Every finding on record at Jefferson Davis Community Hospital Ecf

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure food was stored in a manner that maintained freshness and quality and was properly labeled and dated in accordance with professional standards for food safety for one (1) of two (2) kitchen observations. Findings include:A review of the facility's policy, Storing: Food and Equipment, revealed, Team members must store food in a manner that ensures quality, freshness and safeguards against foodborne illnesses.Scope of Responsibility.All team members must follow food and temperature guidelines, labeling, use-by-dates, food storage chart, freezing and leftover guidelines to ensure food and equipment criteria are met.A record review of the Safe Training, dated 2/1/25, revealed, All Food must be properly labeled and dated.Ensure all food is labeled, including: Food stored in its original container, Food not stored in original container.When to Discard.by use-by-date indicated when storing or sooner if quality is an issue or by manufacturer's use-by-date.How Long to Keep.Food should be discarded or used by the use-by date. The use-by date is the last date the manufacturer recommends use of the food and may be referred to as an expiration date.Prepared Food Held more than 24 Hours. Food that has been prepared and will be held for more than 24 hours must be labeled and dated with the following: Name of the product (common name) Preparation date.On 4/20/26 at 10:36 AM, during an observation and interview with the Assistant Dietary Manager (DD) #2, upon opening refrigerator #3, an odor consistent with decaying cabbage was noted. Three (3) bags of shredded cabbage were observed and confirmed to be expired, including two (2) bags dated 4/5/26 and one (1) bag dated 3/15/26, which appeared deteriorated. During the same observation, six (6) sandwiches prepared for residents were observed in the reach-in cooler without labels or dates. During the interview, DD #2 reported it was the responsibility of all dietary staff to check and rotate dates and remove expired items. She stated the cabbage had been served the previous Thursday and confirmed the sandwiches were prepared that day but were not labeled or dated.On 4/22/26 at 2:55 PM, during an interview with Dietary Manager (DD) #1, accompanied by Assistant Dietary Manager (DD) #2, DD #1 reported her expectation was for all dietary staff to ensure food items were properly dated and labeled and to maintain compliance with food safety practices, including proper stock rotation and disposal of expired items. She reported managerial staff would begin monitoring dietary aides to ensure compliance with labeling, dating, and removal of expired food items.On 4/23/26 at 11:49 AM, during an interview with the Administrator, she was informed of the findings related to expired and undated food items. She reported her expectation was for the dietary department to ensure all food items were properly dated and labeled and that expired food items were discarded.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to privacy during medication administration for one (1) of five (5) residents reviewed for medication administration. Resident #5.Findings include:A review of the facility's policy, Resident Rights Guidelines for all Nursing Procedures, revised 10/2010, revealed, .To provide general guidelines for resident rights while caring for the resident. Preparation 1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including.b. Resident dignity and respect.On 4/21/26 at 11:01 AM, during an observation, Licensed Practical Nurse (LPN) #1 entered Resident #5's room to perform an accucheck and insulin administration. She gathered supplies, explained the procedure, and performed a finger stick to obtain a blood glucose level. The door remained open and the privacy curtain was not pulled during the entire procedure. Staff and other residents were observed passing in the hallway while care was being provided. LPN #1 administered (10) units of NovoLog insulin subcutaneously in the abdomen without providing privacy for the resident.On 4/21/26 at 11:28 AM, during an interview with LPN #1, she confirmed she did not close the door or pull the curtain during the accucheck and insulin administration. She reported she should have closed the door and pulled the curtain prior to providing care and acknowledged this was necessary to protect Resident #5's dignity.On 4/22/26 at 2:52 PM, during an interview with the Director of Nursing (DON), she reported LPN #1 should have provided privacy while completing the accucheck and administering the injection. She stated the expectation was for nursing staff to close the door and pull the curtain during care to maintain resident privacy.A record review of the admission Record revealed the facility admitted Resident #5 on 2/2/26 with diagnoses including Type 2 Diabetes Mellitus.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/10/26 revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated the resident's cognition was moderately impaired.A record review of the Order Summary Report revealed Resident #5 had a physician's order dated 2/2/26 for NovoLog insulin per sliding scale before meals and at bedtime.

Based on staff interview, record review, and facility policy review, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was completed accurately to reflect a diagnosis of Schizophrenia and the use of an antipsychotic medication for one (1) of (16) sampled reviewed. Resident #41.Findings include:A review of the facility's policy, admission Criteria, revised December 2016, revealed, Our facility will admit only those residents whose medical and nursing care needs can be met. Policy Interpretation and Implementation.8. Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with Medicaid Pre-admission Screening and Resident Review program (PASARR) to the extent practicable. 9. Potential residents with mental disorders or intellectual disabilities will only be admitted if the State mental health agency has determined (through the preadmission screening program) that the individual has a physical or mental condition that requires the level of services provided by the facility.A record review of the admission Record revealed the facility admitted Resident #41 on 9/19/23 with diagnoses including Schizophrenia.A record review of the Screening - Questionnaire Status: Submitted (Level I Screening) revealed Resident #41's Medications included Aripiprazole (antipsychotic medication). Further review revealed Disease Diagnoses did not include Schizophrenia and No was selected to indicate the resident was not taking an antipsychotic medication.A record review of the Comprehensive admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/25/23 (original MDS) revealed Resident #41 had a diagnosis of Schizophrenia.On 4/21/26 at 2:18 PM, during an interview with the Director of Nursing (DON), she reported Resident #41 did not have a PASRR Level II evaluation completed because it was not requested by the independent contractor. On 4/22/26 at 9:48 AM, during a follow-up interview with the DON, she reported Resident #41's PASRR was completed and submitted prior to her becoming the DON in 2024 and stated she was unaware the previous PASRR had been completed inaccurately, as it had not been brought to her attention.On 4/22/26 at 10:29 AM, during an interview with the Consultant, she reported she did not make determinations regarding PASRR Level II evaluations. She stated Resident #41 was admitted with a diagnosis of Schizophrenia and this diagnosis was documented on the initial Minimum Data Set (MDS) in 2023.On 4/23/26 at 11:53 AM, during an interview with the Administrator, she reported staff were currently receiving training on PASRR requirements and stated the expectation was for staff to accurately complete PASRR screenings.

Based on observation, interview, record review, and facility policy review, the facility failed to implement care plan interventions related to wound care for one (1) of 16 sampled residents. Resident #1.Findings include:A review of the facility's policy, Care Plans, Comprehensive Person-Centered, dated 12/2016, revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is.implemented for each resident.A record review of the Care Plan Report revealed Resident #1 had a Focus of Resident has actual skin breakdown. with an Interventions including, Cleanse Stage 4 pressure ulcer to left ankle with Vashe and pat dry. Apply A&D ointment to peri wound. Apply Aquacel AG to wound bed and cover with gauze and ABD pad. Wrap with conform daily and prn for soilage and dislodgement.A record review of the Order Summary Report revealed Resident #1 had a Physician's Order, dated 4/21/26 to Cleanse Stage 4 pressure ulcer to the left ankle with Vashe and pat dry. Apply A&D Ointment to per wound. Apply Aquacel AG to wound bed and cover with gauze and ABD pad. Wrap with conform daily and prn (as needed) for soilage and dislodgement.During an observation on 4/21/26 at 2:20 PM, Registered Nurse (RN) #1 provided wound care for Resident #1's Stage 4 pressure ulcer to the left ankle. RN #1 removed the soiled dressing, performed hand hygiene, cleansed the wound with Vashe, and applied A and D ointment to the peri-wound and Aquacel AG to the wound bed. RN #1 then covered the wound with an ABD pad and wrapped with conform. RN #1 did not apply gauze prior to applying the ABD pad per the resident's care plan intervention.During an interview on 4/21/26 at 2:46 PM, RN #1 confirmed she did not follow the physician's order or the care plan to apply gauze prior to the ABD pad. She reported the gauze was intended to help keep the wound dry and stated it was important for nurses to follow physician orders to prevent complications.During an interview on 4/22/26 at 2:58 PM, during an interview, the Director of Nursing (DON), reported care plans should be followed as written, and all staff should follow the care plan.During an interview on 04/22/26 at 3:08 PM, RN #2/Care Plan and Minimum Data Set (MDS) nurse stated the care plan is individualized for each resident and should be followed. She stated she expects staff to follow care plan while doing all care.A record review of the admission Record revealed the facility initially admitted Resident #1 on 5/23/25 and he had diagnoses including Pressure Ulcer of the left ankle, Stage 4.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/26/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of (13), which indicated the resident was cognitively intact. A review of Section M revealed he had a Stage 4 pressure ulcer.

Based on observation, interview, record review, and facility policy review, the facility failed to follow physician orders for treatment of a pressure ulcer for one (1) of (1) resident reviewed for wound care. Resident #1.Findings include:A review of the facility's policy, Wound Care, revised June 2018, revealed, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify that there is a physician's order for the procedure.Steps in the Procedure.8. Apply treatments as indicated.A record review of the Order Summary Report revealed Resident #1 had a Physician's Order, dated 4/21/26 to Cleanse Stage 4 pressure ulcer to the left ankle with Vashe and pat dry. Apply A&D Ointment to per wound. Apply Aquacel AG to wound bed and cover with gauze and ABD pad. Wrap with conform daily and prn (as needed) for soilage and dislodgement.On 4/21/26 at 2:20 PM, during an observation, Registered Nurse (RN) #1, assisted by a Certified Nurse Aide (CNA), provided wound care for Resident #1's Stage 4 pressure ulcer to the left ankle. RN #1 removed the soiled dressing, performed hand hygiene, cleansed the wound with Vashe, and applied A and D ointment to the peri-wound and Aquacel AG to the wound bed. RN #1 then covered the wound with an ABD pad and wrapped with conform. RN #1 did not apply gauze prior to applying the ABD pad as ordered.On 4/21/26 at 2:46 PM, during an interview with RN #1, she confirmed she did not follow the physician's order to apply gauze prior to the ABD pad. She reported the gauze was intended to help keep the wound dry and stated it was important for nurses to follow physician orders to prevent complications.On 4/22/26 at 2:58 PM, during an interview with the Director of Nursing (DON), she reported nurses were expected to follow physician orders as written, step by step, when providing wound care.A record review of the admission Record revealed the facility initially admitted Resident #1 on 5/23/25 and he had diagnoses including Pressure Ulcer of the left ankle, Stage 4.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/26/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of (13), which indicated the resident was cognitively intact. A review of Section M revealed he had a Stage 4 pressure ulcer.

Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to ensure food was stored, labeled, and dated in accordance with professional standards for food safety during an annual recertification survey on 11/21/2024 and was cited again for the same deficiencies during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of seven (7) deficiencies cited. F812Findings include: A review of the facility's policy, Quality Assurance and Performance Improvement (QAPI) Program, revised August 2017, revealed, .This facility shall implement, and maintain an ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals . A record review of the Provider History Report revealed on 11/21/24, the facility was cited F812-Food Procurement, Store/Prepare/Serve-Sanitary A record review of the CMS-2567 (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction), with a survey date of 11/21/24, revealed the facility received a citation for F812, .Based on observation, staff interview, and facility policy review, the facility failed to store food in accordance with professional standards for food safety related to expired foods, overly ripe produce, and scoops stored in dry bins touching food items for one (1) of two (2) kitchen observation.During the current recertification survey, the facility failed to ensure food was stored in a manner that maintained quality and freshness and was properly labeled and dated in accordance with professional standards for food safety for one (1) of two (2) kitchen observations.On 4/23/26 at 1:01 PM, during an interview with the Administrator, she reported it was important to maintain ongoing monitoring of plans of correction to ensure sustained compliance and prevent a decline in quality of care. She reported the dietary department was cited again due to a failure to maintain consistent monitoring of compliance with food safety practices.

Based on observation, interview, record review, and facility policy review, the facility failed to perform hand hygiene to prevent the potential spread of infection during medication administration for one (1) of five (5) residents reviewed for medication administration. Resident #4.Findings include:A review of the facility's policy, Infection Control Guidelines for All Nursing Procedures, revised April 2024, revealed, .To provide guidelines for general infection control while caring for residents .General Guidelines 1. Standard precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease. 5. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol based hand rub.for all the following situations.i. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident.On 4/21/26 at 1:14 PM, during an observation, Licensed Practical Nurse (LPN) #2 administered medication via Percutaneous Endoscopic Gastrostomy (PEG) tube to Resident #4. LPN #2 applied a gown and performed hand hygiene before applying gloves. She verified tube placement by aspiration and auscultation. She then removed her gloves, performed hand hygiene, and applied clean gloves. LPN #2 paused the feeding pump while wearing gloves and proceeded to administer medications via the PEG tube without removing the gloves and performing hand hygiene after contact with the feeding pump, which was in the immediate resident environment.On 4/21/26 at 2:05 PM, during an interview with LPN #2, she confirmed she did not remove gloves and perform hand hygiene after pausing the feeding pump and prior to administering medications. She reported this was an infection control concern and acknowledged residents could develop infections when infection control practices were not followed.On 4/22/26 at 2:55 PM, during an interview with the Director of Nursing (DON), she reported LPN #2 should have performed hand hygiene prior to administering medications via the PEG tube after touching the feeding pump. She stated failure to follow proper hand hygiene practices could result in infection and reported the expectation was for nursing staff to follow infection control guidelines at all times.On 4/23/26 at 9:28 AM, during an interview with Registered Nurse (RN) #3, Infection Preventionist (IP), she reported staff should remove gloves and perform hand hygiene when gloves become contaminated, not only when visibly soiled. She stated failure to perform hand hygiene could result in the spread of infection and negatively impact residents.A record review of the admission Record revealed the facility admitted Resident #4 on 2/3/26 with diagnoses including Cerebral Infarction.A record review of the Order Summary Report revealed Resident #4 had a physician's order dated 2/3/26 for nothing by mouth (NPO) and required all tube feedings and medications to be administered via Percutaneous Endoscopic Gastrostomy (PEG) tube.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/12/26 revealed Resident #4 required a staff assessment for cognition and had severely impaired cognitive skills for daily decision making.

Based on observation, staff interview, and facility policy review, the facility failed to store food in accordance with professional standards for food safety related to expired foods, overly ripe produce, and scoops stored in dry bins touching food items for one (1) of two (2) kitchen observations. Findings included: A review of the facility's policy titled Storing: Food and Equipment revealed, .Team members must store food in a manner that ensures quality, freshness, and safeguards against foodborne illness . Items to Label. Ensure all food items are labeled .How Long to Keep .Generally, food should be discarded or used by the use-by date. The use-by date is the last date the manufacturer recommends use of the food and also may be referred to as the expiration date .Containers .Cover, label, and date all leftovers . Store scoops in a covered area .not in food containers. A review of the facility's policy titled HACCP (Hazard Analysis and Critical Control Points) and Food Preparation Guidelines, revised ,d+[DATE], revealed, Fruits and Vegetables . Inspect for signs of spoilage, bruises, and damage . On [DATE] at 10:13 AM, during an observation with the Patient Service Manager (PSM) and the Food Services Director (FSD), in Refrigerator #1 there were three (3) aluminum pans with cut iced cake slices with no label or date, one (1) opened container of facility-made peanut butter with a prep date of [DATE] and a use-by date of [DATE], one (1) half bologna sandwich with no label or date, two (2) unopened packs of ham with a use-by date of [DATE], and one (1) unopened pack of bologna with a use-by date of [DATE]. In Refrigerator #2, there was one (1) opened container of cooked cauliflower with no label or date, thirty-three (33) bell peppers with soft spots and black and/or white biological growth, and seven (7) tomatoes with soft spots and biological growth. In Refrigerator #3, there was one (1) aluminum foil-wrapped food item identified as pork loin with no label or date, and one (1) opened pack of bologna with a faded and unidentifiable date. In the pantry, a scoop was inside the sugar bin, touching the sugar. On the spice rack, scoops were stored inside the containers and touching the food items in a 4-pound container of kosher salt, a 4-pound container of black pepper, and a 4-pound container of onion powder. On [DATE] at 11:30 AM, during an interview, the [NAME] stated that all kitchen staff are responsible for checking food for expiration and safety, and this monitoring should occur daily. The [NAME] confirmed that staff are in-serviced on food safety one (1) to two (2) times per month. On [DATE] at 11:44 AM, during an interview, the PSM acknowledged the scoops left in the dry bins, overly ripe produce, expired foods, and unlabeled food items observed. The PSM stated that all staff are responsible for checking the food for quality, labeling, and expiration dates. On [DATE] at 11:50 AM, during an interview, the FSD confirmed the findings, including overly ripe produce, scoops left in dry bins, and expired and unlabeled food. The FSD stated that it is everyone's responsibility to check foods for quality and expiration dates, which should take place daily. The FSD stated she conducts monthly in-services on food safety. On [DATE] at 9:45 AM, during an interview, the Administrator acknowledged the concerns observed in the kitchen. The Administrator confirmed that the FSD and PSM are responsible for monitoring food expiration dates and proper storage. He stated that going forward, he expects the kitchen to be in complete compliance.

Based on observation, interview, record review, and facility policy review, the facility failed to provide care and services consistent with professional standards of practice for a pressure ulcer for one (1) of two (2) pressure wound care observations. Resident #11. Findings Include: Review of the facility's procedure Wound Care, revised June 2018, revealed, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Steps in Procedure .7. Use no-touch technique . A record review of the Physician Orders for February 2023 revealed a treatment order with an order date of 1/20/23 for Resident #11 for Wound care for RT (Right) buttock: Cleanse wound w/(with) wound cleanser. Pack wound w/dry gauze. Cover w/5x5 foam border. Change daily or PRN (as needed) or soilage or dislodgement. DX (Diagnosis): Stage 4 Pressure Ulcer Rt Buttock. A treatment order with an order date of 1/26/23 also revealed, Wound care orders for RT buttock: for 9 o'clock (position of area as related to the face of a clock) tunneling (passageway of tissue destruction underneath the skin) of wound: cleanse w/wound cleanser. Pack with Opticell AG silver ribbon and dry gauze change on MWF (Monday, Wednesday, Friday) or prn for soilage or dislodgement. Cover w/5x5 foam border Dx: Stage 4 Pressure Ulcer RT Buttock. On 2/21/23 at 1:35 PM, during an observation of wound care of Resident #11 with Registered Nurse (RN) #1/Treatment Nurse, assisted by Certified Nurse Aide (CNA) #1, RN #1 cleaned the wound bed of the right buttock with wound cleanser. While RN #1 was washing her hands, CNA #1 assisted the resident to turn onto her back, which allowed the clean wound bed to come in contact with the incontinence pad that was soiled with drainage from the wound. Resident #11 was positioned back onto her left side and RN #1 placed a cotton tipped applicator into the wound bed, removed it and used measuring paper to measure the depth of the wound. She then took the same cotton tipped applicator and placed it back into the wound to measure the tunneling at 1 o'clock. RN #1 then removed the applicator from that area of the tunneling wound and held it up to the measuring paper to obtain the depth of the tunneling. RN #1 used the same cotton tipped applicator and placed it into the tunneling at 9 o'clock and held it up to the measuring paper to obtain the depth of the tunneling. On 12/22/23 at 10:26 AM, during an interview with RN #1, she stated that at her previous job, she did not have to stage or measure pressure wounds. She confirmed that during the wound care for Resident #11, she used the same cotton tipped applicator to measure the wound depth, and both wound tunneling and that this could have caused cross contamination of the wound. She said that she was nervous during the observation and did not know why she did not use a different cotton tipped applicator to measure each area of the wound because she had brought several applicators into the room for that very reason. She also verified that CNA #1 allowed the resident's cleaned wound to come in contact with the contaminated incontinence pad and that she did not clean the wound again, but proceeded with packing the wound. On 12/22/23 at 11:00 AM, in an interview with the Director of Nursing (DON) and the Infection Preventionist (IP), they both confirmed that CNA #1 should not have allowed the resident's cleaned wound to come in contact with the contaminated incontinence pad. They also confirmed that the wound care nurse should have used a different cotton tipped applicator when measuring the depth at each tunnel of the wound to avoid cross contamination of the wound. A record review of the facility's document, Wound care reviewed with (Proper Name of RN #1), dated 2/1/23 revealed there were no issues identified during RN #1's wound care technique when observed by management staff. The steps reviewed (1-20) did not address measuring or staging wounds. Record review of the Face Sheet revealed Resident #11 was admitted by the facility on 10/14/2022 and had diagnoses including Hypertension, Encephalopathy, and Senile Degeneration of Brain. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/19/23 revealed that Resident #11 had severely impaired cognitive skills.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure a licensed nurse had the specific competencies and skill set to stage pressure wounds for two (2) of two (2) residents reviewed for pressure wounds. Resident #11 and Resident #13. Findings Include: A review of the facility's policy, Competency of Nursing Staff, revised October 2017, revealed, Policy Statement .2. In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will: b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care .Policy Interpretation and Implementation 1. The staff development and training program is created by the nursing leadership .and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents 2. The following factors are considered in the creation of the competency-based staff development and training program .c. Specialized skills or training needed based on the resident population .4. Competency in skills and techniques necessary to care for residents' needs may include but is not limited to competencies in areas such as .h. Skin and wound care . A review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1 dated October 2019 revealed, .Definition Stage 2 Pressure Ulcer Partial thickness loss of dermis presenting as a shallow open ulcer .without slough . Review of the manual also revealed, .Once a deep tissue injury has opened to an ulcer, reclassify the ulcer into the appropriate stage . Resident #11 Record review of the Wound Assessment Report for Resident #11, dated 2/16/23, revealed Resident #11 had a Pressure Ulcer with the Wound Location of Left Buttock; Stage 2 pressure. The pressure ulcer was listed as a Stage 2 with measurements that indicated the length of the ulcer as 0.10 cm (centimeters), width of 0.20 cm, and depth of 8.30 cm. The wound bed was listed as having 10% slough (non-viable tissue) and the assessment was electronically signed by Registered Nurse (RN) #1 on 2/16/23. On 2/21/23 at 1:35 PM, the State Agency (SA) observed wound care for the left buttock pressure ulcer for Resident #11, with Registered Nurse (RN) #1. RN #1 measured the pressure ulcer depth as 6 cm, which is uncharacteristic of a shallow open ulcer. Record review of the Face Sheet revealed Resident #11 was admitted by the facility on 10/14/2022 and had diagnoses including Hypertension, Encephalopathy, and Senile Degeneration of Brain. Resident #13 Record review of the Wound Assessment Report for Resident #13, dated 2/16/23, revealed Resident #13 had a Pressure Ulcer with the Wound Location of Right Top of Foot: Right Lateral Foot. The pressure ulcer was listed as an Unstageable due to suspected deep tissue injury (DTI). Review of the Notes section revealed, Healing unstageable wound; new measurements are: approx. (approximately) 2.2 cm in length; 1.5 cm in width; 0.3 cm in depth. Wound bed is pink. The assessment was electronically signed by RN #1 on 2/16/23. On 2/22/23 at 10:07 AM, during an observation of wound care for Resident #13 with RN #1, she measured the wound as 1.3 cm length, 2.4 cm width, and 0.3 cm depth. The wound was opened, and muscle and granulated tissue were visible in the wound bed. The open wound was not characteristic of a deep tissue injury. A record review of the Face Sheet revealed Resident #13 was admitted by the facility on 5/21/20 and had diagnoses including Functional Quadriplegia and Contracture, Left Knee. On 12/22/23 at 10:26 AM, during an interview with RN #1, she stated that she previously worked in an acute care hospital for [AGE] years, in which she did not have the responsibility of staging pressure ulcers. She became employed at the facility at the end of September 2022 as the treatment nurse. Her job duties include performing treatments, conducting skin assessments, and completing weekly wound assessments for residents with pressure ulcers. The Infection Preventionist provided her training and worked with her during her orientation. She stated she had asked about possibly becoming wound care certified because she felt as though she would feel better and be more confident when staging wounds. She confirmed that she did not change the stage of the Stage 2 pressure ulcer for Resident #11 after it had progressed to include a depth of 9 cm. She stated the wound parameters were so small that she was unable to visibly assess the wound bed, so she left it staged as it was. She confirmed that she continued to classify the pressure injury for Resident #13 as an unstageable DTI even after it had opened up because she thought the nurse consultant had told her that she couldn't downstage the pressure injury. On 12/22/23 at 11:00 AM, in an interview with the Director of Nursing and the Infection Preventionist (IP), the DON stated that she had taken for granted that RN #1 would know how to stage wounds accurately. The DON and the IP acknowledged that wound care staging and assessments required a certain skill set and that RN #1's work history had been in an acute care setting in which there were specialized staff who were responsible for staging pressure wounds. The DON stated that there are so many nuances involved in staging pressure ulcers and cover a broad area. She confirmed that Resident #11's wound should have been staged as a Stage 4 as the wound progressed and became deeper and verified that a Stage 2 was not accurate. The DON stated that Resident #13's wound should have been reclassified once the wound became opened. She stated she would have classified his wound as a Stage 4. She confirmed that is it her responsibility to oversee the work of RN #1. A record review of the facility's document, Wound care reviewed with (Proper Name of RN #1), dated 2/1/23 revealed there were no issues identified during RN #1's wound care technique when observed by management staff. The steps reviewed (1-20) did not address measuring or staging wounds.

Based of observation, record review, staff interview, and facility policy review, the facility failed to provide a Percutaneous Endoscopic Gastrostomy (PEG) tube dressing change in a manner to prevent cross contamination for two (2) of two (2) resident PEG tube care sites observed, for Resident #23 and Resident #38. This was evidenced by allowing resident clothing to touch/cover the PEG site, after cleaning and prior to applying a dressing, during treatment for [REDACTED].#38. The facility also failed to provide wound care in a manner to prevent cross contamination for one (1) of four (4) resident wound care observations, Resident #31. This was evidenced by the RN touching items with ungloved hands prior to performing the treatment. Findings include: A review of the facility's policy titled, Infection Control Guidelines for all Nursing Procedures, with a revision date of (MONTH) (YEAR), revealed: Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease. A review of Perry and Potter Nursing Skills and Procedures, eighth edition, page 123, revealed: use of personal protective equipment reduces transmission of microorganisms. A review of facility policy titled, Policies and Practices-Infection control, dated (MONTH) (YEAR), revealed, The facility's infection control policies are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. A review of facility policy titled, Gastrostomy/Jejunostomy Site Care, dated (MONTH) (YEAR), revealed: The purpose of this procedure is to promote cleanliness and to protect the Gastrostomy or Jejunostomy site from irritation, breakdown and infection. Resident #31 On 9/18/19 at 9:48 AM, observation of wound care revealed RN #1 used her ungloved hands to place 10 dry 4 x 4 gauze dressings on a Styrofoam plate, sprayed the dressings with normal saline that she had gotten out of her treatment cart, then gloved and performed the wound care on Resident #31, using the 4 x 4 gauze. Resident #31's soiled dressing was observed to have a moderate amount serosanguious drainage. Resident #31's wound bed was pink with scattered red tissue. Resident #38 On 9/18/19 at 11:28 AM, an observation revealed, while RN #1 set up her supplies, she retrieved the 4 x 4 gauze dressings with her ungloved hands and placed them on a Styrofoam plate. She washed her hands, turned on the overbed light, and applied clean gloves, without washing her hands. She removed the soiled tube feeding dressing, washed her hands, applied clean gloves and performed the site care. On 9/18/19 at 11:48 AM, an interview with RN #1 revealed it was a habit for her to retrieve the 4 x 4 gauze with her bare hands and not use gloves. She also stated it made total common sense, that not wearing gloves while handling the 4 x 4 gauze dressings with bare hands, would cause cross contamination. On 9/18/19 at 11:50 AM, an interview with the Director of Nurses (DON) revealed RN #1 should have used gloves, because she had touched a lot of other things in her treatment cart. The DON stated not using gloves to handle the 4 x 4's could cause cross contamination. On 9/19/19 at 9:56 AM, an interview with RN #2 revealed that RN #1 should have used gloves and not her bare hands, while handling the 4 x 4 gauze dressings, to prevent hand to hand contact with the supplies. She also stated RN #1 could pass germs to the residents by using her bare hands to handle the 4 x 4 gauze dressings. Resident #23 An observation on 09/17/19 at 9:45 AM, revealed RN #1/Wound Care Nurse, entered Resident #23's room, washed and dried her hands, and then turned the faucet off with her clean hand. RN #1 left the room, pulled keys out of her pocket, and opened the wound care cart, then returned the keys to her pocket. RN #1 placed several gauze dressings onto a Styrofoam plate, using her bare hands, then opened the drawer of the wound cart, took out a spray bottle of wound cleanser, wet the gauze, and returned the cleanser to the drawer. RN #1 sanitized her hands, gloved, grabbed the side of Resident #23's geri-chair, and pushed the chair to the side, so she could get to the Resident's stoma. RN #1 pulled up Resident #23's shirt, removed the soiled dressing, and cleaned and dried the resident's stoma. RN #1 pulled the resident's shirt over the stoma between intervals, allowing the shirt to touch the dirty and clean stoma. With gloves on, RN #1 pulled Resident #23's shirt down after applying a new dressing, then, picked up Resident #23's baby doll and handed it to the resident, prior to removing her gloves and washing her hands. An interview on 09/18/19 at 11:50 AM, with RN #1 revealed, I do remember reaching in and getting the gauze with my ungloved hands. It is an infection control issue. RN #1 stated she remembered pulling the shirt back down over the cleaned wound, and stated I mean, what's the point of cleaning the wound if your going to put the shirt back on it. It was contaminated and should have been re-cleaned after the shirt touched it, and before putting a clean dressing on it. I know you probably seen me move the chair with my gloves on, but I don't remember it. I probably did it self-consciously. The wound definitely should have been re-cleaned, prior to putting a clean dressing on. An interview on 09/18/19 at 12:06 PM, with the Director of Nursing (DON), revealed the nurse should not have gotten the gauze with her bare hands, because of cross contamination. The DON stated, If she pulled the shirt back over the wound after cleaning it, and before applying a clean dressing, it was cross contamination also. An interview on 09/19/19 at 9:45 AM, with RN #2, revealed she would possibly consider it an infection control issue with the nurse pulling the shirt back over a cleaned stoma, before applying a clean dressing. She stated she would also consider it a possible infection control issue with the nurse picking up the 4 x 4 gauze with her ungloved hands and placing it onto the plate. She stated, You need a barrier between the clean gauze and your hands. You wouldn't want hand to hand contact with something you're going to use on a resident. You could pass germs to a resident. Record review of a facility document titled, JD-ECF treatment check log Nurse Check off, dated 3/16/16, revealed RN #1 received training in Any cross contamination with treatment.

Based on record review, staff interview, and facility policy review, the facility failed to provide written documentation to the resident and/or resident's representative, of the reason for transfer/discharge to the hospital, for six (6) of six (6) hospitalization s reviewed out of 18 residents sampled, Residents #3, #21, #23, #28, #30, and #36. Findings include: A review of the facility's policy titled, Bed-Holds and Returns, with a revision date of (MONTH) (YEAR), revealed: Prior to a transfer, written information will be given to the residents and the resident representatives that explains the details of the transfer. Resident #36 Record review of the physician orders, dated 9/4/19, revealed an order to send Resident #36 to a local Behavior Hospital. The Nurse Progress Note, dated 9/4/19, indicated Resident #36 was observed walking up and down the hallway yelling and cursing staff, and when staff was trying to get the resident back to her room, the resident refused to put clothing on and refused to take medications as well. There was no documented evidence that a written notice was provided to the resident/resident representative regarding information of Resident #36's transfer to the hospital on [DATE]. On 9/17/19 at 1:45 PM, an interview with the Director of Nurses (DON) revealed the facility had not been notifying the resident or the Resident Representatives, in writing, of the reason for transfer to the hospital. On 9/17/19 at 2:07 PM, an interview with Resident #36's Resident Representative revealed no written notice of the reason for transfer to the behavior facility was provided. Resident #3 Record review of physician's orders [REDACTED].#3 was transferred from the facility to the hospital for evaluations. Review of Resident #3's medical record revealed no documentation of a transfer letter to the Resident Representative regarding Resident #3's transfers from the facility to the hospital, prior, during, or shortly after the transfers. The facility failed to provide proof of a written transfer letter mailed to Resident #3's Resident Representative (RR). An interview on 09/17/19 at 11:45 AM, with the Business Office Director (BOD) revealed, We have no documentation that we mailed the Resident Representative written notice of the hospital transfer on any of the days. An interview on 09/17/19 at 11:55 AM, with the DON revealed, The process is that the hospital written transfer sheet should be mailed out the next day after a Resident is transferred out of the facility. It should be mailed by the Social Service Department. An interview on 09/17/19 at 12:00 PM, with the Social Service Director (SSD), confirmed that she did not know of any transfer/bed hold letter that the facility mailed to the Resident Representative when the resident was transferred to the hospital. An interview on 09/17/19 at 1:25 PM, with the DON, revealed the facility did not have a transfer/bed hold sheet for Resident #3 for transfers to the hospital. The DON stated, We don't have any written transfer/bed hold letters that were mailed to the Resident Representative. We don't have proof we mailed anything. Res #23 Review of a physician's orders [REDACTED].#23 was transferred from the facility to the hospital. Review of Resident #23's medical record revealed no written transfer letter to the Resident Representative regarding Resident #23's transfer from the facility. The facility failed to provide proof of a written transfer letter mailed to Resident #23's Resident Representative. Res #30 Review of a physician's orders [REDACTED].#30 was transferred from the facility to the hospital. Review of Resident #30's medical record revealed no written transfer letter to the Resident Representative regarding Resident #30's transfer out of the facility. The facility failed to provide proof of a written transfer letter mailed to Resident #30's Resident Representative. Resident #21 Review of Resident #21's medical record revealed the resident was transferred to the hospital on [DATE], and returned to facility on 5/31/2019, for observation of Pneumonia. Review of Resident #21's medical record revealed no documented evidence of a written transfer notice to the Resident and/or Resident Representative for the 5/27/19 transfer to the hospital. During an interview on 09/17/19 at 1:37 PM, the DON confirmed the facility did not notify the Responsible Party of Resident #2, in writing, for transfer to hospital on [DATE]. Resident #28 Record review revealed Resident #28 was transferred to the hospital on [DATE], and returned on 9/7/2019, for [DIAGNOSES REDACTED]. Review of Resident #28's medical record revealed no documented evidence of a written notice of transfer to the Resident and/or Resident Representative. On 09/18/19 at 3:03 PM, interview with the DON revealed a written notice of transfer was not provided to the Resident Representative regarding the transfer to the hospital on [DATE].

