refrigerator contained foods which were not labeled or dated and were not marked with resident identification. Additionally, there was the appearance of black dots on the bottom shelf of the refrigerator. Further, there was the appearance of blue frost, white substance and a brown hair on the bottom shelf of the freezer. The findings include: Review of the facility's policy titled, Foods Brought by Family/Visitors, dated 10/2017, revealed the nursing staff will discard perishable foods on, or before the use by date. Perishable foods will be labeled with the resident's name, the item and the use by date. Observation on 12/16/2021 at 8:40 AM, of the North Unit resident refrigerator, revealed the appearance of black dot like particles, on the bottom shelf. The refrigerator also contained a four (4) ounce strawberry yogurt, and a 1.5 ounce of sharp cheddar cheese bar, neither of which was labeled, dated, or marked with a resident's identification. Continued observation of the nourishment freezer revealed the freezer had a hue of blue frost, a white substance and a brown hair adhered to the bottom shelf. Interview with Registered Nurse (RN) #7, on 12/17/2021 at 10:37 AM, revealed the Dietary staff brought nourishments and stocked the refrigerator at night. She stated she did not know who was responsible to clean the nourishment refrigerator. Interview with Housekeeper #1, on 12/17/2021 at 10:40 AM, revealed she was not responsible to clean the resident nourishment refrigerator located behind the nurses station. Interview with State Registered Nurse Aide (SRNA) #7, on 12/17/2021 at 10:45 AM, revealed dietary staff was responsible for cleaning out the nourishment refrigerators. Interview with the Registered Dietitian (RD), on 12/17/2021 at 10:30 AM and 2:05 PM, revealed food was delivered to the resident refrigerators on the night shift and foods were rotated at that time. Continued interview revealed food should be labeled with food type, date, and resident identification. Further interview revealed Dietary staff was not responsible for cleaning out the nourishment refrigerator as that was the nursing staff's responsibility. Interview with SRNA #3 and SRNA #8, on 12/17/2021 at 2:22 PM, revealed food received from families was to be labeled with the resident's name and put into the resident's personal refrigerator or the unit resident refrigerator. Interview with the Assistant Director of Nursing (ADON), on 12/17/2021 at 2:25 PM, revealed dietary staff was responsible to clean resident refrigerators on the unit and to rotate the foods in the refrigerator. Interview with the Director of Nursing (DON), on 12/17/2021 at 2:43 PM, revealed Dietary staff was responsible for cleaning the resident unit refrigerators and rotating foods. Further, staff should label and date the food as well as mark the food items with resident identification, prior to placing the food items in the resident unit refrigerator. Interview with the Administrator, on 12/17/2021 at 5:00 PM, revealed it was his expectation for staff to keep the resident nourishment refrigerators clean and food was to be labeled, dated and include a resident identification.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) Healthcare Providers Guideline, review of the facility's education manuals, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19. The facility also failed to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the CDC, and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19 for four (4) of twenty-two (22) sampled residents (Resident #7, #218, #368, and #369). 1. Observation on 12/14/2021, revealed two (2) visitors, escorted by a staff member, entered Resident #218's (recent treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The visitors were not wearing appropriate Personal Protective Equipment (PPE), although there was signage on the door specifying Droplet Precautions and Airborne Precautions. In addition, observation on 12/15/2021, revealed a Healthcare Services Group Manager-in-Training exited Resident #218's room wearing a N-95 mask and eye protection. She walked down the hall before she removed the PPE. 2. Observation on 12/14/2021, revealed Registered Nurse (RN) #3, State Registered Nurse Aide (SRNA) #4, and the Assistant Director of Nursing (ADON) entered Resident #7's (possible C-Diff) room without donning appropriate PPE or performing hand hygiene, although there was signage on the resident's door specifying Contact Precautions. Observation on 12/15/2021, revealed SRNA #5 entered Resident #7's room without donning PPE to refill the resident's water cup. SRNA #5 exited the room with Resident #7's water cup, then entered the resident's room with the same water cup, again without donning PPE. 3. Observation, on 12/14/2021, revealed Nursing Assistant #3 entered and exited both Resident #368's room and Resident #369's room, who were in Droplet and Contact Isolation, without using correct hand hygiene or wearing the appropriate PPE (gloves, gown, and N 95 respirator or mask with goggles). The findings include: Review of the Centers for Disease Control and Prevention (CDC) Healthcare Providers Clean Hands Count for Healthcare Providers Guideline, reviewed 01/08/2021, revealed hand hygiene reduced the spread of infection and disease to patients (residents). Alcohol-based hand rub (ABHR) and washing hands with soap and water were the two (2) methods for hand hygiene. Further review revealed the clinical indications for hand hygiene included immediately before touching a patient, after touching a patient or the patient's immediate environment, when hands were visibly soiled, and before preparing or handling medications. Review of the facility's policy titled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, revised September 2021, revealed the facility followed infection prevention and control practices recommended by the Centers for Disease Control and Prevention. Further review revealed the facility would follow transmission-based precautions where indicated and appropriate use of Personal Protective Equipment (PPE). Additional review revealed administrative practices were in place to mitigate the spread of COVID-19 including education of residents and visitors; and, staff training. Review of the facility's policy titled, Infection Control Program, Version #:2 Effective Date:12/27/2016, revealed the purpose of the policy was to provide a safe sanitary and comfortable living environment to help prevent development and transmission of infection. Further review revealed the infection control program included prevention, surveillance, and control measures to protect residents and personnel from healthcare associated infections and determines when procedures such as isolation needed to be implemented. Review of the Clinical Practice Guidelines for [CONDITION(S)] Infection (CDI) in Adults and Children, Centers of Disease Control, dated 2017, revealed Contact Precautions should be utilized for patients with known or suspected CDI. 1. Review of Resident #218's Electronic Medical Record (EMR) revealed the facility admitted the resident on 12/13/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #218's Discharge Summary, dated 12/13/2021, revealed the resident was admitted to the hospital on 11/26/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the Summary revealed the resident was asymptomatic for COVID-19, and there was no indication for therapeutics. Continued review of the Summary, revealed [CONDITION(S)] was treated with oral [MEDICATION(S)] (antibiotic medication), and the toxin stool test was negative which indicated colonization rather than actual infection. Interview with the Infection Control Preventionist, on 12/14/2021 at 4:15 PM, revealed it was standard protocol, with no Physician's Order required, to place new admissions on Transmission Based Precautions (TBP), which was the reason Resident #218 was on TBP. Observation on 12/14/2021 at 10:35 AM, revealed two (2) signs on Resident #218's door: Droplet Precautions and Airborne Precautions. Per the signage, Droplet Precautions included hand sanitizing before entering and after exiting the room and fully cover the eyes, nose, and mouth before room entry with a N95 or mask with goggles. Additional observation revealed the Airborne Precautions sign stated, Everyone must: Put on a fit-test N-95 or higher-level respirator before room entry. Observation on 12/14/2021 at 10:35 AM, revealed the Business Office Manager (BOM) escorted two (2) of Resident #218's family members into his/her room. Further observation revealed both family members were wearing medical masks and no other Personal Protective Equipment (PPE). Interview with the BOM, on 12/14/2021 at 10:36 AM, revealed she had spoken with Registered Nurse (RN) #2, prior to escorting the visitors into Resident #218's room and was informed the visitors could enter the room. Further interview revealed RN #2 did not direct the BOM to instruct the visitors to wear PPE. Interview with RN #2, on 12/14/2021 at 10:37 AM, revealed she told the BOM that Resident #218's family could visit, but the nurse did not elaborate on instructions given to the BOM as far as PPE upon entering the room. Interview with Resident #218's Visitor #1, on 12/14/2021 at 10:41 AM, revealed his parent had recently been admitted to the facility. Further, he stated he was not informed by anyone in the facility on what PPE to wear when entering his parent's room. Interview with Resident #218's Visitor #2, on 12/14/2021 at 10:42 AM, revealed he was not provided education by the facility on what PPE to wear when entering his grandparent's room. Observation of Resident #218's door, on 12/14/2021 at 4:00 PM, revealed three (3) signs were on his/her door: Droplet Precautions, Airborne Precautions and Contact Precautions. Continued interview with the Infection Control Preventionist, on 12/14/2021 at 4:15 PM, revealed she had added three (3) signs to Resident #218's room for extra precautions because Resident #218 had recently returned from the hospital. Observation on 12/15/2021 at 9:25 AM, revealed a Healthcare Services Group Manager-in-Training exited Resident #218's room wearing a N-95 mask and eye protection. The Manager walked down the hall about fifty (50) feet before she removed the N-95 mask and eye protection. She then utilized the hand sanitizer on the wall. Interview with the Healthcare Services Group Manager-in-Training, on 12/15/2021 at 10:55 AM, revealed she was taught how to keep from spreading COVID and the proper procedures to prevent the spread of COVID during orientation. However, she stated she exited Resident #218's room while wearing a mask and eye protection. 2. Review of Resident #7's EMR, revealed the facility admitted the resident on 09/15/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's Admission Minimum Data Set (MDS) Assessment, dated 09/22/2021, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) which indicated the resident had intact cognition. Additional review revealed the resident required limited assistance for toilet use and was frequently incontinent of bowel with no toileting program in place. Review of Physician's Orders revealed no orders for isolation and/or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the Director of Nursing (DON), on 12/17/2021 at 4:50 PM, revealed nurses were directed to place Resident #7 in TBP while awaiting results of a stool specimen. Observation of Resident #7's door, on 12/14/2021 at 11:01 AM, revealed signage for Contact Precautions. The sign included instructions to clean hands before entering and leaving the room, don (put on) gloves and gown prior to entering the room and discard gloves and gown upon exiting the room. Further, the signage instructions included: use dedicated or disposable equipment, or clean and disinfect reusable equipment before use on another person. Observation on 12/14/2021 at 12:30 PM, revealed RN #3 entered Resident #7's room without donning Personal Protective Equipment (PPE) or performing hand hygiene. Interview with RN #3, on 12/14/2021 at 12:30 PM, revealed she knew the importance of contact isolation, and had been provided training on the types of PPE to wear in Transmission Based Precautions (TBP). Additionally, she stated she should have worn PPE when entering Resident #7's room related to the potential for C-Diff, but since she was just delivering supplies, she chose not to don the necessary PPE. Observation on 12/14/2021 at 12:49 PM, revealed SRNA #4, in Resident #7's room, with no PPE. Further, SRNA #4 exited the room without performing hand hygiene. Interview with SRNA #4, on 12/14/2021 at 12:49 PM, revealed she was not aware Resident #7 was in TBP. Additionally, she was not aware she was supposed to wear PPE when she was in Resident #7's room because the resident just had C-Diff. Further, she stated staff caring for residents with C-Diff were not required to wear PPE. Observation on 12/14/2021 at 3:50 PM, revealed the ADON was in Resident #7's room without PPE. The ADON exited the resident's room without performing hand hygiene and carried a clear garbage bag out of the room. She then walked down the hallway with the clear garbage bag to the soiled closet. When she exited the soiled closet, she used hand sanitizer in the hallway and re-entered Resident #7's room without PPE. Interview with the ADON, on 12/14/2021 at 4:05 PM, revealed all staff were trained upon hire, monthly and as needed on TBP and PPE usage. Additionally, she expected all staff to don and doff PPE per guidelines when entering a room with TBP. Per interview, she should have donned PPE prior to entering Resident #7's room. Further interview revealed residents who required TBP and PPE were discussed in morning Clinical Meeting, Monday through Friday with the Director of Nursing (DON), Assistant Director of Nursing (ADON), Minimum Data Set (MDS) Nurse and Registered Dietician (RD). Continued interview revealed during the 12/14/2021 Clinical Meeting, Resident #7 was discussed, and the Interdisciplinary Team (IDT) determined the resident had potential C-Diff and required a transfer to a private room and contact isolation until labs confirmed the infection, since he/she had symptoms of C-Diff. Interview with Resident #7, on 12/15/2021 at 3:59 PM, revealed he/she had multiple diarrhea stools, and was moved to a private room and was placed on Transmission Based Precautions (TBP), on 12/14/2021 due to a poop infection. Observation on 12/15/2021 at 4:04 PM, revealed SRNA #5 entered Resident #7's room without donning PPE to refill the resident's water cup. SRNA #5, exited the room with Resident #7's water cup, then entered the resident's room with the water cup, again without donning PPE. Interview with SRNA #5, on 12/15/2021 at 4:04 PM, revealed he received training on infection control and was knowledgeable on types of TBP and what PPE to wear. However, he had not been instructed on the facility's protocol on proper handling of water cups/refilling water glasses for residents in isolation. Further, he stated he should have worn PPE when entering Resident #7's room and should not have removed the water cup out of isolation into the hallway. 3. A. Review of Resident #369's medical record revealed the facility admitted the resident on 12/08/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #369 resided on the Rehab Unit. Review of Resident #369's Physician's Orders, dated 12/08/2021, revealed no orders for isolation and no orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] B. Review of Resident #368's medical record revealed the facility admitted the resident, on 12/10/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS Assessment, dated 12/17/2021, revealed the facility assessed the resident as having a BIMS score of fifteen (15) of fifteen (15) indicating intact cognition. Resident #368 resided on the Rehab Unit. Review of Resident #368's Physician's Orders, dated 12/08/2021, revealed no orders for isolation and no orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] However, continued interview with Infection Control Preventionist, on 12/14/2021 at 4:15 PM, revealed Resident #369 and Resident #368 were in TBP because of their recent admissions. Observation on 12/14/2021 at 12:15 PM, of Resident #368's and Resident #369's doors, revealed both had signage for Droplet Precautions that included hand sanitizing before entering and after exiting the room and fully cover the eyes, nose, and mouth before room entry with a N95 or mask with goggles. Further observation revealed both doors had signage for Contact Precautions that included instructions to clean hands before entering and leaving the room; don gloves and gown prior to entering the room and discard gloves and gown upon exit of the room; and, use dedicated or disposable equipment, or clean and disinfect reusable equipment before use on another person. Further observation revealed both doors had a third sign which included instructions for the correct sequence to don (put on) and doff (remove) Personal Protective Equipment (PPE). Continued observation on 12/14/2021 at 12:15 PM, revealed Nurse Assistant (NA) #3 walked up the South Hall pushing an unsampled resident in a wheelchair. While pushing the wheelchair, NA #3 was observed to stop in front of Resident #369's room as the call light was ringing. NA #3 did not perform hand hygiene, but donned only a hospital mask with no other PPE and entered Resident #369's room. NA #3 stood in the middle of the resident's room and asked the resident what he/she needed. The observation revealed NA #3 then, without doffing (removing) the mask or performing hand hygiene, exited Resident #369's room. Continued observation on 12/14/2021 at 12:15 PM, revealed after NA #3 exited Resident #369's room, she immediately entered Resident #368's room as the call light was ringing; however, the NA did not perform hand hygiene or don PPE prior to entering. NA #3 had on the same hospital mask. NA #3 stood in the middle of the resident's room and asked the resident what he/she needed. The call light went off. Further observation revealed NA #3 then, without doffing the mask or performing hand hygiene, exited Resident #368's room. NA #3 then proceeded to push the unsampled resident down the hall in the wheelchair. Interview with NA #3, on 12/14/2021 at 12:45 PM, revealed she was in a hurry but should have donned PPE prior to entering residents' rooms with signage posted for TBP, which included a gown, mask, face shield, and gloves. She further stated it was important to wear appropriate PPE to protect the residents and staff from anything that could be contagious. Continued interview revealed she failed to perform hand hygiene prior to entering and prior to exiting Resident #369's and Resident #368's rooms. Interview with RN #2 on 12/15/2021 at 10:30 AM, revealed she worked on the Rehab Unit. She stated staff were required to wear a gown, gloves, face shield or goggles into residents' rooms that were on TBP. She stated signage was placed on the residents' doors to identify those residents who were on TBP. Per interview, staff was also to practice good hand hygiene prior to entering and prior to exiting resident rooms. Continued interview revealed Resident #368 and Resident #369 did not have known infections, but it was standard protocol to place new admissions in precautions. Interview with Resident #369, on 12/15/2021 at 11:40 AM, revealed he/she did not know why SSA Surveyors were wearing PPE into his/her room. He/she stated staff did not wear PPE into his/her room. Further, he/she was unaware of the the signs on his/her door, and staff did not explain to him/her the meaning of the signs. Additional interview with the Infection Control Preventionist (ICP) on 12/17/2021 at 4:34 PM, revealed signs were placed on the residents' doors listing the required PPE to wear prior to entering a room with TBP. The ICP stated if staff did not wear the appropriate PPE, this could cause the spreading of microorganisms amongst residents and staff. Further interview revealed it was important for staff to practice good hand hygiene before entering or exiting a resident's room for infection control purposes. Interview with the Director of Nursing (DON), on 12/17/2021 at 4:50 PM, revealed NA #3 should have asked another staff member to answer the call lights or return the unsampled resident to his/her room and then answer the call lights. Further interview revealed it was her expectation for all staff to follow the facility's practice of wearing appropriate PPE in TBP rooms and to practice good hand hygiene prior to entering and exiting a resident's room and any time it was appropriate for infection control. Continued interview revealed staff needed to advise visitors of the need to utilize PPE when appropriate and also inform residents why they were placed on TBP with signage on their doors. Interview with the Administrator, on 12/17/2021 at 5:00 PM, revealed it was his expectation for staff to don/doff PPE according to the signage on the TBP resident room doors in order to prevent potential spread of infections. Further, it was his expectation staff practice hand hygiene as per policy for infection control.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to treat each resident with respect and dignity, and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for two (2) of twenty-two (22) sampled residents (Resident #2 and Resident #271). Observation, on 12/14/2021, revealed Nurse Assistant (NA) #1 failed to knock prior to entering Resident #271's room. When Resident #271 asked NA #1 when she would make his/her bed, NA #1 walked out without responding to Resident #271. Observation, on 12/14/2021 at 12:17 PM, during the lunch meal service, revealed Resident #271 and Resident #2 were both in room [ROOM NUMBER] and NA #1 started assisting Resident #2 with meal service. However, Resident #271 received his/her tray approximately forty-five (45) minutes after his/her roommate (Resident #2) received a meal tray. On 12/14/2021, State Registered Nurse Aide (SRNA) #1, was interviewed as to why Resident #271 had not received his/her meal tray. In front of Resident #2, SRNA responded, All of the feeders are taken care of first. Observation, on 12/15/2021 at 12:00 PM, revealed Resident #2 (Resident #271's roommate) received a meal tray and was assisted by therapy. However, Resident #271 did not receive his/her lunch meal tray until approximately one (1) hour later, even though they were both in the same room during meal service. Observation on 12/15/2021 at 5:36 PM, revealed Resident #271, had not received his/her dinner meal tray; however, Resident #2 who was in the same room, received his/her meal and was feeding himself/herself. The findings include: Review of the facility's Resident Rights policy, dated 11/28/2017, revealed residents had a right to a dignified existence and access to persons and services inside and outside of the facility. The facility must treat each resident with respect and dignity and, care for residents in a manner which promoted enhancement of his/her quality of life. The facility must provide a homelike environment for each resident. Review of Resident #271's clinical record revealed the facility admitted the resident on 12/10/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the resident was homeless before he/she entered this facility. Record review revealed Resident #271's Admission Minimum Data Set (MDS) Assessment had not been completed due to the resident being a new admission. There was no Brief Interview for Mental Status (BIMS) completed for the resident. However, observation on 12/15/2021, revealed the resident communicated with the State Survey Agency (SSA) Representative and the resident was able to make wants and needs known. Review of Resident #2's clinical record revealed the facility admitted the resident on 04/06/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 12/09/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) indicating severe cognitive impairment. The MDS Assessment further revealed the resident required one (1) person physical assistance for bed mobility, and supervision, cueing, encouragement, and one (1) person physical assist for eating. Resident #2 was wheelchair-bound. 1. Observation on 12/14/2021 at 12:13 PM, revealed Nurse Assistant (NA) #1 entered Resident #271's room (room [ROOM NUMBER]) and did not knock on the door prior to entering. At that time, Resident #271 asked her when she would make his/her bed. NA #1 walked out without responding to Resident #271. Further observation revealed NA #1 returned a few minutes later with linen, tossed it on Resident #271's bed and turned to walk out. Resident #271 asked, Aren't you supposed to make that for me? NA #1 told the resident she would be back later. Interview with SRNA #1, on 12/15/2021 at 11:40 AM, revealed residents were to be treated with dignity and respect, and staff were to honor residents' requests and assist residents with their needs to the extent possible. SRNA #1 stated staff should always knock on residents' doors before they entered the room because that was their home. Interview with Resident #271, on 12/15/2021 at 12:20 PM, revealed he/she watched as NA #1 stood outside the room and talked and did not work. The resident stated NA #1 would come into his/her room many times and not speak to him/her at all. Resident #271 further stated if he/she asked NA #1 to do something, she would take a very long time to do it and did not communicate the process. Interview with NA #1, on 12/16/2021 at 1:55 PM, revealed she had been at the facility for three (3) months, and had passed all of her check-offs and was ready to take the SRNA test. NA #1 explained staff should show residents dignity and respect and should always be nice and help the residents. She further stated staff should always knock before entering residents' rooms, but sometimes she did not knock because she was used to the residents. Continued interview with NA #1, on 12/16/2021 at 1:55 PM, revealed staff was not to change linens when trays were passed out. Per interview, staff could only change linens during meal service if the resident or the bed was wet or soiled. She stated she should have talked with Resident #271 to explain how things would be done when she delivered the linen to the resident on 12/14/2021. Further interview revealed Resident #271 had complained several times that Resident #2 (Resident #271's roommate) got better care and more attention. NA #1 stated she explained to Resident #271, that Resident #2 required more help. Additionally, NA #1 stated she did not engage with Resident #271 because the resident was usually asleep, and she did not want to bother him/her. Interview with Registered Nurse (RN) #7, on 12/17/2021 at 9:41 AM, revealed residents should be treated like, we would want to be treated. RN #7 stated staff should take their concerns to heart and always address them. She stated, she had actually watched NA #1 avoid areas and residents in order to not have to provide care for them. Further interview revealed she was not in a supervisory position, but as an RN, she was responsible for the care staff delivered. She stated she had voiced concerns related to NA #1 to both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) on more than one occasion. Interview with the DON, on 12/17/2021 at 2:59 PM, revealed it was not appropriate for staff to take linens in the resident's room and drop it on the bed and walk out without an explanation as to what would take place. She stated this did not show respect for the resident. 2. Observation on 12/14/2021 at 12:17 PM, revealed NA #1 entered room [ROOM NUMBER] and talked with Resident #2, (Resident #271's roommate) and asked the resident if he/she needed a fork. Resident #2 explained he/she was unable to use a fork on his/her own. Further observation revealed NA #1 assisted Resident #2. SRNA #1 then entered the room and told NA #1 that she provided care for Resident #2. However, Resident #271, who was also in room [ROOM NUMBER] at the time, had not received a meal tray and at no time did either staff member inform Resident #271 when his/her tray would be there, nor did they talk to Resident #271. Resident #271 was noted to be standing in his/her room waiting for lunch to be delivered. Observation on 12/14/2021 at 12:20 PM, revealed Resident #271 had not received the meal tray at the time of the observation. The SSA Representative asked Resident #271 when he/she would receive his/her meal tray and the resident responded, This is how it is every day. Interview on 12/14/2021 at 12:20 PM, with SRNA#1, revealed Resident #271 had not received his/her meal tray yet as All of the feeders are taken care of first. SRNA #1 stated this in front of Resident #2. When SRNA #1 was asked if it was appropriate to refer to the residents as feeders, she stated, Ah, yeah. Observation on 12/14/2021 at 1:00 PM, revealed Resident #271 still had not received his/her lunch tray. Interview with SRNA #1, on 12/14/2021 at 1:00 PM, revealed Resident #271's meal trays came from a different cart and maybe that was why the resident had not received his/her tray yet. She further stated, meal trays would be delivered first for some residents who ate in the dining room, but if the resident was not in the dining room, the tray would be left on the cart and delivered to the resident when all the other trays for their area had been passed out. However, further interview revealed Resident #271 ate in his/her room. Observation on 12/14/2021 at 1:03 PM, revealed Resident #271 received his/her lunch tray, which was approximately forty-five (45) minutes after his/her roommate (Resident #2) received a meal tray. Per observation, Resident #271 was able to feed self. Interview with the Assistant Director of Nursing (ADON), on 12/14/2021 at 1:03 PM revealed the delay in Resident #271 receiving his/her meal tray could have happened because the resident was scheduled for meals in the dining room. However, she was not sure if this was the case for this resident. She stated the residents made the choice as to where they wanted to eat. Further interview with the ADON, revealed it was not appropriate for staff members to refer to a resident as a feeder. Interview on 12/14/2021 at 1:05 PM, with Resident #271, revealed staff had never asked him/her if he/she wanted to eat in the dining room. The resident stated, nobody had talked to him/her about preference for location for dining. Interview with Resident #271, on 12/15/2021 at 12:20 PM, revealed he/she had just met with the Dietary Aide and finally got his/her menu straightened out. Resident #271 stated, I go last for everything, eating, everything. He/she stated this made him/her feel bad and he/she did not feel like he/she was treated equally to the other residents. 3. Observation on 12/15/2021 at 12:00 PM, revealed Resident #2 (Resident #271's roommate) received a meal tray and was assisted by therapy. Further observation revealed residents in room [ROOM NUMBER] received their lunch meal trays at 12:36 PM. Residents in room [ROOM NUMBER] received their lunch meal trays at 12:40 PM, and residents in room [ROOM NUMBER] received their lunch meal trays at 12:45 PM. At 1:03 PM, Resident #271 who was in room [ROOM NUMBER] and residents in room [ROOM NUMBER] had not received their lunch trays. SRNA #1 was observed to walk down to the North Long Hall to obtain Resident #271's meal tray to deliver to room [ROOM NUMBER], and to obtain meal trays for the residents in room [ROOM NUMBER]. Resident #271 received the lunch meal tray approximately one (1) hour after Resident #2 (Resident #271's roommate) received his/her lunch tray. Interview with SRNA #1, on 12/15/2021 at 1:03 PM, revealed she delivered the last trays to rooms [ROOM NUMBERS]. SRNA stated she did not know why residents in these rooms received their food so late. She stated rooms [ROOM NUMBERS] were on the South Hall, but the carts that come to South Long hall were completely full and the trays for rooms [ROOM NUMBERS] were on the cart for the North Long Hall. 4. Observation of Resident #271, on 12/15/2021 at 5:36 PM, revealed the resident had not received his/her dinner meal tray. However, Resident #2 who was Resident #271's roommate had received his/her meal and was self feeding. Further observation revealed other residents on the South Hall had received their meal trays. Interview with Registered Nurse (RN) #7, on 12/17/2021 at 9:41 AM, revealed residents on the South Long Halls including Resident #271 were to receive their meal trays first. RN #7 stated the correct process to deliver trays was to ensure both residents in a room received their meal trays at the same time and if this did not occur, it could be a dignity issue. Further interview revealed she was unaware Resident #271 was not receiving the meal tray at the same time as his/her roommate. Interview with the Dietitian/Kitchen Manager, on 12/17/2021 at 1:30 PM, revealed food trays were delivered to the units on five (5) different carts. The first cart went to the North dining room as some residents were assigned to eat in there. She further stated if the resident was not at the dining room when trays were delivered, the trays were to be taken straight to the resident in their room. Per interview, the tray was not to be left or put back on the cart because of temperature concerns. Further interview revealed Resident #2 was documented to be in the dining room for meals, and this was why that resident received his/her tray first. Per interview, staff was to ensure Resident #2 was up, dressed and down in the dining room for meals. The Dietitian/Kitchen Manager further stated, when there were two (2) residents in one (1) room, both were supposed to receive their food at the same time. Further interview with the Dietitian/Kitchen Manager, on 12/17/2021 at 1:30 PM, revealed trays were set up for delivery for Rooms 209, 210, 211, 212 and 213 on the South Long Hall Cart. She stated rooms [ROOM NUMBERS] were to receive their trays with rooms, 216 to 225, which were delivered on the Short South Hall Cart. When observations of tray pass on 12/15/2021 were explained to the Dietitian/Kitchen Manager, she stated she could not explain how or why that would happen. Interview with the Director of Nursing (DON), on 12/17/2021 at 2:59 PM, revealed residents should be treated with dignity and respect. Further, it was not appropriate to refer to residents as feeders as this was a dignity issue. Continued interview revealed she expected staff to treat residents with dignity at all times including during meal service. Further, staff should knock on residents' doors to obtain permission to enter. The DON stated she had worked with staff in the past on customer service. Interview with the Administrator, on 12/17/2021 at 4:46 PM, revealed it was his expectation for staff to treat the residents with dignity and respect during all interactions as the facility was their home. Further, all staff should knock and announce before they entered a resident's room, because we would not want someone just walking into our house. He further stated staff should ensure residents were treated respectfully during meal service. Continued interview revealed he expected staff not to use any old nursing home terms such as feeder.

Based on observation, interview, record review, and review of the facility's Policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of seven (7) sampled Residents (Resident #6). Resident #6 was admitted by the facility on 12/05/19, review of the residents electronic health record (EHR), the facility failed to perform initial admission [MEDICAL CONDITION] ([CONDITION]) skin test. The findings include: Review of the facility's [MEDICAL CONDITION] Screening Policy, dated 05/17/16, revealed prior to admission, each resident shall be required to have a health assessment, including history of significant past or present infectious diseases and a statement that the resident show no evidence of [MEDICAL CONDITION] in an infectious stage as verified upon admission and yearly thereafter. Further review revealed residents who have not had documented negative [MEDICATION NAME] skin test result during the preceding twelve (12) months, the baseline [MEDICATION NAME] skin testing should employ the two-step method. If the first step is negative, a second test should be performed within one (1) to three (3) weeks after the first test. Review of Resident #6's medical record revealed the facility admitted the resident on 12/05/19 with [DIAGNOSES REDACTED]. Review of Resident #6's Immunization Report from the Electronic Health Record (EHR), revealed no documented evidence of [MEDICATION NAME] Skin Test (TST) as being performed. Resident #6's physician's orders [REDACTED]. Interview on [DATE]20 at 10:45 AM with Registered Nurse (RN) #1, revealed, she was the admission nurse for Resident #6 on 12/05/19. She stated that when she receives a new admission the resident was to receive a two (2) step TST upon admission. Per interview she did not recall if she administered the first step to Resident #6. She further stated if she had done the test it would be documented in the resident's EHR. Per interview, the risk factors of not performing the test could cause infection and the spread of the disease. Per interview, she was responsible for administering the test as being the admission nurse. She further stated when the orders are populated in the EHR, the orders would pop up on the computerized electronic Medication Administration Record [REDACTED]. Interview with RN #2, on [DATE]20 at 10:35 AM, revealed she had worked at the facility since March 2019. She stated when a resident was admitted it was the responsibility of the admission nurse to order and perform initial TST. Per interview it was important to administer the TST to determine if the resident had [MEDICAL CONDITION]. She further stated the risk factors of not performing the test could expose and endanger others to the disease. Interview on [DATE]20 at 09:35 AM with the Assistant Director of Nursing (ADON), revealed TST should be ordered on admission and administered. Per interview the admission nurse on the floor are responsible. She further stated it was the responsibility of the ADON or DON to follow up after a resident was admitted to audit that the administration of the TST had been done. Per interview Resident #6 should have received a TST and there was no documented evidence that this had been done on admission. She further stated the risk factors of not performing this test are others being exposed to the disease. Interview with the Director of Nursing (DON), on [DATE]20 at 11:00 AM, revealed she did not know how or why the initial TST was missed on Resident #6. She further stated it was her expectation for the TST to be administered and the Risk Factor Assessment to be completed by the admitting nurse on admission. She further stated the TST results were to be recorded as per regulation. Interview with the Administrator, on [DATE]20 at 11:20 AM, revealed he had worked at the facility since December 2019. He stated it was his expectation for the policy and procedure regarding [MEDICAL CONDITION] Screening to be followed by all staff. Per interview he was unaware Resident #6 had not received the TST skin test until today. He further stated it should have been done on admission and the risk factors could be exposure to others to the disease.

Based on interview, record review, and review of facility Policy, it was determined the facility failed to ensure residents were free from abuse for one (1) of seven (7) sampled residents (Resident #2). On 01/02/2020 at approximately 10:30 PM, Resident #2 overheard SRNA #5 say at the nurses station, he/she doesn't have any sense, his/her IQ isn't more than [AGE] and this was upsetting to the resident. Resident #2 reported this incident to Registered Nurse (RN) #4 on the morning of 01/03/2020. The findings include: Review of the facility's Freedom from Abuse and Neglect, Policy, revised 10/30/19, revealed the purpose: to prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of property. Further review revealed the definition of abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish. Review of the facility's Investigation, dated 01/03/2020, signed by the Administrator, revealed Resident #2 reported to RN #4 on 01/03/2020 that on 01/02/2020 the resident overheard State Registered Nursing Assistant (SRNA) #5 state she doesn't have any sense, her IQ isn't more than [AGE]. Per the facility's Investigation, Resident #2 stated this was upsetting to him/her. Review of the Long Term Care -Self Reported Form Five (5) Day Follow Up/Report, dated 0[DATE]20, revealed the facility had in fact substantiated the allegation of verbal abuse between SRNA #5 and Resident #2. Further review revealed SRNA #5 did not deny stating this about Resident #2 and was terminated following the findings of the investigation. Review of Resident #2's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BI[CONDITION]) score of twelve (12) out of fifteen (15) indicating cognitively intact. Interview with Resident #2, on 01/13/2020 at 2:45 PM, revealed he/she recalled what they overheard SRNA #5 stated at the nurses station on 01/02/20. During the interview, the resident stated they hated to have to report the incident however it bothered him/her and he should not be allowed to make statements about him/her and hurt their feelings. Further interview revealed he/she felt safe in the facility and once it was reported to RN #4, the facility handled the situation and he/she never saw SRNA #5 again. Resident #2 further stated it was their understanding that SRNA #5 was fired. Interview on 01/14/2020 at 10:10 AM with Assistant Director of Nursing (ADON), revealed she had been employed at the facility for approximately eight (8) months. She stated she was aware of the verbal abuse allegation, she further stated she witnessed the phone conversation between the Director of Nursing (DON) and SRNA #5, on 01/03/2020. Per interview SRNA #5 did not deny verbally abusing Resident #2, in fact he laughed when he was asked if he made the statement. Continued interview revealed she was aware of other allegations in the past involving SRNA #5; however, previous facility owners would not allow termination. She further stated she was happy he was terminated. Phone Interview on 01/14/20 at 11:30 AM, with Registered Nurse (RN) #4, revealed she was assigned to Resident #2 on 01/03/2020 and Resident #2 had reported to her on the morning of 01/03/2020 that on the evening of 01/02/2020 he/she overheard SRNA #5 state he/she has no sense and he/she only had the IQ of [AGE]. Per interview she immediately reported the incident to the DON. Per interview Resident #2 did state he/she did not want to get anyone in trouble however what was said was very hurtful to them. Per interview, she has not seen SRNA #5 and was unsure if he was terminated, once she reported to DON she was no longer involved in the investigation. Interview on 01/14/2020 at 2:10 PM, with the Social Services Director (SSD), revealed she was informed of the allegation by the Administrator on 01/03/2020. Per interview the Administrator did not tell her what happened just asked her to go and interview Resident #2. Resident #2 informed her that his/her [MEDICAL CONDITION] bag had busted a couple times on the evening of 01/02/2020. Resident #2 stated it was not intentional and SRNA #5 assisted him/her to take care of it. Per interview, she said the resident was crying during the interview. She further stated the resident has always been emotional since admission to the facility. Per interview, the resident reported he/she put themselves in the wheelchair and wheeled themselves out into the hallway, when he/she got to the doorway they overheard SRNA #5 state he/she does not have any sense, their IQ is eighty ([AGE]). The resident then stated they turned around and went to bed. The SSD reassured the resident it was not okay for anyone to speak about them like that in any manner. Per interview she has been involved in several allegations regarding SRNA #5 and that he had moved all over the building related to the allegations. She further stated he had been coached, educated and counseled. Per interview she does not make the decision with regards to disciplinary action with staff. She further stated with previous owners of the facility they received lots of pushback with regards to terminating the employee. She feels his previous behaviors could have potentially put others at risk for being abused. Continued interview revealed she is grateful the employee was terminated. Interview with the DON, on 01/14/2020 at 3:50 AM, revealed she had worked at the facility since November 2018. Her expectation was for residents to be free from abuse as per policy. She expected staff to treat each resident with dignity and respect. She further stated this should be a safe place for the residents. Per interview, when RN #4 notified her of the allegation of verbal abuse she immediately notified the Administrator and started an investigation. She stated, she called SRNA #5 on the phone with the ADON as a witness. She stated SRNA #5 did not deny making the statement about Resident #2, and that he even laughed about it over the phone. She further stated SRNA #5 was suspended pending the investigation and staff began conducting skin assessments on all of the residents along with interviews of residents and staff. She stated the facility substantiated the allegation of verbal abuse and terminated SRNA #5. Per interview they provided education to all of the staff related to abuse. Per interview there were other incidents involving SRNA #5 and that he was educated, counseled and disciplined; however, she was unable to ever terminate him, had she been able to terminate him she would have done so long before now. She further stated she had zero tolerance for anyone acting in this manner. Interview on [DATE]20 at 11:20 AM with the Administrator, revealed it was his expectation residents were free from any form of abuse as per the facility's policy. Per interview he expected staff to treat all residents with dignity and respect. However, further interview revealed after the investigation was conducted the facility substantiated that verbal abuse did occur between Resident #2 and SRNA #5 and SRNA #5 was terminated.

Based on observation, interview, record review, and review of the facility Policies, it was determined the facility failed to have safeguards and systems in place to control, account for, and reconcile controlled medications to ensure all controlled medications were maintained for two (2) of seven (7) sampled residents (Resident #3 and Resident #4). Resident #4 was prescribed [MEDICATION NAME] one (1) milligram (mg) (anxiety medication) to be administered by mouth twice a day for anxiety. The pharmacy delivered 30 (tablets), which was a fifteen (15) day supply of [MEDICATION NAME] tablets on [DATE]. However, on [DATE] when the licensed practical nurse (LPN) went to administer the medication, there were none available to administer. Resident #3 was prescribed [MEDICATION NAME] 5-325 milligram (mg) (narcotic pain medication) to be administered every four (4) hours PRN (as needed) for pain. The Pharmacy delivered thirty (30) tablets, which was a fifteen (15) day supply of [MEDICATION NAME] 5-325 mg tablets on [DATE]. However, on [DATE], nine (9) days later, when the facility was doing an audit of narcotics they determined this medication was missing and the resident's Controlled Drug Record for the sixty (30) [MEDICATION NAME] 5-325 mg tablets could not be located. The facility failed to ensure the thirty (30) [MEDICATION NAME] 5-325 mg tablets and thirty (30) [MEDICATION NAME] 1 mg which were delivered on [DATE], were accurately reconciled and added to the locked narcotic medication drawer. The findings include: Review of the facility's Controlled Medications Policy, undated, revealed medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state law regulations. Further review revealed when drugs are delivered, the nurse on duty checks the drugs against the pharmacy order sheet and signs the receipt for delivery. Review of the facility's Storage of Medications Policy, dated 04/2019, revealed the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Further review revealed Schedule II Controlled Substances are stored in a separate compartment within the locked medication carts and should have a different key or access device. 1. Review of Resident #3's medical record revealed the facility admitted the resident on 03/11/19 with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], Localized [MEDICAL CONDITION] and Essential Hypertension. Review of Resident #3's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BI[CONDITION]) score of nine (09) out of fifteen (15), indicating moderate cognitive impairment. Further review of the MDS Assessment revealed the facility assessed the resident as having no pain during the last five (5) days of the assessment reference period at a zero (0) on a scale of zero (0) to ten (10). Review of Resident #3's Monthly physician's orders [REDACTED]. Further review revealed an order on 1[DATE] to discontinue the medication due to non-usage. Review of the Pharmacy Delivery Sheet, dated [DATE], revealed thirty (30) [MEDICATION NAME] 5-325 mg tablets were delivered to the facility for Resident #3 on [DATE], (fifteen (15) day supply), and Assistant Director of Nursing signed the Sheet as receiving the medication. 2. Review of Resident #4's medical record revealed the facility admitted the resident on 07/29/19 with [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly Minimum Data Set (MDS) Assessment, dated 12/05/09, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BI[CONDITION]) score of eight (8) out of fifteen (15), indicating moderate cognitive impairment. Further review of the MDS Assessment revealed the facility assessed the resident as receiving seven (7) days of antianxiety medications during the assessment period. Review of Resident #4's Monthly physician's orders [REDACTED]. Review of the Pharmacy Delivery Sheet, dated [DATE], revealed thirty (30) [MEDICATION NAME] one (1) mg tablets were delivered to the facility for Resident #4 on [DATE], (fifteen (15) day supply), and Assistant Director of Nursing (ADON) signed the Sheet as receiving the medication. Interview with ADON, on 01/14/2020 at 10:10 AM, revealed she signed for one (1) skid (pack) of [MEDICATION NAME] 5-325 mg tablets which were delivered by Pharmacy on [DATE] for Resident #3 and one (1) skid pack of [MEDICATION NAME] one (1) mg tablets which were delivered by Pharmacy on [DATE] for Resident #4. Per interview, the normal process on [DATE], was for the nurse that received the medication from pharmacy to hand over the medication to whichever nurse was caring for the resident at the time so that nurse could add the medication to the resident's locked narcotic drawer and put the Controlled Drug Sheet in the Narcotic Book with the nurses signing for the transfer of the medication. She further stated when she received the medications from pharmacy she did not see the staff nurse on the floor, she placed the medications in her pocket and went out for a smoke break with the Director of Nursing (DON). Once she returned she handed Resident #3's [MEDICATION NAME] medication skid and Resident #4's 1 mg [MEDICATION NAME] skid and the accompanying Controlled Drug Records to Licensed Practical Nurse (LPN) #2. Per interview, LPN #2 accepted the medications. She further stated she has no keys to the medication cart was why she did not place them there herself. She further stated she should have signed and observed LPN #2 place the medications in the cart however she failed to follow the facility's policy and procedures and failed to sign with the LPN #2 of medications being added to the medications controlled locked compartment. Per interview, she was suspended during the investigation. Interview with LPN #1, on 01/14/2020 at 10:45 AM, revealed she had worked at the facility for a year. She stated it was the facility's policy/procedure for two nurses to sign for the receipt of narcotics. Per interview they sign two (2) different sheets. One sheet is the pink sheet admitting they received the narcotics from pharmacy. The other sheet is controlled drug record sheet that medication is added to the medication cart. Per interview she was not working the day the incident happened, she only heard rumors of missing narcotics. Phone message left for LPN #2 to return call, on 01/14/2020 at 10:40 AM. Phone message left for LPN #3 to return call, on 01/14/2020 at 10:45 AM. Post exit message for LPN #3 to return call, on 01/22/2020 at 1:30 PM. The State Agency Representative was unable to interview Resident #3 or Resident #4 related to cognitive impairment. The facility was unable to locate or submit for review the Controlled Drug Record related to the [MEDICATION NAME] or [MEDICATION NAME] delivered on [DATE]. Interview with the Director of Nursing (DON), on [DATE]20 at 11:00 AM, revealed it was reported to her by LPN #3 that the pharmacy reported they could not fill the [MEDICATION NAME] one (1) mg as requested earlier in the day on [DATE] related to the fact that a skid of thirty (30) [MEDICATION NAME] one (1) mg had been delivered and signed for by the ADON on [DATE]. She stated she spoke with the ADON who reported she handed the medications to LPN #2; however, LPN #2 denied receiving any narcotics from the ADON. Per interview there was a procedure failure with regards to the receipt of the narcotics from the ADON. Per interview the ADON and LPN #2 should have both signed the control drug log form that the medications were received and both signed the form in the narcotic book and added to the medication cart. She stated both were suspended pending investigation. Further, she stated she checked the pharmacy delivery receipt against the narcotic count sheets and found no record of the change of ownership. Additional interview with the DON, revealed after the incident related to the missing medications, nursing staff were educated on the procedure/policy. She stated when narcotic medication was delivered from pharmacy, both the nurse who received the medication from pharmacy and the nurse who was assigned to the medication cart in which the narcotic was to be stored, had to sign the pink sheet from pharmacy. Further, both nurses had to ensure the medication was locked in the medication cart and the Controlled Drug Record was placed into the Narcotic Book. Per interview, it was her expectation for staff to follow the policy and procedure regarding the receiving and storage of narcotic medication. Interview with the Administrator, on [DATE]20 at 11:20 AM, revealed it was his expectation for staff to follow policy and protocols regarding storage and handling of narcotics. Per interview, the ADON and LPN #2 were suspended pending the investigation. LPN #2 was later terminated for failure to return any phone calls and assist in the investigation. Resident #4's medication was replaced at no cost to the resident and Resident #3's medications was discontinued due to non-use.

