Every finding on record at Medford Nursing Center

Based on observation, interview, and facility policy review, the facility failed to ensure staff trimmed the fingernails of 1 (Resident (R)57) of 3 sampled residents reviewed for activities of daily living.Findings included:Review of an undated facility policy titled, Activities of Daily Living revealed, Policy: Staff assists or performs activities of daily living as indicated.Review of a facility policy titled, Nail Care, dated 04/2008, revealed, Policy: Resident's [sic] will receive proper nail care.Review of R57's admission Record revealed the facility admitted R57 on 06/12/2025. According to the admission Record, the resident had a medical history that included but was not limited to, diagnoses of, vascular dementia and cognitive communication deficit.Review of R57's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/10/2026, revealed R57 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required substantial/maximal assistance with personal hygiene.Review of R57's Care Plan Report included a focus area revised on 08/11/2025, that indicated the resident required assistance with activities of daily (ADL) care. Interventions directed staff to check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse (initiated 07/30/2025).During an observation on 03/16/2026 at 10:02 AM and 03/17/2026 at 1:45 PM, R57 was resting in bed with their hands placed on her chest. R57's fingernails were long and extended past their fingertips.During an interview on 03/17/2026 at 2:40 PM, Certified Nursing Assistant (CNA)4 stated she was assigned to provide care to R57 and gave the resident a shower on 03/17/2026. CNA4 stated residents were usually offered nail care if the resident requested. CNA4 stated she did not observe R57's fingernails when she gave the resident a shower and explained that she did not even look at the resident's fingernails.During a concurrent observation and interview on 03/17/2026 at 2:48 PM, R57 was resting in bed with their hands placed on their chest. CNA4 observed R57's fingernails on both hands and stated the resident's fingernails needed to be trimmed.During an interview on 03/18/2026 at 11:09 AM, Licensed Practical Nurse (LPN)8 stated a resident's fingernails should be trimmed, if needed, as part of the resident's shower. LPN8 stated she would expect for the CNA staff to ensure a resident's fingernails were trimmed.During an interview on 03/19/2026 at 2:03 PM, the Director of Nursing (DON) stated the CNA staff primarily provided showers and bed baths to the residents at the facility. The DON stated nail care would typically be offered outside of the shower time because it could be too much for a resident to handle all at one time, so they would usually offer it in between shower days if it was needed. The DON stated R57 depended on the CNA staff to assist them with ADL care.During an interview on 03/19/2026 at 2:31 PM, the Executive Director (ED) stated residents could be offered nail care any time they requested. The ED stated if a resident was not able to make their needs known, the CNA staff should evaluate the resident's need for nail care during routine care. The ED stated resident's fingernails that extended past the resident's fingertips would be a good indicator the resident's fingernails needed to be trimmed, and she would expect CNA staff to keep the resident's fingernails trimmed, as long as the resident approved.

Based on interview, record review, and facility policy review, the facility failed to ensure a resident's medical record accurately reflected the resident's use of a hearing amplifier (a device designed to amplify environmental sound that was not prescribed by a professional or intended to treat hearing loss) for 1 (Resident (R)61) of 1 sampled resident reviewed for communication and sensory issues.Findings include:Review of a facility policy titled, Maintenance of Clinical Records, dated 07/2023, revealed, . 2. In accordance with accepted professional standards of practices, the facility must maintain medical records on each resident's that are: a. Complete b. Accurately documented.Review of R61's admission Record revealed the facility admitted R61 on 04/29/2024. According to the admission Record, the resident had a medical history that included but was not limited to, diagnoses of, need for assistance with personal care and cognitive communication deficit.Review of R61's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/17/2026, revealed R61 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident had intact cognition. The MDS indicated the resident used a hearing aid or other hearing appliance.Review of R61's Care Plan Report included a focus area revised on 07/08/2025, that indicated the resident was at risk for complications/injury related to difficulty hearing and wore bilateral hearing aids as tolerated. Interventions directed staff to assist the resident with placement of and removal of hearing aids as needed (initiated 07/07/2025) and turn hearing aids on and off as indicated (initiated 07/07/2025).Review of R61's Physician Orders revealed an order dated 11/27/2024 that directed the staff to remove the resident's hearing aids every night and place them on the nurses' cart, and an order dated 11/28/2024 that directed staff to place the resident's hearing aids in the resident's ear every morning.Review of R61's Treatment Administration Record [TAR] for the timeframe 03/01/2026 - 03/31/2026, revealed the transcription of a physician's order that specified remove the resident's hearing aid every night and place on the nurses' cart and place the resident's hearing aids in their ear every morning. According to the TAR, staff placed their initials on the TAR to indicate they placed R61's hearing aids in the resident's ear every morning and removed the hearing aids every night and placed them on the nurses' cart on 03/01/2026 to 03/16/2026.During an interview on 03/18/2026 at 9:07 AM, Licensed Practical Nurse (LPN)2 stated R61 did not have hearing aids and never had hearing aids.During an interview on 03/18/2026 at 9:15 AM, the Social Services Director (SSD) stated R61 had hearing amplifiers. Per the SSD, she was not sure why R61 had orders or a care plan that directed staff to put hearing aids in the resident's ear every morning and take them off at night.During an interview on 03/18/2026 at 12:49 PM, the Director of Nursing (DON) stated R61 and their responsible party were given options, but the responsible party did not wish to go forward with hearing aids for the resident. The DON stated the facility ordered amplifiers for the resident, and there was a noticeable difference when the resident had the amplifiers in and when they did not have them in. The DON stated she expected a resident's care plan to be accurate.During a follow-up interview on 03/19/2026 at 10:25 AM, the DON stated she expected information contained within a resident's medical record to accurately reflect the care provided.During an interview on 03/19/2026 at 10:30 AM, the Executive Director stated all information contained within the resident's medical record should be accurate.

Based on observation, interview, and record review, the facility failed to provide continuous oxygen therapy for one (Resident (R)62) of one resident reviewed for respiratory. This failure could potentially cause R62's condition to exacerbate. Findings include: Review of R62's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 12/18/24, located in the MDS tab of the electronic medical record (EMR), revealed an admitted [DATE] and had a Brief Interview for Mental Status (BIMS) of 10 out of 15, indicating moderate cognition impairment. R62 had diagnoses of acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, shortness of breath, wheezing, and received oxygen therapy. Review of R62's order, dated 09/10/24, located in the EMR under the Order tab revealed Oxygen: Oxygen at 2L[liter]/mins[minutes] via NC[nasal cannula] continuously, every shift. Review of R62's care plan, revised 01/13/24, located in the EMR under the Care Plan, revealed The resident has risk for altered respiratory status/difficulty breathing r/t [related to] dx [diagnosis] of Respiratory Failure with oxygen dependence. Hx [history] of COVID-19, hx of pneumonia. An intervention included Administer oxygen as ordered. Assist resident with positioning nasal cannula as tolerated. On 02/06/25 at 10:42 AM, R62's door was closed, and a green dot was noted on the door frame. The surveyor knocked on the door and did not receive a response. The door was opened, and Certified Nurse Aide (CNA)1 was observed at R62's bedside performing personal care. After care was completed on 02/06/25 at 10:54 AM, R62 was observed laying on her back with the bed flat with no pillow or blanket and R62 asking for her oxygen. R62 then pointed to her nasal cannula out of R62's reach that was located on the right side of the bed. During an interview on 02/06/25 at 10:56 AM, CNA1 was informed R62 was requesting her oxygen via the nasal cannula. CNA1 stated when she gets R62 in the wheelchair R62 will put in on. On 02/06/25 at 1:18 PM, R62 was in her room in the wheelchair eating lunch and wearing a nasal cannula. R62 was in no distress. R62 was asked if she had her oxygen on when CNA1 was providing incontinent care earlier that morning. R62 stated, No, CNA1 took it off. R62 was asked if she took it off and R62 stated, No the CNA did. R62 was asked if she was okay with the oxygen being off during her personal care and R62 stated, No, she would rather have it on. R62 stated some girls keep it on and some take it off, but she would rather have it on as it makes her feel better. During a follow up interview on 02/06/25 at 1:23 PM, CNA1 confirmed she took R62's nasal cannula off during incontinent care because R62 gets moved back and forth and CNA1 didn't want to tug on the tubing. CNA1 was asked why the oxygen wasn't put back on R62 after she had completed her incontinent care and R62 was laying on the bed waiting for CNA1 to retrieve the mechanical left and to transfer her into the wheelchair as 18 minutes had passed without oxygen. CNA1 did not comment. During an interview on 02/06/25 at 1:31 PM, the Director of Nursing (DON) was asked about CNA1 taking off R62's oxygen nasal cannula during incontinent care and what her expectation was. The DON stated, CNA1 should have kept it on during care unless R62 takes it off or refuses, but R62 didn't. The DON stated an oxygen policy would be provided. At the time of the exit, no policy was provided.

Based on observation, interview, and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP) while performing incontinent care for one (Resident (R)62) of two residents reviewed for infection control. This deficient practice could potentially lead to increased risk of infection and complications for R62 with an open gastrostomy stoma. Findings include: Review of the facility policy titled Enhanced Barrier Precautions, revised 03/24, provided by the facility revealed It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that use targeted gown and gloves during high contact resident care activities. b. PPE [personal protection equipment] for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 4. High-contact resident care activities include: .d. Providing hygiene . f. Changing briefs or assisting with toileting. Review of R62's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 12/18/24, located in the MDS tab of the electronic medical record (EMR), revealed an admitted [DATE] and had a Brief Interview for Mental Status (BIMS) of 10 out of 15, indicating moderate cognition impairment, was incontinent of bowel and bladder, and had diagnoses of dementia, gastrostomy status, and cutaneous abscess of abdominal wall. Review of R62's order, dated 02/05/25, located in the EMR under the Order tab revealed Enhanced Barrier Precautions every shift related to Encounter for Attention to Gastrostomy; Encounter for Prophylactic Measures, unspecified. Review of R62's care plan, revised 08/16/24, located in the EMR under the Care Plan tab revealed The resident requires assistance with ADLs [activities of daily living] related to dx [diagnoses] of AFIB [atrial fibrillation], dementia, HTN [hypertension], DM [diabetes mellitus], malnutrition, dysphagia, PEG [percutaneous endoscopic gastrostomy] tube placement, and limited mobility. An intervention included Enhanced Barrier Precautions. On 02/06/25 at 10:42 AM, R62's door was closed, and a green dot was noted on the door frame. The surveyor knocked on the door and did not receive a response. The door was opened, and Certified Nurse Aide (CNA)1 was observed at R62's bedside performing personal care without wearing the appropriate gown. On 02/06/25 at 10:52 AM, CNA1 was observed leaving R62's room. CNA1 was asked if she was supposed to wear PPE while providing personal care for R62. CNA1 stated, Yes, and confirmed she did not have a gown on and the green dot on R62's door meant Enhanced Barrier Protection (EBP). During an interview on 02/06/25 at 11:31 AM, the Infection Preventionist (IP) was asked if R62 was under EBP. The IP stated, Yes, and R62 had the green dot on her door that identified to staff R62 was under EBP. The IP stated R62 was under EBP due to R62's gastrostomy site being still open. The IP stated once the site was closed, the EBP would be removed. The IP was asked should the nurse aides wear PPE during R62's personal care. The IP stated, Yes. The IP was informed CNA1 did not utilize PPE during R62's incontinent care on 02/06/25 at 10:42 AM. The IP stated maybe CNA1 was confused about the EBP and thought it wasn't necessary. The IP was informed CNA1 confirmed she did not use PPE but should have. The IP stated that more education was necessary. During an interview on 02/06/25 at 1:27 PM, the Director of Nursing (DON) was asked about CNA1 not wearing PPE during R62's incontinent care and what her expectation was. The DON stated CNAs should wear PPE and they have been educated on it.

Based on review of facility policy, observations, and interviews, the facility failed to follow appropriate infection control practices for hand hygiene and glove wearing for one resident (Resident (R)57) observed during wound care out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Handwashing/Hand Hygiene dated 2/18 revealed, Policy: Staff will wash hands use hand sanitizer to aide in the prevention of the transmission Of infection .Purpose: To provide guidelines to employees for appropriate hand washing and hand sanitation .Procedure Hand washing: 1.Wet hands. 2. Apply soap and lather your hands by rubbing them together with the soap. 3. Scrub surfaces of hands for 20 seconds. 4. Rinse hands. 5. Dry hands with a clean paper towel and discard or air-dry hands. Hand Sanitizer: 1. Place sufficient amount of hand sanitizer cleanser on hands. 2. Rub hands together until hands feel dry (This should take around 20 seconds) . During an observation with Registered Nurse (RN)1 on 06/07/23 at 1:20 PM revealed, RN1 donned a pair of gloves as she prepared items on a treatment tray, ready to perform wound care on R57. At 1:21 PM, RN1 removed her gloves, touched R57's bedside table and bed, raising the bed up to a height for wound care. RN1 did not perform hand hygiene after removing her gloves. At 1:22 PM, RN1 donned another pair of gloves without performing hand hygiene. RN1 proceeded to the bathroom to get a bowl of water and returned still wearing the same gloves. At 1:23 PM, RN1 removed her gloves, did not perform hand hygiene, and donned another pair of gloves. RN1 cleansed R57's left toe wound. RN1 moved to R57's right heel wound without changing gloves and wrapped the heel wound in a clean bandage. RN1 removed the gloves and performed hand hygiene. On 06/07/23 at 1:35 PM, RN1 was told of the foregoing observations of several glove changes without performing hand hygiene. RN1 stated, ok. During an interview with the Director of Nursing on 06/08/23 at 9:16 AM, the DON stated it was her expectation that RN1 use hand sanitizer between glove changes every single time.

