Every finding on record at Immanuel's Healthcare

Based on observation, interview, and record review the facility failed to provide a private meeting space for residents' monthly Resident Council Meeting for 5 of 5 confidential residents reviewed for Resident Council for 1 of 1 facility.The facility failed to provide a private area and/or space for residents who attended monthly Resident Council Meetings.This failure could place residents who attend the monthly Resident Council Meetings at risk of not being able to voice their concerns amongst each other due to a lack of privacy.Findings included:Record review of the facility's Resident Council Minutes for June 2026 to August 2026 reflected there were about 13 to 20 residents who attended the facility's monthly Resident Council Meetings.During an interview with the Activities Director on 08/17/26 at 10:30 a.m., she stated that the confidential group meeting at an undisclosed date with the residents of Resident Council and the State Surveyor would not be held in the facility's Dining Room, where the monthly Resident Council Meetings were normally held. The Activities Director stated that the confidential group meeting at an undisclosed date and time with the residents of Resident Council and the State Surveyor would be held in the Private Dining Room adjacent to the facility's Dining Room. The Activities Director stated the Private Dining Room had 1 door for privacy.During a confidential group meeting at an undisclosed date and time was held in the facility's Private Dining Room adjacent to the Dining Room. In the confidential group meeting, 5 residents that regularly attended the facility's monthly Resident Council Meetings stated that their monthly Resident Meetings were normally held in facility's Dining Room. The residents described the facility's Dining Room as an open area with 2 doors on each side. The residents stated that the TV Room was connected to the facility's Dining Room and the area was open without any doors. The residents stated that the 2 doors at the end of the Dining Room led to resident rooms and staff offices. The residents stated the facility's Dining Room had a large area that was open to the public and did not have any interior or exterior doors. The residents stated that the large opening that led to the TV Room did not provide any privacy for the residents to discuss what they needed to discuss about the facility operations, including their concerns regarding the staff and the care that they were receiving from the staff and there was no privacy. The residents stated that they had never had any Resident Council Meetings in the area where the Resident Council Meeting was being held with the Surveyor at an undisclosed date and time. The residents stated during some of their previous monthly Resident Council Meetings, the Activities Director would place several signs on the 2 double interior doors and the wall adjacent to the Dining Room, which was the TV Room. The residents stated previously during their monthly Resident Council Meetings, they were disrupted by staff entering the Dining Room. The residents stated they would prefer that staff did not enter the Dining Room during their confidential monthly Resident Council meetings, which occurred on several occasions. The residents stated that they would like the option to have their monthly Resident Council Meetings in a location that had doors to ensure privacy and would not cause staff or residents to overhear what was being discussed in their meetings to prevent retaliation from staff and other residents.During an observation on 08/18/26 at 2:46 p.m. of the facility's TV Room revealed the space was an open area and was adjacent to the facility's Dining Room. The TV Room shared a common wall with the Dining Room. The TV Room did not include any doors that separated the Dining Room and TV areas. The Dining Room area had 2 double interior doors that led to hallways. The 2 interior doors on the east side of the Dining Room when opened provided access to the Kitchen, Central Supply Room, Laundry Room and resident rooms on Station 2. The 2 interior doors on the west side of the Dining Room when opened had access to the Salon, Staff Restroom, Oxygen Storage Room/Lounge, Computer Room, Physical Therapy, and resident rooms on Station 1.During an interview on 08/19/26 at 12:33 p.m., the Activities Director stated she had been employed at the facility for 11 years. She stated the residents in Resident Council met once a month and reported that up to 20 residents attended the monthly meetings, but the attendance varied due to residents not attending the meetings due to health concerns. The Activities Director stated she was unaware that the facility needed to have a private area that allowed residents who attended the monthly Resident Council Meetings with privacy, which included doors to ensure privacy for the residents during their meetings. She stated prior to the beginning of the monthly Resident Council meetings, she placed signs on the 2 interior doors on the east side of the Dining Room leading to Station 2. The Activities Director stated she placed signs on the 2 interior doors on the west side of the Dining Room leading to Station 1. The Activities Director stated she placed signs on the wall in the TV Room. She stated the 3 posted signs stated, Do Not Disturb due to Meeting in Progress, and the signs advised everyone not to disturb the residents monthly Resident Council meetings. The Activities Director stated that the residents that had attended the facility's previous monthly Resident Council meetings had not voiced to her any concerns about there not being enough privacy during their monthly Resident Council Meetings. She stated during the facility's previous Resident Council meetings, there had not been any disruptions from anyone including residents, staff and visitors during their monthly Resident Council meetings. The Activities Director stated she understood that the residents that attend the monthly Resident Council Meetings should feel free to express their opinions about what they need to discuss amongst each other. The Activities Director stated she was unaware that the facility needed to provide the residents who attended the monthly Resident Council meetings with a private area with doors for privacy. She stated that the residents monthly Resident Council Meetings have always been held in the facility's Dining Room since her employment at the facility. She stated she would meet with the ADMIN and locate another area for the residents to have their monthly Resident Council Meetings for privacy purposes. The Activities Director stated the residents' monthly Resident Council meetings could not be held in the facility's Private Dining Room area due to the area being too small to accommodate the up to 20 residents that attended the meetings. The Activities Director stated that there were risks to residents that attended the monthly Resident Council Meetings to have everything they mentioned in the meeting being overheard by someone who did not attend the meeting. She stated residents should feel comfortable in a safe environment to voice their concerns and have privacy. The Activities Director stated that harm could be caused to a resident, if their discussions were overheard, which could cause retaliation and an unsafe environment for the staff and residents. She stated residents may feel depressed and sad and become isolated if they felt they were unable to voice their concerns during their monthly Resident Council meetings.During an interview on 08/19/26 at 1:21 p.m. with the ADON revealed she had been employed at the facility for 1 month. The ADON stated she was unaware that the facility needed to have a private area that allowed residents who attended the monthly Resident Council Meetings with privacy, which included doors to ensure privacy for the residents during their meetings. The ADON stated that she had not received any concerns from residents that attended the facility's monthly Resident Council meetings about wanting to have more privacy during their monthly Resident Council Meetings. The ADON stated that the risk of not having a secure area for the residents during their monthly Resident Council is that they do not have any privacy due to there not being any doors in between the Dining Room and TV Room areas. The ADON stated that if a resident(s) mentioned their concerns during one of their monthly Resident Council Meetings and their concerns were about another resident or staff member, there was a potential for harm to the residents in the meeting to be bullied, harassed or physically hurt, and there being a potential of retaliation from residents and staff.During an interview on 8/19/26 at 4:41 p.m. with the SW, she revealed she had been employed at the facility for 10 months. The SW stated that she was unaware that the facility needed to have a private area for residents to have their monthly Resident Council Meetings. The SW stated that she was the facility's Grievance Officer and had not received any concerns/complaints from residents who attended the monthly Resident Council Meetings regarding their lack of privacy in the Private Dining Room during their meetings. The SW stated that she did not feel that there was any risk or harm to residents due to the facility not providing a private area/space for the residents to have their monthly Residential Council Meetings.During an interview on 08/19/26 at 4:52 p.m., the ADMIN revealed she had been employed at the facility for 2 years. The ADMIN stated that the monthly Resident Council Meeting location was set up by the Activities Director. The ADMIN stated that the Activities Director held the monthly Resident Council Meetings in the facility's Dining Room, which was adjacent to the facility's TV Room. The ADMIN stated the Resident Council meetings had been held in the facility's Dining Room since her employment at the facility. The ADMIN stated according to the Activities Director, the Resident Council meetings were held in the facility's Dining Room since the Activities Director had been employed at the facility. The ADMIN stated that no one previously mentioned to her that the facility needed to provide an enclosed private area or space for the residents to have their monthly Resident Council meetings. The ADMIN stated the TV Room and the Dining Room had a common wall and there were not any doors to separate both areas. The ADMIN stated that she was unaware that the facility needed to have a private area that allowed residents who attended the monthly Resident Council Meetings for privacy, which included doors to ensure privacy for the residents during their meetings. The ADMIN stated that the residents had not brought to his attention that they wanted a private area for their monthly meetings to ensure privacy. The ADMIN stated that she understood the need for residents to feel safe and secure about what they were discussing in their meetings during their monthly Resident Council Meetings and not have to worry about the potential of retaliation from staff and residents. The ADMIN stated that there was a potential of residents in the Resident Council Meeting being harmed if someone overheard what was being discussed during the monthly Resident Council Meetings, which their discussions were private. The ADMIN stated she and the Activities Director have agreed to have the residents' future monthly Resident Council Meetings to be held in the MDS Coordinator's Office, which was a large area that would accommodate the 20 residents that attended the Resident Council Meetings. The ADMIN stated the MDS Coordinators Office had a door that opened and closed for privacy. The ADMIN stated that she was going to provide some reeducation and training via In-Service Trainings to all staff members to advise them not to disrupt the monthly Resident Council Meetings as well as ensure that the monthly Resident Council Meetings are always held in a private and secured area with doors without any exceptions.Record review of the facility's policy, Resident Council, revised February 2021, reflected:Policy Statement:The facility supports residents' rights to organize and participate in the resident council.Policy Interpretation and Implementation:1. The purpose of the resident council is to provide a forum for: a. residents, families and resident representatives to have input in the operation of the facility; b. discussion of concerns and suggestions for improvement; c. consensus building and communication between residents and facility staff; and d. disseminating information and gathering feedback from interested residents.2. All residents are eligible to participate in the resident council. The facility staff encourages residents who are willing to participate. Staff, visitors, or other guests may attend resident council meetings if invited by the respective resident group.3. The resident council group is provided with space, privacy and support to conduct meetings.

Based on observation, interview, and record review, the facility failed to ensure the right to file grievances anonymously for 5 of 5 confidential residents reviewed for grievances.The facility failed to ensure that residents at the facility had access to file a grievance anonymously.The facility's failure could place the residents at risk for concerns not being reported and addressed.Findings included:Record review of the facility's Grievance Logs for June 2026 and August 2026 reflected there were not any grievances filed by residents at the facility relating to concerns of filing a Grievance Form anonymously.During a confidential group meeting at an undisclosed date and time, the residents stated that the facility's Grievance Forms were located on the wall at the Nurses Station (Station 1 and Station 2) in a clear container on the wall behind the Nurses' Station. The residents stated there were also blank Grievance Forms in a clear container on the wall beside the piano in the facility's TV Room. The residents stated that they have completed grievances at the facility on several occasions. The residents stated that their concerns that were on their Grievance Forms had been addressed. The residents stated the SW completed Grievance Forms for residents. The residents stated that after completing and filing a grievance, they would give it to staff and were uncertain if any staff were able to view their grievances and share with other staff or residents their grievance concerns after they have been filed. The residents stated that the staff at the facility were not only coworkers, but also friends outside of work and they have not filed any grievances regarding their concerns because they feared being retaliated against by their caregivers and staff at the facility. The residents stated that they would like the facility to provide an option to file a grievance anonymously in a location that was in a discrete location for the Grievance Forms to be submitted.During an observation on 08/18/26 at 2:52 p.m., there were blank Grievance Forms in a clear container on the wall beside the piano in the facility's TV Room. The front of the clear container in the TV Room had a paper sign labeled, Grievance Forms.During an observation on 08/18/26 at 2:54 p.m., there were blank Grievance Forms in a clear container on the wall located behind the Nurses' Station desk on Station 1. The front of the clear container at the Nurses' Station on Station 1 had a paper sign labeled, Grievance Forms.During an observation on 08/18/26 at 2:54 p.m., there were blank Grievance Forms in a clear container on the wall located behind the Nurses' Station desk on Station 2. The front of the clear container at the Nurses' Station on Station 2 had a paper sign labeled, Grievance Forms.During an interview on 08/19/26 at 1:13 p.m. with ADON revealed she had been employed at the facility for 1 month. The ADON stated that she was unaware that the facility needed to have an area for Grievance Forms that could be completed and submitted anonymously by residents, visitors and/or family members of residents. The ADON stated that the facility's Grievance Forms were in one area, which was on the wall in the facility's TV Room in a file folder on the wall beside the piano. The ADON stated that after a Grievance Form was completed, it was submitted to the facility's SW. The ADON stated that if the residents, their family members, friends and/or visitors wanted or needed to voice their concerns about something at the facility there should be an area designated for them to voice their concerns anonymously. The ADON stated that harm could be caused to a resident if a Grievance Form submitted by a resident, visitor and/or family members of residents was completed and was about a staff member, the person delivering the Grievance Form could read the Grievance Form before delivering the document before submitting it to the SW. The ADON stated that if a resident(s), visitors, and/or family members of residents mentioned their concerns on the Grievance Forms, and their concerns were about another resident or staff member, there was a potential for harm to the person that submitted the Grievance on the Grievance Form to be bullied, harassed or physically hurt, and there being a potential of retaliation from residents and staff. The ADON stated that the potential harm could be resident abuse (ie: mental, verbal, emotional, and physical), resident neglect, retaliation against the resident and psychological harm to their well-being.During an interview on 08/19/26 at 1:45 p.m. with CNA B revealed she had been employed at the facility for 3 years. CNA B stated that she was unaware that the facility needed to have an area for Grievance Forms that could be completed and submitted anonymously. CNA B stated that there were 2 areas she was aware that the facility's Grievance Forms were located which were at the Nurses' Station at Station 1 and Station 2 on a wall in a clear container on the wall behind the Nurses' Station desks. CNA B stated that a resident, visitor and/or family of residents had never requested a Grievance Form during any of her shifts. She stated that she was advised by the SW that if a Grievance Form was given to her, to give it to the SW. CNA B stated the SW informed staff that when she was not on duty to deliver the completed Grievance Forms to her office and put them underneath the door. She stated if a resident reported any concerns about the care they were receiving at the facility, abuse and neglect she would immediately notify the DON and ADMIN. CNA B stated if she suspected or was aware of resident abuse or neglect, she would immediately notify the ADMIN who was the facility's Abuse Coordinator. CNA B stated that the risk of there not being a designated location for anyone to complete and submit a Grievance Form is that there was no privacy and the Grievance Form may not be submitted due to fear, which can cause issues, such as anxiety, and someone feeling abused, neglected, and like they were not able to talk to anyone. CNA B stated if someone had an issue with a staff member or the care they were receiving, the staff member that received the Grievance Form may read it and throw it away. CNA B stated the person that received the Grievance Form may also tell the person who the Grievance referenced about the information that was on the Grievance Form. CNA B stated that harm could be caused if the staff member, who received the Grievance Form knows the person who the Grievance was about and could retaliate against the person that filed the Grievance. CNA B stated the person who completed the Grievance Form may experience some forms of mental, verbal abuse, and physical harm and become isolated, not feel safe at the facility and become restless.During an interview on 8/19/26 at 4:46 p.m. with the SW she revealed she had been employed at the facility for 10 months. The SW stated she was the facility's Grievance Officer. She stated that currently there was not any way for a resident, visitors, and/or family members to file a grievance with the facility anonymously, but that a resident could report concerns to her. The SW stated most of the facility's residents are unable to complete a Grievance Form on their own, therefore she or other staff would need to assist them with completing and submitting their Grievance Forms. The SW stated that she was unaware that the facility needed to have an area for Grievance Forms that could be completed and submitted anonymously. The SW also stated that any staff member could take a grievance and fill it out for the residents. The SW stated if a Grievance is completed and filed after her business hours, staff can place the Grievance Form underneath her door. The SW stated a resident could file a grievance by getting a form from the Nurses' Stations (Station 1 and Station 2), and TV Room and stated that there were not any other places in the facility for anyone to obtain a Grievance Form. The SW stated that she was not aware if residents, visitors, and/or family members of residents had access to the Grievance Forms if there was not a staff member at the Nurses' Stations. The SW stated that after a Grievance Form was completed, it was given to her, and she read the Grievance Form and assigned the Grievance Form to the department that the concern was about. The SW stated that she did not feel that there was any risk or harm to residents due to not having the opportunity to complete and submit a Grievance Form anonymously.During an interview on 08/19/26 at 4:57 p.m. with the ADMIN, she revealed she had been employed at the facility for 2 years. The ADMIN stated that the SW was the Grievance Officer at the facility. The ADMIN stated she was unaware that the facility needed to have an area for Grievance Forms that could be completed and submitted anonymously. The ADMIN stated that the facility's Grievance Forms were located at the Nurses' Station (Station 1 and Station 2), and beside the piano in the TV Room. The ADMIN stated residents who were bed bound would have to receive a Grievance Form from a staff member. The ADMIN stated that the facility was in the process of posting grievance forms on the wall so that the Grievance Forms could be obtained and filed anonymously. The ADMIN stated that there will be a designated area in the facility's Dining Room for Grievance Forms to be obtained, completed and filed anonymously. The ADMIN stated that the facility has a black lock box for the Grievance Forms to be completed and submitted anonymously in the Dining Room beside the Grievance Forms. The ADMIN stated that the staff will be retrained and reeducated on Grievances, the location of the Grievance Forms and how to submit Grievances anonymously via In-Service Training. He stated that he would be the only person in the facility to have a key to the lock box to retrieve the Grievance Forms. The ADMIN stated that residents, family members, or visitors who could not file anonymous grievances were at risk for not being able to safely express their concerns. The ADMIN stated that the potential harm to residents, family members, or visitors who could not file anonymous grievances was that there was a potential of retaliation against the person filing the Grievance Form by staff, and/or other residents.Record review of the facility policy, Residence Grievances/Complaints - Staff Responsibility, revised October 2017, reflected:Policy Statement:Staff members are encouraged to guide residents about where and how to file a grievance and/or complaint when the resident believes that his/her rights have been violated.Policy Interpretation and Implementation:1. Should a staff member overhear or be the recipient of a complaint voiced by a resident, a resident's representative (sponsor), or another interested family member of a resident concerning the resident's medical care, treatment, food, clothing, or behavior of other residents, etc., the staff member is encouraged to guide the resident, or person acting on the resident's behalf, as to how to file a written complaint with the facility.2. Staff members will inform the resident or the person acting on the resident's behalf that he or she may file a grievance or complaint with the administrator or other government agencies as noted on the resident's bulletin board, without fear of threat or any other form of reprisal.Staff members will inform the resident or the person acting on the resident's behalf as to where to obtain a Resident Grievance/Complaint Form and where to locate the procedures for filing a grievance or complaint (e.g., posted on the residents' bulletin board). Record review of the facility policy, Grievances/Complaints, Filing, revised April 2017, reflected:Policy Statement:Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman).The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative.Policy Interpretation and Implementation:1.Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished.2. Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal.5. Grievances and/or complaints may be submitted orally or in writing, and may be filed anonymously.

Based on observations, interviews and record reviews, the facility failed to properly label, dispose and store all drugs and biological under proper temperature controls in accordance with currently accepted professional principles and when applicable and in accordance with State and Federal laws, for three resident (Resident#100, Resident#50, and Resident# 67) on one medication cart (station 1 nurses medication cart) of three medication carts reviewed for medication storage. The facility failed on 08/17/2026 to ensure Nystop 100,000 units per gram was labeled with a proper prescription label before storing in the Station 1 nurses medication cart. The facility failed on 08/17/2026 to ensure proper storage of Resident #67's insulin lispro Injection unit which required refrigeration per manufacturer's guidelines was observed stored unrefrigerated in the medication cart. The facility failed on 08/17/2026 to ensure Resident# 45's Novolog insulin Injection 100unit/ml was dated after opening and storing on the station 1 nurses medication cart . The facility failed on 08/17/2026 to ensure Resident'50s Trelegy Elliptica100mcg/62.5mcg/25mcg was dated after opening and storing on the Station 1 medication cart. The facility failed to ensure Resident #100's medication was removed for the station 1 nurses' cart after the resident expired. These failures could place residents at risk of medication errors, reduced therapeutic effectiveness, unsafe administration, and potential adverse outcomes due to improper storage of medication. Findings included: Resident #100Review of Resident #100s Discharge MDS Assessment, dated 07/19/2026, reflected Resident #100 was admitted on [DATE], she was an [AGE] year-old female, discharged on 07/18/2026. Resident #45Review of Resident #45's Comprehensive MDS Assessment, dated 06/12/2026, reflected a [AGE] year-old male admitted on [DATE], and had a BIMs score of 10, indicating moderate cognitive impairment. The resident had diagnoses which included Type 2 diabetes mellitus (a chronic metabolic condition characterized by insulin resistance and relative insulin deficiency). Review of Resident #45's Comprehensive Care Plan, revised 11/10/2025, reflected: The resident has Diabetes Mellitus. Interventions Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of Resident #45's active physician orders, dated:08/17/2026, reflected: NovoLOG Injection Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 151 - 200 = 2units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 -350 = 8 units; 351 - 400 = 10 units FBS OVER 400 CALL MD., subcutaneously with meals for diabetes start 07/11/2026. Resident#67Review of Resident #67s Comprehensive MDS Assessment, dated 08/20/2026, reflected Resident #67 was admitted on [DATE]. She was a [AGE] year-old female, and no BIMs score was recorded which indicated no interview was conducted. Review of Resident #67's Comprehensive Care Plan, initiated 08/17/2026, reflected: The resident has Diabetes Mellitus. Facility intervention: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of Resident #67's active physician orders, dated:08/17/2026, reflected: INSULIN LISPRO 100 UNIT/ML Inject as per sliding scale: if 0 - 150 = 0; 151 - 200 = 2; 201 - 250 =4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10 FBS>400 CALL MD, with meals for DM start 08/14/2026. Resident#50Review of Resident #50's Comprehensive MDS Assessment, dated 06/15/2026, reflected a [AGE] year-old male admitted on [DATE], and had a BIMs score of 03 indicated he had severe cognitive impairment. The resident had diagnoses which included asthma (a long-term lung disease that causes swelling, tight muscles, and extra mucus in your airways). Review of Resident #50's Comprehensive Care Plan, revised 09/23/2025, did not reflect any problems, goals, or interventions related to the trelegy medication. Review of Resident #50's active physician orders Dated:08/17/2026 reflected: Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT (prescription combination inhaler used for the long-term maintenance treatment of chronic obstructive pulmonary disease and asthma in adults) 1 puff inhale orally one time a day for Asthma Rinse mouth after use start 11/11/2025. Observation on 08/17/2026 at 10:12 AM with RN B, assigned the Station 1 nurses medication cart, revealed Resident #100's (expired Resident) Allopurinol 100mg (18 tablets), Bupropion 75mg (101 tablets),Atorvastatin 80mg (21 tablets), Carvedilol 3.125mg (30 tabs), Resident#45's opened Novolog insulin 110unit/ml with no opening date, Resident #67's unopened insulin lispro not refrigerated, Resident #50's opened Trelegy Elliptica100mcg/62.5mcg/25mcg with no opening date, and Nystop 100,000 units per gram with no resident label. During an interview 08/17/2026 at 10:16 AM, RN B stated she was not sure why Resident# 67's unopened insulin was in the cart. She stated that she unaware Resident #45's insulin and Resident # 50's Trelegy Elliptica100mcg/62.5mcg/25mcg did not have opening dates. She stated she was a new employee and was not sure when Resident #100 was discharged from the facility. She stated the nurses were responsible for ensuring all insulin was dated after opening. She stated all unopened insulin should be refrigerated to maintain the potency of the medication, and all opened insulin should be dated after opening because insulin expired 28 days after opening. She stated the risk was medication not being effective when administered to residents. She stated that having medication in the cart for residents that were no longer at the facility could result in administering medication to the wrong resident, which may result in hospitalization. She stated she was in serviced on medication storage and labeling. During an interview on 08/18/2026 at 10:15 AM, the ADON stated the nurses were responsible for making sure all medications were labeled and stored appropriately. She stated she was newly employed and had not had a chance to audit the medication carts but going forward she intended to audit the medication carts weekly. She stated the importance of refrigerating unopened insulin was to ensure it remains potent. She stated it was important to date opened insulins because opened insulins expired after 28 days and it would not be effective in reducing blood sugar levels. She stated she was in-serviced on medication storage and dating all opened insulins. During an interview on 08/18/26 at 1:04 PM, the DON stated nurses were responsible for ensuring medication carts were clean, and all medications were properly labeled and not expired. She stated the pharmacy consultant audited the medication room, and the medication carts every three months. She stated if medications were supposed to be refrigerated, it should be refrigerated because the medication could lose its effectiveness. She stated the policy was to remove a discharged resident's medication from the cart as soon as they were discharged . She stated all insulins should be dated when they were opened because insulin expired 28 days after opening. She stated that if the nurses were doing the medication rights, they should be able to ensure they gave the right medication to the right resident. She stated the nurses were in serviced on medication storage. Review of the facility's policy, Medication Access and Storage, revised 2/2023, reflected the following, 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.6. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly.Medication Labeling1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.2. The medication label includes, at a minimum: a. medication name (generic and/or brand); b. prescribed dose; c. strength; d. expiration date, when applicable; e. resident's name; f. route of administration; and g. appropriate instructions and precautions.8. If medication containers have missing, incomplete, improper, or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure food items that were placed in the refrigerator were sealed, dated, and labeled appropriately on 08/18/2026 at 12:00 p.m. 2. The facility failed to ensure food items with expired use by dates were disposed of properly 08/18/2026 at 12:00 p.m. These failures could place residents at risk for food-borne illnesses. Findings included: Observation on 08/18/2026 at 12:00 p.m., revealed seasonings on the top rack were labeled and dated. A jar of bay leaves was labeled and had an expiration date of 08/11/2023. The walk in cooler temperature was at 35 degrees Fahrenheit. Inside there was a labeled container of mandarin oranges. The oranges had an open date and used by date of 8/10/2026. There was a container labeled as butter scotch pudding that had an open date of 8/12/2026 and had a use by date of 8/14/2026. Interview of Dietary Manager on 8/18/2026 at 12:15 p.m., stated she has worked at the facility for six months. She stated their policy for labeling and dating includes putting an open date on all food items. She stated dry seasonings have a shelf life of a year. She was asked about the date on the bay leaves container. She stated 8/11/23 is the wrong date. She stated she knows she bought the bay leaves when she first started. She pointed at a different part of the container that was also dated. The second dated label had the same date of 8/11/23. She was asked about the container labeled mandarin oranges and the use by date. She stated it was a mistake in the labeled use by date because the mandarin oranges have a four-to-five-day shelf life. She was asked about the container labeled butter scotch pudding. She stated the butter scotch pudding was just opened and there was a mistake in labeling. Interview of Dietary [NAME] E on 8/19/26 at 2:15 p.m., stated she has worked at the facility for four years. She stated all dietary staff were responsible for labeling and dating food items. She stated all items have a received date, open date, and expiration date. She stated dry seasoning has a year shelf life, but other items have different used by dates. She stated soups will be given a three-day use by date. She stated the dietary manager does daily auditing to check labels and dates. She stated she was told about the bay leaves, but her manager found out bay leaves can last one to three years. She stated she was not made aware of the mandarin oranges or the butter scotch pudding. She stated they try not to mislabel items. She stated allergies are printed on the residents' meal tickets. She stated the risk to residents includes residents getting sick from items they are not supposed to have or eating items that are expired. Interview of Dietary [NAME] F on 8/19/26 at 2:30 p.m., stated she has worked at the facility for eight years. She stated everyone is responsible for labeling and dating food items. She stated when items come in they look for a preexisting expiration date. Once they receive an item it gets an open date and a use by date. She stated the dietary manager reviews open and use by dates at the end of every shift. She stated seasonings have a thirty-to-ninety-day shelf life. She stated she was informed about the bay leaves, but bay leaves can last one to three years. She stated she was know about the oranges or the butter scotch pudding. She stated the risk to residents includes residents getting sick and infection control. Interview of Dietary Manager on 8/19/26 at 2:45 p.m., stated she has been working at the facility for six months. She stated the facility policy is to label and date everything. She stated items are labeled with the date it is open and how long it is good for. She stated all dietary staff is responsible for label and dating items. She stated the sandwiches and snacks are made by dietary aides daily. She stated the cooks must go in the freezer and cooler to pull meat and veggies. Each time they pull something or open a box they have to make sure it is labeled and dated. She stated her job is to go around to double check all labels and dates. She stated she googled the bay leaves, and it showed they have a one-to-three-year shelf life. She was informed that the date of 8/11/23 would still be expired if their policy is to follow what she found on google. She stated the facility has guidelines for shelf-life dates. She stated salt and pepper has a on year shelf life, cummin has a two-year shelf life, and bay leaves have one-to-three-year shelf life. She stated with the new company that bought the facility she has not met the dietitian and there was a new one hired a month ago. She stated she has older dietary staff that needs more one on one supervision. She stated she has completed in-service with her staff. She stated she does not get complaints about food from residents. She stated there were complaints during the first couple of months when she was hired. She stated she was going to resident counsel meetings to discuss their concerns with residents. She stated the risk to residents consuming mislabeled or expired food includes bacterial infections or stomach problems. Record review of the facility's policy titled: Food Receiving and Storage Revised November 2022 stated: Policy: Food shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation:1. All food stored in the refrigerator or freezer will be covered, labeled and dated ( use by date.)2. Refrigerated foods are labeled, dated, and monitored so they are used by their use by date, frozen, or discarded.3. Spices (and herbs), dried and ground has a one-to-two-year storage time in airtight containers. Discard when scent fades. Review of the U.S. Public Health Service Food Code, dated 2022, reflected: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 Celsius (41 Fahrenheit) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest prepared or first-prepared ingredient. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request.

Based on interviews and record review the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) level 1 residents with mental illness were provided with a PASRR level 2 evaluation for 1 of 4 residents (Resident#6) reviewed for resident assessments.Resident #6's PASRR Level I screening form did not reflect mental illness, and the resident did not have a PASRR Level II evaluation.This failure could place residents at risk of not receiving necessary specialized services to meet their individual needs.Findings included: Record Review of Resident #6's MDS assessment dated [DATE], reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident's BIMS score was 15, indicating no cognitive impairment. Resident #6's diagnoses included Bipolar Disorder (mental condition marked by alternating periods of elation and depression), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Generalized Anxiety Disorder (disorder characterized by feelings of worry, anxiety, or fear that are enough to interfere with one's daily activities), Psychotic Disorder with Delusions (mental illnesses characterized by a disconnection from reality, often involving hallucinations, delusions, and disorganized thinking), Vascular Dementia (type of dementia caused by reduced blood flow to the brain, leading to cognitive decline and memory issues). Record review of Resident #6's Care Plan dated 08/07/2022, reflected: Administer medications as ordered. Monitor/document for side effects effectiveness. Assist resident in developing a program of activities that is meaningful and of interest. Encourage and provide opportunities for exercise, physical activity. Assist resident to identify strengths, positive coping skills and reinforce these. Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) Record review of Resident #6's PASRR Level 1 Screening dated 07/27/2022, under Section C - PASRR reflected the resident did not have evidence of a mental illness. During an interview on 08/19/2026 at 9:12 AM, the MDS Coordinator stated she was responsible for doing PASRR screenings for the facility. The MDS Coordinator stated upon admission to the facility, if the resident came from a health-setting or facility the PASRR would already be completed and she would not check for accuracy. The MDS Coordinator looked in the system and confirmed that Resident #6's PASRR screening reflected negative. The MDS Coordinator stated based on Resident #6's diagnoses she could be re-evaluated to see if she qualified for additional services. The MDS Coordinator stated she would forward information over to MHMR to come out to see Resident #6 and depending on the services she fell under, she would be evaluated. The MDS Coordinator stated if a resident was deemed negative incorrectly, the resident could be limited from benefits available to them such as mental support and services and restrict them from receiving additional services.During an interview on 08/19/2026 at 10:00 AM, the DON stated the MDS Coordinator was responsible for making sure PASRRs are completed and accurate. The DON stated the risk to a resident not having an accurate PASRR screening would be the resident not benefiting for services they qualify for and not getting extra services or equipment.Record Review of the facility's PASRR Policy dated 01/20/2026 reflected in part the following:Purpose The aim of the PASRR program is to identify residents with Mental Illness (MI), Intellectual Disability (ID) or Developmental Disability (DD)/Related Conditions (RC) and to ensure they are properly placed, whether in community or in a Nursing Facility (NF) and to ensure they receive the services they require for their MI, or ID/DD. ProcedureThe PASRR Level 1 Screen (PL1)The facility Admissions Coordinator or designee will ensure the referring entity provides a copy of the PL1 upon admission. In the event the facility is considering an admission from the community (home, homeless shelter, jail, group home, off the street etc.) and if the facility Interdisciplinary Team (IDT) suspects any MI, ID or DD the community Admissions Coordinator prior to admission will contact the LIDDA and follow the preadmission process. 1) The referring entity (the family, group home, homeless shelter, jail, off the street, etc) faxes PL1 to LIDDA (72-hour timer starts) If needed, the NF can assist the family, etc. to complete and fax the PL1 to the LIDDA. 2) LIDDA submits PL1 in Portal. 3) LIDDA performs PE within 72 hours of receipt of PL1. 4) LIDDA submits PE on Portal within 7 days of receipt of PL1. 5) NF certifies able or unable to serve individual on PL1 in the Portal (Certify PL1 in Portal) 6) LIDDA coordinates placement of individual NF The MDS Coordinator or designee will input all other PL1s into the online portal on admission. This includes negative preadmission PL1s, and PL1s for residents who qualify for exempted or expedited status. In the event of a positive PL1 that indicates the individual may have ID/DD or MI;1. The MDS Coordinator, Social Worker or designee will; a. Notify the LIDDA or LMHA/LBHA within 2 calendar days of admission to schedule the IDT and initiate the PE process. b. Monitor the Simple portal daily for the PE c. Will review the PE, print the form and place in the medical record. d. Will determine if the individual will be permanently admitted e. Will certify the PL1 in the online portal, that the NF can provide or support the services recommended on the PE within 7 calendar days after PE is entered into the online portal by the LIDDA/LMHA/LBHA.2. When it is determined that a PL1 was filled out incorrectly, the MDS Coordinator, Social Worker or designee will reach out to the hospital/responsible case worker and ask them to correct the form.a. If the referring case worker is unwilling/unable to correct the PL1 that contains a potential error, the social worker or designee will complete and submit a form 1012 (MI) or new PL1 (ID/DD). A subsequent positive PL1 will be entered according to 1012 findings (MI).3. When it is determined that an individual's diagnosis was changed and/or a state surveyor determines the PL1 was incorrect, the social worker or designee will complete and submit a form 1012 (MI) or new PL1 (ID/DD). A subsequent positive PL1 will be entered according to 1012 findings.

Based on observation, interview, and record review, the facility failed to ensure the residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one of four(Resident #3) reviewed for activities of daily living. The facility failed to ensure staff provided shower/baths to Resident #3 when requested on 08/18/26. This failure could place residents at risk of not receiving hygiene care needed which could cause feelings of helplessness, a loss of dignity, skin breakdowns, and infections. Findings included: Record review of undated Face sheet reflected Resident #3 was a six-nine-year-old female who was admitted to the facility on [DATE]. Her diagnoses included: cerebrovascular disease (conditions that affect blood flow to your brain), anemia (condition in which the body does not have enough healthy red blood cells), other hypoglycemia(low blood sugar level), schizoaffective disorder (mental health/mood disorder, depression, hypertension(high blood pressure), rheumatoid arthritis (chronic inflammation in joints), generalized muscle weakness, lack of coordination. Observation of Resident #3 on 8/17/2026 at 11:00 a.m., revealed she was sleeping in her bed. She did have a pressure-relieving mattress. Her feet were not offloaded, and she was laying diagonally without support of her extremities or neck. Record review on 8/17/2026 at 1:00 p.m., revealed Resident #3's Minimum Data Set Assessment was completed on 4/17/2026. She did not display any hallucinations or delusions. Her daily functions showed she was impaired on both sides of her lower extremities and ambulated using a wheelchair. She was dependent on staff for toileting, showering/bathing, tub/shower transfer, lower body dressing, and putting on/taking off footwear. She was substantially dependent on help for lying-to-sitting and sit-to-stand. MDS showed Resident #3 was always incontinent and at risk for pressure ulcers. She scored thirteen on her Brief Interview for Mental Status. Interview of Resident #3 on 8/18/26 at 10:30 a.m., stated she was a resident for three years. She stated her stay at the facility had been okay. She stated she received baths on Tuesdays, Thursdays, and Saturdays. She stated sometimes she did not get her bath when she was supposed to. She stated she gets bed baths and showers. She stated the last time she did not get a bath was Saturday 08/15/26. She stated she asked for staff to give her a bath this morning (8/18/26) since it was her bath day. She stated staff responded when she utilized her call light. She stated she has pain in her feet, back, knees, and joints. She stated her pain could be due to her arthritis. She stated staff repositioned her a few times a day, but she did not know how many times. She stated she did not have any issues with the food or her care as a resident. She stated she just wanted to get her baths when she was supposed to because she did not want to smell. She stated she also needed her hair washed. In an Interview and observation on 08/18/26 at 10:40 a.m. with CNA F revealed CNA F acknowledged Resident #3 was requesting her bath, and she wanted to be repositioned. CNA F then walked into Resident 3's room. Interview of CNA F on 8/18/26 at 1:30 p.m., stated she was PRN and has worked at the facility for two months. She stated the facility does not have shower aides. CNAs are responsible for completing all baths/showers for residents. She stated Resident #3 got showers/baths on Mondays, Wednesdays, and Fridays, but Resident #3 would say she gets her showers on Saturdays. She stated once a shower was completed the CNA completed a shower sheet and took it to the on-duty nurse for them to sign it was completed. She stated once the nurse signs the CNA will take the signed shower sheet to the DON. She stated if the DON is not in the facility, the CNA will leave the shower sheet in the black box on the wall next to the DON's office. She stated Resident 3 was good at telling staff she wants a shower or letting the nurse know she did get her shower. She stated the nurse will tell the CNA to make sure Resident 3 gets her shower/bath before the end of their shift. She stated Resident 3 refused her shower/bath sometimes. She stated Resident 3 was also repositioned every two hours. She was asked if Resident 3 received her bath she requested this morning (08/16/26) and she stated she did not. She stated Resident 3 refused her shower. Interview of Resident 3 on 8/18/26 at 1:35 p.m., revealed Resident #3 had a neck pillow positioning her upright in her bed. Her feet were not offloaded, and she had on the same clothing she was observed in earlier, 8/18/26 at 10:30 a.m. CNA F also walked into Resident 3's room with a shower sheet in her hand. Resident #3 was aked if she received her shower and she shook her head no. CNA F stated to Resident 3 she thought Resident #3 told her Resident #3's shower days were Wednesday. Resident 3 stated no her shower days were Tuesdays and tomorrow was Wednesday. Interview with the DON on 8/18/26 @1:40 p.m., revealed there was a black open mesh mailbox on the wall next to her office door. The DON stated staff will turn shower sheets into her or leave in the mailbox on her door if she is not present. She stated she kept all resident shower sheets in a box that was observed full on the floor. Requested shower sheets for Resident 3 for the past two months. She stated she would have to go through the box and provide once she has them. Interview with ADMIN on 8/18/26 at 1:45 p.m., stated CNAs completed baths/showers and fill out a shower sheet. She stated once the shower sheet is completed CNAs turn the sheets into the DON by handing it to her or placing it in the black box on the wall next to the DON's office. She stated shower sheets are supposed to be placed in a folder by the DON and organized based on halls and months. She was informed that currently all shower sheets are in one box that the DON has to go through to provide Resident 3's shower sheets for the months of July and August. She stated the facility used to keep a folder at the nursing station on a cart that was organized by month with each resident on the hall. She stated she did not know when the facility stopped using that process. She stated she has known residents or families who complained about residents not receiving their showers/baths. She stated another resident used to complain about not getting his/her showers but the issue was resolved. She was asked about Resident 3 medical records showing checks for yes or no at multiple times on the same day. She stated she did not know why there are multiple checks and she would need to refer me to the DON. Observation of Resident #3 on 8/18/26 at 2:00 p.m., revealed she had received her shower and her hair was washed. Her feet were offloaded. She was sleeping and positioned with her neck pillow. Interview of RN I on 8/18/2026 at 2:10 p.m., stated she has worked at the facility for two months. She stated Resident 3 is repositioned every two hours. She stated she does not know how repositioned are documented because there isn't a physician order for Resident 3 to be offloaded. She stated Resident 3 is scheduled to get bath/showers in the morning on Tuesdays, Thursdays, and Saturdays. She stated Resident 3 will refuse her bath/shower sometimes. She stated showers/baths are completed by CNAs and the shower sheet is given to her to sign it was completed. Once she signs the shower sheet the CNAs will give to the DON and if the DON is not there, CNAs will leave the shower sheet at her door in the mailbox. Interview of DON on 8/19/2026 at 2:30 p.m., she stated shower sheets are provided directly to her and if she isn't their staff will place shower sheets in the box on the wall next to her door. She stated she was not aware of any resident complaint regarding not getting their showers/baths. She was informed of the incident with Resident #3 asking for her shower this morning and CNA F being informed. She stated Resident #3 was showered now. She was informed Resident 3 requested her shower this morning and CNA F stated Resident #3 refused. She stated she was not aware of it and Resident 3 always gets her bed baths because she doesn't get showers. Interview of CNA D on 8/19/2026 at 1:45 p.m., stated she has worked at the facility for three years. She stated Resident 3 is scheduled for showers in the morning on Tuesdays, Thursdays, and Saturdays. She stated Resident #3 complained about not getting her shower a while ago and it was made up on the next shift, 2 p.m.-10 p.m. She stated she doesn't remember when this happened. She stated sometimes Resident 3 will refuse a shower and choose a bed bath instead. She stated there has not been a time when Resident 3 will refuse a shower and bed bath. She stated CNAs have to fill out the shower sheet for residents and have the nurse on duty sign off, even if a resident refused. If a resident refuses the nurse will speak with the resident to ensure the resident is refusing. She stated once the nurse signs the shower sheet, CNAs are to give to the DON or slide under the DON's office door. She stated there have been issues with residents not getting their showers on the L5 hall connected to Station 1. She stated residents in B beds will say they did not get their showers. Interview of ADMIN on 8/19/2026 at 3:53 p.m., stated the facility policy was to provide showers upon request, even if it isn't a shower day for all residents. She stated if a resident refuses a shower CNAs should get a nurse to confirm and sign the shower sheet. She was informed about the incident with Resident 3 and CNA F on 8/17/26. She stated DON informed her of the incident and she has taken care of it. She stated the box for shower sheets were removed from DON's door. She stated going forward shower sheets will be given to the charge nurse and charge nurse is responsible to give to the ADON. The ADON will place shower sheets in a binder. Interview of the SW on 08/19/26 at 4:41 p.m., stated she has worked at the facility since October 2025. She stated she has not been informed of Resident 3 not receiving her showers. She stated she used to be Resident 3's Guardian Angel and has a relationship with Resident #3's family member. She stated Resident #3's family has not told her anything about Resident# 3 not getting her showers. Record Review of the facility's policy titled: Activities of Daily Living (ADL), Supporting Revised February 2025 reflected: Policy: Residents will be provided with care, treatment, services as appropriate to maintain or improve their ability to care out activities of daily living. Policy Interpretation and Implementation:Residents will be provided with care, treatment, and services that their activities of daily living do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable.Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the residents and in accordance with the plan of care, including appropriate support and assistance with hygiene, mobility, elimination, dining, and communication. Record review of the facility's policy titled: Bath, Shower/Tub Revised February 2018 reflected: Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the conditions of the resident's skin.Policy Interpretation and Implementation:Staff will initial and date the shower/tub bath was performed.Document all evaluations data obtained during the shower/tub bath.Document if a resident refused the shower/tub bath, the reason(s).Notify the supervisor if the resident refuses the shower/tub bath.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained free of accident hazards as possible for 1 station out of 2 stations reviewed for accidents and hazards.The facility failed to ensure that the mechanical lift on station 1 was locked and secured when not in use.This failure could place residents at risk of falls and/or injuries.Findings Included:Observation on 08/17/26 at 10:17am on station 1 revealed an unlocked and unsecured mechanical lift parked on the hallway. Residents were observed wheeling themselves up and down the hallway.During an interview on 08/17/26 at 10:28am with LVN A, revealed that mechanical lifts should always be locked and stored away from high traffic areas where residents could not access them and get hurt. She stated she had been in-serviced on mechanical lifts to include storage. During an interview on 08/19/26 at 10:28am, the ADON stated that mechanical lifts should always be locked when not being used. The ADON stated that mechanical lifts were stored by the side of the hallway away from residents. She stated that the failure to lock mechanical lifts could cause accidents that could injure residents including getting fractures that could lead to hospitalization.During an interview on 08/19/26 at 1:52pm with CNA D, she stated she always stored the mechanical lifts at the end of the hall and ensured the lift was locked to prevent residents from hurting themselves. She stated she had been in-serviced on mechanical lifts to include securing and storing. During an interview on 08/19/26 at 2:15pm with the DON, she stated that her expectation was that all mechanical lifts should be locked when they were not in use. The DON stated that all staff had been educated on locking mechanical lifts. She stated that all mechanical lifts were to be stored on one side of the building and locked when not in use. She stated that she would re-educate staff with In-service training on mechanical lifts and mechanical lift storage and safety. She stated that there was a risk to residents if they attempted to pull themselves up using an unlocked and unsecured mechanical lift, which could cause injuries.Record Review of requested facility's policy for Lifting Machine, using a Mechanical Level II (Revised July 2017) did not provide any information regarding accidents and hazards relating to mechanical lift safety and storage.

Based on observation, interview, and record review, the facility to provide food that accommodated resident allergies, intolerances, and preferences for one resident (Resident#48) of 7 residents review for food allergies and intolerances. The facility failed on 08/17/2026 at 10:03AM to ensure Resident #48's allergy to peanuts was communicated to the dietary department and documented on the resident's meal ticket. The facility failed on 08/17/2026 at 10:03AM to ensure that Resident #48, who had documented allergies to peanuts, was not served food with peanuts. This failure could place residents at risk of receiving and consuming the identified allergen and experiencing potential serious allergic reaction.Findings included:Review of Resident #48's Comprehensive MDS Assessment, dated 06/01/2026, reflected a [AGE] year-old female admitted on [DATE], and had a BIMs score of 10 indicated she had moderate cognitive impairment. The resident had diagnoses which included malnutrition (a person gets too few, too many, or the wrong mix of nutrients). Review of Resident #48's Comprehensive Care Plan, revised 10/22/2024, reflected: Allergic to Amoxicillin, Peanuts. Interventions Do not administer and/or come in contact with allergen. Inform MD if the allergen is ordered. Make note on chart of all allergies. Review of Resident #48's active physician orders, dated:08/17/2026, reflected: Allergies: Amoxicillin(10/21/2024), Peanuts (10/21/2024). During an interview on 08/17/2026 at 10:03AM, Resident #48 stated she did not like what was served for breakfast and she had requested a snack. She stated that the staff gave her a peanut butter sandwich, but she did not eat the sandwich because she was allergic to peanuts. Review of the Resident #48's meal ticket on the breakfast tray did not list any allergies. This surveyor observed a peanut butter sandwich on the resident tray wrapped in plastic wrap. During an interview on 08/17/2026 at 11:15AM, the Dietary Manager stated she was not aware that Resident #48 had peanut allergies. She stated allergies were communicated from the nursing department to the dietary department using communication sheets. She stated she had spoken to Resident #48 many times when she complained about her meals, but Resident #48 had not mentioned that she had peanut allergies. She stated all residents that received snacks had their names on the snacks so that the staff could give the right snack to the right resident. She stated she was going to request a communication sheet form the nursing department then she would update the allergies on Resident #48's meal tickets and add her to the snack list so that she could have a snack with her name . During an interview on 08/18/2026 at 11:41AM,CNA G stated she was not aware that Resident #48 had peanut allergies. She stated the CNAs were responsible for passing snacks to the residents. She stated the resident's food allergies were listed on the meal tickets or the nurses communicated with the CNAs. She stated she was in serviced on verifying with the nurses before she passed snacks to residents. During an interview on 08/18/2026 at 2:15PM., RN B stated residents allergies were listed on the resident chart. She stated she was not aware that Resident #48 was allergic to peanuts. She stated she did not know who gave Resident #48 the peanut butter sandwich. RN B stated the risk of not communicating a resident's allergies could result in the resident being served food they were allergic to and that could make them have a severe life-threatening allergic reaction and even die. During an interview on 08/18/2026 at 2:25PM., the DON stated all residents should have their allergies documented on their meal tickets. She stated she verified with Resident #48 and the nursing staff nursing that Resident #48 did not consume or touch the peanut butter sandwich that was on her tray. She stated the nurses were supposed to communicate Resident #48's allergies with dietary using the dietary communication sheet. She stated t the nursing department sent the communication sheets to dietary, then the dietary department had its own system that generated the meal tickets. She stated the company recently changed systems and the allergies might have dropped when the systems changed. She stated she would audit meal tickets to ensure the allergies were added to the meal ticket and she would Inservice the staff on verifying resident allergies before giving a resident snack. Review of the facility's policy and procedures manual titled, Menu Planning, revised 2023, reflected the following: 3. Individuals who prefer to eat at nontraditional times or outside of scheduled mealtimes will be offered suitable nourishing alternative meals, consistent with the individual's care plan. a. Suitable and nourishing alternative meals or snacks are of similar nutritive value as the meals or snacks normally scheduled and are consistent with the individual's care plan. b. Significant information and/or response to everyone's diet will be recorded in the medical record and/or care plan.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #21 and Resident #46) reviewed for infection control.The facility failed on 8/18/2026 to ensure MA C and sanitized the blood pressure cuffs to prevent the spread of infections. This failure placed residents at risk for healthcare associated cross contamination and infections. Findings included:Review of Resident #21's Comprehensive MDS Assessment, dated 07/16/2026, reflected an [AGE] year-old female admitted on [DATE], and had a BIMs score of 11 indicated he had moderate cognitive impairment. The resident had diagnoses which included hypertension (it is a common condition where the force of blood against the artery walls is consistently too high). Review of Resident #21's Comprehensive Care Plan, initiated 08/17/2026, reflected the resident has hypertension (HTN) r/t stroke. Interventions included: Avoid taking the blood pressure reading after physical activity or emotion distress.[KA21.1] Review of Resident #21's active physician orders dated:08/17/2026 reflected: Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 1 tablet by mouth two times a day for HTN hold for SBP <110 or DBP <60 or HR less than07/16/2026. Review of Resident #46's Quarterly MDS Assessment, dated 07/01/2026, reflected a [AGE] year-old female admitted on [DATE], and had a BIMs score of 08 indicated she had moderate cognitive impairment. The resident had diagnoses which included hypertension (it is a common condition where the force of blood against the artery walls is consistently too high). Review of Resident #46's Comprehensive Care Plan, revised 06/06/2025, reflected, [Resident #46] has dx of Hypertension Medication: Hydralazine. Interventions included: Obtain blood pressure readings Q shift. Take blood pressure readings under the same conditions each time. Review of Resident #46's active physician orders dated:08/17/2026 reflected: hydrALAZINE HCl Tablet 25 MG Give 25 mg by mouth three times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) hold for sbp less than 110, dbp less than 60, hr less than 07/06/2026. An observation on 08/01/2026 at 8:10 AM., revealed MA C checked Resident #21's blood pressure and did not sanitize the blood cuff. An observation on 08/01/2026 at 8:16AM .,revealed MA C checked Resident #46's blood pressure and did not sanitize the blood pressure cuff. During an interview on 08/18/26 at 8:35 A.M.,MA C stated she was supposed to sanitize the blood pressure cuff after use with each resident. She stated the failure to sanitize the blood pressure cuffs could put the residents at risk for infection and contamination of other items in the medication cart. During an interview on 08/18/26 at 8:40 A.M.,LVN A revealed all shared medical equipment should be sanitized between residents. She stated the risk to the resident was infection. She stated she was in serviced on infection control. During an interview on 08/19/26 at 10:30 A.M., the ADON stated that her expectation was that staff sanitized blood pressure cuff in between residents using disinfecting wipes. She stated that the risk to the residents was infection. She stated that staff had been in serviced on infection control. During an interview on 08/18/26 at 1:30 P.M., DON stated her expectation was that staff sanitized blood pressure cuffs between residents by using disinfecting wipes. She stated the risk to the resident was infection spreading from one resident to another. She stated staff were in serviced on infection control. Record review of the facility policy titled, Administering Medications, dated 04/2019, reflected: 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Record review of the facility policy titled, Infection Control - Clinical Protocol, revised 2001, did not mention sanitization of shared medical equipment.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and provided care in a manner that promoted maintenance or enhancement of his or her quality of life for one of six residents (Resident #10) reviewed for resident rights. The facility failed to ensure visual privacy for Resident #10, whose buttocks was left uncovered while lying in bed when LVN A left resident's care area for 10 minutes. This failure could place residents at risk for diminished quality of life, loss of dignity, and self-worth.Findings included: Record review of Resident #10's Face Sheet, dated 07/08/26, reflected she was an [AGE] year-old female, readmitted [DATE], with diagnoses including Diabetes Mellitus (a chronic condition where your body struggles to process blood sugar), Cognitive Communication Deficit ( difficulties with communication caused by disrupted thinking skills rather than a primary speech or language impairment) and anxiety disorder (a group of mental health conditions characterized by intense, excessive, and persistent fear or worry about everyday situations). Record review of Resident #10's MDS Assessment, dated 06/09/26, reflected a BIMS Score of 02, indicating a severe cognitive impairment. Record review of Resident #10's Physician's Orders, dated 07/08/26, did not reflect any orders regarding requirements for personal care assistance. Record review of Resident #10's Care Plan, dated 01/14/25, reflected she had an ADL self-care performance deficit and required the assistance of at least one staff member for ADLs such as transfers, repositioning, dressing, bathing/showering, and other personal hygiene activities. During an observation on 07/08/26 at 10:50 AM, reflected Resident #10 was lying in her bed. LVN A uncovered resident, removed her brief and wound dressing to her buttocks dated 07/08/2026. LVN A left Resident #10's buttocks uncovered down to her knees and left the room for 10 minutes to gather supplies for wound care while the surveyor was in the room. Observation indicated Resident #10's privacy curtain was halfway drawn, and her room's door was open. During an interview with LVN A on 07/08/26 at 11:28 AM, she stated she left the room to gather additional supplies she needed to perform incontinent and wound care. She stated that she forgot to cover Resident #10 before leaving the room and should have pulled her privacy curtain shut. LVN A stated the risk of a resident not being provided with visual privacy and/or having their buttocks exposed was a lack of dignity. During an interview with Resident #10 on 07/08/26 at 1:15 PM, she could not speak. Resident #10 could not explain how she felt related to the exposure. During an interview with the DON on 07/08/26 at 3:00 PM, she stated Resident #10 should have been covered when LVN A left the care area. The DON stated she was not sure of any risks when residents' privacy curtain was not drawn but that resident dignity was not provided when her buttocks were exposed. Record review of the Residents Rights policy, dated 2003, reflected, .Each resident was treated with consideration, respect and full recognition of his/her dignity and individuality, including privacy in treatment and in care for personal needs. The policy did not specifically address visual privacy.

Based on observation, interview, and record review, the facility failed to ensure that residents' environment remained free of hazards as was possible for one of six residents (Resident #15) reviewed for accident hazards. The facility failed to ensure a pair of scissors and nail clippers were not on Resident #15's bedside table on 07/08/2026. These failures could place the residents at risk of avoidable accidents.Findings included: Record review of Resident #15's Face Sheet, dated 07/08/2026, reflected a [AGE] year-old male, readmitted on [DATE]. The resident was diagnosed with Chronic Respiratory Failure (a long-term condition where the lungs cannot adequately pull oxygen into the blood or remove carbon dioxide from it), Lack of coordination, Depression ( a common, serious mood disorder that causes persistent sadness, loss of interest, and physical fatigue) and Anxiety disorder (mental health conditions characterized by excessive, persistent, and disproportionate fear or worry about everyday situations). Record review of Resident #15's Quarterly MDS Assessment, dated 05/11/2026, reflected a BIMS score of 15 indicating cognitive function is intact and diagnosis of Seizure disorder (A seizure is a sudden, uncontrolled surge of electrical activity in the brain that can cause temporary disruptions in awareness, behavior, sensations, or muscle control). Record review of Resident #15's Care Plan, dated 12/04/22, reflected he had an ADL self-care performance deficit and required the assistance of at least one staff member for ADLs such as transfers, repositioning, dressing, bathing/showering, and other personal hygiene activities. Resident #15 was diabetic; CNAs cannot perform nail cutting. Resident #15 had depression and anxiety with interventions including administering medications as ordered and monitor/document side effects for hopelessness, sadness, anxiety etc. During an observation and interview on 07/08/2026 at 11:15 AM, Resident #15 was in his room, sitting in his wheelchair watching television. His room was clean and homelike. It was observed that on top of the resident's bedside table were a pair of scissors and nail clippers unattended and within reach. During an interview on 07/08/2026 at 11:15 AM, Resident #15 stated the scissors, and nail clippers were his own and he used them when he wanted to cut things and trim his nails. During an interview on 07/08/2026 at 11:20 AM, the administrator stated she was not aware Resident #15 had scissors and nail clippers in his room. The administrator stated the items should not be inside Resident #15's room because they could cause harm or injury to Resident #15 or to others. The administrator witnessed the scissors and nail clipper at Resident #15's bedside table and removed the items for secured storage. During an interview on 07/08/2026 at 11:50 AM, LVN A stated she was not aware Resident #15 had scissors and nail clippers in his room. LVN A stated the risk of having the scissors was injury as Resident #15 may cut himself or others. During an interview on 07/08/2026 at 3:00 PM, the DON stated Resident #15 may have brought the scissors and fingernail clippers to the facility. She stated her expectation was that all staff removed sharp and dangerous items from resident rooms and stored them for supervised use. The DON stated staff were educated and trained in the proper use and safety of sharp objects like scissors and fingernail clippers. She stated the risk to residents could be danger to themselves. Record review of the facility's policy titled, Accidents and Incidents-Investigating and Reporting, revised July 2017, did not address residents' possession of sharp and dangerous objects.

Based on observation, interview, and record review the facility failed to establish and maintain respiratory care including oxygen services, including the safe handling, humidification, cleaning, storage, and dispensing of oxygen for two (Resident #13 and #15) of six residents reviewed for respiratory care. 1.) The facility failed to ensure that Resident #13's nebulizer mask was bagged in a plastic bag.2.) The facility failed to ensure that Resident #15's oxygen tubing/nasal cannula was bagged in a plastic bag. These failures could place residents receiving respiratory therapy at risk of health-associated infections.Findings included: 1. Record review of Resident #13's Face Sheet, dated 07/08/26, reflected she was a [AGE] year-old female readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (an ongoing, progressive lung condition that restricts airflow and makes it difficult to breathe) and congestive heart failure (a medical condition where the heart can't pump enough blood to meet the body's needs). Record review of Resident #13's MDS Assessment, dated 05/11/26, reflected she had a BIMS score of 15 indicating cognitive function was intact. MDS did not address her breathing treatment use. Record review of Resident #13's Physician's Orders, dated 07/08/26, reflected an active order for Budesonide Inhalation Suspension 0.5MG/2ML inhale orally one time a day for SOB/Wheezing and Change nebulizer mask and tubing once a week every night shift every Sunday. Record review of Resident #13's Care Plan, dated 01/22/26, reflected (.medication: Budesonide with goal -Resident will be free of signs/symptoms of respiratory infection .). Observation on 07/08/26 at 11:12 AM, revealed Resident #13's nebulizer mask was not in use and was lying on her bedside table, unbagged. Resident #13 was not in her room. 2. Record review of Resident #15's Face Sheet, dated 07/08/2026, reflected a [AGE] year-old male, readmitted on [DATE]. The resident was diagnosed with Chronic Respiratory Failure (a long-term condition where the lungs cannot adequately pull oxygen into the blood or remove carbon dioxide from it), Lack of coordination, Depression ( a common, serious mood disorder that causes persistent sadness, loss of interest, and physical fatigue) and Anxiety disorder (mental health conditions characterized by excessive, persistent, and disproportionate fear or worry about everyday situations). Record review of Resident #15's Quarterly MDS Assessment, dated 05/11/2026, reflected a BIMS score of 15 indicating cognitive function was intact. MDS did not address his oxygen use. Record review of Resident #15's Physician's Orders, dated 07/08/26, reflected an active PRN order for oxygen at 2-3 L/Minute via nasal cannula every 24 hours as needed. Observation and interview on 07/08/26 at 11:15 AM, revealed Resident #15's oxygen tubing/nasal cannula was not in use and was lying on a bedside table, unbagged. Resident #15 stated he used his oxygen mainly at night and when he returned from dialysis. Resident #15 stated could put on and off his oxygen nasal cannula. During an interview with CNA A on 07/08/26 at 11:25 AM, she confirmed observing Resident #13's nebulizer mask and Resident #15's oxygen tubing/nasal cannula, not in use and unbagged. CNA A stated nebulizer masks and oxygen tubing/nasal cannulas should all be bagged when not in use. She stated the risk of not bagging the items included the potential for infection. During an interview with the DON on 07/08/26 at 3:00 PM, she stated oxygen tubing/nasal cannulas and nebulizer masks should all be bagged when not in use. She stated the risk of not bagging these items included the potential for infection. The DON stated it was the responsibility of every staff member to ensure respiratory equipment was appropriately bagged when not in use to prevent infection. During an interview with the Administrator on 07/08/26 at 3:20 PM, she stated they did not have a policy related to proper storage of respiratory equipment (such as oxygen tubing/nasal cannulas and nebulizer masks).

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #10) of 6 residents, reviewed for infection control. LVN A failed to don PPE prior to performing the high contact resident care activity on a resident who was on enhanced barrier precautions. This failure placed residents at risk for healthcare associated cross contamination and infections.Findings included: Record review of Resident #10's Face Sheet dated 07/08/26, reflected she was an [AGE] year-old female, readmitted [DATE], with diagnoses including Diabetes Mellitus (a chronic condition where your body struggles to process blood sugar), Cognitive Communication Deficit ( difficulties with communication caused by disrupted thinking skills rather than a primary speech or language impairment) and anxiety disorder (a group of mental health conditions characterized by intense, excessive, and persistent fear or worry about everyday situations). Record review of Resident #10's MDS Assessment, dated 06/09/26, reflected a BIMS Score of 02, indicated severe cognitive impairment. Record review of Resident #10's Physician's Orders, dated 07/08/26, reflected Cleanse skin tear with wound cleanser and pat dry. Apply Alginate Calcium and cover with an island gauze dressing every day shift, for wound healing and as needed if soiled, saturated or dislodged and Enhanced barrier Precautions as needed. Record review of Resident #10's Care Plan, dated 01/14/25, reflected that she had an ADL self-care performance deficit and required the assistance of at least one staff member for ADLs such as transfers, repositioning, dressing, bathing/showering, and other personal hygiene activities. An observation on 07/08/2026 at 10:50 AM, revealed Resident #10's room had an Enhanced Barrier Precaution sign outside her room, and cart set up with PPE outside the room. LVN A prepared Resident #10's incontinent and wound care items and entered resident's room, she performed high contact resident activities of repositioning, removing resident brief and removing resident's wounds dressings without wearing PPE (gown). During an interview with CNA A on 07/08/26 at 11:25 AM, she stated she wears gown and glove when she gave care to Resident #10. CNA A stated residents with wounds, G/tube, catheters and open body areas were put on EBP. She stated the risk of not using PPE included the potential for infection. An interview on 07/08/26 at 11:28 AM, LVN A revealed she knew Resident #10 was on enhanced barrier precautions, and she should have donned PPE before repositioning, removing brief and removing Resident #10's wound dressings. LVN A stated she forgot to wear the gown and failure to use PPE could put the resident at risk for infection. She stated she had been in-serviced on enhanced barrier precautions. An interview on 07/08/2026 at 3:00 PM, the DON revealed her expectation was staff should use appropriate PPE while providing care to residents on enhanced barrier precautions. She stated the risk to the patient was infection. She stated staff had been in-serviced on infection control and Enhance Barrier Precautions. EBP policy dated February 2025 was reviewed. Record review of the facility policy titled Enhanced Barrier Precautions revised February 2025: Policy Interpretation and Implementation stated1. Enhanced barrier precautions (EBP) are used as an infection prevention and control intervention to reduce the spread of multi drug resistant organisms (MDROs) to residents.2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.a. Gloves and gown are applied prior to performing the high contact resident care activities (as opposed to before entering the room)b. personal protective equipment (PPE) is changed before caring for another resident.c. face protection may be used if there is also a risk of splashes or spray.3. Examples of high-contact resident care activities requiring the use of gowns and gloves for EBPs include:a. dressing;b. bathing/showering;c. transferring;d. providing hygiene;e. changing linens;f. changing briefs or assisting with toileting;g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing.).

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs for one (Resident #1) of five residents reviewed for comprehensive care plans. The facility failed to complete a comprehensive care plan within 21 days of Resident #1's admission to the facility. This failure could place residents at risk of not receiving effective, person-centered care, and maintaining his or her highest practicable quality of life. Findings included: Record review of Resident #1's admission MDS assessment, dated 05/17/26, revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1's primary diagnoses included stage four chronic kidney disease (the kidneys are severely damaged and function at less than 29% of their capacity) and required dialysis (filters waste, toxins and excess fluid from the blood), depression (serious mood disorder) and neuropathy (numbness and tingling in extremities). Additionally, Resident #1 was incontinent of bowel and bladder, and required moderate assistance for transfers. A record review of Resident #1's chart revealed there was not a comprehensive care plan in the facility's electronic health records (EHR) system. During an interview with the MDS Nurse on 06/03/26 at 1:00pm, the MDS Nurse was asked when Resident #1's comprehensive care plan should have been completed. The MDS Nurse stated that when a resident admitted to the facility, they had 14 days to complete the CAA, and 7 days after that to complete the care plan. She further stated they were behind on Resident #1's. She stated his MDS was signed on 05/17/26, and she should have had it done by 05/25/26. The MDS Nurse stated there was a risk for the resident if the comprehensive care plan was not completed, because there was a specific timeframe for a purpose, although they did have other guidelines in place for care needs. A record review of the facility's Comprehensive Care Plan Policy, revised March 2022, stated The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.

Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for one (Resident #1) of three residents reviewed for abuse. The facility failed to implement their abuse policy and procedure after an allegation of abuse was made regarding Resident #1. After making an allegation of verbal abuse by the Administrator, the Administrator confronted Resident #1 regarding the allegation. This failure could place residents at risk of abuse due to facility failure to follow their policy and procedures for abuse.Findings included: Record review of the facility policy, Abuse/Neglect, not dated, reflected:F. ProtectionThe facility will take necessary measures to protect residents .from harm during and following an abuse investigation.Allegations of abuse.will remain confidential.3. Harassment and interfering with an investigation will result in disciplinary action up to and including termination. Record review of Resident #1's Annual MDS, dated [DATE], reflected he was a [AGE] year-old admitted to the facility on [DATE]. His cognitive skills for daily decision making were intact. His diagnoses included stroke, seizures, and Non-Alzheimer's dementia. Record review of Resident #1's Care Plan, dated 09/05/24, reflected:Resident #1 had a PASARR positive status (indicating that Resident #1 had been screened and found to have a serious mental illness or intellectual/developmental disability) related to intellectual disability. An interview on 01/06/26 at 11:30 am with Resident #1 revealed in October 2025 (10/15/25) during a fall festival, the Administrator and Activity Director told him to shut up, mind your business and don't say anything. Resident #1 said he was told this because he said it was not fair that the festival was not just for the residents. Other people came to the facility for the festival. He said the Activity Director was just joking with him when she said it, but the Administrator meant it. He said the Administrator took it to a whole new level. Resident #1 said he had a PASSAR meeting in December 2025 (12/02/25) and he told the staff present that the Administrator told him to shut up, mind your business and don't say anything during a festival in October 2025. He said he did not report the allegation before the meeting in December but did not say why. Resident #1 said the MDS Nurse went to get the Administrator. The Administrator came to the meeting. Resident #1 said he told the Administrator that she told him to shut up, and she told the resident, No I did not. The resident said he tried to argue with her, but every time he tried to say something, the Administrator would put her hand up to make him stop talking. Resident #1 said if the Administrator said something to him, then he had the right to speak up. Resident #1 said the Administrator was trying to talk to the people in the room and clear it up and he let her speak. He said he felt upset at the time of the meeting but did not hold any grudges and did not feel bad anymore. Resident #1 said the Administrator stayed in the room and argued with him about what she said to him, then left the room right before the other staff did. Resident #1 said he did not know if the Administrator left for the day but did tell him that she would not speak to him without a witness. The resident said he did not speak to the Activity Director about the statement, because she was just joking. An interview on 01/06/26 at 10:55 am with the Administrator revealed she entered the conference room and reported she wanted to give information about the self-reports the facility made. The Administrator said the facility had a fall festival on 10/15/25 and vendors came to the facility. She said there was a cake walk and a grilling station. The Administrator said she was working at the grill station. The Administrator said there was a self-report regarding Resident #1. She said Resident #1 accused her and the Activity Director of verbally abusing him during his PASSAR meeting in December 2025 (12/02/25). She said she was not in the meeting. She said the MDS Nurse came and got her because Resident #1 reported concerns during the meeting. The Administrator said she went to the meeting and the resident said he was told residents could not go to the festival and that she said to shut up, mind your business. The resident was never at my grill station. She stated she told him that she did not interact with him at that time of the party and that she doesn't use the word shut up. The Administrator said the Activity Director was not at the meeting. The Administrator said it was not facility policy to allow the alleged perpetrator to question the resident, but at the time it was just a conversation between the resident and her. She said in hindsight she should not have talked to the resident if he made a verbal allegation of abuse against her, but she thought Resident #1 wanted to [NAME] the [NAME]. The Administrator said the resident made the allegation of verbal abuse before the MDS Nurse went to get her to go to the meeting. The Administrator said she did not know who else was in the meeting other than the MDS nurse. The Administrator said after she spoke to Resident #1 in the meeting she suspended herself for one day and notified the Owner of the facility. The Administrator said the DON completed the self-report investigation. An interview on 01/06/26 at 12:00 pm with the MDS Nurse revealed she was at the PASSAR meeting for Resident #1 on 12/02/25. She said the meeting was held in her office and the Therapy Director and PASSAR staff were there. The MDS Nurse said Resident #1 made an allegation of verbal abuse against the Administrator and Activity Director that occurred during the Fall Festival. The MDS Nurse said she felt the accused had the right to face their accuser. She said she left the meeting to get the Administrator because she was the Abuse Coordinator. The MDS Nurse said she did not know what else to do. The MDS Nurse said the Administrator asked Resident #1 what his concerns were. Resident #1 told the Administrator that she told him to shut up and mind his own business. The Administrator said she explained to everyone in the room how the set-up was for the Fall Festival and then she left the room. The MDS Nurse said if a resident had to face their alleged perpetrator they could have a fear of retaliation and feel it was not a safe place to report their concerns. An interview on 01/06/26 at 1:00 PM with the ECC Service Coordinator revealed she was at the PASSAR meeting for Resident #1 on 12/02/25. She said Resident #1 made an allegation of verbal abuse against the Administrator. Resident #1 said the Administrator told him to shut-up. Resident #1 said he had not reported the allegation prior to the meeting. She said the MDS Nurse left the room to get the Administrator and address the allegation. The ECC Service Coordinator said the Administrator came to the meeting and negated Resident #1's claim of verbal abuse. She said the Administrator said he was fabricating the allegation due to retaliation. She said the Administrator argued back and forth with the resident about the allegation and she denied the allegation. She said the Administrator did not leave the room after the resident made the allegation. An interview on 01/07/26 at 11:40 AM with the Activity Director revealed she said she did not verbally abuse Resident #1. An interview on 01/06/26 at 2:45 PM with the Administrator revealed she said facility staff were supposed to contact the DON or Corporate Staff if she was named as the alleged perpetrator. She said since the summer of 2025, Resident #1 had made 4-5 calls to the state and that he would say his rights were affected. She said Resident #1 was upset because he could not sell stuff out of his room. The Administrator said after he made the verbal allegation against her she told him that she would make the appropriate phone calls. She said later that night she was suspended pending the investigation.

Based on interview and record review, the facility failed to, in response to allegations of abuse, have evidence that all alleged violations were thoroughly investigated for one (Resident #1) of three residents reviewed for abuse. The facility failed to thoroughly investigate an allegation of verbal abuse reported by Resident #1. This failure could place residents at risk of abuse due to facility failure to fully investigate allegations for abuse. Findings included: Record review of Resident #1's Annual MDS, dated [DATE], reflected he was a [AGE] year-old admitted to the facility on [DATE]. His cognitive skills for daily decision making were intact. His diagnoses included stroke, seizures, and non-Alzheimer's dementia. Record review of Resident #1's Care Plan, dated 09/05/24, reflected:Resident #1 had a PASARR positive status (indicating that Resident #1 had been screened and found to have a serious mental illness or intellectual/developmental disability) related to intellectual disability. Review of the Facility Provider Investigation Report for Resident #1 dated 12/09/25 reflected the resident reported an allegation of verbal abuse on 12/02/25 that occurred on 10/15/25. Resident #1 said that he asked to attend the Fall Festival and was told, shut up, mind your business, and don't say anything by the Administrator and Activity Director. The findings of the investigation by the DON revealed the allegation was unfounded.Witness Statement from Activity Director:Activity Director did not speak to Resident #1 on the day of the Fall Festival.Witness Statement from the Administrator:Resident #1 voiced at the end of the PASSAR meeting on 12/02/25 that he complained about not being able to participate at the Fall Festival and was told by the Administrator and Activity Director to shut-up, be quiet and mind his business. The MDS Nurse got the Administrator to attend the meeting. Resident #1 had not reported the allegation prior to 12/02/25. Resident #1 said he was holding a grudge because he was told he could not sell items out of his room.Witness Statement from the MDS Nurse:During his (Resident #1's) PASSAR meeting he complained about the Fall Festival and said when he complained he was told to shut up and mind his business by the Administrator and Activity Director. The MDS Nurse said she excused herself from the meeting to get the Administrator because, I am a firm believer that all accused have the right to face their accuser and this is a strong allegation. The Administrator and MDS Nurse returned to the meeting and the Administrator told the resident that she never said that to him. The meeting came to an end and it was suggested that the Administrator and Resident #1 have a meeting to hash out their differences.The Provider Investigation report did not reflect that Resident #1 was interviewed or given a safe survey. An interview on 01/06/26 at 11:30 AM with Resident #1 revealed in October 2025 (10/15/25) during a fall festival, the Administrator and Activity Director told him to shut up, mind your business and don't say anything. Resident #1 said he was told this because he said it was not fair that the festival was not just for the residents. Other people came to the facility for the festival. He said the Activity Director was just joking with him when she said it, but the Administrator meant it. He said the Administrator took it to a whole new level. Resident #1 said he had a PASSAR meeting in December 2025 (12/02/25) and he told the staff present that the Administrator told him to shut up, mind your business and don't say anything during a festival in October 2025. He said he did not report the allegation before the meeting in December but did not say why. Resident #1 said the MDS Nurse went to get the Administrator. The resident said he was upset but was not afraid to face her. The Administrator came to the meeting. Resident #1 said he told the Administrator that she told him to shut up, and she told the resident, No I did not. The resident said he tried to argue with her, but every time he tried to say something, the Administrator would put her hand up to make him stop talking. Resident #1 said if the Administrator said something to him, then he had the right to speak up. Resident #1 said the Administrator was trying to talk to the people in the room and clear it up and he let her speak. He said he felt upset at the time of the meeting but did not hold any grudges and did not feel bad anymore. Resident #1 said the Administrator stayed in the room and argued with him about what she said to him, then left the room right before the other staff did. Resident #1 said he did not know if the Administrator left for the day but did tell him that she would not speak to him without a witness. The resident said he did not speak to the Activity Director about the statement, because she was just joking. An interview on 01/06/26 at 10:55 AM with the Administrator revealed she entered the conference room and reported she wanted to give information about the self-reports the facility made. The Administrator said the facility had a fall festival on 10/15/25 and vendors came to the facility. She said there was a cake walk and a grilling station. The Administrator said she was working at the grill station. The Administrator said there was a self-report regarding Resident #1. She said Resident #1 accused her and the Activity Director of verbally abusing him during his PASSAR meeting in December 2025 (12/02/25). She said she was not in the meeting. She said the MDS Nurse came and got her because Resident #1 reported concerns during the meeting. The Administrator said she went to the meeting and the resident said he was told residents could not go to the festival and that she said to shut up, mind your business. The resident was never at my grill station. She stated she told him that she did not interact with him at that time of the party and that she doesn't use the word shut up. The Administrator said the Activity Director was not at the meeting. The Administrator said it was not facility policy to allow the alleged perpetrator to question the resident, but at the time it was just a conversation between the resident and her. She said in hindsight she should not have talked to the resident if he made a verbal allegation of abuse against her, but she thought Resident #1 wanted to [NAME] the [NAME]. The Administrator said the resident made the allegation of verbal abuse before the MDS Nurse went to get her to go to the meeting. The Administrator said she did not know who else was in the meeting other than the MDS nurse. The Administrator said after she spoke to Resident #1 in the meeting she suspended herself for one day and notified the Owner of the facility. The Administrator said the DON completed the self-report investigation. An interview on 01/06/26 at 12:00 PM with the MDS Nurse revealed she was at the PASSAR meeting for Resident #1 on 12/02/25. She said the meeting was held in her office and the Therapy Director and PASSAR staff were there. The MDS Nurse said Resident #1 made an allegation of verbal abuse against the Administrator and Activity Director that occurred during the Fall Festival. The MDS Nurse said she felt the accused had the right to face their accuser. She said she left the meeting to get the Administrator because she was the Abuse Coordinator. The MDS Nurse said the Administrator asked Resident #1 what his concerns were. Resident #1 told the Administrator that she told him to shut up and mind his own business. The Administrator said she explained to everyone in the room how the set-up was for the Fall Festival and then she left the room. The MDS Nurse said if a resident had to face their alleged perpetrator they could have a fear of retaliation and feel it was not a safe place to report their concerns. An interview on 01/06/26 at 1:00 PM with the ECC Service Coordinator revealed she was at the PASSAR meeting for Resident #1 on 12/02/25. She said Resident #1 made an allegation of verbal abuse against the Administrator. Resident #1 said the Administrator told him to shut-up. Resident #1 said he had not reported the allegation prior to the meeting. She said the MDS Nurse left the room to get the Administrator and address the allegation. The ECC Service Coordinator said the Administrator came to the meeting and negated Resident #1's claim of verbal abuse. She said the Administrator said he was fabricating the allegation due to retaliation. She said the Administrator argued back and forth with the resident about the allegation and she denied the allegation. She said the Administrator did not immediately leave the room after the resident made the allegation. An interview on 01/07/26 at 11:40 AM with the Activity Director revealed she said she did not verbally abuse Resident #1. An interview on 01/06/26 at 2:45 PM with the Administrator revealed she said facility staff were supposed to contact the DON or Corporate Staff if she was named as the alleged perpetrator. She said since the summer of 2025, Resident #1 had made 4-5 calls to the state and that he would say his rights were affected. She said Resident #1 was upset because he could not sell stuff out of his room. The Administrator said after he made the verbal allegation against her she told him that she would make the appropriate phone calls. She said later that night she was suspended pending the investigation. An interview on 01/06/26 at 4:30 PM with the DON revealed she completed the investigation for the self-report regarding Resident #1. She also said the Corporate Staff assisted her. The DON said she did not interview Resident #1 and just spoke to the MDS Nurse and Administrator. The DON said she did safe surveys with other residents, but not with Resident #1. She said she was probably supposed to interview the resident but did not know what the policy said without reading it. The DON said she did not identify any issues with her investigation. The DON said based on her investigation there was no abuse. The DON said Resident #1 was a fabricator of instances and stories and was care planned for it. The DON said she was told Resident #1 said the Administrator and Activity Director told him to shut up and mind his business. The DON said she spoke with both the Administrator and Activity Director, and they denied the allegation. The DON said she reviewed the witness statements of the MDS Nurse and Administrator. The DON said she did not see the MDS Nurse notified the Administrator so she could confront her accuser (the resident) regarding the allegation of verbal abuse. She also said she did not interview any other members who were present at the PASSAR meeting on 12/02/25. An interview on 01/07/26 at 9:30 AM with Corporate Staff revealed he assisted the DON with the investigation of Resident #1's allegation of verbal abuse. He said he was not aware of any issues with the investigation. He said he did not know the resident was not interviewed but should have been. He said he did speak with the Administrator but thought she removed herself from the room when the resident made the allegation of verbal abuse. He said he did not know the other members present in the meeting were not interviewed. The Corporate Staff said the MDS Nurse should not have notified the Administrator and should have notified the DON. The Corporate Staff said he thought Resident #1 wanted to speak to the Administrator. The Corporate Staff said that failure to complete a thorough investigation could result in missed information. Record review of the facility policy, Abuse/Neglect, not dated, reflected:E. InvestigationAll investigations of abuse.will be investigated.

Based on observation, interviews, and record review, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 (Res#1, Res#2, Res#3 of 4 residents reviewed. The facility failed to ensure that the nursing home staff provided adequate documentation for who received offsite HHD treatments at an ESRD unit. These failures could place dialysis residents at risk for not having adequate documentation of dialysis care in result in a decline in health and quality of care. Findings included:Record review of Resident#1's face sheet, dated 09/04/25 reflected [AGE] year old male who was originally admitted on [DATE] and readmitted on [DATE] and diagnosed not limited to: dependence on renal dialysis (Treatment for people whose kidneys are not working), end stage renal disease (occurs when chronic kidney disease progresses to a point where the kidneys lose nearly all their filtering ability.) acute on chronic diastolic (congestive) heart failure, chronic kidney disease (chronic kidney disease), body mass index [BMI] 45.0-49.9, adult. Record review of Resident#1's MDS, dated [DATE] reflected his BIMS score was 15 which indicated cognitive intact. The MDS reflected Resident#1 Section O - special treatments, procedures and programs reflected, no dialysis services on admission, while a resident or at discharge. Record review of Resident#1 care plan, dated 05/14/25 reflected, Resident#1 needs hemodialysis related to renal failure. Dialysis center M/W/F and enhanced barrier precautions. Interventions included: The resident will have immediate intervention should any complications from dialysis. Interventions included: Check and change dressing daily at access site. Document. Do not draw blood or take B/P in arm with graft, encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis M,W,F, ensure enhanced barrier protection, monitor/document/report to MD PRN any s/sx of infection to access site: redness ,swelling, warmth or drainage and obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and BP immediately. Record review of Resident#1's order summary, dated 09/04/25 reflected, order date 05/08/25, monitor right upper chest dialysis permacath site for s/s infection/irritation. Report any findings to MD ASAP.Record review of Resident#1 active order summary, dated 09/04/25 reflected no order for dialysis treatment at the center. Record review of Resident #1 vitals in the EHR dated 06/11/25 to 09/04/25 reflected no post dialysis weights. Record review of Resident#1's EHR's reflected Resident#1 did not have dialysis communication documentation uploaded from 07/03/25 to 09/04/25. Record review of Resident#1 TMAR dated 07/01/25 to 09/04/25 reflected, no active dialysis/ renal care treatment orders.Record review of Resident# 2's face sheet, dated 09/04/25 reflected [AGE] year-old male who was originally admitted on [DATE] and readmitted on [DATE] and diagnoses not limited to: cerebral infraction (stroke) unspecified, acquired absence of kidney, dependence of renal kidney(Treatment for people whose kidneys are not working), and end stage renal disease (occurs when chronic kidney disease progresses to a point where the kidneys lose nearly all their filtering ability.) Record review of Resident#2's MDS, dated [DATE] reflected his BIMS score was 12 which indicated moderate cognitive impairment. Review of Resident#2 MDS reflected under Section O - special treatments, procedures and programs reflected, dialysis while a resident. Record review of Resident#2 care plan, dated 07/31/25 reflected, date initiated 04/14/22 that Resident #2 goes to dialysis M/W/F.left arm shut.enhanced barrier precautions. Goals reflected, Resident #2 will go to appointments and return to facility without incident. Interventions reflected, educate [Resident #2] on help CNA can assist with, if needed, by accompanying him on dialysis transports, Educate [Resident#2] on reporting any incidents while out on dialysis appointments ensure enhanced barrier protection.ensure [Resident#2] leaves at scheduled time for dialysis. Record review of Resident#2's order summary, dated 09/04/25 reflected, Carvedilol Tablet 6.25 MG Give 1 tablet by mouth two times a day for Hypertension Take with meals, hold on dialysis days, hold for SBP (Top number) <110, DBP (bottom number) <60, or HR<60. Record review of Resident#2 active orders revealed, there were no active orders for dialysis/renal treatment and care and no active orders for care treatment to dialysis access site. Record review of Resident#2's vitals dated 06/25/25 to 09/04/25 in the EHR reflected no post dialysis weights. Record review of Resident#2 EHR reflected Resident#2 did not have dialysis communication documentation uploaded for 06/20/25 to 09/04/25. Record review of Resident #2 TMAR dated August 2025 to September 2025 reflected no active dialysis/ renal care treatment orders. Record review of Resident #3's face sheet, dated 09/04/25 reflected [AGE] year-old male who was admitted on [DATE] and diagnosed with but not limited to: Type 1 Diabetes mellitus with diabetic neuropathy (nerve damage caused by high blood sugar levels in people with diabetes), unspecified, type 1 diabetes mellitus without complications, and essential hypertension (high blood pressure). Record review of Resident #3's MDS, dated [DATE] reflected his reflected his BIMS score was 15 which indicated cognitive intact. Review of Resident#3 MDS reflected under Section O - special treatments, procedures and programs reflected, dialysis while a resident Record review of Resident #3 care plan dated 09/04/25 reflected, Resident#3 had chronic renal failure related to end stage disease. Resident #3 focus reflected he had chronic renal failure related to end stage disease. Resident #3 goals reflected he will be free from infection, the resident will have no s/sx of complications r/t fluid deficit, the resident will have no s/sx of complications related to fluid overload. Resident#3 interventions included but not limited to: dialysis weekly M/W/F and monitor vital signs. Notify MD of significant abnormalities. Record review of Resident #3's order summary, dated 09/04/25 reflected, date initiated 08/16/25, other diet: Regular texture, regular consistency, renal diet. There was no active order for dialysis/ treatment center and no active order for care and treatment to dialysis access site. Record review of Resident#3 vitals in the EHR dated 08/16/25 to 09/04/25 reflected, no post dialysis weights. Record review of EHR reflected Resident#3 did not have dialysis communication documentation uploaded from 08/16/25 to 09/04/25. Record review ofResident#3 the TMAR dated August 2025 to September 2025 reflected no active dialysis/ renal care treatment orders. During an observation and interview on 09/04/ 25 at 11:00 am Resident #1 stated he did not have any concerns. Resident#1 stated that he rode the bus to the dialysis center M/W/F. Resident#1 stated that the staff cleaned his dressing to his dialysis site, and he did not have any concerns. Resident#1 stated he had lost his dialysis form in the past. The Surveyor observed Resident #1's chest sit was covered, and no concerns were noted. During an observation and interview on 09/04/ 25 at 11:10 am Resident #2 stated he goes rode the bus to the dialysis center M/W/F. Resident#2 stated that the staff at the facility cleaned his dressing to his dialysis access site. Resident#2 stated was not sure about a communication form and what happened to it. The Surveyor observed a fistula (surgically made passage between a hollow or tubular organ and the body surface)in his right arm and no concerns were noted. During an observation and interview on 09/04/ 25 at 11:15 am Resident #3 stated he went to dialysis every time and he did not miss any appointments. Resident #3 stated the dialysis center took the form and did not give him one back. Resident#3 stated he did not have any concerns. The Surveyor observed the fistula was covered in the right arm and no concerns were noted. During an interview and observation on 09/04/25 at 11:25 am LVN A stated the facility did not keep a book of the communications from the dialysis center. LVN A stated when residents returned from the dialysis center the forms were placed either in the purple binder or medical records drop box. The Surveyor and LVN A observed no outstanding dialysis forms. LVN A stated Resident# 1, Resident #2 and Resident #3 were on her hall and they all went to dialysis M/W/F. LVN A stated she would have Resident #1 and Resident #3 prepped and ready to go with breakfast and snacks for morning transportation to dialysis. LVN A stated residents were transported by the local- city bus on a set schedule. LVN A stated Resident #2 was transported to dialysis before lunch. LVN A stated she checked and monitored their port entry and none of the residents hadany concerns or issues with their ports. LVN A stated she had not experienced any of the three residents refuse to go to dialysis. LVN A stated if a resident refused or missed dialysis it would be documented in the progress notes. LVN A stated post dialysis vitals were supposed to be documented in the vitals section and progress notes in the EHR when residents returned. LVN A stated she would document the information if the resident vitals were abnormal in the resident's chart and report to the DON and MD. During an interview on 09/04/25 at 11:50 am the DON stated she could not make the dialysis center send the communication forms back. The DON stated if an issue or concern happened at dialysis the dialysis center could call; email and fax and the information would be received. The DON stated they would call to get the form faxed to them. The DON stated she was also over medical records and did not have any medical dialysis communication forms pending to be uploaded. The DON stated the dialysis residents were in and out the hospital a lot. The DON stated the orders were not reactivated when the residents returned to the facility. The DON stated the admitting nurse would be responsible for making sure the orders were activated. The DON stated no resident had missed dialysis because the transportation times were set, and the local bus picked up Resident #1 and Resident #3 together at the same time and Resident #2 was picked up before lunch. The DON stated the dialysis residents' entry sites were checked on every shift and any concerns would be noted in the progress notes and the DON, the MD and RP would be notified.During an interview on 09/04/25 at 1:08 pm the CNA/Central Supply stated she was responsible for doing the residents' pre/post dialysis weights and weekly weights when she was there. The CNA/Central Supply stated she was not always in the facility when Resident #2 returned from dialysis treatment. The CNA/Central Supply stated her schedule was not always the same. During an interview on 09/04/25 at 1:45pm LVN B stated that she checked Resident# 1, Resident #2 and Resident #3's vitals when they returned from dialysis. LVN B stated any abnormalities she would document in the progress notes which was in the resident's chart. and notify the DON, and the MD. LVN B stated the residents were very serious about their dialysis treatments and they did not miss their appointments. LVN B stated she checked the residents' entry sites and monitored the residents for any concerns. During an interview on 09/05/25 at 11:00 am the MD stated he was not responsible for dialysis orders and that was done by the nephrologist at the dialysis center. The MD stated he had too many residents on dialysis and he knew the facility provided care and treatment as ordered. During an interview on 09/05/25 at 3:00 pm with the Admin and the DON, the DON stated the facility had a policy related to the dialysis resident care and treatment to the access site. The DON stated the dialysis residents had not missed treatment or care.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to seal opened items in plastic bags in the freezer area on 06/09/25. 2. The facility failed to ensure an expired item in the dry storage pantry area was removed on 06/09/25. 3. The facility failed to ensure the dented cans in the dry storage area with the other canned food were removed from the shelf on 06/09/25. 4. The facility failed to ensure an expired item in the refrigerator area was removed on 06/09/25. These deficient practices could affect residents who received meals and/or snacks from the facility's only kitchen by placing them at risk for cross contamination and other food-borne illnesses. Findings included: Observation of the facility's kitchen dry storage, refrigerator, and freezer areas on 06/09/25 at 9:09 AM, included the following food items were in unsealed packages and containers, expired, and dented cans with the other canned food: Dry pantry area: * 1 white plastic container of 18 lb. cream cheese icing was unsealed and exposed to air. * 1 plastic container labeled, White Rice was unsealed and exposed to air. * 1 plastic container labeled, Powder Milk was unsealed and exposed to air. * 1 expired container of 1 gallon jalapeno peppers with an expiration date of 04/12/25. * 1 dented 11 oz. can of medium green lima beans. Refrigerator area: * 1 gallon of Caeser Salad Dressing was unsealed and exposed to air and did not have a shelf-life date and expiration date. * 1 plastic container of pickles with an expiration date of 04/23/25. Freezer area: *1 box of bacon was unsealed and exposed to air. *1 box of frozen vegetables was unsealed and exposed to air. *1 box of baby lima beans was unsealed and exposed to air. *1 box of beef luncheon patties was unsealed and exposed to air. *1 box of sugar frozen cookie dough was unsealed and exposed to air. *1 box of sopapilla dough was unsealed and exposed to air. In an interview with the DS on 06/09/25 at 9:55 AM, revealed he had been employed at the facility for 7 years. The Dietary Supervisor stated that he supervised 9 employees in the kitchen that work various shifts. He stated he was unaware there were expired and unsealed items in the kitchen's dry storage, refrigerator, and freezer areas. The DS stated he was unaware there was 1 dented can stored on the shelves with the other canned food in the dry pantry area. He stated all kitchen staff were responsible for ensuring all food items in the kitchen's dry pantry, refrigerator, and freezer areas were sealed, labeled, and checked for expiration dates. The DS stated that the dented cans in the dry pantry area should have been removed from the shelves with the other canned foods and should be placed in his office where there was an area designated for dented cans. The DS stated that there should not be any food items in the kitchen's dry pantry, refrigerator, and freezer areas that were not labeled, sealed, expired, including any dented cans in the dry pantry area. The DS stated that he provided monthly reeducation and retraining via In-Service Trainings for all kitchen staff and the trainings included proper food storage, labeling, and ensuring that there were not any dented cans in the facility's dry pantry, refrigerator and freezer areas. The DS stated that the monthly In-Service Trainings included proper food handling and sanitization to prevent food-borne illness and safety per the facility's policy. The DS stated that it was his expectation is for the kitchen staff to immediately inform him every time they throw away any food items that were expired, unsealed, and exposed to air that were found in the kitchen's dry storage, refrigerator, and freezer areas. The DS stated that staff are to inform him every time they found a dented on the shelves. The DS stated that he was responsible for ensuring that the the food items in the kitchen were labeled, dated, sealed, and not expired. DS stated that he performs a weekly audit of the kitchen's dry pantry, refrigerator, and freezer areas to ensure everything in all areas were labeled, dated, sealed, which included checking the expiration dates on the food items. The DS stated his expectation for her staff, was that they were to use the FIFO (the principle and practice of maintaining precise production and conveyance sequence by ensuring that the first part to enter a process or storage location is also the first part to exit) procedures to ensure there were not any unsealed, and expired food items throughout the kitchen's dry panty, refrigerator, and freezer areas. The DS gave the surveyor a presentation of implanting the FIFO method in the facility's dry pantry area. The DS stated all staff in the kitchen have received training on how to use the First In, First Out Method, which meant kitchen staff should label the food with the dates they store them, and when staff were restocking the shelves, they were to put the older foods in front or on top so they could be used first. The DS stated this system allowed the kitchen staff to use the older food items first to ensure that there were not any expired items in the kitchen. The DS stated the items found in the kitchen by the state surveyor were things that he missed in his weekly audits. The DS stated on 06/09/25, he would immediately retrain and reeducate all kitchen staff via an In-Service Training on food storage, labeling, checking for expired items, proper sealing of containers, bags, and packages, and utilizing the FIFO Method in the kitchen. The DS stated that all the items that the surveyor found in the kitchen would be immediately thrown away. The DS stated that he would continue to reeducate the kitchen staff to ensure everyone knew what his expectations were the kitchen and to follow the guidelines in the facility's Food Storage Policy so that everyone would be on the same page. The DS stated the risk of someone, which included a resident eating food from the facility kitchen's dry storage, refrigerator and freezer areas, expired foods, dented cans were that they could become ill and become sick due to eating something that could cause food-borne illnesses. The DS stated there were risks of food borne illness anytime someone ingested food items from the kitchen any items that had not been labeled and stored properly and from dented cans. The DS stated the harm of someone, which included a resident ingesting food from the facility kitchen's dry storage, refrigerator and freezer areas, expired foods, eating something from a dented can could cause someone to vomit and become ill. In an interview with the Dietary Aide G on 06/09/25 at 10:17 AM, she stated she had been employed at the facility for 4 years. She stated that she was unaware there were expired and unsealed items in the kitchen's dry storage, refrigerator, and freezer areas. She stated she was unaware there was 1 dented can on the shelves with the other canned food items. The Dietary Aide G stated that all the staff were responsible for storing the food items on the shelves and checking the expiration dates, dented cans to make sure there were not any unsealed items in the kitchen. She stated that monthly and sometimes twice a month, the DS will have an In-Service Training(s) with all kitchen staff on food storage, labeling and dating, removing expired items from the shelves in the dry pantry, freezer, and refrigerator areas and for dented cans and the use of the FIFO method. The Dietary Aide G stated that if items are unsealed and exposed to air are found by kitchen staff, they are to immediately throw the items in the trash can and inform the DS about the item(s) that were thrown away. Dietary Aide G stated that when there is a new shipment of food items delivered to the kitchen, the kitchen staff are to use the FIFO method that they were educated on via In-Service Trainings. Dietary Aide G stated that the FIFO method means when new food items are delivered, they are to be placed in the back of the older food items and the older food items are placed in the front to ensure that the older food items are used first. Dietary Aide G stated that if there were any dented cans in the dry pantry area, they are to immediately to be removed from the shelves with the other canned foods and stored in the area in the dry storage area labeled, dented cans, which is in the DS office. She stated that after placing the dented cans in the proper area, she would immediately notify the DS. Dietary Aide G stated if any food items from the facility's dry panty, refrigerator and freezer areas and dented cans were to be eaten by anyone, they have a potential risk of becoming very sick and ill. Dietary Aide G stated that if food is unsealed in the freezer, the food will be freezer burned and stated the risk of anyone ingesting any of the aforementioned items, they could have stomach aches, vomiting, and have parasites in their bodies. In an interview with the Dietary [NAME] H on 06/10/25 at 11:44 AM, she stated that she had been employed at the facility for 7 years. She stated she was unaware there were expired and unsealed items in the kitchen's dry storage, refrigerator and freezer areas. She stated she was unaware there was 1 dented can on the shelves with the other canned food items. She stated all the staff were responsible for storing the items on the shelf and checking the expiration dates, dented cans to make sure there were not any unsealed items in the kitchen's dry storage, refrigerator and freezer areas. Dietary [NAME] H stated that if she found any item(s) in the kitchen's dry storage, refrigerator and freezer areas, she would immediately throw them away and then tell the DS of her findings and notify him the location of her finding(s). Dietary [NAME] H stated that during her employment at the facility she had taken numerous In-Service trainings on food storage, labeling, dented cans, and ensuring that expired items are immediately thrown away. She stated that the In-Service Training included using the FIFO method. Dietary Aide stated that the FIFO method means that older food items are placed in the front on the shelves in the dry pantry area and the newer food items are placed behind the older food items on the shelves. She stated that dented cans are to be removed from the shelves and placed in the area labeled, dented cans in the DS office. She stated if any food items are unsealed in the freezer, the food will be freezer burned. She stated that if anyone ingests food from the kitchen that was expired or came from unsealed packages or containers, their body could breakdown and become sick, vomit, have stomach issues and have an adverse reaction after ingesting the food. [NAME] H stated that if anyone ingests food from the kitchen that was expired or came from unsealed packages or container, they could be harmed by parasites entering their bodies, which can make them ill. Record review of the facility's undated policy titled, Dietary Food Storage, reflected: Policy: All foods and supplies will be stored appropriately upon receipt to protect them from contamination. Procedure: 1. The Dietary Manager or designee is responsible for checking in and properly storing staples, perishables, canned goods and supplies as they arrived. 2. The storage areas should be .ready for new deliveries, with old products positioned in a manner that will cause them to be used first. 12. Cooked foods are placed in suitable containers, dated, labeled . Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on interview and record review, the facility failed to refer all Level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for a Level II resident review for one (Resident #5) of five residents reviewed for PASRR services. The facility failed to refer Resident #5 for a Level II PASRR Evaluation upon receipt of a bipolar diagnosis. This failure could place residents at risk of not receiving necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Review of Resident #5's Face Sheet, dated 06/11/25, reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE], with diagnoses including Sick Sinus Syndrome (a heart rhythm disorder where the sinoatrial node, the heart's natural pacemaker, malfunctions) and Heart Failure (a condition where the heart cannot pump enough blood to meet the body's needs). Resident #5 also had a diagnosis of Bipolar Disorder (a mental illness characterized by extreme shifts in mood, energy, and activity levels, fluctuating between periods of mania, or hypomania, and depression), with a documented onset date of 11/01/22. Review of Resident #5's MDS Assessment, dated 03/14/25, reflected she had a documented diagnosis of Bipolar Disorder. Review of Resident #5's PASRR Level I Screening, dated 03/09/22, reflected she did not qualify for a PASRR Level II Evaluation at that time. There was no evidence that Resident #5 had a mental illness, intellectual disability, or developmental disability. Review of Resident #5's electronic medical record reflected no evidence that any additional PASRR Screenings/Evaluations had been completed since the initial PASRR Level I Screening was conducted on 03/09/22. During an interview with the MDS Coordinator on 06/11/25 at 10:52AM, she stated Resident #5's initial PASRR Level I Screening was completed on 03/09/22. Resident #5 did not qualify for services at that time, as there was no indication that Resident #5 had a mental illness, intellectual disability, and/or developmental disability. The MDS Coordinator said Resident #5 was later diagnosed with bipolar disorder (11/01/22). The MDS Coordinator stated at that time, Resident #5 should have had a PASRR Level II Evaluation completed to determine if she qualified for services. The MDS Coordinator stated she was not employed by the facility at that time, so she did not know why a new PASRR Level II Evaluation was not completed. She stated she planned on conducting a facility-wide audit to ensure no other residents had missed receiving a required PASRR Screening/Evaluation. The MDS Coordinator stated she did not believe there was a risk in Resident #5 not receiving a new PASRR Screening/Evaluation upon her new diagnosis of bipolar disorder, as services were not provided for mental illnesses. She stated the risk would be present if there was a need for services related to an intellectual disability, and/or developmental disability. A policy related to PASRR Evaluations was requested on 06/11/25 at 10:55AM. The Director of Nursing stated the facility did not have a policy related to this and that the expectation was to follow HHSC guidelines.

Based on observation, interview, and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were for 1 of 5 residents (Residents #55) reviewed for pharmacy services. 1.The facility failed to implement a system to consistently and accurately reconcile controlled medications for Resident #55's Lorazepam Oral Tablet 0.5 MG This failures could place residents at risk of not having the medication available due to possible drug diversion. Findings included: 1. Review of Resident #55's Quarterly MDS Assessment, dated 03/13/25, reflected the Resident #55 is an [AGE] year-old female. The BIMs score was blank, section C Cognitive Patterns C0100 Cognitive patterns documented that resident was rarely/never understood. Their diagnoses included the following: HTN, non-Alzheimer's dementia, senile degeneration of the brain (progressive decline in cognitive function, including memory, language, and reasoning, often associated with aging). The resident was on hospice care. Review of Resident #55's Comprehensive Care Plan, dated 01/03/25, reflected the resident used anti-anxiety medication Lorazepam r/t Anxiety. Facility interventions included: Intervention included to give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. Record review of Resident #55's physician orders reflected: Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for anxiety/agitation until 06/19/2025 23:59 Verbal Active 03/17/2025 until 06/19/2025. Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 2 tablet by mouth every 4 hours as needed for anxiety/agitation until 06/19/2025 23:59 Record review of resident# 55's progress notes on 06/11/2025 reflected: (Late Entry). On Thursday June 5, 2025, at 12:24 pm this nurse administered one Lorazepam Oral Tablet 0.5 MG to resident. However, this nurse accidently charted that she gave two Lorazepam Oral Tablet 0.5 MG to resident because resident has two different orders for lorazepam. This nurse has striked out the incorrect documentation. DON has been notified of error. Will continue with plan of care in place. This entry was written by LVN A. An observation on 06/10/2025 at 11:45 AM of the Nurses Cart station1 revealed the medication blister pack for Resident #55's Lorazepam 0.5mg (controlled medication used for anxiety/agitation) had 2 blister seals broken. One damaged blister had the pill still inside secured with tape, and the other damaged blister the pill was missing. At the time the surveyor inspected the medication cart; the count for Resident #55's Lorazepam 0.5mg was documented as 12 pills, the actual number of pills counted in the blister pack was 11 pills. In an interview on 06/10/25 at 11:50 AM, LVN A She stated that she did not notice that the Lorazepam pill was a missing until the surveyor brought it to her attention. LVN A stated she was unaware when the blister pack seal was broken and stated that the resident had never taken the medication (lorazepam 0.5mg). She stated that she did not notice the other broken seals on resident #55's Lorazepam 0.5mg medication blister pack. She stated that the risk of a damaged blister would be a potential for drug diversion. She stated the nurses were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated the count was done at shift change and the count was correct. She stated she did not see the broken blister during the count. In an interview on 06/10/25 at 1:04 PM, the DON stated if the blister pack seal was broken on any controlled medications the pill should be discarded by two nurses. The DON stated it was not acceptable to keep a pill in a blister pack that was opened. She stated that if a blister pack seal is broken it should not be taped over with tape. The DON stated the risk would be losing the medication because the seal was broken. She stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the pharmacy consultant checks the medication room and the medication cart monthly. In an interview on 06/10/25 at 2:06 PM, the DON stated that the LVN A told her that LVN A administered the Lorazepam 0.5mg to Resident #55 on 06/05/2025 but had documented on the wrong place. The DON stated that Resident #55 had an order to give one to two tablets and LVN A told her that she made an error and had documented that she gave two pills instead of one pill. She stated that the LVN A was going to do a late entry to reflect the administration on 06.05.2025. In an interview on 06.11.2025 at 9:07 AM LVN A stated that she administered lorazepam 0.5mg to Resident #55 on 06/05/2025 but forgot to sign the narcotic count sheet but had documented on the MAR in the wrong place so it appeared like she gave two pills instead of one. She stated that she had done a late entry to correct the error. She stated that the risk of not documenting medication administered could lead to an overdose because the medication can be readministered by another nurse. In an interview on 06/11/2025 at 11:53 AM with LVN C reflected that she works in station one and always counts the narcotics with the out going nurse at the beginning of her shift and the oncoming nurse at the end of her shift. She stated that she always made sure the count was correct. She stated that she has never given Resident #55 Lorazepam 0.5mg. She stated that she never gives her key to anyone without counting the narcotic medications. She has been in-serviced on narcotic storage and handling. Risk of not accurately counting and documenting controlled medications could increase the risk of diversion and residents missing medication. Attempt on 06/11/2025 at 1:24PM to interview LVN D unsuccessful unable to leave voicemail because the mailbox was full. Attempts on 06/11/2025 at 1:25PM to interview LVN E who worked 10-6pm unsuccessful left voice mail with call back number. Review of the facility's policy Controlled Substances edited 4.3.2024, reflected the following: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). 1. Only authorized licensed nursing and/or pharmacy personnel have access to Schedule II controlled substances maintained on premises. 2. The director of nursing services identifies staff members who are authorized to handle controlled substances. 3. Controlled substances are counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals sign the designated controlled substance record. 4. If the count is correct, an individual resident controlled substance record is made for each resident who will be receiving a controlled substance. Do not enter more than one (1) prescription per page. This record contains: a. name of the resident. b. name and strength of the medication. c. quantity received. d. number on hand. e. name of the prescriber. f. prescription number. g. name of issuing pharmacy. h. date and time received. I. time of administration. j. method of administration. k. signature of person receiving medication; and l. signature of nurse administering medication. Storing Controlled Substances 1. Controlled substances are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. 2. The charge nurse on duty maintains the keys to controlled substance containers. The director of nursing services maintains a set of back-up keys for all medication storage areas including keys to controlled substance containers. Dispensing and Reconciling Controlled Substances 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage. b. Medication administration records. c. Declining inventory records; and d. Destruction, waste and return to pharmacy records. 3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. 5. The director of nursing services documents irreconcilable discrepancies in a report to the administrator. a. If a major discrepancy or a pattern of discrepancies occurs, or if there is apparent criminal activity, the director of nursing notifies the administrator and consultant pharmacist immediately. b. The administrator, consultant pharmacist, and/or director of nursing services determine whether other action(s) are needed, e.g., notification of police or other enforcement personnel. c. The medication regimen of residents using medications that have such discrepancies are reviewed to assure the resident has received all medications ordered and the goal of therapy is met (example: a resident receiving a pain medication complains of unrelieved pain). d. The director of nursing services consults with the provider pharmacy and the administrator to determine whether any further legal action is indicated. 6. Unless otherwise instructed by the director of nursing services, when a resident refuses a non-unit dose medication (or it is not given), or a resident receives partial tablets or single dose ampules (or it is not given) the medication is destroyed and may not be returned to the container. 7. Waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet. 8. Medications returned to the pharmacy are recorded and signed by the director of nursing services (or designee) and the receiving pharmacy. 9. Disposal methods are used to prevent diversion and/or accidental exposure to controlled or hazardous substances. Fentanyl patches are disposed of in one of the following ways (per state regulations): a. By folding in half, sticky sides together and flushing down the toilet; or b. Using approved drug disposal products specifically for fentanyl patches. 10. Controlled substances are not surrendered to anyone, including the resident's provider, except for the following: a. For a resident on pass or therapeutic leave. b. To a resident or responsible party upon discharge from the facility; or c. To the DEA or other law enforcement officials functioning in a professional capacity in exchange for a receipt documenting the transaction. 11. In the event there is concern about controlled substances being discharged with the resident and/or resident's representative, the attending physician may choose not to discharge the resident with those medications. 12. Some controlled substances may be stored in the emergency medication supply. Reconciliation of controlled substances in the emergency supply is conducted at intervals established by the director of nursing services. 13. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed. 14. Accountability records for discontinued controlled substances are kept with the unused supply until it is destroyed or disposed of as required by applicable law or regulation. 15. The consultant pharmacist or designee routinely monitors controlled substance storage records. 16. The director of nursing services maintains and disseminates to appropriate individuals a list of staff who have access to medication storage areas and controlled substance containers. 17. For guidelines pertaining to disposing of controlled substances, see Discarding and Destroying Medications policy.

