Every finding on record at Island Home Park Health and Rehab

Based on medical record review, observations, and interviews, the facility failed to protect the resident's right to dignity when an indwelling catheter drainage bag was left uncovered and visible to the public for 1 resident (Resident #25) of 3 residents observed for dignity. The findings include: Review of the facility's policy Resident Rights, revised 2/2021, revealed .be treated with dignity . Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Obstructive/Reflux Uropathy (Urine Blockage) and Personal History of Malignant Neoplasm of Prostate (Cancer). Review of the Physician's Orders for Resident #25 dated 2/6/2026, revealed the following order .Ensure foley catheter (Urine drainage system) .drainage bag has privacy cover .every shift . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #25 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review revealed the resident had an indwelling catheter. During an observation on 5/17/2026 at 11:23 AM, revealed Resident #25's foley catheter drainage bag was observed with no privacy cover in place and visible to anyone entering the room. During an observation on 5/18/2026 at 9:35 AM, Resident #25's foley catheter drainage bag was observed with no privacy cover in place and visible to anyone entering the room. During an observation on 5/19/2026 at 8:27 AM, Resident #25's foley catheter drainage bag was observed with no privacy cover in place and visible to anyone entering the room. During an observation and interview on 5/19/2026 at 8:38 AM, Licensed Practical Nurse (LPN) A stated Resident #25 had an order to ensure foley catheter drainage bag had privacy cover and confirmed Resident #25, did not have one (catheter drainage bag privacy cover) in place. During an interview on 5/19/2026 at 9:27 AM, the Director of Nursing (DON) confirmed that it was her expectation that all foley catheter drainage bags would have privacy covers in place to maintain resident dignity.

Based on facility policy review, medical record review, observations, and interviews, the facility staff failed to perform appropriate hand hygiene when serving residents' meal service for 3 residents (Residents #11, #23, and #101) on 1 of 4 units observed for meal tray distribution.The findings include:Review of the facility's policy titled, Handwashing/Hand Hygiene, revealed All personnel shall follow the handwashing/hand hygiene procedures .Hand hygiene products shall be readily accessible .before and after eating .Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Dysphagia, and Anxiety.Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident required set up or clean-up assistance with ADL's (Activities of Daily Living).Review of a comprehensive care plan dated 4/27/2026, revealed Resident #11 had .ADL self-care deficit r/t [related to] generalized ageing .Eating .assist with meal setup .During an observation on 5/17/2026 at 11:37 AM, Certified Nurse Assistant (CNA) B delivered the meal service to Resident #11. CNA B set up meal for Resident #11 and failed to offer hand hygiene to the resident.Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including Malnutrition, Muscle Weakness, and Hypotension.Review of the 5 day MDS assessment 5/4/2026, revealed Resident #23 scored a 13 on the BIMS assessment indicating the resident was cognitively intact. Further review revealed the resident required set up or clean-up assistance with ADL's.Review of the comprehensive care plan for Resident #23 dated 4/16/2026, revealed .ADL .staff assistance r/t generalized weakness .assist with meal set up .During an observation on 5/17/2026 at 11:43 AM, CNA B delivered the meal service to Resident #23. CNA B set up meal for Resident #23 and failed to offer hand hygiene to the resident.Review of the medical record revealed Resident #101 was admitted to the facility on [DATE] with diagnoses including Diabetes, Muscle Weakness, and Anxiety.Review of the admission MDS assessment dated [DATE], revealed Resident #101 scored a 12 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed the resident required set up or clean-up assistance with ADL's.Review of the comprehensive care plan for Resident #101 dated 5/5/2026, revealed .Dependent on staff assistance for ADL's r/t generalized weakness .Assist with meal set up .During an observation on 5/17/2026 at 11:45 AM, CNA B delivered the meal service to Resident #101. CNA B set up meal for Resident #101 and failed to offer hand hygiene to the resident.During an interview on 5/17/2026 at 12:05 PM, CNA B confirmed she had not offered hand hygiene while passing the meal service to Residents #11, #23, and #101.During an interview on 5/19/2026 at 1:48 PM, the Director of Nursing confirmed hand hygiene was to be offered to residents prior to meals.

Based on Long-Term Care Facility Resident Assessment Instrument (RAI) review, medical record review, and interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) screen was accurate after mental health diagnoses was identified for 2 of 7 residents (Resident #13 and #57) reviewed for PASRR.The findings include:Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.1 dated 10/1/2025, revealed .facilities are responsible for accurately reflecting active diagnoses within the assessment process and ensuring coordination with PASRR requirements when residents have serious mental illness, intellectual disability, or related conditions .Review of the Level 1 PASRR for Resident #13 dated 8/29/2025, revealed .no mental health diagnosis is known or suspected .Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnosis of Alzheimer's Disease and acquired a new diagnosis of Anxiety Disorder on 9/12/2025.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 scored a 00 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident had an Anxiety Disorder.Review of the Level 1 PASRR for Resident #57 dated 11/7/2025, revealed .no mental health diagnosis is known or suspected .Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including Dementia with Psychotic Disturbance 11/12/2025, Insomnia 11/12/2025, and Adjustment Disorder with Anxiety 11/18/2025.Review of the quarterly MDS assessment dated [DATE], revealed Resident #57 scored a 6 on the BIMS assessment which indicated the resident had severe cognitive impairment and had active diagnoses of Dementia with Psychotic Disturbance, Insomnia, and Adjustment Disorder with Anxiety.During an interview on 5/19/2026 at 1:49 PM, the Director of Nursing confirmed Resident #13 and Resident #57's current PASRRs were not accurate and did not reflect the residents' current mental health diagnoses.

Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual Version 1.19.1 review, medical record reviews, and interviews the facility failed to ensure MDS assessments were accurate for 3 residents (Resident #33, #40, and #55) of 18 residents reviewed for MDS assessments. The findings include: Review of the MDS 3.0 RAI Manual, dated 10/2024, revealed .Health-related Quality of Life .residents covered by Level II PASRR [Pre-Admission Screening and Resident Review] process may require certain care and services provided by the nursing home .Steps for Assessment .Code .yes if PASRR Level II screening determined that the resident has a serious mental illness .Determination of Pressure Ulcer/Injury Risk .Pressure ulcers/injuries occur when tissue is compressed between a bony prominence and an external surface .Steps for Assessment .Review the medical record, including skin care flow sheets or other skin tracking forms, nurses' notes, and pressure ulcer/injury risk assessments .Examine the resident and determine whether any ulcers, injuries, scars .are present. Assess key areas for pressure ulcer/injury development .sacrum .coccyx .Check A [yes] if resident has .a scar over bony prominence .Special Treatments, Procedures, and Programs .Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs .Dialysis .Code .renal dialysis which occurs at the nursing home or at another facility . Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Insomnia, Seizures, Delusional Disorders, and Anxiety. Review of the PASRR Level Two Outcome for Resident #33 dated 1/30/2020, revealed the PASRR screening determined the resident had a serious mental illness. Review of the annual MDS assessment dated [DATE], revealed Resident #33 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact and the resident was not identified to have a serious mental illness. During a record review and interview on 3/25/2025 at 3:45 PM, MDS Licensed Practical Nurse (LPN) B and MDS LPN C stated Resident #33 had a serious mental illness and confirmed the annual MDS assessment dated [DATE] was inaccurate. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Peripheral Vascular Disease, High Potassium Blood Levels, and Hypertension. Review of the comprehensive care plan for Resident #40 revised 5/27/2024, revealed the resident received dialysis. Review of a quarterly MDS assessment for Resident #40 dated 3/1/2025, revealed the resident scored a 15 on the BIMS assessment which indicated the resident was cognitively intact and the resident did not receive dialysis. During an interview on 3/24/2025 at 2:00 PM, Resident #40 stated she received dialysis on Tuesdays, Thursdays, and Saturdays. During a telephone interview on 3/25/2025 at 3:10 PM, Dialysis Nurse D stated Resident #40 received dialysis treatments. During an interview on 3/25/2025 at 4:15 PM, the Director of Nursing (DON) stated Resident #40 received dialysis treatments and confirmed the quarterly MDS assessment dated [DATE] was inaccurate. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Adult Failure to Thrive, and Difficulty Walking. Review of the skin assessment for Resident #55 dated 2/4/2025, revealed the resident had a wound over a sacral scar. Review of the quarterly MDS assessment for Resident #55 dated 2/5/2025, revealed the resident scored a 4 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident did not have a sacral scar or wound over a bony prominence. During an observation and interview on 3/24/2025 at 9:25 AM, with the wound care nurse revealed Resident #55 had a wound over a sacral scar. The wound care nurse confirmed the wound had slough (dead tissue) and depth. During an interview on 3/25/2025 at 3:45 PM, MDS LPN B and MDS LPN C stated Resident #55 had sacrum scarring with a wound which was over a bony prominence and confirmed the quarterly MDS assessment dated [DATE] was inaccurate.

Based on facility policy review, medical record reviews, and interviews the facility failed to refer 2 residents (Resident #15 and Resident #32) to the state designated Pre-Admission Screening and Resident Review (PASRR) agency after a new mental health diagnosis of 7 residents reviewed for PASRR. The findings include: Review of the facility's policy titled, Behavioral Health Services, undated, revealed .Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care .Residents who do not display symptoms of, or have not been diagnosed with, mental, psychiatric, psychosocial adjustment, substance abuse, or post-traumatic disorder(s) will not develop behavioral disturbances .any assessment that reveals .mental health disorders (PASRR ) will be addressed . Review of a PASRR Level One Screen Outcome for Resident #15 dated 2/5/2024, revealed the resident had 3 mental health conditions which included Schizoaffective Disorder, Depression, and Anxiety. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including Dementia, Depression, Schizoaffective Disorder, Anxiety, and Insomnia. Review of a quarterly Minimum Data Set (MDS) assessment for Resident #15 dated 12/28/2024, revealed the resident scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the medical record revealed on 10/18/2024, Resident #15 was diagnosed with Adjustment Disorder, a new mental health condition. Further review of the medical record revealed the resident had not been referred to the state designated PASRR agency after a new mental health diagnosis was identified. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including Sleep Terrors, Insomnia, Depression, Anxiety, and Hallucinations. Review of a PASRR Level One Screen Outcome for Resident #32 dated 12/7/2021, revealed the resident had 4 mental health conditions which included Major Depression, Anxiety Disorder, Depression, and Insomnia with Night Terrors. Review of the medical record revealed on 10/18/2024, Resident #32 was diagnosed with Psychotic Disorder, a new mental health condition. Further review of the medical record revealed the resident had not been referred to the state designated PASRR agency after a new mental health diagnosis was identified. Review of a quarterly MDS assessment for Resident #32 dated 1/17/2025, revealed the resident scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. During a record review and interview on 3/25/2025 at 4:15 PM, the Director of Nursing (DON) confirmed Resident #15 and Resident #32 were diagnosed with a new mental health condition and the facility failed to refer Resident #15 and Resident #32 to the state designated PASRR agency after a new mental health diagnosis was identified.

Based on facility policy review, medical record review, and interviews the facility failed to revise the care plan timely for 1 resident (Resident #28) of 18 residents' care plan reviewed. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed .The comprehensive, person-centered care plan .describes the services that are to be furnished .care plans are revised as information about the residents and the residents' condition change .the Interdisciplinary team reviews and updates the care plan .at least quarterly, in conjunction with the required quarterly MDS [minimum data set] assessment . Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Difficulty Swallowing, Communication Deficit, Difficulty Speaking, and Gastrostomy Status [a surgical entry into the stomach to deliver feeding]. Review of the comprehensive care plan for Resident #28 dated 9/3/2022, revealed the resident received enteral feeding [by a tube inserted into the stomach]. Review of a quarterly MDS assessment for Resident #28 dated 3/1/2025, revealed the resident scored a 00 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review of the quarterly MDS assessment revealed the resident did not receive nutrition by a tube. During an observation on 3/23/2025 at 3:20 PM, revealed Resident #28 was laying in bed and no enteral feeding was observed. During an interview on 3/24/2025 at 8:00 AM, Licensed Practical Nurse (LPN) A stated Resident #28 previously received enteral feedings, and stated the resident had not received enteral feedings .for a long time . During an observation on 3/24/2025 at 8:10 AM, revealed Resident #28 was seated in a wheelchair and no enteral feeding was observed. During an interview on 3/25/2025 at 2:00 PM, LPN Supervisor stated the resident previously received supplemental enteral tube feedings and stated the enteral tube feedings were discontinued related to the resident's appetite increase. The LPN supervisor stated the enteral tube feedings were discontinued .a while back . During an interview on 3/25/2025 at 3:45 PM, MDS LPN B stated Resident #28 did not currently receive enteral feedings and confirmed the comprehensive care plan had not been revised when the enteral feedings were discontinued.

