Every finding on record at Lafon Nursing Facility Of The Holy Family

Based on interview and record reviews, the facility failed to provide informed consents for psychotropic medications to residents and/or their representatives for 4 (Resident #19, Resident #56, Resident #83, Resident #87) of 5 sampled residents reviewed for unnecessary medications. Findings: Review of the facility's undated Informed Consent for Psychotropic Drugs policy revealed, in part, a psychotropic medication was any drug that affected brain activities associated with mental processes and behavior, including but not limited to antipsychotics, antidepressants, anxiolytics, hypnotics, mood stabilizers, anticonvulsants, central nervous system agents, muscle relaxants, anticholinergics, and antihistamines. Further review revealed informed consent was disclosure of material information to the resident or their representative, allowing them to accept, refuse, or revoke consent. Further review revealed that consent must be obtained prior to initiation or increase. Further review revealed a representative was a legally authorized decision-maker, such as a guardian, durable power of attorney for health care, or other surrogate identified per state law if the resident lacked decision-making capacity. Resident #19 Review of Resident #19's medical record revealed, in part, Resident #19 was admitted to the facility on [DATE]. Review of Resident #19's diagnoses list revealed, in part, Resident #19 had diagnoses of depression and dementia with other behavioral disturbance. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/09/2026 revealed Resident #19 received psychotropic medications. Review of Resident #19's active physician's orders revealed, in part, an active physician's order dated 04/15/2026 for buspirone (a psychotropic medication) 5 milligrams by mouth 3 times daily, and an active physician's order dated 03/27/2026 for sertraline (a psychotropic medication) 100 milligrams by mouth daily. Review of Resident #19's medication administration record revealed Resident #19 received the above mentioned psychotropic medications daily from 08/01/2026 through 08/19/2026. Further review of Resident #19's medical records revealed there was no documented evidence the resident or resident representative was provided an informed consent. Resident #56 Review of Resident #56's medical record revealed, in part, Resident #56 was admitted to the facility on [DATE]. Review of Resident #56's diagnoses list revealed, in part, Resident #56 had diagnoses of depression and dementia. Review of MDS with an ARD of 06/16/2026 revealed, in part, Resident #56 received psychotropic medications. Review of Resident #56's active physician's orders revealed, in part, Resident #56 had an active physician's order dated 05/12/2026 for buspirone 10 milligrams by mouth twice daily, and an active physician's order dated 05/21/2026 for Seroquel (a psychotropic medication) 25 milligrams by mouth daily. Review of Resident #56's medication administration record revealed Resident #56 received the above mentioned psychotropic medications daily from 08/01/2026 through 08/19/2026. Further review of Resident #56's medical records revealed there was no documented evidence the resident or resident representative was provided an informed consent. Resident #83 Review of Resident #83's medical record revealed, in part, Resident #83 was admitted to the facility on [DATE]. Review of Resident #83's diagnoses list revealed, in part, Resident #83 had a diagnoses of insomnia, anxiety disorder, and dementia. Review of Resident #83's active physician's orders revealed, in part, Resident #83 had an active physician's order dated 02/11/2026 for Seroquel (a psychotropic medication) 50 milligrams by mouth at bedtime, an active physician's order dated 12/9/2025 for Trazadone (a psychotropic medication) 50 milligrams by mouth at bedtime, and an active physician's order dated 11/16/2024 for Zoloft (a psychotropic medication) 100 milligrams daily. Review of Resident #83's MDS with an ARD of 06/08/2026 revealed, in part, Resident #83 received psychotropic medication(s). Review of Resident #83's medication administration record revealed Resident #83 received the above mentioned psychotropic medications daily from 08/01/2026 through 08/19/2026. Further review of Resident #83's medical records revealed there were no documented evidence the resident or resident representatives was provided an informed consent. Resident #87 Review of Resident #87's medical record revealed, in part, Resident #87 was admitted to the facility on [DATE]. Further review revealed in part, Resident #87 had diagnosis of vascular dementia with other behavioral disturbance (a decline in thinking skills caused by reduced blood flow to the brain); restlessness and agitation; major depressive disorder; and schizophrenia (a long-term brain condition that makes it hard for a person to tell what is real and what is not). Review of Resident #87's MDS with an ARD of 06/22/2026 revealed, in part, Resident #87 had a BIMS of 10, which indicated Resident #87 had moderate cognitive impairment. Further review revealed Resident #87 was diagnosed with anxiety, depression, schizophrenia, and vascular dementia. Further revealed Resident #87 was prescribed antipsychotics, antidepressants, and anticonvulsants. Further review revealed Resident #87 received antipsychotics on a routine basis. Review of Resident #87's physician's order dated 08/19/2026 revealed, in part, had an active physician's order for Abilify (an antipsychotic medication) 2 milligrams (mg) during the day and 5 mg at bedtime with a start date of 05/13/2026; Buspirone (an antianxiety medication) 5 mg with a start date of 05/27/2026; Fluoxetine (an antidepressant) 20 mg with a start date of 04/23/2026; Mirtazapine (an antidepressant) 7.5 mg with a start date of 05/06/2026; and Trazadone (an antidepressant) 50 mg with a start date of 04/03/2026. Review of Resident #87's medication administration record dated 08/01/2026 through 08/18/2026 revealed, in part, Resident #87 had received Abilify 2 mg and 5 mg, mirtazapine 7.5 mg, trazadone 50 mg, fluoxetine 20 mg, and buspirone 5 mg every day from 08/01/2026 through 08/18/2026 as prescribed. Review of Resident #87's medical record revealed Resident #87 did not have consents for the above mentioned prescribed psychotropic medications. In an interview on 08/19/2026 at 3:37PM, S1Administrator indicated she had no informed consents for psychotropic medications for the above mentioned residents to present to dispute the above mentioned deficient practice and offered no explanation as to why the facility did not have the required documentation.

Based on interviews and record reviews, the facility failed to maintain the resident's right to confidentiality of their medical records for 80 (Resident #1, Resident #2, Resident #3, Resident #R4, Resident #R5, Resident #R7, Resident #R8, Resident #R9, Resident #R10, Resident #R11, Resident #R12, Resident #R13, Resident #R14, Resident #R15, Resident #R16, Resident #R17, Resident #R18, Resident #R19, Resident #R20, Resident #R21, Resident #R22, Resident #R23, Resident #R24, Resident #R25, Resident #R26, Resident #R27, Resident #R28, Resident #R29, Resident #R30, Resident #R31, Resident #R32, Resident #R33, Resident #R34, Resident #R35, Resident #R36, Resident #R37, Resident #R38, Resident #R39, Resident #R40, Resident #R41, Resident #R42, Resident #R43. Resident #R44, Resident #R45, Resident #R46, Resident #R47, Resident #R48, Resident #R49, Resident #R50, Resident #R51, Resident #R52, Resident #R53, Resident #R54, Resident #R55, Resident #R56, Resident #R57, Resident #R58, Resident #R59, Resident #R60, Resident #R61, Resident #R62, Resident #R63, Resident #R64, Resident #R65, Resident #R66, Resident #R67, Resident #R68, Resident #R69, Resident #R70, Resident #R71, Resident #R72, Resident #R73, Resident #R74, Resident #R75, Resident #R76, Resident #R77, Resident #R78, Resident #R79, Resident #R80, Resident #R81) of 80 residents whose medical information were released without their consents. Findings:Review of the facility's Resident Rights and Dignity policy, with a revision date of 03/07/2011, revealed, in part, the facility would safeguard all resident records, whether medical, financial, or social in nature, to protect the confidentiality of the information. Further review revealed release of resident information would be handled in a manner to protect resident rights. Review of S4Social Services electronic mail (e-mail) to a contracted outside provider dated 10/15/2025 revealed Resident #R7, Resident #R8, Resident #R9, Resident #R10, Resident #R11, Resident #R12, Resident #R13, and Resident #R14's face sheets were attached to the e-mail. Further review of Resident #R7, Resident #R8, Resident #R9, Resident #R10, Resident #R11, Resident #R12, Resident #R13, and Resident #R14's face sheets revealed the face sheet contained the following information, in part, the resident's name, the resident's date of birth , the resident's social security number, the resident's admit date , the resident's Medicare and/or Medicaid number, the resident's drug allergies, the resident's care providers, the resident's pharmacy name, the resident's emergency contacts, the resident's diagnoses, and the resident's advance directive. Review of S4Social Services e-mail to a contracted outside provider dated 03/20/2026 revealed the census for 03/16/2026 was emailed to the contracted outside provider. Further review of the attached facility census revealed information for Resident #1, Resident #2, Resident #3, Resident #R4, Resident #R5, and Resident #R7 through Resident #R81 were contained on the census. Further review of the census for the above mentioned residents revealed the following information was contained on the census, the resident's room number, the resident's name, the resident's date of birth , the resident status in the facility, the resident's primary payer source, and the resident's room rate designation. In an interview on 04/22/2026 at 2:41PM, S4Social Services indicated every month to every quarter, she sent a daily census to the contracted outside provider, so the contracted outside provider could go through the list of residents and identify any residents they were not providing services. S4Social Services further indicated the contracted outside provider would then come to the facility and talk with the residents to see if they wanted services. When the surveyor asked to see the evidence of the residents' consent to release medical records, S4Social Services was unable to produce consents for release of medical records to the contracted outside provider at the time of the request. In an interview on 04/23/2026 at 11:59AM, S1Chief Operating Officer (COO) indicated the facility did not have any evidence to present at this time that a consent was received prior to giving the contracted outside provider the residents' information. S1COO further indicated the facility should not have released any of the residents' medical information without the residents or the residents' responsible party consent prior to the release. In an interview on 04/23/2026 at 12:46PM, S4Social Services indicated she had sent medical information to the contracted outside provider on 10/15/2025 and 03/17/2026.

Based on observation, interview, and record review, the facility failed to ensure a resident received the correct enteral feeding (liquid nutrition that was administered through a tube directly into the stomach) for 1 (Resident #3) of 1 sampled residents investigated for enteral feedings.Findings:Review of Resident #3's April 2026 physician's orders revealed, in part, an order to administer Glucerna 1.2 (a type of enteral feeding) at 50 milliliters (ml) per hour for 12 hours a day, and if tolerated, to increase the rate to 60 ml per hour for 21 hours a day.Observation on 04/21/2026 at 1:20PM revealed Isosource (a type of enteral feeding) was being administered to Resident #3 at a rate of 60cml per hour.In an interview and observation on 04/21/2026 at 1:31PM, S8Licensed Practical Nurse (LPN) confirmed Isosource was currently being administered to Resident #3 at 60 ml per hour. S8LPN further indicated the Isosource was the wrong enteral feeding type, and confirmed Resident #3's physician's order was to administer Glucerna 1.2 at 60 ml per hour.In an interview on 04/21/2026 at 2:13PM, S3Director of Nursing indicated S8LPN should have verified Resident #3's physician's order for his enteral feeding before administering the enteral feeding to Resident #3.

Based on observation, interviews, and record reviews, the facility failed to ensure the medication error rate was not greater than 5 percent by having a medication error rate of 29 percent for 1 (Resident #R4) of 8 sampled residents observed during medication administration. Findings:Review of the facility's undated Administering Medications policy revealed, in part, medications were to be administered within one hour of their prescribed time, unless otherwise specified. Review of Resident #R4's April 2026 Physician Orders and April 2026 electronic Medical Administration Record (eMAR) revealed the following medications were scheduled to be administered at 9:00AM: Aspirin (medication used to prevent blood clots) Enteric Coated (EC) 81 milligrams (mg) one tablet by mouth once a day; Calcium Carbonate (medication used as supplement) 600mg one tablet by mouth twice a day; Ascorbic Acid (Vitamin C supplement, medication used to replace vitamin C in the body) 500mg one tablet by mouth once a day; Carvediolol (medication used to treat heart conditions) 25mg one tablet by mouth twice a day; Furosemide (diuretic, medication used remove excessive fluid from the body) 20mg one tablet by mouth once a day; Potassium Chloride (medication used as supplement to replace potassium) Extended Release (ER) 20 milliequivalent (meq) one tablet by mouth; Thiamin Hydrochloride (medication used to replace vitamin B-1 in the body) (Hcl) 100mg one tablet by mouth once a day; Timolol Maleate Ophthalmic (medication used to treat glaucoma) solution 0.5% one drop to both eyes once a day; and,Docusate Sodium (medication used to treat constipation) 100mg one tablet by mouth once a day. Observation on 04/20/2026 at 11:24AM revealed the following medications were administered by S7Licensed Practical Nurse (LPN) to Resident #R4: Aspirin 81 mg one tablet by mouth;Calcium Supplement 600 (600mg) one tablet by mouth;Vitamin C 500mg one tablet by mouth; Carvediolol 25mg one tablet by mouth; Furosemide 20mg one tablet by mouth; Potassium Chloride 20meq one tablet by mouth; Thiamin Vitamin B-1 100mg one tablet by mouth; Timolol Maleate Ophthalmic solution 0.5% one drop to both eyes; and,Docusate Sodium 100mg one tablet by mouth. There were 31 opportunities for error with 9 errors for a medication error rate of 29%. In an interview on 04/21/2026 at 12:31PM, S7LPN indicated the above medications were scheduled to be administered at 9:00AM, and should have been administered between 8:00AM and 10:00AM. In an interview on 04/23/2026 at 11:14AM, S3Director of Nursing (DON) indicated medications were to be administered within one hour before to one hour after the medications prescribed time, and therefore S7LPN should not have administered the above mentioned medications without having a physician order to change the medication order time.