Based on observation, interview and record review, the facility failed to consult the resident's physician, when the resident had an injury and had the potential for requiring physical intervention and when there was a significant change in the resident's physical, mental or psychosocial status for one (Resident #1) of five residents reviewed for resident rights. The facility failed to consult Residents #1's physician when he was discovered to have a sudden and significant skin injury of large multiple blistering and skin coming off over the entirety of his left hand. The facility applied a dry dressing to the injury. Twenty-four hours later, the dressing was noted to be weeping and the blistering had tripled in size and the physician was notified. While waiting for transport to the ER, Resident #1 became unresponsive. At the ER, he was diagnosed with a 2nd degree thermal burn, [CONDITION(S)] and a [CONDITION(S)]. This failure could place residents at risk of not having their physician consulted of changes in condition timely, resulting in a delay in medical intervention and decline in health or possible worsening of symptoms, including death. On 08/16/22 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/17/22, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received the IJ template on 08/16/22 at 2:21 PM. Findings included: Review of Resident #1's quarterly MDS assessment dated [DATE], reflected he was a [AGE] year old male admitted to the facility originally on 12/08/17 and readmitted on [DATE] from an acute hospital. His active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 had unclear speech, was rarely/never understood by others and was rarely/never able to understand others and his vision was highly impaired. He had severely impaired cognitive skills for daily decision-making, signs and symptoms of [CONDITION(S)] which included inattention and disorganized thinking. Resident #1 had no indicators of [CONDITION(S)], verbal or physical behaviors or rejection of care. Resident #1's required extensive physical assistance of one or more staff for bed mobility, transfers, dressing, locomotion in his wheelchair, eating, toilet use and personal hygiene and had range of motion impairment in his lower extremities on both sides. Resident #1 was unable to complete a pain interview; the staff pain assessment indicated he did not have any indicators of possible pain during the assessment period. Review of Resident #1's care plan (undated) reflected he had the potential for alteration in skin integrity related to immobility and incontinence with a goal of, [Resident #1] will have intact skin, free of redness, blisters or discoloration. Interventions included to follow facility protocols for the prevention, treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Report results to MD and follow up as indicated. Review of Resident #1's nursing notes written by LVN A on 07/24/22 at 5:52 AM reflected, While getting resident dressed this morning, aide notified nurse of skin issues. On top of resident's left hand was cluster of blisters, with the biggest one observed to have opened up on the top of his left hand. Other smaller blisters observed over left finger areas. Hand cleaned and covered with dry dressing and wound care notified. Called and left voicemail for RP. There were no vitals noted for that observation. Review of Resident #1's July 2022 physician's orders did not reflect an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's nursing notes the next day on 07/25/22 at 7:31 AM written by LVN A reflected, While doing rounds at the end of shift, this nurse went to check on resident, dressing to left hand appeared slightly wet so nurse unwrapped it to assess before re-wrapping it. When dressing was taken off, this nurse noted existing rosy, red area to top of hand where the first blister had burst open the morning before. No drainage however noted to this area. To surrounding area was however noted multiple huge new clear fluid filled blisters around existing area, on all left fingers and knuckles, and two large blisters on the left palm of his hand. When nurse asked resident if he was in pain, he said no .MD notified immediately and order given to transfer to ER for further eval and to rule out any possible infections/contagious issues .While gathering resident's paperwork while resident was seated at the nurses' station, resident noted to become verbally unresponsive despite being given the sternal rub and was being shaken many times. Review of SBAR (Situation, Background, Assessment, Recommendation) Form completed 07/25/22 at 07:30 AM reflected Resident #1 had a change in condition that started on 07/24/22 and had multiple huge fluid filled blisters to left hand and while awaiting transport to the ER, he became verbally unresponsive. His blood pressure at the time of the SBAR was 94/53 and his pulse was 75. An interview with the hospital critical care RN on 07/28/22 at 12:37 PM revealed Resident #1 was presently at the hospital and had been diagnosed with second degree [CONDITION(S)] to his left hand, [CONDITION(S)] (the body's extreme response to an infection) and a [CONDITION(S)]. The RN said when she first saw Resident #1's left hand, she was re-wrapping it to do wound care. He had blistering and a large open to the back of his left hand and blistering to the front and back down to where the wrist started. His skin on the left hand was blistered with a giant open area to the back of the hand that was red and granulated (having a roughened surface), blistering to all four digits and thumb on the outside and palm side of the hand. She said there were no more skin issues beyond the left hand. The RN said Resident #1 was unable to tell her what happened, and he had dementia and previous stokes and baseline of confusion with mumbling of inappropriate words. The critical care RN said the hospital was concerned because Resident #1 was contracted and immobile. She said she called the facility and spoke initially with MDS RN F who only read her a nursing progress note and did not have any further information. Then the DON called her 30 minutes later and did not believe it was a burn. The critical care RN said, Anyone can tell it is a burn. They did a dry dressing which was not appropriate, it should have been a wet dressing. She said if a dry dressing is applied to a burn such as Resident #1's, essentially it would stick to the wound and worsen it when it was removed. The critical care RN said she asked the DON why they chose that dressing and the DON responded they had notified the wound care nurse. The critical care RN said, I did tell the DON I thought it was a burn and asked if he had any new oils or lotions, hot water exposure and she told me this was first noticed in the middle of the night on the 24th by an aide, so that is the note that was read to me .This is pretty significant. She said when she told the DON about the burn, the DON replied that she had asked Resident #1 if he was in pain, and he said no. The critical care RN said, My thing is he won't even tell you his name. He has dementia. He is not going to do this to himself. The critical care RN said, He came in septic, this poor man, I feel bad .it made me so mad. The critical care RN said she felt Resident #1 had an injury of unknown origin and it was suspicious because it was not an injury that he could do to himself. Review of Resident #1's hospital records revealed he arrived at the hospital emergency department on 07/25/22 at 8:06 AM and was [CONDITION(S)] (a heart rate over 100 beats a minute) to 170's, blisters and loss of epithelial skin (the tissue which covers the internal and external surfaces of the body) on the dorsum (the corresponding area on the top part of the hand) of the left hand consistent with possible [CONDITION(S)] and his upper extremities were contracted. The ED's attending note stated, Patient was sent from a nursing home for elevated heart rate, was reported that yesterday he sustained some blisters on his hand from an unknown process. The ED medical doctor's final impression/diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A request was made for wound care to assess his left hand due to it appearing to be a burn but unable to ascertain a source. Review of Resident #1's wound/plastic surgery consult at the hospital dated 07/26/22 reflected he presented to the ED in [CONDITION(S)] and was found to be septic (the body's extreme response to an infection-life threatening medical emergency) with a thermal injury (occurs when energy is transferred from a heat source to the body, causing an increase in the temperature of local tissue) with blisters on his left hand and fingers. He was unable to provide a history due to his dementia. Resident #1 was assessed as, 1) 2 Palmar (palm of the hand) blisters superior to the palmar crease; blisters of palmer 5th digit (finger) over phalanges (the group of small bones that comprise the bony core of the digits (fingers) of the hand), blister on 4th digit fingertip and over middle phalanx (a bone of the finger); 2) 2nd degree [CONDITION(S)] of the dorsal (top) wrist and hand with absent epidermis (skin) several bullae (large blisters on the skin that are filled with clear fluid) including tubular bulla of dorsal 1st webspace, hemorrhagic blister (when blood pools and forms a blister) in 1st webspace, several small bullae over proximal (situated near) 4th and 5th digit, bulla of 4th digit middle phalanx. He was noted to be neurological confused and unable follow commands or provide history. The plan by the MD was Wound care to continue management of burn per protocol; recommend daily dressing changes liberal [MEDICATION(S)] ointment, [MEDICATION(S)]/xeroform, ABD pad and loose Kerlix wrap and to keep hand elevated on pillow. Five photos were taken of Resident #1's left hand by the hospital at the time of the consult. An interview with the overnight nurse, LVN A, on 07/28/22 at 11:56 AM revealed she had worked at the facility Saturday 2pm-10pm and the overnight shift (07/23/22) and on Sunday (07/24/22) she worked the overnight shift 10 PM-6 AM. LVN A said she was notified by a CNA in the early morning hours before the overnight shift was over Sunday morning (07/25/22) that the CNA was getting him up and noticed issues with his skin and she wanted LVN A to look at it. When LVN A went to his room, Resident #1 initially had a big blister right on top of his hand that had popped and little one right next to it that had not popped but one was draining . She said the skin was still on so she did not want to aggressively rub it and she covered it with a dry dressing and put it on the 24 hour report to remind herself. LVN A said they left him in bed at that time. LVN A said she did not contact MD E or an on-call doctor on Sunday 07/24/22 when she first noticed Resident #1's left hand injuries because the facility lets the treatment nurse look at it first. LVN A said she just cleaned it and wanted the wound nurse to look at it when she came in. She said the wound nurse did not normally work the weekends and that was why she made a note in the 24-hour report to remind herself and alert the oncoming nurse to follow up. However, she said Resident #1 was sent out to the ER the next day in the early morning before the wound care nurse could look at his hand. When LVN A came back to work later that day for her overnight shift (Sunday into Monday 07/24/22-07/25/22), she was rounding and when she looked at the dressing, it looked like it had dried so she changed it. When she unwrapped it, there were triple the amount of new blisters around the entire hand, like big, huge blisters which were not there the day before so the blisters tripled in numbers in 24 hours, and they were on the palm of his hand. LVN A said she cleaned it, wrapped his hand with a dry dressing and texted the DON asking her what to do. She said, As far as I know, there was nothing that had burned him, but the wound was growing. At that point, she called MD E and told him about it for the first time. He said initially he would refer to a dermatologist, but then said to send Resident #1 to the ER in case he had something contagious since it came on that rapidly. An interview with the DON on 07/28/22 at 2:26 PM revealed the facility did not contact the wound care physician to have he/she assess Resident #1's left hand injury because the resident had already been sent out to the hospital. She also stated there was no wound care nurse working on the weekend. The DON said she believed MD E was notified about Resident #1 on Sunday 07/24/22 prior to her arriving at the facility by LVN A. The DON said she was at the facility that day, arriving early in the morning around 6am because she needed to swab residents for COVID-19 due to a recent positive case. She said thought LVN A notified MD E. However, the DON said she did not verify that LVN A called him and did not follow up with her afterwards to see what his orders were. She said she had just assumed LVN A called MD E and she had no idea why she did not call him. The DON said she first saw Resident #1' hand when she arrived that morning around 7AM and when she went to his room, she saw the blisters on his left hand before they erupted. She said he had no indicators of pain and there was no other issues with his skin other than his left hand. The DON said she did not tell LVN A to contact the doctor (MD E) and had assumed she had already done that. An observation and attempted interview of Resident #1 occurred on 08/15/22 at 3:30 PM while he was in his hospital room. Resident #1's eyes were closed but he was awake. He was initially not responsive to questions. Upon increasing the volume of the voice, he stirred and moved his head, but his responses to questions were minimal, with only making a sound each time, no discernable words. His blood pressure was 178/93, pulse 58. The hospital RN unwrapped his left hand to procced with a dressing change. Resident #1 did not wince or make any motions or sounds of discomfort. His left hand was observed to be in a state of healing. There were no more liquid-filled blisters, but the scarring could be seen on his knuckles where the blisters were and on his palm of his hand and the top of his hand and in the webbing of his fingers. The skin had grown back over the top of his hand, however, it was lighter in color than the other surrounding skin. There were no open areas noted. The hospital RN said it looked like Resident #1 may of had something hot poured on top of his hand and it had dripped down and around through his fingers to the underside of his palm, but since she was not present to observe the injury happen, she was only speculating. Review of the facility's policy titled, Notifying the Physician of Significant Change in Status revised March 2013, reflected, The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention; 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record; .3 .The nurse is responsible, however, for responding to a change in condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record; .6. The nurse will monitor and reassess the resident's status and response to interventions. Physicians should develop a working diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/16/22 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/17/22, the facility remained out of compliance at a severity level of severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received the IJ template on 08/16/22 at 2:21 PM. The Plan of Removal (POR) was accepted on 08/17/22 at 2:49 PM and reflected: [Facility Name-Plan of Removal 8/16/2022 1. F580 - Failure to Notify Physician Resident #1 was found with a change in condition to his left hand (blistered all over top and bottom of hand with skin on top gone) on Sunday 07/24/22 in the early morning hours by a CNA when doing incontinent care. He was assessed by the DON and LVN promptly who felt he did not have a burn, but a change in skin condition and put a dry bandage on his hand. The physician was not notified of the change in condition and treatment orders were not obtained at that time. Next morning, Resident #1's dressing was removed, and blisters had tripled in size. Doctor notified at that time and sent resident to ER. At hospital, resident evaluated and found to have 2nd degree thermal (which means burn came from external heat source) [CONDITION(S)] to his left hand, [CONDITION(S)] and [CONDITION(S)]. Noted: Resident #1 cognitive status is considered impaired by having a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . [CNA D] reported to [LVN A] of the observed skin altercation. A skin sweep was performed by [RN Q and LVN G] on 8/17/22 on 8/17/22 and the nurses' identified residents with dryness to bilateral lower extremities. Nurse contacted [MD E] to notify and obtained orders for treatments. Responsible Parties were notified. Clinical Compliance Nurse [CC-RN] will: - On 8/16/2022, a re-education of identifying injury of unknown origin; different types of [CONDITION(S)]; thermal [CONDITION(S)] and how they can occur; notifying physician of change in condition; protocols to obtain treatment orders for skin alteration/ skin injuries, failure to report injury of unknown origin according to federal regulations and state guidelines to the appropriate authorities and investigating injuries of unknown origins including potential causes of the injury to the Director of Nursing. -On 8/16/2022, a re-education of identifying injuries of unknown origin, different types of [CONDITION(S)]; and notifying physician of change of condition for a resident, failure to report injury of unknown origin according to federal regulations and state guidelines to the appropriate authorities and investigating injuries of unknown origins including potential causes of the injury to the Administrator. Director of Nursing/Designee will: - Complete a skin assessment on current residents by 8/17/2022. - Identified new skin alterations and or signs of injury - facility will follow risk management protocol. Risk management protocol includes completing incident report, notifying physician, executing physician orders obtained, and notifying responsible party by 8/17/2022. - Facility staff will be re-educated on identifying injury of unknown origin; different types of [CONDITION(S)], thermal [CONDITION(S)] and how they can occur by 8/17/2022. - Additionally, Licensed Nurses will be re-educated on notifying the physician for a change in condition and protocols to obtain treatment orders for skin alterations/skin injuries by 8/17/2022. - Any staff member not receiving this education by 8/17/2022 will be educated prior to next scheduled shift. An employee roster and schedule will be used to validate education compliance. Facility per diem nurses, new hires, and agency nurses will receive this re-education prior to reporting for duty. - Findings will be addressed at the time of discovery and presented to the facility Quality Assurance Performance Improvement monthly x 3 months through December 2022. - Facility Designee or Administrator will ensure compliance and monthly reporting to Quality Assurance and Performance Improvement (QAPI) . Monitoring interviews for the Immediate Jeopardy were started on 08/17/22 at 10:50 AM and continued through 08/17/22 at 4:30 with 15 staff across all three shifts , including weekdays and weekends, from the nursing, administration, dietary and housekeeping departments. The staff were interviewed about procedures related to change of condition, injuries of unknown origin, notification to ADM, thermal injuries and how they can occur, notification to the physician, obtaining treatment orders, abuse and neglect, and hot water (showers)/liquids (drinks) parameters. Staff were able to verbalize understanding of the training received. Additionally, the Corporate Regional Clinical RN provided an in-service done with the DON and ADM on 08/17/22 related to thermal burn identification, intervention and notification to the physician, obtaining treatment orders, recognizing a change in condition, recognizing an injury of unknown origin, as well as reporting injuries of unknown origin to HHSC and investigating. The following staff's in-service logs and competency tests were reviewed and they were interviewed during the monitoring time frame and were able to articulate what they had been taught, protocols and procedures related to change of condition, injuries of unknown origin, notification to ADM of injuries of unknown origin, thermal burn injuries and how they could occur, notification to the physician, obtaining treatment orders, abuse and neglect, and hot water (showers)/liquids (drinks) parameters: CNA G, RN H, CNA I, Hkpg J, BOM, CNA K, LVN B, Cook L, Laundry Aide M, Med Aide N, LVN O, ADON P, MDS RN F, ADM and DON. Monitoring and review of all resident skin assessments completed by the facility nurses on 08/16/22 and 08/17/22 revealed all residents were checked for any changes to skin, to include reddened areas that remained after pressure reduction, rashes, bruises open [CONDITION(S)], cuts lacerations and skin tears, blisters, open ulcers, dry or flaky skin and [CONDITION(S)]. No residents were found to have any injuries of unknown origin, including [CONDITION(S)]. 19 residents were assessed as having dry and/or flaky skin. For those residents, the physician was notified, and an order was obtained for Eucerin (emollient) for bilateral lower extremities and/or feet. The facility's ADM was notified the IJ was removed on 08/17/22 at 4:35 PM. While the Immediate Jeopardy was removed on 08/17/22, the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the Plan of Removal.

Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and establish policies and procedures to investigate any such allegations for one (Resident #1) of five residents reviewed for abuse, neglect, and exploitation. The facility staff failed to investigate an injury of unknown origin of Resident #1 when the resident was found to have a significant injury to his left hand, and whose source could not be identified by the facility. Resident #1 had to be sent to the ER the following day when he became unresponsive and the blisters had tripled in size, where he was diagnosed with second degree thermal [CONDITION(S)] to his whole left hand, [CONDITION(S)] and a urinary tract infection. The hospital notified the facility that there was a concern that the resident had been burned. The facility abuse/neglect coordinator did not initiate an provider investigation. This failure could place the residents at risk for further potential abuse due to uninvestigated allegations of abuse, neglect, and injuries of unknown origin. On 08/16/22 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/17/22, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received the IJ template on 08/16/22 at 2:21 PM. Findings included: Review of facility's Abuse/Neglect policy revised 08/28/17, reflected, .The Abuse Preventionist will be responsible for receiving, leading the appropriate investigation, assure that required reporting is completed timely . Review of Resident #1's quarterly MDS assessment dated [DATE], reflected he was a [AGE] year old male admitted to the facility originally on 12/08/17 and readmitted on [DATE] from an acute hospital. His active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 had unclear speech, was rarely/never understood by others and was rarely/never able to understand others and his vision was highly impaired. He had severely impaired cognitive skills for daily decision making, signs and symptoms of [CONDITION(S)] which included inattention and disorganized thinking. Resident #1 had no indicators of [CONDITION(S)], verbal or physical behaviors or rejection of care. Resident #1's required extensive physical assistance of one or more staff for bed mobility, transfers, dressing, locomotion in his wheelchair, eating, toilet use and personal hygiene and had range of motion impairment in his lower extremities on both sides. Resident #1 was unable to complete a pain interview; the staff pain assessment indicated he did not have any indicators of possible pain during the assessment period. Review of Resident #1's care plan (undated) reflected he had the potential for alteration in skin integrity related to immobility and incontinence with a goal of, [Resident #1] will have intact skin, free of redness, blisters or discoloration. Interventions included to follow facility protocols for the prevention, treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Report results to MD and follow up as indicated. Review of Resident #1's nursing notes written by LVN A on 07/24/22 at 5:52 AM reflected, While getting resident dressed this morning, aide notified nurse of skin issues. On top of resident's left hand was cluster of blisters, with the biggest one observed to have opened up on the top of his left hand. Other smaller blisters observed over left finger areas. Hand cleaned and covered with dry dressing and wound care notified. Called and left voicemail for RP. Review of Resident #1's nursing notes the next day on 07/25/22 at 7:31 AM written by LVN A reflected, While doing rounds at the end of shift, this nurse went to check on resident, dressing to left hand appeared slightly wet so nurse unwrapped it to assess before re-wrapping it. When dressing was taken off, this nurse noted existing rosy, red area to top of hand where the first blister had burst open the morning before. No drainage however noted to this area. To surrounding area was however noted multiple huge new clear fluid filled blisters around existing area, on all left fingers and knuckles, and two large blisters on the left palm of his hand. When nurse asked resident if he was in pain, he said no .MD notified immediately and order given to transfer to ER for further eval and to rule out any possible infections/contagious issues .While gathering resident's paperwork while resident was seated at the nurses' station, resident noted to become verbally unresponsive despite being given the sternal rub and was being shaken many times. Review of the facility's incident and accident logs for July 2022 revealed Resident #1 was not listed. Review of SBAR (Situation, Background, Assessment, Recommendation) Form completed 07/25/22 at 07:30 AM reflected Resident #1 had a change in condition that started on 07/24/22 and had multiple huge fluid filled blisters to left hand and while awaiting transport to the ER, he became verbally unresponsive. His blood pressure at the time of the SBAR was 94/53 and his pulse was 75. An interview with the hospital critical care RN on -7/28/22 at 12:37 PM revealed Resident #1 was presently at the hospital and had been diagnosed with second degree [CONDITION(S)] to his left hand, [CONDITION(S)] and a [CONDITION(S)]. The RN said when she first saw Resident #1's left hand, she was re-wrapping it to do wound care. He had blistering and a large open to the back of his left hand and blistering to the front and back down to where the wrist started. His skin on the left hand was blistered with a giant open area to the back of the hand that was red and granulated, blistering to all four digits and thumb on the outside and palm side of the hand. She said there were no more skin issues beyond the left hand. The RN said Resident #1 was unable to tell her what happened and he had dementia and previous stokes and baseline of confusion with mumbling of inappropriate words. The critical care RN said the hospital was concerned because Resident #1 was contracted and immobile. She said she called the facility and spoke initially with MDS RN F who only read her a nursing progress note and did not have any further information. Then the DON called her 30 minutes later and did not believe it was a burn. The critical care RN said, I did tell the DON I thought it was a burn and if he had any new oils or lotions, hot water exposure and she told me this was first noticed in the middle of the night on the 24th by an aide, so that is the note that was read to me .This is pretty significant. She said when she told the DON about the burn, the DON replied that she had asked Resident #1 if he was in pain and he said no. The critical care RN said, My thing is he won't even tell you his name. He has dementia. He is not going to do this to himself. The critical care RN said, He came in septic, this poor man, I feel bad .it made me so mad. The critical care RN said she felt Resident #1 had an injury of unknown origin and it was suspicious because it was not an injury that he could do to himself. Review of Resident #1's hospital records revealed he arrived at the hospital emergency department on 07/25/22 at 8:06 AM and was [CONDITION(S)] (a heart rate over 100 beats a minute) to 170's, blisters and loss of epithelial skin (the tissue which covers the internal and external surfaces of the body) on the dorsum (the corresponding area on the top part of the hand) of the left hand consistent with possible [CONDITION(S)] and his upper extremities were contracted. The ED's attending note stated, Patient was sent from a nursing home for elevated heart rate, was reported that yesterday he sustained some blisters on his hand from an unknown process. The ED medical doctor's final impression/diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A request was made for wound care to assess his left hand due to it appearing to be a burn but unable to ascertain a source. Review of Resident #1's wound/plastic surgery consult at the hospital dated 07/26/22 reflected he presented to the ED in [CONDITION(S)] and was found to be septic (the body's extreme response to an infection-life threatening medical emergency) with a thermal injury (occurs when energy is transferred from a heat source to the body, causing an increase in the temperature of local tissue) with blisters on his left hand and fingers. He was unable to provide a history due to his dementia. Resident #1 was assessed as, 1) 2 Palmar (palm of the hand) blisters superior to the palmar crease; blisters of palmer 5th digit (finger) over phalanges (the group of small bones that comprise the bony core of the digits (fingers) of the hand), blister on 4th digit fingertip and over middle phalanx (a bone of the finger); 2) 2nd degree [CONDITION(S)] of the dorsal (top) wrist and hand with absent epidermis (skin) several bullae (large blisters on the skin that are filled with clear fluid) including tubular bulla of dorsal 1st webspace, hemorrhagic blister (when blood pools and forms a blister) in 1st webspace, several small bullae over proximal (situated near) 4th and 5th digit, bulla of 4th digit middle phalanx. He was noted to be neurological confused and unable follow commands or provide history. The plan by the MD was Wound care to continue management of burn per protocol; recommend daily dressing changes liberal [MEDICATION(S)] ointment, [MEDICATION(S)]/xeroform, ABD pad and loose Kerlix wrap and to keep hand elevated on pillow. Five photos were taken of Resident #1's left hand by the hospital at the time of the consult. Review of TULIP database on 07/27/22 revealed no evidence of a provider investigation report or a provider investigation for Resident #1's injury of unknown origin. An interview with the DON on 07/27/22 at 3:00 PM revealed Resident #1 was sent to the hospital because his hand needed to be looked at by a higher level. She said MDS RN F had talked to the critical care hospital RN the day before (07/26/22) who had implied that Resident #1 had been burned or abused. The DON then called the hospital RN because of her feeling the resident was abused and told her it was a skin issue, not abuse. The DON said she took a picture of Resident #1's left hand on Monday morning when he was sent out. She said his left hand was red with a cluster of blisters that had erupted. She said, Initially we had thought maybe this was [CONDITION(S)]. She then said, When I saw it like this (showed her phone of Resident #1's left hand), I told [MD E] it was not presenting as [CONDITION(S)]. She said MD E did not visit Resident #1 in person after being notified on Day 2 of the blisters and she did not send him the picture that she took of Resident #1's hand. The DON said when she saw how much bigger the blisters had gotten on the second day, was when Resident #1 was sent out for further evaluation. The DON said she felt it was some kind of infection, I think. The DON said she did not know how Resident #1 was doing while at the hospital. She said he was not interviewable and sometimes made grunts or would moan when he was in pain, but he did not talk at all. The DON said Resident #1 was not ambulatory, was almost max dependence on ADLs and he was bed bound and wheelchair bound. She said he never went out on pass and rarely had family visitors. The DON said a burn would definitely be red and raw, it could have some black areas around it, and around the edges it would be white with moisture associated skin damage from the resident's own fluid leaking out from the edge of the wound and it would be extremely painful and in various stages all the way to 3rd degree. She said what happened with Resident #1, happened very acutely, very fast. The DON said an incident report was not done because it was never anything to warrant an incident, it was not a wound or injury. She said a wound care nurse or doctor did not look at it and the blisters all happened within 24 hours. The DON said, I know it is not a burn because those blisters did not present like it was a burn. I have seen fluid filled blisters like that, that were not related to burn. That looked like a fluid infection going on in his body. She said the blisters were fluid filled and were small and rapidly grew over the course of that day. She said Resident #1 could not tell them anything about what happened but he could respond to painful stimuli and he never presented with any pain or tearfulness or guardedness. An interview with MDS RN F on 07/27/22 at 3:15 PM revealed the hospital critical care RN had called to find out what happened to Resident #1's hand and said his whole hand was burned. MDS RN F did not know details about it, so she read the progress notes to the hospital critical care RN and then told the DON about the call because the hospital RN sounded disbelieving. An interview with LVN B on 07/28/22 at 10:51 AM revealed she did not see Resident #1 over the weekend of 07/23/22 and 07/24/22 but did see him when she arrived at work on Monday 07/25/22. LVN B said his skin was clear when she left work on Friday 07/22/22 but when she came back on 07/25/22, he had one big blister on the top of his left hand that had already busted and the night nurse (LVN A) was not sure what it was and no one could understand how he got blisters like that. LVN B said she did not know if it was a burn because something real hot would have had to caused it. She said Resident #1's index finger was really swollen and he had a blister on the pointer finger side going towards the thumb. LVN B said Resident #1 normally could talk, but he was not there at all, she shook him, called his name and tried to open his eyes to get a reaction, but he was not responding, which was unusual. She said he could not tell her if he was in pain. She said by that time, the overnight nurse (LVN A) had notified the DON and physician to see what they wanted to do and MD F said to send him out since no one knew what had happened. LVN B said after that, she googled burn blisters on the hand and the pictures on the internet looked like Resident #1's. LVN B said, But I don't want to say it is a burn, because that is not good. LVN B said she did not know if Resident #1 had an injury of unknown origin. She said that would be when a person could not tell how an injury occurred She then said, We don't know how this one occurred. A follow up interview with MDS RN F on 07/28/22 at 11:17 AM revealed she had been employed at the facility for a month and she was the RN manager on duty on Sunday 07/24/22 and had come to the facility last in the morning around 11 AM. She said she had not been notified of any issues related to Resident #1 but as the MOD, she went to each nurses' station, asked how things were going, if there were any new incidents and accidents and she was told no. She then went to the MDS office and did assessments and later helped serve dinner. She said she did not see Resident #1's hand. MDS RN F said she was first made aware of Resident #1's hand during the morning management meeting on Monday 07/25/22, after he had already been sent out. MDS RN F said an injury of unknown origin was something that was abnormal, that was not there before. If that occurs, the facility should look into what happened and start an investigation, see if it was suspicious. An interview with the overnight nurse, LVN A, on 07/28/22 at 11:56 AM revealed she had worked at the facility Saturday 2pm-10pm and the overnight shift (07/23/22) and on Sunday (07/24/22) she worked the overnight shift 10 PM-6 AM. LVN A said she was notified by a CNA in the early morning hours before the overnight shift was over Sunday morning (07/25/22) that the CNA was getting him up and noticed issues with his skin and she wanted LVN A to look at it. When LVN A went to his room, Resident #1 initially had a big blister right on top of his hand that had popped and little one right next to it that had not popped but one was draining. She said the skin was still on so she did not want to aggressively rub it and she covered it with a dry dressing and put it on the 24 hour report to remind herself. LVN A said they left him in bed at that time. LVN A said she did not contact MD E or an on-call doctor on Sunday 07/24/22 when she first noticed Resident #1's left hand injuries because the facility lets the treatment nurse look at it first. LVN A said she just cleaned it and wanted the wound nurse to look at it when she came in. She said the wound nurse did not normally work the weekends and that was why she made a note in the 24 hour report to remind herself and alert the oncoming nurse to follow up. However, she said Resident #1 was sent out to the ER the next day in the early morning before the wound care nurse could look at his hand. When LVN A came back to work later that day for her overnight shift (Sunday into Monday 07/24/22-07/25/22), she was rounding and when she looked at the dressing, it looked like it had dried so she changed it. When she unwrapped it, there were triple the amount of new blisters around the entire hand, like big, huge blisters which were not there the day before so the blisters tripled in numbers in 24 hours, and they were on the palm of his hand. LVN A said she cleaned it, wrapped his hand with a dry dressing and texted the DON asking her what to do. She said, As far as I know, there was nothing that had burned him, but the wound was growing. At that point, she called MD E and told him about it for the first time. He said initially he would refer to a dermatologist, but then said to send Resident #1 to the ER in case he had something contagious since it came on that rapidly. LVN A said, I don't know if he was reacting to anything or if he was burned. LVN A said she did not initially think it was a burn because no one had mentioned anything to her, But with the tripling of them (the blisters) the next day, with the wound wrapped up, I don't know. LVN A said an injury of unknown origin was when a person did not know how it occurred. Observation and record review of the 24-hour book for Hall 100 (Resident #1's hall) revealed no entries on 07/23/22 or 07/24/22 related to the resident. An interview with the wound care LVN G on 07/28/22 at 07/28/22 at 3:10 PM revealed that Resident #1 had not been on her caseload and she did not work over the weekend on 07/23/22-07/24/22. She said no one mentioned anything to her about Resident #1's hand and he had already been sent to the hospital by the time she arrived at work Monday 07/25/22. She said she only found out about it through hearing people talking about it conversationally in the facility. Wound Care LVN G said a burn could present differently, depending on the degree of it. She said there could be blistering, discoloration, redness, some swelling due to the degree, and some skin may be missing due to the degree of the burn. She said most second degree [CONDITION(S)] were blistered and a burn could re-blister, pop on their own and come back up. An interview with CNA C on 07/28/22 at 12:25 PM revealed she had last seen Resident #1 on Friday 07/22/22 and his skin looked great, she could see his hands when she laid him down. When she saw him Monday morning 07/25/22, she was told that he maybe had an infection because his hand was wrapped. CNA C said then the overnight nurse, LVN A took off the dressing and she saw he had pink raw skin on top of his hand. She said she was wondering how that could have happened because Resident #1 always kept his hands balled up and only moved them to itch his face. CNA C described Resident #1's left hand as looking like person who got burned, because she had never seen an infection that took the skin off like that and that he had blisters everywhere on his fingers and palm. Resident #1 could not tell her what happened because he was blind and only spoke a few words and he was not responsive, which was not normal. CNA C said, I said y'all sure it not a burn and they were like shhhhh (be quiet sound) .at the same time I was like what if this is your family member? She said when Resident #1 was not responding to her, she tried to do a sternal rub, But nothing, like he was losing it. CNA C said she told the DON that she should take staff members off the schedule who had worked with Resident #1 before that time frame just in case, and investigate, and she just looked at me. She said, If it was my family member, I would want to know the facility is looking into it. An interview with CNA D on 07/28/22 at 3:58 PM revealed she had worked the overnight shift for the first time on Resident #1's hall on Saturday-Sunday shift (07/23/22-07/24/22), but she knew him from working with him on another hall. She said on that overnight shift, around 3:50 AM, she went in to check on him and he was quiet and she was worried he was not breathing but then looked closer and saw his chest was rising. She said he was a typically a heavy soil and outputs a lot and the entire night when she would go and check on him, he was dry up until 3:50 AM and that was unusual. CNA C said incontinence being not as frequent or not as much as it used to be could be a sign of the body shutting down. She said Resident #1 had not voided at all her shift until then. When she changed him, it was only urine and it could fill her palm so it was not much and he was laying on his hand so she turned him over. When CNA C turned him over, there was a thin brown layer of something next to him. She did not know what it was. She picked it up and then looked at this hand and saw the entire left layer of skin on his left hand was missing. She said, I was like oh my god, I lifted up his hand and he groaned when I lifted it up and it looked like he had been burned. CNA C then went to LVN A and asked what happened because it looked fresh because his fingers where white in color, like being in water too long but he was African American. She said Resident #1's hand was soggy and there were huge blisters all over his hand and fingers. CNA C said she had picked up the piece of his hand skin unknowingly, so she told LVN A. CNA C said Resident #1 was severely injured and he could not walk, see, or move his arms more than to his face, he was stuck in the fetal position and he could not have burned himself. She said LVN A wrapped his hand temporarily because there was puss on his hand. CNA C said Resident #1 did seem to be in pain, like the injury was hurting him. She said when she and LVN A pulled his hand up and started to wipe it down before it was wrapped, he was making little groans. CNA D said she felt like LVN A was not being responsive and CNA C was panicked because she had residents get hurt in front of her before and pass away, so Resident #1's hand made her emotional. She said, Someone that cannot move, cannot do this to themselves. I try not to freak out but there was no sense of urgency or care. When she (LVN A) wrapped his hand too, she didn't clean it, just put on a gauze pad and wrapped it real quick. I was like, just dry gauze on the open flesh, it will stick when you take it off. CNA D said LVN A did not talk to her the rest of the shift and CNA D later talked to the DON about her concerns and not wanting to work with that nurse again or on that hall. CNA D said the DON did make any inquiries into Resident #1's hand. A follow up interview with the DON on 07/28/22 at 2:26 PM revealed she first saw Resident #1's hand on Sunday, 07/24/22 around 7AM because she had to swab him to test for COVID-19. LVN A had already seen his hand and the DON had been notified. When she went to his room, she saw the blisters on his left hand before they erupted. She said he had no indicators of pain and there was no other issues with his skin other than his left hand. The DON said she could not remember when she notified the ADM about Resident #1's hand. The DON said an injury of unknown origin was one that could not be described as to where it came from. She said she did not feel Resident #1 had an injury of unknown origin, she felt it was an infection, not an injury. She claimed no one from the hospital indicated to her that it was a burn. The DON said a nurse was not supposed to diagnose a resident, they can describe the situation to the physician. She said she did not talk to MD E on Sunday 07/24/22 so she did not describe Resident #1's skin change/injury to him, I assumed he had already been called. The DON said the injury did not qualify to be called to HHSC as a self-reported incident by the Abuse and Neglect Coordinator because it presented as an infection and Resident #1 had the ability to let them know if he was in pain, and he was not, and a burn would be extremely painful. The DON said if she had been notified from the hospital that the resident had second degree [CONDITION(S)], then she would have notified the ADM and it would be reported to HHSC and an investigation would be started. An interview with MD E on 07/28/22 at 3:32 PM revealed he was the medical director for the facility and attending physician to Resident #1. He said he vaguely remembered being contacted by the facility Monday morning on 07/25/22 and they were asking him about the [CONDITION(S)] he had which was a bug deal with Monkey Pox going on. He said the facility had no cases of Monkey Pox but it was number one on his list to watch out for and he did not want it to get loose in the facility so he wanted Resident #1 sent out. He said no one from the facility mentioned it could have been a burn and no one contacted him when the injury was first identified on Sunday 07/24/22 for a change in condition. MD E said, If a resident has big blisters all over his hand, they should have notified me for sure. I would have needed a description of the [CONDITION(S)]. He said, A lot of times, I am not sure if the nurses are sure of what they are looking at or seeing. MD E said he remembered being sent a photo of Resident #1's hand on 07/25/22 and that was the reason he sent him out, when he saw it. MD E said she would consider something an injury of unknown origin is the facility did not have any indications of what caused the injury and could not identify any infections or [CONDITION(S)] issues. An interview with the ADM on 07/28/22 at 2:48 PM revealed she was the facility abuse and neglect coordinator and she investigated allegations to determine if there was abuse or not. In the same role, she reported any suspicious injuries and initiated investigations and resolved them one way or another. In that process, the ADM said she may suspend staff or implement things as a result of the allegation. The ADM said she was first told about Resident #1's injury when the DON said she was sending him out Monday morning on 07/25/22. She told the ADON it had something to do with a disease, or whatever disease state he was in, but the ADM could not state what that disease was and she did not ask. The ADM said no one notified her about the injury on Sunday 07/24/22 when the blistering was initially seen. If it was a burn, the ADM said the DON should have let her know, If it was an injury of unknown origin, absolutely. At the stand-up meeting on Monday 07/25/22, the DON stat So Monday, the DON said Resident #1 had been sent out already and that he had some blisters and they were not out of the norm of expectations from his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADM said, I have never seen that before in my life. They tried to show it to me before but I have a weak stomach. I will say I just need your clinical expertise. So when I saw the picture, when I saw the blisters, I was like what is that? She said the DON told her she had seen it before and there were some diseases that when there is a flare up and the body has nowhere to release those toxins, they could come out like that. The ADM stated, So I relied on her, my DON because this was a clinical issue, to let me know if this was a reportable incident to State. I asked during morning meeting too in on Monday in front of other staff about whether it was reportable and she said no, it was part of his disease process. So I did not report. The ADM further said after the admission to the hospital, a hospital nurse called and talked to MDS RN F and the MDS RN F came to her and said the hospital was inferring that he had been burned. That was when the ADM said she went to the DON and she said she would call the hospital and tell them it was not a burn. The ADM said she did not discuss Resident #1's injury with anyone else, just the DON. She said she did not call corporate for counsel on whether to report it to HHSC as an injury of unknown origin and possible abuse/neglect. An interview with the CC-RN on 08/15/22 at 11:15 AM revealed he was an ER nurse in the past and had been a nurse for over [AGE] years. He said he trusted the DON's judgement and clinical assessment of Resident #1's hand injury and she did not feel it was a thermal burn. He said she knew what a burn was and he did as well and it did not present as such. CC-RN stated with a thermal [CONDITION(S)], the blisters would not be identical in size on the top and palm of the hand and the fingers would be scalded, which they were not. He said in order to have been burned, someone would of had to take Resident #1's contracted hand, open it up, and submerge it into a hot liquid. He said that just was not possible and did not happen. He said the DON knew what a burn was and had she felt it was a burn, she would have reported it to ADM as an injury of unknown origin and proceeded with an investigation. But when she saw it, it was not presenting as a burn. The CC-RN said that he saw the color photos of Resident #1's left hand and he did not feel the resident had a thermal burn injury. He said the hospital was not open to communicating with him (specifically the initial MD evaluator of the burn) and he had spent hours trying to contact them to discuss the injury. The CC-RN said the hospital still continued to send residents to the facility for admission and the plan remained for Resident #1 to come back to the facility when he was discharged . Review of the facility's policy titled, Investigating Incidents of Unknown Origin revised January 2020, reflected, The facility will investigate incidents of unknown origin .1. The DON/designee will follow up on the incident report (Gather witness statements, interviewed, follow up on notification of family and physician, ensure completion of documentation, complete the quality assurance review, ensure the incident has been care-planned if required). 2. The incident will be tracked on SOC. 3. The DON/designee will initiated monitoring as indicated. 4. The DON/designee should follow up on the documentation daily until the investigation is complete. 5. Once investigation is completed, the documentation should be reviewed by the QAPI team. On 08/16/22 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/17/22, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementatio

Based on observation, interview, and record review, the facility failed to have evidence that all alleged violations are thoroughly investigated in response to allegations of abuse, neglect, exploitation or mistreatment, and precent further potential abuse, neglect, exploitation or mistreatment while the investigation is in progress for one (Resident #1) of five residents reviewed for abuse, neglect, and exploitation. The facility staff failed to investigate an injury of unknown origin of Resident #1 when the resident was found to have a significant injury to his left hand, and whose source could not be identified by the facility. Resident #1 had to be sent to the ER the following day when he became unresponsive and the blisters had tripled in size, where he was diagnosed with second degree thermal [CONDITION(S)] to his whole left hand, [CONDITION(S)] and a urinary tract infection. The hospital notified the facility that there was a concern that the resident had been burned. The facility abuse/neglect coordinator did not initiate an provider investigation. This failure could place the residents at risk for further potential abuse due to uninvestigated allegations of abuse, neglect, and injuries of unknown origin. On 08/16/22 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/17/22, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received the IJ template on 08/16/22 at 2:21 PM. Findings included: Review of facility's Abuse/Neglect policy revised 08/28/17, reflected, .The Abuse Preventionist will be responsible for receiving, leading the appropriate investigation, assure that required reporting is completed timely . Review of Resident #1's quarterly MDS assessment dated [DATE], reflected he was a [AGE] year old male admitted to the facility originally on 12/08/17 and readmitted on [DATE] from an acute hospital. His active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 had unclear speech, was rarely/never understood by others and was rarely/never able to understand others and his vision was highly impaired. He had severely impaired cognitive skills for daily decision making, signs and symptoms of [CONDITION(S)] which included inattention and disorganized thinking. Resident #1 had no indicators of [CONDITION(S)], verbal or physical behaviors or rejection of care. Resident #1's required extensive physical assistance of one or more staff for bed mobility, transfers, dressing, locomotion in his wheelchair, eating, toilet use and personal hygiene and had range of motion impairment in his lower extremities on both sides. Resident #1 was unable to complete a pain interview; the staff pain assessment indicated he did not have any indicators of possible pain during the assessment period. Review of Resident #1's care plan (undated) reflected he had the potential for alteration in skin integrity related to immobility and incontinence with a goal of, [Resident #1] will have intact skin, free of redness, blisters or discoloration. Interventions included to follow facility protocols for the prevention, treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Report results to MD and follow up as indicated. Review of Resident #1's nursing notes written by LVN A on 07/24/22 at 5:52 AM reflected, While getting resident dressed this morning, aide notified nurse of skin issues. On top of resident's left hand was cluster of blisters, with the biggest one observed to have opened up on the top of his left hand. Other smaller blisters observed over left finger areas. Hand cleaned and covered with dry dressing and wound care notified. Called and left voicemail for RP. Review of Resident #1's nursing notes the next day on 07/25/22 at 7:31 AM written by LVN A reflected, While doing rounds at the end of shift, this nurse went to check on resident, dressing to left hand appeared slightly wet so nurse unwrapped it to assess before re-wrapping it. When dressing was taken off, this nurse noted existing rosy, red area to top of hand where the first blister had burst open the morning before. No drainage however noted to this area. To surrounding area was however noted multiple huge new clear fluid filled blisters around existing area, on all left fingers and knuckles, and two large blisters on the left palm of his hand. When nurse asked resident if he was in pain, he said no .MD notified immediately and order given to transfer to ER for further eval and to rule out any possible infections/contagious issues .While gathering resident's paperwork while resident was seated at the nurses' station, resident noted to become verbally unresponsive despite being given the sternal rub and was being shaken many times. Review of the facility's incident and accident logs for July 2022 revealed Resident #1 was not listed. Review of SBAR (Situation, Background, Assessment, Recommendation) Form completed 07/25/22 at 07:30 AM reflected Resident #1 had a change in condition that started on 07/24/22 and had multiple huge fluid filled blisters to left hand and while awaiting transport to the ER, he became verbally unresponsive. His blood pressure at the time of the SBAR was 94/53 and his pulse was 75. An interview with the hospital critical care RN on -7/28/22 at 12:37 PM revealed Resident #1 was presently at the hospital and had been diagnosed with second degree [CONDITION(S)] to his left hand, [CONDITION(S)] and a [CONDITION(S)]. The RN said when she first saw Resident #1's left hand, she was re-wrapping it to do wound care. He had blistering and a large open to the back of his left hand and blistering to the front and back down to where the wrist started. His skin on the left hand was blistered with a giant open area to the back of the hand that was red and granulated, blistering to all four digits and thumb on the outside and palm side of the hand. She said there were no more skin issues beyond the left hand. The RN said Resident #1 was unable to tell her what happened and he had dementia and previous stokes and baseline of confusion with mumbling of inappropriate words. The critical care RN said the hospital was concerned because Resident #1 was contracted and immobile. She said she called the facility and spoke initially with MDS RN F who only read her a nursing progress note and did not have any further information. Then the DON called her 30 minutes later and did not believe it was a burn. The critical care RN said, I did tell the DON I thought it was a burn and if he had any new oils or lotions, hot water exposure and she told me this was first noticed in the middle of the night on the 24th by an aide, so that is the note that was read to me .This is pretty significant. She said when she told the DON about the burn, the DON replied that she had asked Resident #1 if he was in pain and he said no. The critical care RN said, My thing is he won't even tell you his name. He has dementia. He is not going to do this to himself. The critical care RN said, He came in septic, this poor man, I feel bad .it made me so mad. The critical care RN said she felt Resident #1 had an injury of unknown origin and it was suspicious because it was not an injury that he could do to himself. Review of Resident #1's hospital records revealed he arrived at the hospital emergency department on 07/25/22 at 8:06 AM and was [CONDITION(S)] (a heart rate over 100 beats a minute) to 170's, blisters and loss of epithelial skin (the tissue which covers the internal and external surfaces of the body) on the dorsum (the corresponding area on the top part of the hand) of the left hand consistent with possible [CONDITION(S)] and his upper extremities were contracted. The ED's attending note stated, Patient was sent from a nursing home for elevated heart rate, was reported that yesterday he sustained some blisters on his hand from an unknown process. The ED medical doctor's final impression/diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A request was made for wound care to assess his left hand due to it appearing to be a burn but unable to ascertain a source. Review of Resident #1's wound/plastic surgery consult at the hospital dated 07/26/22 reflected he presented to the ED in [CONDITION(S)] and was found to be septic (the body's extreme response to an infection-life threatening medical emergency) with a thermal injury (occurs when energy is transferred from a heat source to the body, causing an increase in the temperature of local tissue) with blisters on his left hand and fingers. He was unable to provide a history due to his dementia. Resident #1 was assessed as, 1) 2 Palmar (palm of the hand) blisters superior to the palmar crease; blisters of palmer 5th digit (finger) over phalanges (the group of small bones that comprise the bony core of the digits (fingers) of the hand), blister on 4th digit fingertip and over middle phalanx (a bone of the finger); 2) 2nd degree [CONDITION(S)] of the dorsal (top) wrist and hand with absent epidermis (skin) several bullae (large blisters on the skin that are filled with clear fluid) including tubular bulla of dorsal 1st webspace, hemorrhagic blister (when blood pools and forms a blister) in 1st webspace, several small bullae over proximal (situated near) 4th and 5th digit, bulla of 4th digit middle phalanx. He was noted to be neurological confused and unable follow commands or provide history. The plan by the MD was Wound care to continue management of burn per protocol; recommend daily dressing changes liberal [MEDICATION(S)] ointment, [MEDICATION(S)]/xeroform, ABD pad and loose Kerlix wrap and to keep hand elevated on pillow. Five photos were taken of Resident #1's left hand by the hospital at the time of the consult. Review of TULIP database on 07/27/22 revealed no evidence of a provider investigation report or a provider investigation for Resident #1's injury of unknown origin. An interview with the DON on 07/27/22 at 3:00 PM revealed Resident #1 was sent to the hospital because his hand needed to be looked at by a higher level. She said MDS RN F had talked to the critical care hospital RN the day before (07/26/22) who had implied that Resident #1 had been burned or abused. The DON then called the hospital RN because of her feeling the resident was abused and told her it was a skin issue, not abuse. The DON said she took a picture of Resident #1's left hand on Monday morning when he was sent out. She said his left hand was red with a cluster of blisters that had erupted. She said, Initially we had thought maybe this was [CONDITION(S)]. She then said, When I saw it like this (showed her phone of Resident #1's left hand), I told [MD E] it was not presenting as [CONDITION(S)]. She said MD E did not visit Resident #1 in person after being notified on Day 2 of the blisters and she did not send him the picture that she took of Resident #1's hand. The DON said when she saw how much bigger the blisters had gotten on the second day, was when Resident #1 was sent out for further evaluation. The DON said she felt it was some kind of infection, I think. The DON said she did not know how Resident #1 was doing while at the hospital. She said he was not interviewable and sometimes made grunts or would moan when he was in pain, but he did not talk at all. The DON said Resident #1 was not ambulatory, was almost max dependence on ADLs and he was bed bound and wheelchair bound. She said he never went out on pass and rarely had family visitors. The DON said a burn would definitely be red and raw, it could have some black areas around it, and around the edges it would be white with moisture associated skin damage from the resident's own fluid leaking out from the edge of the wound and it would be extremely painful and in various stages all the way to 3rd degree. She said what happened with Resident #1, happened very acutely, very fast. The DON said an incident report was not done because it was never anything to warrant an incident, it was not a wound or injury. She said a wound care nurse or doctor did not look at it and the blisters all happened within 24 hours. The DON said, I know it is not a burn because those blisters did not present like it was a burn. I have seen fluid filled blisters like that, that were not related to burn. That looked like a fluid infection going on in his body. She said the blisters were fluid filled and were small and rapidly grew over the course of that day. She said Resident #1 could not tell them anything about what happened but he could respond to painful stimuli and he never presented with any pain or tearfulness or guardedness. An interview with MDS RN F on 07/27/22 at 3:15 PM revealed the hospital critical care RN had called to find out what happened to Resident #1's hand and said his whole hand was burned. MDS RN F did not know details about it, so she read the progress notes to the hospital critical care RN and then told the DON about the call because the hospital RN sounded disbelieving. An interview with LVN B on 07/28/22 at 10:51 AM revealed she did not see Resident #1 over the weekend of 07/23/22 and 07/24/22 but did see him when she arrived at work on Monday 07/25/22. LVN B said his skin was clear when she left work on Friday 07/22/22 but when she came back on 07/25/22, he had one big blister on the top of his left hand that had already busted and the night nurse (LVN A) was not sure what it was and no one could understand how he got blisters like that. LVN B said she did not know if it was a burn because something real hot would have had to caused it. She said Resident #1's index finger was really swollen and he had a blister on the pointer finger side going towards the thumb. LVN B said Resident #1 normally could talk, but he was not there at all, she shook him, called his name and tried to open his eyes to get a reaction, but he was not responding, which was unusual. She said he could not tell her if he was in pain. She said by that time, the overnight nurse (LVN A) had notified the DON and physician to see what they wanted to do and MD F said to send him out since no one knew what had happened. LVN B said after that, she googled burn blisters on the hand and the pictures on the internet looked like Resident #1's. LVN B said, But I don't want to say it is a burn, because that is not good. LVN B said she did not know if Resident #1 had an injury of unknown origin. She said that would be when a person could not tell how an injury occurred She then said, We don't know how this one occurred. A follow up interview with MDS RN F on 07/28/22 at 11:17 AM revealed she had been employed at the facility for a month and she was the RN manager on duty on Sunday 07/24/22 and had come to the facility last in the morning around 11 AM. She said she had not been notified of any issues related to Resident #1 but as the MOD, she went to each nurses' station, asked how things were going, if there were any new incidents and accidents and she was told no. She then went to the MDS office and did assessments and later helped serve dinner. She said she did not see Resident #1's hand. MDS RN F said she was first made aware of Resident #1's hand during the morning management meeting on Monday 07/25/22, after he had already been sent out. MDS RN F said an injury of unknown origin was something that was abnormal, that was not there before. If that occurs, the facility should look into what happened and start an investigation, see if it was suspicious. An interview with the overnight nurse, LVN A, on 07/28/22 at 11:56 AM revealed she had worked at the facility Saturday 2pm-10pm and the overnight shift (07/23/22) and on Sunday (07/24/22) she worked the overnight shift 10 PM-6 AM. LVN A said she was notified by a CNA in the early morning hours before the overnight shift was over Sunday morning (07/25/22) that the CNA was getting him up and noticed issues with his skin and she wanted LVN A to look at it. When LVN A went to his room, Resident #1 initially had a big blister right on top of his hand that had popped and little one right next to it that had not popped but one was draining. She said the skin was still on so she did not want to aggressively rub it and she covered it with a dry dressing and put it on the 24 hour report to remind herself. LVN A said they left him in bed at that time. LVN A said she did not contact MD E or an on-call doctor on Sunday 07/24/22 when she first noticed Resident #1's left hand injuries because the facility lets the treatment nurse look at it first. LVN A said she just cleaned it and wanted the wound nurse to look at it when she came in. She said the wound nurse did not normally work the weekends and that was why she made a note in the 24 hour report to remind herself and alert the oncoming nurse to follow up. However, she said Resident #1 was sent out to the ER the next day in the early morning before the wound care nurse could look at his hand. When LVN A came back to work later that day for her overnight shift (Sunday into Monday 07/24/22-07/25/22), she was rounding and when she looked at the dressing, it looked like it had dried so she changed it. When she unwrapped it, there were triple the amount of new blisters around the entire hand, like big, huge blisters which were not there the day before so the blisters tripled in numbers in 24 hours, and they were on the palm of his hand. LVN A said she cleaned it, wrapped his hand with a dry dressing and texted the DON asking her what to do. She said, As far as I know, there was nothing that had burned him, but the wound was growing. At that point, she called MD E and told him about it for the first time. He said initially he would refer to a dermatologist, but then said to send Resident #1 to the ER in case he had something contagious since it came on that rapidly. LVN A said, I don't know if he was reacting to anything or if he was burned. LVN A said she did not initially think it was a burn because no one had mentioned anything to her, But with the tripling of them (the blisters) the next day, with the wound wrapped up, I don't know. LVN A said an injury of unknown origin was when a person did not know how it occurred. Observation and record review of the 24-hour book for Hall 100 (Resident #1's hall) revealed no entries on 07/23/22 or 07/24/22 related to the resident. An interview with the wound care LVN G on 07/28/22 at 07/28/22 at 3:10 PM revealed that Resident #1 had not been on her caseload and she did not work over the weekend on 07/23/22-07/24/22. She said no one mentioned anything to her about Resident #1's hand and he had already been sent to the hospital by the time she arrived at work Monday 07/25/22. She said she only found out about it through hearing people talking about it conversationally in the facility. Wound Care LVN G said a burn could present differently, depending on the degree of it. She said there could be blistering, discoloration, redness, some swelling due to the degree, and some skin may be missing due to the degree of the burn. She said most second degree [CONDITION(S)] were blistered and a burn could re-blister, pop on their own and come back up. An interview with CNA C on 07/28/22 at 12:25 PM revealed she had last seen Resident #1 on Friday 07/22/22 and his skin looked great, she could see his hands when she laid him down. When she saw him Monday morning 07/25/22, she was told that he maybe had an infection because his hand was wrapped. CNA C said then the overnight nurse, LVN A took off the dressing and she saw he had pink raw skin on top of his hand. She said she was wondering how that could have happened because Resident #1 always kept his hands balled up and only moved them to itch his face. CNA C described Resident #1's left hand as looking like person who got burned, because she had never seen an infection that took the skin off like that and that he had blisters everywhere on his fingers and palm. Resident #1 could not tell her what happened because he was blind and only spoke a few words and he was not responsive, which was not normal. CNA C said, I said y'all sure it not a burn and they were like shhhhh (be quiet sound) .at the same time I was like what if this is your family member? She said when Resident #1 was not responding to her, she tried to do a sternal rub, But nothing, like he was losing it. CNA C said she told the DON that she should take staff members off the schedule who had worked with Resident #1 before that time frame just in case, and investigate, and she just looked at me. She said, If it was my family member, I would want to know the facility is looking into it. An interview with CNA D on 07/28/22 at 3:58 PM revealed she had worked the overnight shift for the first time on Resident #1's hall on Saturday-Sunday shift (07/23/22-07/24/22), but she knew him from working with him on another hall. She said on that overnight shift, around 3:50 AM, she went in to check on him and he was quiet and she was worried he was not breathing but then looked closer and saw his chest was rising. She said he was a typically a heavy soil and outputs a lot and the entire night when she would go and check on him, he was dry up until 3:50 AM and that was unusual. CNA C said incontinence being not as frequent or not as much as it used to be could be a sign of the body shutting down. She said Resident #1 had not voided at all her shift until then. When she changed him, it was only urine and it could fill her palm so it was not much and he was laying on his hand so she turned him over. When CNA C turned him over, there was a thin brown layer of something next to him. She did not know what it was. She picked it up and then looked at this hand and saw the entire left layer of skin on his left hand was missing. She said, I was like oh my god, I lifted up his hand and he groaned when I lifted it up and it looked like he had been burned. CNA C then went to LVN A and asked what happened because it looked fresh because his fingers where white in color, like being in water too long but he was African American. She said Resident #1's hand was soggy and there were huge blisters all over his hand and fingers. CNA C said she had picked up the piece of his hand skin unknowingly, so she told LVN A. CNA C said Resident #1 was severely injured and he could not walk, see, or move his arms more than to his face, he was stuck in the fetal position and he could not have burned himself. She said LVN A wrapped his hand temporarily because there was puss on his hand. CNA C said Resident #1 did seem to be in pain, like the injury was hurting him. She said when she and LVN A pulled his hand up and started to wipe it down before it was wrapped, he was making little groans. CNA D said she felt like LVN A was not being responsive and CNA C was panicked because she had residents get hurt in front of her before and pass away, so Resident #1's hand made her emotional. She said, Someone that cannot move, cannot do this to themselves. I try not to freak out but there was no sense of urgency or care. When she (LVN A) wrapped his hand too, she didn't clean it, just put on a gauze pad and wrapped it real quick. I was like, just dry gauze on the open flesh, it will stick when you take it off. CNA D said LVN A did not talk to her the rest of the shift and CNA D later talked to the DON about her concerns and not wanting to work with that nurse again or on that hall. CNA D said the DON did make any inquiries into Resident #1's hand. A follow up interview with the DON on 07/28/22 at 2:26 PM revealed she first saw Resident #1's hand on Sunday, 07/24/22 around 7AM because she had to swab him to test for COVID-19. LVN A had already seen his hand and the DON had been notified. When she went to his room, she saw the blisters on his left hand before they erupted. She said he had no indicators of pain and there was no other issues with his skin other than his left hand. The DON said she could not remember when she notified the ADM about Resident #1's hand. The DON said an injury of unknown origin was one that could not be described as to where it came from. She said she did not feel Resident #1 had an injury of unknown origin, she felt it was an infection, not an injury. She claimed no one from the hospital indicated to her that it was a burn. The DON said a nurse was not supposed to diagnose a resident, they can describe the situation to the physician. She said she did not talk to MD E on Sunday 07/24/22 so she did not describe Resident #1's skin change/injury to him, I assumed he had already been called. The DON said the injury did not qualify to be called to HHSC as a self-reported incident by the Abuse and Neglect Coordinator because it presented as an infection and Resident #1 had the ability to let them know if he was in pain, and he was not, and a burn would be extremely painful. The DON said if she had been notified from the hospital that the resident had second degree [CONDITION(S)], then she would have notified the ADM and it would be reported to HHSC and an investigation would be started. An interview with MD E on 07/28/22 at 3:32 PM revealed he was the medical director for the facility and attending physician to Resident #1. He said he vaguely remembered being contacted by the facility Monday morning on 07/25/22 and they were asking him about the [CONDITION(S)] he had which was a bug deal with Monkey Pox going on. He said the facility had no cases of Monkey Pox but it was number one on his list to watch out for and he did not want it to get loose in the facility so he wanted Resident #1 sent out. He said no one from the facility mentioned it could have been a burn and no one contacted him when the injury was first identified on Sunday 07/24/22 for a change in condition. MD E said, If a resident has big blisters all over his hand, they should have notified me for sure. I would have needed a description of the [CONDITION(S)]. He said, A lot of times, I am not sure if the nurses are sure of what they are looking at or seeing. MD E said he remembered being sent a photo of Resident #1's hand on 07/25/22 and that was the reason he sent him out, when he saw it. MD E said she would consider something an injury of unknown origin is the facility did not have any indications of what caused the injury and could not identify any infections or [CONDITION(S)] issues. An interview with the ADM on 07/28/22 at 2:48 PM revealed she was the facility abuse and neglect coordinator and she investigated allegations to determine if there was abuse or not. In the same role, she reported any suspicious injuries and initiated investigations and resolved them one way or another. In that process, the ADM said she may suspend staff or implement things as a result of the allegation. The ADM said she was first told about Resident #1's injury when the DON said she was sending him out Monday morning on 07/25/22. She told the ADON it had something to do with a disease, or whatever disease state he was in, but the ADM could not state what that disease was and she did not ask. The ADM said no one notified her about the injury on Sunday 07/24/22 when the blistering was initially seen. If it was a burn, the ADM said the DON should have let her know, If it was an injury of unknown origin, absolutely. At the stand-up meeting on Monday 07/25/22, the DON stat So Monday, the DON said Resident #1 had been sent out already and that he had some blisters and they were not out of the norm of expectations from his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADM said, I have never seen that before in my life. They tried to show it to me before but I have a weak stomach. I will say I just need your clinical expertise. So when I saw the picture, when I saw the blisters, I was like what is that? She said the DON told her she had seen it before and there were some diseases that when there is a flare up and the body has nowhere to release those toxins, they could come out like that. The ADM stated, So I relied on her, my DON because this was a clinical issue, to let me know if this was a reportable incident to State. I asked during morning meeting too in on Monday in front of other staff about whether it was reportable and she said no, it was part of his disease process. So I did not report. The ADM further said after the admission to the hospital, a hospital nurse called and talked to MDS RN F and the MDS RN F came to her and said the hospital was inferring that he had been burned. That was when the ADM said she went to the DON and she said she would call the hospital and tell them it was not a burn. The ADM said she did not discuss Resident #1's injury with anyone else, just the DON. She said she did not call corporate for counsel on whether to report it to HHSC as an injury of unknown origin and possible abuse/neglect. An interview with the CC-RN on 08/15/22 at 11:15 AM revealed he was an ER nurse in the past and had been a nurse for over [AGE] years. He said he trusted the DON's judgement and clinical assessment of Resident #1's hand injury and she did not feel it was a thermal burn. He said she knew what a burn was and he did as well and it did not present as such. CC-RN stated with a thermal [CONDITION(S)], the blisters would not be identical in size on the top and palm of the hand and the fingers would be scalded, which they were not. He said in order to have been burned, someone would of had to take Resident #1's contracted hand, open it up, and submerge it into a hot liquid. He said that just was not possible and did not happen. He said the DON knew what a burn was and had she felt it was a burn, she would have reported it to ADM as an injury of unknown origin and proceeded with an investigation. But when she saw it, it was not presenting as a burn. The CC-RN said that he saw the color photos of Resident #1's left hand and he did not feel the resident had a thermal burn injury. He said the hospital was not open to communicating with him (specifically the initial MD evaluator of the burn) and he had spent hours trying to contact them to discuss the injury. The CC-RN said the hospital still continued to send residents to the facility for admission and the plan remained for Resident #1 to come back to the facility when he was discharged . Review of the facility's policy titled, Investigating Incidents of Unknown Origin revised January 2020, reflected, The facility will investigate incidents of unknown origin .1. The DON/designee will follow up on the incident report (Gather witness statements, interviewed, follow up on notification of family and physician, ensure completion of documentation, complete the quality assurance review, ensure the incident has been care-planned if required). 2. The incident will be tracked on SOC. 3. The DON/designee will initiated monitoring as indicated. 4. The DON/designee should follow up on the documentation daily until the investigation is complete. 5. Once investigation is completed, the documentation should be reviewed by the QAPI team. On 08/16/22 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/17/22, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated

Based on observation, interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #1) of five residents reviewed for quality of care. The facility failed to ensure Resident #1 was accurately assessed, monitored, and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . He was given a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 had to be sent to the ER the following day when he became unresponsive and the blisters had tripled in size, where he was diagnosed with second degree [CONDITION(S)] to his whole left hand, [CONDITION(S)] and a urinary tract infection. This failure placed residents at risk for skin alteration and injuries and could result in pain, decreased quality of life, serious illness and hospitalization . On 08/16/22 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/17/22, the facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received the IJ template on 08/16/22 at 2:21 PM. Findings included: Review of Resident #1's quarterly MDS assessment dated [DATE], reflected he was a [AGE] year-old male admitted to the facility originally on 12/08/17 and readmitted on [DATE] from an acute hospital. His active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 had unclear speech, was rarely/never understood by others and was rarely/never able to understand others and his vision was highly impaired. He had severely impaired cognitive skills for daily decision making, signs and symptoms of [CONDITION(S)] which included inattention and disorganized thinking. Resident #1 had no indicators of [CONDITION(S)], verbal or physical behaviors or rejection of care. Resident #1's required extensive physical assistance of one or more staff for bed mobility, transfers, dressing, locomotion in his wheelchair, eating, toilet use and personal hygiene and had range of motion impairment in his lower extremities on both sides. Resident #1 was unable to complete a pain interview; the staff pain assessment indicated he did not have any indicators of possible pain during the assessment period. Review of Resident #1's care plan (undated) reflected he had the potential for alteration in skin integrity related to immobility and incontinence with a goal of, [Resident #1] will have intact skin, free of redness, blisters or discoloration. Interventions included to follow facility protocols for the prevention, treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Report results to MD and follow up as indicated. Review of Resident #1's most recent weekly skin assessment completed by LVN A on 07/21/22 reflected his skin color was normal with no bruising, skin tears, abrasions, lacerations, surgical incisions, rash, moisture associated skin damage or wounds. Review of Resident #1's most recent skin site identification from and shower sheet dated 07/22/22 reflected he was provided a shower; hair was washed and nails were cleaned with no indication of skin alteration. Review of Resident #1's nursing notes written by LVN A on 07/24/22 at 5:52 AM reflected, While getting resident dressed this morning, aide notified nurse of skin issues. On top of resident's left hand was cluster of blisters, with the biggest one observed to have opened up on the top of his left hand. Other smaller blisters observed over left finger areas. Hand cleaned and covered with dry dressing and wound care notified. Called and left voicemail for RP. Review of Resident #1's July 2022 physician's orders did not reflect an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's nursing notes the next day on 07/25/22 at 7:31 AM written by LVN A reflected, While doing rounds at the end of shift, this nurse went to check on resident, dressing to left hand appeared slightly wet so nurse unwrapped it to assess before re-wrapping it. When dressing was taken off, this nurse noted existing rosy, red area to top of hand where the first blister had burst open the morning before. No drainage however noted to this area. To surrounding area was however noted multiple huge new clear fluid filled blisters around existing area, on all left fingers and knuckles, and two large blisters on the left palm of his hand. When nurse asked resident if he was in pain, he said no .MD notified immediately and order given to transfer to ER for further eval and to rule out any possible infections/contagious issues .While gathering resident's paperwork while resident was seated at the nurses' station, resident noted to become verbally unresponsive despite being given the sternal rub and was being shaken many times. Review of the facility's incident and accident logs for July 2022 revealed Resident #1 was not listed. Review of SBAR (Situation, Background, Assessment, Recommendation) Form completed 07/25/22 at 07:30 AM reflected Resident #1 had a change in condition that started on 07/24/22 and had multiple huge fluid filled blisters to left hand and while awaiting transport to the ER, he became verbally unresponsive. His blood pressure at the time of the SBAR was 94/53 and his pulse was 75. An interview with the hospital critical care RN on -7/28/22 at 12:37 PM revealed Resident #1 was presently at the hospital and had been diagnosed with second degree [CONDITION(S)] to his left hand, [CONDITION(S)] and a [CONDITION(S)]. The RN said when she first saw Resident #1's left hand, she was re-wrapping it to do wound care. He had blistering and a large open to the back of his left hand and blistering to the front and back down to where the wrist started. His skin on the left hand was blistered with a giant open area to the back of the hand that was red and granulated, blistering to all four digits and thumb on the outside and palm side of the hand. She said there were no more skin issues beyond the left hand. The RN said Resident #1 was unable to tell her what happened and he had dementia and previous stokes and baseline of confusion with mumbling of inappropriate words. The critical care RN said the hospital was concerned because Resident #1 was contracted and immobile. She said she called the facility and spoke initially with MDS RN F who only read her a nursing progress note and did not have any further information. Then the DON called her 30 minutes later and did not believe it was a burn. The critical care RN said, Anyone can tell it is a burn. They did a dry dressing which was not appropriate, it should have been a wet dressing. She said if a dry dressing was applied to a burn such as Resident #1's, essentially it would stick to the wound and worsen it when it was removed. The critical care RN said she asked the DON why they chose that dressing and the DON responded they had notified the wound care nurse. The critical care RN said, I did tell the DON I thought it was a burn and if he had any new oils or lotions, hot water exposure and she told me this was first noticed in the middle of the night on the 24th by an aide, so that is the note that was read to me .This is pretty significant. She said when she told the DON about the burn, the DON replied that she had asked Resident #1 if he was in pain and he said no. The critical care RN said, My thing is he won't even tell you his name. He has dementia. He is not going to do this to himself. The critical care RN said, He came in septic, this poor man, I feel bad .it made me so mad. The critical care RN said she felt Resident #1 had an injury of unknown origin and it was suspicious because it was not an injury that he could do to himself. Review of Resident #1's hospital records revealed he arrived at the hospital emergency department on 07/25/22 at 8:06 AM and was [CONDITION(S)] (a heart rate over 100 beats a minute) to 170's, blisters and loss of epithelial skin (the tissue which covers the internal and external surfaces of the body) on the dorsum (the corresponding area on the top part of the hand) of the left hand consistent with possible [CONDITION(S)] and his upper extremities were contracted. The ED's attending note stated, Patient was sent from a nursing home for elevated heart rate, was reported that yesterday he sustained some blisters on his hand from an unknown process. The ED medical doctor's final impression/diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A request was made for wound care to assess his left hand due to it appearing to be a burn but unable to ascertain a source. Review of Resident #1's wound/plastic surgery consult at the hospital dated 07/26/22 reflected he presented to the ED in [CONDITION(S)] and was found to be septic (the body's extreme response to an infection-life threatening medical emergency) with a thermal injury (occurs when energy is transferred from a heat source to the body, causing an increase in the temperature of local tissue) with blisters on his left hand and fingers. He was unable to provide a history due to his dementia. Resident #1 was assessed as, 1) 2 Palmar (palm of the hand) blisters superior to the palmar crease; blisters of palmer 5th digit (finger) over phalanges (the group of small bones that comprise the bony core of the digits (fingers) of the hand), blister on 4th digit fingertip and over middle phalanx (a bone of the finger); 2) 2nd degree [CONDITION(S)] of the dorsal (top) wrist and hand with absent epidermis (skin) several bullae (large blisters on the skin that are filled with clear fluid) including tubular bulla of dorsal 1st webspace, hemorrhagic blister (when blood pools and forms a blister) in 1st webspace, several small bullae over proximal (situated near) 4th and 5th digit, bulla of 4th digit middle phalanx. He was noted to be neurological confused and unable follow commands or provide history. The plan by the MD was Wound care to continue management of burn per protocol; recommend daily dressing changes liberal [MEDICATION(S)] ointment, [MEDICATION(S)]/xeroform, ABD pad and loose Kerlix wrap and to keep hand elevated on pillow. Five photos were taken of Resident #1's left hand by the hospital at the time of the consult. An interview with the DON on 07/27/22 at 3:00 PM revealed Resident #1 was sent to the hospital because his hand needed to be looked at by a higher level. She said MDS RN F had talked to the critical care hospital RN the day before (07/26/22) who had implied that Resident #1 had been burned or abused. The DON then called the hospital RN because of her feeling the resident was abused and told her it was a skin issue, not abuse. The DON said she took a picture of Resident #1's left hand on Monday morning when he was sent out. She said his left hand was red with a cluster of blisters that had erupted. She said, Initially we had thought maybe this was [CONDITION(S)]. She then said, When I saw it like this (showed her phone of Resident #1's left hand), I told [MD E] it was not presenting as [CONDITION(S)]. She said MD E did not visit Resident #1 in person after being notified on Day 2 of the blisters and she did not send him the picture that she took of Resident #1's hand. She did not have a reason as to why she did not send him the photo at that time. The DON said when she saw how much bigger the blisters had gotten on the second day, was when Resident #1 was sent out for further evaluation. The DON said she felt it was some kind of infection, I think. the DON said she did not know how Resident #1 was doing while at the hospital. She said he was not interviewable and sometimes made grunts or would moan when he was in pain, but he did not talk at all. The DON said Resident #1 was not ambulatory, was almost max dependence on ADLs and he was bed bound and wheelchair bound. She said he never went out on pass and rarely had family visitors. The DON said a burn would definitely be red and raw, it could have some black areas around it, and around the edges it would be white with moisture associated skin damage from the resident's own fluid leaking out from the edge of the wound and it would be extremely painful and in various stages all the way to 3rd degree. She said what happened with Resident #1, happened very acutely, very fast. The DON said an incident report was not done because it was never anything to warrant an incident, it was not a wound or injury. She said a wound care nurse or doctor did not look at it and the blisters all happened within 24 hours. The DON said, I know it is not a burn because those blisters did not present like it was a burn. I have seen fluid filled blisters like that, that were not related to burn. That looked like a fluid infection going on in his body. She said the blisters were fluid filled and were small and rapidly grew over the course of that day. She said Resident #1 could not tell them anything about what happened but he could respond to painful stimuli and he never presented with any pain or tearfulness or guardedness. An interview with MDS RN F on 07/27/22 at 3:15 PM revealed the hospital critical care RN had called to find out what happened to Resident #1's hand and said his whole hand was burned. MDS RN F did not know details about it, so she read the progress notes to the hospital critical care RN and then told the DON about the call because the hospital RN sounded disbelieving. An interview with LVN B on 07/28/22 at 10:51 AM revealed she did not see Resident #1 over the weekend of 07/23/22 and 07/24/22 but did see him when she arrived at work on Monday 07/25/22. LVN B said his skin was clear when she left work on Friday 07/22/22 but when she came back on 07/25/22, he had one big blister on the top of his left hand that had already busted and the night nurse (LVN A) was not sure what it was and no one could understand how he got blisters like that. LVN B said she did not know if it was a burn because something real hot would have had to caused it. She said Resident #1's index finger was really swollen and he had a blister on the pointer finger side going towards the thumb. LVN B said Resident #1 normally could talk, but he was not there at all, she shook him, called his name and tried to open his eyes to get a reaction, but he was not responding, which was unusual. She said he could not tell her if he was in pain. She said by that time, the overnight nurse (LVN A) had notified the DON and physician to see what they wanted to do and MD E said to send him out since no one knew what had happened. LVN B said after that, she googled burn blisters on the hand and the pictures on the internet looked like Resident #1's. LVN B said, But I don't want to say it is a burn, because that is not good. A follow up interview with MDS RN F on 07/28/22 at 11:17 AM revealed she had been employed at the facility for a month and she was the RN manager on duty on Sunday 07/24/22 and had come to the facility last in the morning around 11 AM. She said she had not been notified of any issues related to Resident #1 but as the MOD, she went to each nurses' station, asked how things were going, ask if there were any new incidents and accidents and she was told no. She then went to the MDS office and did assessments and later helped serve dinner. She said she did not see Resident #1's hand. MDS RN F said she was first made aware of Resident #1's hand during the morning management meeting on Monday 07/25/22, after he had already been sent out. She said, A nurse cannot diagnose and did not diagnose, that is why the doctor was called. That was [MD E]. MDS RN F said she did not know if MD E diagnosed Resident #1 but he ordered the treatment. She did not know what kind of treatment MD E ordered and said she was not the front line nurse. An interview with the overnight nurse, LVN A, on 07/28/22 at 11:56 AM revealed she had worked at the facility Saturday 2pm-10pm and the overnight shift (07/23/22) and on Sunday (07/24/22) she worked the overnight shift 10 PM-6 AM. LVN A said she was notified by a CNA D in the early morning hours before the overnight shift was over Sunday morning (07/25/22) that the CNA was getting him up and noticed issues with his skin and she wanted LVN A to look at it. When LVN A went to his room, Resident #1 initially had a big blister right on top of his hand that had popped and little one right next to it that had not popped but one was draining. She said the skin was still on so she did not want to aggressively rub it and she covered it with a dry dressing and put it on the 24 hour report to remind herself. LVN A said they left him in bed at that time. LVN A said she did not contact MD E or an on-call doctor on Sunday 07/24/22 when she first noticed Resident #1's left hand injuries because the facility lets the treatment nurse look at it first. LVN A said she just cleaned it and wanted the wound nurse to look at it when she came in. She said the wound nurse did not normally work the weekends and that was why she made a note in the 24-hour report to remind herself and alert the oncoming nurse to follow up. However, she said Resident #1 was sent out to the ER the next day in the early morning before the wound care nurse could look at his hand. When LVN A came back to work later that day for her overnight shift (Sunday into Monday 07/24/22-07/25/22), she was rounding and when she looked at the dressing, it looked like it had dried so she changed it. When she unwrapped it, there were triple the amount of new blisters around the entire hand, like big, huge blisters which were not there the day before so the blisters tripled in numbers in 24 hours, and they were on the palm of his hand. LVN A said she cleaned it, wrapped his hand with a dry dressing and texted the DON asking her what to do. She said, As far as I know, there was nothing that had burned him, but the wound was growing. At that point, she called MD E and told him about it for the first time. He said initially he would refer to a dermatologist, but then said to send Resident #1 to the ER in case he had something contagious since it came on that rapidly. LVN A said, I don't know if he was reacting to anything or if he was burned. LVN A said she did not initially think it was a burn because no one had mentioned anything to her, But with the tripling of them (the blisters) the next day, with the wound wrapped up, I don't know. Observation and record review of the 24-hour book for Hall 100 (Resident #1's hall) revealed no entries on 07/23/22 or 07/24/22 related to the resident. An interview with the wound care LVN G on 07/28/22 at 07/28/22 at 3:10 PM revealed that Resident #1 had not been on her caseload and she did not work over the weekend on 07/23/22-07/24/22. She said no one mentioned anything to her about Resident #1's hand and he had already been sent to the hospital by the time she arrived at work Monday 07/25/22. She said she only found out about it through hearing people talking about it conversationally in the facility. Wound Care LVN G said a burn could present differently, depending on the degree of it. She said there could be blistering, discoloration, redness, some swelling due to the degree, and some skin may be missing due to the degree of the burn. She said most second degree [CONDITION(S)] were blistered and a burn could re-blister, pop on their own and come back up. Wound care LVN G said she would typically treat a burn by notifying the doctor and getting an order. She stated, There is a lot of stuff as nurses you don't see, even if you have been a nurse for years. My first notion is to call the doctor, take a picture and show them. An interview with CNA C on 07/28/22 at 12:25 PM revealed she had last seen Resident #1 on Friday 07/22/22 and his skin looked great, she could see his hands when she laid him down. When she saw him Monday morning 07/25/22, she was told that he maybe had an infection because his hand was wrapped. CNA C said then the overnight nurse, LVN A took off the dressing and she saw he had pink raw skin on top of his hand. She said she was wondering how that could have happened because Resident #1 always kept his hands balled up and only moved them to itch his face. CNA C described Resident #1's left hand as looking like person who got burned, because she had never seen an infection that took the skin off like that and that he had blisters everywhere on his fingers and palm. Resident #1 could not tell her what happened because he was blind and only spoke a few words and he was not responsive, which was not normal. CNA C said, I said y'all sure it not a burn and they were like shhhhh (be quiet sound) .at the same time I was like what if this is your family member? CNA C said she was asking various nurses and management about it, but did not give names. She said when Resident #1 was not responding to her, she tried to do a sternal rub, But nothing, like he was losing it. CNA C said she told the DON that she should take staff members off the schedule who had worked with Resident #1 before that time frame just in case, and investigate, and she just looked at me. She said, If it was my family member, I would want to know the facility is looking into it. An interview with the DON on 07/28/22 at 2:26 PM revealed the facility did not contact the wound care physician to have he/she assess Resident #1's left hand injury because the resident had already been sent out to the hospital. She also stated there was no wound care nurse working on the weekend. The DON said she believed MD E was notified about Resident #1 on Sunday 07/24/22 prior to her arriving at the facility by LVN A. The DON said she was at the facility that day, arriving early in the morning around 6am because she needed to swab residents for COVID-19 due to a recent positive case. She said thought LVN A notified MD E. However, the DON said she did not verify that LVN A called him and did not follow up with her afterwards to see what his orders were. She said she had just assumed LVN A called MD E and she had no idea why she did not call him. The DON said she first saw Resident #1' hand when she arrived that morning around 7AM because she had to swab him to test for COVID19. LVN A had already seen his hand and the DON had been notified. When she went to his room, she saw the blisters on his left hand before they erupted. She said he had no indicators of pain and there was no other issues with his skin other than his left hand. The DON said she did not tell LVN A to contact the doctor (MD E) and had assumed she had already done that. The DON said that she was the RN in the facility that morning and the manager on duty was MDS RN F who arrived later that day and took over. She said MDS RN F did not see Resident #1's left hand. The DON said she had since started an in-service with the nursing staff on 07/28/22 about how to identify a change in condition. She said when a change in condition occurred with a resident, she expected the nurses to identify the change, complete an SBAR and make sure the resident is stable, call the physician and family and if there was an order given, to follow it up with any further changes. The DON said she initiated that in-service training because there was no order for Resident's treatment given to his left hand. The DON said she saw that LVN A treated it, but there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the DON also admitted that she was the one who told LVN A what type of dressing to use, based on facility standing orders for basic issues like blisters and skin tears and that she did not want to put a cream or ointment on it, just a non-adhesive dressing wrapped in Kurlex. The DON said, If it was a burn, I would have sent him out to the hospital. With [CONDITION(S)], we typically don't treat initial [CONDITION(S)] on the skin. We would wash under cold water and apply Silverdine maybe, but it's whatever the doctor would choose. A copy of the facility standing orders for basic skin treatment was requested but never provided. The DON said a nurse was not supposed to diagnose a resident, they can describe the situation to the physician. She said she did not talk to MD E on Sunday 07/24/22 so she did not describe Resident #1's skin change/injury to him, I assumed he had already been called. An interview with CNA D on 07/28/22 at 3:58 PM revealed she had worked the overnight shift for the first time on Resident #1's hall on Saturday-Sunday shift (07/23/22-07/24/22), but she knew him from working with him on another hall. She said on that overnight shift, around 3:50 AM, she went in to check on him and he was quiet and she was worried he was not breathing but then looked closer and saw his chest was rising. She said he was a typically a heavy soil and outputs a lot and the entire night when she would go and check on him, he was dry up until 3:50 AM and that was unusual. CNA C said incontinence being not as frequent or not as much as it used to could be a sign of the body shutting down. She said Resident #1 had not voided at all her shift until then. When she changed him, it was only urine and it could fill her palm so it was not much and he was laying on his hand so she turned him over. When CNA C turned him over, there was a thin brown layer of something next to him. She did not know what it was. She picked it up and then looked at this hand and saw the entire left layer of skin on his left hand was missing. She said, I was like oh my god, I lifted up his hand and he groaned when I lifted it up and it looked like he had been burned. CNA C then went to LVN A and asked what happened because it looked fresh because his fingers where white in color, like being in water too long but he was African American. She said Resident #1's hand was soggy and there were huge blisters all over his hand and fingers. CNA C said she had picked up the piece of his hand skin unknowingly, so she told LVN A. CNA C said Resident #1 was severely injured and he could not walk, see, or move his arms more than to his face, he was stuck in the fetal position and he could not have burned himself. She said LVN A wrapped his hand temporarily because there was puss on his hand. CNA C said Resident #1 did seem to be in pain, like the injury was hurting him. She said when she and LVN A pulled his hand up and started to wipe it down before it was wrapped, he was making little groans. CNA D said she felt like LVN A was not being responsive and CNA C was panicked because she had residents get hurt in front of her before and pass away, so Resident #1's hand made her emotional. She said, Someone that cannot move, cannot do this to themselves. I try not to freak out but there was no sense of urgency or care. When she (LVN A) wrapped his hand too, she didn't clean it, just put on a gauze pad and wrapped it real quick. I was like, just dry gauze on the open flesh, it will stick when you take it off. CNA D said LVN A did not talk to her the rest of the shift and CNA D later talked to the DON about her concerns and not wanting to work with that nurse again or on that hall. CNA D said the DON did not make any inquiries into Resident #1's hand. An interview with MD E on 07/28/22 at 3:32 PM revealed he was the medical director for the facility and attending physician to Resident #1. He said he vaguely remembered being contacted by the facility Monday morning on 07/25/22 and they were asking him about the [CONDITION(S)] he had which was a big deal with Monkey Pox going on. He said the facility had no cases of Monkey Pox but it was number one on his list to watch out for and he did not want it to get loose in the facility, so he wanted Resident #1 sent out. He said no one from the facility mentioned it could have been a burn and no one contacted him when the injury was first identified on Sunday 07/24/22 for a change in condition. MD E said, If a resident has big blisters all over his hand, they should have notified me for sure. I would have needed a description of the [CONDITION(S)]. He said, A lot of times, I am not sure if the nurses are sure of what they are looking at or seeing. MD E said he remembered being sent a photo of Resident #1's hand on 07/25/22 and that was the reason he sent him out, when he saw it. MD E said he would consider something an injury of unknown origin is the facility did not have any indications of what caused the injury and could not identify any infections or [CONDITION(S)] issues. He said it if Resident #1 had [CONDITION(S)] on his hand and any skin was inflamed underneath it, he would want to use petroleum, skin prep and iodine dressing, but if the skin was broken, he would do another type of dressing, it just depended on the extent of the injury. An interview with the hospital RN for Resident #1 on 08/15/22 at 3:05 pm revealed he had a thermal burn which was caused by heat, but the attending would be able to state that with certainty. She said Resident #1's skin on the top of his left hand was growing back and doing much better. She said he finished his course of ABX for [CONDITION(S)] and [CONDITION(S)] but his blood pressure remained very high, and that was what they were focusing on presently. She said while at the hospital, he had contracted COVID-19. An interview with Resident #1's attending hospital physician on 08/15/22 at 3:12 PM revealed she was an internist but would contact the doctor who completed the burn evaluation. She said Resident #1 was seen by the doctor from the plastic surgery/wound department on 07/26/22, who determined Resident #1 had a thermal burn. She said that doctor did a plastic surgery evaluation because Resident #1 was septic at admission and they wanted to know if the blistering/burn on the left hand could have been caused by the infection. However, when the doctor completed his assessment/evaluation, he determined there was low suspicion that the infection caused the burn, and the [CONDITION(S)] most likely came from the [CONDITION(S)]. He categorized the burn as thermal. She said there were different categories of [CONDITION(S)], but a thermal burn was one that was usually caused by an external heat source. She said he was an internist so her specialization was not in skin. An observation and attempted interview of Resident #1 occurred on 08/15/22 at 3:30 PM while he was in his hospital room. Resident #1's eyes were closed but he was awake. He was initially not responsive to questions. Upon increasing the volume of the voice, he stirred and moved his head, but his responses to questions were minimal, with only making a sound each time, no discernable words. His blood pressure was 178/93, pulse 58. The hospital RN unwrapped his left hand to procced with a dressing change. Resident #1 did not wince or make any motions or sounds of discomfort. His left hand was observed to be in a state of healing. There were no more liquid-filled blisters, but the scarring could be seen on his knuckles where the blisters were and on his palm of his hand and the top of his hand and in the webbing of his fingers. The skin had grown back over the top of his hand, however, it was lighter in color than the other surrounding skin. There were no open areas noted. The hospital RN said it looked like Resident #1 may of had something hot poured

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infection for all 69 residents in the facility. 1. The facility failed to ensure PPE was readily available and that staff wore the appropriate PPE (personal protective equipment) while providing care to residents positive for the COVID-19 virus and residents who were exposed to the COVID-19 virus. 2. The facility failed to correctly cohort residents who tested positive for COVID on the hot zone, residents who were exposed to COVID or had an unknown status on the warm zone and residents who were negative for COVID or had not been exposed on the cold zone. An Immediate Jeopardy/Immediate Threat was identified on 11/19/20. While the Immediate Jeopardy was removed on 11/24/20, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's continued monitoring of the plan of removal. The facility was provided the Immediate Jeopardy template on 11/19/20. These failures placed residents at risk of exposure to COVID-19, which could result in serious illness, hospitalization , or even death. Findings included: An interview on 11/19/20 at 9:20 AM with the ADON revealed the facility was having a COVID-19 outbreak and the facility was divided into hot, warm, and cold zones. The facility had a census of 69 residents with 31 residents who were COVID positive and in the hot zone. She said she did not know how many residents were in the warm and cold zones. She said all residents and staff were being tested for COVID on 11/19/20 and the facility was using the point-of-care (POC) screening test (provides results of COVID within minutes of the test being administered). An interview on 11/19/20 at 9:30 AM with the Administrator revealed the facility outbreak started on 11/05/20 when a staff member tested positive for COVID. He said the hall the staff member who tested positive was assigned to work was where residents first tested positive. He said the ADON was the Infection Preventionist for the facility and the facility was referring to CDC guidance for how to respond to the infection. An interview with the Administrator and observation of the hot zone on 11/19/20 from 10:08 AM to 10:15 AM revealed the designated hot zone of the facility was not a closed unit. The Administrator said originally the area was separated by a plastic liner hanging from the ceiling, but the facility was told to take it down. The hot zone was separated from the warm zone by a piece of blue tape on the floor. Observations revealed all facility staff in the hot and warm zones of the facility were wearing white protective suits, goggle/face shields, and N95 masks. Staff in the hot zone (wearing white protective suits, goggle/face shields, and N95 masks) were not donning new or additional PPE or isolation gowns or doffing PPE as they entered and exited rooms to provide care. There was no PPE or PPE bins observed to be available. Multiple staff, approximately 10, were wearing white protective suits, goggle/face shields, and N95 masks and were entering and exiting resident rooms in the warm zone without changing PPE between rooms. Staff were physically moving residents (approximately 6 to 10), resident beds, and resident supplies from the warm zone rooms next to the hot zone to rooms elsewhere in the facility. They did not change their PPE or put on a gown over their white suits when switching rooms. The Administrator was asked if the facility had sufficient PPE and he said yes, it just needed to be put out for staff. The Administrator said the facility had received more positive COVID results on 11/19/20 and the residents in the warm zone next to the hot zone were being moved to expand the hot zone. A resident, unknown name, walked out of the hot zone wearing a mask and proceeded to walk down the warm zone of the facility. An observation and interview on 11/19/20 at 10:33 AM with Resident #1 revealed she was using her walker and moving out of a warm zone room next to the hot zone. She said she was feeling well and tested negative for COVID. She said she was being moved to a new room. An observation on 11/19/20 at 10:35 AM revealed four staff members were transporting resident beds from the warm zone rooms to other rooms in the facility. Six residents, unknown names were placed in the dining room of the facility. They were sitting in their chairs and one resident was in lying in their bed. The residents' belongings were sitting on the floor next to each of them. One of the residents said they were waiting to go to their new room. The warm zone continued down the opposite side of the hall from the hot zone. Rooms F31 and F28 in the warm zone had isolation signs posted on the doors, but there was no PPE available in the warm zone. Staff were wearing full PPE: white suit, N95 mask, and goggles/face shield. The staff did not doff or donn new or additional PPE to enter resident rooms to provide care. An interview on 11/19/20 at 10:55 AM with CNA A revealed she had been employed for a few months at the facility. She was assigned to care for residents in the warm zone. She said she knew which residents were in isolation because they had posted isolation signs on their door. She said staff were not required to change PPE when providing care to the residents and additional PPE was not available. An interview on 11/19/20 at 11:00 AM with LVN B revealed she was assigned to care for residents in the warm zone residents. Residents in isolation had isolation signs posted on the door. She said there were residents in the warm zone who had tested positive for COVID and were in the process of being moved to the hot zone (isolation). The state surveyor asked where roommates of COVID positive residents were moved to. LVN B said the roommate would stay in the room and a COVID negative resident would move in with them. She said staff were supposed to donn and doff PPE to provide care to residents in isolation rooms, but the staff could not do that because the PPE was locked in the ADON's office. An observation on 11/19/20 at 11:05 AM revealed staff in the hot zone were crossing over the blue taped line to interact with staff in the warm zone. An interview on 11/19/20 at 11:10 AM with LVN C revealed residents in the facility were cohorted based on positive or negative COVID results only. She was assigned to care for residents in the warm zone. She said there were no residents who were considered to have an unknown status even if they had been exposed to a COVID positive roommate. She said residents who tested negative were placed with other residents who tested negative regardless of their exposure. She said the facility had 9 additional COVID positive resident results received on 11/19/20. She was wearing full PPE and said staff were supposed to donn and doff PPE between residents, but there was not PPE accessible unless they went to the ADON's office to get it. An interview on 11/19/20 at 12:25 PM with the ADON revealed staff were not required to change PPE when caring for residents in the hot zone unless it was visibly soiled. She said she did not know if any of the residents in the hot zone had other communicable diseases other than COVID. She said staff in the warm zone were supposed to donn and doff PPE anytime they went into an isolation room to provide care. She said PPE was available in her office and it needed to be put for staff. She said the cold zone of the facility was located in the area with no infection and that residents with an unknown COVID status (possible exposure) were placed in private rooms in the cold zone. She said it was the Corporate Nurses' responsibility to perform contact tracing (fundamental activities that involve working with a patient (symptomatic and asymptomatic) who has been diagnosed with [REDACTED]. An interview on 11/19/20 at 1:15 PM with Corporate Nurse D, the Administrator, and the ADON revealed they were not aware staff were not changing PPE between residents when providing care to residents in the warm zone. They said they received COVID positive results for 9 additional residents on 11/19/20. They said residents who had tested negative were still with residents who had tested positive, but resident moves were being performed. They said they only performed POC screening tests and did not follow-up with the PCR (polymerase chain reaction diagnostic test) to confirm results. They said they had not completed contact tracing or root cause analysis to ensure they were cohorting residents based on their exposure status. They said they did not think they had a cold zone because all residents had been exposed. An observation on 11/19/20 at 2:05 PM of the hot zone revealed it was still open and separated from the warm zone with a piece of blue tape on the floor. Staff in the hot zone were putting on their personal backpacks over their isolation gowns while getting ready to leave for the shift. The staff walked to the backdoor, took their backpacks off, laid them on the nurse counter, took their gowns off, put their backpacks back on, and walked out the exit door. The staff did not remove their N95 masks or face shields prior to leaving the hot zone. An interview on 11/19/20 at 2:07 PM with Medication Aide E revealed she was assigned to the warm zone. She was not wearing eye protection over her glasses but did wear an N95 mask and a white suit to enter resident rooms in the warm zone. She said she did not need to wear goggles or a face shield over her glasses. An interview on 11/19/20 at 4:43 PM with CNA F revealed he was assigned to care for residents in the warm zone. He was wearing a white suit, N95 mask, and eye protection. He said he was not required to change his PPE after providing care to the residents. An interview on 11/19/20 at 4:50 PM with LVN G revealed he was assigned to provide care to residents in the warm zone. He said residents who had tested positive were still being moved to the hot zone from the warm zone. He said prior to 11/19/20 he did not wear PPE to provide care to the residents in the warm zone because it was not available. He said today (11/19/20) he was wearing full PPE but was not required to change it after providing care to residents. He said if he heard a resident coughing, then he would put a gown over his white suit before going into that resident's room because coughing was a symptom of COVID. He said the hot zone was not a closed unit and he often had to re-direct COVID positive residents back to the hot zone after they crossed over to the warm zone. An interview and observation on 11/19/20 at 5:55 PM revealed the Administrator, Corporate Nurse D, and other staff were moving residents in the warm zone. The Corporate Nurse D said the facility was trying to create a cold zone and correctly cohort residents based on their exposure to a COVID positive roommate. An observation on 11/20/20 at 9:50 AM revealed the facility had created a cold zone with a separate warm zone and hot zone. Rooms in the cold zone did not have isolation signs posted. Facility staff in the hot zone were wearing full PPE, and staff working and entering resident rooms in the warm zone were only wearing N95 masks. Staff in the cold zone were wearing N95 masks. An interview on 11/20/20 at 10:39 AM with the ADON revealed she was the Infection Preventionist for the facility. She said the facility created a cold zone the night of 11/19 /20 by cohorting residents who did not have a COVID positive roommate. She said the facility had staff who had tested positive for COVID, but no one had contacted them to find out which residents they had cared for. She said she was not responsible for completing contact tracing or root cause analysis. She said she did look at contact tracing on 11/19/20 to determine which residents should be in isolation. She said staff where supposed to wear an isolation gown, goggles/face shield, N95 mask, and gloves while working in the hot zone, but staff were not required to change their PPE when providing care. She said she did not know if any of the residents in the hot zone had influenza or other communicable disease. She said the facility warm zone consisted of residents who had a previous COVID positive roommate. She said staff were supposed to wear an isolation gown, goggles/face shield, N95 mask, and gloves to provide care to a resident in the warm zone. She said staff were supposed to wear an N95 mask, and goggles/face shield to provide care to residents in the cold zone. An interview on 11/23/20 at 11:20 AM with the DON revealed she had been out ill with COVID. She said she had tested positive on 11/11/20 and 11/23/20 was her first day back to work. She said the first person to test positive (11/05/20) was an employee from laundry who had delivered laundry to residents on Station 2. She said facility staff who had worked with the employee were tested , but the residents who were exposed were not placed in quarantine or isolation. She said those residents were placed in isolation after they tested positive for COVID. She said the ADON was the Infection Preventionist for the facility. The DON said she (DON) was responsible for completing contact tracing and she called staff who tested positive to ask them how they thought they became infected with COVID. She said she did not ask the staff who they worked with or took care of at the facility because her understanding was that she was only supposed to ask them how they thought they became infected. She said residents in the cold zone were not exposed to COVID, residents in the warm zone were exposed to COVID, and residents in the hot zone were COVID positive. She said staff in the hot zone were supposed to wear full PPE at all times, staff in the warm zone were supposed to wear an N95 mask and eye protection at all times, and an isolation gown to provide care. Staff in the cold zone were supposed to wear an N95 mask and eye protection at all times. An observation and interview on 11/20/20 at 1:05 PM with CNA H revealed she put on an isolation gown and gloves before going into an isolation room in the warm zone to provide care but did not put on eye protection. She said she was not required to wear eye protection because she was wearing glasses. An interview on 11/21/20 at 12:40 PM with the Administrator revealed the facility no longer had a designated cold zone. He said he did contact tracing and found staff who tested positive had exposed residents to COVID. He said after talking with the COVID positive staff, he felt like all residents had been exposed to COVID. An observation on 11/21/20 at 12:55 PM revealed the facility no longer had a cold zone. All resident rooms had isolation signs posted and PPE was available outside of some of the resident rooms. An interview on 11/21/20 at 1:20 PM with RN I revealed she was assigned to care for residents in the warm zone. She said her last day worked was 11/14/20 and at that time facility staff were not required to wear an isolation gown while providing care to residents who had been exposed to COVID. She said the residents who tested positive were placed in the hot zone. She said she thought COVID had spread through the facility because the facility did not put in proper protocols to contain it. She said one of the issues was the hot zone was not closed. Residents who were COVID positive would wander out of the hot zone and cross over to the rest of the facility. An observation on 11/22/20 at 1:15 PM of the hot zone revealed some staff were not wearing eye protection or an isolation gown. LVN J was assisting Resident #2 with his meal and leaning over his bedside table. She was wearing an N95 mask, face shield, and an isolation gown. LVN J finished assisting the resident, went to the restroom, removed her gown and gloves and performed hand hygiene. The LVN then left the room and proceeded to walk through the hall without putting on another isolation gown. LVN K walked into the same resident's room wearing gloves, an isolation gown, N95 mask, but no eye protection. LVN K removed her gloves, left the room, and carried her gloves down the hall and placed them in the medication cart trash can. She did not perform hand hygiene. An interview on 11/22/20 at 1:20 PM with LVN J revealed staff were not required to wear full PPE while working in the hot zone. An interview on 11/22/20 at 1:23 pm with Corporate Nurse L revealed she was moving PPE to the hot zone. She said staff were only required to wear an isolation gown if they were providing patient care. She said the CDC had issued new guidance (she did not provide the guidance) stating staff working with COVID positive residents were not required to wear full PPE and the staff in the hot zone were in-serviced regarding PPE use on 11/22/20. Review of the CDC guidance on 11/22/20 for the COVID infection in nursing facilities did not reveal new guidance indicating staff caring for residents in the hot zone did not need to wear full PPE. An interview on 11/22/20 at 1:25 PM with LVN K revealed 11/22/20 was her first day working at the facility and she was assigned to work in the hot zone. She said staff were supposed to change their isolation gown, gloves, and perform hand hygiene before leaving a resident's room. She was not wearing eye protection and said the facility had not provided her with any. Additionally, she said the facility had not in-serviced her regarding what PPE was required to provide care to COVID positive residents. An interview on 11/22/20 at 1:40 PM with Medication Aide M revealed 11/22/20 was her first day working at the facility and she was assigned to work in the hot zone. She was wearing an isolation gown, a N95 mask, but no eye protection. She was preparing medications to administer to a resident. She was not wearing eye protection and said the facility had not provided her with any. Additionally, she said the facility had not in-serviced her regarding what PPE was required to provide care to COVID positive residents. An interview on 11/22/20 at 2:05 PM with the Administrator revealed staff working in the hot zone where supposed to wear an isolation gown, gloves, N95 mask, and eye protection. He said staff were supposed to put on a second isolation gown to provide care to a resident and remove it prior to leaving the room. He said he was not aware staff in the hot zone were not wearing eye protection or an extra isolation gown to provide care. Review of the facility's Infection Control and Procedure Manual, dated 2016, reflected: Infection Control. The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. Procedure for Data Collection/Reporting. This facility will use a system of surveillance designed to identify possible communicable diseases or infection before they can spread to other persons in the facility . Surveillance. Essential elements of a surveillance system include .identification of residents at risk for infection .analysis of data that can uncover an outbreak .Resident Placement. 1. Appropriate resident placement is a significant component of isolation precautions. When available, a private room is important to prevent direct or indirect contact transmission .2. When a private room is not available, an infected resident is placed with an appropriate roommate. Residents infected with the same microorganism can usually share a room provided that they are not infected with other potentially transmissible microorganisms .such sharing of rooms, also called cohorting, is especially useful during outbreaks .4. Masks, respiratory protection, eye protection, face shields .are worn by personnel during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions to provide protection of the mucous membranes of the eyes, nose, and mouth .The wearing of masks, eye protection, and face shields in specified circumstances is mandatory .5. Gowns and protective apparel are worn to provide barrier protection and reduce the opportunity for transmission of microorganisms .Gowns are worn to prevent contamination of clothing and to protect the skin of personnel from blood and bodily fluid exposures .2. Gowns are also worn by personnel during the care of patients infected with epidemiologically important microorganisms to reduce the opportunity for transmission of pathogens .when gowns are used for this purpose, they are removed before the personnel leave the resident's environment. Review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated Nov. 4, 2020, reflected: HCP (healthcare personnel) who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. Review of the CDC Definitions of Diagnostic, Screening, and Surveillance Testing for [DIAGNOSES REDACTED]-CoV-2, updated 09/04/20, reflected: Definition of Diagnostic Testing: Diagnostic testing for [DIAGNOSES REDACTED]-CoV-2 is intended to identify current infection in individuals and is performed when a person has signs or symptoms consistent with COVID-19, or when a person is asymptomatic but has recent known or suspected exposure to [DIAGNOSES REDACTED]-CoV-2. Examples of diagnostic testing include testing symptomatic persons, testing persons identified through contact tracing efforts, and testing those who indicate that they were exposed to someone with a confirmed or suspected case of COVID-19. An Immediate Jeopardy/Immediate Threat was identified on 11/19/20. The Administrator was notified of the Immediate Jeopardy on 11/19/20 at 2:50 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 11/23/20 at 8:35 AM and reflected the following: All staff will be in-serviced on the following policies. a. Infection control b. Donning and doffing of PPE c. Cold/warm/hot zone d. Housekeeping Room Detail and Donning/Doffing e. HOT ZONE Route of Travel Facility will immediately test all residents and staff who previously tested negative on POC tests with a PCR test to confirm results, target completion 11/20/2020 @ 5pm. All COVID positive residents will be moved to a HOT ZONE that is behind fire barrier doors to prevent cross contamination, target completion date/time: 11/19/2020 @ 6pm. 1. In-services performed by the ADON and Corporate Nurse D. 2. In-services initiated on 11/19/2020. All staff that were physically available were in-serviced, given handouts and signed they received in-services. Any staff not available were verbally in-serviced via phone by the DON, target completion date/time: 11/19/2020 @ 9pm. 3. Corporate Nurse D and Corporate Nurse L will monitor and follow-up on the implementation and continued practice of all listed in-services. 4. Monitoring will be daily with auditing of practice twice daily for 2 weeks, then re-evaluate practice, refer to Medical Director and Quality Assurance for reduction or continued auditing. 5. Monitoring per Medical Director/QAPI recommendations. Continue auditing for 30 days. 6. All staff will be in-serviced verbally by 9pm on 11/19/2020 and prior to start of next shift, by designated Nurse. Staff will wear appropriate PPE and change PPE between residents. This includes all zones throughout the facility. When staff are interacting with residents, staff will place a layer of PPE, specifically a gown, over their attire. Any staff working in HOT ZONE will don a gown or protective suit and place a second gown over it when in any resident room providing resident care. Staff will doff 2nd layer gown prior to exiting resident room and place in appropriate receptacle. 1. In-services performed by the ADON and Corporate Nurse D. 2. In-services initiated on 11/19/2020. All staff that were physically available were in-serviced, given hand outs and signed they received in-services. Any staff not available was verbally in-serviced via phone by the DON, target completion date/time: 11/19/2020 @ 9pm. 3. Corporate Nurse D and Corporate Nurse L will monitor and follow-up on the implementation and continued practice of all listed in-services. 4. Monitoring will be daily with auditing of practice twice daily for 2 weeks, then re-evaluate practice, refer to Medical Director and Quality Assurance for reduction or continued auditing. 5. Monitoring per Medical Director/QAPI recommendations. Continue auditing for 30 days. 6. All staff will be in-serviced verbally by 9pm on 11/19/2020 and prior to start of next shift, by designated Nurse. During times of PPE shortage/crisis staff may optimize use of PPE when providing direct resident care of resident with same [DIAGNOSES REDACTED].e. strep, flu,[MEDICAL CONDITION].etc.) and those who do not. Established Zones are Hot for positive, Unknown Status, and Negative. Hot Zone will house positive clients. (see facility map). Unknown Status will consist of Clients that were roommates of Client that tested positive or exposed by COVID+ staff member (see facility map). Negative Clients will be cohorted (see facility map). There is only one entrance into the hot zone and a donning area is set up prior to entering. There is only one exit from the hot zone and a doffing area is set up prior to exiting building. Staff will don and doff PPE between residents as in-serviced on Infection Control and Donning/Doffing PPE. 1. In-services performed by the ADON and Corporate Nurse D. 2. In-services initiated on 11/19/2020. All staff that were physically available were in-serviced, given hand outs and signed they received in-services. Any staff not available was verbally in-serviced via phone by the DON, target completion date/time: 11/19/2020 @ 9pm. 3. Corporate Nurse D and Corporate Nurse L will monitor and follow-up on the implementation and continued practice of all listed in-services. 4. Monitoring will be daily with auditing of practice twice daily for 2 weeks, then re-evaluate practice, refer to Medical Director and Quality Assurance for reduction or continued auditing. 5. Monitoring per Medical Director/QAPI recommendations. Continue auditing for 30 days. 6. All staff will be in-serviced verbally by 9pm on 11/19/2020 and prior to start of next shift, by designated Nurse. Housekeeping staff will clean isolation and non-isolation rooms AND change PPE in between these rooms. 1. In-services performed by the ADON and Corporate Nurse D. 2. In-services initiated on 11/19/2020. All staff that were physically available were in-serviced, given hand outs and signed they received in-services. Any staff not available was verbally in-serviced via phone by the DON, target completion date/time: 11/19/2020 @ 9pm. 3. Corporate Nurse D and Corporate Nurse L will monitor and follow-up on the implementation and continued practice of all listed in-services. 4. Monitoring will be daily with auditing of practice twice daily for 2 weeks, then re-evaluate practice, refer to Medical Director and Quality Assurance for reduction or continued auditing. 5. Monitoring per Medical Director/QAPI recommendations. Continue auditing for 30 days. 6. All staff will be in-serviced verbally by 9pm on 11/19/2020 and prior to start of next shift, by designated Nurse. Facility will only cohort residents that are known COVID positive, known COVID negatives as well as only cohorting residents that are of an unknown status. Facility will provide a line listing and contact tracing for the infection in the facility. Line listing and contact tracing will be performed and overseen by the DON and Administrator. Administrator and DON will be monitoring the above processes to ensure completion. Monitoring will occur daily for 30 days and reported to Medical Director/QAPI. Medical Director/QAPI guidelines will determine if further monitoring is needed. All residents have the potential to have been exposed to Coronavirus. Monitoring of the facility's Plan of Removal included the following : Observations conducted on 11/23/20 starting at 9:00 AM and continued through 11/24/20 at 12:00 PM revealed staff wore appropriate PPE per CDC recommendations to provide care to residents in the warm and hot zones of the facility. The facility did not have a cold zone. Interviews and observations were conducted on 11/23/20 starting at 9:00 AM and continued through 11/24/20 at 12:00 PM with 15 staff members from various shifts. The in-services included PPE required to care for residents in the hot zone, warm zone, and cold zone. The hot zone was a closed unit and the facility only had a hot zone and warm zone. The staff members were able to: Verbalize the appropriate PPE required to care for residents and donning and doffing procedure. Verbalize the difference between residents in hot, warm, and cold zones and the importance of keeping the hot zone a closed unit. Interviewed staff members and shifts were: LVN B - worked day shift CNA N - worked all shifts Housekeeping and Laundry Supervisor - worked day shift CNA O - worked day and evening shift CNA P - worked evening shift Activity Director - worked day shift Medication Aide Q - worked all shifts CNA R - worked all shifts Housekeeper S - worked day shift Activities Assistant - worked day shift Medication Aide T - worked all shifts Restorative Aide - worked day and evening shift LVN U - worked day and evening shift LVN V - worked day shift CNA H- worked all shifts Interviews on 11/24/20 at 12:25 PM, 12:30 PM, and 12:35 PM with the DON, ADON, and Administrator revealed they would be working with nursing management to ensure staff were wearing appropriate PPE to care for their assigned residents, the line listing and contact tracing were kept up to date to track the spread of the infection through the facility, and facility infection control measures would be kept in place per the facility plan of removal. Additionally, the ADON/Infection Preventionist would be taking infection control training courses. An Immediate Jeopardy/Immediate Threat was identified on 11/19/20. While the Immediate Jeopardy was removed on 11/24/20, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. The facility was provided the Immediate Jeopardy template on 11/19/20.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, for one (Resident #6) of eight residents reviewed for wound care. 1. The facility failed to provide Resident #6 with an effective pain management program to address wound care to a Stage 4 pressure injury on her sacrum. 2. ADON A failed to stop wound care treatment to Resident #6's Stage 4 pressure injury when the resident displayed signs and symptoms of pain to include grimacing, moaning, crying out, and verbalizing that she was in pain. These failures could affect the seven residents with pressure injuries by placing them at risk for discomfort, pain, and emotional distress. Findings included: Resident #6's MDS assessment, dated 08/12/16, reflected she was a [AGE] year-old female re-admitted to the facility on [DATE]. The resident had severe cognitive impairment and [DIAGNOSES REDACTED]. The resident was totally dependent on staff for ADL care. Resident #6's care plan, dated 08/22/16, reflected a care plan for pain had been developed which reflected to observe and report withdrawal or resistance to care. The care plan did not address pain related to wounds or pre-medicating the resident with pain medication prior to wound care. Resident #6's Physician order [REDACTED]. [MEDICATION NAME]-[MEDICATION NAME] #3 Tablet 300-30mg - two tablets orally as needed for pain twice a day and two tablets orally three times a day for pain. Tylenol with [MEDICATION NAME] #3 Tablet 300-30mg - two tablets by mouth every four hours as needed for pain. An observation on 08/29/16 at 10:00 a.m. revealed ADON A provided wound care for to the Stage 4 pressure injury on Resident #6's sacrum (tailbone), and CNA B and CNA C assisted her. The resident was turned to her left side, and ADON A removed the dressing covering the sacral wound. The resident's tailbone was visible through the wound. Resident #6 grimaced, moaned, and cried out during this care. She also complained of pain in her leg during the care. The resident continued to moan as ADON A cleaned the wound with normal saline and patted the area dry with gauze. The resident cried out, You're hurting me! CNA B stated the resident had been medicated for pain 45 minutes prior to the procedure. CNA C stated Resident #6 usually moaned and complained of pain when she received wound care treatments. ADON A continued with the wound care, and the resident continued to cry out, Oh, Oh! Both CNAs apologized to the resident. ADON A then inserted green foam into the wound, and Resident #6 used her right hand to push ADON A and CNA B's hands away from her wound. Resident #6 stated, Leave me alone. It hurts. Oh! Oh! It hurts. Leave me alone. Get off me. Leave me alone. ADON A told the resident, I'm so sorry, and continued the dressing change. ADON A did not assess the resident's level of pain. CNA B then asked ADON A if she wanted her to see if there was any other pain medication for the resident, and ADON A said, Yes. Next, ADON A attached the [DEVICE] (negative pressure device) to the wound, and the resident continued to try to push ADON A's hand away from her wound. CNA B returned to the room and told ADON A that they would need to stop the wound care because the resident had no more pain medication scheduled. The resident was repositioned and stopped moaning and crying out. The procedure lasted until 10:23 a.m. The following information was retrieved on 06/02/16 from National Pressure Ulcer Advisory Panel (NPUAP) website at http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change: National Pressure Ulcer Advisory (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury Date: April 13, 2016 .The term pressure injury replaces pressure ulcer in the National Pressure Ulcer Advisory Panel Pressure Injury Staging System according to the NPUAP. The change in terminology more accurately describes pressure injuries to both intact and ulcerated skin. .Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location . The following information was retrieved on 09/08/16 at 08:25 a.m. from the Federal Drug Administration website at <http://www.fda.gov/MedicalDevices> : Negative pressure wound therapy: use with care (Article reprinted from Nursing2010, September issue, p.64-66.) NEGATIVE Pressure wound therapy (NPWT) is used to treat acute and chronic wounds. A vacuum source creates continuous or intermittent negative pressure inside the wound to remove fluid, exudates, and infectious materials to prepare the wound for healing and closure.1 NPWT systems consist of a vacuum pump, drainage tubing, a foam or gauze wound dressing, and an adhesive film dressing that covers and seals the wound. Following the observation of Resident #6's wound care, the resident's Physician order [REDACTED]. Tylenol with [MEDICATION NAME] #4 Tablet 300-60 mg ([MEDICATION NAME]-[MEDICATION NAME]) - give two tablets by mouth every four hours as needed for pain; and Tylenol with [MEDICATION NAME] #4 Tablet 300-60mg ([MEDICATION NAME]-[MEDICATION NAME]) - give two tablets by mouth three times a day for pain. An interview on 08/29/16 at 10:23 a.m. with ADON A revealed she did not know Resident #6's level of pain during the wound care. She acknowledged Resident #6 seemed to be in pain during the procedure. At that time, ADON A asked the resident what her level of pain was on a scale from zero to ten with ten being the worst pain experienced. Resident #6 stated her pain was an eight. ADON A stated if a resident was experiencing pain during a procedure, she would normally complete the dressing change to prevent contamination of the wound. She stated she had provided Resident #6 with wound care one time before, and the resident moaned when the sacral area had been touched. She stated this time the resident was having a lot more pain. ADON A stated Resident #6's nurse told her that the resident had received pain medication 30 minutes before she performed wound care on the resident. She stated she did not know what medication the resident had been given. An interview on 08/29/16 at 10:25 a.m. with CNA C revealed she had assisted with wound care for Resident #6 before, and the resident had expressed similar pain, rated an eight out of ten. An observation on 08/29/16 at 11:01 a.m. revealed Resident #6 complained of throbbing pain which she said was a seven out of ten. At the time of this observation, a nurse entered the resident's room. The nurse stated the resident had a new medication order to receive the pain medication, [MEDICATION NAME]. The nurse stated Resident #6 received this new medication following the wound care. The nurse repositioned the resident at that time. Review of Resident #6's MAR for August 2016 revealed on 08/29/16 the resident received Tylenol #3 two tablets at 5:53 a.m. for pain at a level of seven out of ten and a scheduled routine dose of two tablets of Tylenol #3 at 8:00 a.m. There was no further documentation on the MAR indicated [REDACTED]. An interview on 08/30/16 at 5:39 a.m. with the RN Consultant revealed ADON A began performing all wound care on 08/29/16 because the previous Wound Care Nurse, LVN E, stopped working at the facility on 08/26/16. A telephone interview on 08/29/16 at 1:00 p.m. with LVN E revealed Resident #6 sometimes had pain during wound care. She stated the resident usually cursed and got mad when she was turned on her side. She stated she never had to stop wound care to get additional medications for the resident. She stated she did not think Resident #6 liked being on her side, and the resident never complained specifically that she was in pain. An interview on 08/29/16 at 11:07 a.m. with the RN Consultant revealed she had heard of Resident #6's complaint of pain during wound care earlier that morning and an in-service had been initiated on stopping wound care if the resident complained of pain. The facility's current Pain Management, Assessment Scale Policy and Procedure, dated 02/13/07, reflected the following: Policy .Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility . Procedure .Have the resident rate pain on a scale of one to ten with one being the least pain and ten being the worst pain experienced. The policy and procedure did not specifically address when to stop care due to a resident's complaint of pain. An article from the Journal of Orthopaedic Trauma, February 2013 - Volume 27 - Issue 2 - pages 107-112, reflected the following: [MEDICATION NAME] for Removal of [DEVICE]-Assisted Closure Dressings: A Randomized Double-Blinded Placebo-Controlled Trial .[DEVICE]-assisted closure (VAC) is a technique used frequently by orthopedic surgeons to facilitate wound closure. Bedside VAC removal can be a source of great pain for patients .Conclusion: The patients undergoing an extremity wound VAC dressing removal at the bedside should be pretreated with topical [MEDICATION NAME] because it decreases pain and narcotic requirements. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the DON on 08/30/16, reflected seven residents had pressure injuries.

