Every finding on record at Harborview Health Center of Augusta

Based on observations, staff interviews, and review of facility policies titled, Infection Prevention and Control Program, and Laundry, the facility failed to use proper infection control practices in the laundry area, when storing wash basins on two of five halls and during the provision of tracheostomy care for one of three residents (R) (R5) reviewed with tracheostomies. The deficient practice increased the risk of cross contamination, spread of infection, and increased risk of adverse clinical outcomes. Findings include: Review of the facility policy titled, Infection Prevention and Control Program, reviewed dated 02/01/2025, revealed in section 10. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. In section 13. Residents/Family/Visitor Education and Screening. c. Isolation signs are used to alert staff, family members, and visitor's precautions. d. Passive screening, such as signs, are posted in the facility to alert to family members and visitors to adhere to handwashing, respiratory etiquette, and other infection control principles to limit spread of infection from family members and visitors. Review of the facility policy titled, Laundry, dated 03/01/2022 and revised 11/01/2025, revealed under Policy: The facility launders linens and clothing in accordance with current CDC (Centers for Disease Control) guidelines to prevent transmission of pathogens.6.If using fans in the laundry processing areas, prevent cross-contamination of clean linens from air blowing from soiled processing areas (i.e. the ventilation should not flow from soiled processing areas to clean areas).' 1. During an interview and observation on 06/02/2026 at 9:31 AM, in the laundry, revealed two fans with an accumulation of grey particulate matter on the fan grates that were blowing onto a table that contained clean linens, including sheets and towels. Observation was confirmed and verified by the Housekeeping Supervisor and two Laundry Assistants (LA) (LA NN and LA OO). An Interview and observation in laundry area on 06/03/2026 at 5:41 AM with LA NN revealed the two fans with grey particulate matter had been removed from the laundry. During an interview on 06/04/2026 at 2:16 PM, with the Administrator, revealed that the Administrator expected all staff to follow policies, procedures and regulations and adhere to Infection Control procedures. 2. During observations on 06/01/2026 at 3:00 PM, in the bathroom of room [ROOM NUMBER], there was one wash basin sitting on the rack in the bathroom, not bagged or labeled. During observations on 06/01/2026 at 3:07 PM, in the bathroom for room [ROOM NUMBER], there were eight stacked wash basins under the sink, not bagged nor labeled. During observations on 06/02/2026 at 12:40 PM, in the bathroom for room [ROOM NUMBER], there were three wash basins, not labeled or bagged. During observations on 06/02/2026 at 12:41 PM, in the bathroom for room [ROOM NUMBER]/508 (shared bathroom), there were two wash basins on the rack and four basins stacked on the floor in the bathroom, not bagged or labeled. Observation on 06/04/2026 at 12:29 PM, revealed in room [ROOM NUMBER], three unbagged wash basins, sitting on the rack in the bathroom that was shared. During an interview and observation conducted on 06/02/2026 at 3:24 PM with Unit Manager/Licensed Practical Nurse (LPN) AA, it was noted that the following rooms: room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER], had wash basins that were stacked, uncovered, and unlabeled. LPN AA acknowledged that this posed an infection control issue and that these items should be properly labeled and bagged. It was reported during the interview that Certified Nursing Assistants (CNAs) were tasked with ensuring that items were both bagged and labeled. Interview and Observation on 06/02/2026 at 3:48 PM, with CNA RR, disclosed that she was transferred from the first floor to the 500 hall after lunch and was unaware that the wash basin needed to be labeled and bagged. CNA RR acknowledged that she had observed the wash basin to be unlabeled and uncovered while she was emptying resident urinals. CNA RR expressed that this situation could potentially result in cross-contamination if she inadvertently used the wash basin designated for resident A on resident B. Interview and Observation on 06/02/2026 at 3:52 PM, with CNA SS, who reported that she noticed the basin was neither labeled nor bagged when she entered the bathroom to bathe the resident. She acknowledged that she forgot to bag and label it, which raised an infection control issue. During an interview and observation on 06/04/2026, at 12:18 PM, with the Director of Health Services (DHS), the following rooms with deficient practice were confirmed: In room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER], the wash basins in the bathrooms were neither labelled nor bagged. The DHS confirmed that they should be labelled and bagged due to concerns regarding infection control and the risk of cross-contamination. 3. Review of the electronic medical record (EMR) revealed R5 with pertinent diagnoses that included, but were not limited to, critical illness myopathy, respiratory failure, chronic obstructive pulmonary disease, and tracheostomy status. Review of R5 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated R5 had moderate cognitive impairment. Section GG, functional status, revealed that R5 required extensive assistance for activities of daily living (ADLs) with two-person assistance. Review of the Physician's Orders for R5 included, but was not limited to, pleasure feeds clear liquid, respirator (trach-tracheostomy) circuit change weekly, change trach ties every shift, trach care every shift, and left hip wound care daily. An observation on 06/01/2026 at 1:37 PM, with R5, revealed that the trach circuit hose and water collection bag were on the floor, and the suction canister was full. An observation made on 06/02/2026 at 2:38 PM, of R5, revealed that the trach circuit was still on the floor. An interview with LPN CC on 06/02/2026 at 2:45 PM, confirmed the tracheostomy collar circuit was on the floor. An observation on 06/03/2026 at 10:20 AM, during wound care, revealed that the tracheostomy circuit hose and water collection bag were still on the floor and had not been changed or shortened to lift them off the floor. An interview with the Staff Development Coordinator (SDC) Registered Nurse (RN) on 06/03/2026 at 10:30 AM, revealed that the trach circuits were not changed unless needed by the respiratory therapist, who came twice weekly. An observation of tracheostomy suctioning performed by LPN LL and the SDC, at bedside, on 06/03/2026 at 10:45 AM, revealed contamination during sterile glove donning. LPN LL opened the suction kit, pulled out the sterile gloves, laid them on top of the open suction kit, and donned (put on) them not using sterile technique. She then handled the suction catheter, touching the outside of the tracheostomy, while attempting to pass the catheter into the tracheostomy to suction. An interview with the SDC RN on 06/03/2026 at 2:30 PM, revealed and confirmed the need for sterile gloves and sterile tracheostomy suctioning. An interview with the Director of Nursing (DON) on 06/04/2026 at 11:35 AM, revealed that she expected the staff to perform sterile tracheostomy suctioning and understand that the circuit hose needed to be off the floor. An interview with the Administrator on 06/04/2026 at 1:34 PM ,revealed that she expected all nursing procedures to be performed in accordance with the standards of care.

Based on observations, staff interviews and review of facility policy titled, Preventative maintenance program, the facility failed to ensure residents were provided with a safe, clean, and comfortable environment, as evidenced by unclean Packaged Terminal Air Conditioner (PTAC) unit filters in three of nine rooms on 300 Hall (rooms [ROOM NUMBER]), two of 16 rooms on 400 Hall ( rooms [ROOM NUMBERS] ), and one of 16 rooms on the 500 hall (room [ROOM NUMBER]). This deficient practice had the potential to expose residents to poor air quality and contaminants throughout the environment. Findings Include: Review of facility policy titled, Preventive Maintenance Program. revealed 1. The maintenance director is responsible for developing and maintaining a schedule of maintenance services to ensure that the building's grounds and equipment are maintained in a safe and operable manner. 2. The maintenance director shall assess all aspects of the physical plant to determine if preventative maintenance is required. Required preventive maintenance may be determined from manufacturers recommendations, maintenance requests, grand rounds, life safety requirements, or experience. Review of the facilities online maintenance platform documentation provided by the facility titled, Clean Air filter, revealed the stated schedule (monthly) and instructions on how to clean the filter. Observations conducted on 06/01/2026 at 10:33 AM and 06/02/2026 at 12:43 PM of room [ROOM NUMBER] revealed PTAC filters with heavy gray fuzzy debris. Observation conducted on 06/01/2026 at 10:37 AM and 06/02/2026 at 12:44 PM of room [ROOM NUMBER] revealed PTAC filters with heavy gray fuzzy debris. Observation conducted on 06/01/2026 at 10:52 AM and 06/02/2026 at 12:46 PM of room [ROOM NUMBER] revealed PTAC filters with heavy gray fuzzy debris. Observations conducted on 06/01/2026 at 10:00 AM, 06/02/2026 at 10:55 AM, and 06/03/2026 at 2:00 PM, of room [ROOM NUMBER], revealed PTAC filters with heavy gray, fuzzy debris. Observation conducted on 06/01/2026 at 10:03 AM, 06/02/2026 at 10:57 AM, and 06/03/2026 at 2:03 PM of room [ROOM NUMBER] revealed PTAC filters with heavy gray, fuzzy debris. Observation conducted on 06/01/2026 at 10:11 AM, 06/02/2026 at 11:05 AM, and 06/03/2026 at 2:10 PM of room [ROOM NUMBER] revealed PTAC filters with heavy gray, fuzzy debris. Interview conducted on 06/03/2026 at 2:20 PM with the Maintenance Director confirmed that there was a significant debris present on the units observed. He further stated that PTAC filters were generally cleaned monthly and noted that the PTAC units had not been cleaned recently. He stated that the facilities online maintenance platform would let the staff know when the filters needed to be cleaned and how to go about cleaning them. Interview conducted on 06/04/2026 at 2:16 PM with the Administrator revealed that the usual expectation was to follow the schedule in the facilities online maintenance platform for cleaning the units. The Administrator stated that maintenance were expected to clean the units/filters when they needed cleaning.

Based on observations, record review, staff and resident interviews, and review of the facility policy titled, Activities of Daily Living, the facility failed to ensure that Activities of Daily Living care was provided for one dependent resident (R) (R28) related to bed baths and nail care. The deficient practice had the potential for to place R28 at risk of a diminished quality of life. Findings include:Review of the facility's policy titled, Activities of Daily Living, review date 03/01/2025, revealed in section, Policy Explanation and Compliance Guidelines, . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.Review of the annual Minimum Data Set (MDS) dated [DATE] for R28 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitively intact.Review of the care plan dated 05/31/2025 indicated R28's Focus: needs assist with grooming, bathing, and personal hygieneReview of the bath schedule master sheet revealed room [ROOM NUMBER]B was on the list for a shower and bath on Tuesday, Thursday, and Saturday, and evening shift.Review of shower and bath report for R28 dated April 2026 through June 2026 revealed on 05/16/2026, refused, and 06/02/2026 bed bath completed by Certified Nursing Assistant (CNA) QQ. Bath and shower report documented R28 was not checked for toenails in need of podiatry referral. Review of Podiatry Visit lists dated 02/24/2026, 05/11/2026, 05/12/2026 and tentative mid-July; R28 was not listed for podiatry visits. On 06/03/2026 at 11:41 AM, the Social Service Director provided email to the podiatry partner to add R28 to the list. Observation and interview on 06/01/2026 at 3:02 PM, with R28 revealed that she has not had a shower since her admission. She stated she had not received bed baths, nor had she been offered or provided with toenail grooming.An observation and interview conducted on 06/02/2026 at 12:43 PM, indicated that the R28 toenails was long and untrimmed; however, confirmed she had finally received a bed bath.Observation and Interview on 06/02/2026 at 3:24 PM, conducted with Licensed Practical Nurse (LPN) AA, LPN AA reviewed the shower and bath report for R28 and confirmed that R28's toenails were long and untrimmed.Observation and Interview on 06/02/2026 at 3:52 PM, with CNA SS , CNA SS stated she provided R28 with a bed bath on 06/02/2026. However, during the review of the shower and bath report dated 06/02/2026, CNA SS acknowledged she recorded that she had done so based on R28's response when she inquired if a bed bath had been administered. CNA SS could not confirm the exact dates bed baths were provided from daily charting.During an interview on 06/03/2026 at 10:16 AM, CNA QQ confirmed that she provided R28 with a bed bath on 06/02/ 2026. However, she was not aware that she needed to check off additional observations. CNA QQ confirmed that R28's toenails were long and stated that she would make the necessary corrections to the bath and shower report.Observation and Interview on 06/03/2026 at 10:48 AM, with the Director of Health Services (DHS), indicated that the Certified Nursing Assistant and/or Unit Manager must inform the DHS if a referral was necessary. Depending on the urgency, the resident will be referred to an outside provider but will also be placed on the podiatry referral list as initiated by the Social Services Director.An interview conducted on 06/03/2026 at 11:25 AM with CNA PP indicated that he administered bed baths to R28. CNA PP was unable to confirm the accuracy of dates on which bed baths were provided.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Self-Administration of medication, the facility failed to ensure that one of 60 sampled residents (R) (R7) did not have unauthorized and unsecured medications at the bedside. This failure created the potential for medication errors and unauthorized access to medications by other residents. Findings include:A review of the facility policy titled Self-Administration of Medications, revised December 2016, revealed the Policy Statement is that residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident; . 5. The staff and practitioner will document their findings and the choices of the residents who are able to self-administer mediations; .8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them; 9. Staff shall identify and give to the Charge Nurse and medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party. A review of the electronic medical record (EMR) for R7 revealed resident was admitted with diagnoses of, but not limited to, renal disease, type 2 diabetes, heart failure unspecified, hypertension (HTN), hyperkalemia and bipolar disorder.The resident's Comprehensive admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Review of the EMR for R7 revealed there was no evidence that an assessment was completed for self-medication administration of medications.Review of Physician Orders for R7 revealed there was not an order for resident to have medications at bedside for self-administration. Observation on 06/02/2026 at 12:41 PM, revealed one bottle of over-the- counter calcium carbonate on R7's bedside nightstand, There was no name or open date on the identified medication.Observation on 06/02/2026 at 3:30 PM, revealed the over-the-counter medication remained on R7's bedside nightstand.Observation and interview with R7 on 06/04/2026 at 11:48 AM, revealed that the over-the-medication was still on his room bedside table. He stated that he had it because his doctor told him that he needed it, and the nurses at the facility never gave it to him. He stated that he kept in his nightstand and took it himself before meals. Interview and observation with Licensed Practical Nurse (LPN) AA and the Staff Development Coordinator on 06/04/2026 at 11:51 AM confirmed the over-the-counter medication at the R7's bedside. During an interview on 06/04/2020 at 1:40 PM, with Director of Nursing (DON), the DON revealed that if medications were brought from home, they were to be given to the nurse. She stated that her expectation for any unauthorized medication found at the bedside of a resident should be removed immediately.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Resident Assessment-Coordination with PASARR Program, the facility failed to assess and apply for PASARR II (Preadmission Screening and Resident Review) services for one of 60 sampled residents (R) (R1). This deficient practice had the potential for R1's mental health needs to go unmet.Findings include: Review of the electronic medical record (EMR) revealed R1 was admitted with pertinent diagnoses, including but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the left side, chronic obstructive pulmonary disease, major depressive disorder, general anxiety disorder, unspecified psychosis, and suicidal ideations.Review of R1 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 9, which indicated R1 had moderate cognitive impairment. Section GG, functional status, revealed R1 required extensive assistance for activities of daily living (ADLs) with one or more-person assistance due to pain and weakness.Review of the care plan for R1 revealed, Problem-R1 is at risk for alteration in mood r/t (related to) suicidal ideations, anxiety disorder, major depressive disorder, unspecified psychosis.Interview on 06/01/2026 at 2:18 PM with R1, revealed R1 stated that he does not receive counseling or psychological assistance for his anxiety. An interview with Licensed Practical Nurse (LPN) CC on 06/01/2026 at 2:26 PM revealed R1 had just received that R1 did not have orders for mental health to see him.An interview with the Social Services Director on 06/03/2026 at 10:36 AM revealed that she handled the preadmission PASARR assessments, but if a resident received a mental health diagnosis after admission, she did not apply for a PASARR II assessment.An interview with the Administrator on 06/04/2026 at 11:30 AM, revealed that she was unaware that the Social Service Director had not applied for PASARR II for residents with a psychiatric diagnosis after admission. She confirmed that the Social Service Director was responsible for that aspect of the residents' care.

Based on observations, staff interviews, record review, and review of the facility policy titled, Medication Administration, the facility failed to discard expired medications on two of four medication carts reviewed. This deficient practice created the potential for expired, improperly stored medications to be used in resident care, placing residents at risk for compromised safety and potential adverse consequences.Findings include:Review of the facility's policy titled, Medication Administration, revealed under Policy Explanation and Compliance Guidelines: .13. Identify the expiration date. If expired notify the manager.Observation on 06/02/2026 at 7:56 AM of the medication cart for the 200 Hall revealed two pill bottles containing Novolog insulin vials that had been opened with expiration dates of 04/22/2026 and 05/09/2026; confirmation was done with Licensed Practical Nurse (LPN) CC.Observation of the 400 Hall medication revealed one insulin vial dated 05/27/2026 and confirmed by Certified Medication Aide (CMA) GG were observed on 400 hall medication cart and confirmed by Unit Manager LPN AA.Interview on 06/03/2026 at 11:16 AM with the Administrator revealed that she expected the nurses on the medication carts to check daily for the expired medications.Interview on 06/04/2026 at 11:00 AM with the Director of Nursing (DON) revealed that she expected the cart to be checked daily by the nurse, she stated the label and expiration date should be checked on all the medications and if expired, removed from the cart and call the pharmacy for replacement.Interview on 06/04/2026 at 11:15 AM with the Assistant Director of Nursing (ADON) revealed that she expected the nurse to check expired medication and remove them from the cart daily and then reorder them from the pharmacy. She revealed that nurses should be checking the cart and reordering supplies prior to the ones on the cart expiring.

Based on observation, interview, record review, and policy review, the facility failed to ensure one of one Resident (R)107 reviewed for pain in the sample of 30 residents had his pain managed by ensuring the fentanyl transdermal patches had been available, his pain had been assessed in a consistent manner, and his physician had been notified of the missed pain management medication. This failure resulted in R107 experiencing pain when repositioned. Findings include: Review of the facility's policy titled, Pain Management dated 3/1/2024 revealed The facility must ensure that pain management is provided to residents who require such services .Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. Facility staff will observe for nonverbal indicators, which may indicate the presence of pain. Those indicators include but are not limited to: .facial expressions (e.g. grimacing, frowning, fright, or clenching of jaw) .negative vocalizations (e.g. groaning, crying, whimpering, or screaming.) .The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain. Reviewing the resident's current medical conditions (e.g. pressure injuries, diabetes with neuropathic pain, immobility, infections, amputation, oral health conditions, post CVA (stroke) venous and arterial ulcers, and multiple sclerosis) .Current prescribed pain medications, dosage and frequency . Review of R107's Clinical Census in the Electronic Medical Record (EMR) under the Clinical Census tab revealed he had been admitted on [DATE]. Review of R107's Medical Diagnosis in his EMR under the Medical Diagnosis tab revealed his diagnoses included malignant neoplasm of the colon (colon cancer), secondary malignant neoplasm of the bone (bone cancer), secondary malignant neoplasm of the lung (lung cancer), chronic pain syndrome, pressure ulcers to the right hip, and back. Review of R107's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date of 5/6/2025 revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated he had moderate cognitive impairment. Observation of R107 on 6/2/2025 at 1:30 pm revealed he shook his head yes when asked if he had pain. He was unable to state that he was in pain. He was moaning and grimacing. Licensed Practical Nurse (LPN) 2 gave him his scheduled medications and was aware that he indicated he had pain. LPN 2 did not provide any pain medication for him at that time. The Wound Care/Registered Nurse asked LPN2 on 6/2/2025 at 1:30 pm to administer R107 pain medications prior to his wound care treatment. LPN 2 provided the pain medication at 2:42 pm. Review of R107's May and June 2025 Medication Administration Record (MAR) in the EMR under the Orders tab revealed R107 had not received the fentanyl transdermal patch 25 micrograms/hour (mcg/hr) apply one patch every three days (slow-release pain medication) The medication had been ordered by his physician on 5/17/2025. The pain medication was not available on 5/17/2025, 5/20/2025, 5/29/2025, 6/1/2025, and 6/4/2025. R107 had an order for hydromorphone 1 milligram (mg) per 1 milliliter (ml) give 5 ml every 6 hours as needed for pain ordered during three different time periods; from 5/2/2025 through 5/6/2025, 5/6/2025 with a parameter to give for a pain level between 7 and 10 out of 10, and it was revised on 5/20/2025 without the pain level restrictions. R107 received the hydromorphone 1 mg only once a day. The medication had been ordered that he could receive hydromorphone 1 mg every 6 hours as needed for pain. Review of a pharmacy packing slip dated 5/20/2025 revealed that two fentanyl 25 mcg transdermal patches had been delivered. There were no more packing slips that the Director of Nursing (DON) was able to provide. Interview on 6/5/2025 at 3:52 pm, the DON and Registered Nurse (RN)1 revealed they were not aware R107's fentanyl patches had not been available for the dates of 5/17/2025, 5/20/2025, 5/29/2025, 6/1/2025, and 6/4/2025. RN1 agreed he had a significant amount of pain when he was repositioned, which was often due to his pressure sores. She had tried to ensure he received the hydromorphone on a regular basis. She did not realize he was only receiving the medication one time a day. His physician had not been informed of his pain control issues due to the resident not having the ordered fentanyl patches available.

Based on observation and interview, the facility failed to ensure all items in the refrigerator, and freezer were sealed, labeled, and dated. These failures had the potential to affect 110 of 112 residents who received their meals from the kitchen at risk of foodborne illnesses. Findings include: During an observation on 6/2/2025 at 8:40 am with the kitchen cook (Cook 1) revealed the following observations: Located in the kitchen were four large plastic containers with lids that each contained breadcrumbs, thickener, flour, and sugar. The containers were not labeled and dated. The Walk-In Refrigerator contained metal containers of watermelon, ketchup, and cucumbers. These items were outdated and dated 5/27/2025. There was no labeling or dating on a bowl of icing, two sandwiches, one bag of sliced cheese, one bag of ham, poured glasses of iced tea and a cooked pan of broccoli. The pan of broccoli was not sealed to prevent air from touching the broccoli. The Walk-In Freezer contained one box of biscuits that were not sealed exposing the biscuits to air. Interview on 6/5/2025 at 5:32 pm, the Administrator revealed that staff must be educated on labeling and dating. The Administrator stated, we go over and over this.

Based on observation, interview, record review, review of the facility's policy titled, Medication Administration and review of the facility provided document titled Primary Pharmaceutical Provider Contract, the facility did not ensure medications were available for two of two Residents (R) (R107 and R220). This failure placed residents at risk for complications from missing medications. Findings include: Review of the facility's policy titled, Medication Administration dated 6/1/2024 revealed there was not a procedure for when a medication was not available. Review of the Primary Pharmaceutical Provider Contract dated 5/1/2025 revealed the pharmacy would Provide drugs and supplies as required for patients/residents and Nursing Facility in accordance with facility policy and procedures .Provide a regular delivery on Monday thru Saturday and after-hours deliveries 24 hours per day 7 days per week for new emergency or 'stat' orders not available in emergency kits or thru back-up pharmacy. 1. Review of R107's Clinical Census in his Electronic Medical Record (EMR) under the Clinical Census tab revealed he had been admitted on [DATE]. Review of R107's May 2025 Medication Administration Record (MAR) in the EMR under the Orders tab revealed he had not received medications including fentanyl transdermal patch 25 micrograms/hour (mcg/hr.) apply one patch every three days (slow-release pain medication.) The medication had been ordered by his physician on 5/17/2025. The pain medication was not available on 5/17/2025, 5/20/2025, 5/29/2025, 6/1/2025, and 6/4/2025. Flomax 0.4 milligram (mg) (medication for urinary retention) ordered on 5/2/2025. The medication was not available on 5/22/2025 and 5/29/2025. Levofloxacin 750 mg (antibiotic medication) ordered on 5/15/2025 through 5/31/2025. The medication was not available on 5/15/2025, 5/16/2025, and 5/21/2025. Zolpidem Tartrate, (sleep medication), 10 mg every night. The medication was not available on 5/16/2025 and from 5/19/2025 through 5/31/2025 and 6/2/2025 through 6/4/2025. Observation and interview on 6/2/2025 at 1:30 pm of the 400-wing medication cart revealed there were no fentanyl 25 mch/hr. transdermal patches or narcotic sheet for R107. Licensed Practical Nurse (LPN)2 was not sure where the patches would have been. Interview on 6/5/2025 at 3:52 pm, the Director of Nursing (DON) and Registered Nurse(RN)1 revealed they were not aware R107's fentanyl patches had not been available for the dates of 5/17/2025, 5/20/2025, 5/29/2025, 6/1/2025, and 6/4/2025. They were also not aware of the other medications listed above had not been provided to him. They stated that the new automated medication dispensing system did not have any narcotics that could have been supplied. Phone interview on 6/5/2025 at 4:35 pm, R220's Family Member (FM)1 stated that R220's medications had not been available to R220 when she was admitted . She was upset that the medication were not available. 2. Review of R220's Clinical Census in the EMR under the Clinical Census tab revealed she had been admitted on [DATE] and was discharged on 4/30/2025. Review of R220's April 2025 MAR in the EMR under the Orders tab revealed she had not received amiodarone 200 mg (medication for irregular heartbeat), amlodipine besylate 10 mg (medication for blood pressure), and metoprolol succinate ER 25 mg (medication for blood pressure), and Keppra 750 mg for (medication for seizures) at 9:00 am on 4/17/2025. She had not received Eliquis 5 mg (blood thinner medication) on 4/16/2025 at 9:00 am and 9:00 pm and on 4/17/2025 at 9:00 am. Interview on 6/5/2025 at 3:52 pm, the DON revealed she had not been aware R220 had not received her medications as ordered. The missing medications had not been reported to her by the staff or the resident.

Based on observation, interview, and review of the manufacturer's recommendations, the facility failed to ensure insulin pens or vials had pharmacy labels, were dated when opened, and were not used after the expiration date for two of two medication carts (100 hall and 200 hall). This deficient practice increased the risk of insulin used after the expiration date to be less effective which had the potential to cause high blood sugar levels. Findings include: Review of the manufacturer's recommendations for insulin glargine, Humalog, and Lispro from [Name] and Company revealed when the insulin vial and/or insulin pen was removed from refrigeration it was only effective for 28 days. Review of the manufacturer's recommendations for insulin Novolog and Aspart from Novo Nordisk revealed when the insulin vial and/or insulin pen was removed from refrigeration it was only effective for 28 days. Review of the manufacturer's recommendations for Toujeo Solostar from Sanofi revealed when the insulin vial and/or insulin pen was removed from refrigeration it was only effective for 28 days. Observation and interview on [DATE] at 8:35 am with Licensed Practical Nurse (LPN)3 during the inspection of the west wing medication carts revealed two carts that were used just for insulin, tracheostomy supplies, and tube feeding supplies. Observation of the 100-hall cart revealed one insulin glargine 3 milliliter (ml) prefilled pen with no pharmacy label and when it had been opened and three insulin lispro vials that had not been dated when they had been opened. Observation of the 200-hall cart revealed three insulin aspart flex pens, one had expired on [DATE], one had expired on [DATE], and one had expired on [DATE]. One Toujeo SoloStar insulin pen with no open date or expiration date. Three insulin lispro insulin pens in which one had expired on [DATE], one expired on [DATE], and one with no dates. Two Humalog insulin vials with one that was dated as opened on [DATE] and one with no open or expiration date. One Novolog insulin vial with an opened date of [DATE]. LPN3 stated that the above insulins should have been discarded when expired or labeled when opened. She did not know who was responsible to ensure the insulin had been dated and/or removed when it had expired. Interview on [DATE] at 10:44 am, the Director of Nursing (DON) revealed, her expectations were that the nurse who took the insulin out of the refrigerator would correctly label the vial or pen with the opened date and expiration date. The DON revealed the nurse should always check the expiration date prior to giving.

Based on observation, interview, and record review, the facility failed to update one of two Residents (R) R80 care plan interventions to include measures to prevent pressure ulcers. Specifically, R80 had acquired three pressure ulcers after readmission from the hospital and his care plan had not been revised with interventions to prevent the development of pressure ulcers. Findings include: Review of R80's Clinical Census in the Electronic Medical Record (EMR) under the Clinical Census tab revealed admission date of 1/2/2025, hospitalization on 2/13/2025 and readmission on [DATE]. Review of R80's Medical Diagnosis in the EMR under the Medical Diagnosis tab revealed diagnoses multiple fractures of ribs on the right side, lumbar vertebra fracture, prostate cancer, and diabetes mellitus type 2. Diagnoses added 2/13/2025 to 2/17/2025 hospitalization included deep vein thrombosis (DVT) of the right lower leg, and pneumonia. Review of R80's Care Plan in the EMR found under the Care Plan tab dated 1/14/2025 indicated at risk for altered skin integrity related to diagnoses, incontinent at times, elderly, and fragile skin. Interventions included, Handle gently during transfers and ADLs [activities of daily living],Observe skin during ADLs for any changes in skin condition, notify nurse of any changes, Position properly in bed & [and] [wheelchair] to avoid skin tear or friction, Weekly skin assessments as scheduled. There were no further interventions after R80 was readmitted from the hospital on 2/17/2025 and once the sacral pressure ulcer, right heel pressure ulcer, and a left hip pressure ulcer developed 3/19/2025 . Review of R80's Braden Scale for Predicting Pressure Sore Risk dated 1/9/2025 in the EMR under the Assessments tab revealed a score of 20 which indicated he was not at risk of developing a pressure ulcer. Review of the EMR revealed no further Braden scales had been completed after his 2/17/2025 readmission due to a deep vein blood clot and pneumonia. Observations on 6/2/2025 at 10:30 am, 1:00 pm, and 4:00 pm revealed R80 lying in bed on his back. His heels were not elevated on a pillow. He had a low air loss mattress in place. Observations on 6/3/2025 at 9:00 am, 11:30 am and 3:30 pm revealed R80 lying in bed on his back. His heels were not elevated on a pillow. He had a low air loss mattress in place. Observation on 6/4/2025 at 3:00 pm revealed R80 lying in bed on his back. His heels were not elevated on a pillow. He had a low air loss mattress in place. Interview on 6/4/2025 at 12:37 pm, the Wound Care/Registered Nurse (WC/RN) revealed when R80 was admitted on 0102/25 he was able to get in and out of bed independently. He would walk to meals and to activities independently. After his hospitalization from 2/13/2025 to 2/17/2025 he did not get out of bed. His cognition declined. Staff need to reposition him often. She stated that he was to have his heels elevated when he was in bed. Interview on 6/4/2025 at 12:35 pm, Licensed Practical Nurse (LPN)1 stated that after R80 returned from the hospital, he refused to get up due to pain. He is repositioned with wedges and usually more to his left side. There was no place in his EMR for staff to document when he was repositioned. Review of R80's significant change Minimum Data Set (MDS) in the EMR with an Assessment Reference Date of 2/19/2025 under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R80 was moderately cognitively impaired. Review of the Behavior section revealed he rejected care one to three days out of seven days. Review of his Functional Abilities section revealed re required he needed substantial or maximal assistance with rolling left and right. Review of the Skin Conditions section revealed he had no pressure ulcer or injury, and he was at risk of developing pressure ulcers or injuries. Review of R80's admission MDS in the EMR with an ARD of 3/17/2025 under the MDS tab revealed a BIMS score of five out of 15 which indicated R80 was severely impaired. Review of the Behavior section revealed he rejected care one to three days out of seven days. Review of his Functional Abilities section revealed he needed substantial or maximal assistance with rolling left and right. Review of the Skin Conditions section revealed he had no pressure ulcer or injury, and he was not at risk of developing pressure ulcers or injuries. Review of R80's quarterly MDS in the EMR with an ARD of 3/24/2025 under the MDS tab revealed a BIMS score of 3 out 15 which indicated R80 was severely cognitively impaired. Review of the Behavior section revealed he had not rejected care. Review of his Functional Abilities section revealed he needed substantial or maximal assistance with rolling left and right, sit to lying, and lying to sitting on the side of the bed. Review of the Skin Conditions section revealed he had a pressure ulcer or injury, and he was at risk of developing pressure ulcers or injuries. There was one unstageable pressure ulcer and one unstageable pressure ulcer due to a deep tissue injury listed. Review of R80's Progress Notes in the EMR found under the Progress Notes tab revealed notes dated 3/19/2025 at 9:44 am which indicated, Skin intact Sacral area reddened R/T [related to] incontinence. Butt cream applied as needed. Note dated 3/20/2025 at 9:54 am indicated, .large purple colored area on his Rt [right] heel, reddened area noted on sacral area, treatment team informed of findings. Note dated 3/21/2025 indicated, Resident will be followed in PAR [patient rounds] for wounds. Stage 2 sacrum and DTPI [deep tissue pressure injury] to sacrum. Wounds are new as of 3/20. Treatment [treatment] is Zinc, lotrisome, antifungal daily. DTPI to Rt heel. Note dated 3/28/2025 indicated, Unstageable sacral wound. Wound being treated with honey with calcium alginate covered with foam 3x/week. DTPI to right heel. Treated with betadine gauze covered with ABD [abdominal] pad daily. Wounds are stable. Will continue POC [plan of care]. Note dated 4/4/2025 at 10:18 am indicated, Resident with acquired pressure ulcer to sacrum improving now . resident with acquired pressure ulcer to right heel also improving Note dated 4/18/2025 at 11:10 am a note Resident followed this week on PAR for a Sacral wound, unstageable which is showing improvement with Santyl and foam dressing changes daily and for a stage 3 wound to his Right Heel which is not showing improvement and is being treated with Santyl and rolled gauze. Note dated 5/16/2025 at 11:32 am indicated, Patient being followed by PAR for unstageable wound to sacrum. Wound is not improving. Stage III wound to right heel. Wound has not improved. Treatment changed to calcium alginate and rolled gauze. 3x/week. Will continue POC.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents respiratory equipment was maintained and stored appropriately for one of two resident (Resident (R) 83) reviewed for respiratory care out of 30 sampled residents. These failures placed the resident, who has a tracheostomy, at risk for environmental contamination which could lead to respiratory infections. Findings include: Review of the facility's policy titled, Oxygen Administration dated 03/01/23 revealed .Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated .Keep delivery devices covered in plastic bag when not in use . Review of R83's admission Record located in the resident's electronic medical record (EMR) under the Profile tab, revealed R83 was admitted to the facility on [DATE] with diagnoses which included anoxic brain damage, chronic respiratory failure, gastrostomy, and tracheostomy. Review of R83's Physician Order dated 06/02/25 and located in the resident's EMR under the Orders tab revealed Give O2 5L [liter] via trach, mask continuous with humidified air every shift. Change respiratory supplies and set-up every night shift and every Sunday, dated 06/16/24.Clean O2 concentrator filter once weekly on Sunday during the night shift and as needed, dated 06/11/24. During an observation on 06/02/25 at 3:43 PM revealed R83's oxygen concentrator was dirty with dried particles and was sticky. The air filter was covered in white dust. During an observation and interview on 06/04/25 at 3:31 PM, Licensed Practical Nurse (LPN 4) revealed the oxygen concentrator was still dirty with dried particles and sticky. The air filter was covered in white dust. LPN4 stated, The suction tubing is outdated and the Yankauer suction tip is not bagged. This concentrator is dirty. It should have been cleaned and all tubing changed on Sunday evening. During an interview on 06/05/25 at 5:37 PM, the Administrator revealed Infection control is very important for this resident due to having a tracheostomy. Policies and procedures need to be followed.

Based on staff interview, record review, and review of the facility's policy titled Residents' Rights Regarding Treatment and Advance Directives, the facility failed to provide the resident and/or their representatives with written information of the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for one of six Residents (R) (R59) reviewed for Advanced Directives. This failure created the potential the resident wishes would not be followed if the resident was unable to speak for themselves. Findings include: Review of the facility's policy, titled, Residents' Rights Regarding Treatment and Advance Directives dated 3/1/2025 revealed, Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate advance directives. Policy Explanation and Compliance Guidelines: 1. On admission, the facility will determine if the resident has executed on advance directive, and if not, determine whether the resident would like to formulate an advance directive. 2. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive .9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care . Further review of the facility's policy revealed the policy failed to specify providing information in a written format. Review of R59's undated admission Record located in R59's electronic medical record (EMR) under the Profile tab revealed R59 was admitted to the facility on [DATE] and was re-admitted on [DATE]. Review of R59's EMR revealed no documentation that R59 had an Advance Directive or that the facility provided written information to the resident, or the resident representative concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive. During an interview on 6/4/2025 at 10:15 am, the Director of Nursing (DON) stated, Resident R59 came to the facility under the previous ownership, and we do not have any record of R59 being given any information about advance directives.

Based on observation, interview, and review of the facility's policies titled, Personal Protective Equipment and Handwashing/Hand Hygiene, the facility failed to ensure two of two staff (Certified Nursing Assistants (CNA) (CNA1 and CNA2) wore a gown and performed hand hygiene before, in-between, and after glove changes when they provided personal care to one Residents (R) (R107) who was on Enhanced Barrier Precautions (EBP); one of one Wound Care/Registered Nurse (WC/RN) failed to perform hand hygiene before, in-between, and after glove changes during wound care for R97; and two of two Certified Medication Aides (CMA) (CMA1 and CMA2) failed to sanitize the wrist blood pressure (B/P) cuffs between residents' use for R72 and R82. Findings include: Review of the facility's policy titled, Personal Protective Equipment (PPE) dated October 2018 revealed personnel who perform tasks that may involve exposure to blood/body fluids are provided proper PPE .PPE required for transmission-based precautions is maintained outside and inside the resident's room as needed. Review of the facility's policy titled, Handwashing/Hand Hygiene dated October 2023 revealed hand hygiene is indicated, immediately after glove removal. 1. Observation on 6/2/2025 at 3:30 pm revealed there was a sign on the R107's door that indicated what type of PPE was to be worn for EBP which included wearing a protective gown and gloves when providing any care that had the potential exposure to any type of body fluids. Observation on 6/2/2025 at 3:45 pm, CNA1 and CNA2 provided R107's personal care. R107 was on Enhanced Barrier Precautions (EBP) since he had an indwelling urinary catheter, and he had pressure ulcers. During the care CNA1 and CNA2 did not don a gown. CNA1 had completed indwelling urinary catheter care, removed her gloves, and without performing hand hygiene don new gloves, then with the assistance of CNA2 positioned R107 on his left side, pulled the incontinence brief down, and provided perineal care. R107 had a large amount of bowel movement. She discarded several wipes and pairs of gloves during the care. She did not perform hand hygiene between any of the doffing and donning of clean glove changes. CNA2 assisted with rolling R107 over to his right side to ensure it had been cleaned. She pulled the new brief out from under him and assisted to fasten the brief. CNA1 and CNA2 did not change their gloves prior to touching the blankets, side rails, bed controller, and call light. They both removed their gloves and did not perform any hand hygiene prior to leaving R107's room. 2. Observation on 6/2/2025 at 4:45 pm of Wound Care (WC)/Registered Nurse (RN) during the dressing change for R97 revealed without any hand hygiene, WC/RN donned on gloves, removed R97's soiled dressing from his bottom, disposed of it, doffed his gloves, and with no hand hygiene donned a new pair of gloves. He then cleansed the wound, retrieved a pair of clean gloves from his pocket, and put them on without hand hygiene. He applied a new dressing, disposed of the soiled dressing and the gauze he cleansed the wound, doffed his gloves with no hand hygiene prior to leaving the room. 3. Observation on 6/4/2025 at 8:30 am revealed, CMA2 used a wrist blood pressure (B/P) cuff and obtained R54's B/P. After the B/P was obtained she placed the cuff back on top of the medication cart. She used the same B/P cuff at 8:53 am to obtain R72's B/P. She had not sanitized the B/P cuff between the residents. Observation on 6/4/2025 at 9:24 am, CMA1 used a wrist B/P and obtained R82's B/P. After the B/P was obtained she placed the cuff back on top of the medication cart. She did not sanitize the B/P cuff after she used it for R82. In an interview on 6/4/2025 at 2:51 pm, the Infection Preventionist revealed that staff had training on PPE and hand hygiene. She agreed the procedure the staff used did not follow the facility's policies. In an interview on 6/5/2025 at 3:00 pm, CNA2 confirmed that they did not wear a gown when they provided R107's personal care. She revealed she did not realize that she had not performed hand hygiene for her glove use. In an interview on 6/5/2025 at 4:30 pm, the Director of Nursing (DON) revealed that staff had received infection control education not long ago. She agreed that the proper infection control practices had not been maintained.

Based on record review, and interviews, the facility failed to arrange podiatry services for two (residents (R) 15 and 33) of two residents reviewed in the sample of 30 residents. The facility failed to ensure at risk residents receive appropriate foot care services. Findings include: Review of R33's Face Sheet found in his electronic medical record (EMR) under the Face Sheet tab revealed the resident was originally admitted to the facility on [DATE] with diagnoses that included anxiety, depression, and difficulty walking. Review of R33's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/10/25 in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R33's cognition was moderately impaired. During a review of R33's EMR, a document located under the Documents tab revealed a podiatry visit on 08/30/22. The document indicated that the facility requested podiatry services for R33 in relation to his toenails. The document also indicated that R33 had pain, limited mobility, and the nails were long and thickened. The document noted that his toenails were graded as moderate and indicated that the resident had these symptoms for a few years. The document revealed the results of the physical exam of R33's toenails and determined that first left and right nails were mycotic with 2 millimeter (mm) of thickness with subungual debris. It is also noted that they are thickened, yellowed, and causing pain. The second through fifth toenails, bilaterally, are elongated and dystrophic, meaning to exhibit abnormal changes in appearance. The document confirmed that the debridement occurred bilaterally to toenails one through five. This included reducing the length and thickness, using manual clippers and electric grinder. Per the document, the consulting physician recommended, ongoing preventive routine debridement of the devitalized or contaminated tissue. Debridement will relieve the pressure form the necrotic presence on the nail and provides for better cosmetic appearance. Debulking the nail does help, in combination with other treatments, in that it can decrease the fungal load of the nail itself to decrease [NAME] of infection and breakdown of skin. For a higher cure rate, I have recommended treating the patient's fungal infection with an oral and/or topical anti-fungal medication unless clinically contraindicated. The document also revealed a 9-week follow-up appointment with a consultant podiatrist, but no evidence of an appointment was located in the EMR. Review of R33's care plan found under the Care Plan tab of the EMR revealed that the resident requires assistance with grooming, bathing, and personal hygiene due to self-care impairment. Interventions included providing nail care as needed, initiated 04/28/23. 2. Review of R15's Face Sheet, found in the EMR under the Face Sheet tab revealed the resident was originally admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus with diabetic polyneuropathy and nail dystrophy. Review of R15's annual MDS with an ARD of 03/22/25 in the EMR under the MDS tab revealed a BIMS score of 15 out of 15 which indicated R33's cognition was intact. During an interview with R15 on 06/02/25 at 10:30AM, he stated that his toenails are extremely long and sometimes painful. R15 added that the facility used to have someone who would trim their toenails but that it's been a while since anyone has addressed them. Review of a document found under the Documents tab of the EMR, revealed a consultant podiatry encounter that occurred on 01/30/23. The document confirmed that the facility requested for R15 to have his bilateral toenails evaluated and that all affected nails were debrided to reduce length and thickness using manual clippers and an electric grinder. The consultant also recommended additional follow up of the condition is recommended on a routine basis per routine foot care guidelines for an at-risk patient. Treatment is not recommended if not performed by a qualified medical specialist. Interview on 06/03/25 at 1:58PM, the Regional Nurse Consultant (RNC) 2 stated that podiatry comes to the facility monthly, unless there is an acute concern. When asked how residents are seen she added that she would need to find the roster. During an interview with Certified Medication Aide (CMA) 3, on 06/03/25 at 2:03PM she confirmed that the nurse aides do provide nail care for residents during hygiene care, unless the resident is a diabetic. If they are a diabetic, they are seen by podiatry. The Nursing Home Administrator supplied a binder that was labeled Podiatry List Book. Inside the binder was a single sheet of paper with a handwritten list of residents, titled, List Residents for Podiatry Upcoming. Neither resident R33 or R15 were on the list. During an on 06/03/25 at 3:33PM, the Social Services Director (SSD) stated that the facility recently got a new podiatry provider that will start seeing residents on 06/05/25. When asked if she could provide any documentation of provider visits other than what could be found in the EMR, the SSD stated that she could not, but admitted that there has not been a podiatry provider in the facility for some time and she cannot recall if there was a podiatry provider visit since the new Administrator took over in June of 2024.