Based on facility policy review, medical record review, facility investigation review, and interviews, the facility failed to prevent physical abuse for 1 resident (Resident #1) of 8 residents reviewed for abuse. The findings include: Review of the facility policy titled, Resident Rights, dated 2/2021, revealed .Federal and state laws guarantee certain basic rights to all residents of this facility .include the resident's right to .be free from abuse . Review of the facility policy titled, Abuse, Neglect, Exploitation, Misappropriation Prevention Program, dated 10/2022, revealed .It is the policy of the facility to maintain an environment where residents are free from abuse .Abuse includes but is not limited to .physical .residents have the right to be free from abuse .Protect residents from abuse .by anyone including .facility staff . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Hypertension, and Generalized Muscle Weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 15 on the Brief Interview of Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the facility's investigation documentation for Resident #1 dated 7/11/2024 at 5:15 PM, revealed Certified Nursing Assistant (CNA) D answered Resident #1's call light, the resident stated her back was hurting. Resident #1 stated that she wanted to be put on her side and pillows placed between her legs. CNA D started to put the head of the bed down and Resident #1 started screaming at CNA D to stop. CNA D stopped and explained to Resident #1 she needed to lay flat to be able to turn the resident onto her side. Resident #1 raised herself up and put her finger in CNA D's face and screamed at the CNA. CNA D asked Resident #1 to stop yelling but the resident continued to scream and had her face in CNA D's face. CNA D then touched Resident #1's chin and asked the resident to stop. CNA D stated that she knew what she had done (touching the resident's chin) was wrong, immediately left the room and told Licensed Practical Nurse (LPN) B what had happened. LPN B instructed CNA D to wait in the conference room for further instructions. LPN B went immediately to Resident #1's room and assessed the resident's face. LPN B stated Resident #1 did not have any marks or bruising to face. Resident #1 thanked LPN B for checking her and stated she felt safe in the facility. LPN B assigned another CNA to Resident #1 and notified the Supervisor (LPN E) of what had happened. LPN E immediately went to assess Resident #1 and there were no red areas or bruising to the resident's face. LPN E immediately called the Director of Nursing (DON) and Administrator. CNA D was placed on suspension pending an investigation. CNA D was terminated on 7/12/2024 (1 day after the event) as the result of facility's findings during investigation. Review of the Progress Note for Resident #1 dated 7/11/2024 5:15 PM, revealed . CNA REPORTED TO THIS NURSE THAT SHE TOUCHED PTS [patient's] [Resident #1's] CHEEKS.THIS NURSE WENT TO ASSESS PT [patient] [Resident #1]. SKIN C/D/I. [clean, dry, intact] NO REDNESS OR BRUISING NOTED AT THIS TIME .NO S/S [signs or symptoms] OF DISTRESS OR DISCOMFORT NOTED. SUPERVISOR NOTIFIED. DON NOTIFIED. ADMINISTRATOR NOTIFIED . Review of the facility document titled, Admission Skin Assessment form, for Resident #1 dated 7/11/2024, revealed .no skin issues noted with skin . Review of the Local Police Department Initial Incident Report for Resident #1 dated 7/11/2024, revealed, .spoke with [Resident #1] who stated that [CNA D] had grabbed her chin .no visible injuries noted . Review of the Progress Note for Resident #1 dated 7/12/2024, revealed, .SS [Social Services] met with resident this morning in her room to follow up with event on 7/11 [7/11/2024] .calm throughout conversation with no signs or symptoms of distress noted .stated that she did not remember anything happening yesterday .confirmed that she feels safe in facility and denied any current needs. SS will continue to f/u (follow up) with resident for all SS needs . Review of the Progress Note for Resident #1 dated 7/13/2024, revealed, .lying in bed with eyes open .No s/s ( signs and symptons) of acute distress has been noted or reported .Mood and affect pleasant . Review of the Progress Note for Resident #1 dated 7/16/2024, revealed, .monitor mental status and provide psychotherapy as indicated .resident states she is very tired .she stated she is ok but did not elaborate on anything .did not mention the abuse allegation until asked if there was anything new that had happened .asked if she was feeling better and she said yes . During an observation and interview on 10/7/2024 at 1:05 PM, revealed Resident #1 lying on her left side in bed with the head of the bed elevated. Resident #1 stated she had been at the facility about 6 months, the staff were good to her, and she felt safe in the facility. Resident #1 further stated there was an incident with an associate (CNA D) in the past, the incident had been taken care of, and the resident did not want to talk about the incident anymore. During an interview on 10/7/2024 at 3:04 PM, LPN B stated on 7/11/2024 CNA D alerted LPN B that Resident #1 and CNA D had an altercation in Resident #1's room. CNA D told LPN B that Resident #1 asked to be rolled onto the back related to discomfort. CNA D told LPN B she proceeded to lower Resident #1's head of bed to reposition the resident. Resident #1 became belligerent and yelled at CNA D .don't lower me down, that's not how you do it . the resident continued to yell and point her finger at CNA D. CNA D stated she then squeezed Resident #1's cheeks and told the resident to not speak to her like that. CNA D immediately left Resident #1's room and reported what happened to LPN B. LPN B instructed CNA D not to go into any residents' rooms and to sit in conference room. LPN B went to Resident #1's room and asked the resident how she was doing. Resident #1 responded she was fine but wanted to report CNA D for squeezing her face. LPN B assessed Resident #1's face and there was no red areas or bruising noted. LPN B stated she repositioned Resident #1 while in the room. LPN B stated she asked Resident #1 again if she was okay and informed the resident that her safety was her biggest priority. Resident #1 stated she was fine and thanked LPN B for checking on her. LPN B notified the Supervisor (LPN E) of what had been reported. During an interview on 10/7/2024 at 3:18 PM, LPN E stated on 7/11/2024, LPN B reported to LPN E that CNA D had squeezed Resident #1's face. LPN E immediately assessed Resident #1's face and did not observe any red areas or bruising to the resident's face. LPN E further stated Resident #1 told LPN E that CNA D had squeezed her face. LPN E stated the DON and the Administrator was notified of the event. CNA D was placed on suspension pending and investigation and was sent home. During an interview on 10/8/2024 at 9:15 AM, Social Services Director (SSD) revealed she spoke with Resident #1 on 7/12/2024 and the resident stated she felt safe at the facility. During an observation, interview, and review of the facility investigation on 10/8/2024 at 12:20 PM, with the DON revealed on 7/11/2024 CNA D was providing care to Resident #1 and the resident became aggressive towards CNA D. CNA D touched Resident #1's face. CNA D immediately left the resident's room and told LPN B what happened. LPN B immediately assessed Resident #1's face for any injuries and did not observed red areas or bruising to the resident's face. The DON stated CNA D was asked to write a statement about the event. CNA D was placed on suspension pending an investigation, and the DON instructed CNA D to immediately leave the facility after the witness statement had been completed. During an interview on 10/8/2024 at 1:30 PM, The Executive Director confirmed physical abuse towards Resident #1 had taken place.

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to protect a resident's rights to be free from misappropriation and/or exploitation when money totaling $400.00 was taken from 1 resident (Resident #3) of 4 sampled residents reviewed for misappropriation. The findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, reviewed on ,d+[DATE], revealed .It is the policy of the facility to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Type 2 Diabetes Mellitus, Malignant Neoplasm of Base of Tongue, and Adult Failure to Thrive. Continued review revealed the resident expired in the facility on [DATE] on hospice services. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the facility investigation documentation dated [DATE], revealed Resident #3 reported he was missing $400.00 from his bedside table/nightstand. Resident #3 had stated he had last counted his money on [DATE]. He did not take his money with him on [DATE] when he left his room to go out to a doctor's appointment. Review of a police report dated [DATE], revealed .on [DATE] .received a call to a theft from building .[name of facility] .upon receiving call, the administrator .stated that a resident named .[Resident #3] .wanted to make a report regarding a suspected theft from his room of $400.00 cash .the victim further stated that he had no idea who had taken the money from his room, and did not suspect anyone in particular . During an interview on [DATE] at 3:05 PM, Licensed Practical Nurse (LPN) B stated she was approached by LPN A who stated Resident #3 notified her of the $400.00 missing. Continued interview with LPN B notified the Administrator who had instructed her to go and check the resident's room with his permission for the missing money. The LPN stated the money was not found. During an interview on [DATE] at 9:05 AM, LPN A confirmed she was the first-person Resident #3 had notified about the missing money. Continued interview confirmed both herself and LPN B searched the resident's room for the missing money and the money was not found. During an interview on [DATE] at 1:00 PM, the Administrator confirmed the facility substantiated the allegation of misappropriation for Resident #3. The Administrator stated the $400.00 was reimbursed to Resident #3 by the facility. The Administrator further confirmed the facility could not determine who was responsible for the misappropriation of Resident #3's property.