Based on observation, interview and record review, the facility failed to ensure it was free of a medication rate of five percent (5%) or greater. There were two medication errors observed out of 30 opportunities resulting in a 6% medication error rate. Two MAs (MA B and MA D), of four MAs and one LVN observed made two errors during the medication pass for two (Residents #12 and #16) of nine residents observed. 1. MA B failed to administer PRN [MEDICATION NAME] to Resident #12 per physician orders [REDACTED]. 2. MA D failed to administer potassium chloride to Resident #16 as ordered by the physician. An Immediate Jeopardy (IJ) was identified on 02/25/16. While the IJ was removed on 02/26/16, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. The failures placed the 55 residents, who received their medications from MA B and MA D, at risk for stroke, [MEDICAL CONDITION], heart failure, and death. Findings included: 1. An observation on 02/24/16 at 7:25 a.m. revealed MA B checked Resident #12's blood pressure in his left upper arm, which resulted an error message reading. MA B moved the blood pressure cuff to the resident's left forearm and obtained a result of 227/114. MA B stated, That doesn't seem like that (blood pressure reading) is right. MA B placed the blood pressure cuff on the resident's right forearm and obtained a result of 218/118. MA B then administered two tablets of [MEDICATION NAME] CR 60 mg. Review of Resident #12's physician order [REDACTED]. The following was retrieved on 03/12/16 from the U.S. National Library of Medicine MedlinePlus at https://www.nlm.nih.gov/medlineplus/druginfo/meds/a 8.html, which was last revised on 04/15/15, and reflected: [MEDICATION NAME] is used to treat high blood pressure and to control [MEDICAL CONDITION] (chest pain). Review of Resident #12's February 2016 consolidated physician orders [REDACTED]. The following information was retrieved on 03/12/16 from the U.S. National Library of Medicine MedlinePlus at https://www.nlm.nih.gov/medlineplus/druginfo/meds/a 3.html, which was last revised on 02/15/15, and reflected: [MEDICATION NAME] tablets ([MEDICATION NAME]) are used alone or in combination with other medications to treat high blood pressure. Review of Resident #12's MAR, dated 02/24/16 at 8:00 a.m., reflected his blood pressure was 188/93 and MA B initialed administering [MEDICATION NAME] CR 60 mg two tablets. Further review of the MAR indicated [REDACTED] An interview on 02/24/16 at 9:20 a.m. with LVN E, who was Resident #12's charge nurse, revealed MA B told her Resident #12's blood pressure was high, but MA B did not provide her with the actual blood pressure reading. LVN E stated she told MAR B to recheck the resident's blood pressure, and she was going to recheck the blood pressure as well. She stated the resident's blood pressure was high in the morning, and it usually went down after he received his routine blood pressure medications. An interview on 02/24/16 at 9:21 a.m. with MA B revealed she rechecked Resident #12's blood pressure 30 minutes after she administered the [MEDICATION NAME], and his blood pressure was 170/86. MA B was asked what the resident's blood pressure was during medication pass. She looked at a piece of paper, on top of her medication cart, which had several blood pressure readings documented of various residents. After looking at the paper, MA B stated she did not write Resident #12's blood pressure reading. She stated she told the nurse the reading was 200/98. An interview on 02/24/16 at 9:22 a.m. with LVN E revealed she checked Resident #12's blood pressure, and the blood pressure was 166/76. She stated she would call the doctor. LVN E was asked if the resident had a PRN order for [MEDICATION NAME] and LVN E stated, I don't know, let me check. She was then asked, who was responsible for administering PRN [MEDICATION NAME], and she stated the nurse. At 9:33 a.m., LVN E stated she called the doctor and received an order to administer PRN [MEDICATION NAME] 0.1 mg. She stated the PRN [MEDICATION NAME] was not on her NAR so she had to call the doctor. LVN E was informed Resident #12's blood pressure reading was 227/114 during the medication pass. LVN E responded, That's scary. An interview on 02/24/16 at 9:43 a.m. with the DON revealed she was not aware Resident #12's systolic blood pressure was greater than 200. She had seen a blood pressure monitor in the hallway with a systolic blood pressure reading of 186; however, she was not sure which resident's blood pressure recording it was, but she told the staff to recheck the blood pressure. She revealed the facility procedure was for the MA to take the resident's blood pressure prior to administering blood pressure medication, and the MA was responsible for notifying the nurse if the blood pressure was high. If the blood pressure was high, it should be rechecked in 30 minutes. The DON explained that the nurse was made aware of the high blood pressure reading, so she could assess the resident and give direction to the MA on what to do. She stated PRN [MEDICATION NAME] could be on the MAR used by the MAs or the NAR used by the nurses. The facility's current Blood Pressure Medication Administration policy and procedure, dated 02/24/16, reflected the following: When a resident has a blood pressure medication ordered, the person administering the medication must take the blood pressure prior to administering the medication. If the blood pressure is abnormal especially on the high side, the person administering the medication must report to the charge nurse. If blood pressure is high the charge nurse must: - Assess the resident and take the blood pressure to identify if the resident is symptomatic and to obtain a second blood pressure. The charge nurse will verify the original blood pressure is documented. - Review the medications to verify the resident has a PRN medication for high blood pressure and that there are parameters ordered by the physician. - Ensure the medication administration person has given the routine medication if ordered. - If the resident is symptomatic, contact the physician and request further evaluation. - If the blood pressure has not decreased with the routine medication, administer the prn medication and continue to monitor. Report the high blood pressure to the physician - When ordering a PRN Blood Pressure medication, obtain parameters with instruction when to contact the physician and, place the PRN blood pressure medication on the NAR so to alert the nurse to assess before giving the mediation (sic) and follow up with blood pressures to verify the effectiveness of the medication. The facility's current Brachial Blood Pressure policy and procedure, dated 2003 reflected the following: .15. Document readings. Report abnormal high or low results to the primary nurse/physician immediately The facility's current Medication Administration Procedures policy, dated 2003, reflected the following: .13. Pulse and blood pressure are to be monitored and charted where applicable . The facility's current, undated When to Call the Doctor policy and procedure reflected the physician should be notified when the resident's systolic blood pressure was greater than 200 or the resting pulse was less than 55. The facility's current CMAs Expectations policy and procedure, dated 2003, reflected the following: . Administer PRN (as needed) medications with permission of a licensed nurse - Monitor and report any issues with availability of medications to the charge nurse 2. An observation on 02/24/16 at 8:05 a.m. revealed MA D administered one tablet of multi-vitamin with minerals, Oyster Shell Calcium 500 mg + Vitamin D one tablet, [MEDICATION NAME] 50 mg one tablet, [MEDICATION NAME] 300 mg one tablet, Neudexta 20-10 mg one tablet, [MEDICATION NAME] XR 28 mg one tablet, [MEDICATION NAME] 20 mg one tablet, and [MEDICATION NAME] 5 mg one tablet to Resident #16. Review of Resident #16's physician's orders [REDACTED]. On 02/25/16 at 9:45 a.m. MA D was shown Resident #16's MARs dated 02/24/16 where he initialed that he had administered potassium 20 meq at 8:00 a.m. MA D went through all Resident #16's blister packs of medications, in his medication cart, and he stated Resident #16 did not have a blister pack for the potassium. He stated it was an oversight on his part regarding the potassium being initialed as given. The following information from Nursing 2013 Drug Handbook, Lippincott, Williams & Wilkins, 33rd Edition, Copyright 2013, pages 1102-1104, reflected potassium chloride was used to treat [DIAGNOSES REDACTED] (a deficiency of potassium in the bloodstream). 3. An interview on 02/24/16 at 7:46 a.m. with MA B revealed she and MA D, who both worked on the day shift, passed medications to all of the residents except for the residents who received medications via their [DEVICE]s. 4. An IJ was identified on 02/25/16 at 3:45 p.m. The facility's Executive Director, DON, Corporate Nurse and CEO were notified at that time and a Plan of Removal was requested. 5. The facility's Plan of Removal was accepted on 02/26/16 at 3:15 p.m. and contained the following: The Medical Director was contacted by the facility staff, about all three residents and the events on 02/25/16 at 3:30 p.m. Assessments were completed on Residents' #3, #12 and #16 and no adverse findings were identified. These assessments were completed on 02/25/16 by 4:00 p.m. On 02/26/16 MA B was placed on investigatory suspension. On 02/25/16 MA D was terminated. On 02/26/16 MA C was placed on investigatory suspension. An in-service was conducted, by the DON, on 02/26/16 at 1:00 p.m., on BP parameter protocol. This in-service included the weekend staff. An in-service was conducted, by the Corporate Nurse, on 02/24/16 and 02/25/16, on checking and documenting BP's. These in-services included return demonstrations. An in-service was conducted, by the Corporate Nurse, on 02/24/16 and 02/25/16, with the MAs, on the procedures of a medication pass. This training included, administering regularly prescribed medications, documentation of the administered medications, administering of PRN medications with the permission of the charge nurse, observation and reporting of reactions and side effects of medications to the charge nurse, along with the reporting and documentation procedures of when the medication protocol is outside of its required parameters. This in-service was competency based and completed by 02/26/16 at 8:00 a.m. In-services were conducted by the MDS Nurse on Medication Administration Procedures. These in-services were completed by 02/26/16 at 3:00 p.m. An in-service was conducted by the Corporate Nurse, on MA expectations. This in-service was completed by 02/26/16 at 1:30 p.m. An in-service was conducted by the Corporate Nurse, on Adverse Drug Reaction Monitoring. This in-service was completed by 02/26/16 at 3:00 p.m. The DON, ADON A, ADON I and LVN H conducted an audit to identify any other adverse drug events and to identify any other discrepancies in medication administration during February 2016. The audit would be completed by 02/26/16 at 8:00 a.m. The DON or her designee would conduct Medication Administration Competencies on all nursing staff responsible for administering medications. This would be completed by 02/26/16 at 1:00 p.m. The Medical Director will be involved in the QA Process and ongoing review on the plan with input on any revisions needed. The DON or designee will observe at least 25 medications being administered on random residents. This medication pass will include at least one resident who has a [DIAGNOSES REDACTED]. The medication administration observation will include observation of at least one medication aide. The observations will be conducted at least five times a week and ongoing education will be provided as necessary. The QAPI steering committee will review the current plan during the regularly scheduled meetings and will revise as needed. 6. Review of a training presented on 02/26/16 revealed the following: Medication Aide Instruction on what to when a vial (sic) sign is outside the parameter ordered by the physician: - Obtain the vital sign - Determine the instruction to verify if the routine medication can be given - If acceptable and ordered, give the routine medication ONLY IF IT IS APPROPRIATE - If you are to hold the medication, do so and document the vital sign, and who you informed - If in the case a blood pressure is over the parameter ordered and there is an indication to give PRN medication, the med aide must inform the charge nurse immediately: - If you document that you informed the charge nurse, make sure that you in fact do inform the nurse. The resident has placed their lives in your hands and it is your responsibility to keep them safe - After all communication is given review what you have documented to ensure you have taken all steps to provide the appropriate care. 7. Review of the Medication Administration Record [REDACTED]. The audit reflected medications errors occurred for 11 residents in the facility. 8. Review of lists provided the corporate nurse on 02/28/16 reflected 13 residents had physician orders [REDACTED]. 9. An interview on 02/26/16 at 3:00 p.m. with the Medical Director revealed he was made aware of the IJ on 02/25/16. When asked what he felt caused the IJ he revealed, It's one of my pet peeves, communication. How can you take care of a resident if the MA doesn't communicate with the nurse? He stated the facility and he would discuss this issue in QA and come up with a solution. An interview on 02/28/16 at 11:30 a.m. with the Administrator revealed she thought the IJ was the result of the MAs not following proper procedures for administering medications. She stated she would begin monitoring the DONs medication monitoring audits. An interview on 02/27/16 at 8:20 a.m. with the DON revealed she thought the IJ was caused because, We weren't following our policies and procedures for administering medications and following our physician orders. Therefore, we placed our residents at risk. The DON stated she felt since the CMAs were certified; they were competent. She stated she would have to follow-up more and make sure they were competent. The DON stated she had been doing random medication passes with the MAs but will have to look at their documentation after their medication pass. 10. Interviews were conducted with staff between the dates of 02/26/16, beginning at 3:35 p.m. through 02/29/16 at 10:00 a.m. with the following staff: MA J, MA O, MA P, LVN E, LVN F, LVN G, LVN K, LVN L, LVN N and RN M. All of the MAs stated they had received in-services regarding medication pass, how to take blood pressures, blood pressure medications, what to do when the blood pressure was elevated, notifying the charge nurse when the vital signs were out of the blood pressure parameters. After they notified the charge nurse they were to document in the resident's clinical record what the vital signs were, action taken and which nurse they notified. If a scheduled medication was not on their cart they were to notify the charge nurse and document in the resident's clinical record. All nurses who were interviewed stated they received in-services on medication pass and blood pressure parameters. The nurses' stated if the MAs were to tell them a resident's blood pressure was high, they would go and recheck the blood pressure themselves. They would assess the resident and document their findings. They would administer PRN blood pressure medication available and notify the physician if the medication was not effective. If a MA told the nurse a routine medication was not available on their medication cart, they would retrieve a dose from the facility's emergency kit (e-kit) and give it to the MA for administration. They would then notify the pharmacy so the medication could be delivered. 11. An interview on 02/24/16 at 7:46 a.m. with MA B revealed she, MA C, and MA D passed medications to all the residents except for the residents that had feeding tubes. 12. While the IJ was removed on 02/29/16, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. 13. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the DON on 02/25/16, reflected the census was 61. Therefore, the two MAs administered medication to 55 residents.

Based on observation, interview and record review, the facility failed to ensure residents were free of any significant medication errors for three (Residents #3, #12 and #16) of 20 residents reviewed for medications. 1. MA B failed to administer PRN [MEDICATION NAME] to Resident #12 when the resident's blood pressure was 227/114 and failed to notify LVN E of Resident #12's blood pressure reading during the medication pass. 2. The facility failed to ensure PRN [MEDICATION NAME] was administered to Resident #12, when the resident's blood pressure met the parameters for administration of PRN [MEDICATION NAME], 39 times during the month of February 2016. 3. MA B failed to notify the charge nurse after she held Resident #3's [MEDICATION NAME] 16 times during the month of February 2016. 4. MA C failed to hold [MEDICATION NAME] per physician orders [REDACTED]. 5. MA B failed to administer potassium chloride to Resident #16's per physician orders. An Immediate Jeopardy (IJ) was identified on 02/25/16. While the IJ was removed on 02/26/16, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. The failures placed the 55 residents, who received their medications from MA B, MA C, and MA D, at risk for stroke, hypotensive epsiodes, and death. Findings included: 1. Resident #12's MDS assessment, dated 12/08/15, reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #12's undated care plan reflected a care plan addressing the resident's [DIAGNOSES REDACTED]. The care planned interventions included giving antihypertensive medications as ordered; monitoring for side effects such as orthostatic [MEDICAL CONDITION] and increased heart rate ([MEDICAL CONDITION] and effectiveness; monitoring and recording side effects of medications; and reporting any high readings outside of the parameters to the physician. Review of Resident #12's physician order [REDACTED]. The following was retrieved on 03/12/16 from the U.S. National Library of Medicine MedlinePlus at https://www.nlm.nih.gov/medlineplus/druginfo/meds/a 8.html, which was last revised on 04/15/15, and reflected: [MEDICATION NAME] is used to treat high blood pressure and to control [MEDICAL CONDITION] (chest pain). Review of Resident #12's February 2016 consolidated physician orders [REDACTED]. The following information was retrieved on 03/12/16 from the U.S. National Library of Medicine MedlinePlus at https://www.nlm.nih.gov/medlineplus/druginfo/meds/a 3.html, which was last revised on 02/15/15, and reflected: [MEDICATION NAME] tablets ([MEDICATION NAME]) are used alone or in combination with other medications to treat high blood pressure. Review of Resident #12's vital sign sheets dated February 2016 revealed the following elevated BP readings: 02/01/16 9:56 a.m. - BP 159/87 5:13 p.m. - BP 156/76 02/02/16 9:39 p.m. - BP 168/88 02/03/16 6:29 a.m. - BP 160/79 9:31 a.m. - BP 157/81 4:06 p.m. - BP 154/67 8:45 p.m. - BP 156/76 02/04/16 6:07 a.m. - BP 166/92 4:29 p.m. - BP 155/86 02/05/16 6:03 a.m. - BP 162/90 02/06/16 6:21 a.m. - BP 165/92 7:18 a.m. - BP 152/88 02/08/16 4:31 p.m. - BP 166/67 02/09/16 6:09 a.m. - BP 162/88 02/10/16 5:48 a.m. - BP 160/83 9:40 a.m. - BP 156/89 02/11/16 5:51 a.m. - BP 160/90 9:41 a.m. - BP 168/72 1:18 p.m. - BP 152/77 02/12/16 5:42 a.m. - BP 165/87 9:27 a.m. - BP 156/80 02/13/16 6:13 a.m. - BP 168/84 9:15 a.m. - BP 156/86 02/15/16 7:03 a.m. - BP 164/82 02/16/16 6:01 a.m. - BP 170/86 7:13 a.m. - BP 155/79 8:02 p.m. - BP 161/73 02/17/16 5:45 a.m. - BP 170/85 02/18/16 5:32 a.m. - BP 165/85 8:51 a.m. - BP 166/87 1:25 p.m. - BP 160/89 02/19/16 9:51 p.m. - BP 178/89 02/20/16 6:01 a.m. - BP - 170/86 7:21 a.m. - BP - 156/82 02/22/16 7:02 a.m. - BP - 155/84 8:52 p.m. - BP - 153/77 02/23/16 5:56 a.m. - BP - 175/96 9:03 a.m. - BP -152/75 8:13 p.m. - BP - 176/86 02/24/16 6:02 a.m. - BP - 152/86 8:27 a.m. - BP - 188/93 8:50 a.m. - BP - 166/67 Resident #12's February 2016 MAR reflected the resident had not received the [MEDICATION NAME] for the elevated blood pressure on the above dates. Resident #12's Nursing Progress Notes, dated 02/01/16 through 02/23/16, reflected neither the MAs or the nurses documented in the progress notes that the resident's blood pressure was elevated. An observation on 02/24/16 at 7:25 a.m. revealed MA B checked Resident #12's blood pressure in his left upper arm, which resulted an error message reading. MA B moved the blood pressure cuff to the resident's left forearm and obtained a result of 227/114. MA B stated, That doesn't seem like that (blood pressure reading) is right. MA B placed the blood pressure cuff on the resident's right forearm and obtained a result of 218/118. MA B then administered two tablets of [MEDICATION NAME] CR 60 mg. Review of Resident #12's MAR, dated 02/24/16 at 8:00 a.m., revealed his blood pressure was 188/93 and MA B initialed administering [MEDICATION NAME] CR 60 mg two tablets. Further review of the MAR revealed the PRN physician order [REDACTED]. An interview on 02/24/16 at 9:21 a.m. with MA B revealed she rechecked Resident #12's blood pressure 30 minutes after she administered the [MEDICATION NAME], and his blood pressure was 170/86. MA B was asked what the resident's blood pressure was during medication pass. She looked at a piece of paper, on top of her medication cart, which had several blood pressure readings documented of various residents. After looking at the paper, MA B stated she did not write Resident #12's blood pressure reading. She stated she told the nurse the reading was 200/98. An interview on 02/24/16 at 9:20 a.m. with LVN E, who was Resident #12's charge nurse, revealed MA B told her Resident #12's blood pressure was high, but MA B did not provide her with the actual blood pressure reading. LVN E stated she told MA B to recheck the resident's blood pressure, and she was going to recheck the blood pressure as well. She stated the resident's blood pressure was high in the morning, and it usually went down after he received his routine blood pressure medications. Resident #12's February 2016 vital signs sheet reflected on 02/24/16 at 6:02 a.m. the resident's blood pressure was 152/86; at 8:27 a.m. the blood pressure was 188/93; and 8:50 a.m. the blood pressure was 166/67. Resident #12's February MA MAR reflected [MEDICATION NAME] was not administered to the resident on 02/24/16 as of 9:20 a.m. An interview on 02/24/16 at 9:22 a.m. with LVN E revealed she checked Resident #12's blood pressure, and the blood pressure was 166/76. She stated she would call the doctor. LVN E was asked if the resident had a PRN order for [MEDICATION NAME] and LVN E stated, I don't know, let me check. She was then asked, who was responsible for administering PRN [MEDICATION NAME], and she stated the nurse. At 9:33 a.m., LVN E stated she called the doctor and received an order to administer PRN [MEDICATION NAME] 0.1 mg. She stated the PRN [MEDICATION NAME] was not on her NAR so she had to call the doctor. LVN E was informed Resident #12's blood pressure reading was 227/114 during the medication pass. LVN E responded, That's scary. An interview on 02/24/16 at 9:43 a.m. with the DON revealed she was not aware Resident #12's systolic blood pressure was greater than 200. She had seen a blood pressure monitor in the hallway with a systolic blood pressure reading of 186; however, she was not sure which resident's blood pressure recording it was, but she told the staff to recheck the blood pressure. She revealed the facility procedure was for the MA to take the resident's blood pressure prior to administering blood pressure medication, and the MA was responsible for notifying the nurse if the blood pressure was high. If the blood pressure was high, it should be rechecked in 30 minutes. The DON explained that the nurse was made aware of the high blood pressure reading, so she could assess the resident and give direction to the MA on what to do. She stated PRN [MEDICATION NAME] could be on the MAR used by the MAs or the NAR used by the nurses. An interview on 02/24/16 at 12:55 p.m. with ADON A revealed the MAs on the day and evening shifts documented the residents' vital signs which included blood pressure and pulse. The MAs took the residents' blood pressures prior to administering blood pressure medications, and she stated, The rule of thumb is, if the BP is greater than 150/90 the MA notifies the nurse. An interview on 02/24/16 at 1:08 p.m. with MA B revealed she considered a blood pressure reading of 160s/90ish to be high and would need to be reported to the nurse. An interview on 02/24/16 at 3:20 p.m. with MA C revealed if a resident's blood pressure was greater than 140/80 then he would notify the nurse. He stated he had not documented in the nursing progress notes that he notified the nurse. An interview on 02/24/16 at 3:30 p.m. with LVN F, who was the evening shift charge nurse for Resident #12, revealed she was not aware Resident #12's blood pressure had been high. LVN F states she told MA C last night if he needed to tell her something about a resident that he needed to write it down and hand it to her because she might not hear him if she was doing something else. LVN F stated if the MA told a resident's blood pressure was high, she would retake the resident's blood pressure with a manual cuff because she did not trust machines. An interview on 02/25/16 at 10:05 a.m. with the Medical Director, who was Resident #12's attending physician, revealed MA B should have told the nurse when the resident's blood pressure was was 227/114. He stated, That's not right. 2. Resident #3's MDS assessment, dated 12/02/15, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #3's undated care plan reflected a care plan addressing the resident's history of hypertension and low heart rate. The care planned goal was for the resident not experience any complications related to hypertension or low pulse (heart) rate. The care planned interventions included administering medications as ordered; take the blood pressure and pulse prior to giving medications; following the parameters to hold if less than 110/60; and to report negative findings to the Medical Director of Nurse Practitioner. Resident #3's February 2016 consolidated physician orders [REDACTED]. Resident #3's February 2016 MAR reflected the MAs held the 9:00 a.m. [MEDICATION NAME] dose on 02/01/16, 02/02/16, 02/03/16, 02/04/16, 02/09/16, 02/10/16, 02/11/16, 02/12/16, 02/15/16, 02/16/16, 02/17/16, 02/19/16, 02/22/16, 02/23/16, 02/24/16 and 02/25/16. There were no vital signs documented on the MAR (next to the [MEDICATION NAME] entry) and there was no indication why the medication was held. The MAR reflected MA B held 15 of the 16 doses. MA C administered the 5:00 p.m. [MEDICATION NAME] dose on the following dates when Resident #3's heart rate (pulse) was less than 60: 02/05/16 - HR 50 02/08/16 - HR 53 02/09/16 - HR 48 02/12/16 - HR 48 02/23/16 - HR 49. An interview on 02/26/16 at 8:15 a.m. with MA B revealed she held Resident #3's [MEDICATION NAME] because the resident's pulse was low. She stated, I told the nurse to call the doctor because her (Resident #3's) blood pressure was so high. Resident #3's Nursing Progress Notes, dated 02/05/16 through 02/23/16, did not reflect MA B or MA C notified the nurse when they held Resident #3's 9:00 a.m. and/or 5:00 p.m. doses of [MEDICATION NAME]. After reviewing Resident #3's February 2016 MAR with MA C on 02/25/16 at 3:10 p.m., MA C stated he did not know why he gave the [MEDICATION NAME] when the resident's heart rate was below 60. He acknowledged he should have held the [MEDICATION NAME]. Resident #3's February 2016 Physician order [REDACTED]. Resident #3's February 2016 MAR reflected MA B held the 9:00 a.m. [MEDICATION NAME] HCT dose on 02/01/16, 02/02/16, 02/03/16, and 02/09/16. Resident #3's Nurses' Notes, dated 02/01/16 at 10:41 a.m., reflected [MEDICATION NAME] HCT was held due to the resident's heart rate of 52. The resident's blood pressure was 116/75. This note was signed by MA B. The medication should not have been held on this date. Resident #3's Nurses' Notes, dated 02/02/16 at 10:28 a.m., reflected [MEDICATION NAME] HCT was held due to the resident's heart rate of 53. The resident's blood pressure was 118/77. The entry was signed by MA B. The medication should not have been held. Resident #3's Nurses' Notes, dated 02/03/16 at 10:42 a.m., reflected [MEDICATION NAME] HCT was held due to the resident's heart rate of 55. The resident's blood pressure was 173/77. The entry was signed by MA B. The medication should not have been held. Resident #3's Nurses' Notes, dated 02/09/16 at 10:57 a.m., reflected [MEDICATION NAME] HCT was held due to the resident's heart rate of 55. The blood pressure reading was not recorded. The entry was signed by MA B. The medication should not have been held. An interview on 02/25/16 at 1:40 p.m. with LVN G revealed she had been Resident #3's nurse, on the day shift, and was not aware MA B had been holding his 9:00 a.m. [MEDICATION NAME] doses. She stated when a MA told her a medication was held she would chart it in the resident's progress notes. An interview on 02/25/16 at 3:20 p.m. with the DON revealed she was not aware MA C had held Resident #3's [MEDICATION NAME]. She noticed this morning that MA B was holding Resident #3's [MEDICATION NAME]. The DON thought the [MEDICATION NAME] was being held because of a low pulse, but she stated the pulse was not documented on the MAR. She stated she planned to review Resident #3's [MEDICATION NAME] orders with MA B. The DON stated the MAs should tell the nurse when a medication was held, and the nurse should call the physician if a medication was held more than three times. The DON stated the MARs were not monitored, When the MARs were on paper, I could just flip through the MARs and TARS and see what was being done. She stated she had done a few medication passes with MA B. On 02/27/16 at 7:45 a.m., the Corporate Nurse was made aware MA B had held Resident #3's [MEDICATION NAME] on four separate occasions in February 2016, due to a decreased heart rate. She was informed that on 02/03/16 MA B held the 9:00 a.m. [MEDICATION NAME] because the resident's heart rate was 55 and then administered [MEDICATION NAME] because the resident's blood pressure was 173/77. The Corporate Nurse stated they had already decided to terminate MA B. Review of Nursing 2015 Drug Handbook, Wolters Kluwer, 35th Edition, Copyright 2015, pages 1449-1451, reflected [MEDICATION NAME] was used to treat Hypertension. Caution patient against abruptly stopping drug. Review of Nursing 2015 Drug Handbook, Wolters Kluwer, 35th Edition, Copyright 2015, pages 1440-1441, reflected [MEDICATION NAME] was used to treat Hypertension. 3. Resident #16's MDS assessment, dated 12/12/15, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #16's lab result dated 02/23/16 reflected a potassium level of 3.4. Further review of this lab report reflected the potassium reference ranges were 3.5-5.1. Resident #16's physician's orders [REDACTED]. An observation on 02/24/16 at 8:05 a.m. revealed MA D administered multi-vitamin with minerals, Oyster Shell Calcium 500 mg + Vitamin D, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 300 mg, Neudexta 20-10 mg, [MEDICATION NAME] XR 28 mg, [MEDICATION NAME] 20 mg, and [MEDICATION NAME] 5 mg to Resident #16. On 02/25/16 at 9:45 a.m. MA D was shown Resident #16's MAR dated 02/24/16. He initialed he had administered potassium 20 meq at 8:00 a.m. MA D went through all Resident #16's blister packs of medications, in his medication cart. MA D revealed, She (Resident #16) doesn't even have a blister pack for the Potassium. It was an oversight on my part (that the potassium was charted as administered). The surveyor asked if he had administered Resident #16's medications this morning and he revealed he had. He was asked if he documented that he had administered potassium to the resident this morning and he revealed he had. That was an oversight too, on my part. Review of Nursing 2015 Drug Handbook, Wolters Kluwer, 35th Edition, Copyright 2015, pages 1157-1158, reflected potassium chloride was used to treat [DIAGNOSES REDACTED]. An interview with the DON on 02/25/16 at 12:00 PM revealed she had staff administer potassium chloride 20 meq from the facility's emergency kit to Resident #16. 4. The facility's current Blood Pressure Medication Administration policy and procedure, dated 02/24/16, reflected the following: When a resident has a blood pressure medication ordered, the person administering the medication must take the blood pressure prior to administering the medication. If the blood pressure is abnormal especially on the high side, the person administering the medication must report to the charge nurse. If blood pressure is high the charge nurse must: - Assess the resident and take the blood pressure to identify if the resident is symptomatic and to obtain a second blood pressure. The charge nurse will verify the original blood pressure is documented. - Review the medications to verify the resident has a PRN medication for high blood pressure and that there are parameters ordered by the physician. - Ensure the medication administration person has given the routine medication if ordered. - If the resident is symptomatic, contact the physician and request further evaluation. - If the blood pressure has not decreased with the routine medication, administer the prn medication and continue to monitor. Report the high blood pressure to the physician - When ordering a PRN Blood Pressure medication, obtain parameters with instruction when to contact the physician and, place the PRN blood pressure medication on the NAR so to alert the nurse to assess before giving the mediation (sic) and follow up with blood pressures to verify the effectiveness of the medication. AND .Document Document Document!!!!! The facility's current Brachial Blood Pressure policy and procedure, dated 2003 reflected the following: .15. Document readings. Report abnormal high or low results to the primary nurse/physician immediately Review of the current facility policy and procedure Medication Administration Procedures dated 2003 reflected, .13. Pulse and blood pressure are to be monitored and charted where applicable . The facility's current Medication Administration Procedures policy, dated 2003, reflected the following: .13. Pulse and blood pressure are to be monitored and charted where applicable . The facility's current CMAs (sic) Expectations policy and procedure, dated 2003, reflected the following: . Administer PRN (as needed) medications with permission of a licensed nurse - Monitor and report any issues with availability of medications to the charge nurse 5. An IJ was identified on 02/25/16 at 3:45 p.m. The facility's Executive Director, DON, Corporate Nurse and CEO were notified at that time and a Plan of Removal was requested. 6. The facility's Plan of Removal was accepted on 02/26/16 at 3:15 p.m. and contained the following: The Medical Director was contacted by the facility staff, about all three residents and the events on 02/25/16 at 3:30 p.m. Assessments were completed on Residents' #3, #12 and #16 and no adverse findings were identified. These assessments were completed on 02/25/16 by 4:00 p.m. On 02/26/16 MA B was placed on investigatory suspension. On 02/25/16 MA D was terminated. On 02/26/16 MA C was placed on investigatory suspension. An in-service was conducted, by the DON, on 02/26/16 at 1:00 p.m., on BP parameter protocol. This in-service included the weekend staff. An in-service was conducted, by the Corporate Nurse, on 02/24/16 and 02/25/16, on checking and documenting BP's. These in-services included return demonstrations. An in-service was conducted, by the Corporate Nurse, on 02/24/16 and 02/25/16, with the MAs, on the procedures of a medication pass. This training included, administering regularly prescribed medications, documentation of the administered medications, administering of PRN medications with the permission of the charge nurse, observation and reporting of reactions and side effects of medications to the charge nurse, along with the reporting and documentation procedures of when the medication protocol is outside of its required parameters. This in-service was competency based and completed by 02/26/16 at 8:00 a.m. In-services were conducted by the MDS Nurse on Medication Administration Procedures. These in-services were completed by 02/26/16 at 3:00 p.m. An in-service was conducted by the Corporate Nurse, on MA expectations. This in-service was completed by 02/26/16 at 1:30 p.m. An in-service was conducted by the Corporate Nurse, on Adverse Drug Reaction Monitoring. This in-service was completed by 02/26/16 at 3:00 p.m. The DON, ADON A, ADON I and LVN H conducted an audit to identify any other adverse drug events and to identify any other discrepancies in medication administration during February 2016. The audit would be completed by 02/26/16 at 8:00 a.m. The DON or her designee would conduct Medication Administration Competencies on all nursing staff responsible for administering medications. This would be completed by 02/26/16 at 1:00 p.m. The Medical Director will be involved in the QA Process and ongoing review on the plan with input on any revisions needed. The DON or designee will observe at least 25 medications being administered on random residents. This medication pass will include at least one resident who has a [DIAGNOSES REDACTED]. The medication administration observation will include observation of at least one medication aide. The observations will be conducted at least five times a week and ongoing education will be provided as necessary. The QAPI steering committee will review the current plan during the regularly scheduled meetings and will revise as needed. 7. Review of a training presented on 02/26/16 revealed the following: Medication Aide Instruction on what to when a vial (sic) sign is outsi

Based on interview and record review, it was determined the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident for three (Residents #3, #12, and #16) of 20 residents reviewed for pharmacy services. 1. MA B failed to administer PRN clonidine to Resident #12 when the resident's blood pressure was 227/114 and failed to notify LVN E of Resident #12's blood pressure reading during the medication pass. 2. The facility failed to ensure PRN clonidine was administered to Resident #12, when the resident's blood pressure met the parameters for administration of PRN clonidine, 39 times during the month of February 2016. 3. MA B failed to notify the charge nurse after she held Resident #3's verapamil 16 times during the month of February 2016. 4. MA C failed to hold verapamil per physician orders [REDACTED]. 5. MA B failed to administer potassium chloride to Resident #16's per physician orders. An Immediate Jeopardy (IJ) was identified on 02/25/16. While the IJ was removed on 02/29/16, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. The failures placed the 55 residents, who received their medications from MA B, MA C, and MA D, at risk for stroke, hypotensive episodes, and death. Findings included: 1. Resident #12's MDS assessment, dated 12/08/15, reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #12's undated care plan reflected a care plan addressing the resident's [DIAGNOSES REDACTED]. The care planned interventions included giving antihypertensive medications as ordered; monitoring for side effects such as orthostatic hypotension and increased heart rate (tachycardia) and effectiveness; monitoring and recording side effects of medications; and reporting any high readings outside of the parameters to the physician. Review of Resident #12's physician order [REDACTED]. The following was retrieved on 03/12/16 from the U.S. National Library of Medicine MedlinePlus at https://www.nlm.nih.gov/medlineplus/druginfo/meds/a 8.html, which was last revised on 04/15/15, and reflected: Nifedipine is used to treat high blood pressure and to control angina (chest pain). Review of Resident #12's February 2016 consolidated physician orders [REDACTED]. The following information was retrieved on 03/12/16 from the U.S. National Library of Medicine MedlinePlus at https://www.nlm.nih.gov/medlineplus/druginfo/meds/a 3.html, which was last revised on 02/15/15, and reflected: Clonidine tablets (Catapres) are used alone or in combination with other medications to treat high blood pressure. Review of Resident #12's vital sign sheets dated February 2016 revealed the following elevated BP readings: 02/01/16 9:56 a.m. - BP 159/87 5:13 p.m. - BP 156/76 02/02/16 9:39 p.m. - BP 168/88 02/03/16 6:29 a.m. - BP 160/79 9:31 a.m. - BP 157/81 4:06 p.m. - BP 154/67 8:45 p.m. - BP 156/76 02/04/16 6:07 a.m. - BP 166/92 4:29 p.m. - BP 155/86 02/05/16 6:03 a.m. - BP 162/90 02/06/16 6:21 a.m. - BP 165/92 7:18 a.m. - BP 152/88 02/08/16 4:31 p.m. - BP 166/67 02/09/16 6:09 a.m. - BP 162/88 02/10/16 5:48 a.m. - BP 160/83 9:40 a.m. - BP 156/89 02/11/16 5:51 a.m. - BP 160/90 9:41 a.m. - BP 168/72 1:18 p.m. - BP 152/77 02/12/16 5:42 a.m. - BP 165/87 9:27 a.m. - BP 156/80 02/13/16 6:13 a.m. - BP 168/84 9:15 a.m. - BP 156/86 02/15/16 7:03 a.m. - BP 164/82 02/16/16 6:01 a.m. - BP 170/86 7:13 a.m. - BP 155/79 8:02 p.m. - BP 161/73 02/17/16 5:45 a.m. - BP 170/85 02/18/16 5:32 a.m. - BP 165/85 8:51 a.m. - BP 166/87 1:25 p.m. - BP 160/89 02/19/16 9:51 p.m. - BP 178/89 02/20/16 6:01 a.m. - BP - 170/86 7:21 a.m. - BP - 156/82 02/22/16 7:02 a.m. - BP - 155/84 8:52 p.m. - BP - 153/77 02/23/16 5:56 a.m. - BP - 175/96 9:03 a.m. - BP -152/75 8:13 p.m. - BP - 176/86 02/24/16 6:02 a.m. - BP - 152/86 8:27 a.m. - BP - 188/93 8:50 a.m. - BP - 166/67 Resident #12's February 2016 MAR reflected the resident had not received the clonidine for the elevated blood pressure on the above dates. Resident #12's Nursing Progress Notes, dated 02/01/16 through 02/23/16, reflected neither the MAs or the nurses documented in the progress notes that the resident's blood pressure was elevated. An observation on 02/24/16 at 7:25 a.m. revealed MA B checked Resident #12's blood pressure in his left upper arm, which resulted an error message reading. MA B moved the blood pressure cuff to the resident's left forearm and obtained a result of 227/114. MA B stated, That doesn't seem like that (blood pressure reading) is right. MA B placed the blood pressure cuff on the resident's right forearm and obtained a result of 218/118. MA B then administered two tablets of nifedipine CR 60 mg. Review of Resident #12's MAR, dated 02/24/16 at 8:00 a.m., revealed his blood pressure was 188/93 and MA B initialed administering nifedipine CR 60 mg two tablets. Further review of the MAR revealed the PRN physician order [REDACTED]. An interview on 02/24/16 at 9:21 a.m. with MA B revealed she rechecked Resident #12's blood pressure 30 minutes after she administered the nifedipine, and his blood pressure was 170/86. MA B was asked what the resident's blood pressure was during medication pass. She looked at a piece of paper, on top of her medication cart, which had several blood pressure readings documented of various residents. After looking at the paper, MA B stated she did not write Resident #12's blood pressure reading. She stated she told the nurse the reading was 200/98. An interview on 02/24/16 at 9:20 a.m. with LVN E, who was Resident #12's charge nurse, revealed MA B told her Resident #12's blood pressure was high, but MA B did not provide her with the actual blood pressure reading. LVN E stated she told MA B to recheck the resident's blood pressure, and she was going to recheck the blood pressure as well. She stated the resident's blood pressure was high in the morning, and it usually went down after he received his routine blood pressure medications. Resident #12's February 2016 vital signs sheet reflected on 02/24/16 at 6:02 a.m. the resident's blood pressure was 152/86; at 8:27 a.m. the blood pressure was 188/93; and 8:50 a.m. the blood pressure was 166/67. Resident #12's February MA MAR reflected clonidine was not administered to the resident on 02/24/16 as of 9:20 a.m. An interview on 02/24/16 at 9:22 a.m. with LVN E revealed she checked Resident #12's blood pressure, and the blood pressure was 166/76. She stated she would call the doctor. LVN E was asked if the resident had a PRN order for clonidine and LVN E stated, I don't know, let me check. She was then asked, who was responsible for administering PRN clonidine, and she stated the nurse. At 9:33 a.m., LVN E stated she called the doctor and received an order to administer PRN clonidine 0.1 mg. She stated the PRN clonidine was not on her NAR so she had to call the doctor. LVN E was informed Resident #12's blood pressure reading was 227/114 during the medication pass. LVN E responded, That's scary. An interview on 02/24/16 at 9:43 a.m. with the DON revealed she was not aware Resident #12's systolic blood pressure was greater than 200. She had seen a blood pressure monitor in the hallway with a systolic blood pressure reading of 186; however, she was not sure which resident's blood pressure recording it was, but she told the staff to recheck the blood pressure. She revealed the facility procedure was for the MA to take the resident's blood pressure prior to administering blood pressure medication, and the MA was responsible for notifying the nurse if the blood pressure was high. If the blood pressure was high, it should be rechecked in 30 minutes. The DON explained that the nurse was made aware of the high blood pressure reading, so she could assess the resident and give direction to the MA on what to do. She stated PRN clonidine could be on the MAR used by the MAs or the NAR used by the nurses. An interview on 02/24/16 at 12:55 p.m. with ADON A revealed the MAs on the day and evening shifts documented the residents' vital signs which included blood pressure and pulse. The MAs took the residents' blood pressures prior to administering blood pressure medications, and she stated, The rule of thumb is, if the BP is greater than 150/90 the MA notifies the nurse. An interview on 02/24/16 at 1:08 p.m. with MA B revealed she considered a blood pressure reading of 160s/90ish to be high and would need to be reported to the nurse. An interview on 02/24/16 at 3:20 p.m. with MA C revealed if a resident's blood pressure was greater than 140/80 then he would notify the nurse. He stated he had not documented in the nursing progress notes that he notified the nurse. An interview on 02/24/16 at 3:30 p.m. with LVN F, who was the evening shift charge nurse for Resident #12, revealed she was not aware Resident #12's blood pressure had been high. LVN F states she told MA C last night if he needed to tell her something about a resident that he needed to write it down and hand it to her because she might not hear him if she was doing something else. LVN F stated if the MA told a resident's blood pressure was high, she would retake the resident's blood pressure with a manual cuff because she did not trust machines. An interview on 02/25/16 at 10:05 a.m. with the Medical Director, who was Resident #12's attending physician, revealed MA B should have told the nurse when the resident's blood pressure was was 227/114. He stated, That's not right. 2. Resident #3's MDS assessment, dated 12/02/15, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #3's undated care plan reflected a care plan addressing the resident's history of hypertension and low heart rate. The care planned goal was for the resident not experience any complications related to hypertension or low pulse (heart) rate. The care planned interventions included administering medications as ordered; take the blood pressure and pulse prior to giving medications; following the parameters to hold if less than 110/60; and to report negative findings to the Medical Director of Nurse Practitioner. Resident #3's February 2016 consolidated physician orders [REDACTED]. Resident #3's February 2016 MAR reflected the MAs held the 9:00 a.m. verapamil dose on 02/01/16, 02/02/16, 02/03/16, 02/04/16, 02/09/16, 02/10/16, 02/11/16, 02/12/16, 02/15/16, 02/16/16, 02/17/16, 02/19/16, 02/22/16, 02/23/16, 02/24/16 and 02/25/16. There were no vital signs documented on the MAR (next to the verapamil entry) and there was no indication why the medication was held. The MAR reflected MA B held 15 of the 16 doses. MA C administered the 5:00 p.m. Verapamil dose on the following dates when Resident #3's heart rate (pulse) was less than 60: 02/05/16 - HR 50 02/08/16 - HR 53 02/09/16 - HR 48 02/12/16 - HR 48 02/23/16 - HR 49. An interview on 02/26/16 at 8:15 a.m. with MA B revealed she held Resident #3's verapamil because the resident's pulse was low. She stated, I told the nurse to call the doctor because her (Resident #3's) blood pressure was so high. Resident #3's Nursing Progress Notes, dated 02/05/16 through 02/23/16, did not reflect MA B or MA C notified the nurse when they held Resident #3's 9:00 a.m. and/or 5:00 p.m. doses of verapamil. After reviewing Resident #3's February 2016 MAR with MA C on 02/25/16 at 3:10 p.m., MA C stated he did not know why he gave the verapamil when the resident's heart rate was below 60. He acknowledged he should have held the verapamil. Resident #3's February 2016 Physician order [REDACTED]. Resident #3's February 2016 MAR reflected MA B held the 9:00 a.m. Diovan HCT dose on 02/01/16, 02/02/16, 02/03/16, and 02/09/16. Resident #3's Nurses' Notes, dated 02/01/16 at 10:41 a.m., reflected Diovan HCT was held due to the resident's heart rate of 52. The resident's blood pressure was 116/75. This note was signed by MA B. The medication should not have been held on this date. Resident #3's Nurses' Notes, dated 02/02/16 at 10:28 a.m., reflected Diovan HCT was held due to the resident's heart rate of 53. The resident's blood pressure was 118/77. The entry was signed by MA B. The medication should not have been held. Resident #3's Nurses' Notes, dated 02/03/16 at 10:42 a.m., reflected Diovan HCT was held due to the resident's heart rate of 55. The resident's blood pressure was 173/77. The entry was signed by MA B. The medication should not have been held. Resident #3's Nurses' Notes, dated 02/09/16 at 10:57 a.m., reflected Diovan HCT was held due to the resident's heart rate of 55. The blood pressure reading was not recorded. The entry was signed by MA B. The medication should not have been held. An interview on 02/25/16 at 1:40 p.m. with LVN G revealed she had been Resident #3's nurse, on the day shift, and was not aware MA B had been holding his 9:00 a.m. verapamil doses. She stated when a MA told her a medication was held she would chart it in the resident's progress notes. An interview on 02/25/16 at 3:20 p.m. with the DON revealed she was not aware MA C had held Resident #3's verapamil. She noticed this morning that MA B was holding Resident #3's verapamil. The DON thought the verapamil was being held because of a low pulse, but she stated the pulse was not documented on the MAR. She stated she planned to review Resident #3's verapamil orders with MA B. The DON stated the MAs should tell the nurse when a medication was held, and the nurse should call the physician if a medication was held more than three times. The DON stated the MARs were not monitored, When the MARs were on paper, I could just flip through the MARs and TARS and see what was being done. She stated she had done a few medication passes with MA B. On 02/27/16 at 7:45 a.m., the Corporate Nurse was made aware MA B had held Resident #3's Diovan on four separate occasions in February 2016, due to a decreased heart rate. She was informed that on 02/03/16 MA B held the 9:00 a.m. Diovan because the resident's heart rate was 55 and then administered Clonidine because the resident's blood pressure was 173/77. The Corporate Nurse stated they had already decided to terminate MA B. Review of Nursing 2015 Drug Handbook, Wolters Kluwer, 35th Edition, Copyright 2015, pages 1449-1451, reflected Verapamil was used to treat Hypertension. Caution patient against abruptly stopping drug. Review of Nursing 2015 Drug Handbook, Wolters Kluwer, 35th Edition, Copyright 2015, pages 1440-1441, reflected Diovan was used to treat Hypertension. 3. Resident #16's MDS assessment, dated 12/12/15, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #16's lab result dated 02/23/16 reflected a potassium level of 3.4. Further review of this lab report reflected the potassium reference ranges were 3.5-5.1. Resident #16's physician's orders [REDACTED]. An observation on 02/24/16 at 8:05 a.m. revealed MA D administered multi-vitamin with minerals, Oyster Shell Calcium 500 mg + Vitamin D, Tramadol 50 mg, Gabapentin 300 mg, Neudexta 20-10 mg, Namenda XR 28 mg, Lasix 20 mg, and amlodipine 5 mg to Resident #16. On 02/25/16 at 9:45 a.m. MA D was shown Resident #16's MAR dated 02/24/16. He initialed he had administered potassium 20 meq at 8:00 a.m. MA D went through all Resident #16's blister packs of medications, in his medication cart. MA D revealed, She (Resident #16) doesn't even have a blister pack for the Potassium. It was an oversight on my part (that the potassium was charted as administered). The surveyor asked if he had administered Resident #16's medications this morning and he revealed he had. He was asked if he documented that he had administered potassium to the resident this morning and he revealed he had. That was an oversight too, on my part. Review of Nursing 2015 Drug Handbook, Wolters Kluwer, 35th Edition, Copyright 2015, pages 1157-1158, reflected potassium chloride was used to treat [DIAGNOSES REDACTED]. An interview with the DON on 02/25/16 at 12:00 PM revealed she had staff administer potassium chloride 20 meq from the facility's emergency kit to Resident #16. 4. The facility's current Blood Pressure Medication Administration policy and procedure, dated 02/24/16, reflected the following: When a resident has a blood pressure medication ordered, the person administering the medication must take the blood pressure prior to administering the medication. If the blood pressure is abnormal especially on the high side, the person administering the medication must report to the charge nurse. If blood pressure is high the charge nurse must: - Assess the resident and take the blood pressure to identify if the resident is symptomatic and to obtain a second blood pressure. The charge nurse will verify the original blood pressure is documented. - Review the medications to verify the resident has a PRN medication for high blood pressure and that there are parameters ordered by the physician. - Ensure the medication administration person has given the routine medication if ordered. - If the resident is symptomatic, contact the physician and request further evaluation. - If the blood pressure has not decreased with the routine medication, administer the prn medication and continue to monitor. Report the high blood pressure to the physician - When ordering a PRN Blood Pressure medication, obtain parameters with instruction when to contact the physician and, place the PRN blood pressure medication on the NAR so to alert the nurse to assess before giving the mediation (sic) and follow up with blood pressures to verify the effectiveness of the medication. AND .Document Document Document!!!!! The facility's current Brachial Blood Pressure policy and procedure, dated 2003 reflected the following: .15. Document readings. Report abnormal high or low results to the primary nurse/physician immediately Review of the current facility policy and procedure Medication Administration Procedures dated 2003 reflected, .13. Pulse and blood pressure are to be monitored and charted where applicable . The facility's current Medication Administration Procedures policy, dated 2003, reflected the following: .13. Pulse and blood pressure are to be monitored and charted where applicable . The facility's current CMAs (sic) Expectations policy and procedure, dated 2003, reflected the following: . Administer PRN (as needed) medications with permission of a licensed nurse - Monitor and report any issues with availability of medications to the charge nurse 5. An IJ was identified on 02/25/16 at 3:45 p.m. The facility's Executive Director, DON, Corporate Nurse and CEO were notified at that time and a Plan of Removal was requested. 6. The facility's Plan of Removal was accepted on 02/26/16 at 3:15 p.m. and contained the following: The Medical Director was contacted by the facility staff, about all three residents and the events on 02/25/16 at 3:30 p.m. Assessments were completed on Residents' #3, #12 and #16 and no adverse findings were identified. These assessments were completed on 02/25/16 by 4:00 p.m. On 02/26/16 MA B was placed on investigatory suspension. On 02/25/16 MA D was terminated. On 02/26/16 MA C was placed on investigatory suspension. An in-service was conducted, by the DON, on 02/26/16 at 1:00 p.m., on BP parameter protocol. This in-service included the weekend staff. An in-service was conducted, by the Corporate Nurse, on 02/24/16 and 02/25/16, on checking and documenting BP's. These in-services included return demonstrations. An in-service was conducted, by the Corporate Nurse, on 02/24/16 and 02/25/16, with the MAs, on the procedures of a medication pass. This training included, administering regularly prescribed medications, documentation of the administered medications, administering of PRN medications with the permission of the charge nurse, observation and reporting of reactions and side effects of medications to the charge nurse, along with the reporting and documentation procedures of when the medication protocol is outside of its required parameters. This in-service was competency based and completed by 02/26/16 at 8:00 a.m. In-services were conducted by the MDS Nurse on Medication Administration Procedures. These in-services were completed by 02/26/16 at 3:00 p.m. An in-service was conducted by the Corporate Nurse, on MA expectations. This in-service was completed by 02/26/16 at 1:30 p.m. An in-service was conducted by the Corporate Nurse, on Adverse Drug Reaction Monitoring. This in-service was completed by 02/26/16 at 3:00 p.m. The DON, ADON A, ADON I and LVN H conducted an audit to identify any other adverse drug events and to identify any other discrepancies in medication administration during February 2016. The audit would be completed by 02/26/16 at 8:00 a.m. The DON or her designee would conduct Medication Administration Competencies on all nursing staff responsible for administering medications. This would be completed by 02/26/16 at 1:00 p.m. The Medical Director will be involved in the QA Process and ongoing review on the plan with input on any revisions needed. The DON or designee will observe at least 25 medications being administered on random residents. This medication pass will include at least one resident who has a [DIAGNOSES REDACTED]. The medication administration observation will include observation of at least one medication aide. The observations will be conducted at least five times a week and ongoing education will be provided as necessary. The QAPI steering committee will review the current plan during the regularly scheduled meetings and will revise as needed.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable well-being for one (Resident #1) of eleven residents reviewed for change in condition. - On 01/28/15, LVN A failed to promptly assess Resident #1 after being notified that the resident was in pain. LVN A did not assess the resident until approximately an hour later. - LVN A and LVN D failed to document assessment and monitoring of Resident #1's ankle after it was noted to be swollen and painful. - LVN D failed to ensure Resident #1's x-ray results, which revealed the resident had a fracture to the right ankle, were promptly acted upon. Three hours elapsed before LVN D notified Resident #1's physician, Physician G, that the resident had a fracture to the right ankle. These failures resulted in Resident #1 experiencing a delay in hospital evaluation and treatment. These failures could affect the 34 residents, who resided on Station 2, and placed them at risk for delayed treatment and intervention to address pain, injuries, and other complications. Findings included: Resident #1's MDS quarterly assessment, dated 12/05/14, reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. The resident had moderately impaired cognitive skills with disorganized thinking. Resident #1 was independent with transfers and required supervision with walking/locomotion. Resident #1's Comprehensive Plan of Care, dated 09/17/14, reflected the resident was care planned for being at risk for falls secondary to cognitive impairment and unsteady gait. Observation of Resident #1 on 02/11/15 at 9:45 AM revealed her lying in bed with her right leg wrapped in a soft cast and elevated on a foam block. The resident was unable to recall the incident. Resident #1's Nurse's Notes, dated 01/28/15 at 6:00 AM, written by LVN C reflected: "Arrived at resident's room, door blocked with (symbol used) table - pushed door open - found resident lying on floor. When asked what happened - didn't answer. Tried to help her up resident refused tried several times resident started hitting at us." Resident #1's Nurse's Notes written by LVN A, dated 01/28/15 at 12:35 AM, reflected: "Therapist (PTA E) reported to the nurse (LVN A) resident was complaining of pain when he got her up for exercising. She could not stand up. C/O (Complaint of) (R) (right) ankle in pain." Interview on 02/11/15 at 2:17 PM with PTA E revealed on 01/28/15 before lunch he went to get Resident #1 up for therapy. He stated when he entered the resident's room and told her why he was there she smiled at him. He stated she sat on the side of the bed and was putting her shoes on. While attempting to help her put her shoe on her right foot, Resident #1 exclaimed in pain. PTA E stated he reported the resident's pain to LVN A, and LVN A told him she would check on the resident. PTA E stated he did not know if she checked on the resident after he reported it to her. When asked if Resident #1 would express if she was in pain, he stated she may or may not verbalize pain. PTA A stated Resident #1's right ankle area was "pretty" swollen, and it looked more swollen than her left leg. He stated the right ankle was also tender to touch. Resident #1's Nurse's Notes written by LVN A, dated 01/28/15 at 1:30 PM, reflected: "Called (Physician G), left messages about the resident complaints. Waiting for call back." Resident #1's Nurse's Notes written by LVN A, dated 01/28/15 at 2:45 PM reflected: "Called (Physician G) the 2nd time. Awaiting for call back." Resident #1's Nurse's Notes written by LVN A, dated 01/28/15 at 2:50 PM reflected: "Called (X-ray Company) to order x-ray for (R) ankle c/o pain..." Interview on 02/11/15 at 12:18 PM with LVN A revealed she typically worked the weekend shift; however, she worked the 7:00 AM to 3:00 PM shift on 01/28/15. Upon starting her shift on 01/28/15, she stated she was given report from LVN C, who was the off-going nurse. LVN A explained that Resident #1 had a fall around 6:00 AM on 01/28/15, and the resident had a fall the night before as well. LVN A stated she was informed by a Therapist on 01/28/15 that Resident #1 complained of pain when he attempted to get her up from bed. She stated she was informed that Resident #1 was in pain before the lunch meal service around noon (12:00 PM). She explained that she was assigned to the dining room for the meal service, and she went ahead to her assignment because she was being called to the dining room. LVN A stated she was in the dining room for approximately an hour before she assessed Resident #1's pain. LVN A was asked when she should notify the physician if a resident experienced a change in condition. LVN A stated she should notify the physician right away when a resident had an accident or complained of pain. She stated she should assess the resident right away if they complained of pain. Review of Resident #1's x-ray report, dated 01/28/15, reflected three views of the resident's right ankle were taken at 4:46 PM on that date. The report reflected: "There is an avulsion (the tearing away of a structure or part) of the right posterior malleolus (back of ankle) with a prominent subluxation (partial dislocation) at the ankle joint. ...IMPRESSION: 1. AVULSION, POSTERIOR MALLEOLUS WITH PROMINENT SUBLUXATION RIGHT ANKLE JOINT SPACE." The fax time stamp on the x-ray report reflected Resident #1's x-ray results were faxed to the facility at 7:03 PM on 01/28/15. Interview on 02/11/15 at 1:39 PM with the X-ray Company's Customer Care Representative revealed Resident #1's x-ray results were relayed to Receptionist F by phone at 7:18 PM. The X-ray Company Representative stated the company would call the facility and request the attending nurse for that specific resident. Interview on 02/11/15 at 5:10 PM with Receptionist F revealed she received the call from the radiology provider and the report for Resident #1. Receptionist F stated she immediately took the radiology report to LVN D. She stated she did not relay the verbal phone message from the radiology provider to LVN D. She stated it was around 7:00 PM when she notified LVN D of the x-ray results. Receptionist F stated she was not told not to accept calls from radiology or lab providers. Resident #1's Nurse's Notes, dated 01/28/15 at 10:00 PM, documented by LVN D reflected: "X-ray result received and called to (Physician G). T/O (Telephone order) received to transfer resident to hospital. Resident's (Family Member) was notified. Ambulance called." Resident #1's Nurse's Notes, dated 01/28/15 at 11:00 PM, documented by LVN D reflected: "Resident left facility via ambulance stretcher enroute to...hospital emergency..." Interview on 02/11/15 at 12:58 PM with LVN D revealed she worked the second shift, 3:00 PM to 11:00 PM. LVN D stated on 01/28/15, when she arrived for her shift, she was notified the resident had a fall that same morning. She stated the resident did not complain "much" and an x-ray was ordered. When asked if Resident #1 complained about pain during her shift on 01/28/15, LVN D stated she could not recall because at times the resident may not verbalize her pain. Interview on 02/11/15 at 12:40 PM with CNA H revealed she worked the 3:00 PM to 11:00 PM shift on 01/28/15. She stated she cared for Resident #1 on that shift. While giving the resident a bed bath after the dinner meal, she noticed the resident's ankle was swollen, and the resident was in pain. She stated she reported the swelling and pain to LVN D, and LVN D told her she knew about it. She stated she continued to check on the resident during her shift until the resident went to the hospital. There were no nursing notes documented regarding Resident #1's condition from 2:50 PM to 10:00 PM on 01/28/15. There also was no documentation reflecting an assessment had been conducted by LVN A on 01/28/15 after PTA E notified her that Resident #1 was experiencing pain and could not stand. On 02/11/15 at 1:10 PM, the Administrator was asked for the facility's policy on physician notification, and she stated the information should be in the change of condition policy. The facility's current Condition Change of the Resident policy and procedure, dated 2006, reflected: "...BASIC RESPONSIBILITY Licensed Nurse... PURPOSE To observe, record and report any condition change to the attending physician so proper treatment will be implemented. ...PROCEDURE 1. After all resident falls, possible injuries or changes in physical or mental function can occur. 2. Assess the resident's need for immediate care. 3. Do not leave the resident alone. 4. Assess the resident and notify the attending physician of the resident's condition. Compare the residents' current condition to his or her prior level of function. 5. Assessment and monitoring include, but are not limited to, the following: ...b. Swelling and discoloration; if present, document size, site, amount and color. ...d. Inquire if the resident has...pain. ...i. Generalized weakness. ...k. Gait, posture or balance change. ...m. Proper reflexes (and response to painful stimuli). n. Take vital signs including temperature and pain location and level. ...8. Monitor resident's condition frequently until stable. DOCUMENTATION GUIDELINES Documentation may include: * Date, condition change was identified. * Observation of the resident's findings. * Emergency care provided. * Notification of a physician...." The facility's Census List, dated 02/11/15, reflected 34 residents resided on Station 2, where Resident #1 resided. -

Based on interview and record review, it was determined the facility failed to promptly notify the attending physician of x-ray results for one (Resident #1) of six residents were reviewed for change in condition. Resident #1 fell on [DATE] and experienced swelling and pain to her right ankle. An x-ray was of the resident's right ankle was done at 4:46 PM, and the results were reported to the facility at 7:03 PM revealing that the resident had a fracture to the right ankle. LVN D failed to notify Resident #1's physician, Physician G, of the x-ray results until 10:00 PM. These failures resulted in Resident #1 experiencing a delay in hospital evaluation and treatment. These failures could affect the 34 residents, who resided on Station 2, and placed them at risk for delayed treatment and intervention to address pain, injuries, and other complications. Findings included: Resident #1's MDS quarterly assessment, dated 12/05/14, reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. The resident had moderately impaired cognitive skills with disorganized thinking. Resident #1 was independent with transfers and required supervision with walking/locomotion. Resident #1's Comprehensive Plan of Care, dated 09/17/14, reflected the resident was care planned for being at risk for falls secondary to cognitive impairment and unsteady gait. Observation of Resident #1 on 02/11/15 at 9:45 AM revealed her lying in bed with her right leg wrapped in a soft cast and elevated on a foam block. The resident was unable to recall the incident. Resident #1's Nurse's Notes, dated 01/28/15 at 6:00 AM, written by LVN C reflected: "Arrived at resident's room, door blocked with (symbol used) table - pushed door open - found resident lying on floor. When asked what happened - didn't answer. Tried to help her up resident refused tried several times resident started hitting at us." Resident #1's Nurse's Notes written by LVN A, dated 01/28/15 at 12:35 AM, reflected: "Therapist (PTA E) reported to the nurse (LVN A) resident was complaining of pain when he got her up for exercising. She could not stand up. C/O (Complaint of) (R) (right) ankle in pain." Interview on 02/11/15 at 2:17 PM with PTA E revealed on 01/28/15 before lunch he went to get Resident #1 up for therapy. He stated when he entered the resident's room and told her why he was there she smiled at him. He stated she sat on the side of the bed and was putting her shoes on. While attempting to help her put her shoe on her right foot, Resident #1 exclaimed in pain. PTA E stated he reported the resident's pain to LVN A, and LVN A told him she would check on the resident. PTA E stated he did not know if she checked on the resident after he reported it to her. When asked if Resident #1 would express if she was in pain, he stated she may or may not verbalize pain. PTA A stated Resident #1's right ankle area was "pretty" swollen, and it looked more swollen than her left leg. He stated the right ankle was also tender to touch. Resident #1's Nurse's Notes written by LVN A, dated 01/28/15 at 1:30 PM, reflected: "Called (Physician G), left messages about the resident complaints. Waiting for call back." Resident #1's Nurse's Notes written by LVN A, dated 01/28/15 at 2:45 PM reflected: "Called (Physician G) the 2nd time. Awaiting for call back." Resident #1's Nurse's Notes written by LVN A, dated 01/28/15 at 2:50 PM reflected: "Called (X-ray Company) to order x-ray for (R) ankle c/o pain..." Interview on 02/11/15 at 12:18 PM with LVN A revealed she typically worked the weekend shift; however, she worked the 7:00 AM to 3:00 PM shift on 01/28/15. Upon starting her shift on 01/28/15, she stated she was given report from LVN C, who was the off-going nurse. LVN A explained that Resident #1 had a fall around 6:00 AM on 01/28/15, and the resident had a fall the night before as well. LVN A stated she was informed by a Therapist on 01/28/15 that Resident #1 complained of pain when he attempted to get her up from bed. She stated she was informed that Resident #1 was in pain before the lunch meal service around noon (12:00 PM). She explained that she was assigned to the dining room for the meal service, and she went ahead to her assignment because she was being called to the dining room. LVN A stated she was in the dining room for approximately an hour before she assessed Resident #1's pain. After assessing the resident, LVN A stated she notified the physician that Resident #1 was experiencing pain. The physician ordered an x-ray. LVN A stated the results of the x-ray did not come in during her shift. Review of Resident #1's x-ray report, dated 01/28/15, reflected three views of the resident's right ankle were taken at 4:46 PM on that date. The report reflected: "There is an avulsion (the tearing away of a structure or part) of the right posterior malleolus (back of ankle) with a prominent subluxation (partial dislocation) at the ankle joint. ...IMPRESSION: 1. AVULSION, POSTERIOR MALLEOLUS WITH PROMINENT SUBLUXATION RIGHT ANKLE JOINT SPACE." The fax time stamp on the x-ray report reflected Resident #1's x-ray results were faxed to the facility at 7:03 PM on 01/28/15. Interview on 02/11/15 at 1:39 PM with the X-ray Company's Customer Care Representative revealed Resident #1's x-ray results were relayed to Receptionist F by phone at 7:18 PM. The X-ray Company Representative stated the company would call the facility and request the attending nurse for that specific resident. Interview on 02/11/15 at 5:10 PM with Receptionist F revealed she received the call from the radiology provider and the report for Resident #1. Receptionist F stated she immediately took the radiology report to LVN D. She stated she did not relay the verbal phone message from the radiology provider to LVN D. She stated it was around 7:00 PM when she notified LVN D of the x-ray results. Receptionist F stated she was not told not to accept calls from radiology or lab providers. Resident #1's Nurse's Notes, dated 01/28/15 at 10:00 PM, documented by LVN D reflected: "X-ray result received and called to (Physician G). T/O (Telephone order) received to transfer resident to hospital. Resident's (Family Member) was notified. Ambulance called." Resident #1's Nurse's Notes, dated 01/28/15 at 11:00 PM, documented by LVN D reflected: "Resident left facility via ambulance stretcher enroute to...hospital emergency..." Interview on 02/11/15 at 12:58 PM with LVN D revealed she worked the second shift, 3:00 PM to 11:00 PM. LVN D stated on 01/28/15, when she arrived for her shift, she was notified the resident had a fall that same morning. She stated the resident did not complain "much" and an x-ray was ordered. When asked if Resident #1 complained about pain during her shift on 01/28/15, LVN D stated she could not recall because at times the resident may not verbalize her pain. Interview on 02/11/15 at 12:40 PM with CNA H revealed she worked the 3:00 PM to 11:00 PM shift on 01/28/15. She stated she cared for Resident #1 on that shift. While giving the resident a bed bath after the dinner meal, she noticed the resident's ankle was swollen, and the resident was in pain. She stated she reported the swelling and pain to LVN D, and LVN D told her she knew about it. She stated she continued to check on the resident during her shift until the resident went to the hospital. There were no nursing notes documented regarding Resident #1's condition from 2:50 PM to 10:00 PM on 01/28/15. There also was no documentation reflecting an assessment had been conducted by LVN A on 01/28/15 after PTA E notified her that Resident #1 was experiencing pain and could not stand. The facility's Census List, dated 02/11/15, reflected 34 residents resided on Station 2, where Resident #1 resided.

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status or a need to alter treatment significantly for six (Residents #2, #3, #8, #9, #11 and #13) of 21 residents reviewed for changes in condition. 1) Resident #3 experienced a 16.3% (20.8 pounds) severe weight loss from 11/01/13 to 12/17/13. Staff failed to consult with the physician after they became aware of her 10% weight loss in two weeks until after surveyor intervention. 2) Resident #9 was re-admitted to the facility on [DATE] with a pressure ulcer on her right lateral leg according to facility staff. The staff failed to notify the physician promptly for treatment orders. 3) Staff administered [MEDICATION NAME] (for blood pressure) to Resident #13 despite below normal blood pressure readings of 71/26, 109/36 and 108/58 and failed to notify the resident's physician . They further failed to notify her physician when her evening blood pressures were 71/26, 109/36, 97/68, 88/45 and 108/58. 4) Staff identified an open pressure ulcer on Resdient #11's coccyx and failed to consult with the physician for 12 days for treatment orders. On the 12th day, the pressure ulcer was ideentified as a Stage 3 pressure ulcer by the wound physician. 5) Resident #2 was readmitted to the facility with an indwelling urinary Foley catheter. The facility failed to notify the physician for orders for care and treatment of [REDACTED]. 6) Resident #8 was admitted to the facility with an indwelling urinary Foley catheter and failed to notify the physician for orders for care and treatment of [REDACTED]. These failures to consult the physician with a drop in blood pressure, severe weight loss, orders for an indwelling urinary catheter and for pressure ulcer treatment orders could affect any of the facility's 75 residents, including Residents #2, #3, #8, #9, #11 and #13, and placed them at risk not having their needs met, a delay in needed medical care and treatment, the potential for deterioration in their clinical condition, increasing the length of time needed for healing, the need for hospitalization and even death. An Immediate Jeopardy (IJ) was identified on 01/02/14. While the IJ was removed on 01/11/14, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. Findings included: 1) Resident #3 was a [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she was severely impaired cognitively, was totally dependent on staff for her ADLs, she weighed 133 lbs, and had no weight loss. Resident #3's Care Plan dated 10/24/13 reflected: "(Resident #3) poor appetite eating DT Cognitive Deficit/family declined GT placement." Approaches included: Diet as ordered/preferences per family's request...; Medication as ordered, Assist/Cueing with meal; Document meal % and report % to nurse with meal ticket; Offer fluids frq throughout day...; Dietary consult; Psych consult; Notify Dr./RP of any changes in condition." Resident #3's consolidated physician's orders [REDACTED]. The order was dated 10/24/13. Resident #3's Dietary Progress Notes dated 11/21/13 reflected: "Resident has 11% significant wt. loss X's 180 days R/T poor appetite, refuses to eat after return from hospital. Resident Received fortified foods, likes chocolate milk. Resident on weekly weights. DSM will monitor meal intake, nursing to monitor weight and skin closely, will follow." Resident #3's Food Intake Record for November 2013 revealed she consumed less than 50% of her meal 27 times. Additionally, meal percentages were not documented at all and left completely blank 24 times. Review of Resident #3's MARs for November 2013 revealed an entry dated 09/27/13 for Med Pass 60 cc by mouth as needed if the resident eats less than 50%. There were no doses initialed as administered. Resident #3's Nutritional assessment dated [DATE] reflected her weight was 128 lbs. The Summary and Recommendations reflected: "10/25/13: Dietary consult ordered for low pre-alb. Nutr assess reveals pt readmitted post hospitalization at (hospital name) for possible [DEVICE] eval due to failure to thrive, dysphagia, and UTI; pt shows wt loss 5 lbs/30 days-4%, following overall wt loss 15 lbs/180 days-10.49%; Pt remains within desireable wt range, as reflected by BMI factor; Pt continues w/varying intake of regular, therapeutic diet; [MEDICATION NAME] was ordered 10/28/13 for appetite stimulant; Pro powder was dc'd 10/25/13 due to pt refusal; pt receives med pass 60 cc TID if intake < 50% for add'l 360 cal/15 gm pro; lab reveals low pre-alb level; due to continued wt loss and low pre alb, recommend adding Medpass 2.0 120 cc BID for add'l 480 cal/20 gm pro; pt to be carefully monitored." NOTE: The recommendation for Medpass 120 cc BID was never ordered. Resident #3's Food Intake Record for December 2013 revealed she consumed less than 50% of her meal seven times between 12/01/13 and 12/12/13. Additionally, meal percentages were not documented at all and left completely blank eight times from 12/01/13 through 12/12/13. Review of Resident #3's MARs for December 2013 revealed an entry dated 09/27/13 for Med Pass 60 cc by mouth as needed if the resident eats less than 50%. There were no doses initialed as administered. Observation on 12/11/13 at 8:00 AM revealed Resident #3 was fed breakfast in the dining room by facility staff. Resident #3 consumed 30% of her eggs, 90% of her oatmeal and 75% of her meat. Observation on 12/11/13 at 1:05 PM revealed Resident #3 was fed lunch in the dining room by facility staff. She only consumed 25% of her meat and 60% of her dessert. During an interview on 12/12/13 at 7:10 PM, LVN W was asked about Resident #3's Med Pass order. LVN W stated she did give the resident Med Pass on occasion. She stated she had been giving her health shakes because Resident #3 would drink them up. She could not answer why there were no doses documented. LVN W stated Resident #3's (family member) often came in the evening and "feeds her too much." When asked what she meant by that, LVN W stated he/she would push her to eat yogurt and healthshakes and she (LVN W) thought he "overdoes it." During an interview on 12/13/13 at 8:10 AM, LVN D stated she had not given Resident #3 any Med Pass because she was eating much better and did not need any. When asked about the Food Intake Record and informed there were several times she refused to eat or ate less than 50%, LVN D stated she had her meal tickets somewhere and was not aware of Resident #3 ever eating less than 50%. She stated she knew Resident #3's weight was stable, and she had no weight loss this month. Resident #3's Yearly Weight Record reflected the following weights: 10/24/13 - 128.1 lbs 11/01/13 - 127.6 lbs 12/02/13 - 126.6 lbs 12/09/13 - 126.6 lbs Observation on 12/13/13 at 8:24 AM revealed Resident #3 was weighed by Restorative Aide BB. Resident #3 was weighed in her wheelchair, then assisted to a chair and then the empty wheelchair was weighed. The resident's weight was 109.2 lbs. Restorative Aide BB stated she weighed the resident the same way every time. She stated her weight had dropped, and she would report the findings to LVN D and ensure the resident was weighed daily. She added she would request the scale be calibrated for accuracy. Restorative Aide BB checked her records, which were kept in the therapy department, and discovered she had entered the wrong weights on Resident #3's Yearly Weight Record. She corrected the Yearly Weight Record to reflect the following: 11/1/13 - 127.6 lbs 12/02/13 - 122.6 lbs 12/06/13 - 120.6 lbs 12/13/13 - 109.4 lbs On 12/13/13 at 9:30 AM, LVN D was informed of Resident #3's actual weight of 109 lbs by the surveyor. LVN D stated she had been informed, and they were going to get the scale calibrated. During an interview on 12/14/13 at 10:00 AM, LVN T, Resident #3's weekend Charge Nurse, was shown Resident #3's MAR and asked why no Med Pass had been administered as ordered. LVN T explained since the resident returned from the hospital, she had been doing much better so none was given. LVN T was shown Resident #3's Food Intake Records for November and December 2013 with several weekend entries reflecting she had either refused to eat or consumed less than 50%. LVN T stated, "The aides didn't tell me. They gave the ticket to the clerk. I should have checked." In an interview on 12/16/13 at 3:20 PM , Restorative Aide BB stated she had spoken with the Dietary Manager, who agreed she (Restorative Aide BB) would personally feed Resident #3 in the therapy department and complete a more detailed summary of her intake with every meal. On 12/17/13 at 12:20 PM, Restorative Aide BB stated the scale had been calibrated. At that time, Resident #3 was weighed, and her weight was down to 106.8 lbs. On 12/17/13 at 2:30 PM, Restorative Aide BB reviewed Resident #3's meal intake documents completed for 12/16/13. The form reflected she consumed 25% of her breakfast, no lunch and only 10% of her dinner. Restorative Aide BB stated she discussed her plans to personally feed Resident #3 with LVN D and the DON, who agreed it was a good idea. Review of Resident #3's December 2013 MAR revealed there was still no Med Pass administered on 12/16/13. Review of Resident #3's Nurse's Notes revealed no indication her physician had been notified of her weight loss. Resident #3's Dietary Progress Notes dated 12/13/13 reflected the following: "Resident last weighed @ 109.4, weighed twice. Scales to be checked stated by Rehab aide. Resident continues to have significant amount of weight loss, resident has 14% significant weight loss x's 30 days R/T refusal to eat. (Director of Dietary Services) called dietitian's asst. Dietitian on vacation @ this X, facility needed immediate intervention due to tremendous amount of weight loss within 30 days. Dietitian faxed recommendations, (Director of Dietary Services) was also asked to tell resident's charge nurse of recommendations of Med Pass (with) medications 3x a day. Nurse stated res. already receives 60 cc if she eats less than 50%. Dietitian stated res is a good candidate for appetite stimulant but may not be able to receive it according to what's going on with her. (Director of Dietary Services) talked (with) charge nurse, stated she receives [MEDICATION NAME] already but res still not eating well as observed by (Director of Dietary Services) & rehab aide. Nurse stated she would call the doctor. Doctor's office called (Director of Dietary Services) about dietitian's recommendations and stated she would talk with doctor and get back (with) me. Will follow...." The note was signed by Director of Dietary Services. Resident #3's Nutritional assessment dated [DATE] reflected her weight was 127 lbs. Summary and Recommendations reflected: "12/17/13: Dietary consult requested due to weight loss. Nutr assess reveals wt remains stable/ 30 days, following wt loss 9 lbs/90 days-7%, 13 lbs/180 days-9.29%; Pt remains within desirable wt range, as reflected by BMI factor;...Pt continues to refuse to eat; Pt will accept shakes and chocolate milk; [MEDICATION NAME] continues for appetite stimulant; Med Pass continues 60 cc TID if meal intake is < 50% for add'l 360 cal/15 gm pro, due to continued wt loss and low pre-alb, recommend adding Med Pass 2.0 120 cc BID for add'l 480 cal/20 gm pro; wt loss may be expected; ...continue to monitor closely; goal is to provide adequate cal and pro to stabilize wt." The assessment was signed by Dietary Consultant PP. During an interview on 01/02/14 at 4:10 PM, Dietary Consultant PP was queried about her Nutritional Assessment of Resident #3. Dietary Consultant PP stated she was called for a consultation on 12/17/13 and the weight reflected on her assessment was the weight she was given for Resident #3 by the facility. When asked about her recommendation for the Med Pass 2.0 supplement, Dietary Consultant PP explained she was informed by facility staff Resident #3 had been receiving doses of Med Pass as needed but she wanted to add a scheduled dose in addition to the PRN dose already ordered. She could not remember who told her Resident #3 was taking the Med Pass. When the Dietary Consultant PP was told Resident #3's weight was actually 109 lbs on 12/13/13, then dropped to 106 lbs, she stated she was never made aware of the weight drop. When asked who provided her the information for her consultation, Dietary Consultant PP stated the Director of Dietary Services faxed a weight sheet prior to her arrival. She explained they typically faxed the information in advance so she could prepare for her visit. During an interview on 01/02/14 at 4:35 PM, the Director of Dietary Services was asked what type of information she sent to the dietitian when a consultation was ordered. She stated she sent them the resident's weights. When asked about Resident #3, she confirmed she sent the dietitian her weights. The Director of Dietary Services retrieved a list of monthly weights to show the surveyor. Resident #3's weight for December was documented as 126.6 lbs; a line was drawn through the entry. The Director of Dietary Services stated, "I lined that out later and wrote 109." The Director of Dietary Services retrieved a Dietitian Consultant Worksheet and stated she typically filled it out and gave it to the Dietitian. When asked whether she provided one for Resident #3's consultation, the Director of Dietary Services replied, "I can't remember if I did this last time. They never let me know when they are coming." The Director of Dietary Services also explained she had informed the Dietitian Resident #3 was taking Med Pass supplement. She stated she had been informed by LVN D the resident was getting it. On 12/17/13 at 2:17 PM, an interview with NP P, Resident #3's Nurse Practitioner, revealed she had not been notified of Resident #3's weight loss and was unaware of the recent weight drop. During an interview on 12/17/13 at 3:07 PM, LVN D stated she remembered the surveyor reporting Resident #3's weight loss on 12/13/13. She stated she reported the information to the DON. When asked why she did not call the physician, LVN D stated she was going to wait until the scale was calibrated. In an interview on 12/17/13 at 4:10 PM, the DON stated Resident #3's physician had been called and lab orders were obtained for a CBC, CMP and Pre-[MEDICATION NAME] level to be done. She added a care plan meeting with the family was being arranged and Physician K, Resident #3's attending physician, would attend. The DON stated Resident #3 was getting health shakes instead of Med Pass but staff had not been documenting it. She stated nursing administration was going to take over monitoring Resident #3's meal intake and every resident in the building would be re-weighed. When asked why the physician was not notified on 12/13/13 when the discrepancy was found, the DON stated, "No. It was the intent but it got dropped." An interview on 01/02/14 at 2:21 PM with Restorative Aide BB revealed she had begun re-weighing residents but had not completed the task (16 days since the DON said all residents would be re-weighed.). Restorative Aide BB provided lists dated 12/31/13 through 01/02/14 with the names and weights of residents. When asked when she was asked to initiate re-weighing the residents, she stated she had not been told by anyone to re-weigh the residents. When asked why she was re-weighing the residents, Restorative Aide BB said, "I know that's what you do when you have a discrepancy." In an interview on 01/03/13 at 12:12 PM, the DON was asked whether she had implemented the re-weighing of all the residents as she had informed the surveyor she would. The DON stated, "We are in the process of doing that now." During an interview on 01/06/13 at 12:00 PM, Physician K stated he had taken part in care plan meetings regarding Resident #3. He stated he had decreased her medications, which were not critical to maintain function. Physician K stated he learned the facility had not been calling the family to assist her when she would not eat as had been agreed upon during a previous meeting. 2) The facility's current policy and procedure, Weight and Height Measurement dated 2006 reflected: "Basic Responsibility- Licensed Nurse, Nursing Assistant and Restorative Nursing Assistant ... Purpose: -To obtain accurate weight and height of each resident. -To maintain constant control of weight changes. -To assess nutrition and hydration status of resident -To identify significant change in condition Procedure: 1. Calibrate scale according to manufacturer's instructions ... 3. Assist resident into wheelchair or scale chair. Place wheelchair on scale platform properly, according to manufacturer's directions. 4. Weigh according to manufacturer's directions and subtract weight of wheelchair from total weight to obtain resident's weight... Documentation Guidelines: Documentation may include: -Date and weight ... -Notify the charge nurse or physician of all weight changes of five pounds (or 5%) or more in a 30-day period or ten percent in a 180-day period or per state requirement...." 3) Resident #9 was an [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected resident #9 had a BIMS score of 11, indicating she was moderately impaired cognitively, she was totally dependent on staff for bed mobility, transfers and hygiene and required extensive assistance for dressing. The MDS further reflected Resident #9 was at risk of developing pressure sores but had no pressure sores at that time. Resident #9's most recent Braden Scale dated 08/28/13 reflected a score of 12 indicating she was at high risk for developing pressure sores. Resident #9's Care Plan dated 09/19/13 reflected she was Total-Extensive dependence on staff for completion of ADLs related to debility. Approaches included: "Monitor skin weekly and document. Notify physician of changes." Resident #9's Care Plan dated 09/24/13 reflected she had a decubitus ulcer on her right mid lower leg measuring 2.1 cm x 1.3 cm x 0.2 cm and was Stage II. Approaches included: "Treatment (blank line) as ordered. Notify Dr. of ineffectiveness of treatment...Document wound appearance and notify Dr of S/SX of infection ...Pressure relieving pillows to offload...." The Care Plan was last updated on 12/05/13 and reflected the wound measured 1.8 cm x 0.5 cm x 0.1 cm and reflected: "Cont. tx per order." The Care Plan was signed by the MDS Coordinator. In an interview on 12/11/13 at 4:30 PM, the MD Coordinator was asked why there was no Care Plan for Resident #9's pressure sores prior to 09/24/13. The MDS Coordinator stated she was unaware of the wound prior to 09/24/13. On 12/10/13 at 11:05 AM, during initial tour with LVN A, Resident #9 was observed sleeping in her bed. LVN A stated she was not Resident #9's usual Charge Nurse but was covering the hall that day. She identified the resident as possibly having a pressure sore on her heel. There was a sign above the resident's bed that read: "Boots must be worn on this patient at all times, thanks for your cooperation." Resident #9's Physician's Progress Notes reflected she was last seen by NP O on 10/15/13. The Progress Note dated 10/15/13 reflected no indication she had pressure sores. Observation on 12/10/13 at 1:46 PM with LVN A and CNA M revealed Resident #9 was lying in bed awake and alert. Resident #9's right heel dressing was removed and revealed an open area approximately 1.0 cm X 0.8 cm. Wound care was given as ordered. A dressing was observed on Resident #9's lower right lateral leg dated 12/08/13. When LVN A was queried about the dressing she stated she knew nothing about it. LVN A removed the dressing and revealed an open wound with a moderate amount of beige drainage within the wound and on the dressing. The wound edges were completely macerated and the wound bed could not be visualized. LVN A stated she did not know about the wound. She cleaned the wound with saline, measured the wound at 2.5 cm x 2.0 cm x 0.5 cm, and stated she was going to apply a clean, dry dressing and call the physician. During the care, CNA M stated she knew about the wound and explained it began as a blister caused by a brace she used to wear which was similar to the one on Resident #9's left leg. She stated she thought the blister had started two to three months ago, healed, then reopened. She stated whenever she showered Resident #9, she would tell her nurse and the nurse would change both dressings. LVN A stated there was no order for a treatment for [REDACTED]. When Resident #9 was asked whether she saw the wound doctor, she stated she had not. CNA M explained Resident #9 used to go to [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday but that had changed to Monday, Wednesday and Friday and the wound care physician came weekly on Wednesday. She confirmed the wound care physician had not seen Resident #9 since her wound reopened. Resident #9's Nurse's Notes reflected the following entries related to her dressing changes: 09/24/13 at 10:30 AM: "CNA notified Charge Nurse that resident has an open area to R calf 2.1 x 1.3 x 0.2 cleaned (with) NS applied Collagen & [MEDICATION NAME] dressing. (responsible party) called (phone number) & notified of (change) in condition." Signed by LVN D. (NOTE: There were no further entries indicating the physician was notified or orders obtained.) 10/28/13 at 10:00 AM: "NO (new order) clean R heel NS pat dry apply silver hydrogel, collagen, & dry dressing Q day (responsible party and phone number) informed of new area on foot." Signed by LVN D. 11/02/13 at 2:00 PM: "Assisted resident back to bed after lunch. Tx done to wounds in R heel & R leg. Moderate amount of blood noted. Kept dry and comfortable." Signed by LVN T 11/03/13 at 11:00 AM: "...Tx to R heel and R leg done. Small amt of drainage & blood noted. Heel protectors on resident." Signed by LVN T. 11/09/13 at 11:00 AM: "...Tx done to R leg and heel, heel protectors on bilateral heels...." Signed by LVN T. 11/10/13 at 11:00 AM: "...Tx to R leg and heel done...." Signed by LVN T. 11/11/13 at 8:15 AM: "...wound care to R heel given...." Signed by LVN D. 11/15/13 at 11:00 AM: "Repositioned wound care given ? c/o pain. Podus boots on bil ft." Signed by LVN D. 11/16/13 at 10:00 AM: "...L heel and leg dressing. ? odor noted. Small amount of drainage, blood stain observed." Signed by LVN T. 11/22/13 at 7:40 AM: "...Dressing (change) to R heel...." Signed by LVN D. 11/30/13 at 11:00 AM: "Tx to L heel & leg done. Kept dry and comfortable." Signed by LVN T. 12/01/13 at 11:00 AM: "Dressing to L heel and leg changed. Small amt of drainage noted." Signed by LVN T. 12/07/13 at 11:00 AM: "...L heel and leg tx done...." Signed by LVN T. 12/08/13 at 11:00 AM: "...Dressing to the wound changed. Yellowish drainage noted. Incontinent care provided. Kept dry and comfortable." Signed by LVN T. 12/10/13 at 1:00 PM: ...This nurse observe a wound on the left leg measure 2.5 cm x 2 cm x 0.5 cm. (Physician X) notify and talked to (NP O), an order for [REDACTED]." Signed by LVN A. 12/11/13 at 10:15 AM: Spoke (with) (NP O) for (Physician X). Order clarification to continue previous order for R calf. Cleanse (with) NS, pat dry apply silver hydrogel, collagen, cover (with) dry protective dressing QD...." Signed by LVN D. Resident #9's Physician's Telephone Orders dated 08/29/13 reflected: "...Continue everything on TARS...." Resident #9's Monthly Consolidated Orders for the month of September, 2013 reflected the following handwritten note written across the top: "MD Please compare hosp list before signing 8/31/13. Review" The orders were signed by the ADON on 08/31/13 and by the attending physician on 09/05/13 and included: "Cleanse Rt heel w/ NS, pat dry, apply calcium alginate, silver absorbing agent collagen dressing w/ santyl, cover with dry dressing BID. Cleanse blister on Lt calf w/ NS, pat dry, apply skin prep bid." Resident #9's Treatment Record for September 2013 reflected the following entries: "EZ boot to be worn in bed and chair to offload wound, float heels in bed to offload wound." The order was signed as completed every shift. "Cleanse Rt heel w/ NS, pat dry, apply calcium alginate, silver absorbing agent collagen dressing w/ santyl, cover with dry dressing BID. Cleanse blister on Lt calf w/ NS, pat dry, apply skin prep bid...." The treatments were never signed as completed and both treatments had handwritten noted that reflected: "DC 09/13/13." Review of Resident #9's Physician Telephone orders revealed no order to discontinue the treatments. Resident #9's Physician's Telephone Orders dated 10/28/13 reflected an order to clean the right heel with normal saline, pat dry, apply silver hydrogel, collagen dressing and a dry, protective dressing daily. Review of Resident #9's Treatment Orders for the month of November 2013 revealed there were no wound treatment or prevention orders at all. Resident #9's Treatment Orders for the month of December 2013 reflected an order to cleanse her right heel with normal saline, pat dry, apply silver hydrogel, collagen dressing and a dry, protective dressing daily. The order date was 10/28/13. There were no orders related to her right leg. On 12/10/13, the DON was asked to provide her wound tracking and surveillance records to the survey team. Review of the weekly wound records dated 09/02/13 through 11/06/13 revealed there were no entries related to Resident #9. During an interview on 12/10/13 at 2:30 PM, the DON was asked why Resident #9 was not represented in the wound surveillance reports. The DON explained the lists represented only the residents who were seen by the wound care physician. She stated Resident #9 was not seen by the wound care physician because she was out at [MEDICAL TREATMENT] on those days. When asked how residents with wounds were treated if they had [MEDICAL TREATMENT] or any other scheduling conflicts with the wound care physician, the DON stated the primary care physician provided the orders. During another interview on 12/10/13 at 3:30 PM, the DON was asked if she kept her own surveillance records of wounds in the facility to monitor residents who were not seen by the wound care physician. The DON stated she received report daily and the nurses gave her a sheet with the wound measurements. She stated she was still looking for Resident #9 ' s sheet and had been unable to locate it. The DON stated Resident #9 was the only resident with a wound who was not seen by the wound care physician. On 12/10/13 at 4:38 PM, LVN A informed this surveyor she had obtained an order to apply Calcium Alginate, a dry dressing and consult the wound care physician. When asked whether the physician was aware of the wound, LVN A replied, "No." When asked how the wound care physician was supposed to see Resident #9 when he only came to the facility on Wednesday, her [MEDICAL TREATMENT] day, LVN A stated she did not know. She stated the Doctors were aware the wound care physician only rounded on Wednesday. When LVN A was then asked whether she reminded the physician of that fact when the order for the wound care consult was obtained, she stated she did not. During an interview on 12/11/13 at 8:15 AM, LVN D, Resident #9's usual 7:00 AM to 3:00 PM Charge Nurse, was asked about Resident #9's right leg wound. LVN D stated the wound started as a blister caused by a hard plastic "ski-boot" style brace she was wearing at the time. She stated Resident #9 was sent to the hospital related to blood pressure issues and, when she returned, it was an open wound. When asked about documentation, LVN D stated she documented wounds on Wednesdays and kept the information in a separate folder and she would provide the information. LVN D stated she treated the leg wound by cleaning with normal saline, applying silver hydrogel and collagen, and cover with a dry, protective dressing every day. LVN D stated she had "corrected" the order obtained the day before by LVN A. When asked when she obtained the treatment orders, LVN D stated she would look back and get the exact date. (NOTE: the order was never found.) When LVN D was asked where she documented her treatments, she stated she documented in the Treatment Administration Record. When told there was no entry for Resident #9's leg wound, LVN D stated she "saw that, it's on there now." LVN D then stated she documented in the nurse's notes when the treatments were done. When told there were no entries found there either, LVN D stated she would check. When asked whether a physician had observed Resident #9's right leg wound, LVN D stated the wound care physician was treating until her [MEDICAL TREATMENT] days changed. When asked when that happened, LVN D reviewed Resident #9's record and determined the [MEDICAL TREATMENT] schedule changes on or around 09/13/13. The record also reflected Resident #9 returned from the hospital on [DATE], there were no new orders for wound care. During the same conversation, LVN D located a Pressure Ulcer Record for Resident #9. The Record reflected two wounds. A wound to the right, outer lower leg was identified on a body outline as "Site A" with the date first observed as 09/24/13. The wound was identified as Stage II, 2.1 cm x 1.3 cm x 1.2 cm, no drainage or odor. LVN D stated she measured the wound that morning and documented it on the Record. The entry for the morning of 12/11/13 reflected it measured 1.3 cm x 0.5 cm x 0.1 cm, Stage II with no drainage. When LVN D was asked why the wound documentation was not started until 09/24/13, she replied, "When I got this sheet, that's when I started charting on this sheet, I didn't have this sheet before." When asked where she charted before obtaining the sheet, LVN D replied, "I didn't chart anywhere." LVN D stated she was a CNA before Resident #9 went to the hospital, she explained she was transitioning to a nurse position and, when Resident #9 returned from the hospital, she was her nurse. When LVN D was asked, since she knew about the wound, if she ever called to get orders, she looked through the chart and stated she had spoken to NP O. LVN D stated, "When she came back, I just continued with her previous orders." When asked if she ever checked to see if the orders were written, LVN D replied, "No." During an interview on 12/11/13 at 11:06 AM, NP O stated she was not sure when she became aware of the wound on Resident #9's leg. She confirmed her last note about the resident was dated 10/15/13. She stated she was at the facility on 12/05/13 but she did not see Resident #9. NP O stated she remembers the staff talking to her about a wound that day but she could not say which wound specifically. NP O stated she did not know if she was aware the wound care physician was not treating Resident #9. She could not recall ever looking at Resident #9's wounds. When asked whether LVN D had called her about orders, NP O confirmed she had. NP O stated, "I don't know that I was made aware until yesterday that it had progressed, I did talk to them on the 5th." An observation on 12/12/13 at 10:30 AM, Medical Director/Physician K, accompanied LVN D to Resident #9's room to assess her wounds. When Medical Director/Physician K observed the wound he stated it was a

Based on observation, interview and record review, the facility failed to implement its policies and procedures, which prohibit neglect for five (Residents #2, #3, #9, #11 and #13) of 21 residents reviewed for neglect. 1) Resident #3 experienced a 16.3% (20.8 pounds) severe weight loss from 11/01/13 to 12/17/13. Staff failed to consult with the physician after they became aware of her 10% weight loss for two weeks until surveyor inquiry. 2) Staff identified an open pressure ulcer on Resident #11's coccyx and failed to consult with the physician for 12 days for treatment orders. On the 12th day, the pressure ulcer was identified as a Stage 3 pressure ulcer by the wound physician. 3) Staff administered [MEDICATION NAME] (for blood pressure) to Resident #13 despite below normal blood pressure readings of 71/26, 109/36 and 108/58 and failed to notify the resident's physician . They further failed to notify her physician when her evening blood pressures were 71/26, 109/36, 97/68, 88/45 and 108/58 until surveyor inquiry. 4) Resident #9 was re-admitted to the facility on [DATE] with a pressure ulcer on her right lateral leg according to facility staff. The staff failed to notify the physician promptly for treatment orders until surveyor inquiry. The facility failed to administer 23 different medications to Resident #9, including medications used to treat Heart Failure, Hypertension, [MEDICAL CONDITION], Depression, Diabetes Mellitus, Pressure Ulcers, and [MEDICAL CONDITION] when she left the facility three times a week for [MEDICAL TREATMENT] treatments for four (September, October, November and December 2013) of four months reviewed. Her physician was unaware the medications were not given until surveyor inquiry. 5) Resident #2 was readmitted to the facility with an indwelling urinary Foley catheter. The facility failed to notify the physician for orders for care and treatment of [REDACTED].#2's catheter was not changed for four months until surveyor inquiry. These failures to consult the physician with a drop in blood pressure, severe weight loss, orders for an indwelling urinary catheter, for pressure ulcer treatment orders and the failure to administer physician-ordered medications could affect any of the facility's 75 residents, including Residents #2, #3, #9, #11 and #13, and placed them at risk for not having their needs met, a delay in needed medical care and treatment, the potential for deterioration in their clinical condition, not maintaining therapeutic levels of medications, increased the length of time needed for healing, the need for hospitalization and even death. An Immediate Jeopardy (IJ) was identified on 01/02/14. While the IJ was removed on 01/11/14, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. Findings included: 1) Resident #3 was a [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she was severely impaired cognitively, was totally dependent on staff for her ADLs, she weighed 133 lbs, and had no weight loss. Resident #3's Care Plan dated 10/24/13 reflected: "(Resident #3) poor appetite eating DT Cognitive Deficit/family declined GT placement." Approaches included: Diet as ordered/preferences per family's request...; Medication as ordered, Assist/Cueing with meal; Document meal % and report % to nurse with meal ticket; Offer fluids frq throughout day...; Dietary consult; Psych consult; Notify Dr./RP of any changes in condition." Resident #3's consolidated physician's orders [REDACTED]. The order was dated 10/24/13. Resident #3's Dietary Progress Notes dated 11/21/13 reflected: "Resident has 11% significant wt. loss X's 180 days R/T poor appetite, refuses to eat after return from hospital. Resident Received fortified foods, likes chocolate milk. Resident on weekly weights. DSM will monitor meal intake, nursing to monitor weight and skin closely, will follow." Resident #3's Food Intake Record for November 2013 revealed she consumed less than 50% of her meal 27 times. Additionally, meal percentages were not documented at all and left completely blank 24 times. Review of Resident #3's MARs for November 2013 revealed an entry dated 09/27/13 for Med Pass 60 cc by mouth as needed if the resident eats less than 50%. There were no doses initialed as administered. Resident #3's Nutritional assessment dated [DATE] reflected her weight was 128 lbs. The Summary and Recommendations reflected: "10/25/13: Dietary consult ordered for low pre-alb. Nutr assess reveals pt readmitted post hospitalization at (hospital name) for possible [DEVICE] eval due to failure to thrive, dysphagia, and UTI; pt shows wt loss 5 lbs/30 days-4%, following overall wt loss 15 lbs/180 days-10.49%; Pt remains within desirable wt range, as reflected by BMI factor; Pt continues w/varying intake of regular, therapeutic diet; [MEDICATION NAME] was ordered 10/28/13 for appetite stimulant; Pro powder was dc'd 10/25/13 due to pt refusal; pt receives med pass 60 cc TID if intake < 50% for add'l 360 cal/15 gm pro; lab reveals low pre-alb level; due to continued wt loss and low pre alb, recommend adding Medpass 2.0 120 cc BID for add'l 480 cal/20 gm pro; pt to be carefully monitored." NOTE: The recommendation for Medpass 120 cc BID was never ordered. Resident #3's Food Intake Record for December 2013 revealed she consumed less than 50% of her meal seven times between 12/01/13 and 12/12/13. Additionally, meal percentages were not documented at all and left completely blank eight times from 12/01/13 through 12/12/13. Review of Resident #3's MARs for December 2013 revealed an entry dated 09/27/13 for Med Pass 60 cc by mouth as needed if the resident eats less than 50%. There were no doses initialed as administered. Observation on 12/11/13 at 8:00 AM revealed Resident #3 was fed breakfast in the dining room by facility staff. Resident #3 consumed 30% of her eggs, 90% of her oatmeal and 75% of her meat. Observation on 12/11/13 at 1:05 PM revealed Resident #3 was fed lunch in the dining room by facility staff. She only consumed 25% of her meat and 60% of her dessert. During an interview on 12/12/13 at 7:10 PM, LVN W was asked about Resident #3's Med Pass order. LVN W stated she did give the resident Med Pass on occasion. She stated she had been giving her health shakes because Resident #3 would drink them up. She could not answer why there were no doses documented. LVN W stated Resident #3's (family member) often came in the evening and "feeds her too much." When asked what she meant by that, LVN W stated he/she would push her to eat yogurt and healthshakes and she (LVN W) thought he "overdoes it." During an interview on 12/13/13 at 8:10 AM, LVN D stated she had not given Resident #3 any Med Pass because she was eating much better and did not need any. When asked about the Food Intake Record and informed there were several times she refused to eat or ate less than 50%, LVN D stated she had her meal tickets somewhere and was not aware of Resident #3 ever eating less than 50%. She stated she knew Resident #3's weight was stable, and she had no weight loss this month. Resident #3's Yearly Weight Record reflected the following weights: 10/24/13 - 128.1 lbs 11/01/13 - 127.6 lbs 12/02/13 - 126.6 lbs 12/09/13 - 126.6 lbs Observation on 12/13/13 at 8:24 AM revealed Resident #3 was weighed by Restorative Aide BB. Resident #3 was weighed in her wheelchair, then assisted to a chair and then the empty wheelchair was weighed. The resident's weight was 109.2 lbs. Restorative Aide BB stated she weighed the resident the same way every time. She stated her weight had dropped, and she would report the findings to LVN D and ensure the resident was weighed daily. She added she would request the scale be calibrated for accuracy. Restorative Aide BB checked her records, which were kept in the therapy department, and discovered she had entered the wrong weights on Resident #3's Yearly Weight Record. She corrected the Yearly Weight Record to reflect the following: 11/1/13 - 127.6 lbs 12/02/13 - 122.6 lbs 12/06/13 - 120.6 lbs 12/13/13 - 109.4 lbs On 12/13/13 at 9:30 AM, LVN D was informed of Resident #3's actual weight of 109 lbs by the surveyor. LVN D stated she had been informed, and they were going to get the scale calibrated. During an interview on 12/14/13 at 10:00 AM, LVN T, Resident #3's weekend Charge Nurse, was shown Resident #3's MAR and asked why no Med Pass had been administered as ordered. LVN T explained since the resident returned from the hospital, she had been doing much better so none was given. LVN T was shown Resident #3's Food Intake Records for November and December 2013 with several weekend entries reflecting she had either refused to eat or consumed less than 50%. LVN T stated, "The aides didn't tell me. They gave the ticket to the clerk. I should have checked." In an interview on 12/16/13 at 3:20 PM , Restorative Aide BB stated she had spoken with the Dietary Manager, who agreed she (Restorative Aide BB) would personally feed Resident #3 in the therapy department and complete a more detailed summary of her intake with every meal. On 12/17/13 at 12:20 PM, Restorative Aide BB stated the scale had been calibrated. At that time, Resident #3 was weighed, and her weight was down to 106.8 lbs. On 12/17/13 at 2:30 PM, Restorative Aide BB reviewed Resident #3's meal intake documents completed for 12/16/13. The form reflected she consumed 25% of her breakfast, no lunch and only 10% of her dinner. Restorative Aide BB stated she discussed her plans to personally feed Resident #3 with LVN D and the DON, who agreed it was a good idea. Review of Resident #3's December 2013 MAR revealed there was still no Med Pass administered on 12/16/13. Review of Resident #3's Nurse's Notes revealed no indication her physician had been notified of her weight loss. Resident #3's Dietary Progress Notes dated 12/13/13 reflected the following: "Resident last weighed @ 109.4, weighed twice. Scales to be checked stated by Rehab aide. Resident continues to have significant amount of weight loss, resident has 14% significant weight loss x's 30 days R/T refusal to eat. (Director of Dietary Services) called dietitian's asst. Dietitian on vacation @ this X, facility needed immediate intervention due to tremendous amount of weight loss within 30 days. Dietitian faxed recommendations, (Director of Dietary Services) was also asked to tell resident's charge nurse of recommendations of Med Pass (with) medications 3 x a day. Nurse stated res. already receives 60 cc if she eats less than 50%. Dietitian stated res is a good candidate for appetite stimulant but may not be able to receive it according to what's going on with her. (Director of Dietary Services) talked (with) charge nurse, stated she receives [MEDICATION NAME] already but res still not eating well as observed by (Director of Dietary Services) & rehab aide. Nurse stated she would call the doctor. Doctor's office called (Director of Dietary Services) about dietitian's recommendations and stated she would talk with doctor and get back (with) me. Will follow...." The note was signed by Director of Dietary Services. Resident #3's Nutritional assessment dated [DATE] reflected her weight was 127 lbs. Summary and Recommendations reflected: "12/17/13: Dietary consult requested due to weight loss. Nutr assess reveals wt remains stable/ 30 days, following wt loss 9 lbs/90 days-7%, 13 lbs/180 days-9.29%; Pt remains within desirable wt range, as reflected by BMI factor;...Pt continues to refuse to eat; Pt will accept shakes and chocolate milk; [MEDICATION NAME] continues for appetite stimulant; Med Pass continues 60 cc TID if meal intake is < 50% for add'l 360 cal/15 gm pro, due to continued wt loss and low pre-alb, recommend adding Med Pass 2.0 120 cc BID for add'l 480 cal/20 gm pro; wt loss may be expected; ...continue to monitor closely; goal is to provide adequate cal and pro to stabilize wt." The assessment was signed by Dietary Consultant PP. During an interview on 01/02/14 at 4:10 PM, Dietary Consultant PP was queried about her Nutritional Assessment of Resident #3. Dietary Consultant PP stated she was called for a consultation on 12/17/13 and the weight reflected on her assessment was the weight she was given for Resident #3 by the facility. When asked about her recommendation for the Med Pass 2.0 supplement, Dietary Consultant PP explained she was informed by facility staff Resident #3 had been receiving doses of Med Pass as needed but she wanted to add a scheduled dose in addition to the PRN dose already ordered. She could not remember who told her Resident #3 was taking the Med Pass. When the Dietary Consultant PP was told Resident #3's weight was actually 109 lbs on 12/13/13, then dropped to 106 lbs, she stated she was never made aware of the weight drop. When asked who provided her the information for her consultation, Dietary Consultant PP stated the Director of Dietary Services faxed a weight sheet prior to her arrival. She explained they typically faxed the information in advance so she could prepare for her visit. During an interview on 01/02/14 at 4:35 PM, the Director of Dietary Services was asked what type of information she sent to the dietitian when a consultation was ordered. She stated she sent them the resident's weights. When asked about Resident #3, she confirmed she sent the dietitian her weights. The Director of Dietary Services retrieved a list of monthly weights to show the surveyor. Resident #3's weight for December was documented as 126.6 lbs; a line was drawn through the entry. The Director of Dietary Services stated, "I lined that out later and wrote 109." The Director of Dietary Services retrieved a Dietitian Consultant Worksheet and stated she typically filled it out and gave it to the Dietitian. When asked whether she provided one for Resident #3's consultation, the Director of Dietary Services replied, "I can't remember if I did this last time. They never let me know when they are coming." The Director of Dietary Services also explained she had informed the Dietitian Resident #3 was taking Med Pass supplement. She stated she had been informed by LVN D the resident was getting it. On 12/17/13 at 2:17 PM, an interview with NP P, Resident #3's Nurse Practitioner, revealed she had not been notified of Resident #3's weight loss and was unaware of the recent weight drop. During an interview on 12/17/13 at 3:07 PM, LVN D stated she remembered the surveyor reporting Resident #3's weight loss on 12/13/13. She stated she reported the information to the DON. When asked why she did not call the physician, LVN D stated she was going to wait until the scale was calibrated. In an interview on 12/17/13 at 4:10 PM, the DON stated Resident #3's physician had been called and lab orders were obtained for a CBC, CMP and Pre-[MEDICATION NAME] level to be done. She added a care plan meeting with the family was being arranged and Physician K, Resident #3's attending physician, would attend. The DON stated Resident #3 was getting health shakes instead of Med Pass but staff had not been documenting it. She stated nursing administration was going to take over monitoring Resident #3's meal intake and every resident in the building would be re-weighed. When asked why the physician was not notified on 12/13/13 when the discrepancy was found, the DON stated, "No. It was the intent but it got dropped." An interview on 01/02/14 at 2:21 PM with Restorative Aide BB revealed she had begun re-weighing residents but had not completed the task (16 days since the DON said all residents would be re-weighed.). Restorative Aide BB provided lists dated 12/31/13 through 01/02/14 with the names and weights of residents. When asked when she was asked to initiate re-weighing the residents, she stated she had not been told by anyone to re-weigh the residents. When asked why she was re-weighing the residents, Restorative Aide BB said, "I know that's what you do when you have a discrepancy." In an interview on 01/03/13 at 12:12 PM, the DON was asked whether she had implemented the re-weighing of all the residents as she had informed the surveyor she would. The DON stated, "We are in the process of doing that now." During an interview on 01/06/13 at 12:00 PM, Physician K stated he had taken part in care plan meetings regarding Resident #3. He stated he had decreased her medications, which were not critical to maintain function. Physician K stated he learned the facility had not been calling the family to assist her when she would not eat as had been agreed upon during a previous meeting. 2) Resident #11 was a [AGE] year-old female, readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed the resident was severely impaired for cognitive skills for daily decision-making, was totally dependent on staff for bed mobility and had two Stage 3 pressure ulcers. Review of a care plan for Resident #11 dated 09/15/13 revealed: "PROBLEM: (Resident #11) is at risk for developing Wounds D/T debilitated state/DX AEB Diabetes Mellitus, Contractures and immobility deficit. GOAL: (Resident #11) will not develop wounds this eval period. APPROACHES: 1. Assess skin and document findings q week per wound protocol 2. Reposition with pillows as positioning devices q2h and as needed 3. Shower per shower protocol. Dry well and apply lotion 4. Feedings as ordered 5. Pressure relieving devices as needed: Mattress, W/C Cushions 6. Gentle Passive ROM with personal care daily 7. Medications as ordered 8. Dietary Consult as indicated 9. Not Dr./RP of change in condition" Review of Resident #11's "Weekly Skin Assessment" dated 10/05/13 revealed: Skin: Warm and Dry were both checked Skin Tears: "No" was checked Bruises: "No" was checked Abrasions: "No" was checked Incisions: "Yes" was checked - "If Yes, describe all areas and location:" GT site was hand written in. Rash: "No" was checked Pressure, Diabetic, Venous, Arterial Ulcer, or Incision: "Yes" was checked. "Describe" Coccyx was hand written in. LVN S signed this assessment. Review of Resident #11's Nurse's Notes dated 10/05/13 revealed no mention of an open area on the resident's coccyx. In an interview on 12/13/13 at 11:25 AM the surveyor reviewed Resident #11's "Weekly Skin Assessment" dated 10/05/13 with LVN S, which he completed. LVN S stated, "I think she (Resident #11) came back from the hospital with it (Pressure ulcer)." LVN S documented Resident #11 had a wound on her coccyx and he stated he did not describe the wound on any of the facility documents. "I just change the dressing. I clean the wound with normal saline; sometimes I put a little TAO and a dressing on it (pressure wound), to cover it so it doesn't get infected. I do that when the dressing is dirty and when I do my weekly skin assessments. I look for physician (treatment) orders and if there is not an order I do the TAO." The surveyor asked LVN S if he considered calling the physician if there were no treatment orders and LVN S stated, "No," we have a wound nurse in the house (facility). I call her sometimes." The surveyor asked who the wound nurse was and LVN S stated, (LVN D)." In an interview on 12/12/13 at 8:28 AM the ADON stated when a charge nurse finds a new wound. the charge nurse tells the ADON and DON. "The ADON/DON go look at it (pressure wound) right then." The ADON further stated when the nurse found a new wound he/she needed to get wound treatment orders right then and not wait until the wound doctor made his visit. In an interview on 12/12/13 at 1:15 PM the surveyor asked the DON what she expected her nurses to do when they found a new pressure wound and the DON stated, initiate a weekly skin sheet, document the wound on the twenty-four report, tell the oncoming nurse, measure the wound and document the measurements in the nurse's notes, call the physician, get wound care order. initiate the treatment and call the resident's family. Review of Resident #11's "Weekly Skin Assessment" dated 10/12/13 revealed: Skin: Warm and Dry were both checked Skin Tears: "No" was checked Bruises: "No" was checked Abrasions: "No" was checked Incisions: "Yes" was checked - "If Yes, describe all areas and location:" GT site was hand written in. Rash: "No" was checked Pressure, Diabetic, Venous, Arterial Ulcer, or Incision: "Yes" was checked. "Describe" Coccyx was hand written in. LVN S signed this assessment. Review of Resident #11's Nurse's Notes dated 10/12/13 revealed no mention of an open area on the resident's coccyx. Review of Resident #11's Nurse's Notes dated 10/13/13 at 9:00 PM revealed, "...found bottom (coccyx) with a freshly open stage 2 pressure ulcer, wound dressed and dated, to F/u on wound MD (name of wound doctor)." LVN J signed this note. Review of Resident #11's Nurse's Notes dated 10/14/13 at 9:00 AM revealed, ...Pt. has an old scar at the coccyx re-open measured 6 cm x 6 cm. A communication for wound consult written, an order from the Dr ...." LVN A signed this note. Review of Resident #11's physician orders [REDACTED]." Note this was the first physician order [REDACTED]. In an interview on 12/14/13 at 12:37 PM LVN A stated 10/14/13 was the first time she saw the pressure wound on Resident #11's coccyx. LVN A showed the surveyor her nurse's notes where she documented the size of the wound at 6 cm x 6 cm. The surveyor asked LVN A if she charted observations of wounds, color or drainage and LVN A stated, "Sometimes." The surveyor asked LVN A if she called the physician and got treatment orders for the pressure wound and LVN A stated, "We wait until the wound doctor comes on Wednesdays. I think it (10/14/13) was the day before the wound doctor was supposed to come." The surveyor shared with LVN A, it was two days prior to the wound doctors visit and LVN A stated, "It (pressure wound) wasn't that bad." Review of Resident #11's Nurse's Notes dated 10/14/13 at 2:30 PM, 4:30 PM, 6:30 PM, and 8:30 PM revealed, "...Dsg C-D-I Coccyx." LVN C signed these notes. Review of Resident #11's Nurse's Notes dated 10/15/13 at 12:00 AM revealed, "...coccyx dsg intact." LVN S signed this note. Review of Resident #11's Nurse's Notes dated 10/15/13 at 2:30 PM, 10/15/13 and 10/15/13 at 8:30 PM revealed the resident's dressing on her coccyx was clean, dry and intact. LVN C signed these notes. Review of Resident#11's Nurse's Notes dated 10/16/13 at 2:00 AM, 4:00 AM, and 6:00 AM revealed the dressing on the resident's coccyx was clean, dry and intact. LVN S signed these notes. The Wound Physician note dated 10/16/13 for Resident #11 reflected the following: History of Present Illness - "[AGE] year-old female patient has a stage 3 pressure wound of the sacrum of at least 1 days (sic) duration. There is light serous exudate...no indication of pain...." "Stage 3 Pressure Wound of the Sacrum Etiology (Quality): Pressure Duration: > 1 days (sic) Objective: Palliation Wound size (L x W x D) 5.0 x 5.0 x 0.1 cm Exudate - light serous Granulation Tissue: 100 %" "Dressing: Silver hydrogel, collage dressing, dry protective dressing, foam, once daily." Review of Resident #11's physician orders [REDACTED]. Low air loss mattress." Note this was the first treatment physician order [REDACTED]. Review of Resident #11's treatment administration records revealed the silver treatment was initialed as started on 10/16/13. Further review of this record revealed the low air loss mattress was initialed as started on 10/20/13. Review of a "Detail Admission/Discharge Report" dated 12/12/13 for Resident #11 revealed the resident was: -- admitted to the facility on [DATE], -- Transferred to the hospital on [DATE], -- Readmitted to the facility on [DATE], -- Transferred to the hospital on [DATE] and -- Readmitted to the facility on [DATE]. 3) Resident #13 was a [AGE] year-old female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she had severely impaired cognition and was totally dependent on staff for assistance with ADLs. Resident #13's monthly consolidated physician's orders [REDACTED]. -[MEDICATION NAME] 0.1 mg by mouth daily at 9:00 AM; Hold if SBP less than 110 or DBP less than 60. -[MEDICATION NAME] 50 mg one three times daily at 9:00 AM, 1:00 PM and 5:00 PM; Check B/P and Hold if SBP less than 110 or DBP less than 60. Resident #13's MAR for the month of December 2013 reflected the following: [MEDICATION NAME] 50 mg one by mouth three times a day, Hold if SBP less than 110 or DBP less than 60. The medications were times for 9 AM, 1 PM and 5 PM with spaces provided beneath each day's entry to record the blood pressure. The 5 PM dose entries reflected: 12/02/13- BP 71/26 - dose was initialed as given. 12/10/13- BP 109/36 -dose was initialed as given. A note on the back of a separate page revealed: "12/10/13 5P Held [MEDICATION NAME] 0.1 mg tab PO BP 109/36." Signed by LVN C. 12/11/13- BP 97/68 -dose was circled as held. A note on the back of a separate page revealed: "12/11/13 5P BP 97/68 Held [MEDICATION NAME] 0.1 mg" Signed by LVN C. 12/12/13 -BP 88/45 -dose was circled as held. A note on the back of the page revealed " 12/12/13 5 PM BP 88/45 P 77 Held [MEDICATION NAME] 50 mg " Signed by LVN C. Another note on the back of a separate page revealed: "12/12/13 5P BP 88/45/77 Held [MEDICATION NAME] 0.1 mg. RT (retake?) @ 7P 105/70 P 64" Signed by LVN C. 12/13/13 - BP 108/58 -dose was initialed as given. During an interview with LVN C, Resident #13's 3:00 PM to 11:00 PM Charge Nurse, on 12/16/13 at 3:30 PM, when LVN C was shown Resident #13's December MAR and asked about the blood pressure reading of 71/26 on 12/02/13. LVN C stated,"Initially I write them down, then come back and re-check." LVN C looked in a small book she brought but was unable to find a recheck. When asked when she would call the physician, LVN C stated she would call if the blood pressure readings were consistently lower but (Resident #13) had higher readings in the mornings. When asked what she typically did when the blood pressure readings were low, LVN C stated she would hold blood pressure medications and recheck the blood pressure. When asked how she should document that, LVN C stated she should circle the initialed dose and record the information on the MAR, then return and recheck with a different blood pressure cuff. She explained if the readings were unusual for several residents, she would change the batteries. LVN C was shown her entries in the MAR which reflected she administered [MEDICATION NAME] to Resident #13 with blood pressure readings of 71/26, 109/36 and 108/58. Additionally, she had written entries reflecting she held [MEDICATION NAME] doses on 12/10/13, 12/11/13 and 12/12/13 for low blood pressure readings. Only [MEDICATION NAME] was scheduled on LVN C's shift as [MEDICATION NAME] was scheduled for 9:00 AM. LVN C stated she wasn't ' sure but probably meant to write [MEDICATION NAME]. When LVN C was asked if the low blood pressure trend warranted a call to the physician, she stated she was not sure. When asked how long she would let it go, LVN C replied, "I think they told us by the third day." When asked if she ever called about Resident #13, LVN C replied, "No." Review of Resident #13's Care Plan "Hypertension" dated 07/02/13 revealed: "Problem/ Need - Problem Onset: 07/02/13 (Resident #13) has potential for retaining abnormal body fluids R/T Hx. of HTN. Goal & Target Date: (Resident #13) will maintain within normal body fluid level as evidence of normal related lab values until next review date. Approaches: --Diet as ordered by physician. --Obtain monthly weights. --Diet Consult as needed. --Monitor for S/S of [MEDICAL CONDITION]" 4) A) Resident #9 was an [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected resident #9 had a BIMS score of 11, indicating she was moderately impaired cognitively, she was totally dependent on staff for bed mobility, transfers and hygiene and required extensive assistance for dressing. The MDS further reflected Resident #9 was at risk of developing pressure sores but had no pressure sores at that time. Resident #9's most recent Braden Scale dated 08/28/13 reflected a score of 12 indicating she was at high risk for developing pressure sores. Resident #9's Care Plan dated 09/19/13 reflected she was Total-Extensive dependence on staff for completion of ADLs related to debility. Approaches included: "Monitor skin weekly and document. Notify physician of changes." Resident #9's Care Plan dated 09/24/13 reflected she had a decubitus ulcer on her right mid lower leg measuring 2.1 cm x 1.3 cm x 0.2 cm and was Stage II. Approaches included: "Treatment (blank line) as ordered. Notify Dr. of ineffectiveness of treatment...Document wound appearance and notify Dr of S/SX of infection ...Pressure relieving pillows to offload...." The Care Plan was last updated on 12/05/13 and reflected the wound measured 1.8 cm x 0.5 cm x 0.1 cm and reflected: "Cont. tx per order." The Care Plan was signed by the MDS Coordinator. In an interview on 12/11/13 at 4:30 PM, the MDS Coordinator was asked why there was no Care Plan for Resident #9's pressure sores prior to 09/24/13. The MDS Coordinator stated she was unaware of the pressure ulcer prior to 09/24/13. On 12/10/13 at 11:05 AM, during initial tour with LVN A, Resident #9 was observed sleeping in her bed. LVN A stated she was not Resident #9's usual Charge Nurse but was covering the hall that day. She identified the resident as possibly having a pressure sore on her heel. There was a sign above the resident's bed that read: "Boots must be worn on this patient at all times, thanks for your cooperation." Resident #9's Physician's Progress Notes reflected she was last seen by NP O on 10/15/13. The Progress Note dated 10/15/13 reflected no indication she had pressure sores. Observation on 12/10/13 at 1:46 PM with LVN A and CNA M revealed Resident #9 was lying in bed awake and alert. Resident #9's right heel dressing was removed and revealed an open area approximately 1.0 cm X 0.8 cm. Wound care was given as ordered. A dressing was observed on Resident #9's lower right lateral leg dated 12/08/13. When LVN A was queried about the dressing she stated she knew nothing about it. LVN A removed the dressing and revealed an open wound with a moderate amount of beige drainage within the wound and on the dressing. The wound edges were completely macerated and the wound bed could not be visualized. LVN A stated she did not know about the wound. She cleaned the wound with saline, measured the wound at 2.5 cm x 2.0 cm x 0.5 cm, and stated she was going to apply a clean, dry dressing and call the physician. During the care, CNA M stated she knew about the wound and explained it began as a blister caused by a brace she used to wear which was similar to the one on Resident #9's left leg. She stated she thought the blister had started two to three months ago, heal