Based on observation, interview, record review, review of the facility's policies, and review of the facility's investigation, it was determined the facility failed to have an effective system to revise the Baseline Care Plan to include instructions needed to provide supervision for one (1) of six (6) sampled residents (Resident #1). Resident #1 was admitted to the facility on [DATE], and assessed as severely cognitively impaired memory and independent with ambulation. The Baseline Care Plan was developed on 08/16/19 related to the resident's risk for elopement; however, the Care Plan did not include the supervision level needed to keep the resident safe. On 08/17/19, Resident #1 displayed exit seeking and elopement type behaviors and a wanderguard (a tracking device designed to prevent persons at risk for wandering from leaving the facility, unless they are unaccompanied) was placed on the resident; however, there was no documented evidence the Baseline Care Plan was revised on 08/17/19 to include interventions for increased supervision and monitoring. Subsequently, on 08/17/19, Resident #1 exited the facility without staff's knowledge, activating the wanderguard alarm on the door; however, staff failed to respond to the alarm. Resident #1 was last seen by staff on 08/17/19 at approximately 3:00 PM and was found by the Police on 08/17/19 at approximately 5:01 PM, approximately eight tenths (0.8) of a mile from the facility. Resident #1 left the facility property, walked down a busy four (4) lane highway, crossing the intersection of another busy four (4) lane highway and was found sitting on the side of the highway. The local weather history revealed the temperature was ninety three (93) degrees Fahrenheit and sunny on 08/17/19, during the time the resident was missing. (Refer to F-689) The facility's failure to have an effective system in place to ensure each resident's Baseline Care plan was revised related to providing increased supervision for at risk residents has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 08/22/19 and determined to exist on 08/17/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 08/30/19, alleging removal of the Immediate Jeopardy on 08/31/19. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 08/31/19, prior to exit on 09/05/19, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility Care Plan Procedure, undated, revealed it is the practice of the facility to initiate, complete and revise resident care plans in accordance with all Federal and State regulations and Resident Assessment Instrument (RAI) guidance. The facility must develop a person centered comprehensive care plan for each resident that includes measurable objectives and time tables to meet resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Review of the facility Wandering, Unsafe Resident Policy, revised 08/2014, revealed the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Per Policy, the resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. Review of Resident #1's Clinical Record revealed the facility admitted the resident on 08/16/19 with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Nursing Assessment, dated 08/16/19 at 4:00 PM, signed by Licensed Practical Nurse (LPN) #3, revealed the resident was admitted to the facility from home and the reason for admission was listed as altered mental status and increased confusion. Continued review of the Nursing Assessment, revealed the resident was alert and oriented to person; had memory loss; and was independent with ambulation, transfers, toileting and eating. According to the Nursing Assessment, the resident was at low risk for elopement. This Note was electronically signed by the Director of Nursing (DON) and LPN #3. Interview with the DON, on 08/22/19 at 5:20 PM, revealed Resident #1 was assessed as being at low risk for elopement even though the resident was admitted from home for altered mental status, and increased confusion; and was ambulatory. She further stated the facility did recognize on 08/16/19, the resident was at risk for elopement and there was a Baseline Care Plan related to this developed on that date. Review of the Baseline Care Plan, revealed a focus problem initiated 08/16/19, revealing the resident was at risk for elopement related to wandering. The goal initiated 08/16/19, stated the patient would have no incidence of elopement, and would remain safe during placement at the Living Center. There were several interventions including allow resident to have (empty) electronic cigarette container which contains no nicotine and was used to facilitate smoking cessation; assess for risk of elopement per Living Center Policy; encourage family to bring in personal possessions; introduce patient to other patients in the Living Center; and redirect patient from doors. However, the Baseline Care Plan did not include the supervision level required to keep the resident safe, or specific interventions to keep the resident safe if the resident exhibited wandering and exit seeking behaviors. The Minimum Data Set Nurse #1 initiated this Care Plan and was out of the facility during the Survey on leave, and unable to be interviewed. There was no Minimum Data Set (MDS) Assessment completed due to the resident was a new admission. However, review of the Brief Interview for Mental Status (BIMS) Assessment, dated 08/16/19, revealed the facility assessed Resident #1 as having a Score of three (3) out of fifteen (15), revealing the resident was severely cognitively impaired. Review of the Elopement Risk Assessment, dated 08/17/19, completed by the House Supervisor/Registered Nurse (RN), revealed Resident #1 was assessed as being at High Risk for elopement related to exhibiting exit seeking, and wandering behaviors. Review of the physician's orders [REDACTED]. Additional review of the Baseline Care Plan, revealed it was revised with a new intervention for the wanderguard. However, there was no documented evidence the Baseline Care Plan was revised with interventions for increased supervision and monitoring related to the resident's exit seeking and wandering behaviors when the wanderguard was placed on 08/17/19. Moreover, review of the Progress Notes, revealed no documented evidence the staff implemented increased supervision and monitoring of the resident related to exit seeking behaviors on 08/17/19, when the wanderguard was placed. Review of the facility's Long Term Care Facility-Self Reported Incident Form -Five (5) day Follow Up/Final Report, and attached investigation, dated 08/23/19, which was signed by the Administrator, revealed on 08/17/19 at approximately 4:15 PM, Resident #1 departed the facility's grounds. State Registered Nurse Aide (SRNA) noticed she did not see Resident #1 in the hallway after caring for another resident. The SRNA looked around the building and notified other staff that she could not locate Resident #1, and staff immediately contacted the Police and initiated a search inside and outside the building. A[NAME]Alert was called over the paging system. Resident #1's family was notified the resident was missing. According to the Incident Form, while staff was searching for Resident #1 in the immediate area, Police returned with the resident. Continued review of the Incident Form, revealed Resident #1 was immediately placed on one on one (1:1) supervision, and a head to toe skin assessment was completed by the nurse. Resident #1's wanderguard was still in place and was functioning properly. The Physician was notified of the incident and of Resident #1's return to the facility. Resident #1 remained on one on one (1:1) supervision until he/she was discharged on [DATE]. Interview with SRNA #8, on 09/03/19 at 1:10 PM, revealed he recalled that on 08/17/19, as the day went on, Resident #1 continued to get more confused, pushing on the doors trying to get out. SRNA #8 stated when the door alarm would sound, the resident would back away from the doors and was easily redirected. Further interview revealed staff did try and keep a closer eye on Resident #1 related to exit seeking behaviors; however, there was no instructions from the nurses to initiate one on one (1:1) supervision or to complete checks on the resident at specific intervals on 08/17/19, prior to the resident leaving the facility without staff's knowledge. Phone interview with SRNA #7, on 08/21/19 at 3:14 PM, and on 08/22/19 at 1:38 PM, revealed she was working the South Unit on 08/17/19 from 6:00 AM to 6:30 PM, and was assigned to Resident #1 on that date. She stated Resident #1 wandered the halls most of the day, asking to go home. Per interview, the resident kept going to the therapy door trying to go out the door, and she would redirect the resident back to his/her room. She stated she did not recall the charge nurse informing her to increase supervision of Resident #1 related to his/her exit seeking behaviors on 08/17/19. Interview with Registered Nurse (RN) #2, on 08/22/19 at 08:25 AM, revealed she was assigned to Resident #1 on 08/17/19. She stated Resident #1 was wandering up and down the halls asking to go home that day and also asked her if his/her sister could come pick him/her up. Per interview, she alerted the House Supervisor/Registered Nurse (RN) of the resident's wandering and exit seeking behaviors and the House Supervisor/RN subsequently called the resident's family and obtained consent for the wanderguard. RN #2 further stated, although she was assigned to the resident on 08/17/19 and was aware the resident was exhibiting exit seeking behaviors, she did not ensure the Baseline Care Plan was revised with interventions for increased supervision and monitoring in order for staff to implement these interventions. RN #2 stated she just recalled everyone was trying to keep a closer eye on the resident. Interview with Registered Nurse (RN) #1, on 08/22/19 at 9:50 AM, revealed she was assigned to the South Hall on 08/17/19; however, she was not assigned to Resident #1 or Resident #2. Per interview, she witnessed Resident #1 wandering the halls most of the day, and the resident was asking to go outside and asking to go home. She further stated during the early morning on 08/17/19, another nurse applied a wanderguard on the resident for safety related to the resident's wandering and exit seeking behaviors. However, RN #1 stated staff did not increase the supervision level for the resident when the wanderguard was placed, and she was unsure if the resident's Baseline Care Plan was revised to reflect any new interventions related to the resident's exit seeking behaviors. Interview with the House Supervisor/RN, on 08/21/19 at 11:20 AM, and on 09/03/19 at 3:00 PM, revealed after the wanderguard was placed on Resident #1, she informed staff to keep a closer eye on the resident related to exit seeking behaviors and informed staff of the wanderguard placement. However, she stated she did not think she needed to place the resident on one on one (1:1) supervision, or have staff do frequent checks of the resident at specific intervals because the resident was wearing the wanderguard. She further stated she remembered revising the Baseline Care Plan with an intervention for the wanderguard. However, she stated she should have ensured the Baseline Care Plan was revised with interventions for increased supervision and monitoring for this resident, and ensured these interventions were implemented in an attempt to prevent elopement. Interview with MDS Coordinator #2, on 09/03/19 at 11:14 AM, revealed during the morning meetings Monday through Friday, with the Administrator, DON, Staff Development Coordinator, Director of Maintenance, MDS Nurses, Social Services Director, Assistant Director of Nursing, Medical Records, and the Activities Director, all new physician's orders [REDACTED]. She further stated any nursing staff could update the Care Plans at any time. Further interview revealed when Resident #1 was exhibiting the exit seeking behaviors, the Baseline Care Plan should have been revised with interventions for one on one (1:1) supervision or for frequent checks at specific intervals and these interventions should have been implemented. Further interview with the Director of Nursing, on 08/22/19 at 5:20 PM, revealed on 08/17/19, the nurse did obtain an order for [REDACTED]. Per interview the Care Plan was a reflection of the care to be provided to residents and therefore it should be accurate and specific to the resident's needs. Interview with the Administrator, on 08/22/19 at 5:40 PM, and on 09/04/19 at 8:45 AM, revealed Resident #1 was assessed as being at low risk for elopement on admission as per the Nursing Assessment. She stated the Baseline Care Plan was developed on 08/16/19 related to the resident's risk for elopement and therefore the facility did identify this risk; however, there was no supervision level noted on the Care Plan in order to keep the resident safe. Further interview revealed the following day, on 08/17/19, an elopement assessment was completed and the resident was assessed as being at high risk for elopement and the House Supervisor/RN obtained consent and a physician's orders [REDACTED].#1 was exhibiting exit seeking behaviors on 08/17/19, and the wanderguard was placed, the Baseline Care Plan should have been revised to include specific interventions for one on one (1:1) supervision. The facility provided an acceptable credible Allegation of Compliance (AoC) on 08/30/19, alleging removal of the Immediate Jeopardy on 08/31/19. Review of the AoC revealed the facility implemented the following: 1. On 08/17/19 at 5:00 PM, Resident #1 returned to the facility from the local Police Department. A head to toe assessment was completed on Resident #1 by the Assistant Director of Nursing (ADON) and the nurse assigned to the resident. Resident #1 was offered water and a sandwich upon return. Resident #1 was placed on one to one (1:1) supervision with the ADON until later discharged home with family on 08/17/19. 2. On 08/17/19, a complete head count was performed by nursing staff to ensure all residents were accounted for. All residents were accounted for. 3. On 08/17/19, the DON and ADON performed Elopement Assessments for residents who were assessed as currently being at risk for elopement. No concerns were noted. 4. On 08/18/19, the DON and ADON performed Elopement Assessments for all residents to determine if the existing Assessments were accurate. No concerns were noted. 5. On 08/17/19, the DON and ADON reviewed the Care Plans for residents assessed to be at risk for elopement. Any issues identified, including the need for increased supervision, were addressed immediately by contacting the Physician and/or updating the Care Plan. 6. Any new residents and current residents with a change of condition will be assessed for increased risk of elopement on an ongoing basis by licensed nursing staff, with Physician notification and interventions to prevent elopement reflected in the Care Plans. Interventions would include placement of wanderguard, increased supervision and/or one on one (1:1) with staff member. 7. The DON and ADON will update Care Plans to include increased supervision immediately upon notification by licensed nursing staff that a resident exhibits increased wandering behaviors. 8. On 08/17/19, the Director of Maintenance (DOM) checked all doors and the wanderguard system to ensure the doors and wanderguard system were functioning properly. No Issues were identified. 9. On 08/17/19, the DOM changed the exit codes at all exits. On 08/17/19, the Administrator placed a sign at each door alerting visitors not to allow residents out of the exits. 10. On 08/17/19 at 10:30 PM, Safecare (System Maintenance Company) came to the facility to verify the functions of the doors and wanderguard system and no concerns were noted. Safecare increased both the alarm field and volume of the wandering system at the front door for increased safety awareness on 08/17/19. 11. On 08/30/19, the placement of wanderguards was changed for two (2) residents. For the female resident the transmitter was secured to the wheelchair per Manufacturer's Guidelines. For the male resident, the transmitter was placed on his ankle as per Manufacturer's Guidelines. physician's orders [REDACTED]. 12. On 08/17/18, education began with all current staff including licensed and unlicensed staff, related to the Elopement Policy, and[NAME]Alert Procedure, including response to alarms. This education was presented by the Administrator, DON, ADON, Staff Development Coordinator (SDC), Assistant Dietary Manager, Social Services, Therapy Director, Scheduler and Housekeeping Supervisor. By 08/19/19, one hundred (100) out of one hundred four (104) employees received the education. On 08/17/19, education began for Licensed staff to notify the Medical Director, Administrator, DON and/or ADON if a resident exhibits increased wandering behaviors in order to implement increased supervision or one on one (1:1) with staff member as ordered by the physician. Licensed staff was also educated related to updating the Care Plan. This education was presented by the DON, ADON, and the Administrator. By 08/19/19, twenty-one (21) of twenty-two (22) licensed staff had received the education. Staff who did not receive the education including staff on Family Medical Leave (FML), PRN (as needed) staff, staff on vacation, and contract staff will receive education prior to their next shift presented by the DON, ADON, or Administrator. Newly hired staff will receive this training as part of their new hire orientation by the SDC. 13. On 08/28/19, licensed nursing staff and Medication Technicians were educated by the DON and SDC on proper placement of wanderguards. Twenty-one (21) of twenty-two (22) licensed nurses and Medication Technicians were educated. Staff who did not received the education will not work until they are in-serviced by the DON, ADON or SDC. Newly hired staff will receive this training as part of their new hire orientation by the SDC. 14. On 08/30/19, licensed nursing staff were educated by the DON, ADON, Weekend Supervisor/ Registered Nurse (RN) and SDC to check skin for redness, bruising and open areas for the male resident who had the wanderguard placement changed from the wrist to the ankle. These skin checks and any findings will be documented in the medical record and the Physician and DON will be notified immediately of any skin changes and/or concerns. Licensed Staff who did not receive the education will not work until they are in-serviced by the DON, ADON, RN/Weekend Supervisor or SDC. Newly hired staff will receive this training as part of their new hire orientation by the SDC. 15. On 08/18/19, 08/19/19, and on an ongoing basis, the Administrator and DON will assess staff knowledge of the Elopement Policy;[NAME]Alert Procedure; response to door alarms; increased resident wandering behaviors for increased supervision or one on one (1:1) with staff member as ordered by the Physician, and updating the Care Plan. Random oral testing of ten (10) staff members was completed on 08/18/19 and eight (8) staff members on 08/19/19. Random oral testing of five (5) staff members on various shifts will be completed by the Administrator and/or DON five (5) days a week for four (4) weeks, then in conjunction with ongoing elopement drills. Results are noted on the Random Oral testing Forms. Any staff member that does not demonstrate adequate knowledge of the Elopement Policy;[NAME]Alert Procedure; response to door alarms; increased wandering behaviors for increased supervision or one on one (1:1) with staff member as ordered by Physician, and updating the Care Plan will be re-trained immediately. 16. Starting on 08/18/19, elopement drills on all shifts were conducted by Social Services, DON, Administrator and or Manager on Duty every shift for three (3) days and documented on the elopement drill sign-in sheets. These will continue daily for one (1) week on various shifts; then once a week for four (4) weeks; then monthly for three (3) months; and then will resume quarterly to assess staff knowledge of the procedures to be taken in the event of elopement or missing resident. Any identified issues will be addressed immediately by the Administrator or DON. On 08/19/19, the results (of elopement drills) was reported to Quality Assurance Performance Improvement (QAPI) by the Administrator. 17. The Maintenance Department and/or Manager on Duty will test exit doors and the wanderguard system for proper functioning on a daily basis ongoing. Results will be documented in the Door Check Log, The Administrator or DON will audit documentation one (1) time a week for twelve (12) weeks. Audit Findings will be reported to QAPI by the DON. 18. Proper placement of residents' wanderguards will be checked every shift by licensed nursing staff and/or Medication Technicians and documented in the electronic medical record. The DON and/or ADON will audit documentation one (1) time a week for twelve (12) weeks. Audit findings will be reported to QAPI by the DON. 19. Head to toe skin checks will be conducted for the male resident who had the wanderguard placement changed to the ankle. This will be conducted by licensed nursing staff every four (4) hours for three (3) days, then every shift and documented in the electronic medical record. The DON and/or ADON will audit documentation one (1) time a week for twelve (12) weeks. Audit findings will be reported to QAPI by the DON. 20. On 08/17/19, a QAPI Committee meeting including the Medical Director was held to review the status of the facility programs related to elopements and missing residents; to review the audit results; and, to make recommendations for improvement. 21. On 08/18/19 and 08/19/19, the QAPI committee met again, including the Medical Director to discuss drills, and audit results. Discussion included new residents and residents with change in condition to be assessed for increased risk of elopement on an ongoing basis by licensed nursing staff with interventions to prevent elopement reflected in their care plan. These interventions would include placement of wanderguard and increased supervision or one on one (1:1) with staff member as ordered by the physician. 22. On 08/30/19, a QAPI Committee meeting including the Medical Director was held to discuss changed placement of two (2) residents' wander guards. During the meeting, it was discussed that the DON and/or ADON will immediately update residents' Care Plans when notified by licensed nursing staff a resident exhibits increased wandering behaviors. 23. The QAPI Committee will meet weekly for four (4) weeks to review all monitoring results and make recommendations and then at least monthly thereafter for two (2) months. The State Agency validated the implementation of the facility's AoC as follows: 1. Review of Resident #1's Progress Note, dated 08/17/19 at 5:01 PM, revealed the resident returned to the facility per the police department's car. Further review revealed upon Resident #1's return, staff offered the resident water and a sandwich. The family was present at time of return, and the resident remained one on one (1:1) supervision with the ADON until the resident was discharged home with family on 08/17/19. Interview with the ADON, on 09/05/19 at 9:35 AM, revealed a Head to Toe Assessment was completed on Resident #1 by both her and the licensed nurse assigned to the resident. The ADON also stated she and the licensed nurse completed a Skin Hydration Assessment on 08/17/19 for Resident #1. Per interview, no injuries or concerns were noted. The ADON stated she remained one on one (1:1) with Resident #1 until he/she was discharged home with family the evening of 08/17/19. 2. Record review validated a head count was conducted by staff on 08/17/19, and all residents were accounted for. Further record review validated the DON conducted another headcount on 08/18/19 and all residents were accounted for. Interview with the Director of Nursing (DON), on 09/05/19 at 9:15 AM, revealed staff conducted a headcount for all residents on 08/17/19 to ensure all residents were accounted for. She further stated she conducted another head count on 08/18/19 for all residents for her own peace of mind, and all residents were accounted for. 3. Record review of the Elopement Assessments, validated the DON/ADON completed Elopement Assessments on 08/17/19 for residents previously assessed as at risk for elopement. Interview with the DON, on 09/05/19 at 9:15 AM, revealed she and the ADON completed Elopement Assessments on all residents who had previously been assessed as at high risk for elopement on 08/17/19. She stated no concerns were noted with the assessments. Interview with the ADON, on 09/05/19 at 9:35 AM, revealed she assisted the DON with completing the Elopement Assessments on residents who had previously been assessed as at high risk for elopement on 08/17/19. 4. Review of Elopement Assessments performed by the DON/ADON on 08/18/19 for all residents to determine if the existing assessments were accurate was validated with no concerns noted. Sixty seven (67) residents were assessed. Interview with the DON, on 09/05/19 at 9:15 AM, revealed she and the ADON did complete Elopement Assessments for all residents on 08/18/19, to determine if the existing assessments were accurate. She stated there were no concerns with the assessment results. Interview with the ADON, on 09/05/19 at 9:35 AM, revealed she and the DON assessed all residents to determine if the previous elopement assessments were accurate. She stated no concerns were noted. 5. Review of the Care Plans for residents assessed to be at risk for elopement validated they were updated on 08/17/19, by the DON/ADON. Eleven (11) residents' care plans were reviewed and updated as needed. Interview with the DON, on 09/05/19 at 9:15 AM, revealed she and the ADON reviewed all current care plans of residents previously assessed to be at risk for elopement. Per interview, the Care Plans were updated as needed and any identified issues, including the need for increased supervision was addressed immediately by contacting the Physician and/or updating the Care Plan. Interview with the ADON, on 09/05/19 at 9:35 AM, revealed she confirmed she assisted the DON with updating, reviewing and making sure the Care Plans were accurate to reflect the appropriate interventions for the residents who were assessed for being at risk for elopement. 6. Record review revealed there was only (1) new admit since 08/17/19. Resident #12's Admission Note, dated 09/04/19, revealed an Elopement Assessment was completed by licensed nursing staff. Per the Note, the Assessment scores were discussed with the Physician. No elopement concerns were noted. Interview with LPN #2, on 09/04/19 at 2:55 PM, who admitted Resident #12, revealed she completed all admission assessments on Resident #12 including the Elopement Assessment. She stated she verified orders with the admitting Physician and discussed elopement scores with the Physician. She further stated the Elopement Assessment score was low risk indicating the resident was not at risk for elopement. There were no residents to review related to a change in condition in order to validate if an Elopement Assessment was completed. 7. Record review revealed residents at risk for elopement had Care Plans in place with interventions to prevent elopement. There was only one (1) new admission since 08/17/19, which was Resident #12. Per record review Resident #12 was admitted on [DATE], and this resident was assessed as not at risk for elopement. There were no residents to review related to a change in condition in order to validate if the Care Plan was revised related to risk for elopement. 8. Review of the Door Check Logs, dated 08/17/19, revealed the Director of Maintenance (DOM) checked the functions of the doors as well as the wanderguard system. These logs validated the doors and the wanderguard system were functioning properly on 08/17/19. Interview with the Maintenance Director, on 09/04/19 at 3:35 PM, revealed he did check all doors, door alarms and the wanderguard system to ensure they were functioning properly, on 08/17/19. 9. Observation on 08/21/19 at 2:00 PM, revealed signs were posted on each door, alerting visitors not to allow residents out of the exits. Interview with the Administrator, on 09/05/19 at 9:05 AM, revealed she did post signs at all doors alerting visitors to not allow residents out the exit doors. She stated she typed up the signs and posted them. Further interview revealed she had recently received new signs that were plastic to replace the paper signs. Interview with the Maintenance Director, on 09/04/19 at 3:35 PM, revealed he changed the exit codes on all doors on 08/17/19. 10. Review of Safe Care Service and Report Form, dated 08/18/19, validated the company representative was in the facility on 08/17/19 after a patient egress. Per the form, the facility wanted a check of all doors to ensure proper functioning. The form validated Safe Care checked all seven (7) doors, with both tester boxes and the ankle tag the resident (Resident #1) was wearing at the time of exit. Per the form, all doors were functioning correctly, and locked down when a tag was in the field. Continued review of the form, revealed the technician increased both the alarm field and the volume of the wandering system at the front door, and upon departure all systems were functioning properly. 11. Review of Resident #4's physician's orders [REDACTED]. with increased skin checks. Review of Resident #5's physician's orders [REDACTED].#5's wanderguard transmitter to be secured to the wheelchair as per Manufacturer's Guidelines. Review of Resident #4 and Resident #5's care plans, revealed revisions to reflect change of placement of the wanderguards on 08/30/19, by the DON. Interview with the DON, on 09/05/19 at 9:35 AM, revealed Resident #4's wanderguard was moved from his/her wrist to his/her ankle. Further, Resident #5's wanderguard was moved from the wrist to the wheelchair as per Manufacturer's Guidelines. Per interview, changes in the placement of the wanderguards for these residents were completed to ensure placement was as per Manufacturer's Guidelines. She further stated she updated residents' Care Plans to reflect the placement of

Based on observation, interview, record review, review of the facility's policies, and review of the facility's investigation, it was determined the facility failed to have an effective system to ensure each resident received adequate supervision and monitoring to prevent elopement for three (3) of six (6) sampled residents (Resident #1, #5 and #6). The facility admitted Resident #1 on 08/16/19, and on that date assessed the resident as severely cognitively impaired and as being at low risk for elopement as per the Admission Nursing Assessment. On 08/17/19, Resident #1 displayed exit seeking and elopement type behaviors and a wanderguard (a tracking device designed to prevent persons at risk for wandering from leaving the facility, unless they are unaccompanied) was placed on the resident; however, there was no documented evidence the facility increased the level of supervision. Subsequently, on 08/17/19, Resident #1 exited the building without staff's knowledge, activating the wanderguard alarm on the door; however, staff failed to respond to the alarm. Resident #1 was last seen by staff on 08/17/19 at approximately 3:00 PM and was found by Police on 08/17/19 at approximately 5:01 PM, approximately eight tenths (0.8) of a mile from the facility. Resident #1 left the facility property, ambulated down a busy four (4) lane highway, crossing the intersection of another busy four (4) lane highway and was found sitting on the side of the highway. Review of the local weather history revealed the temperature was ninety three (93) degrees Fahrenheit and sunny on 08/17/19, during the time the resident was missing, and interviews with staff and family members revealed the resident was wearing a sweat suit and was drenched with sweat when found. (Refer to F-655) In addition, the Secure Care Transmitter User Guide, dated 12/11/17, revealed the ankle transmitter (wanderguard) should be placed on the resident's ankle or if confined to a wheelchair, the transmitter must be worn on the ankle of a leg that is not elevated or may be put in the upright position on the rod/leg above the wheel of the wheelchair. Observation on 08/21/19, revealed the wanderguard system was tested with the wanderguard at wrist level and the system did not activate the door to alarm. However, observation on 08/22/19, revealed Resident #5 and Resident #6, who were assessed as at risk for elopement, had their wanderguards placed on their wrists. The facility's failure to have an effective system in place to ensure each resident received adequate supervision to prevent elopement has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 08/22/19 and determined to exist on 08/17/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 08/30/19, alleging removal of the Immediate Jeopardy on 08/31/19. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 08/31/19, prior to exit on 09/05/19, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility Wandering, Unsafe Resident Policy, revised 08/2014, revealed the facility would strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Per Policy, the resident's care plan would indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. Review of the facility Elopement Policy, revised 12/2017, revealed staff shall investigate and report all cases of missing residents. Further review of the Policy, revealed if an employee discovers that a resident is missing from the facility, he/she shall determine if the resident is out on an authorized leave or pass. If the resident was not authorized to leave, initiate a search of the building (s) and premises. Per Policy, if the resident is not found after the search of the center grounds and perimeter, the facility will notify law enforcement. 1. Review of Resident #1's Medical Record revealed the facility admitted the resident on 08/16/19 with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Nursing Assessment, dated 08/16/19 at 4:00 PM, signed by Licensed Practical Nurse (LPN) #3, revealed the resident was admitted from home and the reason for admission was listed as altered mental status and increased confusion. Further review of the Nursing Assessment, revealed the resident was alert and oriented to person; had memory loss; and was independent with ambulation, transfers, toileting and eating. Per the Nursing Assessment, the resident was at low risk for elopement. This note was electronically signed by the Director of Nursing (DON) and LPN #3. Attempts were made to contact LPN #3 for interview on 08/21/19 at 3:30 PM, and 08/23/19 at 11:00 AM, and messages were left with no return phone call. Interview with the DON, on 08/22/19 at 5:20 PM, revealed Resident #1 was assessed as being at low risk for elopement even though the resident was admitted from home for altered mental status, and increased confusion; and was ambulatory. She further stated the facility did recognize on 08/16/19, the resident was at risk for elopement and there was a Baseline Care Plan related to this developed on that date. Review of the Baseline Care Plan, revealed a focus problem initiated 08/16/19, which revealed the resident was at risk for elopement related to wandering. The goal initiated 08/16/19, revealed the patient would have no incidence of elopement, and would remain safe during placement at the Living Center. The interventions included: allow resident to have (empty) electronic cigarette container which contains no nicotine and was used to facilitate smoking cessation; assess for risk of elopement per Living Center Policy; encourage family to bring in personal possessions; introduce patient to other patients in the Living Center; and redirect patient from doors. However, the Baseline Care Plan did not specify the supervision level required to keep the resident safe, or specific interventions to implement if the resident exhibited wandering and exit seeking behaviors. There was no Minimum Data Set (MDS) Assessment completed due to Resident #1 being a new admission. However, review of the Brief Interview for Mental Status (BIMS)Assessment, dated 08/16/19, revealed the facility assessed the resident as having a Score of three (3) out of fifteen (15), indicating the resident was severely cognitively impaired. Review of the Elopement Risk Assessment, dated 08/17/19, completed by the House Supervisor/Registered Nurse (RN), revealed Resident #1 was assessed as being at High Risk for elopement due to exhibiting exit seeking, and wandering behaviors. Review of the physician's orders [REDACTED]. Further review of the Baseline Care Plan, revealed the intervention for wanderguard was added; however, there was no documented evidence the Care Plan was revised with interventions for increased supervision and monitoring related to the resident exhibiting exit seeking and wandering behaviors as per the Elopement Assessment, dated 08/17/19. In addition, review of the Progress Notes, revealed no documented evidence the resident was exhibiting exit seeking and wandering behaviors and no documented evidence staff implemented increased supervision and monitoring of the resident related to exit seeking behaviors on 08/17/19, when the wanderguard was placed. Review of the facility's Long Term Care Facility-Self Reported Incident Form -Five (5) day Follow Up/Final Report, and attached facility's investigation, dated 08/23/19 and signed by the Administrator, revealed on 08/17/19 at approximately 4:15 PM, Resident #1 departed the facility's grounds. Per the Incident Form, the State Registered Nurse Aide (SRNA) noticed she did not see Resident #1 in the hallway after caring for another resident. SRNA looked around the building and notified other staff that she could not locate Resident #1. Staff immediately contacted the Police and initiated a search inside and outside the building. A Golden Alert was called on the paging system. Resident #1's family was notified. Per the Incident Form, while staff was searching for Resident #1 in the immediate area, police returned with the resident. Further review of the Incident Form, revealed Resident #1 was immediately placed on one on one (1:1) supervision, and a head to toe skin assessment was completed by the nurse. Resident #1's wanderguard was noted to be in place and functioning properly. The Physician was notified of the incident and of the resident's return to the facility. Resident #1 remained on one on one (1:1) supervision until he/she was discharged with family on 08/17/19. Review of the local weather history, revealed the temperature was ninety three (93) degrees Fahrenheit and sunny on 08/17/19. Review of the Police Department Records, dated 08/17/19, revealed the Police were dispatched to the facility on [DATE] at 4:37 PM. Per the Dispatch Logs the resident was found and returned to the facility on [DATE] at 5:01 PM. Phone interview with Police Officer #1, on 08/21/19 at 12:10 PM, revealed an actual report related to Resident #1 was not completed as the resident was recovered within ten (10) minutes of the Police receiving the call from the facility. He stated based on the information he received from the facility and the time Police Officer #2 located Resident #1, the resident was noted to be away from the facility for approximately forty-five (45) minutes. He further stated when Police Officer #2 called him via telephone informing him he had located the resident, he was informed the resident was sitting on the side of the road on Highway 60 near the golf park, approximately eight tenths (0.8) of a mile from the facility. Per interview, for the resident to get to the location where he/she was found, the resident would have to cross the intersection of Highway 127. Further interview with Police Officer #1, revealed Police Officer #2, who located the resident, brought the resident back to the facility and upon Resident #1's arrival, the resident agreed to enter the facility. Observation on 08/22/19 11:00 AM, of the elopement route, revealed Resident #1 would have ambulated from the South Unit Hallway turning right passing the main dining room and the receptionist's desk on the way to the front door. The resident would have exited the front door and continued to ambulate through the facility parking lot, down a hill and onto a two (2) lane road without a sidewalk. Resident #1 then would have had to ambulate down a busy four (4) lane highway, crossing the intersection of another busy four (4) lane highway to end up in front of the park. Further observation revealed the location where resident was found by Police was noted to be eight tenths (0.8) of a mile from the facility. Interview with the Director of Maintenance (DOM), on 08/21/19 at 2:10 PM, revealed when the door alarm sounded on the front door, a staff member must punch in the code to the keypad to get the alarm to stop sounding. Interview on 08/21/19 at 10:20 AM, with Resident #2, revealed he/she was Resident #1's spouse and was admitted to the facility the same day as his/her spouse. Per interview, a male SRNA came to get Resident #2 for a shower on 08/17/19 during the middle of the afternoon. Resident #2 stated he/she informed the SRNA that someone from the facility would need to watch Resident #1 while he/she (Resident #2) was in the shower. Per interview, staff reassured him/her that someone would keep Resident #1 on one on one (1:1) supervision until he/she returned from the shower room. Resident #2 stated when he/she returned from the shower, Resident #1 was not in his/her room. Resident #2 further stated when he/she asked where Resident #1 was he/she was told by staff the resident was down the hall talking and visiting with other residents. Per interview, a few hours later, Resident #1 had still not returned to the room, and he/she overheard staff talking at the nurse's station. He/she stated per staff's conversation, they were in a panic and were calling the Police related to a missing resident. Resident #2 stated he/she asked what was going on and was told by Licensed Practical Nurse (LPN) #4, staff could not locate Resident #1. Per interview, he/she called his/her son who came to the facility to help with the search. Resident #2 stated if he/she had known staff was not going to supervise Resident #1, he/she would have refused the shower. Interview with SRNA #8, on 09/03/19 at 1:10 PM, revealed he recalled on 08/17/19, Resident #2 looked at Resident #1 and told the resident to behave while he/she (Resident #2) took a shower. Per interview, SRNA #8 then assisted Resident #2 with a shower, and returned the resident to his/her room. SRNA #8 stated as he assisted Resident #2 back to his/her room after the shower, he noted Resident #1 was roaming down the short hall near his/her room. SRNA #8 could not recall what time he assisted Resident #2 back to his/her room. SRNA #8 stated as the day went on, Resident #1 continued to get more confused, pushing on the doors trying to get out. Per interview, when the door alarm would sound, the resident would back away from the doors and was easily redirected. SRNA #8 stated staff did try and keep a closer eye on Resident #1 related to exit seeking behaviors; however, there was no instructions from the nurses to initiate one on one (1:1) supervision or to complete checks on the resident at specific intervals on 08/17/19. Phone interview with SRNA #7, on 08/21/19 at 3:14 PM, and on 08/22/19 at 1:38 PM, revealed she was working the South Unit on 08/17/19 from 6:00 AM to 6:30 PM, and was assigned to Resident #1. She stated the resident wandered the halls most of the day, asking to go home. She further stated the resident kept going to the therapy door trying to go out the door, and she would redirect the resident back to his/her room. Per interview, she was not instructed by the charge nurse to increase supervision of Resident #1. She stated, she spoke to Resident #2 (Resident #1's spouse) around 3:00 PM and informed him/her not worry, that Resident #1 would not get out of the facility. Further interview with SRNA #7, revealed she was in another resident's room providing care and when she came back out in the hall she searched and could not locate Resident #1. She stated she made Registered Nurse (RN) #2 aware and then all staff began a search for the resident. Per interview, some staff searched every room, closet, bathrooms, lobby, and dining room while others went outside searching, but the resident could not be located. Per interview, the last time she saw the resident on 08/17/19 was at approximately 3:00 PM, and she did not remember hearing an alarm sound after 3:00 PM, and prior to the resident being found. Additional interview revealed when the door alarm sounded staff was to go to the door that was alarming, and look outside to make sure a resident did not get outside. Per interview, if no resident was seen outside, staff was to reset the alarm and inform the nurse in order for a head count to be completed to make sure all residents were accounted for and safe. Interview with Registered Nurse (RN) #2, on 08/22/19 at 08:25 AM, revealed she worked on 08/17/19 and was assigned to Resident #1. She stated the resident was wandering up and down the halls asking to go home, and seemed to be upset with his/her spouse. Per interview, Resident #1 asked her if his/her sister could come pick him/her up. RN #2 stated she explained to to the resident he/she needed to stay at the facility for his/her safety. Per interview, she alerted the House Supervisor/RN of the resident's wandering and exit seeking behaviors and the House Supervisor/RN called the family and obtained consent for the wanderguard. Per interview, after the House Supervisor/RN obtained consent, she called the Physician and obtained orders for the wanderguard and completed an elopement assessment. Further interview with RN #2, revealed Resident #1 was very high functioning, and only needed direction back to his/her room. Per interview, she took Resident #1 for a walk earlier on 08/17/19 inside the building, and even took the resident to the front door in an attempt to calm and redirect the resident. She stated she went to lunch around 3:40 PM and she was unsure if anyone was at the nurse's station while she was on lunch break, but she knew there were a few SRNAs in the hallway charting. She further stated when she returned from lunch she was told Resident #1 was missing and the facility conducted a search. Per interview, she called 911 around 4:30 PM, when the resident could not be located. RN #2 stated, although she was assigned to the resident on 08/17/19 and was aware the resident was exhibiting exit seeking behaviors, she did not recall initiating any increased supervision of the resident, nor did she document the resident's exit seeking behaviors prior to the elopement. Per interview, she just recalled everyone was trying to keep a closer eye on the resident. Interview with RN #1, on 08/22/19 at 9:50 AM, revealed she was assigned to work South Hall on 08/17/19; however, she was not assigned to Resident #1 or Resident #2. Per interview, she saw Resident #1 wandering the halls most of the day, and the resident was asking to go outside and asking to go home. She stated during the early morning on 08/17/19, another nurse applied a wanderguard on the resident for safety related to the resident's wandering and exit seeking behaviors. However, she stated staff did not increase the supervision level for the resident when the wanderguard was placed. Per interview, SRNA #7 did bring the resident to her around 2:00 PM to sit with her at the nurse's station due to the resident trying to get out the therapy doors just down the hall from the South nurse's station. She stated she sat with Resident #1 for about ten (10) minutes and then left the nurse's station and did not recall seeing the resident anymore after that. Per interview, she heard the wanderguard alarm sounding at approximately 4:00 PM and checked the panel at the nurse's station to determine which door, and it was the front door. She stated she got up to go check the door, and about the time she got around the nurse's station, the alarm quit sounding, so she sat back down and did not go to the door to ensure there was no resident outside the building. Further interview with RN #1, revealed the alarms sounded all the time with visitors coming in and out, due to visitors pushing on the doors instead of asking for someone to let them out via the key pad. Per interview, the alarm would continue to sound until a staff member entered the code on the key pad. RN #1 stated she was performing insulin checks around 4:30 PM on 08/17/19, when SRNA #7 came up to her and stated she could not locate Resident #1. Per interview, staff began searching for the resident outside while RN #2 called the Police. She stated the Police showed up shortly afterward and was given a description of the resident and what he/she was wearing. She further stated it was not long after when the Police pulled up outside with the resident inside the car. Per interview, the weather outside was hot, and the resident was sweating. She stated Resident #1 could have been run over, kidnapped, or sustained injury by being outside by himself/herself. She further stated there was the possibility a staff member let Resident #1 out the door not knowing he/she was a resident. Interview with the House Supervisor/RN, on 08/21/19 at 11:20 AM, and on 09/03/19 at 3:00 PM, revealed earlier in the day on 08/17/19 around 8:50 AM, Resident #1 had wandered over to the North Hall and was asking for his/her spouse, and asking to go home. She stated she escorted Resident #1 back to the South Hall where the resident resided and led the resident to his/her room. Per interview, after this she immediately called the resident's Power of Attorney (POA) and informed him of the resident's wandering and exit seeking behavior and asked if a wanderguard bracelet could be placed on the resident's ankle for safety. She stated after obtaining permission, she immediately called and obtained an order for [REDACTED]. She further stated she did not think she needed to place the resident on one on one (1:1) supervision, or have staff perform frequent checks of the resident at specific intervals even though the resident was exhibiting exit seeking behaviors, because the resident was wearing the wanderguard. Further interview with the House Supervisor/RN, revealed she was assigned as Supervisor of the entire facility on 08/17/19; however, she was actually passing medications on the North Hall due to another staff member calling in when RN #2 came over to her side of the building at approximately 4:00 PM and informed her they could not locate Resident #1. She stated she immediately locked the medication cart and began to help search for the resident. Per interview, staff started a head count and she called a Golden Alert (missing resident) overhead on the paging system. She stated staff searched each room, under the beds, in closets and bathrooms and could not locate the resident, and then began searching outside the facility. Per interview, the Police were called when the resident could not be located. Continued interview with the House Supervisor/RN, revealed SRNA #8 informed her a nearby neighbor saw someone fitting the description of Resident #1 walking up the highway. She stated she then left in her car and headed down the road to search for Resident #1 and returned to the facility about ten (10) minutes later as she was unable to locate the resident and a Police Officer was at the facility. Per interview, not long after this another Police Officer notified the Police Officer at the facility, the resident had been located near the golf course up Highway 60. The House Supervisor/RN stated the resident had probably been out of the facility for about thirty (30) to forty (40) minutes and it was hot outside. She stated upon Resident #1's return to the facility the resident was offered water and a sandwich, and RN #2 assessed the resident for injuries. Per interview, Resident #1 did look like a visitor, and a visitor or staff may have let the resident out of the building. Per interview, she did not recall an alarm sounding prior to the resident leaving the facility without staff's knowledge. Interview with the Manager on Duty (MOD), on 08/22/19 at 11:37 AM, revealed she was the Activity Director; however, all managers took a turn working the weekends to be up front to greet guests and let them in and out the doors. She stated she worked on 08/17/19; however, she left around 2:30 PM after she finished the last activity. Per interview, she saw Resident #1 pushing Resident #2 around the building in a wheelchair throughout the day on 08/17/19. She stated once the front door was triggered there was a five (5) second gap before it alerted the nurse's station. She further stated there was a sign on the door that stated, Push and hold for 15 seconds to open the door. She further stated staff had to come to the door and reset the code for the door to stop alarming. Per interview, she was not made aware of any resident missing while she was in the building prior to her leaving on 08/17/19 at 2:30 PM. Interview with Dietary Staff #1, on 08/22/19 at 3:32 PM, revealed she worked on 08/17/19 and was in the kitchen cooking when she heard a Golden Alert paged overhead. She stated she stopped what she was doing and immediately went out to help search for the resident. She further stated nurses drove around in their cars searching. Per interview, there was a doorbell at the front door to allow visitors to come in and out and kitchen staff was to answer the bell if no one was up front in the business office. Dietary Staff #1 stated when the door alarm sounds and no one was noted at the door, staff was to check outside and make sure there were no residents outside the building before resetting the code, and then staff was to make sure the nurse was aware the door was sounding so a head count could be performed. Dietary Staff #1 further stated she did not remember hearing the alarm sound on 08/17/19 around the time the resident was noted to be missing. Per interview, staff was instructed not to allow anyone to exit unless staff was sure the person exiting was not a resident. Phone interview with Resident #1's Daughter, on 08/21/19 at 12:45 PM, revealed she was with Resident #1 on admission on 08/16/19. She stated she did decline the wanderguard placement on admission because she wanted to see how the resident would respond to living in the facility and she did not want him/her to feel like a prisoner. She stated her brother took the call from the facility on 08/17/19, informing them Resident #1 had eloped. Per interview, she and her brother left for the facility immediately, and while riding in the car she called the facility to speak to the nurse caring for the resident. She stated she was informed by RN #2 the Police had been notified of the elopement. She further stated upon arrival to the facility, the Police Officer who was leaving, informed them Resident #1 was in the building. She further stated when she entered the facility she found Resident #1 in the lobby drenched in sweat, and wearing a sweat shirt. Per interview she was surprised as hot as it was outside, that Resident #1 did not have a heat stroke. Phone interview with Resident #1's Son, on 08/21/19 at 10:35 AM, revealed he received a call from Resident #2 stating Resident #1 was missing, and he and his sister immediately left to go to the facility as they lived approximately twenty-five (25) minutes away. He further stated he received a call approximately ten (10) minutes after he was on the road from RN #2, who informed him Resident #1 had escaped, and staff was unable to locate the resident. Per interview, the nurse also informed him the Police had been called. Further interview with Resident #1's Son, revealed upon his arrival to the facility, he was informed by a Police Officer that Resident #1 had been found and was inside the facility. Per interview, upon entrance to the facility, Resident #1 was sitting in the lobby wearing a sweat suit and was sweating. He stated staff was offering the resident water and a sandwich. Continued interview revealed he brought Resident #1 home with him on 08/17/19, as There was no way, he would leave the resident in the facility due to the resident requiring constant supervision. He stated after the incident, he did not think Resident #1 would be safe in the facility as there was no monitoring of the front main door, and anyone could have opened the door and let Resident #1 out. Per interview, he was glad Resident #1 was found safe and unharmed because he/she could have been injured and or kidnapped. Interview with the Staff Development Coordinator, on 09/03/19 at 11:45 AM, revealed she had been working at the facility since (MONTH) 2019. She stated as part of orientation for new hires she discussed the Elopement Policy. She stated if a resident could not be located, Golden Alert should be paged overhead. Further interview revealed if the door alarm sounds, staff should respond to the door and determine what caused the alarm, and if no cause was identified, staff was to call Golden Alert, and begin a search of the facility, the perimeter of the property, and surrounding area. She further stated a Nurse from each unit was to then conduct a head count to ensure all residents were accounted for. However, she stated it was identified by the interdisciplinary team after Resident #1 eloped on 08/17/19, the current written Policies did not include the Golden Alert procedure, nor did the policies include what to do if the door alarm sounds. Per interview, on 08/17/19, she revamped the orientation process to include this Protocol. Interview with the Medical Director, on 09/05/19 at 08:40 AM, revealed Resident #1 was at risk for elopement after admission related to mobility, dementia and exit seeking behaviors. Per interview, the wanderguard was placed as an assistive device in an attempt to keep the resident safe; however, the resident was able to get out of the facility without staff's knowledge. The Medical Director stated on 08/17/19, when the resident exited the door, the alarm was activated and staff failed to respond to the alarm. Interview with the Director of Nursing, on 08/22/19 at 5:20 PM, revealed she did not work on 08/17/19 and therefore was not at the facility prior to Resident #1 leaving the building without staff's knowledge. She stated she reviewed Resident #1's Admission Nursing assessment dated [DATE], which she cosigned and noted Resident #1 was assessed as being at low risk for elopement. Per interview, this was because the family did not inform the facility the resident was exhibiting exit seeking behaviors prior to admission. She further stated on 08/17/19, the nurse did obtain an order for [REDACTED].#1 on 08/17/19 due to the resident exhibiting exit seeking behaviors. However, she stated it was her understanding the resident stayed with staff all day and was in centralized areas most of the day prior to the resident eloping. Continued interview with the DON, revealed she had never had a resident to elope and was unsure if increasing supervision and monitoring of a resident who was exhibiting wandering and exit seeking behaviors was appropriate. She stated she had just never encountered this type of situation. Continued interview revealed when the door alarm sounded, staff was to go to the door, look out, and then go on a perimeter search of the building to ensure a resident had not gone outside unaccompanied by staff. Per interview, if staff could not locate the resident who sounded the alarm, staff was to return inside the building and start a head count. She further stated this procedure should have been followed on 08/17/19, when Resident #1 exited the facility without staff's knowledge because the door alarm would have sounded. She further stated there was the chance for harm or even death to a resident who eloped. Interview with the Administrator, on 08/22/19 at 5:40 PM, and 09/04/19 at 8:45 AM, revealed Resident #1 was assessed as being low risk for elopement on admission. However, she stated the following day on 08/17/19, an elopement assessment was completed and the resident was assessed as being high risk for elopement and the nurse obtained consent and a physician's orders [REDACTED].#1 was exhibiting exit seeking behaviors on 08/17/19, there was no documented evidence staff increased supervision and monitoring of the resident for the resident's safety. Further interview revealed it was her expectation staff address any sounding door alarm as per protocol. The Administrator stated staff should not turn off a sounding alarm until performing an exterior search of the building to ensure a resident had not gon

