Every finding on record at Greenbriar Community Care Center

Based on record review and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the resident's status for 1 (#11) of 5 (#11, #12, #13, #62, and #82) sampled residents reviewed for unnecessary medications.Review of Resident #11's Clinical Record revealed an admission date of 10/11/2021 with diagnoses, which included Abdominal Aortic Aneurysm without Rupture.Review of Resident #11's MDS with an Assessment Reference Date (ARD) of 08/21/2025 revealed in part, the following:Question N0415E1: Medications: Anticoagulant: Yes.Review of Resident #11's current Physician Orders revealed in part, the following:Start date: 10/12/2021, Aspirin Tablet Chewable 81 milligram (MG), give 1 tablet by mouth one time a day. Further review revealed no physician ordered anticoagulant.An interview was conducted on 10/01/2025 at 2:42 p.m. with S3CCC. She reviewed Resident #11's MDS with an ARD of 08/21/2025. She confirmed Question N0415E1 was coded yes, indicating Resident #11 was taking an anticoagulant, and further confirmed the coding was inaccurate.An interview was conducted on 10/01/2025 at 3:31 p.m. with S2DON. He confirmed all residents' MDS should be accurately coded for the medications they received.

Based on observation and interview, the facility failed to post the names, addresses, and telephone numbers of pertinent state agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit.This deficient practice had to the potential to affect all 159 residents residing in the facility.Findings: On 09/29/2025 at 8:15 a.m., an observation of the facility revealed no list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit.On 09/30/2025 at 1:45 p.m., a tour of the facility was conducted with S1ADM. She confirmed a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit was not posted in the facility.

Based on observations and interviews, the facility failed to ensure nurse staffing data posted on a daily basis was at the beginning of each shift and included the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care. This deficient practice had the potential to affect the 159 residents residing in the facility. On 09/29/2025 at 8:00 a.m., an observation was made of the nurse staffing hours posted at the front desk labeled scheduled and dated 09/29/2025. On 09/29/2025 at 2:26 p.m., an interview was conducted with S4AA. She stated she was responsible for posting the nurse staffing data. She stated the nurse staffing hours posted were the scheduled hours for the entire day and not the actual hours. She stated she did not post the nurse staffing hours at the start of every shift. On 09/30/2025 at 8:57 a.m. an observation was made of the nurse staffing hours posted at the front desk labeled scheduled and dated 09/30/2025. On 09/30/2025 at 2:00 p.m., an interview was conducted with S1ADM. She confirmed the nurse staffing hours posted were for the scheduled hours and not for the actual hours worked. She further confirmed the nurse staffing hours were not posted in the beginning of every shift.

52121 Based on interviews and record reviews the facility failed to ensure a resident's comprehensive plan of care was developed and implemented for 1 (#2) of 3 (#1, #2 and #3) residents reviewed for care plans. The facility failed to ensure Resident #2's care plan was developed for wandering behaviors. This deficient practice had the potential to affect the current 28 residents residing on E Hall. Findings: Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included, in part, mild intellectual disabilities. Review of Resident #2's most recent Care Plan did not address or provide interventions for Resident #2's wandering behaviors. An interview was conducted with S7CNA on 03/11/2025 at 12:54 p.m. S7CNA stated Resident #2 is known to wander into other resident rooms. S7CNA stated that redirection techniques, including art and coloring, are used as interventions when Resident #2 exhibits disruptive behaviors such as wandering or shouting. S7CNA stated the resident's care plan does not specify a need for increased supervision. An interview was conducted with Resident #3 on 03/11/2025 at 1:25 p.m. Resident #3 stated Resident #2 wandered into his room uninvited. Resident #3 did not recall any prior incidents like this. Resident #3 recalled that when staff saw Resident #2 in his room, staff immediately removed her. An interview was conducted with S5LPN on 03/13/2025 at 12:35 p.m. S5LPN stated that she is responsible for E Hall care plans. S5LPN stated she is aware Resident #2 is known to wander into other resident rooms' uninvited. S5LPN stated staff will redirect Resident #2's attention when that behavior occurred. S5LPN confirmed Resident #2 should be care planed for these behaviors and was not. An interview was conducted with S2DON on 03/13/2025 at 1:45 p.m. He reviewed Resident #2's care plan and confirmed Resident #2 was not care planned for wandering behaviors and should have been.

Based on record reviews and interviews, the facility failed to ensure an allegation of sexual abuse was reported to the administrator, state agency and the local law enforcement in the appropriate time frame for 1 (#1) of 3 ( #1, #2, and #3) residents reviewed for abuse. Findings: Review of the facility's policy titled, Abuse Components Plan Elder Justice Act and Affordable Care Act with a revision date of 10/24/2022, revealed, in part, the following: Identification: Immediately upon discovery of any alleged and or suspected incident of abuse ., staff is communicating a verbal report to the Charge Nurse and/or Department Head. Reporting: 1. All alleged violations involving abuse .will be reported by the Administrator or designee, to the following persons or agencies as required to provide notification: a. State agency online tracking incident system. d. Law enforcement officials . 2. An alleged violation involving abuse .will be reported immediately, but no later than: a. Two hours if the alleged violation involves abuse . Review of the clinical record for Resident #1 revealed she was admitted to the facility on [DATE]. Review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/2024, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated Resident #1 was cognitively intact. Review of the Nurse's Notes for Resident #1 dated 02/11/2025 at 1:44 a.m., revealed S3LPN documented Resident #1 called her into her room stating, Some man is in here, feeling me down. Review of the Incident/Accident Log dated December 2025 through present revealed no entry for Resident #1 for 02/11/2025. On 03/12/2025 at 8:40 a.m., an interview was conducted with S3LPN. She confirmed she worked 02/11/2025 from 11:00 p.m. to 7:00 p.m. S3LPN stated Resident #1 reported a man was in her room, lifted her shirt up and was feeling her breast. S3LPN stated Resident #1 reported the man was in her room for 15 minutes. S3LPN stated she did not feel like this was an emergency and did not report this allegation immediately to her supervisor. She stated she reported this allegation of sexual abuse to S4LPN on 02/11/2025 at 6:00 a.m. by telephone. On 03/12/2025 at 9:30 a.m., an interview was conducted with S4LPN. S4LPN stated she was never notified of a sexual abuse allegation made by Resident #1 on 02/11/2025. She stated she would expect staff to report all sexual abuse allegations immediately to their supervisor. On 03/13/2025 at 1:45 p.m., an interview was conducted with S2DON. He stated he expected staff to report all allegations of sexual abuse immediately. He stated when Resident #1 alleged she was sexually abused to a staff member, the staff member should have reported the alleged abuse immediately to a supervisor. He confirmed he was not aware of an allegation of sexual abuse made by Resident #1 on 02/11/2025. On 03/13/2025 at 1:50 p.m., an interview was conducted with S1ADM. She stated she expected staff to report all allegations of sexual abuse immediately. She stated when Resident #1 alleged she was sexually abused to a staff member, the staff member should have reported the alleged abuse immediately to a supervisor. She confirmed she was not aware an allegation of sexual abuse was made by Resident #1 on 02/11/2025 and she did not notify the law enforcement or the state agency.

52121 Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status for 1 (#2) of 3 (#1, #2, and #3) residents reviewed for MDS. Findings: Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included, in part, mild intellectual disabilities. Review of Resident #2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/2024 revealed the following, in part: Behavioral Symptoms - Presence & Frequency: Physical behavioral symptoms directed toward others was coded as 0, which indicated the behavior was not exhibited. Review of Resident #2's Nursing Notes dated 11/25/2024 revealed the following, in part: Resident #2 was in the dining room and pulled off the head band of another resident's head and stated that it was hers. Signed by S5LPN. On 03/13/2025 at 1:32 p.m., an interview was conducted with S6SSD. S6SSD stated she was responsible for completing resident's MDS Behavior assessments. S6SSD reviewed Resident #2's nursing progress note dated 11/25/2024 indicating she pulled the head band off of another resident and stated that it was hers. S6SSD confirmed she would consider this a physical behavior. S6SSD reviewed Resident #2's Quarterly MDS with an ARD of 11/27/2024 and confirmed Resident #2 was not coded for physical behaviors and should have been. On 03/13/2025 at 1:45 P.M., an interview was conducted with S2DON. S2DON reviewed the above mentioned findings and confirmed Resident #2's MDS was not coded for physical behaviors and should have been.

52121 Based on record reviews, observation, and interviews the facility failed to revise and implement a comprehensive person-centered care plan which met the needs of 1 (#2) of 3 (#1, #2 and #3) sampled residents. Findings: Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included, in part, mild intellectual disabilities. Review of Resident #2's most recent Care Plan dated 03/10/2024 revealed the following: Problem: I have a behavior problem. I am sexually inappropriate at times and I act out when I don't get my way. Review of Resident #2's nursing progress notes, dated 11/10/2024, revealed Pt pulled up shirt showing breasts in dining area. Signed per S9LPN. An interview was conducted with S7CNA on 03/11/2025 at 12.54 P.M. S7CNA stated she had been employed at this facility for approximately six months and cares for Resident #2. S7CNA did not recall the incident noted 11/10/2024 but knew Resident #2's care plan included inappropriate sexual behaviors. S7CNA stated that redirection to a different activity, like coloring, was her intervention when Resident #2 displayed disruptive or sexually inappropriate behaviors. An interview was conducted with S5LPN on 03/13/2025 at 11:30 a.m. S5LPN confirmed she was responsible for E Hall residents' care plans. S5LPN stated she was aware of the incident on 11/10/2024 and would consider it sexual. S5LPN confirmed the care plan should have been revised after the incident and was not. An interview was conducted with S1ADM on 03/13/2025 at 12:50 P.M. S1ADM stated she reviewed video footage on 11/10/2024 and it revealed Resident #2 lifting her shirt in the common area in front of other residents. S1ADM stated this was considered a behavior. An interview was conducted with S9LPN on 03/13/2025 at 1:04 P.M. S9LPN stated she was caring for and remembered the incident on 11/10/2024. S9LPN stated Resident #2 lifted her shirt up in the common area in front of other residents. S9LPN stated Resident #2 was removed from the area and reported this to S5LPN. An interview was conducted with S2DON on 03/13/2025 at 1:45 P.M. S2DON reviewed the aforementioned incident and confirmed Resident #2's care plan should have been revised after the incident on 11/10/2024 and was not.

Based on interviews and record review the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure a medication was transcribed properly for 1 (#153) of 33 sampled residents. Findings: Review of Resident #153's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Depression and Insomnia. Review of Resident #153's Psychoactive Gradual Dose Reduction Report dated 06/11/2024 revealed the following: 1. Trazadone HCl 100mg give one tablet my mouth at bedtime. Further review revealed on 06/13/2024, S11NP selected a dose reduction was appropriate for Resident #153 and wrote a new order for Trazadone 50 mg HS. Review of Resident #153's active Physician Orders revealed the following: Start Date: 02/16/2024-Trazadone HCl 100 mg give one tablet by mouth at bedtime. Further review revealed no order for Trazadone 50 mg HS. Review of Resident #153's MAR dated June 2024 and September 2024 revealed the resident received Trazadone HCl 100mg po HS. On 09/16/2024 at 9:52 a.m., an interview was conducted with S10MR. She stated she was responsible for making sure Psychoactive Gradual Dose Reduction changes were inputted into the computer for implementation. She stated after the DON reviewed Psychoactive Gradual Dose Reduction reports, she received them and entered the changes into the computer. S10MR reviewed Resident #153's Psychoactive Gradual Dose Reduction report dated 06/11/2024 and Resident #153's active Physician's orders and confirmed she did not see the new order for Trazadone 50 mg HS and did not input it into the computer and stated she should have. On 09/16/2024 at 10:09 a.m., an interview was conducted with S3DON. S3DON stated medical records department was responsible for inputting Psychoactive Gradual Dose Reduction changes into the computer for implementation. S3DON reviewed Resident #153's Psychoactive Gradual Dose Reduction report dated 06/11/2024 and Resident #153's active Physician's orders and confirmed the new order for Trazadone 50 mg HS was not entered into the computer system and should have been. On 09/16/2024 at 11:11 a.m., a telephone interview was conducted with S11NP. She stated she expected staff to properly transcribe orders from the Psychoactive Gradual Dose Reduction reports. S11NP confirmed Resident #153 should have had a current order for Trazadone 50mg HS, not Trazadone HCl 100mg HS.

Based on observation, interviews, and record review, the facility failed to store and prepare food under sanitary conditions. The facility failed to ensure: 1. Food was properly stored and labeled in the walk-in freezer of the facility's kitchen; 2. Food was properly stored and labeled in the walk-in refrigerator of the facility's kitchen; and 3. Food was properly stored and labeled in the walk-in food storage room of the facility's kitchen. This deficient practice had the potential to affect 165 residents who were served meals from the facility's kitchen. Findings: Review of the facility's policy titled Food Receiving and Storage dated October 2017 revealed the following: 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (received and/or open date). During the initial tour of the facility's kitchen with S5DM on 09/09/2024 at 9:00 a.m., the following observations were made: Walk-In Freezer: 1 large black, plastic bag unlabeled and undated containing 2 slabs of uncooked ribs. Walk-In Refrigerator: 1 large plastic container of salad dressing opened and undated. Dry Storage Room: 22 quart plastic container of potatoes, dated opened 08/28/2024. No discard by or expiration date labeled. 16 ounce container of Ground Cinnamon opened and undated. An interview was conducted on 09/10/2024 at 12:45 p.m., S5DM verified the above observations and confirmed the facility failed to store foods under sanitary conditions. She confirmed all opened food products should be labeled with date it was opened and an expiration/discard date. She further stated she was responsible for ensuring staff complied with policy. She confirmed all previously cooked items, stored in refrigerator should be discarded in 3-4 days. An interview was conducted on 09/10/2024 at 1:05 p.m. with S1ADM. S1ADM confirmed all food storage items should be labeled, checked for both opened and expiration dates, and should not contain staff personal food items.

Based on observations, interviews and record review, the facility failed to ensure residents were free of significant medication errors for 1 (#87) of 2 (#82 and #87) residents reviewed during narcotic medication review. The deficient practice had the potential to effect the 165 residents residing in the facility receiving medications. Findings: Review of the facility's policy titled Medication Administration, dated 11/28/2017, revealed the following, in part: 3.0 Procedure Prior to giving medication, regardless of the type of medication, always follow the six rights: 1. Right Individual 2. Right medication 3. Right dose 4. Right time 5. Right route 6. Right documentation Review of Resident #87's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included Pain and Muscle Wasting and Atrophy. Review of Resident #87's Physician Orders dated September 2024 revealed the following, in part: Oxycodone HCL oral tablet 10 mg. Give 10 mg by mouth every 4 hours as needed for breakthrough pain. Order date: 09/03/2024. MS Contin oral tablet 15 mg. Give 15 mg by mouth two times a day for pain. Order date: 09/03/2024. Review of Resident #87's MAR dated 09/01/2024-09/30/2024 revealed the following, in part: Oxycodone HCL oral tablet 10 mg. Give 10 mg by mouth every 4 hours as needed for breakthrough pain. Order date: 09/03/2024. Given on 09/09/2024 at 3:57 p.m. Review of Resident #87's MAR dated 09/01/2024-09/30/2024 revealed the following, in part: MS Contin oral tablet 15 mg. Give 15 mg by mouth two times a day for pain. Order date: 09/03/2024. On 09/09/2024 at 4:03 p.m., an observation was conducted of medication Cart A1 with S8LPN. An observation was made of the narcotic medication sign out documentation for Resident #87. The MS Contin oral tablet 15 mg pill pack was counted and was noted to be missing 1 tablet. S8LPN stated Resident #87 was scheduled to receive MS Contin oral tablet 15 mg daily at 8:00 a.m. and 8:00 p.m. and a second narcotic, Oxycodone, could be given as needed every four hours. S8LPN stated she gave Resident #87 the wrong narcotic medication at 3:57 p.m. S8LPN stated she thought she administered Oxycodone, but had administered MS Contin instead. On 09/10/2024 at 4:00 p.m., an interview was conducted with S3DON. He stated S8LPN removed and administered Resident #87's scheduled MS Contin, instead of the PRN Oxycodone, on 09/09/2024 at 3:57 p.m. He stated this resulted in Resident #87 receiving MS Contin four hours earlier than the medication was scheduled to be administered. He confirmed S8LPN had not followed the 6 rights of medication administration and made a medication error.

Based on observation, interviews, and record review, the facility failed to ensure expired medications and biologicals were not available for use and administration to residents as evidenced by: Having expired medications for 1 (Cart B) of 4 (Cart A1, Cart A2, Cart B, and Cart F) reviewed for med storage. Findings Review of the facility's policy titled Medication Administration dated 11/28/2017 revealed the following: Procedure: Do not administer medications passed their expiration date. An observation was made on 09/09/2024 at 4:36 p.m. with S6CC and S7LPN of Cart B. The following was observed: 1 bottle of eye drops with expiration date 07/2024; 1 bottle of oral liquid Morphine with open date of 07/21/2024 and no expiration date. An interview was conducted with S7LPN on 09/09/2024 at 4:37 p.m. She stated she did not know why the expired medication bottles were in Cart B, but should have been removed. S7LPN verified liquid Morphine was administered on 09/09/2024 at 12:06 a.m. and was beyond expiration date. An interview was conducted with S6CC on 09/09/2024 at 4:40 p.m. She confirmed eye drops were expired and should have been removed from Cart B. She stated nurses were responsible for monitoring and checking the medication carts for expired medications. An interview was conducted with S4ADON on 09/09/2024 at 4:40 p.m. She confirmed the eye drops were beyond expiration date and should have been discarded. She stated it was the night nurses' responsibility to check carts for expired medications. She added all nurses were responsible for checking expiration dates prior to administrating medications. S4ADON confirmed nursing staff had not removed expired medications and should have. An interview was conducted with S3DON on 09/10/2024 at 4:00 p.m. He stated each nurse who administers medications was responsible for checking expiration dates. He further stated the floor nurse was responsible for checking medication carts for expired medications. S3DON confirmed eye drops were expired, should have been discarded, and had not been.

Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 (#87) of 5 (#11, #82, #87, #94, and #146) residents reviewed for infection control. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing care to a resident who was on Enhanced Barrier Precautions (EBP). Findings: Review of the facility's policy titled Enhanced Barrier Precautions revised on 04/2024, revealed the following, in part: Policy Interpretation and Implementation 2. EBP's employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include: g. device care or use Observation of the Enhanced Barrier Precautions sign posted on Resident #87's door revealed the following, in part: Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities. Device care or use: central line Review of Resident #87's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses of Surgical Site Infection and Long Term Current Use of Antibiotics. Review of Resident #87's current Physician Orders revealed the following, in part: Enhanced Barrier Precautions. Every shift for central line, chronic wound. Wear gown and gloves when providing high contact resident care. An observation was made on 09/10/2024 at 10:55 a.m. of S9LPN administering an IV antibiotic to Resident #87 through her PICC line. S9LPN was not wearing a gown during the use of the central line. An interview was conducted on 09/10/2024 at 12:02 p.m. with S9LPN. S9LPN verified Resident #87 was on EBPs. She confirmed she did not wear a gown when administering the IV antibiotic through Resident #87's PICC line and should have. An interview was conducted on 09/10/2024 at 1:14 p.m. with S3DON. S3DON confirmed per EBP guidelines, nurses should wear a gown when administering IV antibiotics through a resident's PICC line.

Based on record review, observations, and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. This had the potential to effect 145 residents who were served meals from the kitchen. Findings: Review of the facility's policy titled Food Preparation and Service revealed the following: Policy Statement: Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Food Preparation, Cooking and Holding Time/Temperatures: 1. The danger zone for food temperatures is between 41 degrees Fahrenheit and 135 degrees Fahrenheit. An observation was made on [DATE] at 8:45 a.m. of the facility's walk-in pantry with S9FSM. The following was observed: -Four boxes of gumbo mix with an expiration date of [DATE]. -Two opened gallons of soy sauce with a label, which read, refrigerate after opening. An observation was made on [DATE] at 8:48 a.m. of the facility's walk-in refrigerator with S9FSM. The following was observed: -One opened bottle of enchilada sauce with black and green fuzzy spots, 1 inch x 1 inch in length, on the bottle's lid. -One opened bottle of sweet and sour sauce with black and green fuzzy spots, 1 inch x 1 inch in length, on the bottle's lid. -One opened half gallon of buttermilk with an expiration date of [DATE] -One opened gallon bottle of raspberry vinaigrette salad dressing with no opened date. An observation was made on [DATE] at 8:50 a.m. of the facility's walk-in freezer with S9FSM. The following was observed: -One opened box of biscuits in an unsealed plastic bag. An interview was conducted on [DATE] at 8:51 a.m. with S9FSM. She confirmed the above observations. She confirmed all of the above food items were available for resident use. She confirmed all expired food items should have been discarded and not available for resident use. She confirmed all food items requiring refrigeration after opening should have been placed in the refrigerator. She stated the black and green fuzzy spots on the lid of the enchilada and sweet and sour sauce bottles were mold. She confirmed all opened food items should have a label including an opened date. She confirmed all food items should be properly sealed at all times. An observation was made on [DATE] at 11:43 a.m. of the food serving station as S13FS performed a temperature check on the potato salad. The temperature check for the potato salad resulted in 42.6 degrees Fahrenheit and S13FS served the potato salad to the residents. An interview was conducted on [DATE] at 11:44 a.m. with S13FS. He stated the temperature of the potato salad should be less than 41 degrees Fahrenheit. S13FS confirmed he served the potato salad, which was 42.6 degrees Fahrenheit, to the residents. An interview was conducted on [DATE] at 11:46 a.m. with S9FSM. She confirmed the potato salad should have been less than 41 degrees Fahrenheit. She confirmed the potato salad, which was 42.6 degrees Fahrenheit, should not have been served to residents. An interview was conducted on [DATE] at 9:05 a.m. with S3ADM. She confirmed all expired food items should have been discarded and not available for resident use. She confirmed all food items requiring refrigeration after opening, should have been stored in the refrigerator. She stated for no reason should mold be growing on a container of food available for resident use. She confirmed all opened food items should have a label including an opened date. She confirmed all food items should be properly sealed at all times. She confirmed the potato salad temperature should have been less than 41 degrees Fahrenheit and should not have been served to the residents at 42.6 degrees Fahrenheit. 46981

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 2 (Med Room a and Med Room b) of 2 (Med Room a and Med Room b) medication storage rooms observed. The facility failed to ensure: 1. Tuberculin multi-dose vial and Influenza Vaccine multi-use vial were labeled with the date opened; and 2. Temperatures were documented for the medication refrigerator in Med Room b. Findings: An observation was made of the medication refrigerator in Med Room b on 10/23/2023 at 10:17 a.m. with S11LPN. There was 1 opened Tuberculin multi-dose vial without an open date on the vial and 1 opened Influenza Vaccine multi-use vial without an open date on the vial. An interview was conducted on 10/23/2023 at 10:17 a.m. with S11LPN. She confirmed all opened multi-dose vials should have an open date. She confirmed both vials were available for resident use and were not labeled with an open date. Review of the Medication Refrigerator Temperature Log for the refrigerator located in Med Room b revealed no documentation of temperatures for 10/20/2023 - 10/23/2023. An interview was conducted on 10/23/2023 at 10:10 a.m. with S10LPN. She confirmed there was no documentation of temperatures recorded for 10/20/2023 - 10/23/2023. She stated night shift was responsible for documenting the medication refrigerator temperatures each night. An interview was conducted on 10/23/2023 at 10:12 a.m. with S5CC. She confirmed there was no documentation of temperatures recorded for 10/20/2023 - 10/23/2023. She stated night shift was responsible for documenting medication refrigerator temperatures each night. An interview was conducted on 10/24/2023 at 10:35 a.m. with S4DON. He confirmed all opened multi-dose vials should have an open date. He confirmed night shift was responsible for ensuring the medication refrigerator temperature log was filled out during their shift. He confirmed these logs should not have any missing data. 46981

Based on observations, interviews and record reviews, the facility failed to ensure interventions for falls were implemented as identified on the care plan for 1(#127) of 3 (#99, #127, and #456) residents reviewed for falls. Findings: A review of the facility's Falls and Fall Risk policy revealed, in part: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent residents from falling and to try to minimize complications from falling. Review of the clinical record for Resident #127 revealed the resident was admitted to the facility on [DATE]. The resident had diagnoses that included Unspecified Dementia and Falls. Review of the most recent MDS with an ARD of 8/13/2023, revealed Resident #127 had a BIMS of 4, which indicated severe cognitive impairment. Maybe add if resident required assistance and to what extent. Did the MDS have anything about falls mentioned? Review of the most current Care Plan revealed the following: Problem: 11/25/2022- Fall- Intervention-11/25/2022- non-slip strips in front of recliner. On 10/24/2023 at 9:50 a.m., an observation was made of Resident #127's room and there were no non- slip strips in front of her recliner. On 10/24/2023 at 12:00 p.m., an interview was conducted with S14CNA. S14CNA stated when Resident #127 sat in her recliner staff had to really watch her because she would scoot out of the chair and fall. On 10/24/2023 at 12:15 p.m., an observation and interview was conducted with S12LPN. S12LPN reviewed Resident #127's care plan and verified the intervention for falls was non- slip strips in front of Resident #127's recliner. During an observation of Resident #127's room, S12LPN verified there were no non-slip strips in front of Resident #127's recliner. On 10/24/2023 at 12:30 p.m., an observation and interview was conducted with S7CC. She verified Resident #127's care plan interventions listed non-slip strips to be placed in front of her recliner. S7CC then verified through observation there were no non slip strips in front of Resident #127's recliner and should have been. On 10/25/2023 at 10:40 a.m., an interview was conducted with S4DON. He confirmed Resident #127's care plan had an intervention for non-slip strips to be place in front of her chair and should have been implemented. 49343

Based on interviews and record review, the facility failed to electronically submit accurate payroll information for direct care staffing as required. Findings: Review of the PBJ Staffing Data Report for Fiscal Year Quarter 3 2023 (April 1-June 30) revealed One Star Staffing Rating was triggered. Review of the facility's CMS Submission Report PBJ Final File Validation Reports for Fiscal Quarter 1, 2, and 3 revealed, in part, Total Employee Link Records were not submitted. An interview was conducted on 10/25/2023 at 9:54 a.m. with S1CHRD. She stated the facility changed payroll systems in December of 2022. She confirmed if the PBJ system did not accept the employee file changes, the information should have been manually entered into the system and it was not. She stated she was responsible for entering employee information for Fiscal Quarter 2 and 3. She stated S2CAO was responsible for entering the employee information during Fiscal Quarter 1. An interview was conducted on 10/25/2023 at 10:50 a.m. with S2CAO. She confirmed the facility changed payroll systems during December of 2022. She stated she was responsible for entering the employee information during Fiscal Quarter 1. She stated the PBJ system did not accept the employee file changes. She confirmed if the PBJ system did not accept the employee file changes, the information should have been manually entered into the system and it was not. She confirmed the facility's staffing data was not entered into the PBJ system for Fiscal Year 2023, Fiscal Quarters 1, 2, and 3. 46981

Based on interviews and record review, the facility failed to ensure the resident had the right to be informed in advance, by the physician or other practitioner or professional, of treatment and to choose the alternative or option he or she preferred for 1(#1) of 5(#1, #2, #3, #4, #5) sampled residents. The facility failed to ensure Resident #1 was informed she was tested for Sexually Transmitted Diseases. Findings: Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis, Neurogenic Bladder, Anxiety and Depression. Review of the annual MDS with an assessment reference date of 03/11/2023 revealed Resident #1 had a BIMS of 15, which indicated she was cognitively intact. Review of the current Physician Orders dated 01/2023 revealed orders for care, treatments, and services consistent with the resident's condition and diagnosis. Orders included: 01/13/2023: UA for chlamydia, gonorrhea, Trichomoniasis, and UA with c/s one time only for burning with urination. Review of the policy titled, Resident Rights revealed the following: Policy: Employees shall treat all residents with kindness, respect and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect kindness and dignity p. be informed of, , his or her care planning and treatment; s. choose an attending physician and participate in decision-making regarding his or her care; On 04/17/2023 at 11:30 a.m., an interview was conducted with Resident #1. She stated she had been a resident at the facility for about two years, and she had a urinary catheter since admission. She stated in January 2023, she had burning with urination and foul smelling urine, which she reported to the nurse. She stated the nurse informed her she was to collect a Urinalysis for a Urinary Tract Infection. She stated she checked her patient portal for her lab results and saw that she had been tested for Sexually Transmitted Diseases. She stated she was not informed other tests were ran. She stated she was offended lab work was ran for Sexually Transmitted Diseases. She stated it made her feel degraded and judged like either she and or her spouse were having an affair. She stated she questioned S2NP, and S2NP stated since she complained of burning with urination, the doctor and herself found it appropriate to test for Sexually Transmitted Diseases. On 04/17/2023 at 1:45 p.m., an interview was conducted with S1LPN. She stated she was very familiar with Resident #1. She stated Resident #1 came to her in January 2023 asking her why she was tested for Sexually Transmitted Diseases when she only complained about burning with urination. She stated she felt like Resident #1 was embarrassed. She stated Sexually Transmitted Diseases were not normally ordered with a Urinalysis in the Nursing Home setting. She stated Resident #1 should have been informed of the testing prior to the urine being collected. On 04/17/2023 at 2:45 p.m., an interview was conducted with S2NP. She confirmed she ordered the Urinalysis for Resident #1 in January 2023 related to burning with urination. She stated she did not inform the resident of the Gonorrhea/Chlamydia test being added to the urinalysis and should have. She stated she did not know the lab results would show up in the patient portal and that her husband would see the results. She stated Resident #1 came to her upset that she had been tested for Sexually Transmitted Diseases.

Based on policy review, record review and interviews, the facility failed to implement their policies and procedures as evidenced by failing to ensure COVID-19 vaccination status of staff was tracked and documentation maintained for 5 (S3LPN, S4DA, S5CNA, S6DA, S7AD) of 234 staff listed on the facility's COVID-19 Staff Vaccination Status for Providers. This deficient practice had the potential to affect the 146 residents who resided in the facility. Findings: Review of the facility's policy, New Federally Mandated Policy Requiring Vaccinations, revealed the following, in part: Documentation of Staff Vaccinations: The CMS IFC also requires that we track and securely document the vaccination status of each staff member, including those for whom there is a temporary delay in vaccination, In order to comply with the CMS mandate, all staff COVID-19 vaccines must be appropriately documented. This documentation will be an ongoing process as new staff are on boarded. Review of the facility's COVID-19 Staff Vaccination Status for Providers form, provided by S2ICP, revealed a list of 234 total staff. Further review revealed 5 (S3LPN, S4DA, S5CNA, S6DA, and S7AD) of the 234 staff were listed as Partially Vaccinated. S3LPN with a date of hire of 10/03/2022, was listed as an active employee with dose 1 of Moderna dated 01/07/2021. S4DA with a date of hire of 12/08/2022, was listed as an active employee with dose 1 of Pfizer dated 12/05/2022. S5CNA with a date of hire of 10/06/2022, was listed as an active employee with dose 1 of Pfizer dated 11/24/2021. S6DA with a date of hire of 08/04/2022, was listed as an active employee with dose 1 of Moderna dated 07/28/2022. S7AD with a date of hire of 10/14/2022, was listed as an active employee with dose 1 of Pfizer dated 10/19/2022. An interview was conducted on 01/17/2023 at 11:00 a.m. with S2ICP. She confirmed S3LPN, S4DA, S5CNA, S6DA, and S7AD have continued to work in the facility since their date of hire with no disruptions. She also confirmed the following: S3LPN was listed as partially vaccinated on vaccination matrix with no exemption or delay for further vaccination. Further review revealed S3LPN received her second dose of Moderna dated 02/04/2021. S2ICP verified the dose was not documented until 01/17/2023 when brought to her attention. S4DA was listed as partially vaccinated on vaccination matrix with no exemption or delay for further vaccination. Further review revealed S4DA did not obtain his second dose of the vaccination. S5CNA was listed as partially vaccinated on vaccination matrix with no exemption or delay for further vaccination. Further review revealed S5CNA received her second dose of Pfizer dated 04/08/2022, and a booster on 12/28/2022. S2ICP verified the doses were not documented until 01/17/2023 when brought to her attention. S6DA was listed as partially vaccinated on vaccination matrix with no exemption or delay for further vaccination. Further review revealed S6DA received her second dose of Moderna dated 01/15/2023. S2ICP verified the dose was not documented until 01/17/2023 when brought to her attention. S7AD was listed as partially vaccinated on vaccination matrix with no exemption or delay for further vaccination. Further review revealed S7AD had not obtained her second dose of the vaccination. S3LPN was present, working and interviewed on 01/18/2023. She stated she was fully vaccinated with 2 doses of Moderna. She provided her vaccination card and it documented she received her Moderna vaccination doses dated 01/07/2021 and 02/04/2021. S2ICP verified the dose was not documented until 01/17/2023 when brought to her attention. An interview was conducted on 01/17/2023 at 11:15 a.m. with S1ADM and S2ICP. Both verified S3LPN, S4DA, S5CNA, S6DA, and S7AD who were listed as partially vaccinated had no exemption, temporary delay, requested or pending exemption. Both, S1ADM and S2ICP confirmed the facility failed to implement their policies and procedures as evidenced by failing to ensure COVID-19 vaccination status of staff was tracked and documentation was maintained.

Based on interviews and record review, the facility failed to implement processes for ensuring staff that provided care, treatment or services for the facility residents met the COVID-19 staff vaccination requirement. The facility failed to ensure 2 (S4DA, S7AD) staff members were fully vaccinated for COVID-19 within the CMS requirement. This deficit practice had the potential to affect 146 residents that resided in the facility. Findings: Review of the facility's policy, New Federally Mandated Policy Requiring Vaccinations revealed the following, in part: Application of the Fully Vaccination Requirement: The CMS IFC requires that each individual who is to be present in the facility or at the physical site of patient care (based upon frequency) must be fully vaccinated.completion of the primary series for vaccination, employees are required to receive the first dose of a 2 dose-series, or the single dose COVID-19 vaccination prior to employment start date and complete the primary series according to manufacture recommendations. An interview was conducted on 01/17/2023 at 11:00 a.m. with S2ICP. She confirmed S4DA and S7AD have continued to work in the facility since their date of hire with no disruptions. She also confirmed the following: S4DA with a date of hire of 12/08/2022 was listed as an active employee with dose 1 of Pfizer dated 12/05/2022. S4DA was listed as partially vaccinated on vaccination matrix with no exemption or delay for further vaccination. Further review revealed S4DA missed his appointment to get his second dose. S7AD with a date of hire of 10/14/2022 was listed as an active employee with dose 1 of Pfizer dated 10/19/2022. S7AD was listed as partially vaccinated on vaccination matrix with no exemption or delay for further vaccination. Further review revealed S7AD had forgot about getting her second dose, and had not received it. An interview was conducted on 01/17/2023 at 11:15 a.m. with S1ADM and S2ICP. Both verified S4DA and S7AD who were listed as partially vaccinated had no exemption, temporary delay, requested or pending exemption. Both, S1ADM and S2ICP confirmed the facility failed to implement processes for ensuring staff that provided care, treatment or services for the facility residents met the COVID-19 staff vaccination requirement.

Based on interviews and record review, the facility failed to make prompt efforts to resolve grievances for 1 (#49) of 28 residents reviewed for grievances. The facility failed to ensure a grievance was promptly investigated when Resident #49 reported missing hearing aids to staff. Findings: Review of facility's Resident Care Grievance Policy states, in part: 1. Upon receipt of a grievance from a resident or any concerned party, an impartial investigation will be initiated by the facility Administrator or their designee. The investigator shall complete the PCC GRIEVANCE/COMPLAINT REPORT form or enter the information in the Risk Management section of the resident's electronic health record. Documentation of the investigation process should include: Date/time of alleged incident Location and circumstances of the alleged incident Name(s) of witnesses and their account of alleged incident Complainant's account of incident (if applicable) Employees/Supervisor/Department Head account of incident (if applicable) Recommendations for corrective action or grievance resolution (if applicable) 4. The grievance investigation report along with recommendations for action should be completed within 5 working days. In all grievance cases the complainant must be informed of the investigation outcome. Resident #49 was admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #49's Quarterly MDS with an ARD of 06/23/2022 revealed Resident #49 had a BIMS Summary score of 15 which indicated Resident #49 was cognitively intact. Appropriate assessments included, in part: Resident #49 used hearing aids. Review of Grievance Log dated August 2022 revealed no grievance report for Resident #49's lost hearing aids. On 09/06/22 at 9:31 a.m., an interview was conducted with Resident #49. She asked for surveyor to speak loudly because she lost her hearing aids two weeks ago. She stated she notified her nurse. She stated her nurse helped her look for them but could not find them. She stated her nurse was going to report them missing but she has not heard anything about them since. On 09/08/2022 at 8:21 a.m., an interview was conducted with S4LPN. S4LPN reported Resident #49's hearing aids had been missing for approximately two weeks. She stated she helped Resident #49 look for them but could not find them. She stated she reported the missing hearing aids to the social worker. She stated whenever a resident loses personal property it is reported to the social worker and the social worker handles it. On 09/08/2022 at 10:15 a.m., an interview was conducted with S6SW. She stated she found out today that Resident #49 lost her hearing aids. She verified there was no grievance filed for the lost hearing aids. She stated when a resident loses personal property the nurse is to file a grievance report and notify the Social Worker so it can be investigated. When S6SW was informed that S4LPN stated she notified her two weeks ago of the lost hearing aids, S6SW replied, I don't know. On 09/09/2022 at 9:07 a.m., an interview was conducted with S1ADM. She confirmed a grievance should have been filed two weeks ago when Resident #49 complained of her hearing aids missing.

