Every finding on record at Legacy Manor Nursing and Rehabilitation Center

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure accurate food temperatures related to improper calibration of the food thermometer and failed to store food in accordance with professional standards for food service safety related to food items not dated, labeled and improperly stored for two (2) of two (2) kitchen observations. Findings include:A review of the facility's policy, Calibration of Thermometers, dated 05/18, revealed, Procedure: 1. All thermometers are to be calibrated: a. Before each meal.2. Ice Point Method.Hold the calibration nut securely with a wrench or other tool and rotate the head of the thermometer until it reads 32 (degrees) F (Fahrenheit).A review of the facility's policy, Storage of Refrigerated Food, dated 09/25 revealed, .The facility ensures the quality and safety of refrigerated foods through accepted storage practices.Procedure: 5. All non-hazardous, opened foods are labeled with name of food, date stored.6. All hazardous open foods are labeled with name of food and the date stored. A record review of the Recalibration Instructions for (Proper Name) Precision 6092N Thermometer, undated, revealed, .Ice Water Method.Check to see that the temperature is 32F.On 05/04/2026 at 8:09 AM, during an interview and observation of the kitchen with the Dietary Manager (DM) the facility's refrigerator was observed to contain one (1) opened carton of thickened apple juice with a Best if used by date of 13 [DATE], a beverage pitcher with no label or date, containing a liquid that the DM stated she was unable to identify. An observation of another refrigerator revealed nine (9) cartons of one and a half (1 1/2) pints of two (2) percent reduced fat milk with a manufacturers' date of May 03, one (1) opened gallon of two (2) percent milk with a Best by date of May 03, one (1) - four (4) ounce carton of yogurt with no date. An observation of a food prep table revealed a tray of cold cut and cheese sandwiches with no date sitting on the table, unattended. The DM was unable to disclose how long the sandwiches had been sitting on the table. An interview with the DM revealed it is her responsibility to monitor the food in the kitchen for labeling and dating, proper storage, quality and to make sure the foods are discarded prior to the expiration dates. The DM stated she will increase daily monitoring rounds and follow-up with labeling and discarding out of date foods.On 05/05/2026 at 11:14 AM, during an interview and observation of the kitchen the [NAME] was preparing to check the temperature of the foods on the holding table and was observed calibrating the thermometer to 40 degrees. The [NAME] proceeded to check the temperature of all the food items on the holding table with the thermometer. An interview with the cook revealed she has worked at the facility for 18 years. The [NAME] confirmed that it is she who calibrates the thermometer for breakfast and lunch and charts in the temperature logs each day she is on duty. The cook stated that she was trained when she started at the facility to calibrate the thermometer to 35 or 38 degrees. The [NAME] affirmed that she chose to calibrate the thermometer to 40 degrees on her own and does so daily. The cook stated that the purpose of calibrating the thermometer to the proper temperature is to keep the food from getting cold. An interview with the DM revealed that the staff are trained and in-serviced as groups and in one-on-one sessions regarding food safety. The DM reported that she has educated the staff on calibrating the thermometer to 32 degrees. The DM noted the purpose of proper calibration of the thermometer is to prevent illnesses and to make sure the food is cooked and stays at the proper temperature. The DM stated that going forward she expects her staff to calibrate the thermometer to 32 degrees and properly check the temperature of food. On 05/06/2026 at 3:12 PM, during an interview with the Administrator, he revealed it is the responsibility of the entire kitchen staff to monitor food for expiration dates, proper storage and proper labeling, but ultimately the DM is responsible for following behind the staff to ensure these things are done. The Administrator noted that the cook is responsible for making sure the thermometer is calibrated correctly so that food temperatures are registered correctly. The Administrator stated the importance of ensuring that foods are discarded by expiration dates, stored properly, labeled and temperatures are accurate is to maintain the health and welfare of the residents. The Administrator stated that he expects there to be training as needed for kitchen staff.

Based on staff interview and record review, the facility failed to ensure the accuracy of Payroll Based Journal (PBJ) data submitted to the Centers for Medicare and Medicaid Services (CMS) when nurses with administrative nursing duties hours were not recorded in the correct job title for three (3) of three (3) months reviewed in the fiscal year (FY) first quarter of 2026.Findings include:A record review of the PBJ Staffing Data Report for FY Quarter 1 2026 (October 1 through December 31) revealed the facility triggered for excessively low weekend staffing during the quarter. A record review of the 1703D Job Title Report for FY Quarter 1 2026, revealed Job Title 6 - Registered Nurse with Administrative Duties had recorded Contract Hours on 10/7/26, 11/5/26, 11/6/26, 12/15/26, and 12/16/26. There were no other days with hours recorded for Job Title 6. A review of Job Title 8 - Licensed Practical/Vocational Nurse with Administrative Duties revealed on 10/7/26, 10/22/26, 10/24/26, 10/25/26, 10/26/26, and 11/2/26 there were Contract Hours recorded on PBJ. Job Title 7 - Registered Nurse and Job Title 9 - License Practical/Vocational Nurse hours are considered direct care hours for PBJ reporting purposes.On 5/4/26 at 2:15 PM, during an interview with Licensed Practical Nurse (LPN) #1, she stated she is the facility's Minimum Data Set (MDS) nurse. She reported she did not work on the floor providing direct resident care during the first quarter of 2026. She provided administrative duties only during that time and stated she typically works Monday through Friday.On 5/4/26 at 2:24 PM, during an interview with Licensed Practical Nurse (LPN) #2, she explained works in Medical Records for the facility and usually works during the week only. She reported that although she has worked on the floor several times providing direct care to residents, she worked most of the first quarter in an administrative role and did not routinely provide direct resident care.On 5/4/26 at 2:30 PM, during an interview with Registered Nurse (RN) #1, she explained she served as the staff development nurse during the first quarter of 2026. RN #1 reported she worked on the floor providing direct care on several occasions but worked primarily in an administrative capacity during the week, Monday through Friday.On 5/7/26 at 9:00 AM, during an interview with the Administrator, the Administrator confirmed the facility did not accurately report direct care staffing during weekdays. The Administrator reported that the corporate staff had entered the Job Title codes incorrectly into PBJ because the hours reflected for nurses with administrative hours did not reflect their actual hours worked. The MDS nurse, medical records nurse, and staff development nurse are salaried nursing staff with administrative duties and typically work on weekdays only and have worked more hours than was reflected on the report. The Administrator stated he was contacting the corporate staff to address the inaccurate PBJ reporting.

REVISED 3/13/25: After quality assurance review with the Centers for Medicare and Medicaid Services (CMS) Regional Office (RO) on 3/13/25, it was determined that an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) should have been identified and cited as Past Non-Compliance (PNC) during the Complaint Investigation conducted on 12/24/24. The IJ and SQC existed at: 42 CFR483.12(a)(1), Freedom from Abuse, Neglect, and Exploitation - F600 Scope/Severity J This situation placed Resident #1 and other residents at risk for the likelihood of serious injury, harm, impairment or death. The State Agency (SA) notified the Administrator of the IJ and SQC on 3/13/25 at 4:50 PM and provided the IJ Template. Based on the facility's implementation of corrective actions on 12/26/24, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 12/27/24, prior to the SA's entrance on 1/14/25. Based on observations, facility security camera video observations, policy reviews, interviews, and record reviews, the facility failed to ensure Resident #1's right to be free from abuse. Resident #1 was punched in the head, face, and chest with a closed fist at least 10 times and flipped over in his wheelchair on to the hallway floor by Certified Nursing Assistant (CNA) #1. Resident #1 received an injury of broken blood vessels to his right eye and swelling and had to be treated and evaluated by a physician. Resident #1 was one (1) of four (4) residents reviewed for abuse and neglect. Findings Include: Review of the facility policy titled: Resident Abuse last review date 01/24 stated, Conduct detrimental to resident care that results in neglect or abuse of any resident is strictly prohibited .B. Any employee suspected of abuse will be suspended immediately and future employment will be based on the outcome of the investigation. Review of the facility policy titled Employee Corporate Compliance Code of Conduct dated 05/18 and signed by CNA #1 on 1/11/23 revealed, Each resident residing in this facility has the right to be free from any type of abuse including verbal, sexual, mental, physical abuse, neglect, misappropriation of resident property and exploitation . Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The facility's undated investigation report that was signed by the Director of Nursing (DON) stated, Staff Development, Licensed Practical Nurse (LPN) #2 and DON to building to review camera footage and noted that on 12/24/24 @ 1553 (3:53 PM) Resident #1 approached CNA#1 in hallway and appears to have tapped her on her arm and then made a motion like he was bowing up on her. CNA #1 was not pinned or trapped like she stated and had ample opportunity to step away. She began to hit him with her closed fist multiple times in the face. We counted approximately 10 times, and then proceeded to flip his wheelchair over. Resident #1 was then left lying on the floor and he proceeded to crawl into his room. At 4:06 PM she appeared back in hallway and picked up his belongings and threw them into his room and shut his door. She also picked wheelchair upright and it was left sitting in hallway. At 4:30 PM LPN #1 in hallway and they entered resident's room and got him up off the floor using lift. DON did assess right eye sclera is noted to be red with what appears to be ruptured blood vessels. Record review of the facility investigation concluded that CNA #1 had abused and neglected Resident #1 on 12/24/24. CNA #1 was terminated on 12/26/24 from the facility for abuse and neglect of Resident #1. Record review of the facility termination form titled Termination Report dated 12/26/24 revealed: (CNA #1) Last Day Worked 12/24/24 Termination Effective Date 12/26/24 Resident Abuse, Violation of Company Policies/Procedure-See Facility Investigation Interview on 01/14/25 at 12:30 PM with the facility Administrator (ADM) revealed that he was not involved in the investigation of the alleged abuse of (Resident #1) that occurred on 12/24/24. ADM stated that he was out of the state for the holidays and the DON and LPN #2 had completed the investigation and they had terminated CNA #1. ADM stated that the facility security video cameras were reviewed by the DON and LPN #2 and they both confirmed that CNA #1 was identified in the video and they both saw in plain view on the video that CNA #1 hit Resident #1 several times in the head, face, and chest with a closed fist. The DON terminated CNA #1 from her employment at the facility upon confirming that CNA #1 had abused and neglected Resident #1 and that she never attempted to remove herself from the encounter and go get help. CNA #1 not only hit Resident #1 with a closed fist, but she grabbed his wheelchair and intentionally flipped the wheelchair over dumping the resident out onto the floor of the hallway and stepped over Resident #1 leaving him unattended and unassessed for over 30 minutes. The ADM stated that the video was hard for him to watch and that the blatant abuse of Resident #1 was sickening. ADM stated that on 12/30/24 the Attorney General's (AG) office had come to the facility, and he too had obtained a copy of the facility video for his investigation. ADM stated that the AG was pursuing charges against CNA #1 for felony abuse and neglect. ADM shared the facility investigation, the facility video, and the phone numbers of the AG with the surveyor and sat down and reviewed and narrated the approximate 45-minute facility security video. Observation of the facility security camera video on 1/14/2025 at 12:45 PM-1:35 PM along with the interview of the ADM verbally identifying the times of the events, along with the video clock (which verified the time of the event as 3:50 PM on 12/24/24 until 4:30 PM on 12/24/24). The video contained no audio. Observation of the facility video revealed that at approximately 3:55 PM on 12/24/24 Resident #1 approached CNA #1 in the hallway as he rolled up close to her in his wheelchair. Immediately CNA #1 began to punch Resident #1 in the face, head and chest with a closed fist. CNA #1 never attempted to obtain assistance, nor did she attempt to leave the situation and go get help. CNA #1 hit Resident #1 many times with a closed fist and was unable to count the fist punches accurately because they were happening too fast. It appeared to be at least a dozen fist punches (approximately) administered by CNA #1 to Resident #1. CNA #1 had several opportunities to leave away from Resident #1, but she did not attempt to remove herself from the situation. CNA #1 reached down near the front wheels of Resident #1's wheelchair and flipped the chair over dumping Resident #1 on to the floor and on to his back. From approximately 4:05 PM on 12/24/24 until approximately 4:20 PM on 12/24/24 Resident #1 was left lying on the floor in the hallway unassisted and unattended. Resident #1's wheelchair remained turned over on its side and personal clothing items and a seat cushion were scattered about the hallway. Resident #1 moved slowly on the floor of the hallway dragging his limp body across the floor and into his room where he disappeared from the camera view. At approximately 4:30 PM on 12/24/24 (LPN #1) appeared on the hallway and she and CNA #1 went into the room of Resident #1. CNA #1 was pushing the full body lift into the room of Resident #1. CNA #1 went into another resident's room across the hall from Resident #1 and left Resident #1 unattended and unassessed lying in the hallway for approximately 30 minutes. When CNA #1 came out of the other resident room she picked up the wheelchair and threw the cushion and clothing from the hallway into Resident #1's room and then reached in and closed the door to Resident #1's room. CNA #1 did not go into Resident #1's room and never assisted Resident #1. CNA #1 never went to get help/assistance for approximately 30 minutes. CNA #1 was never seen on the video reporting the incident to anyone or seeking assistance for Resident #1. ADM stated that CNA #1 never reported a fall or any incident to anyone. CNA #1 worked second shift (3:00 PM-11:00PM) on 12/24/24 and worked third shift (11:00 PM -7:00 AM) on 12/24/24 and never mentioned the incident with Resident #1 to anyone. CNA #1 did not report the altercation between her and Resident #1 to any staff member or to anyone at the facility for two (2) eight-hour shifts (approximately 16 hours), according to the interview with the ADM on 1/14/25 at 12:30 PM. Observation of the facility security camera video and interview on 1/14/25 at 1:00 PM with the DON revealed that she was out of town with her family celebrating Christmas Day when at approximately 12:00 noon she was contacted by LPN #2 and told that there was a report of abuse given by another resident (Resident #3). DON stated that she never in a million years would have believed that CNA#1 would have done such a thing as abuse a resident like she did. DON had to drive to the facility from another state to investigate the situation at the facility. She informed LPN #2 to call CNA #1 and suspend her until the investigation could be completed and to get a statement from CNA #1 over the phone as to what had occurred. CNA #1 told them that Resident #1 attacked her first and pinned her up against the wall with his legs and that she had to get him off of her and she slapped Resident #1 with an open hand and then he slid out of his wheelchair. CNA #1 told LPN #2 that she had not abused Resident #1. LPN #2 and DON both arrived at the facility at approximately 4:00 PM and they together viewed the security video cameras and they could not believe their eyes as they both saw CNA #1 repeatedly hitting Resident #1. CNA #1 flipped over the wheelchair dumping Resident #1 out on his back into the hallway floor. DON stated that they identified several times during the encounter when CNA #1 could have left and gone for assistance, but she never did. She also left Resident #1 in the floor unattended and unassessed for over 30 minutes and she never reported the incident to anyone. DON stated that at no time during the encounter was CNA #1 pinned up to the wall by Resident #1. DON stated that the realization of the video clearly confirmed that Resident #1 was abused and neglected by CNA#1. DON stated that the video was not at all consistent with the statement that was given by CNA #1. DON viewed the video with ADM and surveyor and she identified CNA #1 and Resident #1 and she confirmed that CNA #1 was terminated for the abuse and neglect of Resident #1. DON stated that CNA #1 never reported the incident during the 16 hours that she worked on 12/24/24-12/25/24 and that the incident occurred within an hour of her first coming into work that day. In an interview on 1/14/25 at 1:40 PM with LPN #2 revealed that she was the on call nurse supervisor on 12/25/24. She stated that CNA #3 called her to report that another resident (Resident #3) reported that on 12/24/24 Resident #1 and CNA #1 had been in an altercation in which CNA #1 hit Resident #1. It was reported that on 12/25/24 at 11:48 AM Resident #1 had a swollen eyed with blood vessels busted in his eye. When LPN #2 asked Resident #1 what had occurred he stated that maybe CNA #1 had stuck her finger in his eye when they were on the floor tussling. LPN#2 then called LPN#1 at 11:59 AM on 12/25/24 and asked her what had occurred on 12/24/24 and how did Resident #1 get a blood shot eye. LPN #1 told LPN #2 that she had no idea how Resident #1 had received a blood shot eye. All that had occurred during the second shift on 12/24/24 was Resident #1 had slid out of his wheelchair on to the floor and was assessed by LPN #1 and Resident #1 was found to have had no injuries. LPN #1 had no knowledge of any incidents/accident with Resident #1 on 12/24/24. LPN #2 stated that she received a call from CNA #1 at approximately 12:11 PM on 12/25/24 in which CNA #1 said she had something to report to LPN #2. CNA #1 stated that Resident #1 had attacked her, and he had hit her and pinned her up against the wall. CNA #1 told LPN#2 that she hit Resident #1 with an open hand to get him off of her and that she did not report the incident to LPN #1 and did not seek assistance from anyone. LPN #2 stated that she then went back and watched the security video to see what had happened. LPN #2 and the DON viewed the video together on 12/25/25 and they both were in disbelief at the abuse that they saw on the video to Resident #1 from CNA #1. LPN #2 stated that she and the DON slowed the video down while viewing and counted 10 times that CNA #1 hit Resident #1 with a closed fist. CNA #1 purposefully flipped Resident #1 over in his wheelchair, dumping him onto the floor of the hallway and then walked away leaving Resident #1 on the floor unattended and unassessed. LPN #2 stated that never did she view on the video that Resident #1 had pinned CNA #1 up against the wall. The video did not show the encounter with Resident #1 that CNA #1 had explained. LPN #2 stated that she interviewed Resident #1 on 12/25/24 and he was unable to remember how he received the broken blood vessels to his right eye. LPN #2 called the local Police department at 1:22 PM to come and complete a police report of the incident because it was determined that alleged abuse had occurred. LPN #2 stated that after viewing the facility security video it was determined that CNA #1 had abused and neglected Resident #1 and she was terminated from the facility. LPN #2 stated that she and the DON were so upset by the abuse that they viewed on the video that they both cried. LPN #2 stated that no one, no matter what had happened, deserved what CNA #1 did to Resident #1. LPN #2 stated that CNA #1 had several opportunities to leave and go get help, but she did not, she continued to hit Resident #1 and flipped him over in his wheelchair. An interview on 1/14/25 at 2:00 PM with the AG Investigator, revealed that he came to the facility on [DATE] and obtained copies of the Police Report, the facility video, and copies of Resident #1's records. He stated that he was taking the case to the District Attorney and was asking for felony charges to be placed against CNA #1 for abuse and neglect of Resident #1. The AG stated that he was convinced that the District Attorney would allow him to arrest CNA #1 for abuse and neglect of Resident #1. He stated that the video alone was enough evidence to put CNA #1 in jail. Interview and observation on 1/24/25 at 3:00 PM with Resident #1 revealed an obese male sitting in a wheelchair in his private room, alone. Resident #1 mumbled and made statements that were not relevant to the subjects and appeared to not be cognitive of his surroundings as he rambled and stated that no one had ever hurt him there and that he had not gotten into an altercation with anyone. Interview and observation on 1/24/25 at 3:10 PM with Resident #3 revealed that he remembered the altercation between Resident #1 and CNA #1 that occurred on Christmas Eve. Resident #3 stated that everyday Resident #1 cusses and turns over furniture and causes problems. He also makes sexual comments to the staff and He metals in things that do not belong to him. Interview on 1/14/25 at 3:30 PM with LPN #1 revealed that she was the second shift (3:00 PM-11:00 PM) nurse on 12/24/24. She stated that she was making rounds and giving out medications at approximately 4:30 PM on 12/24/24 when she found Resident #1 lying on the floor of his room. She stated that CNA #1 was coming past with the full body lift, and she asked CNA #1 to help her put Resident #1 back in his bed with the full body mechanical lift. LPN#1 had assessed the resident on the floor and had determined he was not injured and he told her he fell out of his chair. LPN #1 re-assessed Resident #1 again when he was lifted to his bed and he voiced that he was not injured and issued no complaints and gave no information as to how he fell other than he slipped out of his wheelchair. LPN #1 stated that CNA #1 never reported that she had knowledge of Resident #1 falling or that there had been an incident. LPN #1 was busy during that period giving out medications and making rounds and she never heard any disturbances and was unaware that there had been an incident between Resident #1 and CNA #1. Resident #1 has behaviors, and he regularly acts out and gets loud and turns over furniture and makes demands to go home. He is cognitively impaired, and he has sundowners. Interview on 1/14/25 at 4:10 PM with CNA #2, revealed that on 12/24/24 she was the other CNA on that unit along with CNA #1 and LPN #1. She stated that she never heard any disturbances on 12/24/24 between CNA #1 and Resident #1 and that no one had reported to her that Resident #1 had been found on the floor. Record review of Resident #1's Minimum Data Set (MDS) Section C dated 11/12/24 revealed a Brief Interview for Mental Status (BIMS) score of 7 which indicated that Resident #1 was severely cognitively impaired. Record review of Resident #1's Admission Record documented that Resident #1 had been admitted to the facility on [DATE] and had diagnoses which included Alcohol Abuse with Alcohol Induced Mood Disorder; Psychoactive Substance Abuse with Withdrawal; Dementia with Behaviors; and Cognitive Communication Deficit. On 3/13/25, after quality review with CMS/RO, the SA validated through record review that the facility implemented corrective actions on 12/25/24 through 12/26/24 to remove the IJ and SQC. On 12/25/24, DON assessed Resident #1, notified the Medical Director, and suspended CNA#1. The Quality Assurance and Performance Improvement (QAPI) Committee met on 12/25/24 to discuss the abuse, review policies and develop a plan. The facility reported the abuse to the SA and local police department on 12/25/24. Staff inservices on Abuse/Crime Reporting, Aggressive Physical Behavior, Elder Justice Act, Residents Rights, Recognizing and Dealing with Signs of Burnout, Frustration and Stress, and Seven Components to Reduce, Detect and Prevent Abuse and Neglect began on 12/25/24 and continued until all staff were inserviced. Interviews with all residents were initiated on 12/25/24 to identify any other allegations of abuse. Resident Council Meeting was held on 12/26/24 to discuss resident safety and offer counseling. A 100 percent body audit was conducted on 12/26/24 with no adverse findings. CNA #1 was terminated on 12/26/24. The Attorney Generals office was notified on 12/26/24. QAPI implemented monitoring beginning 12/2724 of 1 resident/employee interview weekly for 4 weeks, then twice monthly for 2 months, then monthly for 1 month. Reporting of abuse/safety of residents will be discussed in Resident Council monthly. Beginning 1/22/25, the QAPI committee will address concerns identified from the interviews and the Resident Council meetings monthly for four months and make any recommendations or changes needed.

