Every finding on record at Lebanon Center for Rehabilitation and Healing, LLC

Based on facility policy review, observations, and interviews, the facility failed to maintain the dietary department in a sanitary manner on 2 of 2 observations, affecting 48 of 48 residents in the facility. Review of the facility's policy titled, Cleaning Kitchen Equipment, dated 8/1/2019, revealed, .Small appliances (such as mixers and food processors) will be cleaned and sanitized after and prior to each use .The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food services areas through compliance with a written, comprehensive cleaning schedule .The director of food and nutrition services will determine all cleaning and sanitation tasks needed for the department .A cleaning schedule will be posted for all cleaning tasks, and staff will initial the task as completed .Staff will be accountable for cleaning assignments . Review of the facility's undated policy titled, Sanitizing Buckets, revealed, .All surfaces and equipment will be cleaned and sanitized using red buckets .Clean spills as needed using a clean cloth and warm water .Test water and chemical mixture using strip .Test strip must read between 200-400 PPM [parts per million] .Document PPM on log sheet . Review of the Daily Cleaning Schedule Sample Form dated 8/8/2022 through 8/14/2022 revealed, .Item: Toaster, Can Opener, Stove, Mixer, Slicer, Counter Top, Floor, Bev. [beverage] Carts, Meal Carts, Sinks, Dish Machine, Microwave . were to be cleaned by assigned staff Monday through Sunday. All boxes were initialed the task had been completed. Continued review of the Monthly Cleaning Schedule Sample Form revealed, .Item: Behind Stove, Under Table, Drawers, Shelves, Ice Machine, Oven, Walls, Vents, Doors, Tray Line, Delime, Dishroom, Trayline . were to be cleaned by assigned staff monthly. All months from January 2022 through July 2022 were initialed the task had been completed. Observations in the kitchen on 8/15/2022 at 9:15 AM and 12:15 PM, revealed there was a moderate amount of debris on the floor throughout the kitchen. Further observation revealed dust and debris on the shelf above the stove, on top of the steamer, on the prep cart, the drip tray under the stove top, the sides of the stove, the sides of the steamer, underneath the steamer, on top of the tray cart, on the bottom shelf of the steam table, and on the top surface of the steam table. Observation in the kitchen on 8/16/2022 at 9:30 AM, revealed there were no sanitizer buckets prepared. The Certified Dietary Manager (CDM) prepared a sanitizer bucket with sanitizer solution and warm water. When tested with the test strips, the strips revealed the PPM of sanitizing solution was under the required 200 PPM. The CDM emptied that bucket and prepared another one, and the results were the same. She stated she would call her supplier immediately to find a solution to the problem. When asked how often they test the sanitizer buckets, she stated, At least once a week. During an interview on 8/15/2022 at 9:30 AM, the CDM confirmed there was debris on the floor throughout the kitchen, dust and debris on the shelf above the stove, on top of the steamer, on the prep cart, the drip tray under the stove top, the sides of the stove, the sides of the steamer, underneath the steamer on the stainless steel table, on top of the tray cart, the shelf under the steam table, and on the top surface of the steam table. She stated the dietary department has a daily and monthly cleaning schedule and she would expect the dietary employees to follow the cleaning schedule and the areas should have been clean, and were not. During an interview in the conference room on 8/16/2022 at 3:00 PM, the CDM confirmed the facility's policy stated test strips must read between 200-400 PPM, and it is to be documented on a log sheet. She confirmed the dietary staff did not keep a log of testing the sanitation buckets, and should have.

Based on facility policy, record review, observation and interview, the Nursing Staff and Director of Nursing failed to have equipment needed on crash cart and failed to consistenely check the crash cart per facility policy. The findings include: Review of the undated facility policy Emergency Procedure-Cardiopulmonary Resuscitation revealed .the chance of surviving SCA [Sudden Cardiac Arrest] may be increased if CPR [cardiopulmonary resuscitation] is initiated immediately upon collapse .preparation for CPR .maintain equipment and supplies necessary for CPR/BLS [Basic Life Support] in the facility at all times .if an individual is found unresponsive .instruct a staff member to activate the emergency response system .instruct a staff member to retrieve the automatic external defibrillator . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the 5-day Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 scored 9 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Extensive to total assistance of 1 staff member was required for Activities of Daily Living (ADLs). Resident #1 was dependent on supplemental Oxygen (O2). Medical record review of the Comprehensive Care Plan dated [DATE] revealed assessment and monitoring occurred for respiratory status, skin integrity, fall risk, nutritional status, pain management, and cognitive functioning. The nursing interventions were appropriately implemented. Medical record Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] #1 was a resuscitate with full treatment status. The document was appropriately reviewed and discussed with the Power of Attorney (POA--sister) for Resident #1 and was appropriately signed and dated by all necessary parties. Medical record review of the nursing progress notes dated [DATE] revealed at 6:45 PM Resident #1 was observed to be unresponsive with no pulse or respirations. CPR was initiated and 911 Emergency was called to the facility. The AED (Automated External Defibrillator) was applied. 911 Emergency arrived at the facility at 6:47 PM and took over the CPR. The time of death for Resident #1 was pronounced by 911 Emergency at 7:45 PM. Resident #1's POA was called and no answer obtained. The next contact family member (nephew) was called and informed of Resident #1's death. The family member stated he would notify the POA. The POA arrived at the facility and was screened-in per COVID-10 protocol. The POA was allowed time with Resident #1's body and at 8:40 PM asked the staff to notify the funeral home. The body was picked-up by the funeral home at 9:11 PM. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the 5-day Admission MDS dated [DATE] revealed Resident # 2 scored 10 on the BIMS indicating moderate cognitive impairment. Extensive assistance was required by 1 staff member for ADLs. Medical record review of the Comprehensive Care Plan dated [DATE] revealed assessment and monitoring occurred for respiratory status, nutritional status, pain management, fall risk, self-deficit care, and skin integrity. The nursing interventions were appropriately implemented. Medical record Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] #2 was a resuscitate with full treatment status. The document was appropriately reviewed and discussed with the Power of Attorney (POA--step-daughter) for Resident #2 and was appropriately signed and dated by all necessary parties. Medical record review of the Physician's progress notes by the Nurse Practitioner (NP) dated [DATE] revealed a chronically-ill resident with severe breathing difficulties. The NP spoke with the resident's spouse about the resident's condition. The spouse told the NP the resident had been wanting to die for a month and the resident had smoked cigarettes substantially for years. The spouse stated he did not want hospice care at this time and was upset she was as sick as she was to require care at the nursing home. The step daughter was the responsible party and POA. Medical record review of the nursing progress notes dated [DATE] and [DATE] revealed the family assisted with Resident #2's assessment due to the resident being incoherent. The resident was observed to appear pale and dusky in color at 10:38 PM. The resident did not respond to verbal or painful stimuli and her pupils were dilated and unresponsive. The resident's eyelids were fluttering open and close. Spontaneously the resident's respirations stopped and there was no pulse. The crash cart was immediately obtained and chest compression were started. The back board was appropriately placed under the resident and 2 breaths were given with the AMBU (Air Mask Bag Unit). 911 Emergency was called and took over CPR upon arrival. The time of death for Resident #2 was 11:13 PM. The appropriate administration was notified. The resident's spouse was called with no answer. The next contact was called, the POA. The funeral home was notified and picked up the body at 12:17 AM. Review of deaths in the facility dated ,d+[DATE] to ,d+[DATE] revealed 14 residents had died at the facility. 2 residents of the 14 resident were full code/resuscitation status with full treatment. The 2 residents were Resident #1 and Resident #2. The appropriate documents were in their medical records and the appropriate resuscitative treatment was provided. End-of-Life care and policy were provided and followed. During observation at the nurse's station [DATE] at 10:00AM, the crash cart check list sheet was noted for the month of [DATE]. This surveyor noted a yellow sticky note of items missing on crash cart as of [DATE]. The note listed the following supplies missing from crash cart: venturi mask, nasopharyngeal airway, lockbox, auto shield duo, code blue paper, extension cord, AED pads, and non-rebreather masks times 2. The crash cart check list also had 21 days where the cart had not been signed as being checked on the night shift. Further observation of the crash cart revealed crash cart check list for the month of [DATE] with 6 days missing initials for being checked on night shift and also circled items missing from check list. Further review of the Lebanon Center for Rehabilitation and Healing Emergency Equipment/Crash Cart Check list revealed the following bullet points: Night shift nurse will inspect the break-away lock located on crash cart, Night shift nurse will test AED every night for functioning and check full cart inspection, if lock found intact and AED is operating correctly upon inspection, the night nurse will initial the date above that check was completed, if lock found broken or missing and/or the AED is not operating correctly, the nurse will report it to the immediate supervisor for a full inspection and then reported to the DON, on a weekly basis or as necessary, the crash care equipment will be inspected to make sure that all equipment on the cart is in good working order and the cart is well supplied and there is no expired items.

Based on the facility policy, record review, observation, and interview, the facility failed to administer controlled drugs per standard nursing procedures and failed to keep accurate records of administration of controlled drugs for 6 (Resident # 4, Resident #5, Resident #6, Resident #7, Resident #8, and Resident #9) of 9 residents sampled Review of the undated facility policy Administering Medications revealed .policy Interpretation and Implementation .the Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions .as required or indicated for a medication, the individual administering the medication records in the resident's medical record .the signature and title of the person administering the drug .medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy . The findings include: Review of undated facility policy Discarding and Destroying Medications revealed .medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceutical, hazardous waste and controlled substances .policy interpretation and implementation .completed medication disposition records shall be kept on file in the facility for at least two [2] years, or as mandated by state law governing the retention and storage of such records. Review of the undated facility policy titled Pharmacy Network Services Policy and Procedures revealed .establishing a system of records for receipt and disposition of all controlled medications to enable an accurate reconciliation, and determining that drug records are in order and that an account of all controlled medications is maintained and periodically reconciled .medications included in the Drug Enforcement Administration [DEA] classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and record keeping requirements in the facility, in accordance with federal and state laws and regulations .the Director of Nuring and the contracted consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications .controlled substance medications are dispensed by the provider pharmacy in readily accountable quantities and containers designed for easy counting of contents .the pharmacy will include an individual resident controlled drug record [count sheet] for each controlled substance medication container dispensed to a resident .reorder medication three days in advance of need, as directed by the pharmacy order and delivery schedule, to assure an adequate supply is on hand .controlled substances are reordered when a three day supply remains to allow for transmittal of the written prescription to the pharmacist .medications are not borrowed from other residents .controlled substance inventory sheets are completed, if necessary, and filed appropriately .after administration, return to cart, replace medication container, and document administration in the medication administration record or treatment administration record, and controlled substance sign out record .accurate accountability of the inventory of all controlled drugs is maintained at all times .when a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Pain in Right Hip, [CONDITION(S)] (COPD) and Chronic [CONDITION(S)]. Medical record review of the Admission Minimum Data Set (MDS) with assessment reference date of 5/21/2021 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitive abilities are intact. Continued review revealed Resident #4 had frequent pain that had not caused difficulty sleeping or limiting activities for the last 5 days. Further review revealed Resident #4 reported a 6 on a 0 to 10 pain scale (0=no pain; 10=severe pain) as the worst pain over the last 5 days. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Multiple Sclerois, Low Back Pain, and Chronic Pain Syndrome. Medical record review of the Admission MDS with assessment reference date of 8/22/2021 revealed Resident #5 had a BIMS score of 15 indicating cognitive abilities are intact. Continued review revealed Resident #5 had frequent pain that had not caused difficulty sleeping but had limited some activities over the last 5 days. Further review revealed Resident #5 had moderate pain over the last 5 days. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Diabetes Mellitus, Protein-Calorie Malnutrition, and Dysphargia. Medical record review of the Admission MDS with assessment reference date of 5/28/2021 revealed Resident #6 had a BIMS score of 5 indicating poor cognitive abilities. Continued review revealed she had occasional pain that had not made it hard to sleep or perform her normal activities. Further review revealed a rating of 6 on a 0-10 pain scale (with 0=no pain; 10=severe pain) as the worst pain over the last 5 days. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], Diabetes Mellitus Type 2, Chronic Pain, Coronary Artery Disease and [CONDITION(S)]. Medical record review of the Quarterly MDS with assessment reference date of 7/28/2021 revealed Resident #7 had a BIMS score of 13 indicating some cognitive abilities are intact. Continued review revealed she had frequent pain over the last 5 days that did not make it hard for her to sleep or limit her day-to-day activities. Further review revealed pain intensity to be severe. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Hemilplegia and [CONDITION(S)], Diabetes Mellitus, Cerebral Infarction and White Matter Disease. Medical record review of the Admission MDS with assessment reference date of 8/2/2021 revealed he had a BIMS score of 14 indicating cognitive abilities intact. Continued review revealed he experienced no pain in the last 5 days. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Pain in Knee, Pain in Right Hip, and Low Back Pain. Medical record review of the Quarterly MDS with assessment reference date of 7/6/2021 revealed she had a BIMS score 15 indicating cognitive abilities intact. Continued review revealed she had occasional pain over the last 5 days that did not make it hard for her to sleep or limit her day-to-day activities. Further review revealed mild pain intensity. Review of controlled drug receipt record/disposition form for Resident #5 sheet revealed on 8/22/2021 [MEDICATION(S)] 400 mg was borrowed for Resident #8. Continued Review of controlled drug receipt record/disposition form revealed Resident #9's narcotic sheet revealed on 8/19/2021 [MEDICATION(S)] 100 mg was borrowed for another resident in the facility. Continued review of controlled drug receipt record/disposition form revealed Resident #7's narcotic sheet revealed on 8/17, 8/18, and 8/20/2021 [MEDICATION(S)] 100 mg tablet borrowed for another resident in the facility. Further review of Resident #6's controlled drug receipt record/disposition form revealed on 8/17, 8/20, and 8/21/2021 [MEDICATION(S)] 50 mg borrowed for another resident in the facility. Observation and interview on 8/25/2021 at 8:50 AM revealed Licensed Practical Nurse (LPN) #1 performing 9:00 AM medication pass. During the observation it was noted Resident #4's-controlled drug receipt record/disposition form for Oxycodone-Acetaminophen (APAP) 7.5-325 mg (milligram) had a blank in the signature column between 8/21 and 8/23/2021. LPN #1 confirmed that medication was not signed out but left blank in signature column. During an interview with LPN #2 on 8/25/2021 10:57 AM stated it is not appropriate to borrow narcotics to give to other residents. Typically nursing would send in a refill and pharmacy would let nursing know that the resident needed a new script sent to the pharmacy. LPN #2 stated stat narcotics are in the electronic box and if they don't have a script you can't pull those meds. LPN #2 stated one of the night nurses reported that the DON said we could borrow narcotics. Interview with LPN #1 on 8/25/2021 11:06 AM revealed she had been employed since January. LPN #1 was asked about borrowing of narcotics. She stated she had never borrowed narcotics but she knew they had to let the DON know if medications were borrowed so pharmacy could make sure the resident is not charged for it. Interview with the DON on 8/26/2021 at 8:32 AM when asked about narcotic being borrowed, she stated, It's not the best practice to borrow medications but I do not want the resident to be without their pain medication. It is very rare for the nursing staff to borrow medications, it's not done on a regular basis. The DON stated they (medication nurses) make a copy of the narcotic sheet and put it under her office door. She also stated she sends it to the Pharmacy to get the resident paid back for the medications borrowed. The DON further stated we (facility) would pay for it (the medication) if they (the resident) were on Medicare. The DON was asked to provide the controlled drug record sheets for these residents to show how the medication was added into their normal count and signed by the administering nurse; she was unable to provide these sheets. The DON stated, I review the controlled sheets when they are turned-in, I don't keep them. During a phone interview on 8/26/2021 at 12:58 PM with Pharmacy Network Services, the dispensing Pharmacist and the consultant Pharmacist both were unaware of the facility borrowing narcotics between residents. When the Pharmacists were asked if the DON had sent up sheets to Pharmacy to verify residents were reimbursed for their medications both stated they had not received anything from the DON. The dispensing Pharmacist stated narcotics should never be borrowed and that is not the correct policy and procedure. The dispensing Pharmacist also stated the facility has an electronic dispensing machine that was put in the facility on 7/29/2021 that has many of the meds they need. The dispensing Pharmacist stated the facility should be following the Pharmacy policy and procedures when dispensing medications. The dispensing Pharmacist stated that Pharmacy has a signed agreement with the facility which the Administrator has provided. The DON provided emails sent on 8/25/2021 at 1:45 PM and 3:00 PM to the consultant Pharmacist relating to narcotics borrowed from Resident #5, Resident #6, Resident #7, and Resident #9.

Based on facility policy, observations, and interviews the facility failed to properly store appropriate foods and beverages in the walk-in cooler in the kitchen area to prevent cross-contamination. The findings included Review of undated facility policy Food and Nutrition Services revealed .nutrition services staff will evaluate .food and beverages for resident consumption are appropriately stored . Observation of the walk-in cooler in the kitchen area on 8/25/2021 at 8:25 AM revealed 1-8 ounce (oz) cellophane bag labeled pork rinds with approximately one-fourth of the contents remaining in the bag sitting on the second open shelf to the left of the walk-in cooler door. Continued observation of the walk-in cooler revealed a gray plastic bag containing an unopened 16 oz aluminum can labeled energy drink on the third open shelf to the left of the walk-in cooler door. The Dietary Cook immediately removed the opened cellophane bag and gray plastic bag with the aluminum can. Interview with the Dietary Cook on 8/25/2021 at 8:25 AM confirmed she was left in charge while the Certified Dietary Manager (CDM) ran errands. Continued interview with the Dietary Cook confirmed the open cellophane bag of pork rinds and the aluminum can of energy drink belonged to Dietary staff and were not to be stored in the walk-in cooler. Further interview with the Dietary Cook confirmed the Dietary staff had access to an employee refrigerator across the hall from the dining room. Upon her return at 9:15 AM the CDM confirmed the Dietary staff had received on 8/25/2021 staff education on not using the Dietary Department walk-in cooler to store personal food and drink items.