Based on observation, interview and record review, the facility failed to implement its policies and procedures, which prohibit neglect for two (Residents #1 and #2) of 14 residents reviewed for neglect. 1) a.The facility failed to properly transcribe and administer the following medications for Resident #1 in two of two months reviewed: [MEDICATION NAME] 25 mg - missed three of five doses; [MEDICATION NAME] 20 mg - missed three of five doses; [MEDICATION NAME] eye drops- missed three of five doses; [MEDICATION NAME] 40 mg-20 mg was given and only administered three out of five times; [MEDICATION NAME] - was given in the morning instead of at bedtime as ordered; [MEDICATION NAME] 200 mg- 100 mg was given for three days; [MEDICATION NAME] - was given in the morning instead of at bedtime as ordered; Levetiracetam 1000 mg- 500 mg was administered for three days; [MEDICATION NAME] XL - missed three 60 mg doses and missed five 30 mg doses; and [MEDICATION NAME] 0.1 mg - missed five doses. b. LVN D failed to administer the correct dose of pain medications to Resident #1 when she repeatedly complained of leg pain. LVN D administered one [MEDICATION NAME] 5/325 mg tablet when the ordered dose was two 10/325 mg tablets. 2. The facility failed to discontinue Resident #2's [MEDICATION NAME] 25mg (for Hypertension) as ordered. The morning dose of [MEDICATION NAME] was discontinued on 02/03/14 and the evening dose was not discontinued until after the 02/28/14 dose, for a total of 31 doses. These failures could affect any the facility's 75 residents, including Residents #1 and #2, by placing them at risk for ongoing medication errors resulting in depression, eye discomfort, unrelieved pain, stomach upset, [MEDICAL CONDITION], weakness, confusion, dizziness, headache, [MEDICAL CONDITIONS] and death and could affect the 75 residents in the facility. Findings included: 1) Review of Resident #1's Physician's Telephone Orders dated 02/26/14 revealed she was to be readmitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #1's admission Nurse's Note dated 02/26/14 at 2:20 PM revealed she was confused but able to make her needs known at that time. Review of Resident #1's hospital Medication Profile Report dated 02/25/14 revealed the following medications were among those to be continued when she returned to the facility: [MEDICATION NAME] Hcl 25 mg tablets by mouth twice daily (used to treat high blood pressure); [MEDICATION NAME] 20 mg tablets by mouth twice daily (used to treat chest pain caused by heart damage); [MEDICATION NAME] Sodium 100 mg caps, two twice daily (used to prevent constipation); [MEDICATION NAME] 0.05% eye drops, one drop in each eye twice daily (used for increase tear production); [MEDICATION NAME] 20 mg tablets, give 40 mg at bedtime (used to lower cholesterol); [MEDICATION NAME] 20 mg tablets, give 10 mg by mouth at bedtime (used to treat depression); [MEDICATION NAME] 100 mg tablets, give 200 mg at bedtime (used to treat pain caused by [MEDICAL CONDITION]); [MEDICATION NAME] 325 mg, give one at bedtime (iron supplement used to treat [MEDICAL CONDITION]); Levetiracetam 500 mg tablets, give 1000 mg at bedtime (used to treat [MEDICAL CONDITION]); [MEDICATION NAME] XL 30 mg by mouth every day (used to treat high blood pressure and chest pain); [MEDICATION NAME] XL 60 mg by mouth every evening; and [MEDICATION NAME] HCL 0.1 mg by mouth every day (used to treat high blood pressure). Review of the facility ' s admission orders [REDACTED] [MEDICATION NAME] 30 mg PO QD; and [MEDICATION NAME] HCL 0.1 mg PO QD. Review of Resident #1's February 2014 MARs revealed the following: [MEDICATION NAME] 25 mg tablets twice a day was only transcribed and initialed as administered once on 02/27/14. (Not twice a day as ordered) [MEDICATION NAME] 20 mg tablets was only transcribed and initialed as administered once a day on 02/27/4 and 02/28/14. (Not twice a day as ordered) [MEDICATION NAME] Sodium 100 mg caps was only transcribed and initialed as administered once on 02/27/14 and 02/28/14. (Not twice a day as ordered) [MEDICATION NAME] eye drops were only transcribed and initialed as administered once a day on 02/27/14 and 02/28/14. (Not twice a day as ordered) [MEDICATION NAME] was transcribed as 20 mg at bedtime and only initialed as administered on 02/26/14 and 02/27/14. (Not on 02/28/14 as ordered) [MEDICATION NAME] was transcribed and initialed as administered as 10 mg at 6:30 AM. (Not at bedtime as ordered) [MEDICATION NAME] 100 mg was transcribed and initialed as administered at bedtime. (Not 200mg as ordered) [MEDICATION NAME] 325 mg was transcribed and initialed as administered at 6:30 AM. (Not at bedtime as ordered) Levetiracetam 500 mg was transcribed and initialed as administered daily at bedtime. (Not 1000 mg as ordered) [MEDICATION NAME] XL was transcribed as 30 mg by mouth every evening and was only administered on 02/26/14 and 02/27/14. (Not 60 mg as ordered and none on 02/28/14) [MEDICATION NAME] XL 60 mg was not transcribed to the February MAR and so no doses were given in February. Review of Resident #1's March 2014 MARs revealed the following: [MEDICATION NAME] XL 30 mg by mouth every day was not transcribed and so was not administered from 03/01/14 through 03/05/14, when surveyor inquired. [MEDICATION NAME] HCL 0.1 mg by mouth every day was not transcribed and so was not administered from 03/01/14 through 03/05/14, when surveyor inquired. An interview with the Unit Manager on 03/04/14 at 4:32 PM revealed it was typically her duty to check all orders daily for accuracy but she was pulled off the floor or on 02/24/14 to work on the monthly consolidated orders for the remainder of the month. She stated, during that time, the DON was performing the daily checks on both nurses' stations. During an interview on 03/05/15 at 10:25 AM, LVN C stated she had transcribed the admission orders [REDACTED]. When shown the errors found by the surveyors, LVN C stated she was not aware of the errors. She stated RN A had transcribed the orders to the March MARs and she remembered RN A pointing out some discrepancies to her but she thought she had corrected them. During an interview on 03/05/14 at 11:25 AM, RN A stated she had transcribed the March MARs for Resident #1 but had never looked at February's MARs. RN A stated she had caught a few discrepancies after the hospital orders had been transcribed to the facility's admission orders [REDACTED]. She was not aware of any medication errors. An interview with the DON on 03/05/14 at 11:25 AM revealed all orders, including new admission orders [REDACTED]. The DON explained pink copies of all resident's orders were to be placed in a box and both she and the Unit Manager checked those pink copies every day before they left to ensure all orders written over the past 24 hours were transcribed correctly. When asked about Resident #1, the DON confirmed the Unit Manager was not checking orders at that time as she had been pulled to work on the monthly orders. The DON stated she did not know why Resident #1's orders had not been checked; she stated the pink copies must not have made it into the designated box. b) Review of Resident #1's hospital Medication Profile Report dated 02/25/14 revealed the following medications were among those to be continued when she returned to the facility: [MEDICATION NAME] 10/325 mg one tablet every six hours as needed for pain. [MEDICATION NAME] 10/325 mg two tablets every six hours as needed for pain. Resident #1's admission orders [REDACTED]. Review of Resident #1's MAR for February 2014 revealed an entry for [MEDICATION NAME]-Apap 10-325 two every six hours as needed for pain. The entry was initialed as administered on 02/26/14 at 3:00 PM and 9:00 PM by LVN D. The back of the MAR reflected the following entries: 2/26/14 at 3:00 PM: "Resident c/o pain, pain level 8/10, [MEDICATION NAME] ([MEDICATION NAME]) 5/325 admin, pain level at 3:30 PM 6/10." The entry was signed by LVN D. 2/26/14 at 9:00 PM: "Resident c/o pain, telling, 8/10, [MEDICATION NAME] 5/325 mg admin, pain level @ 9:30 (PM), 7/10, ineffective." The entry was signed by LVN D. During an interview on 03/05/14 at 12:45 PM, LVN D explained she was Resident #1's Charge Nurse on 02/26/14 but LVN C was completing the admission orders [REDACTED]. When asked why she only administered 5/325 mg when the order and MAR both indicated the dose was two 10/325 tablets, LVN D stated she had seen the dose on the MAR but when she went to the medication cart, her old card was still on the cart (from prior to her hospitalization ) and so she just administered that. When asked why she did not question the dosage on the card as it conflicted with the MAR or check the orders in the chart, LVN D stated, "It never occurred to me she was really in pain, I didn't touch the orders, I gave her what she had on the cart." During an interview on 03/05/14 at 2:47 PM, the DON was shown Resident #1's MARs and told about the medication error regarding the [MEDICATION NAME]. The DON stated she was not aware of the error and that it should not have happened. She confirmed [MEDICATION NAME] 10/325 mg tablets were kept in the E-kit and LVN D could have easily retrieved the proper dose. When asked how Resident #1's pain should have been handled, the DON stated if a resident complains of pain, they should be assessed and a pain level ascertained. She stated the resident should be medicated if indicated and re-assessed in 30-45 minutes for relief. The DON stated, if the medication was not effective and another medication could not be given, the physician should be called and made aware of all the details surrounding the situation. An observation on 03/05/14 at 3:28 PM revealed [MEDICATION NAME] 10/325 tablets were stocked in the medication room E-kit at Resident #1's nurse's station. 2. Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed Resident #2 had a BIMS of 4 and was dependent on staff for most of his ADLs. Review of Resident #2's Care Plan dated 02/27/14 revealed: "Date & Problem: DX [MEDICAL CONDITION]/HTN/[MEDICAL CONDITION] Goal: (Resident #2) will not suffer any complications caused by Dx's thru the next eval date. Approaches & Disciplines: Lab as ordered Notify Dr. of results Medications as ordered. Notify Dr of effectiveness Monitor for [MEDICAL CONDITION], SOB, Pain in extremities with discoloration of skin and warm to touch Document and Notify Dr/RP/Hospice" Resident #2's Physician's Telephone Orders dated 01/09/13 reflected [MEDICATION NAME] 25 mg twice a day. Resident #2's Physician's Telephone Orders dated 01/30/14 reflected increase [MEDICATION NAME] to 50 mg twice a day for blood pressure. Review of Resident #2's MARs for the month of January 2014 revealed the last dose of [MEDICATION NAME] 25 mg was on 01/30/14 after the 9:00 PMdose. Further review of this MAR revealed [MEDICATION NAME] 50 mg was started on 01/30/14 at 9:00 PM. Review of Resident #2's MARs for the month of February 2014 revealed [MEDICATION NAME] 50 mg twice a day was administered as ordered. Further review of this MAR revealed the morning dose (9 AM) of [MEDICATION NAME] 25 mg was administered on 02/01/14, 02/02/14/ and 02/03/14. "DC'D" was hand written after the 9 AM dose was administered on 02/03/14. The evening dose (4:00 PM) of [MEDICATION NAME] 25 mg was administered each day during the month of February. A total of 31 doses of [MEDICATION NAME] 25 mg were administered that the physician had discontinued on 01/30/14. During an interview on 03/04/14 at 3:55 PM the surveyor reviewed Resident #2's February 2014's MARs with LVN B, Resident #2's evening charge nurse. LVN B stated she did administer [MEDICATION NAME] 25 mg and [MEDICATION NAME] 50 mg on the days she worked, as were documented on Resident #2's MAR. During an interview on 03/05/14 at 10:05 AM the ADM stated the Unit Manager did the February 2014 monthly recapitulations of physician orders [REDACTED]. During an interview on 03/04/14 at 4:30 PM the Unit Manager stated she checks the pink slips (copy of telephone physician orders) daily to make sure the orders were correct on the MARs. She stated when she did the February 2014 monthly recapitulations of physician orders, she was taken off the floor from 01/25/14 through the end of the month, and the DON took over her tasks, including verifying the pink slips were checked, for the whole building. During an interview on 03/06/14 at 4:30 PM the ADM stated Resident #2 receiving 31 doses of [MEDICATION NAME], which had been discontinued, was a careless error. The ADM further stated the DON told her she did miss a few a days of checking pink slips. During an interview on 03/06/14 at 8:47 AM the surveyor asked the DON how she thought Resident #2's received 31 doses of [MEDICATION NAME] that had been discontinued. The DON stated when RN A taught the Unit Manager how to do the monthly recapitulations of physician orders, RN A did not instruct the Unit Manager to continue to add additional physician orders [REDACTED]. "Nursing 2013 Drug Handbook" 33rd Edition, Wolters Kluwer, Copyright 2013, pages 680 - 681 reflected the following nursing considerations for [MEDICATION NAME]: "Monitor patient's blood pressure, pulse and body weight frequently...Elderly patients may be more sensitive to drug's hypotensive effects...." Overdose signs and symptoms include: [MEDICAL CONDITIONS] headache and flushing. 3. Review of the facility's current undated policy and procedure "Monthly Review of physician's orders [REDACTED]. "Purpose: To ensure that physician order's are accurate. Policy: To verify prior to the beginning of each month that all physician orders [REDACTED]. (RN A)/(Unit Manager) will be responsible for this monthly review. DON will schedule the delivery of the orders. DON will have (RN A) to be removed from the schedule as a floor nurse for the last 5-6 days of each month. (RN A) will inform DON of all concerns regarding the orders upon the completion of the review. (RN A) will take the prior month MARS and compare them to the clinical record. (RN A) will then take the clinical record and compare it to the new MARS. (RN A) will then handwrite onto the new MAR any new orders that will come after the 25th of the month. Attending nurses will write any new orders on the current MAR until the end of the month. If a new admission comes at the end of the month, (RN A)/Designee reviewing the MAR should make a new set of physician's orders [REDACTED]. (RN A)/Designee should also make a new set of MARS and TARS for the next month. (RN A)/Designee will via fax all updates to the person responsible for preparing the monthly orders: (name of pharmacy tech) at [PHONE NUMBER]. Clarifications orders will be written. 11-7 will compare the old MAR to the New MAR for accuracy." Review of the facility's current policy and procedure "Unnecessary Drugs" dated 2012 revealed: "Purpose: Each resident's drug regimen must be free from unnecessary drugs: Procedure: An unnecessary drug is any drug when used: 1. In excessive dose (including duplicate therapy); or 2. For excessive duration; or 3. Without adequate monitoring; or 4. Without adequate indications for its use; or 5. In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or 6. An combination of the reasons above...." Review of an undated Medication Pass Inservice from an RN/LVN Orientation Book located at the Nurse's Station revealed the following: "Steps to take during the med pass:... 16. Before administering the medication, always check 'The 6R 's' 17. Triple check medications vs. MAR before administering the medications. 18. If any of the 6 R's do not match or if you have any questions about the medication itself DO NOT GIVE THE MEDICATION! Check the chart or call the pharmacy with your concern. The pharmacist would rather you ask a question than a mistake be made...." "DURING THE MEDICATION PASS: 'THE 6 Rs' Before administering any medication, always check the 6 Rs, The right resident... The right drug: verify each drug against the medication administration record (MAR) before administering... The right dose: verify against the MAR... The right time: administer drugs as instructed on the MAR and within the time frame established by your facility...." "CHECKPOINTS...Related issues...Make sure discontinued medications have been removed from the cart as soon as they have been discontinued...." 4. Review of the facility's Form-672, Resident Census and Conditions of Residents, dated 03/03/14 and signed by DON reflected a census of 75.

Based on observation, interview and record review, the facility failed to implement its written policies and procedures, which prohibit neglect for six (Residents #2, #3, #8, #9, #11 and #13) of 21 residents reviewed for neglect. 1) Resident #3 experienced a 16.3% (20.8 pounds) severe weight loss from 11/01/13 to 12/17/13. Staff failed to consult with the physician after they became aware of her 10% weight loss for two weeks until surveyor inquiry. 2) Staff identified an open pressure ulcer on Resident #11's coccyx and failed to consult with the physician for 12 days for treatment orders. On the 12th day, the pressure ulcer was identified as a Stage 3 pressure ulcer by the wound physician. 3) Staff administered [MEDICATION NAME] (for blood pressure) to Resident #13 despite below normal blood pressure readings of 71/26, 109/36 and 108/58 and failed to notify the resident's physician . They further failed to notify her physician when her evening blood pressures were 71/26, 109/36, 97/68, 88/45 and 108/58 until surveyor inquiry. 4) Resident #9 was re-admitted to the facility on [DATE] with a pressure ulcer on her right lateral leg according to facility staff. The staff failed to notify the physician promptly for treatment orders until surveyor inquiry. The facility failed to administer 23 different medications to Resident #9, including medications used to treat Heart Failure, Hypertension, [MEDICAL CONDITION], Depression, Diabetes Mellitus, Pressure Ulcers, and [MEDICAL CONDITION] when she left the facility three times a week for [MEDICAL TREATMENT] treatments for four (September, October, November and December 2013) of four months reviewed. Her physician was unaware the medications were not given until surveyor inquiry. 5) Resident #2 was readmitted to the facility with an indwelling urinary Foley catheter. The facility failed to notify the physician for orders for care and treatment of [REDACTED].#2's catheter was not changed for four months until surveyor inquiry. These failures to consult the physician with a drop in blood pressure, severe weight loss, orders for an indwelling urinary catheter, for pressure ulcer treatment orders and the failure to administer physician-ordered medications could affect any of the facility's 75 residents, including Residents #2, #3, #9, #11 and #13, and placed them at risk for not having their needs met, a delay in needed medical care and treatment, the potential for deterioration in their clinical condition, not maintaining therapeutic levels of medications, increased the length of time needed for healing, the need for hospitalization and even death. An Immediate Jeopardy (IJ) was identified on 01/02/14. While the IJ was removed on 01/11/14, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. Findings included: A. The facility's current, undated Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures reflected, "...The administrator assumes the responsibility for the overall coordination and implementation of our facility's abuse prevention program policies and procedures...." The facility's Abuse Prevention Policy, revised September 2012, reflected the policy was to protect all residents from all forms of neglect. It further noted staff would be trained on identifying all forms of neglect. The facility's abuse prevention/intervention program included the following in regard to neglect: Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect; and identifying areas within the facility that may make neglect more likely to occur and conduct frequent monitoring of those areas B. The facility's current Pressure Ulcer Prevention and Wound Care Policy and Procedure dated 09/24/12 reflected the following: Purpose: to provide staff nurses guidelines for documenting, assessing, and preventing pressure ulcers and general procedures for skin care, pressure ulcers and wound care management. Policy: Upon admission, weekly, resident will be assessed for pressure ulcer risks by an assigned nurse. A. Skin Assessment: a. On admission and/or readmission to the facility patient will be assessed for any skin problems (decubitus, sores, bruises, abrasions, etc.). Information will be documented in nurse's notes and admission assessment form. If any skin problem exists, treatment will be obtain (sic) at this time. b. Skin assessments will be done weekly on all residents during the 11 pm-7 am shift and documented. c. All residents will have a skin breakdown/decubitus risk assessment done with initial MDS then quarterly .. . e. Primary Care Physician will be notified of any skin changes and Nurse assigned to resident will obtain skin/wound treatment order(s), and Wound consult order; as needed. B. Skin Care/Decubitus Protocol: a. Are not to be used without primary physician orders... c. Wound Specialist...will consult with residents with wounds weekly, measure, order treatment, and submit progress notes on the same day of the visit. d. DON/ADON will make wound rounds with wound specialist weekly. e. Nurses will measure the wounds on their assigned residents once per week and document in the nurse's notes. f. Nurses will submit pressure/skin sheets/Logs weekly. g. DON/ADON will monitor compliance with wound/skin protocol. h. DON/ADON will Track and Trend skin issues as they occur, to Train and counsel staff as needed. i. Charge Nurses will round on residents, to ensure that bedfast residents are turned and repositioned Q2 hours, and kept clean and dry. (DON/ADON, will monitor compliance). The CMS Form 672, Resident Census and Conditions of Residents dated 12/11/13 and signed by the MDS Coordinator reflected the census was 75 residents. C. Review of the facility's policy and procedure from the policy and procedure book on nurse's station two, titled Catheter Care (Indwelling Catheter) undated revealed: "GENERAL GUIDELINES FOR ASSESSMENT MAY INCLUDE, BUT ARE NOT LIMITED TO: Color, consistency, amount of urine; Condition of skin at site of insertion; Pain, burning, discomfort...." This policy further reflected the following:" GENERAL DOCUMENTATION GUIDELINES....1. Date, time (or shifty), procedure, condition of the perineum and catheter insertion site. 2. Any unusual condition or change in condition. 3. Color, amount consistency and odor of urine...." Review of the facility's policy and procedure from the policy and procedure book on nurse's station two, titled Catheter (Indwelling), Insertion and Removal of (Female and Male) undated revealed under" GENERAL DOCUMENTATION GUIDELINES....1. Date, time, procedure, amount of urine obtained, color, consistency, odor, presence of blood, pus or anything unusual. 2. How well resident tolerated procedure. 3. Signature and title." D. The facility's current policy and procedure, Weight and Height Measurement dated 2006 reflected: "Basic Responsibility- Licensed Nurse, Nursing Assistant and Restorative Nursing Assistant ... Purpose: -To obtain accurate weight and height of each resident. -To maintain constant control of weight changes. -To assess nutrition and hydration status of resident -To identify significant change in condition Procedure: 1. Calibrate scale according to manufacturer's instructions ... 3. Assist resident into wheelchair or scale chair. Place wheelchair on scale platform properly, according to manufacturer's directions. 4. Weigh according to manufacturer's directions and subtract weight of wheelchair from total weight to obtain resident's weight... Documentation Guidelines: Documentation may include: -Date and weight ... -Notify the charge nurse or physician of all weight changes of five pounds (or 5%) or more in a 30-day period or ten percent in a 180-day period or per state requirement...." E. Review of the facility's current undated policy and procedure "MEDICATION ADMINISTRATION BY FACILITY PERSONNEL" revealed, "All medications are to be administered only as prescribed, and only by licensed medical or nursing personnel, certified medication aides, or student nurses or medication aides...." Review of the facility's current undated policy and procedure "CHARGE NURSE DUTIES" revealed, "...5. Prepare and administer medications, enteral nutrition, parental nutrition and treatments as ordered...12. Administer prn medications and treatments as necessary...." 1) Resident #3 was a [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she was severely impaired cognitively, was totally dependent on staff for her ADLs, she weighed 133 lbs, and had no weight loss. Resident #3's Care Plan dated 10/24/13 reflected: "(Resident #3) poor appetite eating DT Cognitive Deficit/family declined GT placement." Approaches included: Diet as ordered/preferences per family's request...; Medication as ordered, Assist/Cueing with meal; Document meal % and report % to nurse with meal ticket; Offer fluids frq throughout day...; Dietary consult; Psych consult; Notify Dr./RP of any changes in condition." Resident #3's consolidated physician's orders [REDACTED]. The order was dated 10/24/13. Resident #3's Dietary Progress Notes dated 11/21/13 reflected: "Resident has 11% significant wt. loss X's 180 days R/T poor appetite, refuses to eat after return from hospital. Resident Received fortified foods, likes chocolate milk. Resident on weekly weights. DSM will monitor meal intake, nursing to monitor weight and skin closely, will follow." Resident #3's Food Intake Record for November 2013 revealed she consumed less than 50% of her meal 27 times. Additionally, meal percentages were not documented at all and left completely blank 24 times. Review of Resident #3's MARs for November 2013 revealed an entry dated 09/27/13 for Med Pass 60 cc by mouth as needed if the resident eats less than 50%. There were no doses initialed as administered. Resident #3's Nutritional assessment dated [DATE] reflected her weight was 128 lbs. The Summary and Recommendations reflected: "10/25/13: Dietary consult ordered for low pre-alb. Nutr assess reveals pt readmitted post hospitalization at (hospital name) for possible [DEVICE] eval due to failure to thrive, dysphagia, and UTI; pt shows wt loss 5 lbs/30 days-4%, following overall wt loss 15 lbs/180 days-10.49%; Pt remains within desirable wt range, as reflected by BMI factor; Pt continues w/varying intake of regular, therapeutic diet; [MEDICATION NAME] was ordered 10/28/13 for appetite stimulant; Pro powder was dc'd 10/25/13 due to pt refusal; pt receives med pass 60 cc TID if intake < 50% for add'l 360 cal/15 gm pro; lab reveals low pre-alb level; due to continued wt loss and low pre alb, recommend adding Medpass 2.0 120 cc BID for add'l 480 cal/20 gm pro; pt to be carefully monitored." NOTE: The recommendation for Medpass 120 cc BID was never ordered. Resident #3's Food Intake Record for December 2013 revealed she consumed less than 50% of her meal seven times between 12/01/13 and 12/12/13. Additionally, meal percentages were not documented at all and left completely blank eight times from 12/01/13 through 12/12/13. Review of Resident #3's MARs for December 2013 revealed an entry dated 09/27/13 for Med Pass 60 cc by mouth as needed if the resident eats less than 50%. There were no doses initialed as administered. Observation on 12/11/13 at 8:00 AM revealed Resident #3 was fed breakfast in the dining room by facility staff. Resident #3 consumed 30% of her eggs, 90% of her oatmeal and 75% of her meat. Observation on 12/11/13 at 1:05 PM revealed Resident #3 was fed lunch in the dining room by facility staff. She only consumed 25% of her meat and 60% of her dessert. During an interview on 12/12/13 at 7:10 PM, LVN W was asked about Resident #3's Med Pass order. LVN W stated she did give the resident Med Pass on occasion. She stated she had been giving her health shakes because Resident #3 would drink them up. She could not answer why there were no doses documented. LVN W stated Resident #3's (family member) often came in the evening and "feeds her too much." When asked what she meant by that, LVN W stated he/she would push her to eat yogurt and healthshakes and she (LVN W) thought he "overdoes it." During an interview on 12/13/13 at 8:10 AM, LVN D stated she had not given Resident #3 any Med Pass because she was eating much better and did not need any. When asked about the Food Intake Record and informed there were several times she refused to eat or ate less than 50%, LVN D stated she had her meal tickets somewhere and was not aware of Resident #3 ever eating less than 50%. She stated she knew Resident #3's weight was stable, and she had no weight loss this month. Resident #3's Yearly Weight Record reflected the following weights: 10/24/13 - 128.1 lbs 11/01/13 - 127.6 lbs 12/02/13 - 126.6 lbs 12/09/13 - 126.6 lbs Observation on 12/13/13 at 8:24 AM revealed Resident #3 was weighed by Restorative Aide BB. Resident #3 was weighed in her wheelchair, then assisted to a chair and then the empty wheelchair was weighed. The resident's weight was 109.2 lbs. Restorative Aide BB stated she weighed the resident the same way every time. She stated her weight had dropped, and she would report the findings to LVN D and ensure the resident was weighed daily. She added she would request the scale be calibrated for accuracy. Restorative Aide BB checked her records, which were kept in the therapy department, and discovered she had entered the wrong weights on Resident #3's Yearly Weight Record. She corrected the Yearly Weight Record to reflect the following: 11/1/13 - 127.6 lbs 12/02/13 - 122.6 lbs 12/06/13 - 120.6 lbs 12/13/13 - 109.4 lbs On 12/13/13 at 9:30 AM, LVN D was informed of Resident #3's actual weight of 109 lbs by the surveyor. LVN D stated she had been informed, and they were going to get the scale calibrated. During an interview on 12/14/13 at 10:00 AM, LVN T, Resident #3's weekend Charge Nurse, was shown Resident #3's MAR and asked why no Med Pass had been administered as ordered. LVN T explained since the resident returned from the hospital, she had been doing much better so none was given. LVN T was shown Resident #3's Food Intake Records for November and December 2013 with several weekend entries reflecting she had either refused to eat or consumed less than 50%. LVN T stated, "The aides didn't tell me. They gave the ticket to the clerk. I should have checked." In an interview on 12/16/13 at 3:20 PM , Restorative Aide BB stated she had spoken with the Dietary Manager, who agreed she (Restorative Aide BB) would personally feed Resident #3 in the therapy department and complete a more detailed summary of her intake with every meal. On 12/17/13 at 12:20 PM, Restorative Aide BB stated the scale had been calibrated. At that time, Resident #3 was weighed, and her weight was down to 106.8 lbs. On 12/17/13 at 2:30 PM, Restorative Aide BB reviewed Resident #3's meal intake documents completed for 12/16/13. The form reflected she consumed 25% of her breakfast, no lunch and only 10% of her dinner. Restorative Aide BB stated she discussed her plans to personally feed Resident #3 with LVN D and the DON, who agreed it was a good idea. Review of Resident #3's December 2013 MAR revealed there was still no Med Pass administered on 12/16/13. Review of Resident #3's Nurse's Notes revealed no indication her physician had been notified of her weight loss. Resident #3's Dietary Progress Notes dated 12/13/13 reflected the following: "Resident last weighed @ 109.4, weighed twice. Scales to be checked stated by Rehab aide. Resident continues to have significant amount of weight loss, resident has 14% significant weight loss x's 30 days R/T refusal to eat. (Director of Dietary Services) called dietitian's asst. Dietitian on vacation @ this X, facility needed immediate intervention due to tremendous amount of weight loss within 30 days. Dietitian faxed recommendations, (Director of Dietary Services) was also asked to tell resident's charge nurse of recommendations of Med Pass (with) medications 3 x a day. Nurse stated res. already receives 60 cc if she eats less than 50%. Dietitian stated res is a good candidate for appetite stimulant but may not be able to receive it according to what's going on with her. (Director of Dietary Services) talked (with) charge nurse, stated she receives [MEDICATION NAME] already but res still not eating well as observed by (Director of Dietary Services) & rehab aide. Nurse stated she would call the doctor. Doctor's office called (Director of Dietary Services) about dietitian's recommendations and stated she would talk with doctor and get back (with) me. Will follow...." The note was signed by Director of Dietary Services. Resident #3's Nutritional assessment dated [DATE] reflected her weight was 127 lbs. Summary and Recommendations reflected: "12/17/13: Dietary consult requested due to weight loss. Nutr assess reveals wt remains stable/ 30 days, following wt loss 9 lbs/90 days-7%, 13 lbs/180 days-9.29%; Pt remains within desirable wt range, as reflected by BMI factor;...Pt continues to refuse to eat; Pt will accept shakes and chocolate milk; [MEDICATION NAME] continues for appetite stimulant; Med Pass continues 60 cc TID if meal intake is < 50% for add'l 360 cal/15 gm pro, due to continued wt loss and low pre-alb, recommend adding Med Pass 2.0 120 cc BID for add'l 480 cal/20 gm pro; wt loss may be expected; ...continue to monitor closely; goal is to provide adequate cal and pro to stabilize wt." The assessment was signed by Dietary Consultant PP. During an interview on 01/02/14 at 4:10 PM, Dietary Consultant PP was queried about her Nutritional Assessment of Resident #3. Dietary Consultant PP stated she was called for a consultation on 12/17/13 and the weight reflected on her assessment was the weight she was given for Resident #3 by the facility. When asked about her recommendation for the Med Pass 2.0 supplement, Dietary Consultant PP explained she was informed by facility staff Resident #3 had been receiving doses of Med Pass as needed but she wanted to add a scheduled dose in addition to the PRN dose already ordered. She could not remember who told her Resident #3 was taking the Med Pass. When the Dietary Consultant PP was told Resident #3's weight was actually 109 lbs on 12/13/13, then dropped to 106 lbs, she stated she was never made aware of the weight drop. When asked who provided her the information for her consultation, Dietary Consultant PP stated the Director of Dietary Services faxed a weight sheet prior to her arrival. She explained they typically faxed the information in advance so she could prepare for her visit. During an interview on 01/02/14 at 4:35 PM, the Director of Dietary Services was asked what type of information she sent to the dietitian when a consultation was ordered. She stated she sent them the resident's weights. When asked about Resident #3, she confirmed she sent the dietitian her weights. The Director of Dietary Services retrieved a list of monthly weights to show the surveyor. Resident #3's weight for December was documented as 126.6 lbs; a line was drawn through the entry. The Director of Dietary Services stated, "I lined that out later and wrote 109." The Director of Dietary Services retrieved a Dietitian Consultant Worksheet and stated she typically filled it out and gave it to the Dietitian. When asked whether she provided one for Resident #3's consultation, the Director of Dietary Services replied, "I can't remember if I did this last time. They never let me know when they are coming." The Director of Dietary Services also explained she had informed the Dietitian Resident #3 was taking Med Pass supplement. She stated she had been informed by LVN D the resident was getting it. On 12/17/13 at 2:17 PM, an interview with NP P, Resident #3's Nurse Practitioner, revealed she had not been notified of Resident #3's weight loss and was unaware of the recent weight drop. During an interview on 12/17/13 at 3:07 PM, LVN D stated she remembered the surveyor reporting Resident #3's weight loss on 12/13/13. She stated she reported the information to the DON. When asked why she did not call the physician, LVN D stated she was going to wait until the scale was calibrated. In an interview on 12/17/13 at 4:10 PM, the DON stated Resident #3's physician had been called and lab orders were obtained for a CBC, CMP and Pre-[MEDICATION NAME] level to be done. She added a care plan meeting with the family was being arranged and Physician K, Resident #3's attending physician, would attend. The DON stated Resident #3 was getting health shakes instead of Med Pass but staff had not been documenting it. She stated nursing administration was going to take over monitoring Resident #3's meal intake and every resident in the building would be re-weighed. When asked why the physician was not notified on 12/13/13 when the discrepancy was found, the DON stated, "No. It was the intent but it got dropped." An interview on 01/02/14 at 2:21 PM with Restorative Aide BB revealed she had begun re-weighing residents but had not completed the task (16 days since the DON said all residents would be re-weighed.). Restorative Aide BB provided lists dated 12/31/13 through 01/02/14 with the names and weights of residents. When asked when she was asked to initiate re-weighing the residents, she stated she had not been told by anyone to re-weigh the residents. When asked why she was re-weighing the residents, Restorative Aide BB said, "I know that's what you do when you have a discrepancy." In an interview on 01/03/13 at 12:12 PM, the DON was asked whether she had implemented the re-weighing of all the residents as she had informed the surveyor she would. The DON stated, "We are in the process of doing that now." During an interview on 01/06/13 at 12:00 PM, Physician K stated he had taken part in care plan meetings regarding Resident #3. He stated he had decreased her medications, which were not critical to maintain function. Physician K stated he learned the facility had not been calling the family to assist her when she would not eat as had been agreed upon during a previous meeting. 2) Resident #11 was a [AGE] year-old female, readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed the resident was severely impaired for cognitive skills for daily decision-making, was totally dependent on staff for bed mobility and had two Stage 3 pressure ulcers. Review of a care plan for Resident #11 dated 09/15/13 revealed: "PROBLEM: (Resident #11) is at risk for developing Wounds D/T debilitated state/DX AEB Diabetes Mellitus, Contractures and immobility deficit. GOAL: (Resident #11) will not develop wounds this eval period. APPROACHES: 1. Assess skin and document findings q week per wound protocol 2. Reposition with pillows as positioning devices q2h and as needed 3. Shower per shower protocol. Dry well and apply lotion 4. Feedings as ordered 5. Pressure relieving devices as needed: Mattress, W/C Cushions 6. Gentle Passive ROM with personal care daily 7. Medications as ordered 8. Dietary Consult as indicated 9. Not Dr./RP of change in condition" Review of Resident #11's "Weekly Skin Assessment" dated 10/05/13 revealed: Skin: Warm and Dry were both checked Skin Tears: "No" was checked Bruises: "No" was checked Abrasions: "No" was checked Incisions: "Yes" was checked - "If Yes, describe all areas and location:" GT site was hand written in. Rash: "No" was checked Pressure, Diabetic, Venous, Arterial Ulcer, or Incision: "Yes" was checked. "Describe" Coccyx was hand written in. LVN S signed this assessment. Review of Resident #11's Nurse's Notes dated 10/05/13 revealed no mention of an open area on the resident's coccyx. In an interview on 12/13/13 at 11:25 AM the surveyor reviewed Resident #11's "Weekly Skin Assessment" dated 10/05/13 with LVN S, which he completed. LVN S stated, "I think she (Resident #11) came back from the hospital with it (Pressure ulcer)." LVN S documented Resident #11 had a wound on her coccyx and he stated he did not describe the wound on any of the facility documents. "I just change the dressing. I clean the wound with normal saline; sometimes I put a little TAO and a dressing on it (pressure wound), to cover it so it doesn't get infected. I do that when the dressing is dirty and when I do my weekly skin assessments. I look for physician (treatment) orders and if there is not an order I do the TAO." The surveyor asked LVN S if he considered calling the physician if there were no treatment orders and LVN S stated, "No," we have a wound nurse in the house (facility). I call her sometimes." The surveyor asked who the wound nurse was and LVN S stated, (LVN D)." In an interview on 12/12/13 at 8:28 AM the ADON stated when a charge nurse finds a new wound. the charge nurse tells the ADON and DON. "The ADON/DON go look at it (pressure wound) right then." The ADON further stated when the nurse found a new wound he/she needed to get wound treatment orders right then and not wait until the wound doctor made his visit. In an interview on 12/12/13 at 1:15 PM the surveyor asked the DON what she expected her nurses to do when they found a new pressure wound and the DON stated, initiate a weekly skin sheet, document the wound on the twenty-four report, tell the oncoming nurse, measure the wound and document the measurements in the nurse's notes, call the physician, get wound care order. initiate the treatment and call the resident's family. Review of Resident #11's "Weekly Skin Assessment" dated 10/12/13 revealed: Skin: Warm and Dry were both checked Skin Tears: "No" was checked Bruises: "No" was checked Abrasions: "No" was checked Incisions: "Yes" was checked - "If Yes, describe all areas and location:" GT site was hand written in. Rash: "No" was checked Pressure, Diabetic, Venous, Arterial Ulcer, or Incision: "Yes" was checked. "Describe" Coccyx was hand written in. LVN S signed this assessment. Review of Resident #11's Nurse's Notes dated 10/12/13 revealed no mention of an open area on the resident's coccyx. Review of Resident #11's Nurse's Notes dated 10/13/13 at 9:00 PM revealed, "...found bottom (coccyx) with a freshly open stage 2 pressure ulcer, wound dressed and dated, to F/u on wound MD (name of wound doctor)." LVN J signed this note. Review of Resident #11's Nurse's Notes dated 10/14/13 at 9:00 AM revealed, ...Pt. has an old scar at the coccyx re-open measured 6 cm x 6 cm. A communication for wound consult written, an order from the Dr ...." LVN A signed this note. Review of Resident #11's physician orders [REDACTED]." Note this was the first physician order [REDACTED]. In an interview on 12/14/13 at 12:37 PM LVN A stated 10/14/13 was the first time she saw the pressure wound on Resident #11's coccyx. LVN A showed the surveyor her nurse's notes where she documented the size of the wound at 6 cm x 6 cm. The surveyor asked LVN A if she charted observations of wounds, color or drainage and LVN A stated, "Sometimes." The surveyor asked LVN A if she called the physician and got treatment orders for the pressure wound and LVN A stated, "We wait until the wound doctor comes on Wednesdays. I think it (10/14/13) was the day before the wound doctor was supposed to come." The surveyor shared with LVN A, it was two days prior to the wound doctors visit and LVN A stated, "It (pressure wound) wasn't that bad." Review of Resident #11's Nurse's Notes dated 10/14/13 at 2:30 PM, 4:30 PM, 6:30 PM, and 8:30 PM revealed, "...Dsg C-D-I Coccyx." LVN C signed these notes. Review of Resident #11's Nurse's Notes dated 10/15/13 at 12:00 AM revealed, "...coccyx dsg intact." LVN S signed this note. Review of Resident #11's Nurse's Notes dated 10/15/13 at 2:30 PM, 10/15/13 and 10/15/13 at 8:30 PM revealed the resident's dressing on her coccyx was clean, dry and intact. LVN C signed these notes. Review of Resident#11's Nurse's Notes dated 10/16/13 at 2:00 AM, 4:00 AM, and 6:00 AM revealed the dressing on the resident's coccyx was clean, dry and intact. LVN S signed these notes. The Wound Physician note dated 10/16/13 for Resident #11 reflected the following: History of Present Illness - "[AGE] year-old female patient has a stage 3 pressure wound of the sacrum of at least 1 days (sic) duration. There is light serous exudate...no indication of pain...." "Stage 3 Pressure Wound of the Sacrum Etiology (Quality): Pressure Duration: > 1 days (sic) Objective: Palliation Wound size (L x W x D) 5.0 x 5.0 x 0.1 cm Exudate - light serous Granulation Tissue: 100 %" "Dressing: Silver hydrogel, collage dressing, dry protective dressing, foam, once daily." Review of Resident #11's physician orders [REDACTED]. Low air loss mattress." Note this was the first treatment physician order [REDACTED]. Review of Resident #11's treatment administration records revealed the silver treatment was initialed as started on 10/16/13. Further review of this record revealed the low air loss mattress was initialed as started on 10/20/13. Review of a "Detail Admission/Discharge Report" dated 12/12/13 for Resident #11 revealed the resident was: -- admitted to the facility on [DATE], -- Transferred to the hospital on [DATE], -- Readmitted to the facility on [DATE], -- Transferred to the hospital on [DATE] and -- Readmitted to the facility on [DATE]. 3) Resident #13 was a [AGE] year-old female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she had severely impaired cognition and was totally dependent on staff for assistance with ADLs. Resident #13's monthly consolidated physician's orders [REDACTED]. -[MEDICATION NAME] 0.1 mg by mouth daily at 9:00 AM; Hold if SBP less than 110 or DBP less than 60. -[MEDICATION NAME] 50 mg one three times daily at 9:00 AM, 1:00 PM and 5:00 PM; Check B/P and Hold if SBP less than 110 or DBP less than 60. Resident #13's MAR for the month of December 2013 reflected the following: [MEDICATION NAME] 50 mg one by mouth three times a day, Hold if SBP less than 110 or DBP less than 60. The medications were times for 9 AM, 1 PM and 5 PM with spaces provided beneath each day's entry to record the blood pressure. The 5 PM dose entries reflected: 12/02/13- BP 71/26 - dose was initialed as given. 12/10/13- BP 109/36 -dose was initialed as given. A note on the back of a separate page revealed: "12/10/13 5P Held [MEDICATION NAME] 0.1 mg tab PO BP 109/36." Signed by LVN C. 12/11/13- BP 97/68 -dose was circled as held. A note on the back of a separate page revealed: "12/11/13 5P BP 97/68 Held [MEDICATION NAME] 0.1 mg" Signed by LVN C. 12/12/13 -BP 88/45 -dose was circled as held. A note on the back of the page revealed " 12/12/13 5 PM BP 88/45 P 77 Held [MEDICATION NAME] 50 mg " Signed by LVN C. Another note on the back of a separate page revealed: "12/12/13 5P BP 88/45/77 Held [MEDICATION NAME] 0.1 mg. RT (retake?) @ 7P 105/70 P 64" Signed by LVN C. 12/13/13 - BP 108/58 -dose was initialed as given. During an interview with LVN C, Resident #13's 3:00 PM to 11:00 PM Charge Nurse, o

Based on observation, interview and record review, the facility failed to implement its policies and procedures, which prohibit neglect for two (Residents #1 and #2) of 14 residents reviewed for neglect. 1) a. The facility failed to properly transcribe and administer the following medications for Resident #1 in two of two months reviewed: [MEDICATION NAME] 25 mg - missed three of five doses; [MEDICATION NAME] 20 mg - missed three of five doses; [MEDICATION NAME] eye drops- missed three of five doses; [MEDICATION NAME] 40 mg-20 mg was given and only administered three out of five times; [MEDICATION NAME] - was given in the morning instead of at bedtime as ordered; [MEDICATION NAME] 200 mg- 100 mg was given for three days; [MEDICATION NAME] - was given in the morning instead of at bedtime as ordered; Levetiracetam 1000 mg- 500 mg was administered for three days; [MEDICATION NAME] XL - missed three 60 mg doses and missed five 30 mg doses; and [MEDICATION NAME] 0.1 mg - missed five doses. b. LVN D failed to administer the correct dose of pain medications to Resident #1 when she repeatedly complained of leg pain. LVN D administered one [MEDICATION NAME] 5/325 mg when the ordered dose was two 10/325 mg tablets. 2. The facility failed to discontinue Resident #2's [MEDICATION NAME] 25mg (for Hypertension) as ordered. The morning dose of [MEDICATION NAME] was discontinued on 02/03/14 and the evening dose was not discontinued until after the 02/28/14 dose, for a total of 31 doses. These failures could affect any the facility's 75 residents, including Residents #1 and #2, by placing them at risk for ongoing medication errors resulting in depression, eye discomfort, unrelieved pain, stomach upset, [MEDICAL CONDITION], weakness, confusion, dizziness, headache, [MEDICAL CONDITIONS] and death and could affect the 75 residents in the facility. Findings include: A. The facility's current, undated Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures reflected, "...The administrator assumes the responsibility for the overall coordination and implementation of our facility's abuse prevention program policies and procedures...." The facility's Abuse Prevention Policy, revised September 2012, reflected the policy was to protect all residents from all forms of neglect. It further noted staff would be trained on identifying all forms of neglect. The facility's abuse prevention/intervention program included the following in regard to neglect: Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect; and identifying areas within the facility that may make neglect more likely to occur and conduct frequent monitoring of those areas. 1) Review of Resident #1's Physician's Telephone Orders dated 02/26/14 revealed she was to be readmitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #1's admission Nurse's Note dated 02/26/14 at 2:20 PM revealed she was confused but able to make her needs known at that time. Review of Resident #1's hospital Medication Profile Report dated 02/25/14 revealed the following medications were among those to be continued when she returned to the facility: [MEDICATION NAME] Hcl 25 mg tablets by mouth twice daily (used to treat high blood pressure); [MEDICATION NAME] 20 mg tablets by mouth twice daily (used to treat chest pain caused by heart damage); [MEDICATION NAME] Sodium 100 mg caps, two twice daily (used to prevent constipation); [MEDICATION NAME] 0.05% eye drops, one drop in each eye twice daily (used for increase tear production); [MEDICATION NAME] 20 mg tablets, give 40 mg at bedtime (used to lower cholesterol); [MEDICATION NAME] 20 mg tablets, give 10 mg by mouth at bedtime (used to treat depression); [MEDICATION NAME] 100 mg tablets, give 200 mg at bedtime (used to treat pain caused by [MEDICAL CONDITION]); [MEDICATION NAME] 325 mg, give one at bedtime (iron supplement used to treat [MEDICAL CONDITION]); Levetiracetam 500 mg tablets, give 1000 mg at bedtime (used to treat [MEDICAL CONDITION]); [MEDICATION NAME] XL 30 mg by mouth every day (used to treat high blood pressure and chest pain); [MEDICATION NAME] XL 60 mg by mouth every evening; and [MEDICATION NAME] HCL 0.1 mg by mouth every day (used to treat high blood pressure). Review of the facility ' s admission orders [REDACTED] [MEDICATION NAME] 30 mg PO QD; and [MEDICATION NAME] HCL 0.1 mg PO QD. Review of Resident #1's February 2014 MARs revealed the following: [MEDICATION NAME] 25 mg tablets twice a day was only transcribed and initialed as administered once on 02/27/14. (Not twice a day as ordered) [MEDICATION NAME] 20 mg tablets was only transcribed and initialed as administered once a day on 02/27/4 and 02/28/14. (Not twice a day as ordered) [MEDICATION NAME] Sodium 100 mg caps was only transcribed and initialed as administered once on 02/27/14 and 02/28/14. (Not twice a day as ordered) [MEDICATION NAME] eye drops were only transcribed and initialed as administered once a day on 02/27/14 and 02/28/14. (Not twice a day as ordered) [MEDICATION NAME] was transcribed as 20 mg at bedtime and only initialed as administered on 02/26/14 and 02/27/14. (Not on 02/28/14 as ordered) [MEDICATION NAME] was transcribed and initialed as administered as 10 mg at 6:30 AM. (Not at bedtime as ordered) [MEDICATION NAME] 100 mg was transcribed and initialed as administered at bedtime. (Not 200mg as ordered) [MEDICATION NAME] 325 mg was transcribed and initialed as administered at 6:30 AM. (Not at bedtime as ordered) Levetiracetam 500 mg was transcribed and initialed as administered daily at bedtime. (Not 1000 mg as ordered) [MEDICATION NAME] XL was transcribed as 30 mg by mouth every evening and was only administered on 02/26/14 and 02/27/14. (Not 60 mg as ordered and none on 02/28/14) [MEDICATION NAME] XL 60 mg was not transcribed to the February MAR and so no doses were given in February. Review of Resident #1's March 2014 MARs revealed the following: [MEDICATION NAME] XL 30 mg by mouth every day was not transcribed and so was not administered from 03/01/14 through 03/05/14, when surveyor inquired. [MEDICATION NAME] HCL 0.1 mg by mouth every day was not transcribed and so was not administered from 03/01/14 through 03/05/14, when surveyor inquired. An interview with the Unit Manager on 03/04/14 at 4:32 PM revealed it was typically her duty to check all orders daily for accuracy but she was pulled off the floor or on 02/24/14 to work on the monthly consolidated orders for the remainder of the month. She stated, during that time, the DON was performing the daily checks on both nurses' stations. During an interview on 03/05/15 at 10:25 AM, LVN C stated she had transcribed the admission orders [REDACTED]. When shown the errors found by the surveyors, LVN C stated she was not aware of the errors. She stated RN A had transcribed the orders to the March MARs and she remembered RN A pointing out some discrepancies to her but she thought she had corrected them. During an interview on 03/05/14 at 11:25 AM, RN A stated she had transcribed the March MARs for Resident #1 but had never looked at February's MARs. RN A stated she had caught a few discrepancies after the hospital orders had been transcribed to the facility's admission orders [REDACTED]. She was not aware of any medication errors. An interview with the DON on 03/05/14 at 11:25 AM revealed all orders, including new admission orders [REDACTED]. The DON explained pink copies of all resident's orders were to be placed in a box and both she and the Unit Manager checked those pink copies every day before they left to ensure all orders written over the past 24 hours were transcribed correctly. When asked about Resident #1, the DON confirmed the Unit Manager was not checking orders at that time as she had been pulled to work on the monthly orders. The DON stated she did not know why Resident #1's orders had not been checked; she stated the pink copies must not have made it into the designated box. b) Review of Resident #1's hospital Medication Profile Report dated 02/25/14 revealed the following medications were among those to be continued when she returned to the facility: [MEDICATION NAME] 10/325 mg one tablet every six hours as needed for pain. [MEDICATION NAME] 10/325 mg two tablets every six hours as needed for pain. Resident #1's admission orders [REDACTED]. Review of Resident #1's MAR for February 2014 revealed an entry for [MEDICATION NAME]-Apap 10-325 two every six hours as needed for pain. The entry was initialed as administered on 02/26/14 at 3:00 PM and 9:00 PM by LVN D. The back of the MAR reflected the following entries: 2/26/14 at 3:00 PM: "Resident c/o pain, pain level 8/10, [MEDICATION NAME] ([MEDICATION NAME]) 5/325 admin, pain level at 3:30 PM 6/10." The entry was signed by LVN D. 2/26/14 at 9:00 PM: "Resident c/o pain, telling, 8/10, [MEDICATION NAME] 5/325 mg admin, pain level @ 9:30 (PM), 7/10, ineffective." The entry was signed by LVN D. During an interview on 03/05/14 at 12:45 PM, LVN D explained she was Resident #1's Charge Nurse on 02/26/14 but LVN C was completing the admission orders [REDACTED]. When asked why she only administered 5/325 mg when the order and MAR both indicated the dose was two 10/325 tablets, LVN D stated she had seen the dose on the MAR but when she went to the medication cart, her old card was still on the cart (from prior to her hospitalization ) and so she just administered that. When asked why she did not question the dosage on the card as it conflicted with the MAR or check the orders in the chart, LVN D stated, "It never occurred to me she was really in pain, I didn't touch the orders, I gave her what she had on the cart." During an interview on 03/05/14 at 2:47 PM, the DON was shown Resident #1's MARs and told about the medication error regarding the [MEDICATION NAME]. The DON stated she was not aware of the error and that it should not have happened. She confirmed [MEDICATION NAME] 10/325 mg tablets were kept in the E-kit and LVN D could have easily retrieved the proper dose. When asked how Resident #1's pain should have been handled, the DON stated if a resident complains of pain, they should be assessed and a pain level ascertained. She stated the resident should be medicated if indicated and re-assessed in 30-45 minutes for relief. The DON stated, if the medication was not effective and another medication could not be given, the physician should be called and made aware of all the details surrounding the situation. An observation on 03/05/14 at 3:28 PM revealed [MEDICATION NAME] 10/325 tablets were stocked in the medication room E-kit at Resident #1's nurse's station. 2. Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed Resident #2 had a BIMS of 4 and was dependent on staff for most of his ADLs. Review of Resident #2's Care Plan dated 02/27/14 revealed: "Date & Problem: DX [MEDICAL CONDITION]/HTN/[MEDICAL CONDITION] Goal: (Resident #2) will not suffer any complications caused by Dx's thru the next eval date. Approaches & Disciplines: Lab as ordered Notify Dr. of results Medications as ordered. Notify Dr of effectiveness Monitor for [MEDICAL CONDITION], SOB, Pain in extremities with discoloration of skin and warm to touch Document and Notify Dr/RP/Hospice" Resident #2's Physician's Telephone Orders dated 01/09/13 reflected [MEDICATION NAME] 25 mg twice a day. Resident #2's Physician's Telephone Orders dated 01/30/14 reflected increase [MEDICATION NAME] to 50 mg twice a day for blood pressure. Review of Resident #2's MARs for the month of January 2014 revealed the last dose of [MEDICATION NAME] 25 mg was on 01/30/14 after the 9:00 PMdose. Further review of this MAR revealed [MEDICATION NAME] 50 mg was started on 01/30/14 at 9:00 PM. Review of Resident #2's MARs for the month of February 2014 revealed [MEDICATION NAME] 50 mg twice a day was administered as ordered. Further review of this MAR revealed the morning dose (9 AM) of [MEDICATION NAME] 25 mg was administered on 02/01/14, 02/02/14/ and 02/03/14. "DC'D" was hand written after the 9 AM dose was administered on 02/03/14. The evening dose (4:00 PM) of [MEDICATION NAME] 25 mg was administered each day during the month of February. A total of 31 doses of [MEDICATION NAME] 25 mg were administered that the physician had discontinued on 01/30/14. During an interview on 03/04/14 at 3:55 PM the surveyor reviewed Resident #2's February 2014's MARs with LVN B, Resident #2's evening charge nurse. LVN B stated she did administer [MEDICATION NAME] 25 mg and [MEDICATION NAME] 50 mg on the days she worked, as were documented on Resident #2's MAR. During an interview on 03/05/14 at 10:05 AM the ADM stated the Unit Manager did the February 2014 monthly recapitulations of physician orders [REDACTED]. During an interview on 03/04/14 at 4:30 PM the Unit Manager stated she checks the pink slips (copy of telephone physician orders) daily to make sure the orders were correct on the MARs. She stated when she did the February 2014 monthly recapitulations of physician orders, she was taken off the floor from 01/25/14 through the end of the month, and the DON took over her tasks, including verifying the pink slips were checked, for the whole building. During an interview on 03/06/14 at 4:30 PM the ADM stated Resident #2 receiving 31 doses of [MEDICATION NAME], which had been discontinued, was a careless error. The ADM further stated the DON told her she did miss a few a days of checking pink slips. During an interview on 03/06/14 at 8:47 AM the surveyor asked the DON how she thought Resident #2's received 31 doses of [MEDICATION NAME] that had been discontinued. The DON stated when RN A taught the Unit Manager how to do the monthly recapitulations of physician orders, RN A did not instruct the Unit Manager to continue to add additional physician orders [REDACTED]. "Nursing 2013 Drug Handbook" 33rd Edition, Wolters Kluwer, Copyright 2013, pages 680 - 681 reflected the following nursing considerations for [MEDICATION NAME]: "Monitor patient's blood pressure, pulse and body weight frequently...Elderly patients may be more sensitive to drug's hypotensive effects...." Overdose signs and symptoms include: [MEDICAL CONDITIONS] headache and flushing. 3. Review of the facility's current undated policy and procedure "Monthly Review of physician's orders [REDACTED]. "Purpose: To ensure that physician order's are accurate. Policy: To verify prior to the beginning of each month that all physician orders [REDACTED]. (RN A)/(Unit Manager) will be responsible for this monthly review. DON will schedule the delivery of the orders. DON will have (RN A) to be removed from the schedule as a floor nurse for the last 5-6 days of each month. (RN A) will inform DON of all concerns regarding the orders upon the completion of the review. (RN A) will take the prior month MARS and compare them to the clinical record. (RN A) will then take the clinical record and compare it to the new MARS. (RN A) will then handwrite onto the new MAR any new orders that will come after the 25th of the month. Attending nurses will write any new orders on the current MAR until the end of the month. If a new admission comes at the end of the month, (RN A)/Designee reviewing the MAR should make a new set of physician's orders [REDACTED]. (RN A)/Designee should also make a new set of MARS and TARS for the next month. (RN A)/Designee will via fax all updates to the person responsible for preparing the monthly orders: (name of pharmacy tech) at [PHONE NUMBER]. Clarifications orders will be written. 11-7 will compare the old MAR to the New MAR for accuracy." Review of the facility's current policy and procedure "Unnecessary Drugs" dated 2012 revealed: "Purpose: Each resident's drug regimen must be free from unnecessary drugs: Procedure: An unnecessary drug is any drug when used: 1. In excessive dose (including duplicate therapy); or 2. For excessive duration; or 3. Without adequate monitoring; or 4. Without adequate indications for its use; or 5. In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or 6. An combination of the reasons above...." Review of an undated Medication Pass Inservice from an RN/LVN Orientation Book located at the Nurse's Station revealed the following: "Steps to take during the med pass:... 16. Before administering the medication, always check 'The 6R 's' 17. Triple check medications vs. MAR before administering the medications. 18. If any of the 6 R's do not match or if you have any questions about the medication itself DO NOT GIVE THE MEDICATION! Check the chart or call the pharmacy with your concern. The pharmacist would rather you ask a question than a mistake be made...." "DURING THE MEDICATION PASS: 'THE 6 Rs' Before administering any medication, always check the 6 Rs, The right resident... The right drug: verify each drug against the medication administration record (MAR) before administering... The right dose: verify against the MAR... The right time: administer drugs as instructed on the MAR and within the time frame established by your facility...." "CHECKPOINTS...Related issues...Make sure discontinued medications have been removed from the cart as soon as they have been discontinued...." 4. Review of the facility's Form-672, Resident Census and Conditions of Residents, dated 03/03/14 and signed by DON reflected a census of 75.

Based on observation, interview any record review, it was determined the facility failed to ensure each resident was free of significant medicaiton errors for seven (Resident #3, #4, #9, #13, #22, #29 and #34) of 25 residents reviewed for medications. 1. The facility failed to administer 23 different medications to Resident #9, including medications used to treat Heart Failure, Hypertension, [MEDICAL CONDITION], Depression, Diabetes Mellitus, Pressure Ulcers, and [MEDICAL CONDITION] when she left the facility three times a week for [MEDICAL TREATMENT] treatments for four (September, October, November and December 2013) of four months reviewed. Her physician was unaware the medications were not given. The facility failed to properly transcribe Resident #9's [MEDICATION NAME] (for blood pressure and chest pain) 60 mg daily causing the drug to be left off her MAR from 10/16/13 through 10/31/13. 2. The facility failed to provide Resident #4 18 doses of physician-ordered PRN [MEDICATION NAME] (for Hypertension) during November 2013 and four doses during December 2013 for an SBP greater than 150 or DBP greater than 90. 3. The facility failed to discontinue Resident #3's [MEDICATION NAME] as ordered. The medication was discontinued on 11/05/13 but restarted on 12/01/13 when staff failed to remove it from the MAR and the physician's consolidated orders. Resident #3 received the [MEDICATION NAME] twice a day until surveyor intervention on12/11/13. The facility failed to administer Resident #3 22 doses of physician-ordered PRN [MEDICATION NAME] (for Hypertension) during November 2013 and seven doses during December 2013 for SBP greater than 150 or DBP greater than 90. 4. The facility failed to administer Resident #22 12 of 14 doses of the physician-ordered antibiotic Nitrofurantpoin for her UTI. 5. Resident #13 was administered [MEDICATION NAME] (for blood pressure) despite documented blood pressure readings of 71/26 and 109/36. She had orders to hold the medication if her SBP was less than 110 or DBP was less than 60. 6. The facility failed to administer Resident #34's [MEDICATION NAME] (for blood pressure) nine times even though her blood pressure was above the physician-ordered parameters to hold the medication. 7..The facility failed to administer to Resident #29, four doses of the physician-ordered PRN [MEDICATION NAME] (for Hypertension) during December 2013 for SBP greater than 160. An Immediate Jeopardy (IJ) was identified on 01/02/14. While the IJ was removed on 01/11/14, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. These failures could affect any the facility's 75 residents, including Residents #3, #4, #9, #13, #22, #29 and #34, by placing them at risk for UTI's not treated, not receiving therapeutic dosages of their medications, [MEDICAL CONDITION], depression, irritability, uncontrolled diabetes, uncontrolled blood pressure and possible death. Findings included: 1. Resident #9 was an [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #9 had a BIMS score of 11, indicating she was moderately impaired cognitively. She was totally dependent on staff for bed mobility, transfers and hygiene and required extensive assistance for dressing. The MDS assessment further reflected Resident #9 exhibited verbal behaviors, "Other behaviors not directed toward others," rejected care at times and was receiving [MEDICAL TREATMENT]. Resident #9's Care Plans reflected the following: Problem Onset: 07/05/13, (Resident #9) has potential for abnormal blood sugar level R/T Hx of Diabetes. Approaches included: Diet as ordered by physician; Monitor meal intake; Offer appropriate snacks according to physician orders; diet consult as needed. (NOTE: there was no mention of testing her blood sugar level or administering medications as ordered.) Problem Onset: 08/19/13, "(Resident #9) is socially inappropriate/has disruptive behavior of cursing/yelling at staff, roommate, refuses care." Approaches included: "...Monitor and document resident behavior. Report any changes to physician/R.P.; Review resident drug regimen for anxiety, depression, [MEDICAL CONDITION] ([MEDICATION NAME], Resperdal) per facility's protocol...." Problem Onset: 07/05/13, "(Resident #9) has potential for retaining abnormal body fluids R/T Hx [MEDICAL CONDITION]& [MEDICAL CONDITION]." Approaches included: "Diet as ordered by physician; Obtain monthly weights; Diet consult as needed." Added 09/20/13: "Explained that [MEDICAL TREATMENT] is her life line. Unable to drink fluids after [MEDICAL TREATMENT] as she would like." Problem Onset: 09/19/13, "(Resident #9) is noncompliance (sic) with therapeutic diet as evidenced by eating food brought in by family/friends. Dx [MEDICAL CONDITION], Diabetes, Hypertension." Approaches included: "...follow her [MEDICAL TREATMENT] plan of care (Note: no such plan of care was found or provided by the facility), ...encourage to comply with medication program; Check V/S, B/P, Blood Sugars as directed. Document and report abnormal finding to physician." Resident #9's most recent physician's Progress Note dated 10/15/13 reflected the following History of Present Illness: "HX [DIAGNOSES REDACTED] post IV ([MEDICATION NAME] - antibiotic) w/ HD. Also w/acute [MEDICAL CONDITION] (blood clot) to RUE on [MEDICATION NAME]. INR has been labile. Seen by psych who adjusted meds down." Resident #9's consolidated physician's orders [REDACTED]. Diagnoses: [REDACTED]. [MEDICAL CONDITION], Debility, Hypertension, Diabetes Mellitus Type 2, Benign Neoplasm Large Intestine, Aortic [MEDICAL CONDITION], Allergy Unspecified, [MEDICAL CONDITION] Reflux, [DIAGNOSES REDACTED], [MEDICAL CONDITIONS], Pressure Ulcer Heel, Debility, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], Late Effect [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. Medications: -Aspirin 81 mg PO once daily at 9 AM (Blood thinner); -[MEDICATION NAME] 325 mg PO once daily at 12 PM (supplement used for [MEDICAL CONDITION]); -[MEDICATION NAME] 100 MG PO once daily at 12 PM (stool softener, Resident #9 frequently needed narcotic pain medications which can cause severe constipation); -Multivitamin one cap PO once daily at 12 PM (supplement); -Bidel 20-37.5 mg PO twice daily at 12 PM and 8 PM (blood pressure); -[MEDICATION NAME] 1600 mg three times daily with meals at 8 AM, 12 PM and 5 PM (used to lower phosphorus levels in the blood); -[MEDICATION NAME] two sprays in each nostril daily at 12 PM (used to treat nasal congestion); -[MEDICATION NAME] 0.5% one drop in both eyes twice a day at 12 PM and 8 PM (used to treat dry eye); -[MEDICATION NAME] 75 mg PO once daily at 12 PM (blood thinner for [MEDICAL CONDITION]) -[MEDICATION NAME] 0.1 mg PO once daily at 12 PM (for high blood pressure); -[MEDICATION NAME] 25 mg PO every 12 hours at 8 AM and 8 PM (used for itching); -[MEDICATION NAME] XL 100 mg PO once daily at 12 PM (for high blood pressure); -Calcium 500 mg PO once daily at 8 AM (supplement); -[MEDICATION NAME] 40 mg PO once daily at 12 PM (diuretic used to control swelling and blood pressure); -B Complex, Vitamin C-Folic Acid 0.8 mg PO once daily at 8 AM (supplement and pressure ulcer healing); -[MEDICATION NAME] 25 mg PO once daily at 12 PM (used to treat diabetes and lower blood sugar); -[MEDICATION NAME] XL 30 mg PO once daily at 8 AM (used to treat high blood pressure and control chest pain); -[MEDICATION NAME] 10 mg PO once daily at 9 AM (used to treat depression); -[MEDICATION NAME] 1 mg PO once daily at 9 AM (Anti-psychotic); -[MEDICATION NAME] 1 packet mixed in 4-6 oz of water PO once daily at 8 AM (nutritional supplement, promotes pressure ulcer healing); -[MEDICATION NAME] Ultra one drop in both eyes three times daily at 8 AM, 12 PM and 4 PM (for dry eyes); -[MEDICATION NAME] XL 60 mg PO once daily at 12 PM (used to treat high blood pressure and control chest pain); -[MEDICATION NAME] 500 mg PO twice daily at 12 PM and 8 PM (used to help control [MEDICAL CONDITION]). Resident #9's Medication Administration Record (MAR) for the month of September 2013 reflected the following medications were circled, or left blank indicating they were not given because she was out for [MEDICAL TREATMENT] on 09/05, 09/10, 09/12, 09/14, 09/16, 09/18, 09/20, 09/23, 09/25, 09/27 and 09/30/13: Nephro vite 0.8 mg once daily; [MEDICATION NAME] sulfate 325 mg once daily; Multivitamin one tablet once daily; Bidel 20-37.5 mg ordered twice daily, one dose missed each day; [MEDICATION NAME] 1600 mg three times daily-two doses missed each day; [MEDICATION NAME] 50 mcg nose spray, two sprays in each nostril daily; [MEDICATION NAME] eye drops twice daily-one dose missed each day; [MEDICATION NAME] 75 mg once daily; [MEDICATION NAME] 0.1 mg once daily; [MEDICATION NAME] 25 mg every 12 hours-one dose missed daily; [MEDICATION NAME] 40 mg once daily; [MEDICATION NAME] 25 mg once daily; [MEDICATION NAME] XL 100 mg once daily; Aspirin 81 mg once daily; Calcium 500 mg once daily; [MEDICATION NAME] 20 mg once daily; [MEDICATION NAME] 100 mg once daily; [MEDICATION NAME] one packet twice daily-one dose missed daily; Systain Ultra eye drops, one drop in both eyes three times daily-two doses missed each day. Further review of the same MAR reflected the following medications were circled or left blank indicating they were not given on [MEDICAL TREATMENT] days as well as non-[MEDICAL TREATMENT] days. [MEDICATION NAME] 1 mg daily on 09/10, 09/12, 09/14, 09/16, 09/18, 09/20, and 09/25/13; [MEDICATION NAME] XL 30 mg daily on 09/10, 09/12, 09/14, 09/16, 09/18, 09/20, 09/23, and 09/25, 09/27, 09/28 and 09/30/13; [MEDICATION NAME] 60 mg on 09/03, 09/05, 09/08, 09/10, 09/12, 09/14, 09/15, 09/16, 09/18, 09/20, 09/23, and 09/25, 09/27 and 09/30/13; [MEDICATION NAME] 200 mg at bedtime on 09/13 and 09/14/13; [MEDICATION NAME] 500 mg twice daily-missed one dose on 09/05, 09/10, 09/12, 09/13, 09/14, 09/16, 09/18, 09/19, 09/20, 09/23 and 09/25, 09/27 and 09/30/13; [MEDICATION NAME] 5 mg twice daily-missed one dose on 09/05, 09/10, 09/12, 09/13, 09/14, 09/16, 09/18, 09/19, 09/20, 09/23 and 09/25, 09/27 and 09/30/13. The back of the MARs for September 2013 reflected entries dated, 09/10/13, 09/12/13, 09/16/13, 09/18/13 and 09/27 and 09/30/13 with simply the word "[MEDICAL TREATMENT]" written to indicate the reason the medications were not given. No other explanations were written. Resident #9's MAR for October 2013 reflected the following medications were circled indicating they were not given because she was out for [MEDICAL TREATMENT] on 10/02, 10/04, 10/07, 10/09, 10/11, 10/14, 10/16, 10/18, 10/21, 10/23, 10/25, 10/28 and 10/30/13: [MEDICATION NAME] 325 mg one daily; [MEDICATION NAME] 100 mg daily; Multivitamin one daily; Bidel 20-37.5 mg ordered twice daily; [MEDICATION NAME] 1600 mg three times daily -two doses missed each day; [MEDICATION NAME] 50 mcg nose spray two sprays each nostril daily [MEDICATION NAME] 0.5% eye drops twice daily -one dose missed daily; [MEDICATION NAME] 75 mg once daily; [MEDICATION NAME] 0.1 mg daily; [MEDICATION NAME] 25 mg every 12 hours -one dose missed daily; [MEDICATION NAME] XL 100 mg daily; Calcium 500 mg daily; [MEDICATION NAME] 40 mg daily; B-Complex, Vitamin C-Folic Acid 0.8 mg daily; [MEDICATION NAME] 25 mg daily; [MEDICATION NAME] XL 30 mg daily; [MEDICATION NAME] 10 mg daily; [MEDICATION NAME] 1 mg daily; [MEDICATION NAME] one packet daily; [MEDICATION NAME] Ultra one drop three times daily -two doses missed each day; [MEDICATION NAME] 500 mg twice daily - missed one dose each day. Resident #9's MAR for October 2013 further reflected the following: Aspirin 81 mg by mouth daily was circled indicating it was not given on 10/02, 10/04, 10/07, 10/09, 10/21, 10/23, 10/25 and 10/30/13. [MEDICATION NAME] 60 mg by mouth daily was circled indicating it was not given on 10/02, 10/04, 10/07, 10/09, 10/11 and 10/14/13. There were no further signatures for this medication for the remainder of the month. A handwritten entry reflected: "Add ER (extended release) to [MEDICATION NAME] 10/15/13." The entry was initialed by ADON MM. Further review of the MAR revealed there was no other entry for [MEDICATION NAME] 60 mg, and no doses signed as administered. The back of the MARs for October2013 reflected entries dated, 10/02/13, 10/04/13, 10/11/13, 10/11/13,10/14/13, 10/18/13, 10/23/13, 10/25/13, with simply the word "[MEDICAL TREATMENT]" written to indicate the reason the medications were not given. No other explanations were written. Resident #9's MARs for November 2013 and December 2013 reflected the following medications were circled indicating they were not given because she was out for [MEDICAL TREATMENT] on 11/01, 11/04, 11/06, 11/08, 11/11, 11/13, 11/15, 11/18, 11/20, 11/22, 11/25, 11/27, and 11/29, 12/02, 12/04, 12/06, 12/09, 12/11, 12/13, and 12/16/13: Aspirin 81 mg one daily; [MEDICATION NAME] 325 mg one daily; [MEDICATION NAME] 100 mg daily; Multivitamin one daily; Bidel 20-37.5 mg ordered twice daily; [MEDICATION NAME] 1600 mg three times daily -two doses missed each day; [MEDICATION NAME] 50 mcg nose spray two sprays each nostril daily [MEDICATION NAME] 0.5% eye drops twice daily -one dose missed daily; [MEDICATION NAME] 75 mg once daily; [MEDICATION NAME] 0.1 mg daily; [MEDICATION NAME] 25 mg every 12 hours -one dose missed daily; [MEDICATION NAME] XL 100 mg daily ); Calcium 500 mg daily; [MEDICATION NAME] 40 mg daily; B-Complex, Vitamin C-Folic Acid 0.8 mg daily; [MEDICATION NAME] 25 mg daily; [MEDICATION NAME] XL 30 mg daily; [MEDICATION NAME] 10 mg daily; [MEDICATION NAME] 1 mg daily; [MEDICATION NAME] one packet daily; [MEDICATION NAME] Ultra one drop three times daily -two doses missed each day; [MEDICATION NAME] XL 60 mg daily; [MEDICATION NAME] 500 mg twice daily - missed one dose each day. Review of Resident #9's Nurses Notes for the months of November 2013 and December 2013 revealed there were no notes that reflected a physician had been notified of the held medications or a request to re-time the doses. Resident #9's most recent Nutritional assessment dated [DATE] reflected the following Summary and Recommendation: "...Pt continues w/ adequate intake of mech soft diet w/ appropriate therapeutic restrictions for diabetic control and [MEDICAL CONDITION] status ...Pt continues w/[MEDICAL CONDITION] to right calf, and has developed Stage II to bottom; Pt continues on Vit C, and [MEDICATION NAME] 1 pack BID for add'l 70 cal/9 gm PRO; HGB levels remain low but improved; Pt is receiving Vit B-Complex, Folic Acid, Multivit, and Iron supplement; No nutr recommendations at this review; goal is to provide adequate cal and pro to promote pressure ulcer healing." During an interview on 12/11/13 at 11:06 AM, NP O stated she was not sure when she became aware of the pressure ulcer on Resident #9's leg. She confirmed her last note about the resident was dated 10/15/13. She stated she was at the facility on 12/05/13 but she did not see Resident #9. NP O stated she remembers the staff talking to her about a pressure ulcer that day but she could not say which pressure ulcer specifically. She stated in her mind, the resident refused treatments a lot, she had been on [MEDICATION NAME], had a [MEDICAL CONDITION] and she was concerned with her other health issues. In another interview on 12/17/13 at 3:55 PM, NP O was asked if she was aware Resident #9 was not receiving most of her medications on her [MEDICAL TREATMENT] days. NP O stated typically that is what happens on [MEDICAL TREATMENT] days, they wait (to give medications). She explained the medications scheduled before [MEDICAL TREATMENT] can be given except for certain blood pressure medications. Those were up to the [MEDICAL TREATMENT] center to decide. NP O stated no one had called her to reschedule medication times. She added, "Often they're given when they return from [MEDICAL TREATMENT]. That's how some of my homes do it." In an interview on 12/17/13 at 9:25 AM, LVN A, Resident #9's Charge Nurse that day, was shown Resident #9's December 2013 MAR and asked about all her morning and noon medication orders. LVN A stated if medications were given within three hours of [MEDICAL TREATMENT], they would "wash out." She stated all medications were held on [MEDICAL TREATMENT] days except for evening medication doses. When asked whether any of the daily medications were given upon her return from [MEDICAL TREATMENT], LVN A stated only the medications due to be given in the evening were given. During an interview on 12/17/13 at 9:30 AM, the DON was asked whether medications should be held completely on [MEDICAL TREATMENT] days for residents receiving [MEDICAL TREATMENT]. The DON stated they should. When asked whether she had a facility policy on the matter, the DON stated the policy would not say that, but there should be a physician's orders [REDACTED]. During an interview on 12/17/13 at 11:15 AM, the Pharmacist was shown Resident #9's December 2013 MARs and asked about the facility's policy on holding medications for residents receiving [MEDICAL TREATMENT] treatments. The Pharmacist explained she thought Resident #9 had an order to hold certain blood pressure medications before her [MEDICAL TREATMENT] treatments but she stated she had explained to the staff she could receive those medications after [MEDICAL TREATMENT]. The Pharmacist was shown all the medications, which were not being given three times a week. The surveyor expressed concern about the nature of the medications, which included blood thinners, anti-depressant and anti-psychotic medications. The Pharmacist stated she remembered telling the staff to change the dose times to the evening but said she did not remember looking at her (Resident #9's) MARs recently. When asked if there was a general rule for medication administration for the [MEDICAL TREATMENT] residents, the Pharmacist stated they usually only held medications, which could affect the [MEDICAL TREATMENT] treatments. During an interview on 12/17/13 at 3:07 PM, LVN D, Resident #9's Charge Nurse, stated she had questioned the resident's medications in the past and someone told her the resident only received the evening medications on [MEDICAL TREATMENT] days. When asked whether she ever called the physician to clarify the orders, LVN D stated she did not, because "they were already doing that when I started." On 12/17/13 at 4:20 PM, the DON stated Resident #9's medication sheets were faxed to her primary care physician and to NP O to determine what medications could be rescheduled and to check the blood pressure medications. The DON stated Physician K was notified because he was the Medical Director. The DON stated she was under the impression the medication administration times would have been changed on her [MEDICAL TREATMENT] days. 2. Resident #4 was a [AGE] year-old male, readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Care Plan for "Hypertension" dated 09/19/13 revealed: "Problem/ Need - Problem Onset: 09/19/13 ________ (Resident #4) has potential for retaining abnormal body fluids R/T Hx. of HTN. Goal & Target Date: ________ (Resident #4) will maintain normal body fluid level as evidence of normal related lab values until next review date. Approaches: --Diet as ordered by physician. --Obtain monthly weights. --Monitor for S/S of [MEDICAL CONDITION] --Diet Consult as needed." Review of Resident #4's Care Plan for "[MEDICAL CONDITION]/[MEDICAL CONDITION] " dated 07/09/13 revealed: "Problem/ Need - Problem Onset: 07/09/13 [MEDICAL CONDITION]/[MEDICAL CONDITION] Goal & Target Date: ________ (Resident #4) will not suffer any ill effects caused by DX thru next eval date Approaches: -Medication given as ordered Monitor and document effects... -Vital Signs as directed an (sic) as needed...." Review of Resident #4's November 2013 consolidated physician orders [REDACTED]. Review of a physician's progress note dated 11/18/13 revealed Resident #4 had [DIAGNOSES REDACTED]. Further review of this note revealed the resident was on medications including [MEDICATION NAME] (for Hypertension), and [MEDICATION NAME] ([MEDICATION NAME] for Hypertension). Review of Resident #4's November 2013 MAR revealed a place to document the resident's BP, at 8:00 AM and 4:00 PM each day totaling 60 times. Eighteen of the 60 times the resident's BP was taken, the SBP results were greater than 150 or the DBP results were greater than 90: 162/82, 165/79,154/100, 152/107, 188/81, 184/69, 145/94, 152/107, 162/118, 183/78, 156/81, 142/107, 166/88, 133/91, 156/80, 126/94, 122/102, and 158/98. The PRN [MEDICATION NAME] was not documented as given. Review of Resident #4's December 2013 MAR revealed a place to document the residents BP. From 12/01/13 through 12/13/13, at 8:00 AM and 4:00 PM each day, Resident #4 had a total of 26 times when her bloos pressure should have been taken. Three of the 26 times the resident's BP was taken, the SBP results were greater than 150 or the DPB results were greater than 90, ranging from 145/103, 114/92, 131/91 and the PRN [MEDICATION NAME] was not documented as given. In an interview on 12/11/13 at 6:55 PM, the surveyor reviewed Resident #4's November and December 2013 MARs with LVN C, which had multiple DBPs greater than 90, with LVN C's initials above the BP results. LVN C stated she was Resident #4's charge nurse and she did take and document Resident #4's blood pressures at 4:00 PM and further stated she had not administered PRN [MEDICATION NAME] as ordered. LVN C stated, "Well her (Resident #4's) blood pressure usually drops after 4:00 PM." The surveyor queried LVN C how she knew that and LVN C stated, "Well you can look at her morning blood pressures," as she pointed to the following days at the 8:00 AM blood pressures. In an interview on 12/11/13 at 7:15 PM, the surveyor showed the DON Resident #4's [MEDICATION NAME] order and asked her when she expected her nurses to administer the [MEDICATION NAME]. The DON stated, "If the SBP is greater than 150 or the DBP is greater than 90." The surveyor showed the DON Resident #4's documented November and December BPs and the [MEDICATION NAME] MAR, which indicated no [MEDICATION NAME] was administered. The DON made no further comment. 3. Resident #3 was a [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she was severely impaired cognitively, and was totally dependent on staff for her ADLs. Resident #3's Physician's Telephone Orders dated 11/05/13 reflected: Discontinue [MEDICATION NAME] liquid, [MEDICATION NAME] 125 mg sprinkles, change [MEDICATION NAME] to 20 mg every other day and add [MEDICATION NAME] 4.6 mg daily. The order was written by ADON MM, Review of Resident #3's consolidated physician's orders [REDACTED]. The orders were signed as reviewed by ADON MM. Review of Resident #3's MARs for the month of November 2013 revealed the following entries: [MEDICATION NAME] 125 mg Sprinkles by mouth twice a day with an order date of 10/24/13 discontinued and ceased to be given on 11/05/13. The MAR further revealed a place to document the resident's BP, at 8:00 AM, 12:00 PM and 6:00 PM each day totaling 90 times. 22 of the 90 times the resident's BP was taken, the SBP results were greater than 150 or the DBP results were greater than 90, 168/83, 160/68, 164/99, 168/106, 163/110, 164/96, 173/60, 158/64, 175/93, 162/81, 154/105, 167/76, 161/91, 156/85, 156/93, 162/96, 164/67, 160/70, 151/81, 164/81, 151/78, 159/74, and 160/85. The PRN [MEDICATION NAME] was not documented as given. Review of Resident #3's MARs for the month of December 2013 revealed the following entries: [MEDICATION NAME] 125 mg Sprinkles by mouth twice a day of 10/24/13. The medication was initialed as administered twice a day from 12/01/13 through 12/11/13. The medication was discontinued after surveyor intervention. During an interview on 12/11/13 at 2:42 PM, the ADON stated she reconciled the medications at the end of the month and signed off on the monthly consolidated physicians orders. When shown Resident #3's orders to discontinue the [MEDICATION NAME] as well as the December consolidated orders where the [MEDICATION NAME] reappeared, the ADON stated she could not explain the discrepancy and would make sure the drug was discontinued immediately. A later review of the MAR for December 2013 revealed the same [MEDICATION NAME] entry had a handwritten note that reflected: "D'CD 12/11/13 @ 1800 (6:00 PM)." However, the medication was signed as administered on 12/11/13 at 8:00 PM and again on 12/12/13 at 8:00 AM. The MAR further revealed a place to document the resident's BP, at 8:00 AM , 12:00 PM and 6:00 PM each day totaling 28 times. Seven of the 28 times the resident's BP was taken, the SBP results were greater than 150 or the DBP results were greater than 90, 153/84, 166/98, 159/63, 152/65, 153/82, 188/81 and 174/86. The PRN [MEDICATION NAME] was not documented as given. An observation on 12/10/13 at 1:11 PM revealed Resident #3 was sitting alone in her room in her wheelchair. She was leaning forward and wincing. Resident #3 complained of pain all over and stated she wanted to go to bed. As she was speaking, MA Z entered the room and checked Resident #3's blood pressure which was 174/86. MA Z stated she would report the blood pressure and complaints of pain to her Charge Nurse. During an interview on 12/12/13 at 8:00 AM, when LVN D, Resident #3's Charge Nurse, was asked how she monitored her resident's blood pressure, she stated the Medication Aides checked the blood pressures and reported any abnormal readings. She stated if the readings were abnormal more than a few times per week, she would notify the physician. When asked about Resident #3's high blood pressure readings and lack of [MEDICATION NAME] administration, LVN D stated she did not know. In an interview on 12/12/13 at 8:06 AM, when MA Z was asked what vital sign parameters she reported to the Charge Nurses, she stated she reported SBP greater than 150, DBP higher than 90 or a heart rate less than 60. When reminded of the blood pressure she took on Resident #3 on 12/10/13 and asked whether she reported it, she said she had. When asked whether she was instructed to administer any [MEDICATION NAME], MA Z stated she was not. She went on to explain she had been told if a resident's heart rate was not greater than 90, she should hold the [MEDICATION NAME]. She stated she would still report the blood pressure. On 12/12/13 at 8:17 AM, LVN A, who was Resident #3's Charge Nurse on 12/10/13, was interviewed. LVN A was queried what the parameters were for Resident #3 to administer [MEDICATION NAME]. LVN A stated the parameters to administer [MEDICATION NAME] were SBP greater than 150 or a DBP greater than 90. When asked about Resident #3's blood pressure on 12/10/13 and why no [MEDICATION NAME] was given, LVN A stated she waited because the resident was in pain, and she planned to recheck her after her pain subsided. During an interview on 12/12/13 at 8:28 AM, ADON MM was asked if anyone monitored the MARs and TARs to ensure PRN orders were administered. ADON MM stated, "As an ADON, I have to look at these things. In the morning I try to look. It is my job." When shown Resident #3's MAR and blood pressure results, ADON MM stated she was not aware of the missed [MEDICATION NAME]. 4. Resident #22 was an [AGE] year-old-female admitted to the facility on [DATE] per her quarterly MDS assessment dated [DATE]. Further review revealed Resident #22 had [DIAGNOSES REDACTED]., [MEDICAL CONDITION], Malignant Hypertension and [MEDICAL CONDITION]. Resident #22's MDS assessment further reflected she was incontinent of bowel and bladder. Review of Resident #22's care plans revealed she had no care plan concerning UTIs. During an interview with ADON MM on 12/15/13 at 12:26 PM, she informed the surveyors they had done a sweep of the building and looked at all people with UTI infections. ADON MM said they looked through the records for everyone who had an infection. She said then they had looked through the residents charts, who had infections to make sure labs were done as ordered by the physician and to see if the physician was called and the follow-up was done. ADON MM said they first looked through their infection control log to get the resident names and then went to the resident charts. When asked how she found out about a new infection, ADON MM said it was the nurse who called the doctor, transcribed the order and then placed a copy in ADON MM's box. When ADON MM got the order from her box, she entered it into her infection control log. ADON MM informed the surveyor she would then go to the resident's chart and find out what infection it was and the ABT ordered. When asked about the organism causing the infection,l ADON MM said she would sometimes put the type of organism, but it generally took two to three days to get the culture results back, so the nurses put it on the Infection Report sheet and then gave that back to ADON MM. ADON MM said she tries to enter the organism on the infection control log as soon as she gets it from a nurse. ADON MM stated the Infection Report should be filled out as soon as the nurse learns of an infection or gets an order for [REDACTED]. On 12/15/12, ADON MM gave the surveyor the results of their UTI infection sweep. Review of the paper work provided for Resident #22 revealed the following: 1) A physician's telephone order dated 09/05/13, which ordered the antibiotic [MEDICATION NAME] ([MEDICATION NAME]) 50 mg by mouth every 12 hours for seven days as well as to continue the antibiotic [MEDICATION NAME] two times a day for ten days; 2) A physician progress notes [REDACTED]. 3) Nurse's notes dated from 09/04/13 at 3:00 PM through 09/12/13 at 9:30 AM reflected various nurses documentation of antibiotics being given for Resident #3's UTI. The antibiotics [MEDICATION NAME] and [MEDICATION NAME] (together) were mentioned in three entries. The antibiotic [MEDICATION NAME] was the only antibiotic mentioned as being used for the UTI in seven entries. In six entries, it included "antibiotics" for her UTI, but did not include the names of the antibiotics; 4) Resident #22's MAR for September 2013 had a handwritten notation at the bottom for [MEDICATION NAME] 50 mg one tab by mouth every 12 hours for seven days and [MEDICATION NAME] two times a day for ten days. In the columns next to [MEDICATION NAME] was written "D/C 9/9/13" and in the columns next to the [MEDICATION NAME] was 9 AM with 9 PM below it. The columns have an arrow through the dates of 09/01/13 through 09/04/13 for both times. The first time the [MEDICATION NAME] was initialed as being given was on 09/08/13 at 9:00 AM and 9:00 PM. There were initials written in for the 9:00 AM dose on 09/09/13, 09/10/13 and 09/11/13, but they were circled to indicate the medication was not given. There were no further initials documented on the Sepember 2013 MAR to indicate either antibiotic was given to Resident #22 for her UTI. 5) Resident #22's laboratory results for the UA C & S dated as collected on 08/30/13 and showed and infection of Escherichia coli (E. coli) >100,000 cfu/ml. Resident #22's MARs for September 2013 reflected an entry for [MEDICATION NAME] 50 mg one tab by mouth every 12 hours for seven days with a start date of 09/05/13 and to be given at 9:00 AM and 9:00 PM. The dates from 09/05/13 through 09/07/13 were blank, which indicated no medication had been given. On 09/08/13, both the 9:00 AM and 9:00 PM doses were initialed for the medication as having been given. However, from 09/09/13 through 09/11/13, the 9:00 AM dose had circled intials and the 9:00 PM dose was left blank. On the back of Resident #22's September 2013 MAR was handwritten three times, "[MEDICATION NAME] 50 mg Not available" to explain the initials with the circles. Further review of Resident #22's September 2013 MAR revealed another page where [MEDICATION NAME] 500 mg cap by mouth two times a day for ten days was handwritten in. It showed all doses to hav

Based on observation, interview any record review, it was determined the facility failed to ensure each resident was free of significant medication errors for two (Resident #1 and #2) of 8 residents reviewed for medications. 1) a.The facility failed to properly transcribe and administer the following medications for Resident #1 in two of two months reviewed: [MEDICATION NAME] 25 mg - missed three of five doses; [MEDICATION NAME] 20 mg - missed three of five doses; [MEDICATION NAME] eye drops- missed three of five doses; [MEDICATION NAME] 40 mg- was only given 20 mg dose and only received it three out of five times; [MEDICATION NAME] - was given in the morning instead of at bedtime as ordered; [MEDICATION NAME] 200 mg- 100 mg was given for three days; [MEDICATION NAME] - was given in the morning instead of at bedtime as ordered; Levetiracetam 1000 mg - 500 mg was given for three days; [MEDICATION NAME] XL - missed three 60 mg doses and missed five 30 mg doses; and [MEDICATION NAME] 0.1mg- missed five doses. b. LVN D failed to administer the correct dose of pain medications to Resident #1 when she repeatedly complained of leg pain. LVN D administered one [MEDICATION NAME] 5/325 mg when the ordered dose was two 10/325 mg tablets. 2) The facility failed to discontinue Resident #2's [MEDICATION NAME] 25mg (for Hypertension) as ordered. The morning dose of [MEDICATION NAME] was discontinued on 02/03/14 and the evening dose was not discontinued until after the 02/28/14 dose, for a total of 31 doses. These failures could affect any the facility's 75 residents, including Residents #1 and #2, by placing them at risk for depression, eye discomfort, unrelieved pain, stomach upset, [MEDICAL CONDITION], weakness, confusion, dizziness, headache, [MEDICAL CONDITIONS] and death and could affect the 75 residents in the facility. Findings included: 1) a) Review of Resident #1's Physician's Telephone Orders dated 02/26/14 revealed she was to be readmitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #1's admission Nurse's Note dated 02/26/14 at 2:20 PM revealed she was confused but able to make her needs known at that time. Review of Resident #1's hospital Medication Profile Report dated 02/25/14 revealed the following medications were among those to be continued when she returned to the facility: [MEDICATION NAME] 20 mg tablets by mouth twice daily (used to treat chest pain caused by heart damage); [MEDICATION NAME] 0.05% eye drops, one drop in each eye twice daily (used for increase tear production); [MEDICATION NAME] 20 mg tablets, give 40 mg at bedtime (used to lower cholesterol); [MEDICATION NAME] 20 mg tablets, give 10 mg by mouth at bedtime (used to treat depression); [MEDICATION NAME] 100 mg tablets, give 200 mg at bedtime (used to treat pain caused by [MEDICAL CONDITION]); [MEDICATION NAME] 325 mg, give one at bedtime (iron supplement used to treat [MEDICAL CONDITION]); Levetiracetam 500 mg tablets, give 1000 mg at bedtime (used to treat [MEDICAL CONDITION]); [MEDICATION NAME] XL 30 mg by mouth every day (used to treat high blood pressure and chest pain); [MEDICATION NAME] XL 60 mg by mouth every evening; [MEDICATION NAME] HCL 0.1 mg by mouth every day (used to treat high blood pressure). Review of Resident #1's February 2014 MARs revealed the following: [MEDICATION NAME] 25 mg tablets twice a day was only transcribed and initialed as administered once on 02/27/14. (Not twice a day as ordered) [MEDICATION NAME] 20 mg tablets was only transcribed and initialed as administered once a day on 02/27/14 and 02/28/14. (Not twice a day as ordered and not on 02/26/14 evening) [MEDICATION NAME] eye drops were only transcribed and initialed as administered once a day on 02/27/14 and 02/28/14. (Not twice a day as ordered) [MEDICATION NAME] was transcribed as 20 mg at bedtime and only initialed as administered on 02/26/14 and 02/27/14. (Not on 02/28/14 as ordered) [MEDICATION NAME] was transcribed and initialed as administered as 10 mg at 6:30 AM. (Not at bedtime as ordered) [MEDICATION NAME] 100 mg was transcribed and initialed as administered at bedtime. (Not 200 mg as ordered) [MEDICATION NAME] 325 mg was transcribed and initialed as administered at 6:30 AM. (Not at bedtime as ordered) Levetiracetam 500 mg was transcribed and initialed as administered daily at bedtime. (Not 1000 mg as ordered) [MEDICATION NAME] XL was transcribed as 30 mg by mouth every evening and was only administered on 02/26/14 and 02/27/14. (Not 60 mg as ordered and none on 02/28/14) [MEDICATION NAME] XL 60 mg was not transcribed to the February MAR and so no doses were given in February. Review of Resident #1's March 2014 MARs revealed the following: [MEDICATION NAME] XL 30 mg by mouth every day was not transcribed and so was not administered from 03/01/14 through 03/05/14, when surveyor inquired. [MEDICATION NAME] HCL 0.1 mg by mouth every day was not transcribed and so was not administered from 03/01/14 through 03/05/14, when surveyor inquired. An interview with the Unit Manager on 03/04/14 at 4:32 PM revealed it was typically her duty to check all orders daily for accuracy but she was pulled off the floor or on 02/24/14 to work on the monthly consolidated orders for the remainder of the month. She stated, during that time, the DON was performing the daily checks on both nurses' stations. During an interview on 03/05/15 at 10:25 AM, LVN C stated she had transcribed the admission orders [REDACTED]. When shown the errors found by the surveyors, LVN C stated she was not aware of the errors. She stated RN A had transcribed the orders to the March MARs and she remembered RN A pointing out some discrepancies to her but she thought she had corrected them. During an interview on 03/05/14 at 11:25 AM, RN A stated she had transcribed the March MARs for Resident #1 but had never looked at February's MARs. RN A stated she had caught a few discrepancies after the hospital orders had been transcribed to the facility's admission orders [REDACTED]. She was not aware of any medication errors. An interview with the DON on 03/05/14 at 11:25 AM revealed all orders, including new admission orders [REDACTED]. The DON explained pink copies of all resident's orders were to be placed in a box and both she and the Unit Manager checked those pink copies every day before they left to ensure all orders written over the past 24 hours were transcribed correctly. When asked about Resident #1, the DON confirmed the Unit Manager was not checking orders at that time as she had been pulled to work on the monthly orders. The DON stated she did not know why Resident #1's orders had not been checked; she stated the pink copies must not have made it into the designated box. b) Review of Resident #1's hospital Medication Profile Report dated 02/25/14 revealed the following medications were among those to be continued when she returned to the facility: [MEDICATION NAME] 10/325 mg one tablet every six hours as needed for pain. [MEDICATION NAME] 10/325 mg two tablets every six hours as needed for pain. Resident #1's admission orders [REDACTED]. Review of Resident #1's MAR for February 2014 revealed an entry for [MEDICATION NAME]-Apap 10-325 two every six hours as needed for pain. The entry was initialed as administered on 02/26/14 at 3:00 PM and 9:00 PM by LVN D. The back of the MAR reflected the following entries: 2/26/14 at 3:00 PM: "Resident c/o pain, pain level 8/10, [MEDICATION NAME] ([MEDICATION NAME]) 5/325 admin, pain level at 3:30 PM 6/10." The entry was signed by LVN D. 2/26/14 at 9:00 PM: "Resident c/o pain, telling, 8/10, [MEDICATION NAME] 5/325 mg admin, pain level @ 9:30 (PM), 7/10, ineffective." The entry was signed by LVN D. During an interview on 03/05/14 at 12:45 PM, LVN D explained she was Resident #1's Charge Nurse on 02/26/14 but LVN C was completing the admission orders [REDACTED]. When asked why she only administered 5/325 mg when the order and MAR both indicated the dose was two 10/325 tablets, LVN D stated she had seen the dose on the MAR but when she went to the medication cart, her old card was still on the cart (from prior to her hospitalization ) and so she just administered that. When asked why she did not question the dosage on the card as it conflicted with the MAR or check the orders in the chart, LVN D stated, "It never occurred to me she was really in pain, I didn't touch the orders, I gave her what she had on the cart." During an interview on 03/05/14 at 2:47 PM, the DON was shown Resident #1's MARs and told about the medication error regarding the [MEDICATION NAME]. The DON stated she was not aware of the error and that it should not have happened. She confirmed [MEDICATION NAME] 10/325 mg tablets were kept in the E-kit and LVN D could have easily retrieved the proper dose. When asked how Resident #1's pain should have been handled, the DON stated if a resident complains of pain, they should be assessed and a pain level ascertained. She stated the resident should be medicated if indicated and re-assessed in 30-45 minutes for relief. The DON stated, if the medication was not effective and another medication could not be given, the physician should be called and made aware of all the details surrounding the situation. An observation on 03/05/14 at 3:28 PM revealed [MEDICATION NAME] 10/325 tablets were stocked in the medication room E-kit at Resident #1's nurse's station. 2. Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed Resident #2 had a BIMS of 4 and was dependent on staff for most of his ADLs. Review of Resident #2's Care Plan dated 02/27/14 revealed: "Date & Problem: DX [MEDICAL CONDITION]/HTN/[MEDICAL CONDITION] Goal: (Resident #2) will not suffer any complications caused by Dx's thru the next eval date. Approaches & Disciplines: Lab as ordered Notify Dr. of results Medications as ordered. Notify Dr of effectiveness Monitor for [MEDICAL CONDITION], SOB, Pain in extremities with discoloration of skin and warm to touch Document and Notify Dr/RP/Hospice" Resident #2's Physician's Telephone Orders dated 01/09/13 reflected [MEDICATION NAME] 25 mg twice a day. Resident #2's Physician's Telephone Orders dated 01/30/14 reflected increase [MEDICATION NAME] to 50 mg twice a day for blood pressure. Review of Resident #2's MARs for the month of January 2014 revealed the last dose of [MEDICATION NAME] 25 mg was on 01/30/14 after the 9:00 PM dose. Further review of this MAR revealed [MEDICATION NAME] 50 mg was started on 01/30/14 at 9:00 PM. Review of Resident #2's MARs for the month of February 2014 revealed [MEDICATION NAME] 50 mg twice a day was administered as ordered. Further review of this MAR revealed the morning dose (9 AM) of [MEDICATION NAME] 25 mg was administered on 02/01/14, 02/02/14/ and 02/03/14. "DC'D" was hand written after the 9 AM dose was administered on 02/03/14. The evening dose (4:00 PM) of [MEDICATION NAME] 25 mg was administered each day during the month of February. A total of 31 doses of [MEDICATION NAME] 25 mg were administered that the physician had discontinued on 01/30/14. During an interview on 03/04/14 at 3:55 PM the surveyor reviewed Resident #2's February 2014's MARs with LVN B, Resident #2's evening charge nurse. LVN B stated she did administer [MEDICATION NAME] 25 mg and [MEDICATION NAME] 50 mg on the days she worked, as were documented on Resident #2's MAR. During an interview on 03/05/14 at 10:05 AM the ADM stated the Unit Manager did the February 2014 monthly recapitulations of physician orders [REDACTED]. During an interview on 03/04/14 at 4:30 PM the Unit Manager stated she checks the pink slips (copy of telephone physician orders) daily to make sure the orders were correct on the MARs. She stated when she did the February 2014 monthly recapitulations of physician orders, she was taken off the floor from 01/25/14 through the end of the month, and the DON took over her tasks, including verifying the pink slips were checked, for the whole building. During an interview on 03/06/14 at 4:30 PM the ADM stated Resident #2 receiving 31 doses of [MEDICATION NAME], which had been discontinued, was a careless error. The ADM further stated the DON told her she did miss a few a days of checking pink slips. During an interview on 03/06/14 at 8:47 AM the surveyor asked the DON how she thought Resident #2's received 31 doses of [MEDICATION NAME] that had been discontinued. The DON stated when RN A taught the Unit Manager how to do the monthly recapitulations of physician orders, RN A did not instruct the Unit Manager to continue to add additional physician orders [REDACTED]. "Nursing 2013 Drug Handbook" 33rd Edition, Wolters Kluwer, Copyright 2013, pages 680 - 681 reflected the following nursing considerations for [MEDICATION NAME]: "Monitor patient's blood pressure, pulse and body weight frequently...Elderly patients may be more sensitive to drug's hypotensive effects...." Overdose signs and symptoms include: [MEDICAL CONDITIONS] headache and flushing. 3. Review of the facility's current undated policy and procedure "Monthly Review of physician's orders [REDACTED]. "Purpose: To ensure that physician order's are accurate. Policy: To verify prior to the beginning of each month that all physician orders [REDACTED]. (RN A)/ (Unit Manager) will be responsible for this monthly review. DON will schedule the delivery of the orders. DON will have (RN A) to be removed from the schedule as a floor nurse for the last 5-6 days of each month. (RN A) will inform DON of all concerns regarding the orders upon the completion of the review. (RN A) will take the prior month MARS and compare them to the clinical record. (RN A) will then take the clinical record and compare it to the new MARS. (RN A) will then handwrite onto the new MAR any new orders that will come after the 25th of the month. Attending nurses will write any new orders on the current MAR until the end of the month. If a new admission comes at the end of the month, (RN A)/Designee reviewing the MAR should make a new set of physician's orders [REDACTED]. (RN A)/Designee should also make a new set of MARS and TARS for the next month. (RN A)/Designee will via fax all updates to the person responsible for preparing the monthly orders: (name of pharmacy tech) at [PHONE NUMBER]. Clarifications orders will be written. 11-7 will compare the old MAR to the New MAR for accuracy." Review of the facility's current policy and procedure "Unnecessary Drugs" dated 2012 revealed: "Purpose: Each resident's drug regimen must be free from unnecessary drugs: Procedure: An unnecessary drug is any drug when used: 1. In excessive dose (including duplicate therapy); or 2. For excessive duration; or 3. Without adequate monitoring; or 4. Without adequate indications for its use; or 5. In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or 6. An combination of the reasons above...." Review of an undated Medication Pass Inservice from an RN/LVN Orientation Book located at the Nurse's Station revealed the following: "Steps to take during the med pass: ... 16. Before administering the medication, always check 'The 6 R's' 17. Triple check medications vs. MAR before administering the medications. 18. If any of the 6 R's do not match or if you have any questions about the medication itself DO NOT GIVE THE MEDICATION! Check the chart or call the pharmacy with your concern. The pharmacist would rather you ask a question than a mistake be made...." "DURING THE MEDICATION PASS: 'THE 6 Rs' Before administering any medication, always check the 6 Rs, The right resident... The right drug: verify each drug against the medication administration record (MAR) before administering... The right dose: verify against the MAR ... The right time: administer drugs as instructed on the MAR and within the time frame established by your facility...." "CHECKPOINTS...Related issues...Make sure discontinued medications have been removed from the cart as soon as they have been discontinued...." 4. Review of the facility's Form-672, Resident Census and Conditions of Residents, dated 03/03/14 and signed by DON reflected a census of 75.

