Every finding on record at Legacy Nursing and Rehabilitation of Tallulah

Based on record review and interviews the facility failed to ensure competent nursing staff provided nursing and related services to attain or maintain the highest practical physical, mental and psychosocial well-being of each resident by failing to administer insulin as ordered for 1 (#56) of 5 residents whose medication regimens were reviewed.Findings:Review of the medical record revealed Resident #56 had an admit date of 11/20/2025 with a diagnosis which included diabetes. Review of the 2026 physician orders revealed the resident was to receive insulin as needed by a sliding scale. The sliding scale indicated the resident was to receive 2 units when her blood sugar ranged from 150 to 199. Review of the April 2026 Medication Administration Record revealed the following blood sugars were obtained and no insulin was given as ordered:04/07/2026 at 9:00 a.m. - 18204/13/2026 at 9:00 a.m. - 15204/18/2026 at 9:00 a.m. - 17004/05/2026 at 5:00 p.m. - 16204/06/2026 at 5:00 p.m. - 16904/07/2026 at 5:00 p.m. - 17204/14/2026 at 5:00 p.m. - 18604/16/2026 at 5:00 p.m. - 197 On 04/22/2026 at 8:50 a.m., interview with S4Nurse Practitioner confirmed the ordered sliding scale insulin injections began at 150 and for blood sugars between 150 to 199 Resident #56 should have received 2 units of insulin.On 04/22/2026 at 9:00 a.m., interview with S2DON confirmed Resident #56 should have received 2 units of insulin on the days where her blood sugars ranged from 150 to 199.

Based on observation, interview and record review, the facility failed to ensure it did not have a medication error rate of greater than 5% by having a medication error rate of 7%.Findings:On 04/21/2026 at 7:50 a.m., a medication pass was observed for Resident #4. During the medication pass, S3LPN used a teaspoon to scoop a dosage of Miralax. Review of the April 2026 physician orders revealed an order for Miralax 17 grams, 1 scoop. Review of the manufacturer's recommendation revealed it instructed to fill the bottle cap to the top of the white section, which is marked to indicate the 17 gram dose. After the completion of the medication pass, review of the April 2026 physician orders revealed Resident #4 should have received Senna 8.6mg by mouth. On 04/21/2026 at 9:15 a.m., interview with S3LPN confirmed she did not administer Senna 8.6mg during the morning medication pass as prescribed and she confirmed she administered only a teaspoon of Miralax. On 04/21/2026 at 9:20 a.m., S2DON was notified of the 2 medication errors resulting in a medication error rate of 7%.

Based on record review and interview, the facility failed to ensure the pharmacist identified irregularities related to adequate monitoring of a prescribed medication for 1 (#14) of 5 residents reviewed for unnecessary medications.Findings:Review of the medical record for Resident #14 revealed an admission date of 07/02/2024 with diagnoses that included cerebral palsy, anxiety, and vitamin deficiency.Review of the care plan revealed Resident #14 had a diagnosis of vitamin deficiency and the interventions included to administer medications as ordered and to draw labs as ordered by the physician. Review of the April 2026 physician orders for Resident #14 revealed an order dated 07/05/2025 for Ergocalciferol (Vitamin D2) oral capsule 1.25 mg, give one capsule by mouth every Friday related to vitamin deficiency. Further review revealed an order dated 08/08/2025 to obtain a Vitamin D level every six months.Review of the medical record for Resident #14 revealed no documented evidence of a Vitamin D level obtained every six months as ordered by the physician.Review of the monthly Drug Regimen Review dated 03/18/2026 revealed the pharmacist failed to identify Resident #14's Vitamin D level was not obtained in February 2026 as ordered.On 04/21/2026 at 3:10 p.m. interview with S2DON confirmed the pharmacist failed to identify the Vitamin D level was not obtained every six months as ordered for Resident #14 on the March 2026 monthly Drug Regimen Review.

Based on record review and interview, the facility failed to ensure residents that had an order for psychotropic medication as needed were not subjected to chemical restraints for 1 (#2) of 5 residents reviewed for unnecessary medications. The facility failed to ensure a prn order for a psychotropic medication was limited to 14 days for Resident #2.Findings:Review of Resident #2's record revealed an admission date of 08/08/2025 with a readmission date of 12/03/2025. Further review revealed diagnoses that included major depressive disorder, anxiety disorder, vascular dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and metabolic encephalopathy.Review of Resident #2's April 2026 Physician's Orders revealed an order dated 12/15/2025 for Lorazepam/Ativan (psychotropic medication) oral tablet 1 mg give 1 tablet via peg tube q 4 hours prn for agitation related to anxiety disorder.Review of the Pharmaceutical Consultant Report (Psychoactive Gradual Dose Reduction) dated 01/19/2026 for Resident #2 revealed the following recommendation for Ativan 1 mg q 4 hours prn: prn psychotropic is limited to 14 days and required the prescriber to evaluate the resident prior to extending the order. If extending the order, document the rationale for the extended time period in the medical record and indicate a specific duration. Further review of the report revealed S4NP failed to document the rationale for an extended time period and failed to indicate a specific duration as per the pharmacist's recommendation.An interview on 04/22/2026 at 9:45 a.m. with S2DON confirmed there was no documented evidence of a rationale for the use of Lorazepam/Ativan prn for Resident #2 and failed to indicate the specific duration for the medication.

Based on record review and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to obtain a Vitamin D level as ordered for 1 (#14) of 5 residents reviewed for unnecessary medications.Findings:Review of the medical record for Resident #14 revealed an admission date of 07/02/2024 with diagnoses that included cerebral palsy, anxiety, and vitamin deficiency.Review of the care plan revealed Resident #14 had a diagnosis of vitamin deficiency and the interventions included to administer medications as ordered and to draw labs as ordered by the physician. Review of the April 2026 physician orders for Resident #14 revealed an order dated 07/05/2025 for Ergocalciferol (Vitamin D2) oral capsule 1.25 mg, give one capsule by mouth every Friday related to vitamin deficiency. Further review revealed an order dated 08/08/2025 to obtain a Vitamin D level every six months.Review of the record revealed there was no documented evidence a Vitamin D level was obtained in February 2026 as ordered. On 04/21/2026 at 12:00 p.m. interview with S2DON confirmed a Vitamin D level was not obtained for Resident #14 in February 2026 as ordered.

Based on record review and interview, the facility failed to report an injury of unknown origin with serious bodily injury to the State Survey Agency in accordance with State law for 1 (#1) of 4 sampled residents. Findings:Review of the facility's undated Abuse Reporting and Investigation Policy and Procedure revealed the following, in part:Policy:1. All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. H. Injuries of unknown origin: An injury should be classified as injury of unknown origin when all of the following criteria are met:1. The source of the injury was not observed by any person, and2. The source of the injury could not be explained by the resident; and3. The injury is suspicious because of the extent of the injury or location of the injury A facility must report any suspicious injury of unknown origin to a resident. Injuries of unknown origin include, but not limited to:1. All injuries to cognitively impaired residents not witnessed.2. Injuries that are non-accidental or explained.3. Fractures, sprains, or dislocations Review of Resident #1's record revealed an admission date of 05/17/2023 with diagnoses including chronic obstructive pulmonary disease, adult failure to thrive, repeated falls, generalized anxiety disorder, dementia with agitation, and delirium due to known physiological condition.Review of the annual Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 which indicates severe cognitive impairment. Further review revealed Resident #1 required 1 person assistance with standing and transfers.Review of the facility's incident reports revealed Resident #1 had an incident entered by the facility on 02/01/2026 at 7:30 p.m. listed under the category of Other.On 02/18/2026 at 8:50 a.m., interview with S2Director of Nursing (DON) revealed Resident #1 was observed to have a bruise and swelling to her lower left leg at 7:30 p.m. on 02/01/2026. Further interview with S2DON revealed the night nurse notified the facility's Nurse Practitioner of the injury and an x-ray of the left leg was ordered for the following morning. S2DON stated the x-ray was completed on 02/02/2026 at 11:15 a.m. and revealed Resident #1 had a fracture of her left leg. S2DON stated Resident #1 was sent to the emergency room for treatment and she began investigating the cause of the fracture. S2DON stated Resident #1 was unable to voice the cause of her injury due to dementia and the facility investigation was unable to find a cause for the leg fracture.On 02/18/2026 at 3:45 p.m., review of Resident #1's x-ray report dated 02/02/2026 at 11:27 a.m. revealed acute mid and distal fractures of the tibia and fibula. Alignment is anatomic. There is no soft tissue swelling or foreign body identified.On 02/23/2026 at 1:00 p.m., interview with S1Administrator revealed he was responsible for notifying the State Survey Agency of an injury of unknown origin with serious bodily injury. S1Administrator confirmed that based on the facility's policy for reporting severe injuries and injuries of unknown origin, the facility should have notified the State Survey Agency.

Based on observations, record reviews, and interviews the facility failed to immediately inform the responsible party of tests results for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for notification of change. The facility failed to ensure that resident #1's responsible party was notified of the resident's x-ray results, in a timely manner. Findings: Review of the medical record revealed resident #1 was readmitted to the facility on [DATE] with diagnoses that included in part, Alzheimer's disease, psychotic disturbance, mood disturbance, anxiety and a personal history of other diseases of the musculoskeletal system and connective tissue. Review of the annual Minimum Data Set, dated dated dated [DATE] revealed resident #1 had a Brief Interview for Mental Status score of 11 which indicated the resident had moderate cognitive impairment with daily decision making skills. Further review revealed resident #1 required assistance with activities of daily living. On 03/31/2025 at 12:15 p.m., an observation revealed resident #1 lying in bed, resting with her right arm exposed. An observation of resident #1's right forearm revealed an area approximately the size the palm of the hand with a faint pinkish color to center of the area. Review of the nursing progress notes dated 03/07/2025 at 10:33 a.m. revealed resident #1 was seen per Nurse Practitioner (NP) with new orders for an x-ray of resident #1's right shoulder/arm. Review of patient report dated 03/07/2025 revealed resident #1 had an x-ray of the right shoulder with 2+ views. The report was electronically signed on 03/07/2025 at 1:23 p.m. by the interpreting physician. Further review revealed S3Licensed Practical Nurse (LPN) had signed and dated the report on 03/07/2025. Review of the medical record revealed there was no documented evidence of resident #1's responsible party being notified of the x-ray report results. On 04/02/2025 at 4:45 p.m., S2Director of Nursing (DON) confirmed resident #1's responsible party had not been notified of the x-ray results in a timely manner. On 04/02/2025 at 5:00 p.m., S1Administrator was notified of the above findings.

Based on observation, interview, and record review the facility failed to accurately assess safety devices for effectiveness and elimination for 1 (#58) of 1 (#58) residents reviewed for restraints. Findings: Review of the facility's Safety and Supervision of Resident's policy and Procedure (undated) revealed the following, in part: 4. Implementing interventions to reduce accident risks and hazards shall include the following: e. Documenting interventions 5. Monitoring the effectiveness of interventions shall include the following: b. evaluating the effectiveness of interventions Review of medical records for resident # 58 revealed an admitted [DATE] with a diagnosis including muscle weakness (generalized), idiopathic orofacial dystonia, mood disorder due to known physiological condition, altered mental status, personal history of transient ischemic attack (TIA), and catatonic schizophrenia. Quarterly Minimal Data Set (MDS) assessment dated [DATE] revealed resident #58 had a Brief Interview for Mental Status (BIMS) score of 4 which indicates cognitive impairment for daily decision making and that the resident required two person assistance with transfers, toileting, and bed mobility. On 02/24/2025 at 08:40 a.m. resident #58 was observed lying in bed. Resident #58's mattress edges were observed to be raised approximately five inches on each side. On 02/25/2025 at 09:34 a.m. resident #58 was observed lying in bed on the mattress with raised edges. On 02/25/2025 at 03:40 p.m. interview with S2Director of Nursing (DON) and S5Licensed Practical Nurse (LPN) confirmed that the safety device assessment dated [DATE] did not include resident # 58's raised edge mattress.

Based on record review and interview, the facility failed to ensure it provided an ongoing program to support the residents in their choice of activities for 1 (#26) of 1 (#26) residents reviewed for activities. The facility failed to provide adequate activities for resident #26 who had a diagnosis of blindness. Findings: On 02/24/2025 at 10:45a.m., interview with resident #26 revealed he was blind and didn't receive any activities. Review of the medical record of resident #26 revealed he had a diagnosis of blindness in the right eye category 3 and blindness in the left eye category 3 indicating a significant degree of vision loss in both eyes. Review of the quarterly activity assessment dated [DATE] revealed resident #26 was provided with the monthly activity calendar. He attended parties/socials and special events and he enjoyed 1:1 conversation while drinking coffee. On 02/25/2025 at 11:00a.m., interview with resident #26 revealed staff do not inform him of when activities are going to take place. On 02/25/2025 at 1:15p.m., interview with S3Activity Director revealed resident #26 was not individually told of upcoming activities. Resident #26 was then interviewed in the presence of S3Activity Director. Resident #26 was asked to rate, from 1 to 10, his satisfaction with the activities he was provided. He rated his satisfaction level as a 2.

Based on observations, record reviews and interviews, the facility failed to: 1) ensure residents had a physician's order for bed rails, 2) obtain informed consent from the resident or resident's representative for bed rail use, and 3) assess residents for the risk of entrapment from bed rails prior to the installation of bed rails for 4 (#23, #30, #34, and #60) of 4 (#23, #30, #34, and #60) residents reviewed for bed rails. Findings: Review of the facility's policy (undated), Restraint Devices - Physical Policy and Procedure revealed the following in part: Procedure: 1. Assess the resident's need for the safety device use. 2. Obtain informed consent for restraint device use. 3. Obtain physician's order for restraint device use. Resident #30 Review of the medical record revealed resident #30 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, hypertension, cerebrovascular disease, major depressive disorder, cerebral infarction, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #30's Brief Interview for Mental Status (BIMS) score was 15 which indicated intact cognition for daily decision making. Resident #30 required extensive - total assistance with most activities of daily living. On 02/24/2025 at 8:52 a.m. and 02/25/2025 at 12:05 p.m., observations of resident #30 revealed she was in the bed with 1/2 bed rails raised on both sides of the bed and both bed rails were loose. On 02/25/2025 at 1:35 p.m., the surveyor and S6Maintenance Supervisor observed the resident's bilateral 1/2 bed rails, and both bed rails were loose. He confirmed the bed rails were loose and needed to be adjusted. Review of resident #30's record revealed no documented evidence of the following: a physician's order for bed rails, informed consent from the resident or resident's representative for bed rail use, and an assessment for the risk of entrapment prior to the installation of bed rails on resident #30's bed. On 02/26/2025 at 9:10 a.m., an interview with S2Director of Nursing (DON) confirmed they failed to obtain a physician's order for bilateral 1/2 bed rails, informed consent for bed rail use from the resident or resident's representative, and an assessment for the risk of entrapment before bed rails were installed on resident #30's bed. 32231 Resident #23 Review of the medical record revealed resident #23 was admitted to the facility on [DATE] with diagnoses including in part, bipolar disorder, Alzheimer's disease, unspecified dementia with agitation, anxiety disorder, insomnia, Spondylolisthesis, muscle weakness (generalized), and personal history of transient ischemic attack. Review of the annual MDS assessment dated [DATE] revealed resident #23's BIMS was documented as severely impaired. Resident #23 required total dependence with 2+ person's physical assist with bed mobility. On 02/25/2025 at 10:06 a.m. and 02/25/2025 at approximately 3:20 p.m., observations revealed resident #23 was lying in bed. Further observation revealed that resident #23's bilateral 1/2 bed rails were raised on both side of the bed. On 02/26/2025 at 9:30 a.m., an observation revealed resident #23 was lying in bed with 1/2 bed raised on the right side of the bed and the other 1/2 side lowered to the left side of the bed, however, the bed rail remained attached to the bed. Review of resident #23's record revealed no documented evidence of the following: a physician's order for bed rails, informed consent from the resident or resident's representative for bed rail use, and an assessment for the risk of entrapment prior to installation of bed rails on resident #23's bed. On 02/26/2025 at 2:35 p.m., S2Director of Nursing was notified of the above findings. She confirmed that after record reviews, resident #23's record revealed no documented evidence of the following: a physician's order for bilateral 1/2 bed rails, informed consent for bed rail use from the resident or representative's representative, and an assessment for the risk of entrapment prior to the installation of bed rails on the resident's bed. Resident #34 Review of the medical record revealed resident #34 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side, aphasia, cerebral palsy, lack of coordination, and difficulty in walking. Review of the quarterly MDS assessment dated [DATE] revealed resident #34's BIMS score was 04 which indicated the resident was severely impaired with his daily decision making skills. Resident #34 required total dependence with 2+ person's physical assist with bed mobility. On 02/25/2025 at 10:00 a.m., 02/25/2025 at 4:06 p.m., and 02/26/2025 at 9:04 a.m., resident #34 was observed lying in bed with 1/2 bed rails raised to both sides of the bed. Review of resident #34's record revealed no documented evidence of the following: a physician's order for bed rails, informed consent from the resident or resident's representative for bed rail use, and an assessment for the risk of entrapment prior to installation of bed rails on resident #34's bed. On 02/26/2025 at 2:35 p.m., S2Director of Nursing was notified of the above findings. She confirmed that after record reviews, resident #34's record revealed no documented evidence of the following: a physician's order for bilateral 1/2 bed rails, informed consent for bed rail use from the resident or representative's representative, and an assessment for the risk of entrapment prior to the installation of bed rails on the resident's bed. Resident #60 Review of the medical record revealed resident #60 was admitted to the facility on [DATE] with diagnoses including aphasia following cerebral infarction, hemiplegia, unspecified, affecting right dominant side. Review of the quarterly MDS assessment dated [DATE] revealed resident #60 had a BIMS score of 10 which indicated moderate cognitive impairment with daily decision making skills. On 02/25/2025 at 10:11 a.m., 02/25/2025 at 4:06 p.m., and 02/26/2025 at 3:35 p.m., observations revealed resident #60 was lying in his bed resting, in his room. Further observation revealed resident #60's 1/2 bed rails raised on both sides of the bed. Review of resident #60's record revealed no documented evidence of the following: a physician's order for bed rails, informed consent from the resident or resident's representative for bed rail use, and an assessment for the risk of entrapment prior to installation of bed rails on resident #60's bed. On 02/26/2025 at 2:35 p.m., S2Director of Nursing was notified of the above findings. She confirmed that after record reviews, resident #60's record revealed no documented evidence of the following: a physician's order for bilateral 1/2 bed rails, informed consent for bed rail use from the resident or representative's representative, and an assessment for the risk of entrapment prior to the installation of bed rails on the resident's bed.

Based on record reviews and interviews, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to monitor for bleeding for a resident who received anticoagulant medication for 1 (#15) of 1 (#15) residents reviewed for anticoagulants. Findings: Review of medical records for resident #15 revealed an admitted [DATE] with diagnosis including cerebral infarction, transient cerebral ischemic attack, atherosclerotic heart disease of native coronary artery without angina pectoris, old myocardial infarction, long term (current) use of anticoagulants, and chronic atrial fibrillation Review of the February 2025 physician orders revealed that resident #15 was ordered Eliquis (anticoagulant) 5 milligrams (mg) every 12 hours and Aspirin (anticoagulant) 81 mg daily. Review of the current care plan revealed resident #15 was at risk for bleeding due to anticoagulant therapy. Interventions included to watch orifices for signs and symptoms of bleeding and notifying the physician of any signs and symptoms of bleeding. Review of resident #15's medical record revealed no documented evidence of monitoring for bleeding. On 02/25/2025 at 1:00 p.m. interview with S2Director of Nursing (DON) confirmed that resident #15 received Eliquis and Aspirin and there was no documentation of monitoring for bleeding for resident #15. On 02/25/2025 02:25 p.m. an interview with S4Licensed Practical Nurse (LPN) confirmed that she does not document bleeding or bruising monitoring when she administers resident # 15's anticoagulants.