Based on observations, interviews and record review, the facility failed to ensure food preparation utensils and equipment were cleaned, sanitized and stored dry. This had the potential to affect all the residents at the facility. The census was 79. The finding included: 1. During the initial tour of the kitchen on 02/17/20 at 9:10 AM, two long handled strainers, one round approximately four inches in diameter and one square approximately 4 inches across, were hanging over a food preparation table. The strainers were observed to have silver colored handles and around the strainer portion, there was a brownish colored buildup. During an additional kitchen tour, on 02/19/20 at 9:53 AM, the square shaped strainer was in use. It was being used to strain green beans. Upon a closer examination with the Certified Dietary Manager (CDM) and Nursing Home Administrator (NHA), it was determined that the brownish matter around the base of the handle, the frame of the strainer and within the mesh of the strainer, was a build up of food matter. The CDM was able to scrape off the matter with his/her fingernail. On 02/19/20 at 10:03 AM, the CDM was interviewed. S/He stated the strainer was made of stainless steel and should not rust. He determined the brownish matter was a build up of food debris and the strainer should not have been in use. On 02/19/20 at 10:05 AM, the round strainer was observed to be in the dirty dish area. The CDM stated the round strainer had the same food debris build up and should not have been in use. On 02/19/20 at 10:07 AM, located on the clean area of the drying rack were seven cooling racks used for fried food. All seven racks were observed to have a build up of food debris on the underside of the racks. The CDM removed the racks from the clean area and placed them in the soiled area. The CDM stated that before they were used again, the racks would have to be scrubbed by hand. 2. On 02/19/20 at 10:10 AM, located on the clean area of the drying rack were six metal 4 food pans and four metal 6 food pans. The pans were observed to be lying upside down and all stacked together. When checked by the CDM, s/he indicated the pans were all wet on the inside. The CDM stated that to dry properly, the pans should not have been stacked together, but on the side of the pans so the water had an opportunity to run off. The policy for kitchen equipment was provided on 02/19/20 at 10:40 AM. The policy stated in part, All food preparation equipment, dishes, and utensils must be maintained in a clean, sanitary, and safe manner and used and repaired according to manufacturer's recommendations. All dishes, utensils and equipment will be air dried after washing. All dishes, utensils and food preparation equipment will be stored dry, covered, or upside down when dry. Any piece of equipment, dish, or utensil will be discarded when it is cracked, broken, discolored or abraded.

Based on interviews and record reviews, it was determined the facility failed to deliver mail to residents on Saturdays. The Resident Census and Conditions of Residents form, dated 02/17/20, identified 79 residents who resided in the facility. The findings included: On 02/18/20 at 1:17 PM, a confidential resident group meeting was attended by eight cognitively alert residents. They were asked if mail was delivered to residents on Saturdays. None of the residents in attendance thought mail delivery was available on Saturdays. On 02/18/20 at 2:03 PM, the Business Office Manager was asked if mail was delivered to residents on Saturdays. She said, No. She stated the mail stayed locked in the mailbox until Monday, and then she would give the mail to the Activities Department staff to deliver to the residents. On 02/18/20 at 3:06 PM, the Administrator stated in (MONTH) 2019 the delivery of residents' mail on Saturdays was identified as an area which needed improvement. He stated, at that time, charge nurses were provided a key to the mail, so, if a resident was expecting mail on the weekend, the charge nurse could check for it. On 02/18/20 at 3:37 PM, the Activities Director was asked if mail was delivered to residents on Saturdays. She stated, if a resident was expecting mail on Saturday, they could ask the nurse to check the mail. She stated the nurses had the key to the mail. On 02/18/20 at 3:41 PM, the Director of Nursing (DON) was asked if mail was delivered to residents on Saturdays. She stated the charge nurses had a key to access the mail. She stated the key to the mail was provided, so if a resident was expecting mail on the weekend, the charge nurse could check for it. She was asked if residents were aware charge nurses had access to the mail on Saturdays. She reviewed the resident council meetings minutes since (MONTH) 2019, as well as information provided to residents in the admission packet and concluded residents had not been informed mail was available to them on Saturdays. She stated the charge nurses had the capability to check and deliver mail on Saturdays, but there was no documentation they had done so. She said, I cannot prove they (charge nurses) check and deliver the mail every Saturday as there is no documentation.

Based on observation, record review, and interviews, the facility failed to provide the necessary care and services for for 9 of 9 residents reviewed for alcohol consumption. The facility failed to obtain a Physician's Order for alcohol consumption for Residents #36, #65, and #8 and failed to have a system for monitoring and documenting alcohol consumption for Residents #92, #93, #41, #38, #80, #62, #36, #65, and #8. The findings included: Observation of Resident #36 on 10/18/16 at approximately 3:00 PM revealed he/she was sitting on the front porch of the facility drinking beer from a white can with a blue koozie. Other residents were present on the porch at that time. The surveyor asked for a list of residents with physician's orders allowing them to consume alcohol. On 10/19/16 at approximately 3:00 PM, the Director of Nursing (DON) provided a list of 6 residents which included Residents #92, #93, #41, #38, #80, and #62. During an interview on 10/19/16 at approximately 3:30 PM, the Activities Director revealed that 4 residents had beer while on the porch on 10/18/16. The Activities Director provided a list of the 4 residents which included Residents #36, #65, #93, and #62. Review of Resident #36's medical record on 10/19/16 at approximately 3:30 PM revealed the facility admitted Resident #36 with [DIAGNOSES REDACTED]. Further review of Resident #36's medical record revealed Resident #36 did not have a Physician's Order to consume alcohol. Review of the October 2016 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed there was no space to document alcohol consumption. A Physician's Order was written dated 10/19/16 after the surveyor spoke with staff. Review of Resident #65's medical record revealed the facility admitted the resident with [DIAGNOSES REDACTED]. Further review of Resident #65's medical record revealed the resident did not have a Physician's Order to consume alcohol. Review of the October 2016 MAR and TAR revealed there was no space to document alcohol consumption. A Physician's Order was written dated 10/19/16 after the surveyor spoke with staff. Review of the medical records for Resident #93 and Resident #62 revealed both residents had an order for [REDACTED]. During an interview on 10/19/16 at approximately 4:10 PM, the Activities Director confirmed that the residents were served beer on the porch on 10/18/16 and stated, It is as the residents desire. The Activities Director stated that there is no schedule of how often residents have beer on the front porch and stated that there is no record kept of which residents have beer on those occasions. The Activities Director stated that he/she buys the beer for the residents. The Activities Director stated that the beer served on 10/18/16 was left over from an activity on Father's Day. When asked if there was documentation related to the purchase of beer for residents, the Activities Director stated that there was no documentation of how much is purchased and no documentation of how much is consumed. Review of the Resident Council Minutes on 10/19/16 at approximately 3:38 PM revealed that the June 2016 minutes indicated staff was asked if the men could have a poker game and drink some cold beer .AD (Activities Director) agreed with the residents and stated that the idea would be communicated to the administrator as well as the nursing staff and a game would be scheduled. Documentation from a Follow-Up Report for June 2016 Resident Council Meeting concerning Men Poker Game and Beer indicated, AD met with the administrator concerning the request to have a poker game and beer. The Administrator approved the request and informed AD to also discuss with nursing staff, to make sure that alcohol would not have an adverse effect medically, on the residents that would be drinking beer. AD asked residents throughout the facility, if they were interested in a poker game and drinking beer. A list was compiled from the residents that were interested and given to the supervisory nursing staff. AD met with (nursing staff), resulting in a final list complied corresponding with a physician order, permitting those residents to consume alcohol. The date for the poker game was scheduled for June 18, 2016 from 6:00 pm until, per residents' request. The evening of the Father's Day Celebration following supper. Review of the Resident Council Minutes for September 2016 indicated that some of the residents requested to have poker day monthly and would also like to have the beer provided for those that wanted to drink during the game. Documentation from the Follow-up Meeting on September 2016 indicated, AD spoke with the administrator who approved the men poker game to be held monthly, per resident choice and beer will be provided for those residents that wanted to drink it. Other beverages would be provided for those that wanted nonalcoholic beverages. Review of the January 2016 Resident Council Meeting minutes indicated a menu for a Super Bowl Party included beer and nonalcoholic beer. On 10/19/16 at approximately 5:15 PM, the AD provided a list of residents who attended the September 2016 poker game. The AD indicated on the list that Residents #93, #41, and #8 had consumed beer on that occasion. The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Review of the medical record revealed there was no Physician's Order for alcohol consumption. Review of the October 2016 MAR and TAR revealed there was no space to document alcohol consumption. A Physician's Order was written dated 10/19/16 after the surveyor spoke with staff. Review of Resident #41's medical record revealed the resident had an order for [REDACTED]. The surveyor requested a list of residents who participated in the June 18, 2016 poker game and who consumed alcohol at the January 2016 Super Bowl Party. A list of those attending the January Super Bowl Party was not available. The AD informed the surveyor that the residents who attended the June 18 poker game and consumed alcohol were the same as those listed on the September list. During an interview on 10/20/16 at approximately 1:30 PM, the DON and Administrator reviewed the information related to Residents #36, #65, and #8 who did not have a Physician's Order for alcohol consumption prior to the surveyor speaking with staff. The DON and Administrator confirmed that alcohol consumption was not documented in the medical record of any resident who consumed alcohol.

Based on observation, interview and review of the facility policy titled, Storage of Drugs, the facility failed to ensure medications were securely locked inside the medication cart before leaving the cart unattended for 1 of 4 medication carts observed. The findings included: An observation on 10/19/2016 at approximately 7:32 AM revealed a medication cart with unsecured medications left unattended by Licensed Practical Nurse (LPN) #1. During an interview on 10/19/2016 at approximately 7:32 AM with LPN #1, he/she confirmed that the medications were left unattended on the medication cart and not secured before leaving the cart. Review on 10/19/2016 at approximately 1:05 PM of the facility policy titled, Storage of Drugs, states under, Policy, All drugs shall be stored appropriately. Under Procedure, number 1 states, Drugs shall be stored in an orderly manner in a locked area.

Based on observations, interviews and review of the facility policy titled, Storage of Drugs, the facility failed to ensure an opened, partially used, sterile dressing was discarded and not placed in 1 of 2 treatment carts with other dressings for resident use. The facility further failed to ensure a medication was removed from medication cart #1 after discontinued and not stored with other medications for resident use in 1 of 4 medication carts. The findings included: An observation on 10/19/2016 at approximately 9:10 AM of 1 of 2 treatment carts revealed a Duoderm Extra Thin Sterile Dressing opened, partially used and returned to the treatment cart with other dressing for resident use. The Lot #5K and the manufacturer is Convatec and will expire on 11/2020. During an interview on 10/19/2016 at approximately 9:10 AM with Registered Nurse (RN) #1, the treatment nurse, confirmed that the sterile dressing had been opened, partially used and placed back in the treatment cart. An observation on 10/20/2016 at approximately 9:20 AM of medication cart #1 revealed a bottle of Magic Mouth Wash, approximately 60 milliliters with RX # 0 was stored on the medication cart and the physician order had been discontinued on 10/6/2016. An interview on 10/20/2016 at approximately 9:20 AM with RN #1, the treatment nurse, confirmed the medication should have been removed from the med cart due to the fact it had been discontinued. Review on 10/20/2016 at approximately 1:05 PM of the facility policy titled, Storage of Drugs, under Policy: states, All drugs shall be stored appropriately. Number 5 under Procedure: states, Discontinued drugs shall be returned to the provider pharmacy for destruction.

Based on observations, interviews and review of the facility policy titled, Medication Handling and Administration Procedure, the facility failed to ensure a Glucometer used for multiple residents, during blood sugar checks, was cleaned and sanitized after resident use and/or prior to placing it in the medication cart during 1 of 1 observations of a blood sugar check. The facility further failed to ensure the medication, [MEDICATION NAME], was not touched with bare hands during administration for 1 of 30 opportunities for medication errors during medication administration. The findings included: An observation on 10/17/2016 at approximately 4:45 PM during a blood sugar check revealed Licensed Practical Nurse (LPN) #2 using a Glucometer used for multiple residents, was not sanitized/cleaned after resident use and prior to placing in a drawer of the medication cart. An interview on 10/17/2016 at approximately 4:45 PM with LPN #2 confirmed that the Glucometer had not been sanitized/cleaned after resident use and before placing it in the medication cart drawer. An observation on 10/19/2016 at approximately 7:47 AM during medication administration revealed LPN #3, removing 2 tablets from a blister card using bare hands to catch the tablets and putting them in the medication cup. During an interview on 10/19/2016 at approximately 7:47 AM with LPN #3, he/she confirmed that his/her bare hands were used to catch the tablets and put them in the medication cup and stated, I should have held the blister card over the cup and released them directly into the medicine cup. Review on 10/19/2016 at approximately 1:05 PM of the facility policy titled, Medication Handling and Administration Procedure, under procedure, number 4 states, Remove medication from the packaging over the medication cup so that the medication falls into the cup.