Based on interview, record review, and facility policy review the facility failed to implement care plan interventions related to Cardiopulmonary Resuscitation (CPR) for a resident who was found to have no respirations and no pulse for one (1) of three (3) sampled residents. Resident #1. The facility's failure to implement the care plan for Resident #1 resulted in the resident not receiving CPR and emergency services when he was found without pulse, respirations or blood pressure. Resident #1 was a Full Code status. The resident subsequently expired in the facility. The situation was determined to be an Immediate Jeopardy (IJ) that began on [DATE] when Resident #1 was found by facility staff to be unresponsive and without respirations, a pulse or blood pressure. The facility Administrator was notified of the IJ on [DATE] at 3:02 PM and was provided an IJ Template. Based on the facility's implementation of corrective actions on [DATE] the State Agency (SA) determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed as of [DATE], prior to the SA's first entrance on [DATE]. Findings Include: Review of the facility's Care Plan Process policy, latest revision date ,d+[DATE], revealed . Interventions are actions that should promote meeting the established goal . Record review of Resident #1's care plan dated [DATE], revealed Advanced Directive - Full Code. Goal: Honor Residents wishes .Approaches: .Honor Resident/Family Advance Directive request .Full Code. A review of the Progress Notes by Licensed Practical Nurse #1 (LPN) dated [DATE] at 7:45 PM, revealed that she walked by Resident #1's room and noticed he did not look well. Upon entering the room, she found the resident unresponsive, with no respirations, pulse, or blood pressure. She then notified the coroner, the family, the Administrator, and the Nurse Practitioner of the resident's death. There was no indication that CPR was initiated or that emergency services were called. Record review of Resident/Family Consent for Cardiopulmonary Resuscitation (CPR) for Resident #1, dated [DATE], revealed I understand that CPR constitutes an extraordinary measure and SHOULD be done on this resident in the case of extreme emergency. Record review of Resident #1's Physician's Telephone Order dated [DATE] revealed an order for Full Code indicating that the resident should receive CPR. On [DATE] at 1:30 PM, during an interview the Administrator confirmed that the care plan was not followed, and Resident #1 did not receive CPR. Record review of the Facesheet for Resident #1 revealed the facility admitted Resident #1 on [DATE] with diagnoses that included Dementia and Chronic Kidney Disease. The facility submitted the following acceptable Corrective Action Plan on [DATE]: Corrective Action Plan On [DATE], while making rounds at 7:45 PM, Licensed Practical Nurse #1 reports glancing into Resident #1's room and observed resident not looking right and entered Resident #1's room to assess Resident #1's status. Licensed Practical Nurse #1 reports that resident was without active vita! signs, face and upper arms cool to touch, rest of body warm. Licensed Practical Nurse #1 then placed a call to the coroner at 7:55 PM and did not initiate cardiac resuscitation measures and call 911. Resident #1 medical record indicates resident was with full code status. Licensed Practical Nurse #1 notified facility Administrator of resident death at 8:00 PM. Licensed Practical Nurse #1 notified Staff Development Nurse #1 at 8:05 PM who instructed Licensed Practical Nurse # 1 to initiate Cardiopulmonary Resuscitation efforts. Licensed Practical Nurse #1 notified Nurse Practitioner at 8:10 PM of resident death. Licensed Practical Nurse #1 contacted Resident #1's sister at 8:15 PM and resident's family arrived at the facility at 8:45 PM. On [DATE], approximately 8:20 AM, it was determined by Staff Development Nurse #1 that Licensed Practical Nurse #1 did not initiate Cardiopulmonary Resuscitation efforts. On [DATE], at approximately 8:30 AM the facility Administrator was notified by Assessment Nurse #1 of the failure by Licensed Practical Nurse #1 to initiate cardiopulmonary resuscitation on Resident #1. On [DATE], at approximately 9:35 AM, Licensed Practical Nurse #1 was suspended via telephone by facility Administrator pending investigation. On [DATE], at approximately 9:30 AM, the facility Administrator interviewed Licensed Practical Nurse #1. The interview indicated Licensed Practical Nurse #1 was aware of the full code status and did not initiate Cardiopulmonary Resuscitation due resident being without signs of life. On [DATE], the Regional Supervisor and [NAME] President interviewed Licensed Practical Nurse #1 via telephone. The interview indicated the Licensed Practical Nurse #1 did not initiate Cardiopulmonary Resuscitation. On [DATE], the Assessment Nurse #1, interviewed the three Certified Nurse's Aide on shift at the time of the incident. The Certified Nurse Aide #1 was interviewed and confirmed that Cardiopulmonary Resuscitation was not initiated by Licensed Practical Nurse #1. The Certified Nurse Aide #2 was interviewed and reported that she had informed Licensed Practical Nurse #1 to start Cardiopulmonary Resuscitation after speaking to Staff Development Nurse #1 via telephone on the evening of [DATE]. Certified Nursing Aide #2 also reported that Licensed Practical Nurse #1 stated no because he is already deceased . Certified Nurse Aide #3 was interviewed and reported that Licensed Practical Nurse #1 did not perform Cardiopulmonary Resuscitation on Resident #1. On [DATE], the approximately 4:30 PM, the State Department of Health was notified of the initial report via telephone of the incident. On [DATE], at approximately 2:00 PM, an initial report was submitted to local law enforcement, Attorney General's Office, and the Mississippi Board of Nursing of the incident involving Licensed Practical Nurse #1. On [DATE], at approximately 3:30 PM Licensed Practical Nurse #1 was terminated via telephone for failure to follow instructions from Staff Development Nurse #1 to initiate cardiopulmonary resuscitation on Resident #1 per facility policy. A facility Quality Assurance Committee meeting was held at approximately 3:30 PM, [DATE], to include facility Quality Assurance Committee members which consisted of the facility Administrator #1, Corporate Nurse #1, Regional Supervisor #1, Staff Development Nurse #1, Infection Preventionist Nurse, Medical Director #1, Assessment Nurse #1, Social Service Director #1, Activities Director #1 and Administrative Assistant #1. Topics discussed included: Failure to initiate CPR measures for a full code resident. The facility corrective actions were reviewed and initiated [DATE], to include the following: in-service training, code drills, medical record audits, and monitoring systems ongoing. On [DATE], in-service training was initiated by Staff Development Nurse #1 and Assessment Nurse #1 to include all Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping and Laundry staff, office personnel and contracted therapy department on the following: (a) Cardiopulmonary Resuscitation Policy, (b) Change in Resident Medical Status, (c) Emergency Care of Residents, (d) Care Plan Process, (e) Advance Directives, physician orders (f) Resident Rights, (g) Resident Abuse/Neglect and Reporting. The in-service conducted on [DATE], included two (2) Registered Nurses, five (5) Licensed Practical Nurses, and eight (8) Certified Nursing Assistants. Facility staff and agency staff if utilized will not be allowed to work until the proper in-service training has been conducted. On [DATE], Cardiopulmonary Resuscitation (CPR) Code Drills were initiated by the facility Staff Development Nurse #1 and the facility Assessment Nurse #1 for all Registered Nurses and Licensed Practical Nurses. Registered Nurses and Licensed Practical Nurses will not be allowed to provide direct patient care until participation in a code drill has been conducted. Code drill exercises will be performed daily until all Registered Nurses and Licensed Practical Nurses have participated in at least one exercise, and then code drills will continue as outlined below. On [DATE], all active resident's medical record charts were audited by the facility Staff Development Nurse #1, and Assessment Nurse #1 to ensure proper code status identification. The results of this audit showed one discrepancy found and was immediately corrected. On [DATE], all active residents plan of care were audited by the facility Assessment Nurse #1 and the Staff Development Nurse #1 to ensure proper code status identification. The audit results showed no issues found. On [DATE], monitoring systems were put in place to sustain compliance. (a) Verify licensed staff Cardiopulmonary Resuscitation certification status upon hire and monthly by the Director of Nursing. (b) All active resident medical records and plan of care will be monitored for the correct code status weekly for four (4) weeks, bi-weekly for three (3) months, then monthly thereafter. (c) the facility began monitoring cardiopulmonary resuscitation code drills on all three shifts, weekly times four (4) weeks, monthly time three (3) months, then per facility protocol thereafter (every four (4) months rotating shifts) (d) the facility began crash cart inventory checks for 30 days and then weekly thereafter. The facility Administration will have a follow up Quality Assurance Meeting on [DATE], and monthly times two months and then quarterly thereafter. The facility alleges that all corrective actions to remove the IJ were completed on [DATE], and the Immediate Jeopardy was removed as of [DATE]. Validation: The State Agency (SA) validation of the Corrective Action Plan was made on-site during the Complaint Investigation (CI) MS #26389 and CI MS #26398. On [DATE], the SA validated through record review and interviews that all corrective actions to remove the IJ were completed by the facility on [DATE] and the IJ was removed on [DATE], prior to the SA entering the building on [DATE].

Based on interviews, record review, and facility policy review, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) and provide emergency services to a resident who was found to have no respirations and no pulse for one (1) of three (3) sampled residents. Resident #1. Resident #1, who had a Full Code status, was found to have no respirations and no pulse. The nurse did not initiate CPR or activate emergency services for Resident #1. The resident expired in the facility. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE] when Resident #1 was found by facility staff to be unresponsive and without respirations, a pulse or blood pressure. The facility Administrator was notified of the IJ and SQC on [DATE] at 3:02 PM and was provided an IJ Template. Based on the facility's implementation of corrective actions on [DATE], the State Agency (SA) determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed as of [DATE], prior to the SA's first entrance on [DATE]. Findings Include: A record review of the facility's Cardiac Resuscitation Policy latest revision date ,d+[DATE], revealed, It is the policy of this facility to provide basic life support, including CPR, Cardiopulmonary Resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician orders and resident choice indicated in the resident's advance directives. Nurses and other care staff are educated to initiate CPR unless a valid Do Not Resuscitate (DNR) order is in place or obvious clinical signs of death are present such as rigor mortis . Record review of the Progress Notes by Licensed Practical Nurse (LPN) #1 dated [DATE] at 7:45 PM, revealed that she walked by Resident #1's room and noticed he did not look well. Upon entering the room, she found the resident unresponsive, with no respirations, pulse, or blood pressure. She then notified the coroner, the family, the Administrator, and the Nurse Practitioner of the resident's death. There was no indication that CPR was initiated or that emergency services were called. Record review of a Progress Note dated [DATE] at 2:57 PM by LPN #1 revealed a clarification note for [DATE], In my previous noted, I did not make it understandable that Resident's face and upper arms were cool to touch but when I uncovered lower arms and legs, his body was still warm . Record review of Resident/Family Consent for Cardiopulmonary Resuscitation (CPR) for Resident #1, dated [DATE], revealed I understand that CPR constitutes and extraordinary measure and SHOULD be done on this resident in the case of extreme emergency. Record review of Resident #1's Physician's Telephone Order dated [DATE] revealed an order for Full Code indicating that the resident should receive CPR. An interview with the Staff Development Coordinator on [DATE] at 12:45 PM, revealed that she instructed LPN #1 via phone to initiate CPR on Resident #1. Staff Development Coordinator further stated that when she asked LPN #1 why she had not performed CPR on Resident #1 LPN #1 responded it was because the resident was already deceased . The Deputy County Coroner revealed in an interview on [DATE] at 12:59 PM, that she received a call from LPN #1 on [DATE] at 7:55 PM, reporting Resident #1's death at 7:45 PM. The Coroner noted that facilities typically notify her after CPR and emergency services have been attempted. She pronounced Resident #1 deceased at the facility at 8:22 PM and observed that the resident did not exhibit rigor mortis or dependent lividity. The Deputy County Coroner further reported that when asked why CPR had not been initiated, LPN #1 stated that she had last seen the resident alive at 6:20 PM and was unsure of the exact time of death. During an interview on [DATE] at 1:30 PM, the Administrator confirmed that CPR should have been initiated on Resident #1, but it was not performed. Record review of the Facesheet for Resident #1 revealed the facility admitted Resident #1 on [DATE] with diagnoses that included Dementia and Chronic Kidney Disease. The facility submitted the following acceptable Corrective Action Plan on [DATE]: Corrective Action Plan On [DATE], while making rounds at 7:45 PM, Licensed Practical Nurse #1 reports glancing into Resident #1's room and observed resident not looking right and entered Resident #1's room to assess Resident #1's status. Licensed Practical Nurse #1 reports that resident was without active vita! signs, face and upper arms cool to touch, rest of body warm. Licensed Practical Nurse #1 then placed a call to the coroner at 7:55 PM and did not initiate cardiac resuscitation measures and call 911. Resident #1 medical record indicates resident was with full code status. Licensed Practical Nurse #1 notified facility Administrator of resident death at 8:00 PM. Licensed Practical Nurse #1 notified Staff Development Nurse #1 at 8:05 PM who instructed Licensed Practical Nurse # 1 to initiate Cardiopulmonary Resuscitation efforts. Licensed Practical Nurse #1 notified Nurse Practitioner at 8:10 PM of resident death. Licensed Practical Nurse #1 contacted Resident #1's sister at 8:15 PM and resident's family arrived at the facility at 8:45 PM. On [DATE], approximately 8:20 AM, it was determined by Staff Development Nurse #1 that Licensed Practical Nurse #1 did not initiate Cardiopulmonary Resuscitation efforts. On [DATE], at approximately 8:30 AM the facility Administrator was notified by Assessment Nurse #1 of the failure by Licensed Practical Nurse #1 to initiate cardiopulmonary resuscitation on Resident #1. On [DATE], at approximately 9:35 AM, Licensed Practical Nurse #1 was suspended via telephone by facility Administrator pending investigation. On [DATE], at approximately 9:30 AM, the facility Administrator interviewed Licensed Practical Nurse #1. The interview indicated Licensed Practical Nurse #1 was aware of the full code status and did not initiate Cardiopulmonary Resuscitation due resident being without signs of life. On [DATE], the Regional Supervisor and [NAME] President interviewed Licensed Practical Nurse #1 via telephone. The interview indicated the Licensed Practical Nurse #1 did not initiate Cardiopulmonary Resuscitation. On [DATE], the Assessment Nurse #1, interviewed the three Certified Nurse's Aide on shift at the time of the incident. The Certified Nurse Aide #1 was interviewed and confirmed that Cardiopulmonary Resuscitation was not initiated by Licensed Practical Nurse #1. The Certified Nurse Aide #2 was interviewed and reported that she had informed Licensed Practical Nurse #1 to start Cardiopulmonary Resuscitation after speaking to Staff Development Nurse #1 via telephone on the evening of [DATE]. Certified Nursing Aide #2 also reported that Licensed Practical Nurse #1 stated no because he is already deceased . Certified Nurse Aide #3 was interviewed and reported that Licensed Practical Nurse #1 did not perform Cardiopulmonary Resuscitation on Resident #1. On [DATE], the approximately 4:30 PM, the State Department of Health was notified of the initial report via telephone of the incident. On [DATE], at approximately 2:00 PM, an initial report was submitted to local law enforcement, Attorney General's Office, and the Mississippi Board of Nursing of the incident involving Licensed Practical Nurse #1. On [DATE], at approximately 3:30 PM Licensed Practical Nurse #1 was terminated via telephone for failure to follow instructions from Staff Development Nurse #1 to initiate cardiopulmonary resuscitation on Resident #1 per facility policy. A facility Quality Assurance Committee meeting was held at approximately 3:30 PM, [DATE], to include facility Quality Assurance Committee members which consisted of the facility Administrator #1, Corporate Nurse #1, Regional Supervisor #1, Staff Development Nurse #1, Infection Preventionist Nurse, Medical Director #1, Assessment Nurse #1, Social Service Director #1, Activities Director #1 and Administrative Assistant #1. Topics discussed included: Failure to initiate CPR measures for a full code resident. The facility corrective actions were reviewed and initiated [DATE], to include the following: in-service training, code drills, medical record audits, and monitoring systems ongoing. On [DATE], in-service training was initiated by Staff Development Nurse #1 and Assessment Nurse #1 to include all Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Housekeeping and Laundry staff, office personnel and contracted therapy department on the following: (a) Cardiopulmonary Resuscitation Policy, (b) Change in Resident Medical Status, (c) Emergency Care of Residents, (d) Care Plan Process, (e) Advance Directives, physician orders (f) Resident Rights, (g) Resident Abuse/Neglect and Reporting. The in-service conducted on [DATE], included two (2) Registered Nurses, five (5) Licensed Practical Nurses, and eight (8) Certified Nursing Assistants. Facility staff and agency staff if utilized will not be allowed to work until the proper in-service training has been conducted. On [DATE], Cardiopulmonary Resuscitation (CPR) Code Drills were initiated by the facility Staff Development Nurse #1 and the facility Assessment Nurse #1 for all Registered Nurses and Licensed Practical Nurses. Registered Nurses and Licensed Practical Nurses will not be allowed to provide direct patient care until participation in a code drill has been conducted. Code drill exercises will be performed daily until all Registered Nurses and Licensed Practical Nurses have participated in at least one exercise, and then code drills will continue as outlined below. On [DATE], all active resident's medical record charts were audited by the facility Staff Development Nurse #1, and Assessment Nurse #1 to ensure proper code status identification. The results of this audit showed one discrepancy found and was immediately corrected. On [DATE], all active residents plan of care were audited by the facility Assessment Nurse #1 and the Staff Development Nurse #1 to ensure proper code status identification. The audit results showed no issues found. On [DATE], monitoring systems were put in place to sustain compliance. (a) Verify licensed staff Cardiopulmonary Resuscitation certification status upon hire and monthly by the Director of Nursing. (b) All active resident medical records and plan of care will be monitored for the correct code status weekly for four (4) weeks, bi-weekly for three (3) months, then monthly thereafter. (c) the facility began monitoring cardiopulmonary resuscitation code drills on all three shifts, weekly times four (4) weeks, monthly time three (3) months, then per facility protocol thereafter (every four (4) months rotating shifts) (d) the facility began crash cart inventory checks for 30 days and then weekly thereafter. The facility Administration will have a follow up Quality Assurance Meeting on [DATE], and monthly times two months and then quarterly thereafter. The facility alleges that all corrective actions to remove the IJ were completed on [DATE], and the Immediate Jeopardy was removed as of [DATE]. Validation: The State Agency (SA) validation of the Corrective Action Plan was conducted on-site during the Complaint Investigation (CI) MS #26389 and CI MS #26398. On [DATE], the SA validated through record review and interviews that all corrective actions to remove the IJ were completed by the facility on [DATE] and the IJ was removed on [DATE], prior to the SA entering the building on [DATE].

