Every finding on record at New Iberia Manor North

Based on record review, interview, and review of the facility's policy and procedure, the facility failed to ensure the resident's medical record contained an assessment of newly identified wounds for 1 (Resident #1) of 3 sampled residents.Findings:On 08/19/2026, a review of the facility's policy titled . Pressure Injury Prevention Program, with a last review date of 03/05/2026, read in part: Standard: All residents will be assessed for the risk of pressure injury development at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Procedure: 5. If a pressure injury/skin breakdown is identified, the following will be done a. If new area found - if pressure injury - complete new wound evaluation/assessment. If non-pressure area - complete new wound evaluation/assessment.Review of Resident #1's Electronic Health Record (EHR) revealed the resident was initially admitted to the facility on [DATE], with diagnoses that included, but were not limited to, other sequelae of cerebral infarction, unspecified protein-calorie malnutrition, and chronic kidney disease stage 3. On 08/17/2026 at 9:33 a.m., a phone interview was conducted with Resident #1's responsible party (RP). She stated that on 07/16/2026, Resident #1 was transferred to the hospital for his kidneys and was not really eating. The resident was admitted to the 8th floor on the same day, and the nurse conducted a full body assessment which revealed Resident #1 had wounds on his right heel and the side of his left ankle. She stated she called the facility's assistant director of nursing (ADON) on 07/23/2026 and was told by the ADON that the director of nursing (DON) had seen wounds on Resident #1 before his hospitalization on 07/16/2026.Review of Resident #1's Grievance from 07/23/2026 revealed the following in part: - A summary: ADON informed Social Service Worker that on 07/23/2026 resident's daughter called her stating that she was not aware that resident had multiple wounds here. DON explained that the wound was found immediately prior to sending him out. Review of Resident #1's EHR failed to reveal a wound assessment of Resident #1's newly identified wounds on 07/16/2026.On 08/17/2026 at 3:47 p.m., a joint interview was conducted with S1ADM and S2DON. S2DON stated she received an update from S4CNA on 07/16/2026 that Resident #1 had something on his right heel, S2DON confirmed she went to assess Resident #1 and saw his right heel was starting to form a DTI (deep tissue injury); it was deep purple in color and felt boggy. She also stated seeing some mild bruising on the outer side of the resident's left ankle, and she confirmed there was no documented evidence of the new wounds that she assessed on 07/16/2026. She stated that she should have recorded the assessment of Resident #1's wounds in the resident's medical records.

Based on interviews and record and policy reviews, the facility failed to immediately inform the resident's responsible party (RP) of a newly identified wound for 1 (Resident #1) of 3 sampled residents. Findings: On 08/19/2026, a review of the facility's policy titled Condition & MD-Family Notification, with a last revised date of 03/03/2026, read in part: Purpose: to ensure that resident's family and/or legal representative . are notified of resident changes that fall under the following categories: . a significant change in the resident's physical, mental or psychosocial status . examples of significant changes: . development of wounds.Review of Resident #1's Electronic Health Record (EHR) revealed the resident was initially admitted to the facility on [DATE], with diagnoses that included, but were not limited to, other sequelae of cerebral infarction, unspecified protein-calorie malnutrition, and chronic kidney disease stage 3. On 08/17/2026 at 9:33 a.m., a phone interview was conducted with Resident #1's RP. She stated that on 07/16/2026, Resident #1 was transferred to the hospital for his kidneys and was not really eating. The resident was admitted to the 8th floor on the same day, and the nurse conducted a full body assessment which revealed Resident #1 had wounds on his right heel and the side of his left ankle. The RP further stated that she was not aware of any wounds before Resident #1 was sent out to the hospital. She stated she called the facility's assistant director of nursing (ADON) on 07/23/2026 and was told by the ADON that the director of nursing (DON) had seen wounds on Resident #1 before his hospitalization on 07/16/2026 and that there must have been a miscommunication.Review of Resident #1's EHR failed to reveal evidence that Resident #1's RP was immediately notified of Resident #1's newly identified wounds discovered on 07/16/2026. Review of Resident #1's current comprehensive care plan revealed the following in part, initiated on 01/27/2026: I have potential for impairment of my skin integrity. with an intervention that read in part, Notify . RP of impairments of skin integrity. Review of Resident #1's Grievance from 07/23/2026 revealed the following in part: - A summary: ADON informed Social Service Worker that on 07/23/2026 resident's daughter called her stating that she was not aware that resident had multiple wounds here. DON explained that the wound was found immediately prior to sending him out and the phone call was not placed to discuss the wounds. On 08/17/2026 at 1:00 p.m., an interview was conducted with S4CNA. S4CNA stated that on 07/16/2026 (she was unsure what time), she noticed Resident #1's right heel was looking like it was about to form into a wound; it was a light purple color, and his skin was hard. S4CNA stated she saw this on 07/16/2026, before he was sent out to the hospital. S4CNA stated she immediately notified S2DON of her findings. On 08/17/2026 at 3:47 p.m., a joint interview was conducted with S1ADM and S2DON. S2DON stated she received an update from S4CNA on 07/16/2026 that Resident #1 had something on his right heel. S2DON confirmed she went to assess Resident #1 and saw his right heel was starting to form a DTI (deep tissue injury); it was deep purple in color and felt boggy. She also stated seeing some mild bruising on the outer side of the resident's left ankle. S2DON confirmed she did not notify Resident #1's RP of the discovery of the new wounds and stated she should have.

Based on observations, interviews, and record reviews, the facility failed to store and serve food in accordance with professional standards for food service safety, and to ensure sanitary conditions were maintained by failing to:ensure two ice scoops were properly stored;properly store and label food items in the dry storage, walk-in cooler, and walk-in freezer;ensure deep fryer was cleaned properly and timely;wear gloves when preparing pureed foods; andensure all temperatures were obtained and documented for breakfast, lunch, and dinner meals The facility had a census of 80 residents.Findings:Review of the facility's policy titled, Food Storage: Dry Goods, with a last reviewed date of 03/03/2026, read in part . Policy Statement: All dry goods will be appropriately stored in accordance with the FDA Food Code. Procedures. 5. All packaged and canned food items will be kept clean, dry, and properly sealed. 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate.Review of facility's policy titled, Food Storage: Cold Foods, with a last reviewed date of 03/03/2026 read in part. Policy Statement: All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedures.5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.On 06/22/2026 at 8:35 a.m., an initial tour of the facility's kitchen was conducted with S9Cook, who stated that he was responsible for the day's management of the kitchen.On 06/22/2026 at 8:39 a.m., an observation of the ice machine was conducted with S9Cook and revealed two ice scoops on top of the ice machine. S9Cook confirmed the two ice scoops were not stored properly and should have been placed in the designated holder and were not.On 06/22/2026 at 8:43 a.m., an observation of the dry storage area was conducted with S9Cook and revealed a large, opened bag of raisin bran. The bag was not labeled with the date and time it was opened nor the used by date. S9Cook confirmed that the bag of raisin bran was opened and not labeled with the date and time it was opened nor the use by date and should have been.On 06/22/2026 at 8:48 a.m., an observation of the walk-in cooler was conducted with S9Cook and revealed a pre-made salad. The lettuce was observed with brown discoloration and appeared wilted that indicated the food was spoiled. Further observation revealed the pre-made salad was not labeled with date and time it was prepared nor the use by date. S9Cook confirmed that the premade salad was expired and should have been discarded and was not. He also confirmed the premade salad was not labeled with the date and time it was prepared nor the use by date and should have been.On 06/22/2026 at 08:51 a.m., an observation of the walk-in freezer was conducted with S9Cook and revealed an open box that contained a large plastic bag of cheddar biscuits. The large plastic bag was not sealed, not labeled with the date and time it was opened, nor the use by date. S9Cook confirmed that the cheddar biscuits should be sealed. He also confirmed that the bag of cheddar biscuits was not labeled with the date and time it was opened nor the use by date and should have been.On 06/22/2026 at 8:55 a.m., an observation of the deep fryer was conducted with S9Cook and revealed a thick layer of debris and food residual on the right side of the fryer. The deep fryer's cooking oil collection area was observed with a thick layer of debris and large pieces of fried food material. S9Cook stated he was unsure when the last time the deep fryer was used, and confirmed the deep fryer was not cleaned and should have been.On 06/22/2026 at 10:51 a.m., an observation was conducted of S9Cook puree the lunch meal. S9Cook added white beans to the blender and was not wearing gloves. S9Cook confirmed that he was not wearing gloves and should have been.On 06/22/2026 at 11:17 a.m., an observation was conducted of S10DA puree the dessert for the lunch meal. S10DA added pieces of cake to the blender and was not wearing gloves. S10DA confirmed that she was not wearing gloves and should have been.On 06/23/2026 at 8:35 a.m., an interview and review of the facility's document titled, Service Line Checklist was conducted with S1ADM. S1ADM confirmed temperatures were not logged for the dinner meal on 06/03/2026 and 06/04/2026; not logged for the breakfast and lunch meals on 06/05/2026; not logged for the dinner meal on 06/06/2026, 06/07/2026, 06/08/2026, and 06/09/2026; not logged for the lunch meal on 06/10/2026; and not logged for the dinner meal on 06/11/2026 and should have been.

Based on observation, interviews, and record review the facility failed to maintain an infection prevention and control program as evidenced by:1.Staff failing to perform hand hygiene prior to and during tracheostomy care for Resident #8. 2.Staff failing to perform hand hygiene during medication administration on Hall B.Findings: Review of the facility's policy titled Handwashing/ Hand Hygiene, with a revision date of 04/16/2026, read in part: Indications for Hand Hygiene: 1. Hand hygiene is indicated: a. immediately before touching a resident; b. before performing an aseptic task (for example, . handling an invasive medical device); . d. after touching a resident; e. after touching the resident's environment; . 5. The use of gloves does not replace hand washing/ hand hygiene. Applying and Removing Gloves: 1. Perform hand hygiene before applying non-sterile gloves. 1. A review of Resident #8's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, traumatic subarachnoid hemorrhage with loss of consciousness and chronic respiratory failure. On 06/23/2026 at 3:15 p.m., an observation was made of S8LPN providing care to Resident #8. S8LPN got up from the nurse's station and went to Resident #8's room. S8LPN put on non-sterile gloves and entered the room. S8LPN did not perform hand hygiene upon entering the resident's room or prior to applying the non-sterile gloves. S8LPN lowered Resident #8's bed, repositioned the blanket on the resident, and then slid the resident up to the head of the bed. S8LPN then opened a sterile glove package and put sterile gloves on top of her non-sterile gloves. S8LPN did not remove her used gloves or perform hand hygiene. S8LPN proceeded to suction Resident #8's tracheostomy. On 06/23/2026 at 3:25 p.m., an interview was conducted with S8LPN. S8LPN confirmed she did not perform hand hygiene upon entering the resident's room or applying non-sterile gloves and she should have. S8LPN also confirmed she did not remove her non-sterile gloves and perform hand hygiene before she suctioned the resident, and she should have. On 06/23/2026 at 4:15 p.m., an interview was conducted with S3ADON/IP. S3ADON/IP stated all staff should perform hand hygiene prior to performing care for a resident. S3ADON/IP also stated S8LPN should have removed her non-sterile gloves after touching Resident #8's environment, performed hand hygiene, and then put on sterile gloves to perform the aseptic task of suctioning Resident #8's tracheostomy. 2. On 06/24/2026, a review of the facility's policy titled Medication Administration with a last reviewed and revised date of 03/05/2026, read in part: Purpose: To ensure medications are prepared, administered, and documented safely, accurately, and in accordance with prescriber orders and accepted nursing standards of practice .Infection Control: Staff follow established infection control practices during medication administration, including: Hand hygiene . On 06/23/2026 at 8:19 a.m., an observation was made of S4LPN during morning med pass on Hall B. S4LPN prepared and administered medications to Residents #31 and #87. She applied gloves each time she entered the resident's room to administer the medications, but did not sanitize/wash her hands before preparing the medications, nor before and after glove use. S4LPN confirmed she did not perform appropriate hand hygiene during the observation of med pass to Residents #31 and #87, and stated she should have. On 06/23/2026 at 4:45 p.m., an interview was conducted with S3ADON/IP. She stated that appropriate hand hygiene included sanitizing hands between patient care and before/after glove use. S3ADON/IP stated S4LPN did not follow the facility's hand hygiene policy.

Based on observations, interviews and record review, the facility failed to ensure a person-centered care plan was implemented for each resident, by failing to implement physician's orders for compression stocking/socks for 1(Resident #13) of 32 sampled residents.Findings:Review of Resident #13's admission record revealed he was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, peripheral vascular disease; type 2 diabetes mellitus with hyperglycemia and atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs.Review of Resident #13's Annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 04/28/2026, revealed he had a Basic Interview for Mental Status (BIMS) score of 15, indicating his cognition was intact.Review of Resident #13's physician orders revealed an order written on 04/27/2026 which read, Please apply compression stocking/socks during the day. Take off at night. Review of Resident #13's June 2026 Medication/Treatment Administration Record (MAR/TAR) revealed no documented evidence that staff was applying the resident's compression stockings/socks.On 06/22/2026 at 9:15 a.m., an observation was made of Resident #13. The resident was sitting in his wheelchair with bilateral feet and lower legs exposed. The resident was not wearing compression stockings/socks.On 06/23/2026 at 8:59 a.m., an interview and an observation of Resident #13's lower extremities was conducted with S13TX. The resident was sitting in his wheelchair with his lower extremities exposed, revealing no compression stockings/socks being worn. S13TX confirmed Resident #13 was not wearing compression stockings/socks.On 06/24/2026 at 8:25 a.m., an interview was conducted with S14PTA who stated that she was aware that Resident #13 struggled with swelling in his legs. S14PTA stated that the resident had never worn compression stockings to therapy.On 06/24/2026 at 8:34 a.m., a third observation of Resident #13 revealed the resident's lower legs and feet remained swollen, and he was not wearing compression stockings/socks. The resident stated he had a pair of compression socks some time ago (unable to state date), but they got dirty and staff had not given him another pair.On 06/24/2026 at 8:47 a.m., an interview was conducted with S6CNA who was assigned to Resident #13. She stated she had never seen the resident wearing compression stockings/socks.On 06/24/2026 at 8:50 a.m., an interview and review of Resident #13's physician orders was conducted with S5LPN/MR who was assigned to the resident. She confirmed the resident had an order for compression stockings/socks to be worn during the day time and he had not been wearing them. S5LPN/MR stated that the resident should have been wearing his compression stockings/socks as ordered. On 06/24/2026 at 8:58 a.m., an interview and review of Resident #13's physician orders was conducted with S3ADON/IP. She confirmed the resident had an order for compression stockings and stated that he should have been wearing them.

Based on observations, interviews, and record review, the facility failed to ensure that services provided met professional standards, as evidenced by the nurse leaving medication at a resident's bedside to self-administer for 1 (#4) of 1 resident investigated for respiratory care.Findings:Review of the facility's policy titled, Medication Administration with a reviewed and revised date of 03/05/2026, read in part, Resident Self-Administration: Residents may self-administer medications only if the physician and interdisciplinary team determine the resident has the cognitive and physical ability to do so safely, and the care plan reflects this determinationReview of Resident #4's End of PPS (Prospective Payment System) Part A Stay MDS (Minimum Data Set) dated 03/24/2026 revealed she was admitted to the facility on [DATE]. Her BIMS (Brief Interview of Mental Status) was 15, indicating that the resident was cognitively intact.Review of Resident #4's electronic medical record revealed her active diagnoses include, but not limited to, acute on chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease, and chronic respiratory failure with hypoxia. On 06/22/2026 at 10:15 a.m., a review of Resident #4's June 2026 MAR (Medication Administration Record) revealed the following medication: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG (milligram)/3ML (milliliter) --3 ml inhale orally every 4 hours as needed for SOB (Shortness of Breath) or Wheezing.Review of Resident #4's care plan revealed she was care planned for altered respiratory status/difficulty breathing related to Chronic respiratory failure with hypercapnia, other specified interstitial pulmonary diseases, and a history of tobacco abuse with possible underlying COPD (chronic obstructive pulmonary disease). Interventions include, but not limited to the following: Document how many minutes it took to administer respiratory/nebulizer treatment after treatment has been administered, and Administer medication/puffers as ordered. Monitor for effectiveness and side effects.On 06/22/2026 at 9:35 a.m., an observation was made of Resident #4's nebulizer machine on her bedside table with a clear liquid in the nebulizer canister. Resident #4 stated that the clear liquid in the canister was her nebulizer treatment medication. She stated that the nurse left it there for her to take later. She stated that the nurses usually leave the treatment there for her to take and come back later to make sure she took the treatment. On 06/22/2026 at 10:15 a.m., Resident #4 was observed lying in bed with her nebulizer treatment in progress. Resident #4 was asked if she had turned on the nebulizer machine to administer her treatment. Resident #4 stated, Yes.On 06/22/2026 at 1:30 p.m., a review of Resident #4's electronic medical record revealed no documentation that the resident was evaluated to self-administer her own medications. On 06/24/2026 at 4:35 p.m., an interview was conducted with S8LPN. She confirmed that she had left the resident's nebulizer treatment next to her bed on 06/22/2026 during the morning medication pass. S8LPN stated that the resident was supposed to turn on the nebulizer machine to administer her treatment. When asked if Resident #4 had been screened to self-administer her own medications, S8LPN stated Resident #4 was not able to administer her own medications. When asked if she was aware if the resident had taken her nebulizer treatment, she stated, I'm not sure because I didn't go back to the resident's room to make sure the resident had taken the treatment. S8LPN stated that she should have applied the resident's treatment mask and turned on her nebulizer machine before she left the resident's room, and she should have returned to the resident's room to ensure that the resident received her treatment. On 06/24/2026 at 11:30 a.m., an interview was conducted with S2DON. She agreed that the nurses should not leave medication at a resident's bedside for the resident to take if that resident had not been evaluated to self-administer their own medications. She stated that she believed that Resident #4 had a self-administration screening done, and she would try to find it. On 06/24/2026 at 1:50 p.m., an interview was conducted with S2DON. S1ADM was present. S2DON was asked if she had found Resident #4's self-administration screening form. She stated that she did not have a chance to look for it yet.On 06/24/2026 at 3:45 p.m., S2DON failed to provide documented evidence that Resident #4 was screened to self-administer her medications prior to the exit of the survey.

Based on observations, record reviews, and interviews the provider failed to carry out Activities of Daily Living (ADL) for 1 (#8) resident out of 5 residents reviewed for ADLs in a sample of 32 residents.Findings:Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, with a revision date of 03/03/2026, read in part: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Review of Resident #8's Electronic Health Record (EHR) revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, traumatic subarachnoid hemorrhage with loss of consciousness, chronic respiratory failure, and diffuse traumatic brain injury with loss of consciousness. A review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] in section C: Brief Interview for Mental Status (BIMS) Should Brief Interview for Mental Status be Conducted: No (resident is rarely/ never understood). Further review revealed in section GG: Functional Abilities- dependent for personal hygiene.Review of Resident #8's care plan revealed the following: The resident has an ADL self-care performance deficit r/t (related to) traumatic subarachnoid hemorrhage persistent vegetative state. Intervention: Shave resident facial hair daily as needed.On 06/22/2026 at 9:38 a.m., an observation was conducted of Resident #8. Resident #8's chin area was covered with thick black facial hair. The resident was unable to state her concerns about the facial hair.On 06/23/2026 at 3:15 p.m., an observation was conducted of Resident #8 with S8LPN. S8LPN confirmed resident #8 had overgrown, thick black facial hair above her upper lip, on both cheeks, on her chin, and on her neck. S8LPN confirmed Resident #8 was dependent on staff for ADL's that included shaving. S8LPN confirmed Resident #8 should have been shaved by the certified nursing assistants daily as needed. On 06/23/2026 at 3:25 p.m., an interview was conducted with S12CNA. S12CNA confirmed that Resident #8 had overgrown, thick black facial hair and needed to be shaved. S12CNA confirmed Resident #8 had not been shaved on 06/22/2026 or 06/23/2026 and needed to be shaved. On 06/24/2026 at 12:45 p.m., an interview was conducted with S1ADM. S1ADM stated she discussed Resident #8's ADL care with S12CNA and confirmed that Resident #8 had not been shaved on 06/22/2026 or 06/23/2026.

Based on record reviews and interviews, the facility failed to ensure ongoing communication and collaboration with the dialysis facility through use of dialysis communication forms for 1 (Resident #61) of 32 sampled residents.Findings:On 06/25/2026, a review of the facility's policy titled, Dialysis Management Policy with a last reviewed date of 03/12/2026, read in part, Coordination with Dialysis Providers: The facility will maintain appropriate communication and coordination with the dialysis provider.Review of Resident #61's electronic health record (EHR) revealed that he was admitted to the facility on [DATE], with diagnoses that included, but were not limited to end stage renal disease and dependence on renal dialysis.A review of Resident #61's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed: Section O - Special Treatments, Procedures, and Programs revealed the resident was receiving dialysis.A review of Resident #61's comprehensive care plan initiated on 09/19/2022, revealed the resident needs hemodialysis related to end stage renal disease. Interventions read in part, dialysis 3 days a week on Monday, Wednesday, and Friday at a contracted dialysis agency.A review of Resident #61's Dialysis Communication Record form located in the resident's EHR from May 2026 to the present. The EHR revealed no documented evidence of Dialysis Communication Record form on 05/22/2026, 05/25/2026, 05/27/2026, and 06/05/2026.On 06/23/2026 at 3:07 p.m., an interview was conducted with S4LPN. She stated Resident #61 attended dialysis Monday, Wednesday and Friday. She stated prior to dialysis, a dialysis communication form is completed and returned to her when the resident arrived back from dialysis. After the dialysis communication form was reviewed it was then put into the black container next to her desk and then S5LPN/MR scanned it into the EHR. She confirmed this was the facility's way to maintain ongoing communication with the contracted dialysis agency, and all forms should have been completed and in the EHR. On 06/23/2026 at 3:17 p.m., an interview was conducted with S5LPN/MR. She stated she was the one who retrieved the forms from the black container at the nurse's station, ensured all forms were completed, and scanned the forms into the EHR. A record review was conducted with S5LPN/MR at this time, and reviewed dialysis communication forms from May 2026 to present. S5LPN/MR confirmed there were several forms missing, and she needed time to check her office to make sure the forms were not in there. On 06/23/2026 at 4:10 p.m., an interview and record review was conducted with S5LPN/MR. S5LPN/MR was coming out of Resident #61's room, and she stated she was making sure Resident #61 did not have any dialysis communication forms in his possession. She stated she found some forms but was still missing some and she could call the dialysis center to retrieve the rest of Resident #61's dialysis communication forms. She confirmed there were dialysis communication forms missing on 05/22/2026, 05/25/2026, 05/27/2026, and 06/05/2026, and confirmed these forms should have been completed and in the facility for review and were not. On 06/23/2026 at 4:25 p.m., a joint interview with S1ADM and S2DON. S2DON stated dialysis communication forms were completed by the nurse before dialysis, reviewed by the nurse upon arrival back to the facility, and placed in the black container for medical record to scan into the EHR. She confirmed after dialysis the communication forms should have been completed and in the EHR to maintain collaboration and communication with the dialysis facility.

Based on observation and interview, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles by failing to ensure 1 (Med Cart A) of 2 medication carts inspected were free of loose pills.Findings:On 06/24/2026, a review of the facility's policy titled Storage of Medications with a last reviewed date of 06/24/2025, read in part: Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation .2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received.On 06/24/2026 at 9:54 a.m., an inspection of the Med Cart A with S7LPN and S3ADON/IP revealed 12 loose pills in the medication cart drawers. They both confirmed the loose pills and acknowledged they were not appropriately stored. On 06/24/2026 at 9:57 a.m., S2DON observed the 12 loose pills that were removed from Med Cart A and acknowledged that loose pills should not have been in the medication cart.

Based on record reviews, observations, and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles as evidenced by having medication labels and physician orders that did not reflect the correct route of administration for 2 (#28, #54) out of 2 (#28, #54) residents whose physician orders and medication labels were reviewed. Findings: Resident #28 Review of resident #28's medical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Dysphagia, Aphasia, and Gastrostomy Status. Review of resident #28's medical record revealed a Quarterly MDS assessment with an ARD (Assessment Reference Date) of 01/29/2025, which read in part . Section K. Nutritional Approaches .Feeding Tube .was indicated. Review of physician orders dated May 2025 for resident #28 revealed the following: 1. Atorvastatin Calcium Tablet 20 mg (milligrams), give 20 mg by mouth at bedtime 2. Metoprolol Tartrate Tablet 25 mg, give 1 tablet by mouth two times a day 3. Gabapentin Capsule 100 mg, give 1 capsule by mouth three times a day On 05/13/2025 at 12:59 p.m., while observing S5LPN (Licensed Practical Nurse) during medication administration, an observation of the label on the blister pack of Resident #28's medications revealed the following: 1. Atorvastatin Calcium Tablet 20 mg, give 1 tablet per tube at bedtime 2. Metoprolol Tartrate Tablet 25 mg, give 1 tablet by mouth twice daily 3. Gabapentin Capsule 100 mg, give 1 capsule by mouth three times a day Resident #54 Review of resident #54's medical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Dysphagia, Aphasia, and Gastrostomy Status. Review of resident #54's medical record revealed a Quarterly MDS assessment with an ARD (Assessment Reference Date) of 02/08/2025, which read in part . Section K. Nutritional Approaches .Feeding Tube .was indicated. Review of physician orders dated May 2025 for resident #54 revealed the following: Ascorbic Acid (Vitamin C) Tablet 500 mg, give 1 tablet by mouth two times a day. On 05/13/2025 at 1:29 p.m., while observing S5LPN during medication administration, an observation of the label on the OTC (over the counter) medication revealed the following: Vitamin C 500 mg tablet. On 05/13/2025 at 2:29 p.m., an interview with S2DON (Director of Nursing) confirmed the labels on the blister packs of medications were labeled for administration by mouth for Metoprolol and Gabapentin, and by tube for Atorvastatin. S2DON also confirmed the label on the OTC was labeled for administration by mouth. On 05/14/2025 at 2:35 p.m., an interview and record review was conducted with S2DON who confirmed Resident #28 and Resident #54 received all medications via peg (percutaneous endoscopic gastrostomy) and there was a discrepancy with medication labels, and physician orders and should not have been.

Based on observations and interviews, the facility failed to maintain a clean and sanitary kitchen, as evidenced by: 1. Equipment: A. Build-up of debris and brown substance inside the conventional oven and the inside of the oven doors. 2. Food storage: A. Walk-in Refrigerator 1. A container of Roux (thickening agent for cooking) not labeled with the date it was opened. 2. A container of chopped garlic with an expiration date of [DATE]. B. Walk-in Freezer 1. A bag of beef patties not labeled with the date it was opened. C. Dry Storage 1. One dented canned good. 2. A bag of pasta not labeled with the date it was opened. D. Main Kitchen: 1. Three bags of bread were not labeled with the date it was opened. 3. S4DC (Dietary Cook) without a hair restraint while in the kitchen. This deficient practice had the potential to affect 75 residents who consumed food from the kitchen. Findings: A review of the facility's undated policy titled, Sanitization, with a last revision date of ,d+[DATE], revealed, in part, the food service area shall be maintained in a clean and sanitary manner . 1. Fixed equipment will be routinely cleaned and maintained . 3. Food contact equipment will be cleaned and sanitized after every use. A review of the facility's undated policy titled, Food Preparation and Service, with a last revision date of ,d+[DATE], revealed, in part, food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. A review of the facility's undated policy titled, Dry Storage, with a last review date of ,d+[DATE], revealed, in part, all expired food items must be removed . All dented cans must be removed . If an item is opened, the food must be tightly sealed. It should be dated with the date that it was opened . Bags of bread products should be closed and dated with the date that it was opened. On [DATE] at 8:27 a.m., an initial tour was conducted with S1ADM (Administrator). She confirmed that all opened food items should have been labeled with the date it was opened, all expired items should be discarded, dented cans should not be in the dry storage room, and the conventional oven should have been cleaned. On [DATE] at 8:54 a.m., an observation of S4DC was conducted. S4DC was prepping lunch, and her hair was down and exposed. It was not completely in a hair restraint while in the kitchen. On [DATE] at 11:00 a.m., a second observation of S4DC was conducted. S4DC was checking food temperatures on the steam table with her hair down and exposed. On [DATE] at 1:07 p.m., an interview was conducted with S1ADM. She confirmed that kitchen staff's hair should be completely covered with hair restraints at all times while in the kitchen.

Based on observations, record review and interviews, the facility failed to ensure a resident's (#34) indwelling urinary catheter drainage bag was positioned off the floor for 1 (#34) out of 2 (#34 and #48) residents investigated for urinary catheter. The total census was 78 residents. Findings: Review of the facility's policy with a review date of 01/01/2024 and a revised date of March 2024, titled, Catheter Care, Urinary read in part .Infection Control: .2. b. be sure the catheter tubing and drainage bag are kept off the floor. Record review revealed Resident #34 was admitted to the facility on [DATE] with the following diagnoses in part, Encounter for palliative care, Encounter for prophylactic measures, unspecified, and Alzheimer's disease. Review of Resident #34's care plan revealed she was care planned for indwelling catheter. On 05/13/2025 at 11:00 a.m., Resident #34's urinary catheter drainage bag was observed out of the blue privacy bag on the floor under the resident's bed. On 05/13/2025 at 11:05 a.m., an observation and interview was conducted with S5LPN (Licensed Practical Nurse). She confirmed that Resident 34's urinary catheter bag was on the floor and out of the blue privacy bag. She stated it should have not been on the floor.

Based on observations, interview and record review, the facility failed to ensure residents unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for 1 (#44) out of 33 sampled residents. The facility had a census of 78. Findings: Review of the facility's policy with a revision date of February 2018 titled, Fingernails/Toenails, Care of read in part, Purpose: the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .General Guidelines, 1. Nail care includes daily cleaning and regular trimming. Review of Resident #44's clinical record revealed that she was admitted to the facility on [DATE]. Her diagnoses include, in part, Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, Diffuse traumatic brain injury with loss of consciousness of unspecified duration, Tracheostomy and gastrostomy status. Review of Resident #44's annual MDS (Minimum Data Set) dated 04/16/2025 revealed the resident had a BIMS (Brief Interview for Mental Status) of 99, indicating the resident was not able to complete the interview. She was dependent on staff for personal hygiene. Review of Resident #44's plan of care revealed she was care planned for ADL (Activities of Daily Living) self-care performance deficit. Interventions included in part, nail care prn . On 05/14/2025 at 10:50 a.m., an observation and interview was conducted with S7CNA (Certified Nursing Assistant). S7CNA removed the covering from Resident #44's hands. The resident's fingernails on both hands were long and untrimmed. A brown substance was observed under the right thumb nail. S7CNA confirmed that the resident's fingernails on both hands were long and untrimmed and there was a brown substance under the resident's right thumb nail. When asked who was responsible for cleaning and trimming the resident's nails, S7CNA stated the shower aid should have cleaned the resident's nails when she showered her this a.m. She also stated that she was unsure who was responsible for trimming the resident's nails. On 05/14/2025 at 11:00 a.m., an observation and interview was conducted with S2DON (Director of Nursing) and S8CN (Corporate Nurse). They both confirmed that the Resident #44's fingernails needed to be trimmed and there was a brown substance under her right thumb nail.

Based on observations, record review, and interviews, the facility failed to develop and implement a person-centered care plan for 1 (#72) out of 1 (#72) sampled resident reviewed for respiratory care by: 1. Failing to follow physician's orders for changing nebulizer treatment tubing every week; and 2. Failing to follow physician's orders for respiratory prior and after orders when administering nebulizer treatments Findings: On 05/14/2025, a review of facility's policy, titled Administering Medications through a Small Volume (Handheld) Nebulizer, with a last revision date of October 2010, revealed in part .Documentation .The following information should be recorded in the resident's medical record .2. The date, time, and length of treatment .5. Pulse, respiratory rate and lung sounds before and after the treatment .8. The resident's tolerance of treatment . Review of Resident #72's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Chronic Obstructive Pulmonary Disease (COPD) and shortness of breath. Review of Resident #72's May 2025 physician's order revealed the following orders dated 11/14/2024: Albuterol Sulfate Nebulization Solution 2.5 mg (milligram)/3 ml (milliliter) 0.083% 3 ml, inhale orally via nebulizer every 8 hours for shortness of breath related to COPD; Change nebulizer treatment tubing q (every) week every night shift every Sun (Sunday). Further review revealed the following orders dated 12/05/2024: Respiratory prior orders: Document number of respirations, pulse per minute, breath sounds prior to administering breathing/nebulizer treatment. Document breath sounds: (1) Normal (2) Abnormal; Respiratory after orders: Document how resident tolerated breathing/nebulizer treatment. G-Good, F-Fair, P-Poor; Document how many minutes it took to administer respiratory/nebulizer treatment after treatment has been administered. Document # (number) of min (minutes) it took to administer treatment; and Document pulse/heart rate, respiratory rate, lung sounds after treatment is completed. Document lung sounds (1) Normal (2) Abnormal. Review of Resident #72's care plan read in part .The resident has altered respiratory status/difficulty breathing r/t (related to) SOB (shortness of breath). Interventions included: Change nebulizer treatment tubing q week .Document how many minutes it took to administer respiratory/nebulizer treatment after treatment has been administered .Document pulse/heart rate, respiratory rate, lung sounds after treatment is complete . Respiratory after orders: Document how resident tolerated breathing/nebulizer treatment. G-Good, F-Fair, P-Poor . Respiratory prior orders: Document number of respirations, pulse per minute, breath sounds prior to administering breathing/nebulizer treatment . Review of Resident #72's May 2025 MAR (Medication Administration Record) revealed the following: Documentation indicated that Albuterol Sulfate nebulization solution was administered on the dates of 05/01/2025-05/13/2025 at 6:00 a.m., 2:00 p.m., and 10:00 p.m. and on the date of 05/14/2025 at 6:00 a.m. and 2:00 p.m. Further review revealed no documentation on these dates that indicated the respiratory prior or after orders were completed. Further review of Resident #72's May 2025 MAR revealed no documentation on 05/11/2025 that changing of the resident's nebulizer treatment tubing was changed. On 05/14/2025 at 3:03 p.m., an interview and record review was conducted S2DON (Director of Nursing). She reviewed Resident #72 May 2025 MAR and confirmed the resident's nebulizer treatment tubing was not changed as ordered on 05/11/2025, and the orders prior and after nebulizer treatments were not completed as ordered in May 2025.

Based on observation, record review, and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessment was completed accurately for 1 (#40) of 1 resident investigated for hospice services out of a finalized sample of 33 residents. Findings: Review of Resident #40's electronic health record revealed the resident was admitted to the facility on [DATE]. Review of Resident #40's current May 2025 physician's orders revealed an order dated 04/04/2025 to admit to Hospice provider related to protein cal (calorie) malnutrition dx (diagnosis). Review of the resident's significant change MDS assessment dated [DATE] revealed under Section J-Health Conditions, prognosis - Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months, was answered No. On 05/14/2025 at 3:50 p.m., an interview was conducted with S6MDS (Minimum Data Set Nurse) who verified Resident #40 started hospice services on 04/04/2025 and should have been coded under Section J prognosis as yes, and was not.