Based on observations and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety by, 1) storing clean pots on a shelf with old food particles, 2) having a buildup of an unknown black substance on the inside of the ice machine and a buildup of dust on the filters of the ice machine, 3) foods items being stored in the freezer that were open and exposed to air, and 4) storing flats of bottled water directly on the storage room floor. According to the Diet Type Report, there was a total of 84 residents who currently received a meal tray from the kitchen. Findings: On 02/24/2025 at 8:25 a.m., an observation of the food preparation table revealed pots and pans that had been turned upside down and stored on the bottom shelf. Further observation revealed there were old food particles scattered on the shelf and in direct contact with the pots and pans. An observation of the ice machine revealed that upon opening the top lid of the ice machine, there was a large amount of an unknown black colored substance that was scattered throughout the lid. Further observation revealed the unknown substance was also observed on an area that was located on the upper inside of the machine. S8Dietary Manager confirmed the ice machine needed to be cleaned. An observation of the outside of the ice machine revealed two large filters. Further observation revealed the filters had a buildup of dust on the slats. S8Dietary Manager confirmed the filters needed to be cleaned. An observation of the walk-in freezer revealed one large box of beef patties and one large box of Churro Bites. Further observation revealed that both boxes were open and the beef patties and Churro Bites were exposed to air. S8Dietary Manager confirmed the food items were not properly sealed. Further observation revealed a storage room that was located in the back of the kitchen. An observation of the storage room revealed two flats of bottled water that was sitting directly on the floor. S8Dietary Manager confirmed the flats should not have been stored on the floor. S8Dietary Manager presented the survey team with a Diet Type Report. Review of the report revealed there was a total of 84 residents who currently received a meal tray from the kitchen. On 02/26/2025 at 11:45 a.m., S1Administrator was notified of the above findings.

Based on observations and interviews, the facility failed to maintain a sanitary environment to help prevent the development and transmission of communicable diseases and infections by, failing to ensure employees did not store their personal belongings in the kitchen food preparation and storage room. According to the Diet Type Report, there was a total of 84 residents who currently received a meal tray from the kitchen. Findings: On 02/24/2025 at 8:25 a.m., an observation of the kitchen revealed one purse that was located on a top shelf next to a measuring cup and other food preparation items. There was a cart that had a large box of parchment paper stored on the bottom shelf. The end of the box was opened, the parchment paper was exposed and there was one large single sheet of the parchment paper lying on the outside of box. Further observation revealed a black colored jacket lying on top of and in direct contact with the exposed parchment paper. S9Dietary [NAME] was present in the kitchen during the observations. She revealed that she did not know who the jacket belonged to. S9Dietary [NAME] confirmed the purse belonged to herself. Further observation of the kitchen revealed a storage room that was located in the back of kitchen. An observation of the storage room revealed three jackets and one purse that were hanging on hooks. The jackets and purse was located next to a rolling cart that contained several cans of soups. S8Dietary Manager was present in the kitchen at the time of the observations. She confirmed that the kitchen staff were not supposed to have their personal belongings stored in the kitchen and storage room due to the possibility of cross contamination. S8Dietary Manager presented the survey team with a Diet Type Report. Review of the report revealed there was a total of 84 residents who currently received a meal tray from the kitchen. On 02/26/2025 at 11:45 a.m., S1Administrator was notified of the above findings.

Based on observations and interviews, the facility failed to maintain all mechanical equipment in safe operating condition by having a buildup of metal shavings on the can opener and a grease buildup inside of the deep fryer. According to the Diet Type Report, there were a total of 84 residents who currently received a meal tray from the kitchen. Findings: On 02/24/2025 at 8:35 a.m., an observation of the kitchen revealed the commercial can opener contained a large buildup of metal shavings underneath the blade. Further observation revealed the large gas fryer had a buildup of grease on the internal components. S8Dietary Manager was present during the observations and confirmed that the can opener and the gas fryer were not in safe operating condition. S8Dietary Manager presented the survey team with a Diet Type Report. Review of the report revealed there was a total of 84 residents who currently received a meal tray from the kitchen. On 02/26/2025 at 11:45 a.m., S1Administrator was notified of the above findings.

Based on observation, interview and record review, the facility failed to ensure each resident received services within a reasonable accommodations of their needs for 1 (#144) of 1 (#144) residents reviewed for accommodation of needs. The facility failed to ensure resident #144 was supplied with a call light that he could activate. Findings: Review of the medical record for resident #144 revealed he was admitted on [DATE] and had a diagnosis of wedge compression fracture of the T11-T12 vertebra. On 02/24/2025 at 12:50 p.m., interview with resident #144 revealed he was unable to activate his call light. Resident #144 demonstrated that he was unable to move his left arm and he was unable to move his right fingers to push the call light button. On 02/25/2025 at 12:45 p.m., S2Director of Nursing (DON) and the surveyor entered the room of resident #144. The resident demonstrated that he was unable to activate the call light due to physical disabilities. S2DON confirmed the resident was unable to activate the call light.

Based on record review and interview, the provider failed to ensure an incident involving an elopement was reported to the State Survey Agency for 1 (#294) of 1 sampled resident reviewed for elopement. Findings: Review of the facility's policy and procedure for resident elopement (no date) revealed in part the following: Purpose: to ensure that all residents are afforded adequate supervision to provide the safest environment possible. Policy: all residents will be assessed for behaviors or conditions that put them at risk for elopement and all residents so identified will have these issues addressed in their individual care plans. Definition: For the purpose of this policy, missing resident shall be defined to mean a resident who has left the facility grounds without signing him/herself out of the facility. Further review of the policy for resident elopement revealed to call or fax a report within 24 hours of the incident and prepare a complete report at the completion of the incident. Contact all the people/agencies previously notified that resident has been found. Review of the record for resident #294 revealed an admitted [DATE] with the following diagnoses: unspecified dementia with other behavioral disturbance and wandering. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed resident #294 had a brief interview for mental status of 3 which indicated that resident #294 had severe cognitive impairment with daily decision making. The assessment also indicated the resident was independent with transfers and did not require mobility devices. Review of elopement risk assessment completed on 11/07/2024 revealed resident was assessed as high risk for elopement with a score of 13. Review of an incident report 11/08/2024 at 1:08 p.m. revealed the following: S7Licensed Practical Nurse (LPN) notified this nurse (S10LPN) that resident #294 was out of facility unattended. Resident #294 was observed walking up Hall A when a sitter leaving out of emergency exit door, let resident #294 out believing that she was a visitor. S7LPN went out of the facility to get resident #294 whom was walking up a side road next to building. S7LPN requested assistance from a neighbor. S7LPN and neighbor transferred resident #294 back to facility in personal vehicle. Resident #294 then assisted to her room. Vitals 138/70; pulse 78, respirations 20, temperature 98 and oxygen saturation was 97% room air and resident #294 denies pain. No skin issues noted. Resident #294 stated that she was headed to her mom's room. Physician aware, no new orders. Daughter notified. Immediate Action taken: resident #294 assisted back to facility; vitals, no skin issues, resident #294 not taken to hospital. No injuries observed at time of incident. Interview with S7LPN on 02/26/2025 at 9:15 a.m. revealed that on 11/08/2024 at approximately 1:00 p.m., S7LPN was working at her desk on Hall A when a sitter for another resident came to her door and stated she (sitter) let someone out of the building at the end of the hall while she was smoking. The sitter stated to S7LPN she thought she was a family member. S7LPN stated she immediately ran down to the door and saw resident #294 walking in the field off Hall A approximately 25 yards from the building. S7LPN stated she realized that she did not have her phone so she notified the sitter to go get staff. S7LPN then ran toward resident #294 and caught up with resident at the side road next to the facility. Further interview revealed that another staff member was driving up to the facility and saw S7LPN and resident #294. S7LPN and resident #294 got into her the car and returned to the front of the facility without incident. Resident #294 was pleasant, no agitation, but was confused. S7LPN stated she was able to return resident #294 into facility without incident. S7LPN stated resident #294 had a wander guard already on and the only way she got out was because the sitter opened the door for her when she (sitter) was smoking. S7LPN confirmed the facility's staff was not aware resident #294 exited the building until notified by sitter. S7LPN confirmed that she never lost visual sight of the resident. Further interview with S7LPN revealed the whole incident, including resident #294 being returned to her room, was less than 10 minutes. Observation at this time with S7LPN revealed the door at end of Hall A was locked. S7LPN opened the door and proceeded to demonstrate the incident. The place in which S7LPN first saw resident #294 was approximately 25 yards from Hall A's exit door. The side road (unpaved) was another 25 yards away and lead directly to the staff parking lot. This road was only for staff parking and there was no thru traffic. Further observation revealed there were no cars and the road was a single lane only leading into the parking lot. Interview with S1Administrator on 02/26/2025 at 10:15 a.m. confirmed that resident #294 was able to elope out of the facility without the staff aware of the incident until a sitter notified the nursing staff. Further interview with S1Administrator confirmed that he did not report resident #294's elopement in the Statewide Incident Management System (SIMS).

Based on observations, record reviews and interviews, the facility failed to ensure each resident received adequate supervision to prevent elopement for 1 (#294) of 1 sampled resident reviewed for elopement. Findings: Review of the facility's policy and procedure for resident elopement (no date) revealed in part the following: Purpose: to ensure that all residents are afforded adequate supervision to provide the safest environment possible. Policy: all residents will be assessed for behaviors or conditions that put them at risk for elopement and all residents so identified will have these issues addressed in their individual care plans. Definition: For the purpose of this policy, missing resident shall be defined to mean a resident who has left the facility grounds without signing him/herself out of the facility. Review of the record for resident #294 revealed an admitted [DATE] with the following diagnoses: unspecified dementia with other behavioral disturbance and wandering. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed resident #294 had a brief interview for mental status of 3 which indicated resident #294 had severe cognitive impairment with daily decision making. The assessment also indicated the resident was independent with transfers and did not require mobility devices. Review of elopement risk assessment completed on 11/07/2024 revealed resident was assessed as high risk for elopement with a score of 13. Review of the care plan revealed resident #294 was an elopement risk related to wandering with the following interventions: alert staff to my wandering behavior; if I wander away from unit, instruct staff to stay with me, converse and gently persuade me to walk back to designated area with them; monitor and document my behavior; notify my (medical doctor) MD and family if I attempt elopement; and place wander guard bracelet on me that sounds alarms when I leave building. Review of an incident report dated 11/08/2024 at 1:08 p.m. revealed the following: S7Licensed Practical Nurse (LPN) notified this nurse (S10LPN) that resident #294 was out of facility unattended. Resident #294 was observed walking up Hall A when a sitter leaving out of emergency exit door, let resident #294 out believing that she was a visitor. S7LPN went out of the facility to get resident #294 whom was walking up a side road next to building. S7LPN requested assistance from a neighbor. S7LPN and neighbor transferred resident #294 back to facility in personal vehicle. Resident #294 then assisted to her room. Vitals 138/70; pulse 78, respirations 20, temperature 98 and oxygen saturation was 97% room air and resident #294 denied pain. No skin issues noted. Resident #294 stated that she was headed to her mom's room. Physician aware, no new orders. Daughter notified. Immediate Action taken: resident #294 assisted back to facility; vitals, no skin issues, resident #294 not taken to hospital. No injuries observed at time of incident. Review of a statement from S7LPN dated 11/08/2024 revealed the following: I was sitting in my office on Hall A, when another resident's private sitter came to my door and stated, This lady just followed me outside the exit door on Hall A, and I don't know if she is a visitor or a patient. I immediately ran to the Hall A exit door and looked and saw it was a patient. I exited the door and started running toward the resident #294. My phone was on my desk, so I told the sitter to call the front desk and tell them I needed help. I kept my eyes on the patient the entire time. A neighbor assisted me in getting resident #294 back to the facility unharmed, without any injury or distress. Resident #294 was assisted inside stable condition. Interview with S7LPN on 02/26/2025 at 9:15 a.m. revealed that on 11/08/2024 at approximately 1:00 p.m., S7LPN was working at her desk on Hall A when a sitter for another resident came to her door and stated she (sitter) let someone out of the building at the end of the hall while she was smoking. The sitter stated to S7LPN she thought she was a family member. S7LPN stated she immediately ran down to the door and saw resident #294 walking in the field off Hall A approximately 25 yards from the building. S7LPN stated she realized that she did not have her phone so she notified the sitter to go get staff. S7LPN then ran toward resident #294 and caught up with resident at the side road next to the facility. Further interview revealed that another staff member was driving up to the facility and saw S7LPN and resident #294. S7LPN and resident #294 got into her the car and returned to the front of the facility without incident. Resident #294 was pleasant, no agitation, but was confused. S7LPN stated she was able to return resident #294 into facility without incident. S7LPN stated resident #294 had a wander guard already on and the only way she got out was because the sitter opened the door for her when she (sitter) was smoking. S7LPN confirmed the facility's staff was not aware resident #294 exited the building until notified by sitter. S7LPN confirmed that she never lost visual sight of the resident. Further interview with S7LPN revealed the whole incident, including resident #294 being returned to her room, was less than 10 minutes. Observation at this time with S7LPN revealed the door at end of Hall A was locked. S7LPN opened the door and proceeded to demonstrate the incident. The place in which S7LPN first saw resident #294 was approximately 25 yards from Hall A's exit door. The side road (unpaved) was another 25 yards away and lead directly to the staff parking lot. This road was only for staff parking and there was no thru traffic. Further observation revealed there were no cars and the road was a single lane only leading into the parking lot. Interview with S5LPN on 02/26/2025 at 9:30 a.m. revealed she did assessments and the care plan for resident #294. S5LPN confirmed resident #294 was admitted to the facility for high risk for wandering and a wander guard was placed on resident #294 on the date of admission, 11/07/2024. Interview with S2Director of Nursing (DON) on 02/26/2025 at 9:45 a.m. confirmed resident #294 was able to elope out of the facility via the Hall A exit door as result of another resident's sitter who was smoking outside the exit door and accidently let resident #294 exit the building. S2DON confirmed the nurse was immediately notified and resident #294 was quickly returned back to the facility. S2DON confirmed resident #294 was high risk for wandering and resident #294 was able to exit the facility without the staff being aware until reported by a sitter. Interview with S6Maintenace Supervisor on 02/26/2025 at 10:00 a.m. confirmed the exit door on Hall A does not have a code alert bracelet (wander guard) system to alert if a resident who was wearing a wander guard was in close proximity to the exit door. S6Maintenance Supervisor confirmed that resident #294 exited out of the facility and there was no alert due to the fact that there was no alert system on exit door of Hall A. Interview with S1Administrator on 02/26/2025 at 10:15 a.m. confirmed resident #294 was able to elope out of the facility without the staff aware of the incident until a sitter notified the nursing staff. Further interview with S1Administrator revealed that it was determined a sitter for another resident let resident #294 out of the facility by mistake as she thought resident #294 was a visitor. S1Administrator confirmed the Hall A exit door did not have a code alert bracelet system and as a result did not alert when resident #294 exited the facility through that door.

Based on record reviews and interviews, the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs for 2 (#1, #5) of 5 (#1, #2, #3, #4, and #5) sampled residents reviewed for unnecessary medications. The facility failed to ensure the nurses' followed an insulin sliding scale as ordered (#1) and blood pressure parameters as ordered (#1, #5). Findings: Review of the facility's Medication Administration Policy and Procedure (no date noted) revealed in part, the facility shall provide medications as ordered by the physician. Resident #1: Review of the medical record revealed resident #1 was readmitted to the facility on [DATE] with diagnoses that included in part, type 2 diabetes mellitus with diabetic retinopathy, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, dry eye syndrome of bilateral lacrimal glands and blindness of the right and left eye, and hypertension. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had a documented Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment and resident #1 required extensive assistance with most activities of daily living. Review of the medical record revealed resident #1 was care planned for having multiple medications. The documented approaches included to administer the resident's medications as ordered by the physician. Review of the August 2024 and September 2024 physician orders revealed resident #1 had an order for Lisinopril Oral Tablet 20 milligrams (mg); give 20 mg by mouth one time a day. Hold if Systolic Blood Pressure (SBP) is less than (<) 120 and /or Diastolic Blood Pressure (DBP) is <75. Review of resident #1's September 2024 Medication Administration Record (MAR) revealed documentation that the nurses failed to follow the above blood pressure parameters 5 times from 09/01/2024- 09/09/2024 when resident #1's dialystolic blood pressure was <75. Review of resident #1's August 2024 MAR revealed documentation that the nurses failed to follow the above blood pressure parameters 14 times from 08/01/2024 - 08/31/2024 when resident #1's diastyolic blood pressure was <75. On 09/10/2024 at 3:53 p.m., the surveyor reviewed resident #1's 08/2024 and 09/2024 MARS with S5Licensed Practical Nurse (LPN). She reported she was unable to view the parameters for the medication Lisinopril on the MARs. S5LPN confirmed that she did not know the hold the Lisinopril when resident #1 had a DBP result of <75 on dates of 08/07/2024, 08/09/2024, 08/12/2024, 08/16/2024, 08/17/2024, 08/18/2024, 08/22/2024, 08/26/2024, 09/01/2024, 09/04/2024, 09/05/2024, and 09/09/2024. On 09/16/2024 at 12:15 p.m., the surveyor reviewed resident #1's 08/2024 and 09/2024 MARS with S3LPN. S3LPN reported she thought she held resident #1's Lisinopril Oral Tablet 20 mg on the following dates: 08/01/2024, 08/04/2024, 08/05/2024, 08/15/2024, 08/28/2024, 08/31/2024, and 09/07/2024. S3LPN confirmed her documentation indicated that the Lisinopril was administered on the above dates. Review of the August 2024 physican's orders revealed resident #1 had an order for Novolog FlexPen subcutaneously Solution Pen-Injector 100 units/milliliter (Insulin Aspart); Inject 9 units subcutaneously with meals for diabetes mellitus, hold if Finger Stick Blood Sugar (FSBS) was <150. Review of resident #1's August 2024 MAR revealed documentation that the nurses failed to follow the insulin parameters 2 times from 08/04/2024 - 08/30/2024 when resident #1's FSBS was <150. On 09/10/2024 at 3:53 p.m., the surveyor reviewed resident #1's August 2024 MAR with S5LPN. S5LPN revealed that she was not aware that she was to hold the medication and confirmed that the Novolog Insulin was admistered on 08/30/2024. On 09/16/2024 at 12:15 p.m., the surveyor reviewed resident #1's August 2024 MAR with S3LPN. S3LPN revealed that she was not aware that she had administered Novolog insulin when resident #1's FSBS was 135 on 08/04/2024. She confirmed that she had not held resident #1 insulin as ordered. On 09/16/2024 at 2:00 p.m., an interview with S2Director of Nursing (DON) confirmed the nurses failed to follow resident # 1's blood pressure and insulin parameters as ordered for the above dates in 08/2024 and 09/2024. On 09/16/2024 at 6:15 p.m., S1Administrator was notified of the above findings. 22575 Resident #5: Review of the medical record for resident #5 revealed an admitted [DATE] with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, unspecified protein-calorie malnutrition, other seizures, and generalized muscle weakness. Review of resident #5's care plan dated 01/22/2024 revealed the resident's hypertension was identified with an intervention to administer the antihypertensive medication as ordered. Review of the Quarterly MDS assessment dated [DATE] revealed resident had a BIMS score of 15, which indicated no cognitive impairment and he required extensive assistance with most activities of daily living. Review of resident #5's Physician Orders revealed an order dated 01/20/2024 for Metoprolol Tartrate (blood pressure medication) 100mg every 12 hours, hold if pulse <60 or systolic blood pressure <110. Review of resident #5's September 2024 MAR revealed documentation that the nurses failed to follow the above blood pressure parameters 6 times from 09/01/2024 - 09/07/2024 when resident #5's pulse was <60 and/or his systolic blood pressure was <110. Review of resident #5's August 2024 MAR revealed documentation that the nurses failed to follow the above blood pressure parameters 10 times from 08/03/2024 - 08/30/2024 when resident #5's pulse was <60 and/or his systolic BP was <110. On 09/16/2024 at 12:00 p.m., the surveyor reviewed resident #5's 08/2024 and 09/2024 MARS with S3LPN. She reported she thought she held resident #5's Metoprolol Tartrate on the following dates: 08/15/2024, 08/23/2024, 09/02/2024, 09/06/2024, 09/07/2024, and 09/08/2024. However, she confirmed her documentation indicated that the Metoprolol Tartrate was administered on the above dates. On 09/16/2024 at 2:00 p.m., an interview with S2DON confirmed the nurses failed to follow resident # 5's blood pressure parameters as ordered for the above dates in 08/2024 and 09/2024.