Based on interviews and record reviews, the facility failed to ensure a resident received medications as ordered by the physician for 1 (Resident #2) of 3 sampled residents records reviewed for pharmaceutical services. Findings:Review of Resident #2's medical records revealed, in part, Resident #2 was re-admitted to the facility after a hospital stay on 03/09/2026. Review of Resident #2's handwritten physician's order sheet revealed in part, on 03/09/2026, Resident #2's physician gave orders for Resident #2 to be administered:-2 tablets of Acetaminophen (a medication used to treat mild pain and/or headaches) 500 milligrams (mg) every 6 hours as needed;-1 tablet of Eliquis (a blood thinning medication) 2.5 mg two times a day;-1 tablet of Buspirone (a medication for anxiety) 5 mg three times a day;-2 tablets of Losartan (a medication used to treat high blood pressure) 25 mg every day;-1 tablet of Mirtazapine (a medication used to treat depression) 7.5 mg every night;-2 tablets of Quetiapine (a medication used to treat mental health issues) 25 mg every night;-1 tablet of Senna Oral (a medication used to relieve occasional constipation) 8.6 mg two times a day; and,-1 tablet of Vistaril (a medication used to treat anxiety) every 8 hours as needed. Review of Resident #2's March 2026 electronic Medical Administration Record (eMAR) revealed, in part, no evidence Resident #2's above mentioned ordered medications were administered to Resident #2 between 03/09/2026 and 03/19/2026.In an interview on 04/23/2026 at 2:52PM, S3Director of Nursing indicated the facility's nurses were responsible for clarifying orders with a resident's physician when a resident came back from the hospital.In an interview on 04/23/2026 at 3:24PM, S5Clinical Support Licensed Practical Nurse indicated Resident #2's medications should have been restarted and administered as per the written physician's orders on 03/09/2026 and were not.

Based on observations, interview, and record reviews, the facility failed to ensure nurses documented the administration of enteral feeding (liquid nutrition that was administered through a tube directly into the stomach) for 1 (Resident #3) of 1 sampled residents investigated for enteral feedings.Findings:Review of Resident #3's April 2026 physician's orders revealed, in part, an order to administer Glucerna 1.2 (a type of enteral feeding) at 50 milliliters (ml) per hour for 12 hours a day, and if tolerated, to increase the rate to 60 ml per hour for 21 hours a day.Review of Resident #3's April 2026 eMAR revealed, in part, no documentation staff administered Resident #3's Glucerna 1.2 at 60 ml per hour for 21 hours on 04/21/2026 and 04/22/2026.Observation on 04/21/2026 at 9:40AM revealed, Resident #3 was being administered Glucerna 1.2 at 60 ml per hour.Observation on 04/22/2026 at 2:41PM revealed, Resident #3 was being administered Glucerna 1.2 at 60 ml per hour.In an interview on 04/23/2026 at 11:04AM, S3Director of Nursing indicated when the nurses administered Resident #3's Glucerna 1.2, they should have documented the administration in the resident's medication administration record.

Based on observation, interview, and record review, the facility failed to ensure the S6Treatment Nurse completed appropriate hand hygiene when performing wound care for 1 (Resident #1) of 1 sampled residents observed for infection control practices during wound care. Findings:Review of the facility's Using Gloves policy and procedure, with a revised date of 03/10/2011, revealed, in part, employees were to wash hands after removing gloves. Further review revealed gloves did not replace handwashing. Review of Resident #1's April 2026 physician's orders revealed, in part, cleanse Resident #1's diabetic wound to the left second toe with normal saline or wound cleanser, pat dry, apply silver alginate (dressing with silver to prevent infections) to the wound bed, and cover with a clean dry dressing three times a week and as needed. Observation on 04/21/2026 at 10:43AM revealed S6Treatment Nurse removed the dressing to Resident #1's left second toe, removed her gloves, did not perform hand hygiene, and applied new gloves. Further observation revealed S6Treatment Nurse then cleaned Resident #1's left second toe wound, removed her gloves, did not perform hand hygiene, and applied new gloves.S6Treatment Nurse then applied the calcium alginate dressing and dry dressing to Resident #1's left second toe wound. In an interview on 04/21/2026 at 10:45AM, S6Treatment Nurse indicated she completed hand hygiene before and after wound care; however she had not completed hand hygiene between each glove change because there was no hand sanitizer in the room, and did not wash her hands as an alternative to hand sanitizer. In an interview on 04/21/2026 at 12:03PM, S3Director of Nursing (DON) indicated S6Treatment Nurse should have performed hand hygiene between every glove change.

Based on interview and record reviews, the facility failed to ensure the facility's Certified Nursing Assistants (CNAs) received no less than 12 hour of in-services per year for 1 (S12CNA) of 4 sampled CNA's personnel records reviewed for training requirements.Findings:Review of S12CNA's personnel file revealed, in part, S12CNA was hired on 03/23/2025. Further review revealed S12CNA had not completed 12 hours of in-service training annually. In an interview on 04/23/2026 at 4:23PM, S1Chief Operations Officer indicated the facility had no documented evidence S12CNA had completed 12 hours of in-service training annually.

Based on observations, interviews, and record reviews, the facility failed to maintain accurate records for 1 (Resident #3) of 3 sampled residents reviewed for accurate documentation. Findings:Review of the facility's undated Licensed Practical Nurse (LPN) job description revealed, in part, duties and responsibilities included maintaining accurate documentation of nursing care, including nurse's notes and electronic records. Review of the facility's undated Checking Gastric Residual Volume (GRV) policy and procedure, revealed, in part, the person performing this procedure should record the date and time the procedure was performed and the amount of gastric residual in the resident's medical record. Review of Resident #3's December 2025 physician's orders revealed, in part, an order dated 11/11/2025 for Isosource 1.5 (a type of liquid nutritional supplement that is typically given through a tube directly inserted into the stomach) at 58 milliliters (mL)/hour via percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted through the skin into the stomach to provide liquid nourishment) for 21 hours to be started at 12:00PM and stopped at 9:00AM. Review of Resident #3's Medication Admin Audit Report, dated 12/17/2025, revealed, in part, S6LPN documented Resident #3's Isosource 1.5 feedings were restarted at a rate of 58 mL/hour on 12/17/2025 at 11:08AM. Review of Resident #3's nurse's notes, dated 12/17/2025 at 12:17PM, written by S6LPN indicated, in part, 315 mL of residual, feeding held. Further review revealed no nurse's notes dated 12/17/2025 when Resident #3's enteral feeds were restarted and/or Resident #3's subsequent residual checks. Observation on 12/17/2025 at 1:00PM revealed Resident #3's feeding pump remained off and feed tubing was not connected to Resident #3's PEG tube port. In an interview on 12/17/2025 at 2:38PM, S6LPN indicated Resident #3's enteral feedings were held and not currently running due to a high residual. S6LPN further indicated she documented Resident #3's enteral feedings were restarted at 11:08AM and should not have been. Observation on 12/17/2025 at 2:45PM revealed Resident #3's feeding pump remained off and feed tubing was not connected to Resident #3's PEG tube port. Observation on 12/17/2025 at 2:51PM revealed S6LPN performed a PEG tube residual check on Resident #3's PEG tube. Further observation revealed 50 mL residual was removed. Observation on 12/17/2025 at 3:08PM revealed S6LPN restarted Resident #3's enteral feeds. Review of Resident #3's medical record revealed, in part, S6LPN did not document the feeding residual check on 12/17/2025 at 2:51PM. Further review revealed S6LPN did not document the actual time Resident #3's enteral feedings were restarted on 12/17/2025. In an interview on 12/22/2025 at 10:19AM, S3Director of Nursing (DON) confirmed S6LPN should have accurately documented Resident #3's enteral feeding times and Resident #3's enteral feeding residual checks including the date, time, and amount in Resident #3's medical record.

Based on observations, interviews, and record reviews, the facility failed to ensure:1. Enhanced Barrier Precaution (EBP) signage was posted in a conspicuous place to identify a resident on EBP (Resident #3); and,2. Staff wore proper protective equipment (PPE) for EBP during high contact patient care activities (Resident #3). This deficient practice was identified for 1 (Resident #3) of 3 sampled residents reviewed for resident quality of care. Findings: Review of the facility's undated CNA job description revealed, in part, duties and responsibilities included following infection control and safety procedures to prevent the spread of disease and ensure a safe environment. Review of the facility's undated Assistant Director of Nursing (ADON) job description revealed, in part, essential duties and responsibilities as the infection control preventionist included ensuring nursing staff followed safety procedures, including the use of PPE and proper infection control protocols. 1.Review of the facility's undated EBP policy and procedure revealed, in part, EBP was indicated for residents with indwelling medical devices including feeding tubes. Further review revealed EBP signs should be posted on the door or wall outside the resident's rooms to communicate PPE required. Review of Resident #3's physician's orders, dated 12/2025, revealed, in part, an order for EBP due to Resident #3 having a percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted through the skin into the stomach to provide liquid nourishment). Review of Resident #3's careplan, initiated on 03/10/2025, revealed, in part, EBP signage would be visible to alert visitors as to the use of EBP. Observation on 12/17/2025 at 10:05AM revealed no EBP signage posted on or around Resident #3's door and/or bed. Observation on 12/17/2025 at 3:45PM revealed no EBP signage posted on or around Resident #3's door and/or bed. In an interview on 12/17/2025 at 3:50PM, S7Certified Nursing Assistant (CNA) indicated Resident #3 did not have any EBP signs posted. 2. Review of the facility's undated EBP policy and procedure revealed, in part, EBP apply when a resident has a wound or indwelling medical device including a feeding tube. Further review revealed high contact resident care activities requiring the use of gown and gloves for EBPs include transferring, providing bed mobility, and feeding tube device care. Review of Resident #3's careplan initiated on 03/10/2025 revealed, in part, EBP would be followed. Observation on 12/17/2025 at 2:51PM revealed S6Licensed Practical Nurse (LPN) entered Resident #3's room to perform PEG tube care without wearing a gown. Further observation revealed S6LPN completed PEG tube residual check and connected Resident #3's PEG feeding tubing to the PEG tube port without wearing a gown. In an interview on 12/17/2025 at 3:15PM S6LPN indicated she did not wear a gown when performing Resident #3's PEG tube care and should have. Observation on 12/18/2025 at 8:11AM revealed an EBP sign on Resident #3's room door indicating staff must wear personal protective equipment during high contact resident care activities. Observation on 12/18/2025 at 12:44PM revealed S7CNA and S8Restorative Aide (RA) entered Resident #3's room to obtain Resident #3's weight using a Hoyer Lift. Further observation revealed S7CNA and S8RA removed Resident #3's blankets, rolled Resident #3 onto a Hoyer lift pad, performed Hoyer lift weight, rolled Resident #3 to remove the Hoyer lift pad, and replaced Resident #3's blankets without wearing a gown. In an interview on 12/18/2025 at 12:45PM, S8RA indicated she did not wear a gown while transferring and repositioning Resident #3 and should have. S8RA further indicated she was unaware Resident #3 was on EBP. In an interview on 12/18/2025 at 12:52PM, S7CNA indicated he did not wear a gown while transferring and repositioning Resident #3 and should have. S7CNA further indicated he was unaware Resident #3 was on EBP. In an interview on 12/18/2025 at 1:15PM, S4Assistant Director of Nursing/Infection Preventionist confirmed Resident #3 was on EBP. S4ADON/IP further indicated staff performing PEG tube care including checking residuals, and transferring/repositioning residents should have worn a gown while providing direct resident care. In an interview on 12/22/2025 at 10:19AM, S3Director of Nursing (DON) confirmed residents on EBP should have EBP signage on their door. S3DON further confirmed a gown should have been worn during PEG tube care and during resident transfer and positioning for a resident on EBP.