Based on observations, interviews and record reviews, the facility failed to ensure there was a sufficient number of Certified Nurse Aides (CNAs) and Shower Aides to provide services in accordance with resident care plans for 1 (Resident #2) of 4 (Residents #1 - #3, and R1) sampled residents. The facility's census was 76. Findings: On 04/15/2025, a review of the facility's policy titled Activities of Daily Living (ADL), Supporting with a revision date of 03/2018 read in part, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good .grooming and personal and oral hygiene. Policy Interpretation and Implementation .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) . Resident #2 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to metabolic encephalopathy and morbid obesity. Review of Resident #2's quarterly (Minimum Data Set) MDS dated [DATE] revealed the client had a Brief Interview for mental Status of 15, which indicated her cognition was intact. Further review revealed in section GG that the resident required substantial/maximal assistance to shower/bathe self. Review of Resident #2's care plan revised on 12/09/2024 revealed a focus area which stated The resident has an ADL self-care performance deficit, and interventions which included substantial maximal assistance to shower/bathe. During an interview with Resident #2 on 04/14/2025 at 9:43 a.m., she stated her shower days were on Monday, Wednesday, and Friday at 9:30 a.m., or 10:30 a.m. The Resident stated it was short staffed every day. She stated that her last shower was on Wednesday of last week (04/09/2025). Resident #2 stated she didn't get a shower on Friday (04/11/2025) because her CNA said they were short staffed. During a follow up interview with Resident #2 on 4/15/25 at 1:08 p.m., the resident stated she did not receive a shower on 03/21/2025 and 03/24/2025. A review of the whirlpool schedule and electronic shower log revealed Resident #2 did not receive her showers as stated above. On 04/14/25 at 12:15 p.m., an interview and review of CNA staffing for April 2025 was conducted with S2DON (Director of Nursing) and S1ADM (Administrator). S2DON confirmed there were only 3 CNAs listed on the schedule for the day shift (04/14/2025) to cover the facility. S2DON stated S3CNA (Certified Nursing assistant), who was scheduled for the shower room, was pulled to work on the floor. S4CNASup (Certified Nursing Assistant Supervisor), and S5RA (Restorative Aide) were assigned to work the floor. S2DON confirmed that if there was no shower aide, the CNAs were responsible for ensuring the residents receive a shower. On 04/14/2025 at 12:20 p.m., an observation of the shower room was conducted with S1ADM and S2DON. S2DON opened the door revealing a dry and unused shower room with shower chairs stored in the shower area behind the curtain. S1ADM and S2DON both confirmed the shower room was not used on the day shift. On 4/14/2025 at 12:26 p.m., an interview and observation of the shower room was conducted with S4CNASup. She stated the residents should have gotten a shower on Friday (04/11/2025) and today (04/14/2025). During the observation of shower room with S4CNASup, she confirmed the room was dry with shower chairs stored behind the shower curtain. S4CNASup confirmed the shower room was not used on the day shift. On 04/14/2025 at 12:34 p.m., an interview was conducted with S3CNA. S3CNA stated she was pulled from the shower room today to work as a CNA on the floor. S3CNA confirmed she did not shower any residents today and that included the ones she was pulled to provide care for. She stated she did not have the time. On 04/14/2025 at 12:36 p.m., an interview was conducted with S6CNA and S4CNASup. S6CNA stated she worked the shower room on 04/11/2025 by herself. S6CNA stated there were 5 aides and herself working that day. She stated she did not shower Resident #2 or any resident who required 2 person assistance because the aides were supposed to bring them to the shower room and help her, but they did not. S4CNASup stated if there was only one shower aide the CNAs were supposed to take the residents who needed assistance to the shower room and assist the shower aide. On 04/14/2025 at 3:18 p.m., an interview was conducted with S7CNA. She stated she worked in the shower room on 03/21/2025 and 03/24/2025. She confirmed Resident #2 had not received a shower on 03/21/2025 and on 03/24/2025. She stated Resident #2 was mad on 03/24/2025 but she could not bathe the resident by herself because she required 2 person assistance. On 04/14/25 at 4:06 p.m., an interview was conducted with S8CNA. She stated that the facility doesn't provide enough help. She stated that today (04/14/2025) they pulled her from the shower room to work on the floor before she was able to shower any resident. On 04/15/2025 at 12:48 p.m., an interview was conducted with S2DON and S1ADM. S1ADM confirmed that there were missed and undocumented scheduled showers identified.

Based on record review and interviews, the facility failed to ensure residents were free from verbal abuse for 1 (Resident #1) out of 5 (Resident #1, Resident #2, Resident #3, Resident #R1, and Resident #R2) sampled residents investigated for abuse. Findings: On 12/03/2024, a review of the facility's manual titled, Abuse Prohibition Policy with a last revision date of 05/17/2024, read in part: Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. The policy also indicated verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging or derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Review of Resident #1's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Cerebral Infarction, Aphasia, and Dementia. Review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was incomplete indicating he was unable to participate in this portion of the MDS. Review of a witness statement dated: 11/11/2024 by S3SSD (Social Service Director) read, Resident #2 informed S3SSD that his roommate was mistreated. Resident #2 stated that Resident #1 was making a grunting noise and the male CNA (Certified Nursing Assistant) told Resident #1 to shut up twice. The third time that Resident #1 made the noise, the male CNA said shut up and Resident #2 heard a slapping noise twice. Resident #2 said that this happened on Friday or Saturday night. Resident #2 stated that he was laying down in bed so he did not see where the CNA slapped Resident #1 but he heard the slapping noise twice . Review of Resident #2's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 15 indicating his cognition was intact. Review of a witness statement dated: 11/12/2024 by S4CNA read, I, S4CNA, around last week (Thursday or Friday), Resident #1 was resistant to care. He is usually calm when he takes his medication but that day was fighting, hitting his hands and pushing his hands away. He stopped and waited until he calmed down. I did not notify the nurse because he calmed down eventually. On the allegation of telling him to shut up, I might have done that because it was out of reflex . On 12/02/2024 at 12:59 p.m., an interview was conducted with Resident #2. Resident #2 stated the night of the incident was either on 11/07/2024 or 11/08/2024, he did not remember exactly what night. He stated his roommate (Resident #1) was nonverbal and only made grunting noises which made him vulnerable. He stated a male CNA entered their room and walked to Resident #1's side of the room. Resident #2 stated he was not able to see what was going on due to the privacy curtain drawn in between them, but he was able to hear the male CNA and Resident #1. Resident #1 made a grunting noise then he heard the male CNA say shut up. He stated Resident #1 made another grunting noise then he heard the male CNA say shut up. He stated the resident made a grunting noise for a third time and he heard the male CNA say shut up again then heard a slapping noise at the same time. Resident #2 stated the male CNA said shut up with an attitude and it sounded like the CNA was expressing frustration towards Resident #1 due to the CNA's harsh tone of voice. He stated he notified S3SSD of the incident a few days later. On 12/02/2024 at 1:08 p.m., an observation was made of Resident #1. Resident #1 was awake and laying down in his bed. Attempted to interview Resident #1, but he was only able to respond by making grunting noises, and was therefore unable to be interviewed. On 12/02/2024 at 1:17 p.m., an interview was conducted with S3SSD. She stated during her morning rounds on the residents Resident #2 (Resident #1's roommate) notified her that he was worried about his roommate. He stated a male CNA that worked either on Thursday 11/07/2024 or Friday 11/08/2024 night came into their room while he was awake. He stated to her the male CNA walked over to Resident #1's side of the room, Resident #1 made a loud grunting sound, and the male CNA said shut up. Resident #1 grunted a few more times and the CNA told Resident #1 to shut up. Resident #1 grunted again and the CNA told him to shut up then heard slapping noises. Resident #2 reported that he was unable to see the incident due to a privacy curtain between the two residents. S3SSD stated she reported this to S2DON (Director of Nursing) and S1ADM (Administrator). She stated S1ADM was able to determine the male CNA that Resident #2 was speaking of was S4CNA. On 12/02/2024 at 2:45 p.m., an interview was conducted with S1ADM. She stated she was told by S3SSD that Resident #2 heard a male CNA tell Resident #1 to shut up and heard a slapping noise. She stated she was able to narrow it down to Friday 11/08/2024, and determined the male CNA was S4CNA. S1ADM interviewed S4CNA who stated he might have said shut up to Resident #1, but it was out of reflex. S1ADM confirmed saying shut up is against professionalism and company policy. On 12/03/2024 at 8:44 a.m., a phone interview was conducted with S4CNA who confirmed he was a previous employee at the facility. Questions were asked regarding these incidents. The phone line was abruptly disconnected. On 12/03/2024 at 11:10 a.m., an interview was conducted with S2DON. Resident #2 notified her of an incident while she was doing morning rounds. She interviewed Resident #2 with S3SSD present when he reported he overheard a male CNA giving care on the other side of the room telling Resident #1 to shut up, but could not see what was going on. She stated Resident #2 told her that the male CNA seemed short with Resident #1. She stated S4CNA saying shut up to the resident was inappropriate.

Based on observations, interviews, and record reviews, the facility failed to ensure that their medication error rate was less than five percent, by failing to administer medications at the right time for 4 of 4 (#16, #41, #53, and #67) residents observed during morning medication pass. This deficient practice had the potential to affect a census of 74 residents. Findings: On 05/15/2024, a review of the facility's policy titled Administering Medications with a revision date of 04/05/2024, read in part: Policy heading: Medications are administered in a safe and timely manner, and as prescribed .3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions .7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . A review of the facility's medication pass schedule revealed Med Pass Times: Culture Times .BID (twice a day): 6 a.m. (before noon) - 11 a.m., 7 p.m. (after noon) - 10 p.m. TID (three time a day): 6 a.m. - 11 a.m., 12 p.m. - 1 p.m., 7 p.m. - 10 p.m . On 05/13/2024 beginning at 11:07 a.m., an observation was made of S18LPN (Licensed Practical Nurse) during morning medication pass on Hall W. As she was preparing the resident's medications, the EMARs (Electronic Medical records) revealed the following residents' names highlighted in red which indicated the medications were being administered late: Resident #16: Resident #16 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Cardiomyopathy, Chronic Diastolic Heart Failure and Essential Primary Hypertension. A review of current physician's orders revealed an order for Carvedilol tablet 3.125mg (milligrams) two times a day related to Essential Primary Hypertension. A review of the medication audit report revealed on 05/13/2024, Carvedilol tablet 3.125 mg was scheduled to be given at 7:00 a.m., but was administered by S18LPN at 12:18 p.m. Resident #41 Resident #41 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Unspecified Atrial Fibrillation, Unspecified Diastolic Congestive Heart Failure, and Anxiety Disorder. A review of current physician's orders revealed an order for Xanax Tablet 0.5 mg. Give 1 tablet by mouth two times a day for anxiety related to Anxiety Disorder. Further review revealed an order for Buspirone HCL (Hydrochloride) tablet 10 mg. Give 1 tablet by mouth two times a day related to Anxiety Disorder. A review of the medication audit report revealed that on 05/13/2024, Xanax Tablet 0.5 mg, and Buspirone HCL Tablet 10mg were scheduled to be given at 7:00 a.m., but were administered by S18LPN at 11:34 a.m. Resident #53 Resident #53 was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, Central Cord Syndrome at C2 Level of Cervical Spinal Cord, Central Cord Syndrome at C4 Level of cervical Spinal Cord, Neuralgia and Neuritis, Pain, and Legal Blindness. A review of current physician's orders revealed orders for Gabapentin capsule 100 mg Give 1 capsule by mouth three times a day for nerve pain related to Neuralgia and Neuritis, Timolol Maleate Ophthalmic Solution 0.5% (percent) Instill 1 drop in left eye two times a day for Intraocular pressure, and Docusate sodium capsule 100 mg. Give 1 capsule by mouth two times a day related to constipation. A review of the medication audit report revealed that on 05/13/2024, Gabapentin capsule 100 mg, Timolol Ophthalmic solution 0.5% and Docusate Sodium capsule 100mg were to be given between 6 a.m. to 11 a.m., and were administered by S18LPN at 12:56 p.m. Resident #67 Resident #67 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to Hypertensive Heart Disease with Heart Failure, Type 2 Diabetes Mellitus without Complications, Atherosclerosis of Coronary Artery Bypass Graft (s) without Angina Pectoris, Vitamin Deficiency, and Critical Illness Myopathy. A review of current physician's orders revealed orders for Apixaban Oral Tablet 5 mg. Give 1 tablet by mouth two times a day related to Atherosclerosis of Coronary Artery Bypass Graft without Angina Pectoris, Jardiance Oral Tablet. Give 1 tablet by mouth one time a day related to Type 2 Diabetes Mellitus with Unspecified Complications, Magnesium Oxide Tablet 400 mg. Give 1 tablet by mouth two times a day related to Vitamin Deficiency, and Metformin HCL Oral Tablet 500 mg. Give 2 tablets by mouth two times a day related to Type 2 Diabetes Mellitus. A review of the medication audit report revealed that on 05/13/2024, Apixaban Oral Tablet 5 mg, Magnesium Oxide Tablet 400 mg, Jardiance Oral Tablet 25 mg, and Metformin HCL oral Tablet 500 mg were scheduled to be given at 7:00 a.m., but were administered by S18LPN at 11:47 a.m. On 05/13/2024 at 12:13 p.m., an interview was conducted with S18LPN. She stated that morning medication pass was between 6:00 a.m. and 11:00 a.m., but she was late for work this morning and reported it to the S3DONIP (Director of Nursing/Infection Control) and S4ADON (Assistant Director of Nursing). S18LPN confirmed all the medications listed above were administered late. On 05/14/2024 at 7:59 a.m., an interview was conducted with S3DONIP and S4ADON. S4ADON stated she worked the night shift on 05/12/2024 and was also on call. She confirmed that S18LPN called to inform her that she was running late for work. S4ADON stated that when she was leaving on 05/13/2024 at 9:30 a.m., S18LPN was just doing her narcotic count. S3DONIP stated that she became aware on 05/13/2024 at 7:18 a.m. that S18LPN was running late for work. She further stated that she was informed by S18LPN on 05/13/2024 at 3:00 p.m. that the medications were late. S3DONIP stated S18LPN should have informed her that residents' medications were going to be late, but she did not.

Based on record review, and interviews, the facility failed to ensure the Nurse Practitioner (NP): 1. Re-evaluated Resident # 66's urinary tract infection symptoms after lab (laboratory) results were received for 1(#66) of 3 residents (#66, #35, #52) investigated for UTI (Urinary Tract Infection); and 2. Responded to staff reporting a change in medical status for 2 (#66, #326) of 2 residents (#66, #326) investigated for UTI and Pain. This deficient practice had the potential to affect 73 residents that reside at the facility. Findings: 1. Resident #66 Review of Resident #66's electronic record revealed an admitted [DATE] with diagnoses that included Major Depressive Disorder. Review of Resident #66's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident's cognition was intact. Review of a S15NP's Progress Note dated 03/26/2024 revealed that Resident #66 was assessed for a chief complaint of frequency with urination with slight burning. S15NP ordered a Urinalysis (UA) C/S (Culture and Sensitivity) to be collected on the morning of 03/27/2024. Review of nurse's note created by S21LPN on 03/26/2024 revealed new orders noted per S15NP UA with C/S in the A.M. Review of UA results collected on 03/26/2024 revealed Trace Blood, Positive Nitrites, and Moderate Bacteria. No Culture and Sensitivity was initiated. On 05/14/2024 at 3:00 p.m., an interview was conducted with Resident #66. The resident reported that she had been having burning with urination and frequency with urination for the last couple of days. She also stated months ago, she was having similar urinary symptoms. She stated she did not see the NP, but the nurse did collect her urine. She stated no one reported the results of her urine sample until she asked the nurse and who told her that she did not have an infection. Resident #66 stated no one, including the S15NP, asked her if her symptoms continued. She states she then treated the symptoms herself with a supply of AZO (medication for urinary pain relief) that she had in her purse. When she ran out of her AZO supply she reported her symptoms were better but returned again a couple of days ago. On 05/15/2024 at 1:12 p.m., an interview was conducted with S15NP along with a review of his progress notes from 03/26/2024 to present date. He verified that he was aware of the UA results from 3/26/2024. He stated he could not recall relaying the results to her nor following up on her symptoms, but he should have. He also verified that there was no documentation from him regarding the UA results received on 03/26/2024 addressing her symptoms until 5/14/24. 2. Resident #66 Review of Section D of Resident #66's Quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed that the resident answered yes to feeling down, depressed or hopeless nearly every day. Section D also revealed that Resident #66 answered yes to trouble falling or staying asleep or sleeping too much. Review of the Resident's PHQ-9 (Patient Health Questionnaire) dated 04/16/2024 completed by S11SSD revealed the resident answered yes to feeling down, depressed or hopeless nearly every day. The PHQ-9 also revealed that resident answered yes to trouble falling or staying asleep or sleeping too much. Interview Details read: Resident stated that she has been depressed on nearly every day in the last two weeks because of things in the past with her family. Resident stated that on several days in the last two weeks she had trouble sleeping because she was worried about things going on with her funds. Further review of the resident's electronic medical record revealed S11SSD placed the resident on the S15NP's list to be seen for depression and difficulty sleeping. Review of S15NP's progress notes from 04/16/2024 to 05/15/2024 revealed no documentation regarding the resident's depression or trouble sleeping. On 05/14/2024 at 03:00 p.m. an interview was conducted with Resident #66. She verified that she had reported feelings of depression and that she was having trouble sleeping to S11SSD. She stated that no one, including the NP, had asked her about these issues since she reported them. She stated that the NP had not come to visit her for these issues, and continued to feel this way. On 05/14/2024 at 3:41 p.m., an interview was conducted with S11SSD. She stated she completed the PHQ-9 with the resident on 04/16/2024. She verified that the resident reported feeling down, depressed, or hopeless nearly every day and also had trouble with sleep. She stated that she placed the resident's name in the communication binder for the NP to address these problems, and she did specify on the communication form what symptoms the resident was experiencing. On 05/15/2024 at 1:12 p.m., an interview was conducted with S15NP who verified that his progress note for a visit on 04/16/2024 had no indication of the resident being assessed for depression or trouble sleeping. Resident #326 Review of Resident #326's electronic record revealed an admitted [DATE] with diagnoses that included Pain Unspecified, Other Chronic Pain, and Chronic Venous Hypertension (Idiopathic) with Ulcer of Bilateral Lower Extremity. Review of Resident #326's MAR (Medication Administration Record) for May 2024 revealed the resident was ordered and received: Acetaminophen Tablet 650 mg (Milligrams). Give one tablet by mouth three times a day related to Other Chronic Pain, started 05/07/2024. Gabapentin Capsule 300 mg. Give 1 capsule by mouth three times a day related to Other Chronic Pain, started 05/07/2024. Oxycodone-Acetaminophen Tablet 7.5-325mg. Give 1 tablet by mouth every four hours as needed for pain, started 05/07/2024. Review of his MAR indicated the resident had been receiving Oxycodone-Acetaminophen as needed 4-5 times a day since his admission. An average pain rating of 8-10 (0 mean no pain, and 10 means the worst possible pain) was recorded prior to Oxycodone-Acetaminophen administration. The resident received a dose on 05/14/2024 at 07:41a.m., approximately two hours before being interviewed below. On 05/14/2024 at 9:37 a.m., an interview was conducted with Resident (#326). He stated that his pain was at a level of 10 on the pain scale and was located in his lower extremities. He stated he had received a dose of pain medication after 7:00 a.m. this morning but he remained in a great amount of pain. He stated that received minimal relief from his pain medications. He stated he informed the nurses of this when they asked him about the effectiveness of pain medications. An interview was conducted with S16LPN on 05/15/2024 at 10:18 a.m. She stated that the resident asked for pain medications every hour and that his pain medications were not effective. She stated that she had informed S15NP at least three times since Resident #326's admission. She stated S15NP reported to her that he could not change the pain medication. On 05/14/2024 at 12:20 p.m., an interview was conducted with S15NP and S3DONNIP. S15NP stated the nurse had reported to him in the past that the resident's pain regimen was ineffective. He stated that he definitely found the pain regimen to be ineffective but wanted to wait for a period of time to make changes to Resident #326's pain medication. S3DONNIP verified that there was no progress note from the NP or nursing documentation since admit mentioning the ineffectiveness of Resident #326's pain regimen.

Based on interview and record review, the facility failed to thoroughly investigate and adequately intervene when the resident reported his pain medication was not treating his pain effectively for 1 resident (#326) out of 1 sampled resident (#326) for pain. Findings: Review of Resident #326's electronic record revealed an admitted [DATE] with diagnoses that included Pain Unspecified, Other Chronic Pain, and Chronic Venous Hypertension (Idiopathic) with Ulcer of Bilateral Lower Extremity. Review of Resident #326's MAR (Medication Administration Record) for May 2024 revealed the resident was ordered and received: Acetaminophen Tablet 650 mg (Milligrams). Give one tablet by mouth three times a day related to Other Chronic Pain, started on 05/07/2024. Gabapentin Capsule 300 mg. Give 1 capsule by mouth three times a day related to Other Chronic Pain, started on 05/07/2024. Oxycodone-Acetaminophen Tablet 7.5-325mg. Give 1 tablet by mouth every four hours as needed for pain, started on 05/07/2024. Review of his MAR indicated the resident had been receiving Oxycodone-Acetaminophen as needed 4-5 times a day since his admission. An average pain rating of 8-10 (0 means no pain, and 10 means the worst possible pain) was recorded prior to Oxycodone-Acetaminophen administration. The resident received a dose on 05/14/24 at 07:41a.m., approximately two hours before being interviewed below. On 05/14/2024 at 09:37 a.m., an interview was conducted with Resident (#326). He stated that his pain was at a level of 10 on the pain scale and was located in his lower extremities. He stated and he had received a dose of pain medication after 7:00 a.m., this morning but he remained in a great amount of pain. He stated that he received minimal relief from his pain medications. He stated he informed the nurses of this when they asked him about the effectiveness of pain medications. On 05/15/2024 at 10:18 a.m., an interview was conducted with S16LPN (Licensed Practical Nurse). She stated that the resident asked for pain medications every hour and that his pain medications were not effective. She stated that she had informed S15NP (Nurse Practitioner) at least three times since Resident #326's admission. She stated S15NP reported to her that he could not change the pain medication. On 05/14/2024 at 12:20 p.m., an interview was conducted with S15NP and S3DONNIP. S15NP stated the nurse had reported to him in the past that the resident's pain regimen was ineffective. He stated that he definitely found the pain regimen to be ineffective but wanted to wait for a period of time to make changes to Resident #326's pain medication. S3DONNIP verified that there was no progress note from the NP or nursing documentation since admit mentioning the ineffectiveness of Resident #326's pain regimen.

Based on record reviews and interviews the facility failed to ensure a resident was receiving adequate assistance during a transfer for 1 (#1) of 2 (#1 and #3) sampled residents who required two-person assist with transfers out of 5 (#1, #2, #3, #4, and #5) total residents sampled for falls. This deficient practice resulted in an actual harm for Resident #1 when on 8-08-22, S6CNA (Certified Nursing Assistant) attempted to transfer the resident, who required 2 person transfer assistance, from a wheelchair to the bed without the assistance of another person. This deficient practice resulted in the resident being sent to the hospital for evaluation. An X-ray was done, which revealed a right distal femur fracture that required surgical intervention. Findings: A review of Resident #1's clinical record revealed an admitted [DATE] with diagnoses including [CONDITION(S)], Cognitive Communication Deficit, Major Depressive Disorder, Muscle Wasting and Atrophy, Contracture of the Right Ankle, Unspecified Intellectual Disabilities, Right Ankle Contracture and Unspecified Pain. On 8-10-22, a diagnosis of a Displaced Supracondylar Fracture without Intra-condylar Extension of Lower End of Right Femur was added to Resident #1's diagnoses. Review of Resident #1's latest quarterly MDS (Minimum Data Set) dated 5-18-22 revealed a BIMS (Brief Interview of Mental Status) score of 3, indicating the resident was severely cognitively impaired. Further review of the MDS revealed that Resident #1 was assessed under Section G: Functional Status as a 3 (extensive assist) and a 4 (total dependence) and 3 (two + persons physical assist) with transfers. Under Section GG: Mobility - resident assessed as substantial/maximum assist with sitting to standing. A record review of Resident #1's MDS (Minimum Data Set) assessment, dated 8-08-22, revealed a discharge entry and on 8-13-22, another MDS assessment revealed a reentry to the facility from an acute hospital. A review of Resident #1's Care Plan revealed the following: Resident has an ADL (Activities of Daily Living) self-care deficit: Resident requires staff assistance with ADL's related to [CONDITION(S)] as follows: Transfers = Total Dependence with 2+ persons physical assistance required. Further review revealed resident was also care planned as a High Risk for Falls related to a diagnoses of [CONDITION(S)] and Decreased Mobility: Actual fall on 8-08-22 in which resident sent to hospital for evaluation. X-ray done and revealed a right distal femur fracture. On 8-13-22, Resident #1's Care Plan was updated to include the following: Resident at risk for pain after returning to facility from acute hospital for surgical aftercare following a fractured femur. A review of the facility's Investigation Report for Resident #1, dated 8-08-22, revealed the following: Incident Description - summoned to room by S6CNA who stated she had to lower resident to the floor when her right foot became caught in the wheel of her wheelchair. Resident assisted to bed per S11LPN and S6CNA. Immediate action taken - resident taken to hospital. Predisposing situation factors - attempting to transfer resident. Notes - Resident complained of pain on 8-08-22 with oncoming night nurse during med pass, nurse assessed resident and noted [CONDITION(S)] to right knee, notified MD, new order for x-ray which revealed a distal femur fracture. Resident sent to hospital for further assessment and was admitted for surgery. A review of the x-ray report, dated 8-08-22, revealed the following findings: there is an acute comminuted displaced supracondylar fracture of the right distal femur. Review of the facility's statement from S6CNA, dated 8-08-22 revealed that she was assisting Resident #1 when she had a fall. Stated that she was in Resident #1's room and resident wanted to get into her bed. S6CNA said she placed the resident's wheelchair next to her bed and assisted her in standing. Resident #1 stood from her wheelchair and she began to try to transfer the resident from her wheelchair and in to the bed. She said that when Resident #1 began to pivot toward the bed, she noticed that the resident's foot was impeded by the wheel of the wheelchair so she moved the resident's foot from the wheel. She stated that the resident was unable to move any further so she lowered the resident to the floor and called the nurse to assist her. Review of the facility's documentation of an interview with S11LPN, the nurse for Resident #1, revealed that S6CNA called her to Resident #1's room and asked if she could assist resident off of the floor. S6CNA told her that Resident #1's foot got caught in the wheel of her chair when she was trying to pivot and transfer her into the bed so she had to lower the resident to the floor in the sitting position. S11LPN stated that she assisted S6CNA in getting Resident #1 off of the floor and then assessed the resident. S11LPN stated that Resident #1 denied being in pain or distress. X-Rays revealed Resident #1 had sustained a fracture of her right supracondylar femur. Due to her fracture, Resident #1 was hospitalized and had surgery on 8-12-22 for a right femur fracture. Resident #1 is now non-weight bearing and has had a decline. On 10-25-22 at 10:25 a.m., an interview was attempted with Resident #1. Resident was not able to answer questions. On 10-25-22 at 10:40 a.m., an interview was attempted with S11LPN. She was not available for interview. On 10-26-22 at 9:53 a.m., an interview was conducted with S6CNA and S2DON. S6CNA confirmed that on the evening of 8-08-22, she was working with Resident #1. She stated that she had attempted to assist Resident #1 without assistance with transferring from her wheelchair into the bed. She stated that she attempted the transfer without assistance because resident was a 1 person assist with transfers. S6CNA stated that as far as she knew, Resident #1 has always been a 1 person assist and did not require more than one person to assist her. She explained that while attempting to transfer the resident from her wheelchair into the bed, her foot got stuck in the wheel of the wheelchair and as a result, she lowered the resident down to the floor. She stated that once she had the resident on the floor, she immediately got a nurse to evaluate the resident. She stated that Resident #1 denied any pain or injuries at that time. On 10-26-22 at 10:00 a.m., an interview was conducted with S2DON (Director of Nursing) in which she confirmed that on 8-08-22, S6CNA attempted to assist Resident #1 from her wheelchair to the bed without assistance. She confirmed that this incident resulted in Resident #1 sustaining a fractured femur that required surgical intervention. On 10-26-22 at 1:30 p.m., an interview and record review conducted with S4MDS nurse confirmed that on 8-08-22, Resident #1 sustained a fracture of her right femur after staff attempted to transfer the resident without assistance. She confirmed that according to Resident #1's latest quarterly MDS assessment dated [DATE], resident was coded under Section G: Functional Status: B. Transfers - total dependence and 2+ persons physical assist. She confirmed that according to Resident #1's MDS, she should not have been transferred without the help of at least two staff members at all times.

Based on record review, observation and interview, the facility failed to ensure that a resident received the necessary treatment consistent with professional standards of practice to prevent and promote the healing of pressure ulcers for 2 residents (#8, #27) out of 6 (#8, #27, #26, #42, #46, and #274) sampled residents reviewed for pressure ulcers by: 1. Failing to ensure staff accurately assessed Resident #8 to identify new skin issues. 2. Failing to implement appropriate wound treatment and follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Failing to perform an accurate skin assessment and implement appropriate treatment on Resident #27's sacral region after an area of concern was identified on 01/07/2022. This deficient practice resulted in actual harm on 3/3/2022 when Resident #8 was assessed to have a new Unstageable pressure ulcer to the Right ischial tuberosity, measuring 5 cm x 2 cm. On 3/30/22 the wound measured 6 cm x 3 cm with slough. The facility failed to perform an accurate assessment and implement appropriate treatment. Findings: Resident #8 Review of the facility's electronic medical record revealed that the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's electronic medical record revealed the following: Physician's Immediate Care Orders, dated 06/01/21, read in part, Wound Care: see facility protocol. Review of the facility's protocol for wound care titled Clinical Guideline for unstageable/wounds with necrosis revealed the following: apply enzymatic [MEDICATION(S)] ointment to wound base, cover with bordered gauze daily and as needed. Review of Resident #8's Minimum Data Set (MDS) Admission assessment dated [DATE] his cognition was not assessed. Pressure ulcers revealed one stage 2 pressure ulcer that was present upon admission. Review of Resident #8's Care Plan, dated 01/20/22, revealed that Resident #8 had the potential for impairment to skin integrity which was related to incontinence, [CONDITION(S)], end stage renal disease, and malnutrition. Interventions included weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations, use caution during transfers, and bed mobility. Further review of the care plan revealed the resident had actual impairment to skin integrity: stage 2 pressure ulcer to right buttock. Interventions included follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's Braden Scale For Predicting Pressure Sore Risk, dated 01/20/22, revealed a score of 15, which indicated the resident was at risk for pressure ulcers. Review of a document titled Weekly Body Skin Check revealed on 02/25/22, per S6LPN (License Practical Nurse), the resident had skin issues and no new skin issues. On 03/03/22 at 1:47 p.m., S13WCN (Wound Care Nurse) documented - resident has an unstageable pressure injury to right ischial tuberosity that measure 5 cm (centimeters) x 2 cm. no depth or tunneling present, area has slough (refers to the yellow/white material in the wound bed which consists of dead cells that accumulate in the wound fluid) covering about 90% of wound bed and there are signs of maceration around the periwound due to constant moisture. Will sureprep the periwound, apply mesalt and a secondary dressing to pressure injury. Review of S13WCN's weekly wound observation note, dated 03/03/22 revealed: 1. Wound information - a facility acquired 5 cm x 2 cm unstageable due to slough/eschar pressure ulcer was identified on the right ischial tuberosity. 5. Drainage - A small amount of serosanguineous drainage was noted with maceration around the peri wound tissue, wound edges were intact. 9E. Comments/Therapy - Referrals-No referral made. Date referral made - left blank. Review of Resident #8's Physician orders, dated 03/03/22, per S15NP (Nurse Practitioner), Cleanse unstageable to right ischial tuberosity with normal saline, pat dry with gauze, apply mesalt, cover with bordered gauze daily and as needed soilage. The order was discontinued on 03/25/22. Review of a document titled Weekly Body Skin Check revealed on 03/04/2022, S10LPN documented the resident had skin issues but no new skin issues. Review of S13CWN's weekly wound observation note dated 03/10/22 revealed: On 03/10/22 - 1. Wound information - unstageable wound to the right ischial tuberosity wound measured 5 cm x 2 cm. 5. Drainage - small amount of serosanguineous was noted. Overall impression unchanged. 9E Comments/Therapy - Referrals - No referral made. On 03/17/22 - 1. Wound information - unstageable wound to the right ischial tuberosity wound measured 5 cm x 3 cm, 50% slough present. 5. Drainage - scant amount of serosanguineous drainage noted, peri wound with maceration. Overall impression the wound is unchanged. 9E Comments/Therapy - Referrals - No referral made. On 03/22/22 at 1:13 p.m., S13WCN documented will have a second opinion to look at wound to resident's right ischial for possible new treatment orders. No further documentation was provided. On 03/23/2022 - 1. Wound information - unstageable wound to the right ischial tuberosity wound measure 5cm x 3 cm. 5. Drainage - small amount of serosanguineous drainage noted. Overall impression improving. 9E Comments/Therapy - Referrals -No referral made. Further review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 03/25/22 Cleanse unstageable to right ischial tuberosity with normal saline, pat dry with gauze, apply santyl to upper wound cover with bordered gauze one time a day. On 03/25/22 cleanse unstageable to right ischial tuberosity with normal saline, pat dry with gauze, apply santyl to upper wound cover with bordered gauze one time daily and as needed soilage. Cleanse unstageable to right ischial tuberosity with normal saline pat dry with gauze apply wound gel #1 to lower wound cover with dressing every day shift. On 03/30/2022 - 1. Wound information - unstageable wound to the right ischial tuberosity wound measure 6 cm x 3 cm, 50% slough. 5. Drainainge - small amount of serosanguineous drainage noted, maceration noted to peri wound tissue, overall impression improving. 9E Comments/Therapy - Referrals - No referral made. Review of Resident #8's Treatment Administration Record (TAR), dated March 2022, revealed: Order dated 03/03/22 stated Cleanse unstageable to right ischial tuberosity with normal saline, pat dry with gauze apply mesalt cover with bordered gauze one time a day. The TAR revealed no signature as the wound care being completed on 3/6, 3/7, 3/12, 3/13, 3/14, 3/19, 3/22, 3/23, and 3/24. Further review revealed that the order was discontinued on 3/25/22. The new order read in part Cleanse unstageable to right ischial tuberosity with normal saline pat dry with gauze apply santyl to upper wound cover with bordered gauze one time a day. Review of the TAR revealed treatment was not signed off on 3/25, 3/26, 3/27, 3/28 and 3/29. Another order was written on 3/25/22 which stated cleanse unstageable to right ischial tuberosity with normal saline pat dry with gauze apply wound gel #1 to lower wound cove with dressing every day shift. Further review that the dressing change was not signed off as being completed on 3/25, 3/26, 3/27, 3/28, and 3/29. On 04/06/22 at 2:25 p.m., an observation of wound care was conducted with S13WCN (Wound Care Nurse) who performed the wound care on Resident #8's Right ischial wound. Upon observation the resident had a large opened area to his right ischial with slough. The measurements were not taken at that time. The area was cleaned and santyl was applied to the slough and a small area of maceration was observed around the edges. On the other portion of the wound S13WCN stated that she applied wound #1 which she stated was [MEDICATION(S)] and something else (she could not remember all the ingredients in the wound #1 paste). When asked who reviewed the wounds with her, she stated that the S2DON was certified in wound care and she thought S3ADON (Assistant Director of Nursing) was also certified. S13WCN stated that no one assessed the wounds with her unless she was having an issue with the wound. S13WCN stated that the resident was admitted with a sacral wound and she did wound care daily on that area. S13WCN stated that she identified the right ischial wound on 03/03/22 which was unstageable and measured 5 cm x 2 cm with slough. She added that she began treatment with mesalt because of the slough. S13WCN was asked - If she did wound care daily on the resident's sacral wound, why was the ischial wound identified for the first time as being so large (5 cm x 2 cm with slough)? S13WCN did not have an answer, she stated that it was discovered on 03/03/22. S13WCN confirmed that mesalt was not the correct treatment according to the facility wound care protocol. On 04/06/22 at 3:30 p.m., an interview was conducted with S15NP (Nurse Practitioner) and S2DON (Director of Nursing). S15NP stated that when S13WCN discovered a wound, she called or texted to inform her of who had the wound and what type of wound it was. S2DON added that S13WCN also informed her and the ADON about any new wounds she discovered. S2DON stated that the facility also had a corporate wound care nurse who they used as needed via telehealth. S2DON confirmed that they did not consult the corporate wound care nurse for the wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/06/22 at 4:15 p.m., a follow up interview was conducted with S15NP, who was unable to recall when she assessed the wound, stated that when she was asked to assess the wound, she observed slough at that particular time and that S13WCN, S3ADON and herself agreed to change the wound care to santyl. At that time, the facility's standing orders for wound care was observed with S15NP who stated that the initial treatment according the facility protocol for an unstageable wound was to apply enzymatic [MEDICATION(S)] ointment to the wound base, cover with bordered gauze, and change daily and as needed. S15NP confirmed that S13WCN should have started with santyl and not mesalt. S15NP also confirmed that she was not certified in wound care but she relied on the staff to inform her of what was going on. S15NP also confirmed that she was not aware of the treatment that was being performed on the resident until she saw the wound and it was agreed that santyl should be started. On 04/06/22 at 4:45 p.m., an interview was conducted with the Resident #8 who answered all questions appropriately and stated that he knew how he got the wound on his right ischial area because his wheelchair was only to be used to bring him to [CONDITION(S)]. He added that when he returned from [CONDITION(S)] sometimes he was left sitting up in the wheelchair for 2 or 3 hours. Resident #27 Review of the resident's electronic medical record revealed that Resident #27 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan, dated 08/25/21, revealed that Resident #27 had impaired skin integrity. Interventions read in part, follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to physician. Review of the MDS Quarterly Assessment, dated 10/26/21, revealed no skin issues. Review of the Progress Note, dated (late entry) 01/07/2022, per S13WCN stated, went to assess resident's skin and noted masd (moisture associated skin damage) to resident's left buttock, no other skin issues were noted. Review of facility document titled Weekly Body Skin Check, dated 01/10/22, per S13WCN revealed in part, that Resident #27 did not have any wounds. Review of Resident #27's electronic medical record from a local hospital dated 01/11/22 at 16:06 revealed that the resident presented in the emergency room (ER) with a stage 2 pressure ulcer to the sacral area. No documentation of measurements were provided. Review of the MDS Discharge assessment dated [DATE] revealed MASD (Moisture Associated Skin Damage) skin damage. Review of Nurses Notes, dated 01/15/22, read in part that the daughter of Resident #27 called to inform the facility about a stage 2 pressure ulcer to his buttocks. The daughter was notified that a skin check was completed on the 10th at 8 am and revealed that he did not have a bed sore or stage 2 to his buttocks and that he went to the hospital on the 11th. Review of the MDS Entry Tracking Record, dated 01/18/22, revealed no skin issues. Review of the Treatment Administration Record (TAR) dated January 2022 revealed an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a weekly body skin check, dated 01/19/22, revealed - new skin issue to the Right and Left buttock. No measurements were documented and they were described as red. Review of the MDS Quarterly Assessment, dated 01/24/22, revealed in part, Cognition - Brief Interview for Mental Status (BIMS) was 8 which indicated moderately impaired cognition. Skin Conditions - one stage 2 pressure ulcer. Bladder and Bowel - Resident #27 was always incontinent of bladder and bowel. Functional Status - Bed mobility 3 (extensive assistance)/2 (one person physical assist); Transfer 3/3 (two plus person physical assist); Toilet use 4 (total dependence)/3 (two plus person physical assist). Review of a facility document titled Braden Scale for Predicting Pressure Sore Risk dated 02/15/22 revealed a score of 16.0 which indicates Resident #27 was at risk for developing pressure ulcers. Further review of the document read in part, no impairment for sensory; moisture rarely moist; activity chairfast; mobility very limited; nutrition adequate; friction and shear problem. On 4/5/22 at 3:43 p.m., an interview was conducted with S13WCN who stated that she saw the wound on 01/07/22 and it was identified as masd. That is all she said and did not document the wound or start wound care orders on the resident and confirmed that she did not do any wound care on the resident prior to him going into the hospital. S13WCN stated that she just got carried away and that it was an innocent mistake.