Based on facility policy review, medical record review, facility documentation review, hospital record review, and interview, the facility failed to prevent a significant medication error for 1 resident (Resident #1) of 7 residents reviewed for medication errors. Resident #1 received 7 medications that were prescribed for Resident #3. The medication error resulted in Resident #1 experiencing [CONDITION(S)] (low blood pressure) and being admitted to an Intensive Care Unit (ICU) in the hospital, which constitutes Harm for Resident #1. The facility was cited past noncompliance and is not required to submit a Plan of Correction (POC). The findings include: Review of the facility's policy titled Administering Medications, dated 4/2019 revealed, .Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescribers [prescriber's] orders .The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include .Checking identification band .Checking photograph attached to the medical record .If necessary, verifying resident identification with other facility personnel .The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method [route] of administration before giving the medication .Medications ordered for a particular resident may not be administered to another resident .New personnel authorized to administer medications are not permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's annual Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The resident received 7 doses of antipsychotic medication, 5 doses of antianxiety medication, 7 doses of antidepressant medication, and 7 doses of diuretics in the last 7 days. Medical record review of Resident #3's Medication Administration Record (MAR) dated 12/1/2021-12/31/2021 revealed the following medications were signed out by Charge Nurse #1 for Resident #3 on 12/31/2021 at 6:20 PM: -[MEDICATION(S)] (to treat anxiety) 0.5 mg (milligrams) -[MEDICATION(S)] (to treat arthritis) 100 mg -[MEDICATION(S)] (antipsychotic medication) 150 mg -[MEDICATION(S)] (to treat depression) 50 mg -[MEDICATION(S)] (pain medication) 400 mg -[MEDICATION(S)] (to treat seizures) 1000 mg -[MEDICATION(S)] (an immunosuppressive medication) 200 mg Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #1's quarterly MDS dated [DATE], revealed the resident was unable to complete the BIMS interview, had short- and long-term memory problems, and had moderately impaired cognition. Continued review revealed the resident received 7 doses of antidepressant medication and 7 doses of Opioids in the last 7 days. Medical record review of Resident #1's Resident Orders dated 12/1/2021-12/31/2021 revealed the resident was ordered the following medications to be administered on 12/31/2021 at 9:00 PM: -[MEDICATION(S)] (pain medication) 50 mg tablet -[MEDICATION(S)] (a medication used to treat diabetes) 500 mg Review of the facility's documentation dated 12/31/2021 revealed Licensed Practical Nurse (LPN) #1, who was on orientation, told Charge Nurse #1 and other nurses on duty that she had given Resident #3's medication to Resident #1 by mistake. Review of the facility's documentation of Charge Nurse #1's statement dated 12/31/2021 revealed, .On 12/31/2021 .while in the process of orienting the new employee [LPN #1] .I instructed her to pull [the process of preparing medication] meds [medications] for the resident [Resident #3] .I observed her check off meds from the roll pack [the plastic clear pill bags] and the resident's [Resident #3] MAR .I stated the resident's [Resident 3's] name to her three times and I also stated the resident's room number to her three times .Aprox [approximately] 10 minutes later the orientee informed me that she had given the resident [Resident #1] .the wrong meds by mistake .I told the orientee to come with me immediately to assess the resident and to obtain a set of vital signs .I reviewed resident's [Resident #1's] chart .to check her allergies and then I reviewed the meds that were given .called Nurse practitioner she gave order to send resident [Resident #1] to ER [emergency room ] for evaluation and treatment .EMS [emergency medical service] arrived at aprox 7:40 pm and took the resident to [hospital] . Review of the facility's documentation dated 12/31/2021 revealed Resident #1 received the following medications on 12/31/2021 at 6:20 PM: [MEDICATION(S)] 0.5 mg, [MEDICATION(S)] 100 mg, [MEDICATION(S)] 150 mg, [MEDICATION(S)] 50 mg, [MEDICATION(S)] 400 mg, [MEDICATION(S)] 1000 mg, and [MEDICATION(S)] 200 mg. The medications administered to Resident #1 were Resident #3's medications. Further review revealed, .Initial assessment of resident [Resident #1] .alert within 30-40 min [minutes] had grown less responsive, sleepy .Immediate assessment of resident [Resident #1] BP [blood pressure] 88/46, HR [heart rate] 92, O2 [oxygen saturation] 97 RA [on room air], RR [respiration rate] 20, T [temperature] 97.8 .ADON [Assistant Director of Nursing] NP [Nurse Practitioner] notified 630p [6:30 PM] .Orders to send to [ER] Departed facility .DON [Director of Nursing], Administrator notified .Family notified . Medical record review of a nurse progress note dated 12/31/2021 at 10:00 PM, revealed, .Resident more sleepy, lethargic and less responsive than usual, B/P 88/46, HR 92 NP notified and orders were given for eval/tx [evaluation and treat] at ER [emergency room ], family notified of change in resident condition and the order for ER eval .Resident was picked up by EMS [emergency medical services] . Medical record review of Resident #1's Telephone Order dated 12/31/2021 revealed, .Send to ER for Eval [evaluation] .Indication Sedation . Review of Resident #1's Hospital Emergency Department (ED) Note dated 12/31/2021 revealed Resident #1 received another resident's prescribed medications while at the nursing home at approximately 6:30 PM. The resident was unresponsive, responded to deep painful stimuli, her systolic blood pressure (pressure caused by the heart contracting and pushing blood) was in the 70's (normal systolic blood pressure 120), intravenous (IV) fluids were administered per EMS, and the resident was transferred to the hospital for further evaluation. The resident's blood pressure responded to the administration of IV fluids and her systolic blood pressure increased to the 90's after she received 500 milliliters of normal saline. The resident's blood pressure remained low, and Resident #1 received [MEDICATION(S)] (a medication used to treat low blood pressure). The ED Physician recommended Resident #1 be admitted to the ICU for further evaluation and treatment. Resident #1 was admitted to the hospital and placed in the ICU. Medical record review of Resident #1's Hospital History and Physical dated 1/1/2022 revealed the resident had an EKG (records the electrical signal from the heart to check for different heart conditions) performed while at the hospital. The EKG showed Resident #1 had sinus [CONDITION(S)] (rapid heartbeat). Critical care was consulted for medication induced [CONDITION(S)] with concerns for [CONDITION(S)]/shock. Continued review revealed .I suspect she has a degree of distributive shock by medication such as [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] . Medical record review of Resident #1's Hospital Discharge Summary dated 1/4/2022 revealed Resident 1's discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed, .Reason for hospitalization .Accidental drug overdose . Resident #1 was admitted to the hospital on 12/31/2021 and was discharged from the hospital and returned to the nursing home on 1/4/2022. During an interview on 4/25/2022 at 12:34 PM, the NP stated on 12/31/2021, after receiving another resident's medications, Resident #1 was hypotensive, lethargic, less responsive, and had a blood pressure of 88/46. The NP stated, .With the resident's blood pressure 88/46 and resident lethargic and hypotensive, it was acutely concerning .The resident had a change in status due to the combination of 4 medications: [MEDICAL RECORD OR PHYSICIAN ORDER] #1 received prescribed to Resident #3 on 12/31/2021] .It was a significant med [medication] error .The resident was not on those meds prior .They were the other resident's [Resident #3's] meds .She went to the ICU due to the medication given .She was lethargic, hypotensive .It caused her harm but not long-term harm . During an interview on 4/25/2022 at 3:03 PM, Certified Nurse Assistant (CNA) #1 stated on 12/31/2021 on 2nd shift, the CNA was seated in a chair in Resident #1's room assisting Resident's #1's roommate with her meal when LPN #1 entered Resident #1's room. The CNA stated LPN #1 administered medications to Resident #1 and the Charge Nurse was not present. The CNA stated, I don't know what she got .I know she [Resident #1] started acting different . The CNA stated Resident #1 would not talk or speak. During an interview on 4/25/2022 at 3:13 PM, CNA #2 stated the Charge Nurse requested the CNA come to Resident #1's room because the CNA had a good rapport with the resident. CNA #2 talked to the resident after the resident received Resident #3's medications and the resident informed the CNA she was not feeling well. The CNA stated Resident #1's speech was slow. During an interview on 4/25/2022 at 4:12 PM, LPN #1 stated while charting at the nursing station on 12/31/2021, LPN #1 walked to the nursing station and stated she made a medication error and had administered Resident #3's medications to Resident #1. LPN's #2 and LPN #3 reviewed Resident #3's MARs to determine what medications Resident #1 had received. LPN #2 confirmed Resident #1 had received [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. During an interview on 4/26/2022 at 1:13 PM, Charge Nurse #1 confirmed she was the Charge Nurse on 12/31/2021 and was also training LPN #1, a new hire on 2nd shift at the facility. The Charge Nurse stated Resident #3 had requested her medication be administered after dinner. After Resident #3 had finished her meal, the Charge Nurse and LPN #1 went to their assigned medication cart together and retrieved Resident #3's medication and placed them in a medication cup. The nurses reviewed Resident #3's picture on the computerized MAR and the resident's name and room number. LPN #1 was instructed not to administer medications without the Charge Nurse. The Charge Nurse stated a resident in the lobby required assistance and when she turned around after assisting the resident, she noted LPN #1 was not at the medication cart. The Charge Nurse stated as she walked down the hall toward Resident #3's room, LPN #1 exited Resident #1's room. The LPN informed the Charge Nurse she gave Resident #3's medication to Resident #1. Continued interview revealed .BP 88/46 .her blood pressure .was too low for her [Resident #1] .I called 911 . The Charge Nurse confirmed Resident #1 had received 7 of Resident #3's prescribed medications in error. The Charge Nurse stated, .She [LPN #1] failed to do any identifiers .I was responsible for the patient [Resident #1] .I was the Charge Nurse .We didn't do the 5 rights .she failed to do any identifiers. She could have looked at her bracelet or asked the resident her name. [Resident #1] could state her name . The Charge nurse confirmed the resident had to be transferred to the hospital for evaluation and treatment. The Charge Nurse stated Resident #1 was in the ICU in critical condition and was diagnosed with [CONDITION(S)] and an accidental drug overdose. The Charge Nurse confirmed the facility failed to prevent a significant medication error for Resident #1. During a telephone interview on 4/27/2022 at 10:50 AM, NP #2 stated she was the on-call provider on 12/31/2021 and was notified by the nursing staff Resident #1 received Resident #3's medications. The NP confirmed Resident #1 had [CONDITION(S)] after receiving another resident's medications on 12/31/2021. The NP stated, They [Nurses] told me what meds they were [medications administered to Resident #1] .So I told them to send her to the ER [emergency room ] .She received all those [medications] and they can cause you to be hypotensive . [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] were all concerning meds .She ended up in the ICU .Her vital signs were not stable . The NP confirmed the facility failed to prevent a significant medication error and failed to prevent harm to Resident #1. During a telephone interview on 4/27/2022 at 2:04 PM, the Medical Director (MD) stated the cumulative effects of [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] were the concern. The MD confirmed Resident #1 was at risk for [CONDITION(S)] after receiving the wrong medications, which were prescribed to Resident #3. The MD stated .The cumulative effects of the medication sent the resident [Resident #1] to the hospital. The resident received medications not prescribed to her .She [Resident #1] had a change in her condition. Resident went to the ICU . Interview confirmed the facility failed to prevent a significant medication error for Resident #1 .It was short term harm . During a telephone interview on 4/27/2022 at 2:18 PM, the Pharmacy Consultant stated the elderly react more acutely to the hypotensive effects of medications. The combination of the 4 medications dropped Resident #1's blood pressure to 88/49 and the resident went to the ICU. The Pharmacy Consultant confirmed the facility failed to prevent a significant medication error for Resident #1 and the resident was harmed but was not permanently harmed. Interview with the Assistant Director of Nursing (ADON) on 4/27/2022 at 2:35 PM, revealed she was notified by Charge Nurse #1 of the medication error on 12/31/2021. The ADON stated, .It was a concern because [Resident #1] was hardly on any medications . The ADON confirmed the facility failed to prevent a significant medication error for Resident #1 on 12/31/2021. During an interview on 4/27/2022 at 3:00 PM, the Director of Nursing (DON) revealed Resident #1 had received Resident #3's medication and had [CONDITION(S)]. Resident #1 had a change in her condition after she received another resident's medication and was hospitalized and placed in the ICU. Further interview confirmed the facility failed to prevent a significant medication error for Resident #1. The facility immediately implemented the following corrective actions validated by the surveyors: 1. Resident #1 was assessed on 12/31/2022, and the DON, ADON, Administrator, Corporate staff, and NP were all notified of the medication error on 12/31/2021. 2. Resident #1 was monitored by nursing 1:1 until EMS arrived and transferred the resident to hospital. 3. LPN #1 was removed from medication administration on 12/31/2022 and self-terminated. LPN #1 did not work again following the medication error. 4. All cognitively intact residents with a BIMS of 9 or more were interviewed for any medication concerns by Social Services and Administrative from 1/4 - 1/6/2022, with no concerns identified. 5. All cognitively impaired residents with a BIMS of 9 or less were monitored for any change in condition or behaviors twice a day on 12/31/2021 - 1/7/2022, with no changes noted. 6. 100% of nursing staff were educated on medication administration and medication rights by the DON, ADON, and Staff Development Coordinator on 1/4 - 1/8/2022. 7. Pharmacist conducted a 100% medication review on 1/4/2022 with no errors identified. 8. On 12/31/2021, Corporate IDT meeting conducted which included the Director of Operations, Administrator, and DON. Root Cause Analysis process was initiated. 9. On 1/1/2022, Corporate IDT meeting conducted which included Administrator, DON, and Director of Clinical Compliance. Topics were the Root Cause Analysis, education, and any needed follow-up. 10. On 1/4/2022, Ad Hoc QA/PI meeting was held with the Director of Operations, Director of Clinical Compliance, Administrator, and DON. Root Cause Analysis process was completed, and Action Plan discussed. 11. Medication Administration Pass audits were conducted by the Staff Development Coordinator and Nursing Administration once a week for 4 weeks, then bi-weekly 4 times, and then to be continued monthly. Medication audits included medication administration competencies added on 1/4/2022. 12. A QA/PI meeting was held on 1/27/2022 and it was determined that the action plan was effective, and compliance had been met. Review during QA/PI meetings will continue. 13. Surveyors conducted a medication pass on 4/26/2022 with no errors found.