Based on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene for 1 (#1) of 5 (#1, #2, #3, #4, and #5) residents reviewed for activities of daily living by, failing to ensure resident #1's feet were kept cleaned and his face was groomed. Findings: Review of the medical record revealed resident #1 was readmitted to the facility on [DATE] with diagnoses that included in part, type 2 diabetes mellitus with diabetic retinopathy, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, and dry eye syndrome of bilateral lacrimal glands and blindness of the right and left eye, category 3. Review of the quarterly minimum data set assessment dated [DATE] revealed resident #1 had a documented brief interview for mental status score of 15. A score of 13-15 indicated that resident was cognitively intact with daily decision making skills. Further review of the assessment revealed resident #1 required extensive assistance with one person physical assist with bed mobility, transfers, and personal hygiene. On 09/09/2024 at 10:53 a.m., an observation revealed resident #1 in his room and lying in bed. S4Certified Nursing Assistant (CNA) was present and preparing the resident for his morning bath. During the bath, a visual inspection of resident #1's skin was completed with S4CNA. During the inspection, resident #1 was observed to have a thick buildup of a black colored crust between the great toe and 2nd toe of both feet. There were areas of moisture with a thick, sticky white coating observed in between resident #1's 4th and 5th toe of the left foot and in between the 2nd - 5th toes of the right resident's right foot. Further observation revealed resident #1's left foot had a slight odor and resident #1 had long, untrimmed nasal hairs protruding from both nares. S4CNA confirmed that resident #1's toes needed to be cleaned and the nasal hairs needed to be trimmed. On 09/09/2024 at 11:45 a.m., S5Licensed Practical Nurse (LPN) was notified of the findings that were identified during the visual skin inspection. S5LPN inspected the resident's feet including the areas between the toes and confirmed the area needed further attention as she smelled the odor coming from resident #1's left foot. On 09/10/2024 at 9:05 a.m., S2Director of Nursing (DON) was notified of the findings regarding crusty buildup, moisture, and coating in between resident #1's toes. She was further notified of the resident having an odor to his left foot and long, untrimmed nasal hair. S2DON confirmed that resident #1's feet, including the areas in between his toes should be cleaned during his baths and his nasal hairs should have been trimmed. On 09/16/2024 at 6:15 p.m., S1Administrator was notified of the above findings.

Based on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. The facility failed practice was evidenced by 1) not turning or repositioning dependent residents every 2 hours for 1 (#50) of 2 (#50, #28) residents investigated for position/mobility and 2) not administering medication as ordered by the physician for 1 (#345) of 2 (#345, #69) residents investigated for respiratory care. Findings: Resident #50 Record review revealed resident #50 was admitted to the facility on [DATE]. Resident #50 had active diagnoses that included Parkinson`s disease, dementia, neurogenic bladder, protein malnutrition, major depressive disorder, dysphagia, aphasia and anxiety. Review of the most recent minimum data set (MDS) dated [DATE] revealed resident #50 did not have a brief interview of mental status (BIMS) score because resident # 50 could rarely or never be understood to complete the assessment. Further review of MDS section G - activities of daily living (ADL) revealed resident #50 had total dependence on staff for bed mobility and required 2 person assistance. Review of the Certified Nursing Assistant (CNA) task history revealed that staff were to turn resident #50 every two hours while awake or in a chair. Further review revealed documentation by staff of resident #50 being turned every 2 hours from 02/29/2024 through 03/13/2024. On 03/13/2024 at 8:10 a.m., resident #50 observed lying in bed on her right side. On 3/13/2024 at 10:40 a.m., resident #50 was provided with wound care. After the procedure was finished, S3 Registered Nurse (RN) positioned resident #50 back on her right side. On 03/13/2024 at 2:10 p.m., an observation of resident #50 revealed she remained in the same position on her right side. Resident #50 appeared to be in the same position as she was at 10:55 a.m. when wound care was completed. On 03/13/2024 at 2:15 p.m., an interview with S5 CNA confirmed she was assigned to provide care for resident #50. S5 CNA confirmed that she had not turned or repositioned resident #50 since her shift began at 07:00 a.m. on 03/13/2024. On 03/13/2024 at 2:42 p.m., an interview with S2 Director of Nursing (DON) confirmed resident #50 should have been turned every 2 hours in accordance with the resident's plan of care. 41829 Resident #345 Record review revealed resident #345 was admitted to the facility on [DATE] from a local hospital after being treated for novel coronavirus (COVID) and pneumonia. Resident #345 had recovered from COVID. Resident #345's diagnoses included the following: pneumonia, type 1 diabetes mellitus with unspecified complications, methicillin susceptible staphylococcus aureus infection as the cause of disease classified elsewhere, myelodysplastic syndrome unspecified, type 2 diabetes mellitus without complications, resistance to multiple antimicrobial drugs, and acquired absence of spleen. Review of resident #345's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental status (BIMS) score of 12 which represents moderate cognitive impairment. Review of resident #345's active March 2024 physician orders revealed an order dated 03/08/2024 with a start date of 03/09/2024 for Ceftriaxone Sodium 2 grams intravenously (IV), flush with 5 milliliters (ml) normal saline (NS) before and after every day until 03/13/2024. Review of resident #345's March 2024 electronic medication administration record (EMAR) revealed documentation on 03/09/2023 at 9:00 a.m. Ceftriaxone Sodium 2 grams intravenously was administered by S7Licensed Practical Nurse (LPN). Further review of the EMAR revealed documentation on 03/10/2023 Ceftriaxone Sodium 2 grams intravenously was not administered by S8 LPN. Further review of the EMAR revealed documentation on 03/11/2023 Ceftriaxone Sodium 2 grams intravenously was not administered by S4 LPN. On 03/11/2024 at 9:35 a.m., an interview with resident #345 revealed she was admitted to the facility on Friday (03/08/2024) from the hospital. The resident reported she was treated for COVID and pneumonia while in the hospital, and she had an intravenous catheter placed in her left hand on 03/03/2024 after being admitted to the facility. Resident #345 reported she is feeling better but still has an occasional cough. An observation of resident #345 revealed respirations were even and unlabored. On 03/12/2024 at 8:48 a.m., an observation of resident #345 revealed she was sitting in chair in room watching television. Interview with the resident reported she had not received any antibiotics yet. Resident #345 reported that she thinks they are waiting for the antibiotics to come in. On 03/12/2024 at 10:20 a.m., an interview with S4 LPN reported resident #345's antibiotic, Ceftriaxone Sodium 2 grams IV, just came in from the pharmacy this morning. S4 LPN revealed she had not administered resident #345 the Ceftriaxone Sodium 2 grams IV, but would be administering the first dose today when the resident returned from therapy. On 03/12/2024 at 3:35 p.m., an interview with S2 DON reported resident #345 was admitted to the facility on [DATE] and was ordered Ceftriaxone Sodium 2 grams IV every day to start on 03/09/2023 through 03/13/2024 related to pneumonia. S2 DON reported she ordered the antibiotic from the pharmacy on 03/08/2024. S2 DON revealed you have to have your physician order submitted to the pharmacy by 10:00 a.m. or you will not receive the medication that same day. S2 DON revealed the pharmacy reported resident #345's IV antibiotic would not be delivered to the facility until Monday (03/11/2023). S2 DON revealed they had the antibiotic in the emergency (ER) kit in the medication room and the nurses were to obtain the antibiotic from the ER kit until it arrived from the pharmacy. On 03/12/2024 at 2:40 p.m., an interview with S4 LPN revealed she administered resident #345's first dose of Ceftriaxone Sodium 2 grams IV today (03/12/2024) at 10:45 a.m. On 03/12/2024 at 3:30 p.m., an interview with S2 DON revealed resident #345 did not receive the Ceftriaxone Sodium 2 grams IV every day as ordered by the physician on 03/09/2024, 03/10/2024 or 03/11/2024. S2 DON confirmed S7 LPN did not administer Ceftriaxone Sodium 2 grams IV to resident #345 on 03/09/2024 that was ordered. S2 DON revealed resident #345's Ceftriaxone Sodium 2 grams IV was not delivered to the facility until this morning (03/12/2024). S2 DON confirmed S4 LPN administered resident #345's first dose of ceftriaxone sodium 2 grams IV on 03/12/2024 at 10:45 a.m.

Based on interview, medical record review, and review the facility's weight loss policies, the facility failed to identify quality deficiencies and develop and implement plans of action to correct these quality deficiencies through the QAA (Quality Assessment and Assurance) Committee. The deficient practice resulted in the QAA Committee's failure to identify concerns with the quality of facility systems involving interventions aimed at preventing further unplanned weight loss. The deficient practice involved 2 (#21, #98) of 2 (#21 and #98) residents with severe weight loss in a total of 3 resident reviewed for weight loss issues in the revisit sample. Findings: 1. Resident #21 Review of the record revealed resident #21 was admitted with [DIAGNOSES REDACTED]. Review of the record revealed the resident was hospitalized from [DATE]-01/24/16. On 02/15/16 at 1:46PM, resident #21's weight was requested from S2DON. She confirmed that the resident had not been weighed but they could weight him now. On 02/15/16 at 2:10PM, S2DON brought a piece of paper with the resident's weight of 105 lbs written on it. She stated that the resident was weighed twice for verification and that she had called the FNP (Family Nurse Practitioner) to notify her. The surveyor mentioned that the resident looked weak. S2DON confirmed that she had not seen the resident today because she had been busy. Review of the resident #21's admit weight on 08/10/15 was 168 lbs. Resident #21's height was noted to be 66 inches on admit. The resident's current weight on 02/15/16 was 105 lbs. Review of the Resident #21's weights revealed: 12/28/15- 135 lbs, 01/04/16- 123 lbs, 01/27/16- 146 lbs, 01/28/16- 139 lbs, 01/29/16- 135 lbs, 02/02/16- 133 lbs, 02/03/16- 130 lbs, 02/08/16- 118 lbs, and 02/15/16- 105 lbs. One weekly weight meeting was held on 02/04/16 (Thursday) and one was held on 02/10/16 (Wednesday). Review of the weekly weight meetings roster dated 02/04/16 and 02/10/16 revealed resident #21 was not on either list of residents that were reviewed during the meetings. On 02/15/16 at 1:30PM, S2DON confirmed that the resident was not on the two weekly weight meetings listed above. When asked if he was reviewed in the meeting, she confirmed that he had not been reviewed in the meeting. S2DON further confirmed that she did not keep documentation regarding who attended the weekly weight meetings and there was no documentation of interventions, if any, that were put into place when the residents were discussed. Review of the nurses' notes dated 02/12/16 by S2DON revealed resident #21 had a 17 pound weight loss to 118 pounds in 42 days. Review of the resident's weights revealed he weighed 135 pounds on 01/29/16 and 118 lbs on on 02/08/16, which was 17 pounds in 10 days, not 42 days as documented in the S2DON nurses' note. Further review of the nurses' note revealed the Registered Dietitian would assess weight loss on next scheduled visit. FNP and family was notified. On 02/16/16 at 12:05PM, an interview with S6RD was conducted. She stated that she visits the facility twice a month and was last here on 01/26/16. S6RD confirmed that she is given a list of residents to consult each visit by the S7DM. When asked if resident #21 was on the list of residents that needed a consult during this visit, S6RD confirmed that resident #21 was not on her list. When asked if she was notified of resident #21's weight loss, S6RD confirmed that she had not been notified of resident #21's weight loss, poor appetite, or decreased intake. When asked if she was aware of resident #21's recent weight of 105 lbs on 02/15/16, S6RD confirmed that she pulled up a list of weights on the computer after she arrived at the facility earlier today and saw that the resident had lost weight down to 105 lbs. When asked if she should have been notified of resident #21's weight loss, S6RD confirmed that she should have been notified. On 02/16/16 at 11:30AM, S2DON was interviewed regarding resident #21's ideal body weight which she noted on the letter dated 01/27/16 as 157-192 lbs and differently on 02/12/16 as 114-154 lbs. She stated that she used a formula to get the ideal body weights and must have gotten it wrong. Resident #21 had a 13 pound weight loss from 02/03/16 (130 lbs) to 02/08/16 (118 lbs) and an additional 12 pound weight loss on 02/15/16 (105 lbs). S2DON confirmed that the resident was not discussed at the weekly weight meetings on 02/04/16 and 02/10/16 because he was not on the list. S2DON further confirmed that the resident should have been on the list because he was a weekly weight. Review of the note by the S2DON dated 02/12/16, noted the weight from 02/08/16 of 118 lbs and documented the RP and FNP were notified. It also noted the Registered Dietitian would assess the weight loss on the next scheduled visit. On 02/16/16 at 1:15PM, an interview with S2DON confirmed that she had not looked at the resident's 02/08/16 weight until 02/12/16 because she had been busy. Review of the meal intake for resident #21 revealed: 02/02/16-breakfast 0%, lunch 0%, supper 25%, 02/03/16- breakfast 75%, lunch 75%, supper 100%, 02/04/16-breakfast 75%, lunch 75%, supper 100%, 02/05/16-breakfast 75%, lunch 75 %, supper 50%, 02/06/16-breakfast 75%, lunch 75%, supper 75%, 02/07/16-breakfast 75%, lunch 100%, supper 0%, 02/08/16-breakfast 50%, lunch 50%, supper 25%, 02/09/16-breakfast 100%, lunch 50%, supper 50%, 02/10/16-breakfast 0%, lunch 0%, supper 25%, 02/11/16-breakfast 25%, lunch 25%, supper 50%, 02/12/16-breakfast 0%, lunch 25%, supper 0%, 02/13/16-breakfast 50%, lunch 75%, supper 0%, 02/14/16-breakfast 0%, lunch 50%, supper 0%, 02/15/16-breakfast 0%, lunch 0%, supper 0%, 02/16/16-breakfast 100% (data entry error), and lunch 0%. On 02/16/16 at 3:00PM, an interview and observation of the above meal intake documentation with S2DON confirmed that she had not looked at the resident's record of meal intake. S2DON further confirmed that the breakfast intake percent on 02/16/16 noted as 100% was a data entry error and the correct meal intake for resident #21 should have been 0%, not 100%. S2DON confirmed that S17CNA told her resident #21 ate a couple of bites of grits for breakfast on 02/16/16 and the meal intake should have been documented as 0%. On 02/16/16 at 3:05PM, the care plan for resident #21. The surveyor was informed that the care plan for resident #21 was in a binder at the nurses' station. There was no care plan for resident #21 at the desk and the care plan was printed. Review of the care plan revealed there was no careplan developed to address resident #21's weight loss. On 02/16/16 at 2:55PM, S15 Wound Care Nurse informed the surveyor that resident #21 was being transferred to another facility to a higher level of care. On 02/17/16 at 2:50PM, S2DON confirmed a care plan had not been developed to address resident #21's current weight loss. 2. Resident #98 Review of the medical record revealed resident #98 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed a BIMS score of 15 (13-15) revealed that the resident is cognitively intact. Review of the physician's orders [REDACTED]. Review of weight history revealed that the resident had a documented weight loss from 151 pounds on 01/04/16 down to 142 pounds on 02/02/16. Review of the medical record revealed care planning for the potential for weight fluctuation gain/loss, nutritional deficiency related to dysphagia, diabetes, [MEDICAL CONDITION] of the colon. The approaches included to determine ideal body weight, refer to dietician for evaluation and recommendation, weigh as ordered and as needed, encourage resident to consume as much as possible, serve diet as ordered, and determine food preferences. Further review revealed that the care plan did not address the current weight loss. Review of nurses' notes dated 02/16/16 at 10:39AM revealed that at 9:15AM, the resident was alert and oriented in all spheres. Lying in bed with head of bed elevated. Resident complaining of nausea and vomiting. Further review of the documentation revealed that the resident had vomited a small amount of light brown milky like substance after readycare was given and that the refused her breakfast tray this am due to the nausea. On 02/16/16 at 09:50AM, a record review and interview with S6RD and S7DM was conducted. S6RD was questioned regarding resident #98's current weight loss for the dates of 01/04/16 to 02/02/16. S6RD revealed that the facility started having weekly weight loss meetings that were every Tuesday. She revealed that the meetings had began on 01/12/16. S6RD stated that she understood that if weight loss was noted, weight letters should be generated during that meeting and the physician and the resident's responsible party were to be notified and should also be brought to her attention. S6RD further stated that she comes to the facility twice a month to review any weight changes. S6RD presented a document named Consultation Needs for Registered Dietitian dated 01/27/16 through 02/16/16. Review of the document revealed a list of resident's names that consisted of any new admits, pressure sores, weight loss, tube fed, abnormal lab values, [MEDICAL TREATMENT], and food intake less than 75%. Further review of the document revealed that resident #98's name was not on the list. S6RD revealed that she was given the list by S7DM. S6RD stated that when she comes to the facility two times a month, she reviews the meal roster, wound and skin status reports, and the weight change history reports for the residents herself. She revealed that the resident #98's weight was stable in January. She confirmed that she had not been notified of any current weight loss until today (referring to 02/16/16) when she pulled up the weight change history report and noted the weight loss. S7DM was questioned regarding the process for being notified of a resident's weight loss. She revealed that her daily routine was to check the diet changes, make changes on the diet cards. She revealed that she attends daily morning meetings with the registered nurses, minimum data set, social service, and S1Administrator regarding any weight changes. Further interview revealed that S7DM stated that her understanding of the weekly meetings was to address weight loss. She revealed that S2DON was to refer the residents with a weight loss to S6RD in the form of a letter. She then stated that S2DON is to put the letter into S7DM's. S7DM would then place the letter in S6RD's box. After reviewing the document, S7DM confirmed that resident #98 was not on the weight loss list and that she was not aware of the resident's current weight loss. On 02/16/16 at 10:45AM, an interview with S2DON was conducted and she was notified of resident #98's current weight loss of 9 lbs from 01/16/16 to 02/02/16. She revealed that the resident did not show up on the 5% weight change history list on 02/2016. She stated that she only looks at the percentage of weight loss and not the actual pounds lost. She revealed that the resident's name did not show up on the weight history change list as having a 5% or greater weight loss, because she looked at a 60 day period and not for the monthly timeframe. When asked if she reviewed the resident's weight monthly, she revealed that it depended on what dates were put into the computer as to the time period. A review of the facility's weekly weight meetings dated 02/04/16 and 02/10/16. A review revealed that the resident's name was not on the list as being identified as having a current weight loss of greater than 5% in a month. S2DON confirmed that she was not aware of the current wt loss of greater than 5% in a month and that resident #98 was not on the list. She stated she does not address the residents that are to be weighed monthly in the weekly meetings. She revealed that she would later address the weight loss for those residents with S8Assistant CNA (certified nursing assistant) Supervisor. S2DON confirmed that the weekly weight meetings for QA (Quality Assurance) only contained a list of residents that were identified with weight concerns. She confirmed that there was no documentation from the weekly weight meeting that was specific to each individual resident which addressed the resident's weight concerns or if and any approaches were implemented. A review of the nurses' notes for the dates of 01/04/16 through 02/02/16 was reviewed with S2DON. She confirmed that there was not any documentation of resident #98's physician or the facility's family nurse practitioner had been notified of the resident's current weight loss. On 02/17/16 at 2:50PM, an interview was conducted with the S2DON. She confirmed that a care plan had not been developed to address the resident's current weight loss. On 02/16/16 at 3:20PM, an interview with S5LPN was conducted and she confirmed that she had not notified the MD or FNP of the resident's poor appetite. An interview with S9CNA was conducted. She was questioned regarding the documentation of the resident's percentage of meals eaten and 0% (nurse notified). She stated that she didn't sign anything and was not aware of the place to document that the nurse was notified. She was asked if she notified the nurse when the resident did not eat her meals and she stated that sometimes she does and sometimes she doesn't. She further stated that she guessed that it pops up and notifies the nurse when she enters 0% as meal consumption. Review of the weekly weight meeting documents dated 02/04/16 and 02/10/16 revealed a list of resident's names noted beneath the headings of Daily Weights, New Admits readmitted and Weekly Weights. Documentation revealed that there was not documented evidence that addressed the following: the names of the staff members who had attended the weekly weight loss meetings, the interventions, if any, that were discussed for residents with identified weight concerns, monitoring of residents that had been identified as having weight loss. Further review revealed that there was no documented evidence of the facility performing tracking and trending of significant weight loss during the weekly weight loss meetings. On 02/16/16 at 2:00PM, an interview with S2DON was conducted and a review of the weekly weight meetings dated 02/04/16 and 02/10/16 were discussed. S2DON confirmed that resident's #21 and #98 have a current weight loss of greater than 5% in one month and she further confirmed that residents #21 and #98 were not on the weekly weight meeting list as being identified as having a current weight loss of greater than 5% in one month. S2DON revealed that she did not discuss any resident with an ordered monthly weight that had identified weight loss, during the weekly weight meetings. She stated that she would later address those resident's weight loss with S8Assistant CNA Supervisor. Review of the survey binder revealed an In-Service Training For Employees document dated 01/14/16 that consisted of the importance of accurate and timely weights, new admits will be weighed daily x 5 days, then weekly x 4 weeks, then monthly unless there is an indication to weigh more often. Weekly weight meetings will continue indefinitely. Review of the document revealed the signature of S8Assistant CNA Supervisor. There was no other employee signatures noted on the in-service document. On 02/17/16 at 2:00PM, an interview with S2DON confirmed that S8Assistant was the only employee that was in-serviced on 01/14/16. An In-service Training was dated 01/14/16. The In-Service Training covered the areas of accurate and timely weights. It noted that new admits will be weighed daily x 5 days, then weekly x 4 weeks, then monthly unless there is an indication to weigh more often. Further review revealed that weekly weight meetings will continue indefinitely. The only employee that attended the in-service was S8Assistant CNA Supervisor. S2DON confirmed that S8Assistant CNA Supervisor was the only employee that attended the in-service training. S2DON further confirmed that S8 Assistant CNA Supervisor does not work seven days a week and that all nurses need to be in-serviced so that if a new resident admits on the weekend the resident would be weighed according to the facility's policy.