Based on record review, interview and observation, the facility failed to ensure 1 (#3) of 7 (#1, #3, #4, #5, #6, #7 and #8) residents was assessed for risk of entrapment prior to installing enabler bars on the resident's bed. This fail practice resulted in an Immediate Jeopardy for Resident #3 on [DATE] at 4:45 a.m. when the resident was found by staff not breathing, without a pulse and her skin color to her face was pale. The resident buttock was positioned on the bed bolster which was resting on the floor, her legs/feet were on the floor, her head was resting on the mattress tucked behind the enabler bar with her face pointed toward the ceiling. On [DATE] at 7:40 a.m., the resident was pronounced deceased by the hospice nurse who at that time observed bright red marks described as ligature marks on the resident's neck. The facility implemented corrective actions which were completed prior to the State Agency's completion of its investigation, thus it was determined to be a Past Noncompliance citation. Findings: A review of the facility's Policy on Physical Restraints and Involuntary Seclusion revised [DATE] revealed the following: #13 Side rails or side rail assist bars/enablers used as an enabler for mobility or transfers must include: Side rail evaluation completed Assessment of the resident's ability to move about in bed Determination of whether the resident is able to use the side rails in turning Determination that the patient's/resident's ability to transfer considering that side rail may add risk to the patient's/resident's self-transfer. Resident #3 A review of Resident #3's clinical record revealed she was admitted to the facility on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was also receiving Hospice services. A review of Resident #3's Quarterly Minimum Data Set (MDS) dated [DATE] revealed she was severely cognitively impaired and she required total assistance for bed mobility, transfers, dressing, eating, toileting and bathing. A review of Resident #3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The start date for these orders could not be determined by record review. During email correspondence with S1Administrator on [DATE] at 3:08 p.m. he pointed out both the bolsters and enabler bars were initiated and in place since [DATE]. A review of Resident #3's current care plan revealed care planning for falls with interventions for the use of bed bolsters and enabler rails x2 to her bed for safety and positioning. A review of Resident #3's Fall Risk Assessments dated [DATE], [DATE] and [DATE], revealed the resident was at risk for falls with a score of 75 (high risk score = 45 or higher). Further review of the record and a request to the facility for bed bolster and enabler use assessment revealed that there were no assessments performed for Resident #3. A review of Resident #3's Nurse's Notes dated [DATE] at 1:36 p.m. revealed the resident was found by S9FormerLPN with her buttocks on the bed bolster which she indicated was turned down, her feet touching the mat on the floor and the top half of her body on the bed. The resident was repositioned by staff and S2DON was notified of the incident. A review of Resident #3's Nurse's Notes dated [DATE] at 4:45 a.m. revealed the resident was found on the side her bed with her neck over railing and leg over the bed bolsters by S3CNA. S4LPN assessed the resident and noted she was pale, had no heartbeat, pulse or respirations and the Hospice agency was contacted and staff were awaiting a call back. At 5:15 a.m. the note revealed the on call nurse from Hospice would be on her way and they'd notify the resident's family. Further review revealed at this time, S4LPN assisted CNA with postmortem care and noted a red area to the resident's neck. A record review was made of The Client Coordination Note Report from the Hospice Company which revealed The Hospice Nurse (Registered Nurse) performed the assessment and pronounced the resident as deceased on [DATE]. The record revealed the assessment was conducted at 7:40 a.m. when she was pronounced and also that the Coroner was contacted to investigate the incident as she thought the patient or anyone else may have directly or indirectly caused the death. A review of a written Witness Statement by S3CNA (Certified Nursing Assistant) dated [DATE] revealed at 4:50 a.m. she discovered Resident #3 on the side of the bed, attempted to reposition her and was unable to do so and ran for help. Further review of the statement revealed she and S4LPN both removed her from the bed the way she was positioned and called for additional assistance from S5LPN in order to lift her back into the bed. S3CNA documented that she noted a red mark on the resident's neck from the way her neck was positioned on the turn rail (enabler bar). Further review also revealed an addendum written by S2DON for a phone interview she conducted with S3CNA. S2DON documented that S3CNA informed her she made rounds on the resident at 2 a.m., the resident's legs were out of the bed and she put her legs back in bed and repositioned her. Further review revealed Resident #3's legs were positioned over the left bolster at the time. A review of a written Witness Statement by S4LPN dated [DATE] revealed she went to Resident #3's room after she heard an overhead call for assistance. She wrote when she arrived the resident was in a prone position with her lower extremities off of the side of the bed. She described the resident's color as pale and she had no pulse or respirations. Additional documentation revealed that later, after the initial assessment, she noted a red mark to the right side of the resident's neck. Further review revealed S4LPN noted the resident had no signs or symptoms of distress and/or variations from her normal behavior on her prior rounds on the resident during her shift. A review of a written Witness Statement by S5LPN dated [DATE] revealed he was called to Resident #3's room to help assist in transferring her from the floor to the bed. He noted there was no clutter in the room. A review of a written Witness Statement by S6CNA dated [DATE] revealed she witnessed Resident #3 trying to get out of bed, turning 360 degrees and often found in different positions than she was left and had to be repositioned. She was unable to recall dates or times when this occurred. A review of the staffing pattern provided by the facility during the week of [DATE] through [DATE] revealed S6CNA rotated work between day and night shifts. A review of a written Witness Statement by S7CNA dated [DATE] revealed that when she arrived in Resident #3's room to assist, unable to recall time, the resident's head was on the bed and her body was on the floor. A telephone interview was conducted with S3CNA on [DATE] at 11:59 a.m. and she stated she worked from 10 p.m. to 6 am on [DATE] through [DATE]. She confirmed she checked on the resident around 2 a.m. and her bolsters and enabler bar were secure in place but the resident's legs were over the bolster on the left side. She pointed out the resident moved around in the bed a lot, she would put her legs on the bolsters but she had never witnessed her trunk on the bolster. She stated the nursing staff were aware that the resident occasionally put her legs over the bolsters but they had not changed any of the interventions in place. S3CNA stated when making her rounds sometime after 4 a.m. she found the resident positioned with her head up towards the ceiling, her knees on the landing pad near the bed and her neck was caught onto the side of the railing/enabler bar. She stated the resident's face was turning blue at the time. She stated she called for assistance from S4LPN who came in the room and together they removed the resident from the enabler bar and placed her on the floor. S3CNA and S4LPN called for additional assistance and they together with S5LPN lifted the resident and placed her back in the bed. A telephone interview was conducted with S4LPN on [DATE] at 5:45 p.m. and she confirmed the details of the witness statement as written. She stated the resident was capable and did move about in the bed, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A telephone interview was conducted with S5LPN on [DATE] at 5:40 p.m. and he confirmed the details of the incident as written but added when he entered the room the resident's entire body was on the floor and he assisted to place her back into the bed. A telephone interview was conducted with S7CNA on [DATE] at 3:45 p.m. and she confirmed the details of the statement as written. She stated it appeared as if she slid down off the bed with her knees up against her chest. She pointed out the resident's head didn't go all the way down to the floor and was caught by the enabler bar. A telephone interview was conducted with S6CNA on [DATE] at 12:45 p.m. and she stated the resident occasionally moved around in the bed, even sometimes turned sideways and had her feet on the wall nearby and had to be repositioned each time. She stated the resident used her feet to turn herself and seemed as if she kept moving she would have fallen out of the bed. A telephone interview was conducted with S9FormerLPN on [DATE] at 3:50 p.m. and she confirmed the details of the Nurse's Notes documented on [DATE]. She stated the resident was found sitting on top of the bolster, which was still in the bed but tilted downward, with her feet on the floor. She stated she notified the DON and was not instructed to complete an incident report. She stated the resident did move around a lot in the bed, she sometimes turned and put her knees on the wall near her bed and this occurred approximately ,d+[DATE] times a week. A telephone interview was conducted on [DATE] at 12:35 a.m. with the Hospice Registered Nurse who performed the assessment of Resident #3 on [DATE]. She pointed out she initially assessed the resident in a dimly lit room after the resident received postmortem care and she observed no issues with her neck. She stated she then received an anonymous phone call informing her that she needed to go back into the resident's room and check out the red marks on her neck from being caught in the bar. She stated that upon re-assessing the resident with bright overhead lights she observed ligature marks on her neck and the bruising on her knees. RN Hospice Nurse stated she then contacted the coroner to investigate the incident. A telephone interview was conducted with S2DON (Director of Nurses) on [DATE] at 12:07 p.m. She confirmed that all witness statements and investigative notes were complete and she had no additional documentation to provide the surveyors. She stated she was notified of the Resident's death around 5:40 a.m. on [DATE] but did not arrive onsite to investigate until approximately 1 p.m. since she was only later notified that the resident had red marks on her neck. S2DON stated Resident #3's body had been removed from the facility when she arrived and S8OT (Occupational Therapist) had initiated the investigation due to the resident's neck having red marks. She stated she brought in staff on duty at the time of the incident, obtained witness statements and determined that the bruising on the right side of the resident's neck was due to the assist bar. She pointed out S3CNA informed her the resident's bolster was off of the bed and under her on the floor when she was found. A telephone interview was conducted with S8OT (Occupational Therapist) on [DATE] at 9:50 a.m. and he stated he was called into the facility on the morning of [DATE] and he determined there were no problems with the bed, the bolsters or the enabler bars. A telephone interview was conducted with S2DON on [DATE] at 2:20 p.m. and she stated she was made aware of the [DATE] incident in which Resident #3 was found with her buttocks on top of the bolster and her feet were touching the floor. She stated she did not initiate an investigation because this was not considered a fall, the bolsters and enabler bars were still safe for use, and no new interventions were put in place because this was the first time this occurred. A phone interview was conducted with S2DON on [DATE] at 10:39 a.m. and she stated there were no documented assessments or evaluations of residents for the safe use and risk/benefits for use of the bed rolls/bolsters and/or enabler bars until after the incident on [DATE]. Throughout the survey dates of [DATE] to [DATE], 17 staff members were interviewed to determine if any additional residents had been found trapped in the side rails. The interviews with the staff members revealed no issues with the safe use of enabler side rails. An onsite tour survey of the facility was conducted on [DATE] at 9:45 a.m. with S1Adminsitrator and S2DON. Three different styles of enabler bars were observed in place on beds in the facility. There were no issues with the placement, all were secure in place and no residents were observed attempting to get out of bed. There were no bolsters observed in use at the facility. Record review revealed that residents with enabler bars in use had been assessed for the use of the enabler bars. The facility implemented the following actions to correct the deficient practice on [DATE]. 1. All bed bolsters were removed from the facility. 2. OT immediately assessed each residents for the use of side rails. 3. Policy and Procedure for assist bars developed updated with use of formal assessments 4. Assist bars removed for 6 residents 5. In services were conducted for all nursing staff, housekeeping and maintenance that included review of facility policies and procedures on physical restraints, discontinuation of bolsters, monitoring and documentation for use of enabler bars and obtaining the approval of the DON and/or Administrator prior to the use of enabler bars. 6. QAPI was implemented on [DATE] and identified the root cause of concern as an injury of unknown origin on Resident #3. Ongoing monitoring was planned for monthly audits of devices and IDT monthly review for the use of devices during QAPI Committee which was planned for [DATE]. The projected completion date was for 3 month monitoring was [DATE].

Based on record review and staff interview, the facility failed to ensure Certified Nurse Aides are able to demonstrate competency in skills and techniques necessary to care for Residents' needs as evidenced by failing to: 1. ensure Resident #6 was not left unattended and unsecured in the back of the facility van with the lifter in the down position on 5/21/12 at 11:16 AM. Resident #6 rolled backwards falling out of the back of the van and sustained a laceration to the back of his head, 2. ensure Resident #1's wheelchair was correctly secured in the transportation van on 9/18/12 prior to moving the van; 3. have annual training and competency evaluations for all Van Drivers which included competency evaluations for loading, unloading and securing residents in the company vehicle. Administrator S1 was informed of the Immediate Jeopardy situation involving Resident #1 on 10/3/12 at 3:10 PM which began on 9/18/12 at 11:00 AM, when the resident fell out of his wheelchair in the back of the van due to staff not properly securing him. This Immediate Jeopardy situation included all 38 Residents(#1, #2,#6-9, #12, #13, #15, #17-19, #21, #23-26, #28-30,#33, #36-38, #40, #44, #48, #49-58 ) initially identified by the facility who required a wheelchair during transportation due to a lack of training and competency evaluations regarding Driver and Vehicle Safety as per facility policy and procedure. The Immediate Jeopardy remained in place until 10/4/12 at 1:10 PM, when complete training was provided to all facility drivers including competency evaluations. This deficient practice remains at an actual harm level for Resident #1. The Administrator was then informed on 10/4/12 at 4:00 PM, of an Immediate Jeopardy situation involving Resident #6, which began on 5/21/12 at 11:16 AM, when he fell backward out of the back of the van and sustained a laceration to the back of his head. Due to a failure to re-train all company van drivers and ensure all company van drivers had the Driver and Vehicle Safety policy and procedure required training and competency evaluations after Resident #6's fall from the van, this Immediate Jeopardy Situation also included all 45 (#1, #3, #6 - #48) Resident who were identified by staff (staff adjusted amount of Residents from above) as having been transported by the facility van between 5/21/12 - 10/4/12. It also included an additional 10 Residents (#49 - #58) identified by staff that potentially needed transportation in the facility van sitting in a wheelchair between 5/21/12 and 10/4/12. The Immediate Jeopardy situation remained in place from 5/21/12 at 11:16 AM and continued until 10/4/12 at 1:10 PM when complete training was provided to all facility drivers including competency evaluations. This deficient practice also remains at an actual harm level for Resident #6. Findings: 1. Resident #6: On 10/4/12 at 1:30 PM, an interview was conducted with Resident #6. He revealed he had an accident a few months back where he fell out of the facility van. A witness statement dated 5/21/12 regarding Resident #6's fall written by Van Driver S10 read: Upon arriving at ---[MEDICAL TREATMENT] unit, I unfastened the oxygen cylinder, which was behind Resident #6's wheelchair, unfastened his wheelchair, got out the side of the van and let the lift unfold. Put the oxygen cylinder on the lift and let down. Before I brought the cylinder to the door when I heard a noise, turned around and saw Resident #6 lying on his back on the lift which was on the ground. I put the cylinder on the side walk by the door, and ran to Resident #6.... A review of Resident #6's nurses notes dated 5/21/12 at 12:00 PM revealed the resident was brought to the emergency room due to a fall off the ramp at [MEDICAL TREATMENT] when he was being loaded. He has a laceration to the back of his head and received medical attention at the emergency room . Subsequent nurses notes indicated Resident #6 was receiving "Neuro Checks". A review of Resident #6's post fall review revealed the probable cause for the fall of 5/21/12 at 11:16 AM was the Patient stated his wheelchair was not locked and the van driver did not pick up the ramp. A review of the inservice provided to Van Driver S10 (dated 5/17/12, but Administrator S1 stated the date was wrong and the inservice was given on 5/21/12 in response to the accident) included: 1. Do not leave resident in the van unattended, 2. Keep resident strapped until ready to immediately take resident out of van, 3. Do not leave lifter in down (ground) position and walk away. On 10/4/12 at 3:00 PM, an interview was conducted with Administrator S1. She confirmed that Van Drivers CNA S5 and CNA S6 had not received the above mentioned in-service after Resident #6's fall from the back of the van to ensure competency of staff to prevent future accidents. Administrator S1 also confirmed they had not reviewed Van Drivers CNA S5 and CNA S6's employee files to ensure all current training, in-services, and competency evaluations had been performed. 2. Resident #1: A review of Resident #1's Incident/Accident Report dated 9/18/12 at 11:00 AM revealed he was returning from a medical appointment transported by substitute driver CNA S5 in the facility van. When the van accelerated from a red light, Resident #1 fell over backward and out of his wheelchair onto the back of the van hitting his head. CNA S5 stopped the van, put something on his head to stop the bleeding. CNA S5 indicated she had applied the straps on the wheelchair, but did not "crank" down the straps to properly secure them. Resident #1 was sent to the emergency room due to the laceration on the back of his head. A review of Resident #1's Emergency Department aftercare instructions dated 9/18/12 at 2:10 PM had a [DIAGNOSES REDACTED]. A review of Resident #1's Nurses notes dated 9/18/12 at 11:00 AM and signed by RN ADON S3 read: Received phone call from CNA S5, van driver, states Resident fell out of wheelchair, is on floor of van and bleeding from his head. Instructed to leave him on floor and bring straight to --- emergency room .... On 10/2/12 at 4:15 PM, an interview was conducted with CNA S5, substitute van driver. She stated on 9/18/12, she was driving Resident #1 in the facility van returning from a doctor's appointment, stopped at a red light, and when the light turned green and she began moving again, she heard the resident yell out. When CNA S5 turned around, she saw that Resident #1 had fallen over backward out of his wheelchair. She stated she had put the lap belt on him that went through the arms of the wheelchair. There was no shoulder belt on. CNA S5 stated she had failed to tightened down or turn the "cranks" to tighten the lap belt down. She indicated the Resident came out of his chair, the chair popped back up, and he remained on the floor of the van. She pulled the van over to check on Resident #1, and called the nursing home. CNA S5 stated she talked to a nurse and was told to bring him to the emergency room . CNA S5 stated she was approximately 5 minutes away from the hospital when this happened. She confirmed that Resident #1 was left on the floor of the van with no seatbelt when she drove him to the emergency room . CNA S5 also confirmed that no nurse assessed the Resident prior to them instructing her to leave him on the floor of the van bleeding and drive him to the emergency room . She confirmed that she told the facility that Resident #1 was on the floor of the van and they instructed her to drive him to the hospital. CNA S5 indicated that the regular van driver had been on vacation at the time of the accident. She had driven the van no more than 10 times, but it had been 2 to 3 months since she had driven the van and maybe longer than that. CNA S5 stated she had not driven the van since that incident, and she does not want to drive it, because it shook her up so badly. A review of the facility's Driver and Vehicle Safety Policy read: ...Obey all laws pertaining to operating a motor vehicle. In the section titled What to do in the event of an accident - In the event of an emergency while transporting residents, employees should follow the established policies and procedures of the company as if in the facility. Following are guidelines for the driver in the event of an accident: ...Call, or have another party call, 911 to summon an ambulance and/or police. ....Contact the facility Administrator or Director of Nursing to report the accident.. If driving a company vehicle, identify the residents being transported and their physical condition. The facility should send assistance to the scene of the accident. Do not drive a resident or employee to the hospital. Wait for an ambulance to transport injured parties. Residents may be evaluated by the hospital or by their treating physician, whichever is appropriate. On 10/2/12 at 5:10 PM, an interview was conducted with RN DON S2 and RN ADON S3. RN ADON S3 stated that she was the nurse who spoke with Van Driver CNA S5 on 9/18/12 at 11:00 AM and she had indeed instructed her to bring him to the hospital. RN ADON S3 stated she felt it was the fastest way to get him to the hospital. RN ADON S3 confirmed she knew that Resident #1 was on the floor of the van with no seatbelt, but felt it was better to get him to the emergency room faster than to call an ambulance or sending one of the facility nurses to assess him. RN DON S2 agreed with the decision RN ADON S3 had made regarding leaving Resident #1 on the floor of the van unsecured and driving him that way to the emergency room . RN DON S2 stated it would have taken 10 to 15 minutes for an ambulance to get to him. They both confirmed there was a seatbelt law in the state of Louisiana. After reviewing the facility's policy and procedure Driver and Vehicle safety, RN DON S2 and RN ADON S3 confirmed Van Driver CNA S5 should have obeyed all laws regarding operating a motor vehicle and in the event of this accident/emergency she should have called 911. A review of the facility driver and vehicle safety policy and procedure driver selection section read: ...Demonstration of a full understanding of this safety policy during in-servicing prior to driving for the company... Demonstrated ability to safely load and unload residents ...under the driver training and development section read: All drivers ... will be in-serviced in the driver and vehicle safety policy before any employee is permitted to drive for the company including the following: Driver safety videos, on-line driver safety training, ... Loading and unloading of residents, including ...and hands-on practice, Securing wheelchairs and other equipment, ...What to do in the event of an accident, what to do if a resident needs assistance during transport, .. The facility will provide annual training to authorized drivers to refresh skills... Annual in-service of company vehicle drivers will include the items listed above and a competency check for loading, unloading and securing residents in the company vehicle. The Securing Residents in Van - Competency Demonstration form included instructions which read: Prior to transport, make a final check of all secured passengers to ensure that all straps are properly attached. If there are any wheelchairs, be sure that they are secured and there is no possible movement from the front to rear or from side to side. On 10/2/12 at 5:00 PM, an interview was conducted with Human Resource Director S4. After reviewing Van Driver CNA S5's personnel file, she confirmed there was no Securing Residents in Van - Competency Evaluation. On 10/3/12 at 09:30 AM, a review of Van Driver CNA S6's personnel file revealed the only training she received regarding transporting Resident's in the facility van was a certificate of completion - driving safety dated 3/31/06. There were no other training or Competency evaluations in the file. This was confirmed by Human Resource Director S4, and she indicated that Van Driver CNA S6 did not have all of the training required now, because she had been driving the van long before all of those rules had come into play. On 10/3/12 at 09:40 AM, an interview was conducted with Van Driver CNA S6. She revealed she had been driving the facility van for approximately 8 years. Van Driver CNA S6 was asked for physical instructions regarding the proper way to secure wheelchairs in the van, so this Surveyor could ensure her demonstration of securing a wheelchair was accurate. After looking through all of the van paperwork including the user manual, she was unable to find instructions regarding the proper way to secure wheelchairs in the van. She also confirmed there was nothing posted on the walls of the van regarding how to secure wheelchairs, but stated that would be a good idea for staff that do not drive the van very often. With no instructions available, there was no way for this Surveyor to ensure the demonstration of safety devices was correct. Van Driver CNA S6 stated she had not had any yearly training regarding driving the van, no videos or check off lists regarding securing Residents in wheelchairs in the van.

Based on observation, record review, and staff interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents by failing to: 1. ensure Resident #6 was not left unattended and unsecured in the back of the facility van with the lifter in the down position on 5/21/12 at 11:16 AM. Resident #6 rolled backwards falling out of the back of the van and sustained a laceration to the back of his head, 2. re-train all company vehicle drivers transporting Residents which included competency evaluations for loading, unloading and securing residents in the company vehicle or annual in-services of company vehicle drivers including a competency evaluation for loading, unloading and securing Residents in the company vehicle as per policy and procedure after the incident involving Resident #6 on 5/21/12; 3. ensure Resident #1's wheelchair was correctly secured in the transportation van on 9/18/12 prior to moving the van; 4. follow facility policy and procedure regarding procedure to follow in the event of incidents involving the transportation van after Resident #1's accident on 9/18/12; 5. assess Resident #1's head injuries following accident in the transportation van on 9/18/12. 6. ensure RN staff directed van driver to call 911 after Residetn #1 experienced a fall out of his wheelchair which resulted in a scalp laceration while in the transportation van on 9/18/12. Resident #6 was in Immediate Jeopardy on 5/21/12 at 11:16 AM, when he was left unattended in an unsecured wheelchair in the facility's transportation van. The van wheelchair lift was in the down position. Resident #6's wheelchair rolled backward out of the back of the van. The resident sustained [REDACTED]. Resident #1 was in Immediate Jeopardy on 9/18/12 at 11:00AM when the van driver failed to correctly secure the resident's wheelchair in the transportation van prior to moving the vehicle. The wheelchair security straps were not secured correctly. When the van driver accelerated, Resident #1 flipped over in his wheelchair, sustaining a scalp laceration which required staples. The van driver contacted the facility and was directed by the RN ADON to leave Resident #1 on the floor of the van and drive the resident to the local emergency room . The van driver did not call 911 for assistance following the incident. The van driver left Resident #1 on the floor of the van without a seatbelt restraint and bleeding from a head injury and drove the resident to the hospital emergency room . The Immediate Jeopardy situation included all 45 residents (1,3,6-48) who were identified by staff as having been transported by the facility van between 5/21/12 through 10/4/12. The immediate jeopardy also included 10 additional residents (49-58) identified by staff that potentially needed transportation in the facility van sitting in a wheelchair between 5/21/12 and 10/4/12. The Immediate Jeopardy situation remained in place from 5/21/12 at 11:16 AM and continued until 10/4/12 at 1:10 PM when complete training was provided to all facility drivers including competency evaluations. This deficient practice also remains at an actual harm level for Resident #6 and Resident #1. Administrator S1 was informed of the Immediate Jeopardy situation involving Resident #1 on 10/3/12 at 3:10 PM which began on 9/18/12 at 11:00 AM, when the resident fell out of his wheelchair in the back of the van due to staff not properly securing him. This Immediate Jeopardy situation included all 38 Residents(#1, #2,#6-9, #12, #13, #15, #17-19, #21, #23-26, #28-30,#33, #36-38, #40, #44, #48, #49-58 ) initially identified by the facility who required a wheelchair during transportation, due to a lack of training and competency evaluations regarding Driver and Vehicle Safety as per facility policy and procedure. The Immediate Jeopardy remained in place until 10/4/12 at 1:10 PM, when complete training was provided to all facility drivers including competency evaluations. This deficient practice remains at an actual harm level for Resident #1. The Administrator was then informed on 10/4/12 at 4:00 PM, of an Immediate Jeopardy situation involving Resident #6, which began on 5/21/12 at 11:16 AM, when he fell backward out of the back of the van and sustained a laceration to the back of his head. Due to a failure to re-train all company van drivers and ensure all company van drivers had the Driver and Vehicle Safety policy and procedure required training and competency evaluations after Resident #6's fall from the van, this Immediate Jeopardy Situation also included all 45 (#1, #3, #6 - #48) Residents who were identified by staff (staff adjusted amount of Residents from above) as having been transported by the facility van between 5/21/12 - 10/4/12. It also included an additional 10 Residents (#49 - #58) identified by staff that potentially needed transportation in the facility van sitting in a wheelchair between 5/21/12 and 10/4/12. The Immediate Jeopardy situation remained in place from 5/21/12 at 11:16 AM and continued until 10/4/12 at 1:10 PM when complete training was provided to all facility drivers including competency evaluations. This deficient practice continues at an actual harm level for Resident #6 and a potential for actual harm that is not Immediate Jeopardy ("E") for Residents #1, #3, #7-#48, and #49-#58 Findings: 1. Resident #6: A review of Resident #6's clinical record revealed [DIAGNOSES REDACTED]. He was observed propelling himself in a wheelchair. On 10/4/12 at 1:30 PM, an interview was conducted with Resident #6. He revealed he had an accident a few months back where he fell out of the facility van. Resident #6 stated the van driver took his oxygen out of the van first, and he thought the lift was behind him and back up. He stated it was mostly his fault because he had not waited and rolled himself out of the van backward. Resident #6 revealed he was sent to the hospital due to a cut to the top of his head. A review of Resident #6's plan of care with a goal date of 9/10/12 revealed a problem of falls with add incident of 5/21/12 Rolled backward off dialysis transport van due to impulsive behavior and an approach of encourage patience and reinforce safety during outing. Wait for assistance before attempting on own. A witness statement dated 5/21/12 regarding Resident #6's fall written by Van Driver S10 read: Upon arriving at ---Dialysis unit, I unfastened the oxygen cylinder, which was behind Resident #6's wheelchair, unfastened his wheelchair, got out the side of the van and let the lift unfold. Put the oxygen cylinder on the lift and let down. Before I brought the cylinder to the door when I heard a noise, turned around and saw Resident #6 lying on his back on the lift which was on the ground. I put the cylinder on the side walk by the door, and ran to Resident #6. ...Resident #6 said "pick me up I can't breathe". A couple of gentlemen and I picked him up and put him in his wheelchair and brought him inside the building. The ambulance arrived and brought him to the hospital. A review of Resident #6's nurses notes dated 5/21/12 at 12:00 PM revealed the resident was brought to the emergency room due to a fall off the ramp at dialysis when he was being loaded. He has a laceration to the back of his head and received medical attention at the emergency room . Subsequent nurses notes indicated Resident #6 was receiving "Neuro Checks". A review of Resident #6's post fall review revealed the probable cause for the fall of 5/21/12 at 11:16 AM was the Patient stated his wheelchair was not locked and the van driver did not pick up the ramp. A review of the inservice provided to Van Driver S10 (dated 5/17/12, but Administrator S1 stated the date was wrong and the inservice was given on 5/21/12 in response to the accident) included: 1. Do not leave resident in the van unattended, 2. Keep resident strapped until ready to immediately take resident out of van, 3. Do not leave lifter in down (ground) position and walk away. On 10/4/12 at 3:00 PM, an interview was conducted with Administrator S1. She confirmed that no other van drivers had received the above mentioned in-service after Resident #6's fall from the back of the van. Administrator S1 also confirmed they had not reviewed the other van drivers employee files to ensure all current training, in-services, and competency evaluations had been performed. 2. Resident #1: A review of Resident #1's clinical record revealed he was a [AGE] year old male with a recent left below the knee amputation with chronic pain. He was admitted to the nursing home on 8/21/12 for rehabilitation. A review of Resident #1's Incident/Accident Report dated 9/18/12 at 11:00 AM revealed he was returning from a medical appointment transported by substitute driver CNA S5 in the facility van. When the van accelerated from red light, Resident #1 fell over backward and out of his wheelchair onto the back of the van hitting his head. CNA S5 stopped the van, put something on his head to stop the bleeding. CNA S5 indicated she had applied the straps on the wheelchair, but did not "crank" down the straps to properly secure them. Resident #1 was sent to the emergency room due to the laceration on the back of his head. A review of Resident #1's Emergency Department aftercare instructions dated 9/18/12 at 2:10 PM had a [DIAGNOSES REDACTED]. A review of Resident #1's Nurses notes dated 9/18/12 at 11:00 AM and signed by RN ADON S3 read: Received phone call from CNA S5, van driver, states Resident fell out of wheelchair, is on floor of van and bleeding from his head. Instructed to leave him on floor and bring straight to --- emergency room .... On 10/2/12 at 4:15 PM, an interview was conducted with CNA S5, substitute van driver. She stated on 9/18/12, she was driving Resident #1 in the facility van returning from a doctor's appointment, stopped at a red light, and when the light turned green and she began moving again, she heard the resident yell out. When CNA S5 turned around, she saw that Resident #1 had fallen over backward out of his wheelchair. She stated she had put the lap belt on him that went through the arms of the wheelchair. There was no shoulder belt on. CNA S5 stated she had failed to tightened down or turn the "cranks" to tighten the lap belt down. She indicated the Resident came out of his chair, the chair popped back up, and he remained on the floor of the van. She pulled the van over to check on Resident #1, and called the nursing home. CNA S5 stated she talked to a nurse and was told to bring him to the emergency room . CNA S5 stated she was approximately 5 minutes away from the hospital when this happened. She confirmed that Resident #1 was left on the floor of the van with no seatbelt when she drove him to the emergency room . CNA S5 also confirmed that no nurse assessed the Resident prior to them instructing her to leave him on the floor of the van bleeding and drive him to the emergency room . She confirmed that she told the facility that Resident #1 was on the floor of the van and they instructed her to drive him to the hospital. CNA S5 indicated that the regular van driver had been on vacation at the time of the accident. She had driven the van no more than 10 times, but it had been 2 to 3 months since she had driven the van and maybe longer than that. CNA S5 stated she had not driven the van since that incident, and she does not want to drive it, because it shook her up so badly. A review of the facility's Driver and Vehicle Safety Policy read: ...Obey all laws pertaining to operating a motor vehicle. In the section titled What to do in the event of an accident - In the event of an emergency while transporting residents, employees should follow the established policies and procedures of the company as if in the facility. Following are guidelines for the driver in the event of an accident: ...Call, or have another party call, 911 to summon an ambulance and/or police. ....Contact the facility Administrator or Director of Nursing to report the accident.. If driving a company vehicle, identify the residents being transported and their physical condition. The facility should send assistance to the scene of the accident. Do not drive a resident or employee to the hospital. Wait for an ambulance to transport injured parties. Residents may be evaluated by the hospital or by their treating physician, whichever is appropriate. On 10/2/12 at 5:10 PM, an interview was conducted with RN DON S2 and RN ADON S3. RN ADON S3 stated that she was the nurse who spoke with Van Driver CNA S5 on 9/18/12 at 11:00 AM and she had indeed instructed her to bring him to the hospital. RN ADON S3 stated she felt it was the fastest way to get him to the hospital. RN ADON S3 confirmed she knew that Resident #1 was on the floor of the van with no seatbelt, but felt it was better to get him to the emergency room faster than to call an ambulance or sending one of the facility nurses to assess him. RN DON S2 agreed with the decision RN ADON S3 had made regarding leaving Resident #1 on the floor of the van unsecured and driving him that way to the emergency room . RN DON S2 stated it would have taken 10 to 15 minutes for an ambulance to get to him. They both confirmed there was a seatbelt law in the state of Louisiana. After reviewing the facility's policy and procedure Driver and Vehicle safety, RN DON S2 and RN ADON S3 confirmed Van Driver CNA S5 should have obeyed all laws regarding operating a motor vehicle and in the event of this accident/emergency she should have called 911. A review of the facility driver and vehicle safety policy and procedure driver selection section read: ...Demonstration of a full understanding of this safety policy during in-servicing prior to driving for the company... Demonstrated ability to safely load and unload residents ...under the driver training and development section read: All drivers ... will be in-serviced in the driver and vehicle safety policy before any employee is permitted to drive for the company including the following: Driver safety videos, on-line driver safety training, ... Loading and unloading of residents, including ...and hands-on practice, Securing wheelchairs and other equipment, ...What to do in the event of an accident, what to do if a resident needs assistance during transport, .. The facility will provide annual training to authorized drivers to refresh skills... Annual in-service of company vehicle drivers will include the items listed above and a competency check for loading, unloading and securing residents in the company vehicle. The Securing Residents in Van - Competency Demonstration form included instructions which read: Prior to transport, make a final check of all secured passengers to ensure that all straps are properly attached. If there are any wheelchairs, be sure that they are secured and there is no possible movement from the front to rear or from side to side. On 10/2/12 at 5:00 PM, an interview was conducted with Human Resource Director S4. After reviewing Van Driver CNA S5's personnel file, she confirmed there was no Securing Residents in Van - Competency Evaluation. On 10/3/12 at 09:30 AM, a review of Van Driver CNA S6's personnel file revealed the only training she received regarding transporting Resident's in the facility van was a certificate of completion - driving safety dated 3/31/06. There were no other training or Competency evaluations in the file. This was confirmed by Human Resource Director S4, and she indicated that Van Driver CNA S6 did not have all of the training required now, because she had been driving the van long before all of those rules had come into play. On 10/3/12 at 09:40 AM, an interview was conducted with Van Driver CNA S6. She revealed she had been driving the facility van for approximately 8 years. Van Driver CNA S6 was asked for physical instructions regarding the proper way to secure wheelchairs in the van, so this Surveyor could ensure her demonstration of securing a wheelchair was accurate. After looking through all of the van paperwork including the user manual, she was unable to find instructions regarding the proper way to secure wheelchairs in the van. She also confirmed there was nothing posted on the walls of the van regarding how to secure wheelchairs, but stated that would be a good idea for staff that do not drive the van very often. With no instructions available, there was no way for this Surveyor to ensure Van Driver CNA S6's demonstration of using the safety devices was correct. Van Driver CNA S6 stated she had not had any yearly training regarding driving the van, no videos or check off lists regarding securing Residents in wheelchairs in the van. On 10/3/12 at 1:30 PM, an interview was conducted with Maintenance Director S13. He was asked for the manufactures instructions or any written instructions regarding the use of safety belts on wheelchairs in the facility van. He was unable to locate any written instructions regarding the use of safety equipment/seatbelts for staff use located in the van. Maintenance Director S13 stated he did not know of any instructions. The staff learn by video and the Regional Maintenance Director was the person who trains the staff. A review of the facility's van use logs revealed Van Driver CNA S5 had driven on 5/12/12, 5/14/12, 5/18/12, 5/21/12, 6/24/12, 9/17/12, and 9/18/12 (date of the incident), which indicated there was approximately a 3 month gap between when CNA S5 had driven in June until September 2012. Based on record review, policy review and interviews the facility failed to ensure that the resident environment remained free of potential accident hazards as possible and each resident receives adequate supervision to prevent accidents. This was evidence by S8 housekeeper left a pump bottle of hazardous chemical in resident #4's room that he allegedly stated he drank some of the fluid he thought was alcohol. This occurred in 1 (#4) of 5 (#1, #2, #3, #4, #5) sampled residents reviewed for incidents/accidents. Findings: Record review revealed Resident #4 was a [AGE] year old male that was admitted to the facility on [DATE] for rehabilitation. He was discharged from the facility on 8-10-12 after therapy was complete. His accumulative [DIAGNOSES REDACTED]. Record review of the Facilities "Incident Report Log" revealed Resident #4 stated he drank liquid out of a chemical bottle that was left in his room. This incident occurred on 8-5-12 at 3:40 p.m.. On 10-3-12 at 10:50 a.m. an interview with S7 LPN revealed, on 8-5-12 Resident #4 told her he had a bottle of alcohol in his room. S7 stated she went into his room and found a chemical spray bottle. She said she showed the resident this bottle and he said this was the bottle he thought was alcohol. She stated he told her he drank some of the liquid. She stated she called the DON and the Housekeeping supervisor regarding the incident. She assessed the resident's mouth for redness and odor and called poison control. She stated they offered fluids to the resident and informed the Nurse Practitioner of the incident. She further revealed his room was cleared of any potential chemicals and the staff keep the resident by the nurses' station after this incident. Record review of a Critical Incident Report dated 8-5-12 revealed Resident # 4 was investigated for care giver neglect which was Unsubstantiated. This report revealed S8 Housekeeper left a bottle of Neutral Cleaner in resident #4's room. The resident informed S7 LPN that someone left a bottle of alcohol in his room. S7 LPN went in residents room and found a bottle of housekeeping cleaner with a spray top. She showed the resident this bottle and asked if this was what he is calling alcohol. He told S7 he drank some of the chemical in the bottle and gestured 12 to 14 inches. On 10-3-12 at 11:00 a.m., an interview with S9 Housekeeping District manager revealed the chemical bottle left in Resident #4's room on 8-5-12 was called U4. He further revealed you could strip floors with this chemical. He further revealed S8 Housekeeper was terminated for leaving the bottle of chemical in Resident #4's room. At this time, S9 presented to this Surveyor an empty pump bottle labeled U4 Power. He stated this was the same type of bottle left in the residents room. The Label read, "U-4 Power. Heavy duty cleaner degreaser. Ingredient: Water, 2-Butoxyethanol, Potassium Hydroxide, Potassium Tall Oil soap, Tetrasodium Pyrophospate, Dye, Fragrance. Caution: May cause eye or skin irritation. Keep out of reach of children." Record review of the Material Safety Data Sheet (MSDS) read, "Section 2: Hazardous Ingredients: 2-Butoxyethanol, Potassium Hydroxide, Potassium Tall Oil soap, Tetrasodium Pyrophospate, Dye. Soluble in water. Section 5: Reactivity Data-Strong oxidizers. Section 6: Health Hazards- eye, skin, oral, inhalation. Section 7: Emergency and first aid procedures- Eyes-flush immediately with water for 15 minutes, Skin wash with soap and water, remove contaminated clothes, Ingestion-drink large quantities of milk or water, call physician. Inhalation-remove exposed person to fresh air. Treat symptomatically. Call a physician." Personnel Record review of S8 Housekeeper file revealed the housekeeper was terminated on 8-5-12 for not complying with the policies in the employee handbook. Page 22 titled, "chemical use." Policy Review titled Chemical Use on page 22 read, "4. Each Housekeeping cart has a lockbox. All chemicals are to be stored in the lockbox. Do Not Leave Your Cart Unattended. Store it properly while you are on break. 5. If you leave a chemical in the janitor's closet, the door must be locked!" On 10-4-12 at 4:00 p.m. an interview with S9 Housekeeping District manager revealed S8 Housekeeper should not have left the chemical bottle in Resident #4's room on 8-5-12. He further revealed S8 Housekeeper should have brought the bottle back to her cart and locked it up.