Based on facility policy review, medical record review, observation, and interview the facility failed to follow their policy for the operation of a mechanical lift, and failed to ensure1 resident (#38) was free from injury of 3 residents reviewed for accidents of 27 sampled residents. The facility's failure to follow their policy resulted in harm to Resident #38. The findings included: Review of the facility policy, Lift Machine-Using a Portable, .The portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures. If not, two (2) nursing assistants will be required to perform the procedure . Review of Transfer In-service dated 12/6/16 revealed .Must ensure 2 person assist with all lift transfers-sit to stand or total lift .Failure to follow the 2 person assist w(with)/mechanical lift transfers can include disciplinary actions, including up to termination . Medical record review revealed Resident #38 was admitted to the facility on [DATE], and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 11/23/16 revealed .Rarely able to communicate and understand others .requires extensive-total assist with ADL's (Activities of Daily Living) poor safety awareness and impaired cognition secondary to dementia . Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE], revealed Resident #38 was rarely/never understood, and had severe cognitive impairment. Continued review of the Functional Status section (G) revealed the resident required extensive assistance with self-performance defined by the MDS as resident involved in activity, staff provide weight-bearing support and 2+ (plus) persons physical assist for bed mobility and transfers. Review of a nursing note dated 12/5/16 at 7:05 PM, revealed CNA stated that the resident has been holding her arm since she put her to bed. (NP) notified and gave new order to get left upper arm xray. Review of a nursing note dated 12/5/16 at 10:50 PM,revealed .640-(6:40) resident being transported to (hospital emergency room ) for left arm eval (evaluation) . Review of a Radiology Report dated 12/5/16 revealed .Conclusion: Recent proximal humeral fracture . Review of a CNA care guide for Resident #38, updated 12/5/16, revealed .sit to stand x 2 . Review of the facility's investigation report dated 12/5/16 revealed .When CNA (Certified Nursing Assistant) assisted the resident to bed via the sit to stand mechanical lift, she said the resident began holding her left arm and yelled .NP (Nurse Practitioner) notified (in building), xray taken and sent to hospital .Event Committee intervention recommendations/corrective actions taken: CNA counseled .sling . Review of the personnel consultation documentation dated 12/7/16 revealed .Date of occurrence 12/5/16 .Date of Counseling 12/7/16 .CNA transferred resident from w/c (wheelchair) to bed using sit to stand mechanical lift with only one person (herself) assist. CNA care guide stated resident was to be transferred via sit to stand with x 2 assist. Also, all lifts are to be used with x 2 assist-as per policy .and as per training .Corrective Action Taken .Policy, manufacturer guidelines et (and) CNA care guide were not followed in transfer of Resident which resulted in actual harm to resident - therefore CNA (#1) is terminated .12/7/16 .Done via phone 10:30 am . Observation of Resident #38 on 6/7/17 at 2:55 PM, lying in her bed. Attempted to interview the resident. The resident was unable to answer questions. The resident opened her eyes but did not communicate with the surveyor. Interview with CNA #2 on 6/7/17 at 3:00 PM, in the 200 hallway confirmed staff had used the sit to stand lift with Resident #38 before her injury. Continued interview confirmed the resident is tranferred now using the hoyer lift with 2 staff members. Interview with CNA #3 on 6/7/17 at 3:10 PM, at the nurses station confirmed there must be 2 staff members when tranferring a resident with the sit to stand or hoyer lift. Interview with the Administrator and Director of Nursing on 6/7/17 at 1:30 PM, in the Administrator's office confirmed CNA #1 used a sit to stand lift to transfer Resident #38 by herself. Continued interview confirmed the CNA had not followed the facility's policy for transfers, and the resident suffered a fracture as a result. Interview with CNA #1 on 6/7/17 at 2:50 PM, by phone in the conference room confirmed she did transfer Resident #38 with a sit to stand lift by herself on 12/5/16. Further interview confirmed the resident was holding her arm and she (the CNA) .knew something was wrong, she wasn't acting right and she wouldn't let me touch her arm, so I reported it to the nurse . Continued interview confirmed the CNA did know the resident's care plan required 2 staff to transfer with the lift. Further interview confirmed the CNA did not work after the incident and was terminated.

Based on facility policy review, observation, medical record review, and interview the facility failed to ensure 1 of 3 Licensed Practical Nurses (LPN) # 2 administered medications with a medication error rate of less than 5 percent (%). A total of 6 errors were observed out of 25 opportunities for medication administration resulting in a medication error rate of 24%. The findings included: A review was conducted of the Medication Administration Policy dated 1/10/17. The policy was provided by the Administrator in the conference room on 6/7/17 at 9:40 AM. The policy indicated staff should verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route. The policy also documented if the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician orders [REDACTED]. An observation of medication administration on the 100 Hall was made on 6/7/17 at 8:00 AM. LPN #2 was observed as she prepared medications for Resident #40. LPN #2 obtained two sealed packets of medications from the medication cart. She verified the medications in the packets were for Resident #40 and compared them to the current Medication Administration Record [REDACTED]. She stated, This is my way of ensuring what was written on the MAR matches what was written on the pre-packaged plastic packets of pills. She opened both medication packets and poured them into a medication cup. LPN #2 was asked to provide the empty packets so they could be documented as the medications LPN #2 was preparing to give to Resident #40. One of the medication packets was noted to have instructions for the medications to be administered at 9:00 PM on 6/7/17. The other medication packet LPN #2 provided had instructions to administer the medications on 6/7/17 at 9:00 AM. LPN #2 continued to prepare the medications. LPN #2 was asked if all of the medications in the cup for Resident #40 were medications that were to be administered at 9:00 AM on 6/7/17. LPN #2 confirmed all of the medications in the cup were Resident #40's 9:00 AM medications and prepared to administer the medications to Resident #40. Prior to administering the medications to Resident #40, LPN #2 was asked to observe the empty medication packets. LPN #2 was informed that one of the medication packets she prepared for Resident #40 was to be given at 9:00 PM. The medication cup was observed with LPN #2 to have the following medications: [REDACTED] [MEDICATION NAME] 0.5 mg 1/2 tablet [MEDICATION NAME] sprinkle ([MEDICATION NAME]) 125 mg 4 tablets [MEDICATION NAME] 10 mg 2 tablets [MEDICATION NAME] 25 mg two 1/2 tablets [MEDICATION NAME] IR 5 mg one tablet [MEDICATION NAME] 150 mg 2 tablets Senna Plus take 4 tablets Trazadone 50 mg 1 tablet by mouth at bedtime (9 PM) During an interview with LPN #2 on 6/7/17 at 8:05 AM while standing by the medication cart on the 100 Hall, she verified she had inadvertently pulled Resident #40's 9:00 PM dose of medications and was preparing to administer the medications to the resident. She stated, I have been a nurse for [AGE] years and I have never done anything like this before. She stated, I am so thankful you identified this error and stopped me from administering the medications. She stated, I am not sure how I missed that when I compared the pills in the packages to the MAR. After the error was identified, LPN #2 verified the medications that should be administered at 9:00 AM and disposed of the duplicate medications. The medication cup was observed to have the physician ordered 9:00 AM medications and included [MEDICATION NAME] 125 mg, 2 tablets. These medications were administered to Resident #40 on 6/7/17 at 8:10 AM. Medical record review on 06/07/17 at 8:14 AM, revealed the medications administered were reconciled with the physician orders [REDACTED]. 1) Trazadone 50 mg, 1 tablet by mouth was to be given at 9:00 PM and not at 9:00 AM which was identified as a timing error. LPN #2 attempted to administer this medication at 9:00 AM, 2) [MEDICATION NAME] 10 mg, 1 tablet was to be administered and LPN #2 prepared to administer 2 tablets which was identified as a dosage error, 3) [MEDICATION NAME] 25 mg, one 1/2 tablet was ordered and LPN #2 prepared to administer two ½ tablets which was identified as a dosage error, 4) [MEDICATION NAME] 150 mg 1 tablet was ordered and LPN #2 prepared to administer 2 tablets which was identified as a dosage error, 5) Senna Plus 2 tablets were ordered and LPN #2 prepared to administer 4 tablets which was identified as a dosage error, and 6) [MEDICATION NAME] sprinkle ([MEDICATION NAME]) 125 mg, 2 tablets was administered to Resident #40; however, the physician order [REDACTED]. This was identified as a dosage error. During the reconciliation of Resident #40's medications, a physician's orders [REDACTED]. During an interview with LPN #2 on 6/7/17 at 8:27 AM while standing at the medication cart in the 100 Hall, she verified she had administered [MEDICATION NAME] sprinkle ([MEDICATION NAME]) 250 mg on 6/7/2017 at 8:05 AM. She also verified the physician orders [REDACTED]. She verified she had administered what was in the pre-packaged medication packet which was [MEDICATION NAME] sprinkle ([MEDICATION NAME]) 125 mg, 2 tablets and had not noticed the difference between what was on the current physician orders [REDACTED].

Based on facility policy review, review of the Lippincott Manual of Nursing Practice 10th Edition (2014), medical record review, observation, and interview the facility failed to administer medications in accordance with physician orders [REDACTED]. This affected 1 (#40) of 3 residents observed for medication administration. The findings included: A review was conducted of the facility's Medication Administration Policy dated 1/10/17 on 6/7/17 at 11:10 AM. The policy was provided by the Administrator in the conference room. The policy indicated the staff should verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route. The policy also documented if the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician orders [REDACTED]. Review of the Lippincott Manual of Nursing Practice 10th Edition (2014), revealed the professional standard of nursing practice included implementing a physician's orders [REDACTED]. An observation of medication administration was made on 6/7/17 at 8:00 AM on the 100 Hall. Licensed Practical Nurse (LPN) #2 was observed as she prepared medications for Resident #40. LPN #2 obtained 2 sealed packets of medications from the medication cart. She verified the medications in the packets and compared them to the current Medication Administration Record [REDACTED]. LPN #2 stated, This is my way of ensuring what was written on the MAR matches what was written on the pre-packaged plastic package of pills. Continued observation revealed she opened both packets of medications and poured them into a medication cup. A request was made of LPN #2 to provide the empty packets so they could be documented as the medications LPN #2 prepared to administer to Resident #40. While writing the names of the medications, it was observed that one of the packets had instructions for the medications to be administered at 9:00 PM on 6/7/17 versus 9:00 AM. The other packet LPN #2 supplied was noted to have instructions to administer the medications in the packet on 6/7/17 at 9:00 AM. LPN #2 continued to prepare the medications. LPN #2 was asked if all of the medications in the cup for Resident #40 were medications that were to be administered at 9:00 AM on 6/7/17. LPN #2 verified all of the medications in the cup were Resident #40's scheduled 9:00 AM medications and prepared to administer the medications to Resident #40. Prior to administering the medication to Resident #40, LPN #2 was asked to observe the empty pill packets. LPN #2 was informed that one of the packets of pills she prepared for Resident #40 was her 9:00 AM dose, and the other packet of pills she had placed in the cup for Resident #40 was to be given at 9:00 PM. During an interview with LPN #2 on 6/7/17 at 8:55 AM, while standing by the medication cart on the 100 Hall, revealed she verified she had inadvertently pulled Resident #40's 9:00 AM and 9:00 PM doses of medications and was preparing to administer the medications to the resident. She stated she had been a nurse for [AGE] years and she had never done anything like this. She stated, I am so thankful you identified this error and stopped me from administering the medications. She stated, I am not sure how I missed that when I compared the pills in the packages to the MAR. Medical record review/reconciliation with the physician orders [REDACTED].#40 was conducted at 8:14 AM on 6/7/17 and revealed [MEDICATION NAME] sprinkle ([MEDICATION NAME]) 125 mg 2 tablets was administered to the resident; however, the physician order [REDACTED]. A physician's orders [REDACTED]. During an interview with LPN #2 at 8:20 AM, she verified she had administered [MEDICATION NAME] sprinkle ([MEDICATION NAME]) 125 mg 2 tablets to Resident #40 instead of the documented order for 4 tablets on the MAR. She had administered the pills that were pre-packaged in the packet. The medication packet had a label indicating to administer [MEDICATION NAME] sprinkle ([MEDICATION NAME]) 125 mg 2 tablets but the MAR indicated [REDACTED].