Based on observation, interview, record review, and review of the facility's Policies, it was determined the facility failed to have an effective system in place to ensure sufficient numbers of nursing staff, including Registered Nurses (RN), Licensed Practical Nurses (LPN) and State Registered Nurse Aides (SRNA), were available to provide nursing care on a twenty-four (24) hour basis for twelve (12) of thirty-nine (39) sampled residents (Residents #1, #3, #4, #7, #8, #9, #10, #11, #14, #15, #16, and #34) The facility failed to ensure there was oversight related to skin management. There was no documented evidence Weekly Skin and Wound Assessments were completed in order to identify and treat Pressure Ulcers and vascular wounds before they deteriorated. Resident #3 #8, #9 #15, and #34's Skin Assessments and Wound Evaluations were not completed for long periods of time and then Stage III, Vascular Wounds, and Deep Tissue Injury Ulcers (DTIs), and Unstageable Wounds were discovered. Also, Resident #15's Stage IV Pressure Ulcer deteriorated after the resident did not receive a Wound Evaluation for seventeen (17) days. Per staff interviews, staff nurses did not have time to ensure the skin assessments and treatments were completed and the Wound Nurse who was responsible for completing weekly Wound Assessments was re-assigned to the floor frequently, preventing her from being able to complete the weekly Wound Assessments/Evaluations for those residents with Pressure Ulcers and Vascular/Diabetic Ulcers due to the staffing shortage. In addition, per staff interview, State Registered Nurse Aides (SRNAs) were also unable to complete the necessary turning and repositioning and incontinence care for residents due to the staffing shortage. This affected Residents #3, #8, #9, #14 #15, and #34. (Refer to F-686) Furthermore, interview with residents and staff revealed baths/showers were not being completed due to the staffing shortage. Review of the Documentation Survey Reports and SRNA Skin and Bath Reports for the months of August, September, and (MONTH) (YEAR), revealed baths/showers were not completed three (3) times per week per resident preference or even twice a week as scheduled. Resident interviews revealed they did not receive showers or baths twice a week nor were they offered a shower or bath twice a week. Further resident interviews revealed the lack of baths or showers impacted their desire to interact with others and it affected their mood. Per resident interviews, they felt embarrassed, ashamed, dirty and bad like they didn't even count and like they did not deserve respect. This affected Residents #1, #3, #4, #7, #9, #10, #11 and #16. (Refer to F-677) The facility's failure to have an effective system in place to ensure sufficient numbers of nursing staff to provide care on a twenty-four (24) hour basis has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 12/20/18 and was determined to exist on 09/28/18. The facility provided an acceptable credible Allegation of Compliance (AoC) on 12/26/18, which alleged removal of the Immediate Jeopardy on 12/26/18. However, the AoC could not be verified based on observations, staff interviews, and review of facility documentation. The immediate Jeopardy is ongoing. The findings include: Interview on 10/24/18 at 2:50 PM with Director of Nursing (DON) #1, revealed the facility did not have a policy related to Sufficient Staffing. 1. Review of the facility's Skin System Policy, undated, revealed the facility would provide necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for residents having a pressure sore. Additionally, the facility would promote the prevention of pressure ulcer development for residents who enter the facility without a pressure sore. Continued review revealed all residents would be assessed with [REDACTED]. Further, upon identification of skin/wound impairment the nurse would complete a Situation Background Action Results (SBAR) Note, and notify the Skin Committee of the changes in the resident's skin condition for additional oversight and monitoring. Per Policy, the physician would evaluate and document the progress of wound healing during resident visits. There was no documented evidence the facility's Policy was followed related to weekly Skin Assessments; and weekly Wound Assessments to ensure continuity in documentation of progression of wound healing; or oversight of the resident's skin/wound care in collaboration with the Wound Nurse and physician. Also, there was no documented evidence of consistent oversight of wounds through a Skin Committee on a weekly basis. Interviews revealed the staff nurses who were responsible for completing weekly skin assessments, notifying the Wound Nurse and Physician of new areas of skin breakdown, and completing treatments as prescribed by the Physician were unable to complete these duties due to the staffing shortage. In addition, interview with Licensed Practical Nurse (LPN) #4/Wound Nurse, revealed she was unable to complete weekly Wound Assessments for those residents with wounds, and was unable to review the medical records and skin documentation by other nurses to ensure she was aware of residents who had new skin breakdown as a result of being re-assigned to work as a staff nurse frequently. Resident #15 was admitted with a Stage IV pressure ulcer to the right hip on 08/03/18, and did not receive consistent wound monitoring and treatment to the pressure ulcer. There was no documented evidence of a Wound Evaluation for Resident #15's pressure ulcer for seventeen (17) days from 09/11/18, until 09/28/18, when the Stage IV pressure ulcer had deteriorated and was assessed as having 1.5 centimeter (cm) undermining and tendon exposed. In addition, Resident #9 received a Skin Assessment on 05/28/18, and did not receive another Skin Assessment prior to being seen by the Wound Clinic on 07/05/18, thirty-seven (37) days later, and was discovered to have unidentified vascular ulcers including a diabetic/venous ulcer to the resident's right lateral foot which measured 10 centimeters (cm) length x 6.5 cm width x 0.2 cm depth, 67% to 100% necrosis; and a diabetic/venous ulcer to the resident's right plantar foot measuring 13 cm length x 7.0 cm width x 0.2 cm depth, and 67% to 100% necrosis. Also, Resident #8 had a Skin Assessment on 09/10/18, revealing the resident's skin was intact. However, Resident #8 did not receive a further Skin Assessment, until 09/23/18, thirteen (13) days later, when the resident was discovered to have a pressure ulcer, which was assessed on 09/24/18, as a Stage III. Additionally, Resident #3 did not receive a Skin Assessment from 06/03/18, until 06/20/18, seventeen (17) days later, when Deep Tissue Injury ulcers (DTIs) to bilateral heels, were discovered. Interview, on 10/22/18 at 12:04 PM, with State Registered Nurse Aide (SRNA) #7, revealed she had been employed at the facility for approximately one (1) year. She stated there was not enough staff to turn, reposition and change residents every two (2) hours as recommended for the prevention of pressure ulcers. Continued interview revealed when residents were not assisted with turning and repositioning every two (2) hours, this could lead to skin breakdown. Interview, on 10/22/18 at 2:30 PM, with SRNA #8, revealed she had been employed at the facility for approximately twenty-nine (29) years. Continued interview revealed it was important to turn and reposition residents every two (2) hours. She stated she tried to turn and reposition residents as often as she could, but this was not possible due to low staffing. Interview, on 10/22/18 at 4:12 PM, with SRNA #3, revealed she had been employed at the facility for approximately two (2) years. Continued interview revealed she attempted to turn and reposition residents every two (2) hours, but low staffing numbers did not allow her to do that. Interview, on 10/22/18 at 4:22 PM, with SRNA #4 revealed she had been employed at the facility for approximately two (2) months. Continued interview revealed residents should be turned and repositioned every 2 hours; however, low staffing numbers meant she was unable to turn and reposition residents every two (2) hours or provide care per their care plans. She stated when residents were not provided proper care, this could result in further skin breakdown. Interview, on 11/05/18 at 10:23 AM, with LPN #4/Wound Care Nurse, revealed she had been employed at the facility for approximately one (1) year before her resignation on 10/22/18. She stated while working at the facility, her duties included completing weekly Wound Evaluations on all residents with wounds, and notifying the Physician for changes in wounds. Per interview, prior to completing her Wound Evaluations she did not review resident Skin Assessments, Progress notes, Minimum Data Assessments (MDS), or physician's orders [REDACTED]. She stated she relied on direct care staff to inform her of new wounds, and also staff was to complete a wound form and place it in her mailbox if a new wound was identified. She further stated this was not an effective system to ensure she was made aware of all residents' wounds, as the nurses would fail to fill out the form, and therefore she would miss assessing some wounds during her weekly rounds. Further interview revealed due to being re-assigned to work the floor in the capacity of staff nurse on a frequent basis, she was unable to complete her weekly wound assessments. Per interview, when she was re-assigned to work the floor as staff nurse, no one else took over the wound care rounds and as a result the Wound Evaluations did not get done each week. Continued interview revealed she resigned because she wasn't happy with staffing and could not complete her wound care duties because of being re-assigned to work the floor as staff nurse frequently. Interview, on 10/22/18 at 2:01 PM, with Licensed Practical Nurse (LPN) #1 revealed she was an agency nurse and had been at the facility for approximately six (6) weeks. Continued interview revealed the facility policy stated residents were to be turned every two (2) hours, but there was usually not enough SRNAs to ensure that happened. She stated skin assessments should be done weekly, but occasionally she was unable to complete the weekly skin assessments and ordered treatments due to low staffing numbers. Interview, on 10/24/18 at 10:27 AM, with RN #2/ House Supervisor, revealed she had been employed at the facility for approximately one (1) year. Per interview, the floor nurses were to complete the skin assessments weekly and the wound care nurse was responsible for measuring and describing wounds on a weekly basis. Continued interview revealed the floor nurses were also responsible for providing the treatments every day. She stated she did not take a patient assignment and she helped out on the floor as she could. However, per interview, she knew some resident care was handed off to the next shift to be completed due to the staff were unable to complete all their assignments. Interview with RN #6, on 10/31/18 at 2:50 PM, revealed low staffing prevented nurses from completing the wound treatments as ordered. She stated she had witnessed many nights that previous shifts had not completed treatments. Continued interview revealed if a pressure ulcer was identified during a Weekly Skin Assessment, the nurse was responsible to measure and assess the wound and notify the provider, but she was not sure this was always done due to low staffing numbers. Interview with the Assistant Director of Nursing (ADON), on 11/02/18 at 11:25 AM, revealed she had been employed at the facility for approximately three (3) months. She stated it was her expectation staff provide care as per the physician's orders [REDACTED]. She further stated it was her expectation wound and skin assessments were completed weekly so that any new areas of skin breakdown would be quickly identified and any existing wounds would be monitored for healing or decline. Further interview revealed if skin treatments were not completed, this could lead to further skin impairment. Continued interview revealed it was her expectation staffing would allow for nurses and SRNAs to complete their duties. Interview with Director of Nursing (DON) #1, on 11/2/18 at 12:07, revealed she had been employed at the facility for approximately five (5) months. She further stated skin assessments were to be completed weekly and were to be documented on the Weekly Skin Review Form by the staff nurses. Per interview, the Wound Nurse was to assess the wounds weekly and document the findings on the Wound Evaluation Flow Sheet. She stated it was important to complete the skin and wound assessments weekly in order to track a resident's skin integrity, to ensure the interventions in place were effective, and to ensure the Physician was notified of any changes in skin integrity or wounds. Continued interview revealed it was her expectation the physician's orders [REDACTED]. Further interview with DON #1, revealed LPN #4 had been the facility Wound Care Nurse and had been responsible for completing the weekly Wound Evaluations/Assessments. Per interview, LPN #4 had resigned two (2) weeks ago. She stated LPN #4 had been pulled to the floor to work as a staff nurse at times, and her duties as wound nurse were not delegated to other administrative nurses or staff nurses. She stated it was her expectation LPN #4 keep up with her wound care duties regardless of sometimes working the floor. When questioned if there was any kind of wound care committee to oversee the wounds, she stated there was a facility skin meeting held weekly to review residents with new and current wounds. Documentation was provided to the State Agency Representative of the meetings; however, the documentation only included copies of the Consultant Registered Dietician's (RD) recommendations and the RD Progress notes. Further interview revealed she knew there was issues with staffing and she was working with corporate to find ways to recruit more staff to include sign on bonuses. She further stated the facility was also utilizing agency staff due to the staffing shortage. Interview with Medical Director (MD), on 11/02/18 at 11:35 AM, revealed he had been the MD at the facility for one (1) month. Additional interview revealed he was not aware weekly skin assessments and weekly wound evaluations were not being completed. He further stated he was unaware treatments were not being completed as ordered. He stated it was his expectation Skin and Wound Assessments be completed weekly and physician's orders [REDACTED]. Further interview revealed it was his expectation there was enough staff to ensure proper and necessary care was provided to the facility's residents. Interview on 11/2/18 at 12:07 with the Interim Executive Director, revealed she had been at the facility for five (5) days and did not yet have her Administrator's license, and was therefore in training. She stated it was her expectation care be provided as per the physician's orders [REDACTED]. She stated if a resident's skin and/or wounds were not assessed as ordered, this could result in the resident sustaining further skin breakdown. She revealed there needed to be enough staff to ensure care was provided as per the physician's orders [REDACTED]. Interview with the Interim Administrator, on 11/02/18 at 12:08 PM, revealed she had an Administrators' license and filled in as Administrator at the facility when needed. Per interview, she had been with the corporation for thirty (30) years, but did not work in the Administrator capacity at this facility until (MONTH) (YEAR), when the previous Administrator left the facility. She stated the administrative staff was aware the facility needed additional staff and were working on several staffing strategies to ensure resident's received necessary care. Additional interview revealed it was her expectation Skin Assessments, and Wound Assessments/Evaluations be completed weekly with the Physician notified of all changes in the resident's skin condition. Further interview revealed treatments should be administered as per physician's orders [REDACTED]. 2. Interview with the Interim Administrator, on 11/2/18 at 12:07 PM, revealed the facility had no specific policy related to grooming and baths; however, per interview it was her expectation the residents were groomed daily and received baths/showers twice a week as per their bath schedules. Resident and Staff interviews revealed residents were not receiving baths/showers twice a week as per facility protocol due to the facility being short staffed. The Documentation Survey Reports and SRNA Skin and Bath Reports revealed: Resident #1 preferred three (3) showers per week; however, received one (1) shower and three (3) bed baths for (MONTH) (YEAR), six (6) bed baths for (MONTH) (YEAR) and one (1) bed bath in (MONTH) (YEAR); Resident #3 preferred two (2) showers per week; however, received four (4) bed baths and one (2) shower for (MONTH) (YEAR), two (2) showers and two (2) bed baths in (MONTH) (YEAR), and three (3) bed baths in (MONTH) (YEAR); Resident #4 preferred three (3) bed baths per week; however, received: eight (8) baths in (MONTH) (YEAR), eight (8) baths in (MONTH) (YEAR) and five (5) baths in (MONTH) (YEAR); Resident #7 preferred two (2) bed baths per week; however, received: seven (7) bed baths in (MONTH) (YEAR) and three (3) bed baths and one (1) shower in (MONTH) (YEAR); Resident #9 preferred three (3) showers per week; however, received: six (6) bed baths in (MONTH) (YEAR), four (4) bed baths in (MONTH) (YEAR), and two (2) bed baths in (MONTH) (YEAR); Resident #10 preferred two (2) bed baths/showers per week; however, received had 3 bed baths in (MONTH) (YEAR), 3 bed baths in (MONTH) (YEAR), and no baths prior to discharge on 10/05/18; Resident #11 preferred three (3) showers per week; however, received three (3) showers and five (5) bed baths in (MONTH) (YEAR), four (4) showers and four (4) bed baths in (MONTH) (YEAR), and one (1) bed bath in (MONTH) (YEAR); and Resident #16 preferred two (2) showers per week; however, received one (1) bed bath and had three (3) refusals in (MONTH) (YEAR), two (2) bed baths and six (6) refusals in (MONTH) (YEAR), and one (1) bed bath and two (2) refusals in (MONTH) (YEAR). Interview with Resident #9, on 10/22/19 at 9:38 AM, revealed facility staffing over the past weekend had been short as usual with a lot of agency. Per interview, he/she no longer liked living at the facility because staffing was short and there was a lot of agency staff that did not know his/her needs. Further interview revealed this morning staff assisted him/her to wash up at the sink, instead of assisting him/her with a shower. Per interview, it made him/her feel dirty when he/she did not receive a shower. Additional interview with Resident #9, on 10/25/18 at 9:55 AM, revealed he/she had not received showers as requested routinely and this made him/her feel bad, and negative about himself/herself. Per interview, he/she had feelings of depression related to not receiving showers. Resident #9 stated he/she was pissed that staff would not offer to assist with bathing routinely, and on the limited occasion when staff did offer to assist him/her, it was just with washing up at the sink in his/her room and not his/her preferred shower. Further interview revealed, he/she felt himself/herself shutting down and withdrawing from activities he/she used to enjoy and find pleasure in because he/she felt dirty and ashamed and did not want to interact with other people. Interview with Resident #4, on 10/29/18 at 9:29 AM, revealed, he/she required a maxi lift to transfer and on some days, staff would not get him/her out of bed due to not having enough staff. Continued interview revealed over the past weekend, he/she did not receive a bath because the facility was short staffed and only had agency staff. Per interview, Resident #4 did not receive his/her preferred three (3) bed baths per week because the facility was short of staff. Further interview revealed, he/she felt dirty and bad like I don't count, like I'm inhuman and don't deserve respect. Interview with Resident #11, on 10/24/18 at 9:53 AM, revealed he/she had requested to receive a shower three (3) times a week; however, was not receiving them. Continued interview revealed he/she was not even receiving a bath or shower two (2) times per week. He/she stated, he/she usually preferred to eat meals in the dining room for socialization, but did not want to eat in the dining room the last two (2) days due to not receiving baths/showers. Per interview, when he/she did not receive a bath/shower at least twice a week, he/she felt dirty and ashamed and this affected his/her desire to be around other people. Resident #11 stated, his/her favorite activity was bingo; however, he/she had not gone to bingo in a few weeks due to being embarrassed about not receiving a bath. Interview with Resident #16, on 10/25/18 at 1:40 PM, revealed he/she did not receive two (2) showers a week as requested and preferred. He/she stated, he/she often refused baths when occasionally offered, because he/she felt the staff did not care enough about him/her to regularly ask about showering. Resident #16 stated he/she sometimes refused baths because the facility had mostly agency staff who were not familiar with him/her and his/her wounds and bathing preferences. Per interview, when he/she did not receive showers or was not offered a shower it was very upsetting and made him/her feel depressed with a decreased desire to leave the room. Interview with Stated Registered Nursing Assistant (SRNA) #7, on 10/22/18 at 12:04 PM, revealed she routinely provided care for resident #4 and #7 and occasionally provided care to the other residents. SRNA #7 stated residents were scheduled two (2) baths a week. Per interview, staff could not provide all the care to each resident related to the facility being short staffed. SRNA #7 stated showers and baths were at times not completed because they were very time consuming. Further interview revealed residents were not receiving quality care because there just was not enough staff scheduled to get the job done. Interview with SRNA #8, on 10/22/18 at 2:30 PM, revealed she routinely provided care to resident #9, #11 and #16. SRNA #8 stated showers should be provided to residents at least two (2) times per week. Continued interview revealed baths/showers were not being consistently provided to residents because when there was less than ideal numbers of staff, this effected the SRNA's ability to get the baths completed for their assigned residents. Further interview revealed baths were sometimes put off until another shift or day when staffing would permit the bath in addition to other duties. Interview with SRNA #5, on 10/23/18 at 1:26 PM, revealed she routinely cared for Resident #3, and Resident #9. Per interview, residents were supposed to have a bath/shower provided to them twice a week. However, she stated the residents were not getting their baths twice a week or per their requests and preference because staffing levels did not allow enough time to get all necessary care completed for each resident. Additional interview revealed SRNAs documented baths/showers in the kiosk (computerized system) and the SRNAs were also asked by the nurses to document baths and showers as completed on the Certified Nurse Assistant (CNA) Bath and Skin Sheets regardless if the bath/shower was actually given. Further, she was unable to complete charting on the residents during her shift because while she charted, resident care was not being completed. Per interview, sometimes she would just not chart the care she had completed in order to provide more care to residents before she went home. Interview with SRNA #9, on 10/25/18 at 8:53 AM, revealed she was assigned to all units and had provided care to all the residents. Per interview, residents were scheduled baths/showers twice a week. However, she stated the residents did not always receive their baths or showers because there was not enough staff to get all resident care completed. Interview with SRNA #2, on 10/22/18 at 3:45 PM, revealed she was agency staff and had been working at the facility for a couple of months over fifty (50) to sixty (60) hours each week. Per interview, since she was agency, the facility assigned her to all units and she never knew which unit she would have for that day. SRNA #2 stated residents were supposed to receive two (2) baths a week. However, she stated most days she was not able to complete baths for the residents because there was not enough staff scheduled to help with resident care. Additional interview revealed she had to prioritize care to ensure the residents received incontinence care, were assisted with meals and were assisted to bed when needed. Further interview revealed when baths/showers were not completed on scheduled bath days, the SRNAs would try to make the baths up on another day, depending on if they had the time and if staffing was sufficient. Interview with SRNA #6, on 10/24/18 at 10:19 AM, revealed she was agency and this was her first day. Continued interview revealed she was unaware if any residents assigned during her shift had scheduled baths. She stated she was provided no orientation at the facility before being assigned to care for the residents. Per interview, she was provided a verbal report on her assigned residents at the beginning of her shift from the SRNA leaving; however, she was not provided with the specific needs of the residents, a care plan or knowledge of how or where to find each resident's care plan. Further interview revealed there was nobody around to ask for help or guidance. Phone interview with LPN #15, on 11/05/18 at 1:31 PM, revealed she was no longer with the facility. Per interview, residents should receive two (2) baths a week, and the SRNAs were to document the baths/showers on the kiosk under ADL tasks and on the Bath and Skin Reports. Per interview, the nurses were to review SRNA documentation to monitor each shift to ensure residents received their scheduled baths. However, she stated SRNAs were not consistent with providing baths or completing ADL documentation related to low staffing numbers. Further interview revealed baths were an important part of resident care to ensure a resident's skin was assessed routinely, to provide basic hygiene, and to promote good self-esteem. Interview with Registered Nurse (RN) #1, on 10/22/18 at 2:55 PM, revealed she routinely provided care to Residents #9, #11 and #16. Per interview, residents were supposed to have two (2) baths/showers per week. Per interview, the SRNAs were supposed to document completed baths/showers in the kiosk in order for the nurses to review the documentation and ensure residents were provided their baths. However, RN #1 stated the facility was understaffed and the scheduled staff did not have enough time to get everything done for each resident. RN #1 stated, unfortunately baths were not always completed or documented. Further interview revealed it was very hard to monitor and supervise SRNAs to ensure they were providing each resident with all necessary care because the nurses were also understaffed. Interview with RN #7, on 11/01/18 at 3:02 PM, revealed she routinely provided care to Resident #3 and #9. RN #7 stated residents were scheduled to receive baths twice a week on assigned days and shifts. However, she stated when the facility was short staffed, as was usually the case, the SRNAs did not have enough hands to complete all baths for residents. Additional interview revealed she could not monitor SRNAs to ensure all baths/showers were provided because of her workload and she relied on the SRNA documentation to monitor if the residents received their baths. Further interview revealed residents should receive baths on preferred days; however, this did not happen unless staffing permitted. Interview with RN #6, on 10/31/18 at 2:50 PM, she had been at the facility for one (1) year and recently went part time due to the staffing shortage at the facility. Per interview, she was assigned different units since she had become part time. RN #6 revealed residents were to receive two (2) baths a week. However, she stated staffing shortages did not accommodate providing two (2) baths or showers per week. RN #6 stated staff could not always accommodate when a resident wanted a bath, as staff could only provide baths when time allowed. Further interview revealed residents should be able to receive baths/showers per their preferred days to maintain Resident Rights and overall good health and well-being. Interview with RN #3 on 11/05/18 at 2:55 PM, she was agency and had worked at the facility for approximately one (1) month. Continued interview revealed her resident assignment would change daily and she had provided care to all the residents. RN #3 revealed residents were scheduled baths two (2) times a week. Per interview, the SRNAs completed the CNA Bath and Skin Reports after completion of baths. Further interview revealed staffing was very short and there was not always enough staff scheduled to complete baths. However, RN #3 stated it was important for residents to receive baths per their choice and preference to ensure quality care and good health. Interview with RN #9, on 11/05/18 at 2:13 PM, revealed she had been at the facility for eight (8) years; however, had resigned due to terrible staffing. RN #9 stated the facility was so short of staff, she was afraid she would loose her nursing license and it was not a safe environment. Per interview, residents were scheduled baths two (2) times a week. However, per interview, baths were not completed related to inadequate staffing numbers. RN #9 stated the SRNAs documented baths in the kiosk and on a CNA Bath and Skin Report when completed; however, baths were not always completed even when documentation showed it was. Further interview revealed baths were provided to residents when staffing allowed and not always per the residents' preferred bathing days and times. Interview with Director of Nursing (DON) #1, on 11/02/18 at 12:07 PM, revealed she was unaware baths and showers were not being provided to the residents. Continued interview revealed, she was aware the facility had a staffing issue and that several staff had recently resigned. Additionally, she stated the facility did not have a process in place to ensure baths were completed routinely, other than a review of documentation during a morning meeting Monday through Thursday. Per interview, the facility was working with the corporation to recruit new staff. Additional interview with the Interim Administrator, on 11/02/18 at 12:07 PM, revealed the former Administrator had recently resigned. She stated she was not aware the residents were not being provided baths/showers until this survey. Per interview, it was her expectation baths or showers be provided per the resident's preference and at least two (2) times per week. Continued interview revealed, as Interim Administrator, she was responsible for oversight of staffing and she was aware of the staffing situation. Per interview, she recognized the facility had staffing issues and had been working with the corp

Based on interview, record review, and review of facility Policy, it was determined the facility failed to have an effective system to promptly notify the Provider of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures and failed to ensure laboratory services were obtained only when ordered by a Provider. These failures affected five (5) of six (6) sampled residents reviewed related to [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) laboratory data out of a total of thirty-nine (39) sampled residents (Resident #23, #31, #32, #33, and #39). (A PT is a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder; the INR is calculated from a PT result and is used to monitor how well the blood thinning medication (anticoagulant-[MEDICATION NAME]) is working to prevent blood clots) (Refer to F-757) The facility's failure to promptly notify the Provider of laboratory results that fall outside of clinical reference ranges related to PT/INR levels for residents receiving [MEDICATION NAME] medication has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was was identified on 01/09/19 and determined to exist on 09/24/18 and is ongoing. The findings include: Review of the facility Standard of Practice Policy, dated 01/2016, revealed the facility would provide the appropriate diagnostic services (laboratory and radiology) required to maintain the overall health of its residents and in accordance with State and Federal guidelines. Per Policy, the physician, physician assistant, and/or nurse practitioner should be notified of laboratory, radiology and other diagnostic findings. Further review revealed the facility would notify the attending physician of critical laboratory results, radiology and other diagnostic results in a timely manner. Per Policy, the facility would communicate the results to the ordering physician as per physician's orders [REDACTED]. The Laboratory Company utilized by the facility, revealed the following ranges for Normal PT/INR levels. Normal Range for [MEDICATION NAME] Time (PT) 9.5 seconds to 11.8 seconds. Normal Range for International Normalized Ratio (INR) 0.9 -1.1. 1. Review of Resident #23's clinical record revealed the facility admitted the resident on 11/13/18 with [DIAGNOSES REDACTED]. Review of Resident #23's Physician Order's, dated 11/13/18, revealed orders for [MEDICATION NAME] 2.5 milligrams (mg) by mouth one (1) time a day for [DIAGNOSES REDACTED]. Further review of Resident #23's Physician Order's dated 11/15/18, revealed orders for [MEDICATION NAME] HCl Solution 25 MG/ML (antibiotic medication), administer 10 ml by mouth four (4) times a day for [MEDICAL CONDITION] with a start date of 11/15/18 and a discontinue date of 11/25/18. Review of Resident #23's Laboratory Reports, dated 11/16/18 (Friday), revealed Resident #23's PT level was 31.2 High and INR level was 2.8 High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). Further review revealed there was no documented evidence the Physician was notified of the results of the PT/INR results drawn on 11/16/18 and the resident continued to received 2.5 mg of [MEDICATION NAME] per day. Review of the Laboratory Report, dated 11/19/18 (Monday), revealed Resident #23's PT level was 65.6 High and the INR level was 5.8 Critically High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). Review of Resident #23's Nurse's Note, dated 11/19/18 at 3:46 PM, revealed the Physician was notified and new orders were received to HOLD [MEDICATION NAME] until the next PT/INR on Wednesday, 11/21/18. Review of Resident #23's Laboratory Report, dated 11/21/18 (Wednesday), revealed Resident #23's PT level was 76.3 High and the INR level was 6.7 Critically High. Review of the Progress Notes, dated 11/21/18 at 3:44 PM, revealed the Physician was contacted and new orders were received to administer five (5) milligrams of Vitamin K. Review of the Progress Notes, dated 11/21/18 at 6:08 PM, completed by Registered Nurse (RN) #1, revealed the resident was found to have an extreme amount of blood in his/her brief with clots, and physician's orders [REDACTED]. 2. Review of Resident #32's clinical record revealed the facility admitted the resident on 09/29/16, and readmitted the resident on 12/12/18, with [DIAGNOSES REDACTED]. Review of Resident #32's Order Summary Report for (MONTH) (YEAR), revealed physician's orders [REDACTED]. Additionally, there was physician's orders [REDACTED]. Review of Resident #32's physician's orders [REDACTED]. Review of the Laboratory Report, dated 09/06/18 (Thursday), reported 09/06/18 at 12:01 PM, revealed High PT/INR results: PT 22.6 High and INR 2.1 High; however, there was no documented evidence the Physician was notified of the High lab results and the resident continued on the same [MEDICATION NAME] dosage. Review of Resident #32's physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Review of Resident #32's Laboratory Report, dated 09/13/18 (Thursday), reported on 09/13/18 at 11:45 AM, revealed High PT/INR results: PT 13.5 High and INR 1.3 High; however, there was no documented evidence the Physician was notified of the High lab results. Review of the Laboratory Report dated 09/17/18 (Monday), reported on 09/17/18 at 11:57 AM, revealed High PT/INR results: PT 21.6 High and INR 2.0 High; however, there was no documented evidence the Physician was notified, on 09/17/18, of the High lab results. Review of the Laboratory Report, dated 09/20/18 (Thursday), reported on 09/20/18 at 11:32 AM, revealed High PT/INR results: PT 17.2 High and INR 1.6 High; however, there was no documented evidence the Physician was notified of the High lab results. Review of the Laboratory Report, dated 09/24/18 (Monday), reported 09/24/18 at 11:32 AM, revealed High PT/INR results: PT 18.8 High and INR 1.7 High. There was a notation on the Report by LPN #21 to increase [MEDICATION NAME] to 2.5 mg daily and re-check PT/INR on 09/27/18. Review of Resident #32's Laboratory Report, dated 09/27/18 (Thursday), reported on 09/27/18 at 12:05 PM, revealed High PT/INR results: PT 15.1 High. and INR 1.4 High; however, there was no documented evidence the Physician was notified of the High lab results. Review of Resident #32's Laboratory Report, dated 10/01/18 (Monday), reported on 10/01/18 at 11:53 AM, revealed High PT/INR results: PT 13.1 High and INR 1.2 High; however, there was no documented evidence the Physician was notified of the High lab results. Review of the Laboratory Report, dated 10/04/18 (Thursday), reported on 10/04/18 at 12:09 PM, revealed High PT/INR results: PT 14.7 High and INR 1.4 High; however, there was no documented evidence the Physician was notified of the High lab results. Review of Resident #32's Laboratory Report, dated 10/08/18 (Monday), reported on 10/08/18 at 12:09 PM, revealed High PT/INR results: PT 29 High and INR 2.6 High; however, there was no documented evidence the Physician was notified of the High lab results. On 10/10/18, two (2) days later, LPN #21 initialed and dated the Report and made a notation that the resident was on [MEDICATION NAME] 2.5 mg every day; however, there was no notation related to notification to the Physician. Review of the Laboratory Report, dated 10/11/18 (Thursday), revealed High PT/INR results; PT 37.1 High and INR 3.3 High (standard anticoagulant 2.0-3.0 INR). However, there was no documented evidence the Physician was notified of these High lab results. (On 10/19/18, eight (8) days later, RN #12 initialed the Laboratory Report, but did not indicate if the Physician was notified of the results). Review of Resident #32's physician's orders [REDACTED]. Review of the Laboratory Report, dated 10/18/18 (Thursday), reported 10/18/18 at 2:21 PM, revealed High PT/ INR results: PT: 78.2 High and INR 6.8 Critically High (standard anticoagulant 2.0-3.0 INR). This Report was not dated or signed by a nurse; however, there was a notation on the Report stating, New Order for PT/INR on 10/19/18, and Hold [MEDICATION NAME]. Review of the Laboratory Report, dated 10/19/18, reported on 10/19/18 at 1:17 PM, revealed High PT/ INR results: PT: 42.6 High and INR 3.8 High (standard anticoagulant 2.0-3.0 INR). However, there was no documented evidence the Physician was notified of the High lab results. Review of the Laboratory Report, dated 10/22/18 (Monday), reported 10/22/18 at 11:59 AM, revealed the resident's laboratory values were: PT 43.3 High and INR 3.9 High (standard anticoagulant 2.0-3.0 INR). LPN # 17 noted on the Lab Results, new orders for Vitamin K 5.0 mg, one (1) dose now and repeat PT/INR in AM (morning), on 10/23/18. Review of the Laboratory Report, dated 10/23/18, reported 10/23/18 at 2:04 PM, revealed High PT/INR; PT 21.1 High and INR 1.9 High; however, there was no documented evidence the Physician was notified of the lab results on 10/23/18. LPN #21 did note on the Report, 10/26/18, three (3) days later, [MEDICATION NAME] 2.5 mg; re-check PT/INR in one (1) week. However, there was no documented evidence of a physician's orders [REDACTED]. Review of Resident #32's physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. However, the morning dose of [MEDICATION NAME] 2.5 mg was not discontinued on the MAR. This resulted in the resident receiving a total of 5.0 mg of [MEDICATION NAME] for five (5) days; 10/26/18 through 10/30/18. Review of Resident #32's (MONTH) (YEAR) MAR, revealed the resident received [MEDICATION NAME] 2.5 mg at 8:00 AM, AND [MEDICATION NAME] 2.5 mg at 5:00 PM from 10/26/18 through 10/30/18. Review of the Laboratory Report, dated 11/01/18 (Thursday), reported on 11/01/18 at 12:34 PM, revealed High PT/INR results: PT 24 High and INR 2.2 High; however, there was no documented evidence the Physician was notified of the High lab results. Review of Resident #32's physician's orders [REDACTED]. Review of the Laboratory Report, dated 11/15/18 (Thursday), reported on 11/15/18 at 12:06 PM, revealed High PT/INR results: PT 29 High and INR 2.6 High; however, there was no documented evidence the Physician was notified of the results and Resident #32 continued to receive [MEDICATION NAME] as ordered. Review of the Laboratory Report, dated 11/19/18 (Monday), reported on 11/19/18 at 12:08 PM, revealed : PT 72 High and INR 6.2 Critical High (standard anticoagulant INR 2.0-3). There was a notation on this Report, stating discontinue [MEDICATION NAME] 3.0 mg; Vitamin K 10 mg; re-check AM (morning), with no nurse's initials or date on the notation. Review of Resident #32's physician's orders [REDACTED]. 3. Review of Resident #39's clinical record revealed the facility admitted the resident on 10/19/18 with the [DIAGNOSES REDACTED]. Review of Resident #39's physician's orders [REDACTED]. Further review of Resident #39's physician's orders [REDACTED]. Review of the Laboratory Report, dated 10/22/18, reported to the facility on [DATE] at 12:10 PM, revealed: PT: 23.2 High and INR: 2.1 High; however, there was no documented evidence the Physician was notified of the laboratory results. Review of Resident #39's physician's orders [REDACTED]. Review of Resident #39's physician's orders [REDACTED]. Review of the Laboratory Report, dated 11/14/18 (Wednesday), reported to the facility on [DATE] at 12:17 PM, revealed: PT: 22.1 High and INR: 2.0 High; however, there was no documented evidence of notification to the Physician of the laboratory results. Review of Resident #39's Hospital Discharge Summary, revealed the resident was hospitalized from [DATE] until 11/28/18, with a [DIAGNOSES REDACTED]. Review of Resident #39's Re-admission physician's orders [REDACTED]. Review of Resident #39's Laboratory Report, dated 11/30/19 (Friday), reported to the facility on [DATE] at 12:34 PM, revealed: PT: 31.8 High and INR: 2.9 High. There was a handwritten notation on the Report which stated noted, sent to MD 11/30/19 at 2:50 PM , by LPN #23. Although LPN #23's notation indicated the lab results were faxed to the Physician, there was no documented evidence the physician was notified regarding the 11/30/18 Laboratory results. Review of the Laboratory Report dated 12/03/18, (Monday) reported to the facility on [DATE] at 12:51 PM, revealed: PT: 23.1 High and INR: 21. High; however, there was no documented evidence the Physician was notified of these laboratory results. 4. Review of Resident #31's medical record revealed the facility admitted the resident on 10/02/18 with the primary [DIAGNOSES REDACTED]. Review of Resident #31's physician's orders [REDACTED]. Review of Resident #31's Laboratory Report, dated 10/03/18, reported to the facility on [DATE] at 1:21 PM, revealed PT 22.2 High and INR 2.2 High; however, there was no documented evidence the Physician was notified of the results. Review of Resident #31's Laboratory Report, dated 10/09/18, revealed results of PT: 41.6 High and INR: 3.7 High. The Report revealed the results were faxed on 10/09/18 at 12:11 PM. However, there was no documented evidence the Physician was contacted related to the laboratory results. Review of the Laboratory Report, revealed labs drawn on 10/25/18, reported 10/25/18 at 11:45 AM (with no documented evidence of a physician's orders [REDACTED]. However, there was no documented evidence the Physician was notified of the laboratory results. Review of the Hospital Discharge Summary, dated 11/07/18, revealed Resident #31 was admitted to the hospital on [DATE], treated for [REDACTED]. Review of Resident #31's physician's orders [REDACTED]. Continued review revealed orders for [MEDICATION NAME] 2.5 mg on Tuesday and Thursday and [MEDICATION NAME] 5.0 mg by mouth in the evening every Sunday, Monday, Wednesday, Friday and Saturday. Review of the Laboratory Report, revealed labs drawn on 11/09/18, reported on 11/09/18 at 11:33 AM. with results: PT: 25.5 High and INR: 2.3 High. However, there was no documented evidence the Physician was notified of the laboratory results. Review of physician's orders [REDACTED]. (Per the Hospital lab dated 12/27/18, the PT was 16.1 (reference range of 9.3-12.1) and the INR was 1.51 (reference range of 2.0-3.0 for standard oral anticoagulant therapy). Review of the Laboratory Report, dated 01/02/19, reported 01/02/19 at 12:36 PM, revealed results: PT: 22.0 High and INR: 2.0 High; however, there was no documented evidence the Physician was notified of the results. 5. Review of Resident #33's clinical record revealed the facility admitted the resident on 12/13/18, with [DIAGNOSES REDACTED]. Review of Resident #33's physician's orders [REDACTED]. Review of Resident #33's physician's orders [REDACTED]. Review of the Laboratory Report, dated 12/20/18, reported on 12/20/18 at 12:17 PM, revealed High PT/INR results: PT 15.8 High and INR 1.5 High. The Report had a handwritten notation to change [MEDICATION NAME] to 3 mg daily and re-check PT/INR in one (1) week; dated 12/20/18 by RN #7. However, there was no documented evidence of a physician's orders [REDACTED]. However, there was no documented evidence of a physician's orders [REDACTED]. Review of Resident #33's physician's orders [REDACTED]. Further review revealed an order for [REDACTED]. Review of Resident #33's physician's orders [REDACTED]. Review of Resident #33's physician's orders [REDACTED]. Review of the Laboratory Report, dated 12/24/18, reported 12/24/18 at 12:16 PM, revealed PT/INR results: PT 11.2 and INR 1.1. However, there was no documented evidence the Physician was notified of these lab results. Review of Resident #33's physician's orders [REDACTED]. Review of the Laboratory Report, dated 12/31/18, reported on 12/31/18 at 12:16 PM, revealed PT/INR results: PT 11.7 and INR 1.1. LPN #10 signed the Lab result, but there was no documented evidence the Physician was notified of the result. Also, there was no documented evidence of a physician's orders [REDACTED]. Review of Resident #33's physician's orders [REDACTED]. Review of Resident #33's physician's orders [REDACTED]. Review of the Laboratory Report, dated 01/09/19, reported 01/09/19 at 12:09 PM, revealed High PT/INR results: PT 18.8 and INR 1.7. However, there was no documented evidence the Physician was notified of the lab results. Interview with RN #16, on 01/10/19 at 2:16 PM revealed the nurses on the unit were responsible for checking the fax machine for Laboratory Reports and notifying the Provider of the laboratory results. Per interview, the nurses would then input the new orders into the computerized system, including new lab orders. However, she stated she was unaware of a tracking system to ensure lab results were reported to the Provider, or to ensure physician's orders [REDACTED]. Interview with the Physician/Medical Director (MD) on 01/10/19 at 2:45 PM, revealed it was his expectation labs be obtained as ordered and nursing staff notify him or the ARNP of all lab results, normal and abnormal, upon receipt of the results. He stated he was unaware labs were being obtained without an order; and that nursing staff was not promptly notifying the Provider of PT/INR results. Further interview revealed he was not aware of any tracking system to ensure PT/INR levels were monitored by the facility and the Provider notified of the results. However, he stated there should be a protocol in place and the nursing staff should be communicating with the Physician and APRN. Interview with Director of Nursing (DON) #2, on 12/28/18 at 9:00 AM, and 01/10/19 at 3:42 PM, revealed she was new to the position as DON, and started in her position late (MONTH) (YEAR). Per interview, lab requisitions were printed with the lab orders by the nurses for the phlebotomists who draw labs for PT/INR during the night shift between the times of 2:00 AM to 5:00 AM. DON #2 further stated the laboratory results were faxed to the facility and the nurses were to check the fax machines throughout the shift and notify the Physician promptly of any lab results by phone. Per interview, if the Provider gave verbal orders related to the lab results, the nurse was to accurately enter the orders into the Point Click Care computerized system as a new order. Further interview revealed DON #2 was unaware of a tracking system for monitoring [MEDICATION NAME] dosages, and lab orders for PT/INR; or notification to the Provider of laboratory results related to PT/INR. Interview with the facility's Administrator on 01/03/18 at 3:45 PM, revealed it was her expectation laboratory reports related to [MEDICATION NAME] or any laboratory results be reported to the Physician by the nurse on the unit as soon as they were faxed to the facility to ensure adequate monitoring of the residents. Per interview [MEDICATION NAME] was a high risk medication and it was especially important for laboratory values related to this medication to be reported to the Physician. Further interview revealed it was her expectation staff follow physician's orders [REDACTED].

Based on interview, record review, review of facility Policy, and review of the Allegation of Compliance (AoC) related to the Immediate Jeopardy identified on 12/20/18, it was determined the facility failed to have a governing body that was effective at implementing policies regarding management and operation of the facility. This was evidenced by the facility's failure to ensure the AoC, with an Immediate Jeopardy removal date of 12/26/18, was implemented related to pressure ulcers. (Refer to F-835) The facility's failure to ensure the facility was administered in an effective manner had caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/20/18 and was determined to exist on 09/28/18, in the areas of 42 CFR 483.10 Resident Rights, F-580 at a S/S of a K; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F-656 and F-657 both at a S/S of a K; 42 CFR 483.25 Quality of Care, F-686 at a S/S of a K; 42 CFR 483.35 Nursing Services, F-725 at a S/S of a K; and 42 CFR 483.70 Administration, F-835 and F-837, both at a S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care. The facility was notified of the Immediate Jeopardy on 12/20/18. The facility submitted an Allegation of Compliance (AoC) in response to Immediate Jeopardy deficiencies identified on 12/20/18, and alleged compliance effective 12/26/18. However, the AoC could not be verified based on observation, staff interview, and review of facility documentation as the facility failed to implement their AoC. The Immediate Jeopardy is ongoing. The findings include: Interview with the Director of Nursing (DON) #2 DON on 01/10/18 at 1:00 PM, revealed the facility was unable to submit Job Descriptions for the Governing Body per their legal counsel. Review of the facility's Skin System Policy, undated, revealed the facility would provide necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for residents having a pressure sore. Additionally, the facility would promote the prevention of pressure ulcer development for residents who enter the facility without a pressure sore. Continued review revealed all residents would be assessed with [REDACTED]. Further, upon identification of skin/wound impairment the nurse would complete a Situation Background Action Results (SBAR) Note, and notify the Skin Committee of the changes in the resident's skin condition for additional oversight and monitoring. Per Policy, the nurse would notify the responsible party and update the Treatment Administration Record (TAR). The facility's AoC, with an Immediate Jeopardy removal date of 12/26/18, could not be validated, per observation, interview, record review, and review of the facility's audits, related to: the facility's failure to document wounds and complete a Wound Evaluation for Resident #14; failure to ensure Care Plans were revised on 12/19/18 per the AoC for Resident #16, Resident #34, Resident #35, and Resident #36; failure to have documented evidence weekly wound rounds were conducted per the AoC and to ensure the audit tool was wound specific due to residents having multiple wounds; failure to monitor the weekly skin inspections as part of the Interdisciplinary Treatment (IDT) meeting per the AoC; and, failure to review staffing in the morning meeting per the AoC. Interview with the Regional Director of Operations (RDO), on 01/03/18 at 4:00 PM, and post survey phone interview on 01/24/19, revealed she developed the AoC after Immediate Jeopardy was identified with the Interim Administrator's assistance. She further stated she ensured the Administrator and other staff was implementing the AoC, by providing oversight in the building seven (7) days a week, by guiding the Administrator and other staff with the daily operations of the facility and giving guidance and support. Per interview, she did audits of the Daily Nursing Assignment sheets which was the tool used to ensure there was enough staff. She stated she discussed staffing with the Director of Nursing (DON) and the Administrator in the mornings and afternoons as well. She further stated there was no tool used for the staffing audit, but the DON and Administrator did initial the Daily Nursing Assignment sheets each day. She further stated the Registered Nurse (RN) Consultant did the wound rounds by visualizing wounds, but she was not sure of the process otherwise. Per interview, to her knowledge the wound rounds were completed weekly. She stated the Care Plans were to be reviewed and updated after wound rounds if there were significant changes in wounds, and to her knowledge the Care Plans were updated timely when a significant change in a wound was noted. Further interview revealed she felt the AoC was implemented.