Based on observation, record review and interview, the facility was not administered in a manner that enabled it to use its resources effectively to maintain the highest physical well-being of each Resident as evidenced by Administration failing to: 1. re-train all company vehicle drivers who transported Residents in the facility van to include competency evaluations for loading, unloading and securing Residents in the company vehicle or review all staff personnel files who transported Residents in the facility to ensure annual training and competency evaluations were performed as per policy and procedure, after Resident #6 fell out of the back of the van and sustained a laceration to his head on 5/21/12 at 11:16 AM due to Van Drive S10 leaving the Resident unsecured and unattended with the van lift in the down position, 2. re-train all company vehicle drivers who transported Residents in the facility van to include competency evaluations for loading, unloading and securing Residents in the company vehicle or review all staff personnel files who transported Residents in the facility to ensure annual training and competency evaluations were performed as per policy and procedure, after Resident #1 fell out of his wheelchair during transportation on 9/18/12 and sustained a scalp laceration which required staples, 3. follow policy and procedure after Resident #1 fell out of his wheelchair during transport in the company vehicle on 9/18/12 where he sustained a scalp laceration, when a member of the Administration staff advised CNA Van Driver S5 to leave Resident #1 on the floor of the van unsecured and bleeding and drive to the hospital instead of calling 911 placing the Resident at further risk. 4. ensure all company vehicle drivers who transported Residents in the facility van had annual training and competency evaluations for loading, unloading and securing Residents in the company vehicle as per policy and procedure, Resident #6 was in Immediate Jeopardy on 5/21/12 at 11:16 AM, when he was left unattended in an unsecured wheelchair in the facility's transportation van. The van wheelchair lift was in the down position. Resident #6's wheelchair rolled backward out of the back of the van. The resident sustained [REDACTED]. Resident #1 was in Immediate Jeopardy on 9/18/12 at 11:00AM when the van driver failed to correctly secure the resident's wheelchair in the transportation van prior to moving the vehicle. The wheelchair security straps were not secured correctly. When the van driver accelerated, Resident #1 flipped over in his wheelchair, sustaining a scalp laceration which required staples. The van driver contacted the facility and was directed by the RN ADON to leave Resident #1 on the floor of the van and drive the resident to the local emergency room . The van driver did not call 911 for assistance following the incident. The van driver left Resident #1 on the floor of the van without a seatbelt restraint and bleeding from a head injury and drove the resident to the hospital emergency room . The Immediate Jeopardy situation included all 45 residents (1,3,6-48) who were identified by staff as having been transported by the facility van between 5/21/12 through 10/4/12. The immediate jeopardy also included 10 additional residents (49-58) identified by staff that potentially needed transportation in the facility van sitting in a wheelchair between 5/21/12 and 10/4/12. The Immediate Jeopardy situation remained in place from 5/21/12 at 11:16 AM and continued until 10/4/12 at 1:10 PM when complete training was provided to all facility drivers including competency evaluations. This deficient practice also remains at an actual harm level for Resident #6 and Resident #1. Administrator S1 was informed of the Immediate Jeopardy situation involving Resident #1 on 10/3/12 at 3:10 PM which began on 9/18/12 at 11:00 AM, when the resident fell out of his wheelchair in the back of the van due to staff not properly securing him. This Immediate Jeopardy situation included all 38 Residents(#1, #2,#6-9, #12, #13, #15, #17-19, #21, #23-26, #28-30,#33, #36-38, #40, #44, #48, #49-58 ) initially identified by the facility who required a wheelchair during transportation, due to a lack of training and competency evaluations regarding Driver and Vehicle Safety as per facility policy and procedure. The Immediate Jeopardy remained in place until 10/4/12 at 1:10 PM, when complete training was provided to all facility drivers including competency evaluations. This deficient practice remains at an actual harm level for Resident #1. The Administrator was then informed on 10/4/12 at 4:00 PM, of an Immediate Jeopardy situation involving Resident #6, which began on 5/21/12 at 11:16 AM, when he fell backward out of the back of the van and sustained a laceration to the back of his head. Due to a failure to re-train all company van drivers and ensure all company van drivers had the Driver and Vehicle Safety policy and procedure required training and competency evaluations after Resident #6's fall from the van, this Immediate Jeopardy Situation also included all 45 (#1, #3, #6 - #48) Resident who were identified by staff (staff adjusted amount of Residents from above) as having been transported by the facility van between 5/21/12 - 10/4/12. It also included an additional 10 Residents (#49 - #58) identified by staff that potentially needed transportation in the facility van sitting in a wheelchair between 5/21/12 and 10/4/12. The Immediate Jeopardy situation remained in place from 5/21/12 at 11:16 AM and continued until 10/4/12 at 1:10 PM when complete training was provided to all facility drivers including competency evaluations. This deficient practice also remains at an actual harm level for Resident #6, and a potential for actual harm that is not Immediate Jeopardy ("E") for Residents (!1, #3, #6-49) and (#49-#58). Findings: 1. Resident #6: On 10/4/12 at 1:30 PM, an interview was conducted with Resident #6. He revealed he had an accident a few months back where he fell out of the facility van. Resident #6 stated the van driver took his oxygen out of the van first, and he thought the lift was behind him and back up. Resident #6 revealed he was sent to the hospital due to a cut to the top of his head. A witness statement dated 5/21/12 regarding Resident #6's fall written by Van Driver S10 read: Upon arriving at ---[MEDICAL TREATMENT] unit, I unfastened the oxygen cylinder, which was behind Resident #6's wheelchair, unfastened his wheelchair, got out the side of the van and let the lift unfold. Put the oxygen cylinder on the lift and let down. Before I brought the cylinder to the door when I heard a noise, turned around and saw Resident #6 lying on his back on the lift which was on the ground. I put the cylinder on the side walk by the door, and ran to Resident #6. ...Resident #6 said "pick me up I can't breath". A couple of gentlemen and I picked him up and put him in his wheelchair and brought him inside the building. The ambulance arrived and brought him to the hospital. A review of Resident #6's nurses notes dated 5/21/12 at 12:00 PM revealed the resident was brought to the emergency room due to a fall off the ramp at [MEDICAL TREATMENT] when he was being loaded. He has a laceration to the back of his head and received medical attention at the emergency room . Subsequent nurses notes indicated Resident #6 was receiving "Neuro Checks". A review of Resident #6's post fall review revealed the probable cause for the fall of 5/21/12 at 11:16 AM was the Patient stated his wheelchair was not locked and the van driver did not pick up the ramp. A review of the inservice provided to Van Driver S10 (dated 5/17/12, but Administrator S1 stated the date was wrong and the inservice was given on 5/21/12 immediately after accident) included: 1. Do not leave resident in the van unattended, 2. Keep resident strapped until ready to immediately take resident out of van, 3. Do not leave lifter in down (ground) position and walk away. There was no documentation that all other company van drivers were re-trained due to this accident to help prevent future accidents, or that Administrative staff reviewed and identified incomplete training and/or that competency reviews were not performed for loading, unloading and securing Residents in the company vehicle as per policy and procedure. On 10/4/12 at 3:00 PM, an interview was conducted with Administrator S1. She confirmed that no other van drivers had received the above mentioned in-service after Resident #6's fall from the back of the van. Administrator S1 also confirmed they had not reviewed the other van drivers employee files to ensure all current training, in-services, and competency evaluations had been performed. 2. A review of Resident #1's Incident/Accident Report dated 9/18/12 at 11:00 AM revealed he was returning from a medical appointment transported by substitute Van Driver CNA S5 in the facility van. When the van accelerated from a red light, Resident #1 fell over backward and out of his wheelchair onto the back of the van hitting his head. CNA S5 stopped the van, put something on his head to stop the bleeding. CNA S5 indicated she had applied the straps on the wheelchair, but did not "crank" down the straps to properly secure them. Resident #1 was sent to the emergency room due to the laceration on the back of his head. A review of Resident #1's Emergency Department aftercare instructions dated 9/18/12 at 2:10 PM had a [DIAGNOSES REDACTED]. On 10/2/12 at 4:15 PM, an interview was conducted with Van Driver CNA S5, substitute van driver. She stated on 9/18/12, she was driving Resident #1 in the facility van returning from a doctor's appointment, stopped at a red light, and when the light turned green and she began moving again, she heard the resident yell out. When Van Driver CNA S5 turned around, she saw that Resident #1 had fallen over backward out of his wheelchair. She stated she had put the lap belt on him that went through the arms of the wheelchair. There was no shoulder belt on. Van Driver CNA S5 stated she had failed to tightened down or turn the "cranks" to tighten the lap belt down. She indicated the Resident came out of his chair, the chair popped back up, and he remained on the floor of the van. As indicated above (Section 1.), Van Driver CNA S5's had no Securing Residents in Van - Competency Evaluation, and Van Driver CNA S6 did not have annual training and competency evaluations, which was confirmed by Human Resource Director S4 and Van Driver CNA S6. There was no indication, Administration reviewed all Van Drivers' personnel records to ensure all training and competencies were current or that re-training was provided immediately to all Van Drivers after the 9/18/12 accident involving Resident #1 to prevent future incidents. 3. A review of Resident #1's Nurses notes dated 9/18/12 at 11:00 AM signed by the RN ADON S3 read: Received phone call from Van Driver CNA S5, states Resident fell out of wheelchair, is on floor of van and bleeding from his head. Instructed to leave him on floor and bring straight to emergency room . On 10/2/12 at 4:15 PM, an interview was conducted with Van Driver CNA S5, substitute van driver. She stated on 9/18/12, she was driving Resident #1 in the facility van returning from a doctor's appointment, stopped at a red light, and when the light turn green and she began moving again, she heard the resident yell out. When Van Driver CNA S5 turned around, she saw that Resident #1 had fallen over backward out of his wheelchair. She pulled the van over to check on Resident #1, and called the nursing home. Van Driver CNA S5 stated she talked to a nurse and was told to bring him to the emergency room . Van Driver CNA S5 stated she was approximately 5 minutes away from the hospital when this happened. She confirmed that Resident #1 was left on the floor of the van with no seatbelt when she drove him to the emergency room . Van Driver CNA S5 also confirmed that no nurse assessed the Resident prior to them instructing her to leave him on the floor of the van bleeding and to drive him to the emergency room . She confirmed that she told the facility that Resident #1 was on the floor of the van and they instructed her to drive him to the hospital. Van Driver CNA S5 indicated that the regular van driver had been on vacation at the time of the accident. She had driven the van no more than 10 times, but it had been 2 to 3 months since she had driven the van and maybe longer than that. Van Driver CNA S5 stated she had not driven the van since that incident, and she does not want to drive it because it shook her up so badly. A review of the facility's Driver and Vehicle Safety Policy read: ...Obey all laws pertaining to operating a motor vehicle. In the section titled What to do in the event of an accident - In the event of an emergency while transporting residents, employees should follow the established policies and procedures of the company as if in the facility. Following are guidelines for the driver in the event of an accident: ...Call, or have another party call, 911 to summon an ambulance and/or police. ....Contact the facility Administrator or Director of Nursing to report the accident.. If driving a company vehicle, identify the residents being transported and their physical condition. The facility should send assistance to the scene of the accident. Do not drive a resident or employee to the hospital. Wait for an ambulance to transport injured parties. Residents may be evaluated by the hospital or by their treating physician, whichever is appropriate. On 10/2/12 at 5:10 PM, an interview was conducted with RN DON S2 and RN ADON S3. RN ADON S3 stated that she was the nurse who spoke with Van Driver CNA S5 on 9/18/12 at 11:00 AM and she had indeed instructed her to bring him to the hospital. RN ADON S3 stated she felt it was the fastest way to get him to the hospital. RN ADON S3 confirmed she knew that Resident #1 was on the floor of the van with no seatbelt, but felt it was better to get him to the emergency room faster than to call an ambulance or sending one of the facility nurses to assess him. RN DON S2 agreed with the decision RN ADON S3 had made regarding leaving Resident #1 on the floor of the van unsecured and driving him that way to the emergency room . RN DON S2 stated it would have taken 10 to 15 minutes for an ambulance to get to him. They both confirmed there was a seatbelt law in the state of Louisiana. After reviewing the facility's policy and procedure Driver and Vehicle safety, RN DON S2 and RN ADON S3 stated they had not known they should not leave the Resident on the floor of the van and drive to the emergency room , and that the policy stated to not drive them to the hospital, but to call 911. They confirmed that driving with Resident #1 unsecured on the floor was not according to state law, and they had told Van Driver CNA S5 to do the wrong thing. 4. A review of the facility driver and vehicle safety policy and procedure driver selection section read: ...Demonstration of a full understanding of this safety policy during in-servicing prior to driving for the company... Demonstrated ability to safely load and unload residents ...under the driver training and development section read: All drivers ... will be in-serviced in the driver and vehicle safety policy before any employee is permitted to drive for the company including the following: Driver safety videos, on-line driver safety training, ... Loading and unloading of residents, including ...and hands-on practice, Securing wheelchairs and other equipment, ...What to do in the event of an accident, what to do if a resident needs assistance during transport, .. The facility will provide annual training to authorized drivers to refresh skills... Annual in-service of company vehicle drivers will include the items listed above and a competency check for loading, unloading and securing residents in the company vehicle. The Securing Residents in Van - Competency Demonstration form included instructions which read: Prior to transport, make a final check of all secured passengers to ensure that all straps are properly attached. If there are any wheelchairs, be sure that they are secured and there is no possible movement from the front to rear or from side to side. On 10/2/12 at 5:00 PM, an interview was conducted with Human Resource Director S4. After reviewing Van Driver CNA S5's personnel file, she confirmed there was no Securing Residents in Van - Competency Evaluation. On 10/3/12 at 09:30 AM, a review of Van Driver CNA S6's personnel file revealed the only training she received regarding transporting Resident's in the facility van was a certificate of completion - driving safety dated 3/31/06. There were no other training or Competency evaluations in the file. This was confirmed by Human Resource Director S4, and she indicated that Van Driver CNA S6 did not have all of the training required now, because she had been driving the van long before all of those rules had come into play. On 10/3/12 at 09:40 AM, an interview was conducted with Van Driver CNA S6. She revealed she had been driving the facility van for approximately 8 years. Van Driver CNA S6 was asked for physical instructions regarding the proper way to secure wheelchairs in the van, so this Surveyor could ensure her demonstration of securing a wheelchair was accurate. After looking through all of the van paperwork including the user manual, she was unable to find instructions regarding the proper way to secure wheelchairs in the van. She also confirmed there was nothing posted on the walls of the van regarding how to secure wheelchairs, but stated that would be a good idea for staff that do not drive the van very often. With no instructions, there was no way for this Surveyor to ensure the demonstration of safety devices was correct. Van Driver CNA S6 stated she had not had any yearly training regarding driving the van, no videos or check off lists regarding securing Residents in wheelchairs in the van.

Based on record review and staff interview, the facility failed to ensure the Registered Nurse met the professional standards of quality per the Louisiana Administrative code, Title 46, Professional and Occupational Standard, Part XLVII, Nurses: Subpart 2. Registered Nurses VI chapter 37 nursing practice 3703 A, Chapter 39. 3903 Standard Number 4, and 3915 Standard Number 7 for 1 (#1) of 2 (#1 and #3) Residents initially reviewed for accidents who utilized facility transportation while in wheelchairs. The facility failed to : 1. ensure RN staff implemented facility policy and procedure for incidents involving facility residents in the transportation van. 2. ensure RN staff directed van driver to call 911 after Resident #1 experienced a fall out of his wheelchair which resulted in a scalp laceration while in the transportation van on 9/18/12.. Resident #1 was in Immediate Jeopardy on 9/18/12 at 11:00AM when the van driver failed to correctly secure the resident's wheelchair in the transportation van prior to moving the vehicle. The wheelchair security straps were not secured correctly. When the van driver accelerated, Resident #1 flipped over in his wheelchair, sustaining a scalp laceration which required staples. The van driver contacted the facility and was directed by the RN ADON to leave Resident #1 on the floor of the van and drive the resident to the local emergency room . The van driver did not call 911 for assistance following the incident. The van driver left Resident #1 on the floor of the van without a seatbelt restraint and bleeding from a head injury and drove the resident to the hospital emergency room . The Immediate Jeopardy situation included all 45 residents (1,3,6-48) who were identified by staff as having been transported by the facility van between 5/21/12 through 10/4/12. The immediate jeopardy also included 10 additional residents (49-58) identified by staff that potentially needed transportation in the facility van sitting in a wheelchair between 5/21/12 and 10/4/12. The Immediate Jeopardy situation remained in place from 5/21/12 at 11:16 AM and continued until 10/4/12 at 1:10 PM when complete training was provided to all facility drivers including competency evaluations. This deficient practice also remains at an actual harm level for Resident #6 and Resident #1. Administrator S1 was informed of the Immediate Jeopardy situation involving Resident #1 on 10/3/12 at 3:10 PM which began on 9/18/12 at 11:00 AM, when the resident fell out of his wheelchair in the back of the van due to staff not properly securing him. This Immediate Jeopardy situation included all 38 Residents(#1, #2,#6-9, #12, #13, #15, #17-19, #21, #23-26, #28-30,#33, #36-38, #40, #44, #48, #49-58 ) initially identified by the facility who required a wheelchair during transportation, due to a lack of training and competency evaluations regarding Driver and Vehicle Safety as per facility policy and procedure. The Immediate Jeopardy remained in place until 10/4/12 at 1:10 PM, when complete training was provided to all facility drivers including competency evaluations. This deficient practice remains at an actual harm level for Resident #1. Finidngs: A review of Resident #1's Incident/Accident Report dated 9/18/12 at 11:00 AM revealed he was returning from a medical appointment transported by substitute driver CNA S5 in the facility van. When the van accelerated from a red light, Resident #1 fell over backward and out of his wheelchair onto the back of the van hitting his head. CNA S5 stopped the van, put something on his head to stop the bleeding. CNA S5 indicated she had applied the straps on the wheelchair, but did not "crank" down the straps to properly secure them. Resident #1 was sent to the emergency room due to the laceration on the back of his head. A review of Resident #1's Emergency Department aftercare instructions dated 9/18/12 at 2:10 PM had a [DIAGNOSES REDACTED]. Be sure not to oversedate patient, hold [MEDICATION NAME] if patient is starting [MEDICATION NAME] as per caregiver with him today, wash and dry wound area daily, apply antibiotic ointment ....Staples out in 10 days. A review of Resident #1's Nurses notes dated 9/18/12 at 11:00 AM and signed by RN ADON S3 read: Received phone call from CNA S5, van driver, states Resident fell out of wheelchair, is on floor of van and bleeding from his head. Instructed to leave him on floor and bring straight to --- emergency room .... On 10/2/12 at 4:15 PM, an interview was conducted with CNA S5, substitute van driver. She stated on 9/18/12, she was driving Resident #1 in the facility van returning from a doctor's appointment, stopped at a red light, and when the light turned green and she began moving again, she heard the resident yell out. When CNA S5 turned around, she saw that Resident #1 had fallen over backward out of his wheelchair. She stated she had put the lap belt on him that went through the arms of the wheelchair. There was no shoulder belt on. CNA S5 stated she had failed to tightened down or turn the "cranks" to tighten the lap belt down. She indicated the Resident came out of his chair, the chair popped back up, and he remained on the floor of the van. She pulled the van over to check on Resident #1, and called the nursing home. CNA S5 stated she talked to a nurse and was told to bring him to the emergency room . CNA S5 stated she was approximately 5 minutes away from the hospital when this happened. She confirmed that Resident #1 was left on the floor of the van with no seatbelt when she drove him to the emergency room . CNA S5 also confirmed that no nurse assessed the Resident prior to them instructing her to leave him on the floor of the van bleeding and drive him to the emergency room . She confirmed that she told the facility that Resident #1 was on the floor of the van and they instructed her to drive him to the hospital. CNA S5 indicated that the regular van driver had been on vacation at the time of the accident. She had driven the van no more than 10 times, but it had been 2 to 3 months since she had driven the van and maybe longer than that. CNA S5 stated she had not driven the van since that incident, and she does not want to drive it, because it shook her up so badly. A review of the facility's Driver and Vehicle Safety Policy read: ...Obey all laws pertaining to operating a motor vehicle. In the section titled What to do in the event of an accident - In the event of an emergency while transporting residents, employees should follow the established policies and procedures of the company as if in the facility. Following are guidelines for the driver in the event of an accident: ...Call, or have another party call, 911 to summon an ambulance and/or police. ....Contact the facility Administrator or Director of Nursing to report the accident.. If driving a company vehicle, identify the residents being transported and their physical condition. The facility should send assistance to the scene of the accident. Do not drive a resident or employee to the hospital. Wait for an ambulance to transport injured parties. Residents may be evaluated by the hospital or by their treating physician, whichever is appropriate. On 10/2/12 at 5:10 PM, an interview was conducted with RN DON S2 and RN ADON S3. RN ADON S3 stated that she was the nurse who spoke with Van Driver CNA S5 on 9/18/12 at 11:00 AM and she had indeed instructed her to bring him to the hospital. RN ADON S3 stated she felt it was the fastest way to get him to the hospital. RN ADON S3 confirmed she knew that Resident #1 was on the floor of the van with no seatbelt, but felt it was better to get him to the emergency room faster than to call an ambulance or sending one of the facility nurses to assess him. RN DON S2 agreed with the decision RN ADON S3 had made regarding leaving Resident #1 on the floor of the van unsecured and driving him that way to the emergency room . RN DON S2 stated it would have taken 10 to 15 minutes for an ambulance to get to him, and they had done this same thing (driving to the emergency room with a hurt Resident on the floor of the van) many times in the past. Both RNs confirmed there was a seatbelt law in the state of Louisiana. After reviewing the facility's policy and procedure Driver and Vehicle safety, RN DON S2 and RN ADON S3 confirmed Van Driver CNA S5 should have obeyed all laws regarding operating a motor vehicle and in the event of this accident/emergency she should have called 911. A review of the facility driver and vehicle safety policy and procedure driver selection section read: ...Demonstration of a full understanding of this safety policy during in-servicing prior to driving for the company... Demonstrated ability to safely load and unload residents ...under the driver training and development section read: All drivers ... will be in-serviced in the driver and vehicle safety policy before any employee is permitted to drive for the company including the following: Driver safety videos, on-line driver safety training, ... Loading and unloading of residents, including ...and hands-on practice, Securing wheelchairs and other equipment, ...What to do in the event of an accident, what to do if a resident needs assistance during transport, .. The facility will provide annual training to authorized drivers to refresh skills... Annual in-service of company vehicle drivers will include the items listed above and a competency check for loading, unloading and securing residents in the company vehicle. The Securing Residents in Van - Competency Demonstration form included instructions which read: Prior to transport, make a final check of all secured passengers to ensure that all straps are properly attached. If there are any wheelchairs, be sure that they are secured and there is no possible movement from the front to rear or from side to side. On 10/2/12 at 5:00 PM, an interview was conducted with Human Resource Director S4. After reviewing Van Driver CNA S5's personnel file, she confirmed there was no Securing Residents in Van - Competency Evaluation. On 10/3/12 at 09:30 AM, a review of Van Driver CNA S6's personnel file revealed the only training she received regarding transporting Resident's in the facility van was a certificate of completion - driving safety dated 3/31/06. There were no other training or Competency evaluations in the file. This was confirmed by Human Resource Director S4, and she indicated that Van Driver CNA S6 did not have all of the training required now, because she had been driving the van long before all of those rules had come into play. On 10/3/12 at 09:40 AM, an interview was conducted with Van Driver CNA S6. She revealed she had been driving the facility van for approximately 8 years. Van Driver CNA S6 was asked for physical instructions regarding the proper way to secure wheelchairs in the van, so this Surveyor could ensure her demonstration of securing a wheelchair was accurate. After looking through all of the van paperwork including the user manual, she was unable to find instructions regarding the proper way to secure wheelchairs in the van. She also confirmed there was nothing posted on the walls of the van regarding how to secure wheelchairs, but stated that would be a good idea for staff that do not drive the van very often. With no instructions available, there was no way this Surveyor could ensure the demonstration of safety devices was correct. Van Driver CNA S6 stated she had not had any yearly training regarding driving the van, no videos or check off lists regarding securing Residents in wheelchairs in the van. On 10/3/12 at 1:30 PM, an interview was conducted with Maintenance Director S13. He was asked for the manufactures instructions or any written instructions regarding the use of safety belts on wheelchairs in the facility van. He was unable to locate any written instructions regarding the use of safety equipment/seatbelts for staff use located in the van. Maintenance Director S13 stated he did not know of any instructions. The staff learn by video and the Regional Maintenance Director was the person who trains the staff. A review of the facility's van use logs revealed Van Driver CNA S5 had driven on 5/12/12, 5/14/12, 5/18/12, 5/21/12, 6/24/12, 9/17/12, and 9/18/12 (date of the incident), which indicated there was approximately a 3 month gap between when CNA S5 had driven in June until September 2012. Louisiana Administrative code, Title 46, Professional and Occupational Standard, Part XLVII, Nurses: Subpart 2. Registered Nurses VI chapter 37 nursing practice 3703 A. a. The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. This assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. i. Any situation where tasks are delegated should meet the following criteria.(a). The person has been adequately trained for the task. (b). The person has demonstrated that the task has been learned. (c). The person can perform the task safely in the given nursing situation. (d). The patient's status is safe for the person to carry out the task. (e). Appropriate supervision is available during the task implementation. (f). The task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all. Chapter 39. 3903. Standard Number 4: Implementation of Nursing Care Plan A. The plan for nursing care is implemented according to the following criteria. ...2. Interventions are implemented in a safe and appropriate manner... 3915 Standard Number 7: Professional Performance A. The registered nurse demonstrates the following professional nursing practice behaviors.... 3. Considers factors related to safety... in planning and delivering nursing care... 6. Makes assignments to others that take into consideration patient safety and which are commensurate with the educational preparation experience...knowledge and ability of the persons to whom the assignments are made.