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to assume responsibility for ensuring the safety and well-being of a resident by failing to protect a resident from verbal and physical abuse by a staff member for 1(Resident #2) of 3 residents reviewed. The findings included: Review of facility policy, Abuse and Neglect Prohibition, revised 7/2018, revealed .Each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms .Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or to others regarding the resident or within the resident's hearing distance regardless of their age, ability to comprehend, or disability .Physical abuse includes, but is not limited to, hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment .Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .The facility will screen for employees with a history of abusive behavior .The facility will train each employee on this policy during orientation, annually, and more often as determined by the facility .The facility Quality Assurance & Performance Improvement Committee will review available data to identify patterns and trends that may indicate the presence of abuse .The facility will protect residents from harm during the investigation .The facility will timely conduct an investigation of any alleged abuse/neglect .Any employee alleged to be involved in an instance of abuse and/or neglect will be interviewed and suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated .The QAPI Committee may make recommendations to the Policy and Procedure Steering Committee for modifications based on identified opportunities for improvement resulting from the review of the investigation . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 scored 14 on the Brief Interview for Mental Status (BIMS) indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #2 required extensive assistance of 1 person with transfers, dressing, toileting, grooming, and bathing; was occasionally incontinent of bladder; and was always continent of bowel. Review of facility investigation of a written statement from Registered Nurse (RN) #1 dated 4/27/19 revealed .I was asked by a nursing technician to visit a resident (named Resident #2) who had made a statement that night nurse (named RN #2) had touched a resident. I visited this resident who said at approximately 2400 the nurse told (named Resident #2) that she would be receiving her medications. (named Resident #2) stated she had been asking since 1930 (7:30 PM) for her pain medication. (named Resident #2) again asked at 0030 (12:30 AM) for her medications and (named RN #2) scolded her verbally and was pointing her finger near her face. She continued to scold her at which point the finger hit the upper lip of (named Resident #2). (named RN #2) apologized to the resident for hitting her in the face. Soon after the incident she received her medications. (named Resident #2) verbalized the above events to myself and in the presence of (named LPN #1) and (named CNA #1) . Review of facility investigation of a written statement from Certified Nurse Aide (CNA) #1 dated 4/27/19 revealed .I arrived on 110B to toilet her. During conversation about her having a rough night she had told me her night shift nurse had been very rude and physical with her by scolding her and pointing a finger to her face and physically touching her above the lip during this time. All (named Resident #2) was asking about was her medicine around 7pm - 7:30. Afterwards she finally received her medicine around 12 - 12:30 AM. I immediately reported this to the nurse and supervisor. I ensure (named Resident #2) she was doing right by telling me. She would be safe . Review of facility investigation of a written statement from Licensed Practical Nurse (LPN) #1 dated 4/27/19 revealed .I was approached by (named CNA #1) to come to room [ROOM NUMBER]B. Upon entering the room the patient stated last night the nurse was off the chain. Pt stated that she began asking for her night meds at 730pm so she could rest. The nurse did not come stated the pt until after midnight. The pt stated that the nurse began to scold her by pointing her finger in her face and telling her she had no meds at this time because they haven't come from the pharmacy. The pt then stated that when she told the nurse that she had been receiving medications all day and she knows they are there the nurse began pointing her finger in her face and scolding her. Pt stated the nurse pushed her upper lip with her pointed finger of her right hand. Pt then stated she told the nurse to never touch her again and the nurse immediately apologized and became nice and went to get her medication. I immediately informed nursing supervisor who then reported to the administrator and director of nursing (DON) . Review of facility investigation of an interview between the DON and Resident #2 dated 4/27/19 revealed .(named Resident #2) stated that nurse (named RN #2) had yelled at her pointing her finger in her face and her finger hit her lip. When asked why the nurse was yelling Resident stated she had asked for pain medication and the nurse was yelling at her saying that her med had not come in yet and there was nothing she could do about it. When asked if she felt the nurse meant to hit her lip (named Resident #2) said I don't think she did. I think it was an accident. When asked how she felt she stated she made me mad. I'm [AGE] years old and don't need to be talked to like that. I was so mad that I wanted to take this (held up TV remote) and hit her in the head with it. I am not afraid, she just made me mad. Assured (named Resident #2) that it would be taken care of and nurse would not be back . Review of facility investigation of an interview between the DON and RN #2 dated 4/29/19 revealed .Asked (named RN #2) if she remembered anything that transpired with (named Resident #2) on Friday 4/26/19. (named RN #2) said I don't remember her or much from that night I was tired. Explained who the resident is and what she said (named RN #2) had done. (named RN #2) said I was pointing at the meds because (named Resident #2) refused to take one and I was indicating which pill. Resident turned her face and my finger touched her lip. I apologized for that. (named RN #2) said she didn't remember yelling at her or talking about her pain meds. Maybe patient sensed I was stressed and took it that I was yelling. (named RN #2) once again stated she couldn't remember . Interview with the Administrator and DON on 5/9/19 at 3:10 PM in the conference room revealed Resident #2 can get testy at times but cooperated with therapy this admission. Prior admissions she had refused therapy at times. The alleged perpetrator pointed her finger in the resident's face and touched her lip when the resident turned her head. The resident told them she didn't need to be chastised in that manner. The nurse said she was trying to find which pill the resident refused and was pointing to it. The nurse was suspended during the investigation and then terminated. Interview with the Administrator on 6/10/19 at 9:30 AM in the conference room revealed as the incident was being investigated it became a he said, she said situation. The Administrator reported it and terminated the nurse as a precaution and also because the nurse was just not making it. When she visited the resident to apologize for the incident the resident was not upset and said she was well cared for in the facility and that is why she keeps coming back for rehabilitation. The Administrator stated the nurse may have raised her voice thinking the resident did not understand what she was telling her about not taking 2 of her pills. Telephone interview with Resident #2 on 6/10/19 at 10:50 AM revealed she was a nurse for many years and the incident didn't bother her. She said she realized they had to report it but it was not a major issue. At the time of the incident she was mad at what occurred but had no fear. It was an accident the nurse's finger touched her lip and only because she turned her head. In summary, Resident #2 asked for pain medication at 7:30 PM according to the resident. She received the medications at midnight along with a scolding from the nurse who also pointed her finger in the resident's face. As the resident turned her head the nurse's finger contacted the resident's skin on the face. The resident was upset at the time of the incident. This behavior constituted verbal and physical abuse.

Based on facility policy review, medical record review, interview and observation, the facility failed to obtain a physician's order for 3 of 27 residents (#31, #196, and #394) reviewed. The findings include: Review of facility policy, Physician Order, revised 11/2017 revealed, .Physician orders are obtained to provide clear direction regarding the care of the resident .A physician's order is required prior to the discontinuation of any current order . Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #31 had a Brief Interview Mental Status (BIMS) score of 15, indicating cognitively intact. Further review of MDS revealed Resident #31 had hospice care while a resident and while not a resident. Medical record review of a Hospice Communication Note dated 9/5/18 revealed hospice services to be discontinued on 9/5/18. Medical record review revealed no physician order to discontinue hospice services. Interview with Resident #31 on 10/2/18 at 2:12 PM in the resident's room confirmed she had hospice services upon admission to the facility but was discharged from hospice services a few days after admission. Interview with Licensed Practical Nurse (LPN) #1 on 10/2/18 at 2:32 PM at the nurse station confirmed there was no order for the discontinuation of hospice services for Resident #31. Medical record review revealed Resident #196 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician Order dated 9/30/18 revealed .Place EDPC (extended dwell peripheral catheter) for long term IV (intravenous) antibiotics . Further review revealed no orders for the care of the EDPC. Observation on 10/1/18 at 10:29 AM in Resident #196's room revealed EPDC to the right upper arm with a dressing date of 9/30/18. Interview with Registered Nurse (RN) #1 on 10/2/18 at 4:40 PM at the nurse station, revealed she only performed the dressing changes and did not put orders into the electronic health records. Further interview with RN #1 stated .when a resident comes on arrival I notate the dates and change the dressing 7 days from the date that is on the dressing or if it is actively needing to be changed I change it. I wasn't aware that a dressing needed an order . Further interview revealed RN #1 was not aware Resident #196 did not have an order for [REDACTED].>Interview with the Nurse Practitioner (NP) on 10/3/18 at 11:05 AM at the nurse station revealed, the wound care nurse changed out the dressing weekly and as needed. Further interview confirmed the NP was unaware that an order was not in place for the care of the EDPC. Medical record review revealed Resident #394 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician Order dated 10/2/18 revealed Oxygen at 2 liters per minute (lpm) per nasal cannula. Observations on 10/1/18 at 10:20 AM and 3:30 PM and on 10/2/18 at 7:17 AM and 2:05 PM in Resident #394's room revealed the resident with oxygen in use per nasal cannula at 2 lpm. Further observation revealed a Peripherally Inserted Central Catheter (PICC) (intravenous catheter for administration of medications or fluids that are unable to be taken by mouth) line to right upper arm with a transparent dressing in place dated 9/26/18. Interview with LPN #1 on 10/2/18 at 2:18 PM at the nurse station confirmed Resident #394 was wearing oxygen per nasal cannula on 10/1/18. Further interview confirmed Resident #394 did not have an order for [REDACTED].>Interview with RN #1 on 10/2/18 at 2:35 PM in Resident #394's room confirmed the resident had a PICC line to right upper arm, dressing intact and dated 10/2/18. Further interview confirmed she had changed Resident #394's PICC line dressing on 10/2/18 and she did all the PICC line care weekly. Further interview confirmed she did not obtain the physician's order for the PICC line care. Interview with RN #2 on 10/2/18 at 2:50 PM at the nurse station confirmed there was no physician order for [REDACTED].>

Based on medical record review, review of facility documentation and interview, the facility failed to accurately assess falls for 1 of 8 residents (#13) with falls; and failed to accurately assess the discharge facility type for 1 of 3 discharged residents (#44) reviewed. The findings include: Medical record review revealed Resident #13 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of facility documentation revealed Resident #13 had falls with no injuries on 2/2/18, 2/3/18, 2/16/18, 2/23/18, 3/3/18, 3/26/18, 3/27/18, and 3/30/18. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] for Resident #13 revealed the facility assessed the resident as having no falls when he had experienced 2 falls during the review period. Medical record review of the Quarterly MDS dated [DATE] for Resident #13 revealed the facility assessed the resident as having no falls when he had experienced 6 falls during the review period. Interview with Registered Nurse (RN) #3/MDS Coordinator, on 10/3/18 at 10:10 AM in her office confirmed the 2/14/18 and 5/17/18 MDS did not accurately assess the falls Resident #13 experienced during the review period. Medical record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 discharged to the hospital. Medical record review of the progress notes dated 9/7/18 revealed Resident #44 was discharged home with home health services. Medical record review of the discharge summary dated 9/7/18 revealed Resident #44 was discharged home with home health services. Interview with the Registered Nurse #3/MDS Coordinator on 10/2/18 at 7:50 AM in her office confirmed she completed the discharge MDS for Resident #44. Further interview with MDS Coordinator confirmed .she made the mistake of entering hospital discharge instead of discharging home .

Based on medical record review, observation and interview, the facility failed to appropriately place a resident on transmission based precaution on admission, and failed to store oxygen tubing when not in use for 1 of 9 residents (#13) receiving respiratory treatment. The findings include: Medical record review revealed Resident #196 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Hospital Discharge Summary dated 9/29/18 revealed .Urinary tract infection .Pseudomonas species with extended spectrum beta lactamase activity . Further review revealed .Meropenenem 1 gram intravenous every 12 hours 7 days . .[MEDICATION NAME] 550 mg 1 tablet twice daily . Observation on 10/1/18 at 10:34 AM and 3:41 PM outside of Resident #196's room revealed no personal protective equipment (PPE) outside of the room. Interview with Licensed Practical Nurse (LPN) #2 on 10/1/18 at 3:39 PM at the nurse station, revealed Resident #196 was admitted on [DATE]. Further interview revealed LPN #2 was told to put Resident #196 on isolation on 10/1/18 by the Nurse Practitioner (NP). Further interview confirmed the . NP does not come on the weekends so that is probably why it got missed . Interview with the Director Of Nursing (DON) on 10/3/18 at 8:35 AM in her office confirmed .all residents are on contact (isolation) we just did not have an order for [REDACTED].>Interview with the Nurse Practitioner (NP) on 10/3/18 at 11:05 AM at the nurse station stated, .I usually see them the next day or if on the weekend I see them on Monday . Further interview with the NP stated .in an ideal situation I would expect the nurses to call, but they don't need to call me to put a resident on isolation . Interview with the NP on 10/3/18 at 1:30 PM in the hall way revealed she found out on 10/1/18 Resident #196 had a [DIAGNOSES REDACTED]. Further interview revealed the NP would have been fine if the nurse put the resident on isolation or called to inform her of Resident #196 status. Medical record review revealed Resident #13 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician order [REDACTED].#13 was to receive oxygen at 2 liters per minute via nasal cannula as needed for oxygen saturation level less than 92% (percent). Observation on 10/1/18 at 10:19 AM, 11:06 AM, and 11:54 AM revealed Resident #13 was not in his room. Further observation revealed the oxygen concentrator had a nasal cannula attached. Further observation revealed the nasal cannula was draped over the top of the oxygen concentrator and hanging down the back of the concentrator. Observation on 10/1/18 at 3:57 PM, with LPN #3 present, revealed Resident #13 in his room. Further observation revealed the nasal cannula was in the same position as observed at 10:19 AM, 11:06 AM and 11:54 AM on 10/1/18. Interview with LPN #3 in Resident #13's room on 10/1/18 at 3:57 PM revealed the LPN was assigned to provide care to the resident. When the LPN was asked the facility practice for oxygen tubing storage when not in use stated .it's to be bagged . Further interview confirmed Resident #13's nasal cannula was not bagged and .should have been . Interview with the DON on 10/3/18 at 10:05 AM in the hallway by the Dining Room revealed the staff was expected to store the oxygen tubing or masks in a bag when not in use.

Based on facility policy, record review and interview, the facility failed to ensure adequate supervision was provided for one of eight sampled residents (Resident #4) during a transfer with a mechanical lift. Review of the undated policy for Lift & Transfer Program indicated, Two trained persons are required to be present when using the lift. Certified Nurse Aide (CNA) #1 transferred Resident #4 using a mechanical Hoyer lift without requesting the assistance of another staff and without connecting the lift's straps securely. Resident #4 fell from the Hoyer lift during a Hoyer lift transfer and sustained a fractured right ankle fibula and a cervical fracture to the C1 vertebrae of the neck resulting in HARM. Findings Include: Review of Resident #4 Admission Record indicated the facility admitted Resident #4 on 10/08/13. [DIAGNOSES REDACTED]. Review Nurses' Notes dated 1/25/18 indicated Resident #4 received Hospice care prior to her death in the facility on 1/25/18. Review of the MDS dated [DATE] revealed Resident #4 requires extensive assistance with all activities of daily living. During the assessment period, transfers occurred only once or twice requiring two-person physical assistance. Resident #4's BIMS score was 3 indicating the resident was severely cognitively impaired. Review of Resident #4 Activities of Daily Living (ADL) care plan and the MDS Kardex revealed Resident #4 required extensive assistance with transfers, with the intervention to transfer the resident per the Mechanical Lift (full body lift and sling remains under pt (patient) with (2) staff assistance for transfers Review of the facility investigation dated 11/06/17 at 10:00 AM revealed, Had been transferring from bed to shower chair via Hoyer lift when one strap came loose from lift and patient fell to floor, strap not secured correctly,CNA#1 did not have another staff helping her . The report indicated CNA#1 was a witness (the nurse aide who operated the Hoyer lift), as well as, there was a sitter for Resident #4 in the room at the time of the transfer. Review of the facility investigation documents revealed the investigation was completed by Licenses Practical Nurse (LPN) #1 and the Director of Nursing (DON). It was also signed by the Administrator and Medical Director. The facility concluded the cause of the accident was strap not secured correctly CNA#1 did not have another staff helping her. Review of the document titled, Physician's Telephone Orders dated 11/6/17 revealed, STAT (immediately) X-Ray: C (cervical)-spine- neck pain, T ([MEDICATION NAME])-spine-back pain, R (right) ankle-[MEDICAL CONDITION]/bruising. Review of Resident #4 Radiology Report Ankle AP right, dated 11/06/17 revealed, There is a fracture involving distal fibula with no displacement. The joint alignment is maintained. There is associated soft tissue swelling. Review of the Radiology Report Cervical Spine dated 11/6/17 indicated, Mild [MEDICAL CONDITION] Changes of the cervical spine. Review of the Radiology Report [MEDICATION NAME] Spine dated 11/6/17 revealed Mild [MEDICAL CONDITION] of the [MEDICATION NAME] spine. Review of the Orthopedic Physician's Progress note dated 11/7/17 documented Please place a pillow or air support on the R (right) ankle, Ice 15 minutes trice a day, Rewrap Ace daily- NO Stretch . Review of the Nurse Practitioner's notes (NP), dated 11/6/17 through 1/9/17, revealed Resident #4 right ankle has some ecchymosis, [MEDICAL CONDITION] and tenderness to palpate. Review of the NP's note dated 11/10/17 indicated enlarged gland right submandibular that was tender. Review of the NP's note dated 11/13/17 indicated, .The patient also presents with ecchymosis. It is located on the face Left temporal region .The symptom is gradual in onset not observed on Friday (November 20, (YEAR)) Review of the Telephone Order, dated 11/13/17 at 14:33 (2:33 PM) indicated, send to Tennova Out Patient for CT of head and neck for [MEDICAL CONDITION] and pain . During an interview with the Director of Nursing (DON) on 4/9/18 at 3:20 PM, the DON stated that after the results of the CT showed the fracture to the cervical spine C1, Resident #4 Orthopedic physician ordered the resident to be sent to the Emergency Department (ED) at St. Thomas. Review of the ED Report revealed, .History of Present Illness, the patient presents with fall at NH (nursing home) one week ago. Dx (diagnosed ) with right ankle fx (fracture) fx Rx (prescription) without splinting (patient is non-ambulatory). CT head/neck today revealed cervical fracture. Sent by EMS (Emergency Medical Services) from outpatient imaging to ED . Interview with CNA#1 on 3/19/18 at 3:05 PM in the conference room, revealed she had worked at the facility for [AGE] years and had received in-service training on using the mechanical Hoyer lift prior to the incident. CNA#1 stated a sitter stayed with the resident 12 hours a day and we (staff) were just so used to the sitter helping us. Continued interview with CNA#1 revealed, I know now that I should have had another staff person with me. Further interview with CNA#1 revealed when she connected the sling to the lift, she thinks one strap did not go past the disc that secures the strap. Further interview with CNA#1 revealed when moved the resident from the bed, across the bolsters, the resident's bottom hit the bolster. CNA#1 stated the strap came off and the resident slide down my legs head first to the floor. CNA #1 stated that the incident happened so fast. CNA# 1, stated she was sent home after the incident and was later retrained on the Hoyer lift with a return demonstration. CNA#1 stated, I will always have another staff person with me . Interview with DON on 03/19/2018 at 11:00 AM in the conference room revealed she was called to the room after Resident #4 fall from the Hoyer lift. Continued interview revealed the resident did not complain of pain. Resident #4 had a sitter in the room at the time of the incident. CNA#1 used the sitter as her assistant to transfer the resident. Interviews with CNA #2 on 4/7/18 and CNA#3 on 4/10/18 in the facility's conference room, confirmed the facility's policy was to use two nursing staff whenever a resident was transferred via Hoyer lift and they could not ask the sitter for Resident #4 to assist with the use of the Hoyer lift, since she was not an employee of the facility and was not certified. The DON stated one of the straps came loose on the Hoyer lift causing the fall. Interview with the DON revealed the Hoyer lift was checked and there was no malfunction. The DON confirmed the strap was not secured properly resulting in a fall from the lift. The resident later had pain and x-rays were initiated. The DON stated that she immediately started an in-service on transfers with a return demonstration of all staff . During an interview on 4/9/18 at 5:10 PM in the conference room, LPN #6 confirmed that whenever a resident was transferred per the Hoyer lift, there were to be two nursing staff assisting with the transfer. LPN# 6 confirmed the sitter for Resident #4 should not have been asked to assist with the use of the Hoyer lift, since she was not an employee of the facility. Telephone interview on 4/10/18 at 9 AM, LPN# 7 indicated the facility's policy was to use two nursing staff whenever a resident was transferred using the Hoyer lift. LPN #7 also confirmed that nursing staff were not to ask any resident's sitter to assist with the transfer since they were not employees of the facility. LPN#7 confirmed that Resident #4's sitter was not an employee of the facility. During an interview on 4/9/18 at 1:45 PM, the NP in the conference room the NP stated Resident #4 only experienced one fall which was on 11/6/17. The NP stated that an x-ray of the cervical area was performed on 11/6/17, since Resident #4 fell head first to the floor. The NP stated that the 11/6/17 x-ray to the cervical area of the neck came back negative for fracture. The NP stated that on 11/13/17, the CT can pick up fractures that the x-ray cannot detect. The NP confirmed that when the CT results of the cervical fracture to C1, the Orthopedic physician ordered the resident to be transferred to the ED of St. Thomas Hospital for further evaluation. The NP confirmed that Resident #4 returned with a hard collar to the neck. Telephone interview on 4/10/18 at 10:05 AM, the Orthopedic physician that reviewed Resident #4's x-ray results of the right ankle and the CT results of the cervical spine stated that it was very difficult for the x-ray of the cervical neck to identify the fracture to the C1 vertebra due to the [MEDICAL CONDITION] spondylosis of the spine. The Orthopedic physician indicated that on 11/6/17 the resident did not have any pain in the neck area. However, as the week progressed after the fall, a small displacement, a 3-4-millimeter shift, could have caused the swelling of the neck. The CT scan is the gold standard and it can detect a fracture that the x-ray was unable to detect. A review of CNA#1 personnel file indicated no issues with CNA#1 performance until she was suspended on 11/06/2017. She had documentation regarding the use of the Hoyer lift on 06/19/2017 and again on 11/13/2017. Review of the undated policy for Lift & Transfer Program indicated, Two trained persons are required to be present when using the lift. This Requirement is not met as evidenced by: Based on review of facility policy, record review and interview, the facility's nursing staff failed to accurately document one of one (Resident #4) resident's condition after the resident experienced a fall with a fracture during a transfer from the bed to the shower chair utilizing the Hoyer lift. After the fall, the resident experienced bruising and [MEDICAL CONDITION] of the right ankle, [MEDICAL CONDITION] to the right neck, and bruising of the left face. Resulting in Harm. Findings include: Review of a facility investigation for a fall that occurred for Resident #4 dated 11/6/17 at 10:00 AM revealed, Certified Nursing Assistant (CNA #1) had been transferring (Resident #4) from bed to shower chair via Hoyer lift (a mechanical device used to transfer) when one strap came loose from the lift and patient (Resident#4) fell to floor, strap when the strap was not secured correctly, CNA #1did not have another staff helping her. Review of the Radiology report dated 11/6/17 revealed, Results, there is a fracture involving distal fibula (one of the 2 bones in the lower leg) with no displacement . Review of the Orthopedic Physician's Progress Note dated (MONTH) 7,2017 revealed, Please place a pillow or air support on the R (right) ankle, Ice 15 minutes trice a day, Rewrap Ace daily- no stretch . Review of the Nurse Practitioner's (NP) note dated 11/6/17 indicated, . Resident #4 had a fall this morning out of the Hoyer lift .she has some tenderness in (her) neck and shoulders when repositioned and her right ankle has some ecchymosis (bruising), [MEDICAL CONDITION] and tenderness to palpate. Review of the NP's note dated 11/7/17 revealed, .joint swelling ankle and joint tenderness ankle.