Based on observations and interviews, the facility failed to ensure residents in semiprivate rooms had a ceiling suspended curtain around the bed for 2 (Resident #3, Resident #R4) of 4 sampled residents observed for environmental requirements. Findings:Observation on 12/18/2025 at 9:45AM revealed Resident #R4 did not have a ceiling suspended privacy curtain suspended around Resident #R4's bed as required, to ensure privacy. Observation on 12/18/2025 at 1:45PM revealed Resident #3 did not have a ceiling suspended privacy curtain suspended around Resident #3's bed as required, to ensure privacy. In an interview on 12/18/2025 at 12:44PM, S7CNA indicated the above mentioned residents were in semi-private rooms and both currently had a roommate. Observation on 12/22/2025 at 9:30AM revealed Resident #3 did not have a ceiling suspended privacy curtain suspended around Resident #3's bed as required, to ensure privacy. Observation on 12/22/2025 at 1:42PM revealed Resident #R4 did not have a ceiling suspended privacy curtain suspended around Resident #R4's bed as required, to ensure privacy. In an interview on 12/22/2025 at 10:00AM, S3Director of Nursing confirmed a resident in a semiprivate room should have a ceiling suspended privacy curtain suspended around the resident's bed to ensure privacy.

Based on observation and interviews, the facility failed to ensure staff followed the manufacturer's instructions for the 3 compartment sink to correctly sanitize dishware. Findings:In an interview on 08/27/2025 at 1:20PM, S4Dietary indicated he routinely washed dishes in the 3 compartment sink. S4Dietary explained that he would dip the dishes into the sanitization solution in the 3 compartment sink, remove the dishes from the sanitization solution, and would place the dishes on the side to air dry. S4Dietary further indicated he did not soak dishes in the sanitization compartment of the 3 compartment sink for any specific amount of time. Observation on 08/27/2025 at 1:26PM revealed the manufacturer's instructions were posted on the wall near the 3 compartment sink that indicated to expose all area's surfaces of the dishware in the sanitization solution for no less than one minute and then allow to air dry. In an interview on 08/27/2025 at 1:26PM, S5Dietary Manager indicated S4Dietary should have followed the manufacturer's instructions posted on the wall near the 3 compartment sink as mentioned above. In an interview on 08/27/2025 at 3:50PM, S1Administrator confirmed S4Dietary should have submerged dishware in the sanitization solution in the 3 compartment sink for no less than one minute as per the manufacturer's instructions

Based on interviews and record reviews, the facility failed to ensure resident MDS (Minimum Data Set) assessments were completed accurately and reflected the resident's status for 2 (Resident #6, Resident #9) of 19 (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #9, Resident #11, Resident #12, Resident #13, Resident #20, Resident #24, Resident #28, Resident #52, Resident #67, Resident #71, Resident #81, Resident #83, Resident #84) sampled residents reviewed for MDS accuracy. Findings:Resident #6 Review of Resident #6's quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 05/13/2025 revealed, in part, Resident #6 had one fall with no injury and one fall with major injury since prior assessment dated [DATE]. Review of Resident #6's quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 08/12/2025 revealed, in part, Resident #6 had one fall with no injury and one fall with major injury since the prior assessment dated [DATE]. Review of the facility's incident reports dated 02/01/2025 – 08/26/2025 revealed, in part, Resident #6 had no incident reports for falls. In an interview on 08/26/2025 at 11:11AM, S2Director of Nursing (DON) indicated Resident #6 did not have a documented fall since 2023. In an interview on 08/26/2025 at 11:30AM, S3Minimum Data Set (MDS) Nurse coordinator confirmed she completed the assessments as mentioned above for Resident #6's and documented Resident #6 to have had one fall with no injury and one fall with major injury since the prior assessment. S3MDS Nurse confirmed Resident #6 did not have any falls since the prior assessments dated 02/11/2025 and 05/12/2025, and the assessments as mentioned above were documented inaccurately. Resident #9 Review of Resident #9's annual MDS with ARD of 07/15/2025 revealed, in part, Resident #9's oral/dental status section was marked none of the above, which included no natural teeth or tooth fragments (edentulous). Observation on 08/25/2025 at 1:27PM revealed Resident #9's oral cavity was visible and no natural teeth were observed. In an interview on 08/25/2025 at 1:27PM Resident #9 stated she did not have any natural teeth and expressed a desire to obtain dentures. In an interview on 08/27/2025 at 2:21PM, S3MDS Nurse Coordinator confirmed she completed the assessment as mentioned above for Resident #9. S3MDS Nurse Coordinator confirmed Resident #9 was edentulous (having no natural teeth) and the assessment as mentioned above was documented inaccurately. In an interview on 08/27/2025 at 2:41PM, S1Administrator acknowledged S3MDS Nurse Coordinator should have coded Resident #9 as edentulous (having no natural teeth) and the MDS was documented inaccurately for Resident #9.

Based on interviews and record reviews, the facility failed to: 1. Ensure a referral to home health was completed prior to a resident's discharge as ordered (Resident #1); and, 2. Clarify a resident's discharge order to ensure a resident had all the necessary supplies and equipment for Percutaneous Endoscopic Gastrostomy (PEG) tube (a feeding tube inserted directly into the stomach through a small incision in the abdomen) feeding before the resident was discharge home (Resident #1). This deficient practice was identified for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for discharge requirements. Findings: Review of the facility's Discharge and Plan policy with a revision date of 03/2025 revealed, in part, the facility should make referrals to local agencies, and support services that could assist in accommodating the resident's post-discharge preferences, as appropriate. 1. Review of Resident #1's Physician's Telephone Order dated 04/07/2025 revealed, in part, an order to discharge Resident #1 home with home health. Review of Resident #1's Transfer/Discharge Report dated 04/10/2025 revealed, in part, Resident #1 was discharged home on [DATE]. Review of Resident #1's record revealed no documented evidence, and the facility was unable to present any documented evidence, a home health referral was accepted for Resident #1 prior to Resident #1's discharge on [DATE]. Review of the facility's facsimile report revealed, in part, Resident #1 was not accepted by a home health agency until 04/11/2025. In an interview on 05/21/2025 at 3:40PM, S1Administrator indicated the facility had no documented evidence a home health agency had accepted a referral prior to Resident #1's discharge on [DATE]. 2. Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 03/25/2025 revealed, in part Resident #1 had a feeding tube for nutritional needs. Review of Resident #1's April 2025 Physician's Orders revealed, in part, an order dated 04/04/2025 for Isosource 1.5 (liquid nutritional formula that is administered through a resident's PEG tube) at 75 milliliters an hour (ml/hr) per PEG tube pump (a device that was used to deliver nutrients directly in the gastrointestinal tract). Review of Resident #1's Physician's Telephone Order dated 04/07/2025 revealed, in part, an order to discharge Resident #1 home with home health to care for PEG tube. Further review of Resident #1's physician's discharge order revealed no evidence Resident #1's PEG tube feeding pump or PEG tube formula was ordered upon discharge. There was no documented evidence, and the facility was unable to present any documented evidence, the facility clarified Resident #1's physician's order to ensure Resident #1's PEG tube feeding pump and PEG tube feeding formula was ordered upon discharge. Review of Resident #1's Transfer/Discharge Report dated 04/10/2025 revealed, in part, Resident #1 was discharged home on [DATE]. Review of Resident #1's Physician's Orders, dated 04/11/2025 at 2:16PM, revealed an order for Resident #1's PEG tube pump and PEG tube formula of Isosource 1.5 at 75 ml/hr per PEG tube pump. Review of the facility's facsimile report dated 04/25/2025 revealed, in part, a referral was made to an infusion company for Resident #1's PEG tube feeding pump and Resident #1's PEG tube formula, with Resident #1's 04/11/2025 physician's orders attached. In an interview on 05/20/2025 at 11:11AM, S2Speech Therapist/Rehabilitation Director (ST/RD) indicated she participated in Resident #1's discharge planning meeting. S2ST/RD further indicated at the time of Resident #1's discharge she was still receiving intermittent PEG tube feeding via pump at night and would need to continue the feedings at home. In a telephone interview on 05/21/2025 at 9:58AM, a patient registration specialist with Resident #1's infusion company indicated a referral for Resident #1's PEG tube pump and PEG tube formula was first received from the facility on 04/25/2025 with Resident #1's physician's orders dated 04/11/2025. In a telephone interview on 05/21/2025 at 10:04AM, a nutrition care specialist with Resident #1's infusion company indicated Resident #1 did not receive a PEG tube feeding pump until 04/30/2025. The nutrition care specialist with Resident #1's infusion company further indicated Resident #1 did not receive 1 case of Isosource 1.5 until 05/01/2025. In an interview on 05/21/2025 at 3:40PM, S1Administrator indicated Resident #1's discharge referral orders were not followed up on to ensure Resident #1 received the necessary PEG tube equipment and formula upon discharge.

Based on interviews and record reviews, the facility failed to ensure transfer or discharge reports were completed for 3 (Resident #1, Resident #2, Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for transfer and discharge requirements. Findings: Review of the facility's transfer and d ischarge plan policy statement with a revision date of 03/2025, revealed, in part, the discharge summary should include the following: a. recapitulation of the resident's stay at the facility (a concise summary of the resident's stay and course of treatment in the facility); b. a final summary of the resident's status at the time of the discharge available for release to authorized individuals and agencies, with the consent of the resident or representative; and Review of Resident #1's record revealed, in part, Resident #1 was discharged on 04/10/2025. Review of Resident #1's t ransfer/d ischarge r eport dated 04/10/2025 revealed, in part, no chief complaint (reason for transfer), no relevant information including detailed instructions for ongoing care and no final summary of Resident #1's status at time of discharge. Review of Resident #2's record revealed, in part, Resident #1 was discharged on 05/07/2025. Review of Resident #2's t ransfer/d ischarge r eport dated 05/07/2025 revealed, in part, no chief complaint, no relevant information, no reason or location where Resident #2 was transferred/discharged and no final summary of Resident #1's status at time of discharge . Review of Resident #3's record revealed, in part, Resident #3 was discharged on 04/27/2025. Review of Resident #3's transfer/discharge report dated 04/27/2025 revealed, no chief reason for complaint, no relevant information, no location to where Resident #3 was transferred/discharged and no final summary of Resident #3's status at time of discharge. In an interview on 05/21/2025 at 3:40PM, S1Administrator indicated Resident #1, Resident #2 and Resident #3 did not have completed t ransfer/d ischarge r eports. S1Administrator further indicated the above mentioned transfer/discharge reports should have been completed.

Based on observations, interviews, and record reviews, the facility failed to ensure a notice of employees' rights against retaliation for reporting crimes against residents was posted in a conspicuous location. Findings: Review of the United States Social Security Act Title XI, Part A, Section 1150B(d)(3) dated 08/14/1935 and amended on 09/26/2024 revealed, in part, each long-term care facility shall post conspicuously in an appropriate location a sign specifying the rights of employees against retaliation for reporting crimes against residents of the facility. Further review revealed, such sign shall include a statement that an employee may file a complaint against a long-term care facility that violates the provisions against retaliation with respect to the manner of filing such a complaint. Observation of the facility's employee common areas on 03/18/2025 at 3:00PM revealed no conspicuous signage related to employees' rights against retaliation for reporting suspected crimes. In an interview on 03/18/2025 at 3:10PM, S6Licensed Practical Nurse (LPN) indicated there was no signage displayed for staff members indicating employees' rights against retaliation for reporting suspected crimes. In an interview on 03/18/2025 at 3:17PM, S2Chief Operations Officer (COO) indicated the facility could not provide any evidence of conspicuous signage related to employee rights and the prohibition and prevention of retaliation for reporting suspected crimes. In an interview on 03/18/2025 at 3:18PM, S4Compliance Executive Nurse indicated she was not aware of the above mentioned signage requirement. In an interview on 03/19/2025 at 1:38PM, S1Administrator confirmed the facility could not provide any evidence a sign was posted in a conspicuous location regarding employees' rights against retaliation. S1Administrator further indicated she was not aware such signage was required.