Based on resident and staff interview, observation, record review and facility policy review the facility failed to maintain a safe environment when a resident's toilet was noted to be loose for one (1) of 30 resident bathrooms observed. Resident #21. Findings include: Record review of the facility policy, titled, Resident Environment, dated 09/15 revealed It is the policy of this facility to provide a safe, clean, comfortable and homelike environment . In an interview and observation on 06/11/24 at 9:23 AM, with Resident #21, the resident stated the toilet in his bathroom is loose and moves when he sits on it. An observation of the toilet in Resident #21's bathroom revealed that three-fourths (3/4) of the caulking around the base of the toilet was missing. A record review of the facility's Maintenance and Repair Log for June 2024 revealed there were no entries reporting the condition of the toilet in Resident #21's room. On 6/12/24 at 11:04 AM, during an observation and interview with the Maintenance Man confirmed three-fourths (3/4) of the caulking around the base of the toilet in Resident #21's bathroom was missing, and the toilet was loose. He stated he was unaware the toilet was in this condition. The Maintenance Man stated that the condition of the toilet was dangerous, and the resident could fall and hurt himself. During an interview on 6/12/24 at 1:10 PM, the Administrator agreed staff should have reported the loose toilet and that the resident could fall and hurt himself.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to implement an Activities of Daily Living (ADL) care plan for residents who required nail care and facial grooming for two (2) or seventeen residents sampled. Resident #21 and Resident #34 Findings include: A review of the facility's Care Plan Process policy, revision date of 08/17, revealed, Regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to a number of specified areas (e.g., customary routine, vision, and continence) . The Physician Orders, Medication Administration Record, and the Treatment Administration Record are part of the Comprehensive Care Plan . Resident #21 A record review of Resident #21's Comprehensive Care Plan with Problem Onset: dated 6/18/21 revealed, Problem: .needs assist with ADLS . Approaches . Bathing-Physical help in bathing activity. On 6/11/24 at 10:00 AM, during an observation and interview revealed that Resident #21's fingernails on both hands were one-half (1/2) inch long past the tip of his fingers. Resident #21 was also noted to have patchy facial hair one (1) inch long. He stated he wanted his nails cut and his face shaved and was unsure of when it had been done last. On 6/12/24 at 9:35 AM, during an interview and observation of Resident #21 with Licensed Practical Nurse #1 (LPN) she confirmed that Resident #21's nails and facial hair were long and that he needed his nails cut and needed to be shaved. LPN #1 was unsure of the last time Resident #21 had his nails cut or was shaved. Record review of the Face Sheet revealed Resident #21 was admitted to the facility on [DATE] with diagnoses that included Primary Open-angle glaucoma and lack of coordination. Resident #34 A record review of Resident #34's Comprehensive Care Plan with Problem Onset: dated 8/25/2023 revealed, Resident #34 needs assist with ADLS and was dependent on staff for bathing. On 06/11/24 at 9:55 AM and 2:30 PM, observations revealed Resident #34 sitting in his wheelchair, bilateral fingernails approximately one-half (1/2) inch long and jagged past the tip of fingers, and a brown substance under each nail. Facial hair was approximately 1/2 inch long and was noted to cheeks and chin. Observation on 06/12/24 at 08:25 AM, revealed Resident #34 lying in bed with no change in his appearance from the previous day. On 06/12/24 at 09:59 AM, observation and interview with the DON confirmed Resident #34's fingernails were long, jagged, and had a brown substance under the fingernails and needed to be cleaned and trimmed. An interview on 06/12/24 at 02:55 PM, with the Minimum Data Set (MDS) nurse revealed she is responsible for developing the care plans. She revealed the care plans are developed so the staff will know how to take care of the residents. She revealed under the ADL care plan that bathing includes nail care and shaving. She confirmed for Resident #21 and Resident #34 if they were not shaven and their nails were not clean and trimmed, then the plan of care was not being followed and it should have been. 47158

47158 Based on observation, staff, and resident interviews, record review, and facility policy review, the facility failed to provide personal hygiene as evidenced by long, jagged nails with brown substance underneath nails, and unshaven facial hair for two (2) of 17 sampled residents. Resident #21 and Resident #34. Findings Include: Record review of the facility policy titled, Nail Care, latest review date 01/24, revealed, Purpose, To promote cleanliness, safety and a neat appearance. Record review of the facility policy titled, Shaving, latest review date 01/24, revealed, Purpose, To provide hygiene in accordance with the resident's preferences and preferred self-image. Resident #21 An observation and interview on 6/11/24 at 10:00 AM, revealed that Resident #21's fingernails on both hands were one-half (1/2) inch long past his fingertips. Resident #21 was also noted to have patchy facial hair one (1) inch long. He stated he wanted his nails cut and his face shaved. He was unsure of when it had been done last. A record review of Active Orders for Resident #21 revealed an order for Nail Care Weekly. Check condition and clean as needed (PRN), with an onset date of 1/2/2024. A record review of Resident #21's Electronic Treatment Record (eTAR), for June 2024 revealed Nail Care Weekly. Check condition and clean prn, with no documentation that weekly nail care was performed during the month of June. A record review of the Resident Care Record for Resident #21, dated 5/1/24 through 6/12/24, revealed that there was no documentation that the resident had received nail care or been shaved during that time period. During an interview and observation of Resident #21 on 6/12/24 at 9:35 AM, with Licensed Practical Nurse #1 (LPN) she stated that the resident's nails are to be cut weekly. She stated that the nurse is responsible for cutting resident's nails if they are diabetic and the Certified Nursing Assistant (CNA) is responsible for cutting the resident's nails if they are not diabetic. LPN #1 was unsure of the last time Resident #21 had his nails cut or was shaved. She agreed that Resident #21's nails and facial hair were long and that he needed his nails cut and needed to be shaved. In an interview and observation of Resident #21, with CNA #1, on 6/12/24 at 9:45 AM, she verified that the CNAs are responsible for cutting residents nails if the resident is not diabetic. CNA #1 stated that Resident #21 was not diabetic, so she was responsible for cutting his nails. She stated that the resident's nails are cut, and they are shaved on their shower days if they need it. CNA #1 verified that Resident #21's nails and facial hair were long. She was unsure of the last time Resident #21 had his nails cut or had been shaved but agreed that it needed to be done. Record review of the Face Sheet revealed Resident #21 was admitted to the facility on [DATE] with diagnoses that included Primary Open-angle glaucoma and Lack of Coordination. Resident #34 Observation on 06/11/24 at 9:55 AM and again at 2:30 PM, revealed Resident #34 sitting in his wheelchair, bilateral fingernails approximately one-half (1/2) inch long and jagged past the tip of fingers, with a brown substance under each nail. Facial hair was approximately one-half inch long on his cheeks and chin. Observation on 06/12/24 at 08:25 AM, revealed Resident #34 lying in bed with no change in his appearance from the previous day. An observation and interview on 06/12/24 at 09:15 AM, revealed CNA #2 shaving Resident #34, and the resident is supposed to be shaved during his shower days which are Tuesday, Thursday, and Saturday. CNA #2 revealed that yesterday was his shower day and stated, I wasn't here and I'm not sure why he didn't get shaved. She confirmed that with his long facial hair, it looked like he hadn't been shaved in quite a while. CNA #2 confirmed Resident #34's nails were long and had a brown substance under them and needed to be cleaned and trimmed. In an interview on 06/12/24 at 9:25 AM, the Director of Nurses (DON) revealed that the CNAs are responsible for shaving their residents during baths or shower times and cleaning and trimming residents' nails if they are non-diabetic. She confirmed Resident #34 was not a diabetic. Observation and interview on 06/12/24 at 09:59 AM, the DON confirmed Resident #34's fingernails were long, jagged, and had a brown substance under the fingernails and needed to be cleaned and trimmed. An interview on 06/12/24 at 02:41 PM, Registered Nurse (RN) #1 revealed I cut and cleaned Resident #34's fingernails this morning when it was brought to my attention that it needed to be done. She revealed the resident is not a diabetic and it was supposed to be done by his CNA. RN #1 confirmed when she went in to clean and trim his nails, they were long and had a brown substance under them. She revealed she wasn't sure how long it had been since his nails had been done. Record review of the Face Sheet revealed Resident #34 was admitted to the facility on [DATE] with diagnoses that included Cognitive Communication Deficit and Weakness.

Based on observations, staff interview, record review and facility policy review the facility failed to prevent the possibility of the spread of infection as evidenced by a towel that had touched the floor being used to dry a resident after a bath for one (1) of three (3) resident's bed bath's observed. Resident #3 Findings Include: Review of the facility policy titled, General Infection Prevention and Control Nursing Policies with last review date of 08/21 revealed It is the policy of this facility that all nursing activities will be performed in a manner to minimize the potential for infection in resident's staff and visitors An observation on 6/28/23 at 9:15 AM, revealed Certified Nurse Assistant (CNA) #1 giving Resident #3 a bed bath and while she was washing the resident with a washcloth, the towel on the foot of the bed fell on the floor. CNA #1 finished washing the resident, then picked the towel up off of the floor and dried the resident's body with that towel. The CNA then removed the resident's brief, washed her bottom with a washcloth and dried her bottom with that same towel; the sacrum wound was covered in a dressing. An interview on 6/28/23 at 9:20 AM, with CNA #1 confirmed that the towel fell on the floor and should have been replaced. She revealed it should not have been used to wipe the resident down since it had touched the floor. She revealed she must have just been nervous. An interview on 6/28/23 at 1:00 PM with the Wound Nurse Practioner confirmed that a towel dropped on the floor should not be used to wipe a resident down, because there is always a possibility of spreading infection. An interview on 6/28/23 at 3:44 PM, with the Infection Preventionist revealed that a towel that had been dropped on the floor should not be used to wipe a resident down, because it could introduce any kind of pathogen or bacteria that it came in contact with from the floor and introduce it into the resident if they had an open wound. She revealed that is definitely a break in infection control. An interview on 6/29/23 at 8:30 AM, with the Director of Nurses (DON) confirmed that CNA #1 should have replaced the towel that she dropped on the floor and not used it to wipe Resident #3 down after her bath. She confirmed that using the dirty towel could cause cross contamination and infection. She revealed that all nursing staff are in-serviced on hire and annually on infection prevention and using clean linens and towels are included in that in-service and training. Review of the facility in-services revealed an Infection Prevention in-service in March 2023 that was attended by CNA #1. Record review of Resident #3's Facesheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus with diabetic neuropathy unspecified, Diabetes with neurological manifestations type 2 or unspecified type, uncontrolled and Pressure ulcer of sacral region, stage 4. Record review of Resident #3's Minimum Data Set with an Assessment Reference Date of 6/13/23 revealed under Section C a Brief Interview for Mental Status (BIMS) of 05, which indicates the resident is severely cognitively impaired and in Section M that the resident had an unhealed Stage 4 Pressure Ulcer.

Based on observations, staff interviews, record review and facility policy review the facility failed to implement the comprehensive care plan for a resident who needed care to promote the healing of a pressure ulcer and was dependent on staff for incontinent care for one (1) of 16 resident care plans reviewed. Resident #8. Findings include: Record review of the facility policy titled, Care Plan Process with a revision date of 08/17 revealed on page 4 .The Care Plan must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being. The facility staff shall follow the care plan . An observation on 2/6/23 at 10:30 AM, revealed Resident #8 sitting on the side of the bed with no brief and her pants pulled down to her knees while Certified Nurse Assistant (CNA) #2 and CNA #1 were assisting the resident out of bed. This observation revealed when the resident stood up that she had a formed bowel movement stuck between her buttock cheeks that was approximately 4 inches long and ran up under the brown and red stained 4x4 dressing on her sacrum. CNA #1 stated, Oh she has had a bowel movement and CNA #2 stated, Just hurry up and put her diaper on so we can sit her down. The CNA's put a clean brief on the resident, pulled her pants up and assisted her to the wheelchair. An interview on 2/6/23 at 11:10 AM, with CNA #1 revealed that Resident #8's bowel movement had not been cleaned yet. She revealed they were letting her eat her breakfast, before they cleaned her up. She revealed that Resident #8 had been sitting in her bowel movement since they got her up around 10:30 AM and that is not good. She revealed, I wouldn't want to have to sit in mine. An interview on 2/6/23 at 11:30 AM, with CNA #2 confirmed that Resident #8 had a bowel movement stuck between her buttock cheeks when they got her up at around 10:30 AM. She confirmed they were letting the resident eat her breakfast before they cleaned her up. She confirmed that the resident had been sitting in her bowel movement since 10:30 and that is not good especially with her having a sore at the top of her butt. An interview on 2/6/23 at 12:30 PM, with Registered Nurse (RN) #1-Treatment Nurse confirmed that Resident #8 has a facility acquired pressure ulcer on her sacrum, is incontinent of both bowel and bladder and has to have incontinent care performed by staff. An interview on 2/8/23 at 1:30 PM, with Minimum Data Set (MDS)/Licensed Practical Nurse (LPN) revealed she was responsible for completing the resident's care plans and putting them in the computer based on the MDS assessments and staff communication. An interview on 2/8/23 at 1:50 PM, with RN-Corporate Nurse confirmed that the resident should have had incontinent care regarding her bowel movement while the CNAs were in the room and should have had the supplies they needed before they entered the room to perform incontinent care. She revealed that the resident sitting in a bowel movement for 30-40 minutes would not be good for the resident's wound. An interview on 2/9/23 at 8:30 AM, with RN #1-Treatment nurse revealed the purpose of the care plan is to address and identify problems with the resident and if it is not implemented then the resident could get worse. An interview on 2/9/23 at 8:50 AM, with MDS/LPN revealed the purpose of the care plan is to see how to take care of the residents and if it is not implemented then care could be omitted. Record review of Resident #8's Face Sheet revealed she was admitted to the facility on [DATE] with medical diagnoses that included Type 2 diabetes mellitus with diabetic neuropathy unspecified, Obesity and Nutritional deficiency and a current diagnosis of Pressure ulcer of sacral region, unspecified stage. Record review of a care plan with a problem onset date of 1/11/2023 revealed (Formal name of Resident #8) has a pressure ulcer to her sacrum .Approaches .Provide Pericare with each incontinence episode Record review of a care plan with a problem onset date of 6/6/2016 revealed, (Formal name of Resident #8) needs assist with ADL's (Activities of Daily Living) . Approaches .Incontinence care every two hours as needed . Record review of Resident #8's MDS with an Assessment Reference Date of 11/23/22 revealed in Section C a Brief Interview for Mental Status of 12, which indicates that the resident is cognitively intact.

Based on observations, staff and resident interviews, record review and facility policy review, the facility failed to provide incontinent care for a resident who was dependent on staff as evidenced by incontinent care not being performed following a bowel movement for one (1) of five (5) residents reviewed that were dependent for their Activities of Daily Living (ADLs) /toilet use. Resident #8 Findings include: Record review of the facility policy titled Activities of Daily Living with a revision date of 12/20 revealed under Procedures .#1 Activities of Daily Living (ADL's) are to be resident specific and reflect current resident status. An observation on 2/6/23 at 10:30 AM, revealed Resident #8 sitting on the side of the bed with no brief and her pants pulled down to her knees while Certified Nurse Assistant (CNA) #2 and CNA #1 were assisting the resident out of bed. This observation revealed when the resident stood up that she had a formed bowel movement stuck between her buttock cheeks that was approximately 4 inches long and ran under the brown and red stained 4x4 dressing on her sacrum. CNA #1 stated, Oh she has had a bowel movement and CNA #2 stated, Just hurry up and put her diaper on so we can sit her down. The CNA's put a clean brief on the resident, pulled her pants up and assisted her to the wheelchair. An interview on 2/6/23 at 11:10 AM with CNA #1 revealed that Resident #8's bowel movement had not been cleaned yet. She revealed they were letting her eat her breakfast, before they cleaned her up. She revealed that Resident #8 had been sitting in her bowel movement since they got her up around 10:30 AM and that is not good. She stated, I wouldn't want to have to sit in mine. An interview on 2/6/23 at 11:30 AM with CNA #2 confirmed that Resident #8 had a bowel movement stuck between her buttock cheeks when they got her up at around 10:30 AM. She confirmed they were letting the resident eat her breakfast before they cleaned her up. She confirmed that the resident had been sitting in her bowel movement since 10:30 and that was not good especially with her having a sore at the top of her buttocks. An interview on 2/6/23 at 12:30 PM, with Registered Nurse (RN) #1-Treatment Nurse confirmed that Resident #8 has a facility acquired pressure ulcer on her sacrum, is incontinent of both bowel and bladder and has to have incontinent care performed by staff. An interview on 2/6/23 at 3:10 PM, with Resident #8 confirmed that the staff have to provide incontinent care. She confirmed she has a sore on her bottom that bothers her. An interview on 2/8/23 at 9:00 AM, with the Administrator confirmed that Resident #8 probably should have been cleaned when they got her up and saw that she had a bowel movement. An interview on 2/8/23 at 11:00 AM, with CNA #1 revealed that during the observation on 2/6/23 at 10:30 AM when she and CNA #2 were getting Resident #8 out of the bed and discovered the bowel movement they realized they did not have wipes in the room and therefore they could not clean the resident. She revealed that they were too embarrassed to tell the State Agency that they did not have wipes in the room and decided to let her eat before they went back and cleaned her up. She admitted that they should have made sure they had the supplies they needed in the room before attempting to get the resident up and clean her. An interview on 2/8/23 at 1:50 PM, with the RN-Corporate Nurse confirmed that the resident should have had incontinent care regarding her bowel movement while the CNAs were in the room and should have had the supplies they needed before they entered the room to perform incontinent care. She revealed that the resident sitting in a bowel movement for 30-40 minute would not be good for the resident's wound. An interview on 2/8/23 at 2:00 PM, with the Director of Nurses (DON) confirmed the CNAs should have had the supplies they needed when they went in the room to perform the incontinent care and that the resident sitting in a bowel movement could cause the residents' wound to get infected. Record review of the Completed Care Details report dated 2/7/23 with a 30 day lookback revealed documentation that indicated Resident #8 had pericare completed 35 times in the last 14 days for an average of 2.5 times per day. Record review of a care plan with a problem onset date of 6/6/2016 revealed, (Formal name of Resident #8) needs assist with ADLs . Goal & (and) Target Date: Formal Name of Resident #8) will be assisted with ADL's while promoting max level of independence through review date of 3/7/23 Approaches .Incontinence care every two hours as needed . Record review of Resident #8's Face Sheet revealed she was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus with diabetic neuropathy unspecified, Obesity and Nutritional deficiency and a current diagnosis of Pressure ulcer of sacral region, unspecified stage. Record review of Resident #8's Minimum Data Set with an Assessment Reference Date of 11/23/22 revealed in Section G that the resident needed extensive assistance with toilet use and in Section C a Brief Interview for Mental Status score of 12, which indicates that the resident is cognitively intact.

Based on observation, staff and resident interviews, record review and facility policy review, the facility failed to provide care to promote the healing of a pressure ulcer as evidenced by incontinent care not being performed after a bowel movement for one (1) of nine (9) residents reviewed for pressure ulcers. Resident # 8 Findings include: Record review of the facility policy titled, Pressure Ulcer Prevention and Treatment Interventions Guidelines with a revision date of 10/22 revealed A. Skin Hygiene Inspection . #3. Keep local areas of skin clean, dry, and free of body wastes, perspiration, and wound drainage D. Incontinence and Moisture Management. 1. Assess and treat incontinence. When incontinence cannot be controlled, use appropriate peri-care with barrier ointment or cream to perineal area after each episode of incontinence . An observation on 2/6/23 at 10:30 AM, revealed Resident #8 sitting on the side of the bed with no brief and her pants pulled down to her knees while Certified Nurse Assistant (CNA) #2 and CNA #1 were assisting the resident out of bed. This observation revealed when the resident stood up that she had a formed bowel movement stuck between her buttock cheeks that was approximately 4 inches long and ran under the brown and red stained 4x4 dressing on her sacrum. CNA #1 stated, Oh she has had a bowel movement and CNA #2 stated, Just hurry up and put her diaper on so we can sit her down. The CNA's put a clean brief on the resident, pulled her pants up and assisted her to the wheelchair. During an interview on 2/6/23 at 11:10 AM, with CNA #1 revealed that Resident #8's bowel movement had not been cleaned yet. She revealed they were letting her eat her breakfast, before they cleaned her up. She revealed that Resident #8 had been sitting in her bowel movement since they got her up around 10:30 AM and that is not good. She stated, I wouldn't want to have to sit in mine. On 2/6/23 at 11:30 AM, during an interview with CNA #2 confirmed that Resident #8 had a bowel movement stuck between her buttock cheeks when they got her up at around 10:30 AM. She confirmed they were letting the resident eat her breakfast before they cleaned her up. She confirmed that the resident had been sitting in her bowel movement since 10:30 and that was not good especially with her having a sore at the top of her buttocks. In interview on 2/6/23 at 12:30 PM, with Registered Nurse (RN) #1-Treatment Nurse confirmed that Resident #8 has a facility acquired pressure ulcer on her sacrum, is incontinent of both bowel and bladder and has to have incontinent care performed by staff. An interview on 2/6/23 at 2:30 PM, with Licensed Practical Nurse (LPN) #3 confirmed that Resident #8 has a wound on her sacrum and sitting in a bowel movement could cause the wound to get infected. Resident #8 reported during an interview on 2/6/23 at 3:10 PM, that the staff have to provide incontinent care for her. She confirmed she has a sore on her bottom that bothers her. An interview on 2/8/23 at 9:00 AM, with the Administrator confirmed that Resident #8 probably should have been cleaned when they got her up and saw that she had a bowel movement. An interview on 2/8/23 at 11:00 AM, with CNA #1 revealed that during the observation on 2/6/23 at 10:30 AM when she and CNA #2 were getting Resident #8 out of the bed and discovered the bowel movement they realized they did not have wipes in the room and therefore they could not clean the resident. She revealed that they were too embarrassed to tell the State Agency that they did not have wipes in the room and decided to let her eat before they went back and cleaned her up. She admitted that they should have made sure they had the supplies they needed in the room before attempting to get the resident up and clean her. An interview with the RN-Corporate Nurse on 2/8/23 at 1:50 PM, she confirmed that the resident should have had incontinent care regarding her bowel movement while the CNAs were in the room and should have had the supplies they needed before they entered the room to perform incontinent care. She revealed that the resident sitting in a bowel movement for 30-40 minutes would not be good for the resident's wound. The Director of Nurses (DON) confirmed during an interview on 2/8/23 at 2:00 PM, the CNAs should have had the supplies they needed when they went in the room to perform the incontinent care and that the resident sitting in a bowel movement could cause the residents' wound to get infected. Record review of Resident #8's Face Sheet revealed she was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus with diabetic neuropathy unspecified, Obesity and Nutritional deficiency and a current diagnosis of Pressure ulcer of sacral region, unspecified stage. Record review of Resident #8's Minimum Data Set with an Assessment Reference Date of 11/23/22 revealed in Section G that the resident needed extensive assistance with toilet use and Section C indicated Resident #8's Brief Interview for Mental Status score was 12, which indicated that the resident is cognitively intact.

Based on observation, staff and resident interviews, record review and facility policy review the facility failed to post oxygen in use signage on a resident's door for a resident using oxygen for one (1) of 5 residents reviewed who were receiving oxygen. Resident # 48. Findings include: Record review of the facility policy titled, Oxygen-Administration, Concentration, Storage, Assemblage with a revision date of 10/17 revealed under, Oxygen Safety .#5 Post an oxygen safety warning sign on the door where oxygen is stored or in use. An observation on 2/6/23 at 11:00 AM, revealed Resident #48 was receiving Oxygen (O2) via nasal cannula at 2 liters/min (LPM), with no oxygen in use sign posted on the resident's room door. An observation on 2/7/23 at 2:45 PM, revealed Resident #48 lying in bed watching TV and receiving O2 via nasal canula at 2L/minute with no oxygen signage on the resident's door. An interview on 2/8/23 at 8:21 AM with the Director of Nurses (DON) confirmed that if a resident is receiving O2 then they should have an O2 in use sign on their door. An interview on 2/8/23 at 8:25 AM with LPN #4 confirmed that Resident #48 receives O2. She confirmed that if a resident is receiving O2 then they should have an O2 in use sign on their door to make people aware that it is in use so that they do not bring stuff in that could cause it to blow up. An interview on 2/8/23 at 8:40 AM with the Staffing Coordinator/Licensed Practical Nurse (LPN) revealed that if a resident is receiving O2 then they should have an O2 sign on their door and confirmed that Resident #48 receives O2 and did not have an O2 sign on his door. An interview on 2/8/23 at 8:40 AM with the Minimum Data Set (MDS)/LPN confirmed that if a resident has O2 then they need a sign on the door of their room. An interview on 2/8/23 at 9:00 AM with the Administrator confirmed that it is the policy of the facility that if a resident is receiving O2 then they should have a sign on their door that indicated O2 in use to make people aware to not come in with anything that might make it combustiable Record review of Resident #48 Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Shortness of breath and hypoxemia. Record review of the February 2023 Physician Orders revealed and order dated 12/29/22 Oxygen @ (at) 2L/MIN via (by) nasal cannula as needed for shortness of breath . Record review of Resident #48's Minimum Data Set with an Assessment Reference Date of 11/16/22, indicated in section O that the resident had oxygen in use. Section C indicated that the resident had a Brief Interview for Mental Status score of 15 which indicates that the resident is cognitively intact.