Based on interview, record review, and review of facility's Policy, it was determined the facility failed to ensure the Comprehensive Care Plan was evaluated and revised to accurately reflect the resident's status and needs related to Pressure Ulcers and Vascular Ulcers. The Care Plans were not being revised when new Pressure Ulcers and Vascular Ulcers were identified and were not being revised as Pressure Ulcers and Vascular Ulcers improved or deteriorated. This failure affected five (5) of thirty-nine (39) sampled residents (Resident's #3, #8, #9, #14, and #15). (Refer to F-686 and F-684) The facility's failure to have an effective system in place to ensure Comprehensive Care Plans were revised has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 12/20/18 and was determined to exist on 09/28/18. The facility provided an acceptable credible Allegation of Compliance (AoC) on 12/26/18, which alleged removal of the Immediate Jeopardy on 12/26/18. However, the AoC could not be verified based on observations, staff interviews, and review of facility documentation. The immediate Jeopardy is ongoing. The findings include: Review of the facility's Care Plan Procedure Policy, undated, revealed it was the practice of the facility to initiate, complete and revise resident care plans in accordance with all Federal and State regulations and Resident Assessment Instrument (RAI) guidance. Continued review revealed the facility would develop a resident centered comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Per Policy, the facility would evaluate the appropriateness of the care plan after each Quarterly assessment and on an on-going basis, and modify the care plan if appropriate. Review of the Resident Assessment Instrument Version 3.0 Manual, revealed the results of the assessment which must accurately reflect the resident's status and needs, were to be used to review and revise each resident's Comprehensive Plan of Care. Further, the Care Plan must be reviewed and revised periodically and services provided or arranged must be consistent with each resident's written plan of care. 1. Review of Resident #15's Electronic Medical Record (EMR) revealed the facility admitted the resident on 07/04/17 and readmitted the resident 08/03/18 with [DIAGNOSES REDACTED]. Review of the Admission Re-Assessment, dated 08/03/18, revealed Resident #15 had skin impairment of the left heel, right boggy heel, right boggy elbow, Pressure Ulcer to the right hip, and bruises and scab to his/her right toes. Review of the Wound Evaluation Flow Sheet, dated 08/03/18, revealed Resident #15 had a right hip Stage IV Pressure Ulcer measuring 6.0 cm length x 6.0 cm width x 2.0 cm depth. This pressure ulcer was described as dark red in color, with scant thick exudate. Review of the Wound Evaluation Flow Sheet, dated 08/03/18, revealed Resident #15 had a left outer foot wound. This Evaluation did not have a description or measurement of the wound. Review of the Wound Evaluation Flow Sheet, dated 08/07/18, completed by LPN #4/Wound Nurse, revealed Resident #15's right hip pressure ulcer was a Stage IV, and measured 4.8 cm length x 4.2 cm width x 1.4 cm depth, and had a moderate amount of clear thin exudate. Review of the Wound Evaluation Flow Sheet, dated 08/07/18, completed by LPN #4/Wound Nurse, revealed Resident #15's left outer foot had an unstageable pressure ulcer measuring 2.1 cm length x 1.0 cm width. Further review revealed the wound was 100% necrotic, and was described as having defined margins with the surrounding skin intact. Review of the Admission Minimum Data Set (MDS) Assessment, dated 08/10/18, revealed Resident #15 was assessed as at risk for developing a pressure ulcer and as having unhealed pressure ulcers. Further review revealed the resident had one (1) Stage IV pressure ulcer and one (1) Unstageable Deep Tissue Injury (DTI). Review of Resident #15's Comprehensive Care Plan (CCP) initiated on 08/14/18, revealed the resident was at risk for skin breakdown and had actual skin impairment including a Stage IV pressure ulcer to the right hip and an unstageable pressure ulcer to the left outer foot due to being chair bound, incontinent, and a history of breakdown. The goal which was initiated on 08/14/18 and revised on 09/27/18, was to improve pressure ulcers. Interventions initiated on 08/14/18 included skin treatments as ordered, and turn and reposition the resident every two (2) to three (3) hours PRN while in bed. Review of the Weekly Skin Review, dated 08/17/18, completed by LPN #6, revealed Resident #15 had bruising to his/her feet, and scratches to his/her toes and right hip. Further review revealed the left coccyx had new treatments in place. This was the first documentation related to skin impairment to the resident's coccyx area. In addition, there was no documented evidence of a Wound Evaluation completed on 08/17/18 related to the skin impairment to the resident's coccyx area. Review of the Wound Assessment, dated 09/28/18, completed by the Physician, revealed there was an unstageable pressure ulcer to the resident's left foot first metatarsal (bone behind the big toe) measured at 1.0 cm length x 0.7 cm width x 0.1 cm depth, which was described as 100% eschar and scant amount of yellow exudate. This was the first identification and measurement of this left foot first metatarsal wound. Additional review of the Wound Assessment, dated 09/28/18, completed by the Physician, revealed an unstageable pressure ulcer to the resident's left buttock which was acquired less than one (1) week ago, and measured 0.5 cm length x 0.4 cm width x 0.1 cm depth. The wound was assessed as 90% granulation and 10% slough with moderate serous exudate. This was the first assessment, staging and measurement of this wound, although there were treatment orders for the wound obtained on 09/21/18. Continued review of the Wound Assessment, dated 09/28/18, completed by the Physician, revealed there was a wound to the resident's right lateral foot, acquired less than one (1) week ago, and measured 1.0 cm length x 1.2 cm width, and was 100% eschar with no exudate. This was the first identification and measurement of this right lateral foot wound. Review of the Wound Evaluation Flow Sheet, dated 09/28/18, completed by LPN #4/Wound Nurse, revealed the resident had an unstageable pressure ulcer to the right great toe, identified on 09/25/18, which measured 2.0 cm length x 1.5 cm width and was 100% necrotic. This was the first identification, staging and measurement of this right great toe wound. Review of the Wound Evaluation Flow Sheet, dated 09/28/18, completed by LPN #4/Wound Nurse, revealed the resident had a Stage III pressure ulcer to the left outer foot at the small toe. Further review revealed the measurements were 1.0 cm length x 1.0 cm width. This was the first identification, staging and measurement of the left outer foot at the small toe pressure ulcer per record review. Review of the Wound Evaluation Flow Sheet, dated 10/02/18, completed by LPN #4/Wound Nurse, revealed the unstageable pressure ulcer to Resident #15's right great toe measured 1.6 cm length x 1.0 cm width. This wound was described as a full thickness wound, 10% slough and 90% necrotic. Review of Resident #15's Wound Evaluation Flow Sheet, dated 10/17/18, completed by LPN #4/Wound Nurse, revealed the unstageable pressure ulcer to the resident's right great toe measured 0.5 cm length x 0.5 cm width, and was described 100% necrotic. Review of the Wound Evaluation Flow Sheet, dated 10/17/18, completed by LPN #4/Wound Nurse, revealed Resident #15's unstageable pressure ulcer to the resident's outer foot at the left small toe toe measured 0.7 cm length x 0.6 cm width x 0.1 cm depth. The CCP was not revised to indicate the resident had new wounds to include the pressure ulcer of the left coccyx first identified in the record on 08/17/18, pressure ulcer to the left buttock first identified in the record on 09/21/18, left foot first metatarsal identified on 09/28/18, right lateral foot identified on 09/28/18, right great toe identified on 09/28/18, and left outer foot at small toe identified on 09/28/18. In addition, there was no revisions on the Care Plan to indicate the improvement or decline of the resident's Stage IV pressure ulcer to the right hip and an unstageable pressure ulcer to the left outer foot. 2. Review of Resident #9's EMR revealed the facility readmitted the resident on 05/24/17 with [DIAGNOSES REDACTED]. Review of Resident #9's Situation Background Action Response (SBAR) Note, dated 05/22/18, completed by Licensed Practical Nurse (LPN) #5, revealed the resident had a new open area to the right lower leg, and orders for treatment to the right lower leg were received. However, there was no documented evidence of a Wound Evaluation with measurements and description of the wound which was noted on 05/22/18. Review of the CCP, dated 05/25/17, revised 05/22/18 revealed Resident #9 was at risk for pressure ulcers and had an actual vascular area on the right lower extremity due to requiring assistance in bed mobility, impaired balance, weakness, pain, impaired cardiac and perfusion, impaired decisions, chronic medication use, DM, and [MEDICAL CONDITION], and routine [MEDICAL TREATMENT]. The goal initiated on 05/25/17, revised 08/29/18, revealed the resident's skin would remain intact. Interventions included: conduct weekly skin inspections, keep skin as dry as possible initiated 05/25/17; provide treatments as ordered, and provide treatments to right lower extremity as ordered, initiated 06/13/17. Review of Resident #9's Annual Minimum Data Set (MDS) Assessment, dated 05/24/18, revealed the facility assessed the resident as having one (1) venous or arterial ulcer present and receiving application of non-surgical dressings and applications of ointments/medications other than to his/her feet. Review of the Wound Evaluation Flow Sheet, dated 06/14/18, completed by LPN#4/Wound Nurse, revealed Resident #9 had a right lower leg arterial wound which measured 2.2 centimeters (cm) length x 1.3 cm width. Further, the wound was weeping serous exudate and the outer skin on the shin had peeled off, and the wound bed was described as 100% granulation. This was the first Wound Evaluation with a description and measurement of the right leg wound. Review of the Progress Note dated 06/21/18, at 2:35 AM, completed by LPN #14/agency nurse, revealed the resident's right foot second and third toes had drainage, and the skin was off. Continued review revealed a dressing and abdominal pad was applied to the toes and they were wrapped with kerlix. Review of the CCP revealed there was no revision to indicate the resident had skin impairment to the right foot second and third toes. Review of the Progress Note, dated 07/02/18, at 6:28 AM, completed by LPN #13, revealed Resident #9's sock on the left foot was moist, the sock was removed, and the foot was washed. Per the Note, a dry dressing was applied to the left foot and non-skid socks were applied. Further review revealed the resident was educated on the importance of keeping feet elevated and dry. However, there was no documented evidence the CCP was revised to include the change in the resident's left foot skin integrity. Review of the Wound Assessment, dated 07/05/18, completed by the Wound Care Clinic, revealed Resident #9 had a diabetic wound/ulcer to his/her right lateral foot and the venous ulcer was open, with a medium amount of purulent yellow/brown/green exudate. Continued review revealed the measurements were 10 cm length x 6.5 cm width x 0.2 cm depth and the wound was described as 67% to 100% necrosis. This was the first identification, measurement, and description of this wound, per record review. Further review of the Wound Assessment, dated 07/05/18, completed by the Wound Care Clinic, revealed Resident #9 had a diabetic wound/ulcer to his/her right plantar foot. Per the , the venous ulcer was open, with a medium amount of purulent yellow/brown/green exudate. The measurements were 13 cm length x 7.0 cm width by 0.2 cm depth and the wound was described as 67% to 100% necrosis. The skin surrounding the wound was macerated. This was the first identification, measurement, and description of this wound, per the medical record. Review of the Wound Culture lab results, dated 07/16/18, revealed the right foot had a heavy growth of pseudomonas aeruginosa (Aerobic bacteria). Further review revealed a physician's orders [REDACTED]. The CCP was not revised to indicate the resident had new wounds to the right plantar foot, and right lateral foot. In addition, the Care Plan was not revised to indicate the resident had a wound infection to the right foot with treatment of [REDACTED]. Review of the Wound Evaluation, dated 07/18/18, completed by LPN #4/Wound Nurse, revealed Resident #9's arterial weeping area to his/her right outer shin wound was 100% granulation. This was the last documented assessment of the right lower leg arterial wound and there was no documented evidence in the medical record the wound resolved/healed or revision to the CCP related to the changes to the right lower leg's skin integrity. Review of the Wound Evaluation dated 07/18/18 revealed the resident had a venous wound to the top of his/her right outer foot which measured 2.0 cm length by 2.2 cm width by 0.2 cm depth and was described as having serous drainage, 25% [MEDICATION NAME], 25% granulation and 50% slough. This was the first documented identification and assessment of this venous wound to the top right outer foot in the medical record. However, there was no documented evidence the CCP was revised related to the wound to the top of the resident's right outer foot. Review of the Wound Evaluation, dated 07/19/18, completed by the Wound Care Clinic, revealed Resident #9 had a left plantar foot diabetic wound. Additional review revealed the wound measured 7.5 cm length x 5.5 cm width x 0.1 cm depth and was described as having a medium amount purulent yellow/brown/green exudate. Continued review revealed the wound was 67% to 100% necrotic. This was the first time the left plantar foot diabetic wound was assessed with [REDACTED]. The CCP was not revised to include the skin impairment to the left plantar foot. 3. Review of Resident #8's closed Electronic Medical Record (EMR), revealed the facility readmitted the resident on 01/05/15, with [DIAGNOSES REDACTED]. Review of Resident #8's Annual Minimum Data Set (MDS) Assessment, dated 04/24/18, revealed the facility assessed the resident as at risk for pressure ulcers, and having no unhealed or healed pressure ulcers. Review of Resident #8's Care Area Assessment (CAA) Worksheet, dated 05/03/18, revealed Resident #8 was assessed as needing extensive assistance with Activities of Daily Living (ADLs) including turning and repositioning. Continued review revealed Resident #8 was at risk for pressure ulcers secondary to incontinence, impaired mobility, and diagnosed skin conditions. Review of Resident #8's CCP, revealed a focus of alteration in skin integrity initiated on 06/04/12. The goal associated with this focus was to ensure the resident's skin would remain intact. The interventions included assisting the resident to turn and reposition every two (2) hours and as needed, keep skin as clean and dry as possible, and conduct weekly skin assessments. Review of Resident #8's Weekly Skin Reviews dated 08/20/18, 08/27/18, 09/03/18 and 09/10/18, revealed the resident had intact skin with no open areas. Further review revealed there was no documented evidence of a skin assessment from 09/10/18 until 09/23/18, thirteen (13) days later. Review of Resident #8's Weekly Skin Review Form, dated 09/23/18, revealed the resident was assessed as having a pressure sore to his/her coccyx, and [MEDICATION NAME] dressing was applied to the pressure sore per physician's orders [REDACTED].>Review of Resident #8's Change of Condition Note, dated 09/23/18 at 6:17 PM, revealed a pressure sore to Resident #8's coccyx was found during a brief change. The Advanced Practice Registered Nurse (APRN) was notified and ordered [MEDICATION NAME] to be applied until the wound nurse could evaluate the wound. Review of Resident #8's Wound Evaluation Sheet, dated 09/24/18, completed by the Wound Care Physician, revealed the resident was assessed as having a Stage III pressure ulcer to his/her sacrum measuring wound 1.8 cm length x 0.8 cm width x 0.1 cm depth. The wound bed was assessed as 90% slough and 10% granulation with a small amount of serous drainage from the wound. Further review of Resident #8's CCP, revealed no documented evidence of a revision to reflect the new Stage III pressure sore to the resident's coccyx, or new interventions related to the pressure sore. 4. Review of Resident #3's EMR, revealed the facility admitted the resident on 05/31/18 with [DIAGNOSES REDACTED]. Review of the Admission Assessment, dated 05/31/18, revealed Resident #3 was assessed as having a surgical wound to the right hip, bruising to upper and lower extremities, and a small blister to his/her pelvic area. Additional review revealed the resident's bilateral heels were unremarkable. Review of the Weekly Skin Review Form, dated 06/03/18, revealed Resident #3 had a surgical incision to the right hip, and abrasion and shearing to his/her left buttock. Additional review revealed the abrasion measurements were 4.0 cm length x 0.5 cm width, and the shearing measurements were 2.0 cm length x 0.5 cm width. Continued review revealed there was a fluid filled small blister to the pelvic area. Review of the Admission MDS Assessment, dated 06/07/18, revealed the resident was assessed as at risk for developing a pressure ulcer and as having unhealed pressure ulcers. Per the MDS, the resident had two (2) Stage I pressure ulcers, a surgical incision, and Moisture Associated Skin Damage (MASD); and was receiving pressure ulcer and surgical wound care and the applications of nonsurgical dressings. Review of the CCP, initiated 06/11/18, revealed Resident #3 had altered skin integrity; non-pressure related to excoriation, shearing, and a surgical wound. The goal initiated 06/11/18, revised 09/21/18, revealed the affected area(s) would heal without complications. Interventions included: monitor signs and symptoms of infection and notify the physician of significant findings, initiated on 06/11/18; provide treatments as ordered, initiated on 06/11/18; and pressure-reducing devices to the resident's bed and wheelchair, initiated on 06/11/18. There was no documented evidence of a Weekly Skin Review or any skin assessment from 06/03/18, until seventeen (17) days later, when the resident was noted to have DTI's to bilateral heels, on 06/20/18. Review of the EMR, revealed an Electronic Interact Note, dated 06/20/18 at 05:15 AM, completed by Registered Nurse (RN) #9, revealing Resident #3 had DTIs to bilateral heels. Additional review revealed the State Registered Nursing Assistant providing care noted the injuries and reported to RN #9. The right heel DTI was measured at 8.5 cm length x 4.0 cm width and the left heel DTI was measured at 6.0 cm length x 2.0 cm width. Further review revealed signs of pain to both heels was present. Continued review revealed the Provider was notified of the changes in Resident #3's skin integrity. Review of the Medicine Progress Notes, dated 06/27/18, revealed the resident had bilateral heel decubitus ulcers. Additional review revealed the areas were currently slightly opened and were a deep red/bluish blackish color. Further review revealed the surrounding skin had no [DIAGNOSES REDACTED] (redness) or odor and there was minimal exudate (drainage); right greater than left. Further review of the CCP, initiated on 06/11/18, revealed there was no documented evidence of a revision to include the development of bilateral heel DTIs with interventions related to the ulcers. 5. Review of Resident #14's EMR, revealed the facility admitted the resident on 07/05/18 with [DIAGNOSES REDACTED]. Review of Resident #14's Wound Evaluation Flow Sheet, dated 07/05/18, completed by LPN #4/Wound Nurse, revealed the resident was admitted with a Stage II pressure ulcer to his/her coccyx measuring 5.0 cm length x 2.0 cm width. This Wound Evaluation did not indicate the resident had any other skin breakdown. Review of Resident #14's Admission Assessment, dated 07/06/18, and not signed, revealed the resident was assessed as having a shearing injury to his/her left gluteal fold and a Deep Tissue Injury (DTI) to the left outer foot. There were no measurements of the skin impairment or DTI documented in the Admission Assessment. Review of Resident #14's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having a Deep Tissue Injury (DTI) that was present upon admission. Resident #14 was also assessed to have Moisture Associated Skin Damage (MASD). Review of Resident #14's CCP, with an initial onset date of 07/19/18, revealed a focus of actual or risk of pressure ulcers and pressure ulcer present. The first goal revealed the pressure ulcer present at the time of initiation on 07/19/18, would heal without complications. The second goal revealed the resident would remain free from further skin breakdown. The interventions included: incontinence management every two to three (2-3) hours, low air loss mattress to alleviate pressure areas, pressure reducing wheelchair cushion, thorough skin care and application of barrier cream after each incontinent episode, complete treatments as ordered, assist to turn and reposition every two to three (2-3) hours, weekly skin inspections, and weekly wound assessments. This CCP was not developed to indicate the resident had Stage II pressure ulcer to his/her coccyx and the DTI to the left outer foot on admission. Review of Resident #14's Wound Evaluation Flow Sheet, dated 07/17/18, revealed the resident had a Stage II pressure ulcer to his/her coccyx that was now healed. There was no documented evidence Resident #14's Suspected Deep Tissue Injury (SDTI) to his/her left outer foot was assessed from admission 07/05/18, until thirteen (13) days later, on 07/18/18. Review of Resident #14's Wound Evaluation Flow Sheet, dated 07/18/18, completed by LPN #4/Wound Nurse, revealed the resident was assessed to have a SDTI to his/her left outer foot measuring a length of 0.3 cm and a width of 0.2 cm. This was the first measurement of this wound which was identified on 07/06/18. Review of Resident #14's Situation Background Assessment Recommendation (SBAR), dated 08/30/18, revealed the resident had a new sheer wound to the left buttocks, and there was a treatment currently in place for his/her coccyx that included a [MEDICATION NAME] being applied every three (3) days and as needed. Per the SBAR, Resident #14's Attending Physician was notified and no new orders were started at that time due to orders already in place to the area. Review of Resident #14's Wound Evaluation Flow Sheet, dated 09/04/18, completed by LPN #4/Wound Nurse, revealed Resident #14 was assessed as having an in-house acquired SDTI to his/her left inner buttock. The SDTI was measured as having a length of 3.8 cm and a width of 2.7 cm with defined margins, no drainage, and no odor. Further review revealed the SDTI wound bed consisted of 100% eschar. There was no documented evidence the CCP was revised related to the new in-house acquired SDTI to his/her left inner buttock which was identified on 08/30/18. Interview on 11/05/18 at 3:30 PM with LPN #4/Wound Nurse, revealed she had been employed at the facility as the wound care nurse for approximately one (1) year before resigning on 10/23/18. She stated the Comprehensive Care Plan should be updated with any changes in skin integrity, including new wounds. Per interview, the Care Plan should be revised to indicate the site and stage or type of wound, as well as revised to indicate if the wounds were progressing or deteriorating. Per interview, the Care Plan should track the wounds in order to ensure current interventions were in place to heal the wounds. Further interview revealed the MDS Coordinators were responsible for revising care plans related to skin integrity and wounds. Interview on 11/02/18 at 9:50 AM, with MDS Coordinator #1, revealed she developed and revised Care Plans with the MDS Assessments. Per interview, she was also responsible for revising Care Plans related to new skin changes and wounds. She stated everyday she checked the Twenty-four Hour Report for changes in residents' condition and also checked daily for new physician's orders [REDACTED]. She stated she also attended the morning meetings Monday through Friday with the interdisciplinary team to learn about any new changes in residents' condition. She revealed Resident #3, #8, #9, #14, and #15's Care Plans should have been revised as change in skin condition and wounds occurred. Per interview, this revision should have included types of wounds, and location of wounds when identified, as well as any new interventions. Further, the care plans should have also been revised to indicate the improvement, healing, or decline of wounds. Interview on 11/02/18 at 10:19 AM, with the MDS Coordinator #2, revealed Care Plans should be developed, and revised based on the MDS Assessments as well as revised related to changes in the residents' condition between MDS Assessments. Per interview, the Care Plan should be revised related to changes in skin integrity, and related to new wounds. She revealed any new wound development should be indicated on the care plan to include type of wound, and location of the wound with new interventions as per physician's orders [REDACTED]. Continued interview revealed it was the responsibility of the Wound Nurse as well as the MDS Coordinators to revise the Care Plans related to changes in skin, and related to wounds. Interview on 11/2/18 at 12:07 PM, with Director of Nursing (DON) #1, revealed it was her expectation the Comprehensive Care Plan be revised with any changes in the resident's condition, including changes in the residents' skin integrity and any new wounds, on an ongoing basis. She stated all staff nurses, MDS Nurses, as well as the Wound Nurse should be revising the Care Plans for changes in skin integrity and wounds to include types of wounds and wound location, and progression of the wounds to indicate if the wounds were progressing or deteriorating. Per interview, DON #1 reviewed new orders as well as reviewed documentation on the EMR, Monday through Friday in the clinical meetings to check for changes in residents' condition and to ensure the Care Plans were revised as necessary. She stated ensuring the care plan was accurate and up to date was important to communicate a resident's needs to the interdisciplinary team, provide continuity of care and ensure effective interventions were in place for the residents. However, she revealed there was not an effective system in place to audit care plans to ensure they were revised in a timely manner related to changes in skin and wounds. Interview on 11/2/18 at 12:07 PM with the Interim Administrator revealed she has been the Interim Administrator for five (5) days. She stated it was her expectation staff revise the Comprehensive Care Plan with any changes in a resident's condition. She stated it was important for the Care Plan to be revised with appropriate intervention to be carried out to ensure residents receive the best quality of care the facility could provide.

Based on interview, record review, review of the Administrator's Job Description, review of facility Policy, and review of the Allegation of Compliance (AoC) related to the Immediate Jeopardy identified on 12/20/18, it was determined the facility failed to ensure it was administered in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evidenced by the facility's failure to ensure the AoC, with an Immediate Jeopardy removal date of 12/26/18, was implemented related to implementing the facility's protocol related to pressure ulcers. The facility's failure to ensure the facility was administered in an effective manner had caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/20/18 and was determined to exist on 09/28/18, in the areas of 42 CFR 483.10 Resident Rights, F-580 at a S/S of a K; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F-656 and F-657 both at a S/S of a K; 42 CFR 483.25 Quality of Care, F-686 at a S/S of a K; 42 CFR 483.35 Nursing Services, F-725 at a S/S of a K; and 42 CFR 483.70 Administration, F-835 and F-837, both at a S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care. The facility was notified of the Immediate Jeopardy on 12/20/18. The facility submitted an Allegation of Compliance (AoC) in response to Immediate Jeopardy deficiencies identified on 12/20/18, and alleged compliance effective 12/26/18. However, the AoC could not be verified based on observation, staff interview, and review of facility documentation as the facility failed to implement their AoC. The Immediate Jeopardy is ongoing. The findings include: Review of the Administrator's Job Description, dated 08/01/16, revealed the Administrator's primary purpose was to direct the day to day functions of the facility in accordance with current federal, state and local standards, guidelines, and regulations to assure the highest degree of quality of care was provided to residents. Additional review revealed the Essential Functions included working in close collaboration with the Director of Nursing (DON) and Medical Director (MD) to assure high quality clinical outcomes. Continued review revealed the Administrator collaborates with Consultants concerning problem areas and utilizes the Quality Assurance Performance Improvement (QAPI) Process to improve performance. Further review revealed the Administrator ensures all staff participate in training programs including policies and procedures, and ensures training is documented properly. Additional review revealed the Administrator ensures Resident Rights are maintained. Review of the facility's Skin System Policy, undated, revealed the facility would provide necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for residents having a pressure sore. Additionally, the facility would promote the prevention of pressure ulcer development for residents who enter the facility without a pressure sore. Continued review revealed all residents would be assessed with [REDACTED]. Further, upon identification of skin/wound impairment the nurse would complete a Situation Background Action Results (SBAR) Note, and notify the Skin Committee of the changes in the resident's skin condition for additional oversight and monitoring. Per Policy, the nurse would notify the responsible party and update the Treatment Administration Record (TAR). Review of the facility's AoC, with a compliance date of 12/26/18, revealed the following information could not be validated per observation, interview, record review, and review of facility audits: Per the AoC, Resident #14's wounds were healed on 12/05/18, by the Registered Nurse (RN). However, record review revealed there was no documented evidence Resident #14's wound to the left buttocks was assessed by the RN on 12/05/18. The facility provided an e-mail dated 12/27/18 at 6:13 PM, which revealed on 12/05/18, the Minimum Data Set (MDS) Nurse stated she assessed Resident #14's wound to the left buttocks and noted the wound was healed. Interview with the MDS Nurse, on 12/28/18 at 3:00 PM, revealed she assessed Resident #14's wound to the left buttock on 12/05/18 and the wound was healed, but she failed to document the findings. Per the AoC, there was a Wound Evaluation for Resident #14 on 12/16/18, by the Charge Nurse which reflected the wound remained healed, referring to the wound to the left buttock. Record review revealed a Licensed Practical Nurse (LPN) did complete a skin assessment on 12/16/18; however, there was no documented evidence of a Wound Evaluation for Resident #14 for the left buttock wound on 12/16/18, as per the AoC. Per the AoC, Care Plans of residents with identified wounds-pressure ulcers, diabetic and vascular wounds were reviewed and updated by the Interdisciplinary Team (IDT) on 12/19/18. However, record review revealed residents' Care Plans were not revised on 12/19/19 related to wounds, for Resident #16, Resident #34, Resident #35, and Resident #36, as per the AoC, Per the AoC, the Administrator and Interdisciplinary Team was educated by the Regional Director of Operations (RDO) on 12/20/18 and again on 12/21/18, on revising and updating care plans. However, Resident #34 was identified to have a healed wound to the left hip and a deterioration to the wound on the right hip on 12/28/18, and there was no documented evidence the resident's Comprehensive Care Plan was updated to reflect the current status of the wounds until 01/02/19. Per the AoC, beginning the week of 12/23/18, the DON/Charge Nurse would conduct weekly wound rounds on residents with identified pressure ulcers and vascular wounds and would ensure weekly documentation of wound progress was in place and notification of wound changes to the Physician. However, when asked to submit review of the weekly wound audits, the Administrator handed over a copy of the Pressure Wound Report. This Report was dated 12/27/18, and included five (5) residents with their wound location, stage, measurement, and treatment. However, the Report did not indicate if the wound had improved or declined, or if there was notification of wound changes to the Physician. There was a notation at the bottom of the Report, stating reviewed by the Registered Nurse (RN) Consultant on 12/28/18. This was the only wound round information submitted for review. Interview on 01/03/19 at 4:30 PM, with the RN Consultant, revealed she completed the wound audit by making rounds with nurses and visualizing wounds and observing wound assessments, but the audit did not indicate the progression of the wound, nor physician notification for changes in the wounds. In addition, observation of Resident #34's wound assessment on 12/28/18 at 7:30 PM, revealed deterioration of the wound to the right hip and a healed pressure ulcer to the left hip since the previous assessments noted in the medical record. However, review of the progress notes from morning meeting revealed no documented evidence there was worsening of the resident's right hip wound and improvement of the resident's left hip wound. Also, there was no documented evidence the Physician was notified of this increase in size of the right hip pressure ulcer. Per the AoC, beginning the week of 12/23/18, there would be audits of weekly documentation of existing pressure ulcers, vascular and diabetic wound progress, and skin inspections. Review of the audit tool for six (6) randomly selected residents revealed check marks to indicate weekly skin inspections were completed and check marks to indicate there was documentation of existing wounds on 12/23/18 and 12/20/18. However, the tool was not wound specific as some of these residents had multiple wounds. In addition, some of the residents chosen for review did not have wounds. Per the AoC, beginning 12/21/18, the Administrator would review staffing in the morning meeting. However, record review revealed staffing was not part of the morning meeting check list, as per the AoC, and there was no documented evidence staffing was discussed in morning meeting. Per the AoC, beginning 12/23/18, the Administrator as part of the IDT would monitor completion of the weekly skin inspections. However record review revealed weekly skin inspections were not part of the morning meeting check list, as per the AoC, and there was no documented evidence weekly skin inspections were discussed in morning meeting. Interview with the Interim Administrator, on 01/10/19 at 4:49 PM, and post survey phone interview on 01/23/18 at 3:53 PM, revealed the Administrator, DON, Director of Human Resources, Social Services, Activities Director, Maintenance Director and all department heads attended the morning meetings Monday through Friday and discussed admissions, pending admissions, clinical reviews, staffing, falls, and behaviors. Per interview, different areas of the AoC were assigned to the department heads to ensure the AoC was being implemented and she verified through reviewing some of the audits that the AoC was being implemented. Further interview revealed she realized now the skin and wound audits were not detailed enough and lacked information. She further stated she did not know how the audits missed care plans not being revised, and the Physician not being notified of changes in wounds. Continued interview revealed department heads did discuss staffing in morning meeting and also discussed skin inspections in morning meeting; however, she had no documented evidence of this. Further interview revealed the facility process for implementing the AoC was not perfect, some concerns were not caught during the audits, and the facility was not in compliance with following the wound protocol.

Based on observation, interview, record review, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), it was determined the facility failed to have an effective system to ensure services were provided in accordance with each resident's written plan of care for fourteen (14) of thirty-nine (39) sampled residents (Resident #1, #3, #4, #7, #9, #10, #11, #14 #16, #23, #31, #32, #33, and #39). The facility failed to provide services as outlined by the Comprehensive Care Plan and the Intermediate Care Plan related to obtaining and monitoring lab/diagnostic work as ordered and reporting results to the Physician; and monitoring medication for residents at risk for complications related to [MEDICATION NAME] Therapy (anticoagulant medication). Laboratory values were not obtained as ordered and reported to the Physician/Provider related to [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) levels for residents receiving [MEDICATION NAME]. In addition, the facility failed to monitor anticoagulant medication to ensure the medication was administered as prescribed. (A PT is a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder; the INR is calculated from a PT result and is used to monitor how well the anticoagulant medication is working to prevent blood clots) This affected Residents #14, #23, #31, #32, #33, and #39. (Refer to F-757) The facility's failure to ensure services were provided by the facility as outlined in the Comprehensive Care Plan and the Intermediate Care Plan related to obtaining and monitoring lab/diagnostic work as ordered and reporting results to the Physician; and monitoring medication regime for residents at risk for complications from [MEDICATION NAME] Therapy has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 01/09/19 and determined to exist on 09/24/18 and is ongoing. In addition, the facility failed to provide services as outlined by the Comprehensive Care Plan related to providing assistance with Activities of Daily Living (ADLs) regarding bathing. Resident #1, #3, #4, #7, #9, #10, #11 and #16 did not receive a minimum of two (2) or three (3) baths or showers (depending on the resident's preference) each week. Interviews with residents and direct care staff revealed staff should assist the residents with bathing per their choice of frequency, and the residents should receive at a minimum two (2) baths or showers per week. Staff interviews further revealed, due to the staffing shortage, the direct care staff were unable to complete the resident's bathing preference (bed bath or shower) and were unable to provide residents with a minimum of two (2) baths, bed baths or showers weekly as per protocol. (Refer to F-677 and F-725). Furthermore, Resident #9's Comprehensive Care Plan revealed interventions for weekly skin inspections and treatments as ordered. Although the resident developed numerous vascular/diabetic wounds between 05/22/18 and 07/18/18; the facility did not ensure consistent monitoring of the resident's skin and wounds or treatments as ordered. There was no documented evidence the resident received a Skin Assessment after 05/28/18, and prior to being seen by the Wound Clinic on 07/05/18, thirty-seven (37) days later, when the resident was assessed as having unidentified vascular ulcers including a diabetic/venous ulcer to the resident's right lateral foot which measured 10 centimeters (cm) length x 6.5 cm width x 0.2 cm depth, 67% to 100% necrosis; and a diabetic/venous ulcer to the resident's right plantar foot measuring 13 cm length x 7.0 cm width x 0.2 cm depth, 67% to 100% necrosis. Also, the resident did not receive Wound Evaluations for periods as long as forty-one (41) days. Furthermore, there was no documented evidence treatments were administered as per physician's orders [REDACTED]. (Refer to F-684 and F-725) The findings include: Interview with Director of Nursing (DON) #1 on 10/30/18 at 11:00 AM revealed the facility did not have a Policy or Protocol specifically related to providing services as outlined in the Comprehensive Care Plan. Further interview revealed she expected all staff to provide care to residents in accordance with their CCP to ensure the individual residents' needs were met. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. The following examples are related to the failure to implement Care Plans related to anticoagulant medication. The Laboratory Company utilized by the facility, revealed the following ranges for Normal PT/INR levels. Normal Range for [MEDICATION NAME] Time (PT) 9.5 seconds to 11.8 seconds. Normal Range for International Normalized Ratio (INR) 0.9 -1.1. (standard anticoagulant 2.0-3.0 INR) 1. Review of Resident #23's medical record revealed the facility admitted the resident on 11/13/18 with [DIAGNOSES REDACTED]. Review of the Intermediate Care Plan dated 11/13/18, revealed safety was a priority. The goal stated continue treatment to improve condition. Interventions included monitoring medications and laboratory values. Resident #23 had physician's orders [REDACTED]. Additional review revealed physician's orders [REDACTED]. Review of the Laboratory Reports, dated 11/16/18 (Friday), faxed to the facility 11/16/18 at 1:17 PM, revealed Resident #23's PT level was 31.2 High and INR level was 2.8 High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). However, there was no documented evidence the Provider was notified of the High PT/INR results as per the Intermediate Care Plan and Resident #23 continued to receive the same dosage of [MEDICATION NAME] medication. Review of the Laboratory Report, dated 11/19/18 (Monday), revealed Resident #23's PT level was 65.6 High and the INR level was 5.8 Critically High. The Provider was notified of the lab results on 11/19/18, and orders were obtained to hold the [MEDICATION NAME] medication. Review of the Laboratory Report dated 11/21/18 (Wednesday), revealed the resident's PT level was 76.3 High and the INR level was 6.7 Critically High. The Nurse's Notes dated 11/21/18 at 6:08 PM, revealed the resident had an extreme amount of blood in his/her brief with clots, and physician's orders [REDACTED]. Review of the Hospital Discharge Summary, dated 11/25/18, revealed Resident #23 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. 2. Review of Resident #14's medical record revealed the facility admitted the resident on 07/05/18 with [DIAGNOSES REDACTED]. Review of Resident #14's Admission Minimum Data Set (MDS) Assessment, dated 07/12/18, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) of a ninety-nine (99) indicating resident was unable to complete the interview. Further review under Section N- Medications, revealed the facility assessed Resident #14 as receiving anticoagulant medication six (6) days out of six (6) days of the seven (7) day look back period. Review of the Comprehensive Care Plan, dated 07/19/18, revealed Resident #14 was at risk for complications related to anticoagulant or antiplatelet medication due to [MEDICAL CONDITION] Fibrillation. The goal initiated 07/19/18, revealed the resident would remain without complications from bleeding or injury. There were several interventions initiated 07/19/18 including: apply prolonged pressure to venipuncture sites; monitor medication regime for medications which increase effects; observe for adverse reactions such as fever, [MEDICAL CONDITION], anorexia, nausea, vomiting, cramps, diarrhea, hemorrhage, and hemoptysis; and observe for signs and symptoms of bleeding: tarry stools, blood in urine, bruising, petechiae. Continued review revealed an intervention initiated 11/07/18 to obtain and monitor lab/diagnostic work as ordered and report results to Physician. The facility failed to monitor Resident #14's medication regime as per the Comprehensive Care Plan. There was no documented evidence weekly PT/INR levels were drawn as ordered for Resident #14 who was receiving [MEDICATION NAME] Therapy. Resident #14 had active physician's orders [REDACTED]. After State Agency Representative intervention, the facility obtained further laboratory results. The laboratory results dated [DATE], for Resident #14 revealed: PT: 51.5 and INR: 4.90 (Reference range 9.5-11.8 for PT and Reference range 0.9-1.1 for INR), which revealed: High PT and Critically High INR. 3. Review of Resident #32's medical record revealed the facility admitted the resident on 09/29/16, and readmitted the resident on 12/12/18, with [DIAGNOSES REDACTED]. Review of Resident #32's Comprehensive Care Plan (CCP), initiated on 11/01/16, revealed a problem of impaired Cardiovascular status related to [MEDICAL CONDITION] Fibrillation. The goal stated the resident would not have a decline in function related to cardiac condition. Interventions initiated 11/01/16 included: obtain lab work as ordered by the Physician; medications as ordered by the Physician and observe use and effectiveness. Continued review of Resident #32 CCP, initiated on 11/01/16, revealed the resident was at risk for bleeding due to medications with blood thinning effects. The goal revealed the resident would remain without complications from bleeding or injury. Interventions included: monitor medication regime for medications which increase side effects, initiated on 11/01/16; obtain and monitor lab/diagnostic work as ordered, report results to the Physician, and follow up as indicated, initiated on 11/01/16; and anticoagulant precautions, initiated 09/12/17. Review of Resident #32's Order Summary Report for (MONTH) (YEAR), revealed physician's orders [REDACTED]. Also, there was physician's orders [REDACTED]. Review of the Laboratory Report, dated 09/03/18 (Monday), reported 09/03/18 at 11:32 AM, revealed lab results: PT 35.6 High and INR 3.2 High. Review of Resident #32's physician's orders [REDACTED]. Review of the Laboratory Report, dated 09/06/18 (Thursday), reported 09/06/18 at 12:01 PM, revealed High PT/INR results: PT 22.6 High and INR 2.1 High. However, there was no documented evidence the Physician was notified of the High lab results, as per the Care Plan. Review of the Laboratory Report, dated 09/10/18 (Monday) reported 09/10/18 at 12:20 PM, revealed High PT/INR results: PT 13.4 High and INR 1.3 High. However, there was no documented evidence the Physician was notified of the High lab results, as per the Care Plan Review of Resident #32's Cardiology Consultation, dated 09/11/18, revealed Resident #32's INR was 1.4. Further review revealed recommendations to begin [MEDICATION NAME] twice daily and increase [MEDICATION NAME] to 2 mg daily. Review of Resident #32's physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR, revealed orders for [MEDICATION NAME] 60 mg IM two (2) times a day ([MEDICATION NAME] is not to be administered intramuscular), indicating the Care Plan was not implemented related to monitoring medication regime. Review of Resident #32's Laboratory Report, dated 09/13/18 (Thursday), reported on 09/13/18 at 11:45 AM, revealed High PT/INR results: PT 13.5 High and INR 1.3 High. However, there was no documented evidence the Physician was notified of the High lab results, indicating the Care Plan was not implemented. Review of Resident #32's Progress Note, dated 09/15/18 at 10:53 PM, revealed there was a default note from the Electronic Medication Administration Record [REDACTED]. Further, review of the MAR, revealed [MEDICATION NAME] 60 mg was held on 09/15/18, indicating medications were not administered as ordered, as per the Care Plan. Review of the Laboratory Report dated 09/17/18 (Monday), reported on 09/17/18 at 11:57 AM, revealed: PT 21.6 High and INR 2.0 High. However, there was no documented evidence the Physician was notified, on 09/17/18, of the High lab results, as per the Care Plan. Review of the Laboratory Report, dated 09/20/18 (Thursday), reported on 09/20/18 at 11:32 AM, revealed High PT/INR results: PT 17.2 High and INR 1.6 High. However, there was no documented evidence the Physician was notified of the High lab results, as per the Care Plan. Review of Resident #32's (MONTH) (YEAR) MAR, revealed [MEDICATION NAME] 2 mg was not signed, indicating the medication was not administered on 09/20/18, 09/21/18, and 09/22/18. Additional review revealed [MEDICATION NAME] 60 mg IM was not signed; indicating the medication was not administered on 09/21/18 and 09/24/18. This revealed the Care Plan was not implemented related to administration of medications as ordered by the Physician. Review of Resident #32's Laboratory Report, dated 09/24/18 (Monday), reported 09/24/18 at 11:32 AM, revealed High PT/INR results: PT 18.8 High and INR 1.7 High. There was a notation on the Report by LPN #21 to increase [MEDICATION NAME] to 2.5 mg daily and then re-check PT/INR on 09/27/18. Per the (MONTH) (YEAR) MAR, Resident #32 missed three (3) doses of [MEDICATION NAME] 2 mg, and 2 doses of [MEDICATION NAME] 60 mg prior to this lab being drawn. Review of Resident #32's physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR, revealed [MEDICATION NAME] 2.5 mg was to be administered at 8:00 AM. Further review revealed the medication was administered at 8:00 AM for the following dates: 09/25/18, 09/26/18, 09/27/18, 09/28/18, 09/29/18, and 09/30/18. This revealed the Care Plan was not implemented related to monitoring medication regime. Review of Resident #32's Laboratory Report, dated 09/27/18 (Thursday), reported on 09/27/18 at 12:05 PM, revealed High PT/INR results: PT 15.1 High. and INR 1.4 High. However, there was no documented evidence the Physician was notified of the High lab results. In addition, the resident received [MEDICATION NAME] 2.5 mg at 8:00 AM on 09/27/18, prior to the facility receiving the PT/INR lab results drawn on 09/27/18. This revealed the Care Plan was not implemented related to reporting lab results to the Physician. Review of the (MONTH) (YEAR) MAR, revealed [MEDICATION NAME] 2.5 mg was administered at 8:00 AM for the following dates: 10/01/18, 10/02/18, 10/03/18, 10/04/18, 10/06/18, 10/07/18, 10/08/18, 10/09/18, 10/10/18, 10/12/18, 10/13/18, 10/14/18, 10/15/18, 10/18/18, 10/26/18, 10/27/18, 10/28/18, 10/29/18, and 10/30/18. This revealed the Care Plan was not implemented related to monitoring medication regime. Interview with the Attending Physician/Medical Director (MD), on 01/10/19 at 2:45 PM, revealed [MEDICATION NAME] medication was to be administered in the evening and there would be no reason why this medication would be administered at 8:00 AM. He stated [MEDICATION NAME] was to be administered in the evening to ensure laboratory values for PT/INR were accurate at the time of review, in order for the [MEDICATION NAME] dosage to be adjusted as necessary. Further interview revealed Resident #32's [MEDICATION NAME] order must have been entered into the computerized system at 8:00 AM due to a clerical error by the nurse, and this was not caught. Review of Resident #32's Laboratory Report, dated 10/01/18 (Monday), reported on 10/01/18 at 11:53 AM, revealed: PT 13.1 High and INR 1.2 High. However, there was no documented evidence the Physician was notified of the High lab results, revealing the Care Plan was not implemented related to reporting lab results to the Physician. Review of the Laboratory Report, dated 10/04/18 (Thursday), reported on 10/04/18 at 12:09 PM, revealed High PT/INR results: PT 14.7 High and INR 1.4 High. However, there was no documented evidence the Physician was notified of the High lab results, revealing the Care Plan was not implemented related to reporting lab results to the Physician. Review of the (MONTH) (YEAR) MAR, revealed [MEDICATION NAME] 2.5 mg was not signed on 10/05/18, indicating the medication was not administered at 8:00 AM on that date. Further, [MEDICATION NAME] 60 mg was not signed on 10/05/18, indicating the medication was not administered at 8:00 AM on that date. This revealed the Care Plan was not implemented related to administration of medications as ordered by the Physician. Review of the Laboratory Report, dated 10/08/18 (Monday), reported on 10/08/18 at 12:09 PM, revealed High PT/INR results: PT 29 High and INR 2.6 High. However, there was no documented evidence the Physician was notified of the High lab results. On 10/10/18, two (2) days later, LPN #21 initialed and dated the Report and made a notation that the resident was on [MEDICATION NAME] 2.5 mg every day, but there was no notation related to notification to the Physician. This revealed the Care Plan was not implemented related to reporting lab results to the Physician. Further, the resident had not received the 10/05/18, 8:00 AM dose of [MEDICATION NAME] or [MEDICATION NAME] prior to the PT/INR being drawn on 10/08/18. Review of the (MONTH) (YEAR) MAR, revealed [MEDICATION NAME] 2.5 mg was not signed, on 10/11/18, indicating the medication was not administered at 8:00 AM. Further, [MEDICATION NAME] 60 mg was not signed on 10/11/18 indicating the medication was not administered at 8:00 AM. The Care Plan was not implemented related to administration of medications as ordered by the Physician. Review of Resident #32's Laboratory Report, dated 10/11/18 (Thursday), revealed High PT/INR results; PT 37.1 High and INR 3.3 High (standard anticoagulant 2.0-3.0 INR). However, there was no documented evidence the Physician was notified of the High lab results. (On 10/19/18, eight (8) days later, RN #12 initialed the Laboratory Report; however, did not indicate the Physician was notified of the results). The Care Plan was not implemented related to reporting lab results to the Physician. Review of the Laboratory Report, dated 10/15/18, (Monday) reported on 10/15/18 at 1:14 PM, revealed High PT/INR results: PT 70.1 High and INR 6.2 Critically High (standard anticoagulant 2.0-3.0 INR). (RN #3 made a notation on the Report to hold [MEDICATION NAME] and re-check PT/INR on Thursday 10/18/18). Review of Resident #32's physician's orders [REDACTED]. However, the 10/15/18 dose had already been administered at 8:00 AM, due to the medication being scheduled at 8:00 AM. The Care Plan was not implemented related to monitoring medication regime. Further review of the (MONTH) (YEAR) MAR, revealed the [MEDICATION NAME] was held as ordered 10/16/18 and 10/17/18. Review of the (MONTH) (YEAR) MAR, revealed [MEDICATION NAME] 60 mg was not signed on 10/16/18, indicating the medication was not administered at 8:00 AM. Therefore, the Care Plan was not implemented related to administration of medications as ordered by the Physician. Review of Resident #32's physician's orders [REDACTED]. Review of the Laboratory Report, dated 10/18/18 (Thursday), reported 10/18/18 at 2:21 PM, revealed: PT: 78.2 High and INR 6.8 Critically High (standard anticoagulant 2.0-3.0 INR). There was a notation on the Report stating, New Order for PT/INR on 10/19/18, and Hold [MEDICATION NAME]. Review of Resident #32's physician's orders [REDACTED]. However, per the (MONTH) (YEAR) MAR, LPN #7 administered the [MEDICATION NAME] 2.5 mg dose on 10/18/18, at 8:00 AM. However, the resident received the [MEDICATION NAME] on 10/18/18 at 8:00 AM, prior to the order being written to hold the medication. Additional physician's orders [REDACTED]. Review of the Laboratory Report, dated 10/19/18, reported on 10/19/18 at 1:17 PM, revealed High PT/ INR results: PT: 42.6 High and INR 3.8 High (standard anticoagulant 2.0-3.0 INR). However, there was no documented evidence the Physician was notified of the High lab results. The Care Plan was not implemented related to reporting lab results to the Physician, and on 10/22/18, the resident's PT/INR levels were even higher, resulting in the need for treatment with Vitamin K. Review of Resident #32's Laboratory Report, dated 10/22/18 (Monday), reported 10/22/18 at 11:59 AM, revealed the resident's laboratory values were: PT 43.3 High and INR 3.9 High (standard anticoagulant 2.0-3.0 INR). LPN #17 noted on the Lab Results, new orders for Vitamin K 5 mg, one (1) dose now and then repeat PT/INR in AM (morning), on 10/23/18. Review of Resident #32's Progress Note, dated 10/22/18 at 7:24 PM, revealed the Advanced Practice Registered Nurse (APRN) was notified of PT/INR results. Further review revealed new orders were received to administer Vitamin K, 5 mg, Now and repeat PT/INR lab in the AM (morning). Additional review revealed Vitamin K was administered as ordered. Review of Resident #32's physician's orders [REDACTED]. A Telephone order was received on 10/22/18 for Vitamin K solution 10 mg per milliliter (ml), inject 5 mg subcutaneous (SQ), one (1) time only for coagulation. Review of the (MONTH) (YEAR) MAR, revealed Vitamin K 5 mg was administered subcutaneous (SQ) on 10/22/18 at 5:32 PM. Review of the Laboratory Report, dated 10/23/18, reported 10/23/18 at 2:04 PM, revealed: PT 21.1 High and INR 1.9 High. However, there was no documented evidence the Physician was notified of the lab results on 10/23/18, as per the Care Plan. LPN #21 did note on the Report, 10/26/18, three (3) days later, [MEDICATION NAME] 2.5 mg; re-check PT/INR in one (1) week; however, there was no documented evidence of a physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR, revealed [MEDICATION NAME] 2.5 mg to be administered at 8:00 AM, starting 09/25/18 for [MEDICATION NAME] 2.5 mg once a day at 8:00 AM, hold 10/15/18, hold 10/18/18 to 10/25/18, then administer starting 10/26/18 and discontinue on 10/31/18. Review of physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. However, the morning dose of [MEDICATION NAME] 2.5 mg was not discontinued on the MAR, which resulted in the resident receiving a total of 5 mg of [MEDICATION NAME] for five (5) days;10/26/18 through 10/30/18. Therefore, the Care Plan was not implemented related to monitoring medication regime, and administration of medication as ordered. Review of the (MONTH) (YEAR) MAR, revealed the resident received [MEDICATION NAME] 2.5 mg at 8:00 AM, AND [MEDICATION NAME] 2.5 mg at 5:00 PM from 10/26/18 through 10/30/18. Review of the Laboratory Report, dated 10/25/18 (Thursday), reported on 10/25/18 at 11:30 AM, revealed lab results: PT 11.4 and INR 1.1. However, there no documented evidence the Physician was notified of the lab results on 10/25/18, as per the Care Plan. On 10/30/18, five (5) days later, LPN #21 initialed and dated the Report; however, did not indicate if the Physician was notified of the lab results. Review of the Laboratory Report, dated 10/29/18 (Monday), reported on 10/29/18 at 12:08 PM, revealed High PT/INR results: PT 19.5 High INR 1.8 High. RN #3 noted on the Report, the Physician was notified on 10/29/18 at 1:50 PM. Additionally, LPN #21 noted on the Report, re-check PT/INR on Thursday, and this notation was dated 11/01/18. Review of Resident #32's Order Summary Report for (MONTH) (YEAR), revealed orders for PT/INR on Mondays and Thursdays starting 06/25/18. Also, there was an order for [REDACTED]. Review of the Laboratory Report, dated 11/01/18 (Thursday), reported on 11/01/18 at 12:34 PM, revealed High PT/INR results: PT 24 High and INR 2.2 High; however, there was no documented evidence the Physician was notified of the High lab results as per the Care Plan. Review of the Laboratory Results, dated 11/05/18 (Monday), reported on 11/05/18 at 12:08 PM, revealed: PT 19.5 High and INR 1.8 High. RN #1 noted on the Report, notification to APRN, current order [MEDICATION NAME] 2.5 mg every day, PT/INR every Monday and Thursday. and no new orders received. Review of the (MONTH) (YEAR) MAR, revealed [MEDICATION NAME] 2.5 mg by mouth in the evening was not signed on 11/01/18, indicating the medication was not administered on 11/01/18, by RN #7. The Care Plan was not implemented related to administration of medications as ordered by the Physician. Review of the Laboratory Report, dated 11/08/18 (Thursday), reported on 11/08/18 at 1:27 PM, revealed: PT 13.3 High and INR 1.2 High; however, there was no documented evidence the Physician was notified of the High lab results as per the Care Plan. On 11/12/18, four (4) days later, LPN #32 made a notation on the Report stating, on 2.5 daily, but there was no indicating the Physician was notified of the results of this lab on 11/12/18. Review of Resident #32's physician's orders [REDACTED]. Additional physician's orders [REDACTED]. Review of the Laboratory Report, dated 11/09/18, reported on 11/09/18 at 11:30 AM, revealed: PT 20.9 High and INR 1.9 High. However, there was no documented evidence the Physician was notified of the High lab results until LPN #7 made a notation on the Report on 11/12/18, which stated No New Orders (NNO). The Physician was notified of these laboratory results three (3) days after the Laboratory Report was faxed to the facility, indicating the Care Plan was not implemented related to reporting lab results to the Physician. Review of Resident #32's Laboratory Report dated 11/12/18, reported 11/12/18 at 11:39 AM, revealed High PT/INR results: PT 20.9 High and INR 1.9 High, with a notation written on the Report stating no new orders. Review of the Laboratory Report, dated 11/15/18 (Thursday), reported on 11/15/18 at 12:06 PM, revealed High PT/INR results: PT 29 High and INR 2.6 High; however, there was no documented evidence the Physician was notified of the lab results, as per the Care Plan. There was no documented evidence the Physician was notified of the High PT/INR results on 11/15/18, and therefore resident continued to receive [MEDICATION NAME] as ordered. Review of the Laboratory Report, dated 11/19/18 (Monday), reported on 11/19/18 at 12:08 PM, revealed Resident #32's results for PT/INR were even higher: PT 72 High and INR 6.2 Critical High (standard anticoagulant INR 2.0-3). Review of Resident #32's Progress Note, dated 11/19/18 at 1:09 PM, by RN #1, revealed the APRN was aware the INR Lab results were at a Critical Value, and new orders were obtained. Review of physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR, revealed LPN #3 administered Vitamin K 10 mg on 11/19/18 at 9:29 PM. Continued review of the MAR, revealed the [MEDICATION NAME] was discontinued on 11/19/18. Review of the Laboratory Report, dated 11/20/18, reported on 11/20/18 at 2:11 PM, revealed High PT/INR results: PT 99.2 and INR 8.9 Critically High (standard anticoagulant 2.0-3.0 INR). The Report revealed Illegible nurse's initials, dated 11/20/18, with a notation stating re-check PT/INR in one (1) week; Resident already has orders for PT/ INR on Thursdays. There was also a notation on the Report by LPN #21, stating, re-check on 11/23/18. Review of Resident #32's Progress Note, dated 11/20/18 at 8:17 PM, revealed the Physician was notified the PT/INR lab results were at a Critical Value and [MEDICATION NAME] was discontinued. Further review revealed an order was received to check PT/INR on 11/22/18. Review of the Laboratory Report, dated 11/22/18 (Thursday), reported on 11/22/18 at 12:11 PM, revealed High PT/INR results: PT 64.9 and INR 5.7 Critically High (standard anticoagulant 2.0-3.0 INR). Review of Resident #32's physician's orders [REDACTED]. Review of the Progress Note, dated 11/22/18 at 3:55 PM, revealed the APRN was notified of the PT/INR lab results. Review of the Laboratory Report, dated 11/23/18, reported on 11/23/18 at 12:08 PM, revealed: PT 40.8 High and INR 3.7 High. RN #7 made a notation on the Report, on 11/23/18, to continue to Hold [MEDICATION NAME]. Review of the Laboratory Report, dated 11/26/18 (Monday), reported on 11/26/18 at 11:57 AM, revealed High PT/INR results: PT 17.9 High and INR 1.7 High. However there was no documented evidence the Physician was notified of the High lab results until 11/27/18, when RN #16 made a notation on the Report to start [MEDICATION NAME] 2 mg; and re-check labs for PT/INR lab on 11/30/18. Therefore, the Care Plan was not implemented related to notification to Physician of lab results. Additionally, there was no documented evidence of a physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Review of the Laboratory Report, dated 11/29/18 (Thursday), reported on 11/29/18 at 12:38 PM, revealed High PT/INR results: PT 13.8 High and INR 1.3 High. RN #3 did note on the Report, [MEDICATION NAME] 2 mg daily; results called to Physician on 11/29/18; new order to increase [MEDICATION NAME] to 2.5 mg daily and re-check PT/INR lab in one (1) week. Review of Resident #32's physician's orders [REDACTED].