Based on interviews and record reviews, the facility failed to ensure an allegation of abuse was reported to the State Survey Agency within the required two hours for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for abuse. Findings: Review of the facility's Abuse Investigation and Reporting policy and procedure dated 03/04/2024 revealed, in part, an alleged violation of abuse, neglect, exploitation or mistreatment would be reported immediately to the State Survey Agency, but not later than 2 hours if the alleged violation involved abuse or had resulted in serious bodily injury. Review of the Louisiana Department of Health (LDH) Health Standards Incident Report #271580 revealed, in part, an allegation of abuse involving Resident #1: -Occurred on 02/19/2025; -Was discovered on 02/21/2025 at 9:39AM; and, -Was entered into the Statewide Incident Management System (SIMS) reporting system on 02/21/2025 at 11:05AM. In an interview on 03/18/2025 at 12:20PM, S1Administrator indicated she was made aware of Resident #1's allegation of abuse on 02/20/2025 at 9:15AM. S1Administartor further confirmed the discovery date and time of Resident #1's allegation of abuse was not accurately documented on the above mentioned LDH Health Standards Incident Report. In an interview on 03/18/2025 at 12:25PM, S3Assistant Chief Operations Officer indicated S8Certified Nursing Assistant was suspended on 02/20/2025 at 1:26PM pending the results of the investigation. In an interview on 03/19/2025 at 1:30PM, S1Administrator confirmed the facility did not report Resident #1's allegation of abuse to the State Survey Agency within two hours and should have.

Based on interviews and record reviews, the facility failed to complete a performance review within 12 months for 1 (S8Certified Nursing Assistant [CNA]) of 5 (S7CNA, S8CNA, S9CNA, S10CNA, S11CNA) personnel records reviewed. Findings: Review of S8CNA's personnel record revealed, in part, S8CNA had a hire date of 03/10/2023. Further review revealed S8CNA's last performance review was dated 03/13/2024. There was no documented evidence, and the facility could not provide any documented evidence a performance review was completed for S8CNA within the past 12 months. In an interview on 03/18/2025 at 1:45PM, S5Human Resources Director indicated the facility could not provide any documented evidence S8CNA had a performance review completed in the past 12 months. In an interview on 03/19/2025 at 12:58PM, S1Administrator confirmed a personnel performance review had not been conducted for S8CNA within the past 12 months as required and should have been.

Based on interviews and record review, the facility failed to ensure monthly weights were documented for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for nutrition. Findings: Review of Resident #1's Care Plan revealed Resident #1 was care planned for monthly weight evaluation notifications as per the dietician's recommendations. Review of Resident #1's Weights and Vitals Report revealed no documented monthly weights for November 2024 and December 2024. In an interview on 03/13/2025 at 8:52AM, S4Dietitian stated she was not able to assess Resident #1's three month weight loss percentage on her 2/24/2025 nutritional assessment because there were no documented weights for November 2024 or December 2024 on Resident #1's Weights and Vitals Summary. In an interview on 03/13/2025 at 9:35AM, S3Compliance Executive Nurse (CEN) indicated it is the policy of the facility to obtain monthly weights on all residents. S3CEN confirmed there were no documented weights for Resident #1 for November 2024 and December 2024. S3CEN further indicated there should be documentation of monthly weights or a reason as to why the monthly weights were not obtained and documented.

Based on record review and interviews, the facility failed to ensure a Discharge/Transfer Minimum Data Set (MDS) assessment was completed and transmitted timely for 1 (Resident #66) of 3 (Resident #12, Resident #66, and Resident #80) residents reviewed for resident assessment. Findings: Review of Resident #66's record revealed, in part, Resident #66 was admitted to the facility on [DATE] and was transferred to the hospital on 04/26/2024. Further review revealed Resident #66 was discharged from the facility and did not return to the facility. Further review of Resident #66's records revealed, in part, no documented evidence a transfer and discharge assessment was completed and/or transmitted since he was discharged . In a telephone interview on 09/13/2024 at 2:08 p.m., S3License Practical Nurse/Minimum Data Set (S3LPN/MDS) confirmed Resident #66's discharge MDS was not completed and transmitted and should have been. In an interview on 09/16/2024 at 11:03 a.m., S7Director of Nursing confirmed Resident #66 did not have a discharge MDS, and should have.

Based on observation, interviews, and record review, the facility failed to keep a resident's environment free of accidents/hazards by failing to ensure the facility's staff used mechanical lift slings that were in good condition for 2 (Resident #3 and Resident #R4) of 4 (Resident #1, Resident #2, Resident #3, Resident #R4) residents investigated for mechanical lift transfers. This deficient practice resulted in an Immediate Jeopardy situation on 04/12/2024 at 4:10 p.m. for Resident #3, when S6Certified Nursing Assistant (CNA) and S10CNA transferred Resident #3 using a mechanical lift, the mechanical lift sling's strap broke, and Resident #3, hit her head when she fell to the floor and had to be sent to the emergency room (ER). The Immediate Jeopardy situation continued on 07/30/2024 at 3:42 p.m., when S4CNA and S5CNA were observed transferring Resident #R4 using a mechanical lift sling on which the blue straps of the sling had been altered/removed. S1Administrator was notified of the Immediate Jeopardy on 07/30/2024 at 6:45 p.m. The Immediate Jeopardy was removed on 07/31/2024 at 5:20 p.m., after it was verified through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. This deficient practice had the likelihood to cause more than minimum harm for any resident residing in the facility who required the use of a mechanical lift for transfers. Findings: Review of the provider's policy titled, Lift Machine, Using a Mechanical last review date 02/22/2024, revealed, in part, the facility's policy was not a substitute for the manufacturer's instructions. Further review revealed the staff were to discard any worn, frayed or ripped slings. Review of the Invacare User Manual for Invacare Reliant 450 Manual/Electric Portable Patient Lift, Copyright date 2011, revealed, in part, the mechanical lift slings are not the be altered. Further review revealed, the mechanical lift slings should be inspected for any cuts or frays, as these mechanical lift slings are unsafe and could result in injury. Review of Resident #3's Electronic Medical Record (EMR) revealed, in part, Resident #3 was admitted to the facility on [DATE]. Further review revealed Resident #3 had diagnoses of Peripheral Vascular Disease, Cerebral Infarction and age related debility. Review of Resident #3's nurse's note dated 04/12/2024 at 6:57 p.m. written by S2Director of Nursing (DON) revealed, in part, Resident #3 had hit her head during a transfer with a mechanical lift and was sent to the emergency room (ER) for evaluation. Review of facility's documented investigation regarding the incident on 04/12/2024 revealed, in part, Resident #3 fell when S6CNA and S10CNA transferred Resident #3 using a mechanical lift, and the mechanical lift sling's strap broke. Further reviewed revealed, Resident #3 hit her head on the floor as a result of the fall and was evaluated at the ER. Review of Resident #3's ER note dated 04/12/2024 revealed, in part, Resident #3 was seen in theER on [DATE] at 7:24 p.m. due to a mechanical lift fall. Further review revealed Resident #3 was diagnosed with a closed head injury. In an interview on 07/30/2024 at 10:31 a.m., S6CNA indicated the straps of the mechanical lift sling broke when she and S10CNA transferred Resident #3 from her bed to the wheelchair on 04/12/2024. In an interview on 07/30/2024 at 1:55 p.m., S11LPN indicated the facility's CNA's were to check the mechanical lift slings for any defects prior to them being used, and defective mechanical lift slings were to be discarded and replaced with new mechanical lift slings. Observation on 07/30/2024 at 3:42 p.m., revealed while preparing to transfer Resident #R4 using a mechanical lift, S4CNA instructed S5CNA to use the blue loops of the mechanical lift sling's straps to hook the sling to the mechanical lift. Further observation revealed S4CNA inspected the sling and then instructed S5CNA to use the green loops of the mechanical lift sling's straps instead of the blue loops. After Resident #R4 was transferred, further observation by the surveyor revealed the blue loops of the mechanical lift sling's straps had been removed, with only the base of the blue loop remaining attached to the mechanical lift sling's strap. In an interview on 07/30/2024 at 3:45 p.m., S4CNA acknowledged the blue loop of the mechanical lift straps were missing from the sling. S4CNA further indicated the blue loop of the mechanical lift sling's strap must have popped like the others and that some people like to keep the old slings so that they will have a spare. S4CNA further acknowledged the mechanical lift sling should have been discarded and not used to transfer Resident #R4. In an interview on 07/30/2024 at 3:47 p.m., S9LPN inspected the above mentioned mechanical lift sling used to transfer Resident #R4, and acknowledged the mechanical lift sling should not had been used to transfer Resident #R4 because the blue loops were missing. In an interview on 07/30/2024 at 3:55 p.m., S2DON indicated staff should visually check mechanical lift slings for defects prior to using the mechanical lift slings to transfer residents, and discard any sling that had cuts, tears or appeared worn. In an interview on 07/31/2024 at 9:50 a.m., S1Administrator indicated it was the facility's policy to discard any slings with defects. S1Administrator further indicated the facility's staff should not have used the mechanical lift sling that had been altered to transfer Resident #R4.