Based on review of facility policy, medical record review, observation, and interview, the facility failed to maintain dignity for one dependent resident (#21) of 35 residents reviewed. The findings included: Review of facility policy, Concern and Comment, undated revealed .It is (facility corporation name)'s commitment to respond to the needs of our customers in a continuing effort to improve the quality of life for each of our residents . Medical record review revealed Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Concern/Comment Report dated 2/22/16 revealed .Resident's husband upset because wife was not changed .brief .bed was saturated .was noted that resident had not got changed timely on 2/10/16 .Start calendar to document times changed will be hung on bulletin board .Will f/u (follow up) c (with) husband . Medical record review of the 5 day Scheduled Assessment Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status was unable to be performed due to the resident was rarely/never understood. Further review revealed Resident #21 cognitive skills were severely impaired, always incontinent and required total dependence for toilet use with two person physical assist. Medical record review of the Care Plan dated 1/28/14 and updated 6/16/16 revealed .Dependent on staff for ADL's (Activities of Daily Living) r/t (related to) weakness secondary to [MEDICAL CONDITION] as evidence by inability to complete bed mobility, transfers, dressing, toileting, hygiene/bathing task independently .Requires total assistance . Observation on 6/13/16 at 6:41 AM, in the resident's room revealed the resident lying on back in bed and husband at bedside. Observation on 6/13/16 at 10:42 AM, in the resident's room revealed the resident lying on back in bed, eyes closed, with husband and daughter at bedside. Interview with Resident #21's husband on 6/13/16 at 11:25 AM, in the resident's room confirmed resident was changed at 5:30 AM and again at 9:30 AM (4 hours) and she had not been checked on since. Further interview with the husband confirmed the resident has had to wait up to 4 hours to be checked and changed when wet or had bowel movement in the past. Interview with Licensed Practical Nurse #1 on 6/13/16 at 1:38 PM, in the 100 hall confirmed .her (resident's) husband gets here at 3 AM . Interview with Resident #21's daughter on 6/13/16 at 1:50 PM confirmed the resident was just changed. Further interview confirmed .she was wet and messy with stool . Interview with Certified Nurse Assistant (CNA) #1 on 6/13/16 at 1:56 PM, in the 100 hall confirmed they check and change the residents every 2 hours. Further interview confirmed they checked and changed Resident #21 at 9:30 AM and .just now . ( 1:56 PM) (approximately 4 hours and 20 minutes). Interview with CNA #2 on 6/13/16 at 1:58 PM, in the 100 hall revealed .We turn them every two hours and change . Further interview confirmed the resident was checked and changed at 9:30 AM and just now (1:56 PM) (approximately 4 hours and 20 minutes). Interview with CNA #3 on 6/14/16 at 1:48 PM, on 100 hall confirmed .She is normally wet every 2 hours . Interview with the Administrator on 6/15/16 at 1:41 PM, in the Administrator's office confirmed .They are supposed to check every 2 hours. Four hours or more is not an acceptable time . Interview with Resident #21's daughter and husband on 6/15/16 at 2:53 PM, in the resident's room confirmed .she would have been embarrassed to be in urine and feces that long .

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure incontinence care was provided timely for 1 resident (#21) of 5 residents reviewed for urinary incontinence. The findings included: Review of facility policy, Nursing Department Responsibilities, undated revealed .Residents must be kept clean of feces and urine. Incontinent care and repositioning rounds are done at a minimum of every 2 hours but immediately whenever a resident is soiled or wet . Review of facility policy, Concern and Comment, undated revealed .It is (facility corporation name)'s commitment to respond to the needs of our customers in a continuing effort to improve the quality of life for each of our residents . Medical record review revealed Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 day Scheduled Assessment Minimum Data Set ((MDS) dated [DATE] revealed the Brief Interview for Mental Status was unable to be performed due to the resident was rarely/never understood. Further review revealed Resident #21's cognitive skills were severely impaired, always incontinent, and required total dependence for toilet use with two person physical assist. Medical record review of the Care Plan dated 1/28/14 and updated 6/16/16 revealed .Dependent on staff for ADL's (Activities of Daily Living) r/t (related to) weakness secondary to [MEDICAL CONDITION] as evidence by inability to complete bed mobility, transfers, dressing, toileting, hygiene/bathing task independently .Requires total assistance . Medical record review of the Concern/Comment Report dated 2/22/16 revealed .Resident's husband upset because wife was not changed .brief .bed was saturated .was noted that resident had not got changed timely on 2/10/16 .Start calendar to document times changed will be hung on bulletin board .Will F/u (follow up) c (with) husband . Medical record review of Departmental Notes dated 5/17/16 revealed .Urinary Continence Incontinence .Activity: 2 Person Assist .Activity: Total Dependence . Observation on 6/13/16 at 6:41 AM, in the resident's room revealed the resident lying on back in bed and husband seated in chair at bedside. Observation on 6/13/16 at 10:42 AM, in the resident's room revealed the resident lying on back in bed with eyes closed and the husband and daughter seated in chairs at the bedside. Interview with Resident #21's husband on 6/13/16 at 11:25 AM, in the resident's room confirmed the resident was changed at 5:30 AM and again at 9:30 AM (4 hours) and she had not been checked on since. Further interview with the husband confirmed the resident has had to wait up to 4 hours to be checked and changed when wet or had bowel movement in the past. Interview with Licensed Practical Nurse (LPN) #1 on 6/13/16 at 1:38 PM, in the 100 hall confirmed .her husband gets here at 3 am . Interview with Resident #21's daughter on 6/13/16 at 1:50 PM, in the resident's room confirmed the resident was just changed. Further interview confirmed .she was very wet and messy with stool . Interview with Certified Nurse Assistant (CNA) #1 on 6/13/16 at 1:56 PM, in the 100 hall confirmed they check and change the residents every 2 hours. Further interview confirmed they checked and changed Resident #21 at 9:30 AM and .just now . (1:56 PM) (approximately 4 hours and 20 minutes). Interview with CNA #2 on 6/13/16 at 1:58 PM, in the 100 hall revealed .We turn them every two hours and change . Further interview confirmed the resident was checked and changed at 9:30 AM and just now (approximately 4 hours and 20 minutes). Interview with LPN #2 on 6/14/16 at 7:52 AM, on the 100 hall confirmed .They get checked and changed every 2 hours at least .We don't expect the family to do her care . Interview with CNA #3 on 6/14/16 at 1:48 PM, on the 100 hall confirmed .She is normally wet every 2 hours . Interview with the Director of Nursing (DON) on 6/15/16 at 1:16 PM, in the nursing office confirmed .I would expect the CNAs to check and change the residents approx. (approximately) every 2 hours .4 hours or more would be a long time, it is more than a 2 hour period . Interview with the Administrator on 6/15/16 at 1:41 PM, in the Administrator's office confirmed .They are supposed to check every 2 hours .Four hours or more is not an acceptable time .

Based on review of facility policy, medical record review, observation, and interview, the facility failed to correctly document inappropriate behavior for 1 resident (#25) of 5 residents reviewed for unnecessary medications The findings included: Review of facility policy, Restraints, Chemical and General Guidelines, undated revealed .Facility staff (such as licensed nurses, certified nurse assistants, activity therapist, social workers, and other staff members) will monitor the resident's medical symptoms, condition, circumstances and environment in order to evaluate the appropriateness of restraint use .Designated Facility staff will document episodes of behavior, the impact of the medication on behavior and presence or absence of side effects . Medical record review revealed Resident #25 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the Psych NP (Psyciatric Nurse Practitioner) seen Resident #25 on 6/13/16 revealed .no current anxious behaviors evident, pt (patient) reports sleep and appetite WNL (Within Normal Limits). Staff reports intermittent anxiety r/t (related to) bathroom and delusional symptoms, not distressing to pt and manageable with current medications . Medical record review of the Behavior/Intervention Monthly Flow Record for June 2016 revealed from 6/1/16 to 6/14/16 no behaviors of Restlessness were noted or any interventions the staff may have implemented. Medical record review of the Medication Administration Record [REDACTED].[MEDICATION NAME] (an anti anxiety medication) 0.5 mg (milligram) 1 tab (tablet) po (by mouth) q (every) 4hrs PRN (as needed) Anxiety . Further review revealed Resident #25 received the PRN [MEDICATION NAME] 2 times (12:30 PM and 8:00 PM) on 6/2/16 for .restless/anxiety increased anxiety . 1 time on 6/3/16 (no time given) for anxiety and 1 time on 6/14/16 at 1:40 PM, for anxiety. Observation on 6/14/16 at various times from 1:00 PM to 4:00 PM, and on 6/15/16 from 7:00 AM to 11:15 AM, of Resident #25's room revealed the resident in the bed asleep. Interview with Licensed Practical Nurse (LPN) #1 on 6/14/16 at 4:00 PM, in the 200 hallway revealed when the resident displays Behaviors the nurse is to indicate it on the Behavior sheets. Interview with the Director Of Nursing on 6/15/16 at 11:00 AM, in the nursing office confirmed the Behavior/Intervention Monthly Flow Record for June 2016 indicated the Resident had not displayed any Behaviors for the month of June 2016 and the June 2016 MAR indicated [REDACTED]. Continued interview confirmed the Behavior monitoring sheets were not correct and it would be difficult to assess if Resident #25's Behavior was treated with other interventions or if the nurse gave the [MEDICATION NAME] as a first intervention.

Based on observation and interview, the facility failed to provide sanitary ice for resident use for 1 of 2 ice machines. The findings included: Observation and interview with the Administrator on 6/13/16 at 1:45 PM, at the ice machine outside of the dining room revealed pink debris and a purple strip approximately 1 inch long on the dispenser cover. Interview at the time of the observation confirmed the ice machine required cleaning. Review of facility, Work History Report, for 2015 and 2016 revealed the last time the ice machine was cleaned/serviced was on 4/30/16. Interview with the Maintance Director at the nurse's station on 6/15/16 at 10:00 AM revealed the facility had no schedule for checking the inside of the ice machine to ensure it was clean. Continued interview confirmed the inside of the ice machine was soiled and required cleaning.

Based on observation and interview, the facility failed to provide a current posting of daily nurse staffing. The findings included: Observation on 6/13/16 at 5:30 AM, in the facility front hall revealed the nurse staffing sheet was dated 6/10/16. Interview with the Assistant Administrator on 6/13/16 at 5:35 AM, in the facility front hall confirmed the nurse staffing sheet posted was not for the current date.

Based on review of facility policies, review of the daily cleaning log, review of the Weekly Cleaning Schedule-Deep Fryer, observation and interview, the facility failed to maintain a sanitary kitchen by not properly cleaning the deep fryer and the stationary can opener, by failure to use opened three bean salad and tapioca pudding by the use by dates, by failing to maintain safe milk temperatures for one of four milks, and by failure to remove a build up of dust particles on a duel cooling fan for one of one walk-in freezer, for one of one kitchen reviewed. The findings included: Review of the facility policy, General Food Preparation and Handling, dated 2009, revealed .all food service equipment should be cleaned, sanitized.after each use. Review of the facility policy, Can Opener, updated 9/2011, revealed .sanitation of equipment.frequency.after each meal. Review of the facility policy, Deep-Fat Fryer, updated 9/2011, revealed .cleaning/sanitation of equipment.frequency: after each use. Review of the Trayline Refrigerated Leftover Storage policy, updated 9/2011, revealed .date container with use by date.pudding.1-2 days., salads-marinated.1 to 3 day storage. Further review revealed fresh milk. at 41 degrees F (Fahrenheit) or less. Review of the Daily Cleaning Log, dated 6/1 through 6/7, 2015, revealed the can opener cleaning frequency each use. Review of the Weekly Cleaning Schedule, Deep Fryer, dated 5/31 to 6/6, 2015, revealed the deep fryer cleaning frequency weekly. Observation with the Certified Dietary Manager (CDM), on 6/8/15, at 8:05 AM, in the kitchen, revealed a covered deep fryer containing brown grease with floating brown crumbs in and around the rim. Observation with the CDM, on 6/8/15, at 8:15 AM, at the Number 3 Reach-In Cooler, revealed a tub of opened tapioca pudding, dated 6/1 and a tub of opened three-bean salad, dated 6/2. Observation with the CDM, on 6/8/15, at 8:25 AM, at the kitchen stationary can opener, revealed dried food and paper particles on the shank and blade of the can opener. Observation with the CDM, on 6/8/15, at 8:30 AM, of milk on ice in a basin, for the breakfast buffet, revealed a carton of whole milk with a temperature of 48 degrees F. Observation with the CDM, on 6/8/15, at 8:45 AM, in the freezer walk-in, revealed dust particles on the duel cooling fans. Interview with the CDM, on 6/8/15, at 8:50 AM, in the kitchen, confirmed the deep fryer had been used on Friday (6/5), the tub of opened tapioca pudding, dated 6/1 and the tub of opened three-bean salad, dated 6/2 should have been discarded, the stationary can opener .should have been cleaned., and the whole milk was too warm. Continued interview confirmed the build up of the dust particles on the duel cooling fans. Interview with the Maintenance Manager, on 6/10/15, at 1:40 PM, in the maintenance hallway, confirmed .there is no preventative maintenance program for cleaning the walk-in freezer.