Based on record review, staff interview, and facility policy review, the facility failed to convey to the receiving provider, the basis for the transfer from the facility for one (1) of six (6) residents with hospital transfers, Resident #3 Findings Include: Review of a statement on facility letterhead, dated 9/19/19, and signed by the Director of Nursing (DON) revealed,We do not have a policy and procedure that specifically addresses the information that is sent out with the resident to the hospital at time of discharge/transfer. Review of a document, provided by the facility, and signed by the DON, dated 9/19/19, revealed Sending residents to the ER- Transfer/discharge sheet once you fill it out in the computer (print). Record review of physician's orders [REDACTED].#3 was transferred from the facility to the hospital for evaluations. Record review of Resident #3's paper and computer chart revealed no documentation that a transfer summary containing Resident #3's medical status/ Resident Representative Contact information was sent to the receiving facility when Resident #3 was transferred to the hospital three (3) times. An interview on 09/17/19 at 1:25 PM, with the Director of Nursing (DON), revealed, We do not have a transfer summary that was sent to the hospital for Resident #3. We are supposed to send a transfer summary including the reason for transfer to the hospital, Medication Administration Record, [REDACTED].

Based on record review, staff interview, and facility policy review, the facility failed to notify the resident and/or resident representative of the facility policy for bed hold, for two (2) of six (6) hospitalization s reviewed, Resident #23, and Resident #30. Findings Include: A review of facility policy titled Bed-Holds and Returns, dated (MONTH) (YEAR), revealed Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. Resident #23 Record review of a physician's orders [REDACTED].#23 was transferred from the facility to the hospital. Record review of Resident #23's medical record revealed no evidence of a bed hold letter delivered to Resident #23 or the Resident Representative. The facility failed to provide evidence of a documented bed hold letter for Resident #23. Res #30 Record review of a physician's orders [REDACTED].#30 was transferred from the facility to the hospital. Record review of Resident #30's medical record revealed no documented evidence of a bed hold letter delivered to Resident #30 or the Resident Representative. The facility failed to provide evidence of a bed hold letter for Resident #30. An interview on 09/17/19 at 12:00 PM, with the Social Service Director, regarding Resident #23 and Resident #30's transfers, revealed that she did not know of any transfer/bed hold letter that the facility mailed to the Resident Representative when the resident was transferred to the hospital. An interview on 09/17/19 at 1:25 PM, with the Director of Nursing (DON), regarding Resident #23 and Resident #30's transfers, revealed there was no documented transfer/bed hold sheet for the residents for when they went out of the facility to the hospital. The DON stated, We don't have any written transfer/bed hold letters that were given to the resident or mailed to the Resident Representative. We don't have proof we mailed anything.

Based on record review, staff interview, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) for one (1) of 18 MDS assessments reviewed, Resident #21. Findings include: Review of a facility statement, regarding the Resident Assessment Instrument (RAI) Policy: A comprehensive assessment of a resident's needs shall be made within 14 days of the resident's admission. According to the M0210: RAI Version 3.0 Manual, If a resident had a pressure ulcer/injury that healed during the look-back period of the current assessment, do no code the ulcer/injury on the assessment. Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/02/2019, Section M revealed documentation that Resident #21 had a Stage 2 Pressure Ulcer. Record review of the Physician's Progress note, revealed documentation that the Pressure Ulcer for Resident #21 was Healed on 6/20/19. Record Review of the Wound/Skin Management Documentation Record, revealed on 06/24/2019, the wound for Resident #21 was intact. On 09/17/19 at 11:24 AM, an interview with Director of Nursing (DON) revealed Resident #21 had no Pressure Ulcer. During an interview on 09/17/19 at 11:25 AM, Register Nurse #1 confirmed Resident #21's physician documented that #21's Stage 2 ulcer was healed on 6/20/19. On 09/17/19 at 3:30 PM, observation of Resident #21 revealed no pressure ulcers. On 09/18/19 at 09:08 AM, an interview with Licensed Practical Nurse #1/MDS Coordinator, and the Director of Nursing, revealed the Stage 2 wound for Resident #21 healed on 6/20/2019, and the MDS was inaccurately coded. Licensed Practical Nurse #1, stated, I did not observe the wound. On 09/18/19 at 10:56 AM, an interview with Resident #21's Physician revealed Resident #21's wound had healed on 6/20/2019, and orders should have been written to discontinue the treatment.

Based on record review, facility policy review, and staff interview, the facility failed to revise the Comprehensive Care Plan to reflect a soft wrist splint and interventions, for Resident #3 and the use of an indwelling catheter for Resident #38, for two (2) of 18 care plans reviewed. Findings Include: A review of facility policy titled, Care Plans-Comprehensive, (no date) revealed, Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The Care-Planning interdisciplinary team is responsible for the review and updating of care plans. Resident #3 Record review of the Working Care Plan on the chart, and the most current care plan, initiated 12/12/18, through the review date of 9/30/19, revealed Resident #3's care plan was not revised to include a soft wrist splint and/or interventions related to the splint. Review of an incident report timeline, provided by the facility, revealed Resident #3 had a right wrist splint placed, per Primary Care Provider, on 8/13/19, for a non-displaced distal radial fracture. An observation on 09/16/19 at 8:53 AM, revealed a soft wrist splint noted on Resident #3's right wrist. During an interview on 09/18/19 at 11:07 AM, the Director of Nursing (DON) stated, after reviewing the current care plan and the working care plan on the chart, The right wrist splint interventions are not on the Resident's current care plan or on the working care plan in the chart. An interview on 09/18/19 at 11:20 AM, with LPN #1 MDS/Care Plan Nurse, revealed the soft wrist splint and interventions were not care planned, and they should have been. LPN #1 stated, The nurse who checks the orders when a resident returns from an appointment, is responsible to write the order and care plan the order if needed. An interview on 09/18/19 at 1:37 PM, with the DON, revealed, It is the RN Supervisor or the LPN's responsibility to check a resident back in after an appointment and they are supposed to write any orders that return with the resident. Then, whoever writes the order, is supposed do to create or update the care plan specific to the order. Resident #38 Review of Resident #38's comprehensive care plan, with a target date of 11/30/19, revealed a care plan related to the resident's incontinence, however, there was no care plan for an indwelling urinary catheter. On 9/17/19 at 9:19 AM, an observation revealed Certified Nursing Assistant (CNA) #1, assisted by CNA #2, performed catheter care for Resident #38. The resident was observed to have an indwelling urinary catheter. On 9/17/19 at 11:00 AM, an interview with the Director of Nurses (DON) revealed there was no physician's order or care plan for the indwelling urinary catheter for Resident #38. On 9/17/19 at 11:10 AM, an interview with Licensed Practical Nurse (LPN) #1 revealed a care plan had not been developed for the resident's indwelling urinary catheter. She also stated the current care plan did not reflect the resident's current status regarding the indwelling urinary catheter. During an interview on 09/18/19 at 8:54 AM, Registered Nurse (RN) #3 revealed Resident #38 returned from the hospital (8/19/19) with the catheter and had not had any complications from the urinary catheter.

Based on observation, record review, staff interview and facility policy review, the facility failed to ensure accuracy of the medical record, related to a soft wrist splint and an indwelling urinary catheter, for two (2) of 18 resident medical records reviewed, Resident #3 and Resident #38. Findings include: A review of the facility's policy titled Medication Orders with a revision date of (MONTH) 2014, revealed a current list of orders must be maintained in the clinical record of each resident. A review of the facility's documented statement, signed by the Director of Nursing (DON), not dated, revealed the facility does not have a policy and procedure that specifically addresses the input of orders after a hospital return. Resident #38 A record review of the physician's orders for (MONTH) 2019, revealed there was no order for Resident #38's indwelling urinary catheter. The most recent Discharge-Return Anticipated Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/27/19, was coded to include an indwelling urinary catheter. The resident had a catheter for entire seven (7) day look-back period. On 9/17/19 at 9:15 AM, an observation revealed Resident #38 lying in bed with his eyes open. Resident #38 was observed with an indwelling urinary catheter. On 9/17/19 at 11:00 AM, an interview, with the Director of Nurses (DON), confirmed the medical record was inaccurate related to no physician's order for the indwelling urinary catheter for Resident #38. She also stated the physician orders did not reflect the resident's current status regarding the indwelling urinary catheter. The DON stated Resident #38 had the catheter upon his hospital return (8/19/19). On 9/18/19 at 8:54 AM, an interview, with Registered Nurse (RN) #3, revealed the resident returned from the hospital with the catheter, had poor kidney function, and is unable to urinate on his own. She also stated she would have to look at the chart to make sure of the diagnoses. She stated the resident had not had any complications from the urinary catheter that she is aware of. Resident #3 Review of Physician orders for (MONTH) 2019, revealed no Physician's order for a soft wrist splint to Resident #3's right wrist on 8/13/19. Review of an incident report timeline, provided by the facility, documented on 8/13/19, revealed Resident #3 received a right soft wrist splint, placed per Primary Care Provider, due to a nondisplaced distal radial fracture. An observation on 09/16/19 at 8:53 AM, revealed a soft wrist splint noted on Resident #3's right wrist. An interview on 09/18/19 at 11:00 AM, with the facility Medical Director, revealed he applied the soft splint to Resident #3's wrist in the emergency roiagnom on [DATE]. An interview on 09/18/19 at 11:07 AM, with the Director of Nursing (DON), revealed there should have been an order written [REDACTED]. The DON confirmed the medical record was inaccurate because there was no order written for the wrist splint. An interview on 09/18/19 at 1:37 PM, with the DON, revealed the RN Supervisor or the LPN who checks a resident back in after an appointment are supposed to write any orders that return with the resident. She stated whoever writes the order, is supposed to create or update the care plan, specific to the order. The DON confirmed there was no Physician's order written for Resident #3's splint, nor a care plan updated with written interventions for the soft right wrist splint.

Based on record review, facility policy review, and staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for falls for one (1) of 12 Resident MDS assessments reviewed, Resident #25 Findings Include: Review of the policy documentation on facility letterhead, provided by the facility, dated 10/31/2018, no signature, revealed the facility followed the Resident Assessment Instrument (RAI) for Minimum Data Set (MDS) coding. Review of Resident #25's Quarterly MDS with an Assessment Reference Date (ARD) of 09/27/2018, revealed Section J1800 coded that no falls, with or without injury, had occurred. Resident #25 had a prior MDS assessment, with an ARD of 07/03/2018, where no falls were coded. Review of a Resident Incident Report, dated 08/17/2018, signed by the Administrator, revealed Resident #25 had a fall with head injury on 08/16/2018. Review of Departmental Notes, dated 08/16/2018 at 1:14 PM, revealed that Resident #25 fell when attempting to go to the bathroom unassisted. During an interview with the Director of Nursing (DON), on 10/30/2018 at 02:15 PM, the DON confirmed that Resident #25 had a fall with head injury on 08/16/2018. An interview with Licensed Practical Nurse (LPN) #1/MDS Coordinator, on 10/31/2018 at 10:40 AM, confirmed that Resident #25's MDS Assessment on 09/27/2018 had been miscoded relating to Resident #25's fall on 08/16/2018. LPN #1 stated that there was nursing documentation on Resident #25's fall with a major injury after the 07/27/2018 MDS assessment and before the 09/27/2018 MDS assessment. LPN #1 stated she agreed that Section J1800 of the 09/27/2018 MDS assessment should have been coded Yes indicating Resident #25 indeed had a fall on 08/16/2018. During an interview on 10/31/2018 at 11:08 AM, the Director of Nursing (DON) confirmed that Resident #25's 09/27/2018 MDS assessment had been miscoded, because of Resident #25's fall on 08/16/2018.

Based on record review and staff interview, the facility failed to refer a resident to the appropriate state designated authority for level 2 Pre-Admission Screening Resident Review (PASSR) evaluation and determination for one (1) of three (3) residents reviewed for PASSR, Resident # 4 Findings Include: A record review of the resident's physician's orders [REDACTED]. Resident #4 was not taking [MEDICAL CONDITION] medication upon admission. During an Interview on 10/31/2108 at 10:50 AM, Licensed Practical Nurse (LPN) #1 stated that she's responsible for the PASSR. LPN #1 stated that all newly diagnosed residents with mental or intellectual disorders should be sent to the appropriate agency (Agency Named) to decide whether a level 2 should be done, however, she was unable to get to it at this time. She stated she will take care of the PASSR for Resident #4 as soon as possible (ASAP). LPN #1 stated that the facility does not have a policy on PASSRs, but it is part of her job duty to make sure they are done correctly and timely. A review of the facility's face sheet revealed the facility admitted Resident #4 on 08/24/2017, with [DIAGNOSES REDACTED].

Based on observation, record review, facility policy review, and staff interview, the facility failed to develop a comprehensive care plan to include interventions of a catheter securing device to prevent tension and trauma; and failed to implement the care plan of providing catheter care in a manner to help prevent infection for one (1) of four (4) care plans reviewed, Resident #30. Findings include: Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised (MONTH) (YEAR), revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of the facility policy, Perineal Care, revised (MONTH) 2010, revealed that the facility policy, if a resident had a catheter, was to gently wash the juncture of the tubing from the Urethra down the catheter about three (3) inches. The facility policy also noted that the catheter tubing should be held to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. Review of the facility policy, Catheter Care, Urinary, revised (MONTH) 2014, revealed the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. The policy also included documentation to ensure that the catheter remains secure with a leg strap to reduce friction aandmovement at the insertion site. Record review revealed Resident #30's care plan, with an on-set date of 10/8/18, revealed a potential for complications related to an indwelling urinary catheter. Interventions included to keep the catheter and drainage bag lower than the bladder at all times and to provide catheter care with soap and water every shift. The care plan did not address the use of a securing device (leg strap). Review of Resident #30's face sheet revealed that she was admitted on [DATE], with a [DIAGNOSES REDACTED]. Observation on 10/31/18 at 10:36 AM, revealed Certified Nursing Assistant (CNA) #1 provided catheter care for Resident #30, along with assistance of CNA #2. Both CNA's were observed to wash hands prior to providing catheter care. Observation revealed there was no leg band to secure the catheter tubing to prevent the catheter from pulling at the Urethra. CNA #2 held the catheter bag above the Resident's bladder and was holding the catheter at the junction of where it meets the bag tubing, instead of securing it at the Urethra. Then, CNA #1 wiped toward the Urethra, instead of away from it. On 10/31/18 at 12:00 PM, interview with CNA#1 revealed that she knew that she wiped incorrectly when she cleaned Resident #30's Foley catheter. The CNA reported she was not sure about a catheter strap, today was her first day to take care of the resident. On 10/31/18 at 12:34 PM, interview with CNA #2 revealed Resident #30 had a leg strap on the day prior. The CNA reported that the resident should have a catheter strap on at all times to help prevent trauma from pulling. The CNA reported that she knew to hold the catheter at the closest point to the Urethra as possible and that CNA #1 should have wiped away from the Urethra, instead of toward it, while providing catheter care. On 10/31/18 at 11:27 AM, interview with the Director of Nursing (DON) revealed that she expected the resident to have a leg strap to secure the catheter. The DON stated that she expected the CNA to wipe the resident from front to back when providing perineal/catheter care and for staff to clean the catheter by wiping away from the Urethra. The DON reported that she expected the CNA to follow the care plan, which included providing care per the policy. Review of the staff education training, dated (MONTH) (YEAR), on incontinent catheter and peri- care, revealed that staff was trained on assuring that the catheter must be below the bladder at all times to prevent urine from flowing back into the bladder. The training also revealed that the catheter should have a secure leg band on and the catheter should be cleaned from the insertion site to approximately four (4) inches outward.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure the Medical Director/physician attended quarterly Quality Assurance (QA) meetings, and failed to identify, develop, implement, and continue a plan of action to correct quality deficiencies related to assessment, and prevention of pressure ulcers and/or worsening pressure ulcers for eight (8) of nine (9) sampled residents, and three (3) of three (3) un-sampled residents. Residents #1, #2, #3, #4, #5, #6, #7, #9, and Un-sampled Residents A, B, and C. The facility's failure to implement, and continue the Plan of Correction (POC) with a completion date of [DATE], for providing accurate weekly skin assessments, providing a Certifed Wound Care Nurse for supervison/oversight of the wound care staff, and providing air mattresses for residents at high risk for pressure ulcers and the failure to have the Medical Director attend quarterly QA meetings placed these residents, and other residents at risk for significant harm, inury, impairment or death. A complaint investigation, with a partially extended survey, was conducted from [DATE] to [DATE]. During the investigation the facility was found not to be in compliance with the Requirements for Participation in Medicare and Medicaid. A partially extended survey was conducted on [DATE] to [DATE]. It was determined that an Immediate Jeopardy was identified on [DATE] at 10:45 AM, and the Administrator, Director of Nursing (DON), and Nurse Consultant (NC) was notified at that time. The Immediate Jeopardy began on [DATE] as a result of Resident #6 being admitted from the facility to the hospital with infections and worsened Pressure Ulcers. The facility submitted an Allegation of Compliance (AOC) at [DATE] at 4:05 PM, which was determined not acceptable. The Immediate Jeopardy was not removed upon exit from the facility on [DATE] at 5:30 PM, and is considered ongoing. Findings Include: A review of the facility policy titled, Medical Director, undated, revealed the Medical Director was responsible for, Overseeing and helping develop, and implement care-related policies and practices. Other functions of the Medical Director included helping to assure that residents received adequate services appropriate to meet their needs, and participating in staff meetings concerning quality assurance, and resident care policies. Review of the facility's Plan of Correction (POC), with a completion date of [DATE], from the previous survey of [DATE], revealed corrective actions for prevention and treatment of [REDACTED]. 2) The Wound Care Nurse will conduct weekly body audits on all residents. 3) A Certified Wound Care Nurse will be available to consult with the Wound Care Nurse on an ongoing basis. The facility Administrator acknowleged the POC's corrective actions were implemented, and ongoing implementation as evidenced by a signature dated [DATE], on the POC. A review of the Facility Policy entitled, Quality Assessment and Assurance Committee, undated, revealed: This facility shall establish and maintain a Quality Assessment and Assurance Committee that oversees the identification and handling of quality issues . Goals of the Committee included: to monitor and evaluate the appropriateness and quality of care provided within the framework of the Quality Assessment and Assurance Plan; to oversee facility systems and processes related to improving quality of care and services; to help identify negative outcomes relative to resident care and resolve them appropriately; to coordinate the development, implementation, monitoring, and evaluation of action plans to achieve specified quality goals; and to help departments, consultants, and ancillary services establish effective accountability for care quality. Resident #6 In an interview with Resident #6's Responsible Party (RP) on [DATE] at 1:16 PM revealed that the physician told him Resident #6 was admitted to the hospital ([DATE]) with a bad kidney infection and infection in her blood caused by the infection in her bedsores. The RP stated the physician discussed amputation of Residents feet. The RP stated as a result of infections and worsened pressure sores, Resident #6 never returned to the facility and expired in the hospital on [DATE]. Review of the Comprehensive Admission Skin Assessment sheet dated [DATE], [DATE], [DATE] and [DATE] reveals worsening of the wounds for Resident #6 and incomplete documentation to include the type, color, odor and type of the drainage, correct location, the staging of the wounds. There was no documentations that Resident #6's wounds were avoidable or unavoidable. In a review of the hospital's History and Physical, it revealed Resident #6 was admitted on [DATE] decreased level of consciousness as the cheif complaint. The Admission [DIAGNOSES REDACTED]. Resident #6's White Blood Count (WBC) was 37.6 (37,600)(normal levels are 4,500 to 10,000) which indicates a severe infection. Resident #6 was noted to have multiple sacral decubiti as well as areas of skin breakdown to the lower extremities, and ankles bilaterally. Resident #6 was treated with Intravenous (IV) fluids and IV antibiotics. In the review of laboratory results for Resident #6 revealed a wound culture dated [DATE] with infectious organisms. A urine culture dated [DATE] revealed Resident #6 had a Urinary Tract Infection [MEDICAL CONDITION]. A blood culture result for Resident #6, dated [DATE], revealed infection in the blood. The Discharge Summary, dated [DATE], revealed the [DIAGNOSES REDACTED]. The Hospital Course documented Resident #6 was transferred to the hospital with decreased level of consciousness. Resident #6 was found to [MEDICAL CONDITION], severe [MEDICAL CONDITION], and severely infected Decubitus Ulcers. Resident #6 was admitted to the hospital and started on antibiotics. Resident #6 had Stage IV Decubitus Ulcers on her heels with tendons exposed on both feet. The surgery consult revealed that they did not think the wounds would get better with conservative management and recommeded amputation of both the legs. Resident #6's family decided to not amputate her legs and admitted her to Hospice for comfort measures. Review of the Hospitalist Discharge Summary dated [DATE] revealed Resident #6 was discharged to inpatient Hospice on [DATE]. Discharge [DIAGNOSES REDACTED]. Resident #6's symptoms did not improve with treatments and remained confused and unresponsive throughout most of her hospitalization . Resident #6 was transferred to Hospice for comfort measures. ( In an interview with Resident #6's RP on [DATE] at 1:16 PM revealed Resident #6 expired on [DATE] in the hospital and the resident never returned to the facility.) The facility admitted Resident #6 to the facility on [DATE], with [DIAGNOSES REDACTED]. The Annual MDS with the ARD of [DATE] revealed Resident #6 had a BIMS score of zero (0) that indicated Resident #6 was severely cognitively impaired. The Plan of Correction (POC) dated [DATE], revealed the facility failed to conduct a weekly body audit to include the staging, size and characteristics of the multiple wound for Resident #6. The facility's Quality Assurance Committee's failure to monitor and assess per the POC, resulted in the development of severe infections and worsening of the Pressure Ulcers for Resident #6 and placed other residents at risk. Resident #1 The facility failed to reveal all characteristics of the pressure ulcer such as the stage, the location and /or the type of wound or accuracy of the assessment for Resident #1. The Wound Care Nurse (WCN) on [DATE] at 1:50 PM failed to provide care in a manner to promote healing and prevent the development of infection by failure to apply Collagen with a tongue blade, 4X4 gauze, or other non contaminated item for Resident #1. A review of Resident #1's face sheet revealed the facility admitted Resident #1 on [DATE]. A review of Resident #l's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #1 had a [DIAGNOSES REDACTED]. In a review of this assessment revealed Resident #1 was at risk for developing pressure ulcers and had no pressure ulcers at that time. Resident #1 scored three (3) of 15 on the Brief Interview of Mental Status (BIMS) that indicated Resident #1 was severely cognitively impaired. Resident #2 The facility failed to reveal all characteristics of the pressure ulcer such as the size and stage, the location and /or the type of wound or accuracy of the assessment for Resident #2. During a wound care observation on [DATE] at 2:52 PM the WCN cross-contaminated two (2) open blisters to the wound located on the upper left thigh area and wiped from top to bottom of the wound instead of a circular motion from the center outward and therefore failed to provide care in a manner to promote healing and prevent the development of infection. A review of Resident #2's face sheet revealed the facility admitted Resident #2 on [DATE]. A review of Resident #2's Quarterly MDS with an Assessment Reference Date (ARD) of [DATE] revealed Resident #2 [DIAGNOSES REDACTED]. This assessment revealed Resident #2 was at risk for the development of pressure ulcers and had no pressure ulcers. Resident #2 scored three (3) on BIMS that indicated Resident #2 was severely cognitively impaired. Resident #3 The facility failed to reveal all characteristics of the pressure ulcer such as the size and stage, the location and /or the type of wound or accuracy of the assessment dated [DATE] and [DATE] for Resident #3's. The facility had identified Resident #3 as high risk for Pressure Ulcers but had not placed Resident #3 on an air mattress. The facility failed to reveal all characteristics of the pressure ulcer such as the stage, the location and /or the type of wound or accuracy of the assessment for Resident #4. In a review of Resident #3's face sheet revealed the facility admitted Resident #3 on [DATE]. A review Resident #3's Quarterly MDS with an ARD of [DATE] revealed Resident #3 had the [DIAGNOSES REDACTED]. This assessment revealed Resident #3 was at risk for developing pressure ulcers and had no pressure ulcers. Resident #3 scored three (3) on the BIMS that indicated Resident #3 was severely cognitively impaired. Resident #4 The facility failed to reveal all characteristics of the pressure ulcer on the skin assessment forms dated [DATE] and [DATE], such as the size and stage, the location and /or the type of wound or accuracy of the assessment. In the Wound Care Observation on [DATE] at 11:05 AM, the WCN failed to clean each open area to the Coccyx separately and did not pat the wound dry. The review of Resident #4's face sheet revealed the facility admitted Resident #4 on [DATE]. A review of Resident #4's Significant Change MDS with an ARD of [DATE] revealed the [DIAGNOSES REDACTED]. This assessment revealed Resident # 4 was at risk of developing pressure ulcers and had a Stage 1 or higher pressure ulcer. The BIMS indicated Resident #4 had a score of zero (0), that indicated Resident #4 was severely cognitively impaired. Resident #5 The facility failed to reveal all characteristics of the pressure ulcer such as the size and stage, the location and /or the type of wound or accuracy of the skin assessments on [DATE], [DATE] and [DATE] for Resident #5. The Wound Care Nurse (WCN), during a wound care observation for Resident #5 on [DATE] at 2:52 PM, cross-contaminated two (2) open blisters to the wound located on the upper left thigh area and wiped from top to bottom of the wound instead of a circular motion from the center outward. In a wound care observation on [DATE] at 2:35 PM the WCN cleaned from the heel wound of the left foot to the middle wound of the left foot ending with the last wound on the left foot near the base of the 5th toe for Resident #5. In this wound care observation the WCN dropped the dressing in a packet onto the floor and picked it up and placed it onto the clean barrier thus contaminating off of the wound care supplies and continued to provide care. The review of Resident #5's face sheet revealed the facility admitted Resident #5 on [DATE]. In a review of Resident #5's Significant Change MDS with the ARD of [DATE] revealed the [DIAGNOSES REDACTED]. This assessment indicated Resident #5 was at risk for the development of pressure ulcers and did not have any pressure ulcers. Resident #5 had a score of 15 on BIMS that indicated Resident #5 was cognitively intact. Resident #7 The facility failed to reveal all characteristics of the pressure ulcer such as the size and stage, the location and/or the type of wound or accuracy of the assessment dated [DATE], [DATE] and [DATE], for Resident #7. The facility had identified Resident #7 as high risk for Pressure Ulcers but had not placed Resident #7 on an air mattress. The review of Resident #7's face sheet revealed the facility admitted Resident #7 on [DATE]. A review of Resident #7's Annual MDS with an ARD of [DATE] revealed the [DIAGNOSES REDACTED]. This assessment indicated Resident #7 was at risk of developing a pressure ulcer and had no pressure ulcers. Resident #7 scored three (3) of 15 on BIMS that indicated Resident #7 was severely cognitively impaired. Resident #9 The facility failed to reveal all characteristics of the pressure ulcer on the skin assessment forms dated [DATE], [DATE] and [DATE], such as the size and stage, the location and /or the type of wound or accuracy of the assessment. The facility failed to provide wound care on [DATE] at 2:20 PM by RN #1, by failure to wash hands before and after care, failed to use a barrier for supplies and did not clean the wound in a circular manner and use one gauze for each wipe. The review of the Facility's face sheet revealed Resident #9 was admitted by the facility on [DATE]. A review of Resident #9's Annual MDS with an ARD of [DATE] revealed the [DIAGNOSES REDACTED]. This assessment indicated Resident #9 did not trigger to be at risk for the development of pressure ulcers and had no pressure ulcers. Resident #9 had a score of 15 on the BIMS that indicated that Resident #9 was cognitively intact. Resident Unsampled B The facility had identified Unsampled Resident #B as high risk for Pressure Ulcers but had not placed Unsampled Resident #B on an air mattress. The review of the Face Sheet revealed the facility admitted Resident Unsampled #B on [DATE]. The review of Unsampled Resident #B's Quarterly MDS with an ARD of [DATE] the [DIAGNOSES REDACTED]. Unsampled Resident #B had a score of 13 on the BIMS that indicated that Unsampled Resident #B was cognitively intact. Resident Unsampled C The facility had identified Unsampled Resident #C as high risk for Pressure Ulcers but had not placed Unsampled Resident #C on an air mattress. The review of the Facility's Face Sheet revealed the facility admitted Resident Unsampled #C to the facility on [DATE]. A review Unsampled Resident #C's Quarterly MDS with an ARD of [DATE] revealed the [DIAGNOSES REDACTED]. This assessment indicated Unsampled Resident #C did not trigger to be at risk for the development of pressure ulcers and had no pressure ulcers. Unsampled Resident #C had a score of six (6) on the BIMS that indicated that Unsampled Resident #C was severely cognitively impaired. In an interview with RN #3 on [DATE] at 12:06 PM confirmed she attended the high risk meetings weekly. An interview on [DATE] at 10:20 AM, with the facility Administrator revealed the facility conducted quarterly Quality Assurance Committee meetings, and the most recent quarterly meeting was held on [DATE], to discuss the previous quarter (October, November and [DATE]). The Administrator stated there had been a plan of correction implemented for pressure sores following the State Agency's identification of quality deficiencies during the annual survey completed on [DATE]. The Administrator stated there had not been any new quality deficiencies identified since the [DATE] meeting, therefore, there had not been any changes in the Quality Assurance plan. The Administrator stated as part of the Plan of Correction regarding pressure ulcers, the facility implemented weekly high risk meetings. In the high risk meetings residents who had pressure sores and/or who were at high risk of developing pressure sores were discussed to include identification or development of any new pressure sores, wounds or skin integrity issues, the treatment and effectiveness of wound care, and any changes needed to treat wounds. The person responsible for relaying information to the high risk committee members regarding wounds and skin issues was the Wound Care Nurse (WCN). The WCN received two (2) days of training with the consultant Certified Wound Care Nurse (CWCN) on [DATE] and [DATE] and assisted in completing assessments on [DATE] and [DATE]. The CWCN was available by phone after those dates and the Administrator stated the WCN had contact with the CWCN on numerous occasions since that date. The Administrator stated she was unsure if there had been any observations or check offs to ensure wound care was being done correctly and assessments were being completed accurately but the Director of Nursing (DON) would be responsible. The Administrator stated that this had not been identified as a quality assurance concern. The administrator stated another measure implemented was that the facility obtained air mattresses for all high risk residents to promote wound healing and prevent development of pressure sores. The Administrator stated the interventions implemented in the Corrective Action Plan were ongoing and were reviewed at weekly high risk meetings. An interview on [DATE] at 12:05 PM, with the DON revealed there had not been any check offs of staff for proper wound care, or accuracy of assessments. The DON stated, if you are a nurse, you should be able to assess the wounds. The DON stated the facility had no Staff Development Nurse, the hospital would not approve the position. The DON stated the RN Supervisor had been out on maternity leave, and she'd pulled the WCN to the floor to supervise. An interview on [DATE] at 11:20 AM, with the Medical Director (MD) revealed he had not attended QA meetings in person until an emergency meeting was held on [DATE], and he was asked to come. He stated he did not receive notices of QA meetings. The MD stated he was not notified of the findings of the most recent annual survey conducted by the State Agency (SA). The MD stated he had no input into the development of policy and procedures of the facility, and all policy and procedures had been developed by the corporation that had taken over. The Medical Director revealed the facility did not have the staff needed to meet the needs of the residents in the facility, and was not able to hire staff without the corporate entity's approval. When asked if he saw a lack of staff based on the acuity of the residents within the facility, he replied, Absolutely. The Medical Director stated he had heard from the Administrator, the DON, and the DON's predecessor for the past two years there was not enough CNAs or Nurses, and they did not have the authority to hire any staff. The Medical Director stated all policy and procedures were developed by the corporate entity, and all hiring had to be approved through the corporate entity. Review of skin assessments, and observations of wound care revealed Residents #1, #2, #3, #4, #5, #6, #7, and #9 had facility acquired pressure ulcers that had worsened from previous assessments and had not been accurately assessed/identified/staged and treated. Residents # 1, #2, #3, #4, #5, and #9's wound care observations revealed issues with infection control techniques. Resident #6's record revealed she was admitted to the hospital with [REDACTED]. A review was conducted of the facility's list of residents identified as High Risk, and the facility's list of residents who had air mattresses. In comparison it was noted that sampled Residents #3, #7, and Un-sampled Residents A, B, and C were identified as high risk, but were not listed as having air mattresses. Observation on tour of the facility [DATE] at 3:14 PM with Licensed Practical Nurse (LPN #1) confirmed Residents #3, #7, and Un-sampled Residents A, B, and C did not have air mattresses in place on their beds. These observations were made by the State Agency (SA) surveyor, and confirmed by LPN #1 for the residents not having the air mattresses as per the facility's High Risk residents list. An interview on [DATE] at 3:35 PM, with the DON revealed she did not have any explanation as to why these facility identified high risk residents did not have air mattresses. An interview with the Wound Care Nurse Consultant (WCNC) on [DATE] at 2:30 PM, revealed she left out on sick leave [DATE], and returned on [DATE], but had not returned to the facility since [DATE]. The WCNC stated she was available by phone. The WCNC reported she did not observe the WCN's techiniques. The WCNC stated,Some of the wounds we probably did, but I would stand back and let her do some. The WCNC stated she mostly taught her how to stage, and measure the wounds, and she watched to an extent, but was not going to say she did it completely. It was more in a teaching mode. The WCNC stated she had not returned to the building since her return to work on [DATE], and had only talked on the phone. In an interview on [DATE] at 3:25 PM, the Nurse Consultant stated they have struggled for months for nurses and Registered Nurses (RN's). We still need a Staff Development Nurse but the managing hospital won't let us hire more. Interview on [DATE] at 12:58 PM, with Certified Nursing Assistant (CNA) #3 revealed only three (3) CNA's working today, and two other CNAs are in orientation, and had not been checked off. CNA #3 stated, This is hard on us.