Based on record review and interviews, the facility failed to ensure an eye appointment, ordered by a physician for Resident #13 was arranged and completed as ordered for 1 of 3 residents reviewed for vision. The findings included: The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Review on 10/19/2016 at approximately 1:28 PM of the medical record for Resident #13 revealed an eye consult with treatment dated 10/16/2014. Included in the consult report was a physician's orders [REDACTED]. Further review on 10/19/2016 at approximately 1:30 PM revealed a nurse's note dated 10/16/2014 at 12:45 PM which reads, Resident returned to the facility via facility van transportation from appointment at(NAME)Regional Eye Center. Prescription for new eye wear received per Dr. Ross. One year follow up appointment to be scheduled. Resident's responsible party made aware. Medical doctor made aware. No documentation could be found in Resident #13's medical record to ensure the ordered follow up eye appointment was arranged by the facility and completed. An interview on 10/19/2016 at approximately 5:18 PM with the Registered Nurse #2, Unit Manager for the 200 Hall confirmed that the follow up eye appointment had not been scheduled and therefore Resident #13 was not seen by the eye doctor as ordered. During the exit conference on 10/20/2016 at approximately 2:30 PM the Director of Nursing supplied an appointment date and time in December 2016 for Resident #13.

Based on record review and interview, the facility failed to ensure each resident received the necessary care and services to maintain the highest practicable physical well-being. Resident #1 was noted to have a fall that was not identified. Resident #1 was not monitored per facility policy after the fall. One of one residents reviewed for unidentified falls. The findings included: The facility submitted a reportable incident to the State Agency for Resident #1 on 5/26/16 related to an injury of unknown origin. Resident #1 was noted to have discoloration and swelling to the right knee. An x-ray was obtained and showed a [MEDICAL CONDITION] femur. Review of the facility's Five-Day Follow-Up Report dated 5/30/16 revealed during interviews with staff, a CNA stated that approximately two weeks ago, Resident #1 was in the shower and let go of the hand rail and began to fall backwards. The CNA stated s/he caught the resident with his/her chair and Resident #1 did not fall all the way to the floor. The CNA stated s/he called the LPN to the shower room and the resident was assessed for injury. The Director of Nursing (DON) questioned the LPN who stated that since Resident #1 did not actually fall to the floor, and there was no apparent injury at the time, s/he did not complete an incident report. The facility felt that Resident #1 sustained the fracture during the above incident. Review of Resident #1's Nurses' Notes for the month of May 2016 revealed only two entries prior to 5/25/16. One on 5/17/16 and one on 5/19/16 with no documentation related to the resident's skin. The Nurses' Note dated 5/25/16 at 1:40 AM was noted as a late entry for 5/24/16 at 7:20 PM. The note indicated LPN #1 was called to Resident #1's room by the CNA. Bruising was noted to the right outer thigh, right inner thigh, and right hip. Resident #1 complained of pain to the right knee. The resident's knee was swollen and red. An x-ray was ordered for the right hip to foot. Review of Resident #1's Skin Inspection Report revealed LPN #2 completed the resident's body audit on 5/20/16. The resident had body audits completed on 5/6/16, 5/13/16, 5/20/16 and 5/27/16. The Skin Inspection Report only listed that the resident's skin was intact. In an interview with the surveyor on 6/20/16 at approximately 2:45 PM, the Director of Nursing (DON) stated that when a body audit is done it is entered in the computer. The program asks if skin is intact or not. If the resident's skin is intact that is what shows on the Skin Inspection Report. If the skin is not intact the computer brings up an area to document where the area is. There is no place to document bruising, bruising should be documented in the Nurses' Notes. Skin inspections are completed by nurses. Review of the resident's care plan revealed potential for further falls and injury was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to record any falls and circumstances/injuries of falls and to notify family and MD of any incident. In an interview with the survey on 6/20/16 at approximately 3:05 PM, LPN #3 (2nd shift LPN supervisor) stated LPN #1 came to him/her and told him/her about the incident. LPN #3 asked LPN #1 if the resident fell and s/he said no the CNA saw the resident and immediately pushed the shower chair under him/her before s/he fell . LPN #3 stated if s/he didn't fall everything was okay. In a telephone interview with the surveyor on 6/22/16 at approximately 12:20 PM, LPN #1 stated that s/he was on duty the day of the incident. CNA #1 had the resident in the shower. They came out and told him/her Resident #1 let go of the shower rail and they caught him/her in the wheelchair. LPN #1 talked with LPN #3 (2nd shift LPN supervisor) and let him/her know what was going on. LPN #3 said it wasn't a fall so don't chart on it or complete an incident report. LPN #1 went and assessed the resident in the shower room. The resident moved extremities as normal. LPN #1 stated s/he completed the Incident Report for the resident's bruising on 5/24/16. S/he was called to the room by a CNA who isn't usually assigned to the resident. The resident had a large bruise on the outer side of the right thigh. The bruise was yellow and green around the edges, dark purple in the middle. The bruise looked old. LPN #1 did a body audit at that time and noted the swelling to the resident's knee. Resident #1 also had bruising to the inner part of his/her right thigh and on both knees. All the bruises were yellow and looked old. LPN #1 stated she could not find where anyone had documented on the bruising that's why s/he completed an Incident Report and notified the DON, physician and family. (on 5/24/16) In an interview with the surveyor on 6/20/16 at approximately 2:50 PM, CNA #3 stated s/he got the resident out of bed and got him/her dressed. When the resident was in the wheelchair s/he said I think my leg needs to be reset, CNA #3 asked why, and the resident said I think it's broken. CNA #3 told LPN #2 and s/he said the resident always complains about things. CNA #3 could not remember what day the above happened. CNA #3 noticed a yellowish purplish bruise on the resident's thigh, the same leg the resident said was broken. CNA #3 thought the bruise was going away and they already knew about. CNA #3 stated s/he had noticed the bruise before that day but it was yellow-purple the first time s/he saw it so s/he thought it was healing and they already knew about. In a telephone interview with the surveyor on 6/22/16 at approximately 3:00 PM, CNA #2 stated s/he does not usually work with the resident. CNA #2 noted bruising on Resident # 1's right thigh. CNA #2 reported the bruising to LPN #1. In an interview with the surveyor on 6/20/16 at approximately 3:15 PM, CNA #1 stated s/he does not remember what day the resident fell . CNA #1 was giving the resident a shower and assisted the resident to stand up. Resident #1 held onto the bar, then s/he started to let go. CNA #1 pulled the shower chair up with his/her foot and caught the resident before s/he hit the floor. CNA #1 called the ward clerk in and let him/her know what happened. Also, called LPN #1 in and let him/her know what happened. LPN #1 came in and looked at the resident and asked if s/he was okay. In a telephone interview with the surveyor on 6/22/16 at approximately 12:40 PM, LPN #2 stated s/he noted bruising on 5/20/16 when s/he completed the resident's body audit. The bruising was located on the right side. The bruising was very yellow, it was healing. LPN #2 stated s/he did not document the bruising because it was old. The resident's skin was intact, not broken. LPN #2 stated s/he would document new bruising, skin tears or any redness. In an interview with the surveyor on 6/20/16 at approximately 3:45 PM, the DON stated the incident would have happened on 5/9/16. That is the only night that all four people who were told about the incident were at the facility at the same time. LPN #1 called him/her at home and said s/he had found a discoloration on Resident #1's thigh, s/he also noticed the resident ' s knee was swollen. The bruising looked old and was turning color. Resident #1's knee was a little swollen an LPN #1 wanted to know if s/he needed to do anything else. The next morning the x-ray tech came and they got the results that morning that it was fractured. The DON started asking around and no one knew what happened. The DON talked to CNA #1 on the phone and s/he told him/her Resident #1 had let go of the rail and s/he caught the resident with the chair. Resident #1 went to the orthopedist and they said the injury looked approximately one-two weeks old. LPN #1 said the bruising looked old but was concerned because of the swelling to the knee. The DON stated nursing should document when a new bruise is found. Nurses should document if they find a bruise during a body audit in the nurses ' notes. The DON stated the nurse should have reported the incident as a fall so they would know if anything came up where it would have come from. The DON stated any transfer of position would be a fall. The DON stated there was no incident report completed for Resident #1's fall in the shower. Review of the facility's Incident/Accident Protocol policy indicated accidents or incidents occurring on their premises must be reported, investigated and documented timely. The procedure included to notify the attending physician and the resident's responsible party. Documentation was to include, but not limited to, the date and time the accident/incident took place, the circumstances surrounding the accident/incident, where the accident/incident took place and follow-up charting every shift for 72 hours. The procedure included to complete and Incident Report Form, which is to include, but not limited to, falls.

Based on observation, interview, and review of the facility policy titled Linen Handling, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to prevent development and transmission of disease and infection. During an observation of the sorting of linen, laundry staff was observed touching the handles, operating buttons on the washer, and the broom/dust pan with the soiled gloves used during the sorting. The findings included: During the observation of the sorting of linen on 6/17/15 at 9:11 AM, Laundry Staff #1 was observed after sorting and placing the linen into the washer, to close the door the washer and select the button for starting the wash with soiled gloves. After starting the washer, he/she obtained a broom and a dust pan and swept out the container which held the soiled items. During an interview with the Laundry Staff #1 at the time of the observation, he/she stated the washers are wiped down every day. When questioned just once a day, he/she then stated and more often as needed. The Laundry Supervisor was in attendance during the sorting and confirmed the washer handle, start button, broom, and dust pan had been touched with the soiled gloves. Review of the facility policy titled Linen Handling, the Procedure section-Soiled linen states the following: Soiled linen can be a source of infection and should be handled carefully. Gloves should be worn when holding grossly contaminated laundry. Use a gloved hand to hold the linen and an ungloved, clean hand to open doors, etc.

Based on an observation, interview and review of the facility policy titled, Gastrostomy/PEG Tube Medication Administration, the facility failed to ensure a Gastrostomy tube was flushed with 30 milliliters (ml) of water prior to administering medications via the tube for 1 of 1 resident observed during med pass with a gastrostomy tube. (Resident #28) The findings included: The facility admitted Resident #28 with [DIAGNOSES REDACTED]. An observation made during med pass on 6/17/2015 at approximately 9:19 AM revealed Licensed Practical Nurse (LPN) #1 preparing to administer Resident #28's morning medications via a gastrostomy tube. LPN #1 checked placement of the gastrostomy tube and proceeded to flush the tube with 30 mls of water prior to administering the medications. He/she inserted the syringe and poured in the 30 mls of water. One of the ports to the tube was open and the 30 mls of water ran out onto the resident and the bed. The resident did not receive the 30 ml flush of water prior to medication administration. During an interview with LPN #1 on 6/17/2015 at approximately 9:20 AM he/she verified that the 30 mls of water flush prior to administering medications via a gastrostomy tube was not done. Review of the facility policy on 6/18/2015 at approximately 11:00 AM, titled, Gastrostomy/PEG Tube Medication Administration, states, under Procedure:,Check placement. Number 13 states, Administer 30 ml flush (water). Number 14 states, Allow flush to flow by gravity. Number 15 states, Administer medications as ordered, and number 16 states, After medication administration is completed, provide another 30 ml flush. And number 17 states, Reconnect tubing and unclamp tubing,

Based on observation, interview and review of the facility policy titled, Storage of Drugs, the facility failed to ensure an expired medication was removed and not stored with medications for resident use in 1 of 4 medication carts. The findings included: An observation of medication cart 1 on [DATE] at approximately 8:40 AM revealed the medication Hydroxyzine HCL 10 milligrams (mg) 20 tablets with RX # 351, Lot # 1D and Manufactured by KF/JD Harris had expired on [DATE]. An interview on [DATE] at approximately 8:40 AM with Registered Nurse (RN) #1 confirmed the 20 tablets of Hydroxyzine 10mg had expired on [DATE]. Review on [DATE] at approximately 10:37 AM of the facility policy titled, Storage of Drugs, states, All drugs in the medication cart shall be stored under the following conditions: Number 6 states, Drugs shall not be kept on hand after the expiration date on the label.