Based on interviews and record reviews the facility failed to immediately inform the resident's physician, nurse practitioner or legal representative of a significant change for 1 (#4) of 5 (#1, #2, #3, #4, #5) residents. The facility failed to: 1. notify the resident's physician, nurse practitioner or legal representative of several loose stools, vomiting, and decreased appetite 2. assess and monitor the resident's condition. Resident #4 was placed in Immediate Jeopardy on 08/23/13 when the she passed 2 large watery stools and vomited. The resident had [DIAGNOSES REDACTED]. The resident's care plan documented she was at risk for dehydration and electrolyte imbalances. The resident continued to have episodes of diarrhea, vomiting and decreased appetite. On 08/26/13 she had a change in her level of consciousness, elevated blood glucose levels and decreased oxygen concentrations. The Immediate Jeopardy situation continued for Resident #4 until she was transferred to a local hospital on [DATE]. The Administrator was notified of the Immediate Jeopardy situation on 09/11/13 at 10:55 a.m. A plan of removal was presented by the Administrator which read as follows: 1. Resident _____ (#4) was affected by deficient practice, was admitted to the hospital on [DATE]. 2. All residents who have a change in condition have a potential to be affected by the deficient practice. 3. The DON (Director of Nursing) or designee will immediately review all existing residents in the facility for any change in condition, as well as ensure that proper responsible party and physician notification have taken place. The DON will immediately in service all nursing staff on the necessity of communication, and policy and procedure on change in condition of residents and notification of responsible party and the primary care physician. Review and in service to all nurses on nurse notification report, for documentation and assessment of any change in condition. 4. The DON or designee will audit nurses' notes for responsible party and physician notification, assessment and monitoring for change in condition . This will be monitored daily X 4 weeks, then 3 X week for two weeks, then randomly thereafter. All findings will be corrected immediately and forwarded to the QI committee until compliance is achieved 5. 09/11/13 6. 09/17/13 (All in services will be completed for entire nursing staff by this day). The Immediate Jeopardy was removed on 09/11/13 at 2:30 p.m. when the surveyor confirmed all residents' records were reviewed for any change in condition and proper responsible party and physician notification. The deficient practice remains at a level 3 for actual harm to Resident #4 Findings: On 09/09/13 at 10:30 a.m. the surveyor requested a copy of the facility's policy and procedure on notification of the physician and responsible party and the facility's policy and procedure on nursing assessment and monitoring of residents' conditions. S1ADM provided the surveyor with a document titled "Change in Resident Medical Status (F 154, F 274)". S1ADM stated the document was not a facility policy but a "Practice". She was asked if she had any policies for nursing assessment and monitoring of residents' conditions. S1ADM stated "No, that comes with their license". S2DON was present during the interview and offered no other policies. Review of the facility's document titled Change in Resident Medical Status (F154, F274) revealed the following: A change in medical status is defined as any physical, psychological and/or medical deviation as compared to the resident's status as noted in the initial assessment.... A significant change is a decline or improvement in a resident' status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard-disease-related clinical interventions is not self limiting A facility must immediately infirm the resident, consult with the resident's physician, and if known, notify the resident's legal representative or an interested family member when there is: 2. A significant change in the resident's physical; mental or psychosocial status 3. A need to alter treatment significantly; or 4. A decision to transfer or discharge the resident from the facility Review of the clinical record revealed Resident #4 was an [AGE] year old woman admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 4 (severe cognitive impairment) The resident used a walker to ambulate and required one person physical assist for toilet use. Review of the care plan revealed the following: Problem Onset: 12/16/11: At risk for alteration in fluid status-dehydration & electrolyte imbalances... Goal & Target Date: Will be monitored for signs/symptoms dehydration/electrolyte imbalances & interventions will be taken as needed; review next care plan (10/03/13) On 09/06/13 at 8:00 a.m. a telephone interview was conducted with the resident's responsible party, her daughter. She reported her mother had been having diarrhea and vomiting since Friday, 08/23/13 and she was not notified. On 08/25/13 her sister, the resident's other daughter, visited their mother and reported to the responsible party their mother had hemorrhoids and was being given some type of cream. On 08/26/13 the responsible party visited her mother and found her receiving IV fluids. She stated after she left the nursing facility she phoned the facility and asked the staff "shouldn't she (the resident) go to the hospital?". She reported later that night, on 08/26/13, her mother was transferred to a local hospital. The resident's responsible party stated her mother was admitted to ICU ( intensive care unit) with "severe dehydration, fever and [MEDICAL CONDITION]". She stated her mother's kidneys failed and for the first time in her life she required [MEDICAL TREATMENT]. She stated her mother's physician, at the hospital, told her the resident may need [MEDICAL TREATMENT] for the rest of her life. The responsible party stated prior to hospitalization her mother ate a regular no added sugar diet and voided on her own. The resident is now on a puree diet and has a foley catheter. The responsible party stated on 09/05/13 her mother was placed in a regular room and is on isolation for a [MEDICAL CONDITION] infection. The responsible party stated her mother's physician and the nurse practitioner from the nursing facility, were not called about the resident's diarrhea and vomiting. Review of the Departmental Notes, the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 08/23/13 (Nurses' Notes) 4:30 p.m. Late entry...ate very little at breakfast, ate a few bites of meal... (Signed by: S5LPN) 08/23/13 (B&B) 10:08 p.m. Bowel Movement: extra large, watery liquid, nurse notified.. (Signed by: S11CNA) 08/23/13 (B&B) 10:09 p.m. Bowel Movement: extra large, watery liquid, nurse notified... (Signed by: S11CNA) 08/23/13 ( MAR) [MEDICATION NAME] 8 mg given for nausea/vomiting at 1:41 a.m..(Signed by: S20LPN) 08/23/13 (MAR) [MEDICATION NAME] 8 mg given for nausea/vomiting at 7:30 p.m ....(Signed by: S7LPN) 08/24/13 (Nurses' Notes) 11:03 p.m. Not eating well due to pain from fall.. (Signed by: S8LPN) 08/24/13 (B&B) 11:02 a.m. Bowel Movement: large, watery liquid, nurse notified.(Signed by: S13CNA) 08/25/13 (Nurses' Notes) 10:06 p.m. ..resident had large loose BM, observed approximately 5 cm of possible rectum protruding. RN Supervisor (S9RN) called and talked with_____ (S4NP) Gave orders for [MEDICATION NAME] BID, she will be here in am to evaluate..(Signed by: S8LPN) 08/26/13 (Nurses' Notes) 9:00 a.m. resident in bed refused breakfast Blood Sugar 160, B/P 109/60, Pulse 130, SPO2 79%. Verbal Orders from S4NP included oxygen per nasal cannula, intravenous fluids at 75 cc per hour and a stool for C -Diff ([MEDICAL CONDITION])...(Signed by S5LPN) 08/26/13 (Nurses' Notes) 9:45 p.m. CNA came to nurse stat stated "resident just vomited". Entered resident's room, found resident sweating profusely, asked resident if she was in pain, she did not respond, CBG (capillary blood glucose) 408, B/P 96/43, pulse 112. Contacted nurse practitioner, RP (Responsible Party) Sent resident to hospital for observation. (Signed by: S7LPN) On 09/09/13 at 1:45 p.m. an interview was conducted with S5LPN the nurse caring for the resident the day she was discharged to the hospital (08/26/13). She was asked what events led to the resident being hospitalized . She reported on 08/26/13 the resident had dry lips and just didn't look right. The resident had not gotten out of bed and when they turned her she had a diarrhea stool that smelled funny, so she sent a culture for [MEDICAL CONDITION]. She reported it was at that time the resident's roommate told the staff the resident had been having diarrhea since Friday. She was asked how long had the resident had diarrhea. S5LPN stated she was not sure how long the resident may have had diarrhea because she toileted herself. She was asked if the resident had fallen on 08/22/13. She stated "Yes". She was asked if the resident had been toileting herself since the fall. S5LPN stated "No". She stated the resident did not eat breakfast or lunch that day (08/26/13). Her blood glucose at breakfast was 200 and 400 at lunchtime. She received a verbal order from S4NP to start oxygen and an IV. She was asked if it had ever been reported by other staff to her that the resident was having diarrhea or vomiting. S5LPN stated "No". She went on to state the resident's appetite was poor on 08/26/13. She was asked if she reported the decreased appetite or diarrhea to the physician or nurse practitioner. S5LPN stated "No". On 09/10/13 at 11:45 a.m. an interview was conducted with S4NP. She was asked if she was the nurse practitioner that worked with Resident #4's physician. She stated "Yes". She reported she was in the facility Monday through Friday and was on call 24/7. She stated staff call her first before calling the physician. She was asked if she had been informed the resident had been having diarrhea, vomiting and a decreased appetite. S4NP stated "no, the only thing I was called about on the 25th was a possible protruding rectum and I ordered [MEDICATION NAME] and saw her the next day". She went on to state that on 08/26/13 she examined the resident and she did appear to have a prolapsed rectum. At the time of the exam she noticed the resident's stool smelled funny and she ordered a [MEDICAL CONDITION] culture be done along with a CXR, O2 per nasal cannula and IV fluids. She was asked if on 08/26/13, when she visited the resident, was she informed the resident had been having diarrhea, decreased appetite, or vomiting. S4NP stated "No". S4NP stated later that evening she was called because the resident's oxygen saturation was low so she ordered her to be sent to the hospital. On 09/10/13 at 3:00 p.m. an interview was conducted with S2DON. She was asked to review the resident's nurses' notes, bowel and bladder (B&B) roster and physician orders [REDACTED]. After reviewing the clinical record, she was asked if there was any documentation the resident's physician, nurse practitioner or responsible party had been notified of the decreased appetite, vomiting or the loose stools on 08/23/13, 08/24/13, 08/25/13 and 08/26/13. S2DON stated "No". On 09/10/13 at 4:30 p.m. an interview was conducted with S11CNA. She verified she had worked with the resident on the evening of 08/23/13. She was asked to review the B&B Roster. She was asked if she had charted the resident had 2 extra large watery stools and had she informed the nurse. S11CNA stated she had charted the resident had 2 extra large watery stools and she had informed S7LPN. On 09/10/13 at 4:55 p.m. an interview was conducted with S7LPN. She verified she had worked with the resident on the evening of 08/23/13 and 08/26/13. She was asked if she had been informed of the resident having had 2 large loose stools on 08/23/13. She stated "I don't remember being told that, but I did give her [MEDICATION NAME] for vomiting". She was asked if she had informed the physician, nurse practitioner or responsible party of the resident's loose stools or vomiting. S7LPN stated "No". Review of the nurses notes for 08/23/13 revealed no documentation of any nursing notes. S7LPN verified she had not documented any nurses' notes on the resident for 08/23/13. Review of the MAR indicated [REDACTED].m for vomiting. S7LPN was asked if she had been the nurse who had sent the resident to the hospital on [DATE]. She stated "Yes", on the evening of 08/26/13 a CNA reported to her the resident had vomited and went she went into the room and found her sweating profusely and when she spoke to the resident she did not respond. S7LPN stated her glucose was 400, S4NP was contacted and the resident was sent to the hospital. On 09/11/13 at 8:45 a.m. an interview was conducted with S13CNA. She verified she had worked with the resident on 08/24/13. She was asked to review the B&B Roster. She was asked if she had charted the resident had a large watery stool and had she informed the nurse. S13CNA stated the resident had a large watery stool and she informed S8LPN. She was asked to explain the notation "nurse notified" on the B&B roster. S13CNA stated after the CNAs enter anything abnormal the words "nurse notified" appears on the screen and the CNA hits the save button. She was asked if this is how the nurse is notified. S13CNA stated "yes". She was asked if she had informed S8LPN verbally. S13CNA stated "I'm not sure, I think I told her". On 09/11/13 at 9:10 a.m. a telephone interview was conducted with S8LPN. She verified she had worked with the resident on 08/24/13 and 08/25/13. After reading her notes to her, dated 08/24/13, she was asked if she had informed the physician or the nurse practitioner of the resident's poor appetite. She stated "No". She was asked if she had been informed of the resident having had a large diarrhea stool on 08/24/13 by the CNA. S8LPN stated "No". She was asked if she had informed the physician or nurse practitioner of the loose stool on 08/24/13. S8LPN stated "No". After reading her notes to her, dated 08/25/13, she was asked if she had informed the physician or the nurse practitioner of the resident's poor appetite and documented large loose bowel movement. S8LPN stated she told S4NP and S9RN. On 09/11/13 at 9:25 a.m. a telephone interview was conducted with S9RN. She verified she had worked on the evening of 08/25/13 and had spoken to S4NP. She was asked what had she spoken to S4NP about. S9RN stated she had informed S4NP that the resident seemed to have part of her rectum protruding and [MEDICATION NAME] was ordered. She was asked if she had informed S4NP of the resident having had a large loose stool. S9RN stated "No, I didn't know the resident had had a loose stool until I got off the phone and talked to S8LPN and then we both realized she didn't need [MEDICATION NAME]". Attempts to reach S20LPN, who documented [MEDICATION NAME] every 6 hours as needed for vomiting, on 08/23/13 at 1:41 a.m., by phone were unsuccessful. On 09/11/13 at 9:45 a.m. an interview was conducted with S2DON. She was asked to review the B&B Roster. She was asked if when the CNAs chart a deviance, such as a loose stool, and the notation "nurse notified" appeared on the screen and the CNAs hit the save button is that message sent to the nurse. S2DON stated "The information is sent to the nurse but the nurse has to seek out that screen to review and they know they are to do that". She was asked how are the CNAs supposed to notify the nurses of deviancies. S2DON stated "They are to chart it and they are also to verbally inform the nurse". S2DON stated "This is a new computer system and we are still getting used to it". On 09/09/13 at 9:00 a.m. an interview was conducted with S18RN, Director of Medical Surgical services at ___________hospital, where the resident was transferred to on 08/26/13. She was asked if the resident had received [MEDICAL TREATMENT]. After reviewing the computerized record she stated "Yes, [MEDICAL TREATMENT] was ordered 3 times a week". She was asked if the resident still received [MEDICAL TREATMENT]. After calling the [MEDICAL TREATMENT] unit, she stated "No, it was put on hold on 09/08/13". She was asked what were the resident's [DIAGNOSES REDACTED]. She is also receiving [MEDICATION NAME] ([MEDICATION NAME] Nutrition) in her IV fluids". She was asked if the resident was in isolation. S18RN stated "Yes, on 09/04/13 a stool specimen was collected and on 09/05/13 the results were positive for [MEDICAL CONDITION]". Review of the hospital's emergency department provider notes revealed the following: 08/26/13 Patient arrives from the nursing home for elevated blood glucose. After discussing with___ (S7LPN) at ____nursing home. She states the patient had an elevated glucose, decreased level of responsiveness to questioning and blood pressure to a systolic in the 90's. She has a baseline confusion and was slower to answering questions today than usual..... Clinical Impression: Fever, severe [MEDICAL CONDITION], needs IV antibiotics and admission to the hospital Review of the Nephrology Consult revealed the following: 08/27/13 Reason for Consult: Acute Kidney Injury Review of Systems: Gastrointestinal positive for diarrhea Assessment/Plan: 1. Acute kidney injury likely intravascular volume depletion 2. Metabolic Acidosis 3. Intravascular volume depletion 4. [MEDICAL CONDITION] The resident was admitted to the Intensive Care unit and on 08/29/13 a [MEDICAL TREATMENT] [MEDICATION NAME] catheter was placed.