Based on observation, staff interview, record review, and policy review the facility failed to maintain a medication error rate of less than five (5) percent, when three medications were not administered per physician's orders. This consisted of three (3) errors out of 35 opportunities resulting in a medication error rate of 8.57%. Resident #23 and Resident #45. Findings include: Record review of the facility policy Administration of Medications with a revision date of 10/17, revealed Purpose To administer medications in accordance with best practices .Oral Medication Administration Procedures .3 Verify the physicians order, comparing the medication label to the MAR (Medication Administration Record) to verify the following .b. Right dosage . Resident #23: An observation and interview with Licensed Practical Nurse (LPN) #1 on 2/8/23 at 8:05 AM revealed LPN #1 set up and administer medications to Resident #23. Resident # 23 asked LPN#1 Are you sure this is all my medication this don't look right. LPN #1 signed off all medications due for 9:00 AM on the E-MAR (Electronic Medication Administration Record) as given. The State Agency (SA) asked the nurse if he was finished administering Resident #23's s medication. LPN #1 stated he was and began moving the medication cart to another area of the hall. Record review of the Physician Order List for Resident #23 revealed an order dated 4/18/2016 Metformin HCL ER 500mg tablet-Give two tabs (1000 mg) by mouth twice a day .Colace 100 mg capsule-give 1 tab (tablet) by mouth twice a day . Recod review of the E-MAR and an interview with LPN #1 on 2/08/23 at 8:20 AM, revealed Metformin HCL ER (extended release) 500 mg (milligrams) tablet -Give two tablets (1000 mg) by mouth twice daily and Colace 100 mg- Give one capsule by mouth twice daily. LPN#1 confirmed he only gave one Metformin and he should have gotten two pills and confirmed he did not give the Colace at all. LPN #1 confirmed he did sign the medications as administered but he did not give the medication. LPN # 1 opened the cart and prepared the Colace as directed and the other half of the Metformin. LPN #1 stated it is the facility's practice that medications are to be verified using the E-MAR with the medication label on the card or bottle, placed in the medication cup and then click prepared on the E-MAR after each individual medication set up. Then, administer the medication and sign the medications as administered on the E-MAR after completion. LPN #1 confirmed he did not click prepared on the E-MAR after each medication was verified and confirmed he should have. LPN # 1 revealed a possible complication from not receiving Metformin is elevated blood sugars and constipation is a concern from missing Colace. An interview with the Director of Nursing (DON) on 2/8/23 at 10:50 AM, revealed a possible complication from not administering Metformin is problems with blood sugars and constipation for not administering Colace therapy. An interview with Resident #23 on 2/8/23 at 3:27 PM, revealed he often takes himself to the bathroom and feels his Colace is controlling his constipation. When asked about his diabetes he expressed he was happy his sugar is being controlled. Record review of Resident #23's Face Sheet revealed he was admitted on [DATE] with diagnoses of Cardiomyopathy, Type 1 and 2 Diabetes, Peripheral Vascular disease, and Constipation. Record review of the Admission MDS Section C with an Assessment Reference Date (ARD) of 01/11/23 revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. Resident #45: An observation with LPN #2 on 2/8/23 at 9:35 AM revealed LPN #2 set up and administer medications for Resident #45. LPN #2 returned to cart and signed all medications as given. LPN # 2 was asked if she was finished preparing giving all medication due for Resident # 45. LPN #2 confirmed that she did not administer Vitamin D 325 mcg (micrograms) but she signed the E-MAR as given. LPN # 2 revealed she should have clicked prepared after each medication to ensure she had them all, but she did not do that. LPN # 2 prepared the Vitamin D3 as ordered and administered as ordered An interview on 2/8/23 at 11:09 AM, with LPN # 2 revealed complications from not giving Vitamin D is bone loss or weakening bones. An interview with the Staffing Coordinator/Floor nurse on 2/08/23 at 2:42 PM, revealed when she gives medications she checks the directions on the medication card. She revealed nurses are to check the E- MAR three times to verify correct, punches the pill in a medication cup, then clicks prepared, and moves to the next medication. The Staffing Coordinator revealed after all medications are verified and prepared, the cart is locked the medications are given to the resident and signed as given. An interview with the Minimum Data Nurse (MDS) on 2/8/23 at 3:18 PM, revealed she works the medication cart when needed. She revealed when she gives medications, she verifies that the label and the E-MAR matches and puts the medication in the cup, clicks prepared on the E-MAR, closes the cart, administers the medications and returns to the cart to sign document as given. The MDS nurse also revealed the possible complications from not receiving metformin would be increased blood sugars and labs, Colace an increase in constipation, and Vitamin D 3 an increase for fracture related to bone loss. Record review of Resident #45's Face Sheet revealed he was admitted on [DATE] with diagnoses of Dysphagia,Dementia, Type 2 Diabetes and Gastrostomy tube . Record review of the Admission MDS Section C with an Assessment Reference Date (ARD) of 12/27/22, revealed Resident # 45 had a Brief Interview for Mental Status (BIMS) score of 5, indicating she had severe cognitive impairment. An interview with the Administrator on 2/9/23 at 8:44 AM, revealed he has no medical background, but if a resident does not receive diabetic medicine as ordered it can cause problems with blood sugars, and if missing Vitamin D3 for a period of time a fracture would be possible.

Based on staff interview, record review and facility policy review the facility failed to notify the responsible party in a written form when the resident was transferred to the hospital for five (5) of six (6) residents reviewed for hospitalization . Residents #25, #53, #24, #45 and #39. Findings include: Record review of the facility's policy titled, Transfer Form, with a revision date of 02/17, revealed a copy of the Transfer Form must be given to the resident or resident representative and maintained in the resident's medical record. On 8/14/19 at 2:30 PM, an interview with the Administrator (ADM) confirmed the facility was not sending a written notification to resident's responsible parties when a resident was transferred out of the facility. The ADM revealed she was not aware of the regulation that required a written notice was to be sent to the responsible parties when the resident was transferred to the hospital. Resident #24 Record review of Resident #24's physician's orders [REDACTED]. Resident #24 was admitted to the hospital for Urinary Tract Infection. Resident #24 did return to the facility on [DATE]. Review of the Face Sheet revealed Resident #24 was admitted by the facility, on 5/15/18 and readmitted on [DATE], with the included [DIAGNOSES REDACTED]. Resident #39 Record review of Resident #39's physician's orders [REDACTED]. Resident #39 remains in the hospital with expected return to the facility. Review of the Face Sheet revealed Resident #39 was admitted by the facility, on 6/19/19, with the included [DIAGNOSES REDACTED]. Resident #53 Record review of Resident 53's Nurses Notes, dated 3/19/19 at 10:04 AM, revealed the resident was transferred to the hospital due to difficulty breathing and lethargy. Review of the Nurses Notes, dated 3/23/19 at 12:43 AM, revealed Resident #53 returned to the facility after both transfers. Review of Resident #53's physician's orders [REDACTED]. Review of the Face Sheet revealed Resident #53 was admitted by the facility, on 3/27/17 and readmitted on [DATE], with included [DIAGNOSES REDACTED]. Resident #25 Record review of a Nurse's Note, dated 5/11/19, at 5:23 AM, revealed Resident #25 was transferred to the local hospital, on 5/11/19, with increased respiratory congestion and an oxygen saturation level of 85 percent. Record review of a Nurse's Note Late Entry, at 5:10 PM on 5/11/19, revealed the resident was admitted to the local hospital. Review of the resident's record revealed the Resident Representative (RR) was not notified in writing of the transfer. On 08/15/19 at 10:00 AM, an interview with the Director of Nursing (DON), revealed the facility did not issue a written notification to the RR at the time of the hospital transfer and that she was not aware of the regulation requiring written notification of RR when a resident was transferred to the hospital. The DON stated the RR would be called, and it should be documented in the record. Record review of Resident #25's Face Sheet revealed the resident was admitted by the facility on 3/7/14, with the included [DIAGNOSES REDACTED]. Record review of the Minimum Data Set (MDS) Quarterly Assessment ,with an Assessment Reference Date (ARD) of 5/24/19, Section C, revealed a staff assessment for mental status was conducted and the resident had severely impaired cognitive skills for daily decision making. Resident #45 Record review of a physician's orders [REDACTED].#45 revealed the resident was transferred to the local hospital emergency roiagnom on [DATE] for evaluation. On 08/15/19, at 3:46 PM, an interview with Administrator revealed the facility was not notifying the Responsible Party in a written form. She stated that the facility sends a transfer form with the resident to the hospital. The Administrator stated, she didn't know, and they would get it in order. Record review of the Face Sheet for Resident #45 revealed the resident was admitted by the facility on 11/08/11, with the included [DIAGNOSES REDACTED]. Review of Section C of the Minimum Data Set (MDS) Prospective Payment System 30 Day Assessment, with an Assessment Reference Date (ARD) of 7/8/19, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition.

Based on observation, staff interview, record review and facility policy review, the facility failed to develop a Care Plan for Resident #43's skin condition, care and treatment for one (1) of 17 residents reviewed for care plan development. The facility failed to implement the Care Plan related to Resident #36's pain management and changing Resident #25's oxygen tubing for two (2) of 17 care plans reviewed for implementation of care plans. Findings include: Record review of the facility's policy titled, Care Plan Process, dated 8/17, revealed the facility staff shall follow the care plan. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical nursing, and mental and psychosocial needs. Resident #43 Record review of Resident #43's Care Plan revealed no care plan or interventions were developed to address the resident's lower extremities' skin condition, the visits to the wound clinic, or any treatment for the lower extremities' skin condition. Further review of the Care Plans revealed the skin condition and compression and [MEDICAL CONDITION] control interventions were not added until 8/14/19, after the surveyor identified there was no care plan or interventions for this concern. On 08/12/19 at 12:33 PM, an observation revealed Resident #43 was sitting in the dining room at a table with noted swelling and blistered areas on her front lower extremities. Review of Resident #43's physician's orders [REDACTED]. Call for appointment if needed. (MONTH) shower without dressing. Keep skin clean and well moisturized (with cream such as [MEDICATION NAME]) daily. ACE 6X5 (Compression Bandage six inches by five feet) to Bilateral Lower Extremity (BLE) as needed (PRN). Compression/[MEDICAL CONDITION] Control: Single Layer Compression Wrap to affected Leg(s). Apply compression wrap from mid-foot to knee, covering heel. Apply in the morning. Remove at bedtime. Keep legs elevated. - ACE 6x5 to BLE PRN. Elevate leg(s) above the level of the heart when sitting - Monitor fluid intake. On 08/14/19 at 4:09 PM, an interview with RN #1/Case Mix/Care Plan Nurse, revealed there was no care plan developed addressing the skin breakdown on Resident #43's lower extremities, the treatments to the skin or the weekly visits to the wound clinic. On 08/14/19 at 10:15 AM, an interview with Registered Nurse (RN) #2, revealed there was no orders for treatment for the skin issues on Resident #43's lower legs. RN #2 also confirmed after review of the orders on 8/1/19 from the wound healing center that she was not aware of these orders for Resident #43's wound clinic visit on 8/1/19 for a single layer compression wrap to affected legs, apply compression wrap from mid-foot to knee, covering heel. Apply in the morning. Remove at bedtime. Keep legs elevated. RN #2 confirmed the order from the wound clinic was not being implemented. Resident #36 Record review of Resident #36's Care Plan revealed a Care Plan, no date, was developed for pain. Further review of the Care Plan revealed the goal stated Resident #36 would not have any pain through the next review on 11/15/19. The Interventions included: Instructed staff to administer medications as ordered. Record review of Resident #36's (MONTH) 2019 Electronic Medication Administration Record, [REDACTED]. On 08/14/19 at 3:50 PM, an interview with RN #1 revealed she was one of the nurses responsible for developing Care Plans, and she confirmed Resident #36's Care Plan had an intervention that instructed staff to administer medications as ordered for pain. RN #1 confirmed the nursing staff did not give an ordered medication to Resident #36 for pain related to her arthritis. Resident #25 Review of Resident #25's Care Plans revealed a care plan, with a problem onset date of 12/07/16, for oxygen therapy with the included approach: Change tubing to oxygen every seven (7) days. An observation, on 8/12/19 at 4:51 PM, revealed there was no date on Resident #25's oxygen (O2) tubing. There was a piece of tape wrapped around the O2 tubing at the connection site to the humidifier bottle, which was torn. The Humidification bottle was dated 8/6/19. An observation, on 8/13/19 at 11:08 AM, revealed the humidification bottle had been changed, but there was no date on the bottle. The O2 tubing with the torn tape was still around the tubing. On 08/13/19 at 1:53 PM, an interview with the Director of Nursing (DON), revealed the care plan was not followed for changing the O2 tubing every seven (7) days. Record review of the (MONTH) 2019 physician's orders [REDACTED]. Record review of Resident #25's Face Sheet revealed the resident was admitted by the facility on 3/7/14, with the included [DIAGNOSES REDACTED]. Record review of the Minimum Data Set (MDS) Quarterly Assessment, with an Assessment Reference Date (ARD) of 5/24/19, Section C, revealed that a staff assessment for mental status was conducted and the resident had severely impaired cognitive skills for daily decision making.

Based on observation, staff interview and facility policy review, the facility failed to revise a care plan for oxygen therapy when the order for oxygen was changed from as needed to continuous for (1) of 17 resident care plans reviewed, Resident #25. Findings include: Review of the facility's policy titled, Care Plan Process, with the latest revision of 08/17, revealed The care plan must be reviewed and revised periodically, on an ongoing basis to reflect the services provided or arranged, and must be consistent with each resident's written plan of care. Record review of Resident #25's Care Plan revealed a Problem/Need for oxygen therapy as needed due to shortness of breath while lying flat. The Onset Date was 12/07/16. The Goal & Target Date stated Resident #25 would receive adequate oxygen saturation, and would have no complications with oxygen therapy thru the next review on 8/27/19. An observation, on 8/12/19 at 4:51 PM, revealed Resident #25 was lying in bed, positioned on his right side with pillows. The head of the bed was elevated approximately 30 degrees. Resident #25 had oxygen (O2) on at two liters per minute (2 L/M) via a nasal cannula attached to an O2 concentrator. Record review of the (MONTH) 2019 physician's orders [REDACTED]. During an interview with the Director of Nursing (DON), on 8/13/19, at 1:53 PM, she confirmed that Resident #25's care plan for oxygen therapy had not been revised to reflect the current oxygen order and that it would be important that the care plan reflect the current condition of the resident. Record review of Resident #25's Face Sheet revealed the resident was admitted to the facility, on 3/7/14, with the included [DIAGNOSES REDACTED]. Record review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 5/24/19, Section C, revealed that a staff assessment for mental status was conducted and the resident had severely impaired cognitive skills for daily decision making.

Based on observation, staff interview, resident interview, record review and facility policy review, the facility failed to provide a skin treatment as ordered by a physician for one (1) of three (3) resident skin observations. Resident #43 Findings include: Record review of the facility's policy titled, Prevention and treatment of [REDACTED]. On 08/12/19 at 12:33 PM, an observation revealed Resident #43 was sitting in the dining room at a table with noted swelling and blistered areas on her front lower extremities. Review of Resident #43's physician's orders [REDACTED]. Call for appointment if needed. (MONTH) shower without dressing. Keep skin clean and well moisturized (with cream such as [MEDICATION NAME]) daily. ACE 6X5 (Compression Bandage six inches by five feet) to Bilateral Lower Extremity (BLE) as needed (PRN). Compression/[MEDICAL CONDITION] Control: Single Layer Compression Wrap to affected Leg(s). Apply compression wrap from mid-foot to knee, covering heel. Apply in the morning. Remove at bedtime. Keep legs elevated. - ACE 6x5 to BLE PRN. Elevate leg(s) above the level of the heart when sitting - Monitor fluid intake. Further review of the (Name of Hospital) Wound Healing Center revealed Physician order [REDACTED]. Both orders stated: Return appointment in one week. Wound Cleansing & Dressings: Dressing/wrap to be changed in seven (7) days, by nurse, upon arrival to the wound healing center. Do not get wrap wet. [MEDICATION NAME] to wound covered with ABD pads, [MEDICATION NAME] cream, [MEDICATION NAME], and ACE 6x5 (Compression bandage six inches by five feet) to RLE (Right Lower Extremity). Compression and [MEDICAL CONDITION] Control: Multi Layer Wrap to affected leg(s) - Do not get leg(s) with wrap wet. If wraps are too tight, elevate leg(s) and the call the wound center. Remove wrap if discomfort continues. ABD pads, [MEDICATION NAME] cream, [MEDICATION NAME], and ACE 6x5 to RLE. Elevate the leg(s) above the level of the heart when sitting - Monitor fluid intake. Physician Review: Discussed Plan of Care at bedside with patient/caregiver. Orders sent to the nursing home, as they provide care for the patient. On 8/12/19 at 3:00 PM, an interview with Resident #43 revealed the nurses do not do any treatments to her legs. On 08/14/19 at 10:15 AM, an interview with Registered Nurse (RN) #2/Treatment Nurse confirmed there were no orders for treatment to Resident #43's lower legs. After review of the orders on 8/1/19, RN #2 confirmed she was not aware of the orders from the wound clinic, dated 8/1/19, for Resident #43 to apply a single layer compression wrap to affected legs, apply compression wrap from mid-foot to knee, covering heel. Apply in the morning. Remove at bedtime. Keep legs elevated. RN #2 confirmed the order from the wound clinic was not being implemented. On 8/15/19 at 11:32 AM, an interview with the Director of Nursing (DON) confirmed the order from the Physician at the wound clinic, on 8/1/19, after Resident #43 was treated there, did not get processed or implemented after she returned to the facility. Record review of Resident #43's (MONTH) 2019 physician's orders [REDACTED]. D ointment twice daily and monitor leg for drainage, open wounds or bleeding. Further review of the orders revealed no orders for treatment to Resident #43's lower legs were written until 8/14/19, after the surveyor brought the absence of orders for the resident's lower leg treatment. Review of the Face Sheet revealed Resident #43 was admitted by the facility, on 7/16/15, and readmitted on [DATE], with included [DIAGNOSES REDACTED].

Based on observation, staff interview, facility policy review and record review the facility failed to change the oxygen tubing every seven (7) days for 1 of five (5) residents reviewed with oxygen. Resident # 25 Findings include: Review of the facility's policy titled, Infection Control Oxygen Equipment Cleaning, latest revision of 03/18, revealed: Use disposable tubing, masks, and cannulas for patients receiving oxygen therapy. This equipment is to be discarded as this procedure dictates: 7. Tubing should be replaced every 7 (seven) days. An observation, on 08/12/19 at 4:51 PM, revealed Resident #25's oxygen (O2) tubing was attached to an O2 concentrator by his bed. The O2 tubing had not date to indicate the date it was connected to the O2 concentrator. There was a piece of torn white tape wrapped around the O2 tubing at the connection to the humidifier bottle. On 08/13/19 at 11:08 AM, an observation revealed the same O2 tubing with the torn tape around the tubing at the connection to the humidifier bottle remained attached to the concentrator. Record review of the (MONTH) 2019 physician's orders [REDACTED]. On 08/13/19 at 11:10 AM, during an interview with Licensed Practical Nurse (LPN) #2 revealed she confirmed the tape looked as if it had been torn off, and that there was no date on the oxygen tubing. LPN #2 stated the whole system is usually changed every Sunday on the 11/7 shift. She stated it was important to change the tubing weekly because we want to be sure they are getting proper air flow. If it has been on too long they may not get the proper air they need, sometimes it will make their nose dry out, and also for sanitary issues, it may cause an infection. LPN #2 confirmed that there would be no way of knowing how long the tubing had been in use without a date. On 08/13/19 at 1:53 PM, in an interview with the Director of Nursing (DON), she stated that the oxygen tubing should be changed weekly on the 11/7 shift, and it should be dated on a piece of tape. The DON stated that it's important to have clean tubing. Record review of Resident #25's Face Sheet revealed the resident was admitted by the facility, on 3/7/14, with a [DIAGNOSES REDACTED]. Record review of the Minimum Data Set (MDS) Quarterly Assessment, with an Assessment Reference Date (ARD) of 5/24/19, Section C, revealed that a staff assessment for mental status was conducted and the resident had severely impaired cognitive skills for daily decision making.

Based on observation, staff interview, resident interview, record review and facility policy review, the facility failed to administer pain medication as ordered by the physician for one (1) of two (2) residents monitored for pain. Resident #36 Findings include: Record review of the facility's policy titled, Pain Screen and Management, dated 9/18 revealed all residents who experience routine pain receive a comprehensive pain screening and a treatment plan until acceptable level of relief is achieved. On 08/12/19 at 04:07 PM an interview with Resident #36 revealed she had arthritis and pain in her hands and wrist, and she was supposed to receive a shot on Saturday for her arthritis, but she did not. Resident #36 revealed she was told by the nurse she did not have any, and she would take care of it on Monday. Record review of Resident #36's Medication Administration Record [REDACTED]. Record review of Resident #36's Physician order [REDACTED]. On 8/15/19 at 11:45 AM, a phone interview with Licensed Practical Nurse (LPN) #1 confirmed she did not give Resident #36 her ordered and scheduled Actemra injection on Saturday at 9:00 AM due to there was none in the facility. LPN #1 revealed she checked in the medication storage room refrigerator, where it was kept, and it was not there. LPN #1 revealed she attempted to call Resident #36's physician but was unable to get him, and she called the pharmacy and was told they did not have the medication in stock and would have to order it and it should be delivered on Monday. LPN #1 confirmed she did not document she attempted to call the physician, that she called the pharmacy and did not document being out of the medication on the 24 hour report. On 08/12/19 at 4:36 PM, an interview with the Director of Nursing (DON) confirmed Resident #36's Electronic Medication Administration Record [REDACTED]. The DON revealed the last injection was given (MONTH) 3, 2019, and should have been reordered at that time but was not. On 8/15/19 at 11:32 AM, an interview with the DON confirmed Resident #36 did not receive her Actemra on Saturday as ordered. The DON revealed the nurse that gave the last injection should have ordered another injection for the next week. The DON revealed Resident #36's physician was notified on 8/13/19. mg/0.9 ml scheduled for 8/10/19 was not administered Record review of Resident #36's Nurses Notes, dated 8/10/19 at 10:15 AM, revealed LPN #1 documented the Actemra 162 .