Based on observation, interview, and record review, the facility did not ensure one of five Residents (R) (R80) who was at risk for acquiring a pressure ulcer had preventative measures in place to avoid the development of pressure ulcers. Specifically, R80 acquired three pressure ulcers after his readmission to the facility. Findings include: Review of R80 ' s Clinical Census in the Electronic Medical Record (EMR) under the Clinical Census tab revealed admission date of 1/2/2025, hospitalization on 2/13/2025 and readmission on [DATE]. Review of R80 ' s Medical Diagnosis in the EMR under the Medical Diagnosis tab revealed diagnoses multiple fractures of ribs on the right side, lumbar vertebra fracture, prostate cancer, and diabetes mellitus type 2. Diagnoses added 2/13/2025 to 2/17/2025 hospitalization included deep vein thrombosis (DVT) of the right lower leg, and pneumonia. Review of R80 ' s Care Plan in the EMR found under the Care Plan tab dated 1/14/2025 indicated at risk for altered skin integrity related to diagnoses, incontinent at times, elderly, and fragile skin. Interventions included, Handle gently during transfers and ADLs [activities of daily living],Observe skin during ADLs for any changes in skin condition, notify nurse of any changes, Position properly in bed & [and} [wheelchair] to avoid skin tear or friction, Weekly skin assessments as scheduled. There were no further interventions after R80 was readmitted from the hospital on 2/17/2025 and once the sacral pressure ulcer, right heel pressure ulcer, and a left hip pressure ulcer developed 3/19/2025 . Review of R80 ' s Braden Scale for Predicting Pressure Sore Risk dated 1/9/2025 in the EMR under the Assessments tab revealed a score of 20 which indicated he was not at risk of developing a pressure ulcer. Review of the EMR revealed no further Braden scales had been completed after his 2/17/2025 readmission due to a deep vein blood clot and pneumonia. Observations on 6/2/2025 at 10:30 am, 1:00 pm, and 4:00 pm revealed R80 lying in bed on his back. His heels were not elevated on a pillow. Observations on 6/3/2025 at 9:00 am, 11:30 am and 3:30 pm revealed R80 lying in bed on his back. His heels were not elevated on a pillow. He had a low air loss mattress in place. Observation on 6/4/2025 at 3:00 pm revealed R80 lying in bed on his back. His heels were not elevated on a pillow. Interview on 6/4/2025 at 12:37 pm, the Wound Care/Registered Nurse (WC/RN) revealed when R80 was admitted on [DATE] he was able to get in and out of bed independently. He would walk to meals and to activities independently. After his hospitalization from 2/13/2025 to 2/17/2025 he did not get out of bed. His cognition declined. Staff needed to reposition him often. She stated that he was to have his heels elevated when he was in bed. Interview on 6/4/2025 at 12:35 pm, Licensed Practical Nurse (LPN)1 stated that after R80 returned from the hospital, he refused to get up due to pain. He was repositioned with wedges and usually more to his left side. There was no place in his EMR for staff to document when he was repositioned. Review of R80 ' s significant change Minimum Data Set (MDS) in the EMR with an Assessment Reference Date of 2/19/2025 under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R80 was moderately cognitively impaired. Review of the Behavior section revealed he rejected care one to three days out of seven days. Review of his Functional Abilities section revealed he required substantial or maximal assistance with rolling left and right. Review of the Skin Conditions section revealed he had no pressure ulcer or injury, and he was at risk of developing pressure ulcers or injuries. Review of R80 ' s admission MDS in the EMR with an ARD of 3/17/2025 under the MDS tab revealed a BIMS score of five out of 15 which indicated R80 was severely impaired. Review of the Behavior section revealed he rejected care one to three days out of seven days. Review of his Functional Abilities section revealed he needed substantial or maximal assistance with rolling left and right. Review of the Skin Conditions section revealed he had no pressure ulcer or injury, and he was not at risk of developing pressure ulcers or injuries. Review of R80 ' s quarterly MDS in the EMR with an ARD of 3/24/2025 under the MDS tab revealed a BIMS score of 3 out 15 which indicated R80 was severely cognitively impaired. Review of the Behavior section revealed he had not rejected care. Review of his Functional Abilities section revealed he needed substantial or maximal assistance with rolling left and right, sit to lying, and lying to sitting on the side of the bed. Review of the Skin Conditions section revealed he had a pressure ulcer or injury, and he was at risk of developing pressure ulcers or injuries. There was one unstageable pressure ulcer and one unstageable pressure ulcer due to a deep tissue injury listed. Review of R80 ' s Progress Notes in the EMR found under the Progress Notes tab revealed notes dated 3/19/2025 at 9:44 am which indicated, Skin intact Sacral area reddened R/T [related to] incontinence. Butt cream applied as needed. Note dated 3/20/2025 at 9:54 am indicated, .large purple colored area on his Rt [right] heel, reddened area noted on sacral area, treatment team informed of findings. Note dated 3/21/2025 indicated, Resident will be followed in PAR [patient rounds] for wounds. Stage 2 sacrum and DTPI [deep tissue pressure injury] to sacrum. Wounds are new as of 3/20. Treatment [treatment] is Zinc, lotrisome, antifungal daily. DTPI to Rt heel. Note dated 3/28/2025 indicated, Unstageable sacral wound. Wound being treated with honey with calcium alginate covered with foam 3x/week. DTPI to right heel. Treated with betadine gauze covered with ABD [abdominal] pad daily. Wounds are stable. Will continue POC [plan of care]. Note dated 4/4/2025 at 10:18 am indicated, Resident with acquired pressure ulcer to sacrum improving now . resident with acquired pressure ulcer to right heel also improving Note dated 4/18/2025 at 11:10 am indicated, Resident followed this week on PAR for a Sacral wound, unstageable which is showing improvement with Santyl and foam dressing changes daily and for a stage 3 wound to his Right Heel which is not showing improvement and is being treated with Santyl and rolled gauze. Note dated 5/16/2025 at 11:32 am indicated, Patient being followed by PAR for unstageable wound to sacrum. Wound is not improving. Stage III wound to right heel. Wound has not improved. Treatment changed to calcium alginate and rolled gauze. 3x/week. Will continue POC. Interview on 6/4/2025 at 4:30 pm, the Director of Nursing (DON) stated that there was not a policy on the prevention of pressure ulcers.

Based on observation, staff interviews, and review of the facility's policies titled, Resident Rights and Confidentiality of Personal and Medical Records, the facility failed to ensure personal information was kept confidential for two residents (R) (R19 and R20) of 20 sampled residents. Specifically, the residents' medication cards containing resident information were left unattended on top of the 400-unit Medication Cart. Findings include: Review of the facility's policy titled, Resident Rights, dated February 2021, documented .3. The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPAA [Health Insurance Portability and Accountability Act] compliance officer. Review of the facility's policy titled, Confidentiality of Personal and Medical Records, revision date of 3/1/2023, documented This facility honors the resident's right to secure and confidential (sic) personal and medical records. This includes the right to confidentially of all information contained in a resident's records, regardless of the form of storage or location of the record. Personal and medical records include all types of records the facility might keep on a resident, whether they are medical, social, funds account, automated, or other .resident's personal or medical information shall not be left unattended or viewable by unauthorized persons .will be disposed of in a way that will not compromise resident's personal or medical information. During an observation conducted on 4/24/2024 from 9:15 am to 9:33 am of the 400-hall, there were two empty resident medication cards on the top of the medication cart, facing up with resident information exposed, and left unattended. There were residents, staff, and visitors walking in the hall during the observation. Review of R19, and R20's medication card, revealed it contained the resident's name, room number, physician name, and medication prescribed. During an interview on 4/25/2024 at 9:33 am, Licensed Practical Nurse (LPN) 5 confirmed the medication cards were inappropriately left unattended. LPN5 demonstrated that the top of medication cards containing the resident's information was supposed to be torn off and placed in the cart to dispose of appropriately. During an interview on 4/25/2024 at 1:00 pm, when questioned what his expectations were for the empty medication cards containing resident information, the Administrator stated he would expect the nurse to tear the top off the medication card and throw away the rest of the card, keeping the residents' information private.

Based on observation, staff interviews, record review, and review of the facility's policy titled Pressure Injury/Wound Treatment Management, the facility failed to ensure that one of two Resident (R) (R 16) observed for pressure ulcer treatment, had a dressing maintained for a stage IV sacral ulcer. Specifically, there was no dressing covering R16's sacral pressure ulcer leaving it exposed to urine and feces. Findings include: Review of the facility's policy titled, Pressure Injury/Wound Treatment Management dated 3/1/2022, documented To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders .3. Dressing changes may be provided outside the frequency parameters in certain situations: a. Feces has seeped underneath the dressing, b. The dressing has dislodged, c. the dressing is soiled otherwise, or is wet. Review of R16's undated Admission Record located in the electronic medical record (EMR) under the Profile tab, indicated R16 was admitted to the facility with diagnoses that included pressure ulcer of sacral region, stage four, type two diabetes with hyperglycemia, and morbid obesity. Review of R16's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 3/22/2024 indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R16 had intact cognition. Further review of the MDS indicated the resident was always incontinent of urine, and frequently incontinent of bowel. Review of R16's Care Plan located in the EMR under the Care Plan tab, dated 2/1/2019 and revised 7/18/2023, revealed .has a chronic pressure ulcer to sacrum .interventions included but not limited to, two-person assistance with all bed mobility and ADL (activities of daily living) care, treatment as ordered. Further review of the care plan, dated 10/30/2018 and revised 8/28/2019, documented .has potential for further pressure ulcer development r/t [related to] decreased mobility, incontinence. Interventions included but not limited to observe dressing daily to ensure it is intact and adhering. Report lose (sic) dressing to treatment nurse. During an observation and interview on 4/24/2024 (Wednesday) at 2:38 pm, during the wound care observation, the Wound Care Nurse (WCN) confirmed the wound was open to air and had no wound dressing intact. The WCN was asked if the wound was supposed to have a dressing applied to the wound. The WCN replied, The Nurse Practitioner (NP) made rounds on Monday and applied a dressing to the wound. The resident receives wound care on Monday, Wednesday, Friday, and as needed. The WCN was asked what should have occurred with the wound if the dressing fell off during care. The WCN stated if the dressing became soiled or fell off, nursing should have either replaced it or notified her to take care of it. During an interview on 4/24/2024 at 3:33 pm, the Assistant Director of Nursing (ADON) was asked what her expectations of the staff were when a resident's wound dressing became soiled or dislodged. The ADON stated her expectation was for the staff to alert the nurse, and for nursing to replace the dressing. During an interview on 4/24/2024 at 3:45 pm, Certified Nurse Aide (CNA) 5 was questioned if she was aware R16's wound dressing was off. CNA5 stated no, she was unaware of that, but would let the nurse know if this had happened when changing the resident. During an interview on 4/24/2024 at 3:48 pm, CNA4 was questioned about what she would do if the resident's dressing came off or was soiled during incontinent care. CNA4 stated she would notify the nurse as soon as possible. During an interview on 4/24/2024 at 3:53 pm, the Administrator was questioned on his expectations of the staff when a wound dressing is soiled, dislodged, or missing. The Administrator responded he would expect the CNA to inform the nurse so they could reapply a dressing.

Based on interviews, record review, and review of the facility's policy titled Resident and Family Grievances, the facility failed to ensure their grievance procedures were followed for one of one resident (R) (R 3) reviewed for grievances of 20 sampled residents. Findings include: Review of the facility's policy titled, Resident and Family Grievances, dated 1/30/2023, indicated .It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal .The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form .Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow-up .All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Official. Prompt efforts include acknowledgement of complaint/grievance .In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum .The date the grievance was received .The steps take to investigate the grievance .A summary of the pertinent findings or conclusions regarding the resident's concerns(s).A statement as to whether the grievance was confirmed or not confirmed. Any action taken or to be taken by the facility as a result of the grievance .The date the written decision was issued . Review of R3's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 1/18/2024 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which revealed the resident was moderately cognitively impaired. Review of a document provided by the facility titled Concern Form, dated 3/9/2024, indicated Resident Representative (RR) 1 filed a grievance with the facility and identified the following concerns: late medication administration, dirty environment, broken toilet seat, and the resident had not been changed timely. On the back of the document, the Administrator verified that the resident's room was clean, and the resolution was to have the Housekeeping Supervisor check the room daily. The concern form indicated the Regional Nurse verified R3's medication was administered timely. There was a section which revealed the date on which the individual was to be notified and it was blank. The date of follow-up and the day that the individual was met with, and these areas were blank. An area on the document had an area whether or not the individual was satisfied with the resolution and again this was blank. During an interview conducted on 4/23/2024 at 12:07 pm, RR1 stated she completed a grievance and had no follow-up provided by the facility. During an interview on 4/24/2024 at 10:30 am, the Social Services Director (SSD) stated she was provided the Concern Form and would log it into her binder for tracking. The SSD stated she did not remember if there was resolution since there had been two different Director of Nursing (DON) since March 2024. The SSD stated the grievance process was to write up the resolution and to have it signed off by the family and the Administrator. During an interview on 4/24/2024 at 10:19 am, the Regional Nurse, who was previously the interim DON, stated she would get involved with the grievances and the first thing she would do would be to write up a response on the Concern Form and then pass it back to the SSD. The Regional Nurse stated the handwriting was not hers on the Concern Form and she must have received a telephone call from the DON at that time. The Regional Nurse stated she did not remember the details of her involvement. During an interview on 4/25/2024 at 1:24 pm, the Administrator stated he attempted to get the resolution done for a resident and/or their representative within 72 hours. The Administrator did not provide an explanation of why the Concern Form was not completed except to state he had met with the family and the medication issue was handled by the clinical staff.

Based on staff interview, record review, and review of a policy provided by the facility titled Maintenance of Clinical Records, the facility failed to ensure that clinical records were complete and contained accurate documentation for three Residents (R) (R 3, R1, and R4) out of 20 sampled residents. Findings include: Review of a policy provided by the facility titled, Maintenance of Clinical Records, dated 3/1/2023, indicated .This facility will maintain clinical records for each resident in accordance with acceptable standards of practice that reflects the current plan of care and services provided .In accordance with accepted professional standards of practices, the facility must maintain medical records on each resident that are .Complete .Accurately documented . 1. Review of R3's electronic medical records (EMR) titled Admission Record located under the Profile tab, indicated the resident was admitted with diagnoses that included chronic pain, left hand contracture, and gastrostomy status. 1. Review of R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/18/2024 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which revealed the resident was moderately cognitively impaired. Review of R3's EMR titled physician Orders located under the Orders tab, dated 1/33/2024, indicated the resident was to receive gabapentin 400 milligrams (mg) via gastrostomy-tube (G-tube) four times a day related to chronic pain. Review of R3's Medication Administration Record (MAR) for March 2024, located under the Orders tab, indicated the gabapentin was not documented as administered on the following times and dates: at 5:00 PM on 3/3/2024, 3/20/2024, and at 9:00 pm on 3/24/2024. There were no corresponding nursing notes which would indicate the reasons for the blank areas on the MAR. Review of R3's MAR for April 2024 located under the Orders tab, indicated the gabapentin was not documented as administered on the following dates: at 5:00 pm on 4/5/2024, 4/6/2024, 4/10/2024, 4/14/2024, and on 4/1520/24. There were no corresponding nursing notes which would indicate the reasons for the blank areas on the MAR. During an interview on 4/25/2024 at 9:15 am, the Regional Nurse stated the missing days for the gabapentin should have been documented as given and the medical record was to be accurate. 29015 2. Review of R1's undated Admission Record located in the EMR under the Profile tab, indicated the resident was admitted with diagnoses that included necrotizing fasciitis, cystitis, and acute respiratory failure with hypoxia. Review of R1's Documentation Survey Report, dated March 2024 and provided by the facility, under the Intervention/Task for Nutrition-Amount Eaten revealed there was no documentation of what R1's intake was for 3/11/2024, 3/15/2024, 3/16/2024, 3/17/2024, and 3/20/2024. 3. Review of R4's undated Admission Record located in the EMR under the Profile indicated the resident was admitted with diagnoses that included chronic kidney disease, type two diabetes, and congestive heart failure. Review of R4's Documentation Survey Report, dated January 2024 and provided by the facility, for the task revealed there was no documentation of personal hygiene, and bladder elimination, being completed on the 7:00 am-7:00 pm shift on 1/1/2024, 1/3/2024, 1/5/2024, 1/7/2024, 1/12/2024, 1/17/2024, 1/22/2024, 1/23/2024, 1/24/2024, 1/26/2024, 1/27/2024, and 1/28/2024. Additionally, there was no documentation on the amount eaten at 6:00 pm on 1/3/2024, 1/9/2024, and 1/13/2024. Review of R4's Documentation Survey Report, dated March 2024 and provided by the facility, for the task revealed there was no documentation for the amount eaten on 3/14/2024, 3/18/2024, and 3/24/2024. Further review of R4's complete EMR revealed there was no documentation of the resident not being out of the facility during the afore-mentioned dates/times. During an interview on 3/25/2024 at 1:28 pm, the Administrator confirmed the missing documentation. The administrator stated his expectation was for the care provided to be documented appropriately.

Based on observation, record review, review of the facility Abuse and Neglect Prohibition Policy (revised 7/2018) and resident and staff interview, the facility failed to ensure that two (2) residents (R) (R#1 and R#2) were protected from abuse by a Resident Care Specialist (RCS/Certified Nursing Assistant (CNA). Furthermore, another RCS/CNA failed to notify supervisory staff immediately of an observation of the physical abuse, resulting in actual harm, of two residents (R) (R)#1 and R#2, on 9/25/19, by the RCS/CNA perpetrator. This failure to immediately report an observation of the physical abuse and harm of R#1 resulted in the subsequent physical abuse and harm of R#2, on 9/25/19, by the same RCS/CNA perpetrator. The sample size was 21 residents. Findings include: Review of the facility Abuse and Neglect Prohibition Policy (revised 7/2018) revealed that each resident has the right to be free from abuse .and mistreatment .Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator. 1. R#1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that R#1 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Continued review revealed that he had no behaviors in the look back period. Further review revealed that he required extensive assistance of staff for activities of daily living (ADLS) and was frequently incontinent of bladder and always incontinent of bowel. Review of the resident's care plan dated 11/12/18 revealed that staff developed appropriate interventions to address his self-care deficit. Continued review revealed that staff addressed his behaviors of pulling his clothing, jerking and using curse words at times. Review of the Facility Incident Report Form for R#1 dated 9/25/19 revealed that on 9/25/19 at 9:30 p.m., RCS/CNA AA had pulled on resident #1's upper body and the resident hit his head on the dresser next to his bed, three times. He sustained a cut on the inside of his mouth. Continued review revealed that RCS/CNA AA also hit R#1 on his upper arm. Review of the care plan for R#1 revealed that it was revised on 10/7/19 to address his behaviors of jerking and pulling with an intervention for staff to explain all procedures to him before initiating care and allow him time to adjust to changes. If his behavior continues, STOP and come back later. When he has behaviors of pulling and jerking, he will stop if you ask him to. Observation and interview on 10/1/19 at 2:21 p.m. with R#1 (roommate of R#2) revealed the resident was lying in his bed. R#1 had no bruising/injuries on his face, neck or arms. He stated at that time that while a RCS/CNA was changing his brief, she grabbed him by his arm and pulled him out of the bed causing him to hit his head on the nightstand next to his bed. Continued interview with R#1 revealed that after providing care for him, the RCS/CNA went to his roommate (R#2) and was speaking loud to him. Further interview revealed that he heard R#2 yell out prior to observing the RCS/CNA leave his room. R#1 stated at that time that he did not know the name of the RCS/CNA who hurt him. R#1 stated that no one else at the facility had abused him and that he felt safe in facility. 2. R#2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed that R#2 had a BIMS score of 5, indicating severe cognitive impairment. Continued review revealed that he had no behaviors in the look back period. Further review revealed that he required extensive assistance from staff for ADLs and was always incontinent of bladder and bowel. Review of the resident's care plan dated 8/28/19 revealed that staff developed appropriate interventions to address his self-care deficit. Continued review revealed that R#2 was resistant to care with an intervention for staff to leave him alone for 5 to 10 minutes and come back to attempt care again. Review of the Facility Incident Report Form for R#2 dated 9/25/19 revealed that on 9/25/19 at 9:45 p.m., RCS/CNA AA was observed by another RCS/CNA to grab the genitals of R#2 causing him to scream and cry. Continued review of both Incident Reports revealed that RCS/CNA AA was suspended and immediately walked out of the building. Both residents were assessed for injuries. Local Law Enforcement and the State Survey Agency (SSA) were notified of the abuse within the mandated two hours. The Responsible Parties (RP) and Physician were notified. Review of the care plan for R#2 revealed that it was revised on 10/7/19 to address his behavior of rejecting care with an intervention to allow him to make decisions about his treatment regime to provide him with a sense of control. An observation and interview on 10/1/19 at 2:16 p.m., revealed that R#2 (roommate of R#1) was lying in his bed. He did not have any obvious bruising/injuries on his face, neck or arms. R#2 did not appear afraid. R#2 had difficulty answering more than yes and no questions due to his [MEDICAL CONDITION]. When asked if anyone had hurt him, R#2 said yes. When asked if anyone currently in facility had hurt him, he said no. When asked if he felt safe in the facility, R#2 said yes, sir, yes sir, yes sir. Review of the Sheriff's Office investigation dated 9/26/19 revealed the incident occurred on 9/25/19 which was related to R#2 being grabbed by genitals by RCS/CNA AA, three times, causing the resident to cry out in pain. R#2 confirmed to the investigator that this occurred at the hands of RCS/CNA A[NAME] Further review revealed an arrest warrant was issued for RCS/CNA AA on 9/30/19, for both R#1 and R#2, by the County District Attorney's office for the offense of: Exploitation and Intimidation of an Elderly/Disabled Adult. A post survey interview on 10/22/19 at 9:41 a.m. with the District Attorney Investigator confirmed that RCS/CNA AA was arrested on 10/1/19 for charges of abuse for R#1 and R#2. Record review revealed that on 10/1/19 the facility held an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting with department heads which included the Administrator, Director of Nursing (DON) and Medical Director. Review of the meeting minutes revealed that interventions were developed and implemented to prevent further abuse of residents. Record review in-service sign-in sheets dated 9/25/19 and 9/26/19 revealed that all staff were in-serviced on Abuse and Neglect. Review of the medical records for R#1 and R#2 revealed that the Social Service Director (SSD) provided psychosocial wellness visits for both residents 72 hours after the abuse to assess for any post-abuse distress. Interview with RCS/CNA BB on 10/1/19 at 3:36 p.m. revealed that she was in orientation at the time of the incident and was assisting RCS/CNA AA in the provision of care for R#1 on 9/25/19 on the 3:00 p.m. to 11:00 p.m. shift. Continued interview revealed that RCS/CNA AA was rough with R#1 and pulling on him during care. R#1 then became combative and RCS/CNA AA punched the resident (R#1) in the arm and chest, three to four times and then grabbed his arm and pulled him off the bed. RCS/CNA BB stated that R#1's mouth was bleeding. RCS/CNA BB then told CNA/RCS AA to obtain clean linens. Further interview with RCS/CNA BB revealed that she finished the care for R#1 and asked him if he was O.K. and he said he was. Continued interview with RCS/CNA BB revealed that R#2, R#1's roommate, was covered in feces so she began providing care for him. RCS/CNA BB stated that RCS/CNA AA came back into the room with clean linens and before RCS/CNA BB could place a clean brief on R#2, RCS/CNA AA grabbed his genitals and squeezed them. Further interview revealed that R#2 cried out in pain. RCS/CNA BB stated that she left the residents' room and notified her preceptor at that time of RCS/CNA AA's abuse. Continued interview revealed that she attempted to notify the Charge Nurse but, the nurse was on the phone. RCS/CNA BB stated that she then went to another hall to assist another RCS/CNA with resident care. When asked why she did not notify supervisory staff immediately after RCS/CNA AA abused R#1 and prior to providing care for R#2, RCS/CNA BB stated, I was in shock and just wanted to finish and get out of there. RCS/CNA BB stated that she was taught in CNA school to immediately notify supervisory staff of any incident of abuse. Interview with the Director of Nursing (DON) on 10/2/19 at 1:39 p.m. revealed that RCS/CNA AA abused R#1 around 9:20 p.m. and abused R#2 around 9:30 p.m. Continued interview revealed that the Charge Nurse was notified by RCS/CNA BB of the events around 9:40 p.m. Further interview with the DON revealed that she had arrived at the facility at around 9:45 p.m. to provide in-services to second shift staff when the Charge Nurse informed her of the incidences. The DON stated, at that time, that RCS/CNA AA was taken to the conference room and a statement was obtained prior to the DON walking her out of the building at around 9:50 p.m. Continued interview revealed that the Administrator arrived shortly after. Review of the in-services provided by the facility on Abuse Prevention revealed that RCS/CNA AA had received in-service on 7/16/19, date of hire, and RCS/CNA BB had received in-service on 9/1/19. Interviews with RCS/CNAs CC on10/1/19 at 4:06 p.m., RCS/CNA DD on 10/1/19 at 4:09 p.m., RCS/CNA EE on 10/1/19 at 4:11 p.m., RCS/CNA FF on 10/1/19 at 4:15 p.m., RCS/CNA GG on 10/1/19 at 4:20 p.m., RCS/CNA JJ on 10/2/19 at 3:37 p.m., RCS/CNA KK on 10/2/19 at 3:34 p.m. revealed that they were not aware of any resident's being abused by staff, before the incident with R#1 and R#2, but if they became aware they would immediately report to the charge nurse and the Administrator. They all confirmed having participated in Abuse in-services at the facility on (MONTH) 25 and 26, 2019. Interviews with Registered Nurses (RN) and Licensed Practical Nurses (LPN) revealed: RN HH on 10/2/19 at 3:20 p.m., RN II on 10/2/19 at 3:22 p.m., and LPN LL on 10/2/19 at 3:37 p.m. were not aware of any incidents of abuse until after the incident with RCS/CNA A[NAME] The were aware to notify their supervisor and the Administrator should they become aware of abuse to a resident. Interviews with cognitively intact residents (Brief Interview for Mental Status (BIMS) of 13-15 indicates cognitively intact and 8-12 indicates moderately cognitvely intact) , R#7 on 10/2/19 at 10:35 a.m. with a BIMS on the Annual MDS dated [DATE] of 15, indicating the resident was cognitively intact, R#5 on 10/2/19 at 10:38 a.m. with a BIMS of 11 on the Quarterly MDS dated [DATE], R#8 with a BIMS of 12 on the Quarterly MDS dated [DATE], R#9 on 10/2/19 at 10:44 a.m. with a BIMS of 11 on the Quarterly MDS dated [DATE], R#10 on 10/2/19 at 10:46 a.m. with a BIMS of 12 on the Admission MDS dated [DATE], R#11 on 10/2/19 at 10:50 a.m. with a BIMS of 14 on the Quarterly MDS dated [DATE], R#13 on 10/2/19 at 11:00 a.m. with a BIMS of 13 on the Quarterly MDS dated [DATE], R#14 on 10/2/19 at 11:06 a.m. with a BIMS of 15 on the Quarterly MDS of 9/25/19, R#15 on 10/2/19 at 11:08 a.m. with a BIMS of 14 on the Quarter MDS dated [DATE], R#16 on 10/2/19 at 11:15 a.m. with a BIMS of 12 on the Admission MDS dated [DATE], R#17 on 10/2/19 at 11:42 a.m. with a BIMS of 15 on the Quarterly MDS dated [DATE], R#18 on 10/7/19 at 12:12 p.m. with a BIMS of 14 on the Admission MDS dated [DATE], R#19 on 10/7/19 at 12:16 p.m. with a BIMS of 13 on the Quarterly MDS dated [DATE], R#20 on 10/7/19 at 12:20 p.m. with a BIMS of 13 on the Annual MDS dated [DATE], and R#21 on 10/7/19 at 12:26 p.m. with a BIMS of 14 on the Quarterly MDS dated [DATE] revealed that they had not been abused or seen any other residents abused. Continued interview revealed that they knew to whom to report any incidences of abuse. An interview with the Administrator, who was the Abuse Prevention Coordinator, on 10/9/19 at 11:01 a.m. revealed that she expected RCS/CNA BB to make sure R#1 was safe first, then get help and notify supervisory staff of the abuse prior to providing care for R#2. The facility failed to ensure that R#1 and R#2 were protected from abuse by RCS/CNA A[NAME] Furthermore, the facility failed to ensure that RCS/CNA BB immediately notified supervisory nursing staff of the abuse of R#1 by RCS/CNA A[NAME] This failure resulted in the subsequent abuse of R#2.

Based on record review, review of the facility's policies entitled, Preventing, Investigating, Reporting Alleged Sexual Assault and Abuse Violation policy (the policy of this center to take appropriate steps to prevent the occurrence of neglect (neglect means the failure to provide goods and services necessary), the Skin Integrity Guidelines policy and procedure, and staff interviews, the facility failed to ensure that residents with pressure ulcers and/or other skin conditions received the services necessary to identify, report, obtain physician orders [REDACTED].#84, R #24, R #50, R #64, R #120, R #180). In addition, the facility failed to ensure that one (1) resident (R #170) identified as an elopement risk on admission received the services necessary to prevent an elopement, the resident eloped from the facility four (4) days after admission. The sample size was fifty-one (51) residents, the census was one-hundred and one (101). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On [DATE] at 11:30 a.m., the ED and Corporate Area Vice President (VP) were notified that IJ existed. It was determined that the IJ was identified to exist on [DATE] related to resident N who was admitted to the facility on [DATE] after a hospital stay from home for a urinary tract infection, history of falls, who ambulated with a walker, with impaired cognition. The resident was discharged from the hospital to the facility with fluid filled blisters on bilateral heels and a reddened sacral area. The facility failed to develop an interim care plan to address the pressure ulcers. The resident was found unresponsive on [DATE] and transferred to the hospital in septic shock. Review of the Hospital Discharge Summary signed on [DATE] revealed the Final [DIAGNOSES REDACTED]. Review of the Georgia Death Certificate revealed the immediate cause of death for Res N was Septic shock secondary to decubitus. A Credible Allegation of Compliance was received on [DATE] at 5:40 p.m., was not acceptable, the ED was notified during the exit meeting that the IJ's would be ongoing. Therefore the IJ was identified to exist on [DATE] and remains on-going. Findings include: Review of the facility's Preventing, Investigating, and Reporting Alleged Sexual Assault and Abuse Violation policy and procedure revealed that it was the policy of this center to take appropriate steps to prevent the occurrence of neglect. Neglect means the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. The executive director (ED) and director of nursing services (DNS) identify, intervene and correct in situations in which neglect is more likely to occur. Review of the facility's Skin Integrity Guideline noted that a routine schedule to review residents with wounds or at risk on a weekly basis and will document findings, and the DNS or designee will be responsible to implement and monitor the skin integrity program. The licensed nurse will be responsible for performing a skin evaluation/observation weekly, utilizing the Weekly Skin Review UDA (user defined assessment). Licensed nurse to document weekly on identified wounds using the Wound Evaluation Flow Sheet (WEFS) UDA. A manual tracking system to monitor completion of weekly WEFS must be created. Monitoring Compliance includes the WEFS UDA is accurately and thoroughly completed for wounds. 1. Record review revealed that resident N was admitted to the facility on [DATE] with fluid-filled blisters on their bilateral heels and a reddened sacral area, with wound care orders from the hospital. However, review of the facility's physician's orders [REDACTED]. Resident N returned to the facility on [DATE] after a hospitalization , and hospital Instructions included Stage I right heel wound, Stage I sacral wound, and unstageable left heel wound. However, there was no evidence that the physician was notified of the readmission and/or no evidence that there were any new physician's orders [REDACTED]. The previous three (3) pressure ulcers the resident was admitted with had become unstageable, and two new pressure ulcers had developed that were also unstageable. Review of the clinical record revealed that resident N was hospitalized on [DATE]. Review of a hospital Discharge Summary revealed that the resident expired on [DATE], and final [DIAGNOSES REDACTED]. 2. Review of the clinical record for resident T' revealed they were admitted to the facility on [DATE] with a Stage II pressure ulcer to the sacrum and non-blanchable pressure ulcers to both heels. Further review revealed physician orders [REDACTED]. The sacral wound healed on [DATE], but there was no evidence that preventive measures were put in place to protect the area, and the sacral wound reopened on [DATE] as a Stage II pressure ulcer. During further record review there was no evidence that an order was obtained to treat this Stage II sacral wound until [DATE]. Review of a General Note dated [DATE] revealed that the pressure sore on the sacrum had deteriorated, had 75% necrotic tissue in the wound bed and measured 4.0 x 3.0 x 0 centimeters (cm). Review of the Treatment Administration Records (TARs) revealed that there was no evidence that treatments were completed as ordered to the heels on [DATE], [DATE], [DATE], and in [DATE] there was no evidence that the every three days heel treatments were completed between [DATE] and [DATE] (8 days between treatments). Review of the TAR for the sacral wound treatments revealed that there was no evidence that the treatments were completed on [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the April and May TARs revealed that there was no evidence that staff performed treatments twice a day for the sacral pressure sore as ordered from [DATE] to [DATE] (6 consecutive days), on [DATE], from [DATE] to [DATE] (3 consecutive days), from [DATE] to [DATE] (6 consecutive days), from [DATE] to [DATE] (4 consecutive days), and on [DATE]. Review of the May TAR revealed that there was no evidence that treatment to the heels was completed on [DATE]. Continued review revealed no evidence that staff performed any treatments to the resident's sacral pressure sore on [DATE] and [DATE]. Review of weekly assessments of the sacral pressure sore and the bilateral heel pressure sores revealed the staff failed to do the assessments as scheduled on [DATE] and [DATE], almost three weeks between assessments. Review of the July TAR revealed no evidence that staff provided treatment as ordered for the sacral wound on [DATE] and [DATE] which resulted in the resident not receiving needed treatment for [REDACTED]. Continued review of the July TAR revealed no documentation that treatments were completed as ordered for the bilateral feet on [DATE] and [DATE], which resulted in the resident not receiving the needed treatment for [REDACTED]. 3. Review of a General Note dated [DATE] revealed that a blister was identified on resident R's right heel. Review of the wound care clinic's Nursing Wound/Ulcer assessment dated [DATE] revealed that resident R had a large callous over the right malleolus (ankle bone) from a previous ulcer which the physician debrided that day but, there was no indication that the right ankle was treated until [DATE], and no indication that staff assessed the right ankle wound until [DATE]. Review of a care plan note dated [DATE] revealed that the Stage II pressure sore on the right ankle measured 1.0 x 1.0 x 0 centimeters (cm), but there was no indication that assessments of the right ankle wound were completed after [DATE] until [DATE], when staff documented that the right ankle wound was now a Stage III pressure sore that measured 1.7 x 0.5 x 0.2 cm. Review of wound care physician's orders [REDACTED]. Review of the May TAR revealed that there was no indication that the right heel pressure sore was treated from [DATE] until [DATE]. Observation of resident R's bilateral foot dressings on [DATE] at 2:40 p.m. revealed that they were dated [DATE], despite orders for daily dressing changes. Review of the resident's TARs revealed that there was no evidence that treatments were done as ordered to one or more wounds on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], and [DATE] through [DATE]. 4. Review of R #84's clinical record revealed that they were admitted to the facility on [DATE] with a Stage IV sacral decubitus. Review of the pressure ulcer documentation from [DATE] to [DATE] revealed that there was increased signs and symptoms of infection, such as increased odor, but the physician was not notified until [DATE]. Further review of the clinical record revealed that the resident was admitted to the hospital on this date, with a temperature of 103.7 degrees. Review of a hospital supervising physician's note dated [DATE] revealed that the resident had multiple infections, including pressure ulcer. Review of a Discharge Summary note dated [DATE] from a local specialty hospital, where the resident had been sent to for long-term intravenous antibiotic therapy, revealed that the reason for admission was an infected decubitus wound. Resident #84 was discharged from the specialty hospital and readmitted to the long-term care (LTC) facility on [DATE], and no wound assessment was completed on readmission, and no reassessments or measurements were completed for the wound from [DATE] until [DATE]. Review of resident #84's TARs from January through [DATE] revealed that there was no evidence that wound care was provided for the sacral wound for the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE], [DATE]. Further review of the July TAR revealed that there was no evidence that the sacral wound care was completed except twice the entire month on [DATE] and [DATE], exactly two (2) weeks apart. After an observation of R #84's wound care on [DATE] at 2:51 p.m., a full skin assessment was done by Licensed Practical Nurse (LPN) Treatment Nurses CC and UU. The resident's bilateral heels were noted to be soft and boggy, and were non-blanchable. An excoriated area was noted to resident's left buttock down the residents left thigh that measured 31.3 cm long and 23.4 cm wide. The skin on both inner thighs were excoriated and measured approximately 4 inches long by 4 inches wide each. The right breast was observed to have a large red excoriated area under the breast. Further observation revealed that under the resident's left arm was a very large red excoriated area that measured 19.7 cm long by 12.9 cm wide. A red excoriated rash was noted from the resident's mid-abdomen around to their right hip. Further observation revealed that under her right arm around to the right shoulder was a red excoriated area as well as an open area of skin, and this open area measured 0.9 cm by 0.7 cm. During interview with the treatment nurses at this time, they stated that they were not aware of these excoriated areas of skin. Continued observation revealed that R #84's scalp was noted to have a thick layer of oily scales which covered the resident's scalp, behind and in the resident's ears, as well as red flaky skin on several areas of the resident's face. 5. During interview and record review with the Director of Nursing Services (DNS) on [DATE] at 3:41 p.m., she verified that there was no evidence that treatments were completed as ordered for R #24's left foot wounds on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 6. Review of R #50's computerized Weekly Skin Reviews revealed that the skin assessments were not completed on [DATE]; [DATE]; and none between [DATE] and [DATE] (a total of twelve missed assessments since admission). This was verified during interview with Registered Nurse (RN) Field Services Clinical Director PPP on [DATE] at 10:24 a.m. Review of the TARs from admission through July revealed no evidence that wound care was completed on [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; and [DATE]. This was verified during interview with the DNS on [DATE] at 11:09 a.m. 7. Review of the clinical record for R #64 revealed that they had a history of [REDACTED]. Review of physician's orders [REDACTED]. Observation of R #64 on [DATE] at 9:50 a.m. revealed that they were positioned on the right side with no visible wedges or pillows, and the heels were not floated and the ankles were on top of each other. Continued observation of R #64 on [DATE] at 10:44 a.m. revealed they were sleeping on the right side, and no pillows, wedges or other positioning devices were visible. Observation on [DATE] at 11:14 a.m. revealed the resident was sleeping on the right side, no positioning devices were visible, and the heels were not floated. Observation on [DATE] at 2:15 p.m. revealed that R #64 was resting on their right side in a fetal position with their full weight on the right trochanter. No positioning devices were visible, and their knees and ankles were resting on top of each other. Observation of R #64 on [DATE] at 5:55 p.m. revealed that their heels were not floated. 8. Review of a General Note dated [DATE] for R #120 revealed that the resident was admitted on [DATE] with an unstageable pressure sore on his/her right heel that measured 6.5 x 4.5 x 0 cm, a Stage IV pressure sore on his/her left trochanter that measured 4.2 x 4.0 x 0.4 cm with tunneling, a Stage IV pressure sore on the left ischium that measured 4.4 x 4.0 x 0.4 cm with tunneling, and a Stage III pressure sore on the sacrum that measured 3.0 x 6.0 x 3.0 cm. Review of the General Note dated [DATE] revealed that the sacral pressure sore had resolved. Review of R #120's Treatment Administration Records (TAR) revealed that there was no evidence that treatments were completed as ordered to the left ischium and left trochanter wounds on [DATE] (Sunday). Further review of the TARs revealed that there was no evidence of treatment provided for the left ischial pressure sore as scheduled on [DATE] (Saturday), [DATE], [DATE], [DATE] and [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of R #120's clinical record revealed that he was hospitalized from [DATE] to [DATE] for urosepsis, and a readmission General Note dated [DATE] revealed that the resident had a sacral wound that measured 13.4 x 12.3 x 0 cm; a left gluteal fold (ischial) wound that measured 4.1 x 5.3 x 2.6 cm; and an unstageable wound on the right heel. Review of the TARs revealed no evidence that treatment was provided to these wounds on [DATE], [DATE], [DATE], or [DATE]. Interview with the DNS on [DATE] at 11:10 a.m. revealed the facility had a full time treatment nurse and a part time treatment nurse from [DATE] to [DATE], at which time the part time nurse resigned. Continued interview revealed that the full time treatment nurse provided treatments by herself from [DATE] until LPN Treatment Nurse UU was hired to assist with treatments a couple of days a week. Further interview with the DNS revealed that the full time treatment nurse became a part time employee on [DATE], at which time Treatment Nurse UU had the responsibility of providing treatments on her own most days. Further interview revealed that UU stated that she was drowning during that time, and the facility hired Treatment Nurse CC on [DATE]. 9. Review of a nursing Progress Note dated [DATE] at 8:40 a.m. (late entry for [DATE]), and in the Additional Notes section of the admission Clinical Health Status form dated [DATE], noted that there was discoloration to the bottom of both of R #180's feet, and pink areas to right and left buttocks without open areas at this time. Review of a Weekly Skin Review dated [DATE] noted that the skin was thin and fragile, and there were open areas to sacrum that looked like burst blisters. Further review of this Skin Review noted blisters to the right buttock, and burst blister to the left buttock. Review of the Treatment Administration Record (TAR) revealed that no measures were documented to prevent skin breakdown to these areas on admission, nor any treatments initiated once the blisters and open area to the buttocks were identified on [DATE]. During interview and record review with Treatment LPN UU on [DATE] at 1:28 p.m., she verified that there was no evidence on R #180's Treatment Administration Records (TAR) that the following treatments were ever completed: May TAR: 5:00 p.m. no evidence that treatments were completed on [DATE]; [DATE]; and [DATE] (the TAR did not specify what wound was being treated). 5:00 p.m. no evidence that treatments were completed to left buttock on [DATE], and to the left buttock, right buttock, and sacrum at 5:00 p.m. from [DATE] to [DATE]. In addition, there was no evidence that the treatment was completed at 9:00 a.m. for any of these three areas on [DATE]. June TAR: The 5:00 p.m. there was no evidence that the treatment to the right and left buttocks and sacrum were completed on [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; and [DATE]. There was no evidence that the daily treatment to the sacrum was completed on [DATE]; [DATE]; and [DATE]. July TAR: There was no evidence that the daily treatments to the sacrum and right buttock were completed on [DATE]; [DATE]; [DATE]; [DATE]; and [DATE]. During interview with LPN Treatment Nurse UU on [DATE] at 1:28 p.m., she verified that the [DATE] Weekly Skin Review for R #180 noted open and closed blisters to the right and left buttocks and sacrum, and that the charge nurse that discovered them should have told the treatment nurse, but that she (LPN UU) was unaware of them. She added that she saw no documentation that these wounds were ever treated before the resident's hospitalization on [DATE]. During further interview, Treatment Nurse UU stated that this was a transition period where she was the only treatment nurse in the facility for about six weeks. During further interview, she stated that she was doing the best that she could to manage the wounds, but that she was the only one and some things may have fallen between the cracks. During interview with Licensed Practical Nurse (LPN) SSS on [DATE] at 5:15 p.m., she stated that about twice a week one of the treatment nurses would come up to her and say that they didn't get a chance to do a treatment on a resident, and ask her to do it. During further interview, she stated that if the resident's treatment was ordered to be done twice a day and the treatment nurse told her that they didn't get to it, that she would change the dressing only once on her shift. Cross-refer to F 157, F 281, F 282, F 314, F 353, F 490, F 520. 10. Review of R #170's clinical record revealed that they were admitted to the facility on [DATE]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] noted that the resident had severe cognitive impairment, wandering occurred one to three days which placed the resident at significant risk of getting to a potentially dangerous place, and significantly intruded on the privacy of activities of others. Review of a Clinical Health Status assessment dated [DATE] noted that R #170 had short- and long-term memory problems, had a history of [REDACTED]. Review of the Risk for Elopement section of this form revealed that the resident had a history of [REDACTED]. Review of R #170's Immediate Plans of Care dated [DATE] revealed that one had not been developed for Elopement. Review of computerized Progress notes revealed a SBAR (Situation-Background-Assessment-Response) Change of Condition entry dated [DATE] at 12:02 a.m. that noted that R #170 was seen ambulating in the road off facility premises and was not injured upon assessment. Review of a Verification of Investigation report with a Date/Time of Occurrence of [DATE] at 6:30 p.m., noted that R #170 was found ambulating outside in the parking lot near the road. Review of the Provide Summary and Outcome Of Investigative Findings section of the form simply noted that the resident had a history of [REDACTED]. During interview with Certified Nursing Assistant (CNA) II on [DATE] at 9:07 a.m., she stated that R #170 could walk and/or propel his wheelchair without assistance, and that they didn't have to do any special monitoring for him. During interview with LPN AA on [DATE] at 9:14 a.m., she stated that she did not do any special monitoring for him, and that he would be allowed to go outside with staff or family supervision only. During interview with LPN Unit Manager HH on [DATE] at 2:28 p.m., she stated that she was not there when R #170 eloped, but it was her understanding that he went out the back door at the end of the 200-hall. During further interview she stated that the wanderguard bracelet was not placed on him until after he exited the building. During interview with the DNS on [DATE] at 3:10 p.m., she stated that she did not know how the resident got out unwitnessed, and it was possibly through a side door in the resident lounge by the west wing nursing station. During interview with LPN QQQ on [DATE] at 8:22 a.m., she stated that she was working evenings the day that R #170 left the building, but that she did not see how he got out, and assumed it was through the exit door at the end of the 200-hall as that was close to his room. She further stated that she never heard an alarm go off, and thought that it was another resident who had told her that there was a resident outside, so she went to investigate. LPN QQQ further stated that she found R #170 by a tree on the hospital campus across the road from the facility, and that he would have had to gone down the steep hill in front of the facility and crossed the two roads and median to get to where he was. During interview with CNA RRR on [DATE] at 9:03 a.m., she stated that the evening that R #170 got outside was the first time she had ever worked with him, and she was not told to do any special monitoring for him. She further stated that the resident must have gone out at the end of the 200-hall door, as that was the last area she saw him right before he was found outside, but that she did not hear an alarm go off. During further interview, she stated that a family member, whose room looked outside to the parking lot, told her that she saw a resident in pajamas outside in the parking lot. Cross-refer to F 323.