On the days of the Recertification and Extended Survey based on record review and interview, the facility failed to assess adequately to determine the resident's condition and enable timely treatment for 4 residents reviewed for assessments out of a sample of 28. Resident #1 with respiratory illness which developed into Pneumonia. Resident #92 with cardiac symptoms which developed into a [MEDICAL CONDITION] Infarction and new onset of left sided weakness which developed into a [MEDICAL CONDITION]. Resident #60 with respiratory illness which resulted in a hospitalization . Resident #40 with elevated blood pressures with no ongoing assessments. The findings included: The facility admitted Resident #92 with [DIAGNOSES REDACTED]. Review of the 11/21/13 Admission Minimum Data Set Assessment (MDS) revealed the Brief Interview for Mental Status(BIMS) revealed a score of 15, indicating the resident was cognitively intact. Review of nurse's notes dated 11/27/13 at 5:30 PM revealed the resident developed chest pain and left arm pain. Paleness and clammy skin was also documented. Vital signs and a Fingerstick Blood Sugar was done which were in normal range. No other assessment was documented related to the resident's symptoms until 6:20 PM when the resident stated there was no relief from Tylenol which had been given and the resident asked to be sent to the emergency room . Review of nurse's notes dated 12/14/13 revealed at 3:25 AM, Resident #92 was noted with left-sided weakness to upper and lower extremities. VS were taken x1 and noted to be within normal range. No other nursing assessment was documented related to the symptoms presented. At 11:30 AM, Vital signs were taken and revealed the resident had an elevated temperature of 101.6. Tylenol was given and at that time the resident was unable to drink from a straw and was unable to respond verbally. No documentation of ongoing assessments related to the symptoms presented were noted. At 3:00 PM, Vital signs were taken, the resident's temperature was documented as 99.6. The resident continued to have left sided weakness and was non-verbal. The resident was sent to the hospital at 5:25 PM. During an interview on 2/28/14 at 12:43 PM with the Medical Director, he/she stated the nurse's should have acted in a more timely manner related to the symptoms presented by the resident. The facility admitted Resident #60 with [DIAGNOSES REDACTED]. Record review on 3/2/14 revealed a physician's orders [REDACTED]. Resident #60 did receive three doses of [MEDICATION NAME] DM Clear on 2/23/14 at 8:34 PM, 2/24/14 at 8:13 PM, and 2/26/14 at 6:23 AM. Review of nurse's notes did not reflect the resident had a cough or congestion from 2/4/14-2/26/14. Further review revealed there was no nursing assessments related to the resident's respiratory condition for the time period of 2/23/14-2/26/14. Review of the physician's progress notes for 2/26/14 revealed the resident presented with a head cold times four days; ?SOB(shortness of breath); Lungs were noted with expiratory wheezes sl(slight) decreased BS(breath sounds) bilat(bilaterally); URI(upper respiratory infection). The resident was hospitalized [DATE]. Review of the chest x-ray 2/26/14 listed the conclusion as "moderate cardiomegaly; consolidation left lower lobe with or without pleural effusion compatible with pneumonia; minimal consolidation right lower lobe." Additional information provided by the facility revealed conclusion of a comparison chest x-ray dated 2/28/14 listed "Cardiomegaly with possible mild left basilar opacity." A CT scan dated 3/4/14 indicated "marked cardiomegaly and some left lower lobe atelectasis secondary to cardiomegaly which corresponds to density on recent chest x-ray." On 3/2/14 at 12:37 PM, the Administrator and Director of Nursing was informed of no ongoing assessments related to the resident's respiratory status. The facility admitted Resident #40 with [DIAGNOSES REDACTED]. Record review of the resident's blood pressures for the months of December 2013, January 2014, February 2014, and March 2014 revealed multiple times the resident's diastolic blood pressures were over 90. Review of the current care plan for potential for elevated or decreased blood pressure related to [DIAGNOSES REDACTED]. Review of the nurse's notes from 12/9/13-2/2614 revealed no assessments related to the elevated blood pressures. An interview with the Nurse Consultant on 3/2/14 at 6:00 PM revealed there was no protocol for elevated blood pressures, you would use nursing judgement. Based on record review and interviews, the facility failed to assess Resident #1 adequately to determine the resident's medical condition and notify the physician of clinical changes to enable timely treatment, resulting in atelectasis/pneumonia. Review of the 8-5-13 Quarterly and 1-21-14 Annual Minimum Data Set (MDS) Assessments on 2-28-14 at 10:41 PM revealed that Resident #1 had Brief Interview for Mental Status (BIMS) scores of "15" and "14" respectively, indicating the resident was cognitively intact. The PHQ9 (mood) score was "0" and no behaviors were noted. Observation and documentation on the MDS revealed the resident was able to speak clearly, understand questions posed, and respond reasonably. The resident received a continuous tube feeding of Nepro at 35 milliliters (ml)/hour (hr) and water at 65 ml/hr. [DIAGNOSES REDACTED]. Review of Nurses Notes at 1:30 PM and physician's orders [REDACTED].#1 developed respiratory symptoms and was treated per standing and/or PRN (as needed) orders for [MEDICATION NAME] and [MEDICATION NAME] for "cough/congestion" 16 times over a period of 5-6 days without adequate assessment and physician notification to enable timely intervention. The physician was not advised of Resident #1's respiratory symptoms until the sixth day, at which time s/he was able to assess the resident and provide medical treatment. On 1-30-14 at 3:22 AM, the nurse documented that the resident could not sleep, was "up and fanning self with personal hand fan... proceeds to use call light again and again." There was no evidence of assessment done to determine the causal factor. Again at 6:45 AM, "Res(ident) awake and back on call light... checked on each time... When asked can I help you? Res looks up or around and comes up with something. Attempt to satisfy res. and leave out of room." The resident's behavior repeated, asking "a staff member to pull up her blankets...then ...pull the covers off..." Again there was no evidence of investigation/assessment to determine the cause of the behavior. Review of the January 2014 Medication Administration Record [REDACTED]. There was no reason for administration documented in the MAR, nor were there Nurses Notes documenting an assessment found for this time period. On 1-31-14 at 3:43 PM, the nurse documented: "Coughing and congestion noted this shift. [MEDICATION NAME] Clear administered per standing order with effectiveness noted... " A standing order was written on 1-31-14 for "[MEDICATION NAME] Clear 5 cc (cubic centimeters) via peg q (every) 4 h(ou)rs PRN (as needed) r/t (related to) cough/congestion x 7 days." The MAR indicated [REDACTED]. There was no evidence of vital signs taken or clinical assessment. "Cough/congestion" was noted in the nursing documentation repeatedly (2-1-14 at 2:16 AM, 8:19 PM, 11:50 PM; on 2-2-14 at 3:49 PM; on 2-3-14 at 1:41 am) with [MEDICATION NAME] noted as being administered as needed. There was no evidence of clinical assessment of the resident's condition included in any of these notes. Vital signs were monitored once on 2-2-14 and twice on 2-3-14. On 2-3-14 at 4:39 AM, "Resident had increased congestion and wheezes at 3:30 am...Gave PRN [MEDICATION NAME] treatment...effective. VS 165/83, 81, 20, 98.8, O2 (oxygen) sat(uration) 96%... Decreased wheezes and congestion noted..." There was no evidence of clinical assessment. On 2-4-13 at 1:09 AM and 4:55 PM, Resident #1 required PRN [MEDICATION NAME] for cough. There was no evidence of vital signs taken or clinical assessment. Review of the February 20l4 MAR indicated [REDACTED]*; on 2-4-14 at 9:10 AM and 9:40 PM; on 2-5-14 at 5:21 AM). [MEDICATION NAME] was administered on 2-2-14 at 4:07 AM, 2-3-14 at 4:03 AM, 2-4-14 at 6:20 PM, and 2-5-14 at 12:40 AM. Nurses Notes were reviewed for the above dates/times and failed to include VS and/or clinical assessment for Resident #1. On 2-5-14 at 6:52 AM, the nurse documented "Some wheezing and shortness of breath noted throughout the night, PRN [MEDICATION NAME] given. Cough and congestion noted, PRN cough med given... Resident very agitated..." A chest x-ray (CXR) was done per Nurses Notes and the attending physician was notified when s/he visited on 2-5-14. Results of the CXR done on 2-5-14 noted "Opacities are present in the lung bases... consistent with atelectasis, or, in the proper clinical context, pneumonia." The Physician's Progress Notes documented a "Cough x (times) ___ (the numbers "2" and "3" written on top of each other) days... Afebrile. VS stable... mild end exp(iratory) wheeze bilat(really)...CXR-atelectasis vs. (versus) pneumonia...mild pneumonia possible." physician's orders [REDACTED]." Review of the MAR indicated [REDACTED]. Vital Signs were requested on 2-28-14 for the period 1-30-14 through 2-5-14. Only one set of VS was recorded in the computerized vital sign record (2-2-14) for the requested time frame. During an interview on 3-1-14 at 7:56 AM, the corporate consultant (in the presence of the Administrator) reviewed the medical record, verified the lack of respiratory assessments and that only 3 sets of VS had been recorded over the 6 day period prior to physician notification and intervention. S/he verified lung sounds were noted as checked only once over the review period. When asked what s/he would expect to see documented with regard to an assessment, the Corporate Consultant stated s/he would expect VS, lung sounds, if the cough was productive or not, and a description of the secretions. When asked about physician notification, s/he stated it would depend on the assessment, but the physician should be notified immediately if there was a change of condition. During a telephone interview on 3-2-14 at 12:15 PM, the attending physician stated s/he was unaware that Resident #1 had experienced coughing/congestion and received PRN medication for 5-6 days prior to being seen on the routine monthly visit. S/he was not aware that staff had not adequately assessed the resident's respiratory status on an on-going basis. When asked what his/her expectations were, the physician stated s/he would expect the assessment to include lung sounds. The physician also noted s/he would expect to be notified earlier, within 2-3 days after the onset of symptoms. When questioned about pneumonia versus atelectasis, the physician stated s/he had treated the symptoms as pneumonia. The Saunders Nursing Drug Book 2008 states, under Nursing Considerations for administration of [MEDICATION NAME], page 635 to "Monitor rate, depth, rhythm, type of respiration; quality, rate of pulse. Assess hung sounds for ronchi, wheezing, rales... Observe for cyanosis..., retractions..., hand tremor. Evaluate for clinical improvement (quieter, slower respirations, relaxed facial expression, cessation of retractions)." Health Assessment for Nursing Practices, Second Edition, pages 363-385 refers to lung and respiratory system assessment including: frequency and characteristics of cough (dry or productive); accompanying symptoms (shortness of breath, chest pain or tightness, fever, stuffy nose, noisy respirations, hoarseness, gagging); color, consistency, odor of sputum; sweating; [MEDICAL CONDITION] of lower extremities; cyanosis; auscultation of breath sounds; breathing effort; and, chest expansion. Based on observations, full and/or limited record reviews, interviews, and review of the facility policies, it was determined on 2/28/14 at approximately 11:16 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility. The facility Administrator was informed of the Jeopardy on 2/28/12 at 11:20 AM. The Administrator provided an Allegation of Compliance (AOC) that was acceptable on 2/28/14 at 5:19 PM and the immediacy of the Immediate Jeopardy at F-157, F-272, F-309, F-490, and F-520 was removed but lowered in scope and severity to a "G". The AOC included the following: 1. Resident #92 was assessed per nurse with no ongoing medical concerns. MD notified of findings. Resident #1 assessed per nurse on 2/26/14, MD notified of findings and resident was transferred to hospital on [DATE]. 2. All resident's nurse's notes for the last twenty four hours were reviewed by RN Unit Managers using a resident condition audit tool and no other residents were identified with an acute change in condition such as signs and symptoms of acute [MEDICAL CONDITION] infarction and [MEDICAL CONDITION]. 3. Director of Nursing and Technical Education Director provided one on one education, including but not limited to acute [MEDICAL CONDITION] infarction and [MEDICAL CONDITION] signs and symptoms to all nurses including supervisory staff utilizing Mosby 4th edition Basic Geriatric Care and Acute Change in Resident Condition Policy on identification and assessment on acute changes in resident condition and MD/911 notification. Nurses will not be allowed to report to work until one on one education is provided. Nurses identified with deficient practice received one on one education and coaching/counseling form per Executive Director. Education will be provided to new hire employees in orientation and annually with staff competency evaluations. Unit Manager/RN Supervisor on weekend will monitor acute changes in condition daily utilizing the resident condition audit tool and will address acute changes in condition when identified with MD or 911 notification and nurses involved with deficient practice will receive one on one education and coaching/counseling as indicated. Identified nurse practitioner is no longer contracted with facility as of 1/15/14. MD is notified of any acute changes in resident condition. Policy for changes in a resident condition or status updated to include: If unable to reach MD/NP, call 911.