Based on review of the record and interview the facility failed to ensure that a resident maintains acceptable parameters of nutritional status such as body weight by not notifying the physician or addressing weight loss for 1 (#21) of 3 (#8, #21 and #28) residents whom met the QCLI criteria for weight loss in a total sample of 28 stage 2 sampled residents. Findings: Review of the medical record for the sampled resident revealed [DIAGNOSES REDACTED]. Review of the Admission Nursing assessment dated [DATE] revealed the resident required extensive assistance with activities of daily living (ADLs). Review of the Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Memory Score = 6 which is severely impaired. Review of the weights revealed the following: 12/16/15 = 131.4 12/14/15 = 130 12/7/15 = 135 11/30/15 = 147 Review of the medical record revealed the last dietary note for the resident with weight loss was dated 11/30/15. Review of the careplan revealed potential for weight fluctuations gain/loss. Further review of the care plan revealed allow ample time to ingest meals, determine ideal body weight, refer to dietician for evaluation and recommendations, weigh as ordered and as needed, notify physician of 5 pound weight gain or loss, monitor for [MEDICAL CONDITION] daily and document abnormal findings, monitor and record percentage of foods/fluids consumed daily and provide supplements, diet and therapy as ordered. Review of the Medication Administration Record [REDACTED]. On 12/16/15 at 10:30AM an interview with S5ADON confirmed the weight loss for the resident was not reported to the physician as stated in the careplan and no new approaches were attempted after the resident had lost 17 pounds in less than one month.

Based on observation, record review, and interview the facility failed to ensure that services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care for 1 (#5) of 2 (#2, #5) residents reviewed with swallowing difficulty. The facility identified 3 residents with swallowing difficulty. An Immediate Jeopardy situation began on 12/30/14 when the CNAs (Certified Nursing Assistant) feeding the resident and the dietary manager was unaware that the resident had nectar thick liquids ordered on [DATE]. Resident #5 was admitted to the hospital on [DATE] with recurrent aspiration pneumonia. A swallowing study was done on 01/16/15 which revealed the resident aspirated on thin liquids. Honey thick liquids were ordered on [DATE] after the swallowing study was completed. The resident continues to be served thin liquids. S1Administrator was notified of the Immediate Jeopardy situation on 03/02/15 at 4:30PM. The Immediate Jeopardy ended on 03/02/15 at 6:15PM when S1Administrator provided an acceptable plan of removal labeled "Immediate Jeopardy for Residents with a thickened liquid diet order" which included the following: Initial Plan of Removal provided on 03/02/15 at 5:05PM 1.) Identified all residents with a thickened liquid diet order 2.) Ensure diet cards are recorded appropriately 3.) Add task to kiosk to residents with a thickened liquid diet order 4.) In-service CNAs, LPNs, and dietary staff on residents with thickened liquid diet orders and our procedure. All new CNAs, LPNs, and dietary staff will be in-serviced upon hire. a. Dietary department is responsible for adding thickening when resident eats in the dining room b. CNAs are responsible for adding thickening when resident eats in his/her room c. LPNs are responsible for adding thickening to medications 5.) In-service CNAs and LPNs on Aspiration Precautions. 6.) Communication/Shift Change Report binder will be at each nurses' station with in-service sheets to be signed by nurses and CNAs 7.) RNs will monitor randomly each day for two weeks the breakfast, lunch, and supper meals, then 3 times a week for 2 weeks, then once monthly for 3 months 8.) This will be put into place immediately Revised Plan of Removal provided on 03/02/15 at 6:15PM and accepted by the team 1.) Identified all residents with a thickened liquid diet order 2.) Ensure diet cards are recorded appropriately 3.) Add task to kiosk to residents with a thickened liquid diet order 4.) In-service CNAs, LPNs, and dietary staff on residents with thickened liquid diet orders and our procedure. All new CNAs, LPNs, and dietary staff will be in-serviced upon hire. a. Dietary department is responsible for adding thickening when resident eats in the dining room b. CNAs are responsible for adding thickening when resident eats in his/her room c. LPNs are responsible for adding thickening to medications 5.) In-service CNAs and LPNs on Aspiration Precautions. 6.) Communication/Shift Change Report binder will be at each nurses' station with in-service sheets to be signed by nurses and CNAs 7.) RNs will monitor randomly each day for two weeks the breakfast, lunch, and supper meals, then 3 times a week for 2 weeks, then once monthly for 3 months 8.) This will be put into place immediately Resident #5's hall nurse and CNAs were in-serviced before supper meal. Resident #5's liquids on her supper tray were thickened according to the physician order. The current Hall 200 nurse, S2LPN will in-service 11-7 shift of resident #5's thickened liquid diet order and have LPNs and CNAs sign the in-service sheet. She will in-service the LPNs and CNAs on our thickened liquid policy and Aspiration precaution policy. The current hall nurses will in-service the 11-7 shift for each of their halls. LPNs and CNAs are being in-serviced now. The deficient practice remains at a pattern of actual harm for resident #5. Findings: A review of resident #5's record revealed an admitted [DATE]. Her [DIAGNOSES REDACTED]. On 12/04/14 the resident was diagnosed with [REDACTED]. A review of the chart revealed that the resident was admitted to the hospital on [DATE] after a brief cardiopulmonary arrest and was found to have dysphagia and severe malnutrition. A peg tube (a tube place into the stomach for feeding purposes) was placed on 12/03/14 and the resident was discharged from the hospital on [DATE]. On return from the hospital on [DATE], resident #5's diet order was for a soft diet with chopped meats, nectar thick fluids, and assist with meals. Her [DIAGNOSES REDACTED]. The hospital discharge summary indicated the Pneumonia was treated and resolved. A review of the chart revealed that the resident was admitted to the hospital again on 12/18/14 with recurrent Aspiration Pneumonia and discharged on [DATE] per the hospital discharge summary. It was also revealed in the hospital discharge summary that the "patient will continue to have recurrent problems with this, as she has very poor swallowing reflexes". A review of the chart revealed that resident #5 was re-admitted to the facility on [DATE]. Her "Admitting Orders-eCharting" form did not have a diet order. However, her hospital discharge summary revealed she was NPO (Nothing by Mouth). A review of the February 2015 physician orders [REDACTED]. A review of the chart revealed that the resident was admitted to the hospital on [DATE] and returned on 01/09/15 with a [DIAGNOSES REDACTED]. A review of the hospital discharge papers for the 01/03/15 admission revealed that the resident was treated for [REDACTED]. A review of the "Admitting orders-eCharting" form dated 01/09/15 revealed that it did not contain a diet order. However, the hospital discharge orders revealed that the resident was to have no oral feeding until after the swallowing test was performed. A review of the "fluid intake" form received on 03/03/15 at 1:15PM per S3LPN and dated 12/30/14 - 01/21/15 revealed that resident #5 received fluids on 12/30/14, 12/31/14, 01/01/15, 01/02/15, 01/09/15, 01/13/15, 01/14/15, and 01/18/15. An interview with S3LPN on 03/03/15 at 1:15PM confirmed that the amounts listed on the "fluid intake" form under the section titled "fluid intake in cc's" on 12/30/14, 12/31/14, 01/01/15, 01/02/15, 01/09/15, 01/13/15, 01/14/15, and 01/18/15 would have been taken orally. A review of a swallowing study done on 01/16/15 revealed that resident #5 had aspirated on thin liquids. Her classification of Dysphagia was listed as severe, oral dysphagia evident, pharyngeal dysphagia evident. The recommendation was that the resident receive a puree diet with either honey or nectar liquids depending on her level of assistance and supervision during feedings. A review of the March 2015 physician orders [REDACTED]. The March 2015 physician orders [REDACTED]. A review of the March 2015 physician orders [REDACTED]. An observation on 03/02/15 at 12:10PM revealed that resident #5 was being fed by S5CNA. The resident's meal consisted of mashed potatoes with gravy, pureed pork chop, pureed turnip greens, and pudding. Resident #5 had a 6oz glass of water and an 8oz glass of tea both un-thickened. At 12:15PM resident #5 began to cough/choke on water being offered per the S5CNA. S5CNA assisting resident #5 stopped offering the water until the resident stopped coughing/choking then offered the resident more water. In total the resident drank about ½ of the water and ¼ of the tea. After choking the resident did not want any more to eat and the CNA removed the lunch tray, but left the un-thickened water and tea at the bedside for the resident. Resident #5 consumed about 25% of her meal. An interview with resident #5 on 03/02/15 at 12:15PM while the resident was assisted with her lunch meal revealed that when asked if the resident had ever had thickened liquid, the resident replied "no". A review of the 12/17/14 BIMS (Brief Interview of Mental Status) revealed that the resident scored a 14 (cognitively intact). An interview with S5CNA on 03/02/15 at 12:15PM while she was feeding resident #5 revealed that when she was asked if the resident had ever had thickened liquids, this CNA replied "no, she usually does not have a problem with her regular liquids". An interview with S4DM on 03/02/15 at 2:40PM revealed that liquids are usually thickened by the dietary staff prior to being placed on the hall cart. She stated that resident #5 usually eats in her room. She further stated that resident #5 had a pureed diet but received regular liquids so dietary would not thicken her liquids prior to putting her tray on the cart to go down the hall. When asked if dietary did not thicken a resident ' s liquid prior to going down the hall then who would thicken their liquids, she stated that the CNAs would probably. A copy of the dietary card printed on 03/02/14 at 2:55PM per S4DM revealed that resident #5's diet was pureed. S4DM stated at this time that if the resident needed thickened liquids it would be listed on the dietary card. An interview with S6CNA on 03/02/15 at 2:30PM revealed that this CNA does not always work with resident #5 but has fed her on occasion. She stated that resident #5 does not have thickened liquids and usually drinks regular liquids. An interview with S7LPN on 03/02/15 at 2:35PM revealed that resident #5's diet is pureed with honey thickened liquids. When asked if she ever observed resident #5 being fed, she stated that she did not usually unless she just happened to be in the room for something else. When asked if resident received thickened liquids normally she stated "yes". When shown the un-thickened water and tea on resident #5's bedside table she stated that the CNA should have thickened the liquids prior to the lunch meal. A can of thickener was noted on the bedside table at this time. When asked who is responsible for thickening the resident's liquid, she stated that the CNA should have done it. An interview with S8DON on 03/02/15 at 2:43PM revealed that the CNAs are responsible for thickening liquids when feeding residents and the nurses are responsible when giving meds. When asked if she was aware if resident #5 was receiving thickened liquids, she stated that the ADON would know about resident #5 since that is her hall. An interview with S10CNA on 03/02/15 at 2:55PM revealed that she does not usually care for resident #5 but has on occasion. She stated that she has fed resident #5 and the resident does not have thickened liquids. She stated that she has fed her thin liquids and the resident was able to drink it "ok". An interview with S11CNA on 03/02/15 at 3:00PM revealed that she was resident #5's regular CNA and has fed her many times. She added that she went to school with resident #5. When asked if resident #5 was able to drink her liquids without any problems, she stated "yes". This CNA was then asked if the resident ever received thickened liquids and she stated "no". An interview with S10CNA on 03/02/15 at 3:05PM revealed that when this surveyor asked her to show her the kiosk information that she sees while caring for residents, she could not find where it indicated that resident #5 received thickened liquids. When asked how else she would know if a resident needed thickened liquids, she stated that if a can of thickener was in the room she would know. A review of the care plan with a next revision date of 03/18/15 revealed that resident #5 was care planned for the following problems: Dysphagia onset 12/04/14 High risk for Aspiration onset 12/04/14 Weight Fluctuations onset 12/04/14-interventions included nectar thickened fluids Gastric Tube onset 12/04/14 An interview with S9ADON on 03/02/15 at 2:50PM revealed that she did not know if resident #5 was receiving thickened liquids. She stated, as she was looking at her computer screen, that she was just seeing that the resident has thickened liquids ordered. She confirmed at this time that resident #5 should be receiving thickened liquids.

Based on observation, record review, and interview the facility failed to ensure each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 (#5) of 2 (#2, #5) residents reviewed with swallowing difficulty. The facility identified 3 residents with swallowing difficulty. The facility failed to provide resident #5 with the therapeutic diet ordered by the physician. An Immediate Jeopardy situation began on 12/30/14 when the CNAs (Certified Nursing Assistant) feeding the resident and the dietary manager was unaware that the resident had nectar thick liquids ordered on [DATE]. Resident #5 was admitted to the hospital on [DATE] with recurrent aspiration pneumonia. A swallowing study was done on 01/16/15 which revealed the resident aspirated on thin liquids. Honey thick liquids were ordered on [DATE] after the swallowing study was completed. The resident continues to be served thin liquids. S1Administrator was notified of the Immediate Jeopardy situation on 03/02/15 at 4:30PM. The Immediate Jeopardy ended on 03/02/15 at 6:15PM when S1Administrator provided an acceptable plan of removal labeled "Immediate Jeopardy for Residents with a thickened liquid diet order" which included the following: Initial Plan of Removal provided on 03/02/15 at 5:05PM 1.) Identified all residents with a thickened liquid diet order 2.) Ensure diet cards are recorded appropriately 3.) Add task to kiosk to residents with a thickened liquid diet order 4.) In-service CNAs, LPNs, and dietary staff on residents with thickened liquid diet orders and our procedure. All new CNAs, LPNs, and dietary staff will be in-serviced upon hire. a. Dietary department is responsible for adding thickening when resident eats in the dining room b. CNAs are responsible for adding thickening when resident eats in his/her room c. LPNs are responsible for adding thickening to medications 5.) In-service CNAs and LPNs on Aspiration Precautions. 6.) Communication/Shift Change Report binder will be at each nurses' station with in-service sheets to be signed by nurses and CNAs 7.) RNs will monitor randomly each day for two weeks the breakfast, lunch, and supper meals, then 3 times a week for 2 weeks, then once monthly for 3 months 8.) This will be put into place immediately Revised Plan of Removal provided on 03/02/15 at 6:15PM and accepted by the team 1.) Identified all residents with a thickened liquid diet order 2.) Ensure diet cards are recorded appropriately 3.) Add task to kiosk to residents with a thickened liquid diet order 4.) In-service CNAs, LPNs, and dietary staff on residents with thickened liquid diet orders and our procedure. All new CNAs, LPNs, and dietary staff will be in-serviced upon hire. a. Dietary department is responsible for adding thickening when resident eats in the dining room b. CNAs are responsible for adding thickening when resident eats in his/her room c. LPNs are responsible for adding thickening to medications 5.) In-service CNAs and LPNs on Aspiration Precautions. 6.) Communication/Shift Change Report binder will be at each nurses' station with in-service sheets to be signed by nurses and CNAs 7.) RNs will monitor randomly each day for two weeks the breakfast, lunch, and supper meals, then 3 times a week for 2 weeks, then once monthly for 3 months 8.) This will be put into place immediately Resident #5's hall nurse and CNAs were in-serviced before supper meal. Resident #5's liquids on her supper tray were thickened according to the physician order. The current Hall 200 nurse, S2LPN will in-service 11-7 shift of resident #5's thickened liquid diet order and have LPNs and CNAs sign the in-service sheet. She will in-service the LPNs and CNAs on our thickened liquid policy and Aspiration precaution policy. The current hall nurses will in-service the 11-7 shift for each of their halls. LPNs and CNAs are being in-serviced now. The deficient practice remains at a pattern of harm for resident #2. Findings: A review of resident #5's record revealed an admitted [DATE]. Her [DIAGNOSES REDACTED]. On 12/04/14 the resident was diagnosed with [REDACTED]. A review of the chart revealed that the resident was admitted to the hospital on [DATE] after a brief cardiopulmonary arrest and was found to have dysphagia and severe malnutrition. A peg tube (a tube place into the stomach for feeding purposes) was placed on 12/03/14 and the resident was discharged from the hospital on [DATE]. On return from the hospital on [DATE], resident #5's diet order was for a soft diet with chopped meats, nectar thick fluids, and assist with meals. Her [DIAGNOSES REDACTED]. The hospital discharge summary indicated the Pneumonia was treated and resolved. A review of the chart revealed that the resident was admitted to the hospital again on 12/18/14 with recurrent Aspiration Pneumonia and discharged on [DATE] per the hospital discharge summary. It was also revealed in the hospital discharge summary that the "patient will continue to have recurrent problems with this, as she has very poor swallowing reflexes" . A review of the chart revealed that resident #5 was re-admitted to the facility on [DATE]. Her "Admitting Orders-eCharting" form did not have a diet order. However, her hospital discharge summary revealed she was NPO (Nothing by Mouth). A review of the February 2015 physician orders [REDACTED]. A review of the chart revealed that the resident was admitted to the hospital on [DATE] and returned on 01/09/15 with a [DIAGNOSES REDACTED]. A review of the hospital discharge papers for the 01/03/15 admission revealed that the resident was treated for [REDACTED]. A review of the "Admitting orders-eCharting" form dated 01/09/15 revealed that it did not contain a diet order. However, the hospital discharge orders revealed that the resident was to have no oral feeding until after the swallowing test was performed. A review of the "fluid intake" form received on 03/03/15 at 1:15PM per S3LPN and dated 12/30/14 - 01/21/15 revealed that resident #5 received fluids on 12/30/14, 12/31/14, 01/01/15, 01/02/15, 01/09/15, 01/13/15, 01/14/15, and 01/18/15. An interview with S3LPN on 03/03/15 at 1:15PM confirmed that the amounts listed on the "fluid intake" form under the section titled "fluid intake in cc's" on 12/30/14, 12/31/14, 01/01/15, 01/02/15, 01/09/15, 01/13/15, 01/14/15, and 01/18/15 would have been taken orally. A review of a swallowing study done on 01/16/15 revealed that resident #5 had aspirated on thin liquids. Her classification of Dysphagia was listed as severe, oral dysphagia evident, pharyngeal dysphagia evident. The recommendation was that the resident receive a puree diet with either honey or nectar liquids depending on her level of assistance and supervision during feedings. A review of the March 2015 physician orders [REDACTED]. The March 2015 physician orders [REDACTED]. A review of the March 2015 physician orders [REDACTED]. An observation on 03/02/15 at 12:10PM revealed that resident #5 was being fed by S5CNA. The resident's meal consisted of mashed potatoes with gravy, pureed pork chop, pureed turnip greens, and pudding. Resident #5 had a 6oz glass of water and an 8oz glass of tea both un-thickened. At 12:15PM resident #5 began to cough/choke on water being offered per the S5CNA. S5CNA assisting resident #5 stopped offering the water until the resident stopped coughing/choking then offered the resident more water. In total the resident drank about ½ of the water and ¼ of the tea. After choking the resident did not want any more to eat and the CNA removed the lunch tray, but left the un-thickened water and tea at the bedside for the resident. Resident #5 consumed about 25% of her meal. An interview with resident #5 on 03/02/15 at 12:15PM while the resident was assisted with her lunch meal revealed that when asked if the resident had ever had thickened liquid, the resident replied "no" . A review of the 12/17/14 BIMS (Brief Interview of Mental Status) revealed that the resident scored a 14 (cognitively intact). An interview with S5CNA on 03/02/15 at 12:15PM revealed CNA stated she usually does not have a problem with her regular liquids". An interview with S4DM on 03/02/15 at 2:40PM revealed that liquids are usually thickened by the dietary staff prior to being placed on the hall cart. She stated that resident #5 had a pureed diet but received regular liquids so dietary would not thicken her liquids prior to putting her tray on the cart to go down the hall. A copy of the dietary card printed on 03/02/14 at 2:55PM per S4DM revealed that resident #5's diet was pureed. S4DM stated at this time that if the resident needed thickened liquids it would be listed on the dietary card. An interview with S6CNA on 03/02/15 at 2:30PM revealed resident #5 does not have thickened liquids and usually drinks regular liquids. An interview with S7LPN on 03/02/15 at 2:35PM revealed that resident #5's diet is pureed with honey thickened liquids. When shown the un-thickened water and tea on resident #5's bedside table she stated that the CNA should have thickened the liquids prior to the lunch meal. An interview with S10CNA on 03/02/15 at 2:55PM revealed Resident #5 does not have thickened liquids. She stated that she has fed her thin liquids and the resident was able to drink it "ok". An interview with S11CNA on 03/02/15 at 3:00PM revealed that she was resident #5's regular CNA and has fed her many times. When asked if resident #5 was able to drink her liquids without any problems, she stated "yes". This CNA was then asked if the resident ever received thickened liquids and she stated "no". An interview with S10CNA on 03/02/15 at 3:05PM revealed that when this surveyor asked her to show her the kiosk information that she sees while caring for residents, she could not find where it indicated that resident #5 received thickened liquids. When asked how else she would know if a resident needed thickened liquids, she stated that if a can of thickener was in the room she would know. An interview with S9ADON on 03/02/15 at 2:50PM revealed that she did not know if resident #5 was receiving thickened liquids. She stated, as she was looking at her computer screen, that she is just seeing that the resident has thickened liquids ordered. She confirmed at this time that resident #5 should be receiving thickened liquids.