Based on record review and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 2 of 13 (Resident#1 and Resident #2) residents. This deficient practice resulted in an Immediate Jeopardy for Resident #1 on [DATE] when the resident experienced low blood glucose readings and both routine and sliding scale insulins continued to be administered to the resident by the nursing staff. The resident's hypoglycemic protocol orders were not implemented nor was the resident's physician notified. On [DATE] at 4:30 a.m., the resident experienced a blood glucose reading of 43 milligrams (mg)/deciliter (dL), was confused and complained of being hot. The resident's hypoglycemic protocol orders were not appropriately implemented nor was the resident's physician notified. On [DATE] during morning shift rounds, the resident was found unresponsive with a blood pressure of ,[DATE] (as documented in the nurse's notes), pulse 24, blood glucose of 63 and a temperature of 96.1. A recheck of the resident's vital signs revealed no evidence of a blood pressure or a pulse. This deficient practice resulted in an Immediate Jeopardy for Resident #2 on [DATE] when the resident was not administered Potassium Effer K 20 milliequivalents (mEq) as ordered by the physician. On [DATE], the resident's physician ordered Potassium Effer K 20 mEq by mouth twice a day. A review of the resident's (MONTH) 2019 MAR indicated [REDACTED]. On [DATE], resident's lab results revealed a potassium level of 2.2 L (low). The resident was transferred to a local hospital for an evaluation of a critically low potassium level. S1Administrator was notified of the Immediate Jeopardy situation on [DATE] at 9:20am. The Immediate Jeopardy situation was removed on [DATE] at 12:24pm, when an acceptable plan of removal was presented. The facility's plan to remove the immediate jeopardy situation included: *All Standing Orders were removed, including the sliding scale and hypoglycemic protocols; *American Diabetic Association (ADA) Recommendations will be implemented for residents with a blood glucose level of less than or equal to 70 and over 400, with immediate Physician notification; *diabetic residents will be listed by units for each nurse on all shifts with the form updated weekly and as needed by the Director of Nurses(DON)/Assistant Director of Nurses(ADON); *An Insulin Administration Verification Report (IAVR) has been implemented to verify that accuchecks and the prescribed insulin dose will be administered. A second nurse will verify the order and the units administered. The Physician will be immediately notified of the refusal of the accucheck or insulin administration by the nurse or supervisor. All communications to the Physician will be documented in a call log with the date, time, and number called. The name of the nurse placing the call will also be documented on the communication log. The shift supervisor will confirm the completion of the IAVR each shift and will submit the report to the DON/ADON for a second verification; *The DON and ADON will train all nurses and all new nurses will be oriented to the process during orientation; *nursing staff were in-serviced on medications not administered and the Medication Not Administered Form which includes process on what to do if a medication was not given, not available, for medication refusal, and the Medication Not Administered form. This form will be given to the supervisor at the end of each shift who will give to the DON/ADON for verification and/or follow-up daily. This form will be incorporated into the orientation of new nurses and the DON/ADON will train all current nursing staff; and *Nurse will transcribe new orders into the Electronic Health Record (EHR) with the shift supervisor to verify that the new order was transcribed and entered into the EHR correctly. The nurse will copy all new orders and put into the Physician order [REDACTED]. This deficient practice continued at a potential for harm for the 30 residents in the facility diagnosed with [REDACTED]. Findings: Resident #1 Review of the facility's accucheck monitoring device manual revealed in part, the following: the testing range of the meter is from 20 to 600 mg/dL. If HI is displayed, your blood glucose result may be higher than 600 mg/dL. If LO is displayed, your blood glucose result may be lower than 20 mg/dL. Review of the facility's policy on physician's orders [REDACTED]. The standing orders are medical treatment orders generated by a Privileged Provider who has identified actions, treatments or medications that must be or can be implemented or administered. The use of standing orders must be documented as an order in the resident's medical record and signed by the nurse responsible for the care of the resident. Nursing 24 hour chart check: 11pm to 7am nurses are responsible for 24 hour review and checks for the order accuracy and appropriate follow-up. Review of Resident #1's record revealed an admitted [DATE] with diagnoses, in part, of Type II Diabetes Mellitus, Diabetic [MEDICAL CONDITION], Left [MEDICAL CONDITION] (BKA), History of Gangrene of Left Foot, [MEDICAL CONDITIONS] Fibrillation, Deep Vein Thrombus, [MEDICAL CONDITION] Embolism, History of a Stroke, Hypertension, and [MEDICAL CONDITION] Stage. Review of Resident #1's record revealed a Do Not Resuscitate (DNR) form which was signed by Resident #1 and the physician on [DATE]. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] revealed, in part, a Brief Interview for Mental Status score of 10, required a two person extensive assistance with bed mobility and transfers, dressing, personal hygiene; range of motion limitation impairment on both sides to lower extremities, used a wheelchair for mobility. Review of Resident #1's care plan revealed a problem identified on [DATE] for resident at risk for coma, skin breakdown, and impaired vision related to [DIAGNOSES REDACTED]. Review of Resident #1's Physician orders [REDACTED]. -Accucheck before meals and at bedtime; [MEDICATION NAME]100 units/milliliter (ml) [MEDICATION NAME] patient specific ,[DATE] units sliding scale before meals and at bedtime: ,[DATE]- 1 unit ,[DATE]- 2 units ,[DATE]- 3 units ,[DATE]- 4 units ,[DATE]- 5 units Greater than 401 give 6 units and notify Physician; -[MEDICATION NAME]100 units/ml [MEDICATION NAME] administer five units subcutaneous with meals- hold if blood glucose less than or equal to 150; -[MEDICATION NAME]100 units/ml give 10 units subcutaneously at bedtime (order dated [DATE]); Further review of Resident #1's (MONTH) 2019 Physician orders [REDACTED]. Review of Resident #1's Physician orders [REDACTED]. Review of Resident #1's record revealed signed standing orders by the resident's physician, not dated, which included the following orders: Hypoglycemic protocol: Mild to Moderate: if person is able to eat and swallow, provide one of the following immediately; 4 to 6 ounces (oz) of fruit juice, 4 to 6 oz. of regular soda, 3 tablespoons of sugar dissolved in small amount of water, notify Provider. Repeat blood sugar in 15 minutes. If blood sugar remains below 80mg/dl repeat same amount of food. If blood sugar above 80mg/dl, repeat blood sugar in 1 hr. Severe: Administer [MEDICATION NAME] 1mg subcutaneously for adult greater than 44 pounds. Notify provider and call 911. (MONTH) repeat in ,[DATE] minutes as needed. Review of Resident #1's electronic Medication Administration Record [REDACTED]. These discrepancies included the following: On [DATE] at 11:00am- [MEDICATION NAME] 5 units insulin was given instead of 1 unit as per the sliding scale order; On [DATE] at 11:00am- [MEDICATION NAME] 5 units insulin was given instead of 1 unit as per the sliding scale order; On [DATE] at 11:00am- [MEDICATION NAME] 5 units insulin was given instead of 1 unit as per the sliding scale order; On [DATE] at 6:00am- [MEDICATION NAME] 4 units insulin was given instead of 1 unit as per the sliding scale order; On [DATE] at 8:00pm- [MEDICATION NAME] 2 units insulin was given instead of 1 unit as per the sliding scale order; On [DATE] at 11:00am- [MEDICATION NAME] 5 units insulin was given instead of 1 unit as per the sliding scale order; On [DATE] at 4:00pm- [MEDICATION NAME] 4 units insulin was given instead of 1 unit as per the sliding scale order; On [DATE] at 11:00am- [MEDICATION NAME] 5 units insulin was given instead of 3 units as per the sliding scale order; On [DATE] at 11:00am- [MEDICATION NAME] 5 units insulin was given instead of 3 units as per the sliding scale order; On [DATE] at 11:00am- [MEDICATION NAME] 4 units insulin was given instead of 3 units as per the sliding scale order; On [DATE] at 11:00am- [MEDICATION NAME] 5 units insulin was given instead of 3 units as per the sliding scale order; On [DATE] at 11:00am- [MEDICATION NAME] 5 units insulin was given instead of 3 units as per the sliding scale order; On [DATE] at 4:00pm- [MEDICATION NAME] 4 units insulin was given instead of 3 units as per the sliding scale order; On [DATE] at 8:00pm- [MEDICATION NAME] 4 units insulin was given instead of 1 unit as per the sliding scale order; On [DATE] at 11:00am- [MEDICATION NAME] 5 units insulin was given instead of 2 units as per the sliding scale order; On [DATE] at 11:00am- [MEDICATION NAME] 5 units insulin was given instead of 3 units as per the sliding scale order; On [DATE] at 11:00am- [MEDICATION NAME] 6 units insulin was given instead of 3 units as per the sliding scale order; On [DATE] at 8:00pm- [MEDICATION NAME] 4 units insulin was given instead of 3 units as per the sliding scale order; On [DATE] at 11:00am- [MEDICATION NAME] 5 units insulin was given instead of 4 units as per the sliding scale order; On [DATE] at 4:00pm- [MEDICATION NAME] 6 units insulin was given instead of 4 units as per the sliding scale order; and On [DATE] at 8:00pm- [MEDICATION NAME] 6 units insulin was given instead of 3 units as per the sliding scale order. Further review of Resident #1's eMAR dated (MONTH) 2019 revealed 5 discrepancies in which insulin was not administered to the resident in accordance with the resident's accucheck readings. These discrepancies included the following: On [DATE] at 11:00am the resident's blood glucose was 189. There was no documented evidence that 1 unit of [MEDICATION NAME]was administered to the resident as per the sliding scale order; On [DATE] at 8:00pm the resident's blood glucose 178. There was no documented evidence that 1 unit of [MEDICATION NAME]was administered to the resident as per the sliding scale order; On [DATE] at 6:00am the resident's blood glucose 200. There was no documented evidence that 2 units of [MEDICATION NAME]was administered to the resident as per the sliding scale order; On [DATE] at 6:00am the resident's blood glucose 222. There was no documented evidence that 2 units of [MEDICATION NAME]was administered to the resident as per the sliding scale order; and On [DATE] at 6:00am the resident's blood glucose 248. There was no documented evidence that 3 units of [MEDICATION NAME]was administered to the resident as per the sliding scale order; Further review of Resident #1's eMAR dated (MONTH) 2019 revealed S4/Assistant Director of Nursing (ADON)/Overnight Supervisor documented a blood glucose of 55 at 6:00am on [DATE]. Review of Resident #1's nurses' notes on [DATE] revealed no documentation that the hypoglycemic protocol was implemented on [DATE] after a blood glucose of 55 and no documentation that the physician was notified. Further review of Resident #1's eMAR dated (MONTH) 2019 revealed 2 accucheck readings documented as low and 3 accucheck readings documented as high. These included the following: On [DATE] at 6:00 am the resident's blood glucose was documented low with no numeric value documented; On [DATE] at 6:00am the resident's blood glucose was documented low with no numeric value documented; On [DATE] at 6:00am the resident's blood glucose was documented high with no numeric value documented, and no documentation of insulin administered; On [DATE] at 6:00am the resident's blood glucose was documented high with no numeric value documented, and no documentation of insulin administered; and On [DATE] at 6:00am the resident's blood glucose was documented high with no numeric value documented, and no documentation of insulin administered. Review of Resident #1's electronic Medication Administration Record [REDACTED]. These discrepancies included the following: On [DATE] at 4:00pm- [MEDICATION NAME] 6 units insulin was given instead of 3 units as per the sliding scale order; On [DATE] at 8:00pm- [MEDICATION NAME] 6 units insulin was given instead of 4 units as per the sliding scale order; On [DATE] at 4:00pm- [MEDICATION NAME] 4 units insulin was given instead of 3 units as per the sliding scale order; On [DATE] at 8:00pm- - [MEDICATION NAME] 5 units insulin was given instead of 3 units as per the sliding scale order; and On [DATE] at 4:00pm- [MEDICATION NAME] 4 units insulin was given instead of 2 units as per the sliding scale order. Further review of Resident #1's eMAR dated (MONTH) 2019 revealed 6 discrepancies in which insulin was not administered to the resident in accordance with the resident's accucheck readings. These discrepancies included the following: On [DATE] at 6:00am the resident's blood glucose was 304. There was no documented evidence that 4 units of [MEDICATION NAME]was administered to the resident as per the sliding scale order; On [DATE] at 6:00am the resident's blood glucose was high. There was no documented evidence of insulin being administered to the resident as per the sliding scale order; On [DATE] at 4:00pm the resident's blood glucose was 241. There was no documented evidence of insulin being administered to the resident as per the sliding scale order; On [DATE] at 11:00am the resident's blood glucose was 221. There was no documented evidence of insulin being administered to the resident as per the sliding scale order; On [DATE] at 8:00pm the resident's blood glucose was 220. There was no documented evidence of insulin being administered to the resident as per the sliding scale order; and On [DATE] at 6:00am the resident's blood glucose was high. There was no documented evidence of insulin being administered to the resident as per the sliding scale order. Review of Resident #1's eMAR dated (MONTH) 2019 revealed the following documentation on [DATE] to [DATE]: [DATE] at 6:00am- blood glucose documented as 69 no insulin administered; [DATE] at 7:30am- blood glucose documented as 174 and [MEDICATION NAME]5 units documented as administered; [DATE] at 11:00am- blood glucose documented as 65 and no insulin administered; [DATE] at 11:30am- blood glucose documented as 65 and no insulin administered; [DATE] at 4:00pm- blood glucose documented as low; 1 unit insulin administered; [DATE] at 4:30pm- blood glucose low; [MEDICATION NAME] 5 units insulin documented as administered; [DATE] at 8:00pm- blood glucose low; 1 unit insulin administered; [DATE] at 8:00pm- [MEDICATION NAME]12 units documented as being administered; and [DATE] at 6:00am- blood glucose documented as 43. Review of Resident #1's nurses' notes dated [DATE] revealed no documentation of an assessment or that the hypoglycemic protocol was implemented with the three low blood glucose readings on [DATE] at 4:00pm, 4:30pm and 8:00pm. Further review of Resident #1's nurse's notes dated [DATE] revealed no documentation of the physician being notified of the low blood glucose levels. Review of Resident #1's nurse's note dated [DATE] at 6:34am S4ADON/Overnight Supervisor documented Resident #1's blood glucose was 43 at 4:30am, displayed confusion, complained being hot, she removed her clothing, standing order for orange juice was used; blood sugar increased to 64 within 30 minutes; resident more alert and now oriented times three; Certified Nursing Assistant assisted her in dressing. Further review of Resident #1's nurse's note dated [DATE] revealed no documentation that the physician was notified or that the hypoglycemic protocol was followed as ordered. Review of nurse's note dated [DATE] at 7:56am revealed in part, while performing shift change rounds, S4 ADON/Overnight Supervisor and S5Licensed Practical Nurse (LPN) entered residents #1's room to discuss residents current health status and Resident #1 was not responding to her name. Vital signs blood pressure ,[DATE], pulse 24, capillary blood glucose (CBG) 63, temperature 96.1; Code blue was called, nursing team responded, oxygen was started at 2 liters per nasal cannula; Emergency Medical Services was called; recheck for blood pressure and pulse, noted resident was now absent of all vital signs. Review of chart noted Resident #1 had do not resuscitate (DNR) order on chart. Cardiopulmonary Resuscitation (CPR)/chest compressions were not started and Resident #1 expired. In an interview on [DATE] at 1:30pm, S2Director of Nursing (DON) stated she thought the hypoglycemic protocol on the standing orders was very confusing for her nurses and had asked the physician/med director for parameters for the hypoglycemic protocol on the standing order sheet after Resident #1 expired. S2DON stated the physician said he did not have to give the nurses parameters because the nurses should know what to do. In an interview on [DATE] at 2:00pm, S5LPN stated she did not know what mild to moderate or severe [DIAGNOSES REDACTED] would be and did not know there was a hypoglycemic protocol on each residents' standing orders. S5/LPN read the hypoglycemic protocol and stated if she had a Resident with a low blood glucose she would give [MEDICATION NAME] and call the physician. S5LPN stated the hypoglycemic protocol did not have parameters and that was a problem. In a telephone interview on [DATE] at 4:08pm, S9Physician/Medical Director stated he reviewed Resident #1's record after her death and the information provided to him, he could not verify that insulin was given appropriately. In regards to the hypoglycemic protocol, S9Physician/Medical Director stated it was not just the blood glucose value, but the resident signs and symptoms that would determine which protocol to use; mild to moderate or severe. S9Physician/Medical Director stated based on his understanding, Resident #1 had critical vital signs, difficulty breathing, along with all signs of severe [DIAGNOSES REDACTED] and [MEDICATION NAME] should have been administered. S9Physician/Medical Director stated in his opinion, [MEDICATION NAME] should have been given when Resident #1 had a blood glucose level of 43 and not orange juice. S9Physician/Medical Director stated a Registered Nurse (RN) should know what severe [DIAGNOSES REDACTED] looks like. In an interview on [DATE] at 9:15am, S4ADON/Overnight Supervisor stated she was the Registered Nurse (RN) night supervisor on [DATE]. S4ADON/Overnight Supervisor stated S22RN reported off to her on [DATE] that Resident #1's blood glucose was fine and the 24 hour report sheet had Resident #1's blood glucose readings as low the last couple of mornings. S4ADON/Overnight Supervisor stated Resident #1's blood glucose reading was 43 at 4:30am on [DATE]. She asked Resident #1 what was wrong because she was not as talkative as normal and Resident #1 stated nothing baby and proceeded to ask her how she felt and Resident #1 stated I'm hot. S4ADON/Overnight Supervisor stated she gave Resident #1 eight ounces of orange juice for the low blood sugar. S4ADON/Overnight Supervisor stated Resident #1 stated she was hungry so S4ADON/Overnight Supervisor gave Resident #1 a pack of crackers and eight ounces of Boost juice and she removed Resident #1's clothing. S4ADON/Overnight Supervisor stated she continued on with her medication pass and returned to Resident #1's room [ROOM NUMBER] minutes later to recheck her blood glucose and it was 64. She stated she did not give anything else to Resident #1. When questioned, by the surveyor, if she notified the physician she stated no. S4ADON/Overnight Supervisor stated if there was an intervention they can use, they don't call the physician until they try the intervention. S4ADON/Overnight Supervisor stated S2DON arrived on her unit around 6:15am on [DATE] and S4ADON/Overnight Supervisor informed her of Resident #1's blood sugar and what interventions she had provided. When the day shift arrived on [DATE], she started her walking rounds with S5LPN and they walked over to Resident #1's bed and she informed S5LPN that Resident #1's blood sugar was low and what interventions were done. When they called out to Resident #1, she was unresponsive. S4ADON/Overnight Supervisor stated she assessed a weak pulse and called a code and put oxygen on her and took Resident #1's vital signs and she had a low blood pressure and a blood sugar of 63. Other nurses came in Resident #1's room and someone else called 911. Resident #1's chart was brought into her room and someone reported she was a DNR. When questioned, by the surveyor, if she felt Resident #1 was displaying a severe hypoglycemic event and would require administering [MEDICATION NAME], S4ADON/Overnight Supervisor stated no. ADON/Overnight Supervisor stated she was just focused on doing CPR, but when it was reported she was a DNR the nurses did not do anything. Record review revealed no documented evidence in Resident #1's medical record or nurse's notes that S4DON/Overnight Supervisor gave the resident a pack of crackers and additional eight ounces of Boost juice on [DATE] after the documented blood glucose reading of 43. In an interview on [DATE] at 10:15am, S24Pharmacist stated the peak effect of [MEDICATION NAME]would be 40 to 50 minutes based on a person's carbohydrate to insulin ratio and the peak effect of [MEDICATION NAME]would be 8 to 10 hours. S24Pharmacist reviewed Resident #1's medications and stated because Resident #1 was on scheduled insulin dose at 8:00pm and a sliding scale accucheck at bedtime with an ordered sliding scale insulin dose, this could put Resident #1 at risk for a hypoglycemic episode. S24Pharmacist stated if Resident #1 did not eat that evening, it could have played a role in her low blood glucose level at 4:30am on [DATE]. In an interview on [DATE] at 10:49am, S2DON reviewed Resident #1's eMAR's dated (MONTH) and (MONTH) 2019 and she stated the nurses should have documented a blood glucose value and should not have documented high or low. S2DON also confirmed that the insulin doses administered to Resident #1 did not follow the sliding scale as ordered by the physician. In an interview on [DATE] at 3:25pm, S22RN stated she worked as the evening supervisor on Tuesday's and Thursday's. S22RN stated she was not notified of any low blood glucose readings with Resident #1 by S19LPN on [DATE] on the 3:00pm to 11:00pm shift. S22RN stated the nurse should follow the standing orders on the hypoglycemic protocol if a resident had a low blood glucose. When questioned, by the surveyor, what protocol should be followed, mild to moderate or severe, S22RN stated there were no parameters on which protocol to use and it was a problem that she has brought up to Administration and it had not changed. In a telephone interview on [DATE] at 10:40am, S19LPN stated she would consider a blood glucose of less than 50 as a low blood glucose and a blood glucose greater than 300 as high. S19LPN stated she did not remember if she gave the scheduled 5 units of [MEDICATION NAME]to Resident #1 on [DATE] at 4:30pm and the scheduled [MEDICATION NAME]12 units on [DATE] at 8:00pm. When asked about the accucheck readings, S19 LPN stated she would notify her Supervisor if she saw a low reading on the accucheck machine. In an interview on [DATE] at 11:40am, surveyor questioned S4ADON/Overnight Supervisor concerning Resident #1's blood glucose reading of 55 documented on [DATE] at 6:00am, and after reviewing Resident #1's nurses' notes, there was no documentation of an intervention or notification to the physician. S4ADON/Overnight Supervisor stated with a blood glucose of 55, Resident #1 would have gotten something and the physician should have been called; however, the physician told her not to call him. S4ADON/Overnight Supervisor stated she would notify S2DON and report to the next shift of Resident #1's low blood sugar. In an interview on [DATE] at 1:25pm, S8LPN reviewed Resident #1's eMAR for (MONTH) and (MONTH) 2019 and confirmed the documented blood glucose readings and insulin doses that she administered to Resident #1 did not follow the sliding scale ordered by the physician. In an interview on [DATE] at 12:50pm S4ADON/Overnight Supervisor reviewed the facility's accucheck daily quality control records for each hall and confirmed there were multiple days on each hall that did not document a quality control on the accucheck machine. When questioned, by the surveyor, how she could ensure the accucheck readings were accurate if the quality controls were not done as required, S4ADON/Overnight Supervisor stated she could not ensure their accuracy because the controls were not done nightly as required for (MONTH) and (MONTH) 2019. In an interview on [DATE] at 9:00am, S2DON reviewed Resident #1's eMAR's for (MONTH) and (MONTH) 2019 and confirmed that at times the resident was administered incorrect dosages of insulin as per the sliding scale order and that at other times insulin was not administered to the resident in accordance with the resident's blood glucose readings. S2DON stated after Resident #1's death she did not review Resident #1's eMAR to verify dosages were given as ordered. S2DON confirmed on [DATE] the documentation showed Resident #1 had multiple low blood glucose readings documented from 6:00am through 8:00pm and there was no documentation of the physician being notified of Resident #1's low blood glucose or that the resident's hypoglycemic protocol orders were implemented on [DATE] for the documented low blood glucose readings. S2DON confirmed the hypoglycemic protocol was not appropriately followed as ordered for Resident #1 on [DATE] when she had a documented blood glucose of 43. S2DON stated the facility needed to get a handle on insulin dosages and accuchecks. Resident #2 Resident #2 was admitted to the facility on [DATE] with the following diagnoses, in part, Age Related Physical Debility, Hypertension, Altered Mental Status, and [DIAGNOSES REDACTED]. Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed, in part, Brief Interview for Mental Status (BIMS) of 5 indicating Resident #3 cognitive skills for daily decision making were severely impaired. Review of Resident #2's physician's orders [REDACTED]. Review of Resident #2's lab results dated [DATE] revealed documentation Potassium (K+) level 3.6. Typically a range is normal (3.5 through 5.5). Review of Resident #2's lab results dated [DATE] revealed documentation K+ level of 2.2L! (critically low). Review of Resident #2's Medication Administration Record [REDACTED]. Further review of MAR indicated [REDACTED]. Review of Resident #2's physician's orders [REDACTED].#2 to be transferred to the local hospital for evaluation for critically low potassium level. Review of Resident #2's nurse's note dated [DATE] at 10:54am revealed Resident #1 left the facility per stretcher at 10:25am. Further review of Resident #2's nurse's note dated [DATE] revealed in part, Resident #1 returned to the facility on [DATE] at 9:15pm with [DIAGNOSES REDACTED]. In an interview on [DATE] at 2:30pm, S2Director of Nurses (DON) stated an N documented on a MAR indicated [REDACTED]. S2DON stated Resident #2's nurses did not contact the pharmacy, the physician or DON to inform Resident #2 Effer K was not administered. In an interview on [DATE] at 4:15pm, S6LPN stated she documented an N on Resident #2's MAR indicated [REDACTED]. S6LPN stated she did not notify pharmacy, physician, or DON when she did not administer Resident #2's Effer K. In an interview on [DATE] at 9:10am, S7LPN stated she documented an N on Resident #2's MAR for Effer K 10meq po at 7:00am for the following dates [DATE], [DATE], [DATE], and [DATE]. S7LPN stated she documented an N on the MAR because she did not administer Resident #2's Effer K because she could not find the medicine in medication cart so she assumed it was not available. S7LPN stated she did not notify pharmacy, physician or DON when she did not administer Resident #2's Effer K. In an interview on [DATE] at approximately 11:45am, S2DON stated on [DATE] at 3:30pm, Resident #2's physician ordered Effer K 20meq po BID and S8LPN transcribed on the MAR indicated [REDACTED]. In an interview on [DATE] at 12:20pm, S9Physician/Medical Director confirmed on [DATE] at 3:30pm he ordered Potassium EfferK 20mEq po BID for Resident #2. S9Physician/Medical Director also confirmed he was not notified by Resident #2's nurses when the Potassium Effer K was not administered or when she refused.