Based on observation, interview, record review and review of the Georiga Nurse Practice Act, Chapter ,[DATE], the facility failed to develop an interim care plan on admission to address an assessment for elopement risk, for resident #170 who eloped from the facility four (4) days after admission. In addition, the facility failed ensure that services were provided in accordance with professional standards of quality as evidenced by the failure in multiple areas of skin and wound management for nine (9) residents (N, R, T, R #180, R #50, R #24, R #120, R #84, R #64) and failed to verify correct placement of the gastric tube ([DEVICE]) for one (1) resident (R#172) during medication administration. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On [DATE] at 1:35 p.m., the Executive Director (ED), Director of Nursing Services (DNS), and Corporate Registered Nurse (RN) Field Services Clinical Director were notified that Immediate Jeopardy (IJ) existed as of [DATE] related to elopement. The non-compliance was related to R #170, who was assessed during admission on [DATE] to be an elopement risk. However, the facility failed to implement effective interventions, failed to sufficiently supervise the resident, and failed to develop an immediate care plan to address the risk for elopement. R #170 eloped from the facility four (4) days after admission on [DATE], and was found off facility grounds after crossing four (4) lanes of automotive traffic with a median dividing the two (2) lanes of traffic. In addition, the resident crossed through the facility parking lot, onto the road, which led into a Medical Office Complex. Additional IJ noncompliance was identified on [DATE] at 4:37 p.m., when during observation of the exit door at the end of the 100 hall, it did not sound an alarm to alert staff that the door was opened. On [DATE] at 7:29 p.m., the facility implemented immediate action to ensure that unsupervised exit did not occur with a staff member assigned to sit at the door and provide continuous monitoring of the 100 hall door. The facility also in-serviced staff about monitoring the 100 hall exit door. On [DATE] at 10:46 a.m., the SSA validated that the 100 hall exit door was repaired and fully functioning. A Credible Allegation of Compliance (AoC) related to 42 C.F.R. 483.25 Quality of Care and 42 C.F.R. 483.20 Resident Assessment was received on [DATE] at 9:56 a.m. However, the facility failed to complete elopement drills as outlined in their AoC, and the ED was notified at exit on [DATE] that the IJ would be on-going until the SSA validated that all interventions were completed in the AoC including the elopement drills as indicated in the facility's AoC. On [DATE] at 11:30 a.m., the ED and Corporate Area Vice President (VP) were notified that IJ existed as of [DATE], when resident T's sacral pressure ulcer had healed, but no preventive measures were put into place to prevent the wound from recurring, which it did on [DATE] as a Stage II pressure ulcer. In addition, no treatment was initiated until [DATE], and the wound had deteriorated to a Stage III. After Supervisory review by the Enforcement Manager it was determined that the IJ was identified to exist on [DATE] related to resident N who was admitted to the facility on [DATE] after a hospital stay from home for a urinary tract infection, history of falls, who ambulated with a walker, with impaired cognition. The resident was discharged from the hospital to the facility with fluid filled blisters on bilateral heels and a reddened sacral area. The facility failed to develop an interim care plan to address the pressure ulcers. The resident was found unresponsive on [DATE] and transferred to the hospital in septic shock. Review of the Hospital Discharge Summary signed on [DATE] revealed the Final [DIAGNOSES REDACTED]. Review of the Georgia Death Certificate revealed the immediate cause of death for Res N was Septic shock secondary to decubitus. A Credible Allegation of Compliance was received on [DATE] at 5:40 p.m., was not acceptable, the ED was notified during the exit meeting that the IJ's would be ongoing. Therefore the IJ was identified to exist on [DATE] and remains on-going. The sample size was fifty-one (51) residents, the census was one-hundred and one (101). Findings include: Review of the Georgia Nurse Practice Act, Chapter ,[DATE] revealed, Practice nursing as a registered professional nurse means to practice nursing by performing for compensation any of the following: Assessing the health status of individuals, groups, or both throughout the life span; Establishing a nursing diagnosis; Establishing nursing goals to meet identified health care needs; Planning, implementing, and evaluating nursing care; Providing for safe and effective nursing care rendered directly or indirectly; Managing and supervising the practice of nursing; Collaborating with other members of the health care team in the management of care, and;Teaching the theory and practice of nursing. 1. Record review for Resident N revealed the resident was admitted to the facility on [DATE]. Review of the hospital discharge records revealed resident N was admitted to the facility with discharge [DIAGNOSES REDACTED]. Review of the facility admission Clinical Health Status assessment dated [DATE] for resident N revealed the resident is alert with memory problems, sometimes understood, able to understand others, skin condition assessment revealed sacral redness and bilateral blisters on heels. Review of the Braden Scale Assessment = 20, indicating resident is at risk for pressure sores. Resident N can ambulate and transfer with assistance, had a fall risk score of 14 indicating the resident is at risk for falls. Additional notes added on [DATE] indicate a late entry: Resident admitted with [DIAGNOSES REDACTED]. Resident noted to have blister filled on bilateral heels intact. Resident sacral ulcer noted to be red with no open areas. Skin warm to touch. Bilateral heels with [MEDICATION NAME] AG applied, wrapped with Kerlix. Dressing will be changed every three (3) days. An Immediate Plan of Care was completed for Resident N dated [DATE] which included planning for Pain, Falls, Nutrition, and Urinary Incontinence, however there was no evidence of an Immediate Care Plan for Pressure Ulcer Risk. Review of the Care Plan completed on [DATE] included planning for Pressure Ulcer Actual or at Risk with multiple interventions including conduct weekly skin assessments, skin assessment to be completed per Living Center Policy, weekly wound assessments, float heels, turn and reposition schedule per assessment. Review of the Treatment Administration Record (TAR), Orders, Medication Administration Records (MAR) and general Progress Notes reveals there were no skin assessments or wound assessments performed for this resident in accordance with the facility policies ' Skin Integrity Guidelines ' or ' Pressure Ulcer Risk Identification/Prevention Guidelines. ' There was no evidence to support that resident N received any pressure ulcer wound care after [DATE]. Wound Care orders were received on [DATE] and wound care performed on [DATE], totaling 6 (six) days without wound care. The Wound Care Orders received [DATE] addressed only the bilateral heels, to wash with soap & H20, pat dry, spray with [MEDICATION NAME] and then apply [MEDICATION NAME] AG to bilateral heels, wrap with Kerlix every (q) three (3) days. On [DATE] Wound Care and measurements were performed. The [DATE]-Wound Note: Stage I to Right. heel with measurements of 8.0 x 7.3 x 0 (No unit of measurement indicated) with clear fluid blister intact at this time. Current orders to cleanse with warm soap and water, pat dry and apply [MEDICATION NAME] AG every 3 days. Stage 1 to Left. heel with measurements of 5.5 x 5.0 x 0 (No unit of measurement indicated) cleanse wound with warm soap and water, pat dry and apply [MEDICATION NAME] AG every 3 days. Will continue to monitor patient. Review of the Treatment Administration Record (TAR) records Wound Care as having been first provided on [DATE] (9 days after admission). The Care Plan dated [DATE] was not reviewed after the hospital discharge and no new Care Plans or changes to the existing Care Plans were made. Further review of the Treatment Administration Record (TAR) records Wound Care as having been provided again on [DATE]. No additional wound care is recorded for resident N until after return from the hospital on [DATE] through [DATE]. Medical Record review reveals the resident was re-admitted on [DATE] but no skin assessment was completed on the Clinical Health Status assessment dated [DATE]. Bilateral bruising to the hands, a tattoo on the left arm, and a scar are noted. Resident N returned with new [DIAGNOSES REDACTED]. Special Instructions include Stage 1 right heel wound, Stage 1 sacral wound, unstageable left heel wound. Patient needs a low flow air mattress, Prevalon boots and [MEDICATION NAME] AG every (q) three (3) days and as needed (PRN). Follow-up Primary Care Physician (PCP) in two (2) weeks. On [DATE] [MEDICATION NAME] ointment was ordered to be applied to the heels twice daily bilaterally. The ointment was never applied because it was listed on the Medication Administration Record, [REDACTED]. Review of the Treatment Administration Record (TAR) records Wound Care was provided on [DATE]. Review of the Treatment Administration Record (TAR) records Wound Care provided on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], however there is no evidence of a progress notes substantiating that wound care was provided on these dates. On [DATE]- (Late Entry on [DATE])-Wound Care Note: Resident right heel noted to have measurements of 3.0 x 4.0. (No unit measurement indicated) Wound cleansed with warm H20, soap, pat dry then apply [MEDICATION NAME] AG then wrap with kerlix wrap. Left heel noted to have measurements of 5.0 x 2.0. (No unit of measurement indicated). Wound cleansed with warm H20, soap, pat dry then apply [MEDICATION NAME] AG then wrap kerlix wrap. Sacral wound noted to have measurements of 3.0 x 1.5. (No unit of measurement indicated) Cleansed area with warm H20, soap, pat dry then apply Santyl then cover with ABD pad secure with tape every (q) day. The Santyl was applied to the bilateral heels on [DATE] prior to a physician's orders [REDACTED]. [MEDICATION NAME] spray was not used as directed by the physician's orders [REDACTED]. The physician was not notified of the changes in the wounds, and no new wound care orders were issued until [DATE]. An appointment was not made for the physician to see the resident 2 (two) weeks after hospital discharge as directed in the Discharge Summary dated [DATE]. Interview with the Director of Nursing Services (DNS) on [DATE] at 11:40 a.m. reveals that the resident was never seen by the physician. On [DATE]: General Note revealed: sacral wound with necrotic tissue to center of wound bed with greenish color to edges. Measurements 8.0 x 4.5. (No unit of measurement indicated) Sacral wound continues to be treated daily. Right heel noted to have deep tissue injury (DTI), measures 5.0 x 6.5 x 0 (No unit of measurement indicated) with black tissue in center of the wound bed with red edges to the wound. Right great toe noted to have DTI with measurements of 1.0 x 0.5 (No unit of measurement indicated). Bottom of right foot DTI present with measurements of 0.5 x 1.0 (No unit of measurement indicated). Left heel DTI noted to have measurements of 4.5 x 5.0 (No unit of measurement indicated) with black tissue to the center of the wound bed. Resident DTI's are cleansed with water, soap, pat dry, [MEDICATION NAME] AG applied then wrap with kerlix every 3 days. Review of the Treatment Administration Record (TAR) records that Wound Care was performed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the medical record for resident N reveals that the resident was discharged to the hospital on [DATE] after being found in his room with lethargy and periods of not breathing. A sternal rub was applied to resident to cause responsiveness. Blood pressure alternated between ,[DATE] and ,[DATE] with heart rate 116 to 123. Resident afebrile. EMS called for hospital transfer. The physician was not notified however, there are no orders for transfer in the medical record. Review of the Hospital admission notes dated [DATE] reveal that resident N was admitted [MEDICAL CONDITION]. The resident was discharged to Hospice on [DATE] with discharge [DIAGNOSES REDACTED]. Resident N was transferred to another hospital and died on [DATE] under the care of hospice. Final [DIAGNOSES REDACTED]. Interview with the Assistant Director Nursing Services (ADNS) on [DATE] at 11:00 a.m. and review of the medical record for resident N revealed that the resident did not receive weekly skin assessments as ordered or weekly wound assessments as ordered. Interview with the Wound Care Nurse LPN CC on [DATE] at 9:35 a.m. revealed that Weekly Assessments are done by the primary care nurse, and Weekly Wound Assessments are done by the wound care team. Interview with the ADNS on [DATE] at 2:37 p.m. who confirms that the interim care plan dated [DATE] developed on Admission was not completed for Pressure Ulcers. The ADNS states that the Wound Care Team was addressing the pressure ulcers; the Care Plan was just not completed. Further interview reveals that the re-admission Assessment for resident N was not completed, and the section for Skin Assessments was not completed to include the existing pressure ulcers. The assessment was not comprehensive. Review of Progress Notes reveals that the physician was not notified of changes in conditions related to the pressure ulcers, interventions were not documented, and staging of the pressure ulcers was not recorded. The ADNS acknowledged that these were not documented. Interview on [DATE] at 9:55 a.m. with Treatment Nurse LPN CC and review of the wound care record. CC confirmed that wounds were not staged and wound depths were often not recorded. CC further states she was extremely busy and some information may not be recorded properly. CC also reveals treatments may have been given but not recorded. CC confirms that physician's orders [REDACTED]. CC states that treatments were performed based on the guidelines for what was appropriate treatment for [REDACTED]. When asked how Wound Care Nurse's (WCN) were notified of resident's that needed wound care, CC stated that when new and readmitted residents are entered, Admissions staff are supposed to notify the wound care nurse. The Wound Care Nurse assesses the resident and reviews the Discharge Summary, then calls the physician for orders. When a resident needs wound care and there are no orders, the WCN follows the guidelines for wound care and calls the doctor. When asked about wound care prevention, CC stated that if it was pre-existing but not documented, it might be overlooked. CC did not know how to assess for [MEDICAL CONDITION] and reveals that he/she has not received any training for this. Interview of the Director of Nursing Service (DNS) on [DATE] at 11:40 a.m. revealed that the wound care orders were put in late for resident N. Resident N was admitted on [DATE] and wound care orders were not entered until [DATE]. Interview with the DNS on [DATE] at 11:45 a.m. who confirms that the pressure ulcers for resident N were not discussed during the Weekly Care Management Meeting. Pressure ulcers were not listed; therefore, they were not discussed. The DNS confirms that the pressure ulcers should have been discussed because this meeting arranges for services and interventions to be added to the resident plan of care related to the issues discussed. Resident N was not discussed in any subsequent Weekly Care Management Meetings. The DNS further reveals that the Care Plan was not updated on re-admission and it should have been for resident N. New and re-admissions are recorded on the 24-hour report and discussed the following morning in the Inter-Disciplinary Team (IDT) Meeting which is attended by Minimum Data Set (MDS), Care Planning, Activities, Dietary, etc. Nursing should have reviewed the current Care Plan and updated it based on the new [DIAGNOSES REDACTED]. Interview on [DATE] at 12:40 p.m. with the Nursing Consultant reveals that Care Plans are updated by Nursing and plan of care should have been updated for resident N. Cross-refer to F 3142. 2. Review of clinical record for Resident #170 revealed that he was admitted to the facility on [DATE]. Review of the admission Clinical Health Status assessment dated [DATE] noted that the resident had a history of [REDACTED]. Review of the Immediate Plans of Care for R #170 revealed that one had not been developed for elopement. Review of the Risk for Falls Immediate Plan of Care dated [DATE] revealed that the risk factor for wandering was not checked, and no interventions were included to address the wandering and elopement risk. Review of the facility's Elopement Guideline noted that documentation should include a care plan that addressed the potential to wander or exit the living center, and measures taken to prevent wandering/elopement. Review of a computerized nursing Situation-Background-Assessment-Recommendation (SBAR) note dated [DATE] at 12:02 a.m. noted that R #170 was noted ambulating in the road off the facility premises. During interview with the DNS on [DATE] at 3:10 p.m., she stated that residents were assessed on admission for elopement risk on the Clinical Health Status form, and if determined to be an elopement risk a wanderguard bracelet was applied and a care plan developed. Cross-refer to F 323. 3. Review of a nursing Progress Note dated [DATE] at 8:40 a.m. (late entry for [DATE]), and in the Additional Notes section of the admission Clinical Health Status form dated [DATE], revealed that there was discoloration to the bottom of both feet of R #180, and pink areas to the right and left buttocks without open areas at this time. Review of a Weekly Skin Review dated [DATE] noted that the skin was thin and fragile, and there were open areas to sacrum that looked like burst blisters. Further review of this Skin Review noted blisters to the right buttock, and burst blister to the left buttock. Review of the Treatment Administration Record (TAR) revealed that no measures were documented to prevent skin breakdown to these areas on admission, nor any treatments completed once the blisters and open area to the buttocks were identified on [DATE]. During interview and record review with Treatment LPN UU on [DATE] at 1:28 p.m., she verified that there was no documentation on TAR that the following treatments were ever completed for R #180: In [DATE] at 5:00 p.m. on [DATE]; [DATE]; and [DATE], in addition the TAR for R#180 did not specify what wound was being treated; at 5:00 p.m. treatments not documented as completed to left buttock on [DATE], and to the left buttock, right buttock, and sacrum at 5:00 p.m. from [DATE] to [DATE]. In addition, the treatment was not documented as completed at 9:00 a.m. for any of these three (3) areas on [DATE]. In [DATE]: The 5:00 p.m. treatment to the right and left buttocks and sacrum were not documented as completed on [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; and [DATE]. The daily treatment to the sacrum was not documented as done on [DATE]; [DATE]; and [DATE]. In [DATE]: The daily treatments to the sacrum and right buttock were not documented as completed on [DATE]; [DATE]; [DATE]; [DATE]; and [DATE]. During observation of wound care by LPN Treatment Nurse CC on [DATE] at 9:59 a.m., R #180 the buttocks and sacral area revealed that it was dry and flaky, and had what appeared to be previously healed wounds to the area. Observation of the wound to the upper left medial buttock revealed that it was shallow with a clean red and pink wound base, and was measured as 1.4 by 0.6 by 0.2 cm. During the wound care, the treatment nurse noted a previously unidentified circular area of skin breakdown on the right upper medial buttock, approximately 1.0 cm in diameter (not measured). Cross-refer to F 314. 4. Review of the computerized Weekly Skin Reviews for R #50 revealed that the skin assessments were not completed on [DATE]; [DATE]; and no evidence of Weekly Skin Reviews between [DATE] and [DATE] (a total of twelve (12) missed assessments since admission). This was verified during interview with Registered Nurse (RN) Field Services Clinical Director PPP on [DATE] at 10:24 a.m. Review of the TARs from admission through July revealed no documentation that wound care was performed on [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; and [DATE]. This was verified during interview with the DNS on [DATE] at 11:09 a.m. Cross-refer to F 314. 5. Although resident T was admitted on [DATE] with a Stage II sacral pressure sore, there was no indication that staff obtained and provided treatment for [REDACTED]. Although the sacral pressure sore healed on [DATE], there was no indication that staff provided preventive treatment for [REDACTED]. There was no indication that staff assessed the Stage II pressure sore weekly after [DATE] to track the progression or deterioration until [DATE] when staff identified an open area on the sacrum with a yellow-green wound bed. There was no indication that the physician was notified of the open area until [DATE] when the physician ordered [MEDICATION NAME] to be applied every day and to obtain a Wound Care consult. On [DATE], staff assessed the wound as 4.0 x 3.0 x 0 cm. pressure sore with 75% necrotic tissue. Staff failed to provide accurate staging of the pressure sores by assessing necrotic tissue and slough as a Stage II and thick, black eschar as Deep Tissue Injury (DTI). Staff failed to provide consistent weekly assessments of the sacral pressure sore in order to track the progression or deterioration of the wound between [DATE] and [DATE] when the resident was assessed at the Wound Care clinic and a wound VAC was ordered. Staff failed to consistently assess the bilateral heel pressure sores to include staging, measurements and description after [DATE]. Staff failed to provide treatments for the sacral pressure sore every day as ordered on [DATE], [DATE], [DATE] and [DATE] and twice (2) a day as ordered for 21 of 27 days between [DATE] and [DATE]. Staff failed to provide treatments for the bilateral heel pressure sores every three (3) days as ordered between [DATE] and [DATE] (8 days between treatments), between [DATE] and [DATE] (23 days between treatments), between [DATE] and [DATE] (5 days between treatment), between [DATE] and [DATE] (5 days between treatments), between [DATE] and [DATE] (4 days between treatments) and between [DATE] and [DATE] (4 days between treatments) when the resident was admitted to the hospital from the wound care clinic for wound infection and debridement of the right heel pressure sore. Cross-refer to F 314. 6. Staff failed to initiate pressure relieving devices for the feet of resident R from [DATE] when the resident developed a Stage II blister on the right heel until [DATE] after the right heel pressure sore had deteriorated to a Stage III. Staff failed to perform consistent weekly assessments of the pressure sores of the right heel, right ankle and left ankle to include staging, measurements and description of the wounds. Staff failed to accurately stage the pressure sores. Staff failed to provide treatments as ordered by the physician. Staff failed to use the correct product in the treatment of [REDACTED]. Staff failed to discontinue the use of the multipodus boots as ordered by the physician. Interview with the Wound Care Physician AAA on [DATE] at 1:00 p.m. revealed that resident R had maggots in his right heel wound that required debridement on [DATE]. Further interview revealed that AAA believed that staff were not cleaning the wounds as they should which resulted in the presence of the maggots and a decline of the wounds. Cross-refer to F 314. 7. Review of the medical record for R#120 revealed that he was admitted on [DATE] with an Unstageable pressure sore on his right heel, a Stage IV pressure sore on his left trochanter, a Stage IV pressure sore on his left ischium and a Stage II pressure sore on his sacrum. Review of the General Note dated [DATE] revealed that the sacral pressure sore had resolved. Review of the TARs revealed that staff failed to provide treatments as ordered for the left ischium and left trochanter on [DATE] and failed to provide treatments as ordered related to the wound VAC for the left ischium on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The resident's left trochanter pressure sore healed. Further review of the resident's medical record revealed [REDACTED]. The resident's pressure sores did not deteriorate. Observation for R#120 of pressure sore treatment on [DATE] at 3:40 p.m., Treatment Nurse CC and Treatment Nurse UU provided treatment as ordered to the resident's sacral and left ischium pressure sores. Treatment to the resident's right heel pressure sore was due [DATE]. The resident's left trochanter pressure sore had resolved. The unstageable sacral pressure sore measured 11.5 x 9.6 x 2.9 cm. The center of the wound had an approximately 5.0 x 4.0 cm area with 95% yellow slough. The outer edges of the wound had beefy red tissue. There was a small amount of serosanguinous drainage and no odor. The Stage IV left ischium pressure sore measured 2.3 x 3.0 x 4.2 cm and was without drainage or odor. The resident's unstageable right heel pressure sore had soft black intact tissue that measured approximately 2.0 x 2.0 cm. Cross-refer to F 314. 8. During interview and record review with the Director of Nursing Services on [DATE] at 3:41 p.m., she verified that there was no evidence that treatments were completed as ordered for R #24's left foot wounds on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Cross-refer to F 314. 9. Observation on [DATE] at 2:25 p.m. revealed LPN AA prepared and administered medication, [MEDICATION NAME] 25 milligrams (mg), via gastrostomy tube ([DEVICE]) for R #172 without verifying correct placement of the tube. LPN AA connected the syringe base to the tube port and poured in the medication mixed with water. LPN AA flushed the tube with water and replaced the cap back on the tube. Interview on [DATE] at 3:10 p.m. with LPN AA revealed she checks placement of the [DEVICE] once per shift by injecting air and listening with the stethoscope. Review of the Physician orders [REDACTED]. Interview with LPN AA on [DATE] at 9:20 a.m. revealed that she was mistaken during her previous interview when she said she checked the placement of the [DEVICE] once per shift. LPN AA stated that she aspirates stomach contents to verify [DEVICE] placement. Interview with the DNS on [DATE] at 7:55 a.m. revealed that her expectation is for [DEVICE] placements to be checked prior to the administration of anything including medications and feedings. Review of the Administration of Enteral Feeding Policy last reviewed on [DATE] revealed that verification of feeding tube placement will be done before the administration of feeding formula, medication or free water flushes, and/or at least one time per shift. Policy documented to verify [DEVICE] placement by slowly drawing back gastric contents and evaluating the color and amount of residual- gastric contents (correct placement). 10. Review of the clinical record for R #64 revealed that her had a history of [REDACTED]. Review of physician's orders [REDACTED]. Observation of R #64 on [DATE] at 9:50 a.m., 10:44 a.m., 11:14 a.m., 2:15 p.m. and 5:55 p.m. revealed the resident lying in her bed on her side. However, staff failed to float the resident's heels as ordered by the physician and the resident's ankles were on top of each. review of the resident's medical record revealed [REDACTED]. Observation on [DATE] at 11:14 a.m. revealed the resident was sleeping on the right side, no positioning devices were visible, and the heels were not floated. Observation on [DATE] at 2:15 p.m. revealed that R #64 was resting on his right side in a fetal position with his full weight on his right trochanter. His heels were not floated, no positioning devices were visible, and his knees and ankles were resting on top of each other. Observation of R #64 on [DATE] at 5:45 p.m. revealed that staff had positioned him onto his left side but, his heels were not floated. Cross-refer to F 314. 11. Review of the clinical record for R #84 revealed that they were admitted to the facili

Based on observation, record review, and resident and staff interviews, it was determined that the facility failed to ensure that care plans were followed for use of a bed alarm and picture identification (ID) for the elopement book for resident #170; for staff to assist with personal hygiene and bathing for residents R, O and S; for staff to evaluate the need for as needed (PRN) pain medication prior to wound treatment for [REDACTED].N, T, #180, #150, #120, and #84. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 07/29/16 at 1:35 p.m., the Executive Director (ED), Director of Nursing Services (DNS), and Corporate Registered Nurse (RN) Field Services Clinical Director were notified that Immediate Jeopardy (IJ) existed as of 07/15/16 related to elopement. The non-compliance was related to R #170, who was assessed during admission on 07/15/16 to be an elopement risk. However, the facility failed to implement effective interventions, failed to sufficiently supervise the resident, and failed to develop an immediate care plan to address the risk for elopement. R #170 eloped from the facility four (4) days after admission on 07/19/16, and was found off facility grounds after crossing four (4) lanes of automotive traffic with a median dividing the two (2) lanes of traffic. In addition, the resident crossed through the facility parking lot, onto the road, which led into a Medical Office Complex. Additional IJ noncompliance was identified on 7/28/16 at 4:37 p.m., when during observation of the exit door at the end of the 100 hall, it did not sound an alarm to alert staff that the door was opened. On 7/28/16 at 7:29 p.m., the facility implemented immediate action to ensure that unsupervised exit did not occur with a staff member assigned to sit at the door and provide continuous monitoring of the 100 hall door. The facility also in-serviced staff about monitoring the 100 hall exit door. On 7/30/16 at 10:46 a.m., the SSA validated that the 100 hall exit door was repaired and fully functioning. A Credible Allegation of Compliance (AoC) was received on 08/02/16 at 9:56 a.m. However, the facility failed to complete elopement drills as outlined in their AoC, and the ED was notified at exit on 08/05/16 that the IJ would be on-going until the SSA validated that all interventions were completed in the AoC including the elopement drills as indicated in the facility's AoC. On 08/03/16 at 11:30 a.m., the ED and Corporate Area Vice President (VP) were notified that IJ existed. It was determined that the IJ was identified to exist on 4/6/16 related to resident N who was admitted to the facility on [DATE] after a hospital stay from home for a urinary tract infection, history of falls, who ambulated with a walker, with impaired cognition. The resident was discharged from the hospital to the facility with fluid filled blisters on bilateral heels and a reddened sacral area. The facility failed to develop an interim care plan to address the pressure ulcers. The resident was found unresponsive on 5/27/16 and transferred to the hospital in septic shock. Review of the Hospital Discharge Summary signed on 6/1/16 revealed the Final [DIAGNOSES REDACTED]. Review of the Georgia Death Certificate revealed the immediate cause of death for Res N was Septic shock secondary to decubitus. A Credible Allegation of Compliance was received on 08/04/16 at 5:40 p.m., was not acceptable, the ED was notified during the exit meeting that the IJ's would be ongoing. Therefore the IJ was identified to exist on 4/6/16 and remains on-going. The sample size was fifty-one (51) residents, the census was one-hundred and one (101). Findings include: 1.Resident N was admitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. Resident received a Skin Assessment on admission as documented on the Clinical Health Status Admission form. An Immediate Care Plan was developed for the resident on 4/6/2016 that failed to include Care Planning for the intact blisters and reddened sacral area. Review of the Care Plan completed on 4/18/2016 with planning for Pressure Ulcer Actual or at Risk with Interventions including: Conduct Weekly Skin Assessments, Skin Assessment to be completed per Living Center Policy and Weekly Wound Assessment. Review of the Progress Notes and the Treatment Administration Notes (TAR) reveals that resident did not receive weekly skin assessments or weekly wound assessments as specified in the Care Plan, the facility policies Pressure Ulcer Risk Identification/Prevention Program and the Skin Integrity Guidelines, or as ordered by the physician and wound care was not provided as ordered or by policies Pressure Ulcer Risk Identification/Prevention Program and the Skin Integrity Guidelines. Resident discharged from the hospital and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Special Instructions include Stage 1 right heel wound, Stage 1 sacral wound, unstageable left heel wound. Patient needs a low flow air mattress, Prevalon boots and [MEDICATION NAME] AG every three days and PRN. Resident did not receive a Skin Assessment on re-admission as documented on the Clinical Health Status Admission form. The Care Plan was not reviewed and no new [DIAGNOSES REDACTED]. Interview with Wound Care Nurse 'CC' on 7/29/2016 at 9:35 a.m. who reveals that Weekly Assessments are done by the primary care nurse, Weekly Wound Assessments are done by the wound care team. Interview with Assitant Director of Nursing Service (ADNS) on 7/29/16 at 11:00 a.m. and review of resident's medical record reveals that resident did not receive weekly skin assessments as ordered or weekly wound assessments as ordered in the Care Plan. Interview with the Director of Nursing Service (DNS) on 8/5/16 at 11:45 who confirms that the resident's pressure ulcers were not discussed during the Weekly Care Management Meeting. Pressure ulcers were not listed; therefore, they were not discussed. DNS confirms that the pressure ulcers should have discussed because this meeting arranges for services and interventions to be added to the resident plan of care related to the issues discussed. Resident was not discussed in any subsequent Weekly Care Management Meetings. The DON further reveals that the resident's Care Plan was not updated on re-admission and it should have been. New and re-admissions are recorded on the 24-hour report and discussed the following morning in the Inter-Disciplinary Team (IDT) Meeting which is attended my MDS, Care Planning, Activities, Dietary, etc. Nursing should have reviewed the resident's current Care Plan and updated it based on the resident's new [DIAGNOSES REDACTED]. Interview on 8/5/2016 at 12:40 p.m. with the Nursing Consultant reveals that Care Plans are updated by Nursing and the resident's plan of care should have been updated. 2. Resident T was admitted [DATE] with a Stage II sacral pressure sore and bilateral heel non-blanchable redness. Review of the 5/31/16 Quarterly MDS revealed that the resident had a Brief Interview for Mental Status (BIMS) score of six (6) indicating that the resident was cognitively impaired, had almost constant moderate pain, did not reject care and had one Stage III pressure sore and two unstageable pressure sores. Review of the care plan dated 12/12/15 revealed that the resident required pain management and monitoring related to his wounds with an intervention to evaluate the characteristics and frequency/pattern of pain and to evaluate the need for routinely scheduled medications rather than as needed (PRN) pain medications. review of the resident's medical record revealed [REDACTED]. Observation of treatment to the sacrum and right heel wounds on 8/2/16 at 2:12 p.m. and observation of treatment to the resident's left foot wounds on 8/3/16 at 6:00 p.m. revealed that the resident exhibited pain during treatments. Although staff had acknowledged that the resident exhibited pain during treatment, review of the 8/2016 Medication Administration Record [REDACTED]. Cross refer to F309. Review of resident medical record for resident T revealed that he was admitted with a Stage II pressure sore on the sacrum and bilateral non-blanchable redness on his/her bilateral heels. Review of the resident's care plan dated 12/3/15 revealed an intervention for staff to provide treatments as ordered. However review of the Treatment Administration Records (TARs) revealed that staff failed to provide treatments as ordered for the sacral wound on 12/5/16, 3/9/16, 3/17/16, 4/9/16, from 4/12/16-4/17/16, 4/19/16, 4/21/16-4/23/16, 4/25/16-4/30/16, 5/3/16-5/6/16, 5/8/16, 714/16 and 7/24/16. Staff failed to provide treatments as ordered to the bilateral heels on 12/30/15, 1/7/16, 3/10/16, 3/13/16, 3/19/16, 3/22/16, 3/25/16, 3/28/16, 4/3/16, 4/6/16, 5/19/16, 7/14/16 and 7/24/16. Interview with Treatment Nurse CC on 7/29/16 at 9:20 a.m., revealed that the facility had two treatment nurses and that they rotated weekends to provide treatments. Continued interview revealed that the charge nurses were responsible for providing treatments in the evenings and if the treatment nurses were not available. Cross refer to F314. 3. Review of the medical record revealed for resident R that he had developed pressure sores on his/her right heel, right ankle and left ankle since admission. Review of the care plan dated 7/23/15 revealed an intervention for staff to provide treatments as ordered. However, review of the TARS revealed that staff failed to provide treatments as ordered for the right heel wound on 10/18/15, 10/21/15, 10/24/15, 11/5/15, 11/14/15, 12/14/15, 12/19/15, 1/2/16, 1/7/16, 2/15/16, 3/17/16, 4/9/16, 4/10/16, 4/12/16, 4/30/16, 5/19/16, 5/31/16, 6/7/16, 7/8/16-7/11/16 and 7/16/16-7/18/16. Staff failed to provide treatments as ordered to the bilateral ankle wounds on 4/30/16, 5/19/16, 5/31/16, 6/7/16, 7/8/16-7/11/16 and 7/16/16-7/18/16. Although staff had documented that treatment was provided to the resident's wounds on 7/23/16, 7/24/16 and 7/25/16, observation of the resident's bilateral feet dressings on 7/26/16 at 2:23 p.m. revealed that staff had dated the dressings as last changed on 7/22/16, four days earlier. Interview with the Wound Care Physician AAA on 8/3/16 at 1:00 p.m. revealed that resident R had maggots in his right heel wound that required debridement on 6/22/16. Further interview revealed that AAA believed that staff were not cleaning the wounds as they should which resulted in the presence of the maggots and a decline of the wounds. Cross refer to F314. Review of the Annual MDS dated [DATE] for resident R' revealed that the resident had a BIMS score of thirteen (13), indicating that he/she was alert and oriented and that he/she was totally dependent on staff for bathing. Review of the care plan dated 7/11/16 revealed that the resident had a physical functioning deficit with an intervention for staff to assist with personal hygiene. Interview with resident R on 7/26/16 at 2:23 p.m. Revealed that staff were supposed to shower him two times a week but, he had not received a shower in three weeks. Continued interview revealed that he/she preferred showers instead of bed baths. Review of the Activities of Daily Living (ADLs) printout revealed that the last time the resident received a shower was on 6/13/16 on the 7:00 a.m. to 3:00 p.m. shift. Staff had documented that the resident was provided partial baths subsequent days. Interview with Treatment Nurse CC on 7/29/16 at 9:25 a.m. revealed that the resident had pressure sores on both feet but, that he could receive showers as scheduled. Continued interview revealed that Treatment Nurse CC was not aware that the resident was not receiving his/her showers. Staff failed to provide showers for resident R. Cross refer to F312. 4. Review of the Quarterly MDS dated [DATE] for resident S revealed that he had carious teeth and required extensive assistance from staff for personal hygiene which included oral care. Review of the current care plan revealed that the resident had a physical functioning deficit with an intervention for staff to assist with oral care every morning and as needed. Interview with resident S on 7/26/2016 at 9:50 a.m. revealed that he had not brushed his/her teeth in over one month because he/she did not have a toothbrush or toothpaste. Continued interview revealed that he had requested a toothbrush and toothpaste but, staff had not provided them yet. Interviews with the resident and observations of the resident's room and bathroom on 7/27/16 at 3:30 p.m. and on 7/29/16 at 5:20 p.m. revealed that staff failed to provide oral care supplies and/or set up oral care supplies for the resident as care planned. Cross refer to F312 5. Review of the medical record for R #120 revealed that he was admitted on [DATE] with pressure sores on his sacrum, left ishium, left trochanter and right heel. Review of the care plan dated 11/7/15 revealed an intervention for staff to provide treatments as ordered. Review of the medical record revealed a physician's orders [REDACTED]. However, staff failed to provide treatment on 11/29/15. Review of the medical record revealed a physician order [REDACTED]. Review of the TARs revealed that staff failed to provide treatment for [REDACTED]. On 3/17/16, treatment was changed to apply Dakin's soaked gauze to the left ischial wound twice a day. However, staff failed to provide treatments twice a day on 3/18/16, 3/20/16, 3/21/16, 3/24/16, 3/26/16 and 3/29/16. Review of the medical record revealed that he was hospitalized [DATE] to 6/23/16 for urosepsis. Review of the General Note dated 6/23/16 revealed that the resident had a sacral wound that measured 13.4 x 12.3 x 0 cms. with tan to blackish wound bed, a left gluteal fold (ischial) wound that measured 4.1 x 5.3 x 2.6 cm with tunneling of 3.9 cms. at 10 o clock, tunneling of 4.3 cms. at 11 o ' clock and 3.7 cms at 12 o ' clock with slough in the wound bed, and an unstageable wound on the right heel that was dark purple to black in color. Although staff documented in the 6/23/16 General note that treatment, Santyl every day, was provided to the sacral wound on 6/23/16, there was no indication that treatment was provided 6/24/16, 6/25/16, 7/9/16 or 7/24/16. Although staff documented that treatment, Dakin's every day, was provided to the left gluteal fold (ischium) on 6/23/16, there was no indication that staff provided treatment on 6/24/16, 6/25/16, 7/9/16 or 7/24/16. Staff failed to provide treatments as ordered as care planned. Cross-refer to F 314. 6. Review of the clinical record for R #180 revealed that they were admitted to the facility on [DATE], hosptalized on [DATE], and readmitted on [DATE]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] noted the resident had severe cognitive impairment, required extensive assist for bed mobility, was a pressure ulcer risk but had no current pressure ulcers, and had moisture associated skin damage (MASD). Review of the care plan developed 05/26/16 for pressure ulcer actual or at risk due to assistance required for bed mobility and bowel incontinence included interventions for weekly skin inspections, skin assessment to be completed per Living Center policy, and treatments as ordered. During interview with the Licensed Practical Nurse (LPN) Treatment Nurse CC on 07/29/16 at 4:15 p.m., she stated that the primary nurse did the weekly skin assessments. Upon further interview, she stated that the treatment nurse was responsible for doing weekly wound assessments including measurements, staging, and description. Review of weekly skin assessments from the original admitted through 07/22/16 revealed that there was no skin assessment done on 05/29/16. Review of a skin assessment dated [DATE] revealed that R #180 had a Stage II to the sacral area with pink tissue present, and Stage II to the right and left buttocks. Review of Physician order [REDACTED]. Further review of Physician order [REDACTED]. Review of the Treatment Administration Records (TAR) for R #180 revealed the following: In May 2016: at 5:00 p.m. treatments not documented as completed on 05/21/16; 05/22/16; 05/24/16 (the TAR does not specify what is being treated); at 5:00 p.m. treatments not documented as done to left buttock on 05/25/16, and to left buttock, right buttock, and sacrum at 5:00 p.m. from 05/26/16 to 05/31/16. In addition, the treatment was not documented as done at 9:00 a.m. for any of these three areas on 05/27/16. In June 2016: The 5:00 p.m. treatment to the right and left buttocks and sacrum were not documented as done on 06/01/16; 06/03/16; 06/04/16; 06/07/16; 06/08/16; 06/09/16; 06/11/16; 06/12/16; 06/15/16; 06/16/16; and 06/17/16. The daily treatment to the sacrum was not documented as done on 06/21/16; 06/24/16; and 06/27/16. In July 2016: The daily treatments to the sacrum and right buttock were not documented as done on 07/06/16; 07/09/16; 07/10/16; 07/11/16; and 07/18/16. This missing wound care documentation was verified during interview with Treatment LPN UU on 08/01/16 at 1:28 p.m. Cross-refer to F 314. 7. Review of the clinical record for R #150 revealed that she was admitted to the facility on [DATE]. Review of her Admission MDS dated [DATE] revealed that she had one unstageable pressure ulcer with slough or eschar. Review of the Quarterly MDS dated [DATE] noted she had one Stage III pressure ulcer with slough. Review of the pressure ulcer care plan revealed interventions for weekly skin inspections, and to do treatments as ordered. Review of computerized Weekly Skin Reviews revealed that the skin assessments were not completed on 03/26/16; 04/09/16; and none between 05/09/16 and 07/26/16 (a total of twelve missed assessments since admission). This was verified during interview with RN Field Services Clinical Director PPP on 08/04/16 at 10:24 a.m. Review of Physician order [REDACTED]. 06/10/16-present time Cleanse right heel with water, soap, pat dry, and apply Santyl then wrap with kerlix wrap every day. Review of the TARs from admission in January 2016 through July 2016 noted blanks in the wound care documentation as follows, and was verified during interview with the DNS on 08/04/16 at 11:09 a.m.: In January 2016: No documentation that the right heel wound care was done on 01/31/16. In February 2016: No documentation that wound care to the right heel was done on 02/09/16; 02/14/16; 02/23/16; and 02/29/16. In March 2016: No documentation that wound care to the right heel was done on 03/03/16; 03/06/16; 03/09/16; 03/12/16; 03/15/16; and 03/21/16. In April 2016: No documentation that the treatment was done to the right heel on 04/06/16. In May 2016: No documentation that the treatment was done to the right heel on 05/04/16; 05/07/16; and 05/19/16. In June 2016: No documentation that the treatment was done to the right heel on 06/09/16; 06/10/16; and 06/21/16. In July 2016: No documentation that the treatment was done to the right heel on 07/06/16; 07/09/16; 07/10/16; 07/18/16; 07/24/16; and 07/31/16. Cross-refer to F 314. 8. Review of the clinical record for R #170 revealed that he was admitted to the facility on [DATE]. Review of the Admission MDS dated [DATE] noted that he had severe cognitive impairment, and wandered 1-3 days of the assessment period. Review of a care plan for risk for wandering initiated on 07/19/16 included an intervention for a bed alarm. Review of a care plan for risk for elopement related to attempts to leave the Living Center initiated 07/22/16 included an intervention to take a picture of the patient on admission for identification for updating the elopement book. Review of a Verification of Investigation report dated 07/19/16 at 6:30 p.m. revealed that R #170 was noted ambulating outside in the parking lot near the road. During observation and interview with Licensed Practical Nurse (LPN) AA on 07/28/16 at 9:14 a.m., she verified that R #170 did not have an alarm on his bed. During interview with LPN Unit Manager HH on 07/28/16 at 2:28 p.m., she verified that there was no photo of the resident in the elopement book, that there should have been, and that either she or the Assistant Director of Nursing Services (DNS) initiated these forms. During interview with the DNS on 07/28/16 at 3:10 p.m., she verified that there was no picture of R #170 in the elopement book, and that there should have been. During observation and interview with Certified Nursing Assistant (CNA) MM on 07/30/16 at 3:24 p.m., she verified that there was no bed alarm on the bed. During observation on 08/02/16 at 9:01 a.m., no alarm was seen on the bed. Cross-refer to F 323. 9. Review of the MDS assessment dated [DATE] for resident O revealed that they had no cognitive impairment, needed extensive assistance for personal hygiene, and had impairment on one side of the upper and lower extremities. Review of the care plan for impaired neurological status related to [MEDICAL CONDITION] (stroke) and [MEDICAL CONDITION] included interventions to assist with ADLs as needed, and monitor ADLs for assistance and render care as needed. Review of the physical functioning deficit related to self-care and mobility impairment care plan included an intervention for personal hygiene assistance. During interview with resident O on 07/26/16 at 10:01 a.m., 07/27/16 at 9:20 a.m., 07/27/16 at 1:49 p.m., 07/28/16 at 10:28 a.m., 07/29/16 at 4:05 p.m., 07/30/16 at 8:04 a.m., and 07/30/16 at 3:25 p.m., the resident stated they had not received oral care that day and/or since February 2016, and white and/or tannish debris was noted along their bottom teeth at the gum line. During interview and observation with Certified Nursing Assistant (CNA) MM on 07/30/16 at 3:30 p.m., she was not able to find any mouth care supplies in he room of resident O. Cross-refer to F 312 10. Review of the clinical record for R #84 revealed that the resident was admitted to the facility on [DATE] was hosptalized on [DATE] and was readmitted to the Long Term Care facility on 01/27/16. Review of the Admission Minimum Data Set ((MDS) dated [DATE] noted that R# 84 had moderate cognitive impairment, was extensive for bed mobility, was a pressure ulcer risk and was admitted with one stage four (IV) pressure ulcer with measurements noted as 6.5 x 5.0 x 0.8 (noted to be error actual depth on admission 8.0 cm). No moisture associated skin damage noted. Review of the Immediate care plan dated 11/12/15 for Pressure Ulcer Risk documents pressure ulcer present with intervention of implement Tender Loving Care (TLC) program where available, Ulcer care Ma65 (low air mattress). Review of care plan dated 01/27/16 for Pressure ulcer actual or at risk due to stage IV to sacrum included interventions for weekly skin assessments, treatments as ordered, weekly wound assessment, skin assessment to be completed per Living Center Policy. Review of the care plan for R #84 revealed the following: Pressure ulcer actual or at risk due to: Pressure ulcer present, assistance required in bed mobility, bed fast, skin desensitized, bowel incontinence, stage IV wound to sacrum. The following care planned interventions are noted: conduct weekly skin inspection, skin assessment to be completed by policy. After resident was readmitted to the Long Term Care facility on 01/27/16, the first weekly skin assessment after re-admitted d 01/28/16 - documents open area- Pre-existing, signed 02/12/16. No wound care description or wound care measurements noted. Skin assessment: 01/28/16 - wound description and measurements. New wound care order for [MEDICATION NAME] AG to be applied to DTI to 3rd toe and unstageable o 2nd digit. There is no documentation that [MEDICATION NAME] was applied for the following dates: 01/28/16, 01/31/16. 02/06/16, 02/09/16, 02/12/16, 02.15/16, 02/18/16, 02/27/16. Review of Nurses Progress Notes revealed only three Nurses Notes addressing R #84's sacral wound from the date of readmission on 01/27/16 until 02/29/16 and include: Nurses Note dated 01/27/16 Admission note: with admitting [DIAGNOSES REDACTED]. Nurses Note dated 01/28/16 at 4:30 p.m. documents: Admission Skin assessment: Skin warm and dry to touch. Sacrum with Stage IV with red granulating tissue, wound bed without slough or necrotic tissue noted, with measurements 5.0 x 5.0 x 1.5. Right foot 2nd digit with eschar noted with measurements of 0.5 x 0.5 x 0 new order for [MEDICATION NAME] AG every 3 days. 3rd digit with Deep Tissue Injury (DTI) noted with measurements of 0.3 x 0.3 x 0. No additional Nurses note or wound care note documented in the Progress Notes from 01/28/16 until 02/21/16 Nurses Note which documents: Wound Note: Stage IV to sacrum with measurements of 6.0 x 4.0 x 1.5 with beefy red granulating tissue noted. Current treatment of [REDACTED]. No odor or signs or symptoms of infection noted. Progress Notes revealed the next wound documentation in the Nurses Note dated 02/29/16 at 10:13 a.m. Wound Note: Stage IV with measurements of 6.0 x 3.0 x 1.5 with beefy red granulating tissue noted with some odor noted, but patient voices no complaint of pain or discomforts at this time. New order for evaluation at JMS wound center on 03/01/16. Review of Weekly Skin Reviews for R #84 revealed a Weekly Skin Review dated 01/27/16 (date R #84 was readmitted to the facility) and documents wound as: Open area, Pre-existing. Site: Sacrum. Description: admitted with open area. (Signed 02/12/16). No other evidence of Weekly Skin Reviews documented from 01/27/16 until 03/03/16. Weekly Skin Review dated 03/03/16 documents Open Area, Site: Sacrum, Description ongoing treatment by wound nurse. No wound description or wound measurements documented. Interview on 08/03/16 at 4:20 p.m. with the Treatment Nurses LPN UU and LPN CC revealed the primary nurse is responsible for doing the weekly skin assessments and if the Primary Nurse finds a problem (like red excoriated skin) then they are supposed to let the treatment nurses know. Interview on 08/05/16 at 8:42 a.m. with the Director of Nursing Services (DNS) revealed that if a resident is experiencing signs and symptoms of wound infection such as nasty drainage, redness, fever, or odor then she expected the nurse to call the Physician and let him know so the Physician can either come in and assess the resident or write an order for [REDACTED]. Wound care nurses are also responsible for changing the first dressing for new residents or readmitted residents. The DNS stated she expects, and it is the policy, for wounds to be assessed and documented at least one (1) time a week and that includes description of the wounds and measurements of the wounds. The DNS stated if an assessment, such as check for pressure relieving measures, are listed on the TAR then she expects each shift to assess for those pressure relieving measures and to document that on the TAR. The DNS went on to say that they were having trouble documenting wounds in the User Defined assessmnet (UDA) from 12/17/15 until 06/13/16 because it was too difficult to use and had a lot of glitches. The DNS stated without the UDA documenting the wound care was not as consistent but even with the UDA the wound care work load was too heavy. The DNS stated she begged the previous Administrator, on at least three different times, to cut back on the wound care admissions but that she never reached out to anyone above the Administrator. The DNS stated that the wound care nurse LPN UU also came in and talked to the previous Administrator about the wound care workload. Review of the TAR for R #84 revealed that wound care orders for sacrum: Dakin's Solution 0.25% Apply to Sacrum topically every day shift for Stage IV cleanse sacrum with warm soap water, pat dry and pack with moistened soaked gauze cover with dry dressing and secure with tape. (Order start date 01/28/16. Order discontinue date 05/16/16). Review of the documented wound care on the TARs for January 2016 through May 2016 revealed no documentation that wound care was provided for the sacral wound for the following dates: 01/31/16, 02/15/16, 03/09/16, 03/15/16, 03/17/16, 04/09/16, 04/10/16, 04/12/16, 04/30/16, 05/04/16. Review of the TAR revealed wound care orders for the right foot, 2nd and 3rd digits as: Cleanse right foot 2nd and 3rd digit with warm soap and water, pat dry and apply Mepiliex AG every 72 hours for Deep Tissue Injury (DTI) to the 3rd toe and unstageable to the 2nd digit. (Order start date: 01/28/16. Order discontinue date: 04/13/16). Review of the documented wound care on the TARs for January through April 2016 revealed no documentation that wound care was provided for the right foot 2nd and 3rd digits for the following dates: 01/31/16, 02/06/16, 02/09/16, 02/12/16, 02/15/16, 02/18/16, 02/27/16, 03/01/16, 03/04/16,03/10/16, 03/13/16, 03/22/16, 03/25/16, 03/28/16, 03/31/16, 04/03/16, 04/06/16, 04/12/16. Further review of the TAR for R #84 revealed an order for [REDACTED]. Discontinued date 05/25/16). There is no documentation of the Pressure Relief Measures being assessed for being in place for the month of April. Review of the TAR for the month of May 2016 revealed no documentation of the Pressure Relief Measures being documented as being assessed to be in place for the following dates: On the Day shift: 05/04/16, 05/19/16; on the Evening shift: 05/03/16, 05/04/16, 05/05/16, 05/06/16, 05/08/16, 05/10/16, 05/11/16, 05/12/16, 05/13/16 05/14/16, 05/17/16, 05/18/16, 05/19/16, 05/21/16, 05/22/16, 05/23/16, and; On the Night: 05/03/16, 05/07/16, 05/12/16, 05/17/16, 05/21/16, and 05/22/16. Review of the TAR revealed Wound Care Order: Sacrum: wash with wound cleanser and dry. Spray barrier to per wound. Place puracyn soaked gauze to wound, cover with ABD. Place [MEDICATION NAME] to per wound and other