Based on interviews, record reviews, and review of Louisiana Administrative code, Title 46, Professional and Occupation Standards Practice XLVII, Nurse Subpart I Practical Nurse, the facility failed to ensure that care and services were provided to 1 (#4) of 5 (#1, #2, #3, #4, #5, ) residents in accordance with professional standards of quality by failing to: 1. notify the resident's physician of several loose stools, vomiting,and decreased appetite 2. assess and monitor the resident's condition. Resident #4 was placed in Immediate Jeopardy on 08/23/13 when the she passed 2 large watery stools and vomited. The resident had [DIAGNOSES REDACTED]. The resident's care plan documented she was at risk for dehydration and electrolyte imbalances. The resident continued to have episodes of diarrhea, vomiting and decreased appetite. On 08/26/13 she had a change in her level of consciousness, elevated blood glucose levels and decreased oxygen concentrations. The Immediate Jeopardy situation continued for Resident #4 until she was transferred to a local hospital on [DATE]. The Administrator was notified of the Immediate Jeopardy situation on 09/11/13 at 10:55 a.m. A plan of removal was presented by the Administrator which read as follows: 1. Resident _____ (#4) was affected by deficient practice, was admitted to the hospital on [DATE]. 2. All residents who have a change in condition have a potential to be affected by the deficient practice. 3. The DON (Director of Nursing) or designee will immediately review all existing residents in the facility for any change in condition, as well as ensure that proper responsible party and physician notification have taken place. The DON will immediately in service all nursing staff on the necessity of communication, and policy and procedure on change in condition of residents and notification of responsible party and the primary care physician. Review and in service to all nurses on nurse notification report, for documentation and assessment of any change in condition. 4. The DON or designee will audit nurses' notes for responsible party and physician notification, assessment and monitoring for change in condition . This will be monitored daily X 4 weeks, then 3 X week for two weeks, then randomly thereafter. All findings will be corrected immediately and forwarded to the QI committee until compliance is achieved 5. 09/11/13 6. 09/17/13 (All in services will be completed for entire nursing staff by this day). The Immediate Jeopardy was removed on 09/11/13 at 2:30 p.m. when the surveyor confirmed all residents' records were reviewed for any change in condition and proper responsible party and physician notification. The deficient practice remains at a level 3 for actual harm to Resident #4 Findings: Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses (As amended through December, 2009) Subpart, I. Practical Nurse, under subchapter E. Curriculum Requirements revealed in part ..."3. development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with [MEDICATION NAME], including increased and ongoing development of self awareness, sound judgement, prudence, ethical thing and behaviors, problem solving and critical thinking abilities...7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health. Clinical experience shall include, but not be limited to, the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, IV therapy, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and writing as member of the interdisciplinary health care team..." On 09/09/13 at 10:30 a.m. the surveyor requested a copy of the facility's policy and procedure on notification of the physician and responsible party and the facility's policy and procedure on nursing assessment and monitoring of residents' conditions. S1ADM provided the surveyor with a document titled "Change in Resident Medical Status (F 154, F 274)". S1ADM stated the document was not a facility policy but a "Practice". She was asked if she had any policies for nursing assessment and monitoring of residents' conditions. S1ADM stated "No, that comes with their license". S2DON was present during the interview and offered no other policies. Review of the facility's document titled Change in Resident Medical Status (F154, F274) revealed the following: A change in medical status is defined as any physical, psychological and/or medical deviation as compared to the resident's status as noted in the initial assessment.... A significant change is a decline or improvement in a resident' status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard-disease-related clinical interventions is not self limiting A facility must immediately infirm the resident, consult with the resident's physician, and if known, notify the resident's legal representative or an interested family member when there is: 2. A significant change in the resident's physical; mental or psychosocial status 3. A need to alter treatment significantly; or 4. A decision to transfer or discharge the resident from the facility Review of the clinical record revealed Resident #4 was an [AGE] year old woman admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 4 (severe cognitive impairment) The resident used a walker to ambulate and required one person physical assist for toilet use. Review of the care plan revealed the following: Problem Onset: 12/16/11: At risk for alteration in fluid status-dehydration & electrolyte imbalances... Goal & Target Date: Will be monitored for signs/symptoms dehydration/electrolyte imbalances & interventions will be taken as needed; review next care plan (10/03/13) On 09/06/13 at 8:00 a.m. a telephone interview was conducted with the resident's responsible party, her daughter. She reported her mother had been having diarrhea and vomiting since Friday, 08/23/13 and she was not notified. On 08/25/13 her sister, the resident's other daughter, visited their mother and reported to the responsible party their mother had hemorrhoids and was being given some type of cream. On 08/26/13 the responsible party visited her mother and found her receiving IV fluids. She stated after she left the nursing facility she phoned the facility and asked the staff "shouldn't she (the resident) go to the hospital?". She reported later that night, on 08/26/13, her mother was transferred to a local hospital. The resident's responsible party stated her mother was admitted to ICU ( intensive care unit) with "severe dehydration, fever and [MEDICAL CONDITION]". She stated her mother's kidneys failed and for the first time in her life she required [MEDICAL TREATMENT]. She stated her mother's physician, at the hospital, told her the resident may need [MEDICAL TREATMENT] for the rest of her life. The responsible party stated prior to hospitalization her mother ate a regular no added sugar diet and voided on her own. The resident is now on a puree diet and has a foley catheter. The responsible party stated on 09/05/13 her mother was placed in a regular room and is on isolation for a [MEDICAL CONDITION] infection. The responsible party stated her mother's physician and the nurse practitioner from the nursing facility, were not called about the resident's diarrhea and vomiting. Review of the Departmental Notes, the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 08/23/13 (Nurses' Notes) 4:30 p.m. Late entry...ate very little at breakfast, ate a few bites of meal... (Signed by: S5LPN) 08/23/13 (B&B) 10:08 p.m. Bowel Movement: extra large, watery liquid, nurse notified.. (Signed by: S11CNA) 08/23/13 (B&B) 10:09 p.m. Bowel Movement: extra large, watery liquid, nurse notified... (Signed by: S11CNA) 08/23/13 ( MAR) [MEDICATION NAME] 8 mg given for nausea/vomiting at 1:41 a.m..(Signed by: S20LPN) 08/23/13 (MAR) [MEDICATION NAME] 8 mg given for nausea/vomiting at 7:30 p.m ....(Signed by: S7LPN) 08/24/13 (Nurses' Notes) 11:03 p.m. Not eating well due to pain from fall.. (Signed by: S8LPN) 08/24/13 (B&B) 11:02 a.m. Bowel Movement: large, watery liquid, nurse notified.(Signed by: S13CNA) 08/25/13 (Nurses' Notes) 10:06 p.m. ..resident had large loose BM, observed approximately 5 cm of possible rectum protruding. RN Supervisor (S9RN) called and talked with_____ (S4NP) Gave orders for [MEDICATION NAME] BID, she will be here in am to evaluate..(Signed by: S8LPN) 08/26/13 (Nurses' Notes) 9:00 a.m. resident in bed refused breakfast Blood Sugar 160, B/P 109/60, Pulse 130, SPO2 79%. Verbal Orders from S4NP included oxygen per nasal cannula, intravenous fluids at 75 cc per hour and a stool for C -Diff ([MEDICAL CONDITION])...(Signed by S5LPN) 08/26/13 (Nurses' Notes) 9:45 p.m. CNA came to nurse stat stated "resident just vomited". Entered resident's room, found resident sweating profusely, asked resident if she was in pain, she did not respond, CBG (capillary blood glucose) 408, B/P 96/43, pulse 112. Contacted nurse practitioner, RP (Responsible Party) Sent resident to hospital for observation. (Signed by: S7LPN) On 09/09/13 at 1:45 p.m. an interview was conducted with S5LPN the nurse caring for the resident the day she was discharged to the hospital (08/26/13). She was asked what events led to the resident being hospitalized . She reported on 08/26/13 the resident had dry lips and just didn't look right. The resident had not gotten out of bed and when they turned her she had a diarrhea stool that smelled funny, so she sent a culture for [MEDICAL CONDITION]. She reported it was at that time the resident's roommate told the staff the resident had been having diarrhea since Friday. She was asked how long had the resident had diarrhea. S5LPN stated she was not sure how long the resident may have had diarrhea because she toileted herself. She was asked if the resident had fallen on 08/22/13. She stated "Yes". She was asked if the resident had been toileting herself since the fall. S5LPN stated "No". She stated the resident did not eat breakfast or lunch that day (08/26/13). Her blood glucose at breakfast was 200 and 400 at lunchtime. She received a verbal order from S4NP to start oxygen and an IV. She was asked if it had ever been reported by other staff to her that the resident was having diarrhea or vomiting. S5LPN stated "No". She went on to state the resident's appetite was poor on 08/26/13. She was asked if she reported the decreased appetite or diarrhea to the physician or nurse practitioner. S5LPN stated "No". On 09/10/13 at 11:45 a.m. an interview was conducted with S4NP. She was asked if she was the nurse practitioner that worked with Resident #4's physician. She stated "Yes". She reported she was in the facility Monday through Friday and was on call 24/7. She stated staff call her first before calling the physician. She was asked if she had been informed the resident had been having diarrhea, vomiting and a decreased appetite. S4NP stated "no, the only thing I was called about on the 25th was a possible protruding rectum and I ordered [MEDICATION NAME] and saw her the next day". She went on to state that on 08/26/13 she examined the resident and she did appear to have a prolapsed rectum. At the time of the exam she noticed the resident's stool smelled funny and she ordered a [MEDICAL CONDITION] culture be done along with a CXR, O2 per nasal cannula and IV fluids. She was asked if on 08/26/13, when she visited the resident, was she informed the resident had been having diarrhea, decreased appetite, or vomiting. S4NP stated "No". S4NP stated later that evening she was called because the resident's oxygen saturation was low so she ordered her to be sent to the hospital. On 09/10/13 at 3:00 p.m. an interview was conducted with S2DON. She was asked to review the resident's nurses' notes, bowel and bladder (B&B) roster and physician orders [REDACTED]. After reviewing the clinical record, she was asked if there was any documentation the resident's physician, nurse practitioner or responsible party had been notified of the decreased appetite, vomiting or the loose stools on 08/23/13, 08/24/13, 08/25/13 and 08/26/13. S2DON stated "No". On 09/10/13 at 4:30 p.m. an interview was conducted with S11CNA. She verified she had worked with the resident on the evening of 08/23/13. She was asked to review the B&B Roster. She was asked if she had charted the resident had 2 extra large watery stools and had she informed the nurse. S11CNA stated she had charted the resident had 2 extra large watery stools and she had informed S7LPN. On 09/10/13 at 4:55 p.m. an interview was conducted with S7LPN. She verified she had worked with the resident on the evening of 08/23/13 and 08/26/13. She was asked if she had been informed of the resident having had 2 large loose stools on 08/23/13. She stated "I don't remember being told that, but I did give her [MEDICATION NAME] for vomiting". She was asked if she had informed the physician, nurse practitioner or responsible party of the resident's loose stools or vomiting. S7LPN stated "No". Review of the nurses notes for 08/23/13 revealed no documentation of any nursing notes. S7LPN verified she had not documented any nurses' notes on the resident for 08/23/13. Review of the MAR indicated [REDACTED].m for vomiting. S7LPN was asked if she had been the nurse who had sent the resident to the hospital on [DATE]. She stated "Yes", on the evening of 08/26/13 a CNA reported to her the resident had vomited and went she went into the room and found her sweating profusely and when she spoke to the resident she did not respond. S7LPN stated her glucose was 400, S4NP was contacted and the resident was sent to the hospital. On 09/11/13 at 8:45 a.m. an interview was conducted with S13CNA. She verified she had worked with the resident on 08/24/13. She was asked to review the B&B Roster. She was asked if she had charted the resident had a large watery stool and had she informed the nurse. S13CNA stated the resident had a large watery stool and she informed S8LPN. She was asked to explain the notation "nurse notified" on the B&B roster. S13CNA stated after the CNAs enter anything abnormal the words "nurse notified" appears on the screen and the CNA hits the save button. She was asked if this is how the nurse is notified. S13CNA stated "yes". She was asked if she had informed S8LPN verbally. S13CNA stated "I'm not sure, I think I told her". On 09/11/13 at 9:10 a.m. a telephone interview was conducted with S8LPN. She verified she had worked with the resident on 08/24/13 and 08/25/13. After reading her notes to her, dated 08/24/13, she was asked if she had informed the physician or the nurse practitioner of the resident's poor appetite. She stated "No". She was asked if she had been informed of the resident having had a large diarrhea stool on 08/24/13 by the CNA. S8LPN stated "No". She was asked if she had informed the physician or nurse practitioner of the loose stool on 08/24/13. S8LPN stated "No". After reading her notes to her, dated 08/25/13, she was asked if she had informed the physician or the nurse practitioner of the resident's poor appetite and documented large loose bowel movement. S8LPN stated she told S4NP and S9RN. On 09/11/13 at 9:25 a.m. a telephone interview was conducted with S9RN. She verified she had worked on the evening of 08/25/13 and had spoken to S4NP. She was asked what had she spoken to S4NP about. S9RN stated she had informed S4NP that the resident seemed to have part of her rectum protruding and [MEDICATION NAME] was ordered. She was asked if she had informed S4NP of the resident having had a large loose stool. S9RN stated "No, I didn't know the resident had had a loose stool until I got off the phone and talked to S8LPN and then we both realized she didn't need [MEDICATION NAME]". Attempts to reach S20LPN, who documented [MEDICATION NAME] every 6 hours as needed for vomiting, on 08/23/13 at 1:41 a.m., by phone were unsuccessful. On 09/11/13 at 9:45 a.m. an interview was conducted with S2DON. She was asked to review the B&B Roster. She was asked if when the CNAs chart a deviance, such as a loose stool, and the notation "nurse notified" appeared on the screen and the CNAs hit the save button is that message sent to the nurse. S2DON stated "The information is sent to the nurse but the nurse has to seek out that screen to review and they know they are to do that". She was asked how are the CNAs supposed to notify the nurses of deviancies. S2DON stated "They are to chart it and they are also to verbally inform the nurse". S2DON stated "This is a new computer system and we are still getting used to it". On 09/09/13 at 9:00 a.m. an interview was conducted with S18RN, Director of Medical Surgical services at ___________hospital, where the resident was transferred to on 08/26/13. She was asked if the resident had received [MEDICAL TREATMENT]. After reviewing the computerized record she stated "Yes, [MEDICAL TREATMENT] was ordered 3 times a week". She was asked if the resident still received [MEDICAL TREATMENT]. After calling the [MEDICAL TREATMENT] unit, she stated "No, it was put on hold on 09/08/13". She was asked what were the resident's [DIAGNOSES REDACTED]. She is also receiving [MEDICATION NAME] ([MEDICATION NAME] Nutrition) in her IV fluids". She was asked if the resident was in isolation. S18RN stated "Yes, on 09/04/13 a stool specimen was collected and on 09/05/13 the results were positive for [MEDICAL CONDITION]". Review of the hospital's emergency department provider notes revealed the following: 08/26/13 Patient arrives from the nursing home for elevated blood glucose. After discussing with___ (S7LPN) at ____nursing home. She states the patient had an elevated glucose, decreased level of responsiveness to questioning and blood pressure to a systolic in the 90's. She has a baseline confusion and was slower to answering questions today than usual..... Clinical Impression: Fever, severe [MEDICAL CONDITION], needs IV antibiotics and admission to the hospital Review of the Nephrology Consult revealed the following: 08/27/13 Reason for Consult: Acute Kidney Injury Review of Systems: Gastrointestinal positive for diarrhea Assessment/Plan: 1. Acute kidney injury likely intravascular volume depletion 2. Metabolic Acidosis 3. Intravascular volume depletion 4. [MEDICAL CONDITION] The resident was admitted to the Intensive Care unit and on 08/29/13 a [MEDICAL TREATMENT] [MEDICATION NAME] catheter was placed.