Based on observation, interview, record review, and review of the facility's Policy, it was determined the facility failed to have an effective system in place to ensure the facility's protocol was implemented related to pressure ulcers to ensure a resident at risk for pressure ulcers or a resident with pressure ulcers, received the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing for five (5) of thirty-nine (39) sampled residents (Residents #3, #8, #14, #15, and #34). Staff interviews revealed staff nurses were to complete weekly skin assessments and document those assessments on the Weekly Skin Review Form on all residents and the facility's Wound Nurse was to complete weekly wound assessments and document those assessments on the Wound Evaluation Flow Sheet. However, further staff interviews revealed due to the building being short staffed, staff nurses were unable to complete skin documentation and treatments as per protocol. In addition, the Wound Nurse was frequently re-assigned to the position of staff nurse when staffing levels were low and was unable to consistently perform Wound Assessments. Review of the facility's Skin System Policy, undated, revealed the facility would provide necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for residents having a pressure sore and would promote the prevention of pressure ulcer development for residents who enter the facility without a pressure sore. However, record review revealed there was no documented evidence of consistent monitoring of residents' skin or the progression of the residents' wounds, and no documented evidence treatment for [REDACTED]. In addition, identified wounds went without treatment orders for prolonged periods of time. (Refer to F-580, F-641, F-656, F-657, F-659, and F-725) The facility's failure to have an effective system in place to ensure Treatment and Services to Prevent/Heal Pressure Ulcers has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 12/20/18 and was determined to exist on 09/28/18. The facility provided an acceptable credible Allegation of Compliance (AoC) on 12/26/18, which alleged removal of the Immediate Jeopardy on 12/26/18. However, the AoC could not be verified based on observations, staff interviews, and review of facility documentation. The Immediate Jeopardy is ongoing. The findings include: Review of the facility's Skin System Policy, undated, revealed the facility would provide necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for residents having a pressure sore. Additionally, the facility would promote the prevention of pressure ulcer development for residents who enter the facility without a pressure sore. Continued review revealed all residents would be assessed with [REDACTED]. Further, upon identification of skin/wound impairment the nurse would complete a Situation Background Action Results (SBAR) Note, and notify the Skin Committee of the changes in the resident's skin condition for additional oversight and monitoring. Per Policy, the physician would evaluate and document the progress of wound healing during resident visits. Interview with Director of Nursing (DON) #1, on 10/24/18 at 2:50 PM, revealed the facility did not have a specific Wound Policy other than the Skin System Policy and Procedure. 1. Review of Resident #15's Electronic Medical Record (EMR) revealed the facility admitted the resident on 07/04/17 and readmitted the resident 08/03/18 with [DIAGNOSES REDACTED]. Review of the Admission Re-Assessment, dated 08/03/18, completed by Licensed Practical Nurse (LPN) #6, revealed Resident #15 had multiple impairments to his/her skin including skin impairment of the left heel, right boggy heel, right boggy elbow, Pressure Ulcer to the right hip, and bruises and scab to his/her right toes. There was no further description and no measurements of the resident's identified skin impairment in this Assessment. Review of the Wound Evaluation Flow Sheet, dated 08/03/18, revealed Resident #15 had a right hip Stage IV Pressure Ulcer measuring 6.0 centimeters (cm) length x 6.0 cm width x 2.0 cm depth. The pressure ulcer was described as dark red in color, with scant thick exudate. Further review revealed there was no pain associated with the wound and a Wound Vac was in place. The signature on the Wound Evaluation was not legible. Review of the Wound Evaluation Flow Sheet, dated 08/03/18, revealed Resident #15 had a left outer foot wound. The Evaluation did not have a description or measurement of the wound. The signature on the Wound Evaluation was not legible. Interview with LPN #4/Wound Nurse, on 11/05/18 at 3:30 PM, revealed on admission, residents with wounds should have an accurate and complete Wound Assessment with measurements and descriptions of all wounds. Additional interview revealed as the facility's Wound Nurse, before resigning on 10/23/18, she would assess the wounds within seven (7) days of the admission assessment if she received the wound sheet from the direct care nurse who completed the admission or the Provider notified her of the wound. She further stated the admission Wound Assessment was important in order to establish the baseline assessment of the wounds. Review of Resident #15's physician's orders [REDACTED]. (40) millimeters (mm); air mattress; and, Venelex ointment to left plantar pressure ulcer twice daily. Review of the Braden Scale for Predicting Pressure Sore Risk, dated 08/04/18, revealed Resident #15's risk factors for developing pressure sores included: completely limited with sensory perception and was unresponsive to painful stimuli; skin was very moist; chairfast, and cannot bear weight; completely immobile and does not make slight changes in body movement without assistance; nutrition probably inadequate; and, had the potential for friction and shear due to skin slides against sheets during a move. Per the Assessment, the resident scored a ten (10) indicating the resident was at high risk for pressure sores. Review of the physician's orders [REDACTED]. Further, cover wound with non-adherent pad and a thin layer of 4 x 4 (guaze dressing) to the lower portion of the wound for excess drainage. Secure in place with large bordered foam wound dressing, and change once daily and PRN. Review of the Wound Evaluation Flow Sheet, dated 08/07/18, completed by LPN #4/Wound Nurse, revealed Resident #15's right hip pressure ulcer was a Stage IV, and measured 4.8 cm length x 4.2 cm width x 1.4 cm depth. Additional review revealed the wound had a moderate amount of clear thin exudate. Review of the Wound Evaluation Flow Sheet, dated 08/07/18, completed by LPN #4/Wound Nurse, revealed the resident's left outer foot had an unstageable pressure ulcer measuring 2.1 cm length x 1.0 cm width. Additional review revealed the wound was 100% necrotic, and was described as having defined margins with the surrounding skin intact. Resident #15 had been in the facility four (4) days before the left outer foot pressure ulcer was assessed and measured. Review of the physician's orders [REDACTED].#15's left outer foot, then apply Skin Prep and cover with [MEDICATION NAME] foam every three (3) days and PRN. Review of the Admission Minimum Data Set (MDS) Assessment, dated 08/10/18, revealed Resident #15 was assessed as having a Brief Interview for Mental Status (BIMS) score of three (3), indicating severe cognitive impairment. Further review revealed the resident was assessed as requiring extensive assistance of two (2) staff for bed mobility; assistance of one (1) staff for transfers; and, total assistance of one (1) staff for toileting. Continued review revealed the resident was assessed as at risk for developing a pressure ulcer and as having unhealed pressure ulcers. Per the MDS Assessment, the Resident had one (1) Stage IV pressure ulcer and one (1) Unstageable Deep Tissue Injury (DTI). Review of the Comprehensive Care Plan (CCP) initiated on 08/14/18, revealed Resident #15 was at risk for skin breakdown and had actual skin impairment areas including a Stage IV pressure ulcer to the right hip and an unstageable pressure ulcer to the left outer foot due to being chair bound, incontinent, and a history of breakdown. The goal, initiated on 08/14/18 and revised on 09/27/18, was to improve pressure ulcers. Interventions initiated on 08/14/18 included skin treatments as ordered, and turn and reposition every two (2) to three (3) hours PRN while in bed. The CCP was not developed to include an intervention for skin assessments/wound assessments weekly. Review of the Wound Evaluation Flow Sheet, dated 08/14/18, completed by LPN #4/Wound Nurse, revealed the Stage IV pressure ulcer to Resident #15's right hip measured 5.4 cm length x 4.0 cm width x 1.6 cm depth. Continued review revealed the wound had moderate amounts of clear thin exudate, and the wound bed was assessed as 10% granulation, 80% percent slough, and 10% necrotic. Further, the wound margins were defined and the surrounding skin was intact. The measurements indicated the wound had deteriorated since 08/07/18; however, there was no documented evidence the Provider was notified. Review of the Wound Evaluation Flow Sheet, dated 08/14/18, completed by LPN #4/Wound Nurse, revealed the unstageable pressure ulcer to Resident #15's left outer foot measured 1.6 cm length x 1.2 cm width. Additional review revealed the wound had no exudate, was 100% necrotic, had defined margins, and the surrounding skin was intact. Review of the Weekly Skin Review, dated 8/17/18, completed by LPN #6, revealed Resident #15 had bruising to his/her feet and scratches to his/her toes; and right hip. Further, the left coccyx had new treatments in place. No description or measurements were noted with this skin assessment. This was the first documentation related to skin impairment to the resident's coccyx area. Review of physician's orders [REDACTED]. Phone interview with LPN #6, on 11/05/18 at 2:04 PM, revealed the resident's assigned nurse should complete Weekly Skin Reviews to help identify changes in the residents' skin and ensure residents receive necessary care and treatment. Additional interview revealed she could not recall the skin assessment she completed on 08/17/18 for Resident #15 and she should have documented a more specific and accurate assessment on that date. She revealed she did not complete a Wound Evaluation of Resident #15's coccyx wound when she identified it on 08/17/18. She could not recall if she notified the Wound Nurse of this pressure ulcer. Review of the Wound Evaluation Flow Sheet, dated 08/21/18, completed by LPN #4/Wound Nurse, revealed the resident's left lateral foot DTI measurements were 1.3 cm length x 0.8 cm width. Additional review revealed the wound had no exudate. Review of the Wound Evaluation Flow Sheet, dated 08/22/18, completed by LPN #4/Wound Nurse, revealed Resident #15's right hip pressure ulcer was described as Stage IV, and measured 5.1 cm length x 4.0 cm width x 0.4 cm depth. Additional reviewed revealed the wound had a scant amount of clear thin exudate. However, there was no documented evidence of a Wound Evaluation with measurements and description of the resident's coccyx/sacrum area identified on 08/17/18. Review of Resident #15's Wound Evaluation Flow Sheet, dated 08/28/18, completed by LPN #4/Wound Nurse, revealed the right hip Stage IV pressure ulcer measured 5.5 cm length x 7.2 cm width x 1.0 cm depth. Additional review revealed the wound had clear thin exudate, 60 % granulation, and 40 % slough. Further, there was no documented evidence the Provider was notified the wound was larger in size. Review of the Wound Evaluation Flow Sheet, dated 08/28/18, completed by LPN #4/Wound Nurse, revealed the resident's left lateral foot DTI measured 0.9 cm length x 0.8 cm width. Further review revealed the wound had no exudate and was necrotic. There was no documented evidence of a Wound Evaluation completed on 08/28/18 with measurements and description of the resident's coccyx/sacrum ulcer identified on 08/17/18. Review of Resident #15's Wound Evaluation Flow Sheet, dated 09/04/18, completed by LPN #4/Wound Nurse, revealed the resident's right hip pressure ulcer was assessed as Stage IV measuring 5.5 cm length x 6.8 cm x 1 cm depth. Additional review revealed the wound had scant, clear, thin exudate. Further review revealed the wound was 60% granulation and 40% slough. Review of the Wound Evaluation Flow Sheet, dated 09/04/18, completed by LPN #4/Wound Nurse, revealed Resident #15's left outer foot DTI measured 0.7 cm length x 0.5 cm width. Further review revealed the DTI had no exudate and was necrotic. However, there was no documented evidence of a Wound Evaluation with measurements and description of the resident's coccyx/sacrum wound on 09/04/18. Review of Resident #15's physician's orders [REDACTED].¼ Dakins in the wound and cover with an abdominal pad twice daily (BID) and PRN. Additional review of the physician's orders [REDACTED]. Review of the Wound Evaluation Flow Sheet, dated 09/11/18, completed by LPN #4/Wound Nurse, revealed the resident's right hip pressure ulcer was a Stage IV and measured 5.6 cm length x 6.7 cm width x 1.2 cm depth. Additional review revealed the wound had a scant amount of clear, thin, exudate, and was described as 50% granulation and 50% slough. Review of the Wound Evaluation Flow Sheet, dated 09/11/18, completed by LPN #4/Wound Nurse, revealed the wound to the resident's left lateral foot was a DTI and measured 0.5 cm length x 0.5 cm width. Further review revealed the wound had no exudate and was necrotic. This was the last documented Wound Evaluation of the left lateral foot pressure ulcer. There was no documented evidence of a Wound Evaluation with measurements and description of Resident #15's coccyx/sacrum wound on 09/11/18, in the medical record. Review of the EMR revealed no documented evidence of a Wound Evaluation for the week of 09/16/18 for any of the resident's pressure ulcers. Review of Resident #15's (MONTH) (YEAR) TAR, revealed the treatment to cleanse the right hip with Normal Saline, apply [MEDICATION NAME] AG (silver) dressing, and cover with abdominal pad every evening was not signed to indicate the treatment was completed on 09/19/18. The Stated Agency Representative attempted to call LPN #12, on 11/05/18 at 2:00 PM, who was assigned to the resident on 09/19/18, and a message was left with no return call. Review of the physician's orders [REDACTED]. There was no documented evidence of an assessment of this pressure ulcer prior to this order. Review of Resident #15's physician's orders [REDACTED]. Further, there were physician's orders [REDACTED]. Review of the (MONTH) (YEAR) TAR, revealed the intervention to cleanse Resident #15's left foot ulcer with Normal Saline, apply [MEDICATION NAME], and cover with [MEDICATION NAME] was not signed to indicate the treatment was completed on 09/27/18 and 09/28/18. Also, the intervention to cleanse the resident's right hip with Normal Saline, apply Dermacol Collagen Matrix dressing, and cover with an abdominal pad was not signed on the TAR to indicate the treatment was completed on 09/27/18 and 09/28/18. There was no documented evidence of a Wound Evaluation for Resident #15 from 09/11/18, until 09/28/18, seventeen (17) days later, when both the Physician and the Wound Nurse found unidentified pressure ulcers. The last Skin Assessment prior to 09/28/18 was completed on 09/21/18, and there were no new areas of skin breakdown noted per this Assessment. Review of the Wound Assessment, dated 09/28/18, completed by the Physician, revealed an unstageable pressure ulcer to the resident's left foot first metatarsal (bone behind the big toe) measured at 1.0 cm length x 0.7 cm width x 0.1 cm depth. Additional review revealed the wound had 100% eschar and scant amount of yellow exudate. This was the first identification and measurement of this wound. Additional review of the Wound Assessment, dated 09/28/18, completed by the Physician, revealed an unstageable pressure ulcer to Resident #15's left buttock which was acquired less than one (1) week ago, and measured 0.5 cm length x 0.4 cm width x 0.1 cm depth. Further, the wound was 90% granulation and 10% slough with moderate serous exudate. This was the first assessment, staging and measurement of this wound, although there were treatment orders for this wound obtained on 09/21/18. Further review of the Wound Assessment, dated 09/28/18, completed by the Physician, revealed there was a wound to the resident's right lateral foot, acquired less than one (1) week ago, and measured 1.0 cm length x 1.2 cm width, and was 100% eschar with no exudate. This was the first identification and measurement of this wound. Review of the Wound Assessment, dated 9/28/18, completed by the Physician, revealed Resident #15 had a Stage IV pressure ulcer to the right hip with measurements 5.0 cm length x 5.5 cm width x 1.0 cm depth, with 1.5 cm undermining from six (6) to ten (10) o'clock. Continued review revealed the pressure ulcer was 70% granulation, 30% slough. Additional review revealed the tendon was exposed and the wound had a large amount of yellow exudate. This was the first assessment to indicate there was tendon exposed and undermining of the pressure ulcer. There was no documented evidence of consistent monitoring of this wound, nor consistent treatments performed to the pressure ulcer as per physician's orders [REDACTED]. In addition, the last Wound Evaluation for this wound was completed on 09/11/18, seventeen (17) days prior to this Evaluation. The Physician did not note in his Wound Assessment, the wound to the resident's coccyx/sacrum, or any further wounds. Review of the Wound Evaluation Flow Sheet, dated 09/28/18, completed by LPN #4/Wound Nurse, revealed Resident #15 had an unstageable pressure ulcer to the right great toe, identified on 09/25/18, which measured 2.0 cm length x 1.5 cm width and was 100% necrotic. This was the first identification, staging and measurement of this wound. Review of the Wound Evaluation Flow Sheet, dated 09/28/18, completed by LPN #4/Wound Nurse, revealed Resident #15 had a Stage III pressure ulcer to the left outer foot at the small toe. Additional review revealed the measurements were 1.0 cm length x 1.0 cm width. This was the first identification, staging and measurement of this wound, per record review. Review of the Wound Evaluation Flow Sheet, dated 09/28/18, completed by LPN #4/Wound Nurse, revealed the resident had an unstageable pressure ulcer to the right hip which measured 5.6 cm length x by 6.7 cm width x 1.2 cm depth. Continued review revealed the wound bed was yellow, 50% slough and 50% granulation, and there was no documented evidence of undermining. (This wound was documented as a Stage IV pressure ulcer with undermining by the Physician on this same date) There was no documented evidence of a Wound Evaluation completed on 09/28/18, by LPN #4/Wound Nurse, related to Resident #15's left foot first metatarsal unstageable pressure ulcer (identified by the Physician on 09/28/18), left buttocks unstageable pressure ulcer (first assessed on 09/28/18), right lateral foot pressure ulcer (identified by the Physician on 09/28/18), left lateral foot (identified on 08/03/18), or the left coccyx/sacrum (identified on 08/17/18). Review of the physician's orders [REDACTED]. However, there were no new orders for the left outer foot by small toe pressure ulcer, the left foot 1st metatarsal pressure ulcer, or the right lateral foot pressure ulcer. Review of the Wound Evaluation Flow Sheet, dated 10/02/18, completed by LPN #4/Wound Nurse, revealed the unstageable pressure ulcer to the resident's right great toe measured 1.6 cm length x 1.0 cm width and was described as a full thickness wound, 10% slough and 90% necrotic. Review of the Wound Evaluation Flow Sheet, dated 10/02/18, completed by LPN #4/Wound Nurse, revealed the pressure ulcer to the resident's right hip was a Stage IV pressure ulcer which measured 5.0 cm length x 5.5 cm width x 1.0 cm depth, with 1.5 cm undermining from six (6) to ten (10) o'clock. Further review revealed the wound bed was 70% granulation, and 30% slough. There was no documented evidence of Wound Evaluations on 10/02/18, related to Resident #15's pressure ulcers to the left outer foot, left lateral foot by small toe, left foot first metatarsal, left buttocks, right lateral foot, or the left coccyx/sacrum. Review of the physician's orders [REDACTED].¼ strength soaked 4 x 4 and an abdominal pad twice daily (BID). Review of the EMR, revealed no documented evidence of Wound Evaluations or skin assessments the week of 10/07/18. Review of the (MONTH) (YEAR) TAR, revealed the intervention to cleanse Resident #15's right great toe, apply Skin Prep, [MEDICATION NAME], and cover with dry dressing each day shift; the intervention to cleanse the left foot ulcer with Normal Saline, apply [MEDICATION NAME] and cover with [MEDICATION NAME] each day shift; and the intervention to cleanse right hip with Normal Saline, cover with Dakins soaked four (4) by four (4) and abdominal pad every day and evening shift were not signed to indicate the treatments were completed on 10/10/18. Review of the physician's orders [REDACTED]. Review of Resident #15's physician's orders [REDACTED]. Review of Resident #15's Wound Evaluation Flow Sheet, dated 10/17/18, completed by LPN #4/Wound Nurse, revealed the unstageable pressure ulcer to the right great toe measured 0.5 cm length x 0.5 cm width, and was described 100% necrotic. This was completed fifteen (15) days after the last Wound Evaluation of this pressure ulcer. Review of the Wound Evaluation Flow Sheet, dated 10/17/18, completed by LPN #4/Wound Nurse, revealed the resident's unstageable pressure ulcer to the resident's outer foot at the left small toe toe measured 0.7 cm length x 0.6 cm width x 0.1 cm depth. This was completed nineteen (19) days after the last Wound Evaluation of this pressure ulcer. Review of the Wound Evaluation Flow Sheet, dated 10/17/18, completed by LPN #4/Wound Nurse, revealed the resident's Stage IV pressure ulcer to the right hip measured 4.5 cm length x 4.5 cm width x 1 cm depth with 1.5 cm undermining from six (6) to ten (10) o'clock. This wound Evaluation was completed fifteen (15) days after the last Wound Evaluation of this pressure ulcer. There was no documented evidence of Wound Evaluations on 10/17/18, related to the resident's pressure ulcers to the left foot first metatarsal, left buttocks, right lateral foot, left lateral foot, or the left coccyx/sacrum. Review of Resident #15's (MONTH) (YEAR) TAR, revealed the treatments were not signed to indicate they were completed on 10/25/18 and 10/26/18 to clean right great toe, cover with [MEDICATION NAME] on day shift; cleanse right hip, cover with Dermacol and an abdominal pad on day shift; and cleanse left foot ulcer with Normal Saline, cover with [MEDICATION NAME] on day shift. Interview with RN #3/agency nurse on 10/25/18 at 1:00 PM, revealed she was assigned to Resident #15 on 10/25/18 and 10/26/18 on day shift. She stated treatments should be provided to residents as per physician's orders [REDACTED].#15 on 10/25/18 and 10/26/18. The CCP was not updated related to the pressure ulcer of the left coccyx first identified in the record on 08/17/18, pressure ulcer to the left buttock first identified in the record on 09/21/18, left foot first metatarsal identified on 09/28/18, right lateral foot identified on 09/28/18, right great toe identified on 09/28/18, and left outer foot at small toe identified on 09/28/18. Per record review, there was no documented evidence of treatment orders obtained for the resident's left foot first metatarsal pressure ulcer identified on 09/28/18, right lateral foot pressure ulcer identified on 09/28/18, and left outer foot at small toe pressure ulcer identified 09/28/18. Observation on 10/23/18 at 3:32 PM, of a skin assessment for Resident #15, completed by LPN #4/Wound Nurse, revealed the resident had an unstageable pressure ulcer to the right hip which measured 5.1 cm length x 4.3 cm width with 1.2 cm undermining from six (6) to ten (10) o'clock and slough covering the wound bed. The wound was larger than when last assessed on 10/17/18. Continued observation revealed there was an unstageable pressure ulcer with 100% eschar to the resident's left outer foot by small toe measuring 1.0 cm length x 1.5 cm. The wound was larger than when last assessed on 10/17/18, and per record review there was no documented evidence of physician's orders [REDACTED]. Additional observation revealed Resident #15 had an unstageable pressure ulcer below the left foot first metatarsal with measurements 0.8 cm length x 0.6 cm width. There was no documented evidence of physician's orders [REDACTED]. Further observation revealed an unstageable pressure ulcer with 100% eschar to the resident's right inner foot with measurements 0.9 cm length x 0.6 cm width. The ustageable pressure ulcer to the right inner foot was not previously identified by the facility, even though the wound was covered with eschar. There were no further pressure ulcers noted per observation. Prior to this skin assessment on 10/23/18, requested by the State Agency Representative, there had been no Wound Evaluations to assess and measure Resident #15's pressure ulcers to the left outer foot since 9/11/18 (42 days); left buttock since 9/28/18 (25 days); left foot first metatarsal since 9/28/18 (25 days); and right lateral foot since 9/28/18 (25 days). Also, there was no documented evidence the left coccyx area had ever been assessed with [REDACTED]. In addition, review of the EMR, on 11/02/18, revealed no documented evidence LPN #4/Wound Nurse documented the Wound Evaluations for the skin assessment observed with the State Agency Representative, on 10/23/18. Furthermore, review of Resident #15's EMR on 11/02/18, revealed no documented evidence the Physician was notified of the worsening measurements to the resident's right hip or left outer foot near small toe pressure ulcers after the skin assessment was observed by the State Agency Representative, on 10/23/18. Further, there was no documented evidence of notification to the Physician to obtain a treatment for [REDACTED]. There was no documented evidence of notification to the Physician for a treatment to the resident's left outer foot at the small toe pressure ulcer which was identified on 09/28/18, and was again identified during the skin assessment observed on 10/23/18. Also, there was no documented evidence the Physician was notified of the unstageable pressure ulcer to the resident's right inner foot which was first identified during the skin assessment on 10/23/18. Interview on 11/05/18 at 3:30 PM, with LPN #4/ Wound Nurse, revealed while working at the facility she tried to complete Wound Evaluations on all pressure ulcers for Resident #15 on the same date; however, if there were Wound Evaluations for some wounds and not other wounds on certain dates, she was probably not aware of the other wounds. LPN #4/Previous Wound Nurse stated she should have reviewed the EMR prior to completing skin assessments for Resident #15 in order to be aware of all wound sites and to evaluate all wounds. Further interview, with LPN #4/ Wound Nurse, revealed she should have documented Resident #15's 10/23/18 skin assessment she completed with the State Agency Representative. Interview with Director of Nursing (DON) #1, on 11/02/18 at 12:08 PM, revealed the nurses should have completed skin assessments each week for Resident #15 and LPN #4/Wound Nurse should have documented weekly Wound Evaluations for all Resident #15's wounds since the resident's admission in order to follow the progression of each wound, and notify the Provider for wound changes. Further, LPN #4/Wound Nurse should have documented the Wound Assessment completed on 10/23/18. 2. Review of Resident #8's closed EMR, revealed the facility originally admitted the resident on 05/31/12, and readmitted the resident on 01/05/15, with [DIAGNOSES REDACTED]. Review of Resident #8's Annual MDS Assessment, dated 04/24/18, revealed the facility assessed the resident as having both short term and long term memory loss and as requiring extensive assist of one (1) person for bed mobility, transfers, and toileting. Further the facility assessed the resident as frequently incontinent of bowel and bladder. Continued review of the MDS Assessment revealed the fac

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to have an effective system to notify the Physician when there was a significant change in the resident's physical condition or a need to alter treatment for [REDACTED].#3 #9, #15, #18, and #34). Staff failed to ensure the Physician was notified of improvements or deterioration in wounds; failed to ensure the Physician was notified of new wounds which were discovered during skin/wound assessments; and failed to ensure the Physician was notified of the need for treatment orders for wounds identified. This failure affected Resident #3, #15, and #34 related to pressure ulcers and Resident #9 related to vascular ulcers. (Refer to F-686 and F-684) Additionally, observation of Resident #18 on 10/29/18, revealed a large purple bruise which covered the entire dorsal right hand and partially covered the 4th and 5th digits. Although the resident's family had identified the bruise and notified staff of the bruise on the morning of 10/29/18, there was no documented evidence the Physician was notified of the bruise in order to alter treatment until 10/30/18, after surveyor intervention, even though the resident was receiving Eliquis (anticoagulant medication). (Refer to F-658) The facility's failure to have an effective system in place to ensure Physician notification when there was a need to alter treatment, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 12/20/18 and was determined to exist on 09/28/18. The facility provided an acceptable credible Allegation of Compliance (AoC) on 12/26/18, which alleged removal of the Immediate Jeopardy on 12/26/18. However, the AoC could not be verified based on observations, staff interviews, and review of facility documentation. The Immediate Jeopardy is ongoing. The findings include: Review of the facility's Change in a Resident's Condition of Status Policy, dated (MONTH) (YEAR), revealed the Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: a discovery of injuries of an unknown source; an accident or incident involving a resident; a significant change in the resident's physical/emotional/mental condition; or a need to alter medical treatment. Further review of the Policy, revealed prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. 1. Review of Resident #15's Electronic Medical Record (EMR) revealed the facility readmitted the resident 08/03/18 with [DIAGNOSES REDACTED]. Review of the Wound Evaluation Flow Sheet, dated 08/03/18, revealed Resident #15 had a right hip Stage IV Pressure Ulcer measuring 6.0 cm length x 6.0 cm width x 2.0 cm depth. The pressure ulcer was described as dark red in color, with scant thick exudate and a Wound Vac was in place. Review of physician's orders [REDACTED]. to right hip at forty (40) millimeters (mm); air mattress. Review of Resident #15's physician's orders [REDACTED]. and as needed (PRN). Review of the Wound Evaluation Flow Sheet, dated 08/07/18, completed by LPN #4/Wound Nurse, revealed the right hip pressure ulcer was a Stage IV, measured 4.8 cm length x 4.2 cm width x 1.4 cm depth, and had a moderate amount of clear thin exudate. Review of the Wound Evaluation Flow Sheet, dated 08/14/18, completed by LPN #4/Wound Nurse, revealed the Stage IV pressure ulcer to the right hip measured 5.4 cm length x 4 cm width x 1.6 cm depth, and had moderate amounts of clear thin exudate,. The wound bed had 10% granulation, 80% percent slough, and 10% necrotic, and the wound margins were defined and the surrounding skin was intact. The measurements indicated this wound had deteriorated since 08/07/18; however, there was no documented evidence the Provider was notified. Review of the Wound Evaluation Flow Sheet, dated 08/22/18, completed by LPN #4/Wound Nurse, revealed the resident's right hip pressure ulcer was described as Stage IV, and measured 5.1 cm length x 4.0 cm width x 0.4 cm depth, with a scant amount of clear thin exudate. Review of the Wound Evaluation Flow Sheet, dated 08/28/18, completed by LPN #4/Wound Nurse, revealed the right hip Stage IV pressure ulcer measured 5.5 cm length x 7.2 cm width x 1.0 cm depth, and was described as having clear thin exudate. The wound bed was assessed as 60% granulation, and 40% slough. Further, this Evaluation indicated the wound was larger; however, there was no documented evidence the Provider was notified. Review of the Wound Evaluation Flow Sheet, dated 09/04/18, completed by LPN #4/Wound Nurse, revealed the right hip pressure ulcer was assessed as Stage IV measuring 5.5 cm length x 6.8 cm by with x 1 cm depth, and was described as having a scant amount of clear, thin exudate. Further review revealed the wound bed was assessed as 60% granulation and 40% slough. Review of the physician's orders [REDACTED].¼ Dakins in the wound and cover with an abdominal pad twice daily and PRN. Review of Resident #15's Wound Evaluation Flow Sheet, dated 09/11/18, completed by LPN #4/Wound Nurse, revealed the right hip pressure ulcer was a Stage IV and measured 5.6 cm length x 6.7 cm width x 1.2 cm depth. Additional review revealed the wound had a scant amount of clear, thin, exudate, and the wound bed was described as 50% granulation and 50% slough. Review of physician's orders [REDACTED]. Review of the Wound Assessment, dated 09/28/18, completed by the Physician, revealed Resident #15 had a Stage IV pressure ulcer to the right hip measuring 5.0 cm length x 5.5 cm width x 1.0 cm depth with 1.5 cm undermining from six (6) to ten (10) o'clock. Additional review revealed the pressure ulcer was 70% granulation, 30% slough. Further review revealed the tendon was exposed and the wound had a large amount of yellow exudate. This was the first assessment to reveal there was undermining of the pressure ulcer. Continued review of the Wound Assessment, dated 09/28/18, completed by the Physician, revealed an unstageable pressure ulcer to the left foot first metatarsal (bone behind the big toe) which measured 1.0 cm length x 0.7 cm width x 0.1 cm depth. Further review revealed the wound had 100% eschar and scant amount of yellow exudate. This was the first identification of this wound per record review and there was no documented evidence the Physician was notified of the wound prior to this Assessment by the Physician. Further review of Resident #15's Wound Assessment, dated 09/28/18, completed by the Physician, revealed there was a wound to the resident's right lateral foot, acquired less than one (1) week ago, and measured 1.0 cm length x 1.2 cm width, and was 100% eschar with no exudate. This was the first identification of this wound per record review and there was no documented evidence the Physician had been notified of this wound prior to this Assessment by the Physician. Review of the Wound Evaluation Flow Sheet, dated 09/28/18, completed by LPN #4/Wound Nurse, revealed a Stage III pressure ulcer to the left outer foot at the small toe, identified on 09/17/18. Further review revealed the measurements were 1.0 cm length x 1.0 cm width. This was the first identification of this wound, per record review. Review of Resident #15's Wound Evaluation Flow Sheet, dated 09/28/18, completed by LPN #4/Wound Nurse, revealed the resident had an unstageable pressure ulcer to the right hip which measured 5.6 cm length x by 6.7 cm width x 1.2 cm depth. Continued review revealed the wound bed was yellow, 50% slough and 50% granulation, and there was no documented evidence of undermining. (This wound was documented as a Stage IV pressure ulcer with undermining by the Physician on this same date) Review of Resident #15's Wound Evaluation Flow Sheet, dated 10/02/18, completed by LPN #4/Wound Nurse, revealed the pressure ulcer to the right hip was a Stage IV and measured 5.0 cm length x 5.5 cm width 1.5 cm undermining from six (6) to ten (10) o'clock. Additional review revealed the wound bed was 70% granulation, and 30% slough. Review of the physician's orders [REDACTED].¼ strength soaked 4 x 4's and abdominal pad twice daily (BID). Review of physician's orders [REDACTED]. Review of Resident #15's Wound Evaluation Flow Sheet, dated 10/17/18, completed by LPN #4/Wound Nurse, revealed the unstageable pressure ulcer to the outer foot at the left small toe toe measured 0.7 cm length x 0.6 cm width x 0.1 cm depth. This assessment was completed nineteen (19) days after the last Wound Evaluation of this pressure ulcer. Review of the Wound Evaluation Flow Sheet, dated 10/17/18, completed by LPN #4/Wound Nurse, revealed the Stage IV pressure ulcer to the resident's right hip measured 4.5 cm length x 4.5 cm width x 1 cm depth with 1.5 undermining from six (6) to ten (10) o'clock. This assessment was completed fifteen (15) days after the last Wound Evaluation of this pressure ulcer. Observation on 10/23/18 at 3:32 PM, of a skin assessment for Resident #15, performed by LPN #4/Wound Nurse, revealed Resident #15 had an unstageable pressure ulcer to the right hip which measured 5.1 cm length x 4.3 cm width with 1.2 cm with undermining from six (6) to ten (10) o'clock and slough covering the wound bed. This wound was larger than when last assessed on 10/17/18. Continued observation revealed there was an unstageable pressure ulcer with 100% eschar to the resident's left outer foot by the small toe measuring 1.0 cm length x 1.5 cm width. The wound was larger than when last assessed on 10/17/18, and per record review there was no documented evidence of physician's orders [REDACTED]. Additional observation revealed there was an unstageable pressure ulcer below the left foot first metatarsal with measurements of 0.8 cm length x 0.6 cm width. There was no documented evidence of physician's orders [REDACTED]. Further observation revealed an unstageable pressure ulcer with 100% eschar to the resident's right inner foot with measurements of 0.9 cm length x 0.6 cm width. The ustageable pressure ulcer to the right inner foot was not previously identified by the facility, although the wound was covered with eschar. There were no further pressure ulcers noted during the skin assessment observed on 10/23/18. Review of the EMR, on 11/02/18, revealed there was no documented evidence LPN #4/Wound Nurse documented the Wound Evaluations for the skin assessment observed with the State Agency Representative, on 10/23/18. In addition, review of Resident #15's EMR on 11/02/18, revealed no documented evidence the Physician was notified of the worsening measurements to the right hip or left outer foot at the small toe pressure ulcers after the skin assessment was observed by the State Agency Representative, on 10/23/18. Also, there was no documented evidence of notification to the Physician to obtain a treatment for [REDACTED]. There was also no documented evidence the Physician was notified for a treatment to the left outer foot at the small toe pressure ulcer which was identified on 09/28/18, and was again identified during the skin assessment observed on 10/23/18. Furthermore, there was no documented evidence the Physician was notified of the unstageable pressure ulcer to the resident's right inner foot which was first identified during the skin assessment on 10/23/18. Phone interview, on 11/05/18 at 3:30 PM, with LPN #4/ Wound Nurse, revealed she had resigned from the facility on 10/23/18; however, recalled performing the skin assessment/wound evaluation on 10/23/18 for Resident #15 with the State Agency Representative. She stated she should have documented the 10/23/18 skin assessment she completed with the State Agency Representative and also notified the Provider of the changes in the resident's skin and wounds to ensure the resident received necessary care and treatment to prevent worsening skin conditions. Per interview, she should have notified the Provider of the need for treatment orders for those wounds identified without treatment orders during the skin assessment on 10/23/18. She further stated it was an oversight that some of Resident #15's wounds did not have treatment orders in place and this was not realized until the skin assessment on 10/23/18. Interview with Director of Nursing (DON) #1, on 11/02/18 at 12:08 PM, revealed LPN #4/Wound Nurse should have completed and documented weekly Wound Evaluations for all Resident #15's wounds since the resident's admission in order to follow the progression of each wound, and also notified the Provider for any changes in the wounds. Continued interview revealed LPN #4/Wound Nurse should have documented the skin assessment completed on 10/23/18 and notified the Provider if the wounds were deteriorating or getting larger, as well as notified the Provider to obtain treatment orders for those wounds which did not have treatment orders. 2. Review of Resident #3's Electronic Medical Record (EMR) revealed the facility admitted the resident on 05/31/18 with [DIAGNOSES REDACTED]. Review of the Admission Assessment, dated 05/31/18, revealed the resident was assessed as having a surgical wound to his/her right hip, bruising to upper and lower extremities, and a small blister to his/her pelvic area. Additional review revealed the resident's bilateral heels were unremarkable. Review of the Electronic Interact Note, dated 06/20/18 at 05:15 AM, completed by Registered Nurse (RN) #9, revealed Resident #3 had Deep Tissue Injuries (DTIs) to bilateral heels. The right heel DTI was measured at 8.5 cm length x 4.0 cm width and the left heel DTI was measured at 6.0 cm length x 2.0 cm width. Continued review revealed the Provider was notified of the changes in Resident #3's skin integrity. physician's orders [REDACTED]. Further physician's orders [REDACTED]. Review of the Medicine Progress Note, dated 07/10/18, revealed Resident #3 had bilateral heel decubitus ulcers, which were improved. Further, the bilateral heels were dry with the appearance of lifting edges. Review of the Progress Note, dated 07/19/18 at 2:19 AM, completed by RN #6, revealed Resident #3 had [MEDICAL CONDITION] to his/her right lower extremity and tolerated the dressing change to his/her heel. Additionally, the right heel had a quarter size dark purple/dark pink area that was firm to touch with no drainage. Further, the color and texture of the resident's left heel appeared within normal limits; no dark areas noted. Review of the Wound Evaluation Flow Sheet, dated 07/31/18, completed by LPN #4/Wound Nurse, revealed Resident #3's right heel measured 0.3 cm length x 0.3 cm width, and the wound was described as 100% necrotic. Review of the Wound Evaluation Flow Sheet, dated 08/07/18, completed by LPN #4/Wound Nurse, revealed the right heel measurements were 0.5 cm length x 0.5 cm width and the wound was described as 100% necrotic. However, there was no documented evidence the Physician was notified the wound was larger in size as completed with the measurements on 07/31/18. Review of the Progress Notes, dated 09/18/18 at 9:45 AM, completed by LPN #4/ Wound Nurse, revealed the resident's son was notified of a new order to Resident #3's right heel wound for [MEDICATION NAME]. Further, the son was notified the resident's right heel wound was now open. Review of Physician Orders, dated 09/19/18, revealed an order to clean Resident #3's right heel, pat dry, apply Skin Prep to surrounding skin of wound; apply Medi honey to wound bed, and cover with foam adhesive dressing. There was no documented evidence of a Wound Evaluation Flow Sheet completed, or of any measurement and description of the resident's right heel pressure ulcer from 08/07/18, until 10/01/18, almost two (2) months later. Review of the Wound Evaluation Flow Sheet, dated 10/01/18, completed by LPN #4/Wound Care Nurse, revealed Resident #3's right heel had a pressure ulcer measuring 1.0 cm length x 0.4 cm width x 0.5 cm depth. Further review revealed the pressure ulcer was a full thickness wound with moderate drainage; 80% granulation and 20% slough. Although the wound had changed significantly as per this Wound Assessment, compared to the Wound assessment dated [DATE], there was no documented evidence the Physician was notified of the change in the right heel wound. Further review revealed a Wound Evaluation Flow Sheet was completed one (1) day later, on 10/02/18, by LPN #4/Wound Care Nurse, revealing different measurements and description. On 10/02/18, the resident's right heel pressure ulcer was measured at 0.4 cm length x 0.5 cm width x 0.1 cm depth. Additional review revealed the wound bed was assessed as 40% [MEDICATION NAME], 40% granulation, and 20% slough. Further review revealed the wound had a red macerated scar formation, and was stable. However, there was no documented evidence the Physician was notified of changes in this wound. 3. Review of Resident #34's medical record revealed the facility admitted the resident on 09/07/18 and readmitted the resident 12/17/18 with [DIAGNOSES REDACTED]. Review of Resident #34's Admission Assessment, dated 09/07/18, at 6:14 PM, completed by RN #16, revealed the resident had skin impairments including an Unstageable Pressure Ulcer to the sacrum/coccyx measuring 2.4 centimeters (cm) length x 1.8 cm width, with no drainage. Further review revealed the resident's right hip had an open area measuring 0.6 cm length by 0.3 cm width. Per the Assessment, the resident also had an Unstageable Pressure Ulcer to the left hip, with no measurements of the wound. However, there was no documented evidence the physician was notified of the wounds to Resident #34's left hip, right hip and sacrum/coccyx, and no documented evidence physician's orders [REDACTED]. The Stated Agency Representative attempted to call RN #16, on 01/02/19 at 3:10 PM, and a message was left; however, there was no return call. Review of Resident #34's Nurse's Note, dated 09/09/18, at 5:04 PM, completed by RN #12, revealed several impairments to the resident's skin were not identified on admission, including an open area to the left hip measuring 0.75 cm length x 0.75 cm width, with scar tissue around the wound; a right hip open area measuring 1.0 cm length x 0.5 cm width, with scar tissue around the wound; an open area to the coccyx measuring 8.0 cm length x 0.9 cm width; an open area to the sacrum measuring 4.0 cm length x 1.2 cm width; and an open area to the right buttock measuring 3.5 cm length x 3.25 cm width. However, there was no documented evidence the Physician was notified of the impaired skin to the right buttock or deterioration of the right hip, coccyx, and sacrum. Also, there was no documented evidence of physician's orders [REDACTED]. There was no documented evidence of treatment orders for the wounds to the resident's coccyx and right hip until 09/11/18, which was four (4) days after the wounds were identified. Review of the physician's orders [REDACTED]. However, there was no documented evidence of a physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. However, there was no documented evidence the Physician was notified of the need for a new order for the right hip wound on this date and there was no documented evidence the right hip wound had resolved. There was no documented evidence the Physician was notified of the need for a treatment order for the wound to the resident's left hip until 09/23/18, sixteen (16) days after the wound was identified, on 09/07/18. Review of the physician's orders [REDACTED]. On 09/27/18, a Wound Evaluation was documented related to the resident's Sacrum wound, which was the first documented measurement of the wound since since 09/16/18, eleven (11) days prior. Also, this was the first documented staging of this wound which was identified on admission, twenty (20) days prior, on 09/07/18. Review of the Wound Evaluation, dated 09/27/18, completed by LPN #4/Wound Nurse, revealed the resident had a sacrum Stage III Pressure Ulcer measuring 0.8 cm length x 0.1 cm width x 0.1 cm depth which was described as pink in color, with a small amount of thin watery exudate. However, there was no documented evidence the Physician was notified the sacrum wound had decreased in size and now had measured depth. Review of Resident #34's physician's orders [REDACTED]. Continued review revealed physician's orders [REDACTED]. This was the first physician's orders [REDACTED]. Review of the Wound Evaluation, dated 10/02/18, completed by LPN #4/Wound Nurse, revealed the resident had a sacrum Stage III Pressure Ulcer measuring 3.1 cm length x 2.6 cm width x 0.3 cm depth. The pressure ulcer was described as red in color; painful, with a pain rating of five (5); with a moderate amount of thin watery serous exudate. However, there was no documented evidence the Physician was notified the resident's sacrum wound had deteriorated since the last Wound Evaluation, which was completed on 09/27/18. Review of the Wound Evaluation, dated 10/02/18, completed by LPN #4/Wound Nurse, revealed the resident had a right trochanter Stage III Pressure Ulcer measuring 1.2 cm length x 0.5 cm width x 0.1 cm depth. This pressure ulcer was described as red and painful, with a small amount of thin watery serous exudate. There was no documented evidence of a Wound Evaluation with measurement and staging of the resident's sacrum wound from 10/02/18 until 10/17/18, which was fifteen (15) days. Review of the Wound Evaluation, dated 10/17/18, completed by LPN #4/Wound Nurse, revealed the resident had a sacrum Stage III Pressure Ulcer measuring 1.5 cm length x 0.3 cm width x 0.2 cm depth, which was described as macerated, with a small amount of thin watery serous exudate. However, there was no documented evidence the Physician was notified of the change in the sacrum wound measurements (decrease in length and width) since the last Wound Evaluation, on 10/02/18. This was the last documented Wound Evaluation for the Stage III sacrum pressure ulcer in the medical record. There was no documented evidence of measurements of the resident's left trochanter wound from 09/09/18 until 10/17/18, which was thirty-eight (38) days. Review of the Wound Evaluation, dated 10/17/18, completed by LPN #4/Wound Nurse, revealed Resident #34 had a left trochanter Stage III Pressure Ulcer measuring 0.3 cm length x 0.1 cm width x 0.1 cm depth, described as having a scant amount of thin watery serous exudate. This was the first staging of this wound which was identified on 09/07/18, forty (40) days prior. However, there was no documented evidence the physician was notified the left trochanter wound measurements now included depth, as compared to the last noted documented wound measurements, per the Nurse's Notes, on 09/09/18. There was no documented evidence of a Wound Evaluation related to the resident's right trochanter wound from 10/02/18 until 10/17/18, which was fifteen (15) days. Review of the Wound Evaluation, dated 10/17/18, completed by LPN #4/Wound Nurse, revealed Resident #34 had a right trochanter Stage III Pressure Ulcer measuring 0.9 cm length x 0.2 cm width x 0.2 cm depth, which was described as not painful, with a small amount of thin watery serous exudate. However, there was no documented evidence the Physician was notified the wound had decreased in size since the last Wound Evaluation, on 10/02/18. Review of Resident #34's physician's orders [REDACTED]. However, there were no new orders on this date for this wound, and no documented evidence the sacrum Stage III pressure ulcer was resolved. Review of Resident #34's physician's orders [REDACTED]. However, the previous physician's orders [REDACTED]. There was a thirty six (36) day period (from 09/20/18 until 10/26/18) in which there were no active orders for treatment to the resident's right hip wound and no documented evidence the Physician had been notified during that time of the need for a treatment order. Also, there was a physician's orders [REDACTED]. However, there was no new treatment ordered for the left hip on this date, and there was no documented evidence in the medical record this wound had healed. Review of Resident #34's physician's orders [REDACTED]. There was no documented evidence of a Wound Evaluation of the resident's right trochanter wound from 10/17/18 until 11/16/18, which was a period of thirty (30) days. Review of the Wound Evaluation, dated 11/16/18, completed by RN #13, revealed the resident had a right trochanter Stage III Pressure Ulcer measuring 0.1 cm length x 0.1 cm width. This pressure ulcer was described as having a scant amount of thin watery serosanguineous exudate. However, there was no documented evidence the Physician was notified the right trochanter wound measurements had changed (smaller in length and width and no depth) since the last Wound Evaluation, on 10/17/18. There was no documented evidence of a Wound Evaluation related to the resident's left trochanter wound from 10/17/18 until 11/27/18, which was forty-one (41) days. Review of the Wound Evaluation, dated 11/27/18, completed by RN #13, revealed the resident had a left trochanter Stage III Pressure Ulcer which was identified on 09/07/18. Per the Evaluation, the wound measured 0.5 cm length x 0.2 cm width and was described as pink with no exudate. The wound measurements were larger per this Wound Evaluation as compared with the last Wound Evaluation dated 10/17/18. The treatment to the resident's left trochanter pressure ulcer had been discontinued on 10/26/18, and there was no documented evidence the Physician was notified of the need for a new treatment order for this wound until the Wound Evaluation on this date, 11/27/18, thirty-two (32) days later. Review of Resident #34's physician's orders [REDACTED]. Review of the Wound Assessment Sheet, dated 12/04/18, completed by the Wound Physician, revealed Resident #34's right hip Stage III pressure ulcer measured 0.8 cm length x 0.1 cm width, x 0.2 cm depth with 0.1 cm undermining from two (2) o'clock to six (6) o'clock. The pressure ulcer was described as pink and having a small amount of serous exudate. This was the first documented Wound Assessment of the right hip pressure ulcer since 11/16/18, which was eighteen (18) days prior, and the wound now had depth and undermining per this assessment. Review of Resident #34's physician's orders [REDACTED]. However, there was no documented evidence this left hip wound had resolved. Review of the Progress Note, dated 12/12/18 at 10:50 AM, revealed a SBAR Change in Condition Note which stated new orders were received for the resident to be sent to the emergency room for evaluation and treatment of [REDACTED]. Review of the Admission Assessment, dated 12/17/18 at 1:00 PM, completed by LPN #17, revealed Resident #34 returned from the hospital with impairments to his/her skin which included a right trochanter Stage III pressure ulcer, and a left trochanter pressure ulcer.