Based on facility policy, record review and interview, the facility failed to ensure a Certified Nurse Aide (CNA)followed the care plan for one (Resident #4) of eight sampled residents during a transfer with a mechanical lift. CNA #1 transferred Resident #4 using a mechanical lift without requesting the assistance of another staff member and without connecting the sling securely to the lift as instructed in the resident's care plan and Minimum Data Set (MDS) (an assessment tool for long term care). Review of the facility policy titled, Lift & Transfer Program revealed, Two trained persons are required to be present when using the lift. Resident #4 fell from the lift during a transfer and sustained a right leg fractured fibula and fractured cervical (neck) vertebrae at C1. Resulting in HARM. Findings Include: Medical record review revealed Resident #4 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS- An assessment tool used by long-term care facilities) dated 8/6/17 revealed Resident #4 required extensive assistance with all activities of daily living. Continued review of the MDS revealed during the assessment period, transfers occurred only once or twice requiring two-person physical assistance. Continued review of the MDS of Resident #4 revealed a BIMS (Brief Interview for Mental Status, range 0-15) score was 3, indicating the resident had severe cognitive impairment. Review of Resident #4 Care Plan with an initiation date of 4/9/18 revealed (Resident #4) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) immobility .Bed Bound.The nterventions, .Transfer, the resident required Mechanical Lift (full body lift and sling remains under pt (patient) with (2) staff assistance for transfers . Review of the undated MDS Kardex Report for (Name of Facility) indicated for the category, ADL Transfer: Support Two persons total lift. Continued review Accidents-Fall Risk revealed, Falls since admission or prior assessment. Review of facility investigation report for the fall that occurred for Resident #4 dated 11/6/17 at 10:00 AM revealed, Certified Nurse Assistant (CNA #1) Had been transferring (Resident #4) from bed to shower chair via Hoyer lift when one strap came loose from lift and patient (Resident #4) fell to floor, continue reviewed revealed strap not secured correct Further reviewed revealed CNA #1 did not have another staff helping her. During an interview with CNA #1 in the conference room on 4/9/18 at 2:30 PM, confirmed the facility policy was to use two nursing staff whenever a resident was transferred via the Hoyer lift. Continued review with CNA #1 confirmed the sitter was not to assist with the use of the Hoyer lift, since the sitter was not an employee of the facility. During an interview on 4/9/18 at 3:15 PM with CNA #2, and on 4/10/18 at 9:50 AM with CNA #3 in the facility's conference room, both confirmed the facility's policy was to use two nursing staff whenever a resident was transferred using the Hoyer lift. CNA #2 and CNA #3 both stated they were aware Resident #4 required two nursing staff to transfer her from the bed to the chair using the Hoyer lift. Both stated the sitter could not be asked to assist since she was not an employee of the facility and was not certified. Interview with the Director of Nursing (DON) on 4/10/18 at 12:215 PM in the Conference room, the DON confirmed that CNA #1 did not follow Resident #4's care plan as well as the MDS Kardex regarding the use of two staff persons when Resident #4 was transferred from the bed to the shower chair. The DON confirmed the facility policy directs the staff to use two staff persons whenever a resident is transferred per the Hoyer lift. Review of the facility policy Lift & Transfer Program revealed Two trained persons are required to be present when using the lift.

Based on review of facility policy, record review and interview, the facility's nursing staff failed to accurately document one of one (Resident #4) resident's condition after the resident experienced a fall with a [MEDICAL CONDITION] and C1 vertebrae of the neck during a transfer from the bed to the shower chair utilizing the Hoyer lift. After the fall, the resident experienced bruising and [MEDICAL CONDITION] of the right ankle, [MEDICAL CONDITION] to the right neck, and bruising of the left face. Resulting in Harm. Findings include: Review of a facility investigation for a fall that occurred for Resident #4 dated 11/6/17 at 10:00 AM revealed, Certified Nursing Assistant (CNA #1) had been transferring (Resident #4) from bed to shower chair via Hoyer lift (a mechanical device used to transfer) when one strap came loose from the lift and patient (Resident#4) fell to floor, when the strap was not secured correctly, CNA #1did not have another staff helping her. report dated 11/6/17 indicated, Results, there is a fracture involving distal fibula (one of the 2 bones in the lower leg) with no displacement . Review of the Orthopedic Physician's Progress Note dated (MONTH) 7, (YEAR) revealed, Please place a pillow or air support on the R (right) ankle, Ice 15 minutes trice a day, Rewrap Ace daily- no stretch . Review of the Nurse Practitioner's (NP) note dated 11/6/17 revealed . Resident #4 had a fall this morning out of the Hoyer lift .she has some tenderness in (her) neck and shoulders when repositioned and her right ankle has some ecchymosis (bruising), [MEDICAL CONDITION] and tenderness to palpate. Review of the NP's note dated 11/7/17 revealed, .joint swelling ankle and joint tenderness ankle. Review of the NP's note dated 11/10/17 revealed, .enlarged gland right submandibular (the neck area under the lower jaw); .tender. Review of the NP's note dated 11/13/17 revealed, .The patient also presents with ecchymosis. It is located on the face Left temporal region (the left side of the face near the eye) .The symptom is gradual in onset not observed on Friday (November 20, (YEAR)). Review of the SBAR (acronym for Situation, Background, Assessment, Recommendation) Form and Progress Note dated 11/6/17 09:47 AM and signed by Licensed Practical Nurse (LPN) #1 revealed, .Situation 1. The change in condition, symptoms or signs I am calling about is witnessed fall from Hoyer lift . There was no documentation regarding the right ankle fracture. Review of Progress Notes dated 11/6/17 at 11:15 AM revealed the nurse documented, Patient observed to have [MEDICAL CONDITION] and bruising to right ankle. Also, c/o (complaint of) back pain. Assessed by NP and STAT (immediate) x-rays ordered. Review of Progress Notes revealed Resident #4's injury was dated 11/8/17 at 8:38 AM revealed, When asked if any pain, Resident denies with shaking her head and drifts back to sleep. Fall on 11/6/17. No new bruising noted. Continued review of Progress Notes dated 11/9/17 at 12:55 PM indicated the nurse documented, .Ace wrap and ice completed . There was no documentation regarding the right ankle or the bruising. Review of the Skin-Head to Toe Skin Checks dated 11/9/17 at 10:04 AM revealed the nurse checked site left ankle and left wrist .no open area noted The Progress Notes dated 11/10/17 at 14:48 (2:48 PM) indicated the nurse documented the pain medication Resident #4 received. Documentation was lacking regarding the right ankle and the bruising as well as the [MEDICAL CONDITION] of the neck as noted by the NP's note dated 11/10/17. Review of the Progress Notes dated 11/13/17 at 17:35 (5:35 PM) revealed the resident was transported to the Baptist Hospital ER per ambulance. Further review of Progress Notes dated 11/14/17 revealed, (Resident #4) returned from the Baptist Hospital ER at 2320 (11:20 PM) per ambulance. Further review revealed there was no documentation of the [MEDICAL CONDITION] to the right side of Resident #4's face or the ecchymosis to the resident's left side of her face. Review of the Skin-Head to Toe Skin Checks document dated 11/16/17 10:04 AM indicated under 1. skin integrity the nurse checked 1c. Exiting Bruises and documented, .3. Site Left Ankle and left wrist .no open areas noted. Review of the Treatment Administration Record (TAR) for (MONTH) (YEAR) revealed an entry that read, Ace wrap one time a day for right ankle fx (fracture) rewrap ace daily- no stretch right ankle dated ordered 11/8/17. Continued review revealed the Ace wrap was rewrapped for the first time on 11/9/17 at 9:00 AM. Further review of the TAR revealed, Ice pack two times a day for Right ankle fracture .The order was dated 11/8/17 and the first treatment was completed 11/8/17 at 1700 (5:00 PM). Review of the (MONTH) (YEAR) TAR revealed no documentation of the description of the bruising of the right ankle or when the ace wrap was removed. During an interview with LPN #6 on 4/9/18 at 4:10 PM in the facility's conference room confirmed she failed to chart the [MEDICAL CONDITION] of Resident #4's face and neck as well as the bruising of Resident's #4's right foot. Continued interview of LPN #6 confirmed she failed to describe the color and size of the bruise. During an interview on 4/10/18 at 9:00 AM by telephone, LPN #7 stated she failed to document in Resident #4 progress notes the color and size of the bruise to Resident #4's right foot as well as the [MEDICAL CONDITION] to her face and neck. LPN #7 also stated that since Resident #4 had an ace wrap to her right ankle, and failed to document whether the resident's right foot was cold to the touch, the color of the toes, whether the ace wrap was to tight causing swelling above and below the ace wrap, whether she could palpate the pulse in the foot, and any new bruising with a description of each bruise as to color, size, and location. LPN #7 stated Resident #4 wore a hard neck collar that was not to be removed. LPN #7 stated that nursing staff washed the resident's neck under the collar. LPN #7 stated she failed to chart whether there was any swelling, redness, or bruising of the neck area for the part of the neck that she could visualize. Review of the facility's policy titled, Changes in Resident Condition dated (MONTH) (YEAR) indicated, Guidelines .4. The SBAR (an acronym for Situation, Background, Assessment, Recommendation to facilitate prompt and appropriate communication) Communication Form and the Progress Note are used to: a. Assess and document changes in condition in an efficient and effective manner b . Provide assessment information to the physician, and c. Provide clear comprehensive documentation . Review of the facility's policy titled, Documentation Guidelines dated 8/25/17 revealed .SBARS must be done for all Incidents/Falls, change in conditions, and if anyone is transferred out of the building . Review of the facility policy titled, Documentation dated (MONTH) (YEAR) indicated, Policy, Healthcare personnel will complete documentation as outlined below and will record in the medical record using accepted principles of documentation .Integrity, Aspects of resident care such as observation and assessments .and services or treatments performed must be documented in the medication record according to policy . During an Interview with the Director of Nursing DON) on 4/10/18 at 11:40 AM in the conference room, the Director of Nursing (DON) confirmed that the facility did not have a policy to follow regarding specific information to document regarding bruises, [MEDICAL CONDITION], and the use of the ace wrap. Continued interview revealed the DON instructs the nurses to refer to the Lippincott manual for professional nursing guidance regarding documentation.

Based on record review and interview, the facility failed to conduct yearly performance evaluations for one of one Certified Nurse Aide (CNA #1) personnel file reviewed. Findings include: Review of CNA #1's personnel file, on 4/10/18 at 11:30 AM, revealed CNA #1's date of hire was 6/23/08. The file contained a document titled, Resident Care Specialist Skill Inventory Checklist (Certified Nursing Assistant# 1), dated (YEAR). The document was incomplete in that the Skills, Demonstrated, Observed, Explained portion of the evaluation was not all evaluated. The document indicated that only 17 of the 39 check off boxes were dated as Met and contained the evaluator's initials. During the review of CNA #1's employee record, the only performance evaluation found in the file was dated 2010. This document was completed and signed by the employee and evaluator. Review of CNA #1's personnel file, on 4/10/18 at 11:30 AM, revealed CNA #1's date of hire was 6/23/08. The file contained a document titled, Resident Care Specialist Skill Inventory Checklist (Certified Nursing Assistant 1), dated (YEAR). The document was incomplete in that the Skills, Demonstrated, Observed, Explained portion of the evaluation was not all evaluated. The document indicated that only 17 of the 39 check off boxes were dated as Met and contained the evaluator's initials. During the review of CNA #1's employee record, the only performance evaluation found in the file was dated 2010. This document was completed and signed by the employee and evaluator. During an interview on 4/10/18 at 11:30 AM in the facility conference room, the Administrator confirmed that CNA #1 personnel file only completed annual performance evaluation was dated 2010. The Administrator, Director of Nursing and Area Staff Development Coordinator confirmed the (YEAR) performance evaluation was incomplete and the Employee and the Evaluator had not signed the document. During the interview on 4/10/18 at 11:30 AM in the facility's conference room, the Administrator stated that he has been the Administrator for the facility approximately one and a half years and that during this time he was aware that annual employee performance evaluations for all staff of the facility was not completed. The Administrator stated that he has not received an annual performance evaluation.

Based on facility policy review, facility document review, observation, and interview the facility failed to maintain a sanitary kitchen in 1 of 1 walk- in refrigerators, 1 of 1 walk-in freezers, 1 of 1 storage rooms and 1 of 1 nourishment rooms refrigerator and freezer affecting 34 out of 37 residents. The findings included: Review of the facility policy Food Storage Cold revised 5/2014, revealed, .The Food Services Director/Cook(s) insures (ensures) that all food items are stored properly in covered containers, labeled and dated . Review of the facility policy Food Storage Dry Goods revised 5/2014 revealed, .The Food services Director or designee ensures that all packaged and canned food items shall be kept clean, dry, and properly sealed . Review of the facility policy Environment revised 5/2014 revealed, .It is the center policy that all food preparation areas, food service areas, and dining area will be maintained in a clean and sanitary condition .The Food Service Director will insure (ensure) that a routine cleaning schedule is in place for all cooking equipment, food services areas and surfaces . Review of the facility documentation Nutrition Refrigeration Cleaning Daily Cleaning (Or as Needed) Weekly Deep Clean Sign Off revealed no documentation the nourishment room refrigerator and freezer was cleaned. Observation with the Regional Dietary Manager on 8/21/17 from 9:35 AM - 9:42 AM, of the walk in refrigerator, revealed: A) One 5 pound of yellow pasteurized process American sliced cheese approximately 160 slices opened to air and undated. B) Twenty 7 ounce (oz) cups of tea on a cart undated and unlabeled. C) One 8 oz cup of lemonade on a cart undated and unlabeled. D) Four 4 oz chocolate shakes on a cart undated. E) Four 4 oz vanilla shakes on a cart undated. F) Four thickened sweet teas 4-6 oz on a cart undated. G) Three 7 oz nectar thickened tea on a cart undated and unlabeled. H) One 8 oz nectar thickened water on a cart undated and unlabeled. I) One 6 oz nectar thickened milk on a cart undated, unlabeled and all items available for resident consumption. Observation with the Regional Dietary Manager on 8/21/17 at 9:46 AM of the walk-in freezer revealed: A) Ten 8 oz cups approximately 1/3- 1/2 full of ice with ice cystals on a tray on the shelf, opened to air and undated. B) 3 plastic bags of 2 pound white loaves of bread undated. C) 3 plastic bags containing 12 hot dog buns each undated. D) 1 bag of 4 pound vegetable blend 1/2 full opened to air, undated and all items available for resident consumption. Interview with the Regional Dietary Manager on 8/21/17 at 9:56 AM, in the kitchen, confirmed the facility failed to ensure all items were labeled, dated, and secured in the walk in refrigerator and the walk in freezer and were available for resident consumption. Observation with the Dietary Manager (DM) on 8/23/17 at 8:25 AM, of the walk in refrigerator in the kitchen, revealed: A) One 256 fluid oz plastic container of hamburger slice pickles opened to air. B) 17 slices of cheese open to air and all items available for resident consumption. Observation with the DM on 8/23/17 at 8:35 AM, of the storage room revealed: A) Approximately a 25-35 gallon plastic container of corn meal with black debris. Continued observation revealed the container was labeled cleaned 6/6/17 and filled 8/11/17. Interview with the DM on 8/23/17 at 8:42 AM, in the kitchen, confirmed the facility failed to secure items in the refrigerator and failed to maintain a clean food supply. Continued interview confirmed the plastic containers of food supply were scheduled to be cleaned every time it was filled and had not been cleaned since 6/6/17. Observation with the DM on 8/23/17 at 8:45 AM, of the nourishment room refrigerator and freezer, near the nursing station, revealed the refrigerator door was open with a temperature reading of 58 degrees. Continued observation revealed the following items: A) Nineteen 4 oz apple juices. B) 5 strawberry banana yogurts. C) 4 cartons of 1 cup whole milk. D) 6 vanilla 32 oz 2.0-med plus supplements. E) Four 46 oz thickened sweet teas. F) Three 5.3 oz black cherry yogurts. G) 4 peanut butter sandwiches. H) A plastic container containing a resident's takeout meal undated. I) Five 8 oz glucose shakes. J) 96 fluid oz of reduced fat milk. K) One 8 oz shake. L) A discharged resident's cotton and plastic lunch box containing two 8 oz Protein Shakes. Further observation revealed all items available for resident consumption. M) Brown/black dirt and debris in 2 drawers in the refrigerator. N) Brown debris and thickened black substances on the shelves in the freezer. Interview with the DM on 8/23/17 at 9:00 AM, in the nourishment room, located near the nursing station, confirmed the facility failed to maintain a sanitary nourishment room refrigerator and freezer by failure to ensure the refrigerator was closed after use and label food items. Continued interview confirmed the facility failed to clean the nourishment room refrigerator on a weekly basis and as needed. Further interview confirmed the facility failed to discard the resident's food in the refrigerator upon discharge. Interview with the DM on 8/23/17 at 9:20 AM, in the conference room, confirmed the DM stated .We haven't been cleaning the nourishment room refrigerator since I've worked here since January of this year .

Based on observation and interview, the facility failed to maintain sanitary storage of equipment in the kitchen in 1 of 2 kitchen observations made. The findings included: Observation and interview with the Dietary Manager on 9/12/16 at 10:10 AM, in the facility kitchen during the initial tour, revealed 3 quarter sized steam table pans with visable debris and 2 quarter sized steam table pans stored wet. Continued observation revealed the items were stored on a clean ready to use rack. Interview with the Dietary Manager confirmed the facility failed to maintain sanitary storage of kitchen equipment.

Based on facility policy review, medical record review, observation, and interview, the facility failed to communicate vital signs and any condition alert on the [MEDICAL TREATMENT] Communication Records for 1 resident (#104) of 2 residents receiving [MEDICAL TREATMENT] of 23 sampled residents. The findings included: Review of the facility policy, [MEDICAL TREATMENT], Care of Residents, revised date 6/2008 revealed .A [MEDICAL TREATMENT] Communication Record (Briggs) is initiated and sent to the [MEDICAL TREATMENT] center each appointment. Medical record review revealed Resident #104 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the [MEDICAL TREATMENT] Communication Records dated 8/10/15, 8/24/15, 8/26/15, and 9/7/15 revealed the section .Resident specific Pre-[MEDICAL TREATMENT] Information (Completed by Facility) Vital Signs.Condition Alert, Nurse Signature, (and) Date. had not been completed. Interview with the Assistant Director of Nursing on 9/10/15 at 12:30 PM, in the conference room, confirmed the facility failed to communicate vital signs and any condition alert on the [MEDICAL TREATMENT] Communication Records for a resident receiving [MEDICAL TREATMENT] services.