Based on observation, interview, record review and facility policy review the facility failed to provide care and services for Pressure Ulcers as evidenced by the failure to implement interventions as identified on the plan of care for eight (8) of nine (9) sampled resident care plans reviewed. (Resident #1, #2, #3, #4, #5, 6, #7, and #9) The facility's failure to implement the intervention on the Plan of Care for Pressure Ulcers put these residents at risk for significant harm. A complaint investigation, with a partially extended survey, was conducted from [DATE] to [DATE]. During the investigation the facility was found not to be incompliance with the Requirements for Participation in Medicare and Medicaid. A partially extended survey was conducted on [DATE] to [DATE]. It was determined that an Immediate Jeopardy was identified on [DATE] at 10:45 AM and the Administrator, Director of Nursing (DON) and Nurse Consultant (NC) was notified at that time. The Immediate Jeopardy began on [DATE] as a result of Resident #6 being admitted from the facility to the hospital with infections and worsened Pressure Ulcers. The facility submitted an Allegation of Compliance (AOC) at [DATE] at 4:05 PM and it was determined not acceptable. The Immediate Jeopardy was not removed upon exit from the facility on [DATE] at 5:30 PM. Findings include: A review of the facility's policy entitled Using the Care Plan, undated, revealed the care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. A review of the facility's policy entitled Care Planning-Interdisciplinary Team, revised on [DATE], revealed the Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The care plan is based on the resident's comprehensive assessment and developed by the Care Planning/Interdisciplinary Team. Resident #6 In an interview with Resident #6's Responsible Party (RP) on [DATE] at 1:16 PM stated the physician told him Resident #6 was admitted to the hospital ([DATE]) with a bad kidney infection and infection in her blood caused by the infection in her bedsores. The RP stated the physician discussed amputation of Resident #6's bilateral legs because they were so bad. The RP stated Resident #6 expired [DATE]. The RP stated the facility kept telling him Resident #6's wounds were getting better but she was getting worse all the time, her feet was about to fall off. In a review of Resident #6's Plan of Care revealed a problem listed of impaired skin integrity as evidenced by pressure ulcers to the left and right heel, buttock, bilateral calf areas and top of both feet. This Care Plan lists approaches to obtain and monitor labs as ordered and report the findings to the doctor; notify the nurse immediately of any new areas of skin breakdown noted during the bath or daily care; administer treatments as ordered and monitor for effectiveness with a target date of [DATE]. Review of Resident #6's physician's orders [REDACTED].>An interview with the Director of Nursing (DON) on [DATE] at 2:50 PM revealed the wound culture for Resident # 6's pressure ulcers (heels) was not obtained on [DATE] due to the late hour of the order and the resident was transferred to the hospital prior to obtaining a culture on [DATE]. The DON stated Resident #6's WBC was so elevated on [DATE] the physician wanted to culture the wounds. The DON stated Resident #6 had bilateral heel pressure ulcers and they did have drainage to culture. The DON stated a body audit was not performed on Resident #6 the day she was transported to the hospital due to emergency transport. Review of the Nurse's Notes for Resident #6, dated [DATE] at 7:44 PM revealed a critical lab result, WBC of 26.6 was called to the ER and reported to a Registered Nurse who would report to the physician and then call the facility for any new orders. There was no physical assessment of Resident #6's condition. There was no further documentation in the Nurse's Notes about the situation until [DATE] at 12:31 PM when a family member came to the facility and demanded an ambulance be called for Resident #6. An order was obtained to transfer resident #6 to the ER per ambulance related to decreased level of consciousness and tremors at 10:28 AM. There was no physical assessment or vital signs documented. Review of the physician's orders [REDACTED].#6 to the emergency room (ER) per ambulance for evaluation with a decreased level of consciousness. Review of the hospital's History and Physical revealed Resident #6 was admitted on [DATE] decreased level of consciousness. [DIAGNOSES REDACTED]. Resident #6's White Blood Count (WBC) was 37.6 (37,600)(normal levels are 4,500 to 10,000) which indicates a severe infection. The resident was noted to have multiple sacral decubiti as well as areas of skin breakdown to the lower extremities, and ankles bilaterally. Resident #1 was treated with Intravenous (IV) fluids and IV antibiotics. Review of laboratory results for Resident #6 revealed a wound culture dated [DATE] with infectious organisms of Staphylococcus aureus and Proteus Mirabilis. A urine culture dated [DATE] revealed the organism Escherichia coli. A blood culture result dated [DATE] revealed Staphylococcus schleiferi. The Discharge Summary, dated [DATE], revealed [DIAGNOSES REDACTED]. The Hospital Course documented: (Resident #6) was brought to the hospital with lethary, decreaed p.o. (by mouth) intake, and was found to [MEDICAL CONDITION], severe [MEDICAL CONDITION], and severely infected decubitus ulcers. Patient at this time was admitted to the hospital and started on antibiotics. As mentioned, she had stage IV decubitus ulcers on her heels with tnedons exposed on the feet. At this time, we asked surgery to evaluate her, and they reported that they did not think the wounds would get better with conservative management and recommeded amputation of both the legs. The patient's family initially was thinking about it, but later changed thier minds. The patient is going to be discharged to inpatient Hospice once they can take her, either this evening or tomorrow. Review of the Hospitalist Discharge Summary dated [DATE] revealed Resident #6 was discharged to inpatient Hospice on [DATE]. Discharge [DIAGNOSES REDACTED]. The patient's symptoms did not improve with treatments and she remained confused and unresponsive throughout most of her hospitalization and will be transferred to Hospice for comfort measures. (Per Resident #6's Responsible Party's interview on [DATE] at 1:16 PM, the resident expired on [DATE] in the hospital, and the resident never returned to the facility.) In a facility closed record review for Resident #6, the Comprehensive Admission Skin assessment dated [DATE] documented the following areas: left buttock 2x1 4x2 (no other information); right buttock pink area intact (no measurements); right top of foot 3.5 cm (centimeters) L (length) x 3.5 cm W (wide) 50% eschar 50% granulation; right heel 6.5 cmL x 6.5 cm W eschar; right lower leg deep tissue injury intact (no measurements); left top of foot 3 cm x 2 cm 50% eschar 50% granulation; left heel 6 cm L x 8 cm W moderate drainage (doesn't describe drainage/odor); left lower leg deep tissue injury intact (no measurements). There was no staging for any of the areas described and no documentation of the type of wounds. There were no wound cultures ordered for the drainage at this time. In a facility closed record review for Resident #6, the Comprehensive Admission Skin assessment dated [DATE] by the WCN revealed documentation of the following listed wounds: Right Buttock-Large 7 centimeter (cm) length X 2 cm width, pink with three (3) small open areas, a. 1 cm length X 0.25 cm width, b. 2 cm length X 0.5 cm width, c. 1 cm length X 0.5 cm width. All pink with scant drainage (the drainage is not described). Left Buttock-has pink area, intact (no measurements). Right top of foot- 3.5 cm X 3.5 cm , Right heel- 6.5 cm X 6.5 cm, with Eschar present and had moderate drainage (does not describe appearance of the drainage). Right calf- unstageable (does not list what)- intact. Left top of foot 3 X 2 (does not list what type of wound or the type of measurement such as centimeter or inch). Left heel- 6 cm X 8 cm with moderate (mod.) drainage (the drainage is not described). Left lower leg on calf- Unstagable wound that is intact (does not include measurements). There were no ordered cultures for the wounds that continued to have drainage. The type of wounds were not identified. A Comprehensive Admission Skin assessment dated [DATE] by the WCN revealed documentation of the following listed wounds for Resident #6: (Does not have documentation of the previous large Right Buttock wounds), Left Buttock- a. 1 cm length X 0.25 cm width, b. 1 cm length X 0.25 cm width. The surrounding tissue is pink and intact. Right top of foot- 5 cm L X 4 cm W with 80% Eschar, Right heel- 8 cm L X 7 cm W, with Eschar present and unstageable. Right calf- unstageable (does not list what)- skin intact and appears deep tissue. Left top of foot 3.5 cm L X 3.5 Wl- 75% eschar. Left heel- 8 cm L X 7 cm W that has eschar and unstageable. Left calf-unstageable wound with the skin intact that appears deep tissue. These wounds are not identified by type and do not have a complete description of the wounds. A Comprehensive Admission Skin Assessment document dated [DATE] by the WCN revealed documentation of the following listed wounds for Resident #6: (Does not have documentation of the previous large Right Buttock wounds), Left Buttock- 1) 2 cm X 1 cm 2) 2 cm X 0.5 cm (no description). Right top of foot- 5 cm X 5 cm with 80% Eschar; Right heel- 8 cm X 7 cm, with Eschar present and unstageable; Right calf- unstageable, skin intact and dark. Left top of foot 4 cm X 4 cm- 80% eschar; Left heel- 8 cm X 7 cm that is eschar and unstageable. Left calf- this wound is unstageable with the skin intact and dark. None of these wounds describe the type of wound. There is no documentation of whether there is drainage or odor for these wounds, yet on [DATE] there is an order for [REDACTED].>Review of the Comprehensive Admission Skin Assessment sheet dated [DATE], [DATE], [DATE] and [DATE] reveals worsening of the wounds for Resident #6 and incomplete documentation to include the type, color, odor and type of the drainage, correct location, the staging of the wounds as listed in the facility policy and Plan of Care. There was no documentations that Resident #6's wounds were avoidable or unavoidable. Review of the [DATE] Physician orders [REDACTED].#6 documented the following: Wound Care to Top Of Bilateral Feet- Cleanse with wound cleanser, pat dry, apply Santyl Ointment and cover with a Hydrogel Gauze, cover with a non-bordered foam, wrap with Kerlix, change every three (3) days and as needed (PRN). Wound Care to Left Heel- Cleanse with wound cleanser, apply Santyl to eschar to left heel, cover with a damp 4 X 4, cover with a dry 4 X 4 and wrap with Kerlix. Change every three (3) days and as needed. Right Heel- Cleanse eschar area with wound cleanser, pat dry, off load with 4X4s and wrap with Kling. Change every three (3) days and PRN. Wound Care to Bilateral Calf Areas- Cleanse areas with wound cleanser, pat dry, wrap with foam dressing and secure with Kerlix. Change the dressing every three (3) days PRN. Buttocks- Clean wound to buttocks with wound cleanser, pat dry, apply TAO to peri-wound, apply powdered Collagen to wound and cover with a bordered foam dressing every day until healed. (The buttocks order does not designate left or right). The facility admitted Resident #6 to the facility on [DATE], with [DIAGNOSES REDACTED]. The Annual MDS with the ARD of [DATE] revealed Resident #6 had a BIMS score of zero that indicated Resident #6 was severely cognitively impaired. Resident #1 A review of Resident #1's care plan revealed Problem Onset: Impaired skin integrity related to Diabetes Mellitus (DM), bedfast, incontinence as evidenced by pressure area to coccyx. The approaches listed included: To observe the appearance, color, wound healing, signs and symptoms of infection and the wound size and stage. Another intervention included to administer treatments as ordered and monitor for effectiveness. On [DATE] the approach was added for wound care to the coccyx, to cleanse area with wound cleanser, pat dry, apply powdered Collagen to the area, cover with a spot bordered foam dressing every day. The facility failed to reveal all characteristics of the pressure ulcer such as the stage, the location and /or the type of wound or accuracy of the assessment per the Resident's Care Plan. The Wound Care Nurse (WCN) applied Collagen to the coccyx with a contaminated gloved hand during a wound care observation on [DATE] at 1:50 PM therefore failed to provide care in a manner to promote healing and prevent the development of infection by Resident #1's Care Plan, by failure to apply Collagen with a tongue blade, 4X4 gauze, or other non contaminated item for Resident #1. A review of Resident #1's face sheet revealed the facility admitted Resident #1 on [DATE]. A review of Resident #l's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #1 had multiple [DIAGNOSES REDACTED]. This assessment revealed Resident #1 was at risk for developing pressure ulcers and had no pressure ulcers at that time. Resident #1 scored three (3) of 15 on the Brief Interview of Mental Status (BIMS) that indicated Resident #1 was severely cognitively impaired. Resident #2 A review of Resident #2's care plan revealed Problem Onset: Impaired skin integrity related to incontinence, DM as evidenced by pressure area to coccyx and area to right lateral ankle. The approaches listed included: To observe the appearance, color, wound healing, signs and symptoms of infection and the wound size and stage. Another intervention included to administer treatments as ordered and monitor for effectiveness. The facility failed to reveal all characteristics of the pressure ulcer such as the size and stage, the location and /or the type of wound or accuracy of the assessment per the Resident #2's Care Plan. The Wound Care Nurse (WCN), during a wound care observation on [DATE] at 2:52 PM, cross-contaminated two (2) open blisters to the wound located on the upper left thigh area and wiped from top to bottom of the wound instead of a circular motion from the center outward and therefore failed to provide care in a manner to promote healing and prevent the development of infection by Resident #2's Care Plan. A review of Resident #2's face sheet revealed the facility admitted Resident #2 on [DATE]. A review of Resident #2's quarterly MDS with an ARD of [DATE] revealed Resident #2 had multiple [DIAGNOSES REDACTED]. This assessment revealed Resident #2 was at risk for the development of pressure ulcers and had no pressure ulcers. Resident #2 scored three (3) on BIMS that indicated Resident #2 was severely cognitively impaired. Resident #3 A review of Resident #3's care plan revealed the problem onset of Impaired Skin Integrity related to fragile skin as evidenced by the skin tear to the left calf with the goal for the wound to show signs of healing by the next review of [DATE]. The approaches listed included: To observe the appearance, color, wound healing, signs and symptoms of infection and the wound size and stage. Another intervention included to administer treatments as ordered and monitor for effectiveness. The facility failed to reveal all characteristics of the pressure ulcer such as the size and stage, the location and /or the type of wound or accuracy of the assessment dated [DATE] and [DATE], per Resident #3's Care Plan. The facility had identified Resident #3 as high risk for Pressure Ulcers but had not placed Resident #3 on an air mattress per the plan of care. There was a large area to mid calf about 12 cm in diameter that was dark blue with quarter size open area to the center and no drainage was noted. There was an open area on top of calf approximately quarter size and dark blue in color with no drainage. This observation of Resident #3's wound on [DATE] at 1:18 PM during the wound care observation was different than the documented assessments on [DATE] by the WCN that documented areas of slough noted to the back of the left calf. A review of Resident #3's face sheet revealed the facility admitted Resident #3 on [DATE]. A review Resident #3's quarterly MDS with an ARD of [DATE] revealed Resident #3 had multiple [DIAGNOSES REDACTED]. This assessment revealed Resident #3 was at risk for developing pressure ulcers and had no pressure ulcers. Resident #3 scored three (3) on the BIMS that indicated Resident #3 was severely cognitively impaired. Resident #4 A review of Resident #4's care plan revealed the problem onset of potential for skin breakdown related to DM, Incontinence, [MEDICAL CONDITIONS], Dementia, Weight loss and Stage I Decubitus to Coccyx. The approaches listed for Resident #4 on the care plan revealed the facility would have skin risk assessments on admission and at regular intervals. The care plan was updated on [DATE] to include an intervention to clean the skin tear on the coccyx area with wound cleanser, apply antibiotic ointment followed by a mini island dressing every day until healed. The care plan did not address the facility acquired Stage II Pressure Ulcer on the coccyx; they addressed as a skin tear.) The facility failed to reveal all characteristics of the pressure ulcer such as the size and stage, the location and /or the type of wound or accuracy of the assessment dated [DATE] by the WCN and [DATE] by the DON per the Resident #4's Care Plan. The facility failed to identify the worsening of the Stage I Pressure Ulcer to a Stage II Pressure Ulcer to the coccyx. During the Wound Care Observation on [DATE] at 11:05 AM, the WCN failed to clean each open area to the Coccyx Wound separately and did not pat the wound dry to prevent the spread of infection and promote healing per Resident #4's plan of care. A review of Resident #4's face sheet revealed the facility admitted Resident #4 on [DATE]. A review of Resident #4's Significant Change MDS with an ARD of [DATE] revealed multiple [DIAGNOSES REDACTED]. This assessment revealed Resident # 4 was at risk of developing pressure ulcers and had a Stage 1 or higher pressure ulcer. The BIMS indicated Resident #4 had a score of 0 that indicated Resident #4 was severely cognitively impaired. Resident #5 A review of Resident #5's care plan revealed the problem onset of impaired skin integrity related to: Recent right Above the Knee Amputation (AKA) with surgical incision to right inner thigh, surgical incision to right knee, pressure ulcer to sacrum upon re-admission. Added three (3) unstageable intact pressure areas to left lateral foot below fifth (5th) toe, mid foot and above heel not dated when added. This care plan revealed the approaches to observe the changes in skin status, appearance, color, wound healing, signs and symptoms of infection and wound size and stage. The Care Plan was updated on [DATE] to clean the wound to the left outer foot with wound cleaner, pat dry, apply (name brand) ointment and cover with a bordered foam dressing daily. (This wound to the left foot developed in-house per the list provided initially by the facility on entrance on [DATE].) The facility failed to reveal all characteristics of the pressure ulcer such as the size and stage, the location and /or the type of wound or accuracy of the assessment per the Resident #5's Care Plan. The Wound Care Nurse (WCN), during a wound care observation on [DATE] at 2:52 PM, cross-contaminated two (2) open blisters to the wound located on the upper left thigh area and wiped from top to bottom of the wound instead of a circular motion from the center outward and therefore failed to provide care in a manner to promote healing and prevent the development of infection by Resident #2's Care Plan. The skin assessments dated [DATE] by the WCN, [DATE] by the WCN and [DATE] by the DON does not show the open area to the middle of the left foot and indicated a closed area to the left foot at the base of the 5th toe but documented the area to be open at 10 cm X 15 cm. In a wound care observation on [DATE] at 2:35 PM the WCN cleaned from the heel wound of the left foot to the middle wound of the left foot ending with the last wound on the left foot near the base of the 5th toe for Resident #5 therefore failing to promote pressure ulcer healing by Resident #5 ' s plan of care. In this wound care observation the WCN dropped the dressing in a packet onto the floor and picked it up and placed it onto the clean barrier thus contaminating off of the wound care supplies and continued to provide care. A review of Resident #5's face sheet revealed the facility admitted Resident #5 on [DATE]. A review of Resident #5's Significant Change MDS with the ARD of [DATE] revealed multiple [DIAGNOSES REDACTED]. This assessment indicated Resident #5 was at risk for the development of pressure ulcers and did not have any pressure ulcers. Resident #5 had a score of 15 on BIMS that indicated Resident #5 was cognitively intact. Resident #7 A review of Resident #7's care plan revealed the problem onset of the potential for skin breakdown related to Dementia, DM, Incontinence of Bowel and Bladder and [MEDICAL CONDITION] with the goal that any skin impairment will not go undetected by the next review of [DATE]. The approaches included to complete skin risk assessments on admission and at regular intervals and notify appropriate staff of changes in the risk assessment. The facility failed to reveal all characteristics of the pressure ulcer such as the size and stage, the location and/or the type of wound or accuracy of the assessment dated [DATE], [DATE] and [DATE], per the Resident #7's Care Plan. The facility had identified Resident #7 as high risk for Pressure Ulcers but had not placed Resident #7 on an air mattress per the plan of care. A review of Resident #7's face sheet revealed the facility admitted Resident #7 on [DATE]. A review of Resident #7's Annual MDS with an ARD of [DATE] revealed multiple [DIAGNOSES REDACTED]. This assessment indicated Resident #7 was at risk of developing a pressure ulcer and had no pressure ulcers. Resident #7 scored 3 of 15 on BIMS that indicated Resident #7 was severely cognitively impaired. Resident #9 A review of Resident #9's plan of care revealed a problem identified of impaired skin integrity related to urinary incontinence, scratching as evidenced by wound to left hip area, redness to scrotum with one (1) open area posteriorly and one (1) open area anteriorly (pencil eraser sized). The approaches listed on Resident #9's plan of care are to observe and notify the Medical Doctor (MD) of any changes in skin status, appearance, color, wound healing, signs and symptoms of infection and wound size and stage. The Care Plan listed to cleanse the area to the right hip with wound cleanser, pat dry, apply triple antibiotic ointment (TAO) and cover with bordered dressing daily until healed. The facility failed to follow the plan of care for assessments from [DATE] by LPN #2, [DATE] by the DON to the comprehensive skin assessment by RN #3 on [DATE]. The facility failed to provide wound care on [DATE] at 2:20 PM by RN #1, in a manner to promote healing and prevent the development of infection by failure to wash hands, before and after care, set wound care supplies on the heater in the room with no barrier, set cup on bed with moistened with wound cleanser that tipped over touching the bed without a barrier, cleaned the wound to the right hip with 4X4 moistened with wound cleanser up and down four times with the same area of the gauze by RN #1, per Resident #9's plan of care. A review of the Facility's face sheet revealed Resident #9 was admitted to the facility on [DATE]. A review Resident #9's annual MDS with an ARD of [DATE] revealed multiple [DIAGNOSES REDACTED]. This assessment indicated Resident #9 did not trigger to be at risk for the development of pressure ulcers and had no pressure ulcers. Resident #9 had a score of 15 on the BIMS that indicated that Resident #9 was cognitively intact. Resident Unsampled B Unsampled Resident #B's plan of care revealed the potential problem of skin breakdown related to Urinary Incontinence, Dementia and DM. The approaches listed to place Unsampled Resident #B on a pressure redistribution mattress/overlay as ordered to promote sound healing and maintain skin integrity per the plan of care. The facility had identified Unsampled Resident #B as high risk for Pressure Ulcers but had not placed Unsampled Resident #B on an air mattress per the plan of care. A review of the Facility's face sheet revealed Unsampled Resident #B was admitted to the facility on [DATE]. A review of Unsampled Resident #B's Quarterly MDS with an ARD of [DATE] revealed multiple [DIAGNOSES REDACTED]. Unsampled Resident #B had a score of 13 on the BIMS that indicated that Unsampled Resident #B was cognitively intact. Resident Unsampled C Unsampled Resident #C's plan of care revealed the potential problem of skin breakdown related to Urinary Incontinence, Dementia and DM. The approaches listed to place Unsampled Resident #C on a pressure redistribution mattress/overlay as ordered to promote sound healing and maintain skin integrity per the plan of care. The facility had identified Unsampled Resident #C as high risk for Pressure Ulcers but had not placed Unsampled Resident #C on an air mattress per the plan of care. A review of the Facility's face sheet revealed Unsampled Resident #C was admitted to the facility on [DATE]. A review Unsampled Resident #C's Quarterly MDS with an ARD of [DATE] revealed multiple [DIAGNOSES REDACTED]. This assessment indicated Unsampled Resident #C did not trigger to be at risk for the development of pressure ulcers and had no pressure ulcers. Unsampled Resident #C had a score of 6 on the BIMS that indicated that Unsampled Resident #C was severely cognitively impaired. An interview on [DATE] at 2:40 PM with RN #1 revealed the care plan is on the chart and includes the wound care and treatments. In an interview on [DATE] at 1:40 PM with the WCN revealed the Care Plan is updated when the treatment is updated or changes are made. In an interview on [DATE] at 11:03 AM with the DON confirmed the facility had an inservice that the nurses had been educated on the care plan and the need to transcribe orders onto the care plan when written. The DON also confirmed the nurses were to discontinue treatments on the care plan when they are discontinued and draw a line through them. [DATE] 12:06 PM in an interview with RN #3 revealed she would look at the chart, nurses notes, medications, consults, and wound assessments that have been done to develop the care plan. RN #3 also confirmed she attends the high risk meetings weekly. RN #3 confirmed she develops the plan of care for all the residents but other nurses, to include the WCN, will update them as needed when concerns are identified or changed. RN #3 stated if a wound is healed the other nurses can discontinue the treatment and other things as needed. Interview with the Administrator on [DATE] at 10:20 AM revealed, as far as she knew, the wound care staff revised and follows the care plans.