Based on observation, record review, and interview the facility failed to ensure that residents received a therapeutic diet prescribed by the attending physician for 1 (#5) of 2 (#2, #5) residents reviewed with swallowing difficulty. The facility identified 3 residents with swallowing difficulty. The facility failed by not providing the prescribed therapeutic diet for resident #5. An Immediate Jeopardy situation began on 12/30/14 when the CNAs (Certified Nursing Assistant) feeding the resident and the dietary manager was unaware that the resident had nectar thick liquids ordered on [DATE]. Resident #5 was admitted to the hospital on [DATE] with recurrent aspiration pneumonia. A swallowing study was done on 01/16/15 which revealed the resident aspirated on thin liquids. The resident continues to be offered thin liquids. Honey thick liquids were ordered on [DATE] after the swallowing study was completed. The resident continues to be served thin liquids. S1Administrator was notified of the Immediate Jeopardy situation on 03/02/15 at 4:30PM. The Immediate Jeopardy ended on 03/02/15 at 6:15PM when S1Administrator provided an acceptable plan of removal labeled "Immediate Jeopardy for Residents with a thickened liquid diet order" which included the following: Initial Plan of Removal provided on 03/02/15 at 5:05PM 1.) Identified all residents with a thickened liquid diet order 2.) Ensure diet cards are recorded appropriately 3.) Add task to kiosk to residents with a thickened liquid diet order 4.) In-service CNAs, LPNs, and dietary staff on residents with thickened liquid diet orders and our procedure. All new CNAs, LPNs, and dietary staff will be in-serviced upon hire. a. Dietary department is responsible for adding thickening when resident eats in the dining room b. CNAs are responsible for adding thickening when resident eats in his/her room c. LPNs are responsible for adding thickening to medications 5.) In-service CNAs and LPNs on Aspiration Precautions. 6.) Communication/Shift Change Report binder will be at each nurses' station with in-service sheets to be signed by nurses and CNAs 7.) RNs will monitor randomly each day for two weeks the breakfast, lunch, and supper meals, then 3 times a week for 2 weeks, then once monthly for 3 months 8.) This will be put into place immediately Revised Plan of Removal provided on 03/02/15 at 6:15PM and accepted by the team 1.) Identified all residents with a thickened liquid diet order 2.) Ensure diet cards are recorded appropriately 3.) Add task to kiosk to residents with a thickened liquid diet order 4.) In-service CNAs, LPNs, and dietary staff on residents with thickened liquid diet orders and our procedure. All new CNAs, LPNs, and dietary staff will be in-serviced upon hire. a. Dietary department is responsible for adding thickening when resident eats in the dining room b. CNAs are responsible for adding thickening when resident eats in his/her room c. LPNs are responsible for adding thickening to medications 5.) In-service CNAs and LPNs on Aspiration Precautions. 6.) Communication/Shift Change Report binder will be at each nurses' station with in-service sheets to be signed by nurses and CNAs 7.) RNs will monitor randomly each day for two weeks the breakfast, lunch, and supper meals, then 3 times a week for 2 weeks, then once monthly for 3 months 8.) This will be put into place immediately Resident #5's hall nurse and CNAs were in-serviced before supper meal. Resident #5's liquids on her supper tray were thickened according to the physician order. The current Hall 200 nurse, S2LPN will in-service 11-7 shift of resident #5's thickened liquid diet order and have LPNs and CNAs sign the in-service sheet. She will in-service the LPNs and CNAs on our thickened liquid policy and Aspiration precaution policy. The current hall nurses will in-service the 11-7 shift for each of their halls. LPNs and CNAs are being in-serviced now. The deficient practice remains at a pattern of harm for Resident #5. Findings: A review of resident #5's record revealed an admitted [DATE]. Her [DIAGNOSES REDACTED]. On 12/04/14 the resident was diagnosed with [REDACTED]. A review of the chart revealed that the resident was admitted to the hospital on [DATE] after a brief cardiopulmonary arrest and was found to have dysphagia and severe malnutrition. A peg tube (a tube place into the stomach for feeding purposes) was placed on 12/03/14 and the resident was discharged from the hospital on [DATE]. On return from the hospital on [DATE], resident #5's diet order was for a soft diet with chopped meats, nectar thick fluids, and assist with meals. Her [DIAGNOSES REDACTED]. The hospital discharge summary indicated the Pneumonia was treated and resolved. A review of the chart revealed that the resident was admitted to the hospital again on 12/18/14 with recurrent Aspiration Pneumonia and discharged on [DATE] per the hospital discharge summary. It was also revealed in the hospital discharge summary that the "patient will continue to have recurrent problems with this, as she has very poor swallowing reflexes". A review of the chart revealed that resident #5 was re-admitted to the facility on [DATE]. Her "Admitting Orders-eCharting" form did not have a diet order. However, her hospital discharge summary revealed she was NPO (Nothing by Mouth). A review of the February 2015 physician orders [REDACTED]. A review of the chart revealed that the resident was admitted to the hospital on [DATE] and returned on 01/09/15 with a [DIAGNOSES REDACTED]. A review of the hospital discharge papers for the 01/03/15 admission revealed that the resident was treated for [REDACTED]. A review of the "Admitting orders-eCharting" form dated 01/09/15 revealed that it did not contain a diet order. However, the hospital discharge orders revealed that the resident was to have no oral feeding until after the swallowing test was performed. A review of the "fluid intake" form received on 03/03/15 at 1:15PM per S3LPN and dated 12/30/14 - 01/21/15 revealed that resident #5 received fluids on 12/30/14, 12/31/14, 01/01/15, 01/02/15, 01/09/15, 01/13/15, 01/14/15, and 01/18/15. An interview with S3LPN on 03/03/15 at 1:15PM confirmed that the amounts listed on the "fluid intake" form under the section titled "fluid intake in cc's" on 12/30/14, 12/31/14, 01/01/15, 01/02/15, 01/09/15, 01/13/15, 01/14/15, and 01/18/15 would have been taken orally. A review of a swallowing study done on 01/16/15 revealed that resident #5 had aspirated on thin liquids. Her classification of Dysphagia was listed as severe, oral dysphagia evident, pharyngeal dysphagia evident. The recommendation was that the resident receive a puree diet with either honey or nectar liquids depending on her level of assistance and supervision during feedings. A review of the March 2015 physician orders [REDACTED]. The March 2015 physician orders [REDACTED]. An observation on 03/02/15 at 12:10PM revealed that resident #5 was being fed by S5CNA. The resident's meal consisted of mashed potatoes with gravy, pureed pork chop, pureed turnip greens, and pudding. Resident #5 had a 6oz glass of water and an 8oz glass of tea both un-thickened. At 12:15PM resident #5 began to cough/choke on water being offered per the S5CNA. S5CNA assisting resident #5 stopped offering the water until the resident stopped coughing/choking then offered the resident more water. In total the resident drank about ½ of the water and ¼ of the tea. After choking the resident did not want any more to eat and the CNA removed the lunch tray, but left the un-thickened water and tea at the bedside for the resident. Resident #5 consumed about 25% of her meal. An interview with resident #5 on 03/02/15 at 12:15PM while the resident was assisted with her lunch meal revealed that when asked if the resident had ever had thickened liquid, the resident replied "no". A review of the 12/17/14 BIMS (Brief Interview of Mental Status) revealed that the resident scored a 14 (cognitively intact). An interview with S5CNA on 03/02/15 at 12:15PM while she was feeding resident #5 revealed that when she was asked if the resident had ever had thickened liquids, this CNA replied "no, she usually does not have a problem with her regular liquids". An interview with S4DM on 03/02/15 at 2:40PM revealed that liquids are usually thickened by the dietary staff prior to being placed on the hall cart. She stated that resident #5 usually eats in her room. She further stated that resident #5 had a pureed diet but received regular liquids so dietary would not thicken her liquids prior to putting her tray on the cart to go down the hall. When asked if dietary did not thicken a resident's liquid prior to going down the hall then who would thicken their liquids, she stated that the CNAs would probably. A copy of the dietary card printed on 03/02/14 at 2:55PM per S4DM revealed that resident #5's diet was pureed. S4DM stated at this time that if the resident needed thickened liquids it would be listed on the dietary card. An interview with S11CNA on 03/02/15 at 3:00PM revealed that she was resident #5's regular CNA and has fed her many times. She added that she went to school with resident #5. When asked if resident #5 was able to drink her liquids without any problems, she stated "yes". This CNA was then asked if the resident ever received thickened liquids and she stated "no". An interview with S9ADON on 03/02/15 at 2:50PM revealed that she did not know if resident #5 was receiving thickened liquids. She stated, as she was looking at her computer screen, that she was just seeing that the resident has thickened liquids ordered. She confirmed at this time that resident #5 should be receiving thickened liquids.

Based on observation, record review, and interview the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (#5) of 2 (#2, #5) residents reviewed with swallowing difficulty. The facility identified 3 residents with swallowing difficulty. The facility failed: 1. Staff followed physicians's order for a therapeutic diet 2. There was a policy/procedure in place for staff related to thicken liquids 3. A system was in place to identify residents on thicken liquids, and 4. CNAs were trained on thickened liquid diets An Immediate Jeopardy situation began on 12/30/14 when the CNAs (Certified Nursing Assistant) feeding the resident and the dietary manager was unaware that the resident had nectar thick liquids ordered on [DATE]. Resident #5 was admitted to the hospital on [DATE] with recurrent aspiration pneumonia. A swallowing study was done on 01/16/15 which revealed the resident aspirated on thin liquids. The resident continues to be offered thin liquids by the CNAs feeding her. Honey thick liquids were ordered on [DATE] after the swallowing study was completed. The resident continues to be served thin liquids. S1Administrator was notified of the Immediate Jeopardy situation on 03/02/15 at 4:30PM. The Immediate Jeopardy ended on 03/02/15 at 6:15PM when S1Administrator provided an acceptable plan of removal labeled "Immediate Jeopardy for Residents with a thickened liquid diet order" which included the following: Initial Plan of Removal provided on 03/02/15 at 5:05PM 1.) Identified all residents with a thickened liquid diet order 2.) Ensure diet cards are recorded appropriately 3.) Add task to kiosk to residents with a thickened liquid diet order 4.) In-service CNAs, LPNs, and dietary staff on residents with thickened liquid diet orders and our procedure. All new CNAs, LPNs, and dietary staff will be in-serviced upon hire. a. Dietary department is responsible for adding thickening when resident eats in the dining room b. CNAs are responsible for adding thickening when resident eats in his/her room c. LPNs are responsible for adding thickening to medications 5.) In-service CNAs and LPNs on Aspiration Precautions. 6.) Communication/Shift Change Report binder will be at each nurses' station with in-service sheets to be signed by nurses and CNAs 7.) RNs will monitor randomly each day for two weeks the breakfast, lunch, and supper meals, then 3 times a week for 2 weeks, then once monthly for 3 months 8.) This will be put into place immediately Revised Plan of Removal provided on 03/02/15 at 6:15PM and accepted by the team 1.) Identified all residents with a thickened liquid diet order 2.) Ensure diet cards are recorded appropriately 3.) Add task to kiosk to residents with a thickened liquid diet order 4.) In-service CNAs, LPNs, and dietary staff on residents with thickened liquid diet orders and our procedure. All new CNAs, LPNs, and dietary staff will be in-serviced upon hire. a. Dietary department is responsible for adding thickening when resident eats in the dining room b. CNAs are responsible for adding thickening when resident eats in his/her room c. LPNs are responsible for adding thickening to medications 5.) In-service CNAs and LPNs on Aspiration Precautions. 6.) Communication/Shift Change Report binder will be at each nurses' station with in-service sheets to be signed by nurses and CNAs 7.) RNs will monitor randomly each day for two weeks the breakfast, lunch, and supper meals, then 3 times a week for 2 weeks, then once monthly for 3 months 8.) This will be put into place immediately Resident #5's hall nurse and CNAs were in-serviced before supper meal. Resident #5's liquids on her supper tray were thickened according to the physician order. The current Hall 200 nurse, S2LPN will in-service 11-7 shift of resident #5's thickened liquid diet order and have LPNs and CNAs sign the in-service sheet. She will in-service the LPNs and CNAs on our thickened liquid policy and Aspiration precaution policy. The current hall nurses will in-service the 11-7 shift for each of their halls. LPNs and CNAs are being in-serviced now. The deficient practice remains at a pattern of actual harm for Resident #5. Findings: 1. Cross refer to finding at Tag F282 2. Cross refer to finding at Tag F309 3. Cross refer to finding at Tag F367 4. Cross refer to finding at Tag F498 An interview with S4DM on 03/02/15 at 2:40PM revealed that liquids are usually thickened by the dietary staff prior to being placed on the hall cart. She stated that resident #5 usually eats in her room. She further stated that resident #5 had a pureed diet but received regular liquids so dietary would not thicken her liquids prior to putting her tray on the cart to go down the hall. When asked if dietary did not thicken a resident's liquid prior to going down the hall then who would thicken their liquids, she stated that the CNAs would probably. A copy of the dietary card printed on 03/02/14 at 2:55PM per S4DM revealed that resident #5's diet was pureed. S4DM stated at this time that if the resident needed thickened liquids it would be listed on the dietary card. An interview with S8DON on 03/02/15 at 2:43PM revealed that the CNAs are responsible for thickening liquids when feeding residents and the nurses are responsible when giving meds. When asked if she was aware if resident #5 was receiving thickened liquids, she stated that the ADON would know about resident #5 since that is her hall. Policy and procedure concerning thickened liquid diets and documentation of training for CNAs on thickened liquids was requested at this time. An interview with S9ADON on 03/02/15 at 2:50PM revealed that she did not know if resident #5 was receiving thickened liquids. She stated, as she was looking at her computer screen, that she is just seeing that the resident has thickened liquids ordered. She confirmed at this time that resident #5 should be receiving thickened liquids. S9ADON provided a thickened liquid policy to the surveyor on 03/02/15 at 3:00PM. This policy was dated 03/02/15. When asked about the date on the policy being 03/02/15, S9DON stated that they did not have a policy on thickened liquid prior to this policy. An interview with S1Administrator on 03/04/15 at 10:50AM confirmed that the facility did not have a policy and procedure regarding thickened liquid diets, did not have any CNA training on thickened liquid diets, and did not have a system in place to monitor whether residents received therapeutic diets.