Based on observation, record review, and staff interview, the facility Quality Assurance Committee failed to ensure an effective quality assurance process that identified problems with the transportation system and implemented appropriate plans of action as evidenced by failing to: 1. in-service all Van Drivers regarding proper vehicle safety, and to review all Van Drivers' personnel files to ensure training and competency evaluations were current in an attempt to prevent a deviation from the transportation safety process, to the extent possible, from occurring again after the incident involving Resident #6 on 5/21/12; 2. review each Van Drivers personnel file and identify that all Van Drivers did not have current vehicle safety training and competency evaluations, and identify driving Resident #1 on the floor of the van bleeding and unsecured on 9/18/12 instead of calling 911 as quality deficiencies or areas for improvement. Resident #6 was in Immediate Jeopardy on 5/21/12 at 11:16 AM, when he was left unattended in an unsecured wheelchair in the facility's transportation van. The van wheelchair lift was in the down position. Resident #6's wheelchair rolled backward out of the back of the van. The resident sustained [REDACTED]. Resident #1 was in Immediate Jeopardy on 9/18/12 at 11:00AM when the van driver failed to correctly secure the resident's wheelchair in the transportation van prior to moving the vehicle. The wheelchair security straps were not secured correctly. When the van driver accelerated, Resident #1 flipped over in his wheelchair, sustaining a scalp laceration which required staples. The van driver contacted the facility and was directed by the RN ADON to leave Resident #1 on the floor of the van and drive the resident to the local emergency room . The van driver did not call 911 for assistance following the incident. The van driver left Resident #1 on the floor of the van without a seatbelt restraint and bleeding from a head injury and drove the resident to the hospital emergency room . The Immediate Jeopardy situation included all 45 residents (1,3,6-48) who were identified by staff as having been transported by the facility van between 5/21/12 through 10/4/12. The immediate jeopardy also included 10 additional residents (49-58) identified by staff that potentially needed transportation in the facility van sitting in a wheelchair between 5/21/12 and 10/4/12. The Immediate Jeopardy situation remained in place from 5/21/12 at 11:16 AM and continued until 10/4/12 at 1:10 PM when complete training was provided to all facility drivers including competency evaluations. This deficient practice also remains at an actual harm level for Resident #6 and Resident #1. Administrator S1 was informed of the Immediate Jeopardy situation involving Resident #1 on 10/3/12 at 3:10 PM which began on 9/18/12 at 11:00 AM, when the resident fell out of his wheelchair in the back of the van due to staff not properly securing him. This Immediate Jeopardy situation included all 38 Residents(#1, #2,#6-9, #12, #13, #15, #17-19, #21, #23-26, #28-30,#33, #36-38, #40, #44, #48, #49-58 ) initially identified by the facility who required a wheelchair during transportation due to a lack of training and competency evaluations regarding Driver and Vehicle Safety as per facility policy and procedure. The Immediate Jeopardy remained in place until 10/4/12 at 1:10 PM, when complete training was provided to all facility drivers including competency evaluations. This deficient practice remains at an actual harm level for Resident #1. The Administrator was then informed on 10/4/12 at 4:00 PM, of an Immediate Jeopardy situation involving Resident #6, which began on 5/21/12 at 11:16 AM, when he fell backward out of the back of the van and sustained a laceration to the back of his head which required staples. Due to a failure to re-train all company van drivers and ensure all company van drivers had the Driver and Vehicle Safety policy and procedure required training and competency evaluations after Resident #6's fall from the van, this Immediate Jeopardy Situation also included all 45 (#1, #3, #6 - #48) Resident who were identified by staff (staff adjusted amount of Residents from above) as having been transported by the facility van between 5/21/12 - 10/4/12. It also included an additional 10 Residents (#49 - #58) identified by staff that potentially needed transportation in the facility van sitting in a wheelchair between 5/21/12 and 10/4/12. The Immediate Jeopardy situation remained in place from 5/21/12 at 11:16 AM and continued until 10/4/12 at 1:10 PM when complete training was provided to all facility drivers including competency evaluations. This deficient practice also remains at an actual harm level for Resident #6. Findings: 1. Resident #6: A review of an incident report and witness statement written by Van Drive S10 regarding an accident involving Resident #6 on 5/21/12 revealed the resident fell out of the facility van and sustained a [MEDICAL CONDITION]. According to the statement, Van Driver S10, transported Resident #6 in the facility Van to [MEDICAL TREATMENT]. When they arrived at the [MEDICAL TREATMENT] unit, Van Driver S10 unfastened Resident #6, got out of the van lift, put his oxygen tank on the lift and lowered it, leaving the Resident in the van unsecured. Van Driver S10 brought the oxygen tank to the [MEDICAL TREATMENT] unit, leaving the lift in the lowered position and the Resident unsecured. The Resident rolled backward and fell out of the van. A review of Resident #6's nurses notes dated 5/21/12 at 12:00 PM revealed the resident was brought to the emergency room due to a fall off the ramp at [MEDICAL TREATMENT] when he was being loaded. He has a laceration to the back of his head and received medical attention at the emergency room . Subsequent nurses notes indicated Resident #6 was receiving "Neuro Checks". A review of the inservice provided to Van Driver S10 (dated 5/17/12, but Administrator S1 stated the date was wrong and the inservice was given on 5/21/12 in response to the accident) included: 1. Do not leave resident in the van unattended, 2. Keep resident strapped until ready to immediately take resident out of van, 3. Do not leave lifter in down (ground) position and walk away. On 10/4/12 at 3:00 PM, an interview was conducted with Administrator S1. She confirmed that no other van drivers had received the above mentioned in-service after Resident #6's fall from the back of the van. Administrator S1 also confirmed they had not reviewed the other van drivers employee files to ensure all current training, in-services, and competency evaluations had been performed. There was no evidence the quality assurance committee evaluated the transportation system after the incident on 5/21/12 to determine the extent of training issues among facility Van Drivers and implement an action plan to prevent a deviation from safety processes, to the extent possible, from arising again. 2. A review of Resident #1's Incident/Accident Report dated 9/18/12 at 11:00 AM revealed he was returning from a medical appointment transported by substitute driver CNA S5 in the facility van. When the van accelerated from a red light, Resident #1 fell over backward and out of his wheelchair onto the back of the van hitting his head. CNA S5 stopped the van, put something on his head to stop the bleeding. CNA S5 indicated she had applied the straps on the wheelchair, but did not "crank" down the straps to properly secure them. Resident #1 was sent to the emergency room due to the laceration on the back of his head. A review of Resident #1's Emergency Department aftercare instructions dated 9/18/12 at 2:10 PM had a [DIAGNOSES REDACTED]. A review of Resident #1's Nurses notes dated 9/18/12 at 11:00 AM and signed by RN ADON S3 read: Received phone call from CNA S5, van driver, states Resident fell out of wheelchair, is on floor of van and bleeding from his head. Instructed to leave him on floor and bring straight to --- emergency room .... On 10/2/12 at 4:15 PM, an interview was conducted with CNA S5, substitute van driver. She stated on 9/18/12, she was driving Resident #1 in the facility van returning from a doctor's appointment, stopped at a red light, and when the light turned green and she began moving again, she heard the resident yell out. When CNA S5 turned around, she saw that Resident #1 had fallen over backward out of his wheelchair. She stated she had put the lap belt on him that went through the arms of the wheelchair. There was no shoulder belt on. CNA S5 stated she had failed to tightened down or turn the "cranks" to tighten the lap belt down. She indicated the Resident came out of his chair, the chair popped back up, and he remained on the floor of the van. She pulled the van over to check on Resident #1, and called the nursing home. CNA S5 stated she talked to a nurse and was told to bring him to the emergency room . CNA S5 stated she was approximately 5 minutes away from the hospital when this happened. She confirmed that Resident #1 was left on the floor of the van with no seatbelt when she drove him to the emergency room . CNA S5 also confirmed that no nurse assessed the Resident prior to them instructing her to leave him on the floor of the van bleeding and drive him to the emergency room . She confirmed that she told the facility that Resident #1 was on the floor of the van and they instructed her to drive him to the hospital. CNA S5 indicated that the regular van driver had been on vacation at the time of the accident. She had driven the van no more than 10 times, but it had been 2 to 3 months since she had driven the van and maybe longer than that. CNA S5 stated she had not driven the van since that incident, and she does not want to drive it, because it shook her up so badly. A review of the facility's Driver and Vehicle Safety Policy read: ...Obey all laws pertaining to operating a motor vehicle. In the section titled What to do in the event of an accident - In the event of an emergency while transporting residents, employees should follow the established policies and procedures of the company as if in the facility. Following are guidelines for the driver in the event of an accident: ...Call, or have another party call, 911 to summon an ambulance and/or police. ....Contact the facility Administrator or Director of Nursing to report the accident.. If driving a company vehicle, identify the residents being transported and their physical condition. The facility should send assistance to the scene of the accident. Do not drive a resident or employee to the hospital. Wait for an ambulance to transport injured parties. Residents may be evaluated by the hospital or by their treating physician, whichever is appropriate. On 10/2/12 at 5:10 PM, an interview was conducted with RN DON S2 and RN ADON S3. RN ADON S3 stated that she was the nurse who spoke with Van Driver CNA S5 on 9/18/12 at 11:00 AM and she had indeed instructed her to bring him to the hospital. RN ADON S3 stated she felt it was the fastest way to get him to the hospital. RN ADON S3 confirmed she knew that Resident #1 was on the floor of the van with no seatbelt, but felt it was better to get him to the emergency room faster than to call an ambulance or sending one of the facility nurses to assess him. RN DON S2 agreed with the decision RN ADON S3 had made regarding leaving Resident #1 on the floor of the van unsecured and driving him that way to the emergency room . RN DON S2 stated it would have taken 10 to 15 minutes for an ambulance to get to him. They both confirmed there was a seatbelt law in the state of Louisiana. After reviewing the facility's policy and procedure Driver and Vehicle safety, RN DON S2 and RN ADON S3 confirmed Van Driver CNA S5 should have obeyed all laws regarding operating a motor vehicle and in the event of this accident/emergency she should have called 911. A review of the facility driver and vehicle safety policy and procedure driver selection section read: ...Demonstration of a full understanding of this safety policy during in-servicing prior to driving for the company... Demonstrated ability to safely load and unload residents ...under the driver training and development section read: All drivers ... will be in-serviced in the driver and vehicle safety policy before any employee is permitted to drive for the company including the following: Driver safety videos, on-line driver safety training, ... Loading and unloading of residents, including ...and hands-on practice, Securing wheelchairs and other equipment, ...What to do in the event of an accident, what to do if a resident needs assistance during transport, .. The facility will provide annual training to authorized drivers to refresh skills... Annual in-service of company vehicle drivers will include the items listed above and a competency check for loading, unloading and securing residents in the company vehicle. The Securing Residents in Van - Competency Demonstration form included instructions which read: Prior to transport, make a final check of all secured passengers to ensure that all straps are properly attached. If there are any wheelchairs, be sure that they are secured and there is no possible movement from the front to rear or from side to side. On 10/2/12 at 5:00 PM, an interview was conducted with Human Resource Director S4. After reviewing Van Driver CNA S5's personnel file, she confirmed there was no Securing Residents in Van - Competency Evaluation. On 10/3/12 at 09:30 AM, a review of Van Driver CNA S6's personnel file revealed the only training she received regarding transporting Resident's in the facility van was a certificate of completion - driving safety dated 3/31/06. There were no other training or Competency evaluations in the file. This was confirmed by Human Resource Director S4, and she indicated that Van Driver CNA S6 did not have all of the training required now, because she had been driving the van long before all of those rules had come into play. On 10/3/12 at 09:40 AM, an interview was conducted with Van Driver CNA S6. She revealed she had been driving the facility van for approximately 8 years. Van Driver CNA S6 was asked for physical instructions regarding the proper way to secure wheelchairs in the van, so this Surveyor could ensure her demonstration of securing a wheelchair was accurate. After looking through all of the van paperwork including the user manual, she was unable to find instructions regarding the proper way to secure wheelchairs in the van. She also confirmed there was nothing posted on the walls of the van regarding how to secure wheelchairs, but stated that would be a good idea for staff that do not drive the van very often. With no instructions available, there was no way for this Surveyor to ensure the demonstration of safety devices was correct. Van Driver CNA S6 stated she had not had any yearly training regarding driving the van, no videos or check off lists regarding securing Residents in wheelchairs in the van. On 10/3/12 at 1:30 PM, an interview was conducted with Maintenance Director S13. He was asked for the manufactures instructions or any written instructions regarding the use of safety belts on wheelchairs in the facility van. He was unable to locate any written instructions regarding the use of safety equipment/seatbelts for staff use located in the van. Maintenance Director S13 stated he did not know of any instructions. The staff learn by video and the Regional Maintenance Director was the person who trains the staff. The facility provided a quality assurance form dated 9/18/12 regarding the issue of Resident #1 falling backward in his wheelchair during transport in the facility van. The action plan included: 1. re-training Van Driver CNA S5 including driving time with the current Van Driver (CNA S6) to make sure that her skills are sufficient and safe before allowing her to drive again. 2. Implementing a mini van orientation to staff who have not driven the facility van for 60 days or longer, including a demonstration of proper securing of residents into the van safety belts and use of the lift before driving. 3. All Van Drivers will be re-educated and demonstrate safely securing residents in the van. The training would be given by the Regional director by 10/15/12. This allowed Van Driver CNA S6, who did not have current training or competency evaluations in her personnel file, to drive for a month after the accident involving Resident #1 without being re-educated. The QA committee did not identify that all Van Drivers did not have current training and competency evaluations in their personnel files, and did not identify that when Van Driver CNA S5 drove with Resident #1 on the floor of the van bleeding and unsecured instead of calling 911 as a problem.

A) Based on record review, interview and observation, the facility failed to ensure that a resident having a pressure sore received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for 1 (#94) of 5 ( 30, 105, 94, 106, and 49) sampled residents identified with pressure ulcers during the survey process. The Facility failed to: 1) Conduct an accurate skin assessment on 11/30/11 when Resident #94 was admitted to the facility from the hospital and the skin assessment was not completed. 2) Accurately stage a right lower buttock skin wound as a stage II pressure wound when it was discovered on 11/30/2011. 3) Notify the physician/nurse practitioner on 12/1/11 when a skin wound was identified on the resident ' s right lower buttock area on 12/1/11 (Resident #94) 4) Conduct accurate ongoing skin assessments of a residents right lower buttock skin wound from 12/1/11 through 1/16/12. (#94) 5) Identify and implement pressure relieving interventions from 11/30/11 to 12/6/11 to prevent the progression of a stage ll right lower buttock pressure wound to an unstageable pressure wound 6) Implement the plan of care for pressure relieving interventions from 12/7/11 to 6/26/12 for resident #94. 7) Obtain treatment orders for a stage ll pressure ulcer (#94) 8) Follow the physician's order [REDACTED]. 9) Provide necessary treatment and service to promote healing, prevent infection and prevent new sores from developing on 2 separate re-admissions. (#94) These failed practices resulted in resident #94 ' s stage ll pressure ulcer advancing to a stage IV pressure ulcer. Resident #94 was hospitalized from [DATE] through 5/21/12 with an admitting [DIAGNOSES REDACTED]. Resident #94 received intravenous antibiotics, surgical debridement of the stage IV sacral decubitus and pain medications during the hospitalization . Resident #94 was placed in immediate jeopardy on 11/30/11 when she was admitted to the facility and in incomplete, inaccurate skin assessment was conducted. The residents right lower buttock skin wound was incorrectly assessed as an excoriated area on 12/1/2011. The facility did not accurately assess the residents right lower buttock skin wound until it had deteriorated to an unstageable wound on 1/16/12. On 3/12/12, the wound was staged as a stage IV pressure ulcer with tunneling. Resident #94 was hospitalized from [DATE] through 5/21/12 with an admitting [DIAGNOSES REDACTED]. Resident #94 received intravenous antibiotics, surgical debridement of the stage IV sacral decubitus and pain medications during the hospitalization . The administrator was informed of the Immediate Jeopardy on 06/22/12 at 4:54 pm. The plan of removal was received and the Immediate Jeopardy was lifted on 06/26/12 at 4:09 pm when the facility ensured that all skin assessments were repeated for accuracy and that all staff was trained on accurate skin assessments. The deficient practice was reduced to an isolated actual harm for Resident #94. FINDINGS: RESIDENT # 94: A review of Resident #94 ' s clinical record revealed that the resident was admitted to the facility from a hospital on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #94 ' s Hospital records dated 11/29/11 revealed a [DIAGNOSES REDACTED]. A review of the Admission Physician order [REDACTED]. A review of the Braden Scale - For Predicting Pressure Sore Risk for Resident #94 dated 11/30/11 revealed a score of 17 to indicate that the resident was at mild risk for pressure ulcers. A review of Resident #94 ' s Skilled Daily Nurses Note failed to reveal findings under the section for the assessment of the resident ' s skin condition. Further review of the nurse ' s note on 11/30/11 at 5:20 pm revealed that the resident was admitted and that the staff was, " Unable to check skin. Passed on to oncoming nurse. " A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated 12/1/11 revealed an excoriated area to the right lower buttock. Further review revealed that the excoriated area measured 3.2 x 2.1 cm with <.1 cm depth and scant blood exudate was observed along with a pink wound bed. A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated 12/10/11 revealed the excoriated area to the right lower buttock measurements were 4.6 x 2.5 cm with 0.1 cm depth and that the wound contained slough in the wound bed. A review of Resident #94 ' s Nurse Practitioner Progress notes dated 12/01/11 failed to reveal that the resident had a pressure ulcer. A review of the Progress notes dated 12/05/11 revealed that the resident had a sacral wound and the area designated for pressure ulcers was blank. A review of a verbal physician's orders [REDACTED]. A review of the Nurse Practitioner Progress notes dated 2/21/12 revealed a new [DIAGNOSES REDACTED]. A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated 01/16/12 revealed that the area to the resident ' s right lower buttock then deteriorated to an Unstageable Wound. Further review revealed that the wound measured 5.1 x 3.2 cm with a depth of 0.1 cm and that tan slough and black eschar were present in the wound bed. Further review of the clinical record revealed that a Wound/Skin Healing Record began on 1/16/12 with the same findings and that the Physician and Resident #94 ' s responsible party were notified on that date. A review of the Nurse ' s Notes dated 1/16/12, no time included, revealed that the treatment for [REDACTED]. A review of the Nurse ' s Notes dated 1/17/12 at 4:30 pm revealed that the wound to Resident #94 ' s right lower buttock classification was changed from an excoriated area to an Unstageable pressure ulcer. Further review revealed that the Nurse Practitioner and responsible party were notified. A review of Resident #94 ' s Wound/Skin Healing Record dated 3/12/12 revealed that the wound to the resident ' s right lower buttock was then staged as a Stage IV pressure ulcer. The pressure ulcer ' s measurements were 3.8 x 3.0 cm with 2.5 cm depth and tunneling was noted. A review of Resident #94 ' s Nurse ' s Notes dated 4/3/12 at 4:00 pm revealed that an x-ray was obtained to the resident ' s right ischial tuberosity to rule out osteo[DIAGNOSES REDACTED] on 4/4/12 due to wound infection and decreased healing. A review of Resident #94 ' s Nurse ' s Notes dated 4/4/12 at 3:00 pm revealed labs were obtained per Nurse Practitioner ' s orders due to the resident ' s altered mental status. Further review revealed that at 5:00 pm the ambulance was called to transport the resident to the hospital due to a critical WBC (white blood cell) count. A review of Resident #94 ' s hospital Discharge Summary revealed that the resident was hospitalized from [DATE] through 05/21/12 with admitting [DIAGNOSES REDACTED]. Further review revealed that the resident received intravenous antibiotics, surgical debridement and that pain medications were increased during the hospitalization . Resident #94 was discharged from the hospital on [DATE] with [DIAGNOSES REDACTED]. A review of Physician ' s Telephone orders for Resident #94 dated 6/14/12 revealed an order for [REDACTED]. An interview was conducted with S7, RN, Treatment Nurse on 6/21/12 at 1:46 pm who confirmed that she completed the skin assessment on Resident #94 on 12/1/11 and identified the wound to her right buttock as an excoriation. S7, RN, Treatment Nurse stated that the wound to Resident #94 ' s right buttock could have been a pressure wound on 12/1/11 due to the fact that it was located over a bony prominence. She stated that there were no interventions to avoid pressure to the resident ' s right buttock and turn every 2 hours due to the fact that there was a dressing over the area and it was not considered a pressure ulcer. An interview was conducted with S2, RN, DON on 6/22/12 at 1:45 pm who stated that Resident #94 ' s Initial Nursing Assessment on 11/30/11 was inaccurate because the skin assessment was not completed. S2, RN, DON also stated that Braden Scale for Predicting Pressure Sore Risk on 11/30/11 could not have been accurate either because the skin assessment was not completed. S2, RN, DON stated that the skin assessment completed 12/1/11 on Resident #94 revealed an excoriation to the resident ' s right buttock could have been a pressure ulcer since the wound was located over a bony prominence. She stated that an intervention on 12/1/11 should have been to begin turning Resident #94 every 2 hours and to keep pressure off of the site to prevent further tissue damage. S2, RN, DON confirmed that there were no interventions on Resident #94 ' s care plan on or around 12/1/11 to relieve pressure to the site of the wound or reposition the resident every 2 hours. An interview was conducted with S17, Corporate Nurse on 06/22/12 at 2 pm who reviewed Resident #94 ' s clinical record and confirmed that there was no documentation to confirm that the resident was being turned or repositioned every 2 hours. An interview was conducted with S2, RN, DON on 6/22/12 at 4:25 pm who confirmed that Resident #94 ' s wound to her right buttock was diagnosed prior to admit on 11/30/11 as a Stage II pressure wound. She stated that the skin assessment completed on 12/1/11 was inaccurate as this was a Stage II pressure ulcer and not an excoriation. S2, RN, DON stated that the wound to Resident #94 ' s right buttock should have been treated as a Stage II pressure ulcer upon admit to the facility on [DATE] with all pressure relieving measures, including relief of pressure to the site. An interview was conducted with Resident #94 ' s husband/responsible party on 6/22/11 at 11:30 am who stated that Resident #94 was hospitalized from [DATE] through 5/21/12 for an infection of a pressure ulcer to her right buttock. He stated that Resident #94 experienced excruciating pain due to the pressure wound that " went all the way to the bone. " He stated that there was no reason for the pressure ulcer that Resident #94 was admitted with on 11/30/11 to deteriorate since she was supposed to be turned every 2 hours and should have been kept off of the wound. He stated that he spends at least 8 hours at the facility every day and that the resident was placed up in her wheelchair each day at 5 am until approximately 1 pm. He stated that the staff only repositioned Resident #94 while up in the wheelchair when her head was falling over to the side of the chair. Resident #94 was uninterviewable due to cognition but observations on 6/18/12 at 12:01 pm, 6/19/12 at 11:20 am, 6/20/12 at 12:00 pm, 6/21/12 at 11:45 am, 6/22/12 at 11:30 am, 6/25/12 at 11:50 am and 6/26/12 at 11:15 am were made of the resident in the dining room and these observations failed to reveal staff repositioning the resident. Each observation revealed that Resident #94 was seated upright in a tilted wheelchair at the dining table each observation and with her husband at her side. An interview was conducted with S9, Nurse Practitioner on 6/21/12 at 2:20pm who confirmed that he was aware that Resident #94 had a wound to her right buttock on 12/1/11 but was informed that it was an excoriation. S9, Nurse Practitioner stated that based on the measurements on 12/1/11 by S7, RN, Treatment Nurse that this wound could have been considered a Stage II Pressure Ulcer. He stated that if the nursing staff would have identified Resident #94 ' s wound to her right buttock as a Stage II pressure ulcer that he would have expected the staff to keep her off of the wound site which was a bony prominence at risk for pressure and additional tissue damage. An additional interview was conducted with S9, Nurse Practitioner on 06/25/12 at 12:20 pm caring for Resident #94. S9, Nurse Practitioner stated that he did not assess Resident #94 ' s wound to her right buttock until 1/16/12 at which time it was an Unstageable pressure ulcer with eschar. S9, Nurse Practitioner stated that he went by the assessment completed by S7, RN, Treatment Nurse and that he did not view the wound until she notified him that it was a pressure wound. He stated that Resident #94 ' s wound was covered with a dressing until 1/16/12 and that he did not remove the dressing to visualize the wound since he was under the impression that it was not a pressure wound. B. Based on record review, interview and observation, the facility failed to and/or was delayed in providing necessary treatment and services to promote healing, prevent infection and prevent new sores from developing on 2 separate re-admissions for resident #30. The facility failed to assess, notify, and provide wound care according to the facility's Pressure Ulcer Prevention Program protocol for 1 (#30) of 5 sampled residents with pressure ulcers (# 30, 105, 94, 49, and 106).The facility failed to: 1) Conduct a thorough skin assessment on 4/20/12 readmission to the facility (#30). 2) Notify the physician/NP on 4/20/12 of the presence of sacral and left buttock stage 2 pressure ulcers found on resident readmission to the nursing facility on 4/20/12. (#30) 3) Notify the physician/NP from 4/20/12 to 4/23/12 of sacral and left buttock stage 2 pressure ulcers identified on resident ' s readmission to the facility o 4/20/12 (30). 4) Obtain physician orders [REDACTED]. (30) 5) Provide care and treatment for [REDACTED]. (#30) 6) Conduct a thorough skin assessment on a sacral decubitus wound on 6/18/12 on readmission to the facility. (30) 7) Notify the physician/NP from 6/18/12 to 6/19/12 of a sacral pressure ulcer noted on readmission of the resident to the facility on [DATE] until it was staged as unstageable pressure ulcer on 6/19/12.(#30) 8) Obtain physician orders [REDACTED]. (#30) 9) Provide care and treatment of [REDACTED]. (#30) FINDINGS: RESIDENT # 30 During a review of resident #30's record on 6-25-12, it was revealed that the resident was a [AGE] year old female who was originally admitted into the facility on [DATE]. The Face Sheet listed [DIAGNOSES REDACTED].. and other medical diagnosis. Both staff members, S2DON and S7Tx. RN, confirmed the facility had no additional documentation to produce which would have supported that the facility's protocol/procedures/standing plan of care was followed for any of resident #30's readmission's of 4-20-12 or 6-18-12. The Face sheet also indicated that the resident was recently readmitted back into the facility on [DATE] after a hospital stay. Additional record review with S2DON and S7Tx. RN, on 6-25-12 at 3:55 p.m., indicated resident #30 was documented as having clear skin on a Weekly Skin Check dated for April 9th, 2012 on the Treatment Administration Record (TAR). S2DON pointed out and explained the check mark located next to the initials of the nurse assessing the resident, indicated that the nurse found no issues with the resident's skin and previous pressure ulcers on the resident had healed. The TAR was noted to have a (H) documented on the following week (4-16-12), which S2DON explained, represented the fact that resident #30 was admitted into the hospital at that time. Review of resident #30's Nurse's Notes dated 4-12-12 and timed for 14:30 (2:30 p.m.), revealed documentation that the resident was sent to the hospital on [DATE] and was admitted . A Resident Summary Re-Admission form dated 4-20-12, documented that the resident arrived back at the facility at 6:30 p.m. on 4/20/12. The Re-Admission Resident Summary also documented that the resident had stage II pressure ulcers to sacrum and left buttocks. The human anatomical diagram on the Re-Admission Summary was noted to identify the locations of the areas of concern with (X's) on the backside of the diagram at the areas of the sacrum and the left buttocks. There was no documentation of measurements, physician orders [REDACTED]. A review of the April 2012 TAR revealed that the Left upper buttock and the left mid buttock pressure ulcer instructions/treatments were initiated on 4-23-12 as evidenced by the staff's initials. A review of the 4-20-12 admission orders [REDACTED]. The first documented evidence of physician notification, concerning the resident's two pressure ulcers, was that of the Physician's Telephone Order dated 4-23-12 and timed for 14:00 (2:00 p.m.). In addition, both S2DON and S7Tx. RN confirmed that the documentation on the facility's Weekly Pressure QI Log and the Wound / Skin Healing Record, for the Left Mid Buttock stage II pressure ulcer, and the Left Upper Buttock Stage II pressure ulcer, each documented the onset of the wounds as 4-20-12, (date of re-admission). Both S2DON and S7Tx. RN also confirmed that the date of notification for dietary, family, and the physician was documented as 4-23-12, (3 days after the resident's return/re-admission). No additional documentation, concerning wound treatment or assessment, prior to 4-23-12, was produced by S2DON or S7Tx. RN. The 4-23-12 assessment on the facility's Wound/Skin Healing Record for the Stage II Left Mid Buttock measured 3.0 x 4.3 x 0.1 cm. S2DON confirmed that the Wound/Skin Healing Record also documented the Left Upper Buttock Stage II pressure ulcer was present upon resident #30's re-admit of 4-20-12, and was assessed for the first time on 4-23-12 as measuring 1.0 x 1.5. x 0.1 cm. Additional review of resident 30's record with S2DON and S7Tx. RN on 6-25-12 at 3:55 p.m., revealed resident #30 was again sent out to the hospital on 6-11-12 and readmitted back to the facility on [DATE]. The Statement of Medical Status dated 6-18-12 documented that resident #30 had a sacral decubitus. Review of the Skilled Daily Nurses note from 6-18-12 at 6:30 p.m. revealed resident #3- returned to the facility on [DATE]. The Skilled Daily Nurses note documented that resident #30 had a sacral wound covered with [MEDICATION NAME] but contained no assessment of the wound status or treatment. The first documentation regarding assessment of the resident's pressure ulcer status, was noted on the Wound/Skin Healing Record dated 6-19-12 at which time the wound was assessed/measured and documented as Unstageable. The first documentation of physician notification was in the form of the a Physician's Telephone Order for wound care/treatment dated 6-19-12 and timed for 2:50 p.m., (20 hours after the resident returned to the nursing home), and when assessed, the wound was assessed as an unstageable 4.0 x 4.4 x 0.1 cm left upper buttock/sacral pressure ulcer. The review of resident #30's record with S2DON and S7Tx. RN on 6-25-12 at 3:55 p.m. confirmed that the facility did not provide necessary treatment and services to promote healing, prevent infection and prevent new sores from developing on 2 separate re-admissions for resident #30. C). Based on record review, interview and observation, the facility failed to provide care and service to prevent the development of new pressure sores for residents who did not have pressure sores for 1(#105) of 5 sampled residents with pressure ulcers (# 30, 105, 94, 49 and 106). The facility failed to: 1) Identify the wheelchair alarm cord as a potential cause of a pressure ulcer for a resident with a history of pressure sore development. (# 105) 2) Prevent the development of a stage II pressure ulcer on a resident ' s left upper lateral thigh caused by the wheelchair alarm cord. (#105) 3) Ensure staff identified a stage II pressure ulcer on a resident ' s left upper lateral thigh.(# 105) Findings: Resident # 105 Record review of the Nurses Notes dated 6-13-12 read, "Resident arrived to facility. Left buttock has open area 2 cm x 1.2 cm with linear line 0.3 cm x 4.0 cm. Right side has opening 0.3 cm x 0.1 cm. Redness to lower buttock." Record review of the Wound/Skin Healing record revealed the following: On 6-13-12 right buttock was a stage II pressure sore that measured 0.3 cm by 0.1cm. On 6-18-12 right buttock was a stage II pressure sore that measured 0.3 cm by 0.1 cm. On 6-13-12 left buttock was a stage II pressure sore that measured 2 cm by 1.2 cm. On 6-18-12 left buttock was a stage II pressure sore that measured 2 cm by 1.2 cm. Record review of Resident #105's Skin Condition Record for non-pressure ulcer skin condition revealed the following: On 6-13-12 left wrist abscess measured 0.6 cm by 1.1 cm. On 6-19-12 left wrist abscess measured 0.5 cm by 1.0 cm. Care Plan review revealed Resident #105 had a potential for skin breakdown. The staff was to do weekly skin assessment per facility protocol and monitor skin for signs and symptoms of breakdown or redness during all direct care. On 6-25-12 at 11:45 a.m. an observation of Resident #105 skin with S7Tx.RN revealed the resident had a left wrist abscess that measured 1.2 cm by 0.5 cm that was a healing sore, a left buttock stage II that was a healing pressure sore. a right buttock pink area that was healed, and a left lateral upper thigh that measured 0.2 cm by 2.3 cm that was a stage II pressure sore. S7 Tx. RN palpated this pressure area and the resident jumped and moaned. On 6-25-12 at 11:50 a.m. an interview with S7Tx RN revealed the wound on Resident # 105 left lateral upper thigh that measured to be 0.2 cm by 2.3 cm was a stage II pressure sore. She further stated that she was not aware of this pressure sore. She revealed that the pressure sore was caused by the cord attached to the wheel chair alarm. Record review of the Wound/Skin Healing record revealed the following: On 6-25-12 right buttock was a stage II pressure sore that measured 0.6 cm by 0.6 cm. On 6-25-12 left buttock was a stage II pressure sore that measured 0.3 cm by 0.3 cm. On 6-25-12 left upper thigh lateral stage II pressure sore that measured 0.2 cm by 2.3 cm. Record review of Resident #105's Skin Condition Record for non-pressure ulcer skin condition revealed the following: On 6-25-12 left wrist abscess measured 0.5 cm by 1.2 cm. Record review of the Physicians Orders dated 6-25-12 read, "Left upper thigh, Lateral Pressure stage II: clean with saf-cleans, pat dry. Apply sensicare daily and PRN until healed." Record Review of the In-Service Training Report dated 6-26-12 revealed S7Tx.RN in-serviced LPN's and C.N.A.'s when putting resident into chair, make sure chair alarm cord is not on seat of chair. This could cause skin breakdown.

A) Based on record review, interview and observation, the facility failed to ensure that a resident having a pressure sore received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for 1 (#94) of 5 ( 30, 105, 94, 106, and 49) sampled residents identified with pressure ulcers during the survey process. The Facility failed to: 1) Conduct an accurate skin assessment on [DATE] when Resident #94 was admitted to the facility from the hospital and the skin assessment was not completed. 2) Accurately stage a right lower buttock skin wound as a stage II pressure wound when it was discovered on [DATE]. (#94) 3) Notify the physician/nurse practitioner on [DATE] when a skin wound was identified on the resident ' s right lower buttock area on [DATE] (Resident #94) 4) Conduct accurate ongoing skin assessments of a resident's right lower buttock skin wound from [DATE] through [DATE]. (#94) 5) Identify and implement pressure relieving interventions from [DATE] to [DATE] to prevent the progression of a stage ll right lower buttock pressure wound to an unstageable pressure wound (#94) 6) Implement the plan of care for pressure relieving interventions from [DATE] to [DATE] for resident #94. 7) Obtain treatment orders for a stage ll pressure ulcer (#94) 8) Follow the physician's order [REDACTED]. 9) Provide necessary treatment and service to promote healing, prevent infection and prevent new sores from developing on 2 separate re-admissions. (#94) These failed practices resulted in resident #94 ' s stage ll pressure ulcer advancing to a stage IV pressure ulcer. Resident #94 was hospitalized from [DATE] through [DATE] with an admitting [DIAGNOSES REDACTED]. Resident #94 received intravenous antibiotics, surgical debridement of the stage IV sacral decubitus and pain medications during the hospitalization . Resident #94 was placed in immediate jeopardy on [DATE] when she was admitted to the facility and in incomplete, inaccurate skin assessment was conducted. The resident's right lower buttock skin wound was incorrectly assessed as an excoriated area on [DATE]. The facility did not accurately assess the resident's right lower buttock skin wound until it had deteriorated to an unstageable wound on [DATE]. On [DATE], the wound was staged as a stage IV pressure ulcer with tunneling. Resident #94 was hospitalized from [DATE] through [DATE] with an admitting [DIAGNOSES REDACTED]. Resident #94 received intravenous antibiotics, surgical debridement of the stage IV sacral decubitus and pain medications during the hospitalization . The administrator was informed of the Immediate Jeopardy on [DATE] at 4:54 pm. The plan of removal was received and the Immediate Jeopardy was lifted on [DATE] at 4:09 pm when the facility ensured that all skin assessments were repeated for accuracy and that all staff was trained on accurate skin assessments. The deficient practice was reduced to an isolated actual harm for Resident #94. FINDINGS: RESIDENT # 94: A review of Resident #94 ' s clinical record revealed that the resident was admitted to the facility from a Hospital on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #94 ' s Hospital records dated [DATE] revealed a [DIAGNOSES REDACTED]. A review of Resident #94 ' s Skilled Daily Nurses Note failed to reveal findings under the section for the assessment of the resident ' s skin condition. Further review of the nurse ' s note on [DATE] at 5:20 pm revealed that the resident was admitted and that the staff was, " Unable to check skin. Passed on to oncoming nurse. " A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated [DATE] revealed an excoriated area to the right lower buttock. Further review revealed that the excoriated area measured 3.2 x 2.1 cm with <.1 cm depth and scant blood exudate was observed along with a pink wound bed. A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated [DATE] revealed the excoriated area to the right lower buttock measurements were 4.6 x 2.5 cm with 0.1 cm depth and that the wound contained slough in the wound bed. A review of Resident #94 ' s Nurse Practitioner Progress notes dated [DATE] failed to reveal that the resident had a pressure ulcer. A review of the Progress notes dated [DATE] revealed that the resident had a sacral wound and the area designated for pressure ulcers was blank. A review of a verbal physician's orders [REDACTED]. A review of the Nurse Practitioner Progress notes dated [DATE] revealed a new [DIAGNOSES REDACTED]. A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated [DATE] revealed that the area to the resident ' s right lower buttock then deteriorated to an Unstageable Wound. Further review revealed that the wound measured 5.1 x 3.2 cm with a depth of 0.1 cm and that tan slough and black eschar were present in the wound bed. Further review of the clinical record revealed that a Wound/Skin Healing Record began on [DATE] with the same findings and that the Physician and Resident #94 ' s responsible party were notified on that date. A review of the Nurse ' s Notes dated [DATE], no time included, revealed that the treatment for [REDACTED]. A review of the Nurse ' s Notes dated [DATE] at 4:30 pm revealed that the wound to Resident #94 ' s right lower buttock classification was changed from an excoriated area to an Unstageable pressure ulcer. Further review revealed that the Nurse Practitioner and responsible party were notified. A review of Resident #94 ' s Wound/Skin Healing Record dated [DATE] revealed that the wound to the resident ' s right lower buttock was then staged as a Stage IV pressure ulcer. The pressure ulcer ' s measurements were 3.8 x 3.0 cm with 2.5 cm depth and tunneling was noted. A review of Resident #94 ' s Nurse ' s Notes dated [DATE] at 4:00 pm revealed that an x-ray was obtained to the resident ' s right ischial tuberosity to rule out osteo[DIAGNOSES REDACTED] on [DATE] due to wound infection and decreased healing. A review of Resident #94 ' s Nurse ' s Notes dated [DATE] at 3:00 pm revealed labs were obtained per Nurse Practitioner ' s orders due to the resident ' s altered mental status. Further review revealed that at 5:00 pm the ambulance was called to transport the resident to the hospital due to a critical WBC (white blood cell) count. A review of Resident #94 ' s hospital Discharge Summary revealed that the resident was hospitalized from [DATE] through [DATE] with admitting [DIAGNOSES REDACTED]. Further review revealed that the resident received intravenous antibiotics, surgical debridement and that pain medications were increased during the hospitalization . Resident #94 was discharged from the hospital on [DATE] with [DIAGNOSES REDACTED]. A review of the Braden Scale - For Predicting Pressure Sore Risk for Resident #94 dated [DATE] revealed a score of 17 to indicate that the resident was at mild risk for pressure ulcers. A review of the Admit Assessment-Resident Summary dated [DATE] revealed that sacral decubitus with [MEDICAL CONDITION] and osteo[DIAGNOSES REDACTED] of the ischium. A review of Physician ' s Telephone orders for Resident #94 dated [DATE] revealed an order for [REDACTED]. A review of Resident #94 ' s Nurse Practitioner Progress notes dated [DATE] failed to reveal that the resident had a pressure ulcer. A review of the Progress notes dated [DATE] revealed that the resident had a sacral wound and the area designated for pressure ulcers was blank. A review of the Nurse Practitioner Progress notes dated [DATE] revealed a new [DIAGNOSES REDACTED]. An interview was conducted with S7, RN, Treatment Nurse on [DATE] at 1:46 pm who confirmed that she completed the skin assessment on Resident #94 on [DATE] and identified the wound to her right buttock as an excoriation. S7, RN, Treatment Nurse stated that the wound to Resident #94 ' s right buttock could have been a pressure wound on [DATE] due to the fact that it was located over a bony prominence. She stated that there were no interventions to avoid pressure to the resident ' s right buttock and turn every 2 hours due to the fact that there was a dressing over the area and it was not considered a pressure ulcer. An interview was conducted with S2, RN, DON on [DATE] at 1:45 pm who stated that Resident #94 ' s Initial Nursing Assessment on [DATE] was inaccurate because the skin assessment was not completed. S2, RN, DON also stated that Braden Scale for Predicting Pressure Sore Risk on [DATE] could not have been accurate either because the skin assessment was not completed. S2, RN, DON stated that the skin assessment completed [DATE] on Resident #94 revealed an excoriation to the resident ' s right buttock could have been a pressure ulcer since the wound was located over a bony prominence. She stated that an intervention on [DATE] should have been to begin turning Resident #94 every 2 hours and to keep pressure off of the site to prevent further tissue damage. S2, RN, DON confirmed that there were no interventions on Resident #94 ' s care plan on or around [DATE] to relieve pressure to the site of the wound or reposition the resident every 2 hours. An interview was conducted with S17, Corporate Nurse on [DATE] at 2 pm who reviewed Resident #94 ' s clinical record and confirmed that there was no documentation to confirm that the resident was being turned or repositioned every 2 hours. An interview was conducted with S2, RN, DON on [DATE] at 4:25 pm who confirmed that Resident #94 ' s wound to her right buttock was diagnosed prior to admit on [DATE] as a Stage II pressure wound. She stated that the skin assessment completed on [DATE] was inaccurate as this was a Stage II pressure ulcer and not an excoriation. S2, RN, DON stated that the wound to Resident #94 ' s right buttock should have been treated as a Stage II pressure ulcer upon admit to the facility on [DATE] with all pressure relieving measures, including relief of pressure to the site. An interview was conducted with Resident #94 ' s husband/responsible party on [DATE] at 11:30 am who stated that Resident #94 was hospitalized from [DATE] through [DATE] for an infection of a pressure ulcer to her right buttock. He stated that Resident #94 experienced excruciating pain due to the pressure wound that " went all the way to the bone. " He stated that there was no reason for the pressure ulcer that Resident #94 was admitted with on [DATE] to deteriorate since she was supposed to be turned every 2 hours and should have been kept off of the wound. He stated that he spends at least 8 hours at the facility every day and that the resident was placed up in her wheelchair each day at 5 am until approximately 1 pm. He stated that the staff only repositioned Resident #94 while up in the wheelchair when her head was falling over to the side of the chair. Resident #94 was uninterviewable due to cognition but observations on [DATE] at 12:01 pm, [DATE] at 11:20 am, [DATE] at 12:00 pm, [DATE] at 11:45 am, [DATE] at 11:30 am, [DATE] at 11:50 am and [DATE] at 11:15 am were made of the resident in the dining room and these observations failed to reveal staff repositioning the resident. Each observation revealed that Resident #94 was seated upright in a tilted wheelchair at the dining table each observation and with her husband at her side. An interview was conducted with S9, Nurse Practitioner on [DATE] at 2:20pm who confirmed that he was aware that Resident #94 had a wound to her right buttock on [DATE] but was informed that it was an excoriation. S9, Nurse Practitioner stated that based on the measurements on [DATE] by S7, RN, Treatment Nurse that this wound could have been considered a Stage II Pressure Ulcer. He stated that if the nursing staff would have identified Resident #94 ' s wound to her right buttock as a Stage II pressure ulcer that he would have expected the staff to keep her off of the wound site which was a bony prominence at risk for pressure and additional tissue damage. An additional interview was conducted with S9, Nurse Practitioner on [DATE] at 12:20 pm caring for Resident #94. S9, Nurse Practitioner stated that he did not assess Resident #94 ' s wound to her right buttock until [DATE] at which time it was an Unstageable pressure ulcer with eschar. S9, Nurse Practitioner stated that he went by the assessment completed by S7, RN, Treatment Nurse and that he did not view the wound until she notified him that it was a pressure wound. He stated that Resident #94 ' s wound was covered with a dressing until [DATE] and that he did not remove the dressing to visualize the wound since he was under the impression that it was not a pressure wound. B) Based on record review and interview the facility failed to keep a resident at his highest practicable well being by not notifying the resident ' s physician when the resident had a change in condition for 1(#17) of 35 sampled residents. The immediate jeopardy situation began on [DATE] at 9:00 AM when the resident (#17) was too lethargic to complete his Speech Therapy due to lethargy. At that time the resident ' s son stated, this is not my father he is too sedated. " The Immediate Jeopardy situation was lifted 0n [DATE] at 10:09 PM when an ambulance was called to bring the resident to the hospital. The client ' s [DIAGNOSES REDACTED]. Findings: On [DATE] resident #17 ' s record was reviewed. It revealed that on [DATE] at 9:00 AM the resident was participating in Speech Therapy. It also stated that the therapy lasted less than 15 minutes due to the resident ' s lethargy. At that time the resident ' s son asked that he " meet with his father ' s doctor for a possible dose reduction on some drugs if possible related to increased lethargy. " The resident ' s son then stated, " This is not my father he is too sedated. " Notes continue, " Will place on Nurse Practitioner log for now for evaluation. " On [DATE] at 1230 PM the resident ' s nurses notes stated " Picking at lunch. No complaints. " On [DATE] at 4:00 AM Awake in bed. No disorientation. However lethargic. Oxygen on saturation 95%. (Resident ' s) Son at bedside concerned about lethargy. Son wants to speak with nurse practitioner/Dr concerning meds that may be causing lethargy. Noted also to nurse practitioner log. " On [DATE] at 9:00 AM the resident ' s nurses notes read, " N.O. (new order) 1. Dysphagia Consult including a modified [MEDICATION NAME] swallow ordered by speech therapy ordered by speech therapy. 2. Change [MEDICATION NAME] to 250 mg by mouth three times a day. NH4(ammonia level, CMP(complete metabolic profile) in AM. Dx ([DIAGNOSES REDACTED]. On [DATE] at 10:00 AM the resident ' s nurses notes stated, " patient uncooperative with staff. Refuses to attempt any self care. Wants staff to do everything for him but is capable of doing things for himself. Continues to throw trash on the floor and discard plastic bags for oxygen tubing. " On [DATE] at 12:30 AM the resident ' s nurses notes stated, " Resident in room yelling for a glass of milk. Instructed resident to use call bell and not yell because he is disturbing the other residents. " On [DATE] at 3:00 AM the resident ' s nurses notes stated that the " resident was on the floor. He stated he wanted to sit up. Resident assisted to wheelchair. " On [DATE] (no time given) the resident ' s nurses notes stated, " resident defecated on wheelchair and put himself back in bed. Sexually inappropriate with staff. Continues to throw trash on the floor. Screaming and cursing out staff while trying to clean him. Uncooperative and abusive to staff. " On [DATE] at 9:55 PM the resident ' s nurses notes state, " resident found lying on floor face down. Resident states he rolled out of bed responsible party and S19 (nurse practitioner) notified. " On [DATE] at 9:58PM CNA assisted with picking resident up. " On [DATE] at 10:05 the resident ' s nurses notes stated, " summoned to resident ' s room by CNA, upon entering room resident unresponsive apnea noted faint pulse noted CBG 152, diaphoretic, pupils fixed, cyanosis noted ALCD noted to left chest wall. " On [DATE] at 10:09 PM the resident ' s nurses notes stated, " S9 (nurse practitioner) notified, CPR initiated ambulance called out STAT. " On [DATE] at 10:40 PM the resident ' s nurses notes stated, " Resident pronounced per ER doctor from local hospital. " On [DATE] at 2:30 PM S3 ADON was interviewed. She stated that she was aware that the resident had gone to the hospital earlier in the month for lethargy. In addition, S2 DON , at that time , confirmed the same. On [DATE] at 2:45 PM S9 (nurse practitioner) was interviewed. He stated that given the information he had now that the nurse taking care of the resident on [DATE] should have informed me about the resident ' s declining condition. I would have been able to order the labs at that time instead of 24 hours later when I got the note about his condition. " On [DATE] the resident ' s record was reviewed. It revealed the resident had an ammonia panic level of 135. The facility was not informed of this panic level until the day after the resident expired. C) Based on observation, record review and interviews the provider failed to maintain Resident #8 highest practicable physical well-being in accordance with the resident plan of care. This was evidence by the staff failing to report that resident #8's eyes were covered with green mucous on [DATE] to ensure she got treated by the physician. This occured for 1 of 35 sampled residents (Resident #8). Findings: On [DATE] at 8:17 a.m. an observation was made of Resident #8 sitting in the dining room drinking a cup of coffee. The residents left eye was completely covered by a thick layer of green mucous that was obstructing her vision. Her right eye had green mucous lining her upper and lower eyebrow. The resident had to clear her left eye with her finger to see the surveyor during the interview. Care Plan Review revealed Resident #8 had a potential for Infection related to a history of [MEDICAL CONDITION]. The goal was the Infection will be accurately identified and resolved through nursing interventions. The approach was to monitor for signs and symptoms of [MEDICAL CONDITION] and report to the physician.. On [DATE] at 3:35 p.m. an interview with S8LPN revealed that Resident #8 should not have mucous in her eyes. She further revealed the resident has a order to put artificial tears in her eyes three times a day . She also revealed that no one had informed her that Resident #8 had green mucous in her eyes on [DATE]. On [DATE] at 4:15 p.m. an observation of Resident #8 revealed she had light yellow mucous that lined the residents Left eye causing her eye lashes to clump together. Record review of the Nurses Note for the dates of [DATE] to [DATE] revealed there was No documentation of thick green mucous drainage or that the resident had complained of her left eye itching. On [DATE] at 9:20 a.m. an observation of Resident #8 was made of her in a wheel chair in the hall. It was observed a small amount yellow mucous on her eyelashes of her left eye. On [DATE] at 9:40 a.m. an interview with S3ADON revealed she's the infection control nurse. She stated none of the nurses told her that Resident #8 had drainage in her eyes. She further revealed she looked back as far as [DATE] in the facilities Nurses Notes and the hospice staffs (nurses and C.N.A) notes and there was no documentation of any drainage in Resident #8's eye. She revealed the staff should assess the drainage and report their findings to her as the infection control nurse. On [DATE] at 9:50 a.m. an interview with S8LPN revealed she wrote in the communication log for S9NP to assess Resident #8's for eye infection. She stated since the resident is on hospice she would inform the hospice nurse and the hospice nurse would assess the resident and write the orders if needed. On [DATE] at 10:10 a.m an interview with S10C.N.A. revealed resident #8 normally has mucous in her eyes every morning. She revealed this was normal for the resident. S10 stated she wiped the mucous out of the residents eyes every morning. She stated she didn't inform anyone of the mucous in the residents eyes. On [DATE] at 12:15 p.m. Resident #8 was asked if her eyes bothered her and she lifted her right hand and rubbed her left eye and stated her eye itched. On 6- ,[DATE] at 12:30 p.m. an interview with Resident #8 with S3ADON present the resident was asked if her eyes itched and she pointed at her left eye and stated her left eye itched. At this time S3ADON stated the resident was able to inform the staff of her needs. On [DATE] at 2:15 p.m. in an interview with S9NP he was asked if anyone had reported to him that Resident #8 had green mucous in her eyes or that she complained her left eye itched. He stated that no one had informed him that Resident #8 had any issues with her eyes. Surveyor explained to S9NP of the observation on [DATE] of the thick green mucous drainage from the residents eyes and her complaint of her Left eye itching. At this time S9 stated this was a different and he revealed these symptoms were signs of infection with the thick green drainage and itching. He revealed he would put Resident #8 on antibiotic eye drops and not [MEDICATION NAME] drops because she's in a Nursing Home and susceptible to infections. He stated the Hospice Nurse told him she had looked at the resident and said she didn't see any problems. Record review of the Progress Notes dated [DATE] read, "after speaking with staff and evaluating patients eyes, unsure of possible infection verses allergy to eyes. Will treat empirically to prevent. Resident #8 presented with eye discharge. Mild. Located in the left eye and in the right eye." Record review of the Physicians Orders dated [DATE] read, "[MEDICATION NAME] (antibiotic) one drop three times a day for 5 days (Empirical preventative measures). Diagnosis: [REDACTED]."