Based on interview and record review, it was determined the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident for seven (Residents #3, #4, #9, #13, #22, #29 and #34) of 25 residents reviewed for pharmacy services. 1. The facility failed to administer 23 different medications to Resident #9, including medications used to treat Heart Failure, Hypertension, DVT, Depression, Diabetes Mellitus, Pressure Ulcers, and Psychotic Disorders when she left the facility three times a week for dialysis treatments for four (September, October, November and December 2013) of four months reviewed. Her physician was unaware the medications were not given. The facility failed to properly transcribe Resident #9's Procardia (for blood pressure and chest pain) 60 mg daily causing the drug to be left off her MAR from 10/16/13 through 10/31/13. 2. The facility failed to provide Resident #4 18 doses of physician-ordered PRN Clonidine (for Hypertension) during November 2013 and four doses during December 2013 for an SBP greater than 150 or DBP greater than 90. 3. The facility failed to discontinue Resident #3's Depakote as ordered. The medication was discontinued on 11/05/13 but restarted on 12/01/13 when staff failed to remove it from the MAR and the physician's consolidated orders. Resident #3 received the Depakote twice a day until surveyor intervention on12/11/13. The facility failed to administer Resident #3 22 doses of physician-ordered PRN Clonidine (for Hypertension) during November 2013 and seven doses during December 2013 for SBP greater than 150 or DBP greater than 90. 4. The facility failed to administer Resident #22 12 of 14 doses of the physician-ordered antibiotic Nitrofurantpoin for her UTI. 5. Resident #13 was administered Hydralazine (for blood pressure) despite documented blood pressure readings of 71/26 and 109/36. She had orders to hold the medication if her SBP was less than 110 or DBP was less than 60. 6. The facility failed to administer Resident #34's Hydralazine (for blood pressure) nine times even though her blood pressure was above the physician-ordered parameters to hold the medication. 7..The facility failed to administer to Resident #29, four doses of the physician-ordered PRN Clonidine (for Hypertension) during December 2013 for SBP greater than 160. An Immediate Jeopardy (IJ) was identified on 01/02/14. While the IJ was removed on 01/11/14, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. These failures could affect any the facility's 75 residents, including Residents #3, #4, #9, #13, #22, #29 and #34, by placing them at risk for untreated UTIs, not receiving therapeutic dosages of their medications, Cerebral Vascular Accidents, depression, irritability, uncontrolled diabetes, uncontrolled blood pressure and possible death. 8. LVN A failed to administer Resident #4's [DEVICE] medications following standards of practice. LVN A combined the resident's liquid Multi Vitamin and liquid Iron into one plastic cup. LVN A then crushed Metoprolol, Aspirin, Namenda, Cranberry tablet, Tylenol and Metformin together and placed the crushed/powdered contents into the plastic cup. She added the liquid Multi Vitamin and liquid Iron to the crushed medication mixture. LVN A then flushed the [DEVICE] and put the cupful of medications through the syringe and flushed the G -tube and restarted the tube feedings. LVN A, by cocktailing, failed to flush between each medication administration. These failures affected Resident #4, and placed her at risk for not receiving therapeutic dosages of their medications and clogging of the [DEVICE], which could result in additional medical treatment and hospitalization . Findings included: 1. Resident #9 was an [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #9 had a BIMS score of 11, indicating she was moderately impaired cognitively. She was totally dependent on staff for bed mobility, transfers and hygiene and required extensive assistance for dressing. The MDS assessment further reflected Resident #9 exhibited verbal behaviors, "Other behaviors not directed toward others," rejected care at times and was receiving dialysis. Resident #9's Care Plans reflected the following: Problem Onset: 07/05/13, (Resident #9) has potential for abnormal blood sugar level R/T Hx of Diabetes. Approaches included: Diet as ordered by physician; Monitor meal intake; Offer appropriate snacks according to physician orders; diet consult as needed. (NOTE: there was no mention of testing her blood sugar level or administering medications as ordered.) Problem Onset: 08/19/13, "(Resident #9) is socially inappropriate/has disruptive behavior of cursing/yelling at staff, roommate, refuses care." Approaches included: "...Monitor and document resident behavior. Report any changes to physician/R.P.; Review resident drug regimen for anxiety, depression, psychosis (Ativan, Cymbalta, Resperdal) per facility's protocol...." Problem Onset: 07/05/13, "(Resident #9) has potential for retaining abnormal body fluids R/T Hx of HTN & CHF." Approaches included: "Diet as ordered by physician; Obtain monthly weights; Diet consult as needed." Added 09/20/13: "Explained that dialysis is her life line. Unable to drink fluids after dialysis as she would like." Problem Onset: 09/19/13, "(Resident #9) is noncompliance (sic) with therapeutic diet as evidenced by eating food brought in by family/friends. Dx ESRD, Diabetes, Hypertension." Approaches included: "...follow her dialysis plan of care (Note: no such plan of care was found or provided by the facility), ...encourage to comply with medication program; Check V/S, B/P, Blood Sugars as directed. Document and report abnormal finding to physician." Resident #9's most recent physician's Progress Note dated 10/15/13 reflected the following History of Present Illness: "HX [DIAGNOSES REDACTED] post IV (Vancomycin - antibiotic) w/ HD. Also w/acute DVT (blood clot) to RUE on Coumadin. INR has been labile. Seen by psych who adjusted meds down." Resident #9's consolidated physician's orders [REDACTED]. Diagnoses: [REDACTED]. Renal Insufficiency, Debility, Hypertension, Diabetes Mellitus Type 2, Benign Neoplasm Large Intestine, Aortic Atherosclerosis, Allergy Unspecified, Esophageal Reflux, [DIAGNOSES REDACTED], Depressive Disorder, Osteoarthritis, DVT, Pressure Ulcer Heel, Debility, Psychosis, Bipolar, [DIAGNOSES REDACTED], Neuropathy, Late Effect Cerebrovascular Accident, CHF and Anemia. Medications: -Aspirin 81 mg PO once daily at 9 AM (Blood thinner); -Ferrous Sulfate 325 mg PO once daily at 12 PM (supplement used for anemia); -Colace 100 MG PO once daily at 12 PM (stool softener, Resident #9 frequently needed narcotic pain medications which can cause severe constipation); -Multivitamin one cap PO once daily at 12 PM (supplement); -Bidel 20-37.5 mg PO twice daily at 12 PM and 8 PM (blood pressure); -Renvela 1600 mg three times daily with meals at 8 AM, 12 PM and 5 PM (used to lower phosphorus levels in the blood); -Flonase two sprays in each nostril daily at 12 PM (used to treat nasal congestion); -Restasis 0.5% one drop in both eyes twice a day at 12 PM and 8 PM (used to treat dry eye); -Plavix 75 mg PO once daily at 12 PM (blood thinner for DVT) -Clonidine 0.1 mg PO once daily at 12 PM (for high blood pressure); -Atarax 25 mg PO every 12 hours at 8 AM and 8 PM (used for itching); -Toprol XL 100 mg PO once daily at 12 PM (for high blood pressure); -Calcium 500 mg PO once daily at 8 AM (supplement); -Lasix 40 mg PO once daily at 12 PM (diuretic used to control swelling and blood pressure); -B Complex, Vitamin C-Folic Acid 0.8 mg PO once daily at 8 AM (supplement and pressure ulcer healing); -Januvia 25 mg PO once daily at 12 PM (used to treat diabetes and lower blood sugar); -Procardia XL 30 mg PO once daily at 8 AM (used to treat high blood pressure and control chest pain); -Celexa 10 mg PO once daily at 9 AM (used to treat depression); -Risperdal 1 mg PO once daily at 9 AM (Anti-psychotic); -Arginaid 1 packet mixed in 4-6 oz of water PO once daily at 8 AM (nutritional supplement, promotes pressure ulcer healing); -Systane Ultra one drop in both eyes three times daily at 8 AM, 12 PM and 4 PM (for dry eyes); -Procardia XL 60 mg PO once daily at 12 PM (used to treat high blood pressure and control chest pain); -Keppra 500 mg PO twice daily at 12 PM and 8 PM (used to help control seizures). Resident #9's Medication Administration Record (MAR) for the month of September 2013 reflected the following medications were circled, or left blank indicating they were not given because she was out for Dialysis on 09/05, 09/10, 09/12, 09/14, 09/16, 09/18, 09/20, 09/23, 09/25, 09/27 and 09/30/13: Nephro vite 0.8 mg once daily; Ferrous sulfate 325 mg once daily; Multivitamin one tablet once daily; Bidel 20-37.5 mg ordered twice daily, one dose missed each day; Renvela 1600 mg three times daily-two doses missed each day; Flonase 50 mcg nose spray, two sprays in each nostril daily; Restasis eye drops twice daily-one dose missed each day; Plavix 75 mg once daily; Clonidine 0.1 mg once daily; Atarax 25 mg every 12 hours-one dose missed daily; Lasix 40 mg once daily; Januvia 25 mg once daily; Toprol XL 100 mg once daily; Aspirin 81 mg once daily; Calcium 500 mg once daily; Celexa 20 mg once daily; Colace 100 mg once daily; Arginaid one packet twice daily-one dose missed daily; Systain Ultra eye drops, one drop in both eyes three times daily-two doses missed each day. Further review of the same MAR reflected the following medications were circled or left blank indicating they were not given on dialysis days as well as non-dialysis days. Risperdal 1 mg daily on 09/10, 09/12, 09/14, 09/16, 09/18, 09/20, and 09/25/13; Procardia XL 30 mg daily on 09/10, 09/12, 09/14, 09/16, 09/18, 09/20, 09/23, and 09/25, 09/27, 09/28 and 09/30/13; Procardia 60 mg on 09/03, 09/05, 09/08, 09/10, 09/12, 09/14, 09/15, 09/16, 09/18, 09/20, 09/23, and 09/25, 09/27 and 09/30/13; Neurontin 200 mg at bedtime on 09/13 and 09/14/13; Keppra 500 mg twice daily-missed one dose on 09/05, 09/10, 09/12, 09/13, 09/14, 09/16, 09/18, 09/19, 09/20, 09/23 and 09/25, 09/27 and 09/30/13; Namenda 5 mg twice daily-missed one dose on 09/05, 09/10, 09/12, 09/13, 09/14, 09/16, 09/18, 09/19, 09/20, 09/23 and 09/25, 09/27 and 09/30/13. The back of the MARs for September 2013 reflected entries dated, 09/10/13, 09/12/13, 09/16/13, 09/18/13 and 09/27 and 09/30/13 with simply the word "Dialysis" written to indicate the reason the medications were not given. No other explanations were written. Resident #9's MAR for October 2013 reflected the following medications were circled indicating they were not given because she was out for dialysis on 10/02, 10/04, 10/07, 10/09, 10/11, 10/14, 10/16, 10/18, 10/21, 10/23, 10/25, 10/28 and 10/30/13: Ferrous Sulfate 325 mg one daily; Colace 100 mg daily; Multivitamin one daily; Bidel 20-37.5 mg ordered twice daily; Renvela 1600 mg three times daily -two doses missed each day; Flonase 50 mcg nose spray two sprays each nostril daily Restasis 0.5% eye drops twice daily -one dose missed daily; Plavix 75 mg once daily; Clonidine 0.1 mg daily; Atarax 25 mg every 12 hours -one dose missed daily; Toprol XL 100 mg daily; Calcium 500 mg daily; Lasix 40 mg daily; B-Complex, Vitamin C-Folic Acid 0.8 mg daily; Januvia 25 mg daily; Procardia XL 30 mg daily; Celexa 10 mg daily; Risperdal 1 mg daily; Arginaid one packet daily; Systane Ultra one drop three times daily -two doses missed each day; Keppra 500 mg twice daily - missed one dose each day. Resident #9's MAR for October 2013 further reflected the following: Aspirin 81 mg by mouth daily was circled indicating it was not given on 10/02, 10/04, 10/07, 10/09, 10/21, 10/23, 10/25 and 10/30/13. Procardia 60 mg by mouth daily was circled indicating it was not given on 10/02, 10/04, 10/07, 10/09, 10/11 and 10/14/13. There were no further signatures for this medication for the remainder of the month. A handwritten entry reflected: "Add ER (extended release) to Procardia 10/15/13." The entry was initialed by ADON MM. Further review of the MAR revealed there was no other entry for Procardia 60 mg, and no doses signed as administered. The back of the MARs for October2013 reflected entries dated, 10/02/13, 10/04/13, 10/11/13, 10/11/13,10/14/13, 10/18/13, 10/23/13, 10/25/13, with simply the word "Dialysis" written to indicate the reason the medications were not given. No other explanations were written. Resident #9's MARs for November 2013 and December 2013 reflected the following medications were circled indicating they were not given because she was out for dialysis on 11/01, 11/04, 11/06, 11/08, 11/11, 11/13, 11/15, 11/18, 11/20, 11/22, 11/25, 11/27, and 11/29, 12/02, 12/04, 12/06, 12/09, 12/11, 12/13, and 12/16/13: Aspirin 81 mg one daily; Ferrous Sulfate 325 mg one daily; Colace 100 mg daily; Multivitamin one daily; Bidel 20-37.5 mg ordered twice daily; Renvela 1600 mg three times daily -two doses missed each day; Flonase 50 mcg nose spray two sprays each nostril daily Restasis 0.5% eye drops twice daily -one dose missed daily; Plavix 75 mg once daily; Clonidine 0.1 mg daily; Atarax 25 mg every 12 hours -one dose missed daily; Toprol XL 100 mg daily ); Calcium 500 mg daily; Lasix 40 mg daily; B-Complex, Vitamin C-Folic Acid 0.8 mg daily; Januvia 25 mg daily; Procardia XL 30 mg daily; Celexa 10 mg daily; Risperdal 1 mg daily; Arginaid one packet daily; Systane Ultra one drop three times daily -two doses missed each day; Procardia XL 60 mg daily; Keppra 500 mg twice daily - missed one dose each day. Review of Resident #9's Nurses Notes for the months of November 2013 and December 2013 revealed there were no notes that reflected a physician had been notified of the held medications or a request to re-time the doses. Resident #9's most recent Nutritional assessment dated [DATE] reflected the following Summary and Recommendation: "...Pt continues w/ adequate intake of mech soft diet w/ appropriate therapeutic restrictions for diabetic control and ESRD status ...Pt continues w/DVT to right calf, and has developed Stage II to bottom; Pt continues on Vit C, and Arginaid 1 pack BID for add'l 70 cal/9 gm PRO; HGB levels remain low but improved; Pt is receiving Vit B-Complex, Folic Acid, Multivit, and Iron supplement; No nutr recommendations at this review; goal is to provide adequate cal and pro to promote pressure ulcer healing." During an interview on 12/11/13 at 11:06 AM, NP O stated she was not sure when she became aware of the pressure ulcer on Resident #9's leg. She confirmed her last note about the resident was dated 10/15/13. She stated she was at the facility on 12/05/13 but she did not see Resident #9. NP O stated she remembers the staff talking to her about a pressure ulcer that day but she could not say which pressure ulcer specifically. She stated in her mind, the resident refused treatments a lot, she had been on Vancomycin, had a Deep Vein Thrombosis and she was concerned with her other health issues. In another interview on 12/17/13 at 3:55 PM, NP O was asked if she was aware Resident #9 was not receiving most of her medications on her dialysis days. NP O stated typically that is what happens on dialysis days, they wait (to give medications). She explained the medications scheduled before dialysis can be given except for certain blood pressure medications. Those were up to the dialysis center to decide. NP O stated no one had called her to reschedule medication times. She added, "Often they're given when they return from dialysis. That's how some of my homes do it." In an interview on 12/17/13 at 9:25 AM, LVN A, Resident #9's Charge Nurse that day, was shown Resident #9's December 2013 MAR and asked about all her morning and noon medication orders. LVN A stated if medications were given within three hours of dialysis, they would "wash out." She stated all medications were held on dialysis days except for evening medication doses. When asked whether any of the daily medications were given upon her return from dialysis, LVN A stated only the medications due to be given in the evening were given. During an interview on 12/17/13 at 9:30 AM, the DON was asked whether medications should be held completely on dialysis days for residents receiving dialysis. The DON stated they should. When asked whether she had a facility policy on the matter, the DON stated the policy would not say that, but there should be a physician's orders [REDACTED]. During an interview on 12/17/13 at 11:15 AM, the Pharmacist was shown Resident #9's December 2013 MARs and asked about the facility's policy on holding medications for residents receiving dialysis treatments. The Pharmacist explained she thought Resident #9 had an order to hold certain blood pressure medications before her dialysis treatments but she stated she had explained to the staff she could receive those medications after dialysis. The Pharmacist was shown all the medications, which were not being given three times a week. The surveyor expressed concern about the nature of the medications, which included blood thinners, anti-depressant and anti-psychotic medications. The Pharmacist stated she remembered telling the staff to change the dose times to the evening but said she did not remember looking at her (Resident #9's) MARs recently. When asked if there was a general rule for medication administration for the dialysis residents, the Pharmacist stated they usually only held medications, which could affect the dialysis treatments. During an interview on 12/17/13 at 3:07 PM, LVN D, Resident #9's Charge Nurse, stated she had questioned the resident's medications in the past and someone told her the resident only received the evening medications on dialysis days. When asked whether she ever called the physician to clarify the orders, LVN D stated she did not, because "they were already doing that when I started." On 12/17/13 at 4:20 PM, the DON stated Resident #9's medication sheets were faxed to her primary care physician and to NP O to determine what medications could be rescheduled and to check the blood pressure medications. The DON stated Physician K was notified because he was the Medical Director. The DON stated she was under the impression the medication administration times would have been changed on her dialysis days. 2. Resident #4 was a [AGE] year-old male, readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Care Plan for "Hypertension" dated 09/19/13 revealed: "Problem/ Need - Problem Onset: 09/19/13 (Resident #4) has potential for retaining abnormal body fluids R/T Hx. of HTN. Goal & Target Date: (Resident #4) will maintain normal body fluid level as evidence of normal related lab values until next review date. Approaches: --Diet as ordered by physician. --Obtain monthly weights. --Monitor for S/S of Edema --Diet Consult as needed." Review of Resident #4's Care Plan for "Cardiac Disease/CHF " dated 07/09/13 revealed: "Problem/ Need - Problem Onset: 07/09/13 Cardiac disease/CHF Goal & Target Date: (Resident #4) will not suffer any ill effects caused by DX thru next eval date Approaches: -Medication given as ordered Monitor and document effects... -Vital Signs as directed an (sic) as needed...." Review of Resident #4's November 2013 consolidated physician orders [REDACTED]. Review of a physician's progress note dated 11/18/13 revealed Resident #4 had [DIAGNOSES REDACTED]. Further review of this note revealed the resident was on medications including Lopressor (for Hypertension), and Catapres (Clonidine for Hypertension). Review of Resident #4's November 2013 MAR revealed a place to document the resident's BP, at 8:00 AM and 4:00 PM each day totaling 60 times. Eighteen of the 60 times the resident's BP was taken, the SBP results were greater than 150 or the DBP results were greater than 90: 162/82, 165/79,154/100, 152/107, 188/81, 184/69, 145/94, 152/107, 162/118, 183/78, 156/81, 142/107, 166/88, 133/91, 156/80, 126/94, 122/102, and 158/98. The PRN Clonidine was not documented as given. Review of Resident #4's December 2013 MAR revealed a place to document the residents BP. From 12/01/13 through 12/13/13, at 8:00 AM and 4:00 PM each day, Resident #4 had a total of 26 times when her bloos pressure should have been taken. Three of the 26 times the resident's BP was taken, the SBP results were greater than 150 or the DPB results were greater than 90, ranging from 145/103, 114/92, 131/91 and the PRN Clonidine was not documented as given. In an interview on 12/11/13 at 6:55 PM, the surveyor reviewed Resident #4's November and December 2013 MARs with LVN C, which had multiple DBPs greater than 90, with LVN C's initials above the BP results. LVN C stated she was Resident #4's charge nurse and she did take and document Resident #4's blood pressures at 4:00 PM and further stated she had not administered PRN Clonidine as ordered. LVN C stated, "Well her (Resident #4's) blood pressure usually drops after 4:00 PM." The surveyor queried LVN C how she knew that and LVN C stated, "Well you can look at her morning blood pressures," as she pointed to the following days at the 8:00 AM blood pressures. In an interview on 12/11/13 at 7:15 PM, the surveyor showed the DON Resident #4's Clonidine order and asked her when she expected her nurses to administer the Clonidine. The DON stated, "If the SBP is greater than 150 or the DBP is greater than 90." The surveyor showed the DON Resident #4's documented November and December BPs and the Clonidine MAR, which indicated no Clonidine was administered. The DON made no further comment. 3. Resident #3 was a [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she was severely impaired cognitively, and was totally dependent on staff for her ADLs. Resident #3's Physician's Telephone Orders dated 11/05/13 reflected: Discontinue Amantadine liquid, Depakote 125 mg sprinkles, change Lasix to 20 mg every other day and add Exelon patch 4.6 mg daily. The order was written by ADON MM, Review of Resident #3's consolidated physician's orders [REDACTED]. The orders were signed as reviewed by ADON MM. Review of Resident #3's MARs for the month of November 2013 revealed the following entries: Depakote 125 mg Sprinkles by mouth twice a day with an order date of 10/24/13 discontinued and ceased to be given on 11/05/13. The MAR further revealed a place to document the resident's BP, at 8:00 AM, 12:00 PM and 6:00 PM each day totaling 90 times. 22 of the 90 times the resident's BP was taken, the SBP results were greater than 150 or the DBP results were greater than 90, 168/83, 160/68, 164/99, 168/106, 163/110, 164/96, 173/60, 158/64, 175/93, 162/81, 154/105, 167/76, 161/91, 156/85, 156/93, 162/96, 164/67, 160/70, 151/81, 164/81, 151/78, 159/74, and 160/85. The PRN Clonidine was not documented as given. Review of Resident #3's MARs for the month of December 2013 revealed the following entries: Depakote 125 mg Sprinkles by mouth twice a day of 10/24/13. The medication was initialed as administered twice a day from 12/01/13 through 12/10/13. The medication was discontinued after surveyor intervention. During an interview on 12/11/13 at 2:42 PM, the ADON stated she reconciled the medications at the end of the month and signed off on the monthly consolidated physicians orders. When shown Resident #3's orders to discontinue the Depakote as well as the December consolidated orders where the Depakote reappeared, the ADON stated she could not explain the discrepancy and would make sure the drug was discontinued immediately. A later review of the MAR for December 2013 revealed the same Depakote entry had a handwritten note that reflected: "D'CD 12/11/13 @ 1800 (6:00 PM)." However, the medication was signed as administered on 12/11/13 at 8:00 PM and again on 12/12/13 at 8:00 AM. The MAR further revealed a place to document the resident's BP, at 8:00 AM , 12:00 PM and 6:00 PM each day totaling 28 times. Seven of the 28 times the resident's BP was taken, the SBP results were greater than 150 or the DBP results were greater than 90, 153/84, 166/98, 159/63, 152/65, 153/82, 188/81 and 174/86. The PRN Clonidine was not documented as given. An observation on 12/10/13 at 1:11 PM revealed Resident #3 was sitting alone in her room in her wheelchair. She was leaning forward and wincing. Resident #3 complained of pain all over and stated she wanted to go to bed. As she was speaking, MA Z entered the room and checked Resident #3's blood pressure which was 174/86. MA Z stated she would report the blood pressure and complaints of pain to her Charge Nurse. During an interview on 12/12/13 at 8:00 AM, when LVN D, Resident #3's Charge Nurse, was asked how she monitored her resident's blood pressure, she stated the Medication Aides checked the blood pressures and reported any abnormal readings. She stated if the readings were abnormal more than a few times per week, she would notify the physician. When asked about Resident #3's high blood pressure readings and lack of Clonidine administration, LVN D stated she did not know. In an interview on 12/12/13 at 8:06 AM, when MA Z was asked what vital sign parameters she reported to the Charge Nurses, she stated she reported SBP greater than 150, DBP higher than 90 or a heart rate less than 60. When reminded of the blood pressure she took on Resident #3 on 12/10/13 and asked whether she reported it, she said she had. When asked whether she was instructed to administer any Clonidine, MA Z stated she was not. She went on to explain she had been told if a resident's heart rate was not greater than 90, she should hold the Clonidine. She stated she would still report the blood pressure. On 12/12/13 at 8:17 AM, LVN A, who was Resident #3's Charge Nurse on 12/10/13, was interviewed. LVN A was queried what the parameters were for Resident #3 to administer Clonidine. LVN A stated the parameters to administer Clonidine were SBP greater than 150 or a DBP greater than 90. When asked about Resident #3's blood pressure on 12/10/13 and why no Clonidine was given, LVN A stated she waited because the resident was in pain, and she planned to recheck her after her pain subsided. During an interview on 12/12/13 at 8:28 AM, ADON MM was asked if anyone monitored the MARs and TARs to ensure PRN orders were administered. ADON MM stated, "As an ADON, I have to look at these things. In the morning I try to look. It is my job." When shown Resident #3's MAR and blood pressure results, ADON MM stated she was not aware of the missed Clonidine. 4. Resident #22 was an [AGE] year-old-female admitted to the facility on [DATE] per her quarterly MDS assessment dated [DATE]. Further review revealed Resident #22 had [DIAGNOSES REDACTED]., Psychotic Disorder, Malignant Hypertension and Osteoporosis. Resident #22's MDS assessment further reflected she was incontinent of bowel and bladder. Review of Resident #22's care plans revealed she had no care plan concerning UTIs. During an interview with ADON MM on 12/15/13 at 12:26 PM, she informed the surveyors they had done a sweep of the building and looked at all people with UTI infections. ADON MM said they looked through the records for everyone who had an infection. She said then they had looked through the residents charts, who had infections to make sure labs were done as ordered by the physician and to see if the physician was called and the follow-up was done. ADON MM said they first looked through their infection control log to get the resident names and then went to the resident charts. When asked how she found out about a new infection, ADON MM said it was the nurse who called the doctor, transcribed the order and then placed a copy in ADON MM's box. When ADON MM got the order from her box, she entered it into her infection control log. ADON MM informed the surveyor she would then go to the resident's chart and find out what infection it was and the ABT ordered. When asked about the organism causing the infection,l ADON MM said she would sometimes put the type of organism, but it generally took two to three days to get the culture results back, so the nurses put it on the Infection Report sheet and then gave that back to ADON MM. ADON MM said she tries to enter the organism on the infection control log as soon as she gets it from a nurse. ADON MM stated the Infection Report should be filled out as soon as the nurse learns of an infection or gets an order for [REDACTED]. On 12/15/12, ADON MM gave the surveyor the results of their UTI infection sweep. Review of the paper work provided for Resident #22 revealed the following: 1) A physician's telephone order dated 09/05/13, which ordered the antibiotic Nitrofurantoin (Macrobid) 50 mg by mouth every 12 hours for seven days as well as to continue the antibiotic Augmentin two times a day for ten days; 2) A physician progress notes [REDACTED]. 3) Nurse's notes dated from 09/04/13 at 3:00 PM through 09/12/13 at 9:30 AM reflected various nurses documentation of antibiotics being given for Resident #3's UTI. The antibiotics Nitrofurantoin and Augmentin (together) were mentioned in three entries. The antibiotic Augmentin was the only antibiotic mentioned as being used for the UTI in seven entries. In six entries, it included "antibiotics" for her UTI, but did not include the names of the antibiotics; 4) Resident #22's MAR for September 2013 had a handwritten notation at the bottom for Nitrofurantoin 50 mg one tab by mouth every 12 hours for seven days and Augmentin two times a day for ten days. In the columns next to Augmentin was written "D/C 9/9/13" and in the columns next to the Nitrofurantoin was 9 AM with 9 PM below it. The columns have an arrow through the dates of 09/01/13 through 09/04/13 for both times. The first time the Nitrofurantoin was initialed as being given was on 09/08/13 at 9:00 AM and 9:00 PM. There were initials written in for the 9:00 AM dose on 09/09/13, 09/10/13 and 09/11/13, but they were circled to indicate the medication was not given. There were no further initials documented on the Sepember 2013 MAR to indicate either antibiotic was given to Resident #22 for her UTI. 5) Resident #22's laboratory results for the UA C & S dated as collected on 08/30/13 and showed and infection of Escherichia coli (E. coli) >100,000 cfu/ml. please show the results of the C&S and what the e. coli was sensitive to. Resident #22's MARs for September 2013 reflected an entry for Nitrofurantoin 50 mg one tab by mouth every 12 hours for seven days with a start date of 09

Based on interview and record review, it was determined the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident for two (Residents #1 and #2) of eight residents reviewed for pharmacy services. 1) a.The facility failed to properly transcribe and administer the following medications for Resident #1 in two of two months reviewed: Hydralazine 25 mg - missed three of five doses; Isosorbide Dinitrate 20 mg - missed three of five doses; Restasis eye drops- missed three of five doses; Lipitor 40 mg-20 mg was given and only administered three out of five times; Celexa - was given in the morning instead of at bedtime as ordered; Gabapentin 200 mg- 100 mg was given for three days; Ferrous Sulfate - was given in the morning instead of at bedtime as ordered; Levetiracetam 1000 mg- 500 mg was administered for three days; Procardia XL - missed three 60 mg doses and missed five 30 mg doses; and Clonidine 0.1 mg - missed five doses. b. LVN D failed to administer the correct dose of pain medications to Resident #1 when she repeatedly complained of leg pain. LVN D administered one Hydrocodone 5/325 mg when the ordered dose was two 10/325 mg tablets. 2. The facility failed to discontinue Resident #2's Hydralazine 25mg (for Hypertension) as ordered. The morning dose of Hydralazine was discontinued on 02/03/14 and the evening dose was not discontinued until after the 02/28/14 dose, for a total of 31 doses. These failures could affect any the facility's 75 residents, including Residents #1 and #2, by placing them at risk for ongoing medication errors resulting in depression, eye discomfort, unrelieved pain, stomach upset, seizures, weakness, confusion, dizziness, headache, fainting, hypotension and death and could affect the 75 residents in the facility. Findings included: 1) Review of Resident #1's Physician's Telephone Orders dated 02/26/14 revealed she was to be readmitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #1's admission Nurse's Note dated 02/26/14 at 2:20 PM revealed she was confused but able to make her needs known at that time. Review of Resident #1's hospital Medication Profile Report dated 02/25/14 revealed the following medications were among those to be continued when she returned to the facility: Hydralazine Hcl 25 mg tablets by mouth twice daily (used to treat high blood pressure); Isosorbide Dinitrate 20 mg tablets by mouth twice daily (used to treat chest pain caused by heart damage); Docusate Sodium 100 mg caps, two twice daily (used to prevent constipation); Restasis 0.05% eye drops, one drop in each eye twice daily (used for increase tear production); Lipitor 20 mg tablets, give 40 mg at bedtime (used to lower cholesterol); Celexa 20 mg tablets, give 10 mg by mouth at bedtime (used to treat depression); Gabapentin 100 mg tablets, give 200 mg at bedtime (used to treat pain caused by neuropathy); Ferrous Sulfate 325 mg, give one at bedtime (iron supplement used to treat anemia); Levetiracetam 500 mg tablets, give 1000 mg at bedtime (used to treat seizures); Procardia XL 30 mg by mouth every day (used to treat high blood pressure and chest pain); Procardia XL 60 mg by mouth every evening; and Clonidine HCL 0.1 mg by mouth every day (used to treat high blood pressure). Review of the facility ' s admission orders [REDACTED] Procardia 30 mg PO QD; and Clonidine HCL 0.1 mg PO QD. Review of Resident #1's February 2014 MARs revealed the following: Hydralazine 25 mg tablets twice a day was only transcribed and initialed as administered once on 02/27/14. (Not twice a day as ordered) Isosorbide Dinitrate 20 mg tablets was only transcribed and initialed as administered once a day on 02/27/4 and 02/28/14. (Not twice a day as ordered) Docusate Sodium 100 mg caps was only transcribed and initialed as administered once on 02/27/14 and 02/28/14. (Not twice a day as ordered) Restasis eye drops were only transcribed and initialed as administered once a day on 02/27/14 and 02/28/14. (Not twice a day as ordered) Lipitor was transcribed as 20 mg at bedtime and only initialed as administered on 02/26/14 and 02/27/14. (Not on 02/28/14 as ordered) Celexa was transcribed and initialed as administered as 10 mg at 6:30 AM. (Not at bedtime as ordered) Gabapentin 100 mg was transcribed and initialed as administered at bedtime. (Not 200mg as ordered) Ferrous Sulfate 325 mg was transcribed and initialed as administered at 6:30 AM. (Not at bedtime as ordered) Levetiracetam 500 mg was transcribed and initialed as administered daily at bedtime. (Not 1000 mg as ordered) Procardia XL was transcribed as 30 mg by mouth every evening and was only administered on 02/26/14 and 02/27/14. (Not 60 mg as ordered and none on 02/28/14) Procardia XL 60 mg was not transcribed to the February MAR and so no doses were given in February. Review of Resident #1's March 2014 MARs revealed the following: Procardia XL 30 mg by mouth every day was not transcribed and so was not administered from 03/01/14 through 03/05/14, when surveyor inquired. Clonidine HCL 0.1 mg by mouth every day was not transcribed and so was not administered from 03/01/14 through 03/05/14, when surveyor inquired. An interview with the Unit Manager on 03/04/14 at 4:32 PM revealed it was typically her duty to check all orders daily for accuracy but she was pulled off the floor or on 02/24/14 to work on the monthly consolidated orders for the remainder of the month. She stated, during that time, the DON was performing the daily checks on both nurses' stations. During an interview on 03/05/15 at 10:25 AM, LVN C stated she had transcribed the admission orders [REDACTED]. When shown the errors found by the surveyors, LVN C stated she was not aware of the errors. She stated RN A had transcribed the orders to the March MARs and she remembered RN A pointing out some discrepancies to her but she thought she had corrected them. During an interview on 03/05/14 at 11:25 AM, RN A stated she had transcribed the March MARs for Resident #1 but had never looked at February's MARs. RN A stated she had caught a few discrepancies after the hospital orders had been transcribed to the facility's admission orders [REDACTED]. She was not aware of any medication errors. An interview with the DON on 03/05/14 at 11:25 AM revealed all orders, including new admission orders [REDACTED]. The DON explained pink copies of all resident's orders were to be placed in a box and both she and the Unit Manager checked those pink copies every day before they left to ensure all orders written over the past 24 hours were transcribed correctly. When asked about Resident #1, the DON confirmed the Unit Manager was not checking orders at that time as she had been pulled to work on the monthly orders. The DON stated she did not know why Resident #1's orders had not been checked; she stated the pink copies must not have made it into the designated box. b) Review of Resident #1's hospital Medication Profile Report dated 02/25/14 revealed the following medications were among those to be continued when she returned to the facility: Hydrocodone 10/325 mg one tablet every six hours as needed for pain. Hydrocodone 10/325 mg two tablets every six hours as needed for pain. Resident #1's admission orders [REDACTED]. Review of Resident #1's MAR for February 2014 revealed an entry for Hydrocodone-Apap 10-325 two every six hours as needed for pain. The entry was initialed as administered on 02/26/14 at 3:00 PM and 9:00 PM by LVN D. The back of the MAR reflected the following entries: 2/26/14 at 3:00 PM: "Resident c/o pain, pain level 8/10, Norco (hydrocodone) 5/325 admin, pain level at 3:30 PM 6/10." The entry was signed by LVN D. 2/26/14 at 9:00 PM: "Resident c/o pain, telling, 8/10, Norco 5/325 mg admin, pain level @ 9:30 (PM), 7/10, ineffective." The entry was signed by LVN D. During an interview on 03/05/14 at 12:45 PM, LVN D explained she was Resident #1's Charge Nurse on 02/26/14 but LVN C was completing the admission orders [REDACTED]. When asked why she only administered 5/325 mg when the order and MAR both indicated the dose was two 10/325 tablets, LVN D stated she had seen the dose on the MAR but when she went to the medication cart, her old card was still on the cart (from prior to her hospitalization ) and so she just administered that. When asked why she did not question the dosage on the card as it conflicted with the MAR or check the orders in the chart, LVN D stated, "It never occurred to me she was really in pain, I didn't touch the orders, I gave her what she had on the cart." During an interview on 03/05/14 at 2:47 PM, the DON was shown Resident #1's MARs and told about the medication error regarding the hydrocodone. The DON stated she was not aware of the error and that it should not have happened. She confirmed Hydrocodone 10/325 mg tablets were kept in the E-kit and LVN D could have easily retrieved the proper dose. When asked how Resident #1's pain should have been handled, the DON stated if a resident complains of pain, they should be assessed and a pain level ascertained. She stated the resident should be medicated if indicated and re-assessed in 30-45 minutes for relief. The DON stated, if the medication was not effective and another medication could not be given, the physician should be called and made aware of all the details surrounding the situation. An observation on 03/05/14 at 3:28 PM revealed Hydrocodone 10/325 tablets were stocked in the medication room E-kit at Resident #1's nurse's station. 2. Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed Resident #2 had a BIMS of 4 and was dependent on staff for most of his ADLs. Review of Resident #2's Care Plan dated 02/27/14 revealed: "Date & Problem: DX CHF/HTN/PVD Goal: (Resident #2) will not suffer any complications caused by Dx's thru the next eval date. Approaches & Disciplines: Lab as ordered Notify Dr. of results Medications as ordered. Notify Dr of effectiveness Monitor for edema, SOB, Pain in extremities with discoloration of skin and warm to touch Document and Notify Dr/RP/Hospice" Resident #2's Physician's Telephone Orders dated 01/09/13 reflected Hydralazine 25 mg twice a day. Resident #2's Physician's Telephone Orders dated 01/30/14 reflected increase Hydralazine to 50 mg twice a day for blood pressure. Review of Resident #2's MARs for the month of January 2014 revealed the last dose of Hydralazine 25 mg was on 01/30/14 after the 9:00 PMdose. Further review of this MAR revealed Hydralazine 50 mg was started on 01/30/14 at 9:00 PM. Review of Resident #2's MARs for the month of February 2014 revealed Hydralazine 50 mg twice a day was administered as ordered. Further review of this MAR revealed the morning dose (9 AM) of Hydralazine 25 mg was administered on 02/01/14, 02/02/14/ and 02/03/14. "DC'D" was hand written after the 9 AM dose was administered on 02/03/14. The evening dose (4:00 PM) of Hydralazine 25 mg was administered each day during the month of February. A total of 31 doses of Hydralazine 25 mg were administered that the physician had discontinued on 01/30/14. During an interview on 03/04/14 at 3:55 PM the surveyor reviewed Resident #2's February 2014's MARs with LVN B, Resident #2's evening charge nurse. LVN B stated she did administer Hydralazine 25 mg and Hydralazine 50 mg on the days she worked, as were documented on Resident #2's MAR. During an interview on 03/05/14 at 10:05 AM the ADM stated the Unit Manager did the February 2014 monthly recapitulations of physician orders [REDACTED]. During an interview on 03/04/14 at 4:30 PM the Unit Manager stated she checks the pink slips (copy of telephone physician orders) daily to make sure the orders were correct on the MARs. She stated when she did the February 2014 monthly recapitulations of physician orders, she was taken off the floor from 01/25/14 through the end of the month, and the DON took over her tasks, including verifying the pink slips were checked, for the whole building. During an interview on 03/06/14 at 4:30 PM the ADM stated Resident #2 receiving 31 doses of Hydralazine, which had been discontinued, was a careless error. The ADM further stated the DON told her she did miss a few a days of checking pink slips. During an interview on 03/06/14 at 8:47 AM the surveyor asked the DON how she thought Resident #2's received 31 doses of Hydralazine that had been discontinued. The DON stated when RN A taught the Unit Manager how to do the monthly recapitulations of physician orders, RN A did not instruct the Unit Manager to continue to add additional physician orders [REDACTED]. "Nursing 2013 Drug Handbook" 33rd Edition, Wolters Kluwer, Copyright 2013, pages 680 - 681 reflected the following nursing considerations for Hydralazine: "Monitor patient's blood pressure, pulse and body weight frequently...Elderly patients may be more sensitive to drug's hypotensive effects...." Overdose signs and symptoms include: hypotension, tachycardia, headache and flushing. 3. Review of the facility's current undated policy and procedure "Monthly Review of physician's orders [REDACTED]. "Purpose: To ensure that physician order's are accurate. Policy: To verify prior to the beginning of each month that all physician orders [REDACTED]. (RN A)/(Unit Manager) will be responsible for this monthly review. DON will schedule the delivery of the orders. DON will have (RN A) to be removed from the schedule as a floor nurse for the last 5-6 days of each month. (RN A) will inform DON of all concerns regarding the orders upon the completion of the review. (RN A) will take the prior month MARS and compare them to the clinical record. (RN A) will then take the clinical record and compare it to the new MARS. (RN A) will then handwrite onto the new MAR any new orders that will come after the 25th of the month. Attending nurses will write any new orders on the current MAR until the end of the month. If a new admission comes at the end of the month, (RN A)/Designee reviewing the MAR should make a new set of physician's orders [REDACTED]. (RN A)/Designee should also make a new set of MARS and TARS for the next month. (RN A)/Designee will via fax all updates to the person responsible for preparing the monthly orders: (name of pharmacy tech) at [PHONE NUMBER]. Clarifications orders will be written. 11-7 will compare the old MAR to the New MAR for accuracy." Review of the facility's current policy and procedure "Unnecessary Drugs" dated 2012 revealed: "Purpose: Each resident's drug regimen must be free from unnecessary drugs: Procedure: An unnecessary drug is any drug when used: 1. In excessive dose (including duplicate therapy); or 2. For excessive duration; or 3. Without adequate monitoring; or 4. Without adequate indications for its use; or 5. In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or 6. An combination of the reasons above...." Review of an undated Medication Pass Inservice from an RN/LVN Orientation Book located at the Nurse's Station revealed the following: "Steps to take during the med pass:... 16. Before administering the medication, always check 'The 6R 's' 17. Triple check medications vs. MAR before administering the medications. 18. If any of the 6 R's do not match or if you have any questions about the medication itself DO NOT GIVE THE MEDICATION! Check the chart or call the pharmacy with your concern. The pharmacist would rather you ask a question than a mistake be made...." "DURING THE MEDICATION PASS: 'THE 6 Rs' Before administering any medication, always check the 6 Rs, The right resident... The right drug: verify each drug against the medication administration record (MAR) before administering... The right dose: verify against the MAR... The right time: administer drugs as instructed on the MAR and within the time frame established by your facility...." "CHECKPOINTS...Related issues...Make sure discontinued medications have been removed from the cart as soon as they have been discontinued...." 4. Review of the facility's Form-672, Resident Census and Conditions of Residents, dated 03/03/14 and signed by DON reflected a census of 75.

Based on observation, interview and record review, it was determined the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for nine (Residents #2, #3, #4, #8, #22, #29, #35, #36, #37, and #38) of 24 residents reviewed for infection control. 1) The facility failed to ensure contact precautions were implemented when Resident #2 had a positive urine culture for MRSA. Staff were using the same leg urinary drainage bag and bedside urinary drainage bag repeatedly for Resident #2, washing them and hanging them to dry in the resident's shared bathroom when changing them every morning and every evening. Resident #2's physician-ordered C&S were not conducted as part of the follow-up for the resident's MRSA UTI. The physician was not notified they were not done until surveyor inquiry. 2) The facility's surveillance program for tracking and trending their infections failed to be effective. Resident infections were missed, entered in the wrong month's tracking logs, organisms were not identified and data regarding the infections was missing. Resident #2, who had MRSA in the urine, was not identified as having MRSA. Resident #22 was not identified with an infection in the correct month and with the correct medications. 3) After a facility outbreak of diarrhea: The facility failed to ensure a physician-ordered stool specimen for Ova and Parasite and for[DIAGNOSES REDACTED] were obtained for Residents #37 and #38. The facility failed to ensure a physician-ordered stool specimen for[DIAGNOSES REDACTED] was obtained for Residents #29, #35 and #36. 4) CNA LL failed to perform hand hygiene before beginning incontinent care. CNA Q failed to perform hand hygiene before, during and after incontinent care for Resident #8; and contaminated wipes, the wipes container, perineal was bottle, the door knobs of the resident's room and the the clean linen cart. CNA Q carried the used container of wipes and perineal wash from Resident #8's room and placed them on the clean linen cart. CNA QQ failed to throughly clean all the BM from the resident. 5) CNA M and CNA N failed to perform hand hygiene during and after performing incontinent care to Resident #3. CNA removed her gloves, picked up the opened package of incontinent wipes, removed them from the room and placed them on the clean linen cart. 6) CNA R failed to perform hand hygiene while providing incontinent care to Resident #4. CNA R failed to clean all the BM from the resident. 7) Facility staff were storing their personal items (coats and tote bags) on the clean linen carts on top of, or alongside the residents' clean linen. An Immediate Jeopardy (IJ) was identified on 01/02/14. While the IJ was removed on 01/11/14, the facility remained out of compliance at a scope of "widespread" and a severity level of "no actual harm with potential for more than minimal harm, that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. Failure to maintain an infection control program to prevent the transmission of disease and infection could result in the spread of infection and could affect the 75 residents in the facility. Findings included: 1) Resident #2 was a [AGE] year-old-female admitted to the facility on [DATE] per her MDS assessment dated [DATE]. The MDS assessment also reflected Resident #2 had active [DIAGNOSES REDACTED]. Resident #2's MDS further reflected she was incontinent of bowel and had an indwelling catheter. Review of Resident #2's current care plans provided by the facility with a most recent date of June 2013 revealed there was no care plan addressing the resident's indwelling Foley catheter. Review of Resident #2's physician's telephone orders revealed an order dated and signed by the physician on 08/15/13, which ordered to continue the Foley and attach it to a leg bag at 6:00 AM every morning and then to a gravity urinary drainage bag every night at 9:00 PM for one month and to then re-evaluate. Review of Resident #2's physician's telephone orders for the August, September, October, November and December 2013 revealed no orders for an indwelling Foley catheter and urinary drainage bag resulting from a re-evaluation. There were no orders for the Foley catheter size, to change the Foley catheter, to document I&O, or to irrigate the Foley catheter. Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/16/13 at 6:00 AM revealed Resident #2's urine was "pinkish in bag and tubing." It further reflected RN I removed the large bag and placed a leg bag as ordered for day time activity. RN I then wrote "Lg bag Rinsed and hung up in BR." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/17/13 at 12:00 AM revealed Resident #2's leg bag was changed to a regular bag, and the "Leg Bag rinsed and hung to dry." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/19/13 at 12:00 AM revealed RN I assessed Resident #2 and the night shift still had her leg bag on so RN I "Removed and Lg drain bag attached to catheter." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/19/13 at 6:30 AM revealed Resident #2's "Big drain bag Removed and leg bag attached. Big bag rinsed (with) H2O X 3 and placed in drawer on clean towel." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/21/13 at 12:00 AM revealed Resident #2's leg bag had been "rinsed and dried, rest in folded towel." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/19/13 at 6:30 AM revealed "Big bag exchanged for small leg bag. " Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/22/13 at 5:00 AM revealed RN I gave Resident #2 some medicine in yogurt and Resident #2 asked what it was for. RN I told Resident #2 it was antibiotics for her UTI. It further reflected "Big bag (changed) for leg bag..." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/24/13 at 12:00 AM revealed "this nurse changed leg bag to foley _ (with) Lg drainage bag." Review of Resident #2's Daily Skilled Nurse's Note for the evening shift on 08/24/13 untimed and unable to read the nurses signature revealed her urine color was "yellow" and it's consistency "cloudy" it further reflected "Changed from leg bag to reg." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/26/13 at 7:00 AM revealed "Foley (changed) to leg bag at this time..." Review of Resident #2's Daily Skilled Nurse's Note dated 08/27/13 at 6:00 AM and unable to read nurses signature revealed "Drainage bag changed to leg bag as ordered." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/30/13 at 12:00 AM revealed "Note still has leg bag to (R) leg for urine drainage. Leg bag off cathe and BS drainage bag to cathe." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/21/13 at 12:00 AM revealed Resident #2 "verbalizes her foley is leaking...note tubing is easily moveable in urethra - 6 cc air was added to tubing bulb." Review of Resident #2's UA C&S collected on 09/20/13 with results dated 09/23/13 revealed she was positive for a UTI by the bacteria Escherichia coli (E. coli) 50,000-99,000 cfu/ml, [MEDICATION NAME] species >100,000 cfu/ml and Methicillin Resistant Staphylococcus aureus (MRSA) > 100,000 cfu/ml. Review of Resident #2's Physician's Telephone Order dated 09/23/13 revealed an order for [REDACTED]. This order also ordered a repeat UA C&S three days after the antibiotic completed for two specimens. There was no order for contact isolation or contact precautions related to the resident's MRSA infection. Review of Resident #2's Physician's Telephone Order dated 09/23/13 revealed an order clarification to change the [MEDICATION NAME] from 50 mg to 100 mg by mouth two times a day for 10 days but still no order for contact isolation or contact precautions due to the resident's MRSA infection. Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/23/13 at 12:00 AM revealed Resident #2 was in her bed and RN I "observed that Res still has Leg Bag to (R) leg. Was Removed and Lg Bag applied (with) drainage to down drain." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/23/13 at 4:00 AM revealed "Lg bag (changed) to small leg Bag...." Review of Resident #2's Daily Skilled Nurse's Note dated 09/23/13 at 4:30 PM (unable to read nurses signature) revealed the nurse received the laboratory results of the UA C&S and Physician K was notified. Orders were received for two antibiotics: [MEDICATION NAME] 150 mg one by mouth two times a day for seven days and [MEDICATION NAME] 50 mg by mouth two times a day for 10 days. It further reflected to repeat the UA C&S three days after the antibiotic was completed two times. Resident #2's nurse's note further reflected Physician K called back and changed the [MEDICATION NAME] to 100 mg by mouth two times a day for 10 days. Review of Resident #2's Nurse's Note dated 09/28/13 at 12:30 PM (unable to read the nurse's signature) revealed Resident #2 "Cont on ABT for MRSA in urine...." Review of Resident #2's Nurse's Note dated 09/28/13 at 2:30 PM (unable to read the nurse's signature) revealed Resident #2 "Cont on ABT for MRSA in urine..." Review of Resident #2's Nurse's Note dated 09/28/13 at 11:30 PM (unable to read the nurse's signature) revealed Resident #2 "ABT cont for MRSA...." Review of Resident #2's Nurse's Note dated 09/29/13 at 11:30 AM (unable to read the nurse's signature) revealed Resident #2 "Cont on ABT for MRSA in urine...." Review of Resident #2's Nurse's Note dated 09/29/13 at 4:45 PM (unable to read the nurse's signature) revealed Resident #2 "Cont on ABT for MRSA in urine...." Review of Resident #2's Nurse's Note dated 10/05/13 at 2:00 PM (unable to read the nurse's signature) revealed Resident #2 was status [REDACTED]." During an interview with LVN G on 12/12/13 at 10:15 AM, she revealed Resident #2 had asked to have her catheter bag changed but since they did not have an extra catheter bag, she did not change it. When asked if she had ever changed the resident's indwelling catheter, LVN G said no she had not. LVN G said there was a nurse on the night shift, who changed residents' catheters but she no longer worked for the facility. LVN G said she did not know if Resident #2's catheter had ever been changed or not and gave the surveyor the name of RN I as having been the night shift nurse who may have changed Resident #2's catheter. LVN G said, to her knowledge, Resident #2 had never complained about her catheter hurting. LVN G said Resident #2's urine used to be amber in color until her physician wrote an order for [REDACTED]. LVN G said her physician felt the catheter was being pulled when Resident #2 ambulated, which was why it was now amber-colored. LVN G said at night the night nurse changed the leg bag to a bedside drainage bag, and in the morning, the night nurse changed it to a leg bag. LVN G said she did not know if there was a leg strap on the catheter except while she wore the leg bag during the day. During a telephone interview with Resident #2's family member on 12/13/13/at 10:09 AM, he/she informed the surveyor he/she had never seen gowns for visitors or staff to put on at any time since Resident #2 had been admitted and never heard or was told she was on any kind of isolation or to wash his/her hands upon entering or leaving Resident #2's room. During a telephone interview with LVN V on 12/13/13 at 2:16 PM, she informed the surveyor she worked on station two "every now and then." LVN V informed the surveyor she had never had to change Resident #2's Foley catheter bag as "The aide will help her (Resident #2) change from the leg bag to the night bag." When asked why it was the CNA's job, LVN V said, "Nobody put that on the aides. That's something they've always done. I've never told them to do it." During an interview with LVN H on 12/13/13 at 3:50 PM, she informed the surveyor she worked with Resident #2 every day Monday through Friday from 3:00 PM - 11:00 PM. LVN H said she had changed Resident #2's leg bag every night and would wash it out in the sink. LVN H said she would use the soap dispenser in Resident #2's bathroom and squirt soap into the end of the leg bag used to drain the urine out. LVN H said she would clean the leg bag inside and out and then hang it on the hand rails in Resident #2's bathroom to dry. When it dried, she would place it in Resident #2's drawer. While telling the surveyor this, LVN H had a very disgusted look on her face and also told the surveyor, they re-used both bags until they started to "look bad and can't clean it as well...about once a month." When asked if Resident #2 had ever been on isolation for the MRSA in her urine, at first LVN H said she did not have to be in isolation because it was in her urine and she had a catheter. When asked about staff emptying and washing the leg bag, she said oh, she would wear a gown and gloves. When asked about Resident #2's bathroom and whether it was shared with the residents in the next room, LVN H said Resident #2's roommate and the two residents in the next room did not get up to the bathroom. The surveyor then pointed out the CNAs used the bathroom to wash their hands as well after providing care. During an interview with the DON on 12/14/13 at 12:15 PM, the surveyor asked whether the nurses or the CNAs were supposed to change Resident #2's Foley catheter bags from the leg bag to the large drainage bag for night. The DON said the nurses were to change the urinary drainage bags, not the CNAs. The DON said the CNAS were never instructed to change the urinary drainage bags. When asked about the facility's infection control program, the DON said ADON MM was responsible for the facility's infection control program. When asked if it had always been the facility's policy to re-use the leg and bed side drainage catheter bags, the DON said it had "never been our policy to re-use catheter bags." When asked, the DON said she had not been aware of the nurses and CNAs washing and re-using the urinary drainage bags and replied with, "No. It's disgusting...just heard about it today." The DON informed the surveyor she would "check into that." When asked what special training her nursing staff had in regard to catheter care, the DON said, "No specific training. It's so obvious. It's a given. Basic one-o-one (101 Nursing)." The DON said there had been no in-services on catheter care for her nursing staff but the CNAs did check-offs for peri care yearly. The DON said the check-offs were done by her charge nurses and the weekend supervisor on "peri care but not necessarily with catheters." When asked how she ensured catheter care was done properly, the DON said she "presumed with their (the CNAs') schooling, they would know." When asked what type of plan she had in place for catheter care, the DON said they had a policy for catheter care. The DON said the nurses "don't have access to it." The DON said there was a policy book at the nurses' station. The DON said the nurses should "monitor if the catheter is functioning, is urine draining, what color is the urine, what consistency is the urine...." During an interview with ADON MM on 12/15/13 at 12:26 PM, when asked if she knew they were re-using the leg and bed-side drainage bags for Resident #2, washing them out in the bathroom sink and hanging them over the hand rails to dry, ADON MM said, "I have never heard that. I had no idea. I would have gone to The Director of Medical Records, QA and Ordering of Supplies." During an interview with the ADM on 12/15/13 at 1:45 PM, when asked about the re-using of the urinary drainage bags and washing them out in the sink, she said, "Absolutely not, I told (ADON MM) to go talk to the CNAs and nurses to find out where they got that idea, to do in-servicing and fix that right now!" The ADM said she did not know why the Director of Medical Records, QA and Ordering of Supplies had not ordered a leg bag for each day. The ADM said the physician's orders [REDACTED]. During an interview with RN L on 12/16/13 at 7:55 AM, she informed the surveyor it was usual for the CNAs to change the catheter urinary drainage bags, and they had to wash them so they were clean. RN L said when she came to work, the leg urinary drainage bags were already clean and hanging. When asked why they re-used the bags, she said, "Everybody cuts costs." When the surveyor asked the RN about the potential for cross-contamination, RN L did not express her understanding of the idea of cross contamination and whether the CNAs and/or residents sharing the bathroom with Resident #2 could have been exposed to the MRSA in the resident's urine. RN L verbalized she had no idea Resident #2 had MRSA in her urine at one time. When asked if she had ever cleaned out one of the urinary drainage bags, RN L said, "CNAs clean them out. I never touched her bag." During an interview with LVN AA on 12/16/13 at 8:55 AM, she informed the surveyor she worked on station two with Resident #2 on Monday and Tuesday nights on the 11:00 PM to 7:00 AM shift off and on for about a year. When asked who changed the urinary drainage bags for Resident #2, LVN AA said the CNAs did after they emptied the bag of urine, they washed them out in Resident #2's bathroom sink. LVN AA said they measured the amount of urine as well and, "Nobody said it. They get her (Resident #2) up and change the (urinary drainage) bag when they get her up. It's just part of getting her up." When asked, LVN AA was not sure if Resident #2 had MRSA in her urine and said Resident #2 "wasn't ever on isolation. I'm thinking because it was in her urine in a catheter, so we didn't have to isolate" her. LVN AA said one time Resident #2 came to her and complained about her catheter. "She (Resident #2) said it felt like it was filling up in her stomach, so I went in and lowered it (the drainage bag) and got all the urine out of her tubing." LVN AA said "No" when asked if she had ever changed the Foley catheter. LVN AA said a lot of things were just oversight, not intentional and should be brought to the nurses' attention so they would not do it again. LVN AA said she still did not know what the facility wanted her to do. LVN AA said she called the other day and got an order for [REDACTED]. "We need to find out what they want us to do. The nurse changes them when she gets a new bag, nightly or weekly or what. They need to clarify if they want me to change them. I will. They just need to decide how they want it done." During a telephone interview with NP P on 12/17/13 at 9:54 AM, she was asked about the order for changing of Resident #2's leg bag to a nighttime bed side drainage bag. NP P said Resident #2 wanted a leg bag during the day and she had an order to "switch the bag from one to another." When asked if she was aware they were re-using and washing out the urinary drainage bags, NP P said, "The bags are not connected to her. The catheter is connected to her and needs to be sterile, except when she had MRSA." The surveyor said the urinary drainage bag was usually connected to a closed system, which should be sterile, and NP P said, "The Foley catheter is connected to the patient. If they didn't understand, they should have called." The surveyor asked if she (NP P) had intended for staff to get new urinary drainage bags each time they changed them, and NP P said, "Each time? No, because that part is not connected to the patient." The surveyor stated the bacteria can travel up the drainage tubing, and NP P said, "We can't do this. Don't have the supplies to do that. They should have called." NP P added, from the point of the catheter, "you also have a balloon up there. The catheter is the sterile part. The (urinary drainage) bag doesn't have to be. It's not connected to the patient." The CDC's (Center for Disease Control and Prevention) Guidelines for Prevention of Catheter-Associated Urinary Tract Infections dated 03/25/03 reflected: " With indwelling catheters, infecting microorganisms can migrate to the bladder along the outside of the catheter in the periurethral mucous sheath. " During an interview on 12/17/13 at 11:00 AM with LVN Y, the Weekend Supervisor, when asked about the admission process when the resident has a Foley catheter, she said the nurse should call the doctor and see if he wants to keep the catheter, get an order for [REDACTED]. The surveyor had to remind LVN Y/Weekend Supervisor about having an order for [REDACTED]. When asked what a nurse should do if a resident with a catheter complained of pain, LVN Y said to do an abdominal assessment, get an order for [REDACTED]. When asked if this was currently being done at the facility, LVN Y said, "No. It has not been happening (getting orders)." When asked what a nurse should do if a resident, such as Resident #2, was found to have an infection with MRSA in her urine, LVN Y said, "Get an order for [REDACTED].#2 had MRSA in her urine. LVN Y said she did no know staff were re-using the urinary drainage bags and washing and hanging them to dry in Resident #2's bathroom. LVN Y also said the nurses, not the CNAs, were to change the urinary drainage bags. When asked if she had ever changed Resident #2's Foley catheter or her urinary drainage bags, she said she had not. During an interview with LVN H on 12/13/13 at 3:50 PM, LVN H said when she got a new drainage leg bag for Resident #2, she sometimes dated and initialed it and sometimes she did not. LVN H said both the large bedside drainage bag and the leg bag would be cleaned and hung to dry in the bathroom and the caps which came with the bags to keep them sterile would not be used so the bags were left open to the air. Review of Resident #2's Lab Report dated 10/09/13 and found in her clinical record, revealed two UA results for Resident #2. At the top of the Lab Report was written, "If a Urine Culture is needed on this specimen, and has not already been ordered, please contact the laboratory within 24 hours to request additional testing." At the bottom of the Lab Report was written, "wanted cxs (cultures)." There were also two sets of illegible initials as well as what appeared to be two different dates. One was illegible and the other date was 10/18/13. During an interview with Physician K on 12/12/13 at 7:44 PM, the surveyor showed him Resident #2's laboratory results dated [DATE] and asked about the order for the UA C&S to be done twice, and the C&Ss evidently not having been done on Resident #2's two UA results. Physician K said he did not know why they had not been done and was not aware they had not been done. Physician K said it should have been automatic as most labs run a culture as routine. During an interview with the DON on 12/13/13 at 11:10 AM, the surveyor showed the DON the laboratory results of the UAs for Resident #2 dated 10/09/13, and asked who should have followed up on the labs. The DON said ADON MM should have followed up on he labs and caught there were no cultures done on the UAs. ADON MM was responsible for the labs for station two. She did not know why there were no cultures run on the UAs, and said she would check in to it. During an interview with LVN H on 12/13/13 at 3:50 PM, the surveyor showed LVN H Resident #2's laboratory results of the UA, which had no C&S results, dated 10/09/13 and asked her if she noticed anything wrong with it. LVN H could find nothing wrong and said she would call the doctor with the results. The surveyor then pointed out there were no C&S results. LVN H said any of the nurses could have received the results. When asked what she did when she received an order for [REDACTED]. LVN H said she put it in the lab book as a UA with C&S and she did not know why a C&S had not been done for the UA dated 10/09/13. During an interview with the DON on 12/14/13 at 12:15 PM, when asked what the process was when an order for [REDACTED]. The DON said the nurse just had to check the box for UA C&S on the lab slip and it was every nurses' responsibility to call the doctor if they received lab results. During an interview with the DON on 12/15/13 at 8:18 AM the surveyor asked the DON for the results of the most recent UA C&S for Resident #2. During an interview with ADON MM on 12/15/13 at 12:26 PM, the ADON said Resident #2 was not on isolation when she had MRSA in her urine because she had a Foley catheter so the infection was "contained." Review of Resident #2's physician's telephone order dated 12/13/13 at 2:00 PM revealed an order for [REDACTED]. During an interview with the DON on 12/16/13 at 10:35 AM she informed the surveyor the urine for Resident #2's "UA was just picked up today." The surveyor asked, "So the order was written on the 13th...and not actually done until today (12/16/13)?" The DON said the doctor specified to pick the urine specimen up on the 16th. Review of Resident #2's nurses' note dated 12/17/13 at 4:10 AM revealed the UA C&S ordered to be done on 12/16/13 was collected and sent to the lab. (This was done one day late according to the order.) Review of Resident #2's UA C&S laboratory results dated [DATE] at 12:43 PM revealed the UA results indicated the resident had a UTI. The results were as follows: Leukocytes esterase result was A-Abnormal and a Small amount were found in the urine; Urinary WBC result was A-Abnormal with 0-5 the amount shown; Urinary RBC result was A-Abnormal with 0-5 the amount shown; Urinary [MEDICATION NAME] cells result was A-Abnormal with "Few" seen; and Urinary Bacteria result was A-Abnormal with a "Moderate amount seen." Review of the web-site: http://www.mayoclinic.com/health/urinalysis/MY /METHOD=print&DSECTION=all; on 12/27/13 at 10:30 revealed the following: "Urinalysis is a test that evaluates a sample of your urine. Urinalysis is used to detect and assess a wide range of disorders, including urinary tract infection, kidney disease and diabetes.... Evidence of infection. [MEDICATION NAME] and leukocyte esterase are produced as a result of an infection. If either [MEDICATION NAME] or leukocyte esterase - a product of white blood cells - is detected in your urine, it may be a sign of a urinary tract infection... Microscopic exam Several drops of the urine are examined with a microscope. If any of the following are observed in above-average levels, additional testing may be necessary: White blood cells (leukocytes) may be a sign of an infection. Red blood cells (erythrocytes) may be a sign of kidney diseases, blood disorders or another underlying medical condition, such as [DIAGNOSES REDACTED]. [MEDICATION NAME] cells - cells that line your hollow organs and form your skin - in your urine may be a sign of a tumor. But more often, they indicate that the urine sample was contaminated during the test, and a new sample is needed. Bacteria or yeasts may indicate an infection." 3) The facility provided their Infection Control Logs for the months of August, September, October and November 2013 to the surveyors on 12/11/13 for review. The Infection Control Logs contained the following: The facility's "Infection Control Log" Sheet dated 1992 reflected the following: "Date Reported to the Infection Control/Quality Assurance Committee _____/_____/_____" "Reporting Period _____ To ____" "Total Number of Infections: Skin____, Urinary Tract Infection_____, Upper Respiratory Infection_____, Eye_____, Other_____." The log had vertical columns on the sheet with the following headings: "Resident admitted Onset Date Site Infection Related DX Culture (With a column for Yes/Date and a column for No) X-Ray Date Organism Antibiotic Isolated (With a column for Yes/Date and a column for No) Nosocomial (With a with a column for Yes and a column for No) Re-Cultured Date Date Resolved September 2013's Infection Control Log was reported to the Infection Control/Quality Assurance Committee on 09/30/13. There were 11 resident names listed. The log began with the date 09/28/13 and ended with the date 09/03/13. The September 2013 log did not include identification of any of the organisms for the infections, which had cultures checked as having been done, except for one UTI with the organism E. coli. The log reflected there were two skin infections, five UTIs, one URI, no eye infections and two "Other" infections. There were no entries in the following columns: admitted , Site, X-Ray Date, Isolated, Nosocomial, Re-Cultured Date or the Date Resolved. On the Culture column, there were four infections checked, but no dates and only the one organism, E. coli had been entered. Under the column "Infection Related [DIAGNOSES REDACTED]. October 2013's Infection Control Log was reported to the Infection Control/Quality Assurance Committee on 10/31/13. There were 12 resident names listed on this log. The log began with the date 10/04/13 and ended with the date 10/28/13. The October log did not identify any organisms which caused the infections although three residents had a culture done (but no date). All of the infections were identified as not being nosocomial or hospital-acquired infections, and none of the residents were isolated. There were no entries in the following columns: admitted , Site, Culture (the No column), X-Ray Date, Organism, Isolated (the yes column), Nosocomial (the yes column), Re-Cultured Date and Date Resolved. The log reflected there were three skin infections, six UTIs, two URIs, no eye infections, and the "Other" was left blank. In the "Infection Related DX" column there were seven UTIs, two URIs, one WBC Increased, one cellulitis and one left blank. (This does not match with the amounts written at the top of the page.) There were three entries with UTIs with no onset dates. November 2013's Infection Control Log was reported to the Infection Control/Quality Assurance Committee on 11/30/13. There were 13 resident names listed on this log. This log began with the date 11/02/13 and ended with the date 11/26/13. The November log did not identify any organisms which caused the infections although nine of the infections had a culture done but not dated. All of the infections were listed as not isolated. Eight infections were listed as nosocomial with four listed as not nosocomial. There were no entries in the admitted , Site, Organism, Isolated Yes/Date column, Re-Cultured date or Date Resolved columns. This log reflected there were two skin infections, six UTIs, one URI, one eye infection and three "Other" infections. In the "Infection Related DX" column, there was one Amputee wound, one GT site skin, five UTIs, one respiratory distress, one tooth extraction, one vaginal discharge/UTI and two increased WBCs. (This does not match with the amounts written at the top of the page.) A) Resident #2 was a [AGE] year-old-female admitted to the facility on [DATE] per her admission assessment dated [DATE]. This document also reflected Resident #2 had active [DIAGNOSES REDACTED].

Based on interview and record review, it was determined the administrator and DON failed to use the facility's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psycho-social well-being for 15 (Residents #2, #3, #4, #9, #11, #13, #16, #22, #29, #34, #35, #36, #37, #38, and #40) of 40 residents reviewed for neglect, quality of care, infection control, and/or change of condition. 1) The Administrator failed to monitor and supervise the DON to ensure the DON carried out her responsibilities to ensure nursing services were provided in a manner to promote the well-being of the 15 residents reviewed for neglect, quality of care, infection control and/or change of condition.. 2) The DON failed to monitor and supervise the facility nursing staff to: a) ensure the residents' physicians were notified of the residents' changes of condition in a timely manner (Residents #2, #3, #9, #11, and #13); b) ensure indwelling catheters were not used without valid medical reasons (Resident #2); c) received the necessary care and services to prevent infection (Resident #22); d) ensure the residents with pressure sores received the necessary care and services to promote healing, prevent infections and prevent new sores from developing (Residents #9, #11 and #16) ; e) ensure the residents maintained acceptable parameters of nutritional status, such as body weight and ensure Dietitian's recommendations were followed (Residents #3 and #40). f) ensure pharmacy services were carried out in such a way as to prevent the administration of unnecessary drugs and ensure the residents were free from significant medication errors (Residents ##3, #9, #4, #13, #22, and #34); and g) ensure the facility's infection control policies and procedures were implemented (Resident #2, #29, #35, #36, #37 and #38). An Immediate Jeopardy (IJ) was initially identified on 12/12/13. Further Immediate Jeopardy (IJ) situations were identified on 01/02/14. While the IJ was removed on 01/11/14, the facility remained out of compliance at a scope of "widespread" and a severity level of "actual harm that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. These failures could affect any of the facility's 75 residents placing them at risk [MEDICAL CONDITION], pressure ulcer development and infection, development of serious medical conditions, delay of medical interventions, pain, diminished quality of life, hospitalization and death. Findings included: 1) During an interview on 01/10/14 at 4:00 PM, the Administrator was queried about the training her DON had received. When asked if she had ever asked the DON to sign a job description with her specific responsibilities outlined, the Administrator stated if there was not one in her personnel file, she did not get one. When asked how the DON knew what her responsibilities were, the Administrator explained they had a form they had started out with where she was told she had to check orders; check Medicare charting; check Medicaid residents; check new admissions for orders and admission assessments; if someone dies, go look at the chart to ensure everything is in order; if someone goes to the hospital, go and find out why. The Administrator stated she told the DON when she was hired it would probably take a year or so to learn it all. She added she had typed a list for her to follow. When asked if she was referring to the list dated August 2013, she replied, "Yes, but I had told her months before ...told her these are things to focus on now." She stated she told the DON to tell her everything that was going on, no matter how small. The Administrator was asked again if she had put anything in writing prior to 08/23/13, she stated, "No, because we had been discussing things all along." When the Administrator was asked about LVN D, she stated the LVN had just been evaluated in November 2013 and was still working as a CNA as well as a nurse. She stated she had told the DON she wanted her to work both positions because she wanted her watched as she was a new nurse. When asked who was responsible for watching her, the Administrator said both the DON and ADON MM. She added they both thought LVN D had a lot of potential. The Administrator stated LVN D did present her residents the best at the daily meetings and seemed very organized. The Administrator stated LVN D was evaluated to determine whether she needed to remain a CNA or a nurse. She stated she did not know what ADON MM had done with the evaluation itself but they had decided in November to continue to watch her. A document titled DISCIPLINARY WARNING NOTICE dated 08/09/13 located in the DON's personnel file reflected: "The purpose of this notice is to make you aware that either your behavior and/or performance is not acceptable. You have been oriented and in-serviced as to company policies and procedures. You have violated company policy as indicated below: DEFECTIVE WORK (was checkmarked)..." "Describe how violation occurred: DON failed to thoroughly follow-through on monitoring of orders & thoroughly investig. hospital transfer of resident/death including reviewing of chart, labs, nurses notes, orders (all) calling hospital, speaking w/staff (nurses/aides) etc." "Employee written rebutal (sic): ...From this experience I have learned to take a more thorough approach to my daily routine of checking the new orders and omissions by not just checking that the doctor's order (sic) have been transcribed to the MAR/TAR correctly as well as all necessary labs. I will also put into practice exploring the reasoning behind every hospital transfer &/or death regardless if I feel I know all the information." The document was signed by the Administrator and the DON. A document titled, NURSING ADMINISTRATION DAILY DUTIES dated 08/23/13 located in the DON's personnel file reflected: "1. Reviewing the 24 hour report ...looking for triggers regarding residents (sic) care. 2. Reviewing within 24 hours the admission assessment of a new resident. Including the transcribing of the orders. 3. Ensuring that the medication aides are reviewing the mars for holes in them. 3.(a) Nurses have 24 hours to correct their omissions. 4. Confirm that the medicare, Medicaid, & wound care charting is completed from the day before. 6. (sic) Review chart of all who are d/c'd to the hospital and or who pass away. 7. Reviewing the head to toe assessment due daily on the 11-7 shift. 8. Reviewing the incidents from the day before. 9. Review daily the charting of one who has acquired a wound...2 hour charting." The document was initialed by the Administrator, the DON and ADON MM. During an interview on 01/11/14 at 10:45 AM, when the DON was asked about LVN D's evaluation, she stated ADON MM had conducted it and she was unable to find any record of it. The DON stated the plan was to switch LVN D to a full time Charge Nurse after seeing how she performed through the end of the year. She was unable to recall when LVN D began taking residents as a nurse. When asked who was responsible for overseeing her care as she was a new nurse, the DON replied, "(ADON MM) and I told her, if she had any questions to run it by us." When asked if she had performed any follow-up with LVN D to go behind her and check her wound care and documentation, the DON explained they had "spot checked" all the staff but had done no specific follow-up for LVN D. 2) The Face Sheet dated 08/01/13 reflected Resident #2 was admitted to the facility on [DATE] with diagnoses, which included but were not limited to Bacterial Pneumonia, Difficulty in Walking, and a History of Respiratory Disease. Resident #2 was a [AGE] year-old-female admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Further review of this assessment revealed Resident #2's cognitive skills for daily decision making were moderately impaired. Resident #2 had an indwelling catheter and was always incontinent of bowel. Resident #2 required extensive assistance of one person for bed mobility, transfers, locomotion and was totally dependent of one person for dressing, eating, and toileting. During an interview on 01/07/14 at 4:00 PM, the MDS Coordinator stated she was unable to find any care plans for Resident #2. Review of Resident #2's Admission Nursing assessment dated [DATE] revealed the resident had a "Foley in place." (The nurse's signature was not legible.) It further reflected she had an 18 French 30 cc balloon catheter, and her urine was yellow and cloudy. Review of Resident #2's admission orders [REDACTED]. Review of Resident #2's consolidated physician's orders [REDACTED]." Note: There was no order for the use of [REDACTED]. During an interview with the DON on 12/13/13 at 11:10 AM, she was asked what her expectations were when a resident had a Foley catheter. The DON informed the surveyor when a resident had a Foley catheter, she would expect them to document the resident's I & O, catheter care, and color and consistency of the urine. When asked what she meant about catheter care, the DON said to clean the Foley catheter tubing and make sure it was not "gunky." When asked about physician's orders [REDACTED].#2, the DON said she was not aware there were no orders for the resident to have a catheter except for "cath care q shift," on the resident's consolidated physician's orders [REDACTED]. During an interview with LVN H on 12/13/13 at 3:50 PM she informed the surveyor she worked with Resident #2 every day Monday through Friday from 3:00 PM - 11:00 PM. When asked if she had ever changed Resident #2's Foley catheter, LVN H said,"No. I haven't put in a new Foley but I changed the (urinary drainage) bag." When asked what a nurse was supposed to do when a resident had a catheter, LVN H replied they would get an order from the doctor to change the catheter "every month on this date at this time." LVN H told the surveyor the facility policy was usually for the night shift to change the catheters. LVN H said if she had received the order, but "I didn't," she would include it on the TAR, and if she admitted a resident with a Foley catheter, she would get the order to change it and write it on the TAR. LVN H said when they first got an order, it would depend upon the doctor and when he wanted the catheter changed the first time. LVN H said, it "might depend on where she came from and the hospital orders." LVN H informed the surveyor if she or another nurse had realized Resident #2's catheter had not been changed, "We should have checked to see (if it had been changed)." LVN H said she had never called to get an order to change Resident #2's Foley catheter, but any shift could call the doctor and get orders for the Foley catheter. LVN H said she never realized Resident #2's catheter had not been changed or noticed there was nothing on the TAR to change the Foley catheter. During an interview with LVN G on 12/12/13 at 10:15 AM, when asked if she had ever changed Resident #2's Foley catheter, LVN G said,"No," she had not. LVN G said there was a nurse on the night shift, who changed the residents' catheters, but she no longer worked for the facility. LVN G said she did not know if Resident #2's catheter had ever been changed and identified RN I as the previous night shift nurse, who may have changed Resident #2's catheter. During an interview with RN U on 12/13/13 at 10:42 AM, she informed the surveyor she worked with Resident #2 on the night shift on Saturday nights only and reconciled the comprehensive orders every month for station two, which included Resident #2. When asked if she had ever changed the Foley catheter, RN U said she did not remember if she had changed it or not. When asked how often a Foley catheter should be changed, RN U replied,"It's usually on the orders to change every 30 days or one time a month." When asked if Resident #2 had any orders for her Foley catheter on her consolidated orders, RN U said she was "not sure if she has an order or not." During the initial tour with LVN G on 12/10/13 at 11:17 AM, Resident #2 was not in her room. LVN G described Resident #2 as alert and oriented with confusion at times. LVN G said Resident #2 was incontinent of bowel but had an indwelling catheter for [MEDICAL CONDITION]. The resident was ambulatory with a rolling walker and was stand by assist with most of her ADLs. On 12/10/13 at 1:15 PM, Resident #2 was observed in her room sitting in a chair. She was well-groomed and dressed appropriately. Resident #2 informed the surveyor she had not been in the facility for very long and had come from another facility. When asked about her Foley catheter, Resident #2 informed the surveyor her catheter leaked sometimes and showed the surveyor her urinary drainage leg bag, which was on her right leg above her knee and had light tea-colored urine in it. When asked, Resident #2 said some of the new girls (CNAs) pulled too hard on the catheter and it leaked (Resident #2 pointed at her Peri area). Resident #2 also informed the surveyor when she had a urinary drainage leg bag for a long time, it would leak sometimes as well. In the Confidential Resident Group Interview on 12/11/13 at 1:30 PM, the attending residents, identified by the facility as alert and oriented, were asked this question: "How do staff members treat the residents here, not just yourselves, but others who can't speak for themselves?" One of the residents reported he/she knew of a resident, who complained out loud about wanting to have her (indwelling urinary) catheter changed, which annoyed the CNAs. The CNAs would then respond to the resident, telling him/her the nurses were supposed to change the catheter, not them (the CNAs). The CNAs would then tell the nurses, who would ignore both the CNAs and the resident. Two other residents agreed with the first resident. They described the resident, who had the catheter as a resident who used a walker and talked loudly. The resident with the catheter was confirmed as being Resident #2. During an interview with LVN G on 12/12/13 at 10:15 AM, she stated Resident #2 had asked to have her catheter bag changed, but since the facility did not have an extra catheter drainage bag, she did not change it. When asked if she had ever changed the catheter, LVN G said,"No," she had not. LVN G said there had been a nurse on the night shift, who changed the residents' catheters, but she no longer worked for the facility. LVN G said she did not know if Resident #2's catheter had ever been changed or not and identified RN I as the previous night shift nurse, who may have changed Resident #2's catheter. LVN G said, to her knowledge, Resident #2 had never complained about her catheter hurting. LVN G said Resident #2's urine used to be amber in color until her physician wrote an order for [REDACTED].#2 ambulated, which was why it was amber-colored. LVN G said at night, the night nurse changed the leg bag to a bedside urinary drainage bag, and in the morning, the night nurse changed it back to the leg bag. When asked about securing Resident #2's catheter, LVN G said she did not know if there was a leg strap on the catheter. Review of Resident #2's Daily Skilled Nurse's Note dated 08/04/13 at 7:00 PM (nurse's signature illegible) revealed the resident's Foley catheter was intact and in place. The note further reflected the resident complained of pain at the catheter site, so the nurse gave Resident #2 [MEDICATION NAME] 2.5/500 mg 1 tab PO, which she tolerated well. Review of Resident #2's Daily Skilled Nurse's Note dated 08/07/13 at 5:00 PM (nurse's signature illegible) revealed the nurse had assessed Resident #2's catheter and noticed blood in the catheter bag. The nurse called Physician K, Resident #2's attending physician, and spoke with NP P, who ordered [MEDICATION NAME] (anti-fungal) 100 mg 1 tab PO X 3 days. Resident #2's Daily Skilled Nurse's Note dated signed by RN I on 08/10/13 at 2:00 AM reflected Resident #2 had a Foley catheter, which was draining pinkish-colored urine and there were no blood clots. Review of Resident #2's Daily Skilled Nurse's Note dated 08/10/13 at 9:00 AM (nurse's signature illegible) revealed the resident's Foley catheter was intact, and her urine was getting clear of blood. Review of Resident #2's Daily Skilled Nurse's Note dated and signed by LVN E on 08/12/13 (no time) revealed Resident #2's Foley catheter was intact and draining light pink urine. The Note further reflected Physician K was notified, and he had instructed the nurse to drain Resident #2's catheter bag and to continue to monitor the resident's urine. Review of Resident #2's Daily Skilled Nurse's Note dated 08/13/13 at 12:00 AM (nurse's signature illegible) revealed Resident #2's Foley catheter was in place to gravity drainage. It further reflected her urine was amber colored, clear and without any odor noted. Review of Resident #2's Daily Skilled Nurse's Note dated 08/13/13 at 12:00 AM (nurse's signature illegible) revealed Resident #2's urine was amber-colored and clear. It also reflected the nurse notified Physician K, and he said to put tape on Resident #2's catheter to prevent it from pulling. Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/14/13 at 12:00 AM revealed Resident #2's Foley catheter was to gravity drainage, and the urine was pinkish colored with"red clumps (clots) visible." Review of Resident #2's Daily Skilled Nurse's Note dated 08/14/13 untimed (nurse's signature illegible) revealed Resident #2's urine color was amber and clear. It further reflected the nurse called Physician K, and he gave a new order for a UA with C&S. Review of Resident #2's Daily Skilled Nurse's Note dated 08/14/13 at 5:00 PM (nurse's signature illegible) revealed Resident #2's Foley catheter was in place with drainage to gravity. It further reflected her urine was amber-colored and clear. Review of Resident #2's Daily Skilled Nurse's Note dated 08/15/13 at 2:00 AM and signed by RN I revealed the RN collected a sample of urine from Resident #2's catheter tubing for the UA C&S using "sterile technique." Review of Resident #2's Daily Skilled Nurse's Note dated 08/15/13 at 5:00 PM (nurse's signature illegible) revealed her Foley catheter was in place to gravity drainage. It further reflected Resident #2's urine was amber-colored, clear and without an odor. Review of Resident #2's physician's telephone orders revealed an order dated and signed by the physician on 08/15/13, which ordered to continue the Foley catheter and to attach it to a urinary drainage leg bag at 6:00 AM every morning and then to a gravity urinary drainage bag every night at 9:00 PM for one month and then re-evaluate. Further review of Resident #2's physician's telephone orders for August, September, October, November and December 2013 failed to reveal any orders resulting from a re-evaluation of the resident's catheter, orders for the Foley catheter and leg drainage bag, any order for the Foley catheter size, a frequency to change the Foley catheter, whether to document I&O, or to irrigate the Foley catheter. Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/16/13 at 2:00 AM revealed Resident #2 was awake, and when the CNA had assessed her, Resident #2's "diaper is wet." The nurses' note further reflected the CNA reported this to RN I as well as the statement, "Her cath hurts." RN I's nurses' note further reflected she went and assessed Resident #2"and noted that Res crys (sic) out with pain when Foley tubing is moved only slightly - Foley bulb deflated and (catheter) removed. Res c/o much discomfort. Obtained a #18 with 10 cc bulb (Foley catheter) and inserted it with minimal discomfort noted...Res passing pink color urine...." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/16/13 at 6:00 AM revealed Resident #2's urine was"pinkish in bag and tubing." It further reflected RN I removed the large bag and placed a leg bag as ordered for day time activity. RN I then wrote"Lg bag Rinsed and hung up in BR." Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/17/13 at 12:00 AM, 08/19/13 at 12:00 AM, 08/19/13 at 6:30 AM, 08/21/13 at 12:00 AM, 08/19/13 at 6:30 AM, 08/22/13 at 5:00 AM, 08/24/13 at 12:00 AM reflected Resident #2's leg bag was changed to a regular urinary drainage bag and/or, depending upon the time, the leg bag was changed to the regular urinary drainage bag. Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/22/13 at 5:00 AM revealed RN I gave Resident #2 some medicine in yogurt and Resident #2 asked why she was being given medicine. RN I told Resident #1 it was antibiotics for her UTI. Resident #2's Daily Skilled Nurse's Notes including 08/24/13, 08/26/13 at 7:00 AM, 08/27/13 at 6:00 AM, 08/30/13 at 12:00 AM, 08/30/13 at 12:00 AM, 08/30/13 at 7:00 AM, 09/02/13 at 12:00 AM continued to reflect the resident's use of either a leg bag for urinary drainage or a large bag. A description of Resident #2's urine was also included occasionally. Review of Resident #2's Daily Skilled Nurse's Note dated 09/04/13 at 9:00 PM (nurse's signature illegible) revealed the nurse notified Physician K (Resident #2's PCP and the facility's Medical Director) there was blood in Resident #2's urine. It further reflected Physician K ordered a UA C&S for in the morning. Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/02/13 at 12:00 AM revealed Resident #2 was awake and restless. It further reflected her incontinent brief was wet. RN I assessed Resident #2's Foley catheter and"determine fluid in bulb low, slowly added more fluid...." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/06/13 at 6:00 AM revealed"Drainage Bag (changed) to leg bag." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/07/13 at 2:00 AM revealed Resident #2 was awake and restless and complained "Feels full. Observed Foley tubing (with) scant urine in it, none in bag. Realigned tubing under Res (R) leg (with) down grade to Bag had to pump tubing to encourage urine to flow...." Review of Resident #2's Daily Skilled Nurse's Note dated 09/10/13 at 9:30 PM (nurse's signature illegible) revealed Resident #2 was on an antibiotic due to UTI, and her urine was"still cloudy in color." Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/11/13 at 12:00 AM, 09/11/13 at 6:00 AM and 09/12/13 at 6:00 AM, 09/13/13 at 6:00 AM, 09/14/13 at 6:30 AM, 09/16/13 at 5:00 AM, 09/19/13 at 12:00 AM, 09/18/13 at 6:30 AM, 09/19/13 at 4:00 AM reflected the resident either had the large urinary drainage bag in place or the leg bag or they were changed. Review of Resident #2's Daily Skilled Nurse's Note dated 09/12/13 at 9:30 PM (nurse's signature illegible) revealed Resident #2's"urine still cloudy...." Review of Resident #2's Daily Skilled Nurse's Note dated 09/19/13 at 10:30 AM (nurse's signature illegible) revealed the nurse"noted amber-colored urine in residents urine bag, urine was drained, resident assisted to sit in her bed and relax because she had been walking around." It also reflected NP P was called and an order was received for a UA C&S for the next day. Review of Resident #2's Daily Skilled Nurse's Note dated 09/19/13 at 4:30 PM (nurse's signature illegible) revealed a CNA informed the nurse they thought Resident #2's"Foley bag was leaking, nurse went to check on it, Foley bag was intact was not leaking...." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/20/13 at 12:00 AM revealed, "Note urine in foley tubing is pink will monitor for Redness." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/20/13 at 7:00 AM revealed RN I informed Resident #2 of the need to collect urine for a UA. The Note reflected "open cath tubing and only 2-3 cc urine...bladder empty at this time." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/21/13 at 12:00 AM revealed Resident #2 "verbalizes her foley is leaking...note tubing is easily moveable in urethra - 6 cc air was added to tubing bulb." Note: The Foley catheter was not changed. Attempts to contact RN I for an interview were unsuccessful. Review of Resident #2's Daily Skilled Nurse's Note dated 09/23/13 at 4:30 PM (nurse's signature illegible) revealed the nurse received the laboratory results of the UA C&S and Physician K was notified. New orders were received: [MEDICATION NAME] (anti-[MEDICAL CONDITION] and for acute UTIs) 150 mg one by mouth two times a day for seven days; [MEDICATION NAME] (for UTIs) 50 mg by mouth two times a day for 10 days; and to repeat the UA C&S three days after the antibiotic was completed two times. Resident #2's Daily Skilled Nurse's Note further reflected Physician K called back and changed the [MEDICATION NAME] to 100 mg by mouth two times a day for 10 days. Resident #2's Nurse's Note dated 09/28/13 at 12:30 PM, 09/28/13 at 2:30 PM, 09/28/13 at 11:30 PM, 09/29/13 at 11:30 AM and 09/29/13 at 4:45 PM all included the resident being on an antibiotic [MEDICAL CONDITION] in her urine. During an interview with ADON MM on 12/15/13 at 12:26 PM, when asked, ADON MM said Resident #2 was not on isolation when she [MEDICAL CONDITION] in her urine because she had a Foley catheter so it was contained. Review of Resident #2's Nurse's Note dated 10/05/13 at 2:00 PM (nurse's signature illegible) revealed Resident #2 was status [REDACTED]." Review of Resident #2's Nurse's Note dated 10/13/13 at 12:00 AM (nurse's signature illegible) revealed Resident #2 "C/O bladder pain...." It further reflected the catheter was draining urine and the nurse informed the resident it may have been pulled when she was out on pass with her family. The nurses' note also reflected Resident #2 received [MEDICATION NAME] 2.5/500 mg for the pain. Resident #2's physician's telephone order dated 10/18/13 reflected an order for [REDACTED]. Review of Resident #2's Nurse's Note dated 11/08/13 at 2:00 AM (nurse's signature illegible) revealed Resident #2 "C/O abd pain...." The Nurses' Note further reflected Resident #2 was medicated with [MEDICATION NAME] 2.5/500 mg for the pain and her Foley catheter was patent and irrigated. On 12/12/13 at 4:00 PM, the surveyor observed Resident #2 ambulating in the hallway. She was well-groomed and dressed appropriately. When asked if her catheter had been changed, Resident #2 said,"No," they had changed the urinary drainage bag but not the catheter itself. During an interview with RN L on 12/13/13 at 9:55 AM, when asked if she had ever worked with Resident #2, she said at least one night a week. When asked if she had ever changed Resident #2's Foley catheter, RN L said, "No," she had not. RN L said she did not change the catheter bags either as"the CNAs change from the bedside drainage bag to the leg bag." RN L said sometimes Resident #2 calls her "to fix it." The leg bag strap would be "too tight," so RN L would loosen it for Resident #2. During a telephone interview with Resident #2's family member on 12/13/13/at 10:09 AM, he/she informed the surveyor Resident #2 had gone to two physician appointments. The family member said another family member had taken Resident #2 to her General Practitioner on 10/07/13 and then to her Oncologist on 11/27/13. The family member said there had been no Urology appointment, but they had been waiting for one, so the Urologist could "fix" the problem Resident #2 was having with her catheter. He/She said Resident #2 "was a very clean lady," and she had complained to the family member about her Foley catheter leaking. The surveyor asked the family member if Resident #2 complained about the Foley catheter bag leaking or if it was leaking in her "private area," and he/she said she had complained about it leaking in her "private area." The surveyor asked him/her if the resident complained about pain, and he/she said,"No," just that it had been leaking about her "private area" and the resident did not like to feel wet even though she wore incontinent briefs. The resident was also very afraid about (urine) odor. When asked whether Resident #2's Foley catheter had been changed since her admission to the facility, the family member said he/she did not think the Foley catheter had been changed since being admitted to the facility. The family member asked the surveyor how often the Foley catheter should be changed, and the surveyor told him/her every 30 days, or once a month was the norm. The family member said,"Well, she (Resident #2) would have told me if they were changing it (Foley catheter) like that." During an interview with RN U on 12/13/13 at 10:42 AM, she informed the surveyor she worked with Resident #2 on the night shift on Saturday nights only and reconciled the comprehensive orders every month for station two, which included Resident #2. When asked if Resident #2 ever complained about pain or her catheter, RN U said,"Yes. Sometimes she (Resident #2) complained about her cath (catheter)." RN U said Resident #2 would sometimes say, "It's not in the right place, and we (staff) would assure her it's in the right place and draining well." When asked if she had ever changed the Foley catheter, RN U said she did not remember if she had changed it or not. When asked how often a Foley catheter should be changed, RN U replied,"It's usually on the orders to change every 30 days or one time a month." When asked if Resident #2 had any orders for her Foley catheter on her consolidated orders, RN U said she was "not sure if she has an order or not." During a telephone interview with LVN T on 12/13/13 at 2:07 PM, the LVN reported she had only worked on station two and taken care of Resident #2 one time. LVN T said Resident #2 had not complained to her about her catheter when she had worked with her that one time. LVN T said she did remember when she had worked a long time ago, Resident #2 said she felt like she"had to pee" but she had not been her nurse so had done nothing about it. During a telephone interview with LVN V on 12/13/13 at 2:16 PM, she informed the surveyor she worked on station two "every now and then." When asked what she would check on Resident #2's Foley catheter, LVN V said she would check the color of her urine. LVN V said Resident #2 had never complained about her catheter. LVN V also said she had never changed Resident #2's catheter. When asked how she would know to change Resident #2's catheter, LVN V said usually, the physician's orders [REDACTED]." When asked why it was the CNAs' job, LVN V said, "Nobody put that on the aides. That's something they've always done. I've never told them to do it." On 12/13/13 at 2:42 PM, the surveyor observed Resident #2 lying flat in her bed on top of her personal blanket with her legs straight, her pants down about her ankles and her incontinent brief pulled down to just above her knees. The surveyor observed LVN

Based on interview and record review, it was determined the administrator and DON failed to use the facility's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psycho-social well-being for 2 (Residents #1 and #2) of 14 residents reviewed for neglect and quality of care. 1) The Administrator failed to monitor and supervise the DON to ensure the DON carried out her responsibilities to ensure nursing services were provided in a manner to promote the well-being of the 15 residents reviewed for neglect and quality of care. 2) The DON failed to monitor and supervise the facility nursing staff to: a) ensure pharmacy services were carried out in such a way as to prevent the administration of unnecessary drugs and ensure the residents were free from significant medication errors (Residents #1, and #2); and ensure Resident #1 received the necessary care and services to manage her pain. The facility failed to properly transcribe and administer the following medications for Resident #1 in two of two months reviewed: [MEDICATION NAME] 25 mg - missed three of five doses; [MEDICATION NAME] 20 mg - missed three of five doses; [MEDICATION NAME] eye drops- missed three of five doses; [MEDICATION NAME] 40 mg-20 mg was given and only administered three out of five times; [MEDICATION NAME] - was given in the morning instead of at bedtime as ordered; [MEDICATION NAME] 200 mg- 100 mg was given for three days; [MEDICATION NAME] - was given in the morning instead of at bedtime as ordered; Levetiracetam 1000 mg- 500 mg was administered for three days; [MEDICATION NAME] XL - missed three 60 mg doses and missed five 30 mg doses; and [MEDICATION NAME] 0.1 mg - missed five doses. b. LVN D failed to administer the correct dose of pain medications to Resident #1 when she repeatedly complained of leg pain. LVN D administered one [MEDICATION NAME] 5/325 mg when the ordered dose was two 10/325 mg tablets. c. The facility failed to discontinue Resident #2's [MEDICATION NAME] 25mg (for Hypertension) as ordered. The morning dose of [MEDICATION NAME] was discontinued on 02/03/14 and the evening dose was not discontinued until after the 02/28/14 dose, for a total of 31 doses. These failures could affect any the facility's 75 residents, including Residents #1 and #2, by placing them at risk for ongoing medication errors resulting in depression, eye discomfort, unrelieved pain, stomach upset, [MEDICAL CONDITION], weakness, confusion, dizziness, headache, [MEDICAL CONDITIONS] and death and could affect the 75 residents in the facility. Findings included: 1) Review of Resident #1's Physician's Telephone Orders dated 02/26/14 revealed she was to be readmitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #1's admission Nurse's Note dated 02/26/14 at 2:20 PM revealed she was confused but able to make her needs known at that time. Review of Resident #1's hospital Medication Profile Report dated 02/25/14 revealed the following medications were among those to be continued when she returned to the facility: [MEDICATION NAME] Hcl 25 mg tablets by mouth twice daily (used to treat high blood pressure); [MEDICATION NAME] 20 mg tablets by mouth twice daily (used to treat chest pain caused by heart damage); [MEDICATION NAME] Sodium 100 mg caps, two twice daily (used to prevent constipation); [MEDICATION NAME] 0.05% eye drops, one drop in each eye twice daily (used for increase tear production); [MEDICATION NAME] 20 mg tablets, give 40 mg at bedtime (used to lower cholesterol); [MEDICATION NAME] 20 mg tablets, give 10 mg by mouth at bedtime (used to treat depression); [MEDICATION NAME] 100 mg tablets, give 200 mg at bedtime (used to treat pain caused by [MEDICAL CONDITION]); [MEDICATION NAME] 325 mg, give one at bedtime (iron supplement used to treat [MEDICAL CONDITION]); Levetiracetam 500 mg tablets, give 1000 mg at bedtime (used to treat [MEDICAL CONDITION]); [MEDICATION NAME] XL 30 mg by mouth every day (used to treat high blood pressure and chest pain); [MEDICATION NAME] XL 60 mg by mouth every evening; and [MEDICATION NAME] HCL 0.1 mg by mouth every day (used to treat high blood pressure). Review of the facility's admission orders [REDACTED] [MEDICATION NAME] 30 mg PO QD; and [MEDICATION NAME] HCL 0.1 mg PO QD. Review of Resident #1's February 2014 MARs revealed the following: [MEDICATION NAME] 25 mg tablets twice a day was only transcribed and initialed as administered once on 02/27/14. (Not twice a day as ordered) [MEDICATION NAME] 20 mg tablets was only transcribed and initialed as administered once a day on 02/27/4 and 02/28/14. (Not twice a day as ordered) [MEDICATION NAME] Sodium 100 mg caps was only transcribed and initialed as administered once on 02/27/14 and 02/28/14. (Not twice a day as ordered) [MEDICATION NAME] eye drops were only transcribed and initialed as administered once a day on 02/27/14 and 02/28/14. (Not twice a day as ordered) [MEDICATION NAME] was transcribed as 20 mg at bedtime and only initialed as administered on 02/26/14 and 02/27/14. (Not on 02/28/14 as ordered) [MEDICATION NAME] was transcribed and initialed as administered as 10 mg at 6:30 AM. (Not at bedtime as ordered) [MEDICATION NAME] 100 mg was transcribed and initialed as administered at bedtime. (Not 200mg as ordered) [MEDICATION NAME] 325 mg was transcribed and initialed as administered at 6:30 AM. (Not at bedtime as ordered) Levetiracetam 500 mg was transcribed and initialed as administered daily at bedtime. (Not 1000 mg as ordered) [MEDICATION NAME] XL was transcribed as 30 mg by mouth every evening and was only administered on 02/26/14 and 02/27/14. (Not 60 mg as ordered and none on 02/28/14) [MEDICATION NAME] XL 60 mg was not transcribed to the February MAR and so no doses were given in February. Review of Resident #1's March 2014 MARs revealed the following: [MEDICATION NAME] XL 30 mg by mouth every day was not transcribed and so was not administered from 03/01/14 through 03/05/14, when surveyor inquired. [MEDICATION NAME] HCL 0.1 mg by mouth every day was not transcribed and so was not administered from 03/01/14 through 03/05/14, when surveyor inquired. An interview with the Unit Manager on 03/04/14 at 4:32 PM revealed it was typically her duty to check all orders daily for accuracy but she was pulled off the floor or on 02/24/14 to work on the monthly consolidated orders for the remainder of the month. She stated, during that time, the DON was performing the daily checks on both nurses' stations. During an interview on 03/05/15 at 10:25 AM, LVN C stated she had transcribed the admission orders [REDACTED]. When shown the errors found by the surveyors, LVN C stated she was not aware of the errors. She stated RN A had transcribed the orders to the March MARs and she remembered RN A pointing out some discrepancies to her but she thought she had corrected them. During an interview on 03/05/14 at 11:25 AM, RN A stated she had transcribed the March MARs for Resident #1 but had never looked at February's MARs. RN A stated she had caught a few discrepancies after the hospital orders had been transcribed to the facility's admission orders [REDACTED]. She was not aware of any medication errors. An interview with the DON on 03/05/14 at 11:25 AM revealed all orders, including new admission orders [REDACTED]. The DON explained pink copies of all resident's orders were to be placed in a box and both she and the Unit Manager checked those pink copies every day before they left to ensure all orders written over the past 24 hours were transcribed correctly. When asked about Resident #1, the DON confirmed the Unit Manager was not checking orders at that time as she had been pulled to work on the monthly orders. The DON stated she did not know why Resident #1's orders had not been checked; she stated the pink copies must not have made it into the designated box. b) Review of Resident #1's hospital Medication Profile Report dated 02/25/14 revealed the following medications were among those to be continued when she returned to the facility: [MEDICATION NAME] 10/325 mg one tablet every six hours as needed for pain. [MEDICATION NAME] 10/325 mg two tablets every six hours as needed for pain. Resident #1's admission orders [REDACTED]. Review of Resident #1's MAR for February 2014 revealed an entry for [MEDICATION NAME]-Apap 10-325 two every six hours as needed for pain. The entry was initialed as administered on 02/26/14 at 3:00 PM and 9:00 PM by LVN D. The back of the MAR reflected the following entries: 2/26/14 at 3:00 PM: "Resident c/o pain, pain level 8/10, [MEDICATION NAME] ([MEDICATION NAME]) 5/325 admin, pain level at 3:30 PM 6/10." The entry was signed by LVN D. 2/26/14 at 9:00 PM: "Resident c/o pain, telling, 8/10, [MEDICATION NAME] 5/325 mg admin, pain level @ 9:30 (PM), 7/10, ineffective." The entry was signed by LVN D. During an interview on 03/05/14 at 12:45 PM, LVN D explained she was Resident #1's Charge Nurse on 02/26/14 but LVN C was completing the admission orders [REDACTED]. When asked why she only administered 5/325 mg when the order and MAR both indicated the dose was two 10/325 tablets, LVN D stated she had seen the dose on the MAR but when she went to the medication cart, her old card was still on the cart (from prior to her hospitalization ) and so she just administered that. When asked why she did not question the dosage on the card as it conflicted with the MAR or check the orders in the chart, LVN D stated, "It never occurred to me she was really in pain, I didn't touch the orders, I gave her what she had on the cart." During an interview on 03/05/14 at 2:47 PM, the DON was shown Resident #1's MARs and told about the medication error regarding the [MEDICATION NAME]. The DON stated she was not aware of the error and that it should not have happened. She confirmed [MEDICATION NAME] 10/325 mg tablets were kept in the E-kit and LVN D could have easily retrieved the proper dose. When asked how Resident #1's pain should have been handled, the DON stated if a resident complains of pain, they should be assessed and a pain level ascertained. She stated the resident should be medicated if indicated and re-assessed in 30-45 minutes for relief. The DON stated, if the medication was not effective and another medication could not be given, the physician should be called and made aware of all the details surrounding the situation. An observation on 03/05/14 at 3:28 PM revealed [MEDICATION NAME] 10/325 tablets were stocked in the medication room E-kit at Resident #1's nurse's station. 2. Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed Resident #2 had a BIMS of 4 and was dependent on staff for most of his ADLs. Review of Resident #2's Care Plan dated 02/27/14 revealed: "Date & Problem: DX [MEDICAL CONDITION]/HTN/[MEDICAL CONDITION] Goal: (Resident #2) will not suffer any complications caused by Dx's thru the next eval date. Approaches & Disciplines: Lab as ordered Notify Dr. of results Medications as ordered. Notify Dr of effectiveness Monitor for [MEDICAL CONDITION], SOB, Pain in extremities with discoloration of skin and warm to touch Document and Notify Dr/RP/Hospice" Resident #2's Physician's Telephone Orders dated 01/09/13 reflected [MEDICATION NAME] 25 mg twice a day. Resident #2's Physician's Telephone Orders dated 01/30/14 reflected increase [MEDICATION NAME] to 50 mg twice a day for blood pressure. Review of Resident #2's MARs for the month of January 2014 revealed the last dose of [MEDICATION NAME] 25 mg was on 01/30/14 after the 9:00 PM dose. Further review of this MAR revealed [MEDICATION NAME] 50 mg was started on 01/30/14 at 9:00 PM. Review of Resident #2's MARs for the month of February 2014 revealed [MEDICATION NAME] 50 mg twice a day was administered as ordered. Further review of this MAR revealed the morning dose (9 AM) of [MEDICATION NAME] 25 mg was administered on 02/01/14, 02/02/14/ and 02/03/14. "DC'D" was hand written after the 9 AM dose was administered on 02/03/14. The evening dose (4:00 PM) of [MEDICATION NAME] 25 mg was administered each day during the month of February. A total of 31 doses of [MEDICATION NAME] 25 mg were administered that the physician had discontinued on 01/30/14. During an interview on 03/04/14 at 3:55 PM the surveyor reviewed Resident #2's February 2014's MARs with LVN B, Resident #2's evening charge nurse. LVN B stated she did administer [MEDICATION NAME] 25 mg and [MEDICATION NAME] 50 mg on the days she worked, as were documented on Resident #2's MAR. During an interview on 03/05/14 at 10:05 AM the ADM stated the Unit Manager did the February 2014 monthly recapitulations of physician orders [REDACTED]. During an interview on 03/04/14 at 4:30 PM the Unit Manager stated she checks the pink slips (copy of telephone physician orders) daily to make sure the orders were correct on the MARs. She stated when she did the February 2014 monthly recapitulations of physician orders, she was taken off the floor from 01/25/14 through the end of the month, and the DON took over her tasks, including verifying the pink slips were checked, for the whole building. During an interview on 03/06/14 at 4:30 PM the ADM stated Resident #2 receiving 31 doses of [MEDICATION NAME], which had been discontinued, was a careless error. The ADM further stated the DON told her she did miss a few a days of checking pink slips. During an interview on 03/06/14 at 8:47 AM the surveyor asked the DON how she thought Resident #2's received 31 doses of [MEDICATION NAME] that had been discontinued. The DON stated when RN A taught the Unit Manager how to do the monthly recapitulations of physician orders, RN A did not instruct the Unit Manager to continue to add additional physician orders [REDACTED]. "Nursing 2013 Drug Handbook" 33rd Edition, Wolters Kluwer, Copyright 2013, pages 680 - 681 reflected the following nursing considerations for [MEDICATION NAME]: "Monitor patient's blood pressure, pulse and body weight frequently...Elderly patients may be more sensitive to drug's hypotensive effects...." Overdose signs and symptoms include: [MEDICAL CONDITIONS] headache and flushing. 3. During an interview on 03/06/14 at 8:45 AM, the DON stated she had in-serviced the staff regarding medication transcription and pain assessments. The DON was asked who was responsible for carrying out the Unit Manager's duties when she was pulled off the floor at the end of the month. The DON explained, "In February, I was on her side (of the building), I have to do both sides." When asked about her duties as DON, the DON explained she had to check all new orders and admission orders [REDACTED]'s orders, ensure families and physicians are notified as necessary, review resident charts if discharged and check charts for orders. When the DON was asked if she felt all those responsibilities were "doable" she stated, "For me, at the end of the month, sometimes not doable." When asked how Resident #1's admission orders [REDACTED]. When asked if that had prompted her to check for admission orders [REDACTED]. When asked how she felt the error regarding Resident #1's pain medication had occurred, the DON stated she thought LVN D was an incompetent nurse and she had had to write her up in the past about "things a prudent nurse should know." The DON further stated it was an error on all the nurses for leaving the [MEDICATION NAME] 5/325 mg on the medication cart when the resident went to the hospital. When asked about Resident #2 and how she felt the medication errors occurred, the DON stated the procedure was to check the medical record against the old MAR as well as the new MARs to ensure any errors on either MAR were found. She stated the procedure was not followed or the errors would have been found. The DON explained the Unit Manager checked new MARs on the 25th of the month and had not been trained to check the new MAR for new orders written after that time. She explained she had retrained the charge nurses to transcribe any new orders written toward the end of the month on the MARs for the following month. During an interview with on 03/06/14 at 4:32 PM, the Administrator was asked how she felt the errors occurred with Resident #2. The Administrator stated it was not like the Unit Manager not to be careful but she was careless. She stated the Unit Manager did not usually make those mistakes but it was an error not to discontinue the 4:00 PM entry for the medication. The Administrator stated she spoke with RN A and learned RN A had forgotten to train the Unit Manager to go and check for any orders written between the 25th and the 30th of the month. When asked about the errors related to Resident #1, the Administrator stated the DON and the Unit Manager had daily round check off sheets, which verified they checked daily physician orders [REDACTED].#2' s) admission orders They (DON/Unit Manager) didn't tell methey were overwhelmed, but they did tell me today (03/06/14) they were overwhelmed, after I asked." She stated missing Resident #1 was a problem as she had discussed the resident quite a bit. The ADM further stated, " It wasn't that the system isn't in place, it was missed." 4. Review of the facility's current undated policy and procedure "Monthly Review of physician's orders [REDACTED]. "Purpose: To ensure that physician orders [REDACTED]. Policy: To verify prior to the beginning of each month that all physician orders [REDACTED]. (RN A)/(Unit Manager) will be responsible for this monthly review. DON will schedule the delivery of the orders. DON will have (RN A) to be removed from the schedule as a floor nurse for the last 5-6 days of each month. (RN A) will inform DON of all concerns regarding the orders upon the completion of the review. (RN A) will take the prior month MARS and compare them to the clinical record. (RN A) will then take the clinical record and compare it to the new MARS. (RN A) will then handwrite onto the new MAR any new orders that will come after the 25th of the month. Attending nurses will write any new orders on the current MAR until the end of the month. If a new admission comes at the end of the month, (RN A)/Designee reviewing the MAR should make a new set of physician's orders [REDACTED]. (RN A)/Designee should also make a new set of MARS and TARS for the next month. (RN A)/Designee will via fax all updates to the person responsible for preparing the monthly orders: (name of pharmacy tech) at [PHONE NUMBER]. Clarifications orders will be written. 11-7 will compare the old MAR to the New MAR for accuracy." Review of the facility's current policy and procedure "Unnecessary Drugs" dated 2012 revealed: "Purpose: Each resident's drug regimen must be free from unnecessary drugs: Procedure: An unnecessary drug is any drug when used: 1. In excessive dose (including duplicate therapy); or 2. For excessive duration; or 3. Without adequate monitoring; or 4. Without adequate indications for its use; or 5. In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or 6. An combination of the reasons above...." Review of an undated Medication Pass Inservice from an RN/LVN Orientation Book located at the Nurse's Station revealed the following: "Steps to take during the med pass:... 16. Before administering the medication, always check 'The 6R 's' 17. Triple check medications vs. MAR before administering the medications. 18. If any of the 6 R's do not match or if you have any questions about the medication itself DO NOT GIVE THE MEDICATION! Check the chart or call the pharmacy with your concern. The pharmacist would rather you ask a question than a mistake be made...." "DURING THE MEDICATION PASS: 'THE 6 Rs' Before administering any medication, always check the 6 Rs, The right resident... The right drug: verify each drug against the medication administration record (MAR) before administering... The right dose: verify against the MAR... The right time: administer drugs as instructed on the MAR and within the time frame established by your facility...." "CHECKPOINTS...Related issues...Make sure discontinued medications have been removed from the cart as soon as they have been discontinued...." Review of the facility ' s Pain Policy and Procedure dated 09/24/12 revealed the following: " Purpose: Resident ' s pain will be managed at a level that is acceptable to that resident. Policy: 1. A resident will be assessed on admission for pain (location, duration, onset, alleviating/aggravating factors) a. If pain is present it will be assessed for its characteristics ...5. Resident will be assessed with [REDACTED]. 6. A pain of any level unacceptable to the resident requires further assessment and follow up. Procedure: 1. Nurses will assess, monitor, anf follow-up on reported verbal, physical, and/or nonverbal signs and symptoms of pain or discomfort ... 5. Review pain management care plan and implement. 6. Update care plan as often as necessary to maintain efficiency. 7. Determine the resident ' s preference for managing pain. 8. Nurse will assess and determine medication history and its effectiveness. 9. Nurse will review pain medicine ordered and its effectiveness to reduce pain to an acceptable level for the resident. 10. Nurse will reassess resident ' s perception of pain within 1 hour of any intervention and document. 11. Follow up with MD if resident receives no noted relief to perceived pain, for further orders ... 13. Document findings in resident ' s chart. 14. Communicate pain status if any and interventions used during shift report and 24 (hour) report. " 4. Review of the facility's Form-672, Resident Census and Conditions of Residents, dated 03/03/14 and signed by DON reflected a census of 75.