Based on interview, and record review, it was determined the facility failed to develop and maintain policies and procedures for the Monthly Drug Regimen Review (MDRR), and failed ensure the pharmacist reports irregularities to the Attending Physician, Medical Director and Director of Nursing at least monthly for six (6) of six (6) sampled residents reviewed for medication management related to [MEDICATION NAME] (anticoagulant medication) out of a total of thirty-nine (39) sampled residents (Residents #14, #23, #31, #32, #33, and #39). The facility failed to have written polices and procedures related to the Monthly Drug Regimen Review and failed to have an effective system in place to ensure the Consulting Pharmacist reports irregularities related to [MEDICATION NAME] (anticoagulant medication) and laboratory values related to [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) levels for residents receiving [MEDICATION NAME]. Although laboratory values for PT/INR were not being obtained as ordered; laboratory values for PT/INR were not consistently reported to the Provider; and [MEDICATION NAME] was not being administered as prescribed; there was no documented evidence this was identified as irregularities during the MDRR. Interview with the Consulting Pharmacist revealed when completing her record reviews at the facility she had to work between two (2) computer systems making it difficult to access all the residents' laboratory values; therefore she did not review all PT/INR results obtained for the month, and did not verify labs were obtained per physician's orders [REDACTED]. (A PT is a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder; the INR is calculated from a PT result and is used to monitor how well the anticoagulant medication is working to prevent blood clots). This failure affected Residents #14, #23, #31, #32, #33, and #39). (Refer to F-757) In addition, Resident #33's Pharmacy Consultation Report, dated 12/19/18, revealed the most recent INR, obtained on 12/17/18 was 1.6, which was below the recommended therapeutic range. The Consulting Pharmacist made recommendations to increase [MEDICATION NAME] ([MEDICATION NAME]) dose, and re-check INR lab on days three (3) and seven (7), after dosage adjustment to achieve a target INR of two to three (2-3). The Attending Physician/Medical Director declined the recommendation; however, there was no documented rationale provided for declining the recommendation. The facility's failure to develop and maintain policies and procedures for the Monthly Drug Regimen Review, and failure to ensure the Pharmacist reports irregularities to the Attending Physician, Medical Director and Director of Nursing at least monthly for residents receiving [MEDICATION NAME] medication has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 01/09/19 and determined to exist on 09/24/18 and is ongoing. The findings include: Interview on 01/10/19 at 3:42 PM with Director of Nursing (DON) #2, revealed there was no facility policy related to Monthly Drug Regimen Review. The Laboratory Company utilized by the facility, revealed the following ranges for Normal PT/INR levels. Normal Range for [MEDICATION NAME] Time (PT) 9.5 seconds to 11.8 seconds. Normal Range for International Normalized Ratio (INR) 0.9 -1.1 (standard anticoagulant 2.0-3.0 INR). 1. Review of Resident #23's clinical record revealed the facility admitted the resident on 11/13/18 with [DIAGNOSES REDACTED]. Resident #23 had physician's orders [REDACTED]. Further review revealed physician's orders [REDACTED]. Review of the Laboratory Reports, dated 11/16/18 (Friday), faxed on 11/16/18 at 1:17 PM, revealed Resident #23's PT level was 31.2 High and INR level was 2.8 High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). However, there was no documented evidence the Provider was notified of the High PT/INR results and the resident continued to receive the same dosage of [MEDICATION NAME] medication. Review of the Laboratory Report, dated 11/19/18 (Monday), revealed Resident #23's PT level was 65.6 High and the INR level was 5.8 Critically High. The Provider was notified of the lab results on 11/19/18, and orders were received to hold the [MEDICATION NAME] medication. Review of the Laboratory Report dated 11/21/18 (Wednesday), revealed Resident #23's PT level was 76.3 High and the INR level was 6.7 Critically High. The Nurse's Notes dated 11/21/18 at 6:08 PM, revealed the resident was found to have an extreme amount of blood in his/her brief with clots, and physician's orders [REDACTED]. Review of the Hospital Discharge Summary, dated 11/25/18, revealed the resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacy Communication to Physician dated 11/23/18, revealed an anti-psychotic [DIAGNOSES REDACTED]. Review of the Consultation Report from Pharmacy, dated 12/24/18, revealed recommendations to attempt taper off of [MEDICATION NAME]; however, there was no documented evidence the Pharmacist reviewed the [MEDICATION NAME] dosages and PT/INR values for this resident. There was no documented evidence of a MDRR, Consultation Report from Pharmacy,or Consultant Pharmacy Communication to Physician related to [MEDICATION NAME] medication management submitted for review for Resident #23. 2. Review of Resident #14's clinical record revealed the facility admitted the resident on 07/05/18 with [DIAGNOSES REDACTED]. The facility failed to ensure weekly PT/INR levels were drawn as ordered for Resident #14 who was receiving [MEDICATION NAME]. Although the resident had active physician's orders [REDACTED]. After State Agency Representative intervention, further laboratory results were obtained. The laboratory results dated [DATE], revealed: PT: 51.5 and INR: 4.90 (Reference range 9.5-11.8 for PT and Reference range 0.9-1.1 for INR), which revealed: High PT and Critically High INR. There was no documented evidence of a MDRR, Consultation Report from Pharmacy or Consultant Pharmacy Communication to Physician related to [MEDICATION NAME] medication management submitted for review for Resident #14. 3. Review of Resident #32's clinical record revealed the facility admitted the resident on 09/29/16, and readmitted the resident on 12/12/18, with [DIAGNOSES REDACTED]. Record review for Resident #32 from (MONTH) (YEAR) through 01/07/19, revealed there was no documented evidence laboratory values for PT/INR were consistently obtained as ordered and no documented evidence the Provider was notified of all PT/INR results. In addition, physician's orders [REDACTED]. The medication was not discontinued until 10/17/18, and there was no documented evidence this error was identified by pharmacy. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. 10/01/18, 10/02/18, 10/03/18, 10/04/18, 10/06/18, 10/07/18, 10/08/18, 10/09/18, 10/10/18, 10/12/18, 10/13/18, 10/14/18, 10/15/18, 10/18/18, 10/26/18, 10/27/18, 10/28/18, 10/29/18, and 10/30/18. This resulted in the resident receiving the 8:00 AM dose of [MEDICATION NAME] before the Laboratory Reports for PT/INR values were reviewed by the Physician. However, there was no documented evidence this error was identified by pharmacy. Review of physician's orders [REDACTED]. This was related to the Laboratory Report, dated 10/18/18 (Thursday), reported 10/18/18 at 2:21 PM, which revealed High PT/ INR results: PT: 78.2 High and INR 6.8 Critically High (standard anticoagulant 2.0-3.0 INR). However, the resident received the [MEDICATION NAME] 2.5 mg on 10/18/18 at 8:00 AM, prior to the order being written, due to the medication being scheduled for 8:00 AM on the MAR. Review of the Laboratory Report, dated 10/19/18, reported on 10/19/18 at 1:17 PM, revealed High PT/INR results: PT: 42.6 High and INR 3.8 High. However, there was no documented evidence the Physician was notified of the High lab results, and on 10/22/18, the resident's PT/INR levels were even higher (43.3 High and INR 3.9 High) (standard anticoagulant 2.0-3.0 INR), resulting in the need for treatment with Vitamin K. However, there was no documented evidence of a MDRR to indicate the Consultant Pharmacist was aware of the resident receiving Vitamin K on 10/22/18. Additionally, Resident #32's physician's orders [REDACTED]. Per the (MONTH) (YEAR) MAR, [MEDICATION NAME] 2.5 mg was to be administered in the evening, at 5:00 PM, with a start date of 10/24/18 and end date of 11/08/18. However, the morning dose of [MEDICATION NAME] 2.5 mg was not discontinued on the MAR, resulting in the resident receiving a total of 5.0 mg of [MEDICATION NAME] for five (5) days; 10/26/18 through 10/30/18. There was no documented evidence this error was identified by pharmacy. Furthermore, review of the Laboratory Report, dated 11/15/18 (Thursday), reported on 11/15/18 at 12:06 PM, revealed High PT/INR results: PT 29 High and INR 2.6 High; however, there was no documented evidence the Physician was notified of the High PT/INR results on 11/15/18, and the resident continued to receive [MEDICATION NAME] 3.0 mg in the evening as ordered. Review of the Laboratory Report, dated 11/19/18 (Monday), reported on 11/19/18 at 12:08 PM, revealed results for PT/INR were even higher: PT 72 High and INR 6.2 Critical High (standard anticoagulant INR 2.0-3); resulting in the need for treatment with Vitamin K. However, there was no documented evidence Pharmacy was aware of the resident receiving Vitamin K on 11/19/18. Review of the Consultant Pharmacist Communication to the Physician Report, dated 12/17/18, revealed INR was less than 2.5. Additional review revealed a recommendation to discontinue [MEDICATION NAME]. Continued review revealed the Physician marked the box titled I Agree. However, the last INR obtained on 12/13/18 was 2.9 and the [MEDICATION NAME] had previously been discontinued on 10/17/18, prior to this Note, indicating the Consultant Pharmacist Report did not reflect the resident's current status. There was no further documented evidence of a MDRR, Consultation Report from Pharmacy or Consultant Pharmacy Communication to Physician related to [MEDICATION NAME] medication management submitted for review for Resident #32. 4. Review of Resident #39's clinical record revealed the facility admitted the resident on 10/19/18 with the [DIAGNOSES REDACTED]. Record review for Resident #39 from (MONTH) (YEAR) thorough 01/07/19, revealed the resident was receiving [MEDICATION NAME] medication; however, there was no documented evidence laboratory values for PT/INR were being obtained as ordered, and laboratory values for PT/INR were promptly reported to the Provider. Additionally, there was no documented evidence of a MDRR, Consultation Report from Pharmacy, or Consultant Pharmacy Communication to Physician related to [MEDICATION NAME] medication management submitted for review for Resident #39. 5. Review of Resident #31's clinical record revealed the facility admitted the resident on 10/02/18 with the primary [DIAGNOSES REDACTED]. Record review for Resident #31 from (MONTH) (YEAR) through 01/02/19, revealed the resident was receiving [MEDICATION NAME] medication; however, there was no documented evidence the laboratory values for PT/INR were consistently being obtained as ordered and laboratory values for PT/INR were promptly reported to the Provider during this timeframe. There was no documented evidence the resident's PT/INR levels were obtained from 11/09/18 until 11/29/18, twenty (20) days. Review of the Laboratory Report, revealed labs drawn on 11/29/18, reported 11/29/18 at 12:49 PM, with results of PT: 42.2 High and INR: 3.8 High. There was a notation at the bottom of the Report stating PT/INR in the AM 12/01/18, written by LPN #23. However, there was no documented evidence a physician's orders [REDACTED]. physician's orders [REDACTED]. There was no documented evidence of a PT/INR obtained from 11/29/18 until 12/10/18 (11 days); however, the labs should have been drawn on 12/03/18, and 12/05/18, and 12/07/18 while the resident was receiving antibiotics. The (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the Pharmacy Consultant Note, dated 12/01/18, revealed Resident has orders for labs to be drawn, but at the time of this review they were not available in the resident record. The missing lab values include: INR. Recommendation: unless otherwise indicated, please follow up with the lab and have results forwarded to the facility. Also, there was no documented evidence of PT/INR laboratory results for 12/12/18, 12/14/18, 1217/18, 12/19/18, 12/21/18, 12/24/18, or 12/26/18, although the resident was still receiving antibiotic medication per the (MONTH) (YEAR) MAR. There was no further documented evidence of a MDRR, Consultation Report from Pharmacy or Consultant Pharmacy Communication to Physician related to [MEDICATION NAME] medication management submitted for review for Resident #31 before or after 12/01/18, for the review period. 6. Review of Resident #33's clinical record revealed the facility admitted the resident on 12/13/18, with [DIAGNOSES REDACTED]. Record review for Resident #33 from 12/13/18 through 01/09/18, revealed the resident was receiving [MEDICATION NAME] medication; however, there was no documented evidence laboratory values for PT/INR were consistently being obtained as ordered and laboratory values for PT/INR were promptly reported to the Provider during this timeframe. Review of the Pharmacy Consultation Report, dated 12/19/18, revealed the resident received [MEDICATION NAME] for stroke prevention and the most recent INR of 1.6 on 12/17/18 appears to be below the recommended therapeutic range of 2-3. There were recommendations to increase [MEDICATION NAME] ([MEDICATION NAME]) dose, and re-check INR lab on days three (3) and seven (7), after dosage adjustment to achieve a target INR of two to three (2-3). The Physician declined the recommendations on 12/24/18. However, there was no documented rationale provided for declining the recommendation. There was no further documented evidence of a MDRR, Consultation Report from Pharmacy or Consultant Pharmacy Communication to Physician related to [MEDICATION NAME] medication management. Interview with the Attending Physician/Medical Director, on 01/10/19 at at 2:45 PM and 4:37 PM, revealed he should have documented a rationale for declining the Pharmacist's recommendation on the Pharmacy Consultation Report, dated 12/19/18. He stated this was an oversight. Further interview revealed the reason he declined Resident #33's recommendation on 12/19/19, was because the timing was contemporaneous with the resident's most recent INR lab results. Continued interview revealed a re-draw was necessary to see where the resident's lab values were before he could make any necessary medication changes. Interview with the facility's Consultant Pharmacist, on 01/09/19 at 11:03 AM, and on 01/10/19 at 11:03 AM, revealed she came to the facility on ce a month and reviewed medical records for medication interactions. Per interview, she also checked to ensure medications were being prescribed with an accurate [DIAGNOSES REDACTED]. Further interview revealed when auditing a resident who was receiving [MEDICATION NAME], she would look at the last PT/INR draw to make sure the facility had addressed the lab values, but did not check the frequency of the lab draws. Continued interview revealed it was her expectation for labs to be obtained per physician's orders [REDACTED]. Additional interview revealed when completing her record reviews at the facility she had to work between two (2) computer systems making it difficult to access all the residents' laboratory results. Further interview revealed she expected the Physician to document rationale for decline of recommendations per regulations. Interview with the facility's Pharmacy Physician, on 12/27/18 at 11:20 AM, revealed there must be proper PT/INR monitoring to ensure adequate therapeutic levels and efficacy when a resident was receiving [MEDICATION NAME] therapy, because if PT/INR levels were too high, there could be adverse consequences such as bleeding. Interview with the Physician/Medical Director (MD) on 01/10/19 at 2:45 PM, and 4:37 PM, revealed he was unaware until this Survey that PT/INR laboratory values were not being obtained as ordered and that the Providers were not being notified promptly of lab results. He further stated he was unaware [MEDICATION NAME] was not being prescribed as ordered or that [MEDICATION NAME] had been administered at 8:00 AM for any resident. He stated he expected the Consultant Pharmacist to complete MDRR that adequately monitored lab work in regards to high risk medications such as [MEDICATION NAME]. Interview with Director of Nursing (DON) #2, on 12/28/18 at 9:00 AM, and 01/10/19 at 3:42 PM, revealed she was new to the position as DON. However, it was her expectation PT/INR values be obtained as ordered, and the Physician be promptly notified of these lab results. When questioned related to the MDRR, she stated she received pharmacy recommendations via email from the Consultant Pharmacist. However, per interview, in (MONTH) (YEAR) her email was not set-up so they were sent to another employee at the facility who printed them off. DON #2 stated, once the pharmacy recommendations were printed, they were put in a folder and given to the Medical Director (MD) who reviewed them and then gave them to the Medical Records Clerk. Per interview, the Medical Records Clerk then gave the pharmacy recommendations to the nurses on the floor. Further interview, revealed if the recommendations were signed by the Provider, and marked agree; write order, the recommendation acted as a verbal order to be inputted into the Point Click Care (PCC) computerized system by the floor nurses. Additional interview with DON #2, revealed she kept a copy of the pharmacy recommendations in her office and would compare the recommendations with the physician's orders [REDACTED]. When questioned as to how she ensured MDRRs were completed for residents each month, she stated she reviewed the bright colored document in the hard chart which the Pharmacist signed monthly for each resident. However, further clarification interview with DON #2 on 01/10/19 at 4:20 PM, revealed there was no bright colored document in the hard chart which the Pharmacist signed monthly for the MDRR. She stated the Consultant Pharmacist completed a pharmacy note in the Electronic Medical Record (EMR), which served as the MDRR. Additional interview revealed it was important for the MDRR to be completed each month for every resident by a specialist to ensure the residents were receiving appropriate medications in the correct dosage and to ensure there were no drug interactions with the residents' medication regimen. DON #2 stated she expected the Consulting Pharmacist to review each resident's medical record each month and identify and report irregularities related to medications including [MEDICATION NAME] as this was a high risk medication. Additional interview with DON #2, revealed the Medical Providers were to document a rationale for declining a recommendation from the pharmacist as per regulation. Interview with the Interim Administrator, on 01/10/19 at 4:49 PM, revealed to her knowledge, there was no written polices and procedures related to the MDRR. Per interview, the Consulting Pharmacist was to complete the MDRR monthly for each resident, and identify irregularities, especially related to high risk medications. Per interview, it was her expectation the Consultant Pharmacist review laboratory values related to medications monthly and verify laboratory values had been obtained as ordered. Per interview, it was important to have a second pair of eyes helping to monitor the residents. Continued interview revealed the facility had no process in place to ensure the MDRRs were completed monthly and to ensure high risk medications were thoroughly reviewed by the Consultant Pharmacist. Further interview revealed it was her expectation the Medical Providers document on the pharmacy recommendations why they declined a recommendation, as per regulation.

Based on interview, record review, and review of facility Policy, it was determined the facility failed to have an effective system to ensure each resident's drug regimen was free from unnecessary drugs for six (6) of six (6) sampled residents reviewed for medication management related to [MEDICATION NAME] (anticoagulant medication) out of a total of thirty-nine (39) sampled residents (Residents #14, #23, #31, #32, #33, and #39). The facility failed to have an effective system in place to monitor and track laboratory values, in order to ensure laboratory values were obtained as ordered and reported to the Physician related to [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) levels for residents receiving [MEDICATION NAME] (anticoagulant medication). Additionally, the facility failed to respond appropriately to elevated PT/INR levels that were above target range for treatment resulting in residents having to have Vitamin K administered or having to be hospitalized . Also, the facility failed to monitor anticoagulant medication to ensure the medication was administered as prescribed. (A PT is a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder; the INR is calculated from a PT result and is used to monitor how well the anticoagulant medication is working to prevent blood clots). (Refer to F-659, F-756, F-770, and F-773) The facility's failure to ensure each resident's drug regimen was free from unnecessary drugs and to ensure monitoring of anticoagulant medication and PT/INR levels for residents receiving [MEDICATION NAME], has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 01/09/19 and determined to exist on 09/24/18 and is ongoing. The findings include: Review of the facility Standard of Practice Policy, dated 01/2016, revealed the facility would provide the appropriate diagnostic services (laboratory and radiology) required to maintain the overall health of its residents and in accordance with State and Federal guidelines. Per Policy, the physician, physician assistant, and/or nurse practitioner should be notified of laboratory, radiology and other diagnostic findings. Further review revealed the facility would notify the attending physician of critical laboratory results, radiology and other diagnostic results in a timely manner. Per Policy, the facility would communicate the results to the ordering physician as per physician's orders [REDACTED]. The Laboratory Company utilized by the facility, revealed the following ranges for Normal PT/INR levels. Normal Range for [MEDICATION NAME] Time (PT) 9.5 seconds to 11.8 seconds. Normal Range for International Normalized Ratio (INR) 0.9 -1.1. 1. Review of Resident #23's medical record revealed the facility admitted the resident on 11/13/18 with [DIAGNOSES REDACTED]. Review of the Intermediate Care Plan dated 11/13/18, revealed safety was a priority with a goal to continue treatment to improve condition. Interventions included monitoring medications and laboratory values. Review of Resident #23's Physician Order's, dated 11/13/18, revealed orders for [MEDICATION NAME] 2.5 milligrams (mg) by mouth one (1) time a day related to [MEDICAL CONDITION] Fibrillation. Further review revealed physician's orders [REDACTED]. Review of Resident #23's Physician Order's dated 11/15/18, revealed orders for [MEDICATION NAME] HCl Solution 25 MG/ML (antibiotic medication), give 10 ml by mouth four (4) times a day for [MEDICAL CONDITION] with a start date of 11/15/18 and a discontinue date of 11/25/18. Review of the Laboratory Reports, dated 11/16/18 (Friday), revealed Resident #23's PT level was 31.2 High and INR level was 2.8 High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). The Laboratory Report was faxed to the facility on [DATE] at 1:17 PM. Continued review revealed there was no documented evidence the Physician was notified of the results of the PT/INR results drawn on 11/16/18. Review of the facility's daily staffing sheets for the day shift on 11/16/18, revealed Registered Nurse (RN) #7 was the assigned to Resident #23. Interview with RN #7, on 12/27/18 at 10:30 AM, revealed she was unaware of any laboratory results that she had failed to call in. She stated labs will come through on the fax machines on both the North and South Units. Per interview, she worked the North Unit where Resident #23 resided, and when the laboratory results came through per fax, she reviewed them and notified the Physician of the results. She stated if the Physician gave new orders related to the laboratory results, she would write the orders on the Laboratory Report, but not in the physician's orders [REDACTED]. [REDACTED].#7 and the nurse verified she worked that day; however, stated she did not remember the laboratory result coming in on that date. Review of the facility's daily staffing sheets for the evening shift on 11/16/18, revealed Licensed Practical Nurse (LPN) #7 was assigned to Resident #23 on that date. Interview with LPN #7 on 01/10/19 at 11:43 AM, revealed she was unaware of any lab results she failed to call in to the Provider. She stated when she received a laboratory result she would contact the Physician with the results and input any new orders in the Electronic Medical Record. Review of the Medication Administration Record (MAR), dated 11/16/18, 11/17/18, and 11/18/19, revealed the resident received the [MEDICATION NAME] 2.5 mg as ordered. Review of the Laboratory Report, dated 11/19/18 (Monday), revealed Resident #23's PT level was 65.6 High and the INR level was 5.8 Critically High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). This Laboratory Report was faxed to the facility on [DATE] at 12:08 PM. Review of Resident #23's Nurse's Note, dated 11/19/18 at 3:46 PM, revealed the Physician was notified and new orders were received to HOLD [MEDICATION NAME] until next PT/INR on Wednesday, 11/21/18. Review of the physician's orders [REDACTED]. Review of the (YEAR) (MONTH) MAR, revealed on the dates of 11/19/18 and 11/20/18 at 6:00 PM, the [MEDICATION NAME] dose was held. Review of the Laboratory Report, dated 11/21/18 (Wednesday), revealed Resident #23's PT level was 76.3 High and the INR level was 6.7 Critically High. The Laboratory Report was faxed to the facility on [DATE] at 12:21 PM. Review of Resident #23's Progress Notes, dated 11/21/18 at 3:44 PM, revealed the Physician was contacted and new orders were received to administer five (5) milligrams of Vitamin K. However, there was no documented evidence on the (MONTH) (YEAR) MAR, that Vitamin K was administered on 11/21/18, per the physician's orders [REDACTED].>Review of Resident #23's Progress Notes, dated 11/21/18 at 6:08 PM, completed by Registered Nurse (RN) #1, revealed the resident was found to have an extreme amount of blood in his/her brief with clots. Per the Note, a new physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. The State Agency Representative called RN #1 on 01/10/19 at 9:00 AM, on 01/11/19 at 10:00 AM and on 01/13/19 at 9:23 AM, for additional information and messages were left; however, there was no return phone call. Review of Resident #23's Hospital Consultation Report, dated 11/22/18, revealed the patient was transferred to the hospital on [DATE], with complaints of intermittent bright red blood per rectum. The patient was on [MEDICATION NAME] and labs showed supratherapeutic INR of 7.23, which was reversed with Kcentra and Vitamin K. Per the Report, the initial laboratory data showed Hemoglobin greater than nine (9). Review of the Hospital laboratory results dated [DATE] at 7:30 PM, revealed the resident's Hemoglobin was 9.4 Low (reference range of 12.4-16.2 grams per deciliter (g/dL), Hematocrit was 30.1 Low (reference range of 38.9-44.7 %), PT was 67.9 High (reference range of 9.3-12.1), and INR was 7.23 High with recommended therapeutic range for standard [MEDICATION NAME] therapy, 2.0 to 3.0. Review of Resident #23's Hospital Discharge Summary, dated 11/25/18, revealed the patient was admitted to the hospital on [DATE] secondary to bright red blood per rectum, and was found to be supratherapeutic as far as INR. The patient was admitted with [MEDICATION NAME] drip, continued to improve and did not show signs of diarrhea. INR remained within normal limits as well as the patient's bleeding stopped. Further review revealed the patient's anticoagulant will need to be held for at least two (2) more weeks. The Discharge [DIAGNOSES REDACTED]. Interview with the Attending Physician/Medical Director, on 12/20/18 at 3:00 PM, and on 12/27/18 at 2:00 PM, revealed if he was made aware of the PT/INR lab results on 11/16/18, he would have re-drawn Resident #23's labs on 11/17/18, instead of waiting until 11/19/18 in order to closely monitor the resident. However, he stated he would not have held the [MEDICATION NAME] or changed the [MEDICATION NAME] dose on 11/16/18, because the resident was in the therapeutic range for [MEDICATION NAME] on that date, as per the Laboratory Report. Interview with Director of Nursing (DON) #2, on 12/28/18 at 9:00 AM, revealed it was her expectation staff contact the Physician for notification of any lab results. Per interview, there could be consequences of administering [MEDICATION NAME] without closely monitoring PT/INR labs including bleeding. Per interview, the Physician should have been notified of Resident #23's lab results on 11/16/18. 2. Review of Resident #14's medical record revealed the facility admitted the resident on 07/05/18 with [DIAGNOSES REDACTED]. Review of Resident #14's Admission Minimum Data Set (MDS) Assessment, dated 07/12/18, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) of a ninety-nine (99) indicating resident was unable to complete the interview. Further review under Section N- Medications, revealed Resident #14 received anticoagulant medication six (6) days out of six (6) days of the seven (7) day look back period. Review of Resident #14's Comprehensive Care Plan, dated 07/19/18, revealed the resident was at risk for complications related to anticoagulant or antiplatelet medication due to [MEDICAL CONDITION] Fibrillation. The goal initiated 07/19/18, stated the resident would remain without complications from bleeding or injury. The interventions initiated 07/19/18 included: apply prolonged pressure to venipuncture sites; monitor medication regime for medications which increase effects; observe for adverse reactions such as fever, [MEDICAL CONDITION], anorexia, nausea, vomiting, cramps, diarrhea, hemorrhage, and hemoptysis; and observe for signs and symptoms of bleeding: tarry stools, blood in urine, bruising, petechiae. Further review revealed an intervention initiated 11/07/18 to obtain and monitor lab/diagnostic work as ordered and report results to Physician. Review of Resident #14's Order Summary Report with Order Date Range from 07/01/18 through 01/31/18, revealed active orders for weekly [MEDICATION NAME] Time and International Normalized Ratio (PT/INR), every Monday per protocol with the start date of 07/11/18. Review of Resident #14's physician's orders [REDACTED]. Review of Resident #14's Laboratory Reports revealed the resident received no PT/INR lab work from 08/27/18 to 09/24/18, twenty-eight (28) days. Review of the Laboratory Report dated 09/24/18, revealed: PT: 16.5 High and INR: 1.5 High. (Reference range 9.5-11.8 for PT and Reference range 0.9-1.1 for INR). Review of physician's orders [REDACTED]. Review of Resident #14's Laboratory Reports, revealed the resident received no PT/INR lab work from 09/27/18 to 11/06/18, thirty-nine (39) days. Review of the Laboratory Report, dated 11/06/18, revealed: PT: 18.2 High and INR: 1.7 High. Review of Resident #14's Laboratory Reports, revealed the resident received no PT/INR lab work from 11/12/18 to 12/20/18, thirty-eight (38) days. Review of the Laboratory Report, dated 12/20/18, revealed: PT: 51.5 High and INR: 4.90 Critically High. (Reference range 9.5-11.8 for PT and Reference range 0.9-1.1 for INR). Review of the nurse's notation dated 12/20/18, written on this Laboratory Report, revealed the Physician was notified and new orders were received to discontinue the resident's [MEDICATION NAME] dose and recheck PT/INR on 12/21/18. Review of physician's orders [REDACTED]. Review of the Laboratory Report, dated 12/21/18, revealed PT 16.2 High and INR 1.5 High. Interview on 12/28/18 at 11:45 AM, with Licensed Practical Nurse (LPN) #10, who was assigned to Resident #14, revealed PT/INR lab draws were typically drawn on Monday and Thursdays during night shift between the times of 2:00 AM to 5:00 AM; however, she was unaware of any policy or protocol indicating the labs were to be drawn weekly. Interview with LPN #21, on 12/22/18 at 11:30 AM, revealed she performed an audit of laboratory results for residents on [MEDICATION NAME] as per the request of Director of Nursing (DON) #2, on 12/19/18, and noticed Resident #14 had no recent labs drawn for PT/INR. She stated she then obtained an order from the Physician to draw a PT/INR lab on 12/19/18. Interview with the Attending Physician/Medical Director, on 12/20/18 at 3:00 PM, and 12/27/18 at 2:00 PM, revealed it was his expectation PT/INR labs be drawn routinely, at least every week if the resident was stable. He stated a resident should not go a month without receiving PT/INR labs when receiving [MEDICATION NAME] medication, as this was unacceptable. Per interview, the facility should have followed physician's orders [REDACTED].#14. He stated it was important to maintain therapeutic levels of PT/INR when receiving [MEDICATION NAME] medication. Interview with DON #2, on 12/28/18 at 9:00 AM, revealed the facility should have closely monitored PT/INR levels for Resident #14 in order to ensure therapeutic levels were maintained. When questioned if she was aware of the concern with Resident #14's PT/INR levels not being obtained as ordered prior to the Surveyor requesting information related to residents receiving [MEDICATION NAME] and requesting laboratory results, she would not answer. Further interview revealed Resident #14's PT/INR levels should have been obtained weekly as ordered. 3. Review of Resident #32's medical record revealed the facility admitted the resident on 09/29/16, and readmitted the resident on 12/12/18, with [DIAGNOSES REDACTED]. Review of Resident #32's Comprehensive Care Plan (CCP), initiated on 11/01/16, revealed Resident #32 had impaired Cardiovascular status related to [MEDICAL CONDITION] Fibrillation, with a goal stating the resident would not have a decline in function related to cardiac condition. Interventions initiated 11/01/16 included: lab work as ordered by the Physician; medications as ordered by the Physician; and, observe use and effectiveness. Continued review of the CCP, initiated on 11/01/16, revealed Resident #32 was at risk for bleeding due to medications with blood thinning effects. The goal stated the resident would remain without complications from bleeding or injury. Interventions included: monitor medication regime for medications, which increase side effects, initiated on 11/01/16; obtain and monitor lab/diagnostic work as ordered, report results to the Physician, and follow up as indicated, initiated on 11/01/16; and, anticoagulant precautions, initiated on 09/12/17. Review of Resident #32's Order Summary Report for (MONTH) (YEAR), revealed physician's orders [REDACTED]. Additionally, there was physician's orders [REDACTED]. Review of the Laboratory Report, dated 09/03/18 (Monday) and reported to the facility on [DATE] at 11:32 AM, revealed PT 35.6 High and INR 3.2 High. Review of Resident #32's physician's orders [REDACTED]. Review of the Laboratory Report, dated 09/06/18 (Thursday) and reported on 09/06/18 at 12:01 PM, revealed High PT/INR results: PT 22.6 High and INR 2.1 High. However, there was no documented evidence the Physician was notified of the High lab results. Review of the Laboratory Report, dated 09/10/18 (Monday) reported 09/10/18 at 12:20 PM, revealed High PT/INR results: PT 13.4 High and INR 1.3 High. However, there was no documented evidence the Physician was notified of the High lab results. Review of Resident #32's (MONTH) Medication Administration Record (MAR), revealed no documented evidence [MEDICATION NAME] 1.0 mg was administered on 09/09/18 to Resident #32 by LPN #11. On 01/10/19 at 3:15 PM, a phone message was left for LPN #11, to return the call to the State Agency Representative; however, there was no return phone call. Review of the Cardiology Consultation, dated 09/11/18, revealed Resident #32's INR was 1.4. today. Additional review revealed recommendations to begin [MEDICATION NAME] twice daily and increase [MEDICATION NAME] to 2.0 mg daily. Review of Resident #32's physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR, revealed orders for [MEDICATION NAME] 60 mg IM two (2) times a day. Interview with RN #16, on 01/10/19 at 2:16 PM, who was assigned to Resident #32, revealed [MEDICATION NAME] should be administered subcutaneous to decrease complications with bleeding. Further, she stated the order related to administer [MEDICATION NAME] IM must have been a clerical error when inputting the order in the Electronic Medical Record (EMR) because [MEDICATION NAME] was never to be given IM. Review of Resident #32's Laboratory Report, dated 09/13/18 (Thursday) and reported on 09/13/18 at 11:45 AM, revealed High PT/INR results: PT 13.5 High and INR 1.3 High. However, there was no documented evidence the Physician was notified of the High lab results. Review of Resident #32's Progress Note, dated 09/15/18 at 10:53 PM, revealed there was a default note from the Electronic Medication Administration Record (EMAR) related to [MEDICATION NAME] 60 mg, stating the medication was not available. Further review of the MAR, revealed [MEDICATION NAME] 60 mg was held on 09/15/18 at 8:00 PM. Review of the Laboratory Report dated 09/17/18 (Monday) and reported on 09/17/18 at 11:57 AM, revealed High PT/INR results: PT 21.6 High and INR 2.0 High. However, there was no documented evidence the Physician was notified, on 09/17/18, of the High lab results. Review of the Laboratory Report, dated 09/20/18 (Thursday) and reported on 09/20/18 at 11:32 AM, revealed High PT/INR results: PT 17.2 High and INR 1.6 High. However, there was no documented evidence the Physician was notified of the High lab results. Review of Resident #32's (MONTH) (YEAR) MAR, revealed [MEDICATION NAME] 2.0 mg was not signed, indicating the medication was not administered on 09/20/18, 09/21/18, and 09/22/18. Additional review revealed [MEDICATION NAME] 60 mg IM was not signed; indicating the medication was not administered on 09/21/18 and 09/24/18. On 01/10/19 at 3:16 PM, a phone message was left for RN #7 to return the call to the State Agency Representative. She was responsible for administration of [MEDICATION NAME] on 09/20/18. However, the nurse did not return the phone call. On 01/10/19 at 3:18 PM, a phone message was left for LPN #6 to return call to the State Agency Representative. She was responsible for administration of [MEDICATION NAME] on 09/21/18 and 09/22/18, and the administration of [MEDICATION NAME] on 09/21/18 and 09/24/18. However, the nurse did not return the phone call. Review of the Laboratory Report, dated 09/24/18 (Monday and reported on 09/24/18 at 11:32 AM, revealed High PT/INR results: PT 18.8 High and INR 1.7 High. There was a notation on the Report by LPN #21 to increase [MEDICATION NAME] to 2.5 mg daily and re-check PT/INR on 09/27/18. However, per the (MONTH) (YEAR) MAR, Resident #32 missed three (3) doses of [MEDICATION NAME] 2.0 mg, and 2 doses of [MEDICATION NAME] 60 mg prior to this lab result and there was no documented evidence the Physician was aware of the missed doses prior to changing the [MEDICATION NAME] dose. Review of Resident #32's Provider Progress Note, dated 09/24/18, by the Advance Registered Nurse Practitioner (ARNP), revealed labs were reviewed and PT/INR was 18.8/1.7. Additionally, the Resident had long term use of anticoagulants that was ongoing and stable. Further, [MEDICATION NAME] would be increased to 2.5 mg daily; PT/INR check on 09/27/18; and, re-evaluate in two (2) to three (3) days. Review of the physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR, revealed [MEDICATION NAME] 2.5 mg was to be administered at 8:00 AM versus in the afternoon. Further review revealed the medication was administered at 8:00 AM for the following dates: 09/25/18, 09/26/18, 09/27/18, 09/28/18, 09/29/18, and 09/30/18. Interview with LPN #24, on 01/10/19 at 2:00 PM, who was assigned to Resident #32, revealed [MEDICATION NAME] should be administered in the evening. Additional interview revealed administration of [MEDICATION NAME] in the evening allows for lab results drawn in the morning to be reviewed and medication adjustments to be made as necessary before the medication was administered. Further, she stated she was unaware of any Policy related to [MEDICATION NAME]. Review of Resident #32's Laboratory Report, dated 09/27/18 (Thursday) and reported on 09/27/18 at 12:05 PM, revealed High PT/INR results: PT 15.1 High. and INR 1.4 High. However, there was no documented evidence the Physician was notified of the High lab results. In addition, the resident received [MEDICATION NAME] 2.5 mg at 8:00 AM on 09/27/18, prior to the facility receiving the PT/INR lab results drawn on 09/27/18. Review of the (MONTH) (YEAR) MAR, revealed [MEDICATION NAME] 2.5 mg was administered at 8:00 AM on the following dates: 10/01/18, 10/02/18, 10/03/18, 10/04/18, 10/06/18, 10/07/18, 10/08/18, 10/09/18, 10/10/18, 10/12/18, 10/13/18, 10/14/18, 10/15/18, 10/18/18, 10/26/18, 10/27/18, 10/28/18, 10/29/18, and 10/30/18. Review of Resident #32's Laboratory Report, dated 10/01/18 (Monday) and reported on 10/01/18 at 11:53 AM, revealed High PT/INR results: PT 13.1 High and INR 1.2 High. However, there was no documented evidence the Physician was notified of the High lab results. Review of the Laboratory Report, dated 10/04/18 (Thursday) and reported on 10/04/18 at 12:09 PM, revealed High PT/INR results: PT 14.7 High and INR 1.4 High. However, there was no documented evidence the Physician was notified of the High lab results. Review of the (MONTH) (YEAR) MAR, revealed [MEDICATION NAME] 2.5 mg was not signed on 10/05/18, indicating the medication was not administered at 8:00 AM on that date. Further, [MEDICATION NAME] 60 mg was not signed on 10/05/18, indicating the medication was not administered at 8:00 AM on that date. RN #7 was the nurse responsible for administration of the resident's medications the morning of 10/05/18. Interview with RN #7, on 01/10/19 at 3:20 PM revealed she often forgot to sign the MAR after administration of medication. However, she stated she should sign the MAR to show when medications were administered in order to ensure an accurate medical record. Review of Resident #32's Laboratory Report, dated 10/08/18 (Monday) and reported on 10/08/18 at 12:09 PM, revealed High PT/INR results: PT 29 High and INR 2.6 High. However, there was no documented evidence the Physician was notified of the High lab results. On 10/10/18, two (2) days later, LPN #21 initialed and dated the Report and made a notation that the resident was on [MEDICATION NAME] 2.5 mg every day, but there was no notation related to notification to the Physician. Further, the resident had not received the 10/05/18, 8:00 AM dose of [MEDICATION NAME] or [MEDICATION NAME] prior to the PT/INR being drawn on 10/08/18. Review of the (MONTH) (YEAR) MAR, revealed [MEDICATION NAME] 2.5 mg was not signed, on 10/11/18, indicating the medication was not administered at 8:00 AM. Further, [MEDICATION NAME] 60 mg was not signed on 10/11/18 indicating the medication was not administered at 8:00 AM. Review of the Laboratory Report, dated 10/11/18 (Thursday), revealed High PT/INR results: PT 37.1 High and INR 3.3 High (standard anticoagulant 2.0-3.0 INR). However, there was no documented evidence the Physician was notified of the High lab results. On 10/19/18, eight (8) days later, RN #12 initialed the Laboratory Report, but did not indicate the Physician was notified of the results. Review of the Laboratory Report, dated 10/15/18, (Monday) and reported on 10/15/18 at 1:14 PM, revealed High PT/INR results: PT 70.1 High and INR 6.2 Critically High (standard anticoagulant 2.0-3.0 INR). RN #3 made a notation on the Report to hold [MEDICATION NAME] and re-check PT/INR on Thursday 10/18/18, three (3) days later. Review of Resident #32's physician's orders [REDACTED]. However, the 10/15/18 dose had already been administered at 8:00 AM, due to the medication being scheduled at 8:00 AM. Review of the (MONTH) (YEAR) MAR, revealed RN #3 administered the 2.5 mg dose of [MEDICATION NAME] on 10/15/18, at 8:00 AM. On 01/10/19 at 3:30 PM, a phone message was left for RN #3 to return the call to the State Agency Representative; however, there was no return phone call. Review of Resident #32's Provider Progress Notes, dated 10/15/18, by the Advanced Practice Registered Nurse (APRN), revealed the resident's [MEDICAL CONDITION] Fibrillation was stable and controlled with [MEDICATION NAME] 2.5 mg daily. Additionally, past medical history, medications, treatments, and most recent labs were reviewed. Further review revealed [MEDICATION NAME] was to continue as ordered and PT/INR was checked weekly. However, the most recent PT/INR levels obtained on 10/11/18 and 10/15/18 were High and were not addressed in the APRN's note. Further review of the (MONTH) (YEAR) MAR, revealed the [MEDICATION NAME] was held as ordered 10/16/18 and 10/17/18, as per the physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR, revealed [MEDICATION NAME] 60 mg was not signed on 10/16/18, indicating the medication was not administered at 8:00 AM. Review of Resident #32's physician's orders [REDACTED]. Review of the Laboratory Report, dated 10/18/18 (Thursday) and reported on 10/18/18 at 2:21 PM, revealed High PT/ INR results: PT: 78.2 High and INR 6.8 Critically High (standard anticoagulant 2.0-3.0 INR). The Report was not dated or signed by a nurse; however, there was a notation on the Report stating, New Order for PT/INR on 10/19/18, and Hold [MEDICATION NAME]. Review of Resident #32's physician's orders [REDACTED]. However, per the (MONTH) (YEAR) MAR, LPN #7 had already administered the [MEDICATION NAME] 2.5 mg dose on 10/18/18, at 8:00 AM. There was no documented evidence the Physician was notified the resident received the medication on 10/18/18 at 8:00 AM, prior to the order being written to hold the medication, even though the resident's INR was 6.8 Critically High, on 10/18/18 as reported at 2:21 PM. Additional physician's orders [REDACTED]. Review of Resident #32's Provider Progress Note, dated 10/19/18, by the ARNP, revealed the resident's [MEDICAL CONDITION] Fibrillation was stable and controlled with [MEDICATION NAME] 2.5 mg daily. Additionally, past medical history, medications, treatments, and most recent labs were reviewed. However, review of the Laboratory Reports revealed the most recent INR lab on 10/18/18 was Critical High, and the Provider did not include this information in the Note. Review of the Laboratory Report, dated 10/19/18 and reported on 10/19/18 at 1:17 PM, revealed High PT/ INR results: PT: 42.6 High and INR 3.8 High (standard anticoagulant 2.0-3.0 INR). However, there was no documented evidence the Physician was notified of the High lab results and on 10/22/18, the resident's PT/INR levels were even higher resulting in the need for treatment with Vitamin K. Review of the Laboratory Report, dated 10/22/18 (Monday) and reported 10/22/18 at 11:59 AM, revealed the resident's laboratory values were: PT 43.3 High and INR 3.9 High (standard anticoagulant 2.0-3.0 INR). LPN # 17 noted on the Lab Results, new orders for Vitamin K 5.0 mg, one (1) dose now and repeat PT/INR in AM (morning), on 10/23/18. Review of Resident #32's Progress Note, dated 10/22/18 at 7:24 PM, revealed the APRN was notified of PT/INR results. Additionally review revealed new orders were received to administer Vitamin K, 5.0 mg, Now and repeat PT/INR lab in the AM (morning). Continued review revealed Vitamin K was administered as ordered. Further, there were no signs or symptoms of bleeding at this time. Review of Resident #32's physician's orders [REDACTED]. Further, a Telephone order was received on 10/22/18 for Vitamin K solution 10 mg per milliliter (ml), inject 5.0 mg subcutaneous (SQ), one (1) time only for coagulation. Review of the (MONTH) (YEAR) MAR, revealed Vitamin K five (5) mg was administered subcutaneous (SQ) on 10/22/18 at 5:32 PM. Review of the Provider Progress Note, dated 10/23/18 revealed Resident #32's [MEDICAL CONDITION] Fibrillation was stable, [MEDICATION NAME] was on Hold, and PT/INR lab would be checked today. Additionally, past medical history, medications, treatments, and most recent labs were reviewed. Further, [MEDICATION NAME] was to continue on hold; PT/INR lab pending. Review of the Laboratory Report, dated 10/23/18 and reported 10/23/18 at 2:04 PM, revealed High PT/INR; PT 21.1 High and INR 1.9 High. There was no documented evidence the Physician was notified of the lab results on 10/23/18. LPN #21 noted on the Report, 10/26/18, three (3) days later, [MEDICATION NAME] 2.5 mg; re-check PT/INR in one (1) week. However, there was no documented evidence of a physician's orders [REDACTED].