On the days of the survey, based on record review and interviews, the facility failed to ensure that 4 of 28 sampled residents reviewed received necessary care and services. Resident #1 with a respiratory condition not treated timely; Resident #35 pain medication not given as ordered; Resident #40 no interventions implemented for elevated blood pressures, and Resident #92 with a change in condition x 2 without timely interventions. The findings included: The facility admitted Resident #92 with [DIAGNOSES REDACTED]. Review of the Admission MDS(Minimum Data Set) dated 11/21/13 and the Readmission MDS dated [DATE] listed the resident as having a BIMS(Brief Interview for Mental Status) as 15. Review of the drug regimen for November 2013 revealed the resident was on no cardiac medications. Review of nurse's notes dated 11/27/13 revealed the following: At 5:30 PM, the resident complained of chest pain and left arm pain. The resident was alert and verbally responsive. Vital signs were taken and revealed a blood pressure of 129/80, pulse 58, respirations 18, and temperature of 97 with a pulse oximetry of 98% on room air. The resident exhibited clammy skin and some paleness was noted. A fingerstick blood sugar was done which registered 119. Tylenol was given. At 6:20 PM, Resident #92 voiced no relief and requested to go to the emergency room . Fifty minutes after the onset of symptoms, vital signs were taken which revealed a blood pressure of 140/85, pulse 68, respirations 18, temperature 97.2 and an oxygen saturation of 98% on room air. The resident's skin was warm and dry with no pallor. The Nurse Practitioner was notified and at 7:00 PM(one and one-half hour after onset of symptoms) the resident was transferred to the hospital. Resident #92 was admitted to the hospital on [DATE] with complaint of chest pain discharged to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nurse's notes dated 12/14/13 revealed the following: At 3:25 AM the resident's vital signs were blood pressure 97/60, pulse 78, respirations 20, temperature 97.5 with an oxygen saturation of 97%. Resident was noted on several attempts trying to stand up with assist. Resident #92 was observed with left-sided weakness to upper and lower extremities on this shift. The Nurse Practitioner was called times three attempts with no response. A message was left on the answering machine for the Nurse Practitioner. At 11:30 AM(eight hours after onset of left sided weakness), the resident's blood pressure was 106/64, pulse 86, respirations 18, and an elevated temperature was recorded as 101.6. The resident's oxygen saturation was 98%. Resident #92 was unable to drink through a straw. Weakness continued on the resident's left side and he/she was unable to respond verbally or lift left arm and/or left leg. The resident was placed in a posey chair at the nurse's station to be monitored. At 3:00 PM, the resident's blood pressure was 90/57, pulse 69, respirations 24, and temperature 99.2 with an oxygen saturation of 94% on room air. Resident remained non-verbal and with left sided weakness. The Nurse Practitioner was called at 3:08 PM and a message was left as to the status of the resident. At 4:13 PM, the facility received an order to transfer the resident to the emergency room (approximately twelve hours and 45 minutes after onset of symptoms). The resident was transferred to the hospital at 5:25 PM(fourteen hours after onset of symptoms). On 12/14/13, the resident was admitted to the hospital and discharged to the facility on [DATE] with discharge [DIAGNOSES REDACTED]. During an interview with Unit Manager #1 on 2/28/14 at 9:21 AM, he/she stated was aware of the incident on 11/27/13. He/she stated Tylenol was not an intervention for chest pain. And continued by stating using his/her nursing judgement would have tried to send resident out sooner. He/she was also aware of the incident on 12/14/13. He/she stated there was a schedule for physician's on call and nurse's can always call the physician on call if needed. He/she stated the incident on 12/14/13 should have been handled differently in that more thorough assessments should have been done and the issue should have been taken care of in a more timely manner. Stand up meetings are conducted and the 24-hour reports are reviewed and discussed related to residents and if they went to the hospital and why. At the time of the interview, Unit Manager #1 could not remember if he/she had reviewed the nurse's notes for the resident but his/her usual practice was to review nurse's notes. He/she continued by stating he/she could not remember if any inservices had been given related to a resident's change in condition. He/she stated when a resident had a change in condition the resident should be put on the 24-hour report and the physician should be notified. The Administrator on 2/28/14 stated complete notes were not available related to the stand up meetings. During and interview with the Director of Nursing on 2/28/14 at 9:48 AM, after reviewing the incident of 11/27/13, he/she stated that Tylenol was not an intervention for chest pain. He/she continued by stating the situation should have been looked into more thoroughly and would have assessed if the resident had a cough. He/she continued by stating Resident #92 when presenting something was not always clear while at other times he/she was very exact. He/she is not always clear where the pain is located and he/she is very adamant about what he/she wants. When asked should a resident have to ask to go to the emergency room , he/she stated I see what you are saying. After reviewing the notes for the 12/14/13 incident, the DON stated he/she read nurse's notes but could not remember when he/she read the notes for Resident #92. He/she continued by stating 911 should have been called related to the incident and the staff did not make the right judgement call. During an interview with LPN(Licensed Practical Nurse)#6 on 2/28/14, he/she stated that more documentation should have been done related to the incident on 11/27/13. Resident #92 was complaining with chest pain, arm pain, and was anxious. I did not think he/she was having a [MEDICAL CONDITION], I thought it was anxiety. He/she would get anxious around the time his/her medication is due. I was in and out of the room and when in the room with him/her, he/she even laughed with me. If I thought he/she was having a [MEDICAL CONDITION], I would have sent him/her out. The way the note reads it does present as symptoms of a [MEDICAL CONDITION]. He/she had never presented with all four signs before. During an interview with LPN #5 on 2/28/14 at 2:35 PM, after reading the nurse's note, he/she stated that weakness to upper and lower extremities were new for him. Whenever there is a change in condition we are to notify the FNP(Family Nurse Practitioner.) With this change, I did not think it was an emergency situation. I had had to hold his/her blood pressure medicines due to a low systolic blood pressure and that was why I was trying to reach the FNP. When we can not reach her, we leave a message. After the third attempt to reach the FNP, the resident appeared to be in stable condition so I passed the information to the oncoming shift. An interview on 2/28/14 at 5:18 PM with LPN #4 revealed he/she had received report from the previous nurse who had taken care of Resident #92 and had been informed of the left sided weakness. He/she continued by stating he/she knew of the previous [MEDICAL CONDITION] Infarction and the resident had gone down hill. He/she also stated he/she worked on an as needed basis and was not exactly aware of what the resident's specific condition was since readmission. He/she had contacted the nurse practitioner due to the resident's vital signs and oxygen saturation level going down and also due to the left sided weakness. When asked if he/she had known this was a new onset of left sided weakness, he/she stated would not have waited as long to call and if the NP could not be reached, 911 would have been called. On 2/28/14 at 12:43 PM, during an interview with the Medical Director, he/she stated remembering the resident being sent out and having had a [MEDICAL CONDITION] Infarction. The resident had a history of [REDACTED]. If a nurse observed a resident with chest pain, left arm pain, clammy and pale, the expectation would be the nurse would call the NP or physician on call, let them know of the resident's condition and give [MEDICATION NAME] if ordered. If the resident had an order for [REDACTED]. When asked what his/her expectation of the nurse during the event of 12/14/13 he/she stated if there was no response from the FNP, the nurse should have called the on call physician and should have done this in 15-20 minutes. The Medical Director was asked if he/she had any input in inservices as in nurses having problems recognizing symptoms and when to notify the physician, he/she stated if we knew there was a problem inservices would be done. To his knowledge this was the first time a problem had been found of this nature and continued by stating the facility needed to work on this, to let the nurses know what to do and not to just wait around. In his/her professional opinion: the nurse should have initiated the next step or called the FNP in a timely manner. An inservice was given by the facility on 1/25/13 which included nursing interventions and change in condition. The facility admitted Resident #35 with [DIAGNOSES REDACTED]. Review of the Admission MDS(Minimum Data Set) dated 12/27/13 revealed the resident's BIMS(Brief Interview for Mental Status) score was 14. Further review of the MDS revealed the resident frequently had pain; sometimes hard to sleep at night; limited day to day activities due to pain and on a scale of 0-10 scored a 9 for pain. Review of the care plan dated 1/17/14 revealed the resident was care planned for pain related to chronic pain in the right knee with approaches as follows: 1) Assist to reposition for comfort as needed 2) Observe and report patterns of pain and possible contributing factors 3) Handle gently and try to eliminate any environmental stimuli 4) Encourage to express fears and concerns 5) Administer medication as ordered 6) Instruct in relaxation techniques 7) Provide rest periods prn(as needed) 8) Consult MD if current drug regimen does not provide relief. Review of a partial Medication Drug Regime revealed the resident was on the following: December 2013- 1) [MEDICATION NAME] HCL 15 mg(milligrams) by mouth TID(three times per day); 2) Tylenol 325 mg give 650 mg q(every) 6 hours prn(as needed for pain. Do not exceed 3 grams in 24 hours; 3) [MEDICATION NAME] 10 mg by mouth at bedtime; 4) [MEDICATION NAME] 5% patch to right knee every hour sleep x 2 weeks(started 12/31/13). January 2014- 1) [MEDICATION NAME] 10 mg by mouth at bedtime; 2) [MEDICATION NAME] 300 mg by mouth at bedtime(started 1/15/14); 3) [MEDICATION NAME] discontinued 1/2/14 and [MEDICATION NAME] 100 mg twice a day x 4 weeks started 1/1/14; 4) [MEDICATION NAME] HCL 15 mg by mouth TID; 5) Tylenol 325 mg give 650 mg q 6 hours prn. February 2014- 1) [MEDICATION NAME] 10 mg by mouth at bedtime; 2) [MEDICATION NAME] 300 mg by mouth at bedtime; 3) [MEDICATION NAME] HCL 15 mg by mouth TID; 4) Tylenol 325 mg give 650 mg q 6 hours prn. Review of the MAR's(Medication Administration Records) revealed the following times as pain was documented but no documentation that prn Tylenol was given: 12/25/13 pain scale = 5 1/7 & 8/14 pain scale = 5 1/18/14 pain scale = 6 1/23/14 pain scale = 2 2/14/14 pain scale = 3 Per administration record, Tylenol was effective when given. During an interview on 2/25/14 at 3:02 PM, Resident #35 stated he/she had right foot/leg pain and pain medicine does not relieve it completely. He/she continued by stating the nurse knew about the pain and was going to bring it to the attention of the doctor. He/she also stated pain medicine was given in between the regular pain medicine he/she received. Review of physician and/or Family Nurse Practitioner notes revealed the following: 12/31/13 - the resident had multiple complaints- [MEDICAL CONDITION] Joint Disease Right Knee-Dementia. 1/15/14 - c/o burning pain and tingling to toes on right foot, worse at night. Stated it had been going on for a while but worsened last week. [MEDICATION NAME] given but reports that is not helping pain-[MEDICATION NAME] added. 1/22/14- wants pain meds increased but h/o substance abuse. 2/5/14- wants meds for nerves and pain. [MEDICATION NAME] added. Review of the nurse's notes from 12/20/13-3/1/14 revealed the resident had not voiced complaints of any pain. Review of the pain assessment dated [DATE] indicated the resident had back and joint pain which hurt a little. The measures that alleviate pain were listed as non-medical intervention, medications prescribed, rehab referral, and call MD. Review of Occupational Therapy notes dated 12/20/13-2/28/14 revealed the resident complained of pain in his/her left shoulder. On 2/26/14, the patient stated that neither the diathermy nor the ROM(Range of Motion) exercises were changing the pain level in the left shoulder. On 3/2/14 at 9:56 AM, the MAR's for December 2013, January 2014, and February 2014 were reviewed with the Nurse Consultant and the Administrator who confirmed there was no documentation that prn Tylenol was given as ordered on six occasions. On 3/2/14 at 10:00 AM, during an interview with the Unit Manager, he/she stated that he/she talked with the resident on a daily basis and he/she had not complained of any pain and certainly had not complained of continuous pain. He/she continued by stating that he/she did not know of anything which precipitated the pain and Tylenol appeared to take care of the break through pain. On 3/12/14 at 10:12 AM, LPN #9 stated he/she took care of the resident about one time per week. He/she continued by stating he/she did complain of leg pain and if it was not time for his/her scheduled pain medication, Tylenol was given which seemed to be effective. He/she describes the pain as a throbbing pain in leg and the toes sometime tingle. He/she will sometimes complain of a headache. He/she has never complained of shoulder pain. During the interview, LPN #9 stated he/she did not know what precipitated the pain, but that the resident got around really good. When he complains of leg pain, I check to see that the wrap is not too tight. If he/she is in bed, I elevate his/her leg and ask him/her to keep turning from side to side. The pain never impedes him from going around the facility. An interview was conducted on 3/2/14 at 10:31 with CNA #6 who stated he/she cared for the resident three times per week. He/she stated the resident never complained of pain but if he/she did would ask the resident how bad the pain was and notify his/her nurse. He/she continued by stating the resident was always happy. The facility admitted Resident #40 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]. December 2013 [MEDICATION NAME] XL 60 mg by mouth qd(every day) [MEDICATION NAME] 50 mg by mouth BID(twice daily) [MEDICATION NAME] ER 90 mg by mouth qd January 2014, February 2014, and March 2014 [MEDICATION NAME] 50 mg po(by mouth) BID [MEDICATION NAME] ER 90 mg po qd On 12/20/13 upon readmission to the facility, verbal orders did not list [MEDICATION NAME] XL 60 mg. Review of standing facility orders did not list parameters for blood pressure readings. Resident #40 did not have blood pressure parameters as to when to notify the physician. Record review on 3/1/14 of the MAR's(Medication Administration Records) for the months of December 2013, January 2014, February 2014, and March 2014 revealed elevated diastolic blood pressures above 90 as follows: December 2013- 12/9/13-10:00 AM-154/97 12/11/13- 9:00 PM-157/95 12/12/13- 9:00 PM-156/92 12/13/13-10:00 AM-201/119 12/17/13- 9:00 PM-163/92 12/23/13- 9:00 PM-180/97 12/24/13- 9:00 PM-167/91 12/25/13-10:00 AM-170/92 12/31/13-10:00 AM-165/100 January 2014- 1/1/14- 10:00 AM-177/100 1/1/14-9:00 PM-150/93 1/2/14-10:00 AM-153/96 1/3/14-10:00 AM-157/92 1/4/14- 10:00 AM- 151/92 1/4/14- 9:00 PM-157/98 1/7/14- 9:00 PM-159/91 1/8/14-9:00 PM-160/95 1/9/14-9:00 PM-167/96 1/10/14-10:00 AM-156/92 1/13/14-10:00 AM-151/99 1/15/14-9:00 PM-195/117 1/16/14-10:00 AM-156/93 1/17/14-10:00 AM-175/89 1/20/14-9:00 PM-157/99 1/22/14-9:00 PM-187/100 1/23/14-10:00 AM-165/97 1/25/14-9:00 PM-170/93 1/26/14-9:00 PM-153/92 1/28/15-10:00 AM-140/91 1/28/14-9:00 PM-165/95 1/29/14-9:00 PM-154/95 February 2014 2/1/14-10:00 AM-162/92 2/3/14-9:00 PM-141/92 2/6/14-9:00 PM-157/92 2/8/14-10:00 AM-173/93 2/8/14-9:00 PM-187/92 2/11/14-9:00 PM-151/91 2/14/14-10:00 AM-175/94 2/14/14-9:00 PM-170/92 2/15/14-10:00 AM-173/95 2/16/14-10:00 AM-153/95 2/17/14-10:00 AM-176/109 2/22/14-10:00 AM-174/91 2/24/14-10:00 AM-152/91 2/24/14-9:00 PM-151/92 2/25/14-10:00 AM-159/95 2/26/14-10:00 AM-170/96 2/28/14-10:00 AM-150/92 Review of nurse's notes revealed only one notification of the resident's elevated blood pressure dated 12/13/13. The FNP(Family Nurse Practitioner) was notified of the resident's elevated blood pressure and per orders for the nurse to monitor the blood pressure over the week-end. No further documentation was noted in the nurse's notes related to notifying the physician related to the continuing elevated blood pressures or assessment of the resident's condition at the time of the blood pressure monitoring. During an interview with the Nurse Consultant on 3/2/14 at 6:00 PM, he/she stated there was no facility protocol related to elevated blood pressures and staff would have use their nursing judgement. Based on record review and interviews, the facility failed to assess Resident #1 adequately to determine the resident's medical condition and notify the physician of clinical changes to enable timely treatment, resulting in atelectasis/pneumonia. Review of the 8-5-13 Quarterly and 1-21-14 Annual Minimum Data Set (MDS) Assessments on 2-28-14 at 10:41 PM revealed that Resident #1 had Brief Interview for Mental Status (BIMS) scores of "15" and "14" respectively, indicating the resident was cognitively intact. The PHQ9 (mood) score was "0" and no behaviors were noted. Observation and documentation on the MDS revealed the resident was able to speak clearly, understand questions posed, and respond reasonably. The resident received a continuous tube feeding of Nepro at 35 milliliters (ml)/hour (hr) and water at 65 ml/hr. [DIAGNOSES REDACTED]. Review of Nurses Notes at 1:30 PM and physician's orders [REDACTED].#1 developed respiratory symptoms and was treated per standing and/or PRN (as needed) orders for [MEDICATION NAME] and [MEDICATION NAME] for "cough/congestion" 16 times over a period of 5-6 days without adequate assessment and physician notification to enable timely intervention. The physician was not advised of Resident #1's respiratory symptoms until the sixth day, at which time s/he was able to assess the resident and provide medical treatment. On 1-30-14 at 3:22 AM, the nurse documented that the resident could not sleep, was "up and fanning self with personal hand fan... proceeds to use call light again and again." There was no evidence of assessment done to determine the causal factor. Again at 6:45 AM, "Res(ident) awake and back on call light... checked on each time... When asked can I help you? Res looks up or around and comes up with something. Attempt to satisfy res. and leave out of room." The resident's behavior repeated, asking "a staff member to pull up her blankets...then ...pull the covers off..." Again there was no evidence of investigation/assessment to determine the cause of the behavior. Review of the January 2014 Medication Administration Record [REDACTED]. There was no reason for administration documented in the MAR, nor were there Nurses Notes documenting an assessment found for this time period. On 1-31-14 at 3:43 PM, the nurse documented: "Coughing and congestion noted this shift. [MEDICATION NAME] Clear administered per standing order with effectiveness noted... " A standing order was written on 1-31-14 for "[MEDICATION NAME] Clear 5 cc (cubic centimeters) via peg q (every) 4 h(ou)rs PRN (as needed) r/t (related to) cough/congestion x 7 days." The MAR indicated [REDACTED].There was no evidence of vital signs taken or clinical assessment. "Cough/congestion" was noted in the nursing documentation repeatedly (2-1-14 at 2:16 AM, 8:19 PM, 11:50 PM; on 2-2-14 at 3:49 PM; on 2-3-14 at 1:41 am) with [MEDICATION NAME] noted as being administered as needed. There was no evidence of clinical assessment of the resident's condition included in any of these notes. Vital signs were monitored once on 2-2-14 and twice on 2-3-14. On 2-3-14 at 4:39 AM, "Resident had increased congestion and wheezes at 3:30 am...Gave PRN [MEDICATION NAME] treatment...effective. VS 165/83, 81, 20, 98.8, O2 (oxygen) sat(uration) 96%... Decreased wheezes and congestion noted..." There was no evidence of clinical assessment. On 2-4-13 at 1:09 AM and 4:55 PM, Resident #1 required PRN [MEDICATION NAME] for cough. There was no evidence of vital signs taken or clinical assessment. Review of the February 20l4 MAR indicated [REDACTED]*; on 2-4-14 at 9:10 AM and 9:40 PM; on 2-5-14 at 5:21 AM). [MEDICATION NAME] was administered on 2-2-14 at 4:07 AM, 2-3-14 at 4:03 AM, 2-4-14 at 6:20 PM, and 2-5-14 at 12:40 AM. Nurses Notes were reviewed for the above dates/times and failed to include VS and/or clinical assessment for Resident #1. On 2-5-14 at 6:52 AM, the nurse documented "Some wheezing and shortness of breath noted throughout the night, PRN [MEDICATION NAME] given. Cough and congestion noted, PRN cough med given... Resident very agitated..." A chest x-ray (CXR) was done per Nurses Notes and the attending physician was notified when s/he visited on 2-5-14. Results of the CXR done on 2-5-14 noted "Opacities are present in the lung bases... consistent with atelectasis, or, in the proper clinical context, pneumonia." The Physician's Progress Notes documented a "Cough x (times) ___ (the numbers "2" and "3" written on top of each other) days... Afebrile. VS stable... mild end exp(iratory) wheeze bilat(really)...CXR-atelectasis vs. (versus) pneumonia...mild pneumonia possible." physician's orders [REDACTED]." Review of the MAR indicated [REDACTED]. Vital Signs were requested on 2-28-14 for the period 1-30-14 through 2-5-14. Only one set of VS was recorded in the computerized vital sign record (2-2-14) for the requested time frame. During an interview on 3-1-14 at 7:56 AM, the corporate consultant (in the presence of the Administrator) reviewed the medical record, verified the lack of respiratory assessments and that only 3 sets of VS had been recorded over the 6 day period prior to physician notification and intervention. S/he verified lung sounds were noted as checked only once over the review period. When asked what s/he would expect to see documented with regard to an assessment, the Corporate Consultant stated s/he would expect VS, lung sounds, if the cough was productive or not, and a description of the secretions. When asked about physician notification, s/he stated it would depend on the assessment, but the physician should be notified immediately if there was a change of condition. During a telephone interview on 3-2-14 at 12:15 PM, the attending physician stated s/he was unaware that Resident #1 had experienced coughing/congestion and received PRN medication for 5-6 days prior to being seen on the routine monthly visit. S/he was not aware that staff had not adequately assessed the resident's respiratory status on an on-going basis. When asked what his/her expectations were, the physician stated s/he would expect the assessment to include lung sounds. The physician also noted s/he would expect to be notified earlier, 2-3 days after the onset of symptoms. When questioned about pneumonia versus atelectasis, s/he stated s/he treated the symptoms as pneumonia. The Saunders Nursing Drug Book 2008 states, under Nursing Considerations for administration of [MEDICATION NAME], page 635 to "Monitor rate, depth, rhythm, type of respiration; quality, rate of pulse. Assess hung sounds for ronchi, wheezing, rales... Observe for cyanosis..., retractions..., hand tremor. Evaluate for clinical improvement (quieter, slower respirations, relaxed facial expression, cessation of retractions)." Health Assessment for Nursing Practices, Second Edition, pages 363-385 refers to lung and respiratory system assessment including: frequency and characteristics of cough (dry or productive); accompanying symptoms (shortness of breath, chest pain or tightness, fever, stuffy nose, noisy respirations, hoarseness, gagging); color, consistency, odor of sputum; sweating; [MEDICAL CONDITION] of lower extremities; cyanosis; auscultation of breath sounds; breathing effort; and, chest expansion. Based on observations, full and/or limited record reviews, interviews, and review of the facility policies, it was determined on 2/28/14 at approximately 11:16 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility. The facility Administrator was informed of the Jeopardy on 2/28/12 at 11:20 AM. The Administrator provided an Allegation of Compliance (AOC) that was acceptable on 2/28/14 at 5:19 PM and the immediacy of the Immediate Jeopardy at F-157, F-272, F-309, F-490, and F-520 was removed but lowered in scope and severity to a "G". The AOC included the following: 1. Resident #92 was assessed per nurse with no ongoing medical concerns. MD notified of findings. Resident #1 assessed per nurse on 2/26/14, MD notified of findings and resident was transferred to hospital on [DATE]. 2. All resident's nurse's notes for the last twenty four hours were reviewed by RN Unit Managers using a resident condition audit tool and no other residents were identified with an acute change in condition such as signs and symptoms of acute [MEDICAL CONDITION] infarction and [MEDICAL CONDITION]. 3. Director of Nursing and Technical Education Director provided one on one education, including but not limited to acute [MEDICAL CONDITION] infarction and [MEDICAL CONDITION] signs and symptoms to all nurses including supervisory staff utilizing Mosby 4th edition Basic Geriatric Care and Acute Change in Resident Condition Policy on identification and assessment on acute changes in resident condition and MD/911 notification. Nurses will not be allowed to report to work until one on one education is provided. Nurses identified with deficient practice received one on one education and coaching/counseling form per Executive Director. Education will be provided to new hire employees in orientation and annually with staff competency evaluations. Unit Manager/RN Supervisor on weekend will monitor acute changes in condition daily utilizing the resident condition audit tool and will address acute changes in condition when identified with MD or 911 notification and nurses involved with deficient practice will receive one on one education and coaching/counseling as indicated. Identified nurse practitioner is no longer contracted with facility as of 1/15/14. MD is notified of any acute changes in resident condition. Policy for changes in a resident condition or status updated to include: If unable to reach MD/NP, call 911.