Based on record review, interview and observation, the facility failed to ensure that services were provided in accordance with each resident ' s written plan of care as evidenced by: 1) failing to ensure that a resident was turned and repositioned every 2 hours as per the plan of care (#94) and 2) failing to ensure that a resident received care for pressure ulcers upon admit assessment according to the plan of care and facility protocol for 2 (#94 and # 30) of 5 residents reviewed for pressure ulcers out of 29 total residents receiving preventative care to prevent pressure ulcers 3) failing to ensure that a bed alarm was in place for a resident as per the plan of care (#86) and 4) failing to ensure that residents received nailcare as per the plan of care (#21,#8) This failure to ensure that Resident #94 was turned or repositioned every 2 hours to as per the plan of care resulted in a Stage II pressure ulcer to her right buttock progressing from a Stage II on admit to a Stage IV which required hospitalization [MEDICAL CONDITION], osteo[DIAGNOSES REDACTED] and pain due to the necrotic pressure wound. As a result, Resident #94 and 29 other residents, identified by facility as requiring preventative skin care, residing in the facility were placed at a potential for injury, harm or impairment which places them in an immediate jeopardy. The administrator was informed of the Immediate Jeopardy on 06/22/12 at 4:54 pm. The plan of removal was received and the Immediate Jeopardy was lifted on 06/26/12 at 4:09 pm when the facility ensured that all skin assessments were repeated for accuracy and that all staff was trained on accurate skin assessments. The deficient practice was reduced to an isolated actual harm for Resident #94. FINDINGS: 1) Resident #94 A review of Resident #94 ' s clinical record revealed that the resident was admitted to the facility from a hospital on [DATE] with [DIAGNOSES REDACTED]. A review of a verbal physician's order [REDACTED].#94 every 2 hours while in bed. A review of the Nurse ' s Notes dated 1/17/12 at 4:30 pm revealed that a wound to Resident #94 ' s right lower buttock classification was changed from an excoriated area to an Unstageable pressure ulcer. A review of Resident #94 ' s Wound/Skin Healing Record dated 3/12/12 revealed that the wound to the resident ' s right lower buttock was then staged as a Stage IV pressure ulcer. The pressure ulcer ' s measurements were 3.8 x 3.0 cm with 2.5 cm depth and tunneling was noted. A review of Resident #94 ' s care plan revealed care planning for pressure ulcer which was identified on 1/16/12 with intervention to turn and reposition the resident every 2 hours and as needed to keep pressure off of the ulcer. Further review revealed that the problem onset (pressure ulcer) was 1/16/12 with a goal date of 3/16/12. A review of the clinical record, including MAR (Medication Administration Records) and ADL (Activities of Daily Living) Kiosk with S16, Corporate Nurse revealed staff turning and repositioning Resident #94 every shift. An interview was conducted with S17, Corporate Nurse on 06/22/12 at 2 pm who reviewed Resident #94 ' s clinical record and confirmed that there was no documentation to confirm that the resident was being turned or repositioned every 2 hours. An interview was conducted with S2, RN, DON on 6/22/12 at 1:45 pm who stated that Resident #94 ' s care plan should have included an intervention on 12/1/11 to begin turning every 2 hours and to keep pressure off of the site to prevent further tissue damage. S2, RN, DON confirmed that there were no interventions on Resident #94 ' s care plan on or around 12/1/11 to relieve pressure to the site of the wound or reposition the resident every 2 hours. An interview was conducted with S2, RN, DON on 6/22/12 at 4:25 pm who confirmed that Resident #94 ' s wound to her right buttock was diagnosed prior to admit on 11/30/11 as a Stage II pressure wound. She stated that the skin assessment completed on 12/1/11 was inaccurate as this was a Stage II pressure ulcer and not an excoriation. S2, RN, DON stated that the wound to Resident #94 ' s right buttock should have been treated as a Stage II pressure ulcer upon admit to the facility on [DATE] with all pressure relieving measures, including relief of pressure to the site. An interview was conducted with Resident #94 ' s husband/responsible party on 6/22/11 at 11:30 am who stated that Resident #94 was hospitalized from [DATE] through 5/21/12 for an infection of a pressure ulcer to her right buttock. He stated that Resident #94 experienced excruciating pain due to the pressure wound that " went all the way to the bone. " He stated that there was no reason for the pressure ulcer that Resident #94 was admitted with on 11/30/11 to deteriorate since she was supposed to be turned every 2 hours and should have been kept off of the wound. He stated that he spend at least 8 hours at the facility every day and that the resident was placed in up in her wheelchair each day at 5 am until approximately 1 pm. He stated that the staff only repositioned Resident #94 while up in the wheelchair when her head was falling over to the side of the chair. Resident #94 was uninterviewable due to cognition but observations on 6/18/12 at 12:01 pm, 6/19/12 at 11:20 am, 6/20/12 at 12:00 pm, 6/21/12 at 11:45 am, 6/22/12 at 11:30 am, 6/25/12 at 11:50 am and 6/26/12 at 11:15 am were made of the resident in the dining room and these observations failed to reveal staff repositioning the resident. Each observation revealed that Resident #94 was seated upright in a tilted wheelchair at the dining table each observation and with her husband at her side. An interview was conducted with S9, Nurse Practitioner on 6/21/12 at 2:20pm who confirmed that he was aware that Resident #94 had a wound to her right buttock on 12/1/11 but was informed that it was an excoriation. S9, Nurse Practitioner stated that based on the measurements on 12/1/11 by S7, RN, Treatment Nurse that this wound could have been considered a Stage II Pressure Ulcer. He stated that if the nursing staff would have identified Resident #94 ' s wound to her right buttock as a Stage II pressure ulcer that he would have expected the staff to keep her off of the wound site which was a bony prominence at risk for pressure and additional tissue damage. 2) Resident #30 Resident #30 was recently readmitted back into the facility on 2 separate occasions after inpatient hospital stays. On each of the two re-admits, resident #30's record documented that she had pressure ulcers to her buttocks/sacral areas upon her re-admit. The two dates of which resident #30 was readmitted back into the facility, were 4-20-2012, and 6-18-2012. A review of the facility's form for protocols/procedures, (Pressure Ulcer Prevention Program, revised October 2010), revealed the following documented (Standard): (All residents will be assessed for the risk of pressure ulcer development at the time of admission, ...... etc. Based on the results of this assessment, specific interventions will be implemented to prevent, ...., or treat existing pressure ulcers). The documentation in the section labeled as, (Procedure), revealed: ( 1. All resident will be screened for risk of pressure ulcer development utilizing the Braden Scale/Norton Scale. This will be done at the time of admission/readmission, ..... etc). (5. If a pressure ulcer/skin breakdown is identified,the following will be done, -- The licensed nurse will complete a thorough assessment of the affected area. The assessment must include size, stage, location, drainage and odor. -- The licensed nurse will notify the physician and the family. -- Treatment will be initiated per physician orders. ... etc). A review of the facility's (Admission/Readmission Checklist) for resident #30, dated 4-20-12, revealed the following procedures were checked off as performed, in addition to others: * If a resident has overnight stay, all assessments must be redone, ... etc. * .... Notify physician for additional [DIAGNOSES REDACTED]. . * Nursing admissions assessment completed .... . * Braden scale completed-If <18 skin risk analysis form and interventions initiated. * Skin check completed-treatment initiated as needed - If non pressure use ...., and if decubitus, use "Wound/Skin Healing Record". RP notified. Results placed on 24 hour report. *Interim plan of care completed - use "Admission Care Plan". The form was signed by the nurse completing the form and dated 4-20-12 (date of one of the resident's readmission's). A review of the resident #30's record for the readmission of 4-30-12, revealed the following. A Resident Summary Re-Admission form dated 4-20-12, documented that the resident arrived back at the facility at p.m. on that day. The Re-Admission Resident Summary also documented that the resident had stage II pressure ulcers to (Sacrum, left Buttocks). Under the Skin Treatments section of the form, it documented (See TAR). The anatomical human diagram on the Re-Admission Summary was noted to identify the locations of the areas of concern with (X's) on the backside of the diagram at the areas of the sacrum and the left buttocks. A review of of resident #30's record with S2DON and S7Tx. RN on 6-25-12 at 3:55 p.m. revealed in the facility's Weekly Pressure Ulcer QI Log, that the resident was admitted back into the facility on [DATE] with both the Left upper buttock stage II pressure ulcer and the Left mid buttock stage II pressure ulcer. Review of the facility's Wound/Skin Healing Record, revealed and indicated that resident #30 was admitted on [DATE] with both the Left mid buttock stage II pressure ulcer and the Left upper buttock stage II pressure ulcer. Continued review of the Wound/Skin Healing Records for resident #30 revealed that neither of the two pressure wounds received an assessment/measurement, or treatments until 4-23-12 (3 days after re-admit). Both S2DON and S7TX. RN confirmed that the facility had no documentation of an assessment of, physician/RP notification of, or physician's orders [REDACTED]. The 4-23-12 dated assessments/treatments were the facility's first assessments/treatments of the pressure ulcers of which the resident was admitted with on 4-20-12. The form of which the facility used, Braden Scale-For Predicting Pressure Sore Risk, contained assessment dates of 10-3-2011, 2-11-12, and 5-12. There was no Braden Scale assessment for predicting pressure ulcer risk for the readmitted s of 4-20-12 or for 6-18-12. However, the facility did have two separate (Skin Risk Analysis And Interventions) forms dated for 4-20-12 and each had a Skin Risk Score of (10). Additional review of resident #30's record revealed the resident was transferred out and was hospitalized on [DATE]. A Re-Admit Resident Summary dated 6-18-12 documented that resident #30 was readmitted at 6:30 p.m. on that date. Again, the Skin section of the form documented that the resident had a pressure sure with no stage indicated, but, the location was noted as (sacrum) and contained a written entry of (See TAR). The 6-18-12 Skilled Daily Nurses Note timed for 6:30 p.m. documented the resident's re-admit and had a sacral wound covered with a [MEDICATION NAME]. The Wound/Skin Healing Record was dated 6-19-12, and documented that the unstagable, left upper buttock/sacral pressure ulcer had an onset date of (6-19-12) and measured 4.0 x 4.4 x 0.1 cm. The June 2012 Medication Sheet and Treatment Administration Record (TAR), both indicated, with staff's initials, that the resident's wound received no assessment or care until 6-19-12, (the day after the resident was readmitted into the nursing home). Both S2DON and S7Tx. RN reviewed the record and confirmed the 6-18-12 at 6:30 p.m. entry on the Skilled Daily Note documented the resident's return to the facility, and the 6-19-12 at 14:50 treatment Nurse's Note documented the wound's first assessment and treatment. Both confirmed the resident's wound was not assessed or treated for [REDACTED]. Both staff members, S2DON and S7Tx.RN, confirmed the facility had no additional documentation to produce which would have supported that the facility's protocol/procedures/standing plan of care was followed for either of resident #30's readmission's of 4-20-12 or 6-18-12. Additional interview with S7Tx. RN on 6-26-12 at 12:15 p.m. confirmed that the first physician's orders [REDACTED]. Orders dated 6-19-12 and timed for 14:50 (2:50 p.m.), which addressed the Left upper buttock/Sacral Wound. An additional Physician's Telephone Order dated 6-19-12 and timed for 17:30, addressed the (Mid buttock) wound/pressure ulcer. S7Tx. RN confirmed the facility had no documentation of any assessment, (staging/measurements), and the treatment was not done until she (S7Tx. RN) returned to work on 6-19-12. S7Tx. RN stated that any resident who was admitted or readmitted into the facility was to have an initial assessment which was a complete skin assessment including the assessment/measuring of all wounds. 3) Resident #86 Record review revealed Resident #86's was a [AGE] year old male with accumulative [DIAGNOSES REDACTED]. Record review of the Fall Risk Evaluation dated 5-17-12 and 6-19-12 revealed Resident #86 was assessed and his score for both of these evaluation dates were 18 meaning he was a high risk for falls. Record review of the Physicians Orders for June 2012 read, "Bed alarms to enhance staff awareness of resident need for assistance. Chair alarm to enhance staff awareness of resident need of assistance." Record review of the TAR (treatment administration record) dated June 2012 read, "Bed alarm to enhance staff awareness of resident need for assistance. Chair alarm to enhance staff awareness of resident need of assistance." Care Plan review revealed Resident #86 will receive no injury due to preventable falls. The facility placed the resident in the fall preventing program. The C.N.A's were to ensure bed and chair alarms were under the resident each shift. Record review of the Incident Report Log revealed Resident #86 fell on [DATE] and was found sitting on the floor in front of his toilet because he was weak. On 5-17-12 the resident fell on his buttocks while standing near his wheel chair in the hall way. On 6-21-12 at 3:00 p.m. an observation revealed resident #86 lying in his bed. There was no bed alarm under the resident. Observed at the foot of the bed was a wheel chair with a pressure alarm in the seat of the wheel chair. On 6-21-12 at 3:05 p.m. an interview with S11C.N.A. revealed resident #86 has a wheel chair alarm that the staff transfer to his bed and use it for the bed alarm. At this time the alarm was observed to be in the residents wheel chair. She revealed the resident takes the alarm off his bed and put it on the bedside table. On 6-22-12 at 10:25 a.m. an observation with S2DON revealed the resident was lying in the bed and did not have a bed alarm under him. At this time S2 acknowledged the resident did not have a bed alarm under him. On 6-22-12 at 10:45 a.m. an observation with S12LPN revealed Resident #86 was lying in his bed. It was observed there was a chair alarm in his wheel chair. The resident did not have a alarm under him in the bed. 4) Resident #21, Resident #8 Resident #21. On 6/18/12 at 2:30 p.m. Resident #21 was observed with long, untrimmed fingernails with jagged edges and dried brown substance under the fingernails. At this time an interview with the resident confirmed that her fingernails needed to be trimmed and cleaned. On 6/18/12 at 2:35 p.m. an interview with S17LPN confirmed that the resident's fingernails were long, untrimmed and needed to be cleaned. A review of Resident #21's clinical record revealed that the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Care Plan review dated 7-12-12 revealed Resident #21 required assistance with ADL's due to generalized weakness and depression. The staff were to provide nail care weekly and as needed. A review of Resident #21's quarterly MDS dated [DATE] revealed the resident's cognitive status was moderately impaired. The residents behavior indicate that the resident did not reject care. The resident required limited assistance by one person for bed mobility, transfers, dressing, toileting, bathing and personal hygiene including washing/drying face and hands. On 5/20/12 at 1:00 p.m. an interview with S2DON confirmed that Resident #21's care plan included an intervention to provide weekly nail care. She stated that if Resident #21's nails were long, untrimmed and jagged with dried dark substance under the nails that this would indicate that the staff were not following the plan of care. Resident #8. On 06-19-12 at 11:08 a.m. Resident #8 was observed with black grim under her fingernails. Her fingernails were cut jagged. At this time the Resident stated the staff didn't manicure and clean her fingernails very well. Record review of Face Sheet revealed Resident #8 was [AGE] years old female. The resident had accumulative [DIAGNOSES REDACTED]. Care Plan: 6-4-12 Requires assist with ADL's related to physical condition and Diagnosis. of dementia. . Will be clean, neatly groomed and dressed as appropriate for time and season. Nail Care as needed On 6-21-12 at 11:20 a.m. an observation of Resident #8's was made with S3ADON. The resident was observed with black grim under her fingernails and her fingernails were cut jagged. At this time S3ADON revealed Resident #8's fingernails were dirty and needed filling. She further revealed the C.N.A.'s are to assess, clean and cut the residents fingernails daily if needed. S3ADON further revealed Resident #8 was not able to cut and clean her fingernails. Record review of Mandatory Nursing Meeting dated 5-30-12 revealed the staff had been in-serviced on cleaning and cutting the residents fingernails. This in-service read in part; "D.) Resident Hygiene, 3.) Fingernails are to be assessed daily and clipped and filed as needed."

Based on record review, interview and observation, the facility failed to ensure that services provided to residents met professional standards of quality by failing to ensure that a resident admitted to the facility with a Stage II pressure ulcer received accurate initial and periodic skin assessments to promote healing and prevent the wound from progressing to a Stage IV Pressure wound for 1 (#94) of 5 (#94, #30, #105, #106 and #49) sampled resident reviewed for pressure wounds. This failure to accurately assess an existing pressure wound to Resident #94 ' right buttock on admit and upon additional assessments for 7 weeks resulted in the facility ' s failure to initiate pressure relief to the wound. Resident #94 ' s Stage II pressure wound progressed to a Stage IV pressure wound which required hospitalization [MEDICAL CONDITION], osteo[DIAGNOSES REDACTED] and pain due to the necrotic pressure wound. Resident #94 was placed in immediate jeopardy on 11/30/11 when she was admitted to the facility and an incomplete, inaccurate skin assessment was conducted. The resident's right lower buttock skin wound was incorrectly assessed as an excoriated area on 12/1/11. The facility did not accurately assess the resident's right lower buttock skin wound until it had deteriorated to an unstageable wound on 1/16/12. On 3/12/12, the wound was staged as a stage IV pressure ulcer with tunneling. Resident #94 was hospitalized from [DATE] through 5/21/12 with an admitting [DIAGNOSES REDACTED]. Resident #94 received intavenous antibiotics, surgical debridement of the stage IV sacral decubitus and pain medications during the hospitalization . The administrator was informed of the Immediate Jeopardy on 6/22/12 at 4:54 pm. The plan of removal was received and the Immediate Jeopardy was lifted on 6/26/12 at 4:09 pm when the facility ensured that all skin assessments were repeated for accuracy and that all staff was trained on accurate skin assessments. The deficient practice was reduced to an isolated actual harm for Resident #94. FINDINGS: A review of the Louisiana State Board of Nursing Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management revealed that the, " Nursing care of skin/wound conditions involves the identification, assessment, managemen, and ongoing evaluation of patients with alterations in skin/tissue integrity .... " Further review revealed that in accord with LRS 37:913 (14) (1) and LAC 46:XLVEE.3703, such as the National Pressure Ulcer Advisory Panel , the Wound Ostomy and Continence Nurses Society agreed upon the following definitions and clinical presentations of the stages of pressure ulcers: " Stage II: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. " Resident #94 A review of Resident #94 ' s clinical record revealed that the resident was admitted to the facility from a hospital on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #94 ' s Hospital records dated 11/29/11 revealed a [DIAGNOSES REDACTED]. A review of the Admission Physician order [REDACTED]. A review of the Braden Scale - For Predicting Pressure Sore Risk for Resident #94 dated 11/30/11 revealed a score of 17 to indicate that the resident was at mild risk for pressure ulcers. A review of the Admit Assessment-Resident Summary dated 11/30/11 revealed that Resident #94 ' s skin with no findings. A review of Resident #94 ' s Skilled Daily Nurses Note failed to reveal findings under the section for the assessment of the resident ' s skin condition. Further review of the nurse ' s note on 11/30/11 at 5:20 pm revealed that the resident was admitted and that the staff was, " Unable to check skin. Passed on to oncoming nurse. " A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated 12/1/11 revealed an excoriated area to the right lower buttock. Further review revealed that the excoriated area measured 3.2 x 2.1 cm with <.1 cm depth and scant blood exudate was observed along with a pink wound bed. A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated 12/10/11 revealed the excoriated area to the right lower buttock measurements were 4.6 x 2.5 cm with 0.1 cm depth and that the wound contained slough in the wound bed. A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated 01/16/12 revealed that the area to the resident ' s right lower buttock then deteriorated to an Unstageable Wound. Further review revealed that the wound measured 5.1 x 3.2 cm with a depth of 0.1 cm and that tan slough and black eschar were present in the wound bed. Further review of the clinical record revealed that a Wound/Skin Healing Record began on 1/16/12 with the same findings and that the Physician and Resident #94 ' s responsible party were notified on that date. A review of the Nurse ' s Notes dated 1/16/12, no time included, revealed that the treatment for [REDACTED]. A review of the Nurse ' s Notes dated 1/17/12 at 4:30 pm revealed that the wound to Resident #94 ' s right lower buttock classification was changed from an excoriated area to an Unstageable pressure ulcer. Further review revealed that the Nurse Practitioner and responsible party were notified. A review of Resident #94 ' s Wound/Skin Healing Record dated 3/12/12 revealed that the wound to the resident ' s right lower buttock was then staged as a Stage IV pressure ulcer. The pressure ulcer ' s measurements were 3.8 x 3.0 cm with 2.5 cm depth and tunneling was noted. A review of Resident #94 ' s Nurse ' s Notes dated 4/3/12 at 4:00 pm revealed that an x-ray was obtained to the resident ' s right ischial tuberosity to rule out osteo[DIAGNOSES REDACTED] on 4/4/12 due to wound infection and decreased healing. A review of Resident #94 ' s Nurse ' s Notes dated 4/4/12 at 3:00 pm revealed labs were obtained per Nurse Practitioner ' s orders due to the resident ' s altered mental status. Further review revealed that at 5:00 pm the ambulance was called to transport the resident to the hospital due to a critical WBC (white blood cell) count. A review of Resident #94 ' s hospital Discharge Summary revealed that the resident was hospitalized from [DATE] through 05/21/12 with admitting [DIAGNOSES REDACTED]. Further review revealed that the resident received intravenous antibiotics, surgical debridement and that pain medications were increased during the hospitalization . Resident #94 was discharged from the hospital on [DATE] with [DIAGNOSES REDACTED]. A review of Physician ' s Telephone orders for Resident #94 dated 6/14/12 revealed an order for [REDACTED]. A review of Resident #94 ' s Nurse Practitioner Progress notes dated 12/01/11 failed to reveal that the resident had a pressure ulcer. A review of the Progress notes dated 12/05/11 revealed that the resident had a sacral wound and the area designated for pressure ulcers was blank. A review of the Nurse Practitioner Progress notes dated 2/21/12 revealed a new [DIAGNOSES REDACTED]. An interview was conducted with S7, RN, Treatment Nurse on 6/21/12 at 1:46 pm who confirmed that she completed the skin assessment on Resident #94 on 12/1/11 and identified the wound to her right buttock as an excoriation. S7, RN, Treatment Nurse stated that the wound to Resident #94 ' s right buttock could have been a pressure wound on 12/1/11 due to the fact that it was located over a bony prominence. She stated that there were no interventions to avoid pressure to the resident ' s right buttock and turn every 2 hours due to the fact that there was a dressing over the area and it was not considered a pressure ulcer. An interview was conducted with S2, RN, DON on 6/22/12 at 1:45 pm who stated that Resident #94 ' s Initial Nursing Assessment on 11/30/11 was inaccurate because the skin assessment was not completed. S2, RN, DON also stated that Braden Scale for Predicting Pressure Sore Risk on 11/30/11 could not have been accurate either because the skin assessment was not completed. S2, RN, DON stated that the skin assessment completed 12/1/11 on Resident #94 revealed an excoriation to the resident ' s right buttock could have been a pressure ulcer since the wound was located over a bony prominence. She stated that an intervention on 12/1/11 should have been to begin turning Resident #94 every 2 hours and to keep pressure off of the site to prevent further tissue damage. S2, RN, DON confirmed that there were no interventions on Resident #94 ' s care plan on or around 12/1/11 to relieve pressure to the site of the wound or reposition the resident every 2 hours. An interview was conducted with S17, Corporate Nurse on 06/22/12 at 2 pm who reviewed Resident #94 ' s clinical record and confirmed that there was no documentation to confirm that the resident was being turned or repositioned every 2 hours. An interview was conducted with S2, RN, DON on 6/22/12 at 4:25 pm who confirmed that Resident #94 ' s wound to her right buttock was diagnosed prior to admit on 11/30/11 as a Stage II pressure wound. She stated that the skin assessment completed on 12/1/11 was inaccurate as this was a Stage II pressure ulcer and not an excoriation. S2, RN, DON stated that the wound to Resident #94 ' s right buttock should have been treated as a Stage II pressure ulcer upon admit to the facility on [DATE] with all pressure relieving measures, including relief of pressure to the site. An interview was conducted with Resident #94 ' s husband/responsible party on 6/22/11 at 11:30 am who stated that Resident #94 was hospitalized from [DATE] through 5/21/12 for an infection of a pressure ulcer to her right buttock. He stated that Resident #94 experienced excruciating pain due to the pressure wound that " went all the way to the bone. " He stated that there was no reason for the pressure ulcer that Resident #94 was admitted with on 11/30/11 to deteriorate since she was supposed to be turned every 2 hours and should have been kept off of the wound. He stated that he spends at least 8 hours at the facility every day and that the resident was placed up in her wheelchair each day at 5 am until approximately 1 pm. He stated that the staff only repositioned Resident #94 while up in the wheelchair when her head was falling over to the side of the chair. Resident #94 was uninterviewable due to cognition but observations on 6/18/12 at 12:01 pm, 6/19/12 at 11:20 am, 6/20/12 at 12:00 pm, 6/21/12 at 11:45 am, 6/22/12 at 11:30 am, 6/25/12 at 11:50 am and 6/26/12 at 11:15 am were made of the resident in the dining room and these observations failed to reveal staff repositioning the resident. Each observation revealed that Resident #94 was seated upright in a tilted wheelchair at the dining table each observation and with her husband at her side. An interview was conducted with S9, Nurse Practitioner on 6/21/12 at 2:20pm who confirmed that he was aware that Resident #94 had a wound to her right buttock on 12/1/11 but was informed that it was an excoriation. S9, Nurse Practitioner stated that based on the measurements on 12/1/11 by S7, RN, Treatment Nurse that this wound could have been considered a Stage II Pressure Ulcer. He stated that if the nursing staff would have identified Resident #94 ' s wound to her right buttock as a Stage II pressure ulcer that he would have expected the staff to keep her off of the wound site which was a bony prominence at risk for pressure and additional tissue damage. An additional interview was conducted with S9, Nurse Practitioner on 06/25/12 at 12:20 pm caring for Resident #94. S9, Nurse Practitioner stated that he did not assess Resident #94 ' s wound to her right buttock until 1/16/12 at which time it was an Unstageable pressure ulcer with eschar. S9, Nurse Practitioner stated that he went by the assessment completed by S7, RN, Treatment Nurse and that he did not view the wound until she notified him that it was a pressure wound. He stated that Resident #94 ' s wound was covered with a dressing until 1/16/12 and that he did not remove the dressing to visualize the wound since he was under the impression that it was not a pressure wound.