The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for two (Residents #2 and #8) of three residents reviewed with indwelling urinary catheters and for one (Resident #22) of four residents reviewed for UTIs. 1. Resident #2: a) Had no orders for changing her indwelling Foley catheter, the size of catheter to use, and I & O from her admission on 07/29/13 to December 2013 until surveyor inquiry; b) Did not have her indwelling Foley catheter changed from August through December 2013 (for four months) until surveyor inquiry; c) Had staff using the same leg urinary drainage bag (for day) and large urinary drainage bag (for night), cleaning and rinsing them daily in the resident-shared bathroom even when the resident had a urine infection [MEDICAL CONDITION] until surveyor inquiry; d) Had three UTIs within two months of admission; e) Had a fourth UTI in October 2013, which was diagnosed per a UA, but there was no follow-up C&S done and/or antibiotic ordered for the UTI until surveyor inquiry in December 2013; f) Had a urinary consult ordered on [DATE], which was not done until surveyor inquiry in December 2013. These failures caused Resident #2 pain and discomfort, continued urinary catheterization, and repeated UTIs, decreased socialization, embarassment at urinary odor and loss of quality of life; and placed Resident #2 at risk [MEDICAL CONDITION], dehydration, injury to the urinary tract, and loss of bladder function, resulting in the need for permanent urinary catheterization, repeated use of antibiotics, the need for stronger (and more expensive) antibiotics and the need for hospitalization . These failures could have affected all 42 residents residing on station two. 2. The facility failed to obtain orders for Resident #8's indwelling urinary catheter when she was readmitted to the facility: for changing the catheter, the size of catheter to use, catheter care and for monitoring I&O and for Resident #8 who was admitted to the facility with an indwelling catheter. After surveyor inquiry, the indwelling urinary catheter was discontinued. These failures affected Resident #8 by failing to ensure the resident needed a catheter and received the care she needed because she had an indwelling urinary catheter, but no orders for it and placed her at risk for infection [MEDICAL CONDITION], pain and discomfort, the need for lab tests and medication and possible hospitalization , resulting in loss of quality of life and decreased health and wellness, and or causing death. This failure could have affected the three residents in the facility, who had indwelling urinary catheters. 3. The facility failed to administer [MEDICATION NAME] to Resident #22, which was needed to treat the infection of E. coli in her urine in September 2013. This failure could have caused Resident #22 to become septic, increasing her discomfort, the need for medication, the need for possible hospitalization , and or causing death. This failure could have affected the 33 residents on station two who were administered medications by MA EE. An Immediate Jeopardy (IJ) was identified on 12/13/13. While the IJ was removed on 01/11/14, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm, that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. Findings included: 1) The Face Sheet dated 08/01/13 reflected Resident #2 was admitted to the facility on [DATE] with diagnoses, which included but were not limited to Bacterial Pneumonia, Difficulty in Walking, and a History of Respiratory Disease. Resident #2 was a [AGE] year-old-female admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Further review of this assessment revealed Resident #2's cognitive skills for daily decision making were moderately impaired. Resident #2 had an indwelling catheter and was always incontinent of bowel. Resident #2 required extensive assistace of one person for bed mobility, transfers, locomotion and was totally dependent of one person for dressing, eating, and toileting. During an interview on 01/07/14 at 4:00 PM, the MDS Coordinator stated she was unable to find any care plans for Resident #2. Review of Resident #2's Admission Nursing assessment dated [DATE] revealed the resident had a "Foley in place." (The nurse's signature was not legible.) It further reflected she had an 18 French 30 cc balloon catheter, and her urine was yellow and cloudy. Review of Resident #2's admission orders [REDACTED]. Review of Resident #2's consolidated physician's orders [REDACTED]." Note: There was no order for the use of [REDACTED]. During an interview with the DON on 12/13/13 at 11:10 AM, she was asked what her expectations were when a resident had a Foley catheter. The DON informed the surveyor when a resident had a Foley catheter, she would expect them to document the resident's I & O, catheter care, and color and consistency of the urine. When asked what she meant about catheter care, the DON said to clean the Foley catheter tubing and make sure it was not "gunky." When asked about physician's orders [REDACTED].#2, the DON said she was not aware there were no orders for the resident to have a catheter except for "cath care q shift," on the resident's consolidated physician's orders [REDACTED]. During an interview with LVN H on 12/13/13 at 3:50 PM she informed the surveyor she worked with Resident #2 every day Monday through Friday from 3:00 PM - 11:00 PM. When asked if she had ever changed Resident #2's Foley catheter, LVN H said,"No. I haven't put in a new Foley but I changed the (urinary drainage) bag." When asked what a nurse was supposed to do when a resident had a catheter, LVN H replied they would get an order from the doctor to change the catheter "every month on this date at this time." LVN H told the surveyor the facility policy was usually for the night shift to change the catheters. LVN H said if she had received the order, but "I didn't," she would include it on the TAR, and if she admitted a resident with a Foley catheter, she would get the order to change it and write it on the TAR. LVN H said when they first got an order, it would depend upon the doctor and when he wanted the catheter changed the first time. LVN H said, it "might depend on where she came from and the hospital orders." LVN H informed the surveyor if she or another nurse had realized Resident #2's catheter had not been changed, "We should have checked to see (if it had been changed)." LVN H said she had never called to get an order to change Resident #2's Foley catheter, but any shift could call the doctor and get orders for the Foley catheter. LVN H said she never realized Resident #2's catheter had not been changed or noticed there was nothing on the TAR to change the Foley catheter. During an interview with LVN G on 12/12/13 at 10:15 AM, when asked if she had ever changed Resident #2's Foley catheter, LVN G said,"No," she had not. LVN G said there was a nurse on the night shift, who changed the residents' catheters, but she no longer worked for the facility. LVN G said she did not know if Resident #2's catheter had ever been changed and identified RN I as the previous night shift nurse, who may have changed Resident #2's catheter. During an interview with RN U on 12/13/13 at 10:42 AM, she informed the surveyor she worked with Resident #2 on the night shift on Saturday nights only and reconciled the comprehensive orders every month for station two, which included Resident #2. When asked if she had ever changed the Foley catheter, RN U said she did not remember if she had changed it or not. When asked how often a Foley catheter should be changed, RN U replied,"It's usually on the orders to change every 30 days or one time a month." When asked if Resident #2 had any orders for her Foley catheter on her consolidated orders, RN U said she was "not sure if she has an order or not." During the initial tour with LVN G on 12/10/13 at 11:17 AM, Resident #2 was not in her room. LVN G described Resident #2 as alert and oriented with confusion at times. LVN G said Resident #2 was incontinent of bowel but had an indwelling catheter for [MEDICAL CONDITION]. The resident was ambulatory with a rolling walker and was stand by assist with most of her ADLs. On 12/10/13 at 1:15 PM, Resident #2 was observed in her room sitting in a chair. She was well-groomed and dressed appropriately. Resident #2 informed the surveyor she had not been in the facility for very long and had come from another facility. When asked about her Foley catheter, Resident #2 informed the surveyor her catheter leakd sometimes and showed the surveyor her urinary drainage leg bag, which was on her right leg above her knee and had light tea-colored urine in it. When asked, Resident #2 said some of the new girls (CNAs) pulled too hard on the catheter and it leaked (Resident #2 pointed at her Peri area). Resident #2 also informed the surveyor when she had a urinary drainage leg bag for a long time, it would leak sometimes as well. In the Confidential Resident Group Interview on 12/11/13 at 1:30 PM, the attending residents, identified by the facility as alert and oriented, were asked this question: "How do staff members treat the residents here, not just yourselves, but others who can't speak for themselves?" One of the residents reported he/she knew of a resident, who complained out loud about wanting to have her (indwelling urinary) catheter changed, which annoyed the CNAs. The CNAs would then respond to the resident, telling him/her the nurses were supposed to change the catheter, not them (the CNAs). The CNAs would then tell the nurses, who would ignore both the CNAs and the resident. Two other residents agreed with the first resident. They described the resident, who had the catheter as a resident who used a walker and talked loudly. The resident with the catheter was confirmed as being Resident #2. During an interview with LVN G on 12/12/13 at 10:15 AM, she stated Resident #2 had asked to have her catheter bag changed, but since the facility did not have an extra catheter drainage bag, she did not change it. When asked if she had ever changed the catheter, LVN G said,"No," she had not. LVN G said there had been a nurse on the night shift, who changed the residents' catheters, but she no longer worked for the facility. LVN G said she did not know if Resident #2's catheter had ever been changed or not and identified RN I as the previous night shift nurse, who may have changed Resident #2's catheter. LVN G said, to her knowledge, Resident #2 had never complained about her catheter hurting. LVN G said Resident #2's urine used to be amber in color until her physician wrote an order for [REDACTED].#2 ambulated, which was why it was amber-colored. LVN G said at night, the night nurse changed the leg bag to a bedside urinary drainage bag, and in the morning, the night nurse changed it back to the leg bag. When asked about securing Resident #2's catheter, LVN G said she did not know if there was a leg strap on the catheter. Review of Resident #2's Daily Skilled Nurse's Note dated 08/04/13 at 7:00 PM (nurse's signature illegible) revealed the resident's Foley catheter was intact and in place. The note further reflected the resident complained of pain at the catheter site, so the nurse gave Resident #2 [MEDICATION NAME] 2.5/500 mg 1 tab PO, which she tolerated well. Review of Resident #2's Daily Skilled Nurse's Note dated 08/07/13 at 5:00 PM (nurse's signature illegible) revealed the nurse had assessed Resident #2's catheter and noticed blood in the catheter bag. The nurse called Physician K, Resident #2's attending physician, and spoke with NP P, who ordered [MEDICATION NAME] (anti-fungal) 100 mg 1 tab PO X 3 days. Resident #2's Daily Skilled Nurse's Note dated signed by RN I on 08/10/13 at 2:00 AM reflected Resident #2 had a Foley catheter, which was draining pinkish-colored urine and there were no blood clots. Review of Resident #2's Daily Skilled Nurse's Note dated 08/10/13 at 9:00 AM (nurse's signature illegible) revealed the resident's Foley catheter was intact, and her urine was getting clear of blood. Review of Resident #2's Daily Skilled Nurse's Note dated and signed by LVN E on 08/12/13 (no time) revealed Resident #2's Foley catheter was intact and draining light pink urine. The Note further reflected Physician K was notified, and he had instructed the nurse to drain Resident #2's catheter bag and to continue to monitor the resident's urine. Review of Resident #2's Daily Skilled Nurse's Note dated 08/13/13 at 12:00 AM (nurse's signature illegible) revealed Resident #2's Foley catheter was in place to gravity drainage. It further reflected her urine was amber colored, clear and without any odor noted. Review of Resident #2's Daily Skilled Nurse's Note dated 08/13/13 at 12:00 AM (nurse's signature illegible) revealed Resident #2's urine was amber-colored and clear. It also reflected the nurse notified Physician K, and he said to put tape on Resident #2's catheter to prevent it from pulling. Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/14/13 at 12:00 AM revealed Resident #2's Foley catheter was to gravity drainage, and the urine was pinkish colored with"red clumps (clots) visible." Review of Resident #2's Daily Skilled Nurse's Note dated 08/14/13 untimed (nurse's signature illegible) revealed Resident #2's urine color was amber and clear. It further reflected the nurse called Physician K, and he gave a new order for a UA with C&S. Review of Resident #2's Daily Skilled Nurse's Note dated 08/14/13 at 5:00 PM (nurse's signature illegible) revealed Resident #2's Foley catheter was in place with drainage to gravity. It further reflected her urine was amber-colored and clear. Review of Resident #2's Daily Skilled Nurse's Note dated 08/15/13 at 2:00 AM and signed by RN I revealed the RN collected a sample of urine from Resident #2's catheter tubing for the UA C&S using "sterile technique." Review of Resident #2's Daily Skilled Nurse's Note dated 08/15/13 at 5:00 PM (nurse's signature illegible) revealed her Foley catheter was in place to gravity drainage. It further reflected Resident #2's urine was amber-colored, clear and without an odor. Review of Resident #2's physician's telephone orders revealed an order dated and signed by the physician on 08/15/13, which ordered to continue the Foley catheter and to attach it to a urinary drainage leg bag at 6:00 AM every morning and then to a gravity urinary drainage bag every night at 9:00 PM for one month and then re-evaluate. Further review of Resident #2's physician's telephone orders for August, September, October, November and December 2013 failed to reveal any orders resulting from a re-evaluation of the resident's catheter, orders for the Foley catheter and leg drainage bag, any order for the Foley catheter size, a frequency to change the Foley catheter, whether to document I&O, or to irrigate the Foley catheter. Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/16/13 at 2:00 AM revealed Resident #2 was awake, and when the CNA had assessed her, Resident #2's "diaper is wet." The nurses' note further reflected the CNA reported this to RN I as well as the statement, "Her cath hurts." RN I's nurses' note further reflected she went and assessed Resident #2"and noted that Res crys (sic) out with pain when Foley tubing is moved only slightly - Foley bulb deflated and (catheter) removed. Res c/o much discomfort. Obtained a #18 with 10 cc bulb (Foley catheter) and inserted it with minimal discomfort noted...Res passing pink color urine...." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/16/13 at 6:00 AM revealed Resident #2's urine was"pinkish in bag and tubing." It further reflected RN I removed the large bag and placed a leg bag as ordered for day time activity. RN I then wrote"Lg bag Rinsed and hung up in BR." Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/17/13 at 12:00 AM, 08/19/13 at 12:00 AM, 08/19/13 at 6:30 AM, 08/21/13 at 12:00 AM, 08/19/13 at 6:30 AM, 08/22/13 at 5:00 AM, 08/24/13 at 12:00 AM reflected Resident #2's leg bag was changed to a regular urinary drainage bag and/or, depending upon the time, the leg bag was changed to the regular urinary drainage bag. Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/22/13 at 5:00 AM revealed RN I gave Resident #2 some medicine in yogurt and Resident #2 asked why she was being given medicine. RN I told Resident #1 it was antibiotics for her UTI. Resident #2's Daily Skilled Nurse's Notes including 08/24/13, 08/26/13 at 7:00 AM, 08/27/13 at 6:00 AM, 08/30/13 at 12:00 AM, 08/30/13 at 12:00 AM, 08/30/13 at 7:00 AM, 09/02/13 at 12:00 AM continued to reflect the resident's use of either a leg bag for urinary drainage or a large bag. A description of Resident #2's urine was also included occasionally. Review of Resident #2's Daily Skilled Nurse's Note dated 09/04/13 at 9:00 PM (nurse's signature illegible) revealed the nurse notified Physician K (Resident #2's PCP and the facility's Medical Director) there was blood in Resident #2's urine. It further reflected Physician K ordered a UA C&S for in the morning. Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/02/13 at 12:00 AM revealed Resident #2 was awake and restless. It further reflected her incontinent brief was wet. RN I assessed Resident #2's Foley catheter and"determine fluid in bulb low, slowly added more fluid...." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/06/13 at 6:00 AM revealed"Drainage Bag (changed) to leg bag." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/07/13 at 2:00 AM revealed Resident #2 was awake and restless and complained "Feels full. Observed Foley tubing (with) scant urine in it, none in bag. Realigned tubing under Res (R) leg (with) down grade to Bag had to pump tubing to encourage urine to flow...." Review of Resident #2's Daily Skilled Nurse's Note dated 09/10/13 at 9:30 PM (nurse's signature illegible) revealed Resident #2 was on an antibiotic due to UTI, and her urine was"still cloudy in color." Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/11/13 at 12:00 AM, 09/11/13 at 6:00 AM and 09/12/13 at 6:00 AM, 09/13/13 at 6:00 AM, 09/14/13 at 6:30 AM, 09/16/13 at 5:00 AM, 09/19/13 at 12:00 AM, 09/18/13 at 6:30 AM, 09/19/13 at 4:00 AM reflected the resident either had the large urinary drainage bag in place or the leg bag or they were changed. Review of Resident #2's Daily Skilled Nurse's Note dated 09/12/13 at 9:30 PM (nurse's signature illegible) revealed Resident #2's"urine still cloudy...." Review of Resident #2's Daily Skilled Nurse's Note dated 09/19/13 at 10:30 AM (nurse's signature illegible) revealed the nurse"noted amber-colored urine in residents urine bag, urine was drained, resident assisted to sit in her bed and relax because she had been walking around." It also reflected NP P was called and an order was received for a UA C&S for the next day. Review of Resident #2's Daily Skilled Nurse's Note dated 09/19/13 at 4:30 PM (nurse's signature illegible) revealed a CNA informed the nurse they thought Resident #2's"Foley bag was leaking, nurse went to check on it, Foley bag was intact was not leaking...." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/20/13 at 12:00 AM revealed, "Note urine in foley tubing is pink will monitor for Redness." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/20/13 at 7:00 AM revealed RN I informed Resident #2 of the need to collect urine for a UA. The Note reflected "open cath tubing and only 2-3 cc urine...bladder empty at this time." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/21/13 at 12:00 AM revealed Resident #2 "verbalizes her foley is leaking...note tubing is easily moveable in urethra - 6 cc air was added to tubing bulb." Note: The Foley catheter was not changed. Attempts to contact RN I for an interview were unsuccessful. Review of Resident #2's Daily Skilled Nurse's Note dated 09/23/13 at 4:30 PM (nurse's signature illegible) revealed the nurse received the laboratory results of the UA C&S and Physician K was notified. New orders were received: [MEDICATION NAME] (anti-[MEDICAL CONDITION] and for acute UTIs) 150 mg one by mouth two times a day for seven days; [MEDICATION NAME] (for UTIs) 50 mg by mouth two times a day for 10 days; and to repeat the UA C&S three days after the antibiotic was completed two times. Resident #2's Daily Skilled Nurse's Note further reflected Physician K called back and changed the [MEDICATION NAME] to 100 mg by mouth two times a day for 10 days. Resident #2's Nurse's Note dated 09/28/13 at 12:30 PM, 09/28/13 at 2:30 PM, 09/28/13 at 11:30 PM, 09/29/13 at 11:30 AM and 09/29/13 at 4:45 PM all included the resident being on an antibiotic [MEDICAL CONDITION] in her urine. During an interview with ADON MM on 12/15/13 at 12:26 PM, when asked, ADON MM said Resident #2 was not on isolation when she [MEDICAL CONDITION] in her urine because she had a Foley catheter so it was contained. Review of Resident #2's Nurse's Note dated 10/05/13 at 2:00 PM (nurse's signature illegible) revealed Resident #2 was status [REDACTED]." Review of Resident #2's Nurse's Note dated 10/13/13 at 12:00 AM (nurse's signature illegible) revealed Resident #2 "C/O bladder pain...." It further reflected the catheter was draining urine and the nurse informed the resident it may have been pulled when she was out on pass with her family. The nurses' note also reflected Resident #2 received [MEDICATION NAME] 2.5/500 mg for the pain. Resident #2's physician's telephone order dated 10/18/13 reflected an order for [REDACTED]. Review of Resident #2's Nurse's Note dated 11/08/13 at 2:00 AM (nurse's signature illegible) revealed Resident #2 "C/O abd pain...." The Nurses' Note further reflected Resident #2 was medicated with [MEDICATION NAME] 2.5/500 mg for the pain and her Foley catheter was patent and irrigated. On 12/12/13 at 4:00 PM, the surveyor observed Resident #2 ambulating in the hallway. She was well-groomed and dressed appropriately. When asked if her catheter had been changed, Resident #2 said,"No," they had changed the urinary drainage bag but not the catheter itself. During an interview with RN L on 12/13/13 at 9:55 AM, when asked if she had ever worked with Resident #2, she said at least one night a week. When asked if she had ever changed Resident #2's Foley catheter, RN L said, "No," she had not. RN L said she did not change the catheter bags either as"the CNAs change from the bedside drainage bag to the leg bag." RN L said sometimes Resident #2 calls her "to fix it." The leg bag strap would be "too tight," so RN L would loosen it for Resident #2. During a telephone interview with Resident #2's family member on 12/13/13/at 10:09 AM, he/she informed the surveyor Resident #2 had gone to two physician appointments. The family member said another family member had taken Resident #2 to her General Practitioner on 10/07/13 and then to her Oncologist on 11/27/13. The family member said there had been no Urology appointment, but they had been waiting for one, so the Urologist could "fix" the problem Resident #2 was having with her catheter. He/She said Resident #2 "was a very clean lady," and she had complained to the family member about her Foley catheter leaking. The surveyor asked the family member if Resident #2 complained about the Foley catheter bag leaking or if it was leaking in her "private area," and he/she said she had complained about it leaking in her "private area." The surveyor asked him/her if the resident complained about pain, and he/she said,"No," just that it had been leaking about her "private area" and the resident did not like to feel wet even though she wore incontinent briefs. The resident was also very afraid about (urine) odor. When asked whether Resident #2's Foley catheter had been changed since her admission to the facility, the family member said he/she did not think the Foley catheter had been changed since being admitted to the facility. The family member asked the surveyor how often the Foley catheter should be changed, and the surveyor told him/her every 30 days, or once a month was the norm. The family member said,"Well, she (Resident #2) would have told me if they were changing it (Foley catheter) like that." During an interview with RN U on 12/13/13 at 10:42 AM, she informed the surveyor she worked with Resident #2 on the night shift on Saturday nights only and reconciled the comprehensive orders every month for station two, which included Resident #2. When asked if Resident #2 ever complained about pain or her catheter, RN U said,"Yes. Sometimes she (Resident #2) complained about her cath (catheter)." RN U said Resident #2 would sometimes say, "It's not in the right place, and we (staff) would assure her it's in the right place and draining well." When asked if she had ever changed the Foley catheter, RN U said she did not remember if she had changed it or not. When asked how often a Foley catheter should be changed, RN U replied,"It's usually on the orders to change every 30 days or one time a month." When asked if Resident #2 had any orders for her Foley catheter on her consolidated orders, RN U said she was "not sure if she has an order or not." During a telephone interview with LVN T on 12/13/13 at 2:07 PM, the LVN reported she had only worked on station two and taken care of Resident #2 one time. LVN T said Resident #2 had not complained to her about her catheter when she had worked with her that one time. LVN T said she did remember when she had worked a long time ago, Resident #2 said she felt like she"had to pee" but she had not been her nurse so had done nothing about it. During a telephone interview with LVN V on 12/13/13 at 2:16 PM, she informed the surveyor she worked on station two "every now and then." When asked what she would check on Resident #2's Foley catheter, LVN V said she would check the color of her urine. LVN V said Resident #2 had never complained about her catheter. LVN V also said she had never changed Resident #2's catheter. When asked how she would know to change Resident #2's catheter, LVN V said usually, the physician's orders [REDACTED]." When asked why it was the CNAs' job, LVN V said, "Nobody put that on the aides. That's something they've always done. I've never told them to do it." On 12/13/13 at 2:42 PM, the surveyor observed Resident #2 lying flat in her bed on top of her personal blanket with her legs straight, her pants down about her ankles and her incontinent brief pulled down to just above her knees. The surveyor observed LVN B on Resident #2's right side and LVN G on her left side. LVN B had just completed inserting a new Foley catheter, and Resident #2 was moaning. LVN B said she had some urine return, so she reached with her right hand, picked up a syringe and injected some sterile water into a port to inflate the bulb. The surveyor asked LVN B if she had ever replaced Resident #2's catheter before and she said, "No. This was the first time." LVN G was holding Resident #2's hand and comforting her. LVN B picked up and laid the Foley catheter drainage bag onto the floor (not hanging it on the bed frame), picked up the trash and left the room. Resident #2 was upset, because there was no leg bag, and LVN G was explaining to her they would get a new leg bag. LVN G had Resident #2 lift her bottom off the bed and retrieved the sterile drape from under her bottom. Resident #2 became more upset and mumbled to LVN G she needed something. LVN G assumed she wanted a leg bag and told her she would go get her one, but Resident #2 would not put her bottom back on the bed and said she did not want to get anything on her blanket. LVN G kept telling her it would be alright, she just needed to relax as she would get a leg bag soon. The surveyor intervened and told LVN G Resident #2 did not want to get her blanket dirty, so maybe LVN G could get an incontinent pad to put under Resident #2's bottom. Resident #2, still with her bottom up in the air, smiled at the surveyor and said, "You know what I need." LVN G left the room and came back a few moments later with an incontinent brief, placed it under Resident #2's bottom and Resident #2 placed her bottom down on the bed. Review of Resident #2's nurse's note dated and signed by LVN B on 12/13/13 at 2:30 PM revealed, "SN removed old foley catheter...175 cc of cloudy urine...Drain bag attached to side of bed...Pt c/o slight pain during insertion...." Review of Resident #2's next nurse's note dated and signed by LVN G revealed, "late entry 12-13-13 @ 2:00 PM Called ___ (Physician K) received orders for catheter care, to change 16 Fr 5-10 CC Foley catheter Q 6 weeks and PRN, may irrigate Foley (with) 20 cc of sterile water PRN. UA C&S on Monday 12/16/13, record input & output Q shift." During an interview with LVN H on 12/13/13 at 3:50 PM she informed the surveyor she worked with Resident #2 every day Monday through Friday from 3:00 PM - 11:00 PM. LVN H said Resident #2 would complain her catheter was leaking, so LVN H would call NP P and let her know about it. LVN H said NP P told her to monitor it. LVN H said, Resident #2 "had a consult with Urology. I think she had it...." During an interview with LVN Y/Weekend Supervisor on 12/17/13 at 11:00 AM when asked about the admission process when the Resident has a Foley catheter, she said the nurse should call the doctor and see if he wanted to keep the catheter, get an order for [REDACTED]. It has not been happening (not getting orders)." When asked what a nurse should do when a resident like Resident #2 had a [DIAGNOSES REDACTED]. LVN Y/Weekend Supervisor also said the nurses, not the CNAs, were to change the

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for two (Residents #1, #3, #5 and #6) of 19 residents reviewed for quality of care. 1) The facility failed to medicate Resident #3 when he was observed in pain. The resident continued to complain of pain every two hours for two shifts. 2) LVN D twice failed to administer the correct dose of pain medication to Resident #1 when she repeatedly complained of leg pain. LVN D administered one [MEDICATION NAME] 5/325 mg tablet when the ordered dose was two 10/325 mg tablets. 3) Resident #5 received nine doses of [MEDICATION NAME] between 10:00 pm and 11:30 PM (from 03/04/14 to 03/21/14), despite her physician's specific orders that she was not to have the medication at bedtime. No pain assessments were documented and the physician was not notified. 4) Resident #6 received 22 doses of pain medication between 02/04/14 and 03/03/14 with no pre and/or post pain assessments documented. An Immediate Jeopardy (IJ) was initially identified on 03/20/14. While the IJ was removed on03/24/14, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. Failure to intervene appropriately when a resident complains of pain, administer pain medications as ordered by the physician and assess the effects of those medications could affect any of the 50 residents who were assigned to LVNs D, F, O, P, and T and placed them at risk for unrelieved pain, over sedation and poor quality of life. Findings included: 1) Resident #3 was a [AGE] year-old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed Resident #3's cognitive skills for daily decision-making were moderately impaired, decisions poor and required total dependence of staff for his ADLs. This MDS assessment revealed Resident #3 was on scheduled pain medications and required PRN pain medication. Resident #3 had indicators of pain or possible pain observed in one or two days. Review of Resident #3's Care Plan dated 03/20/14 revealed: "PROBLEM - (Resident #3) expresses pain of joints on movement/personal care RESIDENT GOAL - (Resident #3) will be assessed for pain w/routine med pass this eval period APPROACH PLAN 1. Pain meds per physician orders [REDACTED]. 2. Monitor for adverse reaction and effectiveness. 3. Therapy to eval and tx as indicated. 4. Encourage resident to make frequent changes in position. 5. Notify physician/Family of any/all changes. 6. Monitor for causes of increased pain (ie: activity, temperature). -Ask/assess for pain or discomfort w/routine med pass." Review of Resident #3's physician progress notes [REDACTED].Pt indicating having increased back pain ...." Review of Resident #3's consolidated physician orders [REDACTED]. - [MEDICATION NAME] ([MEDICATION NAME]) Patch 50 mcg topically every 72 hours - [MEDICATION NAME] 10 ml every eight hours per [DEVICE] - [MEDICATION NAME] ml every four hours as needed per [DEVICE] for pain. Review of Resident #3's MARs dated March 2014 revealed the [MEDICATION NAME] Patch 50 mcg was initialed as administered on 03/15/14. Further review of this MAR revealed the [MEDICATION NAME] Patch 50 mcg patch was not initialed as administered on 03/18/14. During an observation on 03/20/14 at 4:55 PM, Resident #3 was observed in bed and CNA G was at his bedside. This surveyor was accompanied by the Unit Manager and MDS nurse. When Resident #3 was asked for permission to perform a skin check to ensure he was wearing only one [MEDICATION NAME], he nodded indicating it was. As the skin check proceeded, Resident #3 was observed to be grimacing and wincing with movement. When asked by CNA G if he was in pain, Resident #3 blinked his eyes rapidly and nodded his head. When CNA G told him she would tell his charge nurse, he nodded in agreement. Only one, undated [MEDICATION NAME] was observed on Resident #3's left chest. Review of Resident #3's Nurse's Notes dated 03/20/14 at 5:00 PM revealed, "[DEVICE] infusing well (with) no difficulty patent, (and) intact. Routine meds administered. HOB (up). Abdomen soft non-distended." LVN J signed this note. Review of Resident #3's [MEDICATION NAME] Patch Usage & Disposal Record revealed a [MEDICATION NAME] Patch 50 mcg Patch was applied to Resident #3 on 03/20/14 at 6:00 PM. The Unit Manager signed that she applied the patch. This patch was applied after it was verified by the Unit Manager that the [MEDICATION NAME] scheduled to be applied on 03/18/14 was not applied. She stated the [MEDICATION NAME] last applied was on 03/15/14. Review of Resident #3's [MEDICATION NAME] Narcotic sheet dated 03/20/14 and 03/21/14 revealed the medication was given at the following times: - 03/20/14 at 2:15 AM - PRN dose - 03/20/14 at 6:15 AM - scheduled dose - 03/20/14 at 2:00 PM - scheduled dose - 03/21/14 at 2:00 AM - PRN dose -03/21/14 at 6:00 AM - scheduled dose ... Record review of Resident #3's MAR dated 03/20/14 revealed a scheduled dose of [MEDICATION NAME] was signed as administered at 10:00 PM. During an interview on 03/21/14 at 5:05 PM, CNA G was reminded of the observation with Resident #3 and asked if she had reported his pain to anyone. CNA G stated she reported Resident #3's pain to LVN B immediately after leaving his room. A telephone interview on 03/23/14 at 3:25 PM LVN B stated she was Resident #3's charge nurse on 03/20/14 from 3-7:30 PM. She stated LVN J came in at 6:00 PM to replace her. LVN J stated CNA G did tell her Resident #3 was in pain approximately 6:00 PM. She further stated she was passing medications via a [DEVICE] at the time to another resident and she told LVN J Resident #3 was in pain. An interview on 03/22/14 at 4:25 PM CNA G stated she was Resident #3's CNA on 03/20/14 on the3-11 PM and the 11 P-7AM shifts. The surveyor asked CNA G how Resident #3 was on her shift. CNA G stated, "He (Resident #3) complained of pain every two hours. He is not typically like that." She stated she told LVN J (6-11 PM nurse) that Resident #3 was in pain and LVN J said, "Ok." CNA G stated she told RN M (11 PM -7 AM nurse) that Resident #3 was in pain. The surveyor told CNA G that Resident #3 that Resident #3 did not get any PRN pain medication on 3-11 PM shift and CNA G stated, "No wonder he was hollering. He has never asked me for pain medicaiton so many times. I asked him (Resident #3) if he was in pain, he said yes. I told the nurse every time." CNA G further stated she did not tell nursing management. Review of Resident #3's Nurse's Notes dated 03/20/14 at 9:00 PM revealed, "Routine PRN med administered via G tube. No s/s of distress. Respirations even (and) unlabored. SR (up) x 2. Call light in reach. Reposition for comfort. Incontinent care provided. [MEDICATION NAME] 1.5 infusing well @ 55 cc/hr." LVN J signed this note. An interview on 03/23/14 at 3:25 PM LVN B stated she was Resident #3's charge nurse on 03/20/14 from 3 - 7:30 PM. She stated LVN J came in at 6:00 PM to replace her. LVN J stated CNA G did tell her Resident #3 was in pain approximately 6:00 PM. She further stated she was passing medications via a [DEVICE] at the time to another resident and she told LVN J Resident #3 was in pain. An interview on 03/21/14 at 3:50 PM LVN J stated she came to work approximately 6:00 PM on 03/20/14 to cover for LVN B, who was leaving her shift early. She stated LVN B was Resident #3's charge nurse. The surveyor showed LVN J her Nurse's Note on 03/20/14 at 5:00 PM for Resident #3 and asked her if she started her shift at 6:00 PM why she had an entry for 5:00 PM. LVN J stated, "Don't we have an hour either way? " LVN J stated LVN B told her she had passed all of her [DEVICE] medications (Resident #3 had a [DEVICE]) so she LVN J began passing medications to the residents to other residents, when she started at 6 PM. The surveyor asked LVN J if she was notified by CNA G Resident #3 was in pain and she stated she was not. 2) Review of Resident #1's Physician's Telephone Orders dated 02/26/14 revealed she was to be readmitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #1's admission Nurse's Note dated 02/26/14 at 2:20 PM revealed she was confused but able to make her needs known at that time. Review of Resident #1's Comprehensive Plan of Care dated 03/06/14 revealed she complained of increased pain/discomfort due to leg and generalized pain. Approaches included: "1) Monitor for s/s of increased pain/discomfort-assess resident for possible causes give meds, tx.s, physical and relaxation modalities, etc-assess for relief...." Review of Resident #1's hospital Medication Profile Report dated 02/25/14 revealed the following medications were among those to be continued when she returned to the facility: [MEDICATION NAME] 10/325 mg one tablet every six hours as needed for pain. [MEDICATION NAME] 10/325 mg two tablets every six hours as needed for pain. [MEDICATION NAME] 50 mg every 12 hours as needed for pain. Resident #1's Pain assessment dated [DATE] reflected she had no pain. Review of Resident #1's MAR for February 2014 revealed: An entry for [MEDICATION NAME]-Apap 10-325 two tablets every six hours as needed for pain. The entry was initialed as administered on 02/26/14 at 3:00 PM and 9:00 PM by LVN D. An entry for [MEDICATION NAME] 50 mg every 12 hours as needed for pain. The entry was initialed as administered on 02/26/14 at 8:00 PM by LVN D. The back of the MAR reflected the following entries: 2/26/14 at 3:00 PM: "Resident c/o pain, pain level 8/10, [MEDICATION NAME] ([MEDICATION NAME]) 5/325 admin, pain level at 3:30 PM 6/10." The entry was signed by LVN D. 02/26/14 at 8:00 PM: "Resident c/o pain 8/10, [MEDICATION NAME] 50 mg admin, pain level after 30 mins, 7/10." The entry was signed by LVN D. 2/26/14 at 9:00 PM: "Resident c/o pain, telling, 8/10, [MEDICATION NAME] 5/325 mg admin, pain level @ 9:30(PM), 7/10, ineffective." The entry was signed by LVN D. Review of Resident #1's nurse's noted for 02/26/14 revealed LVN D made no entries related to Resident #1's pain. During an interview on 03/05/14 at 12:45 PM, LVN D explained she was Resident #1's Charge Nurse on 02/26/14 but LVN C was completing the admission orders Kept complaining of pain, her (Resident #1) legs were hurting and she wanted pain medication. I medicated her with [MEDICATION NAME] 5/325 mg at 4:00 PM. An hour later she was still complaining of pain. Every time I passed her room, she was yelling in pain. She told the CNAs to tell me. The CNAs told me she was hurting. She kept yelling throughout my shift. She (Resident #1) said, "Her legs were hurting real bad." When asked why she only administered 5/325 mg when the order and MAR both indicated the dose was two 10/325 tablets, LVN D stated she had seen the dose on the MAR but when she went to the medication cart, her old card was still on the cart (from prior to her hospitalization ) and so she just administered that. When asked why she did not question the dosage on the card as it conflicted with the MAR or check the orders in the chart, LVN D stated, "I didn't think her (Resident #1) pain was legitimate. She is mean all the time. It never occurred to me she was in so much pain. I didn't touch the orders, I just gave her what she had in the cart." When LVN D was reminded this resident had just returned from spending over a month in the hospital due to a wound on her leg, LVN D hesitated then stated, "I didn't think she was in pain." An Interview with Resident #1 on 03/05/14 at 2:30 PM with Resident #1 revealed she could not remember having pain the day she was admitted and her current pain management was effective. During an interview on 03/05/14 at 2:47 PM, the DON was shown Resident #1's MARs and told about the medication error regarding the [MEDICATION NAME]. The DON stated she was not aware of the error and that it should not have happened. She confirmed [MEDICATION NAME] 10/325 mg tablets were kept in the E-kit and LVN D could have easily retrieved the proper dose. When asked how Resident #1's pain should have been handled, the DON stated if a resident complains of pain, they should be assessed and a pain level ascertained. She stated the resident should be medicated if indicated and re-assessed in 30-45 minutes for relief. The DON stated, if the medication was not effective and another medication could not be given, the physician should be called and made aware of all the details surrounding the situation. An observation on 03/05/14 at 3:28 PM revealed [MEDICATION NAME] 10/325 tablets were stocked in the medication room E-kit at Resident #1's nurse's station. 3) Resident #5 was an [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she had no cognitive impairment; was receiving scheduled and PRN pain medications, and she reported she had "occasional" pain rated 4 out of 10 on a 1-10 scale with10 being most severe. Review of Resident #5's Comprehensive Resident Care Plan dated 11/7/13 and reviewed 01/30/14 revealed the following: "PROBLEM: Pain management for Spinal Stenosis, Muscle Spasms Arthropathy and Late Effect [MEDICAL CONDITION] GOAL: (Resident #5) will be at her comfort level within 30 mins of discomfort this eval period. APPROACHES: 1. Assess for pain/discomfort and document 2. Medication per order ... [MEDICATION NAME] (routine & PRN) 3. Document/Notify physician of effects of meds. 4. Will be assessed/asked if in pain/discomfort @ time of Routine Med Pass Q shift ...." Review of Resident #5's physician's Progress Note dated 03/05/14 revealed she had a past medical history of [REDACTED]. The assessment/plan portion of the note reflected: "...DJD-on [MEDICATION NAME]/[MEDICATION NAME] (pain medication) ...." Resident #5's Physician's Telephone Orders dated 02/24/14 reflected: "N/O's 1) D/C [MEDICATION NAME] (sleeping pill) 1 mg PO PRN 2) Add [MEDICATION NAME] 1 mg tab (1) PO q HS Dx: [MEDICAL CONDITION] 3) [MEDICATION NAME] 7.5/325 Give (1) PO BID @ 9A & 6 PM. 4) [MEDICATION NAME] 7.5/325 Give (1) PRN tab in the daytime not at H.S. Q6(hours)" The order was written by LVN F. Resident #5's Physician's Telephone Orders dated 03/05/14 reflected: "Order clarification for Med time change for: ([MEDICATION NAME]) pregabalin 75 mg give 1 cap po BID @ 10:00 AM and 10:00 PM ...." Review of Resident #5's MAR for the month of March 2014 revealed: An entry for "[MEDICATION NAME] 7.5/325 mg 1 PO BID at 10 AM and 6 PM" An entry for "[MEDICATION NAME] 7.5/325 mg 1 PO Q 6 HRS PRN PAIN Give in daytime only NOT HS." The MAR revealed only three PRN doses were signed as administered and those were given in the afternoon hours with pain assessments completed by LVN L. Review of Resident #5's Controlled Substance Record for [MEDICATION NAME] 7.5/325 mg revealed the following doses were signed out in the evening hours: 03/04/14 at 11:30 PM by LVN F 03/11/14 at 11:00 PM by LVN F 03/12/14 at 10:00 PM by LVN F 03/13/14 at 10:00 PM by LVN F 03/14/14 at 10:00 PM by LVN F 03/17/14 at 11:00 PM by LVN F 03/18/14 at 11:00 PM by LVN F 03/19/14 at 11:30 PM by LVN F 03/21/14 at 11:00 PM by LVN F Review of Resident #5 ' s Nurse ' s Notes revealed the following: An undated, untimed entry made by LVN F reflected the following: " Physician R called (with) request to (change) resident [MEDICATION NAME] 7.5/325 to TID @ (sic) she takes it PRN like a routine @ HS. Physician R declined & stated to continue [MEDICATION NAME] 7.5/325 BID 9A & 6P & Give [MEDICATION NAME] 7.5/325 PRN in the daytime not @ HS Q6 (hours). 1) D/C [MEDICATION NAME] 1 mg PO PRN 2) Add [MEDICATION NAME] 1 mg tab PO q HS. Dx. [MEDICAL CONDITION]. Notified_____ RP. OK. " Further review of the Nurse's Notes for February and March 2014 revealed there were no entries related to Resident #5 complaining of pain or requesting medication. Review of Resident #5's Weekly Summary dated 03/05/14-03/11/14 revealed she had "vocal complaints" of "moderate pain" rated "6" out of 10. Primary Diagnosis(es) included: "DM II, Debility, [MEDICAL CONDITION], Chronic Back Pain." The Summary was completed by LVN F. Review of Resident #5's Weekly Summary dated 03/12/14-03/(illegible)/14 revealed she had "occasional" pain rated "6" out of 10. Primary Diagnosis(es) included: "DM II, Debility, PKD (sic), Chronic Back Pain." The summary was completed by LVN F. During an interview on 03/23/14 at 10:45 AM, LVN L, (Resident #5's weekend Charge Nurse) was asked about pain management. He stated if a resident complained of pain, he would administer a pain pill then monitor for effectiveness, if not effective, the doctor should be called. LVN L stated the pre and post pain assessments were documented on the MAR. When asked about Resident #5's pain, LVN L explained she used to get a PRN dose at night but the order changed, He explained she would ask for it every night but when he saw the order changed so she could not have it at night anymore, he took the order to her and sowed it to her. He stated he offered to call the physician for her and she told him not to. She told him she wanted to talk to the doctor herself. LVN L stated, since that time, she had not requested pain medication from him at night any longer. During an interview on 03/23/14 at 1:15 PM, LVN F (Resident #5 ' s 3:00 PM - 11:00 PM Charge Nurse) stated all PRN pain assessments should be documented on the back of the MAR and logged on the Narcotic Sheet. When she was asked about Resident #5's pain management, she stated, "...(Resident #5) hurts all the time, she begs for pain pills at night. I called (Physician R), she was getting it ([MEDICATION NAME]) at night. She would be asking as soon as I walked in and again at 10:00 (PM). She was still complaining so I said I'll see if I can have an order for [REDACTED]. her to have it TID, she said she could have it PRN in the daytime not at bedtime." LVN F confirmed that was when she had written the order on 02/24/14. LVN F stated she had also spoken with Physician R when she came in and had encouraged Resident #5 to speak with her as well. She stated the physician did not change her mind and still did not want the resident to have [MEDICATION NAME] at night. LVN F stated Resident #5 continued to ask for a dose at bedtime and she gave it to her. When asked if she called the Physician first, LVN F replied, "No, I didn't think it was a good order." When shown the routing sleeping pill order and asked if that was maybe why the physician did not want her to have the medication, LVN F replied, " She's been taking it for a long time." When LVN F was again asked if it occurred to her to call the physician all those nights the resident was complaining and ask what she should do, she replied, "No, because it's (Physician R) and her response is not that good ...with call back, it's not that good." A surveyor asked LVN F if she realized she could not give that dose. LVN F replied, "Yeah, I realize that. I shouldn't give her a pill that late." When LVN F was asked if she ever signed the medication out on the MAR, documented any pain assessments during these episodes or made any nursing notes on the matter, she reviewed the documentation and replied, " I guess not. " On 3/23/14 at 3:20 PM, Resident #5 was observed sitting in her room, watching television. At that time, when Resident #5 was asked about her pain management by the facility she stated it was " OK. " When asked whether she had pain at night, Resident #5 replied, " Sometimes it hurts in my back, sometimes not. " When asked whether she was getting pain medication at night, Resident #5 stated she did occasionally and it sometimes helped. When asked whether she had spoken with her doctor about the pain, Resident #5 stated she had and was told there was nothing they could do. When asked who gave her pain medication at night, Resident #5 stated, " Whatever nurse is on. " 4) Resident #6 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed he had clear speech, no cognitive impairment, was totally dependent on staff for his activities of daily living, was receiving PRN pain medication but denied pain at the time of the assessment. Review of Resident #6's Comprehensive Resident Care Plan dated 08/15/13 and reviewed 01/30/14 revealed the following: "PROBLEM: Pain management for Contractures R/T Late [MEDICAL CONDITION]/ [MEDICAL CONDITION] GOAL: (Resident #6) will be free of pain or discomfort/at his comfort level within 30 mins of c/o pain or discomfort thru this eval period. APPROACHES: 1. Medication per order [MEDICATION NAME], Tylenol PRN [MEDICATION NAME] routinely (routine & PRN) 2. Document/Notify Dr. effect of medication. 3. Assess/Document pain level freq and tolerance ...." Review of Resident #6 's physician ' s Progress Note dated 03/05/14 revealed he ...c/o pain back/knee-start scheduled [MEDICATION NAME] & cont. PRN as well ...." Resident #6's Physician's Telephone Orders dated 03/05/14 reflected: "[MEDICATION NAME] 10/325 1 po BID." Review of Resident #6's MAR for the month of February 2014 revealed: An entry for "[MEDICATION NAME] 5/325 mg 1 TAB PO Q 6 HRS PRN MODERATE OT SEVERE PAIN" An entry for "[MEDICATION NAME] 5/325 mg 2 TABS PO Q 6 HRS PRN MODERATE TO SEVERE PAIN " Review of Resident #6's active clinical record, controlled drug record (CDR) and MAR (the document identified by the DON as the location of resident PRN pain pre and post- assessments) for 02/04/14 through 03/03/14 revealed [MEDICATION NAME] 5/325 mg tablets were signed out as administered on the CDR and without documented pre and post pain assessments for the following dates and times: 02/04/14 at 04:00 PM by LVN F 02/05/14 at 04:00 PM by LVN F 02/06/14 at 02:30 PM by LVN O 02/06/14 at 04:00 PM by LVN F 02/06/14 at 08:00 PM by LVN F 02/07/14 at 04:00 PM by LVN F 02/10/14 at 09:00 AM by LVN O 02/11/14 at 04:00 PM by LVN F 02/12/14 at 04:00 PM by LVN F 02/13/14 at 04:00 PM by LVN O 02/13/14 at 04:00 PM by LVN F 02/13/14 at 10:00 PM by LVN F 02/17/14 at 09:00 AM by LVN T 02/17/14 at 04:00 PM by LVN F 02/18/14 at 04:00 PM by LVN F 02/18/14 at 10:00 PM by LVN F 02/19/14 at 04:00 PM by LVN F 02/20/14 at 08:00 PM by LVN F 02/24/14 at 06:00 PM by LVN F 02/24/14 at 04:00 PM by LVN F 02/28/14 at 09:00 AM by LVN T 03/03/14 at 10:00 AM by LVN T During an interview on 03/22/14 at 1:50 PM, Resident #6 stated, "I have a lot of pain." Resident #6 stated his pain was "...sometimes in his knees, sometimes all over." Resident #6 stated his pain "comes and goes" and medication usually helped, but not always that good." During an interview on 03/23/14 at 1:15 PM, LVN F was asked about Resident #6's pain. LVN F stated Resident #6 had chronic pain and asked for medication "around the clock." She stated sometimes he would complain he did not get his pain medication when he did get it. LVN F stated most of the time he complained of pain in his legs and "if you move him, he'll start screaming" When asked if she had ever contacted the physician about Resident #6's "around the clock" pain medication, LVN F stated, "(Physician U) was aware of it, I suppose I could have called." NOTE: Physician U stopped working for the facility on 12/31/14 and was not Resident #6's physician. When asked if she know why she did not sign the medication out on the MAR, LVN F replied, "No." When LVN F was asked how anyone would know whether he was getting any relief, LVN F stated she thought he was. She stated sometimes he would ask for two pills but she would not give it to him because she thought it would over-sedate him. She stated she had taken care of him when he had been given two tablets and he did not want to get up for dinner. When asked whether she had documented that or shared that with anyone, she stated she had not. During an interview on 03/24/14 at 9:58 AM, LVN O was shown Resident #3's MARs and CDRs and asked about his pain assessments. LVN O acknowledged she had failed to document them and stated she should have flipped the MAR and documented his pain before and after medicating him. 5) Review of an undated Medication Pass In-service from an RN/LVN Orientation Book located at the Nurse's Station revealed the following: "Steps to take during the med pass:... 16. Before administering the medication, always check 'The 6 R's' 17. Triple check medications vs. MAR before administering the medications. 18. If any of the 6 R's do not match or if you have any questions about the medication itself DO NOT GIVE THE MEDICATION! Check the chart or call the pharmacy with your concern. The pharmacist would rather you ask a question than a mistake be made...." "DURING THE MEDICATION PASS: 'THE 6 Rs' Before administering any medication, always check the 6 Rs, The right resident... The right drug: verify each drug against the medication administration record (MAR) before administering... The right dose: verify against the MAR ... The right time: administer drugs as instructed on the MAR and within the time frame established by your facility...." "CHECKPOINTS...Related issues...Make sure discontinued medications have been removed from the cart as soon as they have been discontinued...." Review of the facility's Pain Policy and Procedure dated 09/24/12 revealed the following: "Purpose: Resident's pain will be managed at a level that is acceptable to that resident. Policy: 1. A resident will be assessed on admission for pain (location, duration, onset, alleviating/aggravating factors) a. If pain is present it will be assessed for its characteristics...5. Resident will be assessed with [REDACTED]. 6. A pain of any level unacceptable to the resident requires further assessment and follow up. Procedure: 1. Nurses will assess, monitor, anf follow-up on reported verbal, physical, and/or nonverbal signs and symptoms of pain or discomfort ... 5. Review pain management care plan and implement. 6. Update care plan as often as necessary to maintain efficiency. 7. Determine the resident ' s preference for managing pain. 8. Nurse will assess and determine medication history and its effectiveness. 9. Nurse will review pain medicine ordered and its effectiveness to reduce pain to an acceptable level for the resident. 10. Nurse will reassess resident's perception of pain within 1 hour of any intervention and document. 11. Follow up with MD if resident receives no noted relief to perceived pain, for further orders ... 13. Document findings in resident's chart. 14. Communicate pain status if any and interventions used during shift report and 24 (hour) report." 6) An Immediate Jeopardy situation was identified on 03/20/14. On 03/20/14 at 11:30 AM, the Administrator was notified of the IJ, and a Plan of Removal for the IJ was requested. 7) The facility's Plan of Removal was accepted on 03/23/14 at 9:00 AM and contained the following: On March 20th, the Department of Human Services informed this Administrator that Immanuel's HealthCare had been placed in an Immediate Jeopardy due to the failure to adequately assessing a resident for pain. THE FOLLOWING STEPS HAVE BEEN TAKEN TO REMOVE THE IMMEDIATE JEOPARDY: On March 20th This Administrator contacted the Medical Director and informed him. March 21st: DON or Nurse Manager {Unit Manager) will in-service the licensed staff on the rights of the Medication Administration. This in-service will be completed by the end or business on March 22nd, Prior to March 20th (March 6th) Administrator counseled with DON, Nurse Manager and Weekend Supervisor on promptly and efficiently reviewing all initial nursing assessments. Prior to March 20th The attending nurse for Resident #1 had been suspended in early March and has not worked at the facility since. On March 20th Unit Manager and MDS Coordinator began in-servicing/testing the licensed nursing staff on pain management. This in-service will be completed by the close of business Saturday March 22nd. On March 20th Also, Unit Manager, and MDS Coordinator completed an in-house Wong Baker pain assessment on all residents. This assessment included asking the cognitive residents about their pain regiment's effectiveness. This effort was to re-visit and ensure that all residents experiencing pain had an effective pain regiment in place. Prior to March 20th (March 10th) DON in-serviced/ tested the licensed Nursing staff on the new pain management policy. This policy included assessing daily q shift for pain. On March 21st, DON will repeat the new pain policy in-service/testing. This policy includes assessing daily q shift for pain. This in-service will be completed by the close of business on Saturday March 22nd. (SEE POLICY ATTACHED) On March 21st In addition to the pain assessments included in the initial nursing assessment package, and the MDS's Assessments, the review of pain will be added to the daily clinical review for the next 6 months. On March 21st, Director of Nursing and Nursing Manager will meet at the end of EACH day in the Administrator ' s Office to present PROOF that orders, initial assessments ...items from daily nursing round sheet are indeed completed. EACH MONDAY the Weekend Supervisor will meet the Administrator to provide the proof of completed task from the weekend. This meeting will continue through 2014. On the days that I am not in the building the proof will be provided to the CEO. (See copy of the daily nursing round sheet) On March 21st The pain management initiative will be added to the monthly Q. A. agenda with Medical Director for the remainder of 2014. On March 21st all new hires, staff on vacation, out ill ....etc. ... will not be allowed back to work prior to completing all of the above in-services/trainings. On March 22nd, Director of Nursing began in-servicing/testing licensed nursing on the 5 rights of medication administration. This will be completed by March 24th. 8) The following staff were interviewed following their attendance at the facility in-services: LVN J on 03/23/14 at 9:20 AM RN M on 03/23/14 at 10:00 AM LVN L on 03/23/14 at 10:45 AM LVN H on 03/23/14 at 12:05 PM LVN E on 03/23/14 at 12:30 PM LVN I on 03/23/14 at 2:45 PM LVN O on 03/24/14 at 12:30 PM LVN K on 03/24/14 at 12:45 PM LVN Q on 03/24/14 at 3:30 PM When interviewed, staff verbalized learning how often to do pain assessments, what to do when another staff member told them one of their residents was complaining of pain, how to complete pre and post pain assessments and correct documentation after administering a PRN pain medication. The following MA was interviewed following their attendance at the facility in-services: MA N on 03/23/14 at 12:40 PM. When interviewed, MA N verbalized understanding he should always report any resident complaints to the Charge Nurse immediately. He stated the Charge Nurse was responsible for assessing the resident ' s pain before and after medications were given. 9) On 03/24/14 at 10:26 AM, when the DON was asked how she thought the IJ occurred she stated: Regarding Resident #3 missing a [MEDICATION NAME], the nurse was new and she thought she was struggling. The DON stated the next day, the Unit Manager was unable to check MARs because she had to work the floor (take a nurse assignment) and the daily rounds were not done. The DON stated that nurse had since cut her hours and she has had to assist her on her shift. The DON stated she could not explain LVN P other than to say she was a new nurse in the facility and had to work a split hall, which meant working out of different carts, which was difficult. Resident #5 received [MEDICATION NAME] at HS, when it was not ordered she stated, " I

Based on observation, interview and record review, the facility failed to ensure residents received the necessary treatment and services to promote healing and prevent new pressure ulcers from developing for six (Residents #8, #9, #11, #12, #13 and #16) of 16 residents reviewed for pressure ulcers. 1) Resident #9 was re-admitted to the facility on [DATE] with a pressure ulcer on her right outer leg. The staff failed to: A) Provide accurate and timely skin assessments; B) Ensure complete and accurate descriptions of pressure ulcers for continued monitoring; C) Ensure there were physician orders [REDACTED]. D) Notify the physician promptly for treatment orders; and E) Ensure care plans were initiated and carried out. 2) Resident #11 was identified with skin breakdown during a weekly head to toe skin assessment on 10/05/13, but there were no treatment orders until 10/16/13. The facility further failed to: A) Ensure the physician was notified promptly for treatment orders; B) Ensure there were physician orders [REDACTED]. C) Ensure complete and accurate descriptions of pressure ulcer for continued monitoring; D) Ensure care plans were developed timely and carried out; E) Ensure skin assessments were conducted regularly and F) Ensure weekly nursing assessments were completed correctly. 3) Resident #16 developed two Stage II pressure ulcers on her buttocks, which deteriorated to Stage III. The Wound Care Physician changed her treatment order, which the facility failed to implement. 4) Resident #13 was identified with a reddened area on her buttock on 11/21/13. The staff failed to: A) Ensure the Dietician's recommendations were implemented; B) Ensure complete and accurate skin assessments and descriptions were obtained; C) Ensure treatments were not conducted without a physician's orders [REDACTED]. D) Notify the physician promptly for treatment orders; and E) Ensure physician-ordered treatments were implemented. 5) Resident #8 was readmitted to the facility with pressure ulcers to both her great toes and the facility failed to: A) Provide accurate and timely skin assessments; B) Ensure complete and accurate descriptions of the pressure ulcers for continued monitoring; C) Ensure treatments were not conducted without a physician's orders [REDACTED]. D) Notify the physician promptly for treatment orders; and E) Ensure care plans were initiated and carried out. 6) Resident #12 had a pressure area on her right lateral foot and the facility failed to: A) Provide accurate skin assessments; B) Ensure complete and accurate descriptions of the pressure ulcers for continued monitoring; C) Ensure physician-ordered treatments were implemented in a timely manner. D) Ensure LVN G conducted a thorough head to toe assessment. An Immediate Jeopardy (IJ) was identified on 12/12/13. While the IJ was removed on 01/11/14, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. These failures to accurately assess/stage pressure ulcers, consult with the residents' physicians and provide treatments as ordered could affect the facility's 72 residents identified receiving preventive skin care, including Residents #8, #9, #11, #12, #13 and #16, which placed them at risk for further deterioration of existing pressure ulcers and the development of new pressure ulcers, which could result in increased healing time, infection,[MEDICAL CONDITION], discomfort, pain, and the potential need for hospitalization . Findings included: 1) Resident #9's MDS assessment dated [DATE] reflected she was an [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #9 had a BIMS score of 11, indicating she was moderately impaired cognitively. She was totally dependent on staff for bed mobility, transfers and hygiene and required extensive assistance for dressing. The MDS assessment further reflected Resident #9 was at risk for developing pressure ulcers but had no pressure ulcers at that time. Resident #9's most recent Braden Scale assessment for pressure ulcers was dated 08/28/13 and reflected a score of 12, which indicated she was at high risk for developing pressure ulcers. Resident #9's Admission Nursing assessment dated [DATE] reflected the following skin issues: "...Left heel soft eschar intact, R heel soft intact...." There was no mark on the body diagram or entry noted on the right leg. Resident #9's Monthly Consolidated Orders for September 2013 reflected the following handwritten note written across the top: "MD Please compare hosp list before signing 8/31/13. Review" The orders were signed by ADON MM on 08/31/13 and by the attending physician on 09/05/13 and included: "Cleanse Rt heel w/ NS, pat dry, apply calcium alginate, silver absorbing agent collagen dressing w/ santyl, cover with dry dressing BID. Cleanse blister on Lt calf w/ NS, pat dry, apply skin prep bid." Resident #9's Physician's Telephone Orders dated 08/29/13 reflected: "...Continue everything on TARS...." Resident #9's TAR for September 2013 reflected the following entries: "EZ boot to be worn in bed and chair to offload wound, float heels in bed to offload wound." The treatment order was signed as completed every shift. "Cleanse Rt heel w/ NS, pat dry, apply calcium alginate, silver absorbing agent collagen dressing w/santyl, cover with dry dressing BID. Cleanse blister on Lt calf w/ NS, pat dry, apply skin prep bid...." The two previous treatments were never signed as completed and both treatments had handwritten notes, which reflected: "DC 09/13/13." Review of Resident #9's Physician Telephone orders revealed no order to discontinue the treatments Resident #9's Care Plan dated 09/19/13 reflected she was totally dependent on staff and required extensive assistance for completion of ADLs related to her debility. Approaches included: "Monitor skin weekly and document. Notify physician of changes." Resident #9's Care Plan dated 09/24/13 reflected she had a Stage II decubitus (pressure) ulcer on the middle of her right lower leg, which measured 2.1 cm x 1.3 cm x 0.2 cm. Approaches included: "Treatment (blank line) as ordered. Notify Dr. of ineffectiveness of treatment... Document wound appearance and notify Dr of S/SX of infection... Pressure relieving pillows to offload...." The Care Plan was last updated on 12/05/13 and reflected the pressure ulcer measured 1.8 cm x 0.5 cm x 0.1 cm and to "Cont. tx per order." The Care Plan was signed by the MDS Coordinator. In an interview on 12/11/13 at 4:30 PM, the MDS Coordinator was asked why there was no Care Plan for Resident #9's pressure ulcer prior to 09/24/13. The MDS Coordinator stated she was unaware of the pressure ulcer prior to 09/24/13. Resident #9's Nurse's Notes reflected on the following entries related to her dressing changes: Resident #9's Nurse's Notes reflected on 09/24/13 at 10:30 AM: "CNA notified Charge Nurse that resident has an open area to R calf 2.1 x 1.3 x 0.2 cleaned (with) NS applied Collagen & [MEDICATION NAME] dressing. (responsible party) called (phone number) & notified of (change) in condition." Signed by LVN D. NOTE: There were no further entries indicating the physician was notified or orders obtained. Resident #9's Physician's Progress Notes reflected she was last seen by NP O on 10/15/13. The Progress Note dated 10/15/13 reflected no indication she had pressure ulcers. Resident #9's Nurse's Notes reflected on 10/28/13 at 10:00 AM: "NO (new order) clean R heel NS pat dry apply silver hydrogel, collagen, & dry dressing Q day (responsible party and phone number) informed of new area on foot." Signed by LVN D. Resident #9's Physician's Telephone Orders dated 10/28/13 reflected an order to clean the right heel with normal saline, pat dry, apply silver hydrogel, collagen dressing and apply a dry, protective dressing daily. Review of Resident #9's Treatment Orders for November 2013 revealed there were no pressure ulcer treatment orders or preventative orders at all. Resident #9's Nurse's Notes reflected on 11/02/13 at 2:00 PM: "Assisted resident back to bed after lunch. Tx done to wounds in R heel & R leg. Moderate amount of blood noted. Kept dry and comfortable." Signed by LVN T. Resident #9's Nurse's Notes reflected on 11/03/13 at 11:00 AM: "...Tx to R heel and R leg done. Small amt of drainage & blood noted. Heel protectors on resident." Signed by LVN T. Resident #9's Nurse's Notes reflected on 11/09/13 at 11:00 AM: "...Tx done to R leg and heel, heel protectors on bilateral heels...." Signed by LVN T. Resident #9's Nurse's Notes reflected on 11/10/13 at 11:00 AM: "...Tx to R leg and heel done...." Signed by LVN T. Resident #9's Nurse's Notes reflected on 11/11/13 at 8:15 AM: "...wound care to R heel given...." Signed by LVN D. Resident #9's Nurse's Notes reflected on 11/15/13 at 11:00 AM: "Repositioned wound care given ? c/o pain. Podus boots on bil ft." Signed by LVN D. Resident #9's Nurse's Notes reflected on 11/16/13 at 10:00 AM: "...L heel and leg dressing. ? odor noted. Small amount of drainage, blood stain observed." Signed by LVN T. Resident #9's Nurse's Notes reflected on 11/22/13 at 7:40 AM: "...Dressing (change) to R heel...." Signed by LVN D. Resident #9's Nurse's Notes reflected on 11/30/13 at 11:00 AM: "Tx to L heel & leg done. Kept dry and comfortable." Signed by LVN T. Resident #9's Treatment Orders for December 2013 reflected an order to cleanse her right heel with normal saline, pat dry, apply silver hydrogel, collagen dressing and apply a dry, protective dressing daily. The order date was 10/28/13. There were no orders related to the pressure ulcer on her right calf. Resident #9's Nurse's Notes reflected on 12/01/13 at 11:00 AM: "Dressing to L heel and leg changed. Small amt of drainage noted." Signed by LVN T. Resident #9's Nurse's Notes reflected on 12/07/13 at 11:00 AM: "..L heel and leg tx done...." Signed by LVN T. Resident #9's Nurse's Notes reflected on 12/08/13 at 11:00 AM: "...Dressing to the wound changed. Yellowish drainage noted. Incontinent care provided. Kept dry and comfortable." Signed by LVN T. Resident #9's Nurse's Notes reflected on 12/10/13 at 1:00 PM: "...This nurse observe a wound on the left leg measure 2.5 cm x 2 cm x 0.5 cm. (Physician X) notify and talked to (NP O), an order for [REDACTED]. Resident #9's Nurse's Notes reflected on 12/11/13 at 10:15 AM: "Spoke (with) (NP O) for (Physician X). Order clarification to continue previous order for R calf. Cleanse (with) NS, pat dry apply silver hydrogel, collagen, cover (with) dry protective dressing QD...." Signed by LVN D. Resident #9's Weekly Summaries dated 10/24/13, 10/31/13, 11/07/13, 11/21/13, and 11/28/13 all reflected "None" under the section provided to identify skin conditions. The Summaries were completed by LVN W, Resident #9's 3:00 PM to 11:00 PM Charge Nurse. . During an interview on 12/11/13 at 6:55 PM, LVN W stated she was aware Resident #9 had pressure ulcers but did not perform the dressing changes. She stated she had been told by LVN D that she (LVN D) was in charge of treatments. When LVN W was shown the Weekly Summaries, which she had completed, and was asked why no skin issues were identified, LVN W stated, "That's my fault." Resident #9's Weekly Skin Assessments dated 10/09/13 through 12/04/13 reflected the following answers to the entry: Pressure, Diabetic, Venous, Arterial Ulcer, or Incision- __No, __Yes, Describe: 10/09/13: "No" was checked. 10/16/13: "Yes" was checked."Coccyx" 10/23/13: "No" was checked. "coccyx." 10/30/13: "Yes" was checked,"Coccyx, Bi-heels." 11/06/13: "Yes" was checked. "Coccyx, heels." 11/13/13: "Yes" was checked. "Coccyx, heel." 11/20/13: "Yes" was checked. "Coccyx, heel." 11/27/13: "No" was checked. "R-leg, heel." 12/04/13: "Yes" was checked "Coccyx, R-leg, L heel." The weekly assessments were signed as completed by LVN S, Resident #9's 11:00 PM to 7:00 AM Charge Nurse. During an interview on 12/13/13 at 11:15 AM, LVN S was asked about his weekly skin assessments of Resident #9. LVN S stated when he completed a skin assessment, he did not remove dressings if they were intact. LVN S stated he had changed Resident #9's dressing several times. LVN S was asked how he knew what treatment to apply to the pressure ulcer since there were no treatment orders. LVN S responded when there was no order in the book, he put Calcium Alginate on the wound or triple antibiotic ointment (TAO). When asked why he would use those treatments, LVN S stated, "TAO you can use for everything. I see what's on it and use that." When LVN S was asked whether he had reported the issue to anyone, he stated he told the afternoon Charge Nurse there were no orders. When asked why he did not call the physician himself, LVN S stated, "No, we have someone who does the skin with the doctor every week." On 12/10/13 at 11:05 AM, during initial tour with LVN A, Resident #9 was observed sleeping in her bed. LVN A stated she was not Resident #9's usual Charge Nurse but was covering the hall that day. She identified the resident as alert and interviewable and possibly having a pressure ulcer on her heel. There was a sign above the resident's bed, which reflected: "Boots must be worn on this patient at all times, thanks for your cooperation." Observation on 12/10/13 at 1:46 PM with LVN A and CNA M revealed Resident #9 was lying in bed awake and she was alert. She had a large, soft boot on her right leg and a hard, white plastic brace on her left leg, which was open in the front and extended from her upper calf past her toes. Her left leg was completely turned inward toward her right leg. The brace was removed and was observed to have two inflatable air chambers along the inside walls of the brace. The air chamber along the medial wall of the brace had very little air within it, providing no protection to Resident #9's leg from the hard surface of the brace. The inside of Resident #9's left leg was pink and wrinkled where it lay in the brace. When asked who was responsible for ensuring the brace was properly inflated, CNA M stated she thought the Therapy Department monitored and cared for the boot. LVN A stated she did not know how to care for the brace. At that time, Resident #9's right heel dressing was removed and revealed a pressure ulcer approximately 1.0 cm X 0.8 cm. Wound care was given as ordered. A dressing was also observed on Resident #9's right outer, lower leg, which was dated 12/08/13 (two days earlier). When queried about the dressing, LVN A stated she knew nothing about it. LVN A removed the dressing and revealed a pressure ulcer with a moderate amount of beige-colored drainage both within the wound bed and on the dressing. The edges of the pressure ulcer were completely macerated and the wound bed could not be visualized. LVN A stated she did not know about the pressure ulcer. LVN A cleaned the pressure ulcer with saline, measured the pressure ulcer at 2.5 cm x 2.0 cm x 0.5 cm. LVN A said she was going to apply a clean, dry dressing and call the physician. During this time, CNA M stated she knew about the pressure ulcer and explained it began as a blister caused by a brace Resident #9 used to wear, which was similar to the brace on Resident #9's left leg. She stated she thought the blister started two to three months ago, healed, and then reopened. She stated whenever she showered Resident #9, she would tell her nurse, and the nurse would change both dressings. LVN A then stated there was no treatment ordered for that pressure ulcer. At that same time, when Resident #9 was asked whether she had seen the wound doctor, she stated she had not. CNA M explained Resident #9 used to go to [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday but her schedule changed to Monday, Wednesday and Friday; and the wound care physician only came on Wednesdays. Resident #9 confirmed the wound care physician had not seen her (Resident #9) since her pressure ulcer had reopened. During an interview on 12/10/13 at 4:38 PM, LVN A informed the surveyor she had obtained an order for [REDACTED]." When asked how the wound care physician was supposed to see Resident #9 when he only came to the facility on Wednesday, her [MEDICAL TREATMENT] day, LVN A stated she did not know. She stated the Doctors were aware the wound care physician only saw the residents on Wednesday. When LVN A was then asked whether she reminded the physician of that fact when the order for the wound care consult was obtained, she stated she did not. On 12/10/13, the DON was asked to provide Resident #9's pressure ulcer tracking and surveillance records to the survey team. Review of the weekly skin assessment records dated from 09/02/13 through 11/06/13 revealed there were no entries related to Resident #9. During an interview on 12/10/13 at 2:30 PM, the DON was asked why Resident #9 was not represented in the pressure ulcer surveillance reports. The DON explained the lists represented only the residents who were seen by the wound care physician. She stated Resident #9 was not seen by the wound care physician because she was out at [MEDICAL TREATMENT] on those days. When asked how residents with pressure ulcers were treated if they had [MEDICAL TREATMENT] or any other scheduling conflicts with the wound care physician's visits, the DON stated the primary care physician provided the orders. During another interview on 12/10/13 at 3:30 PM, the DON was asked if she kept her own surveillance records of pressure ulcers in the facility to monitor residents who were not seen by the wound care physician. The DON stated she received report daily and the nurses gave her a sheet with the pressure ulcer measurements. She stated she was still looking for Resident #9's sheet and had been unable to locate it. The DON stated Resident #9 was the only resident with a pressure ulcer, who was not seen by the wound care physician. During an interview on 12/11/13 at 8:15 AM, LVN D, Resident #9's usual 7:00 AM to 3:00 PM Charge Nurse, was asked about Resident #9's right leg pressure ulcer. LVN D stated the pressure ulcer started as a blister caused by a hard plastic "ski-boot" style brace the resident was wearing at the time. She stated Resident #9 was sent to the hospital due to her blood pressure, and when she returned, it was an open pressure ulcer. When asked about documentation, LVN D stated she documented pressure ulcers on Wednesdays and kept the information in a separate folder. LVN D stated she would provide the information. When asked about the treatment for [REDACTED]. LVN D then stated she had "corrected" the order obtained the day before by LVN A. When asked when she obtained the treatment orders, LVN D stated she would look back and get the exact date. (NOTE: the order was never found.) When LVN D was asked where she documented her treatments, she stated she documented them in the TAR. When told there was no entry for Resident #9's leg pressure ulcer, LVN D stated she "saw that. It's on there now." LVN D then stated she documented in the nurse's notes when the treatments were done. When told there were no entries found there either, LVN D stated she would check. When asked whether a physician had seen Resident #9's right leg pressure ulcer, LVN D stated the wound care physician was treating Resident #9's pressure ulcers until her [MEDICAL TREATMENT] days changed. When asked when that happened, LVN D reviewed Resident #9's clinical record and determined the [MEDICAL TREATMENT] schedule changed on or around 09/13/13. The clinical record also reflected Resident #9 returned from the hospital on [DATE]. Review of the physician's orders [REDACTED]. During the same conversation, LVN D located a Pressure Ulcer Record for Resident #9. The Record reflected two pressure ulcers: a pressure ulcer to the right, outer lower leg was identified on a body outline as "Site A" with the date first observed as 09/24/13. The pressure ulcer was identified as Stage II, 2.1 cm x 1.3 cm x 1.2 cm, no drainage or odor. LVN D stated she measured the pressure ulcer that morning and documented it on the Record. The entry for the morning of 12/11/13 reflected the pressure ulcer measured 1.3 cm x 0.5 cm x 0.1 cm, Stage II with no drainage. (Note: observation of the pressure ulcer on 12/10/13 revealed the pressure ulcer had beige-colored drainage and the base of the pressure ulcer could not be visualized due to the drainage.) When LVN D was asked why the pressure ulcer documentation was not started until 09/24/13, she replied, "When I got this sheet, that's when I started charting on this sheet. I didn't have this sheet before." When asked where she charted before obtaining the sheet, LVN D replied, "I didn't chart anywhere." LVN D explained she was a CNA before Resident #9 went to the hospital and was transitioning to a nursing position and when Resident #9 returned from the hospital, she was her nurse. LVN D was then asked, since she knew about Resident #9's pressure ulcer, did she ever call to get orders. LVN D looked through Resident #9's clinical record and stated she had spoken to NP O. LVN D stated, "When she (Resident #9) came back, I just continued with her previous orders." When asked if she ever checked to see if the orders were written, LVN D replied, "No." During an interview on 12/11/13 at 11:06 AM, NP O stated she was not sure when she became aware of the pressure ulcer on Resident #9's leg. She confirmed her last note about the resident was dated 10/15/13. She stated she was at the facility on 12/05/13 but she did not see Resident #9. NP O stated she remembered the staff talking to her about a pressure ulcer that day, but she could not say which pressure ulcer specifically. NP O stated she did not know if she was aware the wound care physician was not treating Resident #9. She could not recall ever looking at Resident #9's pressure ulcers. When asked whether LVN D had called her about treatment orders, NP O confirmed the LVN had. NP O stated, "I don't know that I was made aware until yesterday that it had progressed. I did talk to them (staff) on the fifth (of December)." In an interview on 12/11/13 at 3:30 PM, when the DON was asked whether she had seen Resident #9's pressure ulcer, she stated she had seen it the week before. When asked if she had documented anything about the pressure ulcer, she stated she had not. The DON explained she sometimes made rounds with the wound care physician or would watch the nurses perform dressing changes. When queried what she typically monitored when watching her nurses, the DON stated she wanted to see how the pressure ulcer was progressing, how the pressure ulcer was reacting to the treatments and how the nurse performed. When asked how she could have monitored any of those criteria for Resident #9 when there were no orders for treatment and no documentation or measurements readily available, the DON stated she knew it was smaller than when she saw it previously. When asked when she saw it previously, the DON replied, "On the calf? I can't say." During a meeting with the Administrator and the DON on 12/11/13 at 5:30 PM the survey team shared their concerns related to the facility's wound/pressure ulcer program and Resident #9's pressure ulcers, particularly the lack of treatment orders; inaccurate, sporadic documentation of the pressure ulcer and the failure to ensure the physician visualized the pressure ulcer. The Administrator stated she met with her nursing staff every day. She explained during the meeting, which was attended by the DON, ADON MM and the MDS Coordinator, each nurse reported about their residents. The Administrator stated she spoke with LVN D specifically about Resident #9 and the only pressure ulcer ever mentioned was the one on her heel. She stated the pressure ulcer on her lower leg was never mentioned and she had no idea Resident #9 had a second pressure ulcer. The DON was asked why, if she knew about the pressure ulcer, she did not correct LVN D during the meetings. The DON stated she only learned about the pressure ulcer two weeks ago. When asked why it was not mentioned last week, the DON did not answer. On 12/12/13 at 10:30 AM, Medical Director/Physician K, accompanied LVN D and the surveyor to Resident #9's room to assess her pressure ulcers. Upon entering the room, Resident #9 was observed with her right foot dangling off the bed wearing only a sock. Her left foot was also only wearing a sock, and her heel was on the bed. A pillow was beneath her knees. When LVN D was asked by the surveyor where the resident's heel protectors were, she did not reply. The surveyor located Resident #9's heel protector boots across the room, on a chair beneath a bedspread. When Physician K observed the pressure ulcer, he stated it was an old pressure ulcer, which had reopened. He added there was slough (soft, dead tissue) within the pressure ulcer causing it to be unstageable. Physician K ordered a treatment of [REDACTED]. LVN D measured the pressure ulcer at that time, only measuring the inner part of pressure ulcer and stated the pressure ulcer measured 1.7 cm x 1.2 cm. The surveyor questioned why the macerated edges were not included in the measurement, and Physician K instructed LVN D to measure the entire pressure ulcer. At that time, the pressure ulcer measured 2.2 cm x 2.5 cm. Resident #9 was observed again on 12/12/13 at 4:55 PM. She was in bed with both legs flat on her mattress with no offloading or heel protection. Resident #9 stated she had not had her "boots" on at all since the surveyor and LVN D were in earlier with the doctor (six hours earlier). When asked if she ever refused to wear the boots, Resident #9 stated she did not mind wearing the soft one, but the hard plastic one hurt her leg. Resident #9 stated she got to look at the pressure ulcer on her leg, and "It looked bad." During an interview on 12/13/13 at 8:10 AM, LVN D was asked whether she ever went back to check on Resident #9 on 12/12/13 to ensure she was wearing her heel protection and was positioned properly. LVN D stated she did go check on her but the resident was in bed, and "I didn't pull the cover back to look. I know they are on today (12/13/13)." During an interview on 12/12/13 at 2:05 PM, LVN T, Resident #9's weekend Charge Nurse, stated she changed the dressing on Resident #9's pressure ulcers on her right leg and heel. When asked what treatment she provided on the resident's leg, LVN T stated she applied Collagen, Hydrogel and a dressing. She explained she did the treatments as instructed by LVN D. When asked why she did not call the physician herself, LVN T stated she was told by LVN D it was what the doctor wanted. LVN T stated she had told LVN D there were no orders and the TAR needed to be fixed. LVN T stated she later told the DON to remind LVN D to get orders but it had not happened. (Note: On 12/12/13 at 10:30 AM, Physician K ordered a daily treatment of [REDACTED].) A Quick Reference Guide for Pressure Ulcer Treatment developed by the European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Ulcer Advisory Panel (NPUAP), copyright 2009, pages 26 reflected the following: Hydrogel Dressings: Use for treatment of [REDACTED]. Alginate Dressings: Use for the treatment of [REDACTED]. Retrieved on 01/16/14 from http://www.santyl.com/ - Santyl (ointment) "helps remove nonliving tissue without harming granulation (healing) tissue." In an interview on 12/17/13 at 11:00 AM, LVN Y, Weekend Supervisor, stated one of her duties was no make sure treatments were being done. When asked how she knew who had wounds/pressure ulcers, LVN Y stated the DON called her and gave her a report and left a list in the Weekend Supervisor folder. LVN Y further stated she looked in the treatment book to ensure the correct treatments were being done. When asked what she knew about Resident #9, LVN Y stated she knew the resident had a pressure ulcer on her heel but was unaware of a pressure ulcer on her leg. The DON had not informed her about it. LVN Y stated she had seen the heel pressure ulcer but never noticed the dressing on her lower leg. She stated she had since heard the weekday nurses were changing the dressing. 2) Resident #11 was a [AGE] year-old female, readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed the resident was severely impaired for cognitive skills for daily decision-making, was totally dependent on staff for bed mobility and had two Stage III pressure ulcers. Review of a "Detail Admission/Discharge Report" dated 12/12/13 for Resident #11 revealed the resident was: -- admitted to the facility on [DATE], -- Transferred to the hospital on [DATE], -- Readmitted to the facility on [DATE], -- Transferred to the hospital on [DATE] and -- Readmitted to the facility on [DATE]. Resident #11's care plan dated 09/15/13 reflected: "PROBLEM: (Resident #11) is at risk for developing Wounds D/T debilitated state/DX AEB Diabetes Mellitus, Contractures and immobility deficit. GOAL: (Resident #11) will not develop wounds this eval period. APPROACHES: 1. Assess skin and document findings q week per wound protocol 2. Reposition with pillows as positioning devices q2h and as needed 3. Shower per shower protocol. Dry well and apply lotion 4. Feedings as ordered 5. Pressure relieving devices as needed: Mattress, W/C Cushions 6. Gentle Passive ROM with personal care daily 7. Medications as ordered 8. Dietary Consult as indicated 9. Not (notify) Dr./RP of change in condition." Review of Resident #11's "Weekly Skin Assessment" dated 10/05/13 revealed: Skin: Warm and Dry were both checked Skin Tears: "No" was checked Bruises: "No" was checked Abrasions: "No" was checked Incisions: "Yes" was checked - "If Yes, describe all areas and location:" GT site was hand written in. Rash: "No" was checked Pressure, Diabetic, Venous, Arterial Ulcer, or Incision: "Yes" was checked. "Describe" Coccyx was hand written in. LVN S signed this assessment. Review of Resident #11's Nurse's Notes dated 10/05/13 revealed no mention of an open area/pressure ulcer on the resident's coccyx. In an interview on 12/13/13 at 11:25 AM, the surveyor reviewed Resident #11's "Weekly Skin Assessment" dated 10/05/13 with LVN S, which he completed. LVN S stated, "I think she (Resident #11) came back from the hospital with it (Pressure ulcer)." LVN S documented Resident #11 had a pressure ulcer on her coccyx, and he stated he did not describe the pressure ulcer on any of the facility documents. "I just change the dressing. I clean the wound with normal saline; sometimes I put a little TAO and a dressing on it (pressure ulcer), to cover it so it doesn't get infected. I do that when the dressing is dirty and when I do my weekly skin assessments. I look for physician (treatment) orders and if there is not an order, I do the TAO." The surveyor asked LVN S if he considered calling the physician if there were no treatment orders, and LVN S stated, "No," we have a wound nurse in the house (facility). I call her sometimes." The surveyor asked who

Based on observation, interview and record review, the facility failed to ensure based on the resident's comprehensive assessment two (Residents #2 and #8) of three residents reviewed with indwelling urinary catheters had a clinical condition demonstrating that catheterization was necessary and one (Resident #22) of four residents reviewed for UTIs who were incontinent received appropriate treatment and services for urinary tract infections. 1. Resident #2: a) Had no orders for changing her indwelling Foley catheter, the size of catheter to use, and I & O from her admission on 07/29/13 to December 2013 until surveyor inquiry in December 2013; b) Did not have her indwelling Foley catheter changed from August through December 2013 (for four months) until surveyor inquiry in December 2013; c) Had staff using the same leg urinary drainage bag (for day) and large urinary drainage bag (for night), cleaning and rinsing them daily in the resident-shared bathroom even when the resident had a urine infection [MEDICAL CONDITION] until surveyor inquiry in December 2013; d) Had three UTIs within two months of admission; e) Had a fourth UTI in October 2013, which was diagnosed per a UA, but there was no follow-up C&S done and/or antibiotic ordered for the UTI until surveyor inquiry in December 2013; f) Had a urinary consult ordered on [DATE], which was not done until surveyor inquiry in December 2013. These failures caused Resident #2 pain and discomfort, continued urinary catheterization, and repeated UTIs, decreased socialization, embarassment at urinary odor and loss of quality of life; and placed Resident #2 at risk [MEDICAL CONDITION], dehydration, injury to the urinary tract, and loss of bladder function, resulting in the need for permanent urinary catheterization, repeated use of antibiotics, the need for stronger (and more expensive) antibiotics and the need for hospitalization . These failures could have affected all 42 residents residing on station two. 2. The facility failed to obtain orders for Resident #8's indwelling urinary catheter when she was readmitted to the facility: for changing the catheter, the size of catheter to use, catheter care and for monitoring I&O and for Resident #8 who was admitted to the facility with an indwelling catheter. After surveyor inquiry, the indwelling urinary catheter was discontinued. These failures affected Resident #8 by failing to ensure the resident needed a catheter and received the care she needed because she had an indwelling urinary catheter, but no orders for it and placed her at risk for infection [MEDICAL CONDITION], pain and discomfort, the need for lab tests and medication and possible hospitalization , resulting in loss of quality of life and decreased health and wellness, and or causing death. This failure could have affected the three residents in the facility, who had indwelling urinary catheters. 5. The facility failed to administer [MEDICATION NAME] to Resident #22, which was needed to treat the infection of E. coli in her urine in September 2013. This failure could have caused Resident #22 to become septic, increasing her discomfort, the need for medication, the need for possible hospitalization , and or causing death. This failure could have affected the 33 residents on station two who were administered medications by MA EE. An Immediate Jeopardy (IJ) was identified on 12/13/13. While the IJ was removed on 01/11/14, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm, that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. Findings included: 1) The Face Sheet dated 08/01/13 reflected Resident #2 was admitted to the facility on [DATE] with diagnoses, which included but were not limited to Bacterial Pneumonia, Difficulty in Walking, and a History of Respiratory Disease. Resident #2 was a [AGE] year-old-female admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Further review of this assessment revealed Resident #2's cognitive skills for daily decision making were moderately impaired. Resident #2 had an indwelling catheter and was always incontinent of bowel. Resident #2 required extensive assistace of one person for bed mobility, transfers, locomotion and was totally dependent of one person for dressing, eating, and toileting. During an interview on 01/07/14 at 4:00 PM, the MDS Coordinator stated she was unable to find any care plans for Resident #2. Review of Resident #2's Admission Nursing assessment dated [DATE] revealed the resident had a "Foley in place." (The nurse's signature was not legible.) It further reflected she had an 18 French 30 cc balloon catheter, and her urine was yellow and cloudy. Review of Resident #2's admission orders [REDACTED]. Review of Resident #2's consolidated physician's orders [REDACTED]." Note: There was no order for the use of [REDACTED]. During an interview with the DON on 12/13/13 at 11:10 AM, she was asked what her expectations were when a resident had a Foley catheter. The DON informed the surveyor when a resident had a Foley catheter, she would expect them to document the resident's I & O, catheter care, and color and consistency of the urine. When asked what she meant about catheter care, the DON said to clean the Foley catheter tubing and make sure it was not "gunky." When asked about physician's orders [REDACTED]. physician's orders [REDACTED]. During an interview with LVN H on 12/13/13 at 3:50 PM she informed the surveyor she worked with Resident #2 every day Monday through Friday from 3:00 PM - 11:00 PM. When asked if she had ever changed Resident #2's Foley catheter, LVN H said,"No. I haven't put in a new Foley but I changed the (urinary drainage) bag." When asked what a nurse was supposed to do when a resident had a catheter, LVN H replied they would get an order from the doctor to change the catheter "every month on this date at this time." LVN H told the surveyor the facility policy was usually for the night shift to change the catheters. LVN H said if she had received the order, but "I didn't," she would include it on the TAR, and if she admitted a resident with a Foley catheter, she would get the order to change it and write it on the TAR. LVN H said when they first got an order, it would depend upon the doctor and when he wanted the catheter changed the first time. LVN H said, it "might depend on where she came from and the hospital orders." LVN H informed the surveyor if she or another nurse had realized Resident #2's catheter had not been changed, "We should have checked to see (if it had been changed)." LVN H said she had never called to get an order to change Resident #2's Foley catheter, but any shift could call the doctor and get orders for the Foley catheter. LVN H said she never realized Resident #2's catheter had not been changed or noticed there was nothing on the TAR to change the Foley catheter. During an interview with LVN G on 12/12/13 at 10:15 AM, when asked if she had ever changed Resident #2's Foley catheter, LVN G said,"No," she had not. LVN G said there was a nurse on the night shift, who changed the residents' catheters, but she no longer worked for the facility. LVN G said she did not know if Resident #2's catheter had ever been changed and identified RN I as the previous night shift nurse, who may have changed Resident #2's catheter. During an interview with RN U on 12/13/13 at 10:42 AM, she informed the surveyor she worked with Resident #2 on the night shift on Saturday nights only and reconciled the comprehensive orders every month for station two, which included Resident #2. When asked if she had ever changed the Foley catheter, RN U said she did not remember if she had changed it or not. When asked how often a Foley catheter should be changed, RN U replied,"It's usually on the orders to change every 30 days or one time a month." When asked if Resident #2 had any orders for her Foley catheter on her consolidated orders, RN U said she was "not sure if she has an order or not." During the initial tour with LVN G on 12/10/13 at 11:17 AM, Resident #2 was not in her room. LVN G described Resident #2 as alert and oriented with confusion at times. LVN G said Resident #2 was incontinent of bowel but had an indwelling catheter for [MEDICAL CONDITION]. The resident was ambulatory with a rolling walker and was stand by assist with most of her ADLs. On 12/10/13 at 1:15 PM, Resident #2 was observed in her room sitting in a chair. She was well-groomed and dressed appropriately. Resident #2 informed the surveyor she had not been in the facility for very long and had come from another facility. When asked about her Foley catheter, Resident #2 informed the surveyor her catheter leakd sometimes and showed the surveyor her urinary drainage leg bag, which was on her right leg above her knee and had light tea-colored urine in it. When asked, Resident #2 said some of the new girls (CNAs) pulled too hard on the catheter and it leaked (Resident #2 pointed at her Peri area). Resident #2 also informed the surveyor when she had a urinary drainage leg bag for a long time, it would leak sometimes as well. In the Confidential Resident Group Interview on 12/11/13 at 1:30 PM, the attending residents, identified by the facility as alert and oriented, were asked this question: "How do staff members treat the residents here, not just yourselves, but others who can't speak for themselves?" One of the residents reported he/she knew of a resident, who complained out loud about wanting to have her (indwelling urinary) catheter changed, which annoyed the CNAs. The CNAs would then respond to the resident, telling him/her the nurses were supposed to change the catheter, not them (the CNAs). The CNAs would then tell the nurses, who would ignore both the CNAs and the resident. Two other residents agreed with the first resident. They described the resident, who had the catheter as a resident who used a walker and talked loudly. The resident with the catheter was confirmed as being Resident #2. During an interview with LVN G on 12/12/13 at 10:15 AM, she stated Resident #2 had asked to have her catheter bag changed, but since the facility did not have an extra catheter drainage bag, she did not change it. When asked if she had ever changed the catheter, LVN G said,"No," she had not. LVN G said there had been a nurse on the night shift, who changed the residents' catheters, but she no longer worked for the facility. LVN G said she did not know if Resident #2's catheter had ever been changed or not and identified RN I as the previous night shift nurse, who may have changed Resident #2's catheter. LVN G said, to her knowledge, Resident #2 had never complained about her catheter hurting. LVN G said Resident #2's urine used to be amber in color until her physician wrote an order for [REDACTED].#2 ambulated, which was why it was amber-colored. LVN G said at night, the night nurse changed the leg bag to a bedside urinary drainage bag, and in the morning, the night nurse changed it back to the leg bag. When asked about securing Resident #2's catheter, LVN G said she did not know if there was a leg strap on the catheter. Review of Resident #2's Daily Skilled Nurse's Note dated 08/04/13 at 7:00 PM (nurse's signature illegible) revealed the resident's Foley catheter was intact and in place. The note further reflected the resident complained of pain at the catheter site, so the nurse gave Resident #2 [MEDICATION NAME] 2.5/500 mg 1 tab PO, which she tolerated well. Review of Resident #2's Daily Skilled Nurse's Note dated 08/07/13 at 5:00 PM (nurse's signature illegible) revealed the nurse had assessed Resident #2's catheter and noticed blood in the catheter bag. The nurse called Physician K, Resident #2's attending physician, and spoke with NP P, who ordered [MEDICATION NAME] (anti-fungal) 100 mg 1 tab PO X 3 days. Review of Resident #2's Daily Skilled Nurse's Note dated signed by RN I on 08/10/13 at 2:00 AM revealed Resident #2 had a Foley catheter, which was draining pinkish-colored urine and no blood clots were observed. Review of Resident #2's Daily Skilled Nurse's Note dated 08/10/13 at 9:00 AM (nurse's signature illegible) revealed the resident's Foley catheter was intact, and her urine was getting clear of blood. Review of Resident #2's Daily Skilled Nurse's Note dated and signed by LVN E on 08/12/13 (no time) revealed Resident #2's Foley catheter was intact and draining light pink urine. The Note further reflected Physician K was notified, and he had instructed the nurse to drain Resident #2's catheter bag and to continue to monitor the resident's urine. Review of Resident #2's Daily Skilled Nurse's Note dated 08/13/13 at 12:00 AM (nurse's signature illegible) revealed Resident #2's Foley catheter was in place to gravity drainage. It further reflected her urine was amber colored, clear and without any odor noted. Review of Resident #2's Daily Skilled Nurse's Note dated 08/13/13 at 12:00 AM (nurse's signature illegible) revealed Resident #2's urine was amber-colored and clear. It also reflected the nurse notified Physician K, and he said to put tape on Resident #2's catheter to prevent it from pulling. Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/14/13 at 12:00 AM revealed Resident #2's Foley catheter was to gravity drainage, and the urine was pinkish colored with"red clumps (clots) visible." Review of Resident #2's Daily Skilled Nurse's Note dated 08/14/13 untimed (nurse's signature illegible) revealed Resident #2's urine color was amber and clear. It further reflected the nurse called Physician K, and he gave a new order for a UA with C&S. Review of Resident #2's Daily Skilled Nurse's Note dated 08/14/13 at 5:00 PM (nurse's signature illegible) revealed Resident #2's Foley catheter was in place with drainage to gravity. It further reflected her urine was amber-colored and clear. Review of Resident #2's Daily Skilled Nurse's Note dated 08/15/13 at 2:00 AM and signed by RN I revealed the RN collected a sample of urine from Resident #2's catheter tubing for the UA C&S using "sterile technique." Review of Resident #2's Daily Skilled Nurse's Note dated 08/15/13 at 5:00 PM (nurse's signature illegible) revealed her Foley catheter was in place to gravity drainage. It further reflected Resident #2's urine was amber-colored, clear and without an odor. Review of Resident #2's physician's telephone orders revealed an order dated and signed by the physician on 08/15/13, which ordered to continue the Foley catheter and to attach it to a urinary drainage leg bag at 6:00 AM every morning and then to a gravity urinary drainage bag every night at 9:00 PM for one month and then re-evaluate. Further review of Resident #2's physician's telephone orders for August, September, October, November and December 2013 failed to reveal any orders resulting from a re-evaluation of the resident's catheter, orders for the Foley catheter and leg drainage bag, any order for the Foley catheter size, a frequency to change the Foley catheter, whether to document I&O, or to irrigate the Foley catheter. Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/16/13 at 2:00 AM revealed Resident #2 was awake, and when the CNA had assessed her, Resident #2's "diaper is wet." The nurses' note further reflected the CNA reported this to RN I as well as the statement, "Her cath hurts." RN I's nurses' note further reflected she went and assessed Resident #2"and noted that Res crys (sic) out with pain when Foley tubing is moved only slightly - Foley bulb deflated and (catheter) removed. Res c/o much discomfort. Obtained a #18 with 10 cc bulb (Foley catheter) and inserted it with minimal discomfort noted...Res passing pink color urine...." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/16/13 at 6:00 AM revealed Resident #2's urine was"pinkish in bag and tubing." It further reflected RN I removed the large bag and placed a leg bag as ordered for day time activity. RN I then wrote"Lg bag Rinsed and hung up in BR." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/17/13 at 12:00 AM revealed Resident #2's leg bag was changed to a regular urnary drainage bag and the"Leg Bag rinsed and hung to dry." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/19/13 at 12:00 AM revealed RN I assessed Resident #2 and she still had her leg bag on. RN I "Removed (leg bag) and Lg drain bag attached to catheter." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/19/13 at 6:30 AM revealed Resident #2's"Big drain bag Removed and leg bag attached. Big bag rinsed __ (with) Cla (?) H2O X 3 and placed in drawer on clean towel." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/21/13 at 12:00 AM revealed Resident #2's leg bag had been"rinsed and dried, rest in folded towel." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/19/13 at 6:30 AM revealed"Big bag exchanged for small leg bag." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/22/13 at 5:00 AM revealed RN I gave Resident #2 some medicine in yogurt and Resident #2 asked why she was being given medicine. RN I told Resident #1 it was antibiotics for her UTI. The Note further reflected"Big bag (changed) for leg bag...." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/24/13 at 12:00 AM revealed:"this nurse changed leg bag to foley _ (with) Lg drainage bag." Review of Resident #2's Daily Skilled Nurse's Note for the evening shift on 08/24/13 untimed (nurse's signature illegible) revealed her urine was "yellow" and "cloudy." The Note further reflected,"Changed from leg bag to reg." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/26/13 at 7:00 AM revealed,"Foley (changed) to leg bag at this time...." Review of Resident #2's Daily Skilled Nurse's Note dated 08/27/13 at 6:00 AM (nurse's signature illegible) revealed "Drainage bag changed to leg bag as ordered." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/30/13 at 12:00 AM revealed "Note still has leg bag to (R) leg for urine drainage. Leg bag off cathe and BS drainage bag to cath." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/30/13 at 12:00 AM revealed, "Has Lg bag in place urine is pinkish in tubing." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 08/30/13 at 7:00 AM revealed"Big bag changed to leg bag...." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/02/13 at 12:00 AM revealed "Has lg drainage bag in place c/o her belly hurts. Repositioned tubing...." Review of Resident #2's Daily Skilled Nurse's Note dated 09/04/13 at 9:00 PM (nurse's signature illegible) revealed the nurse notified Physician K (Resident #2's PCP and the facility's Medical Director) there was blood in Resident #2's urine. It further reflected Physician K ordered a UA C&S for in the morning. Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/02/13 at 12:00 AM revealed Resident #2 was awake and restless. It further reflected her incontinent brief was wet. RN I assessed Resident #2's Foley catheter and"determine fluid in bulb low, slowly added more fluid...." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/06/13 at 6:00 AM revealed"Drainage Bag (changed) to leg bag." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/07/13 at 2:00 AM revealed Resident #2 was awake and restless and complained"Feels full. Observed Foley tubing (with) scant urine in it, none in bag. Realigned tubing under Res (R) leg (with) down grade to Bag had to pump tubing to encourage urine to flow...." Review of Resident #2's Daily Skilled Nurse's Note dated 09/10/13 at 9:30 PM (nurse's signature illegible) revealed Resident #2 was on an antibiotic due to UTI, and her urine was"still cloudy in color." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/11/13 at 12:00 AM revealed Resident #2"has lg drainage bag in place...." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/11/13 at 6:00 AM revealed,"Foley cath changed from Lg bag to leg Bag...." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/12/13 at 6:00 AM revealed, "Foley bag changed to leg bag and elastic adjusted to her liking." Review of Resident #2's Daily Skilled Nurse's Note dated 09/12/13 at 9:30 PM (nurse's signature illegible) revealed Resident #2's"urine still cloudy...." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/13/13 at 6:00 AM revealed"Big bag removed and Leg Bag applied." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/14/13 at 6:30 AM revealed"Big urine bag (changed) back to leg Bag...." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/16/13 at 5:00 AM revealed"Lg drain Bag (changed) to Leg Bag to (R) leg." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/18/13 at 6:30 AM revealed"foley (changed) to leg Bag." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/19/13 at 12:00 AM revealed"has Lg urine drainage Bag at Bedside...." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/19/13 at 4:00 AM revealed Resident #2 was awake and wanted to get up."Foley Bag Removed (and) leg bag applied." Review of Resident #2's Daily Skilled Nurse's Note dated 09/19/13 at 10:30 AM (nurse's signature illegible) revealed the nurse"noted amber-colored urine in residents urine bag, urine was drained, resident assisted to sit in her bed and relax because she had been walking around." It also reflected NP P was called and an order was received for a UA C&S for the next day. Review of Resident #2's Daily Skilled Nurse's Note dated 09/19/13 at 4:30 PM (nurse's signature illegible) revealed a CNA informed the nurse they thought Resident #2's"Foley bag was leaking, nurse went to check on it, Foley bag was intact was not leaking...." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/20/13 at 12:00 AM revealed, "Note urine in foley tubing is pink will monitor for Redness." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/20/13 at 7:00 AM revealed RN I informed Resident #2 of the need to collect urine for a UA. The Note reflected "open cath tubing and only 2-3 cc urine...bladder empty at this time." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/21/13 at 12:00 AM revealed Resident #2 "verbalizes her foley is leaking...note tubing is easily moveable in urethra - 6 cc air was added to tubing bulb." Note: The Foley catheter was not changed. Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/23/13 at 12:00 AM revealed Resident #2 was in her bed. RN I "observed that Res still has Leg Bag to (R) leg. Was Removed and Lg Bag applied (with) drainage to down drain." Review of Resident #2's Daily Skilled Nurse's Note dated and signed by RN I on 09/23/13 at 4:00 AM revealed"Lg bag (changed) to small leg Bag...." Attempts to contact RN I for an interview were unsuccessful. Review of Resident #2's Daily Skilled Nurse's Note dated 09/23/13 at 4:30 PM (nurse's signature illegible) revealed the nurse received the laboratory results of the UA C&S and Physician K was notified. New orders were received: [MEDICATION NAME] (anti-[MEDICAL CONDITION] and for acute UTIs) 150 mg one by mouth two times a day for seven days; [MEDICATION NAME] (for UTIs) 50 mg by mouth two times a day for 10 days; and to repeat the UA C&S three days after the antibiotic was completed two times. Resident #2's Daily Skilled Nurse's Note further reflected Physician K called back and changed the [MEDICATION NAME] to 100 mg by mouth two times a day for 10 days. Review of Resident #2's Nurse's Note dated 09/28/13 at 12:30 PM (nurse's signature illegible) revealed Resident #2"Cont on ABT [MEDICAL CONDITION] in urine...." During an interview with ADON MM on 12/15/13 at 12:26 PM, when asked, ADON MM said Resident #2 was not on isolation when she [MEDICAL CONDITION] in her urine because she had a Foley catheter so it was contained. Review of Resident #2's Nurse's Note dated 09/28/13 at 2:30 PM (nurse's signature illegible) revealed Resident #2 "Cont on ABT [MEDICAL CONDITION] in urine...." Review of Resident #2's Nurse's Note dated 09/28/13 at 11:30 PM (nurse's signature illegible) revealed Resident #2"ABT cont [MEDICAL CONDITION]." Review of Resident #2's Nurse's Note dated 09/29/13 at 11:30 AM (nurse's signature illegible) revealed Resident #2"Cont on ABT [MEDICAL CONDITION] in urine...." Review of Resident #2's Nurse's Note dated 09/29/13 at 4:45 PM (nurse's signature illegible) revealed Resident #2"Cont on ABT [MEDICAL CONDITION] in urine...." Review of Resident #2's Nurse's Note dated 10/05/13 at 2:00 PM (nurse's signature illegible) revealed Resident #2 was status [REDACTED]." Review of Resident #2's Nurse's Note dated 10/13/13 at 12:00 AM (nurse's signature illegible) revealed Resident #2 "C/O bladder pain...." It further reflected the catheter was draining urine and the nurse informed the resident it may have been pulled when she was out on pass with her family. The nurses' note also reflected Resident #2 received [MEDICATION NAME] 2.5/500 mg for the pain. Resident #2's physician's telephone order dated 10/18/13 reflected an order for [REDACTED]. Review of Resident #2's Nurse's Note dated 11/08/13 at 2:00 AM (nurse's signature illegible) revealed Resident #2 "C/O abd pain...." The Nurses' Note further reflected Resident #2 was medicated with [MEDICATION NAME] 2.5/500 mg for the pain and her Foley catheter was patent and irrigated. On 12/12/13 at 4:00 PM, the surveyor observed Resident #2 ambulating in the hallway. She was well-groomed and dressed appropriately. When asked if her catheter had been changed, Resident #2 said,"No," they had changed the urinary drainage bag but not the catheter itself. During an interview with RN L on 12/13/13 at 9:55 AM, when asked if she had ever worked with Resident #2, she said at least one night a week. When asked if she had ever changed Resident #2's Foley catheter, RN L said, "No," she had not. RN L said she did not change the catheter bags either as"the CNAs change from the bedside drainage bag to the leg bag." RN L said sometimes Resident #2 calls her "to fix it." The leg bag strap would be "too tight," so RN L would loosen it for Resident #2. During a telephone interview with Resident #2's family member on 12/13/13/at 10:09 AM, he/she informed the surveyor Resident #2 had gone to two physician appointments. The family member said another family member had taken Resident #2 to her General Practitioner on 10/07/13 and then to her Oncologist on 11/27/13. The family member said there had been no Urology appointment, but they had been waiting for one, so the Urologist could "fix" the problem Resident #2 was having with her catheter. He/She said Resident #2 "was a very clean lady," and she had complained to the family member about her Foley catheter leaking. The surveyor asked the family member if Resident #2 complained about the Foley catheter bag leaking or if it was leaking in her "private area," and he/she said she had complained about it leaking in her "private area." The surveyor asked him/her if the resident complained about pain, and he/she said,"No," just that it had been leaking about her "private area" and the resident did not like to feel wet even though she wore incontinent briefs. The resident was also very afraid about (urine) odor. When asked whether Resident #2's Foley catheter had been changed since her admission to the facility, the family member said he/she did not think the Foley catheter had been changed since being admitted to the facility. The family member asked the surveyor how often the Foley catheter should be changed, and the surveyor told him/her every 30 days, or once a month was the norm. The family member said,"Well, she (Resident #2) would have told me if they were changing it (Foley catheter) like that." During an interview with RN U on 12/13/13 at 10:42 AM, she informed the surveyor she worked with Resident #2 on the night shift on Saturday nights only and reconciled the comprehensive orders every month for station two, which included Resident #2. When asked if Resident #2 ever complained about pain or her catheter, RN U said,"Yes. Sometimes she (Resident #2) complained about her cath (catheter)." RN U said Resident #2 would sometimes say, "It's not in the right place, and we (staff) would assure her it's in the right place and draining well." When asked if she had ever changed the Foley catheter, RN U said she did not remember if she had changed it or not. When asked how often a Foley catheter should be changed, RN U replied,"It's usually on the orders to change every 30 days or one time a month." When asked if Resident #2 had any orders for her Foley catheter on her consolidated orders, RN U said she was "not sure if she has an order or not." During a telephone interview with LVN T on 12/13/13 at 2:07 PM, the LVN reported she had only worked on station two and taken care of Resident #2 one time. LVN T said Resident #2 had not complained to her about her catheter when she had worked with her that one time. LVN T said she did remember when she had worked a long time ago, Resident #2 said she felt like she"had to pee" but she had not been her nurse so had done nothing about it. During a telephone interview with LVN V on 12/13/13 at 2:16 PM, she informed the surveyor she worked on station two "every now and then." When asked what she would check on Resident #2's Foley catheter, LVN V said she would check the color of her urine. LVN V said Resident #2 had never complained about her catheter. LVN V also said she had never changed Resident #2's catheter. When asked how she would know to change Resident #2's catheter, LVN V said usually, the physician's orders [REDACTED]. LVN V informed the surveyor she had never changed Resident #2's Foley catheter bag as "The aide will help her change from the leg bag to the night bag." When asked why it was the CNAs' job, LVN V said, "Nobody put that on the aides. That's something they've always done. I've never told them to do it." On 12/13/13 at 2:42 PM, the surveyor observed Resident #2 lying flat in her bed on top of her personal blanket with her legs straight, her pants down about her ankles and her incontinent brief pulled down to just above her knees. The surveyor

Based on observation, interview, and record review, it was determined the facility failed to ensure that a resident maintained acceptable parameters of nutritional status, such as body weight for three (Resident #3, #40 and #41) of 12 residents reviewed for nutrition. 1. Resident #3 experienced a 16.3% (20.8 lbs) loss of body weight from 11/01/13 to 12/17/13. Failures included: a) Staff failed to document Resident #3's meal intake and administer Med Pass nutritional supplement as ordered when she consumed less than 50% of her meals. b) Staff failed to accurately document Resident #3's weight, and nursing staff was unaware of the extent of her weight loss. c) Staff failed to implement the recommendations made for Resident #3 by the Dietitian after she was consulted by the physician. d) Staff failed to notify the physician after they became aware of her 10% weight loss in two weeks until surveyor inquiry. 2) Resident #40 experienced a 5.67% (9.8 lbs) loss of body weight from 12/03/13 to 01/03/14. Failures included: a) Staff failed to record and document Resident #40's meal intake accurately. b) Staff failed to ensure the Dietary Consultant saw the resident once she was admitted to the facility. c) Staff failed to notify the physician after they became aware of Resident #40's 5.67% weight loss for three days. d) Staff failed to initiate a Care Plan regarding Resident #40 pocketing her food for two months. 3. Resident #41 was identified on 11/26/13 as having a 6% weight loss in 20 days. Failures included: a) Staff failed to notify the physician of the weight loss and recommendations made by the consulting dietitian. b) Staff failed to implement the recommendations made by the dietitian.. An Immediate Jeopardy (IJ) was identified on 01/02/14. While the IJ was removed on 01/11/14, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. These failures resulted in: - Resident #3 losing approximately 21 lbs since 11/01/13, placing her at risk for further debility, pressure sores and deterioration of her physical condition. - Placeing Resident #40 at risk for continued weight loss and complicaitons from pocketing her foods. - Placing Resident #41 at risk for continued weight loss and deterioration of her physicial condition. These failures could affect any of the facility's 75 residents placing them at risk for unplanned weight loss, extended healing time, [MEDICAL CONDITION], dehydration and fatigue. Findings included: 1. Resident #3 was a [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she was severely impaired cognitively, was totally dependent on staff for her ADLs, she weighed 133 lbs, and had no weight loss. 1) Resident #3's Care Plan dated 10/24/13 reflected: "(Resident #3) poor appetite eating DT Cognitive Deficit/family declined GT placement." Approaches included: Diet as ordered/preferences per family's request...; Medication as ordered, Assist/Cueing with meal; Document meal % and report % to nurse with meal ticket; Offer fluids frq throughout day...; Dietary consult; Psych consult; Notify Dr./RP of any changes in condition." Resident #3's consolidated physician's orders [REDACTED]. The order was dated 10/24/13. Resident #3's Dietary Progress Notes dated 11/21/13 reflected: "Resident has 11% significant wt. loss X's 180 days R/T poor appetite, refuses to eat after return from hospital. Resident Received fortified foods, likes chocolate milk. Resident on weekly weights. DSM will monitor meal intake, nursing to monitor weight and skin closely, will follow." Resident #3's Food Intake Record for November 2013 revealed she consumed less than 50% of her meal 27 times. Additionally, meal percentages were not documented at all and left completely blank 24 times. Review of Resident #3's MARs for November 2013 revealed an entry dated 09/27/13 for Med Pass 60 cc by mouth as needed if the resident eats less than 50%. There were no doses initialed as administered. Resident #3's Nutritional assessment dated [DATE] reflected her weight was 128 lbs. The Summary and Recommendations reflected: "10/25/13: Dietary consult ordered for low pre-alb. Nutr assess reveals pt readmitted post hospitalization at (hospital name) for possible [DEVICE] eval due to failure to thrive, dysphagia, and UTI; pt shows wt loss 5 lbs/30 days-4%, following overall wt loss 15 lbs/180 days-10.49%; Pt remains within desireable wt range, as reflected by BMI factor; Pt continues w/varying intake of regular, therapeutic diet; [MEDICATION NAME] was ordered 10/28/13 for appetite stimulant; Pro powder was dc'd 10/25/13 due to pt refusal; pt receives med pass 60 cc TID if intake < 50% for add'l 360 cal/15 gm pro; lab reveals low pre-alb level; due to continued wt loss and low pre alb, recommend adding Medpass 2.0 120 cc BID for add'l 480 cal/20 gm pro; pt to be carefully monitored." NOTE: The recommendation for Medpass 120 cc BID was never ordered. Resident #3's Food Intake Record for December 2013 revealed she consumed less than 50% of her meal seven times between 12/01/13 and 12/12/13. Additionally, meal percentages were not documented at all and left completely blank eight times from 12/01/13 through 12/12/13. Review of Resident #3's MARs for December 2013 revealed an entry dated 09/27/13 for Med Pass 60 cc by mouth as needed if the resident eats less than 50%. There were no doses initialed as administered. Observation on 12/11/13 at 8:00 AM revealed Resident #3 was fed breakfast in the dining room by facility staff. Resident #3 consumed 30% of her eggs, 90% of her oatmeal and 75% of her meat. Observation on 12/11/13 at 1:05 PM revealed Resident #3 was fed lunch in the dining room by facility staff. She only consumed 25% of her meat and 60% of her dessert. During an interview on 12/12/13 at 7:10 PM, LVN W was asked about Resident #3's Med Pass order. LVN W stated she did give the resident Med Pass on occasion. She stated she had been giving her health shakes because Resident #3 would drink them up. She could not answer why there were no doses documented. LVN W stated Resident #3's (family member) often came in the evening and "feeds her too much." When asked what she meant by that, LVN W stated he/she would push her to eat yogurt and healthshakes and she (LVN W) thought he "overdoes it." During an interview on 12/13/13 at 8:10 AM, LVN D stated she had not given Resident #3 any Med Pass because she was eating much better and did not need any. When asked about the Food Intake Record and informed there were several times she refused to eat or ate less than 50%, LVN D stated she had her meal tickets somewhere and was not aware of Resident #3 ever eating less than 50%. She stated she knew Resident #3's weight was stable, and she had no weight loss this month. Resident #3's Yearly Weight Record reflected the following weights: 10/24/13 - 128.1 lbs 11/01/13 - 127.6 lbs 12/02/13 - 126.6 lbs 12/09/13 - 126.6 lbs Observation on 12/13/13 at 8:24 AM revealed Resident #3 was weighed by Restorative Aide BB. Resident #3 was weighed in her wheelchair, then assisted to a chair and then the empty wheelchair was weighed. The resident's weight was 109.2 lbs. Restorative Aide BB stated she weighed the resident the same way every time. She stated her weight had dropped, and she would report the findings to LVN D and ensure the resident was weighed daily. She added she would request the scale be calibrated for accuracy. Restorative Aide BB checked her records, which were kept in the therapy department, and discovered she had entered the wrong weights on Resident #3's Yearly Weight Record. She corrected the Yearly Weight Record to reflect the following: 11/1/13 - 127.6 lbs 12/02/13 - 122.6 lbs 12/06/13 - 120.6 lbs 12/13/13 - 109.4 lbs On 12/13/13 at 9:30 AM, LVN D was informed of Resident #3's actual weight of 109 lbs by the surveyor. LVN D stated she had been informed, and they were going to get the scale calibrated. During an interview on 12/14/13 at 10:00 AM, LVN T, Resident #3's weekend Charge Nurse, was shown Resident #3's MAR and asked why no Med Pass had been administered as ordered. LVN T explained since the resident returned from the hospital, she had been doing much better so none was given. LVN T was shown Resident #3's Food Intake Records for November and December 2013 with several weekend entries reflecting she had either refused to eat or consumed less than 50%. LVN T stated, "The aides didn't tell me. They gave the ticket to the clerk. I should have checked." In an interview on 12/16/13 at 3:20 PM , Restorative Aide BB stated she had spoken with the Dietary Manager, who agreed she (Restorative Aide BB) would personally feed Resident #3 in the therapy department and complete a more detailed summary of her intake with every meal. On 12/17/13 at 12:20 PM, Restorative Aide BB stated the scale had been calibrated. At that time, Resident #3 was weighed, and her weight was down to 106.8 lbs. On 12/17/13 at 2:30 PM, Restorative Aide BB reviewed Resident #3's meal intake documents completed for 12/16/13. The form reflected she consumed 25% of her breakfast, no lunch and only 10% of her dinner. Restorative Aide BB stated she discussed her plans to personally feed Resident #3 with LVN D and the DON, who agreed it was a good idea. Review of Resident #3's December 2013 MAR revealed there was still no Med Pass administered on 12/16/13. Review of Resident #3's Nurse's Notes revealed no indication her physician had been notified of her weight loss. Resident #3's Dietary Progress Notes dated 12/13/13 reflected the following: "Resident last weighed @ 109.4, weighed twice. Scales to be checked stated by Rehab aide. Resident continues to have significant amount of weight loss, resident has 14% significant weight loss x's 30 days R/T refusal to eat. (Director of Dietary Services) called dietitian's asst. Dietitian on vacation @ this X, facility needed immediate intervention due to tremendous amount of weight loss within 30 days. Dietitian faxed recommendations, (Director of Dietary Services) was also asked to tell resident's charge nurse of recommendations of Med Pass (with) medications 3x a day. Nurse stated res. already receives 60 cc if she eats less than 50%. Dietitian stated res is a good candidate for appetite stimulant but may not be able to receive it according to what's going on with her. (Director of Dietary Services) talked (with) charge nurse, stated she receives [MEDICATION NAME] already but res still not eating well as observed by (Director of Dietary Services) & rehab aide. Nurse stated she would call the doctor. Doctor's office called (Director of Dietary Services) about dietitian's recommendations and stated she would talk with doctor and get back (with) me. Will follow...." The note was signed by Director of Dietary Services. Resident #3's Nutritional assessment dated [DATE] reflected her weight was 127 lbs. Summary and Recommendations reflected: "12/17/13: Dietary consult requested due to weight loss. Nutr assess reveals wt remains stable/ 30 days, following wt loss 9 lbs/90 days-7%, 13 lbs/180 days-9.29%; Pt remains within desirable wt range, as reflected by BMI factor;...Pt continues to refuse to eat; Pt will accept shakes and chocolate milk; [MEDICATION NAME] continues for appetite stimulant; Med Pass continues 60 cc TID if meal intake is < 50% for add'l 360 cal/15 gm pro, due to continued wt loss and low pre-alb, recommend adding Med Pass 2.0 120 cc BID for add'l 480 cal/20 gm pro; wt loss may be expected; ...continue to monitor closely; goal is to provide adequate cal and pro to stabilize wt." The assessment was signed by Dietary Consultant PP. During an interview on 01/02/14 at 4:10 PM, Dietary Consultant PP was queried about her Nutritional Assessment of Resident #3. Dietary Consultant PP stated she was called for a consultation on 12/17/13 and the weight reflected on her assessment was the weight she was given for Resident #3 by the facility. When asked about her recommendation for the Med Pass 2.0 supplement, Dietary Consultant PP explained she was informed by facility staff Resident #3 had been receiving doses of Med Pass as needed but she wanted to add a scheduled dose in addition to the PRN dose already ordered. She could not remember who told her Resident #3 was taking the Med Pass. When the Dietary Consultant PP was told Resident #3's weight was actually 109 lbs on 12/13/13, then dropped to 106 lbs, she stated she was never made aware of the weight drop. When asked who provided her the information for her consultation, Dietary Consultant PP stated the Director of Dietary Services faxed a weight sheet prior to her arrival. She explained they typically faxed the information in advance so she could prepare for her visit. During an interview on 01/02/14 at 4:35 PM, the Director of Dietary Services was asked what type of information she sent to the dietitian when a consultation was ordered. She stated she sent them the resident's weights. When asked about Resident #3, she confirmed she sent the dietitian her weights. The Director of Dietary Services retrieved a list of monthly weights to show the surveyor. Resident #3's weight for December was documented as 126.6 lbs; a line was drawn through the entry. The Director of Dietary Services stated, "I lined that out later and wrote 109." The Director of Dietary Services retrieved a Dietitian Consultant Worksheet and stated she typically filled it out and gave it to the Dietitian. When asked whether she provided one for Resident #3's consultation, the Director of Dietary Services replied, "I can't remember if I did this last time. They never let me know when they are coming." The Director of Dietary Services also explained she had informed the Dietitian Resident #3 was taking Med Pass supplement. She stated she had been informed by LVN D the resident was getting it. On 12/17/13 at 2:17 PM, an interview with NP P, Resident #3's Nurse Practitioner, revealed she had not been notified of Resident #3's weight loss and was unaware of the recent weight drop. During an interview on 12/17/13 at 3:07 PM, LVN D stated she remembered the surveyor reporting Resident #3's weight loss on 12/13/13. She stated she reported the information to the DON. When asked why she did not call the physician, LVN D stated she was going to wait until the scale was calibrated. In an interview on 12/17/13 at 4:10 PM, the DON stated Resident #3's physician had been called and lab orders were obtained for a CBC, CMP and Pre-[MEDICATION NAME] level to be done. She added a care plan meeting with the family was being arranged and Physician K, Resident #3's attending physician, would attend. The DON stated Resident #3 was getting health shakes instead of Med Pass but staff had not been documenting it. She stated nursing administration was going to take over monitoring Resident #3's meal intake and every resident in the building would be re-weighed. When asked why the physician was not notified on 12/13/13 when the discrepancy was found, the DON stated, "No. It was the intent but it got dropped." An interview on 01/02/14 at 2:21 PM with Restorative Aide BB revealed she had begun re-weighing residents but had not completed the task (16 days since the DON said all residents would be re-weighed.). Restorative Aide BB provided lists dated 12/31/13 through 01/02/14 with the names and weights of residents. When asked when she was asked to initiate re-weighing the residents, she stated she had not been told by anyone to re-weigh the residents. When asked why she was re-weighing the residents, Restorative Aide BB said, "I know that's what you do when you have a discrepancy." In an interview on 01/03/13 at 12:12 PM, the DON was asked whether she had implemented the re-weighing of all the residents as she had informed the surveyor she would. The DON stated, "We are in the process of doing that now." During an interview on 01/06/13 at 12:00 PM, Physician K stated he had taken part in care plan meetings regarding Resident #3. He stated he had decreased her medications, which were not critical to maintain function. Physician K stated he learned the facility had not been calling the family to assist her when she would not eat as had been agreed upon during a previous meeting. 2) Resident #40, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed the resident's cognitive skills for daily decision-making were moderately impaired. This assessment reflected Resident #40 required set up help only for meals, had no swallowing disorders and required a mechanically altered diet. Review of Resident #40's admission weight on 11/05/13 was 172.6 lbs. Review of Resident #40's "INITIAL CARE PLAN" dated 11/05/13 revealed: "PROBLEM: Nutritional Risk related to: Mech soft INITIAL CARE PLAN OUTCOME: Will maintain weight within two lbs of each month. NURSING INTERVENTION: Weigh wkly x 4 then per protocol. Diet as ordered: Report food intake of less than 75% of five meals in two days to R.D. for assessment. Offer fluids throughout shifts." Review of Resident #40's Nurse's Notes dated 11/09/13 on the day shift revealed the resident was pocketing her food in her mouth and the nurse received an order for [REDACTED]. The evening shift documented Resident #40 continued to pocket her food and crushed medication. Resident #40, "cont to pocket everything you put into her (Resident #40's) mouth. DON/ADON informed." Review of the Speech Therapist note dated 11/10/13 revealed, "Reason For Referral: This [AGE] year old female presents to speech therapy with a recent decline in swallowing and cognitive abilities...Swallowing Lingual Function - moderate impairment (50-75% impairment; combination of oral and non-oral nutrition; requires thickened liquids, difficulty masticated foods) ...Impact on Burden of Care/Daily Life - The patient requires mod to max cues of PO intake and ADL participation due to safety reasons...." Review of Resident #40's "DIETARY PROGRESS NOTES" dated 11/12/13 revealed, "Resident (Resident #40) new admit has hx of Altered Mental Status, DM II, UTI, [MEDICAL CONDITION], HTN, Alzheimer's, Hypercholesteromia, [MEDICAL CONDITION], Dementia. Res. receives Puree diet tol. well (with) no difficulty @ this x...." The Director of Dietary Services signed this note. Review of Resident #40's Nurse's Noted dated 12/21/13 (day shift) revealed, "...can't swallow medicine...." During an interview on 01/06/14 at 3:15 PM, the surveyor asked MA EE, assigned to pass medications to Resident #40, if the resident could swallow her medications. MA EE stated she could swallow her medicaitons. It just took time. Review of Resident #40's "COMMUNICATION PAGE" dated 12/23/13 revealed: "(Resident #40) - Refusing to eat - holding food + liquids in mouth! When swallowing liquids - she coughs and refuses to open mouth. (no) signs of tearing (of eyes) or running nose this AM. Will not swallow medicine. Points to throat. Asked if she was having a hard time swallowing. She nods head yes and holds mouth shut. Tongue thick in mouth, sticks at roof of mouth. Also experiencing cognitive change. Coaching x 4 to swallow or participate (with) therapy. Tongue coated (with) food + meds." "To: DON: MDS: ADON: Dietary: C Nurse." Restorative Aide BB signed this note.. During an interview on 01/06/14 at 2:25 PM, Restorative Aide BB stated she became aware Resident #40 was pocketing food (in her mouth) on 12/23/13 and wrote a communication page, regarding the pocketing. Restorative Aide BB further stated she gave a copy of the communication page to the DON, ADON, Charge Nurse LVN F and to the Director of Dietary Services. Review of Resident #40's "DIETARY PROGRESS NOTES" dated 12/23/13 revealed, "Resident (Resident #40) refusing to eat, pocketing food + liquids in mouth when swallowing resident coughs + refuses to open her mouth. No tearing (of eyes) or runny nose @ this x. Resident would not swallow medicine that AM. Resident will point @ throat. Resident was asked if she was having a hard time swallowing + she nodded her head yes + held her mouth shut. Resident also experiencing some cognitive change. Resident coached x's 4 to swallow or participate (with) therapy. Tongue coated (with) food + meds. To continue to monitor closely, will follow resident to be placed on weekly weights." The Director of Dietary Services signed this note. Review of Resident #40's Nurse's Notes dated 12/23/13 (day shift) revealed "Alert, pleasant assist to DR, unable to swallow pureed food well, does pocket food (in mouth). Has to be spoon fed meal unable to complete task ...." During an interview on 01/06/14 at 10:50 AM, the DON stated she was aware Resident #40 was pocketing food (in her mouth). The DON further stated the Speech Therapist told her Resident #40's pocketing was due to "cognitive (deterioration). I have been watching her (Resident #40) over the last week, not consistent (pocketing), mainly breakfast." The surveyor asked the DON if the physician had been notified of the resident pocketing and the DON stated, "Yes, that's how speech therapy got notified." The surveyor asked the DON if pocketing triggered calling the Dietary Consultant and the DON stated, "If the resident ate less than 50%." Review of Resident #40's Yearly Weight Record revealed: 11/05/13 (Admission) - 172.6 lbs 12/03/13 - 172.4 lbs Review of Resident #40's Care Plan, completed by the Director of Dietary Services, on 01/03/14 revealed Resident #40's weight was 163.6 lbs. Review of Resident #40's Nurse's Notes dated 01/03/14 revealed no mention of the resident's weight loss. Observation on 01/05/14 at 1:00 PM revealed Resident #40 was in the dining room, feeding herself lunch. Resident #40 had a divided plate (three sections), which contained puree chicken, mashed potatoes, puree peas, a separate bowl of applesauce and two 6-ounce glasses of nectar-thickened fluids. At approximately 1:20 PM, a CNA approached Resident #40 to move her from the dining room. The resident still had a spoon in her hand. The resident put the spoon down and was moved to the television room. One third of the divided plate (mashed potatoes) and one third of one of the fluid-filled glasses was consumed. ADON NN and LVN FF were standing over the table where Resident #40 sat. LVN FF, who had been the assigned nurse for the dining room, picked up Resident #40's meal ticket and wrote 50% on it, indicating the resident's intake. The surveyor looked at the meal ticket and asked LVN FF if he thought Resident #40 ate 50% and he said, "Yes." The surveyor then asked ADON NN if she thought Resident #40 at 50% and she said, "No." The surveyor asked ADON NN how much the resident ate, and she stated, "25%." Review of Resident #40's "FOOD INTAKE RECORD" dated 01/05/14 revealed Resident #40 ate 50% of her lunch meal. Note: this documentation occurred after the surveyor verified with LVN FF and ADON NN Resident #40 actually ate 25% of her lunch meal. During an interview on 01/05/14 at 1:45 PM, the surveyor asked LVN FF if the unit clerks (who recorded the resident meal tickets) notified him when the residents ate less than 50%. LVN FF replied, "Sometimes, but I know how much the residents eat because I'm always in the dining room during meal times on the weekends. If a resident ate less than 25%, I give them cereal or a shake." The surveyor asked LVN FF if he ever notified the physician when a resident ate less than 25%, and LVN FF stated, "No, but the families know if they come in during meal time." Observation on 01/06/14 at 10:30 AM revealed Resident #40 was being weighed. The resident's witnessed weight was 162.8 lbs. Review of Resident #40's Nurse's Notes dated 01/06/14 at 7:50 PM revealed, "_____ (Physician K) present in facility at this time, notified of 9 lb weight loss in 30 days. New orders given at this time to start [MEDICATION NAME] ES 625 mg/5 mL give 5 mL PO QD + Med Pass give 60 mL PO TID...." Note: This was three days after Resident #40's significant weight was identified by the faciity staff. During an interview on 01/07/14 at 2:30 PM, the MDS Coordinator stated she was feeding Resident #40, around Christmas time, and noticed the resident was pocketing her food (in her mouth). The MDS Coordinator stated she notified the Restorative Aide, who swept out the resident's mouth. The MDS Coordinator stated she did tell the resident's charge nurse, but did not remember who, and the charge nurse already knew about Resident #40s pocketing of food. She further stated this was the first time she (the MDS Coordinator) knew about the resident pocketing her food. During an interview on 01/07/14 at 3:40 PM, the Director of Dietary Services stated she generated Care Plans for Resident #40, which were still on her computer. She further stated these care plans remained on her computer until the next quarterly Care Plan meeting. Then she would print them and add them to any other care plans written by nursing. The following Care Plans were on the Directorof Diretary Services computer, requested by the surveyor. Related Diagnosis: [REDACTED]. "Problem Onset: 11/12/2013 _____ (Resident #40) has potential for choking and aspiration R/T Hx. Of Swallowing Difficulty _____ (Resident #40) is at risk for aspiration/Weight loss D/T AMS/Occasional Pocketing of food w/o staff's ability to redirect On 1/03/2014 ______ (Resident #40) has Weight loss per weight committee (Weight: 163.6) Goal & Target Date _____ (Resident #40) will experience no S/S of choking or aspiration until next review date _____ (Resident #40) will be assisted with consumption therapeutic diet for needed caloric intake thru the next eval date Approaches Diet as ordered by physician Monitor for s/s of choking or aspiration Diet Consult as needed ST to screen, eval tx as indicated Spoonfed while queing (sic) to chew and swallow Remove any food she pockets before leaving Dining Rm. Report to Charge Nurses and Document % (meal eaten) Keep her in upright position during meals and at least 30 min post meals Document Meal % Notify Dr./RP of any changes in resident Notify Dr/RP of change in weight Document weigth (sic) Weight per facility's protocol Contact Family/RP for family conference Appt: [DATE] @1:30 pm Problem Onset: 11/12/2013 _____ (Resident #40) has potential for weight loss R/T Hx. Of Altered Mental Status/Alzheimers. Goal & Target Date _____ (Resident #40) will experience no significant weight loss until next review date Approaches Diet as ordered by physician Obtain monthly weights Diet Consult as needed." During an interview on 01/07/14 at 10:10 AM, Dietary Consultant OO stated she usually saw each new admission within 30 days of admission, if the resident was not having any problems. She acknowledged she had not seen Resident #40 yet. Dietary Consultant OO further stated she should have been notified once Resident #40 began pocketing foods (in her mouth). Review of Resident #40's Nutritional assessment dated [DATE] revealed Resident #40 lost nine lbs in 30 days. "STAFF REPORTING PT IS HAVING DIFFICULTY W/SWALLOWING AND POCKETING OF FOOD. 12/23/13 PT'S DIET DOWNGRADED TO PUREED REQUIRING NTL DUE TO DYSPHAGIA. PT BEING SEEN BY SPEECH DUE TO WT LOSS RECOMMEND FORTIFIED DIET FOR ADDIT 1358 CAL. 60 GM PROT WHICH INCLUDES SHAKE QD, FORTIFIED SOUP AND CEREAL; PT IS RECEIVING MED PASS 2.0 FOR ADDIT 360 CAL/15 GM PROTEIN; RECOMMEND >MED PASS TO 120 CC TID FOR ADDIT 720 CAL/30 GM PROT ...PT IS BEING WEIGHED WEEKLY...." Dietary Consultant OO signed this note. Note: This was the first time Resident #40 was seen/assessed by a Dietary Consultant since her admission (on 11/05/13, two months previously). 3) Resident #41 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected she had severe cognitive impairment, was independent with eating, weighed 130 lbs and had no weight loss. Resident #41's Care Plan (retrieved by the MDS Coordinator from her computer) dated 09/19/13 reflected she had the potential for weight loss related to a history of [MEDICAL CONDITIONS] and Dementia. Resident #41's Care Plan was updated on 01/03/14 to include the resident's weight loss of 7 lbs per the weight committee. Approaches included: Diet as ordered by physician; Monitor meal intake, document percentage and notify the doctor and responsible party for intake of 50% or less; Diet Consult as needed; Offer supplements and snacks when consumes 50% or less of meal. Resident #41's physician's orders [REDACTED]. A Communication Page regarding Resident #41, dated 11/26/13 and signed by Restorative Aide BB, reflected it was addressed to the DON, ADON, Dietary, and Charge Nurse. The Note reflected: "Wt-Loss Alert; 11/6-130.0 wt; 11/26-122.4- (down) 7.6 in 20 days. Not feeling very well after flu shot; refusing to eat." Review of Resident #41's Nurse's Notes dated 11/26/13 revealed the resident's family was called about a "situation," but there was no indication her physician had been notified of her weight loss. During an interview on 01/07/14 at 9:46 AM, LVN F, Resident #41's Charge Nurse, was asked about the resident's weight loss. LVN F confirmed she had received a communication form from Restorative Aide BB. She stated she remembered sharing the information with Resident #41's family but could not recall whether or not she notified the physician. Resident #41's Dietary Progress Notes had an entry dated 12/12/13 that reflected: "Resident continues to receive NAS diet tol. well with no difficulty @ this X ...wt @ 130 fairly stable x's 30 days...(Director of Dietary Services) will continue to monitor meal intake, nursing to monitor wt. & skin, will follow." The note was signed by the Director of Dietary Services. In an interview on 01/07/14 at 2:15 PM, the Director of Dietary Services confirmed she had received the communication form reflecting Resident #41's weight loss. When asked why she documented the resident weighed 130 lbs, when she weighed 122 lbs, the Director of Dietary Services replied, "I must have looked at an old sheet." Resident #41's Nutritional assessment dated [DATE] reflected she weighed 122 lbs. The Summary and Recommendations reflected: Nutr Assess reveals wt loss 8 lbs/30 days-6%, 11 lbs/90 days-8%, 8 lbs/180 days-6.15%. Pt remains within desirable wt range, as reflected by BMI factor...Recommend adding fortified food plan, including shake QD, for add'l 1358 Cal/60 gm PRO; Continue to monitor monthly weights; Goal is to provide adequate Cal and PRO to stabilize wt." An observation on 01/05/14 at 12:58 PM revealed Resident #41 was eating in the dining room. Her tray ticket reflected she received a regular, no added salt diet and "shake w/meals." Observation revealed no shake was offered to her during or following the meal service. She consumed approximately 75% of her lunch. Another observation on 01/06/14 at 8:50 AM revealed Resident #41 was eating breakfast in her room. Her breakfast tray ticket reflected she received a regular, no added salt diet and "shake w/meals." There was no shake on her tray. During an interview on 01/06/14 at 9:00 AM, The Director of Dietary Services