Based on observation, staff interview, record review, facility policy/procedure review, and Material Safety Data Sheet (MSDS) review, the facility failed to ensure hazardous, caustic chemicals located in the housekeeping and nursing storage areas were stored, locked, secured, and inaccessible to residents for two (2) housekeeping chemical storage areas and two (2) nursing chemical storage areas on the East and West Units where two (2) wandering ambulatory residents with cognitive impairment were housed, one (1) on each unit, Resident #10 and Unsampled Resident #D. This was two (2) of 10 ambulatory residents The facility failed to ensure the safety of the residents when Housekeeping and Nursing staff failed to secure hazardous chemicals behind locked doors and away from cognitively impaired, wandering residents. This failure had the likelihood of placing two (2) cognitively impaired, wandering residents at risk for serious injury, harm, impairment, or death. There were 10 ambulatory residents in the facility of which two (1) had severe cognitive impairment. One (1) resident was identified on the East Hall and one (1) on the West Hall who were cognitively impaired and mobile with access to the unlocked areas. An Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 6/27/16, and was determined to exist on 6/27/16 when an observation during initial tour of the facility revealed cleaning chemicals were stored unsecured in an unlocked housekeeping storage closet and nursing storage area. The State Agency (SA) notified the facility on 6/27/16, of the IJ and SQC. The facility submitted a credible Allegation of Compliance (AOC) on 6/28/16. The SA Surveyor validated the facility's Allegation of Compliance (AOC) and the Immediate Jeopardy was determined to be removed on 6/29/16, prior to exit from the facility on 7/2/16. Therefore, 42 CFR 483.25 (h), F 323 was lowered from a K level deficiency to a E level or patterned deficiency while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Housekeeping Safety policy, revised 8/13, revealed, All hazardous supplies must be locked up when unattended. West Hall Observations: During the initial tour on 6/27/16 at 1:50 PM, an observation/interview with Registered Nurse (RN) #1, revealed the housekeeping closet (West Hall) was found unlocked with no staff present and the lights off. The following chemicals were identified, along with the hazards associated with the chemicals: 1. A metal shelf in the housekeeping closet contained two (2) quart spray cans of glass cleaner with warnings for inhalation, skin and eye irritation. 2. Four (4) spray cans of foaming disinfectant cleaner with warnings for eye irritation, possible skin and respiratory irritation. 3. On the floor of the housekeeping closet was one (1) gallon of liquid Odor Control Eliminator with no lid with warnings for eye/skin irritation, call poison control if ingested, if inhaled move to fresh air. 4. On the floor of the housekeeping closet was one (1) gallon of liquid Disinfectant Bathroom Cleaner with the lid loose with a warning that it may cause eye/skin/respiratory irritation, ingestion may cause gasrointestinal irritation and irritation to mucous membranes. RN #1, who was on the initial tour 6/27/16 at 1:50 PM, revealed she thought the doors should be locked. On 6/27/16 at 4:35 PM, an observation and interview with Licensed Practical Nurse (LPN) #2, revealed the nursing storage closet on the (West Hall) door was found unlocked with no staff present and the lights off. The following chemicals were identified with the hazards associated with the chemicals: 1. On the floor were two (2) red buckets of Emulsion Floor Sealer with a warning of harmful if swallowed, causes serious eye damage and may cause allergic skin reaction. 2. On the floor were two (2) blue buckets of Spray Glass Cleaner with warnings for inhalation, skin and eye irritation. LPN #2, who was on the tour, stated that the door wasn't locked because the Certified Nursing Assistants (CNAs) used the room for washing out the incontinent pads. East Hall Observations: Observation of the East hall with Registered Nurse #2 on 06/27/16 beginning at 2:30 PM, revealed an unlocked housekeeping closet and boiler room closet both containing hazardous chemicals. The unsecured chemicals in the East hall housekeeping closet were the following, along with the hazards associated with the chemicals: 1. One (1) bottle of Comet with bleach spray with warnings reading could cause eye/skin/respiratory irritation, get medical attention if ingested or symptoms occur. 2. One(1) gallon of odor eliminator disinfectant and a five (5) gallon bucket of odor eliminator disinfectant 1/3 full and another gallon bottle sitting on the housekeepers cart (in closet) with with side cut and a toilet brush sitting inside it. The chemical warning was for eye/skin irritation, call poison control if ingested. If inhaled move to fresh air. 3. There was one (1) gallon of foaming disinfectant with warnings for eye irritation, possible skin and respiratory irritation; call poison control or MD if not feeling well. 4. Three (3) cans of all-purpose degreaser that may cause irritation to eyes/skin/respiratory. If ingested may cause gastrointestinal irritation and harm the central nervous system. 5. One (1) Packet of hard surface wipes with a warning reading may cause skin/eye/respiratory irritation and large amounts may produce gastrointestinal disturbance. 6. One (1) gallon H2O (water) base shine maintenance with a warning reading may cause skin/eye/respiratory and gastrointestinal irritation. The East storage room had one (1) gallon of odor eliminator disinfectant with a warning for eye/skin irritation, call poison control if ingested. If inhaled move to fresh air. During an interview on 06/27/16 at 2:40 PM, Registered Nurse (RN) #2 confirmed the findings in the unlocked East housekeeping closet and the storage room. RN#2 stated that the door should be locked at all times and that Housekeeping Worker #1 and the Administrator were the only ones that had a key. The facility had two wings, East and West, with a front and back hall to each wing. There were 25 residents on the East wing and 27 residents on the West wing at the time of survey and one (1) resident in the hospital. Both the Housekeeping closet and the nursing storage closet were located on the West and East Hall used by residents. Two (2) cognitively impaired, ambulatory residents were identified as wanderers with the ability to access the rooms where the chemicals were stored. Resident #10's room was on the East back hall, approximately 12 doors from the storage room. Unsampled Resident #D's room was on the West Hall two (2) doors from the storage area where chemicals were found. Both were identified, care planned and monitored for wandering behavior. Entry into the four (4) doors, two (2) housekeeping chemical storage areas and two (2) nursing chemical storage areas on the East and West Units, may prove difficult or heavy for wheelchair bound residents but would not pose a problem for ambulatory residents. On 6/27/16 at 3:55 PM, an interview with the Maintenance/Housekeeping Staff #1, revealed, he was responsible for housekeeping, maintenance and laundry. The Maintenance/Housekeeping Staff #1 stated that everybody knows that the storage room doors should be locked and the door is not suppose to be left open. He said the housekeeping staff that gets off at 5:00 PM are supposed to make sure the door is locked. He stated he randomly checked the door every day or two to make sure that it was locked. On 6/27/16 at 4:00 PM, an interview with the Administrator revealed, There is a key at the nurse's station, the housekeeper on duty has a key, (Name of Maintenance Supervisor) has a key and there is one(1) in the lock box in the business office. (Key to storage areas) On 6/27/16 at 4:10 PM, an interview with Maintenance/Housekeeping Staff #1, revealed, It's a key lock, it is not a self lock, you have to lock it. He stated that a storage room should have a self-lock to ensure when it closed the door would lock. He stated the facility needed to change the lock but he had not had a chance to fix it all. On 6/28/16 at 9:20 AM, an interview with Housekeeping/Maintenance Staff #3 revealed, I actually do not know why it was unlocked. We are suppose to lock it (housekeeping closet) when we go out and, It should stay locked to keep residents from harming themselves by getting in the chemicals. Interview with the DON on 7/28/16 at 2:30 PM, revealed that she had not seen any resident attempt to enter the closets where chemicals were stored and that it usually stayed locked. Review of the facility's copies of the Material Data Sheets (MSDS) for the chemicals discovered in the unlocked housekeeping closet and the nursing storage closet revealed MSDS were available for the chemicals. Review of these sheets revealed multiple warnings for swallowing, eye irritation, skin irritation, and inhaling vapors. The facility submitted a credible Allegation of Compliance on 6/28/16 for the Immediate Jeopardy. Review of the facility's credible Allegation of Compliance revealed the facility took the following measures to remove the Immediate Jeopardy: 1. On 6/27/16, at approximately 4:52 PM, the survey team informed the Administrator that the Housekeeping Supply Room on the East and West Wings were unlocked during their initial tour upon arrival at the facility. When surveyors made a second round in the facility at 4:45 PM, the Housekeeping Supply Rooms doors were locked, but the East and West Wing Hopper Room doors were unlocked and hazardous cleaning chemicals were present in that room and accessible to residents. 2. All rooms were checked for hazardous chemicals and doors to the Housekeeping Supply Rooms and Hopper Rooms (nursing storage rooms) were locked at 4:55 PM on 6/27/16 by the Administrator. Two (2) wandering residents had access to the areas. 3. An in-service was started with ten (10) of twenty-five Certified Nursing Assistants, nine (9) of nineteen Licensed Nurses, one (1) of one (1) Maintenance Supervisor, two (2) of three (3) Laundry employees, four (4) of eight (8) Dietary employees, two (2) of four (4) Therapy employees, (0) zero of seven (7) Housekeeping employees, two (2) of two (2) Administrative employees, one (1) of one (1) Social Services Director, and one (1) of one (1) Activities Director in the facility at 5:15 PM by the Administrator and Minimum Data Set Nurse on 6/27/16, on making sure that any room containing hazardous chemicals or housekeeping supplies is locked at all times and where to locate Safety-Data Sheets and the policy titled, Safety Data Sheets (SDSs). In-service was conducted on 6/27/16, starting at 5:15 PM, by the Administrator and Minimum Data Set Nurse on making sure that any room containing hazardous chemicals or housekeeping supplies is locked at all times. Employees will not be allowed to work until in servicing on keeping Housekeeping and Hopper Room doors locked at all times has been completed. 4. Four (4) housekeeping employees that were on duty on 6/27/16 were disciplined with written warnings for not keeping housekeeping doors locked at all times and violation of safety rules by the Maintenance Director and Administrator on 6/28/16 starting at 6:30 am. The Maintenance Supervisor was disciplined with a written warning for violation of safety policies and not keeping housekeeping doors locked at all times by the Administrator on 6/27/16 at 5:30 PM. The four (4) Certified Nursing Assistants that worked West Wing on 6/27/16 were disciplined with written warnings for violation of safety rules and not keeping the Hopper Rooms locked at all times by the Director of Nursing on 6/28/16 starting at 7:00 am. The four (4) Certified Nursing Assistants that worked East Wing on 6/27/16 were disciplined with written warnings for violation of safety rules and not keeping the Hopper Rooms locked at all times by the Director of Nursing on 6/28/16 starting at 7:00 AM. 5. Twice a shift rounds are being made by the Charge Nurses to ensure Housekeeping Rooms and Hopper Rooms doors are locked starting at 5:30 PM on 6/27/16, and documented on the rounds flow record form that will be kept in a binder at each nursing station. 6. Automatic door locks were installed by the Maintenance Supervisor on all Housekeeping Room doors and Hopper Room doors starting at 11:00 AM on 6/28/16. 7. A facility Quality Assurance Committee meeting was held on 6/28/16 at 10:00 AM which included the Administrator, Director of Nursing, Maintenance Supervisor, Accounts Manager, Medical Records Clerk, Social Services, Dietary Manager and the facility Medical Director. The facility's immediate jeopardy and corrective action plan was reviewed during the Quality Assurance meeting on 6/28/16 at 10:00 AM with procedure changes to include the Charge Nurses making rounds twice a shift to ensure Housekeeping and Hopper Room doors are locked at all times and documenting these rounds on the rounds flow record form kept in the binder at each nurses station. 8. Please accept this as our credible allegation of compliance for abating the deficient practice as determined on June 27, 2016 to place the facility in the Immediate Jeopardy status. 9. All activities to remove the immediate jeopardy were completed and we allege the immediate jeopardy will be considered removed on 6/29/16. On 6/30/16-7/1/06, the State Agency (SA) Surveyors validated the facility had implemented measures to remove the Immediate Jeopardy as of 6/29/16. The acceptable Allegation of Compliance was verified by interviews and record review of in-services across all disciplines. These interviews included two (2) Kitchen/Cook Aides, two (2) Housekeepers, two (2) Social Workers, Three (3) Certified Nursing Assistants, one (1) Laundry worker, four (4) Licensed Practical Nurses, two (2) Registered Nurses, and one (1) Activity Director. The staff interviewed revealed knowledge of the facility's policy/procedure for Chemical Storage (of keeping doors locked and chemicals secured) and attendance of the in-service on Chemical Storage that began on 06/27/16. On 7/1/16 at 8:30 AM, an observation of the housekeeping closet and the nursing storage room on the West Hall revealed doors closed and locked. Record review of personal files revealed the Maintenance Supervisor, four (4) housekeepers and four (4) Certified Nursing Assistants were disciplined and in-serviced on secured storage of chemicals. Record review of the log sheets in the binder at the nurse's station confirmed that visual audits of locked chemical doors were being completed twice per shift. Record review revealed a Quality Assurance (QA) Committee meeting sign in sheet, dated 6/28/16. Those attending the QA meeting included the Medical Director, Administrator, Dietary Manager, Medical Records, Licensed Social Worker, Maintenance, Accounts Manager and the Director of Nursing per documented signature. Record review of the sign-in sheets revealed an in-service began staff wide on 6/27/16 and that no staff were allowed to work until in-serviced. This was accomplished through facility staff roster and inservice sign in comparison. Review of the list of the 10 ambulatory residents were compared with the Brief Interview for Mental Status (BIMS) scores for those residents identified with cognitive impairment. It was confirmed that Resident #10 and Unsampled Resident #D were the only two (2) ambulatory residents with severe cognitive impairment. Observation during the survey confirmed no residents attempting to enter the housekeeping and nurse storage areas where the chemicals had been unsecured.

CI MS # Based on observation and record review, the facility failed to develop and revise a care plan to reflect changes for treatment for [REDACTED].#4). Resident #4's pressure ulcer to the buttock increased from a Stage II and he developed other pressure ulcers/wounds that were not identified and/or treated timely. Findings include: Resident #4 Record review revealed Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #4 was admitted for Hospice Services. Review of Resident #4's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/1/13 revealed that he had severe cognitive impairment and required extensive to total assistance with all activities of daily living and had no documentation of pressure ulcers or other ulcers present on this assessment. Observation of Resident #4 during wound treatment by Registered Nurse (RN) #1/Treatment (Tx) Nurse on 5/23/13 at 9:40 a.m. revealed the right hip dressing that had slight drainage was removed to reveal two (2) small areas with a skin bridge between them. One (1) area measured approximately 2.0 x 1.5 cm and shallow almost scraped depth and the other 2.0 x 1.3 x 0.6 cm. This area was cleansed with normal saline, dried and [MEDICATION NAME] applied. The Left sacral/coccyx area had no dressing, a large area of slough covering the wound which measured approximately 9.0 x 10.0 cm and unable to determine the depth, slight foul odor-area was cleansed with normal saline, dried and [MEDICATION NAME] applied. RN #1 stated that this area had worsened and that Resident #4 was running a fever and not eating well. The left hip/trochanter revealed a darkened eschar area approximately 10 cm x 4 cm area. RN #1 stated that she was not aware of this area, that the resident had once had a skin tear to that area and would see what Hospice wanted to do. Review of the "Hospice Interdisciplinary Plan of Care/physician's orders [REDACTED]. (This order was not in the resident's chart). Review of Resident #4's admission physician's orders [REDACTED]. Review of a nurse's note dated 5/8/13 at 8:15 a.m. revealed, "Resident (#4) has a non-healing left buttock decubitus ulcer and sacral pressure ulcer now included with eschar tissue noted in the center. Left heel stasis ulcer present." Review of a Wound Care Center note for Resident #4 on 5/10/13 revealed a coccyx pressure ulcer that measured 5.6 x 6.0 x 0.1 cm with small serous drainage. The ulcer was classified as a Stage II and [MEDICATION NAME]/slough debridement was performed which left the wound measuring 5.7 x 6.1 x 0.2. New orders were obtained for SSD (Silver [MEDICATION NAME]) Review of a nurse's note dated 5/11/13 at 6:43 a.m. revealed a small blister was observed on Resident #4's left upper thigh and MD was notified with no new orders noted. Review of a Hospice note for Resident #4 dated 5/22/13 revealed a new pressure ulcer to the right thigh measuring 2.0 x 1.0 x 0.1 cm. and was treated with [MEDICATION NAME] Ointment and covered with a 4 x 4 and tape. This documentation was not in the resident's chart. There was no documentation by the facility of an assessment of the pressure ulcer on Resident #4's right thigh until 5/23/13 when the area was measured as 6.0 cm x 2.0 cm x 1.0 cm with minimal sloughing and serosanguinous minimal drainage. Review of Resident #4's care plan dated 5/1/13 revealed that the resident had "Potential for impaired skin integrity r/t (related to) bowel/bladder incontinence...Apply Skin Sak To Affected Areas On Buttocks. Apply Skin Sake To Affected Areas On Scrotum...Interventions, dated 5/10/13, noted, " May apply xeraderm ointment for skin barrier to scrotal area q (every) shift. Cleanse coccyx w/ns (with normal saline) apply SSD ([MEDICATION NAME] ointment), cover w/ (with) dry gauze and secure w/tape. Turn resident q (every) 2 hrs (hours) and float heals. Return to wound care center (name) on 5/17/13 @ 1p (1:00 p.m.)." There was no documented evidence that a care plan had been revised for treatment of [REDACTED]. Cross refer to F314 for the facility's failure to provide treatment and services to the current pressure ulcer to the buttock and/or prevent further skin breakdown.