Based on review of facility policy, medical record review, observation, and interview, the facility failed to obtain a physician's order to place an indwelling urinary catheter for one resident (#137) of 2 residents reviewed for indwelling urinary catheters, of 30 residents reviewed. The findings included: Review of the facility policy Physician's Orders revealed .All treatments and medications must be ordered, signed and dated by the resident's attending physician.Physician orders include:.f) Special medical procedures required for the safety and well being of the resident.NOTE: Medications, diets, therapy, or any treatment may not be administered to the resident without a written order from the attending physician. Medical record review revealed Resident #137 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Continued review revealed Resident #137 was admitted to Hospice Care on 6/6/15. Medical record review of the Physician's Orders for Resident #137 failed to reveal an order to place an indwelling urinary catheter. Observation of Resident #137 on 6/8/15, at various times from 9:30 AM, to 4:45 PM, on 6/9/15, from 8:00 AM to 4:30 PM, and on 6/10/15, from 7:30 AM to 1:00 PM, in the resident's room revealed the resident lying in the bed and unresponsive to verbal or physical stimuli. Continued observation revealed an indwelling urinary catheter with a small amount of light yellow urine in the urine collection bag. Interview with the Director of Nursing (DON) and the Corporate Nurse Consultant on 6/9/15, at 12:45 PM, in the DON's office, confirmed a Hospice nurse placed the indwelling urinary catheter in Resident #137 on 6/6/15, and failed to obtain a physician's order from the attending physician.

Based on observation, medical record review, and interview, the facility failed to develop a comprehensive care plan for Dental Care for 1 Resident (#30) of 2 residents reviewed for Dental Status, of 30 residents reviewed. The findings included: Observation of Resident #30, on 6/9/15, at 8:00 AM, in the resident's room, revealed the resident was missing all of her top teeth and several of her bottom teeth. Medical record review revealed Resident #30 was admitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Resident #30's comprehensive care plan dated 4/13/15, revealed there had been no care plan developed addressing Resident #30's dental status. Interview with the Director of Nursing (DON) on 6/10/15 at 10:31 AM, in the DON's office, confirmed the facility had failed to develop a care plan to address Resident #30's dental status.

Based on facility policy review, review of a Narcotic Count Sheet, medical record review, review of the Medication Occurrence Report, and interview, the facility failed to notify the physician when significant medication errors for one resident (#20) occurred of thirty-one residents reviewed. The facility's failure to notify the physician of significant medication errors was likely to cause serious injury, harm, impairment, or death to resident #20. On May 4, 12:05 p.m., in the office of the administrator, the administrator and the corporate nurse consultant were informed of the Immediate Jeopardy. The findings included: Resident #20 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the nurse's progress notes for February 19, 2011, at 10:15 a.m., revealed, "...Spoke with (names of two sons). Total comfort care agreed. No hospitalization . New order for MSO4 ([MEDICATION NAME], a narcotic) and [MEDICATION NAME] (decreases secretions)...Will monitor." Review of the physician's orders [REDACTED]. Record review of the third Narcotic Count Sheet dated February 20, 2011,(used to record each narcotic dose administered) for liquid [MEDICATION NAME] for resident #20 revealed a sticker-type label adhered to the top right of the sheet with the following information included: "(resident #20's name); room # (number); [MEDICATION NAME] SULFATE 100 MG/5 ML (milliliter) substituted for [MEDICATION NAME] 20 MG/ML SOLUTION; 02/19/11(date); Take 0.05ML-0.1ML (1-2MG) EVERY HOUR AS NEEDED; QTY (quantity) 30 ML.(total dispensed from the pharmacy)" Interview at 10:00 a.m., on May 3, 2011, in the conference room with the Director of Nurses (DON) revealed the following: 1) the narcotic count was incorrect at 3:00 p.m., February 23, 2011, with less liquid narcotic remaining than on the Narcotic Count Sheet record; 2) the DON did not investigate the discrepancy in the narcotic count; 3) the DON changed the amount left to count; 4) on February 23, 2011, the DON interviewed the 11-7 (night shift) Licensed Practical Nurse (LPN #2) and LPN #2 stated the resident had been given 1 ml (20 mg of [MEDICATION NAME] instead of 2 mg) at 1:00 a.m., 3:00 a.m., and 5 a.m., on February 22, 2011; 5) the DON stated knowledge of the day shift LPN #1 giving two additional 1.0 ml doses of [MEDICATION NAME] instead of 0.1 ml (20 mg of [MEDICATION NAME] instead of 2 mg) on February 22, 2011 at 7:00 a.m. and 11:00 a.m. The DON did not define a timeframe for when the DON realized the resident had received a total of five incorrect doses on February 22, 2011. Interview confirmed the DON had not considered the irreconcilable narcotic count as a significant medication error and did not notify the physician. Review of the facility's policy 'Medication Error...Reporting' revealed, "Procedures: a. In the event of a significant medication error...immediate action is taken, as necessary, to protect the resident's safety and welfare. b. The attending physician is notified promptly...c. The physician's orders [REDACTED]." Record review of a 'Medication Occurrence Report' revealed the Medical Director was informed of the significant medication error on February 24, 2011. Interview on May 4, 2011, in the conference room with the DON at 8:45 a.m., verified the DON had not followed the facility policy to notify the physician when the significant medication error occurred. Continued interview confirmed on February 22, 2011, in a 10 hour period, resident #20 received 100 mg of [MEDICATION NAME] instead of the ordered 10 mg and the physician was not notified. The Immediate Jeopardy was effective from February 22, 2011, through May 6, 2011, and was removed on May 6, 2011. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated on site by the survey team on May 6, 2011 through review of facility documents, staff interviews, and observations. The survey team verified the allegation of compliance by: 1.) Verifying one nurse involved in the significant medication error was no longer employed by the facility; and verified the other remaining nurse involved in the significant medication error had been counseled and educated regarding medication administration and had completed return demonstration of medication administration of liquid narcotics on May 6, 2011. The Director of Nursing on site at the start of the survey had resigned without notice on May 4, 2011 and an interim Director of Nursing had been established on May 4, 2011. 2.) Verifying all liquid narcotics records were reviewed by the Regional Director of Clinical Services and a Registered Nurse on May 4, 2011 to confirm accuracy of the Medication Administration Records and the Narcotic Count Sheets to determine if other residents were affected. In addition the surveyors conducted observation of liquid narcotic administration on May 6, 2011. 3.) Verification by the survey team on May 6, 2011 ensured by interviews with the licensed nursing staff and review of in-service logs that the nurses received information regarding the five rights of medication administration; alert charting to be initiated on every shift for seventy-two hours after a medication error; timely notification of the Physician, Director of Nursing and the Administrator after a medication error; and notification of revision of the medication policy addressing the change of administration of liquid narcotics requiring verification and signatures by two nurses if the amount to be administered is less than 5 milliliters. The survey team verified the facility's Audit Form for Medication Error Notification to begin May 5, 2011 and be conducted daily through May 19, 2011 then decreased to two times weekly for two months through July 19, 2011. Compliance to be conducted by the Regional Director of Clinical Services. 4.) The survey team verified the facility's plan of daily monitoring by a Registered Nurse for a two week duration, beginning May 5, 2011 through May 19, 2011, then two times a week for two months until July 18, 2011 to include a 100 % audit of Medication Error Sheets for proper notification of the Physician, Administrator, and Director of Nursing; a 100 % audit of the Medication Administration Records of residents receiving liquid narcotic doses less than 5 milliliters to ensure compliance of two nurses verifying the dose and signing the Medication Administration Record; and auditing of the alert charting log against the medication error reports to verify alert charting compliance for 72 hours. The survey team verified the facility's plan for the Regional Director of Clinical Services to perform a compliance review of 100% of the audit forms and related data weekly until the end of the monitoring time. The survey team verified the facility's plan to relay results to the Quality Assurance Performance Improvement committee monthly through the end of the monitoring time for review and recommendations. The survey team verified the facility's plan to have the Quality Assurance Performance Improvement committee determine if any revisions are needed to the audit plan. The survey team verified the facility's plan to have the Quality Assurance Performance Improvement committee consist of, at a minimum, the Administrator, Director of Nursing, Medical Director, and Dietary, Activities, Maintenance, Business office, Social Services, and Pharmacy departments. Non-compliance continues at a "D" level for monitoring of corrective actions. The facility is required to submit a plan of correction. c/o # .