Based on medical record review and interview, the facility failed to develop an individualized comprehensive care plan that provided specific interventions to prevent the development of pressure ulcers and to treat existing pressure ulcers and failed to provide specific and individualized interventions to meet pain management needs for one (Resident #2) resident of 5 residents reviewed for pressure ulcers. The facility's failure to develop a comprehensive care plan resulted in actual harm to Resident #2. The findings included: Medical record review revealed Resident #2 was admitted on [DATE], readmitted on [DATE], and discharged on [DATE]. Continued medical record review revealed [DIAGNOSES REDACTED]. Medical record review of the resident's comprehensive care plan for pressure ulcers revealed an update on 8/8/14 to reflect a "Stage II left medial buttock"; update on 9/8/14 to reflect a "Stage II buttock"; update on 10/5/14 to reflect "unstageable right buttock with eschar"; update on 10/18/14 to reflect "right buttock with eschar - slough depth, undermining, foul odor 3.5 x 3.0 x 3.0 cm (centimeter)." Medical record review of the comprehensive care plan revealed interventions included: apply pressure reduction mattress to bed, apply pressure reduction cushion to chair, reposition in chair frequently for comfort and pressure reduction, turn and reposition while in bed frequently, provide incontinence care, measure and stage wound weekly using the pressure ulcer healing assessment form, complete a full body check weekly and document, pressure ulcer treatment as ordered. Medical record review of the resident's comprehensive care plan revealed no specific pressure ulcer interventions were provided on the care plan to treat existing pressure ulcers. Medical record review of a Head to Toe Skin Check dated 7/28/14 revealed documentation of an abrasion to the left buttock. Review of a facility Incident/Accident Report dated 8/8/14 revealed an injury of an "...open area on her left medial buttock/self inflicted abrasion..." Review of a facility Incident/Accident Report dated 9/8/14 revealed "...wound on left buttock has increased in size - worse in last few days." Review of the Weekly Pressure Ulcer QA&A dated 9/21/14 revealed Resident #2 had a Stage III pressure ulcer (1.4 x1 x 0.4) to the coccyx and a Stage II pressure ulcer (2.4 x 1.6 x 0.2) to the left buttock. Review of the Weekly Pressure Ulcer QA&A dated 9/28/14 revealed Resident #2 had a Stage III pressure ulcer (1.0 x 1.0 x 0.4) to the coccyx and a Stage II pressure ulcer (1.2 x 2.0 x 0.2) to the left buttock. Review of the Weekly Pressure Ulcer QA&A dated 10/6/14 revealed Resident #2 had a Stage III pressure ulcer (1.0 x 1.0 x 0.4) to the coccyx and a Stage II pressure ulcer (2.8 x 2.0 x 0.2) to the left buttock. Medical Record review of the Weekly Pressure Ulcer Record dated 9/26/14 revealed documentation of a pressure ulcer (2.4 x 1.6 x 0.2) to the right buttock "closest to outside" (no stage documented) and a Stage III pressure ulcer (1.4 x 1.0 x 0.4) to the right buttock "closest to inside". Medical record review of the Weekly Pressure Ulcer Record dated 10/5/14 revealed documentation of a pressure ulcer (1.7 x 1.5 x1) to the "coccyx closest to inside", "coccyx wound bed black in color" and a Stage II pressure ulcer (1.9 x 2.6 x 0.2) to the right buttock. Medical record review revealed Resident #2 was transferred to a local hospital on [DATE] due to "...suspected wound infection with foul odor, necrotic tissue, slough and purulent drainage." Review of the hospital medical record revealed the resident was admitted with a "stage III decubitus ulcer in pre-sacral area with tunneling and necrotic tissue...placed on a [DEVICE]" Interview with the Director of Nursing (DON) on 3/26/15 at 10:15 AM in the DON's office confirmed the Weekly Pressure Ulcer Record description of the resident's wounds and the description of the wounds on the resident's care plan were inconsistent. Medical record review of the resident's comprehensive care plan related to pain dated 4/17/14 and updated on 7/17/14 and 10/7/14 revealed interventions to provide scheduled pain meds, medicate resident for pain prior to treatments and therapy, if indicated, notify physician if interventions are not consistently effective, administer [MEDICATION NAME] as ordered and implement pain management flowsheet. Medical record review of a Medication Administration Record [REDACTED] [MEDICATION NAME]-Acetamin ([MEDICATION NAME]) 5mg (milligram)-325mg tablet ([MEDICATION NAME]) 1 tablet by mouth every 8 hours scheduled hold for sedation. Scheduled at 6:00 AM, 2:00 PM and 10:00 PM. ordered on [DATE]. [MEDICATION NAME]-[MEDICATION NAME] 7.5-325mg tablet ([MEDICATION NAME]) 1 tablet by mouth twice daily PRN (as needed for pain). Ordered 2/16/14.There was no documentation of the PRN medication on the MAR- a hand written note said "see pain flow sheet." [MEDICATION NAME] 650mg (2 tabs of 325 = 650mg) (Tylenol) (650mg) by mouth every 6 hours as needed pain (rated 1-5). Ordered 7/25/12. There was no documentation of the PRN medication on the MAR- a hand written note said "see pain flow sheet." Medical record review of the PRN (as needed) Pain MAR indicated [REDACTED]. There was no post administration documentation describing how effective the medication was or what the pain was rated after administration. Review of the MAR indicated [REDACTED]. There was no further documentation explaining why the resident did not receive her scheduled pain medication. There was no 8/2014 PRN Pain MAR provided by the facility. Review of the 9/2014 MAR indicated [REDACTED]. Medical record review of a Nurse's Notes dated 9/1/14 at 12:30 AM revealed "...resident lying in bed with complaint of pain while turning and repositioning. Wound to (L) (left) buttock cleaned and dressing applied..." No PRN pain medication provided. Continued review revealed an untimed, unsigned Nurse's Note dated 9/24/14 documented "...wound to (L) buttock cleaned and [MEDICATION NAME] dressing applied. Resident complained of pain and received scheduled pain medication..." No PRN pain medication was documented as given to the resident prior to wound care as ordered by the physician. Medical record review of a Weekly Pressure Ulcer Record dated 9/26/14 revealed "...Pt (patient) c/o (complained of) pain while dressing is being changed....Pt c/o (increased) pain when sitting up..." Medical record review of an Activities Progress Note dated 10/6/14 revealed "...not as alert...frequently yells out in pain when awake..." Medical record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/7/14 revealed the resident had received scheduled pain medication, and PRN (as needed) pain medication within the last 5 days, but had not received a non-medication intervention for pain. The resident experienced pain or hurting frequently and the pain had made it hard for her to sleep at night, and she was unable to answer if there were limitations in her day to day activities related to pain. The resident was unable to rate the pain on a 1-10 numeric scale. No further documentation regarding pain was noted on the MDS. An interview with the Director of Nursing and Administrator on 3/31/15 at 6:30 PM in the Conference Room confirmed the facility failed to develop a comprehensive care plan with specific interventions to prevent and treat existing pressure ulcers and accurately reflect the resident's pressure sore development, failed to develop a comprehensive care plan that provided specific and individualized interventions for pain management and resulted in actual harm to Resident #2.

Based on medical record review, observation, weekly pressure ulcer record review, interdisciplinary care conference attendance record review, and interview, the facility failed to obtain a physician's order for wound care treatment for 1 (Resident #3) residents of 7 residents reviewed, and failed to implement, and modify pain management interventions for 1 (Resident #2) resident of 7 residents reviewed for pain management resulting in the resident's inability to maintain and reach her highest practicable well being and causing actual harm to Resident #2. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE], was readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/14 revealed the resident was totally dependent requiring assistance from 2 people for transferring, dressing, toileting, personal hygiene and required assistance from 1 person for bathing. The resident required extensive assistance from 2 people for bed mobility and assistance from 1 person for eating. The resident was assessed to be frequently incontinent of urine and always incontinent of bowel. The resident was assessed to have been on scheduled pain medication, and had received PRN (as needed) pain medication over the last 5 days and had also received non-medication intervention for pain. The resident answered "yes" she had pain or hurting in the past 5 days but was unable to answer how often. The resident was unable to answer if her day to day activities were limited because of the pain. The location of the pain was documented as generalized joint pain caused by arthritis and [MEDICAL CONDITION]. The Pain Evaluation revealed rest, positioning and medication administration relieved the pain. The resident was unable to describe the quality of the pain. The manner of expressing pain symptoms documented verbalization, grimacing, groaning, and frowning. The Brief Interview for Mental Status (BIMS) scored the resident a 2 out of 15 signifying the resident was severely cognitively impaired. Medical record review of the comprehensive care plan dated 7/17/14 with a problem of potential Pain related to joint pain, chronic disease process, neuropathic pain and musculoskeletal documented Approaches of Positioning/support; Administer [MEDICATION NAME] as ordered; See physician orders; Implement pain management flowsheet; Observe resident for signs and symptoms of pain, including verbal expressions and nonverbal expressions (facial grimacing bracing, restlessness, rubbing, other) Frequency of monitoring QS (every shift); Notify physician if interventions are not consistently effective; Medicate resident for pain prior to treatments and therapy, if indicated; therapy referral as indicated. The care plan was updated on 10/7/14 with a problem of actual pain related to a skin ulcer/wound. A new intervention of "...scheduled pain meds (medications) was added at this time. Medical record review of a Medication Administration Record [REDACTED] [MEDICATION NAME]-Acetamin ([MEDICATION NAME]) 5mg (milligram)-325mg tablet ([MEDICATION NAME]) 1 tablet by mouth every 8 hours scheduled hold for sedation. Scheduled at 6:00 AM, 2:00 PM and 10:00 PM. ordered on [DATE] [MEDICATION NAME]-[MEDICATION NAME] 7.5-325mg tablet ([MEDICATION NAME]) 1 tablet by mouth twice daily as needed for pain. Ordered 2/16/14. There was no documentation of the PRN medication on the MAR- a hand written note said "see pain flow sheet." [MEDICATION NAME] 650mg (2 tabs of 325 = 650mg) (Tylenol) (650mg) by mouth every 6 hours as needed pain (rated 1-5). Ordered 7/25/12.There was no documentation of the PRN medication on the MAR- a hand written note said "see pain flow sheet." Medical record review of the PRN Pain MAR indicated [REDACTED]. There was no post administration documentation describing how effective the medication was or what the pain was rated after administration. The resident received another dose on 7/25 at 3:30 PM after facial grimaces of a "10" were observed. Review of the MAR indicated [REDACTED]. There was no further documentation explaining why the resident did not receive her scheduled pain medication. There was no 8/2014 PRN Pain MAR provided by the facility. Review of the 9/2014 MAR indicated [REDACTED]. Medical record review of a Nurse's Notes dated 9/1/14 at 12:30 AM revealed "...resident lying in bed with complaint of pain while turning and repositioning. Wound to (L) (left) buttock cleaned and dressing applied..." No PRN pain medication provided. Continued review revealed an untimed, unsigned Nurse's Note dated 9/24/14 documented "...wound to (L) buttock cleaned and [MEDICATION NAME] dressing applied. Resident complained of pain..." Medical record review of a Weekly Pressure Ulcer Record dated 9/26/14 revealed "...Pt (patient) c/o (complained of) pain while dressing is being changed...Pt c/o (increased) pain when sitting up..." Medical record review of an Activities Progress Note dated 10/6/14 revealed "...not as alert..frequently yells out in pain when awake..." Medical record review of the Quarterly MDS with an ARD of 10/7/14 revealed the resident had received scheduled pain medication, and PRN (as needed) pain medication within the last 5 days, but had not received a non-medication intervention for pain. The resident experienced pain or hurting frequently and the pain had made it hard for her to sleep at night, and she was unable to answer if there were limitations in her day to day activities related to pain. The resident was unable to rate the pain on a 1-10 numeric scale. Review of Nursing Progress note dated 10/13/14 at 4:09 PM revealed "...patient yelling while dressing changed..." Review of an Interdisciplinary Care Conference Attendance Record dated 10/16/14 revealed "...called son to inform of...wound decline and episodes of resident yelling out and pain..." Medical record review of a physicians order dated 10/18/14 revealed "...Foley cath (catheter) placement dx (diagnosis): intractable pain..." Medical record review of a Nursing Progress Note dated 10/19/14 at 10:24 PM revealed "...while...performed peri-care...resident noted to be crying..." Medical record review of the 10/2014 MAR indicated [REDACTED]. Medical record review of a physicians order dated 10/20/14 at 9:00 AM revealed "send to...ER (emergency room ) for evaluation of buttock wound-eschar/slough-foul odor, drainage-undermining-severe pain..." Review of an Interdisciplinary Care Conference Attendance Record dated 10/20/14 revealed "...called son (approx 11:45 AM)...informed him of uncontrollable pain during ADL's (Activities of Daily Living) and dressing changes..." Interview with the Director of Nursing (DON) and the Administrator on 3/31/15 at 6:30 PM in the conference room confirmed Resident #2 had severe pain related to pressures ulcers during repositioning, peri-care, dressing changes, and all ADL's. The facility failed to administer scheduled pain medication 2 times in August and 2 times in September. The facility documented the resident's pain worsened beginning 9/1/14 during peri-care and failed to administer PRN medications. The resident was incontinent of bladder and bowel and had a Stage II pressure ulcer to the buttock documented on 9/8/14 and a Stage III pressure ulcer to the coccyx documented on 9/28/14. an order for [REDACTED]. or maintain her highest well being. The facility failed to notify the physician in a timely manner the current pain management plan was not consistently effective, thus resulting in actual harm to Resident #2. Medical record review of Resident #3 revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician's Orders dated 3/9/15 revealed "...Right outer calf... Cleanse with warm water and soap, pat dry and cover with [MEDICATION NAME] (an absorbant dressing) QOD (every other day) and PRN (as needed)for soiling..." Observation of wound care treatment on 03/19/15 at 1:40 PM in the Resident's room revealed LPN #2 applied Calcium Alginate (an absorbant medication) to the wound. Interview with LPN #2 on 3/19/15 1:46 PM in the resident's room when asked what was placed on the wound, LPN #2 stated "Calcium Alginate. I don't have an order for [REDACTED]. Interview with the DON on 3/19/15 at 3:00 PM in the DON's office, when asked about the absence of orders for Calcium Alginate, the DON confirmed there were no physician's orders for Calcium Aginate and stated "You must have a Physician's Order before applying it."