Based on observation, record review, and interview the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 (#5) of 2 (#2, #5) residents reviewed with swallowing difficulty. The facility identified 3 residents with swallowing difficulty. An Immediate Jeopardy situation began on 12/30/14 when the CNAs (Certified Nursing Assistant) feeding the resident and the dietary manager was unaware that the resident had nectar thick liquids ordered on [DATE]. Resident #5 was admitted to the hospital on [DATE] with recurrent aspiration pneumonia. A swallowing study was done on 01/16/15 which revealed the resident aspirated on thin liquids. Honey thick liquids were ordered on [DATE] after the swallowing study was completed. The resident continues to be served thin liquids. S1Administrator was notified of the Immediate Jeopardy situation on 03/02/15 at 4:30PM. The Immediate Jeopardy ended on 03/02/15 at 6:15PM when S1Administrator provided an acceptable plan of removal labeled "Immediate Jeopardy for Residents with a thickened liquid diet order" which included the following: Initial Plan of Removal provided on 03/02/15 at 5:05PM 1.) Identified all residents with a thickened liquid diet order 2.) Ensure diet cards are recorded appropriately 3.) Add task to kiosk to residents with a thickened liquid diet order 4.) In-service CNAs, LPNs, and dietary staff on residents with thickened liquid diet orders and our procedure. All new CNAs, LPNs, and dietary staff will be in-serviced upon hire. a. Dietary department is responsible for adding thickening when resident eats in the dining room b. CNAs are responsible for adding thickening when resident eats in his/her room c. LPNs are responsible for adding thickening to medications 5.) In-service CNAs and LPNs on Aspiration Precautions. 6.) Communication/Shift Change Report binder will be at each nurses' station with in-service sheets to be signed by nurses and CNAs 7.) RNs will monitor randomly each day for two weeks the breakfast, lunch, and supper meals, then 3 times a week for 2 weeks, then once monthly for 3 months 8.) This will be put into place immediately Revised Plan of Removal provided on 03/02/15 at 6:15PM and accepted by the team 1.) Identified all residents with a thickened liquid diet order 2.) Ensure diet cards are recorded appropriately 3.) Add task to kiosk to residents with a thickened liquid diet order 4.) In-service CNAs, LPNs, and dietary staff on residents with thickened liquid diet orders and our procedure. All new CNAs, LPNs, and dietary staff will be in-serviced upon hire. a. Dietary department is responsible for adding thickening when resident eats in the dining room b. CNAs are responsible for adding thickening when resident eats in his/her room c. LPNs are responsible for adding thickening to medications 5.) In-service CNAs and LPNs on Aspiration Precautions. 6.) Communication/Shift Change Report binder will be at each nurses' station with in-service sheets to be signed by nurses and CNAs 7.) RNs will monitor randomly each day for two weeks the breakfast, lunch, and supper meals, then 3 times a week for 2 weeks, then once monthly for 3 months 8.) This will be put into place immediately Resident #5's hall nurse and CNAs were in-serviced before supper meal. Resident #5's liquids on her supper tray were thickened according to the physician order. The current Hall 200 nurse, S2LPN will in-service 11-7 shift of resident #5's thickened liquid diet order and have LPNs and CNAs sign the in-service sheet. She will in-service the LPNs and CNAs on our thickened liquid policy and Aspiration precaution policy. The current hall nurses will in-service the 11-7 shift for each of their halls. LPNs and CNAs are being in-serviced now. The deficient practice remains at a pattern of actual harm for resident #5. Findings: A review of resident #5's record revealed an admitted [DATE]. Her [DIAGNOSES REDACTED]. On 12/04/14 the resident was diagnosed with [REDACTED]. A review of the chart revealed that the resident was admitted to the hospital on [DATE] after a brief cardiopulmonary arrest and was found to have dysphagia and severe malnutrition. A peg tube (a tube place into the stomach for feeding purposes) was placed on 12/03/14 and the resident was discharged from the hospital on [DATE]. On return from the hospital on [DATE], resident #5's diet order was for a soft diet with chopped meats, nectar thick fluids, and assist with meals. Her [DIAGNOSES REDACTED]. The hospital discharge summary indicated the Pneumonia was treated and resolved. A review of the chart revealed that the resident was admitted to the hospital again on 12/18/14 with recurrent Aspiration Pneumonia and discharged on [DATE] per the hospital discharge summary. It was also revealed in the hospital discharge summary that the "patient will continue to have recurrent problems with this, as she has very poor swallowing reflexes". A review of the chart revealed that resident #5 was re-admitted to the facility on [DATE]. Her "Admitting Orders-eCharting" form did not have a diet order. However, her hospital discharge summary revealed she was NPO (Nothing by Mouth). A review of the February 2015 physician orders [REDACTED]. A review of the chart revealed that the resident was admitted to the hospital on [DATE] and returned on 01/09/15 with a [DIAGNOSES REDACTED]. A review of the hospital discharge papers for the 01/03/15 admission revealed that the resident was treated for [REDACTED]. A review of the "Admitting orders-eCharting" form dated 01/09/15 revealed that it did not contain a diet order. However, the hospital discharge orders revealed that the resident was to have no oral feeding until after the swallowing test was performed. A review of the "fluid intake" form received on 03/03/15 at 1:15PM per S3LPN and dated 12/30/14 - 01/21/15 revealed that resident #5 received fluids on 12/30/14, 12/31/14, 01/01/15, 01/02/15, 01/09/15, 01/13/15, 01/14/15, and 01/18/15. An interview with S3LPN on 03/03/15 at 1:15PM confirmed that the amounts listed on the "fluid intake" form under the section titled "fluid intake in cc's" on 12/30/14, 12/31/14, 01/01/15, 01/02/15, 01/09/15, 01/13/15, 01/14/15, and 01/18/15 would have been taken orally. A review of a swallowing study done on 01/16/15 revealed that resident #5 had aspirated on thin liquids. Her classification of Dysphagia was listed as severe, oral dysphagia evident, pharyngeal dysphagia evident. The recommendation was that the resident receive a puree diet with either honey or nectar liquids depending on her level of assistance and supervision during feedings. A review of the March 2015 physician orders [REDACTED]. The March 2015 physician orders [REDACTED]. A review of the March 2015 physician orders [REDACTED]. An observation on 03/02/15 at 12:10PM revealed that resident #5 was being fed by S5CNA. The resident ' s meal consisted of mashed potatoes with gravy, pureed pork chop, pureed turnip greens, and pudding. Resident #5 had a 6oz glass of water and an 8oz glass of tea both un-thickened. At 12:15PM resident #5 began to cough/choke on water being offered per the S5CNA. S5CNA assisting resident #5 stopped offering the water until the resident stopped coughing/choking then offered the resident more water. In total the resident drank about ½ of the water and ¼ of the tea. After choking the resident did not want any more to eat and the CNA removed the lunch tray, but left the un-thickened water and tea at the bedside for the resident. Resident #5 consumed about 25% of her meal. An interview with resident #5 on 03/02/15 at 12:15PM while the resident was assisted with her lunch meal revealed that when asked if the resident had ever had thickened liquid, the resident replied "no". A review of the 12/17/14 BIMS (Brief Interview of Mental Status) revealed that the resident scored a 14 (cognitively intact). An interview with S5CNA on 03/02/15 at 12:15PM while she was feeding resident #5 revealed that when she was asked if the resident had ever had thickened liquids, this CNA replied "no, she usually does not have a problem with her regular liquids". An interview with S4DM on 03/02/15 at 2:40PM revealed that liquids are usually thickened by the dietary staff prior to being placed on the hall cart. She stated that resident #5 usually eats in her room. She further stated that resident #5 had a pureed diet but received regular liquids so dietary would not thicken her liquids prior to putting her tray on the cart to go down the hall. When asked if dietary did not thicken a resident ' s liquid prior to going down the hall then who would thicken their liquids, she stated that the CNAs would probably. A copy of the dietary card printed on 03/02/14 at 2:55PM per S4DM revealed that resident #5's diet was pureed. S4DM stated at this time that if the resident needed thickened liquids it would be listed on the dietary card. An interview with S6CNA on 03/02/15 at 2:30PM revealed that this CNA does not always work with resident #5 but has fed her on occasion. She stated that resident #5 does not have thickened liquids and usually drinks regular liquids. An interview with S7LPN on 03/02/15 at 2:35PM revealed that resident #5's diet is pureed with honey thickened liquids. When shown the un-thickened water and tea on resident #5's bedside table she stated that the CNA should have thickened the liquids prior to the lunch meal. When asked who is responsible for thickening the resident's liquid, she stated that the CNA should have done it. An interview with S8DON on 03/02/15 at 2:43PM revealed that the CNAs are responsible for thickening liquids when feeding residents and the nurses are responsible when giving meds. An interview with S10CNA on 03/02/15 at 2:55PM revealed that she does not usually care for resident #5 but has on occasion. She stated that she has fed resident #5 and the resident does not have thickened liquids. She stated that she has fed her thin liquids and the resident was able to drink it "ok". An interview with S11CNA on 03/02/15 at 3:00PM revealed that she was resident #5's regular CNA and has fed her many times. This CNA was then asked if the resident ever received thickened liquids and she stated "no". An interview with S10CNA on 03/02/15 at 3:05PM revealed that when this surveyor asked her to show her the kiosk information that she sees while caring for residents, she could not find where it indicated that resident #5 received thickened liquids. When asked how else she would know if a resident needed thickened liquids, she stated that if a can of thickener was in the room she would know. An interview with S9ADON on 03/02/15 at 2:50PM revealed that she did not know if resident #5 was receiving thickened liquids. She stated, as she was looking at her computer screen, that she is just seeing that the resident has thickened liquids ordered. She confirmed at this time that resident #5 should be receiving thickened liquids. An interview with S1Administrator on 03/04/15 at 10:50AM confirmed that the facility did not have any CNA training on thickened liquid diets.

Based on record review and interview, the facility failed to ensure that residents rights were executed by failing to implement the Advanced Directive to initiate CPR for 1 (#7) of 2 (#7, 65,) deceased residents reviewed due to resident #7 being found with no pulse and no respirations and had signed Advanced Directives requesting CPR. The total Stage 2 sample reviewed was 21 residents. The facility failed to have a system in place to ensure staff was aware of residents Advanced Directives in order to honor them for 2 sampled residents (#88, 149) in a total sample of 21 Stage 2 residents. This had the potential to affect all 114 residents in the facility. This deficient practice resulted in sampled resident #7 being in an Immediate Jeopardy situation on [DATE] at 5:14AM when she was found unresponsive by facility staff and CPR was not initiated per her signed Advanced Directive. The Immediate Jeopardy ended for resident #7 when she died on [DATE]. The Immediate Jeopardy continued for all other 114 residents in the facility by failing to have a system in place for staff to immediately determine the residents' Advanced Directives regarding initiation of CPR. The Administrator was notified of the Immediate Jeopardy on [DATE] at 4:30PM. The facility's plan of removal submitted by the the facility included: 1. A policy was written for CPR-DNR procedures. 2. Inservices began on the ,[DATE] shift and will continue each shift until all LPNs, CNAs and key staff are informed of the new CPR-DNR policy and procedure. 3. The LPN working with client #7 on the night of [DATE] will be counseled regarding proper documentation and CPR-DNR policy and procedure. 4. Every resident's paper chart was checked for LaPOST and/or Advanced Directives. 5. Every resident's computer chart was updated to reflect the resident's paper chart. 6. Red stickers were placed on the back side of name plates of all residents that have a DNR. The Immediate Jeopardy ended on [DATE] at 9:40AM for the remaining 114 residents in the facility when the plan of correction was implemented. The Immediate Jeopardy was lowered to Actual Harm for resident #7 on [DATE] when she expired. The deficient practice remains at a potential for more than minimal harm for all 114 residents in the facility. Findings: Resident #7 Review of the medical record for sampled resident #7 revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed the resident was alert and oriented but required assistance with all ADLs. Review of the resident's record revealed a form titled Louisiana Physician order [REDACTED]. This form was signed by the resident and her physician and stated that she desired to be a full code, including CPR, antibiotics and tube feeding if needed. The record also included another form titled Louisiana Natural Death Act Declaration dated [DATE] and signed by the resident and two witnesses. This form stated that the resident desired to be a full code and she wanted all life-sustaining procedures to be used on her. Review of the nurses notes dated [DATE] at 2:27AM revealed the resident remains alert. Oriented to person. Speech clear and normal. Resident is able to make needs known. Review of the next nurses note dated [DATE] at 6:24AM revealed the nurse was summoned to resident's room per CNAs. CNAs report resident found at this time without respirations or heart tones. Examined to find no pulse apically or at carotid. No respirations noted at 5:14AM. Resident's physician was notified of residents demise. There was no evidence in the record that CPR was initiated on the resident, per her signed Advanced Directive. On [DATE] at 1:15PM, interview with S2LPN revealed that the residents' code status should be in the front of their charts or on the face sheet of their computerized medical record. S2LPN further revealed that she would just begin CPR if she didn't know the code status of a resident in an emergency. On [DATE] at 1:50PM, interview with S1DON revealed that she was not very familiar with resident #7 because the resident was not at the facility very long. S1DON further revealed that she was not aware that CPR was not initiated on the resident. When asked what staff is to do if they walk into a room and find a resident unresponsive (no respirations or pulse), S1DON stated that they are to immediately begin CPR and either send another nurse to look for the resident's chart or call the resident's physician. S1DON further revealed that if you can't find the resident's chart or get in touch with the physician, continue CPR until you find out the code status of the resident. S1DON stated that if you determine that the resident is a No Code, CPR should be stopped. The survey team asked S1DON if the residents' code status was noted on their computerized medical record. At that time, S1DON reviewed resident #7's computerized medical record and stated that she was unable to find the resident's code status. On [DATE] at 3:20PM, interview with S3LPN revealed that she would begin CPR if she walked in on an unresponsive resident and did not immediately know their code status. S3LPN further revealed that the resident's code status should be on their facesheet in their chart or on their computerized medical record. On [DATE] at 3:20PM, interview with S10LPN revealed that she was unsure of how to determine code status of the residents in the facility. S10LPN further revealed that she would start CPR if she did not know the code status of a resident who was pulseless and without respirations. On [DATE] at 3:30PM, interview with S14LPN revealed that residents code status is in their computerized medical record. S14LPN further revealed that in an emergency, the CNAs could pull up the residents code status in their wall kiosk on the halls and notify the nurse. On [DATE] at 3:35PM, the survey team asked S13CNA to pull up a residents code status on the wall kiosk. At that time, S13CNA was unable to locate that information on the kiosk. On [DATE] at 3:30PM, another interview with S1DON revealed that the facility did not have policy or system in place for staff to immediately determine the residents' Advanced Directives regarding initiation of CPR. Further interview with S1DON revealed that resident #7 was a full code and CPR should have been initiated on the resident. On [DATE] at 4PM, interview with S4Administrator revealed that the facility did not have a system in place to immediately determine code status of the residents. On [DATE] at 9:20AM, interview with S1DON revealed that she had gotten in contact with S5LPN on [DATE] and counseled her regarding not following resident #7's Advanced Directive. At that time, review of S5LPN's written statement (dated [DATE]) revealed she was called to the resident's room by the CNA. When she got to the room, she found the resident without signs of life and immediately went to the nurses station and called the resident's physician. The physician asked if the resident was "gone, gone" and S5LPN stated yes. The physician replied that he would be right up to the facility. Resident #149 On [DATE] at 3:55PM, the facility provided the survey team with a list of all residents and their code status. Interview with S1DON at that time, revealed the list was pulled from the residents' face sheets on their computerized medical record. Review of the list revealed sampled resident #149 was a Full Code. Review of the record for resident #149 revealed an admitted [DATE]. Further review of the record revealed there was a signed Advanced Directive indicating the resident did not want to be resuscitated in the event of no respirations or heart beat (No Code). Review of the resident's information in the computerized medical record information revealed the information was not correct. On the face sheet in the computer, the resident was listed as wanting to have cardio [MEDICAL CONDITION] resuscitation done in the event the resident stopped breathing or had no heart beat (Full Code). On [DATE] at 3:00PM, interview with S6Social Service Director confirmed the information in the computer was not correct and it did not follow the resident's Advance Directives. Resident # 88 On [DATE] at 3:55PM, the facility provided the survey team with a list of all residents and their code status. Interview with S1DON at that time, revealed the list was pulled from the residents face sheets on their computerized medical record. Review of the list revealed sampled resident #88 was a Full Code. Further review of resident #88's computerized medical record (including Face Sheet, [DATE] Physician Orders, and [DATE] MAR) revealed documentation that the resident was a Full Code. Review of the resident's hard copy of the chart revealed a signed Advanced Directive in which she indicated she did not want CPR initiated in the event of cardiac and/or respiratory arrest (No Code). The resident signed and dated the form on [DATE]. There was a discrepancy of the code status in the resident's computerized medical record and the hard copy of the chart. Interviews on [DATE], with various nurses at the facility revealed they were unsure how to determine residents' DNR status. Also, they indicated they would initiate CPR without knowing the residents' wishes indicated on their advanced directives. The nurses were unaware of the proper procedure to follow regarding DNR status of residents. On [DATE] at 2:00PM, interview with S6Social Services confirmed the facility failed to have a system in place to ensure all staff were aware of the residents' wishes indicated on their Advanced Directives. On [DATE] at 4:00PM, an interview with S4Administrator confirmed the facility failed to have a system in place to ensure the resident's rights were honored regarding their Advanced Directives. She also confirmed the facility failed to have a system in place to ensure all staff were aware of the residents' wishes indicated on their Advanced Directives.

Based on record review and interview, the facility failed to ensure that the services provided met professional standards of quality by failing to have a nurse initiate CPR on 1 (#7) of 2 (#7, 65) deceased residents reviewed who were found with no pulse and no respirations and who had a signed Advanced Directive to be a full code. There was a total of 21 residents in Stage 2. This deficient practice resulted in sampled resident #7 being in an Immediate Jeopardy situation on [DATE] at 5:14AM when she was found unresponsive by facility staff and CPR was not initiated per her signed Advanced Directive. The Immediate Jeopardy ended for resident #7 when she died on [DATE]. The Immediate Jeopardy continued for all other 114 residents in the facility by failing to have a system in place for staff to immediately determine the residents' Advanced Directives regarding initiation of CPR. The Administrator was notified of the Immediate Jeopardy on [DATE] at 4:30PM. The facility's plan of removal submitted by the the facility included: 1. A policy was written for CPR-DNR procedures. 2. Inservices began on the ,[DATE] shift and will continue each shift until all LPNs, CNAs and key staff are informed of the new CPR-DNR policy and procedure. 3. The LPN working with client #7 on the night of [DATE] will be counseled regarding proper documentation and CPR-DNR policy and procedure. 4. Every resident's paper chart was checked for LaPOST and/or Advanced Directives. 5. Every resident's computer chart was updated to reflect the resident's paper chart. 6. Red stickers were placed on the back side of name plates of all residents that have a DNR. The Immediate Jeopardy ended on [DATE] at 9:40AM for the remaining 114 residents in the facility when the plan of correction was implemented. The Immediate Jeopardy was lowered to Actual Harm for resident #7 on [DATE] when she expired. The deficient practice remains at a potential for more than minimal harm for all 114 residents in the facility. Findings: Review of the Centers for Medicare and Medicaid Services memo Ref: S & C: ,[DATE]-NH (dated [DATE]) revealed that prior to arrival of emergency medical services (EMS), nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's advanced directives or in the absence of advanced directives or a Do Not Resuscitate (DNR) order. The AHA (American Heart Association) urges all potential rescuers to initiate CPR unless: 1) a valid DNR order is in place; 2) obvious signs of clinical death (rigor mortis, dependent lividity, decapitation, transaction, or decomposition) are present; or 3) initiating CPR could cause injury or peril to the rescuer. AHA guidelines for CPR provide the standard for the American Red Cross, state EMS agencies, healthcare providers and the general public. Review of the medical record for sampled resident #7 revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed the resident was alert and oriented but required assistance with all ADLs. Review of the resident's record revealed a form titled Louisiana Physician order [REDACTED]. This form was signed by the resident and her physician and stated that she desired to be a full code, including CPR, antibiotics and tube feeding if needed. The record also included another form titled Louisiana Natural Death Act Declaration dated [DATE] and signed by the resident and two witnesses. This form stated that the resident desired to be a full code and she wanted all life-sustaining procedures to be used on her. Review of the nurses notes dated [DATE] at 2:27AM revealed the resident remains alert. Oriented to person. Speech clear and normal. Resident is able to make needs known. Review of the next nurses note dated [DATE] at 6:24AM revealed the nurse was summoned to resident's room per CNAs. CNAs report resident found at this time without respirations or heart tones. Examined to find no pulse apically or at carotid. No respirations noted at 5:14AM. Resident's physician was notified of residents demise. There was no evidence in the record that CPR was initiated on the resident, per her signed Advanced Directive. On [DATE] at 1:15PM, interview with S2LPN revealed that the residents' code status should be in the front of their charts or on the face sheet of their computerized medical record. S2LPN further revealed that she would just begin CPR if she didn't know the code status of a resident in an emergency. On [DATE] at 1:50PM, interview with S1DON revealed that she was not very familiar with resident #7 because the resident was not at the facility very long. S1DON further revealed that she was not aware that CPR was not initiated on the resident. When asked what staff is to do if they walk into a room and find a resident unresponsive (no respirations or pulse), S1DON stated that they are to immediately begin CPR and either send another nurse to look for the resident's chart or call the resident's physician. S1DON further revealed that if you cant find the resident's chart or get in touch with the physician, continue CPR until you find out the code status of the resident. S1DON stated that if you determine that the resident is a No Code, CPR should be stopped. The survey team asked S1DON if the residents' code status was noted on their computerized medical record. At that time, S1DON reviewed resident #7's computerized medical record and stated that she was unable to find the resident's code status. On [DATE] at 3:20PM, interview with S3LPN revealed that she would begin CPR if she walked in on an unresponsive resident and did not immediately know their code status. S3LPN further revealed that the resident's code status should be on their face sheet in their chart or on their computerized medical record. On [DATE] at 3:20PM, interview with S10LPN revealed that she was unsure of how to determine code status of the residents in the facility. S10LPN further revealed that she would start CPR if she did not know the code status of a resident who was pulseless and without respirations. On [DATE] at 3:30PM, interview with S14LPN revealed that residents code status is in their computerized medical record S14LPN further revealed that in an emergency, the CNAs could pull up the residents code status in their wall kiosk on the halls and notify the nurse. On [DATE] at 3:35PM, the survey team asked S13CNA to pull up a residents code status on the wall kiosk. At that time, S13CNA was unable to locate that information on the kiosk. On [DATE] at 3:30PM, another interview with S1DON revealed that the facility did not have policy or system in place for staff to immediately determine the residents' Advanced Directives regarding initiation of CPR. Further interview with S1DON revealed that resident #7 was a full code and CPR should have been initiated on the resident. On [DATE] at 4PM, interview with S4Administrator revealed that the facility did not have a system in place to immediately determine code status of the residents. On [DATE] at 9:20AM, interview with S1DON revealed that she had gotten in contact with S5LPN on [DATE] and counseled her regarding not following resident #7's Advanced Directive. At that time, review of S5LPN's written statement revealed she was called to the resident's room by the CNA. When she got to the room, she found the resident without signs of life and immediately went to the nurses station and called the resident's physician. The physician asked if the resident was "gone, gone" and S5LPN stated yes. The physician replied that he would be right up to the facility.