A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 (Resident #1 and Resident #2) of 13 sampled residents. This deficient practice resulted in an Immediate Jeopardy for Resident #1 on [DATE] when the resident experienced low blood glucose readings and both routine and sliding scale insulins continued to be administered to the resident by the nursing staff. The resident's hypoglycemic protocol orders were not implemented nor was the resident's physician notified. On [DATE] at 4:30 a.m., the resident experienced a blood glucose reading of 43 milligrams (mg)/deciliter (dL), was confused and complained of being hot. The resident's hypoglycemic protocol orders were not appropriately implemented nor was the resident's physician notified. On [DATE] during morning shift rounds, the resident was found unresponsive with a blood pressure of ,[DATE] (as documented in the nurse's notes), pulse 24, blood glucose of 63 and a temperature of 96.1. A recheck of the resident's vital signs revealed no evidence of a blood pressure or a pulse. This deficient practice resulted in an Immediate Jeopardy for Resident #2 on [DATE] when the resident was not administered Potassium Effer K 20 milliequivalents (mEq) as ordered by the physician. On [DATE], the resident's physician ordered Potassium Effer K 20 mEq by mouth twice a day. A review of the resident's (MONTH) 2019 MAR indicated [REDACTED]. On [DATE], resident's lab results revealed a potassium level of 2.2 L (low). The resident was transferred to a local hospital for an evaluation of a critically low potassium level. This deficient practice resulted in an Immediate Jeopardy for resident #1 on [DATE] when the resident experienced an unwitnessed fall from a chair to the floor resulting in the suture line to her left [MEDICAL CONDITION] reopening. Prior to this fall, the resident who had not had a fall assessment completed, experienced a previous fall on [DATE]. After the fall on [DATE], the resident was screened by a physical therapist who made recommendations for a bed alarm, chair alarm and a low bed with a fall mat. These recommendations were not addressed and/or implemented. On [DATE] at 4:38pm, the resident experienced another unwitnessed fall. The facility did not address, identify and implement appropriate and/or recommended fall prevention interventions for the resident. S1Administrator was notified of the Immediate Jeopardy situation on [DATE] at 9:20am. The Immediate Jeopardy situation was removed on [DATE] at 12:24pm, when an acceptable plan of removal was presented. The facility's plan to remove the immediate jeopardy situation included: *All new admits will receive a fall risk assessment by the RN upon admission, after each fall, and quarterly with the Director of Nurses (DON)/Assistant Director of Nurses (ADON) utilizing the Admission Checklist to ensure this is completed; *When a resident has an unwitnessed fall or falls with a head injury, an incident report will be completed by the unit nurse, the supervisor will be notified of the fall, the Physician and responsible party will be notified, neuro checks will be initiated every 15 minutes for 1 hour prior to transferring the resident to the emergency room for evaluation. Neuro checks will resume if the resident returns within 48 hours of the fall, and neuro checks will continue up to 48 hours post fall. The unit nurse will document neuro checks on the neuro assessment tool on the electronic Medication Administration Record [REDACTED] *When a resident had a witnessed fall, without head injury, a head to toe assessment will be performed to determine the level of care needed. The supervisor, Physician, and responsible party will be notified immediately. The nurse will continue to re-asses the resident for pain and discomfort tor 48 hours with documentation per shift on fall follow-up and/or as needed in a regular nurse's note. A pain and skin assessment must be done every 8 hours for 48 hours following a witnessed fall; *An incident report will be generated by the nurse, a copy of the incident report will be submitted to the supervisor, and the supervisor will submit the report to the DON and ADON for notification; *If the resident has fallen, the cause of the fall will have a resident specific investigation done within 24 hours, the need for intervention will be assessed and resident specific intervention will be care planned. Physical therapy will also evaluate the resident and submit the screening the DON/ADON; *The DON and/or ADON will train all nursing staff, including weekend/part-time, prior to them working their shift and all new nurses will be oriented on the process during orientation; and *All Standing Orders were removed, including the sliding scale and hypoglycemic protocols; *American Diabetic Association (ADA) Recommendations will be implemented for residents with a blood glucose level of less than or equal to 70 and over 400, with immediate Physician notification; *Diabetic residents will be listed by units for each nurse on all shifts with the form updated weekly and as needed by the Director of Nurses (DON)/Assistant Director of Nurses (ADON); *An Insulin Administration Verification Report (IAVR) has been implemented to verify that accuchecks and the prescribed insulin dose will be administered. A second nurse will verify the order and the units administered. The Physician will be immediately notified of the refusal of the accucheck or insulin administration by the nurse or supervisor. All communications to the Physician will be documented in a call log with the date, time, and number called. The name of the nurse placing the call will also be documented on the communication log. The shift supervisor will confirm the completion of the IAVR each shift and will submit the report to the DON/ADON for a second verification; and *The DON and ADON will train all nurses, and all new nurses will be oriented to the process during orientation; *nursing staff were in-serviced on medications not administered and the Medication Not Administered Form which includes process on what to do if a medication was not given, not available, for medication refusal, and the Medication Not Administered form. This form will be given to the supervisor at the end of each shift who will give to the DON/ADON for verification and/or follow-up daily. This form will be incorporated into the orientation of new nurses and the DON/ADON will train all current nursing staff; and *Nurse will transcribe new orders into the Electronic Health Record (EHR) with the shift supervisor to verify that the new order was transcribed and entered into the EHR correctly. The nurse will copy all new orders and put into the Physician order [REDACTED]. The deficient practice continued at a potential for harm for the 112 residents in the facility who were at risk for falls. This deficient practice continued at a potential for harm for the 30 residents in the facility diagnosed with [REDACTED]. Findings: Cross Reference Tag F684 and Tag F689. Resident #1 In an interview on [DATE] at 1:30pm, S2Director of Nursing (DON) stated the nurses should have performed assessments on Resident #1. S2DON confirmed there was no documentation of an assessment for 48 hours after Resident #1's unwitnessed falls on [DATE], [DATE] and [DATE]. S2DON stated she did not review nurses' notes to ensure there was appropriate documentation after Resident #1's falls and stated she only looked at the incident reports. In an interview on [DATE] at 10:49am, S2DON stated they did not implement any changes to their fall policy and procedures or monitor nurse documentation after Resident #1's fall on [DATE], [DATE] that resulted in an injury to her stump, and [DATE] fall with her subsequent death on [DATE]. S2DON stated she did not discover there was no documentation in the nurses' notes for Resident #1's falls until after speaking with the surveyor. She stated the facility did not review residents' with falls for proper documentation and interventions after Resident #1's falls and subsequent death. S2DON also confirmed there had been no additional training with the nursing staff regarding falls, no additional monitoring of the nursing staff, no additional training in regards to Physical Therapy (PT) recommendations, and no additional training in regards to updating the care plans with appropriate and measurable interventions. In an interview on [DATE] at 1:11pm, S2DON stated the admit nurse completed the fall risk assessments on admit and quarterly. If a resident was a fall risk it was documented at the bottom of the physician orders. S2DON reviewed Resident #1's physician orders [REDACTED].#1 being a fall risk. S2DON stated Resident #1 was a fall risk because she was an [MEDICAL CONDITION]. S2DON stated if a resident was a fall risk upon admit, they would implement a chair and bed alarm and a fall mat and those orders should go on the physician orders [REDACTED]. S2DON stated Resident #1 should have had the bed and chair alarm and a fall mat on admit and she had neither of them implemented on admit. In an interview on [DATE] at 1:25pm, S3AssistantDirectorofNursing (ADON) stated she was responsible for placing the bed and chair alarms for residents. S3ADON stated she did not implement a bed or chair alarm for Resident #1 and she was not aware of Resident #1's fall on [DATE]. S3ADON stated she did not know who was given the PT recommendations dated [DATE], but it was not given to her. S3ADON confirmed Resident #1 did not have a bed or chair alarm, or a fall mat in place. In an interview on [DATE] at 2:00pm, S2DON confirmed the PT recommendations dated [DATE] for Resident #1 slipped through the cracks and Resident #1 should have had a bed and chair alarm implemented on admit because she was a fall risk with her left leg amputated. She stated Resident #1's bed should have always stayed in a low position. In an interview on [DATE] at 9:00am, S2DON reviewed Resident #1's electronic Medication Administration Records (eMAR's) for (MONTH) and (MONTH) 2019 and confirmed that at times the resident was administered incorrect dosages of insulin as per the sliding scale order and that at other times insulin was not administered to the resident in accordance with the resident's blood glucose readings. S2DON stated after Resident #1's death she did not review Resident #1's eMAR to verify dosages were given as ordered. S2DON confirmed on [DATE] the documentation showed Resident #1 had multiple low blood glucose readings documented from 6:00am through 8:00pm and there was no documentation of the physician being notified of Resident #1's low blood glucose or that the resident's hypoglycemic protocol orders were implemented on [DATE] for the documented low blood glucose readings. S2DON confirmed the hypoglycemic protocol was not appropriately followed as ordered for Resident #1 on [DATE] when she had a documented blood glucose of 43. S2DON stated the facility needed to get a handle on insulin dosages and accuchecks. Resident #2 In an interview on [DATE] at 2:30pm, S2Director of Nurses (DON) stated an N documented on a MAR indicated [REDACTED]. S2DON stated Resident #2's nurses did not contact the pharmacy, the physician or DON to inform Resident #2 Effer K was not administered. In an interview on [DATE] at approximately 11:45am, S2DON stated on [DATE] at 3:30pm, Resident #2's physician ordered Effer K 20meq po BID and S8LPN transcribed on the MAR indicated [REDACTED]. In an interview on [DATE] at 12:20pm, S9Physician/Medical Director confirmed on [DATE] at 3:30pm he ordered Potassium EfferK 20mEq po BID for Resident #2. S9Physician/Medical Director also confirmed he was not notified by Resident #2's nurses when the Potassium Effer K was not administered or when she refused.