Based on medical record review, facility policy review, review of facility Incident/Accident reports, Weekly Pressure Ulcer Logs, and interview, the facility failed to prevent, implement, monitor, and provide the necessary treatment for [REDACTED].#1, Resident #6) residents of 5 residents reviewed. The failure of the facility to prevent and provide care to treat pressures ulcers resulted in actual harm to 2 (Resident #2, Resident #5) residents of 5 residents reviewed with pressure ulcers. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE], was readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of the Skin Management facility policy with a revision date of 8/12 revealed "...Residents who are at risk or with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes..." Further review revealed for bed bound residents "...Avoid positioning a resident directly on a pressure ulcer whenever possible...Use positioning devices. Devices should be used to completely raise the pressure sore area...off of the support surface...Establish an individualized turning schedule based on the resident's clinical condition...Assess for risk of developing additional ulcers..." Medical record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/14 revealed the resident was totally dependent requiring assistance from 2 people for transferring, dressing, toileting, personal hygiene and required assistance from 1 person for bathing. The resident required extensive assistance from 2 people for bed mobility and assistance from 1 person for eating. The resident was assessed to be frequently incontinent of urine and always incontinent of bowel. The Brief Interview for Mental Status (BIMS) scored the resident a 2 out of 15 signifying the resident was severely cognitively impaired. Review of the Braden Scale for Predicting Pressure Sore Risk dated 7/11/14 scored the resident an "11". A total score of 12 or less represents high risk. Risk factors included; Constantly moist; Chairfast; Completely Immobile;and a Friction and Shear problem. Medical record review of the resident's comprehensive care plan revealed a problem of an actual pressure ulcer on 8/8/14 related to moisture/incontinence, impaired mobility and a friction and shear problem, and described as "...self inflicted scratch/abrasion Stage II (L) (left) medial buttock..." Interventions included; apply pressure reduction mattress to bed; apply pressure reduction cushion to chair; reposition in chair frequently for comfort and pressure reduction; turn and reposition while in bed frequently for comfort and pressure reduction; provide incontinence care after each incontinent episode; measure and stage wound weekly using the pressure ulcer healing assessment form, complete a full body check weekly and document; monitor lab values as ordered; Registered Dietitian referral; pressure ulcer treatment as ordered. The care plan was updated 9/8/14 with a problem of a Stage II buttock ulcer, and again on 10/5/14 with a problem of an unstageable (R) (right) buttock c (with) eschar. The interventions remained the same as were present on 8/8/14. The care plan was updated on 10/18/14 with an actual pressure ulcer to "...(R) buttock c (with)eschar-slough, depth, undermining, foul odor..." the measurements were 3.5 x 3.0 x 3.0 cm (centimeters). The interventions remain the same with the addition of "...NP (Nurse Practitioner) referral to be seen 10/19/14 for (changes) in house..." Medical record review of a physician's orders [REDACTED]. Review of a facility Incident/Accident Report dated 8/8/14 revealed an injury of an "...open area on her left medial buttock/self inflicted abrasion..." The Summary of Investigation documented "...wound appears to be a scratch...has long hard nails...noted with thick lengthy nails and scratches often..." Past Interventions Attempted documented N/A (not applicable). Recommendations/New Interventions included; "...trim resident's nails; apply skin barrier to buttocks after incontinence; treatments as ordered; observe area for increase in size, odor, pain, drainage, Notify MD/NP..." The measurement of the wound was documented as 1 x 0.2 cm of sheared skin. Medical record review of a TAR dated 8/1-8/31/14 revealed an order dated 8/8/14 to "...apply [MEDICATION NAME] (highly absorbent dressing) to left medial buttock q (every) 3 days and PRN (as needed)..." There was no documentation of wound care to the left medial buttock on 8/14, 8/17, 8/20 or 8/29. There was no documentation the weekly skin assessments were completed on 8/4, 8/11, or 8/18. The resident went 11 consecutive days without any wound care or a skin assessment from 8/12-8/23/14. Review of a facility Incident/Accident Report dated 9/8/14 revealed an injury documented as "...wound on left buttock has increased..." The description of the situation documented "...wound from a scratch on left buttock...increased in size...measures...2.2 cm x 3.6 cm no depth..." The Summary of Investigation documented "...noted followup stage 2 next to self inflicted abrasion..." The Past Interventions Attempted documented "[MEDICATION NAME] was being applied q 3 days after being clean (with) W/C (wound cleaner). Recommendations/New Interventions included; "...Clean (with) W/C, pat dry, apply thera-honey and cover (with) [MEDICATION NAME] every Mon, Wed & Friday & PRN; Resident placed on air mattress 9/9/14..." Review of a Weekly Pressure Ulcer QA&A Log dated for the week of 9/28/14 revealed the resident had a Stage II pressure ulcer to the left buttock measuring 1.2 x 2.0 x 0.2 with no odor but positive for drainage. There was also a Stage III pressure ulcer to the coccyx measuring 1.0 x 1.0 x 0.4 with no odor but positive for drainage. Medical record review of a TAR dated 9/1-9/30/14 revealed the weekly skin assessments were not documented as completed on 9/6, 9/13 or 9/26/14. Medical record review of a Weekly Pressure Ulcer Record dated 10/5/14 revealed Wound #1 to the "...coccyx closest to inside..." as an unstageable pressure ulcer measuring 1.7 x 1.5 x 1 cm. There was no exudate, the wound bed was black. Wound #2 was located on the "...(R) buttock outter area...", was a Stage II pressure ulcer measuring 1.9 x 2.6 x .2 with a scant amount of serous exudate. LPN #6 documented "...Sm. (small) amt. (amount) yellow slough (upper) (R) corner.." Medical record review of a TAR dated 10/1-10/31/14 revealed the weekly skin assessments were not documented as completed on 10/6 or 10/13/15. A physician's orders [REDACTED].@ (at) coccyx (with) W/C, apply Santyl (medicine that removes dead tissue from wounds) to wound bed, pack (with) [MEDICATION NAME] rope (alginate wound dressing that absorbs moderate to heavy drainage), cover (with) [MEDICATION NAME]" was not documented as completed on 10/16/14. Continuation of the order to "...Cleanse (R) buttock outer area (with) W/C apply hydrogel (helps create and maintain a moist environment) and cover daily and PRN..." was not documented as completed on 10/16 and 10/18/14. Medical record review of a physicians order dated 10/20/14 revealed "...Send to...ER (emergency room ) for evaluation of buttock wound-eschar/slough-foul, drainage-undermining...evaluation for debridement potential..." Interview with the DON on 3/18/15 at 4:00 PM in the DON's office confirmed the staff nurses had been responsible for assessing and documenting weekly skin assessments on their assigned residents, and documenting the Weekly Pressure Ulcer Record when a resident was known to have a pressure ulcer. The DON stated, "The nurses don't know how to stage a wound...we need a consistent treatment nurse." Interview with the DON on 3/30/15 at 4:00 PM in the conference room confirmed the weekly Head to Toe Skin Checks should be completed on all residents. Continued interview confirmed the assessments were not completed as ordered. Interview with LPN #1 on 3/31/15 at 1:10 PM in the conference room confirmed the Head to Toe Skin Check sheet was to be completed upon admission and weekly thereafter on all residents whether they had a wound or not. Continued interview confirmed the weekly Head to Toe Skin Check was also to be documented on the MAR on a weekly basis for those residents that had wounds, or as ordered by the physician. Interview with RN #1 on 3/31/15 at 1:50 PM in the conference room confirmed Resident #2 was bed and chair bound and was dependent on staff for her care and mobility. The RN confirmed seeing the resident frequently laying in a geri-chair in a reclined position slumped to one side or the other. Interview with the DON on 3/31/15 at 6:30 PM in the conference room confirmed Resident #2 did not receive weekly Head to Toe Skin assessments as ordered. The DON confirmed there was no documentation on 8/4, 8/11, 8/18, 9/8, 9/15, 9/22 or 9/29/14 the resident received a Head to Toe Skin check. Continued interview with the DON confirmed the resident had a documented injury of a self-inflicted abrasion to her left medial buttock measuring 1 x 0.2 cm due to "...long hard nails...scratches often..." The DON confirmed the Past Interventions Attempted documented "N/A" was not correct, as the injury on 7/8/14 interventions included to trim the residents nails. The DON confirmed there was no documentation the residents nails had been trimmed after the injury on 7/8/14 or the injury on 8/8/14. Continued interview confirmed the resident was to receive wound care to the left medial buttock every 3 days and PRN and there was no documentation the resident received wound care on 8/14, 8/17, 8/20, or 8/29/14. The DON confirmed the wound to the left buttock had increased to 2.2 x 3.6 cm as documented on 9/8/14 and was now a Stage II pressure ulcer. The DON confirmed by 9/28/14 the resident was documented to have 2 pressure ulcers; the Stage II to the left buttock and a Stage III to the coccyx measuring 1.0 x 1.0 x 0.4; by 10/5/14 the Stage II pressure ulcer to the buttock measured 1.9 x 2.6 x 0.2 cm and the coccyx pressure ulcer measured 3.5 x 3.0 x 3cm, was unstageable, and the wound bed was black. The DON confirmed new treatment orders to both of these wounds was ordered on [DATE], and there was no documentation the resident received pressure ulcer treatment to the coccyx on 10/16/14 and no pressure ulcer treatment was received to the buttock on 10/16 or 10/18/14. Continued interview with the DON confirmed the resident was transferred to "...ER (emergency room ) for evaluation of buttock wound-eschar/slough-foul odor, drainage-undermining...evaluation for debridement potential..." on 10/20/14. Continued interview with the DON confirmed as a result of the facility's failure to trim the residents nails, missed skin assessments, and pressure ulcer treatment not completed as ordered, Resident #2 suffered actual harm as the facility failed to prevent and treat a scratch to the buttock measuring 1 x 0.2 cm on 8/8/14 which developed into a Stage II pressure ulcer by 10/5/14 measuring 1.9 x 2.6 x 0.2 cm; a second pressure ulcer to the coccyx developed on 9/28/14 as a Stage III and increased to an unstageable pressure ulcer with eschar, foul odor, drainage and undermining measuring 1.7 x 1.5 x 1 cm by 10/5/14 and increasing to 3.5 x 3.0 x 3.0 cm by 10/18/14. The resident had to be sent to theER on [DATE] for evaluation and treatment of [REDACTED].#2. Medical record review of Resident #5 revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Care Plan initiated 12/2/14 and revised on 3/5/15 revealed "...has potential/actual skin issues... Provide wound care/preventative skin care per order (initiated 12/2/14)...Treatment as ordered (initiated 3/5/15)..." Medical record review of Nursing Admission Data Collection dated 2/19/15 revealed " ...Skin Assessment: Coccyx, Skin Shearing, 7 x 2 cm; Right Trochanter (hip), Surgical Incision, 30 x 1 cm...Left Heel, Pressure, 3 x 2 cm, Unstageable... " Medical record review of Wound Care Specialist Initial Evaluation dated 2/27/15 revealed "...Stage III Pressure Wound on the Left, Medial Buttock..." Medical record review of the physician's orders [REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the 2/2015 and 3/2015 TAR revealed pressure ulcer treatment to the left sacrum was not documented on 2/28, 3/1, 3/2, 3/3 and 3/11/15. Medical record review of the Skin-Head to Toe Skin Checks dated 2/26/15 revealed "... Sacrum, Pressure, 3.5cm x 4.5cm, depth 0.3cm, Stage III..." Medical record review of the Nursing Initial Plan of Care with an admitted 2/19/15 revealed "...has potential/actual skin issues...Interventions: Treatments as ordered..." Interview with LPN # 3 on 3/30/15 at 11:15 AM in the conference room, when asked why the LPN did not call the physician on 2/19/15 to obtain orders for wound treatment, the LPN stated, "I didn't know I was supposed to get orders and put them in the computer." Interview with LPN # 1 on 3/31/15 at 1:10 PM in the Conference Room revealed "The initial assessment is completed within the first couple of hours. The Assistant Director of Nursing (ADON) puts in the orders and we double check them. The Nurses are responsible for checking the orders. We call the hospital, if needed, for other orders or call the doctor." Interview with the DON on 3/31/15 at 6:00 PM in the Conference Room confirmed that Resident #5 had no pressure ulcer treatment orders from date of admission 2/19/15 until 2/27/15 when seen by the wound care specialist and then was assessed to have a Stage III pressure ulcer to the left medial buttock. Continued interview confirmed by not obtaining and implementing physician orders [REDACTED].#5. Medical record review revealed Resident #1 was admitted to the facility on [DATE], discharged to the hospital on [DATE], re-admitted on [DATE] and discharged back to the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/12/15 documented the resident required extensive assistance from 2 people for bed mobility and transfers, assistance from 1 person for dressing, eating, toileting, and personal hygiene, and was totally dependent for bathing. Medical record review of the Nursing Initial Plan of Care, effective date 2/27/15 and signed on 3/11/15 revealed, "...Potential/Actual Skin Issues related to: Pressure Ulcer related to Incontinence, pressure ulcer to sacrum with treatment in place..." Interventions include "...provide wound care/preventative skin care per order; Skin checks weekly per facility protocol, document findings; Notify MD of changes in wound or emerging wounds; Turn and reposition frequently to decrease pressure...try/dry and provide pericare q2h (every 2 hours) and prn for incontinence..." Medical record review of a Weekly Pressure Ulcer Record dated 2/28/15 completed by LPN #3 revealed the existence of a pressure ulcer to the left gluteal fold measuring 7 x .5 cm and described as "...blood filled blister to left gluteal fold. Unopen..." Medical record review of a Nursing Admission Data Collection assessment with an effective date of 3/5/15 completed by LPN #2 revealed the presence of moisture on a coccyx wound measuring 7 x 10.2 cm. Continued review revealed "...coccyx irregular shape (butterfly shape) thin layer of skin peeling, area red, small area yellow slough at 9 o'clock..." Review of the Wound Care Specialist Initial Evaluation notes dated 3/5/15 revealed an unstageable (due to necrosis) pressure ulcer of the sacrum measuring 6 x 8 x 0.3 cm. The wound was 30% yellow necrotic tissue, 20% granulation tissue and 50% skin. The assessment and plan included "...Santyl (wound medication)-Every Two Days and PRN, [MEDICATION NAME] (dressing)-Every Two Days and PRN with follow-up within 7 days. The facility could not produce any additional follow-up notes from the Wound Care Specialist after 3/5/15. Medical record review of the TAR dated 3/1/15- 3/31/15 revealed a verbal order for "...Santyl Ointment 250 UNIT/GM (gram) ([MEDICATION NAME]) Apply to Sacral Wound topically every day shift every other day for Sacral wound Cleanse with WC (wound cleaner), pat dry, cover wound boarder with Sureprep (wound treatment), apply Santyl (wound bed only), cover with [MEDICATION NAME] dressing, and change QOD (every other day) and PRN for soiling..." The order date was 3/6/15. Continued review revealed no documentation for wound care/treatment was noted on 3/7, 3/9, or 3/11/15. Interview with the DON on 3/31/15 at 5:20 PM in the conference room confirmed Resident #1 had a physician's orders [REDACTED]. The DON also acknowledged the inconsistencies in the assessments of the resident's wound regarding location i.e., left gluteal fold versus coccyx versus sacrum; the measurements of the wound upon admission i.e., 7 x 10.2 versus 6 x 8 x 0.3; the difference in descriptions i.e., butterfly shape, red, peeling skin versus unstageable due to necrosis. Medical record review of Resident #6 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Nursing Admission Data Collection dated 3/12/15 revealed "... Skin Assessment ...Right Buttock, Abrasion; Left Buttock, Abrasion; Right Thigh (rear), Surgical Incision; Right Ankle (outer), Bruising, 3.0 x 1.5 (cm); Right Heel, Pressure, 3.5 x 4.8 (cm), Unstageable; Left Heel, Pressure, 1.5 x 2.5 (cm), Unstageable..." Medical record review of MDS dated [DATE] revealed the resident requires extensive assistance of 2 or more people for turning and positioning. Further review of the MDS revealed the resident had 1 Stage II Pressure Ulcer, 1 Stage III Pressure Ulcer and 2 unstageable Pressure Ulcers upon admission to the facility. Medical record review of the TAR dated 3/2015 revealed "...Right and Left Heel ...Sureprep QD and PRN ...Right Buttock ...Cleanse with WC, pat dry, apply Alginate Cover with Dry Dressing and change QD..." Medical record review of Head to Toe Skin Checks dated 3/19/15 revealed "...Right Buttock, Pressure, 0.5 x 0.5 (cm)...Right Heel , Pressure, 1.7 x 3.0 (cm), Unstageable, Left Heel, Pressure, 1.6 x 2.7 (cm), Unstageable..." Medical record review of Skin-Head to Toe Skin Checks dated 3/26/15 revealed "..Right Buttock, Pressure, 0x 0 (cm), depth 0 (cm)...Right Heel , Pressure, 3.0 x 4.0 (cm), Unstageable, Left Heel, Pressure, 1.6 x 2.7 (cm), Unstageable..." Medical record review of Nursing Initial Plan of Care dated 3/12/15 revealed "...has potential/actual skin issues...Interventions: ...Skin checks weekly per facility protocol ...Turn and reposition frequently to decrease pressure...." Medical record review of Care Plan dated 3/27/15 revealed "...admitted with several pressure ulcers ...Stage III Right Buttock and unstageable to Bilateral (both) Heels... Administer treatment as ordered and observe for effectiveness..." Medical record review of TAR dated 3/1/15-3/31/15 revealed pressure uilcer treatment to the right and left heels was not documented on 3/17/15 and 3/19/15. Medical record review of TAR dated 3/1/15-3/31/15 revealed pressure uilcer treatment to the right buttock was not documentedon 3/17/15 and 3/19/15. Interview with the DON on 03/18/15 at 11:40 AM in the DON's office, when asked about missing documentation on the TARS, the DON stated, "Blanks on the MAR or TAR were missed or not done." Interview with the DON on 3/19/15 at 3:00 PM in the DON's office, when asked about presure ulcer and infection control competency evaluations for nurses, the DON stated, "We have none. We expect nurses to use their basic nursing knowledge."

Based on medical record review, review of the weekly pressure ulcer log, and interview the facility failed to maintain accurate, complete clinical records for 5 (Resident #1, Resident #2, Resident #3, Resident #5 and Resident #6) of 7 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE], discharged to the hospital on [DATE], re-admitted on [DATE] and discharged back to the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the facility policy Physician Orders with a revision date of 9/11 revealed "...Physician orders are obtained to provide clear direction regarding the care of the resident...Discipline-specific treatment orders can be written by a licensed health care professional, but must be counter-initialed and dated by a licensed nurse acknowledging receipt and notification of the physician..." Medical record review of the Treatment Administration Record (TAR) dated 3/1/15- 3/31/15 revealed a verbal order dated 3/6/15 for "...Santyl (wound medication) Ointment 250 UNIT/GM (gram) ([MEDICATION NAME]) Apply to Sacral Wound topically every day shift every other day for Sacral wound Cleanse with WC (wound cleaner), pat dry, cover wound boarder with Sureprep (wound treatment), apply Santyl (wound bed only), cover with [MEDICATION NAME] dressing, and change QOD (every other day) and PRN (as needed) for soiling..." Continued review revealed no documentation for wound care/ pressure ulcer treatment was noted on 3/7, 3/9, or 3/11/15. The notation for 3/9/15 revealed "...3=Hold due to Condition..." No documentation as to what the "condition" was which warranted holding the wound treatment could be found. Medical record review of the Nursing Daily Skilled Charting dated 3/7, 3/10, and 3/16/15 revealed no documentation regarding skin changes to the resident and a "No" was marked for any changes in the resident's Skin Integrity. There were no Nursing Daily Skilled Charting notes for 3/6, 3/8, 3/9, 3/11, 3/12, 3/13, 3/14 and 3/15/15 for the resident. Review of the Weekly Pressure Ulcer QA & A Log for the week of 3/5/15 revealed the resident had an unstageable pressure ulcer of the sacrum measuring 6 x 8 x 0.3 cm and was being treated with Santyl and a [MEDICATION NAME] dressing. The week of 3/13/15 documented the resident had an unstageable cluster pressure ulcer to the sacrum measuring 6 x 7.5 x 0.3 and was being treated with Santyl and a [MEDICATION NAME] dressing QOD. The log contained no initials or signature of the person documenting the wound site, staging, size and treatment. Interview with LPN #3 on 3/30/14 at 2:55 PM in the conference room confirmed the process for obtaining and transcribing orders from the Wound Care Specialist as follows: This nurse rounds with the physician once a week on Thursdays to each resident noted to have a wound. The physician describes, measures, stages and treats the wound, and gives a verbal order and the nurse records it on her own piece of paper. She then reviews it with the physician after rounds are completed and re-writes it onto the Weekly Pressure Ulcer QA & A Log or the Weekly Non-Pressure Ulcer QA & A Log. From there she enters each treatment order into the computer, prints a copy to be faxed to the pharmacy and another copy for the physician to sign the next week when he rounds again. The LPN confirmed there was no hand written verbal order to read back, note off, or have checked by another nurse and kept as permanent documentation in the resident's medical record. Interview with the DON on 3/31/15 at 5:20 PM in the conference room confirmed Resident #1 had a physician's order for pressure ulcer treatment dated 3/6/15 and no treatment was documented until 3/13/15. The DON also acknowledged the inconsistencies in the documentation of the resident's pressure ulcer regarding location i.e., left gluteal fold versus coccyx versus sacrum; the measurements of the wound upon admission i.e., 7 x 10.2cm versus 6 x 8 x 0.3 cm ; the difference in descriptions i.e., butterfly shape, red, peeling skin versus unstageable due to necrosis. Further interview with the DON confirmed the absence of the Nursing Daily Skilled Charting notes for 8 of the 12 days the resident was in the facility, as well as the incomplete charting under the skin section of the daily assessment on 3/7, 3/10, and 3/16/15. Further interview confirmed the same process that LPN #3 described in obtaining and transcribing treatment orders from the Wound Care Specialist. The DON stated, "You don't have to write down a verbal order anymore, you can just type it right into the computer." Medical record review revealed Resident #2 was admitted on [DATE], readmitted on [DATE], and discharged on [DATE]. Continued medical record review revealed [DIAGNOSES REDACTED]. Medical record review of the resident's care plan for pressure ulcers dated 4/17/14 and updated 7/17/14, 10/6/14 and 10/18/14 revealed an approach to "complete a full body check weekly and document." Continued medical record review of the weekly Head to Toe Skin Checks revealed that on the following weeks for 1/2014 through 10/2014 Head to Toe Skin Checks were not completed: 2/5/14, 2/19/14, 2/26/14, 3/5/14, 3/12/14, 5/28/14, 7/14/14, 8/4/14, 8/11/14, 8/18/14, 9/8/14, 9/15/14, 9/22/14, 10/13/14, and 10/20/14. Medical record review of a Head to Toe Skin Check dated 7/28/14 revealed documentation of an abrasion to the left buttock. Review of a facility Incident/Accident Report dated 8/8/14 revealed an injury of "...open area on her left medial buttock/self inflicted abrasion..." Review of a facility Incident/Accident Report dated 9/8/14 revealed "...wound on left buttock has increased in size - worse in last few days." Review of the Weekly Pressure Ulcer QA&A dated 9/21/14 revealed Resident #2 had a Stage III pressure ulcer to the coccyx measuring 1.4 x 1 x 0.4 cm and a Stage II pressure ulcer to the left buttock measuring 2.4 x 1.6 x 0.2 cm. Review of the Weekly Pressure Ulcer QA&A dated 9/28/14 revealed Resident #2 had a Stage III pressure ulcerto the coccyx measuring 1.0 x 1.0 x 0.4 cm and a Stage II pressure ulcer to the left buttock measuring 1.2 x 2.0 x 0.2 cm. Review of the Weekly Pressure Ulcer QA&A dated 10/6/14 revealed Resident #2 had a Stage III pressure ulcerto the coccyx measuring 1.0 x 1.0 x 0.4 cm and a Stage II pressure ulcer to the left buttock measuring 2.8 x 2.0 x 0.2 cm. Medical record review of the Weekly Pressure Ulcer Record dated 9/26/14 revealed documentation of a pressure ulcer to the right buttock ("closest to outside")measuring 2.4 x 1.6 x 0.2 cm (no stage documented) and a Stage III pressure ulcer to the right buttock (closest to inside) measuring 1.4 x 1.0 x 0.4 cm. Medical record review of the Weekly Pressure Ulcer Record dated 10/5/14 revealed documentation of a pressure ulcer to the "coccyx (closest to inside)" measuring 1.7 x 1.5 x1 cm, "coccyx wound bed black in color" and a Stage II pressure ulcer to the right buttock measuring 1.9 x 2.6 x 0.2 cm. Interview with the Director of Nursing (DON) on 3/29/15 at 10:15 AM in the DON's office, the DON confirmed the Weekly Pressure Ulcer Record description of the resident's wounds and the description of the wounds on the resident's care plan were inconsistent. Medical record review of the Weekly Head to Toe Skin checks revealed no skin checks were completed on Resident #2 after 8/2014. Continued review revealed no Weekly Pressure Ulcer Record documentation for pressure ulcers for the weeks of 8/18, 8/22, 8/29, 9/5, 9/12, 9/19, and 10/13/14 after the resident was identified to have a pressure ulcer on 8/8/14. Review of the Weekly Pressure Ulcer QA&A reports revealed weekly reports were not completed for Resident #2 after 10/6/14. Medical record review of the resident's care plan for pressure ulcers revealed an update on 8/8/14 to reflect a "...Stage II left medial buttock..."; update on 9/8/14 to reflect a "...Stage II buttock..."; update on 10/5/14 to reflect "...unstageable right buttock with eschar..."; update on 10/18/14 to reflect "...right buttock with eschar - slough depth, undermining, foul odor 3.5 x 3.0 x 3.0 cm..." Medical record review of the 8/2014 TAR revealed an order to "...apply [MEDICATION NAME] to left medial buttock every 3 days..." Continued review of the TAR revealed pressure ulcer treatments were not documented on the following dates: 8/14, 8/17, 8/20, and 8/29/14. Medical record review of the 9/2014 TAR revealed an order to "...apply [MEDICATION NAME] to left medial buttock every 3 days..." Continued review of the TAR revealed pressure ulcer treatments were not documented on the following dates: 9/10, 9/13, and 9/16/14. Medical record review of physician's orders on 9/26/14 revealed an order to "...clean wound on buttock with wound cleaner, pat dry, apply Thera Honey and cover with [MEDICATION NAME]" every 3 days. There was no documentation on the 9/2014 TAR of this pressure ulcer treatment being administered. Medical record review of the 10/2014 TAR revealed a treatment to "...cleanse inner area at coccyx with wound cleaner, apply Santyl to wound bed and pack with [MEDICATION NAME] rope, cover with [MEDICATION NAME]" Continued review of the TAR revealed pressure ulcer treatment was not documented on 10/16/14. Review of the 10/2014 TAR revealed a treatment to "...cleanse outer area right buttock with wound cleaner, apply hydrogel and cover daily..." Continued review of the TAR revealed pressure ulcer treatments were not documented on 10/16 and 10/19/14. Interview with the DON on 3/31/14 at 6:30 PM in the conference room confirmed wound treatments were not provided as ordered by the physician. Medical record review of Resident #3 revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a TAR entry dated 3/9/15 revealed "...Right outer thigh (donor site), outer calf, Cleanse with warm water and soap, pat dry and cover with [MEDICATION NAME] QOD (every other day)and PRN for soiling...Cover all scabbed areas (Healing Deep Tissue Injuries) on heel and toes with Sureprep (a skin protectant) BID (twice daily)..." Medical record review of a TAR dated 3/1/15-3/31/15 revealed "...Healing Deep Tissue Injury (DTI), cover scabbed areas on heel and toes with Sureprep BID. Continued review of the TAR dated revealed pressure ulcer treatment to the "heel and toes" was not documented on 3/6, 3/7 and 3/10/15. Interview with the DON on 3/18/15 at 11:40 AM in the DON's office confirmed blanks on the TAR were missing pressure ulcer treatment documentation. and the DON stated, "I looked for...documentation and was unable to find it...there is an issue with documentation." Medical record review of Resident #5 revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Admission Data Collection dated 2/19/15 revealed "...Skin Assessment: Coccyx, Skin Shearing, 7 x 2 (cm); Right Trochanter (hip), Surgical Incision, 30 x 1 (cm) ...Left Heel, Pressure, 3 x 2 (cm), Unstageable..." Medical record review of a physician's order dated 2/27/15 revealed "...Left heel... Cleanse with wound cleaner, pat dry, apply SurePrep (skin protectant) to wound borders, apply Santyl (topical ointment aids in wound healing) to wound bed only and cover with dry dressing QOD (every other day) and PRN..." Review of a physician's order dated 2/27/15 revealed "...Sacrum...Cleanse with wound cleaner, pat dry, apply SurePrep to wound borders, apply Santyl to wound bed only and cover with dry dressing QOD and PRN..." Medical record review of a physician's order dated 3/3/15/15 revealed "...Right Hip ...Cleanse with wound cleaner, pat dry, coat staple line with sure prep and cover with long boarder gauze QD (every day) and PRN for soiling ..." Review of a physician's order dated 3/3/15 revealed "...Left Heel ...Cleanse with wound cleaner, pat dry, apply sure prep to wound borders, apply Santyl to wound bed only, apply Alginate (an absorbent wound dressing), and cover with dry dressing (not foam) QOD and PRN for soiling..." Medical record review of a TAR dated 2/1/15-2/28/15 revealed pressure ulcer treatment to the left heel was not documented on 2/28/15. Review of a TAR dated 2/1/15-2/28/15 revealed pressure ulcer treatment to the left sacrum was not documented on 2/28/15. Medical record review of a TAR dated 3/1/15-3/31/15 revealed pressure ulcer treatment to the left heel was not documented on 3/10/15 and 3/21/15. Review of a TAR dated 3/1/15-3/31/15 revealed pressure ulcer treatment to the left sacrum was not documented on 3/1, 3/2, 3/3, 3/4 and 3/11/15. Review of TAR dated 3/1/15-3/31/15 revealed pressure ulcer treatment to the right hip was not documented on 3/7/15, 3/10/15, 3/11/15, 3/13/15 and 3/18/15. Interview with the DON on 3/18/15 at 11:40 AM in the DON's office confirmed blanks on the TAR were missing pressure ulcer treatment documentation and the DON stated, "I looked for...documentation and was unable to find it...there is an issue with documentation." Medical record review of Resident #6 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Admission Data Collection dated 3/12/15 revealed "...Skin Assessment...Right Buttock, Abrasion; Left Buttock, Abrasion; Right Thigh (rear), Surgical Incision; Right Ankle (outer), Bruising, 3.0 x 1.5 cm; Right Heel, Pressure, 3.5 x 4.8 cm, Unstageable, Left Heel, Pressure, 1.5 x 2.5 cm, Unstageable..." Medical record review of a physician's order dated 3/12/15 revealed "...Right Thigh...apply Sureprep QD and PRN..." Review of a physician's order dated 3/12/15 revealed "...Left Buttock ...Every day and night shift...Apply Barrier Cream BID..." Medical record review of a physician's order dated 3/17/15 revealed "...Right Buttock ...Cleanse with WC (Wound Cleaner), pat dry, apply Alginate, Cover with Dry Dressing and change QD..." Medical record review of Physician's Orders dated 3/27/15 revealed "...Right Lateral Ankle ... Cleanse with WC, pat dry, apply Alginate, Cover with Dry Dressing and change QD and PRN for soiling..." Medical record review of a TAR dated 3/1/15-3/31/15 revealed pressure ulcer treatment to the right lateral ankle was not documented on 3/28/15. Medical record review of TAR dated 3/1/15-3/31/15 revealed pressure ulcer treatment to the right and left heels was not documented on 3/17/15 and 3/19/15. Medical record review of a TAR dated 3/1/15-3/31/15 revealed pressure ulcer treatment to the right buttock was not documented on 3/17/15 and 3/19/15. Medical record review of a TAR dated 3/1/15-3/31/15 revealed pressure ulcer treatment to the right thigh was not documented on 3/19/15. Medical record review of a TAR dated 3/1/15-3/31/15 revealed pressure ulcer treatment to the left buttock was not documented on 3/16 at 11:00PM, 3/19 at 7:00AM and 3/19/15 at 11:00PM. Medical record review of Head to Toe Skin Checks dated 3/19/15 revealed "...Right Buttock, Pressure, 0.5 x 0.5 cm...Right Heel, Pressure, 1.7 x 3.0 cm, Unstageable; Left Heel, Pressure, 1.6 x 2.7 cm, Unstageable...." Interview with the DON on 3/18/15 at 11:40 AM in the DON's office confirmed blanks on the TAR were missing pressure ulcer treatment documentation and the DON stated, "I looked for ... documentation and was unable to find it... there is an issue with documentation."