CI MS # Based on observation, staff interview, record review, and policy review, the facility failed to ensure that one (1) of four (4) residents (Resident #4) with pressure ulcers was provided the appropriate treatment and services per physician's orders and that services were coordinated between the Hospice Agency and the facility to promote the healing of current pressure ulcers and/or prevent further skin breakdown. Resident #4 was admitted with a Stage II pressure sore to the left buttock which increased in size and other pressure ulcers/wounds developed that were not identified and/or treated timely. Findings include: Resident #4 Record review revealed Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #4 was admitted for Hospice Services. Observation of and interview with Resident #4 on 5/22/13 at 1:45 p.m. revealed that he was alert and oriented to person, was supine in bed with the head of bed elevated. An alternating air mattress was in place. Resident #4 had a water pitcher with a straw in his hands. The room was clean and no noted odor. Bilateral foot/heel protectors were in place and pillows were used for elevation. Resident #4 had oxygen at 2 liters per nasal biprong and a Foley catheter was in place draining amber colored urine. The bed pad was dry under the resident. Observation of Resident #4 during wound treatment by Registered Nurse (RN) #1/Treatment (Tx) Nurse on 5/23/13 at 9:40 a.m. revealed the right hip dressing that had slight drainage was removed to reveal two (2) small areas with a skin bridge between them. One (1) area measured approximately 2.0 x 1.5 cm and shallow almost scraped depth and the other 2.0 x 1.3 x 0.6 cm. This area was cleansed with normal saline, dried and [MEDICATION NAME] applied. The Left sacral/coccyx area had no dressing, a large area of slough covering the wound which measured approximately 9.0 x 10.0 cm and unable to determine the depth, slight foul odor-area was cleansed with NS, dried and [MEDICATION NAME] applied. RN #1 stated that this area had worsened and that Resident #4 was running a fever and not eating well. The left hip/trochanter revealed a darkened eschar area approximately 10 cm x 4 cm area. RN #1 stated that she was not aware of this area, that the resident had once had a skin tear to that area and would see what Hospice wanted to do. Review of Resident #4's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/1/13 revealed that he had severe cognitive impairment and required extensive to total assistance with all activity of daily living and had no documentation of pressure ulcers or other ulcers present on this assessment. Review of a "Skin at Risk Screening" for Resident #4, dated 4/26/13 revealed that he had a risk score of 19. A score greater than 12 was documented as high risk. Resident #4 was care planned as high risk. Review of a "Registered Nurse Assessment" for Resident #4, dated 4/24/13, revealed that there was a pressure ulcer present and other skin conditions present. Documentation included "Pressure ulcer, red in color and irregularly shaped, noted to left buttock. Also black areas noted to outside and inside of left heel as well as an open dry ulcer to second toe on left foot." The assessment indicated that if a wound was present, continue with assessment indicating wound stage and description of each wound by utilizing Wound/Skin Management Documentation Record per facility policy as indicated. There was no measurements or stages of the pressure ulcer documented. There was no measurements or descriptions of any of Resident #4's wounds/ulcers documented by facility staff until 5/23/14. Measurements were documented by Hospice staff weekly, however, this information was not in Resident #4's chart or at the facility until 5/23/13. Review of the Hospice Intake form for Resident #4, dated 4/23/13 revealed that Resident #4 was admitted for Hospice Care in the facility requiring Level 3, highest care which indicated that patient care should not be interrupted. The frequency of nurse visits was documented at 2 x weekly and prn. The skin section revealed that Resident #4 had a Stage II pressure ulcer to the left buttock and venous ulcers x 2 to the left heel. The left buttock ulcer had documented measurements of 6.0 centimeters (cm) x 2.0 cm x 0.2 cm. The right heel inner aspect measured 2.0 cm diameter with necrotic tissue and the left heel measured 3.0 cm diameter with necrotic tissue. Treatment to the left buttock documented that it was cleaned with soap/water and [MEDICATION NAME] Ointment was applied. Review of the "Hospice Interdisciplinary Plan of Care/Physician's Orders" for Resident #4 dated 4/23/13 revealed a treatment to Clean left buttock ulcer daily and prn (as needed) with soap and water, pat dry and apply [MEDICATION NAME] Ointment and leave open to air. (This order was not in the resident's chart). Review of Resident #4's admission physician's orders dated 4/23/13 revealed an order for [REDACTED]. Review of the April 2013 and May 2013 Treatment Sheet for Resident #4 revealed that the only documented treatments by the facility staff was for Skin Sake to the affected areas to the buttocks on 4/27/13, 4/28/13, 5/4/13 and 5/5/13. (the treatment was discontinued on 5/10/13). (Hospice had documentation of visits and treatment to the buttock on 4/23/13 of [MEDICATION NAME] Ointment; 4/30/13 [MEDICATION NAME] (changed from [MEDICATION NAME]), 5/2/13, 5/7/13 with [MEDICATION NAME]. (No physician's order was located for the [MEDICATION NAME] that Hospice was treating with). This meant that the resident's buttock/scrotal area was not treated per physician's orders other than the above mentioned dates. Review of a nurse's note dated 5/8/13 at 8:15 a.m. revealed that Resident #4 has a non-healing left buttock pressure ulcer and sacral pressure ulcer now included with eschar tissue noted in the center. Resident to have wound care evaluation on 5/10/13. Hospice nurse was telephoned with the orders per MD. There was no measurements documented by the facility of the wounds. Review of a Wound Care Center note for Resident #4 on 5/10/13 revealed a coccyx pressure ulcer that measured 5.6 x 6.0 x 0.1 cm with small serous drainage. The ulcer was classified as a Stage II and [MEDICATION NAME]/slough debridement was performed which left the wound measuring 5.7 x 6.1 x 0.2. New orders were obtained for SSD (Silver [MEDICATION NAME]) Review of a Wound Care Center note dated 5/17/13 revealed that Resident #4's coccyx pressure ulcer measured 8.0 x 7.0 x 0.1 cm., Stage II with small serous exudates, large necrotic area with black eschar, yellow [MEDICATION NAME]/slough. Post debridement measurements were 8.1 x 7.1 x 0.2 c.m. treatment of [REDACTED]. Review of a physician's order dated 5/10/13 for Resident #4, revealed to cleanse the coccyx/left buttock with normal saline, pat dry, apply SSD ([MEDICATION NAME]) and cover with dry gauze and secure with tape daily. Review of the May 2013 Treatment Record for Resident #4 revealed no documentation by the facility staff for treatments of [MEDICATION NAME] daily for 5/13/13-5/17/13 and 5/20/13-5/22/13. Hospice documentation included treatments of [MEDICATION NAME] on 5/14/13, 5/16/13, 5/20/13 and 5/22/13. This meant that Resident #4 had no treatments to the coccyx on 5/13/13, 5/15/13, 5/17/13 and 5/21/13. Review of a nurse's note dated 5/11/13 at 6:43 a.m. revealed a small blister was observed on Resident #4's left upper thigh and MD was notified with no new orders noted. The nurse's notes continued on 5/11/13, 5/12/13 and 5/13/13 that the blister to the left thigh was intact. There was no documentation of measurements or further assessment of Resident #4's left upper thigh until 5/23/13 when it was documented at 12:23 p.m. for the left trochanter/upper thigh measurement of 10.9 cm x 6.0 cm., no drainage, wound bed dark in color. A late entry nurse's note documented on 5/23/13 at 12:53 p.m. for 5/22/13 at 7:00 p.m. revealed that the area to the left hip had pink edges and necrotic tissue, hospice nurse and MD made aware and new orders were received on 5/23/13. Review of a Hospice note for Resident #4 dated 5/22/13 revealed a new pressure ulcer to the right thigh measuring 2.0 x 1.0 x 0.1 cm. and was treated with [MEDICATION NAME] Ointment and covered with a 4 x 4 and tape. This documentation was not in the resident's chart. There was no documentation by the facility of an assessment of the pressure ulcer on Resident #4's right thigh until 5/23/13 when the area was measured as 6.0 cm x 2.0 cm x 1.0 cm with minimal sloughing and serosanguinous minimal drainage. No order for treatment of [REDACTED]. Review of Resident #4's medical record revealed no documentation by Hospice of visits, wound measurements and treatments. The documentation of visits, wound measurements/evaluation and Hospice orders was obtained by the Administrator on 5/23/13 from the Hospice company when requested by the surveyor. Review of a nurse's note dated 5/23/13 at 12:23 p.m. revealed the following documentation of Resident #4's decubitus ulcers: Coccyx: cleanse with normal saline, pat dry apply [MEDICATION NAME] dry dressing-wound appears filled with maceration, dark area, with minimal sloughing noted, minimal drainage noted, in color of sloughing, foul odor noted. measures approx (approximately) 9.0 cm x 10 cm x 0.1 cm; Right trochanter: cleanse with normal saline, pat dry applied [MEDICATION NAME], dry dressing, wound appears pinkish red with minimum sloughing noted, minimum drainage noted in serous sangeous, no odor measured approximately 6.0 cm x 2.0 cm x 1.0 cm; Left trochanter/upper thigh: measurements taken 10.9 cm x 6.0 cm, no drainage, woundbed dark in color, no orders received from Hospice at this time. There had been no facility documentation of assessments/measurements of the pressure ulcers prior to this note. Review of the "Weekly Skin Report" dated 4/26/13, 5/1/13, 5/3/19, 5/10/19 and 5/17/19 revealed no documentation of Resident #4's skin concerns or pressure ulcers. Review of Weekly Body Audits for Resident #4 dated 4/27/13, and 5/4/13 revealed that new skin issues were noted, see nurse's notes. (There were no corresponding nurse's notes that identified skin issues on 4/27/13). Audits dated 5/10/13 and 5/17/13 were not documented because resident was out of the building. Audits dated 5/11/13 and 5/18/13 documented no new skin issues were noted. Review of Resident #4's care plan dated 5/1/13 revealed that the resident was on Hospice services involved in care related to progression of disease process. Interventions included the Hospice aide to observe skin during care and the facility nurse to notify Hospice promptly of any changes and declines. Interview with Registered Nurse (RN) #1/Treatment (Tx) Nurse, on 5/22/13 at 3:20 p.m. revealed that she did not do treatments on Resident #4, that the Hospice Nurse did treatments daily Monday through Friday and the weekend Treatment Nurses did them on Saturday and Sunday. RN #1 stated that she had not seen Resident #4's wounds since right after he was admitted and had not measured them or assessed them weekly, that Hospice did all of that. Interview with the Director of Nursing (DON) on 5/23/13 at 10:50 a.m., in the presence of RN #1 and the Administrator, revealed that Hospice Aides came three (3) times daily to feed Resident #4 and report any changes to Hospice and the Hospice Nurse came at least twice weekly, not daily. The DON stated that the Treatment Nurse was supposed to do treatments on days when the Hospice Nurse didn't come and that there had been no treatments to any of Resident #4's wounds/ulcers on the 7-3 shift during the week except by the Hospice (who came 2 x week). Interview with Registered Nurse (RN) #1 on 5/23/13 at 11:00 a.m. in the presence of the Director of Nursing (DON) and Administrator, and again on 5/23/13 at 1:45 p.m. revealed that she had not been doing treatments for Resident #4, she thought that the Hospice Nurse was doing daily treatments. RN #1 stated that she had treated Resident #4's heel when he first came in, but was not aware that he had a wound to the coccyx. RN #1 stated that she had done a treatment to a skin tear on the resident's thigh before, but had not seen the resident's skin at any time in the month of May until today (5/23/13) during treatment. RN #1 stated that she had not assessed or measured Resident #4's wounds weekly and had not included him on the weekly skin report that went to the DON. Interview with the Director of Nursing (DON) on 5/23/13 at 11:05 a.m., in the presence of Registered Nurse #1 and the Administrator, revealed that she was not aware that Resident #4 had any wounds/ulcers except to the heel and thighs. The DON stated that she had not been aware of the coccyx ulcer and had been made aware of the left hip wound on 5/22/13, but that it had not been documented. The DON stated that she had overlooked that Resident #4 was not listed on the weekly skin report. Interview with the Administrator on 5/23/13 at 11:10 a.m. revealed that the Treatment Nurse was responsible for assessing, treating and documenting wounds/ulcers/skin concerns and letting the DON know per policy. The Administrator stated that the Treatment Nurse should have been looking at Resident #4's skin daily and doing treatments when Hospice not here and doing her own assessments/measurements. Interview with Certified Nurse Aide (CNA) #1 on 5/23/13 at 11:45 a.m. revealed that she was not sure that all of Resident #4's sores were being treated, that he had developed a red area on his left hip over the past week and the coccyx was worse than when he came in. CNA #1 stated that Resident #4's coccyx sore was a small open area when he first came in and now it was big; right hip a small open area that didn't look good. CNA #1 stated that she had notified the primary nurses (LPN {Licensed Practical Nurse} #1 and LPN #2) and they usually notify the Treatment nurse. CNA #1 stated that she had not notified the Treatment nurse herself of Resident #4's sores. CNA #1 stated that there was a "Jot Book", but review of the Jot Book with CNA #1 revealed no documentation of Resident #4's skin condition. CNA #1 stated that she must not have documented when she notified LPN #1, but she knew CNA #2 had notified somebody last week about Resident #4's skin. (Couldn't recall who was notified). CNA #1 stated that she'd not seen anyone but the Hospice Nurse treat Resident #4's sores. Interview with Licensed Practical Nurse (LPN) #2 on 5/23/13 at 11:50 a.m. revealed that she had not had reports from any of the CNAs about Resident #2's skin changes. LPN #2 stated that if the dressing came loose that she would see a wound but that she had done no treatments to Resident #4. LPN #2 stated that she had seen Resident #4's skin when he first came in, an area to the coccyx, scrotum and heels and thought there may have been something on one of his heels. LPN #2 stated that she was not aware of any other Hospice documentation other than what was in the chart. LPN #2 stated that she wasn't sure how often the Hospice Nurse came, that she would typically only see her one (1) day out of the two (2) that she worked on that station and the only communication between them was that the treatments had been done. Interview with Certified Nurse Aide (CNA) #2 on 5/23/13 at 11:55 a.m. revealed that she worked four (4) days on and two (2) days off and had just returned today (5/23/13). CNA #2 stated that Resident #4's left hip was really red when she left and now it was dark and the one on his butt had started stinking the last day that she worked (5/20/13). CNA #2 stated that she had asked Licensed Practical Nurse #1 about who treated Resident #4's sores when Hospice wasn't here and she was going to find out. CNA #2 stated Hospice Nurse only came about twice weekly and she'd not seen anyone else do treatments to Resident #4. Interview per return phone call from Licensed Practical Nurse (LPN) #1 on 5/24/13 at 11:00 a.m. revealed that she communicated with the Hospice Nurse about Resident #4 about his care and any new orders and the wound care center but there were no written reports left at the facility by Hospice. LPN #1 stated that Registered Nurse (RN) #1 was the Treatment Nurse Monday through Friday and had other TX nurses on the weekends. LPN #1 stated that the facility nurses was supposed to do treatments when the Hospice Nurse wasn't here to do them. LPN #1 stated that the Hospice Nurse usually came at least twice weekly. LPN #1 stated that she had not done any of Resident #4's treatments herself or seen any of his wounds recently. LPN #1 stated that one of the CNAs had talked with her about the places on Resident #4 and she told her that she would get with the Hospice Nurse; didn't recall exactly when but did talk with the Hospice Nurse about Resident #4's wounds/treatments. LPN #1 stated that there was very little written documentation in Resident #4's chart from Hospice. Interview and review of the Hospice documentation for Resident #4 with the Administrator on 5/23/13 at 12:10 p.m. revealed that none of the Hospice documentation was in Resident #4's chart, that he had to request the information for visits and wound assessment/documentation/treatments and get it faxed from Hospice today (5/23/13). The Administrator stated that the Hospice documentation should have been in the medical record where everyone could be on the same page. Interview and review of facility treatment sheets for Resident #4 with the Administrator on 5/23/13 at 12:30 p.m. revealed that treatments were being provided by facility staff on the weekends but not during the week unless done by the Hospice nurse. The Administrator stated that the facility staff should be assessing and treating residents and not relying on Hospice for assessment and care of residents; the treatment nurse should be doing treatments when Hospice not here. The Administrator stated that Hospice documentation should be kept at the facility. Interview with the Director of Nursing (DON), with the Nurse Consultant present, on 5/23/13 at 1:20 p.m. revealed that Hospice came to facility two (2) times weekly and that she had never told the Treatment Nurse that she didn't have to do treatments and had asked her who told her that she didn't have to do treatments to Resident #4 and she said she had just assumed because the other Hospice nurse (with another company) had came to the facility daily. The DON stated that there was no weekly notes or wound/pressure ulcer assessments by the facility staff and there should have been. The Nurse Consultant stated that there was no documentation on the treatment sheets that Resident #4's treatments had been done by facility staff except for the weekends; no documentation on the weekly skin management report of Resident #4's skin concerns; and no Hospice documentation of assessments/treatments left in the facility and should have been. Interview with Licensed Practical Nurse (LPN) #3, Minimum Data Set Nurse, on 5/23/13 at 1:50 p.m. revealed that on admission Resident #4 came in on Hospice and had areas to the heels; didn't recall anything on either hip and the coccyx was pink-looked like it had previously healed. LPN #3 stated that she had talked with the Hospice Nurse about [MEDICATION NAME] for Resident #4's heels. LPN #3 stated that the only other communication that she recalled with the Hospice Nurse was about Resident #4's urine. LPN #3 stated that she was not aware that the Hospice Nurse only came two (2) times weekly; not sure how often that she came. LPN #3 stated that she had talked with the Hospice nurse the evening before (5/22/13) and asked what areas she was aware of for Resident #4 and was told the heel, buttock and inner thigh and that's when the Hospice Nurse told her that she usually came two (2) times per week and had assumed that since Resident #4 was a nursing home patient that the facility nurses would do treatments when she wasn't there. LPN #3 stated that Hospice was supposed to leave documentation in the resident's record about visits/treatments. Interview with the Hospice Nurse/Registered Nurse (RN) #3, on 5/23/13 at 2:00 p.m. revealed that she came to the facility two (2) times weekly for Resident #4 and usually talked with the nurse at the desk, usually LPN (Licensed Practical Nurse) #1. RN #3 stated that the nurses would usually tell her if the physician needed to be contacted and would give them documentation from the wound care center. (Wound Care Center information was in the medical record). RN #3 stated that there is a folder at the facility and the secretary (from Hospice) sends documentation to the facility, but this had not been done for Resident #4. RN #3 stated that when Resident #4 was admitted that he had two (2) left heel stasis ulcers and a left gluteal wound which spread to the coccyx and got necrotic and we sent him to the wound center. RN #3 stated that the wound happened really fast. RN #3 stated that Resident #3 had a few blisters to come up on the thigh areas because of fluid and got [MEDICATION NAME] for that and the left thigh healed. RN #3 stated that there had been some ulcer to the right hip/thigh area developing that finally showed up. RN #3 stated that she had not communicated with the DON or the Treatment Nurse at the facility, only LPN #1 and LPN #3 mostly. RN #3 stated that she assumed that the facility nurses were treating Resident #4's ulcers/skin concerns when she was not there. RN #3 stated that Resident #4's coccyx had worsened and that further breakdown had developed but this was probably expected due to his condition. RN #3 stated that she couldn't say that Resident #4's places worsened due to the facility not treating him on the days that she wasn't there, but that it was possible. Interview with Registered Nurse (RN) #2/Medicare Nurse, on 5/23/13 at 2:10 p.m., revealed that she had observed Resident #4's skin with the Hospice Nurse on admit. RN #2 stated that she had not measured any wounds because the Hospice nurse did. RN #2 stated that there was a reddened area on Resident #4's upper buttocks, a deep beefy red, and didn't recall that it was open or draining. RN #2 stated that there was a stasis ulcer to the left heel and a dried lesion on his toe. RN #2 stated that she never looked at Resident #4's skin again because he was Hospice and not skilled. RN #2 stated that the Hospice Nurse didn't say how often that she would be coming and she never had communication with her again. RN #2 stated that she documented an assessment of Resident #4's skin but failed to document any measurements. RN #2 stated that Hospice usually documented their own records and she thought that it is left at the facility. Interview with the Director of Nursing, Administrator and Nurse Consultant on 5/23/13 at 3:00 p.m. confirmed that the policy/procedures for Wound/Skin management and Skin Care had not been followed for Resident #4 due to no completion of assessment/treatment of [REDACTED].#4's pressure ulcer to the coccyx worsened with development of other skin issues that weren't readily identified/treated by staff until 5/23/13. Review of the facility's "Wound/Skin Management Documentation" policy, revised 11/10, noted, "1. Upon admission or discovery of a Pressure Ulcer, Other Ulcer, (diabetic, arterial, venous) Surgical Wound and/or Open Lesion, a Wound/Skin Management Documentation Record is initiated. 2. A complete assessment by RN is done and orders for required treatments are obtained. 3. The Wound/Skin Management Documentation must be completed weekly or sooner should a significant change to the wound occur. 4. A weekly audit is done by Medical Records to validate this documentation has been complete." Review of the facility's "Skin Care Policy and Procedure" policy, revised 5/11, noted, "It is the policy of this facility that skin problems will be minimized to the greatest extent possible through an aggressive approach consisting of four components. Those are: I. Prevention, Evaluation and Screening; II. Ongoing Surveillance; III. Treatment Orders; IV. Treatment Regimen. Overseeing these efforts will be the Director of Nursing, who will have ultimate responsibility of ensuring that this policy is applied consistently...Prevention, Evaluation and Screening:..."Skin Problems which are present, or which develop later will be followed carefully and treated according to medical direction...Admission procedure:...If resident is admitted with pressure sores or pressure sores are discovered on admission skin check, an RN must assess and stage these pressure sores...Ongoing Surveillance section:...Documentation, reporting and treatment of [REDACTED]. to treatment; Dietary, physician and responsible family member notified of any change; Presence of tunneling...Treatment Orders section:...Accurate treatment orders will ensure that each licensed nurse administer the treatments per the physician's order...Under the Treatment Regime section: "treatment for [REDACTED]. Carefully document condition...The physician's order is sought for both direct care to the problem by nursing personnel and for any associated treatments....Usual nursing measures might include...local care, including cleansing and dressing as ordered." Review of the facility's "Physician Orders - Transcribing and Implementing" policy, revised 5/11, noted, "It is the policy of this facility that all physician's orders will be implemented timely and carried out in a professional manner by the nursing staff..." Review of the job description for the "Treatment Nurse" revealed that the treatment nurse is responsible for the assessment and follow up of each resident's need for and result of treatments provided in the facility...Some of the responsibilities included review of nursing communication books/systems, provide treatment for [REDACTED]. (Pressure sore and non-decub skin condition records), complete weekly skin report for at least the DON and Administrator, skin rounds with the DON at least weekly discussing prevention and possible alternative intervention, and notify the physician of the healing or lack of healing of any lesion. Review of the Nursing Home Facility Agreement with Hospice dated 10/1/03, noted, "Hospice shall develop a plan of hospice in conjunction with the nursing home staff and approved by the nursing home with respect to the care and treatment of [REDACTED]. Review of the facility's "Hospice Charts" policy, revised 12/03, noted, "Medical Records for hospice patients will be retained with the nursing home medical record in a blue binder in order to be easily recognized for hospice services. These charts will be kept at the nurse's station with other residents charts." (Resident #4's chart was blue in color). Review of the facility's "Hospice Services" policy, revised 7/09, noted, "...Any services not provided by the Hospice agency but which are normally provided to residents of this facility, will be provided to these residents following facility policies and procedures."