Based on record review and interview, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents and to ensure the environment remained as free of accidents hazards as possible for 1 (Resident #1) of 13 sampled residents. This deficient practice resulted in an Immediate Jeopardy for resident #1 on [DATE] when the resident experienced an unwitnessed fall from a chair to the floor resulting in the suture line to her left [MEDICAL CONDITION] reopening. Prior to this fall, the resident who had not had a fall assessment completed, experienced a previous fall on [DATE]. After the fall on [DATE], the resident was screened by a physical therapist who made recommendations for a bed alarm, chair alarm and a low bed with a fall mat. These recommendations were not addressed and/or implemented. On [DATE] at 4:38pm, the resident experienced another unwitnessed fall. The facility did not address, identify and implement appropriate and/or recommended fall prevention interventions for the resident. S1Administrator was notified of the Immediate Jeopardy situation on [DATE] at 9:20am. The Immediate Jeopardy situation was removed on [DATE] at 12:24pm, when an acceptable plan of removal was presented. The facility's plan to remove the immediate jeopardy situation included: *All new admits will receive a fall risk assessment by the Registered Nurse (RN) upon admission, after each fall, and quarterly with the Director of Nurses (DON)/Assistant Director of Nurses (ADON) utilizing the Admission Checklist to ensure this is completed; *When a resident has an unwitnessed fall or falls with a head injury, an incident report will be completed by the unit nurse, the supervisor will be notified of the fall, the physician and responsible party will be notified, neuro checks will be initiated every 15 minutes for 1 hour prior to transferring the resident to the emergency room for evaluation. Neuro checks will resume if the resident returns within 48 hours of the fall, and neuro checks will continue up to 48 hours post fall. The unit nurse will document neuro checks on the neuro assessment tool on the electronic Medication Administration Record [REDACTED] *When a resident had a witnessed fall, without head injury, a head to toe assessment will be performed to determine the level of care needed. The supervisor, physician, and responsible party will be notified immediately. The nurse will continue to re-asses the resident for pain and discomfort tor 48 hours with documentation per shift on fall follow-up and/or as needed in a regular nurse's note. A pain and skin assessment must be done every 8 hours for 48 hours following a witnessed fall; *An incident report will be generated by the nurse, a copy of the incident report will be submitted to the supervisor, and the supervisor will submit the report to the DON and ADON for notification; *If the resident has fallen, the cause of the fall will have a resident specific investigation done within 24 hours, the need for intervention will be assessed and resident specific intervention will be care planned. Physical therapy will also evaluate the resident and submit the screening the DON/ADON; and *The DON and/or ADON will train all nursing staff prior to them working their shift and all new nurses will be oriented on the process during orientation. The deficient practice continued at a potential for harm for the 112 residents residing in the facility who were at risk for falls. Findings: Review of facility's falls and fall risk policy revealed, in part, if a resident has just fallen, or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities. Nursing staff will observe for delayed complications of a fall for approximately forty-eight hours after an observed or suspected fall, and will document findings in the medical record. Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings. Further review of the falls and fall risk policy revealed within 24 hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident. They will refer to resident-specific evidence including medical history, known functional impairments, etc. The policy included the following information should be recorded in the resident's medical record: 1. The condition in which the resident was found; 2. Assessment data, including vital signs and any obvious injuries; 3. Interventions, first aid, or treatment administered; 4. Notification of the physician and family as, indicated; 5. Completion of a falls risk assessment; 6. Appropriate interventions taken to prevent future falls; 7. The signature and title of the person recording the data. Review of Resident #1's record revealed an admitted [DATE] with diagnoses, in part, of Type II Diabetes Mellitus, Diabetic [MEDICAL CONDITION], Left [MEDICAL CONDITION] (BKA), History of Gangrene of Left Foot, [MEDICAL CONDITIONS] Fibrillation, Deep Vein Thrombus, [MEDICAL CONDITION] Embolism, History of a Stroke, Hypertension, and [MEDICAL CONDITION] Stage. Resident #1's record revealed a Do Not Resuscitate (DNR) form which was signed by Resident #1 and the physician on [DATE]. Review of Resident #1's Minimum Data Set ((MDS) dated [DATE] revealed, in part, a Brief Interview for Mental Status score of 10, a two person extensive assistance with bed mobility and transfers, dressing, personal hygiene, range of motion limitation impairment on both sides to lower extremities, used a wheelchair for mobility and had no falls since admission. Review of Resident #1's record revealed no documentation of a fall risk assessment completed upon admit to the facility. Review of Resident #1's investigative reports revealed the resident had unwitnessed falls on [DATE], [DATE], and [DATE]. Review of Resident #1's investigative report dated [DATE] revealed no documentation of the time of the unwitnessed fall. Further review of the report revealed the activity at time of fall was from chair to wheelchair. Resident #1 was found on the floor and first aid was documented as being given by S3 Assistant Director of Nursing (ADON) on [DATE] at 3:10pm. There was no documentation of vital signs being taken and no documentation of the physician being notified of the unwitnessed fall. Further review of the incident report revealed the incident investigation page was blank. Review of Resident #1's record revealed no documentation of a fall risk assessment completed after Resident #1's unwitnessed fall on [DATE]. Review of Resident #1's nurses' notes dated [DATE] through [DATE] revealed no documentation of an assessment for 48 hours after the unwitnessed fall on [DATE]. Further review of the nurses' notes revealed no documentation of the physician being notified of the unwitnessed fall on [DATE]. Review of Resident #1's physical therapy screen request form revealed reason for screen: found on floor [DATE]. Further review of the therapy screen results dated [DATE] revealed resident is currently on restorative nursing program addressing strength and transfers; recommend bed/chair alarm and low bed with fall mat. Review of Resident #1's care plan [DATE] revealed a problem identified for potential for fall/injury related to left [MEDICAL CONDITION], impaired mobility and need for assist with transfers and wheel chair for mobility; [DATE] reported fall without injury. Further review of the care plan revealed no documentation of the physical therapy recommendations on [DATE] for bed/chair alarm, fall mat and low bed. Review of Resident #1's investigative report dated [DATE] at 5:46am revealed she was found on the floor and activity at time of the fall was from chair without assistance. Further review of the investigative report revealed the resident was calling, stated she was saying her prayer and slipped out the chair. Left [MEDICAL CONDITION] (BKA) was blast open, suture line add, moderate amount of bleeding noted on dressing. Immediate actions that were taken included: assist resident off floor, vital signs taken, rewrap left BKA with wet normal saline 4x4, call transport to local hospital. Further Review of the POS [REDACTED]. Review of Resident #1 care plan with a revised date of [DATE] revealed no documentation of a new intervention, which was measurable with timetables, implemented after Resident #1's unwitnessed fall with injury on [DATE]. The revision to the care plan on [DATE] indicated Resident #1 was sent to hospital for evaluation and treatment. Review of Resident #1's investigative report dated [DATE] at 4:38pm revealed resident observed lying on floor beside bed. She stated she was trying to get into wheelchair beside bed. Head to toe assessment done, no injuries noted, resident was able to move all extremities without difficulty. Further review of nurses' notes revealed no documentation of an assessment, after the unwitnessed fall on [DATE]. Review of nurse's note dated [DATE] at 7:56am revealed in part, while performing shift change rounds, S4 ADON/Overnight Supervisor and S5Licensed Practical Nurse (LPN) entered Residents #1's room to discuss resident's current health status and Resident #1 was not responding to her name. Code blue called and Resident #1 was found to be a DNR and 911 was called and Resident #1 expired at 7:18am. In an interview on [DATE] at 1:00pm, S14LPN was questioned about documentation after a fall, and she stated sometimes they document a head to toe assessment in nurses notes every shift, the next shift or for 24 hours after a fall. In an interview on [DATE] at 1:30pm, S2DON stated the nurses should have performed assessments on Resident #1. S2DON confirmed there was no documentation of an assessment for 48 hours after Resident #1's unwitnessed falls on [DATE], [DATE] and [DATE]. S2DON stated she did not review nurses' notes to ensure there was appropriate documentation after Resident #1's falls and stated she only looked at the incident reports. In a telephone interview on [DATE] at 4:30pm, S19LPN stated she could not remember the time of Resident #1's unwitnessed fall on [DATE], but stated Resident #1 did have a fall on her evening shift on [DATE] and the supervisor filled out the incident report. S19LPN stated nursing actions after a fall were dependent on physician orders. In an interview on [DATE] at 9:15am, S4ADON/Overnight Supervisor stated she was the night supervisor on [DATE] for the 11:00pm to 7:00am shift and she was Resident #1's nurse for the night shift on [DATE]. S4ADON stated the evening nurse supervisor reported to her that Resident #1 had a fall transferring from bed to chair. In an interview on [DATE] at 1:11pm, S2DON stated the admit nurse completed the fall risk assessments on admit and quarterly. If a resident was a fall risk it was documented at the bottom of the physician orders. S2DON reviewed Resident #1's physician orders [REDACTED].#1 being a fall risk. S2DON stated Resident #1 was a fall risk because she was an [MEDICAL CONDITION]. S2DON stated if a resident was a fall risk upon admit, they would implement a chair and bed alarm and a fall mat and those orders should go on the physician orders [REDACTED]. S2DON stated Resident #1 should have had the bed and chair alarm and a fall mat on admit and she had neither of them implemented on admit. In an interview on [DATE] at 1:25pm, S3ADON stated she was responsible for placing the bed and chair alarms for residents. S3ADON stated she did not implement a bed or chair alarm for Resident #1 and she was not aware of Resident #1's fall on [DATE]. S3ADON stated she did not know who was given the Physical Therapy (PT) recommendations dated [DATE], but it was not given to her. S3ADON confirmed Resident #1 did not have a bed or chair alarm, or a fall mat in place. In an interview on [DATE] at 1:40pm, S21Physical Therapist (PT) stated she gets a list of all resident falls and she screens each resident and talks to the nurse and the resident and then she would make recommendations. S21PT stated she wrote recommendations for Resident #1 on [DATE] for a bed and chair alarm, and low bed with floor mat and gave the recommendations to a floor nurse. S21PT stated she did not remember who she spoke to and she filed the recommendation form in Resident #1's chart. S21PT stated Resident #1 did not have a bed or charm alarm, a fall mat or low bed in place at the time of her assessment and that was why she made those recommendations. In an interview on [DATE] at 1:45pm, S14LPN stated she worked with Resident #1 when she had a fall on [DATE]. S14LPN stated it was reported to her that Resident #1 was found on the floor. S14LPN confirmed she completed the incident report and did not document an assessment after Resident #1's fall. When surveyor asked if she could be certain Resident #1 did not hit her head since it was unwitnessed, she stated no, she really did not know if Resident #1 hit her head or not. In an interview on [DATE] at 2:00pm, S2DON confirmed the PT recommendations dated [DATE] for Resident #1 slipped through the cracks and Resident #1 should have had a bed and chair alarm implemented on admit because she was a fall risk with her left leg amputated. She stated Resident #1's bed should have always stayed in a low position. In an interview on [DATE] at 3:25pm, S22Registered Nurse (RN) stated she worked as evening supervisor on Tuesday's and Thursday's. S22RN stated she completed the incident report on Resident #1's fall on [DATE] to help out the floor nurse. S22RN stated she did not document in the medical record her assessment, she only documented on the incident report. In an interview on [DATE] at 9:20am, S23MDS nurse stated the DON, ADON, and Administrator reviewed the daily fall log during their morning meeting along with therapy screens and they make recommendations. S23MDS stated the PT recommendations should be sent to the DON and the ADON, then the ADON notified the care plan nurse so the care plan can be revised. Resident #1's care plan was reviewed with S23MDS nurse and she confirmed the PT recommendations dated [DATE] were not implemented after Resident #1's fall on [DATE]. S23MDS nurse stated the interventions on the care plan for Resident #1's [DATE] and [DATE] falls were not measurable interventions with timetables. In an interview on [DATE] at 9:25am, S2DON clarified with surveyor if a resident was admitted with a history of a fall at home or a fall at the hospital then they would implement a bed and chair alarm on admit. S2DON stated if a resident was a high risk for falls then they monitor and put interventions in place to prevent a fall and if a resident has a fall then they would implement a bed and chair alarm at that time. Surveyor asked S2DON if Resident #1 was high risk for falls on admit and she stated yes. When asked if Resident #1 should have had a bed and chair alarm in place after her 1st fall she stated yes. In an interview on [DATE] at 8:50am, S21PT stated prior to surveyors entering the facility, the process in place for any therapy recommendations were to give the recommendations to the resident's nurse. S21PT stated the therapist assumed the nurse would forward the recommendations to whoever needed the information. In an interview on [DATE] at 11:40am, S4ADON/Overnight Supervisor stated the nurses should document a fall follow-up for three days following a fall and nurses should document a note in the medical record. She stated the nurses would document an assessment including whether a safety mat, bed alarm or chair alarm was present. S4/ADON/Overnight Supervisor stated she should have documented an assessment of Resident #1's fall on her [DATE] night shift, but she understood that the fall was the day before. In an interview on [DATE] at 10:49am, S2DON stated they did not implement any changes to their fall policy and procedures or monitor nurse documentation after Resident #1's fall on [DATE], [DATE] that resulted in an injury to her stump, and [DATE] fall with her subsequent death on [DATE]. S2DON stated she did not discover there was no documentation in the nurses' notes for Resident #1's falls until after speaking with the surveyor. She stated the facility did not review residents' with falls for proper documentation and interventions after Resident #1's falls and subsequent death. S2DON also confirmed there had been no additional training with the nursing staff regarding falls, no additional monitoring of the nursing staff, no additional training in regards to PT recommendations, and no additional training in regards to updating the care plans with appropriate and measurable interventions