On the days of the Recertification and Extended Survey, based on record reviews, interviews, observations and review of the facility policies, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for residents with change in condition. The findings included: The Administration failed to ensure appropriate systems were in place to monitor notification of physician and/or responsible party, to perform timely and accurate nursing assessments to assure appropriate and timely interventions, to provide appropriate care and services as indicated with changes in condition, and to ensure that the Quality Assurance process was utilized to act on these system failures. Cross refer to F-157 related to untimely notification of the physician and/or responsible party on change of condition of residents Cross refer to F-272 related to assessment of residents adequately to determine the resident's condition and enable timely treatment appropriately Cross refer to F-309 related to delay in treatment to residents after failure of staff to assess residents exhibiting signs and symptoms of acute change in condition CFR refer F-520 related to facility Administration failure to ensure that the Quality Assurance process was utilized to identify, monitor and implement a plan of action related to identifying and acting in a timely fashion for changes in conditions of residents. Based on observations, full and/or limited record reviews, interviews, and review of the facility policies, it was determined on 2/28/14 at approximately 11:16 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility. The facility Administrator was informed of the Jeopardy on 2/28/12 at 11:20 AM. The Administrator provided an Allegation of Compliance (AOC) that was acceptable on 2/28/14 at 5:19 PM and the immediacy of the Immediate Jeopardy at F-157, F-272, F-309, F-490, and F-520 was removed but lowered in scope and severity to a "G". The AOC included the following: 1. Resident #92 was assessed per nurse with no ongoing medical concerns. MD notified of findings. Resident #1 assessed per nurse on 2/26/14, MD notified of findings and resident was transferred to hospital on [DATE]. 2. All resident's nurse's notes for the last twenty four hours were reviewed by RN Unit Managers using a resident condition audit tool and no other residents were identified with an acute change in condition such as signs and symptoms of acute [MEDICAL CONDITION] infarction and [MEDICAL CONDITION]. 3. Director of Nursing and Technical Education Director provided one on one education, including but not limited to acute [MEDICAL CONDITION] infarction and [MEDICAL CONDITION] signs and symptoms to all nurses including supervisory staff utilizing Mosby 4th edition Basic Geriatric Care and Acute Change in Resident Condition Policy on identification and assessment on acute changes in resident condition and MD/911 notification. Nurses will not be allowed to report to work until one on one education is provided. Nurses identified with deficient practice received one on one education and coaching/counseling form per Executive Director. Education will be provided to new hire employees in orientation and annually with staff competency evaluations. Unit Manager/RN Supervisor on weekend will monitor acute changes in condition daily utilizing the resident condition audit tool and will address acute changes in condition when identified with MD or 911 notification and nurses involved with deficient practice will receive one on one education and coaching/counseling as indicated. Identified nurse practitioner is no longer contracted with facility as of 1/15/14. MD is notified of any acute changes in resident condition. Policy for changes in a resident condition or status updated to include: If unable to reach MD/NP, call 911.