Based on observation, staff interview, record review and facility policy review the facility failed to ensure appropriate measures/systems were in place to help prevent pressure ulcers from developing/worsening for eight (8) of nine (9) sampled residents and three (3) of three (3) Unsampled (US) residents, Resident #1, #2, #3, #4, #5, #6, #7, #9, and US #A, #B and #C, as evidenced by not having accurate wound assessments for Residents #1, #2, #3, #4, #5, #6, #7 and #9; failure to identify and stage wounds accurately for Residents #1, #2, #3, #4, #5, #6 #7 and #9; failure to follow the infection control guidelines to prevent infection for observed treatments for Residents #1, #2, #3, #4, #5, and #9, lack of air mattresses/interventions for identified high risk residents for Residents #3, #7, US #A, #B and #C, lack of supervision of the Wound Care Nurse for all Residents with pressure ulcers or the potential for pressure ulcers; and failure to obtain physician's orders [REDACTED].#5. Residents #1, #2, #3, #4, #5, #6, #7 and #9 had in-house acquired pressure ulcers with no documentation of avoidable or unavoidable and all had worsened since identification. The failure to assess, identify, treat, and obtain orders to treat pressure ulcers put these and other residents at risk for significant harm, injury, impairment and death. Resident #6 had pressure ulcers to the sacrum, calves, and bilateral heels with documented wound cultures of Staphalococcus aureus and Proteus mirabilis infections. Resident #6 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Resident #6 expired on [DATE] at the hospital and never returned to the facility, per family interview, due to the infection in her blood caused by the infection in her pressure ulcers. The Stage Agency (SA) conducted a complaint investigation, with a partially extended survey, from [DATE] to [DATE]. During the investigation the facility was found not to be in compliance with the Requirements for Participation in Medicare and Medicaid. A partially extended survey was conducted on [DATE] to [DATE]. It was determined that an Immediate Jeopardy was identified on [DATE] at 10:45 AM and the Administrator, Director of Nursing (DON) and Nurse Consultant (NC) was notified at that time. The Immediate Jeopardy began on [DATE] as a result of Resident #6 being admitted from the facility to the hospital with infections and worsened Pressure Ulcers. The facility submitted an Allegation of Compliance (AOC) at [DATE] at 4:05 PM which was determined not acceptable. The Immediate Jeopardy was not removed upon exit from the facility on [DATE] at 5:30 PM and is considered ongoing. Findings include: Review of the facility's policy Pressure Ulcers/Skin Breakdown-Clinical Protocol, not dated, revealed: The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores. In addition, the nurse shall assess and document/report the following: vital signs, full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue, Pain assessment, Resident's age and sex, resident's mobility status, active diagnoses, and current treatments, including support surfaces. The physician will help the staff define the type (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc.) of an ulceration. The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. Review of the facility's Support Surface Guidelines, undated, revealed: Support surfaces alone are not effective in preventing pressure ulcers, but studies indicated the use of appropriate support surfaces with interventions such as turning, repositioning, and moisture management can reduce pressure ulcer development by 50%. Elements of support surfaces that are critical to pressure ulcer prevention and general safety include pressure redistribution, moisture control, shear reduction, heat dissipation-temperature control, friction control, infection control, flammability and life expectancy. Any individual at risk for developing pressure ulcers should be placed on a pressure-reducing device, such as foam, static air, alternating air, gel, or water mattresses when lying in bed. When residents are in a bed/chair, pillows are an effective method of redistributing pressure. The effectiveness of the pressure relief regime and takes taken if ineffective must be documented in the medical record. All assessment data obtained when inspecting/treating the wound should be documented, to include wound bed color, size and drainage. Review of the facility's Wound Care policy, not dated, revealed the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The Wound Care policy revealed the following steps: Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. Wash and dry your hands thoroughly. Be certain all clean items are on clean field. Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. Review of the facility's Plan of Correction, with a completion date of [DATE], from the previous survey of [DATE] revealed corrective actions for prevention and treatment of [REDACTED]. 2) The Wound Care Nurse will conduct weekly body audits on all residents. 3) A Certified Wound Care Nurse will be available to consult with the Wound Care Nurse on an ongoing basis. Resident #6 In an interview with Resident #6's Responsible Party (RP) on [DATE] at 1:16 PM stated the physician told him Resident #6 was admitted to the hospital ([DATE]) with a bad kidney infection and infection in her blood caused by the infection in her bedsores. The RP stated the physician discussed amputation of Resident #6's bilateral legs because they were so bad. The RP stated Resident #6 expired [DATE]. The RP stated the facility kept telling him Resident #6's wounds were getting better but she was getting worse all the time, her feet was about to fall off. Review of Resident #6's physician's orders [REDACTED]. Review of Resident #6's physician's orders [REDACTED]. Review of the Urine C&S collected by the facility on [DATE] and reported [DATE] (after hospital admit) revealed the infectious agent Escheriachia coli (E-coli). An interview with the Director of Nursing (DON) on [DATE] at 2:50 PM revealed the wound culture for Resident # 6's pressure ulcers (heels) was not obtained on [DATE] due to the late hour of the order and the resident was transferred to the hospital prior to obtaining a culture on [DATE]. The DON stated Resident #6's White Blood Count (WBC) was so elevated on [DATE] the physician wanted to culture the wounds. The DON stated Resident #6 had bilateral heel pressure ulcers and they did have drainage to culture. The DON stated a body audit was not performed on Resident #6 the day she was transported to the hospital due to emergency transport. Review of the Nurse's Notes for Resident #6, dated [DATE] at 7:44 PM revealed a critical lab result, WBC of 26.6 was called to the ER and reported to a Registered Nurse who would report to the physician and then call the facility for any new orders. There was no physical assessment of Resident #6's condition by the facility prior to transport to the hospital. There was no further documentation in the Nurse's Notes about the situation until [DATE] at 12:31 PM when a family member came to the facility and demanded an ambulance be called for Resident #6. An order was obtained to transfer resident #6 to the ER per ambulance related to decreased level of consciousness and tremors at 10:28 AM. There was no physical assessment or vital signs documented by the facility. Review of the physician's orders [REDACTED].#6 to the emergency room (ER) per ambulance for evaluation with a decreased level of consciousness. Review of the hospital's History and Physical revealed Resident #6 was admitted on [DATE] with decreased level of consciousness. [DIAGNOSES REDACTED]. Resident #6's White Blood Count (WBC) was 37.6 (37,600)(normal levels are 4,500 to 10,000) which indicates a severe infection. The resident was noted to have multiple sacral decubiti as well as areas of skin breakdown to the lower extremities, and ankles bilaterally. Resident #1 was treated with Intravenous (IV) fluids and IV antibiotics. Review of laboratory results for Resident #6 revealed a wound culture dated [DATE] with infectious organisms of Staphylococcus aureus and Proteus Mirabilis. A urine culture dated [DATE] revealed the organism Escherichia coli. A blood culture result dated [DATE] revealed Staphylococcus schleiferi. The Discharge Summary, dated [DATE], revealed [DIAGNOSES REDACTED]. The Hospital Course documented: (Resident #6) was brought to the hospital with lethary, decreaed p.o. (by mouth) intake, and was found to [MEDICAL CONDITION], severe [MEDICAL CONDITION], and severely infected decubitus ulcers. Patient at this time was admitted to the hospital and started on antibiotics. As mentioned, she had stage IV decubitus ulcers on her heels with tnedons exposed on the feet. At this time, we asked surgery to evaluate her, and they reported that they did not think the wounds would get better with conservative management and recommeded amputation of both the legs. The patient's family initially was thinking about it, but later changed thier minds. The patient is going to be discharged to inpatient Hospice once they can take her, either this evening or tomorrow. Review of the Hospitalist Discharge Summary dated [DATE] revealed Resident #6 was discharged to inpatient Hospice on [DATE]. Discharge [DIAGNOSES REDACTED]. The patient's symptoms did not improve with treatments and she remained confused and unresponsive throughout most of her hospitalization and will be transferred to Hospice for comfort measures. (Per Resident #6's Responsible Party's interview on [DATE] at 1:16 PM, the resident expired on [DATE] in the hospital, and the resident never returned to the facility.) In a facility closed record review for Resident #6, the Comprehensive Admission Skin assessment dated [DATE] documented the following areas: left buttock 2x1 4x2 (no other information); right buttock pink area intact (no measurements); right top of foot 3.5 cm (centimeters) L (length) x 3.5 cm W (wide) 50% eschar 50% granulation; right heel 6.5 cmL x 6.5 cm W eschar; right lower leg deep tissue injury intact (no measurements); left top of foot 3 cm x 2 cm 50% eschar 50% granulation; left heel 6 cm L x 8 cm W moderate drainage (doesn't describe drainage/odor); left lower leg deep tissue injury intact (no measurements). There was no staging for any of the areas described and no documentation of the type of wounds. There were no wound cultures ordered for the drainage at this time. In a facility closed record review for Resident #6, the Comprehensive Admission Skin assessment dated [DATE] by the WCN revealed documentation of the following listed wounds: Right Buttock-Large 7 centimeter (cm) length X 2 cm width, pink with three (3) small open areas, a. 1 cm length X 0.25 cm width, b. 2 cm length X 0.5 cm width, c. 1 cm length X 0.5 cm width. All pink with scant drainage (the drainage is not described). Left Buttock-has pink area, intact (no measurements). Right top of foot- 3.5 cm X 3.5 cm , Right heel- 6.5 cm X 6.5 cm, with Eschar present and had moderate drainage (does not describe appearance of the drainage). Right calf- unstageable (does not list what)- intact. Left top of foot 3 X 2 (does not list what type of wound or the type of measurement such as centimeter or inch). Left heel- 6 cm X 8 cm with moderate (mod.) drainage (the drainage is not described). Left lower leg on calf- Unstagable wound that is intact (does not include measurements). There were no ordered cultures for the wounds that continued to have drainage. The type of wounds were not identified. A Comprehensive Admission Skin assessment dated [DATE] by the WCN revealed documentation of the following listed wounds for Resident #6: (Does not have documentation of the previous large Right Buttock wounds), Left Buttock- a. 1 cm length X 0.25 cm width, b. 1 cm length X 0.25 cm width. The surrounding tissue is pink and intact. Right top of foot- 5 cm L X 4 cm W with 80% Eschar, Right heel- 8 cm L X 7 cm W, with Eschar present and unstageable. Right calf- unstageable (does not list what)- skin intact and appears deep tissue. Left top of foot 3.5 cm L X 3.5 Wl- 75% eschar. Left heel- 8 cm L X 7 cm W that has eschar and unstageable. Left calf-unstageable wound with the skin intact that appears deep tissue. These wounds are not identified by type and do not have a complete description of the wounds. A Comprehensive Admission Skin Assessment document dated [DATE] by the WCN revealed documentation of the following listed wounds for Resident #6: (Does not have documentation of the previous large Right Buttock wounds), Left Buttock- 1) 2 cm X 1 cm 2) 2 cm X 0.5 cm (no description). Right top of foot- 5 cm X 5 cm with 80% Eschar; Right heel- 8 cm X 7 cm, with Eschar present and unstageable; Right calf- unstageable, skin intact and dark. Left top of foot 4 cm X 4 cm- 80% eschar; Left heel- 8 cm X 7 cm that is eschar and unstageable. Left calf- this wound is unstageable with the skin intact and dark. None of these wounds describe the type of wound. There is no documentation of whether there is drainage or odor for these wounds, yet on [DATE] there is an order for [REDACTED].>Review of the Comprehensive Admission Skin Assessment sheet dated [DATE], [DATE], [DATE] and [DATE] reveals worsening of the wounds for Resident #6 and incomplete documentation to include the type, color, odor and type of the drainage, correct location, the staging of the wounds as listed in the facility policy. There was no documentations that Resident #6's wounds were avoidable or unavoidable. The Quarterly Braden Risk Assessment Report by RN #3 on [DATE] revealed Resident #6 had a Risk Score of 12 that indicated Resident #6 was at high risk for Pressure Ulcers. Review of the [DATE] Physician orders [REDACTED].#6 documented the following: Wound Care to Top Of Bilateral Feet- Cleanse with wound cleanser, pat dry, apply Santyl Ointment and cover with a Hydrogel Gauze, cover with a non-bordered foam, wrap with Kerlix, change every three (3) days and as needed (PRN). Wound Care to Left Heel- Cleanse with wound cleanser, apply Santyl to eschar to left heel, cover with a damp 4 X 4, cover with a dry 4 X 4 and wrap with Kerlix. Change every three (3) days and as needed. Right Heel- Cleanse eschar area with wound cleanser, pat dry, off load with 4X4s and wrap with Kling. Change every three (3) days and PRN. Wound Care to Bilateral Calf Areas- Cleanse areas with wound cleanser, pat dry, wrap with foam dressing and secure with Kerlix. Change the dressing every three (3) days PRN. Buttocks- Clean wound to buttocks with wound cleanser, pat dry, apply Triple Antibiotic Ointment (TAO) to peri-wound, apply powdered Collagen to wound and cover with a bordered foam dressing every day until healed. (The buttocks order does not designate left or right). The facility admitted Resident #6 to the facility on [DATE], with [DIAGNOSES REDACTED]. The Annual MDS with the ARD of [DATE] revealed Resident #6 had a BIMS score of zero that indicated Resident #6 was severely cognitively impaired. Resident #1 In a wound care observation for Resident #1, on [DATE] at 1:50 PM, the Wound Care Nurse (WCN) applied Collagen with a gloved hand after providing wound care to the coccyx. Observed a Stage II Pressure Ulcer to the coccyx without redness or drainage measuring approximately one (1) inch long and approximately one-fourth (,[DATE]) inch wide with a pink center. In an interview with the WCN on [DATE] at 2:15 PM she confirmed she used a gloved hand to apply the Collagen to the Coccyx Stage II Pressure Ulcer. The WCN also confirmed the area to the upper medial buttock was healed with no treatment needed and treatment should have been discontinued because Resident #1 no longer had a Stage I Pressure Ulcer there. Record review of the weekly Comprehensive Admission Skin Assessment for Resident #1 with the reference date of [DATE], by the WCN revealed a Pressure Ulcer to the Gluteal Fold 0.5 cm length X 0.25 cm width with no depth and no drainage. Resident #1 did have an air mattress on the bed. Record review of the weekly Comprehensive Admission Skin Assessment for Resident #1 with the reference date of [DATE], by LPN #2 revealed no signs of pressure/skin breakdown noted, no heel protectors worn, slight bruising to back of arms due to insulin injections and no other bruising noted. Review of Resident #1's medical record revealed a physician's orders [REDACTED]. The February 2016 Treatment Administration Record (TAR) confirmed the treatments were documented. Therefore Resident #1's skin assessment of [DATE] was inaccurate due to the skin assessment did not reveal a stage, or the type of wound. Record review of the weekly Comprehensive Admission Skin Assessment for Resident #1 with the reference date of [DATE] by the DON revealed pink area to sacrum, 0.5 cm X 0.5 cm and no drainage. (No staging of the area was documented). Record review and observation of the weekly Comprehensive Admission Skin Assessment for Resident #1, with the reference date of [DATE], by the WCN with the State Agency (SA) surveyor present, revealed Gluteal fold Stage II 1.2 cm length X 0.3 cm width, no drainage, pink tissue. (This assessment showed a worsening of Resident #1's pressure ulcer from a reddened area on [DATE] to a stage II on [DATE], and discrepancy of what had been previously assessed. Resident #1's pressure sore was facility acquired and the facility provided no documentation of avoidable or unavoidable.) A review of Resident #1's Face Sheet revealed the facility admitted Resident #1 on [DATE]. A review Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #1 had multiple [DIAGNOSES REDACTED]. The MDS revealed Resident #1 was at risk for developing pressure ulcers and had no pressure ulcers at the time. Resident #1 scored three (3) of 15 on the Brief Interview of Mental Status (BIMS) indicating that Resident #1 was severely cognitively impaired. Resident #2 A wound care observation for Resident #2 on [DATE] at 2:52 PM revealed the resident on an air mattress and redness was noted between both knees with no observed pressure relieving device. The WCN, assisted by Certified Nurse Assistant (CNA) #1, cleaned Wound #1 from the top to the bottom of the wound four (4) times instead of starting in the center and wiping outward in a circular manner to prevent contamination. Wound #1 was located on the upper left thigh area on back of the leg and had a red area approximately the size of a large orange with two (2) open blisters like areas in the center that was less than a pencil eraser size. The WCN cut the [MEDICATION NAME] AG and placed in the center of the wound with scissors not cleaned with a germicidal agent that increased the risk for the spread of infection. Observation of wound treatment for [REDACTED]. In an interview with the WCN on [DATE] at 3:15 PM, after the wound care observation, revealed when asked what pressure relieving devices are used?, the WCN responded pillows or wedges. The WCN stated the CNAs use the pressure relieving devices as needed and confirmed there was no device between Resident #2's knees and no hand roll to the left hand. The WCN was asked Who is responsible to make sure the CNAs did what they were supposed to do? The WCN responded the nurses are supposed to. Review of Resident #2's medical record revealed Wound #3 was listed on the February 2016 TAR and in the February 2016 physician's orders [REDACTED]. Record review of the weekly Comprehensive Admission Skin Assessment for Resident #2 with the reference date of [DATE] by the WCN revealed the left ischium- red purple area 5 cm X 4 cm area to center -small area 1 cm X 1 cm open- scant drainage; right ankle pink, intact; Gluteal fold 1 cm length X 1 cm width- Bordered Foam dressing (BF drsg). (No identification of the wounds and no staging). Record review of the weekly Comprehensive Admission Skin Assessment for Resident #2, with the reference date of [DATE] ([DATE]) by the DON revealed; heel proctors on, skin intact, sacrum- normal, healthy pink, scrotum red, right thigh red next to scrotum. Review of the February 2016 physician's orders [REDACTED].#2's skin issues on [DATE]. Record review of the weekly Comprehensive Admission Skin Assessment for Resident #2, with the reference date of [DATE] by the WCN, with the SA Surveyor present, revealed: Gluteal fold 1.5 cm X 0.2 cm pressure ulcer with no depth and no drainage and pink; pink area to right inner buttock, intact, no drainage; left ischium 7 cm length X 4 cm width dark area with a 0.2 cm length X 0.1 width inside of dark area at 7 o'clock area, no drainage; left upper thigh pimple type area intact; bruise to second finger left hand tip of finger; red pimple areas to right side of face ,[DATE] areas. (This assessment revealed Resident #2's Gluteal pressure ulcer had worsened since the [DATE] skin assessment. The left Ichium pressure ulcer had not been identified and staged. The pressure ulcers were facility acquired. The facility provided no documentation of the pressure areas being unavoidable.) A review of Resident #2's face sheet revealed the facility admitted Resident #2 on [DATE]. A review Resident #2's quarterly MDS with an ARD of [DATE] revealed Resident #2 had multiple [DIAGNOSES REDACTED]. The MDS documented Resident #2 at risk for the development of pressure ulcers with no pressure ulcers present. Resident #2 scored three (3) of 15 on The Brief Interview of Mental Status (BIMS) indicating that Resident #2 was severely cognitively impaired. Resident #3 In an observation of wound care on Resident #3 on [DATE] at 1:18 PM revealed the WCN lifted the left lower leg and wiped a small open area to the upper part of the left calf area with a clean 44 gauze moistened with wound cleanser. The WCN wiped the wound top to bottom two (2) times with each wipe. The WCN did not start in the center of the wound and wipe outward. The WCN then wiped a larger open area to mid left lower leg from top to bottom three (3) times, with a clean moistened 4 x 4 gauze, and then put the left leg down on top of the resident's pillow with no barrier. The WCN then applied Collagen Powder to the larger wound on the mid calf with a gloved hand and lowered the left leg again on the pillow with no barrier. The large area to mid calf was larger than a grapefruit size dark blue area with quarter size open area and no drainage noted. The open area (pressure sore) on top of the calf was approximately quarter sized and dark blue in color with no drainage. In an observation on [DATE] at 3:14 PM with LPN #1 revealed Resident #3 did not have an air mattress on the bed. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of [DATE] revealed Resident #3 was at high risk for Pressure Ulcers. The facility had identified Resident #3 as a high risk for pressure ulcers on the provided list of those at high risk. In an interview on [DATE] at 1:40 PM the WCN stated she provides care as ordered for Resident #3. The WCN stated the dressing change for Resident #3 was clean so there was no need for a barrier on the pillow. The WCN stated it was okay to apply Collagen with a gloved hand and stated I don't know how else to do put it on. Record review of the weekly Comprehensive Admission Skin Assessment for Resident #3, with the reference date of [DATE] by the WCN revealed; top of left calf, appears to be a boil, white center, intact area 1 cm width X 1 cm length; area to back of calf closed but tender; areas of slough noted to back of calf. (The facility assessment did not identify the sloughed area as an open wound.) Record review of the weekly Comprehensive Admission Skin Assessment for Resident #3, with the reference date of [DATE] by the DON revealed; skin intact; continue to monitor back of left calf for worsening, no treatment changes at this time. (The assessment did not describe the left calf area.) Record review of the weekly Comprehensive Admission Skin Assessment for Resident #3, with the reference date of [DATE], by the WCN with the SA Surveyor present, revealed; right lower leg-bruises, [MEDICAL CONDITION] skin shiny-right foot, forth toe-nail with black spot-skin intact; left foot great toe open area 1 cm length X 0.5 cm, pink area underneath- intact; left lower leg 1 cm top of calf- edges approximated- 1 cm round boil appearing intact, 3 cm length X 1 cm width posterior calf- Stage II, 8 cm diameter to posterior calf with small open areas throughout. (The facility failed to accurately assess and identify the open areas, black areas and pressure sores, on the great toe and had no treatments in place for the great toe. Resident #3's pressure ulcers were facility acquired with no documentation of whether avoidable/unavoidable.) A review of Resident #3's face sheet revealed the facility admitted Resident #3 on [DATE]. A review Resident #3's quarterly MDS with an ARD of [DATE] revealed Resident #3 had multiple [DIAGNOSES REDACTED]. Resident #3 was at risk for developing pressure ulcers and had no pressure ulcers identified on the MDS. Resident #3 scored three (3) of 15 on The Brief Interview of Mental Status (BIMS) indicating that Resident #3 was severely cognitively impaired. Resident #4 During a wound care observation on [DATE] at 11:05 AM the WCN cleaned the wound to the coccyx for Resident #4 in a circular motion with a 4 X 4 soaked in wound cleanser, starting in the center of the red area that was approximately grapefruit sized with two (2) circular open areas, one (1) a quarter size and one (1) a dime size; both Stage II wounds. The WCN wiped both open areas in the center of the reddened area with the same gauze and repeated in the same manner. The WCN then wiped the top wound with 4 X 4 soaked gauze from top to bottom then with new 4 X 4 soaked gauze and wiped the bottom wound from top to bottom and did not change gloves in between the wound care. The WCN then did not pat the wound dry before applying the Triple Antibiotic Ointment. During an interview on [DATE] at 11:40 AM the WCN stated she was nervous and forgot to pat the wound dry and when asked the purpose of drying the wound she responded to get rid of the moisture. The WCN did not respond when asked if she should have changed gloves between two (2) wounds. Record review of the weekly Comprehensive Admission Skin Assessment for Resident #4 with the reference date of [DATE] by the WCN revealed red buttocks/coccyx with skin intact. Record review of the weekly Comprehensive Admission Skin Assessment for Resident #4 with the reference date of [DATE] by the DON revealed bruised left wrist, red sacrum, skin intact except small 1.0 X O.5 cm tear to Gluteal fold. Record review of the weekly Comprehensive Admission Skin Assessment for Resident #4 with the reference date of [DATE] by the WCN and with the SA Surveyor present to observe revealed scattered bruising and dry skin noted to left arm, inside left fourth toe small area appears toenail scratched, right elbow pink intact, right foot second toe small black area 0.2 cm X 0.25 cm, right foot third toe red area intact 0.2 cm X 0.2 cm, right upper arm with bruises X three (3)- skin intact, 2 cm X 1 cm left inside buttock deep red, 1 cm X 1 cm above rectum. Gluteal Fold ,[DATE] cm length then 10 cm diameter surrounding breakdown to coccyx. (The facility failed to accurately identify, assess, stage and treat the identified areas documented on the [DATE] skin audit prior to [DATE]. Resident #4's pressure ulcers were facility acquired and the coccyx area had worsened from the previous assessment on [DATE].) A review of Resident #4's face sheet revealed the facility admitted Resident #4 on [DATE]. A review of Resident #4's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed multiple [DIAGNOSES REDACTED]. Resident # 4 was at risk of developing pressure ulcers and had a Stage 1 or higher pressure ulcer. Resident #4 scored 0 of 15 on The Brief Interview of Mental Status (BIMS) indicating that Resident #4 was severely cognitively impaired. Resident #5 In the Wound Care Observation and interview on [DATE] at 10:40 AM the WCN cleaned from the left heel wound to the end of the left 5th toe with a 4 X 4, moistened with wound cleanser, covering all three (3) wounds with one wipe. The WCN then cleansed each wound separately but failed to change gloves between each wound. The WCN dropped a bordered gauze packet on the floor and picked it up and placed it onto the clean barrier on the over bed table with all of the other supplies for wound care; contaminating all of the supplies. The WCN confirmed the Treatment Administration Record (TAR) for Resident #5 did not include the Stage II wound to the lateral middle of the left foot measuring 2 centimeters (cm) X 0.5 cm (measured and Staged per the WCN on [DATE] at 10:40 AM) with no drainage or redness but open. The WCN confirm the TAR did not include the Deep Tissue injury to the lateral side of the left foot at the base of the fifth (5th) toe measuring approximately pea size. The only order for treatment was for t

Based on observation, staff interview, record review, and facility policy review, the facility failed to follow infection control practices to prevent the spread of infection for: 1) One (1) of one (1) closed record reviews, Resident #6. Resident #6, had an order for [REDACTED]. Resident #6's hospital record revealed a wound culture dated [DATE], with Staphylococcus aureus and Proteus mirabilis growth (infectious organisms). 2) Five of seven (5 of 7) wound care observations of nine (9) identified wounds in the facility, Resident #2, #3 #4, #5, and #9 as evidenced by the Wound Care Nurse (WCN) failed to sanitize the wound care scissors with an antimicrobial agent prior to providing Resident #2's wound care, placed Resident #3's leg wound on the resident's pillow at intervals during the wound care, cleaned Resident #4's two (2) wound sites with the same gauze, and did not change her gloves between each wound site care. The WC Nurse dropped a clean wound dressing on the floor, and placed it on the surface barrier with the other clean wound supplies prior to beginning Resident #5's treatments. The WC Nurse cleaned Resident #5's three (3) wounds with the same gauze, and did not change her glove between each wound care site. During Resident #9's wound care treatment, Registered Nurse (RN) #1 did not wash her hands before, or after the wound care, did not have a clean barrier for the wound care supplies, and used a plastic cup of gauze sprayed with wound cleanser that tipped over on the resident's bed. The facility's failure to follow infection control practices during wound care provided by the WC Nurse on [DATE], and [DATE], and RN #1 on [DATE], placed Residents #2, #3, #4, #5, #9, and other residents of the facility in a situation that was likely to cause serious injury, harm, impairment, or death. Resident #6's wound and urine infection resulted in the resident's hospitalization on [DATE] and per Responsible Party (RP) interview that resulted in the death of Resident #6 on [DATE]. An abreviated complaint investigation was conducted at the facility from [DATE] to [DATE]. During the investigation the facility was found not to be in compliance with the requirements for participation for Medicare and Medicaid, and regulations were cited. A partially extended survey was conducted on [DATE] to [DATE]. It was determined that an Immediate Jeopardy was identified on [DATE] at 10:45 AM due to the Wound Care Nurse (WCN) and Registered Nurse (RN) #1's wound care observations revealed techniques that increased the risk of wound contamination/infection, residents with pressure ulcers/assessed as high risk for pressure ulcers did not have air mattresses in place as stated on the previous annual survey's POC dated [DATE], and inaccurate skin/wound assessments that did not identify the wound type, stage, or measurements. The Administrator, Director of Nursing (DON), and Nurse Consultant (NC) were notified of the Immedicate Jeopardy on [DATE] at 10:45 AM. The Immediate Jeopardy began on [DATE] as a result of Resident #6 being admitted from the facility to the hospital with infections and worsened Pressure Ulcers. The facility submitted an Allegation of Compliance (AOC) at [DATE] at 4:05 PM, which was determined not acceptable. The Immediate Jeopardy was not removed upon exit from the facility on [DATE] at 5:30 PM, and is considered ongoing. Findings include: Review of the facility policy,Policies and Practices-Infection Control, revised [DATE], revealed: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of our infection control policies and practices are to: prevent, detect, investigate, and control infections in the facility. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter. Review of the facility's policy, Handwashing/Hand Hygiene, revised [DATE], revealed: The facility considers hand hygiene the primary means to prevent the spread of infection. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: Before and after changing a dressing, before handling clean or soiled dressings, and after removing gloves. The policy also documented the use of gloves does not replace handwashing/hand hygiene. Review of the facility's Wound Care policy, not dated, revealed the following steps: Use disposable cloth (paper towel is adequate) to establish clean field on resident ' s overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. Wash and dry your hands thoroughly. Be certain all clean items are on clean field. Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. Review of the facility's policy, Cleaning and Disinfection of Resident Care Items and Equipment, revised [DATE], revealed: Resident-care equipment, including re-usable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control) recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Current CDC guidelines do not recommend alcohol for sterilizing medical instruments principally because they lack sporicidal action and cannot penetrate protein-rich materials. Review of the Lippincott Nursing Center, Basic Wound Cleaning Step by Step Nursing Made Incredibly Easy: September/[DATE], Volume 6 Number 5, Pages ,[DATE]: For an open wound, such as a pressure ulcer, gently wipe in concentric circles, starting directly over the wound and moving outward. Resident #6 Interview with Resident #6's Responsible Party (RP) on [DATE] at 1:16 PM, revealed the physician told him Resident #6 was admitted to the hospital ([DATE]) with a bad kidney infection, and infection in her blood caused by the infection in her bedsores. The RP stated the physician discussed amputation of Resident #6's bilateral legs because they were so bad. The RP stated Resident #6 expired on [DATE]. The RP stated the facility kept telling him Resident #6's wounds were getting better but she was getting worse all the time, her feet was about to fall off. Review of a Comprehensive Admission Skin assessment dated [DATE], revealed Resident #6 had wounds to the following areas: Left buttock with two (2) areas; 2.0 cm ( two centimeters) x 1.0 (one) cm and 2.0 (two) cm x 0.5 (five tenths) cm. The top of the left foot wound measured 4 (four) cm x 4 (four) cm with 80% eschar. The top of the right foot wound measured 5 (five) cm x 5 (five) cm with 80% eschar. The right heel wound, unstageable, measured 8 (eight) cm x 7 (seven) cm with eschar. The left heel wound, unstageable, measured 8 (eight) cm x 7 (seven) cm with eschar. The left and right calf had no measurements documented, however, the documentation revealed Unstageable, skin intact and dark. Compared to the prior skin assessment dated [DATE], all areas had declined with the exception of the left/right heel being unchanged. Review of Resident #6's Physician's Orders dated [DATE], revealed an order: Hemocult x2 (two); wound culture; urine with culture and sensitivity, and [MEDICATION NAME] 300 milligram (mg) four (4) times daily for 10 days. Review of the Physician's Orders revealed an order dated [DATE] at 10:15 AM, to transfer Resident #6 to the emergency room (ER) per ambulance for evaluation with a decreased level of consciousness. Review of the ER report dated [DATE], revealed Resident #6's White Blood Count (WBC) was 37.6 (37,600)(normal levels are 4,500 to 10,000). The Urine culture dated [DATE], and reported on [DATE], revealed the bacteria Escherichia Coli was present. The resident was noted to have multiple sacral decubiti as well as areas of skin breakdown to the lower extremities, and ankles bilaterally. Review of the hospital record revealed Resident #6 was admitted on [DATE] decreased level of consciousness. [DIAGNOSES REDACTED]. The Discharge Summary documented [DIAGNOSES REDACTED]. Resident #6's treatment included Intravenous Fluids, and broad spectrum Antibiotics. The patient did not improve and Resident #6 remained confused and unresponsive throughout most of the hospitalization . Resident #6 was to be transferred to inpatient Hospice for comfort measures. The Discharge Summary, dated [DATE], revealed [DIAGNOSES REDACTED]. The Hospital Course documented: (Resident #6) was brought to the hospital with lethary, decreaed p.o. (by mouth) intake, and was found to have sepsis, severe hyponatremia, and severely infected decubitus ulcers. Patient at this time was admitted to the hospital and started on antibiotics. As mentioned, she had stage IV decubitus ulcers on her heels with tnedons exposed on the feet. At this time, we asked surgery to evaluate her, and they reported that they did not think the wounds would get better with conservative management and recommeded amputation of both the legs. The patient's family initially was thinking about it, but later changed thier minds. The patient is going to be discharged to inpatient Hospice once they can take her, either this evening or tomorrow. Review of laboratory results for Resident #6 revealed a wound culture dated [DATE] with organisms of Staphylococcus aureus and Proteus Mirabilis. A urine culture dated [DATE] revealed the organism Escherichia coli. A blood culture result dated [DATE] and reported [DATE] revealed Staphylococcus schleiferi. Review of the face Sheet revealed the facility admitted Resident #6 on [DATE]. Resident #6's [DIAGNOSES REDACTED]. Review of the most recent (Minimum Data Set) MDS with an Assessment Reference Date (ARD) of [DATE], revealed a Basic Interview for Mental Status (BIMS) score of zero (0), which indicated Resident #6 had severe cognitive impairment. Further review of the MDS revealed one (1) stage III pressure ulcer and four (4) Unstagealble pressure ulcers. Resident #2 Review of the February 2016 Physician's Orders revealed an order dated [DATE] to cleanse Resident #2's left Ischium deep tissue injury with wound cleanser, and pat dry. To the small stage II, cut [MEDICATION NAME] AC to fit the wound, and cover the entire area with a bordered foam dressing. Change every three (3) days, and as needed. An observation of Resident #2's wound care on [DATE] at 2:52 PM, revealed the WC Nurse cleaned her scissors with an alcohol swab pad, then with wound cleanser, SAF-CLens AF then cut the [MEDICATION NAME] AG with the scissors, and placed the [MEDICATION NAME] in the center of a pressure ulcer to Resident #2's left upper thigh area (Ischium). The WC Nurse cleaned the scissors with the wound cleanser, and placed the scissors back inside the treatment cart. Interview with the WC Nurse on [DATE] at 3:15 PM, revealed she only used alcohol prep pads to clean the wound care scissors, and stated she didn't know why she used the wound cleanser. The WC Nurse stated she'd never had an in-service on cleaning the scissors. Review of the face Sheet revealed the facility admitted Resident #2 on [DATE]. Resident #2's [DIAGNOSES REDACTED]. Resident #2's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 (three), which indicated severe cognitive impairment. Resident #3 Review of the February 2016 Physician Orders revealed an order dated [DATE] for wound care to Resident #3's left lower leg and calf area: Cleanse areas with wound cleanser; apply Bactoban to areas on the front of lower leg, and to the areas on the calf. Apply Collagen Powder to the area on the calf; cover with a large foam, and secure with Kerlix and tape; change daily. Observation of Resident #3's wound care on [DATE] at 1:10 PM, revealed the WC Nurse washed Resident #3's two (2) lower left leg/calf ulcers from the top to the bottom with the wound cleanser, then placed the resident's cleansed leg on the resident's pillow without the use of a surface barrier in place. The WC Nurse applied [MEDICATION NAME] ointment to the top smaller ulcer with a tongue blade, and then the larger area on the left lower leg/calf with a different blade. The WC Nurse placed Resident #3's leg on the pillow in between the treatments. The WC Nurse placed Collagen powder to the larger area on the calf with a gloved hand, lowered the leg onto the pillow, and wrapped the leg with Kerlix. During an interview on [DATE] at 1:40 PM, the WC Nurse stated the dressing change for Resident #3 was a clean procedure, so a barrier was not needed on the pillow. The WC Nurse stated it was okay to put Collagen on with a gloved hand, and stated, I don't know how else to put it on. Review of the face sheet revealed the facility admitted Resident #3 on [DATE]. Resident #3's [DIAGNOSES REDACTED]. Resident #3's most recent MDS with an ARD of [DATE] revealed a BIMS score of 3 (three), indicating a severe cognitive deficit. Resident #4 Review of the February 2016 Physician's Orders revealed an order on [DATE] to cleanse the skin tear on the coccyx area with wound cleanser. Apply Antibiotic Ointment and Mini Island Dressing every day until healed. Observation on [DATE] at 11:05 AM revealed the WC Nurse removed the dressing to Resident #4's coccyx area to reveal a large red area the approximate size of a grapefruit with two (2) circular open areas to the center; one the size of a quarter and one the size of a dime; both stage II. The WC Nurse cleansed both open areas with wound cleanser from the center of the wound outward to include both open areas at the same time. The WC Nurse left the room and returned with staff assistance and cleansed both wounds again with wound cleanser, one at a time, without changing gloves between the treatment of [REDACTED]. During an interview on [DATE] at 11:40 AM the WC Nurse stated she was nervous and forgot to pat the areas dry during wound care for Resident #4 so that it would get rid of the moisture. The WC Nurse did not respond when the surveyor asked if she should change gloves between the treatment of [REDACTED]. Review of the face sheet revealed the facility admitted Resident #4 on [DATE]. Resident #4's [DIAGNOSES REDACTED]. The most recent MDS with an ARD of [DATE] revealed Resident #1's BIMS score of (0)zero, indicating severe cognitive impairment. Resident #5 Review of Resident #5's February 2016 Physician's Orders revealed an order: Clean wound to left outer foot with wound cleanser, pat dry, apply Santyl to wound bed. Cover with bordered foam dressing daily until healed. Observation of Resident #5's wound care on [DATE] at 10:40 AM revealed the WC Nurse placed all supplies on a barrier on the over bed table. The WC Nurse dropped the [MEDICATION NAME] (bordered foam dressing) on the floor, picked it up and placed on the clean barrier with the other supplies. Resident #5 had a total of three (3) wounds on the left foot; a quarter sized area to the outer side of the left heel, and open area to the middle lateral aspect of the left foot, and a deep tissue pea-sized black area to the base of the left 5th toe to the lateral aspect of the foot. The WC Nurse wiped from the heel wound to the center wound to the wound at the base of the toe with one (1) of the pre-moistened (with wound cleanser) 4 x 4, wiping through all three (3) wounds with one stroke. The WC Nurse then cleansed each wound individually but failed to change gloves between each wound treatment. During an interview on [DATE] at 11:50 AM, the WC Nurse stated, I should have done one (1) dressing at a time. The WC Nurse confirmed she dropped the bordered dressing on the floor, picked it up and placed on the clean barrier with the other clean supplies. The WC Nurse stated she should have wiped each wound separately at the beginning. The WC Nurse confirmed being nervous and stated she didn't realize she didn't change her gloves between each wound care. Review of the face sheet revealed the facility admitted Resident #5 on [DATE]. Resident #5's [DIAGNOSES REDACTED]. Review of Resident #5's most recent MDS with an ARD of [DATE] revealed a BIMS score of 15, indicating no cognitive deficit. Resident #9 Review of a Physician's Order dated [DATE] for Resident #9 revealed an order: Cleanse area to right hip with wound cleanser, pat dry, apply Triple Antibiotic Ointment and cover with bordered dressing daily until healed. Observation of wound care with RN #1 on [DATE] at 2:20 PM revealed the RN sprayed wound cleanser on 4 x 4's and placed them in a cup, obtained Triple Antibiotic Ointment, and placed two (2) [MEDICATION NAME] Bordered foam dressings in the right front pocket of her scrubs. RN #1 set the supplies on top of a heater. RN #1 gloved without washing her hands and set the cup (with moistened 4 x 4's on the bed with Resident #9 without a barrier. The cup fell on the side allowing the 4 x 4's to touch the top sheet. RN #1 removed the soiled dressing to Resident #9's right hip and without washing her hands, changed gloves. RN #1 used the wet gauze (4 x 4s) and touched the wound up and down four times using the same area of the 4 x 4. Triple Antibiotic Ointment was applied from the single use packet without the use of a tongue blade or cotton tip applicator. RN #1 removed the [MEDICATION NAME] dressing from her pocket and applied to the Resident's wound. RN #1 did not wash her hands after providing care for Resident #9. Interview with RN #1 on [DATE] at 2:40 PM revealed she had no special training on wound care and handwashing when hired. RN #1 stated, We just know to do that. Review of the face sheet revealed the facility admitted Resident #9 on [DATE]. Resident #9's current [DIAGNOSES REDACTED]. Review of Resident #9's most recent MDS with an ARD of [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. During an interview on [DATE] at 11:10 AM, the Wound Care Nurse (WCN) stated she has been employed since [DATE] and had just completed the wound care certification course (the week prior). She also stated that due to a nurse being out on medical leave, she's had to do wound care treatments and serve in supervisory capacities, as well. An interview on [DATE] at 10:20 am with the facility administrator revealed there had been a plan of correction implemented for pressure sores following the State Agency's identification of quality deficiencies during the annual survey completed on [DATE]. The administrator stated as part of the plan of correction regarding pressure ulcers, the facility implemented weekly high risk meetings. In the high risk meetings residents who had pressure sores and/or who were at high risk of developing pressure sores were discussed to include identification or development of any new pressure sores, wounds or skin integrity issues, the treatment and effectiveness of wound care, and any changes needed to treat wounds. The person responsible for relaying information to the high risk committee members regarding wounds and skin issues was the Wound Care Nurse. The WCN received two (2) days of training with the consultant Certified Wound Care Nurse (CWCN) on [DATE] and [DATE] and assisted in completing assessments on [DATE] and [DATE]. The Administrator stated she was unsure if there had been any observations or check offs to ensure wound care was being done correctly, but the Director of Nursing (DON) would be responsible. An interview on [DATE] at 12:05pm with the DON revealed there had not been any check offs of staff for proper wound care or accuracy of assessments. The DON stated if you are a nurse, you should be able to assess the wounds.