Based on observation, record review, review of the facility's policy and procedures for pressure sore management, review of the facility's Wound Evaluation Flow Sheet, and resident and staff interview, it was determined that the facility failed to have an effective pressure sore recognition and management program as evidenced by failure to perform consistent weekly skin assessments for residents at risk for skin breakdown (N ); failure to identify pressure sores on admission and readmission in order to notify the physician and initiate treatment timely (N); failure to obtain treatment timely for identified pressure sores (T, R); failure to perform treatments as ordered by the physician to facilitate wound healing (N, T, R, R #84, R #24, R #50, R #64, R #120, R #180); failure to provide treatment with the correct wound care supplies as ordered by the physician (R); failure to provide consistent weekly assessment of pressure sores to include accurate staging, measurements and thorough description of the wounds in order to determine progression or deterioration of the pressure sores (T, R, R #84); failure to remove a resident's multipodus boots which were thought to contribute to breakdown (R); and failure to implement interventions to prevent the recurrence of pressure sores (T) and/or deterioration of pressure sores (R) for nine (9) (R, T, N, R #180, R #50, R #24, R #120, R #84 and R #64) of eleven (11) residents reviewed for pressure sores from a sample of fifty-one (51) residents, the census was one-hundred and one (101). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On [DATE] at 1:35 p.m., the Executive Director (ED), Director of Nursing Services (DNS), and Corporate Registered Nurse (RN) Field Services Clinical Director were notified that Immediate Jeopardy (IJ) existed as of [DATE] related to R #170, who was assessed during admission on [DATE] to be an elopement risk. However, the facility failed to implement effective interventions, failed to sufficiently supervise the resident, and failed to develop an immediate care plan to address the risk for elopement. R #170 eloped from the facility four (4) days after admission on [DATE], and was found off facility grounds after crossing four (4) lanes of automotive traffic with a median dividing the two (2) lanes of traffic. In addition, the resident crossed through the facility parking lot, onto the road, which led into a Medical Office Complex. Additional IJ noncompliance was identified on [DATE] at 4:37 p.m., when during observation of the exit door at the end of the 100 hall, it did not sound an alarm to alert staff that the door was opened. On [DATE] at 7:29 p.m., the facility implemented immediate action to ensure that unsupervised exit did not occur with a staff member assigned to sit at the door and provide continuous monitoring of the 100 hall door. The facility also in-serviced staff about monitoring the 100 hall exit door. On [DATE] at 10:46 a.m. the SSA validated that the 100 hall exit door was repaired and fully functioning. A Credible Allegation of Compliance (AoC) was received on [DATE] at 9:56 a.m. However, the facility failed to complete elopement drills as outlined in their AoC, and the ED was notified at exit on [DATE] that the IJ would be on-going until the SSA validated that all interventions were completed in the AoC including the elopement drills as indicated in the facility's AoC. On [DATE] at 11:30 a.m., the ED and Corporate Area Vice President (VP) were notified that IJ existed. It was determined that the IJ was identified to exist on [DATE] related to resident N who was admitted to the facility on [DATE] after a hospital stay from home for a urinary tract infection, history of falls, who ambulated with a walker, with impaired cognition. The resident was discharged from the hospital to the facility with fluid filled blisters on bilateral heels and a reddened sacral area. The facility failed to develop an interim care plan to address the pressure ulcers. The resident was found unresponsive on [DATE] and transferred to the hospital in septic shock. Review of the Hospital Discharge Summary signed on [DATE] revealed the Final [DIAGNOSES REDACTED]. Review of the Georgia Death Certificate revealed the immediate cause of death for Resident N was Septic shock secondary to decubitus. A Credible Allegation of Compliance was received on [DATE] at 5:40 p.m., was not acceptable, the ED was notified during the exit meeting that the IJ's would be ongoing. Therefore the IJ was identified to exist on [DATE] and remains on-going. The facility's failure to report and obtain orders for wounds present on admission and readmission to the facility for resident N delayed treatment and the wounds deteriorated, and the resident developed septic shock. In addition, the facility failed to implement interventions to prevent the recurrence of a sacral wound for resident T, and did not implement treatment to the wound in a timely manner for the resident, and the Stage II pressure sore deteriorated to a Stage III pressure sore with yellow-green wound bed. In addition, the facility's failure to provide treatments as ordered possibly contributed to the deterioration of a wound for resident R per wound clinic staff interview. Findings include: Review of the facility's Wound Evaluation Flow Sheet revealed that assessments of pressure sores should include measurements, description of the wound bed and periwound, and presence or absence of exudate. Pressure sores should also be staged according to the following criteria: Suspected Deep Tissue Injury- Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlining soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage I- Intact skin with non-blanchable redness to a localized area usually over a bony prominence. Stage II- Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage III- Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon and muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV- Full thickness tissue loss with exposed bone, tendon or muscle, Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable- Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Review of the facility's Skin Integrity Guideline included the following: Purpose: To provide a comprehensive approach for monitoring skin conditions. To decrease pressure ulcer and/or wound formation by identifying those residents who are at risk, and implementing appropriate interventions. To promote healing of wounds of any etiology, whether admitted or acquired. General Guideline: Residents will be assessed or observed for risk of skin breakdown within 24 hours of admission or readmission, quarterly, before transfer or discharge to any setting (unless emergent nature), and as necessitated by change in condition. Living Center develops a routine schedule to review residents with wounds or at risk on a weekly basis and will document findings. DNS or designee will be responsible to implement and monitor the skin integrity program. Wound status is monitored on a weekly basis. The interdisciplinary plan of care will address problems, goals and interventions directed toward prevention of pressure ulcers and/or skin integrity concerns identified. Documentation and Care Interventions for Skin Integrity: Residents will be observed by the CNA daily for reddened/open areas, [MEDICAL CONDITION] of feet or sacrum. Changes will be reported to the licensed nurse and documented. Documentation of Weekly Skin Evaluation/Observations: Licensed nurse will be responsible for performing a skin evaluation/observation weekly, utilizing the Weekly Skin Review User Defined Assessment (UDA). Licensed nurse to document weekly on identified wounds using the Wound Evaluation Flow Sheet (WEFS) UDA (one UDA per wound identified). Each LivingCenter must create a manual tracking system to monitor completion of weekly WEFS since this UDA cannot be scheduled. Care plan is to be implemented, evaluated and revised based on the needs of the resident. Monitoring Compliance: Wound Evaluation Flow Sheet UDA is accurately and thoroughly completed for wounds. Visual observation that physical interventions are in place. Weekly Skin Review UDA's are in place. DNS or designee evaluates/observes wounds on a weekly basis. 1. Resident N (a closed record review) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Clinical Health Status Admission assessment dated [DATE] revealed that the resident did not have any skin breakdown. However, staff documented a late entry note dated [DATE] on the [DATE] Clinical Health Status Admission Assessment that the resident was admitted with redness on his/her sacrum and bilateral fluid filled blisters on his/her bilateral heels. However, staff failed to stage and measure the wounds and failed to indicate if the sacral redness was blanchable or non-blanchable. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] for resident N revealed that the resident was severely cognitively impaired, had no behaviors, required extensive assistance from staff for activities of daily living (ADLS), was always incontinent of bowel and bladder, had two (2) Stage II pressure sores with [MEDICATION NAME] tissue that were identified on [DATE] and was at high risk for the development of additional pressure sores. Review of the thirty (30) day Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident occasionally rejected care. Although resident N was admitted with redness on his sacrum and bilateral heel blisters, staff failed to develop interventions on the interim care plan to address the actual pressure sores or the prevention of additional pressure sores. Review of the comprehensive care plan dated [DATE] revealed that the resident had actual pressure sores and was at risk for the development of additional pressure sores with interventions for staff to conduct weekly skin inspections, to perform weekly wound assessments and to provide treatments as ordered. However, there was no indication that staff performed weekly skin assessments as care planned from his/her admission on [DATE] to his/her final discharge to the hospital on [DATE]. Review of the General Note dated [DATE] revealed for resident N was again assessed on [DATE] with intact bilateral heel blisters and a red sacrum without any open areas. Staff documented that Prevalon boots had been placed on the bilateral feet. However, there was no indication that the pressure sores on the bilateral heels or sacrum were staged or measured on the [DATE] admission or on the [DATE] assessment. Review of the ,[DATE] Treatment Administration Record (TAR) for resident N revealed that although the resident was assessed on admission with pressure sores on the bilateral heels, there was no indication that staff had notified the physician and obtained treatment for [REDACTED]. On [DATE], staff obtained an order to apply Cavalon spray and then [MEDICATION NAME] AG to the bilateral heel wounds every three days. However, staff failed to provide treatment to the heels on [DATE] for resident N and did not provide treatment until three (3) days later on [DATE], nine (9) days after the resident was admitted . Furthermore there was no indication that staff notified the physician about the red sacral area in order to obtain and initiate treatment to prevent the reddened area on the sacrum from deteriorating. Review of the Skin Integrity Guideline revealed for resident N that Stage I non-blanchable reddened areas that present over a bony prominence (such as the sacrum) may require a thin [MEDICATION NAME] or Foam dressing to be changed per physician order. Review of the [DATE] Registered Dietician (RD) note for resident N revealed that Cal 90 cubic centimeters (ccs) twice a day and large meat portions at meals was initiated to address the underweight status and to promote wound healing. Review of the General Note/Wound Note dated [DATE] revealed that the resident had a Stage II intact fluid filled blister on his/her right heel that measured 8.0 x 7.3 x 0 centimeter (cm), a Stage II pressure sore on his/her left heel that measured 5.5 x 5.0 x 0 cm and a red sacrum with no open areas. However, staff failed to indicate if the Stage II on the left heel was an intact blister or an open wound and staff failed to stage and measure the persistent redness on the sacrum. Review of the Situation Background Assessment Review (SBAR) Change of Condition Note dated [DATE] for resident N revealed that the resident was sent to the hospital for chest pain and was diagnosed with [REDACTED]. Review of the Hospital Discharge Summary dated [DATE] revealed for resident N had a Stage I pressure sore on the right heel, an unstageable pressure sore on the left heel and a Stage I pressure sore on his sacrum at discharge from the hospital. Continued review of the Hospital Discharge Summary for resident N revealed that staff were supposed to apply [MEDICATION NAME] AG every three days and as needed to the wounds. Review of the Readmission Clinical Health Status assessment dated [DATE] for resident N revealed that staff failed to assess the resident with breakdown on his/her feet but, staff identified redness on his sacrum. Although the Hospital Discharge Summary indicated that [MEDICATION NAME] AG was to be applied to the pressure sores every three days, the order was not written. Review of the physician order [REDACTED]. However, there was no indication that staff notified the physician about the sacral wound in order to obtain and initiate treatment to prevent further deterioration of the wound. Review of the ,[DATE] Medication Administration Record [REDACTED]. However, there was no indication that treatment was provided to the sacral wound to prevent deterioration of the wound until [DATE] when the pressure sore had deteriorated and had necrotic tissue in the wound bed. There was no indication that staff had performed weekly pressure sore assessments after readmission as scheduled on [DATE] or [DATE] for resident N . Review of the Nutrition Note by the RD dated [DATE] revealed that the resident had increased needs related to wound healing as evidenced by a Stage II pressure sore on the bilateral heels and an Unstageable pressure sore on the sacrum per wound report. However, there was no indication that staff had staged and assessed the pressure sores prior to the RD's [DATE] note. Review of the General Note/Wound Note dated [DATE] revealed that the right heel wound measured 3.0 x 4.0 cm, the left heel wound measured 5.0 x 2.0 cm and the sacral wound measured 3.0 x 1.5 cm. However, staff failed to stage and describe the pressure sores to include a description of the wound bed, presence/absence of exudate and presence/absence of odor for resident N . Staff failed to perform weekly assessments of the pressure sores as scheduled on [DATE] until [DATE], two (2) weeks later. Review of the General Note/Wound Care Note dated [DATE] for resident N revealed that the sacral pressure sore had increased in size and measured 8.0 x 4.5 cm and had deteriorated as evidenced by necrotic tissue in the wound bed and greenish tissue on the edges of the wound. Continued review of the General Note/Wound Care Note dated [DATE] for resident N revealed that the resident had a Deep Tissue Injury (DTI) on the right heel that measured 5.0 x 6.5 x 0 cm and had black tissue in the wound bed and red wound edges; a DTI on the left heel that measured 4.5 x 5.0 cm and had black tissue in the wound bed; and a new DTI on the right great toe that measured 1.0 x 0.5 cm and a new DTI on the bottom of the right foot that measured 5.0 x 1.0 cm. Review of the ,[DATE] Medication Administration Record [REDACTED]. However, there was no indication that the bilateral heel wounds had healed at that time. Review of the physician orders [REDACTED]. However, review of the ,[DATE] TAR revealed that staff treated the left heel on [DATE]. There was no indication that staff clarified the orders with the physician for resident N . Review of the ,[DATE] TAR revealed that staff failed to obtain and provide treatments to the sacral pressure sore from [DATE] to [DATE]. Review of the ,[DATE] TAR revealed that staff applied a [MEDICATION NAME] dressing on the sacral wound on [DATE]. Review of the General Note dated [DATE] at 1:45 p.m. for resident N revealed that the resident was lethargic, had periods of apnea and had a low blood pressure. The resident was transferred to the hospital. Review of the Hospital Discharge Summary dated [DATE] for resident N revealed that the resident was admitted with a Stage IV sacral pressure sore that was malodorous and septic shock with blood cultures positive for Corynebacterium and bacteroides fragilis. Continued review of the Discharge Summary for resident N revealed that the resident was not a surgical candidate for debridement of the sacral wound because of the septic shock. Further review revealed that the resident did not respond to treatment and family placed the resident on Hospice services for comfort measures. Continued review revealed that the final hospital [DIAGNOSES REDACTED]. The resident expired [DATE]. The resident's Certificate of Death indicated that the immediate cause of death was septic shock and sacral decubitus. Interview with Licensed Practical Nurse (LPN) Treatment Nurse UU on [DATE] at 9:35 a.m. revealed that the charge nurses were responsible for performing weekly skin assessments and that the treatment nurse and Director of Nursing Service (DNS) were responsible for obtaining weekly pressure sore assessments. Interview with the Assistant Director of Nursing Service (ADNS) on [DATE] at 2:37 p.m. revealed that the physician was not notified of the resident's sacral pressure sore so that treatment could be obtained and initiated timely to prevent deterioration of the wound. Interview with Treatment Nurse UU on [DATE] at 9:55 a.m. revealed that the resident's pressure sores were not consistently assessed weekly to include staging, measurements and descriptions because she was extremely busy during that time. Continued interview revealed that treatments may have been provided but, not documented. Further interview with UU revealed that when a resident was admitted or readmitted from the hospital, the treatment nurse assessed the resident and reviewed the Hospital Discharge Summary for orders. If there were no orders, then the treatment nurse notified the physician to obtain treatment orders. Staff failed to notify the physician about the sacral redness on the [DATE] admission for resident N and the [DATE] readmission in order to obtain and initiate treatment timely to prevent deterioration of the wound until [DATE] when the wound measured 8.0 x 4.5 cm and had necrotic tissue in the wound bed and red wound edges. This failure resulted in the resident's hospitalization on [DATE] and eventual death from septic shock secondary to the sacral decubitus on [DATE]. Staff failed to perform weekly skin assessments as care planned after the admission on [DATE] to his final discharge to the hospital on [DATE]. Staff failed to perform consistent weekly pressure sore assessments to include staging, measurements, description of the wound bed, and presence/absence of drainage and odor from admission on [DATE] to the resident's final discharge to the hospital on [DATE]. Staff failed to provide treatment as ordered to the bilateral heel wounds on [DATE] and from [DATE] to [DATE]. 2. Resident T was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the [DATE] Admission Minimum Data Set (MDS) assessment revealed that the resident T was admitted with one (1) Stage II pressure sore, was non-ambulatory, required extensive assistance from staff for bed mobility, was always incontinent of bowel and bladder, had occasional moderate pain and did not reject care. Review of the [DATE] Quarterly MDS assessment revealed that resident T now had one (1) Stage III pressure sore and two (2) unstageable pressure sores. Continued review of the [DATE] Quarterly MDS assessment revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 6 indicating that the resident was cognitively impaired, had almost constant moderate pain and did not reject care. Review of the care plan dated [DATE] for resident T revealed that the resident had an actual Stage II pressure sore on the sacrum and soft bilateral heels with non-blanchable redness on admission with an intervention for staff to provide treatments as ordered. Continued review of the resident's care plan for pressure sores revealed that she was at risk for developing additional pressure sores due to impaired mobility, incontinence and [DIAGNOSES REDACTED]. Review of the Wound Evaluation Flow Sheet dated [DATE] revealed that the resident T was admitted with a Stage II pressure sore on her sacrum that measured 0.5 x 0.5 x 0 cm with 75% epithelization and 25% granulation tissue and red, non-blanchable pressure sores on her bilateral heels. However, staff failed to stage and measure the bilateral heel pressure sores at that time. Review of the [DATE] Treatment Administration Record (TAR) revealed that staff failed to obtain treatment for [REDACTED]. Review of the [DATE] TAR for resident T revealed that staff applied Pravalon boots to the feet of resident T. A pressure reduction mattress was also applied to her bed. Vitamin C, Zinc, a multivitamin with minerals and 2 Cal 120 cubic centimeters (ccs) every day was initiated to promote wound healing. Review of the General Note dated [DATE] for resident T revealed that the right heel pressure sore had deteriorated to a deep tissue injury (DTI) that measured 4.0 x 4.0 x 0 cm. and the left heel pressure sore had deteriorated to a DTI that measured 1.5 x 3.8 x 0 cm. Review of the [DATE] and [DATE] TARs revealed that staff applied Cavalon spray to the pressure sores every day as ordered except for [DATE] and [DATE]. Review of the general Note dated [DATE] revealed that the Stage II sacral pressure sore measured 0.5 x 0.5 x 1 cm. with a dark pink wound bed. Review of the General Notes dated [DATE] to [DATE] for resident T revealed that the bilateral heel pressure sores were assessed weekly and continued to be DTIs. Review of the General Note dated [DATE] revealed that the left heel pressure sore was a Stage II that measured 3.0 x 4.0 x 0 cm. With a pink wound bed. The right heel pressure sore was a Stage II that measured 2.0 x 4.5 x 0 cm with a pink wound bed. The physician was notified of the change in the pressure sores at that time and ordered Silavadene to be applied every day. Review of the February 2016 TAR revealed that staff failed to perform treatment on [DATE]. Review of the General Note dated [DATE] for resident T revealed that the Stage II pressure sore on the sacrum had healed and that treatment was discontinued at that time. However, there was no indication that staff had initiated any other interventions to prevent the recurrence of a pressure sore on the sacrum after treatment was discontinued on [DATE]. Further review of the General Note dated [DATE] for resident T revealed that the pressure sore on the sacrum had reopened and was identified as a Stage II pressure sore that measured 1.0 x 1.0 x 0 cm. However, review of the [DATE] TAR for resident T revealed that staff had failed to obtain treatment for [REDACTED]. Review of the General Note dated [DATE] for resident T revealed that the resident had excoriation on her sacrum but, there was no documentation about the presence or absence of the Stage II pressure sore. Review of the [DATE] and February 2016 TARs for resident T revealed that staff failed to obtain treatment for [REDACTED]. Review of the SBAR note dated [DATE] (Late entry for [DATE]) for resident T revealed that the resident's sacral pressure sore had a yellowish-green wound bed with some pink tissue and had uneven borders. However, there was no staging or measurement of the pressure sore. Review of the February 2016 TAR for resident T revealed that staff failed to obtain treatment timely for the pressure sore on [DATE] when it was first identified until four days later on [DATE], when the physician ordered [MEDICATION NAME] to be applied to the pressure sore every day and to obtain a Wound Care consult. Review of the February 2016 TAR for resident T revealed that staff failed to perform treatment for [REDACTED]. Review of the General Note dated [DATE] revealed that the pressure sore on the sacrum had deteriorated, had 75% necrotic tissue in the wound bed and measured 4.0 x 3.0 x 0 cm. Staff incorrectly staged the pressure sore as a Stage II. Review of the Vascular Center office visit note dated [DATE] revealed that resident T had a Doppler study done which suggested ,[DATE]% stenosis of the distal superficial femoral arteries bilaterally. Continued review revealed that the resident was assessed as having [MEDICAL CONDITION] with pressure and ischemic ulcerations on both feet. Further review of the office note revealed that the resident was at high risk for amputation. Review of the care plan note revealed that staff had documented weekly on the bilateral heel pressure sores from [DATE] to [DATE] for resident T . Review of the care plan note dated [DATE] revealed that the left heel pressure sore was unstageable with eschar and measured 3.0 x 2.0 x 0 cm and the right heel pressure sore was unstageable with eschar and measured 5.0 x 4.0 x 0 cm. Review of the General Note dated [DATE] for resident T revealed that the sacral pressure sore measured 4.0 x 3.0 x 1.0 cm. with 25% necrotic tissue in the wound bed and tunneling noted at 10 o ' clock and 11 o ' clock. Staff incorrectly staged the pressure sore as a Stage II for resident T. Review of the [DATE] TAR revealed that staff continued to apply [MEDICATION NAME] to the wound every day until [DATE]. There was no subsequent documentation regarding tunneling of the pressure sore after [DATE]. Review of the General Notes dated [DATE] and [DATE] for resident T revealed that the sacral pressure sore had necrotic tissue and/or slough in the wound bed and now had odor. Staff incorrectly staged the sacral pressure sore as a Stage II. Staff continued to perform weekly pressure sore assessments for the bilateral heels that included measurements and staging. The bilateral feet pressure sores continued to be assessed as unstageable with hard eschar through [DATE]. Review of the General Note dated [DATE] revealed that resident T was assessed at the Wound Care clinic and returned with orders for staff to apply Santyl and Dakin's soaked gauze to the sacral pressure sore every day and apply Exalt/[MEDICATION NAME] to all wounds on the bilateral feet every three days. Review of the [DATE] and [DATE] TARs revealed that staff failed to provide the treatment every day as ordered for the sacral pressure sore on [DATE], [DATE], [DATE] and [DATE]. Staff failed to provide treatment as ordered every three days for the bilateral heels between [DATE] and [DATE] (8 days between treatments) and between [DATE] and [DATE] (23 days between treatments) for resident T . Review of the General Note dated [DATE] for resident T revealed that the sacral pressure sore measured 6.0 x 6.0 x 3.5 cm, had necrotic tissue, a foul odor and was now a Stage III pressure sore. Review of the General Note dated [DATE] (late entry for [DATE]) revealed that the sacral pressure sore had increased in size to 7.0 x 4.0 x 3.0 cm but, continued to be a Stage III wound with 25% slough. Review of the General Note dated [DATE] (late entry for [DATE]) for resident T revealed that the pressure sores on the bilateral heels remained unchanged. Review of the General Note dated [DATE] revealed that resident T was assessed at the Wound Care clinic and treatment for [REDACTED]. However, review of the [DATE] and [DATE] TARs for resident T revealed that staff failed to perform treatment twice a day for the sacral pressure sore as ordered from [DATE] through [DATE] (6 consecutive days), on [DATE], from [DATE] through [DATE] (3 consecutive days), from [DATE] through [DATE] (6 consecutive days), from [DATE] through [DATE] (4 consecutive days) and on [DATE]. Continued review revealed that staff failed to perform any treatments at all to the sacral pressure sore on [DATE] and [DATE] for resident T . Review of the [DATE] and [DATE] TARs revealed that staff performed treatment as ordered to the feet wounds. Review of the care plan note dated [DATE] for resident T revealed that the sacral pressure sore was a Stage III and measured 5.5 x 4.5 x 2.5 cm., the left heel unstageable pressure sore measured 4.5 x 4.5 x 0 cm., and the right heel unstageable pressure sore measured 5.0 x 4.0 x 0 cm. However, staff failed to obtain weekly assessments of the sacral pressure sore and the bilateral heel pressure sores as scheduled on [DATE] and [DATE], almost three weeks between assessments. Review of the General Note dated [DATE] for resident T revealed that the resident was assessed at the Wound Care clinic on [DATE] and the Wound Care physician ordered a [DEVICE] assisted closure (VAC) to be applied to the sacral wound at a continuous suction of 125 mmHg to promote healing and for the sponge to be changed every Tuesday and Friday. On [DATE], the treatment order was changed to every Monday and Thursday for resident T . Review of the [DATE] and [DATE] TARs revealed that the t

Based on record review and staff interviews, the facility failed to provide sufficient nursing staff to provide the services necessary to ensure that residents with pressure ulcers received timely treatments and/or treatments as per physician orders [REDACTED].#84, R #24, R #50, R #64, R #120, R #180); failed to provide sufficient staff to supervise one (1) resident (R#170) that the facility identified as at risk for elopement, and who eloped four (4) days after admission. In addition, the facility failed to provide sufficient nursing staff to ensure that residents received timely assistance with activities of daily living (ADL) care for ten unstamped residents, and for nine (9) residents (R#73, R#89, R#93, R#35, R#38, R#113, R#172, R#199, R#50) who voiced grievances about care and services. The sample size was fifty-one (51) residents, and the census was one-hundred and one (101). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 07/29/16 at 1:35 p.m., the Executive Director (ED), Director of Nursing Services (DNS), and Corporate Registered Nurse (RN) Field Services Clinical Director were notified that Immediate Jeopardy (IJ) existed as of 07/15/16 was related to R #170, who was assessed during admission on 07/15/16 to be an elopement risk. However, the facility failed to implement effective interventions, failed to sufficiently supervise the resident, and failed to develop an immediate care plan to address the risk for elopement. R #170 eloped from the facility four (4) days after admission on 07/19/16, and was found off facility grounds after crossing four (4) lanes of automotive traffic with a median dividing the two (2) lanes of traffic. In addition, the resident crossed through the facility parking lot, onto the road, which led into a Medical Office Complex. Additional IJ noncompliance was identified on 7/28/16 at 4:37 p.m., when during observation of the exit door at the end of the 100 hall, it did not sound an alarm to alert staff that the door was opened. On 7/28/16 at 7:29 p.m., the facility implemented immediate action to ensure that unsupervised exit did not occur with a staff member assigned to sit at the door and provide continuous monitoring of the 100 hall door. The facility also in-serviced staff about monitoring the 100 hall exit door. On 7/30/16 at 10:46 a.m. the SSA validated that the 100 hall exit door was repaired and fully functioning. A Credible Allegation of Compliance (AoC) was received on 08/02/16 at 9:56 a.m. However, the facility failed to complete elopement drills as outlined in their AoC, and the ED was notified at exit on 08/05/16 that the IJ would be on-going until the SSA validated that all interventions were completed in the AoC including the elopement drills as indicated in the facility's AoC. On 08/03/16 at 11:30 a.m., the ED and Corporate Area Vice President (VP) were notified that IJ existed. It was determined that the IJ was identified to exist on 4/6/16 related to resident N who was admitted to the facility on [DATE] after a hospital stay from home for a urinary tract infection, history of falls, who ambulated with a walker, with impaired cognition. The resident was discharged from the hospital to the facility with fluid filled blisters on bilateral heels and a reddened sacral area. The facility failed to develop an interim care plan to address the pressure ulcers. The resident was found unresponsive on 5/27/16 and transferred to the hospital in septic shock. Review of the Hospital Discharge Summary signed on 6/1/16 revealed the Final [DIAGNOSES REDACTED]. Review of the Georgia Death Certificate revealed the immediate cause of death for Res N was Septic shock secondary to decubitus. A Credible Allegation of Compliance was received on 08/04/16 at 5:40 p.m., was not acceptable, the ED was notified during the exit meeting that the IJ's would be ongoing. Therefore the IJ was identified to exist on 4/6/16 and remains on-going. Findings include: 1. During interview with Licensed Practical Nurse (LPN) Treatment Nurse UU on 08/01/16 at 1:28 p.m., she stated that there was a transition period when she was the only treatment nurse in the facility for about six (6) weeks. She stated that she was doing the best that she could to manage the wounds, but that she was the only one and some things may have fallen between the cracks. She stated that the previous Executive Director (ED) was aware that they were down to one treatment nurse, and during this transition time interviews were being conducted for a new treatment nurse to help with treatments. During further interview with Treatment Nurse UU at this time, she stated that she started as a treatment nurse in January of 2016. During interview with the DNS on 07/30/16 at 4:00 p.m., she stated that if a treatment nurse was not available, the charge nurses assigned to that resident were responsible for doing their own dressing changes. During interview with the DNS on 08/04/16 at 10:54 a.m., she stated that a previous treatment nurse told the (previous) ED that she was having a hard time keeping up with all of the treatments, but didn't remember exactly when this was. Upon further interview, the DNS stated that she had told the (previous) ED not to admit so many residents with wounds as there was only one treatment nurse, but she didn't remember the exact date when this was. The DNS further stated that LPN Treatment Nurse UU had expressed her concerns to the previous ED a couple times that she was having trouble keeping up with all of the treatments, too. During interview with LPN Treatment Nurse UU on 08/05/16 at 8:12 a.m., she stated that starting on 05/07/16, she was the only treatment nurse in the facility except for the previous treatment nurse who had begun working prn (as needed), mostly on the weekends. She further stated that the other current LPN Treatment Nurse CC started working at the facility the second week in June, but did not actually start to assist her with treatments until the week after that. LPN UU stated that she did wounds by herself for about six (6) weeks, with only occasional assistance from a nurse, if there was an extra one, who would help turn and position the resident during wound care. LPN UU further stated that she did not know why there was so many blanks on the Treatment Administration Records (TAR) for wound care. During interview with LPN UU on 08/05/16 at 10:54 a.m., she stated that she told the previous ED the second week that she was by herself that she was having a hard time keeping up with the treatments. She added that when she would tell the ED or DNS that she was having a hard time with keeping up, they would say we're working on it. Review of the facility treatment nurses' time-clock records revealed that for the 61 days in May and June, there was only one treatment nurse scheduled for 43 of these days. During interview with the ED on 08/05/16 at 12:04 p.m., she stated that she did not know why there was a lot of problems with pressure ulcers, but in her opinion it was because there had been such a large amount of turnover in clinical staff. Nine residents N, T, R, R #84, R #24, R #50, R #64, R #120, R #180, did not have treatments completed per the physicians order, staged, sized or measure to monitor the progress or lack of progress, preventive pressure devices implemented, care plans initiated, implemented and/or revised. Cross-refer to F 157, F 224, F 281, F 282, F 314, F 490, F 520. 2. Review of the clinical record for R#170 revealed that they were admitted to the facility on [DATE]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] noted that the resident had severe cognitive impairment, wandering occurred one to three days which placed the resident at significant risk of getting to a potentially dangerous place, and significantly intruded on the privacy of activities of others. Review of a Clinical Health Status assessment dated [DATE] noted that the resident had a history of [REDACTED]. Review of R #170's Immediate Plans of Care dated 07/15/16 revealed that one had not been developed for elopement. Review of computerized Progress Notes revealed a Situation-Background-Assessment-Response (SBAR) Change of Condition entry dated 07/20/16 at 12:02 a.m. that noted that R #170 was seen ambulating in the road off facility premises and was not injured upon assessment. During interview with LPN Unit Manager HH on 07/28/16 at 2:28 p.m., she stated that she was not there when R #170 eloped, but it was her understanding that he went out the back door at the end of the 200-hall. During interview with the DNS on 07/28/16 at 3:10 p.m., she stated that she did not know how the resident got out unwitnessed, and it was possibly through a side door in the resident lounge by the west wing nursing station. During interview on 07/28/16 at 7:03 p.m., the DNS stated that the nurse that did the admission assessment would be the one to apply a wanderguard for a resident assessed as an elopement risk, and she did not know why this was not done for R #170. During interview with LPN QQQ on 07/29/16 at 8:22 a.m., she stated that she was working evenings the day that R #170 left the building, but that she did not see how he got out, and assumed it was through the exit door at the end of the 200-hall as that was close to his room. She further stated that she never heard an alarm go off. During interview with Certified Nursing Assistant (CNA) RRR on 07/29/16 at 9:03 a.m., she stated that the evening that R #170 got outside was the first time she had ever worked with him, and she was not told to do any special monitoring for him. She further stated that the resident must have gone out at the end of the 200-hall door, as that was the last area she saw him right before he was found outside, but that she did not hear an alarm go off. Further interview with both LPN QQQ and CNA RRR revealed that it was a visitor who told them that a resident had gotten outside. Cross-refer to F 323. 3. Review of the facility Grievance Tracking Log from February 2016 through July of 2016 revealed the following concerns related to assistance with Activities of Daily Living (ADL) care: On 02/02/16: R #73 stated that an unsampled resident was not being assisted to eat as the resident was blind, and R #73 had to feed him. On 03/13/16: A family member notified a nurse that an unsampled resident needed to go to the restroom, the nurse went to tell a CNA, the family waited over ten (10) minutes and took the resident to the restroom herself, and the resident urinated all over the bathroom. On 03/13/16: R #89 stated she was told she wouldn't be getting up that day because they were short-staffed that evening and it would be hard to put her back to bed. On 03/14/16: Family member of an unsampled resident voiced the resident had on the same clothes for six (6) days, and had not had a bath. On 03/22/16: A family member of an unsampled resident stated she asked a CNA how often they changed the resident, and was told when I have time, whenever we have time, but the CNA was seen sitting down eating popcorn. On 03/25/16: A family member of R #93 voiced that when she visited on the 3:00 p.m. to 11:00 p.m. shift, the resident was not clean and she had to shower her herself. On 03/26/16: An unsampled resident stated he had requested assistance with care over one (1) hour ago, staff informed him she would return but never did. On 04/02/16: An unsampled resident stated that she put her call light on around 3:30 a.m. on Saturday to request a pain pill, but did not get it until 6:00 a.m. She stated that she had told two (2) CNAs. Review of the facility response was that the CNA was unaware that she had been assigned to this resident, as no assignment had been made. On 04/04/16: An unsampled resident voiced she had to wait a long time for assistance on the 11:00 p.m. to 7:00 a.m. shift, and that on 04/03/16 a CNA had left her wet and never came in to change her. On 04/07/16: An unsampled resident said that a CNA on 04/06/16 told him to get up and get water himself, and didn't want to assist him with his bath. On 04/07/16: An unsampled resident said she had her call light on last evening for over two (2) hours, and when the CNA came they told her that they had other residents to help too and that's what took them so long. On 04/13/16: A family member of an unsampled resident stated that every Sunday afternoon when they visited, the resident was very wet and needed changing. On 04/16/16: A family member of R #35 stated the resident was not getting his showers twice a week, and his scalp had dried dandruff and she had to wash his face when she visited. On 04/21/16: R #50 stated that she had to wait hours for assistance, and could not get taken care of. On 04/22/16: A family member of R #138 stated that the resident was soaked with urine as well as the bed sheets, and that the resident's breakfast tray was left unattended so the family member had to feed them. On 04/28/16: A family member of R #113 stated that the resident was not getting her showers, call light was on for ten (10) minutes and staff never answered the call light. 05/03/16: An unsampled resident said the second shift was leaving her wet; R #73 stated that he was left wet during breakfast until after 9:00 a.m., and; An unsampled resident said he hadn't received a shower. On 05/09/16: A family member of an unsampled resident said the resident was not getting changed properly, being left wet, their clothing was not getting changed, and they were not being turned. On 05/12/16: R #172 stated when they asked to be changed they indicated that they were a Physical Therapist so they could get a quicker response, otherwise if the resident identified that it was him requesting assistance he to wait or would be told they would come back then they won't come back. On 05/12/16: An unsampled resident said a nurse was supposed to change his dressing, but didn't return for four to five hours. On 05/23/16: An unsampled resident voiced concerns of another unsampled resident not being assisted by staff in feeding him his meals. On 06/06/16: A family member of R #93 voiced concerns that the resident wasn't being fed in a timely manner, that the food was being left on the cart. They stated that on the second shift that day (a Sunday) around 7:00 p.m. that the resident's tray was still on the cart and the CNAs were picking up trays from down the hall, and the CNAs told the visitor that they were real busy and short-staffed. The visitor stated this was not the first time this had happened. On 06/15/16: A family member of R #138 stated that the resident was left in urine from 7:00 p.m. until 4:30 a.m. On 06/15/16: An unsampled resident stated he was not being gotten ready for [MEDICAL TREATMENT], had not gotten a bath and no snack to go with him, and transportation had to wait for him to get dressed. On 07/04/16: A family member of R #138 stated that the resident's feeding tube was never hooked up from 1:20 to 4:10, and when they pressed the call light for assistance to go to the restroom it was 36 minutes before anyone came to help. They stated the same thing happened over the weekend, and; A family member of an unsampled resident said the resident was soaked and covered in food on the 3:00 to 11:00 p.m. shift. On 07/11/16: An unsampled resident said it took some time for a staff member to come and help her. On 07/16/16: A family member of resident #199 said that the resident was not getting up to the wheelchair. On 07/20/16: An unsampled resident stated that they needed to be changed and was told from a 3:00 p.m. to 11:00 p.m. CNA that they didn't change residents when they were passing out trays, and gave them the wipes so they could change themselves, and the 11:00 p.m. to 7:00 a.m. shift had to clean them up. Review of Resident Council Department Response Forms for concerns related to ADL assistance from November of 2015 to July of 2016 included the following: On 11/03/15: The 3:00 p.m. to 11:00 p.m. CNAs are leaving residents wet too long. On 01/05/16: Not enough CNAs for all the building on all three shifts. Over-working the ones here, CNAs leaving, only three CNAs on the second shift on 01/04/16. The facility's response was that they were constantly taking actions to ensure the 3:00 p.m. to 11:00 p.m. shift was fully staffed. We are asking the 7:00 a.m. to 3:00 p.m. CNAs to stay over and work. We are planning a job fair on 02/04/16. On 03/01/16: Call lights not being answered in a timely manner. Cross-refer to F 312. 4. Review of the Punch Detail History staffing sheet from December 2015 and January 2016 revealed there was no evidence of Registered Nurse (RN) coverage on 12/19/15, 12/31/15, and 01/3/16. This was verified during interview with the Business Office Manager on 07/29/16 at 9:20 a.m.

Based on record review and staff interview, the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that identified, developed, and implemented corrective action plans for residents with pressure ulcers. The QAA committee also failed to identify that their established policy for Skin Integrity Guidelines was not being fully operationalized, and therefore failed to implement corrective actions to address the problems. In addition, the QAA committee failed to ensure that concerns with pressure ulcers identified during the Standard survey on 07/25/13 continued to be effectively monitored to prevent recurrence. The facility census was one hundred and one (101) residents, and the sample size was fifty-one (51) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 07/29/16 at 1:35 p.m., the Executive Director (ED), Director of Nursing Services (DNS), and Corporate Registered Nurse (RN) Field Services Clinical Director were notified that Immediate Jeopardy (IJ) existed as of 07/15/16 related to R #170, who was assessed during admission on 07/15/16 to be an elopement risk. However, the facility failed to implement effective interventions, failed to sufficiently supervise the resident, and failed to develop an immediate care plan to address the risk for elopement. R #170 eloped from the facility four (4) days after admission on 07/19/16, and was found off facility grounds after crossing four (4) lanes of automotive traffic with a median dividing the two (2) lanes of traffic. In addition, the resident crossed through the facility parking lot, onto the road, which led into a Medical Office Complex. Additional IJ noncompliance was identified on 7/28/16 at 4:37 p.m., when during observation of the exit door at the end of the 100 hall, it did not sound an alarm to alert staff that the door was opened. On 7/28/16 at 7:29 p.m., the facility implemented immediate action to ensure that unsupervised exit did not occur with a staff member assigned to sit at the door and provide continuous monitoring of the 100 hall door. The facility also in-serviced staff about monitoring the 100 hall exit door. On 7/30/16 at 10:46 a.m. the SSA validated that the 100 hall exit door was repaired and fully functioning. A Credible Allegation of Compliance (AoC) was received on 08/02/16 at 9:56 a.m. However, the facility failed to complete elopement drills as outlined in their AoC, and the ED was notified at exit on 08/05/16 that the IJ would be on-going until the SSA validated that all interventions were completed in the AoC including the elopement drills as indicated in the facility's AoC. On 08/03/16 at 11:30 a.m., the ED and Corporate Area Vice President (VP) were notified that IJ existed. It was determined that the IJ was identified to exist on 4/6/16 related to resident N who was admitted to the facility on [DATE] after a hospital stay from home for a urinary tract infection, history of falls, who ambulated with a walker, with impaired cognition. The resident was discharged from the hospital to the facility with fluid filled blisters on bilateral heels and a reddened sacral area. The facility failed to develop an interim care plan to address the pressure ulcers. The resident was found unresponsive on 5/27/16 and transferred to the hospital in septic shock. Review of the Hospital Discharge Summary signed on 6/1/16 revealed the Final [DIAGNOSES REDACTED]. Review of the Georgia Death Certificate revealed the immediate cause of death for Res N was Septic shock secondary to decubitus. A Credible Allegation of Compliance was received on 08/04/16 at 5:40 p.m., was not acceptable, the ED was notified during the exit meeting that the IJs would be ongoing. Therefore the IJ was identified to exist on 4/6/16 and remains on-going. Findings include: During an interview with the Director of Nursing Services (DNS) on 08/04/16 at 10:54 a.m., she stated that they had not identified an issue with missing treatments. During an interview with the Licensed Practical Nurse (LPN) Treatment Nurse UU on 08/05/16 at 8:12 a.m., she stated that she did not know why there was so many blanks on the Treatment Administration Records (TAR) for wound care. During an interview with LPN UU on 08/05/16 at 10:54 a.m., she stated that she told the previous ED, the second week that she was by herself as the only treatment nurse, that she was having a hard time keeping up with the treatments. Of the eleven residents reviewed by the survey team for pressure ulcers, nine of these residents (N, T, R, R#84, R#24, R#50, R#64, R#120, R#180) were identified to have concerns related to treatments not consistently documented as completed per Physician order. Review of the federal citation F 314 written during the facility's standard survey on 07/25/13, revealed that the facility failed to consistently document the appearance of a pressure ulcer for one resident, failed to consistently provide wound measurements and a clear description of a heel wound; failed to clarify an order from a Wound Clinic for treatment to heal wounds; and failed to follow the order for treatment to the right heel wound for one resident. During the standard survey with exit date of 08/05/16, the survey team identified concerns in multiple areas of pressure ulcer care for nine (9) residents (N, T, R, R#84, R#24, R#50, R#64, R#120, R#180). This included failure to consistently complete weekly skin and/or wound assessments; failure to report wounds present on admission delaying treatment; failure to perform wound care as ordered; failure to obtain an order for [REDACTED]. During an interview with the ED on 08/05/16 at 12:04 p.m., she stated that pressure ulcers were a standard item that the facility monitored and discussed in QAPI (Quality Assurance Performance Improvement) meetings since at least June of 2015, per her review of the QAPI meeting minutes. Upon further interview, she stated that she saw that a Performance Improvement Plan (PIP) for skin assessments and wounds had been initiated in January 2016 after noting an increase in acquired pressure ulcers. During further interview, she stated that she did not know why there was still a lot of problems with pressure ulcers, but in her opinion it was because there had been such a large amount of turnover in the clinical staff. A post survey telephone interview on 08/22/16 at 2:32 p.m. with the former administrator revealed that, he stated that he left employment at GLC Windermere at the end of July. He stated that to his knowledge the facility did not have any major issues with wound care. He stated that they had two wound care nurses, and that the Director of Clinical Consultant and the Director of Nursing Services (DNS) reviewed all clinical data and focused on wound care, and they did not notify him that they had any concerns with wounds. He stated that under his leadership, they hired two full-time wound care nurses. He stated that to his knowledge, there were no concerns identified through their QAPI (Quality Assessment/Performance Improvement) committee related to wound care treatments, sufficient staffing, or documentation. He stated that he was made aware of a increase in facility-acquired wounds at one time, but that the numbers would fluctuate. He stated that the DNS would develop a PIP (Performance Improvement Plan) as needed to address an increase in wounds, and that they used a company benchmark of 98% for an acceptable rate of acquired pressure ulcers. He stated that although the rate did increase, it was nothing that alarmed him, and the rate of acquired wounds would go up and down. He stated that nothing was brought to his attention by the DNS or Director of Clinical Consultant of any concerns with wound care and/or documentation of wound care. He stated that if an issue was identified, an ad hoc QAPI would be done by the DNS if it was not time for the scheduled QAPI meeting. He stated that he started working at the facility in 2014, and during their standard survey in 2015 they had no clinical issues cited. He stated that to his knowledge, the concerns with pressure ulcers cited during the standard survey in 2013 was not kept in QAPI. He stated that acquired wounds were discussed in the monthly QAPI meetings. He stated that PIPs had been developed recently for several months to address acquired pressure ulcers, and to address the weekly skin assessments (that the charge nurses did) not always being done or not done correctly. He stated that their focus for this was for the clinical managers to do random skin assessments to make sure that the charge nurses were identifying wounds. Review of the facility's Skin Integrity Guideline revealed that the DNS or designee will be responsible to implement and monitor the skin integrity program. Tracking and analysis of pressure ulcer trends is completed monthly through the QAPI Committee. Identification of trends and/or opportunities for improvement with skin integrity system reviewed and discussed with action items and/or formal PIP implemented. Cross-refer to F 157, F 224, F 281, F 282, F 314, F 353, F 490.