Based on interviews and record reviews the facility failed to ensure 1 ( #4) of 5 (#1, #2, #3, #4, #5) residents received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to: 1. notify the resident's physician of several loose stools, vomiting,and decreased appetite 2. assess and monitor the resident's condition. Resident #4 was placed in Immediate Jeopardy on 08/23/13 when the she passed 2 large watery stools and vomited. The resident had [DIAGNOSES REDACTED]. The resident's care plan documented she was at risk for dehydration and electrolyte imbalances. The resident continued to have episodes of diarrhea, vomiting and decreased appetite. On 08/26/13 she had a change in her level of consciousness, elevated blood glucose levels and decreased oxygen concentrations. The Immediate Jeopardy situation continued for Resident #4 until she was transferred to a local hospital on [DATE]. The Administrator was notified of the Immediate Jeopardy situation on 09/11/13 at 10:55 a.m. A plan of removal was presented by the Administrator which read as follows: 1. Resident _____ (#4) was affected by deficient practice, was admitted to the hospital on [DATE]. 2. All residents who have a change in condition have a potential to be affected by the deficient practice. 3. The DON (Director of Nursing) or designee will immediately review all existing residents in the facility for any change in condition, as well as ensure that proper responsible party and physician notification have taken place. The DON will immediately in service all nursing staff on the necessity of communication, and policy and procedure on change in condition of residents and notification of responsible party and the primary care physician. Review and in service to all nurses on nurse notification report, for documentation and assessment of any change in condition. 4. The DON or designee will audit nurses' notes for responsible party and physician notification, assessment and monitoring for change in condition . This will be monitored daily X 4 weeks, then 3 X week for two weeks, then randomly thereafter. All findings will be corrected immediately and forwarded to the QI committee until compliance is achieved 5. 09/11/13 6. 09/17/13 (All in services will be completed for entire nursing staff by this day). The Immediate Jeopardy was removed on 09/11/13 at 2:30 p.m. when the surveyor confirmed all residents' records were reviewed for any change in condition and proper responsible party and physician notification. The deficient practice remains at a level 3 for actual harm to Resident #4 Findings: On 09/09/13 at 10:30 a.m. the surveyor requested a copy of the facility's policy and procedure on notification of the physician and responsible party and the facility's policy and procedure on nursing assessment and monitoring of residents' conditions. S1ADM provided the surveyor with a document titled "Change in Resident Medical Status (F 154, F 274)". S1ADM stated the document was not a facility policy but a "Practice". She was asked if she had any policies for nursing assessment and monitoring of residents' conditions. S1ADM stated "No, that comes with their license". S2DON was present during the interview and offered no other policies. Review of the facility's document titled Change in Resident Medical Status (F154, F274) revealed the following: A change in medical status is defined as any physical, psychological and/or medical deviation as compared to the resident's status as noted in the initial assessment.... A significant change is a decline or improvement in a resident' status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard-disease-related clinical interventions is not self limiting A facility must immediately infirm the resident, consult with the resident's physician, and if known, notify the resident's legal representative or an interested family member when there is: 2. A significant change in the resident's physical; mental or psychosocial status 3. A need to alter treatment significantly; or 4. A decision to transfer or discharge the resident from the facility Review of the clinical record revealed Resident #4 was an [AGE] year old woman admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 4 (severe cognitive impairment) The resident used a walker to ambulate and required one person physical assist for toilet use. Review of the care plan revealed the following: Problem Onset: 12/16/11: At risk for alteration in fluid status-dehydration & electrolyte imbalances... Goal & Target Date: Will be monitored for signs/symptoms dehydration/electrolyte imbalances & interventions will be taken as needed; review next care plan (10/03/13) On 09/06/13 at 8:00 a.m. a telephone interview was conducted with the resident's responsible party, her daughter. She reported her mother had been having diarrhea and vomiting since Friday, 08/23/13 and she was not notified. On 08/25/13 her sister, the resident's other daughter, visited their mother and reported to the responsible party their mother had hemorrhoids and was being given some type of cream. On 08/26/13 the responsible party visited her mother and found her receiving IV fluids. She stated after she left the nursing facility she phoned the facility and asked the staff "shouldn't she (the resident) go to the hospital?". She reported later that night, on 08/26/13, her mother was transferred to a local hospital. The resident's responsible party stated her mother was admitted to ICU ( intensive care unit) with "severe dehydration, fever and [MEDICAL CONDITION]". She stated her mother's kidneys failed and for the first time in her life she required [MEDICAL TREATMENT]. She stated her mother's physician, at the hospital, told her the resident may need [MEDICAL TREATMENT] for the rest of her life. The responsible party stated prior to hospitalization her mother ate a regular no added sugar diet and voided on her own. The resident is now on a puree diet and has a foley catheter. The responsible party stated on 09/05/13 her mother was placed in a regular room and is on isolation for a [MEDICAL CONDITION] infection. The responsible party stated her mother's physician and the nurse practitioner from the nursing facility, were not called about the resident's diarrhea and vomiting. Review of the Departmental Notes, the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 08/23/13 (Nurses' Notes) 4:30 p.m. Late entry...ate very little at breakfast, ate a few bites of meal... (Signed by: S5LPN) 08/23/13 (B&B) 10:08 p.m. Bowel Movement: extra large, watery liquid, nurse notified.. (Signed by: S11CNA) 08/23/13 (B&B) 10:09 p.m. Bowel Movement: extra large, watery liquid, nurse notified... (Signed by: S11CNA) 08/23/13 ( MAR) [MEDICATION NAME] 8 mg given for nausea/vomiting at 1:41 a.m..(Signed by: S20LPN) 08/23/13 (MAR) [MEDICATION NAME] 8 mg given for nausea/vomiting at 7:30 p.m ....(Signed by: S7LPN) 08/24/13 (Nurses' Notes) 11:03 p.m. Not eating well due to pain from fall.. (Signed by: S8LPN) 08/24/13 (B&B) 11:02 a.m. Bowel Movement: large, watery liquid, nurse notified.(Signed by: S13CNA) 08/25/13 (Nurses' Notes) 10:06 p.m. ..resident had large loose BM, observed approximately 5 cm of possible rectum protruding. RN Supervisor (S9RN) called and talked with_____ (S4NP) Gave orders for [MEDICATION NAME] BID, she will be here in am to evaluate..(Signed by: S8LPN) 08/26/13 (Nurses' Notes) 9:00 a.m. resident in bed refused breakfast Blood Sugar 160, B/P 109/60, Pulse 130, SPO2 79%. Verbal Orders from S4NP included oxygen per nasal cannula, intravenous fluids at 75 cc per hour and a stool for C -Diff ([MEDICAL CONDITION])...(Signed by S5LPN) 08/26/13 (Nurses' Notes) 9:45 p.m. CNA came to nurse stat stated "resident just vomited". Entered resident's room, found resident sweating profusely, asked resident if she was in pain, she did not respond, CBG (capillary blood glucose) 408, B/P 96/43, pulse 112. Contacted nurse practitioner, RP (Responsible Party) Sent resident to hospital for observation. (Signed by: S7LPN) On 09/09/13 at 1:45 p.m. an interview was conducted with S5LPN the nurse caring for the resident the day she was discharged to the hospital (08/26/13). She was asked what events led to the resident being hospitalized . She reported on 08/26/13 the resident had dry lips and just didn't look right. The resident had not gotten out of bed and when they turned her she had a diarrhea stool that smelled funny, so she sent a culture for [MEDICAL CONDITION]. She reported it was at that time the resident's roommate told the staff the resident had been having diarrhea since Friday. She was asked how long had the resident had diarrhea. S5LPN stated she was not sure how long the resident may have had diarrhea because she toileted herself. She was asked if the resident had fallen on 08/22/13. She stated "Yes". She was asked if the resident had been toileting herself since the fall. S5LPN stated "No". She stated the resident did not eat breakfast or lunch that day (08/26/13). Her blood glucose at breakfast was 200 and 400 at lunchtime. She received a verbal order from S4NP to start oxygen and an IV. She was asked if it had ever been reported by other staff to her that the resident was having diarrhea or vomiting. S5LPN stated "No". She went on to state the resident's appetite was poor on 08/26/13. She was asked if she reported the decreased appetite or diarrhea to the physician or nurse practitioner. S5LPN stated "No". On 09/10/13 at 11:45 a.m. an interview was conducted with S4NP. She was asked if she was the nurse practitioner that worked with Resident #4's physician. She stated "Yes". She reported she was in the facility Monday through Friday and was on call 24/7. She stated staff call her first before calling the physician. She was asked if she had been informed the resident had been having diarrhea, vomiting and a decreased appetite. S4NP stated "no, the only thing I was called about on the 25th was a possible protruding rectum and I ordered [MEDICATION NAME] and saw her the next day". She went on to state that on 08/26/13 she examined the resident and she did appear to have a prolapsed rectum. At the time of the exam she noticed the resident's stool smelled funny and she ordered a [MEDICAL CONDITION] culture be done along with a CXR, O2 per nasal cannula and IV fluids. She was asked if on 08/26/13, when she visited the resident, was she informed the resident had been having diarrhea, decreased appetite, or vomiting. S4NP stated "No". S4NP stated later that evening she was called because the resident's oxygen saturation was low so she ordered her to be sent to the hospital. On 09/10/13 at 3:00 p.m. an interview was conducted with S2DON. She was asked to review the resident's nurses' notes, bowel and bladder (B&B) roster and physician orders [REDACTED]. After reviewing the clinical record, she was asked if there was any documentation the resident's physician, nurse practitioner or responsible party had been notified of the decreased appetite, vomiting or the loose stools on 08/23/13, 08/24/13, 08/25/13 and 08/26/13. S2DON stated "No". On 09/10/13 at 4:30 p.m. an interview was conducted with S11CNA. She verified she had worked with the resident on the evening of 08/23/13. She was asked to review the B&B Roster. She was asked if she had charted the resident had 2 extra large watery stools and had she informed the nurse. S11CNA stated she had charted the resident had 2 extra large watery stools and she had informed S7LPN. On 09/10/13 at 4:55 p.m. an interview was conducted with S7LPN. She verified she had worked with the resident on the evening of 08/23/13 and 08/26/13. She was asked if she had been informed of the resident having had 2 large loose stools on 08/23/13. She stated "I don't remember being told that, but I did give her [MEDICATION NAME] for vomiting". She was asked if she had informed the physician, nurse practitioner or responsible party of the resident's loose stools or vomiting. S7LPN stated "No". Review of the nurses notes for 08/23/13 revealed no documentation of any nursing notes. S7LPN verified she had not documented any nurses' notes on the resident for 08/23/13. Review of the MAR indicated [REDACTED].m for vomiting. S7LPN was asked if she had been the nurse who had sent the resident to the hospital on [DATE]. She stated "Yes", on the evening of 08/26/13 a CNA reported to her the resident had vomited and went she went into the room and found her sweating profusely and when she spoke to the resident she did not respond. S7LPN stated her glucose was 400, S4NP was contacted and the resident was sent to the hospital. On 09/11/13 at 8:45 a.m. an interview was conducted with S13CNA. She verified she had worked with the resident on 08/24/13. She was asked to review the B&B Roster. She was asked if she had charted the resident had a large watery stool and had she informed the nurse. S13CNA stated the resident had a large watery stool and she informed S8LPN. She was asked to explain the notation "nurse notified" on the B&B roster. S13CNA stated after the CNAs enter anything abnormal the words "nurse notified" appears on the screen and the CNA hits the save button. She was asked if this is how the nurse is notified. S13CNA stated "yes". She was asked if she had informed S8LPN verbally. S13CNA stated "I'm not sure, I think I told her". On 09/11/13 at 9:10 a.m. a telephone interview was conducted with S8LPN. She verified she had worked with the resident on 08/24/13 and 08/25/13. After reading her notes to her, dated 08/24/13, she was asked if she had informed the physician or the nurse practitioner of the resident's poor appetite. She stated "No". She was asked if she had been informed of the resident having had a large diarrhea stool on 08/24/13 by the CNA. S8LPN stated "No". She was asked if she had informed the physician or nurse practitioner of the loose stool on 08/24/13. S8LPN stated "No". After reading her notes to her, dated 08/25/13, she was asked if she had informed the physician or the nurse practitioner of the resident's poor appetite and documented large loose bowel movement. S8LPN stated she told S4NP and S9RN. On 09/11/13 at 9:25 a.m. a telephone interview was conducted with S9RN. She verified she had worked on the evening of 08/25/13 and had spoken to S4NP. She was asked what had she spoken to S4NP about. S9RN stated she had informed S4NP that the resident seemed to have part of her rectum protruding and [MEDICATION NAME] was ordered. She was asked if she had informed S4NP of the resident having had a large loose stool. S9RN stated "No, I didn't know the resident had had a loose stool until I got off the phone and talked to S8LPN and then we both realized she didn't need [MEDICATION NAME]". Attempts to reach S20LPN, who documented [MEDICATION NAME] every 6 hours as needed for vomiting, on 08/23/13 at 1:41 a.m., by phone were unsuccessful. On 09/11/13 at 9:45 a.m. an interview was conducted with S2DON. She was asked to review the B&B Roster. She was asked if when the CNAs chart a deviance, such as a loose stool, and the notation "nurse notified" appeared on the screen and the CNAs hit the save button is that message sent to the nurse. S2DON stated "The information is sent to the nurse but the nurse has to seek out that screen to review and they know they are to do that". She was asked how are the CNAs supposed to notify the nurses of deviancies. S2DON stated "They are to chart it and they are also to verbally inform the nurse". S2DON stated "This is a new computer system and we are still getting used to it". On 09/09/13 at 9:00 a.m. an interview was conducted with S18RN, Director of Medical Surgical services at ___________hospital, where the resident was transferred to on 08/26/13. She was asked if the resident had received [MEDICAL TREATMENT]. After reviewing the computerized record she stated "Yes, [MEDICAL TREATMENT] was ordered 3 times a week". She was asked if the resident still received [MEDICAL TREATMENT]. After calling the [MEDICAL TREATMENT] unit, she stated "No, it was put on hold on 09/08/13". She was asked what were the resident's [DIAGNOSES REDACTED]. She is also receiving [MEDICATION NAME] ([MEDICATION NAME] Nutrition) in her IV fluids". She was asked if the resident was in isolation. S18RN stated "Yes, on 09/04/13 a stool specimen was collected and on 09/05/13 the results were positive for [MEDICAL CONDITION]". Review of the hospital's emergency department provider notes revealed the following: 08/26/13 Patient arrives from the nursing home for elevated blood glucose. After discussing with___ (S7LPN) at ____nursing home. She states the patient had an elevated glucose, decreased level of responsiveness to questioning and blood pressure to a systolic in the 90's. She has a baseline confusion and was slower to answering questions today than usual..... Clinical Impression: Fever, severe [MEDICAL CONDITION], needs IV antibiotics and admission to the hospital Review of the Nephrology Consult revealed the following: 08/27/13 Reason for Consult: Acute Kidney Injury Review of Systems: Gastrointestinal positive for diarrhea Assessment/Plan: 1. Acute kidney injury likely intravascular volume depletion 2. Metabolic Acidosis 3. Intravascular volume depletion 4. [MEDICAL CONDITION] The resident was admitted to the Intensive Care unit and on 08/29/13 a [MEDICAL TREATMENT] [MEDICATION NAME] catheter was placed.

Based on interviews and record reviews the facility failed to ensure the Quality Assessment and Assurance Committee identified actual quality deficiencies and implement appropriate plans of action for quality of care issues necessary to correct quality deficiencies (cross reference F157, F281, F282, F309, F441) Findings: On 09/11/13 at 12:55 p.m an interview was conducted with S3ADON. She was asked if she was the person responsible for the facility's quality assessment and assurance (QAA) and infection control programs. She stated "Yes". She was asked how does the QAA committee identify issues to be addressed by the QAA program. S3ADON stated "I just took this over, but we discuss any high risk issues such as skin, falls and social services issues". She was asked how often the QAA committee meets. She stated "we meet quarterly, our last meeting was on 07/25/13". She was asked if the QAA committee had identified quality deficiencies related to physician notification, nursing assessments, following physician orders, or isolation procedures. After reviewing the meeting minutes for 07/25/13, S3ADON stated "No". S3ADON stated "we did have an in service on universal precautions and handwashing". After reviewing the in service material, the ADON was asked if the in service had included any instruction on isolation procedures. S3ADON stated "No".

Based on observation, record review and interview, the facility failed to ensure that the Physician was consulted with and provided an accurate description of a resident's burn injury on an ongoing basis to ensure appropriate and continuous medical care for 1 of 1 residents (#3) investigated for burn injuries out of a sample of 14. Resident #3 was a nonverbal, cognitively impaired resident who was totally dependent on staff assistance with eating. On 1/19/11 at 6:00 p.m., a food tray containing a bowl of chili with a temperature of 200 degrees Fahrenheit was placed in front of resident #3 without staff supervision or assistance. The resident spilled hot food on herself resulting in a significant burn to her left anterior thigh. Resident #3 was placed in Immediate Jeopardy after the burn on 1/19/11 when the facility failed to notify the physician with an accurate assessment of the burn and the extent of the burn so that appropriate treatments for the burn and treatment for [REDACTED]. The Immediate Jeopardy ended for the resident on 2/16/11 when the physician examined the resident's 3rd degree burn wound and gave orders for treatment. The deficient practice continued for resident #3 at actual harm. The resident experienced a delay in treatment of [REDACTED]. The deficient practice continues as the facility has not implemented a system with quality assurance to ensure the deficient practice does not occur again. Findings: A review of resident #3's clinical record revealed [DIAGNOSES REDACTED]. A review of resident #3's Minimum Data Sheet, dated 12/22/10, revealed the facility assessed the resident as Cognitively impaired - decisions poor, cues/supervision required; Vision highly impaired - object identification in question, no corrective lenses and totally dependent on staff assistance for eating. On 2/15/11 at 4:00 p.m. an interview was conducted with S8LPN. S8LPN stated that resident #3 was nonverbal, but would make sounds. She stated that the resident was unable to do anything for herself and was fed by staff. S8LPN stated that on 1/19/11 she was the evening nurse assigned to resident #3. She stated that around supper time one of the CNAs brought resident #3 to her room from the dining room. She stated that she went into the resident's room and observed that the resident had chili all over her clothes. She stated that she asked a CNA to change the resident's clothes and was informed by the CNA that resident #3 had a red burn on her leg. She stated that she called the resident's physician and informed him that resident #3 had a burn to her left leg, the size of a hand. She stated that the physician gave her an order to apply a cool compress to the burn during the night and to apply [MEDICATION NAME] ointment to the burn for 7 days. She stated that she ordered the [MEDICATION NAME] ointment from the pharmacy and it was delivered to the facility the next day on 1/20/11. On 2/15/11 at 2:30 p.m. an observation was made of resident #3's left leg with S4RN/Wound Care Nurse and S6LPN. This observation revealed a wound to the resident's left upper, anterior thigh. The wound was irregularly shaped, and had a thick solid, brownish/yellow colored area that covered the wound. The edges of the wound were pink in color. S4RN stated she had not communicated with the resident's physician regarding the resident's burn injury. She stated that the primary nurse on duty when the injury occurred notified the physician. She further stated that she had not taken any measurements of the wound. The surveyor asked S4RN to measure the wound at this time. S4RN measured the wound and stated that the wound was 4.5 centimeters (cm) x 6.0 cm. She stated that the resident's leg injury occurred on 1/19/11 when she was burned by food. She stated the [MEDICATION NAME] was delivered to the facility from the pharmacy on 1/20/11. She stated that beginning on 1/20/11, the resident's wound was treated with [MEDICATION NAME] twice daily for 7 days. A review of the January 2011 TAR (Treatment Administration Record) for resident #3 revealed the following: 1/19/11 (start date) [MEDICATION NAME] burn ointment to left inner thigh twice daily for 7 days (7-3 and 3-11) - initialed by the nurses as administered: 1/20/11 - 7-3 and 3-11 shifts 1/21/11 - 7-3 and 3-11 shifts 1/24/11 - 7-3 and 3-11 shifts 1/25/11 - 7-3 and 3-11 shifts 1/26/11 - 7-3 and 3-11 shifts Further review of the January 2011 TAR for resident #3 revealed the following: 1/22/11 - 7-3 shift, not initialed as administered for 3-11 shift 1/23/11 - No documented evidence that [MEDICATION NAME] ointment was administered to resident #3's left leg burn for 7-3 and 3-11 shifts 1/27/11 - Completed There was no documented evidence on the TAR or Nurses' Notes that resident #3 received any treatment to the burn on her left thigh after 1/26/11. On 2/15/11 at 3:45 p.m. an interview was conducted with S28 Assistant Dietary Manager (DM). She stated that facility dietary staff take food temperatures on the stove and on the steam table just prior to serving the residents. She reviewed the facility's Daily Food Temperature Monitoring Log, dated 1/19/11, for the dinner meal. After reviewing the Log, she confirmed chili was served to the residents for dinner on 1/19/11. She further confirmed that the temperature taken of the chili in the pan on the stove and steam table was 200 degrees Fahrenheit. On 2/16/11 at 2:40 p.m. an interview was conducted with S5LPN. S5LPN stated that on 1/19/11, she worked the 3-11 shift and was in the dining room at the time dinner was served to the residents. She stated that it was evident that resident #3 had spilled the chili on herself. She stated that she knew something was wrong when she observed the frightened look on resident #3's face. On 2/16/11 at 1:45 p.m. an interview was conducted with S4RN/Wound Care Nurse. S4RN stated she had not received any training on caring for burn wounds. She stated that the 3-11 nurse contacted resident #3's physician when the burn wound occurred. She stated that she did not speak to the doctor regarding the resident's burn wound. She stated that orders for treatment of [REDACTED]. She stated that she thought the burn would be a 2nd degree burn because of the blisters that had formed at the burn site. She stated that when she first observed the wound on 1/20/11 it had blisters, but they burst, it had some dryness and at first it was very superficial. A review of the Weekly Body Audits performed by the facility on resident #3 from 1/19/11 through 2/12/11 revealed the following: 1/19/11: Burn noted to left inner thigh, water blisters also noted. Physician notified, new order - [MEDICATION NAME] burn ointment to site twice daily for 7 days and use cool compresses to area throughout night. 1/22/11: Burn to left thigh 1/29/11 through 2/12/11 - There was no documented evidence of an assessment of the resident's burn wound to her left thigh. A review of resident #3's Nurses' Notes dated 1/20/11 revealed, in part, the following: Dressing changed to left inner thigh area. Area noted to be reddened with minimum blistering noted at this time. There was no documented evidence on the Weekly Body Audits or in the Nurses' Notes that the burn wound to resident #3's left thigh was reassessed by the nursing staff after 1/20/11. A review of the Physician's Progress Notes from January 19, 2011 through February 15, 2011 which revealed a notation dated 1/27/11 that read in part, "Resident in wheelchair ..., Left inner thigh burn from spilling hot chili being treated with [MEDICATION NAME] ointment." There was no documented evidence that resident #3's burn wound to her left thigh was physically examined by the Nurse Practitioner on 1/27/11. On 2/16/11 at 2:30 p.m. an interview was conducted with S2DON. She stated that resident #3's Nurse Practitioner was in the facility on 1/27/11 for the resident's monthly medical evaluation. She confirmed that there was no documented evidence in resident #3's clinical record of documentation that the Nurse Practitioner evaluated the resident's burn wound on 1/27/11 or on any other date. She stated that she telephoned the Nurse Practitioner and asked her if she had evaluated resident #3's burn on 1/27/11. S2DON stated that the Nurse Practitioner told her that she did not evaluate the resident's burn when she was at the facility on 1/27/11 because the resident was sitting up in her wheelchair. S2DON verified that the Nurse Practitioner did not assess or evaluate the resident's burn to her left leg on 1/27/11. On 2/16/11 at 11:10 a.m. a telephone interview was conducted with S16 Medical Doctor (MD). He stated that he relied on the nurse's description and notification when an injury occurs. He stated that the description of resident #3's burn wound should have been communicated to him. On 2/16/11 at 1:40 p.m. an interview was conducted with S16 MD while he examined the burn wound to resident #3's left thigh. He stated that the burn was full thickness and that it was a third degree burn. He stated that he was notified when the burn occurred, but did not know that it was a third degree burn. S16 MD wrote orders for treatment of [REDACTED]. S16 MD verified that the facility should have sent the resident to the emergency roiagnom on the date the burn occurred for assessment and treatment. He verified that 2/16/11 was the first time he had observed resident #3's burn wound to her left thigh. A review of the New physician's orders [REDACTED]. 1. Wet to dry saline wound dressing to left thigh daily; 2. Gently remove or pull off eschar as tolerated; 3. Once eschar removed, apply [MEDICATION NAME] Ointment daily to wound until healed. On 2/16/11 at 2:30 p.m. an interview was conducted with S2DON. She confirmed that the documentation in resident #3's Care Plan documented the burn wound to the resident's left thigh as resolved. S2DON verified that the burn wound had not resolved.