Based on observation, record review, and interview, the facility failed to ensure a resident without a pressure ulcer did not develop any unless the resident's clinical condition demonstrated it was unavoidable as evidenced by 1 (#62) of 4 Stage 2 sampled residents (#62, #99, #88, and #30) reviewed for pressure ulcers not receiving skin assessments weekly as per the facility's policy which resulted in actual harm when the resident developed a stage 3 pressure ulcer. The facility failed to: 1) Follow the facility's weekly skin assessment policy in an attempt to discover newly developed pressure ulcers early by not conducting weekly body audits from 10/31/11 through 2/8/12 for Resident #62. 2) Ensure the care plan was updated after a stage 3 sacral pressure ulcer was discovered on 12/30/11 for Resident #62. These failed practices had the potential to affect any resident residing at the facility that was assessed as being at a risk for pressure ulcer development. There were 8 residents listed as having pressure ulcers on the facility ' s Resident Census and Conditions of Residents form. The total stage 2 sample was 39 and the total facility census was 89. Findings: Review of the facility's policy on Skin and Wound Management revealed, in part, a pressure ulcer risk assessment will be completed upon admission, with each additional assessment; quarterly, annually and with significant changes. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. Observation on 2/8/2012 at 10:25am during a skin assessment revealed Resident #62 had a healing Stage 3 Sacral pressure ulcer with wound measuring length of 2.0cm and width of 0.5cm and no depth. Review of Resident #62's Skin Condition Monitoring Form dated 3/18/2010 revealed the resident had a history of [REDACTED]. Review of the resident's Pressure Ulcer Risk Assessment sheet dated 3/18/2010 revealed she had an assessed score of 13, a score of 8 or greater was assessed as being at high risk for the development of pressure ulcers. Further review revealed none of the required quarterly assessments were done between 9/11/2010 to 8/30/2011. Review of the resident's Weekly Body Audit dated 10/30/2011 revealed the resident's skin was assessed as intact. Further review of the clinical record revealed no other weekly body audits were done from 10/30/2011 to 2/8/2012. Review of the facility's contracted wound care company's Wound Documentation/Progress Notes dated 12/30/2011 revealed the resident was first assessed as having a stage 3 pressure ulcer to the sacrum. Review of these notes revealed no measurements were done to the sacrum pressure ulcer for 12/30/2011, 1/6/2012, 1/27/2012, and 2/3/2012. Further review of the sacrum pressure ulcer revealed on 1/13/2012 the length and width of the wound was 1.42cm x 0.64cm and no depth and on 1/20/2012 the length and width of the wound was 0.88cm x 0.32cm and no depth. These above two dates were the only noted measurements of the sacrum pressure ulcer that were documented. Review of the resident's care plan with a goal date of 2/10/2012 revealed the resident was care planned for the potential for skin breakdown on 8/19/2011. Further review revealed the care plan was not updated on 12/30/2011 when the resident was assessed as having an actual stage 3 pressure ulcer. In an interview on 2/8/2012 at 11:35am, after presenting the above information and reviewing the resident's record, S2/DON indicated the Weekly Body Audits should have been done weekly, the Quarterly Skin Risk Assessments should have been done quarterly, care plan should have been updated to reflect the current status of the resident, and wound measurements should have been done weekly.