Based on observation, review of the facility job descriptions, corporate, wound clinic, and facility staff interviews, the facility failed to be administered in a manner to provide sufficient oversight of the skin and wound program, to ensure that residents with the risk for, or actual pressure ulcers, and other skin concerns received the necessary care and services to prevent and/or promote healing of wounds, and failed to provide adequate training of two (2) newly-hired treatment nurses. Concerns were identified with pressure ulcer care for nine (9) residents (N, T, R, R #84, R #24, R #50, R #64, R #120, R #180) of the eleven (11) residents reviewed for pressure ulcers. The sample size was fifty-one (51) residents, the census was one-hundred and one (101). The non-compliance included the failure to report and obtain orders for wounds present on admission and readmission to the facility for resident N, which delayed treatment, the wounds deteriorated, and the resident developed septic shock and expired on [DATE]. The non-compliance also included failure to implement interventions in place to prevent the recurrence of a sacral wound for one (1) resident T, and also failed to implement treatment to the wound in a timely manner for this resident, whose Stage II pressure sore deteriorated to a Stage III pressure sore with a yellow-green wound bed. In addition, the facility's failure to provide treatments as ordered contributed to the deterioration of a wound for resident R per wound clinic staff interview. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On [DATE] at 1:35 p.m., the Executive Director (ED), Director of Nursing Services (DNS), and Corporate Registered Nurse (RN) Field Services Clinical Director were notified that Immediate Jeopardy (IJ) existed as of [DATE] was related to R #170, who was assessed during admission on [DATE] to be an elopement risk. However, the facility failed to implement effective interventions, failed to sufficiently supervise the resident, and failed to develop an immediate care plan to address the risk for elopement. R #170 eloped from the facility four (4) days after admission on [DATE], and was found off facility grounds after crossing four (4) lanes of automotive traffic with a median dividing the two (2) lanes of traffic. In addition, the resident crossed through the facility parking lot, onto the road, which led into a Medical Office Complex. Additional IJ noncompliance was identified on [DATE] at 4:37 p.m., when during observation of the exit door at the end of the 100 hall, it did not sound an alarm to alert staff that the door was opened. On [DATE] at 7:29 p.m., the facility implemented immediate action to ensure that unsupervised exit did not occur with a staff member assigned to sit at the door and provide continuous monitoring of the 100 hall door. The facility also in-serviced staff about monitoring the 100 hall exit door. On [DATE] at 10:46 a.m. the SSA validated that the 100 hall exit door was repaired and fully functioning. A Credible Allegation of Compliance (AoC) was received on [DATE] at 9:56 a.m. However, the facility failed to complete elopement drills as outlined in their AoC, and the ED was notified at exit on [DATE] that the IJ would be on-going until the SSA validated that all interventions were completed in the AoC including the elopement drills as indicated in the facility's AoC. On [DATE] at 11:30 a.m., the ED and Corporate Area Vice President (VP) were notified that IJ existed. It was determined that the IJ was identified to exist on [DATE] related to resident N who was admitted to the facility on [DATE] after a hospital stay from home for a urinary tract infection, history of falls, who ambulated with a walker, with impaired cognition. The resident was discharged from the hospital to the facility with fluid filled blisters on bilateral heels and a reddened sacral area. The facility failed to develop an interim care plan to address the pressure ulcers. The resident was found unresponsive on [DATE] and transferred to the hospital in septic shock. Review of the Hospital Discharge Summary signed on [DATE] revealed the Final [DIAGNOSES REDACTED]. Review of the Georgia Death Certificate revealed the immediate cause of death for Res N was Septic shock secondary to decubitus. A Credible Allegation of Compliance was received on [DATE] at 5:40 p.m., was not acceptable, the ED was notified during the exit meeting that the IJ's would be ongoing. Therefore the IJ was identified to exist on [DATE] and remains on-going. Findings include: Interview with LPN Treatment Nurse UU on [DATE] at 1:28 p.m., she stated that this was a transition period where she was the only treatment nurse in the facility for about six weeks. During further interview, she stated that she was doing the best that she could to manage the wounds, but that she was the only one and some things may have fallen between the cracks. Interview with Licensed Practical Nurse (LPN) Treatment Nurse UU on [DATE] at 8:12 a.m., she stated that she did not know why there was so many blanks on the Treatment Administration Records (TAR) for wound care. Interview with the DNS on [DATE] at 8:00 a.m. revealed that she was not aware that resident R had maggots in his wound on [DATE]. Interview with the Director of Nursing Services (DNS) on [DATE] at 10:54 a.m., she stated that they had not identified an issue with missing skin/wound care treatments. The DNS stated that the tool that they used to detect blanks in the documentation on the TARs stopped working about six or seven months ago, and so for the past three months she has had the ADNS check each residents TAR for incomplete documentation, but that they had not identified an issue with the missing treatments. During further interview she stated that a previous treatment nurse, who resigned on [DATE], had told the previous Executive Director (ED) that she was having a hard time keeping up with all of the treatments, and the DNS said she had asked the (previous) ED not to admit so many residents with wounds as they had only one treatment nurse. The DNS added that she was aware that LPN Treatment Nurse UU had expressed her concerns to the ED a couple of times about having trouble keeping up with all of the treatments, too. During interview with LPN UU on [DATE] at 10:54 a.m., she stated that she told the previous ED the second week that she was by herself as the only treatment nurse that she was having a hard time keeping up with the treatments. Interview with the DNS on [DATE] at 11:10 a.m. revealed the facility had a full time treatment nurse and a part time treatment nurse from [DATE] to [DATE], at which time the part time nurse resigned. Continued interview revealed that the full time treatment nurse provided treatments by herself from [DATE] until LPN Treatment Nurse UU was hired to assist with treatments a couple of days a week. Further interview with the DNS revealed that the full time treatment nurse became a part time employee on [DATE], at which time Treatment Nurse UU had the responsibility of providing treatments on her own most days. Further interview revealed that UU stated that she was drowning during that time, and the facility hired Treatment Nurse CC on [DATE]. Interview with Corporate Medical Director III on [DATE] at 1:20 p.m., she stated that two (2) of the corporate staff working with her conducted skin assessments for all the residents not already identified with skin issues by facility staff. They identified eleven (11) additional residents with some type of skin issues, such as dry skin, yeast, unidentified dressings for R #43 (unidentified as the resident was not on the current list of residents with wounds), skin tear, skin damage from scratching, rash, and moisture associated skin damage. She further stated that three (3) of these eleven (11) residents (#3, #55, and an unsampled resident) had possible Stage II pressure ulcers. During interview with Corporate Registered Nurse (RN) LLL at this time, she stated that she showed these skin concerns to the facility's treatment nurse, and the treatment nurse was not aware of and was currently not providing treatment for [REDACTED]. Interview with Corporate Medical Director III on [DATE] at 1:40 p.m. revealed that the right lateral heel wound was a venous stasis ulcer with a pressure component but, the other wounds were venous stasis ulcers. Continued interview revealed that resident R had bilateral [MEDICAL CONDITION]. When asked about the maggots in the wound, III stated that the resident's dressing may have come off for a brief period or loosened which allowed a fly to lay eggs in the wound. Continued interview revealed that it would take 3 to 5 days for the maggots to develop. Further interview revealed that someone from the corporate office had incorrectly told staff that vascular wounds did not need to be measured or assessed. Post survey interview conducted on [DATE] at 2:32 p.m. with the facility ' s previous Administrator revealed that to his knowledge the facility did not have any major issues with wound care. He stated that to his knowledge there no concerns identified through QAPI (Quality Assessment/Performance Improvement) committee related to wound care treatments, sufficient staffing, or documentation. He stated that he was made aware of an increase in the facility-acquired wounds at one time, but that the numbers would fluctuate. He stated that although the rate did increase, it was nothing that alarmed him and the rate of acquired wounds would go up and down. He stated that nothing was brought to his attention by the DNS or the Director of Clinical Consultant of any concerns with wound care and / or documentation of wound care. The previous Administrator went on to say that he was never told that any staff was going to resign because they were having a hard time keeping up with their workload. He stated that the DNS never told him to stop admitting resident with wounds because they were having trouble keeping up. He state that if a resident was to be admitted to the facility that had wounds, the DNS was supposed to look at the wound packet to make sure that they could take care of the resident. He stated that if her recommendation was that they could not take of that resident, then ten out of ten times he would not object. Cross-refer to F 157, F 224, F 281, F 282, F 314, F 353, F 520.

Based on observations, record review, and resident and staff interviews, the facility failed to ensure that the medical records were accurate for five (5) residents (R #42, R, R#120, R#180, and R#24) and that the medical records was complete for one (1) resident (R#138). The sample size was fifty-one (51) residents, the census was one-hundred and one (101). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 07/29/16 at 1:35 p.m., the Executive Director (ED), Director of Nursing Services (DNS), and Corporate Registered Nurse (RN) Field Services Clinical Director were notified that Immediate Jeopardy (IJ) existed as of 07/15/16 related to R #170, who was assessed during admission on 07/15/16 to be an elopement risk. However, the facility failed to implement effective interventions, failed to sufficiently supervise the resident, and failed to develop an immediate care plan to address the risk for elopement. R #170 eloped from the facility four (4) days after admission on 07/19/16, and was found off facility grounds after crossing four (4) lanes of automotive traffic with a median dividing the two (2) lanes of traffic. In addition, the resident crossed through the facility parking lot, onto the road, which led into a Medical Office Complex. Additional IJ noncompliance was identified on 7/28/16 at 4:37 p.m., when during observation of the exit door at the end of the 100 hall, it did not sound an alarm to alert staff that the door was opened. On 7/28/16 at 7:29 p.m., the facility implemented immediate action to ensure that unsupervised exit did not occur with a staff member assigned to sit at the door and provide continuous monitoring of the 100 hall door. The facility also in-serviced staff about monitoring the 100 hall exit door. On 7/30/16 at 10:46 a.m. the SSA validated that the 100 hall exit door was repaired and fully functioning. A Credible Allegation of Compliance (AoC) was received on 08/02/16 at 9:56 a.m. However, the facility failed to complete elopement drills as outlined in their AoC, and the ED was notified at exit on 08/05/16 that the IJ would be on-going until the SSA validated that all interventions were completed in the AoC including the elopement drills as indicated in the facility's AoC. On 08/03/16 at 11:30 a.m., the ED and Corporate Area Vice President (VP) were notified that IJ existed. It was determined that the IJ was identified to exist on 4/6/16 related to resident N who was admitted to the facility on [DATE] after a hospital stay from home for a urinary tract infection, history of falls, who ambulated with a walker, with impaired cognition. The resident was discharged from the hospital to the facility with fluid filled blisters on bilateral heels and a reddened sacral area. The facility failed to develop an interim care plan to address the pressure ulcers. The resident was found unresponsive on 5/27/16 and transferred to the hospital in septic shock. Review of the Hospital Discharge Summary signed on 6/1/16 revealed the Final [DIAGNOSES REDACTED]. Review of the Georgia Death Certificate revealed the immediate cause of death for Res N was Septic shock secondary to decubitus. A Credible Allegation of Compliance was received on 08/04/16 at 5:40 p.m., was not acceptable, the ED was notified during the exit meeting that the IJ's would be ongoing. Therefore the IJ was identified to exist on 4/6/16 and remains on-going. The facility's failure to report and obtain orders for wounds present on admission and readmission to the facility for resident N delayed treatment and the wounds deteriorated, and the resident developed septic shock. In addition, the facility failed to implement interventions to prevent the recurrence of a sacral wound for resident T, and did not implement treatment to the wound in a timely manner for the resident, and the Stage II pressure sore deteriorated to a Stage III pressure sore with yellow-green wound bed. In addition, the facility's failure to provide treatments as ordered possibly contributed to the deterioration of a wound for resident R per wound clinic staff interview. Findings include: 1. Observation on 8/3/16 at 8:40 a.m. revealed R #42 was observed not to eat her breakfast. Licensed Practical Nurse (LPN) QQQ was informed that the resident refused to eat her breakfast however, record review of the report titled, Resident Meals by Day revealed that the Certified Nursing Assistant (CNA) GGG charted that R #42 had eaten one hundred (100) percent (%) of her breakfast. Interview on 8/3/16 at 10:30 a.m. with CNA GGG revealed they had documented the R #42's percentage of breakfast eaten in error. Observation on 8/3/16 at 10:35 a.m. revealed CNA GGG going to the Kiosk to change the percentage of breakfast eaten by R#42. CNA GGG then learned that she was not able to make a correction to the percentage of food that R #42 had eaten. The Clinical Consultant, revealed that he/she would have to make the change in the percentage eaten on the meal report. 2. Review of the closed record revealed R #138 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the computerized charting program Census in Point Click Care (PCC) revealed that R #138 was transported to a local hospital on [DATE]. However, there was no evidence of a Situation-Background-Assessment-Recommendation (SBAR) noted for this resident prior to the resident being discharged from the facility to the local hospital. Further record review revealed that there were no nursing notes documenting the transfer of the resident to the hospital. Interview on 7/29/16 at 5:00 p.m. with MDS Coordinator OOO revealed that R #138 was admitted to the Long Term Care (LTC) facility on 5/24/16 and then was readmitted to the Long Term Care facility on 6/6/16 confirming that the resident had been transferred from the facility to the hospital. Interview on 7/29/16 at 5:43 p.m. with the Registered Nurse (RN) Assistant Director of Nursing Services (ADNS) confirmed that R #138 was discharged to the hospital but that there was no evidence of documentation that a Situation, Background, Assessment and Response (SBAR) form or any evidence of any nursing notes documenting that the resident had been sent to the hospital. However, according to the facility's census record documented in PCC the residents transferred out of the facility to the hospital on [DATE] at 5:51 p.m. Interview on 07/30/2016 at 12:31 p.m. with the Director of Nursing Services (DNS) stated that her expectation is for the nurse to write an SBAR on any change in a resident's condition. The DNS confirmed the nurse did not complete an SBAR prior to the resident being sent to the hospital. 3. Interview with resident R on 7/26/16 at 2:23 p.m. revealed that he was supposed to have daily dressing changes for wounds to his bilateral feet but, the staff had not changed the dressings since Friday, 7/22/16. On 7/26/16 at 2:40 p.m., Unit Manager HH removed the resident's multipodus boots and revealed that the dressings on the resident's bilateral feet were dated 7/22/16. Review of the physician's orders [REDACTED]. Review of the July 2016 Treatment Administration Record (TAR) revealed that staff had inaccurately documented that the treatment had been provided for the resident's wounds on 7/23/16, 7/24/16 and 7/25/16. Review of the 7/2016 TAR with CC on 7/28/16at 3:45 p.m., revealed that she had documented that she had provided treatment to the resident's pressure sores on 7/25/16, Monday. CC stated that the documentation was incorrect and that she should have documented a 5 with her initial indicating that treatment was not provided due to the resident was out of the facility. CC confirmed that two different LPNs had initialed that they provided treatment on 7/23/16 and7/24/16. CC stated that staff should not have documented that treatment was provided on7/23/16 and 7/24/16 if treatment was not performed Interview with the Director of Nursing Services (DNS) on 7/29/16 at 2:30 p.m. revealed that staff should not have documented that treatments were provided 7/23/16 through 7/25/16 if treatments were not done. 4. Review of the medical record for R# 120 revealed that treatments were done as ordered for 10/2016. Review of the medical record revealed a physician order [REDACTED]. However, staff failed to provide treatment on 11/29/15. Review of the medical record revealed a physician order [REDACTED]. Review of the TARs revealed that staff failed to provide treatment for [REDACTED].On 3/17/16, treatment was changed to apply Dakin's soaked gauze to the left ischial wound twice a day. However, staff failed to provide treatments twice a day on 3/18/16, 3/20/16, 3/21/16, 3/24/16, 3/26/16 and 3/29/16. Although staff documented in the 6/23/16 General note that treatment, Santyl every day, was provided to the sacral wound on 6/23/16, there was no indication that treatment was provided 6/24/16, 6/25/16, 7/9/16 or 7/24/16. Although staff documented that treatment, Dakin's every day was provided to the left gluteal fold (ischium) on 6/23/16, there was no indication that staff provided treatment on 6/24/16, 6/25/16, 7/9/16 or 7/24/16. 5. Review of the wound care order for R#180 to the right buttock dated 06/21/16 noted to cleanse the area with soap and water, apply xeroform with [MEDICATION NAME] pad daily. Review of weekly skin assessments from the original admitted through 07/22/16 revealed that there was no skin assessment done on 05/29/16. Medical record review on 05/26/16: Resident is noted to have two Stage II sacral areas with measurements of 1.8x 2.9 and 1.5 x 1.2 with pink wound bed present. However, there was no evidence of the depth of the wound documented. Medical record review on 05/31/16: Resident noted to have three open areas to the sacrum. Resident is noted to have Stage II. There was no evidence of the depth of the wound documented, and no documentation of the left buttock wound noted on 05/26/16. Continued staging the gluteal fold wound as a Stage II despite slough present. No staging of the gluteal fold wound. Medical record review on 06/07/16: Resident is noted have three open areas to the sacrum. Resident is noted to have a Stage II to top right side of the sacrum with slough present to wound bed, Second open area to sacrum is noted and a third open area is noted to the sacral area. Wounds with slough are staged as a Stage II. There was no evidence of the wound depth documented and no staging of two of the three wounds. Medical record review on 06/14/16: R#180 noted to have three areas to sacrum. Top right side of sacrum with Stage II measuring 2.8 cm x 2.4 cm x 0 cm, slough noted to middle of wound bed, no odor noted. Next wound just below top right side of sacrum Third area to sacrum. However, the description of the location of the wound sites changed from week to week, so unable to tell from the documentation of the wounds if these wounds are the same wounds or if they are different wounds. Continued staging wounds as a Stage II despite there being slough in the wound bed. Medical record review on 06/21/16: Resident is noted have three areas to the sacral area. However, two of the wounds do not have depth documented. Medical record review on 06/28/16: R#180 noted to have Stage II to sacral area. Documentation continues to stage wounds with slough as a Stage II. There is no documentation of what happened to the other two sacral wounds, and if the left buttock wound is new or one of the existing wounds. No depth recorded of the left buttock wound. Medical record review on 07/05/16: R#180 noted to have a wound to sacrum However, there is no staging of the wound, and no mention of the other wounds previously treated. Medical record review on 07/12/16: R#180 noted to have Stage II. However, there is no description of the wound bed other than pink. During interview and record review with LPN Treatment Nurse UU on 08/01/16 at 1:28 p.m., she verified she saw no documentation that these wounds were ever treated before the resident ' s hospitalization on [DATE]. During further interview and record review at this time, Treatment Nurse UU verified that there was no documentation for R #180 that the three Stage II to the buttocks and sacrum identified on readmission on 05/17/16 were treated for [REDACTED]. The treatment nurse verified that in the Wound Care Notes on 05/26/16, that the wounds were described in different locations, but that they were actually the same wounds described in the previous assessment, and that she did not document the depth of the wounds, nor stage and describe the wound bed of the left buttock wound. The treatment nurse LPN UU added that this must have been an oversight, but that she was doing the treatments by herself and doing the best she could. During further interview she stated that she just recently learned that you couldn't stage a wound with slough as a Stage II. She verified that left gluteal fold wound on the 05/31/16 Wound Care Notes had no staging or measurements recorded, and that the three wounds in these notes were described as different locations but were actually the same wounds as previously described. Treatment Nurse LPN UU verified that no depth was documented for any of the wounds on 06/07/16, and on 06/07/16 and 06/14/16, there was no staging for two of the three wounds. She verified that there were no depth measurements for two of the three wounds on 06/21/16. She verified that there was no staging or depth measurements of the left buttock wound on06/28/16. During further interview, she verified that she never documented that the right and left buttock pressure sores had healed. She verified that there was no documentation in the clinical record that she staged the sacral wound on 07/05/16. During continued interview and record review with Treatment LPN UU on 08/01/16 at 1:28p.m., she verified that there was no documentation on the TAR for R #180 that the following treatments were ever completed: In May 2016 at 5:00 p.m. No evidence that treatments were completed on 05/21/16; 05/22/16; and 05/24/16 (the TAR did not specify what wound was being treated).5:00 p.m. No evidence that treatments were completed to the left buttock on 05/25/16, and to the left buttock, right buttock, and sacrum at5:00 p.m. from 05/26/16 through 05/31/16. In addition, there was no evidence that treatments were completed at 9:00 a.m. for any of these three areas on 05/27/16. Continued review revealed for the month of June 2016 there was no evidence that the 5:00 p.m. treatments were completed to the right and left buttocks and sacrum on 06/01/16; 06/03/16; 06/04/16; 06/07/16; 06/08/16; 06/09/16; 06/11/16; 06/12/16; 06/15/16; 06/16/16; and 06/17/16. There was no evidence that treatments were completed to the sacrum on 06/21/16; 06/24/16; and 06/27/16.In July 2016 there was no evidence that treatments were completed to the sacrum and right buttock on 07/06/16; 07/09/16; 07/10/16;07/11/16; and 07/18/16. During interview with Corporate Medical Director III on 08/04/16 at 9:09 a.m., she stated that she was asked to help investigate concerns with wounds at the facility, and her team was finding some of the same issues that the state survey team found as far as assessing and documenting wounds, and the training of the treatment nurses, and stated that wound care at the facility was a mess. Upon further interview, she stated that all wounds should be assessed and measured, even if the resident had a [DIAGNOSES REDACTED]. 6. Interview with the DNS on 7/30/16 at 3:41 p.m. revealed the DNS confirmed that no documentation was available indicating treatments were done for 8/4/15, 8/5/15, 8/7/15, 8/14/15, 9/4/15, 9/5/15, 9/11/15, and 9/14/15. The DNS revealed that no explanation was available for the blanks on the treatment record. Cross-refer to F 157, F 281, F 282, F 314, F 353, F 490, F 520.

Based on observation, record review, and staff interview, it was determined that the facility failed to notify the physician as the resident's status changed as evidenced by failure to obtain physician's orders [REDACTED].#84) and failed to notify the physican of pain for resident T, and the facility failed to notify the Physician that an ordered antibiotic was not administered until two days after it was ordered for one (1) resident (R#28) of the sampled fifty-one (51) residents, the census was one-hundred and one (101). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On [DATE] at 11:30 a.m., the ED and Corporate Area Vice President (VP) were notified that IJ existed. It was determined that the IJ was identified to exist on [DATE] related to resident N who was admitted to the facility on [DATE] after a hospital stay from home for a urinary tract infection, history of falls, who ambulated with a walker, with impaired cognition. The resident was found unresponsive on [DATE] and transferred to the hospital in septic shock. Review of the Hospital Discharge Summary signed on [DATE] revealed the Final [DIAGNOSES REDACTED]. Review of the Georgia Death Certificate revealed the immediate cause of death for Res N was Septic shock secondary to decubitus. A Credible Allegation of Compliance was received on [DATE] at 5:40 p.m., was not acceptable, the ED was notified during the exit meeting that the IJ's would be ongoing. Therefore the IJ was identified to exist on [DATE] and remains on-going. Findings include: 1. Resident N (a closed record review) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Clinical Health Status Admission assessment dated [DATE] revealed a late entry note dated [DATE] on the [DATE] Clinical Health Status Admission Assessment that the resident was admitted with redness on his sacrum and bilateral fluid filled blisters on his bilateral heels. Although staff indicated that the resident actually had blisters on his heels and redness on his sacrum on [DATE], there was no indication that staff notified the physician about the resident's pressure sores or obtained treatment orders on [DATE]. Review of the General Note dated [DATE] revealed that the resident was again assessed on [DATE] with intact bilateral heel blisters and a red sacrum without any open areas. Review of the ,[DATE] Treatment Administration Record (TAR) revealed that staff eventually obtained a treatment order for the bilateral heel wounds on [DATE], six (6) days after admission. However, there was no indication that staff notified the physician about the red sacral area from [DATE] to [DATE] when the resident went to the hospital. Review of the ,[DATE] Treatment Administration Record (TAR) for resident N revealed that although the resident was assessed on admission with pressure sores on the bilateral heels, there was no indication that staff had notified the physician and obtained treatment for [REDACTED]. Furthermore there was no indication that staff notified the physician about the red sacral area in order to obtain and initiate treatment to prevent the red area on the sacrum from deteriorating for ,[DATE]. Review of the SBAR/Change of Condition Note dated [DATE] revealed that resident N was sent to the hospital for chest pain and was diagnosed with [REDACTED]. However, there was no indication that staff notified the physician about the sacral area until [DATE]. Review of the General Note/Wound Care Note dated [DATE] revealed that resident N sacral pressure sore had increased in size and measured 8.0 x 4.5 centimeters (cms.) and had deteriorated as evidenced by necrotic tissue in the wound bed and greenish tissue on the edges of the wound. Review of the General Note dated [DATE] at 1:45 p.m. revealed that the resident was lethargic, had periods of apnea and had a low blood pressure. The resident was transferred to the hospital. Review of the Hospital Discharge Summary dated [DATE] revealed that resident N was admitted with a Stage IV sacral pressure sore that was malodorous and septic shock with blood cultures positive for Corynebacterium and Bacteroides fragilis. Continued review of the Discharge Summary revealed that the resident was not a surgical candidate for debridement of the sacral wound because of the septic shock. Further review revealed that the resident did not respond to treatment and the family placed the resident on Hospice services for comfort measures. Continued review revealed that the final hospital [DIAGNOSES REDACTED]. The resident expired on [DATE]. The resident's Certificate of Death indicated that the immediate cause of death was septic shock and sacral decubitus. Interview with Treatment Nurse UU on [DATE] at 9:55 a.m. revealed that when a resident was admitted or readmitted from the hospital, the treatment nurse assessed the resident and reviewed the Hospital Discharge Summary for treatment orders. If there were no orders, then the treatment nurse notified the physician to obtain treatment orders. Interview with the Assistant Director of Nursing Service (ADNS) on [DATE] at 2:37 p.m. revealed that the physician was not notified of the sacral pressure sore or of changes in conditions related to the pressure ulcers. Staff failed to notify the physician about the sacral redness for resident N on his [DATE] admission and [DATE] readmission in order to obtain and initiate treatment timely to prevent deterioration of the sacral redness. This failure resulted in the resident's hospitalization on [DATE] for septic shock secondary to a Stage IV sacral decubitus and eventual death. Cross-refer to F 314 2. Review of the clinical record for resident T' revealed they were admitted to the facility on [DATE] with a Stage II pressure ulcer to the sacrum and non-blanchable pressure ulcers to both heels. Further review revealed physician orders [REDACTED]. The sacral wound healed on [DATE]. The sacral wound reopened on [DATE] as a Stage II pressure ulcer; however there was no evidence that an order was obtained to treat this Stage II sacral wound until [DATE]. Review of the the care plan for Resident T dated [DATE] revealed that the resident required pain management and monitoring related to his wounds with an intervention to evaluate the characteristics and frequency/pattern of pain and to evaluate the need for routinely scheduled medications rather than as needed (PRN) pain medications. Although resident T was admitted on [DATE] with a Stage II sacral pressure sore, there was no indication that staff obtained and provided treatment for [REDACTED]. Although the sacral pressure sore healed on [DATE] for resident T, on [DATE] the staff identified an open area on the sacrum with a yellow-green wound bed on resident T. There was no indication that the physician was notified of the open area until [DATE] when he ordered [MEDICATION NAME] to be applied every day and to obtain a Wound Care consult. On [DATE], staff assessed the 4.0 x 3.0 x 0 cm. pressure sore with 75% necrotic tissue. Review of the vascular Physicians note dated [DATE] revealed that the resident had peripheral arterial occlusive disease with pressure and ischemic ulcerations of both feet. Continued review revealed that the left foot had dry gangrene. On [DATE] at 2:12 p.m. Licensed Practical Nurse (LPN) Treatment Nurse CC and Treatment Nurse UU he resident yelled when staff approached him to assist him with turning and repositioning in the bed. The resident yelled out whenever staff touched his legs and when staff removed his pravalon boots. During the treatments to the sacrum and right foot the resident yelled Don 't hurt me Oh, Lord Jesus, help me. The resident would continue to watch Treatment Nurse CC provide treatment to his right foot and begin yelling again. As soon as the treatment was completed, the resident stopped yelling. Review of the medical record for the resident revealed a Physicians order dated [DATE] for [MEDICATION NAME] 200 milligrams (mgs.) every day for pain that was scheduled for 9:00 a.m. and an order dated [DATE] for [MEDICATION NAME] 50 mgs. every six (6) hours as needed (PRN) for pain. Interview with LPN Treatment Nurse CC on [DATE] at 12:05 p.m. revealed she had not notified the physician that the [MEDICATION NAME] was not managing the resident's pain during treatment and that his pain management may need to be reevaluated. Cross-refer to F 314 and F 309 3. Review of the clinical record for R#84 revealed that they were admitted to the facility on [DATE] with a Stage IV sacral decubitus. Review of the pressure ulcer documentation from [DATE] to [DATE] revealed that there was increased signs and symptoms of infection, such as increased odor, but the physician was not notified until [DATE]. 4. Interview on [DATE] at 11:55 a.m. with the Director of Nursing Services (DNS) revealed that the physician was never notified that the antibiotic for R #28 was not administered until two days after it was prescribed. Cross-refer to F 314

Based on observation, record review, review of the facility's Elopement Guideline policy, and staff interview, the facility failed to implement preventive measures on admission and provide supervision to prevent an elopement for one (1) resident (R #170), who was identified on admission to be an elopement risk and eloped from the facility four (4) days after admission. In addition, the facility failed to conduct a thorough investigation to determine how R #170 exited the building. Five (5) residents were reviewed for wandering and/or elopement, and the sample size was fifty-one (51) residents, the census was one-hundred and one (101). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 07/29/16 at 1:35 p.m., the Executive Director (ED), Director of Nursing Services (DNS), and Corporate Registered Nurse (RN) Field Services Clinical Director were notified that Immediate Jeopardy (IJ) existed as of 07/15/16 related to R #170, who was assessed during admission on 07/15/16 to be an elopement risk. However, the facility failed to implement effective interventions, failed to sufficiently supervise the resident, and failed to develop an immediate care plan to address the risk for elopement. R #170 eloped from the facility four (4) days after admission on 07/19/16, and was found off facility grounds after crossing four (4) lanes of automotive traffic with a median dividing the two (2) lanes of traffic. In addition, the resident crossed through the facility parking lot, onto the road, which led into a Medical Office Complex. Additional IJ noncompliance was identified on 7/28/16 at 4:37 p.m., when during observation of the exit door at the end of the 100 hall, it did not sound an alarm to alert staff that the door was opened. On 7/28/16 at 7:29 p.m., the facility implemented immediate action to ensure that unsupervised exit did not occur with a staff member assigned to sit at the door and provide continuous monitoring of the 100 hall door. The facility also in-serviced staff about monitoring the 100 hall exit door. On 7/30/16 at 10:46 a.m. the SSA validated that the 100 hall exit door was repaired and fully functioning. A Credible Allegation of Compliance (AoC) was received on 08/02/16 at 9:56 a.m. However, the facility failed to complete elopement drills as outlined in their AoC, and the ED was notified at exit on 08/05/16 that the IJ would be on-going until the SSA validated that all interventions were completed in the AoC including the elopement drills as indicated in the facility's AoC. Findings include: 1. Review of the clinical record for R#170 revealed that they were admitted to the facility on [DATE]. Review of a General Note dated 07/22/16 at 2:33 p.m. indicated that the resident was admitted for rehab in order to progress back home, and that he had some cognitive loss problems and had a potential to wander. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed that the resident had severe cognitive impairment, wandering occurred one to three days which placed the resident at significant risk of getting to a potentially dangerous place, and significantly intruded on the privacy of activities of others. Review of a Clinical Health Status assessment dated [DATE] revealed that R #170 had short- and long-term memory problems, had a history of [REDACTED]. At the bottom of this Risk for Elopement section was that if Yes was marked for the first two items and any of the other items, to consider a prevention plan of care for elopement. Review of Immediate Plan of Care dated 07/15/16 for R#170 revealed that one had not been developed for Elopement as directed in the Risk for Elopement section of the Clinical Health Status form. An Immediate Plan of Care for At Risk for Falls dated 07/15/16 noted that the risk factor of Wandering was not selected. Review of computerized Progress notes revealed a SBAR (Situation-Background-Assessment-Response) Change of Condition entry completed by Licensed Practical Nurse (LPN) QQQ dated 07/20/16 at 12:02 a.m. that noted that R #170 was seen ambulating in the road off facility premises and was not injured upon assessment. Review of a Verification of Investigation report with a Date/Time of Occurrence of 07/19/16 at 6:30 p.m. that was completed by LPN QQQ noted that R #170 was found ambulating outside in the parking lot near the road. Further review of this form revealed that the resident had a history of [REDACTED]. Review of the Provide Summary and Outcome of Investigative Findings section of the form simply noted that the resident had a history of [REDACTED]. Further review of this form revealed that the section of Witnesses: Identify All That May Have Knowledge of Event Prior To, during or after Alleged Event, was left blank. Review of the comprehensive at risk for wandering care plan dated 07/19/16 revealed an intervention for a bed alarm. Review of a comprehensive care plan for risk for elopement related to attempts to leave Living Center and cognitive impairment dated 07/22/16 revealed an intervention to take picture of patient upon admission for identification for updating elopement book. Review of Physician order [REDACTED]. During interview with Certified Nursing Assistant II on 07/28/16 at 9:07 a.m., she stated that R #170 could walk and/or propel his wheelchair without assistance, and that they didn't have to do any special monitoring for him. During interview with LPN AA on 07/28/16 at 9:14 a.m., she stated that she had never known the resident to elope from the building before, but thought she heard that he tried to a while back. Upon further interview, she stated that she did not do any special monitoring for him, and that he would be allowed to go outside with staff or family supervision only. During observation and interview at this time, LPN AA verified that there was no bed alarm on his bed. During an observation on 07/28/16 at 9:03 a.m., no bed alarm was seen on the bed. During interview with LPN Unit Manager HH on 07/28/16 at 2:28 p.m., she stated that she was not there when R #170 eloped, but it was her understanding that he went out the back door at the end of the 200-hall. During further interview, she stated that if you pushed on the door long enough it would open, but then it would alarm. LPN HH further stated that is how the staff knew the resident got out, because the alarm was sounding, and that he was still in the parking lot when he was brought back in. During further interview she stated that the wanderguard bracelet was not placed on him until after he exited the building. LPN Unit Manager HH further stated that when a resident was identified as an elopement risk, they filled out the Elopement Risk Assessment Tool which was kept in a notebook at the nurse's station. Review of this form for R #170 dated 07/22/16 noted the following: He had not been identified as elopement risk on admission. Exhibited wandering in past 90 days. Wandered aimlessly about the facility, exhibited night wandering, increased confusion. Walks alone. The Space for resident's photo section on the Missing Person Report page of the Elopement Risk Assessment Tool was blank. This was verified by LPN HH, who stated that either she or the Assistant Director of Nursing Services (ADNS) initiated completion of these forms, and that there should have been a picture included for R #170. During interview with the DNS on 07/28/16 at 3:10 p.m., she stated that she thought she interviewed CNA RRR after the elopement of R#170, and was told the CNA saw the resident still in the facility parking lot as the CNA drove into the parking lot after a supper break. The DNS further stated that she did not know how the resident got out unwitnessed, and it was possibly through a side door in the resident lounge by the west wing nursing station. During further interview, the DNS stated that she also interviewed the nurse that was on duty the night the resident eloped (LPN QQQ). The DNS further stated that residents were assessed on admission for elopement risk on their Clinical Health Status form, and if found to be an elopement risk a wanderguard was placed at that time, the resident was care planned for elopement, and the resident's information was put in the elopement book. During further interview, the DNS verified that R #170 was assessed as having several factors putting him at risk for elopement, but that a wanderguard was not placed until after he eloped, and stated that it should have been applied once he was assessed as being high risk for elopement on admission. The DNS verified that there was no picture in the elopement book for R #170, and that there should have been. During further interview, the DNS stated that she was unaware of the documentation in the SBAR of R #170 being in the road off facility premises, and thought it may have been documented that way in error as the CNA told her she witnessed him in the facility's parking lot. During interview with the Maintenance Director on 07/28/16 beginning at 4:37 p.m., he stated the only exit doors not locked at all times were the Cafe door, the front entrance door; and the ambulance entrance/resident lounge door that was close to the west wing nurse's station. He further stated that these three doors locked down if a resident with a wanderguard approached one of them. During observation at this time, all exit doors were checked and functioned properly except the exit door at the end of the 100-hall, which opened when pushed on and did not alarm. This was verified during interview with the Maintenance Director, who stated that they checked the exit doors daily, and that it functioned properly yesterday. Review of Door Alarm Daily Logs for March 2016 through July 2016 revealed that the door alarms were checked daily except for Sundays, and the 100-hall exit door was initialed as checked on 07/28/16. During interview on 07/28/16 at 7:29 p.m., the Executive Director (ED), DNS, and Registered Nurse (RN) Field Services Clinical Director PPP were asked to provide documentation of how they would ensure that the exit door at the end of the 100-hall would be monitored to prevent an elopement until such time as it could be fixed, and the facility implemented continuous monitoring at this door and in services for staff about monitoring the 100-hall exit door, this was done until the door was fixed on 07/30/16 at 10:46 a.m. Review of the Door Alarm Daily Log noted that the exit doors were checked on 07/19/16 (the date of the elopement), with no concerns documented. During interview with the DNS on 07/28/16 at 3:10 p.m., she verified that there was no picture of R #170 in the elopement book, and that there should have been. During observation and interview with Certified Nursing Assistant (CNA) MM on 07/30/16 at 3:24 p.m., she verified that there was no bed alarm on the bed. During observation on 08/02/16 at 9:01 a.m., no alarm was seen on the bed. During interview on 07/28/16 at 7:03 p.m., the DNS stated that the nurse that did the admission assessment would be the one to apply a wanderguard for a resident assessed as an elopement risk, and she did not know why this was not done for R #170. During interview with LPN QQQ on 07/29/16 at 8:22 a.m., she stated that she was working evenings the day that R #170 left the building, but that she did not see how he got out, and assumed it was through the exit door at the end of the 200-hall as that was close to his room. She further stated that she never heard an alarm go off, and thought that it was another resident who had told her that there was a resident outside, so she went to investigate. LPN QQQ further stated that she found R #170 by a tree on the hospital campus across the road from the facility, and that he would have had to gone down the steep hill in front of the facility and crossed the two roads and median to get to where he was. She further stated that she and a CNA brought him back to the facility, that he was not injured, and that she applied a wanderguard as soon as she brought him back in. During further interview, LPN QQQ stated that whenever she did a new admission's assessment, if she noted that they were at risk for elopement, she would apply a wanderguard bracelet right away. During interview with CNA RRR on 07/29/16 at 9:03 a.m., she stated that the evening that R #170 got outside was the first time she had ever worked with him, and she was not told to do any special monitoring for him. She further stated that the resident must have gone out at the end of the 200-hall door, as that was the last area she saw him right before he was found outside, but that she did not hear an alarm go off. During further interview, she stated that a family member, whose room looked outside to the parking lot, told her that she saw a resident in pajamas outside in the parking lot. The CNA further stated that when she went outside, she found R #170 in the facility's parking lot, and pointed to a cluster of bushes at the end of an intersection of sidewalks coming both from the 200-hall exit door and the ambulance exit door. During interview with LPN QQQ on 07/29/16 at 9:37 a.m., she stated that she had no doubt where she found R #170, and that he was across the street on the hospital grounds, and that it was CNA RRR who helped her bring the resident back. During interview with RN Clinical Director PPP on 07/29/16 at 9:56 a.m., he stated that they were unable to determine which nurse admitted R #170, as more than one nurse documented on him that day and the Clinical Health Status form was not signed. Upon further interview, he stated that the Unit Manager reviewed the Clinical Health Assessments, and would have also been responsible for ensuring that a wanderguard bracelet been placed on R #170 when he was identified as an elopement risk. During interview and record review with LPN Unit Manager HH on 07/29/16 at 10:04 a.m., she stated that it was the facility's process for the unit manager to review the admission assessment to ensure that everything was completed, and verified her signature was on R #170's Clinical Health Status form. Upon further interview, she stated that she did not recall if she reviewed and/or completed any of the Risk for Elopement section on this form, and that because the resident was assessed as an elopement risk on this form, they should have immediately put a wanderguard bracelet on him. She further stated that she didn't know why this was not done, and that it would have been the responsibility of the admitting nurse or herself. During interview with the DNS on 07/29/16 at 11:02 a.m., she stated that the only investigation documented for R #170's elopement was on the Verification of Investigation form, which she said the nurse on duty completed at the time of the incident and that she then reviewed. The DNS verified that she had no documentation that she reviewed and/or conducted an investigation as to how R #170 eloped. During interview on 07/29/16 at 11:16 a.m., LPN QQQ verified that the documentation on the Verification of Investigation form was hers. During further interview she was asked to clarify her notation on this form of the resident ambulating outside in the parking lot near the road, and stated that he was across the road on the hospital grounds. She verified that the wanderguard was NOT in place until after the elopement. During interview with the RN Clinical Director PPP on 07/29/16 at 11:40 a.m., he stated that staff in services related to the elopement procedure were currently being conducted, and included in the in-service was that whoever identified a resident as being an elopement risk would be responsible for putting a wanderguard bracelet on him/her, and that this was where they went wrong with R #170. On 07/30/16 at 12:44 p.m., R #170 was asked if he could move his wheelchair by himself, and he demonstrated that he could easily self-propel the chair with his feet and without assistance. During observation on 07/30/16 at 3:24 p.m., no alarm was seen on R #170's bed. This was verified during interview with CNA MM at 3:30 p.m., who stated that she knew what a resident's care needs were by looking on the CNA Kardex. Review of R #170's CNA Kardex updated 07/30/16 revealed that he had a wanderguard and was an elopement risk, but did not reflect the comprehensive care plan intervention for a bed alarm. During observation on 08/02/16 at 9:01 a.m., no bed alarm was seen on the bed of R#170. During interview with RN Clinical Director PPP on 08/04/16 at 10:28 a.m., he stated that the DNS and/or charge nurse were supposed to update the CNA's Kardex with any changes. Review of facility's Elopement Guideline included the following: Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision. Upon admission, each resident is reviewed to establish elopement risk using the Clinical Health Status form, and are assessed quarterly and as needed. A specific system has been developed to notify staff that an external door has been opened in an area accessible to residents. Door alarms are tested daily, results are recorded on designated log. The charge nurse or designee shall test resident personal alarms/devices according to the manufacturer's recommendation. Documentation should include: Admission assessment, which may indicate potential to wander or exit living center. Care plan that addresses potential to wander or exit living center and measures taken to prevent wandering/elopement. All attempts to elope, efforts to locate, notification and results of efforts. Bracelet alarm/device is in place and functioning. The ED (Executive Director) shall notify the State agency as necessary by state requirement, family and responsible party. All elopement events will be reviewed, analyzed and summarized by the QAPI (Quality Assurance Performance Improvement) Committee to ensure the appropriate process improvement actions have been taken. All residents identified at risk have a picture in the elopement book. Care plan for elopement in place and interventions individualized and implemented per physical observation. Staff able to verbalize knowledge of elopement procedure. Door alarms are checked and documented in Building Engines. Alarm bracelet function is checked daily and documented.