Based on medical record review, facility policy review, and interview the facility failed to update the care plan to reflect the residents specific wound care needs and interventions, and to revise the care plan after the resident was readmitted to the facility for 3 ( Resident #1, Resident #5, Resident #6) residents of 7 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE], discharged to the hospital on [DATE], re-admitted on [DATE] and discharged back to the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/12/15 revealed the resident required extensive assistance from 2 people for bed mobility and transfers, assistance from 1 person for dressing, eating, toileting, and personal hygiene, and was totally dependent for bathing. Review of the care plan development policy in the PointClickCare system with a revision date of 10/18/13 revealed "...process of care plan development requires the review of the resident's status in a holistic manner...must represent the resident's status, needs...each resident shall have an Initial Plan of Care developed within 24 hours of admission to the facility that addresses identified risk areas and resident's initial individual needs ...is developed based on information received from the referring facility, physician orders...clinical screens and assessments...any additional plan of care entries will be made manually on paper by the (IDT) Interdisciplinary Team..." Medical record review of the Nursing Initial Plan of Care, effective date 2/27/15 and signed on 3/11/15 revealed,"...Potential/Actual Skin Issues related to: Pressure Ulcer related to Incontinence, pressure ulcer to sacrum with treatment in place..." Interventions include "...provide wound care/preventative skin care per order; Skin checks weekly per facility protocol, document findings; Notify MD of changes in wound or emerging wounds; Turn and reposition frequently to decrease pressure...try/dry and provide pericare q2h (every 2 hours) and prn (as needed) for incontinence..." Medical record review of a physician's orders [REDACTED]. soiling ..." Interview with LPN #1 on 3/31/15 at 1:10 PM in the conference room confirmed a newly admitted resident is assigned to a specific nurse, and that nurse is responsible for initiating an interim care plan within the first 24 hours. Continued interview confirmed that when a resident is readmitted , the complete admission process starts over, including physician orders, assessments, and a new or updated care plan. Interview with the DON on 3/31/15 at 5:20 PM in the conference room confirmed the Nursing Initial Plan of Care dated 2/27/15 did not contain specific wound care interventions for Resident #1 and had not be revised or updated after the 3/5/15 re-admission to the facility. Medical record review of Resident #5 revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Nursing Admission Data Collection dated 2/19/15 revealed "...Skin Assessment: Coccyx, Skin Shearing, 7 x 2 cm; Right Trochanter (hip), Surgical Incision, 30x 1 cm....Left Heel, Pressure, 3 x 2 cm, Unstageable...." Medical record review of Nursing Initial Plan of Care initiated on 12/2/14 and revised on 3/17/15 revealed "....has potential/actual skin issues ...Interventions: Provide wound care/preventive skin care per order (initiated 12/2/14)...Treatment as ordered (date initiated 3/5/15)..." Medical record review of physician's orders [REDACTED]. Medical record review of physician's orders [REDACTED]. Medical record review of physician's orders [REDACTED]. Medical record review of Physician s Orders dated 3/3/15 revealed "...Left Heel ...Cleanse with wound cleaner, pat dry, apply sure prep to wound borders, apply Santyl to wound bed only, apply Alginate (an absorbent wound dressing), and cover with dry dressing (not foam) QOD and PRN for soiling..." Medical record review of Treatment Administration Record (TAR) dated 2/1/15-2/28/15 revealed no documentation of wound care administered to the left heel on 2/28/15. Medical record review of TAR dated 2/1/15-2/28/15 revealed no documentation of wound care administered to the left sacrum on 2/28/15. Medical record review of TAR dated 3/1/15-3/31/15 revealed no documentation of wound care administered to the left heel on 3/10/15 and 3/21/15. Medical record review of TAR dated 3/1/15-3/31/15 revealed no documentation of wound care administered to the left sacrum until 3/4/15 and then again on 3/11/15. Medical record review of TAR dated 3/1/15-3/31/15 revealed no documentation of wound care administered to the right hip on 3/7/15, 3/10/15, 3/11/15, 3/13/15 and 3/18/15. Interview with the DON on 3/31/15 at 6:00 PM in the Conference Room confirmed the care plan for Resident #5 was not revised upon the resident's readmission to the facility on [DATE]. The DON further confirmed that the resident's care plan was dated 12/2/14 and not revised until 3/17/15. Medical record review of Resident #6 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Wound Care Orders dated 3/12/15 revealed "...Right and Left Heel...Sureprep QD and PRN...Right Buttock...Cleanse with WC, pat dry, apply Alginate Cover with Dry Dressing and change QD..." Medical record review of Nursing Initial Plan of Care dated 3/12/15 revealed "...has potential/actual skin issues...Interventions: "... Skin checks weekly per facility protocol... Turn and reposition frequently to decrease pressure..." No interventions addressing the resident's pressure ulcers and pressure ulcer treatment were present on the interim care plan. Medical record review of the Care Plan dated 3/27/15 revealed "... admitted with several pressure ulcers...Stage III Right Buttock and unstageable to Bilateral Heels...Administer treatment as ordered and observe for effectiveness..." Medical record review of TAR dated 3/1/15 to 3/31/15 revealed "...Right Buttock...Cleanse with WC, pat dry, apply Alginate Cover with Dry Dressing and change QD, Order Date 3/12/15..."Continued review of the TAR revealed no documentation that pressure ulcer care was provided on 3/17/15 and 3/19/15. Interview with the DON on 3/31/15 at 6:00 PM in the Conference Room confirmed the interim care plan dated 3/12/15 for Resident #6 did not address the resident's pressure ulcer treatment needs.