A) Based on record review, interview and observation, the facility failed to ensure that a resident having a pressure sore received accurate assessemts in or to provide services to promote healing, prevent infection and prevent new sores from developing for 1 (#94) of 5 ( 30, 105, 94, 106, and 49) sampled residents identified with pressure ulcers during the survey process. The Facility failed to: 1) Conduct an accurate skin assessment on 11/30/11 when Resident #94 was admitted to the facility from the hospital and the skin assessment was not completed. 2) Accurately stage a right lower buttock skin wound as a stage II pressure wound when it was discovered on 11/30/2011. 3) Notify the physician/nurse practitioner on 12/1/11 when a skin wound was identified on the resident ' s right lower buttock area on 12/1/11 (Resident #94) 4) Conduct accurate ongoing skin assessments of a residents right lower buttock skin wound from 12/1/11 through 1/16/12. (#94) 5) Identify and implement pressure relieving interventions from 11/30/11 to 12/6/11 to prevent the progression of a stage ll right lower buttock pressure wound to an unstageable pressure wound 6) Implement the plan of care for pressure relieving interventions from 12/7/11 to 6/26/12 for resident #94. 7) Obtain treatment orders for a stage ll pressure ulcer (#94) 8) Follow the physician's order [REDACTED]. 9) Provide necessary treatment and service to promote healing, prevent infection and prevent new sores from developing on 2 separate re-admissions. (#94) These failed practices resulted in resident #94 ' s stage ll pressure ulcer advancing to a stage IV pressure ulcer. Resident #94 was hospitalized from [DATE] through 5/21/12 with an admitting [DIAGNOSES REDACTED]. Resident #94 received intravenous antibiotics, surgical debridement of the stage IV sacral decubitus and pain medications during the hospitalization . Resident #94 was placed in immediate jeopardy on 11/30/11 when she was admitted to the facility and in incomplete, inaccurate skin assessment was conducted. The residents right lower buttock skin wound was incorrectly assessed as an excoriated area on 12/1/2011. The facility did not accurately assess the residents right lower buttock skin wound until it had deteriorated to an unstageable wound on 1/16/12. On 3/12/12, the wound was staged as a stage IV pressure ulcer with tunneling. Resident #94 was hospitalized from [DATE] through 5/21/12 with an admitting [DIAGNOSES REDACTED]. Resident #94 received intravenous antibiotics, surgical debridement of the stage IV sacral decubitus and pain medications during the hospitalization . The administrator was informed of the Immediate Jeopardy on 06/22/12 at 4:54 pm. The plan of removal was received and the Immediate Jeopardy was lifted on 06/26/12 at 4:09 pm when the facility ensured that all skin assessments were repeated for accuracy and that all staff was trained on accurate skin assessments. The deficient practice was reduced to an isolated actual harm for Resident #94. FINDINGS: RESIDENT # 94: A review of Resident #94 ' s clinical record revealed that the resident was admitted to the facility from a hospital on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #94 ' s Hospital records dated 11/29/11 revealed a [DIAGNOSES REDACTED]. A review of the Braden Scale - For Predicting Pressure Sore Risk for Resident #94 dated 11/30/11 revealed a score of 17 to indicate that the resident was at mild risk for pressure ulcers. A review of Resident #94 ' s Skilled Daily Nurses Note failed to reveal findings under the section for the assessment of the resident ' s skin condition. Further review of the nurse ' s note on 11/30/11 at 5:20 pm revealed that the resident was admitted and that the staff was, " Unable to check skin. Passed on to oncoming nurse. " A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated 12/1/11 revealed an excoriated area to the right lower buttock. Further review revealed that the excoriated area measured 3.2 x 2.1 cm with <.1 cm depth and scant blood exudate was observed along with a pink wound bed. A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated 12/10/11 revealed the excoriated area to the right lower buttock measurements were 4.6 x 2.5 cm with 0.1 cm depth and that the wound contained slough in the wound bed. A review of Resident #94 ' s Nurse Practitioner Progress notes dated 12/01/11 failed to reveal that the resident had a pressure ulcer. A review of the Progress notes dated 12/05/11 revealed that the resident had a sacral wound and the area designated for pressure ulcers was blank. A review of a verbal physician's orders [REDACTED]. A review of the Nurse Practitioner Progress notes dated 2/21/12 revealed a new [DIAGNOSES REDACTED]. A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated 01/16/12 revealed that the area to the resident ' s right lower buttock then deteriorated to an Unstageable Wound. Further review revealed that the wound measured 5.1 x 3.2 cm with a depth of 0.1 cm and that tan slough and black eschar were present in the wound bed. Further review of the clinical record revealed that a Wound/Skin Healing Record began on 1/16/12 with the same findings and that the Physician and Resident #94 ' s responsible party were notified on that date. A review of the Nurse ' s Notes dated 1/16/12, no time included, revealed that the treatment for [REDACTED]. A review of the Nurse ' s Notes dated 1/17/12 at 4:30 pm revealed that the wound to Resident #94 ' s right lower buttock classification was changed from an excoriated area to an Unstageable pressure ulcer. Further review revealed that the Nurse Practitioner and responsible party were notified. A review of Resident #94 ' s Wound/Skin Healing Record dated 3/12/12 revealed that the wound to the resident ' s right lower buttock was then staged as a Stage IV pressure ulcer. The pressure ulcer ' s measurements were 3.8 x 3.0 cm with 2.5 cm depth and tunneling was noted. A review of Resident #94 ' s Nurse ' s Notes dated 4/3/12 at 4:00 pm revealed that an x-ray was obtained to the resident ' s right ischial tuberosity to rule out osteo[DIAGNOSES REDACTED] on 4/4/12 due to wound infection and decreased healing. A review of Resident #94 ' s Nurse ' s Notes dated 4/4/12 at 3:00 pm revealed labs were obtained per Nurse Practitioner ' s orders due to the resident ' s altered mental status. Further review revealed that at 5:00 pm the ambulance was called to transport the resident to the hospital due to a critical WBC (white blood cell) count. A review of Resident #94 ' s hospital Discharge Summary revealed that the resident was hospitalized from [DATE] through 05/21/12 with admitting [DIAGNOSES REDACTED]. Further review revealed that the resident received intravenous antibiotics, surgical debridement and that pain medications were increased during the hospitalization . Resident #94 was discharged from the hospital on [DATE] with [DIAGNOSES REDACTED]. A review of Physician ' s Telephone orders for Resident #94 dated 6/14/12 revealed an order for [REDACTED]. A review of Resident #94 ' s Nurse Practitioner Progress notes dated 12/01/11 failed to reveal that the resident had a pressure ulcer. A review of the Progress notes dated 12/05/11 revealed that the resident had a sacral wound and the area designated for pressure ulcers was blank. A review of the Nurse Practitioner Progress notes dated 2/21/12 revealed a new [DIAGNOSES REDACTED]. An interview was conducted with S7, RN, Treatment Nurse on 6/21/12 at 1:46 pm who confirmed that she completed the skin assessment on Resident #94 on 12/1/11 and identified the wound to her right buttock as an excoriation. S7, RN, Treatment Nurse stated that the wound to Resident #94 ' s right buttock could have been a pressure wound on 12/1/11 due to the fact that it was located over a bony prominence. She stated that there were no interventions to avoid pressure to the resident ' s right buttock and turn every 2 hours due to the fact that there was a dressing over the area and it was not considered a pressure ulcer. An interview was conducted with S2, RN, DON on 6/22/12 at 1:45 pm who stated that Resident #94 ' s Initial Nursing Assessment on 11/30/11 was inaccurate because the skin assessment was not completed. S2, RN, DON also stated that Braden Scale for Predicting Pressure Sore Risk on 11/30/11 could not have been accurate either because the skin assessment was not completed. S2, RN, DON stated that the skin assessment completed 12/1/11 on Resident #94 revealed an excoriation to the resident ' s right buttock could have been a pressure ulcer since the wound was located over a bony prominence. She stated that an intervention on 12/1/11 should have been to begin turning Resident #94 every 2 hours and to keep pressure off of the site to prevent further tissue damage. S2, RN, DON confirmed that there were no interventions on Resident #94 ' s care plan on or around 12/1/11 to relieve pressure to the site of the wound or reposition the resident every 2 hours. An interview was conducted with S17, Corporate Nurse on 06/22/12 at 2 pm who reviewed Resident #94 ' s clinical record and confirmed that there was no documentation to confirm that the resident was being turned or repositioned every 2 hours. An interview was conducted with S2, RN, DON on 6/22/12 at 4:25 pm who confirmed that Resident #94 ' s wound to her right buttock was diagnosed prior to admit on 11/30/11 as a Stage II pressure wound. She stated that the skin assessment completed on 12/1/11 was inaccurate as this was a Stage II pressure ulcer and not an excoriation. S2, RN, DON stated that the wound to Resident #94 ' s right buttock should have been treated as a Stage II pressure ulcer upon admit to the facility on [DATE] with all pressure relieving measures, including relief of pressure to the site. An interview was conducted with Resident #94 ' s husband/responsible party on 6/22/11 at 11:30 am who stated that Resident #94 was hospitalized from [DATE] through 5/21/12 for an infection of a pressure ulcer to her right buttock. He stated that Resident #94 experienced excruciating pain due to the pressure wound that " went all the way to the bone. " He stated that there was no reason for the pressure ulcer that Resident #94 was admitted with on 11/30/11 to deteriorate since she was supposed to be turned every 2 hours and should have been kept off of the wound. He stated that he spends at least 8 hours at the facility every day and that the resident was placed up in her wheelchair each day at 5 am until approximately 1 pm. He stated that the staff only repositioned Resident #94 while up in the wheelchair when her head was falling over to the side of the chair. Resident #94 was uninterviewable due to cognition but observations on 6/18/12 at 12:01 pm, 6/19/12 at 11:20 am, 6/20/12 at 12:00 pm, 6/21/12 at 11:45 am, 6/22/12 at 11:30 am, 6/25/12 at 11:50 am and 6/26/12 at 11:15 am were made of the resident in the dining room and these observations failed to reveal staff repositioning the resident. Each observation revealed that Resident #94 was seated upright in a tilted wheelchair at the dining table each observation and with her husband at her side. An interview was conducted with S9, Nurse Practitioner on 6/21/12 at 2:20pm who confirmed that he was aware that Resident #94 had a wound to her right buttock on 12/1/11 but was informed that it was an excoriation. S9, Nurse Practitioner stated that based on the measurements on 12/1/11 by S7, RN, Treatment Nurse that this wound could have been considered a Stage II Pressure Ulcer. He stated that if the nursing staff would have identified Resident #94 ' s wound to her right buttock as a Stage II pressure ulcer that he would have expected the staff to keep her off of the wound site which was a bony prominence at risk for pressure and additional tissue damage. An additional interview was conducted with S9, Nurse Practitioner on 06/25/12 at 12:20 pm caring for Resident #94. S9, Nurse Practitioner stated that he did not assess Resident #94 ' s wound to her right buttock until 1/16/12 at which time it was an Unstageable pressure ulcer with eschar. S9, Nurse Practitioner stated that he went by the assessment completed by S7, RN, Treatment Nurse and that he did not view the wound until she notified him that it was a pressure wound. He stated that Resident #94 ' s wound was covered with a dressing until 1/16/12 and that he did not remove the dressing to visualize the wound since he was under the impression that it was not a pressure wound.

Based on record review, interview and observation the facility failed to conduct initial and periodic, comprehensive, accurate assessments of each resident as evidenced by: A) Failing to obtain clinical history of an assessment of an existing [DIAGNOSES REDACTED].#94,#30) and to perform periodic accurate assessments to identify the exisiting Stage II pressure ulcer for 7 weeks after admit, at which time it progress to an Unstageable pressure ulcer and a Stage IV pressure ulcer (#94) for 1 of 5 residents identified with pressure ulcers out of a total of 29 residents on preventative skin care to prevent ulcers. (#94,#30) B) failing to assess Resident #105 to prevent new pressure sores from developing. This was evidence during a skin assessment on 6-25-12 when Resident # 105 was observed to have a stage II pressure sore on his left upper lateral thigh that S7Tx.RN was not aware and C) failing to assess Resident #8 for potential eye infection as care planned. This was evidence when Resident # 8 was observed on 6-19-12 with green mucous drainage in both eyes where the left eye drainage was obstructing the residents vision. This occured in 1 of 35 sampled residents (Resident #8). These failed practices resulted in resident #94 ' s stage ll pressure ulcer advancing to a stage IV pressure ulcer. Resident #94 was hospitalized from [DATE] through 5/21/12 with an admitting [DIAGNOSES REDACTED]. Resident #94 received intravenous antibiotics, surgical debridement of the stage IV sacral decubitus and pain medications during the hospitalization . Resident #94 was placed in immediate jeopardy on 11/30/11 when she was admitted to the facility and in incomplete, inaccurate skin assessment was conducted. The residents right lower buttock skin wound was incorrectly assessed as an excoriated area on 12/1/2011. The facility did not accurately assess the residents right lower buttock skin wound until it had deteriorated to an unstageable wound on 1/16/12. On 3/12/12, the wound was staged as a stage IV pressure ulcer with tunneling. Resident #94 was hospitalized from [DATE] through 5/21/12 with an admitting [DIAGNOSES REDACTED]. Resident #94 received intravenous antibiotics, surgical debridement of the stage IV sacral decubitus and pain medications during the hospitalization . The administrator was informed of the Immediate Jeopardy on 06/22/12 at 4:54 pm. The plan of removal was received and the Immediate Jeopardy was lifted on 06/26/12 at 4:09 pm when the facility ensured that all skin assessments were repeated for accuracy and that all staff was trained on accurate skin assessments. The deficient practice was reduced to an isolated actual harm for Resident #94. FINDINGS: RESIDENT # 94: A review of Resident #94 ' s clinical record revealed that the resident was admitted to the facility from a hospital on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #94 ' s Hospital records dated 11/29/11 revealed a [DIAGNOSES REDACTED]. A review of the Admission Physician order [REDACTED]. A review of the Braden Scale - For Predicting Pressure Sore Risk for Resident #94 dated 11/30/11 revealed a score of 17 to indicate that the resident was at mild risk for pressure ulcers. A review of the Admit Assessment-Resident Summary dated 11/30/11 revealed that sacral decubitus with [MEDICAL CONDITION] and osteo[DIAGNOSES REDACTED] of the ischium. A review of Resident #94 ' s Skilled Daily Nurses Note failed to reveal findings under the section for the assessment of the resident ' s skin condition. Further review of the nurse ' s note on 11/30/11 at 5:20 pm revealed that the resident was admitted and that the staff was, " Unable to check skin. Passed on to oncoming nurse. " A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated 12/1/11 revealed an excoriated area to the right lower buttock. Further review revealed that the excoriated area measured 3.2 x 2.1 cm with <.1 cm depth and scant blood exudate was observed along with a pink wound bed. A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated 12/10/11 revealed the excoriated area to the right lower buttock measurements were 4.6 x 2.5 cm with 0.1 cm depth and that the wound contained slough in the wound bed. A review of Resident #94 ' s Nurse Practitioner Progress notes dated 12/01/11 failed to reveal that the resident had a pressure ulcer. A review of the Progress notes dated 12/05/11 revealed that the resident had a sacral wound and the area designated for pressure ulcers was blank. A review of a verbal physician's orders [REDACTED]. A review of the Nurse Practitioner Progress notes dated 2/21/12 revealed a new [DIAGNOSES REDACTED]. A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated 01/16/12 revealed that the area to the resident ' s right lower buttock then deteriorated to an Unstageable Wound. Further review revealed that the wound measured 5.1 x 3.2 cm with a depth of 0.1 cm and that tan slough and black eschar were present in the wound bed. Further review of the clinical record revealed that a Wound/Skin Healing Record began on 1/16/12 with the same findings and that the Physician and Resident #94 ' s responsible party were notified on that date. A review of the Nurse ' s Notes dated 1/16/12, no time included, revealed that the treatment for [REDACTED]. A review of the Nurse ' s Notes dated 1/17/12 at 4:30 pm revealed that the wound to Resident #94 ' s right lower buttock classification was changed from an excoriated area to an Unstageable pressure ulcer. Further review revealed that the Nurse Practitioner and responsible party were notified. A review of Resident #94 ' s Wound/Skin Healing Record dated 3/12/12 revealed that the wound to the resident ' s right lower buttock was then staged as a Stage IV pressure ulcer. The pressure ulcer ' s measurements were 3.8 x 3.0 cm with 2.5 cm depth and tunneling was noted. A review of Resident #94 ' s Nurse ' s Notes dated 4/3/12 at 4:00 pm revealed that an x-ray was obtained to the resident ' s right ischial tuberosity to rule out osteo[DIAGNOSES REDACTED] on 4/4/12 due to wound infection and decreased healing. A review of Resident #94 ' s Nurse ' s Notes dated 4/4/12 at 3:00 pm revealed labs were obtained per Nurse Practitioner ' s orders due to the resident ' s altered mental status. Further review revealed that at 5:00 pm the ambulance was called to transport the resident to the hospital due to a critical WBC (white blood cell) count. A review of Resident #94 ' s hospital Discharge Summary revealed that the resident was hospitalized from [DATE] through 05/21/12 with admitting [DIAGNOSES REDACTED]. Further review revealed that the resident received intravenous antibiotics, surgical debridement and that pain medications were increased during the hospitalization . Resident #94 was discharged from the hospital on [DATE] with [DIAGNOSES REDACTED]. A review of Physician ' s Telephone orders for Resident #94 dated 6/14/12 revealed an order for [REDACTED]. A review of Resident #94 ' s Nurse Practitioner Progress notes dated 12/01/11 failed to reveal that the resident had a pressure ulcer. A review of the Progress notes dated 12/05/11 revealed that the resident had a sacral wound and the area designated for pressure ulcers was blank. A review of the Nurse Practitioner Progress notes dated 2/21/12 revealed a new [DIAGNOSES REDACTED]. An interview was conducted with S7, RN, Treatment Nurse on 6/21/12 at 1:46 pm who confirmed that she completed the skin assessment on Resident #94 on 12/1/11 and identified the wound to her right buttock as an excoriation. S7, RN, Treatment Nurse stated that the wound to Resident #94 ' s right buttock could have been a pressure wound on 12/1/11 due to the fact that it was located over a bony prominence. She stated that there were no interventions to avoid pressure to the resident ' s right buttock and turn every 2 hours due to the fact that there was a dressing over the area and it was not considered a pressure ulcer. An interview was conducted with S2, RN, DON on 6/22/12 at 1:45 pm who stated that Resident #94 ' s Initial Nursing Assessment on 11/30/11 was inaccurate because the skin assessment was not completed. S2, RN, DON also stated that Braden Scale for Predicting Pressure Sore Risk on 11/30/11 could not have been accurate either because the skin assessment was not completed. S2, RN, DON stated that the skin assessment completed 12/1/11 on Resident #94 revealed an excoriation to the resident ' s right buttock could have been a pressure ulcer since the wound was located over a bony prominence. She stated that an intervention on 12/1/11 should have been to begin turning Resident #94 every 2 hours and to keep pressure off of the site to prevent further tissue damage. S2, RN, DON confirmed that there were no interventions on Resident #94 ' s care plan on or around 12/1/11 to relieve pressure to the site of the wound or reposition the resident every 2 hours. An interview was conducted with S17, Corporate Nurse on 06/22/12 at 2 pm who reviewed Resident #94 ' s clinical record and confirmed that there was no documentation to confirm that the resident was being turned or repositioned every 2 hours. An interview was conducted with S2, RN, DON on 6/22/12 at 4:25 pm who confirmed that Resident #94 ' s wound to her right buttock was diagnosed prior to admit on 11/30/11 as a Stage II pressure wound. She stated that the skin assessment completed on 12/1/11 was inaccurate as this was a Stage II pressure ulcer and not an excoriation. S2, RN, DON stated that the wound to Resident #94 ' s right buttock should have been treated as a Stage II pressure ulcer upon admit to the facility on [DATE] with all pressure relieving measures, including relief of pressure to the site. An interview was conducted with Resident #94 ' s husband/responsible party on 6/22/11 at 11:30 am who stated that Resident #94 was hospitalized from [DATE] through 5/21/12 for an infection of a pressure ulcer to her right buttock. He stated that Resident #94 experienced excruciating pain due to the pressure wound that " went all the way to the bone. " He stated that there was no reason for the pressure ulcer that Resident #94 was admitted with on 11/30/11 to deteriorate since she was supposed to be turned every 2 hours and should have been kept off of the wound. He stated that he spends at least 8 hours at the facility every day and that the resident was placed up in her wheelchair each day at 5 am until approximately 1 pm. He stated that the staff only repositioned Resident #94 while up in the wheelchair when her head was falling over to the side of the chair. Resident #94 was uninterviewable due to cognition but observations on 6/18/12 at 12:01 pm, 6/19/12 at 11:20 am, 6/20/12 at 12:00 pm, 6/21/12 at 11:45 am, 6/22/12 at 11:30 am, 6/25/12 at 11:50 am and 6/26/12 at 11:15 am were made of the resident in the dining room and these observations failed to reveal staff repositioning the resident. Each observation revealed that Resident #94 was seated upright in a tilted wheelchair at the dining table each observation and with her husband at her side. An interview was conducted with S9, Nurse Practitioner on 6/21/12 at 2:20pm who confirmed that he was aware that Resident #94 had a wound to her right buttock on 12/1/11 but was informed that it was an excoriation. S9, Nurse Practitioner stated that based on the measurements on 12/1/11 by S7, RN, Treatment Nurse that this wound could have been considered a Stage II Pressure Ulcer. He stated that if the nursing staff would have identified Resident #94 ' s wound to her right buttock as a Stage II pressure ulcer that he would have expected the staff to keep her off of the wound site which was a bony prominence at risk for pressure and additional tissue damage. An additional interview was conducted with S9, Nurse Practitioner on 06/25/12 at 12:20 pm caring for Resident #94. S9, Nurse Practitioner stated that he did not assess Resident #94 ' s wound to her right buttock until 1/16/12 at which time it was an Unstageable pressure ulcer with eschar. S9, Nurse Practitioner stated that he went by the assessment completed by S7, RN, Treatment Nurse and that he did not view the wound until she notified him that it was a pressure wound. He stated that Resident #94 ' s wound was covered with a dressing until 1/16/12 and that he did not remove the dressing to visualize the wound since he was under the impression that it was not a pressure wound. Resident #30 During a review of resident #30's record on 6-25-12, it was revealed that the resident was a [AGE] year old female who was originally admitted into the facility on [DATE]. The Face Sheet listed [DIAGNOSES REDACTED].. and other medical diagnosis. Both staff members, S2DON and S7Tx. RN, confirmed the facility had no additional documentation to produce which would have supported that the facility's protocol/procedures/standing plan of care was followed for any of resident #30's readmission's of 4-20-12 or 6-18-12. The Face sheet also indicated that the resident was recently readmitted back into the facility on [DATE] after a hospital stay. Additional record review with S2DON and S7Tx. RN, on 6-25-12 at 3:55 p.m., indicated resident #30 was documented as having clear skin on a Weekly Skin Check dated for April 9th, 2012 on the Treatment Administration Record (TAR). S2DON pointed out and explained the check mark located next to the initials of the nurse assessing the resident, indicated that the nurse found no issues with the resident's skin and previous pressure ulcers on the resident had healed. The TAR was noted to have a (H) documented on the following week (4-16-12), which S2DON explained, represented the fact that resident #30 was admitted into the hospital at that time. Review of resident #30's Nurse's Notes dated 4-12-12 and timed for 14:30 (2:30 p.m.), revealed documentation that the resident was sent to the hospital on [DATE] and was admitted . A Resident Summary Re-Admission form dated 4-20-12, documented that the resident arrived back at the facility at 6:30 p.m. on 4/20/12. The Re-Admission Resident Summary also documented that the resident had stage II pressure ulcers to sacrum and left buttocks. The human anatomical diagram on the Re-Admission Summary was noted to identify the locations of the areas of concern with (X's) on the backside of the diagram at the areas of the sacrum and the left buttocks. There was no documentation of measurements, physician orders [REDACTED]. A review of the April 2012 TAR revealed that the Left upper buttock and the left mid buttock pressure ulcer instructions/treatments were initiated on 4-23-12 as evidenced by the staff's initials. A review of the 4-20-12 admission orders [REDACTED]. The first documented evidence of physician notification, concerning the resident's two pressure ulcers, was that of the Physician's Telephone Order dated 4-23-12 and timed for 14:00 (2:00 p.m.). In addition, both S2DON and S7Tx. RN confirmed that the documentation on the facility's Weekly Pressure QI Log and the Wound / Skin Healing Record, for the Left Mid Buttock stage II pressure ulcer, and the Left Upper Buttock Stage II pressure ulcer, each documented the onset of the wounds as 4-20-12, (date of re-admission). Both S2DON and S7Tx. RN also confirmed that the date of notification for dietary, family, and the physician was documented as 4-23-12, (3 days after the resident's return/re-admission). No additional documentation, concerning wound treatment or assessment, prior to 4-23-12, was produced by S2DON or S7Tx. RN. The 4-23-12 assessment on the facility's Wound/Skin Healing Record for the Stage II Left Mid Buttock measured 3.0 x 4.3 x 0.1 cm. S2DON confirmed that the Wound/Skin Healing Record also documented the Left Upper Buttock Stage II pressure ulcer was present upon resident #30's re-admit of 4-20-12, and was assessed for the first time on 4-23-12 as measuring 1.0 x 1.5. x 0.1 cm. Additional review of resident 30's record with S2DON and S7Tx. RN on 6-25-12 at 3:55 p.m., revealed resident #30 was again sent out to the hospital on 6-11-12 and readmitted back to the facility on [DATE]. The Statement of Medical Status dated 6-18-12 documented that resident #30 had a sacral decubitus. Review of the Skilled Daily Nurses note from 6-18-12 at 6:30 p.m. revealed resident #3- returned to the facility on [DATE]. The Skilled Daily Nurses note documented that resident #30 had a sacral wound covered with [MEDICATION NAME] but contained no assessment of the wound status or treatment. The first documentation regarding assessment of the resident's pressure ulcer status, was noted on the Wound/Skin Healing Record dated 6-19-12 at which time the wound was assessed/measured and documented as Unstageable. The first documentation of physician notification was in the form of the a Physician's Telephone Order for wound care/treatment dated 6-19-12 and timed for 2:50 p.m., (20 hours after the resident returned to the nursing home), and when assessed, the wound was assessed as an unstageable 4.0 x 4.4 x 0.1 cm left upper buttock/sacral pressure ulcer. The review of resident #30's record with S2DON and S7Tx. RN on 6-25-12 at 3:55 p.m. confirmed that the facility did not provide necessary treatment and services to promote healing, prevent infection and prevent new sores from developing on 2 separate re-admissions for resident #30. Resident #105 B) Record review of the Nurses Notes dated 6-13-12 read, "Resident arrived to facility. Left buttock has open area 2 cm x 1.2 cm with linear line 0.3 cm x 4.0 cm. Right side has opening 0.3 cm x 0.1 cm. Redness to lower buttock." Record review of the Wound/Skin Healing record revealed the following: On 6-13-12 right buttock was a stage II pressure sore that measured 0.3 cm by 0.1cm. On 6-18-12 right buttock was a stage II pressure sore that measured 0.3 cm by 0.1 cm. On 6-13-12 left buttock was a stage II pressure sore that measured 2 cm by 1.2 cm. On 6-18-12 left buttock was a stage II pressure sore that measured 2 cm by 1.2 cm. Record review of Resident #105's Skin Condition Record for non-pressure ulcer skin condition revealed the following: On 6-13-12 left wrist abscess measured 0.6 cm by 1.1 cm. On 6-19-12 left wrist abscess measured 0.5 cm by 1.0 cm. Care Plan review revealed Resident #105 had a potential for skin breakdown. The staff was to do weekly skin assessment per facility protocol and monitor skin for signs and symptoms of breakdown or redness during all direct care. On 6-25-12 at 11:45 a.m. an observation of Resident #105 skin with S7Tx.RN revealed the resident had a left wrist abscess that measured 1.2 cm by 0.5 cm that was a healing sore, a left buttock stage II that was a healing pressure sore. a right buttock pink area that was healed, and a left lateral upper thigh that measured 0.2 cm by 2.3 cm that was a stage II pressure sore. S7 TxRN palpated this pressure area and the resident jumped and moaned. On 6-25-12 at 11:50 a.m. an interview with S7Tx RN revealed the wound on Resident # 105 left lateral upper thigh that measured to be 0.2 cm by 2.3 cm was a stage II pressure sore. She further stated that she was not aware of this pressure sore. She revealed that the pressure sore was caused by the cord attached to the wheel chair alarm. Record review of the Wound/Skin Healing record revealed the following: On 6-25-12 right buttock was a stage II pressure sore that measured 0.6 cm by 0.6 cm. On 6-25-12 left buttock was a stage II pressure sore that measured 0.3 cm by 0.3 cm. On 6-25-12 left upper thigh lateral stage II pressure sore that measured 0.2 cm by 2.3 cm. Record review of Resident #105's Skin Condition Record for non-pressure ulcer skin condition revealed the following: On 6-25-12 left wrist abscess measured 0.5 cm by 1.2 cm. Record review of the Physicians Orders dated 6-25-12 read, "Left upper thigh, Lateral Pressure stage II: clean with saf-cleans, pat dry. apply sensicare daily and PRN until healed." Record Review of the In-Service Training Report dated 6-26-12 revealed S7Tx.RN in-serviced LPN's and C.N.A.'s when putting resident into chair, make sure chair alarm cord is not on seat of chair. This could cause skin breakdown. Resident #8 C) On 6-19-12 at 8:17 a.m. an observation was made of Resident #8 sitting in the dinning room drinking a cup of coffee. The residents left eye was completely covered by a layer of thick green mucous that was obstructing her vision. Her right eye had thick green mucous lining her upper and lower eyebrow. The resident had to clear her left eye with her fingers to see the surveyor during the interview. Care Plan Review revealed Resident #8 had potential for Infection related to a history of [MEDICAL CONDITION]. The goal was for the Infection to be accurately identified and resolved thru nursing interventions. The approach was to monitor for signs and symptoms of [MEDICAL CONDITION] and report to the Physician.. On 6-20-12 at 3:35 p.m. an interview with S8LPN revealed that Resident #8 should not have mucous in her eyes. She further revealed the resident has a order to put artificial tears in her eyes three times a day . She also revealed that no one had informed her that Resident #8 had green mucous in her eyes on 6-19-12. On 6-20-12 at 4:15 p.m. a observation of Resident #8 revealed she had light yellow mucous that lined the residents left eye causing her eye lashes to clump together. Record review of the Nurses Note for the dates of 6-19-12 to 6-21-12 revealed there was No documentation of thick green mucous drainage or that the resident had complained of her left eye itching. On 6-21-12 at 9:20 a.m. an observation was made of Resident #8 in her wheel chair in the Hall. It was observed a small amount yellow mucous on her eyelashes of her left eye. On 6-21-12 at 9:40 a.m. an interview with S3ADON revealed that she's the infection control nurse. She stated none of the nurses told her that resident #8 had drainage in her eyes. She further revealed she looked back as far as 5-15-12 in the facilities Nurses Notes and the hospice staffs (nurses and C.N.A) notes and there was no documentation of any drainage in Resident #8's eye. She revealed the staff should assess the drainage and report their findings to her as the infection control nurse. On 6-21-12 at 9:50 a.m. an interview with S8LPN revealed she wrote in the communication log for S9NP to assess Resident #8's for eye infection. She stated since the resident is on hospice she would inform the hospice nurse and she would assess the resident and write the orders if needed. On 6-21-12 at 10:10 a.m. an interview with S10C.N.A. revealed resident #8 normally has mucous in her eyes every morning. She revealed this was normal for the resident. S10 stated she wiped the mucous out of the residents eyes every morning. She stated she didn't inform anyone of the mucous in the residents eyes. On 6-21-12 at 12:15 p.m. Resident #8 was asked if her eyes bothered her and she lifted her right hand and rubbed her left eye and stated her eye itched. On 6- 21-12 at 12:30 p.m. an interview with Resident #8 with S3ADON present, the resident was asked if her eyes itched and she pointed at her left eye and stated that her left eye itched. At this time S3ADON stated the resident was able to inform the staff of her needs. On 6-21-12 at 2:15 p.m. and interview with S9NP was asked if anyone had reported to him that Resident #8 had green mucous in her eyes or that she complained that her left eye itched. He stated that no one had informed him that Resident #8 had any issues with her eyes. Surveyor explained to S9NP of the observation on 6-19-12 of the thick green mucous drainage from the residents eyes and her complaint of her Left eye itching. At this time S9 stated this was a different and he revealed these symptoms were a sign of infection with the green drainage and itching. He revealed he would put Resident #8 on an antibiotic eye drops and not [MEDICATION NAME] drops because she's in a Nursing Home and susceptible to infections. He stated the Hospice Nurse told him she had looked at the resident and said she didn't see any problems. Record review of the Progress Notes dated 6-21-12 read, "after speaking with staff and evaluating patients eyes, unsure of possible infection verses allergy to eyes. Will treat empirically to prevent. Resident #8 presented with eye discharge. Mild. Located in the left eye and in the right eye." Record review of the Physician order [REDACTED]. Diagnosis: [REDACTED]."