Based on interview, record review, and review of facility Policy, it was determined the facility failed to have an effective system to provide or obtain laboratory services to meet the needs of its residents for five (5) of six (6) sampled residents reviewed related to [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) laboratory data out of a total sample of thirty-nine (39) residents (Resident's #14, #31, #32, #33, and #39). A PT is a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder; the INR is calculated from a PT result and is used to monitor how well the blood thinning medication (anticoagulant-[MEDICATION NAME]) is working to prevent blood clots. The facility failed to ensure weekly PT/INR levels were drawn as ordered for Resident #14 who was receiving [MEDICATION NAME] medication. Although the resident had active physician's orders [REDACTED]. After Surveyor intervention further laboratory results were obtained. The laboratory results dated [DATE], revealed: PT: 51.5 and INR: 4.90 (Reference range 9.5-11.8 for PT and Reference range 0.9-1.1 for INR), revealing High PT and a Critically High INR. In addition, record review revealed laboratory values for PT/INR were not obtained as per physician's orders [REDACTED].#32, #33, and #39. (Refer to F-757) The facility's failure to ensure laboratory services were obtained to meet the needs of its residents related to PT/INR levels for residents receiving [MEDICATION NAME] medication has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 01/09/19 and determined to exist on 09/24/18 and is ongoing. The findings include: Review of the facility Standard of Practice Policy, dated 01/2016, revealed the facility would provide the appropriate diagnostic services (laboratory and radiology) required to maintain the overall health of its residents and in accordance with State and Federal guidelines. The Laboratory Company utilized by the facility, revealed the following ranges for Normal PT/INR levels. Normal Range for [MEDICATION NAME] Time (PT) 9.5 seconds to 11.8 seconds. Normal Range for International Normalized Ratio (INR) 0.9 -1.1. 1. Review of Resident #14's medical record revealed the facility admitted the resident on 07/05/18 with [DIAGNOSES REDACTED]. Review of the Order Summary Report with Order Date Range from 07/01/18 through 01/31/19, revealed active orders for weekly PT/INR every Monday per protocol with the start date of 07/11/18. Review of Resident #14's physician's orders [REDACTED]. Review of Resident #14's Laboratory Reports revealed no documented evidence of PT/INR lab work from 08/27/18 to 09/24/18, twenty-eight (28) days. The Laboratory Report dated 09/24/18, revealed: PT: 16.5 High and INR: 1.5 High. Review of physician's orders [REDACTED]. Review of Resident #14's Laboratory Reports, revealed no documented evidence of PT/INR lab work from 09/27/18 to 11/06/18, thirty-nine (39) days. The Laboratory Report, dated 11/06/18, revealed: PT: 18.2 High and INR: 1.7 High. Review of Laboratory Reports, revealed no documented evidence of PT/INR lab work from 11/12/18 to 12/20/18, thirty-eight (38) days. The Laboratory Report, dated 12/20/18, revealed: PT: 51.5 High and INR: 4.90 Critically High. (Reference range 9.5-11.8 for PT and Reference range 0.9-1.1 for INR). The nurse's notation dated 12/20/18, written on this Laboratory Report, revealed the Physician was notified and new orders were received to discontinue [MEDICATION NAME] and recheck PT/INR on 12/21/18. Review of physician's orders [REDACTED]. Review of the Laboratory Report, dated 12/21/18, revealed results: PT 16.2 High and INR 1.5 High. Interview on 12/28/18 at 11:45 AM, with Licensed Practical Nurse (LPN) #10, who was assigned to Resident #14, revealed PT/INR lab draws were normally drawn on Monday and Thursdays during night shift between the times of 2:00 AM to 5:00 AM; however, she was unaware of any policy or protocol indicating the labs were to be drawn weekly. Interview with LPN #21, on 12/22/18 at 11:30 AM, revealed she performed an audit of laboratory results for residents on [MEDICATION NAME] at the request of Director of Nursing (DON) #2, on 12/19/18, and identified Resident #14 had no recent labs drawn for PT/INR. Continued interview revealed she then obtained a physician's orders [REDACTED]. Interview with the Attending Physician/Medical Director, on 12/20/18 at 3:00 PM, and 12/27/18 at 2:00 PM, revealed the facility should have followed physician's orders [REDACTED].#14. He further stated it was important to maintain therapeutic levels of PT/INR for [MEDICATION NAME] medication. Interview with Director of Nursing (DON) #2, on 12/28/18 at 9:00 AM, revealed the facility should have closely monitored PT/INR levels in order to ensure therapeutic levels were maintained for Resident #14. When questioned if she was aware of the concern with Resident #14's PT/INR levels not being obtained weekly as ordered, prior to the State Agency Representative requesting information related to residents receiving [MEDICATION NAME] and requesting laboratory results, she would not answer. Additional interview revealed Resident #14's PT/INR levels should have been obtained weekly as ordered. 2. Review of Resident #32's medical record revealed the facility admitted the resident on 09/29/16, and readmitted the resident on 12/12/18, with [DIAGNOSES REDACTED]. Review of Resident #32's Order Summary Report for (MONTH) (YEAR), revealed physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Review of the Laboratory Report, dated 11/26/18 (Monday), reported on 11/26/18 at 11:57 AM, revealed : PT 17.9 High and INR 1.7 High. RN #16 made a notation on the Report to start [MEDICATION NAME] 2 milligrams (mg); and re-check PT/INR lab on 11/30/18. However, there was no documented physician's orders [REDACTED]. Review of Resident #32's physician's orders [REDACTED]. Review of Resident #32's Laboratory Report, dated 11/29/18 (Thursday), reported on 11/29/18 at 12:38 PM, revealed: PT 13.8 High and INR 1.3 High. RN #3 made a note on the Report, stating [MEDICATION NAME] 2.0 mg daily; results called to Physician on 11/29/18; new order to increase [MEDICATION NAME] to 2.5 mg daily and re-check PT/INR lab in one (1) week. Review of the physician's orders [REDACTED]. Additionally, there were physician's orders [REDACTED]. Continued review revealed physician's orders [REDACTED]. Further review revealed physician's orders [REDACTED]. However, there was no documented evidence of orders to re-check PT/INR lab in one (1) week as per the notation on the 11/29/18 Laboratory Report, and no documented evidence of a lab obtained in one (1) week, on 12/06/18. Review of Resident #32's Order Summary Report for (MONTH) (YEAR), revealed an order for [REDACTED].>Review of physician's orders [REDACTED]. Further review of the medical record revealed Resident #32 was admitted to the hospital on [DATE], related to a decline, and weakness. Review of Resident #32's Progress Note, dated 12/12/18 at 3:58 PM, revealed the resident was readmitted to the facility from the Hospital. Continued review revealed the Physician was notified and the medication list was verified to continue. Review of physician's orders [REDACTED]. Review of Resident #32's Laboratory Report, dated 12/13/18, reported 12/13/18 at 12:17 PM, revealed: PT 31.9 and INR 2.9. On 12/14/18, LPN #21 noted on the Report: 1.0 mg [MEDICATION NAME]; and re-check 12/15/18. However, the note did not say what was to be re-checked on 12/15/18, and there was no documented evidence of physician's orders [REDACTED]. 3. Review of Resident #39's medical record revealed the facility admitted the resident on 10/19/18 with [DIAGNOSES REDACTED]. Review of Resident #39's physician's orders [REDACTED]. Further review of Resident #39's physician's orders [REDACTED]. Review of Resident #39's Laboratory Report, dated 10/22/18, reported to the facility on [DATE] at 12:10 PM, revealed: PT: 23.2 High and INR: 2.1 High. Review of the Laboratory Report dated 10/24/18, reported to the facility on [DATE] at 12:08 PM, revealed PT: 22.1 High and INR 2.0 High. However, there was no documented evidence of PT/INR levels obtained on the dates of 10/26/18 and 10/28/18. Review of Resident #39's Laboratory Report, dated 10/30/18, reported to the facility on [DATE] at 11:58 AM, revealed: PT: 31.7 High and INR: 2.9 High. There was no documented evidence of routine orders for PT/INR labs for Resident #39 after the antibiotic was discontinued on 10/29/18. Review of physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Review of Resident #39's Laboratory Report, dated 11/14/18 (Wednesday), reported to the facility on [DATE] at 12:17 PM, revealed: PT: 22.1 High and INR: 2.0 High. Review of Resident #39's Laboratory Report, dated 11/16/18, (Friday), reported to the facility on [DATE] at 1:22 PM, revealed PT: 20.2 High and INR: 1.8 High. Per the Hospital Discharge Summary, Resident #39 was hospitalized from [DATE] until 11/28/18, with a [DIAGNOSES REDACTED]. Review of Resident #39's Re-admission physician's orders [REDACTED]. Review of the Laboratory Report, dated 11/29/18, reported to the facility on [DATE] at 12:40 PM, revealed results: PT: 36.8 High and INR 3.3 High. The handwritten notation on the Report, revealed the Physician was notified and new orders were received to hold [MEDICATION NAME] dose today and recheck PT/INR in the AM. Review of physician's orders [REDACTED]. Further review revealed orders dated 11/29/18 for PT/INR every Monday, Wednesday and Friday while on antibiotics. However, there was no documented evidence the resident was ordered antibiotics on re-admit from the hospital; therefore, it was unclear for how long the PT/INR levels were to be drawn on Monday, Wednesday, and Friday. There was no documented evidence of a clarification order. Review of Resident #39's Laboratory Report, dated 11/30/19 (Friday), reported to the facility on [DATE] at 12:34 PM, revealed: PT: 31.8 High and INR: 2.9 High. Review of the Laboratory Report dated 12/03/18, (Monday) reported to the facility on [DATE] at 12:51 PM, revealed: PT: 23.1 High and INR: 21. High. There was no documented evidence of a Laboratory Report for 12/05/18 (Wednesday), although physician's orders [REDACTED]. Review of Resident #39's Laboratory Report dated 12/06/18, (Thursday) (with no documented evidence of a physician's orders [REDACTED]. The Physician was notified and to recheck PT/INR on 12/13/18, per the handwritten notation on the Report. There was no documented evidence of PT/INR levels drawn for Resident #39 on 12/07/18 (Friday), 12/10/18 (Monday), or 12/12/18 (Wednesday), and when PT/INR levels were obtained on 12/13/18, the resident's INR level was Critically High. Review of the Laboratory Report, dated 12/13/18, reported to the facility on [DATE] at 12:17 PM, revealed a PT: 52.2 High and INR:4.6 Critically High. There was a handwritten notation on the Report which stated recheck PT/INR labs on 12/15/18. Also, there was a Progress Note dated 12/13/18, to hold [MEDICATION NAME] and recheck PT/INR on 12/15/18. Review of Resident #39's Physician order [REDACTED]. However, there was no documented evidence of physician's orders [REDACTED]. Per the MAR, dated 12/13/18, the [MEDICATION NAME] was discontinued. There was no documented evidence of PT/INR levels drawn for Resident #32 on 12/14/18 (Friday), 12/17/18 (Monday), or 12/19/18 (Wednesday). Review of the Laboratory Report, dated 12/20/18 (Thursday), (with no documented evidence of a physician's orders [REDACTED]. Review of Resident #39's Physician order [REDACTED]. However, there was no documented evidence of PT/INR levels obtained on 12/28/18 (Friday). Review of the Laboratory Report, dated 12/24/18 (Monday), reported to the facility on [DATE] at 12:20 PM, revealed: PT: 11.1 and INR:1.1 with a handwritten notation on the Report stating recheck PT/INR Wednesday 12/26/18 per the physician. However, there was no documented evidence of a physician's orders [REDACTED]. In addition, there was no documented evidence the PT/INR was obtained on that date. Further review of Resident #39's physician's orders [REDACTED]. Review of the Laboratory Report, dated 01/01/19 (Tuesday), (with no documented evidence of a physician's orders [REDACTED]. Review of the Progress Note dated 01/01/19 at 4:25 PM written by LPN #16, stating resident will be getting PT/INR on 01/03/19, 01/05/19 and 01/07/19 while on antibiotics. Review of Resident #39's physician's orders [REDACTED]. Review of the Laboratory Reports, revealed PT/INR levels were obtained on 01/03/19 and 01/07/18. However, there was no documented evidence the PT/INR was obtained on 01/05/19, as per physician's orders [REDACTED]. 4. Review of Resident #31's medical record revealed the facility admitted the resident on 10/02/18 with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. There was no documented evidence of PT/INR orders for Resident #31 on admission. Review of the Hospital Discharge Summary, dated 11/07/18, revealed Resident #31 was admitted to the hospital on [DATE] and treated for [REDACTED]. Per the Summary. the resident was discharged from the hospital and returned to the facility on [DATE]. Review of the physician's orders [REDACTED]. Continued review revealed orders for [MEDICATION NAME] 2.5 mg on Tuesday and Thursday and [MEDICATION NAME] 5.0 mg by mouth in the evening every Sunday, Monday, Wednesday, Friday and Saturday. There was no documented evidence of orders for routine PT/INR. Review of Resident #31's physician's orders [REDACTED]. However, there was no documented evidence of a PT/INR obtained on 11/28/18. Review of physician's orders [REDACTED]. Review of Resident #31's Laboratory Report, revealed labs were drawn on 11/29/18, reported 11/29/18 at 12:49 PM, with results of PT: 42.2 High and INR: 3.8 High. There was a notation at the bottom of this Report stating PT/INR in the AM 12/01/18, written by LPN #23. However, there was no documented physician's orders [REDACTED]. Per record review, there was no documented evidence of a PT/INR obtained from 11/29/18 until 12/10/18 (11 days); however, per the physician's orders [REDACTED]. Per the (MONTH) (YEAR) MAR, the resident received Keflex for the entire month. Review of Resident #31's Laboratory Report dated 12/10/18, reported 12/10/18 at 12:25 PM, revealed PT: 12.3 and INR: 1.1 High. However, there was no documented evidence of PT/INR laboratory results for 12/12/18, 12/14/18, 1217/18, 12/19/18, 12/21/18, 12/24/18, or 12/26/18, even though the resident was still receiving antibiotic medication, per the (MONTH) (YEAR) MAR. 5. Review of Resident #33's medical record revealed the facility admitted the resident on 12/13/18, with [DIAGNOSES REDACTED]. Review of Resident #33's physician's orders [REDACTED]. However, there was no documented evidence of a PT/INR lab drawn on 12/28/18. Interview on 01/09/19 at 9:42 AM, with the Laboratory's Regional Operations Specialist, in charge of the laboratory services provided for the facility, revealed facility staff was to input labs to be drawn nightly on a requisition form online and the phlebotomist would draw the labs according to these requisitions. He further stated if there was no requisition for a lab to be drawn for a resident, the lab would not be drawn as that was company protocol. Further interview revealed the facility should check to ensure requisitions were in place each day for any labs to be drawn in order to capture all residents in need of labs. Further interview revealed the Laboratory was not responsible for tracking and maintaining the lab orders for the facility. Interview with the Physician/Medical Director (MD) on 01/10/19 at 2:45 PM, revealed he was not aware of the facility protocol related to obtaining laboratory values, specifically PT/INR after the physician's orders [REDACTED]. However, per interview, it was his expectation labs be obtained as ordered and nursing staff notify him or the ARNP of all lab results, normal and abnormal, upon receipt of the results. Further interview revealed he was unaware PT/INR labs were not obtained as ordered. Additional interview revealed he was not aware of any tracking system to ensure PT/INR levels were obtained as ordered. Interview with Director of Nursing (DON) #2, on 12/28/18 at 9:00 AM, and 01/10/19 at 3:42 PM, revealed she was new to the position as DON at the facility and just started towards the end of (MONTH) (YEAR). She stated it was her expectation staff follow physician's orders [REDACTED]. Per interview, lab requisitions were printed with the lab orders by the nurses for the phlebotomists who drew labs for PT/INR during night shift between the times of 2:00 AM to 5:00 AM. Further interview revealed the laboratory results were faxed to the facility and the nurses were to check the fax machines throughout the shift and notify the Physician of any lab results by phone. She stated the Physician would then give verbal orders related to the lab results which the nurse would enter into the Point Click Care computerized system as a new order. However, further interview revealed she was unaware of the system to ensure routine PT/INR labs were obtained. Additional interview with DON #2, revealed the facility had no specific written policy related to [MEDICATION NAME]/PT/INR monitoring and this had not been discussed in previous Quality Assurance meetings. When questioned about a tracking system for monitoring [MEDICATION NAME] dosages and PT/INR results, and a system to ensure labs were obtained as ordered related to PT/INR, she was unable to submit for review any documented evidence this was monitored or tracked. She did state residents needed to be closely monitored when receiving [MEDICATION NAME] to ensure the PT/INR levels were in therapeutic range and to prevent adverse consequences. Interview with the facility's Administrator on 01/03/18 at 3:45 PM, and on 01/10/19 at 4:45 PM, revealed she was unaware of a written facility policy related to [MEDICATION NAME] or monitoring of labs related to [MEDICATION NAME]. However, she stated it was her expectation laboratory data related to [MEDICATION NAME] be obtained as per physician's orders [REDACTED].

Based on observation, interview, record review, review of facility's Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for five (5) of thirty-nine (39) sampled residents (Resident #3, #8, #14, #15, and #34). The Comprehensive Care Plans related to Pressure Ulcers were not developed to indicate the existing Pressure Ulcers. In addition, the Care Plans were not developed and implemented related to Weekly Skin Assessments, Weekly Wound Assessments and treatments as ordered for residents with Pressure Ulcers. This failure affected Residents #3, #8, #14 #15, and #34. (Refer to F-686 and F-760) The facility's failure to have an effective system in place to ensure Comprehensive Care Plans were developed and implemented has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 12/20/18 and was determined to exist on 09/28/18. The facility provided an acceptable credible Allegation of Compliance (AoC) on 12/26/18, which alleged removal of the Immediate Jeopardy on 12/26/18. However, the AoC could not be verified based on observations, staff interviews, and review of facility documentation. The immediate Jeopardy is ongoing. The findings include: Review of the facility's Care Plan Procedure Policy, undated, revealed it was the practice of the facility to initiate, complete and revise resident care plans in accordance with all Federal and State regulations and Resident Assessment Instrument (RAI) guidance. Continued review revealed the facility would develop a resident centered comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Further review revealed the Care Plan should include the services that are to be furnished. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Interview with Director of Nursing (DON) #1, on 10/24/18 at 2:50 PM, revealed per facility protocol, staff nurses were to complete weekly skin assessments and document those assessments on the Weekly Skin Review Form on all residents; and the facility's Wound Nurse was to complete weekly wound assessments and document those assessments on the Wound Evaluation Flow Sheet. 1. Review of Resident #15's Electronic Medical Record (EMR) revealed the facility admitted the resident on 07/04/17 and readmitted the resident 08/03/18 with [DIAGNOSES REDACTED]. Review of the Wound Evaluation Flow Sheet, dated 08/03/18, the date of admission, revealed Resident #15 had a right hip Stage IV Pressure Ulcer measuring 6.0 cm length x 6.0 cm width x 2.0 cm depth which was dark red in color, with scant thick exudate, and a Wound Vac was in place. Further review of the Wound Evaluation Flow Sheet, dated 08/03/18, revealed Resident #15 had a left outer foot wound; however, there was no description or measurement of the wound. Review of the Wound Evaluation Flow Sheet, dated 08/07/18, completed by LPN #4/Wound Nurse, revealed the resident's right hip pressure ulcer was a Stage IV, measured 4.8 cm length x 4.2 cm width x 1.4 cm depth, and had a moderate amount of clear thin exudate. Further review of the Wound Evaluation Flow Sheet, dated 08/07/18, completed by LPN #4/Wound Nurse, revealed Resident #15's left outer foot had an unstageable pressure ulcer measuring 2.1 cm length x 1.0 cm width which was described as 100% necrotic, and having defined margins with the surrounding skin intact. Review of the Admission Minimum Data Set (MDS) Assessment, dated 08/10/18, revealed the facility assessed the resident as at risk for developing a pressure ulcer and as having unhealed pressure ulcers. Further, the facility assessed the Resident as having one (1) Stage IV pressure ulcer and one (1) Unstageable Deep Tissue Injury (DTI). Review of the Comprehensive Care Plan (CCP) initiated 08/14/18, revealed Resident #15 was at risk for skin breakdown and had actual skin impairment areas including a Stage IV pressure ulcer to the right hip and an unstageable pressure ulcer to the left outer foot related to being chair bound, incontinent, and a history of breakdown. The goal which was initiated 08/14/18, and revised 09/27/18, was to improve pressure ulcers. The interventions initiated on 08/14/18 included skin treatments as ordered, and turn and reposition every two (2) to three (3) hours PRN while in bed. However, the CCP was not developed to include an intervention for weekly skin assessments/wound assessments. Review of the Wound Evaluation Flow Sheet, dated 08/14/18, completed by LPN #4/Wound Nurse, revealed Resident #15's Stage IV pressure ulcer to the right hip measured 5.4 cm length x 4.0 cm width x 1.6 cm depth. The wound had moderate amounts of clear thin exudate, and was assessed as 10% granulation, 80% percent slough, and 10% necrotic. Wound margins were defined and the surrounding skin was intact. The measurements indicated the wound had deteriorated since 08/07/18. Review of the Wound Evaluation Flow Sheet, dated 08/14/18, completed by LPN #4/Wound Nurse, revealed the unstageable pressure ulcer to the resident's left outer foot measured 1.6 cm length x 1.2 cm width. Further review revealed the wound had no exudate, was 100% necrotic, had defined margins, and the surrounding skin was intact. Review of the Weekly Skin Review, dated 8/17/18, completed by LPN #6, revealed Resident #15 had bruising to his/her feet and scratches to his/her toes; and right hip. Per the Review, the left coccyx had new treatments in place. Although this was the first indication in the EMR, the resident had skin impairment to the resident's coccyx area, the facility did not ensure there was a description of the area. Review of the Wound Evaluation Flow Sheet, dated 08/21/18, completed by LPN #4/Wound Nurse, revealed the resident's left lateral foot DTI measured 1.3 cm length x 0.8 cm width, and the wound was described as having no exudate. Review of the Wound Evaluation Flow Sheet, dated 08/22/18, completed by LPN #4/Wound Nurse, revealed Resident #15's right hip pressure ulcer was described as Stage IV, measured 5.1 cm length x 4.0 cm width x 0.4 cm depth, and had a scant amount of clear thin exudate. However, there was no documented evidence of a weekly Wound Evaluation with measurements and description of the resident's coccyx/sacrum area identified on 08/17/18. Review of Resident #15's Wound Evaluation Flow Sheet, dated 08/28/18, completed by LPN #4/Wound Nurse, revealed the resident's right hip Stage IV pressure ulcer measured 5.5 cm length x 7.2 cm width x 1.0 cm depth, had clear thin exudate, 60 % granulation, and 40 % slough. Per this Evaluation, the wound was larger in size. Review of the Wound Evaluation Flow Sheet, dated 08/28/18, completed by LPN #4/Wound Nurse, revealed Resident #15's left lateral foot DTI measured 0.9 cm length x 0.8 cm width, had no exudate, and was necrotic. However, there was no documented evidence of a weekly Wound Evaluation completed on 08/28/18 with measurements and description of the resident's coccyx/sacrum ulcer, identified on 08/17/18. Review of Resident #15's Wound Evaluation Flow Sheet, dated 09/04/18, completed by LPN #4/Wound Nurse, revealed the resident's right hip pressure ulcer was assessed as Stage IV measuring 5.5 cm length x 6.8 cm x 1 cm depth. Additional review revealed the wound was described as having a scant amount of clear, thin, exudate, and as 60% granulation and 40% slough. Review of the Wound Evaluation Flow Sheet, dated 09/04/18, completed by LPN #4/Wound Nurse, revealed Resident #15's left outer foot DTI measured 0.7 cm length x 0.5 cm width, and was described as necrotic, with no exudate. However, there was no documented evidence of a Wound Evaluation with measurements and description of the resident's coccyx/sacrum wound on 09/04/18. Review of the Wound Evaluation Flow Sheet, dated 09/11/18, completed by LPN #4/Wound Nurse, revealed the resident's right hip pressure ulcer was a Stage IV and measured 5.6 cm length x 6.7 cm width x 1.2 cm depth. Further, the wound had scant, clear, thin, exudate, and was described as 50% granulation and 50% slough. Review of the Wound Evaluation Flow Sheet, dated 09/11/18, completed by LPN #4/Wound Nurse, revealed the wound to the resident's left lateral foot was a DTI measuring 0.5 cm length x 0.5 cm width. The wound had no exudate and was necrotic per this Evaluation. There were no further Wound Evaluations of the left lateral foot pressure ulcer noted. There was no documented evidence of a Wound Evaluation with measurements and description of Resident #15's coccyx/sacrum wound on 09/11/18, although there was no indication the wound had healed. Review of the EMR revealed there was no documented evidence of a Wound Evaluation for the week of 09/16/18 for any of Resident #15's pressure ulcers. Review of Resident #15's (MONTH) (YEAR) Treatment Administration Record (TAR), revealed the treatment to cleanse the right hip with Normal Saline, apply Maxsorb AG (silver) dressing, and cover with abdominal pad every evening was not signed to indicate the treatment was completed on 09/19/18, indicating the Care Plan was not implemented related to treatments as ordered. Review of the (MONTH) (YEAR) TAR, revealed the intervention to cleanse Resident #15's left foot ulcer with Normal Saline, apply [MEDICATION NAME], and cover with [MEDICATION NAME] was not signed to indicate the treatment was completed on 09/27/18 and 09/28/18, indicating the Care Plan was not implemented related to treatments as ordered. Also, the intervention to cleanse the resident's right hip with Normal Saline, apply Dermacol Collagen Matrix dressing, and cover with an abdominal pad was not signed on the TAR to indicate the treatment was completed on 09/27/18 and 09/28/18, indicating the Care Plan was not implemented related to treatments as ordered. There was no documented evidence of a Wound Evaluation for Resident #15 from 09/11/18, until 09/28/18, seventeen (17) days later, when both the Physician and the Wound Nurse found unidentified pressure ulcers. Review of the Wound Assessment, dated 09/28/18, completed by the Physician, revealed an unstageable pressure ulcer to the resident's left foot first metatarsal (bone behind the big toe) measured at 1.0 cm length x 0.7 cm width x 0.1 cm depth, which was 100% eschar with a scant amount of yellow exudate. This was the first identification and measurement of this wound. Additional review of the Wound Assessment, dated 09/28/18, completed by the Physician, revealed an unstageable pressure ulcer to the resident's left buttock which was acquired less than one (1) week ago, and measured 0.5 cm length x 0.4 cm width x 0.1 cm depth. Continued review revealed the wound was 90% granulation and 10% slough with moderate serous exudate. This was the first assessment, staging and measurement of this wound, although treatment orders were obtained for this wound on 09/21/18. Further review of the Wound Assessment, dated 09/28/18, completed by the Physician, revealed the resident's right lateral foot had a wound acquired less than one (1) week ago, and measured 1.0 cm length x 1.2 cm width, and was 100% eschar with no exudate. This was the first identification and measurement of the right lateral foot wound. Review of the Wound Assessment, dated 09/28/18, completed by the Physician, revealed Resident #15 had a Stage IV pressure ulcer to the right hip with measurements 5.0 cm length x 5.5 cm width x 1.0 cm depth, with 1.5 cm undermining from six (6) to ten (10) o'clock. The pressure ulcer was assessed as 70% granulation, 30% slough. Additional review revealed the tendon was exposed and the wound had a large amount of yellow exudate. This was the first assessment to indicate there was tendon exposed and undermining of the pressure ulcer. There was no documented evidence of consistent monitoring of this wound, nor consistent treatments performed to the pressure ulcer as per physician's orders [REDACTED]. In addition, the last Wound Evaluation for this wound was completed on 09/11/18, seventeen (17) days prior to this Evaluation. The Physician did not note in his Wound Assessment, the wound to the resident's coccyx/sacrum, or any further wounds. Review of Resident #15's Wound Evaluation Flow Sheet, dated 09/28/18, completed by LPN #4/Wound Nurse, revealed the resident had an unstageable pressure ulcer to the right great toe, identified on 09/25/18, which measured 2.0 cm length x 1.5 cm width and was 100% necrotic. This was the first identification, staging and measurement of the right great toe wound. Review of the Wound Evaluation Flow Sheet, dated 09/28/18, completed by LPN #4/Wound Nurse, revealed the resident had a Stage III pressure ulcer to the left outer foot at the small toe. Continued review revealed the measurements were 1.0 cm length x 1.0 cm width. This was the first identification, staging and measurement of the left outer foot at the small toe wound, per record review. Review of the Wound Evaluation Flow Sheet, dated 09/28/18, completed by LPN #4/Wound Nurse, revealed Resident #15 had an unstageable pressure ulcer to the right hip which measured 5.6 cm length x by 6.7 cm width x 1.2 cm depth. The wound bed was described as yellow, 50% slough and 50% granulation, and there was no documented evidence of undermining. (This wound was documented as a Stage IV pressure ulcer with undermining by the Physician this same date) There was no documented evidence of a Wound Evaluation completed on 09/28/18, by LPN #4/Wound Nurse, related to the resident's left foot first metatarsal unstageable pressure ulcer (identified by the Physician on 09/28/18), left buttocks unstageable pressure ulcer (first assessed on 09/28/18), right lateral foot pressure ulcer (identified by the Physician on 09/28/18), left lateral foot (identified on 08/03/18), or the left coccyx/sacrum (identified on 08/17/18). Review of the Wound Evaluation Flow Sheet, dated 10/02/18, completed by LPN #4/Wound Nurse, revealed the unstageable pressure ulcer to Resident #15's right great toe measured 1.6 cm length x 1.0 cm width and was described as a full thickness wound, 10% slough and 90% necrotic. Review of the Wound Evaluation Flow Sheet, dated 10/02/18, completed by LPN #4/Wound Nurse, revealed the pressure ulcer to the resident's right hip was a Stage IV pressure ulcer measured 5.0 cm length x 5.5 cm width x 1.0 cm depth and had 1.5 cm undermining from six (6) to ten (10) o'clock. The wound bed was described as 70% granulation, and 30% slough. There was no documented evidence of Wound Evaluations on 10/02/18, related to the resident's pressure ulcers to the left outer foot, left lateral foot by small toe, left foot first metatarsal, left buttocks, right lateral foot, or the left coccyx/sacrum. Review of the EMR, revealed no documented evidence of Wound Evaluations or skin assessments for the week of 10/07/18. Review of the (MONTH) (YEAR) TAR, revealed the intervention to cleanse Resident #15's right great toe, apply Skin Prep, [MEDICATION NAME], and cover with dry dressing each day shift; the intervention to cleanse the left foot ulcer with Normal Saline, apply [MEDICATION NAME] and cover with [MEDICATION NAME] each day shift; and the intervention to cleanse right hip with Normal Saline, cover with Dakins soaked four (4) by four (4) and abdominal pad every day and evening shift were not signed to indicate the treatments were completed on 10/10/18. This indicated the Care Plan was not implemented related to treatments as ordered. Review of Resident #15's Wound Evaluation Flow Sheet, dated 10/17/18, completed by LPN #4/Wound Nurse, revealed the resident's unstageable pressure ulcer to the right great toe measured 0.5 cm length x 0.5 cm width, and was described 100% necrotic. This Evaluation was completed fifteen (15) days after the last Wound Evaluation of this pressure ulcer. Review of the Wound Evaluation Flow Sheet, dated 10/17/18, completed by LPN #4/Wound Nurse, revealed the unstageable pressure ulcer to the resident's outer foot at the left small toe toe measured 0.7 cm length x 0.6 cm width x 0.1 cm depth. This Evaluation was completed nineteen (19) days after the last Wound Evaluation of this pressure ulcer. Review of Resident #15's Wound Evaluation Flow Sheet, dated 10/17/18, completed by LPN #4/Wound Nurse, revealed the resident's Stage IV pressure ulcer to the right hip measured 4.5 cm length x 4.5 cm width x 1 cm depth with 1.5 cm undermining from six (6) to ten (10) o'clock. This wound Evaluation was completed fifteen (15) days after the last Wound Evaluation of the right hip pressure ulcer. Record review revealed there was no documented evidence of Wound Evaluations on 10/17/18, related to the resident's pressure ulcers to the left foot first metatarsal, left buttocks, right lateral foot, left lateral foot, or the left coccyx/sacrum. Review of Resident #15's (MONTH) (YEAR) TAR, revealed the treatments were not signed to indicate they were completed on 10/25/18 and 10/26/18 to clean right great toe, cover with [MEDICATION NAME] on day shift; cleanse right hip, cover with Dermacol and an abdominal pad on day shift; and cleanse left foot ulcer with Normal Saline, cover with [MEDICATION NAME] on day shift. This indicated the Care Plan was not implemented related to treatments as ordered. Record review on 10/23/18, revealed there had been no Wound Evaluations to assess and measure Resident #15's pressure ulcers to the left outer foot since 9/11/18 (42 days); left buttock since 9/28/18 (25 days); left foot first metatarsal since 9/28/18 (25 days); right lateral foot since 9/28/18 (25 days). Also, there was no documented evidence the left coccyx area had ever been assessed with [REDACTED]. 2. Review of Resident #8's closed EMR, revealed the facility readmitted the resident on 01/05/15, with [DIAGNOSES REDACTED]. Review of Resident #8's Annual MDS Assessment, dated 04/24/18, revealed the facility assessed the resident as being at risk for pressure ulcers, and having no unhealed or healed pressure ulcers. Review of Resident #8's CCP, revealed a problem of alteration in skin integrity initiated on 06/04/12. The goal revealed the resident's skin would remain intact. The interventions included assisting the resident to turn and reposition every two (2) hours and as needed, keep skin as clean and dry as possible, and conduct weekly skin assessments. However, the Care Plan was not developed with an intervention to perform treatments as ordered. Review of Resident #8 Weekly Skin Review, dated 07/10/18, revealed the resident's skin was intact. Review of Resident #8's TAR, dated (MONTH) (YEAR), revealed an intervention for a weekly skin assessment to be performed. Staff signed to indicate the weekly skin assessment was completed on 07/16/18. However, review of the EMR, revealed there was no documented evidence of a weekly skin assessment on 07/16/18, indicating the Care Plan was not implemented related to weekly skin assessments. In addition, there was no documented evidence Resident #8 received a skin assessment as per the Care Plan from 07/10/18 until 07/23/18, thirteen (13) days later. Review of the Weekly Skin Review dated 07/23/18, revealed the resident was assessed as having excoriation to the buttocks and barrier cream was applied. Review of Resident #8's TAR, dated (MONTH) (YEAR), revealed staff did not sign that a skin assessment was completed the week of 08/06/18. Continued review revealed staff signed to indicate a skin assessment was completed on 08/13/18. However, review of the EMR, revealed there was no documented evidence of a skin assessment completed on 08/13/18. This indicated the Care Plan was not implemented related to weekly skin assessments. There was no documented evidence of a weekly skin assessment as per the Care Plan, from 07/23/18 until 08/20/18, twenty-eight (28) days later. Review of Resident #8's Weekly Skin Reviews dated 08/20/18, 08/27/18, 09/03/18 and 09/10/18, revealed the resident had intact skin with no open areas. Review of Resident #8's TAR, dated 09/17/18, revealed Registered Nurse (RN) #1 signed as completing a skin assessment. However, review of the EMR, revealed there was no documented evidence of a skin assessment on 09/17/18, indicating the Care Plan was not implemented related to weekly skin assessments. Further review revealed there was no documented evidence of a weekly skin assessment as per the Care Plan, from 09/10/18 until 09/23/18, thirteen (13) days later. Review of the Weekly Skin Review, dated 09/23/18, revealed the resident was assessed as having a pressure sore to his/her coccyx, and [MEDICATION NAME] dressing was applied per physician's orders [REDACTED]. Review of the Wound Evaluation Sheet, dated 09/24/18, completed by the Wound Care Physician, revealed Resident #8 was assessed as having a Stage III pressure ulcer to the sacrum measuring wound 1.8 centimeters (cm) length x 0.8 cm width x 0.1 cm depth. The wound bed was assessed as 90% slough and 10% granulation, with a small amount of serous drainage from the wound. This was the first documented description, staging, and measurement of this wound since the wound was identified on 09/23/18. Review of the Wound Evaluation Flow Sheet, dated 09/28/18, completed by LPN #4/Wound Nurse, revealed Resident #8 was assessed as having a Stage III in house acquired pressure ulcer to his/her coccyx which was identified on 09/23/18. The pressure ulcer was measured to have a length of 1.8 cm, a width of 0.8 cm, and a depth of 0.1 cm, with defined edges and was assessed to have approximately 10% granulation and 90% slough. Review of Resident #8's TAR, dated 10/01/18, revealed LPN #1 signed to indicate a weekly skin assessment was complete. However, review of the EMR revealed no documented evidence of a skin assessment on that date, indicating the Care Plan was not implemented related to weekly skin assessments. Review of the Wound Evaluation Sheet, dated 10/01/18, completed by the Wound Care Physician, revealed Resident #8 was assessed as having a Stage III pressure ulcer to his/her sacrum measuring 4.7 cm length x 0.9 cm width, x 0.1 cm depth, with the wound bed assessed as 50% granulation and 50% slough with a moderate amount of serous drainage. Per the Evaluation, the wound had declined since the previous assessment. Review of Resident #8's Wound Evaluation Flow Sheet, dated 10/02/18, completed by LPN #4/Wound Nurse, revealed the resident's Stage III sacral pressure ulcer was measured to have a length of 4.7 cm, a width of 0.9 cm, and a depth of 0.1 cm with defined edges. The measurements indicated the wound had deteriorated since the previous assessment. Per the Flow Sheet, the tissue surrounding the wound was found to have maceration (a breaking down of skin due to prolonged exposure to moisture). The Flow Sheet revealed the wound was approximately 50% granulation and 50% slough, with a moderate amount of thin, watery serous drainage. A Situation Background Assessment Recommendation (SBAR) Note, dated 10/07/18, revealed Resident #8 was discharged from the facility to the hospital. Review of Resident #8's Hospital emergency room Note, dated 10/07/18, revealed the resident was admitted to the hospital with [REDACTED]. 3. Review of Resident #3's EMR, revealed the facility admitted the resident on 05/31/18 with [DIAGNOSES REDACTED]. Review of the Admission Assessment, dated 05/31/18, revealed Resident #3 was assessed as having a surgical wound to his/her right hip, bruising to upper and lower extremities, and a small blister to the pelvic area. Further review revealed the resident's bilateral heels were unremarkable. Review of the Weekly Skin assessment dated [DATE], revealed the resident had surgical incisions to the right hip, and abrasion/shearing to the left buttock measuring 4.0 cm x 0.5 cm and 2.0 cm x 0.5 cm with treatment in progress. Review of the Admission MDS Assessment, dated 06/07/18, revealed Resident #3 was assessed as having unhealed pressure ulcers. Per the MDS, the resident had two (2) Stage I pressure ulcers, a surgical incision, and Moisture Associated Skin Damage (MASD); and was receiving pressure ulcer and surgical wound care and the applications of nonsurgical dressings. Review of the CCP, initiated 06/11/18, revealed Resident #3 had altered skin integrity; non-pressure related to excoriation, shearing, and a surgical wound. The goal initiated 06/11/18, revised 09/21/18, revealed the affected area(s) would heal without complications. Interventions included: monitor signs and symptoms of infection and notify the physician of significant findings, initiated on 06/11/18; provide treatments as ordered, initiated on 06/11/18; and pressure-reducing devices to the resident's bed and wheelchair, initiated on 06/11/18. However, the CCP was not developed to state the location of the excoriation, and shearing, and was not developed with an intervention for weekly skin/wound assessments. There was no documented evidence of a Weekly Skin Review or any skin assessment from 06/03/18, until seventeen (17) days later, when the resident was noted to have Deep Tissue Injury (DTI) to bilateral heels, on 06/20/18. Review of Resident #3's Electronic Interact Note, dated 06/20/18 at 05:15 AM, revealed Resident #3 had DTIs to bilateral heels. Per the Note, the right heel DTI was measured at 8.5 cm length x 4.0 cm width and the left heel DTI was measured at 6.0 cm length x 2.0 cm width. Review of the Wound Evaluation Flow Sheet, dated 06/20/18, completed by RN #9, revealed Resident #3 had a DTI to the right heel, with measurements 8.5 cm length x 4.0 cm width and necrotic tissue in the wound bed. Additional review revealed there was no exudate, and the wound margins and surrounding skin was red. However, there was no documented evidence of a Wound Evaluation on this date related to the left heel DTI. Review of the Wound Evaluation Flow Sheet, dated 06/26/18, completed by LPN #4/Wound Nurse, revealed the resident's right heel DTI measured 5.2 cm length x 4.8 cm width. The heel was a necrotic fluid filled blister with intact surrounding tissue and well-defined margins. However, there was no Wound Evaluation addressing the left heel DTI. Review of Resident #3's Wound Evaluation Flow Sheet, dated 07/03/18, completed by LPN #4/Wound Nurse, revealed the resident's right heel DTI measured 4.0 cm length x 2.0 cm width. and was described as having [MEDICATION NAME] tissue, defined wound margins, and the surrounding skin was intact. However, there was no Wound Evaluation to address the left heel DTI. Review of Resident #3's Wound Evaluation Flow Sheet, dated 07/10/18, completed by LPN #4/Wound Care Nurse, revealed the resident's right heel DTI measured 3.2 cm length x 1.8 cm width and was 100% necrotic. However, there was no Wound Evaluation to address the left heel DTI. Review of the Wound Evaluation Flow Sheet, dated 07/17/18, completed by LPN #4/Wound Care Nurse, revealed the resident's right heel DTI measured 2.0 cm length x 2.0 cm width and was 100% necrotic. However, there was no Wound Evaluation to address the left heel DTI. Review of the Wound Evaluation Flow Sheet, dated 07/18/18, the next day, completed by LPN #4/Wound Care Nurse, revealed the resident's right heel DTI measured 2.0 cm length x 2.1 cm width and was 100% necrotic. However, there was no documented evidence of a Wound Evaluation to address the left heel DTI. Review of a Progress Note, dated 07/19/18 at 2:19 AM, revealed the resident's right heel had a quarter size dark purple/dark pink area that was firm to touch with no drainage. Further review revealed the color and texture of the resident's left heel appeared within normal limits; no dark areas noted. Although the Progress Note, dated 07/19/18, revealed the resident's left heel DTI had resolved, there was no documented evidence the left heel DTI had been assessed and monitored since identified on 06/20/18, almost a month earlier. Review of the Wound Evaluation Flow Sheet, dated 07/24/18, completed by LPN #4/Wound Nurse, revealed the resident's right heel DTI was measured at 0.5 cm length x 0.3 cm width, and was described as 100 % necrotic, with intact surrounding tissue. Review of the Wound Evaluation Flow Sheet, dated 07/31/18, completed by LPN #4/Wound Nurse, revealed the resident's right heel measurements were 0.3 cm length x 0.3 cm width, and the wound was described as 100 % necrotic. Review of the Wound Evaluation Flow Sheet, dated 08/07/18, completed by LPN #4/Wound Nurse, revealed Resident #3's right heel measurements were 0.5 cm length x 0.5 cm width and the wound was described as 100% necrotic. Review of the TAR, dated 09/20/18, 09/27/18 and 09/28/18, revealed the intervention was not signed to indicate the treatment had been performed to apply Skin Prep and Medi honey to the resident's right heel and cover with a foam adhesive dressing. This indicated the Care Plan was not implemented related to treatments as ordered. There was no documented evidence of a Wound Evaluation Flow Sheet completed, or of any measurement and description of the resident's right heel pressure ulcer from 08/07/18, until 10/01/18, almost two (2) months later. Review of the Wound Evaluation Flow Sheet, dated 10/01/18, completed by LPN #4/Wound Care Nurse, revealed Resident #3's right heel pressure ulcer measured 1.0 cm length x 0.4 cm width x 0.5 cm depth. Continued review revealed the pressure ulcer was a full thickness wound with moderate drainage; 80% granulation and 20% slough. The wound had changed significantly per this Wound Assessment, compared to the Wound assessment dated [DATE]. Further review revealed a Wound Evaluation Flow Sheet was completed one (1) day later, on 10/02/18, by LPN #4/Wound Care Nurse, which revealed different measurements and description. Per this Evaluation on 10/02/18, the resident's right heel pressure ulcer was measured at 0.4 cm length x 0.5 cm width x 0.1 cm depth and was assessed as 40% [MEDICATION NAME], 40% granulation, and 20% slough. Review of the (MONTH) (YEAR) TAR, revealed the treatment to the right heel for the applications of Skin Prep and Medi honey and cover with a foam adhesive dressing was not signed as completed on 10/02/18, 10/04/18, 10/05/18, 10/11/18. 10/16/18 and 10/19/18, indicat