Based on observation, interview, and record review, it was determined the facility failed to ensure two (Residents #3 and #13) of 20 residents reviewed for medication regimen were free from unnecessary medications. 1) The facility failed to discontinue Resident #3's [MEDICATION NAME] (anti-psychotic) as ordered. The medication was discontinued on 11/05/13 but restarted on 12/01/13 when staff failed to remove it from the December 2013 MAR. Resident #3 received the [MEDICATION NAME] twice a day until surveyor intervention on 12/11/13 for a total of 23 doses. 2) Resident #13 was administered [MEDICATION NAME] (for blood pressure) despite documented abnormally low blood pressure readings of 71/26 and 109/36. She had orders to hold the medication if her SBP was less than 110 or DBP was less than 60. An Immediate Jeopardy (IJ) was identified on 01/02/14. While the IJ was removed on 01/11/14, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm, that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. These failures placed Residents #3 and #13 at risk for weakness, drowsiness, nervousness, loss of appetite, weight loss, dizziness, [MEDICAL CONDITION] and death and could affect the 43 residents, who resided on Station One. Findings included: 1) Resident #3 was a [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she was severely impaired cognitively, and was totally dependent on staff for her ADLs. Observation on 12/11/13 at 12:55 PM revealed Resident #3 was sitting in the dining room with her head on the table and appeared to be sleeping. At 1:05 PM, a staff member arrived, roused her and fed her lunch. She only consumed 25% of her meat and 60% of her dessert. Review of Resident #3's Nurse's Notes dated 11/05/13 reflected the following: "Had meeting (care plan) (with) (Physician K) and (family members) who expressed some concern about (Resident #3). (Physician K) decided to DC [MEDICATION NAME] (antiparkinsonism) liq 50 mg/5 ml BID, [MEDICATION NAME] 125 mg sprinkles BID, (change) [MEDICATION NAME] (diuretic) 20 mg daily to [MEDICATION NAME] QOD, then add [MEDICATION NAME] Patch (anti-Alzheimer)...family in agreement. Place on mars, fax to Rx...." The note was signed by ADON MM. Resident #3's Physician's Telephone Orders dated 11/05/13 reflected: Discontinue [MEDICATION NAME] liquid, [MEDICATION NAME] 125 mg sprinkles, change [MEDICATION NAME] to 20 mg every other day and add [MEDICATION NAME] 4.6 mg daily. The order was written by the ADON MM. Review of Resident #3's MARs for the month of November 2013 revealed an entry for [MEDICATION NAME] 125 mg Sprinkles by mouth twice a day with an order date of 10/24/13. The entry was noted to be discontinued and ceased to be given on 11/05/13. Review of Resident #3's consolidated physician's orders [REDACTED]. The orders were signed as reviewed by the ADON MM. Review of Resident #3's MARs for December 2013 revealed the following entries: [MEDICATION NAME] 125 mg Sprinkles by mouth twice a day with an order date of 10/24/13. The medication was initialed as administered twice a day from 12/01/13 through 12/11/13. The medication was discontinued after surveyor intervention. During an interview on 12/11/13 at 2:42 PM, ADON MM stated she reconciled the medications at the end of the month and signed off on the monthly consolidated physicians orders. ADON MM was shown Resident #3's orders to discontinue the [MEDICATION NAME] as well as the December 2013 consolidated orders with [MEDICATION NAME] 125 mg Sprinkles by mouth twice a day ordered. ADON MM stated she could not explain the discrepancy and would make sure the drug was discontinued immediately. A later review of the MAR for December 2013 revealed the same [MEDICATION NAME] entry had a handwritten note that reflected: "D'CD 12/11/13 @ 1800 (6:00 PM)." However, the medication was signed as administered on 12/11/13 at 8:00 PM and again on 12/12/13 at 8:00 AM. "Nursing 2013 Drug Handbook" 31st Edition, Wolters Kluwer, Copyright 2013, 33rd Edition, pages 1379 - 1382, reflected the following for [MEDICATION NAME]: Start [MEDICATION NAME] at a lower dosage for elderly patients increasing the dosage slowly. Common reactions to [MEDICATION NAME] included asthenia (abnormal weakness or lack of energy), dizziness, somnolence (drowsiness), and anorexia (loss of appetite). Fatal liver toxicity may follow nonspeciic symptoms such as malaise, fever, anorexia, gacial [MEDICAL CONDITION], vomiting, weakness and lethargy. If these symptoms occur during therapy, notify the prescriber at once. 2) Resident #13 was a [AGE] year-old female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she had severely impaired cognition and was totally dependent on staff for assistance with ADLs. Review of Resident #13's Care Plans revealed the only care plan for the resident for "Hypertension" revealed it was dated 07/02/13 and initiated by the Director of Dietary Services. It reflected: "Problem/ Need - Problem Onset: 07/02/13 (Resident #13) has potential for retaining abnormal body fluids R/T Hx. of HTN. Goal & Target Date: (Resident #13) will maintain within normal body fluid level as evidence of normal related lab values until next review date. Approaches: --Diet as ordered by physician. --Obtain monthly weights. --Diet Consult as needed. --Monitor for S/S of [MEDICAL CONDITION]" Resident #13's consolidated physician's orders [REDACTED]. -[MEDICATION NAME] 0.1 mg by mouth daily at 9:00 AM; Hold if SBP less than 110 or DBP less than 60. -[MEDICATION NAME] 50 mg one three times daily at 9:00 AM, 1:00 PM and 5:00 PM; Check B/P and Hold if SBP less than 110 or DBP less than 60. Resident #13's MAR for December 2013 reflected the following: [MEDICATION NAME] 50 mg one by mouth three times a day, Hold if SBP less than 110 or DBP less than 60. The medication was scheduled for 9 AM, 1 PM and 5 PM with spaces provided beneath each day's entry to record the blood pressure. The 5 PM dose entry for [MEDICATION NAME] reflected: --12/02/13 - BP 71/26 - dose was initialed as given. --12/10/13 - BP 109/36 - dose was initialed as given. A note on the back of a separate page reflected: "12/10/13 5P Held [MEDICATION NAME] 0.1 mg tab PO BP 109/36." Signed by LVN C. Note: LVN C could not have held the [MEDICATION NAME] because it was scheduled for 9:00 AM and LVN C did not work the day shift. --12/11/13 - BP 97/68 - dose was circled as held. A note on the back of a separate page revealed "12/11/13 5P BP 97/68 Held [MEDICATION NAME] 0.1 mg." Signed by LVN C. Note: Again, LVN C could not have held the [MEDICATION NAME]. --12/12/13 -BP 88/45 - dose was circled as held. A note on the back of the page reflected: "12/12/13 5 PM BP 88/45 P 77 Held [MEDICATION NAME] 50 mg." Signed by LVN C. Another note on the back of a separate page reflected: "12/12/13 5P BP 88/45...Held [MEDICATION NAME] 0.1 mg. RT (retake) @ 7P 105/70 P 64." Signed by LVN C. LVN C, Resident #13's 3:00 PM to 11:00 PM Charge Nurse, was interviewed on 12/16/13 at 3:30 PM. LVN C was shown Resident #13's December MAR and asked about the blood pressure reading of 71/26 on 12/02/13. LVN C stated, "Initially I write them down, then come back and re-check (the BP)." LVN C looked in a small book she brought, but was unable to find a recheck BP. When asked when she would call the physician, LVN C stated she would call if the blood pressure readings were consistently lower, but LVN C further stated Resident #13 had higher readings in the mornings. When asked what she typically did when the blood pressure readings were low, LVN C stated she would hold blood pressure medications and recheck the blood pressure. When asked how she should document that, LVN C stated she should circle the initialed dose and record the information on the back of the MAR, then return and recheck with a different blood pressure cuff. She explained if the readings were unusual for several residents, she would change the batteries of the electronic BP cuff. LVN C was shown her entries in the December 2013 MAR, which reflected she administered [MEDICATION NAME] to Resident #13 with blood pressure readings of 71/26, 109/36 and 108/58. Additionally, she had written entries reflecting she held [MEDICATION NAME] doses on 12/10/13, 12/11/13 and 12/12/13 for low blood pressure readings. Only [MEDICATION NAME] was scheduled on LVN C's shift as [MEDICATION NAME] was scheduled for 9:00 AM (not on her 3 -11 PM shift). LVN C stated she was not sure but she probably meant to write [MEDICATION NAME]. When LVN C was asked if the low blood pressure trend warranted a call to the physician, she stated she was not sure. When asked how long she would let it go, LVN C replied, "I think they told us by the third day." When asked if she had ever called the resident's physician about Resident #13, LVN C replied, "No." "Nursing 2013 Drug Handbook" 33rd Edition, Wolters Kluwer, Copyright 2013, pages 680 - 681 reflected the following nursing considerations for [MEDICATION NAME]: "Monitor patient's blood pressure, pulse and body weight frequently...Elderly patients may be more sensitive to drug's hypotensive effects...." Overdose signs and symptoms include: [MEDICAL CONDITIONS] headache and flushing. http://www.nlm.nih.gov/medlineplus/ency/article/ 8.htm retrieved on 01/22/14 reflected the following related to [MEDICAL CONDITION]: "Possible Complications Falls due to low blood pressure in older adults can lead to a broken hip or spine fracture. These injuries can reduce a person's health and ability to move around Sudden severe drops in your blood pressure starves your body of oxygen. This can lead to damage of the heart, brain, and other organs. This type of low blood pressure can be life threatening if not treated right away...." 3) Review of the facility's current undated policy and procedure "MEDICATION ADMINISTRATION BY FACILITY PERSONNEL" revealed, "All medications are to be administered only as prescribed, and only by licensed medical or nursing personnel, certified medication aides, or student nurses or medication aides...." Review of the facility's current undated policy and procedure "CHARGE NURSE DUTIES" revealed, "...5. Prepare and administer medications, enteral nutrition, parental nutrition and treatments as ordered...12. Administer prn medications and treatments as necessary...." Review of the facility's current policy and procedure "Unnecessary Drugs" dated 2012 revealed: Purpose: Each resident's drug regimen must be free from unnecessary drugs. Procedure: An unnecessary drug is any drug when used 1. In excessive dose (including duplicate therapy); or 2. For excessive duration; or 3. Without adequate monitoring; or 4. Without adequate indications for its use; or 5. In the presence of adverse consequences, which indicate the dose should be reduced or discontinued; or 6. Any combination of the reasons above...." 4) An IJ was identified on 01/02/14 at 8:00 AM. The Administrator was notified at that time an IJ was identified, and a Plan of Removal for the IJ was requested. 5) The facility's Plan of Removal was accepted on 01/10/14 at 2:00 PM and contained the following: The following steps have been taken to remove the Immediate Jeopardy: On 01/02/14, the Administrator contacted Physician K, the Medical Director, and informed him of the IJ. In addition to the residents listed below all residents in the facility were at risk. On 01/02/14, ADON MM was terminated by the Administrator. Effective 01/02/14, Nursing Administration will spot check daily (for 6 months) the administering of blood pressure medications, medications for [MEDICAL TREATMENT] residents, and those on antibiotics. Weekend Supervisor LVN Y will continue this review of medications on the weekends. The daily review will cease on 07/01/14. However, the reviewing of charts periodically will continue. Effective 01/02/14, the Attending Nurse and MA will adhere to the MEDICATION REVIEW POLICY. It is clearly stated in the policy the Medication Aide must inform the Attending Nurse if a blood pressure is elevated or too low. The Attending Nurse must: Assess the resident. Approve the PRN to be given or to be held by the Medication Aide. Monitor the resident for any effects. Contact the Physician if blood pressures don't improve. The Attending Nurse should always contact Physician if the blood pressures are too low or too high and the PRN is of non effect. The Medication Aide or Nurse should ensure that all antibiotics are given until complete. Medication Aide or Nurses should ensure that [MEDICAL TREATMENT] residents receive all of their medications on the days of their [MEDICAL TREATMENT] and not have them held. Nursing Administration will in-service on this policy on January 10th, 2014. This policy will be reviewed via the Q.A. monthly for the next 6 months and periodically thereafter. Jan. 2nd, ADON NN was hired as the ADON by the Administrator. On Jan. 3rd,DON,and ADON NN will begin conducting an audit of all resident's medication's. This audit will be conducted by comparing the November 1st orders (including the telephone orders) the December order, and the January orders to the clinical record. The DON and ADON NN will be monitoring for orders with parameters, and ensuring that all current orders are transcribed correctly. This task will be completed by Wednesday January 8th, 2014. On Jan. 6th Medical Director/Physician K approved the plan of removal, and will meet with the Q.A. Committee monthly until systems are in place. On Jan. 7th, Nursing Consultant will facilitate an in-service/ competency based test to licensed nursing and medication aides on the proper verification of month end orders, and unnecessary medications. This in-service and competency based testing will be completed on Tuesday January 7th. All staff( including new hires, prn,etc.) will not be allowed to work until completed satisfactorily. RN U will be responsible for verifying the month end orders for the entire building. This process will occur by: On the 24th or 25th of each month, RN U will take the prior MARS and compare them to the clinical record. Then RN U will take the clinical record and compare it to the current MARS. On the 24th- 25th of every month forward, all new orders will be handwritten onto the current MAR, and RN U will write them onto the new MAR as she will continue to collect copies of the pink slips for the remainder of month. IF an new admission comes at the end of the month, the nurse reviewing the MAR should make a new set of Physician order [REDACTED]. The reviewing nurse should also make a new set of MARs & TARs for the next month. Computer updates should be made and faxed to the person (responsible for printing our monthly orders) at [PHONE NUMBER] for any room changes or change of physician or any corrections. Clarification of orders should be written if a medication needs to be given at a specific time other than the printed out time. Do not just cross out and write in a new time, not acceptable. 11-7 nurses will compare the old MAR to the new MAR for accuracy. RN U will also train (as a backup) Wound Nurse LVN B. The DON will be responsible for monitoring this process by: Scheduling the arrival date of the new orders each month Removing RN U from the floor as a charge nurse during the last 5-6 days of each month so she can concentrate solely on the orders. Officially meet with RN U upon her completion of her review of the orders to discuss any concerns or action items. The DON will then verbally report to the Administrator the assignment is completed/updated (physician consolidated orders are updated).... The Administrator will train staff on this new policy on 01/10/14. On 01/16/14, the current DON will be relieved of her duties. On 01/16/14, ADON NN will be the new DON of the facility. 6) Review of the facility's new, current undated policy and procedure "Monthly Review of physician's orders [REDACTED]. "Purpose: To ensure that physician order's are accurate. Policy: To verify prior to the beginning of each month that all physician orders [REDACTED]. RN (RN U)/LVN (LVN B) will be responsible for this monthly review. DON will schedule the delivery of the orders. DON will have RN (RU) to be removed from the schedule as a floor nurse for the last 5-6 days of each month. R.N. (RN U) will inform DON of all concerns regarding the orders upon the completion of the review. R.N. (RN U) will take the prior month MARS and compare them to the clinical record. R.N. (RN U) will then take the clinical record and compare it to the new MARS. R.N. (RN U) will then handwrite onto the new MAR any new orders that will come after the 25th of the month. Attending nurses will write any new orders on the current MAR until the end of the month. If a new admission comes at the end of the month, R.N. (RN U)/Designee reviewing the MAR should make a new set of physician's orders [REDACTED]. R.N. (RN U)/Designee should also make a new set of MARS and TARS for the next month. R.N. (RN U)/Designee will via fax all updates to the person responsible for preparing the monthly orders: (name of pharmacy tech) at [PHONE NUMBER]. Clarifications orders will be written. 11-7 will compare the old MAR to the New MAR for accuracy." 7) During an interview on 01/10/14 at 3:03 PM, LVN H stated PRN BP medication orders have ranges, "To guide us." She further stated after the PRN BP medication was administered she would recheck the resident's BP an hour later. LVN H stated if she saw holes on the MAR (missing initials indicating the medication was not given) or circles on the MAR (indicating the medication was not given) she would see if the medication was available, call the pharmacy, DON and the resident's responsible party. In an interview on 01/10/14 at 3:15 PM, LVN C stated she had attended in-service training related to medication administration. LVN C stated she needed to follow the parameters given for blood pressure medications and notify the physician if blood pressure readings were high or low for three days. LVN C stated if the blood pressure readings were too high or too low, she should notify the physician immediately. LVN C stated she should always go back and re-check the blood pressure if the reading was low or if she had to give a PRN dose. When asked what she should do if she observed medications with several circled doses or blanks indicating the medications had not been given, LVN C stated she should check with the previous shift to find out why and notify the physician. In an interview on 01/10/14 at 3:30 PM, LVN W stated she had attended in-service training related to medications. LVN W stated when a resident had high blood pressure, she needed to assess the resident, administer PRN medications as necessary and re-check for effectiveness. LVN W stated any blood pressure readings that were too high or too low for three days needed to be reported to the physician and family. When asked about several circled medications or missed doses, LVN W stated she needed to report it to her DON, and investigate the reason. In an interview on 01/10/14 at 5:12 PM, LVN A stated she had attended in-service training related to medication administration. LVN A stated if the Medication Aide reported an abnormal blood pressure, she would assess the resident and re-check the blood pressure, administer PRN medication as indicated and recheck the pressure in about an hour. If the pressure was still high, or if the resident required PRN medications three times in a row, she would notify the physician. LVN A stated if the resident's blood pressure was low, she would hold any applicable medication and re-check the pressure. She stated she would notify the physician if the resident's medications were held three times. When asked what she needed to do if the resident's MAR indicated several circled medications or blanks, LVN A stated she would investigate the cause and report any concerns. During an interview on 01/10/14 at 5:15 PM, LVN F stated MAs cannot administer PRN medications. She stated when a nurse gives a PRN medication he/she has to document the medication administration on the back of the resident's MAR. LVN F stated if she administered PRN [MEDICATION NAME], she would recheck the resident's BP in one half hour, and document the results in the Nurse's Notes. If the BP was still high, she would call the doctor. LVN F stated if she saw holes on the MAR (missing initials indicating the medication was not given) or circles on the MAR (indicating the medication was not given) she would tell the DON/ADON. In an interview on 01/10/14 at 5:33 PM, LVN G stated she had attended in-service training related to medication administration. LVN G stated if the Medication Aide reported an abnormal blood pressure, she would check the orders, re-check the blood pressure, administer the PRN as indicated or call for an order if there was no PRN ordered. She would later re-check the blood pressure and call the physician if there was no improvement. She would call the physician as well if there was a trend of three high or low blood pressures or dangerous levels. When asked what she needed to do if the resident's MAR indicated several circled medications or blanks, LVN G stated she would check the back of the MARs for an explanation and investigate the cause. She would contact the physician for new orders if needed. During an interview on 01/11/14 at 6:20 AM, RN U stated she usually did the monthly medication recaps for Station Two. She stated the new monthly MARs would now be delivered to the facility on the 25th or 26th of the month. She stated she would review the old MAR with the new MAR and review the new MAR with all telephone/verbal orders written for the month. She would check the pink slips (third copy of telephone orders), to ensure accuracy. RN U stated LVN B will be her back up, if she was not available. RN U stated when she administers PRN BP medication she checked the BP medication parameters, gives the PRN medication if warranted and then rechecks the resident's BP in 30 to 60 minutes. If the BP remained elevated she would recheck the resident's BP in two hours, assess the resident for headache or chest pain and call the resident 's physician. RN U stated if she saw holes on the MAR (missing initials indicating the medication was not given) or circles on the MAR (indicating the medication was not given) she would call the previous nurse and see if the medication was given. And then report it to DON/ADON. In an interview on 01/11/14 at 6:25 AM, LVN QQ stated she had attended in-service training related to medication administration. LVN QQ stated if her resident's BP was high, she would administer any scheduled medication, then recheck the BP. If the blood pressure was still high and the resident had an order for [REDACTED]. If there was no order or the blood pressure remained high, she would notify the physician. LVN QQ stated if her resident's BP was abnormally high or low for three days or very high or low, she would notify the physician. When asked what she needed to do if the resident's MAR indicated several circled medications or blanks, LVN QQ stated she would investigate the cause and report any concerns. In an interview on 01/11/14 at 7:50 AM, LVN S stated he had attended in-service training related to medication administration. LVN S stated if a resident had high blood pressure, most of the time they had a PRN order. He stated he would give the PRN medication then re-assess the resident after 45 minutes to one hour. If the blood pressure was still high, he would notify the physician and family. If it continued to happen, he should notify the physician after the third time. LVN S stated if the resident's blood pressure was low, he would hold the medication and re-assess. If continued, call the physician. When asked what he needed to do if the resident 's MAR indicated several circled medications or blanks, LVN S stated he would report it to the DON and she (DON) would take over. During an interview on 01/11/14 at 8:20 AM, LVN T stated if a resident had an order for [REDACTED]. She stated the MA should tell the nurse what the resident's BP was and what the parameters were and then the nurse will tell the MA to administer the PRN. She stated after one or two hours, she would go back and recheck the resident's BP and document the results in the Nurse's Notes. LVN T stated if the BP was still high, she would call the physician and ask what she should do. LVN T stated if she saw holes on the MAR (missing initials indicating the medication was not given) or circles on the MAR (indicating the medication was not given) she would find out what happened. She would call the physician and family and report to the supervisor. In an interview on 01/11/14 at 8:29 AM, LVN J stated he had attended in-service training related to medication administration. LVN J stated if a resident had high blood pressure, he should check for a PRN order and administer it based on the given parameters then re-check after an hour. LVN J stated if the Resident's blood pressure was still high, or if there was a trend of three or more high readings, he should call the physician. LVN J stated if the resident's blood pressure was low, he would hold any applicable medications, recheck the resident after an hour and notify the physician if there was no improvement. When asked what he needed to do if the resident's MAR indicated several circled medications or blanks, LVN J stated if issue was [MEDICAL TREATMENT] or other reasons, he would call the physician. If there were holes, he would call the charge nurse for that particular shift. In an interview on 01/11/14 at 8:55 AM, LVN FF stated he had attended in-service training related to medication administration. LVN FF stated if a resident had high blood pressure, he should administer PRN medications as ordered and recheck the blood pressure in an hour. If PRN medications were required three of four times, he should call the physician. LVN FF stated if the blood pressure was low, he should hold applicable medications and recheck the resident. If the blood pressure remained low or if it was below 90/60, he should call the physician. When asked what he needed to do if the resident's MAR indicated several circled medications or blanks, LVN FF stated he would call the nurse to determine why medications were held and take it from there. If the issue was [MEDICAL TREATMENT], he should call and request a change in administration times. During an interview on 01/10/14 at 3:03 PM LVN H stated PRN BP medication orders have ranges, "To guide us." She further stated after the PRN BP medication was administered she would recheck the resident's BP an hour later. LVN H stated if she saw holes on the MAR (missing initials indicating the medication was not given) or circles on the MAR (indicating the medication was not given) she would see if the medication was available, call the pharmacy, DON and the resident's responsible party. LVN H stated if a resident was scheduled to receive [MEDICAL TREATMENT] at the same time their medications were scheduled she would call the physician and reschedule the resident's medications for when the resident was in the facility. 8) On 01/11/14, the DON provided the results of the chart audit conducted as part of the facility's Plan of Removal. The audit reflected the following medication discrepancies: "- (Resident #46) No BP checks before giving [MEDICATION NAME] in December. - (Resident #47) No BP checks before giving [MEDICATION NAME] (9 am & 1 pm) on December 19, 20 & 27th. [MEDICATION NAME] level not drawn order written by (ADON MM). - (Resident #48) No Vit D level drawn order written by (ADON MM). Order written to hold [MEDICATION NAME] until INR less than 3 only held one day on MAR, Caught before administered (order clarified) 1/2/14. - (Resident #26) No BP taken before giving [MEDICATION NAME] in December (8 am) No BP taken before giving [MEDICATION NAME] 12.5 No BP taken before giving [MEDICATION NAME] in January... - (Resident #52) November parameters not followed for [MEDICATION NAME] (should be held)... - (Resident #53) No BP checks with [MEDICATION NAME] BID (corrected) - (Resident #54) BP parameters not followed in November (beginning of month) med should've been held ((LVN C)) Insulin parameters not followed Separate orders for dosing and route for [MEDICATION NAME], and [MEDICATION NAME] [MEDICATION NAME] vs breathing treatment for [REDACTED]. - (Resident #31) Hctz ([MEDICATION NAME]) no BP or [MEDICAL CONDITION] checks - (Resident #55) [MEDICATION NAME] BP (9 am & 5 pm) - (Resident #57) Hydro ([MEDICATION NAME])/Apap 7.5/500 vs 7.5/325" 9) On 01/06/14 at 3:40 PM, the DON was asked what training had been provided to her nurses and medication aides to prevent the administration of unnecessary medications and medication errors. The DON stated all nurses had been trained on transcribing orders and if they received an order, they were responsible for following it all the way through. She stated the medication aides were taught on parameters on 12/24/13 and both the medication aides and the nurses were given training in August, 2013. The DON explained the medication aides were taught to administer the medications as written. If the blood pressure was out of range, they needed to go to their charge nurse because there might be something else going on. When asked if there was any follow-up on the training to ensure the staff were compliant, the DON stated she would randomly do "scenario testing" and just give the staff an example of a situation and ask them how they handle it. There was no follow-up by checking the MARs. When asked about any ongoing monitoring, the DON replied, "Not really." And stated she would occasionally check a MAR. When the DON was asked how the IJ occurred, she stated the nurses were not using the knowledge they had, no follow-up, not checking the parameters they had. When asked about the monthly recapitulation of the orders, the DON stated the staff were not thoroughly checking every step and failed to ensure the orders made it to the person responsible for the computer entry. She added staff should not just compare MARs but needed to check orders as well. 10) On 01/11/14 at 11:20 AM, when the Administrator was asked what procedure had existed to ensure the nursing needs of the residents were met, she explained ADON MM I thought ADON MM was terminated on 01/02/14??? Are you interviewing about what used to happen? or what was now going to happen?? We asked her to explain the process before the IJ and what her current plan was. and RN U were responsible for checking the orders at the end of the month to ensure what was to be carried over and get ready for the upcoming month. What was not available, was someone to follow-up with the recapitulated orders except for the 11:00 PM to 7:00 AM nurse, who was checking MAR to MAR. The Administrator stated, as far as blood pressure medications were concerned, she had instructed the DON and ADOM MM to check the MARs for omissions, and check up on the Medication Aides then make sure to do spot checks. The Administrator went on to explain she was not a part of the meetings when the pharmacist would report their evaluations and any triggers that were found. She stated the Pharmacy Consultant would talk to her but had never mentioned any of these issues. She added she was going to trend the consultant reports for at least six months to focus on things like [MEDICAL TREATMENT] residents, antibiotics etc. When the Administrator w

Based on interview and record review, it was determined the facility failed to ensure two (Residents #2 and #5) of 12 residents reviewed for medication regimen were free from unnecessary medications. 1.The facility failed to discontinue Resident #2's [MEDICATION NAME] 25mg (for Hypertension) as ordered. The morning dose of [MEDICATION NAME] was discontinued after the AM dose on 02/03/14 and the evening dose was discontinued after the PM dose on 02/28/14, for a total of 31 doses. 2. Resident #5 received nine doses of [MEDICATION NAME] between 10:00 pm and 11:30 PM (from 03/04/14 to 03/21/14), despite her physician ' s specific orders that she was not to have the medication at bedtime. No pain assessments were documented and the physician was not notified. An Immediate Jeopardy (IJ) was initially identified on 03/20/14. While the IJ was removed on03/24/14, the facility remained out of compliance at a scope of "widespread" and a severity level of "actual harm that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. These failures placed Residents #2 and #5 at risk for weakness, confusion, dizziness, headache, [MEDICAL CONDITIONS], over sedation, lethargy, and death and could affect the 75 residents in the facility. Findings included: 1. Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed Resident #2 had a BIMS of 4 and was dependent on staff for most of his ADLs. Review of Resident #2's Care Plan dated 02/27/14 revealed: "Date & Problem: DX [MEDICAL CONDITION]/HTN/[MEDICAL CONDITION] Goal: (Resident #2) will not suffer any complications caused by Dx ' s thru the next eval date. Approaches & Disciplines: Lab as ordered Notify Dr. of results Medications as ordered. Notify Dr of effectiveness Monitor for [MEDICAL CONDITION], SOB, Pain in extremities with discoloration of skin and warm to touch Document and Notify Dr/RP/Hospice." Resident #2's Physician's Telephone Orders dated 01/09/13 reflected [MEDICATION NAME] 25 mg twice a day. Resident #2's Physician's Telephone Orders dated 01/30/14 reflected increase [MEDICATION NAME] to 50 mg twice a day for blood pressure. Review of Resident #2's MARs for the month of January 2014 revealed the last dose of [MEDICATION NAME] 25 mg was on 01/30/14 after the 9:00 PM dose. Further review of this MAR revealed [MEDICATION NAME] 50 mg was started on 01/30/14 at 9:00 PM. Review of Resident #2's MARs for the month of February 2014 revealed [MEDICATION NAME] 50 mg twice a day was administered as ordered. Further review of this MAR revealed the morning dose (9 AM) of [MEDICATION NAME] 25 mg was administered on 02/01/14, 02/02/14/ and 02/03/14. "DC'D" was hand written after the 9 AM dose was administered on 02/03/14. The evening dose (4:00 PM) of [MEDICATION NAME] 25 mg was administered each day during the month of February. A total of 31 doses of [MEDICATION NAME] 25 mg were administered that the physician had discontinued on 01/30/14. During an interview on 03/04/14 at 3:55 PM the surveyor reviewed Resident #2's February 2014's MARs with LVN B, Resident #2's evening charge nurse. LVN B stated she did administer [MEDICATION NAME] 25 mg and [MEDICATION NAME] 50 mg on the days she worked, as were documented on Resident #2's MAR. During an interview on 03/05/14 at 10:05 AM the ADM stated the Unit Manager did the February 2014 monthly recapitulations of physician orders [REDACTED]. During an interview on 03/04/14 at 4:30 PM the Unit Manager stated she checks the pink slips (copy of telephone physician orders) daily to make sure the orders were correct on the MARs. She stated when she did the February 2014 monthly recapitulations of physician orders, she was taken off the floor from 01/25/14 through the end of the month, and the DON took over her tasks, including verifying the pink slips were checked, for the whole building. During an interview on 03/06/14 at 4:30 PM the ADM stated Resident #2 receiving 31 doses of [MEDICATION NAME], which had been discontinued, was a careless error. The ADM further stated the DON told her she did miss a few a days of checking pink slips. During an interview on 03/06/14 at 8:47 AM the surveyor asked the DON how she thought Resident #2's received 31 doses of [MEDICATION NAME] that had been discontinued. The DON stated when RN A taught the Unit Manager how to do the monthly recapitulations of physician orders, RN A did not instruct the Unit Manager to continue to add additional physician orders [REDACTED]. "Nursing 2013 Drug Handbook" 33rd Edition, Wolters Kluwer, Copyright 2013, pages 680 - 681 reflected the following nursing considerations for [MEDICATION NAME]: "Monitor patient's blood pressure, pulse and body weight frequently...Elderly patients may be more sensitive to drug's hypotensive effects...." Overdose signs and symptoms include: [MEDICAL CONDITIONS] headache and flushing. 2. Resident #5 was an [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she had no cognitive impairment; was receiving scheduled and PRN pain medications, and she reported she had " occasional " pain rated 4 out of 10 on a 1-10 scale with10 being most severe. Review of Resident #5 ' s Comprehensive Resident Care Plan dated 11/7/13 and reviewed 01/30/14 revealed the following: " PROBLEM: Pain management for Spinal Stenosis, Muscle Spasms Arthropathy and Late Effect [MEDICAL CONDITION] GOAL: (Resident #5) will be at her comfort level within 30 mins of discomfort this eval period. APPROACHES: 1. Assess for pain/discomfort and document 2. Medication per order ... [MEDICATION NAME] (routine & PRN) 3. Document/Notify physician of effects of meds. 4. Will be assessed/asked if in pain/discomfort @ time of Routine Med Pass Q shift .... " Review of Resident #5 ' s physician ' s Progress Note dated 03/05/14 revealed she had a past medical history of [REDACTED]. The assessment/plan portion of the note reflected: " ...DJD-on [MEDICATION NAME]/[MEDICATION NAME] (pain medication) .... " Resident #5 ' s Physician ' s Telephone Orders dated 02/24/14 reflected: " N/O ' s 1) D/C [MEDICATION NAME] (sleeping pill) 1 mg PO PRN 2) Add [MEDICATION NAME] 1 mg tab (1) PO q HS Dx: [MEDICAL CONDITION] 3) [MEDICATION NAME] 7.5/325 Give (1) PO BID @ 9A & 6 PM. 4) [MEDICATION NAME] 7.5/325 Give (1) PRN tab in the daytime not at H.S. Q6(hours) " The order was written by LVN F. Resident #5 ' s Physician ' s Telephone Orders dated 03/05/14 reflected: " Order clarification for Med time change for: ([MEDICATION NAME]) pregabalin 75 mg give 1 cap po BID @ 10:00 AM and 10:00 PM .... " Review of Resident #5 ' s MAR for the month of March 2014 revealed: An entry for " [MEDICATION NAME] 7.5/325 mg 1 PO BID at 10 AM and 6 PM " An entry for " [MEDICATION NAME] 7.5/325 mg 1 PO Q 6 HRS PRN PAIN Give in daytime only NOT HS. " The MAR revealed only three PRN doses were signed as administered and those were given in the afternoon hours with pain assessments completed by LVN L. Review of Resident #5 ' s Controlled Substance Record for [MEDICATION NAME] 7.5/325 mg revealed the following doses were signed out in the evening hours: 03/04/14 at 11:30 PM by LVN F 03/11/14 at 11:00 PM by LVN F 03/12/14 at 10:00 PM by LVN F 03/13/14 at 10:00 PM by LVN F 03/14/14 at 10:00 PM by LVN F 03/17/14 at 11:00 PM by LVN F 03/18/14 at 11:00 PM by LVN F 03/19/14 at 11:30 PM by LVN F 03/21/14 at 11:00 PM by LVN F Review of Resident #5 ' s Nurse ' s Notes revealed the following: An undated, untimed entry made by LVN F reflected the following: " Physician R called (with) request to (change) resident [MEDICATION NAME] 7.5/325 to TID @ (sic) she takes it PRN like a routine @ HS. Physician R declined & stated to continue [MEDICATION NAME] 7.5/325 BID 9A & 6P & Give [MEDICATION NAME] 7.5/325 PRN in the daytime not @ HS Q6 (hours). 1) D/C [MEDICATION NAME] 1 mg PO PRN 2) Add [MEDICATION NAME] 1 mg tab PO q HS. Dx. [MEDICAL CONDITION]. Notified_____ RP. OK. " Further review of the Nurse ' s Notes for February and March 2014 revealed there were no entries related to Resident #5 complaining of pain or requesting medication. Review of Resident #5 ' s Weekly Summary dated 03/05/14-03/11/14 revealed she had " vocal complaints " of " moderate pain " rated " 6 " out of 10. Primary Diagnosis(es) included: " DM II, Debility, [MEDICAL CONDITION], Chronic Back Pain. " The Summary was completed by LVN F. Review of Resident #5 ' s Weekly Summary dated 03/12/14-03/(illegible)/14 revealed she had " occasional " pain rated " 6 " out of 10. Primary Diagnosis(es) included: " DM II, Debility, PKD (sic), Chronic Back Pain. " The summary was completed by LVN F. During an interview on 03/23/14 at 10:45 AM, LVN L, (Resident #5 ' s weekend Charge Nurse) was asked about pain management. He stated if a resident complained of pain, he would administer a pain pill then monitor for effectiveness, if not effective, the doctor should be called. LVN L stated the pre and post pain assessments were documented on the MAR. When asked about Resident #5 ' s pain, LVN L explained she used to get a PRN dose at night but the order changed, He explained she would ask for it every night but when he saw the order changed so she could not have it at night anymore, he took the order to her and sowed it to her. He stated he offered to call the physician for her and she told him not to. She told him she wanted to talk to the doctor herself. LVN L stated, since that time, she had not requested pain medication from him at night any longer. During an interview on 03/23/14 at 1:15 PM, LVN F (Resident #5 ' s 3:00 PM ? 11:00 PM Charge Nurse) stated all PRN pain assessments should be documented on the back of the MAR and logged on the Narcotic Sheet. When she was asked about Resident #5 ' s pain management, she stated, " ...(Resident #5) hurts all the time, she begs for pain pills at night. I called (Physician R), she was getting it ([MEDICATION NAME]) at night. She would be asking as soon as I walked in and again at 10:00 (PM). She was still complaining so I said I ' ll see if I can have an order for [REDACTED]. her to have it TID, she said she could have it PRN in the daytime not at bedtime. " LVN F confirmed that was when she had written the order on 02/24/14. LVN F stated she had also spoken with Physician R when she came in and had encouraged Resident #5 to speak with her as well. She stated the physician did not change her mind and still did not want the resident to have [MEDICATION NAME] at night. LVN F stated Resident #5 continued to ask for a dose at bedtime and she gave it to her. When asked if she called the Physician first, LVN F replied, " No, I didn ' t think it was a good order. " When shown the routing sleeping pill order and asked if that was maybe why the physician did not want her to have the medication, LVN F replied, " She ' s been taking it for a long time. " When LVN F was again asked if it occurred to her to call the physician all those nights the resident was complaining and ask what she should do, she replied, " No, because it ' s (Physician R) and her response is not that good ...with call back, it ' s not that good. " A surveyor asked LVN F if she realized she could not give that dose. LVN F replied, " Yeah, I realize that. I shouldn ' t give her a pill that late. " When LVN F was asked if she ever signed the medication out on the MAR, documented any pain assessments during these episodes or made any nursing notes on the matter, she reviewed the documentation and replied, " I guess not. " On 3/23/14 at 3:20 PM, Resident #5 was observed sitting in her room, watching television. At that time, when Resident #5 was asked about her pain management by the facility she stated it was " OK. " When asked whether she had pain at night, Resident #5 replied, " Sometimes it hurts in my back, sometimes not. " When asked whether she was getting pain medication at night, Resident #5 stated she did occasionally and it sometimes helped. When asked whether she had spoken with her doctor about the pain, Resident #5 stated she had and was told there was nothing they could do. When asked who gave her pain medication at night, Resident #5 stated, " Whatever nurse is on. " 3. Review of the facility's current undated policy and procedure "Monthly Review of physician's orders [REDACTED]. "Purpose: To ensure that physician order's are accurate. Policy: To verify prior to the beginning of each month that all physician orders [REDACTED]. (RN A)/ (Unit Manager) will be responsible for this monthly review. DON will schedule the delivery of the orders. DON will have (RN A) to be removed from the schedule as a floor nurse for the last 5-6 days of each month. (RN A) will inform DON of all concerns regarding the orders upon the completion of the review. (RN A) will take the prior month MARS and compare them to the clinical record. (RN A) will then take the clinical record and compare it to the new MARS. (RN A) will then handwrite onto the new MAR any new orders that will come after the 25th of the month. Attending nurses will write any new orders on the current MAR until the end of the month. If a new admission comes at the end of the month, (RN A)/Designee reviewing the MAR should make a new set of physician's orders [REDACTED]. (RN A)/Designee should also make a new set of MARS and TARS for the next month. (RN A)/Designee will via fax all updates to the person responsible for preparing the monthly orders: (name of pharmacy tech) at [PHONE NUMBER]. Clarifications orders will be written. 11-7 will compare the old MAR to the New MAR for accuracy." Review of the facility's current policy and procedure "Unnecessary Drugs" dated 2012 revealed: "Purpose: Each resident's drug regimen must be free from unnecessary drugs: Procedure: An unnecessary drug is any drug when used: 1. In excessive dose (including duplicate therapy); or 2. For excessive duration; or 3. Without adequate monitoring; or 4. Without adequate indications for its use; or 5. In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or 6. An combination of the reasons above ...." 4) An Immediate Jeopardy situation was identified on 03/20/14. On 03/20/14 at 11:30 AM, the Administrator was notified of the IJ, and a Plan of Removal for the IJ was requested. 5) On March 20th The Department of Aging and Disabilities informed this Administrator that IHC was being placed back into an Immediate Jeopardy for unnecessary medications. THE FOLLOWING STEPS HAVE BEEN TAKEN TO REMOVE THE IMMEDIATE JEOPARDY: Prior to March 20th (March 4th) This Administrator and the DON realized that there was a flaw in the current Monthly Review of the physician's order [REDACTED]. Therefore DON revised/in-serviced on the revision that includes all nurses to be responsible for adding new orders at the end of the month. (from the 25th of the month forward) to the current MAR and the new MAR (that will be placed in the medication room). Prior to March 20th (March 6th) this Administrator counseled with DON and Unit Manager on the importance of daily checking the orders for accuracy. Prior to March 20th (March 10th) DON in-serviced/tested her licensed nurses on the revised Monthly Review of the Physician order [REDACTED]. On March 20th Unit Manager LVN and MDS Director in-serviced/tested licensed nursing staff on transcribing orders, and the new revision to the monthly recap policy. This in-service/test will be completed by the end of business March 22nd. On March 21st DON and Unit Manager LVN will continue to in-service/test the licensed staff on Monthly Review of Physicians Orders Policy, Receiving and Reordering Medication Order ' s Policy, Admissions Orders ' Policy, the Discontinued Order ' s Policy. Also, Pharmacy Consultant prepared an in-service/test on Medication Ordering, Documenting and Removing Medications from the Medication Cart for Destruction. These in-services/test will be completed by the close of business on March 22nd. On March 21 (DON will continue to review with R.N. A, and Unit Manager at the beginning of each month to ensure that all orders received from the 25th of the month forward all were properly transcribed to the current and the new MAR. (see form) On March 21st the DON and Unit Manager will meet at the end of EACH DAY in the Administrator ' s office to present PROOF that orders, initial assessments, items from the daily nursing round sheet are indeed completed. EACH MONDAY THE Weekend Supervisor R.N. will meet the Administrator to provide the proof of the completed task vie the daily nursing round sheet. This meeting will continue through 2014. On the days that I am not in the building the proof will be provided to the CEO. (see copies of the daily nursing round sheets) On March 21st F-TAG 329 Unnecessary Meds will continue to be a part of the monthly Q.A. with the Medical Director for the remainder of 2014. On March 21st Director of Nursing began in-servicing/testing the licensed staff on the 5 rights of medication administration. This training/testing will be completed by the end of business March 24th. On March 21st all new hires, staff, on vacation, out ill etc .... will not be allowed back to work prior to completing all o the above in-services/testing ... On March 22nd, Director of Nursing R.N. began in-servicing/testing the licensed staff on the 5 rights of medication administration. This will be completed on March 24th. 6. Review of a current facility policy and procedure " Transcribing Physician order [REDACTED]. " Purpose: To ensure that the resident medications, labs and treatments are being transcribe (sic) according to the physician orders. To ensure licensed nurses are following correct physician orders. Policy: The Nursing Administration Department will review the MAR to ensure that the attending nurses properly transcribe all physician orders. Procedure: The attending nurse will: 1.Received physician order a. Medication b. Lab c. X-ray/US d. Consults e. Diet changes f. Wound care g. Fole care h. [DEVICE] care i. Oxygen 2. Write in on the MAR or TAR 3. Document on: a. 24 hour report b. Nurse Notes 4. Send order to pharmacy 5. Call X-ray/US, write confirmation number on telephone order. 6. If lab, write requisition and plan in lab book. 7. Notify responsible part. " 7. The following staff were interviewed following their attendance at the facility in-services: LVN J on 03/23/14 at 9:20 AM RN M on 03/23/14 at 10:00 AM LVN L on 03/23/14 at 10:45 AM LVN H on 03/23/14 at 12:05 PM LVN E on 03/23/14 at 12:30 PM LVN I on 03/23/14 at 2:45 PM LVN O on 03/24/14 at 12:30 PM LVN K on 03/24/14 at 12:45 PM LVN Q on 03/24/14 at 3:30 PM When interviewed, staff verbalized learning how they knew which medications to administer to their assigned residents, what follow up to do after a PRN pain medication was administered, how to update current and next month ' s MARs after a new physician order [REDACTED]. The following MA was interviewed following their attendance at the facility in-services: MA N on 03/23/14 at 12:40 PM. When interviewed, MA N verbalized understanding he should always report any resident complaints to the Charge Nurse immediately. He stated he should compare the medication cards to the MAR and if there was any question related to his medication administration he should check with his Charge Nurse. 8. On 03/06/14 at 8:47 AM the DON stated when the Unit Manager was pulled off the floor to complete monthly recaps, she (the DON) has to pick up verifying daily physician and admission orders [REDACTED]. On 03/24/14 at 10:26 AM the DON when asked how she thought LVN F administered Resident #5 pain medication without an order and the DON stated, " I ' m not sure Resident #5 even go the [MEDICATION NAME]. I ' m not sure what happened. I think some things were going on with LVN F. " 9. On 03/06/14 at 4:30 PM when the ADM was asked how she thought Resident #2 ' s errors occurred she stated it was just a careless error. She further stated the Unit Manager was not taught to look for further physician orders [REDACTED]. On 03/24/14 at 12:08 PM when the ADM was asked how she thought Resident #5 ' s medication errors occurred she stated the resident ' s nurse let her emotions get in the way. The nurse did not follow the physician orders [REDACTED].#5 ' s complaint of pain. The ADM further stated the nurse did not follow the facility policy and procedure; she did follow her professional judgment and techniques and let bad habits overrule the protocol. 10. While the IJ was removed on 03/24/14, the facility remained out of compliance at a scope of "widespread" and a severity level of "actual harm that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. 11. Review of the facility's Form-672, Resident Census and Conditions of Residents, dated 03/04/14 and signed by DON reflected a census of 75.

Based on observation, interview and record review, the facility failed to implement the facility's policies and procedures, which prohibit neglect for one (Resident #1) of eight residents reviewed for neglect. LVN A failed to transcribe the physician's orders [REDACTED]. LVN A wrote the order on the Laboratory Log, which was later altered. Resident #1's PT/INRs were only checked on [DATE] and [DATE]. The ADON failed to recognize Resident #1 was receiving [MEDICATION NAME], but did not have physician's orders [REDACTED]. Resident #1's attending physician, who was also the facility's Medical Director, and his NP failed to recognize Resident #1 was receiving [MEDICATION NAME] without the monitoring of her PT/INR levels to check the medication's therapeutic level. The facility's contracted Pharmacist failed to recognize Resident #1 was receiving [MEDICATION NAME] without checking the resident's PT/INR for monitoring the [MEDICATION NAME]'s therapeutic level, when the Pharmacist completed the facility's Drug Regimen Review for each resident on [DATE]. These failures resulted in Resident #1 having rectal bleeding, being hypotensive, not responding well, and being in mild respiratory distress on [DATE] and being transferred to the hospital where she expired 25 minutes after arriving in the Emergency Department of the local hospital. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility had not yet in-serviced all nursing staff and fully implemented their Plan of Removal. These failures could affect the nine residents receiving [MEDICATION NAME] by placing them at risk for not having their PT/INRs monitored, which could result in bleeding and/or death. Findings included: Resident #1's hospital History and Physical, dated [DATE] reflected Resident #1 was admitted to the hospital after a fall with fracture at home. The History and Physical also reflected, "living alone in her own home... Patient is not taking any medicines at all at home, except for [MEDICATION NAME] Review of Systems - the patient is edentulous, but she said she can chew very well with her gums. She cooks. She denies nausea, vomiting. She denies diarrhea, dysuria, hematuria, anuria. Denies constipation, abdominal pain. Denies chest pain. Denies shortness of breath. All other systems are reviewed and negative...GI and [MEDICAL CONDITION]. Will start her on [MEDICATION NAME], as well as [MEDICATION NAME] at this time." Resident #1's hospital Facility Transfers Orders, printed [DATE], reflected, "...recheck CBC, CMP in ,[DATE] days. Check [MEDICAL CONDITION] in (one) week." Resident #1's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment also reflected she was cognitively intact, required extensive assistance with bed mobility, transfers, dressing, and was totally dependent on staff for toileting, bathing, and locomotion off the unit. Her life expectancy was not less than six months, she was in isolation, and was expected to be discharged back to the community. Resident #1's facility admission orders [REDACTED]. The Orders also reflected Aspirin (blood thinner) 81 mg daily. Resident #1's facility admission orders [REDACTED]. Lippincott, Williams & Wilkins Nursing 2013 Drug Handbook on page 1409, regarding [MEDICATION NAME], reflected, "Overdose S&S (signs and symptoms: Blood in stools...NURSING CONSIDERATIONS Black Box Warning [MEDICATION NAME] ([MEDICATION NAME]) can cause major or fatal bleeding, which is more likely to occur during the starting period and with a higher dose. Regularly monitor INR in all patients Consider more frequent INR monitoring in those at high risk for bleeding...Regularly check for...tarry stools...Elderly patients...are especially sensitive to drugs effect...." Resident #1's Nurse's Notes, dated [DATE], reflected, "...medications confirmed by (Resident #1's physician), new orders obtained, lab requisition [MEDICATION NAME] give (sic) from Emergency Kit...." Resident #1's Physician's Telephone Orders, dated [DATE] through [DATE], did not reflect any orders to check her PT/INR. On [DATE] at 3:30 p.m., the Administrator stated, "...The lab company did not come and draw the blood every 3 days...." The facility's copy of the Laboratory Log, dated [DATE], reflected, "PT/INR every 3 days" for Resident #1. The Log also reflected, "Forwarded x (times) 9 days" and underneath were the phlebotomist's initials circled. However, the facility's contracted laboratory services provider's Laboratory Log, dated [DATE], reflected "Every" was crossed out and "in ,[DATE] days" was inserted to reflect "PT/INR in ,[DATE] days." The Log also reflected "Forward For [DATE]" and the "x 9 days" was crossed out. The initials were still present. An interview on [DATE] at 5:40 p.m. with LVN A, the nurse who admitted Resident #1, revealed when asked about the procedure for obtaining orders for new admissions, he replied, "After I complete the assessment, you call the doctor and report your findings, read the hospital discharge orders to him, obtain orders. I write them down on plain paper then write on the telephone order (form). I remember there was an order for [REDACTED]. I did write it on the Laboratory Log." LVN A reviewed a copy of the Laboratory Log, dated [DATE] with an entry for Resident #1. He confirmed he wrote the information on the copy presented to him. LVN A said, "During the time she was here we were doing stools for [MEDICAL CONDITION]. I collected the stool specimens myself and there was never any blood. When she went to the hospital, I was told in report she went to the hospital, she was bleeding from the rectum. I specifically asked if there was a lot of blood. I knew she was [MEDICATION NAME]. (LVN G) said, 'There was a lot of blood.'" LVN A denied Resident #1 ever complained of abdominal pain. "They suspended me yesterday and said I'm under investigation." Interview on [DATE] at 10:30 a.m. with the facility's only ADON revealed she reviewed the copies of the physician's orders [REDACTED]. When asked how she missed there were no orders to check Resident #1's PT/INR, when the resident was on [MEDICATION NAME], she replied, "I don't know." Resident #1's Physician's Telephone Order, dated [DATE], reflected to increase the [MEDICATION NAME] to 3.5 mg daily. Resident #1's Laboratory Report, dated [DATE], reflected her PT/INR results were PT 13.6 seconds with a reference range of 10.4 - 13.8 seconds and an INR 1.34 with a reference range of 0.80 - 1.20 ratio. The Report also reflected her Complete Blood Count results were all within normal ranges. The Report also reflected the physician reviewed the lab on [DATE] as evidenced by his signature, and he increased her [MEDICATION NAME] to 3.5 mg daily. The facility's Pharmacist's Medication Regimen Review, dated [DATE], reflected, "...Some lab results were not completed/filed for review this visit. Per staff lab audit already requested and should be completed this month." The Review also reflected for Resident #1, "Resident with orders from prior placement with [MEDICATION NAME] 10 mg QD and started on [MEDICATION NAME] 15 mg QD upon admit. With orders for Mag Ox 400 mg PRN and order started routine for the resident. Please clarify both orders and update. Nurse notified." The Pharmacist's Medication Regimen Review, dated [DATE], did not address the lack of physician's orders [REDACTED]. Resident #1's Nursing Facility History and Physical, dated [DATE] and signed by Resident #1's physician, reflected [DIAGNOSES REDACTED]. The History and Physical also reflected the resident was in the hospital for an open reduction and internal fixation for a fracture, and she was currently taking [MEDICATION NAME] and [MEDICATION NAME]. Resident #1's Nursing Facility History and Physical, dated [DATE], did not reflect the physician reviewed the resident's PT/INR from [DATE] or the need to check her PT/INR. Resident #1's Care Plans, dated [DATE], did not address monitoring her for signs and symptoms of bleeding as it related to the administration of [MEDICATION NAME]. The care plan for "Problem of Pain management: [MEDICAL CONDITION] of Leg/[MEDICAL CONDITION] medication ([MEDICATION NAME]/[MEDICATION NAME]) as ordered Report lab result to Physician...." Resident #1's Laboratory Report, dated [DATE], reflected the results of her PT/INR were PT 19.5 seconds with a reference range of 10.4 - 13.8 seconds and an INR of 2.47 with a reference range of 0.80 - 1.20 ratio. The Report also reflected her Complete Blood Count results were all within normal ranges. A handwritten note on the Report reflected, "Order [DATE] D/C (discontinue) [MEDICATION NAME] when INR 2 Med (medication) D/Cd (discontinued)." Another handwritten note on the Report reflected, "Hold [MEDICATION NAME] MD not (sic) called awaiting call back" with a date of [DATE]. Interview on [DATE] at 12:25 p.m. with the DON revealed the only labs she could locate for Resident #1 for PT/INR levels were dated [DATE] and [DATE]. The DON stated she thought Resident #1 had a transfer order from the hospital regarding the frequency for obtaining laboratory values for PT/INR levels. She stated she was unable to locate any orders for routine monitoring of the PT/INR. Further interview with the DON on [DATE] at 3:55 p.m. revealed when asked about the system for monitoring [MEDICATION NAME], she replied, "There is a sign-in sheet - count sheet. Normally labs (PT/INR) are drawn weekly. Based on that lab, the medication is increased or decreased by the doctor to keep at therapeutic level. The nurse always gives it ([MEDICATION NAME])." Telephone interview with Resident #1's physician, who was also the facility's Medical Director, on [DATE] at 1:35 p.m. revealed his standards of care included weekly laboratory tests for PT/INR levels to monitor residents who were administered [MEDICATION NAME]. He stated every resident was different, and at this time, he could not explain why Resident #1 did not have a physician's orders [REDACTED]. Resident #1's NP M's Progress Note, dated [DATE], reflected the boxes for "Meds reviewed: See medical orders in chart...Continue with current medications; Continue with current treatments; Reviewed PMH (Past Medical History)/family/social; Reviewed Labs/X-rays; Reviewed Hospital documents." Resident #1's Physician's Telephone Order, dated [DATE], reflected, "...D/C [MEDICATION NAME] when INR is 2 or greater...D/C [MEDICATION NAME]." Resident #1's Nurse's Notes, dated [DATE] at 7:00 a.m., reflected, "Went to awaken Res (resident) and Res is not responding does not awaken to strong patting of chest as she has been doing no respiratory effort noted. Hands are cool body is slight warm; continue to try to awaken res unsuccessful. Rush to desk to determine code status she is full code - ask for assistance. Went back to res to start code blue, and called Res name and strongly patted chest. Res Responds a little by turning head and ...Res mumbles a sound. Then makes facial grimace continue patting chest...." An interview on [DATE] at 7:40 a.m. with RN I revealed, "One morning I had a hard time waking her up. I was read to call a code on her. One of the other girls came in - called her name and she opened her eyes." The episode on [DATE] was reviewed with RN I, who said it "was a one-time occurrence. The last morning she (Resident #1) was here the CNAs got her up and took her to the dining room early. I went to the dining room to give her meds. She could respond a little bit - raised her head up when I called her name. I told her it was time to take her meds. She let me put them in her mouth. She opened her mouth and took some water that didn't immediately drool out, but it did drool out." When asked about bleeding, RN I replied, "I never saw any blood from her rectum. I remember asking about and what happened to her. I was told she was bloody stool - a diaper full." The facility's 24 Hour Report, for [DATE], did not reflect the above episode. A Nurse's Note, dated [DATE] at 3:05 p.m. and signed by Resident #1's physician, reflected he spoke to the resident's family member via telephone about the resident's anorexia. The Nurse's Note, dated [DATE] at 3:05 p.m., and signed by Resident #1's physician, indicated the physician was in the facility, but the Note did not address the use of [MEDICATION NAME] or lack of PT/INR monitoring. Resident #1's [DATE] MAR reflected she received Aspirin 81 mg daily except on [DATE]; [MEDICATION NAME] 3 mg on [DATE]; and [MEDICATION NAME] 3.5 mg daily beginning on [DATE] through the rest of the month. The MAR also reflected she received [MEDICATION NAME] on [DATE], [DATE], and [DATE]. Further review of the [DATE] MAR revealed a handwritten note, which reflected, "Hold the [MEDICATION NAME] PT/INR 2.47." After that handwritten note was another note, which reflected, "DC." Resident #1's NP M's Progress Note, dated [DATE], reflected the box for Reviewed labs/X-rays was unchecked. Resident #1's Nurse's Notes, dated [DATE] and untimed, reflected, "...informed by aid that their (sic) was something black on resident's diaper. Nurse took a look at diaper and noticed a dark smear on residents diaper. Notified (NP M) NP for (Resident #1's physician), order for KUB (Kidneys, Ureters, and Bladder pertaining to anteroposterior projection films of the abdomen), H&H on [DATE] notified RP (Responsible Party)...." The Notes did not reflect any vital signs. Resident #1's Nurse's Notes, dated [DATE], reflected "1445 (1:45 p.m.) coming out of another resident's room when aide told me that resident was bleeding. ON getting into residents room, I was speaking to her all of sudden she stop reply and became unresponsive, called her name several times, called for a code blue, upon waiting to start CPR (Cardiopulmonary Resuscitation) resident became responsive, O2 (oxygen) was given to resident 911 was called, v/s (vital signs) taken BP (Blood Pressure) ,[DATE], P (pulse) 74, O2 86 emergency persons came resident transported to (name of hospital)." An interview with LVN G on [DATE] at 12:40 p.m. revealed she was summoned to Resident #1's room on the morning of [DATE], after breakfast, by a CNA to observe a dark smear on the resident's adult brief. LVN G stated she instructed the CNA to "watch" the resident for "anymore." LVN G said she called the resident's physician about the smear in the brief, but was unable to recall if she mentioned the resident was receiving routine [MEDICATION NAME]. When asked about any established parameters for Resident #1's PT/INR levels, LVN G replied, the [MEDICATION NAME] was discontinued when the INR was 2. LVN G revealed sometime after lunch on [DATE], she was walking down the hall when she "smelled something funny, something bad" coming from Resident #1's room. LVN G stated she immediately entered Resident #1's room and was "alarmed." LVN G revealed she observed dark, red blood coming from the resident's rectum. She stated her first thought was to dial 911 and "get her out." LVN G stated she was in Resident #1's room when the resident became unresponsive. Further interview with LVN G on [DATE] at 4:10 p.m. revealed, "That morning ([DATE]) the aide called my attention to a black smear on (Resident #1's) diaper. I notified the ADON and called the Nurse Practitioner and told her it was a dark smear. She ordered some labs and a KUB X-ray. I told the CNA (CNA H) to continually check on her and monitor her. Later in the day, I was across the hall. I was coming out and met my CNA (CNA H). I smelled a funny smell. (CNA H) said (Resident #1) had some dark thing coming out. CNA left it open so I could see. It was really dark. It had a particular smell. Once you smell blood you never forget it. It wasn't a lot, but it was black. (Resident #1) quit responding. I screamed Code Blue. She started responding. 911 came and she went to the hospital. What I saw was a little blood not a 'pool' of blood." Continued interview with LVN G on [DATE] at 4:10 p.m. revealed, "The ADON wrote the Transfer Sheet. When a resident is admitted on [MEDICATION NAME], we call the doctor to clarify orders for labs and x-rays. If they don't give you orders for labs, call their attention to it. We give the pink copies of the orders to the ADON. They (DON and ADON) get a copy of all orders. When (Resident #1) was here, she wasn't eating. She would not eat." Another interview with LVN G on [DATE] at 10:10 a.m. revealed when asked how much blood she observed Resident #1 lose, she replied, "It wasn't a lot of blood, but I could smell it." When LVN G was asked about Resident #1's Resident Transfer Form, dated [DATE], which reflected, "secondary [DIAGNOSES REDACTED]. I didn't see a lot of blood." LVN G acknowledged she could smell the blood from across the hall. An interview on [DATE] at 9:07 a.m. with CNA H revealed she remembered Resident #1. She stated, "She was my resident. The nurse (LVN G) wanted me to check on her every hour because she was bleeding. I checked her after lunch. The nurse (LVN G) came in to check vital signs. She (Resident #1) went out for 2 - 3 seconds. We yelled "STAT!' by the time everybody got there she was ok. I smelled the blood. It's a bad smell. There was only about a quarter size - no diaper full. I don't really remember how much blood she had in her brief." An interview on [DATE] at 12:55 p.m. with the ADON revealed she heard "Code Blue" and went to get the crash cart. She stated she did not remember what Resident #1 looked like, and she did not remember who was in the room at that time. An interview with the DON on [DATE] at 3:40 p.m. revealed, "I heard them call a code on (Resident #1). I don't remember if they called overhead or if someone came and got me. After I got there, she was responding, oxygen was on her. The staff was routinely doing vital signs and monitoring her oxygen saturation until the paramedics arrived. I did not see any blood. There was no blood noted in her diaper - no sign of blood." Another interview with the ADON on [DATE] at 3:45 p.m. revealed, "I heard the code call over the intercom, took the crash cart to her room, went back to get the paperwork ready and send her out to the hospital, make a phone call to the responsible party and (family member). Prior to that the nurse (LVN G) did mention to me she cleaned her up. I asked to see the diaper that she removed. She (LVN G) went and got it. There was a black smudge on it." The ADON said there was no black tarry stool in the brief. Resident #1's Resident Transfer Form, dated [DATE], reflected, "...dark black 'pool' liquid from rectum...VITALS AT TIME OF TRANSFER...B/P ,[DATE]...." Resident #1's Ambulance Report, dated [DATE], reflected they arrived at the facility at 2:27 p.m. and departed at 2:55 p.m. Chief Complaint was [MEDICAL CONDITION] and Altered Mental Status and a list of medications including [MEDICATION NAME]. The Report reflected, "...lying in her bed at her nh (nursing home) where staff stated that she was unresponsive and has developed a gi bleed today...They were talking to her upon our arrival and she was moving her extremities and looking around but would not communicate with us. i was unable to obtain a pulse ox reading...she had no radial pulse and i as unable to obtain an auscultated bp...the pt (patient) seemed to be in a little distress and could not keep her arms still. her bp remained low enroute to (hospital)." The Report also reflected, "Symptoms: General: Malaise And Fatigue; Confusion, RESP: Tachypnea (very rapid rate of respiration)[MEDICAL CONDITION]; NEURO: Altered Mental Status; GI: Stool (Dark/Tarry)...Scene Findings: Blood; Feces...Breathing Quality...Regularity: Tachypnea Effort: Mild Distress...Estimated Blood Loss; ,[DATE] ml...." Resident #1's Emergency Department records, dated [DATE], reflected she arrived in the Emergency Department at 3:14 p.m. with a chief complaint of GI Bleed, Altered Mental Status, and [MEDICAL CONDITION]. The Records also reflected, "...NH (nursing home) reports 'acute onset of blood in stool' 1 hr (hour) PTA (prior to arrival)...Patient is awake but not alert, non-verbal, and not following commands. Unable to obtain BP or O2 sat (saturation) on patient arrival. HR (Heart Rate) SR in 90s...1531 (3:31 p.m.) patient lost pulse, compressions began...1539 (3:39 p.m.) TOD (Time of Death) called by (physician's name)...Stool Amount moderate...Stool Consistency tarry...adult brief in place on arrival...." An interview with the DON on [DATE] at 4:05 p.m. revealed, "I called the lab for their policy and procedure (for monitoring of [MEDICATION NAME]); was told they didn't have a policy and procedure and would have to call the doctor and come up with one." An interview with the Administrator on [DATE] at 6:00 p.m. revealed, "We don't have a policy on anticoagulation therapy. It's not in our pharmacy policy book or in our policy book. I instructed (the DON) to write up a policy of the things we do for [MEDICATION NAME]." The facility's Abuse Prevention Policy, revised [DATE], reflected the policy was to protect all residents from all forms of neglect. It further noted staff would be trained on identifying all forms of neglect. The facility's abuse prevention/intervention program included the following in regard to neglect: Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect; and identifying areas within the facility that may make neglect more likely to occur and conduct frequent monitoring of those areas. On [DATE] an IJ was identified. On [DATE] at 3:18 p.m., the Administrator, LVN J, the ADON, and DON were notified of the IJ and a Plan of Removal was requested at that time. An interview with Resident #1's physician on [DATE] at 11:18 a.m. revealed, "I do a PT/INR when [MEDICATION NAME] started, stop the [MEDICATION NAME] then do weekly PT/INR. I start the [MEDICATION NAME] at 3 mg day. The dose is determined by metabolic functions especially liver functions. What's really scary about [MEDICATION NAME] is a person's nutrition and other drugs. I was aware (Resident #1) was not eating. I visited with her (family member) and told (him/her) how serious her condition was. (Resident #1) was in the hospital with a GI Bleed. She came here with a history of GI Bleed." When asked about Resident #1's PT/INR lab results, the physician replied, "I can't recall seeing it. I don't know how often I visited. You have to trust ancillary orders, labs are doing what I ordered and that they report the results to me or my staff. They write on the lab report that I've been notified and put (the report) in my folder and I review them or my staff reviews them. You have to trust there are systems in place to monitor labs and follow orders. I review them when I go there." When Resident #1's physician was asked what would trigger him to recognize he was not being notified of ordered lab results or seeing ordered lab results, he replied, "You have to trust there are systems in place." Further interview with Resident #1's physician on [DATE] at 4:15 p.m. revealed nurses should be documenting the date, time, who was notified and what the physician said on the actual laboratory reports. He stated he did not review Resident #1's clinical record to ensure PT/INR laboratory levels were being completed, but he relied on the facility's systems. The Medical Director stated there was a system to review labs, but there was no method for follow-up that labs were completed. An interview with the Administrator on [DATE] at 6:00 p.m. revealed when asked how she monitored the DON to ensure the systems the DON was responsible for were completed sufficiently, the Administrator replied, "We just meet and go over things. I ask about responsibilities, orders, charting." When asked how she thought the IJ occurred, the Administrator responded, "I don't think they (the ADON and DON) have been thorough. DON and ADON admitted they had not been doing a thorough job, keeping employees who are not complying with their job responsibilities. There was a lab system failure - not monitoring daily and being focused. We did not follow the system, and if the lab or pharmacy fell through - it was a mistake that should have never been made. The IJ showed me we didn't have a system to monitor [MEDICATION NAME]. The nurse wasn't careful when he wrote the doctor's order. He wrote the lab information on the Laboratory Log and did not write an order for [REDACTED]." When asked what training had been completed with the CNAs, the Administrator replied, "To report changes in condition." The Administrator stated the initials on the altered laboratory log belonged to a lab staff member, who said one of the facility nurses changed the log for Resident #1. Further interview with the Administrator on [DATE] at 1:30 p.m. revealed, "The lab person identified my nurse (LVN N) as person who changed the lab log (regarding the frequency of PT/INR lab tests for Resident #1). She described her." An interview with LVN N on [DATE] at 10:22 a.m. revealed, "I only work on Monday and Tuesday nights. I work Station 2 on Monday night. I remember (Resident #1). I think when I came back to work...." When asked if the lab technician questioned an order for [REDACTED].! I would have no reason to do that. Before I would do anything like that I would have checked the chart and orders." LVN N confirmed she was working with Resident #1 on the night of [DATE] (when Resident #1 had her first PT/INR). Another interview with the Administrator on [DATE] at 4:30 p.m. revealed the DON and ADON checked residents' orders daily and should have discovered the issues related to Resident #1. She stated because of this both the DON and ADON were written up. She revealed the pharmacist consultant conducted an audit on [DATE] and did not identify the problem related to Resident #1. She stated the facility missed an opportunity at that time to address the issue. The facility's undated Anticoagulation Policy, provided on [DATE] at 6:45 p.m. reflected, "Purpose: To establish a standard approach to reduce the risk of adverse events and management of residents receiving medications used for anticoagulation. Policy: It's the policy (name of facility) that all patients will receive individualized dosing of anticoagulants based on doctor's orders, diagnosis, lab results, and risks. Procedures: 1. As part of the initial assessment, the charge nurse will help identify residents who are currently receiving anticoagulant therapy. a. Assess for signs or symptoms related to subtherapeutic or greater than therapeutic drug levels of that particular anticoagulant. b. Ensure each resident on anticoagulant therapy has an order for [REDACTED]. The charge nurse will assess, document, and report the following: a. Current anticoagulant therapy (drug and dose) b. Recent labs, including therapeutic dose monitoring c. Signs and symptoms of bleeding or clots 3. Upon Administering Anticoagulant medication the charge nurse will a. Recognize and adhere to the rights of drug administration b. sign/initial the MAR and controlled substance sheet at time of administration. c. Document and assess for any adverse reactions. i. Report to resident's PCP (primary care physician) immediately if any noted." An interview with the DON on [DATE] at 3:10 p.m. revealed when asked what training did she ensure the nurses had to care for a resident receiving anticoagulant therapy, she replied, "Can't recall any in-services on anticoagulation therapy since I've been here." The DON was asked to check if any in-services on anticoagulation therapy were completed. When asked how she ensured the nurses were competent in their skills in caring for residents with anticoagulation therapy, the DON replied, "By checking the orders. I hear follow-up conversations with the doctors regarding labs and medication changes." When asked what type of plan was in place for anticoagulation therapy, the DON responded, "Check the charts to be sure orders are transcribed. Nurses see me checking the pink telephone order copies, but sometimes I don't get them." When asked how she thought the IJ occurred, the DON replied, "While we do chart checking on admissions, transcription of doctors' orders wasn't done." When asked who was responsible to check if the orders were transcribed, the DON responded, "The DON/ADON were responsible to check the pink copies of the orders, but they (pink copies) don't always make it to me." When asked how she was going to repair the system failure, the DON replied, "In-service. Put a system in place to monitor lab, doctor notification and change in orders will be done daily by the LVNs and weekly monitoring by the DON/ADON." The facility's accepted Plan of Removal, dated [DATE], reflected: "...THE FOLLOWING PROCEDURES HAVE BEEN IMPLEMENTED: ANTICOAGULANT FORM: On Aug. 6th (the DON) created and in-serviced staff on an anticoagulant form. that was posted on the inside of the MARS of those who are receiving anticoagulants. This form was designed as a tool to ensure that when a nurse is administering [MEDICATION NAME] this tool will serve as a trigger to follow up on the required labs if ordered. The nurse will list the date, [MEDICATION NAME] dose, last PT/INR, Dr. notification, order change date, lab value, and the nurses signature. This tool will alert the nurse to act even if the lab or pharmacy consultant were to fail...This new procedure will be monitored each week in the Admin. (Administrative) Review meet with the director of nursing (DON) and the assistant director of nursing. This training was started on [DATE]th and was completed on [DATE]th...This monitoring of this system will continue until Jan. 31, 2014 then quarterly thereafter. Lab Tracking Books: On [DATE]th (the DON) & ADON (name) both prepared and initiated the use of lab tracking books to be utilize (sic) solely by each of them. Each book has a 'daily lab form' inside that will allow DON (name) & designee to list the name of the resident, the lab order, the date of the draw, the value, dr. notification, if the lab was actually drawn, and nurses notes...PT/INR ALERT: Effective [DATE]th, MDS Coordinator (LVN J) printed the notation: PT/INR on the MAR next to all residents who (sic) on [MEDICATION NAME] therapy. The notation serves as a reminder for the nurse administering the medication. Effective September the PT/INR notation will be listed on the MAR permanently...ADMISSION CHECKLIST...Effective Aug. 9th The admission check list if a form that allows the admitting nurse to check off each segment of the admission packet during the assessment, and sign it. Upon completion the charge nurse will place under DON (name's) door for review of accuracy...These files will be monitored weekly at the admin review. This will be ongoing...Effective [DATE]th Administrator has decided to terminate contract (with laboratory services provider). INSERVICES: On [DATE]th (the DON) and ADON started in-servicing and testing the nursing dept. on the following subjects: Lab procedures----Medication Administration Anticoagulation Monitoring Sheet Signs & Symptoms of one receiving blood thinners Physician order [REDACTED]. Completion will be on [DATE]th, 2013ZXXXZ

Based on observation, interview and record review, the facililty failed to implement the facility's written policies and procedures, which prohibit neglect for one (Resident #1) of eight residents reviewed for neglect. LVN A failed to transcribe the physician's orders [REDACTED]. LVN A wrote the order on the Laboratory Log, which was later altered. Resident #1's PT/INRs were only checked on [DATE] and [DATE]. The ADON failed to recognize Resident #1 was receiving [MEDICATION NAME], but did not have physician's orders [REDACTED]. Resident #1's attending physician, who was also the facility's Medical Director, and his NP failed to recognize Resident #1 was receiving [MEDICATION NAME] without the monitoring of her PT/INR levels to check the medication's therapeutic level. The facility's contracted Pharmacist failed to recognize Resident #1 was receiving [MEDICATION NAME] without checking the resident's PT/INR for monitoring the [MEDICATION NAME]'s therapeutic level, when the Pharmacist completed the facility's Drug Regimen Review for each resident on [DATE]. These failures resulted in Resident #1 having rectal bleeding, being hypotensive, not responding well, and being in mild respiratory distress on [DATE] and being transferred to the hospital where she expired 25 minutes after arriving in the Emergency Department of the local hospital. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility had not yet in-serviced all nursing staff and fully implemented their Plan of Removal. These failures could affect the nine residents receiving [MEDICATION NAME] by placing them at risk for not having their PT/INRs monitored, which could result in bleeding and/or death. Findings included: 1. The facility's undated Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures reflected, "...The administrator assumes the responsibility for the overall coordination and implementation of our facility's abuse prevention program policies and procedures...." The facility's Abuse Prevention Policy, revised [DATE], reflected the policy was to protect all residents from all forms of neglect. It further noted staff would be trained on identifying all forms of neglect. The facility's abuse prevention/intervention program included the following in regard to neglect: Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect; and identifying areas within the facility that may make neglect more likely to occur and conduct frequent monitoring of those areas. 2. Resident #1's hospital History and Physical, dated [DATE] reflected Resident #1 was admitted to the hospital after a fall with fracture at home. The History and Physical also reflected, "living alone in her own home... Patient is not taking any medicines at all at home, except for [MEDICATION NAME] Review of Systems - the patient is edentulous, but she said she can chew very well with her gums. She cooks. She denies nausea, vomiting. She denies diarrhea, dysuria, hematuria, anuria. Denies constipation, abdominal pain. Denies chest pain. Denies shortness of breath. All other systems are reviewed and negative...GI and [MEDICAL CONDITION]. Will start her on [MEDICATION NAME], as well as [MEDICATION NAME] at this time." Resident #1's hospital Facility Transfers Orders, printed [DATE], reflected, "...recheck CBC, CMP in ,[DATE] days. Check [MEDICAL CONDITION] in (one) week." Resident #1's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment also reflected she was cognitively intact, required extensive assistance with bed mobility, transfers, dressing, and was totally dependent on staff for toileting, bathing, and locomotion off the unit. Her life expectancy was not less than six months, she was in isolation, and was expected to be discharged back to the community. Resident #1's facility admission orders [REDACTED]. The Orders also reflected Aspirin (blood thinner) 81 mg daily. Resident #1's facility admission orders [REDACTED]. Lippincott, Williams & Wilkins Nursing 2013 Drug Handbook on page 1409, regarding [MEDICATION NAME], reflected, "Overdose S&S (signs and symptoms: Blood in stools...NURSING CONSIDERATIONS Black Box Warning [MEDICATION NAME] ([MEDICATION NAME]) can cause major or fatal bleeding, which is more likely to occur during the starting period and with a higher dose. Regularly monitor INR in all patients Consider more frequent INR monitoring in those at high risk for bleeding...Regularly check for...tarry stools...Elderly patients...are especially sensitive to drugs effect...." Resident #1's Nurse's Notes, dated [DATE], reflected, "...medications confirmed by (Resident #1's physician), new orders obtained, lab requisition [MEDICATION NAME] give (sic) from Emergency Kit...." Resident #1's Physician's Telephone Orders, dated [DATE] through [DATE], did not reflect any orders to check her PT/INR. On [DATE] at 3:30 p.m., the Administrator stated, "...The lab company did not come and draw the blood every 3 days...." The facility's copy of the Laboratory Log, dated [DATE], reflected, "PT/INR every 3 days" for Resident #1. The Log also reflected, "Forwarded x (times) 9 days" and underneath were the phlebotomist's initials circled. However, the facility's contracted laboratory services provider's Laboratory Log, dated [DATE], reflected "Every" was crossed out and "in ,[DATE] days" was inserted to reflect "PT/INR in ,[DATE] days." The Log also reflected "Forward For [DATE]" and the "x 9 days" was crossed out. The initials were still present. An interview on [DATE] at 5:40 p.m. with LVN A, the nurse who admitted Resident #1, revealed when asked about the procedure for obtaining orders for new admissions, he replied, "After I complete the assessment, you call the doctor and report your findings, read the hospital discharge orders to him, obtain orders. I write them down on plain paper then write on the telephone order (form). I remember there was an order for [REDACTED]. I did write it on the Laboratory Log." LVN A reviewed a copy of the Laboratory Log, dated [DATE] with an entry for Resident #1. He confirmed he wrote the information on the copy presented to him. LVN A said, "During the time she was here we were doing stools for [MEDICAL CONDITION]. I collected the stool specimens myself and there was never any blood. When she went to the hospital, I was told in report she went to the hospital, she was bleeding from the rectum. I specifically asked if there was a lot of blood. I knew she was [MEDICATION NAME]. (LVN G) said, 'There was a lot of blood.'" LVN A denied Resident #1 ever complained of abdominal pain. "They suspended me yesterday and said I'm under investigation." Interview on [DATE] at 10:30 a.m. with the facility's only ADON revealed she reviewed the copies of the physician's orders [REDACTED]. When asked how she missed there were no orders to check Resident #1's PT/INR, when the resident was on [MEDICATION NAME], she replied, "I don't know." Resident #1's Physician's Telephone Order, dated [DATE], reflected to increase the [MEDICATION NAME] to 3.5 mg daily. Resident #1's Laboratory Report, dated [DATE], reflected her PT/INR results were PT 13.6 seconds with a reference range of 10.4 - 13.8 seconds and an INR 1.34 with a reference range of 0.80 - 1.20 ratio. The Report also reflected her Complete Blood Count results were all within normal ranges. The Report also reflected the physician reviewed the lab on [DATE] as evidenced by his signature, and he increased her [MEDICATION NAME] to 3.5 mg daily. The facility's Pharmacist's Medication Regimen Review, dated [DATE], reflected, "...Some lab results were not completed/filed for review this visit. Per staff lab audit already requested and should be completed this month." The Review also reflected for Resident #1, "Resident with orders from prior placement with [MEDICATION NAME] 10 mg QD and started on [MEDICATION NAME] 15 mg QD upon admit. With orders for Mag Ox 400 mg PRN and order started routine for the resident. Please clarify both orders and update. Nurse notified." The Pharmacist's Medication Regimen Review, dated [DATE], did not address the lack of physician's orders [REDACTED]. Resident #1's Nursing Facility History and Physical, dated [DATE] and signed by Resident #1's physician, reflected [DIAGNOSES REDACTED]. The History and Physical also reflected the resident was in the hospital for an open reduction and internal fixation for a fracture, and she was currently taking [MEDICATION NAME] and [MEDICATION NAME]. Resident #1's Nursing Facility History and Physical, dated [DATE], did not reflect the physician reviewed the resident's PT/INR from [DATE] or the need to check her PT/INR. Resident #1's Care Plans, dated [DATE], did not address monitoring her for signs and symptoms of bleeding as it related to the administration of [MEDICATION NAME]. The care plan for "Problem of Pain management: [MEDICAL CONDITION] of Leg/[MEDICAL CONDITION] medication ([MEDICATION NAME]/[MEDICATION NAME]) as ordered Report lab result to Physician...." Resident #1's Laboratory Report, dated [DATE], reflected the results of her PT/INR were PT 19.5 seconds with a reference range of 10.4 - 13.8 seconds and an INR of 2.47 with a reference range of 0.80 - 1.20 ratio. The Report also reflected her Complete Blood Count results were all within normal ranges. A handwritten note on the Report reflected, "Order [DATE] D/C (discontinue) [MEDICATION NAME] when INR 2 Med (medication) D/Cd (discontinued)." Another handwritten note on the Report reflected, "Hold [MEDICATION NAME] MD not (sic) called awaiting call back" with a date of [DATE]. Interview on [DATE] at 12:25 p.m. with the DON revealed the only labs she could locate for Resident #1 for PT/INR levels were dated [DATE] and [DATE]. The DON stated she thought Resident #1 had a transfer order from the hospital regarding the frequency for obtaining laboratory values for PT/INR levels. She stated she was unable to locate any orders for routine monitoring of the PT/INR. Further interview with the DON on [DATE] at 3:55 p.m. revealed when asked about the system for monitoring [MEDICATION NAME], she replied, "There is a sign-in sheet - count sheet. Normally labs (PT/INR) are drawn weekly. Based on that lab, the medication is increased or decreased by the doctor to keep at therapeutic level. The nurse always gives it ([MEDICATION NAME])." Telephone interview with Resident #1's physician, who was also the facility's Medical Director, on [DATE] at 1:35 p.m. revealed his standards of care included weekly laboratory tests for PT/INR levels to monitor residents who were administered [MEDICATION NAME]. He stated every resident was different, and at this time, he could not explain why Resident #1 did not have a physician's orders [REDACTED]. Resident #1's NP M's Progress Note, dated [DATE], reflected the boxes for "Meds reviewed: See medical orders in chart...Continue with current medications; Continue with current treatments; Reviewed PMH (Past Medical History)/family/social; Reviewed Labs/X-rays; Reviewed Hospital documents." Resident #1's Physician's Telephone Order, dated [DATE], reflected, "...D/C [MEDICATION NAME] when INR is 2 or greater...D/C [MEDICATION NAME]." Resident #1's Nurse's Notes, dated [DATE] at 7:00 a.m., reflected, "Went to awaken Res (resident) and Res is not responding does not awaken to strong patting of chest as she has been doing no respiratory effort noted. Hands are cool body is slight warm; continue to try to awaken res unsuccessful. Rush to desk to determine code status she is full code - ask for assistance. Went back to res to start code blue, and called Res name and strongly patted chest. Res Responds a little by turning head and ...Res mumbles a sound. Then makes facial grimace continue patting chest...." An interview on [DATE] at 7:40 a.m. with RN I revealed, "One morning I had a hard time waking her up. I was read to call a code on her. One of the other girls came in - called her name and she opened her eyes." The episode on [DATE] was reviewed with RN I, who said it "was a one-time occurrence. The last morning she (Resident #1) was here the CNAs got her up and took her to the dining room early. I went to the dining room to give her meds. She could respond a little bit - raised her head up when I called her name. I told her it was time to take her meds. She let me put them in her mouth. She opened her mouth and took some water that didn't immediately drool out, but it did drool out." When asked about bleeding, RN I replied, "I never saw any blood from her rectum. I remember asking about and what happened to her. I was told she was bloody stool - a diaper full." The facility's 24 Hour Report, for [DATE], did not reflect the above episode. A Nurse's Note, dated [DATE] at 3:05 p.m. and signed by Resident #1's physician, reflected he spoke to the resident's family member via telephone about the resident's anorexia. The Nurse's Note, dated [DATE] at 3:05 p.m., and signed by Resident #1's physician, indicated the physician was in the facility, but the Note did not address the use of [MEDICATION NAME] or lack of PT/INR monitoring. Resident #1's [DATE] MAR reflected she received Aspirin 81 mg daily except on [DATE]; [MEDICATION NAME] 3 mg on [DATE]; and [MEDICATION NAME] 3.5 mg daily beginning on [DATE] through the rest of the month. The MAR also reflected she received [MEDICATION NAME] on [DATE], [DATE], and [DATE]. Further review of the [DATE] MAR revealed a handwritten note, which reflected, "Hold the [MEDICATION NAME] PT/INR 2.47." After that handwritten note was another note, which reflected, "DC." Resident #1's NP M's Progress Note, dated [DATE], reflected the box for Reviewed labs/X-rays was unchecked. Resident #1's Nurse's Notes, dated [DATE] and untimed, reflected, "...informed by aid that their (sic) was something black on resident's diaper. Nurse took a look at diaper and noticed a dark smear on residents diaper. Notified (NP M) NP for (Resident #1's physician), order for KUB (Kidneys, Ureters, and Bladder pertaining to anteroposterior projection films of the abdomen), H&H on [DATE] notified RP (Responsible Party)...." The Notes did not reflect any vital signs. Resident #1's Nurse's Notes, dated [DATE], reflected "1445 (1:45 p.m.) coming out of another resident's room when aide told me that resident was bleeding. ON getting into residents room, I was speaking to her all of sudden she stop reply and became unresponsive, called her name several times, called for a code blue, upon waiting to start CPR (Cardiopulmonary Resuscitation) resident became responsive, O2 (oxygen) was given to resident 911 was called, v/s (vital signs) taken BP (Blood Pressure) ,[DATE], P (pulse) 74, O2 86 emergency persons came resident transported to (name of hospital)." An interview with LVN G on [DATE] at 12:40 p.m. revealed she was summoned to Resident #1's room on the morning of [DATE], after breakfast, by a CNA to observe a dark smear on the resident's adult brief. LVN G stated she instructed the CNA to "watch" the resident for "anymore." LVN G said she called the resident's physician about the smear in the brief, but was unable to recall if she mentioned the resident was receiving routine [MEDICATION NAME]. When asked about any established parameters for Resident #1's PT/INR levels, LVN G replied, the [MEDICATION NAME] was discontinued when the INR was 2. LVN G revealed sometime after lunch on [DATE], she was walking down the hall when she "smelled something funny, something bad" coming from Resident #1's room. LVN G stated she immediately entered Resident #1's room and was "alarmed." LVN G revealed she observed dark, red blood coming from the resident's rectum. She stated her first thought was to dial 911 and "get her out." LVN G stated she was in Resident #1's room when the resident became unresponsive. Further interview with LVN G on [DATE] at 4:10 p.m. revealed, "That morning ([DATE]) the aide called my attention to a black smear on (Resident #1's) diaper. I notified the ADON and called the Nurse Practitioner and told her it was a dark smear. She ordered some labs and a KUB X-ray. I told the CNA (CNA H) to continually check on her and monitor her. Later in the day, I was across the hall. I was coming out and met my CNA (CNA H). I smelled a funny smell. (CNA H) said (Resident #1) had some dark thing coming out. CNA left it open so I could see. It was really dark. It had a particular smell. Once you smell blood you never forget it. It wasn't a lot, but it was black. (Resident #1) quit responding. I screamed Code Blue. She started responding. 911 came and she went to the hospital. What I saw was a little blood not a 'pool' of blood." Continued interview with LVN G on [DATE] at 4:10 p.m. revealed, "The ADON wrote the Transfer Sheet. When a resident is admitted on [MEDICATION NAME], we call the doctor to clarify orders for labs and x-rays. If they don't give you orders for labs, call their attention to it. We give the pink copies of the orders to the ADON. They (DON and ADON) get a copy of all orders. When (Resident #1) was here, she wasn't eating. She would not eat." Another interview with LVN G on [DATE] at 10:10 a.m. revealed when asked how much blood she observed Resident #1 lose, she replied, "It wasn't a lot of blood, but I could smell it." When LVN G was asked about Resident #1's Resident Transfer Form, dated [DATE], which reflected, "secondary [DIAGNOSES REDACTED]. I didn't see a lot of blood." LVN G acknowledged she could smell the blood from across the hall. An interview on [DATE] at 9:07 a.m. with CNA H revealed she remembered Resident #1. She stated, "She was my resident. The nurse (LVN G) wanted me to check on her every hour because she was bleeding. I checked her after lunch. The nurse (LVN G) came in to check vital signs. She (Resident #1) went out for 2 - 3 seconds. We yelled "STAT!' by the time everybody got there she was ok. I smelled the blood. It's a bad smell. There was only about a quarter size - no diaper full. I don't really remember how much blood she had in her brief." An interview on [DATE] at 12:55 p.m. with the ADON revealed she heard "Code Blue" and went to get the crash cart. She stated she did not remember what Resident #1 looked like, and she did not remember who was in the room at that time. An interview with the DON on [DATE] at 3:40 p.m. revealed, "I heard them call a code on (Resident #1). I don't remember if they called overhead or if someone came and got me. After I got there, she was responding, oxygen was on her. The staff was routinely doing vital signs and monitoring her oxygen saturation until the paramedics arrived. I did not see any blood. There was no blood noted in her diaper - no sign of blood." Another interview with the ADON on [DATE] at 3:45 p.m. revealed, "I heard the code call over the intercom, took the crash cart to her room, went back to get the paperwork ready and send her out to the hospital, make a phone call to the responsible party and (family member). Prior to that the nurse (LVN G) did mention to me she cleaned her up. I asked to see the diaper that she removed. She (LVN G) went and got it. There was a black smudge on it." The ADON said there was no black tarry stool in the brief. Resident #1's Resident Transfer Form, dated [DATE], reflected, "...dark black 'pool' liquid from rectum...VITALS AT TIME OF TRANSFER...B/P ,[DATE]...." Resident #1's Ambulance Report, dated [DATE], reflected they arrived at the facility at 2:27 p.m. and departed at 2:55 p.m. Chief Complaint was [MEDICAL CONDITION] and Altered Mental Status and a list of medications including [MEDICATION NAME]. The Report reflected, "...lying in her bed at her nh (nursing home) where staff stated that she was unresponsive and has developed a gi bleed today...They were talking to her upon our arrival and she was moving her extremities and looking around but would not communicate with us. i was unable to obtain a pulse ox reading...she had no radial pulse and i as unable to obtain an auscultated bp...the pt (patient) seemed to be in a little distress and could not keep her arms still. her bp remained low enroute to (hospital)." The Report also reflected, "Symptoms: General: Malaise And Fatigue; Confusion, RESP: Tachypnea (very rapid rate of respiration)[MEDICAL CONDITION]; NEURO: Altered Mental Status; GI: Stool (Dark/Tarry)...Scene Findings: Blood; Feces...Breathing Quality...Regularity: Tachypnea Effort: Mild Distress...Estimated Blood Loss; ,[DATE] ml...." Resident #1's Emergency Department records, dated [DATE], reflected she arrived in the Emergency Department at 3:14 p.m. with a chief complaint of GI Bleed, Altered Mental Status, and [MEDICAL CONDITION]. The Records also reflected, "...NH (nursing home) reports 'acute onset of blood in stool' 1 hr (hour) PTA (prior to arrival)...Patient is awake but not alert, non-verbal, and not following commands. Unable to obtain BP or O2 sat (saturation) on patient arrival. HR (Heart Rate) SR in 90s...1531 (3:31 p.m.) patient lost pulse, compressions began...1539 (3:39 p.m.) TOD (Time of Death) called by (physician's name)...Stool Amount moderate...Stool Consistency tarry...adult brief in place on arrival...." An interview with the DON on [DATE] at 4:05 p.m. revealed, "I called the lab for their policy and procedure (for monitoring of [MEDICATION NAME]); was told they didn't have a policy and procedure and would have to call the doctor and come up with one." An interview with the Administrator on [DATE] at 6:00 p.m. revealed, "We don't have a policy on anticoagulation therapy. It's not in our pharmacy policy book or in our policy book. I instructed (the DON) to write up a policy of the things we do for [MEDICATION NAME]." On [DATE] an IJ was identified. On [DATE] at 3:18 p.m., the Administrator, LVN J, the ADON, and DON were notified of the IJ and a Plan of Removal was requested at that time. An interview with Resident #1's physician on [DATE] at 11:18 a.m. revealed, "I do a PT/INR when [MEDICATION NAME] started, stop the [MEDICATION NAME] then do weekly PT/INR. I start the [MEDICATION NAME] at 3 mg day. The dose is determined by metabolic functions especially liver functions. What's really scary about [MEDICATION NAME] is a person's nutrition and other drugs. I was aware (Resident #1) was not eating. I visited with her (family member) and told (him/her) how serious her condition was. (Resident #1) was in the hospital with a GI Bleed. She came here with a history of GI Bleed." When asked about Resident #1's PT/INR lab results, the physician replied, "I can't recall seeing it. I don't know how often I visited. You have to trust ancillary orders, labs are doing what I ordered and that they report the results to me or my staff. They write on the lab report that I've been notified and put (the report) in my folder and I review them or my staff reviews them. You have to trust there are systems in place to monitor labs and follow orders. I review them when I go there." When Resident #1's physician was asked what would trigger him to recognize he was not being notified of ordered lab results or seeing ordered lab results, he replied, "You have to trust there are systems in place." Further interview with Resident #1's physician on [DATE] at 4:15 p.m. revealed nurses should be documenting the date, time, who was notified and what the physician said on the actual laboratory reports. He stated he did not review Resident #1's clinical record to ensure PT/INR laboratory levels were being completed, but he relied on the facility's systems. The Medical Director stated there was a system to review labs, but there was no method for follow-up that labs were completed. An interview with the Administrator on [DATE] at 6:00 p.m. revealed when asked how she monitored the DON to ensure the systems the DON was responsible for were completed sufficiently, the Administrator replied, "We just meet and go over things. I ask about responsibilities, orders, charting." When asked how she thought the IJ occurred, the Administrator responded, "I don't think they (the ADON and DON) have been thorough. DON and ADON admitted they had not been doing a thorough job, keeping employees who are not complying with their job responsibilities. There was a lab system failure - not monitoring daily and being focused. We did not follow the system, and if the lab or pharmacy fell through - it was a mistake that should have never been made. The IJ showed me we didn't have a system to monitor [MEDICATION NAME]. The nurse wasn't careful when he wrote the doctor's order. He wrote the lab information on the Laboratory Log and did not write an order for [REDACTED]." When asked what training had been completed with the CNAs, the Administrator replied, "To report changes in condition." The Administrator stated the initials on the altered laboratory log belonged to a lab staff member, who said one of the facility nurses changed the log for Resident #1. Further interview with the Administrator on [DATE] at 1:30 p.m. revealed, "The lab person identified my nurse (LVN N) as person who changed the lab log (regarding the frequency of PT/INR lab tests for Resident #1). She described her." An interview with LVN N on [DATE] at 10:22 a.m. revealed, "I only work on Monday and Tuesday nights. I work Station 2 on Monday night. I remember (Resident #1). I think when I came back to work...." When asked if the lab technician questioned an order for [REDACTED].! I would have no reason to do that. Before I would do anything like that I would have checked the chart and orders." LVN N confirmed she was working with Resident #1 on the night of [DATE] (when Resident #1 had her first PT/INR). Another interview with the Administrator on [DATE] at 4:30 p.m. revealed the DON and ADON checked residents' orders daily and should have discovered the issues related to Resident #1. She stated because of this both the DON and ADON were written up. She revealed the pharmacist consultant conducted an audit on [DATE] and did not identify the problem related to Resident #1. She stated the facility missed an opportunity at that time to address the issue. The facility's undated Anticoagulation Policy, provided on [DATE] at 6:45 p.m. reflected, "Purpose: To establish a standard approach to reduce the risk of adverse events and management of residents receiving medications used for anticoagulation. Policy: It's the policy (name of facility) that all patients will receive individualized dosing of anticoagulants based on doctor's orders, diagnosis, lab results, and risks. Procedures: 1. As part of the initial assessment, the charge nurse will help identify residents who are currently receiving anticoagulant therapy. a. Assess for signs or symptoms related to subtherapeutic or greater than therapeutic drug levels of that particular anticoagulant. b. Ensure each resident on anticoagulant therapy has an order for [REDACTED]. The charge nurse will assess, document, and report the following: a. Current anticoagulant therapy (drug and dose) b. Recent labs, including therapeutic dose monitoring c. Signs and symptoms of bleeding or clots 3. Upon Administering Anticoagulant medication the charge nurse will a. Recognize and adhere to the rights of drug administration b. sign/initial the MAR and controlled substance sheet at time of administration. c. Document and assess for any adverse reactions. i. Report to resident's PCP (primary care physician) immediately if any noted." An interview with the DON on [DATE] at 3:10 p.m. revealed when asked what training did she ensure the nurses had to care for a resident receiving anticoagulant therapy, she replied, "Can't recall any in-services on anticoagulation therapy since I've been here." The DON was asked to check if any in-services on anticoagulation therapy were completed. When asked how she ensured the nurses were competent in their skills in caring for residents with anticoagulation therapy, the DON replied, "By checking the orders. I hear follow-up conversations with the doctors regarding labs and medication changes." When asked what type of plan was in place for anticoagulation therapy, the DON responded, "Check the charts to be sure orders are transcribed. Nurses see me checking the pink telephone order copies, but sometimes I don't get them." When asked how she thought the IJ occurred, the DON replied, "While we do chart checking on admissions, transcription of doctors' orders wasn't done." When asked who was responsible to check if the orders were transcribed, the DON responded, "The DON/ADON were responsible to check the pink copies of the orders, but they (pink copies) don't always make it to me." When asked how she was going to repair the system failure, the DON replied, "In-service. Put a system in place to monitor lab, doctor notification and change in orders will be done daily by the LVNs and weekly monitoring by the DON/ADON." The facility's accepted Plan of Removal, dated [DATE], reflected: "...THE FOLLOWING PROCEDURES HAVE BEEN IMPLEMENTED: ANTICOAGULANT FORM: On Aug. 6th (the DON) created and in-serviced staff on an anticoagulant form. that was posted on the inside of the MARS of those who are receiving anticoagulants. This form was designed as a tool to ensure that when a nurse is administering [MEDICATION NAME] this tool will serve as a trigger to follow up on the required labs if ordered. The nurse will list the date, [MEDICATION NAME] dose, last PT/INR, Dr. notification, order change date, lab value, and the nurses signature. This tool will alert the nurse to act even if the lab or pharmacy consultant were to fail...This new procedure will be monitored each week in the Admin. (Administrative) Review meet with the director of nursing (DON) and the assistant director of nursing. This training was started on [DATE]th and was completed on [DATE]th...This monitoring of this system will continue until Jan. 31, 2014 then quarterly thereafter. Lab Tracking Books: On [DATE]th (the DON) & ADON (name) both prepared and initiated the use of lab tracking books to be utilize (sic) solely by each of them. Each book has a 'daily lab form' inside that will allow DON (name) & designee to list the name of the resident, the lab order, the date of the draw, the value, dr. notification, if the lab was actually drawn, and nurses notes...PT/INR ALERT: Effective [DATE]th, MDS Coordinator (LVN J) printed the notation: PT/INR on the MAR next to all residents who (sic) on [MEDICATION NAME] therapy. The notation serves as a reminder for the nurse administering the medication. Effective September the PT/INR notation will be listed on the MAR permanently...ADMISSION CHECKLIST...Effective Aug. 9th The admission check list if a form that allows the admitting nurse to check off each segment of the admission packet during the assessment, and sign it. Upon completion the charge nurse will place under DON (name's) door for review of accuracy...These files will be monitored weekly at the admin review. This will be ongoing...Effective [DATE]th Administrator has decided to terminate contract (with laboratory services provider). INSERVICES: On [DATE]th (the DON) an