CI MS # Based on staff interview, record review and policy review, the facility failed to have effective communication and documentation from the Hospice Agency to ensure continuity of care for the services that were provided to one (1) of one (1) resident (Resident #4) reviewed for Hospice services. Findings include: Resident #4 Review of the Hospice Intake form for Resident #4, dated 4/23/13 revealed that Resident #4 was admitted for Hospice Care in the facility requiring Level 3/highest care which indicated that patient care should not be interrupted. The frequency of nurse visits was documented at 2 x weekly and prn. The skin section revealed that Resident #4 had a Stage II pressure ulcer to the left buttock and venous ulcers x 2 to the left heel. The left buttock ulcer had documented measurements of 6.0 centimeters (cm) x 2.0 cm x 0.2 cm. The right heel inner aspect measured 2.0 cm diameter with necrotic tissue and the left heel measured 3.0 cm diameter with necrotic tissue. Treatment to the left buttock documented that it was cleaned with soap/water and [MEDICATION NAME] Ointment was applied. This information was not in Resident #4's medical record at the facility until 5/23/13. Review of the "Hospice Interdisciplinary Plan of Care/physician's orders [REDACTED]. (This order was not in the resident's chart until 5/23/13). Review of Resident #4's medical record revealed no documentation by Hospice of visits, wound measurements and treatments. The documentation of visits, wound measurements/evaluation and Hospice orders was obtained by the Administrator on 5/23/13 from the Hospice company when requested by the surveyor. Review of Resident #4's care plan dated 5/1/13 revealed that the resident was on Hospice services involved in care related to progression of disease process. Interventions included the Hospice aide to observe skin during care and the facility nurse to notify Hospice promptly of any changes and declines. Interview with the Director of Nursing (DON) on 5/23/13 at 10:50 a.m., in the presence of Registered Nurse #1 and the Administrator, revealed that Hospice Aides came three (3) times daily to feed Resident #4 and report any changes to Hospice and the Hospice Nurse came at least twice weekly, not daily. The DON stated that the Treatment Nurse was supposed to do treatments on days when the Hospice Nurse didn't come and that there had been no treatments to any of Resident #4's wounds/ulcers on the 7-3 shift during the week except by the Hospice (who came 2 x week). Interview with RN #1 on 5/23/13 at 11:00 a.m. in the presence of the Director of Nursing (DON) and Administrator, and again on 5/23/13 at 1:45 p.m. revealed that she had not been doing treatments for Resident #4, she thought that the Hospice Nurse was doing daily treatments. RN #1 stated that she had treated Resident #4's heel when he first came in, but was not aware that he had a wound to the coccyx. RN #1 stated that she had done a treatment to a skin tear on the resident's thigh before, but had not seen the resident's skin at any time in the month of May until today (5/23/13) during treatment. Interview with the Administrator on 5/23/13 at 11:10 a.m. revealed that the Treatment Nurse was responsible for assessing, treating and documenting wounds/ulcers/skin concerns and letting the Director of Nursing know per policy. The Administrator stated that the Treatment Nurse should have been looking at Resident #4's skin daily and doing treatments when Hospice not here and doing her own assessments/measurements. Interview with Licensed Practical Nurse (LPN) #2 on 5/23/13 at 11:50 a.m. revealed that she had not had reports from any of the CNAs about Resident #2's skin changes. LPN #2 stated that she was not aware of any other Hospice documentation other than what was in the chart. LPN #2 stated that she wasn't sure how often the Hospice Nurse came, that she would typically only see her one (1) day out of the two (2) that she worked on that station and the only communication between them was that the treatments had been done. Interview per return phone call from Licensed Practical Nurse (LPN) #1 on 5/24/13 at 11:00 a.m. revealed that she communicated with the Hospice Nurse about Resident #4 about his care and any new orders and the wound care center but there were no written reports left at the facility by Hospice. LPN #1 stated that RN #1 was the Treatment Nurse Monday through Friday and had other treatment nurses on the weekends. LPN #1 stated that the facility nurses was supposed to do treatments when the Hospice Nurse wasn't here to do them. LPN #1 stated that the Hospice Nurse usually came at least twice weekly. LPN #1 stated that she had not done any of Resident #4's treatments herself or seen any of his wounds recently. LPN #1 stated that there was very little written documentation in Resident #4's chart from Hospice. Interview and review of the Hospice documentation for Resident #4 with the Administrator on 5/23/13 at 12:10 p.m. revealed that none of the Hospice documentation was in Resident #4's chart, that he had to request the information for visits and wound assessment/documentation/treatments and get it faxed from Hospice today (5/23/13). The Administrator stated that the Hospice documentation should have been in the medical record where everyone could be on the same page. Interview with the Director of Nursing (DON), with the Nurse Consultant present, on 5/23/13 at 1:20 p.m. revealed that Hospice came to facility two (2) times weekly and that she had never told the Treatment Nurse that she did not have to do treatments and had asked her who told her that she didn't have to do treatments to Resident #4 and she said she had just assumed because the other Hospice nurse (with another company) had came to the facility daily. The DON stated that there was no weekly notes or wound/pressure ulcer assessments by the facility staff and there should have been. The Nurse Consultant stated that there was no documentation on the treatment sheets that Resident #4's treatments had been done by facility staff except for the weekends; no documentation on the weekly skin management report of Resident #4's skin concerns; and no Hospice documentation of assessments/treatments left in the facility and should have been. Interview with Licensed Practical Nurse (LPN) #3, Minimum Data Set Nurse, on 5/23/13 at 1:50 p.m. revealed that on admission Resident #4 came in on Hospice and had areas to the heels; didn't recall anything on either hip and the coccyx was pink-looked like it had previously healed. LPN #3 stated that she had talked with the Hospice Nurse about [MEDICATION NAME] for Resident #4's heels. LPN #3 stated that the only other communication that she recalled with the Hospice Nurse was about Resident #4's urine. LPN #3 stated that she was not aware that the Hospice Nurse only came two (2) times weekly; not sure how often that she came. LPN #3 stated that she had talked with the Hospice nurse the evening before (5/22/13) and asked what areas she was aware of for Resident #4 and was told the heel, buttock and inner thigh and that's when the Hospice Nurse told her that she usually came two (2) times per week and had assumed that since Resident #4 was a nursing home patient that the facility nurses would do treatments when she wasn't there. LPN #3 stated that Hospice was supposed to leave documentation in the resident's record about visits/treatments. Interview with the Hospice Nurse, Registered Nurse (RN) #3, on 5/23/13 at 2:00 p.m. revealed that she came to the facility two (2) times weekly for Resident #4 and usually talked with the nurse at the desk, usually LPN (Licensed Practical Nurse) #1. RN #3 stated that the nurses would usually tell her if the physician needed to be contacted and would give them documentation from the wound care center. (Wound Care Center information was in the medical record). RN #3 stated that there is a folder at the facility and the secretary (from Hospice) sends documentation to the facility, but this had not been done for Resident #4. RN #3 stated that when Resident #4 was admitted that he had two (2) left heel stasis ulcers and a left gluteal wound which spread to the coccyx and got necrotic and we sent him to the wound center. RN #3 stated that the wound happened really fast. RN #3 stated that Resident #3 had a few blisters to come up on the thigh areas because of fluid and got [MEDICATION NAME] for that and the left thigh healed. RN #3 stated that there had been some ulcer to the right hip/thigh area developing that finally showed up. RN #3 stated that she had not communicated with the DON or the Treatment Nurse at the facility, only LPN #1 and LPN #3 mostly. RN #3 stated that she assumed that the facility nurses were treating Resident #4's ulcers/skin concerns when she wasn't there. RN #3 stated that Resident #4's coccyx had worsened and that further breakdown had developed but this was probably expected due to his condition. RN #3 stated that she couldn't say that Resident #4's places worsened due to the facility not treating him on the days that she wasn't there, but that it was possible. Interview with Registered Nurse(RN) #2/Medicare Nurse, on 5/23/13 at 2:10 p.m. revealed that she had observed Resident #4's skin with the Hospice Nurse on admit. RN #2 stated that she had not measured any wounds because the Hospice nurse did. RN #2 stated that there was a reddened area on Resident #4's upper buttocks, a deep beefy red, and didn't recall that it was open or draining. RN #2 stated that there was a stasis ulcer to the left heel and a dried lesion on his toe. RN #2 stated that she never looked at Resident #4's skin again because he was Hospice and not skilled. RN #2 stated that the Hospice Nurse didn't say how often that she would be coming and she never had communication with her again. RN #2 stated that she documented an assessment of Resident #4's skin but failed to document any measurements. RN #2 stated that Hospice usually documented their own records and she thought that it is left at the facility. Interview with the Director of Nursing, Administrator and Nurse Consultant on 5/23/13 at 3:00 p.m. confirmed that the policy/procedures for Wound/Skin management and Skin Care had not been followed for Resident #4 due to no completion of assessment/treatment of [REDACTED].#4's pressure ulcer to the coccyx worsened with development of other skin issues that weren't readily identified/treated by staff until 5/23/13. Review of the Nursing Home Facility Agreement with Hospice dated 10/1/03, revealed that Hospice shall develop a plan of hospice in conjunction with the nursing home staff and approved by the nursing home with respect to the care and treatment of [REDACTED]. The Hospice and Nursing Home shall provide to each other access to resident records with resident consent forms. Review of the facility's "Hospice Charts" policy, revised 12/03, noted, "Medical Records for hospice patients will be retained with the nursing home medical record in a blue binder in order to be easily recognized for hospice services. These charts will be kept at the nurse's station with other residents charts." (Resident #4's chart was blue in color). Review of the facility's "Hospice Services" policy, revised 7/09, noted, "...Any services not provided by the Hospice agency but which are normally provided to residents of this facility, will be provided to these residents following facility policies and procedures..." Cross refer to F314 and F514 for the facility's failure to ensure for coordination of services between the facility and the Hospice Agency to promote the healing of current pressure ulcers and/or prevent further skin breakdown. Resident #4 was admitted with a Stage II pressure sore to the left buttock which increased in size and he developed other pressure ulcers/wounds that were not identified and/or treated timely.

CI MS # Based on staff interview, record review and policy review, the facility failed to maintain accurate and complete medical records for one (1) of four (4) residents with pressure ulcers as evidenced by the lack of documentation of treatment and services provided to Resident #4, and to ensure that the documentation in the medical record reflected the coordination of care between the facility and the Hospice Agency. Findings include: Review of a "Skin at Risk Screening" for Resident #4, dated 4/26/13 revealed that he had a risk score of 19. A score greater than 12 was documented as high risk. Resident #4 was care planned as high risk. Review of a "Registered Nurse Assessment" for Resident #4, dated 4/24/13, revealed that there was a pressure ulcer present and other skin conditions present. Documentation included "Pressure ulcer, red in color and irregularly shaped, noted to left buttock. Also black areas noted to outside and inside of left heel as well as an open dry ulcer to second toe on left foot." The assessment indicated that if a wound was present, continue with assessment indicating wound stage and description of each wound by utilizing Wound/Skin Management Documentation Record per facility policy as indicated. There was no measurements or stages of the pressure ulcer documented. There was no measurements or descriptions of any of Resident #4's wounds/ulcers documented by facility staff until 5/23/14. Measurements were documented by Hospice staff weekly, however, this information was not in Resident #4's chart or at the facility until 5/23/13. Review of the "Hospice Interdisciplinary Plan of Care/physician's orders [REDACTED]. (This order was not in the resident's chart). Review of a nurse's note dated 5/8/13 at 8:15 a.m. revealed that Resident #4 has a non-healing left buttock pressure ulcer and sacral pressure ulcer now included with eschar tissue noted in the center. Resident to have wound care evaluation on 5/10/13. Hospice nurse was telephoned with the orders per MD. There was no measurements documented by the facility of the wounds. Review of the May 2013 Treatment Record for Resident #4 revealed no documentation by the facility staff for treatments of [MEDICATION NAME] daily for 5/13/13-5/17/13 and 5/20/13-5/22/13. Review of a nurse's note dated 5/11/13 at 6:43 a.m. revealed a small blister was observed on Resident #4's left upper thigh and MD was notified with no new orders noted. The nurse's notes continued on 5/11/13, 5/12/13 and 5/13/13 that the blister to the left thigh was intact. There was no documentation of measurements or further assessment of Resident #4's left upper thigh until 5/23/13 when it was documented at 12:23 p.m. for the left trochanter/upper thigh measurement of 10.9 cm x 6.0 a.m., no drainage, wound bed dark in color. A late entry nurse's note documented on 5/23/13 at 12:53 p.m. for 5/22/13 at 7:00 p.m. revealed that the area to the left hip had pink edges and necrotic tissue, hospice nurse and MD made aware and new orders were received on 5/23/13. Review of a Hospice note for Resident #4 dated 5/22/13 revealed a new pressure ulcer to the right thigh measuring 2.0 x 1.0 x 0.1 cm. and was treated with [MEDICATION NAME] Ointment and covered with a 4 x 4 and tape. This documentation was not in the resident's chart. There was no documentation by the facility of an assessment of the pressure ulcer on Resident #4's right thigh until 5/23/13 when the area was measured as 6.0 cm x 2.0 cm x 1.0 cm with minimal sloughing and serosanguinous minimal drainage. No order for treatment of [REDACTED]. Review of Resident #4's medical record revealed no documentation by Hospice of visits, wound measurements and treatments. The documentation of visits, wound measurements/evaluation and Hospice orders was obtained by the Administrator on 5/23/13 from the Hospice Agency when requested by the surveyor. Review of a nurse's note dated 5/23/13 at 12:23 p.m. revealed the following documentation of Resident #4's pressure ulcers: Coccyx: cleanse with normal saline, pat dry apply [MEDICATION NAME] dry dressing-wound appears filled with maceration, dark area, with minimal sloughing noted, minimal drainage noted, in color of sloughing, foul odor noted. measures approx (approximately) 9.0 cm x 10 cm x 0.1 cm; Right trochanter: cleanse with normal saline, pat dry applied [MEDICATION NAME], dry dressing, wound appears pinkish red with minimum sloughing noted, minimum drainage noted in serous sanguinous, no odor measured approximately 6.0 cm x 2.0 cm x 1.0 cm; Left trochanter/upper thigh: measurements taken 10.9 cm x 6.0 cm, no drainage, wound bed dark in color, no orders received from Hospice at this time. There had been no facility documentation of assessments/measurements of the pressure ulcers prior to this note. Review of the "Weekly Skin Report" dated 4/26/13, 5/1/13, 5/3/19, 5/10/19 and 5/17/19 revealed no documentation of Resident #4's skin concerns or pressure ulcers. Review of Weekly Body Audits for Resident #4 dated 4/27/13, and 5/4/13 revealed that new skin issues were noted, see nurse's notes. (There were no corresponding nurse's notes that identified skin issues on 4/27/13). Interview with Registered Nurse (RN) #1/Treatment (Tx) Nurse, on 5/22/13 at 3:20 p.m. revealed that she did not do treatments on Resident #4, that the Hospice Nurse did treatments daily Monday through Friday and the weekend Treatment Nurses did them on Saturday and Sunday. RN #1 stated that she had not seen Resident #4's wounds since right after he was admitted and had not measured them or assessed them weekly, that Hospice did all of that. Interview with Registered Nurse (RN) #1 on 5/23/13 at 11:00 a.m. in the presence of the Director of Nursing (DON) and Administrator, and again on 5/23/13 at 1:45 p.m. confirmed that she had not assessed or measured Resident #4's wounds weekly and had not included him on the weekly skin report that went to the DON. Interview with the Director of Nursing (DON) on 5/23/13 at 11:05 a.m., in the presence of Registered Nurse #1 and the Administrator, revealed that she was not aware that Resident #4 had any wounds/ulcers except to the heel and thighs. The DON stated that she had not been aware of the coccyx ulcer and had been made aware of the left hip wound on 5/22/13, but that it had not been documented. The DON stated that she had overlooked that Resident #4 was not listed on the weekly skin report. Interview with the Administrator on 5/23/13 at 11:10 a.m. revealed that the Treatment Nurse was responsible for assessing, treating and documenting wounds/ulcers/skin concerns and letting the DON know per policy. The Administrator stated that the Treatment Nurse should have been looking at Resident #4's skin daily and doing treatments when Hospice was not here and doing her own assessments/measurements. Interview and review of the Hospice documentation for Resident #4 with the Administrator on 5/23/13 at 12:10 p.m. revealed that none of the Hospice documentation was in Resident #4's chart, that he had to request the information for visits and wound assessment/documentation/treatments and get it faxed from Hospice today (5/23/13). The Administrator stated that the Hospice documentation should have been in the medical record where everyone could be on the same page. During an interview with the Director of Nursing (DON), and the Nurse Consultant on 5/23/13 at 1:20 p.m. revealed the DON stated that there was no weekly notes or wound/pressure ulcer assessments by the facility staff and there should have been. The Nurse Consultant stated that there was no documentation on the treatment sheets that Resident #4's treatments had been done by facility staff except for the weekends; no documentation on the weekly skin management report of Resident #4's skin concerns; and no Hospice documentation of assessments/treatments left in the facility and should have been. Interview on 5/23/13 at 2:00 p.m. with the Hospice Nurse/Registered Nurse (RN) #3 revealed that she came to the facility two (2) times weekly for Resident #4 and usually talked with the nurse at the desk, usually LPN (Licensed Practical Nurse) #1. RN #3 stated that the nurses would usually tell her if the physician needed to be contacted and would give them documentation from the wound care center. (Wound Care Center information was in the medical record). RN #3 stated that there is a folder at the facility and the secretary (from Hospice) sends documentation to the facility, but this had not been done for Resident #4. Interview on 5/23/13 at 2:10 p.m. with Registered Nurse (RN) #2/Medicare Nurse revealed that she had observed Resident #4's skin with the Hospice Nurse on admit. RN #2 stated that she had not measured any wounds because the Hospice nurse did. RN #2 stated that she documented an assessment of Resident #4's skin but failed to document any measurements. RN #2 stated that Hospice usually documented their own records and she thought that it is left at the facility. Interview per return phone call from Licensed Practical Nurse (LPN) #1 on 5/24/13 at 11:00 a.m. revealed that she communicated with the Hospice Nurse about Resident #4 about his care and any new orders and the wound care center but there were no written reports left at the facility by Hospice. LPN #1 stated that there was very little written documentation in Resident #4's chart from Hospice. Review of the facility's "Wound/Skin Management Documentation" policy, revised 11/10, noted, "1. Upon admission or discovery of a Pressure Ulcer, Other Ulcer, (diabetic, arterial, venous) Surgical Wound and/or Open Lesion, a Wound/Skin Management Documentation Record is initiated. 2. A complete assessment by RN is done and orders for required treatments are obtained. 3. The Wound/Skin Management Documentation must be completed weekly or sooner should a significant change to the wound occur. 4. A weekly audit is done by Medical Records to validate this documentation has been complete." Review of the facility's "Skin Care Policy and Procedure" policy, revised 5/11, noted, "..Ongoing Surveillance Section... Documentation, reporting and treatment of [REDACTED]. to treatment; Dietary, physician and responsible family member notified of any change; Presence of tunneling...Treatment Orders section:...Accurate treatment orders will ensure that each licensed nurse administer the treatments per the physician's orders [REDACTED]. Carefully document condition...The physician's orders [REDACTED].Usual nursing measures might include...local care, including cleansing and dressing as ordered." Review of the facility's "Hospice Charts" policy, revised 12/03, noted, "Medical Records for hospice patients will be retained with the nursing home medical record in a blue binder in order to be easily recognized for hospice services. These charts will be kept at the nurse's station with other residents charts." (Resident #4's chart was blue in color). Cross refer to F314 and to F500 for the facility's failure to ensure for coordination of services between the facility and the Hospice Agency to promote the healing of current pressure ulcers and/or prevent further skin breakdown. Resident #4 was admitted with a Stage II pressure sore to the left buttock which increased in size and he developed other pressure ulcers/wounds that were not identified and/or treated timely.