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a resident who is unable to carry out Activities of Daily Living (ADLs) receives the necessary services to maintain good grooming and personal hygiene for eight (8) of thirty-nine (39) sampled residents (Residents #1, #3, #4, #7, #9, #10, #11 and #16) Interview with residents and staff revealed baths/showers were not being completed twice a week as scheduled or three (3) times a week as preferred and requested for Residents #1, #3, #4, #7, #9, #10, #11 and #16. In addition, review of the Hygiene Reports for the months of (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR), revealed baths/showers were not completed twice a week or three (3) times a week. Interviews with staff revealed staffing shortage was the reason for residents not receiving their scheduled baths. Interviews with interviewable residents revealed the lack of bathing made them feel bad, dirty, depressed and ashamed. Residents also reported not wanting to go to activities they normally enjoyed and not wanting to go to the dining room for meals because of feeling dirty. Substandard Quality of Care with actual Psychosocial Harm was identified related to the facility's systemic failure and staffing shortage. (Refer to F-659) The findings include: Review of the facility's Activities of Daily Living (ADLs) Supporting Policy, revised 03/2018, revealed appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). Further review revealed interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. Interview with Director of Nursing (DON) #1, on 11/02/18 at 12:07 PM revealed it was the facility's process to provide at least two (2) baths and or showers each week, per the resident's choice. Continued interview revealed, the facility utilized a computer program, titled Documentation Survey Report to document a resident's bath/shower. Further interview revealed, the facility did employee agency staff that were not familiar with the facility's computer charting system so they did allow staff to document bathing/showers on a hard copy form, titled Certified Nursing Assistant (CNA) Bath and Skin Report. Review of the facility's Federal Resident Rights and Facility Responsibilities Policy, undated, revealed residents have a right to be treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Further review revealed residents have a right to make choices about aspects of his or her life in the facility that are significant to the resident. Review of the facility's Kentucky Resident Rights and Facility Responsibilities, Policy, undated, revealed residents have a right to be treated with consideration, respect, and full recognition of his dignity and individuality. Further review revealed residents have the right to be suitable dressed at all times and given assistance when needed in maintaining body hygiene and good grooming. 1. Review of Resident #9's medical record revealed the facility readmitted the resident on 05/24/17 with [DIAGNOSES REDACTED]. Review of the Admission Assessment, dated 05/24/17, revealed Resident #9's bathing preference was three (3) showers a week in the evenings on Tuesday, Thursday, and Saturday. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/23/18, revealed Resident #9 was assessed by the facility as having a Brief Interview for Mental Status score (BIMS) of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Continued review of Resident #9's MDS Assessment, revealed the facility assessed the resident to require limited assistance of one (1) person physical assist for dressing and personal hygiene and extensive assistance of one (1) staff for bathing. Review of the Comprehensive Care Plan revealed a focus problem of Physical Functional Deficit related to Mobility Impairment, Range of Motion Limitations in bilateral lower extremities and right upper extremity, Self-Care Impairment with impaired standing balance issues, weakness and debility, medication use, and impaired memory that may impact decisions and safety needs, initiated on 06/13/17. Review of the goal, revised 08/29/18, revealed the resident would improve the current level of physical function. Interventions included: staff to encourage choice with care, assist of one (1) to two (2) for transfers as needed, assist the resident to the toilet then supervise, inspect skin with care, report reddened areas, rashes, bruising, or open areas, monitor and report changes in physical functioning ability, nail care as needed and praise Resident #9's efforts at participation. Review of the facility's bathing/shower records for (MONTH) (YEAR) revealed, a Documentation Survey Report dated (MONTH) (YEAR), for Resident #9. Continued review revealed, Resident #9 received a bath/shower on 08/03/18 and 08/12,18. Review of the Certified Nursing Assistant (CNA) Bath and Skin Reports, revealed Resident #9 received a bed bath on 08/04/18, a bath on 08/07/18 and a bed bath on 08/11/18 and 08/14/18; however, no showers as per the resident's choice were documented. Per facility documentation, Resident #9 requested to receive three (3) showers a week; however, only received six (6) bath/showers for the entire month of (MONTH) (YEAR). Review of the facility's bathing/shower records for (MONTH) (YEAR) revealed, a Documentation Survey Report for Resident #9. Continued review revealed, Resident #9 received no showers for (MONTH) (YEAR). Review of the CNA Bath and Skin Reports, revealed Resident #9 received a bed bath on 09/02/18, 09/10/18, 09/11/18 and 09/16/18. Per facility documentation, Resident #9 requested to receive three (3) showers per week; however, only received four (4) bed baths for the entire month of (MONTH) (YEAR). Review of the facility's bathing/shower records for (MONTH) (YEAR) revealed, a Documentation Survey Report for Resident #9. Continued review revealed, Resident #9 received a shower on 10/10/18 and 10/13/18. Review of the CNA Bath and Skin Reports, revealed no additional baths/showers were provided. Per facility documentation, Resident #9 requested to receive three (3) showers per week; however, only received two (2) baths/showers for the entire month of (MONTH) (YEAR). Observation of Resident #9, 10/22/19 at 9:38 AM, revealed the resident was sitting up on the side of the bed with a breakfast meal on the bedside tray. Interview with Resident #9, on 10/22/19 at 9:38 AM, revealed staff had wrapped his wounds on his legs. Per interview, he/she did not get his/her shower. He/she stated staff assisted him/her to wash up at the sink; however, that was not a shower and he/she stated he/she still felt dirty because he/she had not received a shower. Continued interview revealed facility staffing over the weekend had been short as usual with a lot of agency staff. Per interview, he/she no longer liked living at the facility because staffing was short and there was a lot of agency staff that did not know his/her needs. Interview with Resident #9, on 10/25/18 at 9:55 AM, revealed he/she had not received showers as requested routinely and this made him/her feel bad, and negative about himself/herself. Per interview, he/she had feelings of depression related to not receiving showers. Resident #9 stated he/she was pissed that staff would not offer to assist with bathing routinely, and on the limited occasion when staff did offer to assist him/her, it was just with washing up at the sink in his/her room and not his/her preferred shower. Further interview revealed he/she felt him/herself shutting down and withdrawing from activities he/she used to enjoy and find pleasure in because he/she felt dirty and ashamed, and did not want to interact with other people. 2. Review of Resident #4's medical record revealed, the facility admitted Resident #4 on 05/01/17 with [DIAGNOSES REDACTED]. Review of Resident #4's Admission Assessment, dated 05/01/17, revealed the resident's bathing request and preference was three (3) bed baths a week in the mornings. Further review revealed, Sunday, Tuesday and Friday were the days of the week the Resident preferred to bathe. Review of Resident #4's Quarterly MDS Assessment, dated 10/20/18, revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Continued review of the MDS Assessment revealed the facility assessed Resident #4 to require extensive assistance of one (1) person physical assistance in the areas of dressing, toileting and personal hygiene. Further review revealed the facility assessed Resident #4 to require total dependence of one (1) person physical assist for bathing. Review of Resident #4's Comprehensive Care Plan, initiated 06/02/17, revealed a focus problem of Physical Function Deficit and Self-Care Impairment with a goal initiated on 10/03/18 stating the resident would maintain the current level of physical functioning, be clean, dry, well nourished, groomed and dressed and odor free. Interventions included: to encourage choices with care and to provide assist with ADLs as indicated. Review of the facility's bathing/shower records for (MONTH) (YEAR) revealed, a Documentation Survey Report, for Resident #4. Continued review revealed, the resident preferred day shift bed baths. Further review revealed Resident #4 received a bath on 08/01/18, 08/08/18, 08/25/18 and 08/29/18. Review of the CNA Bath and Skin Reports, revealed Resident #4 received a bed bath on 08/04/18, 08/11/18, 08/18/18, 08/22/18 and refused on 08/15/18. Per facility documentation, Resident #4 requested three (3) bed baths per week; however, received eight (8) bath/showers for the entire month of (MONTH) (YEAR). Review of the facility's bathing/shower records for (MONTH) (YEAR), revealed a Documentation Survey Report, for Resident #4. Continued review revealed the resident preferred day shift bed baths. Further review revealed Resident #4 received a bed bath on 09/05/18, 09/08/18, 09/12/18 and 09/26/18. Review of the CNA Bath and Skin Reports, revealed Resident #4 received a bed bath on 09/15/18, 09/19/18, 09/22/18 and 09/29/18. Per facility documentation, Resident #4 requested three (3) bed baths per week; however, received eight (8) bed bath for the entire month of (MONTH) (YEAR). Review of the facility's bathing/shower records for (MONTH) (YEAR), revealed a Documentation Survey Report for Resident #4. Continued review revealed Resident #4 received a bath on 10/03/18 and 10/06/18. Review of the CNA Bath and Skin Reports, revealed Resident #4 received a bed bath on 10/13/18, 10/18/18 and 10/21/18. Per facility documentation, Resident #4 requested three (3) bed baths per week; however, received five (5) bed baths for the entire month of (MONTH) (YEAR). Observation of Resident #4, on 10/29/18 at 9:29 AM, revealed, he/she was in bed wearing a gown. Interview with Resident #4, on 10/29/18 at 9:29 AM, revealed, he/she required a maxi lift to transfer and on some days staff would not get him/her out of bed due to not having enough staff. Continued interview revealed over the weekend, he/she did not receive a bath because the facility was short of staff and there was mostly agency staff. Per interview, Resident #4 did not receive the three (3) bed baths per week because the facility was short of staff. Further interview revealed he/she felt dirty and bad like I don't count, like I'm unhuman and don't deserve respect. 3. Review of Resident #11's medical record revealed the facility admitted the resident on 12/01/17 with [DIAGNOSES REDACTED]. Review of Resident #11's Admission Assessment, dated 12/01/17, revealed the resident preferred to receive showers three (3) times a week on Sundays, Tuesdays, and Thursdays during the evening. Review of Resident #11's Quarterly MDS Assessment, dated 09/26/18, revealed the facility assessed the resident as having a BIMS score of thirteen (13) out of fifteen (15), indicating the resident was cognitively intact. Continued review revealed the facility assessed Resident #11 to require extensive assistance of one (1) person physical assist for dressing, toileting and personal hygiene. Further review revealed the facility assessed Resident #11 to require total assistance of one (1) person physical assist for bathing. Review of Resident #11's Comprehensive Care Plan, revealed a focus of Physical Functioning Deficit, initiated on 12/14/17. The goal initiated 08/05/18 and revised on 10/09/18, revealed the resident would maintain current range of motion (ROM), and maintain current level of physical functioning. Interventions implemented on 12/14/17 included: encouraging choices with care, inspect skin with care, report reddened areas, rashes, bruising, or open areas, maxi lift for transfers, monitor and report changes in physical functioning ability, nail care as needed, turning a positioning every two (2) to three (3) hours, toileting assistance of two (2) and praise efforts at participation. Review of the facility's bathing/shower records for (MONTH) (YEAR), revealed a Documentation Survey Report for Resident #11. Continued review revealed Resident #11 received a shower on 08/14/18. Review of the CNA Bath and Skin Reports, revealed Resident #11 received a shower on 08/01/18, bed bath on 08/04/18, a shower on 08/08/18, a bed baths on 08/11/18, 08/15/18, 08/18/18 and 08/22/18. Per facility documentation, Resident #11 requested three (3) showers per week; however, received three (3) showers and five (5) bed baths for the entire month of (MONTH) (YEAR). Review of the facility's bathing/shower records for (MONTH) (YEAR), revealed a Documentation Survey Report for Resident #11. Continued review revealed no documented bath/shower for (MONTH) (YEAR). Review of the CNA Bath and Skin Reports, revealed Resident #11 received a bed bath on 09/01/18, 09/12/18, 09/19/18, 09/26/18 and received a shower on 09/05/18, 09/08/18, 09/15/18 and 09/29/18. Per facility documentation, Resident #11 requested three (3) showers per week; however, received four (4) showers and four (4) bed baths for the entire month of (MONTH) (YEAR). Review of the facility's bathing/shower records for (MONTH) (YEAR), revealed a Documentation Survey Report for Resident #11. Continued review revealed, no documented bath/showers provided. Review of the CNA Bath and Skin Reports, revealed a bed bath was provided on 10/21/18. Per facility documentation, Resident #11 requested three (3) showers per week; however, received one (1) bed bath for the entire month of (MONTH) (YEAR). Observation of Resident #11, on 10/24/18 at 9:53 AM, revealed the resident was in bed with the breakfast meal on the bedside table. Continued observation revealed the resident was wearing a gown with food on the front of the gown. Interview with Resident #11, on 10/24/18 at 9:53 AM, revealed he/she had requested to receive a shower three (3) times a week; however, was not receiving them. Continued interview revealed he/she was not even receiving a bath or shower two (2) time per week. He/she stated, he/she usually preferred to eat meals in the dining room for socialization, but did not want to eat in the dining room the last two (2) days due to not receiving baths/showers. Per interview, when he/she did not receive a bath/shower at least twice a week, he/she felt dirty and ashamed and this affected his/her desire to be around other people. Resident #11 stated, his/her favorite activity was bingo; however, he/she had not gone to bingo in a few weeks due to being embarrassed about not receiving a bath. 4. Review of Resident #16's medical record revealed the facility admitted the resident on 01/25/16 with [DIAGNOSES REDACTED]. Review of Resident #16's Quarterly MDS Assessment, dated 07/27/18, revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Continued review of the MDS Assessment, revealed the facility assessed the resident as requiring extensive assistance of one (1) person physical assist with dressing, toileting and personal hygiene. Further review revealed bathing for Resident #16 did not occur during the seven (7) day look back period. Review of Resident #16's Comprehensive Care Plan, revealed a focus problem of Physical Functioning Deficit related to Self-Care Impairment, initiated 02/03/16. The goal, initiated 06/14/16 and revised 08/02/18, stated the resident would maintain his/her current level of physical functioning, and maintain current range of motion (ROM). The interventions included: encourage choices with care, maxi lift for transfers with assist of one (1) to two (2) staff as indicated and provide assistance with ADLs as indicated. Review of the facility's bathing/shower records for (MONTH) (YEAR), revealed a Documentation Survey Report for Resident #16. Continued review revealed, Resident #16 received a bed bath on 08/11/18. Review of the CNA Bath and Skin Reports, revealed Resident #16 refused a bath or shower on 08/02/18, 08/04/18 and 08/20/18. Per facility documentation, Resident #16 received one (1) bed bath for the entire month of (MONTH) (YEAR). Review of the facility's bathing/shower records for (MONTH) (YEAR) revealed, a Documentation Survey Report for Resident #16. Continued review revealed no documented baths or showers for (MONTH) (YEAR). Review of the CNA Bath and Skin Reports, revealed Resident #16 received a bed bath on 09/08/18, 09/30/18 and refused on 09/01/18, 09/06/16, 09/14/18, 09/15/18, 09/20/18 and 09/22/18. Per facility documentation, Resident #16 received two (2) bed baths for the entire month of (MONTH) (YEAR). Review of the facility's bathing/shower records for (MONTH) (YEAR), revealed a Documentation Survey Report for Resident #16. Continued review revealed, no documented baths or showers for (MONTH) (YEAR). Review of the CNA Bath and Skin Reports, revealed Resident #16 received a bed bath on 10/20/18 and refused on 10/04/18 and 10/06/18. Per facility documentation, Resident #16 received one (1) bed bath the entire month of (MONTH) (YEAR). Observation of Resident #16, on 10/25/18 at 1:40 PM. revealed the resident was in his/her room sitting in the wheel chair. There was a stop sign at the entrance to the resident door. Interview with Resident #16, on 10/25/18 at 1:40 PM, revealed he/she did not receive two (2) showers a week as requested and preferred. Per interview, Resident #16 stated he/she was not offered baths/showers twice per week. He/she stated, he/she often refused baths when asked, because he/she felt the staff did not care enough about him/her to regularly ask about showering. He/she further stated, he/she had refused baths because the facility had mostly agency staff who were not familiar with him/her and his/her wounds and bathing preferences of taking showers. He/she stated, when he/she did not receive showers or was not offered a shower it was very upsetting and made him/her feel depressed and he/she had a decreased desire to leave his/her room. 5. Review of Resident #3's medical record revealed the facility admitted the resident on 05/31/18 with [DIAGNOSES REDACTED]. Review of Resident #3's Admission Assessment, dated 05/31/18, revealed Resident #3's bathing preference was two (2) showers a week in the mornings on Monday and Thursday. Review of Resident #3's Quarterly MDS Assessment, dated 07/30/18, revealed the resident was assessed by the facility as having a BIMS score of 10 (ten) out of fifteen (15) indicating moderate cognitive impairment. Continued review of the MDS Assessment revealed the facility assessed Resident #3 to require limited assistance of one (1) person physical assist for dressing and extensive assistance of one (1) person physical assist for toileting and personal hygiene. Additional review revealed bathing did not occur during the seven (7) day look back period. Review of the Comprehensive Care Plan, revealed a focus problem of Physical Functioning Deficit related to Impaired Mobility and Self-Care Impairment initiated on 06/11/18. Review of the goal initiated on 06/11/18, revised 09/21/18, revealed the resident would improve current level of physical functioning. Interventions included: encourage choice with care, personal hygiene and dressing assistance of one (1), toileting assistance and transfer assistance of one (1) or two (2), and to praise efforts at participation. Review of the facility's bathing/shower records for (MONTH) (YEAR) revealed, a Documentation Survey Report for Resident #3. Continued review revealed the resident preferred two (2) showers per week that would be provided on Tuesday and Friday; however, there was no documentation on the report that Resident #3 received a bath/shower for (MONTH) (YEAR). Review of the CNA Bath and Skin Reports, revealed Resident #3 received a bath on 08/04/18, 08/11/18, 08/22/18, 08/22/18 and a shower on 08/15/18. Per facility documentation, the resident refused a bath or shower on 08/01/18 and 08/08/18. Per facility documentation, Resident #3 requested two (2) showers per week; however received one (1) shower and four (4) baths for the entire month of (MONTH) (YEAR). Review of the facility's bathing/shower records for (MONTH) (YEAR) revealed, a Documentation Survey Report for Resident #3. Continued review revealed no documentation on the report that Resident #3 received a bath/shower for (MONTH) (YEAR). Review of the CNA Bath and Skin Reports, revealed Resident #3 received a shower on 09/03/18, a bath on 09/05/18, a shower on 09/19/18, a bath on 09/22/18 and refused bathing on 09/15/18. Per facility documentation, Resident #3 requested two (2) showers per week; however, received two (2) bed baths and two (2) showers for the entire month of (MONTH) (YEAR). Review of the facility's bathing/shower records for (MONTH) (YEAR) revealed a Documentation Survey Report for Resident #3. The Report revealed no documented evidence Resident #3 received a bath/shower for the month of October. Review of the CNA Bath and Skin Reports, revealed Resident #3 received a bath on 10/10/18, 10/13/18 and 10/17/18. Per facility documentation, Resident #3 requested two (2) showers per week; however, received three (3) bath for the entire month of (MONTH) (YEAR). Observation of Resident #3, 10/22/18 at 9:32 AM, revealed the resident was lying in bed under a blanket. Continued observation revealed the resident's bedding was wet with a yellow shaded substance. Interview with Resident #3, on 10/22/18 at 9:32 AM, revealed the resident reported she had urinated on his/her self and was not feeling well. Continue interview revealed things were fair to midland. 6. Review of Resident #7's medical record revealed the facility readmitted the resident on 05/02/18 with [DIAGNOSES REDACTED]. Review of Resident #7's Admission Assessment, dated 05/02/18, revealed the resident requested a preferred two (2) bed baths per week to be done on Tuesday and Friday afternoons. Review of Resident #7's Quarterly MDS Assessment, dated 09/18/18, revealed the facility assessed the resident to be moderately cognitively impaired with short term and long term memory problems. Continued review of the MDS Assessment, revealed the facility assessed the resident to require total dependence of one (1) person physical assist with toileting, personal hygiene and bathing. Review of Resident #7's Comprehensive Care Plan, initiated 05/15/18, revealed a focus area of a Physical Functioning Deficit related to Mobility Impaired, Range of Motion Limitations of upper and lower extremities, Self Care Impairment, and Impaired Intellectual Disability with Altered Safety Needs. Review of the goal, initiated 05/15/18, revealed the resident would maintain current level of functioning. The interventions included: to encourage choices with care, inspect skin with care and report reddened areas, rash, bruising, or open areas, monitor and report changes in physical functioning ability, nail care as needed and to praise efforts at participation. Review of the facility's bathing/shower records for (MONTH) (YEAR), revealed a Documentation Survey Report for Resident #7. Review of the Report, revealed a bed bath was provided on 08/14/18. Review of the CNA Bath and Skin Reports, revealed Resident #7 received a bed bath on 08/01/18, 08/04/18, 08/08/18, 08/11/18, 08/18/18/ and 08/22/18. Per facility documentation, Resident #7 requested two (2) bed baths per week; however, received seven (7) bed baths for the entire month of (MONTH) (YEAR). Review of the facility's bathing/shower records for (MONTH) (YEAR), revealed a Documentation Survey Report for Resident #7. Continued review revealed per the Report, the resident received a bed bath on 10/05/18, 10/06/18 and 10/17/18. Review of the CNA Bath and Skin Reports, revealed Resident #7 received a shower on 10/03/18. Per facility documentation, Resident #7 requested two (2) bed baths per week; however, received three (3) bed baths and one (1) shower for the entire month of (MONTH) (YEAR). Observation of Resident #7, on 10/22/18 at 11:00 AM, revealed the resident was in bed lying on his/her back. Continued observation revealed the resident was wearing a gown that was wet at the neckline. 7. Review of Resident #10's closed medical record revealed the facility admitted the resident on 01/06/15 with [DIAGNOSES REDACTED]. Continued review revealed Resident #10 was readmitted to the facility from an acute care hospital on [DATE]. Further review revealed Resident #10 was discharged from the facility on 10/05/18. Review of Resident #10's Admission Assessment, dated 02/13/18, revealed the resident requested and preferred two (2) showers or bed baths per week on Monday and Thursday morning. Review of Resident #10's Quarterly MDS Assessment, dated 09/10/18, revealed the facility assessed the resident as severely impaired in his/her ability for daily decision making. Per the MDS Assessment, the resident was unable to be interviewed for a BIMS score. Staff assessment of Resident #10's memory indicated both short-term and long-term memory problems. Further review revealed the facility assessed the resident as totally dependent with one (1) person physical assist for completing Activities of Daily Living (ADLs), including dressing, personal hygiene, and bathing. Review of Resident #10's Comprehensive Care Plan, revealed a focus of Physical Functioning Deficit related to Self Care Impairment initiated on 2/14/18. Review of the goal initiated on 02/14/18, revealed the resident would maintain the current level of physical function. The interventions included: encouraging choices with care, maxi lift for transfers, personal hygiene assistance of one (1), and provide assistance with ADLs as indicated and monitor and report changes in physical functioning ability. Review of the facility's bathing/shower records for (MONTH) (YEAR), revealed a Documentation Survey Report for Resident #10. Continued review revealed the resident received no documented baths for (MONTH) (YEAR). Review of the CNA Bath and Skin Reports, revealed Resident #10 received a bed bath on 08/07/18, 08/10/18 and 08/14/18. Per facility documentation, Resident #10 requested two (2) showers or bed baths per week; however, received three (3) bath/showers for the entire month (MONTH) (YEAR). Review of the facility's bathing/shower records for (MONTH) (YEAR), revealed a Documentation Survey Report for Resident #10. Continued review revealed per the Report, there was no documented baths for the month of (MONTH) (YEAR). Review of the CNA Bath and Skin Reports, revealed Resident #10 received a bed bath on 09/07/18, on 09/11/18 and 09/18/18. Per facility documentation, Resident #10 requested two (2) showers or bed baths per week; however, received three (3) bath/showers for the entire month of (MONTH) (YEAR). Review of the facility's bathing/shower records for (MONTH) (YEAR) revealed, a Documentation Survey Report for Resident #10. Continued review revealed no documented baths during (MONTH) prior to Resident #10's discharge on 10/05/18. 8. Review of Resident #1's closed medical record revealed the facility admitted the resident on 05/26/17 with [DIAGNOSES REDACTED]. Resident #1 was discharged from the facility on 10/15/18. Review of Resident #1's Admission Assessment, dated 05/26/17, revealed the resident requested and preferred three (3) showers per week in the mornings. Review of Resident #1's Quarterly MDS Assessment, dated 07/19/18, revealed the facility assessed the resident as having a BIMS score of 10 (ten) out of fifteen (15), indicating moderate cognitive impairment. Continued review of the MDS Assessment, revealed the facility assessed the resident as requiring extensive assistance of one (1) person physical assist for dressing, toileting and personal hygiene. Further review revealed the facility assessed the resident to require total assistance of one (1) person physical assist for bathing. Review of the Comprehensive Care Plan, revealed a focus problem of Physical Functioning Deficit and Self-Care Impairment was initiated on 07/10/17. A goal was initiated on 01/10/18, for the resident to improve current level of physical functioning. Interventions for this goal included: encourage choice with care and to provide assistance with ADLs as indicated. Review of the facility's bathing/shower records for (MONTH) (YEAR), revealed a Documentation Survey Report for Resident #1 which revealed no documented evidence the resident received a bath/shower for (MONTH) (YEAR). Review of the CNA Bath and Skin Reports, revealed Resident #1 received a bed bath on 08/03/18, a shower on 08/07/18 and a bath on 08/10/18 and 08/21/18. Per facility documentation, Resident #1 requested three (3) showers per week; however, received one (1) shower and three (3) bath/bed baths for the entire month of (MONTH) (YEAR). Review of the facility's bathing/shower records for (MONTH) (YEAR), revealed a Documentation Survey Report for Resident #1. Continued review revealed the resident preferred showers; however, there was no documentation on the Report that Resident #1 received a bath/shower for (MONTH) (YEAR). Review of the CNA Bath and Skin Reports, revealed Resident #1 received a bed bath on 09/04/18, 09/07/18, 09/11/18, 09/14/18, 09/25/18 and 09/28/18. Per facility documentation, Resident #1 requested three (3) showers p

Based on observation, interview, record review, and review of the facility's Policy, it was determined the facility failed to provide necessary treatment and care related to vascular ulcers/diabetic ulcers for one (1) of thirty-nine (39) sampled residents (Resident #9). Interview with Director of Nursing (DON) #1, revealed staff nurses were to complete weekly Skin Assessments and the facility's Wound Nurse was to complete weekly Wound Evaluations on all wounds. Resident #9 developed several vascular/diabetic wounds between 05/22/18 and 07/18/18; however, record review revealed there was no documented evidence of consistent Skin Assessments, or monitoring of Resident #9's wounds. Per record review, the resident did not receive Wound Evaluations for periods as long as forty-one (41) days. In addition, the facility completed a Skin Assessment on 05/28/18; however, there was no documented evidence of further Skin Assessments prior to the Wound Clinic finding unidentified Wounds on 07/05/18, including a diabetic/venous ulcer to the resident's right lateral foot which measured 10 centimeters (cm) length x 6.5 cm width x 0.2 cm depth and was described as 67% to 100% necrosis; and a diabetic/venous ulcer to the resident's right plantar foot measuring 13 cm length x 7.0 cm width x 0.2 cm depth and was described as 67% to 100% necrosis. Further, most Wound Evaluations were completed by the Wound Clinic or the Provider, as the Wound Nurse only completed Wound Evaluations sporadically. Also, treatments were not consistently ordered when a new wound was identified. Per record review, a new venous wound to the resident's dorsal right outer foot was identified on 07/18/18 measuring 2.0 cm length x 2.2 cm width x 0.2 cm depth, and was described as 25% [MEDICATION NAME], 25% granulation and 50% slough. However, there was no documented evidence of a treatment for [REDACTED]. Furthermore, there was no documented evidence treatments were administered as per physician's orders [REDACTED].#9, this was due to a staffing shortage. Actual Harm was identified. (Refer to F-580, F-657, F-659, and F-725) The findings include: Review of the facility's Skin System Policy, undated, revealed the facility would provide necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for residents. Continued review revealed all residents would be assessed with [REDACTED]. Further, upon identification of skin/wound impairment the nurse would complete a Situation Background Action Results (SBAR) Note, and notify the Skin Committee of the changes in the resident's skin condition for additional oversight and monitoring. Per Policy, the physician would evaluate and document the progress of wound healing during resident visits. Interview with DON #1 on 10/24/18 at 2:50 PM, revealed the facility did not have a specific Wound Policy other than the Skin System Policy and Procedure. Review of Resident #9's Electronic Medical Record (EMR), revealed the facility readmitted the resident on 05/24/17 with [DIAGNOSES REDACTED]. Review of the Situation Background Action Response (SBAR), dated 05/22/18, completed by Licensed Practical Nurse (LPN) #5, revealed Resident #9 had a new open area to the right lower leg, and orders for treatment to the right lower leg were received. However, there was no documented evidence of a Wound Evaluation with measurements and description of the wound noted on 05/22/18. Review of Resident #9's physician's orders [REDACTED]. Review of the Comprehensive Care Plan (CCP), dated 05/25/17, revised 05/22/18 revealed the resident was at risk for pressure ulcers and had an actual vascular area on the right lower extremity due to requiring assistance in bed mobility, impaired balance, weakness, pain, impaired cardiac and perfusion, impaired decisions, chronic medication use, DM, and [MEDICAL CONDITION], and routine [MEDICAL TREATMENT]. The goal initiated on 05/25/17, revised 08/29/18, revealed the resident's skin would remain intact. Interventions included: conduct weekly skin inspections, keep skin as dry as possible initiated 05/25/17; provide treatments as ordered, and provide treatments to right lower extremity as ordered, initiated 06/13/17. Review of Resident #9's Annual Minimum Data Set (MDS) Assessment, dated 05/24/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating intact cognition. Additional review revealed the facility assessed the resident as requiring limited assistance of one (1) staff with bed mobility, transfer, and toileting. Per the MDS Assessment, the facility assessed the resident as having one (1) venous or arterial ulcer present and receiving application of non-surgical dressings and applications of ointments/medications other than to his/her feet. Review of the Skin assessment dated [DATE], revealed Resident #9 had open areas to the lower extremities with treatment in progress. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR), revealed the intervention to apply [MEDICATION NAME] Cream 1% to the right lower leg and cover with abdominal pad and wrap with kerlix every day and night shift was not signed on 05/26/18 and 05/27/18, to indicate the treatments were completed. Review of the Wound Evaluation Flow Sheet, dated 06/14/18, completed by LPN #4/Wound Nurse, revealed Resident #9 had a right lower leg arterial wound, identified on 06/04/18 (however, per the record the wound was identified on 05/22/18). Additional review revealed the wound measured 2.2 centimeters (cm) length x 1.3 cm width. Continued review revealed the wound was weeping serous exudate and the outer skin on the shin had peeled off, and the wound bed was described as 100% granulation. This was the first Wound Evaluation with a description and measurement of the right leg wound, although the wound was identified on 05/22/18, twenty-three (23) days earlier. Review of the Progress Note dated 06/21/18, at 2:35 AM, completed by LPN #14/agency nurse, revealed Resident #9's right foot second and third toes had drainage, and the skin was off. Additional review revealed a dressing and abdominal pad was applied to the toes and they were wrapped with kerlix. Further, the Provider would be notified. Review of physician's orders [REDACTED]. Review of the CCP revealed there was no revision to indicate the resident had skin impairment to the right foot second and third toes. (Refer to F-657) In addition, there was no documented evidence of a Wound Evaluation to include description and measurements of the wounds to the resident's right foot second and third toes, and there was no documented evidence of further skin assessments related to these wounds. Review of the (MONTH) (YEAR) TAR, revealed treatments were not signed to indicate they were administered per physician's orders [REDACTED]. Review of Resident #9's physician's orders [REDACTED]. Review of the (MONTH) (YEAR) TAR, revealed treatments were not signed to indicate they were administered per physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Review of the (MONTH) (YEAR) TAR, revealed treatments were not signed to indicate they were administered per physician's orders [REDACTED]. Review of the Progress Note, dated 07/02/18, at 6:28 AM, completed by LPN #13, revealed the resident's sock on the left foot was moist, the sock was removed, and the foot was washed. Continued review revealed a dry dressing was applied to the left foot and non-skid socks were applied. Further, the resident was educated on the importance of keeping feet elevated and dry. However, there was no documented evidence of an assessment of the left foot which was bandaged, per this Note. In addition, there was no documented evidence the Provider was notified of the change in the resident's left foot skin integrity on this date in order to obtain an order for [REDACTED]. The State Agency Representative called LPN #13, on 11/05/18 at 2:04 PM, and left a message to return the call; however, the call was not returned. There had been no Skin Assessments for Resident #9 documented since 05/28/18 (over a month), prior to the Wound Clinic identifying new wounds on 07/05/18. Review of the Wound Assessment, dated 07/05/18, completed by the Wound Care Clinic, revealed Resident #9 had a diabetic wound/ulcer to his/her right lateral foot that gradually appeared and was acquired on 06/07/18. Additional review revealed the venous ulcer was open, with a medium amount of purulent yellow/brown/green exudate. Further review revealed the measurements were 10 cm length x 6.5 cm width x 0.2 cm depth and the wound was described as 67% to 100% necrosis. However, there was no documented evidence in the medical record to support the wounds development on 06/07/18 as stated in this Assessment. In addition, this was the first identification, measurement, and description of this wound, per record review. Additional review of the Wound Assessment, dated 07/05/18, completed by the Wound Care Clinic, revealed Resident #9 had a diabetic wound/ulcer to his/her right plantar foot that gradually appeared and was acquired on 06/07/18. Additional review revealed the venous ulcer was open, with a medium amount of purulent yellow/brown/green exudate. Further review revealed the measurements were 13 cm length x 7.0 cm width by 0.2 cm depth and the wound was described as 67% to 100% necrosis. Further review revealed the skin surrounding the wound was macerated. However, there was no documented evidence in the medical record to support the wounds development on 06/07/18, as stated in this Assessment. In addition, this was the first identification, measurement, and description of this wound, per the medical record. Review of the Wound Assessment, dated 07/05/18, completed by the Wound Care Clinic, revealed Resident #9 had a venous ulcer to his/her right anterior lower leg that gradually appeared and was acquired on 06/07/18. Additional review revealed the diabetic ulcer was open, with a large amount of purulent yellow/brown/green exudate. Continued review revealed the measurements were 0.9 centimeters length x 0.3 cm width x 0.1 cm depth and the wound was described as having 34% to 66% necrosis. However, there was no documented evidence to support this wounds development on 06/07/18. This Assessment was completed twenty-one (21) days after the last Wound Evaluation for this right anterior wound, on 06/14/18. There was no documented evidence of an assessment by the Wound Care Clinic on 07/05/18, related to the alteration in skin integrity which was noted in the Progress Note dated 07/02/18. Although the resident's right lateral foot wound and right plantar foot wound was identified on 07/05/18, there was no documented evidence of physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Additional review of Resident #9's physician's orders [REDACTED]. Further review revealed an order to cleanse right plantar foot with Normal Saline and apply [MEDICATION NAME], then apply dry gauze, and wrap with Kerlix and Ace Wrap from toes to knees, every day and evening shift. Further review of physician's orders [REDACTED]. There was no documented evidence of a Skin Assessment from 05/28/18 until 07/09/18, over a month. Review of the Skin assessment dated [DATE], revealed the resident had wounds to his/her lower extremity,which were being treated by Outpatient Wound Care. Further the left plantar foot had an opening and was draining and Wound Care would address with next visit. Review of the (MONTH) (YEAR) TAR, revealed treatments were not signed to indicate they were administered per physician's orders [REDACTED]. 07/09/18, 07/13/18, and 07/16/18 to cleanse left plantar foot with Normal Saline and apply [MEDICATION NAME] and dry gauze, then wrap with Kerlix every night shift; 07/10/18, 07/11/18, 07/12/18, 07/13/18, 07/16/18 to cleanse the right anterior lower leg wound with Normal Saline, apply Collagen-Puracol/Puracol Silver (AG) and apply dry dressing, then wrap with Kerlix and Ace wrap from toes to knees every day shift; 07/10/18, 07/11/18, 07/12/18, 07/13/18, 07/16/18, and 07/17/18, to clean the wound to the right lateral foot with Normal Saline, apply [MEDICATION NAME] and dry dressing, then wrap with kerlix and Ace wrap from toes to knees every day, and evening shift; 07/10/18, 07/11/18, 07/12/18, 07/13/18, 07/17/18, to clean wound to right plantar foot with Normal Saline and apply [MEDICATION NAME] and a dry gauze, then wrap with a kerlix and Ace wrap from toes to knees every day and evening; and 07/12/18, 07/13/18, 07/17/18, to cleanse areas between toes, apply [MEDICATION NAME] Silver (AG) between toes and cover with a 4 x 4 gauze daily. Review of the Wound Culture lab results, dated 07/16/18, revealed the right foot had a heavy growth of pseudomonas aeruginosa (Aerobic bacteria). Further review revealed a physician's orders [REDACTED]. The CCP was not revised related to the right plantar foot wound, right lateral foot wound, or the wound infection to the right foot with treatment of [REDACTED]. Review of the Wound Evaluation, dated 07/18/18, completed by LPN #4/Wound Nurse, revealed Resident #9 had an arterial weeping area to his/her right outer shin, identified on 06/04/18 per the Wound Care Center (however, per record review LPN #5 identified this wound on 05/22/18). Additional review revealed the outer skin on the shin had peeled off, serous exudate was noted, and the wound was 100% granulation. However, there were no measurements documented on the Wound Evaluation for the arterial wound to the right lower leg. This was the first Wound Evaluation of this wound documented by the facility since 07/05/18, thirteen (13) days ago. Further, this was the last documented assessment of the right lower leg arterial wound and there was no documented evidence in the medical record the wound resolved/healed or revision to the CCP related to the changes to the right lower leg's skin integrity. (Refer to F-657) Review of the Wound Evaluation dated 07/18/18, for the right plantar foot ulcer, completed by LPN #4/Wound Nurse, thirteen (13) days after the last Wound Evaluation for this ulcer, on 07/05/18, revealed the wound to the right bottom foot was a venous wound. Additional review revealed the wound measurements were 3.7 cm length x 2.4 cm width x 0.2 cm depth. Continued review revealed the wound was 25% granulation, 75% slough. Further, the wound measurements had decreased in size greatly since the Wound Care Clinic Wound Assessment on 07/05/18. However, there was no documented evidence the Provider was notified of the improvement in the wound measurements. (Refer to F-580) Further, there was no documented evidence LPN #4/Wound Care Nurse assessed the right lateral foot wound on 07/18/18. Continued review of Wound Evaluation dated 07/18/18, completed by LPN #4/Wound Nurse, revealed Resident #9 had a venous wound to the top of his/her right outer foot. Additional review revealed the wound measurements were 2.0 cm length x 2.2 cm width x 0.2 cm depth, and the wound was identified on 07/10/18. Further the wound had serous drainage and was 25% [MEDICATION NAME], 25% granulation and 50% slough. However, there was no documented evidence in the medical record to support the wounds development on 07/10/18. This was the first documented identification and assessment of the venous wound to the top right outer foot in the medical record. Also, there was no documented evidence the Physician was notified of this wound in order to obtain treatment orders, and no documented evidence the CCP was revised related to the wound to the top of the resident's right outer foot. (Refer to F-580 and F-657) There was no documented evidence of Wound Evaluations related to the resident's right lateral foot ulcer after the Wound Clinic identified the area on 07/05/18, until 07/19/18, fourteen (14) days later, when the Wound Clinic again evaluated the wound. Review of the Wound Evaluation, dated 07/19/18, completed by the Wound Care Clinic, revealed Resident #9 had a right lateral foot diabetic wound which measured 8.0 cm length x 13.5 cm width x 0.1 cm depth and was described as having a large amount of purulent yellow/brown/ green exudate. Continued review revealed the wound was 1% to 33% granulation and 67% to 100% necrotic. Further review revealed the wound had deteriorated since the Wound Assessment on 07/05/18, by the Wound Care Clinic. However, there was no documented evidence the Provider was notified the wound had deteriorated. (Refer to F-580) Review of the Wound Evaluation, date 07/19/18, completed by the Wound Care Clinic, revealed Resident #9 had a right plantar foot diabetic wound measuring 16.5 cm length x 6.5 cm width x 0.1 cm depth. The wound was described as having a large amount of purulent yellow/brown/ green exudate. Continued review revealed the wound was 1% to 33% granulation and 67% to 100% necrotic. Further, the wound had deteriorated since the 07/18/18 Wound Evaluation completed by LPN #4/Wound Care Nurse and the Wound Assessment, on 07/05/18, by the Wound Clinic. However, there was no documented evidence the Provider was notified the wound had deteriorated. (Refer to F-580) Review of the Wound Evaluation, dated 07/19/18, completed by the Wound Care Clinic, revealed Resident #9 had a left plantar foot diabetic wound. Additional review revealed the wound measured 7.5 cm length x 5.5 cm width x 0.1 cm depth and was described as having a medium amount purulent yellow/brown/green exudate. Continued review revealed the wound was 67% to 100% necrotic. This was the first time the left plantar foot diabetic wound was assessed with [REDACTED]. The CCP was not revised to include the skin impairment to the left plantar foot. (Refer to F-657) Additional review of the medical record, revealed there was no documented evidence the Wound Care Clinic assessed the wound to the top of the right lateral foot on 07/19/18. In addition, there was no documented evidence the Wound Care Clinic assessed the vascular wound to the right lower anterior leg on 07/19/18, although there was no indication in the medical record that the wound had resolved/healed and there was still active physician's orders [REDACTED]. Further review of the (MONTH) (YEAR) TAR, revealed treatments were not signed to indicate they were administered per physician's orders [REDACTED]. 07/20/18, 07/21/18, 07/22/18, to clean the wound to the right lateral foot with Normal Saline, apply [MEDICATION NAME] and dry dressing, then wrap with kerlix and Ace wrap from toes to knees every day and evening shift; 07/20/18, 07/21/18, to clean wound to right plantar foot with Normal Saline and apply [MEDICATION NAME] and a dry gauze, then wrap with a kerlix and Ace wrap from toes to knees every day and evening; and 07/22/18, to cleanse left plantar foot with Normal Saline, apply [MEDICATION NAME], dry gauze and wrap with kerlix every day and night shift; Review of the Wound Assessment, dated 07/26/18, completed by the Wound Care Clinic, revealed the resident's right lateral foot diabetic wound measured 4.0 cm length x 13 cm width x 0.1 cm depth. Additional review revealed the wound had a medium amount of serous amber exudate and the wound bed was 33% granulation and 67% to 100% necrotic. Review of the Wound Assessment, dated 07/26/18, completed by the Wound Care Clinic, revealed the resident's right plantar foot diabetic wound was measured at 4.5 cm length x 7.0 cm width x 0.1 cm depth. Additional review revealed the wound had a medium amount of serous amber exudate and was 67% to 100% necrotic. Review of the Wound Assessment, dated 07/26/18, completed by the Wound Care Clinic, revealed the resident's left plantar foot diabetic wound measured 0.2 cm length x 1.5 cm width x 0.1 cm depth. Additional review revealed the wound had a medium amount of serous amber exudate, and was 1% to 33% percent granulation and 67% to 100% necrotic. There was no documented evidence the Wound Care Clinic evaluated the vascular wound to the top of the resident's right lateral foot, or the vascular wound to the right lower anterior leg on 07/26/18. Review of Resident #9's physician's orders [REDACTED]. However, there was no documented evidence in the medical record the right anterior lower leg wound was healed/resolved. Review of the physician's orders [REDACTED]. Continued review of the (MONTH) (YEAR) TAR, revealed treatments were not signed to indicate they were administered per physician's orders [REDACTED]. 07/27/18 and 07/30/18 to apply [MEDICATION NAME] Silver (AG) between all of the toes on the right foot every day and night shift; 07/27/18, and 07/30/18 for the right lateral foot to be cleansed with Normal Saline; apply [MEDICATION NAME] and dry dressing, then wrap with kerlix and Ace wrap from toes to knees every day and evening shift; 07/27/18 07/30/18 to clean wound to right plantar foot with Normal Saline and apply [MEDICATION NAME] and a dry gauze, then wrap with a kerlix and Ace wrap from toes to knees every day and evening; and 07/30/18 to cleanse the left plantar foot with Normal Saline, apply [MEDICATION NAME], dry gauze, and wrap with kerlix every day and night shift. Review of the Wound Assessment, dated 08/02/18, completed by the Wound Care Clinic, revealed the resident's right lateral foot diabetic wound, measured 4.0 cm length x 13 cm width x 0.1 cm depth. Additional review revealed the wound had large amounts of serous amber exudate, and was 1% to 33% granulation and 67% to 100% necrotic. Additional review of the Wound Assessment, dated 08/02/18, completed by the Wound Care Clinic, revealed the Resident #9's right plantar foot diabetic wound, measured 5.3 cm length x 5 cm width x 0.1 cm depth. Additional review revealed the wound had a medium amount of serous amber exudate, had no granulation and was 67% to 100% necrotic. Further, review of the Wound Assessment, dated 08/02/18, completed by the Wound Care Clinic, revealed the resident's left plantar foot diabetic wound was healed. Continued review of the medical record revealed no documented evidence the vascular wound to the top of the right lateral foot was assessed on 08/02/18, at the Wound Care Clinic. Review of the (MONTH) (YEAR) TAR, revealed staff did not sign to indicate treatments were administered on the following dates: 08/02/18 to apply [MEDICATION NAME] AG between all toes on the right foot every day and night shift; 08/02/18, 08/03/18, 08/04/18, 08/05/18, and 08/09/18, to clean the right lateral foot wound with Normal Saline, apply [MEDICATION NAME] and a dry dressing, then wrap with kerlix and Ace Wrap from toes to knees every day and night shift; 08/02/18 to cleanse the left plantar foot with Normal Saline, apply [MEDICATION NAME] and dry gauze, then wrap with kerlix every day and night shift; and 08/02/18, 08/03/18, 08/04/18, 08/05/18, and 08/09/18 to clean the right plantar foot wound with Normal Saline, apply [MEDICATION NAME] and a dry gauze, then apply kerlix and Ace wrap from toes to knees every day and night shift. There was no documented evidence of a Skin Assessment from 07/09/18 until 08/08/18, almost a month later. Review of the Skin assessment dated [DATE], revealed the resident had treatments to the right lower leg. There was no further information related to the resident's skin. Review of the Wound Assessment, dated 08/09/18, completed by the Wound Care Clinic, revealed the resident's right lateral foot diabetic wound measured 3.7 cm length x 7.1 cm width x 0.1 cm depth. Additional review revealed the wound had a large amount of serous amber exudate, and was 1% to 34% to 66% granulation and 34% to 66% necrotic. Additional review of the Wound Assessment, dated 08/09/18, completed by the Wound Clinic, revealed Resident #9's right plantar foot diabetic wound measured 2.6 cm length x 5.0 cm width x 0.1 cm depth. Additional review revealed the wound had a large amount of serous amber exudate, and was 1% to 34% to 66 granulation and 34% to 66% necrotic. Further review of the Wound Assessment, dated 08/09/18, completed by the Wound Clinic, revealed the vascular wound to the top of the right lateral foot was not assessed. Further review if the (MONTH) (YEAR) TAR, revealed treatments were not signed to indicate they were administered per physician's orders [REDACTED]. 08/10/18, 08/12/18, 08/13/18, 08/14/18, and 08/15/18 to clean the right lateral foot wound with Normal Saline, apply [MEDICATION NAME] and dry dressing, then wrap with kerlix and Ace wrap from toes to knees every day and night shift; 08/12/18, 08/13/18, 08/14/18, and 08/15/18 to clean the right plantar foot wound with Normal Saline, apply [MEDICATION NAME] and a dry dressing, then apply kerlix and Ace wrap from toes to knees every day and night shift; 08/18/18 and 08/19/18 to clean right lateral foot wound with Normal Saline, apply [MEDICATION NAME] and a dry dressing, then wrap with kerlix and Ace wrap from toes to knees every day and night shift; and 08/18/18 and 08/19/18 to clean right plantar foot wound with Normal Saline, apply [MEDICATION NAME] and dry gauze, then apply kerlix and Ace wrap from toes to knees every day and night shift. Review of Resident #9's physician's orders [REDACTED]. Continued review revealed an order, dated 08/19/18, to clean right lateral foot with Normal Saline, apply ¼ strength Dakin's and cover with a dry gauze, then wrap Kerlix and Ace Wrap from toes to knees every day and night shift. Further review of physician's orders [REDACTED]. Continued review revealed an order dated 08/19/18 to clean right plantar foot with Normal Saline, apply Calcium Alginate with silver to wound bed and between toes on right foot, then cover with dry gauze and wrap with Kerlix and Ace wrap from toes to knees, every day and night shift. Continued review of the (MONTH) (YEAR) TAR, revealed treatments were not signed to indicate they were administered per physician's orders [REDACTED]. 08/23/18, 08/24/18, 08/27/18, 08/29/18, 08/30/18, and 08/31/18 to clean the right lateral foot clean wound with Normal Saline, apply ¼ strength Dakins and cover with a dry gauze, then wrap with kerlix and Ace wrap from toes to knees every day and evening shift; and 08/23/18, 08/24/18, 08/27/18, 08/29/18, 08/30/18 and 08/31/18 to clean the right plantar foot clean wound with Normal Saline, apply Calcium Alginate with silver to wound bed and between toes on the right foot; and cover with dry gauze, kerlix and Ace wrap from toes to knees every day and night shift. Review of the Wound Evaluation, dated 08/28/18, completed by the Provider, revealed the resident's right lateral foot [MEDICAL CONDITION] measured 4.2 cm length x 6.5 cm width x 0.2 cm depth. Additional review revealed the wound had a small amounts of serosanguineous exudate, and was 80% granulation and 20% slough. This was the first Wound Evaluation/Assessment of this wound since 08/09/18, nineteen (19) days prior. Review of the Wound Evaluation, dated 08/28/18, completed by the Provider, revealed the right plantar foot [MEDICAL CONDITION]'s measured 2.0 cm length x 4.5 cm width x 0.1 cm depth. Additional review revealed the wound had a small amount of serosanguineous exudate, and the wound was 70% granulation and 30% percent necrotic. This Wound Evaluation was completed nineteen (19) days after the last Wound Evaluation, on 08/09/18, for this wound. Continued review of the Wound Evaluation, dated 08/28/18, completed by the Provider, revealed the right dorsal [MEDICAL CONDITION] measurements were 2.0 cm length x 4.0 cm width x 0.1 cm depth, acquired date illegible. Additional review revealed the wound had a small amount of serosanguineous exudate. The wound was described as 70% granulation and 30% necrotic. Further, this was the first documentation and assessment of the right dorsal [MEDICAL CONDITION] since LPN 4/Wound Care Nurse identified it on 07/18/18, which was forty-one (41) days earlier. However, continued review revealed no documented evidence of physician's orders [REDACTED]. There was no documented evidence of a Skin Assessment from 08/08/18, until 09/02/18, almost a month later. Review of the Skin assessment dated [DATE], revealed there were no areas of concern. There was no further information related to the resident's skin. Review of the (MONTH) TAR revealed treatments were not signed to indicate they were administered per physician's orders [REDACTED].