Based on facility policy review, review of a Narcotic Count Sheet, medical record review, review of facility documents, review of Standard of Practice for Advanced Trauma Life Support and interview, the facility failed to take appropriate action when 1) significant narcotic medication errors for one resident (#20) occurred and 2) a fall resulting in a fracture with an inappropriate transfer occurred for one resident (#2) of thirty-one residents reviewed. The facility's failure to investigate significant narcotic medication errors and to immediately notify the Administrator, physician, and pharmacist was likely to cause serious injury, harm, impairment or death to resident #20. On May 4, 2011 at 12:05 p.m. in the office of the Administrator, the Administrator and the Corporate Nurse Consultant were informed of the Immediate Jeopardy. The findings included: Resident #20 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Record review of the third Narcotic Count Sheet dated February 20, 2011,(used to record the amount of narcotic remaining) for liquid [MEDICATION NAME] for resident #20 revealed a sticker-type label adhered to the top right of the sheet with the following information included: "(resident #20's name); room#; [MEDICATION NAME] SULFATE 100 MG/5 ML (milliliters) substituted for [MEDICATION NAME] 20 MG/ML SOLUTION; 02/19/11(date); Take 0.05ML-0.1ML (1-2MG) EVERY HOUR AS NEEDED; QTY (quantity) 30 ML (total dispensed from the pharmacy)." Continued review of the 'Dose Given' column revealed six LPNs had recorded on the third Narcotic Count Sheet beginning February 20, 2011, at 2:00 p.m., and all had recorded the dose given as 0.1 ml. Review revealed the first four LPNs had subtracted an amount of 0.1 ml from the 'Quantity Remaining' column and the subsequent two LPNs (the nightshift/LPN #2 and the dayshift/LPN #1) had subtracted 1.0 ml from the total liquid remaining when administering the liquid MSO4 narcotic from 1:00 a.m., on February 22, 2011, through 11:00 a.m., on February 22, 2011; the entries were as follows: "...2-21-11 9 pm 0.1 mL (dose given) 28.3 mL (quantity remaining)...2-21-11 10 pm 0.1 mL (dose given) 28.2 mL (quantity remaining)...2-21-11 11 pm 0.1 mL (dose given) 28.1 mL (quantity remaining)...2-22-11 1 am 0.1 mL (dose given) 27.1 mL (quantity remaining)...2-22-11 3 am 0.1 mL (dose given) 26.1 mL (quantity remaining)...2-22-11 5 am 0.1 mL (dose given) 25.1 mL (quantity remaining)...2-22-11 7 am 0.1 mL (dose given) 24.1 mL (quantity remaining)...2-22-11 11 am 0.1 mL (dose given) 23.1 mL (quantity remaining)..." Continued record review of the third Narcotic Count Sheet for resident #20 revealed a discrepancy in the amount 'left to count' on February 22, 2011. Review of the Narcotic Count Sheet revealed Licensed Practical Nurse (LPN#1) administered a dose of MSO4 on February 22, 2011 at 11:00 a.m., and recorded 23.1 ml in the column 'Quantity Remaining.' Continued review revealed a line marked through the 23.1 total remaining and 20 ml written and signed by the Director of Nurses (DON). Interview in the conference room, with the DON, on May 3, 2011, at 10:00 a.m., revealed the DON stated the [MEDICATION NAME] liquid left in the bottle did not match the amount of 23.1 ml 'Quantity Remaining' on the Narcotic Count Sheet during the 3:00 p.m. shift change count on February 22, 2011. Continued interview revealed the oncoming evening shift LPN #7 stated the amount remaining was not accurate if the total amount given from the time the LPN had left at 11:00 p.m., the evening of February 21, 2011 to the present was 0.1 ml with each subsequent five doses. Continued interview revealed the DON did no further questioning about the amount remaining to be 20 ml (equal to 40 milligrams of narcotic medication), and recorded 20 ml remained. Continued interview confirmed the DON had signed the Narcotic Count Sheet in the column to the left of 'Quantity Remaining', wrote in 20 ml, and took no further action until February 23, 2011. During interview, the DON stated on the morning of February 23, 2011, the night shift nurse, LPN #2, was questioned by the DON and revealed the resident had been given a 1 ml dose of [MEDICATION NAME] (20 mg instead of 2 mg ordered) at 1:00 a.m., 3:00 a.m., and 5:00 a.m., by LPN #2 on February 22, 2011. During interview, the DON stated he/she did not realize the two doses given by LPN #1 on February 22, 2011, at 7:00 a.m., and 11:00 a.m., had also been 1 ml each (20 mg instead of 2 mg ordered) until "later." Review of the facility's policy 'Medication Error ...Reporting' revealed, "Procedures: a. In the event of a significant medication error ...immediate action is taken, as necessary, to protect the resident's safety and welfare. b. The attending physician is notified promptly ...c. The physician's orders [REDACTED]." Review of the 'Controlled Medication Storage' policy and procedures revealed, "...e. Any discrepancy in controlled substance medication counts is reported to the director of nursing immediately. The director...makes every reasonable effort to reconcile all reported discrepancies. Irreconcilable discrepancies are documented by the director of nursing in a report to the administrator. If a major discrepancy...occurs...the director of nursing notifies the administrator and consultant pharmacist immediately..." Interview with the DON at 8:45 a.m., on May 4, 2011, in the conference room confirmed the DON had not followed the facility policy for reconciliation of a controlled medication; had not followed facility policy when the significant medication error occurred; had not investigated the 7.5 ml (equaling 150 mg) of [MEDICATION NAME] not accounted for on February 22, 2011; and had not notify the administrator, physician, and consultant pharmacist "immediately." Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the July 15, 2010, Minimum Data Set (MDS), revealed the resident had a history of [REDACTED]. Medical record review of physical therapy progress notes, dated July 15, 2010, revealed the resident was safe to transfer independently, and was referred to the restorative program. Medical record review of nurse's notes, dated September 5, 2010, revealed "Sitting in BR (bathroom) floor with pants down states, 'I lost my balance'-c/o (complains of) pain R (right) hip-can move all exts (extremities) except for R (right) LE (lower extremity)-assisted to w/c (wheelchair)-resident vomited x (times) 1 lg (large) amt (amount) white frothy-face red, shaking, R leg 1/2 in (inch) shorter than L (left)..." Continued medical record review of nurse's notes revealed the resident was subsequently transferred to the emergency room with the [DIAGNOSES REDACTED]. Review of facility documents revealed a nursing department inservice was held on September 7, 2010, at 3:00 p.m. "Should a fall occur-Resident should not be moved until: ROM (range of motion); assess for pain/injury; neur (neurological) checks if head injury...should resident be unable to completed (complete) ROM, c/o (complain) of pain/injury or display evidence of fx (fracture)-Do Not Move...make resident comfortable where they are with pillow/blankets and notify M.D. (physician) and EMS (emergency medical services), as needed." Continued review of facility documents revealed on September 9, 2010, LPN #3 received a "corrective action" because the LPN moved the resident after the resident exhibited signs/symptoms of a possible fracture. Interview with the Director of Nursing on May 3, 2011, at 4:45 p.m., in the conference room, confirmed LPN #3 moved the resident from a lying to a sitting position (into the wheelchair), after LPN #3 assessed the resident's inability to move the lower right extremity, and the resident's right leg being "1/2 inch shorter than the left". Continued interview with the Director of Nursing confirmed moving the resident was not in accordance with acceptable standards of practice. Standard of practice for Advanced Trauma Life Support requires "...the development of the advanced trauma life support (ATLS) approach by the American College of Surgeons. ATLS is the standard of care for trauma patients, and it is built around a standardized protocol for patient evaluation. This protocol ensures that the most immediate life-threatening conditions are actively identified and addressed in the order of their risk potential. The objectives of the initial evaluation of the trauma patient are as follows: (1) to stabilize the trauma patient, (2) to identify life-threatening injuries and to initiate adequate supportive therapy, and (3) to efficiently and rapidly organize either definitive therapy or transfer to a facility that provides definitive therapy..." The Immediate Jeopardy was effective from February 22, 2011, through May 6, 2011, and was removed on May 6, 2011. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the survey team through review of facility documents, staff interviews, and observations conducted onsite on May 6, 2011. The survey team verified the allegation of compliance by: 1.) Verifying one nurse involved in the significant medication error was no longer employed by the facility; and verified the other remaining nurse involved in the significant medication error had been counseled and educated regarding medication administration and had completed return demonstration of medication administration of liquid narcotics on May 6, 2011. The Director of Nursing on site at the start of the survey had resigned without notice on May 4, 2011 and an interim Director of Nursing had been established on May 4, 2011. 2.) Verifying all liquid narcotics records were reviewed by the Regional Director of Clinical Services and a Registered Nurse on May 4, 2011 to confirm accuracy of the Medication Administration Records and the Narcotic Count Sheets to determine if other residents were affected. In addition the surveyors conducted observation of liquid narcotic administration on May 6, 2011. 3.) Verification by the survey team on May 6, 2011 ensured by interviews with the licensed nursing staff and review of in-service logs that the nurses received information regarding the five rights of medication administration; alert charting to be initiated on every shift for seventy-two hours after a medication error; timely notification of the Physician, Director of Nursing and the Administrator after a medication error; and notification of revision of the medication policy addressing the change of administration of liquid narcotics requiring verification and signatures by two nurses if the amount to be administered is less than 5 milliliters. The survey team verified the facility's Audit Form for Medication Error Notification to begin May 5, 2011 and be conducted daily through May 19, 2011 then decreased to two times weekly for two months through July 19, 2011. Compliance to be conducted by the Regional Director of Clinical Services. 4.) The survey team verified the facility's plan of daily monitoring by a Registered Nurse for a two week duration, beginning May 5, 2011 through May 19, 2011, then two times a week for two months until July 18, 2011 to include a 100 % audit of Medication Error Sheets for proper notification of the Physician, Administrator, and Director of Nursing; a 100 % audit of the Medication Administration Records of residents receiving liquid narcotic doses less than 5 milliliters to ensure compliance of two nurses verifying the dose and signing the Medication Administration Record; and auditing of the alert charting log against the medication error reports to verify alert charting compliance for 72 hours. The survey team verified the facility's plan for the Regional Director of Clinical Services to perform a compliance review of 100% of the audit forms and related data weekly until the end of the monitoring time. The survey team verified the facility's plan to relay results to the Quality Assurance Performance Improvement committee monthly through the end of the monitoring time for review and recommendations. The survey team verified the facility's plan to have the Quality Assurance Performance Improvement committee determine if any revisions are needed to the audit plan. The survey team verified the facility's plan to have the Quality Assurance Performance Improvement committee consist of, at a minimum, the Administrator, Director of Nursing, Medical Director, and Dietary, Activities, Maintenance, Business office, Social Services, and Pharmacy departments. Non-compliance continues at a "D" level for monitoring of corrective actions. The facility is required to submit a plan of correction. c/o # c/o # .

Based on facility policy review, review of a Narcotic Count Sheet, medical record review, observation, and interview, the facility failed to ensure one resident (#20) was free of significant medication errors of thirty-one residents reviewed. The facility's failure to ensure residents were free of significant medication errors was likely to cause serious injury, harm, impairment, or death to resident #20. On May 4, 2011 at 12:05 p.m., in the office of the Administrator, the Administrator and the Corporate Nurse Consultant were informed of the Immediate Jeopardy. The findings included: Resident #20 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the nurse's progress notes for February 19, 2011, at 10:15 a.m., revealed, " ...Spoke with (names of two sons). Total comfort care agreed. No hospitalization . New order for MSO4 ([MEDICATION NAME], a narcotic) and [MEDICATION NAME] (decreases secretions)...Will monitor." Review of the physician's orders [REDACTED]. Record review of the third Narcotic Count Sheet dated February 20, 2011,(used to record the amount of narcotic remaining) for liquid [MEDICATION NAME] for resident #20 revealed a sticker-type label adhered to the top right of the sheet with the following information included: "(resident #20's name); room# (number); [MEDICATION NAME] SULFATE 100 MG/5 ML (milliliters) substituted for [MEDICATION NAME] 20 MG/ML SOLUTION; 02/19/11(date); Take 0.05ML-0.1ML (1-2MG) EVERY HOUR AS NEEDED; QTY (quantity) 30 ML (total dispensed from the pharmacy)." Continued review of the 'Dose Given' column revealed six LPNs had recorded on the third Narcotic Count Sheet beginning February 20, 2011, at 2:00 p.m., and all had recorded the dose given as 0.1 ml. Review revealed the first four LPNs had subtracted an amount of 0.1 ml from the 'Quantity Remaining' column and the subsequent two LPNs (the nightshift/LPN #2 and the dayshift/LPN #1) had subtracted 1.0 ml from the total liquid remaining when administering the liquid MSO4 narcotic from 1:00 a.m., on February 22, 2011, through 11:00 a.m., on February 22, 2011; the entries were as follows: "...2-21-11 9 pm 0.1 mL (dose given) 28.3 mL (quantity remaining)...2-21-11 10 pm 0.1 mL (dose given) 28.2 mL (quantity remaining)...2-21-11 11 pm 0.1 mL (dose given) 28.1 mL (quantity remaining)...2-22-11 1 am 0.1 mL (dose given) 27.1 mL (quantity remaining)...2-22-11 3 am 0.1 mL (dose given) 26.1 mL (quantity remaining)...2-22-11 5 am 0.1 mL (dose given) 25.1 mL (quantity remaining)...2-22-11 7 am 0.1 mL (dose given) 24.1 mL (quantity remaining)...2-22-11 11 am 0.1 mL (dose given) 23.1 mL (quantity remaining)..." Continued record review of the third Narcotic Count Sheet for resident #20 revealed a discrepancy in the amount 'left to count' on February 22, 2011. Review of the Narcotic Count Sheet revealed Licensed Practical Nurse (LPN#1) administered a dose of MSO4 on February 22, 2011 at 11:00 a.m., and recorded 23.1 ml in the column 'Quantity Remaining.' Continued review revealed a line marked through the 23.1 total remaining and 20 ml written and signed by the Director of Nurses (DON). Interview in the conference room, with the DON, on May 3, 2011, at 10:00 a.m., revealed the DON stated the [MEDICATION NAME] liquid left in the bottle did not match the amount of 23.1 ml 'Quantity Remaining' on the Narcotic Count Sheet during the 3:00 p.m. shift change count on February 22, 2011. Continued interview revealed the oncoming evening shift LPN #7 stated the amount remaining was not accurate if the total amount given from the time the LPN had left at 11:00 p.m., the evening of February 21, 2011 to the present was 0.1 ml with each subsequent five doses. Interview revealed the DON did no further questioning about the amount remaining, judged the amount remaining to be 20 ml (equal to 40 milligrams of narcotic medication), and recorded 20 ml remained. Interview confirmed the DON had signed the Narcotic Count Sheet in the column to the left of 'Quantity Remaining', wrote in 20 ml, and took no further action until February 23, 2011. During interview, the DON stated on the morning of February 23, 2011, the night shift nurse, LPN #2, was questioned by the DON and revealed the resident had been given a 1 ml dose of [MEDICATION NAME] (20 mg instead of 2 mg ordered) at 1:00 a.m., 3:00 a.m., and 5:00 a.m., by LPN #2 on February 22, 2011. During interview, the DON stated he/she did not realize the two doses given by LPN #1 on February 22, 2011 at 7:00 a.m. and 11:00 a.m. had also been 1 ml each (20 mg instead of 2 mg ordered) until "later." Review of the facility's policy 'Medication Error ...Reporting' revealed, "Procedures: a. In the event of a significant medication error ...immediate action is taken, as necessary, to protect the resident's safety and welfare. b. The attending physician is notified promptly ...c. The physician's orders [REDACTED]." Interview in the 300 Hall on May 4, 2011, at 8:30 a.m., with LPN #1 verified LPN #1 had administered a 1 ml (20 mg) amount of MSO4 ([MEDICATION NAME]) at 7:00 a.m., and 11:00 a.m., on February 22, 2011, (instead of the 2 mg ordered by the physician). Interview continued, after the DON joined the interview, and LPN #1 stated no one had ever explained the 1.0 ml amount was not the 0.1 ml dose LPN #1 had recorded as given, but ten times that amount. Interview on May 4, 2011, in the conference room with the DON at 8:45 a.m., immediately following the interview with LPN #1, verified the DON had not followed the facility policy when the significant medication error occurred. Interview confirmed if the dosing by the night shift LPN #2 and the day shift LPN #1 had been in the appropriate amount (including one wasted dose) there would have been 27.5 ml 'Quantity Remaining' when the evening shift LPN #7 was conducting the narcotic count at 3:00 p.m., on February 22, 2011. Interview confirmed, instead of 27.5 ml liquid [MEDICATION NAME] remaining, there were 20 ml remaining according to the DON. Interview confirmed the DON did not investigate the 7.5 ml (equaling 150 mg) of liquid [MEDICATION NAME] not accounted for on February 22, 2011. Interview continued and confirmed the DON did not assess the resident, did not notify the physician, and left the facility without resolution of the narcotic discrepancy. On February 22, 2011, in a 10 hour period, resident #20 received 100 mg of [MEDICATION NAME] instead of the ordered 10 mg. Incorrect doses were given on February 22, 2011, at 1:00 a.m., 3:00 a.m., 5:00 a.m., 7:00 a.m., and 11:00 a.m. The Immediate Jeopardy was effective from February 22, 2011, through May 6, 2011, and was removed on May 6, 2011. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated on site by the survey team on May 6, 2011 through review of facility documents, staff interviews, and observations. The survey team verified the allegation of compliance by: 1.) Verifying one nurse involved in the significant medication error was no longer employed by the facility; and verified the other remaining nurse involved in the significant medication error had been counseled and educated regarding medication administration and had completed return demonstration of medication administration of liquid narcotics on May 6, 2011. The Director of Nursing on site at the start of the survey had resigned without notice on May 4, 2011 and an interim Director of Nursing had been established on May 4, 2011. 2.) Verifying all liquid narcotics records were reviewed by the Regional Director of Clinical Services and a Registered Nurse on May 4, 2011 to confirm accuracy of the Medication Administration Records and the Narcotic Count Sheets to determine if other residents were affected. In addition the surveyors conducted observation of liquid narcotic administration on May 6, 2011. 3.) Verification by the survey team on May 6, 2011 ensured by interviews with the licensed nursing staff and review of in-service logs that the nurses received information regarding the five rights of medication administration; alert charting to be initiated on every shift for seventy-two hours after a medication error; timely notification of the Physician, Director of Nursing and the Administrator after a medication error; and notification of revision of the medication policy addressing the change of administration of liquid narcotics requiring verification and signatures by two nurses if the amount to be administered is less than 5 milliliters. The survey team verified the facility's Audit Form for Medication Error Notification to begin May 5, 2011 and be conducted daily through May 19, 2011 then decreased to two times weekly for two months through July 19, 2011. Compliance to be conducted by the Regional Director of Clinical Services. 4.) The survey team verified the facility's plan of daily monitoring by a Registered Nurse for a two week duration, beginning May 5, 2011 through May 19, 2011, then two times a week for two months until July 18, 2011 to include a 100 % audit of Medication Error Sheets for proper notification of the Physician, Administrator, and Director of Nursing; a 100 % audit of the Medication Administration Records of residents receiving liquid narcotic doses less than 5 milliliters to ensure compliance of two nurses verifying the dose and signing the Medication Administration Record; and auditing of the alert charting log against the medication error reports to verify alert charting compliance for 72 hours. The survey team verified the facility's plan for the Regional Director of Clinical Services to perform a compliance review of 100% of the audit forms and related data weekly until the end of the monitoring time. The survey team verified the facility's plan to relay results to the Quality Assurance Performance Improvement committee monthly through the end of the monitoring time for review and recommendations. The survey team verified the facility's plan to have the Quality Assurance Performance Improvement committee determine if any revisions are needed to the audit plan. The survey team verified the facility's plan to have the Quality Assurance Performance Improvement committee consist of, at a minimum, the Administrator, Director of Nursing, Medical Director, and Dietary, Activities, Maintenance, Business office, Social Services, and Pharmacy departments. Non-compliance continues at a "D" level for monitoring of corrective actions. The facility is required to submit a plan of correction. c/o #