Based on observation, record review, review of the facility Medication Administration-Preparation and General Guidelines policy and procedure, and staff interviews, the facility failed to administer an antibiotic medication in a timely manner for one (1) resident (#28) with a urinary tract infection [MEDICAL CONDITION]; failed to implement an order for [REDACTED]. The sample size was fifty-one (51) residents, the census was one-hundred and one (101). Although staff identified that resident T exhibited pain during wound care, staff failed to evaluate the need for routinely scheduled pain medication prior to wound treatment. This failure resulted in harm for resident T who exhibited symptoms of pain during wound care on 8/2/16 and 8/3/16 and harm was identified for R #42, who was experiencing shortness of breath and staff had failed to administer an as needed medicine for this. Findings include: 1. Resident T was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the 05/31/16 Quarterly MDS assessment revealed that the resident had a Brief Interview for Mental Status (BIMS) score of six (6) indicating that the resident was cognitively impaired, had almost constant moderate pain, did not reject care and had one Stage III pressure sore and two unstageable pressure sores. Review of the the care plan for Resident T dated 12/12/15 revealed that the resident required pain management and monitoring related to his/her wounds with an intervention to evaluate the characteristics and frequency/pattern of pain and to evaluate the need for routinely scheduled medications rather than as needed (PRN) pain medications. Review of the vascular Physicians note dated 1/20/16 revealed that the resident had peripheral arterial occlusive disease with pressure and ischemic ulcerations of both feet. Continued review revealed that the left foot had dry gangrene. On 08/02/16 at 2:12 p.m. Licensed Practical Nurse (LPN) Treatment Nurse CC and Treatment Nurse UU provided treatments for the residents sacral and right foot wounds. The resident yelled when staff approached him to assist him with turning and repositioning in the bed. The resident refused to allow staff to assist him/her with turning to his/her side but managed to slowly turn himself/herself independently. The resident yelled out whenever staff touched his/her legs and when staff removed his/her pravalon boots. During the treatments to the sacrum and right foot the resident yelled Don 't hurt me Oh, Lord Jesus, help me. During the procedure, LPN Treatment Nurse UU held the hand of the resident and distracted the resident with conversation for brief periods only. However, the resident would continue to watch Treatment Nurse CC provide treatment to his/her right foot and begin yelling again. Treatment Nurse CC stated at that time that the resident had been pre-medicated with pain medication. As soon as the treatment was completed, the resident stopped yelling. Review of the medical record for resident T revealed a Physicians order dated 1/28/16 for [MEDICATION NAME] 200 milligrams (mgs.) every day for pain that was scheduled for 9:00 a.m. and an order dated 3/5/16 for [MEDICATION NAME] 50 mgs. every six (6) hours as needed (PRN) for pain. Review of the 8/2016 Medication Administration Record [REDACTED]. Continued review of the TAR revealed that the as needed (PRN) [MEDICATION NAME] was not administered until 11:17 p.m. that night. There was no indication that staff had pre-medicated the resident with the as needed [MEDICATION NAME] prior to treatment on 8/2/16. Interview with LPN Treatment Nurse CC on 8/3/16 at 12:05 p.m. revealed that resident T yelled out during every treatment, during care and sometimes even when staff just touched him/her. However, continued interview revealed that CC believed the resident felt pain during treatment and that she asked the charge nurse to administer the as needed pain medication to the resident prior to treatment. Further interview revealed that LPN Treatment Nurse UU had informed the charge nurse to pre-medicate the resident with as needed pain medication prior to the treatment performed on 8/2/16. However, interview with LPN Treatment Nurse UU on 8/3/16 at 12:30 p.m. revealed that she thought that LPN Treatment Nurse CC had notified the charge nurse to pre-medicate the resident with pain medication prior to treatment on 8/2/16. Continued interview with UU revealed that she had not notified the physician that the [MEDICATION NAME] was not managing the residents pain during treatment and that his/her pain management may need to be reevaluated. Interview with the Licensed Practical Nurse/Charge Nurse DDD on 8/3/16 at 12:25 p.m. revealed that resident T had pain during any positioning. Continued interview with DDD revealed that she had administered the [MEDICATION NAME] to the resident on 8/2/16 at approximately 9:00 a.m. and the resident did not complain of pain after that time. Further interview revealed that she did not administer as needed [MEDICATION NAME] to the resident on 8/2/16. Continued interview with LPN/Charge Nurse DDD revealed that the LPN Treatment Nurse would notify her when a resident needed to be pre-medicated prior to treatment. Although staff stated that resident T yelled out in pain during wound treatments that were provided daily, review of the 7/2016 MAR indicated [REDACTED] On 8/3/16 at 6:00 p.m., LPN Treatment Nurses CC and UU provided treatment for [REDACTED]. Resident T yelled out when the nurses adjusted his/her gown. When the LPN Treatment Nurse CC obtained scissors to cut and remove the Kerlix from the residents left foot, the resident began to yell Don't cut me, don't cut me!. When LPN Treatment Nurse CC removed the gauze that covered the wounds, the resident said it hurts when you pull it. The LPN Treatment Nurse UU held the residents hand during the treatment and distracted the resident with conversation for brief periods only. Review of the 8/2016 MAR for resident T, revealed that staff had administered the [MEDICATION NAME] to the resident at 9:00 a.m. on 8/3/16. However, there was no indication that staff had administered the as needed [MEDICATION NAME] to the resident prior to treatment at 6:00 p.m., nine (9) hours later. Interview with the DNS on 8/5/16 at 8:00 a.m., revealed that the staff believed that routine pain medication would result in over-sedation for the resident. Continued interview revealed that the resident knew when she/he had pain and could request pain medication. Further interview revealed that the resident yelled out when staff got too close to him/her and he/she thought staff would touch him/her. Continued interview revealed that the DNS believed that the resident did have pain during wound treatment and that staff should have administered the as needed pain medication prior to treatment. Interview with Corporate Medical Director III on 8/5/16 at 1:40 p.m. revealed that they assessed the resident on 8/4/16 as having eleven (11) wounds. Continued interview with III revealed that all wounds on the bilateral feet were arterial wounds except for the bilateral heels which were arterial with a pressure sore component. Further interview revealed that arterial wounds were painful. Review of the facility's Pain Assessment and Management Policy revealed that pain was an unpleasant sensory and emotional experience that could be acute, recurrent or persistent. Different types of pain included Incident Pain which was pain that was predictable and related to a precipitating event such as movement or certain actions, i.e., wound care. Continued review of the policy revealed that the facility would promptly assess the pain level and provide relief of symptoms whenever feasible, using a resident-centered and interdisciplinary approach. Residents would be assessed for pain based on their exhibiting symptoms of pain and pharmacological and non-pharmacological interventions would be initiated. Although the staff identified that resident T exhibited pain during wound care, staff failed to evaluate the need for routinely scheduled pain medication prior to wound treatment as care planned. This failure resulted in harm for resident T who experienced pain during wound care on 8/2/16 and 8/3/16. 2. Review of the clinical record for R #28 revealed she was admitted to the facility on [DATE]. Review of the care plan for Infection- Actual or at Risk For Related to: UTI, developed on 07/27/16, revealed that the resident was at risk for UTIs, and included an intervention to administer the antibiotic as ordered. Review of a urinalysis (UA) and Culture and Sensitivity (C&S) report dated 07/17/16 revealed a positive culture for [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE). Review of a Physician order for [REDACTED]. Review of the July 2016 Medication Administration Record [REDACTED]. Further review of the July MAR indicated [REDACTED]. Review of the policy titled Medication Administration-Preparation and General Guidelines dated 06/15 included the following: If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (e.g., the resident is not in the facility at scheduled dose time, or a starter does of antibiotic is needed), the space provided on the front of the Medication Administration Record [REDACTED]. An explanatory note is entered on the reverse side of the record. If vital medication is withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response. Interview on 07/27/16 at 3:10 p.m. with Registered Nurse (RN) WW revealed she was working on the evening of 07/18/16 and noticed a faxed physicians order for [MEDICATION NAME] 50 mg QID for R #28. RN WW further stated that she transcribed the order to the July MAR, and forwarded the order to the pharmacy in the early morning of 07/19/16. RN WW further stated she never looked in the Automatic Dispensing Unit (ADU) for the medication so that she could administer the first dose, and that she was not aware of the facility policy. Interview on 07/28/16 at 1:22 p.m. with the Hospice RN Case Manager XX revealed that R #28 was treated for [REDACTED]. She further stated that the antibiotic medication should have been started as soon as possible. Interview on 07/30/16 at 11:55 a.m. with the Director of Nursing Services (DNS) revealed the nurses were expected to remove the first dose of an antibiotic from the ADU. She further stated that If the antibiotic ordered by the physician was not available, the nurses were expected to call the pharmacy to obtain the first dose. The DNS further stated that the physician was never notified that the antibiotic for R #28 was not administered until two days after it was prescribed. 3. Record review for R #42 revealed a re-admission to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Further clinical record review revealed that they were admitted to hospice services on 04/20/16. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score of three (3), indicating severe cognitive impairment. Observation of R #42 on 08/03/16 at 10:45 a.m. with a Hospice Registered Nurse (RN) revealed that the resident was short of breath and had audible wheezing. Interview with the Hospice RN at this time revealed that R #42 had an order for [REDACTED].#42 continued to appear to be in distress as evidenced by shortness of breath with audible wheezing, and the resident was unable to verbally communicate her needs. Record review for R #42 revealed a Physician Order from the Hospice provider dated 06/01/16 for [MEDICATION NAME] 20 milligram (mg) per 1 milliliter (mL), give 0.5 mL to 1 mL by mouth every one hour for pain and/or dyspnea. Review of the faxed date on the order form revealed that it was sent on 06/02/16, and was located in the Physician Order section of the chart. However, review of the Medication Administration Record [REDACTED]. Interview on 08/03/16 at 12:00 p.m. with the East Wing RN Unit Manager revealed that she was not aware that the pain medication ([MEDICATION NAME]) for R #42 had not been transcribed on the MAR. During further interview, she was not able to explain why the medication was not faxed to the pharmacy so that the medication could be filled, nor why it hadn't been transcribed to the resident MAR. Observation on 08/03/16 at 1:00 p.m. revealed LPN QQQ administering a medication to R #42 with an oral syringe. During interview with LPN QQQ at this time, she stated that she was administering the [MEDICATION NAME]. Observation on 08/03/16 at 3:00 p.m. revealed R #42 sleeping with no shortness of breath noted. 4. Review of the clinical record for R #32 revealed that she was admitted to the facility on [DATE]. During observation on 08/02/16 at 2:05 p.m., R #32 was noted to have bilateral shoulder, arm, hand and knee contractures, and she was tilted to left side with her legs contracted to the right. During further observation, her fingernails were observed to be long and uneven, with jagged edges, and she was observed scratching her skin. Further observation at this time revealed that she had approximately twenty-five to thirty shallow linear-shaped open areas of skin on her right thigh, which extended up to eight inches in length. During interview with Licensed Practical Nurse (LPN) EE at this time, she stated that the resident had always scratched her skin since admission more than ten years ago, and that the areas of skin affected differed according to whatever area the resident was able to access. She further stated that R #32 had scratched their stomach, right thigh, and chest at different times. LPN EE further stated that when the scratching got bad, the resident was administered anti-[MEDICATION NAME] medications. Review of the care plans for R #32 dated 04/21/16 revealed that care plans had not been for scratching and/or allergies [REDACTED]. During interview with the Director of Nursing Services (DNS) on 08/02/16 at 2:45 p.m., she stated that the scratched areas on right thigh of R #32 should have been noted on a weekly skin assessment, and reported on an SBAR (Situation-Background-Assessment-Recommendation). Review of Weekly Skin Assessments from 05/12/16 through 07/27/16 (eleven weeks total), revealed no evidence of any skin problems. During interview with Certified Nursing Assistant (CNA) OO on 08/03/16 at 12:48 p.m., she stated that R #32 would scratch their skin anytime that it was exposed, and that any scratches or skin changes should be reported to the charge nurse. Review of Physician Orders and the Medication Administration Record [REDACTED]. Review of the facility policy Skin Integrity Guideline revealed that Patient/Resident will be evaluated/observed for risk of skin breakdown and existing areas including but not limited to bruising, skin tears, wounds, abrasions, arterial and venous wounds and pressure ulcers within twenty-four (24) hours of admission, quarterly, and with decline in condition.

Based on clinical record review, Medication Administration Record [REDACTED]#3, #13, and #15) who received Coumadin drug therapy, and failed to ensure that an irregularity related to PT/INR laboratory testing identified in the Consultant Pharmacist's drug regimen review was acted upon for one (1) resident (#10) who received Coumadin drug therapy. A total of nine (9) sampled residents received Coumadin drug therapy on the survey sample of twenty-one (21) residents. This failure resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents, as outlined below: - For Resident #3, the facility failed to ensure that a drug irregularity involving the facility's failure to administer Coumadin anticoagulant drug therapy as ordered was identified in the drug regimen review: Resident #3 was ordered to receive daily Coumadin drug therapy, but facility nursing staff held the resident's ordered Coumadin dose, in error, from 10/28/2014 through 11/02/2014. However, review of the Clinical Pharmacist Medication Regimen Review (CPMRR) Summary for Resident #3 revealed no evidence to indicate that this drug irregularity involving the facility's failure to administer Coumadin drug therapy as ordered was identified in the drug regimen review. - For Resident #13, the facility failed to ensure that a drug irregularity involving the facility's failure to obtain drug-related weekly PT/INR laboratory tests as ordered was identified in the drug regimen review: Resident #13 received Coumadin drug therapy and was ordered to receive weekly PT/INR laboratory tests. However, record review for Resident #13 revealed no evidence to indicate that the resident's ordered weekly PT/INR laboratory tests were done after a laboratory test of 11/26/2014. Record review revealed no evidence to indicate that this irregularity involving the facility's failure to obtain Resident #13's drug-related PT/INR laboratory testing as ordered was identified in the drug regimen review. - For Resident #10, the facility failed to ensure that an irregularity, identified during the drug regimen review, involving the failure to obtain PT/INR laboratory testing as ordered was acted upon: Resident #10 received Coumadin drug therapy, and a physician's orders [REDACTED]. There was, however, no evidence of any PT/INR laboratory tests having been completed for Resident #10 after 11/24/2014. The Consultant Pharmacist identified, via a 12/15/2014 entry in Resident #10's CPMRR Summary report, that the last PT/INR laboratory test, which was ordered weekly, had been completed on 11/24/2014. However, record review for Resident #10 revealed no evidence to indicate that this drug regimen review irregularity involving the facility's failure to obtain PT/INR laboratory tests as ordered, and identified in the 12/15/2014 drug regimen review report, was acted upon. - For Resident #15, the facility failed to ensure that a drug irregularity involving the failure to obtain drug-related weekly PT/INR laboratory tests as ordered was identified in the drug regimen review: Resident #15 received Coumadin drug therapy, and a physician's orders [REDACTED]. However, record review for Resident #15 revealed no evidence to indicate that weekly PT/INR laboratory tests were completed after 11/24/2014. There was also no evidence to indicate that this irregularity involving the facility's failure to obtain Resident #15's drug-related PT/INR laboratory testing as ordered was identified in the drug regimen review. As outlined above, the facility's failure to obtain PT/INR laboratory tests as ordered and/or administer Coumadin anticoagulant drug therapy as ordered for Resident #3, Resident #10, Resident #13, and Resident #15 resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator was informed of the immediate jeopardy on December 23, 2014 at 8:30 a.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on December 1, 2014, the date the facility failed to obtain the first of three (3) missed Prothrombin Time/International Ratio (PT/INR) laboratory tests ordered to be done weekly for Resident #10, who received Coumadin anticoagulant drug therapy. The immediate jeopardy continued through December 22, 2014, and was removed on December 23, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on December 22, 2014. An allegation of jeopardy removal was received on December 23, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on December 23, 2014. The facility remained out of compliance at a lower scope and severity of "E" while the process of evaluating modifications of the laboratory requisition and medication administration systems continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's processes for obtaining laboratory tests as ordered by the physician and the administration of resident medication. Resident record reviews were conducted to assess facility staffs' conformance with physicians' orders regarding the requisition and acquisition of laboratory tests. In addition, resident record reviews were conducted, and observation of medication administration were made, to assess staffs' conformance with physicians' medication orders. Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment of 10/08/2014 documented diagnoses, in Section I - Active Diagnoses, including, but not limited to, Hypertension, Peripheral Vascular Disease, Heart Failure, Coronary Artery Disease, and Atrial Fibrillation. Resident #3's October 2014 physician's orders [REDACTED]. A laboratory report of 10/27/2014 for Resident #3 documented a high PT of 31.8 seconds (Reference Range: 11.0 - 15 seconds) and an INR of 3.2 (Recommended Therapeutic Range for Prevention of Embolism: 2.00 - 3.00). Resident #3's physician noted on this report to continue the resident's Coumadin therapy at the same dose. However, even though the physician's orders [REDACTED]. and November 2014 Medication Administration Records (MARs) documented that Coumadin 2.5 mg therapy was held on 10/29/2014, 10/30/2014, 11/01/2014 and 11/02/2014, and Coumadin 5 mg therapy was held on 10/28/2014 and 10/31/2014, in error. Further record review for Resident #3 revealed a CPMRR Summary which documented that on 11/17/2014, the Consultant Pharmacist reviewed the resident's medication regimen. The Consultant Pharmacist documented, in the Notes section of this form, that Resident #3 received Cymbalta therapy, and also noted the resident received weekly PT/INR laboratory testing. However, further review of Resident #3's CPMRR Summary revealed no evidence to indicate that the Consultant Pharmacist identified the irregularity involving Resident #3 failing to receive Coumadin anticoagulant drug therapy as ordered during the six (6) day period from 10/28/2014 through 11/02/2014. Cross refer to F309, example 1, for more information regarding Resident #3. 2. Resident #13's 11/01/2014 Quarterly MDS assessment documented diagnoses, in Section I - Active Diagnoses, including, but not limited to, Diabetes Mellitus, Anemia, and Heart Failure. Resident #13's December 2014 Order Review Report documented an order for [REDACTED]. An 11/26/2014 laboratory report for Resident #13 documented a PT of 26.8 seconds and an INR of 2.56, but further record review revealed no evidence of PT/INR laboratory tests, ordered weekly for Resident #13, after 11/26/2014. However, even though Resident #13 received Coumadin anticoagulant drug therapy and was ordered to receive weekly PT/INR laboratory tests, and even though there was no evidence of any PT/INR laboratory tests after 11/26/2014, review of Resident #13's November and December 2014 CPMRR Summaries revealed no evidence to indicate that the Consultant Pharmacist identified the irregularity involving the failure to obtain the ordered weekly PT/INR laboratory tests for Resident #13 after 11/26/2014. During a 12/23/2014, 09:25 a.m. interview, Unit Manager Registered Nurse (RN) "EE" acknowledged that the Consultant Pharmacist should have identified Resident #13's missing PT/INR laboratory tests. Cross refer to F309, example 2, for more information regarding Resident #13. 3. Resident #10's Annual MDS assessment of 11/01/2014 documented diagnoses, in Section I - Active Diagnoses, including, but not limited to, Hypertension, Anemia, Diabetes Mellitus, Peripheral Vascular Disease, and Coronary Artery Disease. Current physician's orders [REDACTED]. An 11/24/2014 laboratory report for Resident #10 documented a PT of 14.8 seconds and an INR of 1.18. However, futher record review revealed no evidence of PT/INR laboratory tests for Resident #10 after 11/24/2014, even though the order specified weekly PT/INR laboratory tests. Review of the CPMRR Summary form for Resident #10 revealed an entry dated 12/15/2014 in which the Consultant Pharmacist noted that Resident #10 was to receive PT/INR laboratory tests weekly, and noted the last weekly PT/INR was dated 11/24/2014 (approximately three (3) weeks prior to the Summary report date of 12/15/2014). However, further record review for Resident #10 revealed no evidence to indicate that this irregularity involving the resident's weekly PT/INR laboratory testing, and identified in the 12/15/2014 drug regimen review, had been acted upon by facility staff upon identification by the Consultant Pharmacist. During a post-survey Quality Assurance interview with RN "EE" conducted via telephone on 01/29/2015 at 2:46 p.m., RN "EE" acknowledged the absence of evidence of action taken by the facility in response to the 12/15/2014 drug regimen review finding regarding Resident #10's PT/INR laboratory testing prior to the initiation of this abbreviated survey. Cross refer to F309, example 3, for more information regarding Resident #10. 4. Resident #15's Quarterly MDS assessment of 09/25/2014 documented [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A laboratory report for Resident #15 dated 11/24/2014 documented a PT of 24.2 and an INR of 2.24, but record review revealed no evidence of any PT/INR laboratory tests, ordered weekly, for Resident #15 after 11/24/2014. Review of the CPMRR Summary form for Resident #15 revealed an entry dated 12/15/2014 in which the Consultant Pharmacist made the note "PT/NR". However, further review of Resident #15's CPMRR Summary form revealed no notation by the Consultant Pharmacist identifying that the facility had failed to obtain Resident #15's PT/INR laboratory tests, ordered to be done weekly, since 11/24/2014. During a 12/23/2014, 09:25 a.m. interview, RN "EE" acknowledged that the Consultant Pharmacist should have identified Resident #15's missing PT/INR laboratory tests. Cross refer to F309, example 5, for more information regarding Resident #15. The facility presented an acceptable credible allegation of jeopardy removal (CAJR) on December 23, 2014. Based on this CAJR, it was determined that the immediate jeopardy had been removed on December 23, 2014, at which time the facility had implemented the following interventions: 1. On 12/21/2014, the facility's Medical Director was notified of the missed PT/INR laboratory tests, and physicians' orders were given to obtain these PT/INR laboratory tests. All PT/INR laboratory test results were received by the facility on 12/22/2014, and the physician was notified of the results. Orders were received to recheck these laboratory test results on 12/29/2014. Laboratory requisitions were completed for these residents having PT/INR laboratory testing ordered to be completed on 12/29/2014. 2. On 12/21/2014, the facility initiated a procedure by which the monitoring of resident Coumadin will be conducted. The DNS/Nurse Supervisor will monitor, via an audit, 100 percent of resident Coumadin drug orders and laboratory orders daily for thirty (30) days, then weekly for four (4) weeks, then monthly for six (6) months. Any negative findings will be addressed immediately with a time frame not to exceed the end of the current shift and will include 1:1 staff retraining and education. Additionally, any negative findings will be reviewed by the Quality Assessment and Assurance (QAA) Committee during monthly meetings for (6) six months. 3. On 12/22/2014, the facility conducted record reviews for all residents receiving Coumadin anticoagulant drug therapy to ensure that all orders were correct and that PT/INR laboratory tests were scheduled for completion, per physicians' orders. Entries were updated on the Diagnostic Tracking Form. The specific purposes for the Diagnostic Tracking Form were to ensure that each diagnostic test had been ordered/requisitioned, to ensure the laboratory had collected the specimen, and to ensure the laboratory results had been received and the physician notified of the results. This Diagnostic Tracking Form will be utilized by all licensed nursing staff for all PT/INR laboratory orders, regardless of who is to draw the laboratory test. Licensed nurses will enter the new PT/INR orders on the Diagnostic Tracking Form, with the date the PT/INR is to be drawn. The Diagnostic Tracking Form will also be used to track the laboratory results as they are received, and to track physician notification of the laboratory test results. The Unit Manager/Registered Nurse will notify the physician of PT/INR laboratory results upon receipt daily by telephone. A daily audit of resident Diagnostic Tracking Forms will be conducted by the Unit Manager/RN Supervisor. 4. On 12/22/2014, the facility initiated a procedure by which the Unit Manager/Nurse Supervisor will be responsible for completing the PT/INR Flow Sheets. The PT/INR Flow Sheets serve to document the following information for each resident receiving anticoagulant drug therapy and PT/INR laboratory testing: the date of the laboratory test; the PT/INR result; the anticoagulant drug dose; the date the next laboratory test is ordered; the initials of the staff person taking the order; and any pertinent comments. The process of completion of these resident PT/INR Flow Sheets will be monitored daily by the Unit Manager/RN Supervisor for compliance. 5. On 12/22/2014, the facility initiated a procedure by which the DNS/Designated Nurse Supervisor will conduct random audits the Diagnostic Tracking Form and PT/INR Flow Sheets for residents receiving anticoagulant drug therapy daily for thirty (30) days, then weekly for four (4) weeks, then monthly for six (6) months to monitor for nursing staff compliance. The DNS/Nurse Supervisor will sign and date the Diagnostic Tracking Forms sheets and PT/INR Flow Sheets as evidence of these random audits. Any negative findings will be addressed immediately, with the time frame not to exceed the end of the current shift, and will include 1:1 retraining and education. Additionally, any negative audit findings will be reviewed by the QAA Committee during monthly Committee meetings. 6. On 12/22/2014, the facility reviewed the care plans for all residents receiving Coumadin anticoagulant drug therapy. Care plan revisions were made as needed. 7. On 12/22/2014, the facility initiated a procedure by which the DNS will conduct random, weekly audits involving three (3) residents who receive Coumadin drug therapy to ensure care plan completion. This audit process will continue for six (6) months to ensure compliance. 8. On 12/22/2014, the facility conducted nursing staff in-service training regarding the facility's anticoagulant clinical guidelines, including laboratory order entry for PT/INR laboratory tests, the facility's laboratory requisition procedures, and the process of documentation to be used by nursing staff when completing the Diagnostic Tracking Forms and PT/INR Flow Sheets. Additionally, licensed nursing staff who administer resident medications received in-service training related to the administration of medications in conformance with the facility's anticoagulant therapy guidelines. As of 12/22/2014, a total of twenty-two (22) of the facility's twenty-seven (27) licensed nursing staff had received this in-service training. The remaining five (5) licensed nursing staff who had been unavailable for training at that time, due to being off work, will receive this in-service training upon their return to work and will not be allowed to work until training has been provided. Newly-hired licensed staff will receive in-service training regarding the facility's anticoagulant clinical and therapy guidelines during the facility's orientation process. 9. On 12/22/2014, the facility's QAA Committee met to review the procedures and interventions put into place to address the identified quality deficiencies related to the failure to obtain PT/INR laboratory testing as ordered and the failure to administer anticoagulant drug therapy as ordered. A procedure was developed and implemented by which the results of management staff monitoring of the Coumadin anticoagulant drug therapy monitoring, as well as the management staffs' audits of the Diagnostic Tracking Forms and the PT/INR Flow Sheets, would be presented to the QAA Committee each month by the Executive Director and/or DNS. This will allow the QAA Committee to monitor staff compliance with the facility's policies and procedures regarding the receipt, transcription, and implementation of physicians' orders for Coumadin dosing, and PT/INR monitoring through laboratory testing, to ensure that these policies, procedures, and systems are in compliance. During this abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 12/23/2014, interview with the DNS confirmed that the Medical Director was notified of missed PT/INR laboratory tests. Additional interview with the DNS, and resident record reviews conducted during this abbreviated survey, confirmed that physicians' orders had been obtained for these PT/INR laboratory tests and that test results were received by the facility as of 12/22/2014. This was in conformance with Step 1 of the facility's CAJR referenced above. - On 12/23/2014, DNS interview and audit tool review confirmed that the facility had initiated a procedure allowing for DNS/Nurse Supervisor audits of 100 percent of resident Coumadin drug orders and laboratory orders daily for thirty (30) days, weekly for four (4) weeks, then monthly for six (6) months. Negative findings would be addressed immediately and reviewed by the QAA Committee monthly. This was in accordance with Step 2 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator and DNS, and also ongoing resident record review during the abbreviated survey, confirmed that the facility had reviewed all resident records of residents receiving Coumadin drug therapy to assess for order accuracy and to ensure that PT/INR laboratory tests were scheduled. Administrator and DNS interview confirmed that Diagnostic Tracking Form entries had been updated, and that this Form would be used by nursing staff to document and track PT/INR laboratory orders, PT/INR date, laboratory results, and physician notification. This was in accordance with Step 3 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator and DNS confirmed the facility's procedure for completion of the PT/INR Flow Sheets by the Unit Manager/Nurse Supervisor. Review of the PT/INR Flow Sheet confirmed that the Flow Sheet tracked laboratory test dates, PT/INR results, anticoagulant drug dose, date of next laboratory test, and initials of the staff taking an order. This was in conformance with Step 4 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator and DNS confirmed the facility's procedure by which the DNS/Designated Nurse Supervisor will conduct random audits the Diagnostic Tracking Form and PT/INR Flow Sheets daily for thirty (30) days, then weekly for four (4) weeks, then monthly for six (6) months to monitor for compliance. This was in conformance with Step 5 of the facility's CAJR referenced above. - On 12/23/2014, resident record reviews, which had been ongoing through the survey, confirmed, via documented updates, that the care plans of residents receiving Coumadin anticoagulant drug therapy had been reviewed and updated. This was in conformance with Step 6 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator and DNS confirmed the facility's procedure of DNS weekly audits, continuing for six (6) months, of the records of three (3) residents who receive Coumadin drug therapy to ensure care plan completion. This was in conformance with Step 7 of the facility's CAJR referenced above. - On 12/23/2014, review of facility in-service training records confirmed that the facility had conducted nursing staff in-service training for twenty-two (22) of twenty-seven (27) licensed nursing staff regarding the anticoagulant clinical guidelines, including order entry for PT/INR tests, laboratory requisition procedures, and the documentation process used when completing Diagnostic Tracking Forms and PT/INR Flow Sheets. This in-service training record review confirmed that licensed nursing staff who administer medications had received training regarding medication administration per anticoagulant therapy guidelines. This is accordance with Step 8 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator, and review of a QAA Committee signature sheet dated 12/22/2014 presented by the facility, confirmed that the QAA Committee had met on 12/22/2014 to review the new procedures and processes regarding PT/INR laboratory testing and anticoagulant medication administration, and the new procedure regarding the Committee's monthly review of management staff audit results, via use of the Diagnostic Tracking Form review and PT/INR Flow Sheet review. This was in accordance with Step 9 of the facility CAJR referenced above. Based on these corrective actions which had been developed and implemented by the facility on 12/22/2014 as outlined in the CAJR referenced above, it was determined that the immediacy of the deficient practice was removed on 12/23/2014; however, the effectiveness of the corrective action plans could not be fully assessed at the time of survey exit to ensure ongoing application and completion. On 12/22/2014, the facility conducted nursing staff in-service training regarding the facility's anticoagulant clinical guidelines for PT/INR laboratory test order entry, laboratory requisition procedures, and the process of completing the Diagnostic Tracking Forms and PT/INR Flow Sheets. Licensed nursing staff had also received in-service training regarding medication administration per the anticoagulant therapy guidelines. However, as of 12/22/2014, twenty-two (22) of the facility's twenty-seven (27) licensed nursing staff had received this training, but five (5) licensed nursing staff were unavailable for training at that time and would need to receive this in-service training upon their return to work. Therefore, the completion of this in-service training for these remaining licensed nursing staff who had not yet received training could not be assessed at the time of survey exit, and would need to be assessed at a future date. Additionally, on 12/22/2014, the facility initiated a procedure by which the DNS/Designated Nurse Supervisor would conduct random audits Diagnostic Tracking Forms and PT/INR Flow Sheets for residents receiving anticoagulant drug therapy. The audits of the Diagnostic Tracking Forms would assess nursing staff conformance with metrics which included, but were not limited to, the ordering and requisitioning of laboratory tests to ensure that laboratory tests were received and that physicians were notified of laboratory test results. The PT/INR Flow Sheet audits would assess nursing staff conformance with metrics which included, but were not limited to, laboratory testing dates and results, and the date the next laboratory test was ordered. The DNS/Nurse Supervisor audits would be conducted daily for thirty (30) days, then weekly for four (4) weeks, then monthly for six (6) months to monitor for compliance. Any negative results of these management staff audits of the Diagnostic Tracking Forms and PT/INR Flow Sheets would be reviewed by the QAA Committee during the monthly QAA Committee meetings. The QAA Committee had met on 12/22/2014 to approve this audit process for the monitoring, via management staff audits, of nursing staff conformance with the facility's anticoagulant clinical guidelines and anticoagulant therapy guidelines. However, this management staff audit process had been initiated only on 12/22/2014, and the QAA Committee had therefore not had the opportunity to meet to begin the process of evaluating, on an ongoing basis, the results of these ongoing staff audits to determine the potential need for procedure revision or additional staff training. Therefore, the QAA Committee's ongoing oversight of facility staff conformance with anticoagulant drug administration and laboratory requisition procedures could not be fully assessed at the time of survey exit, and will need further evaluation at a future date. Based on the above, due to the need for continued evaluation of the facility's corrective action plans to ensure ongoing effectiveness, application, and completion, the noncompliance continues, with the scope and severity reduced to the "E" level.

Based on clinical record review, Medication Administration Record [REDACTED]#3, #10, #13, #15, and #16) who received [MEDICATION NAME] anticoagulant drug therapy and had physicians' orders for [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) laboratory testing, and related to the administration of [MEDICATION NAME] drug therapy as ordered by the physician for one (1) resident (#3). A total of nine (9) sampled residents received [MEDICATION NAME] drug therapy on the survey sample of twenty-one (21) residents. This failure resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents, as outlined below: - For Resident #3, the facility failed to provide care in accordance with the resident's care plan by failing to administer [MEDICATION NAME] drug therapy as ordered and failing to obtain weekly PT/INR laboratory tests as ordered: Resident #3 received [MEDICATION NAME] drug therapy for [MEDICAL CONDITION] Fibrillation. However, even though the physician ordered on [DATE] to continue the resident's [MEDICATION NAME] dose, and even though the resident's care plan specified to administer anticoagulant medications as ordered, nursing staff held [MEDICATION NAME], in error, from 10/28/2014 through 11/02/2014. In addition, even though a physician's orders [REDACTED].#3 receive weekly PT/INR laboratory tests, and even though the resident's care plan specified to maintain the INR in therapeutic range, the facility failed to obtain the ordered weekly PT/INR tests after 11/28/2014, when a laboratory report of that date revealed PT/INR results of 22.7 and 2.06, respectively. On 12/21/2014, after surveyor inquiry, a PT/INR laboratory test for Resident #3 revealed PT/INR results of 17.9 and 1.65, respectively, and the physician increased the [MEDICATION NAME] dose to 5 mgs nightly. - For Resident #13, the facility failed to provide care in accordance with the resident's care plan by failing to obtain weekly PT/INR laboratory tests as ordered: Resident #13 received [MEDICATION NAME] drug therapy related to Embolism, Arterial [MEDICAL CONDITION], and [MEDICAL CONDITION] Fibrillation. However, even though Resident #13 was ordered to receive weekly PT/INR laboratory tests, and even though the resident's care plan specified to obtain laboratory/diagnostic work as ordered, the facility failed to obtain the weekly PT/INR tests as ordered after 11/26/2014, when a PT/INR laboratory test of that date documented PT/INR results of 26.8 and 2.56, respectively. On 12/21/2014, after surveyor inquiry, a PT/INR laboratory test revealed PT/INR results of 13.2 and 1.24, respectively, and the physician increased [MEDICATION NAME] to 4 milligrams (mgs) at bedtime. - For Resident #10, the facility failed to provide care in accordance with the resident's care plan by failing to obtain PT/INR laboratory tests as ordered: Resident #10 received [MEDICATION NAME] drug therapy. However, even though a physician's orders [REDACTED]. the physician modified the [MEDICATION NAME] dose. On 12/22/2014, after surveyor inquiry, a PT/INR laboratory test was obtained and documented PT/INR results of 11.3 and 1.07, respectively, and the physician increased the [MEDICATION NAME] dose to 3 mgs daily for Phlebitis/[MEDICAL CONDITION]. - For Resident #16, the facility failed to provide care in accordance with the resident's care plan by failing to obtain a repeat PT/INR laboratory test as ordered: Resident #16 received [MEDICATION NAME] drug therapy, and a laboratory report of 11/26/2014 documented PT/INR results of 29.8 and 2.94, respectively. However, even though the physician ordered to repeat Resident #16's PT/INR level one (1) week from 11/26/2014, and even though the care plan specified to obtain laboratory/diagnostic work as ordered, the facility failed to obtain the repeat PT/INR test ordered for Resident #16. On 12/21/2014, after surveyor inquiry, a laboratory report documented high PT/INR results of 33.3 and 2.96, respectively, and the physician changed the [MEDICATION NAME] dose to 4 mgs at bedtime. - For Resident #15, the facility failed to provide care in accordance with the resident's care plan by failing to obtain weekly PT/INR laboratory tests as ordered: Resident #15 received [MEDICATION NAME] drug therapy. However, even though a physician's orders [REDACTED].#15, and even though the care plan specified that laboratory/diagnostic work be obtained as ordered, the facility failed to obtain the weekly PT/INR laboratory tests as ordered after 11/24/2014, when a laboratory test revealed PT/INR results of 24.2 and 2.24, respectively. On 12/22/2014, after surveyor inquiry, a PT/INR test revealed Resident #15's PT/INR result to be 32.1 and 2.86, respectively, and the physician lowered [MEDICATION NAME] to 3.5 mgs at bedtime. As outlined above, the facility's failure to obtain PT/INR laboratory tests as ordered and/or administer [MEDICATION NAME] anticoagulant drug therapy as ordered for Resident #3, Resident #10, Resident #13, Resident #15, and Resident #16 resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator was informed of the immediate jeopardy on December 23, 2014 at 8:30 a.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on December 1, 2014, the date the facility failed to obtain the first of three (3) missed [MEDICATION NAME] Time/International Ratio (PT/INR) laboratory tests ordered to be done weekly for Resident #10, who received [MEDICATION NAME] anticoagulant drug therapy. The immediate jeopardy continued through December 22, 2014, and was removed on December 23, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on December 22, 2014. An allegation of jeopardy removal was received on December 23, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on December 23, 2014. The facility remained out of compliance at a lower scope and severity of "E" while the process of evaluating modifications of the laboratory requisition and medication administration systems continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's processes for obtaining laboratory tests as ordered by the physician and the administration of resident medication. Resident record reviews were conducted to assess facility staffs' conformance with physicians' orders regarding the requisition and acquisition of laboratory tests. In addition, resident record reviews were conducted, and observation of medication administration were made, to assess staffs' conformance with physicians' medication orders. Findings include: 1. Resident #3's Annual Minimum Data Set (MDS) assessment of 10/08/2014 documented diagnoses, in Section I - Active Diagnoses, which included, but were not limited to, Hypertension, [MEDICAL CONDITION], Heart Failure, [MEDICAL CONDITION], and [MEDICAL CONDITION] Fibrillation. This MDS also documented in Section N - Medications that Resident #3 received anticoagulant drug therapy for seven (7) of seven (7) days during the look-back period. Review of the comprehensive care plan for Resident #3 revealed a Focus area, originally dating from 10/19/2013, identifying that the resident had an alteration in cardiac output related to [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITION], and Hypertension, and was at risk for bleeding related to the use of [MEDICATION NAME] drug therapy. Resident #3's care plan referenced, as a Goal, that the resident's INR would be within therapeutic range, and identified Interventions which included to administer the anticoagulant medication as ordered by the physician. Resident #3's October 2014 physician's orders [REDACTED]. Additionally, a 09/17/2014 physician's orders [REDACTED].#3 receive weekly PT/INR laboratory tests. A Clinical Laboratory Services (CLS) laboratory report of 10/27/2014 for Resident #3 revealed a high PT of 31.8 seconds (Reference Range: 11.0 - 15 seconds) and an INR of 3.2 (Recommended Therapeutic Range for Prevention of Embolism: 2.00 - 3.00). The physician responded via facsimile return of this CLS laboratory report (with a stamped date of 10/28/2014), with a handwritten note to continue the dose of [MEDICATION NAME]. However, even though the physician ordered on [DATE] to continue Resident #3's [MEDICATION NAME] therapy as ordered, the resident's October and November 2014 Medication Administration Records (MARs) documented nursing staff held [MEDICATION NAME] 2.5 mgs on 10/29/2014, 10/30/2014, 11/01/2014, and 11/02/2014, and held [MEDICATION NAME] 5 mgs on 10/28/2014 and 10/31/2014. Additionally, Resident #3's PT/INR flow sheet documented a weekly PT/INR test on 11/28/2014, but there was no evidence of any PT/INR laboratory tests being completed after this 11/28/2014 PT/INR, even though the physician's orders [REDACTED]. During interview on 12/21/2014 at 10:45 a.m., Registered Nurse (RN) "EE" acknowledged that Resident #3's [MEDICATION NAME] was not given as ordered from 10/28/2014 through 11/02/2014. Based on the above, Resident #3 had physician's orders [REDACTED]. The resident's care plan specified to administer anticoagulant therapy as ordered and to maintain the resident's INR within therapeutic range. However, Resident #3's [MEDICATION NAME] therapy was held and not administered as ordered from 10/28/2014 through 11/02/2014. The facility also failed to obtain Resident #3's PT/INR laboratory tests, ordered to be done weekly, after 11/28/2014, thus failing to monitor the INR as ordered by the physician to ensure that the INR remained within therapeutic range, as specified by the care plan. Cross refer to F309, example 1, and F502, example 1, for more information regarding Resident #3. 2. Resident #13's Quarterly MDS assessment of 11/01/2014 documented diagnoses, in Section I - Active Diagnoses, which included, but were not limited to, Diabetes Mellitus, [MEDICAL CONDITION], and Heart Failure, and Section N - Medications documented that the resident received anticoagulant drug therapy seven (7) of (7) days during the look-back period. The care plan for Resident #13 identified a Focus area, originally dating from 04/04/2014, which indicated the resident was at risk for complications related to anticoagulant medication. Interventions identified on Resident #13's care plan related to the receipt of anticoagulant drug therapy included to obtain and monitor laboratory/diagnostic work as ordered by the physician. A December 2014 Order Review Report for Resident #13 specified a physician's orders [REDACTED]. A weekly CLS laboratory report dated 11/26/2014 for Resident #13 documented a PT result of 26.8 seconds and an INR result of 2.56, but further record review revealed no evidence of any PT/INR laboratory tests being completed for Resident #13 after this 11/26/2014 laboratory test, even though weekly PT/INR tests were ordered. During an interview conducted on 12/21/2014 at 3:40 p.m., the Director of Nursing Services (DNS) noted no evidence of a PT/INR laboratory test for Resident #13 after the 11/26/2014 PT/INR laboratory report referenced above. Based on the above, even though Resident #13 received [MEDICATION NAME] anticoagulant drug therapy, even though the resident was ordered to receive weekly PT/INR laboratory tests, and even though the resident's care plan specified to obtain laboratory/diagnostic work as ordered by the physician related to the anticoagulant drug therapy, the facility failed to obtain weekly PT/INR laboratory tests as ordered after a laboratory test of 11/26/2014 (which revealed an elevated of PT of 26.8 seconds and an INR of 2.56). Cross refer to F309, example 2, and F502, example 2, for more information regarding Resident #13. 3. Resident #10's Annual MDS assessment of 11/01/2014 documented diagnoses, in Section I - Active Diagnoses, which included, but were not limited to, Hypertension, [MEDICAL CONDITION], Diabetes Mellitus, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Section N - Medications documented that Resident #10 received anticoagulant drug therapy for seven (7) of seven (7) days during the look-back period. The care plan of Resident #10 identified a Focus area indicating that the resident was at risk for complications related to the receipt of anticoagulant/antiplatelet medication, and specified as an Intervention to obtain and monitor laboratory/diagnostic work as ordered. A physician's orders [REDACTED].#10 receive the anticoagulant [MEDICATION NAME] 2.5 mgs by mouth at bedtime, and another physician's orders [REDACTED]. An 11/24/2014 CLS laboratory report for Resident #10 documented a PT result of 14.8 seconds and an INR result of 1.18, and a physician's orders [REDACTED]. However, even though Resident#10 was ordered to receive weekly PT/INR laboratory tests, there was no evidence that any PT/INR laboratory tests were done for Resident #10 after the 11/24/2014 PT/INR test referenced above. During interview conducted on 12/21/2014 at 12:20 p.m., RN "EE" acknowledged the failure to obtain Resident #10's weekly PT/INR tests as ordered after 11/24/2014. Based on the above, despite Resident #10 receiving [MEDICATION NAME] anticoagulant drug therapy, despite a physician's orders [REDACTED]. Cross refer to F309, example 3, and F502, example 3, for more information regarding Resident #10. 4. Resident #16's Quarterly MDS assessment of 11/26/2014 documented [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The care plan for Resident #16 identified as a Focus area, dating from 09/12/2014, that the resident was at risk for complications related to the receipt of anticoagulant medication. Resident #16's care plan identified Interventions, to address this risk of anticoagulant therapy complications, which included to obtain and monitor laboratory/diagnostic work as ordered. A CLS laboratory report for Resident #16 dated 11/26/2014 documented a high PT of 29.8 seconds and an INR of 2.94. A handwritten note on this laboratory report documented that the physician had ordered a repeat PT/INR in one (1) week. Record review, however, revealed no evidence to indicate that the PT/INR laboratory test, ordered to be completed one week after the 11/26/2014 PT/INR laboratory test above, was done for Resident #16. During an interview conducted on 12/21/2014 at 2:00 p.m., RN "EE" acknowledged the repeat PT/INR laboratory test ordered for Resident #16, via the 11/26/2014 physician's orders [REDACTED]. Based on the above, Resident #16 received [MEDICATION NAME] anticoagulant drug therapy and had a care plan Intervention specifying that laboratory testing be obtained as ordered. After a laboratory report of 11/26/2014 documented an elevated PT of 29.8 seconds and an elevated INR of 2.94, the physician ordered a repeat PT/INR in 1 week; however, the facility failed to obtain this repeat PT/INR laboratory test as ordered. Cross refer to F309, example 4, and F502, example 4, for more information regarding Resident #16. 5. Resident #15's Quarterly MDS of 09/25/2014 documented diagnoses, in Section I - Active Diagnoses, which included, but were not limited to, [MEDICAL CONDITION] and Hypertension. Section N - Medications of this MDS documented Resident #15 received anticoagulant drug therapy seven (7) of seven (7) days during the look-back period, and the resident's Admission Record form documented a History of Venous [MEDICAL CONDITION] and Embolism. A physician's orders [REDACTED]. The care plan of Resident #15 identified a Focus area, originally dated 03/01/2013, which indicated the resident was at risk for complications related to anticoagulant or antiplatelet medication due to the risk of, or actual, [MEDICAL CONDITION]. A care plan Intervention for Resident #15's risk of complications related to anticoagulant/antiplatelet medication specified to obtain the resident's laboratory/diagnostic work as ordered. A weekly laboratory report of 11/24/2014 for Resident #15 revealed a PT of 24.2 seconds and an INR of 2.24. Further record review, however, revealed no evidence of any PT/INR laboratory tests completed for Resident #15 after this 11/24/2014 PT/INR level, even though PT/INR tests were ordered to be done weekly related to the resident's anticoagulant drug therapy. During an interview conducted on 12/21/2014 at 2:00 p.m., RN "EE" acknowledged the PT/INR laboratory tests for Resident #15 were omitted. Based on the above, Resident #15 received [MEDICATION NAME] anticoagulant drug therapy, had a physician's orders [REDACTED]. However, the facility failed to obtain weekly PT/INR laboratory tests as ordered for Resident #15 after 11/24/2014, even though the resident's care plan specified that laboratory tests would be obtained as ordered by the physician. Cross refer to F309, example 5, and F502, example 5, for more information regarding Resident #15. The facility presented an acceptable credible allegation of jeopardy removal (CAJR) on December 23, 2014. Based on this CAJR, it was determined that the immediate jeopardy had been removed on December 23, 2014, at which time the facility had implemented the following interventions: 1. On 12/21/2014, the facility's Medical Director was notified of the missed PT/INR laboratory tests, and physicians' orders were given to obtain these PT/INR laboratory tests. All PT/INR laboratory test results were received by the facility on 12/22/2014, and the physician was notified of the results. Orders were received to recheck these laboratory test results on 12/29/2014. Laboratory requisitions were completed for these residents having PT/INR laboratory testing ordered to be completed on 12/29/2014. 2. On 12/21/2014, the facility initiated a procedure by which the monitoring of resident [MEDICATION NAME] will be conducted. The DNS/Nurse Supervisor will monitor, via an audit, 100 percent of resident [MEDICATION NAME] drug orders and laboratory orders daily for thirty (30) days, then weekly for four (4) weeks, then monthly for six (6) months. Any negative findings will be addressed immediately with a time frame not to exceed the end of the current shift and will include 1:1 staff retraining and education. Additionally, any negative findings will be reviewed by the Quality Assessment and Assurance (QAA) Committee during monthly meetings for (6) six months. 3. On 12/22/2014, the facility conducted record reviews for all residents receiving [MEDICATION NAME] anticoagulant drug therapy to ensure that all orders were correct and that PT/INR laboratory tests were scheduled for completion, per physicians' orders. Entries were updated on the Diagnostic Tracking Form. The specific purposes for the Diagnostic Tracking Form were to ensure that each diagnostic test had been ordered/requisitioned, to ensure the laboratory had collected the specimen, and to ensure the laboratory results had been received and the physician notified of the results. This Diagnostic Tracking Form will be utilized by all licensed nursing staff for all PT/INR laboratory orders, regardless of who is to draw the laboratory test. Licensed nurses will enter the new PT/INR orders on the Diagnostic Tracking Form, with the date the PT/INR is to be drawn. The Diagnostic Tracking Form will also be used to track the laboratory results as they are received, and to track physician notification of the laboratory test results. The Unit Manager/Registered Nurse will notify the physician of PT/INR laboratory results upon receipt daily by telephone. A daily audit of resident Diagnostic Tracking Forms will be conducted by the Unit Manager/RN Supervisor. 4. On 12/22/2014, the facility initiated a procedure by which the Unit Manager/Nurse Supervisor will be responsible for completing the PT/INR Flow Sheets. The PT/INR Flow Sheets serve to document the following information for each resident receiving anticoagulant drug therapy and PT/INR laboratory testing: the date of the laboratory test; the PT/INR result; the anticoagulant drug dose; the date the next laboratory test is ordered; the initials of the staff person taking the order; and any pertinent comments. The process of completion of these resident PT/INR Flow Sheets will be monitored daily by the Unit Manager/RN Supervisor for compliance. 5. On 12/22/2014, the facility initiated a procedure by which the DNS/Designated Nurse Supervisor will conduct random audits the Diagnostic Tracking Form and PT/INR Flow Sheets for residents receiving anticoagulant drug therapy daily for thirty (30) days, then weekly for four (4) weeks, then monthly for six (6) months to monitor for nursing staff compliance. The DNS/Nurse Supervisor will sign and date the Diagnostic Tracking Forms sheets and PT/INR Flow Sheets as evidence of these random audits. Any negative findings will be addressed immediately, with the time frame not to exceed the end of the current shift, and will include 1:1 retraining and education. Additionally, any negative audit findings will be reviewed by the QAA Committee during monthly Committee meetings. 6. On 12/22/2014, the facility reviewed the care plans for all residents receiving [MEDICATION NAME] anticoagulant drug therapy. Care plan revisions were made as needed. 7. On 12/22/2014, the facility initiated a procedure by which the DNS will conduct random, weekly audits involving three (3) residents who receive [MEDICATION NAME] drug therapy to ensure care plan completion. This audit process will continue for six (6) months to ensure compliance. 8. On 12/22/2014, the facility conducted nursing staff in-service training regarding the facility's anticoagulant clinical guidelines, including laboratory order entry for PT/INR laboratory tests, the facility's laboratory requisition procedures, and the process of documentation to be used by nursing staff when completing the Diagnostic Tracking Forms and PT/INR Flow Sheets. Additionally, licensed nursing staff who administer resident medications received in-service training related to the administration of medications in conformance with the facility's anticoagulant therapy guidelines. As of 12/22/2014, a total of twenty-two (22) of the facility's twenty-seven (27) licensed nursing staff had received this in-service training. The remaining five (5) licensed nursing staff who had been unavailable for training at that time, due to being off work, will receive this in-service training upon their return to work and will not be allowed to work until training has been provided. Newly-hired licensed staff will receive in-service training regarding the facility's anticoagulant clinical and therapy guidelines during the facility's orientation process. 9. On 12/22/2014, the facility's QAA Committee met to review the procedures and interventions put into place to address the identified quality deficiencies related to the failure to obtain PT/INR laboratory testing as ordered and the failure to administer anticoagulant drug therapy as ordered. A procedure was developed and implemented by which the results of management staff monitoring of the [MEDICATION NAME] anticoagulant drug therapy monitoring, as well as the management staffs' audits of the Diagnostic Tracking Forms and the PT/INR Flow Sheets, would be presented to the QAA Committee each month by the Executive Director and/or DNS. This will allow the QAA Committee to monitor staff compliance with the facility's policies and procedures regarding the receipt, transcription, and implementation of physicians' orders for [MEDICATION NAME] dosing, and PT/INR monitoring through laboratory testing, to ensure that these policies, procedures, and systems are in compliance. During this abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 12/23/2014, interview with the DNS confirmed that the Medical Director was notified of missed PT/INR laboratory tests. Additional interview with the DNS, and resident record reviews conducted during this abbreviated survey, confirmed that physicians' orders had been obtained for these PT/INR laboratory tests and that test results were received by the facility as of 12/22/2014. This was in conformance with Step 1 of the facility's CAJR referenced above. - On 12/23/2014, DNS interview and audit tool review confirmed that the facility had initiated a procedure allowing for DNS/Nurse Supervisor audits of 100 percent of resident [MEDICATION NAME] drug orders and laboratory orders daily for thirty (30) days, weekly for four (4) weeks, then monthly for six (6) months. Negative findings would be addressed immediately and reviewed by the QAA Committee monthly. This was in accordance with Step 2 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator and DNS, and also ongoing resident record review during the abbreviated survey, confirmed that the facility had reviewed all resident records of residents receiving [MEDICATION NAME] drug therapy to assess for order accuracy and to ensure that PT/INR laboratory tests were scheduled. Administrator and DNS interview confirmed that Diagnostic Tracking Form entries had been updated, and that this Form would be used by nursing staff to document and track PT/INR laboratory orders, PT/INR date, laboratory results, and physician notification. This was in accordance with Step 3 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator and DNS confirmed the facility's procedure for completion of the PT/INR Flow Sheets by the Unit Manager/Nurse Supervisor. Review of the PT/INR Flow Sheet confirmed that the Flow Sheet tracked laboratory test dates, PT/INR results, anticoagulant drug dose, date of next laboratory test, and initials of the staff taking an order. This was in conformance with Step 4 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator and DNS confirmed the facility's procedure by which the DNS/Designated Nurse Supervisor will conduct random audits the Diagnostic Tracking Form and PT/INR Flow Sheets daily for thirty (30) days, then weekly for four (4) weeks, then monthly for six (6) months to monitor for compliance. This was in conformance with Step 5 of the facility's CAJR referenced above. - On 12/23/2014, resident record reviews, which had been ongoing through the survey, confirmed, via documented updates, that the care plans of residents receiving [MEDICATION NAME] anticoagulant drug therapy had been reviewed and updated. This was in conformance with Step 6 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator and DNS confirmed the facility's procedure of DNS weekly audits, continuing for six (6) months, of the records of three (3) residents who receive [MEDICATION NAME] drug therapy to ensure care plan completion. This was in conformance with Step 7 of the facility's CAJR referenced above. - On 12/23/2014, review of facility in-service training records confirmed that the facility had conducted nursing staff in-service training for twenty-two (22) of twenty-seven (27) licensed nursing staff regarding the anticoagulant clinical guidelines, including order entry for PT/INR tests, laboratory requisition procedures, and the documentation process used when completing Diagnostic Tracking Forms and PT/INR Flow Sheets. This in-service training record review confirmed that licensed nursing staff who administer medications had received training regarding medication administration per anticoagulant therapy guidelines. This is accordance with Step 8 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator, and review of a QAA Committee signature sheet dated 12/22/2014 presented by the facility, confirmed that the QAA Committee had met on 12/22/2014 to review the new procedures and processes regarding PT/INR laboratory testing and anticoagulant medication administration, and the new procedure regarding the Committee's monthly review of management staff audit results, via use of the Diagnostic Tracking Form review and PT/INR Flow Sheet review. This was in accordance with Step 9 of the facility CAJR referenced above. Based on these corrective actions which had been developed and implemented by the facility on 12/22/2014 as outlined in the CAJR referenced above, it was determined that the immediacy of the deficient practice was removed on 12/23/2014; however, the effectiveness of the corrective action plans could not be fully assessed at the time of survey exit to ensure ongoing application and completion. On 12/22/2014, the facility conducted nursing staff in-service training regarding the facility's anticoagulant clinical guidelines for PT/INR laboratory test order entry, laboratory requisition procedures, and the process of completing the Diagnostic Tracking Forms and PT/INR Flow Sheets. Licensed nursing staff had also received in-service training regarding medication administration per the anticoagulant therapy guidelines. However, as of 12/22/2014, twenty-two (22) of the facility's twenty-seven (27) licensed nursing staff had received this training, but five (5) licensed nursing staff were unavailable for training at that time and would need to receive this in-service training upon their return to work. Therefore, the completion of this in-service training for these remaining licensed nursing staff who had not yet received training could not be assessed at the time of survey exit, and would need to be assessed at a future date. Additionally, on 12/22/2014, the facility initiated a procedure by which the DNS/Designated Nurse Supervisor would conduct random audits Diagnostic Tracking Forms and PT/INR Flow Sheets for residents receiving anticoagulant drug therapy. The audits of the Diagnostic Tracking Forms would assess nursing staff conformance with metrics which included, but were not limited to, the ordering and requisitioning of laboratory tests to ensure that laboratory tests were received and that physicians were notified of laboratory test results. The PT/INR Flow Sheet audits would assess nursing staff conformance with metri