On the days of the Recertification and Extended Surveys, based on observations, interviews, record reviews, and review of facility policies, it was determined on 2/28/14 at approximately 11:16 AM that Immediate Jeopardy and/or Substandard Quality of Care existed for CFR 483.75 F-520 which was identified at a scope and severity of "K". Starting 11/27/13, the facility failed to identify quality deficiencies related to changes of condition of residents. The facility failed to identify that assessments were not being done and families and/or physicians were not being notified in a timely manner of changes in condition requiring medical intervention. No plans of action were developed for notification related to changes in condition. Failure of the QAA committee to identify and implement action plans to ensure resident assessment and timely notification with noted changes in condition resulted in immediate jeopardy for Residents #92, #40, and #1. In addition, although the facility identified concerns in 9-13 related to laboratory (lab) tests done without physician's orders [REDACTED]. The findings included: Based on record reviews, interviews, and review of quality assurance information provided by Licensed Practical Nurse #7, RN #1, and the Corporate Consultant, the facility failed to identify a concern related to physician notification of lab results and develop a plan of action to correct the deficient practice. Although labs were identified and reviewed in a Quality Assurance (QA) process, the specific area of physician notification was not identified. During an interview on 3-1-14 at 10:08 AM regarding notification of abnormal lab results for Resident #68, Registered Nurses #2 and #3 reviewed the medical record and confirmed there was no evidence of timely physician notification for multiple lab tests drawn and reported on 11-4-13. During an interview on 3-1-14 at 1:32 PM regarding timely notification of abnormal lab results for Resident #87, the Corporate Consultant reviewed the medical record and verified there was no evidence of physician notification in the Nurses Notes. S/he confirmed the delay in physician notification as documented on the 10-30-13 and 11-21-13 lab reports. During an interview on 3-1-14 at 430 PM, the Corporate Consultant reviewed the medical record and verified there was no evidence of physician notification of lab results in the Nurses Notes for labs reported on 3-7-13 and 9-25-13. S/he confirmed the delay in physician notification as documented on the lab reports. During an interview on 3-2-14 at 2:20 PM regarding notification of abnormal lab results for Resident #47, the Corporate Consultant verified that the physician had not been notified in a timely manner of abnormal lab results reported in 8-13. S/he confirmed that the lab due in 11-13 had not been done as ordered and stated that the facility had "QA'd labs". During an interview on 3-2-14 at 417 PM, Registered Nurse (RN) #1 reviewed the medical record and verified there was no evidence of physician notification of lab results in the Nurses Notes for Resident #25. S/he confirmed the delay in physician notification as documented on multiple reported results from 2-13 through 11-13 and also confirmed that one lab was not done as ordered in 12-13. RN #1 and Licensed Practical Nurse (LPN) #7 noted they were aware that the HgbAlc due in 8-13 had not been done as ordered. The LPN stated that they had QA'd missing labs and provided information that the HgbAlc had been done on 9-19-13. No results were provided, however, for the missing BMP due in 12-13. The 9-18-13 QA plan of action completed for "Labs done without evidence of written MD order August 14, 2013" provided by LPN #7 and RN #1 was reviewed with the Corporate Consultant. The Plan of Action noted the following: 1.) LPN UM (Unit Manager) obtained order from MD for 8-14-13 HgbAlc. COO and LPN UM reviewed Lab Book and lab was not checked to be drawn in August; 2.) 100% audit of all August labs to make sure drawn by UM; 3.) Lab tracker book implemented with UM and ward secretaries to monitor; 4.) Lab QA to be reviewed in upcoming QA/PI (Process Improvement) mtg. (meeting). Target Date: 10-31-13. The plan did not address staff education. The audit did not address the cited deficient practice-it addressed labs done according to orders, instead of labs drawn without orders. The plan did not address who would be responsible for or when information was to be entered into the tracker. The plan did not address who would review what specific data, how often it would be monitored for compliance, or how it would be documented. The Lab Tracker form included resident name, lab ordered, date drawn, date results received, and initial for when lab is placed on the chart. The form made no reference to physician notification or how monitoring would be done for labs drawn without orders, as the lab tracker form only addressed follow-up for written orders. When asked about follow-up to the plan, LPN #7 could provide no written documentation of subsequent compliance audits or evidence of ongoing monitoring to ensure continued compliance. There was no evidence that the action plan was followed. If adequate auditing and ongoing monitoring had been conducted routinely per a specific QA plan of action, the labs not done as ordered would have been identified and corrected for Residents #25 and #47. Just four months after lab audits were done as above noted, another QA plan of action was identified as needing to be implemented. On 3-2-14 at 4:27 PM, the Corporate Consultant and LPN #7 provided a 2-24-14 QA plan of action for review related to labs not done as ordered in January 2014. The plan stated: "MD made aware of labs not being obtained and order to obtain labs was given; 100% audit of labs per UM and Ward Clerks by target date of 3-7-14; Monthly lab audits done per UM and Ward clerks; QAPI team to review." The plan did not address staff education. The plan did not address who would be responsible for or when and what information was to be audited. The plan did not address who would review what specific data, how often it would be monitored for compliance, or how it would be documented. No changes were made to the Lab Tracker form. The form made no reference to physician notification or how monitoring would be done. Although the target date was listed as 2-28-14, there was no evidence provided that any part of the plan had been initiated. During an interview on 3-2-14 at 6 PM, the Corporate Consultant and Administrator presented a quality concern that had been identified and implemented regarding "Change of Condition" for one resident on 1-20-14. The plan of action stated: 1.) "DON (Director of Nursing) educate Nursing in huddle/huddle communication to always...document head to toe assessment with changes in resident condition and notify MD/RP (responsible party) timely; 2.) DON monitors documentation in EHR on a daily basis; 3.) DON to monitor change in condition documentation prn (as needed) from Daily Stand Up Mtg.; 4.) CCO to monitor documentation periodically for compliance." The Target Date was listed as 2-28-14. The Corporate Consultant reviewed the plan of action and verified that the plan did not include a method to determine if any other residents were affected by the deficient practice. When asked for documentation of implementation of the plan, there was no evidence of audits of current residents, review of 24 Hour Reports, documentation of daily review of Nurses Notes by the DON. Evidence of staff education was provided but failed to include timely physician notification of changes in condition. Attendance failed to include all applicable individuals. concern failed to be identified in a timely manner as evidence by Res 92. incidents. During an interview on 3-2-14 at 6:20 PM, the Corporate Consultant verified the staff had not identified timely physician notification of abnormal lab results as a quality care concern. S/he stated that s/he would have reviewed the 1-20-14 Change of Condition QA and audit on the target date of 2-28-14. The Consultant verified that the plan did not include who, what, when, where, how... and did not include specific review for compliance when & by whom. During an interview with the Nurse Consultant on 3/2/14, he/she confirmed the facility failed to identify changes in condition with delays in notification and treatment for [REDACTED]. Based on observations, full and/or limited record reviews, interviews, and review of the facility policies, it was determined on 2/28/14 at approximately 11:16 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility. The facility Administrator was informed of the Jeopardy on 2/28/12 at 11:20 AM. The Administrator provided an Allegation of Compliance (AOC) that was acceptable on 2/28/14 at 5:19 PM and the immediacy of the Immediate Jeopardy at F-157, F-272, F-309, F-490, and F-520 was removed but lowered in scope and severity to a "G". The AOC included the following: 1. Resident #92 was assessed per nurse with no ongoing medical concerns. MD notified of findings. Resident #1 assessed per nurse on 2/26/14, MD notified of findings and resident was transferred to hospital on [DATE]. 2. All resident's nurse's notes for the last twenty four hours were reviewed by RN Unit Managers using a resident condition audit tool and no other residents were identified with an acute change in condition such as signs and symptoms of acute [MEDICAL CONDITION] infarction and [MEDICAL CONDITION]. 3. Director of Nursing and Technical Education Director provided one on one education, including but not limited to acute [MEDICAL CONDITION] infarction and [MEDICAL CONDITION] signs and symptoms to all nurses including supervisory staff utilizing Mosby 4th edition Basic Geriatric Care and Acute Change in Resident Condition Policy on identification and assessment on acute changes in resident condition and MD/911 notification. Nurses will not be allowed to report to work until one on one education is provided. Nurses identified with deficient practice received one on one education and coaching/counseling form per Executive Director. Education will be provided to new hire employees in orientation and annually with staff competency evaluations. Unit Manager/RN Supervisor on weekend will monitor acute changes in condition daily utilizing the resident condition audit tool and will address acute changes in condition when identified with MD or 911 notification and nurses involved with deficient practice will receive one on one education and coaching/counseling as indicated. Identified nurse practitioner is no longer contracted with facility as of 1/15/14. MD is notified of any acute changes in resident condition. Policy for changes in a resident condition or status updated to include: If unable to reach MD/NP, call 911.