Based on observation, interview, record review, policy review, review of the Mississippi Nursing Practice Law, and Professional Standards of Practice Guidelines/Articles, the facility failed to ensure accepted standards of practice were followed/maintained for eight (8) of nine (9) residents reviewed, Residents #1, #2, #3, #4, #5, #6, #7 and #9 as evidenced by not having written physician's orders [REDACTED]. The failure to accurately assess, identifiy and provide treatment/interventions and obtain appropriate physician orders [REDACTED].#6 and was likely to cause significant injury, harm or death of other residents. An Immediate Jeopardy began on [DATE] as a result of Resident #6 being admitted from the facility to the hospital with infections and worsened Pressure Ulcers. The facility failed to submit an acceptable Allegation of Compliance (AOC). The Immediate Jeopardy was not removed upon exit from the facility on [DATE] at 5:30 PM, and is considered ongoing. Findings include: In a review of the Mississippi Nursing Practice Law, dated [DATE], stated, Nursing practice includes, but is not limited to, administration, teaching, conseling, delegation and spervision of nursing, and execution of the medical regimen, including the admininistration of medications and treatments prescribed by any licensed or legally authorized physician or dentist. Review of an article Infection Control Today, [DATE], Wound Care: Pressure Ulcer Best Practices revealed: Regular follow-up assessment and modifications of the treatment plan when idicated are also necessary to assure optimal wound repair and efficient use of resources, including supplies. Strategies to manage pressure ulcers and facilitate healing include proper tissue load management as well as appropriate ulcer care and management of infection. Initial ulcer care involves wound cleansing, dressing application and possible adjunctive therapy. When caring for wounds, sterile instruments and clean dressings must be used. To prevent cross contamination and the spread of infectious materials it is imperative for clinicians to wear the appropriate personal protective equipment as well as change their gloves and perform thorough and proper hand hygiene between patients. The National Pressure Ulcer Advisory Panel Prevention and treatment of [REDACTED]. Assessment of Pressure Ulcers (PU), and Monitoring of Healing: Complete a comprehensive initial assessment of the individual with a pressure ulcer. Reassess the pressure ulcer and plan of care if the PU doesn't show signs of healing. Re-assess the PU at least weekly and document all assessments. With each dressing change observe the PU for signs of improvement, deterioration and infection and address immediately. Assess and document physical characteristics of the PU: location, category/stage, size, tissue type, color, periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate and odor. Use the findings of a pressure ulcer assessment to plan and document interventions that will best promote wound healing. Cleanse the PU at the time of each dressing change. Develop an educational policy for PU prevention and treatment and provide regular evidence-based education. In a review of the Lippincott Nursing Center webpage for Basic Wound Cleansing Step by Step revealed for an open wound, such as a pressure ulcer, gently wipe in concentric circles, starting directly over the wound and moving outward. Review of the facility's policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, not dated, revealed: The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores. In addition, the nurse shall assess and document/report the following: full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue. Review of the facility's policy titled,Support Surface Guidelines, undated, revealed: All assessment data obtained when inspecting/treating the wound should be documented, to include wound bed color, size and drainage. Review of the Wound Care policy, not dated, revealed to use a disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Wash and dry your hands thoroughly. Be certain all clean items are on clean field. Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. Resident #6 In an interview with Resident #6's Responsible Party (RP) on [DATE] at 1:16 PM stated the physician told him Resident #6 was admitted to the hospital ([DATE]) with a bad kidney infection and infection in her blood caused by the infection in her bedsores. The RP stated the hospital physician discussed amputation of Resident #6's bilateral legs because they were so bad. The RP stated Resident #6 expired [DATE]. The RP stated the facility kept telling him Resident #6's wounds were getting better but she was getting worse all the time, her feet was about to fall off. RP stated that Resident #6 never returned to the facility and expired in the hospital on [DATE] from infections as a result of her Pressure Ulcers. Review of Resident #6's facility's physician's orders [REDACTED]. Review of Resident #6's physician's orders [REDACTED]. An interview with the Director of Nursing (DON) on [DATE] at 2:50 PM revealed the wound culture for Resident # 6's pressure ulcers (heels) was not obtained on [DATE] due to the late hour of the order and the resident was transferred to the hospital prior to obtaining a culture on [DATE]. The DON stated Resident #6's White Blood Cell Count (WBC) was so elevated on [DATE] the physician wanted to culture the wounds. The DON stated Resident #6 had bilateral heel pressure ulcers and they did have drainage to culture. The DON stated a body audit was not performed on Resident #6 the day she was transported to the hospital due to emergency transport. Review of the Nurse's Notes for Resident #6, dated [DATE] at 7:44 PM revealed a critical lab result, WBC of 26.6 (normal range of 4.8 to 10.8 bil/L (Billion per liter), was called to the ER and reported to a Registered Nurse who would report to the physician and then call the facility for any new orders. There was no physical assessment of Resident #6's condition. There was no further documentation in the Nurse's Notes about the situation until [DATE] at 12:31 PM when a family member came to the facility and demanded an ambulance be called for Resident #6. An order was obtained by the nurse to transfer resident #6 to the ER per ambulance related to decreased level of consciousness and tremors on [DATE] at 10:28 AM. There was no physical assessment or vital signs documented. Review of the physician's orders [REDACTED].#6 to the emergency room (ER) per ambulance for evaluation with a decreased level of consciousness. Review of the hospital's History and Physical revealed Resident #6 was admitted on [DATE] with decreased level of consciousness. [DIAGNOSES REDACTED]. Resident #6's White Blood Count (WBC) was 37.6 (37,600)(normal levels are 4,500 to 10,000) which indicates a severe infection. The resident was noted to have multiple sacral decubiti as well as areas of skin breakdown to the lower extremities, and ankles bilaterally. Resident #6 was treated with Intravenous (IV) fluids and IV antibiotics. Review of hospital's laboratory results for Resident #6 revealed an infection in the wound, urine and blood. The wound culture dated [DATE] with infectious organisms of Staphylococcus aureus and Proteus Mirabilis. A urine culture dated [DATE] revealed the organism Escherichia coli. A blood culture result dated [DATE] revealed Staphylococcus schleiferi. The Discharge Summary, dated [DATE], revealed [DIAGNOSES REDACTED]. The Hospital Course documented: (Resident #6) was brought to the hospital with lethary, decreaed p.o. (by mouth) intake, and was found to [MEDICAL CONDITION], severe [MEDICAL CONDITION] (low Sodium in the blood), and severely infected decubitus ulcers. Patient at this time was admitted to the hospital and started on antibiotics. As mentioned, she had Stage IV Decubitus Ulcers on her heels with tendons exposed on the feet. At this time, we asked surgery to evaluate her, and they reported that they did not think the wounds would get better with conservative management and recommeded amputation of both the legs. The patient's family initially was thinking about it, but later changed thier minds. The patient is going to be discharged to inpatient Hospice once they can take her, either this evening or tomorrow. Review of the Hospitalist Discharge Summary dated [DATE] revealed Resident #6 was discharged to inpatient Hospice on [DATE]. Discharge [DIAGNOSES REDACTED]. The patient's symptoms did not improve with treatments and she remained confused and unresponsive throughout most of her hospitalization and was admitted to Hospice for comfort measures. (Per Resident #6's Responsible Party's interview on [DATE] at 1:16 PM, the resident expired on [DATE] in the hospital, and never returned to the facility.) In a facility closed record review for Resident #6, the Comprehensive Admission Skin Assessment by the Wound Care Nurse (WCN) revealed inaccurate documentation, per professional standards of practice, by failure to include the staging, type, characteristics such as color, odor and drainage. The Comprehensive Admission Skin assessment dated [DATE], [DATE], [DATE] and [DATE] failed to give the type of measurements (centimeters or inch), failed to measure all of the wounds listed, failed to identify the type of wounds, failed to describe the drainage/odor of the wounds and failed to stage the wounds. There was no documentations that Resident #6's wounds were avoidable or unavoidable. The Quarterly Braden Risk Assessment Report by RN #3 on [DATE] revealed Resident #6 had a Risk Score of 12 that indicated Resident #6 was at high risk for Pressure Ulcers. The facility admitted Resident #6 to the facility on [DATE], with [DIAGNOSES REDACTED]. The Annual MDS with the ARD of [DATE] revealed Resident #6 had a BIMS score of zero that indicated Resident #6 was severely cognitively impaired. Resident #5 In a review of the weekly Comprehensive Admission Skin Assessment for Resident #5, dated [DATE], [DATE] and [DATE] revealed the facility failed to describe the characteristices, identify what type of wound and identity the correct location of three (3) unstageable wounds. A review of Resident #5's face sheet revealed the facility admitted Resident #5 on [DATE]. A review of Resident #5's Significant Change MDS with an ARD of [DATE] revealed multiple [DIAGNOSES REDACTED]. Resident #5 was at risk for the development of pressure ulcers and did not have any pressure ulcers documented at the time. Resident #5 scored 15 of 15 on The Brief Interview of Mental Status (BIMS) indicating that Resident #5 was cognitively intact. Resident #1 A wound care observation for Resident #1, on [DATE] at 1:50 PM, revealed the Wound Care Nurse (WCN) applied Collagen with a gloved hand (instead of using a cotton tipped applicator or tongue blade by professional standards of practice) after providing wound care to the stage II pressure ulcer of the coccyx which measured approximately one (1) inch long and approximately one-fourth (,[DATE]) inch wide with a pink center. In an interview with the WCN on [DATE] at 2:15 PM she confirmed she used a gloved hand to apply the Collagen to the Coccyx Stage II Pressure Ulcer. In a review of the weekly Comprehensive Admission Skin Assessment for Resident #1 dated [DATE] documented by the WCN, revealed a Pressure Ulcer to the Gluteal Fold 0.5 cm length X 0.25 cm width with no depth and no drainage. This assessment failed to list the stage of the Pressure Ulcer. The assessment for [DATE] was completed by LPN #2 and documented no signs of pressure/skin breakdown only slight bruising to back of arms due to insulin injections and no other bruising noted. This assessment failed to identify the Pressure Ulcer that continued to be identified on [DATE] by the DON that revealed pink area to sacrum, 0.5 cm X 0.5 cm and no drainage. The facility failed to stage or identify the type of skin concern identified. The assessment dated [DATE], by the WCN with the State Agency (SA) surveyor present, revealed Gluteal fold Stage II pressure ulcer that had worsened from a red area to a Stage II, and discrepancy of what had been previously assessed. The facility identified Resident #1's pressure sore as facility aquired. The facility provided no documentation Resident #1's Pressure Ulcer was avoidable or unavoidable. A review of Resident #1's face sheet revealed the facility admitted Resident #1 on [DATE] with no pressure ulcers. A review Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #1 had multiple [DIAGNOSES REDACTED]. The MDS revealed Resident #1 was at risk for developing pressure ulcers and had no pressure ulcers at the time. Resident #1 scored three (3) of 15 on the Brief Interview of Mental Status (BIMS) indicating that Resident #1 was severely cognitively impaired. Resident #2 A wound care observation for Resident #2 on [DATE] at 2:52 PM revealed the WCN cut the [MEDICATION NAME] AG with scissors not cleaned with a germicidal agent and placed the [MEDICATION NAME] AG in the center of the wound. Observation of treatment for [REDACTED]. An interview with the WCN on [DATE] at 3:15 PM, confirmed wiped top to bottom of wound instead of in a circular motion from center outward. Review of Resident #2's medical record revealed Wound #3 listed on the TAR and in the February 2016 physician's orders [REDACTED]. In a review of the weekly Comprehensive Admission Skin Assessment for Resident #2 dated [DATE] and [DATE] ([DATE]) revealed incorrect assessment with no identification of the stage of the wound or characteristics, and there was no measurements of the wounds noted on the documentation. Review of the February 2016 physician's orders [REDACTED].#2's skin issues documented on [DATE] by the DON. The assessment dated [DATE] revealed the pressure ulcer to the left hip area had not been identified, measured or staged. The pressure ulcers were facility acquired. The facility provided no documentation of the pressure areas being unavoidable. A review of Resident #2's face sheet revealed the facility admitted Resident #2 on [DATE]. A review of Resident #2's quarterly MDS with an ARD of [DATE] revealed Resident #2 had the [DIAGNOSES REDACTED]. The MDS documented Resident #2 at risk for the development of pressure ulcers with no pressure ulcers present. Resident #2 scored three (3) of 15 on The Brief Interview of Mental Status (BIMS) that indicated Resident #2 was severely cognitively impaired. Resident #3 An observation of wound care on Resident #3 on [DATE] at 1:18 PM revealed the WCN wiped the wound to the left leg from top to bottom twice with each wipe and did not start in the center of the wound and wipe outward. The WCN and then put the left leg down on top of the resident's pillow with no barrier and applied Collagen Powder to the larger wound on the mid calf with a gloved hand and lowered the left leg again on the pillow with no barrier. In an interview on [DATE] at 1:40 PM the WCN stated she provides care as ordered for Resident #3. The WCN stated the dressing change for Resident #3 was clean so there was no need for a barrier on the pillow. The WCN stated it was okay to apply Collagen with a gloved hand and stated I don't know how else to do put it on. Record review of the weekly Comprehensive Admission Skin Assessment for Resident #3, dated [DATE] by the WCN revealed: top of left calf, appears to be a boil, white center, intact area 1 cm width X 1 cm length; area to back of calf closed but tender; areas of slough noted to back of calf. (The facility assessment did not identify the wound associated with the sloughed area.) Record review of the weekly Comprehensive Admission Skin Assessment for Resident #3, dated [DATE] by the DON revealed: skin intact; continue to monitor back of left calf for worsening, no treatment changes at this time. The assessment did not describe the left calf area. The assessment is incomplete. Record review of the weekly Comprehensive Admission Skin Assessment for Resident #3, dated [DATE], by the WCN with the SA Surveyor present, revealed; right lower leg-bruises, [MEDICAL CONDITION] skin shiny-right foot, forth toe-nail with black spot-skin intact; left foot great toe open area 1 cm length X 0.5 cm, pink area underneath- intact; left lower leg 1 cm top of calf- edges approximated- 1 cm round boil appearing intact, 3 cm length X 1 cm width posterior calf- Stage II, 8 cm diameter to posterior calf with small open areas throughout. The facility failed to accurately assess and identify the open areas, black areas and pressure sores, on the great toe and had no treatments in place for the great toe. Resident #3's pressure ulcers were facility acquired from [DATE] -[DATE] with no documentation of whether avoidable/unavoidable. A review of Resident #3's face sheet revealed the facility admitted Resident #3 on [DATE]. A review of Resident #3's quarterly MDS with an ARD of [DATE] revealed Resident #3 had multiple [DIAGNOSES REDACTED]. Resident #3 was at risk for developing pressure ulcers and had no pressure ulcers identified on the MDS. Resident #3 scored three (3) of 15 on The Brief Interview of Mental Status (BIMS) indicating that Resident #3 was severely cognitively impaired. Resident #4 A wound care observation on [DATE] at 11:05 AM revealed the WCN cleaned Resident #4's wound to the coccyx in a circular motion with a 4X4 soaked in wound cleanser, starting in the center of the red area that was approximately grapefruit sized with two (2) circular open areas, one (1) a quarter size and one (1) a dime size; both Stage II wounds. The WCN wiped both open areas in the center of the reddened area with the same gauze and repeated in the same manner. The WCN then wiped the top wound with 4X4 soaked gauze from top to bottom then with new 4X4 soaked gauze and wiped the bottom wound from top to bottom and did not change gloves in between the wound care. The WCN then did not pat the wound dry before applying the Triple Antibiotic Ointment (TAO). During an interview on [DATE] at 11:40 AM the WCN stated she was nervous and forgot to pat the wound dry. When asked the purpose of drying the wound she responded, to get rid of the moisture. The WCN did not respond when asked if she should have changed gloves between wounds during care. Record review of the weekly Comprehensive Admission Skin Assessment for Resident #4 dated [DATE] by the WCN revealed: red buttocks/coccyx with skin intact. Record review of the weekly Comprehensive Admission Skin Assessment for Resident #4 dated [DATE] by the DON revealed: bruised left wrist, red sacrum, skin intact except small 1.0 X O.5 cm tear to gluteal fold. Record review of the weekly Comprehensive Admission Skin Assessment for Resident #4 dated [DATE] by the WCN and with the SA Surveyor present to observe revealed: scattered bruising and dry skin noted to left arm, inside left fourth toe small area appears toenail scratched, right elbow pink intact, right foot second toe small black area 0.2 cm X 0.25 cm, right foot third toe red area intact 0.2 cm X 0.2 cm, right upper arm with bruises X three (3)- skin intact, 2 cm X 1 cm left inside buttock deep red, 1 cm X 1 cm above rectum. Gluteal Fold ,[DATE] cm length then 10 cm diameter surrounding breakdown to coccyx. The facility failed to accurately identify, assess, stage and treat the identified areas documented on the [DATE] skin audit prior to [DATE]. Resident #4's pressure ulcers were facility acquired and the coccyx area had worsened from the previous assessment on [DATE]. A review of Resident #4's face sheet revealed the facility admitted Resident #4 on [DATE]. A review of Resident #4's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed multiple [DIAGNOSES REDACTED]. Resident # 4 was at risk of developing pressure ulcers and had a Stage 1 or higher pressure ulcer. Resident #4 scored 0 of 15 on The Brief Interview of Mental Status (BIMS) indicating that Resident #4 was severely cognitively impaired. Resident #7 A wound care observation of Resident #7 on [DATE] at 4:00 PM with RN #2, revealed Resident #7 not on an air mattress. (Resident #7 was listed as high risk for Pressure Ulcers on the list provided by the facility.) Resident #7's right heel had a quarter size black eschar area (Pressure Ulcer), no drainage and no redness and the left heel had a nickel sized black eschar area (Pressure Ulcer) with no redness or drainage. RN #2 removed the dressings on the left heel, no dressing was on the right heel, and reapplied a dressing to both heels without cleaning the ulcers. Review of the physician's orders [REDACTED].#7's ulcers prior to applying the dressing. The order dated [DATE] revealed: Change bordered foam dressing to bilateral heels every three (3) days and as needed. No dressing on the right heel on observation [DATE] at 4:00 PM during wound care observation. Record review of the weekly Comprehensive Admission Skin Assessment for Resident #7, dated [DATE], by the WCN, revealed: skin intact. Record review of the weekly Comprehensive Admission Skin Assessment for Resident #7, dated [DATE], by the WCN, revealed: scrotal redness, no drainage; bilateral heels, intact, clear fluid areas. Record review of the weekly Comprehensive Admission Skin Assessment Resident #7, dated [DATE] by LPN #2 noted: bandages applied to both heels on resident, heel protectors in place. There is no documented visual assessment of Resident #7's heels. Record review of the weekly Comprehensive Admission Skin Assessment Resident #7, dated [DATE] by RN #3, revealed notations on the body chart: light purple bruise to the inner left lower lip; 0.25 cm round area to left side of lower lip, no drainage, no odor, no pain; linear scars to bilateral knees; mild abrasions times three (3), no drainage to the left lower leg; left heel with 1.5 cm X 4.5 cm intact eschar, no drainage, no odor, no pain; right heel with intact eschar 1.4 cm X 1.8 cm, no drainage, no odor, no pain. The facility failed to identify, assess, and stage Resident #7's pressure ulcers to bilateral heels from [DATE] to [DATE]. Resident #7's ulcers developed and worsened during this time period. These ulcers were facility acquired with no documention of avoidable or unavoidable. A review of Resident #7's face sheet revealed the facility admitted Resident #7 on [DATE]. A review of Resident #7's Annual MDS with an ARD of [DATE] revealed multiple [DIAGNOSES REDACTED]. Resident #7 was at risk of developing a pressure ulcer and had no pressure ulcers documented. Resident #7 scored 3 of 15 on The Brief Interview of Mental Status (BIMS) indicating that Resident #7 was severely cognitively impaired. Resident #9 During the Wound Care Observation for Resident #9 on [DATE] at 2:20 PM by Registered Nurse (RN) #1, assisted by CNA #2, revealed RN #1 provided wound care without washing her hands prior and after providing wound care for Resident #9. RN #1 placed wound care supplies onto the heater without a barrier, and placed a cup with 4X4s soaked with wound cleanser on top of the bed without a barrier. The cup with the gauze tipped over with the gauze touching Resident #9's top covers. RN #1 provided wound care to Resident #9 with the gauze which touched the resident's bed sheet. RN #1 did not wash hands or change gloves after removing the soiled bandage. RN #1 cleaned the wound to the right hip by touching the moistened 4X4 gauze four (4) times up then down the wound without changing the gauze. RN #1 did not start in the center of the wound and wipe in a circular manner outward and did not change gauze between wipes. RN #1 then opened a packet (single use) of Triple Antibiotic Ointment (TAO) and squeezed contents in packet onto the wound without using a tongue blade or cotton tipped applicator. An interview with RN #1 on [DATE] at 2:40 PM revealed she was hired about a week prior and had no long term care experience. RN #1 stated she had been an RN for fourteen (14) years. RN #1 confirmed the area on Resident #9's right hip was found the previous night during the 100 percent body audits by the facility and she was not aware of the wound until then. RN #1 stated she did not have any special training for wound care or training on proper hand washing when hired. Record review of the weekly Comprehensive Admission Skin Assessment for Resident #9, dated [DATE] by LPN #2 revealed: a wound to the right hip/upper leg on right approximately 1 cm X 1 cm. The facility failed to correctly identify, stage, and describe the open area to Resident #9's right hip/upper leg . Record review of the weekly Comprehensive Admission Skin Assessment for Resident #9, dated [DATE] by the DON, revealed: right hip red, blanchable [DIAGNOSES REDACTED] measures 1 cm X 1 cm, resident stated it itches; [MEDICAL CONDITION] to bilateral feet, TED hose adjusted. The facility failed to identify/stage the area on the hip or describe characteristics of the area. Record review of the weekly Comprehensive Admission Skin Assessment for Resident #9, dated [DATE], by RN #3, revealed: three (3) pinpoint abrasions to inner left brown area, no drainage, no [MEDICAL CONDITION]; 0.25 cm X 0.25 cm round area to right nose, skin intact, no drainage, no [MEDICAL CONDITION]; posterior scrotum with redness and one (1) open area, no drainage; lighter redness to anterior scrotum with one (1) open area, no drainage; 1 cm X 1 CM area with 0.25 X 0.25 cm center, no drainage, no [MEDICAL CONDITION], to the right ischium. The facility failed to accurately assess/identify/stage the open areas. The open areas had worsed since prior assessments and was facility acquired. A review of the facility's face sheet revealed the facility admitted Resident #9 on [DATE]. A review Resident #9's Annual MDS with an ARD of [DATE] revealed multiple [DIAGNOSES REDACTED]. Resident #9 did not trigger to be at risk for the development of pressure ulcers and had no pressure ulcers at the time. Resident #9 scored 15 of 15 on The Brief Interview of Mental Status (BIMS) indicating that Resident #9 was cognitively intact. Interview with the WCN on [DATE] at 11:10 AM confirmed she'd completed wound care training the prior week. The WCN stated she tried to do body audits weekly, especially on high risk residents but was unable to complete all audits weekly related to being pulled to be the Nursing Supervisor position and she just couldn't get to everyone every week. Interview with the DON on [DATE] at 11:03 AM confirmed the wound care assessments are different based on the nurse doing the assessments and therefore not always the same. The DON stated some nurses are better at covering all the aspects of wounds than others like staging, documenting the assessments, and drainage. An interview with the DON on [DATE] at 12:05 PM, revealed the assessments were not put in the computer, they were put on the wound assessment sheets. The DON stated any nurse should be able to assess wounds. When asked if anyone observed or checked off staff for proper wound care or other skills and the DON responded no. The DON stated the facility didn't have a Staff Development Nurse, the hospital would not approve the position. The DON stated the RN Supervisor had been out on medical leave and she'd pulled the WCN to the floor to supervise.

Based on observation, staff interview, record review, and facility policy review, the facility failed to update and revise the care plan related to pressure ulcers and their treatments for 4 (four) of 12 residents reviewed for pressure ulcers, Resident #1, #4, #6, and #8. Findings Include: Review of the facility ' s policy entitled, Care Plans-Comprehensive , (no date), revealed, 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident ' s condition change. Observation on 12/3/2015 at 9:30 AM of Foley catheter care for Resident #4 (four), revealed a large dark pink area on left lower buttocks. The area had a small dark red blister formation in the center. Interview during Foley catheter care with Certified Nursing Assistants (CNA) #1 (one) and #3 (three) revealed that cream was put on Resident #4. Interview on 12/3/2015 at 11:00 AM with Registered Nurse (RN) #3 revealed he/she was unaware of any new skin issues or treatment for [REDACTED]. RN #3 stated the only treatments were ointment to the scrotum and baby oil to the scalp. Interview on 12/4/2015 at 12:30 PM with RN #2 revealed Resident #4 was not being seen for any wound care and he/she did not look at Stage 1 (one) wounds but did look at deep tissue injuries. Record review of the care plan for Potential for skin breakdown revealed approaches for skin risk assessment on admission and at regular intervals and notify appropriate staff of changes in risk assessment. Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, or discoloration noted during bath/daily care per CNAs. No updates for ointments or creams were listed on the care plan. Care plan goal was any skin impairment would not go undetected by next review date of 2/28/2016. Review of the facility ' s face sheet revealed the facility admitted the resident on 1/12/06. Resident #4 ' s [DIAGNOSES REDACTED]. Review of the Minimum Data Set with an Assessment Reference Date of 3/11/2015 revealed a Brief Interview of Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Section M 150 revealed the resident was at risk for developing pressure ulcers. Section M1200 revealed no skin and ulcer treatments were checked.

Based on record review, staff interview and the facility policy review, the facility failed to monitor and document skin assessments for residents with moderate to high risk for skin breakdown for 2 (two) of 5 (five) residents reviewed for risk of skin breakdown, Resident #4 and Resident #6. Findings Include: Review of the facility ' s policy, Pressure Ulcer Risk Assessment , (no date) revealed, 2. Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. 3. Monitoring: a. Staff will maintain a skin alert , performing routine skin inspections daily or every other day as needed. C. Nurses will conduct skin assessments at least weekly to identify changes. Interview on 12/3/2015 at 10:45 AM with Director of Nursing revealed the statement they (nurses) do not do weekly body audits. Stated the CNAs were instructed to report any skin breakdown. There was no wound care nurse at this time and RNs (registered nurses) who worked on the floor did the wound treatments. DON was unable to tell the surveyors when the last body audits were done. Was unable to state when the last wound/skin in-service was done. Stated he/she placed too much responsibility on the CNAs for reporting skin issues. Agreed with the surveyors that the wording on the care plans for regular intervals for skin risk assessments was too vague and did not reflect the need for more frequent assessments on high risk residents. Stated he/she was unaware of the skin breakdown on residents #4 and #6. Interview on 12/3/2015 at 12:45 PM with CNA #2 (two) revealed skin assessment was covered on his/her hire date and orientation. Stated he/she would report first to the nurse on the hall or other nurses and the chain of command. Interview on 12/3/2015 at 2:30 PM with LPN (licensed practical nurse) #2 (two) revealed he/she did not do a weekly skin audit. I have not been in serviced on skin assessments. Interview on 12/3/2015 at 2:40 PM wit CNA #1 (one) revealed the statement, We were told to follow the chain of command when reporting skin issues. Record review of the Braden Risk Assessment for Resident #4 revealed a score of 14 which indicated a moderate risk for skin breakdown. Care plan for risk for skin breakdown for Resident #4 revealed no interventions for creams, ointments, or dressings. No updates for current skin breakdown or deep tissue injury. Review of skin treatment record for Resident #4 revealed no treatment for [REDACTED].#6 revealed a high risk for skin breakdown with the last date of assessment as 10/7/2015. Review of treatment record for Resident #6 had a treatment for [REDACTED]. Apply [MEDICATION NAME] ointment underneath right breast and buttocks daily until excoriated areas are healed had a start date of 2/3/2015 and were being continued. Review of the care plan for Resident #6 revealed no updates or revisions to include the skin breakdown observed on 12/3/2015. Review of wound healing progress report dated 12/2/2015 revealed no information for skin breakdown for Resident #4 and Resident #6.

Based on observation, record review, staff interviews, and the facility policy review, the facility failed to identify skin breakdown for 2 (two) of 5 (five) residents reviewed for skin breakdown, Resident #4, Resident #6. Findings Include: Review of the facility ' s policy entitled, Pressure Ulcer Risk Assessment , no date, revealed, 2. Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. 3. Monitoring: a. Staff will maintain a skin alert performing routine skin inspections daily or every other day as needed. c. Nurses will conduct skin assessments at least weekly to identify changes. Observation of foley catheter care on 12/3/2015 at 9:30 AM for Resident #4 revealed a large circular reddened area on left buttocks. A small dark red blister was noted on the dark red area. No dressing was in place. Resident had contractures of upper extremities and was unable to reposition without assistance. Interview on 12/3/2015 at 10:45 AM with Director of Nursing and Quality Assurance Nurse revealed they were unaware of the pressure area on Resident #4. Director of Nursing stated they did not do weekly body audits and the certified nursing assistants were instructed to report any skin breakdown. The facility did not have a nurse designated as a wound care nurse at this time. Director of Nursing and Quality Assurance Nurse could not state when the last in-service for wounds had been done. Present Director of Nursing was also the Minimum Data Set and Care Plan Co-coordinator. Interview on 12/3/2015 at 11:00 AM with Registered Nurse #3 (three) revealed the certified nursing assistants had not reported any skin breakdown for Resident #4. RN #3 was unaware of any skin treatment to buttocks but would look at it. Interview on 12/3/2015 at 2:30 PM with LPN (licensed practical nurse) #2 (two) revealed he/she did not do weekly skin audits. Stated he/she had not been in-serviced on skin assessments. Interview on 12/3/2015 at 2:40 PM with CNA #1 (one) that the red area on Resident #4 had been there since he/she had been employed at the facility. Stated he/she put cream on the area. Stated he/she had been told to follow the chain of command when reporting skin issues. Stated he/she had not reported the area to the nurses but was going to report. Interview on 12/4/2015 at 12:30 PM with RN #2 (two), wound care clinical specialist, stated Resident #4 was not on his/her caseload and had not seen Resident #4 for any wound care. Stated he/she came once a month and taught about advanced wound care products and change/recommend products and wound treatments. Stated the wound treatments were usually ordered for 30 days. Stated he/she did not look at stage 1 wounds but would check on the deep tissue injuries. Record review of care plan for potential for skin breakdown revealed no revisions for application of ointments or suspected deep tissue injury. Skin risk assessment for skin inspection at regular intervals was listed as an approach. No approaches were listed for referral to wound care specialist if needed. Review of wound healing progress report did not include Resident #4. Review of the Braden skin risk assessment listed Resident #4 as a moderate risk for developing pressure sores. Review of the treatment record for the month of November 2015 revealed the application of ointment to scrotal area with no other treatments for prevention.