Based on clinical record review and staff interview, facility administration failed to ensure that laboratory testing related to anticoagulant drug therapy was performed in accordance with physicians' orders, and/or failed to ensure the administration of anticoagulant drug therapy in accordance with physicians' orders, for six (6) residents (#3, #9, #10, #13, #15, and #16) who received [MEDICATION NAME] anticoagulant drug therapy, on the total survey sample of twenty-one (21) residents. For Resident #3, Resident #10, Resident #13, Resident #15, and Resident #16, all of whom received [MEDICATION NAME] drug therapy and had physicians' orders for PT/INR laboratory testing, the facility failed to obtain PT/INR laboratory tests as ordered to monitor the [MEDICATION NAME] drug therapy of these residents. Additionally, the facility failed to administer [MEDICATION NAME] drug therapy in accordance with physician's orders [REDACTED].#9. This failure resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator was informed of the immediate jeopardy on December 23, 2014 at 8:30 a.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on December 1, 2014, the date the facility failed to obtain the first of three (3) missed PT/INR laboratory tests ordered to be done weekly for Resident #10, who received [MEDICATION NAME] anticoagulant drug therapy. The immediate jeopardy continued through December 22, 2014, and was removed on December 23, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on December 22, 2014. An allegation of jeopardy removal was received on December 23, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on December 23, 2014. The facility remained out of compliance at a lower scope and severity of "E" while the process of evaluating modifications of the laboratory requisition and medication administration systems continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's processes for obtaining laboratory tests as ordered by the physician and the administration of resident medication. Resident record reviews were conducted to assess facility staffs' conformance with physicians' orders regarding the requisition and acquisition of laboratory tests. In addition, resident record reviews were conducted, and observation of medication administration were made, to assess staffs' conformance with physicians' medication orders. Findings include: Cross refer to F309. Based on clinical record review and staff interview, the facility failed to obtain laboratory tests in accordance with physicians' orders for Residents #3, #10, #13, #15, and #16 who received [MEDICATION NAME] anticoagulant drug therapy and had physicians' orders for PT/INR laboratory testing. The facility also failed to administer [MEDICATION NAME] drug therapy as ordered for Residents #3 and #9. For Resident #3, who received [MEDICATION NAME] drug therapy, the facility failed to administer [MEDICATION NAME] anticoagulant drug therapy as ordered from 10/28/2014 through 11/02/2014, and failed to obtain weekly PT/INR laboratory tests as ordered after 11/28/2014. For Resident #9, the facility failed to administer [MEDICATION NAME] anticoagulant drug therapy as ordered by administering [MEDICATION NAME] 3 mg doses on 12/14/2014 at 9:00 a.m. and 9:00 p.m., rather than one (1) [MEDICATION NAME] 3 mg dose as ordered on that date, and administered [MEDICATION NAME] 6 mg doses at 9:00 a.m. and 9:00 p.m., and a [MEDICATION NAME] 3 mg dose at 9:00 p.m. on 12/19/2014, rather than administering one (1) [MEDICATION NAME] 6 mg dose on that date as ordered. For Resident #10, who received [MEDICATION NAME] drug therapy, the facility failed to obtain weekly PT/INR laboratory tests as ordered after 11/24/2014. For Resident #13, who received [MEDICATION NAME] drug therapy, the facility failed to obtain weekly PT/INR laboratory tests as ordered after 11/26/2014. For Resident #15, who received [MEDICATION NAME] drug therapy, the facility failed to obtain weekly PT/INR laboratory tests as ordered 11/24/2014. For Resident #16, who received [MEDICATION NAME] drug therapy, the facility failed to obtain a repeat PT/INR laboratory test in one (1) week as ordered after a laboratory report of 11/26/2014 documented PT/INR results of 29.8 and of 2.94, respectively. During an interview with the Administrator conducted on 12/24/2014 at 8:20 a.m., the Administrator was questioned regarding the issues identified during this abbreviated survey involving the facility's failure to provide laboratory tests, ordered in conjunction with anticoagulant drug therapy, in accordance with physicians' orders. During this interview, the Administrator stated that he was unaware of the facility's failure to provide PT/INR laboratory testing as ordered by the physician, prior to the 12/21/2014, when the issue was discovered during this abbreviated survey. During a subsequent interview with the Administrator and the Director of Nursing Services (DNS) conducted on 12/24/2014 at 9:25 a.m., these staff persons stated in the past, facility nursing staff were to utilize the Diagnostic Tracking Form and the PT/INR Flow Sheet for tracking ordered laboratory tests. The nurse who received an order for [REDACTED]. [REDACTED]. According to the Administrator and DNS, this process of laboratory test acquisition was to be routinely monitored by nursing management and reviewed in morning clinical meetings. However, both staff members acknowledged that this process regarding the monitoring of laboratory test acquisition had not been followed by the facility, and stated that there had been no checks in place to ensure that resident Diagnostic Tracking Forms and the PT/INR Flow Sheets were accurate. The Administrator and DNS further stated that had this process of monitoring, regarding the provision of PT/INR laboratory testing, been reviewed in clinical meetings, per the established process, the Administrator would have heard the discussions and been aware of any laboratory issues that were identified. However, during this interview, the Administrator acknowledged the failure to review and discuss the established process involving the monitoring of laboratory test acquisition in morning meetings; however, the Administrator provided no evidence of any actions he had taken, prior to the initiation of this abbreviated survey, in response to the acknowledged failure of management staff to report laboratory test monitoring in morning meetings, to thereby ensure effective oversight regarding resident laboratory testing. The facility presented an acceptable credible allegation of jeopardy removal (CAJR) on December 23, 2014. Based on this CAJR, it was determined that the immediate jeopardy had been removed on December 23, 2014, at which time the facility had implemented the following interventions: 1. On 12/21/2014, the facility's Medical Director was notified of the missed PT/INR laboratory tests, and physicians' orders were given to obtain these PT/INR laboratory tests. All PT/INR laboratory test results were received by the facility on 12/22/2014, and the physician was notified of the results. Orders were received to recheck these laboratory test results on 12/29/2014. Laboratory requisitions were completed for these residents having PT/INR laboratory testing ordered to be completed on 12/29/2014. 2. On 12/21/2014, the facility initiated a procedure by which the monitoring of resident [MEDICATION NAME] will be conducted. The DNS/Nurse Supervisor will monitor, via an audit, 100 percent of resident [MEDICATION NAME] drug orders and laboratory orders daily for thirty (30) days, then weekly for four (4) weeks, then monthly for six (6) months. Any negative findings will be addressed immediately with a time frame not to exceed the end of the current shift and will include 1:1 staff retraining and education. Additionally, any negative findings will be reviewed by the Quality Assessment and Assurance (QAA) Committee during monthly meetings for (6) six months. 3. On 12/22/2014, the facility conducted record reviews for all residents receiving [MEDICATION NAME] anticoagulant drug therapy to ensure that all orders were correct and that PT/INR laboratory tests were scheduled for completion, per physicians' orders. Entries were updated on the Diagnostic Tracking Form. The specific purposes for the Diagnostic Tracking Form were to ensure that each diagnostic test had been ordered/requisitioned, to ensure the laboratory had collected the specimen, and to ensure the laboratory results had been received and the physician notified of the results. This Diagnostic Tracking Form will be utilized by all licensed nursing staff for all PT/INR laboratory orders, regardless of who is to draw the laboratory test. Licensed nurses will enter the new PT/INR orders on the Diagnostic Tracking Form, with the date the PT/INR is to be drawn. The Diagnostic Tracking Form will also be used to track the laboratory results as they are received, and to track physician notification of the laboratory test results. The Unit Manager/Registered Nurse will notify the physician of PT/INR laboratory results upon receipt daily by telephone. A daily audit of resident Diagnostic Tracking Forms will be conducted by the Unit Manager/RN Supervisor. 4. On 12/22/2014, the facility initiated a procedure by which the Unit Manager/Nurse Supervisor will be responsible for completing the PT/INR Flow Sheets. The PT/INR Flow Sheets serve to document the following information for each resident receiving anticoagulant drug therapy and PT/INR laboratory testing: the date of the laboratory test; the PT/INR result; the anticoagulant drug dose; the date the next laboratory test is ordered; the initials of the staff person taking the order; and any pertinent comments. The 2process of completion of these resident PT/INR Flow Sheets will be monitored daily by the Unit Manager/RN Supervisor for compliance. 5. On 12/22/2014, the facility initiated a procedure by which the DNS/Designated Nurse Supervisor will conduct random audits the Diagnostic Tracking Form and PT/INR Flow Sheets for residents receiving anticoagulant drug therapy daily for thirty (30) days, then weekly for four (4) weeks, then monthly for six (6) months to monitor for nursing staff compliance. The DNS/Nurse Supervisor will sign and date the Diagnostic Tracking Forms sheets and PT/INR Flow Sheets as evidence of these random audits. Any negative findings will be addressed immediately, with the time frame not to exceed the end of the current shift, and will include 1:1 retraining and education. Additionally, any negative audit findings will be reviewed by the QAA Committee during monthly Committee meetings. 6. On 12/22/2014, the facility reviewed the care plans for all residents receiving [MEDICATION NAME] anticoagulant drug therapy. Care plan revisions were made as needed. 7. On 12/22/2014, the facility initiated a procedure by which the DNS will conduct random, weekly audits involving three (3) residents who receive [MEDICATION NAME] drug therapy to ensure care plan completion. This audit process will continue for six (6) months to ensure compliance. 8. On 12/22/2014, the facility conducted nursing staff in-service training regarding the facility's anticoagulant clinical guidelines, including laboratory order entry for PT/INR laboratory tests, the facility's laboratory requisition procedures, and the process of documentation to be used by nursing staff when completing the Diagnostic Tracking Forms and PT/INR Flow Sheets. Additionally, licensed nursing staff who administer resident medications received in-service training related to the administration of medications in conformance with the facility's anticoagulant therapy guidelines. As of 12/22/2014, a total of twenty-two (22) of the facility's twenty-seven (27) licensed nursing staff had received this in-service training. The remaining five (5) licensed nursing staff who had been unavailable for training at that time, due to being off work, will receive this in-service training upon their return to work and will not be allowed to work until training has been provided. Newly-hired licensed staff will receive in-service training regarding the facility's anticoagulant clinical and therapy guidelines during the facility's orientation process. 9. On 12/22/2014, the facility's QAA Committee met to review the procedures and interventions put into place to address the identified quality deficiencies related to the failure to obtain PT/INR laboratory testing as ordered and the failure to administer anticoagulant drug therapy as ordered. A procedure was developed and implemented by which the results of management staff monitoring of the [MEDICATION NAME] anticoagulant drug therapy monitoring, as well as the management staffs' audits of the Diagnostic Tracking Forms and the PT/INR Flow Sheets, would be presented to the QAA Committee each month by the Executive Director and/or DNS. This will allow the QAA Committee to monitor staff compliance with the facility's policies and procedures regarding the receipt, transcription, and implementation of physicians' orders for [MEDICATION NAME] dosing, and PT/INR monitoring through laboratory testing, to ensure that these policies, procedures, and systems are in compliance. During this abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 12/23/2014, interview with the DNS confirmed that the Medical Director was notified of missed PT/INR laboratory tests. Additional interview with the DNS, and resident record reviews conducted during this abbreviated survey, confirmed that physicians' orders had been obtained for these PT/INR laboratory tests and that test results were received by the facility as of 12/22/2014. This was in conformance with Step 1 of the facility's CAJR referenced above. - On 12/23/2014, DNS interview and audit tool review confirmed that the facility had initiated a procedure allowing for DNS/Nurse Supervisor audits of 100 percent of resident [MEDICATION NAME] drug orders and laboratory orders daily for thirty (30) days, weekly for four (4) weeks, then monthly for six (6) months. Negative findings would be addressed immediately and reviewed by the QAA Committee monthly. This was in accordance with Step 2 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator and DNS, and also ongoing resident record review during the abbreviated survey, confirmed that the facility had reviewed all resident records of residents receiving [MEDICATION NAME] drug therapy to assess for order accuracy and to ensure that PT/INR laboratory tests were scheduled. Administrator and DNS interview confirmed that Diagnostic Tracking Form entries had been updated, and that this Form would be used by nursing staff to document and track PT/INR laboratory orders, PT/INR date, laboratory results, and physician notification. This was in accordance with Step 3 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator and DNS confirmed the facility's procedure for completion of the PT/INR Flow Sheets by the Unit Manager/Nurse Supervisor. Review of the PT/INR Flow Sheet confirmed that the Flow Sheet tracked laboratory test dates, PT/INR results, anticoagulant drug dose, date of next laboratory test, and initials of the staff taking an order. This was in conformance with Step 4 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator and DNS confirmed the facility's procedure by which the DNS/Designated Nurse Supervisor will conduct random audits the Diagnostic Tracking Form and PT/INR Flow Sheets daily for thirty (30) days, then weekly for four (4) weeks, then monthly for six (6) months to monitor for compliance. This was in conformance with Step 5 of the facility's CAJR referenced above. - On 12/23/2014, resident record reviews, which had been ongoing through the survey, confirmed, via documented updates, that the care plans of residents receiving [MEDICATION NAME] anticoagulant drug therapy had been reviewed and updated. This was in conformance with Step 6 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator and DNS confirmed the facility's procedure of DNS weekly audits, continuing for six (6) months, of the records of three (3) residents who receive [MEDICATION NAME] drug therapy to ensure care plan completion. This was in conformance with Step 7 of the facility's CAJR referenced above. - On 12/23/2014, review of facility in-service training records confirmed that the facility had conducted nursing staff in-service training for twenty-two (22) of twenty-seven (27) licensed nursing staff regarding the anticoagulant clinical guidelines, including order entry for PT/INR tests, laboratory requisition procedures, and the documentation process used when completing Diagnostic Tracking Forms and PT/INR Flow Sheets. This in-service training record review confirmed that licensed nursing staff who administer medications had received training regarding medication administration per anticoagulant therapy guidelines. This is accordance with Step 8 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator, and review of a QAA Committee signature sheet dated 12/22/2014 presented by the facility, confirmed that the QAA Committee had met on 12/22/2014 to review the new procedures and processes regarding PT/INR laboratory testing and anticoagulant medication administration, and the new procedure regarding the Committee's monthly review of management staff audit results, via use of the Diagnostic Tracking Form review and PT/INR Flow Sheet review. This was in accordance with Step 9 of the facility CAJR referenced above. Based on these corrective actions which had been developed and implemented by the facility on 12/22/2014 as outlined in the CAJR referenced above, it was determined that the immediacy of the deficient practice was removed on 12/23/2014; however, the effectiveness of the corrective action plans could not be fully assessed at the time of survey exit to ensure ongoing application and completion. On 12/22/2014, the facility conducted nursing staff in-service training regarding the facility's anticoagulant clinical guidelines for PT/INR laboratory test order entry, laboratory requisition procedures, and the process of completing the Diagnostic Tracking Forms and PT/INR Flow Sheets. Licensed nursing staff had also received in-service training regarding medication administration per the anticoagulant therapy guidelines. However, as of 12/22/2014, twenty-two (22) of the facility's twenty-seven (27) licensed nursing staff had received this training, but five (5) licensed nursing staff were unavailable for training at that time and would need to receive this in-service training upon their return to work. Therefore, the completion of this in-service training for these remaining licensed nursing staff who had not yet received training could not be assessed at the time of survey exit, and would need to be assessed at a future date. Additionally, on 12/22/2014, the facility initiated a procedure by which the DNS/Designated Nurse Supervisor would conduct random audits Diagnostic Tracking Forms and PT/INR Flow Sheets for residents receiving anticoagulant drug therapy. The audits of the Diagnostic Tracking Forms would assess nursing staff conformance with metrics which included, but were not limited to, the ordering and requisitioning of laboratory tests to ensure that laboratory tests were received and that physicians were notified of laboratory test results. The PT/INR Flow Sheet audits would assess nursing staff conformance with metrics which included, but were not limited to, laboratory testing dates and results, and the date the next laboratory test was ordered. The DNS/Nurse Supervisor audits would be conducted daily for thirty (30) days, then weekly for four (4) weeks, then monthly for six (6) months to monitor for compliance. Any negative results of these management staff audits of the Diagnostic Tracking Forms and PT/INR Flow Sheets would be reviewed by the QAA Committee during the monthly QAA Committee meetings. The QAA Committee had met on 12/22/2014 to approve this audit process for the monitoring, via management staff audits, of nursing staff conformance with the facility's anticoagulant clinical guidelines and anticoagulant therapy guidelines. However, this management staff audit process had been initiated only on 12/22/2014, and the QAA Committee had therefore not had the opportunity to meet to begin the process of evaluating, on an ongoing basis, the results of these ongoing staff audits to determine the potential need for procedure revision or additional staff training. Therefore, the QAA Committee's ongoing oversight of facility staff conformance with anticoagulant drug administration and laboratory requisition procedures could not be fully assessed at the time of survey exit, and will need further evaluation at a future date. Based on the above, due to the need for continued evaluation of the facility's corrective action plans to ensure ongoing effectiveness, application, and completion, the noncompliance continues, with the scope and severity reduced to the "E" level.

Based on clinical record review and staff interview, the facility failed to provide laboratory services to meet the needs of five (5) residents (#3, #10, #13, #15, and #16), who received [MEDICATION NAME] anticoagulant drug therapy, by failing to obtain [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) laboratory testing as ordered by the physician for these residents. A total of nine (9) sampled residents received [MEDICATION NAME] drug therapy on the survey sample of twenty-one (21) residents. This failure resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents, as outlined below: - For Resident #3, the facility failed to ensure the provision of laboratory services to meet the resident's needs by failing to obtain weekly PT/INR laboratory tests as ordered: Resident #3 received [MEDICATION NAME] drug therapy. However, despite a physician's orders [REDACTED].#3 receive weekly PT/INR laboratory tests, there was no evidence to indicate that the facility obtained weekly PT/INR laboratory test as ordered after 11/28/2014. - For Resident #13, the facility failed to ensure the provision of laboratory services to meet the resident's needs by failing to obtain weekly PT/INR laboratory tests as ordered: Resident #13 received [MEDICATION NAME] drug therapy. However, despite a physician's orders [REDACTED].#13 receive weekly PT/INR laboratory tests, there was no evidence to indicate that the facility obtained the weekly PT/INR laboratory tests as ordered after 11/26/2014. - For Resident #10, the facility failed to ensure the provision of laboratory services to meet the resident's needs by failing to obtain weekly PT/INR laboratory tests as ordered: Resident #10 received [MEDICATION NAME] drug therapy. However, despite a physician's orders [REDACTED].#10, there was no evidence to indicate that the facility obtained weekly PT/INR testing as ordered after 11/24/2014. - For Resident #16, the facility failed to ensure the provision of laboratory services to meet the resident's needs by failing to obtain a repeat PT/INR laboratory test as ordered: Resident #16 received [MEDICATION NAME] drug therapy. A laboratory report of 11/26/2014 for Resident #16 documented PT/INR results of 29.8 and 2.94, respectively, and the physician ordered to repeat the PT/INR level in one (1) week. However, there was no evidence to indicate that the facility obtained this repeat PT/INR laboratory test for Resident #16 as ordered. - For Resident #15, the facility failed to ensure the provision of laboratory services to meet the resident's needs by failing to obtain weekly PT/INR laboratory tests as ordered: Resident #15 received [MEDICATION NAME] drug therapy. However, despite a physician's orders [REDACTED].#15, there was no evidence to indicate that the facility obtained weekly PT/INR testing as ordered after 11/24/2014. As outlined above, the facility's failure to obtain PT/INR laboratory tests as ordered for Resident #3, Resident #10, Resident #13, Resident #15, and Resident #16 resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator was informed of the immediate jeopardy on December 23, 2014 at 8:30 a.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on December 1, 2014, the date the facility failed to obtain the first of three (3) missed [MEDICATION NAME] Time/International Ratio (PT/INR) laboratory tests ordered to be done weekly for Resident #10, who received [MEDICATION NAME] anticoagulant drug therapy. The immediate jeopardy continued through December 22, 2014, and was removed on December 23, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on December 22, 2014. During an interview with the Administrator and the Director of Nursing Services (DNS) conducted on 12/24/2014 at 9:25 a.m., these staff members stated that the facility had a system for the requisitioning of laboratory tests, but acknowledged that laboratory test requisition system had not been followed. An allegation of jeopardy removal was received on December 23, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on December 23, 2014. The facility remained out of compliance at a lower scope and severity of "E" while the process of evaluating modifications of the laboratory requisition and medication administration systems continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's processes for obtaining laboratory tests as ordered by the physician and the administration of resident medication. Resident record reviews were conducted to assess facility staffs' conformance with physicians' orders regarding the requisition and acquisition of laboratory tests. In addition, resident record reviews were conducted, and observation of medication administration were made, to assess staffs' conformance with physicians' medication orders. Findings include: 1. Resident #3's Annual Minimum Data Set (MDS) assessment of 10/08/2014 documented, in Section I - Active Diagnoses, that [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#3 receive the anticoagulant [MEDICATION NAME] 2.5 milligrams (mgs) at bedtime on Sunday, Monday, Wednesday, Thursday, and Saturday, and 5 mgs at bedtime on Tuesday and Friday. A physician's orders [REDACTED].#3's [MEDICATION NAME] to 2.5 mgs at bedtime on Sunday, Monday, Wednesday, Thursday, and Friday, and 5 mgs at bedtime on Tuesday and Saturday. Record review for Resident #3 also revealed that, during the period of time when the 10/08/2014 and 11/18/2014 physician's orders [REDACTED]. A weekly 11/28/2014 PT/INR laboratory test for Resident #3 revealed a PT of 22.7 and an INR of 2.06. However, further record review revealed no evidence to indicate that the facility obtained the weekly PT/INR laboratory tests as ordered, or obtained any PT/INR tests, for Resident #3 after the 11/28/2014 PT/INR test referenced above. During a 12/21/2014, 10:45 a.m. interview, Registered Nurse (RN) "EE" acknowledged that Resident #3's PT/INR laboratory tests were ordered weekly but were not done during December of 2014. Based on the above, Resident #3 received [MEDICATION NAME] drug therapy and had a physician's orders [REDACTED]. However, the facility failed to obtain these PT/INR tests, ordered to be done weekly, after a PT/INR laboratory test of 11/28/2014. The facility therefore failed to provide laboratory services to meet the needs of Resident #3 by failing to obtain the weekly PT/INR laboratory tests as ordered. Cross refer to F309, example 1, for more information regarding Resident #3. 2. Resident #13's Quarterly MDS assessment of 11/01/2014 documented diagnoses, in Section I - Active Diagnoses, including, but not limited to, Diabetes Mellitus, [MEDICAL CONDITION], and Heart Failure. A December 2014 physician's orders [REDACTED].#13 receive [MEDICATION NAME] 3 mgs at bedtime, and an order dating from 09/24/2014 specified a weekly PT/INR laboratory test. A weekly laboratory report dated 11/26/2014 for Resident #13 documented a PT of 26.8 and an INR of 2.56, but record review revealed no evidence of any PT/INR laboratory tests for Resident #13 after this 11/26/2014 PT/INR test. During a 12/21/2014, 3:40 p.m. interview, no evidence was presented by the Director of Nursing Services (DNS) of any PT/INR test for Resident #13 after 11/26/2014. Based on the above, Resident #13 received [MEDICATION NAME] drug therapy and had a physician's orders [REDACTED]. However, the facility failed to obtain these ordered weekly PT/INR laboratory tests after 11/26/2014. The facility therefore failed to provide laboratory services to meet the needs of Resident #13 by failing to obtain the weekly PT/INR laboratory tests as ordered. Cross refer to F309, example 2, for more information regarding Resident #13. 3. Resident #10's Annual MDS assessment of 11/01/2014 documented diagnoses, in Section I - Active Diagnoses, including, but not limited to, Hypertension, [MEDICAL CONDITION], Diabetes Mellitus, [MEDICAL CONDITION], and [MEDICAL CONDITION]. A physician's orders [REDACTED]. Subsequent physician's orders [REDACTED].#10's [MEDICATION NAME] therapy to 1 mg at bedtime every Tuesday, Thursday, and Saturday, and 1.5 mg at bedtime every Monday, Wednesday, and Friday. Then, a physician's orders [REDACTED].#1 receive [MEDICATION NAME] 2 mgs in the evening. Resident #10's record also revealed a December 2014 physician's orders [REDACTED]. This was in conjunction with the period of time during which Resident #10 received [MEDICATION NAME] anticoagulant therapy, per the orders of 10/23/2014, 11/19/2014, and 12/02/2014 referenced above. However, despite Resident #10's physician's orders [REDACTED].#10's record revealed no evidence of a PT/INR test after a PT/INR test of 11/24/2014, which documented a PT result of 14.8 and an INR result of 1.18. During interview on 12/21/2014 at 12:20 p.m., RN "EE" acknowledged the facility's failure to obtain Resident #10's weekly PT/INR tests after 11/24/2014. Based on the above, despite Resident #10 receiving [MEDICATION NAME] anticoagulant drug therapy and a physician's orders [REDACTED]. The facility therefore failed to provide laboratory services to meet the needs of Resident #10 by failing to obtain the weekly PT/INR laboratory tests as ordered. Cross refer to F309, example 3, for more information regarding Resident #10. 4. Resident #16's Quarterly MDS assessment of 11/26/2014 documented diagnoses, in Section I - Active Diagnoses, which included, but were not limited to, Dementia, Diabetes Mellitus, [MEDICAL CONDITION], and [MEDICAL CONDITION]. physician's orders [REDACTED].#16 receive [MEDICATION NAME] 4.5 mgs at bedtime every Monday, Wednesday, and Friday, and 4 mgs in the evening every Sunday, Tuesday, Thursday, and Saturday. An 11/26/2014 laboratory report for Resident #16 documented PT/INR results of 29.8 and 2.94, respectively, and a notation on this report documented a physician's orders [REDACTED]. However, review of Resident #16's record revealed no evidence of a PT/INR laboratory test after the 11/26/2014 PT/INR test referenced above. During interview on 12/21/2014 at 2:00 p.m., RN "EE" acknowledged that the facility failed to obtain the repeat PT/INR laboratory test as ordered for Resident #16. Based on the above, Resident #16 received [MEDICATION NAME] drug therapy. A laboratory report of 11/26/2014 documented elevated PT/INR results, and the physician ordered a repeat PT/INR test in one (1) week; however, the facility failed to obtain this repeat PT/INR test for Resident #16. The facility therefore failed to provide laboratory services to meet the needs of Resident #16 by failing to obtain the repeat PT/INR laboratory test as ordered. Cross refer to F309, example 4, for more information regarding Resident #16. 5. Resident #15's Quarterly MDS assessment of 09/25/2014 documented in Section I - Active Diagnoses, the resident's [DIAGNOSES REDACTED]. The current December 2014 physician's orders [REDACTED].#15 to receive [MEDICATION NAME] 4 mgs in the evening, and an order originally dating from 09/24/2014 for a PT/INR laboratory test weekly. A laboratory report dated 11/24/2014 for Resident #15 documented that a weekly PT/INR laboratory test had been obtained on that date; however, record review revealed no subsequent PT/INR laboratory tests for Resident #15. During interview on 12/21/2014 at 2:00 p.m., RN "EE" acknowledged Resident #15's omitted PT/INR laboratory tests. Based on the above, Resident #15 received [MEDICATION NAME] anticoagulant drug therapy and had a physician's orders [REDACTED]. The facility, however, failed to obtain weekly PT/INR tests as ordered for Resident #15 after 11/24/2014. The facility therefore failed to provide laboratory services to meet the needs of Resident #15 by failing to obtain weekly PT/INR laboratory tests as ordered. Cross refer to F309, example 5, for more information regarding Resident #15. The facility presented an acceptable credible allegation of jeopardy removal (CAJR) on December 23, 2014. Based on this CAJR, it was determined that the immediate jeopardy had been removed on December 23, 2014, at which time the facility had implemented the following interventions: 1. On 12/21/2014, the facility's Medical Director was notified of the missed PT/INR laboratory tests, and physicians' orders were given to obtain these PT/INR laboratory tests. All PT/INR laboratory test results were received by the facility on 12/22/2014, and the physician was notified of the results. Orders were received to recheck these laboratory test results on 12/29/2014. Laboratory requisitions were completed for these residents having PT/INR laboratory testing ordered to be completed on 12/29/2014. 2. On 12/21/2014, the facility initiated a procedure by which the monitoring of resident [MEDICATION NAME] will be conducted. The DNS/Nurse Supervisor will monitor, via an audit, 100 percent of resident [MEDICATION NAME] drug orders and laboratory orders daily for thirty (30) days, then weekly for four (4) weeks, then monthly for six (6) months. Any negative findings will be addressed immediately with a time frame not to exceed the end of the current shift and will include 1:1 staff retraining and education. Additionally, any negative findings will be reviewed by the Quality Assessment and Assurance (QAA) Committee during monthly meetings for (6) six months. 3. On 12/22/2014, the facility conducted record reviews for all residents receiving [MEDICATION NAME] anticoagulant drug therapy to ensure that all orders were correct and that PT/INR laboratory tests were scheduled for completion, per physicians' orders. Entries were updated on the Diagnostic Tracking Form. The specific purposes for the Diagnostic Tracking Form were to ensure that each diagnostic test had been ordered/requisitioned, to ensure the laboratory had collected the specimen, and to ensure the laboratory results had been received and the physician notified of the results. This Diagnostic Tracking Form will be utilized by all licensed nursing staff for all PT/INR laboratory orders, regardless of who is to draw the laboratory test. Licensed nurses will enter the new PT/INR orders on the Diagnostic Tracking Form, with the date the PT/INR is to be drawn. The Diagnostic Tracking Form will also be used to track the laboratory results as they are received, and to track physician notification of the laboratory test results. The Unit Manager/Registered Nurse will notify the physician of PT/INR laboratory results upon receipt daily by telephone. A daily audit of resident Diagnostic Tracking Forms will be conducted by the Unit Manager/RN Supervisor. 4. On 12/22/2014, the facility initiated a procedure by which the Unit Manager/Nurse Supervisor will be responsible for completing the PT/INR Flow Sheets. The PT/INR Flow Sheets serve to document the following information for each resident receiving anticoagulant drug therapy and PT/INR laboratory testing: the date of the laboratory test; the PT/INR result; the anticoagulant drug dose; the date the next laboratory test is ordered; the initials of the staff person taking the order; and any pertinent comments. The process of completion of these resident PT/INR Flow Sheets will be monitored daily by the Unit Manager/RN Supervisor for compliance. 5. On 12/22/2014, the facility initiated a procedure by which the DNS/Designated Nurse Supervisor will conduct random audits the Diagnostic Tracking Form and PT/INR Flow Sheets for residents receiving anticoagulant drug therapy daily for thirty (30) days, then weekly for four (4) weeks, then monthly for six (6) months to monitor for nursing staff compliance. The DNS/Nurse Supervisor will sign and date the Diagnostic Tracking Forms sheets and PT/INR Flow Sheets as evidence of these random audits. Any negative findings will be addressed immediately, with the time frame not to exceed the end of the current shift, and will include 1:1 retraining and education. Additionally, any negative audit findings will be reviewed by the QAA Committee during monthly Committee meetings. 6. On 12/22/2014, the facility reviewed the care plans for all residents receiving [MEDICATION NAME] anticoagulant drug therapy. Care plan revisions were made as needed. 7. On 12/22/2014, the facility initiated a procedure by which the DNS will conduct random, weekly audits involving three (3) residents who receive [MEDICATION NAME] drug therapy to ensure care plan completion. This audit process will continue for six (6) months to ensure compliance. 8. On 12/22/2014, the facility conducted nursing staff in-service training regarding the facility's anticoagulant clinical guidelines, including laboratory order entry for PT/INR laboratory tests, the facility's laboratory requisition procedures, and the process of documentation to be used by nursing staff when completing the Diagnostic Tracking Forms and PT/INR Flow Sheets. Additionally, licensed nursing staff who administer resident medications received in-service training related to the administration of medications in conformance with the facility's anticoagulant therapy guidelines. As of 12/22/2014, a total of twenty-two (22) of the facility's twenty-seven (27) licensed nursing staff had received this in-service training. The remaining five (5) licensed nursing staff who had been unavailable for training at that time, due to being off work, will receive this in-service training upon their return to work and will not be allowed to work until training has been provided. Newly-hired licensed staff will receive in-service training regarding the facility's anticoagulant clinical and therapy guidelines during the facility's orientation process. 9. On 12/22/2014, the facility's QAA Committee met to review the procedures and interventions put into place to address the identified quality deficiencies related to the failure to obtain PT/INR laboratory testing as ordered and the failure to administer anticoagulant drug therapy as ordered. A procedure was developed and implemented by which the results of management staff monitoring of the [MEDICATION NAME] anticoagulant drug therapy monitoring, as well as the management staffs' audits of the Diagnostic Tracking Forms and the PT/INR Flow Sheets, would be presented to the QAA Committee each month by the Executive Director and/or DNS. This will allow the QAA Committee to monitor staff compliance with the facility's policies and procedures regarding the receipt, transcription, and implementation of physicians' orders for [MEDICATION NAME] dosing, and PT/INR monitoring through laboratory testing, to ensure that these policies, procedures, and systems are in compliance. During this abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 12/23/2014, interview with the DNS confirmed that the Medical Director was notified of missed PT/INR laboratory tests. Additional interview with the DNS, and resident record reviews conducted during this abbreviated survey, confirmed that physicians' orders had been obtained for these PT/INR laboratory tests and that test results were received by the facility as of 12/22/2014. This was in conformance with Step 1 of the facility's CAJR referenced above. - On 12/23/2014, DNS interview and audit tool review confirmed that the facility had initiated a procedure allowing for DNS/Nurse Supervisor audits of 100 percent of resident [MEDICATION NAME] drug orders and laboratory orders daily for thirty (30) days, weekly for four (4) weeks, then monthly for six (6) months. Negative findings would be addressed immediately and reviewed by the QAA Committee monthly. This was in accordance with Step 2 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator and DNS, and also ongoing resident record review during the abbreviated survey, confirmed that the facility had reviewed all resident records of residents receiving [MEDICATION NAME] drug therapy to assess for order accuracy and to ensure that PT/INR laboratory tests were scheduled. Administrator and DNS interview confirmed that Diagnostic Tracking Form entries had been updated, and that this Form would be used by nursing staff to document and track PT/INR laboratory orders, PT/INR date, laboratory results, and physician notification. This was in accordance with Step 3 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator and DNS confirmed the facility's procedure for completion of the PT/INR Flow Sheets by the Unit Manager/Nurse Supervisor. Review of the PT/INR Flow Sheet confirmed that the Flow Sheet tracked laboratory test dates, PT/INR results, anticoagulant drug dose, date of next laboratory test, and initials of the staff taking an order. This was in conformance with Step 4 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator and DNS confirmed the facility's procedure by which the DNS/Designated Nurse Supervisor will conduct random audits the Diagnostic Tracking Form and PT/INR Flow Sheets daily for thirty (30) days, then weekly for four (4) weeks, then monthly for six (6) months to monitor for compliance. This was in conformance with Step 5 of the facility's CAJR referenced above. - On 12/23/2014, resident record reviews, which had been ongoing through the survey, confirmed, via documented updates, that the care plans of residents receiving [MEDICATION NAME] anticoagulant drug therapy had been reviewed and updated. This was in conformance with Step 6 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator and DNS confirmed the facility's procedure of DNS weekly audits, continuing for six (6) months, of the records of three (3) residents who receive [MEDICATION NAME] drug therapy to ensure care plan completion. This was in conformance with Step 7 of the facility's CAJR referenced above. - On 12/23/2014, review of facility in-service training records confirmed that the facility had conducted nursing staff in-service training for twenty-two (22) of twenty-seven (27) licensed nursing staff regarding the anticoagulant clinical guidelines, including order entry for PT/INR tests, laboratory requisition procedures, and the documentation process used when completing Diagnostic Tracking Forms and PT/INR Flow Sheets. This in-service training record review confirmed that licensed nursing staff who administer medications had received training regarding medication administration per anticoagulant therapy guidelines. This is accordance with Step 8 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator, and review of a QAA Committee signature sheet dated 12/22/2014 presented by the facility, confirmed that the QAA Committee had met on 12/22/2014 to review the new procedures and processes regarding PT/INR laboratory testing and anticoagulant medication administration, and the new procedure regarding the Committee's monthly review of management staff audit results, via use of the Diagnostic Tracking Form review and PT/INR Flow Sheet review. This was in accordance with Step 9 of the facility CAJR referenced above. Based on these corrective actions which had been developed and implemented by the facility on 12/22/2014 as outlined in the CAJR referenced above, it was determined that the immediacy of the deficient practice was removed on 12/23/2014; however, the effectiveness of the corrective action plans could not be fully assessed at the time of survey exit to ensure ongoing application and completion. On 12/22/2014, the facility conducted nursing staff in-service training regarding the facility's anticoagulant clinical guidelines for PT/INR laboratory test order entry, laboratory requisition procedures, and the process of completing the Diagnostic Tracking Forms and PT/INR Flow Sheets. Licensed nursing staff had also received in-service training regarding medication administration per the anticoagulant therapy guidelines. However, as of 12/22/2014, twenty-two (22) of the facility's twenty-seven (27) licensed nursing staff had received this training, but five (5) licensed nursing staff were unavailable for training at that time and would need to receive this in-service training upon their return to work. Therefore, the completion of this in-service training for these remaining licensed nursing staff who had not yet received training could not be assessed at the time of survey exit, and would need to be assessed at a future date. Additionally, on 12/22/2014, the facility initiated a procedure by which the DNS/Designated Nurse Supervisor would conduct random audits Diagnostic Tracking Forms and PT/INR Flow Sheets for residents receiving anticoagulant drug therapy. The audits of the Diagnostic Tracking Forms would assess nursing staff conformance with metrics which included, but were not limited to, the ordering and requisitioning of laboratory tests to ensure that laboratory tests were received and that physicians were notified of laboratory test results. The PT/INR Flow Sheet audits would assess nursing staff conformance with metrics which included, but were not limited to, laboratory testing dates and results, and the date the next laboratory test was ordered. The DNS/Nurse Supervisor audits would be conducted daily for thirty (30) days, then weekly for four (4) weeks, then monthly for six (6) months to monitor for compliance. Any negative results of these management staff audits of the Diagnostic Tracking Forms and PT/INR Flow Sheets would be reviewed by the QAA Committee during the monthly QAA Committee meetings. The QAA Committee had met on 12/22/2014 to approve this audit process for the monitoring, via management staff audits, of nursing staff conformance with the facility's anticoagulant clinical guidelines and anticoagulant therapy guidelines. However, this management staff audit process had been initiated only on 12/22/2014, and the QAA Committee had therefore not had the opportunity to meet to begin the process of evaluating, on an ongoing basis, the results of these ongoing staff audits to determine the potential need for procedure revision or additional staff training. Therefore, the QAA Committee's ongoing oversight of facility staff conformance with anticoagulant drug administration and laboratory requisition procedures could not be fully assessed at the time of survey exit, and will need further evaluation at a future date. Based on the above, due to the need for continued evaluation of the facility's corrective action plans to ensure ongoing effectiveness, application, and completion, the noncompliance continues, with the scope and severity reduced to the "E" level.