Based on observation, interview and record review the facility failed to assess a resident on an ongoing basis for 1 of 1 residents (#3) investigated for burn injuries out of a sample of 14. Resident #3 experienced a burn to the left inner thigh on 1/19/11 from hot chili. For resident #3, the facility failed to: 1. provide ongoing assessment, including measurements, of the burn until healed, and 2. assess the resident for pain from the burn. Resident #3 was a nonverbal, cognitively impaired resident who was totally dependent on staff assistance with eating. On 1/19/11 at 6:00 p.m., a food tray containing a bowl of chili with a temperature of 200 degrees Fahrenheit was placed in front of resident #3 without staff supervision or assistance. The resident spilled hot food on herself resulting in a significant burn to her left anterior thigh. Resident #3 was placed in Immediate Jeopardy after the burn on 1/19/11 when the facility failed to assess, on an ongoing basis, the burn and the extent of the burn so that appropriate treatments for the burn and treatment for [REDACTED]. The Immediate Jeopardy ended for the resident on 2/16/11 when the physician examined the resident's 3rd degree burn wound and gave orders for treatment. The deficient practice continued for resident #3 at actual harm. The resident experienced a delay in treatment of [REDACTED]. The deficient practice continues as the facility has not implemented a system with quality assurance to ensure the deficient practice does not occur again. Findings: A review of resident #3's clinical record revealed [DIAGNOSES REDACTED]. A review of resident #3's Minimum Data Sheet, dated 12/22/10, revealed the facility assessed the resident as Cognitively impaired - decisions poor, cues/supervision required; Vision highly impaired - object identification in question, no corrective lenses and totally dependent on staff assistance for eating. On 2/16/11 at 2:40 p.m. an interview was conducted with S5LPN. S5LPN stated that on 1/19/11, she worked the 3-11 shift and was in the dining room at the time dinner was served to the residents. She stated that it was evident that resident #3 had spilled the chili on herself. She stated that she knew something was wrong when she observed the frightened look on resident #3's face. She stated she observed chili on her and immediately got the resident's nurse, S8LPN. She verified that she did not wipe the chili off of the resident. On 2/15/11 at 4:00 p.m. an interview was conducted with S8LPN. S8LPN stated that resident #3 was nonverbal, but would make sounds. She stated that the resident was unable to do anything for herself and was fed by staff. S8LPN stated that on 1/19/11 she was the evening nurse assigned to resident #3. She stated that on 1/19/11, around supper time one of the CNAs brought resident #3 to her room from the dining room. She stated that she went into the resident's room and observed that the resident had chili all over her clothes. She stated that she asked a CNA to change the resident's clothes and was informed by the CNA that resident #3 had a red burn on her leg. She stated that she called the resident's physician and informed him that resident #3 had a burn to her left leg, the size of a hand. She stated that when the resident was touched at the area of the burn, she would make a facial grimace. She stated that the physician gave her an order to apply a cool compress to the burn during the night and to apply [MEDICATION NAME] ointment to the burn for 7 days. She stated that she ordered the [MEDICATION NAME] ointment from the pharmacy and it was delivered to the facility the next day on 1/20/11. A review of the Nurses Notes regarding resident #3 revealed the following: 1/19/11, 6:45 p.m.: Reported to resident's room per CNA. Resident observed with moderate burn to left inner thigh, water blisters also noted. Resident nonverbal and unable to state what happened. Prior to resident being given care in room, resident was in dining room at feeder table. Resident noted with food on clothes and resident was taken to room to change clothes. Burn to left thigh is consistent with chili stain on clothes. Incident was unwitnessed. Doctor notified and new order received for [MEDICATION NAME] burn ointment to area twice a day for seven days and use cool compresses throughout the night. On 2/15/11 at 2:30 p.m. an observation was made of resident #3's left leg with S4RN/Wound Care Nurse and S6LPN. This observation revealed a wound to the resident's left upper, anterior thigh. The wound was irregularly shaped, and had a thick solid, brownish/yellow colored area that covered the wound. The edges of the wound were pink in color. S4RN stated she had not communicated with the resident's physician regarding the resident's burn injury. She stated that the primary nurse on duty when the injury occurred notified the physician. She further stated that she had not taken any measurements of the wound. The surveyor asked S4RN to measure the wound at this time. S4RN measured the wound and stated that the wound was 4.5 centimeters (cm) x 6.0 cm. She stated that the resident's leg injury occurred on 1/19/11 when she was burned by food. She stated the [MEDICATION NAME] was delivered to the facility from the pharmacy on 1/20/11. She stated that beginning on 1/20/11, the resident's wound was treated with [MEDICATION NAME] twice daily for 7 days. On 2/16/11 at 1:45 p.m. an interview was conducted with S4RN/Wound Care nurse. She stated that she documents wound treatments on the TAR. She stated she had not received any training on caring for burn wounds. She stated that she did not review the facility's policy & procedure for treatment of [REDACTED].#3's physician when the burn wound occurred. She stated that she did not speak to the doctor regarding the resident's burn wound as she was not working when the burn occurred. She stated that when she first observed the wound on 1/20/11 it had blisters, but they burst, it had some dryness and at first it was very superficial. A review of the Weekly Body Audits performed by the facility on resident #3 from 1/19/11 through 2/12/11 revealed the following: 1/19/11: Burn noted to left inner thigh, water blisters also noted. Physician notified, new order - [MEDICATION NAME] burn ointment to site twice daily for 7 days and use cool compresses to area throughout night. 1/22/11: Burn to left thigh 1/29/11 through 2/12/11 - There was no documented evidence of an assessment of the resident's burn wound to her left leg. A review of the January 2011 and February 2011 TAR (Treatment Administration Record) for resident #3 revealed the following: 1/19/11 (start date) [MEDICATION NAME] burn ointment to left inner thigh twice daily for 7 days (7-3 and 3-11) - initialed by the nurses as administered: 1/20/11 - 7-3 and 3-11 shifts 1/21/11 - 7-3 and 3-11 shifts 1/24/11 - 7-3 and 3-11 shifts 1/25/11 - 7-3 and 3-11 shifts 1/26/11 - 7-3 and 3-11 shifts Further review of the January 2011 TAR for resident #3 revealed the following: 1/22/11 - 7-3 shift, not initialed as administered for 3-11 shift 1/23/11 - No documented evidence that [MEDICATION NAME] ointment was administered to resident #3's left leg burn for 7-3 and 3-11 shifts 1/27/11 - Completed There was no documented evidence on the January 2011 or February 2011 TAR that resident #3 received any treatment to her left thigh burn wound after 1/26/11. A review of the January 2011 and February 2011 MAR was conducted. There was no documented evidence on the January 2011 or February 2011 MAR that resident #3 received any treatment to the burn on her left thigh after 1/26/11. A review of the January 2011 and February 2011 revealed no documented evidence on the January 2011 or February 2011 Nurses Notes that resident #3 received any treatment or assessment to the burn on her left thigh after 1/26/11. A review of the Care Plan for resident #3 with a Goal date of 2/20/11 revealed in part the following: Problem Onset: 1/19/11 - Burn to left inner thigh Approaches: Treatment as Ordered; Monitor for signs and symptoms of infection. Goal & Target Date: 2/20/11 - Will remain free from [MEDICAL CONDITION]- Resolved On 2/16/11 at 2:30 p.m. an interview was conducted with S2DON. She confirmed that the documentation in resident #3's Care Plan documented the burn wound to the resident's left thigh as resolved. S2DON verified that the burn wound had not resolved. A review of resident #3's Nurses' Notes dated 1/20/11 revealed, in part, the following: Dressing changed to left inner thigh area. Area noted to be reddened with minimum blistering noted at this time. There was no documented evidence on the Weekly Body Audits or in the Nurses' Notes that the burn wound to resident #3's left thigh was reassessed by the nursing staff after 1/20/11. A review of the Physician's Progress Notes from January 19, 2011 through February 15, 2011 which revealed a notation dated 1/27/11 that read in part, "Resident in wheelchair ..., Left inner thigh burn from spilling hot chili being treated with [MEDICATION NAME] ointment." There was no documented evidence that resident #3's burn wound to her left thigh was physically examined by the Nurse Practitioner on 1/27/11. On 2/16/11 at 2:30 p.m. an interview was conducted with S2DON. She stated that resident #3's Nurse Practitioner was in the facility on 1/27/11 for the resident's monthly medical evaluation. She confirmed that there was no documented evidence in resident #3's clinical record of documentation that the Nurse Practitioner evaluated the resident's burn wound on 1/27/11 or on any other date. She stated that she telephoned the Nurse Practitioner and asked her if she had evaluated resident #3's burn on 1/27/11. S2DON stated that the Nurse Practitioner told her that she did not evaluate the resident's burn when she was at the facility on 1/27/11 because the resident was sitting up in her wheelchair. S2DON verified that the Nurse Practitioner did not assess or evaluate the resident's burn to her left leg on 1/27/11. On 2/16/11 at 11:10 a.m. a telephone interview was conducted with S16 Medical Doctor (MD). He stated that he relied on the nurse's description and notification when an injury occurs. He stated that the description of resident #3's burn wound should have been communicated to him. On 2/16/11 at 1:40 p.m. an interview was conducted with S16 MD while he examined the burn wound to resident #3's left thigh. He stated that the burn was full thickness and that it was a third degree burn. He stated that he was notified when the burn occurred, but did not know that it was a third degree burn. S16 MD wrote orders for treatment of [REDACTED]. S16 MD verified that the facility should have sent the resident to the emergency roiagnom on the date the burn occurred for assessment and treatment. He verified that 2/16/11 was the first time he had observed resident #3's burn wound to her left thigh. II. Based on record review and staff interview, the facility failed to ensure that residents were assessed for pressure sores/skin problems for 2 of 23 sampled residents reviewed for skin assessments (#1 #16). Findings: Review of the facility's policy and procedure, entitled Weekly Body Audit Assessment, revealed the following: 1. DON will assign to nursing staff, residents for weekly body audits. All licensed staff, except night shift (If a resident routinely awakens early in the AM - 5:00 or 6:00 am - then a body audit may be done at that time), should be involved in scheduled weekly body audits and must physically assess resident for pressure sores/skin problems. Weekly body audits will be documented on the MAR/TAR. New problems not identified since last body audit, will be indicated by a "Y". No new problems will be indicated by a "N". 2. When "Y" is noted, there must be follow-up documentation on the "Weekly Body Audit Sheet" (Form NS - 699) and follow-up care according to applicable policies and procedures, i.e.: assessment and care plan. Resident #1 Review of the resident's record revealed that the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the resident's MDS assessments dated 12/05/10 and 01/19/11, revealed that the resident was incontinent of urine, and was non-ambulatory. Review of the resident's assessments revealed that the resident was assessed to be at risk for skin breakdown. The record also revealed that the resident was hospitalized from [DATE] to 12/01/10. Review of the February 2011 MAR revealed the following: Weekly Body Audit, Y = New Problem, N = No New Problem. Start Date: 12/01/10 Time Codes: 3 - 11. Review of the MAR revealed that the body audit was scheduled for Mondays. There was no documented evidence on the MAR that the weekly body audits had been done. Review of the record revealed that only one Weekly Body Audit was documented for the month of January. This body audit dated 01/12/11 revealed the following: Right foot - small blackened area (dime sized) area under skin next to pinky toe, black bruise on top of right hand, greenish bruise upper right forearm. Review of the binder of Weekly Body Audits revealed that Resident #1 had only one weekly body audit, but the date was not legible. The body audit revealed, "No new breakdowns". There was no documented evidence of any weekly body audits from 01/12/11 to the one audit in February. There was no documented evidence of any follow up to the skin problems documented on the 01/12/11 body audit. On 02/16/11 at 11:20 a.m., S21LPN was interviewed. After reviewing the February MAR and the Weekly Body Audit records, she verified that there was no documentation on the MAR that any weekly body audits were done in February. After reviewing the binder of Weekly Body Audits done in February, she verified that one weekly body audit was in the binder for Resident #1, but verified that she could not tell what the date of the audit was. After checking the schedule for the resident's body audits, she stated that the resident was scheduled to have a body audits done on Wednesdays on the 3 - 11 shift. After reviewing the MAR she verified that the schedule on the MAR was for the audits to be done on Mondays on the 3 - 11 shift. On 02/16/11 at 11:25 a.m., S4RN Wound Nurse was interviewed. After reviewing the resident's record, she verified that there was no documented evidence of any weekly body audits since 01/12/11. S4RN stated that all of the body audits that were in the binder were from February. After reviewing the binder, she verified that she could not tell what the date of the audit was, but knew that it was in February because only the current month of body audits were kept in the binder. S4RN verified that there was no documented evidence of any weekly body audits from 01/12/11 to the one done in February. Resident #16 Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Admission MDS revealed the resident required extensive assistance with transfers and ADL's. On 02/17/11 at 9:00 a.m., during an interview with the resident, S11CNA and S20CNA came into the resident's room to provide incontinent care. An observation at that time revealed a large bruised area around the resident's vas cath site on her upper right shoulder. There was also bruising around her right breast and under her right arm. The resident also had several bruises on her lower extremities. She reported the bruising was from the other facility she had lived at until about 3 weeks ago. When asked about the bruising on her right breast and shoulder she reported she couldn't remember when that happened. The resident said she went to the [MEDICAL TREATMENT] unit every Mon-Wed-Fri. Record review revealed the following documentation on the Initial Nursing assessment dated [DATE]: "Multiple bruising's to arms, legs, stomach, and back. Scar to (R) side /\ stomach to mid stomach. Scar (L) upper under arm. Port on (R) /\ chest-dressing clean dry & intact. Red blanchable area to /\ buttock. O (no) open areas noted." Review of the MAR dated February 2011 revealed an order to "Check Bruit & Thrill Twice Daily." The nurse's documented the checks daily on the 7-3 and 3-11 shifts. The MAR also had documentation that the resident's body audit was done on 02/04/11 and 02/11/11. Review of the Nurse's Notes revealed the following documentation: 02/09/11 at 3:30 p.m. "Called to room c (with) 3-11 nurse. Noted resident sitting on floor b between w/c & bed. Good ROM to all extremities. Denies any discomfort. Assisted by 2 nurses & CNA into bed............" The note was signed by S17LPN. 02/10/11 at 9:30 a.m. "Resident states she started having discomfort to (R) shoulder & mid back during night, obtained order for x-ray of (R) shoulder and T-spine." 02/10/11 at 4:00 p.m. "X-ray results back all being normal.........." On 02/17/11 at 9:45 a.m. an interview with assigned to care for the resident revealed she was unaware of any bruising on resident's right breast, right shoulder or right under arm. She reported she knew the resident had bruising on her legs, thighs, and arms. She said the resident had a vas cath in her right upper shoulder and went to [MEDICAL TREATMENT] 3 times a week. She reported the resident receives blood thinners during her treatment and that could have caused the bruising. The LPN reported she did the resident's Weekly Body Audit on Friday, 02/11/11, and didn't see the bruising. She said she documented on the MAR when she did the body audit but there were no changes so she didn't have to do the Weekly Body Audit form. On 02/17/11 at 10:00 a.m. an interview was held with S3ADON. She reviewed the Body Audit Book and found no body audits for 01/28/11, 02/04/11 or 02/11/11. She reviewed the CNA Jot Book and found no documentation of the bruising on the resident's right shoulder, breast or under arm. She reviewed the body audit from when the resident was admitted on [DATE] and acknowledged there was no documentation of the bruising on the resident's right shoulder, right breast or right under arm. On 02/17/11 at 10:10 a.m. an interview with S11CNA, who provided incontinent care to the resident that morning, revealed one day last week she went in the resident's room with S18CNA and saw the large bruised area on the resident's right shoulder and breast. She said she asked S18CNA, who was the resident's regular CNA, about the bruising. She reported S18CNA told her the nurse knew about the bruising around the resident's right breast. She acknowledged she didn't write in the CNA Jot Book about the bruising. At that time she wrote in the CNA Jot Book about the bruising. On 02/17/11 at 10:20 a.m. a skin assessment was done, with S3ADON and S17LPN, of the resident when she returned from therapy. They both acknowledged the large bruised area on the resident's right breast, right underarm and right upper arm at the vas cath site. S17LPN reported she didn't see the bruising when she did the resident's body audit on Friday, 02/11/11. She reported no one had told her about the bruising. S3ADON said the bruising should have been assessed and documented. She reported the resident did have a fall on 02/09/11 which could have caused the bruising. On 02/17/11 at 3:05 p.m. an interview was held with S18CNA who took care of the resident on the evening shift (3-11pm). She reported she noticed the bruising last week and told S28, the nurse that worked on the evening. She said the nurse worked Monday through Friday on the evening shift and she thought she told her on Monday evening, 02/07/11. She reported she works on different halls in the facility and when she sees something wrong with the residents she tells the nurse. She reviewed the CNA Jot Book and acknowledged she didn't document the bruising when she found it. On 02/17/11 at 3:20 p.m. an interview with S19LPN, who worked on the 3-11 shift with the resident for the past 3 nights. She reported no one told her about the bruising to the resident's right shoulder, breast or underarm. She said she didn't know anything about it. On 02/17/11 at 3:35 p.m. an interview with S29 Assistant Administrator revealed S28 was on maternity leave and her last day to work was 02/09/11.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain the highest practicable physical and psychosocial well-being for 1 of 1 resident (#3) investigated [MEDICAL CONDITION] of a sample of 14. Resident #3 experienced a burn to the left inner thigh on 1/19/11 from hot chili. For resident #3, the facility failed to: 1. provide ongoing assessment, including measurements, of the burn until healed; 2. care plan approaches for nursing to continuously assess the burn and consult with the physician if the burn did not improve; 3. care plan approaches to observe/assess/manage pain secondary to the burn on the resident's left thigh; 4. treat the burn after the 7 days of [MEDICATION NAME] tx. ended on 1/26/11; 5. treat the resident for pain; 6. notify the nurse practitioner of the condition of the burn on 1/27/11; 7. notified the physician of a thorough description of the burn and it ' s severity. Resident #3 was a nonverbal, cognitively impaired resident who was totally dependent on staff assistance with eating. On 1/19/11 at 6:00 p.m., a food tray containing a bowl of chili with a temperature of 200 degrees Fahrenheit was placed in front of resident #3 without staff supervision or assistance. The resident spilled hot food on herself resulting in a significant burn to her left anterior thigh. Resident #3 was placed in Immediate Jeopardy after the burn on 1/19/11 when the facility failed to conduct an accurate comprehensive assessment of the burn area and notify the physician of the extent of the burn so that appropriate treatments for the burn and treatment for [REDACTED]. The Immediate Jeopardy ended for the resident on 2/16/11 when the physician examined the resident's 3rd degree burn wound and gave orders for treatment. The deficient practice continued for resident #3 at actual harm. The resident experienced a delay in treatment of [REDACTED]. The deficient practice continues as the facility has not implemented a system with quality assurance to ensure the deficient practice does not occur again. Findings: A review of resident #3's clinical record revealed [DIAGNOSES REDACTED]. A review of resident #3's Minimum Data Sheet, dated 12/22/10, revealed the facility assessed the resident as Cognitively impaired - decisions poor, cues/supervision required; Vision highly impaired - object identification in question, no corrective lenses and totally dependent on staff assistance for eating. A review of resident #3's Nutritional Progress Notes dated 12/22/10 revealed the resident was on a soft mechanical, thin liquids diet and was fed by staff in the dining room. A review of the Eating Assistance Room listed that resident #3 ate at Table 5 for her meals. On 2/15/11 at 4:00 p.m. an interview was conducted with S8LPN. S8LPN stated that resident #3 was nonverbal, but would make sounds. She stated that the resident was unable to do anything for herself and was fed by staff. S8LPN stated that on 1/19/11 she was the evening nurse assigned to resident #3. She stated that around supper time one of the CNAs brought resident #3 to her room from the dining room. She stated that she went into the resident's room and observed that the resident had chili all over her clothes. She stated that she asked a CNA to change the resident's clothes and was informed by the CNA that resident #3 had a red burn on her leg. She stated that she called the resident's physician and informed him that resident #3 had a burn to her left leg which was the size of a hand. She stated that the physician gave her an order to apply a cool compress to the burn during the night and to apply [MEDICATION NAME] ointment to the burn for 7 days. She stated that she ordered the [MEDICATION NAME] ointment from the pharmacy and it was delivered to the facility the next day on 1/20/11. She stated that when the resident was touched at the area of the burn, she would make a facial grimace. On 2/15/11 at 2:30 p.m. an observation was made of resident #3's left leg with S4RN/Wound Care Nurse and S6LPN. This observation revealed a wound to the resident's left upper, anterior thigh. The wound was irregularly shaped, and had a thick solid, brownish/yellow colored area that covered the wound with pink edges. S4RN stated she had not taken any measurements of the wound. The surveyor asked S4RN to measure the wound at this time. S4RN measured the wound and stated that the wound was 4.5 centimeters (cm) x 6.0 cm. She stated that the resident's leg was burned by food on 1/19/11. She stated that the resident had cool compresses applied to the wound during the night of 1/19/11. She stated the [MEDICATION NAME] was delivered to the facility on [DATE] and that starting on 1/20/11, the resident's wound was treated with [MEDICATION NAME] twice daily for 7 days. S4RN/Wound Care Nurse verified that resident #3 received no further treatment for [REDACTED]. On 2/16/11 at 2:30 p.m. an interview was conducted with S9DM. She verified that the cooked food temperatures are monitored only to ensure that they don't fall below 165-180 degrees Fahrenheit when served to the residents. S9DM further verified that the temperature of the chili served to the residents at dinner on 1/19/11 was 200 degrees Fahrenheit. A review of the Nurses Notes regarding resident #3 revealed the following: 1/19/11, 6:45 p.m.: Reported to resident's room per CNA. Resident observed with moderate burn to left inner thigh, water blisters also noted. No signs or symptoms of pain noted. Resident nonverbal and unable to state what happened. Prior to resident being given care in room, resident was in dining room at feeder table. Resident noted with food on clothes and resident was taken to room to change clothes. Burn to left thigh is consistent with chili stain on clothes. Incident was unwitnessed. Doctor notified and new order received for [MEDICATION NAME] burn ointment to area twice a day for seven days and use cool compresses throughout the night. Tylenol 1000 milligrams (mg) also given at this time for pain. On 2/16/11 at 2:30 p.m. an interview was conducted with S10 RN. She stated that she was the RN Supervisor in the dining room for dinner on 1/19/11. She stated that at 6:00 p.m. she brought resident #3's food tray and put it on her table on 1/19/11. She stated that there was someone at the table when she placed the tray on the table. She stated that at approximately 6:30 p.m. - 6:40 p.m. she was informed by the floor tech that resident #3 had spilled her food. She stated that she did not clean the chili off of the resident or assess her at that time. She stated that she wheeled the resident back to her room at that time. She verified that a CNA was supposed to be at the table with the residents when the meal tray was placed on the table and to remain at the table with the residents until the meal trays were removed. S10 RN further verified that she was unable to say that there was a CNA at each feeding table with the residents on 1/19/11. On 2/16/11 at 1:35 p.m. an interview was conducted with S5LPN. She stated that she was present in the dining room on 1/19/11 when resident #3 was burned by the chili. She stated that resident #3 normally doesn't respond to much, but when that chili hit her leg, you should have seen her face, it really hurt her. On 2/16/11 at 2:40 p.m. an interview was conducted with S5LPN. S5LPN stated that on 1/19/11, she worked the 3-11 shift and was in the dining room at the time dinner was served to the residents. She stated that it was evident that resident #3 had spilled the chili on herself. She stated that she knew something was wrong when she observed the frightened look on resident #3's face. She stated she observed chili on the resident and immediately got the resident's nurse, S8LPN. She verified that she did not wipe the chili off of the resident. A review of the Nurses Notes regarding resident #3 revealed the following: 1/19/11, 6:45 p.m.: Reported to resident's room per CNA. Resident observed with moderate burn to left inner thigh, water blisters also noted. No signs or symptoms of pain noted. Resident nonverbal and unable to state what happened. Prior to resident being given care in room, resident was in dining room at feeder table. Resident noted with food on clothes and resident was taken to room to change clothes. Daughter visiting at this time. Burn to left thigh is consistent with chili stain on clothes. Incident was unwitnessed. Doctor notified and new order received for [MEDICATION NAME] burn ointment to area twice a day for seven days and use cool compresses throughout the night. Tylenol 1000 milligrams (mg) also given at this time for pain. A review of the January 2011 MAR (Medication Administration Record) for resident #3 revealed, in part, the following: 1/19/11 (start date): Cool Compress to Left Inner Thigh throughout night - initialed by the nurses as administered for the 3-11 and 11-7 shifts on 1/19/11. 1/13/11 (start date): Tylenol Extra Strength (ES) 2 tablets by mouth every 6 hours as needed for fever or pain - initialed by the nurses as administered on 1/19/11 at 8:30 p.m. for burn to left inner thigh - facial grimacing when touched and on 1/21/11 at 6:30 p.m. for burn to left inner thigh. Further review of resident #3's January 2011 and February 2011 MAR indicated [REDACTED]. On 2/16/11 at 9:35a.m. an interview was conducted with S4RN/Wound Care Nurse. S4RN stated that to her knowledge, resident #3 had not expressed any pain after her leg was burned on 1/19/11. She stated that the resident was nonverbal and would make noises. S4RN stated that she was unaware of how resident #3 expresses pain. A review of the January 2011 TAR (Treatment Administration Record) for resident #3 revealed the following: 1/19/11 (start date) [MEDICATION NAME] burn ointment to left inner thigh twice daily for 7 days (7-3 and 3-11) - initialed by the nurses as administered: 1/20/11 - 7-3 and 3-11 shifts 1/21/11 - 7-3 and 3-11 shifts 1/24/11 - 7-3 and 3-11 shifts 1/25/11 - 7-3 and 3-11 shifts 1/26/11 - 7-3 and 3-11 shifts Further review of the January 2011 TAR for resident #3 revealed the following: 1/22/11 - 7-3 shift, not initialed as administered for 3-11 shift 1/23/11 - No documented evidence that [MEDICATION NAME] ointment was administered to resident #3's left leg burn for 7-3 and 3-11 shifts 1/27/11 - Completed There was no documented evidence on the TAR or Nurses' Notes that resident #3 received any treatment to the burn on her left thigh after 1/26/11. A review of the Care Plan for resident #3 with a Goal date of 2/20/11 revealed in part the following: Problem Onset: 1/19/11 - Burn to left inner thigh Approaches: Treatment as Ordered; Monitor for signs and symptoms of infection. Notify doctor if it should occur; Staff to use caution during meals while feeing. Goal & Target Date: 2/20/11 - Will remain free from [MEDICAL CONDITION]- Resolved Further review of the Care Plan for resident #3 revealed no approaches to observe/assess/manage pain secondary to the burn on the resident's left thigh, incurred on 1/19/11. On 2/16/11 at 11:30 a.m. an interview was conducted with S2DON while reviewing resident #3's clinical record. S2DON stated that the nurse documented that the resident made facial grimaces when touched at the burn site. She stated that the resident received Tylenol 500mg. on 1/19/11 and again on 1/21/11. S2DON stated that the facility had a Pain Assessment Form which the nurses use to document their assessment of a resident's pain. S2DON verified that there was no documented evidence in resident #3's clinical record of a pain assessment done on resident #3 after her left leg was burned on 1/19/11. On 2/16/11 at 1:45 p.m. an interview was conducted with S4RN/Wound Care Nurse. She stated she had not received any training on caring for burn wounds. She stated that she did not review the facility's policy & procedure for treatment of [REDACTED].#3's physician when the burn wound occurred. She stated that she did not speak to the doctor regarding the resident's burn wound as she was not working when the burn occurred. She stated that orders for treatment of [REDACTED]. She stated that she thought the burn would be a 2nd degree burn because of the blisters that had formed at the burn site. She stated that when she first observed the wound on 1/20/11 it had blisters, but they burst, it had some dryness and at first it was very superficial. A review of resident #3's Nurses' Notes dated 1/20/11 revealed, in part, the following: Dressing changed to left inner thigh area. Area noted to be reddened with minimum blistering noted at this time. There was no documented evidence in resident #3's clinical record of an assessment of the characteristics, intensity or type of pain the resident experienced as a result of the third degree burn wound to her left thigh incurred on 1/19/11 after spilling a bowl of chili with a temperature of 200 degrees Fahrenheit onto herself. II. Based on record review and staff interview, the facility failed ensure that the resident received the necessary care and service to attain the highest practicable physical, mental, and psychosocial well-being by failing to ensure that hospice and facility services were coordinated to ensure that the resident did not experience any lack of facility services. The facility failed to ensure that the resident receiving hospice services received a bath by facility staff for 1 of 2 sampled residents receiving hospice services (Resident #9). Findings: Resident #9 Review of the resident's record revealed that the resident returned to the facility from a hospital admission on 01/01/11. The record revealed that the resident was admitted to a local hospice agency on 01/10/11 with the [DIAGNOSES REDACTED]. Review of the hospice binder in the facility revealed that the hospice aide made visits 3 times a week on Monday, Wednesday, and Friday, and provided a bed bath (Resident had PEG tube). Review of the facility's plan of care revealed the following: Problem Onset: 01/10/11 Problem: Resident is hospice per _____ (Local hospice name) related to [DIAGNOSES REDACTED]. Approaches: Hospice nurse/CNA to correlate care with nursing home staff. Hospice to be invited to care plan meetings; Hospice CNA visit throughout week and provide ADL care and bathe/Nurse to visit weekly and assess. Review of the facility's ADL documentation for the month of February 2011, revealed the following: (A) Bed: Bath Days on Monday, Wednesday, Friday. Time Code: 7-3. Review of the section with space to document bath daily, revealed, "Hospice" written across the spaces. There was no documented evidence that the resident had received a bath from the facility. On 02/15/11 at 2:25 p.m., S17LPN was interviewed and verified that she was assigned to Resident #9. S17LPN stated that the hospice aide visited on Monday, Wednesday, and Friday and bathed the resident. When asked when the facility bathed the resident, she stated that the resident was in the "A" bed and all residents in "A" beds were on a bath schedule of Monday, Wednesday, and Friday. S17LPN stated that the residents in the "B" beds were bathed on Tuesday, Thursday, and Saturday. S17LPN verified that the hospice aide bathed the resident on Monday, Wednesday, and Friday. On 02/15/11 at 2:30 p.m., S24RN MDS was interviewed. When asked how the resident's care was coordinated with the hospice agency, she stated that she invited the hospice nurse to their care plan meeting. When asked how specifically the aide visits were coordinated, she stated, "It's a given that the hospice aide visits on Monday, Wednesday, and Friday." S24RN stated that the hospice aide providing the resident's bath was, "Part of the care they help us with." S24RN stated that the resident did not need a bath every day. When informed that the resident's schedule at the facility was that she was bathed by the facility on Monday, Wednesday, and Friday, she verified that the bath schedule had not been coordinated with the hospice agency. On 02/16/11 at 9:20 a.m., S20CNA was interviewed and verified that she was assigned to Resident #9. When asked when the resident received a bath, she stated that the hospice aide gives the bath. S20CNA verified that they do not give her a bath on Tuesday, Thursday, or Saturday. She verified that residents in the "A" bed are bathed on Monday, Wednesday, and Friday. S20CNA stated that the hospice aide has already visited today and gave the resident a bath. On 02/16/11 at 10:25 a.m., the hospice agency case manager/RN was present in the building and was interviewed. When asked about the hospice aide visits for Resident #9, she stated that the aide visited on Monday, Wednesday, and Friday, and gave the resident a bath. When informed that the facility schedule for the resident's bath was on Monday, Wednesday, and Friday, she stated that she did not know that. She stated that the facility used to have a CNA Supervisor and she would change the resident's bath schedule to other days. She stated that she did not know that the resident was not being bathed by the facility. She stated, "We did not communicate that very well." She verified that the hospice and facility bath schedules were not coordinated.