On the days of the Recertification and Extended Survey, based on observations, record reviews, review of the facility policy entitled "Changes in Resident's Condition and Status" and interviews, the facility failed to ensure that 6 of 28 sampled residents' physicians and/or responsible parties were notified and/or notified timely of residents' changes in condition requiring physician intervention. The facility failed to notify the physician in a timely manner when Resident #92 suffered two significant changes in medical condition, one involving cardiac symptoms, and one related to new onset of weakness and inability to speak. Resident #40 had multiple incidents of elevated blood pressures and one incident of a low blood sugar without interventions implemented and without physician notification. Although Resident #1 developed ongoing respiratory symptoms on 1-30-14, the physician and family were not notified until 2-5-14 of clinical changes, resulting in treatment for [REDACTED].#68's family of elevated blood sugars and weight loss requiring physician intervention. The physician and family were not notified in a timely manner when Resident #81 had blood sugar results of less than 60 that were not reported to the physician as ordered. Resident #56's wound worsened without evidence of physician notification. Resident #87's family was not notified when his/her [MEDICAL TREATMENT] clotted. The findings included: The facility admitted Resident #92 with [DIAGNOSES REDACTED]. Record review of the Nurse's Notes on 2/27/14 revealed that Resident #92 complained of chest pain and left arm pain on 11/27/13 at 5:30 PM. The resident's skin was clammy and some paleness was noted. Tylenol was given at that time. At 6:20 PM, Resident #92 voiced no relief from the Tylenol and requested to go to the emergency room . The FNP(Family Nurse Practitioner) was notified approximately fifty minutes after onset of symptoms and the resident was transferred to the hospital one and one-half hours after the onset of symptoms. Further review of the Nurse's Notes dated 12/14/13 at 3:25 AM revealed Resident #92 attempting to stand up unassisted on multiple occasions. The resident was noted with left sided weakness to upper and lower extremities during this shift. Three attempts were made to contact the Family Nurse Practitioner (FNP) with no response. At 11:30 AM, Resident #92 was noted with a temperature of 101.6 degrees. Resident #92 was unable to drink through a straw and juice was given through a straw using the droplet method. Weakness continued on the left side and the resident was unable to respond verbally nor could he/she lift his/her left arm and/or leg. The resident was placed in a posey chair by the nurse's station for monitoring. At 3:00 PM, the resident continued to have the same symptoms and at 3:08 PM another message was left for the FNP. At 4:13 PM, an order was received to send the resident to the hospital, approximately thirteen hours after the onset of symptoms. The responsible party was called at that time. During an interview with Unit Manager #1 on 2/28/14 at 9:21 AM, he/she stated there was an on call schedule for physicians and that the nurses on duty could always call the physician if needed. During an interview on 2/28/14 at 9:48 AM, the Director of Nursing (DON) stated, for the incidents related to Resident #92, s/he would have probably called the physician sooner. The facility admitted Resident #40 with [DIAGNOSES REDACTED]. Review of the Medication Administration Records (MAR's) on 3/1/14 for the months of December 2013, January 2014, and February 2014 revealed elevated diastolic blood pressures above 90 as follows: December 2013- 12/9/13-10:00 AM-154/97 12/11/13- 9:00 PM-157/95 12/12/13- 9:00 PM-156/92 12/13/13-10:00 AM-201/119 12/17/13- 9:00 PM-163/92 12/23/13- 9:00 PM-180/97 12/24/13- 9:00 PM-167/91 12/25/13-10:00 AM-170/92 12/31/13-10:00 AM-165/100 January 2014- 1/1/14- 10:00 AM-177/100 1/1/14-9:00 PM-150/93 1/2/14-10:00 AM-153/96 1/3/14-10:00 AM-157/92 1/4/14- 10:00 AM- 151/92 1/4/14- 9:00 PM-157/98 1/7/14- 9:00 PM-159/91 1/8/14-9:00 PM-160/95 1/9/14-9:00 PM-167/96 1/10/14-10:00 AM-156/92 1/13/14-10:00 AM-151/99 1/15/14-9:00 PM-195/117 1/16/14-10:00 AM-156/93 1/20/14-9:00 PM-157/99 1/22/14-9:00 PM-187/100 1/23/14-10:00 AM-165/97 1/25/14-9:00 PM-170/93 1/26/14-9:00 PM-153/92 1/28/15-10:00 AM-140/91 1/28/14-9:00 PM-165/95 1/29/14-9:00 PM-154/95 February 2014 2/1/14-10:00 AM-162/92 2/3/14-9:00 PM-141/92 2/6/14-9:00 PM-157/92 2/8/14-10:00 AM-173/93 2/8/14-9:00 PM-187/92 2/11/14-9:00 PM-151/91 2/14/14-10:00 AM-175/94 2/14/14-9:00 PM-170/92 2/15/14-10:00 AM-173/95 2/16/14-10:00 AM-153/95 2/17/14-10:00 AM-176/109 2/22/14-10:00 AM-174/91 2/24/14-10:00 AM-152/91 2/24/14-9:00 PM-151/92 2/25/14-10:00 AM-159/95 2/26/14-10:00 AM-170/96 2/28/14-10:00 AM-150/92 Review of nurse's notes revealed only one notification of the resident's elevated blood pressure, dated 12/13/13. The FNP was notified of the resident's elevated blood pressure and gave orders for the nurse to monitor the blood pressure over the week-end. On 12/10/13 at 8:45 PM, the resident was noted to be unresponsive to stimuli and the skin was cool and clammy. The fingerstick blood sugar was 25. [MEDICATION NAME] was administered. No documentation was noted that the physician or responsible party was notified of the low blood sugar and administration of [MEDICATION NAME]. The above was shared with the facility and no further documentation was provided. Review of the facility policy dated 4/2008 entitled "Changes in a Resident's Condition or Status" revealed under 1d. The Nurse Supervisor/Charge Nurse will notify the resident's attending physician or On Call Physician when there has been a significant change in the resident's physical/emotional/mental condition. Under section 2b, unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's responsible party when: There is a significant change in the resident's physical, mental or psychosocial status. Based on record review and interviews, the facility failed to assess Resident #1 adequately to determine the resident's ongoing respiratory condition and notify the physician in a timely manner of clinical changes, resulting in treatment for [REDACTED]. Review of the 8-5-13 Quarterly and 1-21-14 Annual Minimum Data Set (MDS) Assessments on 2-28-14 at 10:41 PM revealed that Resident #1 had Brief Interview for Mental Status (BIMS) scores of "15" and "14" respectively, indicating the resident was cognitively intact. The PHQ9 (mood/depression) score was "0" and no behaviors were noted. Observation and documentation on the MDS revealed the resident was able to speak clearly, understand questions posed, and respond reasonably. The resident received a continuous tube feeding of Nepro at 35 milliliters (ml)/hour (hr) and water at 65 ml/hr. [DIAGNOSES REDACTED]. Review of Nurses Notes at 1:30 PM and Physician's Orders at 3:10 PM on 2-28-14 revealed that Resident #1 developed respiratory symptoms and was treated per standing and/or PRN (as needed) orders for [MEDICATION NAME] and [MEDICATION NAME] for "cough/congestion" 16 times over a period of 5-6 days without adequate assessment and physician notification to enable timely intervention. The physician was not advised of Resident #1's respiratory symptoms until the sixth day, at which time s/he was able to assess the resident and provide medical treatment. The family was notified after the resident was seen by the physician and antibiotic therapy ordered. On 1-30-14 at 3:22 AM, the nurse documented that the resident could not sleep, was "up and fanning self with personal hand fan... proceeds to use call light again and again." There was no evidence of assessment done to determine the causal factor. Again at 6:45 AM, "Res(ident) awake and back on call light... checked on each time... When asked can I help you? Res looks up or around and comes up with something. Attempt to satisfy res. and leave out of room." The resident's behavior repeated, asking "a staff member to pull up her blankets...then ...pull the covers off..." Again there was no evidence of investigation/assessment to determine the cause of the behavior. There was no evidence of family or physician notification of this change in behavior/ medical condition. Review of the January 2014 Medication Administration Record [REDACTED]. There was no reason for administration documented in the MAR, nor were there Nurses Notes documenting an assessment found for this time period. On 1-31-14 at 3:43 PM, the nurse documented: "Coughing and congestion noted this shift. [MEDICATION NAME] Clear administered per standing order with effectiveness noted... " A standing order was written on 1-31-14 for "[MEDICATION NAME] Clear 5 cc (cubic centimeters) via peg q (every) 4 h(ou)rs PRN (as needed) r/t (related to) cough/congestion x 7 days." The MAR indicated [REDACTED]. There was no evidence of vital signs taken or clinical assessment. There was no evidence of family or physician notification of the change in condition requiring the implementation of standing orders. "Cough/congestion" was noted in the nursing documentation repeatedly (2-1-14 at 2:16 AM, 8:19 PM, 11:50 PM; on 2-2-14 at 3:49 PM; on 2-3-14 at 1:41 am) with [MEDICATION NAME] noted as being administered as needed. There was no evidence of clinical assessment of the resident's condition included in any of these notes. Vital signs were monitored once on 2-2-14 and twice on 2-3-14. On 2-3-14 at 4:39 AM, "Resident had increased congestion and wheezes at 3:30 am...Gave PRN [MEDICATION NAME] treatment...effective. VS 165/83, 81, 20, 98.8, O2 (oxygen) sat(uration) 96%... Decreased wheezes and congestion noted..." There was no evidence of clinical assessment. On 2-4-13 at 1:09 AM and 4:55 PM, Resident #1 required PRN [MEDICATION NAME] for cough. There was no evidence of vital signs taken or clinical assessment. Review of the February 20l4 MAR indicated [REDACTED]*; on 2-4-14 at 9:10 AM and 9:40 PM; on 2-5-14 at 5:21 AM). [MEDICATION NAME] was administered on 2-2-14 at 4:07 AM, 2-3-14 at 4:03 AM, 2-4-14 at 6:20 PM, and 2-5-14 at 12:40 AM. Nurses Notes were reviewed for the above dates/times and failed to include VS and/or clinical assessment for Resident #1. On 2-5-14 at 6:52 AM, the nurse documented "Some wheezing and shortness of breath noted throughout the night, PRN [MEDICATION NAME] given. Cough and congestion noted, PRN cough med given... Resident very agitated..." A chest x-ray (CXR) was done per Nurses Notes and the attending physician was notified when s/he visited on 2-5-14. Results of the CXR done on 2-5-14 noted "Opacities are present in the lung bases... consistent with atelectasis, or, in the proper clinical context, pneumonia." The Physician's Progress Notes documented a "Cough x (times) ___ (the numbers "2" and "3" written on top of each other) days... Afebrile. VS stable... mild end exp(iratory) wheeze bilat(really)...CXR-atelectasis vs. (versus) pneumonia...mild pneumonia possible." Physician's Orders were written for "[MEDICATION NAME] 750 mg (milligrams) PO (by mouth) q day X 1 w(ee)k." Review of the MAR indicated [REDACTED]. Vital Signs were requested on 2-28-14 for the period 1-30-14 through 2-5-14. Only one set of VS was recorded in the computerized vital sign record (2-2-14) for the requested time frame. During an interview on 3-1-14 at 7:56 AM, the corporate consultant (in the presence of the Administrator) reviewed the medical record, verified the lack of respiratory assessments and that only 3 sets of VS had been recorded over the 6 day period prior to physician notification and intervention. S/he verified lung sounds were noted as checked only once over the review period. When asked what s/he would expect to see documented with regard to an assessment, the Corporate Consultant stated s/he would expect VS, lung sounds, if the cough was productive or not, and a description of the secretions. When asked about physician notification, s/he stated it would depend on the assessment, but the physician should be notified immediately if there was a change of condition. During a telephone interview on 3-2-14 at 12:15 PM, the attending physician stated s/he was unaware that Resident #1 had experienced coughing/congestion and received PRN medication for 5-6 days prior to being seen on the routine monthly visit. The physician noted s/he would expect to be notified earlier, within 2-3 days after the onset of symptoms. When questioned about pneumonia versus atelectasis, the physician stated s/he had treated the symptoms as pneumonia due to clinical assessment. In a signed written statement provided after the Exit Interview dated 3-12-14, the physician stated s/he had treated the resident "because of the wheezes noted on his (her) exam..." The facility admitted Resident #68 with [DIAGNOSES REDACTED]. Based on record review and interview, the facility failed to notify Resident #68's family of changes in his /her medical condition (elevated blood sugars and weight loss) requiring physician intervention. Review of the 11-13 Medication Administration Records (MAR) on 3-1-14 at 8:39 AM revealed that Resident #68 had a blood sugar of 434 at 6 AM on 11-2-13. Further review revealed 11-2-13 Physicians Orders to "Give [MEDICATION NAME] 10 units SQ (subcutaneous) X1 dose r/t (related to) elevated BS (blood sugar)." There was no Nurses Note relating this incident and there was no evidence of family notification found in the record. Review of the MAR indicated [REDACTED]. Nurses Notes documented a recheck of 517. The Nurse Practitioner was notified and the resident was given 10 units of [MEDICATION NAME] Insulin. There was no evidence of family notification Continued review revealed that Resident #68 had a blood sugar of 494 at 6 PM on 11-20-13. Nurses Notes documented a recheck of 517. Six units of [MEDICATION NAME] Insulin were administered per Physicians Orders. There was no evidence of family notification. Review of the weight records on 3-1-14 at 9:40 AM revealed that Resident #68 had a significant weight loss of 9.3% from 10-31-13 (admission=123.5#) to 11-13-13 (112#). Physicians Orders were written on ll-24-13 for interventions including lab tests and supplements. There was no evidence found in the medical record that the family was notified. During an interview on 3-1-14 at 10:08 Am, Registered Nurses #2 and #3 reviewed the medical record and confirmed the concern related to notification. The 24 Hour Report Sheets were also reviewed by the nurses for notification without documentation found of notification. The facility admitted Resident #56 with the [DIAGNOSES REDACTED]. Review of Resident #56's medical record on 2/27/14 at approximately 9:50 AM revealed a Nurses Note dated 4/15/13 that noted: "Resident noted to have dark purplish discoloration of left lower leg. Area noted when weekly body audit done. Discolored area is approximately 10 centimeters (cm) x 6 cm." Further review of the resident's medical record revealed [REDACTED]. Thick white drainage and foul smelling odor noted. Warmth and redness present. MD notified and ordered a culture on wound." There was no indication that Resident #56's legal representative/Responsible Party (RP) was notified of the change in the resident's condition. During an interview with Unit Manager #1 on 2/28/14 at approximately 9:03 AM, s/he confirmed there was no documentation to indicate that Resident #56's RP was notified of the change in condition. The facility admitted Resident #81 with the [DIAGNOSES REDACTED]. Review of Resident #81's Cumulative Physician's Orders on 3/1/14 at approximately 9:50 AM revealed an order for [REDACTED].>) 400." Review of Resident #81's Nurses Notes on 3/1/14 at approximately 10:08 AM revealed an entry dated 12/23/13 which stated: "Resident noted alert, but stated his (her) sugar was dropping. He (she) stated he (she) felt like it was dropping. Blood sugar (BS) check result 40, given apple juice which res consumed. FSBS recheck and result 67." There was no documentation of Physician notification found in the medical record. Further record review revealed documentation on 12/31/13 that stated: "Called down to the residents room, noted resident responding, resident is able to speak and swallow. No sweating noted. FSBS result 30, given 8 ounce (oz) apple juice, rechecked bs-74." There was no documented Physician notification During an interview on 3/1/14 at approximately 11:32 AM, Licensed Practical Nurse (LPN) #4 confirmed there was no documentation to indicate that the Physician was notified of the low FSBS results. LPN #4 confirmed Resident #81's Physician's Order to notify of elevated or low FSBS. S/he stated that the nurse utilized the [DIAGNOSES REDACTED] Protocol. Review of the [DIAGNOSES REDACTED] Protocol with the revision date of 8/11 noted "To ensure adequate treatment and response to low blood sugar levels in all residents with or without exhibiting signs and symptoms of [DIAGNOSES REDACTED]. Procedure: (unless otherwise indicated per individual resident MD orders). 1) If blood sugar is 60 or less without s/sx of [DIAGNOSES REDACTED]:(a) observe closely, recheck if resident becomes symptomatic (b) If next meal is greater than 2 hours away, give 8 ounces of juice (c) Recheck FSBS in 30 minutes and if FSBS less than 60, notify MD. If blood sugar is 60 or less with signs or symptoms of [DIAGNOSES REDACTED] (decreased mental status, diaphoresis, palpitations and tremors): (a) If resident is alert/able to swallow: Give 8 ounces of juice or 15 grams Insta-Glucose sublingually and recheck blood sugar in 30 minutes after treatment and again in one hour and if FSBS remains below 80 call MD. (b) If resident is alert and is fed via tube: give 8 ounces of juice via tube and recheck blood sugar 30 minutes after treatment and again in one hour and if FSBS remains less than 80 after treatment. The facility admitted Resident #87 with [DIAGNOSES REDACTED]. Record review on 3/1/14 @ 8:18 AM revealed an entry in the Nurses Notes where the resident had a change in condition without indication that the RP was notified. On 11/30/13 "The resident left the facility to [MEDICAL TREATMENT] center, returned back to facility at 1 pm due to (d/t) clotted graft, no bruit or thrill noted upon auscultation and palpation. [MEDICAL TREATMENT] will notify nurse at Medford on further instruction." There was no documentation of RP notification. During an interview with Unit Manager #2 on 3/1/14, s/he confirmed there was no documentation to indicate the resident's RP had been notified. Based on observations, full and/or limited record reviews, interviews, and review of the facility policies, it was determined on 2/28/14 at approximately 11:16 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility. The facility Administrator was informed of the Jeopardy on 2/28/12 at 11:20 AM. The Administrator provided an Allegation of Compliance (AOC) that was acceptable on 2/28/14 at 5:19 PM and the immediacy of the Immediate Jeopardy at F-157, F-272, F-309, F-490, and F-520 was removed but lowered in scope and severity to a "G". The AOC included the following: 1. Resident #92 was assessed per nurse with no ongoing medical concerns. MD notified of findings. Resident #1 assessed per nurse on 2/26/14, MD notified of findings and resident was transferred to hospital on [DATE]. 2. All resident's nurse's notes for the last twenty four hours were reviewed by RN Unit Managers using a resident condition audit tool and no other residents were identified with an acute change in condition such as signs and symptoms of acute [MEDICAL CONDITION] infarction and [MEDICAL CONDITION]. 3. Director of Nursing and Technical Education Director provided one on one education, including but not limited to acute [MEDICAL CONDITION] infarction and [MEDICAL CONDITION] signs and symptoms to all nurses including supervisory staff utilizing Mosby 4th edition Basic Geriatric Care and Acute Change in Resident Condition Policy on identification and assessment on acute changes in resident condition and MD/911 notification. Nurses will not be allowed to report to work until one on one education is provided. Nurses identified with deficient practice received one on one education and coaching/counseling form per Executive Director. Education will be provided to new hire employees in orientation and annually with staff competency evaluations. Unit Manager/RN Supervisor on weekend will monitor acute changes in condition daily utilizing the resident condition audit tool and will address acute changes in condition when identified with MD or 911 notification and nurses involved with deficient practice will receive one on one education and coaching/counseling as indicated. Identified nurse practitioner is no longer contracted with facility as of 1/15/14. MD is notified of any acute changes in resident condition. Policy for changes in a resident condition or status updated to include: If unable to reach MD/NP, call 911.