Based on clinical record review, PT/INR ([MEDICATION NAME]/International Normalized Ratio) Flow Sheet review, Medication Administration Record [REDACTED]#15, and #16) who received [MEDICATION NAME] anticoagulant drug therapy and had physicians' orders for PT/INR laboratory testing, and failed to administer [MEDICATION NAME] anticoagulant drug therapy as ordered by the physician for two (2) residents (#3 and #9). A total of nine (9) sampled residents received [MEDICATION NAME] drug therapy on the survey sample of twenty-one (21) residents. This failure resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents, as outlined below: - For Resident #3, the facility failed to administer [MEDICATION NAME] anticoagulant drug therapy as ordered, and failed to obtain weekly PT/INR laboratory tests as ordered: Resident #3 received [MEDICATION NAME] drug therapy for [MEDICAL CONDITION] Fibrillation. However, even though the physician ordered on [DATE] to continue the resident's [MEDICATION NAME] dose after a PT/INR laboratory test of 10/27/2014, nursing staff held the resident's [MEDICATION NAME] dose, in error, from 10/28/2014 through 11/02/2014, for a total of 6 days. In addition, even though a physician's orders [REDACTED].#3 receive weekly PT/INR laboratory tests, and even though a weekly PT/INR laboratory test of 11/28/2014 revealed a PT of 22.7 and an INR of 2.06, the facility failed to obtain weekly PT/INR laboratory tests after 11/28/2014. On 12/21/2014, after surveyor inquiry regarding the missing PT/INR laboratory tests for Resident #3, a PT/INR laboratory test was obtained and revealed a PT of 17.9 seconds and an INR of 1.65, and the physician ordered to increase [MEDICATION NAME] to 5 mgs nightly at bedtime related to [MEDICAL CONDITION] Fibrillation. - For Resident #13, the facility failed to obtain weekly PT/INR laboratory tests as ordered: Resident #13 received [MEDICATION NAME] anticoagulant drug therapy related to Embolism, Arterial [MEDICAL CONDITION] of the Lower Extremity, and [MEDICAL CONDITION] Fibrillation. However, even though Resident #13 was ordered to receive weekly PT/INR laboratory tests, and even though an 11/26/2014 PT/INR laboratory test documented a high PT of 26.8 seconds and an an INR of 2.56, the facility failed to obtain the ordered weekly PT/INR tests after 11/26/2014. On 12/21/2014, after surveyor inquiry regarding Resident #13's missing PT/INR tests, a PT/INR laboratory test revealed a PT of 13.2 and an INR of 1.24, and the physician ordered to increased the dose of [MEDICATION NAME] to 4 mgs at bedtime. - For Resident #10, the facility failed to obtain weekly PT/INR laboratory tests as ordered: Resident #10 received [MEDICATION NAME] drug therapy for Acute [MEDICAL CONDITION] Infarction and Phlebitis/[MEDICAL CONDITION]. However, even though a physician's orders [REDACTED]. On 12/22/2014, after a 12/21/2014 surveyor inquiry regarding the missing PT/INR laboratory tests for Resident #10, a PT/INR laboratory test documented a PT of 11.3 and an INR of 1.07, and the physician ordered an increase in Resident #10's [MEDICATION NAME] to 3 mgs daily for Phlebitis/[MEDICAL CONDITION] of the Upper Extremity. - For Resident #16, the facility failed to obtain a repeat PT/INR laboratory test as ordered: Resident #16, who received [MEDICATION NAME] anticoagulant drug therapy, had a laboratory report of 11/26/2014 which documented a PT of 29.8 and an INR of 2.94. However, even though the physician ordered to repeat the PT/INR level in one (1) week, the facility failed to obtain this repeat PT/INR laboratory test for Resident #16. On 12/21/2014, after surveyor inquiry regarding the missed PT/INR test, a laboratory report was obtained which documented a high PT of 33.3 and a high INR of 2.96, and the physician modified the [MEDICATION NAME] dose to 4 mgs at bedtime. - For Resident #15, the facility failed to obtain weekly PT/INR laboratory tests as ordered: Resident #15 received [MEDICATION NAME] anticoagulant drug therapy. However, even though a physician's orders [REDACTED].#15, and even though a weekly PT/INR laboratory test of 11/24/2014 revealed a PT of 24.2 and an INR of 2.24, the facility failed to obtain the ordered weekly PT/INR tests after 11/24/2014. On 12/22/2014, after surveyor inquiry, a PT/INR laboratory test was obtained and documented Resident #15 to have a PT of 32.1 and an INR of 2.86, and the physician lowered the [MEDICATION NAME] dose to 3.5 mgs at bedtime. - For Resident #9, the facility failed to administer [MEDICATION NAME] anticoagulant drug therapy as ordered: Resident #9 received [MEDICATION NAME] therapy at a 3 mg daily dose. However, Resident #9 was given [MEDICATION NAME] 3 mg doses on 12/14/2014 at 9:00 a.m. and 9:00 p.m., in error. In addition, despite a physician's orders [REDACTED].#9 received [MEDICATION NAME] 6 mg doses at 9:00 a.m. and 9:00 p.m., and a [MEDICATION NAME] 3 mg dose at 9:00 p.m. on 12/19/2014, in error. As outlined above, the facility's failure to obtain PT/INR laboratory tests as ordered and/or administer [MEDICATION NAME] anticoagulant drug therapy as ordered for Resident #3, Resident #9, Resident #10, Resident #13, Resident #15, and Resident #16 resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator was informed of the immediate jeopardy on December 23, 2014 at 8:30 a.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on December 1, 2014, the date the facility failed to obtain the first of three (3) missed PT/INR laboratory tests ordered to be done weekly for Resident #10, who received [MEDICATION NAME] anticoagulant drug therapy. The immediate jeopardy continued through December 22, 2014, and was removed on December 23, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on December 22, 2014. During an interview with the Administrator and the Director of Nursing Services (DNS) conducted on 12/24/2014 at 9:25 a.m., these staff members stated that the facility had a system for requisitioning laboratory tests ordered by the physician and for receiving the results of these laboratory tests. However, both the Administrator and DNS acknowledged that this process involving the acquisition and tracking of resident laboratory tests had not been followed. An allegation of jeopardy removal was received on December 23, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on December 23, 2014. The facility remained out of compliance at a lower scope and severity of "E" while the process of evaluating modifications of the laboratory requisition and medication administration systems continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's processes for obtaining laboratory tests as ordered by the physician and the administration of resident medication. Resident record reviews were conducted to assess facility staffs' conformance with physicians' orders regarding the requisition and acquisition of laboratory tests. In addition, resident record reviews were conducted, and observation of medication administration were made, to assess staffs' conformance with physicians' medication orders. Findings include: 1. Record review for Resident #3 revealed an Annual Minimum Data Set (MDS) assessment having an Assessment Reference Date of 10/08/2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Review of the October 2014 physician's orders [REDACTED]. Another physician's orders [REDACTED].#3 receive [MEDICATION NAME] 5 mgs at bedtime every Tuesday and Friday related to [MEDICAL CONDITION] Fibrillation. A physician's orders [REDACTED].#3 receive PT/INR laboratory tests weekly and as ordered by the physician. Review of a Clinical Laboratory Services (CLS) laboratory report for Resident #3, which documented a blood sample collection date of 10/27/2014, revealed a high PT result of 31.8 seconds (Reference Range: 11.0 - 15 seconds), and an INR result of 3.2 (Recommended Therapeutic Range for Prevention of Embolism: 2.00 - 3.00). This CLS laboratory report for Resident #3 also documented 10/27/2014 as the date this PT/INR laboratory test result was reported back to the facility. A handwritten notation signed by the nurse on the CLS laboratory report requested that Resident #3's [MEDICATION NAME] 2.5 mg and [MEDICATION NAME] 5 mg drug therapy be held for three (3) days, unless the physician would prefer otherwise. A facsimile-stamped date of 10/28/2014 atop this CLS laboratory report documented 10/28/2014 as the date Resident #3's physician responded back to the facility regarding the nurse's request to hold Resident #3's [MEDICATION NAME] 2.5 mg and 5 mg drug therapy, and a notation by the physician indicated to continue the same dose of [MEDICATION NAME] (rather than holding [MEDICATION NAME] drug therapy). However, review of Resident #3's October 2014 and November 2014 Medication Administration Records (MARs) revealed that the resident's [MEDICATION NAME] 2.5 mg drug therapy was held on 10/29/2014 (Wednesday), 10/30/2014 (Thursday), 11/01/2014 (Saturday) and 11/02/2014 (Sunday), and [MEDICATION NAME] 5 mg drug therapy was held on 10/28/2014 (Tuesday) and 10/31/2014 (Friday). This was despite the physician's orders [REDACTED].#3's CLS laboratory report referenced above, which specified to continue the resident's [MEDICATION NAME] drug therapy. This therefore represented a total of six (6) days (10/28/2014, 10/29/2014, 10/30/2014, 10/31/2014, 11/01/2014, and 11/02/2014) during which Resident #3's [MEDICATION NAME] anticoagulant drug therapy was not administered as ordered. Resident #3's November MAR indicated [REDACTED]. During an interview with Unit Manager Registered Nurse (RN) "EE" conducted on 12/21/2014 at 10:45 a.m., RN "EE" acknowledged that Resident #3's [MEDICATION NAME] drug therapy had been held from 10/28/2014 through 11/02/2014, as documented on the resident's October and November 2014 MARs. Additionally, review of the November 2014 physician's orders [REDACTED]. Record review for Resident #3 also revealed November and December 2014 physician's orders [REDACTED]. A CLS report form for Resident #3, reflecting 11/14/2014 as the date of blood sample collection, revealed a high PT result of 19.5 seconds (Reference Range: 11.0 - 15.0 seconds), and an INR result of 1.69 (Reference Range: 2.00 - 3.00 for prevention of systemic embolism). A handwritten notation dated 11/15/2014 on this CLS report form documented the physician was notified of the PT/INR laboratory results for Resident #3. physician's orders [REDACTED].#3's previous orders of 11/03/2014, referenced above, for [MEDICATION NAME] 2.5 mg (on Sunday, Monday, Wednesday, Thursday, and Saturday) and [MEDICATION NAME] 5 mg (on Tuesday). These 11/18/2014 physician's orders [REDACTED].#3 receive [MEDICATION NAME] 2.5 mgs by mouth at bedtime at the modified frequency of every Sunday, Monday, Wednesday, Thursday, and Friday, and [MEDICATION NAME] 5 mgs by mouth at bedtime every Tuesday and Saturday, related to [MEDICAL CONDITION] Fibrillation. Review of the PT/INR flow sheet for Resident #3 revealed that after the weekly 11/14/2014 PT/INR laboratory tests referenced above, weekly PT/INR laboratory tests were done as ordered on [DATE] (revealing a PT result of 21.9 seconds and an INR result of 1.97) and 11/28/2014 (revealing a PT result of 22.7 and an INR result of 2.06). However, further record review for Resident #3, to include review of the resident's PT/INR flow sheet, revealed no evidence to indicate that any PT/INR laboratory tests were completed for this resident after the 11/28/2014 PT/INR test referenced above. This was despite Resident #3's physician's orders [REDACTED]. Further review of Resident #3's clinical record revealed that, despite the facility's failure to obtain the weekly PT/INR laboratory tests ordered to monitor Resident #3's blood coagulation as related to the [MEDICATION NAME] drug therapy, the resident's December 2014 Medication Administration Record [REDACTED]. During the 12/21/2014, 10:45 a.m. interview with Unit Manger RN "EE" referenced above, RN "EE" acknowledged that the PT/INR laboratory tests, ordered to be done weekly, had not been obtained for Resident #3 during the month of December 2014, and stated that a laboratory test would be obtained. A laboratory coagulation report form for Resident #3 reflecting a blood sample collection date of 12/21/2014 (after the initiation of this abbreviated survey) revealed that the resident's PT result was high at 17.9 seconds, and revealed an INR result of 1.65. Further record review for Resident #3 revealed a Physician's Pharmacy Order form which documented that when contacted on 12/21/2014, the physician ordered to increase [MEDICATION NAME] anticoagulant drug therapy to 5 mgs by mouth nightly at bedtime related to [MEDICAL CONDITION] Fibrillation. Based on the above, Resident #3 received [MEDICATION NAME] anticoagulant drug therapy for the [DIAGNOSES REDACTED]. However, the facility held the resident's daily [MEDICATION NAME] doses from 10/28/2014 through 11/02/2014 (a total of 6 days) in the absence of a physician's orders [REDACTED]. In addition, after completion of a PT/INR laboratory test on 11/28/2014, the resident continued to receive daily [MEDICATION NAME] drug therapy as ordered, but the facility failed to obtain any additional PT/INR laboratory tests during the month of December 2014 until 12/21/2014 (after facility staff was questioned regarding the absence of PT/INR tests). This represented a period of approximately three (3) weeks during which Resident #3 continued to receive [MEDICATION NAME] anticoagulant drug therapy in the absence of the weekly PT/INR laboratory tests ordered to monitor the resident's coagulation function as related to [MEDICATION NAME]. Once a PT/INR test was obtained on 12/21/2014, Resident #3's physician increased the resident's [MEDICATION NAME] drug therapy to 5 mgs daily. 2. Record review for Resident #13 revealed a Quarterly MDS assessment having an Assessment Reference Date of 11/01/2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Further review of Resident #13's medical record revealed an Admission Record form which documented an additional [DIAGNOSES REDACTED]. Review of Resident #13's December 2014 Order Review Report revealed a current physician's orders [REDACTED]. Resident #13's December 2014 Order Review Report also documented an order, originally dating from 09/24/2014, which specified that a PT/INR laboratory test be done weekly and as ordered by the physician. Review of the medical record of Resident #13 revealed a weekly CLS laboratory report, reflecting 11/26/2014 as the blood sample collection date, which documented the resident's PT was high at 26.8 seconds, documented an INR of 2.56, and documented physician notification of this laboratory test result. However, further record review for Resident #13 revealed no evidence to indicate that any PT/INR laboratory tests, ordered to be completed weekly per the 09/24/2014 physician's orders [REDACTED].#13 after the 11/26/2014 PT/INR laboratory test documented on the CLS laboratory report referenced above. During an interview with the DNS conducted on 12/21/2014 at 3:40 p.m., the DNS reviewed the laboratory findings for Resident #13, but provided no evidence of a PT/INR laboratory test being provided for the resident after the PT/INR results documented on Resident #13's 11/26/2014 CLS laboratory report referenced above. Subsequent to the 12/21/2014, 3:40 p.m. DNS interview referenced above, a Physician's Laboratory Order form for Resident #13 documented a 12/21/2014, 9:43 p.m. physician's orders [REDACTED]. A clinical laboratory report, documenting a blood sample collection date of 12/21/2014, revealed a PT result of 13.2 seconds, and an INR of 1.24 (compared to Resident #13's PT of 26.8 seconds and INR of 2.56, as documented in the previous 11/26/2014 laboratory report referenced above). A 12/21/2014 physician's orders [REDACTED]. of [MEDICATION NAME] to 4 mgs by mouth at bedtime, related to Embolism, Arterial [MEDICAL CONDITION] of the Lower Extremity, and [MEDICAL CONDITION] Fibrillation. Review of Resident #13's December 2014 MAR indicated [REDACTED]. Based on the above, Resident #13 received [MEDICATION NAME] drug therapy for [MEDICAL CONDITION], and was ordered to receive weekly PT/INR laboratory tests. However, the facility failed to obtain the weekly PT/INR laboratory tests as ordered (or any PT/INR laboratory test) after 11/26/2014, when a laboratory test of 11/26/2014 documented a PT of 26.8 seconds and an INR of 2.56. After facility staff was questioned on 12/21/2014 regarding the Resident #13's PT/INR laboratory test order, a physician's orders [REDACTED]. A 12/21/2014 physician's orders [REDACTED].#13's nightly [MEDICATION NAME] dose to 4 mgs related to Embolism, Arterial [MEDICAL CONDITION] of the Lower Extremity, and [MEDICAL CONDITION] Fibrillation. 3. Record review for Resident #10 revealed an Annual MDS assessment having an Assessment Reference Date of 11/01/2014. Section I - Active [DIAGNOSES REDACTED].#10 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#10 receive [MEDICATION NAME] 2.5 mgs by mouth at bedtime related to Acute [MEDICAL CONDITION] Infarction (Unspecified). A December 2014 Order Review Report for Resident #10 also documented a physician's orders [REDACTED]. A CLS laboratory report for Resident #10, with 11/17/2014 listed as the blood sample collection date, documented a high PT result of 18.7 seconds, and an INR result of 1.6. physician's orders [REDACTED].#10 then modified the resident's [MEDICATION NAME] drug therapy, specifying to administer [MEDICATION NAME] 1 mg by mouth at bedtime every Tuesday, Thursday, and Saturday, and [MEDICATION NAME] 1.5 mg by mouth at bedtime every Monday, Wednesday, and Friday related to Phlebitis and [MEDICAL CONDITION] of the Upper Extremity (Unspecified). A CLS laboratory report, dated 11/24/2014 as the blood sample collection date, documented Resident #10's PT result as 14.8 seconds and INR result as 1.18. Subsequent to the 11/24/2014 CLS laboratory report referenced above (which documented an INR of 1.18, below the listed Reference Range of 2:00 - 3:00), a physician's orders [REDACTED].#1's [MEDICATION NAME] drug therapy, specifying to administer [MEDICATION NAME] 2 mgs by mouth in the evening related to Phlebitis and [MEDICAL CONDITION] of the Upper Extremity (Unspecified). However, even though Resident#10's physician's orders [REDACTED].#10 revealed no evidence of any PT/INR laboratory tests having been completed after the 11/24/2014 PT/INR test documented on the 11/24/2014 CLS laboratory report referenced above. During an interview with Unit Manager RN "EE" conducted on 12/21/2014 at 12:20 p.m., RN "EE" acknowledged that the last PT/INR laboratory report done for Resident #10 was the 11/24/2014 PT/INR laboratory report referenced above. A Physician's Laboratory Order form for Resident #10 documented a 12/22/2014 (the day after Unit Manager RN "EE" was questioned regarding the PT/INR laboratory testing during the 12/21/2014 interview referenced above) physician's orders [REDACTED].#10 have a one-time PT/INR laboratory test. Review of Resident #10's 12/22/2014 PT/INR Coagulation laboratory form test results revealed the resident's PT result was 11.3 seconds and the INR result was 1.07 (both lower than the PT result of 14.8 seconds and the INR result of 1.18 as documented on the 11/24/2014 CLS Laboratory report referenced above). Resident #10's Physician's Pharmacy Order form then specified a physician's orders [REDACTED]. Based on the above, despite Resident #10 receiving [MEDICATION NAME] anticoagulant drug therapy related to Phlebitis and [MEDICAL CONDITION] and having a physician's orders [REDACTED]. Upon the discovery, during this abbreviated survey, of the facility's failure to obtain the ordered weekly PT/INR laboratory tests for Resident #10, a one-time PT/INR laboratory test was ordered and revealed an even lower PT result of 11.3 seconds and a lower INR result of 1.07, and the physician ordered an increase in Resident #10's [MEDICATION NAME] from a dose of 2 mgs daily to a dose of 3 mgs daily. 4. Record review for Resident #16 revealed a Quarterly MDS assessment having an Assessment Reference Date of 11/26/2014 which documented in Section I - Active [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A CLS laboratory report for Resident #16, which reflected 11/26/2014 as the blood sample date of collection, documented the resident's PT result was high at 29.8 seconds, and documented an INR result of 2.94. A handwritten notation on this 11/26/2014 CLS laboratory report for Resident #16 documented the physician made no changes to the resident's [MEDICATION NAME] drug therapy, but documented a physician's orders [REDACTED]. However, further record review for Resident #16 revealed no evidence of any PT/INR laboratory tests being obtained for this resident after the 11/26/2014 PT/INR laboratory tests documented above which revealed an elevated PT of 29.8 seconds and an elevated INR of 2.94, despite the 11/26/2014 physician's orders [REDACTED]. During an interview with Unit Manager RN "EE" conducted on 12/21/2014 at 2:00 p.m., RN "EE" acknowledged the missed PT/INR laboratory test for Resident #16 and stated that she was securing a physician's orders [REDACTED]. A Physician's Laboratory Order form for Resident #16 documented a 12/21/2014 physician's orders [REDACTED]. Further review of Resident #16's record then revealed a clinical laboratory report having a blood sample collection date of 12/21/2014 which documented the resident to have a high PT result of 33.3 seconds and a high INR of 2.96. A subsequent Physician's Pharmacy Order form for Resident #16 documented a 12/21/2014 physician's orders [REDACTED]. [REDACTED]. Based on the above, Resident #16 had physician's orders [REDACTED]. A CLS laboratory report of 11/26/2014 documented an elevated PT of 29.8 seconds and an elevated INR of 2.94, and the physician ordered to repeat the PT/INR level in one (1) week. However, the facility failed to obtain this repeat PT/INR laboratory test for Resident #16 as ordered. On 12/21/2014, after inquiry regarding Resident #16's missed PT/INR laboratory test during this abbreviated survey, a laboratory report was obtained after physician notification and revealed a high PT result of 33.3 seconds and a high INR of 2.96. The physician then modified the resident's [MEDICATION NAME] anticoagulant drug dose to 4 mgs by mouth at bedtime. 5. Record review for Resident #15 revealed a Quarterly MDS assessment having an Assessment Reference Date of 09/25/2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Further review of Resident #15's medical record revealed an Admission Record form which documented an additional [DIAGNOSES REDACTED]. The December 2014 Order Review Report form for Resident #15 revealed a physician's orders [REDACTED]. This Order Report Form for Resident #15 also documented a physician's orders [REDACTED]. A CLS laboratory report for Resident #15 revealed a weekly PT/INR laboratory test, reflecting 11/24/2014 as the blood sample draw-date, which documented a PT result of 24.2 seconds and an INR result of 2.24. However, even though weekly PT/INR laboratory tests were ordered for Resident #15 per the physician's orders [REDACTED].#15 revealed no evidence of any subsequent PT/INR laboratory tests performed after this 11/24/2014 PT/INR test, as documented on this CLS laboratory report of that date. Review of Resident #15's December 2014 MAR indicated [REDACTED]. During an interview Unit Manager RN "EE" conducted on 12/21/2014 at 2:00 p.m., RN "EE" acknowledged the missed PT/INR laboratory tests for Resident #15, and stated that she was obtaining a physician order [REDACTED]. Review of a laboratory test report form for Resident #15, reflecting a 12/22/2014 date of blood sample collection, revealed the report to document the resident's PT as high at 32.1 seconds, and to document the INR as 2.86. A Progress Notes entry for Resident #15 documented the resident's elevated PT result of 32.1 seconds and INR result of 2.90 (approximate), as referenced in the 12/22/2014 laboratory test report referenced above, and also documented these results were called to the physician. An Order Summary form, having an Order Date of 12/22/2014, for Resident #15 documented a physician's orders [REDACTED]. Based on the above, Resident #15 received [MEDICATION NAME] 4 mgs nightly as a blood thinner and had an order for [REDACTED].#15's December 2014 MAR indicated [REDACTED]. On 12/21/2014, after surveyor inquiry regarding the absence PT/INR tests for Resident #15, facility nursing staff contacted the physician and obtained an order for [REDACTED]. 6. Record review for Resident #9 revealed an Admission MDS assessment having an Assessment Reference Date of 12/18/2014 which also documented a facility admission date of [DATE]. Section I - Active [DIAGNOSES REDACTED].#9 had [DIAGNOSES REDACTED]. A Physician's Pharmacy Order form for Resident #9 documented a 12/14/2014 physician's orders [REDACTED]. However, review of Resident #9's December 2014 MAR indicated [REDACTED]. Further record review for Resident #9 revealed a CLS laboratory report form, having a blood sample collection date of 12/16/2014, which documented the resident's PT result to be high at 17.2 seconds, and documented the INR to be 1.44. Physician's

Based on clinical record review, resident Medication Administration Record [REDACTED]#3, #10, #13, #15, and #16) who received [MEDICATION NAME] anticoagulant drug therapy, and failed to administer [MEDICATION NAME] anticoagulant drug therapy as ordered, and as specified by professional standards of quality, for two (2) residents (#3 and #9). A total of nine (9) sampled residents received [MEDICATION NAME] drug therapy on the survey sample of twenty-one (21) residents. The facility's failure to provide nursing care to residents in accordance with nursing professional standards of quality (as defined in the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice) resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents, as outlined below: - For Resident #3, the facility failed to ensure nursing care in accordance with professional standards of quality by failing to administer [MEDICATION NAME] anticoagulant drug therapy as ordered and failing to obtain weekly PT/INR laboratory tests as ordered: Resident #3 received [MEDICATION NAME] drug therapy for [MEDICAL CONDITION] Fibrillation. However, even though an order of 10/28/2014 specified to continue the [MEDICATION NAME] dose, and even though the nursing professional standard of practice specified that the nurse administer medications accurately, nursing staff held the resident's [MEDICATION NAME] dose, in error, from 10/28/2014 through 11/02/2014. In addition, even though a physician's orders [REDACTED].#3 receive weekly PT/INR laboratory tests, and even though the nursing professional standard of practice specified that the nurse implement procedures in a timely manner, facility nursing staff failed to obtain the weekly PT/INR laboratory tests after an 11/28/2014 PT/INR test revealed results of 22.7 and 2.06, respectively. On 12/21/2014, after surveyor inquiry, a PT/INR laboratory test obtained for Resident #3 revealed PT/INR results of 17.9 and 1.65, respectively, and the physician increased [MEDICATION NAME] to 5 mgs nightly. - For Resident #13, the facility failed to ensure nursing care in accordance with professional standards of quality by failing to obtain weekly PT/INR laboratory tests as ordered: Resident #13 received [MEDICATION NAME] anticoagulant drug therapy related to Embolism, Arterial [MEDICAL CONDITION], and [MEDICAL CONDITION] Fibrillation. However, even though Resident #13 was ordered to receive weekly PT/INR laboratory tests, and even though the nursing standard of practice specified that the nurse implement procedures timely, facility nursing staff failed to obtain the ordered weekly PT/INR laboratory tests after 11/26/2014, when a PT/INR laboratory test revealed PT/INR results of 26.8 and 2.56, respectively. On 12/21/2014, after surveyor inquiry, a PT/INR laboratory test revealed Resident #13 to have PT/INR results of 13.2 and 1.24, respectively, and the physician increased [MEDICATION NAME] to 4 mgs at bedtime. - For Resident #10, the facility failed to ensure nursing care in accordance with professional standards of quality by failing to obtain weekly PT/INR laboratory tests as ordered: Resident #10 received [MEDICATION NAME] drug therapy. However, even though a physician's orders [REDACTED]. On 12/22/2014, after surveyor inquiry regarding the missing PT/INR laboratory tests, a PT/INR laboratory test documented PT/INR results of 11.3 and 1.07, respectively, and the physician increased Resident #10's [MEDICATION NAME] dose to 3 mgs daily. - For Resident #16, the facility failed to ensure nursing care in accordance with professional standards of quality by failing to obtain a repeat PT/INR laboratory test as ordered: Resident #16 received [MEDICATION NAME] anticoagulant drug therapy, and a laboratory report of 11/26/2014 documented PT/INR results of 29.8 and 2.94, respectively. However, the facility failed to ensure nursing care in accordance with the nursing standard of practice specifying that the nurse obtain procedures timely by failing to obtain a repeat PT/INR level as ordered one (1) week after the 11/26/2014 laboratory test referenced above. On 12/21/2014, after surveyor inquiry, a laboratory report documented high PT/INR results of 33.3 and 2.96, respectively, and the physician modified the [MEDICATION NAME] dose to 4 mgs at bedtime. - For Resident #15, the facility failed to ensure nursing care in accordance with professional standards of quality by failing to obtain weekly PT/INR laboratory tests as ordered: Resident #15 received [MEDICATION NAME] anticoagulant drug therapy. However, even though a physician's orders [REDACTED].#15, the facility failed to ensure nursing care in accordance with the professional standard of quality specifying that the nurse obtain procedures in a timely manner by failing to obtain the ordered weekly PT/INR laboratory tests after an 11/24/2014 PT/INR test revealed PT/INR results of 24.2 and 2.24, respectively. On 12/22/2014, after surveyor inquiry, a PT/INR test for Resident #15 revealed PT/INR results of 32.1 and 2.86, respectively, and the physician lowered the [MEDICATION NAME] dose to 3.5 mgs at bedtime. - For Resident #9, the facility failed to ensure nursing care in accordance with professional standards of quality by failing to administer [MEDICATION NAME] anticoagulant drug therapy as ordered: Resident #9 was ordered to receive [MEDICATION NAME] at the dose of 3 mgs daily, but nursing staff administered [MEDICATION NAME] 3 mg doses on 12/14/2014 at 9:00 a.m. and 9:00 p.m., in error. Then, a physician's orders [REDACTED].#9 receive [MEDICATION NAME] 6 mgs on Sunday, Wednesday, and Friday, and 3 mgs the other days of the week; however, nursing staff administered [MEDICATION NAME] 6 mg doses at 9:00 a.m. and 9:00 p.m., and a [MEDICATION NAME] 3 mg dose at 9:00 p.m. on 12/19/2014, in error. The facility thus failed to ensure the provision of nursing care to Resident #9 in accordance with professional standards of quality by failing to administer the resident's medication accurately, as specified by professional standards of quality. As outlined above, the facility's failure to ensure the provision of care in accordance with nursing professional standards of quality, by failing to obtain PT/INR laboratory tests as ordered and/or administer [MEDICATION NAME] anticoagulant drug therapy as ordered, for Resident #3, Resident #9, Resident #10, Resident #13, Resident #15, and Resident #16 resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator was informed of the immediate jeopardy on December 23, 2014 at 8:30 a.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on December 1, 2014, the date the facility failed to obtain the first of three (3) missed [MEDICATION NAME] Time/International Ratio (PT/INR) laboratory tests ordered to be done weekly for Resident #10, who received [MEDICATION NAME] anticoagulant drug therapy. The immediate jeopardy continued through December 22, 2014, and was removed on December 23, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on December 22, 2014. An allegation of jeopardy removal was received on December 23, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on December 23, 2014. The facility remained out of compliance at a lower scope and severity of "E" while the process of evaluating modifications of the laboratory requisition and medication administration systems continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's processes for obtaining laboratory tests as ordered by the physician and the administration of resident medication. Resident record reviews were conducted to assess facility staffs' conformance with physicians' orders regarding the requisition and acquisition of laboratory tests. In addition, resident record reviews were conducted, and observation of medication administration were made, to assess staffs' conformance with physicians' medication orders. Findings include: Review of the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules revealed that the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice, Section 2.3.2(i)(2), specified that the nurse implements treatments and procedures in a timely manner. In addition, Section 2.3.2.(i)(3) of Chapter 2 of these Model Nursing Administrative Rules specified that the nurse administers medications accurately. 1. Review of Resident #3's Annual Minimum Data Set (MDS) assessment of 10/08/2014 revealed diagnoses, documented in Section I - Active Diagnoses, which included, but were not limited to, Hypertension, [MEDICAL CONDITION], Heart Failure, [MEDICAL CONDITION], and [MEDICAL CONDITION] Fibrillation. The October 2014 physician's orders [REDACTED].#3 documented a 10/08/2014 order specifying the anticoagulant [MEDICATION NAME] 2.5 milligrams (mgs) at bedtime every Sunday, Monday, Wednesday, Thursday, and Saturday, and [MEDICATION NAME] 5 mgs at bedtime every Tuesday and Friday, related to [MEDICAL CONDITION] Fibrillation. Further record review for Resident #3 revealed that prior to the October 2014 order for [MEDICATION NAME] drug therapy referenced above, a 09/17/2014 physician's orders [REDACTED]. A Clinical Laboratory Services (CLS) report of 10/27/2014 documented that Resident #3's PT result was high at 31.8 seconds (Reference Range: 11.0 - 15 seconds), and her INR result was 3.2 (Recommended Therapeutic Range for Prevention of Embolism: 2.00 - 3.00). The nurse wrote a notation on this laboratory report requesting to hold the resident's [MEDICATION NAME] for three (3) days; however, the physician responded on 10/28/2014 (documented by a facsimile-stamped date of 10/28/2014 on the report), and noted on this report to continue Resident #3's [MEDICATION NAME] drug therapy at the same dose. However, Resident #3's October 2014 and November 2014 Medication Administration Records (MARs) documented that nursing staff held the [MEDICATION NAME] 2.5 mg doses on 10/29/2014, 10/30/2014, 11/01/2014, and 11/02/2014, and the [MEDICATION NAME] 5 mg doses on 10/28/2014 and 10/31/2014 (a total of six (6) days), before resuming [MEDICATION NAME] drug therapy on 11/03/2014. This was despite the 10/28/2014 physician's orders [REDACTED].(i)(3) of Chapter 2 of the Model Nursing Administrative Rules referenced above which specified, as a nursing professional standard of practice, that nurses administer medications accurately. Additionally, Resident #3's November and December 2014 physician's orders [REDACTED]. An 11/28/2014 PT/INR laboratory report for Resident #3 revealed a PT of 22.7 seconds and an INR of 2.06, but further record review revealed no evidence of a PT/INR laboratory test having been completed after this 11/28/2014 PT/INR test. This was despite Resident #3's physician's orders [REDACTED]. During an interview conducted on 12/21/2014 at 10:45 a.m., Unit Manager Registered Nurse (RN) "EE" acknowledged that nursing staff held Resident #3's [MEDICATION NAME] from 10/28/2014 through 11/02/2014 in error, and acknowledged that weekly PT/INR laboratory tests were not done as ordered for Resident #3. Based on the above, Resident #3 had physician's orders [REDACTED]. However, licensed nursing staff failed to administer Resident #3's daily [MEDICATION NAME] as ordered from 10/28/2014 through 11/02/2014 (6 days), and failed to obtain weekly PT/INR laboratory test as ordered during the month of December 2014. This was despite professional nursing standards of practice specifying, per Chapter 2 of the Model Nursing Administrative Rules referenced above, that licensed nurses would administer medications accurately and would implement procedures in a timely manner. Cross refer to F309, example 1, and F502, example 1, for more information regarding Resident #3. 2. Resident #13's Quarterly MDS assessment of 11/01/2014 documented [DIAGNOSES REDACTED].#13's Admission Record form documented the additional [DIAGNOSES REDACTED]. Further record review for Resident #13 revealed current December 2014 physician's orders [REDACTED]. A weekly CLS laboratory report dated 11/26/2014 for Resident #13 documented a high PT of 26.8 and an INR of 2.56, but further review revealed no evidence to indicate that nursing staff obtained any PT/INR laboratory tests as ordered for Resident #13 during December 2014. This was despite the physician's orders [REDACTED].#13 receive weekly PT/INR laboratory tests, and despite Chapter 2, Section 2.3.2(i)(2) of the Model Nursing Administrative Rules specifying, as a professional standard of practice, that the nurse implement procedures timely. During an interview with the Director of Nursing Service (DNS) conducted on 12/21/2014 at 3:40 p.m., no evidence was presented regarding weekly PT/INR laboratory tests for Resident #13 after the laboratory report of 11/26/2014. Based on the above, Resident #13 received [MEDICATION NAME] anticoagulant drug therapy and had a physician's orders [REDACTED]. However, licensed nursing staff failed to ensure care to Resident #13 in accordance with professional standards of practice (as outlined in the Model Nursing Administrative Rules referenced above which specified that licensed nurses implement procedures timely) by failing to ensure the provision of Resident #13's ordered weekly PT/INR laboratory tests during the month of December 2014. Cross refer to F309, example 2, and F502, example 2, for more information regarding Resident #13. 3. Resident #10's Annual MDS assessment of 11/01/2014 documented diagnoses, in Section I - Active Diagnoses, which included, but were not limited to, Hypertension, [MEDICAL CONDITION], Diabetes Mellitus, [MEDICAL CONDITION], and [MEDICAL CONDITION]. A December 2014 physician's orders [REDACTED].#10 receive a weekly PT/INR laboratory test, and a physician's orders [REDACTED]. An 11/24/2014 CLS laboratory report for Resident #10 documented a PT of 14.8 seconds and an INR of 1.18, and a subsequent 12/02/2014 physician's orders [REDACTED]. However, further record review revealed no evidence of a PT/INR test for Resident #10 after the 11/24/2014 PT/INR test referenced above. This was despite the physician's orders [REDACTED].#10 receive weekly PT/INR tests (thus requiring a subsequently weekly PT/INR laboratory test to be done 12/01/2014 ), and despite Chapter 2, Section 2.3.2(i)(2) of the Model Nursing Administrative Rules specifying, as a nursing standard of practice, that the nurse implement procedures timely. During an interview on 12/21/2014 at 12:20 p.m., RN "EE" acknowledged the failure of staff to obtain weekly PT/INR laboratory tests for Resident #10 after 11/24/2014. Based on the above, even though Resident #10 received [MEDICATION NAME] drug therapy and even though the resident had a physician's orders [REDACTED]. The facility thus failed to ensure the provision of care to Resident #10, related to laboratory services, in accordance with professional standards of practice as outlined in the Model Nursing Administrative Rules referenced above, which specified that licensed nurses implement procedures timely. Cross refer to F309, example 3, and F502, example 3, for more information regarding Resident #10. 4. Resident #16's Quarterly MDS assessment of 11/26/2014 documented diagnoses, in Section I - Active Diagnoses, which included, but were not limited to, Dementia, Diabetes Mellitus, [MEDICAL CONDITION], and [MEDICAL CONDITION]. A current physician's orders [REDACTED]. An 11/26/14 CLS laboratory report for Resident #16 documented a PT of 29.8 and an INR of 2.94. A physician's orders [REDACTED].#16's record revealed no evidence of a PT/INR for this resident after the 11/26/14 PT/INR test referenced above. During interview on 12/21/2014 at 2:00 p.m., RN "EE" acknowledged the facility's failure to obtain the ordered PT/INR laboratory test for Resident #16. Based on the above, Resident #16 received daily [MEDICATION NAME] anticoagulant drug therapy. An 11/26/2014 laboratory test documented a PT of 29.8 and an INR of 2.94, after which the physician ordered a repeat PT/INR level in 1 week. However, the facility failed to obtain this repeat PT/INR laboratory test for Resident #16 as ordered. The facility thus failed to ensure the provision of care regarding laboratory services in accordance with professional standards of practice, per the Model Nursing Administrative Rules referenced above, which specified that licensed nurses implement procedures timely. Cross refer to F309, example 4, and F502, example 4, for more information regarding Resident #16. 5. Resident #15's Quarterly MDS assessment of 09/25/2014 documented diagnoses, in Section I - Active Diagnoses, which included, but were not limited to, [MEDICAL CONDITION] and Hypertension, and the resident's Admission Record form documented a [DIAGNOSES REDACTED]. Resident #15's December 2014 Order Review Report form specified an order dating from 08/26/2014 for [MEDICATION NAME] 4 mgs in the evening as a blood thinner. This Order Report Form also documented a 09/24/2014 order for weekly PT/INR laboratory tests. An 11/24/2014 laboratory report for Resident #15 documented a PT/INR test revealing a PT result of 24.2 seconds and an INR result of 2.24. However, despite the physician's orders [REDACTED].#15 after this 11/24/2014 PT/INR test. During a 12/21/2014, 2:00 p.m. interview, RN "EE" acknowledged the failure of facility staff to obtain the weekly PT/INR laboratory tests for Resident #15 as ordered. Based on the above, Resident #15 received [MEDICATION NAME] drug therapy, and a physician's orders [REDACTED]. However, the facility failed to obtain the ordered weekly PT/INR laboratory tests for Resident #15 after 11/24/2014. The facility therefore failed to provide care related to laboratory services in accordance with professional standards of practice, as indicated by the Model Nursing Administrative Rules referenced above which specified that the nurse implement procedures timely. Cross refer to F309, example 5, and F502, example 5, for more information regarding Resident #15. 6. Record review for Resident #9 revealed an Admission MDS assessment of 12/18/2014 which documented facility admission on 12/11/2014, with Section I - Active [DIAGNOSES REDACTED]. A Physician's Pharmacy Order form for Resident #9 documented a 12/14/2014 order for the [MEDICATION NAME] 3 mgs at bedtime for [MEDICAL CONDITION] Fibrillation. However, Resident #9's December 2014 MAR indicated [REDACTED]. Additionally, a 12/19/2014 laboratory report for Resident #9 documented a PT of 16.5 seconds and an INR of 1.36, and a handwritten order on this laboratory report specified that the resident receive [MEDICATION NAME] 6 mgs on Sunday, Wednesday, and Friday, and 3 mgs the other days of the week. However, Resident #9's December 2014 MAR indicated [REDACTED]. During interview on 12/21/2014 at 12:05 p.m., Licensed Practical Nurse (LPN) "BB" acknowledged the medication error involving Resident #9's [MEDICATION NAME] referenced above. In addition, review of Resident #9's initial care plan, developed after the resident's facility admission of 12/11/2014 (as documented on the 12/18/2014 Admission MDS assessment referenced above) and prior to the development of the resident's Comprehensive Care Plan, revealed no evidence of any reference on the initial care plan related to Resident #9's receipt of [MEDICATION NAME] anticoagulant therapy, or of care interventions related to this [MEDICATION NAME] therapy. During a post-survey Quality Assurance telephone interview conducted on 01/20/2015 at 5:50 p.m., the DNS acknowledged the absence of an initial care plan reference to Resident #9's receipt of [MEDICATION NAME] anticoagulant drug therapy. Based on the above, despite the Model Nursing Administrative Rules referenced above specifying that the nurse administer medications accurately as a standard of practice, nursing staff administered two (2) [MEDICATION NAME] 3 mg doses to Resident #9 on 12/14/2014, rather than one (1) [MEDICATION NAME] 3 mg dose as ordered. In addition, on 12/19/2014, nursing staff administered [MEDICATION NAME] 6 mg doses at 9:00 a.m. and 9:00 p.m., and also a [MEDICATION NAME] 3 mg dose at 9:00 p.m., even though the physician's orders [REDACTED]. Additionally, after Resident #9's admission to the facility on [DATE], the facility failed to develop an initial care plan which identified the resident's receipt of [MEDICATION NAME] drug therapy and the care related to this drug therapy. Cross refer to F309, example 6, for more information regarding Resident #9. The facility presented an acceptable credible allegation of jeopardy removal (CAJR) on December 23, 2014. Based on this CAJR, it was determined that the immediate jeopardy had been removed on December 23, 2014, at which time the facility had implemented the following interventions: 1. On 12/21/2014, the facility's Medical Director was notified of the missed PT/INR laboratory tests, and physicians' orders were given to obtain these PT/INR laboratory tests. All PT/INR laboratory test results were received by the facility on 12/22/2014, and the physician was notified of the results. Orders were received to recheck these laboratory test results on 12/29/2014. Laboratory requisitions were completed for these residents having PT/INR laboratory testing ordered to be completed on 12/29/2014. 2. On 12/21/2014, the facility initiated a procedure by which the monitoring of resident [MEDICATION NAME] will be conducted. The DNS/Nurse Supervisor will monitor, via an audit, 100 percent of resident [MEDICATION NAME] drug orders and laboratory orders daily for thirty (30) days, then weekly for four (4) weeks, then monthly for six (6) months. Any negative findings will be addressed immediately with a time frame not to exceed the end of the current shift and will include 1:1 staff retraining and education. Additionally, any negative findings will be reviewed by the Quality Assessment and Assurance (QAA) Committee during monthly meetings for (6) six months. 3. On 12/22/2014, the facility conducted record reviews for all residents receiving [MEDICATION NAME] anticoagulant drug therapy to ensure that all orders were correct and that PT/INR laboratory tests were scheduled for completion, per physicians' orders. Entries were updated on the Diagnostic Tracking Form. The specific purposes for the Diagnostic Tracking Form were to ensure that each diagnostic test had been ordered/requisitioned, to ensure the laboratory had collected the specimen, and to ensure the laboratory results had been received and the physician notified of the results. This Diagnostic Tracking Form will be utilized by all licensed nursing staff for all PT/INR laboratory orders, regardless of who is to draw the laboratory test. Licensed nurses will enter the new PT/INR orders on the Diagnostic Tracking Form, with the date the PT/INR is to be drawn. The Diagnostic Tracking Form will also be used to track the laboratory results as they are received, and to track physician notification of the laboratory test results. The Unit Manager/Registered Nurse will notify the physician of PT/INR laboratory results upon receipt daily by telephone. A daily audit of resident Diagnostic Tracking Forms will be conducted by the Unit Manager/RN Supervisor. 4. On 12/22/2014, the facility initiated a procedure by which the Unit Manager/Nurse Supervisor will be responsible for completing the PT/INR Flow Sheets. The PT/INR Flow Sheets serve to document the following information for each resident receiving anticoagulant drug therapy and PT/INR laboratory testing: the date of the laboratory test; the PT/INR result; the anticoagulant drug dose; the date the next laboratory test is ordered; the initials of the staff person taking the order; and any pertinent comments. The process of completion of these resident PT/INR Flow Sheets will be monitored daily by the Unit Manager/RN Supervisor for compliance. 5. On 12/22/2014, the facility initiated a procedure by which the DNS/Designated Nurse Supervisor will conduct random audits the Diagnostic Tracking Form and PT/INR Flow Sheets for residents receiving anticoagulant drug therapy daily for thirty (30) days, then weekly for four (4) weeks, then monthly for six (6) months to monitor for nursing staff compliance. The DNS/Nurse Supervisor will sign and date the Diagnostic Tracking Forms sheets and PT/INR Flow Sheets as evidence of these random audits. Any negative findings will be addressed immediately, with the time frame not to exceed the end of the current shift, and will include 1:1 retraining and education. Additionally, any negative audit findings will be reviewed by the QAA Committee during monthly Committee meetings. 6. On 12/22/2014, the facility reviewed the care plans for all residents receiving [MEDICATION NAME] anticoagulant drug therapy. Care plan revisions were made as needed. 7. On 12/22/2014, the facility initiated a procedure by which the DNS will conduct random, weekly audits involving three (3) residents who receive [MEDICATION NAME] drug therapy to ensure care plan completion. This audit process will continue for six (6) months to ensure compliance. 8. On 12/22/2014, the facility conducted nursing staff in-service training regarding the facility's anticoagulant clinical guidelines, including laboratory order entry for PT/INR laboratory tests, the facility's laboratory requisition procedures, and the process of documentation to be used by nursing staff when completing the Diagnostic Tracking Forms and PT/INR Flow Sheets. Additionally, licensed nursing staff who administer resident medications received in-service training related to the administration of medications in conformance with the facility's anticoagulant therapy guidelines. As of 12/22/2014, a total of twenty-two (22) of the facility's twenty-seven (27) licensed nursing staff had received this in-service training. The remaining five (5) licensed nursing staff who had been unavailable for training at that time, due to being off work, will receive this in-service training upon their return to work and will not be allowed to work until training has been provided. Newly-hired licensed staff will receive in-service training regarding the facility's anticoagulant clinical and therapy guidelines during the facility's orientation process. 9. On 12/22/2014, the facility's QAA Committee met to review the procedures and interventions put into place to address the identified quality deficiencies related to the failure to obtain PT/INR laboratory testing as ordered and the failure to administer anticoagulant drug therapy as ordered. A procedure was developed and implemented by which the results of management staff monitoring of the [MEDICATION NAME] anticoagulant drug therapy monitoring, as well as the management staffs' audits of the Diagnostic Tracking Forms and the PT/INR Flow Sheets, would be presented to the QAA Committee each month by the Executive Director and/or DNS. This will allow the QAA Committee to monitor staff compliance with the facility's policies and procedures regarding the receipt, transcription, and implementation of physicians' orders for [MEDICATION NAME] dosing, and PT/INR monitoring through laboratory testing, to ensure that these policies, procedures, and systems are in compliance. During this abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 12/23/2014, interview with the DNS confirmed that the Medical Director was notified of missed PT/INR laboratory tests. Additional interview with the DNS, and resident record reviews conducted during this abbreviated survey, confirmed that physicians' orders had been obtained for these PT/INR laboratory tests and that test results were received by the facility as of 12/22/2014. This was in conformance with Step 1 of the facility's CAJR referenced above. - On 12/23/2014, DNS interview and audit tool review confirmed that the facility had initiated a procedure allowing for DNS/Nurse Supervisor audits of 100 percent of resident [MEDICATION NAME] drug orders and laboratory orders daily for thirty (30) days, weekly for four (4) weeks, then monthly for six (6) months. Negative findings would be addressed immediately and reviewed by the QAA Committee monthly. This was in accordance with Step 2 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator and DNS, and also ongoing resident record review during the abbreviated survey, confirmed that the facility had reviewed all resident records of residents receiving [MEDICATION NAME] drug therapy to assess for order accuracy and to ensure that PT/INR laboratory tests were scheduled. Administrator and DNS interview confirmed that Diagnostic Tracking Form entries had been updated, and that this Form would be used by nursing staff to document and track PT/INR laboratory orders, PT/INR date, laboratory results, and physician notification. This was in accordance with Step 3 of the facility's CAJR referenced above. - On 12/23/2014, interview with the Administrator and DNS confirmed the facility's procedure for completion of the PT/INR Flow Sheets by the Unit Manager/Nurse Supervisor. Review of the PT/INR Flow Sheet confirmed that the Flow Sheet