Based on observation, record review and interview, the facility failed to provide adequate supervision to prevent accidents and allow hot food to become an accident hazard for 1 of 1 residents(#3) investigated for burns out of a sample of 14. The facility failed to: 1. provide supervision to a cognitively impaired resident when served hot food. The resident was served hot food and left unattended. 2. provide assistance with feeding to a cognitively impaired resident (#3) who was identified as needing assistance. Resident #3 was a nonverbal, cognitively impaired resident who was totally dependent on staff assistance with eating. Resident #3 was placed in Immediate Jeopardy on 1/19/11 at 6:00 p.m. when a food tray containing a bowl of chili with a temperature of 200 degrees Fahrenheit was placed in front of the resident without staff supervision or assistance. The facility failed to realize the hot food was an accident hazard when served to this cognitively impaired resident who was totally dependent on staff assistance for eating. The resident spilled hot food on herself resulting in a 3rd degree burn to her left anterior thigh. 36 cognitively impaired residents (#1, #6, #7, #8, #9, #10, #11, #13, #17, #R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26 and R27) identified by the facility as requiring assistance and supervision with feeding were also in immediate jeopardy as they could be served food that could cause burns and not be supervised. The Administrator was informed of the Immediate Jeopardy for resident #3 and for all cognitively impaired residents requiring assistance and supervision with eating on 2/17/11 at 11:45 a.m. The facility submitted a plan of removal to the surveyors including supervision of cognitively impaired residents when they are served hot food. Surveyors determined that the Immediate Jeopardy ended for Resident #3 and the other 36 cognitively impaired residents (#1, #6, #7, #8, #9, #10, #11, #13, #17, #R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26 and R27) on 2/17/11 at 4:45 pm but the deficient practice continues at an actual harm for resident #3 and a potential for more than minimal harm for residents #1, #6, #7, #8, #9, #10, #11, #13, #17, #R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26 and R27 as the facility has not implement a system with quality assurance to ensure the deficient practice does not occur again. Findings: A review of resident #3's clinical record revealed [DIAGNOSES REDACTED]. A review of resident #3's Minimum Data Sheet, dated 12/22/10, revealed the facility assessed the resident as Cognitively impaired - decisions poor, cues/supervision required; Vision highly impaired - object identification in question, no corrective lenses and totally dependent on staff assistance for eating. A review of resident #3's Nutritional Progress Notes dated 12/22/10 revealed the resident was on a soft mechanical, thin liquids diet and was fed by staff in the dining room. A review of the Eating Assistance Room listed that resident #3 ate at Table 5 for her meals. On 2/15/11 at 2:25 p.m. an interview was conducted with S#6LPN. He stated that he was the nurse caring for resident #3. He stated that the resident was alert, but didn't understand and was not always understood. He stated that the resident vocalized sounds, but not words. He stated that resident #3 received assistance with all activities of daily living and was fed by staff in the dining room. On 2/16/11 at 3:15 p.m. an interview was conducted with resident #3's daughter. She stated that her mother's leg was burned when a bowl of chili spilled on her leg. She stated that it occurred approximately 3 weeks to 1 month ago, she was unable to recall the date. She stated she arrived at the facility at approximately 7:30 p.m. to visit her mother. She stated that she entered her mother's room and saw her mother sitting in her room by herself covered in chili. She stated that her mother is fed by the staff in the dining room. She stated that her mother was wheeled from the dining room to her room with the chili left on her. She stated that she went home and got Aloe Vera with Lidocaine, returned to the facility and put the Aloe Vera on her mother's burn. She stated she did this because the facility didn't have any medicine to put on her mother's burn. She further stated that she did this without the assistance of staff. She stated that later that night the facility got an order for [REDACTED]. She stated that the burn to her mother's leg was really awful at that time. She stated that before she left the facility for the night, blisters had formed. On 2/15/11 at 4:00 p.m. an interview was conducted with S8LPN. S8LPN stated that resident #3 was nonverbal, but would make sounds. She stated that the resident was unable to do anything for herself and was fed by staff. S8LPN stated that on 1/19/11 she was the evening nurse assigned to resident #3. She stated that around supper time one of the CNAs brought resident #3 to her room from the dining room. She stated that she went into the resident's room and observed that the resident had chili all over her clothes. She stated that she asked a CNA to change the resident's clothes and was informed by the CNA that resident #3 had a red burn on her leg. She stated that she went to look at the resident's leg at that time along with the resident's daughter who was in the facility at that time. She stated that she called the resident's physician and informed him that resident #3 had a burn to her leg. She stated that when the resident was touched at the area of the burn, she would make a facial grimace. She stated that she informed the physician the burn was the size of a hand. She stated that the physician gave her an order to apply a cool compress to the burn during the night and to apply Silvadene ointment to the burn for 7 days. She stated that she ordered the Silvadene ointment from the pharmacy and it was delivered to the facility the next day on 1/20/11. On 2/15/11 at 2:30 p.m. an observation was made of resident #3's left leg with S4RN/Wound Care Nurse and S6LPN. This observation revealed a wound to the resident's left upper, anterior thigh. The wound was irregularly shaped, and had a thick solid, brownish/yellow colored area that covered the wound with pink edges. S4RN stated she had not taken any measurements of the wound. The surveyor asked S4RN to measure the wound at this time. S4RN measured the wound and stated that the wound was 4.5 centimeters (cm) x 6.0 cm. She stated that the resident's leg was burned by food on 1/19/11. She stated that the resident had cool compresses applied to the wound during the night of 1/19/11. She stated the Silvadene was delivered to the facility on [DATE] and that starting on 1/20/11, the resident's wound was treated with Silvadene twice daily for 7 days. S4RN/Wound Care Nurse verified that resident #3 received no further treatment for [REDACTED]. A review of the facility's Policy & Procedure for Monitoring Temperatures of Cooked Foods revealed, in part, the following: Policy: The temperature of potentially hazardous cooked foods will be monitored to insure that the foods are not in the danger zone (above 41 degrees Fahrenheit and below 135 degrees Fahrenheit) for more than 6 hours. Procedure: Potentially hazardous cooked foods, after being cooked to the required minimum internal temperature, will be held on hot holding equipment that will keep the food at a minimum 135 degrees Fahrenheit or higher. The temperature of each potentially hazardous food will be taken at the following times: a) When the cooking process is completed. ... Food will be placed in hot holding equipment immediately after the cooking process is completed. b) When the food is placed in the hot holding equipment c) After food has been in the holding equipment for 2 hours. Further review of the Policy & Procedure revealed no documented evidence of monitoring for food temperatures above 165 degrees Fahrenheit. On 2/15/11 at 3:45 p.m. an interview was conducted with S28 Assistant Dietary Manager (DM). She stated that facility dietary staff take food temperatures on the stove and on the steam table just prior to serving the residents. She reviewed the facility's Daily Food Temperature Monitoring Log, dated 1/19/11, for the dinner meal. After reviewing the Log, she confirmed that the temperature taken of the chili in the pan on the stove was 200 degrees Fahrenheit. S28 further confirmed that the temperature taken of the chili on the steam table was 200 degrees Fahrenheit. S28 Assistant DM verified that the normal temperature range to serve hot foods to residents was 165-180 degrees Fahrenheit. On 2/16/11 at 2:30 p.m. an interview was conducted with S9DM. She verified that the cooked food temperatures are monitored only to ensure that they don't fall below 165-180 degrees Fahrenheit when served to the residents. S9DM further verified that the temperature of the chili served to the residents at dinner on 1/19/11 was 200 degrees Fahrenheit. On 2/17/11 at 11:45 a.m. an interview was conducted with S11CNA. S11CNA stated that there was no way she could determine if food served to the residents was hot except when the residents put it in their mouths and they tell her. She stated that if she saw steam coming off the food, she would tell the residents to blow on the food. On 2/17/11 at 11:55 a.m. an interview was conducted with S12CNA. S12CNA stated that there was no way to tell if food was too hot. On 2/17/11 at 12:05 p.m. an interview was conducted with S13CNA. S13CNA stated that she didn't know how to tell if the food was too hot. She stated, "Isn't the kitchen supposed to do the food temperatures?" A review of an Internet article by Hazard Prevention, Burn Injury Facts - Scald Burns in Restaurant Workers, April 2009, Report #86-7-2009 revealed in part the following: "Burns are classified according to how seriously tissue has been damaged. A first degree burn causes redness and swelling in the outmost layers of the skin. A second degree burn involves redness, swelling, and blistering. The damage may extend to deeper layers of the skin. A Third degree burn destroys the entire depth of the skin. It can also damage fat, muscle, organs or bones beneath the skin. Scald burns ... occur when skin comes into contact with hot liquids or steam. ... Water Temperature Time for a third degree burn to occur 120 Degrees F 5 minutes 133 Degrees F 15 seconds 155 Degrees F 1 second Boiling water occurs at 212 degrees F Simmering water occurs between 185-200 degrees F. ..." A review of the Nurses Notes regarding resident #3 revealed the following: 1/19/11, 6:45 p.m.: Reported to resident's room per CNA. Resident observed with moderate burn to left inner thigh, water blisters also noted. No signs or symptoms of pain noted. Resident nonverbal and unable to state what happened. Prior to resident being given care in room, resident was in dining room at feeder table. Resident noted with food on clothes and resident was taken to room to change clothes. Daughter visiting at this time. Burn to left thigh is consistent with chili stain on clothes. Incident was unwitnessed. Doctor notified and new order received for Silvadene burn ointment to area twice a day for seven days and use cool compresses throughout the night. Tylenol 1000 milligrams (mg) also given at this time for pain. A review of the Accident/Injury Investigation Form dated 1/19/11 and Daily Food Temperature Monitoring Log dated 1/19/11, revealed the following: Name of Person Injured: Resident #3 Date/Time of Incident: 1/19/11, 6:45 pm Description of Incident: Burn observed to resident's left inner thigh. Food wasted on resident during feeding, area was found while care was being given per staff. Physical Exam by MD: N/A (not applicable) Witnesses: Unwitnessed Burn to left inner thigh, water blisters noted, redness noted to right lateral hand Interventions to help prevent possibility of reoccurrence: Educate staff on proper care during activities of daily living. Food Temperature Log, 1/19/11, Dinner: Entree/Meat: Chili - Temperature at end of cooking: 200/Temperature at start of service: 200. A review of the Employee Warning Report dated 1/21/11 and attached handwritten employee statement of S27CNA, dated 1/21/11, revealed the following: Supervisor's/Employer's Statement: Date of Violation: 1/19/11, Dinner Type of Violation: Substandard Work Quality, Carelessness CNA was aware that resident spilled chili on her. Went to RN Supervisor and asked for another bowl. Failed to report chili was all over resident and failed to help clean/or find CNA assigned to resident to clean her. Employee statement: I walked across the room to assist a client with her dinner tray, I heard another resident say you're wasting all the food. I turned and said why would someone put a tray in front of a resident and just leave it there if they wasn't going to sit and feed that resident because she will mess with the tray. I walked and told the supervisor what I saw because that day was very crazy. On 2/16/11 at 2:30 p.m. an interview was conducted with S10 RN. She stated that she was the RN Supervisor in the dining room for dinner on 1/19/11. She stated that at 6:00 p.m. she brought resident #3's food tray and put it on her table on 1/19/11. She stated that there was someone at the table when she placed the tray on the table. She stated that at approximately 6:30 p.m. - 6:40 p.m. she was informed by the floor tech that resident #3 had spilled her food. She stated that she did not clean the chili off of the resident or assess her at that time. She stated that she wheeled the resident back to her room at that time. She verified that a CNA was supposed to be at the table with the residents when the meal tray was placed on the table and to remain at the table with the residents until the meal trays were removed. S10 RN further verified that she was unable to say that there was a CNA at each feeding table with the residents on 1/19/11. On 2/16/11 at 11:30 a.m. an interview was conducted with S2DON. S2DON stated that on 1/19/11, resident #3 was at the feeding table in the dining room. She stated that a food tray containing a bowl of chili was placed on the table by the resident. She stated that resident #3 grabbed the bowl of chili and spilled it on herself. She stated that she was unaware if staff were sitting at the table with the resident at that time. She stated that one of the CNAs noticed that resident #3 was holding an empty bowl. She stated that the CNA got the bowl from the resident, brought it to the Registered Nurse (RN) Supervisor and asked for another bowl of chili for the resident. She stated that the CNA did not inform the RN Supervisor that the resident had spilled the bowl of chili on herself. She stated that the RN Supervisor brought the resident a second bowl of chili and noticed that resident #3 had spilled the first bowl on herself. She stated that the RN Supervisor brought the resident to her room. S2DON stated that normally staff would be sitting at the feeding table with the residents when the tray is placed on the table. She stated that the chili was within the acceptable temperature range. She stated that she spoke to the resident's daughter and was told by the daughter that resident #3's skin was sensitive and sunburned easily. S2DON verified that resident #3 spilled a bowl of chili with a facility documented temperature of 200 degrees Fahrenheit onto herself during dinner on 1/19/11 resulting in a burn injury on her left thigh. She further verified that the resident was not assisted or supervised by the facility staff during dinner on 1/19/11. On 2/16/11 at 1:35 p.m. an interview was conducted with S5LPN. She stated that she was present in the dining room on 1/19/11 when resident #3 was burned by the chili. She stated that resident #3 normally doesn't respond to much, but when that chili hit her leg, you should have seen her face, it really hurt her. On 2/16/11 at 2:40 p.m. an interview was conducted with S5LPN. S5LPN stated that on 1/19/11, she worked the 3-11 shift and was in the dining room at the time dinner was served to the residents. She stated that it was evident that resident #3 had spilled the chili on herself. She stated that she knew something was wrong when she observed the frightened look on resident #3's face. She stated she observed chili on her and immediately got the resident's nurse, S8LPN. She verified that she did not wipe the chili off of the resident. A review of the January 2011 MAR (Medication Administration Record) for resident #3 revealed, in part, the following: 1/19/11 (start date): Cool Compress to Left Inner Thigh throughout night - initialed by the nurses as administered for the 3-11 and 11-7 shifts on 1/19/11. 1/13/11 (start date): Tylenol Extra Strength (ES) 2 tablets by mouth every 6 hours as needed for fever or pain - initialed by the nurses as administered on 1/19/11 at 8:30 p.m. for burn to left inner thigh - facial grimacing when touched and on 1/21/11 at 6:30 p.m. for burn to left inner thigh. A review of the January 2011 TAR (Treatment Administration Record) for resident #3 revealed the following: 1/19/11 (start date) Silvadene burn ointment to left inner thigh twice daily for 7 days (7-3 and 3-11) - initialed by the nurses as administered: 1/20/11 - 7-3 and 3-11 shifts 1/21/11 - 7-3 and 3-11 shifts 1/24/11 - 7-3 and 3-11 shifts 1/25/11 - 7-3 and 3-11 shifts 1/26/11 - 7-3 and 3-11 shifts Further review of the January 2011 TAR for resident #3 revealed the following: 1/22/11 - 7-3 shift, not initialed as administered for 3-11 shift 1/23/11 - No documented evidence that Silvadene ointment was administered to resident #3's left leg burn for 7-3 and 3-11 shifts 1/27/11 - Completed There was no documented evidence on the MAR or TAR or Nurses' Notes that resident #3 received any treatment to the burn on her left thigh after 1/26/11. A review of the Care Plan for resident #3 with a Goal date of 2/20/11 revealed in part the following: Problem Onset: 1/19/11 - Burn to left inner thigh Approaches: Treatment as Ordered; Monitor for signs and symptoms of infection. Notify doctor if it should occur; Staff to use caution during meals while feeding. Goal & Target Date: 2/20/11 - Will remain free from further burns - Resolved On 2/16/11 at 2:30 p.m. an interview was conducted with S2DON. She confirmed that the documentation in resident #3's Care Plan documented the burn wound to the resident's left thigh as resolved. S2DON verified that the burn wound had not resolved. On 2/16/11 at 1:45 p.m. an interview was conducted with S4RN/Wound Care Nurse. She stated she had not received any training on caring for burn wounds. She stated that she did not review the facility's policy & procedure for treatment of [REDACTED].#3's physician when the burn wound occurred. She stated that she did not speak to the doctor regarding the resident's burn wound as she was not working when the burn occurred. She stated that orders for treatment of [REDACTED]. She stated that she thought the burn would be a 2nd degree burn because of the blisters that had formed at the burn site. She stated that when she first observed the wound on 1/20/11 it had blisters, but they burst, it had some dryness and at first it was very superficial. A review of the Weekly Body Audits performed by the facility on resident #3 from 1/19/11 through 2/12/11 revealed the following: 1/19/11: Burn noted to left inner thigh, water blisters also noted. Physician notified, new order - Silvadene burn ointment to site twice daily for 7 days and use cool compresses to area throughout night. 1/22/11: Burn to left thigh 1/29/11 through 2/12/11 - There was no documented evidence that the burn to the resident's left thigh had been reassessed. A review of the Physician's Progress Notes from January 19, 2011 through February 15, 2011 which revealed a notation dated 1/27/11 that read in part, "Resident in wheelchair ..., Left inner thigh burn from spilling hot chili being treated with Silvadene ointment." There was no documented evidence that resident #3's burn wound to her left thigh was physically examined by the Nurse Practitioner on 1/27/11. On 2/16/11 at 2:30 p.m. an interview was conducted with S2DON. She stated that resident #3's Nurse Practitioner was in the facility on 1/27/11 for the resident's monthly medical evaluation. She confirmed that there was no documented evidence in resident #3's clinical record of documentation that the Nurse Practitioner evaluated the resident's burn wound on 1/27/11 or on any other date. She stated that she telephoned the Nurse Practitioner and asked her if she had evaluated resident #3's burn on 1/27/11. S2DON stated that the Nurse Practitioner told her that she did not evaluate the resident's burn when she was at the facility on 1/27/11 because the resident was sitting up in her wheelchair. S2DON verified that the Nurse Practitioner did not assess or evaluate the resident's burn to her left leg on 1/27/11. On 2/16/11 at 11:10 a.m. a telephone interview was conducted with S16 Medical Doctor (MD). He stated that he relied on the nurse's description and notification when an injury occurs. He stated that the description of resident #3's burn wound should have been communicated to him. On 2/16/11 at 1:40 p.m. an interview was conducted with S16 MD while he examined the burn wound to resident #3's left thigh. He stated that the burn was full thickness and that it was a third degree burn. He stated that he was notified when the burn occurred, but did not know that it was a third degree burn. S16 MD wrote orders for treatment of [REDACTED]. S16 MD verified that the facility should have sent the resident to the emergency roiagnom on the date the burn occurred for assessment and treatment. He verified that 2/16/11 was the first time he had observed resident #3's burn wound to her left thigh. A review of the New physician's orders [REDACTED]. 1. Wet to dry saline wound dressing to left thigh daily; 2. Gently remove or pull off eschar as tolerated; 3. Once eschar removed, apply Bactroban Ointment daily to wound until healed.