Based on medical record review, review of the physician's on-call answering service log, emergency medical services documentation review, hospital record review, facility policy review, professional standards publications review, and interview, the facility failed to monitor and provide treatment for [REDACTED].#5); the facility failed to provide emergent care in a timely manner for one resident (#5); the facility failed to follow physician's orders [REDACTED].#12, #13, #14); and the facility failed to follow facility policy for reporting critical and abnormal lab values for four residents (#5, #12, #13, #14) of nineteen residents reviewed. The facility's failure has caused or is likely to cause serious harm, injury, impairment or death to residents #5, #12, #13, and #14. Resident #5 died as a result of an acute [MEDICAL CONDITION] with a critical potassium level of 8.4. The Administrator and the Regional Clinical Director were informed of the Immediate Jeopardy in the Conference Room on [DATE], at 11:15 a.m. F309 resulted in Substandard Quality of Care. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's hospital lab results on [DATE], through February 4, 2011, revealed the resident's potassium level fluctuated daily from a 3.3 L (low) level on [DATE] and 29, 2011, to a critical high level of 6.1 on [DATE], with the hospital's reference range for normal identified as 3.4 to 5.1 mmol (millimoles)/L (liter). Review of the hospital's discharge summary (discharged on [DATE]), dictated and transcribed on February 23, 2011, revealed, "...potassium level was [MEDICATION NAME] to (facility name) for continued care, where they would continue ...nephrostomy tube care and [MEDICATION NAME] tube care, with recording the output, ostomy care, physical therapy, and occupational therapy." Review of the Therapy Progress and Update notes from Occupational Therapy for the week of February 8 - 15, 2011, revealed, "...Pt (patient) with gains towards goals..." Review of the Therapy Progress Notes for Physical Therapy dated for the week of February 15 - 21, 2011, revealed, "...Pt (patient) has done very well over the past week of therapy...has met all STGS (short term goals) & (and) most LTGS (long term goals)..." Review of the facility's Interdisciplinary Plan of Care (POC), Need/Problem/Concern, dated February 18, 2011, revealed, "...Pot (potential) for abn. (abnormal) electrolytes AEB (as evidenced by)...(arrow pointing upward signifying increased) K+ (chemical symbol for potassium) level." Continued review of the Outcome/Goals section of the POC, revealed, "Will have no s/s (signs and symptoms) of [MEDICAL CONDITION] (elevated potassium) thru ,[DATE]." Continued review of the Interventions/Approaches, revealed, "1) Monitor labs; 2) Meds (medications) as ordered; 3) Observe for leg cramps, chest pain, SOB (shortness of breath)." Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Physician's Telephone Orders dated February 21, 2011, revealed, " (1) BMP (basic metabolic panel), CBC (complete blood count) today." Review of the lab results dated February 21, 2011, revealed a critical potassium level of 6.2 H! ("!" is the lab's symbol for identifying critical labs) with 3.6 - 5.4 mEq (milliequivalents) / (per) L (liter) used by the laboratory as the reference range for normal limits. Review of the Physician's Telephone Orders dated February 21, 2011, revealed, "Hold KCL (medication abbreviation for potassium chloride) tomorrow. Repeat KCL (lab) in AM (morning). Report to MD (medical doctor)." Review of the lab results dated February 22, 2011, revealed a critical potassium level of 6.4 H! Review of the Physician's Telephone Order dated February 22, 2011, revealed, "[MEDICATION NAME] (potassium lowering medication) 15 g (grams) po (by mouth) x (times) 1 dose taken from ER (emergency) box. BMP (lab) in am." Review of the lab results dated February 23, 2011, revealed the potassium level was 5.4 (within normal range.) Review of the Physician's Telephone Orders dated February 23, 2011, revealed, "Hold KCL (potassium medication) Thurs (Thursday was [DATE]) & (and) Fri (Friday was [DATE]) Do BMP Fri ( [DATE]) & Mon (Monday was [DATE]) If KCL (potassium lab) remains within normal limits continue to hold KCL (medication)." Review of the Physician's Telephone Orders dated February 24, 2011, revealed, "BMP (lab) [DATE]. D/C (discontinue) BMP on [DATE] - redraw on [DATE] per order." Review of the lab results dated February 24, 2011, revealed the potassium level was 5.6 H (high). Medical record review of the same lab report and nurses notes revealed no documentation the physician had been notified of the abnormal lab. Review of the lab results dated February 28, 2011, revealed the potassium level was 5.6 H. Continued review of the lab result revealed the Nurse Practitioner initialed the lab result without the date or time the result had been reviewed. Interview with Licensed Practical Nurse (LPN) #8 on [DATE], at 8:40 a.m., confirmed the Nurse Practitioner (NP) made rounds on [DATE], and reviewed the labs from February 28, 2011. Continued interview confirmed the NP ordered the BMP to be completed the next day. Telephone interview with the NP on [DATE], at 11:10 a.m., from the conference room confirmed, "It is possible I reviewed the labs from February 28, 2011, and ordered the BMP on [DATE], during my rounds." Review of the Physician's Telephone Order dated [DATE], revealed, "BMP in AM." Review of the resident's lab result dated [DATE], revealed the potassium level was 6.0 H (high). Medical record review revealed no documentation the physician had been notified of the abnormal lab result on [DATE]. Continued review revealed the abnormal lab result had been faxed to the physician's office on [DATE], (four days from the day the facility received the results). Interview with Registered Nurse (RN) #3 on [DATE], at 2:15 p.m., in the conference room confirmed the RN found the abnormal lab result (potassium 6.0 H) dated [DATE], "on the desk" on [DATE], and faxed the result to the physician's office because RN #3 did not know if the physician had been made aware of the abnormal results. Interview with the resident's attending physician via telephone conversation on [DATE], at 10:00 a.m., revealed the physician denied receiving the lab results. Continued interview confirmed the following interventions would have been in order had the physician received the elevated potassium results on [DATE], of 6.0 H (high). 1) Review the resident's medications to ensure potassium was not being given; 2) Talk to the nurses; 3) Review the resident's diet and assessed hydration status; 4) Force fluids if needed; 5) Probably give oral [MEDICATION NAME] (medication to reduce potassium levels in the blood stream). Telephone interview with the resident's attending physician on [DATE], at 1:30 p.m., confirmed the physician's office had no record of any faxed notification of the abnormal potassium (6.0 H) lab result for [DATE]. Telephone interview on [DATE], at 10:47 a.m., with the physician on-call [DATE], denied knowledge of notification of the abnormal potassium level, but confirmed had the physician received notification of the abnormal potassium level of 6.0 H on [DATE], the physician would have ordered treatment, "repeated the lab, maybe done an electrocardiogram (EKG), Calcium level, and sent to emergency room (ER)." Medical record review revealed no new physician's orders [REDACTED]. Review of the Nursing Daily Skilled Summary (nurse's note) dated [DATE], at 10:00 a.m., revealed the resident complained of nausea and vomiting. Continued review of the narrative note from Licensed Practical Nurse (LPN) #8 revealed, "Rec'd (received) orders...to get CBC (complete blood count), CMP, UA (urinalysis) C&S (culture and sensitivity), and [MEDICATION NAME] (an anti-emetic for nausea and vomiting) 4 mg (milligrams) po (by mouth) q (every) 6 hr (hours) prn (as needed) N/V (nausea and vomiting)." Review of the lab results dated [DATE], revealed the resident had a critical potassium level of 8.4 H! (The exclamation point signified a critical level per telephone interview with the Lab Manager on [DATE], at 10:25 a.m.) Continued review of the [DATE], lab result revealed the lab representative informed Registered Nurse (RN) #2 of the critical potassium level at 5:57 p.m. Review of the Nursing Daily Skilled Summary dated [DATE], 6:00 p.m., revealed RN #2 received the critical lab information from the lab, and reported the critical lab result to RN #3. Review of the Nursing Daily Skilled Summary dated [DATE], revealed RN #3 attempted to notify the physician through the physician's answering service at 7:00 p.m. Continued review of the nurse's note revealed the physician did not return the call until 7:45 p.m. Continued review revealed the physician ordered the resident to be sent to the emergency room for evaluation. Review of the physician's answering service call log dated [DATE], revealed the physician on-call service did not receive the call until 7:50 p.m., with the message, "(resident name) very pail (pale) & (and) sick @ (at) stomach w/t (with) pain pls (please) call." Review of the nurse's note written by RN #3 dated [DATE], revealed the emergency services transport had been called at 8:10 p.m. Review of the emergency services transport record revealed the call from the facility was received at 8:37 p.m. Continued review revealed emergency services (EMS) were at the facility at 8:50 p.m.; departed the facility at 9:14 p.m., and arrived at the emergency room (ER) at 9:17 p.m. Interview with RN #2 in the conference room on [DATE], at 1:30 p.m., confirmed RN #2 had received the call from the laboratory at 6:00 p.m., with the critical lab result for resident #5. Continued interview confirmed RN #2 relayed the information verbally to RN #3, and solicited a response from RN #3 regarding understanding of information relayed. Continued interview with RN #2 confirmed RN #3 responded affirmatively. Interview with RN #3 in the conference room on [DATE], at 2:15 p.m., confirmed the RN could not recall treatments, resident symptoms, or interventions provided for the resident during the length of time from 6:00 p.m. until 7:50 p.m., to call the physician's answering service; and from 7:50 p.m. to 8:37 p.m., to call the ambulance service. Telephone interview with Certified Nurse Aide (CNA) #5 on [DATE], at 12:07 p.m., confirmed the CNA worked second shift (3 p.m. to 11:00 p.m.) had been assigned to care for resident #5 on [DATE]. Continued interview confirmed the resident was "okay" at 2:30 p.m. (beginning of shift). Continued interview confirmed the resident had complained about not feeling good around 4:00 p.m. Review of the Nursing Daily Skilled Summary written by RN #3, dated [DATE], at 8:10 p.m., revealed, " ...Call placed to ambulance. Pt (patient) given a PRN (as needed) pain med (medication) for C/O (complains of) pain to lower ABD (abdomen) rated @ (at) 5 on a scale of ,[DATE] ..." Continued review revealed, "...8:50 p.m. ambulance here to pick up and transport to hospital..." Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME]/[MEDICATION NAME] (narcotic pain medication) 5 mg - 325 mg, Take 1 tablet by mouth every 4 hours as needed for pain..." Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical record review revealed no documentation of the transfer assessment or vital signs provided to the emergency medical transport services. Review of the emergency transport services report dated [DATE], revealed, "...The call came in as critical labs. After arriving on the scene...called for assistance on a working code ..." (A code is the term used to define resuscitative measures performed in the absence of breath and/or pulse ). Review of the emergency room Initial Assessment Form dated [DATE], at 9:15 p.m., revealed, "[MEDICAL CONDITION] pre-hospital..." Continued review revealed the resident presented to the ER with CPR (cardiopulmonary resuscitation) in progress. Review of the hospital Code Blue Flow Sheet dated [DATE], at 9:21 p.m., revealed, "...Type of Arrest...Cardiopulmonary, [MEDICAL CONDITION]; Patient Diagnosis: [REDACTED]. Review of professional literature on potassium imbalance from the Diseases and Disorders Handbook, revealed, "...Because serum potassium level has such a narrow normal range (3.5 - 5 mEq/liter), a slight deviation in either direction can produce profound clinical consequences. Paradoxically, both hypokalemia (potassium deficiency) and [MEDICAL CONDITION] (potassium excess) can lead to muscle weakness and flaccid paralysis...Both conditions also diminish excitability and conduction rate of the heart muscle, which may lead to [MEDICAL CONDITION]" Continued review revealed clinical features of potassium imbalance include nausea, diarrhea, and abdominal cramps. Review of the facility's policy, Laboratory Management, revealed, "...If the results of the lab tests are Abnormal or Critical Values, the attending Physician/Licensed Provider will be notified immediately at the time the results are received. Date, time, and person notified should be documented on the lab report and signed by the Licensed Nurse...If a resident's primary care Physician/Licensed Provider (or their on-call coverage) cannot be reached to report a critical or abnormal value, the facility Medical Director or the Medical Director's NP (Nurse Practitioner)/designee and the DON (Director of Nursing)/designee will be contacted with the results." Telephone interview with the resident's attending physician on [DATE], at 1:30 p.m., confirmed the potassium level of 8.4 H! (critical) would have required emergency treatment. Interview with the Director of Nursing on [DATE], at 11:20 a.m., in the conference room confirmed the facility's policy for reporting abnormal and critical lab values had not been followed. Continued interview confirmed the documentation was unclear as to why the resident had not been treated sooner. In summary, resident #5 was admitted to the facility status [REDACTED]. The resident was admitted for rehabilitation with the goal of returning home upon discharge. Lab results obtained on February 24 and 28, 2011, and [DATE], indicated elevated and abnormal K+ levels for which physician notification on those dates cannot be verified. When the resident complained of nausea, vomiting, and abdominal pain (all indicators of elevated potassium) on [DATE], new labs were ordered, and the critical potassium level of 8.4 was revealed. From the time the lab reported the critical K+ level to the facility at 5:57 p.m., on [DATE], until the ambulance arrived at 8:50 p.m., 2 hours and 53 minutes of time elapsed, resulting in a delay in treatment. RN #3 stated the physician was notified as soon as he/she had been informed of the lab (around 6:00 p.m.) The physician's answering service call log indicated the call was not received until 7:50 p.m. (1 hour, 50 minutes) later. RN #3 stated the emergency transport services had been notified at 8:10 p.m. The emergency services transport services log indicated the call was received at 8:37 p.m. The failure of facility staff to follow facility policy in notifying the physician and calling for emergency medical services resulted in delay of treatment. Subsequently, as the resident was being loaded into the emergency transport, vital signs ceased, and resuscitation measures began. Review of the emergency room records revealed resuscitation continued in the ER, without success. The resident died of Acute [MEDICAL CONDITION] at 9:35 p.m., on [DATE]. Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission orders [MEDICATION NAME] 1000 mg (milligrams) IV (intravenous) once daily..." Continued review revealed, "...peak & (and) trough q (every) 3rd (third) dose. Pharmacy to dose..." Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the facility's policy, Blood Sampling for Peak and Trough Values, revealed, "1. The peak is a measurement of drug in the blood after it has been given and at its highest level of concentration. Ideally ,[DATE] minutes following infusion. 2. The trough is a measurement of drug in the blood right before the next dose and at its lowest level of concentration in the blood. Ideally just prior to infusion...4. The ACTUAL TIME a specimen is obtained and the ACTUAL TIME the dose was hung is CRITICAL to accurately interpret drug levels for dosing considerations..." Review of the lab record dated February 18, 2011, and identified by the lab as "Trough" revealed a critical result of 37.1 H! ("!" indicates a critical lab value) with a reference range of 10.0 - 20.0. Continued review revealed the Medical Director had initialed the lab report and written "Stopped [MEDICATION NAME]" with no time or date. Review of the physician's orders [REDACTED]. On February 24, 2011, the resident was readmitted to the hospital for acute exacerbation of chronic lower back pain. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Nursing 2010 Drug Handbook, revealed adverse reactions of [MEDICATION NAME] include fever, pain, [MEDICAL CONDITION], pseudomembranous [MEDICAL CONDITION], nausea, nephrotoxicity, and [MEDICATION NAME]. Continued review revealed, "...Patients with renal dysfunction need dosage adjustment. Monitor blood levels to adjust I.V. (intravenous) dosage. Normal therapeutic levels of [MEDICATION NAME] are peak, 30 to 40 mg (milligrams)/L (liter) (drawn 1 hour after infusion ends), and trough, 5 to 10 mg/L (drawn just before next dose is given). Interview with the Medical Director on [DATE], at 1:15 p.m., by telephone from the conference room confirmed, "Was not aware the resident continued to receive the medication...Someone told me it had been stopped...I was not the patient's primary physician, but I pay attention to the labs...We have a kink in notification, signing what has been done...You know what they say, not documented, not done...That is a problem..." In summary, the facility continued to administer an anti-infective ([MEDICATION NAME]) for 6 days after the critical lab value was received. Resident #13 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the TPN (Total [MEDICATION NAME] Nutrition)/PPN (Peripheral [MEDICATION NAME] Nutrition) Order Form, revealed the resident was admitted with "Custom Formula (specific ingredients, measured additives)" orders for TPN on [DATE]. Review of the admission orders CMP (Complete Metabolic Panel); Mag (Magnesium); CBC (Complete Blood Count) q (every) 3 days." The definition of TPN provided by Taber's Cyclopedic Medical Dictionary is as follows: Provision of the total caloric needs by intravenous route for a patient who is unable to take food orally. Review of the Handbook for Geriatric Nursing Care revealed TPN is the [MEDICATION NAME] administration of [MEDICATION NAME], proteins, electrolytes, vitamins, and trace elements in amounts that exceed the patient's energy expenditure and thereby achieve anabolism (The building up of the body substance). Review of the Dietary Progress Notes dated [DATE], revealed, "...TPN to meet nutritional needs secondary to malabsorptio[DIAGNOSES REDACTED]...CMP/Mag(magnesium)/CBC q 3 days & communicate to MD (Medical Doctor) who will be managing TPN." Review of the laboratory results from [DATE], through [DATE], revealed no labs had been completed on [DATE], the first day the labs were due since the resident's admission on [DATE]. Review of the resident's lab results dated [DATE], revealed the following abnormal lab values: Blood Urea Nitrogen (normal: ,[DATE]) 52 H (H= high); Creatinine (normal: 0XXX,[DATE].1) 1.2 H; BUN/Creatinine Clearance (normal: 6XXX,[DATE].0) 43.7 H; Glomerular Filtration Rate (normal: greater than 60) 55 L (L= low); Chloride (normal: ,[DATE]) 91 L; CO2 (normal: ,[DATE]) 35 H; Calcium (normal:8XXX,[DATE].4) 8.5 L; Total Protein (normal 6XXX,[DATE].0) 5.9 L; [MEDICATION NAME] (normal: 3XXX,[DATE].0) 3.0 L; Alkaline [MEDICATION NAME] (normal: ,[DATE]) 145 H; Red Blood Cells (normal: 3XXX,[DATE].0) 3.09 L; Hemoglobin (normal: 11XXX,[DATE].5) 9.0 L; Hematocrit (normal: ,[DATE]) 27.5 L ...Continued review revealed no documentation the physician had been notified of the abnormal labs. Continued review revealed no changes in the TPN formula order. Review of the resident's lab results dated [DATE], revealed the following abnormal lab values: Blood Urea Nitrogen (normal: ,[DATE]) 45 H; Creatinine (normal: XXX,[DATE].1) 1.4 H; BUN/Creatinine Clearance (normal: 6XXX,[DATE].0) 32.2 H; Glomerular Filtration Rate (normal: greater than 60) 46 L; Chloride (normal: ,[DATE]) 93 L; CO2 (normal: ,[DATE]) 34 H; Calcium (normal:8XXX,[DATE].4) 8.3 L; Total Protein (normal 6XXX,[DATE].0) 5.3 L; [MEDICATION NAME] (normal: 3XXX,[DATE].0) 2.6 L; Alkaline [MEDICATION NAME] (normal: ,[DATE]) 163 H; [MEDICATION NAME] (normal: ,[DATE]) 13.1 L; Glucose (normal: ,[DATE]) 169 H ...Continued review revealed no documentation the physician had been notified. Continued review revealed no changes in the TPN formula order. Review of the facility's policy, Total [MEDICATION NAME] Nutrition Checklist, revealed, "...monitor labs frequently per physician's orders [REDACTED]. TPN formula may need to be adjusted..." Telephone interview with the Pharmacy Representative on [DATE], at 10:55 a.m., in the conference room confirmed residents come from the hospital or home with initial TPN orders. The TPN orders are transcribed to the TPN standardized form (TPN/PPN Order Form), and sent to the physician for approval before the TPN formula is sent to the facility. Continued interview confirmed the pharmacy maintains care plans for each TPN resident, contacts the facility for order changes, and any formula changes made are a result of the physician's orders [REDACTED]. Continued interview confirmed any changes in the TPN formula must come from the Physician. Telephone interview with the Pharmacy Representative on [DATE], at 12:45 p.m., confirmed the pharmacy had no copies of labs in resident #13's care plan. Continued interview confirmed according to the pharmacy's care plan, the IV (Intravenous) Technician called the facility every other day, spoke with the nurse in charge of the resident, and inquired of physician changes to the orders for TPN. Continued interview confirmed no changes to the TPN orders had been communicated by the nurses to the pharmacy during the resident's stay in the facility. Interview with the Regional Clinical Director (RCD) #1 on [DATE], at 3:00 p.m., in the conference room, confirmed there was no record of lab tests completed on [DATE], as ordered by the physician. Telephone interview with the Medical Director on [DATE], at 2:45 p.m., confirmed the resident had been admitted from the hospital on TPN. Continued interview confirmed the facility was responsible for obtaining the resident's labs and reporting the results to the physician to ensure the appropriate TPN formula. Continued interview confirmed the Physician's understanding was the facility faxed the lab results to the Pharmacy; the Pharmacy made recommendations based on the lab results for changes in the TPN formula; and the Physician approved the changes. Continued interview confirmed the physician was not aware the Pharmacy had not reviewed the lab results. Continued interview confirmed, "...No system is perfect...work toward effectiveness...learn from these mistakes...educate constantly..." Interview with RCD #1 and RCD #2 in the conference room on [DATE], at 9:15 a.m., confirmed the TPN formula had not been changed as a result of the abnormal lab results at any time during the resident's stay. Interview with the Registered Dietician (RD) in the conference room on [DATE], at 9:25 a.m., with RCD #1 and #2 present, confirmed the RD was not responsible for the TPN formula. In summary, the resident #13 was admitted with TPN orders, approved and signed by the physician. The physician ordered labs on admission to monitor the resident's needs regarding the TPN formula. The physician stated the pharmacy monitored the labs and would have made recommendations for changes. The pharmacy stated the physician monitored the labs and made changes. The [DATE], lab had not been completed as ordered. The facility failed to provide care and services based on monitoring and review of lab results obtained on [DATE] and [DATE]. Prior to formulating and dispensing TPN formula, the pharmacy records indicated a pharmacy representative contacted facility nurses to check for changes in the physicians orders. According the Pharmacy Representative, no changes were made to the TPN formula during the resident's stay at the facility. The resident was discharged to the emergency roiagnom on [DATE], with complaints of shortness of breath and increased anxiety. Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the lab results dated [DATE], revealed the resident had abnormal lab values specifically a low potassium level of 3.4 with 3.6 - 5.4 identified as the normal range. Continued review revealed a notation on the bottom of the lab sheet, "...results called to Dr (doctor)..." and signed by the Licensed Practical Nurse (LPN). Continued review revealed an order, "40 meq (milliequivalents) po (by mouth) Potassium Chloride x (times) 1 now..." Review of the Handbook of Geriatric Nursing Care, revealed, "...Potassium imbalances may result in such complications as muscle weakness and flaccid paralysis, and may also lead to [MEDICAL CONDITION]" Review of the physician's orders [REDACTED]. Give Potassium Chloride 40 meq (milliequivalents) 1 po (by mouth) now..." Interview with the LPN #1 on [DATE], at 9:05 a.m., in the conference room, confirmed the physician had not been notified of the [DATE], lab result until [DATE]. In summary, the facility failed to notify the Physician timely of abnormal lab results received on [DATE], and not reported until [DATE], resulting in a 3 day delay in treatment for [REDACTED]. The Immediate Jeopardy was effective from [DATE], through [DATE], and was removed [DATE]. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the survey team through review of facility documents, staff interviews, and observations conducted onsite on [DATE]. The survey team verified the allegation of compliance by: 1.) Reviewing the facility's plan for ensuring physician orders [REDACTED]. Reviewing the facility's plan for auditing records to ensure staff are following the plan. Reviewing the facility's in-service records to ensure nursing staff have been or will be educated before resuming work regarding changes to and implementation of the facility's policy for processing, tracking, reporting, and monitoring labs. The Director of Nursing (DON) on site at the beginning of the survey resigned on [DATE], and an interim DON had been appointed on [DATE]. 2.) Conducting interviews with 9 of 21 nurses on staff to determine the level of comprehension gained through in-service education conducted regarding the changes to the facility policy for ordering, receiving, reporting, and tracking lab results including the use of the Lab Tickler Tool for monitoring to ensure all labs are completed and reported timely. Continued interviews to confirm nurses were knowledgeable of the facility's process for reporting critical and abnormal labs to the physicians; knowledgeable of how to reach physician's after hours, and the time to wait for a call back from the physician; knowledgeable of who to contact if the physician cannot be reached or does not return the call timely. 3.) Reviewing additional charts for 3 of 4 residents currently receiving [MEDICATION NAME] to ensure the medication is being administered according to the facility's policy and physician's orders [REDACTED]. Interviewing nursing staff to ensure comprehension of the importance of the peak and trough labs, when each should be drawn, and who should draw the labs. Interviewing staff to ensure comprehension of the importance of administering the medication on a strict schedule and notifying the physician if unable to adhere to that schedule. Verifying resident careplans and cardexes included individualized interventions related to lab management. 4.) Reviewing additional charts for 1 out of 1 resident currently receiving TPN to assure the TPN is being administered according to facility policy and physician's orders [REDACTED].