Based on record review and interview, the facility failed to ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical well-being when staff failed to perform CPR on a resident that was found pulseless and not breathing (#7). This deficient practice resulted in sampled resident #7 being in an Immediate Jeopardy situation on [DATE] at 5:14AM when she was found unresponsive by facility staff and CPR was not initiated per her signed Advanced Directive. The Administrator was notified of the Immediate Jeopardy situation on [DATE] at 4:30PM. The deficient practice had the potential to effect all 114 residents in the facility. The facility failed to: 1. Immediately identify residents wanting CPR when they were found pulseless. 2. Ensure staff honored the residents CPR directives that was signed on [DATE] (Resident #7) that indicated she wanted all possible measures taken to revive her if her heart stopped beating. 3. Ensure staff immediately initiated CPR on a resident found pulseless and not breathing (Resident #7) on [DATE]. 4. Immediately call 911 emergency services when a resident was found pulseless and not breathing (Resident #7) on [DATE]. 5. Have procedures in place for residents found pulseless and not breathing who wanted life saving measures performed in an emergency situation. 6. Ensure staff were aware of procedures to determine if the remaining 114 residents wanted life saving measures in an emergency situation. The Immediate Jeopardy ended for resident #7 when she died on [DATE]. The Immediate Jeopardy continued for all other 114 residents in the facility, including 2 of 21 Stage 2 sampled residents (#88, 149), by failing to have a system in place for staff to immediately determine the residents' Advanced Directives regarding initiation of CPR. The Administrator was notified of the Immediate Jeopardy on [DATE] at 4:30PM. The facility's plan of removal submitted by the the facility included: 1. A policy was written for CPR-DNR procedures. 2. Inservices began on the ,[DATE] shift and will continue each shift until all LPNs, CNAs and key staff are informed of the new CPR-DNR policy and procedure. 3. The LPN working with client #7 on the night of [DATE] will be counseled regarding proper documentation and CPR-DNR policy and procedure. 4. Every resident's paper chart was checked for LaPOST and/or Advanced Directives. 5. Every resident's computer chart was updated to reflect the resident's paper chart. 6. Red stickers were placed on the back side of name plates of all residents that have a DNR. The Immediate Jeopardy ended on [DATE] at 9:40AM for the remaining 114 residents in the facility when the facility implemented their plan of removal for immediately educating staff to provide CPR for residents with no vital signs and ensured that staff were inserviced regarding the initiation of CPR if a resident is found pulseless and not breathing. The Immediate Jeopardy was lowered to Actual Harm for resident #7 on [DATE] when she expired. The deficient practice remains at a potential for more than minimal harm for all 114 residents in the facility by failing to have a system in place for staff to immediately determine the residents Advanced Directives regarding initiation of CPR. Findings: Resident #7 Review of the medical record for sampled resident #7 revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed the resident was alert and oriented and revieqw of the [DATE] 14 day MDS revealed the resident required extensive assistance with all ADLs. The MDS also indicated the resident used a walker and wheelchair for mobility. Review of the resident's record revealed a form titled Louisiana Physician order [REDACTED]. This form was signed by the resident and her physician and stated that she desired to be a full code, including CPR, antibiotics and tube feeding if needed. The record also included another form titled Louisiana Natural Death Act Declaration dated [DATE] and signed by the resident and two witnesses. This form stated that the resident desired to be a full code and she wanted all life-sustaining procedures to be used on her. Review of the nurses notes dated [DATE] at 2:27AM revealed the resident remains alert. Oriented to person. Speech clear and normal. Resident is able to make needs known. Review of the next nurses note dated [DATE] at 6:24AM revealed the nurse was summoned to resident's room per CNAs. CNAs report resident found at this time without respirations or heart tones. Examined to find no pulse apically or at carotid. No respirations noted at 5:14AM. Resident's physician was notified of residents demise. There was no evidence in the record that CPR was initiated on the resident, per her signed Advanced Directive. On [DATE] at 1:15PM, interview with S2LPN revealed that the residents' code status should be in the front of their charts or on the face sheet of their computerized medical record. S2LPN further revealed that she would just begin CPR if she didn't know the code status of a resident in an emergency. On [DATE] at 1:50PM, interview with S1DON revealed that she was not very familiar with resident #7 because the resident was not at the facility very long. S1DON further revealed that she was not aware that CPR was not initiated on the resident. When asked what staff is to do if they walk into a room and find a resident unresponsive (no respirations or pulse), S1DON stated that they are to immediately begin CPR and either send another nurse to look for the resident's chart or call the resident's physician. S1DON further revealed that if you cant find the resident's chart or get in touch with the physician, continue CPR until you find out the code status of the resident. S1DON stated that if you determine that the resident is a No Code, CPR should be stopped. The survey team asked S1DON if the residents' code status was noted on their computerized medical record. At that time, S1DON reviewed resident #7's computerized medical record and stated that she was unable to find the resident's code status. On [DATE] at 3:20PM, interview with S3LPN revealed that she would begin CPR if she walked in on an unresponsive resident and did not immediately know their code status. S3LPN further revealed that the resident's code status should be on their facesheet in their chart or on their computerized medical record. On [DATE] at 3:20PM, interview with S10LPN revealed that she was unsure of how to determine code status of the residents in the facility. S10LPN further revealed that she would start CPR if she did not know the code status of a resident who was pulseless and without respirations. On [DATE] at 3:30PM, interview with S14LPN revealed that residents code status is in their computerized medical record S14LPN further revealed that in an emergency, the CNAs could pull up the residents code status in their wall kiosk on the halls and notify the nurse. On [DATE] at 3:35PM, the survey team asked S13CNA to pull up a residents code status on the wall kiosk. At that time, S13CNA was unable to locate that information on the kiosk. On [DATE] at 3:30PM, another interview with S1DON revealed that the facility did not have policy or system in place for staff to immediately determine the residents' Advanced Directives regarding initiation of CPR. Further interview with S1DON revealed that resident #7 was a full code and CPR should have been initiated on the resident. On [DATE] at 4PM, interview with S4Administrator revealed that the facility did not have a system in place to immediately determine code status of the residents. On [DATE] at 9:20AM, interview with S1DON revealed that she had gotten in contact with S5LPN on [DATE] and counseled her regarding not following resident #7's Advanced Directive. At that time, review of S5LPN's written statement (dated [DATE]) revealed she was called to the resident's room by the CNA. When she got to the room, she found the resident without signs of life and immediately went to the nurses station and called the resident's physician. The physician asked if the resident was "gone, gone" and S5LPN stated yes. The physician replied that he would be right up to the facility. Resident #88 On [DATE] at 3:55PM, the facility provided the survey team with a list of all residents and their code status. Interview with S1DON at that time, revealed the list was pulled from the residents face sheets on their computerized medical record. Review of the list revealed sampled resident #88 was a Full Code. Further review of resident #88's computerized medical record (including Face Sheet, [DATE] Physician Orders, and [DATE] MAR) revealed documentation that the resident was a Full Code. Review of the resident's hard copy of the chart revealed a signed Advanced Directive in which she indicated she did not want CPR initiated in the event of cardiac and/or respiratory arrest (No Code). The resident signed and dated the form on [DATE]. There was a discrepancy of the code status in the resident's computerized medical record and the hard copy of the chart. Interviews with various nurses at the facility revealed they were unsure how to determine residents' DNR status. Also, they indicated they would initiate CPR without knowing the residents' wishes indicated on their advanced directives. The nurses were unaware of the proper procedure to follow regarding DNR status of residents. On [DATE] at 2:00PM, interview with S6Social Services confirmed the facility failed to have a system in place to ensure all staff were aware of the residents' wishes indicated on their Advanced Directives. On [DATE] at 4PM, an interview with S4Administrator confirmed the facility failed to have a system in place to ensure the resident's rights were honored regarding their Advanced Directives. She also confirmed the facility failed to have a system in place to ensure all staff were aware of the residents' wishes indicated on their Advanced Directives. Resident #149 On [DATE] at 3:55PM, the facility provided the survey team with a list of all residents and their code status. Interview with S1DON at that time, revealed the list was pulled from the residents face sheets on their computerized medical record. Review of the list revealed sampled resident #149 was a Full Code. Review of the record for resident #149 revealed an admitted [DATE]. Further review of the record revealed there was a signed Advanced Directive indicating the resident did not want to be resuscitated in the event of no respirations or heart beat (No Code). Review of the resident's information in the computerized medical record information revealed the information was not correct. On the face sheet in the computer, the resident was listed as wanting to have cardio [MEDICAL CONDITION] resuscitation done in the event the resident stopped breathing or had no heart beat (Full Code). On [DATE] at 3PM, interview with S6Social Service Director confirmed the information in the computer was not correct and it did not follow the resident's Advance Directives.

Based on record review and interview, the facility failed to be administered in a manner that enables it to use its resources effectively to attain the highest practicable physical well-being in accordance with the resident's Advanced Directive to be a Full Code for 1 (#7) of 2 (#7, 65) deceased residents reviewed in a total sample of 21 Stage 2 residents. The facility failed to: 1. Have a policy and procedure in place for residents who wish to have CPR performed. 2. Ensure staff honored the residents CPR directive for resident #7 on [DATE]. 3. Ensure staff initiated CPR on a resident found pulseless and not breathing (resident #7) on [DATE]. 4. Immediately call 911 emergency services when a resident was found pulseless and not breathing (resident #7) on [DATE]. 5. Have a system in place to ensure staff honored all residents Advanced Directives. This deficient practice resulted in sampled resident #7 being in an Immediate Jeopardy situation on [DATE] at 5:14AM when she was found unresponsive by facility staff and CPR was not initiated per her signed Advanced Directive. The Administrator was notified of the Immediate Jeopardy situation on [DATE] at 4:30PM. The Immediate Jeopardy ended for resident #7 when she died on [DATE]. The Immediate Jeopardy continued for all other 114 residents in the facility by failing to have a system in place for staff to immediately determine the residents' Advanced Directives regarding initiation of CPR. The facility's plan of removal submitted by the the facility included: 1. A policy was written for CPR-DNR procedures. 2. Inservices began on the ,[DATE] shift and will continue each shift until all LPNs, CNAs and key staff are informed of the new CPR-DNR policy and procedure. 3. The LPN working with client #7 on the night of [DATE] will be counseled regarding proper documentation and CPR-DNR policy and procedure. 4. Every resident's paper chart was checked for LaPOST and/or Advanced Directives. 5. Every resident's computer chart was updated to reflect the resident's paper chart. 6. Red stickers were placed on the back side of name plates of all residents that have a DNR. The Immediate Jeopardy ended on [DATE] at 9:40AM for the remaining 114 residents in the facility when the facility implemented their plan of removal for immediately educating staff to provide CPR for residents with no vital signs and ensured that staff were inserviced regarding the initiation of CPR if a resident is found pulseless and not breathing. The Immediate Jeopardy was lowered to actual harm for resident #7 on [DATE] when she expired. The deficient practice remains at a potential for more than minimal harm for all other 114 residents in the facility by failing to have a system in place for staff to immediately determine the residents Advanced Directives regarding initiation of CPR. Findings: 1. Cross refer to findings at F155. 2. Cross refer to findings at F281. 3. Cross refer to findings at F309. On [DATE] at 1:15PM, interview with S2LPN revealed that the residents' code status should be in the front of their charts or on the face sheet of their computerized medical record. S2LPN further revealed that she would just begin CPR if she didn't know the code status of a resident in an emergency. On [DATE] at 1:50PM, interview with S1DON revealed that she was not very familiar with resident #7 because the resident was not at the facility very long. S1DON further revealed that she was not aware that CPR was not initiated on the resident. When asked what staff is to do if they walk into a room and find a resident unresponsive (no respirations or pulse), S1DON stated that they are to immediately begin CPR and either send another nurse to look for the resident's chart or call the resident's physician. S1DON further revealed that if you cant find the resident's chart or get in touch with the physician, continue CPR until you find out the code status of the resident. S1DON stated that if you determine that the resident is a No Code, CPR should be stopped. The survey team asked S1DON if the residents' code status was noted on their computerized medical record. At that time, S1DON reviewed resident #7's computerized medical record and stated that she was unable to find the resident's code status. On [DATE] at 3:20PM, interview with S3LPN revealed that she would begin CPR if she walked in on an unresponsive resident and did not immediately know their code status. S3LPN further revealed that the resident's code status should be on their facesheet in their chart or on their computerized medical record. On [DATE] at 3:20PM, interview with S10LPN revealed that she was unsure of how to determine code status of the residents in the facility. S10LPN further revealed that she would start CPR if she did not know the code status of a resident who was pulseless and without respirations. On [DATE] at 3:30PM, interview with S14LPN revealed that residents code status is in their computerized medical record S14LPN further revealed that in an emergency, the CNAs could pull up the residents code status in their wall kiosk on the halls and notify the nurse. On [DATE] at 3:35PM, the survey team asked S13CNA to pull up a residents code status on the wall kiosk. At that time, S13CNA was unable to locate that information on the kiosk. On [DATE] at 3:30PM, another interview with S1DON revealed that the facility did not have policy or system in place for staff to immediately determine the residents' Advanced Directives regarding initiation of CPR. Further interview with S1DON revealed that resident #7 was a full code and CPR should have been initiated on the resident. On [DATE] at 3:55PM, the facility provided the survey team with a list of all residents and their code status. Interview with S1DON at that time, revealed the list was pulled from the residents face sheets on their computerized medical record. Further review of the list revealed that the code status on the computerized medical record did not match the code status of the hard copy of the chart for all residents. On [DATE] at 4PM, interview with S4Administrator revealed that the facility did not have a system in place to immediately determine code status of the residents. Further interview with S4Administrator confirmed that there was a discrepancy with the residents code status in the computerized medical record and hard copy of chart.