Part I CI MS # Based on interviews, policy review, medical record review, and review of an Autopsy Report from the Mississippi State Medical Examiner's Office, the facility failed to develop a care plan for the potential for constipation/fecal impaction in an effort to prevent constipation/fecal impactions. This resulted in Resident #2's death due to a "Massive colon dilatation due to fecal impaction resulting in [MEDICAL CONDITION] and Asphyxia." This is for three (3) of six (6) sampled residents reviewed (Residents #1, #2, and #4). The lack of implementation to ensure that the facility developes a care plan for the potential for constipation/fecal impaction in an effort to prevent constipation/fecal impactions was deemed an Immediate Jeopardy to begin on 12-31-11 and was removed on 5-11-12. The facility Administrator, Director of Nursing (DON), Risk Manager, and Administrator of the hospital were notified of the Immediate Jeopardy on 5-10-12 at 2:45 p.m. The facility provided a credible Allegation of Compliance (AoC) on 5-11-12 at 5:30 p.m. Based on verification of the facility's corrective actions that were validated by observations, in-service review forms, staff review of testing, review of revised care plans, and review of policy development/revisions, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 5-11-12 to a "H" level, which constituted actual harm that is not an Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee. Findings Include: Cross Refer to F-309 for the facility's failure to assess residents using all information available, develop care plans to address the potential for constipation, re-assess the residents as necessary, accurately monitor resident's bowel elimination, and follow up with interventions to prevent constipation as necessary. The facility provided a crediable Allegation of Compliance on 5-11-12 at 5:30 p.m. "Crediable Allegation of Compliance" "Addendum to Allegation of Compliance of 5/11/12. Resident #1 was identified 5-16-12. Resident #1 is an eighty-two year old female admitted to (Nursing Facility) on 3/16/06 status [REDACTED]. On 4/20/12 Resident #1 was sent for x-ray of right hip due to complaints of pain and history of hip replacement. X-ray report indicated increased stool is noted in the rectosigmoid colon. Resident #1 charted indicated bowel movement times one on 4/20/12 and bowel movements times two on 4/21/12. Resident #1 care plan was updated to include at risk for constipation. Resident #2 was a seventy-three (73) year old female who was admitted to (Nursing Facility) on 11/12/1991 following a severe stroke. On 12/28/11 at 11:45 a.m. Resident #2 was seen by her primary physician. No new orders were written. From the time Resident #2 was seen by her primary physician until 12/31/11, there was not change in her condition. About 8:15 a.m. on 12/31/11 the LPN (Licensed Practical Nurse) suctioned salvia from Resident #2 mouth and Resident #2 replied "thank you". At 8:45 a.m. on 12/31/11 the LPN entered Resident #2's room to administer medication(s) at which time the LPN noted Resident #2 was pale, not breathing and did not have a pulse. The LPN checked Resident #2 for respiration, blood pressure, and pulse but none could be obtained. At 8:53 a.m. on 12/31/11 the on-call physician was notified. At 8:55 a.m. (County Coroner) was notified. At 8:57 a.m. Resident #2's responsible was notified. On 12/31/11 at 9:10 a.m. Resident #2 was pronounced by (County Coroner). Resident #4 was an eighty-eight (88) year old female who was admitted to (Nursing Facility) on 11/3/10. On 8/24/11 Resident #4 had esophagram. Findings were complete absence of primary and secondary peristalsis of the esophagus with distal tertiary contractions note, findings of poor relaxation of the GE junction resulting in extensive stasis of contrast in the esophagus. On 2/28/12 at 7:15 a.m. LPN contacted primary physician concerning coffee ground emesis, test for blood pressure was ordered. On 2/28/12 at 9:45 a.m. LPN contacted Resident #4 primary physician about positive blood in emesis and LPN received order to transfer Resident #4 to emergency room for evaluation. On 2/28/12 at 10:00 a.m. family was notified of order to transfer to emergency room . On 2/28/12 at 12:45 p.m. (Nursing Facility) was notified by emergency room that Resident #4 was being transferred to (local hospital). While (local hospital) per physician progress notes [REDACTED]. On 3/06/12 at 4:05 p.m. Resident #4 was readmitted to the (Nursing Facility), and Resident #4 verbalized on 3/06/12 that she was glad to be home and sleeping in her own bed. On 3/08/12 at 7:30 p.m. the primary physician of Resident #4 was contacted per LPN about coffee ground emesis and primary physician stated "I have talked with family and they understood what is going on, there is nothing we can do about it just continue to monitor her". On 3/09/12 at 1:30 p.m. Resident #4 was noted to have irregular respiratory pattern while asleep. At this time the RN assessed Resident #4 and lung sounds were clear, pulse oxemetry was at ninety-seven percent on room air. On 3/10/12 at 10:30 p.m. Resident #4 noted with black coffee ground emesis, breathing pattern irregular, Resident #4 awake and talking to LPN. On 3/11/12 at 10:00 a.m. Resident #4 was noted by LPN to be resting quietly with irregular breathing pattern. On 3/11/12 at 6:40 p.m. LPN informed per C.N.A. (Certified Nursing Assistant) that Resident #4 appeared to have no respirations. Absences of vital signs verified by RN (Registered Nurse) times three attempts. Family notified on 3/11/12 at 6:45 p.m. Son-in-law stated will be en-route. (County Coroner) was notified on 3/11/12 at 6:47 p.m. On 3/11/12 at 7:15 p.m. Resident #4 was pronounced by (County Coroner), with Son-in-law and LPN was present. A policy and procedure was developed by the Administrator, the Director of Nursing, and the Minimum Data Set Nurse on 5/10/12 at 4:00 p.m. outlining the utilization of Professional Standards of Practice for bowel movements. The Medical Director reviewed and approved the policy on 5/10/12 at 4:45 p.m. RN #2, LPN #1, LPN #2 were in-serviced on the policy by the Minimum Data Set Nurse on 5/10/12 at 5:15 p.m. and LPN #5 and LPN #6 were in-serviced on 5/10/12 at 6:30 p.m. On 5/11/12 at 6:30 a.m. the Minimum Data Set Nurse in-serviced RN #1, LPN #3, and LPN #4 on the Professional Standards of Practice for bowel movement policy. On 5/10/12 at 4:45 p.m. RN #2, LPN #1, LPN #2, C.N.A. #8,16,19,20,and 21 were in-serviced on bowel elimination by the Minimum Data Set Nurse and completed a test to demonstrate understanding of content of the in-service with one-hundred percent passing rate. On 5/10/12 at 6:30 p.m. and LPN #5 and LPN #6 were in-serviced by the Minimum Data Set Nurse and completed a test to demonstrate understanding of content of the in-service with one-hundred percent passing rate. On 5/11/12 at 6:30 a.m. RN #3, LPN #3, LPN #4, C.N.A, #27, 24 , 5, 14, 6, 10 13, 15, 25 were in-serviced on bowel elimination by the Minimum Data Set Nurse and completed a test to demonstrate understanding of content of the in-service with one-hundred percent passing rate. The Care Plan policy and procedure was reviewed and revised on 5/10/12 at 4:30 p.m. by the Administrator, the Director of Nursing, and the Minimum Data Set Nurse. The previous policy was four pages. The revisions to the previous policy were deletion of contacting Ombudsman if no family, condensing policy and procedure to eliminate redunence, and to make wording of policy more user friendly and to improve staff understanding of policy. The Medical Director reviewed and approved the policy on 5/10/12/at 4:45 p.m. The Director of Nursing in-serviced the Activity Director and the Social Service Director on 5/11/12 at 8:00 a.m. on the revised Care Plan Policy. On 5/11/12 at 3:30 p.m. RN #1, RN #2, LPN #3, LPN #4 were in-serviced by Nurse Consultant on the revised care plan policy and procedure. Abuse and Neglect in-services was conducted on 5/11/12 at 3:00 p.m. and at 3:30 p.m. by Nurse Consultant. Staff attending the in-service were RN #3, LPN #4, RN #2, RN #1, LPN #3, and Minimum Data Set Nurse, C.N.A. #21, 20, 16, 19, 5, 13, 10, 8, 15, and 6. The in-service included review of current policy on abuse and neglect , as well as accurate reporting and documentation of bowel movements and the consequences of failure to report or document bowel elimination. All staff will have to attend above in-services before being allowed to work. The Director of Nursing and the Minimum Data Set Nurse have reviewed fifty (50) Residents' care plans, of a current census of 50 Residents on 5/10/12 at 5:00 p.m. to determine which Residents have a current order for a medication to promote bowel movements. Residents' care plan was revised as needed on 5/10/12 by the Director of Nursing and the Minimum Data Set Nurse. Reviews and revisions were completed on 5/10/12 at 9:00 p.m. The Director of Nursing and the Minimum Data Set Nurse reviewed X-Ray results in Residents' current medical record on 5/10/12 at 5:00 p.m. while reviewing care plans. Reviews and revisions were complete on 5/10/12 at 9:00 p.m. The care plans that were revised were for Resident A, B, C, D, E, F, G, H, I. On-coming nurse(s) will review the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. If a Resident is noted to not have had a bowel movement in three days, the RN/LPN will administer a laxative to promote a bowel movement. In the event the laxative does not produce a bowel movement, the RN/LPN will administer a suppository. In the event the suppository does not produce bowel movement, the RN/LPN will contact the Resident's primary physician/on-call physician. The Director of Nursing or his/her designee will review Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Director of Nursing or his/her designee will report findings of the medication administration review to the Quality Assurance Committee and recommendations will be followed. The Director of Nursing or his/her designee will review medical record at lease monthly to ensure care plans have been revised as needed. The Director of Nursing or his/her designee will report findings of the medical record review and care plan revisions to the Quality Assurance Committee and recommendations will be followed." Based on verification of the facility's corrective actions that were validated by observations, in-service review forms, staff review of testing, review of revised care plans, and review of policy development/revisions, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 5-11-12 to a "H" level, which constituted actual harm that is not an Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

Part I CI MS # Based on interviews, policy review, medical record review, and review of an Autopsy Report from the Mississippi State Medical Examiner's Office, the facility failed to adequately assess, care plan, monitor, and re-assess residents for the potential for constipation/fecal impaction in an effort to prevent constipation/fecal impactions. This resulted in Resident #2's death due to a "Massive colon dilatation due to fecal impaction resulting in [MEDICAL CONDITION] and Asphyxia." This is for three (3) of six (6) sampled residents reviewed (Residents #1, #2, and #4). The lack of implementation to ensure that the facility adequately assess, care plan, monitor, and re-assess residents for the potential for constipation/fecal impaction in an effort to prevent constipation/fecal impactions was deemed an Immediate Jeopardy to begin on 12-31-11 and was removed on 5-11-12. The facility Administrator, Director of Nursing (DON), Risk Manager, and Administrator of the hospital were notified of the Immediate Jeopardy on 5-10-12 at 2:45 p.m. The facility provided a credible Allegation of Compliance (AoC) on 5-11-12 at 5:30 p.m. Based on verification of the facility's corrective actions that were validated by observations, in-service review forms, staff review of testing, review of revised care plans, and review of policy development/revisions, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 5-11-12 to a "H" level, which constituted actual harm that is not an Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee. Findings Include: Cross Refer to F-309 for the facility's failure to assess residents using all information available, develop care plans to address the potential for constipation, re-assess the residents as necessary, accurately monitor resident's bowel elimination, and follow up with interventions to prevent constipation as necessary. The facility provided a crediable Allegation of Compliance on 5-11-12 at 5:30 p.m. "Crediable Allegation of Compliance" "Addendum to Allegation of Compliance of 5/11/12. Resident #1 was identified 5-16-12. Resident #1 is an eighty-two year old female admitted to (Nursing Facility) on 3/16/06 status [REDACTED]. On 4/20/12 Resident #1 was sent for x-ray of right hip due to complaints of pain and history of hip replacement. X-ray report indicated increased stool is noted in the rectosigmoid colon. Resident #1 charted indicated bowel movement times one on 4/20/12 and bowel movements times two on 4/21/12. Resident #1 care plan was updated to include at risk for constipation. Resident #2 was a seventy-three (73) year old female who was admitted to (Nursing Facility) on 11/12/1991 following a severe stroke. On 12/28/11 at 11:45 a.m. Resident #2 was seen by her primary physician. No new orders were written. From the time Resident #2 was seen by her primary physician until 12/31/11, there was not change in her condition. About 8:15 a.m. on 12/31/11 the LPN (Licensed Practical Nurse) suctioned salvia from Resident #2 mouth and Resident #2 replied "thank you". At 8:45 a.m. on 12/31/11 the LPN entered Resident #2's room to administer medication(s) at which time the LPN noted Resident #2 was pale, not breathing and did not have a pulse. The LPN checked Resident #2 for respiration, blood pressure, and pulse but none could be obtained. At 8:53 a.m. on 12/31/11 the on-call physician was notified. At 8:55 a.m. (County Coroner) was notified. At 8:57 a.m. Resident #2's responsible was notified. On 12/31/11 at 9:10 a.m. Resident #2 was pronounced by (County Coroner). Resident #4 was an eighty-eight (88) year old female who was admitted to (Nursing Facility) on 11/3/10. On 8/24/11 Resident #4 had esophagram. Findings were complete absence of primary and secondary peristalsis of the esophagus with distal tertiary contractions note, findings of poor relaxation of the GE junction resulting in extensive stasis of contrast in the esophagus. On 2/28/12 at 7:15 a.m. LPN contacted primary physician concerning coffee ground emesis, test for blood pressure was ordered. On 2/28/12 at 9:45 a.m. LPN contacted Resident #4 primary physician about positive blood in emesis and LPN received order to transfer Resident #4 to emergency room for evaluation. On 2/28/12 at 10:00 a.m. family was notified of order to transfer to emergency room . On 2/28/12 at 12:45 p.m. (Nursing Facility) was notified by emergency room that Resident #4 was being transferred to (local hospital). While (local hospital) per physician progress notes [REDACTED]. On 3/06/12 at 4:05 p.m. Resident #4 was readmitted to the (Nursing Facility), and Resident #4 verbalized on 3/06/12 that she was glad to be home and sleeping in her own bed. On 3/08/12 at 7:30 p.m. the primary physician of Resident #4 was contacted per LPN about coffee ground emesis and primary physician stated "I have talked with family and they understood what is going on, there is nothing we can do about it just continue to monitor her". On 3/09/12 at 1:30 p.m. Resident #4 was noted to have irregular respiratory pattern while asleep. At this time the RN assessed Resident #4 and lung sounds were clear, pulse oxemetry was at ninety-seven percent on room air. On 3/10/12 at 10:30 p.m. Resident #4 noted with black coffee ground emesis, breathing pattern irregular, Resident #4 awake and talking to LPN. On 3/11/12 at 10:00 a.m. Resident #4 was noted by LPN to be resting quietly with irregular breathing pattern. On 3/11/12 at 6:40 p.m. LPN informed per C.N.A. (Certified Nursing Assistant) that Resident #4 appeared to have no respirations. Absences of vital signs verified by RN (Registered Nurse) times three attempts. Family notified on 3/11/12 at 6:45 p.m. Son-in-law stated will be en-route. (County Coroner) was notified on 3/11/12 at 6:47 p.m. On 3/11/12 at 7:15 p.m. Resident #4 was pronounced by (County Coroner), with Son-in-law and LPN was present. A policy and procedure was developed by the Administrator, the Director of Nursing, and the Minimum Data Set Nurse on 5/10/12 at 4:00 p.m. outlining the utilization of Professional Standards of Practice for bowel movements. The Medical Director reviewed and approved the policy on 5/10/12 at 4:45 p.m. RN #2, LPN #1, LPN #2 were in-serviced on the policy by the Minimum Data Set Nurse on 5/10/12 at 5:15 p.m. and LPN #5 and LPN #6 were in-serviced on 5/10/12 at 6:30 p.m. On 5/11/12 at 6:30 a.m. the Minimum Data Set Nurse in-serviced RN #1, LPN #3, and LPN #4 on the Professional Standards of Practice for bowel movement policy. On 5/10/12 at 4:45 p.m. RN #2, LPN #1, LPN #2, C.N.A. #8,16,19,20,and 21 were in-serviced on bowel elimination by the Minimum Data Set Nurse and completed a test to demonstrate understanding of content of the in-service with one-hundred percent passing rate. On 5/10/12 at 6:30 p.m. and LPN #5 and LPN #6 were in-serviced by the Minimum Data Set Nurse and completed a test to demonstrate understanding of content of the in-service with one-hundred percent passing rate. On 5/11/12 at 6:30 a.m. RN #3, LPN #3, LPN #4, C.N.A, #27, 24 , 5, 14, 6, 10 13, 15, 25 were in-serviced on bowel elimination by the Minimum Data Set Nurse and completed a test to demonstrate understanding of content of the in-service with one-hundred percent passing rate. The Care Plan policy and procedure was reviewed and revised on 5/10/12 at 4:30 p.m. by the Administrator, the Director of Nursing, and the Minimum Data Set Nurse. The previous policy was four pages. The revisions to the previous policy were deletion of contacting Ombudsman if no family, condensing policy and procedure to eliminate redunence, and to make wording of policy more user friendly and to improve staff understanding of policy. The Medical Director reviewed and approved the policy on 5/10/12/at 4:45 p.m. The Director of Nursing in-serviced the Activity Director and the Social Service Director on 5/11/12 at 8:00 a.m. on the revised Care Plan Policy. On 5/11/12 at 3:30 p.m. RN #1, RN #2, LPN #3, LPN #4 were in-serviced by Nurse Consultant on the revised care plan policy and procedure. Abuse and Neglect in-services was conducted on 5/11/12 at 3:00 p.m. and at 3:30 p.m. by Nurse Consultant. Staff attending the in-service were RN #3, LPN #4, RN #2, RN #1, LPN #3, and Minimum Data Set Nurse, C.N.A. #21, 20, 16, 19, 5, 13, 10, 8, 15, and 6. The in-service included review of current policy on abuse and neglect , as well as accurate reporting and documentation of bowel movements and the consequences of failure to report or document bowel elimination. All staff will have to attend above in-services before being allowed to work. The Director of Nursing and the Minimum Data Set Nurse have reviewed fifty (50) Residents' care plans, of a current census of 50 Residents on 5/10/12 at 5:00 p.m. to determine which Residents have a current order for a medication to promote bowel movements. Residents' care plan was revised as needed on 5/10/12 by the Director of Nursing and the Minimum Data Set Nurse. Reviews and revisions were completed on 5/10/12 at 9:00 p.m. The Director of Nursing and the Minimum Data Set Nurse reviewed X-Ray results in Residents' current medical record on 5/10/12 at 5:00 p.m. while reviewing care plans. Reviews and revisions were complete on 5/10/12 at 9:00 p.m. The care plans that were revised were for Resident A, B, C, D, E, F, G, H, I. On-coming nurse(s) will review the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. If a Resident is noted to not have had a bowel movement in three days, the RN/LPN will administer a laxative to promote a bowel movement. In the event the laxative does not produce a bowel movement, the RN/LPN will administer a suppository. In the event the suppository does not produce bowel movement, the RN/LPN will contact the Resident's primary physician/on-call physician. The Director of Nursing or his/her designee will review Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Director of Nursing or his/her designee will report findings of the medication administration review to the Quality Assurance Committee and recommendations will be followed. The Director of Nursing or his/her designee will review medical record at lease monthly to ensure care plans have been revised as needed. The Director of Nursing or his/her designee will report findings of the medical record review and care plan revisions to the Quality Assurance Committee and recommendations will be followed." Based on verification of the facility's corrective actions that were validated by observations, in-service review forms, staff review of testing, review of revised care plans, and review of policy development/revisions, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 5-11-12 to a "H" level, which constituted actual harm that is not an Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

Part I CI MS # Based on record review, policy review, interviews and review of an autopsy report from the Mississippi State Medical Examiner's Office, the facility failed to ensure that the bowel elimination of residents was accurately monitored, that the resident received laxatives as needed, and that the potential for constipation was identified and interventions were planned according to the resident's needs to prevent constipation/fecal impactions. This resulted in Resident #2's death due to a "Massive colon dilatation due to fecal impaction resulting in [MEDICAL CONDITION] and Asphyxia." This is for three (3) of six (6) residents reviewed (Residents #1, #2 and #4). The lack of implementation to ensure that the bowel elimination of residents was accurately monitored, that the resident received laxatives as needed, and that the potential for constipation was identified and interventions were planned according to the resident's needs to prevent constipation/fecal impactions was deemed Substandard Quality of Care and an Immediate Jeopardy to begin on [DATE] and was removed on [DATE]. The facility Administrator, Director of Nursing (DON), Risk Manager, and Administrator of the hospital were notified of the Immediate Jeopardy on [DATE] at 2:45 p.m. The facility provided a credible Allegation of Compliance (AoC) on [DATE] at 5:30 p.m. Based on verification of the facility's corrective actions that were validated by observations, in-service review forms, staff review of testing, review of revised care plans, and review of policy development/revisions, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on [DATE] to a "H" level, which constituted actual harm that is not an Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee. Findings Include: Resident #2 Resident #2 could not be observed as this record was closed. Record review for Resident #2 Revealed that the resident was born [DATE]. Resident #2 was admitted to the facility [DATE]. Review of Resident #2's Discharge Summary dated [DATE] revealed that the resident's [DIAGNOSES REDACTED]. The Discharge Summary also noted that the Discharge [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment with the Assessment Reference Date (ARD) of [DATE] revealed that Resident #2 was unable to complete the Brief Interview for Mental Status (BIMS) and had short and long term memory problems. This assessment indicated that Resident #2 had unclear speech, was sometimes understood by others, and that she usually understood most conversation. Resident #2 was totally dependent on facility staff for bed mobility, dressing, eating, toilet use and personal hygiene. Nurses Notes for Resident #2, dated [DATE], documented the following: ",[DATE] 0815 (8:15 a.m.) Resident grunting, mouth full of salavia (saliva) suctioned resident to clear mouth out. When finished wiped face off and sat her head up. Resident said 'Thank you'. Will cont (continue) to monitor." ",[DATE] 0845 (8:45 a.m.) Pulled up residents medicine went into room to give residents am (morning) meds (medicine). When got to bedside, held feeding tube and pulled covers down to get tube and noted resident was extremely pale. Noted resident didn't appear to be breathing. Felt for carotid pulse, absent. Turn (turned) feeding off, got BP (blood pressure) cuff and stethescope attempted to obtain blood pressure, unable to hear anything. RN (Registered Nurse) in to assess, unable to hear pulse and no O2 sat (oxygen saturation) able to obtain. 0853 (8:53 am) MD (Medical Doctor) ....(Name) FNP (Family Nurse Practitioner) on call notified of residents death. 0855 (8:55 am) coroner called, no answer, then paged. 0857 (8:57 am) residents sister, ...(name), RP (Responsible Party) notified she needed to come to facility. Stated she will be here shortly. 0900 (9:00 am) coroner returned call and stated he was on his way. 0902 (9:02 am) Residents sister and another family member arrived, informed residents (resident's) sister that resident had passed. 0910 (9:10 am) coroner arrived @ (at) facility, pronounced resident. 0915 (9:15 am) Funeral Home .... (Name) called and notified. 0926 (9:26 am) Funeral home arrived. Body removed @ 0935 (9:35 am) from facility. Family left as well and stated they would be back later and get her stuff." Resident #2 expired on [DATE] and was embalmed. Review of the autopsy report signed by the Chief Medical Examiner revealed that on [DATE] authority was given for an autopsy to be performed. On [DATE] an autopsy was performed on the body of Resident #2. The Opinion section of the autopsy report stated "This [AGE] year-old woman identified as .... (Resident #2) died as a result of [MEDICAL CONDITION] due to Mechanical Asphyxia that resulted from massive dilatation of the colon caused by a fecal impaction. This ultimately resulted in severe superior (upward) displacement of the diaphragm and compression of her lungs. There was no evidence of traumatic injury that would have resulted in her death. With the currently available information and the autopsy findings, the cause of death is Mechanical Asphyxia and the manner of death is accident." Review of the Statement to Amend Cause "of Death", dated [DATE], revealed the Immediate Cause of death was listed as Mechanical Asphyxia. Colon Obstruction and Fecal Impaction were listed as leading to immediate cause. Interview with the Funeral Home Staff on [DATE] at 3:15 p.m. that embalmed Resident #2, revealed that Resident #2's rectum had been evacuated as part of the embalming process. Interview with Resident #2's Attending Physician on [DATE] at 12:45 p.m., revealed that there was no medical condition or [DIAGNOSES REDACTED]. The Attending Physician stated that Resident #2 had been managed for [AGE] years without problems. The Attending Physician stated that there were no signs or symptoms of constipation preceding the [DATE] incident. Resident #2 had no vomiting. The Attending Physician stated that he had not been consulted by the facility staff regarding Resident #2 being constipated. Interview with the Director of Nursing (DON) on [DATE] at 2:20 p.m., revealed that she had worked as a floor nurse assigned to Resident #2 on [DATE] and noted no signs or symptoms of constipation at that time. The DON continued to say that she made rounds with the resident's physician on [DATE] and assisted him to assess Resident #2's abdomen and no problems were identified then. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 4:10 p.m., assigned to care for Resident #2 on [DATE], revealed that she had suctioned approximately ten (10) cubic centimeters (cc) of what appeared to be clear yellow liquid from the resident's mouth that morning. At the same time she checked the stomach residual and there was none. The stomach was not distended. LPN #1 stated that Resident #2 could indicate if she was in pain and that there were no complaints of pain. The Resident #2 was not vomiting that day. Interview with Certified Nurse Aide (CNA) #1 on [DATE] at 11:55 a.m., in the presence of the Risk Manager at the request of the CNA #1 , revealed that the CNA #1 was familiar with Resident #2 having worked with her in the past. CNA #1 stated that she was not assigned to the resident on [DATE] but did assist with preparing the body for transport to the funeral home after the coroner had pronounced the death. CNA #1 stated that she noticed that the resident had a "brown/tanish" drainage from her mouth down the side of her face, and Licensed Practical Nurse (LPN) #1 was notified of this. CNA #1 stated that she noted that the resident's rectum was open about the size of a quarter but no feces was noted in the rectum. CNA #1 also stated that Resident #2's abdomen was distended "a little bit". Interview with CNA #3 on [DATE] at 12:22 p.m., revealed that she also was assisting with the preparation of Resident #2's body for transportation to the funeral home. CNA #3 stated that the Resident #2 was bathed and when they attempted to apply an adult brief (the resident's normal size brief) they could hardly fasten the tabs secondary to the resident's abdomen being so distended. As the rectum was cleaned, CNA #3 noticed that the rectum was open more than the size of a quarter. Feces was noted to be present in the rectum. CNA #3 stated that when they rolled the Resident #2 from side to side, a "dark greenish brown drainage" came from the resident's mouth. CNA #3 continued, saying that she had seen residents with the rectum open and feces present in the past and she would call the nurse who would "dig them out". Interview with CNA #4 on [DATE] at 8:40 a.m., revealed that she had checked on Resident #2 at about 6:30 a.m. on [DATE] and the resident was her usual self. CNA #4 said she checked on the resident again about 7:30 a.m. and Resident #2 was gasping for breath. Nurses were summoned and three nurses came to assess the resident. The nurses were identified as LPN #1, Registered Nurse (RN) #1, and LPN #2. Before long the resident passed. As Resident #2 took her last breath, a dark, slimy, foul smelling drainage came from the resident's mouth. CNA #4 stated that she could only describe it as a bowel movement. As the CNA's were bathing Resident #2, this substance continued to come out of the resident's mouth. The rectum was observed to be stretched as big around as a drink can. A large amount of hard feces was noted at the end of the rectum. CNA #4 stated that she informed RN #1 of this. Interview with RN #1 on [DATE] at 1:25 p.m., revealed that she was working the day that Resident #2 expired. She was called in when the resident ceased breathing. RN #1 stated that there was nothing coming from the resident's mouth or nose. Interview with the Director of Nursing (DON) on [DATE] at 4:35 p.m., revealed that there was no written facility policy for the prevention of constipation to include the monitoring of bowel movements (BM). The method of monitoring bowel movements was what all nurses learned in school. Daily records are kept documenting the number of bowel movements. If the resident has no BM in three (3) days a laxative is given. Interview with the DON on [DATE] at 12:30 p.m., revealed that she was instructed not to provide a written statement as to the standard of practice that the facility followed to prevent constipation. Review of the [DATE] records for BMs for Resident #2 revealed that the resident had no documented BM on [DATE], [DATE], [DATE], or [DATE]. Review of the Physician Orders, Nurses Notes, and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #2 had no BM documented on [DATE], [DATE], [DATE], and [DATE]. There was no documentation found on the Physician Orders, Nurses Notes, and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with the LPN Minimum Data Set Assessment/Care Plan Nurse on [DATE] at approximately 3:15 p.m., revealed that the care plan for Resident #2 which was in effect from [DATE] through February 25, 2012 did not identify and address the potential for constipation. Resident #1 Resident #1 was observed on [DATE] at 10:00 a.m. in the lobby of the facility sitting in a wheelchair eating crackers. Interview with the DON of the facility at the time of this observation revealed that the resident received tube feedings at night. Record review revealed that Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An x-ray of the abdomen for Resident #1 dated [DATE] revealed the Clinical History was Constipation. The Findings stated "There is a large amount of stool in the rectum ...." The Impression was "Large stool in the rectum". Record review of Resident #1's Nurses Notes revealed that the resident was in the Geripsych Unit [DATE] through [DATE]. Interview with the DON on [DATE] at 2:20 p.m., revealed that the x-ray dated [DATE] was done as part of a routine admission work-up for the Geripsych unit. The DON stated that if the x-ray had reported stool in the colon or anywhere other than the rectum, the facility would have addressed the possibility of constipation. Review of the monitoring of bowel movements for the month of [DATE] revealed that there was no documentation from [DATE] through [DATE] as Resident #1 was out of the facility. To the side of the [DATE] entry was a notation that the "last BM [DATE]". Going from that documentation, the resident had no documented BM for three days, ,[DATE], ,[DATE], ,[DATE]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further record review for Resident #1 revealed that on [DATE] the resident was seen in the emergency room (ER) for chest pain. A KUB (kidneys, ureters, and bladder) x-ray was done. The history for this ER visit revealed upper abdominal and chest pain. At 11:15 a.m. the resident was given a [MEDICATION NAME] Suppository. At 12:10 p.m. the resident had a "large, soft, brown BM". Resident #1 was discharged back to the facility. Record review of the KUB report under findings indicated "Moderate amount of fecal material is seen in the colon especially the rectum ...." Further record review for Resident #1 revealed that on [DATE] a report of an x-ray of the right hip was faxed to the facility. "Increased stool is noted in the rectosigmoid colon." Interview with the LPN Care Plan Nurse on [DATE] at 3:00 p.m., confirmed that the care plan in effect from [DATE] through [DATE] did not identify constipation as a problem. Resident #4 Resident #4 could not be observed as this record was closed. Resident #4 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review for Resident #4 Computed Tomography of the chest with contrast was done on [DATE]. In the Findings section "a large amount of stool in the ascending colon" was reported. On [DATE] Resident #4 was seen in the emergency room with the chief complaint of nausea, vomiting, and abdominal distention. The physician documented positive for a low fecal impaction. A soapsuds enema was given and the physician documented had a large BM. There was a physician order [REDACTED]. Record review of a Physician Fax Request for Resident #4, dated [DATE], stated under Problems/Concerns "Can resident have a liquid laxative order daily or PRN (when necessary) to help with stool and constipation?" The physician ordered MOM 30 cc every 6 hours PRN. Review of the BM monitoring for Resident #4 for [DATE], revealed that there was no BM documentation for 3 days ([DATE] and 8, 2012). Review of the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with the LPN Care Plan nurse on [DATE] at 3:15 p.m. confirmed that the care plan for February 2011 through [DATE] for this resident did not address the potential for constipation. On [DATE] at 9:55 a.m., the DON was asked for documented evidence that the x-ray reports as outlined above were reviewed, that the resident was assessed, and approaches were implemented as determined to be necessary. Interview with the DON on [DATE] at 2:45 p.m., confirmed that no documented evidence was found to show that all information received was utilized in assessing residents to determine their needs so that effective approaches could be implemented. However, the facility staff said residents were reviewed with no change (there is no documented evidence to support). Interview with the LPN Care Plan Nurse on [DATE] at 4:30 p.m., revealed that she does not see x-rays and would not have considered those reports when identifying resident problems when developing a care plan. Interview with the emergency room Physician on [DATE] at 3:55 p.m., who documented a fecal impaction for Resident #4, revealed that he would define a fecal impaction as a large amount of fecal material in the colon and rectum that must be removed digitally. That was not the case with Resident #4. The [DIAGNOSES REDACTED]. Will be more careful from now on. Interview with the Radiologist on [DATE] at 10:45 a.m., who identified himself as one among 16 radiologists who interpreted x-rays for the facility, revealed that in his opinion that if fecal matter was addressed in an x-ray that it was out of the ordinary. This physician stressed that this was his opinion and he could not speak for the other 15 physicians in his group. On [DATE] at 2:45 p.m., the DON was asked to provide copies of any in-services provided for the facility staff regarding the prevention of constipation prior to [DATE] and after [DATE]. On [DATE] at 1:30 p.m. the DON provided a copy of an in-service on the importance of nutrition. Record review of the [DATE] inservice presented by the RD (Registered Dietition) revealed the inservice addressed increasing fluid and fiber intake as steps to address constipation. The facility provided a crediable Allegation of Compliance on [DATE] at 5:30 p.m. "Crediable Allegation of Compliance" "Addendum to Allegation of Compliance of [DATE]. Resident #1 was identified [DATE]. Resident #1 is an eighty-two year old female admitted to (Nursing Facility) on [DATE] status [REDACTED]. On [DATE] Resident #1 was sent for x-ray of right hip due to complaints of pain and history of hip replacement. X-ray report indicated increased stool is noted in the rectosigmoid colon. Resident #1 charted indicated bowel movement times one on [DATE] and bowel movements times two on [DATE]. Resident #1 care plan was updated to include at risk for constipation. Resident #2 was a seventy-three (73) year old female who was admitted to (Nursing Facility) on [DATE] following a severe stroke. On [DATE] at 11:45 a.m. Resident #2 was seen by her primary physician. No new orders were written. From the time Resident #2 was seen by her primary physician until [DATE], there was not change in her condition. About 8:15 a.m. on [DATE] the LPN (Licensed Practical Nurse) suctioned salvia from Resident #2 mouth and Resident #2 replied "thank you". At 8:45 a.m. on [DATE] the LPN entered Resident #2's room to administer medication(s) at which time the LPN noted Resident #2 was pale, not breathing and did not have a pulse. The LPN checked Resident #2 for respiration, blood pressure, and pulse but none could be obtained. At 8:53 a.m. on [DATE] the on-call physician was notified. At 8:55 a.m. (County Coroner) was notified. At 8:57 a.m. Resident #2's responsible was notified. On [DATE] at 9:10 a.m. Resident #2 was pronounced by (County Coroner). Resident #4 was an eighty-eight (88) year old female who was admitted to (Nursing Facility) on [DATE]. On [DATE] Resident #4 had esophagram. Findings were complete absence of primary and secondary peristalsis of the esophagus with distal tertiary contractions note, findings of poor relaxation of the GE junction resulting in extensive stasis of contrast in the esophagus. On [DATE] at 7:15 a.m. LPN contacted primary physician concerning coffee ground emesis, test for blood pressure was ordered. On [DATE] at 9:45 a.m. LPN contacted Resident #4 primary physician about positive blood in emesis and LPN received order to transfer Resident #4 to emergency room for evaluation. On [DATE] at 10:00 a.m. family was notified of order to transfer to emergency room . On [DATE] at 12:45 p.m. (Nursing Facility) was notified by emergency room that Resident #4 was being transferred to (local hospital). While (local hospital) per physician progress notes [REDACTED]. On [DATE] at 4:05 p.m. Resident #4 was readmitted to the (Nursing Facility), and Resident #4 verbalized on [DATE] that she was glad to be home and sleeping in her own bed. On [DATE] at 7:30 p.m. the primary physician of Resident #4 was contacted per LPN about coffee ground emesis and primary physician stated "I have talked with family and they understood what is going on, there is nothing we can do about it just continue to monitor her". On [DATE] at 1:30 p.m. Resident #4 was noted to have irregular respiratory pattern while asleep. At this time the RN assessed Resident #4 and lung sounds were clear, pulse oxemetry was at ninety-seven percent on room air. On [DATE] at 10:30 p.m. Resident #4 noted with black coffee ground emesis, breathing pattern irregular, Resident #4 awake and talking to LPN. On [DATE] at 10:00 a.m. Resident #4 was noted by LPN to be resting quietly with irregular breathing pattern. On [DATE] at 6:40 p.m. LPN informed per C.N.A. (Certified Nursing Assistant) that Resident #4 appeared to have no respirations. Absences of vital signs verified by RN (Registered Nurse) times three attempts. Family notified on [DATE] at 6:45 p.m. Son-in-law stated will be en-route. (County Coroner) was notified on [DATE] at 6:47 p.m. On [DATE] at 7:15 p.m. Resident #4 was pronounced by (County Coroner), with Son-in-law and LPN was present. A policy and procedure was developed by the Administrator, the Director of Nursing, and the Minimum Data Set Nurse on [DATE] at 4:00 p.m. outlining the utilization of Professional Standards of Practice for bowel movements. The Medical Director reviewed and approved the policy on [DATE] at 4:45 p.m. RN #2, LPN #1, LPN #2 were in-serviced on the policy by the Minimum Data Set Nurse on [DATE] at 5:15 p.m. and LPN #5 and LPN #6 were in-serviced on [DATE] at 6:30 p.m. On [DATE] at 6:30 a.m. the Minimum Data Set Nurse in-serviced RN #1, LPN #3, and LPN #4 on the Professional Standards of Practice for bowel movement policy. On [DATE] at 4:45 p.m. RN #2, LPN #1, LPN #2, C.N.A. #8,16,19,20,and 21 were in-serviced on bowel elimination by the Minimum Data Set Nurse and completed a test to demonstrate understanding of content of the in-service with one-hundred percent passing rate. On [DATE] at 6:30 p.m. and LPN #5 and LPN #6 were in-serviced by the Minimum Data Set Nurse and completed a test to demonstrate understanding of content of the in-service with one-hundred percent passing rate. On [DATE] at 6:30 a.m. RN #3, LPN #3, LPN #4, C.N.A, #27, 24 , 5, 14, 6, 10 13, 15, 25 were in-serviced on bowel elimination by the Minimum Data Set Nurse and completed a test to demonstrate understanding of content of the in-service with one-hundred percent passing rate. The Care Plan policy and procedure was reviewed and revised on [DATE] at 4:30 p.m. by the Administrator, the Director of Nursing, and the Minimum Data Set Nurse. The previous policy was four pages. The revisions to the previous policy were deletion of contacting Ombudsman if no family, condensing policy and procedure to eliminate redunence, and to make wording of policy more user friendly and to improve staff understanding of policy. The Medical Director reviewed and approved the policy on [DATE]/at 4:45 p.m. The Director of Nursing in-serviced the Activity Director and the Social Service Director on [DATE] at 8:00 a.m. on the revised Care Plan Policy. On [DATE] at 3:30 p.m. RN #1, RN #2, LPN #3, LPN #4 were in-serviced by Nurse Consultant on the revised care plan policy and procedure. Abuse and Neglect in-services was conducted on [DATE] at 3:00 p.m. and at 3:30 p.m. by Nurse Consultant. Staff attending the in-service were RN #3, LPN #4, RN #2, RN #1, LPN #3, and Minimum Data Set Nurse, C.N.A. #21, 20, 16, 19, 5, 13, 10, 8, 15, and 6. The in-service included review of current policy on abuse and neglect , as well as accurate reporting and documentation of bowel movements and the consequences of failure to report or document bowel elimination. All staff will have to attend above in-services before being allowed to work. The Director of Nursing and the Minimum Data Set Nurse have reviewed fifty (50) Residents' care plans, of a current census of 50 Residents on [DATE] at 5:00 p.m. to determine which Residents have a current order for a medication to promote bowel movements. Residents' care plan was revised as needed on [DATE] by the Director of Nursing and the Minimum Data Set Nurse. Reviews and revisions were completed on [DATE] at 9:00 p.m. The Director of Nursing and the Minimum Data Set Nurse reviewed X-Ray results in Residents' current medical record on [DATE] at 5:00 p.m. while reviewing care plans. Reviews and revisions were complete on [DATE] at 9:00 p.m. The care plans that were revised were for Resident A, B, C, D, E, F, G, H, I. On-coming nurse(s) will review the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. If a Resident is noted to not have had a bowel movement in three days, the RN/LPN will administer a laxative to promote a bowel movement. In the event the laxative does not produce a bowel movement, the RN/LPN will administer a suppository. In the event the suppository does not produce bowel movement, the RN/LPN will contact the Resident's primary physician/on-call physician. The Director of Nursing or his/her designee will review Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Director of Nursing or his/her designee will report findings of the medication administration review to the Quality Assurance Committee and recommendations will be followed. The Director of Nursing or his/her designee will review medical record at lease monthly to ensure care plans have been revised as needed. The Director of Nursing or his/her designee will report findings of the medical record review and care plan revisions to the Quality Assurance Committee and recommendations will be followed." Based on verification of the facility's corrective actions that were validated by observations, in-service review forms, staff review of testing, review of revised care plans, and review of policy development/revisions, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on [DATE] to a "H" level, which constituted actual harm that is not an Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