Based on medical record review, review of wound tracking reports, facility policy review, observation, and interview the facility failed to prevent pressure ulcers from developing for two residents (#8 and #23) of thirty-one residents reviewed. The facility's failure to consistently implement measures to prevent the development of pressure sores resulted in harm to residents #8 and #23, who developed pressure sores. The findings included: Resident #8 was admitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], and the Annual MDS dated [DATE], revealed the resident did not have a history of pressure ulcer and did not have any pressure ulcer at the time of the assessments. Review revealed the Annual MDS stated the resident required extensive assist of one person for bed mobility. Medical record review of the 'Braden Scale-For Predicting Pressure Sore Risk' assessed the resident on February 24, 2011 with a score of 13, indicating a 'moderate risk' for pressure sore development. Record review of the resident's care plan dated December 3, 2010, included the problems, "Self care deficit secondary to Dementia, needs extensive assistance" and "Risk for skin breakdown r/t (related to) inc' (incontinent) B/B (bladder and bowel)...Goal - Maintain intact skin integrity by next review 5/16/11..." Review of the care plan revealed handwritten additions dated April 11, 2011, "Blister...L (left) heel...will show s/s (signs and symptoms) of healing, will not show s/s of infection by 5/20/11...wound care treatment as ordered ...float heels." Record review of the progress note from the consulting psychiatric nurse practitioner on March 9, 2011, revealed, "...long h/o (history of) depression, [MEDICAL CONDITION], agitation...No increase in behavior symptoms...Lying in bed today...Will try increase in [MEDICATION NAME] (an anti-depressant medication also used as a hypnotic and appetite stimulant)..." Review of the next progress note from the consulting psychiatric nurse practitioner on April 13, 2011, revealed, "...More somnolent and lethargic. Always in bed...is lying in bed today. " Medical record review of the physician's orders [REDACTED]. Observations at 6:30 a.m., and 1:00 p.m., on May 2, 2011, revealed the resident lying in bed with the left foot resting on the mattress. Observation at 8:50 a.m., on May 3, 2011, revealed the resident lying in bed, being fed by a certified nursing assistant (CNA) with the left foot resting on the mattress. Interview in the conference room, with Licensed Practical Nurse (LPN #4) on May 5, 2011, at 4:00 p.m., verified the facility used pillows for floating the residents' heels off of the bed and this was frequently ineffective due to the residents (including resident #8) kicking the pillows out from under their feet and legs. Medical record review of the 'Weekly Skin Integrity Assessment' from the week of March 23, 2011 through April 20, 2011, revealed each week, including April 6, 2011, the assessment stated resident #8's skin integrity was intact. Interview on May 3, 2011, at 3:30 p.m., at the nursing station, with LPN #6 (responsible for the April 6, 2011, skin assessment) revealed, "...hard to assess...doesn't want to be bothered...I missed it (referring to the left heel blister)" Review of the "INHOUSE" PRESSURE Wound Tracking Report revealed on April 6, 2011, resident #8 had a left heel blister as follows: "Presenting-Stage 2, Size (cm/centimeters)-0.7 x 2.1, Progress-New." Review of the Wound Tracking Report dated April 27, 2011, revealed the pressure ulcer remained a Stage 2 with the size in cms "0.6 x 0.4 with 0 depth." Medical record review of the Dietary Progress Notes of April 15, 2011, revealed the first entry by the registered dietician (RD), nine days after the left heel pressure ulcer was identified, as follows: "...April wt (weight) 164# (pounds). Usual wt ~ (approximately) 165-175# over past year...Eating 52% (percent) average per 7 day review...whole milk TID (three times a day)...house supplement TID...Needs an additional 15 gm (grams) protein/day...Increased nutrition needs to promote healing... " During interview, with the RD in the conference room on May 4, 2011, at 10:50 a.m., the RD stated, "(resident) was eating well by the time the pressure ulcer developed." Interview and observation on May 4, 2011, at 10:00 a.m., in the resident's room with the Wound Care Nurse, revealed the pressure ulcer was observed as the same size and stage as measured on April 27, 2011. During observation, the Wound Care Nurse verified the left foot of the resident was dry with flaking dead skin and confirmed the left heel ulcer had occurred due to pressure. Resident #23 was admitted to the facility on [DATE], and readmitted to the facility December 9, 2010, with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE] and March 18, 2011, revealed the resident had impaired memory, severely impaired cognition, was dependent on staff for activities of daily living, and had no pressure ulcers. Medical record review of the Nursing Admission Assessment Pressure Sore assessment dated [DATE], revealed "...Is resident at risk of developing pressure ulcer...Yes...Total Score for Skin Risk Part One: Lower score indicates higher risk...(resident scored 14)...13 to 14 = Moderate Risk...Pressure Sore Risk Assessment Part 2...Total Score for Pressure Ulcer Risk Assessment Part 2. 14. Review the scores for Part 1 and Part 2 of the Pressure Ulcer Risk Assessment. If the score for Part 1 is 14 or below or the score for Part 2 is 8 or above complete the Pressure Ulcer Prevention Check List and implement care plan for treatment or prevention..." Continued review of the Pressure Sore Assessment revealed it was marked as Pressure Ulcer Prevention Checklist being completed, but no checklist had been completed. Continued review of the Pressure Sore Risk assessment revealed the resident had severe [MEDICAL CONDITION] (swelling) and had at least three or more predisposing diseases for pressure ulcer development ([MEDICAL CONDITIONS], and Diabetes Mellitus). Medical record review of the Care Plan dated January 25, 2011, revealed the resident was identified as "Risk for skin breakdown, hx (history) blisters..." with interventions implemented to prevent pressure ulcers including "...Float Heels..." Medical record review of the physician progress notes [REDACTED]. Medical record review of the Wound Tracking Report revealed the resident was noted to have a blister to the left heel on April 12, 2011, noted as a stage 2 pressure ulcer, and treatment was implemented. Continued review of the Wound Tracking Report revealed April 20, 2011, the wound was a stage 2 pressure ulcer, 2.3 cm (centimeters) by 3.2 cm, described as a blister, and improving. Continued review of the Wound Tracking Report revealed April 27, 2011, the wound was a stage 2 pressure ulcer, 1.8 cm by 3.4 cm, described as a blister, and improving. Medical record review of the Departmental Notes revealed the following notes: "April 12, 2011, 4:40 AM...Change of Status. Left heel with new tx (treatment) orders noted and started - heels floated...April 13, 2011, 1:23 PM...Tx nurse continues care for left heel, shoes left off all times, heels floated in bed...April 27, 2011, 12:38 PM...Treatment continues to L (left) heel ulcer. Wound bed is approximately 20% black eschar (area of dead tissue), with the remaining wound bed granulating and clean. No odor is noted and small amount of yellowish drainage noted on removed bandage. +2 [MEDICAL CONDITION] noted in bed, pedal pulse difficult to feel but is present...will continue to float heels while in bed..." Interview with the Treatment Nurse and observation of the left heel on May 4, 2011, from 1:50 p.m., until 2:05 p.m., in the resident's room, revealed the wound first appeared as a blood-filled blister, measured 3.4 cm by 3.6 cm with an area of eschar approximately 2 cm by 2.5 cm, and the Treatment Nurse called the wound a Stage 2 pressure ulcer. Review of the facility's treatment of [REDACTED]. Therefore, you cannot stage pressure ulcers that are covered with necrotic tissue until the eschar is debrided and the base of the wound is visible (NPUAP (National Pressure Ulcer Advisory Panel), 2007). Until debridement can be done, document that the ulcer is unstageable..." Interview with the Treatment Nurse and observation of the resident on May 4, 2011, at 5:10 p.m., in the resident's room, confirmed the resident was in bed with the lower legs placed on top of one folded pillow, and both heels were pressing into the mattress. Continued observation and interview confirmed, when the blister appeared, the resident had been wearing approved diabetic shoes, which were now in the resident's closet and no longer worn by the resident. Continued observation and interview confirmed the treatment nurse obtained more pillows and utilized three pillows to float the resident's heels off the mattress. Medical record review and interview with the Treatment Nurse on May 4, 2011, at 4:50 p.m., 5:00 p.m., and 5:20 p.m., at the nursing station, and at 5:10 p.m., in the resident's room, confirmed the nurse had not documented when the blister had "burst." Further medical record review and interview confirmed the wound had inaccurately been described as a blister on the Wound Tracking Report April 20 and 27, 2011; the wound was inaccurately described as a Stage 2, when eschar was present; the Pressure Ulcer Prevention Checklist had not been completed on December 10, 2010, when the resident was identified as a high risk for development of pressure ulcers; and the resident's heels had not been floated off the mattress as required by the care plan and treatment interventions. .