Based on observation, record review, interview and policy review, the facility failed to provide adequate supervision to ensure care and services were provided to residents, dependent on staff, in a timely manner as evidenced by one (1) certified nurse aides was observed to be sleeping on one (1) of two (2) halls on the 11 to 7 shift on 9/26/12, and incontinent residents, Residents #8, #11, #12 and #17 were not provided incontinence care in a timely manner as care planned. Findings include: Group meeting on 9/25/12 at 2:30 p.m. revealed four (4) of the five (5) residents in attendance complained of staff sleeping and not providing incontinence care on the 11-7 shift. On 9/6/12 at 4:05 a.m., surveyors entered the facility. The staff on the East Wing of the facility included two (2) Certified Nurse Aides (CNAs) and one (1) Licensed Practical Nurse (LPN). The facility ' s roster/sample matrix identified 30 residents on the East Wing with 18 of the residents being incontinent. Observation of the staff included the following observations on 9/26/12: 4:10 a.m., CNA #2 was going in and out of rooms. One (1) staff (LPN #1) was observed to appear asleep at the nurse's station as evidenced by her head on the desk. LPN #1's shoulders were covered with a white sheet/blanket. There were no lights on at the desk and the hallways appeared dark. CNA #1 appeared to be sleeping with her head down on a table near the television in the day area. CNA #1's shoulders were covered with a white sheet/blanket. The staff did not acknowledge that surveyors were at the desk. CNA #2 approached the desk and told LPN #1 that a resident was requesting a Tylenol. LPN #1 mumbled and continued to keep her head down. LPN #1 still did not acknowledge the surveyor standing by the desk. 4:15 a.m. Both LPN #1 and CNA #1 continued to appear to be sleeping and did not acknowledge the surveyors at the desk. 4:20 a.m. Both LPN #1 and CNA #1 appeared to be sleeping. There was no response or movement from the two (2) staff members. 4:22 a.m. LPN #1 still at the desk with her head down and shoulders covered with a blanket/sheet. CNA #1 still appeared to be sleeping with her head down on a table. 4:24 a.m. Both staff members appeared to be sleeping and did not acknowledge the surveyors. 4:26 a.m. LPN #1 got up from her chair and walked around the desk before acknowledging the surveyors standing at the desk. 4:28 a.m. CNA #1 was observed to still appear asleep with her head down on the table. The surveyor called CNA #1 by name three (3) times before the CNA #1 acknowledged the surveyor's presence. Observations of incontinence care were conducted for sampled Residents #8, #11, #12 and #17. Resident #8 Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status score of 11 which indicated that Resident #8's cognitive status was moderately impaired. This MDS coded that Resident #8 required extensive assistance with toileting and has urinary incontinence. Review of Resident #8's care plan, documented: "Problem Onset: 5/28/12. Potential for skin impairments r/t (related/to) immobility. Goal & (and) Target Date: Will Implement Measures To Reduce Risk Of Skin Impairment Thru (through) Target Date 10/28/12 ... Approaches: Toilet Q (every) 2 Hours And PRN (as needed) With Prompt Incont (incontinent) Care Following Each Incont. Episode; Be Sure To Thoroughly Cleanse And Dry Skin ...Avoid Prolonged Skin To Skin Contact ..." Observation on 9/26/12 at 7:25 a.m. revealed Certified Nurse Aide (CNA) #1 provided incontinence care to Resident #8. Resident #8's bed linens appeared soaked and had a strong odor of urine. CNA #1 placed the dirty linens on the bathroom floor. CNA #1 was observed to leave Resident #8 seated on the side of the bed completely uncovered from the waist downward while CNA #1 left the room to go get bath cloths. CNA #1 stated she had made rounds between 1:30 a.m. and 2:00 a.m. Resident #8 was not provided incontinence care until 7:25 a.m. Resident #11 Record review revealed that Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status of 11 which indicated that Resident #11's cognitive status was moderately impaired. This MDS coded that Resident #11 had limited range of motion of the upper extremity and required extensive assistance with bed mobility, dressing, toilet use and hygiene, and that Resident #11 has urinary incontinence. Observation of incontinence care on 9/26/12 at 6:55 a.m. revealed Certified Nurse Aide (CNA) #1 was observed to pull back the covers and remove Resident #11's brief. CNA #1 left the resident uncovered from the waist downward of the lower extremities as CNA #1 went back and forth to the bathroom to rinse the bath cloth in the sink. CNA #1 was asked to describe Resident #11's brief and she stated the brief was soaked. Resident #12 Record review revealed that Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status score of 6, which indicated that Resident #12's cognitive status was severely impaired. This MDS coded that Resident #12 required extensive assistance with bed mobility; had limitation of upper extremities on both sides and was totally dependent on staff for toilet use, hygiene and bathing, and that Resident #12 was always incontinent of bowel and bladder. Review of the facility's "Wound/Skin Management Documentation Record", documented that Resident #12 had been assessed to have a Stage II pressure area on the right heel. Interview on 9/24/12 at 3:30 p.m. with Resident #12 revealed Resident #12 complained that he stays wet all night. Observation of incontinence care on 9/26/12 at 4:38 a.m. revealed Resident #12 was observed to be lying in bed with the call system out of the resident's range to activate. The specialty call light had to be activated by the resident blowing on the mouthpiece. CNA #1 acknowledged that the resident was changed previously between 1:45 and 2:00 a.m. and that Resident #12's linens, including the under pad and bottom sheet, were soaked with urine. During the observation of care revealed CNA #1 left Resident #12's completely uncovered from the waist down while CNA #1 went to the bathroom to obtain a pan of water. Resident #17 Record review revealed that Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status score of 0, which indicated that Resident #17's cognitive status was severely impaired. This MDS coded that Resident #17 required extensive assistance from staff for bed mobility, dressing, eating, personal hygiene and bathing, was totally dependent on staff for toilet use, and was always incontinent of bowel and bladder. Review of the care plan documented, "Problem Onset: 5/24/09. At risk for skin breaks due to episodes of incont (incontinent) of Bowel and Bladder and physical immobility. " Approaches: Turn and reposition q (every 2 hr (hour) ...incont care after each episode and prn (as needed) ...Problem Onset: 05/28/2012, Potential for skin impairments r/t (related/to) immobility and incontinence. Goal & Target Date: Will Implement Measures To Reduce Risk Of Skin Impairment ... Approaches: Toilet Q (every) 2 Hours And PRN (as needed) With Prompt Incont (incontinent) Care Following Each Incont Episode; Be Sure To Thoroughly Cleanse And Dry Skin ..." Observation of Resident #17 on 9/26/12 revealed: 4:36 a.m. Resident was observed to be awake and lying in bed. The blue bedspread and top sheet appeared to be wet. A strong urine odor was noted in the room. 5:15 a.m. Resident was observed to be up on bedside calling out stating that she was in her bedroom. Linens appeared wet and a strong urine odor was noted. 5:20 a.m. Resident was up on the bedside. Linens and resident's gown appears wet. Observation revealed incontinence care was not provided for Resident #17 until 5:25 a.m. on 9/26/12. During the incontinence care, Certified Nurse Aide (CNA) # 1 was observed to remove Resident #17's gown and acknowledged that the gown was wet. Resident #17 was observed to sit completely uncovered on the side of the bed while CNA #1 washed Resident #1's upper extremities. Resident #17 was observed to be left completely uncovered and shivering while CNA #1 went to the bathroom to obtain another pan of water. At 5:30 a.m., another CNA (CNA #2) entered the room and assisted CNA #1 to transfer Resident #17 to a standing position with the stand up lift at 5:38 a.m. Resident #17 was observed to be in an upright position supported by the lift sling under Resident #17's arms from 5:38 a.m. until 5:48 a.m., while CNA #1 finished the incontinence care. CNA #1 was observed to wipe the Resident #17's perineal area in a back and forth manner while Resident #17 was standing in the lift. Resident #17 was uncovered from the waist downward of the lower extremities. During the observation CNA #1 was asked to describe Resident #17's linen and she stated the under pad, and the bottom and top sheet were soaked. CNA #1 stated she changed Resident #17 at 2:00 a.m. Interview on 9/26/12 at 8:08 a.m. revealed Certified Nurse Aide #1 acknowledged that she became aware of the surveyors being on the hall when she was awakened by the surveyor. CNA #1 stated she worked two (2) jobs and was tired. CNA #1 also acknowledged that she had not completed rounds on residents every two (2) hours. Review of the facility's "Perineal Care" policy, revised 5/12, documented: "To cleanse perineum, To eliminate odor, To prevent irritation or infection, To enhance resident's self-esteem, Use a screen or privacy curtain for resident privacy ...Supplies: Washcloths and towels, Soap or other cleansing agent, Toilet tissue, Underpad, Trash bag, Wash basin or sink, Running water, Gloves ...4. Provide privacy and help the patient to a supine position ...5. Drape the resident appropriately..." Review of the facility's job description for "Nursing Assistant, Certified", not dated, documented: "Job Summary. He/She is responsible for the care of the residents in a designated area of the facility. He/She is knowledgeable of the information as outlined on the interdisciplinary Care Plan and follows the plan ... Responsibilities ...03. Checks residents and makes rounds on assigned group noting significant issues for intervention. Begin planning time to assure all resident's needs are met throughout the shift. 04. Assists residents as indicated to provide A.M., P.M. and daily care to assure residents are clean, dry, toileted, continent, well-groomed and cared for in Interdisciplinary Care Plan. Provides for privacy and dignity at all times ...17. Checks all residents frequently and at least every 2 hours assuring the resident is repositioned, turned, toileted, clean, safe, etc. (and so forth). Provides intervention as needed to provide a safe clean environment ...28. Follows appropriate infection control practices in working with the residents and equipment ... "

Based on observation, record review, interview and policy review the facility failed to seek alternative interventions for pain management in a timely manner for one (1) of four (4) residents reviewed for pain. On 9/25/12 Resident #16 complained of unrelieved pain in the right shoulder. The attending physician's office was notified on 9/25/12; however, the physician did not respond until 9/26/12, more than 24 hours after the resident voiced complaints of unrelieved pain. Resident #16 was observed for two (2) days of the survey with facial grimacing and complaints of pain (Resident #16). Findings include: Record review revealed that Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 11, which indicated that Resident #19 was moderately impaired. This MDS coded that Resident #16 required extensive assistance from staff for activities of daily living, and coded that a pain assessment had been conducted and the resident had no pain during the assessment period. Review of the care plan, documented, "Problem Onset: 8/1/12, Resident has dx (diagnosis) of chronic pain. Goal & (and) Target Date: Will Implement Measures To Promote Optimum Level Of Comfort Thru (through) Target Date 11/01/12 ...Approaches included: " Administer Pain Medication As Ordered And Monitor For Effectiveness. Assess For S/S (signs/symptoms) Of Pain Q (every) Shift Using Scale: 0 = None, 1 = Slight, 2 = Mild, 3 = Moderate, 4 = Excruciating. Initiate Acute Charting For 3 Or Greater Level Of Pain. Observation on 9/25/12 at 7:30 a.m. revealed Resident #16 was in the dining room. Resident #16 was to have facial grimacing and complained of pain in the right arm and shoulder. Observation revealed that at 7:38 a.m. Registered Nurse (RN) #2 told the resident she would look at her arm after breakfast. Review of the September 2012 physician's orders [REDACTED]. Review of the " Nurses Medication Notes, " documented, " Date: 9/25/12, Hour: 8:10 A (AM) [MEDICATION NAME] HCL 50 mg...Reason: c/o (complained/of) (symbol for right) shoulder pain. " The response was observed to be charted at 11:00 a.m. and documented a symbol indicating no relief. There was no documentation to identify the level of pain before or after the administration of the PRN (as needed) medication. Observation on 9/25/12 at 12:20 p.m. revealed Resident #16 was lying in bed. Licensed Practical Nurse (LPN) #3 was in the room to check the resident ' s blood glucose. Resident #16 told LPN #3 that she still had pain in the right shoulder. LPN #3 told the resident that she had called the doctor because her pain medication was only ordered every eight (8) hours. At this time, Resident #16 was observed to be grimacing and had a sad facial expression. Observation on 9/25/12 at 3:50 p.m. revealed Resident #16 was lying in bed and moaning. Certified Nurse Aide (CAN) #4 and CNA # 8 were in the room to provide incontinent care. At this time, CNA #4 asked Resident #16, why are you moaning? Resident #16 stated she still had not got easy from the pain in the right shoulder. CNA #4 stated that Resident #16 had been complaining all day about her shoulder hurting. Interview, at this time, with CNA #4 and CNA #8 following the incontinent care on 9/25/12 regarding Resident #16's condition on 9/25/12, revealed CNA #8 stated Resident #16 had been complaining of pain all day and the resident does not usually complain. CNA #4 stated she knew something was wrong with Resident #16 because Resident #16 is usually laughing and joking; however; today Resident #16 was complaining of pain in her arm and shoulder. Interview on 9/26/12 at 7:58 a.m. with Licensed Practical Nurse (LPN) #3 revealed LPN #3 stated se called the doctor's office on 9/25/12 regarding Resident #16 and the doctor had not called back at this time. Observation on 9/26/12 at 2:00 p.m. revealed Resident 16 was up in a Geri-chair. Interview, at this time, revealed Resident #16 stated she never did get any relief and her shoulder still hurts. Interview on 9/26/12 at 2:15 p.m. with Licensed Practical Nurse (LPN) #3 acknowledged during the interview that the pain scale was not documented on Resident #16 on 9/25/12. LPN #3 stated the resident's pain at 8:10 a.m. was a 10, and the pain was 8, when she charted "no relief" at 11:00 a.m. LPN #3 acknowledged that she still had not heard from Resident #16's physician regarding the resident's pain. LPN #3 also acknowledged that she had not notified the Director of Nurses (DON) or the Medical Director of being unable to obtain orders from Resident #16's physician. Interview on 9/26/12 at 2:30 p.m. revealed the Director of Nurses (DON) acknowledged that the Medical Director can be called in the event the facility cannot contact a resident ' s physician. The DON acknowledged that she had not been made aware that Resident #16's physician had not called back as of 9/26/12 and the Medical Director had not been contacted. Observation on 9/26/12 at 5:07 p.m. revealed Resident #16 was in a wheelchair being brought to the resident's room by CNA #3. Resident #16 had a grimacing facial expression and stated that her arm/shoulder was hurting. The Corporate Nurse assessed Resident #16's pain, and noted the resident stated the pain was a 10. Licensed Practical Nurse (LPN) # 3 was observed to push the medication cart to Resident #16's door at 5:08 p.m. and stated the doctor had just called back and changed the order to [MEDICATION NAME] for Resident #16 (This was more than 24 hours since the resident complained of unrelieved pain.) Interview on 9/27/12 at 8:40 a.m. with the Certified Nurse Aide (CNA) #3 assigned to Resident #16 on 9/26/12 regarding Resident #16's condition, revealed CNA #4 acknowledged that something was wrong because the resident was not herself; and stated Resident #16 had a sad, pained look on her face. Review of the nurse's notes, documented the following: "9/25/12. 9:40 A (AM) [MEDICATION NAME] 50 mg (milligram) given this shift ...c/o (complains of pain to (symbol for right) shoulder ..." "9/25/12. 10:30 A ...Res (resident) cont (continues) to c/o pain to (symbol for right) shoulder. Call placed to (name of physician)'s office to notify of pain." "9/25/12. 2:00 P (PM) Call placed to (name of Dr's) office. Awaiting return call." "9/26/12. 8:20 AM. F/U (follow/up) call placed to (name of physician)'s office. (Name of physician)'s nurse states MD (Medical Doctor) was @ (at) WC (wound center) yesterday et (and) will be in this morning et will F/U with med (medication) adjustment." "9/26/12, 12:30 P.(PM) Nurse stated (name of physician)'s office called. Went to desk to call ...Message left." "9/26/12, 2:15 P, Call placed to Dr's (name) office. Made aware of multiple calls et (and) resident's condition. New orders received. (name) states Dr. is not going to adjust pain med until (symbol for after) XR (x-ray) results ...PRN [MEDICATION NAME] given for pain to (symbol for right) shoulder rating "10..." "9/26/12, 3:00 P. (PM) Res LOA (leave of absence) to (name of facility) of XR ..." "9/26/12, 5:10 P (PM), Res returned to facility. Res continues to c/o pain to (symbol for right) shoulder. Dr. (name) paged per answering service. Awaiting return call." "9/26/12 5:15 P. Dr (name) returned call. Made aware of res c/o pain since 9/25/12 et (and) ineffectiveness of [MEDICATION NAME]. New order received [MEDICATION NAME] 5/500 mg given at this time." Interview on 9/27/12 at 8:45 a.m. revealed Resident #16 was smiling and stated she felt better. Resident #16 stated her arm and shoulder finally got easy. Review of the facility's form NS (Nursing Service)-764, Thermometer Pain Scale, dated 2/10, documented a thermometer scale to identify pain with 0 (zero) indicating no pain, 8 (eight) indicating very severe pain and 10 (ten) indicating worst possible pain." Review of the facility's "Pain Screen and Management" policy, revised 05/11, documented, "All residents who experience routine pain receive a comprehensive pain screening and a treatment plan until acceptable level of relief is achieved. All residents have the right to treatment for [REDACTED]...2. A pain scale is used whereby the resident describes his/her pain and amount of pain relief (See Thermometer Pain Scale Form NS-764) must be posted in room or bulletin board ...Acute onset of pain: a. A pain screen is completed when a resident has a new onset of pain, a new type of pain or breakthrough pain, and/or new pain medication has been added or changed ...c. When documenting regarding pain the following elements should be addressed: Date and time of onset, Location of pain, Character, Severity (must use pain scale), Alleviation factors (what makes it better), Exacerbation factors (what makes it worse), Treatments and medications, Responses. d. A pain Screen is completed with each complaint of a new type of pain, a new medication or treatment, or when a resident has not experienced an acceptable level of pain relief ..." Review of the facility's "Guidelines for A Medical Director in a Long - Term Care Facility" policy, revised 04/06, documented, " ...16. Agrees to be on call for 24 hour coverage for emergency services when the facility is unable to reach each resident's own physician or designated alternate ..." Although Resident #16 complained multiple times of pain in the right shoulder, there was no evidence that the facility implemented any alternative measures to manage Resident #16's pain other than waiting for more than 24 hours for a response from Resident #16's physician. There was no evidence the facility contacted the Medical Director when the attending physician did not return the facility's call in a timely manner.

Based on observation, record review, policy review and interview the facility failed to provide wound care for one (1) of three (3) residents (Resident #12) in a manner to promote healing as evidenced by the facility failed to transcribe a standing order for a wound culture into the physician's orders [REDACTED].#12's right heel and the need for obtaining a culture on 9/7/12; failed to follow up to ensure the physician was aware of the culture results [MEDICAL CONDITIONS] on 9/11/12; failed to revise and update Resident #12's plan of care to address an identified Stage II pressure wound and infection control measures, and failed to obtain a dietary consult to assess Resident #12's nutrition for wound healing. Findings include: Review of the facility's "Skin Care Policy & (and) Procedure", dated 03/95, documented: "...IV Treatment Regimen" treatment for [REDACTED]. Carefully document condition. B. The physician's orders [REDACTED]. C ...3. Special attention to keeping the resident clean and dry ...D Accessory care might include: 2. Involvement of the Registered Dietician for weight evaluation, evaluation of diet ...Supplemental nutrients such as MTV, Vitamin C, Zinc and nitrogen. Documentation of weekly nutrition and skin at risk meetings. 3. Skin problems will be incorporated in the interdisciplinary plan of care along with approaches so that the entire staff has an increased awareness of those special needs. Review of the facility's "Stage II Wound Care and Skin Care Protocol" policy, revised 11/06, documented: "Problem: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Goal: Skin show improvement/healing as evidenced by decreased dimensions of blister or wound base and will not worsen. Interventions: A. Utilize risk assessment tools to assess on admission, weekly and/or PRN (as needed). Document changes whenever they occur, noting size, site and stage description of affected areas. B. Eliminate causative factors, i.e. (for example) pressure friction, shear and maceration ...3. Maceration a. Decrease exposure to body wastes, i.e. incontinence ...C. Assess nutritional status ...c. Request dietary consultant for nutritionally compromised residents. Consider vitamin/mineral supplement. d. Monitor lab values indicating nutritional status, particularly CBC (Complete Blood Count), [MEDICATION NAME] levels, total protein ..." Review of the facility's "Standing Orders" policy, revised 9/10, documented: "Policy: Attending physicians have the privilege of issuing orders for routine resident care ...3. When implementing a standing order, it must be written in the clinical record on the physician's orders [REDACTED]. Review of Resident #12's physician's "Nursing Home Standing Order", dated 06/11/12, documented: "...7. Inflamed Abrasion: TAO (triple antibiotic ointment) BID (two times daily) to inflamed area. Notify MD (Medical Doctor) if lesion has drainage or odor ..." Review of the facility's "Laboratory Services" policy, revised 4/12, documented: "...4. The attending physician will be notified of abnormal laboratory results promptly after the facility has been advised of the results ...The notification of the physician will be documented in the medical record. 7. All lab work must be retained in the residents chart and abnormal finding documented with report results and follow up from the physician ..." Record review revealed that Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status Score of 6, which indicated that Resident #12's cognitive status was severely impaired. This MDS coded that Resident #12 required extensive assistance with bed mobility, had limitation of upper extremities on both sides, was totally dependent on staff for transfers, dressing, toilet use, hygiene and bathing, and was always incontinent of bowel and bladder. Review of the nurse's notes revealed the following documentation: "8/30/12 ...Abrasion to Right heel noted. Area 3 cm (centimeters) x (times) 4 cm. Applied skin sake. Notified (name of Doctor) ... 9/07/12..Cultured wound to right heel. Draining SS (serosanguinous) liquid. Resident states tender to touch ..." Both entries were signed by Registered Nurse #3. Review of the facility's "Bacteriology" Lab report documented: "Procedure: Wound Culture ...R (right) Heel. Received Date: 9/7/12 Final Report...Heavy Staphylococcus Aureus Susceptibility to follow on 9/10/12. Proteus Mirabilis, [MEDICAL CONDITION] ... " A hand written note at the bottom of the page documented " faxed to (name of Resident #12's physician) 9/11/12." Review of the facility's "Wound/Skin Management Documentation Record", documented: "Site: Right Heel, Onset Date 08/30/12. (a) 8/31..Stage 2 measuring 3 cm (centimeters) Length x (times) 4 cm width and no depth. B (Bloody) exudate. (b) 9/7..Stage 2 measuring 3 cm length x 4.1 cm width, 0.2 cm depth, B exudate. (c) 9/14..Stage 2 measuring 3 cm length x 3 cm width, 0.2 cm depth, B exudate. (d) 9/21..Stage 2 measuring 3.2 cm length x 3 cm width, 0.2 cm depth. B exudate. (e) 9/27..Stage 2 measuring 4.5 cm length x 3 cm width, 0.3 cm depth, SS (serosanguinous) exudate. The entries were signed by Registered Nurse # 3. Observation of wound care on 9/27/12 at 11:00 a.m. with Registered Nurse (RN) #3 described the area on Resident #12's right heel as a Stage II pressure wound. RN #3 said the area measured 4.4 cm by 3 cm and 0.3 cm depth with a moderate amount of serosanginous drainage. Review of Resident #12's record revealed the standing order implemented for the culture done on 9/7/12 was not transcribed into the physician's orders [REDACTED].#12's plan of care to address a Stage II pressure wound or infection control measures, and there was no evidence of obtaining a dietary consult to assess Resident #12's nutrition for wound healing. Interview on 9/26/12 at 4:35 p.m. revealed Registered Nurse (RN) #3 acknowledged that the standing order was not copied into the medical record. RN #3 also acknowledged that she was not aware of the culture results of 9/11/12 and was unsure if the doctor was aware of the culture results. Interview on 9/27/12 at 11:30 a.m. with the Nurse Practitioner (NP) from Resident #12's physician's office acknowledged that Resident #12's physician was not aware of the wound culture report until the facility texted a message on 9/26/12 and notified by telephone on 9/27/12 regarding the culture report of 9/7/12 . The NP stated as soon as the physician's office was aware of the culture report that antibiotics were ordered. Interview on 9/27/12 at 1:40 p.m. with Licensed Practical Nurse (LPN) #2, who is responsible for the Minimum Data Set and care planning, revealed LPN #2 acknowledged that care plan had not been updated to address Resident #12's Stage II pressure area and the recent culture [MEDICAL CONDITIONS] because she was not aware of the resident's condition. LPN #2 stated if she had been aware she would have notified the Doctor and implemented protocol. Interview on 9/27/12 at 2:10 p.m. revealed Registered Nurse (RN) #3 acknowledged that she did not contact the physician on 9/7/12 when a culture was obtained from drainage of Resident #12's foot. RN #3 also acknowledged that she had not informed the physician about the culture report until 9/27/12 because she was not aware the culture report was on the chart. RN #3 acknowledged that she could not recall discussing Resident #12's wound in the weekly wound care meeting and she had not notified the RD (Registered Dietitian) for a nutritional assessment regarding wound healing. RN #3 was asked to provide any documentation of the latest assessment of the resident's nutrition by the RD. The only documentation provided was as follows: "RD Nutrition Assessment", dated 6/26/12, documented: "...Nutrition Focused Findings ...Physical Findings ...no wounds noted." The facility did not provide any additional information during the survey that a nutritional assessment had been initiated after the identification of a Stage II pressure area, according to the facility's policy for wound care. Review of the record documented: "Physician's Telephone Order, Bactrim DS Tablet, take one tablet by mouth BID (two times daily) X (times) 14 days ...MRSA ([MEDICAL CONDITION]). The facility failed to ensure Resident #12's physician received the culture report of 9/11/12, [MEDICAL CONDITIONS] and follow up with the physician to obtain orders for treatment until 9/27/12.