Part II CI MS # Based on video card review, observation, staff interview, record review and policy review, the facility failed to ensure that one (1) of ten (10) sampled residents (Resident #7) was free from physical abuse by a Certified Nurse Aide (CNA) #5 on or about 5-11-12. Evidence, in the form of a video card, was provided by a relative of Resident #7. CNA #5 roughly transferred Resident #7 from the bed to the wheelchair, pushed the resident from side to side to position her in the wheelchair, hit the resident in the forehead with a comb, and jerked the comb through the Resident #7's hair. The lack of implementation of safety measure to ensure Resident #7 had the right to be free from abuse was deemed Substandard Quality of Care and an Immediate Jeopardy to begin on 5-11-12 and was removed on 5-16-12. The facility Administrator, Director of Nursing, and the Hospital Administrator were notified of the Immediate Jeopardy on 5-17-12 at 4:10 p.m. The facility provided a credible Allegation of Compliance (AOC) on 5-18-12 at 4:30 p.m. Based on verification of the facility's corrective actions that were validated by observations, resident interviews, family interview, and in-service review forms the Immediate Jeopardy was removed and the scope and severity was lowered on 5-16-12 to a "D" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee. Findings Include: On 5-14-12, the facility self-reported an allegation of abuse made against CNA #5. Evidence, in the form of a video card, was provided by a relative of Resident #7 to the facility. CNA #5 was immediately suspended pending an investigation of the allegations of abuse. CNA #5 clocked out at 1:37 p.m. on 5-11-12 and left the facility. The Administrator called the Mississippi State Department of Health-Abuse Unit at approximately 6:00 p.m. on 5-11-12 and made a oral report of the incident. The Administrator completed the written report of the incident to the Mississippi State Department of Health-Abuse Unit on 5-14-12 and faxed the written report to the Mississippi State Department of Health-Abuse Unit on 5-14-12. The Administrator mailed the original written report via certified mail to the Mississippi Department of Health-Abuse Unit on 5/14/12. The Administrator of the facility reported the incident to the Attorney General's office as required. CNA #5 was terminated by the Human Resource Director on 5-16-12 at 10:30 a.m., upon completion of the investigation, that Resident #7's allegation of abuse was substantiated by the facility. Upon review of the video card, which recorded the abuse of Resident #7 by CNA #5, it was observed that the CNA roughly transferred Resident #7 from the bed to the wheelchair, pushed the resident from side to side to position her in the wheelchair, hit the resident in the forehead with a comb, and jerked the comb through Resident #7's hair. Observation of Resident #7 on 5-17-12 at 4:30 p.m., revealed a nicely dressed female resting in her bed. Resident #7 did not respond when her name was called. Record review for Resident #7 revealed that she was admitted to the facility on [DATE]. Resident #7's [DIAGNOSES REDACTED]. Review of Resident #7's physician progress notes [REDACTED]. The Neuro (neurological) section of the Physical Examination documented that "The patient has significant difficulties from her [MEDICAL CONDITION] and previous stroke." Review of Resident #7's Nurses Notes (NN) on 5-13-12, revealed that "up in lobby in w/c (wheelchair). Calm. Continues ? (with) no bruising or injury." Initial tour of the facility on 5-17-12 and ongoing observation of residents in the facility , during the survey, revealed no problems with bruising or injuries of other residents. Interview with CNA #5 on 5-18-12 at 11:05 a.m., revealed that she denied any abuse of Resident #7. The CNA #5 stated that she had worked in a nursing home for [AGE] years and would not hurt an old person. CNA #5 stated that the son of Resident #7 did not like her. Interview with the son of Resident #7 on 5-18-12 at 12:05 p.m., confirmed that he had put the camera in his mother's private room that had recorded the abuse. Review of the facility policy Preventing Resident Abuse, revised 2006, revealed that "The facility's goal is to achieve and maintain an abuse-free environment." In the Reporting Abuse to Facility Management, revised 2010, section under 2. a. "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish." The facility provided a credible Allegation of Compliance (AOC) on 5-18-12 at 4:30 p.m. " Credible Allegation of Compliance " "Resident #7 is a ninety (90) year old female who was admitted to (Nursing Facility) on 5/28/09. Resident #7 primary [DIAGNOSES REDACTED]. Resident #7 Minimum Data Set Section B and Section C dated 4/30/12 indicate difficulty with speech and memory. On 5/11/12 at approximately 1:30 p.m. the son of Resident #7 stated to the Administrator that a staff member "hit" his mother. The Administrator asked the son of Resident #7 the name of the staff member and he replied C.N.A. #5. The Administrator informed the Director of Nursing that there had been an allegation of staff to resident abuse. The Administrator instructed the Director of Nursing to inform C.N.A. #5 to clock-out and C.N.A. #5 was suspended pending an investigation of the allegation of abuse. C.N.A. #5 clocked out at 1:37 p.m. on 5/11/12 and left the facility. The RN Supervisor conducted a head-to-toe body audit of Resident #7 at 3:00 p.m. on 5/11/12. There were no signs of bruising or any other signs or symptoms of injury. Resident #7 primary physician was notified on 5/11/12 at approximately 3:30 p.m. of the allegation of abuse. The Director of Nursing spoke to Resident #7 and assured her C.N.A. #5 was no longer in the facility nor would C.N.A. #5 be allowed to return to the facility. Resident #7 smiled and nodded acknowledgement to the Director of Nursing. Resident #7 continues to be monitored for any physical or mental signs of abuse. The Nurse Consultant and the Minimum Data Set Nurse began conducting in-services at 3:00 p.m. on 5/11/12 on the Vulnerable Adult Act; in particular all aspects of the section on abuse. All staff had to attend the in-service prior to being allowed to work. The Director of Nursing conducted interviews on 5/14/12, beginning at approximately 2:00 p.m., with 31 interviewable Residents, of a current census of 50, including those Residents C.N.A. #5 had recently provided direct care for. No Resident reported any physical or mental mistreatment. There were 19 noninterviewable Residents, of a current census of 50. Of the 19 noninterviewable Residents, of a current census of 50, C.N.A. #5 had provided direct care to 5 of the 19 noninterviewable. Head-to-toe assessments were preformed on all 5 of these Residents beginning at 2:00 p.m. 5/14/12 and no signs or symptoms of abuse were noted. The Director of Nursing initiated contact with family members, including those non-interviewable Residents, and encourages family members to voice any concerns or complaints. All assessments and interviews were completed at 6:00 p.m. on 5/14/12. The Administrator called the Mississippi State Department of Health-Abuse Unit at approximately 6:00 p.m. on 5/11/12 and made a oral report of the incident. The Administrator completed the written report of the incident to the Mississippi State Department of Health-Abuse Unit on 5-14-12 and faxed the written report to the Mississippi State Department of Health-Abuse Unit on 5-14-12. The Administrator mailed the original written report via certified mail to the Mississippi Department of Health-Abuse Unit on 5/14/12. The Administrator completed the on-line report of the incident to the Attorney General's Office-Medicaid Fraud Unit at 6:00 p.m. on 5/11/12. The Administrator completed the written report to the Attorney General's Office-Medicaid Fraud Unit on 5/14/12 and faxed the written report to the Attorney General's Office-Medicaid Fraud Unit on 5/14/12. The Administrator contacted an investigator for the Attorney General's Office-Medicaid Fraud Unit on 5/15/12. The investigator with the Attorney General's Office-Medicaid Fraud Unit informed the Administrator he had received the on-line report and he would be at the facility on 5/16/12 at approximately 9:00 a.m. Upon the arrival, the investigator with the Attorney General's Office-Medicaid Fraud Unit received the written report/investigation of the incident. The investigator with the Attorney General's Office-Medicaid Fraud Unit discussed the incident with the Administrator and the Director of Nursing. The investigator with the Attorney General's Office-Medicaid Fraud Unit stated he needed to interview C.N.A. #5. (Nursing Facility's) Human Resource Director contacted C.N.A. #5 and informed C.N.A #5 she needed to come to the Human Resource Department Office, which is located in (Hospital). C.N.A. #5 was interviewed privately by the investigator with the Attorney General's Office-Medicaid Fraud Unit at 10:00 a.m. on 5/16/12. After the investigator for the Attorney General's Office-Medicaid Fraud Unit completed his interview, C.N.A. #5 was terminated at 10:30 a.m. by .Human Resource Director due to the allegation of abuse being substantiated. C.N.A. #5 was instructed by the Human Resource Director and the Administrator that C.N.A. #5 would not be allowed on the premises of (Hospital/Nursing Facility). The investigator with the Attorney General's Office-Medicaid Fraud unit informed the Administrator and the Director of Nursing that he would be pursuing criminal charges against C.N.A. #5. Director of Nursing viewed all Residents, of a current census of 50 Residents, beginning at 2:00 p.m. on 5/14/12. The Director of Nursing conducted interviews with 31 of the interviewable Residents, of a current census 50. There were 19 non-interviewable Residents, of a current census of 50. Interviewable Residents were asked "has anyone ever mistreated you or been mean to you". All 31 Residents interviewed verbally and non-verbally indicated no one at the facility had ever been mean to them or mistreated them. The Director of Nursing informed 31 Residents of a current census of 50, that at any time they could report to the Administrator, the Director of Nursing, or other staff members if they feel someone was mistreating them or being mean to them and that the report would be anonymous and would be without retribution. All Residents indicated understanding of reporting. The Director of Nursing frequently has conversations with family members, including those non-interviewable Residents, and encourages family members to voice any concerns or complaints. The Nurse Consultant, the Minimum Data Set Nurse, and the Administrator conducted in-the definitions of abuse, their duty and responsibility to report, how, when and where to report, the consequences not reporting, the consequences for making a false report, and the punishment for abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property or resources. No staff member was allowed to work prior to attending the in-service. Residents will be reminded on a continuous basis of their right to be free from abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property or resources by leadership staff of (Hospital). Residents will be observed by leadership staff (which included Administrator, Director of Nursing, Social Service Director, Activities Director, and the Minimum Data Set Nurse), registered nurses, licensed practical nurses, and certified nurse aides for any signs or symptoms of mistreatment and/or abuse. All staff will be in-serviced on the Vulnerable Adult Act upon hire by the Administrator and/or designee and annually by the Director of Nursing and/or designee thereafter. The Vulnerable Adult Act will be reiterated at monthly staff meetings. The investigator with the Attorney General's Office-Medicaid Fraud Unit has offered to conduct the 2012 annual in-service on the Vulnerable Adult Act. Social Services Director and/or designee will re-interview interviewable Residents weekly for four weeks then monthly for six months. The Director of Nursing and/or designee will reassess non-interviewable Residents weekly for four weeks then monthly for six months for any signs or symptoms of abuse. The Administrator and/or designee will re-interview staff from each department on the definitions of abuse, their duty and responsibility to report, how, when and where to report, and the consequences for not reporting, the consequences for making a false report, and the punishment for abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property or resources weekly for four weeks then monthly for six months. The Administrator and/or designee will also re-question staff from each department if he/she has knowledge of or reasonable cause to believe any Resident has experienced any type of abuse or mistreatment weekly for four weeks then monthly for six months." Based on verification of the facility's corrective actions that were validated by observations, resident interviews, family interview, and in-service review forms the Immediate Jeopardy was removed and the scope and severity was lowered on 5-16-12 to a "D" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

Part I CI MS # Based on record review, policy review, interviews and review of an autopsy report from the Mississippi State Medical Examiner's Office, the facility failed to ensure that the bowel elimination of residents was accurately monitored, that the resident received laxatives as needed, and that the potential for constipation was identified and interventions were planned according to the resident's needs to prevent constipation/fecal impactions. This resulted in Resident #2's death due to a "Massive colon dilatation due to fecal impaction resulting in [MEDICAL CONDITION] and Asphyxia." This is for three (3) of six (6) residents reviewed (Residents #1, #2 and #4). The lack of implementation to ensure that the bowel elimination of residents was accurately monitored, that the resident received laxatives as needed, and that the potential for constipation was identified and interventions were planned according to the resident's needs to prevent constipation/fecal impactions was deemed Substandard Quality of Care and an Immediate Jeopardy to begin on [DATE] and was removed on [DATE]. The facility Administrator, Director of Nursing (DON), Risk Manager, and Administrator of the hospital were notified of the Immediate Jeopardy on [DATE] at 2:45 p.m. The facility provided a credible Allegation of Compliance (AoC) on [DATE] at 5:30 p.m. Based on verification of the facility's corrective actions that were validated by observations, in-service review forms, staff review of testing, review of revised care plans, and review of policy development/revisions, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on [DATE] to a "H" level, which constituted actual harm that is not an Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee. Findings Include: Resident #2 Resident #2 could not be observed as this record was closed. Record review for Resident #2 Revealed that the resident was born [DATE]. Resident #2 was admitted to the facility [DATE]. Review of Resident #2's Discharge Summary dated [DATE] revealed that the resident's [DIAGNOSES REDACTED]. The Discharge Summary also noted that the Discharge [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment with the Assessment Reference Date (ARD) of [DATE] revealed that Resident #2 was unable to complete the Brief Interview for Mental Status (BIMS) and had short and long term memory problems. This assessment indicated that Resident #2 had unclear speech, was sometimes understood by others, and that she usually understood most conversation. Resident #2 was totally dependent on facility staff for bed mobility, dressing, eating, toilet use and personal hygiene. Nurses Notes for Resident #2, dated [DATE], documented the following: ",[DATE] 0815 (8:15 a.m.) Resident grunting, mouth full of salavia (saliva) suctioned resident to clear mouth out. When finished wiped face off and sat her head up. Resident said 'Thank you'. Will cont (continue) to monitor." ",[DATE] 0845 (8:45 a.m.) Pulled up residents medicine went into room to give residents am (morning) meds (medicine). When got to bedside, held feeding tube and pulled covers down to get tube and noted resident was extremely pale. Noted resident didn't appear to be breathing. Felt for carotid pulse, absent. Turn (turned) feeding off, got BP (blood pressure) cuff and stethescope attempted to obtain blood pressure, unable to hear anything. RN (Registered Nurse) in to assess, unable to hear pulse and no O2 sat (oxygen saturation) able to obtain. 0853 (8:53 am) MD (Medical Doctor) ....(Name) FNP (Family Nurse Practitioner) on call notified of residents death. 0855 (8:55 am) coroner called, no answer, then paged. 0857 (8:57 am) residents sister, ...(name), RP (Responsible Party) notified she needed to come to facility. Stated she will be here shortly. 0900 (9:00 am) coroner returned call and stated he was on his way. 0902 (9:02 am) Residents sister and another family member arrived, informed residents (resident's) sister that resident had passed. 0910 (9:10 am) coroner arrived @ (at) facility, pronounced resident. 0915 (9:15 am) Funeral Home .... (Name) called and notified. 0926 (9:26 am) Funeral home arrived. Body removed @ 0935 (9:35 am) from facility. Family left as well and stated they would be back later and get her stuff." Resident #2 expired on [DATE] and was embalmed. Review of the autopsy report signed by the Chief Medical Examiner revealed that on [DATE] authority was given for an autopsy to be performed. On [DATE] an autopsy was performed on the body of Resident #2. The Opinion section of the autopsy report stated "This [AGE] year-old woman identified as .... (Resident #2) died as a result of [MEDICAL CONDITION] due to Mechanical Asphyxia that resulted from massive dilatation of the colon caused by a fecal impaction. This ultimately resulted in severe superior (upward) displacement of the diaphragm and compression of her lungs. There was no evidence of traumatic injury that would have resulted in her death. With the currently available information and the autopsy findings, the cause of death is Mechanical Asphyxia and the manner of death is accident." Review of the Statement to Amend Cause "of Death", dated [DATE], revealed the Immediate Cause of death was listed as Mechanical Asphyxia. Colon Obstruction and Fecal Impaction were listed as leading to immediate cause. Interview with the Funeral Home Staff on [DATE] at 3:15 p.m. that embalmed Resident #2, revealed that Resident #2's rectum had been evacuated as part of the embalming process. Interview with Resident #2's Attending Physician on [DATE] at 12:45 p.m., revealed that there was no medical condition or [DIAGNOSES REDACTED]. The Attending Physician stated that Resident #2 had been managed for [AGE] years without problems. The Attending Physician stated that there were no signs or symptoms of constipation preceding the [DATE] incident. Resident #2 had no vomiting. The Attending Physician stated that he had not been consulted by the facility staff regarding Resident #2 being constipated. Interview with the Director of Nursing (DON) on [DATE] at 2:20 p.m., revealed that she had worked as a floor nurse assigned to Resident #2 on [DATE] and noted no signs or symptoms of constipation at that time. The DON continued to say that she made rounds with the resident's physician on [DATE] and assisted him to assess Resident #2's abdomen and no problems were identified then. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 4:10 p.m., assigned to care for Resident #2 on [DATE], revealed that she had suctioned approximately ten (10) cubic centimeters (cc) of what appeared to be clear yellow liquid from the resident's mouth that morning. At the same time she checked the stomach residual and there was none. The stomach was not distended. LPN #1 stated that Resident #2 could indicate if she was in pain and that there were no complaints of pain. The Resident #2 was not vomiting that day. Interview with Certified Nurse Aide (CNA) #1 on [DATE] at 11:55 a.m., in the presence of the Risk Manager at the request of the CNA #1 , revealed that the CNA #1 was familiar with Resident #2 having worked with her in the past. CNA #1 stated that she was not assigned to the resident on [DATE] but did assist with preparing the body for transport to the funeral home after the coroner had pronounced the death. CNA #1 stated that she noticed that the resident had a "brown/tanish" drainage from her mouth down the side of her face, and Licensed Practical Nurse (LPN) #1 was notified of this. CNA #1 stated that she noted that the resident's rectum was open about the size of a quarter but no feces was noted in the rectum. CNA #1 also stated that Resident #2's abdomen was distended "a little bit". Interview with CNA #3 on [DATE] at 12:22 p.m., revealed that she also was assisting with the preparation of Resident #2's body for transportation to the funeral home. CNA #3 stated that the Resident #2 was bathed and when they attempted to apply an adult brief (the resident's normal size brief) they could hardly fasten the tabs secondary to the resident's abdomen being so distended. As the rectum was cleaned, CNA #3 noticed that the rectum was open more than the size of a quarter. Feces was noted to be present in the rectum. CNA #3 stated that when they rolled the Resident #2 from side to side, a "dark greenish brown drainage" came from the resident's mouth. CNA #3 continued, saying that she had seen residents with the rectum open and feces present in the past and she would call the nurse who would "dig them out". Interview with CNA #4 on [DATE] at 8:40 a.m., revealed that she had checked on Resident #2 at about 6:30 a.m. on [DATE] and the resident was her usual self. CNA #4 said she checked on the resident again about 7:30 a.m. and Resident #2 was gasping for breath. Nurses were summoned and three nurses came to assess the resident. The nurses were identified as LPN #1, Registered Nurse (RN) #1, and LPN #2. Before long the resident passed. As Resident #2 took her last breath, a dark, slimy, foul smelling drainage came from the resident's mouth. CNA #4 stated that she could only describe it as a bowel movement. As the CNA's were bathing Resident #2, this substance continued to come out of the resident's mouth. The rectum was observed to be stretched as big around as a drink can. A large amount of hard feces was noted at the end of the rectum. CNA #4 stated that she informed RN #1 of this. Interview with RN #1 on [DATE] at 1:25 p.m., revealed that she was working the day that Resident #2 expired. She was called in when the resident ceased breathing. RN #1 stated that there was nothing coming from the resident's mouth or nose. Interview with the Director of Nursing (DON) on [DATE] at 4:35 p.m., revealed that there was no written facility policy for the prevention of constipation to include the monitoring of bowel movements (BM). The method of monitoring bowel movements was what all nurses learned in school. Daily records are kept documenting the number of bowel movements. If the resident has no BM in three (3) days a laxative is given. Interview with the DON on [DATE] at 12:30 p.m., revealed that she was instructed not to provide a written statement as to the standard of practice that the facility followed to prevent constipation. Review of the [DATE] records for BMs for Resident #2 revealed that the resident had no documented BM on [DATE], [DATE], [DATE], or [DATE]. Review of the Physician Orders, Nurses Notes, and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #2 had no BM documented on [DATE], [DATE], [DATE], and [DATE]. There was no documentation found on the Physician Orders, Nurses Notes, and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with the LPN Minimum Data Set Assessment/Care Plan Nurse on [DATE] at approximately 3:15 p.m., revealed that the care plan for Resident #2 which was in effect from [DATE] through February 25, 2012 did not identify and address the potential for constipation. Resident #1 Resident #1 was observed on [DATE] at 10:00 a.m. in the lobby of the facility sitting in a wheelchair eating crackers. Interview with the DON of the facility at the time of this observation revealed that the resident received tube feedings at night. Record review revealed that Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An x-ray of the abdomen for Resident #1 dated [DATE] revealed the Clinical History was Constipation. The Findings stated "There is a large amount of stool in the rectum ...." The Impression was "Large stool in the rectum". Record review of Resident #1's Nurses Notes revealed that the resident was in the Geripsych Unit [DATE] through [DATE]. Interview with the DON on [DATE] at 2:20 p.m., revealed that the x-ray dated [DATE] was done as part of a routine admission work-up for the Geripsych unit. The DON stated that if the x-ray had reported stool in the colon or anywhere other than the rectum, the facility would have addressed the possibility of constipation. Review of the monitoring of bowel movements for the month of [DATE] revealed that there was no documentation from [DATE] through [DATE] as Resident #1 was out of the facility. To the side of the [DATE] entry was a notation that the "last BM [DATE]". Going from that documentation, the resident had no documented BM for three days, ,[DATE], ,[DATE], ,[DATE]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further record review for Resident #1 revealed that on [DATE] the resident was seen in the emergency room (ER) for chest pain. A KUB (kidneys, ureters, and bladder) x-ray was done. The history for this ER visit revealed upper abdominal and chest pain. At 11:15 a.m. the resident was given a [MEDICATION NAME] Suppository. At 12:10 p.m. the resident had a "large, soft, brown BM". Resident #1 was discharged back to the facility. Record review of the KUB report under findings indicated "Moderate amount of fecal material is seen in the colon especially the rectum ...." Further record review for Resident #1 revealed that on [DATE] a report of an x-ray of the right hip was faxed to the facility. "Increased stool is noted in the rectosigmoid colon." Interview with the LPN Care Plan Nurse on [DATE] at 3:00 p.m., confirmed that the care plan in effect from [DATE] through [DATE] did not identify constipation as a problem. Resident #4 Resident #4 could not be observed as this record was closed. Resident #4 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review for Resident #4 Computed Tomography of the chest with contrast was done on [DATE]. In the Findings section "a large amount of stool in the ascending colon" was reported. On [DATE] Resident #4 was seen in the emergency room with the chief complaint of nausea, vomiting, and abdominal distention. The physician documented positive for a low fecal impaction. A soapsuds enema was given and the physician documented had a large BM. There was a physician order [REDACTED]. Record review of a Physician Fax Request for Resident #4, dated [DATE], stated under Problems/Concerns "Can resident have a liquid laxative order daily or PRN (when necessary) to help with stool and constipation?" The physician ordered MOM 30 cc every 6 hours PRN. Review of the BM monitoring for Resident #4 for [DATE], revealed that there was no BM documentation for 3 days ([DATE] and 8, 2012). Review of the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with the LPN Care Plan nurse on [DATE] at 3:15 p.m. confirmed that the care plan for February 2011 through [DATE] for this resident did not address the potential for constipation. On [DATE] at 9:55 a.m., the DON was asked for documented evidence that the x-ray reports as outlined above were reviewed, that the resident was assessed, and approaches were implemented as determined to be necessary. Interview with the DON on [DATE] at 2:45 p.m., confirmed that no documented evidence was found to show that all information received was utilized in assessing residents to determine their needs so that effective approaches could be implemented. However, the facility staff said residents were reviewed with no change (there is no documented evidence to support). Interview with the LPN Care Plan Nurse on [DATE] at 4:30 p.m., revealed that she does not see x-rays and would not have considered those reports when identifying resident problems when developing a care plan. Interview with the emergency room Physician on [DATE] at 3:55 p.m., who documented a fecal impaction for Resident #4, revealed that he would define a fecal impaction as a large amount of fecal material in the colon and rectum that must be removed digitally. That was not the case with Resident #4. The [DIAGNOSES REDACTED]. Will be more careful from now on. Interview with the Radiologist on [DATE] at 10:45 a.m., who identified himself as one among 16 radiologists who interpreted x-rays for the facility, revealed that in his opinion that if fecal matter was addressed in an x-ray that it was out of the ordinary. This physician stressed that this was his opinion and he could not speak for the other 15 physicians in his group. On [DATE] at 2:45 p.m., the DON was asked to provide copies of any in-services provided for the facility staff regarding the prevention of constipation prior to [DATE] and after [DATE]. On [DATE] at 1:30 p.m. the DON provided a copy of an in-service on the importance of nutrition. Record review of the [DATE] inservice presented by the RD (Registered Dietition) revealed the inservice addressed increasing fluid and fiber intake as steps to address constipation. The facility provided a crediable Allegation of Compliance on [DATE] at 5:30 p.m. "Crediable Allegation of Compliance" "Addendum to Allegation of Compliance of [DATE]. Resident #1 was identified [DATE]. Resident #1 is an eighty-two year old female admitted to (Nursing Facility) on [DATE] status [REDACTED]. On [DATE] Resident #1 was sent for x-ray of right hip due to complaints of pain and history of hip replacement. X-ray report indicated increased stool is noted in the rectosigmoid colon. Resident #1 charted indicated bowel movement times one on [DATE] and bowel movements times two on [DATE]. Resident #1 care plan was updated to include at risk for constipation. Resident #2 was a seventy-three (73) year old female who was admitted to (Nursing Facility) on [DATE] following a severe stroke. On [DATE] at 11:45 a.m. Resident #2 was seen by her primary physician. No new orders were written. From the time Resident #2 was seen by her primary physician until [DATE], there was not change in her condition. About 8:15 a.m. on [DATE] the LPN (Licensed Practical Nurse) suctioned salvia from Resident #2 mouth and Resident #2 replied "thank you". At 8:45 a.m. on [DATE] the LPN entered Resident #2's room to administer medication(s) at which time the LPN noted Resident #2 was pale, not breathing and did not have a pulse. The LPN checked Resident #2 for respiration, blood pressure, and pulse but none could be obtained. At 8:53 a.m. on [DATE] the on-call physician was notified. At 8:55 a.m. (County Coroner) was notified. At 8:57 a.m. Resident #2's responsible was notified. On [DATE] at 9:10 a.m. Resident #2 was pronounced by (County Coroner). Resident #4 was an eighty-eight (88) year old female who was admitted to (Nursing Facility) on [DATE]. On [DATE] Resident #4 had esophagram. Findings were complete absence of primary and secondary peristalsis of the esophagus with distal tertiary contractions note, findings of poor relaxation of the GE junction resulting in extensive stasis of contrast in the esophagus. On [DATE] at 7:15 a.m. LPN contacted primary physician concerning coffee ground emesis, test for blood pressure was ordered. On [DATE] at 9:45 a.m. LPN contacted Resident #4 primary physician about positive blood in emesis and LPN received order to transfer Resident #4 to emergency room for evaluation. On [DATE] at 10:00 a.m. family was notified of order to transfer to emergency room . On [DATE] at 12:45 p.m. (Nursing Facility) was notified by emergency room that Resident #4 was being transferred to (local hospital). While (local hospital) per physician progress notes [REDACTED]. On [DATE] at 4:05 p.m. Resident #4 was readmitted to the (Nursing Facility), and Resident #4 verbalized on [DATE] that she was glad to be home and sleeping in her own bed. On [DATE] at 7:30 p.m. the primary physician of Resident #4 was contacted per LPN about coffee ground emesis and primary physician stated "I have talked with family and they understood what is going on, there is nothing we can do about it just continue to monitor her". On [DATE] at 1:30 p.m. Resident #4 was noted to have irregular respiratory pattern while asleep. At this time the RN assessed Resident #4 and lung sounds were clear, pulse oxemetry was at ninety-seven percent on room air. On [DATE] at 10:30 p.m. Resident #4 noted with black coffee ground emesis, breathing pattern irregular, Resident #4 awake and talking to LPN. On [DATE] at 10:00 a.m. Resident #4 was noted by LPN to be resting quietly with irregular breathing pattern. On [DATE] at 6:40 p.m. LPN informed per C.N.A. (Certified Nursing Assistant) that Resident #4 appeared to have no respirations. Absences of vital signs verified by RN (Registered Nurse) times three attempts. Family notified on [DATE] at 6:45 p.m. Son-in-law stated will be en-route. (County Coroner) was notified on [DATE] at 6:47 p.m. On [DATE] at 7:15 p.m. Resident #4 was pronounced by (County Coroner), with Son-in-law and LPN was present. A policy and procedure was developed by the Administrator, the Director of Nursing, and the Minimum Data Set Nurse on [DATE] at 4:00 p.m. outlining the utilization of Professional Standards of Practice for bowel movements. The Medical Director reviewed and approved the policy on [DATE] at 4:45 p.m. RN #2, LPN #1, LPN #2 were in-serviced on the policy by the Minimum Data Set Nurse on [DATE] at 5:15 p.m. and LPN #5 and LPN #6 were in-serviced on [DATE] at 6:30 p.m. On [DATE] at 6:30 a.m. the Minimum Data Set Nurse in-serviced RN #1, LPN #3, and LPN #4 on the Professional Standards of Practice for bowel movement policy. On [DATE] at 4:45 p.m. RN #2, LPN #1, LPN #2, C.N.A. #8,16,19,20,and 21 were in-serviced on bowel elimination by the Minimum Data Set Nurse and completed a test to demonstrate understanding of content of the in-service with one-hundred percent passing rate. On [DATE] at 6:30 p.m. and LPN #5 and LPN #6 were in-serviced by the Minimum Data Set Nurse and completed a test to demonstrate understanding of content of the in-service with one-hundred percent passing rate. On [DATE] at 6:30 a.m. RN #3, LPN #3, LPN #4, C.N.A, #27, 24 , 5, 14, 6, 10 13, 15, 25 were in-serviced on bowel elimination by the Minimum Data Set Nurse and completed a test to demonstrate understanding of content of the in-service with one-hundred percent passing rate. The Care Plan policy and procedure was reviewed and revised on [DATE] at 4:30 p.m. by the Administrator, the Director of Nursing, and the Minimum Data Set Nurse. The previous policy was four pages. The revisions to the previous policy were deletion of contacting Ombudsman if no family, condensing policy and procedure to eliminate redunence, and to make wording of policy more user friendly and to improve staff understanding of policy. The Medical Director reviewed and approved the policy on [DATE]/at 4:45 p.m. The Director of Nursing in-serviced the Activity Director and the Social Service Director on [DATE] at 8:00 a.m. on the revised Care Plan Policy. On [DATE] at 3:30 p.m. RN #1, RN #2, LPN #3, LPN #4 were in-serviced by Nurse Consultant on the revised care plan policy and procedure. Abuse and Neglect in-services was conducted on [DATE] at 3:00 p.m. and at 3:30 p.m. by Nurse Consultant. Staff attending the in-service were RN #3, LPN #4, RN #2, RN #1, LPN #3, and Minimum Data Set Nurse, C.N.A. #21, 20, 16, 19, 5, 13, 10, 8, 15, and 6. The in-service included review of current policy on abuse and neglect , as well as accurate reporting and documentation of bowel movements and the consequences of failure to report or document bowel elimination. All staff will have to attend above in-services before being allowed to work. The Director of Nursing and the Minimum Data Set Nurse have reviewed fifty (50) Residents' care plans, of a current census of 50 Residents on [DATE] at 5:00 p.m. to determine which Residents have a current order for a medication to promote bowel movements. Residents' care plan was revised as needed on [DATE] by the Director of Nursing and the Minimum Data Set Nurse. Reviews and revisions were completed on [DATE] at 9:00 p.m. The Director of Nursing and the Minimum Data Set Nurse reviewed X-Ray results in Residents' current medical record on [DATE] at 5:00 p.m. while reviewing care plans. Reviews and revisions were complete on [DATE] at 9:00 p.m. The care plans that were revised were for Resident A, B, C, D, E, F, G, H, I. On-coming nurse(s) will review the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. If a Resident is noted to not have had a bowel movement in three days, the RN/LPN will administer a laxative to promote a bowel movement. In the event the laxative does not produce a bowel movement, the RN/LPN will administer a suppository. In the event the suppository does not produce bowel movement, the RN/LPN will contact the Resident's primary physician/on-call physician. The Director of Nursing or his/her designee will review Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Director of Nursing or his/her designee will report findings of the medication administration review to the Quality Assurance Committee and recommendations will be followed. The Director of Nursing or his/her designee will review medical record at lease monthly to ensure care plans have been revised as needed. The Director of Nursing or his/her designee will report findings of the medical record review and care plan revisions to the Quality Assurance Committee and recommendations will be followed." Based on verification of the facility's corrective actions that were validated by observations, in-service review forms, staff review of testing, review of revised care plans, and review of policy development/revisions, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on [DATE] to a "H" level, which constituted actual harm that is not an Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