Based on observation, record review and interview, the facility failed to: 1) assess and monitor the skin of 1 of 1 resident who was paralyzed from the waist down and at risk for pressure sore development in a total sample of 3. As a result, the resident developed 4 Stage IV pressure sores. (Sample #1) 2) assess and monitor the skin of 1 of 1 resident at risk for pressure sore development whose pressure sores were not identified until they were a Stage III pressure sore in a total sample of 3. (Sample #7) 3) perform ongoing wound assessments for 3 of 3 residents who had pressure sores in a total sample of 3. As a result, the residents developed Stage IV pressure sores. (Sample #1, 5, 7) Findings: 1. Review of the medical record revealed sampled resident #1 was readmitted back to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change MDS dated [DATE] revealed the resident had modified independence in cognition, required extensive assistance with ADL's, had an indwelling Foley catheter and was incontinent of bowel. Review of the pressure sore risk assessment updated on 08/05/10 revealed sampled resident #1 was a mild risk for pressure sores. Review of the careplan initiated on 08/13/10 revealed the resident was at risk for developing pressure ulcers related to decreased mobility, deep tissue injury top of left foot, left heel, left lateral foot and right heel. Review of the nurses post hospital assessment dated [DATE] revealed multiple bruises to the arms due to old IV insertion sites and redness noted to the sacrum area. Review of S2Treatment LPN nurses notes dated 08/05/10 at 2:30PM revealed [DIAGNOSES REDACTED] noted to buttocks upon admission; skin is intact at this time. S1Treatment RN visualized the buttocks. Orders to apply [MEDICATION NAME] to buttocks every day until [DIAGNOSES REDACTED] is resolved was initiated on the treatment administration record. There was no documented evidence of any pressure ulcers when the resident returned from the hospital on this date. There were no further assessments of the residents skin until 7 days after she returned from the hospital with a [DIAGNOSES REDACTED]. Review of the treatment nurse notes completed by S2Treatment LPN dated 08/12/10 at 10:00AM revealed resident's feet were assessed to find deep purple areas of discoloration on both heels and left lateral malleolus. MD orders were obtained to apply Elastogel to left and right heel and left lateral malleolus every 3 days and as needed until healed. There was no documentation that the responsible party was immediately notified of the wounds. Review of treatment nurses notes dated 08/13/10 at 10:20AM revealed a new discolored area was noted on top of the left foot. MD orders obtained to apply Elastogel to top of left foot every 3 days and as needed until healed. On 08/24/10 at 10:10AM, review of the treatment notes revealed the sacrum was found with "superficial" area thought to be from friction. MD was notified and orders were given to clean sacrum with wound cleanser and apply SAF gel and cover with dressing everyday until healed. There was no documentation that the responsible party was notified of the change in the resident's sacral area. Review of the RN Wound assessment form dated 08/12/10 revealed a Stage IV pressure ulcer to the left lateral malleolus noted as an unstageable deep tissue injury measuring 2cm x 1cm without odor or drainage. On 08/18/10 the wound measured 2.7cm x 2cm with a red/purple wound bed without drainage or odor. On 08/27/10 the wound measured 4.5cm x 2cm and on 08/31/10 the wound measured 4.2cm x 2cm x less than 0.1cm with a red/purple wound bed, small pink to yellow exudate. On 08/31/10 at 3:30PM, observation revealed S1Treatment RN assessed the resident's left lateral malleolus wound and S2Treatment LPN dressed the wound as ordered. Observation of the left lateral malleolus revealed a dark purple to black wound with a quarter sized opened area with yellow slough noted. On 09/01/10 at 2:45PM S1Treatment RN reported to the surveyor that she did not notice the open area on the left lateral malleolus. At this time, S2Treatment LPN confirmed that there was an open area on the wound and that she had cleaned it with wound cleanser before applying the ordered dressing. S1Treatment RN and S2Treatment LPN confirmed they had not notified of the physician or the family of the change in the wound. Review of the RN Wound assessment form dated 08/12/10 revealed a Stage IV pressure ulcer to the left heel noted as an unstageable deep tissue injury measuring 3cm x 2cm without odor or drainage and a red/purple wound bed. On 08/18/10 the wound measured 7cm x 3cm with a red/purple wound bed without drainage or odor. On 08/27/10 the wound measured 3cm x 3cm and on 08/31/10 the wound measured 4cm x 4cm x less than 0.1cm with a red/purple wound bed, without odor or drainage. Review of the RN Wound assessment form dated 08/13/10 revealed a Stage IV pressure ulcer to the top of the left foot noted as an unstageable deep tissue injury measuring 0.1cm x 2cm without odor or drainage. On 08/18/10 the wound measured 1cm x 1cm with a red/purple wound bed. On 08/27/10 the wound measured 1cm x 4cm with a red/purple wound bed without drainage or odor. On 08/31/10 the wound measured 1cm x 2cm x less than 0.1cm with a red/purple wound bed, without odor or drainage. Review of the RN Wound assessment form dated 08/12/10 revealed a Stage IV pressure ulcer to the right heel noted as an unstageable deep tissue injury measuring 2cm x 1cm with a red/purple wound bed without odor or drainage. On 08/18/10 the wound measured 2cm x 2.5cm with a red/purple wound bed. On 08/27/10 the wound measured 3cm x 2cm x less than 0.1 with a red/purple wound bed without drainage or odor. On 08/31/10 the wound measured 3.2cm x 3cm x less than 0.1cm with a red/purple wound bed, without odor or drainage. Review of the RN Wound assessment dated [DATE] (3 days after the "superficial" area was found by S2Treatment LPN) revealed a Stage II pressure ulcer measured 6cm x 4cm with partial thickness, small amount of pink to yellow drainage with red/purple wound bed. On 08/31/10 the Stage II pressure ulcer measured 6cm x 6cm x less than 0.1cm with small amount of pink to yellow drainage without odor noted. On 09/01/10 at 3:00PM, interview with S1Treatment RN and S2Treatment LPN confirmed the wound assessment of the left lateral malleolus on 8/31/10 was inaccurate. They further confirmed that the pressure ulcers to the left and right heel, top of left foot and left lateral malleolus were found at Stage IV. They further confirmed that the only assessments of the wound were the weekly wound assessments performed by S1 Treatment RN. There was no documented evidence of ongoing assessments of the resident's pressure sores in between the weekly staging/assessments performed by S1Treatment RN. The pressure sores were not being monitored or assessed frequently enough to determine if they were deteriorating and needing new treatment. Further interview with S1Treatment RN and S2Treatment LPN confirmed that there was no documented evidence that the resident ' s physician or family was immediately notified of all changes in the wound status. 2. Review of the medical record for sampled resident #7 was admitted to the facility on [DATE]. Further review of the medical record revealed the resident had [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed the resident required extensive assistance with activities of daily living. Review of the nurses notes dated dated 05/06/10 revealed the resident returned from the hospital to the nursing facility. Review of the body audit dated 05/06/10 (upon return to the facility) revealed an open area to the right outer ankle and excoriation to the buttocks. Review of the 08/10 physician orders [REDACTED]. Review of the nurses notes dated 05/09/10 and 05/10/10 revealed the resident refused to allow the nurse to apply Zinc Oxide to the buttocks area. Review of the nurses notes dated 05/11/10 revealed the resident allowed the nurse to apply the paste to the buttocks area and the nurse noted the skin to be macerated and darkly discolored. Review of the nurses notes dated 05/13/10 revealed broken skin was observed on the resident's sacrum, the skin was darkly discolored and the skin was sloughing to the sacral area. Review of the body audit dated 05/13/10 revealed an old wound to the right outer ankle and excoriation to the buttocks. Review of the wound assessment form dated 5/14/10 revealed a Stage III pressure ulcer to the right lower lateral leg. The ulcer measured 1.2cm x 1.0cm x less than 0.1cm depth, with full thickness, 75% necrotic slough. Treatment at this time was clean with wound cleanser and apply Elastogel, cover and secure, change every 3 days. Review of the wound assessment form dated 5/14/10 revealed a Stage III to the coccyx. The ulcer measured 5.0cm x 4.0cm x less than 0.1cm depth, with full thickness, 75% necrotic tissue with slough. Treatment at this time was to clean with wound cleanser and apply [MEDICATION NAME], cover and secure, change every 5 days then every other day. Review of the wound assessment form dated 5/21/10 revealed the right lower lateral leg pressure ulcer developed into a Stage IV. The ulcer measured 5.0cm x 2.7cm x less than 0.1 depth, with full thickness and 100% necrotic eschar. Treatment at this time was to clean with wound cleanser apply Elastogel, cover and secure and change every 3 days. Review of the wound assessment form dated 5/21/10 revealed the coccyx pressure ulcer developed into a Stage IV. The ulcer measured 10cm x 10cm x less than 0.1cm depth, with full thickness and 75% necrosis with eschar. Treatment at this time was to clean the wound with wound cleanser, apply [MEDICATION NAME] cover and secure, change every other day. Review of the medical record revealed no documentation that the physician was notified of the deterioration in the pressure sores from 5/14/10 - 5/21/10. On 09/01/10 at 3:00PM, interview with S1Treatment RN and S2Treatment LPN confirmed the body audit on 5/13/10 was inaccurate. They further confirmed that the pressure ulcers to the coccyx and right lower lateral leg were found at Stage III and progressed to Stage IV. 3. Review of the medical record for sampled resident #5 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed the resident was admitted with a Stage II pressure sore to the sacrum measuring 3.3cm x 3cm x less than 0.1cm depth. Admit orders were to clean the sacrum with wound cleanser and apply Saf-gel and dressing every day. Review of the weekly wound assessment form dated 05/21/10 completed by S1 Treatment RN revealed the wound remained a Stage II pressure sore, now measuring 1cm x 2cm x less than 0.1cm depth. The wound bed was pink. Treatment at this time was [MEDICATION NAME] ointment applied daily to the wound, which was ordered on [DATE]. Review of S2 Treatment LPNs nurses notes dated 05/26/10 revealed the resident ' s wound was regressing with a darkly discolored wound base and peri-wound skin. The notes revealed that the peri-wound skin is sloughing away. New orders were obtained on 05/26/10 to change the treatment to use [MEDICATION NAME] on wound and cover with Allevyn every other day. Review of the weekly wound assessment form dated 05/28/10 completed by S1 Treatment RN revealed the wound continued to be assessed as a Stage II pressure sore. The wound bed was documented as being red, with clear peri-wound skin. No slough of the wound was documented. The next documentation regarding as assessment of the resident ' s wound to the sacrum was 7 days later, on 06/04/10. Review of the wound assessment form dated 06/04/10 performed by S1 Treatment RN revealed the resident ' s wound had extensively deteriorated and was now a Stage IV pressure sore, with 100% eschar. The wound measured 5cm x 4.8cm x less than 0.1cm depth (There is no way to measure the depth of a sore covered with eschar). Further review of the form revealed the treatment order remained the same. There was no documented evidence that the resident ' s physician or family was immediately notified of the decline in the pressure sore. On 06/07/10, three days after discovering the decline in the resident ' s pressure sore, the physician was notified and new orders were obtained to treat the area. The new orders were to apply Santyl and cover with a dressing every day. Review of the resident ' s medical record revealed there were no ongoing assessments of the resident ' s sacral pressure sore after it declined to a Stage IV. The only documentation of wound assessments were weekly assessments performed by S1 Treatment RN. Review of the wound assessment form dated 06/18/10 performed by S1 Treatment RN revealed the wound remained a Stage IV pressure sore, measuring 5.3cm x 4cm x less than 0.1cm depth. The wound was 100% necrotic with no tunneling or undermining. There was no ongoing assessments of the resident ' s Stage IV pressure sore to the sacrum until 7 days later, when S1 Treatment RN performed her weekly assessment. Review of the wound assessment form dated 06/25/10 completed by S1 Treatment RN revealed the wound remained a Stage IV, measuring 4.8cm x 5.8cm x 3cm depth. Further review of the wound assessment form revealed the wound now was tunneling and undermining, and had liquefying necrotic exudate. The physician was notified and new treatment was ordered. There was no documented evidence that the resident ' s family was notified of the deteriorating pressure sore. On 09/01/10 at 3PM, interview with S1 Treatment RN and S2 Treatment LPN confirmed that there was no documented evidence that frequent, ongoing assessments of the resident ' s sacral would was performed in order to prevent the wound from further deterioration. They further confirmed that the only assessments of the wound were the weekly wound assessments performed by S1 Treatment RN.

Based on observation, record review and interview, the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores and a resident having pressure sores receives necessary treatment and services to promote healing and prevent new sores from developing. The facility failed to: 1) assess and monitor the skin of 1 of 1 resident who was paralyzed from the waist down and at risk for pressure sore development in a total sample of 3. As a result, the resident developed 4 pressure sores that were not identified until they were Stage IV. (Sample #1) 2) assess and monitor the skin of 1 of 1 resident at risk for pressure sore development whose pressure sores were not identified until they were a Stage III pressure sore in a total sample of 3. (Sample #7) 3) perform ongoing wound assessments for 3 of 3 residents who had pressure sores in a total sample of 3. As a result, the residents developed Stage IV pressure sores. (Sample #1, 5, 7) Findings: 1. Review of the medical record revealed sampled resident #1 was readmitted back to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change MDS dated [DATE] revealed the resident had modified independence in cognition, required extensive assistance with ADL's, had an indwelling Foley catheter and was incontinent of bowel. Review of the pressure sore risk assessment updated on 08/05/10 revealed sampled resident #1 was a mild risk for pressure sores. Review of the careplan initiated on 08/13/10 revealed the resident was at risk for developing pressure ulcers related to decreased mobility, deep tissue injury top of left foot, left heel, left lateral foot and right heel. Review of the nurses post hospital assessment dated [DATE] revealed multiple bruises to the arms due to old IV insertion sites and redness noted to the sacrum area. Review of S2Treatment LPN nurses notes dated 08/05/10 at 2:30PM revealed [DIAGNOSES REDACTED] noted to buttocks upon admission; skin is intact at this time. S1Treatment RN visualized the buttocks. Orders to apply [MEDICATION NAME] to buttocks every day until [DIAGNOSES REDACTED] is resolved was initiated on the treatment administration record. There was no documented evidence of any pressure ulcers when the resident returned from the hospital on this date. There were no further assessments of the resident's skin until 08/12/10, 7 days after the resident returned from the hospital with a [DIAGNOSES REDACTED]. MD orders were obtained to apply Elastogel to left and right heel and left lateral malleolus every 3 days and as needed until healed. There was no documentation that the responsible party was immediately notified of the wounds. Review of treatment nurses notes dated 08/13/10 at 10:20AM revealed a new discolored area was noted on top of the left foot. MD orders obtained to apply Elastogel to top of left foot every 3 days and as needed until healed. On 08/24/10 at 10:10AM, review of the treatment notes revealed the sacrum was found with "superficial" area thought to be from friction. MD was notified and orders were given to clean sacrum with wound cleanser and apply SAF gel and cover with dressing everyday until healed. There was no documentation that the responsible party was notified of the change in the resident's sacral area. Review of the RN Wound assessment form dated 08/12/10 revealed a Stage IV pressure ulcer to the left lateral malleolus noted as an unstageable deep tissue injury measuring 2cm x 1cm without odor or drainage. On 08/18/10 the wound measured 2.7cm x 2cm with a red/purple wound bed without drainage or odor. On 08/27/10 the wound measured 4.5cm x 2cm and on 08/31/10 the wound measured 4.2cm x 2cm x less than 0.1cm with a red/purple wound bed, small pink to yellow exudate. On 08/31/10 at 3:30PM, observation revealed S1Treatment RN assessed the resident's left lateral malleolus wound and S2Treatment LPN dressed the wound as ordered. Observation of the left lateral malleolus revealed a dark purple to black wound with a quarter sized opened area with yellow slough noted. On 09/01/10 at 2:45PM S1Treatment RN reported to the surveyor that she did not notice the open area on the left lateral malleolus. At this time, S2Treatment LPN confirmed that there was an open area on the wound and that she had cleaned it with wound cleanser before applying the ordered dressing. S1Treatment RN and S2Treatment LPN confirmed they had not notified of the physician or the family of the deterioration in the wound. Review of the RN Wound assessment form dated 08/12/10 revealed a Stage IV pressure ulcer to the left heel noted as an unstageable deep tissue injury measuring 3cm x 2cm without odor or drainage and a red/purple wound bed. On 08/18/10 the wound measured 7cm x 3cm with a red/purple wound bed without drainage or odor. On 08/27/10 the wound measured 3cm x 3cm and on 08/31/10 the wound measured 4cm x 4cm x less than 0.1cm with a red/purple wound bed, without odor or drainage (There is no way to measure the depth of a Stage IV pressure sore because you cannot visualize or measure what is underneath the surface of the skin). Review of the RN Wound assessment form dated 08/13/10 revealed a Stage IV pressure ulcer to the top of the left foot noted as an unstageable deep tissue injury measuring 0.1cm x 2cm without odor or drainage. On 08/18/10 the wound measured 1cm x 1cm with a red/purple wound bed. On 08/27/10 the wound measured 1cm x 4cm with a red/purple wound bed without drainage or odor. On 08/31/10 the wound measured 1cm x 2cm x less than 0.1cm with a red/purple wound bed, without odor or drainage (There is no way to measure the depth of a Stage IV pressure sore because you cannot visualize or measure what is underneath the surface of the skin). Review of the RN Wound assessment form dated 08/12/10 revealed a Stage IV pressure ulcer to the right heel noted as an unstageable deep tissue injury measured 2cm x 1cm with a red/purple wound bed without odor or drainage. On 08/18/10 the wound measured 2cm x 2.5cm with a red/purple wound bed. On 08/27/10 the wound measured 3cm x 2cm x less than 0.1 with a red/purple wound bed without drainage or odor. On 08/31/10 the wound measured 3.2cm x 3cm x less than 0.1cm with a red/purple wound bed, without odor or drainage (There is no way to measure the depth of a Stage IV pressure sore because you cannot visualize or measure what is underneath the surface of the skin). Review of the RN Wound assessment dated [DATE] (3 days after the "superficial" area was found by S2Treatment LPN) revealed a Stage II pressure ulcer measured 6cm x 4cm with partial thickness, small amount of pink to yellow drainage with red/purple wound bed. On 08/31/10 the Stage II pressure ulcer measured 6cm x 6cm x less than 0.1cm with small amount of pink to yellow drainage without odor noted. On 09/01/10 at 3:00PM, interview with S1Treatment RN and S2Treatment LPN confirmed the wound assessment of the left lateral malleolus on 8/31/10 was inaccurate. They further confirmed that the pressure ulcers to the left and right heel, top of left foot and left lateral malleolus were found at Stage IV. They further confirmed that the only assessments of the wounds were the weekly wound assessments performed by S1Treatment RN. There was no documented evidence of ongoing assessments of the resident's pressure sores in between the weekly staging/assessments performed by S1Treatment RN. The pressure sores were not being monitored or assessed frequently enough to determine if they were deteriorating and needing new treatment. Further interview with S1Treatment RN and S2Treatment LPN confirmed that there was no documented evidence that the resident ' s physician or family was immediately notified of all changes in the wound status. 2. Review of the medical record for sampled resident #5 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed the resident was admitted with a Stage II pressure sore to the sacrum measuring 3.3cm x 3cm x less than 0.1cm depth. Admit orders were to clean the sacrum with wound cleanser and apply Saf-gel and dressing every day. Review of the weekly wound assessment form dated 05/21/10 completed by S1Treatment RN revealed the wound remained a Stage II pressure sore, now measuring 1cm x 2cm x less than 0.1cm depth. The wound bed was pink. Treatment at this time was [MEDICATION NAME] ointment applied daily to the wound, which was ordered on [DATE]. Review of S2Treatment LPNs nurses notes dated 05/26/10 revealed the resident ' s wound was regressing with a darkly discolored wound base and peri-wound skin. The notes revealed that the peri-wound skin is sloughing away. New orders were obtained on 05/26/10 to change the treatment to use [MEDICATION NAME] on wound and cover with Allevyn every other day. Review of the weekly wound assessment form dated 05/28/10 completed by S1Treatment RN revealed the wound continued to be assessed as a Stage II pressure sore. The wound bed was documented as being red, with clear peri-wound skin. No slough of the wound was documented. The next documentation regarding as assessment of the resident ' s wound to the sacrum was 7 days later, on 06/04/10. Review of the wound assessment form dated 06/04/10 performed by S1Treatment RN revealed the resident ' s wound had extensively deteriorated and was now a Stage IV pressure sore, with 100% eschar. The wound measured 5cm x 4.8cm x less than 0.1cm depth (There is no way to measure the depth of a sore covered with eschar because you cannot measure or visualize what is under the eschar). Further review of the form revealed the treatment order remained the same. There was no documented evidence that the resident ' s physician or family was immediately notified of the decline in the pressure sore. On 06/07/10, three days after discovering the decline in the resident ' s pressure sore, the physician was notified and new orders were obtained to treat the area. The new orders were to apply Santyl and cover with a dressing every day. Review of the resident ' s medical record revealed there were no ongoing assessments of the resident ' s sacral pressure sore after it declined to a Stage IV. The only documentation of wound assessments were weekly assessments performed by S1Treatment RN. Review of the wound assessment form dated 06/18/10 performed by S1Treatment RN revealed the wound remained a Stage IV pressure sore, measuring 5.3cm x 4cm x less than 0.1cm depth. The wound was 100% necrotic with no tunneling or undermining. There was no ongoing assessments of the resident ' s Stage IV pressure sore to the sacrum until 7 days later, when S1Treatment RN performed her weekly assessment. Review of the wound assessment form dated 06/25/10 completed by S1 Treatment RN revealed the wound remained a Stage IV, measuring 4.8cm x 5.8cm x 3cm depth. Further review of the wound assessment form revealed the wound now was tunneling and undermining, and had liquefying necrotic exudate. The physician was notified and new treatment was ordered. There was no documented evidence that the resident ' s family was notified of the deteriorating pressure sore. On 09/01/10 at 3PM, interview with S1 Treatment RN and S2 Treatment LPN confirmed that there was no documented evidence that frequent, ongoing assessments of the resident ' s sacral would was performed in order to prevent the wound from further deterioration. They further confirmed that the only assessments of the wound were the weekly wound assessments performed by S1Treatment RN. Further interview with S1Treatment RN and S2Treatment LPN confirmed that there was no documented evidence that the resident ' s physician or family was immediately notified of all changes in the wound status. 3. Review of the medical record for sampled resident #7 was admitted to the facility on [DATE]. Further review of the medical record revealed the resident had [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed the resident required extensive assistance with activities of daily living. Review of the nurses notes dated dated 05/06/10 revealed the resident returned from the hospital to the nursing facility. Review of the body audit dated 05/06/10 (upon return to the facility) revealed an open area to the right outer ankle and excoriation to the buttocks. Review of the 08/10 physician orders [REDACTED]. Review of the nurses notes dated 05/09/10 and 05/10/10 revealed the resident refused to allow the nurse to apply Zinc Oxide to the buttocks area. Review of the nurses notes dated 05/11/10 revealed the resident allowed the nurse to apply the paste to the buttocks area and the nurse noted the skin to be macerated and darkly discolored. Review of the medical record revealed no documented evidence that the physician was notified of the change in the resident's condition. Review of the nurses notes dated 05/13/10 revealed broken skin was observed on the resident's sacrum, the skin was darkly discolored and the skin was sloughing to the sacral area. Review of the body audit dated 05/13/10 revealed an old wound to the right outer ankle and excoriation to the buttocks. Review of the wound assessment form dated 5/14/10 revealed a Stage III pressure ulcer to the resident's right lower lateral leg. The ulcer measured 1.2cm x 1.0cm x less than 0.1cm depth, with full thickness, 75% necrotic slough. Treatment at this time was clean with wound cleanser and apply Elastogel, cover and secure, change every 3 days. Review of the wound assessment form dated 5/14/10 revealed a Stage III to the resident's coccyx. The ulcer measured 5.0cm x 4.0cm x less than 0.1cm depth, with full thickness, 75% necrotic tissue with slough. Treatment at this time was to clean with wound cleanser and apply [MEDICATION NAME], cover and secure, change every 5 days then every other day. Review of the wound assessment form dated 5/21/10 revealed the right lower lateral leg pressure ulcer developed into a Stage IV. The ulcer measured 5.0cm x 2.7cm x less than 0.1 depth, with full thickness and 100% necrotic eschar. Treatment at this time was to clean with wound cleanser apply Elastogel, cover and secure and change every 3 days. Review of the wound assessment form dated 5/21/10 revealed the coccyx pressure ulcer developed into a Stage IV. The ulcer measured 10cm x 10cm x less than 0.1cm depth, with full thickness and 75% necrosis with eschar. Treatment at this time was to clean the wound with wound cleanser, apply [MEDICATION NAME] cover and secure, change every other day. Review of the medical record revealed no documented evidence that the physician was notified of the change in the resident's condition. On 09/01/10 at 3:00PM, interview with S1Treatment RN and S2Treatment LPN confirmed the body audit on 5/13/10 was inaccurate. They further confirmed that the pressure ulcers to the coccyx and right lower lateral leg were found at Stage III and progressed to Stage IV.