Based on record review, interview and observation, the facility failed to ensure that a resident 's physician was immediately informed of a significant change in a resident's condition for 2 (#94 and #30) of 5 (#94, #30, #105, #106 and #49) sampled resident with pressure ulcers of of 29 residents on preventative skin care to prevent pressure ulcers and for 1 (#17) of 35 sampled residents reviewed for hospitalization as evidenced by: 1) failing to notify the resident's Physician/Nurse Practitioner of a Stage II pressure ulcer upon admit, as well as failing to notify of changes upon additional skin assessments which classified the wound as a pressure wound (#94). This failure to notify #94's Physician/Nurse Practitioner of a Stage II pressure ulcer on admit and upon additional assessments which classified the wound as an excoriation to Resident #94 ' s right buttock for 7 weeks resulted in the facility ' s failure to initiate pressure relief to the wound. Resident #94 ' s Stage II pressure wound progressed to a Stage IV pressure wound which required hospitalization [MEDICAL CONDITION], osteo[DIAGNOSES REDACTED] and pain due to the necrotic pressure wound. Resident #94 was placed in immediate peopardy on [DATE] when she was admitted to the facility and an incomple, inaccurate skin assessment was conducted. The resident's right lower buttock skin wound was incorrectly assessed as an excoriated area on [DATE]. The facility did not accurately assess the resident's right lower buttock skin wound until it had deteriorated to an unstageable wound on [DATE]. On [DATE], the wound was staged as a stage IV pressure ulcer with tunneling. Resident #94 was hospitalized from [DATE] through [DATE] with an admitting [DIAGNOSES REDACTED]. Residnt #94 received intavenous antibiotics, surgical debridement of the stage IV sacral decubitus and pain medications during the hospitalization . The administrator was informed of the Immediate Jeopardy on [DATE] at 4:54 pm. The plan of removal was received and the Immediate Jeopardy was lifted on [DATE] at 4:09 pm when the facility ensured that all skin assessments were repeated for accuracy and that all staff was trained on accurate skin assessments. The deficient practice was reduced to an isolated actual harm for Resident #94. 2. Failing to notify the physician on [DATE] when resident #17 became too lethargic to complete his speech therapy on [DATE] and the family member requested to speak to the physician. The immediate jeopary situation began on [DATE] at 9:00 a.m. when resident (#17) was too lethargic to complete his Speech Therapy due to lethargy and the facility did not notify the physician. At that time the resident's son stated, "this is not my father he is too sedated." The Immediate Jeopardy situation was lifted on [DATE] at 10:09 pm when an ambulance was called to bring the resident to the hospital. The client's [DIAGNOSES REDACTED]. 3) failing to notify the resident's Physician concerning the lack of/or need for orders to address pressure wounds on two returns/re-admits to the facility. As a result, resident #30 ' s new onset pressure ulcers of [DATE] were not assessed or treated by the facility until [DATE] (3 days after re-admit), and the noted (Sacral wound covered with a [MEDICATION NAME]) on [DATE] at 6:30 p.m., was not assessed or treated until [DATE] at 14:50 (2:50 p.m.) (#30) FINDINGS: Resident #94 A review of Resident #94 ' s clinical record revealed that the resident was admitted to the facility from a Hospital on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #94 ' s Hospital records dated [DATE] revealed a [DIAGNOSES REDACTED]. A review of Resident #94 ' s Skilled Daily Nurses Note failed to reveal findings under the section for the assessment of the resident ' s skin condition. Further review of the nurse ' s note on [DATE] at 5:20 pm revealed that the resident was admitted and that the staff was, " Unable to check skin. Passed on to oncoming nurse. " A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated [DATE] revealed an excoriated area to the right lower buttock. Further review revealed that the excoriated area measured 3.2 x 2.1 cm with <.1 cm depth and scant blood exudate was observed along with a pink wound bed. A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated [DATE] revealed the excoriated area to the right lower buttock measurements were 4.6 x 2.5 cm with 0.1 cm depth and that the wound contained slough in the wound bed. A review of Resident #94 ' s Nurse Practitioner Progress notes dated [DATE] failed to reveal that the resident had a pressure ulcer. A review of the Progress notes dated [DATE] revealed that the resident had a sacral wound and the area designated for pressure ulcers was blank. A review of a verbal physician's orders [REDACTED]. A review of the Nurse Practitioner Progress notes dated [DATE] revealed a new [DIAGNOSES REDACTED]. A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated [DATE] revealed that the area to the resident ' s right lower buttock then deteriorated to an Unstageable Wound. Further review revealed that the wound measured 5.1 x 3.2 cm with a depth of 0.1 cm and that tan slough and black eschar were present in the wound bed. Further review of the clinical record revealed that a Wound/Skin Healing Record began on [DATE] with the same findings and that the Physician and Resident #94 ' s responsible party were notified on that date. A review of the Nurse ' s Notes dated [DATE], no time included, revealed that the treatment for [REDACTED]. A review of the Nurse ' s Notes dated [DATE] at 4:30 pm revealed that the wound to Resident #94 ' s right lower buttock classification was changed from an excoriated area to an Unstageable pressure ulcer. Further review revealed that the Nurse Practitioner and responsible party were notified. A review of Resident #94 ' s Wound/Skin Healing Record dated [DATE] revealed that the wound to the resident ' s right lower buttock was then staged as a Stage IV pressure ulcer. The pressure ulcer ' s measurements were 3.8 x 3.0 cm with 2.5 cm depth and tunneling was noted. A review of Resident #94 ' s Nurse ' s Notes dated [DATE] at 4:00 pm revealed that an x-ray was obtained to the resident ' s right ischial tuberosity to rule out osteo[DIAGNOSES REDACTED] on [DATE] due to wound infection and decreased healing. A review of Resident #94 ' s Nurse ' s Notes dated [DATE] at 3:00 pm revealed labs were obtained per Nurse Practitioner ' s orders due to the resident ' s altered mental status. Further review revealed that at 5:00 pm the ambulance was called to transport the resident to the hospital due to a critical WBC (white blood cell) count. A review of Resident #94 ' s hospital Discharge Summary revealed that the resident was hospitalized from [DATE] through [DATE] with admitting [DIAGNOSES REDACTED]. Further review revealed that the resident received intravenous antibiotics, surgical debridement and that pain medications were increased during the hospitalization . Resident #94 was discharged from the hospital on [DATE] with [DIAGNOSES REDACTED]. A review of the Braden Scale - For Predicting Pressure Sore Risk for Resident #94 dated [DATE] revealed a score of 17 to indicate that the resident was at mild risk for pressure ulcers. A review of Physician ' s Telephone orders for Resident #94 dated [DATE] revealed an order for [REDACTED]. A review of Resident #94 ' s Nurse Practitioner Progress notes dated [DATE] failed to reveal that the resident had a pressure ulcer. A review of the Progress notes dated [DATE] revealed that the resident had a sacral wound and the area designated for pressure ulcers was blank. A review of the Nurse Practitioner Progress notes dated [DATE] revealed a new [DIAGNOSES REDACTED]. An interview was conducted with S7, RN, Treatment Nurse on [DATE] at 1:46 pm who confirmed that she completed the skin assessment on Resident #94 on [DATE] and identified the wound to her right buttock as an excoriation. S7, RN, Treatment Nurse stated that the wound to Resident #94 ' s right buttock could have been a pressure wound on [DATE] due to the fact that it was located over a bony prominence. She stated that there were no interventions to avoid pressure to the resident ' s right buttock and turn every 2 hours due to the fact that there was a dressing over the area and it was not considered a pressure ulcer. An interview was conducted with S2, RN, DON on [DATE] at 1:45 pm who stated that Resident #94 ' s Initial Nursing Assessment on [DATE] was inaccurate because the skin assessment was not completed. S2, RN, DON also stated that Braden Scale for Predicting Pressure Sore Risk on [DATE] could not have been accurate either because the skin assessment was not completed. S2, RN, DON stated that the skin assessment completed [DATE] on Resident #94 revealed an excoriation to the resident ' s right buttock could have been a pressure ulcer since the wound was located over a bony prominence. She stated that an intervention on [DATE] should have been to begin turning Resident #94 every 2 hours and to keep pressure off of the site to prevent further tissue damage. S2, RN, DON confirmed that there were no interventions on Resident #94 ' s care plan on or around [DATE] to relieve pressure to the site of the wound or reposition the resident every 2 hours. An interview was conducted with S17, Corporate Nurse on [DATE] at 2 pm who reviewed Resident #94 ' s clinical record and confirmed that there was no documentation to confirm that the resident was being turned or repositioned every 2 hours. An interview was conducted with S2, RN, DON on [DATE] at 4:25 pm who confirmed that Resident #94 ' s wound to her right buttock was diagnosed prior to admit on [DATE] as a Stage II pressure wound. She stated that the skin assessment completed on [DATE] was inaccurate as this was a Stage II pressure ulcer and not an excoriation. S2, RN, DON stated that the wound to Resident #94 ' s right buttock should have been treated as a Stage II pressure ulcer upon admit to the facility on [DATE] with all pressure relieving measures, including relief of pressure to the site. An interview was conducted with Resident #94 ' s husband/responsible party on [DATE] at 11:30 am who stated that Resident #94 was hospitalized from [DATE] through [DATE] for an infection of a pressure ulcer to her right buttock. He stated that Resident #94 experienced excruciating pain due to the pressure wound that " went all the way to the bone. " He stated that there was no reason for the pressure ulcer that Resident #94 was admitted with on [DATE] to deteriorate since she was supposed to be turned every 2 hours and should have been kept off of the wound. He stated that he spends at least 8 hours at the facility every day and that the resident was placed up in her wheelchair each day at 5 am until approximately 1 pm. He stated that the staff only repositioned Resident #94 while up in the wheelchair when her head was falling over to the side of the chair. Resident #94 was uninterviewable due to cognition but observations on [DATE] at 12:01 pm, [DATE] at 11:20 am, [DATE] at 12:00 pm, [DATE] at 11:45 am, [DATE] at 11:30 am, [DATE] at 11:50 am and [DATE] at 11:15 am were made of the resident in the dining room and these observations failed to reveal staff repositioning the resident. Each observation revealed that Resident #94 was seated upright in a tilted wheelchair at the dining table each observation and with her husband at her side. An interview was conducted with S9, Nurse Practitioner on [DATE] at 2:20pm who confirmed that he was aware that Resident #94 had a wound to her right buttock on [DATE] but was informed that it was an excoriation. S9, Nurse Practitioner stated that based on the measurements on [DATE] by S7, RN, Treatment Nurse that this wound could have been considered a Stage II Pressure Ulcer. He stated that if the nursing staff would have identified Resident #94 ' s wound to her right buttock as a Stage II pressure ulcer that he would have expected the staff to keep her off of the wound site which was a bony prominence at risk for pressure and additional tissue damage. An additional interview was conducted with S9, Nurse Practitioner on [DATE] at 12:20 pm caring for Resident #94. S9, Nurse Practitioner stated that he did not assess Resident #94 ' s wound to her right buttock until [DATE] at which time it was an Unstageable pressure ulcer with eschar. S9, Nurse Practitioner stated that he went by the assessment completed by S7, RN, Treatment Nurse and that he did not view the wound until she notified him that it was a pressure wound. He stated that Resident #94 ' s wound was covered with a dressing until [DATE] and that he did not remove the dressing to visualize the wound since he was under the impression that it was not a pressure wound. 2. Resident #17. According to the resident ' s nurses notes on [DATE] at 12:30 AM resident #17 was " in bed. Difficult to arouse. " The resident was " on 3 Liters of oxygen per nasal cannula in place. Vital Signs ,[DATE], pulse 103, temperature 97.6. respirations 20, oxygen saturation 96%. Will continue to monitor. " On [DATE] at 2:00 AM the resident ' s nurses notes stated, " oxygen saturation 96%, pulse 103, 3 liters of oxygen per nasal cannula in progress. Still sedated. " On[DATE] at 0400 the resident ' s nurses notes stated, " oxygen saturation 96%. Pulse 110. Blood Pressure ,[DATE]. Respirations 22, Temperature 97.6. Still Sedated. " On [DATE] at 4:30 AM the resident ' s nurses noted stated, " Oxygen Saturation 90% Respirations 32 Blood Pressure ,[DATE]. On [DATE] at 5:00 AM S9 (Nurse Practitioner) was notified of the resident ' s condition and sent to a local hospital for evaluation with a [DIAGNOSES REDACTED]. On [DATE] at 0515 AM the resident ' s nurses notes stated, " Ambulance leaving with patient. Patient unresponsive with stable vital signs. " On [DATE] at 3:30 PM the resident returned to the facility. On [DATE] resident #17 ' s record was reviewed. It revealed that on [DATE] at 9:00 AM the resident was participating in Speech Therapy. It also stated that the therapy lasted less than 15 minutes due to the resident ' s lethargy. At that time the resident ' s son asked that he " meet with his father ' s doctor for a possible dose reduction on some drugs if possible related to increased lethargy. " The resident ' s son then stated, This is not my father he is too sedated. " Notes continue, " Will place on Nurse Practitioner log for now for evaluation. " On [DATE] at 1230 PM the resident ' s nurses notes stated " Picking at lunch. No complaints. " On [DATE] at 4:00 AM Awake in bed. No disorientation. However lethargic. Oxygen on saturation 95%. (Resident ' s) Son at bedside concerned about lethargy. Son wants to speak with nurse practitioner/Dr concerning meds that may be causing lethargy. Noted also to nurse practitioner log. " On [DATE] at 9:00 AM the resident ' s nurses notes read, " N.O. (new order) 1. Dysphagia Consult including a modified [MEDICATION NAME] swallow ordered by speech therapy ordered by speech therapy. 2. Change [MEDICATION NAME] to 250 mg by mouth three times a day. NH4(ammonia level, CMP(complete metabolic profile) in AM. Dx ([DIAGNOSES REDACTED]. On [DATE] at 10:00 AM the resident ' s nurses notes stated, " patient uncooperative with staff. Refuses to attempt any self care. Wants staff to do everything for him but is capable of doing things for himself. Continues to throw trash on the floor and discard plastic bags for oxygen tubing. " On [DATE] at 12:30 AM the resident ' s nurses notes stated, " Resident in room yelling for a glass of milk. Instructed resident to use call bell and not yell because he is disturbing the other residents. " On [DATE] at 3:00 AM the resident ' s nurses notes stated that the " resident was on the floor. He stated he wanted to sit up. Resident assisted to wheelchair. " On [DATE] (no time given) the resident ' s nurses notes stated, " resident defecated on wheelchair and put himself back in bed. Sexually inappropriate with staff. Continues to throw trash on the floor. Screaming and cursing out staff while trying to clean him. Uncooperative and abusive to staff. " On [DATE] at9:55 PM the resident ' s nurses notes state, " resident found lying on floor face down. Resident states he rolled out of bed responsible party and S19 (nurse practitioner) notified. " On [DATE] at 9:58PM CNA assisted with picking resident up. " On [DATE] at 10:05 the resident ' s nurses notes stated, " summoned to resident ' s room by CNA, upon entering room resident unresponsive apnea noted faint pulse noted CBG 152, diaphoretic, pupils fixed, cyanosis noted ALCD noted to left chest wall. " On [DATE] at 10:09 the resident ' s nurses notes stated, " S9 (nurse practitioner) notified, CPR initiated ambulance called out STAT. " On [DATE] at 10:40 PM the resident ' s nurses notes stated, " Resident pronounced per ER doctor from local hospital. " On [DATE] at 2:30 PM S3 ADON was interviewed. She stated that she was aware that the resident had gone to the hospital earlier in the month for lethargy. In addition, S2 DON confirmed the same. On [DATE] at 2:45 PM S9 (nurse practitioner) was interviewed. He stated that given the information he had now that the nurse taking care of the resident on [DATE] should have informed me about the resident ' s declining condition. I would have been able to order the labs at that time instead of 24 hours later when I got the note about his condition. " On [DATE] the resident ' s record was reviewed. It revealed the resident had an ammonia panic level of 135. The facility was not informed of this panic level until the day after the resident expired. 3) Resident #30. During a review of resident #30's record on [DATE], it was revealed that the resident was a [AGE] year old female who was originally admitted into the facility on [DATE]. The Face Sheet listed [DIAGNOSES REDACTED].. and other medical diagnosis. The Face sheet also indicated that the resident was recently readmitted back into the facility on [DATE] after a hospital stay. Additional record review with S2DON and S7Tx. RN, on [DATE] at 3:55 p.m., indicated resident #30 was documented as having clear skin on a Weekly Skin Check dated for [DATE]th, 2012 on the Treatment Administration Record (TAR). S2DON pointed out and explained the check mark located next to the initials of the nurse assessing the resident, indicated that the nurse found no issues with the resident's skin and previous pressure ulcers on the resident had healed. The TAR was noted to have a (H) documented on the following week ([DATE]), which S2DON explained, represented the fact that resident #30 was admitted into the hospital at that time. Review of resident #30's Nurse's Notes dated [DATE] and timed for 14:30 (2:30 p.m.), revealed documentation that the resident was sent out to the hospital at that time, and was admitted . A Resident Summary Re-Admission form dated [DATE], documented that the resident arrived back at the facility at 9 p.m. on that day. The Re-Admission Resident Summary also documented that the resident had stage II pressure ulcers to (Sacrum, left Buttocks). Under the Skin Treatments section of the form, it documented (See TAR). The human anatomical diagram on the Re-Admission Summary was noted to identify the locations of the areas of concern with (X's) on the backside of the diagram at the areas of the sacrum and the left buttocks. A review of the [DATE] TAR revealed that the Left upper buttock and the left mid buttock pressure ulcer instructions/treatments were initiated on [DATE] as evidenced by the staff's initials. A review of the [DATE] admission orders [REDACTED]. The first documented evidence of physician notification, concerning the lack of/need for orders to address the ulcers, is that of the Physician's Telephone Order dated [DATE] and timed for 14:00 (2:00 p.m.). In addition, both S2DON and S7Tx. RN confirmed that the documentation on the facility's Weekly Pressure QI Log and the Wound / Skin Healing Record, for the Left Mid Buttock stage II pressure ulcer, and the Left Upper Buttock Stage II pressure ulcer, each documented the onset of the wounds as [DATE], (date of return). Both S2DON and S7Tx. RN also confirmed that the date of notification for dietary, family, and the physician was documented as ([DATE], (3 days after the resident's return/re-admission). No additional documentation, concerning the need for or lack of wound treatment orders, was produced by S2DON or S7Tx. RN. Additional review of resident #30's record with S2DON and S7Tx. RN on [DATE] at 3:55 p.m., revealed resident #30 was again sent out to the hospital and admitted on [DATE]. Skilled Daily Nurses Note dated [DATE] and timed at 6:30 p.m., documented the resident's return to the nursing facility. The same form documented the presence of (Sacral wound covered with a [MEDICATION NAME]). Again the admission orders [REDACTED]. The Statement of Medical Status dated [DATE], documented the presence of a sacral ulcer with [MEDICATION NAME], but, no additional orders were noted. The first documentation of a physician's notification of the need for or lack of orders to address the sacral wound/care, was noted on a Physician's Telephone Order for wound care/treatment dated [DATE] and timed for 14:50 (2:50 p.m.), (some 20 hours after the resident returned to the nursing home) with an (unstagable 4.0 x 4.4 x 0.1 cm) left upper buttock/sacral pressure ulcer.

Based on observation, record review and interview the facility ' s administration failed to utilize effective training methods and staff supervision to assure each resident maintained their highest practicable physical, mental, and psychosocial well-being as evidenced by: The Facility failed to: 1) Have a system in place to ensure that complete and accurate skin assessments were conducted when resident was admitted to the facility on [DATE] (#94) and when a resident (#30) was re-admitted to the facility on [DATE] and [DATE]. 2) Have a system of monitoring in place to ensure that skin wounds were identified and staged correctly (#94). 3) Have a system to ensure notification of resident physician when there was a change in residnt's clinical status (#94, #17) 4) Have a system in place to ensure notification that a skin assessment was not completed on [DATE] when Resident #94 was admitted to the facility from the hospital. 5) Have a system in place to accurately stage a right lower buttock skin wound as a stage II pressre wound when it was discovered on [DATE]. (#94) 6) Have a system in place to ensure implemention of the plan of care for pressure relieving interventions from [DATE] to [DATE] for resident #94. 7) Have a system in place to ensure treatment orders were obtained for a stage ll pressure ulcer (#94) 8) Follow the physician's order [REDACTED]. 9) Provide necessary treatment and service to promote healing, prevent infection and prevent new sores from developing on 2 separate re-admissions. (#94) These failed practices resulted in resident #94 ' s stage ll pressure ulcer advancing to a stage IV pressure ulcer. Resident #94 was hospitalized from [DATE] through [DATE] with an admitting [DIAGNOSES REDACTED]. Resident #94 received intravenous antibiotics, surgical debridement of the stage IV sacral decubitus and pain medications during the hospitalization . Resident #94 was placed in immediate jeopardy on [DATE] when she was admitted to the facility and in incomplete, inaccurate skin assessment was conducted. The residents right lower buttock skin wound was incorrectly assessed as an excoriated area on [DATE]. The facility did not accurately assess the residents right lower buttock skin wound until it had deteriorated to an unstageable wound on [DATE]. On [DATE], the wound was staged as a stage IV pressure ulcer with tunneling. Resident #94 was hospitalized from [DATE] through [DATE] with an admitting [DIAGNOSES REDACTED]. Resident #94 received intravenous antibiotics, surgical debridement of the stage IV sacral decubitus and pain medications during the hospitalization . The administrator was informed of the Immediate Jeopardy on [DATE] at 4:54 pm. The plan of removal was received and the Immediate Jeopardy was lifted on [DATE] at 4:09 pm when the facility ensured that all skin assessments were repeated for accuracy and that all staff was trained on accurate skin assessments. The deficient practice was reduced to an isolated actual harm for Resident #94. FINDINGS: RESIDENT # 94: A review of Resident #94 ' s clinical record revealed that the resident was admitted to the facility from a Hospital on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #94 ' s Hospital records dated [DATE] revealed a [DIAGNOSES REDACTED]. A review of the Braden Scale - For Predicting Pressure Sore Risk for Resident #94 dated [DATE] revealed a score of 17 to indicate that the resident was at mild risk for pressure ulcers. A review of Resident #94 ' s Skilled Daily Nurses Note failed to reveal findings under the section for the assessment of the resident ' s skin condition. Further review of the nurse ' s note on [DATE] at 5:20 pm revealed that the resident was admitted and that the staff was, " Unable to check skin. Passed on to oncoming nurse. " A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated [DATE] revealed an excoriated area to the right lower buttock. Further review revealed that the excoriated area measured 3.2 x 2.1 cm with <.1 cm depth and scant blood exudate was observed along with a pink wound bed. A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated [DATE] revealed the excoriated area to the right lower buttock measurements were 4.6 x 2.5 cm with 0.1 cm depth and that the wound contained slough in the wound bed. A review of Resident #94 ' s Nurse Practitioner Progress notes dated [DATE] failed to reveal that the resident had a pressure ulcer. A review of the Progress notes dated [DATE] revealed that the resident had a sacral wound and the area designated for pressure ulcers was blank. A review of a verbal physician's orders [REDACTED]. A review of the Nurse Practitioner Progress notes dated [DATE] revealed a new [DIAGNOSES REDACTED]. A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated [DATE] revealed that the area to the resident ' s right lower buttock then deteriorated to an Unstageable Wound. Further review revealed that the wound measured 5.1 x 3.2 cm with a depth of 0.1 cm and that tan slough and black eschar were present in the wound bed. Further review of the clinical record revealed that a Wound/Skin Healing Record began on [DATE] with the same findings and that the Physician and Resident #94 ' s responsible party were notified on that date. A review of the Nurse ' s Notes dated [DATE], no time included, revealed that the treatment for [REDACTED]. A review of the Nurse ' s Notes dated [DATE] at 4:30 pm revealed that the wound to Resident #94 ' s right lower buttock classification was changed from an excoriated area to an Unstageable pressure ulcer. Further review revealed that the Nurse Practitioner and responsible party were notified. A review of Resident #94 ' s Wound/Skin Healing Record dated [DATE] revealed that the wound to the resident ' s right lower buttock was then staged as a Stage IV pressure ulcer. The pressure ulcer ' s measurements were 3.8 x 3.0 cm with 2.5 cm depth and tunneling was noted. A review of Resident #94 ' s Nurse ' s Notes dated [DATE] at 4:00 pm revealed that an x-ray was obtained to the resident ' s right ischial tuberosity to rule out osteo[DIAGNOSES REDACTED] on [DATE] due to wound infection and decreased healing. A review of Resident #94 ' s Nurse ' s Notes dated [DATE] at 3:00 pm revealed labs were obtained per Nurse Practitioner ' s orders due to the resident ' s altered mental status. Further review revealed that at 5:00 pm the ambulance was called to transport the resident to the hospital due to a critical WBC (white blood cell) count. A review of Resident #94 ' s hospital Discharge Summary revealed that the resident was hospitalized from [DATE] through [DATE] with admitting [DIAGNOSES REDACTED]. Further review revealed that the resident received intravenous antibiotics, surgical debridement and that pain medications were increased during the hospitalization . Resident #94 was discharged from the hospital on [DATE] with [DIAGNOSES REDACTED]. A review of Physician ' s Telephone orders for Resident #94 dated [DATE] revealed an order for [REDACTED]. A review of Resident #94 ' s Nurse Practitioner Progress notes dated [DATE] failed to reveal that the resident had a pressure ulcer. A review of the Progress notes dated [DATE] revealed that the resident had a sacral wound and the area designated for pressure ulcers was blank. A review of the Nurse Practitioner Progress notes dated [DATE] revealed a new [DIAGNOSES REDACTED]. An interview was conducted with S7, RN, Treatment Nurse on [DATE] at 1:46 pm who confirmed that she completed the skin assessment on Resident #94 on [DATE] and identified the wound to her right buttock as an excoriation. S7, RN, Treatment Nurse stated that the wound to Resident #94 ' s right buttock could have been a pressure wound on [DATE] due to the fact that it was located over a bony prominence. She stated that there were no interventions to avoid pressure to the resident ' s right buttock and turn every 2 hours due to the fact that there was a dressing over the area and it was not considered a pressure ulcer. An interview was conducted with S2, RN, DON on [DATE] at 1:45 pm who stated that Resident #94 ' s Initial Nursing Assessment on [DATE] was inaccurate because the skin assessment was not completed. S2, RN, DON also stated that Braden Scale for Predicting Pressure Sore Risk on [DATE] could not have been accurate either because the skin assessment was not completed. S2, RN, DON stated that the skin assessment completed [DATE] on Resident #94 revealed an excoriation to the resident ' s right buttock could have been a pressure ulcer since the wound was located over a bony prominence. She stated that an intervention on [DATE] should have been to begin turning Resident #94 every 2 hours and to keep pressure off of the site to prevent further tissue damage. S2, RN, DON confirmed that there were no interventions on Resident #94 ' s care plan on or around [DATE] to relieve pressure to the site of the wound or reposition the resident every 2 hours. An interview was conducted with S17, Corporate Nurse on [DATE] at 2 pm who reviewed Resident #94 ' s clinical record and confirmed that there was no documentation to confirm that the resident was being turned or repositioned every 2 hours. An interview was conducted with S2, RN, DON on [DATE] at 4:25 pm who confirmed that Resident #94 ' s wound to her right buttock was diagnosed prior to admit on [DATE] as a Stage II pressure wound. She stated that the skin assessment completed on [DATE] was inaccurate as this was a Stage II pressure ulcer and not an excoriation. S2, RN, DON stated that the wound to Resident #94 ' s right buttock should have been treated as a Stage II pressure ulcer upon admit to the facility on [DATE] with all pressure relieving measures, including relief of pressure to the site. An interview was conducted with Resident #94 ' s husband/responsible party on [DATE] at 11:30 am who stated that Resident #94 was hospitalized from [DATE] through [DATE] for an infection of a pressure ulcer to her right buttock. He stated that Resident #94 experienced excruciating pain due to the pressure wound that " went all the way to the bone. " He stated that there was no reason for the pressure ulcer that Resident #94 was admitted with on [DATE] to deteriorate since she was supposed to be turned every 2 hours and should have been kept off of the wound. He stated that he spends at least 8 hours at the facility every day and that the resident was placed up in her wheelchair each day at 5 am until approximately 1 pm. He stated that the staff only repositioned Resident #94 while up in the wheelchair when her head was falling over to the side of the chair. Resident #94 was uninterviewable due to cognition but observations on [DATE] at 12:01 pm, [DATE] at 11:20 am, [DATE] at 12:00 pm, [DATE] at 11:45 am, [DATE] at 11:30 am, [DATE] at 11:50 am and [DATE] at 11:15 am were made of the resident in the dining room and these observations failed to reveal staff repositioning the resident. Each observation revealed that Resident #94 was seated upright in a tilted wheelchair at the dining table each observation and with her husband at her side. An interview was conducted with S9, Nurse Practitioner on [DATE] at 2:20pm who confirmed that he was aware that Resident #94 had a wound to her right buttock on [DATE] but was informed that it was an excoriation. S9, Nurse Practitioner stated that based on the measurements on [DATE] by S7, RN, Treatment Nurse that this wound could have been considered a Stage II Pressure Ulcer. He stated that if the nursing staff would have identified Resident #94 ' s wound to her right buttock as a Stage II pressure ulcer that he would have expected the staff to keep her off of the wound site which was a bony prominence at risk for pressure and additional tissue damage. An additional interview was conducted with S9, Nurse Practitioner on [DATE] at 12:20 pm caring for Resident #94. S9, Nurse Practitioner stated that he did not assess Resident #94 ' s wound to her right buttock until [DATE] at which time it was an Unstageable pressure ulcer with eschar. S9, Nurse Practitioner stated that he went by the assessment completed by S7, RN, Treatment Nurse and that he did not view the wound until she notified him that it was a pressure wound. He stated that Resident #94 ' s wound was covered with a dressing until [DATE] and that he did not remove the dressing to visualize the wound since he was under the impression that it was not a pressure wound. Resident #17 Facility failed to ensure the physician was notified of a significant change in resident condition (#17) Based on record review and interview the facility failed to keep a resident from further decline by not informing the resident ' s physician about a change in the resident ' s condition which caused an immediate jeopardy situation by allowing the resident to decline to the point of having to be transported from the facility by ambulance and later died . Resident #17 was in Immediate Jeopardy on [DATE] at 9:00 AM when the resident was too lethargic to complete his Speech Therapy. At that time the resident ' s son stated, this is not my father he is too sedated. " The facililty failed to contact the resident physician. The Immediate Jeopardy situation was lifted 0n [DATE] at 10:09 PM when an ambulance was called to bring the resident to the hospital. The client ' s [DIAGNOSES REDACTED]. (#17 and #30) Findings: Resident #17. According to the resident ' s nurses notes on [DATE] at 12:30 AM resident #17 was " in bed. Difficult to arouse. " The resident was " on 3 Liters of oxygen per nasal cannula in place. Vital Signs ,[DATE], pulse 103, temperature 97.6. respirations 20, oxygen saturation 96%. Will continue to monitor. " On [DATE] at 2:00 AM the resident ' s nurses notes stated, " oxygen saturation 96%, pulse 103, 3 liters of oxygen per nasal cannula in progress. Still sedated. " On[DATE] at 0400 the resident ' s nurses notes stated, " oxygen saturation 96%. Pulse 110. Blood Pressure ,[DATE]. Respirations 22, Temperature 97.6. Still Sedated. " On [DATE] at 4:30 AM the resident ' s nurses noted stated, " Oxygen Saturation 90% Respirations 32 Blood Pressure ,[DATE]. On [DATE] at 5:00 AM S9 (Nurse Practitioner) was notified of the resident ' s condition and sent to a local hospital for evaluation with a [DIAGNOSES REDACTED]. On [DATE] at 0515 AM the resident ' s nurses notes stated, " Ambulance leaving with patient. Patient unresponsive with stable vital signs. " On [DATE] at 3:30 PM the resident returned to the facility. On [DATE] resident #17 ' s record was reviewed. It revealed that on [DATE] at 9:00 AM the resident was participating in Speech Therapy. It also stated that the therapy lasted less than 15 minutes due to the resident ' s lethargy. At that time the resident ' s son asked that he " meet with his father ' s doctor for a possible dose reduction on some drugs if possible related to increased lethargy. " The resident ' s son then stated, This is not my father he is too sedated. " Notes continue, " Will place on Nurse Practitioner log for now for evaluation. " On [DATE] at 1230 PM the resident ' s nurses notes stated " Picking at lunch. No complaints. " On [DATE] at 4:00 AM Awake in bed. No disorientation. However lethargic. Oxygen on saturation 95%. (Resident ' s) Son at bedside concerned about lethargy. Son wants to speak with nurse practitioner/Dr concerning meds that may be causing lethargy. Noted also to nurse practitioner log. " On [DATE] at 9:00 AM the resident ' s nurses notes read, " N.O. (new order) 1. Dysphagia Consult including a modified [MEDICATION NAME] swallow ordered by speech therapy ordered by speech therapy. 2. Change [MEDICATION NAME] to 250 mg by mouth three times a day. NH4(ammonia level, CMP(complete metabolic profile) in AM. Dx ([DIAGNOSES REDACTED]. On [DATE] at 10:00 AM the resident ' s nurses notes stated, " patient uncooperative with staff. Refuses to attempt any self care. Wants staff to do everything for him but is capable of doing things for himself. Continues to throw trash on the floor and discard plastic bags for oxygen tubing. " On [DATE] at 12:30 AM the resident ' s nurses notes stated, " Resident in room yelling for a glass of milk. Instructed resident to use call bell and not yell because he is disturbing the other residents. " On [DATE] at 3:00 AM the resident ' s nurses notes stated that the " resident was on the floor. He stated he wanted to sit up. Resident assisted to wheelchair. " On [DATE] (no time given) the resident ' s nurses notes stated, " resident defecated on wheelchair and put himself back in bed. Sexually inappropriate with staff. Continues to throw trash on the floor. Screaming and cursing out staff while trying to clean him. Uncooperative and abusive to staff. " On [DATE] at9:55 PM the resident ' s nurses notes state, " resident found lying on floor face down. Resident states he rolled out of bed responsible party and S19 (nurse practitioner) notified. " On [DATE] at 9:58PM CNA assisted with picking resident up. " On [DATE] at 10:05 the resident ' s nurses notes stated, " summoned to resident ' s room by CNA, upon entering room resident unresponsive apnea noted faint pulse noted CBG 152, diaphoretic, pupils fixed, cyanosis noted ALCD noted to left chest wall. " On [DATE] at 10:09 the resident ' s nurses notes stated, " S9 (nurse practitioner) notified, CPR initiated ambulance called out STAT. " On [DATE] at 10:40 PM the resident ' s nurses notes stated, " Resident pronounced per ER doctor from local hospital. " On [DATE] at 2:30 PM S3 ADON was interviewed. She stated that she was aware that the resident had gone to the hospital earlier in the month for lethargy. In addition, S2 DON confirmed the same. On [DATE] at 2:45 PM S9 (nurse practitioner) was interviewed. He stated that given the information he had now that the nurse taking care of the resident on [DATE] should have informed me about the resident ' s declining condition. I would have been able to order the labs at that time instead of 24 hours later when I got the note about his condition. " On [DATE] the resident ' s record was reviewed. It revealed the resident had an ammonia panic level of 135. The facility was not informed of this panic level until the day after the resident expired.

Based on record review, interview and observation, the facility failed to ensure that each resident ' s medical care was supervised by a physician who performed initial and periodic skin assessments for a resident admitted with a Stage II pressure ulcer. The Physician/Nurse Practioner was unaware of a resident ' s Stage II pressure wound upon admit and for 7 weeks after admit at which time it progressed to an unstageable pressure wound and a Stage IV pressure wound for 1 (#94) out of 5 (#30, #94, #49, #105 and #106)sampled residents reviewed for pressure wounds. The failure to accurately assess and ensure that additional pressure was alleviated from the wound resulted in a resident ' s Stage II pressure ulcer progressing to a Stage IV pressure ulcer for 1 of 5 sampled residents identified with pressure ulcers during the survey process. Resident #94 ' s Stage II pressure wound progressed to a Stage IV pressure wound which required hospitalization [MEDICAL CONDITION], osteo[DIAGNOSES REDACTED] and pain due to the necrotic pressure wound. (#94) Resident #94 was placed in immediate jeopardy on 11/30/11 when she was admitted to the facility and in incomplete, inaccurate skin assessment was conducted. The residents right lower buttock skin wound was incorrectly assessed as an excoriated area on 12/1/2011. The facility did not accurately assess the residents right lower buttock skin wound until it had deteriorated to an unstageable wound on 1/16/12. On 3/12/12, the wound was staged as a stage IV pressure ulcer with tunneling. Resident #94 was hospitalized from [DATE] through 5/21/12 with an admitting [DIAGNOSES REDACTED]. Resident #94 received intravenous antibiotics, surgical debridement of the stage IV sacral decubitus and pain medications during the hospitalization . The administrator was informed of the Immediate Jeopardy on 06/22/12 at 4:54 pm. The plan of removal was received and the Immediate Jeopardy was lifted on 06/26/12 at 4:09 pm when the facility ensured that all skin assessments were repeated for accuracy and that all staff was trained on accurate skin assessments. The deficient practice was reduced to an isolated actual harm for Resident #94. Resident #94 A review of Resident #94 ' s clinical record revealed that the resident was admitted to the facility from a hospital on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #94 ' s Hospital records dated 11/29/11 revealed a [DIAGNOSES REDACTED]. A review of the Admission Physician order [REDACTED]. A review of the Admit Assessment-Resident Summary dated 11/30/11 revealed that Resident #94 ' s skin with no findings. A review of Resident #94 ' s Skilled Daily Nurses Note failed to reveal findings under the section for the assessment of the resident ' s skin condition. Further review of the nurse ' s note on 11/30/11 at 5:20 pm revealed that the resident was admitted and that the staff was, " Unable to check skin. Passed on to oncoming nurse. " A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated 12/1/11 revealed an excoriated area to the right lower buttock. Further review revealed that the excoriated area measured 3.2 x 2.1 cm with <.1 cm depth and scant blood exudate was observed along with a pink wound bed. A review of Resident #94 ' s Skin Condition Record for non-pressure ulcer skin conditions dated 12/10/11 revealed the excoriated area to the right lower buttock measurements were 4.6 x 2.5 cm with 0.1 cm depth and that the wound contained slough in the wound bed. A review of the Nurse ' s Notes dated 1/17/12 at 4:30 pm revealed that the wound to Resident #94 ' s right lower buttock classification was changed from an excoriated area to an Unstageable pressure ulcer. Further review revealed that the Nurse Practitioner and responsible party were notified. A review of Resident #94 ' s Wound/Skin Healing Record dated 3/12/12 revealed that the wound to the resident ' s right lower buttock was then staged as a Stage IV pressure ulcer. The pressure ulcer ' s measurements were 3.8 x 3.0 cm with 2.5 cm depth and tunneling was noted. A review of Resident #94 ' s hospital Discharge Summary revealed that the resident was hospitalized from [DATE] through 05/21/12 with admitting [DIAGNOSES REDACTED]. Further review revealed that the resident received intravenous antibiotics, surgical debridement and that pain medications were increased during the hospitalization . Resident #94 was discharged from the hospital on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #94 ' s Nurse Practitioner Progress notes dated 12/01/11 failed to reveal that the resident had a pressure ulcer. A review of the Progress notes dated 12/05/11 revealed that the resident had a sacral wound and the area designated for pressure ulcers was blank. A review of the Nurse Practitioner Progress notes dated 2/21/12 revealed a new [DIAGNOSES REDACTED]. An interview was conducted with S7, RN, Treatment Nurse on 6/21/12 at 1:46 pm who confirmed that she completed the skin assessment on Resident #94 on 12/1/11 and identified the wound to her right buttock as an excoriation. S7, RN, Treatment Nurse stated that the wound to Resident #94 ' s right buttock could have been a pressure wound on 12/1/11 due to the fact that it was located over a bony prominence. She stated that there were no interventions to avoid pressure to the resident ' s right buttock and turn every 2 hours due to the fact that there was a dressing over the area and it was not considered a pressure ulcer. An interview was conducted with S2, RN, DON on 6/22/12 at 4:25 pm who confirmed that Resident #94 ' s wound to her right buttock was diagnosed prior to admit on 11/30/11 as a Stage II pressure wound. She stated that the skin assessment completed on 12/1/11 was inaccurate as this was a Stage II pressure ulcer and not an excoriation. S2, RN, DON stated that the wound to Resident #94 ' s right buttock should have been treated as a Stage II pressure ulcer upon admit to the facility on [DATE] with all pressure relieving measures, including relief of pressure to the site. An interview was conducted with S9, Nurse Practitioner on 6/21/12 at 2:20pm who confirmed that he was aware that Resident #94 had a wound to her right buttock on 12/1/11 but was informed that it was an excoriation. S9, Nurse Practitioner stated that based on the measurements on 12/1/11 by S7, RN, Treatment Nurse that this wound could have been considered a Stage II Pressure Ulcer. He stated that if the nursing staff would have identified Resident #94 ' s wound to her right buttock as a Stage II pressure ulcer that he would have expected the staff to keep her off of the wound site which was a bony prominence at risk for pressure and additional tissue damage. An additional interview was conducted with S9, Nurse Practitioner on 06/25/12 at 12:20 pm caring for Resident #94. S9, Nurse Practitioner stated that he did not assess Resident #94 ' s wound to her right buttock until 1/16/12 at which time it was an Unstageable pressure ulcer with eschar. S9, Nurse Practitioner stated that he went by the assessment completed by S7, RN, Treatment Nurse and that he did not view the wound until she notified him that it was a pressure wound. He stated that Resident #94 ' s wound was covered with a dressing until 1/16/12 and that he did not remove the dressing to visualize the wound since he was under the impression that it was not a pressure wound.

Based on record review and interview the facility failed to maintain a quality assessment and assurance committee that identified issues with respect to quality and assurance as evidenced by the failure to develop and implement plans of action to correct quality deficiencies for pressure ulcers and the immediate notification of Physicians for a change in skin condition or mental status. (#94, #17) FINDINGS: An interview was conducted on 6/26/12 at 3:30 pm with S2, RN, DON who denied knowledge of a problem with the skin assessments being performed and notification of physicians for changes in pressure ulcers. S2, RN, DON stated that the facility did not perform quality assurance on these problems since she was not aware that there were present in the facility.