Based on interview and record review, it was determined the facility, failed to keep each resident's drug regimen free from unnecessary drugs, including a drug without adequate monitoring, for one (Resident #1) of eight residents reviewed for a change in condition. LVN A failed to transcribe the physician's orders [REDACTED]. LVN A wrote the order on the Laboratory Log, which was later altered. Resident #1's PT/INRs were only checked on [DATE] and [DATE]. The ADON failed to recognize Resident #1 was receiving [MEDICATION NAME], but did not have physician's orders [REDACTED]. Resident #1's attending physician, who was also the facility's Medical Director, and his NP failed to recognize Resident #1 was receiving [MEDICATION NAME] without the monitoring of her PT/INR levels to check the medication's therapeutic level. The facility's contracted Pharmacist failed to recognize Resident #1 was receiving [MEDICATION NAME] without checking the resident's PT/INR for monitoring the [MEDICATION NAME]'s therapeutic level, when the Pharmacist completed the facility's Drug Regimen Review for each resident on [DATE]. These failures resulted in Resident #1 having rectal bleeding, being hypotensive, not responding well, and being in mild respiratory distress on [DATE] and being transferred to the hospital where she expired 25 minutes after arriving in the Emergency Department of the local hospital. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility had not yet in-serviced all nursing staff and fully implemented their Plan of Removal. These failures could affect the nine residents receiving [MEDICATION NAME] by placing them at risk for not having their PT/INRs monitored, which could result in bleeding and/or death. Findings included: Resident #1's hospital History and Physical, dated [DATE] reflected Resident #1 was admitted to the hospital after a fall with fracture at home. The History and Physical also reflected, "living alone in her own home... Patient is not taking any medicines at all at home, except for [MEDICATION NAME] Review of Systems - the patient is edentulous, but she said she can chew very well with her gums. She cooks. She denies nausea, vomiting. She denies diarrhea, dysuria, hematuria, anuria. Denies constipation, abdominal pain. Denies chest pain. Denies shortness of breath. All other systems are reviewed and negative...GI and [MEDICAL CONDITION]. Will start her on [MEDICATION NAME], as well as [MEDICATION NAME] at this time." Resident #1's hospital Facility Transfers Orders, printed [DATE], reflected, "...recheck CBC, CMP in ,[DATE] days. Check [MEDICAL CONDITION] in (one) week." Resident #1's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment also reflected she was cognitively intact, required extensive assistance with bed mobility, transfers, dressing, and was totally dependent on staff for toileting, bathing, and locomotion off the unit. Her life expectancy was not less than six months, she was in isolation, and was expected to be discharged back to the community. Resident #1's facility admission orders [REDACTED]. The Orders also reflected Aspirin (blood thinner) 81 mg daily. Resident #1's facility admission orders [REDACTED]. Lippincott, Williams & Wilkins Nursing 2013 Drug Handbook on page 1409, regarding [MEDICATION NAME], reflected, "Overdose S&S (signs and symptoms: Blood in stools...NURSING CONSIDERATIONS Black Box Warning [MEDICATION NAME] ([MEDICATION NAME]) can cause major or fatal bleeding, which is more likely to occur during the starting period and with a higher dose. Regularly monitor INR in all patients Consider more frequent INR monitoring in those at high risk for bleeding...Regularly check for...tarry stools...Elderly patients...are especially sensitive to drugs effect...." Resident #1's Nurse's Notes, dated [DATE], reflected, "...medications confirmed by (Resident #1's physician), new orders obtained, lab requisition [MEDICATION NAME] give (sic) from Emergency Kit...." Resident #1's Physician's Telephone Orders, dated [DATE] through [DATE], did not reflect any orders to check her PT/INR. On [DATE] at 3:30 p.m., the Administrator stated, "...The lab company did not come and draw the blood every 3 days...." The facility's copy of the Laboratory Log, dated [DATE], reflected, "PT/INR every 3 days" for Resident #1. The Log also reflected, "Forwarded x (times) 9 days" and underneath were the phlebotomist's initials circled. However, the facility's contracted laboratory services provider's Laboratory Log, dated [DATE], reflected "Every" was crossed out and "in ,[DATE] days" was inserted to reflect "PT/INR in ,[DATE] days." The Log also reflected "Forward For [DATE]" and the "x 9 days" was crossed out. The initials were still present. An interview on [DATE] at 5:40 p.m. with LVN A, the nurse who admitted Resident #1, revealed when asked about the procedure for obtaining orders for new admissions, he replied, "After I complete the assessment, you call the doctor and report your findings, read the hospital discharge orders to him, obtain orders. I write them down on plain paper then write on the telephone order (form). I remember there was an order for [REDACTED]. I did write it on the Laboratory Log." LVN A reviewed a copy of the Laboratory Log, dated [DATE] with an entry for Resident #1. He confirmed he wrote the information on the copy presented to him. LVN A said, "During the time she was here we were doing stools for [MEDICAL CONDITION]. I collected the stool specimens myself and there was never any blood. When she went to the hospital, I was told in report she went to the hospital, she was bleeding from the rectum. I specifically asked if there was a lot of blood. I knew she was [MEDICATION NAME]. (LVN G) said, 'There was a lot of blood.'" LVN A denied Resident #1 ever complained of abdominal pain. "They suspended me yesterday and said I'm under investigation." Interview on [DATE] at 10:30 a.m. with the facility's only ADON revealed she reviewed the copies of the physician's orders [REDACTED]. When asked how she missed there were no orders to check Resident #1's PT/INR, when the resident was on [MEDICATION NAME], she replied, "I don't know." Resident #1's Physician's Telephone Order, dated [DATE], reflected to increase the [MEDICATION NAME] to 3.5 mg daily. Resident #1's Laboratory Report, dated [DATE], reflected her PT/INR results were PT 13.6 seconds with a reference range of 10.4 - 13.8 seconds and an INR 1.34 with a reference range of 0.80 - 1.20 ratio. The Report also reflected her Complete Blood Count results were all within normal ranges. The Report also reflected the physician reviewed the lab on [DATE] as evidenced by his signature, and he increased her [MEDICATION NAME] to 3.5 mg daily. The facility's Pharmacist's Medication Regimen Review, dated [DATE], reflected, "...Some lab results were not completed/filed for review this visit. Per staff lab audit already requested and should be completed this month." The Review also reflected for Resident #1, "Resident with orders from prior placement with [MEDICATION NAME] 10 mg QD and started on [MEDICATION NAME] 15 mg QD upon admit. With orders for Mag Ox 400 mg PRN and order started routine for the resident. Please clarify both orders and update. Nurse notified." The Pharmacist's Medication Regimen Review, dated [DATE], did not address the lack of physician's orders [REDACTED]. Resident #1's Nursing Facility History and Physical, dated [DATE] and signed by Resident #1's physician, reflected [DIAGNOSES REDACTED]. The History and Physical also reflected the resident was in the hospital for an open reduction and internal fixation for a fracture, and she was currently taking [MEDICATION NAME] and [MEDICATION NAME]. Resident #1's Nursing Facility History and Physical, dated [DATE], did not reflect the physician reviewed the resident's PT/INR from [DATE] or the need to check her PT/INR. Resident #1's Care Plans, dated [DATE], did not address monitoring her for signs and symptoms of bleeding as it related to the administration of [MEDICATION NAME]. The care plan for "Problem of Pain management: [MEDICAL CONDITION] of Leg/[MEDICAL CONDITION] medication ([MEDICATION NAME]/[MEDICATION NAME]) as ordered Report lab result to Physician...." Resident #1's Laboratory Report, dated [DATE], reflected the results of her PT/INR were PT 19.5 seconds with a reference range of 10.4 - 13.8 seconds and an INR of 2.47 with a reference range of 0.80 - 1.20 ratio. The Report also reflected her Complete Blood Count results were all within normal ranges. A handwritten note on the Report reflected, "Order [DATE] D/C (discontinue) [MEDICATION NAME] when INR 2 Med (medication) D/Cd (discontinued)." Another handwritten note on the Report reflected, "Hold [MEDICATION NAME] MD not (sic) called awaiting call back" with a date of [DATE]. Interview on [DATE] at 12:25 p.m. with the DON revealed the only labs she could locate for Resident #1 for PT/INR levels were dated [DATE] and [DATE]. The DON stated she thought Resident #1 had a transfer order from the hospital regarding the frequency for obtaining laboratory values for PT/INR levels. She stated she was unable to locate any orders for routine monitoring of the PT/INR. Further interview with the DON on [DATE] at 3:55 p.m. revealed when asked about the system for monitoring [MEDICATION NAME], she replied, "There is a sign-in sheet - count sheet. Normally labs (PT/INR) are drawn weekly. Based on that lab, the medication is increased or decreased by the doctor to keep at therapeutic level. The nurse always gives it ([MEDICATION NAME])." Telephone interview with Resident #1's physician, who was also the facility's Medical Director, on [DATE] at 1:35 p.m. revealed his standards of care included weekly laboratory tests for PT/INR levels to monitor residents who were administered [MEDICATION NAME]. He stated every resident was different, and at this time, he could not explain why Resident #1 did not have a physician's orders [REDACTED]. Resident #1's NP M's Progress Note, dated [DATE], reflected the boxes for "Meds reviewed: See medical orders in chart...Continue with current medications; Continue with current treatments; Reviewed PMH (Past Medical History)/family/social; Reviewed Labs/X-rays; Reviewed Hospital documents." Resident #1's Physician's Telephone Order, dated [DATE], reflected, "...D/C [MEDICATION NAME] when INR is 2 or greater...D/C [MEDICATION NAME]." Resident #1's Nurse's Notes, dated [DATE] at 7:00 a.m., reflected, "Went to awaken Res (resident) and Res is not responding does not awaken to strong patting of chest as she has been doing no respiratory effort noted. Hands are cool body is slight warm; continue to try to awaken res unsuccessful. Rush to desk to determine code status she is full code - ask for assistance. Went back to res to start code blue, and called Res name and strongly patted chest. Res Responds a little by turning head and ...Res mumbles a sound. Then makes facial grimace continue patting chest...." An interview on [DATE] at 7:40 a.m. with RN I revealed, "One morning I had a hard time waking her up. I was read to call a code on her. One of the other girls came in - called her name and she opened her eyes." The episode on [DATE] was reviewed with RN I, who said it "was a one-time occurrence. The last morning she (Resident #1) was here the CNAs got her up and took her to the dining room early. I went to the dining room to give her meds. She could respond a little bit - raised her head up when I called her name. I told her it was time to take her meds. She let me put them in her mouth. She opened her mouth and took some water that didn't immediately drool out, but it did drool out." When asked about bleeding, RN I replied, "I never saw any blood from her rectum. I remember asking about and what happened to her. I was told she was bloody stool - a diaper full." The facility's 24 Hour Report, for [DATE], did not reflect the above episode. A Nurse's Note, dated [DATE] at 3:05 p.m. and signed by Resident #1's physician, reflected he spoke to the resident's family member via telephone about the resident's anorexia. The Nurse's Note, dated [DATE] at 3:05 p.m., and signed by Resident #1's physician, indicated the physician was in the facility, but the Note did not address the use of [MEDICATION NAME] or lack of PT/INR monitoring. Resident #1's [DATE] MAR reflected she received Aspirin 81 mg daily except on [DATE]; [MEDICATION NAME] 3 mg on [DATE]; and [MEDICATION NAME] 3.5 mg daily beginning on [DATE] through the rest of the month. The MAR also reflected she received [MEDICATION NAME] on [DATE], [DATE], and [DATE]. Further review of the [DATE] MAR revealed a handwritten note, which reflected, "Hold the [MEDICATION NAME] PT/INR 2.47." After that handwritten note was another note, which reflected, "DC." Resident #1's NP M's Progress Note, dated [DATE], reflected the box for Reviewed labs/X-rays was unchecked. Resident #1's Nurse's Notes, dated [DATE] and untimed, reflected, "...informed by aid that their (sic) was something black on resident's diaper. Nurse took a look at diaper and noticed a dark smear on residents diaper. Notified (NP M) NP for (Resident #1's physician), order for KUB (Kidneys, Ureters, and Bladder pertaining to anteroposterior projection films of the abdomen), H&H on [DATE] notified RP (Responsible Party)...." The Notes did not reflect any vital signs. Resident #1's Nurse's Notes, dated [DATE], reflected "1445 (1:45 p.m.) coming out of another resident's room when aide told me that resident was bleeding. ON getting into residents room, I was speaking to her all of sudden she stop reply and became unresponsive, called her name several times, called for a code blue, upon waiting to start CPR (Cardiopulmonary Resuscitation) resident became responsive, O2 (oxygen) was given to resident 911 was called, v/s (vital signs) taken BP (Blood Pressure) ,[DATE], P (pulse) 74, O2 86 emergency persons came resident transported to (name of hospital)." An interview with LVN G on [DATE] at 12:40 p.m. revealed she was summoned to Resident #1's room on the morning of [DATE], after breakfast, by a CNA to observe a dark smear on the resident's adult brief. LVN G stated she instructed the CNA to "watch" the resident for "anymore." LVN G said she called the resident's physician about the smear in the brief, but was unable to recall if she mentioned the resident was receiving routine [MEDICATION NAME]. When asked about any established parameters for Resident #1's PT/INR levels, LVN G replied, the [MEDICATION NAME] was discontinued when the INR was 2. LVN G revealed sometime after lunch on [DATE], she was walking down the hall when she "smelled something funny, something bad" coming from Resident #1's room. LVN G stated she immediately entered Resident #1's room and was "alarmed." LVN G revealed she observed dark, red blood coming from the resident's rectum. She stated her first thought was to dial 911 and "get her out." LVN G stated she was in Resident #1's room when the resident became unresponsive. Further interview with LVN G on [DATE] at 4:10 p.m. revealed, "That morning ([DATE]) the aide called my attention to a black smear on (Resident #1's) diaper. I notified the ADON and called the Nurse Practitioner and told her it was a dark smear. She ordered some labs and a KUB X-ray. I told the CNA (CNA H) to continually check on her and monitor her. Later in the day, I was across the hall. I was coming out and met my CNA (CNA H). I smelled a funny smell. (CNA H) said (Resident #1) had some dark thing coming out. CNA left it open so I could see. It was really dark. It had a particular smell. Once you smell blood you never forget it. It wasn't a lot, but it was black. (Resident #1) quit responding. I screamed Code Blue. She started responding. 911 came and she went to the hospital. What I saw was a little blood not a 'pool' of blood." Continued interview with LVN G on [DATE] at 4:10 p.m. revealed, "The ADON wrote the Transfer Sheet. When a resident is admitted on [MEDICATION NAME], we call the doctor to clarify orders for labs and x-rays. If they don't give you orders for labs, call their attention to it. We give the pink copies of the orders to the ADON. They (DON and ADON) get a copy of all orders. When (Resident #1) was here, she wasn't eating. She would not eat." Another interview with LVN G on [DATE] at 10:10 a.m. revealed when asked how much blood she observed Resident #1 lose, she replied, "It wasn't a lot of blood, but I could smell it." When LVN G was asked about Resident #1's Resident Transfer Form, dated [DATE], which reflected, "secondary [DIAGNOSES REDACTED]. I didn't see a lot of blood." LVN G acknowledged she could smell the blood from across the hall. An interview on [DATE] at 9:07 a.m. with CNA H revealed she remembered Resident #1. She stated, "She was my resident. The nurse (LVN G) wanted me to check on her every hour because she was bleeding. I checked her after lunch. The nurse (LVN G) came in to check vital signs. She (Resident #1) went out for 2 - 3 seconds. We yelled "STAT!' by the time everybody got there she was ok. I smelled the blood. It's a bad smell. There was only about a quarter size - no diaper full. I don't really remember how much blood she had in her brief." An interview on [DATE] at 12:55 p.m. with the ADON revealed she heard "Code Blue" and went to get the crash cart. She stated she did not remember what Resident #1 looked like, and she did not remember who was in the room at that time. An interview with the DON on [DATE] at 3:40 p.m. revealed, "I heard them call a code on (Resident #1). I don't remember if they called overhead or if someone came and got me. After I got there, she was responding, oxygen was on her. The staff was routinely doing vital signs and monitoring her oxygen saturation until the paramedics arrived. I did not see any blood. There was no blood noted in her diaper - no sign of blood." Another interview with the ADON on [DATE] at 3:45 p.m. revealed, "I heard the code call over the intercom, took the crash cart to her room, went back to get the paperwork ready and send her out to the hospital, make a phone call to the responsible party and (family member). Prior to that the nurse (LVN G) did mention to me she cleaned her up. I asked to see the diaper that she removed. She (LVN G) went and got it. There was a black smudge on it." The ADON said there was no black tarry stool in the brief. Resident #1's Resident Transfer Form, dated [DATE], reflected, "...dark black 'pool' liquid from rectum...VITALS AT TIME OF TRANSFER...B/P ,[DATE]...." Resident #1's Ambulance Report, dated [DATE], reflected they arrived at the facility at 2:27 p.m. and departed at 2:55 p.m. Chief Complaint was [MEDICAL CONDITION] and Altered Mental Status and a list of medications including [MEDICATION NAME]. The Report reflected, "...lying in her bed at her nh (nursing home) where staff stated that she was unresponsive and has developed a gi bleed today...They were talking to her upon our arrival and she was moving her extremities and looking around but would not communicate with us. i was unable to obtain a pulse ox reading...she had no radial pulse and i as unable to obtain an auscultated bp...the pt (patient) seemed to be in a little distress and could not keep her arms still. her bp remained low enroute to (hospital)." The Report also reflected, "Symptoms: General: Malaise And Fatigue; Confusion, RESP: Tachypnea (very rapid rate of respiration)[MEDICAL CONDITION]; NEURO: Altered Mental Status; GI: Stool (Dark/Tarry)...Scene Findings: Blood; Feces...Breathing Quality...Regularity: Tachypnea Effort: Mild Distress...Estimated Blood Loss; ,[DATE] ml...." Resident #1's Emergency Department records, dated [DATE], reflected she arrived in the Emergency Department at 3:14 p.m. with a chief complaint of GI Bleed, Altered Mental Status, and [MEDICAL CONDITION]. The Records also reflected, "...NH (nursing home) reports 'acute onset of blood in stool' 1 hr (hour) PTA (prior to arrival)...Patient is awake but not alert, non-verbal, and not following commands. Unable to obtain BP or O2 sat (saturation) on patient arrival. HR (Heart Rate) SR in 90s...1531 (3:31 p.m.) patient lost pulse, compressions began...1539 (3:39 p.m.) TOD (Time of Death) called by (physician's name)...Stool Amount moderate...Stool Consistency tarry...adult brief in place on arrival...." An interview with the DON on [DATE] at 4:05 p.m. revealed, "I called the lab for their policy and procedure (for monitoring of [MEDICATION NAME]); was told they didn't have a policy and procedure and would have to call the doctor and come up with one." An interview with the Administrator on [DATE] at 6:00 p.m. revealed, "We don't have a policy on anticoagulation therapy. It's not in our pharmacy policy book or in our policy book. I instructed (the DON) to write up a policy of the things we do for [MEDICATION NAME]." The facility's Abuse Prevention Policy, revised [DATE], reflected the policy was to protect all residents from all forms of neglect. It further noted staff would be trained on identifying all forms of neglect. The facility's abuse prevention/intervention program included the following in regard to neglect: Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect; and identifying areas within the facility that may make neglect more likely to occur and conduct frequent monitoring of those areas. On [DATE] an IJ was identified. On [DATE] at 3:18 p.m., the Administrator, LVN J, the ADON, and DON were notified of the IJ and a Plan of Removal was requested at that time. An interview with Resident #1's physician on [DATE] at 11:18 a.m. revealed, "I do a PT/INR when [MEDICATION NAME] started, stop the [MEDICATION NAME] then do weekly PT/INR. I start the [MEDICATION NAME] at 3 mg day. The dose is determined by metabolic functions especially liver functions. What's really scary about [MEDICATION NAME] is a person's nutrition and other drugs. I was aware (Resident #1) was not eating. I visited with her (family member) and told (him/her) how serious her condition was. (Resident #1) was in the hospital with a GI Bleed. She came here with a history of GI Bleed." When asked about Resident #1's PT/INR lab results, the physician replied, "I can't recall seeing it. I don't know how often I visited. You have to trust ancillary orders, labs are doing what I ordered and that they report the results to me or my staff. They write on the lab report that I've been notified and put (the report) in my folder and I review them or my staff reviews them. You have to trust there are systems in place to monitor labs and follow orders. I review them when I go there." When Resident #1's physician was asked what would trigger him to recognize he was not being notified of ordered lab results or seeing ordered lab results, he replied, "You have to trust there are systems in place." Further interview with Resident #1's physician on [DATE] at 4:15 p.m. revealed nurses should be documenting the date, time, who was notified and what the physician said on the actual laboratory reports. He stated he did not review Resident #1's clinical record to ensure PT/INR laboratory levels were being completed, but he relied on the facility's systems. The Medical Director stated there was a system to review labs, but there was no method for follow-up that labs were completed. An interview with the Administrator on [DATE] at 6:00 p.m. revealed when asked how she monitored the DON to ensure the systems the DON was responsible for were completed sufficiently, the Administrator replied, "We just meet and go over things. I ask about responsibilities, orders, charting." When asked how she thought the IJ occurred, the Administrator responded, "I don't think they (the ADON and DON) have been thorough. DON and ADON admitted they had not been doing a thorough job, keeping employees who are not complying with their job responsibilities. There was a lab system failure - not monitoring daily and being focused. We did not follow the system, and if the lab or pharmacy fell through - it was a mistake that should have never been made. The IJ showed me we didn't have a system to monitor [MEDICATION NAME]. The nurse wasn't careful when he wrote the doctor's order. He wrote the lab information on the Laboratory Log and did not write an order for [REDACTED]." When asked what training had been completed with the CNAs, the Administrator replied, "To report changes in condition." The Administrator stated the initials on the altered laboratory log belonged to a lab staff member, who said one of the facility nurses changed the log for Resident #1. Further interview with the Administrator on [DATE] at 1:30 p.m. revealed, "The lab person identified my nurse (LVN N) as person who changed the lab log (regarding the frequency of PT/INR lab tests for Resident #1). She described her." An interview with LVN N on [DATE] at 10:22 a.m. revealed, "I only work on Monday and Tuesday nights. I work Station 2 on Monday night. I remember (Resident #1). I think when I came back to work...." When asked if the lab technician questioned an order for [REDACTED].! I would have no reason to do that. Before I would do anything like that I would have checked the chart and orders." LVN N confirmed she was working with Resident #1 on the night of [DATE] (when Resident #1 had her first PT/INR). Another interview with the Administrator on [DATE] at 4:30 p.m. revealed the DON and ADON checked residents' orders daily and should have discovered the issues related to Resident #1. She stated because of this both the DON and ADON were written up. She revealed the pharmacist consultant conducted an audit on [DATE] and did not identify the problem related to Resident #1. She stated the facility missed an opportunity at that time to address the issue. The facility's undated Anticoagulation Policy, provided on [DATE] at 6:45 p.m. reflected, "Purpose: To establish a standard approach to reduce the risk of adverse events and management of residents receiving medications used for anticoagulation. Policy: It's the policy (name of facility) that all patients will receive individualized dosing of anticoagulants based on doctor's orders, diagnosis, lab results, and risks. Procedures: 1. As part of the initial assessment, the charge nurse will help identify residents who are currently receiving anticoagulant therapy. a. Assess for signs or symptoms related to subtherapeutic or greater than therapeutic drug levels of that particular anticoagulant. b. Ensure each resident on anticoagulant therapy has an order for [REDACTED]. The charge nurse will assess, document, and report the following: a. Current anticoagulant therapy (drug and dose) b. Recent labs, including therapeutic dose monitoring c. Signs and symptoms of bleeding or clots 3. Upon Administering Anticoagulant medication the charge nurse will a. Recognize and adhere to the rights of drug administration b. sign/initial the MAR and controlled substance sheet at time of administration. c. Document and assess for any adverse reactions. i. Report to resident's PCP (primary care physician) immediately if any noted." An interview with the DON on [DATE] at 3:10 p.m. revealed when asked what training did she ensure the nurses had to care for a resident receiving anticoagulant therapy, she replied, "Can't recall any in-services on anticoagulation therapy since I've been here." The DON was asked to check if any in-services on anticoagulation therapy were completed. When asked how she ensured the nurses were competent in their skills in caring for residents with anticoagulation therapy, the DON replied, "By checking the orders. I hear follow-up conversations with the doctors regarding labs and medication changes." When asked what type of plan was in place for anticoagulation therapy, the DON responded, "Check the charts to be sure orders are transcribed. Nurses see me checking the pink telephone order copies, but sometimes I don't get them." When asked how she thought the IJ occurred, the DON replied, "While we do chart checking on admissions, transcription of doctors' orders wasn't done." When asked who was responsible to check if the orders were transcribed, the DON responded, "The DON/ADON were responsible to check the pink copies of the orders, but they (pink copies) don't always make it to me." When asked how she was going to repair the system failure, the DON replied, "In-service. Put a system in place to monitor lab, doctor notification and change in orders will be done daily by the LVNs and weekly monitoring by the DON/ADON." The facility's accepted Plan of Removal, dated [DATE], reflected: "...THE FOLLOWING PROCEDURES HAVE BEEN IMPLEMENTED: ANTICOAGULANT FORM: On Aug. 6th (the DON) created and in-serviced staff on an anticoagulant form. that was posted on the inside of the MARS of those who are receiving anticoagulants. This form was designed as a tool to ensure that when a nurse is administering [MEDICATION NAME] this tool will serve as a trigger to follow up on the required labs if ordered. The nurse will list the date, [MEDICATION NAME] dose, last PT/INR, Dr. notification, order change date, lab value, and the nurses signature. This tool will alert the nurse to act even if the lab or pharmacy consultant were to fail...This new procedure will be monitored each week in the Admin. (Administrative) Review meet with the director of nursing (DON) and the assistant director of nursing. This training was started on [DATE]th and was completed on [DATE]th...This monitoring of this system will continue until Jan. 31, 2014 then quarterly thereafter. Lab Tracking Books: On [DATE]th (the DON) & ADON (name) both prepared and initiated the use of lab tracking books to be utilize (sic) solely by each of them. Each book has a 'daily lab form' inside that will allow DON (name) & designee to list the name of the resident, the lab order, the date of the draw, the value, dr. notification, if the lab was actually drawn, and nurses notes...PT/INR ALERT: Effective [DATE]th, MDS Coordinator (LVN J) printed the notation: PT/INR on the MAR next to all residents who (sic) on [MEDICATION NAME] therapy. The notation serves as a reminder for the nurse administering the medication. Effective September the PT/INR notation will be listed on the MAR permanently...ADMISSION CHECKLIST...Effective Aug. 9th The admission check list if a form that allows the admitting nurse to check off each segment of the admission packet during the assessment, and sign it. Upon completion the charge nurse will place under DON (name's) door for review of accuracy...These files will be monitored weekly at the admin review. This will be ongoing...Effective [DATE]th Administrator has decided to terminate contract (with laboratory services provider). INSERVICES: On [DATE]th (the DON) and ADON started in-servicing and testing the nursing dept. on the following subjects: Lab procedures----Medication Administration Anticoagulation Monitoring Sheet Signs & Symptoms of one receiving blood thinners Physician order [REDACTED].

Based on interview and record review, the Administrator and the DON failed to ensure the facility was administered in a manner, which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for one (Resident #1) of eight residents reviewed for a change of condition. The Administrator failed to implement the facility's Abuse Prevention Program Policies and Procedures. The Administrator failed supervise the DON to ensure she was doing a thorough job of ensuring staff were complying with their job responsibilities and systems were implemented for monitoring of [MEDICATION NAME] and physician-ordered labs. The DON failed to supervise the facility's only ADON and staff to ensure: Physician-ordered labs were completed and results were received. [MEDICATION NAME] was being monitored. Orders were appropriate and transcribed correctly. The residents' drug regimen review was monitored for accuracy. LVN A failed to transcribe the physician's orders [REDACTED]. The ADON failed to recognize Resident #1 was receiving [MEDICATION NAME], but did not have physician's orders [REDACTED]. The facility's contracted Pharmacist failed to recognize Resident #1 was receiving [MEDICATION NAME] without checking the resident's PT/INR for monitoring the [MEDICATION NAME]'s therapeutic level, when the Pharmacist completed the facility's Drug Regimen Review for each resident on [DATE]. These failures resulted in Resident #1 having rectal bleeding, being hypotensive, not responding well, and being in mild respiratory distress on [DATE] and being transferred to the hospital where she expired 25 minutes after arriving in the Emergency Department of the local hospital. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility had not yet in-serviced all nursing staff and fully implemented their Plan of Removal. These failures could affect the nine residents receiving [MEDICATION NAME] by placing them at risk for not having their PT/INRs monitored, which could result in bleeding and/or death. Findings included: Resident #1's hospital History and Physical, dated [DATE] reflected Resident #1 was admitted to the hospital after a fall with fracture at home. The History and Physical also reflected, "living alone in her own home... Patient is not taking any medicines at all at home, except for [MEDICATION NAME] and [MEDICAL CONDITION]. Will start her on [MEDICATION NAME], as well as [MEDICATION NAME] at this time." Resident #1's hospital Facility Transfers Orders, printed [DATE], reflected, "...recheck CBC, CMP in ,[DATE] days. Check [MEDICAL CONDITION] (infectious diarrhea) in (one) week." Resident #1's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her life expectancy was not less than six months, she was in isolation, and was expected to be discharged back to the community. Resident #1's facility admission orders [REDACTED]. The Orders also reflected Aspirin (blood thinner) 81 mg daily. Resident #1's facility admission orders [REDACTED]. Lippincott, Williams & Wilkins Nursing 2013 Drug Handbook on page 1409, regarding [MEDICATION NAME], reflected, "Overdose S&S (signs and symptoms: Blood in stools...NURSING CONSIDERATIONS Black Box Warning [MEDICATION NAME] ([MEDICATION NAME]) can cause major or fatal bleeding, which is more likely to occur during the starting period and with a higher dose. Regularly monitor INR in all patients Consider more frequent INR monitoring in those at high risk for bleeding...Regularly check for...tarry stools...Elderly patients...are especially sensitive to drugs effect...." Resident #1's Nurse's Notes, dated [DATE], reflected, "...medications confirmed by (Resident #1's physician), new orders obtained, lab requisition [MEDICATION NAME] give (sic) from Emergency Kit...." Resident #1's Physician's Telephone Orders, dated [DATE] through [DATE], did not reflect any orders to check her PT/INR. On [DATE] at 3:30 p.m., the Administrator stated, "...The lab company did not come and draw the blood every 3 days...." The facility's copy of the Laboratory Log, dated [DATE], reflected, "PT/INR every 3 days" for Resident #1. The Log also reflected, "Forwarded x (times) 9 days" and underneath were the phlebotomist's initials circled. However, the facility's contracted laboratory services provider's Laboratory Log, dated [DATE], reflected "Every" was crossed out and "in ,[DATE] days" was inserted to reflect "PT/INR in ,[DATE] days." The Log also reflected "Forward For [DATE]" and the "x 9 days" was crossed out. The initials were still present. An interview on [DATE] at 5:40 p.m. with LVN A, the nurse who admitted Resident #1, revealed when asked about the procedure for obtaining orders for new admissions, he replied, "After I complete the assessment, you call the doctor and report your findings, read the hospital discharge orders to him, obtain orders. I write them down on plain paper then write on the telephone order (form). I remember there was an order for [REDACTED]. I did write it on the Laboratory Log." LVN A reviewed a copy of the Laboratory Log, dated [DATE] with an entry for Resident #1. He confirmed he wrote the information on the copy presented to him. LVN A said, "During the time she was here we were doing stools for [MEDICAL CONDITION]. I collected the stool specimens myself and there was never any blood. When she went to the hospital, I was told in report she went to the hospital, she was bleeding from the rectum. I specifically asked if there was a lot of blood. I knew she was [MEDICATION NAME]. (LVN G) said, 'There was a lot of blood.'" LVN A denied Resident #1 ever complained of abdominal pain. "They suspended me yesterday and said I'm under investigation." Interview on [DATE] at 10:30 a.m. with the facility's only ADON revealed she reviewed the copies of the physician's orders [REDACTED]. When asked how she missed there were no orders to check Resident #1's PT/INR, when the resident was on [MEDICATION NAME], she replied, "I don't know." Resident #1's Physician's Telephone Order, dated [DATE], reflected to increase the [MEDICATION NAME] to 3.5 mg daily. Resident #1's Laboratory Report, dated [DATE], reflected her PT/INR results were PT 13.6 seconds with a reference range of 10.4 - 13.8 seconds and an INR 1.34 with a reference range of 0.80 - 1.20 ratio. The Report also reflected her Complete Blood Count results were all within normal ranges. The Report also reflected the physician reviewed the lab on [DATE] as evidenced by his signature, and he increased her [MEDICATION NAME] to 3.5 mg daily. The facility's Pharmacist's Medication Regimen Review, dated [DATE], reflected, "...Some lab results were not completed/filed for review this visit. Per staff lab audit already requested and should be completed this month." The Review also reflected for Resident #1, "Resident with orders from prior placement with [MEDICATION NAME] 10 mg QD and started on [MEDICATION NAME] 15 mg QD upon admit. With orders for Mag Ox 400 mg PRN and order started routine for the resident. Please clarify both orders and update. Nurse notified." The Pharmacist's Medication Regimen Review, dated [DATE], did not address the lack of physician's orders [REDACTED]. Resident #1's Nursing Facility History and Physical, dated [DATE] and signed by Resident #1's physician, reflected [DIAGNOSES REDACTED]. The History and Physical also reflected the resident was in the hospital for an open reduction and internal fixation for a fracture, and she was currently taking [MEDICATION NAME] and [MEDICATION NAME]. Resident #1's Nursing Facility History and Physical, dated [DATE], did not reflect the physician reviewed the resident's PT/INR from [DATE] or the need to check her PT/INR. Resident #1's Laboratory Report, dated [DATE], reflected the results of her PT/INR were PT 19.5 seconds with a reference range of 10.4 - 13.8 seconds and an INR of 2.47 with a reference range of 0.80 - 1.20 ratio. The Report also reflected her Complete Blood Count results were all within normal ranges. A handwritten note on the Report reflected, "Order [DATE] D/C (discontinue) [MEDICATION NAME] when INR 2 Med (medication) D/Cd (discontinued)." Another handwritten note on the Report reflected, "Hold [MEDICATION NAME] MD not (sic) called awaiting call back" with a date of [DATE]. Interview on [DATE] at 12:25 p.m. with the DON revealed the only labs she could locate for Resident #1 for PT/INR levels were dated [DATE] and [DATE]. The DON stated she thought Resident #1 had a transfer order from the hospital regarding the frequency for obtaining laboratory values for PT/INR levels. She stated she was unable to locate any orders for routine monitoring of the PT/INR. Further interview with the DON on [DATE] at 3:55 p.m. revealed when asked about the system for monitoring [MEDICATION NAME], she replied, "There is a sign-in sheet - count sheet. Normally labs (PT/INR) are drawn weekly. Based on that lab, the medication is increased or decreased by the doctor to keep at therapeutic level. The nurse always gives it ([MEDICATION NAME])." Telephone interview with Resident #1's physician, who was also the facility's Medical Director, on [DATE] at 1:35 p.m. revealed his standards of care included weekly laboratory tests for PT/INR levels to monitor residents who were administered [MEDICATION NAME]. He stated every resident was different, and at this time, he could not explain why Resident #1 did not have a physician's orders [REDACTED]. Resident #1's Physician's Telephone Order, dated [DATE], reflected, "...D/C [MEDICATION NAME] when INR is 2 or greater...D/C [MEDICATION NAME]." Resident #1's Nurse's Notes, dated [DATE] at 7:00 a.m., reflected, "Went to awaken Res (resident) and Res is not responding does not awaken to strong patting of chest as she has been doing no respiratory effort noted. Hands are cool body is slight warm; continue to try to awaken res unsuccessful. Rush to desk to determine code status she is full code - ask for assistance. Went back to res to start code blue, and called Res name and strongly patted chest. Res Responds a little by turning head and ...Res mumbles a sound. Then makes facial grimace continue patting chest...." An interview on [DATE] at 7:40 a.m. with RN I revealed, "One morning I had a hard time waking her up. I was read to call a code on her. One of the other girls came in - called her name and she opened her eyes." The episode on [DATE] was reviewed with RN I, who said it "was a one-time occurrence. The last morning she (Resident #1) was here the CNAs got her up and took her to the dining room early. I went to the dining room to give her meds. She could respond a little bit - raised her head up when I called her name. I told her it was time to take her meds. She let me put them in her mouth. She opened her mouth and took some water that didn't immediately drool out, but it did drool out." When asked about bleeding, RN I replied, "I never saw any blood from her rectum. I remember asking about and what happened to her. I was told she was bloody stool - a diaper full." The facility's 24 Hour Report, for [DATE], did not reflect the above episode. A Nurse's Note, dated [DATE] at 3:05 p.m. and signed by Resident #1's physician, reflected he spoke to the resident's family member via telephone about the resident's anorexia. The Nurse's Note, dated [DATE] at 3:05 p.m., and signed by Resident #1's physician, indicated the physician was in the facility, but the Note did not address the use of [MEDICATION NAME] or lack of PT/INR monitoring. Resident #1's [DATE] MAR reflected she received Aspirin 81 mg daily except on [DATE]; [MEDICATION NAME] 3 mg on [DATE]; and [MEDICATION NAME] 3.5 mg daily beginning on [DATE] through the rest of the month. The MAR also reflected she received [MEDICATION NAME] on [DATE], [DATE], and [DATE]. Further review of the [DATE] MAR revealed a handwritten note, which reflected, "Hold the [MEDICATION NAME] PT/INR 2.47." After that handwritten note was another note, which reflected, "DC." Resident #1's Nurse's Notes, dated [DATE] and untimed, reflected, "...informed by aid that their (sic) was something black on resident's diaper. Nurse took a look at diaper and noticed a dark smear on residents diaper. Notified (NP M) NP for (Resident #1's physician), order for KUB (Kidneys, Ureters, and Bladder pertaining to anteroposterior projection films of the abdomen), H&H on [DATE] notified RP (Responsible Party)...." The Notes did not reflect any vital signs. Resident #1's Nurse's Notes, dated [DATE], reflected "1445 (1:45 p.m.) coming out of another resident's room when aide told me that resident was bleeding. ON getting into residents room, I was speaking to her all of sudden she stop reply and became unresponsive, called her name several times, called for a code blue, upon waiting to start CPR (Cardiopulmonary Resuscitation) resident became responsive, O2 (oxygen) was given to resident 911 was called, v/s (vital signs) taken BP (Blood Pressure) ,[DATE], P (pulse) 74, O2 86 emergency persons came resident transported to (name of hospital)." An interview with LVN G on [DATE] at 12:40 p.m. revealed she was summoned to Resident #1's room on the morning of [DATE], after breakfast, by a CNA to observe a dark smear on the resident's adult brief. LVN G stated she instructed the CNA to "watch" the resident for "anymore." LVN G said she called the resident's physician about the smear in the brief, but was unable to recall if she mentioned the resident was receiving routine [MEDICATION NAME]. When asked about any established parameters for Resident #1's PT/INR levels, LVN G replied, the [MEDICATION NAME] was discontinued when the INR was 2. LVN G revealed sometime after lunch on [DATE], she was walking down the hall when she "smelled something funny, something bad" coming from Resident #1's room. LVN G stated she immediately entered Resident #1's room and was "alarmed." LVN G revealed she observed dark, red blood coming from the resident's rectum. She stated her first thought was to dial 911 and "get her out." LVN G stated she was in Resident #1's room when the resident became unresponsive. Further interview with LVN G on [DATE] at 4:10 p.m. revealed, "That morning ([DATE]) the aide called my attention to a black smear on (Resident #1's) diaper. I notified the ADON and called the Nurse Practitioner and told her it was a dark smear. She ordered some labs and a KUB X-ray. I told the CNA (CNA H) to continually check on her and monitor her. Later in the day, I was across the hall. I was coming out and met my CNA (CNA H). I smelled a funny smell. (CNA H) said (Resident #1) had some dark thing coming out. CNA left it open so I could see. It was really dark. It had a particular smell. Once you smell blood you never forget it. It wasn't a lot, but it was black. (Resident #1) quit responding. I screamed Code Blue. She started responding. 911 came and she went to the hospital. What I saw was a little blood not a 'pool' of blood." Continued interview with LVN G on [DATE] at 4:10 p.m. revealed, "The ADON wrote the Transfer Sheet. When a resident is admitted on [MEDICATION NAME], we call the doctor to clarify orders for labs and x-rays. If they don't give you orders for labs, call their attention to it. We give the pink copies of the orders to the ADON. They (DON and ADON) get a copy of all orders. When (Resident #1) was here, she wasn't eating. She would not eat." Another interview with LVN G on [DATE] at 10:10 a.m. revealed when asked how much blood she observed Resident #1 lose, she replied, "It wasn't a lot of blood, but I could smell it." When LVN G was asked about Resident #1's Resident Transfer Form, dated [DATE], which reflected, "secondary [DIAGNOSES REDACTED]. I didn't see a lot of blood." LVN G acknowledged she could smell the blood from across the hall. An interview on [DATE] at 9:07 a.m. with CNA H revealed she remembered Resident #1. She stated, "She was my resident. The nurse (LVN G) wanted me to check on her every hour because she was bleeding. I checked her after lunch. The nurse (LVN G) came in to check vital signs. She (Resident #1) went out for 2 - 3 seconds. We yelled "STAT!' by the time everybody got there she was ok. I smelled the blood. It's a bad smell. There was only about a quarter size - no diaper full. I don't really remember how much blood she had in her brief." An interview on [DATE] at 12:55 p.m. with the ADON revealed she heard "Code Blue" and went to get the crash cart. She stated she did not remember what Resident #1 looked like, and she did not remember who was in the room at that time. An interview with the DON on [DATE] at 3:40 p.m. revealed, "I heard them call a code on (Resident #1). I don't remember if they called overhead or if someone came and got me. After I got there, she was responding, oxygen was on her. The staff was routinely doing vital signs and monitoring her oxygen saturation until the paramedics arrived. I did not see any blood. There was no blood noted in her diaper - no sign of blood." Another interview with the ADON on [DATE] at 3:45 p.m. revealed, "I heard the code call over the intercom, took the crash cart to her room, went back to get the paperwork ready and send her out to the hospital, make a phone call to the responsible party and (family member). Prior to that the nurse (LVN G) did mention to me she cleaned her up. I asked to see the diaper that she removed. She (LVN G) went and got it. There was a black smudge on it." The ADON said there was no black tarry stool in the brief. Resident #1's Resident Transfer Form, dated [DATE], reflected, "...dark black 'pool' liquid from rectum...VITALS AT TIME OF TRANSFER...B/P ,[DATE]...." Resident #1's Ambulance Report, dated [DATE], reflected they arrived at the facility at 2:27 p.m. and departed at 2:55 p.m. Chief Complaint was [MEDICAL CONDITION] and Altered Mental Status and a list of medications including [MEDICATION NAME]. The Report reflected, "...lying in her bed at her nh (nursing home) where staff stated that she was unresponsive and has developed a gi bleed today...They were talking to her upon our arrival and she was moving her extremities and looking around but would not communicate with us. i was unable to obtain a pulse ox reading...she had no radial pulse and i as unable to obtain an auscultated bp...the pt (patient) seemed to be in a little distress and could not keep her arms still. her bp remained low enroute to (hospital)." The Report also reflected, "Symptoms: General: Malaise And Fatigue; Confusion, RESP: Tachypnea (very rapid rate of respiration)[MEDICAL CONDITION]; NEURO: Altered Mental Status; GI: Stool (Dark/Tarry)...Scene Findings: Blood; Feces...Breathing Quality...Regularity: Tachypnea Effort: Mild Distress...Estimated Blood Loss; ,[DATE] ml...." Resident #1's Emergency Department records, dated [DATE], reflected she arrived in the Emergency Department at 3:14 p.m. with a chief complaint of GI Bleed, Altered Mental Status, and [MEDICAL CONDITION]. The Records also reflected, "...NH (nursing home) reports 'acute onset of blood in stool' 1 hr (hour) PTA (prior to arrival)...Patient is awake but not alert, non-verbal, and not following commands. Unable to obtain BP or O2 sat (saturation) on patient arrival. HR (Heart Rate) SR in 90s...1531 (3:31 p.m.) patient lost pulse, compressions began...1539 (3:39 p.m.) TOD (Time of Death) called by (physician's name)...Stool Amount moderate...Stool Consistency tarry...adult brief in place on arrival...." An interview with the DON on [DATE] at 4:05 p.m. revealed, "I called the lab for their policy and procedure (for monitoring of [MEDICATION NAME]); was told they didn't have a policy and procedure and would have to call the doctor and come up with one." An interview with the Administrator on [DATE] at 6:00 p.m. revealed, "We don't have a policy on anticoagulation therapy. It's not in our pharmacy policy book or in our policy book. I instructed (the DON) to write up a policy of the things we do for [MEDICATION NAME]." The facility's Abuse Prevention Policy, revised [DATE], reflected the policy was to protect all residents from all forms of neglect. It further noted staff would be trained on identifying all forms of neglect. The facility's abuse prevention/intervention program included the following in regard to neglect: Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect; and identifying areas within the facility that may make neglect more likely to occur and conduct frequent monitoring of those areas. The facility's undated Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures reflected, "...The administrator assumes the responsibility for the overall coordination and implementation of our facility's abuse prevention program policies and procedures...." On [DATE] an IJ was identified. On [DATE] at 3:18 p.m., the Administrator, LVN J, the ADON, and DON were notified of the IJ and a Plan of Removal was requested at that time. An interview with Resident #1's physician on [DATE] at 11:18 a.m. revealed, "I do a PT/INR when [MEDICATION NAME] started, stop the [MEDICATION NAME] then do weekly PT/INR. I start the [MEDICATION NAME] at 3 mg day. The dose is determined by metabolic functions especially liver functions. What's really scary about [MEDICATION NAME] is a person's nutrition and other drugs. I was aware (Resident #1) was not eating. I visited with her (family member) and told (him/her) how serious her condition was. (Resident #1) was in the hospital with a GI Bleed. She came here with a history of GI Bleed." When asked about Resident #1's PT/INR lab results, the physician replied, "I can't recall seeing it. I don't know how often I visited. You have to trust ancillary orders, labs are doing what I ordered and that they report the results to me or my staff. They write on the lab report that I've been notified and put (the report) in my folder and I review them or my staff reviews them. You have to trust there are systems in place to monitor labs and follow orders. I review them when I go there." When Resident #1's physician was asked what would trigger him to recognize he was not being notified of ordered lab results or seeing ordered lab results, he replied, "You have to trust there are systems in place." Further interview with Resident #1's physician on [DATE] at 4:15 p.m. revealed nurses should be documenting the date, time, who was notified and what the physician said on the actual laboratory reports. He stated he did not review Resident #1's clinical record to ensure PT/INR laboratory levels were being completed, but he relied on the facility's systems. The Medical Director stated there was a system to review labs, but there was no method for follow-up that labs were completed. An interview with the Administrator on [DATE] at 6:00 p.m. revealed when asked how she monitored the DON to ensure the systems the DON was responsible for were completed sufficiently, the Administrator replied, "We just meet and go over things. I ask about responsibilities, orders, charting." When asked how she thought the IJ occurred, the Administrator responded, "I don't think they (the ADON and DON) have been thorough. DON and ADON admitted they had not been doing a thorough job, keeping employees who are not complying with their job responsibilities. There was a lab system failure - not monitoring daily and being focused. We did not follow the system, and if the lab or pharmacy fell through - it was a mistake that should have never been made. The IJ showed me we didn't have a system to monitor [MEDICATION NAME]. The nurse wasn't careful when he wrote the doctor's order. He wrote the lab information on the Laboratory Log and did not write an order for [REDACTED]." When asked what training had been completed with the CNAs, the Administrator replied, "To report changes in condition." The Administrator stated the initials on the altered laboratory log belonged to a lab staff member, who said one of the facility nurses changed the log for Resident #1. Further interview with the Administrator on [DATE] at 1:30 p.m. revealed, "The lab person identified my nurse (LVN N) as person who changed the lab log (regarding the frequency of PT/INR lab tests for Resident #1). She described her." An interview with LVN N on [DATE] at 10:22 a.m. revealed, "I only work on Monday and Tuesday nights. I work Station 2 on Monday night. I remember (Resident #1). I think when I came back to work...." When asked if the lab technician questioned an order for [REDACTED].! I would have no reason to do that. Before I would do anything like that I would have checked the chart and orders." LVN N confirmed she was working with Resident #1 on the night of [DATE] (when Resident #1 had her first PT/INR). Another interview with the Administrator on [DATE] at 4:30 p.m. revealed the DON and ADON checked residents' orders daily and should have discovered the issues related to Resident #1. She stated because of this both the DON and ADON were written up. She revealed the pharmacist consultant conducted an audit on [DATE] and did not identify the problem related to Resident #1. She stated the facility missed an opportunity at that time to address the issue. The facility's undated Anticoagulation Policy, provided on [DATE] at 6:45 p.m. reflected, "Purpose: To establish a standard approach to reduce the risk of adverse events and management of residents receiving medications used for anticoagulation. Policy: It's the policy (name of facility) that all patients will receive individualized dosing of anticoagulants based on doctor's orders, diagnosis, lab results, and risks. Procedures: 1. As part of the initial assessment, the charge nurse will help identify residents who are currently receiving anticoagulant therapy. a. Assess for signs or symptoms related to subtherapeutic or greater than therapeutic drug levels of that particular anticoagulant. b. Ensure each resident on anticoagulant therapy has an order for [REDACTED]. The charge nurse will assess, document, and report the following: a. Current anticoagulant therapy (drug and dose) b. Recent labs, including therapeutic dose monitoring c. Signs and symptoms of bleeding or clots 3. Upon Administering Anticoagulant medication the charge nurse will a. Recognize and adhere to the rights of drug administration b. sign/initial the MAR and controlled substance sheet at time of administration. c. Document and assess for any adverse reactions. i. Report to resident's PCP (primary care physician) immediately if any noted." An interview with the DON on [DATE] at 3:10 p.m. revealed when asked what training did she ensure the nurses had to care for a resident receiving anticoagulant therapy, she replied, "Can't recall any in-services on anticoagulation therapy since I've been here." The DON was asked to check if any in-services on anticoagulation therapy were completed. When asked how she ensured the nurses were competent in their skills in caring for residents with anticoagulation therapy, the DON replied, "By checking the orders. I hear follow-up conversations with the doctors regarding labs and medication changes." When asked what type of plan was in place for anticoagulation therapy, the DON responded, "Check the charts to be sure orders are transcribed. Nurses see me checking the pink telephone order copies, but sometimes I don't get them." When asked how she thought the IJ occurred, the DON replied, "While we do chart checking on admissions, transcription of doctors' orders wasn't done." When asked who was responsible to check if the orders were transcribed, the DON responded, "The DON/ADON were responsible to check the pink copies of the orders, but they (pink copies) don't always make it to me." When asked how she was going to repair the system failure, the DON replied, "In-service. Put a system in place to monitor lab, doctor notification and change in orders will be done daily by the LVNs and weekly monitoring by the DON/ADON." The facility's accepted Plan of Removal, dated [DATE], reflected: "...THE FOLLOWING PROCEDURES HAVE BEEN IMPLEMENTED: ANTICOAGULANT FORM: On Aug. 6th (the DON) created and in-serviced staff on an anticoagulant form. that was posted on the inside of the MARS of those who are receiving anticoagulants. This form was designed as a tool to ensure that when a nurse is administering [MEDICATION NAME] this tool will serve as a trigger to follow up on the required labs if ordered. The nurse will list the date, [MEDICATION NAME] dose, last PT/INR, Dr. notification, order change date, lab value, and the nurses signature. This tool will alert the nurse to act even if the lab or pharmacy consultant were to fail...This new procedure will be monitored each week in the Admin. (Administrative) Review meet with the director of nursing (DON) and the assistant director of nursing. This training was started on [DATE]th and was completed on [DATE]th...This monitoring of this system will continue until Jan. 31, 2014 then quarterly thereafter. Lab Tracking Books: On [DATE]th (the DON) & ADON (name) both prepared and initiated the use of lab tracking books to be utilize (sic) solely by each of them. Each book has a 'daily lab form' inside that will allow DON (name) & designee to list the name of the resident, the lab order, the date of the draw, the value, dr. notification, if the lab was actually drawn, and nurses notes...PT/INR ALERT: Effective [DATE]th, MDS Coordinator (LVN J) printed the notation: PT/INR on the MAR next to all residents who (sic) on [MEDICATION NAME] therapy. The notation serves as a reminder for the nurse administering the medication. Effective September the PT/INR notation will be listed on the MAR permanently...ADMISSION CHECKLIST...Effective Aug. 9th The admission check list if a form that allows the admitting nurse to check off each segment of the admission packet during the assessment, and sign it. Upon completion the charge nurse will place under DON (name's) door for review of accuracy...These files will be monitored weekly at the admin review. This will be ongoing...Effective [DATE]th Administrator has decided to terminate contract (with laboratory services provider). INSERVICES: On [DATE]th (the DON) and ADON started in-servicing and testing the nursing dept. on the following subjects: Lab procedures----Medication Administration Anticoagulation Monitoring Sheet Signs & Symptoms of one receiving blood thinners Physician order [REDACTED]. Completion will be on [DATE]th, 2013...NEGLECT AND ABUSE TRAINING Aug. 11 The Administrator has in-serviced and tested (DON) and MDS Coor (LVN J). This will be monitored during the weekly admin review meetings then quarterly thereafter...ANTICOAGULATION MONITORING RESULTS...[DATE]th Anticoagulation lab audit conducted the DON (name) and ADON (name) The audit was completed to ensure that all residents receiving the anticoagulation therapy were in compliance. Findings good...ADMINISTRATOR: ADON (name): Suspended on [DATE] Terminated on [DATE]...(LVN N): SUSPENDED [DATE] THRU (sic) [DATE]. (LVN

Based on observation, interview and record review, the facility failed to provide the necessary care and services for three (ResidentS #7, #10, and #18) of eight sampled residents, who required assessment and administration of insulin to maintain their highest physical well-being. 1. Resident #10 had a finger stick blood sugar of 67 mg/dL on 01/20/11 at 5:00 PM. The nurse did not assess or monitor the resident for adverse effect and administered the resident a routine dose of a long-action insulin. The resident was not monitored or assessed again until 6:10 AM the next day, at which time her blood sugar was 38 mg/dL. Upon second assessment at that time the blood sugar registered "Lo" and the resident was sent to the hospital. 2. Resident #18 received insulin based on a sliding scale blood sugar without a physician's orders [REDACTED]. 3. Resident #7 was ordered on admission (01/07/11) to receive insulin based on the resident's blood sugar twice daily. The order was not clarified for parameters and was not initiated until three days later (01/10/11). These failures resulted in Resident #10 experiencing a episode of [DIAGNOSES REDACTED] and requiring hospitalization . These failures could result in uncontrolled blood sugars for the facility 24 diabetic residents. Findings included: 1. Review of the Face Sheet for Resident #10 revealed she had been admitted to the facility on [DATE] and her DOB was 10/13/50. Her admitting [DIAGNOSES REDACTED]. Observation of Resident #10 during initial tour on 01/18/11 at 9:35 AM revealed a bedfast resident with [DEVICE] feedings. She was non-verbal with her eyes opened. Her right lateral great toe joint had a pressure ulcer present. She was dressed in a gown. She was odor free. The head of her bed was positioned at a 45 degree angle. She had pillows to support her head and her arms. Resident #10's physician's orders [REDACTED]. The orders also reflected the resident was to receive Regular Insulin based on a sliding scale BID. The scale specified: BS 70 mg/dL-150 mg/dL,0 insulin; BS 150-200 mg/dL, 2 units; BS 201-250 mg/dL, 4 units; BS 251-300 mg/dL, 6 units; BS 301-350 mg/dL, 8 units; BS 351-400 mg/dL, 10 units. The order reflected, "Call MD for BS less than 60 mg/dL or greater than 400 mg/dL." Review of the MAR indicated [REDACTED]. Her FSBS (fingerstick blood sugars) were done at 6:30 AM and again at 5:00 PM. On 01/20/11 at 5:00 PM, her FSBS registered 67 mg/dL on the glucometer (blood sugar test machine). Her usual blood sugars in the evenings had been 120s mg/dL and above. The next recorded blood sugar on the MAR indicated [REDACTED]. The result was 38 mg/dL. The MAR indicated [REDACTED]. Review of Resident #10's Nurses' Notes for 01/20/11 reflected no notes regarding the low blood sugar reading at 5:00 PM. There were no notes to reflect any further nursing actions by the nurse who had taken the 5:00 PM FSBS which had registered 67 mg/dL. Review of the Nurses' Notes for 01/21/11 at 6:10 AM reflected that the FSBS was 38 mg/dL. The Nurse's Notes continued with an assessment of Resident #10 and reflected,"Resident clammy-responds with eye movements slowly reactive. Gave [MEDICATION NAME] 1 mg IM left arm. Vitals - O2 sat. 92%. TPR- 95.2-64-16, BP-118/70. FSBS rechecked 24 (mg/dL). Oxygen at 2 LPM per nasal cannula -90%. 911 called due to lower blood sugar." At 6:15 AM, the Nurse's Notes continued, "FSBS - 21 (mg/dL). Spoke with Dr. ___, said to send to hospital for emergency care. New order noted and gave second dose of [MEDICATION NAME] 1 mg IM right arm. FSBS now reading Low with slow response. Med Star here... Resident left at 7:15 AM per ambulance." Review of the 24 Hour Report/Change of Condition Report dated 01/20/11 reflected the residents' names and any remarks the nurses had to relate to the next shift. There were columns to record remarks for each shift; Day, Evening, and Night. Beside Resident #10's name; "? (no) problems" was recorded for evening shift. In a telephone interview with LVN C on 01/21/11 at 12:20 PM, she stated Resident #10 had "nothing wrong with her." She stated she had performed another FSBS at 8:00 PM on 01/20/11 and the result was "111 (mg/dL) or 112 (mg/dL)." Later in the evening, around 9:00 PM, she stated she had given Resident #10 her evening dose of insulin, [MEDICATION NAME] Insulin 45 units. She stated she had not told "anybody" about the low blood sugar result earlier. She stated she, "Did not think to not give the 9:30 PM dose of insulin due to the blood sugar recheck an hour to an hour and a half ago." In a telephone interview with LVN D on 01/21/11 at 12:30 PM, she stated she noted Resident #10 sweating as she gave her medications per [DEVICE]. She stated,Resident #10 "was not responding as well by opening her eyes more slowly." She performed the FSBS at 6:10 AM and the result was 38 mg/dL. She stated she began to give "sugar water in the [DEVICE] as the flush with the medications." She stated she gave "[MEDICATION NAME] at 6:10 AM and again at 6:30 AM." She had the Med Aide to call 911. She stated she "rechecked the FSBS and the result was 24 (mg/dL), then it read Low." She continued her story with, "The paramedics arrived somewhere around 6:20 to 6:30 AM. Her (Resident #10's) blood sugar was 20 at that time. They began to work on her. It looked like they started an IV to help get her blood sugar up. They checked her blood sugar and it was in the 30s. She was opening her eyes when the paramedics left with her." The conversation was re-directed with the events leading up to the change in condition. LVN D stated the nurse aide had gone into Resident #10's room at "5:30 AM to change her and make her comfortable. She went into the room [ROOM NUMBER] to 15 minutes after the nurse aide had left to administer medications and perform the FSBS at 6:10 AM. It was at this time she first noticed Resident #10 "sweating and not waking up like she usually does. She immediately called for help and pulled the emergency call bell and went to get the [MEDICATION NAME]." She stated she had not noticed the MAR indicated [REDACTED]." In fact, LVN C reported that Resident #10 "had no problems." Review of the Triage/Initial Assessment at the Emergency Department at JPS on 01/21/11 at 07:46 AM; revealed, "Pt (patient) arrived via EMS for low BSG 20 (mg/dL) and given [MEDICATION NAME]. EMS BSG 31 (mg/dL) and given one amp D50 with repeat BSG 105 (mg/dL)." Review of the literature for the glucometer ([MEDICATION NAME] EZ) used at the facility to test blood sugar indicated "LO means your blood glucose may be lower than 20 mg/dL." The information continued with "High or low blood glucose results may have serious medical consequences." "[DIAGNOSES REDACTED] can happen suddenly. It is usually mild and can be treated quickly and easily by eating or drinking a small amount of glucose-rich food. If left untreated, [DIAGNOSES REDACTED] can get worse and cause confusion, clumsiness, or [MEDICAL CONDITION]. Severe [DIAGNOSES REDACTED] can lead to [MEDICAL CONDITION], coma, and even death...For people with diabetes, a blood glucose level below 70 mg/dL is considered [DIAGNOSES REDACTED]." (Retrieved at <http://diabetes.niddk.nih.gov/dm/pubs/[DIAGNOSES REDACTED]/> on 2/10/11) 2. Review of the Face Sheet for Resident #18 dated 01/09/11 revealed she had been admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. On 01/19/11 at 6:30 AM during Med Pass with LVN B, Resident #18's blood sugar was checked via a finger stick and Regular Insulin, 2 units, were administered. Review of Resident #18's Admission physician's orders [REDACTED]. Review of the MAR indicated [REDACTED]. The parameters for insulin administration handwritten on the MAR indicated [REDACTED] BS 150-200 mg/dL= 2 units; BS 201-250 mg/dL = 4 units; BS 251-300 mg/dL= 6 units; BS 300-350 mg/dL = 8 units; BS 351-400 mg/dL = 10 units; BS over 400 mg/dL = call MD. The MAR indicated [REDACTED] 01/06/11 at 4:30 PM for BS of 159 mg/dL- received 2 units; 01/07/11 at 4:30 PM for BS of 170 mg/dL- received 2 units; 01/18/11 at 4:30 PM for BS of 154 mg/dL- received 2 units; 01/19/11 at 6:30 AM for BS of 193 mg/dL- received 2 units; and 01/19/11 at 4:30 PM for BS of 174 mg/dL- received 2 units. The MAR indicated [REDACTED]. In an interview on 01/20/11 at 11:30 AM, LVN ADON N was asked about Resident #18's finger stick and sliding scale orders. She stated the resident was supposed to receive the sliding scale insulin and she would talk with the nurse responsible (LVN E) for writing the orders. Later on 01/20/11 at 5:45 PM, LVN ADON N brought a copy of her written investigation. LVN E's written statement reflected, "The reason sliding scale was not in orders is because I was using Standing Sliding Scale that ___ (Nurse Practitioner) uses on all ___(Doctor's) patients and failed to write it on Doctor Order sheet. I thought I wrote it but could not find it." Review of the investigation revealed no information about the process of enforcing their policy to review medications received from the pharmacy against the physician's orders [REDACTED]. Nor was there mention of the facility's policy to NOT use Standing Orders. 3. Resident #7, an [AGE] year-old male, was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of admission orders [MEDICATION NAME] SSI (sliding scale insulin) BID." The order did not have any specific parameters for the sliding scale insulin. Review of the Physician's Telephone Orders dated 01/10/11 at 4:00 AM revealed an order for [REDACTED].= 2 units, 201-250 mg/dL= 3 units and > 250mg/dL = 4 units." Review of the handwritten MAR indicated [REDACTED]. Further review of this form revealed Resident #7's blood sugar required insulin administration as follows: 01/11/11 at 4:30 PM for BS of 170 mg/dL- received 2 units; 01/12/11 at 4:30 PM for BS of 169 mg/dL- received 2 units; 01/15/11 at 4:30 PM for BS of 169 mg/dL- received 2 units; 01/16/11 at 4:30 PM for BS of 153 mg/dL- received 2 units; 01/17/11 at 6:30 AM for BS of 201 mg/dL- received 3 units; and 01/17/11 at 4:30 PM for BS of 193 mg/dL - received 2 units. During an interview on 01/20/11 at 12:55 PM regarding Resident #7's admission physician order [REDACTED]. I'm the one who checked the chart on Monday (01/10/11) and had the nurse clarify the order." During an interview on 01/20/11 at 2:20 PM, LVN Q reviewed Resident #7's physician order [REDACTED]." 4. The facility's current policy and procedure for Blood Sugar Monitoring, undated, under Procedure, it read, "1. check physician's orders [REDACTED]. The facility's current policy and procedure for Medication Order/Receipt Control, undated, reflected, "Medications may be administered only upon the order of a physician. All physician's orders [REDACTED]. There are to be no standing orders for prescription medications or treatments...." Telephone interview on 2/10/11 at 4:15 PM with the facility administration revealed 24 residents with [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility failed to ensure residents received adequate care and services to promote healing, prevent infection and prevent new pressure ulcers from developing for five (Residents #3, #4, #6, #7, #11) of ten sampled residents. 1. Resident #7 entered the facility on 01/07/11. No skin assessment was done at the time of admission. The resident was identified with a "wound" on this right great toe on 01/10/11, but no full assessment was completed and no action taken until 01/14/11, when the wound care physician made rounds. At this time the resident was identified with a "blister" (minimum Stage 2 pressure ulcer) on his right great toe and treatment was orders. The treatment was not initiated until surveyor inquiry on 01/18/11. There was no nursing care plan for the prevention and treatment of [REDACTED]. 2. Resident #11 was admitted on [DATE] with a reddened areas on her coccyx and right lower leg. The resident's treatments were not consistently done, assessments were not completed, and nursing care plans were not developed. An unstageable pressure ulcer on the resident's right calf was identified and recorded on the pressure ulcer log on 12/17/10. Although the resident received treatment for [REDACTED]. The resident developed an unstageable pressure ulcer on the sacrum that was identified by the wound care physician on 12/31/10. On 01/29/11, after surveyor inquiry, an additional pressure ulcer (Stage 2 on the left calf) was identified. 3. Resident #4 was admitted to the facility on [DATE] with a Stage 3 pressure ulcer on her sacrum and a Stage 3 pressure ulcer on her right buttock. The resident's treatments were not consistently done, assessments were not completed, and nursing care plans were not developed. On 01/19/11, after surveyor inquiry, the resident had developed a Stage 2 pressure ulcer on her right thigh. 4. Resident #6 was admitted on [DATE] with a Stage 3 pressure ulcer. The resident's treatments were not consistently done, assessments were not completed, and nursing care plans were not developed. 5) Resident #3 had a history of [REDACTED]. She was identified on her MDS assessment dated [DATE] as at risk for Pressure Ulcers. Resident #3 was assessed by staff on 01/20/11 and identified as having two Stage II areas on her coccyx. No prior documentation of these areas were done and no care plans related to skin care were done. These failures resulted in Residents #3, #4, #7 and #11's development of new pressure ulcers and decline of current pressure ulcers, which required extensive treatments resulting in the potential for extreme pain and decreased quality of life and had the potential to affect Resident #6 and all 15 residents with pressure ulcers. Findings included: 1) Resident #7, an [AGE] year-old male, was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation during initial tour on 01/18/11 at approximately 9:35 AM revealed Resident #7 up in a wheelchair. The resident was alert and oriented. At that time, LVN S revealed the resident had a pressure ulcer on his right great toe. Review of Skilled Nursing Notes dated 01/08/11 revealed Resident #7 was alert, was totally dependent for mobility, transfers, locomotion on the unit, limited assistance with toilet use and extensive assistance with personal hygiene. The section designated for the resident's skin assessment was blank. The narrative section of the the notes reflected the skin was "warm & dry." There was no other assessment of the skin. Review of Resident #7's Skilled Nursing Notes dated 01/09/11 revealed the section designated for the resident's skin assessment was blank. The narrative section of the the notes again only referred to the skin was being warm and dry. The Skilled Nursing Notes dated 01/10/11, reflected the section designated for the resident's skin assessment was blank. The narrative section reflected a "wound to ? (right) BIG toe" was identified by the 3-11 PM nurse. No action taken was documented. On Resident #7's Skilled Nursing Notes dated 01/11/11, 01/12/11, and 01/14/11 the skin assessment sections were blank, but the notes identified the presence of a "wound" on the resident's great toe by the 3-11 PM nurse with no action taken. (Note: The notes on 01/13/11 and 01/15/11 did not address any skin concerns.) On 01/16/11 at 11:30 AM, Resident #7's Skilled Nursing Notes reflected, "...2x2 cm blood blister noted on ? Great toe unopened." No action was documented. The Wound Care Assessment completed by the wound care physician dated 01/14/11 revealed Resident #7 had a blood filled blister on his right first toe which measured 1.3 x 1.0 cm (depth not measurable). The assessment had recommendations which included off-loading , protecting from trauma and elevating the legs. Review of Physician Telephone Orders dated 01/14/11 revealed the following treatment order: "cleanse rt (right) 1st toe w/ns (with normal saline) apply skin prep QD." Review of Body Assessment form dated 01/16/11 revealed a 2 cm x 2 cm blood blister was noted on Resident #7's lateral great toe. (Note: This was the only dated entry on this form.) WHEN WAS THIS PROVIDED? AFTER INTERVIEW AT 2:00 pm? On 01/18/11 at 2:00 PM, the surveyor requested Resident #7's pressure ulcer assessment from MDS LVN A, the facility's designated wound care nurse. MDS LVN A stated, "Can you give me a few minutes?" MDS LVN A was specifically asked if any documentation of Resident #7's skin assessments were completed. MDS LVN A stated, "No." On 01/18/11 at 2:05 PM, MDS LVN A was queried regarding treatments to Resident #7's pressure ulcer. MDS LVN A replied, "It would be on the MAR." After attempting to find the resident's treatment documentation, LVN A revealed she could not find the MARs for the treatment. MDS LVN A was then queried regarding what treatment was being done on Resident #7's pressure ulcer and she stated, "[MEDICATION NAME] and foam dressing for a blister." MDS LVN A revealed she did not do Resident #7's treatment the day prior (01/17/10). On 01/18/11 at 2:07 PM the surveyor queried LVN Q if she did Resident #7's treatment on 01/17/10 and she stated, "No." On 01/18/11 at 2:10 PM, MDS LVN A provided a treatment sheet for Resident #7 and stated she had "made a new one." Review of the treatment sheet with MDS LVN A at this time, revealed initials on the new treatment sheet to reflect the treatment was done on 01/17/11. When queried again about the resident's treatment, MDS LVN A stated, "I was confused;" MDS LVN A revealed she did do the treatment on 01/17/11. Review of Treatment Record provided for Resident #7 revealed the treatment order "Apply Skin Prep QD Leave OTA (open to air)" dated 01/14/11. The treatments were initialed as completed on 01/14/11, 01/17/11 and 01/18/11. (Note 01/15/11 and 01/16/11 were not initialed which indicated the treatment was not done.) Review of Resident #7's clinical record revealed no admission assessment (01/07/11) was found. On 01/18/11 at 2:15 PM the DON was asked about Resident #7's Admission Assessment. The DON had not explanation as to why there was no assessment done. She stated it was the ADON's responsibility to follow-up and ensure it was done. At 2:17 PM on 01/18/11, the ADON was queried about the Admission Assessment for Resident #7. She revealed she had worked the floor providing resident care and did not fulfil her ADON responsibilities. At 2:25 PM on 01/18/11, ADON N revealed when a nurse found a pressure ulcer, it was their responsibility to inform the wound care nurse (MDS LVN A) and document it in the nurse's notes. The wound nurse was responsible for evaluating the pressure ulcer and getting treatment orders. The wound care doctors came every Friday and evaluated and treated the pressure ulcers. During an interview on 01/18/11 at 2:25 PM, ADON N revealed the 11 PM - 7 AM nurses were assigned and responsible for weekly skin assessments on all residents. The assessment were then placed in the Skin Assessment Book kept at the nurses station. Once a pressure ulcer was identified, the wound care nurse assessed and managed it, including description, measurements, treatments, and orders. Every Monday, the wound nurse provided a copy of all pressure ulcers to the ADM, DON and ADONs. During an interview on 01/18/11 at 3:10 PM, MDS LVN A revealed she was the wound nurse and responsible for all assessments and treatments. She stated "I'm suppose to chart wounds every day. I have a wound book that I keep it in my office. I do not have any documentation on (Resident #7's) wounds nor notes. I will get it for you." Surveyor queried how she remembered the wounds to document for the past month. MDS LVN A stated, "I see them every day, so I know about them. Information in wound care nurse books goes into the residents' charts after the wound has healed." On 01/18/11 at 3: 50 PM, Resident #7's pressure ulcer was observed with LVN R. At that time the pressure ulcer appeared as a small (approximately 1.3 x 1 cm) black dried blister. On 01/19/11 at 8:00 AM, MDS LVN A produced Nurse's Note with documentation for Resident #7's pressure ulcer. (Note: Yesterday, the nurse revealed she had no documentation.) Review of the notes revealed entries dated 01/13/11, 01/14/11, 01/17/11 and 01/18/11. The notes reflected: On 1/13/11 at 2:30 PM, "Cleanse Rt (right) great toe w/ns applied skin prep & left open to air. Wound is blood blister. No drainage." On 01/14/11 at 8:15 AM, "Dr. ______(name) rounds. Cleanse Rt great toe (with) NS Applied skin prep and OTA (open to air). No drainage or discomfort noted." On 01/17/11 at 9:00 AM, "Cleansed Rt great toe w/ns. Applied skin prep and OTA. No drainage or odor (sic - odor) noted. Blister blood filled. No c/o (complaints of) pain. Verbalized to resident to off load Rt foot. Try to keep elevated." On 01/18/11 at 2:00 PM, "Cleanse Rt toe w/ns, using aseptic tech (technique). Applied skin prep. OTA. No drainage noted. No c/o discomfort. Encouraged resident to off load & elevate foot." (Note: The wound was not identified as a pressure ulcer or staged. There were not measurements.) On 01/19/11 at 9:30 AM, ADON N revealed she was supposed to receive weekly logs of all the pressure ulcers from MDS LVN A. She stated she had not received any updates since 12/17/10. She state she and the Administration had repeatedly asked for the log updates but none were received. On 01/19/11 at 10:05 a.m. MDS LVN A revealed the MDS assessments for Residents #7 were not available. MDS LVN A stated, "I have the information I just have not entered it yet." She further revealed the resident did not have any care plans that would be generated from the assessment. During an interview on 01/20/11 at 9:30 AM, MDS LVN A was queried regarding the appearance of Resident #7's pressure ulcer on 01/18/11. MDS LVN A stated it was "ruby red, no drainage." (Note: The wound was black when observed by surveyor on 01/18/11.) MDS LVN A was asked if the pressure ulcer changed in appearance, what would she do? MDS LVN A stated, "I should document the changes." During an interview on 01/20/11 at 10:50 AM, the ADM revealed she was concerned about the pressure ulcer assessments and stated, "I told her (MDS LVN A) to be caught up (with pressure ulcer documentation) this past Monday." After reviewing Resident #7's nurse's notes, the ADM stated, "That is falsifying records." Review of Pressure Ulcer Record dated 01/20/11 revealed an unstageable, 1.5 x 1 cm, no granulation, no drainage and no odor pressure ulcer. On the body diagram there is a hand drawn circle around the right great toe, which indicated where the pressure ulcer was. A Braden Scale assessment for the prediction of pressure ulcer risk, dated 01/12/11, reflected the resident was not at high risk. Review of Resident #7's facility chart revealed no care plans for the prevention or treatment of [REDACTED]. Review of current undated Policy and Procedure "Admission Of The Resident" revealed "Documentation to be completed on admission: Comprehensive Resident Assessment. Start on Admission and include height, weight and vital signs. Admission note should include where resident was before admission, the resident's condition, time of arrival, how transported, who accompanied resident, notification of the M.D., orders obtained or verified and notification of pertinent hospital departments: pharmacy, laboratory, X-ray, therapists, etc...." 2. Resident #11, a [AGE] year-old female, was admitted to the facility on [DATE] per facility face sheet dated 11/30/10. During initial tour on 01/18/11 at approximately 9:30 AM, Resident #11 was observed from the hallway lying in bed on an air mattress. The resident asked that no one enter at that time. Resident #11 was identified by MA T as having entered the facility with "issues to her leg and bottom." Review of Resident #11's MDS assessment dated [DATE] revealed [DIAGNOSES REDACTED]. The resident was totally dependant on staff for bed mobility, transfers and hygiene and was continent of bowel and bladder. The MDS assessment further revealed Resident #11 had one pressure ulcer identified as "Unstageable" measuring 8.5 x 3.0 x 1.0 cm (right lower leg). The assessment indicated the resident was not "at risk of developing pressure ulcers." Review of Resident #11's Care Plan dated 11/29/10 identified an ADL deficit related to Confusion. Approaches included "...6. give peri (perineal) care prn and every 2 hour turn ...8. Observe skin for irritation and breakdown 9. report any abnormals to charge nurse to report to physician and family." There was no care plan for risk of or existing pressure ulcer. Admission Nursing Assessment for Resident #11 dated 11/29/10 reflected the resident required two person to assist with transfers; was incontinent of bowel and bladder; needed supportive devices (footboard, air mattress and hand rolls); and experienced constant pain. The assessment identified a reddened area on the coccyx area and an area on the right outer lower leg that was not described. Additional comment included, "Skin dry all over." Resident #11's Braden Scale-For Predicting Pressure Sore risk dated 11/29/10 reflected a score of six with a score of 12 or less representing "high risk." Review of Resident #11's treatment record for the month on January 2011 revealed an order dated 12/31/10 for treatments to the coccyx. The order reflected "Cleanse coccyx (with) N/S (Normal Saline) apply Santyl and [MEDICATION NAME] to wound then CA Ag (Calcium Alginate)and cover (with) border foam Dsg (dressing) QD (daily) and PRN (as needed). Resident #11's Body Assessment forms for December 2010 and January 2011 reflected "INSTRUCTIONS: Assess the patient/resident/client for skin breakdown, per facility policy ...Review prior entries (under 'Findings/Comments') to ensure all areas of skin breakdown are identified and addressed. Document all pressure ulcers/wounds/skin conditions assessed under 'Findings/Comments.' Initiate/update plan of care. Also initiate Wound/Skin Assessment, any site-specific assessments, Pressure Ulcer Risk Assessment and/or Contracture assessment, as appropriate." The Findings/Comment areas of the form reflected boxes marked "Skin Impaired" with no further documentation regarding the skin. Weekly Pressure Ulcer Logs dated 12/17/10, 12/24/10 and 12/31/10 reflected Resident #11 had an unstageable wound to the right calf measuring 5.5 x 2.5 x 1.0 cm. Weekly Pressure Ulcer Logs dated 12/31/10 reflected a "Facility Acquired," unstageable pressure sore that measured 1.8 x 1.0 cm was added. Review of Wound Care assessment dated [DATE] and completed by the wound care physician revealed Resident #11's lower sacrum wound identified as "unstageable necrosis (dead tissue)" and measured 1.8 x 1.0 cm. Wound debridement was performed during the visit with a post debridement depth of 1.5 cm. Review of Pressure Sore Record completed by the facility 1/19/11 after surveyors' inquiry revealed Resident #11 had three areas of skin breakdown. The facility staff identified the following: Site A (sacrum) Stage IV measured 2.5 x 1.3 x 0.5 cm; Site B (left calf) Stage II measured 0.5 x 0.5 cm (NOTE: This wound was previously unidentified.); Site C (right calf) Stage IV measured 4.4 x 1.5 x 0.2 cm. Observation on 01/20/11 at 2:01 PM of Resident #11's wound measurements and treatments performed by MDS LVN A revealed the following measurements: Site A was measured 2.4 x 1.0 x 0.5 cm with 0.5 cm undermining; Site B was measured 0.5 x 0.5 cm; Site C was measured 4.0 x 1.5 cm. Wound Care assessment dated [DATE], completed by the wound care physician reflected the following: Site A measured 1.9 x 0.8 cm with a post-debridement depth of 0.8 cm; Site B measured 0.3 X 0.2 CM and was identified as "trauma." An observation was made on 01/20/11 at 2:01 PM of MDS LVN A performing wound care on Resident #11. MDS LVN A cleaned the resident's bedside table and laid out paper towels as a barrier. She then washed her hands, donned gloves and used scissors to remove Resident#11's old dressing from her leg. MDS LVN A removed her gloves, opened the new wound dressings and cut them using the same scissors. The scissors were never cleaned and were laid on the resident's bed between uses. Resident #11's right lower leg wound was cleaned and a new dressing was applied. MDS LVN A changed her gloves and removed the soiled dressing from Resident #11 ' s coccyx ulcer. Skin Prep was applied around the wound. MDS LVN A removed her right glove and opened the new dressings and cut them with scissors. She removed her left glove and squeezed [MEDICATION NAME] ointment onto the inside wrapper of the dressings, then added Santyl ointment and mixed the two with a cotton swab. The new re-gloved and she filled the wound with the ointment mixture. She covered the open wound with a Calcium Alginate dressing, removed her gloves again and opened and applied a foam dressing and transparent dressing with her bare hands. She re-gloved again and removed the backing from the dressing. At no time did she perform any type of hand hygiene, wash or using a sanitizing gel. MDS LVN A did not clean her scissors after care. 3. Resident #4, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During initial tour with MA T on 01/18/11 at approximately 9:40 AM, Resident #4 was observed sitting in the hallway in a wheelchair. A cushion was observed on the seat of the wheelchair. Resident #4 asked MA T for pain meds and was told they were due in 30 minutes. MA T stated Resident #11 had a large pressure sore on her bottom and frequently asked for pain meds because of it. When queried whether Resident #4 entered with the sore or developed it in house, MA T stated she was not sure but thought she developed it there. Resident #4's admission MDS assessment dated [DATE] reflected she had two Stage III ulcers, required limited assistance with bed mobility, extensive assistance with transfers, was totally independent with eating and was totally dependant on staff for dressing, toileting, personal hygiene and bathing. Additionally, Resident #4 was assessed as incontinent of bowel and bladder and had pain daily identified as "moderate." Review of Resident #4's Admission Nursing assessment dated [DATE] revealed a Stage III wound to her sacrum measuring 1.2 x 0.8 x 0.3 cm and a Stage III wound to her right buttock measuring 0.3 x 0.4 x 0.2 cm. Resident #4's pain frequency was described as "constant" and intensity was described as "horrible." Record review revealed no other skin assessment done. Resident #4's most recent quarterly MDS assessment dated [DATE] reflected she had two Stage II ulcers, was totally dependant on staff for most ADLs including bed mobility and transfers and required extensive assistance with eating. Resident #4's pain was still assessed as "daily" but intensity had increased to "times when pain is horrible or excruciating." Review of Resident #4's care plans revealed there were no care plans addressing skin, pain or ADLs. On 01/18/11 at 2:55 PM, when MDS LVN A was asked for her wound assessments for January 2011 and December 2010 she replied, "I'll tell you, I have not charted this week or last week." When queried how often she measured and assessed wounds she replied, "I am supposed to chart every day." In 01/18/11 at 3:35 PM, records were provided by MDS LVN A, including the Weekly Pressure Ulcer QI Logs dated 12/03/10, 12/10/10 and 12/17/10 and her Nurse's Notes pertaining to Resident #4's dressing changes. The last entry was dated 12/24/10. At that time, MDS LVN A stated she was trying to catch up on her charting. When queried how and when the wounds were measured, MDS LVN A stated she made rounds with the Wound Care Physician on Fridays. During those rounds, the doctor debrided and measured the wounds and she did the treatments. She added, "I document what she (doctor) measures ...I turn my sheets in on Monday." When queried to whom the sheets were turned in, she replied, "Administrator, DON, ADON and Dietary." Review of Weekly Pressure Ulcer QI Log dated 12/17/10 revealed Resident #4 had a Stage III pressure ulcer to her coccyx measuring 3.5 x 2.5 x 0.5 cm. Review of Resident #4's Wound Care assessment dated [DATE], completed by the wound care physician revealed a pressure ulcer that measured 3.5 x 2.0 x 0.5 cm. There was 0.8 cm of undermining detected. The pressure ulcer was debrided and the post depth of the pressure ulcer was 0.6 cm. "Dressings" reflected, "Silver Absorbing Agent" and "Collagen Dressing" daily. Review of Resident #4's Treatment Records for December 2010 and January 2011 revealed there were no initials indicating her dressings were changed on December 25-26 2010 and January 17, 2011. Review of Treatment Record for November 2010 revealed there were no dressing changes documented on November 5-6, 13-14, or 29-30, 2010. Resident #4's Body Assessment forms for the past three months reflected, "INSTRUCTIONS: Assess the patient/resident/client for skin breakdown, per facility policy ...Review prior entries (under 'Findings/Comments') to ensure all areas of skin breakdown are identified and addressed. Document all pressure ulcers/wounds/skin conditions assessed under 'Findings/Comments.' Initiate/update plan of care. Also initiate Wound/Skin Assessment, any site-specific assessments, Pressure Ulcer Risk Assessment and/or Contracture assessment, as appropriate." Review of the Findings/Comment areas of the form revealed boxes marked "Skin Impaired" with no further documentation regarding the skin. Review of Resident #4's clinical record revealed no skin assessments since admission and incomplete pain assessments. Pain assessment reflected no pain indicators despite the fact Resident #4 was taking scheduled and frequent PRN (as needed) pain medications related to phantom leg pain and pressure ulcer pain. An observation was made on 01/19/11 at 9:04 AM of MDS LVN A providing wound care to Resident #4. MDS LVN A entered the room with her supplies. She moved items (coffee cup, soiled napkins and personal items) around on the resident's bedside table to make room for her supplies and placed her supplies on the table, without cleaning it or placing a barrier. Among the supplies was a pile of gloves placed adjacent to the soiled coffee cup. MDS LVN A did not wash her hands. MDS LVN A removed a pair of gloves from the pile and put them on. MDS LVN A then removed the resident's soiled dressing and changed her gloves, but did not perform any hand hygiene. She pulled scissors from her pocket and trimmed the clean dressings with the scissors. MDS LVN A then proceeded to pack the wound with the dressing. After packing the wound, MDS LVN A removed her soiled gloves and donned gloves pulled from her pocket, without performing hand hygiene. She picked up the clean dressing and covered the wound. At no time was MDS LVN A observed to wash her hands. Immediately following the observation, MDS LVN A was queried about hand hygiene. MDS LVN A stated it was not the facility policy to wash their hands between the soiled and clean dressings. On 01/20/11 at 9:32 AM, when MDS LVN A was queried where the skin assessments for Resident #4 could be found, she would not answer. When shown pain assessment dated [DATE] and queried whether she thought the pain assessment was accurate, she stated she did not see any indicators at that time. When queried whether these assessments were only specific to that particular date and time, she stated, "No, I look back 14 days." Resident #4's MAR indicated [REDACTED]. MDS LVN A was queried whether she thought the pain assessment accurately reflected someone needing that much pain medication. MDS LVN A replied, "I guess I didn't look at it right; I missed it." On 1/20/11 after surveyor inquiry, Pressure Ulcer Records were provided by the Administrator for all residents identified with pressure ulcers. Administrator revealed all residents were assessed the night before and skin conditions documented. Pressure Ulcer Record dated 1/19/11 for Resident #4 revealed the following findings: Site A, indicated on a diagram as the coccyx area, was identified as a Stage IV, 4 x 2.5 x 1.5 cm, with granulation and drainage; Site B, indicated on the diagram as the left upper buttock, was identified only as 0.3 x 0.3 cm. No Stage or other description was given; Site C, indicated on the diagram as posterior right upper, inner thigh, was identified as a Stage II, 1 x 1 x 0.1 cm with no granulation, drainage or odor. This site was previously unidentified. Observation of Resident #4's wound measurements and treatments on 01/20/11 at 2:35 PM performed by MDS LVN A revealed the following: Site A was measured 4.5 x 2.0 x 1.5 cm with 1.0 cm undermining and a small amount of serous drainage ,per MDS LVN A; Site B was measured 0.2 x 0.2 cm with no drainage; Site C was measured 1 x 0.5 cm with no drainage. The wound care physician's Wound Care assessment dated [DATE] reflected the following measurements: Site A was measured as 3.4 x 2.5 x 1.0 cm and 0.8 cm undermining with a moderate amount of serous exudate; Site B was measured as 0.2 x 0.2 x 0.1 cm with a moderate amount of serous exudate. Site C was measured as 1.2 x 1.0 cm. Depth was identified as "Not measurable cm" with a small amt of serous exudate. This wound was debrided at that visit and post debridement depth was 0.3 cm. Another observation of wound care performed by MDS LVN A was made on 01/20/11 at 2:35 PM. MDS LVN A carried her supplies into the room and placed them on Resident #4's bedside table. She then assisted Resident #4 with repositioning and then moved the resident's personal items to one end of the bedside table. The nurse opened the dressings using the wrappers as a barrier and trimmed Fiber Col (dressing) with a pair of scissors without cleaning them. She then set the scissors on the wrapper next to the dressing, raised the resident's siderail and left the room stating she needed to check an order. MDS LVN A returned to the room and continued to trim the dressings with her bare hands. She then donned a pair of gloves removed from a bag and removed Resident #4's soiled coccyx dressing. She measured the wounds with a measuring tape and placed her gloved finger inside the wound to check for tunneling (channels extending from the central injury into the surrounding tissue, such as muscle and skin). Note: This gloved finger was also used to remove the soiled dressing. MDS LVN A then removed her soiled gloves and cleansed the wound with a saline spray, wiped it with gauze and packed it with Fiber Col and Silver AG. She removed her gloves, placed a foam dressing onto a transparent adhesive film, placed a glove on her right hand and placed the foam dressing onto the wound after touching the surface with her bare left hand and secured the dressing. After completing the wound care to the coccyx, MDS LVN A left the room to obtain another tape measure, returned, replaced her gloves and exposed a "new" Stage II Pressure Ulcer located below the left buttock. She stated it was "found last night." She cleaned the area with saline spray and covered it with a dressing. At no time was she observed to perform any type of hand hygiene, wash or using a sanitizing gel. Following the procedure, MDS LVN A was queried again regarding handwashing. MDS LVN A stated this was how she did it when she made rounds with the wound care physician. She added that when she was with the wound care physician she carried a hand sanitizer pump with her at those times and used it between residents. 4. Resident #6, a [AGE] year-old male, was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 01/18/11 at 9:02 AM revealed Resident #6 was alert and oriented, but non-English speaking. He had a [MEDICAL CONDITION] for bowel elimination and a Foley catheter for urine elimination. LVN R revealed at that time that the resident had a Stage 2 pressure ulcer on his coccyx. Review of Skilled Nursing Notes dated 12/21/10 revealed Resident #6 was alert, was totally dependent for mobility, transfers, locomotion on the unit, dressing, toilet use and personal hygiene. Further review of this nurse's note revealed Resident #6 had a Stage 3 coccyx pressure ulcer and an open abdominal incision. Review of Admission Nursing assessment dated [DATE] at 1:25 PM revealed "...coccyx wound Stage 3 ..." (Note: There was no further documentation regarding the wound.) Review of admission orders [REDACTED]. Review of Wound Care Assessment completed by a wound care physician dated 12/24/10 revealed Resident #6 had a Lower Sacrum Wound which measured 2.5 x 1.0 x cm, (depth not measurable) and surface area of 2.50 cm. The wound was debrided at this visit and post depth of the wound was 0.7 cm. Further review of this assessment had recommendations which included Off-Load Wound, Reposition per facility protocol, protect from trauma and low air loss mattress. Review of Treatment Record dated 12/21/10 revealed Santyl to sacral wound topically daily. Further review of this record revealed this wound care treatment was not initialed on any date indicating this treatment was never done. Further review of this record revealed a treatment to cleanse coccyx with normal saline, apply Santyl and [MEDICATION NAME], then Calcium Alginate sheet and cover with border foam dressing every day and as needed. This treatment was initiated as completed on 12/24/10, 12/27/10, 12/28/10, 12/29/10, 12/30/10 and 12/31/10. Note no treatments were done on 12/21/10, 12/22/10, 12/23/10, 12/26/10 and 12/27/10. Review of Wound Care Assessment completed by a wound care physician dated 12/31/10 revealed Resident #6 had a Lower Sacrum Wound which measured 2.4 cm x 0.8 cm x depth Not Measurable with surface area of 1.92 cm. The wound was debrided at this visit and the post depth of the wound was 0.5 cm. Further review of this assessment had recommendations which included off-load wound, Reposition per facility protocol, protect from trauma and low air loss mattress. Review of the undated Treatment Record revealed "cleanse coccyx (with) N/S - apply Santyl and [MEDICATION NAME] then cover ca (calcium), cover (with) border foam drg (dressing) QD" dated 12/31/10. The dates of 01/14/10 and 01/17/10 wer

Based on observation, interview, and record review, it was determined the facility failed to ensure the necessary care and services were provided to attain or maintain the highest practicable physical well-being for one (Resident #1) of ten residents reviewed for assessments/interventions following a fall. Resident #1 fell on [DATE] at 12:45 p.m. Failures included: 1) Therapy personnel moved the resident from the floor to the bed without allowing a licensed nurse to assess the resident before moving her. 2) The only neurological (neuro) check of Resident #1 was conducted at 1:45 p.m., one hour after the resident fell instead of immediately following the resident's fall, and LVN A did not conduct another assessment prior to leaving at the end of the 7-3 shift. 3) Nurse's notes for Resident #1 had no documentation from 1:45 p.m. (7-3 shift) until 11:45 p.m. (11-7 shift). LVN A did not document anything for Resident #1 for the 3-11 shift. 3) The next and only thorough assessment by a licensed nurse was not conducted until 11:45 p.m., eleven hours after the resident's fall. 4) LVN B (7-3 shift) did not include the resident's fall on the 24 Hour Report for future shifts to reference. 5) LVN A (3-11 shift), who had been given report about the resident's fall, did not tell CNA F Resident #1 had fallen, so as to be aware of any change of condition for the resident. 6) There was no evidence LVN A assessed Resident #1 at the beginning of the 3-11 shift to conduct a neuro check or to monitor the resident's status, post-fall. 7) At 5:00 PM (four hours after the resident's fall) when Resident #1 was too weak to ambulate to the bathroom, refused to eat and vomited, CNA F did not report the change in condition of the resident to LVN A so he could assess the resident and potentially contact the physician with report. 8) The resident vomited a second time at 7:00 p.m., and CNA F reported it to LVN A, but did not tell LVN A it was the second occurrence or report the resident's change of condition. 9) At 7:00 p.m., LVN A told CNA F he would check the resident, but there was no evidence to reflect the LVN assessed Resident #1 at that time or notified the physician. 10) CNA F told LVN A when the resident vomited again at 9:00 p.m. There was no evidence to reflect LVN A assessed Resident #1 at that time or notified the physician of the resident's status. 11) LVN A did not document anything in Resident #1's clinical record for the 3-11 shift on 10/08/10. 12) LVN A reported to RN C (11-7 shift) the resident had vomited, but did not report the resident's fall. 13) LVN A did not document Resident #1's fall or vomiting on the 24 Hour Report for future shifts to reference. On 10/08/10 at 11:45 p.m., RN C found Resident #1 weak, lethargic, responding to verbal and painful stimuli, breathing slightly labored and her blood pressure and pulse were elevated. Without the knowledge of Resident #1 having fallen, RN C administered [MEDICATION NAME] (for the elevated blood pressure) and Oxygen. Even with these treatments, at 12:04 a.m. (10/09/10), the resident was nonresponsive and her arms were flaccid (limp). RN C called 911, the paramedics arrived and transported the resident to the hospital, where she was diagnosed with [REDACTED]. On 10/14/10 an Immediate Jeopardy (IJ) situation was identified in the area of Quality of Care with Substandard Quality of Care (SQC). While the IJ was lowered on 10/18/10, the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "pattern" as the facility continued to monitor the implementation of its plan of removal. These failures could affect the facility's 64 residents, and placed them at risk for not having a change in condition assessed timely, not being provided timely medical interventions, not having a change in condition communicated to staff, and having physicians' orders followed resulting in the potential for pain, injury, the need for invasive medical treatment, hospitalization and death. Findings included: Review of the face sheet dated 10/14/10 revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of an Admission MDS assessment dated [DATE] revealed Resident #1 was able to transfer independently or with assistance of one person, had no limitations in range-of-motion, was usually continent of bowel and bladder, and used a walker for an unsteady gait. The MDS assessment reflected Resident #1 had severe cognitive impairment and had experienced no falls during the 180 days prior to the MDS Assessment Reference Date of 08/27/10. The MDS assessment reflected direct care staff believed Resident #1 was capable of increased independence in at least some of her activities of daily living. The Resident Assessment Protocol Summary (RAPS) dated 08/30/10 reflected Resident #1 was at risk for falls. Review of an undated Incident/Accident Report revealed, "resident (Resident #1) was found sitting c (with) back on bed and bottom on floor unable to tell us how she got there." The time of the incident/accident was 12:45 p.m. (on 10/08/10). Resident #1's vital signs, documented on the incident report were: blood pressure 128/89, pulse 116, respirations 17, and temperature 98.2 degrees Fahrenheit. An Investigation Witness Statement dated 10/08/10 included with the Incident/Accident Report reflected a PTA heard Resident #1 "yelling" and entered her room. The PTA observed Resident #1 on the floor "with her legs extended up against the wall." The statement reflected the PTA notified the nursing staff. Review of a Neurological assessment dated [DATE] revealed it was timed at 1:45 p.m. (one hour after the fall occurred). The assessment reflected both Resident #1's pupils were three (3) millimeters in size with a brisk reaction to light. Resident #1's level of consciousness was "oriented" and grip strength was "strong." There was no assessment documented for speech. The assessment reflected Resident #1 responded to her name and painful stimuli. Resident #1 did not complain of headache or pain and was not vomiting. The same vital signs were documented on the Incident/Accident Report timed at 12:45 p.m. The blood pressure was 128/89. Review of a nurse's note dated 10/08/10 and timed at 2:00 p.m. revealed, "Res (Resident #1) was found on floor by OT (occupational therapist), he had just placed her on the bed and left when he heard yelling. PT (physical therapist) and OT found her sitting on (her) bottom with back on bed no injuries denies pain." The same vital signs documented on the Neurological Assessment (1:45 p.m.) and the Incident/Accident Report (12:45 p.m.) were documented in the nurse's note timed at 2:00 p.m. Resident #1's nurse's note dated 10/08/10 had no documentation for the 3:00 p.m. to 11:00 p.m. shift. The next entry in the nurse's notes on 10/08/10 was timed at 11:45 p.m. (eleven hours after Resident #1's fall) and reflected, "Reported by the 3-11 (3:00 p.m. to 11:00 p.m.) nurse ____ (LVN A) resident had episode of vomiting, assessment done, noted undigested food on the gown resident eyes close appears weak and lethargic, able to respond to verbal and pain stimuli, breathing slightly labored. Resident O2 (oxygen) sat (saturation) between 87 - 89% on room air (without supplemental oxygen). Skin is dry and warm to touch. BP 219/138, pulse 120, respiration 22, temperature 98 degrees (F). [MEDICATION NAME] 0.1 mg (milligram) 1 po (by mouth) given O2 at 3 LPM (liters per minute) via mask started." The next entry was timed at 12:04 a.m. (10/09/10) and reflected Resident #1's upper extremities were flaccid (limp), and she was not responsive to painful stimuli. The note reflected Resident #1's oxygen rate was increased to five (5) LPM, her BP was 220/122, pulse 125, respirations 23, 911 was called, and the resident was transported to the hospital by the paramedics. During an interview with the ADM on 10/12/10 at 10:50 a.m., it was revealed Resident #1 remained hospitalized in the Intensive Care Unit (ICU). The ADM stated Resident #1 was on life support and had been since her hospital admission on 10/09/10. The ADM stated she had interviewed witnesses and reviewed statements. The ADM stated the facility Social Worker notified her on 10/09/10 (Saturday) at approximately 10:30 a.m. regarding Resident #1's transfer to the hospital, because the hospital was not able to contact Resident #1's family at the numbers provided by the facility. The ADM stated she informed the SW someone would need to go to Resident #1's family member's home and notify them of her hospitalization if the SW was unable to reach them by telephone. The ADM stated she went to the facility after receiving the call from the SW and started reviewing the Incident/Accident Report of Resident #1's fall. The ADM stated she reviewed Resident #1's chart and saw the documentation regarding the fall. The ADM stated there was no documentation of Resident #1's fall on the 24 hour report and she was unable to locate the incident report, the investigative worksheet, witness statements, or neurological assessments on the chart. The ADM stated she located the incident report, investigative worksheet, and witness statement at the nurse's station but was still unable to locate the neurological assessments. Additionally, the ADM stated there was no documentation after Resident #1's fall on 10/08/10 by LVN A, the 3:00 p.m. to 11:00 p.m. nurse. The ADM stated Resident #1 was assisted to bed by the PTA who heard her scream after he left the room. The PTA returned to the room and observed Resident #1 on the floor. The PTA did not immediately notify nursing staff of the fall and instead went to the therapy department to obtain assistance. The PTA and OTR moved the resident from the floor to the bed prior to reporting the fall to the nursing staff. The ADM stated she interviewed LVN B, who stated she gave the Neurological Assessment sheet to LVN A. The ADM stated she interviewed LVN A, and he stated LVN B did not give him the Neurological Assessment sheet for Resident #1, and he did not believe Resident #1's condition was serious. During an interview with LVN B on 10/12/10 at 1:40 p.m. it was revealed she was at the nurse's station on 10/08/10 when the Therapy (OTR) Manager old to the facility's only ADON Resident #1 had fallen. LVN B stated she obtained a blood pressure cuff and went to Resident #1's room. Resident #1 was sitting on the side of the bed and was talking. The OTR informed LVN B she (OTR) had checked Resident #1. LVN B stated she checked Resident #1's vital signs, and Resident #1's blood pressure was elevated. LVN B checked Resident #1's blood pressure a second time, and it was still elevated. LVN B stated Resident #1 was asked twice if she hit her head, and Resident #1 replied, " No" each time. Resident #1 was asked about pain, and she denied pain twice. LVN B stated Resident #1 was lying in bed when the neurological assessment was completed. Resident #1 participated in the neurological assessment without difficulty and assessment of the resident's mental status revealed it was unchanged. LVN B stated she checked Resident #1's head and there was no hematoma or [MEDICAL CONDITION] (swelling) present. LVN B obtained different blood pressure equipment and checked Resident #1's blood pressure again. The blood pressure was lower and was what she had documented in the nurse's notes and on the Neurological Assessment sheet. LVN B stated she notified the physician and spoke with the NP. No new orders were given and no X-rays were ordered. LVN B stated she completed the required paperwork following a fall for Resident #1 including an Incident/Accident Report, Investigative Report, Witness Statement, and Neurological Assessment sheet. LVN B stated she left a message for the family to call the facility. LVN B stated she did not assess Resident #1 again on 10/08/10 before going off duty. At approximately 2:30 p.m. on 10/08/10, LVN B stated she reported to LVN A Resident #1 fell , was not injured, and the paperwork was complete except for the time the family called back, which needed to be filled in on the incident report. LVN B stated LVN A replied, "Okay." LVN B stated she left the paperwork at the nurses' station and confirmed she did not document the information on the 24 hour report. LVN B stated she was informed by the ADON on 10/11/10 Resident #1 was sent to the hospital on [DATE] and was on life support. During an interview with the OTR on 10/12/10 at 12:40 p.m., it was revealed Resident #1 had been receiving therapy due to weakness. The OTR stated Resident #1 had been able sit at her bedside independently and for all meals. The OTR stated on 10/08/10 at approximately 1:30 p.m. the PTA came and asked her to assist with Resident #1. Resident #1 was on the floor with bare feet, trying to get up. The resident could not get traction with her bare feet and her feet kept sliding on the floor. Resident #1 was lying on the floor sideways to the bed propped on her right elbow. Resident #1 had removed her house dress. It was on the left side of the bed at the foot of the bed. Resident #1 was on the right side of the bed on the floor. Resident #1's shoes were under the edge of the bed. The OTR stated Resident #1 was able to move all upper and lower extremities. There was no blood observed anywhere about the resident. Resident #1 could answer questions and was denying pain. The PTA placed a gait belt on the resident. The OTR and the PTA assisted the resident up from the floor and sat her on the side of the bed. The OTR stated when LVN B arrived and started to assess the resident, her BP was high the first time it was taken. LVN B took the BP a second time, and it remained high. LVN B asked the resident what happened, and Resident #1 stated, "I fell backwards." The OTR asked Resident #1 about the house dress, and Resident #1 stated, "Took it off." The OTR asked if Resident #1 stood and took off the house dress. Resident #1 replied, "Yes. I fell backward." LVN B asked Resident #1 twice if she hit her head, and the resident denied hitting her head each time. LVN B asked Resident #1 if she had pain two different times, and she denied pain both times. LVN B obtained alternate blood pressure equipment and took the resident's blood pressure. The blood pressure had come down. During a telephone interview with the PTA on 10/12/10 at 4:00 p.m., it was revealed Resident #1 was independent with transfers and toileting. Resident #1 was wearing a house dress during therapy on 10/08/10. The PTA returned Resident #1 to her room in a wheelchair after therapy. The PTA stated Resident #1 transferred to the bed from the wheelchair. Resident #1 told the PTA to leave her wheelchair at the foot of her bed. The PTA stated Resident #1's walker was within reach at the head of the bed. The PTA left the room and walked down the hall toward the PT Gym. As he turned the corner to the Gym, he heard a yell. The PTA returned to Resident #1's room, and the resident was on the floor. Resident #1 did not have on the house dress or any shoes. The PTA stated Resident #1 was sitting on the floor with her legs out straight, resting her upper body upon her right elbow with her head against the wall. The PTA asked Resident #1 if she was okay, and Resident #1 stated, "Yes." The PTA left the room and returned with the OTR. Resident #1 asked for help to get up off the floor due to the floor being cold. Resident #1 would not allow her shoes to be put on and kicked the shoes off when they were put on her feet. Resident #1 denied pain and the PTA stated he did not see any injuries. The PTA left the OTR in the room with Resident #1 and returned with a gait belt. The gait belt was placed on Resident #1 and the OTR and PTA lifted Resident #1 from the floor to the bed side. The OTR asked Resident #1 what happened, and Resident #1 stated, "I fell backwards." The house dress was observed on the foot of the bed. The OTR asked Resident #1 if she had attempted to remove the house dress. Resident #1 replied, "Yes, and I fell backwards." During an interview with CNA F on 10/12/10 at 3:25 p.m., it was revealed CNA F worked and provided care to Resident #1 on 10/08/10 on the 3-11 shift. CNA F stated at approximately 5:00 p.m. on 10/08/10, Resident #1 was sitting on the side of the bed. Resident #1 requested to go to the bathroom. CNA F stated Resident #1 "did not look right" and appeared weak. CNA F attempted to assist Resident #1 to a standing position and got her walker. Halfway across the room, Resident #1 started having difficulty walking. Resident #1 was unable to balance herself and was leaning toward one side. CNA F told Resident #1 she needed to return to the bed. CNA F stated Resident #1 required physical assistance back to the bed. CNA F had difficulty supporting Resident #1 while assisting her back to bed. CNA F stated she managed to get Resident #1 back in the bed. CNA F stated she told Resident #1 she (the CNA) could not get her (Resident #1) up but the CNA would put a brief on her. Resident #1 insisted on getting up and started vomiting. CNA F stated she cleaned Resident #1 up and, "She seemed fine." CNA F stated she returned to Resident #1's room with her dinner tray, and Resident #1 refused to eat. Resident #1 shook her head she did not want it (food). CNA F stated she left the tray in the room and returned later to try and get Resident #1 to eat. Resident #1 refused to eat or drink. When queried regarding whether or not she reported Resident #1's vomiting, unsteady gait, weakness, and refusal of food or fluids to LVN A, CNA F stated she did not report anything about Resident #1 to LVN A until Resident #1 vomited the second time. CNA F stated, at approximately 8:00 p.m., she heard the resident gagging and she went in the room. The resident had vomited (again). CNA F stated at that time, she told LVN A Resident #1 was vomiting. CNA F stated she did not know if LVN A checked on the resident. CNA F stated Resident #1 vomited again at approximately 9:00 p.m., and she reported to LVN A the resident had vomited again. LVN A told CNA F he was going to medicate Resident #1 and went down the hall. CNA F could not verify if LVN A went into Resident #1's room after she vomited at 8:00 p.m. or 9:00 p.m. CNA F stated she was not provided any information regarding Resident #1 having had a fall on the previous (7:00 a.m. to 3:00 p.m.) shift. CNA F stated she would not have attempted to assist Resident #1 to the bathroom if she had known about her fall. CNA F stated residents were to remain in bed for 24 hours after a fall. During an interview with RN C on 10/12/10 at 11:21 p.m., it was revealed on 10/08/10 at 11:45 p.m., she made her inital rounds and observed Resident #1 in bed, who appeared to be asleep. RN C stated LVN A had informed her in shift change report Resident #1 had vomited twice and he had medicated her for the vomiting. RN C went in to check on Resident #1 and observed a towel was across the resident's chest. RN C removed the towel and observed undigested food on her gown. Resident #1 appeared weak and lethargic, was slow to respond to verbal and painful stimuli, and her breathing was slightly labored. RN C stated her oxygen saturation (O2 sat) level was 87 - 89% on room air (normal is greater than 95%). Her vital signs were taken, BP was 219/138, pulse was 120, respirations 22, and her temperature 98 degrees F. She gave Resident #1 a [MEDICATION NAME] 0.1 mg tablet by mouth. She attempted to place oxygen on the resident with a nasal cannula. The resident kept pushing RN C's hands away. RN C was unable to place the cannula on the resident. RN C stated she left the room and returned with a face mask for the oxygen. She placed the oxygen mask on Resident #1 and gave her oxygen at 3 LPM. She called CNA G to change and clean up Resident #1. At 12:04 a.m. on 10/09/10, after CNA G had finished Resident #1's care, RN C returned to the room to check on Resident #1. RN C stated Resident #1's BP was 220/122, her pulse was 125, and her respirations were 23. Both upper extremities were flaccid (limp), and Resident #1 did not respond to touch or painful stimuli. RN C stated she increased the rate of the oxygen to 5 LPM via face mask. Resident #1's O2 Sat was 98%. RN C stated she called 911 for transport for Resident #1 to go the hospital, and she continued to monitor Resident #1 closely. At 12:09 a.m., the Paramedics arrived at the facility. At 12:20 a.m. Resident #1 was transported to the emergency room . RN C stated at 12:28 a.m., she notified Resident #1's physician of her change of condition and spoke with the NP. At 12:30 a.m., she left a message on the family's answering machine. RN C stated at 1:00 a.m., she attempted to contact LVN A regarding Resident #1's condition on the 3 -11 shift and her episode of vomiting. There was nothing charted on Resident #1 for the 3-11 shift on 10/08/10. LVN A had stated Resident #1 was medicated for vomiting on the 3-11 shift. Resident #1 did not have any medications ordered for nausea or vomiting on the October 2010 MAR indicated [REDACTED]. RN C stated she left a message for LVN A to call the facility. RN C stated at approximately 1:10 a.m. on 10/09/10 as she was charting on Resident #1's nurses' notes, she read LVN B's charting and learned Resident #1 fell on the 7:00 a.m. to 3:00 p.m. shift. RN C stated during report, LVN A did not report Resident #1 had a fall. There was nothing written or communicated on the 24 hour report regarding Resident #1 and her fall for either shift (7:00 a.m. to 3:00 p.m. or 3:00 p.m. to 11:00 p.m.). RN C found the incident report on the fall for Resident #1 later in the shift, after she sent the resident to the hospital. RN C stated she saw the witness statement and the investigative report regarding the fall. RN C stated she took the incident report, investigative report and witness statement and clipped them onto the 24 hour report. Review of Resident #1's monthly consolidated physician's orders [REDACTED]. Review of the emergency physician record dated 10/09/10 revealed a Computed Tomography (CT) scan of the Resident #1's head had been done, which revealed an [MEDICAL CONDITION]. A procedure note for endotracheal intubation dated 10/09/10 reflected Resident #1 was intubated secondary to respiratory compromise. An ICU (Intensive Care Unit) note dated 10/10/10 reflected Resident #1 was on full ventilator support. During an interview with LVN A on 10/13/10 at 3:50 p.m., it was revealed at shift change on 10/08/10, LVN B had provided report. LVN A stated LVN B informed him Resident #1 had fallen and was "Okay" with no injuries. LVN A stated he was further informed by LVN B all of the required paperwork for Resident #1's fall was complete, and he needed to write in the time Resident #1's family returned a call to the facility on the incident report. LVN B stated he placed the paperwork on the desk in the nurses' station. LVN B and LVN A went to the facility's biweekly meeting following report. After the meeting, LVN A stated he was informed only two nurses would be working the 3 - 11 shift, and the main resident station would be split (divided between the two nurses). LVN A stated he made the assignments for the CNAs. LVN A stated he was assigned to monitor the dining room. While monitoring the dining room at approximately 7:00 p.m. or 7:30 p.m., CNA F reported Resident #1 had vomited. After the last resident left the dining room, LVN A stated he went to Resident #1's room and checked on her. LVN A stated, "Didn't see anything out of the ordinary," and Resident #1 seemed "okay." LVN A then added Resident #1's pulse was a "little tachy (fast/rapid)," and he thought her pulse was related to her vomiting. Resident #1's BP was her "usual." LVN A stated he believed Resident #1 was vomiting due to an upset stomach. LVN A stated he was not aware at that time Resident #1 had not eaten. When queried regarding the actual blood pressure and pulse readings due to no documentation in Resident #1's chart, LVN A stated he could not remember what either reading was and did not write Resident #1's vital signs down. LVN A stated toward the end of the shift, at approximately 10:00 p.m., CNA F reported Resident #1 had vomited a second time. LVN A stated he went to the room, and Resident #1 was in a semi-fowlers position (head of bed is raised from 30-45 degrees), and in bed. LVN A stated he gave Resident #1 a drink of water. LVN A stated he was not familiar with Resident #1. She looked lethargic, responded to verbal commands and seemed exhausted. When queried as to physician notification of Resident #1's vomiting, LVN A stated he did not contact the physician. LVN A added he did not review/read the incident report and was not told neurological assessments needed to be performed. When queried, LVN A responded an in-service was conducted after the incident of Resident #1's fall, regarding the completion of neurological checks after all falls, charting a resident's change in condition, and notifying the Director of Nurses (DON) of all incidents. Review of an In-service Training Report dated 10/11/10 revealed the topic, "Neuro (neurological) Checks." The contents or summary of the training session portion of the report reflected neuro checks should be performed every 15 minutes for 2 hours, every 30 minutes for 2 hours, every hour for 2 hours, every 2 hours for 2 hours, every 4 hours times 2, then every 8 hours until 72 hours had passed. The report reflected the in-service was conducted by the ADON, an LVN. Signatures of attendance for LVN A and LVN B were present on the report. During an interview with the ADON on 10/13/10 at 2:00 p.m., it was revealed on 10/08/10, the OTR came to the nurses station and whispered to her Resident #1 had fallen. The ADON and DON were standing at the nurses' station. The ADON stated she told the OTR to tell LVN B, who was Resident #1's nurse. The ADON stated she was not aware Resident #1 went to the hospital on [DATE] or of Resident #1's condition until she was notified by the ADM on 10/09/10. The ADM informed her Resident #1 had vomited, there were no assessments and no neurological checks. The ADON stated she informed the ADM she would call the facility and have the weekend supervisor start in-services. Review of an In-service Training Report dated 10/09/10 revealed the training included fall precautions, assessment and care if a fall occurs. There was no documentation of training regarding shift-to-shift communication, communicating information regarding a resident's change in condition to the CNAs, use of the 24 hour report, and no information/training regarding CNAs reporting a change in condition to licensed staff. Additionally, there was no documentation of staff training regarding non licensed staff moving a resident after a fall and prior to a licensed nurse conducting an assessment. No time was provided on the training report, and the reverse side of the form reflected seven staff attended the training. A Disciplinary Warning Notice dated 10/11/10 reflected LVN B was given a "First Warning" for not completing Neurological checks (on Resident #1) and not documenting information regarding (Resident #1's) fall on 10/08/10 on the 24 hour report. A Disciplinary Warning Notice dated 10/12/10 reflected LVN A was given a "Verbal First Warning" for no follow up on an unwitnessed fall, not reviewing the Incident/Accident Report, not charting, not notifying the physician for a change in condition, and not providing report to the nurse on the next shift. Review of the facility's investigation dated 10/18/10 revealed multiple discrepancies in written statements provided by the nursing staff, the PTA and OTR. Review of an undated written statement from the Weekend Supervisor revealed the DON informed her Resident #1 had fallen with a physical therapist present in the room. The DON informed her the physical therapist asked a CNA to assist in getting Resident #1 off the floor without calling a nurse to assess Resident #1. Later the nurse was informed of the fall and assessed the resident. Per the written statement, the DON told the nurse to notify the doctor and see if he wanted an X-ray. Review of the Incident/Accident Report (copy), previously undated, and included in the facility's investigation, revealed the date of the incident was filled in as "10/09/10" instead of 10/08/10. Review of the facility's current (undated) Fall Protocol revealed: "Protocol: 1. To create a safe environment for the resident. 2. To communicate concerns about residents' falls. General Instructions 1. Leave resident where they have fallen. 2. Go get a nurse or call for someone else to do so. 3. Make resident as comfortable as possible without moving them. 4. Never move a resident until they have been assessed by a nurse. 5. Support the resident's body well during all positioning, transferring and ambulation after a fall...." On 10/14/10 at 1:40 p.m., an IJ situation was identified in the area of Quality of Care with SQC. The ADON was notified of the IJ on 10/14/10 at approximately 5:40 p.m.; the Assistant Administrator was notified of the IJ via telephone on 10/14/10 at approximately 5:40 p.m.; and the Administrator was notified of the IJ upon her arrival to the facility 10/14/10 at approximately 6:45 p.m.. A Plan of Removal for the IJ was requested. The Plan of Removal for the IJ dated 10/15/10, which was accepted on 10/15/10 at 4:55 p.m., reflected the facility's actions included: "1. Calls will begin today to all nurses to schedule a time to in-service and train them on the 6 categories of assessments. a. General Survey b. Assessing the Head and Neck c. Assessing the Thorax and Lungs d. Cardiovascular Assessment e. Assessing the Abdomen f. Musculoskeletal and Neurological Assessment 2. In-service and re-training will begin today on [DATE] for the nurses on assessment skills. Written exams will be given at the end of the in-service and/or re-training session. 3. In-service and training will begin today on [DATE] for nurses on proper documentation of Assessment Findings. Written exams will be given at the end of the in-service and/or re-training session. 4. Additional in-service and re-training will begin today on [DATE] for nurses on the use of the 24 hour report sheet on which to record items and to give report to oncoming shift. 5. In-service began for nurses and will continue on 10-9-10 for neuro checks and proper assessment of falls. Written exams will be given at the end of the in-service and/or retraining session. 6. Nurse re-inservice and training mandating that all falls will be immediately be followed by neuro checks began on 10-11-10 and 10-13-10. 7. All nursing staff will be in serviced and trained with return demonstration and Check off of skills starting 10-15-10. Intervention procedures will be taken from: a. Nursing Interventions & Clinical Skills (Elkin-Perry-Potter) b. Demonstration with return demonstration. c. Skills check off list d. Specifics nurses need to report for changes of condition, falls, etc. Nausea/Vomiting Unable to ambulate Lethargic/Unable to answer questions, does not respond to verbal, tactical or pain stimuli. Change in vital signs Increase or signs of agitation. DON and ADON will be in charge of in-service and train Nursing starting [DATE]. Nurses will be trained and checked off on hire, monitored weekly for 6 weeks after hire, checked randomly and quarterly thereafter and at quarterly QA meetings by DON and