Based on medical record review, review of the physician's on-call answering service log, facility policy review, emergency medical services documentation review, hospital record review, professional standards publications review, and interview the facility failed to notify the physician of an elevated potassium level and failed to immediately notify the physician of a subsequent critical potassium level for one resident (#5); the facility failed to notify the physician of lab results required for accurate dosing of medications for one resident (#12) receiving [MEDICATION NAME] (anti-infective) intravenously, and one resident (#13) receiving total [MEDICATION NAME] nutrition (TPN) feedings intravenously; and the facility failed to notify the physician timely of abnormal lab results for one resident (#14) with a low potassium level of nineteen residents reviewed. The facility's failure has caused or is likely to cause serious harm, injury impairment or death to residents #5, #12, #13, and #14. Resident #5 died as a result of an acute [MEDICAL CONDITION] with a critical potassium level of 8.4. The Administrator and the Regional Clinical Director were informed of the Immediate Jeopardy in the Conference Room on [DATE], at 11:15 a.m. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's hospital lab results on [DATE], through February 4, 2011, revealed the resident's potassium level fluctuated daily from a 3.3 L (low) level on [DATE] and 29, 2011, to a critical high level of 6.1 on [DATE], with the hospital's reference range for normal identified as 3.4 to 5.1 mmol (millimoles)/L (liter). Review of the hospital's discharge summary (discharged on [DATE]), dictated and transcribed on February 23, 2011, revealed, "...potassium level was [MEDICATION NAME] to (facility name) for continued care, where they would continue ...nephrostomy tube care and [MEDICATION NAME] tube care, with recording the output, ostomy care, physical therapy, and occupational therapy." Review of the Therapy Progress and Update notes from Occupational Therapy for the week of February 8 - 15, 2011, revealed, "...Pt (patient) with gains towards goals..." Review of the Therapy Progress Notes for Physical Therapy dated for the week of February 15 - 21, 2011, revealed, "...Pt (patient) has done very well over the past week of therapy...has met all STGS (short term goals) & (and) most LTGS (long term goals)..." Review of the facility's Interdisciplinary Plan of Care (POC), Need/Problem/Concern, dated February 18, 2011, revealed, "...Pot (potential) for abn. (abnormal) electrolytes AEB (as evidenced by)...(arrow pointing upward signifying increased) K+ (chemical symbol for potassium) level." Continued review of the Outcome/Goals section of the POC, revealed, "Will have no s/s (signs and symptoms) of [MEDICAL CONDITION] (elevated potassium) thru ,[DATE]." Continued review of the Interventions/Approaches, revealed, "1) Monitor labs; 2) Meds (medications) as ordered; 3) Observe for leg cramps, chest pain, SOB (shortness of breath)." Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Physician's Telephone Orders dated February 21, 2011, revealed, " (1) BMP (basic metabolic panel), CBC (complete blood count) today." Review of the lab results dated February 21, 2011, revealed a critical potassium level of 6.2 H! ("!" is the lab's designated symbol for identifying critical labs) with 3.6 - 5.4 mEq (milliequivalents) / (per) L (liter) used by the laboratory as the reference range for normal limits. Review of the Physician's Telephone Orders dated February 21, 2011, revealed, "Hold KCL (medication abbreviation for potassium chloride) tomorrow. Repeat KCL (lab) in AM (morning). Report to MD (medical doctor)." Review of the lab results dated February 22, 2011, revealed a critical potassium level of 6.4 H! Review of the Physician's Telephone Order dated February 22, 2011, revealed, "[MEDICATION NAME] (potassium lowering medication) 15 g (grams) po (by mouth) x (times) 1 dose taken from ER (emergency) box. BMP (lab) in am." Review of the lab results dated February 23, 2011, revealed the potassium level was 5.4 (within normal range.) Review of the Physician's Telephone Orders dated February 23, 2011, revealed, "Hold KCL (potassium medication) Thurs (Thursday was [DATE]) & (and) Fri (Friday was [DATE]) Do BMP Fri ([DATE]) & Mon (Monday was [DATE]) If KCL (potassium lab) remains within normal limits continue to hold KCL (medication)." Review of the Physician's Telephone Orders dated February 24, 2011, revealed, "BMP (lab) [DATE]. D/C (discontinue) BMP on [DATE] - redraw on [DATE] per order." Review of the lab results dated February 24, 2011, revealed the potassium level was 5.6 H (high). Medical record review of the same lab report and nurses notes revealed no documentation the physician had been notified of the abnormal lab. Review of the lab results dated February 28, 2011, revealed the potassium level was 5.6 H. Continued review of the lab result revealed the Nurse Practitioner initialed the lab result without the date or time the result had been reviewed. Interview with Licensed Practical Nurse (LPN) #8 on [DATE], at 8:40 a.m., confirmed the Nurse Practitioner (NP) made rounds on [DATE], and reviewed the labs from February 28, 2011. Continued interview confirmed the NP ordered the BMP to be completed the next day. Telephone interview with the NP on [DATE], at 11:10 a.m., from the conference room confirmed, "It is possible I reviewed the labs from February 28, 2011, and ordered the BMP on [DATE], during my rounds." Review of the Physician's Telephone Order dated [DATE], revealed, "BMP in AM." Review of the resident's lab result dated [DATE], revealed the potassium level was 6.0 H (high). Medical record review revealed no documentation the physician had been notified of the abnormal lab result on [DATE]. Continued review revealed the abnormal lab result had been faxed to the physician's office on [DATE], (four days from the day the facility received the results). Interview with Registered Nurse (RN) #3 on [DATE], at 2:15 p.m., in the conference room confirmed the RN found the abnormal lab result (potassium 6.0 H) dated [DATE], "on the desk" on [DATE], and faxed the result to the physician's office because RN #3 did not know if the physician had been made aware of the abnormal results. Interview with the resident's attending physician via telephone conversation on [DATE], at 10:00 a.m., revealed the physician denied receiving the lab results. Continued interview confirmed the following interventions would have been in order had the physician received the elevated potassium results on [DATE], of 6.0 H (high). 1) Review the resident's medications to ensure potassium was not being given; 2) Talk to the nurses; 3) Review the resident's diet and assessed hydration status; 4) Force fluids if needed; 5) Probably give oral [MEDICATION NAME] (medication to reduce potassium levels in the blood stream). Telephone interview with the resident's attending physician on [DATE], at 1:30 p.m., confirmed the physician's office had no record of any faxed notification of the abnormal potassium (6.0 H) lab result for [DATE]. Telephone interview on [DATE], at 10:47 a.m., with the physician on-call [DATE], denied knowledge of notification of the abnormal potassium level, but confirmed had the physician received notification of the abnormal potassium level of 6.0 H on [DATE], the physician would have ordered treatment, "repeated the lab, maybe done an electrocardiogram (EKG), Calcium level, and sent to emergency room (ER)." Medical record review revealed no new physician's orders [REDACTED]. Review of the Nursing Daily Skilled Summary (nurse's note) dated [DATE], at 10:00 a.m., revealed the resident complained of nausea and vomiting. Continued review of the narrative note from Licensed Practical Nurse (LPN) #8 revealed, "Rec'd (received) orders...to get CBC (complete blood count), CMP, UA (urinalysis) C&S (culture and sensitivity), and [MEDICATION NAME] (an anti-emetic for nausea and vomiting) 4 mg (milligrams) po (by mouth) q (every) 6 hr (hours) prn (as needed) N/V (nausea and vomiting)." Review of the lab results dated [DATE], revealed the resident had a critical potassium level of 8.4 H! (The exclamation point signified a critical level per telephone interview with the Lab Manager on [DATE], at 10:25 a.m.) Continued review of the [DATE], lab result revealed the lab representative informed Registered Nurse (RN) #2 of the critical potassium level at 5:57 p.m. Review of the Nursing Daily Skilled Summary dated [DATE], 6:00 p.m., revealed RN #2 received the critical lab information from the lab, and reported the critical lab result to RN #3. Review of the Nursing Daily Skilled Summary dated [DATE], revealed RN #3 attempted to notify the physician through the physician's answering service at 7:00 p.m. Continued review of the nurse's note revealed the physician did not return the call until 7:45 p.m. Continued review revealed the physician ordered the resident to be sent to the emergency room for evaluation. Review of the physician's answering service call log dated [DATE], revealed the physician on-call service did not receive the call until 7:50 p.m., with the message, "(resident name) very pail (pale) & (and) sick @ (at) stomach w/t (with) pain pls (please) call." Review of the nurse's note written by RN #3 dated [DATE], revealed the emergency services transport had been called at 8:10 p.m. Review of the emergency services transport record revealed the call from the facility was received at 8:37 p.m. Continued review revealed emergency services (EMS) were at the facility at 8:50 p.m.; departed the facility at 9:14 p.m., and arrived at the emergency room (ER) at 9:17 p.m. Interview with RN #2 in the conference room on [DATE], at 1:30 p.m., confirmed RN #2 had received the call from the laboratory at 6:00 p.m., with the critical lab result for resident #5. Continued interview confirmed RN #2 relayed the information verbally to RN #3, and solicited a response from RN #3 regarding understanding of information relayed. Continued interview with RN #2 confirmed RN #3 responded affirmatively. Interview with RN #3 in the conference room on [DATE], at 2:15 p.m., confirmed the RN could not recall treatments, resident symptoms, or interventions provided for the resident during the length of time from 6:00 p.m. until 7:50 p.m., to call the physician's answering service; and from 7:50 p.m. to 8:37 p.m., to call the ambulance service. Telephone interview with Certified Nurse Aide (CNA) #5 on [DATE], at 12:07 p.m., confirmed the CNA worked second shift (3 p.m. to 11:00 p.m.) had been assigned to care for resident #5 on [DATE]. Continued interview confirmed the resident was "okay" at 2:30 p.m. (beginning of shift). Continued interview confirmed the resident had complained about not feeling good around 4:00 p.m. Review of the Nursing Daily Skilled Summary written by RN #3, dated [DATE], at 8:10 p.m., revealed, "...Call placed to ambulance. Pt (patient) given a PRN (as needed) pain med (medication) for C/O (complains of) pain to lower ABD (abdomen) rated @ (at) 5 on a scale of ,[DATE]..." Continued review revealed, "...8:50 p.m. ambulance here to pick up and transport to hospital..." Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME]/[MEDICATION NAME] (narcotic pain medication) 5 mg - 325 mg, Take 1 tablet by mouth every 4 hours as needed for pain..." Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical record review revealed no documentation of the transfer assessment or vital signs provided to the emergency medical services transport. Review of the emergency transport services report dated [DATE], revealed, "...The call came in as critical labs. After arriving on the scene...called for assistance on a working code (A code is the term used to define resuscitative measures performed in the absence of breath and/or pulse )..." Review of the emergency room Initial Assessment Form dated [DATE], at 9:15 p.m., revealed, "[MEDICAL CONDITION] pre-hospital..." Continued review revealed the resident presented to the ER with CPR (cardiopulmonary resuscitation) in progress. Review of the hospital Code Blue Flow Sheet dated [DATE], at 9:21 p.m., revealed, "...Type of Arrest...Cardiopulmonary, [MEDICAL CONDITION]; Patient Diagnosis: [REDACTED]. Review of professional literature on potassium imbalance from the Diseases and Disorders Handbook, revealed, "...Because serum potassium level has such a narrow normal range (3.5 - 5 mEq/liter), a slight deviation in either direction can produce profound clinical consequences. Paradoxically, both hypokalemia (potassium deficiency) and [MEDICAL CONDITION] (potassium excess) can lead to muscle weakness and flaccid paralysis...Both conditions also diminish excitability and conduction rate of the heart muscle, which may lead to [MEDICAL CONDITION]" Continued review revealed clinical features of potassium imbalance include nausea, diarrhea, and abdominal cramps. Review of the facility's policy, Laboratory Management, revealed, "...If the results of the lab tests are Abnormal or Critical Values, the attending Physician/Licensed Provider will be notified immediately at the time the results are received. Date, time, and person notified should be documented on the lab report and signed by the Licensed Nurse...If a resident's primary care Physician/Licensed Provider (or their on-call coverage) cannot be reached to report a critical or abnormal value, the facility Medical Director or the Medical Director's NP (Nurse Practitioner)/designee and the DON (Director of Nursing)/designee will be contacted with the results." Telephone interview with the resident's attending physician on [DATE], at 1:30 p.m., confirmed the potassium level of 8.4 H! (critical) would have required emergency treatment. Interview with the Director of Nursing on [DATE], at 11:20 a.m., in the conference room confirmed the facility's policy for reporting abnormal and critical lab values had not been followed. Continued interview confirmed the documentation was unclear as to why the resident had not been treated sooner. In summary, resident #5 was admitted to the facility status [REDACTED]. The resident was admitted for rehabilitation with the goal of returning home upon discharge. Lab results obtained on February 24 and 28, 2011, and [DATE], indicated elevated and abnormal K+ levels for which physician notification on those dates cannot be verified. When the resident complained of nausea, vomiting, and abdominal pain (all indicators of elevated potassium) on [DATE], new labs were ordered, and the critical potassium level of 8.4 was revealed. From the time the lab reported the critical K+ level to the facility at 5:57 p.m., on [DATE], until the ambulance arrived at 8:50 p.m., 2 hours and 53 minutes of time elapsed resulting in a delay in treatment. RN #3 stated the physician was notified as soon as he/she had been informed of the lab (around 6:00 p.m.) The physician's answering service call log indicated the call was not received until 7:50 p.m. (1 hour, 50 minutes) later. RN #3 stated the emergency transport services had been notified at 8:10 p.m. The emergency services transport services log indicated the call was received at 8:37 p.m. The failure of facility staff to follow the facility policy in notifying the physician and calling for emergency services resulted in the delay of treatment. Subsequently, as the resident was being loaded into the emergency transport, vital signs ceased, and resuscitation measures began. Review of the emergency room records revealed resuscitation continued in the ER, without success. The resident died of Acute [MEDICAL CONDITION] at 9:35 p.m., on [DATE]. Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission orders [MEDICATION NAME] 1000 mg (milligrams) IV (intravenous) once daily..." Continued review revealed, "...peak & (and) trough q (every) 3rd (third) dose. Pharmacy to dose..." Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the facility's policy, Blood Sampling for Peak and Trough Values, revealed, "1. The peak is a measurement of drug in the blood after it has been given and at its highest level of concentration. Ideally ,[DATE] minutes following infusion. 2. The trough is a measurement of drug in the blood right before the next dose and at its lowest level of concentration in the blood. Ideally just prior to infusion...4. The ACTUAL TIME a specimen is obtained and the ACTUAL TIME the dose was hung is CRITICAL to accurately interpret drug levels for dosing considerations..." Review of the lab record dated February 18, 2011, and identified by the lab as "Trough" revealed a critical result of 37.1 H! (H! indicates a critical lab value) with a reference range of 10.0 - 20.0. Continued review revealed the Medical Director had initialed the lab report and written "Stopped [MEDICATION NAME]" with no time or date. Review of the physician's orders [REDACTED]. On February 24, 2011, the resident was readmitted to the hospital for acute exacerbation of chronic lower back pain. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Nursing 2010 Drug Handbook, revealed adverse reactions of [MEDICATION NAME] include fever, pain, [MEDICAL CONDITION], pseudomembranous [MEDICAL CONDITION], nausea, nephrotoxicity, and [MEDICATION NAME]. Continued review revealed, "...Patients with renal dysfunction need dosage adjustment. Monitor blood levels to adjust I.V. (intravenous) dosage. Normal therapeutic levels of [MEDICATION NAME] are peak, 30 to 40 mg (milligrams)/L (liter) (drawn 1 hour after infusion ends), and trough, 5 to 10 mg/L (drawn just before next dose is given). Interview with the Medical Director on [DATE], at 1:15 p.m., by telephone from the conference room confirmed, "Was not aware the resident continued to receive the medication...Someone told me it had been stopped...I was not the patient's primary physician, but I pay attention to the labs...We have a kink in notification, signing what has been done...You know what they say, not documented, not done...That is a problem..." In summary, the facility continued to administer an anti-infective ([MEDICATION NAME]) for 6 days after the critical lab value was received. Resident #13 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the TPN (Total [MEDICATION NAME] Nutrition)/PPN (Peripheral [MEDICATION NAME] Nutrition) Order Form, revealed the resident was admitted with "Custom Formula (specific ingredients, measured additives)" orders for TPN on [DATE]. Review of the admission orders CMP (Complete Metabolic Panel); Mag (Magnesium); CBC (Complete Blood Count) q (every) 3 days." The definition of TPN provided by Taber's Cyclopedic Medical Dictionary is as follows: Provision of the total caloric needs by intravenous route for a patient who is unable to take food orally. Review of the Handbook for Geriatric Nursing Care revealed TPN is the [MEDICATION NAME] administration of [MEDICATION NAME], proteins, electrolytes, vitamins, and trace elements in amounts that exceed the patient's energy expenditure and thereby achieve anabolism (The building up of the body substance). Review of the Dietary Progress Notes dated [DATE], revealed, "...TPN to meet nutritional needs secondary to malabsorptio[DIAGNOSES REDACTED]...CMP/Mag(magnesium)/CBC q 3 days & communicate to MD (Medical Doctor) who will be managing TPN." Review of the laboratory results from [DATE], through [DATE], revealed no labs had been completed on [DATE], the first day the labs were due since the resident's admission on [DATE]. Review of the resident's lab results dated [DATE], revealed the following abnormal lab values: Blood Urea Nitrogen (normal: ,[DATE]) 52 H (H= high); Creatinine (normal: XXX,[DATE].1) 1.2 H; BUN/Creatinine Clearance (normal: 6XXX,[DATE].0) 43.7 H; Glomerular Filtration Rate (normal: greater than 60) 55 L (L= low); Chloride (normal: ,[DATE]) 91 L; CO2 (normal: ,[DATE]) 35 H; Calcium (normal:8XXX,[DATE].4) 8.5 L; Total Protein (normal 6XXX,[DATE].0) 5.9 L; [MEDICATION NAME] (normal: 3XXX,[DATE].0) 3.0 L; Alkaline [MEDICATION NAME] (normal: ,[DATE]) 145 H; Red Blood Cells (normal: 3XXX,[DATE].0) 3.09 L; Hemoglobin (normal: 11XXX,[DATE].5) 9.0 L; Hematocrit (normal: ,[DATE]) 27.5 L ...Continued review revealed no documentation the physician had been notified of the abnormal labs. Continued review revealed no changes in the TPN formula order. Review of the resident's lab results dated [DATE], revealed the following abnormal lab values: Blood Urea Nitrogen (normal: ,[DATE]) 45 H; Creatinine (normal: XXX,[DATE].1) 1.4 H; BUN/Creatinine Clearance (normal: 6XXX,[DATE].0) 32.2 H; Glomerular Filtration Rate (normal: greater than 60) 46 L; Chloride (normal: ,[DATE]) 93 L; CO2 (normal: ,[DATE]) 34 H; Calcium (normal:8XXX,[DATE].4) 8.3 L; Total Protein (normal 6XXX,[DATE].0) 5.3 L; [MEDICATION NAME] (normal: 3XXX,[DATE].0) 2.6 L; Alkaline [MEDICATION NAME] (normal: ,[DATE]) 163 H; [MEDICATION NAME] (normal: ,[DATE]) 13.1 L; Glucose (normal: ,[DATE]) 169 H ...Continued review revealed no documentation the physician had been notified. Continued review revealed no changes in the TPN formula order. Review of the facility's policy, Total [MEDICATION NAME] Nutrition Checklist, revealed, "...monitor labs frequently per physician's orders [REDACTED]. TPN formula may need to be adjusted..." Telephone interview with the Pharmacy Representative on [DATE], at 10:55 a.m., in the conference room confirmed residents come from the hospital or home with initial TPN orders. The TPN orders are transcribed to the TPN standardized form (TPN/PPN Order Form), and sent to the physician for approval before the TPN formula is sent to the facility. Continued interview confirmed the pharmacy maintains care plans for each TPN resident, contacts the facility for order changes, and any formula changes made are a result of the physician's orders [REDACTED]. Continued interview confirmed any changes in the TPN formula must come from the Physician. Telephone interview with the Pharmacy Representative on [DATE], at 12:45 p.m., confirmed the pharmacy had no copies of labs in resident #13's care plan. Continued interview confirmed according to the pharmacy's care plan, the IV (Intravenous) Technician called the facility every other day, spoke with the nurse in charge of the resident, and inquired of physician changes to the orders for TPN. Continued interview confirmed no changes to the TPN orders had been communicated by the nurses to the pharmacy during the resident's stay in the facility. Interview with the Regional Clinical Director (RCD) #1 on [DATE], at 3:00 p.m., in the conference room, confirmed there was no record of lab tests completed on [DATE], as ordered by the physician. Telephone interview with the Medical Director on [DATE], at 2:45 p.m., confirmed the resident had been admitted from the hospital on TPN. Continued interview confirmed the facility was responsible for obtaining the resident's labs and reporting the results to the physician to ensure the appropriate TPN formula. Continued interview confirmed the Physician's understanding was the facility faxed the lab results to the Pharmacy; the Pharmacy made recommendations based on the lab results for changes in the TPN formula; and the Physician approved the changes. Continued interview confirmed the physician was not aware the Pharmacy had not reviewed the lab results. Continued interview confirmed, "...No system is perfect...work toward effectiveness...learn from these mistakes...educate constantly..." Interview with RCD #1 and RCD #2 in the conference room on [DATE], at 9:15 a.m., confirmed the TPN formula had not been changed as a result of the abnormal lab results at any time during the resident's stay. Interview with the Registered Dietician (RD) in the conference room on [DATE], at 9:25 a.m., with RCD #1 and #2 present, confirmed the RD was not responsible for the TPN formula. In summary, the resident #13 was admitted with TPN orders, approved and signed by the physician. The physician ordered labs on admission to monitor the resident's needs regarding the TPN formula. The physician stated the pharmacy monitored the labs and would have made recommendations for changes. The pharmacy stated the physician monitored the labs and made changes. The [DATE], lab had not been completed as ordered. There was no documentation the physician was notified for abnormal lab results for lab obtained on [DATE] and [DATE]. Prior to formulating and dispensing TPN formula, the pharmacy records indicated a pharmacy representative contacted facility nurses to check for changes in the physicians orders. According the Pharmacy Representative, no changes were made to the TPN formula during the resident's stay at the facility. The resident was discharged to the emergency roiagnom on [DATE], with complaints of shortness of breath and increased anxiety. Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the lab results dated [DATE], revealed the resident had abnormal lab values specifically a low potassium level of 3.4 with 3.6 - 5.4 identified as the normal range. Continued review revealed a notation on the bottom of the lab sheet, "...results called to Dr (doctor)..." and signed by the Licensed Practical Nurse (LPN). Continued review revealed an order, "40 meq (milliequivalents) po (by mouth) Potassium Chloride x (times) 1 now..." Review of the Handbook of Geriatric Nursing Care, revealed, "...Potassium imbalances may result in such complications as muscle weakness and flaccid paralysis, and may also lead to [MEDICAL CONDITION]" Review of the physician's orders [REDACTED]. Give Potassium Chloride 40 meq (milliequivalents) 1 po (by mouth) now..." Interview with the LPN #1 on [DATE], at 9:05 a.m., in the conference room, confirmed the physician had not been notified of the [DATE], lab result until [DATE]. In summary, the facility failed to notify the Physician timely of abnormal lab results received on [DATE], and not reported until [DATE], resulting in a 3 day delay in treatment for [REDACTED]. The Immediate Jeopardy was effective from [DATE], through [DATE], and was removed [DATE]. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the survey team through review of facility documents, staff interviews, and observations conducted onsite on [DATE]. The survey team verified the allegation of compliance by: 1.) Reviewing the facility's plan for ensuring physician orders [REDACTED]. Reviewing the facility's plan for auditing records to ensure staff are following the plan. Reviewing the facility's in-service records to ensure nursing staff have been or will be educated before resuming work regarding changes to and implementation of the facility's policy for processing, tracking, reporting, and monitoring labs. The Director of Nursing (DON) on site at the beginning of the survey resigned on [DATE], and an interim DON had been appointed on [DATE]. 2.) Conducting interviews with 9 of 21 nurses on staff to determine the level of comprehension gained through in-service education conducted regarding the changes to the facility policy for ordering, receiving, reporting, and tracking lab results including the use of the Lab Tickler Tool for monitoring to ensure all labs are completed and reported timely. Continued interviews to confirm nurses were knowledgeable of the facility's process for reporting critical and abnormal labs to the physicians; knowledgeable of how to reach physician's after hours, and the time to wait for a call back from the physician; knowledgeable of who to contact if the physician cannot be reached or does not return the call timely. 3.) Reviewing additional charts for 3 of 4 residents currently receiving [MEDICATION NAME] to ensure the medication is being administered according to the facility's policy and physician's orders [REDACTED]. Interviewing nursing staff to ensure comprehension of the importance of the peak and trough labs, when each should be drawn, and who should draw the labs. Interviewing staff to ensure comprehension of the importance of administering the medication on a strict schedule and notifying the physician if unable to adhere to that schedule. Verifying resident careplans and cardexes included individualized interventions related to lab management. 4.) Reviewing additional charts for 1 out of 1 resident currently receiving TPN to assure the TPN is being administered according to facility policy and physician's orders [REDACTED]. Once dosing recommendations are received from the pharmacy, the