Based on observation, interview, and record review, administration failed to use its resources effectively and efficiently to attain the highest practical physical, mental and psychosocial well-being of each resident for 1 of 1 residents(#3) investigated [MEDICAL CONDITION] for 36 cognitively impaired residents (#1, #6, #7, #8, #9, #10, #11, #13, #17, #R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26 and R27). Administration failed to: 1. have a policy and procedure regarding supervision of cognitively impaired residents who required assistance and supervision and [MEDICAL CONDITION] hot food. 2. have a policy and procedure regarding temperature of hot food served to cognitively impaired residents who required assistance and supervision and [MEDICAL CONDITION] hot food. 3. have a system of clinical supervision to ensure cognitively impaired residents who required assistance and supervision with feeding were actually supervised and assisted. 4..have a system of clinical supervision in place to ensure nursing assessed on an ongoing basis and notified physician of change in resident status. Resident #3 was a nonverbal, cognitively impaired resident who was totally dependent on staff assistance with eating. Resident # 3 was in Immediate Jeopardy on 1/19/11 at 6:00 p.m. when a food tray containing a bowl of chili with a temperature of 200 degrees Fahrenheit was placed in front of the resident without staff supervision or assistance. While unsupervised, the resident spilled the bowl of hot chili on herself resulting in a significant burn to her left anterior thigh. Resident # 3 was in Immediate Jeopardy after the burn on 1/19/11 when the facility failed to conduct an ongoing accurate and comprehensive assessment and notify the physician of the size, condition, and extent of the burn so that appropriate treatments for the burn and treatment for [REDACTED]. In addition, 36 cognitively impaired residents (#1, #6, #7, #8, #9, #10, #11, #13, #17, #R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26 and R27) who required assistance and supervision with feeding were in immediate jeopardy as they could be served hot food and left unattended and burn themselves. The Immediate Jeopardy regarding assessment and physician consultation ended on 2/16/11 when the physician examined resident #3's burn and gave orders for treatment. The Administrator was informed of the Immediate Jeopardy for resident #3 and for all cognitively impaired residents requiring assistance and supervision with eating on 2/17/11 at 11:45a.m. The facility submitted a plan of removal to the surveyors including supervision of cognitively impaired residents when they are served hot food. Surveyors determined the Immediate Jeopardy regarding provision of supervision and assistance of cognitively impaired residents during feeding ended for resident #3 and the other 36 cognitively impaired residents (#1, #6, #7, #8, #9, #10, #11, #13, #17, #R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26 and R27) on 2/17/11 at 4:45 pm. The deficient practice continues at an actual harm for resident # 3. The resident experienced a third degree burn and a delay in treatment of [REDACTED]. The deficient practice continues as a potential for more than minimal harm for residents #1, #6, #7, #8, #9, #10, #11, #13, #17, #R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26 and R27 as the facility has not implemented a system with quality assurance to ensure the deficient practice does not occur again. Findings: The facility failed to consult with the physician regarding severity of a burn to a resident and pain associated with the burn. Cross refer to F157 The facility failed to conduct an ongoing accurate and thorough assessment of a resident'[MEDICAL CONDITION] of pain associated with the burn. Cross refer to F272 The facility failed to ensure a resident reached the highest level of well being by failing to conduct ongoing accurate and thorough assessments of a residents burn and of associated pain, consult with the physician regarding the burn and associated pain, and administer pain medication. Cross refer to F309 The facility failed to provide supervision and assistance with feeding to a cognitively impaired resident when served hot food. Cross refer to F323