Part II CI MS # Based on video card review, observation, staff interview, record review and policy review, the facility failed to ensure that one (1) of ten (10) sampled residents (Resident #7) was free from physical abuse by a Certified Nurse Aide (CNA) #5 on or about 5-11-12. Evidence, in the form of a video card, was provided by a relative of Resident #7. CNA #5 roughly transferred Resident #7 from the bed to the wheelchair, pushed the resident from side to side to position her in the wheelchair, hit the resident in the forehead with a comb, and jerked the comb through the Resident #7's hair. The lack of implementation of safety measure to ensure Resident #7 had the right to be free from abuse was deemed Substandard Quality of Care and an Immediate Jeopardy to begin on 5-11-12 and was removed on 5-16-12. The facility Administrator, Director of Nursing, and the Hospital Administrator were notified of the Immediate Jeopardy on 5-17-12 at 4:10 p.m. The facility provided a credible Allegation of Compliance (AOC) on 5-18-12 at 4:30 p.m. Based on verification of the facility's corrective actions that were validated by observations, resident interviews, family interview, and in-service review forms the Immediate Jeopardy was removed and the scope and severity was lowered on 5-16-12 to a "D" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee. Findings Include: On 5-14-12, the facility self-reported an allegation of abuse made against CNA #5. Evidence, in the form of a video card, was provided by a relative of Resident #7 to the facility. CNA #5 was immediately suspended pending an investigation of the allegations of abuse. CNA #5 clocked out at 1:37 p.m. on 5-11-12 and left the facility. The Administrator called the Mississippi State Department of Health-Abuse Unit at approximately 6:00 p.m. on 5-11-12 and made a oral report of the incident. The Administrator completed the written report of the incident to the Mississippi State Department of Health-Abuse Unit on 5-14-12 and faxed the written report to the Mississippi State Department of Health-Abuse Unit on 5-14-12. The Administrator mailed the original written report via certified mail to the Mississippi Department of Health-Abuse Unit on 5/14/12. The Administrator of the facility reported the incident to the Attorney General's office as required. CNA #5 was terminated by the Human Resource Director on 5-16-12 at 10:30 a.m., upon completion of the investigation, that Resident #7's allegation of abuse was substantiated by the facility. Upon review of the video card, which recorded the abuse of Resident #7 by CNA #5, it was observed that the CNA roughly transferred Resident #7 from the bed to the wheelchair, pushed the resident from side to side to position her in the wheelchair, hit the resident in the forehead with a comb, and jerked the comb through Resident #7's hair. Observation of Resident #7 on 5-17-12 at 4:30 p.m., revealed a nicely dressed female resting in her bed. Resident #7 did not respond when her name was called. Record review for Resident #7 revealed that she was admitted to the facility on [DATE]. Resident #7's [DIAGNOSES REDACTED]. Review of Resident #7's physician progress notes [REDACTED]. The Neuro (neurological) section of the Physical Examination documented that "The patient has significant difficulties from her [MEDICAL CONDITION] and previous stroke." Review of Resident #7's Nurses Notes (NN) on 5-13-12, revealed that "up in lobby in w/c (wheelchair). Calm. Continues ? (with) no bruising or injury." Initial tour of the facility on 5-17-12 and ongoing observation of residents in the facility , during the survey, revealed no problems with bruising or injuries of other residents. Interview with CNA #5 on 5-18-12 at 11:05 a.m., revealed that she denied any abuse of Resident #7. The CNA #5 stated that she had worked in a nursing home for [AGE] years and would not hurt an old person. CNA #5 stated that the son of Resident #7 did not like her. Interview with the son of Resident #7 on 5-18-12 at 12:05 p.m., confirmed that he had put the camera in his mother's private room that had recorded the abuse. Review of the facility policy Preventing Resident Abuse, revised 2006, revealed that "The facility's goal is to achieve and maintain an abuse-free environment." In the Reporting Abuse to Facility Management, revised 2010, section under 2. a. "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish." The facility provided a credible Allegation of Compliance (AOC) on 5-18-12 at 4:30 p.m. " Credible Allegation of Compliance " "Resident #7 is a ninety (90) year old female who was admitted to (Nursing Facility) on 5/28/09. Resident #7 primary [DIAGNOSES REDACTED]. Resident #7 Minimum Data Set Section B and Section C dated 4/30/12 indicate difficulty with speech and memory. On 5/11/12 at approximately 1:30 p.m. the son of Resident #7 stated to the Administrator that a staff member "hit" his mother. The Administrator asked the son of Resident #7 the name of the staff member and he replied C.N.A. #5. The Administrator informed the Director of Nursing that there had been an allegation of staff to resident abuse. The Administrator instructed the Director of Nursing to inform C.N.A. #5 to clock-out and C.N.A. #5 was suspended pending an investigation of the allegation of abuse. C.N.A. #5 clocked out at 1:37 p.m. on 5/11/12 and left the facility. The RN Supervisor conducted a head-to-toe body audit of Resident #7 at 3:00 p.m. on 5/11/12. There were no signs of bruising or any other signs or symptoms of injury. Resident #7 primary physician was notified on 5/11/12 at approximately 3:30 p.m. of the allegation of abuse. The Director of Nursing spoke to Resident #7 and assured her C.N.A. #5 was no longer in the facility nor would C.N.A. #5 be allowed to return to the facility. Resident #7 smiled and nodded acknowledgement to the Director of Nursing. Resident #7 continues to be monitored for any physical or mental signs of abuse. The Nurse Consultant and the Minimum Data Set Nurse began conducting in-services at 3:00 p.m. on 5/11/12 on the Vulnerable Adult Act; in particular all aspects of the section on abuse. All staff had to attend the in-service prior to being allowed to work. The Director of Nursing conducted interviews on 5/14/12, beginning at approximately 2:00 p.m., with 31 interviewable Residents, of a current census of 50, including those Residents C.N.A. #5 had recently provided direct care for. No Resident reported any physical or mental mistreatment. There were 19 noninterviewable Residents, of a current census of 50. Of the 19 noninterviewable Residents, of a current census of 50, C.N.A. #5 had provided direct care to 5 of the 19 noninterviewable. Head-to-toe assessments were preformed on all 5 of these Residents beginning at 2:00 p.m. 5/14/12 and no signs or symptoms of abuse were noted. The Director of Nursing initiated contact with family members, including those non-interviewable Residents, and encourages family members to voice any concerns or complaints. All assessments and interviews were completed at 6:00 p.m. on 5/14/12. The Administrator called the Mississippi State Department of Health-Abuse Unit at approximately 6:00 p.m. on 5/11/12 and made a oral report of the incident. The Administrator completed the written report of the incident to the Mississippi State Department of Health-Abuse Unit on 5-14-12 and faxed the written report to the Mississippi State Department of Health-Abuse Unit on 5-14-12. The Administrator mailed the original written report via certified mail to the Mississippi Department of Health-Abuse Unit on 5/14/12. The Administrator completed the on-line report of the incident to the Attorney General's Office-Medicaid Fraud Unit at 6:00 p.m. on 5/11/12. The Administrator completed the written report to the Attorney General's Office-Medicaid Fraud Unit on 5/14/12 and faxed the written report to the Attorney General's Office-Medicaid Fraud Unit on 5/14/12. The Administrator contacted an investigator for the Attorney General's Office-Medicaid Fraud Unit on 5/15/12. The investigator with the Attorney General's Office-Medicaid Fraud Unit informed the Administrator he had received the on-line report and he would be at the facility on 5/16/12 at approximately 9:00 a.m. Upon the arrival, the investigator with the Attorney General's Office-Medicaid Fraud Unit received the written report/investigation of the incident. The investigator with the Attorney General's Office-Medicaid Fraud Unit discussed the incident with the Administrator and the Director of Nursing. The investigator with the Attorney General's Office-Medicaid Fraud Unit stated he needed to interview C.N.A. #5. (Nursing Facility's) Human Resource Director contacted C.N.A. #5 and informed C.N.A #5 she needed to come to the Human Resource Department Office, which is located in (Hospital). C.N.A. #5 was interviewed privately by the investigator with the Attorney General's Office-Medicaid Fraud Unit at 10:00 a.m. on 5/16/12. After the investigator for the Attorney General's Office-Medicaid Fraud Unit completed his interview, C.N.A. #5 was terminated at 10:30 a.m. by .Human Resource Director due to the allegation of abuse being substantiated. C.N.A. #5 was instructed by the Human Resource Director and the Administrator that C.N.A. #5 would not be allowed on the premises of (Hospital/Nursing Facility). The investigator with the Attorney General's Office-Medicaid Fraud unit informed the Administrator and the Director of Nursing that he would be pursuing criminal charges against C.N.A. #5. Director of Nursing viewed all Residents, of a current census of 50 Residents, beginning at 2:00 p.m. on 5/14/12. The Director of Nursing conducted interviews with 31 of the interviewable Residents, of a current census 50. There were 19 non-interviewable Residents, of a current census of 50. Interviewable Residents were asked "has anyone ever mistreated you or been mean to you". All 31 Residents interviewed verbally and non-verbally indicated no one at the facility had ever been mean to them or mistreated them. The Director of Nursing informed 31 Residents of a current census of 50, that at any time they could report to the Administrator, the Director of Nursing, or other staff members if they feel someone was mistreating them or being mean to them and that the report would be anonymous and would be without retribution. All Residents indicated understanding of reporting. The Director of Nursing frequently has conversations with family members, including those non-interviewable Residents, and encourages family members to voice any concerns or complaints. The Nurse Consultant, the Minimum Data Set Nurse, and the Administrator conducted in-the definitions of abuse, their duty and responsibility to report, how, when and where to report, the consequences not reporting, the consequences for making a false report, and the punishment for abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property or resources. No staff member was allowed to work prior to attending the in-service. Residents will be reminded on a continuous basis of their right to be free from abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property or resources by leadership staff of (Hospital). Residents will be observed by leadership staff (which included Administrator, Director of Nursing, Social Service Director, Activities Director, and the Minimum Data Set Nurse), registered nurses, licensed practical nurses, and certified nurse aides for any signs or symptoms of mistreatment and/or abuse. All staff will be in-serviced on the Vulnerable Adult Act upon hire by the Administrator and/or designee and annually by the Director of Nursing and/or designee thereafter. The Vulnerable Adult Act will be reiterated at monthly staff meetings. The investigator with the Attorney General's Office-Medicaid Fraud Unit has offered to conduct the 2012 annual in-service on the Vulnerable Adult Act. Social Services Director and/or designee will re-interview interviewable Residents weekly for four weeks then monthly for six months. The Director of Nursing and/or designee will reassess non-interviewable Residents weekly for four weeks then monthly for six months for any signs or symptoms of abuse. The Administrator and/or designee will re-interview staff from each department on the definitions of abuse, their duty and responsibility to report, how, when and where to report, and the consequences for not reporting, the consequences for making a false report, and the punishment for abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property or resources weekly for four weeks then monthly for six months. The Administrator and/or designee will also re-question staff from each department if he/she has knowledge of or reasonable cause to believe any Resident has experienced any type of abuse or mistreatment weekly for four weeks then monthly for six months." Based on verification of the facility's corrective actions that were validated by observations, resident interviews, family interview, and in-service review forms the Immediate Jeopardy was removed and the scope and severity was lowered on 5-16-12 to a "D" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

Part I CI MS # Based on interviews, policy review, medical record review, and review of an Autopsy Report from the Mississippi State Medical Examiner's Office, the facility failed to develop a care plan for the potential for constipation/fecal impaction in an effort to prevent constipation/fecal impactions. This resulted in Resident #2's death due to a "Massive colon dilatation due to fecal impaction resulting in [MEDICAL CONDITION] and Asphyxia." This is for three (3) of six (6) sampled residents reviewed (Residents #1, #2, and #4). The lack of implementation to ensure that the facility developes a care plan for the potential for constipation/fecal impaction in an effort to prevent constipation/fecal impactions was deemed an Immediate Jeopardy to begin on 12-31-11 and was removed on 5-11-12. The facility Administrator, Director of Nursing (DON), Risk Manager, and Administrator of the hospital were notified of the Immediate Jeopardy on 5-10-12 at 2:45 p.m. The facility provided a credible Allegation of Compliance (AoC) on 5-11-12 at 5:30 p.m. Based on verification of the facility's corrective actions that were validated by observations, in-service review forms, staff review of testing, review of revised care plans, and review of policy development/revisions, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 5-11-12 to a "H" level, which constituted actual harm that is not an Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee. Findings Include: Cross Refer to F-309 for the facility's failure to assess residents using all information available, develop care plans to address the potential for constipation, re-assess the residents as necessary, accurately monitor resident's bowel elimination, and follow up with interventions to prevent constipation as necessary. The facility provided a crediable Allegation of Compliance on 5-11-12 at 5:30 p.m. "Crediable Allegation of Compliance" "Addendum to Allegation of Compliance of 5/11/12. Resident #1 was identified 5-16-12. Resident #1 is an eighty-two year old female admitted to (Nursing Facility) on 3/16/06 status [REDACTED]. On 4/20/12 Resident #1 was sent for x-ray of right hip due to complaints of pain and history of hip replacement. X-ray report indicated increased stool is noted in the rectosigmoid colon. Resident #1 charted indicated bowel movement times one on 4/20/12 and bowel movements times two on 4/21/12. Resident #1 care plan was updated to include at risk for constipation. Resident #2 was a seventy-three (73) year old female who was admitted to (Nursing Facility) on 11/12/1991 following a severe stroke. On 12/28/11 at 11:45 a.m. Resident #2 was seen by her primary physician. No new orders were written. From the time Resident #2 was seen by her primary physician until 12/31/11, there was not change in her condition. About 8:15 a.m. on 12/31/11 the LPN (Licensed Practical Nurse) suctioned salvia from Resident #2 mouth and Resident #2 replied "thank you". At 8:45 a.m. on 12/31/11 the LPN entered Resident #2's room to administer medication(s) at which time the LPN noted Resident #2 was pale, not breathing and did not have a pulse. The LPN checked Resident #2 for respiration, blood pressure, and pulse but none could be obtained. At 8:53 a.m. on 12/31/11 the on-call physician was notified. At 8:55 a.m. (County Coroner) was notified. At 8:57 a.m. Resident #2's responsible was notified. On 12/31/11 at 9:10 a.m. Resident #2 was pronounced by (County Coroner). Resident #4 was an eighty-eight (88) year old female who was admitted to (Nursing Facility) on 11/3/10. On 8/24/11 Resident #4 had esophagram. Findings were complete absence of primary and secondary peristalsis of the esophagus with distal tertiary contractions note, findings of poor relaxation of the GE junction resulting in extensive stasis of contrast in the esophagus. On 2/28/12 at 7:15 a.m. LPN contacted primary physician concerning coffee ground emesis, test for blood pressure was ordered. On 2/28/12 at 9:45 a.m. LPN contacted Resident #4 primary physician about positive blood in emesis and LPN received order to transfer Resident #4 to emergency room for evaluation. On 2/28/12 at 10:00 a.m. family was notified of order to transfer to emergency room . On 2/28/12 at 12:45 p.m. (Nursing Facility) was notified by emergency room that Resident #4 was being transferred to (local hospital). While (local hospital) per physician progress notes [REDACTED]. On 3/06/12 at 4:05 p.m. Resident #4 was readmitted to the (Nursing Facility), and Resident #4 verbalized on 3/06/12 that she was glad to be home and sleeping in her own bed. On 3/08/12 at 7:30 p.m. the primary physician of Resident #4 was contacted per LPN about coffee ground emesis and primary physician stated "I have talked with family and they understood what is going on, there is nothing we can do about it just continue to monitor her". On 3/09/12 at 1:30 p.m. Resident #4 was noted to have irregular respiratory pattern while asleep. At this time the RN assessed Resident #4 and lung sounds were clear, pulse oxemetry was at ninety-seven percent on room air. On 3/10/12 at 10:30 p.m. Resident #4 noted with black coffee ground emesis, breathing pattern irregular, Resident #4 awake and talking to LPN. On 3/11/12 at 10:00 a.m. Resident #4 was noted by LPN to be resting quietly with irregular breathing pattern. On 3/11/12 at 6:40 p.m. LPN informed per C.N.A. (Certified Nursing Assistant) that Resident #4 appeared to have no respirations. Absences of vital signs verified by RN (Registered Nurse) times three attempts. Family notified on 3/11/12 at 6:45 p.m. Son-in-law stated will be en-route. (County Coroner) was notified on 3/11/12 at 6:47 p.m. On 3/11/12 at 7:15 p.m. Resident #4 was pronounced by (County Coroner), with Son-in-law and LPN was present. A policy and procedure was developed by the Administrator, the Director of Nursing, and the Minimum Data Set Nurse on 5/10/12 at 4:00 p.m. outlining the utilization of Professional Standards of Practice for bowel movements. The Medical Director reviewed and approved the policy on 5/10/12 at 4:45 p.m. RN #2, LPN #1, LPN #2 were in-serviced on the policy by the Minimum Data Set Nurse on 5/10/12 at 5:15 p.m. and LPN #5 and LPN #6 were in-serviced on 5/10/12 at 6:30 p.m. On 5/11/12 at 6:30 a.m. the Minimum Data Set Nurse in-serviced RN #1, LPN #3, and LPN #4 on the Professional Standards of Practice for bowel movement policy. On 5/10/12 at 4:45 p.m. RN #2, LPN #1, LPN #2, C.N.A. #8,16,19,20,and 21 were in-serviced on bowel elimination by the Minimum Data Set Nurse and completed a test to demonstrate understanding of content of the in-service with one-hundred percent passing rate. On 5/10/12 at 6:30 p.m. and LPN #5 and LPN #6 were in-serviced by the Minimum Data Set Nurse and completed a test to demonstrate understanding of content of the in-service with one-hundred percent passing rate. On 5/11/12 at 6:30 a.m. RN #3, LPN #3, LPN #4, C.N.A, #27, 24 , 5, 14, 6, 10 13, 15, 25 were in-serviced on bowel elimination by the Minimum Data Set Nurse and completed a test to demonstrate understanding of content of the in-service with one-hundred percent passing rate. The Care Plan policy and procedure was reviewed and revised on 5/10/12 at 4:30 p.m. by the Administrator, the Director of Nursing, and the Minimum Data Set Nurse. The previous policy was four pages. The revisions to the previous policy were deletion of contacting Ombudsman if no family, condensing policy and procedure to eliminate redunence, and to make wording of policy more user friendly and to improve staff understanding of policy. The Medical Director reviewed and approved the policy on 5/10/12/at 4:45 p.m. The Director of Nursing in-serviced the Activity Director and the Social Service Director on 5/11/12 at 8:00 a.m. on the revised Care Plan Policy. On 5/11/12 at 3:30 p.m. RN #1, RN #2, LPN #3, LPN #4 were in-serviced by Nurse Consultant on the revised care plan policy and procedure. Abuse and Neglect in-services was conducted on 5/11/12 at 3:00 p.m. and at 3:30 p.m. by Nurse Consultant. Staff attending the in-service were RN #3, LPN #4, RN #2, RN #1, LPN #3, and Minimum Data Set Nurse, C.N.A. #21, 20, 16, 19, 5, 13, 10, 8, 15, and 6. The in-service included review of current policy on abuse and neglect , as well as accurate reporting and documentation of bowel movements and the consequences of failure to report or document bowel elimination. All staff will have to attend above in-services before being allowed to work. The Director of Nursing and the Minimum Data Set Nurse have reviewed fifty (50) Residents' care plans, of a current census of 50 Residents on 5/10/12 at 5:00 p.m. to determine which Residents have a current order for a medication to promote bowel movements. Residents' care plan was revised as needed on 5/10/12 by the Director of Nursing and the Minimum Data Set Nurse. Reviews and revisions were completed on 5/10/12 at 9:00 p.m. The Director of Nursing and the Minimum Data Set Nurse reviewed X-Ray results in Residents' current medical record on 5/10/12 at 5:00 p.m. while reviewing care plans. Reviews and revisions were complete on 5/10/12 at 9:00 p.m. The care plans that were revised were for Resident A, B, C, D, E, F, G, H, I. On-coming nurse(s) will review the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. If a Resident is noted to not have had a bowel movement in three days, the RN/LPN will administer a laxative to promote a bowel movement. In the event the laxative does not produce a bowel movement, the RN/LPN will administer a suppository. In the event the suppository does not produce bowel movement, the RN/LPN will contact the Resident's primary physician/on-call physician. The Director of Nursing or his/her designee will review Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Director of Nursing or his/her designee will report findings of the medication administration review to the Quality Assurance Committee and recommendations will be followed. The Director of Nursing or his/her designee will review medical record at lease monthly to ensure care plans have been revised as needed. The Director of Nursing or his/her designee will report findings of the medical record review and care plan revisions to the Quality Assurance Committee and recommendations will be followed." Based on verification of the facility's corrective actions that were validated by observations, in-service review forms, staff review of testing, review of revised care plans, and review of policy development/revisions, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 5-11-12 to a "H" level, which constituted actual harm that is not an Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

Part I CI MS # Based on interviews, policy review, medical record review, and review of an Autopsy Report from the Mississippi State Medical Examiner's Office, the facility failed to adequately assess, care plan, monitor, and re-assess residents for the potential for constipation/fecal impaction in an effort to prevent constipation/fecal impactions. This resulted in Resident #2's death due to a "Massive colon dilatation due to fecal impaction resulting in [MEDICAL CONDITION] and Asphyxia." This is for three (3) of six (6) sampled residents reviewed (Residents #1, #2, and #4). The lack of implementation to ensure that the facility adequately assess, care plan, monitor, and re-assess residents for the potential for constipation/fecal impaction in an effort to prevent constipation/fecal impactions was deemed an Immediate Jeopardy to begin on 12-31-11 and was removed on 5-11-12. The facility Administrator, Director of Nursing (DON), Risk Manager, and Administrator of the hospital were notified of the Immediate Jeopardy on 5-10-12 at 2:45 p.m. The facility provided a credible Allegation of Compliance (AoC) on 5-11-12 at 5:30 p.m. Based on verification of the facility's corrective actions that were validated by observations, in-service review forms, staff review of testing, review of revised care plans, and review of policy development/revisions, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 5-11-12 to a "H" level, which constituted actual harm that is not an Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee. Findings Include: Cross Refer to F-309 for the facility's failure to assess residents using all information available, develop care plans to address the potential for constipation, re-assess the residents as necessary, accurately monitor resident's bowel elimination, and follow up with interventions to prevent constipation as necessary. The facility provided a crediable Allegation of Compliance on 5-11-12 at 5:30 p.m. "Crediable Allegation of Compliance" "Addendum to Allegation of Compliance of 5/11/12. Resident #1 was identified 5-16-12. Resident #1 is an eighty-two year old female admitted to (Nursing Facility) on 3/16/06 status [REDACTED]. On 4/20/12 Resident #1 was sent for x-ray of right hip due to complaints of pain and history of hip replacement. X-ray report indicated increased stool is noted in the rectosigmoid colon. Resident #1 charted indicated bowel movement times one on 4/20/12 and bowel movements times two on 4/21/12. Resident #1 care plan was updated to include at risk for constipation. Resident #2 was a seventy-three (73) year old female who was admitted to (Nursing Facility) on 11/12/1991 following a severe stroke. On 12/28/11 at 11:45 a.m. Resident #2 was seen by her primary physician. No new orders were written. From the time Resident #2 was seen by her primary physician until 12/31/11, there was not change in her condition. About 8:15 a.m. on 12/31/11 the LPN (Licensed Practical Nurse) suctioned salvia from Resident #2 mouth and Resident #2 replied "thank you". At 8:45 a.m. on 12/31/11 the LPN entered Resident #2's room to administer medication(s) at which time the LPN noted Resident #2 was pale, not breathing and did not have a pulse. The LPN checked Resident #2 for respiration, blood pressure, and pulse but none could be obtained. At 8:53 a.m. on 12/31/11 the on-call physician was notified. At 8:55 a.m. (County Coroner) was notified. At 8:57 a.m. Resident #2's responsible was notified. On 12/31/11 at 9:10 a.m. Resident #2 was pronounced by (County Coroner). Resident #4 was an eighty-eight (88) year old female who was admitted to (Nursing Facility) on 11/3/10. On 8/24/11 Resident #4 had esophagram. Findings were complete absence of primary and secondary peristalsis of the esophagus with distal tertiary contractions note, findings of poor relaxation of the GE junction resulting in extensive stasis of contrast in the esophagus. On 2/28/12 at 7:15 a.m. LPN contacted primary physician concerning coffee ground emesis, test for blood pressure was ordered. On 2/28/12 at 9:45 a.m. LPN contacted Resident #4 primary physician about positive blood in emesis and LPN received order to transfer Resident #4 to emergency room for evaluation. On 2/28/12 at 10:00 a.m. family was notified of order to transfer to emergency room . On 2/28/12 at 12:45 p.m. (Nursing Facility) was notified by emergency room that Resident #4 was being transferred to (local hospital). While (local hospital) per physician progress notes [REDACTED]. On 3/06/12 at 4:05 p.m. Resident #4 was readmitted to the (Nursing Facility), and Resident #4 verbalized on 3/06/12 that she was glad to be home and sleeping in her own bed. On 3/08/12 at 7:30 p.m. the primary physician of Resident #4 was contacted per LPN about coffee ground emesis and primary physician stated "I have talked with family and they understood what is going on, there is nothing we can do about it just continue to monitor her". On 3/09/12 at 1:30 p.m. Resident #4 was noted to have irregular respiratory pattern while asleep. At this time the RN assessed Resident #4 and lung sounds were clear, pulse oxemetry was at ninety-seven percent on room air. On 3/10/12 at 10:30 p.m. Resident #4 noted with black coffee ground emesis, breathing pattern irregular, Resident #4 awake and talking to LPN. On 3/11/12 at 10:00 a.m. Resident #4 was noted by LPN to be resting quietly with irregular breathing pattern. On 3/11/12 at 6:40 p.m. LPN informed per C.N.A. (Certified Nursing Assistant) that Resident #4 appeared to have no respirations. Absences of vital signs verified by RN (Registered Nurse) times three attempts. Family notified on 3/11/12 at 6:45 p.m. Son-in-law stated will be en-route. (County Coroner) was notified on 3/11/12 at 6:47 p.m. On 3/11/12 at 7:15 p.m. Resident #4 was pronounced by (County Coroner), with Son-in-law and LPN was present. A policy and procedure was developed by the Administrator, the Director of Nursing, and the Minimum Data Set Nurse on 5/10/12 at 4:00 p.m. outlining the utilization of Professional Standards of Practice for bowel movements. The Medical Director reviewed and approved the policy on 5/10/12 at 4:45 p.m. RN #2, LPN #1, LPN #2 were in-serviced on the policy by the Minimum Data Set Nurse on 5/10/12 at 5:15 p.m. and LPN #5 and LPN #6 were in-serviced on 5/10/12 at 6:30 p.m. On 5/11/12 at 6:30 a.m. the Minimum Data Set Nurse in-serviced RN #1, LPN #3, and LPN #4 on the Professional Standards of Practice for bowel movement policy. On 5/10/12 at 4:45 p.m. RN #2, LPN #1, LPN #2, C.N.A. #8,16,19,20,and 21 were in-serviced on bowel elimination by the Minimum Data Set Nurse and completed a test to demonstrate understanding of content of the in-service with one-hundred percent passing rate. On 5/10/12 at 6:30 p.m. and LPN #5 and LPN #6 were in-serviced by the Minimum Data Set Nurse and completed a test to demonstrate understanding of content of the in-service with one-hundred percent passing rate. On 5/11/12 at 6:30 a.m. RN #3, LPN #3, LPN #4, C.N.A, #27, 24 , 5, 14, 6, 10 13, 15, 25 were in-serviced on bowel elimination by the Minimum Data Set Nurse and completed a test to demonstrate understanding of content of the in-service with one-hundred percent passing rate. The Care Plan policy and procedure was reviewed and revised on 5/10/12 at 4:30 p.m. by the Administrator, the Director of Nursing, and the Minimum Data Set Nurse. The previous policy was four pages. The revisions to the previous policy were deletion of contacting Ombudsman if no family, condensing policy and procedure to eliminate redunence, and to make wording of policy more user friendly and to improve staff understanding of policy. The Medical Director reviewed and approved the policy on 5/10/12/at 4:45 p.m. The Director of Nursing in-serviced the Activity Director and the Social Service Director on 5/11/12 at 8:00 a.m. on the revised Care Plan Policy. On 5/11/12 at 3:30 p.m. RN #1, RN #2, LPN #3, LPN #4 were in-serviced by Nurse Consultant on the revised care plan policy and procedure. Abuse and Neglect in-services was conducted on 5/11/12 at 3:00 p.m. and at 3:30 p.m. by Nurse Consultant. Staff attending the in-service were RN #3, LPN #4, RN #2, RN #1, LPN #3, and Minimum Data Set Nurse, C.N.A. #21, 20, 16, 19, 5, 13, 10, 8, 15, and 6. The in-service included review of current policy on abuse and neglect , as well as accurate reporting and documentation of bowel movements and the consequences of failure to report or document bowel elimination. All staff will have to attend above in-services before being allowed to work. The Director of Nursing and the Minimum Data Set Nurse have reviewed fifty (50) Residents' care plans, of a current census of 50 Residents on 5/10/12 at 5:00 p.m. to determine which Residents have a current order for a medication to promote bowel movements. Residents' care plan was revised as needed on 5/10/12 by the Director of Nursing and the Minimum Data Set Nurse. Reviews and revisions were completed on 5/10/12 at 9:00 p.m. The Director of Nursing and the Minimum Data Set Nurse reviewed X-Ray results in Residents' current medical record on 5/10/12 at 5:00 p.m. while reviewing care plans. Reviews and revisions were complete on 5/10/12 at 9:00 p.m. The care plans that were revised were for Resident A, B, C, D, E, F, G, H, I. On-coming nurse(s) will review the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. If a Resident is noted to not have had a bowel movement in three days, the RN/LPN will administer a laxative to promote a bowel movement. In the event the laxative does not produce a bowel movement, the RN/LPN will administer a suppository. In the event the suppository does not produce bowel movement, the RN/LPN will contact the Resident's primary physician/on-call physician. The Director of Nursing or his/her designee will review Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Director of Nursing or his/her designee will report findings of the medication administration review to the Quality Assurance Committee and recommendations will be followed. The Director of Nursing or his/her designee will review medical record at lease monthly to ensure care plans have been revised as needed. The Director of Nursing or his/her designee will report findings of the medical record review and care plan revisions to the Quality Assurance Committee and recommendations will be followed." Based on verification of the facility's corrective actions that were validated by observations, in-service review forms, staff review of testing, review of revised care plans, and review of policy development/revisions, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 5-11-12 to a "H" level, which constituted actual harm that is not an Immediate Jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.